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Vol. 83, No. 1 • January, 1990
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HEALTH SCIENCES LIBRARY UNIVERSITY OF MARYLAND BALTIMORE
JAN 30 1990
SECU NOT TO CIRC. ;
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TENNESSEE MEDICAL ASSOCIATION 155th Annual Meeting April 4-7, 1990 Hyatt Regency Hotel Knoxville, Tennessee
Let us cut you a deal!
THE TMA MEDICAL PLAN
For a limited time only, we will reward you for allowing us to quote the TMA Medical Plan for your firm. Our sales representative will deliver with the quotation a valuable " Parker Pocket Knife."
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For Deductible Options:
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Plan pays 80% of the first $5,000 of eligible expenses in the calendar year. Member pays 20%.
Plan pays 1 00% of the eligible expenses in a calendar year up to a maximum of $1 ,000,000.
The Special Plan Benefits
• 100% Special Out-Patient Surgical Benefit
• 100% of First $300. - Special Out-Patient Accidental Injury Benefit
• $5.00 Per 90 Day Supply - Special Maintenance Prescription Drug Plan
• Up to 10% Discount on your portion of the Flospital Bill at many hospitals statewide
• Special Surviving Dependent Benefit
For A Quotation,
Call Your Representative:
Administered by:
THE TMA ASSOCIATION INSURANCE AGENCY, INC.
RONNIE McCLISTER, CLU, ChFC GORDON LOWE, CLU
The TMA Association Insurance .Agency, Inc. 822 McCallie Avenue P.O. Box 1109 Chattanooga, TN 37401
1-800-347-1108
Local 267-0915
WE LOOK FORWARD TO HEARING FROM YOU!
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Vol. 83, No. 1 January, 1990
OFFICE OF PUBLICATION
1 12 Louise Ave., Nashville, 37203 (615) 327-1451
EDITOR
John B. Thomison, M.D. 230 25th Ave. North Nashville, 37203
BUSINESS MANAGER
L Hadley Williams
MANAGING EDITOR
Jean Wishnick
TMA OFFICERS
PRESIDENT William O. Miller, M.D. 939 Emerald Ave. Knoxville, 37917
PRESIDENT-ELECT Hamel B. Eason, M.D. 4628 Peppertree Lane Memphis, 38117
CHAIRMAN, BOARD OF TRUSTEES James T. Craig, Jr., M.D.
616 W. Forest Jackson, 38301
TMA EXECUTIVE STAFF
EXECUTIVE DIRECTOR L. Hadley Williams
ASSOCIATE EXECUTIVE DIRECTOR Donald H. Alexander
DIRECTOR OF STUDENT EDUCATION FUND AND HEALTH SERVICES William V. Wallace
DIRECTOR OF EDUCATION AND MEETING SERVICES John H. Grant Jr.
DIRECTOR OF GOVERNMENTAL AND LEGISLATIVE AFFAIRS Charles W. Cato II
EXECUTIVE ASSISTANT Mark Greene
DIRECTOR OF COMMUNICATIONS Russell E. Miller Jr.
STAFF ATTORNEY Dennis Lord
Journal of the Tennessee Medical Association ISSN 0040-3318
Published monthly under the direction of the Board of Trustees for and by members of the Tennessee Medical Association, a nonprofit organization with a definite membership for scientific and educational
purposes.
Devoted to the interests of the medical profession of Tennessee. This Association does not officially endorse opinions presented in various papers published herein. Advertisers must conform to policies and regulations established by the Board of Trustees of the Tennessee Medical Association. Subscriptions (nonmembers) $20 per year for US, $26 for Canada and foreign. Single copy $2.50. Payment of Tennessee Medical Association membership dues includes the subscription price of this Journal. Copyright 1990, Tennessee Medical Association. All material subject to this copyright appearing in the Journal may be photocopied for non- commercial scientific or educational use only. Second Class postage paid at Nashville, TN. POSTMASTER: Send address changes to Journal of the Tennessee Medical Association, 1 1 2 Louise Ave. , Nashville, TN 37203.
coiiicnl/
Original Contributions
9 Medical Grand Rounds and Prescribed Credit by the American Academy of Family Physicians — Raymond Massengill, Jr., Ed.D.; Leo Harvill, Ph.D.
11 Remote Metastases From Uveal Melanoma — Timothy Powers, M.D.; Rodolfo Laucirica, M.D.; Sandra Brooks, M.D.; Sophie Leopold, MRS, CT (ASCP); Michael Whitson, M.D., James Earn urn, M.D.
15 Cutaneous Alternaria Infection in a Patient on Chronic Corticoste- roids— Richard M. Sneeringer, M.D.; David W. Haas, M.D.
18 Colonoscopic Removal of a Gallstone Obstructing the Sigmoid Co- lon— Shauna R. Roberts, M.D.; Cindy Chang, M.D.; Todd Chapman, M.D.; Paul G. Koontz, Jr., M.D.; Gerald O. Early, M.D.
Regular Features
20 Trauma Rounds — Recognition of the Subtle Signs of Child Abuse 22 Vanderbilt Morning Report — A Case of Cyanosis Without Hypoxemia; A Case of Syncope in the Church Choir
24 Health and Environment Report — Disposal of Infectious Wastes in Sanitary Landfills
25 Medicolegal Junction — Reach for the Moon: The TMA-TBA Code of Cooperation
27 Loss Prevention Case of the Month — Help Needed — Not Called For
TMA Organizational
40 Highlights of the TMA Board of Trustees Meeting — October 15, 1989 43 IMPACT Members — 1989
President’s Page
31 Emotions and Perceptions in a Postop Waiting Room
Editorials
32 A Time for Hope— A Time for Danger
34 CME for Credit
35 Looking Back — and Forth
Departments
37 in Memoriam
38 New Members 38 Personal News
38 PRA Recipients
39 Announcements
48 Continuing Medical Education Opportunities
51 Placement Service
52 Information for Authors 52 Advertisers in this Issue
3
YOCON’
YOHIMBINE HCI
Description: Yohimbine is a 3a-15a-20B-17a-hydroxy Yohimbine-16a-car- boxylic acid methyl ester. The alkaloid is found in Rubaceae and related trees. Also in Rauwolfia Serpentina (L) Benth. Yohimbine is an indolalkylamine alkaloid with chemical similarity to reserpine. It is a crystalline powder, odorless. Each compressed tablet contains (1/12 gr.) 5.4 mg of Yohimbine Hydrochloride.
Action: Yohimbine blocks presynaptic alpha-2 adrenergic receptors Its action on peripheral blood vessels resembles that of reserpine, though it is weaker and of short duration. Yohimbine's peripheral autonomic nervous system effect is to increase parasympathetic (cholinergic) and decrease sympathetic (adrenergic) activity. It is to be noted that in male sexual performance, erection is linked to cholinergic activity and to alpha-2 ad- renergic blockade which may theoretically result in increased penile inflow, decreased penile outflow or both.
Yohimbine exerts a stimulating action on the mood and may increase anxiety. Such actions have not been adequately studied or related to dosage although they appear to require high doses of the drug Yohimbine has a mild anti-diuretic action, probably via stimulation of hypothalmic centers and release of posterior pituitary hormone.
Reportedly, Yohimbine exerts no significant influence on cardiac stimula- tion and other effects mediated by B-adrenergic receptors, its effect on blood pressure, if any, would be to lower it; however no adequate studies are at hand to quantitate this effect in terms of Yohimbine dosage, indications: Yocon^ is indicated as a sympathicolytic and mydriatric. It may have activity as an aphrodisiac.
Contraindications: Renal diseases, and patient's sensitive to the drug. In view of the limited and inadequate information at hand, no precise tabulation can be offered of additional contraindications.
Warning; Generally, this drug is not proposed for use in females and certainly must not be used during pregnancy. Neither is this drug proposed for use in pediatric, geriatric or cardio-renal patients with gastric or duodenal ulcer history. Nor should it be used in conjunction with mood-modifying drugs such as antidepressants, or in psychiatric patients in general.
Adverse Reactions; Yohimbine readily penetrates the (CNS) and produces a complex pattern of responses in lower doses than required to produce periph- eral a-adreneigic blockade. These include, anti-diuresis, a general picture of central excitation including elevation of blood pressure and heart rate, in- creased motor activity, irritability and tremor. Sweating, nausea and vomiting are common after parenteral administration of the drug.i '2 Also dizziness, headache, skin flushing reported when used orally. '' ■3 Dosaga and Adminlstaation; Experimental dosage reported in treatment of erectile impotence. ^ 'S '* 1 tablet (5.4 mg) 3 times a day, to adult males taken orally. Occasional side effects reported with this dosage are nausea, dizziness or nervousness. In the event of side effects dosage to be reduced to Va tablet 3 times a day, followed by gradual increases to 1 tablet 3 times a day. Reported therapy not more than 10 weeks.3 How ^ppiiod: Oral tablets of Yocon® 1/12 gr. 5.4 mg in
2.
bottles of 100’s NDC 53159-001-01 and 1000’s NDC 53159-001-10.
References:
1. A. Morales et al., New England Journal of Medi- cine: 1221 . November 12, 1981 .
Goodman, Gilman — The Pharmacological basis of Therapeutics 6th ed., p. 176-188.
McMillan December Rev. 1/85.
3. Weekly Urological Clinical letter, 27:2, July 4,
1983.
4. A. Morales et al. , The Journal of Urology 1 28;
45-47, 1982.
Rev. 1/85
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Each capsule contains 5 mg chlordiazepoxide HCLand 2.5 mg clidinium bromide.
Please consult complete prescribing information, a summary of which follows:
* Indications: Based on a review of this drug by the National Academy of Sciences— National Research Council and/or other information, FDA has classified the indications as follows:
"Possibly” effective: as adjunctive therapy in the treatment of peptic ulcer and in the treatment of the irritable bowel syndrome (irritable colon, spastic colon, mucous colitis) and acute enterocolitis.
Final classification of the less-than-effective indicabons requires further investigation.
Contraindications: Glaucoma; prostatic hypertrophy, benign bladder neck obstruction; hypersensitivity to chlordiazepoxide HCI and/or clidinium Br. Warnings: Caution patients about possible combined effects with alcohol and other CNS depressants, and against hazardous occupations requiring complete mental alertness (e g., operating machinery, driving).
Usage in Pregnanof: Use of minor tranquilizers during first trimester should almost always be avoided because of increased risk of congeni- tal malformations as suggested in several studies. Consider possibility of pregnancy when instituting therapy. Advise patients to discuss therapy if they intend to or do become pregnant.
As with aU anticholinergics, inhibition of lactation may occur.
Withdrawal symptoms of the barbiturate type have occurred after discontinuation of benzodiazepines (see Drug Abuse and Dependence).
Precautions: In elderly and debilitated, limit dosage to smallest effective amount to preclude ataxia, oversedation, confusion (no more than 2 capsules/day initially; increase gradually as needed and tolerated) . Though generally not recommended, if combination therapy with other psychotropics seems indicated, carefully con- sider pharmacology of agents, particularly potentiating drugs such as MAO inhib- itors, phenothiazines. Observe usual precautions in presence of impaired renal or hepatic function. Paradoxical reactions reported in psychiatric patients. Employ usual precautions in treating anxiety states with evidence of impending depres- sion; suicidal tendencies may be present and protective measures necessary. Variable effects on blood coagulation reported very rarely in patients receiving the drug and oral anticoagulants; causal relationship not established. Inform patients to consult physician before increasing dose or abruptly discontinuing this drug. Adverse Reactions: No side effects or manifestations not seen with either com- pound alone reported with Librax. When chlordiazepoxide HCI is used alone, drowsiness, ataxia, confusion may occur, especially in elderly and debilitated; avoidable in most cases by proper dosage adjustment, but also occasionally observed at lower dosage ranges. Syncope reported in a few instances. Also encountered; isolated instances of skin eruptions, edema, minor menstrual irreg- ularities, nausea and constipation, extrapyramidal symptoms, increased and decreased libido— aU infrequent, generally controUed with dosage reduction; changes in EEG patterns may appear during and after treatment; blood dyscrasias (including agranulocytosis), jaundice, hepatic dysfunction reported occasionaUy with chlordiazepoxide HCI, making periodic blood counts and liver function tests advisable during protracted therapy. Adverse effects reported with Librax typical of antichohnergic agents, i.e., dryness of mouth, blurring of vision, urinary hesi- tancy, constipation. Constipation has occurred most often when Librax therapy is combined with other spasmolytics and/or low residue diets.
Drug Abuse and Dependence: Withdrawal symptoms similar to those noted with barbiturates and alcohol have occurred foUowing abrupt discontinuance of chlor- diazepoxide; more severe seen after excessive doses over extended periods; milder after taking continuously at therapeutic levels for several months. After extended therapy, avoid abrupt discontinuation and taper dosage. Carefully supervise addiction-prone individuals because of predisposition to habituation and dependence.
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Vol. 83, No. Q- February, 1990
OFFICE OF PUBLICATION
1 12 Louise Ave., Nashville, 37203 (615) 327-1451
EDITOR
John B. Thomison, M.D. 230 25th Ave. North Nashville, 37203
BUSINESS MANAGER
L. Hadley Williams
MANAGING EDITOR
Jean Wishnick
TMA OFFICERS
PRESIDENT William O. Miller, M.D. 939 Emerald Ave. Knoxville, 37917
PRESIDENT-ELECT Hamel B. Eason, M.D. 4628 Peppertree Lane Memphis, 38117
CHAIRMAN, BOARD OF TRUSTEES James T. Craig, Jr., M.D.
616 W. Forest Jackson, 38301
TMA EXECUTIVE STAFF
EXECUTIVE DIRECTOR L. Hadley Williams
ASSOCIATE EXECUTIVE DIRECTOR Donald H. Alexander
DIRECTOR OF STUDENT EDUCATION FUND AND HEALTH SERVICES William V. Wallace
DIRECTOR OF EDUCATION AND MEETING SERVICES John H. Grant Jr.
DIRECTOR OF GOVERNMENTAL AND LEGISLATIVE AFFAIRS Charles W. Cato II
EXECUTIVE ASSISTANT Mark Greene
DIRECTOR OF COMMUNICATIONS Russell E. Miller Jr.
EXECUTIVE ASSISTANT Marty Vaughn
Journal of the Tennessee Medical Association ISSN 0040-3318
Published monthly under the direction of the Board of Trustees for and by members of the Tennessee Medical Association, a nonprofit organization with a definite membership for scientific and educational
purposes.
Devoted to the interests of the medical profession of Tennessee. This Associotion does not officially endorse opinions presented in various papers published herein. Advertisers must conform to policies and regulations established by the Board of Trustees of the Tennessee Medical Association. Subscriptions (nonmembers) $20 per year for US, $26 for Canada and foreign. Single copy $2.50. Payment of Tennessee Medical Association membership dues includes the subscription price of this Journal. Copyright 1990, Tennessee Medical Association. All moterial subject to this copyright appearing in the Journal may be photocopied for non- commercial scientific or educotional use only. Second Class postage paid at Nashville, TN. POSTMASTER: Send address changes to Journal of the Tennessee Medical Association, 1 12 Louise Ave., Nashville, TN 37203.
content/
Original Contributions
63 Paramedic and Emergency Medical Technician Ciinicai Encounter Management System for Tennessee — Paul S. Auerbach, M.D., M.S.M. 71 The Foul Smelling, Removable Tonsillar Concretion; A Poorly Ap- preciated Manifestation of Colonization With Actinomyces — Abra- ham Verghese, M.D.; Cedric Fernando, M.D.; Donna Roberson, B.S.; Constantino Diaz, M.D.; James Farnum, M.D.
Regular Features
74 Trauma Rounds — Trauma in Pregnancy
77 Radiology Case of the Month — CT Scan of the Abdomen in the Eval- uation of Splenic Infarction
79 Vanderbilt Morning Report — A Fatal Case of Hiccups; A Case of Goodpasture’s Disease and Interstitial Pulmonary Infiltrates
82 Health and Environment Report — Tuberculosis in Tennessee: Cur- rent Trends and Program Update
84 Loss Prevention Case of the Month — Continuing Supervision of Staff — A Necessity
Special Features
85 Minutes of the Tennessee State Board of Medical Examiners Meet- ings— August 23, 1989 and October 11, 1989
86 Minutes of the Tennessee State Board of Medical Examiners Meet- ings— October 3-4, 1989
President’s Page
93 Looking for a Silver Lining
Editorials
94 Solidarity
96 All Junked Up: Out It Goes WIGART
97 Tender — Legal, Not Non-Tough
Departments
98 In Memoriam
98 New Members
99 Personal News 99 PRA Recipients 99 Announcements
102 Continuing Medical Education Opportunities
105 Placement Service
106 Information for Authors 106 Advertisers in this Issue
57
PHYSICIANS
• Monthly Stipend for Physicians in training leading to qualification as General/Orthopedic/Neurosurgeon or anesthesiologist.
• Loan repayment of up to $20,000 for Board eligible General/Orthopedic surgeons and anesthesiologists.
• Flexible drilling options.
• CME opportunities.
Promotion Opportunities *Prestige
For graduates of AM A approved Medical Schools
1-800-443-6419
NAVAL RESERVE
You are Tomorrow. You are the Navy.
58
JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION
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Vol. 83, No. 3 March, 1990
OFFICE OF PUBLICATION
1 12 Louise Ave., Nashville, 37203 (615) 327-1451
EDITOR
John B. Thomison, M.D. 230 25th Ave. North Nashville, 37203
BUSINESS MANAGER
L. Hadley Williams
MANAGING EDITOR
Jean Wishnick
TMA OFFICERS
PRESIDENT William O. Miller, M.D. 939 Emerald Ave. Knoxville, 379 1 7
PRESIDENT-ELECT Hamel B. Eason, M.D. 4628 Peppertree Lane Memphis, 38117
CHAIRMAN, BOARD OF TRUSTEES James T. Craig, Jr., M.D.
6 1 6 W. Forest Jackson, 38301
TMA EXECUTIVE STAFF
EXECUTIVE DIRECTOR L. Hadley Williams
ASSOCIATE EXECUTIVE DIRECTOR Donald H. Alexander
DIRECTOR OF STUDENT EDUCATION FUND AND HEALTH SERVICES William V. Wallace
DIRECTOR OF EDUCATION AND MEETING SERVICES John H. Grant Jr.
DIRECTOR OF GOVERNMENTAL AND LEGISLATIVE AFFAIRS Charles W. Cato II
EXECUTIVE ASSISTANT Mark Greene
DIRECTOR OF COMMUNICATIONS Russell E. Miller Jr.
EXECUTIVE ASSISTANT Marty Vaughn
Journal of the Tennessee Medical Association ISSN 0040-3318
Published monthly under the direction of the Board of Trustees tor and by members of the Tennessee Medical Association, a nonprofit organization with a definite membership for scientific and educational
purposes.
Devoted to the interests of the medical profession of Tennessee. This Association does not officially endorse opinions presented in various papers published herein. Advertisers must conform to policies and regulations established by the Board of Trustees of the Tennessee Medical Association. Subscriptions (nonmembers) $20 per year for US, $26 for Canada and foreign. Single copy $2.50. Payment of Tennessee Medical Association membership dues includes the subscription price of this Journal. Copyright 1990, Tennessee Medical Association. All material subject to this copyright appearing in the Journal may be photocopied for non- commercial scientific or educational use only. Second Class postage paid at Nashville, TN. POSTMASTER: Send address changes to Journal of the Tennessee Medical Association, 1 12 Louise Ave., Nashville, TN 37203.
coAicnl/
Original Contributions
119 Rapid Management of Intracranial Hypertension To Reverse Trans- tentorial Herniation — Usa Verderber, B.A.; Robert Maciunas, M.D.; John Morris, M.D.
124 Diagnosis of Acoustic Neuroma By Magnetic Resonance Imag- ing— Raymond Massengill, Jr., Ed.D.; William Johnstone, M.D.; Jeffrey Robbins, M.D.
AMA 1989 Interim Meeting Reports
128 Strengthening the American Medical Association — Fiscal Respon- sibility and Oversight
130 Address of the AMA Executive Vice President — James H. Sam- mons, M.D.
132 Address of the Chairman of the AMA Board of Trustees — John J. Ring, M.D.
Regular Features
134 Trauma Rounds — Inverse Ratio Ventilation for Posttraumatic Respira- tory Failure
136 Vanderbilt Morning Report — Fever and Foot Drop in a 61 -Year-Old;
A Case of Abdominal Pain and Diarrhea 138 Health and Environment Report — Adolescent Pregnancy in Tennessee
140 Loss Prevention Case of the Month — I Thought I Saw That Report
President’s Page
145 Growing Pains
Editorials
146 Money, Money Everywhere
147 The Use and Abuse of Power
149 Rewriting History; A Corregendum
Departments
149 In Memoriam
150 New Members
150 PRA Recipients
151 Personal News 151 Announcements
154 Continuing Medical Education Opportunities
159 Placement Service
160 Information for Authors 160 Advertisers in this Issue
1 1 1
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Discover the thrill of fly- ing, the end of office overhead and the enjoy- ment of a general prac- tice as an Air Force flight surgeon. Talk to an Air Force medical program manager about the tremendous benefits of being an Air Force medi- cal officer:
• Quality lifestyle, quali- ty practice
• 30 days vacation with pay per year
• Support of skilled professionals
• Non-contributing retirement plan if qualified
Discover how to take flight as an Air Force flight surgeon. Talk to the Air Force medical team today. Call
USAF Health Professions (800) 423-USAF Toll-Free
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Vol. 83, No. 4 April, 1990
OFFICE OF PUBLICATION
1 12 Louise Ave., Nashville, 37203 (613) 327-1431
EDITOR
John B. Thomison, M.D. 230 23th Ave. North Nashville, 37203
BUSINESS MANAGER
L. Hadley Williams
MANAGING EDITOR
Jean Wishnick
TMA OFFICERS
PRESIDENT William O. Miller, M.D. 939 Emerald Ave. Knoxville, 3791 7
PRESIDENT-ELECT Hamel B. Eason, M.D. 4628 Peppertree Lane Memphis, 38117
CHAIRMAN, BOARD OF TRUSTEES James T. Craig, Jr., M.D.
616 W. Forest Jackson, 38301
TMA EXECUTIVE STAFF
EXECUTIVE DIRECTOR L. Hadley Williams
ASSOCIATE EXECUTIVE DIRECTOR Donald H. Alexander
DIRECTOR OF STUDENT EDUCATION FUND AND HEALTH SERVICES William V. Wallace
DIRECTOR OF EDUCATION AND MEETING SERVICES John H. Grant Jr.
DIRECTOR OF GOVERNMENTAL AND LEGISLATIVE AFFAIRS Charles W. Cato II
EXECUTIVE ASSISTANT Mark Greene
DIRECTOR OF COMMUNICATIONS Russell E. Miller Jr.
EXECUTIVE ASSISTANT Marty Vaughn
Journal of the Tennessee Medical Association ISSN 0040-3318
Published monthly under the direction of the Board of Trustees for and by members of the Tennessee Medical Association, a nonprofit organization with a definite membership for scientific and educational
purposes.
