March/April - West Virginia State Medical Association

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Continuing Medical Education 

Opportunities at CAMC Health Education 

and Research Institute 

The CAMC Health Education and Research Institute is dedicated to improving health through 

research, education and community health development. The Institute’s Education Division 

offers live conferences, seminars, workshops, teleconferences and on-site programs to health care 

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

Continuing Medical Education to sponsor continuing medical education for physicians. The CAMC 

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

Physicians should only claim credit commensurate with the extent of their participation in the 

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

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SEMInARS 

Advanced Geriatric Skills 

(AGES) 

Friday through Sunday 

April 1-3 

Bridgeport Conference Center 

Bridgeport, WV 

Health Literacy Training 

Program 

Wednesday and Thursday 

April 27 and 28 

Clarion Hotel 

Shepherdstown, WV 

3rd Annual CAMC Urology 

Conference 

Friday, April 29 

Embassy Suites Hotel 

Charleston, WV 

LIfE SuppORt tRAInIng 

Log-on to our website to register 

at www.camcinstitute.org 

Advanced Cardiovascular Life 

Support (ACLS) – Provider 

March 24 and April 5 

Advanced Cardiovascular 

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Recertification 

March 14, 23 and April 6, 21 

Advanced Trauma Life Support 

– Provider 

March 21 

Advanced Trauma Life Support 

– Reverification 


BLS Instructor Course 


Pediatric Advanced Life Support 

(PALS) - Provider 


Pediatric Advanced Life Support 

(PALS) – Recertification 


Sepsis Simulation 

March 9 and April 13 

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©Charleston Area Medical Center Health System, Inc. 2011 22804-A11

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e h r s g . c o m | e h r t o o l s . c o m | 3 0 4 . 7 2 0 . 3 3 0 0 o p t i o n 1 | i n f o @ e h r s g . c o m

contents 

March/April 2011, Volume 107, No. 2 

features 

4 President’s Message 

5 Congratulations Dr. Spangler! 

7 Resolutions Committee Report 

23 Book Review - Atlas of Otoscopy 

42 General News 

43 WESPAC Contributors 

43 New Members 

44 Call to Action 

45 MPLA Suit Statistics 

46 Annual Meeting Highlights 

48 2011 Legislative Briefs 

54 West Virginia University Health Sciences News 

55 Marshall University Joan C. Edwards School 

of Medicine News 

56 West Virginia School of Osteopathic 

Medicine News 

57 Bureau for Public Health News 

58 West Virginia Medical Insurance Agency News 

60 CMOM Registration Form 

61 Physician Practice Advocate News 

62 Obituaries 

64 Classified Ads 

65 Professional Directory NEW! 

67 2012 Call for Papers 

68 Manuscript Guidelines/Advertisers 

In this issue… 

Scientific Articles 

8 A Controversy: Linking Atypical Femoral Fractures 

to Bisphosphonate Therapy 

14 Report of Increased Number of Children with 

Parapneumonic Empyema as a Complication of 

Bacterial Pneumonia in West Virginia in 2005 

21 Medical Management of Cerebellar Abscess: A 

Case Report and Review of the Literature 

24 Primary Care Office Responses to a Stroke 

Scenario 

30 Clinical Cardiac Electrophysiology in 

West Virginia: 2010 

37 Post-ablative Hypothyroidism 

 

U P C O M I N G E V E N T S 

 

 

Certified Medical Office Manager Class (CMOM) 

— March 24-24 & March 31-April 1, 2011 

Healthcare Summit — The Greenbrier 

August 26-28, 2011 

Cover photo courtesy 

of Doug Gronholm 

Editor 

F. Thomas Sporck, MD, FACS 

Charleston 

Managing Editor/Director of Communications 

Angela L. Lanham, Dunbar 

Executive Director 

Evan H. Jenkins, Huntington 

Associate Editors 

James D. Felsen, MD, MPH, Charleston 

Douglas L. Jones, MD, White Sulphur Springs 

Steven J. Jubelirer, MD, Charleston 

Roberto Kusminsky, MD, MPH, FACS, Charleston 

Joel Levien, MD, Charleston 

Robert J. Marshall, MD, Huntington 

Martha D. Mullett, MD, Morgantown 

Louis C. Palmer, MD, Clarksburg 

Stanley Zaslau, MD, Morgantown 

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

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

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

WVSMA Info: PO Box 4106, Charleston, WV 25364 

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

President’s Message 

Be Careful What You Wish For 

You know the old saying, ‘Be 

careful what you wish for.’ Last 

August I said in my inaugural 

speech this year would be dedicated 

to “Creating Change.” Little did I 

know the scope of this change… 

whether we created it or not. 

The Republican takeover of the 

US House of Representatives last 

November coupled with a series of 

Federal Court rulings has the full 

implementation of ObamaCare in 

doubt. At the state level, the passing 

of Senator Byrd has precipitated a 

succession of power sequence that 

fostered an unexpectedly contentious 

race for the US Senate; a court 

mandated 2011 election for Governor; 

and now a full blown power struggle 

at the Statehouse with the individuals 

holding the top leadership position of 

the House, Senate and Governor all 

running this year for Governor. This 

will repeat itself in 2012 when the 

same senate seat and governorship 

are up for election along with 117 

seats in the West Virginia Legislature 

and two seats on the West Virginia 

Supreme Court of Appeals. 

While we are living in unique 

times and change is here, we 

still must ‘create change’ by 

seizing this opportunity and 

fully engage in the process of 

transformation. Our profession 

and patients are counting on us. 

What has not changed is the 

mass of healthcare legislation 

considered by the West Virginia 

Legislature every legislative 

session. Working with our 

WVSMA legislative committee 

and meeting with legislators and 

key members of the legislative 

leadership, we are working hard 

to make sure the voice of medicine 

is heard and well represented. 

The 2011 Regular Session 

has passed the half way point 

and a full legislative update is 

printed later in this issue of the 

Journal. Please review that report 

and know that your WVSMA is 

advocating on your behalf. Let 

me highlight several issues, 

Synthetic Marijuana and Cocaine 

– West Virginia is on the verge of 

joining the growing number of states 

that prohibit the sale, distribution and 

possession of these highly addictive 

substances that have been largely 

unregulated and freely sold in retail 

stores throughout the state. Popular 

among our youth, the addictive 

and hallucinogenic effects of these 

products are leading to countless 

ER visits and tragically linked to 

fatalities around the country. 

Tobacco Tax Increase - Healthcare 

and tobacco control advocates have 

succeeded in getting movement on 

legislation in both the House and 

Senate to significantly increase the 

state sales tax on cigarettes and the 

wholesale tax on smokeless tobacco. 

The tax on a pack of cigarettes would 

increase from the current 55 cents 

to $1.55 and the wholesale tax on 

smokeless tobacco would increase 

from 7 percent to 50 percent. The 

annual combined total revenue 

increase is projected to be $133 

million with most of the money 

earmarked for health related issues. 

Learned Intermediary - Several 

years ago, our State Supreme 

Court refused to adopt the ‘learned 

intermediary’ rule. In some states, 

the ‘learned intermediary’ rule 

enables a drug manufacturer to 

use as an affirmative defense in 

a product liability suit that there 

was a ‘learned intermediary’ (i.e., 

physician, pharmacist, etc.) between 

the drug manufacturer and the 

patient. This could shift some 

the responsibility and reduce the 

manufacturer’s liability. Legislation 

being considered would put in code 

a modified ‘learned intermediary’ 

rule in our state that is limited to 

drug manufacturers not engage 

in direct to consumer advertising. 

We are watching this closely to 

ensure it does not create new 

liability exposure for physicians or 

undermine the prescriber immunity 

protections we successfully 

lobbied for just a few years ago. 

Scope of Practice – Round 

two of the effort by Optometrists 

to substantially increase their 

scope of practice through greater 

prescriptive authority and the use of 

injections is moving. The WVSMA 

and a broad coalition of healthcare 

advocates are working to match the 

 

West Virginia Medical Journal

Optometrist’s scope of practice to 

their actual education and training 

in order to protect patient safety. 

Though it is and will be critical to 

work with many other healthcare 

providers, we do not support the 

dissolution of the collaborative 

practice agreement in place between 

the Boards of Medicine and Nursing. 

Health Care Reform 

Implementation - The Offices of 

the Insurance Commissioner (OIC) 

is pushing two bills to facilitate the 

implementation of federal healthcare 

reform in West Virginia. One bill 

grants the OIC the authority to 

regulate and enforce implementation 

of those reforms that took effect 

last September that generally 

have broad public support, i.e., 

elimination of lifetime caps, limits 

on rescission, and dependent age 

increase. The other bill establishes 

the state health insurance exchange 

which will provide health insurance 

purchasers the opportunity to price 

compare different policy packages. 

Controlled Substance Monitoring 

Database - This powerful tool was 

created almost a decade ago to aid 

healthcare providers in tracking 

prescriptions filled at West Virginia 

pharmacies and to help avoid 

unintended drug interactions. With 

the growing epidemic of prescription 

drug misuse, abuse and diversion in 

our state, law enforcement officials 

want expanded access beyond the 

current limited authority granted 

to members of state and local drug 

enforcement task force teams. There 

is also a significant push to shift 

the database from a ‘healthcare’ 

tool to a ‘law enforcement’ tool that 

incorporates a flagging system to 

triggers reports to law enforcement 

of prescribers who fall outside yet 

to be defined practice parameters. 

All Payor Database – Three 

state entities (Health Care 

Authority, Offices of the Insurance 

Commissioner and DHHR) want 

to enact a statutory mandate that 

virtually all health insurance payors, 

public and private, be required 

to submit paid claim data to a 

centralized database. The aggregate 

data would be available for study 

and analysis. The legislation states 

its purpose is to enable these 

governmental entities to analyze paid 

claims, compare the cost of specific 

health care procedures and determine 

quality. The prospect of our state 

government becoming the healthcare 

‘quality czar’ should send a chill 

through the bones of every physician. 

While the news in the daily 

paper is focused on these and other 

bills moving between the House 

and Senate, the WVSMA is also 

watching closely the work of the 

West Virginia Supreme Court of 

Appeals. On March 8, the Court will 

hear oral arguments on our critically 

important medical liability reforms 

enacted in 2003. A final decision is 

not expected until late Spring. This is 

one area I hope we will not see any 

‘change’. Our reforms have worked 

well and must be maintained! 

John H. Schmidt III, MD 

WVSMA President 

Congratulations 

Elizabeth Spangler, MD 

2011 YWCA Women of 

Achievement Honoree 

The West Virginia State 

Medical Association congratulates 

Dr. Elizabeth Spangler upon being 

selected as a 2011 YWCA Women 

of Achievement Honoree. 

Dr. Spangler served as our 

Association’s first female president 

in 2005 and is a past president of the 

Kanawha County Medical Society. 

Dr. Spangler has a great passion 

for medical care and the patients she 

serves. Her career includes positions 

as a member and/or chair of a 

variety of hospital, state and national 

healthcare committees and boards. 

We appreciate her dedication 

to the physicians and patients 

of West Virginia. 

March/April 2011 | Vol. 107

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| Report of the Resolutions Committee 

Report of the Resolutions Committee — January 22, 2011 

Your Committee on Resolutions 

has carefully considered the 

Resolutions offered in the First 

Session of the House of Delegates 

on Saturday, January 22, 2011. 

We are happy to report that a 

number of interested physicians 

appeared at the meeting of the 

Committee on Saturday and 

discussed in detail the Resolutions 

pending before the Committee. 

The cooperation of those 

physicians present was most 

helpful to the Committee in 

reaching decisions and we express 

appreciation to those who took the 

time to attend the opening hearing. 

Mr. Speaker, your Committee 

assures the members of the 

Association that the one and only 

consideration that has guided the 

Committee in its deliberations has 

been the criteria as to whether each 

of the resolutions was or would 

be in the best interest of the entire 

medical profession in West Virginia 

in giving its patients the best of care. 


considered Resolution 1, pertaining 

to Access to Information and the 

State’s Public Health System. 


recommends that Resolution 1 not 

be adopted and that the following 

substitute Resolution 1 be adopted: 

RESOLVED, That the WVSMA 

request the Secretary of the West 

Virginia Department of Health and 

Human Resources to aggressively 

pursue efforts to develop policies 

and if necessary legislation, 

regulations and/or rules that would 

mandate that any agency within 

the state’s public health system 

share any and all information 

with local health departments. 


moves the adoption of 

substitute Resolution 1. 


considered Resolution 2, 

pertaining to Clarifying Rights 

of Physician Service. 


recommends that the Resolution 2 be 

referred to the Executive Committee. 


moves that Resolution 2 be referred. 



to Governance Structure Review. 

Mr. Speaker, your 

Committee recommends that 

Resolution 3 be adopted. 

RESOLVED, that the WVSMA 

Executive Committee oversee a 

comprehensive evaluation of the 

governance structure options and 

take such action as necessary through 

an appropriate committee to present 

to the House of Delegates at its next 

meeting any recommendation(s) 

it considers warranted for 

consideration and possible adoption. 


moves the adoption of Resolution 3. 


considered Resolution 4, 

pertaining to Wind Turbine 

Facilities and Public Health. 





RESOLVED, that the WVSMA will 

endeavor to inform physicians and 

encourage evidence-based research 

regarding the public health effects of 

West Virginia energy production. 






to End of Life Decision Making. 






and the West Virginia Medical 

Foundation provide support and 

education to physicians regarding 

advance care planning and end of life 

decision making; and be it further 

RESOLVED, that the WVSMA and 

West Virginia Medical Foundation 

support initiatives that increase 

public awareness of advance care 

planning and end of life decision 

making and be it further 


encourage its component societies 

to cultivate appropriate community 

partners to encourage advance 

care planning and end of life 

decision making; and be it further 


support the use of public funds that 

actively promotes advance care 

planning and end of life discussions. 

Mr. Speaker, your committee 



Mr. Speaker, we wish to thank 

the members of the WVSMA 

who appeared before the 

Committee for their participation, 

patience, enthusiasm, wisdom, 

endurance, and time devoted to 

the study of the resolutions. 

In addition to me, as Chairman, 

the appointed members of the 

Committee who participated 

in these deliberations were: 

John Holloway, MD 

R. Austin Wallace, MD 

Joseph Reed, MD 

James Felsen, MD 

David Avery, MD 

Joseph Selby, MD 

WVSMA Staff 

Evan Jenkins, Executive Director 

Karie Sharp 

Respectfully submitted, 

F. Thomas Sporck, MD 

Vice President 2010-2011 


Scientific Article | 

A Controversy: Linking Atypical Femoral Fractures to 

Bisphosphonate Therapy 

Christopher C. Trotter, MD 

Alfred K. Pfister, MD 

Brant A. Whited, MSIII 

Todd H. Goldberg, MD 

Steven A. Artz, MD 

West Virginia University School of 

Medicine, Charleston, WV 

Abstract 

Several cases have been reported of 

unusual spontaneous fractures with 

minimal trauma in the subtrochanteric and 

diaphyseal areas of the femur linked to 

long-term bisphosphonate use. After 

encountering three such patients, we 

conducted a review of published cases. 

The average age of these individuals 

were 68 years and approximately 25% 

had received concomitant glucocorticoids. 

Histomorphometric bone biopsy studies 

performed in some individuals have 

suggested that severe suppression of 

bone turnover may be the underlying 

cause; however, cause and effect has not 

been firmly established. Moreover, 

population studies have found this type of 

fracture rare and not increased in patients 

who have received bisphosphonate 

treatment. Physicians should continue to 

use bisphosphonate agents as a primary 

treatment for osteoporosis. 

Introduction 

In normal premenopausal states 

the osteoclastic resorption of old bone 

is balanced by osteoblastic build up 

of new bone. 1 In this instance, a 

continued synthesis of type 1 collagen 

allows for the flexibility of bone, but 

varying degrees of mineralization 

with calcium hydroxy-apatite crystals 

adds to subsequent stiffness. As 

mineralization of collagen matures, 

secondary mineralization occurs with 

larger and more dense crystals. This 

heterogeneous distribution of crystals 

throughout bone collagen limits the 

susceptibility and progression of 

microcrack formation. 

In postmenopausal osteoporosis 

bone turnover becomes accelerated 

with an uncoupling of the 

remodeling process. Osteoclastic 

resorption now exceeds the ability 

of osteoblasts to build new bone, 

and mineralized bone collagen 

is removed before completing 

secondary mineralization. 2 Inhibition 

of this osteoclastic resorption by 

bisphosphonate therapy results in 

a higher secondary mineralization 

with subsequent increases in bone 

mineral density and strength. 

Eventually, the increased rates of 

osteoblastic new bone formation 

during bisphosphonate treatment 

decline as does osteoclastic bone 

resorption, and the biochemical 

markers of bone turnover return 

to premenopausal ranges. 3 This 

reduction in remodeling appears 

to primarily account for the antifracture 

effect of these compounds. 4 

Bisphosphonates are widely 

accepted and prescribed for the 

treatment of postmenopausal 

osteoporosis. A meta-analysis 

of clinical trials has shown these 

compounds to be quite effective 

with a primary prevention of 45% 

for vertebral fractures as well as a 

secondary prevention of 39% for 

hip and 50% for wrist fractures. 5 

Prolonged use of alendronate over 

7 to 10 years has shown a continued 

increase in the bone mineral density 

without any adverse skeletal events. 6‐8 

However, some have questioned 

whether this prolonged and severe 

suppression of bone turnover may 

have negative effects by causing 

accumulation of microdamage and 

localized highly mineralized bone. 9‐10 

This may potentially increase the 

risk of stress fractures. Several cases 

of atypical fractures associated 

with long-term bisphosphonate 

therapy have been reported in 

the proximal femoral shaft with 

minimal or no trauma. 11-24 The 

purpose of this report is to review 

the characteristics of these unusual 

fractures from published reports 

and cases which we encountered 

and evaluate what evidence exists to 

link bisphosphonate treatment to the 

occurrence of these atypical fractures. 

Methods 

The data for 89 atypical femoral 

fractures which were primarily 

suspected as being linked to longterm 

bisphosphonate treatment was 

reviewed. The analysis consisted of 

86 cases obtained from PUBMED 

English-language articles from 2006 

through 2009 and three noted in 

our region over a 30 month period. 

We recorded gender, age at the 

time of fracture, and duration of 

treatment. Additional characteristics 

of delayed healing, concomitant 

glucocorticoid treatment and other 

agents which may inhibit bone 

metabolism, prodromal thigh 

pain, and contralateral cortical 

thickening or stress fractures were 

also evaluated when reported. 

Results 

The pertinent clinical findings 

of 89 cases (86 women and 3 men) 

are provided in Table 1. These 

patients had a mean (SD) age 

of 66.8 (8.4) years with a range 

of 42 to 91 years, and a mean 

(SD) duration of bisphosphonate 

treatment of 5.97 (2.4) years with 

a range 1 to 10 years. Virtually all 

patients received alendronate but 

seven had subsequent treatment 

with ibandronate or risedronate, 

whereas one patient received 

only pamidronate. Concomitant 

glucocorticoid use was observed 

in 28% (19/67). An additional 

24% (12/50) had been prescribed 

other agents (estrogen, tamoxifen, 

raloxifene, methotrexate, or 

 

West Virginia Medical Journal

| Scientific Article 

tibolene) which suppress bone 

turnover, and over one-half of 

these were concomitantly taken 

with glucocorticoids. Adequate 

vitamin D status by serum levels 

or supplements was reported in 

27% (21/79). Either unilateral or 

bilateral thigh pain was experienced 

for weeks or months prior to 

fracturing in 66% (38/58). Minimal 

or no trauma commonly preceded 

the fracture event. The unusual 

radiographic features observed were 

simple transverse or shortly oblique 

fractures with a unicortical spike 

along with cortical hypertrophy in 

the diaphyseal or subtrochanteric 

areas of the femur. Additionally, 

contralateral fractures or stress lines 

along with cortical hypertrophy 

and delayed healing was reported 

in 41% (16/39). Radiographic 

images of these unique fractures are 

illustrated in Figures 1, 2 and 3. 

Discussion 

Histomorphometric studies 

to determine the pathogenesis 

of these atypical fractures have 

implicated severe suppression 

of bone turnover resulting in 

increased fracture susceptibility and 

delayed healing. 11,17,21 Decreased 

osteoblastic and osteoclastic surfaces 

to bone surface ratios were noted 

in endocortical, intracortical, and 

cancellous bone. Importantly, bone 

formation rates were markedly 

reduced including cortical 

areas. Some, however, could not 

conclusively state that suppression 

of bone turnover was the underlying 

cause, and bone biopsies were 

generally performed much later than 

the time of fracture. 21 One report 

which biopsied the patient at the time 

of fracture found a marked increase 

in osteoclasts attached to the bone 

in the femur and concluded that an 

imbalance of bone resorption and 

formation as the likely cause. 19 

If severe suppression of bone 

turnover is plausible as the 

pathogenic mechanism, long-term 

concomitant glucocorticoid therapy 

may play a role once bisphosphonate 

therapy is initiated. 25 Glucocorticoids 

increase osteoblast and osteocyte 

apoptosis which consequently 

results in a decrease in osteoblast 

number and bone formation rates. 26 

Increased osteocyte apoptosis with 

glucocorticoid therapy causes 

disruption of the canalicular system 

resulting in the failure to detect 

microcrack signaling and subsequent 

repair. 27 Inhibition of osteoclastic 

bone resorption by bisphosphonate 

therapy under these circumstances 

theoretically would result in severe 

suppression of bone turnover 

and microdamage accumulation, 

but several randomized, placebocontrolled 

trials have shown that 

bisphosphonate compounds increase 

or maintain the bone mineral 

density in patients receiving chronic 

glucocorticoid therapy. 28-33 On the 

other hand, with the exception of 

one trial performed over a twoyear 

period, all other trials were 

conducted for only a one-year period. 

Vertebral fractures were viewed as 

secondary outcomes and reduced in 

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Table 1. Summary of characteristics in patients with atypical femoral fractures associated with bisphosphonate therapy. 

mean mean yrs. n gluco- n delayed n prodromal n contralateral 

n* age treatment corticoid healing symptoms cortical reaction 

Reference duration therapy or fracture 

11 5 60.2 5.6 2 4 N/A † 2 

12 9 66.9 4.2 2 N/A 5 N/A 

13 1 82 10 0 N/A 1 1 

14 1 73 7 0 1 1 1 

15 19 69.4 6.2 N/A N/A N/A N/A 

16 17 66 4.8 2 N/A 13 9 

17 3 62.6 8.3 3 2 2 3 

18 3 63.3 7 N/A N/A 2 2 

19 1 76 8 1 1 1 1 

20 1 60 6 1 N/A 1 1 

21 7 55.1 6.5 3 3 N/A 2 

22 8 66.9 5.4 4 2 2 4 

23 4 66.3 8.4 0 2 3 1 

24 7 61 8.6 0 0 4 7 

Unpublished 3 76 7.3 1 1 3 2 

*= Numbers of patients presented with specific characteristic in each report. 

† = Information not available in reports. 

most but not all studies; however, no 

reduction in nonvertebral fractures 

was observed. Interestingly, one 

trial conducted over one year did 

not find impaired fracture healing in 

individuals receiving glucocorticoids 

and bisphosphonates. 33 No 

trials of longer duration (e.g., 

five or more years) exist to 

provide evidence whether longer 

treatment with bisphosphonates 

in patients on glucocorticoids 

have an increased susceptibility 

of these atypical fractures. 

These atypical fractures have 

only been retrospectively linked 

to bisphosphonate therapy. 

Furthermore, population-based 

studies have not been able to validate 

this association. A Danish registry 

cohort observational study found 

that fractures in the subtrochanteric 

and diaphyseal locations were no 

more frequent in patients receiving 

alendronate. 34 However, the average 

age of patients with fractures in these 

locations were 12 years older than 

those in our review, and the authors 

were unable to access records to 

determine whether atypical x-ray 

patterns were present similar to the 

reported cases. An Australian study 

after reviewing hip fractures from 

the previous year found that atypical 

femoral fractures were rare and no 

more common in patients who were 

treated with bisphosphonates. 35 

Furthermore, a report reviewing 

three large randomized trials 

also found these fractures to be 

quite rare and not significantly 

increased even in patients who 

received bisphosphonates for as 

long as 10 years. These authors, 

however, were not able to view 

all images of atypical fractures. 

