September/October - West Virginia State Medical Association

West Virginia University’sPediatric Allergy/PulmonologyCenter of ExcellenceWe’ve got everything your patients need, all in one place.When a young patient has an allergy or respiratory condition that isn’t getting better, we can help.Our nationally and internationally respected physicians are experts in allergy and pulmonarydisorders, such as:• asthma•cough• sinusitis• chronic lung diseases• sleep apnea• atopic dermatitis• pneumonias•allergies• respiratory infections• allergic rhinitis•foodallergies• immuno-deficiencies• exercise-induced asthma• broncho-pulmonary dysplasia• cystic fibrosisHere at WVU, we offer every aspect of care your patient may need: world-class specialists,compassionate staff, unparalleled laboratory facilities, and our own Children’s Hospital—all underthe same roof.AllergyYesim Y. Demirdag, MDPulmonaryGiovanni Piedimonte, MD, FCCP, FAAPDavid P. Skoner, MDMaple T. Landvoight, MDOtolaryngologyHassan Ramadan, MD, MSc, FACSSilvia C. Cardenas, MDTalia B. Sotomayor, MDKathryn S. Moffett, MDFor more information or to make referrals, call800-WVA-MARS (982-6277) wvukids.comMichael Lincoln, RN

WHY YOU SHOULDCHOOSE THE MUTUALFinancial Stability… through sound underwritingand financial management.Aggressive Defense… claims staff and defense counselexperienced in West Virginia.Innovative Risk Management… participation reduces risk andearns premium credits.Advocacy… a voice with all branches ofWest Virginia government.Your Company… committed to our policyholders– not out-of-state interests.And in the future… dividend program that sharesprofits with policyholders.(304) 343-3000 • (888) 998-7642www.wvmic.com

contentsSeptember/October 2009, Volume 105, No. 5features4 President’s Message6 Our Editor Speaks—Letter to President Obama8 Guest Editorial—Alvin H. Moss, MD, FAAHPM35 MPLA Suit Statistics36 West Virginia Medical Professionals HealthProgram News38 General News38 New Members39 AMA Delegation Report40 Robert C. Byrd Health Sciences Center ofWest Virginia University News41 Marshall University Joan C. Edwards Schoolof Medicine News42 West Virginia School of OsteopathicMedicine News43 Physician Practice Advocate News44 Bureau for Public Health News50 West Virginia Medical Foundation News53 WESPAC Contributors56 West Virginia Medical Insurance Agency News58 Obituaries59 Classifi ed Ads60 Manuscript Guidelines/Advertisers IndexIn this issue…Scientific Articles12 Chronic Kidney Disease: The New Epidemic and ItsImpact on West Virginia19 Lower Eyelid Reconstruction Following Mohs Surgery24 Leuconostoc spp Sepsis in an Extremely Low BirthWeight Infant: A Case Report and Review ofthe Literature28 Caudal Epidural Blood Patch30 Parathyroid FNA and Hormone AssayUPCOMING EVENTSOctober 15—Golf Scramble—Stonewall Resort—registration form pg. 49October 15-16—Advancing Excellence in Healthcareand Health Information Technology Conference—StonewallResort—program and registration form pg. 45HIGHLIGHTSKnow Your Numbers—pg.51Thank you to auctionsupporters—pg. 522009 Healthcare Summitphotos—see pg. 54Cover photo by Don Feenertywww.feenerty.comEditorF. Thomas Sporck, MD, FACSCharlestonManaging Editor/Director of CommunicationsAngela L. Lanham, CharlestonExecutive DirectorEvan H. Jenkins, HuntingtonAssociate EditorsJames D. Felsen, MD, MPH, CharlestonDouglas L. Jones, MD, White Sulphur SpringsRoberto Kusminsky, MD, MPH, FACS, CharlestonSteven J. Jubelirer, MD, CharlestonRobert J. Marshall, MD, HuntingtonDavid Z. Morgan, MD, MorgantownMartha D. Mullett, MD, MorgantownLouis C. Palmer, MD, ClarksburgThe West Virginia Medical Journal is published bimonthly by the West Virginia State Medical Association, 4307 MacCorkle Ave., SE, Charleston, WV25304, under the direction of the Publication Committee. The views expressed in the Journal are those of the individual authors and do not necessarilyreflect the policies or opinions of the Journal’s editor, associate editors, the WVSMA and affiliate organizations and their staff.WVSMA Info: PO Box 4106, Charleston, WV 253641-800-257-4747 or 304-925-0342

President’s MessageThese Are Volatile Times andUncertainty is its HallmarkTOLERATING IT IS CRUCIAL.The 19th century poet John Keatscoined the phrase negative capability,which he defined as the “capabilityto embrace uncertainties, mysteries,doubts, without any irritablereaching after fact and reason.”Indeed, we need negative capabilityto engage in our world today.We need negative capabilityto engage in West Virginiatoday. Consider that—• West Virginia has the secondhighest death rate due to diabetes.• West Virginia’s chronic lowerrespiratory disorders are the thirdhighest in the United States.• West Virginia has the fifth highestdeath rate due to low birth weight.• West Virginia’s cancer toll is thesixth highest in the United States.• West Virginians with heartdisease rank the seventh highestin the United States.• West Virginians with end stagekidney disease rank the eighth highest.• Pregnant West Virginians are thetenth highest in pre-term birth rate.• West Virginia tied for thirteenthfor stroke as cause of death.• West Virginia’s infant mortality is thefifteenth highest in the United States.• Finally West Virginia has becomenumber one in our region in problemsassociated with prescription painmedications.As I prepare for my new role in theWest Virginia State Medical Association,I have polled a number of you on issuesthat are of major importance to you.• 90% of the doctors asked worryabout healthcare reform.• 7% were concerned with the stimulusmoney, Health Information Technologyand Electronic Medical Records.• 2% worry about protectingthe Medical Liability Act.• 1% were concerned about medicalmanpower, the physicians healthprogram and conflicts with othernon-physician health providers.Today I would like to taketime to discuss my perspectiveon healthcare reform.Most of you are aware of the poorperformance of the United States healthstatus when compared to other nations.Among the 30 developed nations thatmake up the Organization for EconomicCooperation and Development (OECD),the United States ranks near the bottomon mortality standard measures ofhealth status. Among the 192 nationsfor which 2004 data is available, the USranks 46th in average life expectancyfrom birth. Life expectancy for womenwas 80.1. The highest was Japan at 85.3.Life expectancy for men from birthin 2003 was 74.8. The highest for menwas in Iceland who lived to be 79.7.Health is influenced in five domains:• Behavioral Patterns 40%• Genetics disposition 30%• Social circumstances 15%• Healthcare 10%• Environmental Exposures 5%Presently there’s not much we cando to change or modify genetics.The single greatest opportunity toimprove health and reduce prematuredeath lies in changing personal behavior.The latest breakdown of thenumbers of US deaths frombehavioral causes in 2000 was:Smoking 435,000Obesity & inactivity 365,000Alcohol 85,000Motor Vehicle 43,000Guns 29,000Sexual behavior 20,000Drug induced 17,000The prevalence of smoking in theUnited States declined among menfrom 57% in 1955 to 23% in 2005 andamong women from 34% in 1965 to18% in 2005. I must say that Ohio andMarshall Counties led the state inmandating smoke free status in publicplaces. In West Virginia, smoking is arite of passage and the first experienceoccurs at age nine for most boysand thirteen for most girls. SmokingAmericans die 15 years earlier thannon-smokers and spend their finalyears ravaged by dyspnea and pain.In addition, smoking among pregnantwomen is a major contributor topremature births and infant mortality.The Price Waterhouse CooperHealth Research Institute published thefollowing numbers of wasted revenues.Behavioral303-493 BillionObesity/Overweight 200 BillionSmoking167-191 BillionNon-compliance 100 BillionClinical312 BillionDefensive medicine 210 BillionPreventable hospitalreadmission25 BillionPoorly managedDiabetes22 BillionMedical error17 BillionUnnecessary ER visits 14 BillionTreatment variation 10 BillionHospital acquiredinfection3 BillionOver prescribingantibiotic1 BillionOperational126-315 BillionClaims processing 21-210 BillionIneffective use of it 81-88 BillionStaffing turnover21 BillionPaper prescriptions 4 Billion4 West Virginia Medical Journal

Although inadequate healthcareaccounts for only 10% of prematuredeaths, healthcare receives byfar the greatest abuse of shareof resources and attention.In the case of heart disease, itis estimated that healthcare hasaccounted for half of the 40% declinein mortality over the past decades.One can argue that the excessivereliance on international mortalitycomparisons short change the resultsof America’s healthcare system.The buzz in the nation today isPresident Obama’s signature issue,“healthcare reform.” He is aimingto seek badly needed changes foruniversal access, delivery and financingof healthcare in the United States.Although the President did notwant to include any meaningfultort reform, health reform cannotbe achieved without tort reform.Remember the Physician Dictum ofPrimum Non Nocere – “First Of All Do NoHarm”—This has now been replaced byThe Wall Street Journal’s mantra PrimumQui Pacere, “First Of All Who Pays.”Previous presidents have attemptedto enact some kind of universal healthinsurance. In the 1940’s, Harry S.Truman thought of it, in the 1970’sRichard Nixon attempted, and in the1990’s Bill Clinton failed to pass it.Dr. Fuchs, Economic professor atStanford University, writes of four majorissues that can derail healthcare reform.First—many of us, organizations andindividuals, prefer the status quo. Theseinclude health insurance companies(recall that America’s insurance planswho commissioned the “Harry andLouise” TV ads dealt the coupe-degraceto Bill Clinton’s health plans),manufacturers of drugs, medicalequipment and devices; companiesthat employ mostly young healthyindividuals, high income employeeswhose health insurance is heavilysubsidized through a tax exemptionfor the portion of their compensationspent on health insurances; businessleaders and others who are ideologicallyopposed to a larger role of government.Second—Niccolo Machiavellipresciently wrote in 1513, “There isnothing more difficult to manage,nor more doubtful of success thanto initiate a new order of things. Thereformer has enemies in all those whoprofit from the old order and onlylukewarm defenders in all those whowould profit from the new order.” Thiskeenly observed dynamic, known asthe “Law of Reform,” suggests that adetermined and concentrated minority,fighting to preserve the status quo,has a considerable advantage over adiffering majority who favor reform withvarying degrees of willingness to forgetfor a promised but uncertain benefit.Third – is our country’spolitical system that opens manypotential choke points.Fourth— reformers have failedto unite behind a single approach.What is the physician’srole in healthcare reform?I firmly believe that physiciansshould first help create a shared visionthat will overcome the philosophicalchasm and bring providers togetherto create a system that binds publicneeds with provider’s fundamentalinterests and values. We must recognizethat improving a complex healthcaresystem requires action on many fronts.In its landmark report, TheInstitute of Medicine, (IOM) describeda chain of affect that links thesystems at four different levels.For healthcare reform to progress,physicians through WVSMA andthe AMA should lead the country toembrace the so called triple aims – betterexperience of care (safe, effective,patient-centered, timely, efficientand equitable) better health for thepopulation—lower total per capita costs.The second level—is the designof the care processes that affect thepatient— clinical microsystems.Physicians, through their participationin quality improvement initiativesin their practices and hospitals canand should lead the changes.The third level—is healthcareorganizations that honor almostall clinical micro-systems and canensure coordination among them,(coordinated healthcare). We cancreate a high performing healthcaresystem only if integrated deliverysystems become the mainstayorganizational design. Organizationscould be virtually integrated,such as a network of independentphysicians sharing electronic healthrecords with administrative andclinical support for care managementand quality improvement.The fourth level—is the environment,which includes the payment, regulatory,legal and educational system. Againno health reform is going to besuccessful without tort reform.The World Health Organization,in its June 2000 assessment ofmedical care systems aroundthe world, used responsivenessas one of its major criteria.This concept encompasses the coreprinciples of medical humanities—specifically, dignity for individuals andfamilies and the autonomy for them tomake decisions for their own health.This new model incorporates“shared decision making,” in whichthe physician attempts to providethe patient and the family with thefull range of information about theclinical problem so that they can assesspotential risks and benefits and make aninformed decision on how to proceed.Part of the ethical basis ofshared decision making is medicalprofessionalism—the firm determinationthat doctors should always aligntheir interests with those of theill person and be free of any selfservingmotivation so that patientcan trust their physicians advice.I started with the notion of negativecapabilities. For the ordered scientificmind who craves linearity and order,one might have a tough time notknowing. Dealing with uncertaintyoften involves reversing decisions.I find comfort that Conchita trainedme well, that the mark of an intelligentman is assuming the mind of a womanand that is the ability to change one’smind. Another tactic is to break downthe uncertainty in smaller elements.Those who thrive in uncertain timesclosely follow the second part of Keatsprescription. They don’t believe they’llresolve things by diving into data. Theyallow themselves time for reflection.In an increasingly diverse countrythat has a widening gap betweenrich and poor, a more promisingapproach is to start with thequestions that matters to us most.• Will the system care for uswhen we are sick and help preventillness when we are well?• Will we have access tomedical care throughout our liveswithout risking financial ruin?• Will we be able to navigatethe system easily without jumpingthrough unnecessary hoops?• Will healthcare spendingbe managed wisely?Perhaps that’s one way thatin the midst of the fog, you andI will glimpse opportunities.Carlos C. Jimenez, MDWVSMA PresidentSeptember/October 2009 | Vol. 105 5

Our Editor Speaks6 West Virginia Medical Journal

Guest EditorialPrescription Opioids and Physician ResponsibilityIn the last several years WestVirginia has received another poorgrade on its healthcare report card;this time it is for deaths from drugabuse and diversion. In its February9, 2007 Morbidity and Mortality WeeklyReport, the Centers for Disease Controland Prevention noted that between1999 and 2004 West Virginia had thelargest increase in unintentional drugpoisoning deaths in the country (550%).Then in a December 2008 JAMAarticle, researchers reported on the“pharmacoepidemic” in West Virginia:the majority of overdose deaths inWest Virginia in 2006 were associatedwith the diversion of pharmaceuticals,primarily opioid analgesics. Of the 295deaths reported in the JAMA article, 63(21.4%) were accompanied by evidenceof doctor shopping. According tothe West Virginia Code §60A-4-410, doctor shopping is illegal, “It isunlawful for a patient, with the intentto deceive and obtain a prescriptionfor a controlled substance, to withholdinformation from a practitioner thatthe patient has obtained a prescriptionfor a controlled substance of a similartherapeutic use in a concurrent timeperiod from another practitioner.”Unlike obesity on which WestVirginia healthcare also receivesa failing grade, West Virginiaphysicians can do something directlyabout prescription drug abuse anddiversion. Here are ten things theycan (and in most cases should) do:1To identify possible doctorshoppers, check the West VirginiaBoard of Pharmacy ControlledSubstances Monitoring Programwebsite (https:/65.78.228.163)before prescribing a Schedule II orSchedule III controlled substance.2Refuse to prescribe controlledsubstances to doctor shoppers.3Take a prior and current historyof alcohol and other drug useand abuse. There are several shorttools which physicians can use toidentify patients at high risk of opioidabuse (available on request from theauthor): the Opioid Risk Tool (ORT)and the Screening Instrument forSubstance Abuse Potential (SISAP).Patients with prior or current historyof substance abuse should be referredto an interdisciplinary pain clinic or atleast co-managed with pain specialists.4Require patients to sign a painmanagement agreement (contract)for all patients receiving prescriptionsfor Schedule II or Schedule III opioidanalgesics (a sample is available fromthe author on request). The agreementshould stipulate that new prescriptionswill not be provided for lost or stolenprescriptions. To enable physiciansto report doctor shoppers withoutviolating HIPAA, physicians may wantto include the following language intheir agreement, “I hereby authorizethe staff of (Name of Physician’sPractice) to furnish to any local,state, or federal enforcement agencyany information obtained pursuantto my treatment which is deemedby the staff of (Name of physician’sPractice) to evidence possible criminaldrug activity by me in connectionwith medications prescribed tome as part of said treatment.”5Report patients to state lawenforcement officials when apatient is engaged in doctor shoppingon the physician’s premises. HIPAApermits disclosure of protectedhealth information on a patient whenthat patient is engaged in criminalconduct on the physician’s premises.6On follow-up visits, perform urinetoxicological screens (includinga specific screen for oxycodone forpatients on oxycodone) on patientsprescribed controlled substances.7On each visit, assess whetherthe opioid analgesic isimproving the patient’s functionand quality of life and whetheror not it should be continued.8Counsel patients about the riskof overdose to themselves andto others with whom they might betempted to share their medication.Patients should be explicitly toldthat they are NOT to share theirmedications with others.9Advise patients not to storetheir pain medications in theirmedicine cabinet in their bathroom.This is the first place that visitorsseeking drugs will look. Instructpatients to store pain medicationsin a safe, preferably locked, place.For physicians in a group10 practice, agree on how tohandle requests for controlledsubstances from a colleague’s patient.Inform patients that prescriptionsfor controlled substances will onlybe written by the patient’s primaryphysician on a scheduled visit andthat they will not be able to obtainprescriptions from another physicianin their practice at any time.In following these steps, WestVirginia physicians will exercisetheir responsibility to combat themajor drug abuse and diversionproblem in our state and play amajor role in decreasing the highrate of overdose deaths from opioidanalgesics in West Virginia.To request opioid riskscreening tools or a sample painmanagement contract, e-mailDr. Moss at amoss@hsc.wvu.edu.Alvin H. Moss, MD, FAAHPM8 West Virginia Medical Journal

Continuing Medical Education Opportunitiesat CAMC Health Education and Research InstituteThe CAMC Health Education and Research Institute is dedicated to improving health through research, educationand community health development. The Institute’s Education Division offers live conferences, seminars, workshops,teleconferences and on-site programs to health care professionals. The CAMC Institute’s CME program is accredited bythe Accreditation Council for Continuing Medical Education to sponsor continuing medical education for physicians.The CAMC Institute designates this educational activity for a maximum of 1 AMA PRA Category 1 Credit(s). Physiciansshould only claim credit commensurate with the extent of their participation in the activity. For more information onthese and future programs provided by the Institute, please call (304) 388-9960 or fax (304) 388-9966.SEMINARS2009 Bereavement Conference:Dancing with Grief- Caregivers Griefand its Impact on the BereavedFriday, Sept. 11, 20098 a.m. to 4 p.m.Auditorium-Robert C Byrd HealthSciences Center of West VirginiaUniversity-Charleston DivisionCharleston, WV2009 Patient Safety ConferenceAvoiding “Never-Never” LandFriday, Sept. 18, 20098 a.m. to 3 p.m.Auditorium-Robert C. Byrd HealthSciences Center of West VirginiaUniversity-Charleston DivisionCharleston, WV2009 OB/Gyn Jr. Fellow SymposiumSaturday, Sept. 19, 20098 a.m. to 4 p.m.Auditorium- Robert C. Byrd HealthSciences Center of West VirginiaUniversity- Charleston DivisionCharleston, WVAnesthesia in the 21st CenturySaturday and Sunday, Sept. 26-27,2009Charleston Marriott Town CenterCharleston, WVForensic Death InvestigationMonday through Thursday, Oct. 5-8,2009Days HotelSutton, WVPediatric Acute and Critical CareConference: Current Trends inPediatric Respiratory CareFriday, Oct. 9, 20098 a.m. to 4 p.m.Auditorium- Robert C Byrd HealthSciences Center of West VirginiaUniversity- Charleston DivisionCharleston, WV2009 WV Vascular/EndovascularSurgery SymposiumSaturday and Sunday, Oct. 17-18,2009Greenbrier ResortWhite Sulphur Springs, WVWV Rural Health Conference3 R’s of WV Rural Health: Reinvesting,Recovery and ResilienceWednesday through Friday, Oct. 21-23, 2009The Resort at Glade SpringsDaniels, WV20th Annual Respiratory CareConferenceFriday, Nov. 6, 20098 a.m. to 4:30 p.m.Auditorium- Robert C Byrd HealthSciences Center of West VirginiaUniversity- Charleston DivisionCharleston, WV2009 West Virginia Public HealthInfectious Diseases ConferenceThursday and Friday, Nov. 19-20,20098 a.m. to 4 p.m.Charleston Marriott Town CenterCharleston, WVLIFE SUPPORT TRAININGLog on to our web site to register atwww.camcinstitute.org.Basic Life Support (BLS) – InstructorSept. 21Advanced Cardiac Life Support(ACLS) – RenewalSept. 22 and 23; Oct. 8 and 27Advanced Cardiovascular Life Support(ACLS) – ProviderSept. 16; Oct. 6 and 28Advanced Cardiovascular Life Support(ACLS) – InstructorOct. 12Advanced Trauma Life Support(ATLS) – ProviderSept. 28Advanced Trauma Life Support(ATLS) – ReverificationSept. 29Pediatric Advanced Life Support(PALS) - RenewalSept. 15 and Oct. 15Pediatric Advanced Life Support(PALS) - ProviderSept. 24 and Oct. 13PALS – Instructor CourseOct. 26S.T.A.B.L.E. Neonatal CourseOct. 19CME ONLINE PROGRAMS/ARCHIVED GUEST LECTUREPROGRAMSLog on to our web site atwww.camcinstitute.orgSystem requirementsEnvironment: Windows 98, SE, NT,2000 or XPResolution: 800 x 600Web Browser: Microsoft’s InternetExplorer 5.0 or above or NetscapeNavigator 4.7x. (Do not useNetscape 7.1)Video Player: Windows Media Player6.4 or better. Dial-up or broadbandconnection. Minimum speed, 56k(broadband is recommended)Other archived CME opportunities:Geriatric seriesEthics seriesResearch seriesNET Reach libraryCharleston Area Medical Center Health System, Inc. 2009 21129-G09

Experience Matters.Dave Higgins, Steve Stocktonand Paul Papadopoulos have thecombined experience of beingcounsel of record in morethan half of the state andlocal tax cases decided bythe West Virginia SupremeCourt over the last 15 years.When choosing a law firm torepresent you in a state or local taxcase in West Virginia, let our taxteam’s experience work for you.Experience does matter.

