March/April - West Virginia State Medical Association

Hematology/Oncology Updatefor the Primary Care PhysicianFriday, April 27, 20127:30 a.m. – 1:30 p.m.in the Harless Auditorium on the campus ofthe Edwards Comprehensive Cancer CenterThis conference is jointly sponsoredby Cabell Huntington Hospital andMarshall University Joan C. EdwardsSchool of Medicine.Join us for an interactive presentationdesigned especially for primary carephysicians and have your questionsanswered about chemotherapy, radiation,anemia, breast and lung cancerscreenings, anticoagulation and more.There is no charge for Marshall University physicians,medical students or residents. Registration is $25 forall others and includes conference materials and lunch.Marshall University Joan C. Edwards School of Medicinedesignates this educational activity for a maximum of4.5 AMA PRA Category 1 Credit(s). Physicians shouldonly claim credit commensurate with the extent of theirparticipation in the activity.For more information, or to register:cancerconferences@chhi.orgor call 304-399-6551

contentsMarch/April 2012, Volume 108, No. 2features4 President’s Message6 Special Article Commentary Winners39 General News40 2012 Annual Business Meeting and PhysicianPractice Conference Photo Highlights42 2012 WVSMA Legislative Briefs48 West Virginia Medical Insurance Agency News49 WESPAC Contributors49 New Members50 West Virginia University Healthcare and HealthSciences News52 West Virginia School of Osteopathic Medicine53 Marshall University Joan C. Edwards Schoolof Medicine News54 West Virginia Bureau for Public Health News55 AMA Resolutions Committee Report56 Obituaries57 Professional Directory58 Classified Ads60 Manuscript Guidelines/AdvertisersIn this issue…Scientific Articles8 Optimum Utilization of CholecystokininCholescintigraphy (CCK-HIDA) in Clinical Practice:An Evidence Based Review12 Intact Bronchogenic Cyst Presenting as a Lung MassProvoking a Pleural Effusion: A Rare Presentation16 Moyamoya in a Non-Asian Patient: A Case Report andReview of the Literature20 Hepatitis C (HCV) Treatment is Not a “One Size Fits All”26 Acromegaly Caused by Growth Hormone ReleasingHormone (GHRH) Secreting Tumor in MultipleEndocrine Neoplasia (MEN-1)32 Physician-Patient Communication: Breaking Bad News36 Schwannoma of the Ulnar Nerve: A Case Report andReview of the LiteratureEducational/CEU OpportunitiesMastering E/M CodingThursday, March 29, 2012 ...call 304-925-0342, ext. 12 toregister.Certified Medical OfficeManager Class (CMOM)Thursday, April 26 & Friday,April 27 and Thursday, May 3& Friday, May 4, 2012 ... seepg. 47 for registration form.Cover photo courtesy ofPatsy Lee Andersonwww.etsy.com/shop/PatsysjoyEditorF. Thomas Sporck, MD, FACSCharlestonManaging Editor/Director of CommunicationsAngela L. Lanham, DunbarExecutive DirectorEvan H. Jenkins, HuntingtonAssociate EditorsJames D. Felsen, MD, MPH, Great CacaponLynne Goebel, MD, HuntingtonCollin John, MD, MPH, MorgantownDouglas L. Jones, MD, White Sulphur SpringsSteven J. Jubelirer, MD, CharlestonRoberto Kusminsky, MD, MPH, FACS, CharlestonLouis C. Palmer, MD, ClarksburgRichard C. Rashid, MD, CharlestonFranklin D. Shuler, MD, HuntingtonSteven B. Sondike, MD, CharlestonRichard A. Vaughan, MD, FACS, MorgantownRobert Walker, MD, CharlestonDavid B. Watson, MorgantownStanley Zaslau, MD, MorgantownThe West Virginia Medical Journal is published bimonthly by the West Virginia State Medical Association, 4307 MacCorkle Ave., SE, Charleston, WV 25304, under thedirection 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 theJournal’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 MessageIs This The World We Want?Health care in the United Stateshas been in a state of evolution overthe past 40 to 50 years. A numberof factors influence these changes,including economic pressures,advances in technology, politicalpressures, and the changingdemographics of our nation.What do we have to look forwardto as physicians? If the opinionsof many experts hold true, thereplacement of the independent,private physician practice modelis inevitable. Many pressures willforce physicians to consolidatewith other physicians, or becomeemployees of a hospital, or healthcare delivery system because theywill lack the money or technicalor administrative resourcesneeded to survive on their own.The emerging practice modelswill vary depending on wherein the country one practices.New terms such as AccountableCare Organizations (ACOs),Medical Home, Aligned Groups,Concierge Practice, CommunityHealth Centers, and Small AlignedGroups will be common place.Current and future health carereforms will impact physicians inways not seen in the past. Complyingwith government regulations isgoing to become a minefield; andof course, open up new, potentialareas of liability. Many of you haveheard of the “Whistleblower”. Thegovernment is pouring a great dealof money into this program to recoupfunds possibly obtained by fraud.The government is also discussingsuspension of the need to provethat one intended to defraud. Theaverage doctor is going to be outmatched in this environment.This new medical practice climateis going to cause many physicians toretire early or change careers. Sadly,I would imagine that many youngpeople will not be encouraged bypracticing physicians to seek a careerin medicine. If we think we have aphysician shortage now, what onearth does the future offer? Primarycare shortages especially are goingto be severe. There is no doubt thatfuture primary care doctors willspend less time with patients. Heor she will spend the bulk of theirtime reviewing practice patterns,seeing the most difficult cases, andupdating information technologytemplates on their computer. Thismay appeal to the individual whodoes not enjoy interacting one onone with their patients. I do notpersonally believe that anyonehas been trained for this. Thosephysicians are going to be pressuredto change practice patterns. We willutilize more and more allied healthprofessionals in order to meet publicand government demand for higherquality care at a lower price. Look atall the problems with the SustainableGrowth Rate (SGR) formula and askyourself if increased reimbursementfor your services despite increasingoverhead costs is going to bepart of this NEW WORLD.Surveys of physicians abouthealth care reforms have been widelyunfavorable. Most physicians feelthat the reforms cause them to workharder for less pay in order to carefor their patients in this environment.Physicians wonder if they can affordto practice medicine. The future ofthe full-time, independent physicianaccepting third party payments willdie. New physician classifications willbe Part-Time Physician, EmployedPhysician, and Concierge Physician.Thomas Paine wrote on December23, 1776 “These are the times that trymen’s souls, but he that stands by itnow, deserves the love and thanksof man and woman”. My fellowWest Virginia physicians, these aretroubling times for men and womenof medicine. If you feel you can tacklethe issues on your own, then continueon as if no storm is brewing. If youare concerned, which I feel many ofyou are, then embrace and supportorganized medicine’s efforts to havea voice in the decision process. Ifwe have greater numbers, maybewe can MOVE THE WORLD.MaryAnn N. Cater, DOWVSMA President4 West Virginia Medical Journal

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Top Four most innovative and thought-provoking...Comments on “Teaching the Art of Medicine”We want to thank the authors of the original article, "Teaching the Art of Medicine: A Changing Portrait in Today's MedicalSchools"; R. Aaron Lambert, MD, Todd W. Gress, MD, MPH and Marie Veitia, PhD. Their article appeared in the November/December 2011 West Virginia Medical Journal. Additionally, we are grateful to Dr. Jim Felsen for his insightful introductionarticle, "Retaining the Art of Medicine", which preceded the special article.Greenbrier Almond, MDTotal Life Clinicians LLC“Always exceed your patient’sexpectations!” Doc declared duringa live broadcast of my weekly TVprogram, “Tender Loving Care”streaming out through our localcommunity access TV channel.Doc was responding to my queryabout the Art of Medicine.I had followed my father, HaroldD. Almond MD, into the practice ofmedicine but I had yet to have mypatients love me like his loved him.“Dad”, I said exasperated, “that isa prescription for burn-out”. EvenWVU Medical School Dean, RobertD’Alessandri MD, praised Doc on theopening day of class in 1998 whenhe invited Dad to tell three storiesfrom his memoir, STORIES OF AWEST VIRGINIA DOCTOR. Dean“Bob” explained, “You will learnmuch about the scientific basis ofmedicine in the next four years buttoday you will learn much aboutthe compassion and caring of ourhealing profession.” The studentsappeared impressed and cameforward for autographs afterwards.Doc stuck by his guns on the TVshow as he recalled his brother’sdeath from erysipelas when hewas ten years old. There were noantibiotics and witch hazel didnot cure. Doc prayed to God for achance to be a physician. God heardhis prayer though much happenedalong the way including his mother’sdeath, the Great Depression andWorld War II. “I wanted my chanceto practice medicine and I got it!”Still pondering Dad’s remarksthe next evening, I covered theoffice while he delivered a babyat St. Joseph’s Hospital. A motherwith three coughing and wheezingchildren came in and waitedtheir turn. Doc worked withoutappointments. “I want to see folkwhen they are sick. If they have towait two weeks for an appointmentthey will either be well or be dead.”After examining the children andprescribing medication for thechildren I told Mom that it wouldbe $10.00 for each child as this wasDoc’s customary fee. She actedsurprised. “No”, she insisted,“When I bring all three at the sametime Doc only charges for one.”“Yes, of course, that will be$10.00. You are fortunate tohave such fine children.”Philip Eskew, JD, MBA, MSIVWest Virginia School of Osteopathic MedicineUnfortunately the question, “[c]an the art of medicine be taught?” israrely reached. The art of medicinecould certainly be taught in anyphase of medical school. Can theart of medicine be tested? This isthe roadblock question. Too muchof medical education is designedaround taking standardized exams.Students might want to learn theart of medicine, but this artisticfreedom remains unavailable untilstudents prove they can memorizestandard science verbatim.It appears that most physicianswould agree that medicine is asmuch an art as a science. We runinto problems because we are ina suffocating standardized examenvironment, where the frequencyof standardized exams via boardcertification has grown exponentiallyover the years. If we truly embracethe “art of medicine” concept, itrequires an admission that not allaspects of medicine can be tested, andthat these same subjective aspects ofmedicine are often important. Greatartists become great through practiceand dedication, not via standardizedexams. A physician’s patients arethe only ones qualified to judge hisartistic ability, and until we cometo this realization as a profession,the art of medicine will suffer.Shirley Neitch, MDProfessor of Medicine, and Chief,Sections of General Internal Medicine and GeriatricsDepartment of Internal MedicineMarshall University/Joan C. Edwards School of MedicineDrs. Lambert, Gress, andVeitia raise an important andheretofore neglected questionwhich has implications formedical education and practice.For those of us who have been inpractice for ….ahem… “a while”,the value of art of medicine isunassailable. Yet looking back, weprobably didn’t astutely recognizethis when we were younger. Asyoung students and residents weare all about the numbers and ourability to manipulate them. Thentime passes, and abundant and6 West Virginia Medical Journal

diverse patients pass through ourpractices, and we realize that wehaven’t always been right whenwe’ve manipulated, and outcomeshaven’t always been what sciencetold us to expect. Only when webegin to understand that indeed,human beings are “fearfully andwonderfully made” (Psalm 139:14)in ways beyond science, do we fullyrealize the importance of the art.The art of medicine can clearlybe learned, but whether it canbe successfully taught is anotherquestion. This is clearly importantfor medical education and forpractice. We are frustrated dailyby performance standards whichblatantly ignore the art of medicineand its contribution to patients’well-being. But, as much as we railagainst the standard-setters, are theyfully to blame for acting like scienceand numbers matter most, since wedid the same as our younger selves?I propose that rather than tryingto teach the art of medicine, weneed to let time and experience dothat while we find ways to teachrespect for the art of medicine. Asimportant as they are, the students’sole heroes shouldn’t be theintensivists and interventionalistsand other purveyors of quickresults and formulaic order sets.We need to discover ways to showboth students and policy makersthat sometimes not doing is moreimportant than doing, and sometimesnot knowing is perfectly okay.Joseph V. Russo, MS-1Marshall University Joan C. Edwards SOMThe “Art” of medicine, from theperspective of a first-year medicalstudent, is an elusive concept whichrepresents the culmination of years oftraining and experience. However,there is some substance to thisconcept which even those in processof attaining skills and experience canrecognize in their mentors and aspiretoward. The question as to whetherit can be taught is difficult because Idon’t think that the traditional lectureor group discussion formats canconvey this type of information. Inmy opinion, the “Art” of medicinegoes beyond the study of professionalethics and the biopsychosocialmodel of medicine which fit neatlyinto the context of classroomdiscussion. Instead, I believe the“Art” of medicine is best modeledby those practitioners who havemastered the ability to consistentlycommunicate effectively withpatients. It is this skill which I ammost anxious to acquire, and whichI have observed both exemplary andpoor examples of so far in the clinic.Little formal discussion is necessarybecause as an observer there isa clear difference in the clinicalencounter when a patient feels thata physician has truly listened tothem and values them as a person.

Scientific Article |Optimum Utilization of CholecystokininCholescintigraphy (CCK-HIDA) in Clinical Practice:An Evidence Based ReviewBryan K. Richmond, MD, MBA, FACSAssociate Professor of SurgeryWest Virginia University/Charleston DivisionAbstractLaparoscopic cholecystectomyremains one of the most commonlyperformed operations in the UnitedStates. Of the cholecystectomiesperformed, approximately 30% are carriedout for a diagnosis of gallbladderdyskinesia, for which diagnosis is basedon a reduced gallbladder ejection fractionas determined by a sincalide(cholecystokinin) stimulated hepatobiliaryiminodiacetic scan (CCK-HIDA). Despitethe widespread acceptance of thispractice standardization of the testmethodology and high quality dataindicating efficacy of cholecystectomy inthe treatment of this condition are lacking.This manuscript reviews this problem indetail based on the current availableliterature.IntroductionCholecystokinin-cholescintigraphy(CCK-HIDA) is commonly performedto evaluate patients with upperabdominal pain thought to bebiliary in origin and in whom thegallbladder is found to be normalon ultrasound. Cholecystectomyis commonly performed basedon the finding of an abnormallylow gallbladder ejection fraction. 1The testing methods and resultsof surgery for biliary dyskinesiaare controversial and poorlyunderstood by many clinicians. Thisreview discusses the controversiessurrounding the testing methods,the determination of normal vs.abnormal values, and the databoth supporting and questioningits use in current practice.BackgroundFor years, surgeons,gastroenterologists and primarycare physicians have encounteredpatients with complaintsconsistent with biliary disease,but with negative ultrasoundimaging of the gallbladder, thuscreating a diagnostic dilemma.In 1991 a randomized, prospectivestudy was published by Yap et al. 2in which a population of patientswith suspected pain of biliaryorigin (and a negative gallbladderultrasound) underwent CCK-HIDA scan with calculation of thegallbladder ejection fraction. Thosewith an abnormal ejection fraction(

| Scientific ArticleReasons Limiting theUsefulness of CCK-HIDATo understand the shortcomingsof these various studies, and thecurrent knowledge gaps in thisarea of clinical practice, one mustfirst understand the controversiessurrounding the performance of theCCK-HIDA scan itself. A key aspectof the CCK-HIDA scan is the mannerin which normal vs. abnormalgallbladder ejection fraction resultsare determined, and how this differsfrom other diagnostic tests. Withthe majority of diagnostic tests,an abnormal value is predictive ofpathology – for example, the finding ofgallstones on ultrasound, a spiculateddensity on mammography, or aninfiltrate on chest X-ray. CCK-HIDAis distinctly different however, inthat the normal vs. abnormal valuesfor GBEF are calculated from valuesobtained from normal subjects, withthe cutoff of normal vs. abnormaltypically designated at three standarddeviations from the mean. 2,6 In otherwords, the values are calculatedfrom what is “normal” in the generalpopulation and “abnormal” values,by definition, are therefore notnecessarily predictive of a diseasestate. They simply are values thatfall outside the normal distribution.For this reason, it is expected thatsome normal volunteers will havean abnormal GBEF. Conversely,some patients with functionalbiliary pain may have GBEFvalues within the normal range.Additionally, much controversyexists in the testing methodology.CCK-HIDA, despite widespreaduse in clinical practice, suffers froma lack of standardization of testmethodology in several importantareas. These include dose of sincalide(CCK) administered, duration ofadministration, and time at whichGBEF is calculated. A review ofthe published studies on the use ofCCK-HIDA revealed CCK dosesfrom 0.005mcg/kg to 0.03 mcg/kg, infusion durations ranging from2-3 minutes all the way up to 45minutes, and normal vs. abnormalcutoff values ranging from 35%-65%. In some published studies,the exact nature of the testingprotocol was not even described. 7Zeissman et al. examined thisissue in a multicenter trial designedto determine the most reliable,reproducible, and least variableprotocol. They conducted studieson normal subjects with a varietyof infusion and imaging protocolsand found their results to be themost consistent and reproduciblewith a dose of 0.02mcg/kg CCK,continuously infused over 60minutes, and with the GBEFcalculated at 60 minutes. Thethreshold for normal vs. abnormal intheir study was 38%. 6 This study wasonly recently published however,and testing protocols continueto vary from center to center.Finally, the test is often conductedunder conditions which mayadversely affect the accuracy ofthe results. The Society of NuclearMedicine and other thought leadersin the nuclear medicine field havespecifically stated, for example, thatCCK-HIDA should be performedsolely on an outpatient basis, andnot while the patient is acutely ill, sothat confounding factors includingthe effects of medications may beavoided. It is further recommendedthat opiates be withheld for a fullfour half-lives of the drug prior totesting. A number of other drugs,including benzodiazepines, atropine,nifedipine, indomethacin, octreotide,theophylline, phentolamine, andprogesterone are also capable ofaffecting the test results and shouldalso be avoided for several hoursprior to testing. Failure to adhereto these recommendations mayresult in lower values for GBEF thanwould be obtained under optimaltest conditions in the same patient. 8Proper Patient SelectionPatient selection may also be anissue that has affected the reliabilityof CCK-HIDA in predicting symptomrelief after cholecystectomy. Currentexpert opinion based on the availabledata favors cholecystectomy forpatients with biliary symptoms andan abnormal GBEF, and discouragescholecystectomy in cases involvingatypical symptoms. 1,9 The definitionof what constitutes the mostappropriate and valid descriptionof biliary symptoms is a matter ofdebate and has been a source ofcontroversy in previously publishedreviews on this subject. 5 Symptomshowever remain crucial in selectingwhich patients should undergodiagnostic biliary testing, includingCCK-HIDA. It only seems logical thatremoval of the gallbladder will beof greatest benefit to those patientssuffering from gallbladder pathology.Furthermore, in the review byDiBaise and Oleynikov, the authorscommented that a standardized andreliable set of diagnostic criteriafor functional biliary pain wasimportant in selecting patients forfurther biliary testing (CCK-HIDA). 5The results of their pooled analysisrevealed that outcomes were betterin selected patients – i.e., those withbiliary symptoms and an abnormalGBEF. Outcomes were not improvedin patients with biliary symptomsand a normal GBEF when comparedwith observational controls. 5These data, although once againlimited by the retrospective natureof the study, the heterogeneity ofthe pooled data, and the high riskof bias, suggest the need for reliablediagnostic criteria in the selection ofpatients for CCK-HIDA, since it is thecombination or typical symptoms andan abnormal GBEF that provide thebest chance of success with operation.March/April 2012 | Vol. 108 9