Conclusion 

Physicians should continue to 

prescribe bisphosphonates for the 

treatment of osteoporosis. The 

occurrence of atypical fractures 

in the femur with minimal or no 

trauma in patients receiving longterm 

bisphosphonates appears to 

be rare and the evidence linking 

bisphosphonates as a cause has 

not been strongly substantiated. A 

prospective observational study 

viewing radiographic images along 

with clinical symptoms would 

help to verify the population-based 

studies. New onset of thigh pain 

in a patient receiving long-term 

bisphosphonates warrants imaging 

of the femur. Individuals receiving 

concomitant glucocorticoids or 

other agents which suppress bone 

turnover should also raise awareness 

of the possibility of these fractures. 

Acknowledgements 

The authors acknowledge the 

following persons: Brittain McJunkin, 

MD and Robert Cagna, JD for 

assistance in manuscript review; 

10 West Virginia Medical Journal


Figure 1. 

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

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

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

teriparatide for recovery. 

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West Virginia University - Charleston Division 

Robert C. Byrd Health Sciences Center 

Charleston Division 

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Please submit letter of interest and curriculum vitae to: 

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Professor and Chairman 

Department of Internal Medicine 

West Virginia University 

Charleston Division 

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Fax: (304) 347-1344 

Office: (304) 347-1254 

E-mail: grosencrance@hsc.wvu.edu 

Women and minorities are encouraged to apply. 

West Virginia University is an Affirmative Action 

Equal Employment Opportunity Employer 

22554-J10 

March/April 2011 | Vol. 107 11


Figure 2. 

A 66 year old female on alendronate for 7 years noted bilateral thigh pain for several 

weeks. When turning from a standing position, she experienced severe thigh pain and 

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

Nuclear imaging revealed a contralateral stress reaction (b). 

Figure 3. 

A 68 year-old white female who received 

estrogen and bisphosphonates for 5.5 

years experienced right thigh pain for 2 

weeks causing her to fall which resulted 

in a subtrochanteric fracture. 

orthopedists William G. Sale, MD 

and Tony C. Majestro, MD for their 

review of cases and radiographic 

images; and the late Paul D. 

Saville, MD for his comments. 

References 

1. Chavassieux P, Seeman E, Delmas PD. 

Insights into the material and structural 

basis of bone fragility from diseases 

associated with fracture: How determinants 

of the biomechanical properties of bone are 

compromised by disease. Endocrine 

Reviews. 2007;28:151-164. 

2. NIH Consensus Development Panel on 

Osteoporosis, Diagnosis, and Therapy. 

Osteoporosis diagnosis, and therapy. JAMA 

2001;285:785-795. 

3. Greenspan S, Parker RA, Ferguson L, 

Rosen HN, Maitland-Ramsey L, Karpf DB. 

Early changes in biochemical markers of 

bone turnover predict the long-term 

response to alendrodronate therapy in 

representative elderly women. J Bone Miner 

Res 1998;13:1431- 1438. 

4. Cummings SR, Karpf DB, Harris F, et al. 

Improved spine bone mineral density and 

reduction in risk of vertebral fractures during 

treatment with antiresorptive drugs. Am J 

Med. 2002;112;281-289. 

5. Wells GA, Craney A, Peterson J, et al. 

Alendronate for the primary and secondary 

prevention of osteoporotic fractures in 

postmenopausal women. Cochrane 

Database of Systematic Reviews. 2008, 

Issue 1. Art No.:CD001155. 

DOI:10.1002/14651858. CD001155.pub2. 

6. Bone HG, Hosking D, Devogelaer J-P, et al. 

Ten years’ experience with alendronate for 

osteoporosis. New Engl J Med 

2004;350:1189-1199. 

7. Tonino R, Meunier PJ, Emkey R, et al. 

Skeletal benefits of alendronate: 7-Year 

treatment of postmenopausal osteoporotic 

women. J Clin Endocrinol Metab 

2000;85:3109-3115. 

8. Black DM, Schwartz AV,Ensrud KE, et al. 

Effects of continuing or stopping 

alendronate after 5 years of treatment. 

JAMA 2006;296:2927-2938. 

9. Ott SM. Fractures after long-term 

alendronate therapy. J Clin Endocrinol 

Metab. 2001;86: 1835. 

10. Hirano T, Turner CH, Forwood MR, 

Johnston CC, Burr DB. Does suppression 

of bone turnover impair mechanical 

properties by allowing microdamage 

accumulation Bone. 2000;21:13-20. 

11. Odvina CV, Zerwekh JE, Sudhaker Rao D, 

Maalouf N, Gottshalk FA, Pak CYC. 

Severely suppressed bone turnover: A 

potential complication of alendronate 

therapy. J Clin Endo- crinol Metab. 

2005;90:1294-1301. 

12. Goh SK, Yang KY, Koh JSB, et al. 

Subtrochanteric insufficiency fractures in 

patients on alendronate therapy: A caution. 

J Bone Joint Surg Br. 2007;89:349-353. 

13. Cheung RKH, Leung KK, Lee KC, Chow 

TC. Sequential non-traumatic femoral neck 

fractures in a patient on long-term 

alendronate. Hong Kong Med J. 

2007;13:485-489. 



14. Sayed-Noor A, Sjoden GO. Subtrochanteric 

displaced insufficiency fracture after longterm 

alendronate therapy- a case report. 

Acta Orthopaedica. 2008;79:565-567. 

15. Neviaser AS, Lane JM, Lenart BA, Edobor- 

Osula F, Lorich DG. Low-energy femoral 

shaft fractures associated with alendronate 

use. J Orthop Trauma. 2008;22:346-350. 

16. Kwek EBK, Goh SK, Koh JSB, Png MA, 

Howe TS. An emerging pattern of 

subtrochanteric stress fractures: A longterm 

complication of alendronate therapy 

Injury. 2008;39:224- 231. 

17. Visekruna M, Wilson D, McKiernan FE. 

Severely suppressed bone turnover and 

atypical skeletal fragility. J Clin Endocrinol 

Metab. 2008;93:2948-2952. 

18. Schneider JP. Bisphosphonates and lowimpact 

femoral fractures: Current evidence on 

alendronate risk. Geriatrics 2009;64:18-23. 

19. Somford MP, Draijer FW, Thomassen DJW, 

Pascale MC, Boivin G, Papapoulos SE. 

Bilateral fractures of the femur diaphysis in 

a patient with rheumatoid arthritis on longterm 

alendronate: clues to the mechanism 

of increased bone fragility. J Bone Miner 

Res. 2009 [epub ahead of print] 

20. Edwards MH, McCrae FC, Young-Min SA. 

Alendronate-related femoral diaphysis 

fracture- what should be done to predict 

and prevent subsequent fracture of the 

contralateral side Osteoporos Int. 2009 

June 27 [Epub ahead of print] PMID 

19562241. 

21. Armamento-Villareal R, Napoli N, Diemer R, 

et al. Bone turnover in bone biopsies of 

patients with low-energy cortical fractures 

receiving bisphosphonates: A case series. 

Calcif Tissue Int. 2009;85:37-44. 

22. Ing-Lorenzini K, Desmueles J, Plachta O, 

Suva D, Dayer P, Peter R. Low-energy 

fractures associated with long-term use of 

bisphosphonates. Drug Saf. 2009;32:775-785. 

23. Cermak K, Shumelinsky F, Alexiou J, 

Gebhart MJ. Case reports: Subtrochanteric 

stress fractures after prolonged alendronate 

therapy. Clin Orthop Relat Res. 2009 Dec 

18 [Epub ahead of print]. 

24. Capeci CM, Tejwant NC. Bilateral lowenergy 

simultaneous or sequential femoral 

fractures in patients on long-term 

alendronate therapy. J Bone Joint Surg Am. 

2009;91:2556-2561. 

25. Dempster DW, Arlot MA, Meunier PJ. Mean 

wall thickness and formation periods of 

trabecular bone packets in corticosteroidinduced 

osteoporosis. Calcif Tissue Inter. 

1983;36:410-417. 

26. Jilka RL, Weinstein RS, Parfitt AM, 

Manolagas SC. Quantifying osteoblast 

and osteocyte apoptosis: Challenges and 

rewards. J Bone Miner Res. 

2007;22:1492-1501. 

27. Manolagas SC. Corticosteroids and 

fractures: A close encounter of the third cell 

kind. J Bone Miner Res.2000;15:1001-1005. 

28. Reid DM, Hughes RA, Lawn RFJM, et al. 

Efficacy and safety of long-term risedronate 

in the treatment of glucocorticoid-induced 

osteoporosis in men and women: A 

randomized trial. J Bone Miner Res. 

2000;15:1006-1013. 

29. Adachi JD, Saag KG, Delmas PD, et al. 

Two-year effects of alendronate on bone 

mineral density and vertebral fracture in 

patients receiving glucocorticoids. Arth 

Rheum. 2001;44: 202-211. 

30. Saag KG, Emkey R, Schnitzer TG, et al. 

Alendronate for the prevention and treatment 

of glucocorticoid-induced osteoporosis. N 

Engl J Med. 1998;339:292-229. 

31. Adachi JD, Bensen WG, Brown J, et al. 

Intermittent etidronate therapy to prevent 

corticosteroid-induced osteoporosis. N Engl 

J Med. 1997;337:382-287. 

32. Wallach S, Cohen S, Reid DM, et al. Effects 

of risedronate treatment on bone density 

and vertebral fracture in patients on 

corticosteroid therapy. Calcif Tissue Int. 

2000;67:277-285. 

33. Cohen S, Levy RM, Keller M, et al. 

Risedronate therapy prevents 

corticosteroid-induced bone loss. Arthritis 

Rheum. 1999;42:2309-2318. 

34. Abrahamsen B, Eiken P, Eastell R. 

Subrochanteric and diaphyseal femur 

fractures in patients treated with 

alendronate: A register-based national 

cohort study. J Bone Miner Res. 

2009;24:1095-1102. 

35. Lee P. Atypical femoral fractures. CMAJ. 

2010;182:384-385. 

36. Black DM, Kelly MP, Genant HK, et al. 

Bisphosphonates and fractures of the 

subtrochanteric and diaphyseal femur. N 

Eng J Med. 2010 Mar 24 [epub ahead of 

print]. 



Report of Increased Number of Children with 

Parapneumonic Empyema as a Complication of 

Bacterial Pneumonia in West Virginia in 2005 

Kathyrn Moffett, MD 

Associate Professor of Pediatrics 

Ann-Marie Tantoco, MD 

Internal Medicine/Pediatric Resident 

Ohio State University 

Introduction 

Pediatric invasive disease from 

Streptococcus pneumoniae in children 

has diminished since the introduction 

in 2000 of the heptavalent 

pneumococcal conjugate vaccine 

(PCV-7 or Prevnar ®) . 1,2 Pediatric 

parapneumonic empyema (PPE), 

a rare complication of bacterial 

pneumonia in children, has been 

increasing globally due to nonvaccine 

serotype replacements of 

S pneumoniae, with serotype 19A 

most commonly discovered. 3-20 

Recently a similar increase 

of parapneumonic empyema 

complicating bacterial pneumonia in 

2005 was observed in children treated 

at the West Virginia University 

Children’s Hospital (WVU-CH) in 

Morgantown, WV. We conducted 

a retrospective review of medical 

records from 2000-2007 to determine 

the number of children with PPE, 

with an attempt to determine the 

causative agent(s) and risk factors. 

Methods 

This study reviewed the medical 

records of childhood pneumonia 

complicated by parapneumonic 

empyema admitted to WVU-CH. 

The Institutional Review Board of 

West Virginia University reviewed 

and approved this retrospective 

study. The computerized data 

management system was queried 

for all cases of parapneumonic 

empyema in children less than 18 

years of age and for a diagnosis 

of pneumonia for the period of 

January 2000 to December 2007. 

The microbiology data for detection 

of viral respiratory specimens 

(influenza and respiratory syncytial 

viruses) was queried for 2000- 

2007. All children with pneumonia 

and PPE as a complication of 

cardiothoracic surgery, as well as 

premature infants with gestational 

age


Table 1: Demographics of Children with Parapneumonic Empyema at 

WVU-Children’s Hospital from January 1, 2000 to December 31, 2007 

Number of Cases 36 

4 years of age 25 

Females 19 (53%) 

Median Age (years) [Range in years] 7.2 [0.6-17] 

Surgical procedure performed 

Chest tube placement 36 [100%] 

Video-assisted thorascopy or decortication 14 [39%] 

Receipt of Prevnar- 7 Vaccine 8 (25%) 

Length of Stay (days) [Range in days] 10 [5-16] 

Race: Caucasian 33 

African American 2 

Unspecified 1 

State of Residence: West Virginia 29 (80%) 

Pennsylvania 4 (11%) 

Ohio 2 (6%) 

Maryland 1 (3%) 

PPE= Parapneumonic Empyema 

Serotyping of Streptococcus 

pneumoniae isolates 

Five of the 8 isolates of S 

pneumoniae were available for 

serotyping, each showing a different 

serotype: serotype 1 (year isolated 

2001), 7 (2002), 12F (2000), 19A 

(2005), and 19F (2005). Serotypes 

in the PVC-7 vaccine include 4, 

6B, 9V, 14, 18C, 19F, and 23F. 

Antimicrobial treatment 

None of the eight children with 

a positive blood/ pleural culture 

received oral antimicrobial agents 

prior to cultures being obtained; 

one child with a positive blood 

culture also had a positive pleural 

fluid culture. Nine children received 

oral antibiotics prior to blood and 

pleural cultures being obtained, 

which included cedinir (1 child), 

azithromycin/ cefuroxime (1), 

azithromycin/levofloxacin (1), 

amoxicillin-clavulenate (2), and 

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Figure 1. 

azithromycin/amoxicillin-clavulenate 

(4). During hospitalization, antibiotic 

treatment among the 36 children 

was variable, with choices for 

intravenous/ parenteral antibiotics 

including: ticarcillin-clavulenate (1 

culture-negative child), ceftriaxone 

(27 children, including all 8 culturepositive), 

and ceftriaxone and 

clindamycin (8 culture-negative 

children). A minority of the 

children (8) received treatment 

for MRSA infection, although no 

cultures grew any Staphylococcus 

isolates. It is not within the scope 

of this retrospective review to 

determine the reasons behind the 

choice(s) of antimicrobial agents. 

Discussion 

Annual rates of pneumonia in the 

United States in children


Figure 2. 

Serotypes 1, 7, 19A, 19F and 22F 

were present in the culture isolates 

from children treated in West 

Virginia. Only one of those serotypes 

was a PCV-7 serotype in a child 

determined to be immunocompetent. 

Our experience in WV reflects other 

reports in the United States that there 

is an increase in PPE in children 

with an emergence of non-PCV- 

7 serotypes being more prevalent 

as the causative agents, with four 

different non-PCV- S pneumoniae 

7 serotypes isolated. Other studies 

have demonstrated predominance of 

non-PCV-7 serotype 19A, however 

non-PCV-7 serotypes 1, 3, 15, 22F, 

and 33F also been reported as the 

pathogens in children with PPE. 3-20 

Urine antigen testing was not 

performed in all children, but may 

be helpful in guiding therapy in the 

face of a suspected pneumococcal 

invasive infection. The Infectious 

Disease Society of America (IDSA) 

guidelines for evaluation of 

community–acquired pneumonia 

recommend use of the pneumococcal 

urine antigen test, as an adjunct to 

culture in the diagnosis of etiology 

of the infection. The sensitivity of 

the antigen test is 86-100%, and the 

specificity approaches 100%. 22-23 

Studies have looked at the utility of 

antigen testing and polymerase chain 

reaction (PCR) testing of pleural 

fluid, as ways to confirm the etiology 

of infection in bacterial pneumonia 

but not yet clinically available. 24-27 

As a retrospective review, there 

were likely children with PPE 



who may have been missed by our 

database search. In addition, the 

information collected was only as 

accurate as the electronic medical 

records contained. It was not within 

the scope of this study to review all 

medical records with a diagnosis 

of only pneumonia. The number of 

children with positive cultures was 

small (eight) with only five bacterial 

isolates serotyped, and this limits 

understanding the predominate 

S pneumoniae serotype of PPE in 

children in West Virginia. Reports 

of proven bacterial etiology of PPE 

in children include pneumococcus, 

Streptococcus (non-pneumococcal 

species), Staphylococcus, and other, 

unspecified, bacteria. The majority 

of children in our series with 

culture-negative PPE were not 

treated with anti- Staphylococcal 

antimicrobial agents, making MRSA 

an unlikely missed etiology. A 

minority of children in our series 

received antibiotic treatment before 

bacterial blood cultures were 

obtained which limited potential 

assistance in diagnosis; all the 

children with a positive, diagnostic 

blood and/ or pleural cultures 

received no oral antimicrobial 

agents prior to hospitalization 

when the cultures were obtained. 

Even after the approval of the 

conjugate PCV-7 vaccine (meant 

to prevent invasive disease in 

young infants and children), 

bacterial pneumonia, complicated 

by parapneumonic empyema, still 

remains a common infection in of 

the United States. Invasive disease 

from the seven Prevnar ® serotypes 

of S. pneumoniae has been successful: 

reduction of disease in children 

has been reduced. In addition 

carriage of those seven serotypes is 

prevented, and invasive disease in 

adult caregivers of young children 

has been reduced as well. 28-29 

However serotype replacement 

is occurring, as evidenced by 

reports of pneumococcal lower 

respiratory disease. In West Virginia, 

from 2000-2007, 36 children with 

bacterial pneumonia, complicated 

by parapneumonic empyema, 

were treated at WVU- Children’s 

Hospital. In 2005, the highest annual 

number of cases were identified 

(16), compared to other years when 

the mean number was 2.9 cases 

(range 1-4). No explanation for this 

unusual year is evident. The majority 

of these children in 2005 (11 of 

16) were never vaccinated against 

Streptococcus pneumoniae because they 

were ineligible in 2000 when PVC-7 

was available (patients were beyond 

2-years of age and not in the high 

risk category at licensure). It seems 

unlikely that a change in regional 

pneumococcal vaccine coverage for 

that period in 2005 would explain 

the peak in cases; no problem with 

vaccine lots used in the regional or 

national area occurred around that 

time. If there was an emergence of a 

new Streptococcus pneumoniae or other 

Streptococcal (eg Streptococcus pyogenes) 

strain(s) in 2005, it was self-limited, 

given the precipitous drop for 2006 

and 2007 in number of cases of PPE. 

The increased number of cases in 

2005 may have just been a chance 

event, e.g. a statistical anomaly. 

It is well known that invasive acute 

lower respiratory bacterial disease 

commonly follows viral respiratory 

infections. In addition many bacterial 

and viral infections are known to 

occur in cyclical patterns over a 4 

to 5-year period, with some years 

appearing rather mild (low incidence) 

and other years more severe (higher 

incidence). Although few children 

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

pneumonia Antigen, January 1, 2000 to December 31, 2007. 

Results: Bacterial Culture & Streptococcus pneumonia Urine Antigen 

Year 

Pneumonia, 

unspecified 

Empyema Urine Antigen Positive Urine Antigen Negative No Urine Antigen Done 

Culture* + Culture - Culture* + Culture - Culture* + Culture - 

2000 62 3 0 0 0 0 1 2 

2001 86 1 0 1 0 0 0 0 

2002 100 4 0 1 0 1 1 1 

2003 122 4 1 2 0 0 0 1 

2004 117 2 0 1 0 0 0 1 

2005 113 16 3 5 0 6 1 1 

2006 56 3 0 3 0 0 0 0 

2007 97 3 1 1 0 0 0 1 

Totals 753 36 5 14 0 7 3 7 

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

etiology S pneumonia infection 



in our series had concomitant viral 

testing performed, perhaps the 

winter season of 2005 was associated 

with a more virulent viral respiratory 

season, predisposing children to 

secondary bacterial infection. It 

is plausible that this season was 

coincident with an increased cyclical 

season of bacterial invasive disease 

as well; this chance phenomenon 

may explain our findings. 

Continued surveillance for the 

serotypes of S pneumonia is important 

in understanding the disease, with 

perhaps targets for expanded vaccine 

coverage. Appropriate treatment 

includes prompt recognition of 

infection in children, obtaining 

appropriate cultures, and the proper 

initiation of antimicrobial treatment. 

Urine antigen testing and PCR 

testing may be helpful guides in 

determining the etiology of bacterial 

pneumonia. S pneumoniae is still 

the apparent bacterial etiology in 

the majority of cases, as was our 

experience, although diligence for 

methicillin-resistant S aureus (MRSA) 

pneumonia must continue. In 2010 

a new pneumococcal conjugate 

vaccine (Prevnar-13 ® ) has been 

licensed to replace PCV-7, adding 

additional serotype protection 

against pneumococcal disease in 

children and the community. 

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15;42(8):1135-40. Epub 2006 Mar 7. 

25. Menezes-Martins LF, Menezes-Martins JJ, 

Michaelson VS, et al. Diagnosis of 

parapneumonic pleural effusion by 

polymerase chain reaction in children. J 

Pediatr Surg 2005;40:1106-10. 

26. Hamano-Hasegawa K, Morozumi M, 

Nakayama E, Chiba N, Murayama SY, 

Takayanagi R, Iwata S, Sunakawa K, 

Ubukata K; Acute Respiratory Diseases 

Study Group. Comprehensive detection of 

causative pathogens using real-time PCR 

to diagnose pediatric community-acquired 

pneumonia. J Infect Chemother. 2008 

Dec;14(6):424-32. 

27. Smith MD, Sheppard CL, Hogan A, 

Harrison TG, Dance DA, Derrington P, 

George RC; South West Pneumococcus 

Study Group. Diagnosis of Streptococcus 

pneumoniae infections in adults with 

bacteremia and community-acquired 

pneumonia: clinical comparison of 

pneumococcal PCR and urinary antigen 

detection. J Clin Microbiol. 2009 

Apr;47(4):1046-9. 

28. Millar EV, Watt JP, Bronsdon MA, Dallas J, 

Reid R, Santosham M, O’Brien KL. Indirect 

effect of 7-valent pneumococcal conjugate 

vaccine on pneumococcal colonization 

among unvaccinated household members. 

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

29. Azzari C, Resti M. Reduction of carriage 

and transmission of Streptococcus 

pneumoniae: the beneficial “side effect” of 

pneumococcal conjugate vaccine. Clin 

Infect Dis. 2008 Oct 15;47(8):997-9. 



Medical Management of Cerebellar Abscess: A Case 

Report and Review of the Literature 

Ryan C. Turner, B.S. 

Sean C. Dodson, B.S. 

Charles L. Rosen M.D., Ph.D.* 

Department of Neurosurgery, West 

Virginia University, Morgantown 

Abstract 

A large abscess of the posterior fossa 

often warrants surgical intervention. We 

report a case of a 50 year-old male 

presenting with a cerebellar abscess 

measuring 2.8 cm x 1.6 cm located in the 

left cerebellar hemisphere at the level of 

the middle cerebellar peduncle that was 

treated conservatively and successfully 

with antibiotics. Therapeutic management 

options are discussed in regards to this 

case specifically as well as a review of the 

literature. This case illustrates the 

successful medical management of a 

cerebellar abscess of otogenic origin in an 

adult, a unique result in terms of abscess 

size and age of the patient. 

Introduction 

Despite reductions in morbidity 

and mortality as a consequence of 

antibiotic development, cerebellar 

abscess remains a significant 

medical problem particularly in 

the developing world. 6,7,9,12,15-17 

Incidence rates reported in the 

literature identify cerebellar abscess 

as afflicting those primarily in the 

second and third decade of life. 9,11 

Although cerebellar abscess has been 

documented in the literature for over 

one-hundred years, management 

techniques remain controversial. 

Recent studies have described 

treatment protocols that range 

from conservative management 

with only antibiotics 1,3,8,14,16,20 to 

the more common yet invasive 

surgical excision or drainage 

accompanied by antimicrobial 

treatment. 2,4,6,10,12,18,19 Determination 

of the most appropriate clinical 

approach remains largely subjective 

with some suggesting that size 

of the abscess, 14,16,20 age, 20 illness 

duration, 5 and neurological deficit 16,20 

at presentation are criteria to be used 

in determining the most suitable 

management technique for brain 

abscess. Notably, location must 

also be considered 14,16 as posterior 

fossa masses are more likely to 

require surgical intervention. 