Devoted to the interests of the medical profession of Tennessee. This Association does not officially endorse opinions presented in various papers published herein. Advertisers must conform to policies and regulations established by the Board of Trustees of the Tennessee Medical Association. Subscriptions (nonmembers) $20 per year for US, $26 for Canada and foreign. Single copy $2.50. Payment of Tennessee Medical Association membership dues includes the subscription price of this Journal. Copyright 1990, Tennessee Medical Association. All material subject to this copyright appearing in the Journal may be photocopied for non- commercial scientific or educational use only. Second Class postage paid at Nashville, TN. POSTMASTER: Send address changes to Journal of the Tennessee Medical Association, 1 12 Louise Ave., Nashville, TN 37203.
COflIttAl/
Original Contributions
169 On the Role of Alcohol in Nonvehicular Unintentional injuries Among Adolescents — Ian R. H. Rockett, Ph.D., M.P.H.; Sandra L. Putnam, Ph.D.
174 Obstetrics and Obstetrical Care Providers in Rural East Tennes- see— Mark A. Clapp, M.D.
Special Features
179 Special Item — The Birth, Childhood and Early Adolescence of SVMIC — William H. Edwards, M.D.
186 Special Communication — Physician’s Recognition Award — Arthur Osteen, Ph.D.
Regular Features
189 Radiology Case of the Month
190 Vanderbilt Morning Report — Pericarditis Following Antiarrhythmic Therapy; A Case of Peripheral Neuropathy and Hepatitis
192 Health and Environment Report — Results of Immunization Surveys 194 Loss Prevention Case of the Month — A Missed Opportunity?
TMA Organizational
200 The New President — Hamel B. Eason, M.D.
209 Highlights of the TMA Board of Trustees Meeting —
January 13-14, 1990
President’s Page
1 99 In Media Res
Editorials
202 The Appearance of Evil
203 Everybody’s Talkin’ at Me
Departments
205 In Memoriam 205 New Members 207 Personal News
207 PRA Recipients
208 Announcements
211 Continuing Medical Education Opportunities
215 Placement Service
216 Information for Authors 216 Advertisers in this Issue
165
9L173
THE UNITED STATES ARMY RESERVE
HEALTH CARE PROFESSIONALS BONUS TEST PROGRAM
$10,000 - $20,000 - $30,000
The 1989 National Defense Authorization Act requires that the Department of Defense conduct a test to determine the effectiveness of a recruitment bonus to attract health care professionals to the Selective Reserve of the Army.
The Bonus Test Program is scheduled to begin on or about August 1, 1989 and will be
offered to physicians in the following specialties:
ANESTHESIOLOGY ORTHOPAEDIC SURGERY and
GENERAL SURGERY
(Including selected subspecialties)
Applicants must be board certified or meet all requirements for board candidacy in one
of the above specialties.
BONUS ELIGIBILITY: In addition to meeting all criteria for appointment as a medical corps officer in the US Army Reserve, Bonus Test applicants must be civilians and if
prior service, discharged before 28 April 1989.
BONUS AMOUNTS: The test will offer $10,000 bonus for each year of affiliation with the Selected Reserve of the Army, up to a maximum of 3 years. Physicians must choose 1 , 2, or 3 years of affiliation at time of application. Bonuses will be paid annually
at the beginning of each year of agreed affiliation.
TEST PARAMETERS: The design of the test stipulates that bonuses be offered in certain geographic areas. To qualify, applicants must reside within those areas at the
time of accession.
TO FULLY DETERMINE YOUR ELIGIBILITY FOR THIS PROGRAM
PLEASE CONTACT:
ARMY RESERVE HEALTH CARE TEAM 3606 AUSTIN PEAY, SUITE 313, MEMPHIS, TN 38128-3755 OR CALL: (901) 388-9876 or 9877 COLLECT
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Vol. 83, No. 5 May, 1990
OFFICE OF PUBLICATION
1 12 Louise Ave., Nashville, 37203 (615) 327-1451
EDITOR
John B. Thomison, M.D. 230 25th Ave. North Nashville, 37203
BUSINESS MANAGER
L. Hadley Williams
MANAGING EDITOR
Jean Wishnick
TMA OFFICERS
PRESIDENT Hamel B. Eason, M.D. 8673 Classic Dr. Germantown, 38138
PRESIDENT-ELECT Howard L. Salyer, M.D.
1 900 Patterson Nashville, 37203
CHAIRMAN, BOARD OF TRUSTEES Rex A. Amonette, M.D.
1 455 Union Ave. Memphis, 38104
TMA EXECUTIVE STAFF
EXECUTIVE DIRECTOR L. Hadley Williams
ASSOCIATE EXECUTIVE DIRECTOR Donald H. Alexander
DIRECTOR OF STUDENT EDUCATION FUND AND HEALTH SERVICES William V. Wallace
DIRECTOR OF EDUCATION AND MEETING SERVICES John H. Grant Jr.
DIRECTOR OF GOVERNMENTAL AND LEGISLATIVE AFFAIRS Charles W. Cato II
EXECUTIVE ASSISTANT Mark Greene
DIRECTOR OF COMMUNICATIONS Russell E. Miller Jr.
EXECUTIVE ASSISTANT Marty Vaughn
STAFF ATTORNEY Marc Overlook
Journal of the Tennessee Medical Association ISSN 0040-3318
Published monthly under the direction of the Board of Trustees for and by members of the Tennessee Medical Association, a nonprofit organization with a definite membership for scientific and educational
purposes.
Devoted to the interests of the medical profession of Tennessee. This Association does not officially endorse opinions presented in various papers published herein. Advertisers must conform to policies and regulations established by the Board of Trustees of the Tennessee Medical Association. Subscriptions (nonmembers) $20 per year for US, $26 for Canada and foreign. Single copy $2.50. Payment of Tennessee Medical Association membership dues includes the subscription price of this Journol. Copyright 1990, Tennessee Medical Association. All material subject to this copyright appearing in the Journal may be photocopied for non- commercial scientific or educational use only. Second Class postage paid at Nashville, TN. POSTMASTER: Send address changes to Journal of the Tennessee Medical Association, 1 12 Louise Ave.,
TM '(79m
coAlenI/
Original Contributions
225 Nonneoplastic Paraganglionic Tissue in the Gallbladder Wall —
Edward C. McDonald, M.D.
227 Primary Adenocarcinoma of the Vagina Apparently Originating From Cloacal Remnant — Nirmala B. Upadhyaya, M.D., M.P.H.; Pleas R. Co- pas, M.D.; Paul B. Googe, M.D.; Thomas W. McDonald, M.D.; D. Doug- las Wilson, M.D.
230 Condyloma Acuminata in Men: The Role of the Urologist — L. Dean Knoll, M.D.; William L. Furlow, M.D.; Ralph C. Benson, Jr., M.D.
233 Ataxic Hemiparesis Secondary to Paradoxic Embolization — Curtis M. Sauer, M.D.
AMA 1989 Interim Meeting Report
235 Address of the AMA President — Alan R. Nelson, M.D.
Regular Features
239 Vanderbilt Morning Report — A Case of Rash and Digital Necrosis;
Flank Pain Complicating Atrial Fibrillation 242 Trauma Rounds — Ureteropelvic Junction Avulsion Following Blunt Ab- dominal Trauma
244 Health and Environment Report — Incentive Programs Attract Physicians
246 Loss Prevention Case of the Month — A “Cut ” in the Dark
Special Features
262 Minutes of the Tennessee State Board of Medical Examiners Meet- ings— November 14 and 15, 1989
President’s Page
251 TMA — Down and Out?
Editorials
252 The Blandishments of Frugality, or The Great Gored Herd
254 Home Plate
255 Spacing Out
Departments
257 In Memoriam
257 PRA Recipients
258 New Members 258 Personal News 258 Announcements
260 Continuing Medical Education Opportunities
267 Placement Service
268 Information for Authors 268 Advertisers in this Issue
221
PHYSICIANS
• Monthly Stipend for Physicians in training leading to qualification as General/Orthopedic/Neurosurgeon or anesthesiologist.
• Loan repayment of up to $20,000 for Board eligible General/Orthopedic surgeons and anesthesiologists.
• Flexible drilling options.
• CME opportunities.
*Promotion Opportunities *Prestige
For graduates of AM A approved Medical Schools
1-800-443-6419
NAVAL RESERVE
You are Tomorrow. You are the Navy.
222
JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION
Jeumolof Hw
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hmcNoiI Q/zockiHen
Vol. 83, No. 7 July, 1990
OFFICE OF PUBLICATION
1 12 Louise Ave., Nashville, 37203 (615) 327-1451
EDITOR
John B. Thomison, M.D. 230 25th Ave. North Nashville, 37203
BUSINESS MANAGER
L. Hadley Williams
MANAGING EDITOR
Jean Wishnick
TMA OFFICERS
PRESIDENT Hamel B. Eason, M.D. 8673 Classic Dr. Germantown, 38138
PRESIDENT-ELECT Howard L. Salyer, M.D.
1 900 Patterson Nashville, 37203
CHAIRMAN, BOARD OF TRUSTEES Rex A. Amonette, M.D.
1 455 Union Ave. Memphis, 38104
TMA EXECUTIVE STAFF
EXECUTIVE DIRECTOR L. Hadley Williams
ASSOCIATE EXECUTIVE DIRECTOR Donald H. Alexander
DIRECTOR OF STUDENT EDUCATION FUND AND HEALTH SERVICES William V. Wallace
DIRECTOR OF EDUCATION AND MEETING SERVICES John H. Grant Jr.
DIRECTOR OF GOVERNMENTAL AND LEGISLATIVE AFFAIRS Charles W. Cato II
EXECUTIVE ASSISTANT Mark Greene
DIRECTOR OF COMMUNICATIONS Russell E. Miller Jr.
EXECUTIVE ASSISTANT Marty Vaughn
STAFF ATTORNEY Marc Overlock
Journal of the Tennessee Medical Association ISSN 0040-3318
Published monthly under the direction of the Board of Trustees tor and by members of the Tennessee Medical Association, a nonprofit organization with a definite membership tor scientific and educational
purposes.
Devoted to the interests of the medical profession of Tennessee. This Association does not officially endorse opinions presented in various papers published herein. Advertisers must conform to policies and regulations established by the Board of Trustees of the Tennessee Medical Association. Subscriptions (nonmembers) $20 per year for US, $26 for Canada and foreign. Single copy $2.60. Payment of Tennessee Medical Association membership dues includes the subscription price of this Journal. Copyright 1990, Tennessee Medical Association. All material subject to this copyright appearing in the Journal may be photocopied for non- commercial scientific or educational use only. Second Class postage paid at Nashville, TN. POSTMASTER: Send address changes to Journal of the Tennessee Medical Association, 1 12 Louise Ave., Nashville, TN 37203.
coAicnl/
Original Contributions
339 The Pattern of HIV Infection in a Southern State and City: A Model for the Outpatient Clinic — Stephen B. Palte, M.B.Ch.B.; Danny J. Lancaster, M.D.; Stephen T. Miller, M.D.; Robert E. Morrison, M.D.; Lor- etta Bobo, M.D.
344 Adolescents’ Knowledge of AIDS: A Pilot Study in Northeast Ten- nessee— James Granger, M.D.; Russell West, Ph.D.; Harold Nara- more, M.D.; David Snow, M.D.; Helen Clark, ACS14/
347 Central Retinal Vein Occlusion in a Heart Transpiant Patient: A Case Report — Joseph C. Keller, M.D.; John E. Linn, M.D.
Regular Features
349 Trauma Rounds — High Level Positive End Expiratory Pressure in a Trauma Patient With Adult Respiratory Distress Syndrome 352 Vanderbilt Morning Report — Sudden, Profound Weakness and Thy- rotoxicosis: A Case of Bacteremia and a Hepatic Lesion 354 Heaith and Environment Report — AIDS Surveillance in Tennessee: A Report of Trends, 1982-1989
356 The Juris Doctor — AIDS; The Legal Ramifications of Nonconsensual, Mandatory Testing
358 Loss Prevention Case of the Month — It’s Not My Fault, It’s HIS
Special Features
370 Minutes of the Tennessee State Board of Medicai Examiners Meet- ings— Jan. 16-17, 1990; Feb. 3-4, 1990
TMA Organizational
372 Officers and Committee Members 1990-1991
376 Component Society Officers 1990-1991
377 Insurance Plans Sponsored by TMA
President’s Page
361 Brothers By Process
Editorials
362 Responsibility in Government
363 Earth Day
365 Impatience, or, The Belie of the Baitic
Departments
367 In Memoriam 367 New Members
367 PRA Recipients
368 Personal News 368 Announcements
379 Continuing Medical Education Opportunities
383 Placement Service
384 Information for Authors 384 Advertisers in this Issue
335
GENERAL SURCERYTAKES ON NEW MEANING IN THE ARMY RESERVE.
When you take time to serve with the Army Reserve, we’ll make sure it’s time well spent.
For a minimum amount of time, the Reserve will make sure you get a maximum amount of experience you probably won’t find in your civilian practice.
First and foremost, you’ll be an Army officer with all the privileges and benefits which that entails.
Also, service in the Reserve affords you an opportunity to work with dedicated, top profes- sionals from all across the country, as well as attend important medical conferences and even continue your education.
Serving as a general surgeon in the Army Reserve is an adventure waiting to happen. And because your time is important, we can be very flexible about how and when you participate.
For more information about Army Reserve medicine, contact one of our experienced Army Reserve Medical Counselors. They can arrange for you to talk to an Army Reserve physician and visit a Reserve Center or medical facility.
Call or write:
ARMY RESERVE HEALTH CARE TEAM 3606 Austin Peay, Suite 313 Memphis, TN 38128-3755 (^) 388-9876 / 9727
BE ALL YOU CAN BV
ARMY RESERVE
jouf Aol of Hie
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Vol. 83, No. 8 August, 1990
OFFICE OF PUBLICATION
1 12 Louise Ave., Nashville, 37203 (615) 327-1451
EDITOR
John B. Thomison, M.D. 230 25th Ave. North Nashville, 37203
BUSINESS MANAGER
L. Hadley Williams
MANAGING EDITOR
Jean Wishnick
TMA OFFICERS
PRESIDENT Hamel B. Eason, M.D. 8673 Classic Dr. Germantown, 38138
PRESIDENT-ELECT Howard L. Salyer, M.D.
1 900 Patterson Nashville, 37203
CHAIRMAN, BOARD OF TRUSTEES Rex A. Amonette, M.D.
1 455 Union Ave. Memphis, 38104
TMA EXECUTIVE STAFF
EXECUTIVE DIRECTOR L. Hadley Williams
ASSOCIATE EXECUTIVE DIRECTOR Donald H. Alexander
DIRECTOR OF STUDENT EDUCATION FUND AND HEALTH SERVICES William V. Wallace
DIRECTOR OF EDUCATION AND MEETING SERVICES John H. Grant Jr.
DIRECTOR OF GOVERNMENTAL AND LEGISLATIVE AFFAIRS Charles W. Cato II
EXECUTIVE ASSISTANT Mark Greene
DIRECTOR OF COMMUNICATIONS Russell E. Miller Jr.
EXECUTIVE ASSISTANT Marty Vaughn
STAFF ATTORNEY Marc Overlock
Journal of the Tennessee Medical Association ISSN 0040-3318
Published monthly under the direction of the Boord of Trustees for and by members of the Tennessee Medical Association, a nonprofit organization with a definite membership for scientific and educotionol
purposes.
Devoted to the interests of the medicol profession of Tennessee. This Association does not officially endorse opinions presented in vorious papers published herein. Advertisers must conform to policies and regulations established by the Board of Trustees of the Tennessee Medical Association. Subscriptions (nonmembers) $20 per year for US, $26 for Canada and foreign. Single copy $2.50. Payment of Tennessee Medical Association membership dues includes the subscription price of this Journal. Copyright 1990, Tennessee Medical Association. All material subject to this copyright appearing in the Journal may be photocopied for non- commercial scientific or educational use only. Second Class postage paid at Nashville, TN. POSTMASTER: Send address changes to Journal of the Tennessee Medical Association, 1 1 2 Louise Ave. , Nashville, TN 37203.
conicnl/
Original Contributions
393 Sinusoidal Fetal Heart Rate Pattern With Vasa Previa — Pickens A. Gantt, M.D.; Joseph S. Bird, Jr., M.D.; Gary W. Randall, Ph.D.
395 Risk Stratification of the Post-Infarction Patient — Fred L. Haley, M.D.
Regular Features
400 Vanderbilt Morning Report — Cystic Brain Lesions in a Haitian Man 402 Trauma Rounds — Laryngotracheal Transection
404 The Juris Doctor — The New Medical Records Act Amendment
405 Loss Prevention Case of the Month — There Ain’t No Justice
406 Health and Environment Report — Tennessee Medical Home Project
Special Features
409 Special Item — Expressing Concern for the Patient Without Admitting Legal Liability — James G. Frierson, J.D.
412 Special Item — Health Access America — The AMA Proposal to Improve Access to Affordable Quality Health Care 414 Special Communication — HIV Infection Documentation for Disabil- ity— Howard Carpenter
TMA 1990 Annual Meeting Reports
428 Report of the Committee on Legislation
President’s Page
421 BIG D little r period
Editorials
422 Power From the People, or, People Power-less 424 Make the Punishment Fit the Crime
Departments
425 In Memoriam 425 New Members
425 Announcements
426 PRA Recipients
431 Continuing Medical Education Opportunities
435 Placement Service
436 Information for Authors 436 Advertisers in this Issue
andchairn^, Department of Pedialrics, and Dianne Mnrpty, M.D., pediatric infectious disease specialist, pose with MARMA (Mother to Rapid Medical Ass
' Pe&tric Center’s kanaamo mascot. Drs. Moore and Murphy are only two of the many pediatric specialists available for consultation through the TCC.
At The University of Tennessee Medical Center, our pediatric specialists, from endocrinologists to nephrologists, recognize and strive to meet thi special health care needs of children. That is one reason we have created the Tennessee Consultation Center (TCC), a fast, no-cost, physician-to physician consultation service that puts the valuable knowledge of our many pediatric specialists at your fingertips.
To use the TCC service, simply choose the medical or dental specialist with whom you wish to speak from the Directory of Consultants. (If yc do not have a directory, call 1-800-442-8862, and we’ll mail one to you.) Then dial our toll-free number anytime Monday through Friday from 8 a.m. to 6 p.m., or c^ 594-8862 if you are inside Knox County. When the TCC operator answers, give her your name, location and telephom number, and she will connect you with the colleague or service you have requested.
In addition to general consultation, TCC can supply you with laboratory results, patient information and informa- tion on continuing medical or dental education programs.
When you need to know what we know about kids, call TCC. The call and the service are available at no cost.
Tennessee Consultation Center
1-800-442-8861
UNIVERSITY OF TENNESSEE r^ALCENTER AT KNOXVILLE
The University of Tennessee Medical Center at Knoxville is an academic medical ricity blending the best of the art and science of medicine. Since 1956, the Medical Center has provided compassionate patient care in a state-of-the-art setting, comprehensive training for tomorrow’s health
rpgparrh
Jourool of the
lenne//ce
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Vol. 83, No. 9 September, 1990
OFFICE OF PUBLICATION
1 12 Louise Ave., Nashville, 37203 (615) 327-1451
EDITOR
John B. Thomison, M.D. 230 25th Ave. North Nashville, 37203
BUSINESS MANAGER
L. Hadley Williams
MANAGING EDITOR
Jean Wishnick
TMA OFFICERS
PRESIDENT Hamel B. Eason, M.D. 8673 Classic Dr. Memphis, 38125
PRESIDENT-ELECT Howard L. Salyer, M.D.
1 900 Patterson Nashville, 37203
CHAIRMAN, BOARD OF TRUSTEES Rex A. Amonette, M.D. 1455 Union Ave. Memphis, 38104
TMA EXECUTIVE STAFF
EXECUTIVE DIRECTOR L. Hadley Williams
ASSOCIATE EXECUTIVE DIRECTOR Donald H. Alexander
DIRECTOR OF STUDENT EDUCATION FUND AND HEALTH SERVICES William V. Wallace
DIRECTOR OF EDUCATION AND MEETING SERVICES John H. Grant Jr.
DIRECTOR OF GOVERNMENTAL AND LEGISLATIVE AFFAIRS Charles W. Cato II
EXECUTIVE ASSISTANT Mark Greene
DIRECTOR OF COMMUNICATIONS Russell E. Miller Jr.
EXECUTIVE ASSISTANT Marty Vaughn
STAFF ATTORNEY Marc Over lock
Journal of the Tennessee Medical Association ISSN 0040-3318
Published monthly under the direction of the Board of Trustees for and by members of the Tennessee Medical Association, o nonprofit organization with a definite membership for scientific and educational
purposes.
Devoted to the interests of the medical profession of Tennessee. This Association does not officially endorse opinions presented in various papers published herein. Advertisers must conform to policies and regulations established by the Board of Trustees of the Tennessee Medical Association. Subscriptions (nonmembers) $20 per year for US, $26 for Canada and foreign. Single copy $2.50. Payment of Tennessee Medical Association membership dues includes the subscription price of this Journal. Copyright 1990, Tennessee Medical Association. All material subject to this copyright appearing in the Journal may be photocopied for non- commercial scientific or educational use only. Second Class postage paid at Nashville, TN. POSTMASTER; Send address changes to Journal of the Tennessee Medical Association, 1 12 Louise Ave. Nashville, TN 37203.
cenlcnU
Original Contributions
443 AV Nodal Reentrant Tachycardia — Jerry Williams, M.D., Ahmed A. Khan, M.D.
447 Infant Botulism in Tennessee — M. Dianne Murphy, M.D.; Sharon Lail, M.D.
TMA 1990 Annual Meeting Report
450 Report of the Tennessee Deiegation to the American Medicai Association
Regular Features
455 Medical Grand Rounds — A Brief History of Pneumonia
462 Trauma Rounds — Blunt Intestinal Trauma
463 Vanderbilt Morning Report — A Case of Headache and Amnesia; Hy- pokalemia and Weight Loss in a Young Woman
466 Health and Environment Report — Blacks and High Blood Pressure 468 Loss Prevention Case of the Month — The Loser Finally Wins
Special Features
478 Minutes of the Tennessee State Board of Medical Examiners Meet- ing— March 20-21, 1990
President’s Page
471 Obscenities Abound
Editorials
472 Stars in My Eyes
473 RHK, 1898-1990: RIP
474 The Burden of the Burdensome Burden
Departments
475 In Memoriam
476 New Members
476 PRA Recipients
477 Personai News 477 Announcements
480 Continuing Medical Education Opportunities
485 Placement Service
486 Information for Authors 486 Advertisers in this issue
441
GENERAL SURCERYTAKES ON NEW MEANING IN THE ARMY RESERVE.
When you take time to serve with the Army Reserve, we’ll make sure it’s time well spent.
For a minimum amount of time, the Reserve will make sure you get a maximum amount of experience you probably won’t find in your civilian practice.
First and foremost, you’ll be an Army officer with all the privileges and benefits which that entails.
Also, service in the Reserve affords you an opportunity to work with dedicated, top profes- sionals from all across the country, as well as attend important medical conferences and even continue your education.
Serving as a general surgeon in the Army Reserve is an adventure waiting to happen. And because your time is important, we can be very flexible about how and when you participate.