Scientific Article |Table I. The Rome III Criteria for Functional Gallbladder and Sphincer ofOddi Disorders 12I. Functional Gallbladder and Sphincer of Oddi Disorders:Must include episodes of pain located in the epigastrium and right upperquadrant and all of the following:1. Epsisodes lasing 30 minutes or longer2. Recurrent symptoms occurring at different intervals3. The pain builds up to a steady level.4. The pain is severe enough to interrupt the patient’s daily activities orlead to an emergency room visit5. The pain is not relieved by bowel movements6. The pain is not relieved by postural change7. The pain is not relieved by antacids8. Exclusion of other structural diseases that would explain thesymptomsSupportive criteria:The pain may present with one or more of the following:1. Associated with nausea and vomiting2. Radiates to the back and/or right infrascapular area3. Awakens patient from sleep in the middle of the night.II. Functional Gallbladder DisorderMust include all of the following:1. Criteria for functional gallbladder and sphincter of Oddi disorder2. Gallbladder is present3. Normal liver enzymes, conjugated bilirubin, and amylase/lipaseOther misconceptions involvingpatient selection for surgery basedon the results of CCK-HIDA areworth mentioning. One suchmisconception is the assumptionthat the degree of lowering ofGBEF is predictive of success. (Inother words, a GBEF of 3% is morelikely have a favorable response tocholecystectomy than a patient withthe same symptoms but a GBEF of24%). This has not proven to be thecase in the data published to date. 10Another misconception involves theidea that the reproduction of patientsymptoms with CCK injection isanother predictor of success withcholecystectomy. This assumptionhas also proven to be false. CCK isknown to stimulate other organsbesides the gallbladder, includingthe small intestine and stomach,which may produce unpleasant painand cramping. When administeredintravenously, especially in a 2-3minute infusion protocol, unpleasantsymptoms are not uncommonand have no predictive valuewith respect to relief of biliarypain with cholecystectomy. 11The Rome III criteria for functionalgallbladder disorder (Table I), isperhaps the best known standardizedsymptom complex for the diagnosisof functional gallbladder disorderand the subsequent selection ofpatients to undergo CCK-HIDAscanning for suspected biliarydyskinesia. 12 The ordering of CCK-HIDA studies in patients withatypical symptoms not suggestiveof functional biliary disordershould be discouraged, as someof these patients may indeed havean abnormal GBEF in the absenceof disease. Failure to grasp thisconcept may result in inappropriatereferrals for surgery, therebysubjecting the patient to unnecessaryrisk and a higher likelihood of nobenefit from cholecystectomy.SummaryBased on review of the currentliterature on this topic, it seemsappropriate to conclude:• The use of CCK-HIDA scan (andGBEF) to select which patientswith pain of biliary origin shouldundergo cholecystectomy is anacceptable practice under currentSociety of Gastrointestinal andLaparoendocopic Surgeons(SAGES) clinical guidelines.• The use of the CCK-HIDAshould be restricted to thosepatients meeting criteriafor functional biliary pain/functional gallbladder disorderaccording to establishedcriteria, such as those proposedby the Rome III committee.The use of CCK-HIDA inthe investigation of atypicalsymptoms should be avoided.• No data exist to suggest thatsymptom reproduction withCCK injection or degree ofGBEF abnormality is predictiveof relief of symptoms bycholecystectomy, and thesecriteria should not be used toselect patients for surgery.• Clinicians should adhere to therecommendations of the Societyof Nuclear Medicine with respectto the conduct of the CCK-HIDAscan, and to which medicationsshould be held prior to testing,so that the chances of falsepositive scans is minimized.• Further study is needed to definethe optimal protocol for dosing10 West Virginia Medical Journal

| Scientific Articleschedule, CCK infusion time,and cutoff value for normal vs.abnormal values. The recent workof Zeissman et al. proposingthat this should be 0.02mcg/kg infused over 60 minutes,with the cutoff value for normalbeing 38% is a laudable attemptto standardize the practice,but the results will need to bereplicated in subsequent studies.• More randomized, prospective,well-controlled trials are neededinvestigating the role of CCK-HIDA scan in the diagnosis ofacalculous bilary pain/functionalgallbladder disorder, and inpatient selection for the surgicaltreatment of this condition.References1.SAGES guidelines committee. Society ofAmerican Gastrointestinal and EndoscopicSurgeons guidelines for the clinical application of2.3.4.5.6.7.laparoscopic biliary tract surgery. PublishedJanuary 2010. http://www.sages.org/publication/id/06/ (accessed 8/13/10).Yap l, Wycherly A, Morphett A, Toouli J.Acalculous biliary pain: cholecystectomyalleviates symptoms in patients with abnormalcholescintigraphy. Gastroenterology1991;101(3):786-93.Gurusamy KS, Junnarkar S, Farouk M, DavidsonBR. Cholecystectomy for suspected gallbladderdyskinesia, Cochrane Database of SysyematicReviews 2009; Issue 1, Art no. CD007086.Hofeldt M, Richmond B, Huffman K, Nestor J,Maxwell D. Laparoscopic cholecystectomy fortreatment of biliary dyskinesia is safe andeffective in the pediatric population. Am Surgeon2008;74:1069-72.DiBaise JK, Oleynikov D. Does gallbladderejection fraction predict outcome aftercholecystectomy for suspected chronicacalculous gallbladder dysfunction? A systematicreview. Am J Gastroenterol 2003;98:2605-2611.Ziessman HA, Tulchinsky M, Lavely WC, et al.Sincalide-stimulated cholescintigraphy: amulticenter investigation to determine optimalinfusion methodology and gallbladder ejectionfraction normal values. J Nucl Med 2010;51:277-281.Rastogi A, Slivka A, Moser AJ, et al.Controversies concerning pathophysiology andmanagement of acalculous biliary-typeabdominal pain. Dig Dis Sci 2005;50:1391-1401.8. Tulchinsky M, Ciak B, Debelke D, et al. SNMpractice guidelines for hepatobilary scintigraphy4.0. Journal of Nuclear Med Technology 2010;38(4):210-18.9. Vassiliou M, Laycock W. Biliary dyskinesia. SurgClin N Am 2008; 88:1253-72.10. Ozden, N, DiBaise, JK. Gallbladder ejectionfraction and symptom outcome in patients withacalculous biliary-like pain. Dig Dis Sci2003;48:890-897.11. Smythe A, Majeed AW, Fitzhenry M, et al. Arequiem for the cholecystokinin provocation test?Gut 1998;43:571-574.12. Behar J, Corazzari E, Guelrud M, Hohan W,Sherman S, Toouli J. Functional gallbladder andsphincter of Oddi disorders. Gastroenterology2006;130:1498-509.The sensible choicefor specialized care.Providing comprehensive pediatric and adult ear, noseand throat care, Eye & Ear Clinic Physicians also offerscomplete hearing aid services and allergy testing.304.343.EECP(3327) | eecpwv.comFeaturing an extensive selection oF digitalhearing aid devices and accessories FromMarch/April 2012 | Vol. 108 11

Scientific Article |Intact Bronchogenic Cyst Presenting as a Lung MassProvoking a Pleural Effusion: A Rare PresentationMumtaz U. Zaman, MDDepartment of MedicineMarshall University, Joan C. Edwards School ofMedicineFinancial support: TheDepartment of Medicine providedfunds in support of this research.Disclaimer: Accepted for PosterPresentation at the AmericanThoracic Society annual meetingin May 2010, under title of “Intactbronchogenic cyst presenting asa lung mass provoking a pleuraleffusion: A rare presentation".AbstractThis case report describes a 49 yearold woman with an intra-parenchymalbronchogenic cyst masked on chest x-rayexamination by a pleural effusion. Thecyst was intact. It is likely that the cystprovoked the pleural effusion by repetitivemechanical irritation of the pleura. Atsurgery, the cyst was removed and thepleural effusion drained withoutrecurrence. The cyst was unilocular andmeasured 8.5 x 7.0 x 0.8 cm with asmooth and glistening lining. It was filledwith approximately 300 ml of clear fluid.Microscopic examination confirmed thebronchogenic cyst. This is the first case ofan intact intra-parenchymal bronchogeniccyst associated with a pleural effusionthat was not due to rupture of the cyst,infection or malignancy.IntroductionBronchogenic cysts aredevelopmental anomalies resultingfrom an abnormal budding of thetracheobronchial tree. 1 They occurrarely; the incidence is unknown.However, 70-85% of the bronchogeniccysts occur in the mediastinum, andare usually discovered on routinechest roentgenogram, but eventuallybecome symptomatic in adults. 2Uncommonly, they manifest as intraparenchymalcysts, often producingsymptoms of respiratory disease. 3We report a case of an intact intraparenchymalbronchogenic cyst withassociated pleural effusion whichto our knowledge has not beendocumented in the medical literature.Case ReportA 49 year old woman presentedwith left sided pleuritic chestpain, nonproductive cough andprogressive exertional dyspnea fortwo months. She denied fever orhemoptysis. Her vital signs wereRR 22, HR 82, BP 124/72 and tempafebrile. On examination, the chestwas non-tender; the left lower lungfield was dull to percussion withdiminished breath sounds andno rales or wheezes. Clubbing orcyanosis was absent. Chest x-rayshowed left lower lobe airspacedisease with pleural effusion (Figure1). The CT scan revealed an 8.5 cmthin-walled hypodense mass withcalcium deposition in the dependentregion (Figure 2) associated with apleural effusion and compressiveatelectasis. A thoracentesis wasnegative for infection or malignancyand bronchoscopy was normal.Subsequently, a left thoracotomywas performed and a fluid-filledlarge cyst adherent to the adjacentleft lower lobe and diaphragm wasidentified. The cyst was excised anda pleural effusion of 450 ml wasdrained. Gross examination revealedan intact unilocular cyst (8.5 x 7.0x 0.8 cm) with smooth, glisteninglining filled with approximately300 ml of clear fluid. Pathologicexamination of the excised tissueconfirmed the bronchogeniccyst (Figure 3). Malignancy andinfection were absent. The patientrecovered uneventfully (Figure 2).DiscussionBronchogenic cysts are congenitallesions which result from abnormalbudding of the tracheobronchialtree during the first 16 weeks ofgestation. 4 Most cysts are located inthe mediastinum near the trachealcarina, but 15% may occur in thelung parenchyma. 1 The mean ageof presentation in adults is 38 yearswith a range of 17-70 years. Cystswithin the lung parenchyma usuallypresent with cough and chestpain, as our patient manifested.Intraparenchymal cysts aremore frequently located in thelower lobes without predilectionfor either side. 5 At radiography,cysts are usually thin-walled (1-2mm) and may contain an airfluid level when a communicationexists with the tracheobronchialtree. 6 This pattern occurs withother acquired or congenitalpulmonary cystic diseases such aspulmonary sequestrated abscess, orbullous emphysema with which abronchogenic cyst might be confused.Our case is unique since thebronchogenic cyst margins werewell defined without any evidenceof cyst rupture, a finding confirmedat surgery. Percutaneous drainageof the pleural fluid was helpful inexcluding infection and malignancy,but not in establishing the diagnosisof underlying etiology. Twoprevious reports described pleuraleffusion complicating bronchogeniccyst; the first was a mediastinalbronchogenic cyst with a pleural12 West Virginia Medical Journal

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Scientific Article |Figure 1.AP view chest radiograph showing left lower airspace disease with blunting of the leftcostophrenic angle due to a moderate pleural effusionFigure 2.CT scan images before and after surgical removal of bronchogenic cyst showing asmooth, thin walled mass in the left costophrenic angle measuring 8.5 x 7.0 cm withaccumulation of milk of calcium in the dependent region. Associated with the mass isa moderate size left pleural effusion and compressive atelectasis. Following surgicalremoval there is complete resolutioneffusion apparently unrelatedto any other underlying disease,such as congestive heart failureor trauma, and the second was anintra-pulmonary bronchogeniccyst that ruptured and presentedwith a pleural effusion. 7,8In our case, the pleural effusionappeared to have developed asa result of inflammation of thepleura consequent to the fluid filledcyst abutting on the diaphragm.The gradual accumulation ofapproximately 300 ml of fluid inthe cyst, which weighed close to365 grams in its later stages, wouldserve as a heavy weight rhythmicallypounding the diaphragm andinjuring the pleura. It wouldexplain the chest pain and dyspneaexperienced by the patient. Pleuraleffusion can obscure the underlyingcyst on a routine chest x-ray, buta CT scan provides a means toclearly identify the cyst with fluiddensity and the thin walled rim. Inthis case, the weight of fluid in anexpanding cyst likely irritated theadjacent pleural surfaces leading todevelopment of a pleural effusion.ConclusionBronchogenic cysts are rareand pleural effusion in associationwith an intact intra-parenchymalbronchogenic cyst has not beendescribed previously. When thecommon etiologies of pleuraleffusion are eliminated, bronchogeniccyst should be considered as arare cause of pleural effusionAcknowledgmentsThe author thanksMaurice A. Mufson, M.D.,M.A.C.P., for his assistance inreviewing the manuscript.References1.McAdams HP, Kirejczyk WM, Rosado-de-Christenson ML, Matsumoto S. BronchogenicCyst: imaging features with clinical and14 West Virginia Medical Journal

| Scientific Articlehistopathological correlation. Radiology.2000;217:441-446.2. O’Rahilly, Muller F. Respiratory and alimentaryrelations in staged human embryos. Ann. OtolRhinol Laryngol. 1984;93:421-429.3. Ofoegbu RO. Intraparenchymal BronchogenicCysts in Adults. Thorac. Cardiovasc. Surgeon.1982;30:298-301.4. Moore KL. The Developing Human: ClinicallyOriented Embryology. 8 th Edition (2008). T.V.N.Persaud pp 202-208.5. Yoon YC, Lee KS, Kim TS, Kim J, Shim YM, HanJ. Intrapulmonary bronchogenic cyst: CT andpathologic findings in five adult patients. Am JRoentgenol. 2002;179:167-70.6. Cardinale L, Ardissone F, Cataldi A, Gned D,Prato A, Solitro F, Fava C Bronchogenic cyst inthe adult: diagnostic criteria derived from thecorrect use of standard radiography andcomputed tomography. Radiol Med.2008;113:385-394.7. Khalil A, Carette MF, Milleron B, Grivaux M, BigotJM. Bronchogenic cyst presenting as mediastinalmass with pleural effusion. Eur Respir J.1995;8:2185-2187.8. Schmidt CA, Gordon R, Ahn C. Bronchogenic cystpresenting subsequent to intrapleural rupture. WVJ Med. 1981;134:212-4.Figure 3.Pathologic examination showing respiratory-type epithelium with mild chronicinflammation and fibromuscular wall revealing islands of cartilage and submucosalglandsHelping You Manage a Healthier PracticeProviding Professional Services to Physician Practices Since 1973• Practice Analysis & Benchmarking• Tax Planning & Preparation• Core Accounting Services• Practice Operation Improvement• Regulatory ComplianceCharleston 800.788.3844Parkersburg 304.485.6584www.suttlecpas.comMarch/April 2012 | Vol. 108 15

Scientific Article |Moyamoya in a Non-Asian Patient: A Case Report andReview of the LiteratureDaniel Felbaum, MS-IVMarshall University Joan C. Edwards School of MedicineElise Henning, MS-IIIMarshall University Joan C. Edwards School of MedicineBryan R. Payne, MDProfessor and ChairmanMarshall University Joan C. Edwards School ofMedicine, Department of NeuroscienceAbstractMoyamoya disease (MMD) hashistorically been diagnosed in theJapanese population. However, newerstudies have demonstrated worldwidedistribution. Of note, patients ofAppalachian descent with no known Asianancestry have presented with MMD. Weare presenting a case of MMD in anAppalachian, non-Asian patient whopresented to the neurosurgical servicewith a severe headache of four daysduration. The patient was found to havemultiple hemorrhagic infarcts on CT andwas admitted to the ICU. Cerebralangiography findings confirmed thediagnosis of MMD. Our case providesinformation regarding signs andsymptoms, diagnostic neuroimagingfindings, and treatment modalities forMMD.Case ReportCHIEF COMPLAINTHeadacheHISTORY OF PRESENT ILLNESSD.B. is a 46-year-old Caucasianfemale of Appalachian descentwho presented to the EmergencyDepartment (ED) with an unremittingheadache of four days duration.Headache came on suddenly aftermoderate physical activity. Headachewas described as severe, global andcontinuous and dull. The patient tookover-the-counter NSAIDs and restedfor four days but did not experiencerelief of her symptoms. She wentto the ED after the fourth day ofunrelenting headache. Additionalcomplaint was difficulty walkingfrom lower extremity weakness. CTwithout contrast was performed uponadmission that revealed moderateintraventricular hemorrhage, smallintraparenchymal hemorrhage, andmild subarachnoid hemorrhage.PAST MEDICAL HISTORYMultiple sclerosisMajor depressive disorderSeizuresPost-surgical thrombophlebitisAppendectomyTotal hysterectomySOCIAL HISTORYCigarette smoking – 1pack per day for 20 yearsThree cups of coffee per dayMEDICATIONSCitalopram 40mg by mouth1 tablet every nightROS: Negative per HPIPHYSICAL EXAMPatient was intact neurologically.She was alert and oriented to person,place, and time. Cranial nerves2-12 were grossly intact. Strengthwas rated 5/5 in upper and lowerextremities. No sensory deficits to pinprick and light touch. Reflexes were2+ in four extremities. No dysmetriaand dysdiadochokinesia present.TREATMENT PLAN RENDERED:The patient was admitted to theICU. She received an angiogramto localize areas of hemorrhage.Angiogram showed bilateralocclusion of the middle and anteriorcerebral arteries, with mild stenosisof the left and right common carotidarteries. Rete mirabile – numerousbilateral collaterals and tangled,malformed arteries secondaryto increased collateral flow wasdemonstrated. Because she wasneurologically intact and presentedlate in the disease course, medicalmanagement was the agreed upontreatment. Surgical management viarevascularization was considered notappropriate because of the patient’swell-developed collateral circulation.The patient was counseled aboutMMD and instructed to modifyvascular risk factors, includingsmoking cessation and properdiet and exercise behaviors. Shewas discharged home whenheadache abated and was laterseen in clinic for follow-up.DiscussionOur patient is a middle-agedfemale who presented with an acuteintracranial hemorrhage. She isCaucasian and Appalachian with noknown Asian ancestry. The patientpresented to the ED after enduring afour-day headache. She complainedof weakness in her extremitiesbut denied other symptoms. Herprior history of seizures andmigraines could be attributed tominor hemorrhagic causes.MMD is derived from the Japaneseword “puff of smoke” due to theappearance of numerous collateralvessels seen on angiography. Inaddition to multiple collaterals,bilateral occlusion occurs in theterminal segment of the internalcarotid. 1 MMD tends to be bimodal,affecting children around 5 years16 West Virginia Medical Journal