Case Report 

The patient, a 50 year-old white 

male, was treated with an oral course 

of antibiotics for suspected chronic 

otitis media with little success. The 

patient failed to improve following 

the oral antibiotic regimen at which 

time the patient was diagnosed with 

a left-sided encapsulated cerebellar 

abscess and transferred to the medical 

service at West Virginia University 

for treatment. Following transfer 

to West Virginia University, the 

patient’s neurologic exam revealed 

gait abnormalities, finger to nose 

dysmetria, horizontal nystagmus, 

vertigo, tinnitus, positive Weber and 

Rinne test, and severe headache and 

earache. A CT scan demonstrated 

otomastoiditis and question of a left 

cerebellar abscess (Figure 1a,b). The 

patient was immediately started 

on a broad spectrum antibiotic 

regimen (i.v. vancomycin, i.v. 

ceftriaxone, and oral metronidazole). 

Following treatment for 24 hours 

with broad-spectrum antibiotics, 

Neurosurgery was consulted for 

possible surgical intervention. The 

size, location and appearance of the 

lesion were considered appropriate 

for surgical intervention (Figure 1c). 

However, the patient had improved 

substantially since antibiotic 

treatment had been initiated. Upon 

neurologic examination, it was noted 

the patient ambulated normally and 

there was complete resolution of 

finger to nose dysmetria, earache, 

and headache. Consequently, 

conservative management was 

continued with frequent clinical 

observation to reassess the need for 

surgical intervention. The patient’s 

neurologic status continued to 

improve and resolution of the abscess 

was verified with radiographic 

studies obtained two months 

post-presentation (Figure 1d). The 

patient is now 12 months status-post 

completion of antibiotic therapy. No 

recurrence of symptoms has occurred 

and previous deficits have resolved. 

Discussion 

Otogenic cerebellar abscesses, 

particularly in the second and 

third decade of life, are one of the 

most dangerous complications of 

chronic otitis media. 9,11 Although 

mortality rates have continued to 

decline with the advancement of 

modern imaging and antibiotic 

therapy, cerebellar abscesses still 

pose a serious threat and require 

immediate management. 6,7,9,12,15-17 

Currently the recommended 

treatment of such conditions is 

widely debated; however surgical 

intervention appears to be the 

preferred method of treatment. 

The non-surgical management 

technique has been documented as 

a viable approach in the literature, 

particularly in cases of small 

abscesses (less than 2.5-3 cm in 

diameter), 5,6,14,16,20 young patients, 20 

presentation without neurological 

deficits, 1,3,8,20 multiple abscesses, and 

abscesses in locations not amenable 

to surgical intervention. 1,5,14,20 

Other contraindications to surgery 

are meningitis or ventriculitis 

not requiring CSF diversion. 14 



Figure 1. 

a) CT scan illustrates opacification of the left mastoid air cells suggestive of 

otomastoiditis b) CT scan with contrast demonstrating large area of decreased density 

in the left cerebellar hemisphere c) Axial T1WI MRI with contrast showing a bilocular 

cerebellar abscess measuring 2.8 cm x 1.6 cm posterior to the left petrous bone after 

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

broad-spectrum antibiotic regimen, demonstrating resolution of cerebellar abscess 

Rosenblum et al. proposed a 

treatment scheme for nonspecific 

brain abscesses in general based on 

neurological status upon presentation 

in which patients were identified as 

Grade I (alert), Grade II (lethargic), 

Grade III (responds to painful 

stimulus only) or Grade IV (no 

response to pain). In this treatment 

scheme, patients presenting in a 

Grade III or IV neurological state, 

as well as those presenting with 

clinical deficits consistent with the 

lesion, are operated on as soon as 

possible. For patients presenting 

as a stable or improving Grade I or 

II, a targeted antibiotic regimen is 

then administered. 14 Cavusoglu et al. 

proposed that medical management 

of brain abscess without surgical 

intervention may be successful in 

patients with illness duration of 

less than two weeks when four 

conditions are met. These include a 

known pathogen, no neurological 

deficits, abscess less than 3 cm 

in diameter, and no signs of 

increased intracranial pressure. 6 

A case report by Spinnato et al. 

described the successful nonoperative 

treatment of a 4 x 3 cm biloculated 

cerebellar abscess in a five year-old 

child. 20 This case diverged from 

the treatment recommendations by 

Cavusoglu et al. 6 in abscess size and 

presence of elevated intracranial 

pressure due to compression of the 

IV ventricle. This case represents the 

only known resolution of a cerebellar 

abscess greater than 3 cm in diameter 

following nonsurgical treatment. 

Of interest with regards to the 

presented case is that literature up 

until the case presented by Spinnato 

et al. did not address the issue of age 

in determining the most appropriate 

management strategy for brain 

abscess, and cerebellar abscess more 

specifically. Uniquely, Spinnato et al. 

suggest the importance of age and 

neurologic status in determining 

the treatment plan for cerebellar 

abscess as indicated by the successful 

nonsurgical treatment of a large, 

biloculated cerebellar abscess in a 

five year-old child. 20 The case we 

present diverges from the proposed 

guidelines for management by 

Spinnato et al. who stated that age, 

along with neurologic status, is the 

most important factor in determining 

treatment approach. 20 While it is 

clear that neurologic status must 

be considered 13 the authors posit 

that this case would have been 

managed surgically under most 

circumstances. In this unusual 

situation, the patient was treated with 

antibiotics prior to neurosurgical 

consultation. Upon consultation 

the patient still had significant 

neurologic symptoms and deficits, 

but was substantially improved. 

Furthermore his improvement in 

exam resulted in his refusal of more 

“definitive” care. Consequently, he 

was managed conservatively with 

imaging, antibiotics, and frequent 

exams. The pathogen was never 

determined specifically in this 

case yet was treated successfully 

through a broad-spectrum antibiotic 

regimen which counters the 

suggestion by Cavusoglu et al. 

stating that the pathogen must be 

known for antibiotic treatment. 

It is our belief that most 

neurosurgeons would immediately 

initiate surgical evacuation of an 

encapsulated posterior fossa abscess 

presenting with obvious neurologic 

deficits, but our case illustrates 

successful treatment with solely a 



medical approach. We do not propose 

that nonsurgical management is the 

ideal approach to large cerebellar 

abscess. However, our experience 

with this one patient does suggest 

that patients with contraindications to 

surgery can potentially be managed 

successfully with antibiotic treatment, 

despite the radiographic appearance 

of an abscess. Though this concept 

of antibiotic treatment is pervasive 

in the pediatric/young adult 

literature, we are not familiar with an 

equivalent finding in a mature adult. 

References 

1. Barsoum AH, Lewis HC, Cannillo KL. 

Nonoperative Treatment of Multiple Brain 

Abscesses. Surg Neurol 1981; 16(4):283-7. 

2. Bento R, de Brito R, Ribas GC. Surgical 

management of intracranial complications 

of otogenic infection. Ear Nose Throat J 

2006; 85(1):36-9. 

3. Berg B, Franklin G, Cuneo R, et al. 

Nonsurgical Cure of Brain Abscess: Early 

Diagnosis and Follow-up with 

Computerized Tomography. Ann Neurol 

1978; 3(6):474-8. 

4. Brewer NS, MacCarty CS, Wellman WE. 

Brain Abscess: A Review of Recent 

Experience. Ann Intern Med 1975; 82:571-6. 

5. Britt RH, Enzman DR. Clinical stages of 

human brain abscess on serial CT scans 

after contrast infusion. J Neurosurg 1983; 

59:972-89. 

6. Cavusoglu H, Kaya RA, Turkemenoglu 

ON, et al. Brain abscess: analysis of 

results in a series of 51 patients with a 

combined surgical and medical approach 

during an 11-year period. J Neurosurg 

Focus 2008; 24(6):E9. 

7. Hedge AS, Venkataramana NK, Das BS. 

Brain abscess in children. Childs Nerv Syst 

1986; 2:90-2. 

8. Heineman HS, Braude AI, Osterholm JL. 

Intracranial Suppurative Disease. Early 

Presumptive Diagnosis and Successful 

Treatment Without Surgery. JAMA 1971; 

218(10):1542-7. 

9. Kangsanarak J, Fooanant S, 

Ruckphaopunt K, et al. Extracranial and 

intracranial complications of suppurative 

otitis media. Report of 102 cases. J 

Laryngol Otol 1993; 107:999-1004. 

10. Leskinen K, Jero J. Acute complications of 

otitis media in adults. Clin Otolaryngol 

2005; 30:511-6 

11. Manto, M.U. and Pandolfo, M (2002) The 

Cerebellum and its Disorders. Cambridge: 

UK Cambridge University Press, pp 237-47. 

12. Morgan H, Wood MW, Murphey F. 

Experience with 88 consecutive cases of 

brain abscess. J Neurosurg 1973; 38:698- 

704. 

13. Polyzoidis KS, Vranos G, Exarchakos G, et 

al. Subdural empyema and cerebellar 

abscess due to chronic otitis media. Int J 

Clin Pract 2004; 58(2):214-7. 

14. Rosenblum ML, Hoff JT, Norman D, et al. 

Nonoperative treatment of brain abscesses 

in selected high-risk patients. J Neurosurg 

1980; 52:217-25. 

15. Rosenblum ML, Hoff JT, Norman D, et al. 

Decreased mortality from brain abscesses 

since advent of computerized tomography. 

J Neurosurg 1978; 49(5):658-68. 

16. Rosenblum ML, Mampalam TJ, Pons VG. 

Controversies in the Management of Brain 

Abscesses. Clin Neurosurg 1986; 33:603-32. 

17. Samson DS and Clark K. A Current Review 

of Brain Abscess. Am J Med 1973; 54(2): 

201-10. 

18. Seven H, Coskun BU, Calis AB, et al. 

Intracranial abscesses associated with 

chronic suppurative otitis media. Eur Arch 

Otorhinolaryngol 2005; 262:847-51. 

19. Shaw MDM, Russell JA. Cerebellar 

abscess: A review of 47 cases. J Neurol 

Neurosurg Psychiatry 1975; 38:429-35. 

20. Spinnato S, Mazza C, Bricolo A. 

Nonoperative treatment of cerebellar 

abscesses. A case report and review of the 

literature. Childs Nerv Syst 1998; 14:606-09. 

Book Review 

Atlas of Otoscopy 

Dr. Joseph B. Touma and his 

son (and practice partner) Dr. B. 

Joseph Touma of Huntington have 

written an excellent resource, Atlas 

of Otoscopy, Plural Publishing, 

Inc., San Diego: 2006. This atlas 

is a good reference for medical 

students, residents, and practicing 

physicians, (otolaryngologists 

and non-otolaryngologists 

alike.) Dr. Touma, the elder, has 

accumulated numerous photos of 

ear canal, tympanic membrane, and 

middle ear pathologies over the 

years. These have been augmented 

by Dr. Touma, the younger who 

has also provided photos from his 

years in practice as a neuro-otologist. 

Dr. B. Joseph Touma tells me that 

it was quite a chore for the predigital 

age photos to be converted 

to digital form with subsequent 

enhancement. The Drs. Touma 

have succeeded beautifully and 

are to be heartily congratulated. 

This atlas would be an excellent 

addition to the library of anyone 

called upon to diagnose ear disease. 


Otolaryngologist 



Primary Care Office Responses to a Stroke Scenario 

Brett Jarrell, MD 


Stephen M. Davis, MPA, MSW 


John Coyner, MD 

Marshall University 

Todd Crocco, MD 


Charles Whiteman, MD 


This study was conducted at West 

Virginia University and presented at the 

2008 International Stroke Conference, 

February 20-21, 2008, New Orleans, LA 

Abstract 

Purpose: One previous study found 

that healthlines affiliated with academic 

neurology programs recommended nonemergent 

treatment for a hypothetical 

stroke scenario almost one quarter of the 

time, which could contribute to patients 

presenting too late for time dependent 

stroke therapies. We assessed the 

treatment advice given in a hypothetical 

stroke scenario by primary care physician 

offices across the United States. 

Methods: We obtained a national 

listing of United States primary care 

physician offices from Yellowpages.com, 

and selected a systematic random sample 

of numbers to call. The respondent 

answering the phone was presented with 

a standardized, scripted stroke patient 

scenario, and asked to choose one of four 

responses that could be provided (wait for 

symptom resolution, attempt to schedule 

an office appointment later in the day, 

schedule an office visit within two days, 

call 911 for ambulance transport to a 

hospital). 

Results: Forty-two respondents 

completed the survey (average age = 43 

years; 88% female), with 29% (95% CI 

17%-44%) recommending scheduling an 

appointment later in the day if symptoms 

do not resolve. The remaining 

respondents recommended calling 911. 

When presented with a heart attack 

scenario, 100% of respondents 

recommended calling 911. 

Conclusions: Almost one third of the 

primary care physician offices 

recommended scheduling an appointment 

later in the day for a hypothetical stroke 

case, despite always giving the correct 

answer of call 911 for a classic heart attack 

scenario. These results suggest that stroke 

education with specific emphasis on the 

need to call 911 may be needed for 

primary care physician office receptionists. 

Abbreviations 

ED Emergency Department 

BSN Bachelor of Nursing Science 

PCP Primary Care Physician 

LPN Licensed Practical Nurse 

Introduction 

Acute stroke is a time dependent 

emergency in which patients have 

historically presented to the hospital 

outside of the therapeutic window 

for effective intravenous thrombolytic 

therapy. Unfortunately, this trend 

persists to the present day with only 

20% of acute ischemic stroke patients 

arriving at the emergency department 

(ED) within 2.5 hours of symptom 

onset in a recently published study. 1 

Although there are multiple 

factors that contribute to delayed 

ED presentation, prior research has 

suggested that the initial treatment 

advice given to potential stroke 

patients (or their family and friends) 

by the healthcare system itself 

may be a contributing factor. In 

one study, almost one quarter of 

healthline operators affiliated with 

academic neurology programs in 

the United States recommended 

calling a primary care doctor’s office, 

as opposed to 911, for immediate 

ambulance transport to an ED, for 

a hypothetical stroke scenario. 2 

The potential therapeutic benefit of 

calling 911 was demonstrated in a 

separate study, which found that 

the thrombolytic administration 

rate for ischemic stroke patients 

with known onset times would have 

risen from 4% to 29% if 911 had 

initially been called. 3 Therefore, the 

treatment advice given by other areas 

of the healthcare system becomes 

of interest. To our knowledge no 

previous study has examined the 

treatment advice for potential stroke 

given by persons answering the 

phone at a primary care physician 

(PCP) office. Therefore, our primary 

study objective was to estimate the 

proportion of persons answering 

the phone at PCP offices across the 

United States who correctly (or 

incorrectly) advised the caller to 

contact 911 for a potential stroke. 

Methods 

Study Design 

This was a prospective, cross 

sectional telephone survey of 

randomly selected PCP offices located 

in the United States. The Institutional 

Review Board for the Protection of 

Human Subjects granted exempt 

status to this study and waived the 

requirement for written informed 

consent from each participant. 

Study Population 

A national listing of the phone 

numbers of approximately 123,000 

United States PCP offices from 

Yellowpages.com (Physicians & 

Surgeons, Family Medicine & General 

Practice category) was obtained. 

From a random starting point, we 

selected a systematic random sample 

of numbers for inclusion in the study. 

Study Protocol and Key 

Measurements 

Each PCP’s office was called, and 

the person answering the phone was 

asked to participate in the research 

study. No deception of respondents 

was employed. After agreeing to 

participate, the respondent was 

presented with a standardized, 

scripted stroke patient scenario, and 

asked to choose one of four responses 

that could be given to the caller. 

The respondent was then asked 

what advice they would provide 

to a classic heart attack scenario 


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Figure 1 

Stroke Scenario 

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

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

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

fever, or shortness of breath. He seems OK otherwise.” 

“Which one of the following four choices would you recommend to the patient” 

a) Wait and see if symptoms get better 

b) Attempt to schedule later today if symptoms are not getting better 

c) Schedule tomorrow or next day if possible for visit 

d) Call 911 for ambulance transport to local hospital 

Heart Attack Scenario 

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

with shortness of breath and vomiting” 

“Which one of the following four choices would you recommend to the patient” 

Legend 

a) Wait and see if symptoms get better 

b) Attempt to schedule later today if symptoms are not getting better 

c) Schedule tomorrow or next day if possible for visit 

d) Call 911 for ambulance transport to local hospital 

Figure 1. Hypothetical Stroke and Heart Attack Scenarios Posed to Each Person who 

Answered the Phone at the Primary Care Physician Office 

(Figure 1). The respondent was also 

asked to name common stroke signs 

and symptoms, and asked if they 

had ever heard of the Cincinnati 

Prehospital Stroke Scale (CPSS). 4 

The CPSS consists of three clinical 

symptoms indicative of stroke: facial 

droop, arm drift, and slurred speech. 

The presence of any one of these 

items has a sensitivity of 66% and 

a specificity of 87% for identifying 

stroke. 4 The duration of the phone 

call, as well as any transfers from 

the initial call, were also recorded. 

Data Analysis 

The Sample Power 2.0 (SPSS, 

Inc., Chicago, Ill) software program 

was used to calculate a sample size 

based on our goal of recognizing a 

correct answer (call 911) proportion 

significantly different from 50% in the 

population. The constant of 50% was 

chosen because no previous work has 

been done regarding this question 

within the target population. This 

a priori power analysis indicated a 

sample size of 40 to provide over 90% 

power to detect a correct answer (call 

911) significantly different from 50% 

assuming a correct answer proportion 

in the population of approximately 

75% based on previous research. 2 

Data were entered into Microsoft 

Excel® (v. 2003, Microsoft Inc., 

Redmond, WA) and imported into 

SPSS® (v. 13.0, SPSS Inc., Chicago, 

IL) for analysis. A 95% confidence 

interval was constructed around 

the point estimate of the proportion 

giving an answer other than call 911, 

since this was the key outcome of 

interest. Descriptive statistics were 

calculated for all other variables. 

Results 

Forty-two respondents completed 

the survey (average age = 43 years; 

88% female) out of a total of 119 calls 

(35% response rate). Slightly over half 

(55%) of respondents had no medical 

education or training, followed by 

17% with medical assistant training, 

14% with some level of nurse training 

(i.e. nursing assistant, LPN, BSN), 7% 

trained as physicians, 5% trained as 

emergency medical technicians, and 

one individual (2%) who reported 

attending nursing school. The caller 

was placed on hold during 64% of the 

calls for an average of 2.2 minutes, 

with the most common reason being 

a transfer to someone who could 

answer the questions. In one case the 

caller was placed on hold for over 

eight minutes. The total average 

duration of all calls was 4.2 minutes. 

Overall, 29% (95% CI 17%-44%) 

of respondents recommended 

scheduling an appointment later 

in the day if symptoms did not 

resolve. The remaining respondents 

recommended calling 911. When 

presented with the heart attack 

scenario, 100% of respondents 

recommended calling 911. All but 

two of the respondents could name 

at least one stroke sign or symptom, 

but only four had ever heard of the 

Cincinnati Prehospital Stroke Scale. 

Discussion 

Almost one-third of participants 

who answered the phone at a 

primary care physician office in the 

United States directed the caller 

away from emergency treatment for 

a hypothetical classic stroke scenario, 

despite the fact that most could name 

at least one stroke sign or symptom. 

Patients or their families may first 

call their family doctor (instead of 

911) after the onset of acute stroke 

symptoms seeking treatment advice. 

One previous study found that only 

38% of hospitalized stroke cases 



included a call to 911. The 911 call 

was most often (60%) placed by 

family members. 5 Every minute 

between the time the patient was 

last seen neurologically normal and 

arrival at the emergency department 

for treatment potentially increases 

both the amount of irreversible 

brain damage and the probability 

that the patient will be ineligible for 

various thrombolytic treatments due 

to treatment time window limits. 

Therefore, it is critically important 

that the individuals receiving the 

call not only recognize that the 

person may be having a stroke, 

but also advise the caller to seek 

immediate treatment by calling 911 

or a similar emergency number. 

More receptionists in the current 

study could name at least one sign 

or symptom of stroke in comparison 

to the healthline operators affiliated 

with academic neurology programs 

surveyed in a similar study 2 (95% 

versus 76%, respectively). However, 

despite the majority of participants 

in both studies being able to name 

one stroke sign or symptom, both 

groups gave incorrect treatment 

advice greater than 1 in 5 times (29% 

in the present study versus 22% in 

the Healthlines study). It is therefore 

possible that both the receptionists 

and hospital operators may not 

have made the crucial link between 

recognition of stroke signs and 

symptoms AND the need to call 911 

for immediate transport to a hospital. 

There are no definitive answers 

as to why this linkage problem may 

exist. However, one reason may be 

that many stroke onsets are often not 

accompanied by pain. 6 This fact could 

partially explain the observation 

that 100% of our participants 

recommended calling 911 for our 

heart attack scenario, which included 

mention of pain; whereas, our 

stroke scenario was not described as 

painful. Severe pain during stroke 

onset has also been associated with 

decreased presentation delay. 6 

The perceived severity of the 

stroke symptoms could also affect the 

advice given. 7,8 Previous research has 

shown that motor weakness 7,8 and 

speech disturbances 8 are associated 

with shorter delay. However, our 

stroke scenario included both of these 

symptoms. Perhaps it is difficult to 

fully assess the severity of stroke 

symptoms over the phone, because 

a person cannot directly visualize 

the potential stroke patient. This 

situation could explain, in part, 

the incorrect treatment advice 

given in our study. A caller’s 

tone of voice may also impact the 

perceived urgency of symptoms 

on the part of the contacted, but 

we did not test this variable. 

Limitations 

As with any study, there are 

limitations to our reported results. 

Specifically, these results are 

based on responses from only 42 

subjects, which contributes to some 

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imprecision in the study estimates 

(i.e. the proportion giving the 

incorrect answer in the population 

could be anywhere between 17% 

and 44%, or even outside of these 

interval limits). However, the goal 

of this exploratory study was to 

estimate a proportion different 

from the most conservative guess 

of 50% (essentially a coin flip) 

given that this proportion was 

previously unknown, and our power 

calculations were based on this goal. 

The relatively low response 

rate could have also introduced 

non-respondent bias, although 

this response rate is comparable 

to another recent random survey 

examining a similar topic. 8 The 

results may also not be applicable to 

countries outside of the United States, 

and regional differences may exist. 

There may also have been some 

bias introduced by the fact that 

deception was not employed in the 

study design (i.e. callers were told 

that this call was part of a research 

project). However, the decision was 

made to not employ deception to 

yield results similar to the study 

by Jarrell et al. 2 in which healthline 

operators affiliated with academic 

neurology programs were also 

informed of the research nature 

of the call prior to participating. 

The fact that both studies still 

found an incorrect advice answer 

in approximately one fourth to 

one third of the calls is concerning 

given the vast amount of research 

confirming that stroke patients 

who access the emergency medical 

services system arrive at the ED 

faster, which contributes to less 

overall presentation delay. 8,9-14 

Conclusion 

Despite the majority of PCP office 

respondents being able to name one 

stroke sign or symptom, almost one 

third recommended scheduling an 

appointment later in the day for a 

hypothetical stroke case. In contrast, 

100% gave the correct answer of ‘call 

911’ to a classic heart attack scenario. 

Triaging potential stroke patients 

away from emergent care may 

result in stroke patient presentations 

outside of the therapeutic treatment 

windows. These results suggest 

that stroke education with specific 

emphasis on the need to call 911 

may be needed for PCP office 

receptionists. Further studies should 

also examine the advice given by 

other healthcare ‘entry points’, such 

as pharmacies and the internet. 

References 

1. Hills NK, Johnston SC. Why are eligible 

thrombolysis candidates left untreated 

Am J Prev Med. 2006 Dec;31(6 Suppl 2): 

S210-6. Epub 2006 Nov 7. 

2. Jarrell B, Tadros A, Whiteman C, Crocco T, 

Davis SM. National healthline responses to 

a stroke scenario: implications for early 

intervention. Stroke. 2007 Aug;38(8):2376- 

8. Epub 2007 Jul 5. 

3. California Acute Stroke Pilot Registry 

(CASPR) Investigators. Prioritizing 

interventions to improve rates of 

thrombolysis for ischemic stroke. 

Neurology. 2005 Feb 22;64(4):654-9. 

4. Kothari RU, Pancioli A, Liu T, Brott T, 

Broderick J. Cincinnati Prehospital Stroke 

Scale: reproducibility and validity. Ann 

Emerg Med. 1999 Apr;33(4):373-8. 

