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March/April - West Virginia State Medical Association

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Continuing <strong>Medical</strong> Education<br />

Opportunities at CAMC Health Education<br />

and Research Institute<br />

The CAMC Health Education and Research Institute is dedicated to improving health through<br />

research, education and community health development. The Institute’s Education Division<br />

offers live conferences, seminars, workshops, teleconferences and on-site programs to health care<br />

professionals. The CAMC Institute’s CME program is accredited by the Accreditation Council for<br />

Continuing <strong>Medical</strong> Education to sponsor continuing medical education for physicians. The CAMC<br />

Institute designates this educational activity for a maximum of 1 AMA PRA Category 1 Credit(s).<br />

Physicians should only claim credit commensurate with the extent of their participation in the<br />

activity. For more information on these and future programs provided by the Institute, call<br />

(304) 388-9960 or fax (304) 388-9966.<br />

SEMInARS<br />

Advanced Geriatric Skills<br />

(AGES)<br />

Friday through Sunday<br />

<strong>April</strong> 1-3<br />

Bridgeport Conference Center<br />

Bridgeport, WV<br />

Health Literacy Training<br />

Program<br />

Wednesday and Thursday<br />

<strong>April</strong> 27 and 28<br />

Clarion Hotel<br />

Shepherdstown, WV<br />

3rd Annual CAMC Urology<br />

Conference<br />

Friday, <strong>April</strong> 29<br />

Embassy Suites Hotel<br />

Charleston, WV<br />

LIfE SuppORt tRAInIng<br />

Log-on to our website to register<br />

at www.camcinstitute.org<br />

Advanced Cardiovascular Life<br />

Support (ACLS) – Provider<br />

<strong>March</strong> 24 and <strong>April</strong> 5<br />

Advanced Cardiovascular<br />

Life Support (ACLS) –<br />

Recertification<br />

<strong>March</strong> 14, 23 and <strong>April</strong> 6, 21<br />

Advanced Trauma Life Support<br />

– Provider<br />

<strong>March</strong> 21<br />

Advanced Trauma Life Support<br />

– Reverification<br />

<strong>March</strong> 22<br />

BLS Instructor Course<br />

<strong>March</strong> 8<br />

Pediatric Advanced Life Support<br />

(PALS) - Provider<br />

<strong>March</strong> 16<br />

Pediatric Advanced Life Support<br />

(PALS) – Recertification<br />

<strong>March</strong> 15<br />

Sepsis Simulation<br />

<strong>March</strong> 9 and <strong>April</strong> 13<br />

CME OnLInE pROgRAMS/<br />

ARCHIvEd guESt LECtuRE<br />

pROgRAMS<br />

Log-on to our website at<br />

www.camcinstitute.org<br />

System Requirements<br />

Environment: Windows 98,<br />

SE, NT, 2000 or XP<br />

Resolution: 800 x 600<br />

Web Browser: Microsoft’s<br />

Internet Explorer 5.0 or above<br />

or Netscape Navigator 4.7x.<br />

(Do not use Netscape 7.1)<br />

Video Player: Windows Media<br />

Player 6.4 or better.<br />

Dial-Up or Broadband<br />

Connection. Minimum<br />

Speed, 56k (Broadband is<br />

Recommended)<br />

OtHER ARCHIvEd CME<br />

OppORtunItIES:<br />

Geriatric Series<br />

Research Series<br />

NET Reach library<br />

©Charleston Area <strong>Medical</strong> Center Health System, Inc. 2011 22804-A11


B r i n g i n g Y O U<br />

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contents<br />

<strong>March</strong>/<strong>April</strong> 2011, Volume 107, No. 2<br />

features<br />

4 President’s Message<br />

5 Congratulations Dr. Spangler!<br />

7 Resolutions Committee Report<br />

23 Book Review - Atlas of Otoscopy<br />

42 General News<br />

43 WESPAC Contributors<br />

43 New Members<br />

44 Call to Action<br />

45 MPLA Suit Statistics<br />

46 Annual Meeting Highlights<br />

48 2011 Legislative Briefs<br />

54 <strong>West</strong> <strong>Virginia</strong> University Health Sciences News<br />

55 Marshall University Joan C. Edwards School<br />

of Medicine News<br />

56 <strong>West</strong> <strong>Virginia</strong> School of Osteopathic<br />

Medicine News<br />

57 Bureau for Public Health News<br />

58 <strong>West</strong> <strong>Virginia</strong> <strong>Medical</strong> Insurance Agency News<br />

60 CMOM Registration Form<br />

61 Physician Practice Advocate News<br />

62 Obituaries<br />

64 Classified Ads<br />

65 Professional Directory NEW!<br />

67 2012 Call for Papers<br />

68 Manuscript Guidelines/Advertisers<br />

In this issue…<br />

Scientific Articles<br />

8 A Controversy: Linking Atypical Femoral Fractures<br />

to Bisphosphonate Therapy<br />

14 Report of Increased Number of Children with<br />

Parapneumonic Empyema as a Complication of<br />

Bacterial Pneumonia in <strong>West</strong> <strong>Virginia</strong> in 2005<br />

21 <strong>Medical</strong> Management of Cerebellar Abscess: A<br />

Case Report and Review of the Literature<br />

24 Primary Care Office Responses to a Stroke<br />

Scenario<br />

30 Clinical Cardiac Electrophysiology in<br />

<strong>West</strong> <strong>Virginia</strong>: 2010<br />

37 Post-ablative Hypothyroidism<br />

<br />

U P C O M I N G E V E N T S<br />

<br />

<br />

Certified <strong>Medical</strong> Office Manager Class (CMOM)<br />

— <strong>March</strong> 24-24 & <strong>March</strong> 31-<strong>April</strong> 1, 2011<br />

Healthcare Summit — The Greenbrier<br />

August 26-28, 2011<br />

Cover photo courtesy<br />

of Doug Gronholm<br />

Editor<br />

F. Thomas Sporck, MD, FACS<br />

Charleston<br />

Managing Editor/Director of Communications<br />

Angela L. Lanham, Dunbar<br />

Executive Director<br />

Evan H. Jenkins, Huntington<br />

Associate Editors<br />

James D. Felsen, MD, MPH, Charleston<br />

Douglas L. Jones, MD, White Sulphur Springs<br />

Steven J. Jubelirer, MD, Charleston<br />

Roberto Kusminsky, MD, MPH, FACS, Charleston<br />

Joel Levien, MD, Charleston<br />

Robert J. Marshall, MD, Huntington<br />

Martha D. Mullett, MD, Morgantown<br />

Louis C. Palmer, MD, Clarksburg<br />

Stanley Zaslau, MD, Morgantown<br />

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

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

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

WVSMA Info: PO Box 4106, Charleston, WV 25364<br />

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


President’s Message<br />

Be Careful What You Wish For<br />

You know the old saying, ‘Be<br />

careful what you wish for.’ Last<br />

August I said in my inaugural<br />

speech this year would be dedicated<br />

to “Creating Change.” Little did I<br />

know the scope of this change…<br />

whether we created it or not.<br />

The Republican takeover of the<br />

US House of Representatives last<br />

November coupled with a series of<br />

Federal Court rulings has the full<br />

implementation of ObamaCare in<br />

doubt. At the state level, the passing<br />

of Senator Byrd has precipitated a<br />

succession of power sequence that<br />

fostered an unexpectedly contentious<br />

race for the US Senate; a court<br />

mandated 2011 election for Governor;<br />

and now a full blown power struggle<br />

at the <strong>State</strong>house with the individuals<br />

holding the top leadership position of<br />

the House, Senate and Governor all<br />

running this year for Governor. This<br />

will repeat itself in 2012 when the<br />

same senate seat and governorship<br />

are up for election along with 117<br />

seats in the <strong>West</strong> <strong>Virginia</strong> Legislature<br />

and two seats on the <strong>West</strong> <strong>Virginia</strong><br />

Supreme Court of Appeals.<br />

While we are living in unique<br />

times and change is here, we<br />

still must ‘create change’ by<br />

seizing this opportunity and<br />

fully engage in the process of<br />

transformation. Our profession<br />

and patients are counting on us.<br />

What has not changed is the<br />

mass of healthcare legislation<br />

considered by the <strong>West</strong> <strong>Virginia</strong><br />

Legislature every legislative<br />

session. Working with our<br />

WVSMA legislative committee<br />

and meeting with legislators and<br />

key members of the legislative<br />

leadership, we are working hard<br />

to make sure the voice of medicine<br />

is heard and well represented.<br />

The 2011 Regular Session<br />

has passed the half way point<br />

and a full legislative update is<br />

printed later in this issue of the<br />

Journal. Please review that report<br />

and know that your WVSMA is<br />

advocating on your behalf. Let<br />

me highlight several issues,<br />

Synthetic Marijuana and Cocaine<br />

– <strong>West</strong> <strong>Virginia</strong> is on the verge of<br />

joining the growing number of states<br />

that prohibit the sale, distribution and<br />

possession of these highly addictive<br />

substances that have been largely<br />

unregulated and freely sold in retail<br />

stores throughout the state. Popular<br />

among our youth, the addictive<br />

and hallucinogenic effects of these<br />

products are leading to countless<br />

ER visits and tragically linked to<br />

fatalities around the country.<br />

Tobacco Tax Increase - Healthcare<br />

and tobacco control advocates have<br />

succeeded in getting movement on<br />

legislation in both the House and<br />

Senate to significantly increase the<br />

state sales tax on cigarettes and the<br />

wholesale tax on smokeless tobacco.<br />

The tax on a pack of cigarettes would<br />

increase from the current 55 cents<br />

to $1.55 and the wholesale tax on<br />

smokeless tobacco would increase<br />

from 7 percent to 50 percent. The<br />

annual combined total revenue<br />

increase is projected to be $133<br />

million with most of the money<br />

earmarked for health related issues.<br />

Learned Intermediary - Several<br />

years ago, our <strong>State</strong> Supreme<br />

Court refused to adopt the ‘learned<br />

intermediary’ rule. In some states,<br />

the ‘learned intermediary’ rule<br />

enables a drug manufacturer to<br />

use as an affirmative defense in<br />

a product liability suit that there<br />

was a ‘learned intermediary’ (i.e.,<br />

physician, pharmacist, etc.) between<br />

the drug manufacturer and the<br />

patient. This could shift some<br />

the responsibility and reduce the<br />

manufacturer’s liability. Legislation<br />

being considered would put in code<br />

a modified ‘learned intermediary’<br />

rule in our state that is limited to<br />

drug manufacturers not engage<br />

in direct to consumer advertising.<br />

We are watching this closely to<br />

ensure it does not create new<br />

liability exposure for physicians or<br />

undermine the prescriber immunity<br />

protections we successfully<br />

lobbied for just a few years ago.<br />

Scope of Practice – Round<br />

two of the effort by Optometrists<br />

to substantially increase their<br />

scope of practice through greater<br />

prescriptive authority and the use of<br />

injections is moving. The WVSMA<br />

and a broad coalition of healthcare<br />

advocates are working to match the<br />

<br />

<strong>West</strong> <strong>Virginia</strong> <strong>Medical</strong> Journal


Optometrist’s scope of practice to<br />

their actual education and training<br />

in order to protect patient safety.<br />

Though it is and will be critical to<br />

work with many other healthcare<br />

providers, we do not support the<br />

dissolution of the collaborative<br />

practice agreement in place between<br />

the Boards of Medicine and Nursing.<br />

Health Care Reform<br />

Implementation - The Offices of<br />

the Insurance Commissioner (OIC)<br />

is pushing two bills to facilitate the<br />

implementation of federal healthcare<br />

reform in <strong>West</strong> <strong>Virginia</strong>. One bill<br />

grants the OIC the authority to<br />

regulate and enforce implementation<br />

of those reforms that took effect<br />

last September that generally<br />

have broad public support, i.e.,<br />

elimination of lifetime caps, limits<br />

on rescission, and dependent age<br />

increase. The other bill establishes<br />

the state health insurance exchange<br />

which will provide health insurance<br />

purchasers the opportunity to price<br />

compare different policy packages.<br />

Controlled Substance Monitoring<br />

Database - This powerful tool was<br />

created almost a decade ago to aid<br />

healthcare providers in tracking<br />

prescriptions filled at <strong>West</strong> <strong>Virginia</strong><br />

pharmacies and to help avoid<br />

unintended drug interactions. With<br />

the growing epidemic of prescription<br />

drug misuse, abuse and diversion in<br />

our state, law enforcement officials<br />

want expanded access beyond the<br />

current limited authority granted<br />

to members of state and local drug<br />

enforcement task force teams. There<br />

is also a significant push to shift<br />

the database from a ‘healthcare’<br />

tool to a ‘law enforcement’ tool that<br />

incorporates a flagging system to<br />

triggers reports to law enforcement<br />

of prescribers who fall outside yet<br />

to be defined practice parameters.<br />

All Payor Database – Three<br />

state entities (Health Care<br />

Authority, Offices of the Insurance<br />

Commissioner and DHHR) want<br />

to enact a statutory mandate that<br />

virtually all health insurance payors,<br />

public and private, be required<br />

to submit paid claim data to a<br />

centralized database. The aggregate<br />

data would be available for study<br />

and analysis. The legislation states<br />

its purpose is to enable these<br />

governmental entities to analyze paid<br />

claims, compare the cost of specific<br />

health care procedures and determine<br />

quality. The prospect of our state<br />

government becoming the healthcare<br />

‘quality czar’ should send a chill<br />

through the bones of every physician.<br />

While the news in the daily<br />

paper is focused on these and other<br />

bills moving between the House<br />

and Senate, the WVSMA is also<br />

watching closely the work of the<br />

<strong>West</strong> <strong>Virginia</strong> Supreme Court of<br />

Appeals. On <strong>March</strong> 8, the Court will<br />

hear oral arguments on our critically<br />

important medical liability reforms<br />

enacted in 2003. A final decision is<br />

not expected until late Spring. This is<br />

one area I hope we will not see any<br />

‘change’. Our reforms have worked<br />

well and must be maintained!<br />

John H. Schmidt III, MD<br />

WVSMA President<br />

Congratulations<br />

Elizabeth Spangler, MD<br />

2011 YWCA Women of<br />

Achievement Honoree<br />

The <strong>West</strong> <strong>Virginia</strong> <strong>State</strong><br />

<strong>Medical</strong> <strong>Association</strong> congratulates<br />

Dr. Elizabeth Spangler upon being<br />

selected as a 2011 YWCA Women<br />

of Achievement Honoree.<br />

Dr. Spangler served as our<br />

<strong>Association</strong>’s first female president<br />

in 2005 and is a past president of the<br />

Kanawha County <strong>Medical</strong> Society.<br />

Dr. Spangler has a great passion<br />

for medical care and the patients she<br />

serves. Her career includes positions<br />

as a member and/or chair of a<br />

variety of hospital, state and national<br />

healthcare committees and boards.<br />

We appreciate her dedication<br />

to the physicians and patients<br />

of <strong>West</strong> <strong>Virginia</strong>.<br />

<strong>March</strong>/<strong>April</strong> 2011 | Vol. 107


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| Report of the Resolutions Committee<br />

Report of the Resolutions Committee — January 22, 2011<br />

Your Committee on Resolutions<br />

has carefully considered the<br />

Resolutions offered in the First<br />

Session of the House of Delegates<br />

on Saturday, January 22, 2011.<br />

We are happy to report that a<br />

number of interested physicians<br />

appeared at the meeting of the<br />

Committee on Saturday and<br />

discussed in detail the Resolutions<br />

pending before the Committee.<br />

The cooperation of those<br />

physicians present was most<br />

helpful to the Committee in<br />

reaching decisions and we express<br />

appreciation to those who took the<br />

time to attend the opening hearing.<br />

Mr. Speaker, your Committee<br />

assures the members of the<br />

<strong>Association</strong> that the one and only<br />

consideration that has guided the<br />

Committee in its deliberations has<br />

been the criteria as to whether each<br />

of the resolutions was or would<br />

be in the best interest of the entire<br />

medical profession in <strong>West</strong> <strong>Virginia</strong><br />

in giving its patients the best of care.<br />

Mr. Speaker, your Committee<br />

considered Resolution 1, pertaining<br />

to Access to Information and the<br />

<strong>State</strong>’s Public Health System.<br />

Mr. Speaker, your Committee<br />

recommends that Resolution 1 not<br />

be adopted and that the following<br />

substitute Resolution 1 be adopted:<br />

RESOLVED, That the WVSMA<br />

request the Secretary of the <strong>West</strong><br />

<strong>Virginia</strong> Department of Health and<br />

Human Resources to aggressively<br />

pursue efforts to develop policies<br />

and if necessary legislation,<br />

regulations and/or rules that would<br />

mandate that any agency within<br />

the state’s public health system<br />

share any and all information<br />

with local health departments.<br />

Mr. Speaker, your Committee<br />

moves the adoption of<br />

substitute Resolution 1.<br />

Mr. Speaker, your Committee<br />

considered Resolution 2,<br />

pertaining to Clarifying Rights<br />

of Physician Service.<br />

Mr. Speaker, your Committee<br />

recommends that the Resolution 2 be<br />

referred to the Executive Committee.<br />

Mr. Speaker, your Committee<br />

moves that Resolution 2 be referred.<br />

Mr. Speaker, your Committee<br />

considered Resolution 3, pertaining<br />

to Governance Structure Review.<br />

Mr. Speaker, your<br />

Committee recommends that<br />

Resolution 3 be adopted.<br />

RESOLVED, that the WVSMA<br />

Executive Committee oversee a<br />

comprehensive evaluation of the<br />

governance structure options and<br />

take such action as necessary through<br />

an appropriate committee to present<br />

to the House of Delegates at its next<br />

meeting any recommendation(s)<br />

it considers warranted for<br />

consideration and possible adoption.<br />

Mr. Speaker, your Committee<br />

moves the adoption of Resolution 3.<br />

Mr. Speaker, your Committee<br />

considered Resolution 4,<br />

pertaining to Wind Turbine<br />

Facilities and Public Health.<br />

Mr. Speaker, your Committee<br />

recommends that Resolution 4 not<br />

be adopted and that the following<br />

substitute Resolution 4 be adopted:<br />

RESOLVED, that the WVSMA will<br />

endeavor to inform physicians and<br />

encourage evidence-based research<br />

regarding the public health effects of<br />

<strong>West</strong> <strong>Virginia</strong> energy production.<br />

Mr. Speaker, your Committee<br />

moves the adoption of<br />

substitute Resolution 4.<br />

Mr. Speaker, your Committee<br />

considered Resolution 5, pertaining<br />

to End of Life Decision Making.<br />

Mr. Speaker, your Committee<br />

recommends that Resolution 5 not<br />

be adopted and that the following<br />

substitute Resolution 5 be adopted:<br />

RESOLVED, that the WVSMA<br />

and the <strong>West</strong> <strong>Virginia</strong> <strong>Medical</strong><br />

Foundation provide support and<br />

education to physicians regarding<br />

advance care planning and end of life<br />

decision making; and be it further<br />

RESOLVED, that the WVSMA and<br />

<strong>West</strong> <strong>Virginia</strong> <strong>Medical</strong> Foundation<br />

support initiatives that increase<br />

public awareness of advance care<br />

planning and end of life decision<br />

making and be it further<br />

RESOLVED, that the WVSMA<br />

encourage its component societies<br />

to cultivate appropriate community<br />

partners to encourage advance<br />

care planning and end of life<br />

decision making; and be it further<br />

RESOLVED, that the WVSMA<br />

support the use of public funds that<br />

actively promotes advance care<br />

planning and end of life discussions.<br />

Mr. Speaker, your committee<br />

moves the adoption of<br />

substitute Resolution 5.<br />

Mr. Speaker, we wish to thank<br />

the members of the WVSMA<br />

who appeared before the<br />

Committee for their participation,<br />

patience, enthusiasm, wisdom,<br />

endurance, and time devoted to<br />

the study of the resolutions.<br />

In addition to me, as Chairman,<br />

the appointed members of the<br />

Committee who participated<br />

in these deliberations were:<br />

John Holloway, MD<br />

R. Austin Wallace, MD<br />

Joseph Reed, MD<br />

James Felsen, MD<br />

David Avery, MD<br />

Joseph Selby, MD<br />

WVSMA Staff<br />

Evan Jenkins, Executive Director<br />

Karie Sharp<br />

Respectfully submitted,<br />

F. Thomas Sporck, MD<br />

Vice President 2010-2011<br />

<strong>March</strong>/<strong>April</strong> 2011 | Vol. 107


Scientific Article |<br />

A Controversy: Linking Atypical Femoral Fractures to<br />

Bisphosphonate Therapy<br />

Christopher C. Trotter, MD<br />

Alfred K. Pfister, MD<br />

Brant A. Whited, MSIII<br />

Todd H. Goldberg, MD<br />

Steven A. Artz, MD<br />

<strong>West</strong> <strong>Virginia</strong> University School of<br />

Medicine, Charleston, WV<br />

Abstract<br />

Several cases have been reported of<br />

unusual spontaneous fractures with<br />

minimal trauma in the subtrochanteric and<br />

diaphyseal areas of the femur linked to<br />

long-term bisphosphonate use. After<br />

encountering three such patients, we<br />

conducted a review of published cases.<br />

The average age of these individuals<br />

were 68 years and approximately 25%<br />

had received concomitant glucocorticoids.<br />

Histomorphometric bone biopsy studies<br />

performed in some individuals have<br />

suggested that severe suppression of<br />

bone turnover may be the underlying<br />

cause; however, cause and effect has not<br />

been firmly established. Moreover,<br />

population studies have found this type of<br />

fracture rare and not increased in patients<br />

who have received bisphosphonate<br />

treatment. Physicians should continue to<br />

use bisphosphonate agents as a primary<br />

treatment for osteoporosis.<br />

Introduction<br />

In normal premenopausal states<br />

the osteoclastic resorption of old bone<br />

is balanced by osteoblastic build up<br />

of new bone. 1 In this instance, a<br />

continued synthesis of type 1 collagen<br />

allows for the flexibility of bone, but<br />

varying degrees of mineralization<br />

with calcium hydroxy-apatite crystals<br />

adds to subsequent stiffness. As<br />

mineralization of collagen matures,<br />

secondary mineralization occurs with<br />

larger and more dense crystals. This<br />

heterogeneous distribution of crystals<br />

throughout bone collagen limits the<br />

susceptibility and progression of<br />

microcrack formation.<br />

In postmenopausal osteoporosis<br />

bone turnover becomes accelerated<br />

with an uncoupling of the<br />

remodeling process. Osteoclastic<br />

resorption now exceeds the ability<br />

of osteoblasts to build new bone,<br />

and mineralized bone collagen<br />

is removed before completing<br />

secondary mineralization. 2 Inhibition<br />

of this osteoclastic resorption by<br />

bisphosphonate therapy results in<br />

a higher secondary mineralization<br />

with subsequent increases in bone<br />

mineral density and strength.<br />

Eventually, the increased rates of<br />

osteoblastic new bone formation<br />

during bisphosphonate treatment<br />

decline as does osteoclastic bone<br />

resorption, and the biochemical<br />

markers of bone turnover return<br />

to premenopausal ranges. 3 This<br />

reduction in remodeling appears<br />

to primarily account for the antifracture<br />

effect of these compounds. 4<br />

Bisphosphonates are widely<br />

accepted and prescribed for the<br />

treatment of postmenopausal<br />

osteoporosis. A meta-analysis<br />

of clinical trials has shown these<br />

compounds to be quite effective<br />

with a primary prevention of 45%<br />

for vertebral fractures as well as a<br />

secondary prevention of 39% for<br />

hip and 50% for wrist fractures. 5<br />

Prolonged use of alendronate over<br />

7 to 10 years has shown a continued<br />

increase in the bone mineral density<br />

without any adverse skeletal events. 6‐8<br />

However, some have questioned<br />

whether this prolonged and severe<br />

suppression of bone turnover may<br />

have negative effects by causing<br />

accumulation of microdamage and<br />

localized highly mineralized bone. 9‐10<br />

This may potentially increase the<br />

risk of stress fractures. Several cases<br />

of atypical fractures associated<br />

with long-term bisphosphonate<br />

therapy have been reported in<br />

the proximal femoral shaft with<br />

minimal or no trauma. 11-24 The<br />

purpose of this report is to review<br />

the characteristics of these unusual<br />

fractures from published reports<br />

and cases which we encountered<br />

and evaluate what evidence exists to<br />

link bisphosphonate treatment to the<br />

occurrence of these atypical fractures.<br />

Methods<br />

The data for 89 atypical femoral<br />

fractures which were primarily<br />

suspected as being linked to longterm<br />

bisphosphonate treatment was<br />

reviewed. The analysis consisted of<br />

86 cases obtained from PUBMED<br />

English-language articles from 2006<br />

through 2009 and three noted in<br />

our region over a 30 month period.<br />

We recorded gender, age at the<br />

time of fracture, and duration of<br />

treatment. Additional characteristics<br />

of delayed healing, concomitant<br />

glucocorticoid treatment and other<br />

agents which may inhibit bone<br />

metabolism, prodromal thigh<br />

pain, and contralateral cortical<br />

thickening or stress fractures were<br />

also evaluated when reported.<br />

Results<br />

The pertinent clinical findings<br />

of 89 cases (86 women and 3 men)<br />

are provided in Table 1. These<br />

patients had a mean (SD) age<br />

of 66.8 (8.4) years with a range<br />

of 42 to 91 years, and a mean<br />

(SD) duration of bisphosphonate<br />

treatment of 5.97 (2.4) years with<br />

a range 1 to 10 years. Virtually all<br />

patients received alendronate but<br />

seven had subsequent treatment<br />

with ibandronate or risedronate,<br />

whereas one patient received<br />

only pamidronate. Concomitant<br />

glucocorticoid use was observed<br />

in 28% (19/67). An additional<br />

24% (12/50) had been prescribed<br />

other agents (estrogen, tamoxifen,<br />

raloxifene, methotrexate, or<br />

<br />

<strong>West</strong> <strong>Virginia</strong> <strong>Medical</strong> Journal


| Scientific Article<br />

tibolene) which suppress bone<br />

turnover, and over one-half of<br />

these were concomitantly taken<br />

with glucocorticoids. Adequate<br />

vitamin D status by serum levels<br />

or supplements was reported in<br />

27% (21/79). Either unilateral or<br />

bilateral thigh pain was experienced<br />

for weeks or months prior to<br />

fracturing in 66% (38/58). Minimal<br />

or no trauma commonly preceded<br />

the fracture event. The unusual<br />

radiographic features observed were<br />

simple transverse or shortly oblique<br />

fractures with a unicortical spike<br />

along with cortical hypertrophy in<br />

the diaphyseal or subtrochanteric<br />

areas of the femur. Additionally,<br />

contralateral fractures or stress lines<br />

along with cortical hypertrophy<br />

and delayed healing was reported<br />

in 41% (16/39). Radiographic<br />

images of these unique fractures are<br />

illustrated in Figures 1, 2 and 3.<br />

Discussion<br />

Histomorphometric studies<br />

to determine the pathogenesis<br />

of these atypical fractures have<br />

implicated severe suppression<br />

of bone turnover resulting in<br />

increased fracture susceptibility and<br />

delayed healing. 11,17,21 Decreased<br />

osteoblastic and osteoclastic surfaces<br />

to bone surface ratios were noted<br />

in endocortical, intracortical, and<br />

cancellous bone. Importantly, bone<br />

formation rates were markedly<br />

reduced including cortical<br />

areas. Some, however, could not<br />

conclusively state that suppression<br />

of bone turnover was the underlying<br />

cause, and bone biopsies were<br />

generally performed much later than<br />

the time of fracture. 21 One report<br />

which biopsied the patient at the time<br />

of fracture found a marked increase<br />

in osteoclasts attached to the bone<br />

in the femur and concluded that an<br />

imbalance of bone resorption and<br />

formation as the likely cause. 19<br />

If severe suppression of bone<br />

turnover is plausible as the<br />

pathogenic mechanism, long-term<br />

concomitant glucocorticoid therapy<br />

may play a role once bisphosphonate<br />

therapy is initiated. 25 Glucocorticoids<br />

increase osteoblast and osteocyte<br />

apoptosis which consequently<br />

results in a decrease in osteoblast<br />

number and bone formation rates. 26<br />

Increased osteocyte apoptosis with<br />

glucocorticoid therapy causes<br />

disruption of the canalicular system<br />

resulting in the failure to detect<br />

microcrack signaling and subsequent<br />

repair. 27 Inhibition of osteoclastic<br />

bone resorption by bisphosphonate<br />

therapy under these circumstances<br />

theoretically would result in severe<br />

suppression of bone turnover<br />

and microdamage accumulation,<br />

but several randomized, placebocontrolled<br />

trials have shown that<br />

bisphosphonate compounds increase<br />

or maintain the bone mineral<br />

density in patients receiving chronic<br />

glucocorticoid therapy. 28-33 On the<br />

other hand, with the exception of<br />

one trial performed over a twoyear<br />

period, all other trials were<br />

conducted for only a one-year period.<br />

Vertebral fractures were viewed as<br />

secondary outcomes and reduced in<br />

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<strong>March</strong>/<strong>April</strong> 2011 | Vol. 107


Scientific Article |<br />

Table 1. Summary of characteristics in patients with atypical femoral fractures associated with bisphosphonate therapy.<br />

mean mean yrs. n gluco- n delayed n prodromal n contralateral<br />

n* age treatment corticoid healing symptoms cortical reaction<br />

Reference duration therapy or fracture<br />

11 5 60.2 5.6 2 4 N/A † 2<br />

12 9 66.9 4.2 2 N/A 5 N/A<br />

13 1 82 10 0 N/A 1 1<br />

14 1 73 7 0 1 1 1<br />

15 19 69.4 6.2 N/A N/A N/A N/A<br />

16 17 66 4.8 2 N/A 13 9<br />

17 3 62.6 8.3 3 2 2 3<br />

18 3 63.3 7 N/A N/A 2 2<br />

19 1 76 8 1 1 1 1<br />

20 1 60 6 1 N/A 1 1<br />

21 7 55.1 6.5 3 3 N/A 2<br />

22 8 66.9 5.4 4 2 2 4<br />

23 4 66.3 8.4 0 2 3 1<br />

24 7 61 8.6 0 0 4 7<br />

Unpublished 3 76 7.3 1 1 3 2<br />

*= Numbers of patients presented with specific characteristic in each report.<br />