For more information about Army Reserve medicine, contact one of our experienced Army Reserve Medical Counselors. They can arrange for you to talk to an Army Reserve physician and visit a Reserve Center or medical facility.
Call or write:
ARMY RESERVE HEALTH CARE TEAM 3606 Austin Peay, Suite 313 Memphis, TN 38128-3755 (901) 388-9876 / 9727
BE ALL YOU CAN BV
ARMY RESERVE
jouinol of Ihc
lenne//ee
iMclkol Qz/eckilion
Vol. 83, No. 10 October, 1990
OFFICE OF PUBLICATION
1 12 Louise Ave., Nashville, 37203 (615) 327-1451
EDITOR
John B. Thomison, M.D. 230 25th Ave. North Nashville, 37203
BUSINESS MANAGER
L. Hadley Williams
MANAGING EDITOR
Jeon Wishnick
TMA OFFICERS
PRESIDENT Hamel B. Eason, M.D. 8673 Classic Dr. Memphis, 38125
PRESIDENT-ELECT Howard L. Salyer, M.D.
1 900 Patterson Nashville, 37203
CHAIRMAN, BOARD OF TRUSTEES Rex A. Amonette, M.D.
1 455 Union Ave. Memphis, 38104
TMA EXECUTIVE STAFF
EXECUTIVE DIRECTOR L. Hadley Williams
ASSOCIATE EXECUTIVE DIRECTOR Donald H. Alexander
DIRECTOR OF STUDENT EDUCATION FUND AND HEALTH SERVICES William V. Wallace
DIRECTOR OF EDUCATION AND MEETING SERVICES John H. Grant Jr.
DIRECTOR OF GOVERNMENTAL AND LEGISLATIVE AFFAIRS Charles W. Cato II
EXECUTIVE ASSISTANT Mark Greene
DIRECTOR OF COMMUNICATIONS Russell E. Miller Jr.
EXECUTIVE ASSISTANT Marty Vaughn
STAFF ATTORNEY Marc Overlock
Journal of the Tennessee Medical Association ISSN 0040-3318
Published monthly under the direction of the Board of Trustees tor and by members of the Tennessee Medical Association, a nonprofit organization with a definite membership for scientific and educational
purposes.
Devoted to the interests of the medical profession of Tennessee. This Association does not officially endorse opinions presented in various papers published herein. Advertisers must conform to policies ond regulations established by the Board of Trustees of the Tennessee Medical Association. Subscriptions (nonmembers) $20 per year for US, $26 for Canada and foreign. Single copy $2.50. Payment of Tennessee Medical Association membership dues includes the subscription price of this Journal. Copyright 1990, Tennessee Medical Associotion. All material subject to this copyright appearing in the Journal may be photocopied for non- commercial scientific or educational use only. Second Class postage paid at Nashville, TN. POSTMASTER: Send address changes to Journal of the Tennessee Medical Association, 1 1 2 Louise Ave. . Noshville, TN 37203.
conleni/
Original Contributions
499 Vasa Previa — Michael C. Good, M.D.; Pleas R. Copas, M.D.; Gary E. Kleinman, M.D.; Michael R. Caudle, M.D.
502 More Than 17,000 Transurethral Prostatic Resections (TURs): Some of the Things I Have Learned — Oscar Carter, M.D.
Regular Features
508 Trauma Rounds — Traumatic Lung Cyst
510 Vanderbilt Morning Report — An Unusual Case of Ventricular Tachy- cardia; A Case of Refractory Hypotension 512 Health and Environment Report — Communicable Disease Reporting; Why?
Special Features
515 Special Communication — Durable Powers of Attorney for Health Care Decisions: Understanding the Latest Malpractice Risk — David E. Fowler
518 Minutes of the Tennessee State Board of Medical Examiners Meet- ings—May 14-16, 1990; July 17-18, 1990
TMA 1990 Annual Meeting Report
531 Report of the Committee on Communications and Public Service
TMA Organizational
533 Highlights of the TMA Board of Trustees Meeting — July 14-15, 1990
President’s Page
523 Tennessee Healthcare Exchange 90s
Editorials
524 Rockin’ the Boat: A Footnote on History 526 Compared to What?
Departments
528 In Memoriam 528 New Members 528 Personal News
528 PRA Recipients
529 Announcements
534 Continuing Medical Education Opportunities
539 Placement Service
540 Instructions for Authors 540 Advertisers in this Issue
493
Let SEAKO Highlight Your Practice . . . with PMS PLUS
SEAKO’s Practice Management System provides a state-of-the-art automated solution that allows your practice to:
INCREASE CASHFLOW:
Simplifies statements that eliminate confusion
Electronic claims for better accuracy and quicker claims return
Automatic accounts receivable tracking for collecting on-time payments
SAVE TIME AND MONEY:
Automates routine tasks which reduces work load
Patient inquiries, billing, statements, and insurance processing are completely automated
Automates patient recall which enhances follow up care and marketing efforts
GAIN CONTROL:
Produces medical and business reports to help analyze your practice
Provides a revenue report by day, month and year- to-date which allows analysis comparison to determine future trends
Organizes reports for effectiveness in everyday management
PMS PLUS FEATURES:
Automated Billing Automated Insurance Processing Automated Medical Records Management Reports Practice Marketing Word Processing
PMS PLUS SUPPORT:
Toll-Free Hotlines Classroom and On-Site Training Advanced Education Beeper Service Program Enhancements 90-day Unlimited Training
Top-of-the-line Hardware;
IBM OR NEC
Seako offers you complete security. Being a wholly-owned subsidiary of CSC gives SEAKO the backing and resources of a billion dollar company. You can be sure we will be here today and tomorrow.
SEAKO, INC.
A Wholly-Owned Subsidiary of Computer Sciences Corporation 517 Beacon Parkway West Birmingham, Alabama 35209
For more information about highlighting your practice with PMS PLUS call:
(205) 945-8200 In FL (904) 730-3822
494
JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION
JoufAol of Hie
l«nne//ce
m«(lk<il ci/zeckilion
Vol. 83, No. 1 1 November, 1990
OFFICE OF PUBLICATION
1 12 Louise Ave., Nashville, 37203 (615) 327-1451
EDITOR
John B. Thomison, M.D. 230 25th Ave. North Nashville, 37203
BUSINESS MANAGER
L, Hadley Williams
MANAGING EDITOR
Jean Wishnick
TMA OFFICERS
PRESIDENT Hamel B. Eason, M.D. 8673 Classic Dr. Memphis, 38125
PRESIDENT-ELECT Howard L. Salyer, M.D.
1 900 Patterson Nashville, 37203
CHAIRMAN, BOARD OF TRUSTEES Rex A, Amonette, M.D.
1 455 Union Ave. Memphis, 38104
TMA EXECUTIVE STAFF
EXECUTIVE DIRECTOR L. Hadley Williams
ASSOCIATE EXECUTIVE DIRECTOR Donald H. Alexander
DIRECTOR OF STUDENT EDUCATION FUND AND HEALTH SERVICES William V. Wallace
DIRECTOR OF EDUCATION AND MEETING SERVICES John H. Grant Jr.
DIRECTOR OF GOVERNMENTAL AND LEGISLATIVE AFFAIRS Charles W. Cato II
EXECUTIVE ASSISTANT Mark Greene
DIRECTOR OF COMMUNICATIONS Russell E. Miller Jr.
EXECUTIVE ASSISTANT Marty Vaughn
STAFF ATTORNEY Marc Overlock
Journal of the Tennessee Medical Association ISSN 0040-3318
Published monthly under the direction of the Board of Trustees for and by members of the Tennessee Medical Association, a nonprofit organization with a definite membership for scientific and educational
purposes.
Devoted to the interests of the medical profession of Tennessee. This Association does not officially endorse opinions presented in various papers published herein. Advertisers must conform to policies and regulations established by the Board of Trustees of the Tennessee Medical Association. Subscriptions (nonmembers) $20 per year for US, $26 for Canada and foreign. Single copy $2.50. Payment of Tennessee Medical Association membership dues includes the subscription price of this Journal. Copyright 1990, Tennessee Medical Association. All material subject to this copyright appearing in the Journal may be photocopied for non- commercial scientific or educational use only. Second Class postage paid at Nashville, TN. POSTMASTER: Send address changes to Journal of the Tennessee Medical Association, 1 1 2 Louise Ave. Nashville, TN 37203.
cenlcnU
Original Contributions
549 Lower Extremity Revascularization by Percutaneous Atherec- tomy— Edward M. Priest, M.D.; Douglas A. Waldo, M.D.
552 Tissue Characterization of a Parathyroid Adenoma: Sonographic- Pathologic Correlation — Jack Dempsey, M.D.; Jay Brooks, M.D.; Randall L. Scott, M.D.
Regular Features
557 Trauma Rounds — Large Diameter Impalement
559 Radiology Case of the Month
561 Vanderbilt Morning Report — An Unusual Cause of Heart Failure; An Unusual Cause of Solitary Pulmonary Nodule 563 The Juris Doctor — The Privilege of Peer Review 566 Health and Environment Report — Tennessee’s Regulation of Lead in Drinking Water
568 Loss Prevention Case of the Month — Fragmented Evaluation
AMA 1990 Annual Meeting Report
571 Address of the AMA President — The Business at Hand and the Chal- lenges Ahead — Alan R. Nelson, M.D.
TMA 1990 Annual Meeting Reports
574 Report of the Committee on Governmental Medical Services 576 Report of the Committee on Hospitals
President’s Page
579 When Prowess Outstrips Prudence — Muddy Water
Editorials
580 Pretentiousness 582 The Girls from Ipanema
Departments
584 Mail Box — AIDS Issue Response
585 In Memoriam
585 PRA Recipients
586 New Members 586 Personal News 586 Announcements
588 Continuing Medical Education Opportunities
593 Placement Service
594 Information for Authors 594 Advertisers in this issue
545
Charles M. Cooper, M.D. Morgan E. Scott, M.D. Neil P. Dubner, M.D. Arthur E. Kelley, M.D. Basil E. Roebuck, M.D.
Don L. Weston, M.D. Orren LeRoyce Royal, M.D. G. Paul Hlusko, M.D. D. Wilfred Abse, M.D. Ronald L. Myers, M.D. Hal G.GiUespie, M.D.
Greek poet Theocritus said it. The eleven men who comprise the Active Medical Staff of Saint Albans Hospital practice it. Every day.
They combine years of study and experience to bring patients the best available care for emo- tional and psychological troubles. Their special interests cover the broadest spectrum of psychiatric treatment, resulting in both adult and adoles- cent programs for chemical dependency, eating
disorders, phobias and anxieties, and pain management.
Our doctors lead a large group of professionals and volunteers who make compassion and expert care a way of life. Saint Albans. Today and for the past 74 years we are
concerned, above all, with your peace of mind.
2 Saint Albans
np l^hiatric Hospital
Radford, Vireinia fZOSf 639-2481
jouf AOl of HlC
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Vol. 83, No. 12 December, 1990
OFFICE OF PUBLICATION
1 12 Louise Ave., Nashville, 37203 (615) 327-1451
EDITOR
John B. Thomison, M.D. 230 25th Ave. North Nashville, 37203
BUSINESS MANAGER
L Hadley Williams
MANAGING EDITOR
Jeon Wishnick
TMA OFFICERS
PRESIDENT Hamel B. Eason, M.D. 8673 Classic Dr. Memphis, 38125
PRESIDENT-ELECT Howard L. Salyer, M.D.
1 900 Patterson Nashville, 37203
CHAIRMAN, BOARD OF TRUSTEES Rex A. Amonette, M.D.
1 455 Union Ave. Memphis, 38104
TMA EXECUTIVE STAFF
EXECUTIVE DIRECTOR L. Hadley Williams
ASSOCIATE EXECUTIVE DIRECTOR Donald H. Alexander
DIRECTOR OF STUDENT EDUCATION FUND AND HEALTH SERVICES William V. Wallace
DIRECTOR OF EDUCATION AND MEETING SERVICES John H. Grant Jr.
DIRECTOR OF GOVERNMENTAL AND LEGISLATIVE AFFAIRS Charles W. Cato II
EXECUTIVE ASSISTANT Mark Greene
DIRECTOR OF COMMUNICATIONS Russell E. Miller Jr.
EXECUTIVE ASSISTANT Marty Vaughn
STAFF AHORNEY Marc Overlock
Journal of the Tennessee Medical Association ISSN 0040-3318
Published monthly under the direction of the Boord of Trustees for and by members of the Tennessee Medical Association, a nonprofit organization with a definite membership for scientific and educational
purposes.
Devoted to the interests of the medical profession of Tennessee. This Association does not officially endorse opinions presented in various papers published herein. Advertisers must conform to policies and regulations established by the Board of Trustees of the Tennessee Medical Association. Subscriptions (nonmembers) $20 per year for US, $26 for Canada and foreign. Single copy $2.50. Payment of Tennessee Medical Association membership dues includes the subscription price of this Journal. Copyright 1990, Tennessee Medical Association. All material subject to this copyright appearing in the Journal may be photocopied for non- commercial scientific or educational use only. Second Class postage paid at Nashville, TN. POSTMASTER: Send address changes to Journal of the Tennessee Medical Association, 1 12 Louise Ave., Nashville, TN 37203.
conlcAl/
Original Contributions
603 Infective Endocarditis Due to the CDC Group M6 Bacillus — Richard C. Rose, III, M.D.; Allan M. Grossman, M.D.; James kV. Giles, M.D.
605 Tuberculous Epididymo-orchitis and Granulomatous Prostatitis Mimicking Neoplasia — AH Jaffar, M.D.; Jay B. Mehta, M.D.; James H. Godfrey, M.D.
Regular Features
608 Vanderbilt Morning Report — Lung Nodules in a Heart Transplant Patient
609 Health and Environment Report — The Trauma Care System in Tennessee
610 Loss Prevention Case of the Month — Parameters’ in the Emergency Room
Special Features
613 Minutes of the Tennessee State Board of Medical Examiners Meet- ing— Sept. 18-19, 1990
TMA Organizational
623 1990 Membership Roster 644 Index to Volume 83
President’s Page
617 Oh No, I’m on Call This Christmas
Editorials
618 Those Xmas Catalogs
619 Scene and Be Seen
Departments
620 New Members
621 In Memoriam 621 PRA Recipients 621 Personal News
621 Announcements
622 Continuing Medical Education Opportunities
651 Placement Service
652 Information for Authors 652 Advertisers in this Issue
599
PUT YOUR MEDICAL CAREER IN FLIGHT.
Discover the thrill of fly- ing, the end of office overhead and the enjoy- ment of a general prac- tice as an Air Force flight surgeon. Talk to an Air Force medical program manager about the tremendous benefits of being an Air Force medi- cal officer:
• Quality lifestyle, quali- ty practice
• 30 days vacation with pay per year
• Support of skilled professionals
• Non-contributing retirement plan if qualified
Discover how to take flight as an Air Force flight surgeon. Talk to the Air Force medical team today. Call
USAF Health Professions (800) 423-USAF Toll-Free
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OWNED AND PUBUSHED BY THE ASSOGATION
JANUARY, 1990 VOL. 83, NO. 1
Medical Grand Rounds and Prescribed Credit by the American Academy of Family Physicians
RAYMOND MASSENGILL, JR., Ed.D. and LEO HARVILL, Ph.D.
Medical grand rounds take on various formats at the various medical centers. The programs at Bristol Regional Medical Center, which is one of the teaching hospitals of the East Tennessee State University, James H. Quillen College of Medicine, usually consist of a 50-minute lecture followed by a 10-minute question and answ^er pe- riod. The programs for grand rounds are devel- oped by a committee composed of an internist, two surgeons, a family physician, and a medical educator.^
See editorial comment in this issue.
Medical grand rounds have been conducted at Bristol Regional Medical Center for the past 12 years and credit hours in Category 1 of the Phy- sician’s Recognition Award of the American Medical Association have been provided. Since July 1986, these programs have also been re-
From the James H. Quillen College of Medicine, East Tennessee State University, Bristol. Dr. Massengill is director of Medical Education.
Reprint requests to Bristol Regional Medical Center. Bristol, TN 37620 (Dr. Massengill).
viewed and accepted for prescribed credit by the American Academy of Family Physicians (AAFP). The present study deals with what im- pact this change has made on family physician attendance, as well as continuing education cred- it and other educational considerations.
Method
In April 1989, a questionnaire was mailed to 11 family physicians, four of them full-time fac- ulty and seven in private practice, who attend rounds along with a cover letter that indicated that since July 1986, the grand rounds programs had been reviewed and accepted for prescribed credit by the AAFP, and in order to help deter- mine if this procedure should be continued it would be helpful if they would complete the questionnaire shown in Fig. 1.
Results
Ten physicians (91%) of the 11 responded.
Two (20%) of the physicians indicated their at- tendance at rounds was dependent upon the fact that prescribed credit could be obtained, while eight (80%) stated their attendance was not dependent upon this. One of the eight did write that although
JANUARY, 1990
9
FIGURE 1
QUESTIONNAIRE
1. Does your attendance depend upon whether the medical grand rounds programs that have been conducted at Bris- tol Regional Medical Center have been reviewed and ac- cepted for 1 prescribed credit hour by the American Acad- emy of Family Physicians?
Yes No
2. Since grand rounds programs have been reviewed and are accepted for prescribed credit have you been more in- clined to attend?
Yes No
3. Since medical grand rounds are available for prescribed credit at your local hospital and medical center have you obtained more continuing medical education credit than when they were not available?
Yes No
4. From July 1, 1987 through June 30, 1988 a total of 47 grand rounds programs were presented. Out of this total how many would you estimate you attended?
40 or more 30-39 20-29 10-19
less than 10
5. In your opinion should one of the responsibilities of the community hospital and medical center be to conduct medical grand rounds that are approved for continuing medical education credit by the American Academy of Family Physicians?
Yes No
6. Of the medical grand rounds programs that you have attend- ed how many would you estimate have been appropriate for both the internist as well as the family practitioner?
0-25% 26%-50% 51%-75% 76%-100%
he did check no for this first question that he would be very disappointed not to continue to have rounds approved for prescribed credit. Another one, who gave a negative response, wrote that she hoped the programs would continue to be approved for AAFP credit (prescribed).
Eight (80%) indicated that since the programs now offered prescribed credit they had been more inclined to attend, while two (20%) reported this was not an influencing factor.
Eight (80%) indicated they had obtained more continuing medical education credit since rounds were available for prescribed credit at the local hospital and medical center, while one (10%) in- dicated this had not influenced him, and another did not answer this question.
Three (30%) of the physicians indicated they attended 40 or more of the programs from July 1, 1987 through June 30, 1988, one (10%) at-
10
tended between 30-39, four (40%) between 20- 29 and two (20%) between 10-19.
All 10 (100%) respondents felt that one of the responsibilities of the community hospital and medical center was to conduct medical grand rounds that are approved for continuing medical education credit by the AAFP.
Eight (80%) estimated that 76% to 100% of the programs they had attended were appropri- ate for both the internist and the family practi- tioner, while two (20%) estimated 51% to 75%. Because of the small numbers involved in the study, it can do no more than establish a trend.
Discussion
Continuing medical education credit may be desired for many reasons, such as for continued membership in state medical societies, maintain- ing hospital privileges, requirement for malprac- tice self-insurance plans, re-registration of a li- cense to practice medicine,'^ and to keep abreast of the latest developments in medicine.
The medical grand rounds programs that are presented at Bristol Regional Medical Center are based on the needs that have been identified in the hospital and those the grand rounds commit- tee considers important to bring a new or ad- vanced medical concept to the attention of the faculty and staff. Speakers for the medical grand rounds are either members of the medical school faculty or hospital staff or guest professors.^
It seems clear that the respondents to the ques- tionnaire believe that the grand rounds pre- sentations and the prescribed credit for them are meeting their needs. This is evidenced by the influ- ence prescribed credit has had on their attendance, by their expressions of attendance, and by the ex- pressed appropriateness of the presentations.
Family physicians appear to be benefiting from both the availability of medical ground rounds and the availability of prescribed credit from the AAFP.
REFERENCES
1. Ram MD, Thompson JS, Kilner JF, et al: A good death; medical ethics grand rounds. Hosp Pracf 21:31-50, 1986.
2. Kossmann CE, Watanabe A. Nunn SL: Medical grand rounds. CABG; Have the indications changed? J Tenn Med Assoc 78:219-223, 1985.
3. Massengill RM, Culp JS, Derden PJ: Grand rounds. J Med Ed 63:503, 1988.
4. Ayers J: Continuing medical education fact sheet. Chicago, American Medical Association, July, 1987, p 1.
JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION
Remote Metastases From
Uveal Melanoma
TIMOTHY POWERS, M.D.; RODOLFO LAUCIRICA, M.D.; SANDRA BROOKS, M.D.; SOPHIE LEOPOLD, MHS, CT (ASCP); MICHAEL WHITSON, M.D.; and JAMES FARNUM, M.D.
Malignant melanoma is the most common in- traocular neoplasm. It can readily metastasize to the liver as well as other sites. Although most metastasize within five to ten years, metastases 20 to 25 years after the primary diagnosis have been reported. We report two cases of uveal melanoma that metastasized over 15 years after initial diagnosis. In neither case was a diagnosis of malignant melanoma entertained until cyto- logic materials were obtained. We present the cytologic and histologic specimens and review the natural history, prognostic indicators, treatment, and current recommendations for initial evalua- tion and follow-up. We emphasize the need to consider metastatic disease in the patient who has had a previous uveal melanoma regardless of how temporally distant the diagnosis was made.
Case Reports
Case 1. A 65-year-old white man with a two-week history of abdominal distension reported a 40-lb weight loss over the previous three months, but a 10-lb weight gain over the two weeks prior to admission. A history of enucleation of the right eye for melanoma was noted but not further explored. Phys- ical examination showed bitemporal wasting and a right eye prosthesis. Abdominal examination revealed a protuberant abdomen with a liver span of 14 cm, palpable 3 cm below the right costal margin. Prothrombin time was 9.2 seconds, al- bumin 3.3 gm/dl, total bilirubin 0.4 mg/dl, alkaline phospha- tase 95 U/L, SGPT 25 U/L, SCOT 11 U/L, and the LDH was greater than 600 U/L. Ultrasound of the abdomen re- vealed extensive liver metastases and probable renal metas- tases. Liver-spleen scan demonstrated hepatic enlargement with multiple large filling defects in the left and right lobes of the liver. Abdominal paracentesis was performed and showed abundant single malignant tumor cells, diagnosed as malignant melanoma. Subsequent Chiba fine needle aspira- tion (FNA) of the liver demonstrated metastatic malignant melanoma with positive S-100 immunoperoxidase stains. The patient was started on chemotherapy with carmustine (BCNU), dacarbazine (DTIC), cis-platinum, and tamoxifen. His course was complicated by pulmonary edema and respi- ratory failure, and he died. Request for autopsy was denied.
From the Departments of Medicine (Dr. Powers) and Pathology, James H. Quillen College of Medicine, and Mountain Home Veterans Administration Medical Center, East Tennessee State University, Johnson City.
Reprint requests to Department of Pathology, James H. Quillen College of Medicine, East Tennessee State University, P.Q. Box 19540A, Johnson City, TN 37614 (Dr. Farnum).