Scientific ArticlesChronic Kidney Disease:The New Epidemic and Its Impact on West Virginia p. 12Lower Eyelid Reconstruction Following Mohs Surgery p. 19Leuconostoc spp Sepsis in an Extremely Low BirthWeight Infant: A Case Report andReview of the Literature p. 24Caudal Epidural Blood Patch p. 28Parathyroid FNA and Hormone Assay p. 30September/October 2009 | Vol. 105 11

Scientifi c Article |Chronic Kidney Disease:The New Epidemic and Its Impact on West VirginiaRebecca J. Schmidt, DO, FACP, FASNProfessor and Chief, Section ofNephrology, WVU School of Medicine,MorgantownDerrick L. Latos, MD, MACPMedical Director, Wheeling Renal CareNephrology Associates, WheelingClinical Professor of Medicine,WVU School of MedicineAbstractThe prevalence and incidence ofchronic kidney disease (CKD) is growing atan alarming rate. Estimates suggest thatCKD affects an estimated 13 percent ofAmericans, and West Virginia leads theway, with the highest per capita rate in thecountry of patients with kidney failurestarting dialysis (1,2,3). There is a greatlack of awareness about the risks of CKDamong the general population (1), many ofwhom are unaware of their risk status oreven the presence of CKD. Theincreasingly older, diabetic and obesepopulations likely account for the highprevalence of advanced CKD in WestVirginia, as well as the fact that a largepercentage of the state’s population lives2-3 hours’ distance from specialized care.Additionally, there are relatively fewphysicians in West Virginia specifi callytrained to treat the growing numbers ofpatients with kidney disease, which isusually silent until well past the time whenmedical intervention can be successful inreversing or slowing the rate ofprogression to kidney failure. Worse, evenin its early stages, kidney disease posessignifi cant cardiovascular risk; indeed,individuals with advanced CKD are morelikely to die of cardiovascular disease thanlive long enough to need kidneyreplacement therapy (4,5).Magnitude and Scope of theProblemA progressive disease which affectsmore than 20 million adults, CKD isthe ninth leading cause of death in theUnited States. An additional 20 millionare at increased risk for developingCKD, and an estimated 80,000 peopleare diagnosed annually (1). Financialcosts related to caring for patientswith end stage renal disease (ESRD)are formidable and annually on therise, accounting for approximately 6%of the total Medicare budget (6). CKDis a worldwide public health problem,and though figures on worldwideprevalence are not available,extrapolations of prevalence estimatesfrom the US population suggestthat this potentially devastatingdisease possibly exceeds 100 millionindividuals worldwide (3). (Table 1)Table 1. CKD prevalence in theUnited StatesWhy the new focus on CKD?Historically, care of CKD hasoften been reactive and followed asalvage approach. In recent years,nephrologists have taken a proactivestance, urging clinicians to recognizethose at risk early enough to positivelyimpact the course of CKD andreduce the likelihood of progressionto ESRD and dialysis-dependence.For those who do progress, a lesstortuous and complicated transitionfrom CKD to ESRD and dialysis canbe expected for those patients whoare proactively managed. In short,CKD is a common, devastating, andexpensive, but treatable problem.Measurement of KidneyFunction and Classification ofCKD StagesThe National Kidney Foundationhas spearheaded efforts to identifyindividuals with kidney disease andto stratify their level of kidney damageaccording to the estimated glomerularfiltration rate (eGFR) (7, 8). Equationsusing readily available information(serum creatinine, age, sex, and race)have been developed that providereasonable accurate estimates ofGFR. Most clinical laboratories nowprovide results for eGFR whenevera serum creatinine is ordered.Currently, over half of hospital andclinical laboratories in West Virginiaroutinely compute eGFR values. Theseequations are also readily available incommonly used Palm programs, andin various web sites (www.kidney.org, www.nkdep.org). Use of eGFRvalues is very helpful in identifyingindividuals who have decreased levelof kidney function, especially whentheir serum creatinine values may beonly mildly elevated or even with alaboratory’s normal range. Discussionregarding caveats for interpretingeGFR values is beyond the scope ofthis paper, but several referencesare readily available (7, 8, 9).Chronic kidney disease is definedas the presence of kidney damagefor a period of at least three months,as demonstrated by structural orfunctional abnormalities of thekidney, with or without a decrease inGFR, as measured by the estimatingequations or other methods (7, 8).The criteria for damage may bemet on the basis of a pathologicabnormality, by the presence of bloodor urine markers of kidney damage,or the presence of an abnormalityon radiologic imaging tests. An12 West Virginia Medical Journal

| Scientifi c ArticleeGFR of less than 60 ml/min, withor without demonstrable kidneydamage, also defines the presence ofCKD. Formerly called chronic renalfailure or chronic renal insufficiency,chronic kidney disease has becomethe accepted terminology forpersons with the above criteria.The continuum of CKD isrepresented by the designationof five stages which are classifiedbased on the presence of damageand level of GFR (Table 1) (7, 8).Incidence and PrevalenceDiabetes and hypertensionaccount for much of the risingincidence in ESRD and continueto be the leading causes of CKDoverall (1, 3). (Figure 1) (Figure 2)Data from the United States RenalData System (USRDS) has providedstatistics from which projectionsabout the future of ESRD are made.Figure 1.Figure 2.While it is clear that the ESRDpopulation continues to grow, therapidity with which this growth hasoccurred appears to have slowed. Thehigh prevalence of cardiovasculardisease among patients with CKDcoupled with data showing a highrate of death in late stage CKDpatients, prior to reaching dialysis,suggest that the slowing in ESRDgrowth may reflect the fatal impactof cardiovascular disease rather thanimproved medical care (10, 11).Data derived from third NationalHealth and Nutrition ExaminationSurvey (NHANES III) suggestthat more than 15 million peoplehave kidney function levels thatare below normal as definedby a glomerular filtration rate(GFR) of less than 60mL/min per1.73m2 (CKD Stages 3-5) (3).As noted above, and in Table 1,the marked disparity in prevalenceof patients with CKD Stage 3(7.6 million patients) and Stage 4(400,000 patients) might suggestthat progression to Stage 4 indicatesimproved medical care; to thecontrary, data indicate that thisdifference is due largely to thefact that many patients with Stage3 CKD die before progressing toStage 4. Indeed, people with CKDdo not die of kidney failure – theydie of cardiovascular disease,which accounts for 40-50% ofthe deaths in patients with renaldisease and develops early on in thecontinuum of CKD (5, 6, 10, 11).Estimates suggest that 11 percentof adults in the US population haveCKD —an alarming prevalencethat is fueled primarily by thediabetes epidemic and an agingpopulation that better survives longstandingheart disease (5, 6, 8, 12).Projections based on the US RenalData System predict that 136,000people will start ESRD therapy by2015, joining an estimated 712,000prevalent ESRD patients (3, 13).The cost of caring for CKD ofall stages will soon exceed the costof the Medicare renal replacementprogram itself; thus, reducing theburden of CKD and its comorbiditiesearly in their course is a criticalpublic health need (1, 2, 3).Risk Factors, Recognition andDiagnosisRisk factors for CKD are highlyprevalent in West Virginia andinclude age greater than 60 years,the presence of diabetes mellitus,hypertension and a family historyof kidney disease. Other risk factorsare shown in Table 3 (7, 8).Table 3. Risk Factors for KidneyDiseaseRapid increases in the numberof CKD patients reaching end stage(18) have leveled off in recent years(11, 14); nevertheless, the agingbaby boomer generation, coupledwith the epidemic of obesity anddiabetes, are predicted to increase thetotal burden of kidney disease (14).Overall, nephrologists have cometo bear a formidable share of theresponsibility for managing advancedCKD and frequently becomesole providers of primary care todialysis patients (10, 11). The ratioof patients dependent on dialysis(renal replacement therapy) tonephrologists is predicted to exceed160:1 by 2010 (11). This impendingshortage highlights the need forearly recognition and managementof CKD and its consequences byprimary healthcare providersThe recognition that Stage 3 CKDpatients are more likely to die thanto live long enough to reach endstage underscores the need for CKDSeptember/October 2009 | Vol. 105 13

Scientifi c Article |screening as well as the importanceof maintaining a high index ofsuspicion for occult cardiovasculardisease. Primary healthcare providersare thus uniquely poised to detectand treat CKD and its attendantrisk factors at the earliest possiblestage in the CKD continuumbefore complications develop.Clinical and EconomicImplicationsThe clinical and economicimplications of CKD are clear andconcerning. Outcomes are poor,care is costly and complicationsof CKD start long before ESRDdevelops and the need for renalreplacement therapy is apparent.Further, progression to ESRD isnot inevitable for all with CKD,and the need for dialysis can beprevented or ameliorated for manypatients with kidney disease.A preventive, proactive approachcan improve outcomes and reducecosts.Compared to the four most deadlycancers, ESRD has equally pooroutcomes (100 deaths per 1000 patientpopulation), survival rankings beingworse than colon (67 per 1000), breast(41 per 1000) or prostate (30 per 1000)cancer and nearly as formidableas survival for lung (167 per 1000)cancer patients (1). Although life forpatients with ESRD can be sustainedwith transplantation or dialysis, themortality after ESRD is reached,particularly for those on dialysis, isso high (about 20% per year), that asmany people die while being treatedfor kidney failure as from any cancerexcept lung cancer. Life expectancygoes down with age, and patientswith both CKD and diabetes are morelikely to die a cardiovascular deaththan live long enough to reach theneed for kidney replacement therapy.Early treatment does indeedmake a difference. Meticulous bloodpressure control, and in diabetics,meticulous blood glucose control, areof paramount importance and haveFigure 3.Per Patient Per Month Part A Costs: CKD & ESRD PopulationsPer Patient Per Month Part B Costs: CKD & ESRD Populationsbeen clearly shown to retard renalinjury progression of disease. Further,the use of agents that block the reninangiotensin-aldosteronesystem,attention to nutrition, treatment ofanemia, lipids and other cardiacrisk factors are also part of standardCKD management. Such therapiesneed to be provided throughoutthe entire continuum of CKD.Several studies have documentedimproved outcomes among patientswho are referred to nephrologistsearly in the course of their kidneydisease (1, 15). However, late referralcontinues to be common acrossthe country. Among 2264 patientsstarted on dialysis, 57% had notseen a nephrologist 1 year prior todialysis, 34% had permanent vascularaccess (11% fistula), 25% werebeing treated with erythropoietinstimulating agents (ESAs) for anemia,32% had first nephrologist visitless than 4 months prior to startingdialysis (1, 16, 18). Patients in thelate referral group had lower serumalbumin, lower hematocrit (11%using erythropoietin stimulatingagents for anemia), less often had apermanent dialysis access, and moreoften required temporary central14 West Virginia Medical Journal

| Scientifi c Articlevenous dialysis catheters. Currentdata shows that 20-25% and 22-49%of CKD patients start dialysis withinone and four months, respectively, oftheir first nephrology visit (13, 15, 17).Medical and physiologic costsaside, the financial costs relatedto caring for patients with ESRD(approximately 0.5% of all Medicarebeneficiaries) are significant,accounting for perhaps as much as6% of the total Medicare budget.Total Medicare spending for ESRDwas estimated to be $15.4 billionannually in 2001, and by 2010,medical expenses related to ESRDare expected to exceed $28 billionper year, an amount which exceedsthe total National Institutes ofHealth Budget of $23 billion.Broken down by patient permonth, cost of care for an ESRDpatient on dialysis significantlyexceeds that of a patient with CKDnot on dialysis (1). This holdstrue for both Medicare Part Aand Part B costs; respective costsfor a CKD patient are between5- and 10-fold less than those ofan ESRD patient (Figure 3) (1).CKD patients with heart diseaseand congestive heart failure inparticular, have more hospitalizationsthan non-CKD patients with theseconditions and the cost associatedwith the transition to dialysis isenormous as shown in Figure 4 (1).Given the greater likelihood of deathrelative to progression to dialysisin patients with late stage CKD,this represents an important areafor intervention. Recent data fromthe USRDS shows that care priorto ESRD is strongly linked to betteroutcomes, particularly in the first120 days after the start of dialysiswhen the death rate is highest (1).Challenges in West VirginiaSadly, West Virginia has ledthe country in the rate of patientsstarting therapy for ESRD since1994 (4). (Figure 5) Risk factors forkidney disease are more prevalentin West Virginia than the rest of thenation. Past data has suggested thatdiabetes affects 11 percent of WestVirginians compared to a nationalrate of 7 percent (4) (Figure 6),however, more recent data from theBehavioral Risk Factor SurveillanceSurvey, compiled by the Bureaufor Health Statistics in 2006, hassuggested that an alarming 22% ofWV residents admit to a diagnosis ofdiabetes (Personal communication,James Doria, WV Bureau for HealthStatistics). Based on estimates of theState’s population of individuals overage 18, this represents approximately171,000 citizens with diabetes. InDon’t Get Left Behindwhen it comes to EMR.Now is the time to let EMR take your practice tothe next level in patient care. With our experiencedsupport team and Centricity ® EMR by GE Healthcare,we’ll help you get there in no time. Don’t get left behind.Giveusacalltoday.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.bzSeptember/October 2009 | Vol. 105 15

Scientifi c Article |Figure 4.Per person per month expenditure forMedicare patients 67 years and older forthe 6 months before and after startingdialysis; high costs associated withtransition to and early months on dialysis.Figure 5.Incidence of ESRD for West Virginiagreater than national average.Figure 6.Prevalence of DM Awareness in WV.Centers for Disease Control and Prevention (CDC). Behavioral Risk FactorSurveillance System Survey Data, 2005.Figure 7.Prevalence of HTN Awareness in WVCenters for Disease Control and Prevention (CDC). Behavioral Risk FactorSurveillance System Survey Data, 2005.addition, one-third of individualswith diabetes are unaware they havethis condition, which accounts foranother 85,000. With 256,000 of ourcitizens being diabetic, West Virginiahas a looming crisis ahead! Otherrisk factors for kidney failure – highblood pressure and age greater than65 years – are also highly prevalentin West Virginia (CDC) (Figure 7).The estimated prevalence ofCKD in West Virginia is shownin Table 4. These data have beenestimated from CKD estimates fromthe NHANES 1999 - 2004 study (3).Screening programs suggest that theprevalence may be much higher, andif projections based on most recentBRFSS compiled by the WV ChronicDisease Program are accurate, thenumber of West Virginians whoare at high risk for developmentof CKD, based on the prevalenceof diabetes and hypertension, isextraordinary. Indeed, the prevalenceof CKD in the US has increasedduring the time period 1999 – 2004when compared to 1988 – 1994 (3).CKD Screening Programsin West VirginiaOf nearly 1,200 West Virginiaresidents patients who haveparticipated in community-basedkidney disease screening programs,67% learned they had kidney disease,and 22% were diagnosed withpreviously unknown hypertension.Sponsored by the National KidneyFoundation since 2000, the KidneyDisease Early Evaluation Program(KEEP) is a nationwide programdesigned to identify and educatepersons with kidney disease,particularly among those with riskfactors for CKD. Data from thenational perspective are similar tothat among West Virginia residents,underscoring the need for moreeffective programs to identify andtreat those individuals who are at riskfor developing CKD. Importantly,Table 4. CKD Prevalance in WVthese data are consistent with resultsof the 2006 BRFSS described above.Screening events held inGilbert and Beckley (which arerepresentative of many West Virginiacommunities, with populationsof 417 and 17,254, respectively)support the concerns surroundingthe high prevalence of CKD in WestVirginia. A total of 147 participants(78 from Gilbert and 69 from Beckley)were evaluated for blood pressure,weight and renal function. A set ofNHANES III subjects paired by age,sex and race was used as a controlgroup. Hematuria was present in28%, and albuminuria in 41% ofthe 132 WV subjects, for whomcomplete blood and urine resultswere available. A blood pressuregreater than 130/85 mmHg wasnoted in 51% of participants. Themean GFR estimate (as determinedby the MDRD 2 equation) was 72ml/min/1.73m2, a value lower thanthe 78 ml/min/1.73m2 in controls(p=0.001). A GFR less than 60 ml/min/1.73m2 was observed in 22% ofthe WV group, compared to 14% ofmatched NHANES individuals. Thehigh prevalence of elevated bloodpressure and urinary abnormalitiessuggest the prevalence of CKD inWest Virginia may exceed the 1 in9 national estimates. The findingthat 22% subjects had a GFR lessthan 60 is consistent with the highrates of ESRD in West Virginia aswell as the recent survey findingthat 22% of the state’s populationmay be diabetic. Early identificationof CKD clearly benefits those atrisk, and may uncover affected16 West Virginia Medical Journal

Ears, nose and throat medical and surgical care |Audiological testing | Inhalant allergy testing and treatment |Hearing aid evaluation and placement services |Computed Tomography (CT) for sinuses and earsAppointments304.340.2200Hearing Aid Center304.340.2222CompleteComprehensiveServicesentchas.com • 500 Donnally Street • Charleston, WV • Suite 200Hearing Aid Center • Suite 102BOARDCERTIFIEDSPECIALISTSP. Todd Nichols, MDD. Richard Lough, MDMichael R. Goins, MDG. Stephen Dawson, MDF. Thomas Sporck, MD, FACS

Scientifi c Article |individuals who harbor noapparent or perceived threat (19).Discussion and DirectionComprehensive CKD care iskey to improving outcomes andreducing the morbidity and mortalityassociated with both CKD andassociated cardiovascular conditions.The magnitude of CKD has reachedthe national radar screen, promptingformation of the National KidneyDisease Education Program (NKDEP)by the NIH modeled after thenational hypertension and cholesterolpublic education programs. TheNKDEP targets high-risk populationsand primary healthcare providersadvocating screening for those atrisk and early intervention for thosewith early CKD. The program is inkeeping with Healthy People 2010,a framework for preventive healthin the U.S., which now includesCKD in its objectives with the goalto reduce new cases of CKD and itscomplications, disability, death, andeconomic costs. For West Virginia,these programs provide an excellentopportunity to improve the healthof thousands of our residents andto reduce the enormous financialburden that will accompany dealingwith CKD in its advanced stages.The West Virginia Program forChronic Diseases, which coordinatesthe Diabetes Advisory Council, hasrecently undertaken responsibilityfor promoting kidney diseaseprograms. The West Virginia KidneyAdvisory Group, comprised of adiverse group of individuals withextensive experience and expertise inmanagement of persons with CKD,public and professional health careeducation, and research, was integralin the development and publicationof “The Impact of Chronic KidneyDisease in West Virginia,” adocument which provides anextensive overview of the enormouschallenges facing providers andhealth policy makers. Releasedby the West Virginia Departmentof Health and Human Services inApril 2006, this publication outlinesseveral strategies and initiativesthat could assist in dealing with thisimportant public health problem (20).The West Virginia Legislatureand Governor’s Office have alsobeen instrumental in promotingCKD awareness. On February 16,2005, the day that Governor JoeManchin proclaimed as WV KidneyAwareness Day, the Legislaturealso passed Joint Resolution callingfor efforts to promote heightenedawareness of CKD. More recently,during its 2007 regular session, thelegislation was passed that mandatescoverage for kidney disease screeningfor people with risk factors. On anational level, Governor Manchinreceived the 2006 Renal PhysiciansAward in recognition for hissupport for the fight against CKD.Discussion regarding themanagement of CKD patients isbeyond the scope of this paper.The National Kidney Foundationhas released important practiceguidelines to assist practitionersin doing this important work.SummaryIn conclusion, the epidemic ofCKD is growing at alarming rate,and West Virginia has not beenspared. Collaborative efforts withprimary care clinicians from multipledisciplines are needed to assurethe provision of life-saving care forthe thousands of West Virginianswho already have kidney disease,and undoubtedly thousands morewho are at risk for developing CKDand cardiovascular disease. CKDpatients are more likely to DIEfrom cardiovascular disease thanprogress to ESRD. Appropriateinterventions can improve outcomesand delay or prevent progressionto ESRD, and a proactive, ratherthan salvage approach is needed.References:1. U.S. Renal Data System, USRDS 2007Annual Data Report: Atlas of ChronicKidney Disease and End-Stage RenalDisease in the United States, NationalInstitutes of Health, National Institute ofDiabetes and Digestive and KidneyDiseases, Bethesda, MD, 2007.2. Coresh J, Astor BC, Greene T, Eknoyan G,Levey AS. Prevalence of chronic kidneydisease and decreased kidney function inthe adult US population: Third NationalHealth and Nutrition Examination Survey.Am J Kidney Dis 2003;41:1-12.3. Coresh J, Selvin E, Stevens LA, Manzi J,Kusek JW, Eggers P, Van Lente F, LeveyAS. Prevalence of chronic kidney diseasein the United States. JAMA 2007;298(17):2038-2047.4. Gilbertson DT, Liu J, Xue JL, Louis TA,Solid CA, Ebben JP, Collins AJ. Projectingthe number of patients with end-stagerenal disease in the United States to theyear 2015. J Am Soc Nephrol 2005;16:3736-3741.5. Hunsicker LG. The consequences and costsof chronic kidney disease before ESRD. JAm Soc Nephrol 2004;15:1363-1364.6. Collins AJ, Li S, Gilbertson DT, Liu J, ChenSC, Herzog CA. Chronic kidney diseaseand cardiovascular disease in theMedicare population. Kidney Int Suppl2003;S24-31.7. KDOQI Clinical Practice Guidelines andClinical Practice Recommendations forAnemia in Chronic Kidney Disease. Am JKidney Dis 2006;47:S11-1458. KDOQI Clinical Practice Guidelines andClinical Practice Recommendations foranemia in chronic kidney disease: 2007update of hemoglobin target. Am J KidneyDis 2007;50:471-530.9. Levey AS, Bosch JP, Lewis JB, Greene T,Rogers N, Roth D. A more accuratemethod to estimate glomerular fi ltrationrate from serum creatinine: a newprediction equation. Ann Intern Med 1999Mar 16;130(6):461-70.10. Kiberd B. The chronic kidney diseaseepidemic: stepping back and looking forward.J Am Soc Nephrol 2006; 17:2967-2973.11. National Kidney Foundation—Kidney EarlyEvaluation Program: KEEP Annual DataReport 2006, Am J Kidney Dis 2007;49:S1-S160.12. Smith DH, Gullion CM, Nichols G, KeithDS, Brown JB. Cost of medical care forchronic kidney disease and comorbidityamong enrollees in a large HMOpopulation. J Am Soc Nephrol2004;15:1300-1306.13. Hsu CY, McCulloch CE, Curhan GC.Epidemiology of anemia associated withchronic renal insufficiency among adults inthe United States: results from the ThirdNational Health and Nutrition ExaminationSurvey. J Am Soc Nephrol 2002;13:504-510.14. Arora P, Mustafa RA, Karam J, Khalil P,Wilding G, Ranjan R, Lohr J: Care ofelderly patients with chronic kidneydisease. Int Urol Nephrol 2006; 38:363-37015. Stack AG. Impact of timing of nephrologyreferral and pre-ESRD care on mortalityrisk among new ESRD patients in UnitedStates. Am J Kidney Dis 2003; 41:310-318.Please consult authors for additional references.The authors gratefully acknowledge theassistance of Cynthia Feng, West VirginiaUniversity Section of Nephrology inthe preparation of this manuscript.18 West Virginia Medical Journal