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Scientific Article |Figure 1.Presence of intraventricular hemorrhageFigure 2.Note increased collateral circulation onCT-AngiogramFigure 3.Stenosis of supraclinoid Internal CarotidArteryof age and adults around 40 yearsof age. 13-16 Children present withtransient ischemic effects exacerbatedby hyperventilation. 6 In addition,children may present with seizuresor choreiform movements dueto basal ganglia involvement. 18,19Adults present with altered mentalstatus due to intraventricular orintraparenchymal bleeding, howeverresearch suggests ischemia maybe observed in the majority ofall patients, regardless of age. 6,12Headache, similar to migraines,is a common symptom of MMDas a result of dural nociceptorstimulation from vessel dilation. 17Several risk factors for the diseasehave been proposed including,Trisomy 21, Neurofibromatosis 1,history of radiation to head and neck,and various forms of cerebrovascularinflammatory disease. 7 Etiology ofMMD remains unclear, howeverelevated levels of basic-fibroblastgrowth factor (b-FGF) are found inthe CSF of MMD patients. Increasedactivity of b-FGF and its receptor inthe superficial temporal artery implyangiogenic and cytokine participationin the disease process. 6 FamilialMMD may be linked to genetic lociof chromosomes 3, 6, and 17. 6The gold standard for diagnosingMMD requires catheter cerebralangiography. Cases shouldmeet the following findings:1. Bilateral symmetrical stenosesor occlusion of the terminalinternal carotid arteriesand proximal portionsof the anterior and/ormiddle cerebral arteries.2. Several enlargedlenticulostriate andthalamoperforating arteries(this criterion demonstrates“puff of smoke” appearance).3. Several transdural,leptomeningeal, and pialcollateral vessels. 6,9Bilateral involvement is considereda definite case, however unilateralinvolvement affects the contralateralside in 40 percent of patients. 21,22CT and MRI illustrate multipleinfarcts in more than 80 percentof patients, with intraventricularhemorrhage encountered mostoften. In addition, PET scan showsdecreased cortical blood flow fromnarrowed of cerebral blood vessels. 9At this time, no medicaltherapy has been established toalter progression of MMD. 12 Antiplatelettherapy can reduce ischemicsymptoms of emboli formed at sitesof stenosis, and calcium channelblockers can abort headache andmay reduce future transient ischemicattacks. 12 Surgical managementis performed to increase cerebralblood flow. A recent review ofsurgical management concluded thatdirect bypass surgery (STA-MCAanastamoses) or indirect bypasssurgery (laying a vascularizedsoft-tissue flap on the brain surface)improves revascularization. 11 Theseinterventions can prevent furtherischemic or hemorrhagic events.Once considered a diseaseexclusive to Asian patients, MMDis now observed in American andEuropean populations. Rates inAmerica are reported to be 0.086cases per 100,000 persons. 20 The agedistribution is bimodal – seen at fiveyears of age and in the mid-40’s. 13-16Adults are seven times more likelyto have hemorrhage than children.Consequently, we encouragephysicians to include MMD aspart of their differential in patients18 West Virginia Medical Journal

| Scientific ArticleFigure 4.“Puff of smoke” appearancewith hemorrhagic or ischemicevents, particularly in youngerpatients, regardless of ancestry.15. Han DH, Nam DH, Oh CW. Moyamoya disease inadults: characteristics of clinical presentation andoutcome after encephalo-duro-arteriosynangiosis.Clin Neurol Neurosurg1997;99:Suppl 2:S151-S15516. Han DH, Kwon OK, Byun BJ, et al. A co-operativestudy: clinical characteristics of 334 Koreanpatients with moyamoya disease treated atneurosurgical institutes (1976-1994). ActaNeurochir (Wien) 2000;142:1263-127317. Seol HJ, Wang KC, Kim SK, Hwang YS, Kim KJ,Cho BK. Headache in pediatric moyamoyadisease: review of 204 consecutive cases. JNeurosurg 2005;103:Suppl:439-44218. Scott RM, Smith JL, Robertson RL, Madsen JR,Soriano SG, Rockoff MA. Long-term outcome inchildren with moyamoya syndrome after cranialrevascularization by pial synangiosis. J Neurosurg2004;100:Suppl:142-14919. Parmar RC, Bavdekar SB, Muranjan MN, LimayeU. Chorea: an unusual presenting feature inpediatric Moyamoya disease. Indian Pediatr2000;37:1005-100920. Uchino K, Johnston SC, Becker KJ, Tirschwell DL.Moyamoya disease in Washington State andCalifornia. Neurology 2005;65:956-95821. Kelly ME, Bell-Stephens TE, Marks MP, Do HM,Steinberg GK. Progression of unilateralmoyamoya disease: a clinical series. CerebrovascDis 2006;22:109-11522. Smith ER, Scott RM. Progression of disease inunilateral moyamoya syndrome. Neurosurg Focus2008;24:E17-E17.References1. Yonekawa, Y, Kahn, N. Moyamoya Disease.Ischemic Stroke: Advances in Neurology; 2003:92:113-118.2. Khan, N, Yonekawa Y. Moyamoya angiopathy inEurope. Acta Neurochir. 2005; 94:149-152.3. Yonekawa, Y, Nobuyoshi O, et al. Moyamoyadisease in Europe, past and present status.Clinical Neurology and Neurosurgery. 1997;99:S58-S60.4. Chiu D, Shedden P, Bratina P, Grotta J. Clinicalfeatures of moyamoya disease in the UnitedStates. 1998;29:1347-1351.5. Yonekawa Y, Taube E. Moyamoya disease: status1998. Neurologist. 1999. 5:13-23.6. Fukui M, Kono S, Sueishi K, Ikezaki K. Moyamoyadisease. Neuropathology. 2000; 20:S61-S64th7. Greenberg, M. Handbook of Neurosurgery 6Edition. 2006;30:892-894.8. Rengachary, S, Wilkins, R, Wonsiewicz, M,Ramos, M. Neurosurgery. 2 nd , ed. 1996; 2:2090-2092.9. Taki, W, Yonekawa, Y, et al. Cerebral Circulationand Metabolism in Adults’ Moyamoya Disease–PET Study. Acta Neurochir. 1989. 100:150-154.10. Chang S, Steinberg G. Surgical management ofmoyamoya disease. Contemporary Neurosurgery.2000. 10: 1-9.11. Baaj A, et al. Surgical management of Moyamoya.Neurosurgical Focus. 2009. 26; 4: 1-7.12. Scott, R.M., Smith, E.R. Moyamoya disease andmoyamoya syndrome. New England Journal ofMedicine. 2009. 360: 1226-1237.13. Baba T, Houkin K, Kuroda S. Novelepidemiological features of moyamoya disease. JNeurol Neurosurg Psychiatry 2008;79:900-90414. Wakai K, Tamakoshi A, Ikezaki K, et al.Epidemiological features of moyamoya disease inJapan: findings from a nationwide survey. ClinNeurol Neurosurg 1997;99:Suppl 2:S1-S5JoinWESPAC Now!West Virginia Medical PoliticalAction CommitteeVisit www.wvsma.com orCall 304.925.0342, ext. 25March/April 2012 | Vol. 108 19

Scientific Article |Hepatitis C (HCV) Treatment is Not a “One Size Fits All”Faisal A. Bukeirat, MD, FACGConsultant in Digestive DiseasesGovernor of the WV Chapter of American College ofGastroenterology (ACG), MorgantownMimi M. BukeiratSenior at University High School (UHS), MorgantownAbstractDuring the past ten years, there hasbeen a remarkable increase in thenumber and spectrum of medicationsused for the treatment of viral hepatitisinfections including the hepatitis C virusinfection (HCV). Still there is considerablevariability among physicians in the useand duration of treatment of the currentlyavailable medications. Therefore, thecurrent literature on the HCV therapy willbe reviewed and summarized.IntroductionThe hepatitis C virus is a majorpublic health problem, and a leadingcause of chronic liver disease. 1 Withmore than 180 million people infectedworldwide, and more than 4.5 millionAmericans infected with the hepatitisC virus; it is no wonder that chronicHepatitis C viral (HCV) infection isa significant public health issue notonly in the USA but worldwide. 2The Hepatitis C virus is a RNAvirus which is transmitted viainfected blood and body fluids(examples of exposure risk would be:blood transfusion or organ transplantbefore 1992, intravenous drug use,snorting drugs, sexual exposure,and tattooing); as such there is noneed for HCV-infected persons tolimit ordinary household activitiesexcept for those that might resultin blood exposure, such sharing arazor, nail-clipper, or toothbrush. Thehepatitis C virus is not transmittedby hugging, kissing, sharing ofeating utensils or breastfeeding.Infection with the hepatitis Cvirus (HCV) can result in bothacute and chronic hepatitis. AcuteHCV is usually asymptomatic andrarely causes liver failure. On theother hand, chronic HCV is theaftermath of an acute infection,with eighty to one hundredpercent of patients remainingHCV-RNA positive, and sixty toeighty percent developing chronicHCV with persistently abnormalliver enzymes [elevated AST andALT]. The current recommendedtherapy for chronic HCV infectionis the dual therapy consistingof the combination of pegylatedinterferon alfa and ribavirin.MethodsA literature search was performedfrom 2000 to December 2009, usingthe computerized PubMed database,looking for English publicationsregarding Hepatitis C viral(HCV) infection and its availablemedications and treatment options.The most up to date treatment andrecommendations were reviewed andthe results are hereby summarized.In addition the most recent practiceguidelines set forth by the AmericanAssociation for the Study of LiverDiseases (AASLD) were reviewed.Whom to treat?All individuals with chronichepatitis C (HCV) infection shouldbe offered therapy, if there are nocontraindications for it (Table 1).Therefore, all patients presentingto their doctor with abnormal LFTwho are HCV-RNA positive byPCR should be offered therapy.Infection with evidence of activeliver inflammation should beconfirmed by liver biopsy (Bx); as allother tests including ALT levels andviral titers are not reflective of theactual inflammation in the liver orpresence of liver fibrosis/cirrhosis.There are certain contraindicationsto treatment; Table 1 below showsconditions or situations wheretherapy is currently contraindicated: 2What determines patient’sresponse to treatment?Response to treatment isdependent on a number of host(patient) factors and viral factors. 3Patient factors include age, gender,alanine aminotransferase (ALT)levels, amounts of iron deposits inthe liver, stage of fibrosis, insulinresistance, and the patient’s genetics.Recent work by Ge et al. shows thata specific polymorphism locatedclose to the gene, which codesTable 1: Contraindications for HCV Therapy1. Known hypersensitivity to drugs used to treat HCV2. Age less than 2 years3. Major depression or uncontrolled psychiatric health issues4. Autoimmune hepatitis or other autoimmune conditions known to beexacerbated by HCV therapy5. Untreated thyroid disease6. Pregnancy or unwillingness to comply with adequate contraception7. Solid organ transplant (lung, heart, or kidney)8. Severe concurrent medical disease such as severe hypertension, heartfailure, significant coronary artery disease, poorly controlled diabetes,chronic obstructive pulmonary disease (COPD)20 West Virginia Medical Journal

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Scientific Article |for interleukin 28B [IL-28B], wasdemonstrated to strongly influenceSVR with the cure rate being twiceas high if you have the CC allele. 4Viral factors include HCVgenotype, and viral load namelyserum concentrations of HCVRNA at the time of initiationof antiviral therapy.There are three terms that arefrequently used when referring tothe results of HCV therapy; theseare RVR, EVR, and SVR. RVR isRapid Virologic Response at 4 weeksof therapy; EVR is Early VirologicResponse at 12 weeks of therapy, andSVR which is Sustained VirologicResponse at 6 months after therapy.Response is determined by testingthe patient at four, twelve, and 24weeks by ordering both hepatitis CPCR qualitative as well as hepatitisC quantitative viral load by PCR. Ifthe qualitative test is negative, thatwould be a positive response, andif there was a 2-log drop in the viralload, that would constitute a positiveresponse as well (meaning thatpatient is responding to therapy).The dose of interferon can beadjusted according to the degree ofbone marrow suppression, but oncethe platelet count has dropped below50,000 or the absolute neutrophiliccount [ANC] has dropped below500, then treatment should bewithheld. The medication insertthat comes with each of these drugshas a detailed schedule that canhelp guide the dose adjustments ofthese medications and/or a call toyour gastroenterology colleague.Duration of therapy?The initial determinant factor forthe tentative duration of treatmentis the viral genotype: whetherHCV genotype 1,2,3,4,5, or 6.Figure 1.HCV Treatment Options and Duration of TherapyAfter treatment has been initiatedthe factor that predicts long termresponse (sustained virologicresponse “SVR”) is the initialresponse to treatment (the RapidVirologic Response “RVR”).HCV viral genotypes 2 and 3are treated with peg-interferonplus ribavirin (800 mg daily) for 24weeks. If there is a RVR at 4 weeksof therapy, then shortening theduration of therapy to 12 weekscan be considered. If the treatmentis well tolerated, recommendthe full course for 24 weeks.For HCV genotypes 1, 4, 5, and 6,it is recommended that ribavirin isdosed based on patient’s weight (kg):Is one product better than the other?Current treatment for hepatitisC infection consists of combinationtherapy using pegulatedinterferon plus ribavirin.Both available peg-Interferonproducts [Pegasys: peginterferonalfa-2a; Pegintron: peginterferonalfa-2b] that are available on themarket are equally efficaciouswith similar side effects. 2-5The most common sideeffectsthat we should look forare: neuropsychiatric side-effectsincluding anxiety and depression, flulikesymptoms, fatigue and muscleaches, skin rashes and irritation(which respond very well to topicalsteroids), thyroid derangement(both hyper- and hypo-thyrodism),hemolysis with ribavirin, and bonemarrow suppression with interferon.22 West Virginia Medical Journal

| Scientific Articleif patient weighs less than 75kg, then800mg/daily as 400 bid is utilized;however, if the patient weighs morethan 75kg, then 1000mg should beused daily, given in two divideddoses: 400 in the morning and 600 atnight. If the patient weighs more than100kg, the maximum dose of ribavirinof 1200mg/daily could be attemptedwith careful monitoring of the CBC.For HCV genotype 1 (mostcommon in the US); if there isa RVR, the duration of therapycan be shortened to 24 weeksinstead of 48 weeks. If there isa slow viral response (meaningthat the qualitative PCR becomesnegative at 24 weeks rather than12 weeks, or if there is a twologdrop in the viral titer but thequalitative test is still positive at12 weeks) then it is recommendedthat the duration of treatment beextended to 72 weeks (Figure 1).Preceding therapy, patients,both male and female should becounseled to prevent pregnancyduring and up to six months aftertherapy. Furthermore, all patientsshould have a baseline evaluationthat includes the following:a) Psychiatric evaluation andclearance. If patient is takinganti-depressants, requirefour weekly follow-ups totheir psychiatrist for theduration of therapy.b) Baseline retinal examinationby an ophthalmologist, dueto the effects of interferon.c) Blood work should includeCBC with differential,LFT, KFT, and TSH.During therapy, a weekly CBC forthe first month and every four weeksthereafter should be maintained.Any change in the dosage of eitherribavirin or interferon shouldrevert patient to a weekly cycleuntil blood counts are stable.What new therapies are coming?The investigational agentsfor HCV infection can bedivided into three areas:a) Treatments targeting HCVencodedproteins.b) Treatments targeting hostencodedproteins.c) Therapeutic andpreventive vaccines.In addition, there are ongoingdiscussions among the liver expertsabout triple therapy rather thandual therapy. There are somepromising reports with triple therapyusing interferon, ribavirin, plusnitazoxanide “an anti-protozoaldrug” or triple therapy withinterferon, ribavirin, plus one of theprotease inhibitors such as Telapreviror Boceprevir; and or the additionof the antiviral agent Silibinin. 6-15Telaprevir and Boceprevir areprotease inhibitors which belong toa class of agents known as DAA’s(Direct-Acting Anti-virals), and arethe two products currently in phasethree development. Hopefully,these medications will soon beavailable on the market. 16 Oncethese products are readily available,they will be used in conjunctionwith ribavirin and peginterferon forthe initial 8 to 12 weeks of therapyfollowed by another 12 weeksof ribavirin and peginterferon ifnecessary. Due to their excellentanti-viral effects, many physiciansare withholding therapy for newlydiagnosed HCV patients till thesedrugs are available on the market.SummaryThe take home message is that itis our duty as treating physiciansto keep people on therapy byeliminating drop-outs, keeping inmind that it is no longer acceptableto think of genotype 1 and 4 as“difficult to treat” or that genotype 2and 3 are “easy to treat”. Treatmentshould be tailored to the specificpatient and to the specific virus thatinfected that particular patient.Although the genotype is animportant driver of responseand is useful in designing theinitial treatment plan, it is clearthat once treatment is initiated,RVR is the most important andpowerful predictor of SVR. 3It is our opinion that HCV is apotentially treatable disease, buttreatment is not a “one size fits all”,but rather should be tailored andindividualized for each patient.However, if there is a responseat week four of therapy [RVR],treat the patient for 24 weeksonly, regardless of the genotype.If there is a response at week 12 oftherapy [EVR], treat for 48 weeks,regardless of the genotype. If thereis a response at 24 weeks of therapy[Slow Virologic Response], treat for72 weeks regardless of the genotype.Chronic HCV is a potentiallytreatable disease with thefollowing response rates“Sustained Virologic Response”:a) SVR of approximately 70---75% if RVR is achievedb) SVR of approximately 55---63% if EVR is achievedc) SVR of approximately30---33% if there was aSlow Viral ResponseThe most recent and detailedrecommendations about treatmentof HCV can be found in theAmerican Association for the Studyof Liver Diseases (AASLD) practiceguidelines that were published inthe Hepatology Journal in April2009, (2); or at their web site: www.aasld.org/practiceguidelines.Since the preparation of thismanuscript, Incivek [Telaprevir]and Victrelis [Boceprevir] havebecome available on the marketfor the treatment of Hepatitis CGenotype 1 as triple therapy-March/April 2012 | Vol. 108 23

Scientific Article |using one of them in addition toribavirin and pigulated interferon.References1.2.3.4.5.6.Williams R. Global challenges in liver disease.Hepatology 2006; 44:521-526.Ghany et al. Diagnosis, management, andtreatment of Hepatitis C: An update. Hepatology2009; 49:1355-1374.Berg T. Tailored treatment for hepatitis C. MDConsult 2010; at www.mdconsult.com/das/article/body/185458161-2/jorg.Ge D, Fellay J, Thompson AJ, et al. Geneticvariation in IL28B predicts hepatitis C treatmentinducedviral clearance, Nature 2009; 461:798-801.Lindahl K, Stahle L, Bruchfeld A, Schvarcz R.High dose ribavirin in combination with standarddose peg-interferon for treatment of patients withchronic hepatitis C. Hepatology 2005; 41:275-279.Jiang D, Guo H, Xu C, et al. Identification ofthree interferon inducible cellular enzymes thatinhibit the replication of hepatitis C virus. J Virol2008; 82:1665.7. Rossignol JF, Kabil SM, El-Gohary Y, et al.Clinical trial: randomized double-blindedplacebo-controlled study of nitazoxanidemonotherapy for the treatment of patients withchronic hepatitis C genotype 4. AlimentPharmacol Ther 2008; 28:574.8. Rossignol JF, Elfert A, El-Gohary Y, Keefe EB.Improved virologic response in chronic hepatitisC genotype 4 treated with nitazoxanide,peginterferon, and ribavirin. Gastroenterology2009; 136:856.9. Salberg M, Frelin L, Diepolder H, et al. A firstclinical trial of therapeutic vaccination usingnaked DNA delivered in vivo electroporationshows antiviral effects in patients with chronichepatitis C. Presented at the 44 th Annual Meetingof the European Association for the Study of theLiver, Copenhagen, Denmark; April 22-26, 2009;abstract # 43.10. Folori A, Capone S, Ruggeri L, et al. A T-cellHCV vaccine eliciting effective immunity againstheterologous virus challenge in chimpanzees.Nat Med 2006; 12:190.11. Elmowalid GA, Qiao M, Jeong SH, et al.Immunization with hepatitis C virus-like particlesresults in control of hepatitis C virus infection in12.13.14.15.16.chimpanzees. Proc Natl Acad Sci U S A 2007;104:8427.Seeff LB, Curto TM, Szabo G, et al. Herbalproduct use by persons enrolled in the hepatitisC antiviral long-term treatment against cirrhosis(HALT-C) Trial. Hepatology 2008; 47:605.Liu J, Manheimer E, Tsutani K, Gluud C. Medicinalherbs for hepatitis C virus infection: a Cochranehepatobiliary systematic review of randomizedtrials. Am J Gastroenterol 2003; 98: 538.Polyak SJ, Morishima C, Shuhart H, et al.Inhibition of T-cell inflammatory cytokines,hepatocyte NF-KappaB signaling, and HCVinfection by standardized Silymarin.Gastroenterology 2007; 132: 1925.Ferenci P, Screzer TM, Kerschner H, et al.Silibinin is a potent antiviral agent in patients withchronic hepatitis C not responding to pegylatedinterferon/ribavirin therapy. Gastroenterology2008; 135:1561.Herrera J. Treatment of Hepatitis C in thePre-DAA’s Era: treat Now or wait for NewMedications? Practical gastroenterology 2010; 6:13-19.ADVERTISEYOUR PRACTICEin the West Virginia Medical Journal’sProfessional Directory SectionEach physician or group practice space can be upto 2" and includes the information you choose,under the specialty you designate for thenominal fee of $200 per year.Each additional inch is only $100 per year!For more information, contact Angie Lanham,Managing Editor, West VirginiaMedical Journal.304.925.0342, ext. 20 or email yourlisting and billing information toangie@wvsma.com24 West Virginia Medical Journal