Case 2. A 72-year-old white woman with several weeks history of lethargy, weakness, and anorexia had had idi- opathic thrombocytopenic purpura (ITP) treated with high- dose prednisone, and enucleation of the left eye 19 years be- fore admission for malignant uveal melanoma. Physical ex- amination revealed a distended, tender abdomen with a fluid wave and a periumbilical mass. Glucose was 863 mg/dl, BUN 31 mg/dl, creatinine 1.8 mg/dl, LDH 2,067 U/L, alkaline phosphatase 226 U/L, SGOT 208 U/L, SGPT 202 U/L, total bilirubin 0.2 mg/dl, CA-125 935 U/ml (normal less than 35), and a CEA of 2.7 ng/ml (normal 0 to 3). CT scan of the abdomen showed ascites, focal lesions within the liver, mul- tiple peritoneal and mesenteric implants, and masses at the distal portion of the stomach and the pancreas. Cytology of the peritoneal fluid was negative. Chiba FNA of the abdom-
Figure 1. Low-power photomicrograph of 1970 enucleation speci- men, showing uveal melanoma elevating, but not involving, the intact retina (hematoxylin-eosin, x125).
1 1
JANUARY, 1990
UVEAL MELANOMA METASTASES/Powers
inal mass with CT guidance revealed malignant melanoma. The patient and family declined treatment other than suppor- tive care. The patient’s condition deteriorated over the course of several weeks with progressive edema and ascites, and he died. Request for autopsy was denied.
Histologic Findings
Each tumor consisted of a black, nodular sub- retinal mass that measured approximately 1.0 cm in greatest dimension; no transscleral or optic nerve involvement was identified. Microscopic examination revealed similar histologic features in both cases. The tumor filled the choroidal space, and elevated but did not involve the reti- na (Fig. 1). Both spindle and epithelioid cells were found, arranged in fascicles and sheets (Fig. 2). Coarse granular to fine dusty melanin cyto- plasmic pigment was readily identified within some cells. Many of the malignant cells possessed large, ovoid, hyperchromatic to vesicular nuclei and prominent eosinophilic macronucleoli.
FNA of the liver in case 1 yielded diagnostic cellular material (Fig. 3). The malignant cells were pleomorphic and lacked well-defined cellu- lar cohesiveness. The cells contained large, ec- centrically located nuclei, giant macronucleoli, and prominent cytoplasmic granularity. An FNA cell block preparation of the abdominal mass in case 2 (Fig. 4) displayed histologic and cytologic epithelioid features similar to those found in the original uveal tumor.
Discussion
Uveal melanoma is the most common primary intraocular tumor. This disease has special signif- icance to the ophthalmologist as the only prima- ry intraocular process in adults that can be fatal. ^ It also has significance to the primary care phy- sician who will follow the patient after diagnosis, as this tumor has a high incidence of metastasis and requires long-term follow-up.
The epidemiology and risk factors associated with uveal melanoma are diverse and multifac- torial. This uncommon tumor has an annual age- adjusted incidence of 0.7 per 100,000.^ It is rare in childhood,^ with the median age at diagnosis being 55 years. In contrast to other cancers the incidence begins to level off after 70 years of age."* Uveal melanoma is slightly more common in men, with an interesting left-sided excess in men and a right-sided excess in women. ^ Caucasians have a greater than eight-fold risk over blacks in the United States, while there has never been a case
12
reported in American Indians.^ Sunlight expo- sure is now considered an important risk factor, and brown-eyed individuals have been shown to be more protected than blue-eyed individuals. Complexion and hair color are not important risk factors.^ Familial cases are rare.^'p^^^’ The only specific occupational exposure linked to uveal melanoma is welding.^ There have been cluster- ings of cases in jobs with chemical exposure, but no causative agent has been positively identi- fied.^ There is suggestive evidence that trauma and inflammation of the eye have a role in the conversion of a benign pigmented lesion into a malignant melanoma. Chemicals known to in- duce ocular melanomas in animals include nickel subsulfide, platinum, methyeholanthrene, ethionine, N-2-fluorenylacetamide, and radium. Viruses have been used to induce uveal mela- noma in animal models.^
Once the diagnosis of uveal melanoma is made, several factors influence prognosis. The Callender classification is the traditional method of classifying the histologic type of uveal mela- noma, and has definite prognostic implications. According to this classification, there are six var- iations in histologic type: spindle A, spindle B, fascicular, epithelioid, mixed, and necrotic. Spin- dle A tumors are composed primarily of spindle
Figure 2. Medium-power photomicrograph of original tumor (1971 enucleation of uveal melanoma) showing spindle and epithelioid cells arranged in fascicles and sheets, cytoplasmic melanin pigment (cen- ter), occasional mitoses, and pleomorphic nuclei with macronucleoli (hematoxylin-eosin, x250).
JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION
A cells (small spindled nuclei without distinct nu- cleoli and indistinct cytoplasm) and make up 5% of all uveal melanomas. Five-year mortality has previously been thought to be 5%, but Zimmerman* has shown that these tumors do not metastasize and therefore behave as nevi. Spindle B tumors are composed primarily of spindle B cells (prominent spindled nuclei with distinct nucleoli and indistinct cytoplasm) and comprise 33% of uveal melanomas. They have a 14% five-year mortality. A fascicular tumor is characterized by a palisading arrangement of cells, and can be made up of spindle A or spindle B cells. The fascicular pattern accounts for 6% of uveal melanomas, which have a 14% five-year mortality. Epithelioid tumors consist almost ex- clusively of large oval or round epithelioid cells. This cell type comprises 3% of uveal melanomas and has a 69% five-year mortality. A mixed cell type of tumor is one of variable combinations of spindle and epithelioid cells; it comprises 45% of uveal melanomas and has a 51% five-year mor- tality. A necrotic uveal melanoma is one with abundant necrosis, such that the tumor cell type cannot be identified. It comprises 8% of uveal melanomas and has a 51% five-year mortality. Although the Callender classification is widely accepted, the problem of intraobserver variabili- ty has stimulated interest in the development of
Figure 3. High-power photomicrograph of liver FNA smear (case 1) showing metastatic uveal melanoma with pleomorphic, discohesive cells, macronucleoli, and granular cytoplasmic melanin pigment (he- matoxylin-eosin, x500).
a more reproducible tumor classification system. Recently, a more quantitative method of assess- ing cell type has been described in which epithe- lioid cells are counted per high power field and the nucleolar area of tumor cells is measured by image analysis. The inverse standard deviation of nucleolar area is calculated. A high number of epithelioid cells per high power field and a low value for the inverse standard deviation of nu- cleolar area is associated with poor prognosis. A major prognostic factor is tumor size, diame- ter being the single most important clinical and pathologic prognostic factor. Good prognosis is generally expected with tumors less than 10 mm in diameter, and a poor prognosis with tumors larger than 10 mm in diameter. Other ominous factors include scleral extension, high mitotic ac- tivity, increasing age, increased height of tumor, excessive tumor pigmentation, and compromised integrity of Bruch’s membrane.
Discussion of metastatic uveal melanoma has previously focused on metastasis occurring many years after the primary diagnosis. Recently, how- ever, the incidence of metastasis at the time of primary diagnosis has been an area of controver- sy. Though this incidence has been previously thought low, estimated at 1% to 3%,^'^ Albert and associates'^ suggested in 1981 that this incidence had been underestimated. They suggested that if full metastatic workups had been done on all pa- tients, a higher incidence of metastases would have been found. A recent unpublished account
Figure 4. Cell block preparation of abdominal mass FNA (case 2) showing a sheet of pleomorphic, malignant cells with prominent cy- toplasm (HMB-45 immunoperoxidase positive), interpreted as meta- static uveal melanoma (hematoxylin-eosin, x 500).
JANUARY, 1990
13
UVEAL MELANOMA METASTASES/Powers
reported a metastatic incidence as high as 12% at time of primary diagnosis.'^ Metastases are most common to the liver. Other sites include stomach, subcutaneous tissues, spine, lungs, and lymph nodes. Tumor rarely metastasizes to a sec- ond site in the same eye or to the fellow eye. Metastases are believed to be due to tumor in- vasion of blood vessel walls, but tumor cells have been seen circulating in the blood of patients without evidence of metastases. The average on- set of a metastatic focus is 37 months, but it can be as long as 20 to 25 years. There has been one report of a metastatic focus occurring 42 years after primary diagnosis.*’ Because of the strong predilection for the liver, a search for metastases should begin there. Some studies have suggested that liver scans have low yield in patients without overt evidence of metastases and with normal liver enzymes.** However, because of the recent controversy regarding the incidence of metasta- ses at the time of primary diagnosis, prudence may dictate management of patients as per Al- bert’s recommendations.
A conservative surgical philosophy has recent- ly evolved in the treatment of uveal melanoma. Traditionally, enucleation has been the standard treatment, but over the last few years enuclea- tion has been reassessed and other forms of treatment have been studied. Zimmerman*'* ^** has shown that the incidence of death rises sharply after enucleation and that two-thirds of deaths after enucleation can be attributed to surgical dissemination of tumor cells. Other investigators dispute the interpretation of Zimmerman’s find- ings. This controversy has stimulated the devel- opment of other treatment modalities. Appropri- ate treatment can be approached by evaluating the size and elevation of the tumor. For large tumors (over 15 mm in diameter and 5 mm in elevation) there is general agreement that enu- cleation is the treatment of choice. Small tumors (less than 10 mm in diameter and 2 mm in ele- vation) are managed much more conservatively. There is accumulating evidence that the risk in observing small tumors is low, and small tumors that are asymptomatic and small tumors in elder- ly patients are frequently managed by observa- tion only. Certainly if the diagnosis is equivocal (melanoma vs nevus), the tumor should be man- aged only by close observation. Progression or rapid growth and vision impairment can be treat- ed with radiation treatment or enucleation.
14
Treatment of medium-sized tumors (10 mm to 15 mm in diameter and 2 mm to 5 mm in elevation) is more controversial, and much more individual consideration is required, as there is less consen- sus on the management of this size of tumor. Other treatment modalities such as xenon arc photocoagulation, cryotherapy, and local full- thickness eyewall resection are not commonly used.* Recently the use of the high energy argon laser has shown promise in animal models.^*
Conclusions
Clinical prosnostic factors of uveal melanoma in order of greatest significance are tumor size, histologic type, scleral extension, and mitotic ac- tivity. The ophthalmic pathologist has a pivotal role in gross and microscopic examination of the eye. /
Acknowledgments
Figure 2 is courtesy of Robert Baker, M.D., Lexington, KY.
The authors gratefully acknowledge the secretarial assist- ance of Martha Potts and photographic expertise of Medical Media Production Service, VAMC.
REFERENCES
1. Weiss JS. Albert DM: Intraocular melanoma, in DeVita VT. Heilman S, Rosenberg SA (eds): Cancer. Principles and Practice of Oncology, ed. 2. Phila- delphia, JB Lippincott, 1985, pp 1423-1436.
2. Young JL, Percy CL, Asire AJ, et al; Cancer incidence and mortality in the United States, 1973-1977. Cancer Inst Moriogr 57:1-187, 1981.
3. Barr CC, McLean IW, Zimmerman LE: Uveal melanoma in children and adolescents. Arch Ophthalmol 99:2133-2136, 1981.
4. Raivio I: Uveal melanoma in Finland: an epidemiological, clinical, histo- logical and prognostic study. Acta Ophthalmol 133 (suppl): 3-63, 1977.
5. Scotto J, Fraumeni JF, Lee JAH: Melanomas of the eye and other non- cutaneous sites. J Natl Cancer Inst 56:489-491, 1976,
6. Bettman JW: Eye disease among American Indians of the Southwest. I. Overall analysis. Arch Ophthalmol 88:263-268, 1971.
7. Tucker MA, Shields JA, Hartge P. Sunlight exposure as a risk factor for intraocular malignant melanoma. N Engl J Med 313:789-792, 1985.
8. Yanoff M, Fine BS: Ocular melanotic tumors, in Ocular Pathology: A Test and Atlas, ed 3. Philadelphia, JB Lippincott, 1989, p 657.
9. Albert DM, Paliafito CA, Fulton AB, et al: Increased incidence of cho- roidal malignant melanoma occurring in a single population of chemical workers. Am J Ophthalmol 89:323-337, 1980.
10. Reese AB: Tumors of the Eve. ed 3. New York, Harper and Row, 1976, pp 193-196.
11. Shields JA: Tumors of the uveal tract, in Duane TD (ed): Clinical Oph- thalmology. Philadelphia, JB Lippincott, 1988, pp 3-6,
12. Seddon JM, Polivogianis L, Hsieh C: Death from uveal melanoma: num- ber of epithelioid cells and inverse SD of nucleolar area as prognostic factors. Arch Ophthalmol 105:801-806, 1987.
13. Shammas HF, Blodi FC: Prognostic factors in choroidal and ciliary body melanomas. Arch Ophthalmol 95:63-69. 1977.
14. Graham BJ, Duane TD: Meetings, conferences, symposia: report of ocu- lar melanoma task force. Am J Ophthalmol 90:728-733, 1981.
15. Albert DM. Wagoner MD. Smith ME: Are metastatic evaluations indi- cated before enucleation of ocular melanoma? Am J Ophthalmol 90:429-432, 1981.
16. Frederic DR, Chan DH, Ljung BM: Solitary intraocular lymphoma as an initial presentation of widespread disease. Arch Ophthalmol 107:395-397, 1989.
17. Shields JA, Augsburger JJ. Donoso LA, et al: Hepatic metastasis and orbital recurrence of uveal melanoma after 42 years. Am J Ophthalmol 100:666- 668, 1985.
18. Miller TR, Gomez-Moreiras JJ, Smith ME: The value of liver scintigra- phy in choroidal melanoma. Arch Ophthalmol 97:1875-1876, 1979.
19. Zimmerman LE, McLean IW. Foster WD: Does enucleation of the eye containing malignant melanoma prevent or accelerate the dissemination of tumor cells? Br J Ophthalmol 62:420. 1973,
20. Zimmerman LE. McLean IW: An evaluation of enucleation in the man- agement of uveal melanoma. Am J Ophthalmol 87:471. 1979.
21. Jaffe GJ, Mieler WF. Burke JM, et al: Photoablation of ocular mela- noma with a high-powered argon endolaser. Arch Ophthalmol 107:113-118, 1989.
JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION
Cutaneous Alternaria Infection in a Patient on Chronic Corticosteroids
RICHARD M. SNEERINGER, M.D. and DAVID W. HAAS, M.D.
Alternaria is a saprophytic soil fungus found widely in nature. Although it is classified with pathogenic fungi such as Aspergillus, Blasto- myces, and Histoplasma in the class Hyphomy- cetes, it only rarely causes disease in man. Syn- dromes described have included cutaneous infectiond'"* osteomyelitis^ pulmonary granu- lomad peritonitis,' nasal septal infection in a pa- tient with acquired immunodeficiency syndrome (AIDS),® and spore-induced bronchial asthma and hypersensitivity pneumonitis.^ We describe a case of severe cutaneous alternariosis in a patient on chronic systemic steroid therapy. A review of the pertinent literature follows.
Case Report
A 70-year-old white man was admitted to the Nashville Veterans Administration Medical Center with a two-day his- tory of nausea, coffee ground emesis, dehydration, and dys- pnea. He had previously been admitted numerous times for chronic obstructive lung disease, and had received oral pred- nisone therapy (at least 10 mg daily) for the preceding three years. Medications on admission included prednisone 30 mg twice a day as well as digoxin, furosemide, enalapril, theo- phylline, and inhaled isoetharine. Oral trimethoprim-sulfa- methoxazole had been started five days earlier. Physical ex- amination was remarkable for a temperature of 98.6° F with expiratory wheezes over both lungs. His skin and abdomen were normal. Laboratory studies revealed a blood urea nitro- gen of 68 mg/dl, creatinine 8.6 mg/dl, WBC count 17,600/cu mm and hematocrit 41%.
Following further work-up the diagnosis of sulfa-induced interstitial nephritis was made. His renal dysfunction im- proved with discontinuation of the trimethoprim-sulfame- thoxazole. Esophagogastroduodenoscopy (EGD) with biopsy performed the day after admission revealed severe distal esophagitis. Special stains were consistent with herpes sim- plex. His gastrointestinal symptoms improved with intrave- nous acyclovir. On the third hospital day his right forearm was noted to be diffusely erythematous, and by the following
From the Departments of Internal Medicine (Dr. Sneeringer) and Infectious Diseases (Dr. Haas), Vanderbilt University Medical Cen- ter, Nashville.
Reprint requests to Division of Infectious Diseases. Vanderbilt University Medical Center, C-3210 Medical Center North, Nashville, TN 37232 (Dr. Haas).
day developed ecchymotic areas and several hemorrhagic bullae. Initially this was thought to be a chemical cellulitis, possibly due to extravasation of radiocontrast material given two days before, but similar lesions soon appeared on the left forearm. Silver stains of a skin biopsy revealed branching, septate hyphae (Fig. 1). Treatment was begun with ampho- tericin B, 20 mg every other day, topical silvadene, and whirlpool therapy. The lesions progressed to full thickness sloughing of the skin of both upper extremities (Fig. 2). On the fifth day culture of the skin biopsy specimen grew pure growth of a fungus with conidial characteristics of Alternaria (Fig. 3).
The patient's course was complicated by culture-negative sepsis, for which broad-spectrum antimicrobial therapy was begun. He subsequently developed refractory bronchospasm, gastrointestinal bleeding, and hypotension. In accord with the family’s wishes, aggressive resuscitation was not attempted. The patient died on the 20th hospital day. Autopsy revealed bacterial bronchopneumonia, centrilobular emphysema, gas- tric ulcerations, esophagitis, adrenal atrophy, and acute my- ocardial infarction. No evidence of disseminated alternariosis was found.
Discussion
Cutaneous alternariosis was first described in 1933 by Borsock^ following a splinter wound to the hand of a normal host. Subsequently, Yu^° found that Alternaria often colonized normal skin. In 1976, Farmer and Pedersen first identified pri-
Figure 1. Patient's right forearm on hospital day 8.
JANUARY, 1990
15
Figure 2. Skin biopsy demonstrating branching, septate hyphae (ar- row) in the subdermal tissue (Gomori-methenamine silver stain, X 1,200).
mary (nontraumatic) cutaneous alternariosis in immunocompromised hosts. ^ ^ In the interim an increasing number of such cases have been re- ported. Vivianb reviewed 33 cases reported prior to 1981, 19 of whom were immunocompromised, six had renal transplants, five Cushing’s syn- drome, four hematologic malignancies, and one each discoid lupus, topical steroid use, and pri- mary pulmonary hypertension. An additional pa- tient was receiving chronic systemic steroid ther- apy similar to our patient.
The clinical features of cutaneous alternariosis seen in our patient are consistent with those de- scribed elsewhere. Single or multiple erythema- tous papulonodular lesions with later formation of hemorrhagic bullae and ulceration are typical. Early lesions may resemble Mycobacterium mar- inum infection, but unlike mycobacteria, Alter- naria species do not grow on Lowenstein-Jen- sen’s medium.
The clinical diagnosis of alternariosis is com- plicated by Alternaria’s being a frequent contam- inant encountered in the laboratory, especially when samples are obtained from potentially col- onized surfaces such as skin or mucous mem- branes. It grows rapidly on Sabourand agar, forming dark grey to grey-green colonies that lat- er turn black with a white rim.^^ When grown in vitro, ovoid conidia with multiple transverse, longitudinal, and oblique septa (also called dic- tyoconidia) are formed from conidiophores (Fig. 3). Definitive diagnosis of invasive skin infection requires PAS or methenamine silver stain to identify hyphal elements and vesicular bodies in
Figure 3. Alternaria conidia with characteristic multiple transverse (large arrow) and a single oblique (small arrow) septum (cotton phenol blue stain, X 1,200).
the dermal or hypodermal tissues, often associ- ated with microabscesses, a granulomatous infil- trate, or visualization of the organism within macrophages or neutrophils.^
Reports on the treatment of Alternaria with an- timycotic agents are few. Mardh and Hallberg^ tested six stains of Alternaria in vitro and found them all to be susceptible to 10 |JLg/ml of clotrima- zole, natamycin and nystatin. Ketoconazole was ineffective in the treatment of a cutaneous infec- tion.^^ An AIDS patient with invasive nasal alter- nariosis was cured by excision of his nasal septum with administration of 1 gm of amphotericin B. Notably, this patient acquired his infection while receiving ketoconazole for candidiasis.® While it is impossible to make definitive recommendations based upon the limited published experience, early excision of involved tissues when feasible, with concurrent local and/or systemic antimycotic ther- apy, is a reasonable approach.
Summary
We have presented a case of invasive cuta- neous alternariosis in a patient receiving chronic oral steroid therapy. Alternaria must be consid- ered in the differential diagnosis of any progres- sive cutaneous infection in an immunocompro-
16
JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION
CUTANEOUS ALTERNARIA INFECTION/Sneeringer
mised patient. Invasive maneuvers are often needed to confirm the diagnosis. Given the rarity of cases and lack of controlled clinical trials, firm therapeutic guidelines are not available. Clini- cians are likely to encounter more such cases as the population of immunocompromised hosts grows. r ^
REFERENCES
1. Farmer SG, Komorowski RA: Cutaneous microabscess formation from Alternaria alternata. Am J Clin Pathol 66:565-569. 1976.
2. Pedersen NB. Mardh P-A, Hallberg T, et al: Cutaneous alternariosis. Br J Dermatol 94:201-209, 1976.
3. Borsock ME: Skin infection due to Alternaria tenuis. Can Med Assoc J 39:479. 1933.
4. Viviani MA, Tortorano AM, Laria G, et al: Two new cases of cutaneous alternariosis with a review of the literature. Mycopathologia 96:3-12, 1986.
5. Garau J, Diamond RD. Lagrotteria LB. et al: Alternaria osteomyelitis. Ann Intern Med 86:747-748. 1977.
6. Lobritz RW, Roberts TH, Marraro RV, et al: Granulomatous pulmonary disease secondary to Alternaria. JAMA 241:596-597. 1979.
7. Reiss-Levy E, Clingan P: Peritonitis caused by Alternaria alternata. Med J Aust 2:44, 1981.
8. Wiest PM, Weise K, Jacobs MR, et al: Alternaria infection in a patient with acquired immunodeficiency syndrome: case report and review of invasive Alternaria infections. Rev Infect Dis 9:799-803, 1987.
9. Schlueter DP, Pink JN. Hensley GT: Wood-pulp worker's disease: a hy- persensitivity pneumonitis caused by Alternaria. Ann Intern Med 77:907-914. 1972.
10. Yu H: Studies on fungi of normal skin. Acta Derm 60:126. 1965.
11. Mardh P-A, Hallberg T: Alternaria alternata as a cause of opportunistic fungal infections in man. Scand J Inf Dis 16 (suppl): 36-40. 1978.
12. Del Palacio HA, Conde-Zurita JM. Reyes PS. et al: A case of Alternaria alternata infection of the knee. Clin Exp Dermatol 8:641-646, 1983.
JANUARY, 1990
17
Colonoscopic Removal of a Gallstone Obstructing the Sigmoid Colon
SHAUNA R. ROBERTS, M.D.; CINDY CHANG, M.D.; TODD CHAPMAN, M.D.;
PAUL G. KOONTZ, JR., M.D.; and GERALD L. EARLY, M.D.