† = Information not available in reports.<br />

most but not all studies; however, no<br />

reduction in nonvertebral fractures<br />

was observed. Interestingly, one<br />

trial conducted over one year did<br />

not find impaired fracture healing in<br />

individuals receiving glucocorticoids<br />

and bisphosphonates. 33 No<br />

trials of longer duration (e.g.,<br />

five or more years) exist to<br />

provide evidence whether longer<br />

treatment with bisphosphonates<br />

in patients on glucocorticoids<br />

have an increased susceptibility<br />

of these atypical fractures.<br />

These atypical fractures have<br />

only been retrospectively linked<br />

to bisphosphonate therapy.<br />

Furthermore, population-based<br />

studies have not been able to validate<br />

this association. A Danish registry<br />

cohort observational study found<br />

that fractures in the subtrochanteric<br />

and diaphyseal locations were no<br />

more frequent in patients receiving<br />

alendronate. 34 However, the average<br />

age of patients with fractures in these<br />

locations were 12 years older than<br />

those in our review, and the authors<br />

were unable to access records to<br />

determine whether atypical x-ray<br />

patterns were present similar to the<br />

reported cases. An Australian study<br />

after reviewing hip fractures from<br />

the previous year found that atypical<br />

femoral fractures were rare and no<br />

more common in patients who were<br />

treated with bisphosphonates. 35<br />

Furthermore, a report reviewing<br />

three large randomized trials<br />

also found these fractures to be<br />

quite rare and not significantly<br />

increased even in patients who<br />

received bisphosphonates for as<br />

long as 10 years. These authors,<br />

however, were not able to view<br />

all images of atypical fractures.<br />

Conclusion<br />

Physicians should continue to<br />

prescribe bisphosphonates for the<br />

treatment of osteoporosis. The<br />

occurrence of atypical fractures<br />

in the femur with minimal or no<br />

trauma in patients receiving longterm<br />

bisphosphonates appears to<br />

be rare and the evidence linking<br />

bisphosphonates as a cause has<br />

not been strongly substantiated. A<br />

prospective observational study<br />

viewing radiographic images along<br />

with clinical symptoms would<br />

help to verify the population-based<br />

studies. New onset of thigh pain<br />

in a patient receiving long-term<br />

bisphosphonates warrants imaging<br />

of the femur. Individuals receiving<br />

concomitant glucocorticoids or<br />

other agents which suppress bone<br />

turnover should also raise awareness<br />

of the possibility of these fractures.<br />

Acknowledgements<br />

The authors acknowledge the<br />

following persons: Brittain McJunkin,<br />

MD and Robert Cagna, JD for<br />

assistance in manuscript review;<br />

10 <strong>West</strong> <strong>Virginia</strong> <strong>Medical</strong> Journal


| Scientific Article<br />

Figure 1.<br />

A 91 year old lady who had taken alendronate for 10 years and intermittent glucocorticoids for chronic obstructive lung disease<br />

experienced right thigh pain for nine months. Cortical thickening (a) was noted before experiencing a femoral transverse fracture<br />

with a unicortical spike (b). Healing was noted at 3 months (c) as well as contralateral thickening (d). The patient has been receiving<br />

teriparatide for recovery.<br />

Faculty Position<br />

Academic Internist<br />

<strong>West</strong> <strong>Virginia</strong> University - Charleston Division<br />

Robert C. Byrd Health Sciences Center<br />

Charleston Division<br />

Available November 1, 2010<br />

The Department of Internal Medicine is seeking an Academic Internist<br />

for a full-time position at the Robert C. Byrd Health Sciences Center,<br />

<strong>West</strong> <strong>Virginia</strong> University, Charleston Division, available November 1,<br />

2010. The position will provide academic support to a dually accredited<br />

residency program sponsored by Charleston Area <strong>Medical</strong> Center, an<br />

838-bed tertiary hospital located in the capital city of Charleston, <strong>West</strong><br />

<strong>Virginia</strong>. The affiliation between <strong>West</strong> <strong>Virginia</strong> University and Charleston<br />

Area <strong>Medical</strong> Center, which is the oldest regional medical campus in the<br />

nation, offers a clinical training environment for more than 80 medical<br />

students, 150 residents and other health professions.<br />

The candidate must be Board Certified or Board Eligible. The position<br />

requires a significant commitment to resident and medical student<br />

education in Internal Medicine and participation in appropriate<br />

academic, clinical research or other scholarly activity as may be required<br />

of clinical faculty. <strong>West</strong> <strong>Virginia</strong> University offers a flexible job description<br />

with both inpatient and outpatient opportunities available.<br />

Enjoy the beautiful outdoors in a culturally rich area with highly<br />

desirable residential communities and outstanding school systems.<br />

Our compensation package is extremely competitive and commensurate<br />

with qualifications and experience. The search will remain open until a<br />

suitable candidate is identified. This position is not qualified for J-1 Visa.<br />

Please submit letter of interest and curriculum vitae to:<br />

Gregory Rosencrance, MD, FACP<br />

Professor and Chairman<br />

Department of Internal Medicine<br />

<strong>West</strong> <strong>Virginia</strong> University<br />

Charleston Division<br />

3110 MacCorkle Avenue, SE<br />

Charleston, WV 25304<br />

Fax: (304) 347-1344<br />

Office: (304) 347-1254<br />

E-mail: grosencrance@hsc.wvu.edu<br />

Women and minorities are encouraged to apply.<br />

<strong>West</strong> <strong>Virginia</strong> University is an Affirmative Action<br />

Equal Employment Opportunity Employer<br />

22554-J10<br />

<strong>March</strong>/<strong>April</strong> 2011 | Vol. 107 11


Scientific Article |<br />

Figure 2.<br />

A 66 year old female on alendronate for 7 years noted bilateral thigh pain for several<br />

weeks. When turning from a standing position, she experienced severe thigh pain and<br />

was caught by a friend. A transverse fracture was noted at a thickened cortical site (a).<br />

Nuclear imaging revealed a contralateral stress reaction (b).<br />

Figure 3.<br />

A 68 year-old white female who received<br />

estrogen and bisphosphonates for 5.5<br />

years experienced right thigh pain for 2<br />

weeks causing her to fall which resulted<br />

in a subtrochanteric fracture.<br />

orthopedists William G. Sale, MD<br />

and Tony C. Majestro, MD for their<br />

review of cases and radiographic<br />

images; and the late Paul D.<br />

Saville, MD for his comments.<br />

References<br />

1. Chavassieux P, Seeman E, Delmas PD.<br />

Insights into the material and structural<br />

basis of bone fragility from diseases<br />

associated with fracture: How determinants<br />

of the biomechanical properties of bone are<br />

compromised by disease. Endocrine<br />

Reviews. 2007;28:151-164.<br />

2. NIH Consensus Development Panel on<br />

Osteoporosis, Diagnosis, and Therapy.<br />

Osteoporosis diagnosis, and therapy. JAMA<br />

2001;285:785-795.<br />

3. Greenspan S, Parker RA, Ferguson L,<br />

Rosen HN, Maitland-Ramsey L, Karpf DB.<br />

Early changes in biochemical markers of<br />

bone turnover predict the long-term<br />

response to alendrodronate therapy in<br />

representative elderly women. J Bone Miner<br />

Res 1998;13:1431- 1438.<br />

4. Cummings SR, Karpf DB, Harris F, et al.<br />

Improved spine bone mineral density and<br />

reduction in risk of vertebral fractures during<br />

treatment with antiresorptive drugs. Am J<br />

Med. 2002;112;281-289.<br />

5. Wells GA, Craney A, Peterson J, et al.<br />

Alendronate for the primary and secondary<br />

prevention of osteoporotic fractures in<br />

postmenopausal women. Cochrane<br />

Database of Systematic Reviews. 2008,<br />

Issue 1. Art No.:CD001155.<br />

DOI:10.1002/14651858. CD001155.pub2.<br />

6. Bone HG, Hosking D, Devogelaer J-P, et al.<br />

Ten years’ experience with alendronate for<br />

osteoporosis. New Engl J Med<br />

2004;350:1189-1199.<br />

7. Tonino R, Meunier PJ, Emkey R, et al.<br />

Skeletal benefits of alendronate: 7-Year<br />

treatment of postmenopausal osteoporotic<br />

women. J Clin Endocrinol Metab<br />

2000;85:3109-3115.<br />

8. Black DM, Schwartz AV,Ensrud KE, et al.<br />

Effects of continuing or stopping<br />

alendronate after 5 years of treatment.<br />

JAMA 2006;296:2927-2938.<br />

9. Ott SM. Fractures after long-term<br />

alendronate therapy. J Clin Endocrinol<br />

Metab. 2001;86: 1835.<br />

10. Hirano T, Turner CH, Forwood MR,<br />

Johnston CC, Burr DB. Does suppression<br />

of bone turnover impair mechanical<br />

properties by allowing microdamage<br />

accumulation Bone. 2000;21:13-20.<br />

11. Odvina CV, Zerwekh JE, Sudhaker Rao D,<br />

Maalouf N, Gottshalk FA, Pak CYC.<br />

Severely suppressed bone turnover: A<br />

potential complication of alendronate<br />

therapy. J Clin Endo- crinol Metab.<br />

2005;90:1294-1301.<br />

12. Goh SK, Yang KY, Koh JSB, et al.<br />

Subtrochanteric insufficiency fractures in<br />

patients on alendronate therapy: A caution.<br />

J Bone Joint Surg Br. 2007;89:349-353.<br />

13. Cheung RKH, Leung KK, Lee KC, Chow<br />

TC. Sequential non-traumatic femoral neck<br />

fractures in a patient on long-term<br />

alendronate. Hong Kong Med J.<br />

2007;13:485-489.<br />

12 <strong>West</strong> <strong>Virginia</strong> <strong>Medical</strong> Journal


| Scientific Article<br />

14. Sayed-Noor A, Sjoden GO. Subtrochanteric<br />

displaced insufficiency fracture after longterm<br />

alendronate therapy- a case report.<br />

Acta Orthopaedica. 2008;79:565-567.<br />

15. Neviaser AS, Lane JM, Lenart BA, Edobor-<br />

Osula F, Lorich DG. Low-energy femoral<br />

shaft fractures associated with alendronate<br />

use. J Orthop Trauma. 2008;22:346-350.<br />

16. Kwek EBK, Goh SK, Koh JSB, Png MA,<br />

Howe TS. An emerging pattern of<br />

subtrochanteric stress fractures: A longterm<br />

complication of alendronate therapy<br />

Injury. 2008;39:224- 231.<br />

17. Visekruna M, Wilson D, McKiernan FE.<br />

Severely suppressed bone turnover and<br />

atypical skeletal fragility. J Clin Endocrinol<br />

Metab. 2008;93:2948-2952.<br />

18. Schneider JP. Bisphosphonates and lowimpact<br />

femoral fractures: Current evidence on<br />

alendronate risk. Geriatrics 2009;64:18-23.<br />

19. Somford MP, Draijer FW, Thomassen DJW,<br />

Pascale MC, Boivin G, Papapoulos SE.<br />

Bilateral fractures of the femur diaphysis in<br />

a patient with rheumatoid arthritis on longterm<br />

alendronate: clues to the mechanism<br />

of increased bone fragility. J Bone Miner<br />

Res. 2009 [epub ahead of print]<br />

20. Edwards MH, McCrae FC, Young-Min SA.<br />

Alendronate-related femoral diaphysis<br />

fracture- what should be done to predict<br />

and prevent subsequent fracture of the<br />

contralateral side Osteoporos Int. 2009<br />

June 27 [Epub ahead of print] PMID<br />

19562241.<br />

21. Armamento-Villareal R, Napoli N, Diemer R,<br />

et al. Bone turnover in bone biopsies of<br />

patients with low-energy cortical fractures<br />

receiving bisphosphonates: A case series.<br />

Calcif Tissue Int. 2009;85:37-44.<br />

22. Ing-Lorenzini K, Desmueles J, Plachta O,<br />

Suva D, Dayer P, Peter R. Low-energy<br />

fractures associated with long-term use of<br />

bisphosphonates. Drug Saf. 2009;32:775-785.<br />

23. Cermak K, Shumelinsky F, Alexiou J,<br />

Gebhart MJ. Case reports: Subtrochanteric<br />

stress fractures after prolonged alendronate<br />

therapy. Clin Orthop Relat Res. 2009 Dec<br />

18 [Epub ahead of print].<br />

24. Capeci CM, Tejwant NC. Bilateral lowenergy<br />

simultaneous or sequential femoral<br />

fractures in patients on long-term<br />

alendronate therapy. J Bone Joint Surg Am.<br />

2009;91:2556-2561.<br />

25. Dempster DW, Arlot MA, Meunier PJ. Mean<br />

wall thickness and formation periods of<br />

trabecular bone packets in corticosteroidinduced<br />

osteoporosis. Calcif Tissue Inter.<br />

1983;36:410-417.<br />

26. Jilka RL, Weinstein RS, Parfitt AM,<br />

Manolagas SC. Quantifying osteoblast<br />

and osteocyte apoptosis: Challenges and<br />

rewards. J Bone Miner Res.<br />

2007;22:1492-1501.<br />

27. Manolagas SC. Corticosteroids and<br />

fractures: A close encounter of the third cell<br />

kind. J Bone Miner Res.2000;15:1001-1005.<br />

28. Reid DM, Hughes RA, Lawn RFJM, et al.<br />

Efficacy and safety of long-term risedronate<br />

in the treatment of glucocorticoid-induced<br />

osteoporosis in men and women: A<br />

randomized trial. J Bone Miner Res.<br />

2000;15:1006-1013.<br />

29. Adachi JD, Saag KG, Delmas PD, et al.<br />

Two-year effects of alendronate on bone<br />

mineral density and vertebral fracture in<br />

patients receiving glucocorticoids. Arth<br />

Rheum. 2001;44: 202-211.<br />

30. Saag KG, Emkey R, Schnitzer TG, et al.<br />

Alendronate for the prevention and treatment<br />

of glucocorticoid-induced osteoporosis. N<br />

Engl J Med. 1998;339:292-229.<br />

31. Adachi JD, Bensen WG, Brown J, et al.<br />

Intermittent etidronate therapy to prevent<br />

corticosteroid-induced osteoporosis. N Engl<br />

J Med. 1997;337:382-287.<br />

32. Wallach S, Cohen S, Reid DM, et al. Effects<br />

of risedronate treatment on bone density<br />

and vertebral fracture in patients on<br />

corticosteroid therapy. Calcif Tissue Int.<br />

2000;67:277-285.<br />

33. Cohen S, Levy RM, Keller M, et al.<br />

Risedronate therapy prevents<br />

corticosteroid-induced bone loss. Arthritis<br />

Rheum. 1999;42:2309-2318.<br />

34. Abrahamsen B, Eiken P, Eastell R.<br />

Subrochanteric and diaphyseal femur<br />

fractures in patients treated with<br />

alendronate: A register-based national<br />

cohort study. J Bone Miner Res.<br />

2009;24:1095-1102.<br />

35. Lee P. Atypical femoral fractures. CMAJ.<br />

2010;182:384-385.<br />

36. Black DM, Kelly MP, Genant HK, et al.<br />

Bisphosphonates and fractures of the<br />

subtrochan- teric and diaphyseal femur. N<br />

Eng J Med. 2010 Mar 24 [epub ahead of<br />

print].<br />

<strong>March</strong>/<strong>April</strong> 2011 | Vol. 107 13


Scientific Article |<br />

Report of Increased Number of Children with<br />

Parapneumonic Empyema as a Complication of<br />

Bacterial Pneumonia in <strong>West</strong> <strong>Virginia</strong> in 2005<br />

Kathyrn Moffett, MD<br />

Associate Professor of Pediatrics<br />

Ann-Marie Tantoco, MD<br />

Internal Medicine/Pediatric Resident<br />

Ohio <strong>State</strong> University<br />

Introduction<br />

Pediatric invasive disease from<br />

Streptococcus pneumoniae in children<br />

has diminished since the introduction<br />

in 2000 of the heptavalent<br />

pneumococcal conjugate vaccine<br />

(PCV-7 or Prevnar ®) . 1,2 Pediatric<br />

parapneumonic empyema (PPE),<br />

a rare complication of bacterial<br />

pneumonia in children, has been<br />

increasing globally due to nonvaccine<br />

serotype replacements of<br />

S pneumoniae, with serotype 19A<br />

most commonly discovered. 3-20<br />

Recently a similar increase<br />

of parapneumonic empyema<br />

complicating bacterial pneumonia in<br />

2005 was observed in children treated<br />

at the <strong>West</strong> <strong>Virginia</strong> University<br />

Children’s Hospital (WVU-CH) in<br />

Morgantown, WV. We conducted<br />

a retrospective review of medical<br />

records from 2000-2007 to determine<br />

the number of children with PPE,<br />

with an attempt to determine the<br />

causative agent(s) and risk factors.<br />

Methods<br />

This study reviewed the medical<br />

records of childhood pneumonia<br />

complicated by parapneumonic<br />

empyema admitted to WVU-CH.<br />

The Institutional Review Board of<br />

<strong>West</strong> <strong>Virginia</strong> University reviewed<br />

and approved this retrospective<br />

study. The computerized data<br />

management system was queried<br />

for all cases of parapneumonic<br />

empyema in children less than 18<br />

years of age and for a diagnosis<br />

of pneumonia for the period of<br />

January 2000 to December 2007.<br />

The microbiology data for detection<br />

of viral respiratory specimens<br />

(influenza and respiratory syncytial<br />

viruses) was queried for 2000-<br />

2007. All children with pneumonia<br />

and PPE as a complication of<br />

cardiothoracic surgery, as well as<br />

premature infants with gestational<br />

age


| Scientific Article<br />

Table 1: Demographics of Children with Parapneumonic Empyema at<br />

WVU-Children’s Hospital from January 1, 2000 to December 31, 2007<br />

Number of Cases 36<br />

4 years of age 25<br />

Females 19 (53%)<br />

Median Age (years) [Range in years] 7.2 [0.6-17]<br />

Surgical procedure performed<br />

Chest tube placement 36 [100%]<br />

Video-assisted thorascopy or decortication 14 [39%]<br />

Receipt of Prevnar- 7 Vaccine 8 (25%)<br />

Length of Stay (days) [Range in days] 10 [5-16]<br />

Race: Caucasian 33<br />

African American 2<br />

Unspecified 1<br />

<strong>State</strong> of Residence: <strong>West</strong> <strong>Virginia</strong> 29 (80%)<br />

Pennsylvania 4 (11%)<br />

Ohio 2 (6%)<br />

Maryland 1 (3%)<br />

PPE= Parapneumonic Empyema<br />

Serotyping of Streptococcus<br />

pneumoniae isolates<br />

Five of the 8 isolates of S<br />

pneumoniae were available for<br />

serotyping, each showing a different<br />

serotype: serotype 1 (year isolated<br />

2001), 7 (2002), 12F (2000), 19A<br />

(2005), and 19F (2005). Serotypes<br />

in the PVC-7 vaccine include 4,<br />

6B, 9V, 14, 18C, 19F, and 23F.<br />

Antimicrobial treatment<br />

None of the eight children with<br />

a positive blood/ pleural culture<br />

received oral antimicrobial agents<br />

prior to cultures being obtained;<br />

one child with a positive blood<br />

culture also had a positive pleural<br />

fluid culture. Nine children received<br />

oral antibiotics prior to blood and<br />

pleural cultures being obtained,<br />

which included cedinir (1 child),<br />

azithromycin/ cefuroxime (1),<br />

azithromycin/levofloxacin (1),<br />

amoxicillin-clavulenate (2), and<br />

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like to say “I’m HIMG” because every member of our team is proud to carry the strong<br />

reputation of our operation in all that we do.<br />

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group in the state. Our 150,000 square-foot facility and our business practices<br />

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www.himgwv.com<br />

(304) 528-4657<br />

<strong>March</strong>/<strong>April</strong> 2011 | Vol. 107 15


Scientific Article |<br />

Figure 1.<br />

azithromycin/amoxicillin-clavulenate<br />

(4). During hospitalization, antibiotic<br />

treatment among the 36 children<br />

was variable, with choices for<br />

intravenous/ parenteral antibiotics<br />

including: ticarcillin-clavulenate (1<br />

culture-negative child), ceftriaxone<br />

(27 children, including all 8 culturepositive),<br />

and ceftriaxone and<br />

clindamycin (8 culture-negative<br />

children). A minority of the<br />

children (8) received treatment<br />

for MRSA infection, although no<br />

cultures grew any Staphylococcus<br />

isolates. It is not within the scope<br />

of this retrospective review to<br />

determine the reasons behind the<br />

choice(s) of antimicrobial agents.<br />

Discussion<br />

Annual rates of pneumonia in the<br />

United <strong>State</strong>s in children


| Scientific Article<br />

Figure 2.<br />

Serotypes 1, 7, 19A, 19F and 22F<br />

were present in the culture isolates<br />

from children treated in <strong>West</strong><br />

<strong>Virginia</strong>. Only one of those serotypes<br />

was a PCV-7 serotype in a child<br />

determined to be immunocompetent.<br />

Our experience in WV reflects other<br />

reports in the United <strong>State</strong>s that there<br />

is an increase in PPE in children<br />

with an emergence of non-PCV-<br />

7 serotypes being more prevalent<br />

as the causative agents, with four<br />

different non-PCV- S pneumoniae<br />

7 serotypes isolated. Other studies<br />

have demonstrated predominance of<br />

non-PCV-7 serotype 19A, however<br />

non-PCV-7 serotypes 1, 3, 15, 22F,<br />

and 33F also been reported as the<br />

pathogens in children with PPE. 3-20<br />

Urine antigen testing was not<br />

performed in all children, but may<br />

be helpful in guiding therapy in the<br />

face of a suspected pneumococcal<br />

invasive infection. The Infectious<br />

Disease Society of America (IDSA)<br />

guidelines for evaluation of<br />

community–acquired pneumonia<br />

recommend use of the pneumococcal<br />

urine antigen test, as an adjunct to<br />

culture in the diagnosis of etiology<br />

of the infection. The sensitivity of<br />

the antigen test is 86-100%, and the<br />

specificity approaches 100%. 22-23<br />

Studies have looked at the utility of<br />

antigen testing and polymerase chain<br />

reaction (PCR) testing of pleural<br />

fluid, as ways to confirm the etiology<br />

of infection in bacterial pneumonia<br />

but not yet clinically available. 24-27<br />

As a retrospective review, there<br />

were likely children with PPE<br />

<strong>March</strong>/<strong>April</strong> 2011 | Vol. 107 17


Scientific Article |<br />

who may have been missed by our<br />

database search. In addition, the<br />

information collected was only as<br />

accurate as the electronic medical<br />

records contained. It was not within<br />

the scope of this study to review all<br />

medical records with a diagnosis<br />

of only pneumonia. The number of<br />

children with positive cultures was<br />

small (eight) with only five bacterial<br />

isolates serotyped, and this limits<br />

understanding the predominate<br />

S pneumoniae serotype of PPE in<br />

children in <strong>West</strong> <strong>Virginia</strong>. Reports<br />

of proven bacterial etiology of PPE<br />

in children include pneumococcus,<br />

Streptococcus (non-pneumococcal<br />

species), Staphylococcus, and other,<br />

unspecified, bacteria. The majority<br />

of children in our series with<br />

culture-negative PPE were not<br />

treated with anti- Staphylococcal<br />

antimicrobial agents, making MRSA<br />

an unlikely missed etiology. A<br />

minority of children in our series<br />

received antibiotic treatment before<br />

bacterial blood cultures were<br />

obtained which limited potential<br />

assistance in diagnosis; all the<br />

children with a positive, diagnostic<br />

blood and/ or pleural cultures<br />

received no oral antimicrobial<br />

agents prior to hospitalization<br />

when the cultures were obtained.<br />

Even after the approval of the<br />

conjugate PCV-7 vaccine (meant<br />

to prevent invasive disease in<br />

young infants and children),<br />

bacterial pneumonia, complicated<br />

by parapneumonic empyema, still<br />

remains a common infection in of<br />

the United <strong>State</strong>s. Invasive disease<br />

from the seven Prevnar ® serotypes<br />

of S. pneumoniae has been successful:<br />

reduction of disease in children<br />

has been reduced. In addition<br />

carriage of those seven serotypes is<br />

prevented, and invasive disease in<br />

adult caregivers of young children<br />

has been reduced as well. 28-29<br />

However serotype replacement<br />

is occurring, as evidenced by<br />

reports of pneumococcal lower<br />

respiratory disease. In <strong>West</strong> <strong>Virginia</strong>,<br />

from 2000-2007, 36 children with<br />

bacterial pneumonia, complicated<br />

by parapneumonic empyema,<br />

were treated at WVU- Children’s<br />

Hospital. In 2005, the highest annual<br />

number of cases were identified<br />

(16), compared to other years when<br />

the mean number was 2.9 cases<br />

(range 1-4). No explanation for this<br />

unusual year is evident. The majority<br />

of these children in 2005 (11 of<br />

16) were never vaccinated against<br />

Streptococcus pneumoniae because they<br />

were ineligible in 2000 when PVC-7<br />

was available (patients were beyond<br />

2-years of age and not in the high<br />

risk category at licensure). It seems<br />

unlikely that a change in regional<br />

pneumococcal vaccine coverage for<br />

that period in 2005 would explain<br />

the peak in cases; no problem with<br />

vaccine lots used in the regional or<br />

national area occurred around that<br />

time. If there was an emergence of a<br />

new Streptococcus pneumoniae or other<br />

Streptococcal (eg Streptococcus pyogenes)<br />

strain(s) in 2005, it was self-limited,<br />

given the precipitous drop for 2006<br />

and 2007 in number of cases of PPE.<br />

The increased number of cases in<br />

2005 may have just been a chance<br />

event, e.g. a statistical anomaly.<br />

It is well known that invasive acute<br />

lower respiratory bacterial disease<br />

commonly follows viral respiratory<br />

infections. In addition many bacterial<br />

and viral infections are known to<br />

occur in cyclical patterns over a 4<br />

to 5-year period, with some years<br />

appearing rather mild (low incidence)<br />

and other years more severe (higher<br />

incidence). Although few children<br />

Table 2: Number of Cases of Pneumonia, Empyema, and Bacterial Culture Results compared with Streptococcus<br />

pneumonia Antigen, January 1, 2000 to December 31, 2007.<br />

Results: Bacterial Culture & Streptococcus pneumonia Urine Antigen<br />

Year<br />

Pneumonia,<br />

unspecified<br />

Empyema Urine Antigen Positive Urine Antigen Negative No Urine Antigen Done<br />

Culture* + Culture - Culture* + Culture - Culture* + Culture -<br />

2000 62 3 0 0 0 0 1 2<br />

2001 86 1 0 1 0 0 0 0<br />

2002 100 4 0 1 0 1 1 1<br />

2003 122 4 1 2 0 0 0 1<br />

2004 117 2 0 1 0 0 0 1<br />

2005 113 16 3 5 0 6 1 1<br />

2006 56 3 0 3 0 0 0 0<br />

2007 97 3 1 1 0 0 0 1<br />

Totals 753 36 5 14 0 7 3 7<br />

* Bacteria isolated in blood/ pleural culture: Streptococcus pneumoniae; Dark shading: Proven S pneumoniae infection; Light shading: Presumptive<br />

etiology S pneumonia infection<br />

18 <strong>West</strong> <strong>Virginia</strong> <strong>Medical</strong> Journal