Scientific Article |Acromegaly Caused by Growth Hormone ReleasingHormone (GHRH) Secreting Tumor in MultipleEndocrine Neoplasia (MEN-1)Tipu Faiz M. Saleem, MDAssociate Professor, Division of Endocrinology,JCESOM, Marshall University, HuntingtonPrasanna Santhanam, MDAssistant Professor, Division of Endocrinology,JCESOM, Marshall University, HuntingtonEyad Hamoudeh, MDFellow, Division of Endocrinology, JCESOM,Marshall University, HuntingtonTamer Hassan, MDResident, Division of Internal Medicine,JCESOM, Marshall University, HuntingtonSaba Faiz MDFellow, Division of Endocrinology, JCESOM,Marshall University, HuntingtonAbbreviationsMEN-1: Multiple endocrineneoplasia type 1, NECT:Neuroendocrine tumor, GHRH:Growth hormone releasinghormone, GH: Growth hormone,IGF-1: Insulin like growth factor.gland and the NECT. Life longsurveillance is needed as recurrencechance is high.IntroductionMultiple endocrine neoplasiatype 1 (MEN-1) is defined aspresence of any two tumors outof the following; parathyroid,neuroendocrine tumor (NECT)and pituitary neoplasia. 1Hypersecretion of growth hormonereleasing hormone (GHRH) is raremanifestation of NECT; howeverhalf of such cases are found withMEN-1. 2 Incidence rate of acromegalywith GH over secretion is up to 15%in MEN-1 pituitary tumors similarto non-MEN-1 pituitary tumors. 3There are two different etiologicmechanisms of acromegaly caused byexcess GH in MEN-1 with differenttreatment implications. Mostly it isdue to pituitary adenomas, whicharise clonally from inactivation ofboth alleles of the MEN-1 gene in atumor precursor cell. 4 The secondmechanism is overproduction ofGHRH by NECT including pancreaticislet 2 or carcinoid tumor leading topolyclonal and hyperplastic pituitarygland with over production of GH.In this report, we describe acase of acromegaly, in a patientFigure 1.Contrast enhanced CT scan of abdomen. Arrow indicating pancreatic head tumor.AbstractWe are presenting the clinicalfeatures, diagnostic work up andtreatment of acromegaly caused byGrowth hormone releasing hormone(GHRH) secreting neuroendocrine tumor(NECT) in a case of multiple endocrineneoplasia type 1(MEN-1).A 36 year old man, known case ofMEN-1 presented with acromegalicfeatures. He has high IGF-1, GH and veryhigh GHRH levels with a pancreatic headtumor and pituitary mass. He had highGHRH arteriovenous gradient acrosspancreatic tumor and underwent tumorresection, Post operative GHRH level felldramatically. Tumor had high GHRHm-RNA level.Acromegalic patients with MEN-1should be screened for ectopic GHRHsecretion. Measurement of GHRHarteriovenous gradient across NECT ormRNA for GHRH in resected tumor canconfirm the ectopic source. Treatment ofchoice is surgical resection of the tumor.Somatostatin analogue is an alternativebecause of its dual action in the pituitary26 West Virginia Medical Journal

| Scientific ArticleTable-1 Confirmation of GHRH hypersecretion by tumor causing acromegalyBiochemical Features Normal Range Pre-Operative Post-OperativeIGF-1 (114-449) ng/ml 1500 ng/ml 761 ng/mlGH (2-5) ng/ml 93 ng/ml 7.9 ng/mlPeripheral vein GHRH (

Scientific Article |Table 2. Clinical Effects of AcromegalyLocal Tumor Effects Somatic Effects Endocrine and Metabolic EffectsCranial nerve palsyHeadachePituitary enlargementVisual field defectsAcral Enlargement-thickness of handsand soft tissueCardiovascular-Asymmetric septalhypertrophy, Left Ventricular Hypertrophy,HTN, CHF, CardiomyopathyGastrointestinal-Colonic PolypsMusculoskeletal - Acroparasthesias,proximal Myopathy, prognathism,gigantism, carpal tunnel syndrome,frontal bone prominence, arthralgia, jawmalocclusionPulmonary - Narcolepsy, Sleep Apnea-Central and ObstructiveSkin – Hyperhydrosis, Skin tagsVisceromegaly - Kidney, liver, prostate,thyroid, tongue, salivary gland, spleenCarbohydrate - Diabetes Mellitus,Impaired Glucose Tolerance, InsulinResistance and HyperinsulinemiaElectrolytes - Increased Aldosterone,Low ReninLipids - HypertriglyceridemiaMinerals – Hypercalciuria, Increased 1,25(OH)2 D3,Urine HydroxyprolineNeoplasms - MEN-1,Hyperparathyroidism, Islet Cell TumorsReproduction- Galactorrhea, menstrualabnormalities, decreased libido,impotence, low Sex Hormone BindingGlobulinThyroid - low Thyroxine Binding Globulin,GoiterModified from Bonert V, Melmed S. Acromegaly. In Bar RS, ed. Early Diagnosis and Treatment of Endocrine Disorders (ContemporaryEndocrinology). Totowa, NJ: Humana Press, 2002:201-228.Laboratory data showed IGF-11500 ng/ml (114-449 ng/ml), GH93 ng/ml (2-5 ng/ml), calcium11.3, intact PTH 84 pg/ml (11-54).Repeat MRI of head showed2.2 x 1.8 x 1.8 cm pituitary tumorwhich had increased in sizecompared to previous study.GHRH level 6969 pg/ml (

| Scientific ArticleTable 3. When to suspect GHRH dependent acromegaly?Indications for measurement of GHRH levels in acromegaly1.2.3.4.5.Known case of multiple endocrine neoplasia (MEN-1)Family history of multiple endocrine neoplasia (MEN-1)Presence of known neuroendocrine tumor (NECT)Co-existence of hyperprolactinemia and acromegalyAbsence of classic pituitary adenoma in MRI (either normal orhyperplastic pituitary gland)and IGF-I levels after removal ofthe tumor to near normal. 11,12 Ourcase met almost all these criteria.Neuroimaging studies of thehypothalamic pituitary gland inectopic GHRH induced acromegalyhave provided variable results, fromno tumor to slight enlargementor well defined pituitary mass. 9Histopathology specimens ofPituitary glands from GHRHinduced acromegaly have showna continuum of hyperplasia toadenoma and adenomatoustransformation can be found ona background of hyperplasia. 9As MEN-1 patients can haveboth pituitary tumors and NECT,it seems reasonable to screen allMEN-1 patients with acromegaly forectopic GHRH induced acromegaly(Table 3). Serum GHRH levels canbe used as an initial screening test.Previously reported GHRHsecreting NECT were usually largeenough to be seen on CT scan ofabdomen and chest respectively.Octreotide scintigraphy can beuseful in detecting the tumors thathave rich somatostatin receptors 9,13,14but the test is not definitive.Surgical removal of the GHRHproducing tumor is the therapyof choice for ectopic GHRHinduced acromegaly. 9 In case of aninoperable tumor, high surgicalrisk or unsuccessful surgery, GHhypersecretion can be controlledeither by pituitary surgery or pituitaryradiation. Another alternative ismedical treatment. Dopamine agonisttherapy has variable effect on GHand IGF1 levels but doesn’t affectGHRH levels or tumor size. 9 Longacting somatostatin analog octreotidecan inhibit GHRH secretion fromNECT as well as GH secretion fromanterior pituitary gland directly. Itcan reduce GH and IGF1 levels atrelatively lower doses, but higherdoses are required for suppressionof GHRH levels, shrinkage of theprimary tumor and reduction of9, 13,14secondary pituitary enlargement.Want More Than a Boxfrom your EMR software?With Physician’s Business Office and Centricity ®EMR by GE Healthcare, you get state-of-the-artsoftware and an experienced support team workingwith you every step of the way.Give us a call to see how we can help you get tothe next level in patient care.Electronic Medical Records • Practice Management3211 Dudley Avenue, Parkersburg, WV 26104Call Jill Redinger (304) 482-8045 or Jeff Matheny (304) 422-0578web: physiciansbusinessoffice.com • e-mail: jill@pbo.bzMarch/April 2012 | Vol. 108 29

Scientific Article |Although commercially notavailable, GHRH antagonistshave shown to effectivelydecrease GH secretion in ectopicGHRH induced acromegaly onexperimental basis. 15 When potentGHRH antagonists will becomecommercially available, it mightbe the most suitable therapeuticoption for this rare disease.CONCLUSIONPatients with acromegalyand MEN-1 should be screenedfor ectopic GHRH secretion.Measurement of GHRHarteriovenous gradient across NECT,measurement of GHRH or mRNAfor GHRH in resected tumor andpost operative decline in GHRHlevel can confirm the ectopic source.Surgical removal of the GHRHsecreting tumor is the treatmentof choice. Medical therapy withSomatostatin analog is an alternativefor surgically unsuitable patients.Lifelong surveillance forrecurrence of tumor andacromegaly should be continuedwith GHRH and IGF-1 levels.REFERENCES1. Brandi ML, Gagel RF, Angeli A, et al. Guidelinesfor diagnosis and therapy of MEN type 1 andtype 2. J Clin Endocrinol Metab. 2001;86:5658-5671.2. Liu SW, van de Velde CJ, Heslinga JM, Kievit J,Roelfsema F. Acromegaly caused by growthhormone-relating hormone in a patient withmultiple endocrine neoplasia type I. Jpn J ClinOncol. 1996 Feb; 26(1):49-52.3. Marx S, Spiegel AM, Skarulis MC, Doppman JL,Collins FS, Liotta LA. Multiple endocrineneoplasia type 1: clinical and genetic topics. AnnIntern Med. 1998 Sep 15; 129(6):484-94.4. Weil RJ, Vortmeyer AO, Huang S, et al. 11q13allelic loss in pituitary tumors in patients withmultiple endocrine neoplasia syndrome type 1.Clin Cancer Res. 1998 Jul; 4(7):1673-8.5. Throner MO, Frohman LA, Leong DA.Extrahypothalmic growth-hormone-releasingfactor (GFR) secretion is a rare cause ofacromegaly: plasma GRF levels in 177acromegalic patients.J Clin Endocrinol Metab1984; 59:846-9.6. Penny ES, Penman E, Price J, et al. Circulatinggrowth hormone releasing factor concentrationsin normal subjects and patients with acromegaly.Br Med J (Clin Res Ed). 1984 Aug 25;289(6443):453-5.7. Gola M, Doga M, Bonadonna S, Mazziotti G,VVescovi PP, Giustina A. Neuroendocrine tumorssecreting growth hormone-releasinghormone:pathophysiological and clinical aspects.Pituitary 2006; 9 (3):221-98. Faglia G, Arosio M, Bazzoni N. Ectopicacromegaly. Endocrinol Metab Clin North Am.1992 Sep; 21(3):575-95.9. Scheithauer BW, Carpenter PC, Bloch B,Brazeau P. Ectopic secretion of a growthhormone-releasing factor. Report of a case ofacromegaly with bronchial carcinoid tumor. Am JMed. 1984 Apr; 76(4):605-16.10. Stefaneanu L, Kovacs K, Horvath E, et al.Adenohypophysial changes in mice transgenicfor human growth hormone-releasing factor: ahistological, immunocytochemical, and electronmicroscopic investigation. Endocrinology. 1989Nov; 125(5):2710-8.11. Biermasz NR, Smit JW, Pereira AM, et al.Acromegaly caused by growth hormonereleasinghormone-producing tumors: long-termobservational studies in three patients. Pituitary.2007; 10(3):237-4912. Losa M, von Werder K. Pathophysiology andclinical aspects of the ectopic GH-releasinghormone syndrome. Clin Endocrinol (Oxf). 1997Aug; 47(2):123-35.13. de Jager CM, de Heide LJ, van den Berg G, etal. Acromegaly caused by a growth hormonereleasinghormone secreting carcinoid tumor ofthe lung: the effect of octreotide treatment. NethJ Med. 2007 Jul-Aug;65(7):263-6.14. Drange MR, Melmed S., Long-acting lanreotideinduces clinical and biochemical remission ofacromegaly caused by disseminated growthhormone-releasing hormone-secreting carcinoid. JClin Endocrinol Metab. 1998 Sep; 83(9):3104-9.15. Jaffe CA, DeMott-Friberg R, Frohman LA, et al.Suppression of growth hormone (GH)hypersecretion due to ectopic GH-releasinghormone (GHRH) by a selective GHRHantagonist. J Clin Endocrinol Metab. 1997Feb;82(2):634-7.30 West Virginia Medical Journal

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Scientific Article |Physician-Patient Communication: Breaking Bad NewsScott A. Fields, PhDAssociate Professor, WVU School of Medicine,Department of Family Medicine, Charleston DivisionW. Michael Johnson, MDAssociate Director, Family Medicine Residency, GrantMedical Center, Columbus, OHAbstractPhysicians often struggle with how tomanage the task of breaking bad newswith patients. Moreover, the arduousnature of the task can contribute tophysician detachment from the patient oran avoidance of breaking the news in atimely manner. A plan of action can onlyimprove physician confidence in breakingbad news, and also make the task moremanageable. Over a decade ago, Rabowand McPhee offered a strategy; theABCDE plan, which provided a patientcentered framework from which to delivertroubling news to patients and families. Atthe heart of this plan was the creation of asafe environment, the demonstration oftimely communication skills, and thedisplay of empathy on the physician’s part.Careful consideration of the doctor’s ownreactions to death and dying also playedan important role. A close review of the fivetenets of this plan indicates the relevanceof Rabow and McPhee’s strategy today.The patient base in our nation and statecontinues to be older, on average, andphysicians are faced with numerouspatients who have terminal illness. Aconstructive plan with specific ideas forbreaking bad news can help physicianseffectively navigate this difficult task.BackgroundBreaking bad news is an arduoustask for seasoned and neophytephysicians alike. Physicians, notunlike other professionals, tend toavoid tasks for which they feel theyare untrained or unprepared toperform. Thus, some physicians makethe mistake of putting off bearingbad news until they absolutelyhave to provide it. Making mattersworse, for some physicians, thereis a tendency to disengage frompatients as they learn bad news. 1Thus, at a time when patients needthe greatest support, their doctorsmay unwittingly leave them ontheir own. The reasons for this maybe due to: a) feeling unprepared; b)anticipation of an unpleasant reaction(e.g., anger) by the patient and/or family members; c) confusionover how much informationshould be given and at what timeit should be communicated; d) lackof time to deliver bad news andprocess patient/family options.Thus breaking bad news is a majorobstacle for most physicians.Therefore, how can physiciansdeliver bad news more effectively?The ABCDE ModelRabow and McPhee 2 provided asuccinct and powerful framework touse when delivering bad news. Themnemonic is ABCDE. The A standsfor advanced preparation. This helpsto assist the physician with some ofthe time demands and some of the“what if” questions that may ariseprior to the meeting with the patientand the family. The B stands forbuilding a therapeutic environment.In order to properly discuss thepatient’s situation, the physicianneeds to arrange a situation wherepeople can talk freely and openly.The C denotes communicating well.Research indicates that patientsdesire open communicationregarding their condition, 3 providedthat it is compassionate. The D refersto dealing with patient and familyreactions to bad news. While thisrefers to the “normal” reactionsthat family members may have,it also includes the sometimesoverlooked idea that not everybody,or everybody’s family, deals withbad news in the same way. The Edenotes encouraging and validatingpatient and family emotions. This isoften the most important overlookedcomponent as families and patientsmay feel that their feelings aboutthe bad news are being sidesteppedfor other, seemingly more pertinentissues related to the bad news.Advance PreparationThe first step in breaking badnews is advance preparation for theTable 1. Breaking Bad NewsFrameworkABCDE MnemonicA Advance PreparationB Build therapeutic environment/ relationshipC Communicate wellD Deal with patient / familyreactionsE Encourage and validateemotionsAdapted from Rabow, MW, McPhee, SJ.Beyond breaking bad news: how to helppatients who suffer. West J Med. 1999; 171:260-263.meeting with the patient and family.While most physicians are quitebusy, it is nonetheless recommendedthat 15‐30 minutes be set aside forthe meeting. This does not includethe time needed to arrange for theprivate room and to review allgermane clinical records. Physiciansshould arrange for no interruptionsby turning cell phones and pagersto silent mode. In addition, staff atthe clinic or hospital should be toldnot to disturb the meeting unless itis an emergency. Finally, if the news32 West Virginia Medical Journal

| Scientific Articleis delivered in a hospital room, thedoor to the room should be closedas should the curtain toward theother side of the room if the meetingoccurs in a shared hospital room.Bad news is difficult enough withoutan unintended audience or otherdistractions. Advance preparation canassure that patients and doctors haveample preparation, time, and spaceto deal with the taxing task at hand.Building a TherapeuticEnvironmentBuilding a therapeuticenvironment is more difficult than thephrase might imply. Chief among thegoals of a therapeutic environment issupport. The patient will likely havefamily members or friends whomthey wish to participate for moral andemotional support. In addition, thephysician may opt to have clergy ora counselor available depending onthe severity of the bad news beingdelivered. However, not all patientswant to have others present. Thebest approach is to ask about thepatient’s wishes. A good exchangecould include the following:“I have some news that I wish toshare with you. Whom would you liketo be with you when we talk about it?”While we might assume that thepatient needs the family, we need torespect his or her wishes to include,or exclude whomsoever he or shedesires. The patient needs to be ourguide. At times a patient may notwish to know the bad news. If apatient refuses a meeting, one canwait until later in the day or the nextday, depending on the urgency.The final step is to start the sessionwith an introduction and a “warningshot.” The introduction lets the familymembers know who the physicianis. An example of this might be:“Hello, I am Dr. Wilson, Mrs.Johnson’s family doctor.”A warning shot after theintroduction will help prepare thefamily and the patient for the newsthat is about to come. While it islikely that they know that a meetingis rarely for good news, it still ishelpful to soften the blow withsome well chosen words, such as:“I have gathered you all becauseI have some difficult news.”“I regret to say that I havesome tough news for you all.”“I am sorry to say I havesome bad news to share.”Communicating WellThe next task in breaking badnews is communicating well withthe patient (and family). Even inthe present era of high technologyBeckley ARHAdolescent Behavioral Science CenterTeenagers face numerous challengestoday that can sometimes cause them tohave serious issues.Beckley ARH’s Behavioral Science Center can intervene to help themcope and prevent a problem from becoming worse as they enteradulthood.The Unit allows for an excellent opportunity to identify,diagnose and treat problems at an early stage so they can get back toschool and what should be some of the happiest times of their lives.Beckley306 Stanaford Rd | Beckley,WV 25801304-255-3000 | www.arh.orgMarch/April 2012 | Vol. 108 33