Introduction
Biliary-enteric fistula occurs in up to 5% of all patients who have gallstones; cystic duct obstruc- tion, cholecystitis, and multiple episodes of ad- jacent tissue inflammation usually precede fistula formation. As many as 21% of patients who de- velop a biliary enteric fistula will have clinical evidence of gallstone ileus. The majority will pass their gallstones, but once obstruction takes place, passage of the stone almost never occurs. ‘ *
Gallstone ileus is the cause of mechanical small bowel obstruction in up to 4% of the general population. The typical patient is an elderly woman with multiple medical problems and a history of gallstones. Most patients have several days of crampy abdominal pain, vomiting, and intermittent obstipation due to “tumbling” of the stone. (The gallstone typically causes intermit- tent obstruction as it moves distally to its final impaction point.) The clinical picture of small bowel obstruction is usually present, since the il- eocecal valve is the most common site of gall- stone impaction. Other sites of involvement in order of frequency are mid-ileum, jejunum, stomach, duodenum, and colon; approximately 5% of gallstone ileus cases involve obstruction of the colon.
Courvoisier*^ described the first case of a gall- stone obstructing the colon in 1890. Since then, approximately 60 cases have been reported, most of them at a site of a preexisting narrowing. Pri- mary small bowel obstruction may be absent if the stone reaches the colon directly by fistula formation, if a stone is small enough to pass through the small bowel but not an area of dis- eased colon, or if a stone enlarges in the colon
From the Department of Surgery, University of Missouri-Kansas City, and St. Luke’s Hospital, Kansas City, Mo,
Reprint requests to Department of Surgery, University of Tennes- see College of Medicine, 956 Court Ave., Memphis, TN 38163 (Dr. Roberts).
18
(by fecal concretions or inspissation with other stones).
The diagnosis of gallstone ileus is suspected preoperatively in 45% to 55% of cases.^ ^ ^^ Ra- diopaque gallstones are appreciable on abdomi- nal films in about 66% of patients, and there- fore a plain abdominal film that shows bowel obstruction and migration of a preexisting gall- stone out of the right upper quadrant suggests the diagnosis of gallstone ileus. Pneumobilia may be present in up to 71% of cases, but may be difficult to appreciate. About 90% of suspected cases of duodenocolic fistula may be diagnosed by barium enema.
Case Report
An 85-year-old white woman gave a 12-day history of progressive abdominal distension and obstipation after hav- ing earlier experienced recurrent bouts of severe indigestion and abdominal discomfort which had subsequently resolved. The patient had a history of peptic ulcer disease and choleli- thiasis without known cholecystitis. Her primary care physi- cian performed an upper gastrointestinal series, which showed a large calcification in the left lower quadrant similar to that previously seen in the gallbladder (Fig. 1). Significant elec- trolyte and acid-based disturbances were present, and fluid and electrolyte resuscitation were performed.
Sigmoidoscopy revealed a large stone impacted in the mid- sigmoid region. Partial fragmentation of the distal portion of the stone was achieved with the polypectomy snare, but the patient did not pass the stone and had further evidence of bowel distension within a few hours. On a second colonos- copic procedure, the papillotomy balloon was manipulated beyond the largest fragment of the stone (4 cm), which was then gently withdrawn into the distal sigmoid colon; the stone was encircled with the polypectomy snare and gradually with- drawn. Except for diverticulosis, there was no other apparent intraluminal pathology. The patient subsequently regained normal bowel function.
Nine months later, with the patient in good general con- dition, elective cholecystectomy was performed without com- plications.
Discussion
Many aspects of the management of gallstone ileus remain controversial, particularly as to whether or not the operative intervention should be staged, using the initial procedure only to re-
JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION
lieve the obstruction and close the fistulad The mortality rate has been in the 13% to 20% range for single-stage or two-stage therapy. At lapa- rotomy the entire intestinal tract should be care- fully examined for other stones, as multiple stones large enough to obstruct the intestine are present in about 13% of cases. Gallbladder carci- noma occurs in as many as 15% of patients with a biliary enteric fistula, ^ as compared to 0.8% of all patients who have cholecystectomies.^^ Ideally, the fistula should be closed, chole- cystectomy performed, and the common duct evaluated.
This case of gallstone ileus is particularly in- teresting because the gallstone obstructed the sigmoid colon, and the colonic obstruction was relieved nonoperatively in this very ill patient who
Figure 1. The arrow in the patient's left lower quadrant points to a calcification previously seen in the right upper quadrant.
was extremely frail due to age and other medical problems. Although endoscopic retrieval of gall- stones from the stomach has been reported, we are not aware of other reports of endoscopic gallstone extraction from the sigmoid colon.
The condition of the patient may require that the initial procedure consist only of relief of the bowel obstruction. If there is no evidence of common duct obstruction, cholecystectomy and fistula closure can be performed as a “second op- eration.” Indications for cholecystectomy and fistula repair are continuing symptoms, remain- ing gallstones, nonfunctioning gallbladder, and a patent biliary-enteric fistula.^
Summary
For the patient with a single gallstone ob- structing the colon, this technique offers non- operative relief of the obstruction, allowing de- finitive operative therapy to be accomplished at a later time on a more elective basis. The patient should be carefully observed during the interval for intervening recurrent gallstone ileus, r ^
REFERENCES
1. Glenn F, Reed C, Grafe W: Biliary enteric fistula. Surg Gvnecol Obstet 153:527-531. 1981.
2. Hricak H, Vander Molen R: Duodenocolic fistula with gallstone ileus. Am J Gastroenterol 69:711-715. 1978.
3. Kurtz R. Heimann T. Kurtz A: Gallstone ileus: a diagnostic problem. Am J Surg 146:314-317. 1983.
4. Buetow G. Glaubitz J, Crampton R: Recurrent gallstone ileus. Surgery 54:716-724. 1963.
5. Milsom J, MacKeigan J: Gallstone obstruction of the colon: report of two cases and review of management. Dis Colon Rectum 28:367-370, 1985.
6. Cooperman A. Dickson R. ReMine W: Changing concepts in the surgical treatment of gallstone ileus: a review of 15 cases with emphasis on diagnosis and treatment. Ann Surg 167:377-383, 1968.
7. Kurtz R, Heimann T, Beck R. et al: Patterns of treatment of gallstone ileus over a 45-year period. Am J Gastroenterol 80:95-98, 1985.
8. Pryor J: Gallstone obstruction of sigmoid colon with particular reference to aetology. Br J Surg 47:259-260, 1959.
9. Ramanujam P, Shabeeb N. Silver J: Unusual manifestations of gallstone migration into the gastrointestinal tract. South Med J 76:30-32, 1983.
10. Phillips D. Doran J: Obstruction of the colon by a giant gallstone. Br J Hosp Med 36:444, 1986.
11. van Hillo M, van der Vliet J, Weggers T, et al: Gallstone obstruction of the intestine: an analysis of ten patients and a review of the literature. Surgery 101:273-276, 1987.
12. Bedogni G. Contini S, Meinero M, et al: Pyloro-duodenal obstruction due to a biliary stone (Bouveret’s syndrome) managed by endoscopic extraction. Gastrointest Endosc 31:36-38, 1985.
13. Shocket E, Evans J, Jonas S: Cholecysto-duodenocolic fistula with gall- stone ileus. Arch Surg 101:523-526, 1970.
14. Kreel L: Gallstone ileus. Postgrad Med J 61:511-512, 1985.
15. Tomescu O, Levien D. Mahoney W, et al: Surgical options in the treat- ment of gallstone ileus. Contemp Surg 25:11-15, 1984.
16. Berliner S, Burson L: One-stage repair for cholecyst-duodenal fistula and gallstone ileus. Arch Surg 90:313-316, 1965.
JANUARY, 1990
19
Trauma Rounds
Recognition of the Subtle Signs of Child Abuse
R. LESLIE MILES, M.D. and R. PHILLIP BURNS, M.D.
Millions of children are seen every year in pediatric emergency rooms across the nation with traumatic in- juries ranging from minor burns and bruises to serious intra-abdominal and intracranial pathology.' Approxi- mately 1 million of these children will have been the victims of physical abuse or neglect, representing a 1.6% prevalence rate in the population of children un- der 18 years of age.^ Because these victims of nonac- cidental trauma are seen not only by pediatricians but by emergency room physicians and surgeons, and be- cause children are often unwilling or unable to give an adequate history, it is important for the physician to be cognizant of the historical discrepancies and the physical signs and symptoms that should raise one’s index of suspicion for child abuse.
We present a case of child abuse and briefly outline the historical and physical factors that will alert the physician to possible abuse.
Case Report
A 29-month-old black boy was admitted to the emergency room of T. C. Thompson Children’s Hospital in Chattanooga by his stepfather, who stated the child apparently had fallen from the upper level of a bunk bed while he was away from home (the child was unattended), and that the child was un- conscious when he returned. On further questioning, the man admitted he was not actually married to the patient’s mother, and that he had been arrested on another charge.
On physical examination the patient’s blood pressure was 128/78 mm Hg, pulse 128/min, and respirations 36/min. He had multiple bruises and abrasions on both sides of his face. Pupils were small and sluggishly reactive, and both eyes were deviated downward. The abdomen was distended, but non- tender and with normal bowel sounds, and a large abrasion was noted in the right lower quadrant. The child responded purposefully to pain on the left side, but demonstrated very little movement in his right upper or lower extremities. The toes of his left foot had several discrete, old-appearing burn marks. Laboratory examination revealed a hematocrit of 25.6%, an MCV of 72 cup,, and gross hematuria on urinaly- sis. The patient was admitted to the pediatric intensive care unit, where an intracranial pressure monitor was placed and a phenobarbital coma induced. The patient remained in in- tensive care 21 days, during which time he experienced re- current episodes of elevated intracranial pressure, treated with osmotic diuresis and hyperventilation. The patient was dis- charged on disability income with daily physical therapy.
From the Department of Surgery, University of Tennessee Col- lege of Medicine, Chattanooga Unit.
20
Discussion
Over the course of the last three decades the Amer- ican public has become increasingly aware of the prob- lem of child abuse. Physicians, of course, are most often responsible for recognizing the subtle clinical signs asso- ciated with this problem, and often have difficulty in doing so since the history, usually given by the parents, is invariably inaccurate.^ The physician should always have the question, “Could this be abuse?” in the back of his mind as he assesses the injured child, and should repeatedly request clarification and amplification as the parent or child relates the history of the event.
A discrepancy between the history of the trauma and the degree of physical injury will often exist, leading the physician to doubt the verity of the history and requiring the physician to rely much more heavily on clinical signs in assessing the child. The time sequence is important to note in the history. Often the reported time of injury does not correlate with obvious age of injury or the seeking of medical advice, and the history may include repeated trauma with the child having been seen in a number of different emergency rooms. The parents of abused children often respond inappropriately or do not comply at all with medical advice.
Another salient feature to note in the history is age, since toddlers more often sustain intra-abdominal in- juries from physical abuse, while internal injuries in school age children are usually the result of contact sports, a fall onto bicycle handlebars, or traffic acci- dents.^ Information on the child’s birth and medical history as well as the mother’s pregnancy provides im- portant insight into her attitude about the child. ^
Social history is also important in identifying other factors that may be associated with child abuse: socio- economic status, parental divorce, illegitimacy, physi- cal and mental defects in the child, and teen pregnan- cy, all of which are seen with increased frequency in the abused child and his family. In addition, those children who are perceived as different, or actually are different, or actually are different in terms of physical or behavioral characteristics (such as the fussy, irrita- ble, hyperactive child or the child with congenital mal- formation, developmental disability or mental retar- dation) are at higher risk of abuse than the normal child.
JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION
On physical examination, the early signs that should alert the child’s physician to possible abuse are neglect and malnutrition. The earliest signs of actual physical abuse are usually soft tissue injuries, with certain pat- terns and locations of injury being characteristic. These injuries are seen about the head, perioral, perianal, and genital regions, with bruising being the most com- mon manifestation. Often they will be of a bizarre na- ture, such as bites, rope marks, or cigarette burns, and often are in different stages of resolution, indicating multiple episodes of battering and abuse. ^
Another frequently encountered problem is long bone fracture, especially in children under 3 years of age."* These fractures are usually several days old and inadequately explained by the parents. The three most common fractures are humeral, femoral, and rib, with the types of fractures suggestive of jerking or twisting forces. Of course multiple fractures, especially in the toddler, provide even stronger evidence that the inju- ries are nonaccidental. ^
Cranial trauma is the most frequent cause of mor- bidity and death in abused children. Many of these injuries, especially the more serious intracranial inju- ries, are difficult to distinguish from accidental injuries as the manifestations of both are similar. ^
Some of the more common cranial trauma injuries seen are alopecia due to hair pulling, skull fracture, and subdural hematoma. Abusive alopecia is usually diffuse, while complex depressed or diastatic fractures, retinal hemorrhages, and associated findings of abuse make the diagnosis of nonaccidental skull fracture more likely. Subdural hematoma is rarely seen except in in- stances of inflicted injury. Kravitz demonstrated in a study of 330 accidental falls only one infant who sus- tained a subdural hematoma, while Billmire and Myers found that 95% of life-threatening head injuries were the result of child abuse. ^
In summary, the problem of child abuse is charac- terized by denial on the part of the perpetrators. Be- cause they cannot be relied upon to provide an accu- rate history, the physician must approach possible cases of child abuse with a high degree of suspicion and a firm grounding in signs and symptoms commonly as- sociated with child abuse. If child abuse is suspected, the physician must act as an advocate for the child by reporting his findings to the proper authorities to en- sure that the child’s well-being and possibly the child’s life will be protected after the child leaves the physi- cian’s care. /
REFERENCES
1. Ledbetter DJ. et al: Diagnostic and surgical implications of child abuse. Arch Surg 123:1101-1105, 1988.
2. Reece RM. Grodin MA: Recognition of nonaccidental injury. Pediatr Clin North Am 32:41-60, 1985.
3. O'Neill JA, et al: Patterns of injury in the battered child syndrome. J Trauma 13:332-339, 1973.
4. Adyanced Trauma Life Support Student Manual. American College of Surgeons Committee on Trauma, 1984, pp 172-173.
5. Billmire ME, Myers PA: Serious head injury in infants: accident or abuse? Pediatrics 75:340-342, 1985.
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JANUARY, 1990
Vanderbilt Morning Report
A Case of Cyanosis Without Hypoxemia
Case Report
A 24-year-old man entered the emergency room com- plaining of dizziness, nausea, and mild dyspnea after having inhaled several “poppers” (amyl nitrite). His past medical history was unremarkable. On physical examination, he was afebrile, his respiratory rate was 24/min, and his heart rate was 140/min. He was distinctly cyanotic and remained so de- spite supplemental oxygen. An arterial blood gas on 5 L/min oxygen showed pH 7.38, PCO2 39 mm Hg, POi 183 mm Hg. His methemoglobin level was 22% (normal < 3%). The re- mainder of his laboratory data was normal. He was sympto- matically improved after several hours of observation and subsequently was discharged.
Discussion
Methemoglobin is a derivative of hemoglobin in which the iron has been oxidized from the normal (reduced) ferrous (Fe++) state to the ferric (Fe+ + + ) state. Methemoglobin does not transport oxygen, and it has an intense dark blue color which causes clinically apparent cyanosis at concentrations of 15% or greater.’
Spontaneous formation of methemoglobin occurs slowly in vivo. There are several active metabolic processes that reduce methemoglobin back to hemoglobin^; the most active is dependent on reduced nicotinamide-adenine dinucleotide (NADH) and uti- lizes cytochrome bj as the physiologic electron carrier. Other biochemical systems are capable of reducing methemoglobin to hemoglobin but do so in vivo at much slower rates than the NADH-cytochrome sys- tem. One such pathway is an NAD-phosphate de- pendent (NADP-dependent) system which plays little physiologic role in reduction of methemoglobin be- cause an artificial electron carrier, such as methylene blue, is required. However, this enzymatic system is the major pathway by which methylene blue acceler- ates reduction of methemoglobin. The system also re- quires that reduced NADP (NADPH) be generated by the pentose phosphate pathway, the first step of which is catalyzed by glucose-6-phosphate dehydrogenase (G6PD).
Methemoglobinemia may be congenital or ac- quired. Congenital methemoglobinemia may occur either as a result of an abnormality in the hemoglobin molecule (hemoglobin M) or as a result of a biochem- ical deficiency in the normal cellular protective mech- anisms. Acquired methemoglobinemia results from exposure to various drugs and chemicals.’’ Neonates are
Prepared by Thomas E. Ducker, M.D., medical resident, and William F. Fleet, IIF M.D., Hugh J. Morgan chief medical resident, Vanderbilt University Hospital, Nashville.
22
particularly sensitive to induction of methemoglobine- mia. Agents capable of inducing methemoglobinemia include the aniline dyes, antimalarials, chlorates, cop- per sulfate, dapsone, local anesthetics, naphthalene, nitrites^ and nitrates (including sodium nitrite, amyl nitrite, butyl nitrite, nitroglycerin, nitroprusside, and silver nitrate), nitrobenzene, PAS, phenacetin, phen- azopyridine, and sulfonamides. Cases of fatal met- hemoglobinemia due to recreational use of inhaled ni- trites have been reported. ^
Symptoms of methemoglobinemia are dependent on the concentration of methemoglobin. At concentra- tions of 15% to 20%, cyanosis and “chocolate brown” blood are apparent. Concentrations of 20% to 45% are associated with dyspnea, fatigue, lethargy, head- ache, and dizziness. Progressive CNS depression oc- curs at concentrations of 45% to 55%, and concentra- tions greater than 70% are associated with a high mortality rate. The diagnosis of methemoglobinemia should be suspected in patients who present with cy- anosis in the absence of respiratory distress and in those whose cyanosis fails to correct with 100% oxygen administration. The diagnosis of methemoglobinemia is suggested by the failure of blood to become bright red on exposure to oxygen. Blood with 10% or greater methemoglobin leaves a characteristic dark red-brown stain on filter paper. The diagnosis may be confirmed by direct measurement of the methemoglobin level.
Specific therapy for methemoglobinemia should be given to those with methemoglobin concentrations greater than 40% and to those in whom the methe- moglobin level is rapidly rising. Treatment consists of administration of intravenous methylene blue (tetra- methylthionine chloride) in a dose of 0.1 to 0.2 cc/kg of a 1% solution (1 to 2 mg/kg) over five minutes. Methylene blue activates the NADPH-methemoglobin reductase system but is ineffective if the patient has G6PD deficiency. In severely affected patients and in those suffering from chlorate poisoning (in whom methylene blue is ineffective), exchange transfusion should be considered.
REFERENCES
1. Jaffe ER: Methemoglobinemia in the differential diagnosis of cyanosis. Hasp Practice 20:92-110, December 1985.
2. Jaffe ER: Methaemoglobinaemia. Clin Hematol 10:99-122, 1981.
3. Hall AH. Kulig KW. Rumack BH: Drug- and chemical-induced methae- moglobinaemia. Clinical features and management. Med Toxicol 1:253-260, 1986.
4. Walley T, Flanagan M: Nitrite-induced methaemoglobinemia. Postgrad Med J 63:643, 1987.
5. O Toole JB III, Robbins GB, Dixon DS: Ingestion of isobutyl nitrite, a recreational chemical of abuse, causing fatal methemoglobinemia. J Forensic Sci 32:1811-1812, 1957.
JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION
A Case of Syncope in the Church Choir
Case Report
A 78-year-old man was admitted after experiencing syn- cope while singing in his church choir. Before losing con- sciousness, he noted light-headedness and “skipped heart beats”; he regained consciousness quickly. He had experi- enced three similar episodes over the previous two years, each time while singing in the choir. Past medical history was re- markable only for mild coronary artery disease demonstrated by cardiac catheterization in 1980. Medications included pro- pranolol, isosorbide dinitrate, and quinidine gluconate, which he took for suppression of PVCs.
At admission, the blood pressure w'as 100/50 mm Hg in both arms. There were no carotid bruits and no jugular ven- ous distension. Cardiac rhythm was regular with a rate of 68/ min and no murmur or gallop. Neurologic examination w'as normal. Laboratory findings and EKG were unremarkable.
Continuous cardiac monitoring showed no significant dys- rhythmia, and serial cardiac enzyme determinations revealed no evidence of myocardial infarction; echocardiogram was normal. When carotid sinus massage was performed with minimal pressure on the right carotid artery, high degree AV block with marked bradycardia and hypotension developed (Fig. 1); formal electrophysiologic testing confirmed these findings. Premedication with atropine before carotid sinus massage prevented bradycardia and hypotension. It was pos- tulated that the combination of wearing a necktie and per- forming the valsalva maneuver while singing stimulated the hypersensitive carotid sinus. Subsequently, a ventricular de- mand pacemaker was placed for treatment of hypersensitive carotid sinus.
Discussion
Carotid sinus hypersensitivity is not a common cause of syncope, but it should always be considered in the differential diagnosis of recurrent syncope.' Two ma- jor types of this syndrome have been described. In cardio-inhibitory hypersensitivity' asystole or marked bradycardia results from carotid sinus stimulation. The cardio-inhibitory response is mediated by vagal action on the sinoatrial and AV nodes and can be abolished with atropine. Vasodepressor hypersensitivity- causes a significant drop in arterial blood pressure (5=50 mm Hg, or 5=30 mm Hg if symptomatic) in the absence of a change in heart rate. The response is not abolished by atropine. This type of carotid sinus hypersensitivity is much less common than cardio-inhibitory hypersen- sitivity. The two types may coexist.
Patients who have demonstrable carotid sinus hy- persensitivity may have additional causes for their syn- cope. A drop in cerebral perfusion due to atheroscle- rotic carotid artery disease may occasionally mimic carotid sinus hypersensitivity.
Carotid sinus hypersensitivity is more frequent in the elderly; intrinsic conduction system disease is probably not the major underlying cause of this syn- drome (although there is debate about thisj.^"* Predis-
Prepared by Anthony L. Thomas, M.D., medical resident, and William F. Fleet, III, M.D., Hugh J. Morgan chief medical resident, Vanderbilt University Hospital, Nashville.
Figure 1. Continuous rhythm strip during light pressure (indicated by up arrow) on the right carotid sinus. During this maneuver, the patient developed marked sinus bradycardia and AV block, resulting in symptomatic hypotension. The abnormalities resolved after discontin- uing carotid sinus massage (indicated by down arrow).
posing factors include diabetes, hypertension, ather- osclerotic vascular disease, and local abnormalities near the carotid sinus, such as scars or lymph nodes. There appears to be a significant correlation between carotid sinus hypersensitivity and the presence of significant coronary artery disease. ^
Precipitating factors are activities that stimulate the sensitive carotid sinus, including turning the head, shaving, and coughing. Many patients do not recall any specific precipitating factor. Various drugs (including digoxin, alpha-methyldopa, clonidine, and beta block- ers) may exacerbate the symptoms.