| Scientifi c ArticleLower Eyelid Reconstruction Following Mohs SurgeryMatthew J. Schessler, MS-IIIWest Virginia University Schoolof MedicineW. Thomas McClellan, M.D.Plastic SurgeonMorgantown Plastic Surgery AssociatesAbstractLower eyelid defects resulting fromMohs micrographic surgery can bechallenging to repair. These repairs arefraught with potential complication due tothe lower eyelid’s complex anatomy anddefect variability. A single “cookie-cutter”treatment regimen does not exist becausepatients and defects vary. Surgicalclosure techniques include primaryclosure, eyelid advancement, rotationalfl aps, full thickness skin grafts, and/orallografts. We present a discussion oflower eyelid reconstruction includingrelevant anatomy, physical signs, andtreatment options with examples.IntroductionEyelid defects resulting from Mohsmicrographic surgery require carefulconsideration of the anatomy. Athorough physical exam is requiredto properly identify, categorize,and implement the appropriatereconstructive treatment in orderto minimize complications. Mohssurgery is the optimal technique toremove basal and squamous cellcarcinomas from the lower eyelid andother anatomical structures whereunnecessary resection would causefurther disfigurement. Nonetheless,these lower eyelid defects arestill challenging to repair. After athorough examination of the patient’sdefect, eyelid characteristics, and aphysical exam, the optimal treatmentis selected. Common treatmentavenues are based on defect sizeand include primary closure, Tenzel,Hughes, or Tripier flaps. These canbe combined with full thickness skingrafts (FTSG), human allografts,or cartilage grafts. A canthoplastywith a periosteal flap or a fascia latagraft to correct lateral retinaculardehiscence may also be necessary.We discuss the functional anatomy ofthe lower eyelid, necessary physicalexam components, and reconstructivetechniques with patient examples.Additionally, we present analgorithm that integrates lamellardefects with surgical treatments.Anatomy of the Lower EyelidThe lower eyelid’s anatomy iscomplex and must be carefullyconsidered before reconstructivesurgery to prevent post-surgicalcomplications such as entropion,ectropion, canthal distortion, oraltered closure mechanisms.The lower eyelid consists of twolamellae separated by the orbitalseptum (some authors consider theseptum as the middle lamella in atrilamellar system) (1,2). The grey lineis a visible demarcation between theanterior and posterior lamellae andcorresponds to eyelash alignment. Italso aides in realigning the lower lidwhen repairing defects. The lowerlid should oppose the globe at theinferior limbus. Please see Figure 1for a diagram of the eyelid lamellae.Skin and the orbicularis oculimuscle comprise the anterior lamella.The skin is very thin (less than1mm) yet houses numerous finehairs and sebaceous glands. Theinfraorbital nerve (V1) is the primarysensory innervation of the lowerlid with additional contributionsfrom the zygomaticofacial nerve(V2). The orbicularis oculi muscle,innervated by the facial nerve(VII), functions to close the eyeand as the lacrimal pump.The posterior lamella includesthe tarsal plate and the palpebralconjunctiva. The tarsal plate consistsof dense, fibrous tissue that providesstructural support to the eyelidand houses the meibomian glandswhich secrete the sebaceous portionof the tear film. Behind the tarsalplate lies the palpebral conjunctiva,a thin epithelial layer that contactsthe conjunctiva of the globe.The tarsoligamentous slingconsists of the tarsal plates andthe canthal tendons. The slingsupports the globe in the orbitand facilitates eyelid closure (2).The upper and lower eyelids meetat the medial and lateral canthi.Please see Figure 1 for a diagramof the tarsoligamentous sling.The lateral canthus or retinaculumis not fully anchored to increasethe lateral visual field. The medialcanthus remains firmly anchored tothe frontal process of the maxilla. Thisanatomical discrepancy predisposesthe lateral canthus to develop laxityand phimosis with age (1). This senilelaxity must be accounted for whenselecting a reconstructive treatment.Lacrimal secretions drain byaction of the orbicularis oculi muscle.Secretions flow across the eye towardthe puncta near the medial canthus.Lacrimal fluid drains through theFigure 1.Schematic diagrams of the bilamellar system of the lower eyelid (left) and thetarsoligamentous sling (right).September/October 2009 | Vol. 105 19

Scientifi c Article |Figure 2.Measuring eye prominence with a Hertel exophthalamometer (left) and classification of eye prominence based upon Hertelmeasurements (right) (4).Eye Prominence Deep-set Normal ProminentHertel measurement 18mmpuncta into the lacrimal canaliculiand then into the lacrimal sacbehind the medial canthal tendon.The lacrimal sac empties into thenasolacrimal duct and then enters thenose via the inferior nasal meatus.Physical ExamA thorough pre-operative historyand physical exam is necessary toassess the defect, select the bestreconstructive technique, andminimize complications. Lowereyelid tone, canthal tilt, closuremechanics, Hertel measurement, andlower lid/inferior limbus relationshipare necessary to properly evaluate thetarsoligamentous support structure.Visual acuity, extraocular muscles,light reflex, and accommodationshould also be examined. Any historyof dry eye or Bell’s phenomenonshould be noted. The lacrimal ductsystem should also be examined.When a lower eyelid defect precludesa physical exam, examination ofthe contralateral eyelid is helpful.The anterior lid distraction testprovides an objective measurementof lower lid laxity. Lax eyelids canI’m Dr. John Eastone and I choose HIMG because I wanted to work alongside some ofthe best physicians and health care providers in the area. At HIMG, we are a collection of talentedand experienced individuals working together to deliver the absolute best in quality patientcare. We like to say “I’m HIMG” because every member of our team is proud to carry the strongreputation of our operation in all that we do.We’d like you to consider becoming part of our team.Headquartered in Huntington, West Virginia, HIMG is the largest privately held multi-specialtygroup in the state. Our 150,000 square-foot facility and our business practices have been a modelfor many operations throughout the nation. We are currently recruiting physicians and midlevelproviders in many areas and encourage you to contact us for a confidential review of theopportunities available.TM5170 U.S. Route 60 EastHuntington, WV 25705www.himgwv.com(304) 528-465720 West Virginia Medical Journal

| Scientifi c Articlebe distracted 6mm or more (3).Older patients typically havegreater eyelid laxity due to lateralretinacular dehiscence and lossof intrinsic elastic properties.Globe prominence is measuredwith a Hertel exophthalamometerwhich quantifies the distancefrom the cornea to the orbital rim.More prominent eyes requiremore canthal support (4).The location and patency of thelacrimal duct system should beverified with medial wounds. Priorto Mohs or reconstructive surgerysplinting tubes can be placed toidentify or protect the ducts.Surgical OptionsPartial thickness lower eyeliddefects involving the anterior lamellacan be treated conservatively withdressing changes and healing bysecondary intention. These methodsare very successful in the medialcanthal region. Buccal mucosagrafts are useful to repair margindefects that contact the globe.FTSGs are an excellent choice forsubmarginal defects lateral to thepuncta (2). The color and contourof the eyelid are important becausesubtle discrepancies are easilyidentified at conversational distances.The best donor site is excesscontralateral upper eyelid skin.However posterior auricular andsupraclavicular skin have excellentcolor and contour similarity (2,5).Full thickness lower eyeliddefects compromising bothlamellae can be categorized by thepercentage of lid length affected.These categories are 50% defect (6). Defectcategorization aides in selectingthe best reconstructive technique.A longitudinal scar will producea longitudinal force vector than cancontribute to ectropion of the lowereyelid. To prevent this phenomenon,the incision should be pentagonalshaped and directed laterally (2).Figure 3.69 year-old woman with a 20% lower eyelid defect and 8mm of lid laxity.Intraoperative photographs show primary closure of the original defect. Mohs defectand proposed incision in green (left), pentagonal incision (center), and scar directedlaterally (right).Misdirecting scar forces laterallyreduces the inferior contracture forceminimizing the risk for long-termectropion. Please see Figure 3.Defects of less than 25% can bereliably treated with primary closureor a Tenzel flap. The key determinantis the patient’s lid laxity. If a patienthas significant lid laxity (>6mm withanterior traction) or a slow lid snapback test then primary closure isindicated. Rotational advancementflaps such as the Tenzel are betterused in patients with less laxity.Ultimately, the goal is to align thegrey line and restore the lowerlid/inferior limbus relationshipwithout significant laxity or tension.Tenzel flaps, also known asrotational or semicircular flaps,are appropriate for patients withmoderate bilamellar defects, littleeyelid laxity, and normal lid snapback. These flaps can be used torepair up to 50% defects withsome authors reporting modifiedTenzel flaps correcting up to 60%defects (6,7). First a flap is createdbeginning at the lateral canthusand then extending upward in asemicircular pattern. A canthotomyis performed and the eyelid andflap is advanced to directly close thedefect (8,9). A canthoplasty mustbe performed to reset the lateralcanthus using a periosteal flap or afascia lata graft. Please see Figure 4.Twenty-five to 50% defects maybe repaired with a Tenzel flap ora Hughes flap (6). Tenzel flapsyield better results when appliedto short, deep defects whereas aHughes flap is a better treatmentoption for long, shallow defects.Hughes flaps, also calledtarsoconjunctival bridge flaps,advance the tarsal plate andconjunctiva from the ipsilateralupper eyelid to repair the defect inthe lower eyelid (10,11). This flapdelivers a vascularized posteriorlamellae and is inset after 7-14Figure 4.59 year old man with a short, deep 25% defect and little lid laxity (left). Schematic ofa Tenzel flap combined with a periosteal flap for lateral canthal reconstruction (centerleft) with a postoperative photo (center right). Follow up picture at 6 weeks (right).September/October 2009 | Vol. 105 21

Scientifi c Article |Figure 5.55 year old woman with a long, shallow 75% defect (left), and a schematic showingharvest of a Hughes flap (center left). Intraoperative photograph showing the insetof the Hughes flap to repair the posterior lamella (center right) and postoperativephotograph after a FTSG to repair the anterior lamella (right).Figure 6.Intraoperative photographs showing aTripier flap design (left) and inset into ananterior lamella defect (right).days (12-13). Little donor morbidityoccurs if 3-4mm of superior tarsalplate remains in the upper lid. Toreconstruct the anterior lamella, asemicircular flap or a FTSG can beused (13-15). Please see Figure 5.Defects greater than 50% requireseparate reconstructive approachesfor both lamellae. Components of thisbilamellar reconstructive approachare determined by the vascularityof the individual layers. Bothlamellae cannot be simultaneouslyrepaired using grafts becausethey will die due to lack of bloodsupply (2). For example, a Hughesflap can be used to reconstructthe posterior lamella with a FTSGgraft to repair the anterior lamella.If a Tripier or a Mustarde flap isused to repair the anterior lamellathen a tissue graft can be used toreconstruct the posterior lamella.However, using an orbicularisadvancement flap to provide bloodsupply, one can simultaneousreconstruct the anterior andposterior lamellae using grafts (16).In 1889 Tripier developed abipedicled myocuntaneous flapbased on the orbicularis oculimuscle (17). The flap is raised fromthe upper eyelid and transferred tothe lower eyelid while the defectis closed primarily. This flap isan excellent choice to reconstructthe anterior lamella but must beused with a posterior lamellagraft. Please see Figure 6.Commonly used posteriorlamella grafts include hard palate,auricular cartilage, and acellulardermis. Hard palate grafts producethe best aesthetic results with thefewest complications (18). However,techniques using acellular dermalmatrix spacers (Enduragen) arerapidly improving and some authorsreport aesthetic and functional resultssimilar to hard palate grafts (19-20).Additionally, using acellular dermisprecludes the need for anothersurgical site (20). Please see Figure 7.ConclusionLower eyelid defects followingMohs surgery can be complicatedFigure 7.Intraoperative photographs showing potential graft harvest sites useful in eyelidreconstruction. Hard palate (left), buccal mucosa (center left), auricular cartilage(center right), and an acellular dermal matrix (Enduragen) spacer (right).and challenging reconstructive cases.Understanding lower eyelid anatomyand mechanics is essential to preventcomplication. The ultimate goal oflower eyelid reconstruction is torestore the lid/limbus relationshipwhile maintaining proper tensionand canthal tilt of the eyelid. Multipleflaps and grafts may be used incombination to achieve surgicalgoals. Our algorithm categorizesdefects and guides in selectingthe best reconstructive option.References1. Nahai, F. The Art of Aesthetic Surgery:Principles and Techniques. Vol. 1. Chapter19: Applied Anatomy of the Eyelids andOrbit (Codner, MA, Hanna, MK). QualityMedical Publishing, Inc., St. Louis,Missouri. 2005. p. 625-650.2. Chandler DB, Gausas RE. Lower eyelidreconstruction. Otolaryngol Clin North Am.2005 Oct;38(5):1033-42.3. Nahai, F. The Art of Aesthetic Surgery:Principles and Techniques. Vol. 1. Chapter21: Upper and Lower Blepharoplasty(Codner, MA, Hanna, MK). Quality MedicalPublishing, Inc., St. Louis, Missouri. 2005.p. 679-718.4. Nahai, F. The Art of Aesthetic Surgery:Principles and Techniques. Vol. 1. Chapter20: Clinical Decision-Making in AestheticEyelid Surgery. Quality Medical Publishing,Inc., St. Louis, Missouri. 2005. p. 651-678.5. Khan JA. Sub-cilial sliding skin-muscle fl aprepair of anterior lamella lower eyeliddefects. J Dermatol Surg Oncol. 1991Feb;17(2):167-70.6. Gündüz K, Demirel S, Günalp I, Polat B.Surgical approaches used in thereconstruction of the eyelids after excisionof malignant tumors. Ann Ophthalmol(Skokie). 2006 .7. Levine MR, Buckman G. Semicircular fl aprevisited. Arch Ophthalmol. 1986Jun;104(6):915-7.Please consult authors for additional references.22 West Virginia Medical Journal

| Scientifi c ArticleFigure 8.Lower eyelid reconstruction algorithm which accounts for defect size, lower lid characteristics, and bilamellar reconstructive options.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 bycontacting the West Virginia Medical Professionals Health Program. Information about a practitioner’sparticipation in the program is confidential. Practitioners entering the program as self-referralswithout a complaint filed against them are not reported to their licensing board.ALL CALLS ARE CONFIDENTIALWest Virginia Medical Professionals Health ProgramPO Box 40027Charleston, WV 25364(304) 414-0400 | www.wvmphp.orgSeptember/October 2009 | Vol. 105 23

Scientifi c Article |Leuconostoc spp Sepsis in an Extremely Low Birth WeightInfant: A Case Report and Review of the LiteraturePanitan Yossuck, MDWVU School of MedicineDept. of Pediatrics, MorgantownPatricia Miller-Canfield, MDWVU School of MedicineDept. of Pathology, MorgantownKathryn Moffett, MDWVU School of MedicineDept. of Pediatrics, MorgantownJanet Graeber, MDWVU School of MedicineDept. of Pediatrics, MorgantownAbstractA three week old extremely low birthweight (ELBW) infant infected byvancomycin-resistant Leuconostoc spp ispresented. Treatment with appropriateantibiotics was successful after thepercutaneous inserted central catheter(PICC) was removed. The infection withLeuconostoc spp is rare but should besuspected when vancomycin-resistantorganisms resembling streptococci areisolated. Previous pediatric case reportsare also summarized and reviewed.IntroductionLeuconostoc spp are gram-positivecocci known to be present in plant,milk, dairy products and wine (1).It was not until the 1980s that theseorganisms were noted to haveassociation with human and animaldiseases. In 1984, Coleman and Ballreported the isolation of Leuconostocspp from blood cultures (2). In 1985,Buu-Hui et al recognized the invitro resistance of this pathogento vancomycin (3). Sporadic casereports of these organisms causingserious and sometimes fatal diseasein all patient age groups have beenpreviously reviewed by Capatepis etal in 1994 (4) and by Dhodapkar etal in 1996 (5). There were nine morepediatric case (≤ 18 yr) reports inEnglish literature since the review byDhodapkar et al in 1996 (6-12). Wereport an extremely low birth infantwith Leuconostoc bacteremia andreview the case reports caused by thisorganism in the pediatric population.Case ReportThis baby boy was bornprecipitously at 24 4/7 weekgestational age (GA) with birthweight of 700 gm to a 23 year oldmother with a history of smoking.The baby was transferred to ourunit immediately after birth. He wasnoted to have a right pneumothoraxand had chest tube placement for10 days. Initially he was placed onampicillin and gentamicin for 48hour Antibiotics were discontinuedafter negative cultures werereported. Cranial ultrasound showedbilateral grade III intraventricularhemorrhage (IVH). At one weekof age, due to increased ventilatorsupport, metabolic acidosis andincreased white blood cell count, asecond set of blood cultures weresent and the baby was started onvancomycin and gentamicin. Bothantibiotics were again discontinuedafter 48 hours since no organism wasidentified from the blood cultures. Anumbilical catheter (UAC) was initiallyplaced and then was replaced by apercutaneous inserted central catheter(PICC) when the baby was two weeksold. Trophic feeding was startedat day of life 6 and was graduallyincreased. At age 22 days, whilethe baby was still on the ventilatorwith a low FiO2 requirement andreceiving more than half of his caloricintake from enteral feeds, a routineCBC was noted to have WBC of28,000 cell per mm3, I:T ratio of 0.35,and platelet count of 37,000. Bloodcultures from two different siteswere drawn. Lumbar puncture wasperformed after platelet transfusion.The baby was started on vancomycinand gentamicin. A total of twodoses of platelet concentrate wereadministered. Within 24 hours, bloodcultures identified gram-positivecocci which were preliminarilyreported as alpha Streptococci spp.After 48 hours on vancomycin andgentamicin, the repeat blood culturesfrom two different sites were drawn.The initial blood culture was finallyreported as Leuconostoc spp andcoagulase negative Staphylococci(CONS). Ampicillin was addedto the regimen. The second set ofblood cultures continued to growboth organisms. The third set ofblood cultures 48 hours after addingampicillin were drawn whichrevealed both organisms had grown.The PICC was pulled. Another setof blood cultures were drawn at 72hours after PICC was discontinued.This time no organism was identified.The baby completed a two weekcourse of ampicillin, vancomycinand gentamicin. Cerebrospinal fluidprofiles were with in normal limit forage. Nothing grew from the CSF. Atday of life 46, three weeks after theLeuconostoc and CONS bacteremia,the baby developed frequent stools.He was NPO for 24 hour Stool C.difficile toxin test was positive. Notreatment was given since the babyspontaneously resolved and he wasback on full feeding within twodays. No necrotizing enterocolitis(NEC) was noted for the entirecourse of his hospitalization. Hewas discharged home at day 103.DiscussionLeuconostoc spp was thought tobe non-pathogenic to humans untilthe 1980s (3). These gram-positiveorganisms are normally isolated fromsoils, plant materials, dairy productsand wines (13). Although they arenot part of the usual normal flora,Leuconostoc spp have been isolatedfrom vaginal and stools samples (14).The incidence of colonization mayhave changed since the wide spread24 West Virginia Medical Journal