| Scientific Article<br />

in our series had concomitant viral<br />

testing performed, perhaps the<br />

winter season of 2005 was associated<br />

with a more virulent viral respiratory<br />

season, predisposing children to<br />

secondary bacterial infection. It<br />

is plausible that this season was<br />

coincident with an increased cyclical<br />

season of bacterial invasive disease<br />

as well; this chance phenomenon<br />

may explain our findings.<br />

Continued surveillance for the<br />

serotypes of S pneumonia is important<br />

in understanding the disease, with<br />

perhaps targets for expanded vaccine<br />

coverage. Appropriate treatment<br />

includes prompt recognition of<br />

infection in children, obtaining<br />

appropriate cultures, and the proper<br />

initiation of antimicrobial treatment.<br />

Urine antigen testing and PCR<br />

testing may be helpful guides in<br />

determining the etiology of bacterial<br />

pneumonia. S pneumoniae is still<br />

the apparent bacterial etiology in<br />

the majority of cases, as was our<br />

experience, although diligence for<br />

methicillin-resistant S aureus (MRSA)<br />

pneumonia must continue. In 2010<br />

a new pneumococcal conjugate<br />

vaccine (Prevnar-13 ® ) has been<br />

licensed to replace PCV-7, adding<br />

additional serotype protection<br />

against pneumococcal disease in<br />

children and the community.<br />

References<br />

1. Whitney CG, Farley MM, Hadler J, et al.<br />

Decline in invasive pneumococcal disease<br />

after the introduction of proteinpolysaccaride<br />

conjugate vaccine. N Engl J<br />

Med 2003;348:1737-46.<br />

2. Kaplan SL, Mason EO Jr., Wald, ER, et al.<br />

Decrease of invasive pneumococcal<br />

infections in children among 8 children’s<br />

hospitals in the United <strong>State</strong>s after the<br />

introduction of the 7-valent pneumococcal<br />

conjugate vaccine. Pediatrics 2004; 113(3<br />

Pt 1):443-9.<br />

3. Byington CL, Spencer LY, Johnson TA, et<br />

al. An Epidemiological Investigation of a<br />

Sustained High Rate of Pediatric<br />

Parapneumonic Empyema: Risk Factors<br />

and Microbiological <strong>Association</strong>s. Clin<br />

Infect Dis. 2002;34:434-440.<br />

4. Byington CL, Korgenski K, Daly J, et al.<br />

Impact of the Pneumococcal Conjugate<br />

Vaccine on Pneumococcal Parapneumonic<br />

Empyema. Pediatr Infect Dis J.<br />

2006;25(3):250-254.<br />

5. Hicks LA, Harrison LH, Flannery B et al.<br />

Incidence of pneumococcal conjugate<br />

vaccine (PCV-7) serotypes in the United<br />

<strong>State</strong>s during the era of widespread PCV-7<br />

vaccination, 1998-2004. J Infect Dis 2007;<br />

196:1346-54.<br />

6. Singleton R, Hennessy TW, Hammit LL, et<br />

al. Invasive pneumococcal disease caused<br />

by non-vaccine serotypes among Alaskan<br />

Native children with high levels of 7-valent<br />

pneumococcal conjugate vaccine<br />

coverage. JAMA 2007; 297: 1784-92.<br />

7. Byington CL, Samore MH, Stoddard GJ, et<br />

al. Temporal Trends of Invasive Disease<br />

Due to Streptococcus pneumoniae among<br />

Children in the Intermountain <strong>West</strong>:<br />

Emergence of Nonvaccine Serogroups.<br />

Clin Infect Dis. 2005;41(1):21-29.<br />

8. Obando I, Arroyo LA, Sanchez-Tatay D,<br />

Moreno D, Hausdorff WP, Brueggemann<br />

AB. Molecular typing of pneumococci<br />

causing parapneumonic empyema in<br />

Spanish children using multilocus sequence<br />

typing directly on pleural fluid samples.<br />

Pediatr Infect Dis J. 2006 Oct;25(10):962-3.<br />

9. Fletcher M, Leeming J, Cartwright K, Finn<br />

A; South <strong>West</strong> of England Invasive<br />

Community Acquired Infection Study<br />

Group. Childhood empyema: limited<br />

potential impact of 7-valent pneumococcal<br />

conjugate vaccine. Pediatr Infect Dis J.<br />

2006 Jun;25(6):559-60.<br />

10. Kyaw MH, Lynfield R, Schaffner W, et al.<br />

Effect of Introduction of the<br />

Pneumococccal Conjugate Vaccine on<br />

Drug-Resistant Streptococcus<br />

pneumoniae. N Engl J Med.<br />

2006;354(14):1455-1463.<br />

11. Tregnaghi M, Ceballos A, Rüttimann R, et<br />

al. Active Epidemiologic Surveillance of<br />

Pneumonia and Invasive Pneumococcal<br />

Disease in Ambulatory and Hospitalized<br />

Infants in Cordoba, Argentina. Pediatr<br />

Infect Dis J. 2006;25(4):370-372.<br />

12. Hsieh YC, Hsueh PR, Lu CY, et al. Clinical<br />

manifestations and molecular epidemiology<br />

of necrotizing pneumonia and empyema<br />

caused by Streptococcus pneumonia in<br />

children in Taiwan. Clin Infect Dis 2004;<br />

38(6):830-5.<br />

13. Munoz-Almagro, C, Jordan, I, Gene, A, et<br />

al. Emergence of invasive pneumococcal<br />

disease caused by nonvaccine serotypes<br />

in the era of 7-valent conjugate vaccine.<br />

Clin Infec Dis 2008;46:174-182.<br />

14. Bender JM, Ampofo K, Korgenski K, et al.<br />

Pneumococcal necrotizing pneumonia in<br />

Utah: does serotype matter Clin Infect Dis<br />

2008;46:1346-52.<br />

15. Hendrickson DJ, Blumberg DA, Joad JP,<br />

Jhawar S, McDonald RJ. Five-fold<br />

increase in pediatric parapneumonic<br />

empyema since introduction of<br />

pneumococcal conjugate vaccine. Pediatr<br />

Infect Dis J. 2008 Nov;27(11):1030-2.<br />

16. George E, Fong J, Narula P. A Cluster of<br />

Childhood Empyema Cases in Brooklyn.<br />

Pediatr Infect Dis J. 2008 Oct 27(10): 950-<br />

951.<br />

17. Moore MR, Gertz RE Jr, Woodbury RL,<br />

Barkocy-Gallagher GA, Schaffner W,<br />

Lexau C, Gershman K, Reingold A, Farley<br />

M, Harrison LH, Hadler JL, Bennett NM,<br />

Thomas AR, McGee L, Pilishvili T,<br />

Brueggemann AB, Whitney CG, Jorgensen<br />

JH, Beall B. Population snapshot of<br />

emergent Streptococcus pneumoniae<br />

serotype 19A in the United <strong>State</strong>s, 2005. J<br />

Infect Dis. 2008 Apr 1;197(7):1016-27.<br />

18. Park SY, Van Beneden CA, Pilishvili T et<br />

al. Invasive Pneumococcal infections<br />

among vaccinated children in the United<br />

<strong>State</strong>s. I Pediatr 2010; 156:478-83.<br />

19. Grijalia CG, Nuorti JP, ZHU Y, Griffin MR.<br />

Incidence of empyema complicating<br />

childhood community-acquired pneumonia<br />

in the United <strong>State</strong>s. Clin Infec Dis<br />

2010;50:805-813.<br />

20. Hsu KK, Shea KM, Stevensen AE, Pelton<br />

PI. Changing serotypes causing childhood<br />

invasive pneumococcal disease.<br />

Massachusetts, 2001-2007. Pediatr Infect<br />

Dis J2010 Apr; 29(4):289-293.<br />

21. Gonzalez BE, Hulten KG, Dishop, MK, et<br />

al. Pulmonary manifestations in children<br />

with invasive community-acquired<br />

Staphylococcus aureus infection. Clin Infec<br />

Dis 2005; 41:583-93.<br />

22. Domínguez J. Detection of Streptococcus<br />

pneumoniae antigen by a rapid<br />

immunochromatographic assay in urine<br />

samples. 2001 Jan;119(1):243-9.<br />

23. Use of the NOW Streptococcus<br />

pneumoniae urinary antigen test in<br />

cerebrospinal fluid for rapid diagnosis of<br />

pneumococcal meningitis. 2003<br />

Apr;45(4):237-40.<br />

24. Le Monnier A, Carbonnelle E, Zahar JR, Le<br />

Bourgeois M, Abachin E, Quesne G, Varon<br />

E, Descamps P, De Blic J, Scheinmann P,<br />

Berche P, Ferroni A Microbiological<br />

diagnosis of empyema in children:<br />

comparative evaluations by culture,<br />

polymerase chain reaction, and<br />

pneumococcal antigen detection in pleural<br />

fluids. Clin Infect Dis. 2006 Apr<br />

15;42(8):1135-40. Epub 2006 Mar 7.<br />

25. Menezes-Martins LF, Menezes-Martins JJ,<br />

Michaelson VS, et al. Diagnosis of<br />

parapneumonic pleural effusion by<br />

polymerase chain reaction in children. J<br />

Pediatr Surg 2005;40:1106-10.<br />

26. Hamano-Hasegawa K, Morozumi M,<br />

Nakayama E, Chiba N, Murayama SY,<br />

Takayanagi R, Iwata S, Sunakawa K,<br />

Ubukata K; Acute Respiratory Diseases<br />

Study Group. Comprehensive detection of<br />

causative pathogens using real-time PCR<br />

to diagnose pediatric community-acquired<br />

pneumonia. J Infect Chemother. 2008<br />

Dec;14(6):424-32.<br />

27. Smith MD, Sheppard CL, Hogan A,<br />

Harrison TG, Dance DA, Derrington P,<br />

George RC; South <strong>West</strong> Pneumococcus<br />

Study Group. Diagnosis of Streptococcus<br />

pneumoniae infections in adults with<br />

bacteremia and community-acquired<br />

pneumonia: clinical comparison of<br />

pneumococcal PCR and urinary antigen<br />

detection. J Clin Microbiol. 2009<br />

Apr;47(4):1046-9.<br />

28. Millar EV, Watt JP, Bronsdon MA, Dallas J,<br />

Reid R, Santosham M, O’Brien KL. Indirect<br />

effect of 7-valent pneumococcal conjugate<br />

vaccine on pneumococcal colonization<br />

among unvaccinated household members.<br />

Clin Infect Dis. 2008 Oct 15;47(8):989-96<br />

29. Azzari C, Resti M. Reduction of carriage<br />

and transmission of Streptococcus<br />

pneumoniae: the beneficial “side effect” of<br />

pneumococcal conjugate vaccine. Clin<br />

Infect Dis. 2008 Oct 15;47(8):997-9.<br />

<strong>March</strong>/<strong>April</strong> 2011 | Vol. 107 19


| Scientific Article<br />

<strong>Medical</strong> Management of Cerebellar Abscess: A Case<br />

Report and Review of the Literature<br />

Ryan C. Turner, B.S.<br />

Sean C. Dodson, B.S.<br />

Charles L. Rosen M.D., Ph.D.*<br />

Department of Neurosurgery, <strong>West</strong><br />

<strong>Virginia</strong> University, Morgantown<br />

Abstract<br />

A large abscess of the posterior fossa<br />

often warrants surgical intervention. We<br />

report a case of a 50 year-old male<br />

presenting with a cerebellar abscess<br />

measuring 2.8 cm x 1.6 cm located in the<br />

left cerebellar hemisphere at the level of<br />

the middle cerebellar peduncle that was<br />

treated conservatively and successfully<br />

with antibiotics. Therapeutic management<br />

options are discussed in regards to this<br />

case specifically as well as a review of the<br />

literature. This case illustrates the<br />

successful medical management of a<br />

cerebellar abscess of otogenic origin in an<br />

adult, a unique result in terms of abscess<br />

size and age of the patient.<br />

Introduction<br />

Despite reductions in morbidity<br />

and mortality as a consequence of<br />

antibiotic development, cerebellar<br />

abscess remains a significant<br />

medical problem particularly in<br />

the developing world. 6,7,9,12,15-17<br />

Incidence rates reported in the<br />

literature identify cerebellar abscess<br />

as afflicting those primarily in the<br />

second and third decade of life. 9,11<br />

Although cerebellar abscess has been<br />

documented in the literature for over<br />

one-hundred years, management<br />

techniques remain controversial.<br />

Recent studies have described<br />

treatment protocols that range<br />

from conservative management<br />

with only antibiotics 1,3,8,14,16,20 to<br />

the more common yet invasive<br />

surgical excision or drainage<br />

accompanied by antimicrobial<br />

treatment. 2,4,6,10,12,18,19 Determination<br />

of the most appropriate clinical<br />

approach remains largely subjective<br />

with some suggesting that size<br />

of the abscess, 14,16,20 age, 20 illness<br />

duration, 5 and neurological deficit 16,20<br />

at presentation are criteria to be used<br />

in determining the most suitable<br />

management technique for brain<br />

abscess. Notably, location must<br />

also be considered 14,16 as posterior<br />

fossa masses are more likely to<br />

require surgical intervention.<br />

Case Report<br />

The patient, a 50 year-old white<br />

male, was treated with an oral course<br />

of antibiotics for suspected chronic<br />

otitis media with little success. The<br />

patient failed to improve following<br />

the oral antibiotic regimen at which<br />

time the patient was diagnosed with<br />

a left-sided encapsulated cerebellar<br />

abscess and transferred to the medical<br />

service at <strong>West</strong> <strong>Virginia</strong> University<br />

for treatment. Following transfer<br />

to <strong>West</strong> <strong>Virginia</strong> University, the<br />

patient’s neurologic exam revealed<br />

gait abnormalities, finger to nose<br />

dysmetria, horizontal nystagmus,<br />

vertigo, tinnitus, positive Weber and<br />

Rinne test, and severe headache and<br />

earache. A CT scan demonstrated<br />

otomastoiditis and question of a left<br />

cerebellar abscess (Figure 1a,b). The<br />

patient was immediately started<br />

on a broad spectrum antibiotic<br />

regimen (i.v. vancomycin, i.v.<br />

ceftriaxone, and oral metronidazole).<br />

Following treatment for 24 hours<br />

with broad-spectrum antibiotics,<br />

Neurosurgery was consulted for<br />

possible surgical intervention. The<br />

size, location and appearance of the<br />

lesion were considered appropriate<br />

for surgical intervention (Figure 1c).<br />

However, the patient had improved<br />

substantially since antibiotic<br />

treatment had been initiated. Upon<br />

neurologic examination, it was noted<br />

the patient ambulated normally and<br />

there was complete resolution of<br />

finger to nose dysmetria, earache,<br />

and headache. Consequently,<br />

conservative management was<br />

continued with frequent clinical<br />

observation to reassess the need for<br />

surgical intervention. The patient’s<br />

neurologic status continued to<br />

improve and resolution of the abscess<br />

was verified with radiographic<br />

studies obtained two months<br />

post-presentation (Figure 1d). The<br />

patient is now 12 months status-post<br />

completion of antibiotic therapy. No<br />

recurrence of symptoms has occurred<br />

and previous deficits have resolved.<br />

Discussion<br />

Otogenic cerebellar abscesses,<br />

particularly in the second and<br />

third decade of life, are one of the<br />

most dangerous complications of<br />

chronic otitis media. 9,11 Although<br />

mortality rates have continued to<br />

decline with the advancement of<br />

modern imaging and antibiotic<br />

therapy, cerebellar abscesses still<br />

pose a serious threat and require<br />

immediate management. 6,7,9,12,15-17<br />

Currently the recommended<br />

treatment of such conditions is<br />

widely debated; however surgical<br />

intervention appears to be the<br />

preferred method of treatment.<br />

The non-surgical management<br />

technique has been documented as<br />

a viable approach in the literature,<br />

particularly in cases of small<br />

abscesses (less than 2.5-3 cm in<br />

diameter), 5,6,14,16,20 young patients, 20<br />

presentation without neurological<br />

deficits, 1,3,8,20 multiple abscesses, and<br />

abscesses in locations not amenable<br />

to surgical intervention. 1,5,14,20<br />

Other contraindications to surgery<br />

are meningitis or ventriculitis<br />

not requiring CSF diversion. 14<br />

<strong>March</strong>/<strong>April</strong> 2011 | Vol. 107 21


Scientific Article |<br />

Figure 1.<br />

a) CT scan illustrates opacification of the left mastoid air cells suggestive of<br />

otomastoiditis b) CT scan with contrast demonstrating large area of decreased density<br />

in the left cerebellar hemisphere c) Axial T1WI MRI with contrast showing a bilocular<br />

cerebellar abscess measuring 2.8 cm x 1.6 cm posterior to the left petrous bone after<br />

3 days of treatment d) Axial T1WI MRI with contrast, 2 months after initiation of<br />

broad-spectrum antibiotic regimen, demonstrating resolution of cerebellar abscess<br />

Rosenblum et al. proposed a<br />

treatment scheme for nonspecific<br />

brain abscesses in general based on<br />

neurological status upon presentation<br />

in which patients were identified as<br />

Grade I (alert), Grade II (lethargic),<br />

Grade III (responds to painful<br />

stimulus only) or Grade IV (no<br />

response to pain). In this treatment<br />

scheme, patients presenting in a<br />

Grade III or IV neurological state,<br />

as well as those presenting with<br />

clinical deficits consistent with the<br />

lesion, are operated on as soon as<br />

possible. For patients presenting<br />

as a stable or improving Grade I or<br />

II, a targeted antibiotic regimen is<br />

then administered. 14 Cavusoglu et al.<br />

proposed that medical management<br />

of brain abscess without surgical<br />

intervention may be successful in<br />

patients with illness duration of<br />

less than two weeks when four<br />

conditions are met. These include a<br />

known pathogen, no neurological<br />

deficits, abscess less than 3 cm<br />

in diameter, and no signs of<br />

increased intracranial pressure. 6<br />

A case report by Spinnato et al.<br />

described the successful nonoperative<br />

treatment of a 4 x 3 cm biloculated<br />

cerebellar abscess in a five year-old<br />

child. 20 This case diverged from<br />

the treatment recommendations by<br />

Cavusoglu et al. 6 in abscess size and<br />

presence of elevated intracranial<br />

pressure due to compression of the<br />

IV ventricle. This case represents the<br />

only known resolution of a cerebellar<br />

abscess greater than 3 cm in diameter<br />

following nonsurgical treatment.<br />

Of interest with regards to the<br />

presented case is that literature up<br />

until the case presented by Spinnato<br />

et al. did not address the issue of age<br />

in determining the most appropriate<br />

management strategy for brain<br />

abscess, and cerebellar abscess more<br />

specifically. Uniquely, Spinnato et al.<br />

suggest the importance of age and<br />

neurologic status in determining<br />

the treatment plan for cerebellar<br />

abscess as indicated by the successful<br />

nonsurgical treatment of a large,<br />

biloculated cerebellar abscess in a<br />

five year-old child. 20 The case we<br />

present diverges from the proposed<br />

guidelines for management by<br />

Spinnato et al. who stated that age,<br />

along with neurologic status, is the<br />

most important factor in determining<br />

treatment approach. 20 While it is<br />

clear that neurologic status must<br />

be considered 13 the authors posit<br />

that this case would have been<br />

managed surgically under most<br />

circumstances. In this unusual<br />

situation, the patient was treated with<br />

antibiotics prior to neurosurgical<br />

consultation. Upon consultation<br />

the patient still had significant<br />

neurologic symptoms and deficits,<br />

but was substantially improved.<br />

Furthermore his improvement in<br />

exam resulted in his refusal of more<br />

“definitive” care. Consequently, he<br />

was managed conservatively with<br />

imaging, antibiotics, and frequent<br />

exams. The pathogen was never<br />

determined specifically in this<br />

case yet was treated successfully<br />

through a broad-spectrum antibiotic<br />

regimen which counters the<br />

suggestion by Cavusoglu et al.<br />

stating that the pathogen must be<br />

known for antibiotic treatment.<br />

It is our belief that most<br />

neurosurgeons would immediately<br />

initiate surgical evacuation of an<br />

encapsulated posterior fossa abscess<br />

presenting with obvious neurologic<br />

deficits, but our case illustrates<br />

successful treatment with solely a<br />

22 <strong>West</strong> <strong>Virginia</strong> <strong>Medical</strong> Journal


| Scientific Article<br />

medical approach. We do not propose<br />

that nonsurgical management is the<br />

ideal approach to large cerebellar<br />

abscess. However, our experience<br />

with this one patient does suggest<br />

that patients with contraindications to<br />

surgery can potentially be managed<br />

successfully with antibiotic treatment,<br />

despite the radiographic appearance<br />

of an abscess. Though this concept<br />

of antibiotic treatment is pervasive<br />

in the pediatric/young adult<br />

literature, we are not familiar with an<br />

equivalent finding in a mature adult.<br />

References<br />

1. Barsoum AH, Lewis HC, Cannillo KL.<br />

Nonoperative Treatment of Multiple Brain<br />

Abscesses. Surg Neurol 1981; 16(4):283-7.<br />

2. Bento R, de Brito R, Ribas GC. Surgical<br />

management of intracranial complications<br />

of otogenic infection. Ear Nose Throat J<br />

2006; 85(1):36-9.<br />

3. Berg B, Franklin G, Cuneo R, et al.<br />

Nonsurgical Cure of Brain Abscess: Early<br />

Diagnosis and Follow-up with<br />

Computerized Tomography. Ann Neurol<br />

1978; 3(6):474-8.<br />

4. Brewer NS, MacCarty CS, Wellman WE.<br />

Brain Abscess: A Review of Recent<br />

Experience. Ann Intern Med 1975; 82:571-6.<br />

5. Britt RH, Enzman DR. Clinical stages of<br />

human brain abscess on serial CT scans<br />

after contrast infusion. J Neurosurg 1983;<br />

59:972-89.<br />

6. Cavusoglu H, Kaya RA, Turkemenoglu<br />

ON, et al. Brain abscess: analysis of<br />

results in a series of 51 patients with a<br />

combined surgical and medical approach<br />

during an 11-year period. J Neurosurg<br />

Focus 2008; 24(6):E9.<br />

7. Hedge AS, Venkataramana NK, Das BS.<br />

Brain abscess in children. Childs Nerv Syst<br />

1986; 2:90-2.<br />

8. Heineman HS, Braude AI, Osterholm JL.<br />

Intracranial Suppurative Disease. Early<br />

Presumptive Diagnosis and Successful<br />

Treatment Without Surgery. JAMA 1971;<br />

218(10):1542-7.<br />

9. Kangsanarak J, Fooanant S,<br />

Ruckphaopunt K, et al. Extracranial and<br />

intracranial complications of suppurative<br />

otitis media. Report of 102 cases. J<br />

Laryngol Otol 1993; 107:999-1004.<br />

10. Leskinen K, Jero J. Acute complications of<br />

otitis media in adults. Clin Otolaryngol<br />

2005; 30:511-6<br />

11. Manto, M.U. and Pandolfo, M (2002) The<br />

Cerebellum and its Disorders. Cambridge:<br />

UK Cambridge University Press, pp 237-47.<br />

12. Morgan H, Wood MW, Murphey F.<br />

Experience with 88 consecutive cases of<br />

brain abscess. J Neurosurg 1973; 38:698-<br />

704.<br />

13. Polyzoidis KS, Vranos G, Exarchakos G, et<br />

al. Subdural empyema and cerebellar<br />

abscess due to chronic otitis media. Int J<br />

Clin Pract 2004; 58(2):214-7.<br />

14. Rosenblum ML, Hoff JT, Norman D, et al.<br />

Nonoperative treatment of brain abscesses<br />

in selected high-risk patients. J Neurosurg<br />

1980; 52:217-25.<br />

15. Rosenblum ML, Hoff JT, Norman D, et al.<br />

Decreased mortality from brain abscesses<br />

since advent of computerized tomography.<br />

J Neurosurg 1978; 49(5):658-68.<br />

16. Rosenblum ML, Mampalam TJ, Pons VG.<br />

Controversies in the Management of Brain<br />

Abscesses. Clin Neurosurg 1986; 33:603-32.<br />

17. Samson DS and Clark K. A Current Review<br />

of Brain Abscess. Am J Med 1973; 54(2):<br />

201-10.<br />

18. Seven H, Coskun BU, Calis AB, et al.<br />

Intracranial abscesses associated with<br />

chronic suppurative otitis media. Eur Arch<br />

Otorhinolaryngol 2005; 262:847-51.<br />

19. Shaw MDM, Russell JA. Cerebellar<br />

abscess: A review of 47 cases. J Neurol<br />

Neurosurg Psychiatry 1975; 38:429-35.<br />

20. Spinnato S, Mazza C, Bricolo A.<br />

Nonoperative treatment of cerebellar<br />

abscesses. A case report and review of the<br />

literature. Childs Nerv Syst 1998; 14:606-09.<br />

Book Review<br />

Atlas of Otoscopy<br />

Dr. Joseph B. Touma and his<br />

son (and practice partner) Dr. B.<br />

Joseph Touma of Huntington have<br />

written an excellent resource, Atlas<br />

of Otoscopy, Plural Publishing,<br />

Inc., San Diego: 2006. This atlas<br />

is a good reference for medical<br />

students, residents, and practicing<br />

physicians, (otolaryngologists<br />

and non-otolaryngologists<br />

alike.) Dr. Touma, the elder, has<br />

accumulated numerous photos of<br />

ear canal, tympanic membrane, and<br />

middle ear pathologies over the<br />

years. These have been augmented<br />

by Dr. Touma, the younger who<br />

has also provided photos from his<br />

years in practice as a neuro-otologist.<br />

Dr. B. Joseph Touma tells me that<br />

it was quite a chore for the predigital<br />

age photos to be converted<br />

to digital form with subsequent<br />

enhancement. The Drs. Touma<br />

have succeeded beautifully and<br />

are to be heartily congratulated.<br />

This atlas would be an excellent<br />

addition to the library of anyone<br />

called upon to diagnose ear disease.<br />

R. Austin Wallace, MD<br />

Otolaryngologist<br />

<strong>March</strong>/<strong>April</strong> 2011 | Vol. 107 23


Scientific Article |<br />

Primary Care Office Responses to a Stroke Scenario<br />

Brett Jarrell, MD<br />

<strong>West</strong> <strong>Virginia</strong> University<br />

Stephen M. Davis, MPA, MSW<br />

<strong>West</strong> <strong>Virginia</strong> University<br />

John Coyner, MD<br />

Marshall University<br />

Todd Crocco, MD<br />

<strong>West</strong> <strong>Virginia</strong> University<br />

Charles Whiteman, MD<br />

<strong>West</strong> <strong>Virginia</strong> University<br />

This study was conducted at <strong>West</strong><br />

<strong>Virginia</strong> University and presented at the<br />

2008 International Stroke Conference,<br />

February 20-21, 2008, New Orleans, LA<br />

Abstract<br />

Purpose: One previous study found<br />

that healthlines affiliated with academic<br />

neurology programs recommended nonemergent<br />

treatment for a hypothetical<br />

stroke scenario almost one quarter of the<br />

time, which could contribute to patients<br />

presenting too late for time dependent<br />

stroke therapies. We assessed the<br />

treatment advice given in a hypothetical<br />

stroke scenario by primary care physician<br />

offices across the United <strong>State</strong>s.<br />

Methods: We obtained a national<br />

listing of United <strong>State</strong>s primary care<br />

physician offices from Yellowpages.com,<br />

and selected a systematic random sample<br />

of numbers to call. The respondent<br />

answering the phone was presented with<br />

a standardized, scripted stroke patient<br />

scenario, and asked to choose one of four<br />

responses that could be provided (wait for<br />

symptom resolution, attempt to schedule<br />

an office appointment later in the day,<br />

schedule an office visit within two days,<br />

call 911 for ambulance transport to a<br />

hospital).<br />

Results: Forty-two respondents<br />

completed the survey (average age = 43<br />

years; 88% female), with 29% (95% CI<br />

17%-44%) recommending scheduling an<br />

appointment later in the day if symptoms<br />

do not resolve. The remaining<br />

respondents recommended calling 911.<br />

When presented with a heart attack<br />

scenario, 100% of respondents<br />

recommended calling 911.<br />

Conclusions: Almost one third of the<br />

primary care physician offices<br />

recommended scheduling an appointment<br />

later in the day for a hypothetical stroke<br />

case, despite always giving the correct<br />

answer of call 911 for a classic heart attack<br />

scenario. These results suggest that stroke<br />

education with specific emphasis on the<br />

need to call 911 may be needed for<br />

primary care physician office receptionists.<br />

Abbreviations<br />

ED Emergency Department<br />

BSN Bachelor of Nursing Science<br />

PCP Primary Care Physician<br />

LPN Licensed Practical Nurse<br />

Introduction<br />

Acute stroke is a time dependent<br />

emergency in which patients have<br />

historically presented to the hospital<br />

outside of the therapeutic window<br />

for effective intravenous thrombolytic<br />

therapy. Unfortunately, this trend<br />

persists to the present day with only<br />

20% of acute ischemic stroke patients<br />

arriving at the emergency department<br />

(ED) within 2.5 hours of symptom<br />

onset in a recently published study. 1<br />

Although there are multiple<br />

factors that contribute to delayed<br />

ED presentation, prior research has<br />

suggested that the initial treatment<br />

advice given to potential stroke<br />

patients (or their family and friends)<br />

by the healthcare system itself<br />

may be a contributing factor. In<br />

one study, almost one quarter of<br />

healthline operators affiliated with<br />

academic neurology programs in<br />

the United <strong>State</strong>s recommended<br />

calling a primary care doctor’s office,<br />

as opposed to 911, for immediate<br />

ambulance transport to an ED, for<br />

a hypothetical stroke scenario. 2<br />

The potential therapeutic benefit of<br />

calling 911 was demonstrated in a<br />

separate study, which found that<br />

the thrombolytic administration<br />

rate for ischemic stroke patients<br />

with known onset times would have<br />

risen from 4% to 29% if 911 had<br />

initially been called. 3 Therefore, the<br />

treatment advice given by other areas<br />

of the healthcare system becomes<br />

of interest. To our knowledge no<br />

previous study has examined the<br />

treatment advice for potential stroke<br />

given by persons answering the<br />

phone at a primary care physician<br />

(PCP) office. Therefore, our primary<br />

study objective was to estimate the<br />

proportion of persons answering<br />

the phone at PCP offices across the<br />

United <strong>State</strong>s who correctly (or<br />

incorrectly) advised the caller to<br />

contact 911 for a potential stroke.<br />

Methods<br />

Study Design<br />

This was a prospective, cross<br />

sectional telephone survey of<br />

randomly selected PCP offices located<br />

in the United <strong>State</strong>s. The Institutional<br />

Review Board for the Protection of<br />

Human Subjects granted exempt<br />

status to this study and waived the<br />

requirement for written informed<br />

consent from each participant.<br />

Study Population<br />

A national listing of the phone<br />

numbers of approximately 123,000<br />

United <strong>State</strong>s PCP offices from<br />

Yellowpages.com (Physicians &<br />

Surgeons, Family Medicine & General<br />

Practice category) was obtained.<br />

From a random starting point, we<br />

selected a systematic random sample<br />

of numbers for inclusion in the study.<br />

Study Protocol and Key<br />

Measurements<br />

Each PCP’s office was called, and<br />

the person answering the phone was<br />

asked to participate in the research<br />

study. No deception of respondents<br />

was employed. After agreeing to<br />

participate, the respondent was<br />

presented with a standardized,<br />

scripted stroke patient scenario, and<br />

asked to choose one of four responses<br />

that could be given to the caller.<br />

The respondent was then asked<br />

what advice they would provide<br />

to a classic heart attack scenario<br />

24 <strong>West</strong> <strong>Virginia</strong> <strong>Medical</strong> Journal


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Scientific Article |<br />

Figure 1<br />

Stroke Scenario<br />

“It is 10:00am and you receive this phone call regarding a patient well known to the clinic:<br />

Hello, my 65 year old husband has had left arm and leg weakness and is having trouble speaking.<br />

It has lasted roughly 25 minutes. He has not been sick recently and has not had any chest pain,<br />

fever, or shortness of breath. He seems OK otherwise.”<br />

“Which one of the following four choices would you recommend to the patient”<br />

a) Wait and see if symptoms get better<br />

b) Attempt to schedule later today if symptoms are not getting better<br />

c) Schedule tomorrow or next day if possible for visit<br />

d) Call 911 for ambulance transport to local hospital<br />

Heart Attack Scenario<br />

“What if this same patient complained of chest pain radiating to their left arm and was associated<br />

with shortness of breath and vomiting”<br />

“Which one of the following four choices would you recommend to the patient”<br />

Legend<br />

a) Wait and see if symptoms get better<br />

b) Attempt to schedule later today if symptoms are not getting better<br />

c) Schedule tomorrow or next day if possible for visit<br />

d) Call 911 for ambulance transport to local hospital<br />

Figure 1. Hypothetical Stroke and Heart Attack Scenarios Posed to Each Person who<br />

Answered the Phone at the Primary Care Physician Office<br />

(Figure 1). The respondent was also<br />

asked to name common stroke signs<br />

and symptoms, and asked if they<br />

had ever heard of the Cincinnati<br />

Prehospital Stroke Scale (CPSS). 4<br />

The CPSS consists of three clinical<br />

symptoms indicative of stroke: facial<br />

droop, arm drift, and slurred speech.<br />

The presence of any one of these<br />

items has a sensitivity of 66% and<br />

a specificity of 87% for identifying<br />

stroke. 4 The duration of the phone<br />

call, as well as any transfers from<br />

the initial call, were also recorded.<br />

Data Analysis<br />

The Sample Power 2.0 (SPSS,<br />

Inc., Chicago, Ill) software program<br />

was used to calculate a sample size<br />

based on our goal of recognizing a<br />

correct answer (call 911) proportion<br />

significantly different from 50% in the<br />

population. The constant of 50% was<br />

chosen because no previous work has<br />

been done regarding this question<br />

within the target population. This<br />

a priori power analysis indicated a<br />

sample size of 40 to provide over 90%<br />

power to detect a correct answer (call<br />

911) significantly different from 50%<br />

assuming a correct answer proportion<br />

in the population of approximately<br />

75% based on previous research. 2<br />

Data were entered into Microsoft<br />

Excel® (v. 2003, Microsoft Inc.,<br />

Redmond, WA) and imported into<br />

SPSS® (v. 13.0, SPSS Inc., Chicago,<br />

IL) for analysis. A 95% confidence<br />

interval was constructed around<br />

the point estimate of the proportion<br />

giving an answer other than call 911,<br />

since this was the key outcome of<br />

interest. Descriptive statistics were<br />

calculated for all other variables.<br />

Results<br />

Forty-two respondents completed<br />

the survey (average age = 43 years;<br />

88% female) out of a total of 119 calls<br />

(35% response rate). Slightly over half<br />

(55%) of respondents had no medical<br />

education or training, followed by<br />

17% with medical assistant training,<br />

14% with some level of nurse training<br />

(i.e. nursing assistant, LPN, BSN), 7%<br />

trained as physicians, 5% trained as<br />

emergency medical technicians, and<br />

one individual (2%) who reported<br />

attending nursing school. The caller<br />

was placed on hold during 64% of the<br />

calls for an average of 2.2 minutes,<br />

with the most common reason being<br />

a transfer to someone who could<br />

answer the questions. In one case the<br />

caller was placed on hold for over<br />

eight minutes. The total average<br />

duration of all calls was 4.2 minutes.<br />

Overall, 29% (95% CI 17%-44%)<br />

of respondents recommended<br />

scheduling an appointment later<br />

in the day if symptoms did not<br />

resolve. The remaining respondents<br />

recommended calling 911. When<br />

presented with the heart attack<br />

scenario, 100% of respondents<br />

recommended calling 911. All but<br />

two of the respondents could name<br />

at least one stroke sign or symptom,<br />

but only four had ever heard of the<br />

Cincinnati Prehospital Stroke Scale.<br />

Discussion<br />

Almost one-third of participants<br />

who answered the phone at a<br />

primary care physician office in the<br />

United <strong>State</strong>s directed the caller<br />

away from emergency treatment for<br />

a hypothetical classic stroke scenario,<br />

despite the fact that most could name<br />

at least one stroke sign or symptom.<br />

Patients or their families may first<br />

call their family doctor (instead of<br />

911) after the onset of acute stroke<br />

symptoms seeking treatment advice.<br />

One previous study found that only<br />

38% of hospitalized stroke cases<br />

26 <strong>West</strong> <strong>Virginia</strong> <strong>Medical</strong> Journal


| Scientific Article<br />

included a call to 911. The 911 call<br />

was most often (60%) placed by<br />

family members. 5 Every minute<br />

between the time the patient was<br />

last seen neurologically normal and<br />

arrival at the emergency department<br />

for treatment potentially increases<br />

both the amount of irreversible<br />

brain damage and the probability<br />

that the patient will be ineligible for<br />

various thrombolytic treatments due<br />

to treatment time window limits.<br />

Therefore, it is critically important<br />

that the individuals receiving the<br />

call not only recognize that the<br />

person may be having a stroke,<br />

but also advise the caller to seek<br />

immediate treatment by calling 911<br />

or a similar emergency number.<br />

More receptionists in the current<br />

study could name at least one sign<br />

or symptom of stroke in comparison<br />

to the healthline operators affiliated<br />

with academic neurology programs<br />

surveyed in a similar study 2 (95%<br />

versus 76%, respectively). However,<br />

despite the majority of participants<br />

in both studies being able to name<br />

one stroke sign or symptom, both<br />

groups gave incorrect treatment<br />

advice greater than 1 in 5 times (29%<br />

in the present study versus 22% in<br />

the Healthlines study). It is therefore<br />

possible that both the receptionists<br />

and hospital operators may not<br />

have made the crucial link between<br />

recognition of stroke signs and<br />

symptoms AND the need to call 911<br />

for immediate transport to a hospital.<br />

There are no definitive answers<br />

as to why this linkage problem may<br />

exist. However, one reason may be<br />

that many stroke onsets are often not<br />

accompanied by pain. 6 This fact could<br />

partially explain the observation<br />

that 100% of our participants<br />

recommended calling 911 for our<br />

heart attack scenario, which included<br />

mention of pain; whereas, our<br />

stroke scenario was not described as<br />

painful. Severe pain during stroke<br />

onset has also been associated with<br />

decreased presentation delay. 6<br />

The perceived severity of the<br />

stroke symptoms could also affect the<br />

advice given. 7,8 Previous research has<br />

shown that motor weakness 7,8 and<br />

speech disturbances 8 are associated<br />

with shorter delay. However, our<br />

stroke scenario included both of these<br />

symptoms. Perhaps it is difficult to<br />

fully assess the severity of stroke<br />

symptoms over the phone, because<br />

a person cannot directly visualize<br />

the potential stroke patient. This<br />

situation could explain, in part,<br />

the incorrect treatment advice<br />

given in our study. A caller’s<br />

tone of voice may also impact the<br />

perceived urgency of symptoms<br />

on the part of the contacted, but<br />

we did not test this variable.<br />

Limitations<br />

As with any study, there are<br />

limitations to our reported results.<br />

Specifically, these results are<br />

based on responses from only 42<br />

subjects, which contributes to some<br />

2011<br />

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<strong>March</strong>/<strong>April</strong> 2011 | Vol. 107 27