5. Wein TH, Staub L, Felberg R, 

Hickenbottom SL, Chan W, Grotta JC, 

Demchuk AM, Groff J, Bartholomew LK, 

Morgenstern LB. Activation of emergency 

medical services for acute stroke in a 

nonurban population: the T.L.L. Temple 

Foundation Stroke Project. Stroke. 2000 

Aug;31(8):1925-8. 

6. Moser DK, Kimble LP, Alberts MJ, et al. 

Reducing delay in seeking treatment by 

patients with acute coronary syndrome and 

stroke: a scientific statement from the 

American Heart Association Council on 

Cardiovascular Nursing and Stroke 

Council. Circulation 2006;114:168--82. 

7. Zerwic J, Hwang SY, Tucco L. 

Interpretation of symptoms and delay in 

seeking treatment by patients who have 

had a stroke: exploratory study. Heart 

Lung. 2007 Jan-Feb;36(1):25-34. 

8. Mandelzweig L, Goldbourt U, Boyko V, 

Tanne D. Perceptual, social, and 

behavioral factors associated with delays 

in seeking medical care in patients with 

symptoms of acute stroke. Stroke. 2006 

May;37(5):1248-53. Epub 2006 Mar 23. 

9. Jurkowski JM, Maniccia DM, Dennison BA, 

Samuels SJ, Spicer DA. Awareness of 

necessity to call 9-1-1 for stroke 

symptoms, upstate New York. Prev 

Chronic Dis. 2008 Apr;5(2):A41. Epub 

2008 Mar 15. 

10. Rossnagel K, Jungehülsing GJ, Nolte CH, 

Müller-Nordhorn J, Roll S, Wegscheider K, 

Villringer A, Willich SN. Out-of-hospital 

delays in patients with acute stroke. Ann 

Emerg Med. 2004 Nov;44(5):476-83. 

11. Kothari R, Jauch E, Broderick J, Brott T, 

Sauerbeck L, Khoury J, Liu T. Acute stroke: 

delays to presentation and emergency 

department evaluation. Ann Emerg Med. 

1999 Jan;33(1):3-8. 

12. Bohannon RW, Silverman IE, Ahlquist M. 

Time to emergency department arrival and 

its determinants in patients with acute 

ischemic stroke. Conn Med. 2003 

Mar;67(3):145-8. 

13. Morris DL, Rosamond W, Madden K, 

Schultz C, Hamilton S. Prehospital and 

emergency department delays after acute 

stroke: the Genentech Stroke Presentation 

Survey. Stroke. 2000 Nov;31(11):2585-90. 

14. Lacy CR, Suh DC, Bueno M, Kostis JB. 

Delay in presentation and evaluation for 

acute stroke: Stroke Time Registry for 

Outcomes Knowledge and Epidemiology 

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

OFFICE MANAGERS ASSOCIATION 

OF HEALTHCARE PROVIDERS, INC. 

www.officemanagersassociation.com 

We invite you to join our organization which consists of members 

who manage the daily business of healthcare providers. 

Our objectives are to promote educational opportunities, professional knowledge 

and to provide channels of communication to office 

managers in all areas of healthcare. We currently have 

eleven chapters in West Virginia. 

OFFICE MANAGERS ASSOCIATION 

OF HEALTHCARE PROVIDERS, INC. 

www.officemanagersassociation.com 

We invite you to join our organization which consists of members 

who manage the daily business of healthcare providers. 

Our objectives are to promote educational opportunities, professional knowledge 

and to provide channels of communication to office 

managers in all areas of healthcare. We currently have 

eleven chapters in West Virginia. 

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

providers. Our objectives are to promote educational opportunities, professional knowledge 

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

Donna Zahn (President) at 740-283-4770 ext. 105 or 

Tammy Mitchell (Membership) at 304-324-2703. We currently have eleven chapters in West Virginia. 

Visit us on our website for more information or contact 

Donna Zahn (President) at 740-283-4770 ext. 105 or 

Tammy Mitchell (Membership) at 304-324-2703. 


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Clinical Cardiac Electrophysiology in West Virginia: 2010 

Brett A. Faulknier, DO 

Associate Professor of Medicine 

WVU Physicians of Charleston 

Cardiology and Electrophysiology 

Christopher C. Trotter, MD 

Internal Medicine Resident 

WVU/CAMC Department of 

Internal Medicine 

Keron B. Navarengom, MD 

Internal Medicine Resident 

WVU/CAMC Department of 

Internal Medicine 

Introduction 

The last decade has seen an 

explosion in the diagnostic and 

therapeutic options available to the 

clinical cardiac electrophysiologist 

(EP) for the treatment of cardiac 

arrhythmias. Historically, in West 

Virginia, access to an EP physician 

has been limited for specialized care 

in implantable device and arrhythmia 

management. This had led to the 

need for devices to be implanted 

by other implanters and a backlog 

to develop in individuals who may 

benefit from potentially curative 

catheter based ablation procedures. In 

2010 this issue of access is improving 

with the recruitment of additional 

EPs throughout West Virginia. 

Specialized care can be provided in 

the areas of atrial fibrillation (AF), 

supraventricular and ventricular 

arrhythmias (VA), genetic arrhythmia 

syndromes and implantable devices. 

We review each of these areas and 

provide information on up-todate 

techniques of diagnosis and 

management along with insight 

into advances that may open up a 

variety of novel clinical strategies. 

Atrial Fibrillation 

Atrial Fibrillation (AF) is the most 

common cardiac arrhythmia affecting 

more than 2.3 million people in the 

United States. The incidence of AF 

is on the rise and the latest United 

States census estimates this condition 

will affect more than 3 million 

people by 2020. The prevalence of AF 

increases after age 60: it is now seen 

in approximately 10% of individuals 

by age 80. 1 Residents of West Virginia 

are a prime target for this condition 

as diabetes, obesity, heart failure, 

coronary and valvular heart disease; 

all predisposing conditions for AF, 

have a high incidence in our state. 

The question of rate control versus 

rhythm control has been extensively 

studied. Previous evaluations failed 

to show benefit from the rhythm 

control strategy. 2,3 The question was 

recently revisited in AF patients 

with heart failure (HF); these 

deserve special attention as they 

have worse outcomes than those 

in sinus rhythm. The multicenter, 

randomized un-blinded trial enrolled 

1,376 patients with AF and a left 

ventricular ejection fraction (EF) 

≤ 35% and a history of HF or an 

LVEF of ≤ 25%. 4 Rate control was 

achieved with beta-blockers with or 

without digitalis, and rhythm control 

was maintained by cardioversion, 

amiodarone, sotalol, or dofetilide. 

Patients were followed for 37 ± 19 

months for the primary endpoint of 

death from cardiovascular causes 

(25% in the rate control group vs. 

27% in the rhythm control group) 

and secondary end points of overall 

survival, risk of stroke, or worsening 

HF. Secondary end-point outcomes 

were also similar between the two 

treatment arms. This study once 

again failed to confirm benefits of a 

rhythm control strategy, and showed 

that patients treated with rate 

control measures have less need for 

hospitalization and for cardioversion. 

One important new drug in the 

treatment of AF made recently 

available in the management of 

AF is dronaderone. As its name 

suggests, this drug is a class III 

multi-channel blocker much like 

amiodarone; however, dronaderone 

does not contain iodine, and has a 

shorter half-life (approximately 24 

hours), reducing tissue accumulation. 

The efficacy of dronaderone in 

preventing recurrent AF has been 

well-documented in 2 randomized 

placebo controlled trials; however, 

these trials excluded patients with 

class III and IV HF. 5 The 2008 

ANDROMEDA study enrolled 627 

patients and tested dronaderone 

against placebo in patients with New 

York Heart Association (NYHA) 

class II-IV HF who were hospitalized 

with new or worsening HF (wall 

motion index ≤ 1.2, approximating 

an EF ≤ 35%). 6 Only 7 months after 

its inception this study was ended 

because of an increased number of 

deaths in the dronaderone treatment 

group. A total of 37 patients fulfilled 

the primary end point of death, 25 

in the dronaderone group, and 12 

in the placebo group. The risk of 

death associated with dronaderone 

was increased among patients with 

a lower wall-motion index, and 10 

of the 25 dronaderone-associated 

deaths had worsening HF when 

they died. Also, the number of 

patients with a hospitalization for 

an acute cardiovascular cause was 

higher in the dronaderone group 

(71 patients) than in the placebo 

group (50 patients) (p=0.02). 

The ATHENA trial, published 

February 2009, evaluated 

dronaderone versus placebo in 

patients with AF and additional 

risk factors on the primary outcome 

of first hospitalization due to 

cardiovascular events or death. 7 

Additional risk factors included 

age ≥ 75, arterial hypertension 

(on at least two antihypertensive 

drugs of different classes), diabetes 

mellitus, prior stroke, transient 

ischemic attack, EF≤ 40% and left 

atrial diameter ≥50 mm. Patients 

with NYHA functional class IV HF 

and those with decompensated HF 

within the previous 4 weeks were 

excluded. After a mean follow-up of 

21 ± 5 months, the primary outcome 

of first hospitalization or death 

occurred in 734 (32%) patients in the 

dronaderone group and 917 (39%) in 

the placebo group (p


37% in the placebo group, p value 


Table 1: Class I indications for ICD implantation in patients with structural heart disease. Adapted from ACC 

Guidelines, 2008. 12 

Class I ICD indications in patients with structural heart disease 

1) In survivors of cardiac arrest due to VF or hemodynamically unstable VT after excluding any completely reversible 

cause 

2) With structural heart disease and spontaneous sustained VT 

3) With syncope of undetermined origin with sustained VT or VF induced at EP study 

4) With LVEF < 35% who are at least 40-days post MI or 3-months post intervention (PCI or CABG) and who are 

NYHA CHF class II or III 

5) With nonischemic dilated cardiomyopathy and LVEF < 35% and who are NYHA CHF class II or III 

6) LVEF < 30 % who are at least 40-days post MI or 3-months post intervention (PCI or CABG) and who are NYHA 

CHF class I 

7) With non-sustained VT and prior MI, LVEF < 40%, and inducible VF or sustained VT at EP study 

Figure 1. 

3-dimensional electroanatomic map of left atrium with markers representing a typical 

lesion set encircling the left and right pulmonary veins along with radiofrequency ablation 

performed along the roof of the left atrium connecting the encircling lesion sets. 

(ICD) technology has changed 

the management of ventricular 

arrhythmias (VA). Both primary 

prevention (identifying and 

prophylactically treating individuals 

to prevent sudden cardiac death 

(SCD) before an episode of 

ventricular tachycardia (VT) or 

ventricular fibrillation (VF) occurs) 

and secondary prevention (treating 

individuals who have suffered and 

survived an episode of VT or VF) 

has become common place in the 

daily practice of cardiology and 

electrophysiology. As medical and 

device based treatment has improved, 

survival of patients with more severe 

heart disease and heart failure is 

likewise improving. Practitioners 

have to deal with VA almost on 

a daily basis. It is important to 

understand both the pathophysiology 

and the treatment options available 

to individuals with VA. 

Ninety percent of patients with VA 

have structural heart disease (SHD). 9 

This is mostly scar-related reentry 

occurring either at the border zone 

of a scar from myocardial infarction, 

or in areas of scar in nonischemic 

dilated cardiomyopathy, or around 

surgical scars. Reentry has either an 

isthmus bounded by two scars or a 

scar and a line of anatomic barrier 

or physiologic conduction block. 10 In 

general, most scar-based VT arises in 

the left ventricle (LV). VTs with right 

bundle branch block (RBBB) patterns 

always arise in the LV, and VTs with 

left bundle branch block patterns 

almost always arise in or adjacent 

to the LV septum. 11 The QRS axis is 

critical to identifying the exit site of 

the VT. A superior axis (negative in 

inferior leads) suggests an inferior 

wall exit site whereas an inferior axis 

(positive in inferior leads) suggests an 

anterior wall exit site. Scar-based VTs 

typically have QRS duration greater 

than 140 msec and the presence 

of a Q-wave is often suggestive 

of a scar-based mechanism. 

Patients who present with 

polymorphic VT or VF and ischemic 

symptoms should be evaluated for 

active myocardial ischemia. Patients 

with sustained monomorphic VT 

often have stable coronary artery 

disease (CAD) with previous 

myocardial infarction allowing for 

scar-based reentry. The American 

College of Cardiology has published 



Figure 2. 

3-dimensional electroanatomic map of the left ventricle in a 33 year-old male with 

ischemic cardiomyopathy and LVEF 10-15% who had sustained VT at 120 bpm despite 

antiarrhythmic therapy. The red area is low voltage scar tissue along the inferoseptum. 

The purple and green areas represent more viable tissue. The red dots represent the 

radiofrequency ablation lesion set that was made along the scar border. 

extensive guidelines with respect to 

primary and secondary prevention 

of SCD in patients with structural 

heart disease. Table 1 summarizes 

the Class I indications for ICD 

implantation in patients with SHD. 12 

Catheter ablation of scar-based 

VT is recommended in patients 

who are otherwise at low risk for 

sudden cardiac death (SCD) and 

have sustained predominantly 

monomorphic VT that is drug 

resistant, who are drug intolerant, 

or who do not wish long-term drug 

therapy. It is also recommended as 

adjunctive therapy in patients with 

an ICD who are receiving multiple 

shocks as a result of sustained VT that 

is not manageable by reprogramming 

or changing drug therapy or who do 

not wish long-term drug therapy. 13 

The VTACH study group recently 

reported that VT ablation be 

considered early, in selected patients 

who are receiving an ICD for stable 

VT, in whom recurrences of a VT 

are likely. The 110 patients were 

randomized to (ICD) implantation 

alone or implantation with catheter 

ablation. For the primary endpoint 

of survival free from VT or VF, the 

hazard ratio was 0∙61 (95% CI 0∙37– 

0∙99, p=0∙045). Without ablation, VT 

recurred in 71% of patients at 2 years, 

and multiple recurrences, a median 

of three per year, were common. 

Catheter ablation extended the time 

to recurrent VT from a median of 

5∙9 months to 18∙6 months, and 

reduced the frequency of VT. Half of 

the patients who received ablation 

still had at least one recurrence of 

VT. 14 Ablation of VT is not without 

risk. Recent multicenter trials have 

shown the procedural mortality 

rate to be as high as 3%. Figure 2 

is a 3-dimensional electroanatomic 

map of the LV along with markers 

representing the radiofrequency 

ablation lesions made to treat a 

sustained LV tachycardia in a 33 yearold 

man who had, 3-months prior to 

ablation, undergone coronary artery 

bypass surgery for severe CAD and 

ischemic cardiomyopathy. Although 

he had had ICD implantation, he 

continued to have VT at 120 beats per 

minute that could not be controlled 

with antiarrhythmic medications. 

Ten percent of patients with 

VA have no apparent SHD and 

therefore are classified as idiopathic 

ventricular tachycardia (IVT). 15 

Classification of IVT is based on QRS 

morphology, ventricular site of origin 

and response to pharmacological 

agents. The management 

and prognosis of IVT differs 

considerably from VT due to SHD. 

Most cases of IVT belong to the 

class of outflow tract tachycardia. 

The outflow tract consists of the 

right ventricle (RV) region between 

the pulmonary and tricuspid 

valves (RVOT), the basal LV 

including the outflow tract under 

the aortic valve, the aortic cusps 

and the basal LV epicardium. 

Even though most VTs from the 

outflow tract are non-sustained, 

sustained VT can occasionally be 

precipitated by emotional stress 

or exercise. 16 RVOT VT is the most 

common form of outflow tract VT 

(75%). The ECG typically shows 

a RBBB block pattern with an 

inferior axis and a QRS transition 

in precordial leads V3 and V4. 17 

Outflow tract VT has a good 

prognosis in most patients. 18 There 

are few exceptions where cases 

of RVOT premature ventricular 

contractions (PVC) have progressed 

to VF or polymorphic VT. 19 Catheter 



Figure 3. 

ECG of a 52 year-old female with syncope and a family history of sudden cardiac death. 

The QT was measured at 480 msec with a QTc of 529 msec. Note the appearance of a 

prolonged ST segment. The patient underwent implantation of an ICD and was treated 

with beta-blocker therapy. Genetic testing subsequently revealed a LQT3 genotype with 

mutation of the sodium channel (SCN5A). 

ablation may be considered in 

cases where symptoms cannot be 

controlled with medical therapy 

typically using beta blockers and/ 

or verapamil. 20 It is also important 

to differentiate RVOT VT from 

arrhythmogenic right ventricular 

cardiomyopathy (ARVC), which 

has a poorer prognosis, including 

the risk of SCD. The success rate for 

treating RVOT VT using catheter 

ablation reaches more than 80 

percent in some studies with a 

low risk of complications (1%). 20 

Idiopathic left ventricular 

tachycardia (ILVT), first described 

by Zipes and colleagues in 1979, is a 

form of VT that arises from the LV 

and is verapamil sensitive. 21 ILVT 

is described typically in patients 

between 15 and 40 years old and 

most episodes occur at rest. The 

typical symptoms are palpitations, 

fatigue and presyncope. The 

development of syncope or SCD is 

very rare. 22 The ECG is normal in 

almost all cases, and corresponding 

to the origin in the LV, ILVT shows a 

RBBB morphology with a relatively 

narrow QRS duration (


Multiple types of LQTS have been 

identified with over 300 underlying 

gene mutations. LQTS subtypes 

1-3 are the 3 major genotypes with 

each type displaying characteristic 

T-wave repolarization pattern on 

ECG. Type 1 often displays a broad 

based T-wave and Type 2 a biphasic 

T-wave. Type 3 often has a prolonged 

ST segment. Each genotype displays 

unique associations: LQT1 genotype 

displays cardiac events associated 

with exercise; often swimming. LQT2 

genotype has arrhythmic events 

associated with exposure to sudden 

loud noises (i.e. alarm clocks). 

LQT3 genotype experience events 

during sleep or at rest. 27 Medical 

therapy aimed at prophylaxis of 

cardiac events in LQTS has been 

well established; it is more effective 

in LQTS1 and LQTS2. 30 Despite 

the risk reduction with use of betablockers 

residual, cardiac events 

can still occur; in a recent study, 

in as many as 32% of patients with 

LQTS3 on beta-blockers. 31 With this 

in mind, ICD implantation is highly 

effective in high-risk patients and 

those who remain symptomatic 

while on medical therapy. 32 

Figure 3 shows the ECG of a 52 

year old woman who presented 

with syncope and a family history 

of SCD. Her QT interval was 480 

msec with a QTc of 520 msec. She 

was started on beta-blocker therapy 

and, given her significant history, 

underwent implantation of an 

ICD. Genetic testing subsequently 

revealed a LQT3 genotype with 

a mutation in the SCN5A gene. 

ARVC first described in 1982, is 

a genetically determined disorder 

of cardiac myocytes in which RV 

myocardium is replaced with 

fibro-fatty tissue. 33 In the early 

stages structural changes may be 

localized to the RV; later they may 

also involve the LV. 34 Three phases 

have been described; first, an early 

concealed phase followed by an 

overt electrical phase and then a final 

phase with diffuse disease involving 

both ventricles leading to HF. 35 

ARVC is a familial disease with 

an autosomal dominant inheritance 

pattern. Patients may present with 

symptoms such as palpitations, dizzy 

spells, and syncope. SCD is often 

the first manifestation. 36 ARVC has 

an estimated prevalence of 1/5000 

and usually comes to attention when 

a young patient with an otherwise 

normal heart, presents with VT or VF 

originating from the RV. The disease 

affects desmosomes that constitute 

the gap junctions between myocytes. 

In most cases ECG abnormalities 

precede histological changes 

and ventricular dysfunction. 37 

T‐wave inversions in leads V1‐V4 

in individuals above 14 years of 

age with an otherwise healthy 

heart should increase suspicion. 38 

The ECG, signal-averaged ECG, 

echocardiogram, RV angiogram, and 

MRI can be used very effectively 

in accurately diagnosing ARVC. 

Protocols for using such modalities 

are available at www.arvd.org. 

The differentiation between 

ARVC and RVOT VT is very 

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important because the prognosis 

of patients with RVOT VT is 

excellent whereas the risk of SCD 

is about 1% per year in ARVC with 

associated tachycardia. ARVC is a 

familial disorder; hence, screening 

for disease in family members is 

essential in ARVC but not in RVOT 

VT. Patients with ARVC should 

be discouraged from strenuous 

physical activities and organized 

athletic participation. Treatment 

most commonly uses beta blockers 

and sotalol while amiodarone may 

be used as an add-on therapy. 39 

Initial doses and subsequent dose 

changes should be closely monitored 

using the corrected QTC interval. 

ICD implantation confers optimal 

protection against SCD in ARVC. 

Brugada syndrome was first 

defined in 1992 and has since 

gained great interest as a prominent 

cause of SCD in the young and 

in those with structurally normal 

hearts. This syndrome is thought 

to be responsible for 4 – 12 % of 

cases of SCD and to be the cause of 

20% of cases of SCD in those with 

structurally normal hearts. The 

disease is inherited in an autosomal 

dominant fashion; however, 

sporadic cases have been reported. 

Its pathogenesis is largely attributed 

to a defective sodium channel; 

however, recent reports also link 

it to calcium channel mutations. 

Three unique ECG repolarization 

patterns have been associated with 

Brugada syndrome but only the 

type 1 pattern defines the diagnosis 

of the syndrome. The syndrome is 

diagnosed on the basis of a type 1 or 

coved- type ST-segment elevation 

in the right precordial leads plus 

one of the following conditions: 

documented VF or polymorphic VT, 

a family history of SCD at a young 

age (< 45 years) or a type 1 ECG 

in family members, unexplained 

syncope, nocturnal agonal 

respiration, or inducibility of VT /VF 

at electrophysiology study. 40,41 The 

mainstay of treatment of Brugada 

syndrome is ICD implantation. 

Quinidine is a medical treatment 

option, the effectiveness of which 

has been shown in several studies. 

However, its side effects limit its use. 

Hypertrophic cardiomyopathy 

(HCM), an autosomal dominant 

inherited syndrome, is a disease 

of the sarcomere and is the most 

common cause of SCD in individuals 

less than 35 years of age. HCM has a 

mortality rate of about 1% per year. 

Contrary to popular belief HCM is 

predominantly nonobstructive; 75% 

of patients do not have a sizeable 

resting outflow tract pressure 

gradient. The diagnosis is often 

suspected by an abnormal ECG 

(severe left ventricular hypertrophy) 

in 75% to 95% of patients or a 

heart murmur. 42 Sarcomere gene 

mutations are hypothesized to 

trigger hypertrophy and arrhythmias 

before there is evidence of significant 

morphological and histopathological 

changes. 43 ICD implantation remains 

the treatment of choice for HCM. 

Implantable Pacemakers and 

Defibrillators 

ICD therapy is effective in 

aborting SCD. However, there 

remains debate in the published 

clinical guidelines over the use of EF 

of 35% as the value requiring ICD 

implantation. 44,45 Two issues with 

respect to ICDs are the prognostic 

significance of ICD shocks (both 

appropriate and inappropriate) along 

with the avoiding inappropriate 

shocks. Daubert et al. reported that 

the all-cause mortality of patients 

in the MADIT II trial who received 

appropriate and inappropriate shocks 

(but not anti-tachycardia pacing 

[ATP]) was 4 times higher than for 

those without shock therapy. In 

particular, inappropriate shocks 

(occurring in 11.5% of patients) 

increased all-cause mortality 2-fold. 

AF (44%) and supraventricular 

tachycardia (36%) were the major 

triggers for inappropriate shocks. 46 

Inappropriate shocks need to be 

minimized by programming higher 

detection rates (especially in primary 

prevention patients), utilizing a 

longer detection-to-shock duration 

to potentially allow for termination 

of non-sustained VT or VF and the 

use of morphology discrimination. 

Using more aggressive ATP may 

also reduce shock therapy. 

Remote wireless monitoring of 

ICDs and pacemakers facilitates 

daily monitoring and helps to 

identify patients experiencing AF 

or supraventricular arrhythmias 

that may be putting them at higher 

risk of inappropriate shocks. 

Additional steps may be taken, 

including medical or ablation 

therapy. Since many patients 

with implantable devices in West 

Virginia live far from Charleston, 

Huntington or Morgantown, remote 

monitoring is changing the way 

follow-up is conducted, and is 

becoming the standard-of-care. 

Cardiac resynchronization therapy 

(CRT) has become a standard method 

to treat advanced HF in patients 

with LVEF < 35%, class III or IV 

HF and QRS duration > 120 msec. 