| Scientifi c Articleuse of vancomycin in clinical practice.Although infections secondary toLeuconostoc spp are uncommon,there have been sporadic casereports of Leuconostoc spp humaninfection in both pediatric andadult patients (4,5). Most of thesepatients had underlying diseases.In the English literature reviewedby Dhodapkar et al in 1996 (5),there were 29 cases of Leuconostocspp infection. Sixty percent of thecase reports were children. Fiveout of 18 pediatric cases werepremature infants. Since the reviewin 1996, there have been at least ninepediatric case reports. Eight are inEnglish literature. One of these wasa healthy infant. To our knowledge,this presenting case is the youngestand smallest infant that sufferedwith Leuconostoc spp infection.We reviewed 28 cases of pediatricpatient infected with Leuconostocspp from the English literature.Only three cases did not have anunderlying disease. One was a16 year old who presented witha classical manifestation of acutemeningitis (15). The second case wasa 9 month old infant who presentedwith right-side pneumonia (16).The third case was a 2.5 month oldinfant who presented with acutebronchiolitis and concomitantRSV infection (7). There was onecase where the infection occurredin a normal term newborn infantconcomitant with CONS. The infantdid not show any clinical symptomsor signs and was sent home withoutany treatment (16). Eleven out of28 cases (39%) had gastrointestinalabnormalities as an underlyingdisease. Short gut syndrome wasthe majority of these cases. Five casereports, including our case, wereborn prematurely. In the report byHardy (17) the infant was 26 weekGA when she was born. The infectionoccurred at 34 week corrected age.Two cases reported by Gollege (18)occurred in a 28 week-old and 32week-old infant. The corrected ageand the time that the infectionsoccur were not specified. The casereport by Carapetis (4) discussedan infant born at 28 week GA butLeuconostoc spp infection occurredat 20 months of age. In our case, thebaby was born at 24 6/7 week GA.The infection occurred when he was28 week corrected. Besides prematureinfants, the other major categoriesof pediatric patients infected withLeuconostoc spp were those who hadobvious immunosuppressive statessuch as leukemia and the humanimmunodeficiency virus (HIV)infection. Central venous catheter isalso a major risk factor to Leuconostocspp infection. Half of these patientshad central venous catheter inplace when the infection occurred.Exposure to vancomycin was foundin 64% of all pediatric case reports.The source of Leuconostoc sppinfections is still controversial. SomeHELPING WEST VIRGINIA PHYSICIANS TAKE THE RIGHT PATH……in litigation, privacy and security compliance, certificate of need, medical staff and professionaldisciplinary matters, credentialing concerns, complex regulatory matters and business transactions.HEALTH CARE PRACTICE GROUPRyan A. BrownRobert L. CoffieldAlaina N. CrislipJ. Dustin DillardSam FoxMichele GrinbergJohn D. HoffmanAmy R. HumphreysCharlestonJustin D. JackRichard D. JonesEdward C. MartinMark A. RobinsonAmy L. RothmanDon R. Sensabaugh, Jr.Salem C. SmithMorgantownStephen R. BrooksStacie D. HonakerWheelingDavid S. GivensPhillip T. GlyptisRobert C. JamesEdward C. Martin, Responsible Attorney | tedm@fsblaw.com | www.fsblaw.com | (304) 345-0200 | (800) 416-3225September/October 2009 | Vol. 105 25

Scientifi c Article |authors postulate the port of entryis from skin. In our case, we did notdo a skin culture. Some reports raisethe possibility of access to the bloodstream from the gastrointestinaltract, particularly since there havebeen many cases associated withintestinal pathology such as shortbowel syndrome. The stool culturethat was sent in our case was doneafter the baby completed a course ofantibiotics. Leuconostoc spp was notidentified. Noriega et al (19) reportedthe source of infection from a blenderthat was used to prepare formula fora 6 month old infant who had shortgut syndrome. In our case, the babywas receiving half of his caloric intakefrom enteral feeds. The formulawas prepared by our nutritiondepartment under sterile technique.The majority of the previouslyreported cases in premature infantsreceived vancomycin prior toLeuconostoc spp infection. In our case,the baby received only 48 hour ofvancomycin eight days prior to theinfection. Whether prior vancomycintherapy leads to the developmentof Leuconostoc spp infection in thiscase is still uncertain. A centralline catheter was one risk factor inmany of the case reports, both inadult and pediatric patients. In ourcase, the baby had a central catheterfrom birth (first the UAC and thena PICC). Rubin et al (20) reportedthe colonization of Leuconostoc spp ata central line hub in a 6 month oldinfant with short gut syndrome whohad Leuconostoc spp bacteremia. Wedid not investigate the colonizationof the central line hub in our case.The clinical manifestation in ourcase was subtle. The CBC was sentfor a routine lab check. There wasno bleeding diathesis noted whilethrombocytopenia occurred. Thebaby also tolerated feeds well. Therewas no temperature instability. Hedid not have any sign or symptomthat suggested NEC during the timeof infection. The initial report asalpha Streptococcus spp in our casewas commonly seen in other casereports since Leuconostoc spp is oneof a group of gram positive, catalasenegative cocci (3,21-23). Whenisolated on blood horse agar plates,Leuconostoc spp will resemble alphahemolytic Streptococci, however,gram stains performed from theseplates are highly unreliable. A 5-mltube of Todd Hewitt broth must beinoculated and then incubated overnight. A gram stain performed fromthe broth culture will then revealgram positive coccobacilli or grampositive rods. Only Lactobacilli,Leuconostoc and Lactococci in thisgroup will produce this result ofgram stain from broth. Biochemicaltesting of the organism will thenreveal bile esculin positivity, PYRasenegativity and no growth at45 degree Celcius in NaCl (22,23).Finally, the diagnostic test forLeuconostoc spp following the abovefinding is complete vancomycinresistance. This test is performedby dropping a vancomycinimpregnateddisc on a bloodagar plate that has the organismisolated. A no zone of inhibitionafter incubation is demonstrated.Once these findings are confirmed,Leuconostoc spp is reported as thepathogen in the cultured specimen.The species identification andthe anti-microbial susceptibilitywere not performed in our case.Ampicillin was chosen basedon previous literature review. Amajority of cases were treatedsuccessfully with penicillin,ampicillin or amoxicillin. After 48hour of appropriate antibiotics, wecould not eliminate the organismfrom the blood stream. The PICCwas removed which promptedsubsequent resolution. In the twopremature infants cases previouslyreported (4,17), and four otherpediatric cases (5,11,24,25) thecatheters were also removed tosuccessfully clear the infection. Inone case, the resolution of infectionoccurred by having catheterremoved without antibiotic (25). Themanagement of the central catheterin cases of catheter–associatedbacteremia is still unclear.Scano et al (26) reported a caseclusterof Leuconostoc spp infectionin the same unit at the same timeof hospitalization of adult patientswhich indicated transmissionbetween patient. The patientsall had underlying disease andall had compromised skin andmucous membranes. Cappelli (6)et al demonstrated a cluster ofLeuconostoc spp urinary tractinfection in five patients admittedto the same hospital floor whichsuggested the outbreak potentialand the risk of possible nosocomialinfection. Three of these werepediatric patients (≤18 yr). We didnot find any other cases in our unitbesides this reported case. The modeof transmission and reservoirs ofLeuconostoc spp are as yet unknownin most of the cases reported.The increase of coagulase negativeStaphyloccus infections in newbornintensive care units, which accountfor the majority of late onset neonatalsepsis, has led to increase usage ofvancomycin. An increased incidenceof gram-positive cocci that areresistant to vancomycin is expectedto increase in this circumstance. Anorganism that was once thought tobe non-pathogenic and commonmay eventually cause serious andfatal infection, particularly in thecompromised host such as theextremely low birth weight infant.The need for central line cathetersand frequent exposure to vancomycinmakes low birth weight infantsmore vulnerable to the infectionby these organisms. The carefuluse of vancomycin and awarenessof the importance of testing forvancomycin resistance in grampositivecocci are crucial. Leuconostocspp infection should be suspectedin any case with vancomycinresistantstreptococci and shouldbe appropriately managed.References1. Garvie EI. Separation of species of thegenus Leuconostoc and differentiation ofthe Leuconostocs from other lactic acidbaceteria. Methods in Microbiology1984;16:147-178.2. Colman G, Ball LC. Identifi cation of26 West Virginia Medical Journal

| Scientifi c Articlestreptococci in a medical laboratory. J ApplBacteriol 1984;57:1-14.3. Buu-Hoi A, Branger C, Acar JF.Vancomycin -resistant streptococci orLeuconostoc sp. Antimicrob AgentsChemother 1985;28:458-460.4. Carapetis J, Bishop S, Davis J, Bell B,Hogg G. Leuconostoc sepsis in associationwiht continuous enteral feeding: two casereports and a review. Pediatr Infect Dis J1994;13:816-823.5. Dhodapkar KM, Henry NK. LeuconostocBacteremia in an infant with short-gutsyndrome; case report and literature review.Mayo Clin Proc 1996;71:1171-1174.6. Cappelli EA, Barros RR, F.Camello TCF,Teixeira LM, Acar JF, C.Merquior VL.Leuconostoc pseudomesenteroides as acause of nosocomial urinary tractinfections. J Clin Microbiol 1999;37(12):4124-4126.7. Casanova-Roman M, Rios J, Sanchez-Porto A, Gomar JL, Casanova-Bellido M.Leuconostoc bacteremia in a healthyinfant. Minerva Pediatr 2003;55(1):83-86.8. Gillespie RS, Symons JM, McDonald RA.Peritonitis due to Leuconostoc species in achild receiving peritoneal dialysis. PediatrNephrol 2002;17(11):966-968.9. Golan Y, Poutsiaka DD, Tozzi S, Hadley S,Snydman DR. Daptomycin for line-relatedLeuconostoc bacteremia. J AntimicrobChemother 2001;47(3):364-5.10. Helali A, McAlear D, Osoba A.Leuconostoc bacteremia in a child withshort-gut syndrome. Saudi Med J 2005;26(2):311-313.11. Monsen T, Granlund M, Olofsson K, OlsenB. Leuconostoc spp. septicemia in a childwiht short bowel syndrome. Scan J InfectDis 1997;29(3):311-312.12. Mulford JS, Mills J. Osteomyelitis causedby Leuconostoc species. Aust N Z J Surg2004;69(7):541-542.13. Garvie EI. Bergey’s Manual of systmaticbacteriology. Baltimore: Williams&Wilkins,1986.14. Rogosa M, Sharpe ME. Speciesdifferentiation of human vaginal lactobacilli.J of Gen Microbiol 1960;23:197-201.15. Coovadia YM, Solwa Z, Van Den Ende J.Meningitis caused by vancomycin-resistantLeuconostoc spp. J Clin Microbiol 1987;25:1784-1785.16. Coovadia YM, Solwa Z, Van Den Ende J.Potential Pathogenicity of Leuconostoc[letter]. Lancet 1988;1:306.17. Hardy S, Ruoff KL, Catlin EA, Santos JI.catheter-associated infection with avancomycin-resistant gram-positive coccusof the Leuconostoc sp. Pediatr Infect Dis J1988;7(7):519-520.18. Gollege CL. Infection due to Leuconostocspecies [letter]. Rev Infect Dis 1991;11:29-30.19. Noriega FR, Kotloff KL, Martin MA,Schwalbe RS. Nosocomial bacteremiacaused by Enterobacter sakazakii andLeuconostoc mesenteroides resulting fromextrinsic contamination of infant formula.Pediatr Infect Dis J 1990;9:447-449.20. Rubin LJ, Vellozzi E, Shapiro J, IsenbergHD. Infection wiht Vancomycin-Resistant“Streptococci” Due to LeuconostocSpecies [letter]. J Infect Dis 1988;157:216.21. Ruoff KL, Kuritzkes DR, Wolfson JS,Ferraro MJ. Vancomycin-resistant grampositvebacteria isolated from humanresources. J Clin Microbiol 1988;26(10):2064-2068.22. Facklam R, Hollis D, Collins HD.Identifi cation of gram-positive coccal andcoccobacillary vancomycin-resistantbacteria. J Clin Microbiol 1989;27(4): 724-730.23. Isenberg HD, Vellozzi EM, Shapiro J,Rubin LG. Clinical laboratory challanges inthe recognition of Leuconostoc spp. J ClinMicrobiol 1988; 26(3):479-483.24. Bernaldo de Quiros JS, Munoz P,Cercenado E, Hernandez Sampelayo T,Moreno S, Bpiza E. Leuconostoc speciesas a casue of bacterremia: two casereports and a literature review. Eur J ClinMicrobiol Infect Dis 1991;10:505-509.25. Handwerger S, Horowitz H, Coburn K,Kolokathis A, Wormser GP. Infection due toLeuconostoc species: six cases andreview. Rev Infect Dis 1990;12:602-610.26. Scano F, Rossi L, Cattelan A, Carretta G,Meneghetti F, Cadrobbi P et al.Leuconostoc species; a case-clusterhospital infection. Scan J Infect Dis 1999;31(4):371-373.What’s behindquality healthcare inrural West Virginia?For nearly ten years, the Center for Rural HealthDevelopment’s Loan Fund has worked to assisthealthcare providers throughout West Virginia byproviding affordable loans at reasonable termsand conditions to address facility, equipment, andtechnology needs.AFFORDABLE LOANSFOR FACILITIES,EQUIPMENT ANDTECHNOLOGYWhether you’re a dentist, physician, health centeror a hospital, contact Robert Dearing, CFO/Loan Fund Manager today to learn more aboutour commitment to help you to meet your capitalfinancing needs.Center for Rural Health Development, Inc.3465B Teays Valley RoadHurricane, WV 25526(304) 397-4071robert.dearing@wvruralhealth.orgEqual Opportunity LenderSeptember/October 2009 | Vol. 105 27

Scientifi c Article |Caudal Epidural Blood PatchRoger A. Cook, MDRichard P. Driver, Jr., MDDepartment of AnesthesiologySchool of MedicineWest Virginia UniversityImplicationsEpidural blood patch may beemployed through the caudalapproach directly through theepidural needle and does notrequire the placement of a catheterto ensure cephalad spread.AbstractThis report describes the use of asingle shot, through the needle caudalapproach to epidural blood patch (EBP) ina patient with persistent leakage ofcerebrospinal fl uid following lumbosacrallaminectomy. A previous report of caudalEBP in an adult patient with an epiduralcatheter suggested that the success ofthe procedure could be comparablewithout the use of a catheter. This casereport documents the success of throughthe needle caudal EBP in an adult patient.IntroductionPostdural puncture headache(PDPH) complicates penetrationof the dura mater. The mechanisminvolves leakage of cerebrospinalfluid (CSF), decreased intracranialvolume, traction on pain sensitivestructures, and increases incerebral blood flow (1-6).Epidural blood patch (EBP)is frequently employed to treatPDPH (1). The theoretical effect istamponade and obstruction of CSFleakage through several possiblemechanisms (2-4,6). Not all patientsare candidates for standard EBP.Structural abnormalities such aslumbar surgery make the proceduremore difficult. We were asked toperform an EBP on a post-surgicalpatient with known dural leakand failed fluoroscopic EBP.Case DescriptionA 51 year old male with spinalstenosis has continued CSFleakage following decompressivelaminectomy at L3-S1. A secondsurgery to repair the leak failedwith the patient returning oneweek following discharge withrenewed symptoms. The patient wasreferred to interventional radiologyfor fluoroscopically guided EBP.The epidural space was identifiedfluoroscopically at the L3-L4 leveland 10ml of autologous, sterile bloodinjected. Significant epidural scarringwas noted. The patient experiencedimmediate relief but within fourdays noted return of symptoms. TheAnesthesia service was consulted toassess treatment options, particularlythe possibility of repeat EBP. Thepatient related a constant, throbbing,frontal-occipital headache, inabilityto stand, photophobia, neck stiffness,and several near syncopal episodes.Due to the distorted lumbar anatomyand transient relief achieved withfluoroscopically guided EBP, acaudal approach was considered.A rapid literature search supportedthis decision with one case reportdescribing the caudal route withthe use of an epidural catheter.The patient was placed in theleft lateral decubitus position. Thesacral hiatus was readily identified,prepped with betadine solution, and1% lidocaine infiltrated. An 18 gaugeHustead needle was advanced usingthe “Loss of Resistance” technique.Preservative free NS was easilyinjected to help confirm properplacement. Sterile, autologous bloodwas obtained and slowly injected;16ml were injected at which timethe patient complained of sacralpressure and pain in the lowerback. The patient remained supinefor 30 minutes. All symptoms wereresolved. One week after the EBP thepatient noted returning symptoms aspreviously but that he experiencedtotal relief for three days postprocedure.He ultimately underwenta second surgical closure of thedural leak, which was successful.DiscussionEBP is an effective means ofrelieving PDPH. However, accessingthe epidural space can be limitedby post-surgical or pathologicdistortions of native anatomy. Insuch cases alternate techniquesmay successfully gain entry to theepidural space. Medical technologycan identify spinal structures andprovide landmarks to the epiduralspace. EBP with fluoroscopicguidance has been shown to beeffective and may have a highersuccess rate (7). Ultrasonography(USG) may also be used to identifythe epidural space, but may haveless utility in the presence of scartissue (8). We identified one case ofan adult patient treated with an EBPthrough the caudal approach (9).This case described difficult lumbaraccess due to scar tissue and spinalinstrumentation (Herrington rods).A caudal approach for EBP wasused and a catheter was placed toprovide a conduit for more cephaladspread of blood. However, theauthors postulated that the proceduremight have been just as efficaciousas a needle injection rather thanusing a catheter. Our case supportsthis assumption – a through theneedle injection of blood via thecaudal approach is effective. Thereis one pediatric case report of a 4-year old with Acute LymphocyticLeukemia and a subarachnoidfistula that received caudal EBPas a single needle injection (10).Infusion of dextran containingsolutions through a caudal catheterhas also been effective (11).28 West Virginia Medical Journal

| Scientifi c ArticleIt is our practice to place as muchblood into the epidural space astolerated, usually in the range of15-20ml. We anticipated placing asignificantly greater volume with thecaudal space, as much as 20-30ml,to obtain adequate spread to theL3-L4 level, the assumed site of CSFleakage in this patient. This estimatewas based on the larger anestheticvolumes required to obtain sensorylevels with the caudal approach.However, these theoretical volumescould not be achieved due to painand radicular symptoms. The totalamount of injectate was similar tothat which is routinely given throughthe lumbar route. Despite the volumelimitation the patient had total reliefof symptoms for at least 3 days.We were asked to perform anEBP in a patient with known duralleak, distorted lumbar anatomyfollowing spinal surgery, and ascarred, narrowed epidural space.The caudal approach to EBP was areasonable option to avoid repeatspinal surgery and the risk of furtherdural compromise using a standardlumbar approach. Unfortunately,whether fluoroscopically guidedor through the caudal approach,the dural defect was not whollyamenable to EBP and surgicalrepair was ultimately required.References1. Carrie LES. Postdural puncture headacheand extradural blood patch. Br J Anaesth1993;71:179-181.2. Crawford JS. Experiences with epiduralblood patch. Anaesthesia 1980;35:513-515.3. Szeinfeld M, Ihmeidan IH, Moser MM,Machado R. Epidural blood patch:evaluation of the volume and spread ofblood injected into the epidural space.Anesthesiology 1986;64:820-822.4. Loeser EA, Hill GE, Bennett GM. Time vssuccess rate for epidural blood patch.Anesthesiology 1978;49:147-148.5. Beards SC, Jackson A, Griffi ths AG.Magnetic resonance imaging of extraduralblood patches: appearances from 30 min to18 h. Br J Anaesth. 1993;71:182-188.6. Cook MA, Watkins-Pritchford JM. Epiduralblood patch: a rapid coagulation response.Anesth Analg 1990;70:567-568.7. Bhandari A, Anand A, Khan F. Epiduralblood patch: Comparison of fl uoroscopicguided technique vs non-fl uoroscopictechnique. The Pain Clinic 2001;13:77-82.8. Grau T. The evaluation of ultrasoundimaging for neuraxial anesthesia. Can JAnesth 2003;50:R1-R8.9. Gerancher JC, D’Angelo R, Carpenter R.Caudal epidural blood patch for thetreatment of postdural puncture headache.Anesth Analg 1998;87:394-395.10. Kowbel MA, Comfort VK. Caudal epiduralblood patch for the treatment of apaediatric subarachnoid-cutaneous fi stula.Can J Anaesth 1995;42:625-627.11. Aldrete A. Persistent post-dural punctureheadache treated with epidural infusion ofdextran. Headache 1994;34:265-267.The renowned diagnostic and preventive medicine clinic, established in 1948, linked to theworld famous five-diamond Greenbrier Resort, seeks a full-time experienced board-certifiedFamily Practitioner for our outpatient facility GreenbrierCare. Beginning in 2007 the Clinicexpanded its services to include a new outpatient clinic on the resort grounds that offeraffordable healthcare and ancillary services to the Greenbrier Resort employees and their familymembers. This is a wonderful opportunity that affords intellectual stimulation and meaningfulpatient interaction while allowing time for family and the exceptional leisure activities readilyavailable. Greenbrier County is an outstanding place to live. Lewisburg, its sophisticated countyseat, was recently selected a leading small “arts town” in the nation and in National Geographic,a best American small town to visit. Greenbrier County’s schools are superb and nationallyrecognized. The Greenbrier Valley’s recreational opportunities, on and off the resort’s 6500 acres,are simply extraordinary. We are offering a very competitive salary and benefits. Contact EdJones Administrator at 304-536-4870 Ext 376 or email CV to edjones@greenbrierclinic.comSeptember/October 2009 | Vol. 105 29