Scientific Article |and e-charts, a physician still needsto value effective communicationas a tool to help the patient copewith medical issues. Further, theteaching of communication skills isnow recognized in residency as it isone of the six core competencies setforth by the Accreditation Councilfor Graduate Medical Education(ACGME) . 4 At no time are theseskills more important than when aphysician must deliver bad news toa patient and that patient’s family.Prior to describing the bad news,it is important to see what a patientand that patient’s family knows.Sometimes the patient and the familywill already sense that somethingserious is wrong. A good idea isto frame the question in an openendedway to generate discussion.An example might be, “What doyou know about your medical (health)condition?” Once this question isasked, some time should be givento process the answer, if indeed oneis provided. The patient may have avariety of responses to this questionfrom “I don’t know anything” to “Ithink I have cancer.” Regardless of theresponse, time and silence are keyaspects in this portion of the process.When communicating bad news,a physician should be as patientand methodical as possible indiscussing the illness. The patientwill need some time to process whathas been said. Rushing the newswill likely impede that process. Inaddition, it might be a good ideato write a few key notes down forthe patient to have for later whenothers ask questions or when theywant to revisit the news. Ample timeshould be allowed for questionsand discussion. It also is a goodidea to ask the patient to recallwhat they heard so we know whatwe said was understood. On rareoccasions, the patient may ask thephysician to stop. If this occurs, it isimportant to honor this wish. Thenews can be given later, when thepatient is better prepared to hear it.One potentially awkward pieceof breaking bad news is dealingwith silence. Physicians may feelthat they need to fill in the space ofthe discussion but that is typicallyunnecessary. Again, time to processthe news is essential and silence willhelp provide that. If the silence goesfor over 30 seconds, a comment maybe made. One example might be:“I know this news is difficult andit sometimes takes time to set in.”This can fill some of the silenceand normalize patient andfamily reactions to bad news.Finally, a physician needs to beprepared to practice good nonverbaland verbal communication skills.Nonverbal skills such as maintainingan active posture can help thefamily to see that the physician isinterested and invested in helping.An active posture often includesgood eye contact, occasionalnodding when appropriate, andleaning forward when the patient istalking. Verbal skills should includeusing reflection. This refers tocommenting on what the patient saysby mirroring or paraphrasing his orher words. An example might be:“You are saying you wish togo forward with the surgery?”Reflection provides the patientwith knowledge that the doctorwas listening and wanted to furtherunderstand that the patient washeard correctly. Finally, avoidingmedical jargon results in morecomprehensible discussion withpatient and family. Medical termsshould be explained in languagethat the family can understand.Dealing with Patient andFamily ReactionsPart of the pressure of breakingbad news is how best to relay theinformation to a patient and thefamily. However, another big stressorfor a physician is dealing with howthe patient and the family mightreact to bad news. Emotions can varyand may include disbelief, sadness,fear, and anger. The expression ofthese emotions can be unpleasant forthe physician and hospital or clinicstaff. A few approaches can helpin navigating this difficult part ofthe process. It is indeed importantto assess the patient’s emotionalreaction, as this can help in preparinga plan. For example, if the patientis scared, then the physician mayneed to gently work him or her up tothe next part of treatment. Empathyis also important. Carl Rogers,noted psychologist, once describedempathy as striving to generate thefeeling that you have walked in thatpatient’s shoes. 5 Finally, it is best toavoid disparaging or condescendingremarks about colleagues whiledelivering bad news, since this willonly generate unnecessary hardfeelings toward other physiciansand possible future professionalproblems with colleagues.Showing empathy is a goodstart, but it is not all that a doctorneeds to do. It is also important forthe physician to let the patient andfamily know that it is understoodhow they feel. This can be especiallyhelpful when it comes to anger. Ifa family is obviously sad or upset,the physician may respond toemotion with phrases such as:“ I can see you are upset,what angers you the most?”“ It sounds like this newshas been hard for you to hear,what is on your mind?”Addressing the emotion shouldhelp the family in dealing withit and also lets them know thatthe physician is not just there toreport, their doctor is there to listenand be supportive. To that end,it is reasonable for a physician toshow emotion. As humans, we allexperience sadness, frustration,anger, and other emotions whenthings do not go as we planned.While a physician should not turnthe meeting into a mutual periodof grieving, there is indeed nothingwrong with expressing emotions,even if that includes tears. Further,34 West Virginia Medical Journal

| Scientific Articlewhen dealing with questions andresponses from the family, it is okayto say “I am sorry” when appropriate.It is also within reason to say “Ido not know” if an answer is notknown. Such simple statements goa long way in helping the patientand the family understand thephysician's humanistic side.Encouraging and ValidatingEmotionsThe final piece of breaking badnews further deals with how tohandle the often intense emotionsthat can arise once a patient learns ofhis or her condition and prognosis.Expression of emotions should beencouraged, not discouraged. Apatient and family have a right to feelthe way they feel, and this is indeedwhy the news is communicatedin a closed room, so that humanemotions can be expressed morefreely. It is at this stage that thephysician can further explore whatthe news means to the patient andthe family. Asking questions such as:“What does this news mean to you?”“How do you put this together,or make sense of it?”This can also be an importanttime to offer realistic hope for thepatient. If the news is that the illnessis terminal, we can hope for goodtimes with family and a peaceful end.If the news is that it is a manageablelifelong illness, we can hope for apositive outcome in managing theday to day nature of the malady.At the end of the session, we wantto help create a picture of accurate,realistic hope for the patient. Thenews may alter the hope of thepatient, but the idea of “shiftinghope” toward another area can bequite helpful. Thus, while hoping tolive longer than two years may notbe accurate, hoping to get the mostout of those two years with one’sfamily could be a very realistic goal.Toward the end of the meeting, itis also a good idea for the physicianto offer other resources. Dependingon the situation, counselors, clergy,and hospice could be involved.Contact information or brochurescould be provided for the family.Many types of illnesses may havetheir own support system in place.For example, some hospitals havea Cardiac Care Support Programor a Cancer Support Program. Inthis way, the physician can indicatethat this news does not have tobe processed alone and that thefamily need not negotiate themanagement of the illness withoutcontinued professional help.Final ThoughtsA few final precautionary notesare in order regarding the end ofa breaking bad news session. Ameeting should be arranged to followup with the patient very soon. If itis an inpatient situation, then followup the next day is appropriate. If itis outpatient, a one week or soonerfollow up should suffice. As notedearlier, a patient needs support morethan ever at this time and a lengthywait to follow up could be viewedas counterproductive at best andabandonment at worst. Also, if thenews was delivered in an outpatientsetting and it was very difficult news,the patient should be discouragedfrom driving home. The impact ofthe bad news may well distract thepatient from the typically mundanetask of driving home. Instead,a family member or alternativetransportation (e.g., bus, cab) shouldbe utilized to minimize the likelihoodof an ill-timed accident. Althoughrare, a patient in a vulnerable statemay see suicide as an option shortlyafter the bad news and driving acar would unfortunately give thema fairly lethal means to carry outself harm, and could unwittinglyput others on the road at risk.Without a doubt, physicians dealwith many stressful situations. It isoften said that we learn about life bydealing with adversity. Finding outbad news and then communicatingthat bad news can be quite anadverse situation. It is importantduring those times that physiciansremember to care for themselves.First and foremost, it is importantto not take the bad news personally.Patient illness and patient response totreatment does not typically reflect ona doctor’s abilities. After all, the jobof a physician is not to prevent death,it is to manage and hopefully cureillness, if a cure exists. It is importantthat physicians keep their thoughtspositive and try not to personalizeloss and illness. Furthermore, itis also important to bear in mindthat life is not always fair. When amother of two is diagnosed withterminal cancer, it is not fair. Whenan otherwise healthy grandfatherof five and father of three contractspneumonia and dies, it is also notfair. Not to his wife, not to his family,and certainly not to his physician. Allof us must deal with unfair incidentsin life and manage them as best wecan. One must keep this in mind andtry not to personalize these incidents.Therefore, the final challenge afterbreaking bad news is how physicianscontinue to manage self-care inaddition to their professional lives. 6References1. Buckman, RA. Breaking bad news: TheS-P-I-K-E-S strategy. Community Oncol. 2005; 2:138-142.2. Rabow, MW, McPhee, SJ. Beyond breaking badnews: how to help patients who suffer. West JMed. 1999; 171:260-263.3. VandeKieft, GK. Breaking bad news. Am FamPhysician. 2001; 64:1975-1978.4. Lurie, SJ, Mooney, CJ, Lyness, JM. Measurementof the general competencies of the accreditationcouncil for graduate medical education: Asystematic review. Acad Med. 2009; 84 (3):301-309.5. Wachtel, PL. Carl Rogers and the larger context oftherapeutic thought. Psychotherapy: Theory,Research, Practice, Training. 2007; 44 (3):279-284.6. Kearney, MK, Weininger, RB, Vachon, ML,Harrison, RL, Mount, BM. Self-care of physicianscaring for patients at the end of life: “Beingconnected…a key to my survival”. JAMA. 2009;301, 1155-1164.March/April 2012 | Vol. 108 35

Scientific Article |Schwannoma of the Ulnar Nerve: A Case Report andReview of the LiteratureAshley Boustany, MS-IIWest Virginia University School of MedicineW. Thomas McClellan, MDPlastic SurgeonPrivate PracticeAbstractWe report a case of a large ulnarnerve schwannoma, a rare type of softtissue neoplasm. Diagnostic pearls aredescribed to facilitate a more accurateand timely diagnosis. Thesecharacteristics include mobility, Tinel’ssign, MRI target sign, S100 histologicalstaining, Antoni patterns, and others. Witha correct diagnosis, the tumor can beextirpated with preservation of nervefunction and a low risk of recurrence.IntroductionSchwannomas are the mostcommon type of tumor arisingin peripheral nerves. 1 However,peripheral nerve tumors are rare,representing less than 8% of softtissue neoplasms. Schwannomasare non-invasive tumors arisingfrom peripheral nerve sheaths andare encapsulated by epineurium. 2There is a 2:1 occurrence of upperlimb to lower limb schwannomas,generally on the volar surface. Thereis no predisposition for sex or race,but they usually develop in 30-60year olds. 1 Schwannomas are oftenmisdiagnosed due to their indistinctsigns and symptoms, which maylead to detrimental neurologicdeficits if approached incorrectly.It has been shown that less than aquarter of diagnostic tests provide anaccurate diagnosis of schwannoma. 3Case ReportWe present a 53 year old righthand dominant female with a slowlyenlarging mass within her proximalvolar right forearm (Figure 1).The mass had been present for aminimum of two years and hadbecome more painful and noticeableover time. Dull, intermittent painwas reported at rest over the mass,and was moderately sharper duringflexion of the fingers or bumping ofthe forearm. The level of discomfortincreasingly hindered her ability toperform activities of daily living.She was initially treatedconservatively at an outside facilityfor a ruptured forearm musclebelly. Subsequently, her symptomsworsened and a CT guided biopsy ofthe suspected mass was performed.The patient reported the biopsy wasextremely painful and caused anexacerbation of her forearm pain.Histopathology demonstrated apaucicellular specimen with veryrare fragments of fibrous tissue thatwas insufficient for diagnosis.She was referred to our handsurgery service following theinconclusive biopsy. The 5 cm firmmass was mobile perpendicular tothe nerve axis and immobile alongthe parallel axis. A very sensitive andpositive Tinel’s sign radiated in theulnar distribution, with dysthesiasdirectly over the mass and alongthe dorsal ulnar distribution of herhand. Semmes Weinstein testingindicated diminished light touch andhypersensitivity to sharp touch in thesame region. However, her strengthof the intrinsic muscles of the righthand was 5/5 without evidence ofweakness or loss of range of motion.An MRI was performed andshowed a 5.0 cm x 3.0 cm x 4.6cm diameter mass displacing theflexor digitorum superficialis andpalmaris longus muscles (Figure 2).The mass had smooth margins butdisplayed a complex heterogeneoussignal. There was no evidence ofinvasion of adjoining muscles orbones. With gadolinium injection,Figure 1.Preoperative: The dotted line indicates theedge of the palpable tumor. Additionally,the olecranon, medial epicondyle, andpath of the ulnar nerve are identified.an intense irregular enhancementwas seen. A capsule surrounded theeccentrically placed mass. Imagesalso indicated the presence of ahemorrhagic center related to theneedle biopsy. MRI diagnosis wasinconclusive, but the differentialincluded, schwannoma, malignanthistiocytoma, neurofibrosarcoma,or soft tissue malignancy.She was taken to the operatingroom for exploration. Extirpationof the tumor was performed viaa longitudinal access incisionthrough the epineurium and carefulseparation of the nerve and tumor(Figure 3). The tumor measured 4.0cm x 3.0 cm x 1.9 cm (Figure 4). It36 West Virginia Medical Journal

| Scientific ArticleFigure 2.MRI: T1 weighted MRI of the rightupper extremity showing the large welldemarcated but heterogeneous mass.The MRI lacked the traditional “targetsign” that is commonly associated withschwannomas.Figure 3.Intraoperative: The proximal and distal ulnar nerve are identified with vascularloops. Note how the fascicles of the ulnar nerve are splayed out over the tumor.Identification of these fascicles is crucial to determine a safe longitudinal entry pointthrough the epineurium.showed a hypo-cellular tissue withSchwann cells strongly positivefor S100 protein by immunostaintechnique (Figure 5). Antoni Bpatterns predominated with fewareas suggestive of Antoni Apatterns. Incision of the tumoralso revealed hemorrhage andthrombosis consistent with priorneedle aspiration. Three monthsfollowing surgery the patienthas retained full ulnar motorand sensory function as well asimproving sensory paresthesiasin her dorsal ulnar division.DiscussionDiagnosis of a schwannoma in thepreoperative period is challengingbecause of the slow growth andpaucity of symptoms. Diagnosticaccuracy is crucial to maintainingthe integrity of the nerve involvedand to properly plan the appropriatesurgical intervention. Often thesetumors present as palpable masses,tender to displacement withoutmuscles weakness. Tinel’s sign ispositive in the majority of cases. Thetumors are transversely mobile butimmobile longitudinally, likely dueto their nested intraneural location.Schwannomas share many featureswith other soft tissue tumors andare frequently misdiagnosed due tosimilarities. Differential diagnosisshould include neurofibroma,ganglion cysts, malignant tumors,lipomas, and xanthomas. 1,4Neurofibromas, in particular, cannotbe distinguished from schwannomasFigure 4.Tumor: Gross appearance of theSchwannoma following removal fromwithin the ulnar nerve.on physical examination. Thesymptoms appear to be nonspecific,which adds to difficulty in diagnosis. 5They may be differentiated on MRIor fine needle aspiration. Malignantmasses exhibit more distinct signs butare often mistaken for schwannomasin early stages of diagnosis. Unlikeschwannomas, malignant tumorsFigure 5.Histopathology: A hypo-cellular tissuewith Schwann cells staining stronglypositive for S100 protein.often have immobility, firmness,constant pain at rest, and motorweakness. 6 Weakness may occur ifthe benign tumor exceeds 2.5 cmand can be location dependent.Kehoe et al (1995) analyzed 88peripheral nerve tumors, whereonly one was correctly diagnosedas a schwannoma preoperatively.March/April 2012 | Vol. 108 37

Scientific Article |Gadolinium enhanced T1-weighted and T2-weighted MRIsare particularly useful in diagnosingschwannomas. Koga et al (2007)found the presence of the target signto be 100% specific and 59% sensitivefor the tumors. The target sign is thecontrasting central and peripheralintensities demonstrated on theimages. Histological analysis creditsthe central hyperintensities andhypointensities on T1 gadoliniumand T2, respectively, to Antoni Acells. Antoni A patterns are of lowcellular concentration. Antoni Bareas are of high cell concentrationand correspond to peripheralintensities on MRI and CT. 8Histological staining reveals astrongly positive S100 protein thatis specific for schwannomas andhelps to rule out neurofibromas. 5,9Imaging shows the tumors as roundor oval, eccentrically located inrelation to the nerve, encapsulated,isolated, and non-invasive. Incomparison, neurofibromas arenon-encapsulated and intimatelysurround the nerve. They cannotbe surgically removed withoutdamaging the connected nerve, oftennecessitating nerve grafting to repairfunctioning. 2,4,5 Schwannomas, onthe other hand, can be separatedsurgically from the nerve fasciclesavoiding neurologic deficits. 4 Thisemphasizes the importance of acorrect preoperative diagnosis.Despite the structural differences ofsoft tissue tumors, they are difficultto distinguish with imaging.Fine needle aspiration tends tobe extremely painful in cases ofschwannomas, and hemorrhagingmay result with temporaryworsening of symptoms. The resultsare frequently inconclusive, but arehelpful to exclude ganglion cysts. 3Domanksi et al (2006) aspirated 116different schwannomas, and resultswere not sufficient for diagnosisfor about 44% of the cases.Extirpation of the intraneuralschwannoma can be challenging.Sterile tourniquet dissection isrecommended and assists invisualization. Loupe magnificationand or use of the operatingmicroscope is highly recommended.Identification of the nerve proximaland distal to the tumor is the firstimportant step to reducing injury andtraction neuropraxia. Identification ofthe individual splayed nerve fasciclesas they spread over of the tumoris critical in determining the entrythrough epineurium. A longitudinalincision is created between thesplayed fascicles down to the tumorsheath. Once the outer layer of thetumor is identified, a plane canbe developed between the moresuperficial fascicles and the tumorwall. Slow, deliberate, circumferentialdissection with a “peanut” and Littlerscissors facilitates delivery of thetumor. Once the tumor is removed,the nerve is inspected for injury, thetourniquet is released, and precisehemostasis is achieved. Repair ofthe epineurium is not required andthe longitudinally split muscle isrepaired loosely over the nerve.Drains are optional, bulky dressingis preferred, and immediate postoperative hand therapy is instituted.It is uncommon for schwannomasto recur in identical locations. 1 Daset al (2007) found that surgicalremoval of schwannomas wassuccessful in alleviating preoperativesymptoms while maintaining nervefunctioning in 89% of their cases.ConclusionSchwannomas are rare peripheralnerve tumors that have importantdiagnostic and radiographic features.These tumors are transversely mobileand longitudinally immobile, have apositive Tinel’s sign, and exertionaldysathesias or pain. MRI typicallyreveals the target sign of biphasiccontrast of peripheral and centralregions and distinct encapsulationdisplacing the intimately associatednerve fascicles. Surgical resectionmust be approached with cautionto protect nerve function andcontinuity. Surgical resection isassociated with good outcomes.The recurrence rate is low.References1. Ozdemir O, Kurt C, et.al. Schwannomas of thehand and wrist: long-term results and review ofliterature. Journal of Orthopaedic Surgery.2005;13(3):267-272.2. Lin J, Martel W. Cross-sectional imaging ofperipheral nerve sheath tumors: characteristicsigns on CT, MR imaging, and sonography. AmerJourn Roentgenology. 2001 Jan.;176:75-82.3. Rockwell G, Achilleas T, et. al. Schwannoma ofthe hand and wrist. Plast Reconstr Surg. 2003Mar.;111(3):1227-1232.4. Sandberg K, Nilsson J, et. al. Tumors ofperipheral nerves in the upper extremity: A22-year epidemiological study. Scand J PlastReconstr Hand Surg. 2009 Sep.;43:43-49.5. Adani R, Baccarani A, et. al. Schwannomas ofthe upper extremity: diagnosis and treatment.Chir Orani Mov. 2008 Sep.;92:85-88.6. Ogose A, Hotta T, et. al. Tumors of peripheralnerves: correlation of symptoms, clinical signs,imaging features, and histologic diagnosis.Skeletal Radiol. 1999 Jan.;28:183-188.7. Kehoe N, Reid R, et. al. Solitary benignperipheral-nerve tumors: review of 32 years’experience. J Bone Joint Surg. 1995Oct.;77B:497-500.8. Koga H, Matsumoto S, et. al. Definition of thetarget sign and its use for diagnosis ofschwannomas. Clinical Orthopaedics andRelated Research. 2007 Aug.;464:224-229.9. Das S, Ganju A, et. al. Tumors of the brachialplexus. Neurosurg. 2007June;22(6):E26.10. Domanski H, Akerman M, et. al. Fine NeedleAspiration of Neurilemoma (Schwannoma). Aclinicocytopahologic study of 116 patients.Diagnostic Cytopathology. 2006;34:403-412.Do You Need Answers?Your Association staff is here to help! Please call or email.Steve Brown WVMIA Agency Manager ext. 22 steve@wvsma.comBarbara Good Physician Practice Advocate ext. 11 barbara@wvsma.comEvan Jenkins Executive Director ext. 15 evan@wvsma.comAngie Lanham Publications & Advertising ext. 20 angie@wvsma.comDave Mueller WVMIA Phys. Serv. Specialist ext. 29 dave@wvsma.comMona Thevenin Membership Director ext. 16 mona@wvsma.comAmy Tolliver Government Relations Specialist ext. 25 amy@wvsma.comRobin Saddoris WVMIA Account Manager ext. 17 robin@wvsma.comKarie Sharp Conference Coordinator ext. 12 karie@wvsma.comTeresa Warner WVMPHP Case Manager ext. 30 twarner@wvmphp.org38 West Virginia Medical Journal