Scientific Article |<br />

imprecision in the study estimates<br />

(i.e. the proportion giving the<br />

incorrect answer in the population<br />

could be anywhere between 17%<br />

and 44%, or even outside of these<br />

interval limits). However, the goal<br />

of this exploratory study was to<br />

estimate a proportion different<br />

from the most conservative guess<br />

of 50% (essentially a coin flip)<br />

given that this proportion was<br />

previously unknown, and our power<br />

calculations were based on this goal.<br />

The relatively low response<br />

rate could have also introduced<br />

non-respondent bias, although<br />

this response rate is comparable<br />

to another recent random survey<br />

examining a similar topic. 8 The<br />

results may also not be applicable to<br />

countries outside of the United <strong>State</strong>s,<br />

and regional differences may exist.<br />

There may also have been some<br />

bias introduced by the fact that<br />

deception was not employed in the<br />

study design (i.e. callers were told<br />

that this call was part of a research<br />

project). However, the decision was<br />

made to not employ deception to<br />

yield results similar to the study<br />

by Jarrell et al. 2 in which healthline<br />

operators affiliated with academic<br />

neurology programs were also<br />

informed of the research nature<br />

of the call prior to participating.<br />

The fact that both studies still<br />

found an incorrect advice answer<br />

in approximately one fourth to<br />

one third of the calls is concerning<br />

given the vast amount of research<br />

confirming that stroke patients<br />

who access the emergency medical<br />

services system arrive at the ED<br />

faster, which contributes to less<br />

overall presentation delay. 8,9-14<br />

Conclusion<br />

Despite the majority of PCP office<br />

respondents being able to name one<br />

stroke sign or symptom, almost one<br />

third recommended scheduling an<br />

appointment later in the day for a<br />

hypothetical stroke case. In contrast,<br />

100% gave the correct answer of ‘call<br />

911’ to a classic heart attack scenario.<br />

Triaging potential stroke patients<br />

away from emergent care may<br />

result in stroke patient presentations<br />

outside of the therapeutic treatment<br />

windows. These results suggest<br />

that stroke education with specific<br />

emphasis on the need to call 911<br />

may be needed for PCP office<br />

receptionists. Further studies should<br />

also examine the advice given by<br />

other healthcare ‘entry points’, such<br />

as pharmacies and the internet.<br />

References<br />

1. Hills NK, Johnston SC. Why are eligible<br />

thrombolysis candidates left untreated<br />

Am J Prev Med. 2006 Dec;31(6 Suppl 2):<br />

S210-6. Epub 2006 Nov 7.<br />

2. Jarrell B, Tadros A, Whiteman C, Crocco T,<br />

Davis SM. National healthline responses to<br />

a stroke scenario: implications for early<br />

intervention. Stroke. 2007 Aug;38(8):2376-<br />

8. Epub 2007 Jul 5.<br />

3. California Acute Stroke Pilot Registry<br />

(CASPR) Investigators. Prioritizing<br />

interventions to improve rates of<br />

thrombolysis for ischemic stroke.<br />

Neurology. 2005 Feb 22;64(4):654-9.<br />

4. Kothari RU, Pancioli A, Liu T, Brott T,<br />

Broderick J. Cincinnati Prehospital Stroke<br />

Scale: reproducibility and validity. Ann<br />

Emerg Med. 1999 Apr;33(4):373-8.<br />

5. Wein TH, Staub L, Felberg R,<br />

Hickenbottom SL, Chan W, Grotta JC,<br />

Demchuk AM, Groff J, Bartholomew LK,<br />

Morgenstern LB. Activation of emergency<br />

medical services for acute stroke in a<br />

nonurban population: the T.L.L. Temple<br />

Foundation Stroke Project. Stroke. 2000<br />

Aug;31(8):1925-8.<br />

6. Moser DK, Kimble LP, Alberts MJ, et al.<br />

Reducing delay in seeking treatment by<br />

patients with acute coronary syndrome and<br />

stroke: a scientific statement from the<br />

American Heart <strong>Association</strong> Council on<br />

Cardiovascular Nursing and Stroke<br />

Council. Circulation 2006;114:168--82.<br />

7. Zerwic J, Hwang SY, Tucco L.<br />

Interpretation of symptoms and delay in<br />

seeking treatment by patients who have<br />

had a stroke: exploratory study. Heart<br />

Lung. 2007 Jan-Feb;36(1):25-34.<br />

8. Mandelzweig L, Goldbourt U, Boyko V,<br />

Tanne D. Perceptual, social, and<br />

behavioral factors associated with delays<br />

in seeking medical care in patients with<br />

symptoms of acute stroke. Stroke. 2006<br />

May;37(5):1248-53. Epub 2006 Mar 23.<br />

9. Jurkowski JM, Maniccia DM, Dennison BA,<br />

Samuels SJ, Spicer DA. Awareness of<br />

necessity to call 9-1-1 for stroke<br />

symptoms, upstate New York. Prev<br />

Chronic Dis. 2008 Apr;5(2):A41. Epub<br />

2008 Mar 15.<br />

10. Rossnagel K, Jungehülsing GJ, Nolte CH,<br />

Müller-Nordhorn J, Roll S, Wegscheider K,<br />

Villringer A, Willich SN. Out-of-hospital<br />

delays in patients with acute stroke. Ann<br />

Emerg Med. 2004 Nov;44(5):476-83.<br />

11. Kothari R, Jauch E, Broderick J, Brott T,<br />

Sauerbeck L, Khoury J, Liu T. Acute stroke:<br />

delays to presentation and emergency<br />

department evaluation. Ann Emerg Med.<br />

1999 Jan;33(1):3-8.<br />

12. Bohannon RW, Silverman IE, Ahlquist M.<br />

Time to emergency department arrival and<br />

its determinants in patients with acute<br />

ischemic stroke. Conn Med. 2003<br />

Mar;67(3):145-8.<br />

13. Morris DL, Rosamond W, Madden K,<br />

Schultz C, Hamilton S. Prehospital and<br />

emergency department delays after acute<br />

stroke: the Genentech Stroke Presentation<br />

Survey. Stroke. 2000 Nov;31(11):2585-90.<br />

14. Lacy CR, Suh DC, Bueno M, Kostis JB.<br />

Delay in presentation and evaluation for<br />

acute stroke: Stroke Time Registry for<br />

Outcomes Knowledge and Epidemiology<br />

(S.T.R.O.K.E.). Stroke. 2001 Jan;32(1):63-9.<br />

OFFICE MANAGERS ASSOCIATION<br />

OF HEALTHCARE PROVIDERS, INC.<br />

www.officemanagersassociation.com<br />

We invite you to join our organization which consists of members<br />

who manage the daily business of healthcare providers.<br />

Our objectives are to promote educational opportunities, professional knowledge<br />

and to provide channels of communication to office<br />

managers in all areas of healthcare. We currently have<br />

eleven chapters in <strong>West</strong> <strong>Virginia</strong>.<br />

OFFICE MANAGERS ASSOCIATION<br />

OF HEALTHCARE PROVIDERS, INC.<br />

www.officemanagersassociation.com<br />

We invite you to join our organization which consists of members<br />

who manage the daily business of healthcare providers.<br />

Our objectives are to promote educational opportunities, professional knowledge<br />

and to provide channels of communication to office<br />

managers in all areas of healthcare. We currently have<br />

eleven chapters in <strong>West</strong> <strong>Virginia</strong>.<br />

We invite you to join our organization which consists of members who manage the daily business of healthcare<br />

providers. Our objectives are to promote educational opportunities, professional knowledge<br />

Visit us on and our website for to more provide information or contact channels of communication to office managers in all areas of healthcare.<br />

Donna Zahn (President) at 740-283-4770 ext. 105 or<br />

Tammy Mitchell (Membership) at 304-324-2703. We currently have eleven chapters in <strong>West</strong> <strong>Virginia</strong>.<br />

Visit us on our website for more information or contact<br />

Donna Zahn (President) at 740-283-4770 ext. 105 or<br />

Tammy Mitchell (Membership) at 304-324-2703.<br />

28 <strong>West</strong> <strong>Virginia</strong> <strong>Medical</strong> Journal


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Scientific Article |<br />

Clinical Cardiac Electrophysiology in <strong>West</strong> <strong>Virginia</strong>: 2010<br />

Brett A. Faulknier, DO<br />

Associate Professor of Medicine<br />

WVU Physicians of Charleston<br />

Cardiology and Electrophysiology<br />

Christopher C. Trotter, MD<br />

Internal Medicine Resident<br />

WVU/CAMC Department of<br />

Internal Medicine<br />

Keron B. Navarengom, MD<br />

Internal Medicine Resident<br />

WVU/CAMC Department of<br />

Internal Medicine<br />

Introduction<br />

The last decade has seen an<br />

explosion in the diagnostic and<br />

therapeutic options available to the<br />

clinical cardiac electrophysiologist<br />

(EP) for the treatment of cardiac<br />

arrhythmias. Historically, in <strong>West</strong><br />

<strong>Virginia</strong>, access to an EP physician<br />

has been limited for specialized care<br />

in implantable device and arrhythmia<br />

management. This had led to the<br />

need for devices to be implanted<br />

by other implanters and a backlog<br />

to develop in individuals who may<br />

benefit from potentially curative<br />

catheter based ablation procedures. In<br />

2010 this issue of access is improving<br />

with the recruitment of additional<br />

EPs throughout <strong>West</strong> <strong>Virginia</strong>.<br />

Specialized care can be provided in<br />

the areas of atrial fibrillation (AF),<br />

supraventricular and ventricular<br />

arrhythmias (VA), genetic arrhythmia<br />

syndromes and implantable devices.<br />

We review each of these areas and<br />

provide information on up-todate<br />

techniques of diagnosis and<br />

management along with insight<br />

into advances that may open up a<br />

variety of novel clinical strategies.<br />

Atrial Fibrillation<br />

Atrial Fibrillation (AF) is the most<br />

common cardiac arrhythmia affecting<br />

more than 2.3 million people in the<br />

United <strong>State</strong>s. The incidence of AF<br />

is on the rise and the latest United<br />

<strong>State</strong>s census estimates this condition<br />

will affect more than 3 million<br />

people by 2020. The prevalence of AF<br />

increases after age 60: it is now seen<br />

in approximately 10% of individuals<br />

by age 80. 1 Residents of <strong>West</strong> <strong>Virginia</strong><br />

are a prime target for this condition<br />

as diabetes, obesity, heart failure,<br />

coronary and valvular heart disease;<br />

all predisposing conditions for AF,<br />

have a high incidence in our state.<br />

The question of rate control versus<br />

rhythm control has been extensively<br />

studied. Previous evaluations failed<br />

to show benefit from the rhythm<br />

control strategy. 2,3 The question was<br />

recently revisited in AF patients<br />

with heart failure (HF); these<br />

deserve special attention as they<br />

have worse outcomes than those<br />

in sinus rhythm. The multicenter,<br />

randomized un-blinded trial enrolled<br />

1,376 patients with AF and a left<br />

ventricular ejection fraction (EF)<br />

≤ 35% and a history of HF or an<br />

LVEF of ≤ 25%. 4 Rate control was<br />

achieved with beta-blockers with or<br />

without digitalis, and rhythm control<br />

was maintained by cardioversion,<br />

amiodarone, sotalol, or dofetilide.<br />

Patients were followed for 37 ± 19<br />

months for the primary endpoint of<br />

death from cardiovascular causes<br />

(25% in the rate control group vs.<br />

27% in the rhythm control group)<br />

and secondary end points of overall<br />

survival, risk of stroke, or worsening<br />

HF. Secondary end-point outcomes<br />

were also similar between the two<br />

treatment arms. This study once<br />

again failed to confirm benefits of a<br />

rhythm control strategy, and showed<br />

that patients treated with rate<br />

control measures have less need for<br />

hospitalization and for cardioversion.<br />

One important new drug in the<br />

treatment of AF made recently<br />

available in the management of<br />

AF is dronaderone. As its name<br />

suggests, this drug is a class III<br />

multi-channel blocker much like<br />

amiodarone; however, dronaderone<br />

does not contain iodine, and has a<br />

shorter half-life (approximately 24<br />

hours), reducing tissue accumulation.<br />

The efficacy of dronaderone in<br />

preventing recurrent AF has been<br />

well-documented in 2 randomized<br />

placebo controlled trials; however,<br />

these trials excluded patients with<br />

class III and IV HF. 5 The 2008<br />

ANDROMEDA study enrolled 627<br />

patients and tested dronaderone<br />

against placebo in patients with New<br />

York Heart <strong>Association</strong> (NYHA)<br />

class II-IV HF who were hospitalized<br />

with new or worsening HF (wall<br />

motion index ≤ 1.2, approximating<br />

an EF ≤ 35%). 6 Only 7 months after<br />

its inception this study was ended<br />

because of an increased number of<br />

deaths in the dronaderone treatment<br />

group. A total of 37 patients fulfilled<br />

the primary end point of death, 25<br />

in the dronaderone group, and 12<br />

in the placebo group. The risk of<br />

death associated with dronaderone<br />

was increased among patients with<br />

a lower wall-motion index, and 10<br />

of the 25 dronaderone-associated<br />

deaths had worsening HF when<br />

they died. Also, the number of<br />

patients with a hospitalization for<br />

an acute cardiovascular cause was<br />

higher in the dronaderone group<br />

(71 patients) than in the placebo<br />

group (50 patients) (p=0.02).<br />

The ATHENA trial, published<br />

February 2009, evaluated<br />

dronaderone versus placebo in<br />

patients with AF and additional<br />

risk factors on the primary outcome<br />

of first hospitalization due to<br />

cardiovascular events or death. 7<br />

Additional risk factors included<br />

age ≥ 75, arterial hypertension<br />

(on at least two antihypertensive<br />

drugs of different classes), diabetes<br />

mellitus, prior stroke, transient<br />

ischemic attack, EF≤ 40% and left<br />

atrial diameter ≥50 mm. Patients<br />

with NYHA functional class IV HF<br />

and those with decompensated HF<br />

within the previous 4 weeks were<br />

excluded. After a mean follow-up of<br />

21 ± 5 months, the primary outcome<br />

of first hospitalization or death<br />

occurred in 734 (32%) patients in the<br />

dronaderone group and 917 (39%) in<br />

the placebo group (p


| Scientific Article<br />

37% in the placebo group, p value<br />


Scientific Article |<br />

Table 1: Class I indications for ICD implantation in patients with structural heart disease. Adapted from ACC<br />

Guidelines, 2008. 12<br />

Class I ICD indications in patients with structural heart disease<br />

1) In survivors of cardiac arrest due to VF or hemodynamically unstable VT after excluding any completely reversible<br />

cause<br />

2) With structural heart disease and spontaneous sustained VT<br />

3) With syncope of undetermined origin with sustained VT or VF induced at EP study<br />

4) With LVEF < 35% who are at least 40-days post MI or 3-months post intervention (PCI or CABG) and who are<br />

NYHA CHF class II or III<br />

5) With nonischemic dilated cardiomyopathy and LVEF < 35% and who are NYHA CHF class II or III<br />

6) LVEF < 30 % who are at least 40-days post MI or 3-months post intervention (PCI or CABG) and who are NYHA<br />

CHF class I<br />

7) With non-sustained VT and prior MI, LVEF < 40%, and inducible VF or sustained VT at EP study<br />

Figure 1.<br />

3-dimensional electroanatomic map of left atrium with markers representing a typical<br />

lesion set encircling the left and right pulmonary veins along with radiofrequency ablation<br />

performed along the roof of the left atrium connecting the encircling lesion sets.<br />

(ICD) technology has changed<br />

the management of ventricular<br />

arrhythmias (VA). Both primary<br />

prevention (identifying and<br />

prophylactically treating individuals<br />

to prevent sudden cardiac death<br />

(SCD) before an episode of<br />

ventricular tachycardia (VT) or<br />

ventricular fibrillation (VF) occurs)<br />

and secondary prevention (treating<br />

individuals who have suffered and<br />

survived an episode of VT or VF)<br />

has become common place in the<br />

daily practice of cardiology and<br />

electrophysiology. As medical and<br />

device based treatment has improved,<br />

survival of patients with more severe<br />

heart disease and heart failure is<br />

likewise improving. Practitioners<br />

have to deal with VA almost on<br />

a daily basis. It is important to<br />

understand both the pathophysiology<br />

and the treatment options available<br />

to individuals with VA.<br />

Ninety percent of patients with VA<br />

have structural heart disease (SHD). 9<br />

This is mostly scar-related reentry<br />

occurring either at the border zone<br />

of a scar from myocardial infarction,<br />

or in areas of scar in nonischemic<br />

dilated cardiomyopathy, or around<br />

surgical scars. Reentry has either an<br />

isthmus bounded by two scars or a<br />

scar and a line of anatomic barrier<br />

or physiologic conduction block. 10 In<br />

general, most scar-based VT arises in<br />

the left ventricle (LV). VTs with right<br />

bundle branch block (RBBB) patterns<br />

always arise in the LV, and VTs with<br />

left bundle branch block patterns<br />

almost always arise in or adjacent<br />

to the LV septum. 11 The QRS axis is<br />

critical to identifying the exit site of<br />

the VT. A superior axis (negative in<br />

inferior leads) suggests an inferior<br />

wall exit site whereas an inferior axis<br />

(positive in inferior leads) suggests an<br />

anterior wall exit site. Scar-based VTs<br />

typically have QRS duration greater<br />

than 140 msec and the presence<br />

of a Q-wave is often suggestive<br />

of a scar-based mechanism.<br />

Patients who present with<br />

polymorphic VT or VF and ischemic<br />

symptoms should be evaluated for<br />

active myocardial ischemia. Patients<br />

with sustained monomorphic VT<br />

often have stable coronary artery<br />

disease (CAD) with previous<br />

myocardial infarction allowing for<br />

scar-based reentry. The American<br />

College of Cardiology has published<br />

32 <strong>West</strong> <strong>Virginia</strong> <strong>Medical</strong> Journal


| Scientific Article<br />

Figure 2.<br />

3-dimensional electroanatomic map of the left ventricle in a 33 year-old male with<br />

ischemic cardiomyopathy and LVEF 10-15% who had sustained VT at 120 bpm despite<br />

antiarrhythmic therapy. The red area is low voltage scar tissue along the inferoseptum.<br />

The purple and green areas represent more viable tissue. The red dots represent the<br />

radiofrequency ablation lesion set that was made along the scar border.<br />

extensive guidelines with respect to<br />

primary and secondary prevention<br />

of SCD in patients with structural<br />

heart disease. Table 1 summarizes<br />

the Class I indications for ICD<br />

implantation in patients with SHD. 12<br />

Catheter ablation of scar-based<br />

VT is recommended in patients<br />

who are otherwise at low risk for<br />

sudden cardiac death (SCD) and<br />

have sustained predominantly<br />

monomorphic VT that is drug<br />

resistant, who are drug intolerant,<br />

or who do not wish long-term drug<br />

therapy. It is also recommended as<br />

adjunctive therapy in patients with<br />

an ICD who are receiving multiple<br />

shocks as a result of sustained VT that<br />

is not manageable by reprogramming<br />

or changing drug therapy or who do<br />

not wish long-term drug therapy. 13<br />

The VTACH study group recently<br />

reported that VT ablation be<br />

considered early, in selected patients<br />

who are receiving an ICD for stable<br />

VT, in whom recurrences of a VT<br />

are likely. The 110 patients were<br />

randomized to (ICD) implantation<br />

alone or implantation with catheter<br />

ablation. For the primary endpoint<br />

of survival free from VT or VF, the<br />

hazard ratio was 0∙61 (95% CI 0∙37–<br />

0∙99, p=0∙045). Without ablation, VT<br />

recurred in 71% of patients at 2 years,<br />

and multiple recurrences, a median<br />

of three per year, were common.<br />

Catheter ablation extended the time<br />

to recurrent VT from a median of<br />

5∙9 months to 18∙6 months, and<br />

reduced the frequency of VT. Half of<br />

the patients who received ablation<br />

still had at least one recurrence of<br />

VT. 14 Ablation of VT is not without<br />

risk. Recent multicenter trials have<br />

shown the procedural mortality<br />

rate to be as high as 3%. Figure 2<br />

is a 3-dimensional electroanatomic<br />

map of the LV along with markers<br />

representing the radiofrequency<br />

ablation lesions made to treat a<br />

sustained LV tachycardia in a 33 yearold<br />

man who had, 3-months prior to<br />

ablation, undergone coronary artery<br />

bypass surgery for severe CAD and<br />

ischemic cardiomyopathy. Although<br />

he had had ICD implantation, he<br />

continued to have VT at 120 beats per<br />

minute that could not be controlled<br />

with antiarrhythmic medications.<br />

Ten percent of patients with<br />

VA have no apparent SHD and<br />

therefore are classified as idiopathic<br />

ventricular tachycardia (IVT). 15<br />

Classification of IVT is based on QRS<br />

morphology, ventricular site of origin<br />

and response to pharmacological<br />

agents. The management<br />

and prognosis of IVT differs<br />

considerably from VT due to SHD.<br />

Most cases of IVT belong to the<br />

class of outflow tract tachycardia.<br />

The outflow tract consists of the<br />

right ventricle (RV) region between<br />

the pulmonary and tricuspid<br />

valves (RVOT), the basal LV<br />

including the outflow tract under<br />

the aortic valve, the aortic cusps<br />

and the basal LV epicardium.<br />

Even though most VTs from the<br />

outflow tract are non-sustained,<br />

sustained VT can occasionally be<br />

precipitated by emotional stress<br />

or exercise. 16 RVOT VT is the most<br />

common form of outflow tract VT<br />

(75%). The ECG typically shows<br />

a RBBB block pattern with an<br />

inferior axis and a QRS transition<br />

in precordial leads V3 and V4. 17<br />

Outflow tract VT has a good<br />

prognosis in most patients. 18 There<br />

are few exceptions where cases<br />

of RVOT premature ventricular<br />

contractions (PVC) have progressed<br />

to VF or polymorphic VT. 19 Catheter<br />

<strong>March</strong>/<strong>April</strong> 2011 | Vol. 107 33


Scientific Article |<br />

Figure 3.<br />

ECG of a 52 year-old female with syncope and a family history of sudden cardiac death.<br />

The QT was measured at 480 msec with a QTc of 529 msec. Note the appearance of a<br />

prolonged ST segment. The patient underwent implantation of an ICD and was treated<br />

with beta-blocker therapy. Genetic testing subsequently revealed a LQT3 genotype with<br />

mutation of the sodium channel (SCN5A).<br />

ablation may be considered in<br />

cases where symptoms cannot be<br />

controlled with medical therapy<br />

typically using beta blockers and/<br />

or verapamil. 20 It is also important<br />

to differentiate RVOT VT from<br />

arrhythmogenic right ventricular<br />

cardiomyopathy (ARVC), which<br />

has a poorer prognosis, including<br />

the risk of SCD. The success rate for<br />

treating RVOT VT using catheter<br />

ablation reaches more than 80<br />

percent in some studies with a<br />

low risk of complications (1%). 20<br />

Idiopathic left ventricular<br />

tachycardia (ILVT), first described<br />

by Zipes and colleagues in 1979, is a<br />

form of VT that arises from the LV<br />

and is verapamil sensitive. 21 ILVT<br />

is described typically in patients<br />

between 15 and 40 years old and<br />

most episodes occur at rest. The<br />

typical symptoms are palpitations,<br />

fatigue and presyncope. The<br />

development of syncope or SCD is<br />

very rare. 22 The ECG is normal in<br />

almost all cases, and corresponding<br />

to the origin in the LV, ILVT shows a<br />

RBBB morphology with a relatively<br />

narrow QRS duration (


| Scientific Article<br />

Multiple types of LQTS have been<br />

identified with over 300 underlying<br />

gene mutations. LQTS subtypes<br />

1-3 are the 3 major genotypes with<br />

each type displaying characteristic<br />

T-wave repolarization pattern on<br />

ECG. Type 1 often displays a broad<br />

based T-wave and Type 2 a biphasic<br />

T-wave. Type 3 often has a prolonged<br />

ST segment. Each genotype displays<br />

unique associations: LQT1 genotype<br />

displays cardiac events associated<br />

with exercise; often swimming. LQT2<br />

genotype has arrhythmic events<br />

associated with exposure to sudden<br />

loud noises (i.e. alarm clocks).<br />

LQT3 genotype experience events<br />

during sleep or at rest. 27 <strong>Medical</strong><br />

therapy aimed at prophylaxis of<br />

cardiac events in LQTS has been<br />

well established; it is more effective<br />

in LQTS1 and LQTS2. 30 Despite<br />

the risk reduction with use of betablockers<br />

residual, cardiac events<br />

can still occur; in a recent study,<br />

in as many as 32% of patients with<br />

LQTS3 on beta-blockers. 31 With this<br />

in mind, ICD implantation is highly<br />

effective in high-risk patients and<br />

those who remain symptomatic<br />

while on medical therapy. 32<br />

Figure 3 shows the ECG of a 52<br />

year old woman who presented<br />

with syncope and a family history<br />

of SCD. Her QT interval was 480<br />

msec with a QTc of 520 msec. She<br />

was started on beta-blocker therapy<br />

and, given her significant history,<br />

underwent implantation of an<br />

ICD. Genetic testing subsequently<br />

revealed a LQT3 genotype with<br />

a mutation in the SCN5A gene.<br />

ARVC first described in 1982, is<br />

a genetically determined disorder<br />

of cardiac myocytes in which RV<br />

myocardium is replaced with<br />

fibro-fatty tissue. 33 In the early<br />

stages structural changes may be<br />

localized to the RV; later they may<br />

also involve the LV. 34 Three phases<br />

have been described; first, an early<br />

concealed phase followed by an<br />

overt electrical phase and then a final<br />

phase with diffuse disease involving<br />

both ventricles leading to HF. 35<br />

ARVC is a familial disease with<br />

an autosomal dominant inheritance<br />

pattern. Patients may present with<br />

symptoms such as palpitations, dizzy<br />

spells, and syncope. SCD is often<br />

the first manifestation. 36 ARVC has<br />

an estimated prevalence of 1/5000<br />

and usually comes to attention when<br />

a young patient with an otherwise<br />

normal heart, presents with VT or VF<br />

originating from the RV. The disease<br />

affects desmosomes that constitute<br />

the gap junctions between myocytes.<br />

In most cases ECG abnormalities<br />

precede histological changes<br />

and ventricular dysfunction. 37<br />

T‐wave inversions in leads V1‐V4<br />

in individuals above 14 years of<br />

age with an otherwise healthy<br />

heart should increase suspicion. 38<br />

The ECG, signal-averaged ECG,<br />

echocardiogram, RV angiogram, and<br />

MRI can be used very effectively<br />

in accurately diagnosing ARVC.<br />

Protocols for using such modalities<br />

are available at www.arvd.org.<br />

The differentiation between<br />

ARVC and RVOT VT is very<br />

The sensible choice<br />

for specialized care.<br />

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and throat care, Eye & Ear Clinic Physicians also offers<br />

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<strong>March</strong>/<strong>April</strong> 2011 | Vol. 107 35