Scientifi c Article |Parathyroid FNA and Hormone AssayTodd DerreberryMedical Student-IVMarshall University Joan C. EdwardsSchool of Medicine, HuntingtonAbid Yaqub MD, FACPAssistant Professor of MedicineSection of Endocrinology andMetabolism, Department of MedicineMarshall University Joan C. EdwardsSchool of Medicine, HuntingtonAbstractPrimary hyperparathyroidism is arelatively common problem encounteredin clinical endocrine practice. In mostcases the diagnosis is relativelystraightforward, however, when imagingstudies fail to localize the parathyroidadenoma or hyperplasia, managementcan be challenging. We describe heresuch a case where the diagnosis wasmade by a novel method of analysis ofparathyroid hormone levels in the needlewash obtained during fine-needleaspiration of a suspected parathyroidadenoma.A 60 year old white male was fi rstseen in the endocrinology clinic forevaluation of osteoporosis. He had historyof multiple compression vertebralfractures involving thoracic and lumbarvertebrae and fracture of right femoralneck following minimal trauma. He hadhigh normal serum calcium and elevatedurinary calcium levels. His parathyroidhormone level was within normal limits.Work-up for secondary causes ofosteoporosis was unremarkable. He wasstarted on hydrochlorthiazide therapy fora presumptive diagnosis of idiopathichypercalciuria. Subsequently his serumcalcium level became elevated and hecontinued to have signifi canthypercalciuria. The elevation in serumcalcium persisted despite cessation ofhydrochlorthiazide therapy. Parathyroidhormone level remained in mid-normalrange. A diagnosis of primaryhyperparathyroidism was considered atthis stage and imaging studies werecarried out to localize the parathyroidpathology. Parathyroid-sestamibi scan didnot reveal any abnormality. Ultrasoundexamination of the neck showed ahypoechoic nodule posterior to rightthyroid lobe. A fi ne needle aspiration ofthe nodule was carried out with estimationof parathyroid hormone level in the needlewash to indicate the presence ofparathyroid adenoma. This was surgicallyremoved later successfully withsubsequent normalization of serum andurinary calcium levels.The current management ofhyperparathyroidism is primarily surgical.Minimally invasive parathyroid surgery isthe treatment of choice but it requires theclear localization of a parathyroid lesionfor successful removal. In cases wherepreoperative localization is evasive, noveltechniques, such as the one describedabove, can provide useful diagnosticinformation which can aid in thesuccessful management ofhyperparathyroidism. Further studies areneeded before this technique can beapplied on a more widespread basis.IntroductionPrimary hyperparathyroidismis a relatively common problemencountered in clinical endocrinepractice. It is the most common causeof hypercalcemia in an outpatientsetting and is often detectedincidentally through blood testing. Inmost cases the diagnosis is relativelystraightforward with elevated serumcalcium and intact parathyroidhormone. Treatment involvessurgical excision of an adenomaor hyperplastic glands. Successfulpreoperative localization allowsremoval of the glandular tissue via aminimally invasive approach, whichhas a 90-100% success rate withreduced morbidity and operationtime as compared to the conventionalneck exploration technique (1).However, when imaging studies failto localize the parathyroid adenomaor hyperplasia, management can bechallenging. We describe such a casewhere parathyroid sestamibi scanand other imaging studies failedto definitively localize the affectedgland. Thus, a novel techniqueusing ultrasound guided fine needleaspiration and measurement ofintact parathyroid hormone in theneedle wash was used to definitivelylocalize the parathyroid adenoma.Case ReportA 60 year old white male wasfirst seen in the endocrinologyclinic in March 2006 for evaluationof osteoporosis. He had history ofmultiple compression vertebralfractures involving thoracic andlumbar vertebrae and fracture ofright femoral neck following minimaltrauma. The DXA scan done inApril 2005 had shown a T scoreof -2.9 and Z score of -2.4 at spineand T score of -2.4 and Z score of-1.3 at mean femoral neck. He hadalready been started on weeklyTable 1: A temporal flow sheet of patient’s pertinent laboratory testsLaboratory Tests March 2006 May 2007 Nov 2007 June 2008 Aug 2008(Post-operative)Serum Calcium(8.4-10.2 mg/dl) 10.2 10.7 10.9 10.7 10Serum Phosphorus(2.7-4.5 mg/dl) 3.4 3.0 3.6 4.4PTH (10-97 pg/ml) 71.3 52.5 11.725-OH Vitamin D 39.2 51.8 43.21,25 OH Vitamin D 52 44.1Urinary Calcium(100-300 mg/24hr) 447 437 415 26630 West Virginia Medical Journal

| Scientifi c ArticleRisedronate following the DXA scan.He had good nutritional intake withadequate calcium and vitamin Dintake. He exercised regularly andhad a healthy lifestyle. He did notsmoke or drink. His mother andsister both had osteoporosis. Therewas no history of usage of steroidsor any other medications whichcause bone loss. He had no signsor symptoms of malabsorption,liver or kidney disease. He hadhypothyroidism and was onadequate levothyroxine replacement.There was a remote history ofnephrolithiasis about 15 years ago.Further laboratory testing revealedhigh normal serum calcium of 10.2mg/dl (Normal range 8.4-10.2mg/dl)and a normal parathyroid hormonelevel. He had an elevated 24-hoururinary calcium of 447 mg. Therest of the work-up for secondarycauses of osteoporosis including25-hydroxy vitamin D, serumprotein electrophoresis, completeblood count, chemistry panel, celiacdisease panel, and serum testosteronewas within normal limits. Pleaserefer to Table 1 for the initial andsubsequent laboratory evaluations.An initial diagnosis of idiopathichypercalciuria was made and hewas started on hydrochlorthiazideto decrease the urinary calciumexcretion. Subsequent DXA scansdone in March 2006 and May 2007showed an initial improvementand then stabilization of bonemineral density values. However,his urinary calcium continued to beelevated despite hydrochlorthiazidetherapy. In May 2007 he was foundto have elevated serum calcium of10.7mg/dl which was assumed to besecondary to the hydrochlorthiazidetherapy. Hydrochlorthiazide wasdiscontinued and he was advisedto adopt a low-sodium and lowprotiendiet in an attempt to decreasethe urinary calcium excretion.His serum calcium level continuedto be elevated despite the cessationof hydrochlorothiazide therapy.His parathyroid hormone levelwas at the upper half of normalrange at 52.5 pg/dl (Normal range8-97pg/dl), pointing toward PTHmediated hypercalcemia. At thispoint, a diagnosis of primaryhyperparathyroidism was consideredand localization studies were orderedto find the parathyroid adenoma.Parathyroid-Tc 99m Sestamibi scandid not reveal any evidence ofparathyroid adenoma or hyperplasia(Figure 1). MRI examination of theneck failed to localize the parathyroidadenoma. However, ultrasoundSeptember/October 2009 | Vol. 105 31

Scientifi c Article |Figure 1.Parathyroid Tc 99m sestamibi scanshowing no evidence of abnormal uptakeon the delayed images.Figure 2.Ultrasound examination of thyroid showing 13x7x5 mm hypoehoic structure adjacentto right thyroid lobe (Parathyroid adenoma indicated by arrow).examination of the neck in June2008 demonstrated a 1.3 x 0.7 x 0.5cm hypoechoic area immediatelyposterior to the right thyroid glandwhich was reported as a possiblelymph node by the radiologist (Figure2). Due to the questionable nature ofthe lesion identified on ultrasound,and a strong clinical suspicion for apossible parathyroid adenoma, thedecision was made to aspirate thesuspicious hypoechoic nodule. In July2007 he underwent aspiration of thesuspicious nodule performed by thetreating endocrinologist. Under directultrasound guidance and using a 27-G needle, in addition to the materialobtained for cytology, a needlewash specimen was obtained witha saline flush for intact parathyroidhormone and thyroglobulin levels.The cytology report failedto show any thyroid epithelialcells or colloid. The needle washspecimen revealed an intact PTHlevel of 29,994 pg/ml (Control

| Scientifi c ArticleTable 2: Previously published studies using FNA of suspicious lesions to obtain PTH concentration.Author (ref) Year published # of Patients Sensitivity SpecificityOwens et al (8) 2008 10Abraham et al (1) 2007 32 91% 95%Erbil et al (7). 2007 62 100% PPV: 100%Masser et al (15) 2006 12Stephen et al (14) 2005 54 94% 100%Marcocci et al (12) 1998 31 70% 100%Sacks et al (9) 1994 66 100%MacFarlane et al (10) 1994 42 70% 100%Tikkakoski et al (13) 1993 16Doppman et al (11) 1983 21*Note that some studies did not include sensitivity, specifi city, or PTH concentration dataadenoma, and the surgicalpathology specimen confirmed thepresence of parathyroid adenomameasuring 1.4x0.7x0.4 cm andweighing 295mg (Figure 3).He had normalization ofserum and urine calcium levelsfollowing the successful removalof parathyroid adenoma.DiscussionPrimary hyperparathyroidismin the most common cause ofhypercalcemia and is caused bya solitary adenoma in 85-90%of patients. Double adenomas,parathyroid hyperplasia andparathyroid carcinoma accountfor the remaining cases (2). Thecurrent management of primaryhyperparathyroidism involvessurgical removal of the adenomaor hyperplastic glands responsiblefor the inappropriately increasedparathyroid hormone secretion. Ithas been proven in several studiesthat selective surgical excision ofaffected glands after preoperativelocalization leads to the best longterm outcomes in management (3).Successful preoperative localizationallows removal of the glandulartissue via a minimally invasiveapproach, which has reducedmorbidity and operation time ascompared to the conventional neckexploration technique. The procedurerequires preoperative localizationof the adenoma by technetium-99m-sestamibi or ultrasonography.There are currently two methodsto confirm adenoma removal;intraoperative PTH assay, and radioguidedparathyroidectomy. Theintraoperative assay takes advantageof the short half-life of PTH and isa measurement in the reduction ofPTH concentration from pre-incisionlevels (50% reduction in successfulremoval) (4). With the radio-guidedmethod, technetium labeled sestamibiis administered intravenously one totwo hours prior to the operation, andduring the procedure the surgeonuses a gamma probe in the operatingroom to localize and remove thearea of highest radioactivity. Afterremoval of tissue, the radioactivityof the excised specimen is comparedto that of the surgical bed (5).The two most commonly usedlocalization modalities includeultrasonography and technetium Tc99m sestamibi scan. Both techniquesoffer a non-invasive approach toidentifying most parathyroid lesions.The sensitivity of these techniquesfor identification of parathyroidadenomas ranges between 70 to80% (6). Ultrasonography is a usefulmodality to identify parathyroidgland pathology but suffers froma low specificity. It has also beenshown to demonstrate false negativeresults especially with small orectopically located adenomas.Presence of concomitant thyroidnodules is very common and canlead to both false-negative and falsepositive results of technetium Tc99m sestamibi scan. In some cases,preoperative imaging studies providediscordant results, or localizationis evasive and other modalitiesmust be used to correctly identifysuspected lesions (7). In the casepresented above, technetium Tc99m sestamibi scan and the MRI ofneck were negative and we utilizedparathyroid fine needle aspirationand parathyroid hormone assay(PTH-FNA) to confirm that thesuspected hypoechoic structurelocated posterior to the right thyroidlobe on the ultrasound examinationwas actually of parathyroid origin.Abraham et al reported the utilityof PTH-FNA in 30 patients withprimary hyperparathyroidism andconcluded that this procedure hasa sensitivity of 91% and specificityof 95% in localizing parathyroidlesions (1). They described thefollowing procedure for PTH-FNA.Two passes were made with a 27G needle, and part of the specimenwas smeared onto a glass slide forcytological interpretation, while theSeptember/October 2009 | Vol. 105 33

Scientifi c Article |remainder was rinsed in 1.5 ml ofsaline. Cellular debris was removedby centrifugation and the supernatantwas analyzed for intact PTH levels.They also used aspirates from knownthyroid specimens as controls. Themean PTH level was 22,600 pg/mlin their study subjects and 9.0 pg/mlin the controls. They concluded thatPTH-FNA was a useful techniquethat facilitated minimally invasiveparathyroidectomy. Table 2documents the results observed byseveral authors who have measuredparathyroid hormone concentrationvia FNA of suspicious lesions.PTH-FNA is a very effectivetool for discriminating parathyroidlesions from other tissues. Its majorlimitation is parathyroid adenomawhich is not detected on theultrasound. No false positive resultshave been reported in literature.Erbil et al reported a sensitivityand positive predictive value of100% for PTH-FNA to confirm asonographically detected lesion.They also found that in patientswith a concomitant thyroid nodule,PTH-FNA was more accuratethan ultrasound and technetiumTc 99m sestamibi scan to detectthe parathyroid adenoma (7).In the case described above,primary hyperparathyroidism wassuspected because of his PTH beingwithin the normal range in presenceof hypercalcemia as any elevation inserum calcium should suppress thePTH unless the parathyroid glandsare autonomous or non-responsive.The hypoechoic nodule posterior toright thyroid lobe was considered alymph node by the radiologist buta decision was made to performPTH-FNA because of clinicalsuspicion of parathyroid pathology.Markedly elevated level of PTH inthe aspirate was consistent with therange reported by other investigatorsin the past. Thyroglobulin isexclusively produced in the thyroidfollicular cells and undetectableserum thyroglobulin in our patient’saspirate also supported non-thyroidalnature of the nodule biopsied.The current management ofhyperparathyroidism is primarilysurgical. Minimally invasiveparathyroid surgery is the treatmentof choice but it requires the clearlocalization of a parathyroid lesionfor successful removal. In caseswhere preoperative localization isevasive, novel techniques, such asthe one described above, can provideuseful diagnostic information whichcan aid in the successful managementof hyperparathyroidism. Furtherstudies are needed before thistechnique can be applied ona more widespread basis.References1. Abraham D, Sharma PK, Bentz J, GaultPM, Meumayer L, McClain DL. Utility ofultrasound-guided fine-needle aspirationof parathyroid adenomas for localizationbefore minimally invasiveparathyroidectomy. Endocrine practice.2007; 13(4):333-337.2. Ruda JM, Hollenbeak CS, Stack BC. Asystematic review of the diagnosis andtreatment of primary hyperparathyroidismfrom 1995 to 2003. Otolaryngol HeadNeck Surg 2005;132:359.3. Bilezikian JP, Silverberg SJ. ClinicalPractice: Asymptomatic PrimaryHyperparathyroidism. N Engl J Med. 2004Apr 22;350(17):1746-51.4. Vignali, A, Picone, G, Materazzi, S et al. Aquick intraoperative parathyroid hormoneassay in the surgical management ofpatients with primary hyperparathyroidism:a study of 206 consecutive cases. TheEuropean Journal of Endocrinology 2002;146:783-7885. Ollila, D, Abigail, S, Caudle, M et al.Successful minimally invasiveparathyroidectomy for primaryhyperparathyroidism without usingintraoperative parathyroid hormoneassays. The American Journal of Surgery2007;191:52-566. Mariani G, Gulec SA, Rubello D, Boni G,Puccini M et al. Preoperative localizationand radioguided parathyroid surgery. JNuc Med 2003 Sep;44(9):1443-587. Erbil Y, Salmashoglu A, Kabul E, IsseverH, Tunaci M et al. Use of preoperativeparathyroid fine-needle aspiration andparathormona assay in the primaryhyperparathyroidism with concomitantthyroid nodules. The American Journal ofSurgery 2007;193:665-6718. Owens, C, Rekhtman, N, Sokoll, L et al.Differentiating inadvertently sampledparathyroid tissue from thyroid lesions.Diagnostic Cytopathology 2008 Apr; 36(4):227-31.9. Sacks BA, Pallotta JA, Cole A, Hurwitz J.Diagnosis of parathyroid adenomas:efficacy of measuring parathormone levelsin needle aspirates of cervical masses. AmJ Roentgenol 1994;163:1223-610. MacFarlane MP, Prater DL, Shawker TH,Norton JA, Doppman JL, Chang RA, et al.Use of preoperative fine-needle aspirationin patients undergoing reoperation forprimary hyperparathyroidism. Surgery1994;116:959-6411. Doppman JL, Krundy AG, Marx SJ, SaxeA, Schneider P, Norton JA, et al. Aspirationof enlarged parathyroid glands forparathyroid hormone assay. Radiology1983;148:31-512. Marcocci C, Mazzeo S, Bruno-Bossio G,Picone A, Vigaa UE, Ciampi M, et al.Preoperative localization of suspiciousparathyroid adenomas by assay ofparathyroid hormone in needle aspirates.Eur J Endocrinol 1998;139:72-713. Tikkakoski T, Stenfors LE, Typpo T, LohelaP, Apaja-Sarkkinen M. Parathyroidadenomas: Pre-operative localization withultrasound combined with fi ne-needlebiopsy. J Laryngol Otol 1993;107:543-5.14. Stephen AE, Milas M, Garner CN, WagnerCE, Siperstein AE. Use of surgeonperformedoffice ultrasound andparathyroid fine needle aspiration forcomplex parathyroid localization. Surgery2005;138:1143-51.15. Masser C, Donovan P, Santos F,Donabedian R, Rinder C, Scoutt L,Udelsman R. Sonographically guided fi neneedle aspiration with rapid parathyroidhormone assay. Ann Surg Oncol. 2006Dec; 13(12):1690-5.34 West Virginia Medical Journal

STATS | AT A GLANCEEach month, the WVSMA tracks the number of MPLA suits filed in each county throughout West Virginia. Below is a chartsummarizing the case filings from 2003 to July 2009. Please note the annual total for 2005 was significantly impacted by thelarge number of suits brought in Putnam County that year, most of which related to one physician. Excluding the 2005 filings inPutnam County, year-end total filings 2004-2008 were 130, 147, 154, 174, and 178 respectively.COUNTYBarbourBerkeleyBooneBraxtonBrookeCabellCalhounClayDoddridgeFayetteGilmerGrantGreenbrierHampshireHancockHardyHarrisonJacksonJeffersonKanawhaLewisLincolnLoganMarionMarshallMasonMcDowellMercerMineralMingoMonongaliaMonroeMorganNicholasOhioPendeltonPleasantsPocahontasPrestonPutnamRaleighRandolphRitchieRoaneSummersTaylorTuckerTylerUpshurWayneWebsterWetzelWirtWoodWyomingTOTALS(BY INDIVIDUAL YEAR)200319107280005027111141266201026231704310142000012021300011121020140315200402111150000003121611204040211902701170000106300130010010110130200514014700010041008113710922304351010210001012610401000010020602732006031101400050130105304711212118031500150002472000200300115215420070310214001301510094246104022190315102600005145111010100006117420081200313000201501061349006405380214001500007183010100100101101782009thru July0200211000300200023130003102410137013200004640010000001041114TOTAL2003 - 7/20093254319102001190529452501410295913810141613654229923145500131768224133721910815741338September/October 2009 | Vol. 105 35