General | NEWSWVSMA Publications Committee Going StrongThe West Virginia State MedicalAssociation (WVSMA) publishes theWest Virginia Medical Journal,(WVMJ), the only peer-reviewedmedical journal in West Virginia. APublications Committee, composed ofAssociate Editors, who also must beWVSMA members, review scientificsubmissions to the Journal.Associate editors volunteer manyhours of their time to read, research,and write reviews. Their effortsensure a quality medical journal thatwe are proud to publish.2011-2012 brought numerouschanges to the Committee. Twolong-time members, Robert Marshall,MD and Martha Mullett, MD haveretired. Both gave many years toreviewing and editing scientific casereports, literature reviews,retrospective studies and researchworks. We will miss their dedicationand wish them the very best.Joel Levien, MD joined theCommittee in 2010. He relocated in2011. We will miss his thoroughreviews.This year, we welcome eight newassociate editors to the PublicationsCommittee. Lynne Goebel, MD andFranklin D. Shuler, MD ofHuntington, Collin John, MD, MPH,Richard A. Vaughan, MD, FACS, andDavid B. Watson, MD of Morgantown.Additionally, Richard C. Rashid, MD,Steven Sondike, MD, and RobertWalker, MD of Charleston are new tothe Committee.Steven J. Jubelirer, MD, is an Associate Editor for theWVMJ. He is seen here in his office doing what hedoes best, "MULTI-tasking".Photo taken by Tom Hindman and used with permission of theCharleston Daily Mail.2012 West Virginia Medical Journal StaffEditorF. Thomas Sporck, MD, FACSCharlestonManaging EditorAngela L. Lanham, DunbarJames D. Felsen, MD, MPH, Great CacaponFormer Director of the Kanawha-Charleston Health Departmentand Health Officer of Kanawha County, RetiredLynne Goebel, MD, FACP, HuntingtonProfessor, Department of Internal MedicineMarshall UniversityCollin John, MD, MPH, MorgantownAssistant Professor, Internal Medicine/PediatricsWest Virginia UniversityDouglas L. Jones, MD, White Sulphur SpringsInternal Medicine, Endocrinology and MetabolismMedical Director, Greenbrier ClinicSteven J. Jubelirer, MD, CharlestonHematology and OncologyClinical Professor, WVU, Charleston DivisionSenior Research Scientist, CAMC, Health Education and Research InstituteRoberto Kusminsky, MD, MPH, FACS, CharlestonProfessor of SurgeryWest Virginia University-Charleston DivisionLouis C. Palmer, MD, ClarksburgDermatologist, Private PracticeRichard C. Rashid, MD, CharlestonOphthalmologistEye Physicians & SurgeonsAssociate EditorsFranklin D. Shuler, MD, HuntingtonDirector, Orthopaedic ResearchResidency Program Associate DirectorAssociate Professor Orthopaedic TraumatologyMarshall UniversityStephen B. Sondike, MD, CharlestonMedical Director of the Disordered Eating Center of CharlestonAssociate Professor of Pediatrics, WVU, Charleston DivisionRichard A. Vaughan, MD, FACS, MorgantownProfessor and Chair, Department of SurgerySurgeon-in-Chief, West Virginia UniversityRobert Walker, MD, CharlestonVice Chancellor for Health SciencesWest Virginia Higher Education Policy CommissionDavid B. Watson, MorgantownDirector, Headache CenterWest Virginia UniversityStanley Zaslau, MD, MBA, FACS, MorgantownProfessor and ChiefUrology Residency Program DirectorWest Virginia UniversityMarch/April 2012 | Vol. 108 39

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Legislative | NEWS2012 Legislative BriefsProtecting Against a Healthcare Provider TaxPOSITION: The WVSMA applauds the completionof the phase-out of the healthcare provider tax! Westrongly encourage the Legislature to reject any proposalto reinstate a healthcare provider tax in the future.ISSUE: The healthcare provider tax was imposedin 1993 as the Legislature’s solution to generateadditional funding for Medicaid. It was widelyconsidered an unfair burden and repeal of the lawwas sought by the physician community since itsinception. Full repeal became a reality on July 1, 2010.In 2001 the Legislature passed a bill initiatingthe repeal of this tax on all individual practitionersthrough a ten-year phase out. As a result, on July 1,2010 the tax on physicians and all other individualhealthcare practitioners was eliminated.The WVSMA thanks the Legislature fortheir foresight in the passage of this phase-outand for their fortitude in continuing down thepath of repeal. We strongly recommend that nosimilar taxes be considered in the future.Addressing Substance Abuse: BalancingTreatment nd PreventionPOSITION: The WVSMA supports policies thatdiscourage diversion of prescription drugs and thatfacilitate treatment opportunities for individualssuffering from substance use disorders. Such policiesmust be balanced with policies that promote thephysician’s ability to provide comprehensive andcompassionate care, and an individual’s ability to accessappropriate treatment.ISSUE: Substance use disorders are a significantproblem in the United States and in West Virginia.Recent news reports have highlighted the growingproblem with prescription drug diversion, and thisis an epidemic affecting not only adults but also ourchildren and teens. Although the WVSMA recognizesthe importance of policies that prevent substanceabuse and prescription drug diversion through lawenforcement mechanisms, we also recognize thatphysicians have a responsibility to provide appropriatetreatment to patients, and policies should not interferewith their ability to practice good medicine. Policiesshould not focus on requiring physicians to bewatchdogs for potential drug abusers because thiscould deter patients from seeking help or treatment.With the recognition of the problems associated withprescription drug diversion, misuse and addiction in WestVirginia and the understanding that it is the physician’sresponsibility to help lead the effort to address thisepidemic, the WVSMA formed a select committee in thespring of 2011 and developed a comprehensive set of 24physician led recommendations to address prescriptiondrug diversion. The full document is posted at wvsma.com. Those recommendations have been offered to statepolicy makers as a platform for addressing this epidemic.Ensuring Healthcare Provider TransparencyPOSITION: The WVSMA supports legislation toensure transparency regarding the education trainingand licensure of healthcare providers.ISSUE: Patients are confused about the differencesamong various types of healthcare providers.Currently, patients mistake medical doctors withnon-physician providers, and they do not knowthat certain medical specialists are physicians. TheWVSMA believes that patients need increasedclarity and transparency in healthcare.Confusion among patients about who is andwho is not qualified to provide specific patient careundermines the reliability of the healthcare systemand can put patients at risk. To help ensure patientscan answer the simple question “Who is taking careof me?” the WVSMA believes that all healthcareprofessionals – physicians and non-physicians –should be required to accurately and clearly disclosetheir training and qualifications to patients.Regulating Expert Witness TestimonyPOSITION: The WVSMA supports legislationto ensure testimony provided by expert witnesses inmedical liability cases is fair, accurate and reflects theapplicable standard of care. To help ensure this, allexpert witnesses should either be licensed in state orhold a certificate granted by the West Virginia Board ofMedicine or Osteopathy.42 West Virginia Medical Journal

Legislative | News ContinuedISSUE: Expert witnesses are often called upon inmedical negligence cases to provide testimony as toa defendant-physician’s breach of the standard ofcare, and the WVSMA believes that all expert witnesstestimony should be fair and accurate. Out-of-statedoctors serving as expert witnesses are allowed toprovide such testimony, and thus, should be requiredto accurately reflect the applicable standard of care.West Virginia law does not require that an experthold a West Virginia license; thus, physicians who arelicensed in other states routinely provide expert testimonyin medical malpractice cases. Unfortunately, in manyinstances the testimony given does not accurately reflectthe prevailing professional standard of care. One wayto ensure quality testimony, while also implementingaccountability for such testimony, which is not reflectiveof the prevailing standard of care, is to require out-ofstateexperts to obtain a certificate prior to testifying.Regulating the Rental Network PPO MarketPOSITION: The WVSMA supports legislativeinitiatives to increase the transparency and fairness ofrental network PPO activity.ISSUE: In most states, physicians have little controlover how their managed care contracts are marketed,leaving them vulnerable to unauthorized discountsin payments for their services. The lack of regulatoryoversight in the Preferred Provider Organization (PPO)industry has resulted in the proliferation of entities thatare engaged in the lucrative business of developing healthcare provider panels and then leasing the panels andassociated discounts to various entities including but notlimited to third party administrators acting on behalf of aself-insured employer or managed care organization thatdoes not have a physician network in a particular market.These entities are often called “rental network PPOs”.The WVSMA supports legislation to advance theNCOIL Rental Network Contract Arrangements ModelAct, which aims to implement transparent practices.Regulation of the secondary rental network, includingrestricting the number of times a rental network discountcan be sold, is necessary to ensure that this unfairproliferation of physician contract violations ends.Addressing Healthcare Practitioner Scope ofPractice ExpansionsPOSITION: The WVSMA opposes the scope ofpractice expansion of non-physician practitionerswithout the appropriate education, training andsupervision.ISSUE: Every year, in nearly every state, nonphysicianpractitioners lobby for expansion of scope ofpractice to gain prescriptive and independent practicerights that were once the sole domain of physicians.The WVSMA recognizes the inevitability of scopeof practice overlap. While some scope expansionsare appropriate and beneficial to patients, many areunwarranted intrusions into the physician practiceof medicine. The health and safety of patients arethreatened when non-physician practitioners arepermitted to perform services that are not commensuratewith their education, training and experience.Determining whether a specific healthcare professionis capable of providing the proposed care in a safe andeffective manner is of paramount interest and shouldbe done in a deliberate manner not under politicalpressure. The WVSMA does support collaborativearrangements with nurse practitioners, physicianassistants, pharmacists and radiologist assistants.Through such collaboration, patient access and qualitycare can be achieved without threatening patient safety.Protecting Medical Liability Reform LawsPOSITION: The WVSMA strongly maintainsthe need to preserve the integrity of the MedicalProfessional Liability Act and to protect against anythreats to erode the current statute.ISSUE: Ten years ago West Virginia’s healthcaresystem was spiraling into a severe crisis. The lack ofaffordable and available medical liability insuranceforced many physicians to either restrict the servicesthey offer, move their medical practice out of state orquit practicing altogether. Faced with the reality thatWest Virginia’s healthcare system was on the vergeof collapse, the Legislature responded by passingtwo rounds of medical liability reform legislation.First in 2001, the Legislature passed HB 601, whichincluded numerous measures to help put the medicalliability insurance market back on track. In 2003 theLegislature once again addressed the crisis with thepassage of HB 2122, and was the first comprehensivemedical liability reform that had passed in WestVirginia in over 20 years and placed West Virginia atthe forefront of most states in regard to such reformlaws. The new law included a $250,000 non-economicdamages cap, a $500,000 trauma cap, collateral sourceoffset, elimination of joint liability, creation of a patientinjury compensation fund, and more stringent medicalMarch/April 2012 | Vol. 108 43

Legislative | NEWSexpert witness requirements. Additionally, and criticallyimportant, the legislation provided the revenue andmechanism for the creation of a physicians’ mutualinsurance company, a West Virginia based insurerwhich is owned and operated by its policyholders.With this said, long term stabilization of the medicalliability insurance market has been hinged upon whetherthe West Virginia Supreme Court of Appeals woulduphold the caps on damages as constitutional. In Juneof 2011 the Court ruled, in a 4 to 1 decision, to do justthat in the MacDonald v. City Hospital case. This rulingwill go far, securing further stabilization of the market.Authorizing Assignment of BenefitsPOSITION: The WVSMA supports legislativeinitiatives to require all health insurers and thirdparty payers to honor an individual’s request to sendpayments directly to their provider, even if the provideris not in the insured’s network.ISSUE: Assignment of benefits is a complex issueinvolving the relationship of a patient with his or herhealthcare provider and insurance company. Whenservices are provided in-network, the provider alreadyhas the right to submit claims directly to the health planpursuant to terms of the provider contract. The problemis that some insurers will not accept an assignmentof benefits from non-contracted or out-of-networkproviders. This places an unnecessary burden on thepatient, and also creates an administrative hassle forproviders. It is simpler for all involved to take the patientout of the middle and have the insurance companyand the provider resolve the payment of the bill.Many states have laws that help avoid this problemand clarify how this must work in circumstancesinvolving out-of-network providers. Those lawsrequire the insurance companies to honor thepatient’s assignment of benefits and pay the out-ofnetworkprovider directly. The WVSMA joins withthe WV Hospital Association in recommending thatsimilar legislation be passed in West Virginia.Supporting State Healthcare Reform InitiativesPOSITION: The WVSMA supports efforts to achievehealthcare reform in West Virginia.ISSUE: West Virginia, like the rest of the nation,is faced with the serious threat of rising costsin health insurance, decreasing availability ofinsurance and concerns with chronically ill patientsand a progressively unhealthy population. As thefederal government is currently engaged in theimplementation of health system reform and thestates are looked upon to execute the details, theWVSMA believes the following principles shouldbe integral to all initiatives that are considered:Physician-Patient Relationship – Reforminitiatives must preserve the inviolabilityof the physician-patient relationship.Leadership – Physicians must be at the center andprovide the leadership in planning and implementationof innovations in the healthcare delivery system.Scope of Practice – Care delivery models that involveexpansion of the scope of practice for non-physicianmust not expand any scope of practice beyond eachpractitioner’s respective professional category.Funding – Reform initiatives and pilots must beaccompanied by adequate funding so that physiciansare not required to absorb the additional overhead.Evidence – New healthcare delivery models and otherreforms to the system must be continually evaluatedfor their impact on patient outcomes based uponscholarly analysis and evolving medical evidence.Additionally, the following core componentsof reform must be considered:Patient-Centered Medical HomeIn order to appropriately address the chronichealthcare needs of our patients a move towardthe patient-centered medical home is necessary.The fundamental principle that a medical home is“physician” led cannot be underscored enough.Wellness and PreventionAs West Virginia leads the nation in unhealthybehaviors (tobacco use, drug use) and lifestyles(obesity) it is critical that a core component ofany healthcare reform address these issues.Health Information TechnologyEncouraging the use and supporting theexpansion of electronic medical records andother health information technologies is critical toreforming West Virginia’s healthcare system.Medicaid ExpansionWVSMA strongly supports fully funding the WestVirginia Medicaid program to provide appropriatereimbursement to healthcare providers for theirservices. Many physicians must refuse to accept44 West Virginia Medical Journal

Legislative | News ContinuedMedicaid patients or limit the number they treatbecause of the program’s inadequate reimbursements.To help ensure continued access to medical careand to reduce cost-shifting to the private sector, theWVSMA supports responsible initiatives that helpsecure funding to sustain the Medicaid budget.Research and EducationCritical to success is a process that helps toanswer the question of whether the reforms arewhat the public needs or better yet are tailored ina fashion that will lead to successful outcomes.Improving West Virginia’s Perinatal HealthPOSITION: The WVSMA supports initiatives toimprove the health of pregnant women and children inWest Virginia.ISSUE: The health of West Virginia’s babies has atremendous impact on the state’s economy, workforcedevelopment and family well-being. Because of thedeclining status of the health of WV mothers and babiesthe Perinatal Partnership was formed to address theseneeds and the WVSMA has been an active member intheir work. The Partnership and its partner physicians,hospitals, nurses, and certified nurse midwives havebegun quality initiatives to improve the State’s poor ratesfor pre-term birth, primary C-sections, vaginal births aftercesarean section (VBAC), and low birth weight infants.The WVSMA, along with the WV Perinatal Partnership,supports and recommends the following policies tofurther the efforts on improving perinatal wellness. Byworking together, we can make sure that the 21,000 babiesborn each year in West Virginia and their mothers havethe best healthcare possible to assure a healthy beginning:Insurance coverage for dependents for contraceptionand for pregnancyThe WVSMA along with the WV PerinatalPartnership supports legislation to require allhealth insurers cover the cost of maternity careand contraceptive care for covered dependants.Prevention and treatment interventions for pregnantwomen who have substance abuse problems should bepriority.Pregnant women who are found to use drugs and/or alcohol should be directed to early and regularprenatal care that incorporates as part of the practice,substance use detection, diagnosis and referral fortreatment with the goal of delivering a drug free infant.To ensure that women have trusted and confidentialcare available to them, it is essential that the care isobtained without fear of retribution of any kindExpand state education to adequately prepare our youngWest Virginians for parenthoodWest Virginia women under twenty years of age haveworse outcomes for their babies than any other age groupof pregnant women, except for women over 40 years.Advance parenthood preparation of our young studentscould help the State significantly reduce low birth weightand preterm birth among women under twenty years ofage, reduce school drop out rates, decrease the State’shigh rate of infant mortality, among other issues.Strengthening Tobacco Control and CleanIndoor Air InitiativesPOSITION: The WVSMA supports policies thatprotect public health by discouraging tobacco useand promoting clean indoor air. Such policies includesignificantly increasing the tobacco excise tax, allocatingsufficient funding for education programs designedto reduce or eliminate tobacco use and exposure tosecondhand smoke, and supporting counties’ indoor airregulations.ISSUE: The WVSMA seeks to reduce or eliminatetobacco use and exposure to secondhand smoke byWest Virginia citizens, especially children and pregnantwomen. Among the states, West Virginia ranks worstin the nation for smoking rates of adults and youth.We rank first in smoking during pregnancy and secondoverall in women smokers. Further, West Virginia hasthe highest rate of smokeless tobacco use in the nationwith one in three high school students currently usetobacco and one in five males use smokeless tobacco.The deleterious effects of tobacco use affect not onlysmokers but also the public at large. Scientific studiesclearly show that secondhand cigarette smoke is ahazardous, cancer-causing air pollutant. Exposure tosecondhand smoke causes increased risk for disease anddeath in healthy nonsmokers and is the third leadingcause of preventable death among nonsmokers. Theprevalence of tobacco use in West Virginia translates toan enormous economic toll as the state annually spends$1 billion on direct healthcare costs of smoking, andanother $1 billion on occupational costs due to smoking.The WVSMA joins the coalition of a TobaccoFree WV in recommending a three tieredapproach toward addressing tobacco use:March/April 2012 | Vol. 108 45

Legislative | NEWS• Increase the Tobacco Excise Tax• Provide Adequate State Funding forCessation Education Programs• Protect County Clean Indoor Air PoliciesCombating Poor Oral HealthPOSITION: The WVSMA supports efforts to makepolicy changes which foster improved oral health forWest Virginia’s children and families.ISSUE: Regrettably, West Virginia leads the nation inthe percentage of our citizens with tooth loss and decay.By the time of high school graduation, over 80 percentof West Virginia youth have had dental decay; over 60percent have had dental decay by age 8 and over 30percent of West Virginia children suffer from untreateddecay. Strikingly, over 45 percent of West Virginia adults,aged 65 and older, have lost all their natural teeth.Dental disease is the single most prevalent chronicchildhood disease and correlates directly to otherhealth concerns. With today’s tools and technologies,oral disease is almost 100% preventable and is costeffective with the potential to save millions of dollars.Poor oral health can contribute to a lifetime of overallpoor health including diabetes and heart disease.The WVSMA supports the followingrecommendations to address poor oral health:• Encourage school aged children to havedental exams at appropriate intervals.• Prohibit sale of sugary snacksand beverages in schools.• Address the use of smokeless tobaccoamong our youth through increasingthe tobacco tax and increasing countermarketing and cessation programs.Strengthening and Preserving our Safety lawsPOSITION: The WVSMA strongly supportsstrengthening West Virginia’s All-Terrain Vehiclesafety law and maintaining the motorcycle helmet lawfor operators and riders of all ages.ISSUE: Though the Legislature passed All-TerrainVehicle (ATV) Child Safety law in 2004, much moreneeds to be done to protect the health and safety ofour citizens. While the West Virginia State Legislaturehas made great strides toward ATV safety, muchmore is still needed to improve such safety laws.• Removing non road-worthy vehiclesfrom our public roadways.• Expanding the mandatory helmetlaw to cover all persons of age.• Strengthening the requirement for ATV safetyinstruction to require hands-on safety courses• Prohibiting passengers with theexception of machines that manufacturershave designed for passengers.Another important safety issue is that of preservingthe motorcycle helmet law. In recent years, efforts havebeen made by various groups to repeal our criticallyimportant motorcycle helmet law. Such an action by theLegislature would be highly irresponsible. Helmets arethe best evaluated way to reduce motorcycle accidentdeaths and injuries. The WVSMA strongly supports theretention of our State’s current mandated helmet uselaw for all motorcycle operators and riders of all ages.Pictured from left to right: EvanH. Jenkins, Senator, CabellCounty and Executive Director,WVSMA, MaryAnn N. Cater,DO and 2011-2012 WVSMAPresident, Ron Stollings, MD,Senator, Boone County, andDaniel Foster, MD, Senator,Kanawha County.46 West Virginia Medical Journal