Scientific Article |<br />

important because the prognosis<br />

of patients with RVOT VT is<br />

excellent whereas the risk of SCD<br />

is about 1% per year in ARVC with<br />

associated tachycardia. ARVC is a<br />

familial disorder; hence, screening<br />

for disease in family members is<br />

essential in ARVC but not in RVOT<br />

VT. Patients with ARVC should<br />

be discouraged from strenuous<br />

physical activities and organized<br />

athletic participation. Treatment<br />

most commonly uses beta blockers<br />

and sotalol while amiodarone may<br />

be used as an add-on therapy. 39<br />

Initial doses and subsequent dose<br />

changes should be closely monitored<br />

using the corrected QTC interval.<br />

ICD implantation confers optimal<br />

protection against SCD in ARVC.<br />

Brugada syndrome was first<br />

defined in 1992 and has since<br />

gained great interest as a prominent<br />

cause of SCD in the young and<br />

in those with structurally normal<br />

hearts. This syndrome is thought<br />

to be responsible for 4 – 12 % of<br />

cases of SCD and to be the cause of<br />

20% of cases of SCD in those with<br />

structurally normal hearts. The<br />

disease is inherited in an autosomal<br />

dominant fashion; however,<br />

sporadic cases have been reported.<br />

Its pathogenesis is largely attributed<br />

to a defective sodium channel;<br />

however, recent reports also link<br />

it to calcium channel mutations.<br />

Three unique ECG repolarization<br />

patterns have been associated with<br />

Brugada syndrome but only the<br />

type 1 pattern defines the diagnosis<br />

of the syndrome. The syndrome is<br />

diagnosed on the basis of a type 1 or<br />

coved- type ST-segment elevation<br />

in the right precordial leads plus<br />

one of the following conditions:<br />

documented VF or polymorphic VT,<br />

a family history of SCD at a young<br />

age (< 45 years) or a type 1 ECG<br />

in family members, unexplained<br />

syncope, nocturnal agonal<br />

respiration, or inducibility of VT /VF<br />

at electrophysiology study. 40,41 The<br />

mainstay of treatment of Brugada<br />

syndrome is ICD implantation.<br />

Quinidine is a medical treatment<br />

option, the effectiveness of which<br />

has been shown in several studies.<br />

However, its side effects limit its use.<br />

Hypertrophic cardiomyopathy<br />

(HCM), an autosomal dominant<br />

inherited syndrome, is a disease<br />

of the sarcomere and is the most<br />

common cause of SCD in individuals<br />

less than 35 years of age. HCM has a<br />

mortality rate of about 1% per year.<br />

Contrary to popular belief HCM is<br />

predominantly nonobstructive; 75%<br />

of patients do not have a sizeable<br />

resting outflow tract pressure<br />

gradient. The diagnosis is often<br />

suspected by an abnormal ECG<br />

(severe left ventricular hypertrophy)<br />

in 75% to 95% of patients or a<br />

heart murmur. 42 Sarcomere gene<br />

mutations are hypothesized to<br />

trigger hypertrophy and arrhythmias<br />

before there is evidence of significant<br />

morphological and histopathological<br />

changes. 43 ICD implantation remains<br />

the treatment of choice for HCM.<br />

Implantable Pacemakers and<br />

Defibrillators<br />

ICD therapy is effective in<br />

aborting SCD. However, there<br />

remains debate in the published<br />

clinical guidelines over the use of EF<br />

of 35% as the value requiring ICD<br />

implantation. 44,45 Two issues with<br />

respect to ICDs are the prognostic<br />

significance of ICD shocks (both<br />

appropriate and inappropriate) along<br />

with the avoiding inappropriate<br />

shocks. Daubert et al. reported that<br />

the all-cause mortality of patients<br />

in the MADIT II trial who received<br />

appropriate and inappropriate shocks<br />

(but not anti-tachycardia pacing<br />

[ATP]) was 4 times higher than for<br />

those without shock therapy. In<br />

particular, inappropriate shocks<br />

(occurring in 11.5% of patients)<br />

increased all-cause mortality 2-fold.<br />

AF (44%) and supraventricular<br />

tachycardia (36%) were the major<br />

triggers for inappropriate shocks. 46<br />

Inappropriate shocks need to be<br />

minimized by programming higher<br />

detection rates (especially in primary<br />

prevention patients), utilizing a<br />

longer detection-to-shock duration<br />

to potentially allow for termination<br />

of non-sustained VT or VF and the<br />

use of morphology discrimination.<br />

Using more aggressive ATP may<br />

also reduce shock therapy.<br />

Remote wireless monitoring of<br />

ICDs and pacemakers facilitates<br />

daily monitoring and helps to<br />

identify patients experiencing AF<br />

or supraventricular arrhythmias<br />

that may be putting them at higher<br />

risk of inappropriate shocks.<br />

Additional steps may be taken,<br />

including medical or ablation<br />

therapy. Since many patients<br />

with implantable devices in <strong>West</strong><br />

<strong>Virginia</strong> live far from Charleston,<br />

Huntington or Morgantown, remote<br />

monitoring is changing the way<br />

follow-up is conducted, and is<br />

becoming the standard-of-care.<br />

Cardiac resynchronization therapy<br />

(CRT) has become a standard method<br />

to treat advanced HF in patients<br />

with LVEF < 35%, class III or IV<br />

HF and QRS duration > 120 msec.<br />

Studies of CRT implantation in<br />

patients with a narrow QRS complex<br />

(< 120 msec), severe LV systolic<br />

dysfunction and class III or IV HF<br />

with and without other indicators<br />

of mechanical dyssynchrony (i.e.<br />

echo-based dyssynchrony) have not<br />

shown benefit. 47,48 Data from the<br />

recent MADIT-CRT and REVERSE<br />

trials however, have shown benefit<br />

from CRT in patients with reduced<br />

LV systolic dysfunction, QRS<br />

duration >120 msec and NYHA<br />

functional class I and II HF. 49,50 The<br />

future of cardiac resynchronization<br />

therapy appears to be earlier<br />

application to appropriate patients<br />

with less severe heart failure.<br />

For many years a small,<br />

dedicated group of providers has<br />

provided <strong>West</strong> <strong>Virginia</strong>ns with<br />

much needed electrophysiology<br />

services. With the growth of the<br />

electrophysiology community in<br />

<strong>West</strong> <strong>Virginia</strong> it will now be much<br />

easier for patients to receive the<br />

potentially life-saving procedures<br />

that they need and deserve.<br />

Please contact author Brett<br />

Faulknier, MD at bfaulknier@hsc.wvu.<br />

edu for a complete list of references.<br />

36 <strong>West</strong> <strong>Virginia</strong> <strong>Medical</strong> Journal


| Scientific Article<br />

Post-ablative Hypothyroidism<br />

Abid Yaqub, MD, FACP<br />

Associate Professor of Medicine, Joan C.<br />

Edwards School of Medicine, Marshall<br />

University, Huntington<br />

Muhammad I. Choudhry, MD<br />

Endocrinologist, Marquette General<br />

Hospital, MI<br />

Jennifer Wheaton, DO<br />

Endocrinologist, <strong>Virginia</strong> Beach, VA<br />

Todd Gress, MD, MPH<br />

Associate Professor, Joan C. Edwards<br />

School of Medicine, Marshall University,<br />

Huntington<br />

This study was presented at<br />

the 17th Annual Meeting of the<br />

American <strong>Association</strong> of Clinical<br />

Endocrinologists, Orlando Florida.<br />

Abstract<br />

Objective: To determine the incidence<br />

of hypothyroidism following radioactive<br />

iodine (RAI) treatment for hyperthyroidism<br />

and to study the relationship between<br />

pretreatment RAI uptake and treatment<br />

dose and the subsequent development of<br />

hypothyroidism.<br />

Methods: Retrospective chart review<br />

of patients treated with RAI for<br />

hyperthyroidism between 1995 and 2000.<br />

180 charts were reviewed; 41 met the<br />

inclusion criteria. Data were collected<br />

regarding the cause of hyperthyroidism,<br />

initial RAI uptake, initial dose of RAI,<br />

number of RAI treatments, and post<br />

treatment thyroid status.<br />

Results: Patients in toxic nodular<br />

goiter group had significantly lower 24-<br />

hour RAI-123 uptake as compared to<br />

those with Graves’ disease. However<br />

patients with Graves’ disease received<br />

significantly lower RAI dose in<br />

comparison to those with toxic nodular<br />

goiters. Cure rates following RAI<br />

administration were similar in both<br />

groups. 70% of patients with Graves’<br />

disease developed post-ablative<br />

hypothyroidism as compared to 42% in<br />

toxic nodular goiter group (p=0.086).<br />

There was no relationship between the<br />

dose of RAI or pretreatment RAI uptake<br />

and the likelihood of developing<br />

hypothyroidism.<br />

Conclusion: We found that, within<br />

our study population, post-ablative<br />

hypothyroidism tended to be more<br />

prevalent in patients with Graves’ disease<br />

as compared to those with toxic nodular<br />

goiter. However cure rates following RAI<br />

administration were similar in both<br />

groups. We also found that neither the<br />

magnitude of the administered RAI dose<br />

nor the pre-treatment RAI uptake<br />

predicted the development of subsequent<br />

hypothyroidism.<br />

Introduction<br />

Hyperthyroidism affects<br />

approximately 2% of women and<br />

0.2% of men and has considerable<br />

adverse effects on cardiovascular<br />

and skeletal health especially<br />

in older population. 1 Graves’<br />

disease and toxic nodular goiter<br />

are the commonest causes of<br />

hyperthyroidism. Radioactive<br />

iodine I-131 (RAI) is considered<br />

one of the first line therapies for<br />

treatment of hyperthyroidism. RAI<br />

has been proven to be clinically<br />

efficient, safe and cost-effective<br />

when compared to other treatments<br />

namely thyroid surgery and longterm<br />

use of anti-thyroid medications. 2<br />

Although RAI has been used to<br />

treat hyperthyroidism for more than<br />

six decades, controversy still exists<br />

regarding the most appropriate<br />

dosing regimen. There is conflicting<br />

evidence regarding the required<br />

dose of RAI as well as the incidence<br />

of hypothyroidism and persistent<br />

hyperthyroidism following RAI<br />

treatment of Graves’ disease and<br />

toxic nodular goiter. 3 The objective<br />

of this study was to determine<br />

the incidence of hypothyroidism<br />

following RAI treatment for Graves’<br />

disease and toxic nodular goiter<br />

in our endocrinology clinic and to<br />

study the relationship between pretreatment<br />

RAI thyroid uptake and<br />

treatment dose and the subsequent<br />

development of hypothyroidism.<br />

Materials and Methods<br />

Approval for the study was<br />

obtained through the institutional<br />

review board. Only those patients<br />

who were managed by our<br />

University endocrinologists were<br />

included. A completely documented<br />

follow-up for a minimum of 5<br />

years from the date of treatment<br />

was required for inclusion in the<br />

study. Any patient with incomplete<br />

documentation or incomplete followup<br />

was excluded from the study. One<br />

hundred eighty medical charts were<br />

reviewed; of these, only 41 met the<br />

criteria for inclusion. Each of the 41<br />

was seen by a Marshall University<br />

endocrinologist and treated with<br />

RAI ablation for hyperthyroidism<br />

during the 1995 to 2000 time period.<br />

Information was gathered on the<br />

cause of hyperthyroidism, initial<br />

RAI uptake, pre-treatment use of<br />

anti-thyroid medications, dose<br />

of RAI used for treatment, post<br />

treatment thyroid status, age of<br />

patient at treatment, and time to the<br />

development of hypothyroidism.<br />

Cure rate was defined as achievement<br />

of hypothyroid or euthyroid status<br />

for a minimum of 6 months without<br />

the use of anti-thyroid drugs. Cure<br />

rates among the treatment groups<br />

were compared using 2-tailed Fisherexact<br />

test whereas the proportion of<br />

patients developing hypothyroidism<br />

in each group was compared using<br />

the 2-tailed Chi-square test. Data<br />

are presented either as mean +/-<br />

standard deviation or as median with<br />

interquartile range. Wilcoxon Rank<br />

Sum was performed to determine if<br />

there was a statistically significant<br />

difference in the dose of RAI given<br />

or in the pretreatment RAI uptake<br />

between those patients who became<br />

hypothyroid and those who did not<br />

become hypothyroid. A p-value of<br />

< 0.05 was considered significant.<br />

Results<br />

Patient demographics are<br />

presented in Table No. 1. Data for<br />

patients with Graves’ disease and<br />

<strong>March</strong>/<strong>April</strong> 2011 | Vol. 107 37


Scientific Article |<br />

Table No. 1: Demographic characteristics of study patients<br />

Number of patients<br />

Mean age in years<br />

(+/- standard deviation)<br />

Male/Female<br />

All patients 41 49 (+/- 18.1) 9/32<br />

Graves’ disease 27 41 (+/- 12.8) 7/20<br />

Toxic nodular goiter 14 62 (+/- 15) 2/12<br />

Table No. 2: Data for patients with Graves’ disease<br />

All patients with<br />

Graves’ disease<br />

Hypothyroid after<br />

1st RAI treatment<br />

Persistent/Recurrent<br />

hyperthyroidisim<br />

Number of<br />

patients<br />

27<br />

Percentage of<br />

total<br />

19 70%<br />

6 22%<br />

Euthyroid 2 7%<br />

Median dose I-131<br />

(Interquartile range)<br />

10.4 mCi<br />

(9.9-15.7)<br />

10.5 mCi<br />

(9.6—16.3)<br />

12.5 mCi<br />

(10-17.1)<br />

9.2 mCi<br />

(8.5-9.9)<br />

Median pretreatment RAI uptake<br />

(IQR)<br />

52 %(36-77.8)<br />

50 %(37.9-65)<br />

61.9 %(37.3-74)<br />

70%(58-82)<br />

Table 3: Data for patients with toxic nodular goiter<br />

All patients with toxic<br />

nodular goiter<br />

Hypothyroid after 1 st<br />

treatment<br />

Persistent/Recurrent<br />

Hyperthyroidism<br />

Number of<br />

patients<br />

14<br />

Percentage of total<br />

5 36%<br />

2 14%<br />

Euthyroid 6 43%<br />

Transient<br />

hypothyroidism<br />

Median Dose I-131<br />

(IQR)<br />

28.8 mCi<br />

(26.1-30.0)<br />

29.0 mCi<br />

(29-30)<br />

25.7 mCi<br />

(21.3-30)<br />

28.5 mCi<br />

(26.1-29)<br />

Median pretreatment RAI uptake<br />

(IQR)<br />

23.5% (16-37)<br />

38.5% (33-49.7)<br />

51.8% (34.3-69.2)<br />

23.5%(14.6-25)<br />

1 7% 15 mCi 29.8%<br />

Table 4: Time to hypothyroidism<br />

Median time to hypothyroidism (IQR)<br />

All patients 4 months (2-6)<br />

Graves’ disease 3 months (2-7)<br />

Toxic nodular goiter 6 months (4-6)<br />

toxic nodular goiter are presented in<br />

Tables No. 2 & 3 respectively. Time to<br />

hypothyroidism is displayed in Table<br />

No. 4. For the purpose of further<br />

analysis, patients with solitary toxic<br />

adenoma and toxic multinodular<br />

goiter were combined into a toxic<br />

nodular goiter group. Patients in<br />

this group had significantly lower<br />

(p


| Scientific Article<br />

Graves’ disease and those with<br />

toxic nodular goiter. Likewise,<br />

there was no correlation between<br />

the magnitude of RAI-131 dose and<br />

development of hypothyroidism in<br />

patients with Graves’ disease and<br />

those with toxic nodular goiter.<br />

Discussion<br />

Radioactive iodine I-131 is<br />

increasingly being used as the<br />

first line therapy for treatment of<br />

hyperthyroidism both in patients<br />

with Graves’ disease and toxic<br />

nodular goiter. The aim of treatment<br />

is to destroy sufficient thyroid<br />

tissue to cure hyperthyroidism<br />

by rendering the patients either<br />

euthyroid or hypothyroid. However,<br />

no consensus exists regarding<br />

the ideal first dose of RAI in the<br />

treatment of hyperthyroidism. 4<br />

Patients with toxic nodular goiter<br />

are perceived to be relatively resistant<br />

to RAI and there is debate whether<br />

such patients should be treated<br />

with higher doses of RAI than those<br />

with Graves’ disease. Contrary to<br />

previous studies showing lower<br />

cure rates in patients with toxic<br />

nodular goiter, Allahabadia et al.<br />

found almost identical cure rates<br />

in the two groups. 4 They suggested<br />

that approach to treatment with RAI<br />

should be the same for patients with<br />

Graves’ disease and toxic nodular<br />

goiter. They found that a single<br />

fixed dose of 10 millicurie (mci)<br />

is highly effective in curing toxic<br />

nodular hyperthyroidism as well<br />

as Graves’ hyperthyroidism. In our<br />

study patients with toxic nodular<br />

goiter received a significantly higher<br />

mean RAI dose than those with<br />

Graves’ disease. However, the cure<br />

rates were equal in the two study<br />

groups. Although the incidence of<br />

post-ablative hypothyroidism was<br />

greater in patients with Graves’<br />

disease as compared to those with<br />

toxic nodular goiters (70% vs 42%) ,<br />

the difference did not reach statistical<br />

significance (p=0.086). Several<br />

other investigators found a higher<br />

prevalence of hypothyroidism in<br />

Graves’ disease patients following<br />

RAI as compared to those with toxic<br />

nodular goiters. 1,4,5 It is believed that<br />

in patients with toxic nodular goiters,<br />

the radioiodine uptake is restricted<br />

primarily to the hyperfunctioning<br />

autonomous areas within the gland<br />

as opposed to uniform distribution<br />

of radioiodine uptake in Graves’<br />

disease, hence conferring a relative<br />

protection against hypothyroidism. 4<br />

In our study, we found that the<br />

overall incidence of hypothyroidism<br />

was 61% at 5 years after treatment<br />

with RAI. The incidence of postablative<br />

hypothyroidism was 70%<br />

among patients with Graves’ disease<br />

and 42% among patients with toxic<br />

nodular goiter. The incidence of<br />

post-ablative hypothyroidism was<br />

higher in our patients than in those<br />

reported by previous investigators. In<br />

a study by Metso et al., the reported<br />

incidence of hypothyroidism was<br />

24% (at 1 year), 59% (at 10 years) and<br />

82% (at 25 years) for patients with<br />

<strong>March</strong>/<strong>April</strong> 2011 | Vol. 107 39


Scientific Article |<br />

Graves’ disease and 4% (at 1 year),<br />

15% (at 10 years) and 32% (at 25<br />

years) for patients with toxic nodular<br />

goiters. 1 The higher incidence of<br />

post-ablative hypothyroidism in<br />

our study can be explained with<br />

relatively higher doses of RAI<br />

used in our patient population.<br />

A number of studies have<br />

attempted to establish the optimal<br />

dose of RAI for inducing cure of<br />

hyperthyroidism while avoiding the<br />

development of hypothyroidism.<br />

These strategies include varying fixed<br />

doses as well as doses calculated<br />

on thyroid size and radioiodine<br />

uptake. Most of these studies found<br />

no advantage in using the dose<br />

calculation methods for achieving<br />

improvements in cure rates or<br />

preventing hypothyroidism. 6,7 In our<br />

study the dosimetric methods, based<br />

upon estimated thyroid weight,<br />

pre-treatment thyroid uptake and<br />

desired dose to be delivered to a<br />

unit thyroid tissue, were applied in<br />

32% of patients. In the remaining<br />

68% of patients the endocrinologists<br />

used empiric fixed doses based on<br />

anecdotal and subjective preferences.<br />

There is conflicting evidence<br />

regarding the influence of antithyroid<br />

drugs on the outcome of<br />

RAI treatment. Several studies<br />

have suggested relative radioresistance<br />

with increasing incidence<br />

of treatment failure in those patients<br />

treated with anti-thyroid drugs before<br />

RAI 8 while others showed no effect. 9<br />

It has been reported that the use of<br />

anti-thyroid drugs within 2 weeks of<br />

RAI administration was a significant<br />

predictor of treatment failure when a<br />

low fixed dose (5mci) was employed<br />

but did not have an adverse effect<br />

on the outcome when a higher fixed<br />

dose (10mci) was used. 4 In our study,<br />

anti-thyroid drugs were used in up to<br />

75% of patients before RAI. However,<br />

our study was not designed to study<br />

the effect of use of anti-thyroid drugs<br />

on the RAI treatment outcome.<br />

Most of our patients who became<br />

hypothyroid did so within the<br />

first year following RAI treatment.<br />

Some clinicians now prefer to<br />

give a large ablative dose aiming<br />

for early hypothyroidism, so that<br />

the need for long-term follow-up<br />

of thyroid function in euthyroid<br />

patients is obviated. 10 Such a<br />

strategy offers the advantage of<br />

minimizing the chances of patients<br />

getting lost to follow-up and hence<br />

decreases the probability of a late<br />

diagnosis and timely treatment.<br />

When we examined the effect of<br />

pre-treatment RAI thyroid uptake<br />

and the amount of RAI dose, we<br />

found no significant relationship<br />

between these variables and the<br />

development of hypothyroidism.<br />

These findings agreed with those<br />

of Metso et al., who studied 2,043<br />

hyperthyroid patients treated with<br />

RAI and found that neither the<br />

pre-treatment RAI uptake nor the<br />

magnitude of first or cumulative<br />

dose had any influence on the<br />

risk of hypothyroidism in patients<br />

with Graves’ disease. No effect of<br />

pre-treatment RAI uptake on risk<br />

of hypothyroidism was found in<br />

patients with toxic nodular goiters,<br />

but, an inverse relationship between<br />

the first and cumulative RAI dose<br />

and the risk of hypothyroidism was<br />

found, with patients developing<br />

hypothyroidism more easily with<br />

lower RAI dose as compared<br />

to higher doses. 1 However our<br />

finding of lack of effect of RAI<br />

dose on risk of hypothyroidism is<br />

contrary to the observation made<br />

by Allahabadia and colleagues who<br />

were able to demonstrate a significant<br />

direct relationship between the<br />

magnitude of first RAI dose and<br />

risk of hypothyroidism. While<br />

studying various factors predicting<br />

outcome after RAI in a cohort of 813<br />

hyperthyroid patients, findings were<br />

that the gender, goiters of medium<br />

and large size, and severity of<br />

hyperthyroidism were also significant<br />

independent prognostic factors for<br />

cure after a single dose of RAI. 4<br />

Limitations of our study included<br />

a small sample size and a relatively<br />

short follow up period as compared<br />

to some of the previously published<br />

studies. Our patients were almost<br />

exclusively Caucasian; hence the<br />

results might not be applicable to<br />

areas with more culturally diverse<br />

patient populations. All patients<br />

were referred to our endocrinology<br />

clinics by primary care providers<br />

and any possible inclusion<br />

bias could not be excluded.<br />

In conclusion, we found that<br />

within our study population, postablative<br />

hypothyroidism tended<br />

to be more prevalent in patients<br />

with Graves’ disease as compared<br />

to those with toxic nodular goiter<br />

(70% vs. 42% at 5 years, p=0.086).<br />

However cure rates following RAI<br />

administration were similar in both<br />

groups. We also found that neither<br />

the magnitude of the administered<br />

RAI dose nor the pre-treatment RAI<br />

uptake predicted the development<br />

of subsequent hypothyroidism.<br />

References<br />

1. Metso S, Jaatinen P, Huhtala H et al. Longterm<br />

follow-up study of radioiodine<br />

treatment of hyperthyroidism. 2004.<br />

Clinical Endocrinology. 61:641-648<br />

2. Wartofsky L. Radioiodine therapy for<br />

Graves’ disease: case selection and<br />

restrictions recommended to patients in<br />

North America. 1997. Thyroid. 7:213-216<br />

3. Shapiro B. Optimization of radioiodine<br />

therapy of thyrotoxicosis: what have we<br />

learned after 50 years 1993. J Nuc Med.<br />

34:1638-1641<br />

4. Allahabadia A, Daykin J, Sheppard MC,<br />

Gough SC & Franklyn JA. Radioiodine<br />

treatment of hyperthyroidism-prognostic<br />

factors for outcome. 2001. J Clin<br />

Endocrinol Metab. 86:3611-3617<br />

5. Holm Le, Lundell G, Israelsson A, &<br />

Dahlqvist I. Incidence of hypothyroidism<br />

occurring long after iodine-131 therapy of<br />

hyperthyroidism. 1982. J Nuc Med. 23:<br />

103-107<br />

6. Jarlov AE, Hegedus L, Kristensen LO,<br />

Nygaard B,& Hansen BM. Is calculation of<br />

the dose in radioiodine therapy of<br />

hyperthyroidism worthwhile 1995. Clin<br />

Endocrinol (Oxf). 43:325-329<br />

7. Peters H, Fischer C, Bogner U, Reiners C,<br />

Schleusener H. Radioiodine therapy of<br />

Graves’ hyperthyroidism: standard vs.<br />

calculated 131 iodine activity. Results from<br />

a prospective, randomized, multicentre<br />

study. 1995. Eur J Clin Invest. 25:186-193<br />

8. Sabri O, Zimny M, Schulz G, et al.<br />

Success rate of radioiodine therapy in<br />

Graves’ disease: the influence of<br />

thyrostatic medication. 1999. J Clin<br />

Endocrinol Metab. 84:1229-1233<br />

9. Sridama V, McCormick M, Kaplan EL,<br />

Fauchet R, DeGroot LJ. Long-term followup<br />

study of compensated low-dose 131I<br />

therapy for Graves’ disease. 1984. N Eng J<br />

Med. 311:426-432<br />

10. Erem C, Kandemir N, Hacihasanoglu A,<br />

etv al. Radioiodine treatment of<br />

hyperthyroidism: Prognostic factors<br />

affecting outcome. 2004. Endocrine.<br />

25(1):55-60<br />

40 <strong>West</strong> <strong>Virginia</strong> <strong>Medical</strong> Journal


General | NEWS<br />

WVU hosts nation’s first Gold Humanism Week,<br />

February 14-18<br />

In hopes to stimulate discussion<br />

about humanism in healthcare, the WVU<br />

Chapter of the Gold Humanism Honor<br />

Society hosted the nation’s first ever<br />

Gold Humanism Week, February 14-<br />

18, 2011. The event featured a lecture<br />

series with refreshments, the HeART<br />

of Gold art contest, Cans for Caritas<br />

food drive, and the launching of the<br />

Golden Student Star Program. Acting<br />

Gov. Earl Ray Tomblin officially signed<br />

a proclamation declaring February<br />

14-18 as Gold Humanism Week.<br />

Although the culture of healthcare<br />

is one centered on learning,<br />

researching and applying science,<br />

the true practice is an art form.<br />

“As the only Gold Humanism<br />

Honor Society in the state of <strong>West</strong><br />

<strong>Virginia</strong>, we have taken our charge<br />

to promote humanistic qualities<br />

in healthcare professionals quite<br />

seriously,” Norman D. Ferrari III,<br />

M.D., senior associate dean for student<br />

services at the WVU School of Medicine<br />

said. “By setting aside a week with<br />

multiple activities we also hope to<br />

promote a greater inter-professional<br />

dialogue with our colleagues in the<br />

other Health Sciences programs.<br />

The lecture series kicked off on Feb.<br />

14 when Jame Abraham, M.D., section<br />

chief of Hematology and Oncology<br />

at WVU, presented “Medicine: A<br />

Silent Art in the iPhone Age!”.<br />

Mark Wicclair, Ph.D., professor of<br />

philosophy at WVU and bioethicist<br />

at the University of Pittsburgh,<br />

presented “House, M.D. and<br />

Paternalism” on February 15.<br />

Josh Dower, M.D., assistant<br />

professor and palliative care<br />

physician at WVU, presented<br />

“Nurturing Humanism Through the<br />

Healing Arts of Palliative Care.”<br />

The final lecture and highlight of the<br />

series was held on February 18 in the<br />

Fukushima Auditorium. Arthur Ross<br />

III, M.D., dean of the WVU School of<br />

Medicine, hosted a panel discussion<br />

called “Humanism in Healthcare.”<br />

Panel members included Shelia Price,<br />

D.D.S., associate dean for admissions,<br />

recruitment and access at the WVU<br />

School of Dentistry; Clark Ridgway,<br />

R.Ph., assistant dean of student services<br />

at the WVU School of Pharmacy;<br />

Elisabeth “Betty” Shelton, Ph.D.,<br />

associate dean for undergraduate<br />

academic affairs at the WVU School<br />

of Nursing; and Dr. Ferrari.<br />

The inaugural HeART of Gold art<br />

contest was held to provide a means<br />

to express art in healthcare. The first<br />

place winner of the HeART of Gold<br />

Contest was James Kingsburgy, a first<br />

year medical student, who submitted<br />

a drawing titled “A Compassionate<br />

Touch.” The second place winner,<br />

Janice Ahn, a second year medical<br />

student, submitted a collage entitled,<br />

“What’s in a Heart Beat.”<br />

The Golden Student Star Program is<br />

designed to recognize Health Sciences<br />

students who go out of their way to<br />

help others. For his efforts to address<br />

campus violence, Paul Swickline, a<br />

medical laboratory science student, was<br />

named the January Golden Student<br />

Star, the first to receive this honor.<br />

Joanna Adkins, a fourth year medical<br />

student, received the February Golden<br />

Student Star for her service to the local<br />

homeless community. Each month,<br />

a selection committee will choose a<br />

Golden Student Star. That person<br />

will be recognized with a golden star<br />

lapel pin and an announcement on<br />

the School of Medicine’s website.<br />

A “Cans for Caritas” service drive<br />

was held for the entire week. Canned<br />

food and toiletry items were collected<br />

for the Caritas House, Morgantown,<br />

an AIDS service organization.<br />

“We are happy that the HSC family<br />

and the rest of WVU community<br />

joined us for this celebration of<br />

humanism in healthcare,” Allison<br />

Lastinger, vice president of the<br />

WVU chapter and member of the<br />

School of Medicine Class of 2011,<br />

said. “This continues to be a unique<br />

opportunity for us to join together<br />

and recognize a part of healthcare<br />

that is sometimes forgotten – the care<br />

of the patient as a human being.”<br />

The mission of the Gold Humanism<br />

Honor Society is “to promote humanism<br />

and professionalism throughout the<br />

continuum of physician education from<br />

the first day in medical school until<br />

retirement from medical practice.” The<br />

WVU Chapter of the Gold Humanism<br />

Honor Society was established in 2008.<br />

WVU’s Gold Humanism Week was<br />

made possible by a grant from the<br />

Arnold P. Gold Foundation and support<br />

from the WVU School of Medicine.<br />

For more information on Gold<br />

Humanism Week see www.hsc.<br />

wvu.edu/som/Students/GHHS/<br />

Gold-Humanism-Week/.<br />

Evan Jenkins, Gretchen Sprouse, Matt Akers, Cortney Ballengee, Allison Lastinger, Lisa Costello, Gov. Tomblin,<br />

Dean Hansbarger, Jennifer Armbruster, Elisabeth Bowles, Blake Daney, Devin Weber, and Amy Tolliver.<br />

42 <strong>West</strong> <strong>Virginia</strong> <strong>Medical</strong> Journal


| WESPAC Contributors<br />

2011 WESPAC Contributors<br />

The WVSMA would like to thank the following physicians, residents, medical students and Alliance<br />

members for their contributions to WESPAC. These contributions were received as of February 15, 2011:<br />