West Virginia Medical Professionals Health Program | NEWSWest VirginiaHealth ProgramImpairment by Psychiatric Disorders, IncludingAlcoholism and Drug DependenceThe original article utilized inthis writing was titled “The SickPhysician” published in JAMA, Feb. 5,1973. Volume 223, No. 6, wherethe American Medical Associationrecognized mental illness andsubstance abuse as issues affectingphysician health if left untreated.“Accountability to the public,through assurance of competentcare to patients by physiciansand other health professionals,is a paramount responsibility oforganized medicine.” The WestVirginia Medical ProfessionalsHealth Program, WVMPHP,whose board represents manycomponents of organized medicineincluding: the West VirginiaState Medical Association, theWV Mutual Insurance Company,the WV Hospital Association,the WV Podiatric Association,the WV Physician AssistantAssociation and the WV Societyof Addiction Medicine, is theepitome of such accountability.Without the WVMPHP (themedical and osteopathic boardsdesignated physicians healthprogram), potentially impairingpsychiatric disorders, includingalcoholism and drug dependence,such accountability by organizedmedicine would be jeopardized. TheWVMPHP allows for the voluntaryconfidentialassistance and guidancefor mental illness and/or substanceuse disorders in a respectful manner.This directly impacts the earlydetection, evaluation and referralto treatment and thereby betterprotecting the patients we serve.“Ideally, the affected physicianhimself should seek help whendifficulties arise. Often, however,he or she is unable or unwilling torecognize that a problem exists.”Physician health programs, such asthe WVMPHP, provide mechanismswhereby employers, hospitals,partners, spouses and others may alsoseek assistance in dealing with the“sick physician.” A primary concernis the determination of whether thephysician is suffering from a disorderto a degree that interferes with hisor her ability to practice medicine.Estimates of the incidence ofnarcotic addiction in physiciansare similar to and possibly higherthan the general population.This has been referred to as an“occupational hazard.” This is feltto be multi-factorial; primarilydue to the availability of narcotics,the understanding of medicationsand circumstances which bringtogether predisposing personality/conditions in which all arecontributing factors impacting theillness. Many physicians believethey can stop using drugs oralcohol at any time they wish.In 1969, Vaillant et al “noted thatphysicians, especially those who treatpatients, where more likely than nonphysiciansto be involved in heavydrug and alcohol use and to haverelatively unsuccessful marriages.”Untreated substance use disordersundoubtedly can be potentiallyimpairing. Psychiatric disorders,especially psychotic reactions,without question impair the illphysician’s judgment and ability topractice. Suicide among physiciansfar exceeds that of non-physicianssuffering similar diagnoses ofmental illness or substance usedisorder. Providing a means ofassistance in the illness phase of thedisease, prior to impairment is theprimary goal of physician healthprograms. Just as diabetes treatedearly minimizes the extent of heartdisease and renal failure, physiciansbenefit from early recognition andtreatment of addictive disorders.The pioneering effort in thedevelopment of the “sick doctorstatute” came in 1969 Floridalegislature. The “sick doctor statute”defines the inability of a physicianto practice medicine with reasonableskill and safety to his patient(s)because of one or more enumeratedillnesses. These statutes providedfor the disciplining of a practitionerif his alleged misconduct violatesa specific standard of behavior.West Virginia, through SenateBill 573, has additional legislationproviding a mechanism wherebyphysicians may seek help voluntarilyand confidentially in a respectfulmanner. The WVMPHP is availableto provide assistance and guidance,independent of and separate from thedisciplinary process of the licensureboards and other regulatory bodies.“Because physicians are accessibleto most types of dangerous drugsand because they often workunder sustained pressure, whichmay enhance the seeking of drugsfor relief, physicians appearto be a high-risk population interms of exposure to drug abuse.This potential should be clearlyrecognized by medical students andthere should be opportunities inthe training curriculum for them toexplore their own personal posturewith respect to mental illness anddrug use”. The WVMPHP activelyprovides educational activities tostudents and residents in training.In dealing with the “sick doctor,”the preparation of guidelines to assistorganized medicine to deal with theproblem first necessitates delineationof boundaries of responsibility.First, ensuring for safe competentcare for the patient population, thephysician is first in this hierarchyof responsibility. Families, peerreferral, hospitals and others can beactively involved in the “conspiracyof constructive compassion.” TheWVMPHP is available to provideassistance in all of these matters.P. Bradley Hall, MDMedical DirectorWV Medical Professionals Health Program36 West Virginia Medical Journal

General | NEWSNew Secretary of WV DHHR, Director of GO HELP AppointedSince the end of the legislativesession rumors have been flyingabout who would be appointedto serve as the Director of thenewly created Governor’s Office ofHealth Enhancement and LifestylePlanning (GO HELP). In a surprisingpress release issued by GovernorManchin he announced that WestVirginia Department of Healthand Human Resources (DHHR)Secretary Martha Yeager Walkerwill become the acting director ofGO HELP effective September 1.The GO HELP office was establishedwith the passage of Senate Bill 414,this past session to oversee thestate’s health care reform initiativesand collaborate with all stateagencies to coordinate the deliveryof healthcare in West Virginia.Governor Manchin then appointedPatsy Hardy to replace Walkeras Secretary of DHHR. Hardyis a resident of Parkersburg andhas more than 24 years of healthcare management and operationsexperience, including serving asCEO of St. Joseph’s Hospital inParkersburg and CEO of PutnamGeneral Hospital in Hurricane. Shealso was the chief operating officerfor St. Francis Hospital in Charleston.The WVSMA congratulates bothwomen for their appointmentsand looks forward to workingwith them in their new roles.Medicare Scam Alert!The Centers for Medicare &Medicaid Services (CMS) has becomeaware of a scam where perpetratorsare sending faxes to physician officesposing as the Medicare carrier orMedicare Administrative Contractor(MAC). The fax instructs physicianstaff to respond to a questionnaireto provide an account informationupdate within 48 hours in order toprevent a gap in Medicare payments.The fax may have the CMS logo and/or the contractor logo to enhancethe appearance of authenticity.Medicare FFS providers,including physicians, non-physicianpractitioners, should be wary ofthis type of request. If you receive arequest for information in the mannerdescribed above, please check withyour contractor before submittingany information. Medicare providersshould only send information toa Medicare contractor using theaddress found in the downloadsection of the CMS.gov websitefound at http://www.cms.hhs.gov/MLNGenInfo/ or http://www.cms.hhs.gov/MedicareProviderSupEnroll.New Members |We would like to welcome the following physicians and medical students to the WVSMA:Cabell County Medical SocietyRobert Childers, MDEastern Panhandle Medical SocietyWilliam McLaughlin, MDKanawha County Medical SocietyRichard Francis Jr., MDCynthia Wesley, MDMonongalia County Medical SocietyKevin Blankenship, MDParkersburg Academy of MedicineMichael Mendoza, DOPlease direct all membershipinquiries to:Mona Thevenin,WVSMA Membership Director38 West Virginia Medical Journal

| AMA Delegation ReportThe Delegation ReportAnnual AMA House of Delegates MeetingJune 13-17,2009—ChicagoDrs. Joseph Selby, John Holloway,Steve Sebert and I representedthe West Virginia State MedicalAssociation in the proceedings ofthe AMA House of Delegates. Withthe attendance of Evan Jenkins, ourExecutive Director, we were able tocover all the reference committeesdiscussions and debates. The studentsection was well represented with 11students from Marshall UniversityJoan C. Edwards School of Medicineand four from the West VirginiaUniversity School of Medicine.Dr. Hoyt Burdick, of the CabellHuntington Medical Societyrepresented WV at the OrganizedMedical Society Section (OMSS).The OSMAP (the Organization ofState Medical Association Presidentsand Executive Directors) held theirannual meeting as well. The maintopic of discussion was healthcarereform. Each state came preparedwith a reform agenda—no twoalike. The anticipated arrival ofthe President prompted passionatedebates. I felt the President’s speechwas clear and transparent, but themembers of the house of delegatesspent much time dissecting it. Mostof the delegates expressed confidencein the President’s ability to tackle theissues, but held the line that he needsthe AMA’s help to reform the nation’shealthcare woes. As he said, “statusquo is not acceptable, I am committedto a comprehensive healthcarereform.” The President appealedto the audience, “I need your helpdoctors...to most Americans you arethe healthcare system. I will listento you and work with you to pursuereforms that work for you.” In aspeech that lasted about an hour,interrupted by spontaneous standingovations, the President detailedhis plans and recommendationsto Congress, emphasizing the factthat the nation’s healthcare deliverysystem is unsustainable. He callshealthcare reform the most importantthing the government can do toimprove the nation’s economy.The President prompted theloudest and most spontaneousand unanimous standing ovationwhen he said he wanted to givephysicians relief from medicalliability pressures, only to bequieted down by barely audiblegroans from the audience whenhe said, “I still could not supportcapping noneconomic damages.” Ina somewhat apologetic gesture headded “caps can be unfair to peoplewho have been wrongly damaged.”Reactions and reflections abounded.One Chicago paper headline read,”Obama bowed by Doctors.”The next two sessions of the Houseof Delegates focused mainly on twowords, “public options.” Speakerspresented opinions on the “pros”and “cons” of this reform option.Our meeting ended with theconsensus that the AMA supportshealthcare reform alternativesthat are consistent with principlesof pluralism, freedom of choice,freedom of practice withoutintimidation, universal access andmeaningful liability reform.Constantino Y. AmoresChair, WVSMA DelegationOFFICE MANAGERS ASSOCIATIONOF HEALTHCARE PROVIDERS, INC.www.officemanagersassociation.comWe invite you to join our organization which consists of members who manage the daily business of healthcareproviders. Our objectives are to promote educational opportunities, professional knowledgeand to provide channels of communication to office managers in all areas of healthcare.We currently have eleven chapters in West Virginia.Visit us on our website for more information or contact: Toni Charlton – President at 304-670-7197 or Donna Lee - State VP Membership at 276-322-5732.September/October 2009 | Vol. 105 39

Robert C. Byrd Health Sciences Center of West Virginia University | NEWSTexas A&M’s Colenda Named WVU’s Chancellor for Health SciencesCALLS IT ‘A PRIVILEGE OF A LIFETIME’Christopher C. Colenda, MD, MPH,the Jean and Thomas McMullin Deanof Medicine and Vice President forClinical Affairs at Texas A&M HealthScience Center, was named Chancellorfor West Virginia University HealthSciences on August 19.A respected academic physician,researcher and leader, Dr. Colenda, 57,was selected by WVU PresidentJames. P. Clements, following anational search. He will begin his newrole October 30.“This is certainly a wonderful dayfor West Virginia University, ourHealth Sciences enterprise and ourState,” said President Clements.“Chris Colenda is a visionary…astrategic thinker…an energetic anddynamic leader…and above all, he iscommitted to the educational,research, clinical and outreachmissions of WVU Health Sciences.”Clements said Colenda’s stellarcareer as a faculty member, researcher,department chair, dean, vice presidentand now chancellor “speaks volumesabout his abilities.”Dr. Colenda addressed a crowdgathered at Patteson Auditorium forthe announcement, saying, “I amtruly honored to have been offeredthis position. I consider it a privilegeof a lifetime.”A geriatric psychiatrist bytraining, Colenda has been Dean ofMedicine and Professor ofPsychiatry and Behavioral Scienceand Professor of Health PolicyManagement at Texas A&M sinceJanuary 2003. In March, he becameVice President for Clinical Affairs.His background also includesfaculty and administrativeappointments at Michigan StateUniversity College of HumanMedicine, Wake Forest UniversitySchool of Medicine and MedicalCollege of Virginia of VirginiaCommonwealth University.He started his college career at theUnited States Military Academy atWest Point and went on to earndegrees from Wittenburg University,BA, chemistry; The Medical College ofVirginia, MD; and Johns HopkinsUniversity, MPH.NCI Cancer Research at WVU Doubles in Two YearsMARY BABB RANDOLPH CANCER CENTER ALSO NAMES DEPUTY DIRECTORSince 2007 scientists at WestVirginia University have more thandoubled research dollars that flowfrom the National Cancer Institute(NCI) to WVU, said Scot Remick, MD,director of the Mary Babb RandolphCancer Center at WVU.The Cancer Center’s scientists areworking on projects representingalmost $2 million in NCI funding, hesaid during the Cancer Center’sannual retreat in August. Overallresearch grant funding for the CancerCenter is $8 million.Dr. Remick also announced that theCancer Center now has a deputydirector: Laura Gibson, PhD, who inMarch was named the first AlexanderB. Osborn Distinguished Professor inHematological Malignancies Research.Gibson’s research includes a fiveyear,$1.47 million NCI grant tostudy stem cells to find better waysto treat acute lymphoblasticleukemia (ALL), the most commonleukemia in children.WVU Medical Student Receives AMA ScholarshipThe American Medical Association(AMA) Foundation has awardedfourth-year West Virginia UniversitySchool of Medicine student SharonMaas, of Farmington, Pa., a Physiciansof Tomorrow Scholarship.Maas is one of 10 medical studentsawarded the scholarship. Each studentwill receive a $10,000 scholarship tohelp with the cost of medical schoolexpenses. Recipients were nominatedby their medical schools and chosenby a selection committee based onacademic standing, financial status,community involvement, letters ofrecommendation and personalstatement.Maas has served as president of theCirca Terra Medical SurplusReclamation Group, collecting medicalsupplies and equipment forunderserved countries around theworld. She currently serves on WVU’sGlobal Health Advisory Committeeand will travel to Paraguay for aninternational rotation next year. She isalso the recipient of the PatriciaFedeles Award for Compassion inPhysical Diagnosis.Maas plans to practice familymedicine and is interested in openinga clinic for the underserved andunder-insured. She is the daughter ofRolf and Mary Maas.40 West Virginia Medical Journal

Marshall University Joan C. Edwards School of Medicine | Scientifi | NEWS c ArticleCollaborative Clinic Opens Doors in ChapmanvilleThrough h thecollaborationlabof thelocal community, munity, Marshall’s RobertC. Byrd Center for Rural Healthand Marshall’s School of Medicine,a new clinical and educationcenter has opened in the LoganCounty town of Chapmanville.Coalfield Health Center, aproject of the non-profit RuralHealth Access Corporation, beganoperations in late July to increaseaccess to primary care services inthe medically underserved area.With technical assistance andguidance from the Center for RuralHealth and financial support fromthe Logan Healthcare Foundationand the West Virginia Legislature,the center has begun providingprimary care services. In addition,specialty and subspecialtyservices will be provided throughMarshall’s faculty practice plan,University Physicians & Surgeons.Federal funding obtained bySen. Byrd will allow constructionof a permanent medical officefacility for the center. Ground isexpected to be broken later thisyear, with the building scheduledfor occupancy in fall 2010.“This is a part of the state in whichit has been historically very difficultto recruit and retain physicians,”said Jennifer Plymale, director ofthe Center for Rural Health andassistant dean of the medical school.“We are working with members ofthe community to learn from themdirectly what their areas of needare, then working with them tocreate an appropriate, sustainablemodel to meet those needs.”In addition to providing patientcare services, the center is exploringways to incorporate trainingopportunities for resident physiciansand allied health students. Oncein its permanent facility, it willbecome the hub for the RobertC. Byrd Mobile Medical Unit,which now is based at Marshallin the Center for Rural Health.New Subspecialists Join FacultySeveral new subspecialistphysicians have joined the faculty:EndocrinologyLola Olajide, MD,specializes in treatingadults with diabetes,thyroid problems, adrenallesions, pituitary conditionsand bone metabolic diseases suchas osteoporosis. She completeda fellowship in endocrinologyand her internal medicineresidency at the State Universityof New York at Stony Brook.Hematology/OncologyRajesh Sehgal, MD, amedical oncologist andhematologist with expertisein diagnosing and treatingbreast and colon cancer,has extensive experience in researchusing sentinel node proceduresin colon cancer. He completedhis fellowship in hematology andmedical oncology at the Universityof Pittsburgh Medical Center.NeuroscienceCarol A. Foster, MD,former director of ValleyNeurological Headache andResearch Center in Phoenix,Ariz., is the Huntington/Tri-State region’s only neurologistspecifically trained in headachecare. She completed her neurologyresidency at Barrow NeurologicalInstitute in Phoenix and the PrincessMargaret Migraine Clinic in London.J. Douglas Miles, MD,PhD, adds expertisein diagnosing andtreating patients withneuromuscular disorderssuch as muscular dystrophyand carpal tunnel syndrome. Herecently completed his fellowship atUniversity Hospitals in Cleveland atCase Western Reserve University.Orthopaedic SurgeryVincent Battista, MD, anorthopedic hand surgeon, earned hismedical degree from GeorgetownUniversity School ofMedicine and completedhis hand surgeryfellowship training atWalter Reed Army MedicalCenter. A lieutenant colonel in theUnited States Army, he recentlyreturned from active duty as chiefof surgery with the 10th CombatSupport Hospital in Iraq.RheumatologyAdenrele Deji Olajide,MD, specializes in care forpatients with rheumatoidarthritis, SLE/lupus, mixedconnective tissue disease,myositis and other rheumatologicconditions. He completed hisrheumatology fellowship atWinthrop University Hospital/Nassau University Medical Centerand his residency training in internalmedicine at the State Universityof New York at Stony Brook.September/October, 2009, Vol. 105 41

West Virginia School of Osteopathic Medicine | NEWSNew Faculty Members Join WVSOMWest VirginiaSchool ofOsteopathicMedicine welcomesGail Feinberg, DO,to the WVSOMfamily. Dr. FeinbergDr. Feinberg has acceptedthe position ofRegional Assistant Dean of theSouth West Region for WVSOM’sStatewide Campus Program.She will be based out of theHuntington, WV/Ashland, Kentuckyarea where she will serve not onlyas a liaison between WVSOM andthird and fourth-year medicalstudents performing clinicalrotations in that area, but will alsowork on developing curriculum,insuring quality clinical rotations,and securing additional clinicalsites and rotations for students. Shebegan her duties on June 15, 2009.Dr. Feinberg still serves as Directorof Medical Education as well asDirector of the Family PracticeResidency Program at Our Lady ofBellefonte Hospital in Ashland ona part time basis. Previously, sheserved as Medical Director at TrinityStation extended care facility, andAssistant Clinical Professor of FamilyMedicine for WVSOM, PikevilleCollege of Osteopathic Medicine,and Marshall University School ofMedicine and School of Nursing.Feinberg earned a Bachelor ofScience degree in Psychobiologyfrom UCLA in Los Angeles,California. Later, she earned herDoctor of Osteopathic Medicinedegree from the College ofOsteopathic Medicine of the Pacific.Dr. Feinberg is also continuingwork on a Master’s degree programin Medical Education through theUniversity of Cincinnati. “Themore education and courseworkI completed, the more I found Iwas enjoying the academic side ofmedicine,” Dr. Feinberg explained.“I think the Regional Assistant Deanposition with WVSOM’s StatewideCampus is a perfect fit for me.”Feinberg is a native of LosAngeles. She has been married for 26years to Howard Feinberg, DO, whois Rheumatologist with a practicein Ashland. They have two grownchildren: Cheryl, a second-year lawstudent at Vermont Law School;and Kimberly, who is a senior at theUniversity of Louisville, where she isa member of the women’s crew team.Dr. Feinberg resides in Russell, KY.Brian Richards,M.D., joined theWVSOM communityin May 2009 as anAssociate Professorof Geriatrics.Dr. Richards isa graduate fromDr. Richardsthe University ofVirginia and is Board Certified inInternal Medicine and has also hadadded qualifications in Geriatrics.From 1982-2008 Dr. Richardsmaintained a private practice.In addition to teaching at WVSOM,Dr. Richards will also see patients atthe Robert C. Byrd Clinic and willserve as the Associate Director of theFamily Practice Residency programGreenbrier Valley Medical Center.West VirginiaSchool ofOsteopathicMedicine welcomesRalph Wood, DO,FACOFP, to theWVSOM family.Dr. Wood Dr. Wood hasaccepted the positionof Regional Assistant Dean of theNorthern Region for WVSOM’sStatewide Campus Program.He will be based out of theWheeling, WV area where he willserve not only as a liaison betweenWVSOM and third and fourth-yearmedical students performing clinicalrotations in that area, but will alsowork on developing curriculum,insuring quality clinical rotations,and securing additional clinicalsites and rotations for students. Hebegan his duties on May 1, 2009.For Dr. Wood, being associatedwith WVSOM is a family affair.“There are currently 18 osteopathicphysicians in my extended family,”revealed Dr. Wood. “Not onlydid I graduate from WVSOM,l have had three brothers, twocousins and a nephew all graduatefrom WVSOM as well.”Dr. Wood comes to WVSOMfrom Ft. Lauderdale, Florida, wherehe served as Director of MedicalResearch and chairman of theDepartment of Family Medicine atNova Southeastern University. Healso served as Medical Director forthe various affiliated health clinics atNova. He is also the former owner/president of Wood Health CareClinic and Wood Rehab and Fitness.Dr. Wood earned Bachelor ofScience degrees in Chemistry/Biology from West Liberty Universityin West Liberty, WV. Later, heearned a Doctor of OsteopathicMedicine degree from WVSOM. Heis board certified in Family Practiceand Urgent Care Medicine. He is afellow of the American College ofOsteopathic Family Physicians.Wood is a native of Moundsville.He and his wife, Janeen, have threesons; Dr. Zack Wood, a second-yearFamily Medicine Resident at BrowardGeneral Hospital in Ft. Lauderdale,FL; Ryan an entertainer, singer,dancer for Norwegian Cruise Line;and Chad, a senior at West Libertywho has plans to be a physician.42 West Virginia Medical Journal