Studies of CRT implantation in 

patients with a narrow QRS complex 

(< 120 msec), severe LV systolic 

dysfunction and class III or IV HF 

with and without other indicators 

of mechanical dyssynchrony (i.e. 

echo-based dyssynchrony) have not 

shown benefit. 47,48 Data from the 

recent MADIT-CRT and REVERSE 

trials however, have shown benefit 

from CRT in patients with reduced 

LV systolic dysfunction, QRS 

duration >120 msec and NYHA 

functional class I and II HF. 49,50 The 

future of cardiac resynchronization 

therapy appears to be earlier 

application to appropriate patients 

with less severe heart failure. 

For many years a small, 

dedicated group of providers has 

provided West Virginians with 

much needed electrophysiology 

services. With the growth of the 

electrophysiology community in 

West Virginia it will now be much 

easier for patients to receive the 

potentially life-saving procedures 

that they need and deserve. 

Please contact author Brett 

Faulknier, MD at bfaulknier@hsc.wvu. 

edu for a complete list of references. 



Post-ablative Hypothyroidism 

Abid Yaqub, MD, FACP 

Associate Professor of Medicine, Joan C. 

Edwards School of Medicine, Marshall 

University, Huntington 

Muhammad I. Choudhry, MD 

Endocrinologist, Marquette General 

Hospital, MI 

Jennifer Wheaton, DO 

Endocrinologist, Virginia Beach, VA 

Todd Gress, MD, MPH 

Associate Professor, Joan C. Edwards 

School of Medicine, Marshall University, 

Huntington 

This study was presented at 

the 17th Annual Meeting of the 

American Association of Clinical 

Endocrinologists, Orlando Florida. 

Abstract 

Objective: To determine the incidence 

of hypothyroidism following radioactive 

iodine (RAI) treatment for hyperthyroidism 

and to study the relationship between 

pretreatment RAI uptake and treatment 

dose and the subsequent development of 

hypothyroidism. 

Methods: Retrospective chart review 

of patients treated with RAI for 

hyperthyroidism between 1995 and 2000. 

180 charts were reviewed; 41 met the 

inclusion criteria. Data were collected 

regarding the cause of hyperthyroidism, 

initial RAI uptake, initial dose of RAI, 

number of RAI treatments, and post 

treatment thyroid status. 

Results: Patients in toxic nodular 

goiter group had significantly lower 24- 

hour RAI-123 uptake as compared to 

those with Graves’ disease. However 

patients with Graves’ disease received 

significantly lower RAI dose in 

comparison to those with toxic nodular 

goiters. Cure rates following RAI 

administration were similar in both 

groups. 70% of patients with Graves’ 

disease developed post-ablative 

hypothyroidism as compared to 42% in 

toxic nodular goiter group (p=0.086). 

There was no relationship between the 

dose of RAI or pretreatment RAI uptake 

and the likelihood of developing 


Conclusion: We found that, within 

our study population, post-ablative 

hypothyroidism tended to be more 

prevalent in patients with Graves’ disease 

as compared to those with toxic nodular 

goiter. However cure rates following RAI 


groups. We also found that neither the 

magnitude of the administered RAI dose 

nor the pre-treatment RAI uptake 

predicted the development of subsequent 


Introduction 

Hyperthyroidism affects 

approximately 2% of women and 

0.2% of men and has considerable 

adverse effects on cardiovascular 

and skeletal health especially 

in older population. 1 Graves’ 

disease and toxic nodular goiter 

are the commonest causes of 

hyperthyroidism. Radioactive 

iodine I-131 (RAI) is considered 

one of the first line therapies for 

treatment of hyperthyroidism. RAI 

has been proven to be clinically 

efficient, safe and cost-effective 

when compared to other treatments 

namely thyroid surgery and longterm 

use of anti-thyroid medications. 2 

Although RAI has been used to 

treat hyperthyroidism for more than 

six decades, controversy still exists 

regarding the most appropriate 

dosing regimen. There is conflicting 

evidence regarding the required 

dose of RAI as well as the incidence 

of hypothyroidism and persistent 

hyperthyroidism following RAI 

treatment of Graves’ disease and 

toxic nodular goiter. 3 The objective 

of this study was to determine 

the incidence of hypothyroidism 

following RAI treatment for Graves’ 

disease and toxic nodular goiter 

in our endocrinology clinic and to 

study the relationship between pretreatment 

RAI thyroid uptake and 

treatment dose and the subsequent 

development of hypothyroidism. 

Materials and Methods 

Approval for the study was 

obtained through the institutional 

review board. Only those patients 

who were managed by our 

University endocrinologists were 

included. A completely documented 

follow-up for a minimum of 5 

years from the date of treatment 

was required for inclusion in the 

study. Any patient with incomplete 

documentation or incomplete followup 

was excluded from the study. One 

hundred eighty medical charts were 

reviewed; of these, only 41 met the 

criteria for inclusion. Each of the 41 

was seen by a Marshall University 

endocrinologist and treated with 

RAI ablation for hyperthyroidism 

during the 1995 to 2000 time period. 

Information was gathered on the 

cause of hyperthyroidism, initial 

RAI uptake, pre-treatment use of 

anti-thyroid medications, dose 

of RAI used for treatment, post 

treatment thyroid status, age of 

patient at treatment, and time to the 


Cure rate was defined as achievement 

of hypothyroid or euthyroid status 

for a minimum of 6 months without 

the use of anti-thyroid drugs. Cure 

rates among the treatment groups 

were compared using 2-tailed Fisherexact 

test whereas the proportion of 

patients developing hypothyroidism 

in each group was compared using 

the 2-tailed Chi-square test. Data 

are presented either as mean +/- 

standard deviation or as median with 

interquartile range. Wilcoxon Rank 

Sum was performed to determine if 

there was a statistically significant 

difference in the dose of RAI given 

or in the pretreatment RAI uptake 

between those patients who became 

hypothyroid and those who did not 

become hypothyroid. A p-value of 

< 0.05 was considered significant. 

Results 

Patient demographics are 

presented in Table No. 1. Data for 

patients with Graves’ disease and 



Table No. 1: Demographic characteristics of study patients 

Number of patients 

Mean age in years 

(+/- standard deviation) 

Male/Female 

All patients 41 49 (+/- 18.1) 9/32 

Graves’ disease 27 41 (+/- 12.8) 7/20 

Toxic nodular goiter 14 62 (+/- 15) 2/12 

Table No. 2: Data for patients with Graves’ disease 

All patients with 

Graves’ disease 

Hypothyroid after 

1st RAI treatment 

Persistent/Recurrent 

hyperthyroidisim 

Number of 

patients 

27 

Percentage of 

total 

19 70% 

6 22% 

Euthyroid 2 7% 

Median dose I-131 

(Interquartile range) 

10.4 mCi 

(9.9-15.7) 

10.5 mCi 

(9.6—16.3) 

12.5 mCi 

(10-17.1) 

9.2 mCi 

(8.5-9.9) 

Median pretreatment RAI uptake 

(IQR) 

52 %(36-77.8) 

50 %(37.9-65) 

61.9 %(37.3-74) 

70%(58-82) 

Table 3: Data for patients with toxic nodular goiter 

All patients with toxic 

nodular goiter 

Hypothyroid after 1 st 

treatment 

Persistent/Recurrent 

Hyperthyroidism 

Number of 

patients 

14 

Percentage of total 

5 36% 

2 14% 

Euthyroid 6 43% 

Transient 

hypothyroidism 

Median Dose I-131 

(IQR) 

28.8 mCi 

(26.1-30.0) 

29.0 mCi 

(29-30) 

25.7 mCi 

(21.3-30) 

28.5 mCi 

(26.1-29) 

Median pretreatment RAI uptake 

(IQR) 

23.5% (16-37) 

38.5% (33-49.7) 

51.8% (34.3-69.2) 

23.5%(14.6-25) 

1 7% 15 mCi 29.8% 

Table 4: Time to hypothyroidism 

Median time to hypothyroidism (IQR) 

All patients 4 months (2-6) 

Graves’ disease 3 months (2-7) 

Toxic nodular goiter 6 months (4-6) 

toxic nodular goiter are presented in 

Tables No. 2 & 3 respectively. Time to 

hypothyroidism is displayed in Table 

No. 4. For the purpose of further 

analysis, patients with solitary toxic 

adenoma and toxic multinodular 

goiter were combined into a toxic 

nodular goiter group. Patients in 

this group had significantly lower 

(p


Graves’ disease and those with 

toxic nodular goiter. Likewise, 

there was no correlation between 

the magnitude of RAI-131 dose and 

development of hypothyroidism in 

patients with Graves’ disease and 

those with toxic nodular goiter. 

Discussion 

Radioactive iodine I-131 is 

increasingly being used as the 

first line therapy for treatment of 

hyperthyroidism both in patients 

with Graves’ disease and toxic 

nodular goiter. The aim of treatment 

is to destroy sufficient thyroid 

tissue to cure hyperthyroidism 

by rendering the patients either 

euthyroid or hypothyroid. However, 

no consensus exists regarding 

the ideal first dose of RAI in the 

treatment of hyperthyroidism. 4 

Patients with toxic nodular goiter 

are perceived to be relatively resistant 

to RAI and there is debate whether 

such patients should be treated 

with higher doses of RAI than those 

with Graves’ disease. Contrary to 

previous studies showing lower 

cure rates in patients with toxic 

nodular goiter, Allahabadia et al. 

found almost identical cure rates 

in the two groups. 4 They suggested 

that approach to treatment with RAI 

should be the same for patients with 

Graves’ disease and toxic nodular 

goiter. They found that a single 

fixed dose of 10 millicurie (mci) 

is highly effective in curing toxic 

nodular hyperthyroidism as well 

as Graves’ hyperthyroidism. In our 

study patients with toxic nodular 

goiter received a significantly higher 

mean RAI dose than those with 

Graves’ disease. However, the cure 

rates were equal in the two study 

groups. Although the incidence of 

post-ablative hypothyroidism was 

greater in patients with Graves’ 

disease as compared to those with 

toxic nodular goiters (70% vs 42%) , 

the difference did not reach statistical 

significance (p=0.086). Several 

other investigators found a higher 

prevalence of hypothyroidism in 

Graves’ disease patients following 

RAI as compared to those with toxic 

nodular goiters. 1,4,5 It is believed that 

in patients with toxic nodular goiters, 

the radioiodine uptake is restricted 

primarily to the hyperfunctioning 

autonomous areas within the gland 

as opposed to uniform distribution 

of radioiodine uptake in Graves’ 

disease, hence conferring a relative 

protection against hypothyroidism. 4 

In our study, we found that the 

overall incidence of hypothyroidism 

was 61% at 5 years after treatment 

with RAI. The incidence of postablative 

hypothyroidism was 70% 

among patients with Graves’ disease 

and 42% among patients with toxic 

nodular goiter. The incidence of 

post-ablative hypothyroidism was 

higher in our patients than in those 

reported by previous investigators. In 

a study by Metso et al., the reported 

incidence of hypothyroidism was 

24% (at 1 year), 59% (at 10 years) and 

82% (at 25 years) for patients with 



Graves’ disease and 4% (at 1 year), 

15% (at 10 years) and 32% (at 25 

years) for patients with toxic nodular 

goiters. 1 The higher incidence of 

post-ablative hypothyroidism in 

our study can be explained with 

relatively higher doses of RAI 

used in our patient population. 

A number of studies have 

attempted to establish the optimal 

dose of RAI for inducing cure of 

hyperthyroidism while avoiding the 


These strategies include varying fixed 

doses as well as doses calculated 

on thyroid size and radioiodine 

uptake. Most of these studies found 

no advantage in using the dose 

calculation methods for achieving 

improvements in cure rates or 

preventing hypothyroidism. 6,7 In our 

study the dosimetric methods, based 

upon estimated thyroid weight, 

pre-treatment thyroid uptake and 

desired dose to be delivered to a 

unit thyroid tissue, were applied in 

32% of patients. In the remaining 

68% of patients the endocrinologists 

used empiric fixed doses based on 

anecdotal and subjective preferences. 

There is conflicting evidence 

regarding the influence of antithyroid 

drugs on the outcome of 

RAI treatment. Several studies 

have suggested relative radioresistance 

with increasing incidence 

of treatment failure in those patients 

treated with anti-thyroid drugs before 

RAI 8 while others showed no effect. 9 

It has been reported that the use of 

anti-thyroid drugs within 2 weeks of 

RAI administration was a significant 

predictor of treatment failure when a 

low fixed dose (5mci) was employed 

but did not have an adverse effect 

on the outcome when a higher fixed 

dose (10mci) was used. 4 In our study, 

anti-thyroid drugs were used in up to 

75% of patients before RAI. However, 

our study was not designed to study 

the effect of use of anti-thyroid drugs 

on the RAI treatment outcome. 

Most of our patients who became 

hypothyroid did so within the 

first year following RAI treatment. 

Some clinicians now prefer to 

give a large ablative dose aiming 

for early hypothyroidism, so that 

the need for long-term follow-up 

of thyroid function in euthyroid 

patients is obviated. 10 Such a 

strategy offers the advantage of 

minimizing the chances of patients 

getting lost to follow-up and hence 

decreases the probability of a late 

diagnosis and timely treatment. 

When we examined the effect of 

pre-treatment RAI thyroid uptake 

and the amount of RAI dose, we 

found no significant relationship 

between these variables and the 


These findings agreed with those 

of Metso et al., who studied 2,043 

hyperthyroid patients treated with 

RAI and found that neither the 

pre-treatment RAI uptake nor the 

magnitude of first or cumulative 

dose had any influence on the 

risk of hypothyroidism in patients 

with Graves’ disease. No effect of 

pre-treatment RAI uptake on risk 

of hypothyroidism was found in 

patients with toxic nodular goiters, 

but, an inverse relationship between 

the first and cumulative RAI dose 

and the risk of hypothyroidism was 

found, with patients developing 

hypothyroidism more easily with 

lower RAI dose as compared 

to higher doses. 1 However our 

finding of lack of effect of RAI 

dose on risk of hypothyroidism is 

contrary to the observation made 

by Allahabadia and colleagues who 

were able to demonstrate a significant 

direct relationship between the 

magnitude of first RAI dose and 

risk of hypothyroidism. While 

studying various factors predicting 

outcome after RAI in a cohort of 813 

hyperthyroid patients, findings were 

that the gender, goiters of medium 

and large size, and severity of 

hyperthyroidism were also significant 

independent prognostic factors for 

cure after a single dose of RAI. 4 

Limitations of our study included 

a small sample size and a relatively 

short follow up period as compared 

to some of the previously published 

studies. Our patients were almost 

exclusively Caucasian; hence the 

results might not be applicable to 

areas with more culturally diverse 

patient populations. All patients 

were referred to our endocrinology 

clinics by primary care providers 

and any possible inclusion 

bias could not be excluded. 

In conclusion, we found that 

within our study population, postablative 

hypothyroidism tended 

to be more prevalent in patients 

with Graves’ disease as compared 

to those with toxic nodular goiter 

(70% vs. 42% at 5 years, p=0.086). 

However cure rates following RAI 


groups. We also found that neither 

the magnitude of the administered 

RAI dose nor the pre-treatment RAI 

uptake predicted the development 

of subsequent hypothyroidism. 

References 

1. Metso S, Jaatinen P, Huhtala H et al. Longterm 

follow-up study of radioiodine 

treatment of hyperthyroidism. 2004. 

Clinical Endocrinology. 61:641-648 

2. Wartofsky L. Radioiodine therapy for 

Graves’ disease: case selection and 

restrictions recommended to patients in 

North America. 1997. Thyroid. 7:213-216 

3. Shapiro B. Optimization of radioiodine 

therapy of thyrotoxicosis: what have we 

learned after 50 years 1993. J Nuc Med. 

34:1638-1641 

4. Allahabadia A, Daykin J, Sheppard MC, 

Gough SC & Franklyn JA. Radioiodine 

treatment of hyperthyroidism-prognostic 

factors for outcome. 2001. J Clin 

Endocrinol Metab. 86:3611-3617 

5. Holm Le, Lundell G, Israelsson A, & 

Dahlqvist I. Incidence of hypothyroidism 

occurring long after iodine-131 therapy of 

hyperthyroidism. 1982. J Nuc Med. 23: 

103-107 

6. Jarlov AE, Hegedus L, Kristensen LO, 

Nygaard B,& Hansen BM. Is calculation of 

the dose in radioiodine therapy of 

hyperthyroidism worthwhile 1995. Clin 

Endocrinol (Oxf). 43:325-329 

7. Peters H, Fischer C, Bogner U, Reiners C, 

Schleusener H. Radioiodine therapy of 

Graves’ hyperthyroidism: standard vs. 

calculated 131 iodine activity. Results from 

a prospective, randomized, multicentre 

study. 1995. Eur J Clin Invest. 25:186-193 

8. Sabri O, Zimny M, Schulz G, et al. 

Success rate of radioiodine therapy in 

Graves’ disease: the influence of 

thyrostatic medication. 1999. J Clin 

Endocrinol Metab. 84:1229-1233 

9. Sridama V, McCormick M, Kaplan EL, 

Fauchet R, DeGroot LJ. Long-term followup 

study of compensated low-dose 131I 

therapy for Graves’ disease. 1984. N Eng J 

Med. 311:426-432 

10. Erem C, Kandemir N, Hacihasanoglu A, 

etv al. Radioiodine treatment of 

hyperthyroidism: Prognostic factors 

affecting outcome. 2004. Endocrine. 

25(1):55-60 


General | NEWS 

WVU hosts nation’s first Gold Humanism Week, 

February 14-18 

In hopes to stimulate discussion 

about humanism in healthcare, the WVU 

Chapter of the Gold Humanism Honor 

Society hosted the nation’s first ever 

Gold Humanism Week, February 14- 

18, 2011. The event featured a lecture 

series with refreshments, the HeART 

of Gold art contest, Cans for Caritas 

food drive, and the launching of the 

Golden Student Star Program. Acting 

Gov. Earl Ray Tomblin officially signed 

a proclamation declaring February 

14-18 as Gold Humanism Week. 

Although the culture of healthcare 

is one centered on learning, 

researching and applying science, 

the true practice is an art form. 

“As the only Gold Humanism 

Honor Society in the state of West 

Virginia, we have taken our charge 

to promote humanistic qualities 

in healthcare professionals quite 

seriously,” Norman D. Ferrari III, 

M.D., senior associate dean for student 

services at the WVU School of Medicine 

said. “By setting aside a week with 

multiple activities we also hope to 

promote a greater inter-professional 

dialogue with our colleagues in the 

other Health Sciences programs. 

The lecture series kicked off on Feb. 

14 when Jame Abraham, M.D., section 

chief of Hematology and Oncology 

at WVU, presented “Medicine: A 

Silent Art in the iPhone Age!”. 

Mark Wicclair, Ph.D., professor of 

philosophy at WVU and bioethicist 

at the University of Pittsburgh, 

presented “House, M.D. and 

Paternalism” on February 15. 

Josh Dower, M.D., assistant 

professor and palliative care 

physician at WVU, presented 

“Nurturing Humanism Through the 

Healing Arts of Palliative Care.” 

The final lecture and highlight of the 

series was held on February 18 in the 

Fukushima Auditorium. Arthur Ross 

III, M.D., dean of the WVU School of 

Medicine, hosted a panel discussion 

called “Humanism in Healthcare.” 

Panel members included Shelia Price, 

D.D.S., associate dean for admissions, 

recruitment and access at the WVU 

School of Dentistry; Clark Ridgway, 

R.Ph., assistant dean of student services 

at the WVU School of Pharmacy; 

Elisabeth “Betty” Shelton, Ph.D., 

associate dean for undergraduate 

academic affairs at the WVU School 

of Nursing; and Dr. Ferrari. 

The inaugural HeART of Gold art 

contest was held to provide a means 

to express art in healthcare. The first 

place winner of the HeART of Gold 

Contest was James Kingsburgy, a first 

year medical student, who submitted 

a drawing titled “A Compassionate 

Touch.” The second place winner, 

Janice Ahn, a second year medical 

student, submitted a collage entitled, 

“What’s in a Heart Beat.” 

The Golden Student Star Program is 

designed to recognize Health Sciences 

students who go out of their way to 

help others. For his efforts to address 

campus violence, Paul Swickline, a 

medical laboratory science student, was 

named the January Golden Student 

Star, the first to receive this honor. 

Joanna Adkins, a fourth year medical 

student, received the February Golden 

Student Star for her service to the local 

homeless community. Each month, 

a selection committee will choose a 

Golden Student Star. That person 

will be recognized with a golden star 

lapel pin and an announcement on 

the School of Medicine’s website. 

A “Cans for Caritas” service drive 

was held for the entire week. Canned 

food and toiletry items were collected 

for the Caritas House, Morgantown, 

an AIDS service organization. 

“We are happy that the HSC family 

and the rest of WVU community 

joined us for this celebration of 

humanism in healthcare,” Allison 

Lastinger, vice president of the 

WVU chapter and member of the 

School of Medicine Class of 2011, 

said. “This continues to be a unique 

opportunity for us to join together 

and recognize a part of healthcare 

that is sometimes forgotten – the care 

of the patient as a human being.” 

The mission of the Gold Humanism 

Honor Society is “to promote humanism 

and professionalism throughout the 

continuum of physician education from 

the first day in medical school until 

retirement from medical practice.” The 

WVU Chapter of the Gold Humanism 

Honor Society was established in 2008. 

WVU’s Gold Humanism Week was 

made possible by a grant from the 

Arnold P. Gold Foundation and support 

from the WVU School of Medicine. 

For more information on Gold 

Humanism Week see www.hsc. 

wvu.edu/som/Students/GHHS/ 

Gold-Humanism-Week/. 

Evan Jenkins, Gretchen Sprouse, Matt Akers, Cortney Ballengee, Allison Lastinger, Lisa Costello, Gov. Tomblin, 

Dean Hansbarger, Jennifer Armbruster, Elisabeth Bowles, Blake Daney, Devin Weber, and Amy Tolliver. 


| WESPAC Contributors 

2011 WESPAC Contributors 

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

members for their contributions to WESPAC. These contributions were received as of February 15, 2011: 

Chairman’s Club ($1000) 

M. Barry Louden Jr., MD 

Extra Miler ($500) 

Generoso D. Duremdes, MD 

Michael A. Kelly, MD 

Michael A. Stewart, MD 

Dollar-A-Day ($365) 

Edward F. Arnett, MD 

Ann Conjura, MD 

John D. Holloway, MD 

Michael A. Istfan, MD 

Sushil K. Mehrotra, MD 

John A. Wade, Jr., MD 

Campaigner Plus (> $100) 

Finbar G. Powderly, MD 

Richard M. Fulks, MD 

Campaigner ($100) 

James M. Carrier, MD 

James M. Carter, MD 

Stephen P. Cassis, MD 

Patsy P. Cipoletti, MD 

Ruperto D. Dumapit, Jr., MD 

Kenneth F. McNeil, MD 

Stephen K. Milroy, MD 

Brian D. Powderly, MD 

Ophas Vongxaiburana, MD 

Donor 

Pedro F. Lo, MD 

WESPAC is the West Virginia State Medical Association’s 

bipartisan political action committee. We 

work throughout the year with elected officials to 

make sure they understand the many facets of our 

healthcare system. 

WESPAC’s goal is to organize the physician community 

into a powerful voice for quality healthcare in 

the West Virginia Legislature. We seek to preserve 

the vital relationship between you and your patients 

by educating our legislators about issues 

important to our physicians. 

WESPAC contributions provide critical support for 

our endorsed candidates. Your contribution can 

make the difference between a pro-physician/patient 

candidate winning or losing. 

To make a contribution to WESPAC, please 

call (304) 925-0342, ext. 12 

| New Members 

Kanawha County Medical Society 

Kim Bush, MD 

Amanda Deskins, DO 

Lisa Downham, MD 

Andrea Hill ,MD 

John Lilly Jr., MD 

Monongalia County Medical Society 

Melinda Cooper, MD 

Steven Coutras, MD 

Tanya Fancy, MD 

Srinivasan Ganesan, MD 

Todd Harshbarger, MD 

Glen Jacob, MD 

Lisa Jacob, MD 

Pamela Murray, MD 

Songul Onder, MD 

Swati Pawa, MD 

Anthony Roda-Renzelli, MD 

Gregory Schaefer, DO 

Can Talug, MD 

Ohio County Medical Society 

Lori Archbold, MD 

Ronald Hargraves, MD 

Parkersburg Academy of Medicine 

Lisa Casalenuovo, DO 

David Stastny, DO 

Tygart Valley Medical Society 

Peter Wentzel, MD 

Please direct all membership 

inquiries to: Mona Thevenin, 

WVSMA Membership Director 

at 304.925.0342, ext. 16 or 

mona@wvsma.com. 