Legislative | News Continued2012Certified Medical OfficeManager Class (CMOM)Thursday, April 26 & Friday, April 27 and Thursday, May 3 & Friday, May 4, 2012Time: 9:00 a.m. to 4:00 p.m. | Place: St. Marys Medical Center, Huntington, WV (Participants must attend all 4 days.)Participant InformationRegistrant:________________________________________________________ E-mail:__________________________________Practice Name:______________________________________________________________________________________________Street Address:______________________________________________________________________________________________City:___________________________________________________________ State:________________ Zip:_____________________Phone:______________________________________________ Fax:____________________________________________________Program Fee/Discount Policies:Registration Fee: $999 WVSMA members & PMI Certified Professionals: $899 (Includes instructional materials and exam fee.)Payment Method:q American Express q MasterCard q Visa q Discover q Check EnclosedPayable to:West Virginia State Medical AssociationCard No:_ ____________________________________________ Expiration Date: ____________V Code:_______________________(Three digit number on the back of your credit card.)Name As It Appears On Card:_____________________________________ Email address:_________________________________Confirmation will be sent by email.Signature:__________________________________________________________________________________________________Registration Methods:Mail registration form to: Karie Sharp • West Virginia State Medical Association • PO Box 4106, Charleston, WV 25364Fax registration form to: Karie Sharp • (304) 925-0345 Charge by phone: Karie Sharp • (304) 925-0342, ext. 12E-mail: karie@wvsma.comPresented through an exclusive partnership between:March/April 2012 | Vol. 108 47

WV Medical Insurance Agency | NewsValued Assistance in 2011:Accepting New Clients in 2012Now serving physician clients in 40 West Virginia CountiesThe West Virginia MedicalInsurance Agency provided“valued assistance” in 2011 foreach of its physician clients;note the following examples.CARE/RM Credits: In 2011,WVMIA clients renewingwith the West Virginia MutualInsurance Company averaged9.4% (out of a possible 10%) inCARE/RM premium credits,with 93.7% receiving 8% ormore in premium credits.While the Mutual notifies theirinsureds of scheduled programs,the Agency maintains records andfollow ups with its clients aboutneeded credits and the time/date/location of seminars in their area.In addition, the Agency hada representative present at 20Mutual CARE/CME Loss Controlprograms conducted by theMutual throughout the state.BOP and WC Savings:First-year clients of the Agencyachieved premium savingsof 18.5% on businessownerspolicies and 12.7% on workers'compensation policies.Premium Financing: In 2011,the Agency assisted 54 accountsobtain premium financing totaling$1,350,443 at interest rates between2.19% and 4.9%, plus no servicefee was added by the Agency.Exhibiting: In 2011, the Agencyexhibited at four different specialtysociety meetings, (Pediatrics,Orthopaedics, Family Practiceand Otolaryngology), and fourdifferent physician or physicianpractice organization meetings(MGMA, OMA, PhilippineMedical Association, IPA ofthe Upper Ohio Valley).Medical Component SocietyMeetings: In 2011, Agencyrepresentatives attended six differentmedical component society meetings(some more than once) makingpresentations about the valuedassistance provided by the Agency.For more information on howyou can become a client of the WestVirginia Medical Insurance Agency,a wholly-owned subsidiary of theWVSMA, please call Steve Brown,Agency Manager, at 1-800-257-4747 ext. 22 or 304-925-0342 ext22, or email: steve@wvsma.com.401 Retirement Plan(15% Discount for WVSMAMembers): Introduced a newrelationship with The Hartfordto provide WVSMA memberswith a 15% administrative costreduction for acquiring 401Kretirement plan benefits throughThe Hartford and the Agency.15%discount forWVSMA MembersYour Practice.Your Future.Your Agency.1.800.257.4747, ext. 22 » 304.542.0257See our ads on page 60 and the inside back cover.Disability Insurance(15% premium reductionfor WVSMA members):Introduced a new relationshipwith Union Central LifeInsurance Company toprovide WVSMA memberswith a 15% premium discountfor purchasing disabilityinsurance through UnionCentral and the Agency.48 West Virginia Medical Journal

| WESPAC Contributors2012 WESPAC ContributorsThe WVSMA would like to thank the following physicians, residents, medical students and Alliancemembers for their contributions to WESPAC. These contributions were received as of February 15, 2012:Chairman’s Club ($1000)Hoyt J. Burdick, MDM. Barry Louden Jr., MDExtra Miler ($500)James P. Clark II, MDGeneroso D. Duremdes, MDAhmed D. Faheem, MDMichael A. Kelly, MDMichael A. Stewart, MDDollar-A-Day ($365)Edward F. Arnett, MDGina R. Busch, MDSamuel R. Davis, MDDavid Elwood Hess, MDJohn D. Holloway, MDTheodore A. Jackson, MDSushil K. Mehrotra, MDBradley J. Richardson, MDL. Blair Thrush, MDCampaigner Plus (> $100)Richard C. Rashid, MDCampaigner ($100)John A. Adeniyi, MDDerek H. Andreini, MDMichael M. Boustany, MDAdam J. Breinig, DOJames M. Carrier, MDPatsy P. Cipoletti, MDJames D. Felsen, MDRichard M. Fulks, MDPhillip Bradley Hall, MDJoby Joseph, MDMuthusami Kuppusami, MDNancy N. Lohuis, MDTony Majestro, MDStephen K. Milroy, MDKamalesh Patel, MDFrank A. Scattaregia, MDWayne Spiggle, MDMichael L. Stitely, MDSasidharan Taravath, MDOphas Vongxaiburana, MDSherri A. Young, DOResident/Student ($20)Richard W. Eller, MDWESPAC is the West Virginia State Medical Association’sbipartisan political action committee. We work throughoutthe year with elected officials to make sure theyunderstand the many facets of our healthcare system.WESPAC’s goal is to organize the physician communityinto a powerful voice for quality healthcare in theWest Virginia Legislature. We seek to preserve the vitalrelation ship between you and your patients by educatingour legislators about issues important to our physicians.WESPAC contributions provide critical support for ourendorsed candidates. Your contribution can make thedi fer ence between a pro‐physician/patient candidatewinning or losing.To make a contribution to WESPAC, please call(304) 925-0342, ext. 12| New MembersCabell County Medical SocietyJimmy Adams, DOGreenbrier Valley Medical SocietyMark Byrd, MDConstance Anderson, DOKanawha County Medical SocietyPrathima Bodala, MDAditi Girme, MDOhio County Medical SocietyLori Archbold, MDRonald Hargraves, MDParkersburg Academy of MedicineLisa Casalenuovo, DODavid Stastny, DOTygart Valley Medical SocietyPeter Wentzel, MDPlease direct allmembership inquiries to:Mona Thevenin, WVSMAMembership Director at304.925.0342, ext. 16 ormona@wvsma.com.March/April 2012 | Vol. 108 49

West Virginia University Healthcare and Health Sciences | NEWSWVU Hospitals to add 10-story towerFour-year, $280-million expansion project to create 750 jobsGovernor Earl Ray Tomblin, Bruce McClymonds and President James P. Clements, stand before the architect’srendering of the new tower.WVU Hospitals has announcedplans to construct a 10-story towerto address capacity issues and betterserve the healthcare needs of allWest Virginians. The expansionmarks its largest construction projectsince the construction of RubyMemorial Hospital in the late-1980s. As a result of the expansion,WVU Hospitals expects to add 750permanent jobs and 139 new beds.“Our goal is to provide access to allof the great resources we have hereat WVU Hospitals’ Ruby Memorialand WVU Children’s Hospital foranyone who needs them,” BruceMcClymonds, president and CEO ofWVU Hospitals, said. “In doing so,we will remain true to our missionof caring for people from everycorner of the state and beyond.”The $280-million tower willtake four years to complete. It willexpand WVU Children’s Hospital’sNeonatal Intensive Care Unit, theEmergency Department and theJon Michael Moore Trauma Center.The tower will also expand thehospital’s other intensive care units.The expansion will also resultin expanded food service andconference spaces and additionalelevators, parking and campusroadways. Currently, all but30 hospital rooms are private.When the project is complete, allpatient rooms will be private.“As the population of the statecontinues to age, the demand forour services is going to continue togrow,” McClymonds said. “And,with more than 500 transferredto us each month from hospitalsthroughout the state, we canensure West Virginians won’thave to leave the state to receivethe highest quality healthcare.”West Virginia Gov. Earl RayTomblin, who attended a pressconference in January announcing theproject along with WVU PresidentJames P. Clements, Ph.D., called theexpansion “a giant step forward inpatient care.” He added that the jobsit will create are another sign that thestate’s economy is strong. “These 750good jobs, with benefits, show thatWest Virginia is moving forward.”The expansion will be subject toCertificate of Need approval by theWest Virginia Health Care Authority.Construction costs are estimated tobe $248 million with the remaining$32 million for financing and otherrelated costs. The project will befinanced by WVU Hospitals, Inc., amember of the West Virginia UnitedHealth System. No state funds willbe sought and no extraordinaryrate increase is anticipated asa result of the construction.50 West Virginia Medical Journal

West Virginia University Healthcare and Health Sciences | NEWSWVU student presents cancer research at the CapitolJulie Diamond, a senior biologymajor at West Virginia University,presented her cancer research duringUndergraduate Research Day at theCapitol on Jan. 26 in Charleston.The annual event provides studentsin various disciplines at privateand public institutions throughoutthe state an opportunity to sharetheir research with members ofthe West Virginia Legislature andexecutive branch who providefunding for higher education.Working under Laura Gibson,Ph.D., at the Mary Babb RandolphCancer Center as part of her HonorsCollege Program, Diamond’sresearch focuses on a signalingmolecule found in leukemic cellsand believed to contribute to tumorgrowth. She also studies the effectsof chemotherapy on the molecule.“So far, we’ve discovered that thismolecule seems to be controlled by aspecific mechanism that contributesto its production,” Diamond said.“Research like this can potentiallyhelp millions of people sufferingfrom leukemia. I’m excited aboutexplaining the work we do in ourlab to lawmakers and helpingthem understand the importanceof funding biomedical science.”After she graduates from WVUin May, Diamond plans to pursuegraduate school and earn a Ph.D.in biomedical science. Ultimately,she wants to have her own laband do research on finding curesfor cancer and other diseases.Diamond is also a recipient ofthe WVU PROMISE Scholarship,Presidential Scholarship andthe Presidential Award forExcellence and Scholarship.Julie DiamondElectroconvulsive TherapyECT can be beneficial in the followingsituations:• A person’s depression is resistant to antidepressant therapy.• Patients with other medical problems that prevent the use ofantidepressant medication.• Persons who have had a previous response to ECT.• Patients with other clinically diagnosed psychiatric disordersthat have been shown to benefit from ECT.ECT at Beckley ARH Hospital is administered and monitored bytrained staff in an area adjacent to the Operating Room on the 2nd floor.ECT treatment is available on both an inpatient and outpatient basis,and ECT is the treatment of choice for pregnant patients with severe depression.For more information,contact Jeff Lilly at 304-255-3557.Beckley ARH Hospital306 Stanaford Rd | Beckley,WV 25801 | 304-255-3000Beckleywww.arh.orgMarch/April 2012 | Vol. 108 51

West Virginia School of Osteopathic Medicine | NEWSOMM clinic teaches students, provides serviceto communityThe student OsteopathicManipulative Medicine (OMM) clinicoffered by the West Virginia Schoolof Osteopathic Medicine (WVSOM)is a way for second-year studentsto gain hands-on experience withpatients as well as provide treatmenttechniques to community members.The clinic, which began January17 and lasts until April, is oftenthe students’ first chance to useosteopathic principles on patients.“The Student OMM Clinicprovides the students theopportunity to evaluate patientsosteopathically and treat them withthe techniques they have been taughtin Osteopathic Principles & Practiceclasses and labs,” said Dr. DeborahSchmidt, the faculty memberresponsible for organizing the clinic.She said second-year studentsare able to practice what they havelearned in Clinical Skills coursesincluding gathering patient history,performing musculoskeletal physicalexams, organizing a treatment planand treating human patients.The students will be closelysupervised by about 12 physicians— represented by six fulltimefaculty physicians fromthe OMM department and sixlocal osteopathic physicians.“The students will not haveanother opportunity to be so closelysupervised and taught whileperforming OMM,” Schmidt said.This year organizers hopestudents can see more patientsthan they have in prior years.“Because we’re seeing patientsin two separate five-week blocks,we plan to see double the patientswe’ve seen in the past,” saidJeanea Phillips, former OPP coursesecretary. “We’re looking to haveabout 180 to 200 patients seenthroughout the whole 10 weeks.”Schmidt said that the OPP facultyat WVSOM feels that the studentclinic is an invaluable experiencefor the osteopathic students.“WVSOM is recognizedamong osteopathic schoolsfor this Student OMM Clinic.In some other osteopathicschools students never have theexperience of directly treatinga real patient with osteopathictechniques while under the closesupervision of an experiencedosteopathic physician,” she said.But second-year students are notthe only ones who benefit from theclinic. First-year students are requiredto participate in an observational role.“In the last four weeks, thefirst-year students are expected toobserve in the clinic as the secondyearstudents conduct their patientencounters,” Phillips said. “Thefirst-year students will have nohands-on contact with the patients,but it gives them a good idea ofwhat to expect the following year.”Community members interestedin participating in the free clinic willneed a written referral from theirphysician, physician’s assistant ornurse practitioner. Schmidt saidstudents need the opportunity tosee patients with a variety in age,conditions and temperaments.Patients that cannot participate inthe clinic include those with activeworkers’ compensation claims orlitigation cases, or those who requiredocumentation for legal cases.The clinic will be open everyTuesday afternoon through April 3.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 VirginiaMedical Professionals Health Program. Information about a practitioner’s participation in the program is confidential. Prac titionersentering the program as self-referrals without a complaint filed against them are not reported to their licensing board.ALL CALLS ARE CONFIDENTIALWest Virginia Medical Professionals Health ProgramPO Box 40027, Charleston, WV 25364(304) 414-0400 | www.wvmphp.org52 West Virginia Medical Journal

Marshall University Joan C. Edwards School of Medicine | NEWSMaternal Addiction and Recovery Clinic receives $50K grantJoining Dr. David Jude for the check presentation areDr. David Chaffin, John Muraca with Coventry HealthCare and Dr. Ryan Stone.The Department of Obstetrics &Gynecology at Marshall University’sSchool of Medicine recently receiveda $50,000 grant from Carelink HealthPlans, Inc. (dba Coventry HealthPlans in West Virginia) to assist instart-up costs for a new MaternalAddiction and Recovery Clinic. Themoney will be used for the start-upcosts of the clinic including additionalnursing support and support staffand a full-time addiction counselor.The clinic, located in the MarshallUniversity Medical Center on thecampus of Cabell HuntingtonHospital, will provide a newtreatment option for expectantmothers with abuse issuesincluding counseling sessionsthroughout their pregnancy.Coventry Health Care officialssay they decided to assist withthe clinic costs after learningof the escalating issue."Substance abuse in pregnantwomen is a leading preventablecause of mental, physical andpsychological problems in infantsand children and it is a tragedyfor the entire family,” said JohnMuraca, President of CoventryHealth Care and Carelink HealthPlans, Inc. “We are proud to presentthis grant to help the physiciansat Marshall with this work.”“Maternal opiate addictionis the most common high-riskproblem that we encounter in ourobstetrical patients,” said DavidJude, M.D., professor and chair ofthe Department of Obstetrics andGynecology. “We see more pregnantpatients with opiate addictionthan those with hypertension ordiabetes. In this setting, pregnantwomen with opiate addiction willreceive comprehensive care for boththeir pregnancy and their opiateaddiction including counseling,and if indicated, pharmacologictherapy. We are extremely grateful toCoventry Health Care for the grant.”Jude added that resident andstudent physicians at the School ofMedicine will receive education inthe evaluation and managementof women with dependencies.Perinatologists David Chaffin,M.D. and Ryan Stone, M.D., areserving as the primary providersof prenatal care for expectantmothers who will use the clinic.Student receives grant to study diabetic retinopathyA MarshallUniversitybiologystudent hasbeen awardeda grant toconductresearchon diabeticClay Crabtree retinopathy,a commoneye disease during whichexcessive growth of blood vesselscauses damage to the retina.Clay M. Crabtree, a senior fromKenova, will receive the $1,800Grants-in-Aid of Research awardfrom the national science societySigma Xi. The award will helpfund his project to test potentialtreatments for the disease, whichis the leading cause of blindnessamong working-age Americans.According to Crabtree, cigarettesmoking is a risk factor for diabeticretinopathy because nicotinepromotes the growth of blood vessels.“Agents that can block the actionsof nicotine should be useful for thetreatment of diabetic retinopathy,”he continued. “My research involvestesting three of these compoundsfor their ability to block the growthof new vessels in the retina.”Crabtree’s mentor, Dr. PiyaliDasgupta of Marshall’s Departmentof Pharmacology, Physiology andToxicology, said the grant will giveCrabtree the opportunity to furtherhis education through hands-onexperience conducting researchthat could have a real impact on thehealth of people across the region.“The findings from Clay’s projectwill be highly relevant to WestVirginia because our state has alarge number of diabetic patientswho are active smokers,” sheadded. “It is a very commendableachievement to receive one ofthese grants and I look forwardto seeing his project progress.”Students use the funding to payfor travel expenses to and from aresearch site, or for purchase oflaboratory equipment necessary tocomplete their research project.According to Sigma Xi, theGrants-in-Aid of Researchprogram is highly competitive.January/February 2012 | Vol. 108 53