Physician Practice Advocate | NEWS“Evening With the RAC” Conferenceis a Huge Success!The WVSMA’s recent “EveningWith the RAC” conference was atremendously successful program.The large crowd at the conferencewas indicative of the interestin obtaining the most accurateand up to date informationabout the RAC. (Recovery AuditContractors). Those in attendanceagreed that the evening was botheducational and informative.Several physicians commented thatthe presentation seemed to allayfears and concerns about the effectof the RAC on their practices.The evening began with a dinnerreception, followed by a presentationby CMS officials, who explainedthe RAC program mission and thelegislation supporting the RAC.Following the CMS presentation,Medical Director Dr. James Leeand Healthcare Principal, ChristineCastelli from Connolly Consulting(the RAC for Region C whichincludes West Virginia), spoketo the group. They presenteddetailed information regardingConnolly Consulting, includinginformation about the company’smission and review processes.Attendees, both physicians andstaff, then were able to addressboth CMS and Connolly with theirquestions and concerns regardingthe RAC. The presenters stayed untilevery question was answered.Connolly Consulting and theWVSMA are partnering to ensurethat our physicians receive any newinformation about the RAC in anexpeditious manner. Connolly hascommitted to notifying the WVSMAprior to any new initiatives with theRAC program. We will keep youinformed and updated on changesor additions to the RAC program.Any new program, such as theRAC, often causes numerous concernsand questions. It also provides anopportunity for semi-knowledgeablepersons to capitalize on these concernsand offer information which may ormay not be accurate. Please be awareof this when companies contact youroffice with offers to “safeguard” yourpractice. Sometimes you may notreceive all that you are paying for. Ifyou have questions about the validityof information you’re receiving, pleasefeel free to contact the WVSMA.For more information aboutthe RAC, please visit the CMSand Connolly websites, www.cms.hhs.gov/RAC and www.connollyhealthcare.com/RAC.Barbara GoodWVSMA Physician Practice AdvocateFor more information about the RAC, please visit the CMS and Connolly websites,www.cms.hhs.gov/RAC and www.connollyhealthcare.com/RAC.September/October 2009 | Vol. 105 43

Bureau for Public Health | NEWSRevised Federal Guidance for Nursing FacilityMedical DirectorsIn June 2005, the Centers for Medicare& Medicaid Services (CMS) issued revisedGuidance to Surveyors with respect tothe requirement of “Medical Director(F501)” for Medicare / Medicaid-certifiednursing facilities. The requirement states,“§483.75(i) Medical Director (1) Thefacility must designate a physicianto serve as medical director (2). Themedical director is responsible for – (i)Implementation of resident care policies;and (ii) The coordination of medical carein the facility.” The June 2005 revision didnot change the regulation itself; rather,it changed how the State survey agencywas to ascertain whether a nursing facilitywas in substantial compliance with thatregulation. The revision included changesto the Interpretive Guidance and a newInvestigative Protocol with guidelines fordetermining the scope and severity of adeficient practice when noncompliance withthe requirement is found during a survey.Synopsis of the Regulation - Thisrequirement has three (3) aspects: havinga physician to serve as medical director,implementing resident care policies, andcoordinating medical care. As with all otherlong term care requirements, the citationof a deficiency at F501, Medical Director,is a deficiency regarding the facility’sfailure to comply with this regulation.The facility is responsible for designatinga physician to serve as medical directorand is responsible for oversight of, andcollaboration with, the medical directorto implement resident care policies andto coordinate medical care. The facilityis in compliance with this requirement ifit has designated a medical director whois a licensed physician; the physician isperforming the functions of the position; themedical director provides input and helpsthe facility develop, review and implementresident care policies, based on currentclinical standards; and the medical directorassists the facility in the coordination ofmedical care and services in the facility.Investigative Protocol - The objectivesof the new investigative protocol areto determine whether the facility hasdesignated a licensed physician to serve asmedical director; and to determine whetherthe medical director, in collaboration withthe facility, coordinates medical care andthe implementation of resident care policies.This protocol will be used if the survey teamhas identified the facility does not havea licensed physician serving as medicaldirector; and/or the facility has designateda licensed physician to serve as medicaldirector but concerns or noncomplianceidentified indicate the facility has failedto involve the medical director in his/herroles and functions related to coordinationof medical care and/or the implementationof resident care policies; and/or themedical director may not have performedhis/her roles and functions related tocoordination of medical care and/or theimplementation of resident care policies.The investigation will involveinterviews, review of pertinent policiesand procedures, and may involveadditional review of resident care. Thesurvey team will interview the facilityleadership (e.g., administrator, directorof nursing, others as appropriate) abouthow it has identified and reviewed withthe medical director his/her roles andfunctions as a medical director, includingthose related to coordination of medicalcare and the facility’s clinical practicesand care. Additionally, the survey teamwill interview the medical director abouthis/her understanding and performanceof the medical director roles and functionsand about the extent of facility support forperforming his/her roles and functions.Noncompliance for F501 - Aftercompleting the Investigative Protocol,the survey team will analyze the datain order to determine whether or notnoncompliance with the regulation exists.The survey team must identify whetherthe noncompliance cited at other tagsrelates to the medical director’s roles andresponsibilities. In order to cite at F501when noncompliance has been identifiedat another tag, the team must demonstratean association between the identifieddeficiency and a failure of medical direction.Noncompliance for F501 may include(but is not limited to) the facility’sfailure to designate a licensed physicianto serve as medical director; or obtainthe medical director’s input for timelyand ongoing development, review, andapproval of resident care policies.Noncompliance for F501 may alsoinclude (but is not limited to) the facilityand medical director’s failure to:• Coordinate and evaluate the medicalcare within the facility, including thereview and evaluation of aspects ofphysician care and practitioner services;• Identify, evaluate, and address healthcare issues related to the quality ofcare and quality of life of residents;• Assure that residents haveprimary attending and backupphysician coverage;• Assure that physician and health carepractitioner services reflect currentstandards of care and are consistentwith regulatory requirements;• Address and resolve concerns andissues between the physicians, healthcare practitioners and facility staff;• Resolve issues related to continuityof care and transfer of medicalinformation between the facilityand other care settings;• Review individual resident cases,as warranted, to evaluate qualityof care or quality of life concernsor other problematic situations andtake appropriate steps to resolve thesituation as necessary and as requested;• Review, consider and/or act uponconsultant recommendations that affectthe facility’s resident care policiesand procedures or the care of anindividual resident, when appropriate;• Discuss and intervene (as appropriate)with the health care practitioner aboutmedical care that is inconsistent withapplicable current standards of care; or• Assure that a system exists to monitorthe performance and practices ofthe health care practitioners.This does not presume that a facility’snoncompliance with the requirements forthe delivery of care necessarily reflects onthe performance of the medical director.For more information regarding thisand other Federal Medicare / Medicaidcertification requirements for nursingfacilities, please contact: Deanna L.Kramer, RN, MS, NHA, Program ManagerII for the Nursing Home and NursingAssistant Programs within the WestVirginia Office of Health Facility Licensureand Certification at (304) 558-0050.Deanna L. Kramer, RN, MS, NHAOffi ce of Health Facility Licensure and Certification44 West Virginia Medical Journal

“Advancing Excellence in Healthcareand Health Information Technology”A conference for physicians, nurses, community health center staff,hospital administrators, office managers and practice group managersCo-sponsored by CAMC Health Education and Research InstituteOctober 15-16, 2009Stonewall ResortRoanoke, West VirginiaHosted by:Highlights include:The educational and charitable foundation ofthe West Virginia State Medical AssociationRemarks by Martha Walker, Director, Governor’s Office of Health Enhancement andLifestyle Planning (invited)“Meaningful Transitions with Health IT: Caring for Your Patients and Your Practice”David R. Hunt, MD, FACS, Office of the National Coordinator for Health InformationTechnology, US Dept. of Health and Human Services (invited)“Achieving Meaningful Use from Your EHR Using HIT and Care Teams”Sarah Chouinard, MD“Evaluating Return on Your Investment (ROI) for EHR—Stimulus vs. Reality”James L. Comerci, MD“Remote Neurological Presence in Rural Areas”Carl F. McComas, MD8 hours of CME For conference updates, visit wvsma.com/foundationProgram andregistrationpages follow

ProgramThis conference is jointly sponsored by CAMC Health Education and Research Institute, a continuing education event.Thursday, October 158 a.m. – 2 p.m. West Virginia Medical Foundation Golf Scramble9 a.m. – 1 p.m. Exhibit Set-up1 – 2:30 p.m. West Virginia Health Information Network Physician Advisory Committee Meeting1 p.m. Registration and Exhibit Visitation3 – 4:30 p.m. Plenary Session IConference Overview/Opening RemarksMichael O. Fidler, MDThe West Virginia Health Information Network Update and Next StepsSonia D. ChambersWest Virginia Health Information Network, Secretary/Treasurer“Evaluating Return on Your Investment (ROI) for EHR—Stimulus vs Reality”James L. Comerci, MD5:30 – 6:30 p.m Reception, Exhibit Visitation and Golf Scramble Awards Presentation6:30 – 8 p.m. DinnerFriday, October 167 a.m. Continental Breakfast/Informal Roundtable Discussions/Exhibit Visitation8 a.m. Plenary Session IIRemarksMartha Walker, Governor’s Office of Health Enhancement and Lifestyle Planning Director (invited)“What is the West Virginia Statewide Health Information Technology Strategic Plan and Whatit Means to Your Physician Practice, Health Center and Hospital”Roger Chaufournier, CEO, CSI Solutions, LLC9 a.m. CONCURRENT SESSION IA. “Using Data as a Driver for Quality Improvement”Martha Carter, MBA, RN, CNMChief Executive Officer, FamilyCare HealthCenterMary Buffington Jenkins, MDMedical Director, FamilyCare HealthCenterB. “Two New Resources for West Virginia Physicians: WVeScript and MediWeb, a ClinicalWeb Portal”Vicki Cunningham, RPhDrug Utilization Review Coordinator, Bureau for Medical Services46 West Virginia Medical Journal

“How Can Converting to Electronic Medical Records Benefit Your Practice and Your Patients: A RiskManagement Overview”Judith A. Davis-Thomas, RN, BS, ARM, CPHQDirector of Risk Services, West Virginia Mutual Insurance Co.C. National Committee for Quality Assurance (NCQA) Nine Criteria for Medical HomeCertification Learning Laboratory10 a.m. Refreshment Break/Exhibit Visitation10:30 a.m. CONCURRENT SESSION IIConcurrent Sessions A, B and C Repeated11:30 a.m. Plenary Session III“Achieving Meaningful Use from Your EHR using HIT and Care Teams”Sarah Chouinard, MDMedical Director, Primary Care Systems“The Role of Privacy and Security of Information in the Doctor/Patient Relationship”John C. WeisendangerChief Executive Officer, West Virginia Medical Institute12:30 p.m. Lunch in Stillwater’s Restaurant/Exhibit Visitation1:30 p.m. Plenary Session IV“Electronic Health Records and Youth Obesity: Can Technology Make a Difference?”William Neal, MDFEATURED GUEST SPEAKER“Meaningful Transitions with Health IT: Caring for Your Patients and Your Practice”David R. Hunt, MD, FACS, Office of the National Coordinator for Health Information Technology, USDept. of Health and Human Services (invited)3 p.m. Refreshment Break/Exhibit Visitation3:30 p.m. Plenary Session V4:30 p.m. Reception“Remote Neurological Presence in Rural Areas”Carl F. McComas, MD“Broadband Implementation in West Virginia: An Update on the West Virginia TelehealthAlliance”Larry Malone, West Virginia Telehealth Alliance Chair“Unstrung - Wireless and Mobile applications in healthcare”Jack L. Shaffer, Jr.Chief Information Officer, Community Health Network of West VirginiaSeptember/October 2009 | Vol. 105 47

Registration“Advancing Excellence In Healthcare and Health Information Technology”October 15-16, 2009 Stonewall Resort8 hours of CME creditsPlease print clearlyName:___________________________________________________________________(Name as it should appear on the name badge) Degree (MD, DO, RN)Mailing Address: ____________________________________________________________City: _______________________________________ State: _________ Zip: _____________Office Phone: _________________________ E-mail: _______________________________The registration fee includes conference materials, two receptions, Thursday evening dinner, continental breakfast,refreshment breaks, continuing education credits and exhibit visitation.Physician, Physician Assistant or Nurse $175 $_________________Retired Physician $150 $_________________Office Manager, Practice Group Manager,Clinic or Hospital Administrator $150 $_________________To help us obtain an accurate count, please indicate below which functions you plan to attend.___ Thursday Evening Reception, Exhibit Visitation and Golf Scramble Awards Presentation, 5:30 p.m.___ Lunch on Friday in Stillwater’s Restaurant, 12:30 p.m.___ Friday Reception, 4:30 p.m.___ Yes, I plan to participate in the Golf Scramble Oct. 15 $150 $_____________________ hdcp Members of my foursome: __________________________________________________________________________________________________________________________________________________ I plan to attend the dinner Thursday, October 15 at 6:30 p.m.(For paid conference registrants dinner is included in your conference registration fee.)___ I would like to bring my spouse/guest to the Thursday reception and dinner. $50 per person.Name for badge __________________________________$_________________TOTAL AMOUNT DUE$_________________Payment Method:___ Check Enclosed Please make check payable to: West Virginia Medical Foundation___ American Express ___ MasterCard ___ VisaCard No:____________________________ Expiration Date: _______ V Code:___________(Three digit number on the back of your credit card.)Name As It Appears On Card:_____________________________________________________Signature:________________________________________________________________For more information or additional registration forms, visit wvsma.com/foundation or e-mail Helen@wvsma.comPlease fax this form to (304) 925-0345Or mail to: West Virginia Medical Foundation, P.O. Box 4106 Charleston, WV 25364To receive the special conference rate of $99* per night lodging rate, call !-888-278-8150 by September 25th. Please indicateyou are attending the West Virginia Medical Foundation Conference. A limited number of deluxe cabins are also available.*does not include resort fee.

The educational and charitable foundationof the West Virginia State Medical AssociationGolf ScrambleOctober 15, 2009Palmer Course at Stonewall Resort8-8:45 a.m. Registration, Continental Breakfast and PracticeNoon Boxed lunches will be delivered on the course5:30 p.m. Awards ReceptionEntry Deadline: Monday, October 5, 2009Prizes1 st place team, each player will receive a $100 gift certificate for the pro shop2 nd place team, each player will receive a $75 gift certificate for the pro shop3 rd place team, each player will receive a $50 gift certificate for the pro shopRegistrationContact: ___________________________________ E-mail: ____________________ Phone: __________Address: _______________________________________________________________________________Entrant(s):__________________________________________________ Hdcp__________________________________________________ Hdcp__________________________________________________ Hdcp__________________________________________________ HdcpThe entry fee is $150 per player.Payment Method:___ Check Enclosed____ American Express ____ MasterCard ____ VisaCard No:__________________________________ Expiration Date: _____ V Code:____________________(Three digit number on theback of your credit card.)Name As It Appears On Card:________________________________________________Signature:________________________________________________________________We will ____will not ____ stay for the 5:30 p.m. awards reception.We’re unable to participate this year, but enclosed is our check of $_________ to support the West VirginiaMedical Foundation, a 501 (c)3 organization. Your donation to the Foundation is tax deductible.Please make checks payable to West Virginia Medical Foundation and mail no later than October 5th.West Virginia Medical Foundation PO Box 4106 Charleston, WV 25364Phone: (304) 925-0342 Ext. 13 Fax: (304) 925-0345Please note a block of rooms and a few deluxe cabins have been reserved. Please call Stonewall Resort by Sept. 25 14at 304-269-7400 and indicate you will be attending the West Virginia Medical Foundation event.

West Virginia Medical Foundation | NEWSFoundation Joins Alzheimer’s Outreach and RegistryProgram PartnershipThe West Virginia MedicalFoundation has joined with severalpartners to help implement theAlzheimer’s Outreach and RegistryProgram at the Blanchette RockefellerNeurosciences Institute (BRNI).Soon you will hear details aboutthis initiative that brings togetherthe Foundation, the West VirginiaBureau of Senior Services, theAlzheimer’s Association, WestVirginia Chapter and the BlanchetteRockefeller Neurosciences Institute.The aim of the initiative is to reachevery physician and other healthcareproviders in the state to improve thediagnosis, treatment and support forthe more than 44,000 Alzheimer’sdisease patients and their 85,000caregivers in West Virginia.The initiative hasthree components:a. A continuing medicaleducation course to keep physiciansinformed and proactive in the latestdiagnostic techniques and treatmentsavailable for Alzheimer’s Disease;b. A continuing medical educationprogram to connect the medicalcommunity, and through themcaregivers, with local resources tobetter link treatment and care; andc. The first-ever West VirginiaAlzheimer’s Disease Registry tocollect data on patients and thedisease in order to better informstate allocation of resources andto help guide BRNI research.The West Virginia MedicalFoundation is committed to seekways to help mitigate the burdensfamilies face while dealing withAlzheimer’s by reaching out tophysicians, nurses, social workersand caregivers. That is why onSeptember 14 the Foundation, alongwith the Blanchette RockefellerNeuroscience Institute, the WestVirginia Bureau of Senior Services,Alzheimer’s Association, WestVirginia Chapter, and the WestVirginia Cable TelecommunicationsAssociation launched acomprehensive outreach programto educate the medical communityon diagnostic techniques, how tobetter link treatment and care, andto collect data that will better informdiagnosis, treatment and research.Continuing Medical Education(CME) courses will be coming to atown near you. Your participationin these classes is critical to ensurethat we share information, identifybest practices and learn frompatient and physician experiences.Additional information aboutthe CMEs will be made availablesoon on our website at www.wvsma.com/foundation.For information, contact HelenMatheny at Helen@wvsma.com.Thursday, October 15, noonAlzheimer’s Disease Continuing Medical EducationSession– Stonewall Resort, RoanokeTuesday, October 20, 5:30 pmAlzheimer’s Disease Continuing Medical EducationSession–Oglebay Resort and Conference Center, WheelingSave the DateOctober 22, 6:40 pm Alzheimer’s Disease Continuing MedicalEducation Session–Tamarack Conference Center, BeckleyTuesday, Nov. 10, 5:30 pmKanawha County Medical Society, Alzheimer’s DiseaseContinuing Medical Education Session–EdgewoodCountry Club, CharlestonKnow Your Health Numbers Resources are AvailableAs part of the Partnership fora Healthy West Virginia and theWest Virginia Medical Foundation’s“Know Your Numbers” educationalprogram posters and brochuresare available for physician offices.(Please see opposite page.)This effort includes informationabout the healthy range for keyrisk factors such as cholesterol,triglycerides, blood pressure,blood glucose and body massindex. The intent of the effortis to enable individuals to takeresponsibility for their healthby taking action to reduce theirchances of developing heart disease,diabetes and many other illnesses.To receive free copies of theoffice posters or the brochures forpatients, contact Helen Mathenyat Helen@wvsma.com.Funding for this project hasbeen provided by the ClaudeWorthington Benedum Foundation.50 West Virginia Medical Journal

200orLessLessthan100CHOLESTEROL — Total cholesterol - < 200 mg/dLHDL > 50 mg/dLLDL < 100 mg/dL targetTRIGLYCERIDES — Normal range - less than 150borderline-high is 150-199high is 200-499very high is 500 or higherLessthan150BLOOD PRESSURE — Normal blood pressure - less than 120/80Prehypertension - 120-139/80-89Stage 1 high blood pressure - 140-159/90-99Stage 2 high blood pressure - 160 and above/100 and aboveBLOOD GLUCOSE — Fasting blood glucose should be less than 100BODY MASS INDEX — 18.5 or below -underweight18.5 to 24.9 - normal target range18.5greater than 25 - overweighttoover 30 - obese24.9Lessthan120/80Adopting healthy behaviors is as easy as one, two, three:1. eating nutritious foods — fruits and vegetables, whole grains, high ber foods,poultry and sh, low-fat or fat-free dairy products,2. being physically active — at least 30 minutes of moderate intensityof physical activity, and3. stopping tobacco use.Ask your doctor about your numbersand learn how to keep them inthe target zone.Get to KNOW Your Health NumbersFor more information ask your doctor or visit www.healthywv.comThe Know Your Numbers educational effort is a project of the Partnership for a HealthyWest Virginia and the West Virginia Medical Foundation. Funding for this project hasbeen provided by the Claude Worthington Benedum Foundation.September/October 2009 | Vol. 105 51