March/April 2011 | Vol. 107 

3

We need your hELp! 

The WVSMA is fighting to save the Med-Mal Caps 

On March 8, the West Virginia Supreme Court of Appeals will hear the case 

challenging our 2003 medical liability reform. The Trial Lawyers are trying to get 

the Med-Mal Caps tossed out. 

The Caps have been key to the 30% - 40% reduction in physician insurance rates 

in the last few years. If the Trial Lawyers win this one, we could be back where we 

were ten years ago…skyrocketing premium rates, doctors leaving the state and 

patients losing access to care. 

The WVSMA is fighting for you and your patients. We appreciate your 

membership investment which helps fund our efforts to raise awareness about 

the importance of keeping our reforms intact and the costs of our legal filings 

with the Supreme Court. 

We will continue our 

efforts to send a clear 

message to the Legislature 

and the State Supreme 

Court that West Virginia 

physicians are unified in 

our support for keeping 

our Med‐Mal Caps. 

John H. Schmidt III, MD 

WVSMA President

| MPLA Suit Statistics 

Each month, the WVSMA tracks the number of MPLA suits filed in each county throughout West Virginia. Below is a chart summarizing the 

case filings from 2003 to June 2010. Please note the annual total for 2005 was significantly impacted by the large number of suits brought 

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, 

205, and 170 respectively. 

COUNTY 

2003 

2004 

2005 

2006 

2007 

2008 

2009 

2010 

Barbour 

Berkeley 

Boone 

Braxton 

Brooke 

Cabell 

Calhoun 

Clay 

Doddridge 

Fayette 

Gilmer 

Grant 

Greenbrier 

Hampshire 

Hancock 

Hardy 

Harrison 

Jackson 

Jefferson 

Kanawha 

Lewis 

Lincoln 

Logan 

Marion 

Marshall 

Mason 

McDowell 

Mercer 

Mineral 

Mingo 

Monongalia 

Monroe 

Morgan 

Nicholas 

Ohio 

Pendelton 

Pleasants 

Pocahontas 

Preston 

Putnam 

Raleigh 

Randolph 

Ritchie 

Roane 

Summers 

Taylor 

Tucker 

Tyler 

Upshur 

Wayne 

Webster 

Wetzel 

Wirt 

Wood 

Wyoming 

TOTALS 

(BY INDIVIDUAL YEAR) 

1 

9 

1 

0 

7 

28 

0 

0 

0 

5 

0 

2 

7 

1 

1 

1 

14 

1 

2 

66 

2 

0 

10 

2 

6 

2 

3 

17 

0 

4 

31 

0 

1 

4 

20 

0 

0 

0 

1 

20 

21 

3 

0 

0 

0 

1 

1 

1 

2 

1 

0 

2 

0 

14 

0 

315 

0 

2 

1 

1 

1 

15 

0 

0 

0 

0 

0 

0 

3 

1 

2 

1 

6 

1 

1 

20 

4 

0 

4 

0 

2 

1 

1 

9 

0 

2 

7 

0 

1 

1 

7 

0 

0 

0 

0 

10 

6 

3 

0 

0 

1 

3 

0 

0 

1 

0 

0 

1 

0 

11 

0 

130 

1 

4 

0 

1 

4 

7 

0 

0 

0 

1 

0 

0 

4 

1 

0 

0 

8 

1 

1 

37 

1 

0 

9 

2 

2 

3 

0 

4 

3 

5 

10 

1 

0 

2 

10 

0 

0 

1 

0 

126 

10 

4 

0 

1 

0 

0 

0 

0 

1 

0 

0 

2 

0 

6 

0 

273 

0 

3 

1 

1 

0 

14 

0 

0 

0 

5 

0 

1 

3 

0 

1 

0 

5 

3 

0 

47 

1 

1 

2 

1 

2 

1 

1 

8 

0 

3 

15 

0 

0 

1 

5 

0 

0 

0 

2 

4 

7 

2 

0 

0 

0 

2 

0 

0 

3 

0 

0 

1 

1 

5 

2 

154 

0 

3 

1 

0 

2 

14 

0 

0 

1 

3 

0 

1 

5 

1 

0 

0 

9 

4 

2 

46 

1 

0 

4 

0 

2 

2 

1 

9 

0 

3 

15 

1 

0 

2 

6 

0 

0 

0 

0 

5 

14 

5 

1 

1 

1 

0 

1 

0 

1 

0 

0 

0 

0 

6 

1 

174 

1 

2 

0 

0 

3 

13 

0 

0 

0 

2 

0 

1 

5 

0 

1 

0 

6 

1 

3 

49 

0 

0 

6 

4 

0 

5 

3 

8 

0 

2 

14 

0 

0 

1 

5 

0 

0 

0 

0 

7 

18 

3 

0 

1 

0 

1 

0 

0 

1 

0 

0 

1 

0 

11 

0 

178 

0 

2 

1 

0 

2 

27 

0 

0 

0 

5 

0 

0 

6 

0 

0 

0 

5 

4 

2 

53 

0 

0 

7 

4 

0 

3 

4 

15 

1 

4 

17 

0 

1 

5 

4 

0 

0 

0 

0 

6 

11 

4 

0 

0 

1 

0 

0 

0 

0 

0 

1 

1 

0 

8 

1 

205 

0 

2 

1 

1 

1 

17 

0 

0 

0 

0 

0 

0 

5 

0 

0 

0 

7 

1 

1 

56 

0 

0 

9 

2 

0 

2 

0 

5 

1 

3 

15 

0 

0 

0 

11 

0 

0 

0 

0 

5 

6 

4 

0 

0 

0 

0 

0 

0 

4 

0 

0 

1 

0 

9 

0 

170 


Mid-Winter Meetings 2011 

Photo Highlights 

Joseph Selby, MD and Generoso Duremdes, MD. 

The WVSMA chartered bus arrives at the Capitol with physicians ready to 

participate in White Coat Day! 

WVSMA member physicians discuss legislative issues with Senator Ron 

Stollings, MD. 

R. Austin Wallace, MD, Hoyt Burdick, MD, and Tom Valley, MD, 

prepare to meet with legislators. 

Physicians led by WVSMA President, John Schmidt III, 

MD, discuss legislative issues with Senator John Unger. 

Senator Ron Stollings, MD addresses 

members during a pre-White Coat 

Day legislative briefing. 

Brad Henry, MD and Senator Mike Hall, Senate 

Minority Leader. 

WVSMA physicians gather in the senate gallery during the 

legislative session. 


Mid-Winter Meetings 2011 

Photo Highlights 

Delegate Don Perdue speaks to 

White Coat Day participants. 

WVSMA physicians prepare to recite the pledge of allegiance as the 

legislative session commences. 

Joseph Selby, MD and Allison 

Lastinger, MS-IV pose at the 

entrance to the Senate chamber. 

Blanchette Rockefeller Neurosciences Institute hosted the Saturday 

luncheon featuring speaker Daniel Alkon, MD. 

Daniel Alkon, MD, Scientific Director, 

Blanchette Rockefeller Neurosciences 

Institute presents during the Saturday 

luncheon. 

Jane Cline, WV Insurance 

Commissioner outlines the 

implementation of health insurance 

exchanges. 


during the WVSMA House of 

Delegates opening session. 

The practice management conference included an excellent insurance payor panel. Participants learned of key regulatory and 

payment changes for 2011. 

The exhibit hall bustles 

with physicians interested 

in exhibitors’ products and 

services. 

Harold Miller, 

Executive 

Director, Center 

for Healthcare 

Quality and 

Payment 

Reform, gives 

a presentation 

on Accountable 

Care 

Organizations. 


Legislative | NEWS 

2011 Legislative Briefs 

Protecting Medical Liability Reform Laws 

POSITION: The WVSMA strongly maintains the need 

to preserve the integrity of the Medical Professional 

Liability Act and to protect against any threats to erode 

the current statute. 

ISSUE: Ten years ago West Virginia’s healthcare system 

was spiraling into a severe crisis. The lack of affordable 

and/or available medical liability insurance forced many 

physicians to either restrict the services they offer, move 

their medical practice out of state or quit practicing 

altogether. The Legislature made great strides in passing 

new laws designed to stabilize the medical liability 

system and preserve patient access to care. It takes 

many years to fully realize the effects of such sweeping 

climate change. The trend has proven that the reforms 

have worked and the market is continuing to stabilize. 

Currently however, there is a case before the 

State Supreme Court which challenges the caps 

on noneconomic damages. Depending on the 

outcome of this case, West Virginia could be faced 

with another grave crisis within the next year. 

The West Virginia medical malpractice insurance 

market has come a long way. Reforms of this 

magnitude take years to be fully realized as we have 

seen from the positive track record over the past 

ten years. With the threat of the current challenge 

before the WV Supreme Court, now more than 

ever we need to be vigilant and stay the course. 

Regulation of the Rental Network PPO Market 

POSITION: The WVSMA supports legislative 

initiatives to increase the transparency and fairness of 

rental network PPO activity. 

ISSUE: In most states, physicians have little control over 

how their managed care contracts are marketed, leaving 

them vulnerable to illegitimate discounts in payments 

for their services. In recent years, the health insurance 

market has developed a secondary market in physician 

discounts that has negatively affected physician’s ability 

to manage their practices. The lack of regulatory oversight 

in the Preferred Provider Organization (PPO) industry has 

resulted in the proliferation of entities that are engaged in 

the lucrative business of developing healthcare provider 

panels and then leasing the panels and associated 

discounts to various entities. These entities are often called 

“rental network PPOs”. When the physician discount 

is shared without authorization from the physician, the 

arrangement is often referred to as a “silent PPO”. 

The WVSMA supports legislation to advance the 

National Conference of Insurance Legislators (NCOIL) 

Rental Network Contract Arrangements Model Act 

which aims to implement transparent practices. 

Regulation of the secondary rental network, including 

restricting the number of times a rental network discount 

can be sold, is necessary to ensure that this unfair 

proliferation of physician contract violations ends. 

Supporting State Healthcare Reform Initiatives 

POSITION: The WVSMA supports efforts to achieve 

healthcare reform in West Virginia. 

ISSUE: West Virginia, like the rest of the nation, 

is faced with the serious threat of rising costs 

in health insurance, decreasing availability of 

insurance and concerns with chronically ill patients 

and a progressively unhealthy population. 

Though the federal government is currently 

engaged in the development of health system 

reform there are a number of important initiatives 

that West Virginia should simultaneously pursue. 

The WVSMA recommends continued work in the 

following areas Patient-Centered Medical Home; 

Practitioner Credentialing; Wellness and Prevention; 

Health Information Technology; Medicaid Expansion; 

Insurance Exchanges, and Research and Education. 

The WVSMA believes the following principles should 

be integral to all reform initiatives that are considered. 

• Physician-Patient Relationship – Reform 

initiatives must preserve the sanctity of the 

physician-patient relationship which is at the 

core of the art and practice of medicine. 

• Leadership –Physicians must be allowed to provide 

leadership in planning and implementation 

of Accountable Care Organizations, Patient- 

Centered Medical Homes or other innovations 

in the healthcare delivery system, because of 

their unique core competencies in patient care, 

medical knowledge, practice-based learning and 

improvement, interpersonal and communication 

skills and systems-based practice. 

• Scope of Practice – Care delivery models that 

involve expansion of the scope of practice for 

non-physician practitioners must remain focused 

on patient safety and must not expand any 


Legislative | News Continued 

scope of practice beyond each practitioner’s core 

knowledge, training or experience commensurate 

with their respective professional category. 

• Funding – Reform initiatives and pilots must be 

accompanied by adequate funding so that physicians 

are not required to absorb the additional overhead and 

other expenses associated with innovations. Quality 

measures used to adjust physician reimbursement 

must be evidence-based and meaningful. 

• Evidence – New healthcare delivery models 

and other reforms to the healthcare system 

must be continually evaluated for their impact 

on patient outcomes based upon scholarly 

analysis and evolving medical evidence. 

Protecting Against a Healthcare Provider Tax 

POSITION: The WVSMA applauds the completion of 

the phase-out of the healthcare provider tax! We strongly 

encourage the Legislature to not entertain any institution 

of a similar tax in the future. 

ISSUE: The healthcare provider tax was imposed 

in 1993 as the Legislature’s solution to generate 

additional funding for Medicaid. It was considered 

an unfair burden by physicians and other healthcare 

providers and repeal of the law was fervently sought 

since its inception. In 2001 the Legislature passed a 

bill initiating the repeal of this tax on all individual 

practitioners through a ten-year phase out. As a result, 

on July 1, 2010 the tax on physicians and all other 

individual healthcare practitioners was eliminated. 

The WVSMA thanks the Legislature for 

their foresight in the passage of this phase-out 

and for their fortitude in continuing down the 

path of repeal. We strongly recommend that no 

similar taxes be considered in the future. 

Modifying the Open Hospitals Proceedings Act 

POSITION: The WVSMA supports legislation 

clarifying medical staff committees are not governing 

bodies under the Open Hospitals Proceedings Act, 

the executive session topics enumerated in the Act are 

inadequate and at the least should be expanded, and that 

action on those topics should be permitted in executive 

session if the Act is to apply to any medical staff bodies. 

ISSUE: While hospitals must be accountable to the 

public, the nature of healthcare has evolved to where 

a hospital’s public mission may be adversely affected 

by certain aspects of open proceedings. Of greatest 

privacy concern to hospitals and physicians are issues of 

professional credentialing, peer review and discussions 

related to the sensitive and confidential nature of 

medical liability cases, among other areas related to 

the delivery of care, patient safety and operations. 

The West Virginia Supreme Court of Appeals 

in 2007 ruled that one hospital’s Medical Staff 

Executive Committee is a “governing body” 

for purposes of the Open Hospital Proceedings 

Act (OHP Act) and therefore its meetings must 

be conducted in compliance with the Act. 

The decision has a broad effect on all nonprofit 

and government-run hospitals throughout West 

Virginia. Under this decision, arguably all groups 

“that make recommendations to a hospital on 

policy or administration” fall within the definition 

of a “governing body” for purposes of the Act. 

The WVSMA joins with the WV Hospital Association 

in the position that no medical staff committees should 

be considered governing bodies under the OHP Act, that 

the executive session topics enumerated in the Act are 

inadequate and at the least should be expanded, and that 

action on those topics should be permitted in executive 

session if the Act is to apply to any medical staff bodies. 

Encouraging Routine Voluntary Screening for HIV 

POSITION: The WVSMA recommends the West 

Virginia HIV testing laws be updated and modified 

to require simple consent for routine voluntary HIV 

testing. 

ISSUE: Human immunodeficiency virus (HIV) testing 

is entering a new era in this country as lawmakers, 

healthcare and insurance executives and public 

health officials are making changes in their respective 

fields to ensure that more people will know their 

HIV status. Knowing their status is an important 

consideration for maintaining health and reducing 

the spread of the virus. Of particular importance is 

the early detection of HIV infected pregnant women 

since treatments are available to greatly reduce the 

risk of transmission of the disease to the infant. 

In 2006, the CDC revised their recommendations 

for HIV testing of adults, adolescents and pregnant 

women in healthcare settings. The objectives of these 

recommendations are to increase HIV screening of 

patients, by urging routine voluntary screening of all 

persons in the healthcare setting; foster earlier detection 

of HIV infection; identify and counsel persons with 

unrecognized HIV infection and link them to clinical and 

prevention services; and further reduce transmission 

of HIV from pregnant women to their babies. 



The WVSMA recommends passage of legislation that 

will remove the current statutory barriers to routine 

screening for HIV. The essence of this important law 

change is to give priority to identifying West Virginians 

who are unaware of their HIV status and get them into 

care and treatment and prevention while sustaining 

the fundamental voluntary nature of HIV screening. 

Improving West Virginia’s Perinatal Health 

POSITION: The WVSMA supports initiatives to 

improve the health of pregnant women and children in 

West Virginia. 

ISSUE: The health of West Virginia’s babies has a 

tremendous impact on the state’s economy, workforce 

development and family well-being. Fourteen years 

ago, West Virginia birth statistics were much brighter 

than today. The State’s rates for pre-term birth, primary 

C‐sections, vaginal births after cesarean section (VBAC), 

and low birth weight infants were all more positive for 

healthy outcomes. While there are solutions to our child 

health problems, West Virginia has made little progress 

over the past decade in improving infant mortality. 

The number of low birth weight babies has increased 

and more babies are spending the first weeks of life in 

neonatal intensive care. If we want to improve the health 

and well-being of our children we must begin long 

before birth. Better health for our children will be the 

result of better health for pregnant women and infants. 

The WVSMA, along with the WV Perinatal Partnership, 

supports and recommends the following policies to further 

the efforts to improve perinatal wellness. By working 

together, we can make sure that the 21,000 babies born 

each year in West Virginia and their mothers have the 

best healthcare possible to assure a healthy beginning: 

• Establish a permanent home for the West 

Virginia Perinatal Partnership within the Higher 

Education Policy Commission (HEPC), Office 

of the Vice Chancellor for Health Sciences 

and that funding in the amount of $250,000 be 

allocated for it’s work in the state budget; 

• Expand the West Virginia Maternal Mortality Review 

to include an Infant Mortality Review Process; 

• Expand state education to adequately prepare our 

young West Virginians for parenthood; and 

• Require health insurers to include coverage for 

dependents for contraception and for pregnancy. 

Strengthening Tobacco Control and Clean 

Indoor Air Initiatives 

POSITION: The WVSMA supports policies that 

protect public health by discouraging tobacco use 

and promoting clean indoor air. Such policies include 

significantly increasing the tobacco excise tax, allocating 

sufficient funding for education programs designed 

to reduce or eliminate tobacco use and exposure to 

secondhand smoke, and supporting counties’ indoor air 

regulations. 

ISSUE: The WVSMA seeks to reduce or eliminate 

tobacco use by West Virginia citizens, especially children, 

and to eliminate the exposure to secondhand tobacco 

smoke, which is the third leading cause of preventable 

death among nonsmokers. Among the states, West 

Virginia ranks worst in the nation for smoking rates 

of adults and youth. We rank first in smoking among 

women during pregnancy and second overall in women 

smokers. Furthermore, West Virginia has the highest 

rate of smokeless tobacco use in the nation with one 

in three high school students currently using tobacco 

and one in five males using smokeless tobacco. 

The deleterious effects of tobacco use affect not only 

smokers but also the public at large. Scientific studies 

clearly show that secondhand cigarette smoke is a 

hazardous, cancer-causing air pollutant. Exposure to 

secondhand smoke causes increased risk for disease and 

death in healthy nonsmokers and is the third leading 

cause of preventable death among nonsmokers. 

The prevalence of tobacco use in West Virginia 

translates to an enormous economic toll. The 

state spends over $1 billion a year on the direct 

healthcare costs of smoking, and another $1 

billion on occupational costs due to smoking. 

The WVSMA joins with the Coalition of a 

Tobacco Free WV in recommending a three tiered 

approach toward addressing tobacco use: 

• 

• 

Increase the Tobacco Excise Tax 

Provide Adequate State Funding for 

Cessation Education Programs 

Protect County Clean Indoor Air Policies. 

• 

Combating Poor Oral Health 

POSITION: The WVSMA supports efforts to make 

policy changes which foster improved oral health for 

West Virginia’s children and families. 

ISSUE: West Virginia is a leader nationwide in the 

percentage of our citizens with tooth loss and decay. 

By the time of high school graduation, over 80 percent 

of West Virginia youth have had dental decay; over 60 

percent have had dental decay by age 8 and over 30 

percent of West Virginia children suffer from untreated 

decay. Strikingly, over 45 percent of West Virginia adults, 

aged 65 and older, have lost all their natural teeth. 


Legislative | News Continued 

Dental disease is the single most prevalent chronic 

childhood disease and correlates directly to other 

health concerns. With today’s tools and technologies, 

oral disease is almost 100% preventable and is cost 

effective with the potential to save millions of dollars. 

Poor oral health can contribute to a lifetime of overall 

poor health including diabetes and heart disease. 

The WVSMA supports the following 

recommendations to address poor oral health: 

• Establish the Office of Oral Health within 

the Bureau for Public Health 

• Encourage school aged children to have 

dental exams at appropriate intervals. 

• Prohibit sale of sugary snacks and 

beverages in schools. 

• Address the use of smokeless tobacco among 

our youth through the implementation of a 

higher smokeless tobacco tax equaling the 

cigarette tax, the implementation of youth based, 

counter marketing and cessation programs. 

Ensuring Truth in Advertising for 

Healthcare Providers 

POSITION: The WVSMA supports legislation to ensure 

transparency regarding the education training and 

licensure of healthcare providers. 

ISSUE: Patients are confused about the differences 

between various types of healthcare providers. 

Often, patients mistakenly believe they are seeing 

medical doctors when they are not. The WVSMA 

believes that patients deserve to have increased 

clarity and transparency in healthcare. 

Confusion among patients about who is and who is 

not qualified to provide specific patient care undermines 

the reliability of the healthcare system and can put 

patients at risk. To help ensure patients can answer the 

simple question “who is a doctor” the WVSMA believes 

that all healthcare professionals – physicians and nonphysicians 

– should be required to accurately and clearly 

disclose their training and qualifications to patients. 

Asking medical professionals to display their 

credentials and their capabilities would allow the 

public to make informed choices about their healthcare. 

This includes full disclosure in all advertising and 

marketing materials. Legislation is needed to require 

healthcare providers to clearly and honestly state 

their level of training, licensing and what procedures 

they may legally perform in their advertising and 

marketing materials. Patients must be able to rely 

on what their healthcare providers tell them. Truth 

in advertising legislation helps to do just that. 

The WVSMA supports the passage of legislation 

to include the following components: 

• Require all healthcare professionals wear a 

name tag during all patient encounters that 

clearly identifies the type of license they hold 

• Require healthcare professionals to 

display their education, training and 

licensure in his or her office; and 

• Ensure any advertisements or professional 

web sites healthcare providers may have 

do not promote services beyond what they 

are legally permitted to provide. 

Protecting Patients from Non-physician Practitioner 

Scope of Practice Expansion 

POSITION: The WVSMA opposes the scope of practice 

expansion of non-physician practitioners without 

the appropriate education, training and supervision 

and recommends legislation requiring healthcare 

practitioners to clearly identify their credentials and 

training. 

ISSUE: Every year, in nearly every state, non-physician 

practitioners lobby for expansion of scope of practice 

to gain prescriptive and independent practice rights 

that were once the sole domain of physicians. The 

WVSMA recognizes the inevitability of scope of 

practice overlap. While some scope expansions are 

appropriate and beneficial to patients, many are 

unwarranted intrusions into the physician practice 

of medicine. The health and safety of patients are 

threatened when non-physician practitioners are 

permitted to perform services that are not commensurate 

with their education, training and experience. 

Some non-physician healthcare provider groups 

have become increasingly aggressive in efforts to 

expand their scope of practice to include treatments, 

procedures, and authority inconsistent with their 

education and training. These providers seek to expand 

their scopes of practice through legislative, regulatory, 

and administrative means. Debates over scope of 

practice issues have serious implications for patient care. 

If scope of practice expansions are inconsistent with 

the education and training a provider group receives, 

or are not coupled with safeguards, such as practice 

protocol arrangements with a physician who provides 

oversight of the care provided, the safety and quality 

of healthcare delivered to patients is compromised. 

March/April 2011 | Vol. 107 

1


The WVSMA does support collaborative arrangements 

with nurse practitioners, physician assistants, pharmacists, 

and radiologist assistants. Through such collaboration, 

patient access and quality care can be achieved without 

threatening patient safety. However, protection of the 

patient is of the utmost importance. Expanding the 

scope of practice without adequate medical training and 

appropriate physician supervision is unacceptable. 

Additionally, the WVSMA recommends legislation 

to require all healthcare professionals properly 

identify themselves in all patient encounters and 

advertisements. This would help to ensure that patients 

are promptly and clearly informed of the training 

and qualifications of their healthcare practitioner. 

Strengthening and Preserving our Safety laws 

POSITION: The WVSMA strongly supports 

strengthening West Virginia’s All-Terrain Vehicle safety 

law and maintaining the motorcycle helmet law for 

operators and riders of all ages. 