The diagnosis of carotid sinus hypersensitivity is made by the demonstration of an abnormal response to carotid sinus massage. This maneuver should be performed only with continuous cardiac monitoring of the supine patient and after listening for carotid bruits. Complications of carotid sinus massage are rare but include stroke, asystole, and ventricular arrhythmias. In patients with the cardio-inhibitory type of hyper- sensitivity, carotid sinus massage should be repeated after pretreatment with 1 mg of atropine.^ If carotid sinus massage continues to cause hypotension in the absence of bradycardia, an element of vasodepressor response is also present.
Therapy for carotid hypersensitivity includes: dis- continuing drugs that exacerbate the abnormality, an- ticholinergic and sympathomimetic drugs, denervation of the carotid sinus, and, most commonly, insertion of a ventricular pacemaker. Atrial pacing is often ineffec- tive. Symptoms due to the vasodepressor response may respond to a combination of ephedrine and propranolol’ or to a DVI pacer. Occasionally, these patients may require denervation of the carotid sinus.
CZIP
REFERENCES
1. Coplan NL. Schweitzer P: Carotid sinus hypersensitivity. Case report and review of the literature. Am J Med 77;561, 1984.
2. Almquist A, et al: Carotid sinus hypersensitivity: evaluation of the vaso- depressor component. Circulation 71:927-936. 1985.
3. Davies AB. Stephens MR. Davies AG: Carotid sinus hypersensitivity in patients presenting with syncope. Br Heart J 42:583-586. 1979.
4. Leatham A: Carotid sinus syncope (ed). Br Heart J 47:409-410. 1982.
5. Brown KA. Maloney JD, Smith HC. et al: Carotid sinus reflex in patients undergoing coronary angiography: relationship of degree and location of coronary artery disease to response to carotid sinus massage. Circulation 62:697-704, 1980.
6. Walter PF. Crawley SI. Domey ER: Carotid sinus hypersensitivity and syncope. Am J Cardiol 42:396-403. 1978.
7. Keating EC, Burks JM. Calder JR: Mixed carotid sinus hypersensitivity: successful therapy with pacing, ephedrine, and propranolol. PACE 8:356-359. 1985.
JANUARY, 1990
23
Health and Environment Report
Disposal of Infectious Wastes in Sanitary Landfills
SARAH H. SELL, M.D.
In 1988, after lengthy regulatory deliberations, a revised policy was announced for the disposal of infec- tious wastes in sanitary landfills. The current policy was developed by the combined infectious waste rule- making efforts of the divisions of Solid Waste Man- agement, Health Care Facilities, and Air Pollution Control of the Tennessee Department of Health and Environment.
For regulatory purposes the Department has de- fined “infectious wastes” to mean wastes which con- tain pathogens with sufficient virulence and quantity so that exposure to the waste by a susceptible host could result in an infectious disease.
The following are to be considered infectious wastes; isolation wastes, cultures and stocks of infectious agents and associated biologicals, human blood and blood products, pathological wastes, contamined sharp objects, contaminated animal carcasses, body parts or bedding, and facility-specified infectious wastes.
It is recommended that all infectious wastes be in- cinerated, steam sterilized, or otherwise rendered noninfectious prior to disposal in sanitary landfills. However, the Division of Solid Waste Management will permit some infectious wastes to be landfilled provid- ed certain precautions and limitations are strictly en- forced. The following restrictions apply:
® Sharp objects must be securely packaged in puncture-proof packaging.
• Cultures and stocks of infectious agents and as- sociated biologicals must be rendered noninfectious (e.g., autoclaved). Once properly treated, most such wastes may be approved for normal solid waste dis- posal.
• Human blood and blood products and other body fluids may not be landfilled. This restriction applies to bulk liquids or wastes containing substantive amounts of free liquids; it does not, however, apply to blood- contaminated materials such as emptied blood bags, “dirty” linens, or bandages.
• Recognizable human organs and body parts may not be landfilled.
From the Tennessee Department of Health and Environment, Nashville, Dr. Sell is director of the TDHE Environmental Epide- miology Program.
24
Infectious wastes must be managed at the landfill according to these minimal operating restrictions;
• Infectious wastes must be transported to the landfill separately from other solid wastes and in se- curely tied plastic bags or other leak-proof containers.
• Either the landfill operator must obtain advance notice before receiving a shipment of infectious waste, or a routine delivery schedule must be established, so that the operator will have time to prepare to receive the waste.
• The landfill operator must confine unloading and disposal operations to a specific area, separate from the normal working face, prepared to assure proper disposal with minimal complications.
• By the end of the operating day, the landfill op- erator shall have applied at least one foot of cover ma- terial over the waste and shall have compacted the emplaced cover material. There should be no compac- tion of uncovered infectious waste.
It should be noted that this policy does not obligate the Division of Solid Waste Management to allow the disposal of any infectious waste in any landfill. The granting of approval for disposal of any special waste in a landfill is a case-by-case determination made at the division field office level based on several factors. That approval should be denied or revoked if the field office manager has reason to believe that the above requirements will not be or are not being met. Also, it should be noted that the approval does not obligate any landfill operator to accept infectious waste for dis- posal. He may refuse to accept the waste or may im- pose additional conditions on the infectious waste gen- erator.
This policy covers not only wastes generated by hospitals and nursing homes, but also by clinics, phy- sicians’ offices, dental offices, veterinary offices and other generators of infectious waste. Physicians and other generators of infectious waste should give high priority to establishing office or clinic procedures to take care of their wastes in an acceptable manner.
Sharp object disposal poses specific problems. In addition to being “infected” after use, these instru-
(Continued on page 26)
JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION
Medicolegal Junction
Reach for the Moon:
The TMA-TBA Code of Cooperation
DENNIS LORD TMA Staff Attorney
I was 17 years old and living in Athens, Greece. The city set up about 20 television sets in the square near our house so everyone could watch, and hundreds of people gathered around, riveted to the screens. When the lunar module touched down, a great cheer went up from the crowd. Man had landed on the moon. What an accomplishment! The impossible had been done! What a cooperative effort! It was 1969.
That same year accolades must have been ex- pressed right here in Tennessee. Certainly they were for the lunar landing. But another major event also occurred in 1969. The Tennessee Medical Association (TMA) and the Tennessee Bar Association (TBA) hammered out their mutual Code of Cooperation. Now, that was an accomplishment! That was a coop- erative effort. Nothing is impossible!
But that was 20 years ago, and so in June 1989 committees of the TMA and TBA sat down to revise and update the Code. Thomas Ballard, M.D., who participated on both occasions, said it wasn’t as diffi- cult this time. In fact, the revision process went quite smoothly for a number of reasons, not the least of which is that several sections of the Nashville Acade- my of Medicine-Nashville Bar Association Code of Cooperation (promulgated in 1988) were adopted. For that, we owe the two Nashville associations sincere thanks.
Another reason is that the basic framework already existed, taken from the 1969 Code, and in fact much of the language remains the same.
But the most exciting reason that the 1990 revision went so well is expressed in two words — communica- tion and cooperation. A committee from each organi- zation sat down together and talked things out in an atmosphere of mutual respect, patience, and sincerity. There was give and take on both sides, and genuine interest in understanding each other’s position. Ulti- mately, that’s what our Code is all about.
Code History
The first TMA-TBA Code of Cooperation, a four- page pamphlet, was published in 1957, covering inter- relationship, preliminary conferences, records and re-
ports, expert witness fee, court attendance, and administration of the Code.
Under the heading entitled “Inter-Relationship,” was the following:
There should at all times be complete cooperation be- tween the physician and the lawyer, each assuming his proper responsibility, and recognizing that each profession has the duty to develop an enlightened and tolerant understanding of the other.
That is still the point, but it has taken several more pages to cover the same material in the 1990 revision. Times have changed.
The only other revision of the Code was in 1969, when it expanded to 13 pages. Coverage was expand- ed to include such topics as testimony by deposition, and compensation, items that were mentioned in the 1957 Code, but not developed.
The 1969 Code also offered a suggested form of authorization to be completed by the patient/client, al- lowing the physician to furnish medical reports to the attorney.
Finally, the 1957 and the 1969 Codes called for the establishment of a 12-member committee (six from each profession) to administer the Code, and the 1969 Code introduced a grievance procedure to be carried out by the administration committee.
Though apparently the Administration/Grievance Committee has never been implemented, it is to be hoped that TMA and TBA will overcome that hurdle this time and utilize the committee to everyone’s ad- vantage.
The Next Step
The Apollo Space Program placed several more men on the moon after that first “giant step” by Neil Arm- strong in 1969. TMA and TBA face a similar challenge now, which is to carry out the spirit of our mutual Code of Cooperation by improving communication and cooperation between the two professions.
That is easier said than done. After all, we are each caught up in our own world with our own professional priorities, which don’t always overlap conveniently. The committee members who worked on the 1990 Code
JANUARY, 1990
25
were quick to realize that. The most fervent sentiment expressed at their first meeting last year was that both associations must take steps to get the Code to every attorney and physician in the state. We must let peo- ple know that the Code exists — not to be administered as binding rules of conduct, but instead to be used as suggested guidelines to foster cooperation between the professions.
A look at the conclusion of the Code (first articu- lated in 1969 and revised in 1990) provides an appro- priate summary for members of our professions to consider.
Each profession is obligated by its own stature to respect and honor the calling of the other. One who has chosen to be a physician or an attorney and has been found competent to be such by appropriate authorities is vested with high re- sponsibilities and privileges to enable him to serve the public with honor, with dignity, and with effectiveness. These stand- ards of practice are intended as a guide to the attainment of the best in interprofessional conduct and practice.
The interests of the patient/client are primary. Physicians and attorneys should communicate with each other on behalf
of those interests. This Code should be used as a primary instrument to facilitate this communication. . . .
It is hoped that every physician and attorney practicing in Tennessee will abide by the spirit as well as the letter of the principles.
You should be receiving your copy of the 1990 TMA-TBA Code of Cooperation soon. When you do, take a few minutes and look it over. Consider it. Use it. It’s a matter of courtesy between two professions and between individuals. r ^
NOTICE
Your copy of the 1990 TMA-TBA Code of Coopera- tion is being mailed to TMA members along with an updated Physicians' Guide to Tennessee Law. The Physicians’ Guide is current through the 1989 session of the Tennessee General Assembly. It should be used as an educational tool. For specific situations, how- ever, consult your personal attorney.
Health and Environment Report . . .
(Continued from page 24)
ments pose a danger to others who encounter the sharp portions. There have been complaints by garbage han- dlers who have been injured. In addition, there exists a possibility of injury to both adults and children who may pick up used needles and blades around dump- sters where the instruments have fallen out of insecure containers, such as plastic bags.
Physicians are urged to review procedures for in- fectious waste disposal and make necessary modifica- tions to comply with the present rules.
For further information, feel free to call: Mr. Tom Tiesler, Director, Division of Solid Waste Manage- ment, Tennessee Department of Health & Environ- ment; phone (615) 741-3424.
MOVING? Send Us Your Address j
Please notify us six weeks in advance !
Old Address {
Name j
Address j
City State Zip j
New Address !
Address [
City State Zip j
Effective Date of New Address j
Send to; TMA, 112 Louise Ave . Nashville, TN 37203 j
I I
26
JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION
Loss Prevention Case of the Month
Help Needed — Not Called For
J. KELLEY AVERY, M.D.
Case Report
In 1983, our patient was 36 years old and already had had a long history of pelvic pain. When the patient was age 28, an operation disclosed endometriosis. Prior to the second surgical procedure, the patient again complained of proges- sively severe pelvic pain, particularly during the menses, and the examiner noted irregular enlargement of the uterus con- sistent with fibroids. The right adnexa had been found to be thickened, tender, and at times to contain what appeared to be a large and tender follicle cyst.
The patient underwent a total abdominal hysterectomy with a right salpingo-oophorectomy. Extremely dense pelvic adhesions were commented upon in the operative note, but the operation went well and convalescence was uneventful.
In 1988, at age 41, our patient developed increasing pain in the pelvis, particularly on the left, and on examination was found to have a left ovarian cyst, confirmed by ultrasound; the patient was admitted to the hospital for a left salpingo- oophorectomy.
Except for the pelvic examination, which showed the en- larged left adnexa, which was tender and relatively fixed, the preoperative laboratory work and physical examination were within normal limits. The operative note referred repeatedly to “dense adhesions.” There was no operative note that in- dicated that an attempt was made to skeletonize the left ure- ter, but in discussion with the surgeon after the fact, he stat- ed that attempt was made but proved to be impossible due to the severe dense, generalized adhesions.
The surgeon proceeded with the operation, and almost immediately after surgery the patient began to complain of inordinate pain in the left lower abdomen and in the left flank.
The diagnosis of a transsected and ligated ureter on the left was made within five days of the operation. One attempt was made to surgically repair the lesion, but this proved to be unsuccessful. On the second attempt a successful repair of the ureter was accomplished.
Dr. Avery is chairman of the Loss Prevention Committee. State Volunteer Mutual Insurance Company, Brentwood, and medical di- rector for Ambulatory/Outpatient Services, St. Thomas Hospital, Nashville.
The patient had been in the hospital for a number of weeks, she had had three operations, and she had lost her job. In a subsequent lawsuit, defense proved next to impos- sible, and a six-figure settlement was necessary.
Loss Prevention Comments
A thorough review of the record and examination of both the doctor and the patient indicated that there was no problem with the informed consent process. There had been an adequate description of the surgery and its risks and benefits, and specific reference had been made to the rather significant danger of injury to adjacent structures. In fact, a videotape had been shown in the doctor’s office that spoke directly of in- juries to the urinary tract, including the ligation of a ureter that this patient experienced.
Although the consent proved to be adequate within an acceptable standard, there were other severe defi- ciencies in this patient’s management.
Experts who reviewed the record were critical be- cause once the surgeon found that he was not able to skeletonize the ureter because of adhesions, there was no mention of the possibility of calling in a urologist to catheterize the ureters from below so they could be easily identified in the pelvis.
Experts were also critical of there being no attempt by the gynecologist to call in a more experienced col- league and ask for assistance at the table. This oc- curred in a medical center of such size that this kind of consultation would have been both possible and de- sirable.
Again, the very important point must be made that even when informed consent is adequate and appro- priate, quality considerations in the delivery of care are paramount in the assessment of potential liability on the part of the physician. f—
TENNESSEE MEDICAL ASSOCIATION
155TH ANNUAL MEETING April 4-7, 1990
Hyatt Regency Hotel, Knoxville
JANUARY, 1990
27
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BGHM 04-560 01-253
Emotions and Perceptions in a Postop Waiting Room
Let me share with you some impressions of what the parents of a patient go through as they wait in a surgical waiting room, and the anxieties and emotions of the presurgical admission process.
It was good for me to see, feel, and share the loss of control of time and the flow of events and activities that occur once one gets into the system of a hospital. You become utterly dependent for information on volunteers, nurses, orderlies and the multiple levels of hospital personnel with whom you come in contact. These people have specific jobs to do at specific times, and the patient’s progression through the system can make your existence in this journey comfortable, reassuring, miserable, anxious, or angry — the total range of emotions; these are all dependent on a smile, a kind word, a sense of urgency or a sense of boredom, or whether or not the individual may have had a prior confrontation with his employer or fellow employee. You, as a waiting member of the family, have all your antennae out to read all the emotions that may be in the air. Yes, no matter what your level of education or emotional stability, you are anxious to have anyone at any level reassure you and say it is going to be all right.
After the interminable wait for things to get started, you have been sitting with your own thoughts as to why you are there, and realizing no one knows the depth of your concern and no one is aware of the depth of your care, concern, and worry; your wait comes to an end and your loved one leaves you for the operating suite in the care of the nurse or orderly.
You look at the faces of those who are still waiting, and during the time you have waited in silence or not with those others, you have developed a small sense of camaraderie. In their eyes you see a look of “Is it going to be all right, or what am I assured is the outcome?" You find yourself seeking a word of assurance that all is going to be well even from the surgical attendant wheeling the gurney.
Now sitting in the waiting room, with its subdued conversation, you begin to consciously or uncon- sciously scan the faces of those around you, trying to plumb the emotions in their faces and at the same time think of your own anxieties. You try to compare their problems with yours, or their degree of pain or need as compared to yours. As you sit trying to find something to consume your time, or more accurately your level of concentration, you are acutely sensitive to the range of emotions you perceive. You find that you are overhearing the telephone messages that are being sent to the hospital personnel or volunteers, and try to read them.
Once again, for what seems like an eternity, during which time you have been through the full range of emotions, from anxiety, sorrow, desperation, despondence, fear, and anger, to hope, thank- fulness, and gratitude. Then a visit through either telephone or in person, your physician brings things into sharp focus, and then this phase of your contact with the health care system comes to a close.
As I have sat through this experience, I have become aware of how my emotions have been on a rollercoaster, and to what extent my state of mind may have been a function of those support people of the hospital with whom I have been in contact. We as physicians, and I particularly as a surgeon, should be ever alert to how much these support people have been directing the families of our pa- tients. I also became aware of how necessary is the job that they do, and how deserving this whole cadre of people are of our thanks and gratitude for their support of our patients’ families.
William O. Miller
jouf AOl o^ Ihc
tennez/ec
mccNccil cizzockiHon
PUBLISHED MONTHLY
DEVOTED TO THE INTERESTS OF THE MEDICAL PROFESSION OF TENNESSEE
OFFICE OF PUBLICATION: 112 LOUISE AVENUE, NASHVILLE, TN 37203
JOHN B. THOMISON, M.D., EDITOR
ADDISON B. SCOVILLE, JR., M.D., ASSOCIATE EDITOR
JEAN WISHNICK, MANAGING EDITOR
Acceptance for mailing at special rate of postage provided for in Section 1 103, Act of October 3, 1917, authorized July 15, 1932
Copyright for protection against republication. Journals of the American Medical Association and of other state medical associations may feel free to quote from this Journal whenever they desire merely giving credit to this publication.
Address papers, discussions and scientific matter tO:
John B Thomison, M.D., Editor 230 25th Ave. North, Nashville, TN 37203 Address organizational matters to L. Hadley Williams, Executive Director, 1 12 Louise Avenue, Nashville, TN 37203
COMMITTEE ON SCIENTIFIC AFFAIRS
OSCAR M. McCALLUM, M.D , Chairman, Henderson SIDNEY L, BICKNELL, M.D., Jockson FREDERICK D. SLAUGHTER, M.D., Bristol WINSTON P. CAINE, JR., M.D., Chattanoogo FRANCIS W, GLUCK, JR., M.D., Nashville JOHN B. THOMISON, M.D., Nashville, Ex-Officio
JANUARY, 1990
cdHoriol/
A Time of Hope —
A Time of Danger
. . An’ de walls come a’tum-bulin’ down.”
(To the tune of “Joshua fit
de battle ob Jericho”)
Who’d a thunk it?
Nobody, that’s who. There they were — East German Communist workmen (or workers, I be- lieve we are supposed to call them now) hacking away a few days ago at The Wall that had cut
Berlin in two for 28 years; and on top of The Wall — literally in Berlin and figuratively from the North Sea to Czechoslovakia — ordinary East German citizens were chipping away to help. As of right now, Checkpoint Charlie is no more, the Brandenburg Gate is open, and the old Glien- icke Bridge once again links West Berlin with Potsdam. There are indications, disclaimers from East German officialdom notwithstanding, that its new name. Unity Bridge, may soon mean Unity Bridge. It hasn’t been a week since the officials began once again allowing freedom of travel be- tween the two countries; but take down The Wall? Never!
Now, they say, so The Wall is down; so what? Unification next? Never! No, never — well, hard- ly ever; at least, not in your lifetime (cf. above). There is a reason, though, that this time the dis- claimer may have some weight. The reason is that it has the backing of Mr. Gorbachev, and Mr. Bush is not going to do anything to rock the Communist boat. East Germany is a satellite of the Soviet Union, and despite glasnost and all that stuff, a unified Germany would likely be neu- tral— and strong. And who wants it?
Well, for one thing, apparently a lot of Ger- mans on both sides of The Wall do — not their leaders, but folks like you and me, the ones who started the ruckus in the first place by their de- termination to either escape the system or change it. So far they, both those who have left and those who have stayed, appear to have been successful at changing it. So far.
Who else apparently doesn’t want a unified Germany is the West German youth. They have grown up with two Germanies — one an affluent one and the other a poor relation, and a distant one at that. They see East Germans flooding into their country for no better reason than to get a car or their own house sooner than they could get it at home — reasons these youngsters see as not good enough; at the same time, they are causing housing shortages and labor problems for West Germans. The young West Germans do not view the other Germany with the nostalgia of their elders, but as only another foreign country in which they have no stake. In truth, that may be the single greatest hurdle for unification to cross, since the country will after all soon be theirs all by themselves.
Last spring the world watched in wonder as multiplied thousands of Chinese, most of them young, were allowed to demonstrate unchal- lenged in Tiananmen Square in Beijing, demand-
JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION
ing a voice in the nation’s affairs — in short, de- mocracy. The People’s Army slowly gathered, but kept their distance, and seemed sympathetic to- ward the students. But as voices became progres- sively more strident in their demands for even greater reforms and concessions, and the leaders felt their security threatened, the soldiers were ordered to break it up, and they did. The Army of the People slaughtered the People whose army they were supposed to be — mostly the young, bright ones, to the extent that it will take a gen- eration or more for China to recover.
In a special TV program about the Wall of Iron — the army — all of the youthful soldiers in- terviewed waxed eloquent over the great honor that had been accorded them by allowing them to bear arms for the motherland. Every able- bodied Chinese man must serve in the military, and a lot of women do, too. They all are imbued with the necessity for discipline; they do as they are told, even to gunning down, crushing, and incinerating their countrymen for no better rea- son than that it was so ordered, ostensibly as being necessary to their country’s continued well- being. What appeared to be a stable, peaceful, peaceable situation suddenly curdled, and the world was aghast. The system of government that only shortly before had been dismissed as obso- lete, moribund, and in its terminal stages had suddenly arisen phoenix-like from its ashes to crush its detractors.
Presently there is unbridled euphoria through- out Germany, and the euphoria has spread like a plague to Washington, depriving many of our leaders of their reason. Communism, they opine, is obsolete, moribund, and in its terminal stages. The situation ought to remind any person with his wits about him of Yogi Berra’s observation that it is deja vu all over again. Time after time, we have read of happy Germans trooping across the border in both directions, passing “stony- faced” or “unsmiling” East German border guards. It seems to me that should tell us some- thing. It should tell us even more, I think, than that Hans Modrow, the new East German Prime Minister, has been charged by the Politburo with putting together a leadership that will pull the nation back from the brink and restore faith in the party. What it should tell us is that East Ger- man soldiers, like soldiers almost everywhere else (China, the Soviet Union, and yes, the United States, included), mostly do as they are told. It is at best impolitic and at worst dangerous, if not fatal, not to.
In a major address in Tokyo, an address that received wide coverage in the British and Japa- nese press, but which inexplicably and I think unconscionably was never mentioned either in the press or on television in the United States, Mrs. Margaret Thatcher, the British Prime Minister, warned that times of instability, such as the pres- ent situation in Eastern Europe, are times of great danger, and that it would be foolish in the ex- treme for the West to drop its guard; she said further that under no circumstances should nu- clear disarmament be even considered. Such a message is unpopular in Washington, and it ap- pears that Washington may be about to be fool- ish in the extreme, a posture to which it is cer- tainly no stranger. After all, Mr. Gorbachev wants it, and we must do everything we can, we are told (even, one fears, to laying down our country and our very lives on the altar), to as- sure Mr. Gorbachev’s success.