West VirginiaMedicalFoundationThanks the followingsupporters of thecharity auctionJim Brick, MDCoach Bill StewartCoach Bob HugginsFirst and Ten FoundationHateld and McCoy TrailTrailsheaven.comMarshall UniversityJoan C. Edwards School of MedicineMole Hole of CharlestonOhio County Medical Society AlliancePoca Valley Financialpocavalleynancial.comSteve Sebert, MDStonewall Resortstonewallresort.comMichael Switzer DesignWorksmichaelswitzerdesignworks.comThe Homesteadthehomestead.comThe Manahan GroupWaterfront Place Hotelwaterfrontplacehotel.comWest Virginia MedicalInsurance AgencyWest Virginia Radio Corporationwvradioadvertising.comWest Virginia StateMedical AssociationWest Virginia UniversityAlumni Associationalumni.wvu.eduWest Virginia UniversitySchool of Medicineulu Nyala South AfricanSafari Lodgezulunyala.com

| WESPAC Contributors2009 WESPAC ContributorsThe WVSMA would like to thank the following physicians, residents, medical students and Alliancemembers for their recent contributions to WESPAC. These contributions were received as of Sept. 3, 2009:Chairman’s Club ($1000)MaryAnn Nicolas Cater, DOAhmet H. Ozturk, MDB. Joseph Prud’homme, MDStephen L. Sebert, MDPhillip R. Stevens, MDCharles F. Whitaker, III, MDExtra Miler ($500)David A. Bowman, MDHoyt J. Burdick, MDJames P. Clark II, MDJames L. Comerci, MDGeneroso D. Duremdes, MDDavid A. Gnegy, MDPhillip Bradley Hall, MDDavid E. Hess, MDLucas J. Pavlovich Jr., MDFrank A. Scattaregia, MDElizabeth L. Spangler, MDDollar-A-Day Plus (> $365)Mark D. White, MDDollar-A-Day ($365)Greenbrier D. Almond, MDDerek H. Andreini, MDEdward F. Arnett, MDJoseph P. Assaley, MDStephen P. Cassis, MDSamuel R. Davis, MDGary S. DeGuzman, MDWilliam L. Harris, MDMichael A. Istfan, MDMichael A. Kelly, MDM. Barry Louden Jr., MDTeodoro G. Medina, MDSushil K. Mehrotra, MDJoseph B. Selby, MDF. Thomas Sporck, MDJohn G. Tellers, MDJohn A. Wade, Jr., MDJames D. Walker, MDR. Austin Wallace, MDCampaigner Plus (> $100)Kamalesh Patel, MDRichard M. Fulks, MDDiane E. Shafer, MDCampaigner ($100)John A. Adeniyi, MDRuperto D. Dumapit, Jr., MDJames D. Felsen, MDCatherine E. Grant, MDJudith Kemp, MDArturo Y. Lim, MDNancy N. Lohuis, MDHarry A. Marinakis, MDNimish K. Mehta, MDStephen K. Milroy, MDJoseph Momen, MDLydia P. Obleada, MDMichael C. Shockley, MDAdnan Silk, MDStephen M. Smith, MDSasidharan Taravath, MDGanpat G. Thakker, MDRoberto C. Valenzuela, MDOphas Vongxaiburana, MDDonor ($50)Roger A. Abrahams, MDPatsy P. Cipoletti, MDJoseph B. Reed, MDResident/Student ($20)Kyle T. Kutrovac, MDC. Tingler, MDWESPAC Board Members2009-2010STATE AT-LARGE - 2 SEATSPhillip R. Stevens, MD, ChairmanM. Tony Kelly, MDWVSMA COUNCIL REPRESENTATIVE - 1 SEATF. Tom Sporck, MD, SecretaryFIRST CONGRESSIONAL DISTRICT - 2 SEATSKen Nanners, MDDavid W. Avery, MDSECOND CONGRESSIONAL DISTRICT - 2 SEATSJohn Wade, MDOther seat vacantTHIRD CONGRESSIONAL DISTRICT - 2 SEATSAhmed D. Faheem, MDRon Stollings, MDALLIANCE REPRESENTATIVE - 1 SEATTerry WaxmanDIRECTORAmy N. Tolliver, MS, TreasurerSeptember/October 2009 | Vol. 105 53

54 West Virginia Medical Journal

September/October 2009 | Vol. 105 55

WV Medical Insurance Agency | NEWSKnow the Facts Before YouChoose a DI PolicyBy Graham RegerA sports injury,a car accident,a problempregnancy…no oneknows when—orhow—disabilitywill strike. Thatunpredictabilityis why the best disability income(DI) insurance policy is theone that generates the mostbenefits in the greatest numberof disability scenarios.But how do you know whichDI policy is the best for you?Given how much is riding onyour decision—your ability tomaintain your family’s current (andfuture) lifestyle—it is imperativethat you know what to look forbefore you purchase disabilityprotection. It’s equally importantto know what to reasonablyexpect from your insurance carrieronce you become a disabilityincome insurance policyholder.Admittedly, it can be a dauntingprospect. Because disability coverageinvolves many more factors thanlife insurance, sorting throughvarious DI policy provisions mayseem overwhelming. Obviously,it’s key to select an insuranceagent or broker who can workwith you to find optimal coveragefor your individual situation.If your questions or concernsaren’t being addressed to yoursatisfaction, find another advisor.However, you don’t have tobe an insurance professional toknow what to look for. When itcomes to DI, there are a numberof criteria—independent of anyspecific insurance carrier—thatcan help you evaluate a policy.Five Sound Ways to JudgeFirst, look for the signs ofquality coverage. The renewabilityprovision is one of the key featuresof any individual disabilityincome policy. The reason? Thisprovision defines your rights tokeep your DI protection in force.In general, a disability contractmay be guaranteed renewableonly or both non-cancellable andguaranteed renewable. If a policyis guaranteed renewable only, theinsurance company agrees to keeprenewing your contract as long asyou continue to pay the premiumson a timely basis. While the insurercannot change the provisions of thepolicy, it can increase premiums byage, state, occupation class and othercategories with prior notification.When the term non-cancellableis added to guaranteed renewable,the insurance company cannotchange any policy provisions andit cannot increase the premiums.As long as premiums are paid ona timely basis—and assuming thatall underwriting information istruthful and accurate—the insurancecompany cannot cancel the contract.Second, understand the policy’sdefinition of “total disability.” Thereare two basic kinds of DI insuranceavailable: Income Replacement andOwn-Occupation (often referredto as “own-occ”). Each has itsown definition of what constitutesa benefit-worthy disability, soit’s important to know about thedifferences between them.As its name implies, IncomeReplacement pays benefits if yousuffer a loss of income due to adisability. The drawback to thistype of policy is that it doesn’tcover you for the loss of a skilledprofession, such as the practiceof medicine, or other occupationsthat require years of specialized,difficult and expensive training.Own-Occupation pays benefitsif sickness or injury prevents youfrom performing “the materialand substantial duties of youroccupation.” In other words,you may be considered totallydisabled—and receive benefitsaccordingly—as long as you arenot able to work in the occupationin which you were engaged at thetime you became disabled. Thisis true even if you are working inanother capacity—even, for example,if you are earning a significantincome teaching or writing.Medical specialists, take note:A few own-occ policies even takethe own-occupation concept a stepfurther in protecting professionalspecialties. If your occupationis limited to a single medicalspecialty recognized by the AMA,certain policies will consider thatspecialty to be your occupation.Third, be aware of what happensif you don’t experience a “totaldisability.” Disability isn’t always“total.” You may suffer a partial(or residual) disability that limitsyour ability to work and results indecreased income—or an initial totaldisability followed by an extendedperiod of residual disability.In such circumstances, mostgood policies will pay benefitsproportionate to your income lossand, for the first six months’ benefit,at least 50% of the total disabilitybenefit. Beyond that, DI policies canvary significantly when it comesto residual disability benefits. For56 West Virginia Medical Journal

WV Medical Insurance Agency | NEWS Continuedexample, most companies discontinueresidual benefits when your incomeloss falls below 20%. Some policies,however, will continue to payresidual benefits after this point aslong as the monthly benefit is greaterthan a certain pre-specified amount.As with all contracts, it pays(and, in a highly compensatedprofession such as yours, payssubstantially) to read and thoroughlyunderstand the fine print.Fourth, know the specifics ofyour policy’s “elimination period.”All DI policies have an eliminationperiod—that is, the period of timethat must elapse before monthlybenefits begin. It functions somewhatin the way a deductible amountdoes on other types of insurance—except rather than making youresponsible for paying a certaindollar amount before coveragestarts, it is a period of time you mustwait after you become disabledbefore your benefits can begin.Most companies offer severalchoices of elimination periods—from as little as one month to asmuch as two years. The longer theelimination period, the lower thecost of your coverage. Be on thelookout for whether your prospectiveinsurer allows different periodsof disability, from the same or adifferent cause, to count towardsyour elimination period (whichtypically must be accumulatedwithin a certain timeframe,e.g., a three-month eliminationperiod must be accumulatedwithin a seven-month period).If you return to work after aperiod of disability that’s shorterthan your elimination period butthen become disabled again whileyou are still in the accumulationperiod, many companies willrequire the second disability to bedue to the same or related causes,or they’ll apply a new eliminationperiod. Again, understanding thefine print is critical. In this case,understanding how an eliminationperiod is calculated can resultin finding a policy that pays outmore in benefits—and sooner.Finally, customization is key.One size does not fit all. The best DIpolicies offer a variety of optionalbenefits to enhance your coverageand allow you to tailor it to yourspecific situation. Depending onthe insurer, you may be able toadd policy riders to keep yourcoverage in line with your increasingincome, help your disability benefitkeep pace with inflation, workalongside Social Security benefits,even help maintain your coverageif you become unemployed.Okay, now what?Congratulations: You’ve doneyour homework, listened closely toan agent or broker whom you trustand scrutinized the provisions ofthe perfect DI policy. What shouldyou expect once you sign the dottedline and submit an application?Underwriting a life insurancepolicy tends to be a morestraightforward proposition thanunderwriting DI coverage. Inaddition to medical tests, extensivefinancial documentation is requiredfor DI. To avoid delays in policyissue, it’s essential that your agentor broker gathers a complete healthhistory from you, including dates,types and amounts of medications;procedures performed; and namesand addresses of all medicalprofessionals consulted. Obviously,your honesty in disclosing yourmedical history is of paramountimportance, both at the underwritingstage of the process as well as whenand if a claim should need to be filed.The same goes for your finances.If the company’s underwritersdetermine that—due to a pre-existingmedical condition or engagementin an activity that could result in adisability—a risk of your becomingdisabled in the future exists, anumber of outcomes are possible.You may be deemed eligible forcoverage but may be asked to payslightly higher premiums (a processcalled “rating”). A small percentageof applications are declined. Inbetween these two outcomes, manyapplicants with medical conditionscan still obtain excellent DI coveragewith a Medical Exclusion Riderattached (depending on the insurer).The basic idea behind a MedicalExclusion Rider is to offer youdisability income coverage even ifyou have a medical problem—withthe proviso that any disabilityyou suffer that is attributed to orinvolves the condition that has beenexcluded from coverage will resultin no eligibility for benefits. And(again, depending on the insurer),although a Medical ExclusionRider is usually permanent becauseof the nature of the medical riskthat has been identified, in somecases the carrier will considerremoving it if you believe andcan show that the conditionexcluded is no longer a concern.If disability strikesCarefully choosing the right DIpolicy for your circumstances shouldresult in fewer surprises when itcomes time to file a claim. And, whileit may seem unlikely that you willever be in that situation, particularlyif you are young and healthy,consider this: A 35-year old man is 4.1times more likely to suffer a disabilitythat lasts 90 days or more before hereaches age 65 than he is to die; a45-year old is 4.4 times more likely.How you choose to safeguardyour livelihood is one of the mostimportant decisions you will evermake. High-quality disabilitycoverage is expensive. Therefore,you owe it to yourself and to yourloved ones to become the mosteducated DI consumer you can,ask difficult questions and insist oncomprehensive answers, thoroughlyweigh all options and, once you selecta policy, participate honestly andopenly in the underwriting process.If this “due diligence” isexercised, you can feel confidentthat you have done the best youcan to secure reliable DI coveragefrom a reputable company.Graham Reger is an accountexecutive with the West VirginiaMedical Insurance Agency and canbe reached by calling 1-800-257-4747x33 (or locally at 304-925-0342 x33).September/October 2009 | Vol. 105 57

ObituariesThe WVSMA remembersour esteemed colleagues…Mario Cardenas MDMario Cardenas, MD, 85 ofPrinceton, died Wednesday,July 8, 2009, at his residence.Born in Guadalajara, Mexico,October 2, 1923, he was the son of thelate Juan and Berta Lara Cardenas.He graduated from medical schoolat the University of Guadalajarain 1948, then came to the UnitedStates. He began his residencyat the Kanawha Valley Hospitalin obstetrics and surgery.In 1952, he met and marriedthe former Ella Mae Holstein.They were married for 56 years.In 1953 he became chief residentat Charleston Memorial Hospital.In 1965, he and his family moved toPrinceton where he practiced surgeryand obstetrics for 28 years. Duringhis 45 years of practice, he deliveredclose to 10,000 babies and touchedthe hearts and souls of many. Duringhis career, he had served as presidentof both the Wyoming County andMercer County medical societiesand was a former chief of staff atPrinceton Community Hospital.Survivors include his wife of 56years, Ella Mae Holstein Cardenasof Princeton; three children, RodolfoCardenas and his wife, Christine,of Powder Springs, Ga., and theirchildren, Alisha, Wendy, Erica,Veronica and Mario, EsmeraldaCardenas Carmichael and herhusband, Dennis, of Knoxville, Tenn.,and Ignacio Cardenas and his wife,Ann, of Vienna, and their childrenMadison, Cameron, Tyler and Luke;special friends and caregivers, DaveVance of Princeton and the staffof Mountaineer Home Nursing.In lieu of flowers, memorialcontributions may be made to theAmerican Diabetes Association, P.O.Box 238, Huntington, WV 25526; theAmerica Cancer Society, 1816 JeffersonSt., Bluefield, WV 24701, or theMercer County Humane Society, 1003Shelter Road, Princeton, WV 24740.William S. Herold, MDWilliam S. Herold, MD, 89, ofCharleston, died on August 9, 2009,at his residence after a long illness.Born in Muddlety on June 4,1920, he was the son of the late H.Lee and Ona Sawyers Herold.He was educated in theschools of Nicholas County,West Virginia University, theMedical College of Virginia, andthe School of Public Health of theUniversity of North Carolina.As a physician, he served onactive duty in the U.S. Navy Reserveduring the Korean War. Aftermilitary service he completed aresidency in anesthesiology at OhioValley Hospital in Wheeling. Helater became health officer of FayetteCounty and also served in Nicholas,Webster, Clay and Braxton counties.He then became assistant directorof Child Health Services in theWest Virginia Health Department.In the 1960s he transferred to theDivision of Vocational Rehabilitation,from which he retired in 1982.He is survived by his wife,Catherine Anne; sons, WilliamHerold Jr., Douglas Lockridge, andEric Roland; daughters, Frances LeeGrudier and Andrea Lynn Herold;and a sister, Rachel White. He isalso survived by five grandchildrenand four great-grandchildren.In lieu of flowers, donations may bemade to HospiceCare, 1606 KanawhaBlvd. W., Charleston, WV 25312.Loreto Santos Santiago, MDDr. Loreto Santos Santiago, 77, ofSt. Albans died Sunday, June 14, 2009.Born December 10, 1931, inMalabon, Rizal, Philippines, hewas a son of the late Juan andDorothea (Santos) Santiago.He received his undergraduatedegree from the University of SantoThomas, Philippines, and graduatedfrom medical school at ManilaCentral University, Philippines. Heserved his medical residencies atthe Romblon Provincial Hospital,Philippines, and Goldwater MemorialHospital in New York City, NYDr. Santiago served as a staffphysician at Thomas MemorialHospital and as a familypractitioner at the Putnam Clinicand retired in 2001 from theRaleigh-Boone Medical Center.He is survived by his family:wife, Leoncia; daughters, Gerardeenand her husband, Anthony Wang,JoAnne and husband, John Stafford,and sons, Drew and Noah, andLorelee and husband, Samuel Wilkes,and sons Hunter and Bryce.58 West Virginia Medical Journal

| Classifi ed AdsMEDICAL EQUIPMENT& SUPPLIESSince 1858Equipment LeasingAlso Available(New & Used)McLAIN SURGICALSUPPLYA West Virginia Company205 Leon Sullivan WayCharleston, WV 25301-2408Phone: 304-343-4384800-729-3195FAX: 304-343-43853000 Washington St. WestFAMILYMEDICALPRACTICEFOR SALEIncludes building andextensive parking onCharleston’s Westside.Very busy practice.Potential net incometo acquiring physicianapproximately$300,000 per year.Call304-344-9821PHYSICIANPosition available in WVconducting Independent Medical Evaluations.We provide referrals, scheduling, billing, transcription,logistic support and training.No call, no weekends, no holidays.Contact: Susan Gladys1-866-929-8766 | Fax - 1-866-712-5202Emailsusang@tsom.comSeptember/October 2009 | Vol. 105 59

Manuscript GuidelinesOriginality: All scientifi c and special topicmanuscripts for the West Virginia Medical Journal willnot be considered for publication if they have alreadybeen published or are described in a manuscriptsubmitted or accepted for publication elsewhere. Allscientifi c articles should be prepared in accordancewith the “Uniform Requirements for Submission ofManuscripts to Biomedical Journals.” Please go towww.icmje.org for complete details.Authors: A cover letter from the correspondingauthor should be submitted with the manuscript. Allpersons listed as authors should have participatedsufficiently in the work to take public responsibility forthe concept.Format: All articles may be submitted by email or onCD. Microsoft Word is preferred, but other programsare acceptable. All tables or fi gures should becreated separately from the body of the manuscriptas .tif, .jpg or .pdf fi les in a high resolution format withcorresponding fi le names such as,Table 1, Figure 1,etc. Legends should be included for all tables andfi gures.References: References should be prepared inaccordance to the “American Medical AssociationManual of Style.” These instructions for authors areavailable online at www.jama.com.Photographs: Please submit digital fi les either froma digital camera or scan at 300 dpi at 100%. Alloriginal photos should have a label on the backindicating the number of the photo, the author’s nameand an indication of “top.” Do not write on the back ofphotos or scratch them with paper clips.Note to authors: The WV Medical Journal inside pagestraditionally print in black and white. If authors wish tohave photos and figures printed in color, there is a$1,000 charge per article to help defray the printingcosts to the Association. Please indicate your preferencewhen submitting an article. If your article is accepted forpublication, you will be invoiced for the charges inadvance of publication.Please address articles and cover letter to the editor atthis address only:F. Thomas Sporck, M.D., F.A.C.S.West Virginia Medical JournalP.O. Box 4106Charleston, WV 25364or email your article with cover letter to:Angela L. Lanham, Managing Editorangie@wvsma.comThanks To Our Advertisers!CAMC Health Ed. and Research Institute .........................9Center for Rural Health Development Loan Fund ...........27Chapman Printing Co. ......................Inside Back Cover, 59CPR Solutions Group, Inc. ................................................2Cooper Land Development, Inc. ........................................7Ear, Nose & Throat Assoc. of Charleston, Inc. ................17Family Practice For Sale .................................................59Flaherty Sensabaugh & Bonasso PLLC ..........................25Greenbrier Clinic..............................................................29HIMG ...............................................................................20McKinley Carter Wealth Services ..................... Back CoverMcLain Surgical Supply ...................................................59Office Managers Association ...........................................39Physician’s Business Office .............................................15Robinson & McElwee, PLLC ...........................................10Seeking Physician ...........................................................59Stationers, Inc..................................................................59Suttle & Stalnaker ............................................................31West Virginia Medical Insurance Agency ........................37West Virginia Mutual Insurance Co. ..................................1West Virginia University ......................... 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 appearsin the 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 copyPOSTMASTER: 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.©2009, West Virginia State Medical Association60 West Virginia Medical Journal

PRINTINGPRPRPRPRININININININININTITITITITITITINGNGNGNGNGNGNGN, MAILMAMAMAMAMAMAMAILILILILILILIL SERVICICESESESESESESERVRVRVRVRVRVRVICICICICICICE, OFOFFIFICECEOFOFOFOFOFOFFIFIFIFIFIFIFICECECECECECECE FURNRNRITURUREFUFUFUFURNRNRNRNRNRNRNRNITITITITITITITI URURURURURURURE, OFOFOFOFFIFIFIF CECECECEOFOFOFOFOFOFFIFIFIFIFIFIFICECECECECECECE SUSUSUSUPPPPPPPPLILILILIESESESESUSUSUSUSUSUPPPPPPPPPPPPPPLILILILILIL ESESESESESESES ANANANDANANANANANAND PRPROMOTIONANLPRPRPRPROMOMOMOMOMOMOMOMOTOTOTOTOTOTOTIOIOIOIOIOIOIONANANANANANANANL PRODUCTSPRPRPRPRODODODODODODODUCUCUCUCUCUCUCTSTSTSTSTSTSCACALLCALLCAC LLLLLL A REPRESENTATIVEVEVRERER PRPRPRESESESENENTATATITI EVEVE TOTOTOTODADAODAYTOTDADAY!800.824.6620800.824.6620YOYOYOYOURURURYOURYOYOYOURURURURURUR COCOCOCMPCOM LETECOCOCOCOMPMPMPMPMPMPMPLELELELELELEL TETETETETETE MARKETINGMAMAMAMAMAMAMARKRKRKRKRKRKRKETETETETETETE INININININING FULFILLMENTFUFUFUFULFLFLFLFLFL ILILILILILILLMLMLMLMLMENENENENENENENET SOLUTIONOSOSOSOSOSOLULULULULULTITITITITITIONONONONONONHAMPIONHAMPIONNDUSTRIESNDUSTRIESNCNCADADADADADADADAD DESDESDESDIGNGNDESDESDESESESIGNIGNIGNIGNIGN: CINCDYCINDCINCININDYDYDYDYDY COLO LIERCOLCOLCOLOLLIELIELIELIER

West Virginia Medical JournalP.O. Box 4106Charleston, WV 25364www.wvsma.comWhen the journey is just as importantas the destinationMcKinley Carter Wealth Services is pleased to be named in Medical Economicslist of 150 Best Financial Advisers for Doctors.Learn more atwww.mc-ws.com|We understand that managing your moneyis not the most important thing in life,but believe that proper money managementcan help you take better care of the things that are.www.mc-ws.com |866.306.2400Wheeling Charleston PittsburghMcKinley Carter Wealth Services, Inc. (”McKinley Carter”) is an SEC registered investment adviser. For additional information about McKinley Carter, includingfees and services, send for our disclosure statement as set forth on Form ADV. Please read the disclosure statement carefully before you invest or send money.