ISSUE: Though the Legislature passed All-Terrain Vehicle 

(ATV) Child Safety law in 2004, much more needs to 

be done to protect the health and safety of our citizens. 

The West Virginia Legislature has taken a step toward 

ATV safety, but much more needs to be done to improve 

the state’s ATV safety laws. The WVSMA strongly 

supports legislation with the following components: 

• Removing non road-worthy vehicles 

from our public roadways. 

• Expanding the mandatory helmet law 

to cover persons of all ages. 

• Strengthening the requirement for ATV safety 

instruction to require hands-on safety courses. 

• Prohibiting passengers with the exception of machines 

which manufacturers have designed for passengers. 

Another important safety issue is that of preserving 

the motorcycle helmet law. In recent years, efforts have 

been made by various groups to repeal our critically 

important motorcycle helmet law. Such an action by the 

Legislature would be highly irresponsible. Helmets are 

the best evaluated way to reduce motorcycle accident 

deaths and injuries. The WVSMA strongly supports the 

retention of our State’s current mandated helmet use 

law for all motorcycle operators and riders of all ages. 

Addressing Substance Abuse: Balancing 

Treatment and Prevention 

POSITION: The WVSMA supports policies that 

discourage diversion of prescription drugs and that 

facilitate treatment opportunities for individuals 

suffering from substance use disorders. Such policies 

must be balanced with policies that promote the 

physicians’ ability to provide comprehensive and 

compassionate care, and an individual’s ability to access 

appropriate treatment. 

ISSUE: Substance use disorders are a significant problem 

in the United States and in West Virginia. Substance use 

disorders and associated co-morbidities effects more of our 

citizens than any other healthcare concern we are faced 

with today. Experts estimate that prevalence of addiction 

in the general population is between 10 to 12 percent. 

The WVSMA recognizes the importance of policies that 

prevent substance abuse and prescription drug diversion 

through law enforcement mechanisms; however, we also 

recognize that physicians have a responsibility to provide 

appropriate treatment to patients, and policies should not 

interfere with their ability to practice good medicine. 

The WVSMA supports the following recommendations 

to begin to address prescription drug diversion 

and substance use disorders in West Virginia: 

• Appropriately fund and encourage development of 

treatment, education, prevention and intervention 

programs in the state. The Governor’s Comprehensive 

Strategic Plan to Address Substance Abuse in WV 

estimates an investment equal to 5 percent of the direct 

costs of substance abuse be allocated fund programs 

and projects, infrastructure, assessment research and 

evaluation. This equates to $23.5 million annually. 

• Encourage the use of the Board of Pharmacy’s 

Controlled Substances Database by prescribers 

and dispensers of medication and encourage 

better coordination among them to foster 

better care and treatment of patients through 

educational programs coordinated by the Boards 

of Pharmacy, Medicine and the WVSMA. 

• Add the drug Ultram (Tramadol) to the list 

of Schedule IV controlled substances. 

• Prohibit the sale of synthetic marijuana 

and cocaine products. 

• Encourage the expansion of education on 

prescription drug abuse and substance use 

disorders in the curriculum of the schools of 

medicine, nursing, pharmacy and dentistry. 

• Encourage the education on prescription drug 

abuse and substance use disorders into the 

already existing mainstream medicine, leading 

to further education of the patients they serve. 


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West Virginia University Health Sciences | NEWS 

WVU plans to establish new School of Public Health 

Graduates would help address health disparities in WV 


is planning to establish a new 

School of Public Health. 

“The time is right to take this 

step; we already have in place 

about 80 percent of the faculty 

and other requirements we would 

need for a nationally accredited 

school here,” Chancellor for 

Health Sciences Christopher 

Colenda, M.D., M.P.H., said 

Some public health programs 

already exist in the WVU School of 

Medicine, and enrollment has been 

increasing rapidly. The Master’s of 

Public Health (M.P.H.) program has 

doubled enrollment since 2008. WVU 

also offers a master’s degree in school 

health education and a Ph.D. program 

in public health sciences. Several 

community-based health programs 

developed at WVU are having 

national and international impact. 

Dr. Colenda said an independent 

fully accredited school would 

allow the programs to expand 

to attract the best faculty and 

students. He said it would increase 

research investment, which is key 

to developing effective solutions to 

the state’s persistent health issues. 

Creation of the WVU School of 

Public Health requires approval 

from the WVU Board of Governors 

and the West Virginia Higher 

Education Policy Committee. 

WVU Children’s Hospital changing the way it cares for its 

tiniest patients 

There’s a special section of 

the Neonatal Intensive Care Unit 

(NICU) at West Virginia University 

Children’s Hospital with the words 

“Wee Care” over the doorway; it’s 

called the Small Baby Pod. This is 

where the unit’s tiniest patients 

receive care and where a new 

approach to that care is taking place. 

Mark Polak, M.D., director of the 

NICU, said that a multidisciplinary 

team that included physicians, nurses, 

respiratory therapists, physical 

therapists and palliative care staff 

decided that patients would benefit 

from a unified approach for care built 

on evidence-based best practices. 

The Small Baby Pod houses 

babies born before the 26th week 

of pregnancy and those who weigh 

less than two pounds. Dr. Polak 

anticipates that there will always 

be four babies in the pod, which is 

as many as it can hold. They will be 

there for about one month and then 

move to another part of the NICU 

for the remainder of their stay. 

Another change involves 

recognizing and addressing the 

emotional needs of the parents. 

Parents of NICU babies, especially 

those in the Small Baby Pod, face a 

hospital stay of six months or longer. 

Palliative care staff can help the 

parents with the emotional upheaval 

of having a baby in the NICU. 

“What we’re doing now is as close 

to ideal as possible based on what has 

been published,” he said. “We can 

make a big difference on their time 

in the hospital and not only increase 

the quality of care we provide but 

also increase their quality of life.” 

For more information on 

WVU Children’s Hospital 

see www.wvukids.com. 

WVU eye surgery fellowship program one of first to be accredited 

West Virginia University’s 

Ophthalmic Plastic and Reconstructive 

Surgery Fellowship Program is one 

of the first of five programs in the 

country to receive accreditation from 

the Accreditation Council for Graduate 

Medical Education (ACGME). 

Ophthalmic plastic and 

reconstructive surgery, also called 

oculoplastics, includes the surgery of 

all the structures around the eye, such 

as the eyelids, the area behind the 

eye and orbital bone. It also includes 

the surgical treatment of Graves’ 

disease and the removal of the eye 

as the result of trauma and tumors. 

One of the things that makes WVU’s 

program unique is that it involves a lot 

of multidisciplinary collaboration. “We 

work with several different specialties, 

including neurosurgery, plastic 

surgery and otolaryngology,” Jennifer 

Sivak, M.D., director of the WVU 

Ophthalmic Plastic and Reconstructive 

Surgery Fellowship Program, said. 

Norman D. Ferrari III, M.D., senior 

associate dean for student services 

and designated institutional official 

for graduate medical education at the 

WVU School of Medicine, said it is 

not only an honor to be one of the first 

to receive this accreditation, but it is 

also an honor to be considered among 

the leading institutions in the field. 

For more information see 

www.hsc.wvu.edu/som/eye/ 

FellowshipOfferings.aspx. 


Marshall University Joan C. Edwards School of Medicine | Scientific | NEWS Article 

Cancer Center joins major cancer clinical trials network 

The Edwards 

Comprehensive 

Cancer Center has 

been accepted as 

a member of the 

North Central 

Cancer Treatment 

Group, a Mayo 

Clinic–based 

Dr. Tirona international 

cancer 

research network that offers 

access to hundreds of clinical 

trials for most types of cancer. 

Dr. Maria Tria Tirona, a professor 

of internal medicine at Marshall 

and principal investigator for the 

NCCTG at the cancer center, said 

she hopes the clinical trials that 

come through the membership will 

be offered in the future to patients 

throughout West Virginia. 

The NCCTG was founded in 1977 

on the premise that the community 

practice setting, where most cancer 

care occurs, is the most appropriate 

venue for conducting clinical trials. 

The Mayo Clinic Cancer Center 

serves as the research base for the 

network, which is part of the National 

Cancer Program and receives 

financial and scientific support from 

the National Cancer Institute. It 

includes more than 1,200 physicians 

and researchers at more than 375 

treatment locations in North America. 

The Edwards Comprehensive 

Cancer Center also is affiliated with 

the Children’s Oncology Group and 

the SunCoast CCOP Research Base 

(formerly Moffitt Research Base). 

Appalachian Health Summit to focus on obesity 

An Appalachian Health Summit 

in April, co-sponsored by six 

organizations including Marshall, will 

focus on obesity and seek strategies 

to address the problem, which is 

especially prevalent in Appalachia. 

The conference will be April 21 

at the Lexington, Ky., Convention 

Center. Its keynote speaker will be 

William Dietz, M.D., Ph.D., who 

is director of nutrition, physical 

activity and obesity at the Centers 

for Disease Control and Prevention. 

A plenary session will address 

health disparities and health 

behaviors in Appalachia, and 

concurrent sessions will focus on 

topics ranging from childhood obesity 

and obesity/cancer links to research 

networks and social networking. 

Richard Niles, 

Ph.D., Marshall’s 

senior associate 

dean for research 

and a co-chair 

of the summit, 

is organizing 

the obesity and 

cancer session. 

Dr. Niles Noting that the 

obesity problem 

is more prevalent in Appalachia than 

elsewhere, Niles said links between 

obesity and diseases such as diabetes 

and hypertension are well recognized, 

and that obesity is known to increase 

the risk for multiple types of cancer. 

“The summit is designed to 

learn about the obesity problem 

and its prevalence, and to map 

strategies to counteract it,” he said. 

In addition to Marshall, the 

event’s sponsors are the University 

of Kentucky, The Ohio State 

University, the University of 

Cincinnati, Pikeville College and the 

Appalachian Regional Commission. 

Yingling to lead new School of Pharmacy 

Dr. Kevin W. 

Yingling has 

been named 

founding dean 

of the Marshall 

University School 

of Pharmacy. 

A pharmacist 

and physician, 

Dr. Yingling Yingling has 

more than 

20 years’ experience in graduate 

medical education. He is chairman 

of Marshall’s Department of 

Internal Medicine, and he has 

been a registered pharmacist 

since 1981, the medical director 

of the medical school’s Center for 

Pharmacologic Study since 1992 and 

a consultant pharmacist since 1995. 

Yingling received his B.S. in 

pharmacy from West Virginia 

University and his M.D. from 

Marshall. He completed his residency 

and fellowship at the University 

of Cincinnati Medical Center. 

Marshall President Stephen J. Kopp, 

Ph.D., said the pharmacy school will 

help to reverse the significant shortage 

of pharmacists in West Virginia, which 

ranks among the top 10 percent of 

states in unmet pharmacist demand 

— a shortage that is likely to become 

greater as the state’s population ages 

and more pharmacists are needed 

as their practice role evolves in 

outpatient care centers, large specialty 

practices, nursing care facilities, and 

rural health clinics and care centers. 


West Virginia School of Osteopathic Medicine | NEWS 

Adelman Signs Contract; Officially Sworn in as WVSOM President 

Michael D. 

Adelman, D.O., 

D.P.M., J.D., 

assumed the 

Presidency of the 

West Virginia School 

of Osteopathic 

Medicine during 

Dr. Adelman a contract signing 

ceremony at the 

institution’s Board of Governors 

meeting on January 22. The Higher 

Education Policy Commission 

unanimously approved the 

appointment January 21. 

Rodney Fink, D.O., Board Chair, 

stated HEPC members were most 

complimentary of Dr. Adelman’s 

contributions to WVSOM and 

wholeheartedly concurred with 

the Board of Governors selection. 

Dr. Adelman, the second 

osteopathic physician to serve as 

WVSOM’s president, affirmed his 

commitment to continue to embrace 

the institution’s legacy of excellence. 

He further commented that he and 

his wife, Cheryl, fell in love with 

WVSOM and Lewisburg when they 

settled in the area nine years ago. 

“This is our home and you are our 

family,” he stated. “I am incredibly 

grateful to the Board of Governors, 

faculty, staff, students and the 

community for giving Cheryl and me 

the opportunity to serve in this role. 

I look forward to working with all of 

you in moving WVSOM forward.” 

Board of Governors members were 

joined by a capacity crowd of faculty, 

staff and students, offering their 

congratulations and support to Dr. 

Adelman with a standing ovation. 

WVSOM’s Acting President 

for the past nine months, Dr. 

Adelman previously served as 

the Vice President for Academic 

Affairs and Dean since 2002. He 

brings to the Presidency a strong 

background in osteopathic medical 

education on the local, state and 

national levels. He holds doctoral 

degrees in Osteopathic Medicine, 

Podiatric Medicine and Law. 

WVSOM Associate Dean, Board Member 

Contribute to Popular Textbook 

Kendall Wilson, D.O., and 

Karen Steele, D.O., F.A.A.O., have 

made significant contributions 

to a widely used textbook. 

The textbook, entitled “Foundations 

of Osteopathic Medicine 3rd edition,” 

is used by WVSOM students and 

other osteopathic medical students 

across the country as part of their 

medical curriculum. There are 

currently 26 colleges of osteopathic 

medicine offering instruction 

at 34 locations in 25 states. 

Dr. Wilson, Vice Chairman of the 

WVSOM Board of Governors and 

alum, co-authored the chapter entitled 

“Chapman’s Approach,” while Dr. 

Steele, Associate Dean of Osteopathic 

Medical Education at WVSOM, 

served as lead author on the chapter 

entitled “Child with Ear Pain.” 

Both chapters were included 

in Part IV of the publication: 

“Approach of Osteopathic Patient 

Management.” Part IV is devoted to 

a comprehensive discussion of how 

an osteopathic physician approaches 

common patient scenarios. 

Authors were asked to begin 

the chapter with a typical case 

description, and use this case as a basis 

of discussion of that patient’s care. 

Chapters are written in such a way 

that osteopathic students see the five 

models of care commonly utilized by 

osteopathic physicians: biomechanical; 

respiratory-circulatory; neurologic; 

metabolic energy; and behavioral. 

According to Dr. Steele, this 

thought process is designed to help 

students consider the distinctiveness 

of osteopathic care and how they 

will apply this care to their future 

patients. “The chapters summarize 

how osteopathic medicine is 

unique,” she explained. “The book 

is used to mold students into future 

osteopathic practitioners.” 

Dr. Wilson (’81), said he feels 

“very honored” to be a part of the 

publication. “But more importantly, 

I cherish the opportunity to make a 

Dr. Karen Steele (left) and Dr. Kendall Wilson have made 

significant contributions to a widely used textbook. 

contribution to the academic world 

and to make a meaningful contribution 

to Dr. Chapman’s reflex,” Dr. Wilson 

said, referring to the osteopathic 

technique discussed in his chapter. 

Other WVSOM contributors to the 

Foundations of Osteopathic Medicine 

3rd edition include John Glover, 

D.O. (’86), of Vallejo, California, who 

serves as one of the publication’s 

Section Editors, and Richard Van 

Buskirk, D.O. (’87), of Sarasota, 

Florida, who co-authored chapter 

52 entitled “The Still Technique.” 

Authors are solicited by the 

section editors. The book is a 

publication of Lippencott and is 

available in the WVSOM Bookstore. 


Bureau for Public Health | NEWS 

Emergency Medical Services for Children Program 

Revitalizes the Always Ready for Kids Project 

The State Trauma and Emergency 

Medical System’s Office of 

Emergency Medical Services 

(EMS), EMS for Children Program 

has redesigned a project that was 

operational a decade ago, the 

Always Ready for Kids (ARK) project. 

EMS for Children Program (EMS- 

C) is responsible for assuring a 

statewide, standardized system 

exists where all hospital emergency 

departments demonstrate an 

established plan and/or the ability 

to manage medical and trauma 

pediatric emergencies. The goal of 

ARK is to create an effective and 

sustainable method to ensure that 

children who need treatment for life 

threatening illnesses or injuries have 

access to the appropriate facilities, 

equipment and trained personnel. 

The revitalization of ARK 

required input from the EMS-C 

Advisory Committee and other 

stakeholders to develop an effective 

and sustainable program. The 

program guidelines were revised, 

a statewide education process put 

in place, and regional meetings are 

scheduled throughout January 2011 

to educate hospitals. Site visits will 

begin in February 2011 for those 

facilities interested in participating 

in this voluntary program. 

Becoming an ARK recognized 

facility benefits both the hospital 

and the community by: 

• Creating a culture driven to 

continue improvement of 

pediatric patient outcomes, 

availability of equipment, 

services, and up-to-date treatment 

policies and protocols; 

• Increasing the public’s 

confidence in the overall 

quality of care received by 

West Virginia’s children; 

• Recognizing physicians, nurses, 

specialists, and other clinical 

staff for their knowledge, 

abilities, and commitment 

through their employment at 

an ARK recognized facility; 

• Recognizing facilities prepared 

for addressing the critical 

pediatric needs during a 

medical or trauma emergency. 

This will be visible in the form 

of a plaque displayed in the 

facility’s emergency department 

and through the listing of the 

facility on the West Virginia 

Department of Health and Human 

Resources, West Virginia Office 

of Emergency Medical Services’ 

website, and, additionally 

through self-promoting this 

accomplishment through local 

and/or statewide media outlets. 

• Utilizing ARK recognitions as a 

recruiting and marketing tool to 

attract high quality physicians, 

nurses and other specialists. 

• Enhancing potential educational 

and grant offerings that 

have been developed for 

rural hospital settings. 

Facilities achieving 100% 

compliance on the “Essential” 

elements and 70% on the “Desired” 

elements will receive ARK 

recognition. Compliance with the 

guidelines will be determined 

through an onsite visit. Once a 

facility receives ARK recognition, it 

will remain valid for a period of three 

(3) years. At that time, the facility 

has the option of reapplying. If your 

hospital is interested in participating 

in the ARK initiative, complete the 

application online or submit it via 

e-mail to Vicki.L.Hildreth@wv.gov 

or facsimile at (304) 558-8379. 

Drema Mace, PhD 

Director, State Trauma and Emergency 

Medical System (STEMS) 

Vicki Hildreth, BA 

Program Manager, Emergency Medical 

Services for Children Program (EMS-C) 

Drug or Alcohol Problem Mental Illness 

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

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

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

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

ALL CALLS ARE CONFIDENTIAL 

West Virginia Medical Professionals Health Program 

PO Box 40027 


(304) 414-0400 | www.wvmphp.org 


WV Medical Insurance Agency | NEWS 

Why We Also Want to Be Your Agent 

for Workers’ Compensation and 

Business Owners Package Policies 

Since the West Virginia Medical 

Insurance Agency started working 

with physicians to handle their 

workers’ compensation and business 

owners package policies, we have 

successfully impacted the cost 

our clients are paying for these 

insurances as well as improved or 

enhanced the coverages they have. 

Note the following: 

A. Workers’ Compensation 

Insurance: Of the new business 

we have written, all of which was 

previously placed with BrickStreet 

Mutual Insurance Company, we 

have saved our clients on average 

12.7% in premium over what 

they were paying BrickStreet or 

quoted by BrickStreet. That’s an 

average savings of approximately 

$200 on an average premium of 

$1,545. The greater the premium, 

the greater the dollar savings. 

In addition to savings in 

premiums, we have broadened 

coverages by increasing Employer’s 

Liability (Coverage B) limits of 

liability and adding Broad Form 

coverage (including deliberate 

intent) in the same premium. Also, 

we verify the need for workers’ 

compensation by our insureds (in 

particular practicing physicians) 

and review the gross payrolls for 

individual limitations or maximum 

amounts required to be reported 

and these reviews have also 

resulted in premium savings. 

B. Business Owners Package 

(BOPs): Of the new business we have 

written, we have saved our clients 

on average 18.5% in premium over 

what they were previously paying 

or being quoted at renewal. That 

results in an average savings of $327 

on an average premium of $1,773. 

Obviously the greater the premium, 

the greater the dollar savings. 

Business owners package 

policies include but are not 

limited to coverage for buildings 

and/or contents; general liability, 

equipment breakdown, accounts 

receivables, valuable papers and 

records, computers and media, 

personal and advertising liability, 

crime (employee dishonesty), and 

employment practices liability. 

Our review of potential clients’ 

then current coverages frequently 

confirms inadequacies in the 

existing coverages. Therefore, 

some of the price reduction seen 

by our new clients also include 

coverage enhancements. 

How is this possible The 

West Virginia Medical Insurance 

Agency’s primary carrier for 

workers’ compensation and 

business owner’s packages is The 

Hartford and The Hartford prefers 

medical practices/health business 

as a class of business and designs 

specific coverages and preferred 

rating plans for medical practices. 

Are you missing out on this 

opportunity to save premium dollars 

on your workers’ compensation and/ 

or business owners’ packages If so, 

we would welcome the opportunity 

to provide a no obligation review 

for your practice. Please call Steve 

Brown, Agency Manager, at 304- 

925-0342 ext 22, (toll free at 1-800- 

257-4747 ext 22), cell # 304-542-0257 

or e-mail steve@wvsma.com. 

Reasons to Switch Coverage: Not! 

Recently one of our physician 

clients sent me a copy of a 

solicitation he received from an 

agent trying to get him to move 

his medical liability coverage. The 

letter gave “four reasons” why you 

should switch. With this editorial 

piece, I wanted to respond. 

Reason # 1 – Best Price “Did you 

know that the rates may be much 

lower than what you pay right now 

It’s true. You may be surprised that 

the premier medical malpractice 

insurer in the country is also the most 

affordable for select physicians.” 

Response #1 – I question the 

use of the term “best” price when 

speaking about “lowest” price, the 

two are not synonymous. When 

considering price do not be confused 

by the two. The ability to receive 

local service from qualified local 

personnel may be more important 

than a few dollars. Most affordable 

is not always best. Plus what does 

the term “select physicians” mean 

Reason # 2 – Unmatched Financial 

Strength “Company [X] is the highest 

rated medical professional liability 

insurance company in the industry 

with “AA+ S&P and A++ A.M. Best’s 

ratings. You’re covered. Period.” 


Response # 2 – “You’re covered. 

Period.” This sounds like a guarantee 

to me, which in fact is an extremely 

questionable or ethical statement 

to make. I seriously doubt that 

this carrier would want an agent 

making this type of guarantee. 

Additionally, financial ratings 

do not guarantee coverage. 

Reason #3 – Best Defense: “With 

the nation’s most proactive defense 

and winning percentages Company 

[X] has earned a reputation as 

the best in the industry.” 

Response #3 – I believe this type 

of reputation has been promoted 

in West Virginia before. Being the 

“most proactive defense” oriented 

carrier has not always resulted 

in success in West Virginia. West 

Virginia courts have been known to 

be very hard on out-of-state insurers. 

Reason # 4 – Proven Track Record: 

“For more than a century, Company 

[X] has delivered the industry’s best 

financial strength, most winning 

defense and smartest risk solutions. 

Today, more healthcare providers 

across the nation get their protection 

from one company, Company [X].” 

Response #4 – Sounds like a 

restatement of Reason #2. Regardless, 

the writer has provided no record 

or history for this carrier in West 

Virginia; therefore, they may have 

a track record, but not in West 

Virginia. And the statement “Today, 

more healthcare providers across 

the nation get their protection from 

one company” could be interpreted 

as meaning more than 50% or more 

than last year – I’m not sure, are you 

Quite frankly, I am appalled by 

some of the comments in this letter by 

an out-of-state addressed insurance 

agent, who, based on my review of 

an on-line listing from the Offices of 

the Insurance Commission may not 

even be appointed by the carrier. 

I believe there is a value in dealing 

locally whether it be your agent or 

your carrier that was created by 

your state’s legislature to act on 

your behalf at a time of real need 

(where was this other company with 

the proven track record in 1998, 

1999, 2000, 2001, 2002, 2003, 2004, 

2005, 2006, 2007, 2008, and 2009) 

For more details on these 

issues and the real value of the 

West Virginia Mutual Insurance 

Company for the doctors of West 

Virginia, please call Steve Brown, 

Agency Manager, West Virginia 

Medical Insurance Agency, at 

304-925-0342 ext 22 or toll free 

1-800-257-4747 ext 22 to set up an 

appointment to review the details. 


2011 

Certified Medical Office 

Manager Class (CMOM) 

Thursday, March 24 & Friday, March 25 and Thursday, March 31 & Friday, April 1, 2011 

Time: 9:00 a.m. to 4:00 p.m. | Place: St. Francis Hospital, Charleston, WV (Participants must attend all 4 days.) 