Ever since our two countries began cultural exchanges a number of years ago, and travel to the Soviet Union became possible, it has become apparent that the Russians are nice, attractive, intelligent people, people who would make fine next-door neighbors — people, in short, just like us. Too, Mr. Gorbachev is a charismatic, per- suasive leader. But we need to keep in mind that Russian and Soviet are not synonymous. Mr. Gorbachev is both. The Soviet is a hard-line Communist elite who are strongly committed to the notion that not only is Communism not dead, but that it will ultimately bury the Western de- mocracies, just as Mr. Khrushchev prophesied it would and Mr. Lenin insisted it should. The So- viet Union today is perilously close to bankrupt- cy, taken there by its massive military and de- fense buildup. Unlike the United States, it has a well-nigh impenetrable radar net. It suits Mr. Gorbachev’s purposes, and those of the Supreme Soviet, to play footsie with the West to gain breathing room.
It is equally important to remember that Mr. Gorbachev is not alone the Supreme Soviet. He has played his cards well, but there are other powerful Communists in the Soviet Union who are waiting for him to stumble, which is, of course, the source of Washington’s anxiety. East Germany may be a testing ground, and the Bush administration has so far not given evidence of any leadership. Mr. Gorbachev has. A lot is going to happen between the moment of this writing and your reading it. Voices for reform are be- coming strident in East Germany. One must
JANUARY, 1990
33
wonder if it is to become Tiananmen Square all over again. We shall have to wait and see, but one hopes our own leadership will have consid- ered that possibility. Likely nothing will be al- lowed to cause discord before the summit meet- ing in Malta on Dec. 2; but after that?
Mrs. Thatcher is by far the leading authority in the world in such matters. Mr. Roosevelt told Mr. Churchill at Yalta not to worry about Stalin; he could handle Old Joe. And so, as everyone knows, he did. We seem to be retracing our steps, but this time we are likely to get mired up over our heads, and you know what happens when that happens. What Mrs. Thatcher has done in effect is to remind the West that when they see the Greeks talking sweet and bearing gifts, they had better be extra cautious. The Trojans weren’t, and look what happened to them. Characteristic of the thought processes of our leadership is that their response would almost certainly be that the Greeks today are pretty harmless. So what’s the problem?
Well, the problem as I see it is that Mrs. Thatcher and I see a world that is a whole lot more unstable than the one Mr. Bush and Mr. Secretary Baker apparently see, which is one in which they can handle Mr. Gorbachev, so not to worry. Since that is so, this seems at least as good a time as any, and maybe a better time than lat- er, which may not happen (it is right now Nov. 14), to wish you a Happy New Year. By the time this gets to you, most of us will know one way or another whether or not it happened. Just think: this time we get to change two digits in our de- piction of the year. The last Nineties were the Gay ones (used in the classic sense); what will these Nineties be?
Next decade the whole shootin’ match will roll over in what is generally referred to as the Turn of the Century, except that this time it will also be the Turn of the Millennium. That has hap- pened only once before since the time of Christ, and at the moment I think I’d like to stick around to watch. On the other hand, when that time comes there might be a more attractive alterna- tive. Only God knows, and he ain’t tellin’. So Happy 1990. Too bad it can’t be something more poetic than just an old number — like the Year of the Bush, or maybe the Year of the Dragon; could be maybe even the Year of the Hammer and Sickle. Better the first than either of the last. Time magazine will no doubt let you know, but it tells you only after it’s over, and by then it’s too late; when it’s over, it’s over. One must hope,
34
though, or at least I think one must hope, that it won’t all be over — unless it’s time for the start of the Millennium, or whatever else it is, if any- thing, you are expecting when it’s all over except for that.
J.B.T.
CME for Credit
When in 1969 I was launched by Tom Nesbitt, then Speaker of TMA’s House of Delegates, upon my career in continuing medical education (CME) as a member of the newly formed TMA Committee on CME, of which I became chair- man two years later, the CME effort was just getting cranked up nationwide under the aus- pices of the AM A. That spasm was in response to a U.S. presidential blue-ribbon commission report purporting to show that doctors were an ignorant bunch who were disinterested in keep- ing up with what was going on in the world of medicine, and since that was not in their pa- tients’ best interests, somebody had to make them. Just who that somebody ought to be has never been fully clarified, but a variety of bodies in various areas, both geographic and specialty, have taken that task upon themselves. Since I have editorialized at length and on numerous oc- casions on that subject in the ensuing two dec- ades, I’ll not go further into detail here.
The prime mover in all of this was the AMA, who had just begun work on the Physician’s Rec- ognition Award (PRA) for CME, and was begin- ning work on an accreditation program so that state medical societies could accredit organiza- tions and institutions in their own state to mount CME programs that would be approved for Cat- egory 1 credit toward the AMA PRA. Thanks to the foresight of the TMA Board of Trustees in moving ahead with a CME effort, TMA’s CME Committee was the second in the nation to be approved for accrediting its state programs.
There were a lot of conferences in those days for establishing ground rules and procedures and so on, and at those conferences one of the prime topics for conversation was “the carrot or the stick” — was the doctor rewarded for obtaining CME, or was he punished for not? That debate is still going on in specialty societies, state hous- es, and hospitals, some opting for one and some the other. In Tennessee we have been fortunate
JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION
that the legislature has never seen fit to get into the act. Since hospital privileges are tied almost universally to fulfilling some CME requirement, I guess the legislature has not felt the need to, and some states that have had such requirements have now rescinded them.
Throughout the debate I have stoutly main- tained that the doctor who failed to refurbish his attic rather frequently was an anomaly, amount- ing to no more than perhaps 5% of the physician population, a rather widely accepted figure for medical incorrigibles, since for as long as there has been any sort of medical organization at all, doctors have always attended medical meetings; in fact, that was the reason for establishing med- ical societies in the first place. Doctors read jour- nals, and they consult with their colleagues daily, both formally and in hospital corridors, which may in the long run be the most effective learn- ing experience of all. I have maintained all along that with few exceptions my colleagues were ea- ger to learn, so that the whole organized CME accreditation effort was nothing but window dressing to assuage a public misperception.
Imagine my chagrin, then, when I received a paper, published in this issue of the Journal, in- dicating that as many as 80% of a group of doc- tors tied their education to credit. The study is such a small one, involving only 11 family prac- titioners, of whom ten responded, happily mak- ing for nice round numbers, that my initial reac- tion was not to publish it, since the findings have no statistical validity. What the study does clear- ly indicate, though, is that whereas the figure may not be as high as 80%, it would, with a larger sample, still be substantial.
So as to establish itself as a true specialty, dis- tinct from general practice, the American Acad- emy of Family Physicians early in its existence established stringent training and CME require- ments, with provision for periodic reaccredita- tion by its specialty board. It is therefore not sur- prising, and indeed to be expected, that all of the family practitioners surveyed would consider it an obligation of their hospital to furnish them CME that would be accreditable by their board. That is not an unreasonable expectation. I was taken aback, though, that 20% indicated that they would not attend a program that was not so ac- credited. I would have thought sheer curiosity would have drawn better than that. The other 60% said they would be less likely to attend.
What those statistics, weak though they are, say to me is that a substantial number of those
doctors have better things to do than be educat- ed. To be fair, it may be that they believe the educational opportunity is not all that great, and maybe it isn’t; I’ve been to a lot myself where it was not worth my time, but I didn’t know it be- forehand. Then again, maybe they do. As an ad- vocate of the carrot, though, the carrot being the educational experience itself, I must say my ar- gument is weakened thereby.
I suspect that this is neither a local phenome- non nor one confined to a family practice; I very much fear that it is instead just one more hair in the mole on the nose of the monster that the Washington Frankenstein has made of medicine. I also am very much afraid that we shall have to wait until, as Kipling observed, earth’s last pic- ture is painted and the tubes are twisted and dried before we will be able again to paint the thing as we see it for the God of things as they are.
J.B.T.
Looking Back — and Forth
In fourteen hundred and ninety-two
Columbus sailed the ocean blue.
So went the little mnemonic that helped us first-graders remember the date of the discovery of America by Christopher Columbus, and even though it has now transpired that others had been here before him, they had no press agent and left no significant mark to indicate that they laid claim to the land. In any case, Columbus’ contribution has been remembered for half a millenium, lack- ing three years; there aren’t very many that hold up nearly so long. Maintaining interest depends upon perceived importance.
Take, for example, the American Revolution, which is one of the few events schoolchildren re- member these days (and from some of the polls, one has to wonder about the ubiquitousness of even that knowledge). I’m talking now about American schoolchildren (or perhaps it would be more proper to say schoolchildren in the United States of America — in fact, I know it would, be- cause most Canadians, who are American also, do not remember it fondly, and in fact choose to forget it. Brazilians are American, too, who like- ly don’t consider it at all. It rankles those folks no end, certainly not without justification, that we have appropriated the term American. Even
JANUARY, 1990
35
Nordamericano, as we are called south of the border, will not do it, either, as both Mexicans and Canadians fit that description. At the same time, rule those out and I have no suggestions. But I digress). The English, on the other hand, understandably choose not to celebrate, though they, I thought magnanimously, did help us cel- ebrate our Bicentennial. That war was sort of England’s Vietnam — unpopular at home, fought a long way off, in a wilderness where it was im- possible to distinguish friend from foe (they did have a lot of friends here who thought the revolt an abomination), and with a foe who didn’t fight fair. Instead of the thrill of victory, the agony of defeat.
Or take Bastille Day in France. Like our Bi- centennial celebration, theirs was as much a commercial venture as a patriotic gesture, only in their case it was more so, since the dissenters in that revolution were homegrown, and not on some other continent. Though it made a great show on television, the attendees at the celebra- tion thought it something less than wonderful, the only thing wonderful about it being the magni- tude of the overcrowding of Paris and the traffic jams (except that their monumental traffic jams are something to pray fervently not to be a part of on even normal occasions). Many of the French consider their revolution to have been only the swapping of an oppressive monarchy for the reign of terror of a virtual anarchy in which most of the intellectuals lost their heads (literal- ly). Robespierre has been branded by some as the inventor of terror, which, though he was a master, is patently absurd, the Chinese having already been at it for at least a couple of millen- ia. The difference in their revolution and ours is that whereas ours eventuated in the founding of a new nation, the result of theirs was only anoth- er shifting of power, albeit a significant one, in a nation already ancient.
When I was growing up. Armistice Day, Nov. 11, 1918, was one of the days we celebrated. In the first place, World War I had initiated a heal- ing process in our North-South rift, which up un- til then had been still fresh in most southern minds. (Since the downtrodden are slow to for- get, it of course stayed pretty much that way in the South for 20 or so more years, until the real mixing of our population came about in World War II, and wounds of the present took the place of the old ones.) Who now remembers World War I? If it weren’t for the vast array of TV net- works having to fill up all that air time, nobody
36
would. World War II memories are confined to a few of us fading relics; and as for the Spanish- American War — say which? Armistice Day is now Veterans’ Day, to honor all our veterans — and why not? If we clung to all the old days of re- membrance, the calendar would be even a whole lot more cluttered than it already is.
Unless such days of remembrance become embedded in our national tradition as holidays, and mercifully few do, sooner or later they drop out. If they continue to be held as of some im- portance, they are resurrected at intervals, usu- ally for a while in quarter and then half century lots; we are presently at station one for the land- ing of a man on the moon, and station two for the opening gun of World War II. Both were sig- nificant events for the world, since the former expands our horizons, and fallout from the latter could terminate them, given just a little push from the right (read wrong) direction. We will, I guess, teeter forevermore on the brink of that disaster, given the ease of its accomplishment and the reachable depths of human depravity. Mankind is at the point in advanced technology where it doesn’t take much; his spiritual advancement is still, shall we say, generously, tenuous.
If we can avoid that cataclysmic horizon crunch, for my money Aug. 25, 1989 was zero anniversary for a millenial celebration at least equal to Columbus Day. In 1492 it was known, on fairly reputable authority, that if one went far enough east, one would come eventually to Ca- thay. It was a long, hard trip, and dangerous; caravans would set out and often never be heard from again. Furthermore, it took years to know whether they would or would not ever be heard from again. That can be hard on insurance com- panies, not to mention the beloveds. Columbus, being a sailor, thought it would be neat if you (speaking generically) could make the short hop by boat to the far side and get east by going west. He had heard that the Phoenicians had been around the world; the cognoscenti said forget it. The earth is flat, they said; you’ll only fall off the edge into unthinkable, even unimaginable, hor- rors, they said. He didn’t get any encouragement from the Spanish throne, either, which was where the money was. So he went to Portugal, where he found in the persons of Ferdinand and Isabel- la kindred imaginative, adventurous spirits (of course, all they would have to commit to it was money). Their Majesties grub-staked Columbus to three little bitty craft laughingly referred to as ships, the Pinta, the Nina, and the Santa Maria,
JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION
in which he sailed off on a journey that was a lot more than he had bargained for, finally coming to some islands he called the West Indies, be- cause they were just off India, only they weren’t.
In 1976 two robotic spacecraft. Voyager 1 and Voyager 2, set out for parts known, but just barely. The space program had gone to Con- gress, hat in hand, for them, and been rebuffed. Don’cha know there’s a war on, man (in the best manner of King Phillip — who was the one in the long run who gained the most from Columbus’ venture, Spain being the real sea power — only chicken)? Congress finally relented, and the probes were airborne, or maybe more accurate- ly, spaceborne. After problems with its joints, and some other problems with hearing and seeing in its early days (perhaps I should say “her,” since that’s how the space lab people refer to her). Voyager 2 performed so well and was still going so strong at the end of her assignment, that her bosses reprogrammed her toward the far cor- ners, and then some, and told her, “Go, Baby!” and she did. On Saturday, Aug. 26, after sending back spectacular photographs of Neptune, the farthest corner of our solar system, and its moon Triton, Baby, having already explored Saturn and Jupiter with wondrously detailed photography, headed out to sea. Though she will be returning all sorts of data to the lab for possibly years to come, we shan’t be seeing any more pictures from her, since so far as we know there’ll not be any- thing to be seeing pictures of — so far as we know. But then, what do we know? What we know of the universe out past Neptune is infinitesimal by any acceptable standards.
Until now, man’s relationship with the uni- verse for more than a few hundred miles away, and excepting our own star, has been confined to receiving signals, essentially light, and generally weak ones, at that. At last we have answered back with something more tangible than radio waves. Barring a chance disastrous encounter. Voyager 2 will be out there forever, speeding away from us at an ever-increasing velocity, and out of reach of the sun’s gravitational attraction; any chance for any such encounter is vanishingly small, given the vastness of interstellar space.
Why did Baby go? Well, despite all the ready answers, who really knows why? The most per- vasive commentary on the signals she sent from Neptune was that our very imagination is too limited. So many of Voyager’s findings are out- side the realm of possibility, given our present understanding of physical laws. Voyager has
raised more questions about the universe than she has answered. Despite all of that, the probe is allowing us to answer unanswerable questions about our own small piece of ground. There are clearly other reasons to explore space than “be- cause it’s there” (assuming that something that isn’t can be somewhere).
Exploration requires personal risk, but man- kind has never been short on adventurous spirits. Exploration also requires money, though, and those with the money have been considerably less enthusiastic. There are, as with horses and their back ends, a lot fewer Ferdinands and Isabellas than Phillips around. One hopes that when it comes to supporting the space program. Con- gress does not take the approach of Phillip that there are too many other things we need to be spending the money on. (Some of the more ex- pensive of those things could be mitigated by making space ventures a cooperative rather than a competitive effort.)
If the King Phillip line of reasoning had pre- vailed, what we now call the United States of America would not have the opportunity to cel- ebrate anything on the fourth of July, or on any other day, for that matter. The Indians would still have the hemisphere all to themselves, and “voy- ager” would be just someone sailing around the Mediterranean, and possibly, with luck, all the way up to Ireland.
J.B.T.
fncmofkim
Lee F. Cayce, age 74. Died November 7, 1989. Grad- uate of Washington University School of Medicine in St. Louis. Member of Nashville Academy of Medicine.
Hiram Crutchfield, age 29. Died November 15, 1989. Graduate of University of Tennessee College of Med- icine. Member of Knoxville Academy of Medicine.
John H. Saffold, age 76. Died October 23, 1989. Graduate of University of Tennessee College of Med- icine. Member of Knoxville Academy of Medicine.
John Lanier Wyatt, age 73. Died November 1, 1989. Graduate of University of Tennessee College of Med- icine. Member of Nashville Academy of Medicine.
JANUARY, 1990
37
ncul member/
The Journal takes this opportunity to welcome these new members to the Tennessee Medical Association.
BENTON-HUMPHREYS COUNTY MEDICAL SOCIETY
Mark Warren Anderson, M.D., Waverly
BLOUNT COUNTY MEDICAL SOCIETY
Daniel E. Brewer, M.D., Maryville Edward F. Brown, M.D., Maryville Don J. Lapenas, M.D., Maryville
BRADLEY COUNTY MEDICAL SOCIETY
William E. Buchner, Jr., M.D., Cleveland Balram L. Chhajwani, M.D., Cleveland Stephen W. Jackson, M.D., Cleveland
FENTRESS COUNTY MEDICAL SOCIETY
Leonard Carroll, M.D., Jamestown
MAURY COUNTY MEDICAL SOCIETY
Charles R. Harmiith, III, M.D., Columbia Chet H. Jameson, III, M.D., Columbia
TMA Members Receive AMA Physician's Recognition Award
The following TMA members qualified for the AMA Physician’s Recognition Award during October 1989. This list, supplied by the AMA, does not include members who reside in other states.
Physicians can receive the PRA certificate valid for one, two, or three years. For the one- year award, physicians report 50 hours of con- tinuing medical education, including 20 hours of Category 1; for the two-year award, physicians report 100 hours of CME, including 40 hours of Category 1; for the three-year award, physicians report 150 hours of CME, 60 of which are Cat- egory 1.
Jack R. Baker, M.D., Nashville Elijah G. Cline, M.D., LaFollette David N. Collins, M.D., Chattanooga Larry C. Collins, M.D., Cleveland Richard J. Davis, M.D., Nashville Mark P. Freeman, M.D., Nashville Monica A. L. Gefter, M.D., Chattanooga Francis W. Gluck, Jr., M.D., Nashville Vernon Hutton, Jr., M.D., Nashville Denis M. O’ Day, M.D., Nashville James S. Powers, M.D., Nashville Douglas R. Shanklin, M.D., Memphis Rena M. Thomison, M.D., Nashville C. Richard Treadway, M.D., Nashville
38
John A. Maloof, III, M.D., Columbia John O. Simmons, M.D., Columbia Anthony L. Smith, M.D., Columbia
ROANE-ANDERSON COUNTY MEDICAL SOCIETY
Pamela Bridgeman, M.D., Oak Ridge
SMITH COUNTY MEDICAL SOCIETY
Roger Duke, M.D., Carthage
SULLIVAN COUNTY MEDICAL SOCIETY
Matthew W. Wood, Jr., M.D., Bristol
SUMNER COUNTY MEDICAL SOCIETY
Wade Davidson, M.D., Hendersonville
WASHINGTON-UNICOI-JOHNSON COUNTY MEDICAL ASSOCIATION
Brian P. Donovan, M.D., Johnson City Marcia E. Mathes, M.D., Johnson City David B. Welch, M.D., Johnson City George B. Winton, M.D., Johnson City
WILLIAMSON COUNTY MEDICAL SOCIETY
Laura E. Higgins, M.D., Franklin
WILSON COUNTY MEDICAL SOCIETY
Ernest E. Sullivent, M.D., Watertown Steven L. Watkins, M.D., Lebanon
pCf/OACll iiw/
Luthur A. Beazley, M.D., Donelson, has received the Pediatrician of the Year Award from the Tennessee chapter of the American Academy of Pediatrics.
John M. Flexner, M.D., Nashville, has been elected president of the Tennessee Division of the American Cancer Society.
James T. Jackson, M.D., Dickson, has been named Physician of the Year by the Tennessee Academy of Family Physicians.
William T. Mathes, M.D., Johnson City, has received the Milligan College 1989 Distinguished Alumnus Award.
The following TMA members have been certified as diplomates of the American Board of Family Practice: Robert F. Baker, M.D., Sparta; Karl B. Rhea, Jr., M.D., Somerville.
The Mid-South Foundation for Medical Care, Inc., Tennessee’s Peer Review Organization, has an- nounced that James A. Mann, M.D., Memphis, will succeed Kenneth Phelps, Jr., M.D., Lewisburg, as chairman of the Board. Dr. Phelps will become vice- chairman.
JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION
announcement/
CALENDAR OF MEETINGS
NATIONAL
American Academy of Orthopaedic Sur- geons— Hilton, New Orleans American Orthopaedic Foot and Ankle So- ciety— Convention Center. New Orleans Pan-Pacific Surgical Association — Hyatt Regency, Waikoloa Island, Hawaii Society of Toxicology — Fontainebleau, Miami Beach
American Society for Dermatologic Sur- gery— Maui Westin, Maui, Hawaii American College of Psychiatrists — Wynd- ham. Palm Springs, Calif.
American Association for Geriatric Psychia- try— Meridien Hotel, San Diego American College of Utilization Review Physicians — Airport Hilton. Atlanta Central Surgical Association — Drake Hotel, Chicago
U.S. and Canadian Academy of Patholo- gy— Sheraton, Boston American Institute of Ultrasound in Medi- cine— Hilton, New Orleans 17th Annual Critical Care Medicine Course (sponsored by Univ. of Oklahoma) — Holi- day Inn Airport West, Oklahoma City Association for Academic Psychiatry — Stouffer Madison, Seattle U.S. Pharmacopeial Convention — Capital Hilton, Washington, D C.
International Anesthesia Research Soci- ety— Sheraton Waikiki Hotel, Honolulu, Hawaii
American College of Cardiology — Hilton, New Orleans
American Society of Neuroradiology — Wes- tin Century Plaza, Los Angeles American Society of Clinical Pharmacology and Therapeutics — Marriott Moscone Cen- ter, San Francisco
Society for Adolescent Medicine — Hilton Hotel and Towers, Atlanta American Academy of Allergy and Immu- nology— Baltimore
American Society of Clinical Hypnosis — Sheraton World, Orlando American Society of Clinical Pathologists — San Francisco Hilton Square College of American Pathologists — San Francisco Hilton Square American Society of Regional Anesthesia — Peabody, Orlando
American Burn Association — Golden Nug- get, Las Vegas
March 28- April 1 American Society of Contemporary Ophthal- mology— Hyatt, Phoenix
March 28-April 1 Mid-American Orthopaedic Association — Marriott’s Grand Hotel, Point Clear, Ala.
STATE
Feb. 24-25 Tennessee Society of Anesthesiologists, An- nual Meeting — Opryland Hotel. Nashville.
JANUARY, 1990
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Fill out, clip and return the coupon below. We will send you details on a picture perfect TMA sponsored plan of life coverage. Or, call us toll free at 1-800-347-1109.
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P.O. Box 1 109, Chattanooga, TN 37401 Sponsored by the Tennessee Medical Association!