Chairman’s Club ($1000)<br />

M. Barry Louden Jr., MD<br />

Extra Miler ($500)<br />

Generoso D. Duremdes, MD<br />

Michael A. Kelly, MD<br />

Michael A. Stewart, MD<br />

Dollar-A-Day ($365)<br />

Edward F. Arnett, MD<br />

Ann Conjura, MD<br />

John D. Holloway, MD<br />

Michael A. Istfan, MD<br />

Sushil K. Mehrotra, MD<br />

John A. Wade, Jr., MD<br />

Campaigner Plus (> $100)<br />

Finbar G. Powderly, MD<br />

Richard M. Fulks, MD<br />

Campaigner ($100)<br />

James M. Carrier, MD<br />

James M. Carter, MD<br />

Stephen P. Cassis, MD<br />

Patsy P. Cipoletti, MD<br />

Ruperto D. Dumapit, Jr., MD<br />

Kenneth F. McNeil, MD<br />

Stephen K. Milroy, MD<br />

Brian D. Powderly, MD<br />

Ophas Vongxaiburana, MD<br />

Donor<br />

Pedro F. Lo, MD<br />

WESPAC is the <strong>West</strong> <strong>Virginia</strong> <strong>State</strong> <strong>Medical</strong> <strong>Association</strong>’s<br />

bipartisan political action committee. We<br />

work throughout the year with elected officials to<br />

make sure they understand the many facets of our<br />

healthcare system.<br />

WESPAC’s goal is to organize the physician community<br />

into a powerful voice for quality healthcare in<br />

the <strong>West</strong> <strong>Virginia</strong> Legislature. We seek to preserve<br />

the vital relationship between you and your patients<br />

by educating our legislators about issues<br />

important to our physicians.<br />

WESPAC contributions provide critical support for<br />

our endorsed candidates. Your contribution can<br />

make the difference between a pro-physician/patient<br />

candidate winning or losing.<br />

To make a contribution to WESPAC, please<br />

call (304) 925-0342, ext. 12<br />

| New Members<br />

Kanawha County <strong>Medical</strong> Society<br />

Kim Bush, MD<br />

Amanda Deskins, DO<br />

Lisa Downham, MD<br />

Andrea Hill ,MD<br />

John Lilly Jr., MD<br />

Monongalia County <strong>Medical</strong> Society<br />

Melinda Cooper, MD<br />

Steven Coutras, MD<br />

Tanya Fancy, MD<br />

Srinivasan Ganesan, MD<br />

Todd Harshbarger, MD<br />

Glen Jacob, MD<br />

Lisa Jacob, MD<br />

Pamela Murray, MD<br />

Songul Onder, MD<br />

Swati Pawa, MD<br />

Anthony Roda-Renzelli, MD<br />

Gregory Schaefer, DO<br />

Can Talug, MD<br />

Ohio County <strong>Medical</strong> Society<br />

Lori Archbold, MD<br />

Ronald Hargraves, MD<br />

Parkersburg Academy of Medicine<br />

Lisa Casalenuovo, DO<br />

David Stastny, DO<br />

Tygart Valley <strong>Medical</strong> Society<br />

Peter Wentzel, MD<br />

Please direct all membership<br />

inquiries to: Mona Thevenin,<br />

WVSMA Membership Director<br />

at 304.925.0342, ext. 16 or<br />

mona@wvsma.com.<br />

<strong>March</strong>/<strong>April</strong> 2011 | Vol. 107<br />

3


We need your hELp!<br />

The WVSMA is fighting to save the Med-Mal Caps <br />

On <strong>March</strong> 8, the <strong>West</strong> <strong>Virginia</strong> Supreme Court of Appeals will hear the case<br />

challenging our 2003 medical liability reform. The Trial Lawyers are trying to get<br />

the Med-Mal Caps tossed out.<br />

The Caps have been key to the 30% - 40% reduction in physician insurance rates<br />

in the last few years. If the Trial Lawyers win this one, we could be back where we<br />

were ten years ago…skyrocketing premium rates, doctors leaving the state and<br />

patients losing access to care.<br />

The WVSMA is fighting for you and your patients. We appreciate your<br />

membership investment which helps fund our efforts to raise awareness about<br />

the importance of keeping our reforms intact and the costs of our legal filings<br />

with the Supreme Court.<br />

We will continue our<br />

efforts to send a clear<br />

message to the Legislature<br />

and the <strong>State</strong> Supreme<br />

Court that <strong>West</strong> <strong>Virginia</strong><br />

physicians are unified in<br />

our support for keeping<br />

our Med‐Mal Caps.<br />

John H. Schmidt III, MD<br />

WVSMA President


| MPLA Suit Statistics<br />

Each month, the WVSMA tracks the number of MPLA suits filed in each county throughout <strong>West</strong> <strong>Virginia</strong>. Below is a chart summarizing the<br />

case filings from 2003 to June 2010. Please note the annual total for 2005 was significantly impacted by the large number of suits brought<br />

in Putnam County that year, most of which related to one physician. Year-end total filings 2003-2010 were 315, 130, 273, 154, 174, 178,<br />

205, and 170 respectively.<br />

COUNTY<br />

2003<br />

2004<br />

2005<br />

2006<br />

2007<br />

2008<br />

2009<br />

2010<br />

Barbour<br />

Berkeley<br />

Boone<br />

Braxton<br />

Brooke<br />

Cabell<br />

Calhoun<br />

Clay<br />

Doddridge<br />

Fayette<br />

Gilmer<br />

Grant<br />

Greenbrier<br />

Hampshire<br />

Hancock<br />

Hardy<br />

Harrison<br />

Jackson<br />

Jefferson<br />

Kanawha<br />

Lewis<br />

Lincoln<br />

Logan<br />

Marion<br />

Marshall<br />

Mason<br />

McDowell<br />

Mercer<br />

Mineral<br />

Mingo<br />

Monongalia<br />

Monroe<br />

Morgan<br />

Nicholas<br />

Ohio<br />

Pendelton<br />

Pleasants<br />

Pocahontas<br />

Preston<br />

Putnam<br />

Raleigh<br />

Randolph<br />

Ritchie<br />

Roane<br />

Summers<br />

Taylor<br />

Tucker<br />

Tyler<br />

Upshur<br />

Wayne<br />

Webster<br />

Wetzel<br />

Wirt<br />

Wood<br />

Wyoming<br />

TOTALS<br />

(BY INDIVIDUAL YEAR)<br />

1<br />

9<br />

1<br />

0<br />

7<br />

28<br />

0<br />

0<br />

0<br />

5<br />

0<br />

2<br />

7<br />

1<br />

1<br />

1<br />

14<br />

1<br />

2<br />

66<br />

2<br />

0<br />

10<br />

2<br />

6<br />

2<br />

3<br />

17<br />

0<br />

4<br />

31<br />

0<br />

1<br />

4<br />

20<br />

0<br />

0<br />

0<br />

1<br />

20<br />

21<br />

3<br />

0<br />

0<br />

0<br />

1<br />

1<br />

1<br />

2<br />

1<br />

0<br />

2<br />

0<br />

14<br />

0<br />

315<br />

0<br />

2<br />

1<br />

1<br />

1<br />

15<br />

0<br />

0<br />

0<br />

0<br />

0<br />

0<br />

3<br />

1<br />

2<br />

1<br />

6<br />

1<br />

1<br />

20<br />

4<br />

0<br />

4<br />

0<br />

2<br />

1<br />

1<br />

9<br />

0<br />

2<br />

7<br />

0<br />

1<br />

1<br />

7<br />

0<br />

0<br />

0<br />

0<br />

10<br />

6<br />

3<br />

0<br />

0<br />

1<br />

3<br />

0<br />

0<br />

1<br />

0<br />

0<br />

1<br />

0<br />

11<br />

0<br />

130<br />

1<br />

4<br />

0<br />

1<br />

4<br />

7<br />

0<br />

0<br />

0<br />

1<br />

0<br />

0<br />

4<br />

1<br />

0<br />

0<br />

8<br />

1<br />

1<br />

37<br />

1<br />

0<br />

9<br />

2<br />

2<br />

3<br />

0<br />

4<br />

3<br />

5<br />

10<br />

1<br />

0<br />

2<br />

10<br />

0<br />

0<br />

1<br />

0<br />

126<br />

10<br />

4<br />

0<br />

1<br />

0<br />

0<br />

0<br />

0<br />

1<br />

0<br />

0<br />

2<br />

0<br />

6<br />

0<br />

273<br />

0<br />

3<br />

1<br />

1<br />

0<br />

14<br />

0<br />

0<br />

0<br />

5<br />

0<br />

1<br />

3<br />

0<br />

1<br />

0<br />

5<br />

3<br />

0<br />

47<br />

1<br />

1<br />

2<br />

1<br />

2<br />

1<br />

1<br />

8<br />

0<br />

3<br />

15<br />

0<br />

0<br />

1<br />

5<br />

0<br />

0<br />

0<br />

2<br />

4<br />

7<br />

2<br />

0<br />

0<br />

0<br />

2<br />

0<br />

0<br />

3<br />

0<br />

0<br />

1<br />

1<br />

5<br />

2<br />

154<br />

0<br />

3<br />

1<br />

0<br />

2<br />

14<br />

0<br />

0<br />

1<br />

3<br />

0<br />

1<br />

5<br />

1<br />

0<br />

0<br />

9<br />

4<br />

2<br />

46<br />

1<br />

0<br />

4<br />

0<br />

2<br />

2<br />

1<br />

9<br />

0<br />

3<br />

15<br />

1<br />

0<br />

2<br />

6<br />

0<br />

0<br />

0<br />

0<br />

5<br />

14<br />

5<br />

1<br />

1<br />

1<br />

0<br />

1<br />

0<br />

1<br />

0<br />

0<br />

0<br />

0<br />

6<br />

1<br />

174<br />

1<br />

2<br />

0<br />

0<br />

3<br />

13<br />

0<br />

0<br />

0<br />

2<br />

0<br />

1<br />

5<br />

0<br />

1<br />

0<br />

6<br />

1<br />

3<br />

49<br />

0<br />

0<br />

6<br />

4<br />

0<br />

5<br />

3<br />

8<br />

0<br />

2<br />

14<br />

0<br />

0<br />

1<br />

5<br />

0<br />

0<br />

0<br />

0<br />

7<br />

18<br />

3<br />

0<br />

1<br />

0<br />

1<br />

0<br />

0<br />

1<br />

0<br />

0<br />

1<br />

0<br />

11<br />

0<br />

178<br />

0<br />

2<br />

1<br />

0<br />

2<br />

27<br />

0<br />

0<br />

0<br />

5<br />

0<br />

0<br />

6<br />

0<br />

0<br />

0<br />

5<br />

4<br />

2<br />

53<br />

0<br />

0<br />

7<br />

4<br />

0<br />

3<br />

4<br />

15<br />

1<br />

4<br />

17<br />

0<br />

1<br />

5<br />

4<br />

0<br />

0<br />

0<br />

0<br />

6<br />

11<br />

4<br />

0<br />

0<br />

1<br />

0<br />

0<br />

0<br />

0<br />

0<br />

1<br />

1<br />

0<br />

8<br />

1<br />

205<br />

0<br />

2<br />

1<br />

1<br />

1<br />

17<br />

0<br />

0<br />

0<br />

0<br />

0<br />

0<br />

5<br />

0<br />

0<br />

0<br />

7<br />

1<br />

1<br />

56<br />

0<br />

0<br />

9<br />

2<br />

0<br />

2<br />

0<br />

5<br />

1<br />

3<br />

15<br />

0<br />

0<br />

0<br />

11<br />

0<br />

0<br />

0<br />

0<br />

5<br />

6<br />

4<br />

0<br />

0<br />

0<br />

0<br />

0<br />

0<br />

4<br />

0<br />

0<br />

1<br />

0<br />

9<br />

0<br />

170<br />

<strong>March</strong>/<strong>April</strong> 2011 | Vol. 107 45


Mid-Winter Meetings 2011<br />

Photo Highlights<br />

Joseph Selby, MD and Generoso Duremdes, MD.<br />

The WVSMA chartered bus arrives at the Capitol with physicians ready to<br />

participate in White Coat Day!<br />

WVSMA member physicians discuss legislative issues with Senator Ron<br />

Stollings, MD.<br />

R. Austin Wallace, MD, Hoyt Burdick, MD, and Tom Valley, MD,<br />

prepare to meet with legislators.<br />

Physicians led by WVSMA President, John Schmidt III,<br />

MD, discuss legislative issues with Senator John Unger.<br />

Senator Ron Stollings, MD addresses<br />

members during a pre-White Coat<br />

Day legislative briefing.<br />

Brad Henry, MD and Senator Mike Hall, Senate<br />

Minority Leader.<br />

WVSMA physicians gather in the senate gallery during the<br />

legislative session.<br />

46 <strong>West</strong> <strong>Virginia</strong> <strong>Medical</strong> Journal


Mid-Winter Meetings 2011<br />

Photo Highlights<br />

Delegate Don Perdue speaks to<br />

White Coat Day participants.<br />

WVSMA physicians prepare to recite the pledge of allegiance as the<br />

legislative session commences.<br />

Joseph Selby, MD and Allison<br />

Lastinger, MS-IV pose at the<br />

entrance to the Senate chamber.<br />

Blanchette Rockefeller Neurosciences Institute hosted the Saturday<br />

luncheon featuring speaker Daniel Alkon, MD.<br />

Daniel Alkon, MD, Scientific Director,<br />

Blanchette Rockefeller Neurosciences<br />

Institute presents during the Saturday<br />

luncheon.<br />

Jane Cline, WV Insurance<br />

Commissioner outlines the<br />

implementation of health insurance<br />

exchanges.<br />

R. Austin Wallace, MD<br />

during the WVSMA House of<br />

Delegates opening session.<br />

The practice management conference included an excellent insurance payor panel. Participants learned of key regulatory and<br />

payment changes for 2011.<br />

The exhibit hall bustles<br />

with physicians interested<br />

in exhibitors’ products and<br />

services.<br />

Harold Miller,<br />

Executive<br />

Director, Center<br />

for Healthcare<br />

Quality and<br />

Payment<br />

Reform, gives<br />

a presentation<br />

on Accountable<br />

Care<br />

Organizations.<br />

<strong>March</strong>/<strong>April</strong> 2011 | Vol. 107 47


Legislative | NEWS<br />

2011 Legislative Briefs<br />

Protecting <strong>Medical</strong> Liability Reform Laws<br />

POSITION: The WVSMA strongly maintains the need<br />

to preserve the integrity of the <strong>Medical</strong> Professional<br />

Liability Act and to protect against any threats to erode<br />

the current statute.<br />

ISSUE: Ten years ago <strong>West</strong> <strong>Virginia</strong>’s healthcare system<br />

was spiraling into a severe crisis. The lack of affordable<br />

and/or available medical liability insurance forced many<br />

physicians to either restrict the services they offer, move<br />

their medical practice out of state or quit practicing<br />

altogether. The Legislature made great strides in passing<br />

new laws designed to stabilize the medical liability<br />

system and preserve patient access to care. It takes<br />

many years to fully realize the effects of such sweeping<br />

climate change. The trend has proven that the reforms<br />

have worked and the market is continuing to stabilize.<br />

Currently however, there is a case before the<br />

<strong>State</strong> Supreme Court which challenges the caps<br />

on noneconomic damages. Depending on the<br />

outcome of this case, <strong>West</strong> <strong>Virginia</strong> could be faced<br />

with another grave crisis within the next year.<br />

The <strong>West</strong> <strong>Virginia</strong> medical malpractice insurance<br />

market has come a long way. Reforms of this<br />

magnitude take years to be fully realized as we have<br />

seen from the positive track record over the past<br />

ten years. With the threat of the current challenge<br />

before the WV Supreme Court, now more than<br />

ever we need to be vigilant and stay the course.<br />

Regulation of the Rental Network PPO Market<br />

POSITION: The WVSMA supports legislative<br />

initiatives to increase the transparency and fairness of<br />

rental network PPO activity.<br />

ISSUE: In most states, physicians have little control over<br />

how their managed care contracts are marketed, leaving<br />

them vulnerable to illegitimate discounts in payments<br />

for their services. In recent years, the health insurance<br />

market has developed a secondary market in physician<br />

discounts that has negatively affected physician’s ability<br />

to manage their practices. The lack of regulatory oversight<br />

in the Preferred Provider Organization (PPO) industry has<br />

resulted in the proliferation of entities that are engaged in<br />

the lucrative business of developing healthcare provider<br />

panels and then leasing the panels and associated<br />

discounts to various entities. These entities are often called<br />

“rental network PPOs”. When the physician discount<br />

is shared without authorization from the physician, the<br />

arrangement is often referred to as a “silent PPO”.<br />

The WVSMA supports legislation to advance the<br />

National Conference of Insurance Legislators (NCOIL)<br />

Rental Network Contract Arrangements Model Act<br />

which aims to implement transparent practices.<br />

Regulation of the secondary rental network, including<br />

restricting the number of times a rental network discount<br />

can be sold, is necessary to ensure that this unfair<br />

proliferation of physician contract violations ends.<br />

Supporting <strong>State</strong> Healthcare Reform Initiatives<br />

POSITION: The WVSMA supports efforts to achieve<br />

healthcare reform in <strong>West</strong> <strong>Virginia</strong>.<br />

ISSUE: <strong>West</strong> <strong>Virginia</strong>, like the rest of the nation,<br />

is faced with the serious threat of rising costs<br />

in health insurance, decreasing availability of<br />

insurance and concerns with chronically ill patients<br />

and a progressively unhealthy population.<br />

Though the federal government is currently<br />

engaged in the development of health system<br />

reform there are a number of important initiatives<br />

that <strong>West</strong> <strong>Virginia</strong> should simultaneously pursue.<br />

The WVSMA recommends continued work in the<br />

following areas Patient-Centered <strong>Medical</strong> Home;<br />

Practitioner Credentialing; Wellness and Prevention;<br />

Health Information Technology; Medicaid Expansion;<br />

Insurance Exchanges, and Research and Education.<br />

The WVSMA believes the following principles should<br />

be integral to all reform initiatives that are considered.<br />

• Physician-Patient Relationship – Reform<br />

initiatives must preserve the sanctity of the<br />

physician-patient relationship which is at the<br />

core of the art and practice of medicine.<br />

• Leadership –Physicians must be allowed to provide<br />

leadership in planning and implementation<br />

of Accountable Care Organizations, Patient-<br />

Centered <strong>Medical</strong> Homes or other innovations<br />

in the healthcare delivery system, because of<br />

their unique core competencies in patient care,<br />

medical knowledge, practice-based learning and<br />

improvement, interpersonal and communication<br />

skills and systems-based practice.<br />

• Scope of Practice – Care delivery models that<br />

involve expansion of the scope of practice for<br />

non-physician practitioners must remain focused<br />

on patient safety and must not expand any<br />

48 <strong>West</strong> <strong>Virginia</strong> <strong>Medical</strong> Journal


Legislative | News Continued<br />

scope of practice beyond each practitioner’s core<br />

knowledge, training or experience commensurate<br />

with their respective professional category.<br />

• Funding – Reform initiatives and pilots must be<br />

accompanied by adequate funding so that physicians<br />

are not required to absorb the additional overhead and<br />

other expenses associated with innovations. Quality<br />

measures used to adjust physician reimbursement<br />

must be evidence-based and meaningful.<br />

• Evidence – New healthcare delivery models<br />

and other reforms to the healthcare system<br />

must be continually evaluated for their impact<br />

on patient outcomes based upon scholarly<br />

analysis and evolving medical evidence.<br />

Protecting Against a Healthcare Provider Tax<br />

POSITION: The WVSMA applauds the completion of<br />

the phase-out of the healthcare provider tax! We strongly<br />

encourage the Legislature to not entertain any institution<br />

of a similar tax in the future.<br />

ISSUE: The healthcare provider tax was imposed<br />

in 1993 as the Legislature’s solution to generate<br />

additional funding for Medicaid. It was considered<br />

an unfair burden by physicians and other healthcare<br />

providers and repeal of the law was fervently sought<br />

since its inception. In 2001 the Legislature passed a<br />

bill initiating the repeal of this tax on all individual<br />

practitioners through a ten-year phase out. As a result,<br />

on July 1, 2010 the tax on physicians and all other<br />

individual healthcare practitioners was eliminated.<br />

The WVSMA thanks the Legislature for<br />

their foresight in the passage of this phase-out<br />

and for their fortitude in continuing down the<br />

path of repeal. We strongly recommend that no<br />

similar taxes be considered in the future.<br />

Modifying the Open Hospitals Proceedings Act<br />

POSITION: The WVSMA supports legislation<br />

clarifying medical staff committees are not governing<br />

bodies under the Open Hospitals Proceedings Act,<br />

the executive session topics enumerated in the Act are<br />

inadequate and at the least should be expanded, and that<br />

action on those topics should be permitted in executive<br />

session if the Act is to apply to any medical staff bodies.<br />

ISSUE: While hospitals must be accountable to the<br />

public, the nature of healthcare has evolved to where<br />

a hospital’s public mission may be adversely affected<br />

by certain aspects of open proceedings. Of greatest<br />

privacy concern to hospitals and physicians are issues of<br />

professional credentialing, peer review and discussions<br />

related to the sensitive and confidential nature of<br />

medical liability cases, among other areas related to<br />

the delivery of care, patient safety and operations.<br />

The <strong>West</strong> <strong>Virginia</strong> Supreme Court of Appeals<br />

in 2007 ruled that one hospital’s <strong>Medical</strong> Staff<br />

Executive Committee is a “governing body”<br />

for purposes of the Open Hospital Proceedings<br />

Act (OHP Act) and therefore its meetings must<br />

be conducted in compliance with the Act.<br />

The decision has a broad effect on all nonprofit<br />

and government-run hospitals throughout <strong>West</strong><br />

<strong>Virginia</strong>. Under this decision, arguably all groups<br />

“that make recommendations to a hospital on<br />

policy or administration” fall within the definition<br />

of a “governing body” for purposes of the Act.<br />

The WVSMA joins with the WV Hospital <strong>Association</strong><br />

in the position that no medical staff committees should<br />

be considered governing bodies under the OHP Act, that<br />

the executive session topics enumerated in the Act are<br />

inadequate and at the least should be expanded, and that<br />

action on those topics should be permitted in executive<br />

session if the Act is to apply to any medical staff bodies.<br />

Encouraging Routine Voluntary Screening for HIV<br />

POSITION: The WVSMA recommends the <strong>West</strong><br />

<strong>Virginia</strong> HIV testing laws be updated and modified<br />

to require simple consent for routine voluntary HIV<br />

testing.<br />

ISSUE: Human immunodeficiency virus (HIV) testing<br />

is entering a new era in this country as lawmakers,<br />

healthcare and insurance executives and public<br />

health officials are making changes in their respective<br />

fields to ensure that more people will know their<br />

HIV status. Knowing their status is an important<br />

consideration for maintaining health and reducing<br />

the spread of the virus. Of particular importance is<br />

the early detection of HIV infected pregnant women<br />

since treatments are available to greatly reduce the<br />

risk of transmission of the disease to the infant.<br />

In 2006, the CDC revised their recommendations<br />

for HIV testing of adults, adolescents and pregnant<br />

women in healthcare settings. The objectives of these<br />

recommendations are to increase HIV screening of<br />

patients, by urging routine voluntary screening of all<br />

persons in the healthcare setting; foster earlier detection<br />

of HIV infection; identify and counsel persons with<br />

unrecognized HIV infection and link them to clinical and<br />

prevention services; and further reduce transmission<br />

of HIV from pregnant women to their babies.<br />

<strong>March</strong>/<strong>April</strong> 2011 | Vol. 107 49


Legislative | NEWS<br />

The WVSMA recommends passage of legislation that<br />

will remove the current statutory barriers to routine<br />

screening for HIV. The essence of this important law<br />

change is to give priority to identifying <strong>West</strong> <strong>Virginia</strong>ns<br />

who are unaware of their HIV status and get them into<br />

care and treatment and prevention while sustaining<br />

the fundamental voluntary nature of HIV screening.<br />

Improving <strong>West</strong> <strong>Virginia</strong>’s Perinatal Health<br />

POSITION: The WVSMA supports initiatives to<br />

improve the health of pregnant women and children in<br />

<strong>West</strong> <strong>Virginia</strong>.<br />

ISSUE: The health of <strong>West</strong> <strong>Virginia</strong>’s babies has a<br />

tremendous impact on the state’s economy, workforce<br />

development and family well-being. Fourteen years<br />

ago, <strong>West</strong> <strong>Virginia</strong> birth statistics were much brighter<br />

than today. The <strong>State</strong>’s rates for pre-term birth, primary<br />

C‐sections, vaginal births after cesarean section (VBAC),<br />

and low birth weight infants were all more positive for<br />

healthy outcomes. While there are solutions to our child<br />

health problems, <strong>West</strong> <strong>Virginia</strong> has made little progress<br />

over the past decade in improving infant mortality.<br />

The number of low birth weight babies has increased<br />

and more babies are spending the first weeks of life in<br />

neonatal intensive care. If we want to improve the health<br />

and well-being of our children we must begin long<br />

before birth. Better health for our children will be the<br />

result of better health for pregnant women and infants.<br />

The WVSMA, along with the WV Perinatal Partnership,<br />

supports and recommends the following policies to further<br />

the efforts to improve perinatal wellness. By working<br />

together, we can make sure that the 21,000 babies born<br />

each year in <strong>West</strong> <strong>Virginia</strong> and their mothers have the<br />

best healthcare possible to assure a healthy beginning:<br />

• Establish a permanent home for the <strong>West</strong><br />

<strong>Virginia</strong> Perinatal Partnership within the Higher<br />

Education Policy Commission (HEPC), Office<br />

of the Vice Chancellor for Health Sciences<br />

and that funding in the amount of $250,000 be<br />

allocated for it’s work in the state budget;<br />

• Expand the <strong>West</strong> <strong>Virginia</strong> Maternal Mortality Review<br />

to include an Infant Mortality Review Process;<br />

• Expand state education to adequately prepare our<br />

young <strong>West</strong> <strong>Virginia</strong>ns for parenthood; and<br />

• Require health insurers to include coverage for<br />

dependents for contraception and for pregnancy.<br />

Strengthening Tobacco Control and Clean<br />

Indoor Air Initiatives<br />

POSITION: The WVSMA supports policies that<br />

protect public health by discouraging tobacco use<br />

and promoting clean indoor air. Such policies include<br />

significantly increasing the tobacco excise tax, allocating<br />

sufficient funding for education programs designed<br />

to reduce or eliminate tobacco use and exposure to<br />

secondhand smoke, and supporting counties’ indoor air<br />

regulations.<br />

ISSUE: The WVSMA seeks to reduce or eliminate<br />

tobacco use by <strong>West</strong> <strong>Virginia</strong> citizens, especially children,<br />

and to eliminate the exposure to secondhand tobacco<br />

smoke, which is the third leading cause of preventable<br />

death among nonsmokers. Among the states, <strong>West</strong><br />

<strong>Virginia</strong> ranks worst in the nation for smoking rates<br />

of adults and youth. We rank first in smoking among<br />

women during pregnancy and second overall in women<br />

smokers. Furthermore, <strong>West</strong> <strong>Virginia</strong> has the highest<br />

rate of smokeless tobacco use in the nation with one<br />

in three high school students currently using tobacco<br />

and one in five males using smokeless tobacco.<br />

The deleterious effects of tobacco use affect not only<br />

smokers but also the public at large. Scientific studies<br />

clearly show that secondhand cigarette smoke is a<br />

hazardous, cancer-causing air pollutant. Exposure to<br />

secondhand smoke causes increased risk for disease and<br />

death in healthy nonsmokers and is the third leading<br />

cause of preventable death among nonsmokers.<br />

The prevalence of tobacco use in <strong>West</strong> <strong>Virginia</strong><br />

translates to an enormous economic toll. The<br />

state spends over $1 billion a year on the direct<br />

healthcare costs of smoking, and another $1<br />

billion on occupational costs due to smoking.<br />

The WVSMA joins with the Coalition of a<br />

Tobacco Free WV in recommending a three tiered<br />

approach toward addressing tobacco use:<br />

•<br />

•<br />

Increase the Tobacco Excise Tax<br />

Provide Adequate <strong>State</strong> Funding for<br />

Cessation Education Programs<br />

Protect County Clean Indoor Air Policies.<br />

•<br />

Combating Poor Oral Health<br />

POSITION: The WVSMA supports efforts to make<br />

policy changes which foster improved oral health for<br />

<strong>West</strong> <strong>Virginia</strong>’s children and families.<br />

ISSUE: <strong>West</strong> <strong>Virginia</strong> is a leader nationwide in the<br />

percentage of our citizens with tooth loss and decay.<br />

By the time of high school graduation, over 80 percent<br />

of <strong>West</strong> <strong>Virginia</strong> youth have had dental decay; over 60<br />

percent have had dental decay by age 8 and over 30<br />

percent of <strong>West</strong> <strong>Virginia</strong> children suffer from untreated<br />

decay. Strikingly, over 45 percent of <strong>West</strong> <strong>Virginia</strong> adults,<br />

aged 65 and older, have lost all their natural teeth.<br />

50 <strong>West</strong> <strong>Virginia</strong> <strong>Medical</strong> Journal


Legislative | News Continued<br />

Dental disease is the single most prevalent chronic<br />

childhood disease and correlates directly to other<br />

health concerns. With today’s tools and technologies,<br />

oral disease is almost 100% preventable and is cost<br />

effective with the potential to save millions of dollars.<br />

Poor oral health can contribute to a lifetime of overall<br />

poor health including diabetes and heart disease.<br />

The WVSMA supports the following<br />

recommendations to address poor oral health:<br />

• Establish the Office of Oral Health within<br />

the Bureau for Public Health<br />

• Encourage school aged children to have<br />

dental exams at appropriate intervals.<br />

• Prohibit sale of sugary snacks and<br />

beverages in schools.<br />

• Address the use of smokeless tobacco among<br />

our youth through the implementation of a<br />

higher smokeless tobacco tax equaling the<br />

cigarette tax, the implementation of youth based,<br />

counter marketing and cessation programs.<br />

Ensuring Truth in Advertising for<br />

Healthcare Providers<br />

POSITION: The WVSMA supports legislation to ensure<br />

transparency regarding the education training and<br />

licensure of healthcare providers.<br />

ISSUE: Patients are confused about the differences<br />

between various types of healthcare providers.<br />

Often, patients mistakenly believe they are seeing<br />

medical doctors when they are not. The WVSMA<br />

believes that patients deserve to have increased<br />

clarity and transparency in healthcare.<br />

Confusion among patients about who is and who is<br />

not qualified to provide specific patient care undermines<br />

the reliability of the healthcare system and can put<br />

patients at risk. To help ensure patients can answer the<br />

simple question “who is a doctor” the WVSMA believes<br />

that all healthcare professionals – physicians and nonphysicians<br />

– should be required to accurately and clearly<br />

disclose their training and qualifications to patients.<br />

Asking medical professionals to display their<br />

credentials and their capabilities would allow the<br />

public to make informed choices about their healthcare.<br />

This includes full disclosure in all advertising and<br />

marketing materials. Legislation is needed to require<br />

healthcare providers to clearly and honestly state<br />

their level of training, licensing and what procedures<br />

they may legally perform in their advertising and<br />

marketing materials. Patients must be able to rely<br />

on what their healthcare providers tell them. Truth<br />

in advertising legislation helps to do just that.<br />

The WVSMA supports the passage of legislation<br />

to include the following components:<br />

• Require all healthcare professionals wear a<br />

name tag during all patient encounters that<br />

clearly identifies the type of license they hold<br />

• Require healthcare professionals to<br />

display their education, training and<br />

licensure in his or her office; and<br />

• Ensure any advertisements or professional<br />

web sites healthcare providers may have<br />

do not promote services beyond what they<br />

are legally permitted to provide.<br />

Protecting Patients from Non-physician Practitioner<br />

Scope of Practice Expansion<br />

POSITION: The WVSMA opposes the scope of practice<br />

expansion of non-physician practitioners without<br />

the appropriate education, training and supervision<br />

and recommends legislation requiring healthcare<br />

practitioners to clearly identify their credentials and<br />

training.<br />

ISSUE: Every year, in nearly every state, non-physician<br />

practitioners lobby for expansion of scope of practice<br />

to gain prescriptive and independent practice rights<br />

that were once the sole domain of physicians. The<br />

WVSMA recognizes the inevitability of scope of<br />

practice overlap. While some scope expansions are<br />

appropriate and beneficial to patients, many are<br />

unwarranted intrusions into the physician practice<br />

of medicine. The health and safety of patients are<br />

threatened when non-physician practitioners are<br />

permitted to perform services that are not commensurate<br />

with their education, training and experience.<br />

Some non-physician healthcare provider groups<br />

have become increasingly aggressive in efforts to<br />

expand their scope of practice to include treatments,<br />

procedures, and authority inconsistent with their<br />

education and training. These providers seek to expand<br />

their scopes of practice through legislative, regulatory,<br />

and administrative means. Debates over scope of<br />

practice issues have serious implications for patient care.<br />

If scope of practice expansions are inconsistent with<br />

the education and training a provider group receives,<br />

or are not coupled with safeguards, such as practice<br />

protocol arrangements with a physician who provides<br />

oversight of the care provided, the safety and quality<br />

of healthcare delivered to patients is compromised.<br />

<strong>March</strong>/<strong>April</strong> 2011 | Vol. 107<br />

1


Legislative | NEWS<br />

The WVSMA does support collaborative arrangements<br />

with nurse practitioners, physician assistants, pharmacists,<br />

and radiologist assistants. Through such collaboration,<br />

patient access and quality care can be achieved without<br />

threatening patient safety. However, protection of the<br />

patient is of the utmost importance. Expanding the<br />

scope of practice without adequate medical training and<br />

appropriate physician supervision is unacceptable.<br />

Additionally, the WVSMA recommends legislation<br />

to require all healthcare professionals properly<br />

identify themselves in all patient encounters and<br />

advertisements. This would help to ensure that patients<br />

are promptly and clearly informed of the training<br />

and qualifications of their healthcare practitioner.<br />

Strengthening and Preserving our Safety laws<br />

POSITION: The WVSMA strongly supports<br />

strengthening <strong>West</strong> <strong>Virginia</strong>’s All-Terrain Vehicle safety<br />

law and maintaining the motorcycle helmet law for<br />

operators and riders of all ages.<br />

ISSUE: Though the Legislature passed All-Terrain Vehicle<br />

(ATV) Child Safety law in 2004, much more needs to<br />

be done to protect the health and safety of our citizens.<br />

The <strong>West</strong> <strong>Virginia</strong> Legislature has taken a step toward<br />