West Virginia Bureau for Public Health | NEWSInfluenza Vaccination Among West VirginiaPregnant and Postpartum Women 2009-2010Studies have shown thatpregnancy increases the risk ofseasonal influenza complications inthe mother. Moreover, infants bornto vaccinated women have reducedrates of laboratory-confirmedinfluenza during the first 6 monthsof life. 1 Vaccination of pregnantwomen is key to protecting babiesfrom complications of influenza. Itshould be noted that the nasal-sprayinfluenza vaccine is not an optionfor women who are pregnant.West Virginia conducts researchpertaining to maternal and childhealth through the Pregnancy RiskAssessment Monitoring System(PRAMS). PRAMS is a joint researchproject between the West VirginiaDepartment of Health and HumanResources Office of Maternal, Childand Family Health and the Centersfor Disease Control and Prevention(CDC). The project, implemented in1988, is as an on-going, populationbasedsurveillance system designedto identify maternal attitudes andexperiences before, during andafter pregnancy. All West Virginiawomen who have recently had alive birth have a one in fourteenchance of being chosen to participate2-4 months after their baby’s birth.Each month, approximately 200women are randomly selectedfrom the West Virginia BirthCertificate Registry and asked toparticipate in the PRAMS survey.In 2009, WV PRAMS begancollecting information on influenzavaccination among pregnant andpostpartum women. The datapresented covers births from August2009 thru August 2010; a total of19,250 eligible births with 2,506women sampled and a response from1,659 women. Data are weightedto reflect the entire population ofwomen delivering a live infantin WV during this time period.Surveyed women were askedif they received an influenzavaccination during this timeperiod. Results show that 47percent of women did not receivea vaccination, while 12 percentreceived an H1N1 vaccination, 17percent received a seasonal influenzavaccination and 24 percent ofwomen received both the H1N1 andseasonal influenza vaccination.WV PRAMS data demonstratethat healthcare providers play acritical role in the acceptance ofinfluenza vaccine. Pregnant andpostpartum women who wereeither recommended or offeredinfluenza vaccine by their healthcareproviders were 5 times more likelyto be vaccinated than womenwho were not recommendedor offered the vaccine.West Virginia’s PRAMS askedsurveyed women who did notreceive the influenza vaccinationreasons for not doing so. Mostwomen reported that they normallydo not get a flu shot. Over a thirdof women reported concerns aboutside effects for their infants orthemselves. Women had the optionto select more than one reason.Recommended Actions forPrenatal Care Providers*There are many things that canbe done to protect pregnant andpostpartum women and infants fromthis vaccine-preventable disease.• Educate staff and pregnantwomen about the importance ofinfluenza vaccination during pregnancyand its safety; provide a strongrecommendation for vaccination• Issue standing orders forinfluenza vaccination of pregnantand postpartum women• Establish an influenzavaccination reminder system• Post influenza preventionannouncements and provide brochuresto prompt vaccination requests• Offer vaccination to pregnantwomen at the earliest opportunity andthroughout flu season (October–April)• Vaccinate all healthcare personnelin practices to prevent healthcarepersonnel from influenza and fromspreading influenza to patients• Vaccinate postpartum women whowere not vaccinated during pregnancy,preferably before hospital dischargeor at 6 week postpartum visit• Know where to referpatients if influenza vaccine isnot available at the practice• Educate staff and postpartumwomen that breastfeeding is not acontraindication to vaccination• Advise family members andother close contacts of pregnantand postpartum women andinfants that they should also bevaccinated against influenzaFor more information aboutvaccination, including othervaccines for pregnant and/or postpartum women, visit:www.wvdhhr.org/mcfhor www.dhhr.wv.gov/oeps/immunization/Pages/flu.aspx*WV PRAMS October 2011 Issue Brief1CDC. ‘Prevention and control of influenza withvaccines; recommendations of the AdvisoryCommittee on Immunization Practices (ACIP),2010.’ MMWR 2010; 59 (No. RR-8): 1-61.Melissa Baker, M.A.MCH Epidemiologist, Office ofMaternal, Child and Family Health,Bureau for Public HealthJulie Freshwater, PhDFlu Surveillance Coordinator,Office of Epidemiology and PreventionServices, Bureau for Public HealthDee Bixler, M.D., M.P.H.Division of Infectious Disease Director,Office of Epidemiology and PreventionServices, Bureau for Public Health54 West Virginia Medical Journal

AMA | NEWS2011 Fall AMA Meeting - Resolutions Committee ReportThe Riverside Hilton Hotel, New Orleans, Louisiana, November 12-15, 2011The organization of StateMedical Association Presidentsand their Executives met the daybefore the opening of the AMAHouse of Delegates (HOD).Foremost topics of thisyear's agenda were:• Patients' Bill of Rights, thatincludes private contracts,patient empowerment, andpatient choice of physician.• Final fix of the brokenMedicare Payment (SGR)• ACO's• Tort ReformEight-hundred students fromall over the country attended. Thestudent meeting was held Nov.1-12. A range of speakers and topicsincluded disaster preparedness,leadership development, and healthsystem reform. Some of the WVstudents delegation remained totake advantage of the HOD session.One of our Marshall Universitystudent delegates was elected torepresent the Southeast Regions.Dr. Austin Wallace, Presidentand CEO of the West VirginiaMedical Mutual Insurancehosted a dinner reception.The Organized Medical StaffSection (OMSS), with Dr. HoytBurdick, of our delegation reportedthe salient activities of this section.We led the opposition in theHOD to oppose revision of theMedicare Hospital Condition ofParticipation that would limit theautonomy of organized medical staff.Additional topics andspeakers included:• Healthcare Reform Initiative• relationship with accountablecare organizations, and• the future of medicalstaff organization.The House of Delegateshighlighted in their deliberationsthe following key topics:Prescription Drug Abuse-Drug overdose is the mostcommon accidental death in theUSA, with the majority of deathsfrom prescription drugs.National Drug Shortage-the HODvoted to support current legislationin Congress that would requiremanufacturers to notify the FDA ofany discontinuance, interruption oradjustment in the manufacture of adrug that may result in a shortage.Delegates called the drug shortage "anational public health emergency.Private Contracting Bill-The AMAreaffirmed support for the MedicarePatient Empowerment Act thatwould entail restructuring of privatecontracts with medicare patients.Code Conversion- ICD Code 9to ICD code 10 was voted againstby the HOD. It was determinedthat a small group practice of justthree physicians would cost atleast $23,290. For a larger groupof ten physicians, the cost couldreach as much as $285,195.00.The HOD also sought repeal ofthe Medicare Independent PaymentBoard and the provision of expandingnon-physicians' scope of practice.Dr. Peter Carmel in hispresidential address highlightedthe need for Congress to fixthe broken Medicare PaymentFormula (SGR) now and forever.A highlight of this year'smeeting was in a speech givenby Dr. Madara, the new VP andCEO of the AMA in which heemphasized the core value of ourprofession—the sacred relationshipbetween physician and patient.Constantino Y. Amores, MD, FACSChairman, WVSMA delegation to the AMAJoinWESPAC Now!West Virginia Medical PoliticalAction CommitteeVisit www.wvsma.com orCall 304.925.0342, ext. 25March/April 2012 | Vol. 108 55

ObituariesThe WVSMA remembersour esteemed colleagues…Mildred Mitchell-Bateman,MD, PhDMental health pioneer and localicon Dr. Mildred Mitchell-Batemanpassed away January 25, 2012, froma short-term illness. She was 89.Mitchell-Bateman held manypositions during her career, includingvice president of the AmericanPsychiatric Association and directorof the psychiatry department at theMarshall University School of Medicine.In addition to her parents, PastorQuilliford Mitchell and Ella Mitchell, shewas preceded in death by her brother,Dr. Samuel Q. Mitchell; sister, DorothyDixon and husband, William Bateman.Dr. Mildred Mitchell-Batemanis survived by two daughters,Donna Taylor and DanielleShanklin; seven grandchildrenand ten great-grandchildren andseveral nieces and nephews.Thomas W. Crosby, MDDr. Thomas William Crosby ofMorgantown passed away Saturday,November 26 at the age of 70. He wasborn in St. Louis, Missouri, January 1941,the child of William Curtis and FrancisDoorley Crosby.He attended Saint Louis University ona swimming scholarship and later theUniversity of Pennsylvania, beforegraduating from West Virginia Universityin 1965. While at WVU, he met KerrWithrow and the two married in 1964. Hegraduated fro WVU School of Medicine in1970, the first doctor to complete aresidency in Neurology. Following thisresidency, he became an Alexander vonHumboldt Foundation fellow studyingNeuropathology at the University ofGöttingen, Germany. In 1975, he returnedto WVU School of Medicine in theDepartment of Neurology, attaining theposition of Associate Professor beforejoining Morgantown Internal MedicineGroup in 1981. He retired in 2009 becauseof his health.Tom is survived by Kerr, his wife of 47years, their children Katherine and EricChaffin of Rye, NY and Ethan andKathryn Crosby of Crofton, MD; twograndchildren, his brother Roger Crosbyof NY, his brother-in-law Edward Lindnerand nieces.He was preceded in death by his fatherand mother, William C. and Frances D.Crosby, his brother Michael Crosby andsister Ann Lindner.Raymond Lim, MDDr. Raymond Lim, a deeply respected,generous and beloved husband, fatherand grandfather, passed away January 17,2012, following a short illness.Raymond was born June 17, 1937, inManila, Philippines. He graduatedmedical school in 1961 at the University ofSanto Thomas in Manila. He married thelove of his life in 1962, and then moved tothe United States. He performed hisinternship in internal medicine, beginningat Albany Hospital in New York. He andhis family later moved to Chicago in 1972,where Raymond worked at Cook CountyHospital. He and his family eventuallysettled in Charleston, WV, where heinitially established a private practice. Forthe last 15 years he served as the chiefmedical consultant for the DisabilityDetermination Section.Raymond is survived by his wife,Ofelia.William Richard McCune, MDDr. McCune graduated from WestVirginia University in Morgantownand, in 1946, graduated from theMedical College of Virginia. Heserved in the United States NavyFollowing his Navy service, Dr.McCune practiced in Hedgesville,then later in Martinsburg. Hereturned to medical school atthe University of Maryland inBaltimore in 1960, and graduatedas a specialist in urology in 1964.In 1992 Dr. McCune joined theMartinsburg Veterans Administration toattend to patients with urologic problems.In addition to his parents, hewas preceded in death by onebrother, Ralph McCune.He is survived by one daughter,Elizabeth M. Hamrick, and husband,Page Hamrick III; four sons, WilliamRichard McCune Jr. and wife, Judy,Christopher Groves McCune and wife,Ellen, Brance Lindsey McCune and wife,Debbie, and Alex Groves McCune andwife, Tammy; 16 grandchildren; eightgreat-grandchildren; one brother, EugeneMcCune; and, locally, by one sister-inlaw,Jody Groves. Mary Lou McCune, hiswife of 68 years, died November 6, 2011.Donations in memory of Dr. McCunemay be made to the ShenandoahArea Council of the Boy Scouts ofAmerica, 107 Youth DevelopmentCourt, Winchester, VA 22602.Elizabeth Uy-Arceo, MDElizabeth Uy-Arceo, 72, of PalmCoast, passed away January 27, 2012.Elizabeth was born in Manila,Philippines, and moved to Charleston,WV in 2000. She earned her DoctorateDegree at the University of Sto. Tomasand practiced as a Pediatrician. Elizabethwas a member of Santa Maria DelMar Catholic Church and performeda great deal of charity work.She is survived by her husband of 48years Dr. Constantino Arceo; daughtersTina Arceo Burriss and her husband Steveof Raleigh, NC.; Toni Arceo of Charleston,WV.; Dina Arceo and her husband,Glenn Yamagata of Greensboro, NC.; LeaSpagarino and her husband, Andres ofSan Diego, CA; Brothers Vicente Uy ofLas Vegas, NV.; Jun Uy and his wife ElsieCruz - Uy of Palm Coast, ; Antonio Uy ofLos Angeles, CA, and six grandchildren.Donations may be made in Elizabeth’sname to: The Leukemia & LymphomaSociety, Donor Services, P.O. Box 4072,Pittsfield, MA 01202 or Florida HospitalHospice Care, 770 West GranadaBlvd., Ormond Beach, FL 32174.56 West Virginia Medical Journal

Professional DirectoryCompounding PharmacyLoop Pharmacy & Home medicalThe Region’s only PCAB Accredited Compounding Pharmacyserving the medical community for over 25 years. HormoneReplacement, Pain Management, Sterile Compounding,Pediatrics, Autism, Dermatology, and much more. Contact ustoday for more information.In Home Care1-800-696-3170Email: amanda@looppharmacy.comWeb: www.LoopPharmacy.comSa r a hCa r e of barboursvilleAdult Day Care CenterNeurology2 Courtyard LaneBarboursville, WV 25504304-736-3005www.sarahcare.com/barboursville/ALVARO R. GUTIERREZ, MDNEUROLOGYAcademic results with private practice convenience.Headache Rescue Services/EMG/Consultations.Self-referrals accepted.2199 Cheat Road, Morgantown, WV 26508304-594-3258304-594-3498 FaxObstetrics/GynecologyWOMEN’S HEALTH CARE OF MORGANTOWN“Experienced, professional care that puts you first”Diplomates of the American Collegeof Obstetrics and GynecologyWilliam Hamilton, MDJan Thomas, CNMLouise Van Riper, MDGail Rock, CNMMurshid Latif, MDLisa Stout, CNMCraig Herring, MDRhonda Conley, CNMShane Prettyman, MDBjarni Thomas, CNMComplete OB/GYN care:• Prenatal care and delivery with our MD’s or Nurse Midwives• Non-surgical solutions and advanced surgical care• Well woman screenings for all ages• Sneak peek 3D/4D ultrasound1249 Suncrest Towne Centre, Morgantown, WV 26505304-599-6353www.whcofmorgantown.comPAIN MANAGEMENTThe Center for Pain Relief, Inc.Multidisciplinary Interventional Pain ManagementTimothy Deer, MDChristopher Kim, MDRichard Bowman, MDMatthew Ranson, MDSt. Francis Hospital Location400 Court Street, Suite 100, Charleston, WV 25301304.347.6120The Center for Pain Relief, Inc.Teays Valley Hospital LocationDoctors Park, 1400 Hospital DriveHurricane, WV 25526304.757.5420Physical Therapy and Rehabilitation Center,Southridge Location100 Peyton Way, Charleston WV, 25309304.720.6747www.centerforpainrelief.comUROLOGYGREENBRIER VALLEY UROLOGY ASSOCIATES, INC.Adult and Pediatric UrologyProviding healthcare services in West Virginia and Virginiaat multiple locations for over 29 yearsKyle F. Fort, MD, David F. Meriwether, MD,Thomas S. Kowalkowski, MD, JosephMouchizadeh, MD, and James Cauley, MDCertified by the American Board of UrologyDiplomates of the American College of Surgeons119 Maplewood Avenue at Fairlea, Ronceverte, WV 24970-9737304.647.5642 l 304.647.5644 FAXwww.greenbrierurology.com l info@greenbrierurology.comMarch/April 2012 | Vol. 108 57

| Classified AdsMedical Oncologist-Hematologistneeded to join twooncologists in privatepractice in northernWest Virginia. BC/BE.Competitive salary andbenefits.Reply to:3000 Washington St. WestOncologist-HematologistPO Box 4106Charleston, WV 25364Sharing in the Joyof Healthcare EducationProfessional InstructionPersonal Consulting• Claim Processing Guidelines• Coding Concepts and Guidelines• Medical Billing andReimbursement• Quality Assurance andRisk Analysis• Medical Record or Chart Review304.881.4633www.mccabemedicalcoding.com58 West Virginia Medical JournalOFFICE MANAGERS ASSOCIATIONOF HEALTHCARE PROVIDERS, INC.www.officemanagersassociation.comWe invite you to join our organization which consists of memberswho manage the daily business of healthcare providers.Our objectives are to promote educational opportunities, professional knowledgeand to provide channels of communication to officemanagers in all areas of healthcare. We currently haveeleven chapters in West Virginia.Visit us on our website for more information or contactDonna Zahn (President) at 740-283-4770 ext. 105 orOFFICE MANAGERS ASSOCIATIONOF HEALTHCARE PROVIDERS, INC.MEDICAL PRACTICEOFFICE MANAGERS FOR SALE ASSOCIATIONIncludes land, building and equipment.OF HEALTHCARETwoPROVIDERS,LocationsINC.www.officemanagersassociation.comLocation #1: 163 Greenbrier Street,Rupert, WV 25984Approximately 2500 square feet; completelyremodeled office building, fully equipped w/6 exam rooms, 3 dr. offices, 2 nurses stations,staf break room, 2 waiting rooms, a laband plenty of parking.Price: $175,000www.officemanagersassociation.comWe invite you to join our organization We which invite consists you to of members join our organization which consists of memberswho manage the daily business of healthcare providers.who manage the daily business of healthcare providers.Our objectives are to promote educational opportunities, professional knowledgeOur objectives are to promote educational opportunities, and professional to provide knowledge channels of communication to officeand to provide channels of communication managers to office in all areas of healthcare. We currently havemanagers in all areas of healthcare. We currently have eleven chapters in West Virginia.eleven chapters in West Virginia.Visit us on our website for more information or contactDonna Zahn (President) at 740-283-4770 ext. 105 orVisit us on our website for more information or contactTammy Mitchell (Membership) at 304-324-2703.Donna Zahn (President) at 740-283-4770 ext. 105 orTammy Mitchell (Membership) at 304-324-2703.Location #2: 219 @ Dunlap StreetUnion, WV 25984Approximately 1000 square feet; 2 exam rooms,a dr. office, lab & comes fully equipped.Price: $135,000For more information contactPatricia Long304-645-4043amb2@suddenlinkmail.com

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Thanks To Our Advertisers!In case it’s notthis obvious...Your Practice.Your Future.Your Agency.1.800.257.4747, ext. 22 » 304.542.0257Beckley ARH Hospital.................................................... 33,51Cabell Huntington Hospital................................................... 2CAMC Health Education & Research Institute.................... 21Center for Rural Health Development Loan Fund................. 7Chapman Printing.......................................................... 25,58EHR Solutions..................................................................... 13EN&T Associates................................................................ 31Eye & Ear Clinic Physicians, Inc..........................................11Flaherty Sensabaugh & Bonasso ...................................... 27Highmark West Virginia....................................................... 59Hospital Physician Partners................................................ 30McCabe Medical Coding..................................................... 58Medical Practice FOR SALE............................................... 58Oncologists/Hematologists Opportunity.............................. 58Physician’s Business Office................................................ 29Suttle & Stalnaker............................................................... 15Unicare.................................................................................. 5Union Central Life Insurance Company......... Inside Back CoverWest Virginia e-Directive Registry......................................... 1West Virginia Medical Insurance Agency............................ 60West Virginia Mutual Insurance Co. ................................... 17WV Medical Professionals Health Program........................ 52West Virginia REDI...............................................Back CoverWest Virginia University SOM....................Inside Front CoverAdvertising PolicyThe WVSMA reserves the right to deny advertising space to any individual,company, group or association whose products or services interfere withthe mission, objectives, endorsement agreement(s) and/or any contractualobligations of the WVSMA. The WVSMA, in its sole discretion, retains theright to decline any submitted advertisement or to discontinue publishing anyadvertisement previously accepted. The Journal does not accept paid politicaladvertisements.The fact that an advertisement for a product, service, or company appears inthe Journal is not a guarantee by the WVSMA of the product, service orcompany or the claims made for the product in such advertising. The WVSMAreserves the right to enter into endorsements, sponsorship and/or marketingagreements that may limit the placement of advertisements for certainproducts or services.Subscription Rates:$60 a year in the United States$100 a year in foreign countries$10 per single copyTo review theManuscriptGuidelines, pleasevisit our website atwvsma.comPOSTMASTER: Send address changes to the West VirginiaMedical Journal, P.O. Box 4106, Charleston, WV 25364.Periodical postage paid at Charleston, WV.USPS 676 740 ISSN 0043 - 3284Claims for back issues should be made within six months afterpublication. Microfilm editions beginning with the 1972 volume areavailable from University Microfilms International, 300 N. Zeeb Rd.,Ann Arbor, MI 48106.©2012 , West Virginia State Medical Association60 West Virginia Medical Journal

West Virginia Medical JournalP.O. Box 4106Charleston, WV 25364www.wvsma.comRegister todayto beprepared fortomorrow!West Virginia Responder Emergency Deployment InformationWhat is WV REDI?West Virginia Responder Emergency Deployment Information system• WV REDI is a web-based registration system developed to facilitate health andmedical response through identification of West Virginians willing to serve in publichealth emergency and non-emergency situationsWho can register?• Registration is open to West Virginia’s health and medical professionals, and otherswho live or work in West VirginiaHow can I help?• You can help by being willing to assist during a health related emergency or event andby registering in WV REDIWhat if I can’t go when called?• Please remember that “volunteer” truly means volunteer. You can choose, at any time,to decline any request that you receive for deploymentHow do I register?• To register go to www.wvredi.org and click on “register now”Where do I get more information?• For more information, call 304-558-6900 ext. 2009Visit thewww.wvredi.orghomepage and click on“register now.”