Participant Information 

Registrant #1: _____________________________________________________ 

Registrant #2: _____________________________________________________ 

Registrant #3: _____________________________________________________ 

E-mail:__________________________________ 

E-mail:__________________________________ 

E-mail:__________________________________ 

Practice Name: _____________________________________________________________________________________________ 

Street Address: _____________________________________________________________________________________________ 

City: __________________________________________________________State:_______________ Zip:____________________ 

Phone:_____________________________________ Fax:___________________________________________________________ 

Program Fee/Discount Policies: 

Registration Fee: $799 WVSMA members: $699 (Includes instructional materials and exam fee.) 

Payment Method: 

q American Express q MasterCard q Visa q Check Enclosed 

Payable to: 

West Virginia State Medical Association 

Card No: ____________________________________________ Expiration Date:___________V Code:_____________ 

(Three digit number on the back of your credit card.) 

Name As It Appears On Card:________________________________________________ 

Signature: _______________________________________________________________ 

Registration Methods: 

Mail registration form to: Karie Sharp • West Virginia State Medical Association • PO Box 4106, Charleston, WV 25364 

Fax registration form to: Karie Sharp • (304) 925-0345 Charge by phone: Karie Sharp • (304) 925-0342, ext. 12 

E-mail: karie@wvsma.com 

Discounted rooms are available at the Embassy Suites | 304.347.8700, ext. 2035/1-800-EMBASSY or go to 

www.embassysuitescharlestonwv.com and use code SME for March 23-24 or SMD for March 31-April 1. 

Presented through an exclusive partnership between:

Physician Practice Advocate | NEWS 

Medicare Changes that Will Affect Your Practice 

by Barbara Good, CMOM, Physician Practice Advocate, WVSMA 

The Affordable Care Act has 

made some important changes 

to Medicare-covered preventive 

services for dates of service on or 

after January 1, 2011. Some of these 

changes include the addition of the 

new Annual Wellness Visit (AWV) 

with prevention plan benefit, as well 

as the removal of deductibles and 

copays for many services. The Act, 

signed on March 23, 2010, also offers 

a Primary Care Incentive Payment 

Program (PCIP) which is effective 

for services rendered between 

1/1/2011 through 12/31/2015. 

In addition to these changes, 

two new preventive benefits have 

been added by the Centers for 

Medicare and Medicaid (CMS). One 

is Counseling to Prevent Tobacco Use 

and the other is Screening for Human 

Immunodeficiency Virus (HIV) Infection. 

Another provision of the 

Affordable Care Act (ACA) includes 

improvements to the Physician 

Quality Reporting System (formerly 

known as PQRI). In addition to the 

1% reporting payment, CMS has 

announced that during 2011, there 

is now an additional .5% incentive 

available for the January 1-December 

31, 2011 reporting period. 

For more information on these and 

other provisions of the Affordable 

Care Act, you may visit www.cms. 

gov or www.healthcare.gov. 

In addition to the changes made 

by the Affordable Care Act, CMS 

has also released instructions to 

update seasonal influenza codes. 

Although Healthcare Common 

Procedure Coding System Codes 

(HCPCS) became effective for dates 

of service on or after October 1, 2010, 

the Medicare claims processing 

systems didn’t recognize the codes 

until January 1, 2011. Medicare 

systems were unable to process roster 

claims until February 7, 2011, but 

physicians should have been able to 

submit a roster bill as of that date. 

Physicians who submitted 

influenza vaccine claims with 

CPT code 90658 after January 1, 

2011, will receive a rejection and 

must submit a new claim with 

the correct HCPCS codes. 

In other Medicare news, in 

November 2010, the Centers for 

Medicare & Medicaid Services 

announced that beginning in 

2012, eligible professionals who 

are not successful electronic 

prescribers may be subject to a 

payment adjustment. Section 132 

of the Medicare Improvements for 

Patients and Providers Act of 2008 

(MIPPA) authorizes CMS to apply 

this payment adjustment whether 

or not the eligible professional 

is planning to participate in 

the eRx Incentive Program. 

The payment adjustment in 

2012, with regard to all of the 

eligible professionals’ Part B- 

covered professional services, will 

result in the eligible professional 

or group practice receiving 99% of 

the Physician Fee Schedule (PFS) 

amount that would otherwise apply 

to such services. In 2013, eligible 

professionals will receive 98.5% 

of their covered Part B-eligible 

charges if they aren’t successful 

electronic prescribers. In 2014, the 

penalty for not being a successful 

electronic prescriber is 2% resulting 

in eligible professionals receiving 

98% of their covered Part B charges. 

For purposes of determining 

which eligible professionals or group 

practices are subject to the payment 

adjustment in 2012, CMS will analyze 

claims data from January 1, 2011- 

June 30, 2011 to determine if the 

eligible professional has submitted 

at least 10 electronic prescriptions 

during the first six months of 

calendar year 2011. Group practices 

reporting as a GPRO I or GPRO II in 

2011 must report all of their required 

electronic prescribing events in the 

first six months of 2011 to avoid 

the payment adjustment in 2012. 

If an eligible professional or 

selected group practice wishes 

to request an exemption to the 

eRx Incentive Program and the 

payment adjustment, there are 

three “hardship codes” that can be 

reported via claims should one of 

the following situations apply: 

G8642 - The eligible professional 

practices in a rural area without 

sufficient high speed internet 

access and requests a hardship 

exemption from the application 

of the payment adjustment 

under section 1848(a)(5)(A) 

of the Social Security Act. 

G8643 - The eligible professional 

practices in an area without sufficient 

available pharmacies for electronic 

prescribing and requests a hardship 

exemption from the application 

of the payment adjustment 

under section 1848(a)(5)(A) 

of the Social Security Act 

G8644—The eligible professional 

physician practice may indicate 

that they do not have prescribing 

privileges. Reporting this G code 

will prevent the practitioner 

from being subjected to a 

payment adjustment in 2012. 

If you need additional information 

on any of the programs listed above, 

visit the official Medicare website 

www.cms.gov/erxincentive. 


Obituaries 

The WVSMA remembers 

our esteemed colleagues… 

Dennis Marshall Cupit, M.D. 

Dennis Marshall Cupit, M.D., 

59, of Milton passed away at St. 

Mary’s Medical Center on December 

17, 2010 after a sudden illness. 

He was born May 1, 1951, a 

son of the late Charles Cupit and 

Elizabeth Cupit. In addition to 

his parents, he was preceded in 

death by one sister, Sarah Johnson; 

sister-in-law, Susan Cupit; and 

brother-in-law, Jim Yeager. 

He is survived by his wife, 

Marylyn Cupit; son, Private 

Christopher Cupit, serving in 

the Army National Guard; two 

sisters, Linda Amburgey of South 

Charleston and Debbie Yeager of 

Dunbar; one brother, Gordon Cupit 

of Dunbar; and numerous family 

members, friends, and patients. 

In keeping with his wishes, his 

body was donated to Marshall 

University Medical School. 

Echols A. Hansbarger Jr., MD 

Echols A. Hansbarger Jr., 

M.D., 80, of Charleston died 

suddenly on January 20, 2011. 

He was predeceased by his wife, 

Withers, in December 2008. They 

had been married for 53 years. 

Dr. Hansbarger was born 

in Williamson on September 

15, 1930, the only son of Lydia 

White Hansbarger of Matewan, 

Mingo County, and Echols A. 

Hansbarger of Peterstown, 

Monroe County, both deceased. 

He grew up in Charleston 

and graduated from Stonewall 

Jackson High School in 1948. He 

graduated from Washington & Lee 

University, Lexington, Virginia, in 

1952 and from the Medical College 

of Virginia, Richmond, in 1956. 

In 1974, he returned to Charleston 

as director of laboratories at St. 

Francis Hospital and, in 1976, at 

Kanawha Valley Hospital. He 

retired in 1999 after 38 years of 

pathology practice. An additional 

year of part-time practice ended 

with his total retirement in 2000. 

He was a past president of the 

Kanawha Medical Society and 

a member of the State Medical 

Council and a number of other 

medical societies including Alpha 

Omega Alpha Medical Honorary, 

College of American Pathologists 

and the West Virginia State Medical 

Association. He was board certified 

by the American Board of Pathology 

in anatomic pathology, clinical 

pathology and blood banking. 

He was also board certified by 

the American Board of Forensic 

Examiners and the American 

Board of Forensic Medicine. 

He is survived by his daughter, 

Anne Sladky of Dunbar; and sons, 

Echols A. Hansbarger III of Myrtle 

Beach, S.C., Walter Hansbarger, and 

wife, Joselyn Hansbarger, of Virginia 

Beach, Va., and Jeff Hansbarger of 

Point Pleasant. He is also survived by 

four grandchildren. 

Robert Dale Hess, MD 

Robert Dale Hess, M.D., 

age 78, died January 30, 

2011, at his residence. 

Dr. Hess was born February 

6, 1932, son of the late Waonda 

J. and Raymond C. Hess. 

His first wife, Alice Jo Hess, 

preceded him in death in June 1997. 

Surviving are his wife of eight 

years, Patricia Chapman Hess, and 

the following children: John R. Hess 

and his wife, Jane M. Hess; Mary 

K. Hess; Monica A. Garner and her 

husband Roderick J. Garner; Dr. 

Michael R. Hess and his wife, Dr. 

Elizabeth H. Hess; Joseph F. Hess and 

his wife S. Naseem Anjam; Patrick 

R. Chapman and his wife Brandee 

N. Chapman; 13 grandchildren: 

Claire K. Garner, Maxwell J. Garner, 

Meredith R. Garner, Katheryn B. 

Hess, Andrew D. Hess, Christopher 

S. Hess, Harrison R. Hess, Madison 

R. Hess, Allison J. Hess, Patrick R. 

Chapman II, Joseph B. Chapman, 

Dylan P. Chapman and Mackenzee 

E. Chapman. Also survived by two 

brothers, Edgar A. “Bud” Hess, and 

his wife Twylia Hess, and Dr. David 

R. Hess and his wife Marilyn Hess; 

and a sister-in-law, Vera L. Hess. 

He was also preceded in death 

by one brother, George L. Hess, 

and four sisters, Dorothea Ruth 

Gianni, Jerry W. Kinney, Betty 

J. Smith and Helen L. Wetzel. 

Born and raised in Bridgeport, 

WV, Dr. Hess graduated from 

Bridgeport Senior High School in 


1950. He graduated from the pre-med 

program at Potomac State College, 

then West Virginia University School 

of Medicine. He completed his 

medical education at the Medical 

College of Virginia, Richmond, in 

1958. He served his internship and 

residency at Charleston Memorial 

Hospital from 1958-1960. 

He was also a member of the 

Harrison County Medical Society, 

West Virginia State Medical 

Association, American Academy 

of Family Physicians and the 

American Medical Association. 

Over the years, Dr. Hess enjoyed 

numerous leadership positions 

ranging from United Hospital Center 

Board member to founder and 

president of the Family Medicine 

Foundation of West Virginia, 

which provides scholarships to 

medical students and residents 

interested in Family Medicine. 

In lieu of flowers, contributions 

can be made to the Robert D. Hess, 

M.D. Memorial Fund, Wesbanco, 

attention: Lu Bush, 1130 Johnson 

Avenue, Bridgeport, WV 26330. 

Elmond LeMoyne Coffield, MD 

Elmond LeMoyne Coffield, 

M.D., 87, died on February 10, 2011, 

surrounded by his loving family 

and in the caring hands of the 

staff and professionals at Wetzel 

County Hospital, where he cared 

for his patients for 48 years. 

Dr. Coffield was born on 

November 19, 1923, on Coffield Ridge 

in Wetzel County, West Virginia. He 

was the son of Susan Austie (Yoho) 

Coffield and Albert Lee Coffield, 

M.D. and the brother of Olan 

Terrell Coffield, M.D. He married 

Colleen Frost (Harris) Coffield of 

Bannock, Ohio on October 22, 1950. 

Dr. Coffield graduated with a 

Bachelor of Arts from West Virginia 

University in 1943, a Bachelor 

of Science from West Virginia 

University Medical School in 1945, 

and a Medical Doctorate from 

the Medical College of Virginia 

in 1947. He did his medical and 

anesthesia residency at Ohio Valley 

General Hospital from 1947-1950. 

Dr. Coffield joined his brother, 

Dr. Terrell Coffield, and began 

practicing family medicine in New 

Martinsville on July 1, 1950. Dr. 

Coffield, his brother, and their 

father Dr. Albert Lee Coffield 

provided health care to generations 

of Wetzel County families. It is 

estimated that Dr. Coffield and his 

brother delivered over 4,000 babies 

during the 30 years they offered 

obstetrical services as a part of 

their family practice. Dr. Coffield 

and his brother were health care 

innovators by adding a medical office 

pharmacy and the first drive through 

pharmacy service in conjunction with 

Harman’s Drug Store. He provided 

occupational medicine and served 

as the first plant physician at the 

New Martinsville Bayer facility 

(Mobay Chemical) from 1955-1998. 

Dr. Coffield was inducted into the 

United States Army on December 

18, 1943, and reported to duty at 

West Virginia University in the 

Army Specialized Training Program 

which trained physicians for military 

service. He was transferred to the 

Medical College of Virginia and 

was discharged on March 23, 1946. 

During the Korean War, Dr. Coffield 

served in the United States Army 

Medical Corp as a First Lieutenant 

and was stationed at Fort Bragg 

Army Hospital and Fort Knox Army 

Hospital from 1951-1953 where he 

served as an anesthesiologist. 

Dr. Coffield is survived by his 

five children, Jennifer Coffield 

Tobin (Thomas J. Tobin), Rebecca 

Coffield Moore (Charles Thomas 

Moore, Jr.), Melinda Coffield Herrick, 

Colette Coffield Goddard (Aaron 

Goddard), and Robert LeMoyne 

Coffield (Susanne M. Coffield). He 

loved his twelve grandchildren: 

Chad Tobin, Dylan Tobin, Spencer 

Tobin, Thomas Moore, Evan Moore, 

Whitney Herrick Bacalman, Paul 

Herrick, Maggie Herrick, Taylor 

Goddard, Sean Goddard, Daniel 

Coffield, and Rachel Coffield. He 

also loved Goldie, his loyal yellow 

lab. He is further survived by many 

nieces, nephews, other Coffield and 

Harris relatives, neighbors, and many 

friends. In addition to his parents, 

he was preceded in death by the 

love of his life, Colleen Frost (Harris) 

Coffield, who died on July 14, 1978. 

Dr. Coffield was a member of 

the First Christian Church and one 

of the founding members of the 

Wetzel County Historical Society 

Museum. As a member of the Court 

Restaurant “lunch bunch,” Dr. 

Coffield was a wonderful storyteller 

and Wetzel County historian. 

A special thanks to his caregivers 

and the staff at Journey Hospice. 

Memorial donations may be made 

to Wetzel County Hospital, First 

Christian Church, Journey Hospice, 

or a charity of your choice. 

The West Virginia Medical Journal is 

honored to publish the obituaries of 

West Virginia physicians. Please send 

copy to 

Angie Lanham 

Managing Editor, WV Medical Journal 

PO Box 4106, Charleston, WV 25364 or 

E-mail to: angie@wvsma.com 


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American Society of 

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ASAM 

42nd Annual 

Medical Scientific Conference 

April 14-17, 2011 

Washington Hilton Hotel 

Washington, DC 

ASAM is an association of physicians 

dedicated to improving addiction treatment, 

educating physicians and students, promoting 

research and prevention, and information 

communities about these important issues. 

Our Medical-Scientific Conference includes 

scientific symposia, clinically oriented 

courses and workshops, as well as 

presentations of submitted papers. 

The 2011 Ruth Fox Course for Physicians 

and the Pain and Addiction Course are offered 

in addition. 

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I n H o m e C a r e 

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WOMEN’S HEALTH CARE OF MORGANTOWN 

“Experienced, professional care that puts you first” 

Diplomates of the American College 

of Obstetrics and Gynecology 

William Hamilton, MD 

Louise Van Riper, MD 

Murshid Latif, MD 

Craig Herring, MD 

• 

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Jan Thomas, CNM 

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The Center for Pain Relief, Inc. 

Multidisciplinary Interventional Pain Management 

Timothy Deer, MD 

Richard Bowman, MD 

Christopher Kim, MD 

Matthew Ranson, MD 

St. Francis Hospital Location 

400 Court Street, Suite 100, Charleston, WV 25301 

304.347.6120 

see Teays Valley Hospital Location, next page 


WVSMA | Professional Directory (cont’d) 

The Center for Pain Relief, Inc. 

Teays Valley Hospital Location 

Doctors Park, 1400 Hospital Drive 

Hurricane, WV 25526 

304.757.5420 

Physical Therapy and Rehabilitation Center, 

Southridge Location 

100 Peyton Way, Charleston WV, 25309 

304.720.6747 

www.centerforpainrelief.com 

U R O LO G Y 

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Adult and Pediatric Urology 

Providing healthcare services in West Virginia and Virginia 

at multiple locations for over 27 years 

Kyle F. Fort, MD, David F. Meriwether, MD, 

Thomas S. Kowalkowski, MD, Joseph 

Mouchizadeh, MD, and James Cauley, MD 

Certified by the American Board of Urology 

Diplomates of the American College of Surgeons 

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www.greenbrierurology.com l info@greenbrierurology.com 

Helping West Virginia pHysicians take the right path… 

…in litigation, privacy and security compliance, certificate of need, medical staff and professional 

disciplinary matters, credentialing concerns, complex regulatory matters and business transactions. 

health care practice group 

Ryan A. Brown 

Robert L. Coffield 

Alaina N. Crislip 

J. Dustin Dillard 

Sam Fox 

Michele Grinberg 

John D. Hoffman 

Amy R. Humphreys 

Charleston 

Justin D. Jack 

Richard D. Jones 

Edward C. Martin 

Mark A. Robinson 

Amy L. Rothman 

Don R. Sensabaugh, Jr. 

Salem C. Smith 

Morgantown 

Stephen R. Brooks 

Stacie D. Honaker 

Wheeling 

David S. Givens 

Phillip T. Glyptis 

Robert C. James 

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2012 

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

Theme: The Art, Science and ethics of Prevention* 

I. Consistent with the theme, one paper 

(addressing preventive education, screening, 

assessment and interventions) will be accepted 

on each of the following topics (Addressing 

unique WV genetic, cultural, environmental and 

demographic influences is encouraged): 

• 

• 

• 

• 

• 

• 

• 

• 

• 

• 

• 

• 

Women’s Health 

Men’s health 

Newborns/ Growth and Development (pre-teen) 

Adolescent health 

Cardiovascular Disease and Stroke 

Mental Health (including Autism and Dementia) 

Cancer 

Genetics 

Kidney Disease 

Immunizations 

Endocrine Disorders 

Life-Style Medicine 

Submissions must include: 

1) cover letter (include corresponding author’s email address) 

2) manuscript (double-spaced) 

3) short biography for each author 

4) three questions and answers pertaining to the manuscript (for CME Post-test 

Questions) 

5) a paragraph stating the objectives of the paper 

Send to angie@wvsma.com or mail to: 

Angie Lanham 

Managing Editor, WV Medical Journal 

PO Box 4106, Charleston, WV 25364 

II. One paper on the status and role of health 

information technology in assisting physicians 

to meet the expanding preventive health 

challenges. 

III. Two papers addressing ethical issues, 

controversies and dilemmas involved in 

providing preventive care to individual 

patients, including balancing clinical and 

non-clinical benefits and risks, as well 

as the duties and responsibilities of all 

involved parties. (These could be scientific or 

commentary articles.) 

IV. One paper addressing the interplay of the 

ethical obligation of the physician to both the 

individual patient and community, i.e., public 

health. (Commentary article.) 

DEADLINES: 

Manuscript submission: December 1, 2011 

Reviews returned by: February 1, 2012 

Resubmissions: March 1, 2012 

Printing: 

May/June 2012 issue 

6) All figures and photos must be submitted separately as .jpg, .tif or .pdf 

files. 

7) The word count limit is 2,500 with a limit of 5 visuals (i.e., 3 tables and 2 

figures). Actual figure and table size is left to the discretion of the managing 

editor, as space is available. 

Scientific articles should be prepared in accordance with the “Uniform 

Requirements for Submission of Manuscripts to Biomedical Journals.” Please go 

to www.icmje.org for complete details. For additional requirements, please refer to 

Manuscript Guidelines located on the last page of every Journal or go to www. 

wvsma.com/journal and click on the link. 

* 

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, 

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 

“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 

“labeled.” At times it also creates a new tension in the patient- physician relationship as regards the “duties” and “responsibilities” of each party. 

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 

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 

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, 

plowing forward, staying on message, not to be bogged down with conflicting data, nuanced reasoning, or messy statistical analyses.” 

This issue attempts to assist West Virginia physicians better understand, balance and meet these challenges and duties by comprehensively exploring this topic. 


Manuscript Guidelines 

Originality: All scientific and special topic 

manuscripts for the West Virginia Medical Journal will 

not be considered for publication if they have already 

been published or are described in a manuscript 

submitted or accepted for publication elsewhere. All 

scientific articles should be prepared in accordance 

with the “Uniform Requirements for Submission of 

Manuscripts to Biomedical Journals.” Please go to 

www.icmje.org for complete details. 

Authors: A cover letter from the corresponding 

author should be submitted with the manuscript. All 

persons listed as authors should have participated 

sufficiently in the work to take public responsibility for 

the concept. 

Format: All articles may be submitted by email or on 

CD. Microsoft Word is preferred, but other programs 

are acceptable. All tables or figures should be 

created separately from the body of the manuscript 

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

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

etc. Legends should be included for all tables and 

figures. 

References: References should be prepared in 

accordance to the “American Medical Association 

Manual of Style.” These instructions for authors are 

available online at www.jama.com. 

Photographs: Please submit high resolution digital 

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

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

minimum size. Low resolution photos may be 

rejected or print with poor quality. 

Note to authors: The WV Medical Journal inside pages 

traditionally print in black and white. If authors wish to 

have photos and figures printed in color, there is a 

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

costs to the Association. Please indicate your preference 

when submitting an article. If your article is accepted for 

publication, you will be invoiced for the charges in 

advance of publication. 

Please address articles and cover letter to the editor at 

this address only: 

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

Editor 

West Virginia Medical Journal 

P.O. Box 4106 


or email your article with cover letter to: 

Angela L. Lanham, Managing Editor 

angie@wvsma.com 

Thanks To Our Advertisers! 

Alpha Technologies....................................................... 29,53 

American Medical Association (AMA)................................ 41 

American Society of Addiction Medicine............................ 64 

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

Center for Rural Health Development Loan Fund.............. 39 

Chapman Printing Co.................................................... 20,64 

Ear, Nose & Throat Assoc. of Charleston, Inc...................... 6 

EHR Solutions...................................................................... 2 

Eye & Ear Clinic................................................................. 35 

Flaherty Sensabaugh & Bonasso PLLC............................ 66 

HIMG.................................................................................. 15 

Images Computer Graphics & Design............................... 64 

McCabe Medical Coding and Reimbursement, LLC.......... 64 

McLain Surgical Supply..................................................... 64 

Office Managers Association.............................................. 28 

Physician’s Business Office............................................... 13 

PIPAC................................................................................. 29 

Right at Home.................................................................... 17 

Stationers, Inc.................................................................... 64 

Suttle & Stalnaker................................................................ 9 

Unicare............................................................................... 25 

United States Army............................................................ 31 

West Virginia Medical Insurance Agency........................... 59 

West Virginia Medical Professionals Health Program........ 57 

West Virginia Mutual Insurance Co......................Back Cover 

West Virginia REDI................................... Inside Back Cover 

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

West Virginia University, Faculty Position...........................11 

Advertising Policy 

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

company, group or association whose products or services interfere with 

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

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

right to decline any submitted advertisement or to discontinue publishing any 

advertisement previously accepted. The Journal does not accept paid political 

advertisements. 

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

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

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

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

agreements that may limit the placement of advertisements for certain 

products or services. 

Subscription Rates: 

$60 a year in the United States 

$100 a year in foreign countries 

$10 per single copy 

POSTMASTER: Send address changes to the West Virginia 

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

Periodical postage paid at Charleston, WV. 

USPS 676 740 ISSN 0043 - 3284 

Claims for back issues should be made within six months after 

publication. Microfilm editions beginning with the 1972 volume are 

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

Ann Arbor, MI 48106. 

©2011, West Virginia State Medical Association 


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March/April - West Virginia State Medical Association

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