ATV safety, but much more needs to be done to improve<br />

the state’s ATV safety laws. The WVSMA strongly<br />

supports legislation with the following components:<br />

• Removing non road-worthy vehicles<br />

from our public roadways.<br />

• Expanding the mandatory helmet law<br />

to cover persons of all ages.<br />

• Strengthening the requirement for ATV safety<br />

instruction to require hands-on safety courses.<br />

• Prohibiting passengers with the exception of machines<br />

which manufacturers have designed for passengers.<br />

Another important safety issue is that of preserving<br />

the motorcycle helmet law. In recent years, efforts have<br />

been made by various groups to repeal our critically<br />

important motorcycle helmet law. Such an action by the<br />

Legislature would be highly irresponsible. Helmets are<br />

the best evaluated way to reduce motorcycle accident<br />

deaths and injuries. The WVSMA strongly supports the<br />

retention of our <strong>State</strong>’s current mandated helmet use<br />

law for all motorcycle operators and riders of all ages.<br />

Addressing Substance Abuse: Balancing<br />

Treatment and Prevention<br />

POSITION: The WVSMA supports policies that<br />

discourage diversion of prescription drugs and that<br />

facilitate treatment opportunities for individuals<br />

suffering from substance use disorders. Such policies<br />

must be balanced with policies that promote the<br />

physicians’ ability to provide comprehensive and<br />

compassionate care, and an individual’s ability to access<br />

appropriate treatment.<br />

ISSUE: Substance use disorders are a significant problem<br />

in the United <strong>State</strong>s and in <strong>West</strong> <strong>Virginia</strong>. Substance use<br />

disorders and associated co-morbidities effects more of our<br />

citizens than any other healthcare concern we are faced<br />

with today. Experts estimate that prevalence of addiction<br />

in the general population is between 10 to 12 percent.<br />

The WVSMA recognizes the importance of policies that<br />

prevent substance abuse and prescription drug diversion<br />

through law enforcement mechanisms; however, we also<br />

recognize that physicians have a responsibility to provide<br />

appropriate treatment to patients, and policies should not<br />

interfere with their ability to practice good medicine.<br />

The WVSMA supports the following recommendations<br />

to begin to address prescription drug diversion<br />

and substance use disorders in <strong>West</strong> <strong>Virginia</strong>:<br />

• Appropriately fund and encourage development of<br />

treatment, education, prevention and intervention<br />

programs in the state. The Governor’s Comprehensive<br />

Strategic Plan to Address Substance Abuse in WV<br />

estimates an investment equal to 5 percent of the direct<br />

costs of substance abuse be allocated fund programs<br />

and projects, infrastructure, assessment research and<br />

evaluation. This equates to $23.5 million annually.<br />

• Encourage the use of the Board of Pharmacy’s<br />

Controlled Substances Database by prescribers<br />

and dispensers of medication and encourage<br />

better coordination among them to foster<br />

better care and treatment of patients through<br />

educational programs coordinated by the Boards<br />

of Pharmacy, Medicine and the WVSMA.<br />

• Add the drug Ultram (Tramadol) to the list<br />

of Schedule IV controlled substances.<br />

• Prohibit the sale of synthetic marijuana<br />

and cocaine products.<br />

• Encourage the expansion of education on<br />

prescription drug abuse and substance use<br />

disorders in the curriculum of the schools of<br />

medicine, nursing, pharmacy and dentistry.<br />

• Encourage the education on prescription drug<br />

abuse and substance use disorders into the<br />

already existing mainstream medicine, leading<br />

to further education of the patients they serve.<br />

52 <strong>West</strong> <strong>Virginia</strong> <strong>Medical</strong> Journal


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<strong>West</strong> <strong>Virginia</strong> University Health Sciences | NEWS<br />

WVU plans to establish new School of Public Health<br />

Graduates would help address health disparities in WV<br />

<strong>West</strong> <strong>Virginia</strong> University<br />

is planning to establish a new<br />

School of Public Health.<br />

“The time is right to take this<br />

step; we already have in place<br />

about 80 percent of the faculty<br />

and other requirements we would<br />

need for a nationally accredited<br />

school here,” Chancellor for<br />

Health Sciences Christopher<br />

Colenda, M.D., M.P.H., said<br />

Some public health programs<br />

already exist in the WVU School of<br />

Medicine, and enrollment has been<br />

increasing rapidly. The Master’s of<br />

Public Health (M.P.H.) program has<br />

doubled enrollment since 2008. WVU<br />

also offers a master’s degree in school<br />

health education and a Ph.D. program<br />

in public health sciences. Several<br />

community-based health programs<br />

developed at WVU are having<br />

national and international impact.<br />

Dr. Colenda said an independent<br />

fully accredited school would<br />

allow the programs to expand<br />

to attract the best faculty and<br />

students. He said it would increase<br />

research investment, which is key<br />

to developing effective solutions to<br />

the state’s persistent health issues.<br />

Creation of the WVU School of<br />

Public Health requires approval<br />

from the WVU Board of Governors<br />

and the <strong>West</strong> <strong>Virginia</strong> Higher<br />

Education Policy Committee.<br />

WVU Children’s Hospital changing the way it cares for its<br />

tiniest patients<br />

There’s a special section of<br />

the Neonatal Intensive Care Unit<br />

(NICU) at <strong>West</strong> <strong>Virginia</strong> University<br />

Children’s Hospital with the words<br />

“Wee Care” over the doorway; it’s<br />

called the Small Baby Pod. This is<br />

where the unit’s tiniest patients<br />

receive care and where a new<br />

approach to that care is taking place.<br />

Mark Polak, M.D., director of the<br />

NICU, said that a multidisciplinary<br />

team that included physicians, nurses,<br />

respiratory therapists, physical<br />

therapists and palliative care staff<br />

decided that patients would benefit<br />

from a unified approach for care built<br />

on evidence-based best practices.<br />

The Small Baby Pod houses<br />

babies born before the 26th week<br />

of pregnancy and those who weigh<br />

less than two pounds. Dr. Polak<br />

anticipates that there will always<br />

be four babies in the pod, which is<br />

as many as it can hold. They will be<br />

there for about one month and then<br />

move to another part of the NICU<br />

for the remainder of their stay.<br />

Another change involves<br />

recognizing and addressing the<br />

emotional needs of the parents.<br />

Parents of NICU babies, especially<br />

those in the Small Baby Pod, face a<br />

hospital stay of six months or longer.<br />

Palliative care staff can help the<br />

parents with the emotional upheaval<br />

of having a baby in the NICU.<br />

“What we’re doing now is as close<br />

to ideal as possible based on what has<br />

been published,” he said. “We can<br />

make a big difference on their time<br />

in the hospital and not only increase<br />

the quality of care we provide but<br />

also increase their quality of life.”<br />

For more information on<br />

WVU Children’s Hospital<br />

see www.wvukids.com.<br />

WVU eye surgery fellowship program one of first to be accredited<br />

<strong>West</strong> <strong>Virginia</strong> University’s<br />

Ophthalmic Plastic and Reconstructive<br />

Surgery Fellowship Program is one<br />

of the first of five programs in the<br />

country to receive accreditation from<br />

the Accreditation Council for Graduate<br />

<strong>Medical</strong> Education (ACGME).<br />

Ophthalmic plastic and<br />

reconstructive surgery, also called<br />

oculoplastics, includes the surgery of<br />

all the structures around the eye, such<br />

as the eyelids, the area behind the<br />

eye and orbital bone. It also includes<br />

the surgical treatment of Graves’<br />

disease and the removal of the eye<br />

as the result of trauma and tumors.<br />

One of the things that makes WVU’s<br />

program unique is that it involves a lot<br />

of multidisciplinary collaboration. “We<br />

work with several different specialties,<br />

including neurosurgery, plastic<br />

surgery and otolaryngology,” Jennifer<br />

Sivak, M.D., director of the WVU<br />

Ophthalmic Plastic and Reconstructive<br />

Surgery Fellowship Program, said.<br />

Norman D. Ferrari III, M.D., senior<br />

associate dean for student services<br />

and designated institutional official<br />

for graduate medical education at the<br />

WVU School of Medicine, said it is<br />

not only an honor to be one of the first<br />

to receive this accreditation, but it is<br />

also an honor to be considered among<br />

the leading institutions in the field.<br />

For more information see<br />

www.hsc.wvu.edu/som/eye/<br />

FellowshipOfferings.aspx.<br />

54 <strong>West</strong> <strong>Virginia</strong> <strong>Medical</strong> Journal


Marshall University Joan C. Edwards School of Medicine | Scientific | NEWS Article<br />

Cancer Center joins major cancer clinical trials network<br />

The Edwards<br />

Comprehensive<br />

Cancer Center has<br />

been accepted as<br />

a member of the<br />

North Central<br />

Cancer Treatment<br />

Group, a Mayo<br />

Clinic–based<br />

Dr. Tirona international<br />

cancer<br />

research network that offers<br />

access to hundreds of clinical<br />

trials for most types of cancer.<br />

Dr. Maria Tria Tirona, a professor<br />

of internal medicine at Marshall<br />

and principal investigator for the<br />

NCCTG at the cancer center, said<br />

she hopes the clinical trials that<br />

come through the membership will<br />

be offered in the future to patients<br />

throughout <strong>West</strong> <strong>Virginia</strong>.<br />

The NCCTG was founded in 1977<br />

on the premise that the community<br />

practice setting, where most cancer<br />

care occurs, is the most appropriate<br />

venue for conducting clinical trials.<br />

The Mayo Clinic Cancer Center<br />

serves as the research base for the<br />

network, which is part of the National<br />

Cancer Program and receives<br />

financial and scientific support from<br />

the National Cancer Institute. It<br />

includes more than 1,200 physicians<br />

and researchers at more than 375<br />

treatment locations in North America.<br />

The Edwards Comprehensive<br />

Cancer Center also is affiliated with<br />

the Children’s Oncology Group and<br />

the SunCoast CCOP Research Base<br />

(formerly Moffitt Research Base).<br />

Appalachian Health Summit to focus on obesity<br />

An Appalachian Health Summit<br />

in <strong>April</strong>, co-sponsored by six<br />

organizations including Marshall, will<br />

focus on obesity and seek strategies<br />

to address the problem, which is<br />

especially prevalent in Appalachia.<br />

The conference will be <strong>April</strong> 21<br />

at the Lexington, Ky., Convention<br />

Center. Its keynote speaker will be<br />

William Dietz, M.D., Ph.D., who<br />

is director of nutrition, physical<br />

activity and obesity at the Centers<br />

for Disease Control and Prevention.<br />

A plenary session will address<br />

health disparities and health<br />

behaviors in Appalachia, and<br />

concurrent sessions will focus on<br />

topics ranging from childhood obesity<br />

and obesity/cancer links to research<br />

networks and social networking.<br />

Richard Niles,<br />

Ph.D., Marshall’s<br />

senior associate<br />

dean for research<br />

and a co-chair<br />

of the summit,<br />

is organizing<br />

the obesity and<br />

cancer session.<br />

Dr. Niles Noting that the<br />

obesity problem<br />

is more prevalent in Appalachia than<br />

elsewhere, Niles said links between<br />

obesity and diseases such as diabetes<br />

and hypertension are well recognized,<br />

and that obesity is known to increase<br />

the risk for multiple types of cancer.<br />

“The summit is designed to<br />

learn about the obesity problem<br />

and its prevalence, and to map<br />

strategies to counteract it,” he said.<br />

In addition to Marshall, the<br />

event’s sponsors are the University<br />

of Kentucky, The Ohio <strong>State</strong><br />

University, the University of<br />

Cincinnati, Pikeville College and the<br />

Appalachian Regional Commission.<br />

Yingling to lead new School of Pharmacy<br />

Dr. Kevin W.<br />

Yingling has<br />

been named<br />

founding dean<br />

of the Marshall<br />

University School<br />

of Pharmacy.<br />

A pharmacist<br />

and physician,<br />

Dr. Yingling Yingling has<br />

more than<br />

20 years’ experience in graduate<br />

medical education. He is chairman<br />

of Marshall’s Department of<br />

Internal Medicine, and he has<br />

been a registered pharmacist<br />

since 1981, the medical director<br />

of the medical school’s Center for<br />

Pharmacologic Study since 1992 and<br />

a consultant pharmacist since 1995.<br />

Yingling received his B.S. in<br />

pharmacy from <strong>West</strong> <strong>Virginia</strong><br />

University and his M.D. from<br />

Marshall. He completed his residency<br />

and fellowship at the University<br />

of Cincinnati <strong>Medical</strong> Center.<br />

Marshall President Stephen J. Kopp,<br />

Ph.D., said the pharmacy school will<br />

help to reverse the significant shortage<br />

of pharmacists in <strong>West</strong> <strong>Virginia</strong>, which<br />

ranks among the top 10 percent of<br />

states in unmet pharmacist demand<br />

— a shortage that is likely to become<br />

greater as the state’s population ages<br />

and more pharmacists are needed<br />

as their practice role evolves in<br />

outpatient care centers, large specialty<br />

practices, nursing care facilities, and<br />

rural health clinics and care centers.<br />

<strong>March</strong>/<strong>April</strong> 2011 | Vol. 107 55


<strong>West</strong> <strong>Virginia</strong> School of Osteopathic Medicine | NEWS<br />

Adelman Signs Contract; Officially Sworn in as WVSOM President<br />

Michael D.<br />

Adelman, D.O.,<br />

D.P.M., J.D.,<br />

assumed the<br />

Presidency of the<br />

<strong>West</strong> <strong>Virginia</strong> School<br />

of Osteopathic<br />

Medicine during<br />

Dr. Adelman a contract signing<br />

ceremony at the<br />

institution’s Board of Governors<br />

meeting on January 22. The Higher<br />

Education Policy Commission<br />

unanimously approved the<br />

appointment January 21.<br />

Rodney Fink, D.O., Board Chair,<br />

stated HEPC members were most<br />

complimentary of Dr. Adelman’s<br />

contributions to WVSOM and<br />

wholeheartedly concurred with<br />

the Board of Governors selection.<br />

Dr. Adelman, the second<br />

osteopathic physician to serve as<br />

WVSOM’s president, affirmed his<br />

commitment to continue to embrace<br />

the institution’s legacy of excellence.<br />

He further commented that he and<br />

his wife, Cheryl, fell in love with<br />

WVSOM and Lewisburg when they<br />

settled in the area nine years ago.<br />

“This is our home and you are our<br />

family,” he stated. “I am incredibly<br />

grateful to the Board of Governors,<br />

faculty, staff, students and the<br />

community for giving Cheryl and me<br />

the opportunity to serve in this role.<br />

I look forward to working with all of<br />

you in moving WVSOM forward.”<br />

Board of Governors members were<br />

joined by a capacity crowd of faculty,<br />

staff and students, offering their<br />

congratulations and support to Dr.<br />

Adelman with a standing ovation.<br />

WVSOM’s Acting President<br />

for the past nine months, Dr.<br />

Adelman previously served as<br />

the Vice President for Academic<br />

Affairs and Dean since 2002. He<br />

brings to the Presidency a strong<br />

background in osteopathic medical<br />

education on the local, state and<br />

national levels. He holds doctoral<br />

degrees in Osteopathic Medicine,<br />

Podiatric Medicine and Law.<br />

WVSOM Associate Dean, Board Member<br />

Contribute to Popular Textbook<br />

Kendall Wilson, D.O., and<br />

Karen Steele, D.O., F.A.A.O., have<br />

made significant contributions<br />

to a widely used textbook.<br />

The textbook, entitled “Foundations<br />

of Osteopathic Medicine 3rd edition,”<br />

is used by WVSOM students and<br />

other osteopathic medical students<br />

across the country as part of their<br />

medical curriculum. There are<br />

currently 26 colleges of osteopathic<br />

medicine offering instruction<br />

at 34 locations in 25 states.<br />

Dr. Wilson, Vice Chairman of the<br />

WVSOM Board of Governors and<br />

alum, co-authored the chapter entitled<br />

“Chapman’s Approach,” while Dr.<br />

Steele, Associate Dean of Osteopathic<br />

<strong>Medical</strong> Education at WVSOM,<br />

served as lead author on the chapter<br />

entitled “Child with Ear Pain.”<br />

Both chapters were included<br />

in Part IV of the publication:<br />

“Approach of Osteopathic Patient<br />

Management.” Part IV is devoted to<br />

a comprehensive discussion of how<br />

an osteopathic physician approaches<br />

common patient scenarios.<br />

Authors were asked to begin<br />

the chapter with a typical case<br />

description, and use this case as a basis<br />

of discussion of that patient’s care.<br />

Chapters are written in such a way<br />

that osteopathic students see the five<br />

models of care commonly utilized by<br />

osteopathic physicians: biomechanical;<br />

respiratory-circulatory; neurologic;<br />

metabolic energy; and behavioral.<br />

According to Dr. Steele, this<br />

thought process is designed to help<br />

students consider the distinctiveness<br />

of osteopathic care and how they<br />

will apply this care to their future<br />

patients. “The chapters summarize<br />

how osteopathic medicine is<br />

unique,” she explained. “The book<br />

is used to mold students into future<br />

osteopathic practitioners.”<br />

Dr. Wilson (’81), said he feels<br />

“very honored” to be a part of the<br />

publication. “But more importantly,<br />

I cherish the opportunity to make a<br />

Dr. Karen Steele (left) and Dr. Kendall Wilson have made<br />

significant contributions to a widely used textbook.<br />

contribution to the academic world<br />

and to make a meaningful contribution<br />

to Dr. Chapman’s reflex,” Dr. Wilson<br />

said, referring to the osteopathic<br />

technique discussed in his chapter.<br />

Other WVSOM contributors to the<br />

Foundations of Osteopathic Medicine<br />

3rd edition include John Glover,<br />

D.O. (’86), of Vallejo, California, who<br />

serves as one of the publication’s<br />

Section Editors, and Richard Van<br />

Buskirk, D.O. (’87), of Sarasota,<br />

Florida, who co-authored chapter<br />

52 entitled “The Still Technique.”<br />

Authors are solicited by the<br />

section editors. The book is a<br />

publication of Lippencott and is<br />

available in the WVSOM Bookstore.<br />

56 <strong>West</strong> <strong>Virginia</strong> <strong>Medical</strong> Journal


Bureau for Public Health | NEWS<br />

Emergency <strong>Medical</strong> Services for Children Program<br />

Revitalizes the Always Ready for Kids Project<br />

The <strong>State</strong> Trauma and Emergency<br />

<strong>Medical</strong> System’s Office of<br />

Emergency <strong>Medical</strong> Services<br />

(EMS), EMS for Children Program<br />

has redesigned a project that was<br />

operational a decade ago, the<br />

Always Ready for Kids (ARK) project.<br />

EMS for Children Program (EMS-<br />

C) is responsible for assuring a<br />

statewide, standardized system<br />

exists where all hospital emergency<br />

departments demonstrate an<br />

established plan and/or the ability<br />

to manage medical and trauma<br />

pediatric emergencies. The goal of<br />

ARK is to create an effective and<br />

sustainable method to ensure that<br />

children who need treatment for life<br />

threatening illnesses or injuries have<br />

access to the appropriate facilities,<br />

equipment and trained personnel.<br />

The revitalization of ARK<br />

required input from the EMS-C<br />

Advisory Committee and other<br />

stakeholders to develop an effective<br />

and sustainable program. The<br />

program guidelines were revised,<br />

a statewide education process put<br />

in place, and regional meetings are<br />

scheduled throughout January 2011<br />

to educate hospitals. Site visits will<br />

begin in February 2011 for those<br />

facilities interested in participating<br />

in this voluntary program.<br />

Becoming an ARK recognized<br />

facility benefits both the hospital<br />

and the community by:<br />

• Creating a culture driven to<br />

continue improvement of<br />

pediatric patient outcomes,<br />

availability of equipment,<br />

services, and up-to-date treatment<br />

policies and protocols;<br />

• Increasing the public’s<br />

confidence in the overall<br />

quality of care received by<br />

<strong>West</strong> <strong>Virginia</strong>’s children;<br />

• Recognizing physicians, nurses,<br />

specialists, and other clinical<br />

staff for their knowledge,<br />

abilities, and commitment<br />

through their employment at<br />

an ARK recognized facility;<br />

• Recognizing facilities prepared<br />

for addressing the critical<br />

pediatric needs during a<br />

medical or trauma emergency.<br />

This will be visible in the form<br />

of a plaque displayed in the<br />

facility’s emergency department<br />

and through the listing of the<br />

facility on the <strong>West</strong> <strong>Virginia</strong><br />

Department of Health and Human<br />

Resources, <strong>West</strong> <strong>Virginia</strong> Office<br />

of Emergency <strong>Medical</strong> Services’<br />

website, and, additionally<br />

through self-promoting this<br />

accomplishment through local<br />

and/or statewide media outlets.<br />

• Utilizing ARK recognitions as a<br />

recruiting and marketing tool to<br />

attract high quality physicians,<br />

nurses and other specialists.<br />

• Enhancing potential educational<br />

and grant offerings that<br />

have been developed for<br />

rural hospital settings.<br />

Facilities achieving 100%<br />

compliance on the “Essential”<br />

elements and 70% on the “Desired”<br />

elements will receive ARK<br />

recognition. Compliance with the<br />

guidelines will be determined<br />

through an onsite visit. Once a<br />

facility receives ARK recognition, it<br />

will remain valid for a period of three<br />

(3) years. At that time, the facility<br />

has the option of reapplying. If your<br />

hospital is interested in participating<br />

in the ARK initiative, complete the<br />

application online or submit it via<br />

e-mail to Vicki.L.Hildreth@wv.gov<br />

or facsimile at (304) 558-8379.<br />

Drema Mace, PhD<br />

Director, <strong>State</strong> Trauma and Emergency<br />

<strong>Medical</strong> System (STEMS)<br />

Vicki Hildreth, BA<br />

Program Manager, Emergency <strong>Medical</strong><br />

Services for Children Program (EMS-C)<br />

Drug or Alcohol Problem Mental Illness<br />

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

contacting the <strong>West</strong> <strong>Virginia</strong> <strong>Medical</strong> Professionals Health Program. Information about a practitioner’s<br />

participation in the program is confidential. Practitioners entering the program as self-referrals without<br />

a complaint filed against them are not reported to their licensing board.<br />

ALL CALLS ARE CONFIDENTIAL<br />

<strong>West</strong> <strong>Virginia</strong> <strong>Medical</strong> Professionals Health Program<br />

PO Box 40027<br />

Charleston, WV 25364<br />

(304) 414-0400 | www.wvmphp.org<br />

<strong>March</strong>/<strong>April</strong> 2011 | Vol. 107 57


WV <strong>Medical</strong> Insurance Agency | NEWS<br />

Why We Also Want to Be Your Agent<br />

for Workers’ Compensation and<br />

Business Owners Package Policies<br />

Since the <strong>West</strong> <strong>Virginia</strong> <strong>Medical</strong><br />

Insurance Agency started working<br />

with physicians to handle their<br />

workers’ compensation and business<br />

owners package policies, we have<br />

successfully impacted the cost<br />

our clients are paying for these<br />

insurances as well as improved or<br />

enhanced the coverages they have.<br />

Note the following:<br />

A. Workers’ Compensation<br />

Insurance: Of the new business<br />

we have written, all of which was<br />

previously placed with BrickStreet<br />

Mutual Insurance Company, we<br />

have saved our clients on average<br />

12.7% in premium over what<br />

they were paying BrickStreet or<br />

quoted by BrickStreet. That’s an<br />

average savings of approximately<br />

$200 on an average premium of<br />

$1,545. The greater the premium,<br />

the greater the dollar savings.<br />

In addition to savings in<br />

premiums, we have broadened<br />

coverages by increasing Employer’s<br />

Liability (Coverage B) limits of<br />

liability and adding Broad Form<br />

coverage (including deliberate<br />

intent) in the same premium. Also,<br />

we verify the need for workers’<br />

compensation by our insureds (in<br />

particular practicing physicians)<br />

and review the gross payrolls for<br />

individual limitations or maximum<br />

amounts required to be reported<br />

and these reviews have also<br />

resulted in premium savings.<br />

B. Business Owners Package<br />

(BOPs): Of the new business we have<br />

written, we have saved our clients<br />

on average 18.5% in premium over<br />

what they were previously paying<br />

or being quoted at renewal. That<br />

results in an average savings of $327<br />

on an average premium of $1,773.<br />

Obviously the greater the premium,<br />

the greater the dollar savings.<br />

Business owners package<br />

policies include but are not<br />

limited to coverage for buildings<br />

and/or contents; general liability,<br />

equipment breakdown, accounts<br />

receivables, valuable papers and<br />

records, computers and media,<br />

personal and advertising liability,<br />

crime (employee dishonesty), and<br />

employment practices liability.<br />

Our review of potential clients’<br />

then current coverages frequently<br />

confirms inadequacies in the<br />

existing coverages. Therefore,<br />

some of the price reduction seen<br />

by our new clients also include<br />

coverage enhancements.<br />

How is this possible The<br />

<strong>West</strong> <strong>Virginia</strong> <strong>Medical</strong> Insurance<br />

Agency’s primary carrier for<br />

workers’ compensation and<br />

business owner’s packages is The<br />

Hartford and The Hartford prefers<br />

medical practices/health business<br />

as a class of business and designs<br />

specific coverages and preferred<br />

rating plans for medical practices.<br />

Are you missing out on this<br />

opportunity to save premium dollars<br />

on your workers’ compensation and/<br />

or business owners’ packages If so,<br />

we would welcome the opportunity<br />

to provide a no obligation review<br />

for your practice. Please call Steve<br />

Brown, Agency Manager, at 304-<br />

925-0342 ext 22, (toll free at 1-800-<br />

257-4747 ext 22), cell # 304-542-0257<br />

or e-mail steve@wvsma.com.<br />

Reasons to Switch Coverage: Not!<br />

Recently one of our physician<br />

clients sent me a copy of a<br />

solicitation he received from an<br />

agent trying to get him to move<br />

his medical liability coverage. The<br />

letter gave “four reasons” why you<br />

should switch. With this editorial<br />

piece, I wanted to respond.<br />

Reason # 1 – Best Price “Did you<br />

know that the rates may be much<br />

lower than what you pay right now<br />

It’s true. You may be surprised that<br />

the premier medical malpractice<br />

insurer in the country is also the most<br />

affordable for select physicians.”<br />

Response #1 – I question the<br />

use of the term “best” price when<br />

speaking about “lowest” price, the<br />

two are not synonymous. When<br />

considering price do not be confused<br />

by the two. The ability to receive<br />

local service from qualified local<br />

personnel may be more important<br />

than a few dollars. Most affordable<br />

is not always best. Plus what does<br />

the term “select physicians” mean<br />

Reason # 2 – Unmatched Financial<br />

Strength “Company [X] is the highest<br />

rated medical professional liability<br />

insurance company in the industry<br />

with “AA+ S&P and A++ A.M. Best’s<br />

ratings. You’re covered. Period.”<br />

58 <strong>West</strong> <strong>Virginia</strong> <strong>Medical</strong> Journal


Response # 2 – “You’re covered.<br />

Period.” This sounds like a guarantee<br />

to me, which in fact is an extremely<br />

questionable or ethical statement<br />

to make. I seriously doubt that<br />

this carrier would want an agent<br />

making this type of guarantee.<br />

Additionally, financial ratings<br />

do not guarantee coverage.<br />

Reason #3 – Best Defense: “With<br />

the nation’s most proactive defense<br />

and winning percentages Company<br />

[X] has earned a reputation as<br />

the best in the industry.”<br />

Response #3 – I believe this type<br />

of reputation has been promoted<br />

in <strong>West</strong> <strong>Virginia</strong> before. Being the<br />

“most proactive defense” oriented<br />

carrier has not always resulted<br />

in success in <strong>West</strong> <strong>Virginia</strong>. <strong>West</strong><br />

<strong>Virginia</strong> courts have been known to<br />

be very hard on out-of-state insurers.<br />

Reason # 4 – Proven Track Record:<br />

“For more than a century, Company<br />

[X] has delivered the industry’s best<br />

financial strength, most winning<br />

defense and smartest risk solutions.<br />

Today, more healthcare providers<br />

across the nation get their protection<br />

from one company, Company [X].”<br />

Response #4 – Sounds like a<br />

restatement of Reason #2. Regardless,<br />

the writer has provided no record<br />

or history for this carrier in <strong>West</strong><br />

<strong>Virginia</strong>; therefore, they may have<br />

a track record, but not in <strong>West</strong><br />

<strong>Virginia</strong>. And the statement “Today,<br />

more healthcare providers across<br />

the nation get their protection from<br />

one company” could be interpreted<br />

as meaning more than 50% or more<br />

than last year – I’m not sure, are you<br />

Quite frankly, I am appalled by<br />

some of the comments in this letter by<br />

an out-of-state addressed insurance<br />

agent, who, based on my review of<br />

an on-line listing from the Offices of<br />

the Insurance Commission may not<br />

even be appointed by the carrier.<br />

I believe there is a value in dealing<br />

locally whether it be your agent or<br />

your carrier that was created by<br />

your state’s legislature to act on<br />

your behalf at a time of real need<br />

(where was this other company with<br />

the proven track record in 1998,<br />

1999, 2000, 2001, 2002, 2003, 2004,<br />

2005, 2006, 2007, 2008, and 2009)<br />

For more details on these<br />

issues and the real value of the<br />

<strong>West</strong> <strong>Virginia</strong> Mutual Insurance<br />

Company for the doctors of <strong>West</strong><br />

<strong>Virginia</strong>, please call Steve Brown,<br />

Agency Manager, <strong>West</strong> <strong>Virginia</strong><br />

<strong>Medical</strong> Insurance Agency, at<br />

304-925-0342 ext 22 or toll free<br />

1-800-257-4747 ext 22 to set up an<br />

appointment to review the details.<br />

<strong>March</strong>/<strong>April</strong> 2011 | Vol. 107 59


2011<br />

Certified <strong>Medical</strong> Office<br />

Manager Class (CMOM)<br />

Thursday, <strong>March</strong> 24 & Friday, <strong>March</strong> 25 and Thursday, <strong>March</strong> 31 & Friday, <strong>April</strong> 1, 2011<br />

Time: 9:00 a.m. to 4:00 p.m. | Place: St. Francis Hospital, Charleston, WV (Participants must attend all 4 days.)<br />

Participant Information<br />

Registrant #1: _____________________________________________________<br />

Registrant #2: _____________________________________________________<br />

Registrant #3: _____________________________________________________<br />

E-mail:__________________________________<br />

E-mail:__________________________________<br />

E-mail:__________________________________<br />

Practice Name: _____________________________________________________________________________________________<br />

Street Address: _____________________________________________________________________________________________<br />

City: __________________________________________________________<strong>State</strong>:_______________ Zip:____________________<br />

Phone:_____________________________________ Fax:___________________________________________________________<br />

Program Fee/Discount Policies:<br />

Registration Fee: $799 WVSMA members: $699 (Includes instructional materials and exam fee.)<br />

Payment Method:<br />

q American Express q MasterCard q Visa q Check Enclosed<br />

Payable to:<br />

<strong>West</strong> <strong>Virginia</strong> <strong>State</strong> <strong>Medical</strong> <strong>Association</strong><br />

Card No: ____________________________________________ Expiration Date:___________V Code:_____________<br />

(Three digit number on the back of your credit card.)<br />

Name As It Appears On Card:________________________________________________<br />

Signature: _______________________________________________________________<br />

Registration Methods:<br />

Mail registration form to: Karie Sharp • <strong>West</strong> <strong>Virginia</strong> <strong>State</strong> <strong>Medical</strong> <strong>Association</strong> • PO Box 4106, Charleston, WV 25364<br />

Fax registration form to: Karie Sharp • (304) 925-0345 Charge by phone: Karie Sharp • (304) 925-0342, ext. 12<br />

E-mail: karie@wvsma.com<br />

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Physician Practice Advocate | NEWS<br />

Medicare Changes that Will Affect Your Practice<br />

by Barbara Good, CMOM, Physician Practice Advocate, WVSMA<br />

The Affordable Care Act has<br />

made some important changes<br />

to Medicare-covered preventive<br />

services for dates of service on or<br />

after January 1, 2011. Some of these<br />

changes include the addition of the<br />

new Annual Wellness Visit (AWV)<br />

with prevention plan benefit, as well<br />

as the removal of deductibles and<br />

copays for many services. The Act,<br />

signed on <strong>March</strong> 23, 2010, also offers<br />

a Primary Care Incentive Payment<br />

Program (PCIP) which is effective<br />

for services rendered between<br />

1/1/2011 through 12/31/2015.<br />

In addition to these changes,<br />

two new preventive benefits have<br />

been added by the Centers for<br />

Medicare and Medicaid (CMS). One<br />

is Counseling to Prevent Tobacco Use<br />

and the other is Screening for Human<br />

Immunodeficiency Virus (HIV) Infection.<br />

Another provision of the<br />

Affordable Care Act (ACA) includes<br />

improvements to the Physician<br />

Quality Reporting System (formerly<br />

known as PQRI). In addition to the<br />

1% reporting payment, CMS has<br />

announced that during 2011, there<br />

is now an additional .5% incentive<br />

available for the January 1-December<br />

31, 2011 reporting period.<br />

For more information on these and<br />

other provisions of the Affordable<br />

Care Act, you may visit www.cms.<br />

gov or www.healthcare.gov.<br />

In addition to the changes made<br />

by the Affordable Care Act, CMS<br />

has also released instructions to<br />

update seasonal influenza codes.<br />

Although Healthcare Common<br />

Procedure Coding System Codes<br />

(HCPCS) became effective for dates<br />

of service on or after October 1, 2010,<br />

the Medicare claims processing<br />

systems didn’t recognize the codes<br />

until January 1, 2011. Medicare<br />

systems were unable to process roster<br />

claims until February 7, 2011, but<br />

physicians should have been able to<br />

submit a roster bill as of that date.<br />

Physicians who submitted<br />

influenza vaccine claims with<br />

CPT code 90658 after January 1,<br />

2011, will receive a rejection and<br />

must submit a new claim with<br />

the correct HCPCS codes.<br />

In other Medicare news, in<br />

November 2010, the Centers for<br />

Medicare & Medicaid Services<br />

announced that beginning in<br />

2012, eligible professionals who<br />

are not successful electronic<br />

prescribers may be subject to a<br />

payment adjustment. Section 132<br />

of the Medicare Improvements for<br />

Patients and Providers Act of 2008<br />

(MIPPA) authorizes CMS to apply<br />

this payment adjustment whether<br />

or not the eligible professional<br />

is planning to participate in<br />

the eRx Incentive Program.<br />

The payment adjustment in<br />

2012, with regard to all of the<br />

eligible professionals’ Part B-<br />

covered professional services, will<br />

result in the eligible professional<br />

or group practice receiving 99% of<br />

the Physician Fee Schedule (PFS)<br />

amount that would otherwise apply<br />

to such services. In 2013, eligible<br />

professionals will receive 98.5%<br />

of their covered Part B-eligible<br />

charges if they aren’t successful<br />

electronic prescribers. In 2014, the<br />

penalty for not being a successful<br />

electronic prescriber is 2% resulting<br />

in eligible professionals receiving<br />

98% of their covered Part B charges.<br />

For purposes of determining<br />

which eligible professionals or group<br />

practices are subject to the payment<br />

adjustment in 2012, CMS will analyze<br />

claims data from January 1, 2011-<br />

June 30, 2011 to determine if the<br />

eligible professional has submitted<br />

at least 10 electronic prescriptions<br />

during the first six months of<br />

calendar year 2011. Group practices<br />

reporting as a GPRO I or GPRO II in<br />

2011 must report all of their required<br />

electronic prescribing events in the<br />

first six months of 2011 to avoid<br />

the payment adjustment in 2012.<br />

If an eligible professional or<br />

selected group practice wishes<br />

to request an exemption to the<br />

eRx Incentive Program and the<br />

payment adjustment, there are<br />

three “hardship codes” that can be<br />

reported via claims should one of<br />

the following situations apply:<br />

G8642 - The eligible professional<br />

practices in a rural area without<br />

sufficient high speed internet<br />

access and requests a hardship<br />

exemption from the application<br />

of the payment adjustment<br />

under section 1848(a)(5)(A)<br />

of the Social Security Act.<br />

G8643 - The eligible professional<br />

practices in an area without sufficient<br />

available pharmacies for electronic<br />

prescribing and requests a hardship<br />

exemption from the application<br />

of the payment adjustment<br />

under section 1848(a)(5)(A)<br />

of the Social Security Act<br />

G8644—The eligible professional<br />

physician practice may indicate<br />

that they do not have prescribing<br />

privileges. Reporting this G code<br />

will prevent the practitioner<br />

from being subjected to a<br />

payment adjustment in 2012.<br />

If you need additional information<br />

on any of the programs listed above,<br />

visit the official Medicare website<br />

www.cms.gov/erxincentive.<br />

<strong>March</strong>/<strong>April</strong> 2011 | Vol. 107 61


Obituaries<br />

The WVSMA remembers<br />

our esteemed colleagues…<br />

Dennis Marshall Cupit, M.D.<br />

Dennis Marshall Cupit, M.D.,<br />

59, of Milton passed away at St.<br />

Mary’s <strong>Medical</strong> Center on December<br />

17, 2010 after a sudden illness.<br />

He was born May 1, 1951, a<br />

son of the late Charles Cupit and<br />

Elizabeth Cupit. In addition to<br />

his parents, he was preceded in<br />

death by one sister, Sarah Johnson;<br />

sister-in-law, Susan Cupit; and<br />

brother-in-law, Jim Yeager.<br />

He is survived by his wife,<br />

Marylyn Cupit; son, Private<br />

Christopher Cupit, serving in<br />

the Army National Guard; two<br />

sisters, Linda Amburgey of South<br />

Charleston and Debbie Yeager of<br />

Dunbar; one brother, Gordon Cupit<br />

of Dunbar; and numerous family<br />

members, friends, and patients.<br />

In keeping with his wishes, his<br />

body was donated to Marshall<br />

University <strong>Medical</strong> School.<br />

Echols A. Hansbarger Jr., MD<br />

Echols A. Hansbarger Jr.,<br />

M.D., 80, of Charleston died<br />

suddenly on January 20, 2011.<br />

He was predeceased by his wife,<br />

Withers, in December 2008. They<br />

had been married for 53 years.<br />

Dr. Hansbarger was born<br />

in Williamson on September<br />

15, 1930, the only son of Lydia<br />

White Hansbarger of Matewan,<br />

Mingo County, and Echols A.<br />

Hansbarger of Peterstown,<br />

Monroe County, both deceased.<br />

He grew up in Charleston<br />

and graduated from Stonewall<br />

Jackson High School in 1948. He<br />

graduated from Washington & Lee<br />

University, Lexington, <strong>Virginia</strong>, in<br />

1952 and from the <strong>Medical</strong> College<br />

of <strong>Virginia</strong>, Richmond, in 1956.<br />

In 1974, he returned to Charleston<br />

as director of laboratories at St.<br />

Francis Hospital and, in 1976, at<br />

Kanawha Valley Hospital. He<br />

retired in 1999 after 38 years of<br />

pathology practice. An additional<br />

year of part-time practice ended<br />

with his total retirement in 2000.<br />

He was a past president of the<br />

Kanawha <strong>Medical</strong> Society and<br />

a member of the <strong>State</strong> <strong>Medical</strong><br />

Council and a number of other<br />

medical societies including Alpha<br />

Omega Alpha <strong>Medical</strong> Honorary,<br />

College of American Pathologists<br />

and the <strong>West</strong> <strong>Virginia</strong> <strong>State</strong> <strong>Medical</strong><br />

<strong>Association</strong>. He was board certified<br />

by the American Board of Pathology<br />

in anatomic pathology, clinical<br />

pathology and blood banking.<br />

He was also board certified by<br />

the American Board of Forensic<br />

Examiners and the American<br />

Board of Forensic Medicine.<br />

He is survived by his daughter,<br />

Anne Sladky of Dunbar; and sons,<br />

Echols A. Hansbarger III of Myrtle<br />

Beach, S.C., Walter Hansbarger, and<br />

wife, Joselyn Hansbarger, of <strong>Virginia</strong><br />

Beach, Va., and Jeff Hansbarger of<br />

Point Pleasant. He is also survived by<br />

four grandchildren.<br />

Robert Dale Hess, MD<br />

Robert Dale Hess, M.D.,<br />

age 78, died January 30,<br />

2011, at his residence.<br />

Dr. Hess was born February<br />

6, 1932, son of the late Waonda<br />

J. and Raymond C. Hess.<br />

His first wife, Alice Jo Hess,<br />

preceded him in death in June 1997.<br />

Surviving are his wife of eight<br />

years, Patricia Chapman Hess, and<br />

the following children: John R. Hess<br />

and his wife, Jane M. Hess; Mary<br />

K. Hess; Monica A. Garner and her<br />

husband Roderick J. Garner; Dr.<br />

Michael R. Hess and his wife, Dr.<br />

Elizabeth H. Hess; Joseph F. Hess and<br />

his wife S. Naseem Anjam; Patrick<br />

R. Chapman and his wife Brandee<br />

N. Chapman; 13 grandchildren:<br />

Claire K. Garner, Maxwell J. Garner,<br />

Meredith R. Garner, Katheryn B.<br />

Hess, Andrew D. Hess, Christopher<br />

S. Hess, Harrison R. Hess, Madison<br />

R. Hess, Allison J. Hess, Patrick R.<br />

Chapman II, Joseph B. Chapman,<br />

Dylan P. Chapman and Mackenzee<br />

E. Chapman. Also survived by two<br />

brothers, Edgar A. “Bud” Hess, and<br />

his wife Twylia Hess, and Dr. David<br />

R. Hess and his wife Marilyn Hess;<br />

and a sister-in-law, Vera L. Hess.<br />

He was also preceded in death<br />

by one brother, George L. Hess,<br />

and four sisters, Dorothea Ruth<br />

Gianni, Jerry W. Kinney, Betty<br />

J. Smith and Helen L. Wetzel.<br />

Born and raised in Bridgeport,<br />

WV, Dr. Hess graduated from<br />

Bridgeport Senior High School in<br />

62 <strong>West</strong> <strong>Virginia</strong> <strong>Medical</strong> Journal


1950. He graduated from the pre-med<br />

program at Potomac <strong>State</strong> College,<br />

then <strong>West</strong> <strong>Virginia</strong> University School<br />

of Medicine. He completed his<br />

medical education at the <strong>Medical</strong><br />

College of <strong>Virginia</strong>, Richmond, in<br />

1958. He served his internship and<br />

residency at Charleston Memorial<br />

Hospital from 1958-1960.<br />

He was also a member of the<br />

Harrison County <strong>Medical</strong> Society,<br />

<strong>West</strong> <strong>Virginia</strong> <strong>State</strong> <strong>Medical</strong><br />

<strong>Association</strong>, American Academy<br />

of Family Physicians and the<br />

American <strong>Medical</strong> <strong>Association</strong>.<br />

Over the years, Dr. Hess enjoyed<br />

numerous leadership positions<br />

ranging from United Hospital Center<br />

Board member to founder and<br />

president of the Family Medicine<br />

Foundation of <strong>West</strong> <strong>Virginia</strong>,<br />

which provides scholarships to<br />

medical students and residents<br />

interested in Family Medicine.<br />

In lieu of flowers, contributions<br />

can be made to the Robert D. Hess,<br />

M.D. Memorial Fund, Wesbanco,<br />

attention: Lu Bush, 1130 Johnson<br />

Avenue, Bridgeport, WV 26330.<br />

Elmond LeMoyne Coffield, MD<br />

Elmond LeMoyne Coffield,<br />

M.D., 87, died on February 10, 2011,<br />

surrounded by his loving family<br />

and in the caring hands of the<br />

staff and professionals at Wetzel<br />

County Hospital, where he cared<br />

for his patients for 48 years.<br />

Dr. Coffield was born on<br />

November 19, 1923, on Coffield Ridge<br />

in Wetzel County, <strong>West</strong> <strong>Virginia</strong>. He<br />

was the son of Susan Austie (Yoho)<br />

Coffield and Albert Lee Coffield,<br />

M.D. and the brother of Olan<br />

Terrell Coffield, M.D. He married<br />

Colleen Frost (Harris) Coffield of<br />

Bannock, Ohio on October 22, 1950.<br />

Dr. Coffield graduated with a<br />

Bachelor of Arts from <strong>West</strong> <strong>Virginia</strong><br />

University in 1943, a Bachelor<br />

of Science from <strong>West</strong> <strong>Virginia</strong><br />

University <strong>Medical</strong> School in 1945,<br />

and a <strong>Medical</strong> Doctorate from<br />

the <strong>Medical</strong> College of <strong>Virginia</strong><br />

in 1947. He did his medical and<br />

anesthesia residency at Ohio Valley<br />

General Hospital from 1947-1950.<br />

Dr. Coffield joined his brother,<br />

Dr. Terrell Coffield, and began<br />

practicing family medicine in New<br />

Martinsville on July 1, 1950. Dr.<br />

Coffield, his brother, and their<br />

father Dr. Albert Lee Coffield<br />

provided health care to generations<br />

of Wetzel County families. It is<br />

estimated that Dr. Coffield and his<br />

brother delivered over 4,000 babies<br />

during the 30 years they offered<br />

obstetrical services as a part of<br />

their family practice. Dr. Coffield<br />

and his brother were health care<br />

innovators by adding a medical office<br />

pharmacy and the first drive through<br />

pharmacy service in conjunction with<br />

Harman’s Drug Store. He provided<br />

occupational medicine and served<br />

as the first plant physician at the<br />

New Martinsville Bayer facility<br />

(Mobay Chemical) from 1955-1998.<br />

Dr. Coffield was inducted into the<br />

United <strong>State</strong>s Army on December<br />

18, 1943, and reported to duty at<br />

<strong>West</strong> <strong>Virginia</strong> University in the<br />

Army Specialized Training Program<br />

which trained physicians for military<br />

service. He was transferred to the<br />

<strong>Medical</strong> College of <strong>Virginia</strong> and<br />

was discharged on <strong>March</strong> 23, 1946.<br />

During the Korean War, Dr. Coffield<br />

served in the United <strong>State</strong>s Army<br />

<strong>Medical</strong> Corp as a First Lieutenant<br />

and was stationed at Fort Bragg<br />

Army Hospital and Fort Knox Army<br />

Hospital from 1951-1953 where he<br />

served as an anesthesiologist.<br />

Dr. Coffield is survived by his<br />

five children, Jennifer Coffield<br />

Tobin (Thomas J. Tobin), Rebecca<br />

Coffield Moore (Charles Thomas<br />

Moore, Jr.), Melinda Coffield Herrick,<br />

Colette Coffield Goddard (Aaron<br />

Goddard), and Robert LeMoyne<br />

Coffield (Susanne M. Coffield). He<br />

loved his twelve grandchildren:<br />

Chad Tobin, Dylan Tobin, Spencer<br />

Tobin, Thomas Moore, Evan Moore,<br />

Whitney Herrick Bacalman, Paul<br />

Herrick, Maggie Herrick, Taylor<br />

Goddard, Sean Goddard, Daniel<br />

Coffield, and Rachel Coffield. He<br />

also loved Goldie, his loyal yellow<br />

lab. He is further survived by many<br />

nieces, nephews, other Coffield and<br />

Harris relatives, neighbors, and many<br />

friends. In addition to his parents,<br />

he was preceded in death by the<br />

love of his life, Colleen Frost (Harris)<br />

Coffield, who died on July 14, 1978.<br />

Dr. Coffield was a member of<br />

the First Christian Church and one<br />

of the founding members of the<br />

Wetzel County Historical Society<br />

Museum. As a member of the Court<br />

Restaurant “lunch bunch,” Dr.<br />

Coffield was a wonderful storyteller<br />

and Wetzel County historian.<br />

A special thanks to his caregivers<br />

and the staff at Journey Hospice.<br />

Memorial donations may be made<br />

to Wetzel County Hospital, First<br />

Christian Church, Journey Hospice,<br />

or a charity of your choice.<br />

The <strong>West</strong> <strong>Virginia</strong> <strong>Medical</strong> Journal is<br />

honored to publish the obituaries of<br />

<strong>West</strong> <strong>Virginia</strong> physicians. Please send<br />

copy to<br />

Angie Lanham<br />

Managing Editor, WV <strong>Medical</strong> Journal<br />

PO Box 4106, Charleston, WV 25364 or<br />

E-mail to: angie@wvsma.com<br />

<strong>March</strong>/<strong>April</strong> 2011 | Vol. 107 63


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research and prevention, and information<br />

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Our <strong>Medical</strong>-Scientific Conference includes<br />

scientific symposia, clinically oriented<br />

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64 <strong>West</strong> <strong>Virginia</strong> <strong>Medical</strong> Journal


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Louise Van Riper, MD<br />

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Craig Herring, MD<br />

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Multidisciplinary Interventional Pain Management<br />

Timothy Deer, MD<br />

Richard Bowman, MD<br />

Christopher Kim, MD<br />

Matthew Ranson, MD<br />

St. Francis Hospital Location<br />

400 Court Street, Suite 100, Charleston, WV 25301<br />

304.347.6120<br />

see Teays Valley Hospital Location, next page<br />

<strong>March</strong>/<strong>April</strong> 2011 | Vol. 107 65


WVSMA | Professional Directory (cont’d)<br />

The Center for Pain Relief, Inc.<br />

Teays Valley Hospital Location<br />

Doctors Park, 1400 Hospital Drive<br />

Hurricane, WV 25526<br />

304.757.5420<br />

Physical Therapy and Rehabilitation Center,<br />

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100 Peyton Way, Charleston WV, 25309<br />

304.720.6747<br />

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at multiple locations for over 27 years<br />

Kyle F. Fort, MD, David F. Meriwether, MD,<br />

Thomas S. Kowalkowski, MD, Joseph<br />

Mouchizadeh, MD, and James Cauley, MD<br />

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disciplinary matters, credentialing concerns, complex regulatory matters and business transactions.<br />

health care practice group<br />

Ryan A. Brown<br />

Robert L. Coffield<br />

Alaina N. Crislip<br />

J. Dustin Dillard<br />

Sam Fox<br />

Michele Grinberg<br />

John D. Hoffman<br />

Amy R. Humphreys<br />

Charleston<br />

Justin D. Jack<br />

Richard D. Jones<br />

Edward C. Martin<br />

Mark A. Robinson<br />

Amy L. Rothman<br />

Don R. Sensabaugh, Jr.<br />

Salem C. Smith<br />

Morgantown<br />

Stephen R. Brooks<br />

Stacie D. Honaker<br />

Wheeling<br />

David S. Givens<br />

Phillip T. Glyptis<br />

Robert C. James<br />

Edward C. Martin, Responsible Attorney | tedm@fsblaw.com | www.fsblaw.com | (304) 345-0200 | (800) 416-3225<br />

66 <strong>West</strong> <strong>Virginia</strong> <strong>Medical</strong> Journal


2012<br />

C a l l f o r P a P e r s<br />

Theme: The Art, Science and ethics of Prevention*<br />

I. Consistent with the theme, one paper<br />

(addressing preventive education, screening,<br />

assessment and interventions) will be accepted<br />

on each of the following topics (Addressing<br />

unique WV genetic, cultural, environmental and<br />

demographic influences is encouraged):<br />

•<br />

•<br />

•<br />

•<br />

•<br />

•<br />

•<br />

•<br />

•<br />

•<br />

•<br />

•<br />

Women’s Health<br />

Men’s health<br />

Newborns/ Growth and Development (pre-teen)<br />

Adolescent health<br />

Cardiovascular Disease and Stroke<br />

Mental Health (including Autism and Dementia)<br />

Cancer<br />

Genetics<br />

Kidney Disease<br />

Immunizations<br />

Endocrine Disorders<br />

Life-Style Medicine<br />

Submissions must include:<br />

1) cover letter (include corresponding author’s email address)<br />

2) manuscript (double-spaced)<br />

3) short biography for each author<br />

4) three questions and answers pertaining to the manuscript (for CME Post-test<br />

Questions)<br />

5) a paragraph stating the objectives of the paper<br />

Send to angie@wvsma.com or mail to:<br />

Angie Lanham<br />

Managing Editor, WV <strong>Medical</strong> Journal<br />

PO Box 4106, Charleston, WV 25364<br />

II. One paper on the status and role of health<br />

information technology in assisting physicians<br />

to meet the expanding preventive health<br />

challenges.<br />

III. Two papers addressing ethical issues,<br />

controversies and dilemmas involved in<br />

providing preventive care to individual<br />

patients, including balancing clinical and<br />

non-clinical benefits and risks, as well<br />

as the duties and responsibilities of all<br />

involved parties. (These could be scientific or<br />

commentary articles.)<br />

IV. One paper addressing the interplay of the<br />

ethical obligation of the physician to both the<br />

individual patient and community, i.e., public<br />

health. (Commentary article.)<br />

DEADLINES:<br />

Manuscript submission: December 1, 2011<br />

Reviews returned by: February 1, 2012<br />

Resubmissions: <strong>March</strong> 1, 2012<br />

Printing:<br />

May/June 2012 issue<br />

6) All figures and photos must be submitted separately as .jpg, .tif or .pdf<br />

files.<br />

7) The word count limit is 2,500 with a limit of 5 visuals (i.e., 3 tables and 2<br />

figures). Actual figure and table size is left to the discretion of the managing<br />

editor, as space is available.<br />

Scientific articles should be prepared in accordance with the “Uniform<br />

Requirements for Submission of Manuscripts to Biomedical Journals.” Please go<br />

to www.icmje.org for complete details. For additional requirements, please refer to<br />

Manuscript Guidelines located on the last page of every Journal or go to www.<br />

wvsma.com/journal and click on the link.<br />

*<br />

The exponential expansion of scientific knowledge over the last 50 years greatly expands the “proactive” challenge of physicians to fulfill their primary duty to assist each patient prevent, delay the onset of,<br />

or minimize the consequences of disease and disability through provision of timely and appropriate education, screening, assessment and interventions. Such knowledge also introduces new challenges to<br />

“do no harm.” This involves not only “clinical” harm pursuing “false positive” and “false negative” screening results but the psychological, social, economic and related consequences of “knowing” or being<br />

“labeled.” At times it also creates a new tension in the patient- physician relationship as regards the “duties” and “responsibilities” of each party.<br />

An additional area of significant controversy involves each physician’s duty to “protect the public’s health” and the degree to which this extends to the “stewardship” of limited societal resources. Although<br />

the physician’s duty to each unique patient is viewed as sacrosanct, the duties to assist society avoid inappropriate and wasteful use of scarce resources cannot be ignored. As an example, commenting<br />

on the use of screening tests in terminally ill patients, Dr. Danielle Ofri stated “While cancer screening is critically important there is a danger that the screening engine in our society is a one track train,<br />

plowing forward, staying on message, not to be bogged down with conflicting data, nuanced reasoning, or messy statistical analyses.”<br />

This issue attempts to assist <strong>West</strong> <strong>Virginia</strong> physicians better understand, balance and meet these challenges and duties by comprehensively exploring this topic.<br />

<strong>March</strong>/<strong>April</strong> 2011 | Vol. 107 67


Manuscript Guidelines<br />

Originality: All scientific and special topic<br />

manuscripts for the <strong>West</strong> <strong>Virginia</strong> <strong>Medical</strong> Journal will<br />

not be considered for publication if they have already<br />

been published or are described in a manuscript<br />

submitted or accepted for publication elsewhere. All<br />

scientific articles should be prepared in accordance<br />

with the “Uniform Requirements for Submission of<br />

Manuscripts to Biomedical Journals.” Please go to<br />

www.icmje.org for complete details.<br />

Authors: A cover letter from the corresponding<br />

author should be submitted with the manuscript. All<br />

persons listed as authors should have participated<br />

sufficiently in the work to take public responsibility for<br />

the concept.<br />

Format: All articles may be submitted by email or on<br />

CD. Microsoft Word is preferred, but other programs<br />

are acceptable. All tables or figures should be<br />

created separately from the body of the manuscript<br />

as .tif, .jpg or .pdf files in a high resolution format with<br />

corresponding file names such as, Table 1, Figure 1,<br />

etc. Legends should be included for all tables and<br />

figures.<br />

References: References should be prepared in<br />

accordance to the “American <strong>Medical</strong> <strong>Association</strong><br />

Manual of Style.” These instructions for authors are<br />

available online at www.jama.com.<br />

Photographs: Please submit high resolution digital<br />

files with an image size of 300 dpi at 100% of size.<br />

This high resolution size must be equal to 2.5” by 2.5”<br />

minimum size. Low resolution photos may be<br />

rejected or print with poor quality.<br />

Note to authors: The WV <strong>Medical</strong> Journal inside pages<br />

traditionally print in black and white. If authors wish to<br />

have photos and figures printed in color, there is a<br />

$1,000 charge per article to help defray the printing<br />

costs to the <strong>Association</strong>. Please indicate your preference<br />

when submitting an article. If your article is accepted for<br />

publication, you will be invoiced for the charges in<br />

advance of publication.<br />

Please address articles and cover letter to the editor at<br />

this address only:<br />

F. Thomas Sporck, M.D., F.A.C.S.<br />

Editor<br />

<strong>West</strong> <strong>Virginia</strong> <strong>Medical</strong> Journal<br />

P.O. Box 4106<br />

Charleston, WV 25364<br />

or email your article with cover letter to:<br />

Angela L. Lanham, Managing Editor<br />

angie@wvsma.com<br />

Thanks To Our Advertisers!<br />

Alpha Technologies....................................................... 29,53<br />

American <strong>Medical</strong> <strong>Association</strong> (AMA)................................ 41<br />

American Society of Addiction Medicine............................ 64<br />

CAMC Health Ed. and Research Institute............................ 1<br />

Center for Rural Health Development Loan Fund.............. 39<br />

Chapman Printing Co.................................................... 20,64<br />

Ear, Nose & Throat Assoc. of Charleston, Inc...................... 6<br />

EHR Solutions...................................................................... 2<br />

Eye & Ear Clinic................................................................. 35<br />

Flaherty Sensabaugh & Bonasso PLLC............................ 66<br />

HIMG.................................................................................. 15<br />

Images Computer Graphics & Design............................... 64<br />

McCabe <strong>Medical</strong> Coding and Reimbursement, LLC.......... 64<br />

McLain Surgical Supply..................................................... 64<br />

Office Managers <strong>Association</strong>.............................................. 28<br />

Physician’s Business Office............................................... 13<br />

PIPAC................................................................................. 29<br />

Right at Home.................................................................... 17<br />

Stationers, Inc.................................................................... 64<br />

Suttle & Stalnaker................................................................ 9<br />

Unicare............................................................................... 25<br />

United <strong>State</strong>s Army............................................................ 31<br />

<strong>West</strong> <strong>Virginia</strong> <strong>Medical</strong> Insurance Agency........................... 59<br />

<strong>West</strong> <strong>Virginia</strong> <strong>Medical</strong> Professionals Health Program........ 57<br />

<strong>West</strong> <strong>Virginia</strong> Mutual Insurance Co......................Back Cover<br />

<strong>West</strong> <strong>Virginia</strong> REDI................................... Inside Back Cover<br />

<strong>West</strong> <strong>Virginia</strong> University............................Inside Front Cover<br />

<strong>West</strong> <strong>Virginia</strong> University, Faculty Position...........................11<br />

Advertising Policy<br />

The WVSMA reserves the right to deny advertising space to any individual,<br />

company, group or association whose products or services interfere with<br />

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

obligations of the WVSMA. The WVSMA, in its sole discretion, retains the<br />

right to decline any submitted advertisement or to discontinue publishing any<br />

advertisement previously accepted. The Journal does not accept paid political<br />

advertisements.<br />

The fact that an advertisement for a product, service, or company appears in<br />

the Journal is not a guarantee by the WVSMA of the product, service or<br />

company or the claims made for the product in such advertising. The WVSMA<br />

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

agreements that may limit the placement of advertisements for certain<br />

products or services.<br />

Subscription Rates:<br />

$60 a year in the United <strong>State</strong>s<br />

$100 a year in foreign countries<br />

$10 per single copy<br />

POSTMASTER: Send address changes to the <strong>West</strong> <strong>Virginia</strong><br />

<strong>Medical</strong> Journal, P.O. Box 4106, Charleston, WV 25364.<br />

Periodical postage paid at Charleston, WV.<br />

USPS 676 740 ISSN 0043 - 3284<br />

Claims for back issues should be made within six months after<br />

publication. Microfilm editions beginning with the 1972 volume are<br />

available from University Microfilms International, 300 N. Zeeb Rd.,<br />

Ann Arbor, MI 48106.<br />

©2011, <strong>West</strong> <strong>Virginia</strong> <strong>State</strong> <strong>Medical</strong> <strong>Association</strong><br />

68 <strong>West</strong> <strong>Virginia</strong> <strong>Medical</strong> Journal


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