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March 18-22 March 18-23 March 21-23
March 22-25 March 23-28 March 23-28 March 24-29 March 24-29 March 25-28 March 27-30
Highlights of the TMA Board of Trustees Meeting
October 15, 1989
The following is a summary of the major actions taken by the Board of Trustees of the Tennessee Medical Association at its regular fourth quarter meeting in Nashville, October 15.
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TMA Association Insurance Agency, Inc. |
THE BOARD: Received a detailed report from George C. Knox, Jr., vice-president of the TMA Association Insurance Agency, Inc., regarding the TMA Group Health Insurance Plan. |
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Medical Practice Committee |
Received a status report from the Medical Practice Committee on the imple- mentation of Resolution 18-89 (Guidelines for Third Party Queries Regarding Subscriber Patients). |
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Headquarters Building Update |
Received a report from the Executive Director on efforts to locate a suitable property site for the construction of a new TMA headquarters office building. The Board also reviewed a feasibility study report from Carl Storey Company and Adkisson, Harrison & Rick Architects, Inc. The Board authorized the Executive Director to negotiate for the purchase of the property reviewed in the feasibility study. |
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Sexual Addiction |
Received a report from legal staff on the development of recommendations for the appropriate handling of problems arising from the sexual addiction of phy- sicians. The Board authorized the Medical Director of the TMA Impaired Physician Program to work as a consultant with the Board of Medical Exam- iners on problems related to the sexual addiction of physicians. |
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Committee on Scientific Affairs |
Received a report from the Committee on Scientific Affairs regarding the eli- gibility of medical specialty societies for holding meetings in conjunction with the 1990 TMA Annual Meeting. Twenty-one organizations were granted meet- ing space and program assistance for the 1990 Annual Meeting. |
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Interprofessional Liaison Committee |
Received a report on the Sept. 24, 1989 joint meeting of the TMA Interprofes- sional Liaison Committee and the Interprofessional Relations Committee of the Tennessee Pharmacists Association. Both committees are working to im- plement TMA Resolutions 2-89 (Out-of-State Pharmacies), 3-89 (Prescription Time Limit) and 5-89 (Outlawing Anorectic Drugs in Tennessee). |
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Public Relations Program |
Authorized the use of funds from the CARE Program membership dues as- sessment for staff and other expenses. Authorized the Executive Director to employ an additional staff person. |
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Rural and Community Health Committee |
Received a report on the twenty-seventh Rural Health Conference, held on Oct. 4 in Columbia and on Oct. 5 in Milan. |
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HIV Infection and AIDS Committee |
Referred back to the Committee on HIV Infection and AIDS proposed Res- olution 20-89 (HIV Testing for Protection of Health Care Workers); declined to authorize funding for the publication of an AIDS manual for Tennessee physicians until other sources have been investigated. |
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Continuing Medical Education |
Approved a recommendation by the Continuing Medical Education Commit- tee to survey Tennessee hospitals on their current CME activities. |
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Mid-South Foundation for Medical Care |
Received a report from Dr. Otis Warr, III, Medical Director of the Mid-South Foundation for Medical Care, on the PRO sanction process, quality assurance, emergency surgical procedures, duplicate physician license numbers and small area analysis. |
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40 |
JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION |
Impaired Physician Program Renewed the contract for the Medical Director of the TMA Impaired Physi-
cian Program. Appointed Dr. William Cloud, Board of Medical Examiners, to serve on the Impaired Physician Committee.
Coalition on Smoking or Health Appointed Dr. David Jarvis to serve as TMA’s representative on the Tennes- see Coalition on Smoking or Health.
PADS/Triplicate Prescriptions Reaffirmed TMA’s opposition to triplicate prescriptions through a letter to
Governor Ned McWherter.
Sports Medicine Committee Appointed Dr. Dwight R. Wade, Jr., Knoxville, and Dr. Thomas J. Limbird,
Nashville, to the Sports Medicine Committee.
Medical Laboratory Board Agreed to nominate the following physicians for appointment by the Governor
to the Medical Laboratory Board (formerly the Laboratory Advisory Commit- tee): Four-year term position: Drs. Augustus L. Middleton, Jackson; Francis S. Jones, Knoxville; Terry T. Francisco, Memphis. Two-year term position: Drs. David R. Yates, Donelson; Rodger P. Lewis, Union City; Jerome H. Abramson, Chattanooga. / ^
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42
JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION
IMPACT Members— 1989
As Chairman of the Board of IMPACT (Indepen- dent Medicine’s Political Action Committee — Tennes- see), I am pleased to present the following list of IMPACT members for 1989 as of November 15. Al- most 1,500 TMA members have recognized the impor- tance of united participation in the political process by contributing to IMPACT this year. This represents ap- proximately 25% of the total TMA membership and is a substantially higher level of participation than ever before. To those of you whose names are included on the list below, please accept my sincere thanks.
You can be assured that legislators do pay attention to those who help them get elected and stay in office. To the extent that organized medicine is successful in working with the members of the 96th General As-
sembly and the soon to be elected members of the 97th General Assembly, those of you who are IMPACT contributors will be due a great deal of the credit for that success.
If you do not find your name on this list, our rec- ords do not reflect that you were a member of IMPACT for 1989. Memberships are now being ac- cepted for 1990. Annual dues are $150 for sustaining membership. TMA’s future legislative success depends on our continued participation in the political process. Your contribution will be much appreciated and will be put to good use.
Robert Kirkpatrick. M.D.
Chairman
IMPACT Board of Directors
ABELL, JAMES E ADAMS, CARL E ADAMS, JOHN W JR ADAMS, ROBERT RALPH ADAMS, WESLEY F ADAMS, WM MILTON JR ADCOCK, FRANK JOHN III ADKINS, ROBT BENTON AGUIRRE, DENNIS MANUAL AHLER, ALBERT JULIAN AIKEN, MARC A AKIN, HOBART E AKINS, CHARLES D AL-ABDULLA, ABDUL-SAHIB M ALEXANDER, CLYDE VINSON ALEXANDER, CLYDE W JR ALFORD, ROBERT H ALFORD, WM CUTTER JR ALI, MAYSOON SHOCAIR ALI, SUBHI DAWUD ALLEN, BILLY JASON ALLEN, CHAS EDWARD ALLEN, GEORGE S III ALLEN, JAMES LESTER ALLEN, L DIANNE ALLEN, VERNE ELWOOD ALLEY, EDMOND LYNN ALLISON, JACK R ALPER, CHAS H AMADOR, JOSE GARCIA JR AMBROSE, PAUL SEABROOK AMBROSIA, JOHN M AMONETTE, REX ALLEN ANAND, VEENA ANAND, VIRENDER ANDERSON, ALLEN F ANDERSON, EDWARD EUGENE ANDERSON, EDWIN B JR ANDERSON, JOE PAT ANDREWS, DOUGLAS EUGENE ANDREWS, SUSAN T ANTONUCCI , RICHARD A ARCHIE, DAVID S ARKIN, CHAS RICHARD ARNOLD, COLEMAN LEE ARNOLD, EDWARD STANLEY ARNOLD, HENRY GRADY JR ARNOLD, IRA L ARONOFF, PHILIP MELVIN ATKINS, JERRY FRANKLIN ATKINSON, RICHARD AGARD ATWOOD, JOHN WESLEY ATWOOD, SUE C AVERETT, STEPHEN L AVERY, JAMES KELLEY AVERY, ROBERT BRUCE AVERY, SHIRLEY BANNISTER
BACHMAN, HARRY WILSON JR BACKUS, ELIZABETH MAUREEN BACON, STUART PETER BAER, HARRY BAGBY, RICHARD A JR BAGGETT, HENRY W BAILEY, ALLAN H BAILEY, JOS C BAKER, PAUL D JR BAKER, RICHARD DUDLEY BALES, DONALD W BALL, CHARLES A BALLARD, THOS K BALLINGTON, KAREN LOUISE BANKS, SAML LOUIS BANKS, WOODRUFF A JR BARCLAY, LEE ROY BARD, RALPH M BARD, SHIRLEY A BARHAM, HARVEY HAYWOOD BARNARD, VAUGHN N JR BARNES, DAVID R BARNES, JAMES WALTER JR BARNETT, ROBT BURTON BARRON, FREDDIE T BARRY, FREDERICK JAMES BASHAW, ROBERT BASKIN, REED CARL BAYLOSIS, ROBERTO B BEALE, HOBART H BEALS, JOE DUNCAN BEAMER, WILSON C BEASLEY, ALFRED DURANT BEASLEY, JIMMIE L BEASLEY, ROBERT ALAN BEATTY, BRIAN CRAIG BEATY, JAMES HAROLD JR BEAZLEY, LUTHUR BEAZLEY, WILLIAM COOPER BECHTEL, JACK T JR BECK, LARSON DALE BEELER, T CRAIG BELL, JOHN L BELL, RICHARD BRYAN BELL, W KEN BELL, WILLIAM M BELLOMY, BRUCE B BENNING, THOMAS R BERGLUND, ROBERT K BERRIE, WARREN R BETHURUM, ALVA JEFFERSON BHAT, NARAYANA B BICKNELL, SIDNEY LANE BIGBEE, WALLACE BURNS BILBREY, RICHARD LEE BINDER, SAML S BINGHAM, TERRY M
BIRDWELL, DAVID ALLEN BIRDWELL, JOEL STANLEY BISE, STANLEY L BISHOP, CALVIN R BISHOP, MICHAEL ROBT BLACK, WILLIAM D BLACKWELL, CAROLYN FISER BLANTON, FRANK S JR BLANTON, MARVIN A III BLEVINS, MELVIN LEE BLOCK, CLEMENT H JR BLOUNT, HENRY C JR BLYTHE, JOS ALFRED III BOAZ, LONNIE ROY JR BOBO, ROBT THOMPSON BOLIN, MARION G BOLTON, TRAVIS LEON BONE, GEORGE BONE, ROBERT CARVER BOOKOUT, MARK WILLIAM BOOTH, GLENN H JR BORN, MARK L BORTHWICK, THOMAS R BOURLAND, ROBT LEON JR BOURLAND, WM LANDESS BOWERS, ROBT EUGENE BOXELL, JOHN FREDERICK
BOYD, ALLEN STREET JR
BOYE, HARRY GEORGE BOZEMAN, CHARLES H II BRABSON, LEONARD ALLISON BRACKIN, HENRY B JR BRADLEY, DONALD HUGHES BRADSHAW, JAMES C JR BRAKEFIELD, JAMES MARION BRANSON, AUBRA DAVID BRANTLEY, RICHARD GREEN BRAREN, H VICTOR BRASFIELD, JIM C BRATTON, CHRIS H BREWER, RANDALL J BRIMI, JOHN BENJ BRIMMER, ROBERT A II BRINNER, RICHARD A BRITT, JAMES CLYDE BROADSTONE, PAUL A BROCK, HOWARD THOS JR BROGLIO, ANTHONY LEE BRONSTEIN, MAURY W BROTHERS, JOHN CUNNINGHAM BROWN, GERON JR
BROWN, LLOYD TYNTE BRUEGGEMAN, MICHAEL BRUNO, JOHN III BRUNT, CHAS HAL BRYAN, DAVID BRYAN, JOHN MILTON
BRYANT, JOHN FRANK BRYANT, MAX VINCENT BUCHANAN, RICHARD DURR BUCHANAN, ROBT NORMAN JR BUCKLEY, MADISON H JR BUCKSPAN, GLENN S BUCY, GUY STEVEN BUKEAVICH, ALFRED PETER BURKHART, JAMES M BURKHART, JOHN H BURKHART, JOHN MCLAIN BURKHART, PATRICK H BURKHART, WILLIAM L BURNES, JAMES EDMOND BURNETT, LONNIE S BURNS, GERALD ROBT BURNS, RANDEL PHILLIP BUTLER, ARDEN JONES JR BUTTERWORTH, JACKSON JR BUTTERWORTH, JOE S BYRD, JACK
CADENA-CUCTA, GUILLERMO CALDWELL, EDWARD PRICHARD CALDWELL, RONALD DAVID CALLAWAY, JAMES MILLER CALLAWAY, JAMES J CALVERT, DAVID CAMERON, ROBT LYNN CAMPBELL, EARL ROY JR CANALE, DEE JAMES CANCELLARO, LOUIS A CANNON, JESSE J JR CAPPS, ROBERT J CARD, WM JUDSON CARR, HENRY AUSTIN CARR, KENNETH CARRUTH, CYNTHIA CARTER, DENNIS CHARLES CARTER, OSCAR WILLIS CARTER, SAM FRANK III CASEY, ROBERT REID CASSELL, NORMAN M CATE, RONALD C CATLIN, ROGER W CAUGHRAN, BENNETT W CHAFFIN, DAVID C CHALFANT, ROBT L CHAMBERLAIN, MORROW II CHAMBERS, JILL F CHAMPION, JAMES CHANDRA, CHANNAPPA CHAPMAN, JOHN L CHARY, KANDALA RAM CHASTAIN, BRYAN D CHASTAIN, CHALMER JR CHAUHAN, DINESH N CHEATHAM, CHARLES P
JANUARY, 1990
43
CHEEK, RICHARD CALVIN CHESNEY, JOHN TUCKER CHRISTENBERRY, K W JR CHU, ROY W CHURCHWELL, A GRIGG CLARK, JOHN ROGER CLARK, MALCOLM E CLARK, MARC LEWIS CLARK, MURRELL O CLARK, RICHARD G CLARK, ROBT L CLARK, S KATHLEEN CLARK, WARNER L CLARY, THOMAS L CLASSEN, KENNETH LEON CLAYTON, THOMAS EDWARD CLEMENTS, JOEL BENJ CLEMONS, DONALD E CLINE, RICHARD CLOSE, LOUIS WARD CLOUD, WM WILEY COBB, CULLY A JR COBB, R MICHAEL COBBLE, DOUGLAS CATRON COCHRAN, ROBT TAYLOR COCKROFT, ROBT LAWRENCE COHEN, ALAN GARY COLE, CHAS PITTMAN COLE, F HAMMOND JR COLE, FRANCIS HAMMOND COLE, ROBT RELAND COLE, RONALD ARTHUR COLES, JOHN H III COLLINS, DAVID NEWTON COLLINS, LARRY C COMAS, FRANK VILANOVA CONN, ERIC HADLEY CONRAD, DANIEL E CONRAD, JAMES FRANCIS COOGAN, JOAN C COOGAN, PHILIP S COOK, MARY BAXTER COOK, THOMAS ANDREW COOKE, GEO EDWARD COONCE, DANIEL F CORBIN, CHARLES JR COREY, DAVID ANTHONY COSTANZI, JOHN J COTHREN, JACKSON DANL COUCH, BILLY LANIER COUDEN, VINCENT ROBT COUGHLIN, DENNIS JR COURINGTON, DORIS PAYNE COWAN, JOHN DAVID COWDEN, DAVID ANTHONY COX, CHAS WM COX, DAVID A COX, JOHN MICHAEL COX, LARRY H COX, MICHAEL THOMAS COX, SUE CLARKE CRAFT, PHIL DOUGLAS CRAIG, JAMES THOMAS JR CRAIG, JAMES P CRAWFORD, DONALD A CRAWFORD, JOHN D CRAWFORD, LLOYD V CRAWFORD, WALTER MORGAN CREEKMORE, HARRY S CRICK, JAMES M CROCKER, EDWARD F CROCKETT, CLAUDE H JR CROSBY, VIRGIL GLENN CROWDER, VIRGIL HOLT JR CROWN, LOREN ARTHUR CRUTCHFIELD, JAMES DONALD CUNNINGHAM, EDWIN DAYTON CUPP, HORACE BALLARD JR CURLE, RAY EUGENE CURLIN, JOHN PASCHAL CURREY, THOS ARTHUR CURTIS, SHANNON CURTIS, T RANDALL CURTIS, THOS H DANIEL, ESLICK EWING DANIELL, MALCOLM BUTLER DARLING, CHAS ELLETT JR DASH, LAMARR A DAVIS, CARLA SUZANNE
DAVIS, JAMES PHILLIP JR DAVIS, PATRICIA CLIFFORD DAVIS, RICHARD JOHN DAVIS, THOS JOEL JR DAVIS, WM GRAY DAWOUD, SAMIR RIAD DAY, GEORGE LOUIS DEAL, VIRGIL T DEBERRY, JAMES T DELVALLE, RENE CARLOS DEMING, WOOD M DENOFF, FRANK DERRYBERRY, JOHN S DERUITER, PETER LOUIS DEW, RICHARD ALLAN DEWITT, JAN ALLEN DICKERSON, DANL LAWRENCE DIEZ D’AUX, ROBERT C DIRMEYER, PHILLIP HAYS DOANE, DAVID G DODD, DAVID T DODD, ROBERT T DODGE, KENNETH BRENTON DODSON, THOMAS WILLIAM DOELL, ROBERT J DONAHUE, DAVID J DONALDSON, ROBERT C DORIAN, JOHN BERNARD DORROH, CHARLES WILLIAM DORSEY, LARRY DOWNEY, WM LEE DRAKE, ARNOLD MANNAS DRAKE, JAMES ROBT DRAY, ROBERT J DRIVER, CLARENCE DUCKWORTH, JOHN KELLY DUDLEY, B STEPHEN DUDNEY, ELIJAH MORGAN DUER, CARL THOS DUFFY, KAREN BARR DUFFY, MARY BROCK DUNCAN, JERALD MARK DUNCAN, RAPHAEL H JR DUNCAN, THOMAS C DUNCAN, THOS RAY DUNDON, MARY CATHERINE DUNNEBECKE, ROBERT H DURHAM, BEATRICE L DUVAL, J WILLIAM JR DWYER, WM KNOWLES DYER, WM CARL JR EASON, HAMEL BOWEN EASTERLY, JAMES F JR EASTRIDGE, WESLEY V ECKSTEIN, CHARLES W EDGAR, ANDREW S SR EDMONSON, ALLEN S EDWARDS, MARK S EDWARDS, NICHOLAS HENRY EDWARDS, ROBT HARVEY EDWARDS, WM H ELKINS, LARRY H ELLENBURG, DONALD T ELLIOTT, MICHAEL B ELLIS, E STEPHEN ELLIS, THOMAS W ELROD, BURTON F JR EPLEY, JOHN M
EPPS, JOHN MICHAEL ERWIN, J W ESCOBAR, ALFONSO ESTEP, DENNIS PAUL ESTES, TERRELL C EVANS, JOHN HAROLD EVANS, JOHN THOS EVANS, THOMAS S EYSSEN, JAMES EDWARD EZELL, ROY CLAY FALVEY, WILLIAM DAVIS FANCHER, WILLIAM H FANNING, DAVID FARDON, DAVID FAVREAU FARRAR, THOMAS CROWELL FARRIS, RICHARD KENT FAULKNER, CHAS TAYLOR FAUST, LARRY M FECHER, MARK P FEIT, RICHARD A FELCH, JAMES W
FELTS, STEPHEN KAREY FEMAN, STEPHEN S FENLEY, JAMES L JR FENTRESS, J VANCE FERGUSON, JAMES V FERGUSON, JERE W FERRELL, M CRAIG FIEDLER, GEO ADOLPH JR FINCHER, JOHN A JR FIORANELLI, RAYMOND JAMES FISHER, BENJ FISHER, JACK FISHER, ROBT MOORE FITTS, JAMES MORGAN JR FLEMING, JAMES CHRISTIAN FLINN, CARL EDWIN FLOHR, ROBERT STEPHEN FLORENDO, NOEL TADIAR FOGLE, RICHARD ALLEN FORD, AUGUSTUS C FORD, DENNIS CLIFFORD FORD, DIANNE J FOSTER, CHAS STEPHEN FOSTER, HENRY WENDELL FOSTER, JERRY M FOSTER, LARRY J FOSTER, NELSON RAY FRANCIS, HUGH JR FRANCIS, ROBT STANLEY FRANCISCO, JERRY THOS FRANKLIN, JOHN DAVID FRANKLIN, SELMON T III FREEMAN, COY FREEMAN, JERRE MINOR FREEMAN, MARK PEARCE FREEMON, DAVID NOBLE FRENCHMAN, KHUSHRU H FRIST, JOHN C JR FROST, CHAS LESTER FRY, MELLON ALMA JR FRYE, AUGUSTUS H JR FULK, CHARLES S FURLOW, WILLIAM LOOMIS FURR, FRED M FUSTE, RICARDO R FUTRELL, DANNY W GAFTHE, GORDON GAILLARD, THADDEUS B GAINES, DONALD LEE GALIARDI, MARTY P GALYON, JAMES THEODORE GAMMILL, STEPHEN LANE GANTT, PICKENS A GARBARINO, A J JR GARBER, BRIAN H GARDNER, BENNY A GARDNER, LAWRENCE G JR GARNER, JAMES WM JR GARRETT, HARVEY E JR GARRIOTT, DAVID KENT GASTINEAU, JERRY LEE GASTON, ROBT B GAVIGAN, WM MITCHEL GAZALEH, SHAWN GEDDIE, DANL CLARK GEFTER, JEFFREY W GELFAND, MICHAEL S GERALD, BARRY ELMO GERKIN, DAVID GEORGE GETTELFINGER, THOMAS C GIBSON, CARL EUGENE GIBSON, DONALD BAKER GILBERTSON, ROBT B GILLESPIE, JAMES T GILLESPIE, RICHARD ALLEN GLASCOCK, FRANK B GLASGOW, SAMUEL MCPHEETERS GLASSCOCK, MICHAEL E GLAZER, LOUIS GLAZER, MARK D GLOVER, DANNIE WELDEN GLUCK, FRANCIS W JR GODWIN, CHAS WAYNE GOLDEN, BILLY N GOODE, FLETCHER HOWARD GOODMAN, CHAS EDWARD JR GOODMAN, JACK A GOODWIN, STEPHEN GOTTEN, NICHOLAS
GOUFFON, CHAS ALLEN GOULD, HOWARD R GOULDING, CLARENCE E JR GOWDER, TIMOTHY DENNIS GRAHAM, LARRY GILL GRAHAM, RANDAL 0 GRAVES, CHAS G JR GRAVES, HERSCHEL A JR GRAY, JAMES TRAVIS GRAY, MCDONALD GREEN, BRUCE QUINTON GREEN, HUGH E GREEN, JAMES DONALD GREEN, PATRICIA A GREEN, PAUL A JR GREENE, RICHARD W GREENE, RICHARD S GREENWOOD, JEFFERY D GREER, CLIFTON E JR GREER, PATRICK RODDY GREER, WM C
GREMILLION, DANIEL E JR GRIFFIN, WILLIAM C GRIGSBY, WM PAUL GRIME, HARVEY H GRINDE, STEPHEN E GRISCOM, JOHN HOOPER GRISE, JERRY WADE GRISOLANO, JAMES MARTIN GROCE, ANN GRONEWALD, WM ROBT GROSSMAN, ALLAN M GULLETT, DAVID LAIRD GURLEY, LARRY D GUTCH, WM JOHN III GUTOW, GARY SAML GUTOW, RICHARD FINEMAN GYURIK, CATHERINE E HAASE, THEODORE F JR HACKWORTH, JOHN BIBLE JR HAGAN, KEVIN F HAGENAU, CURTIS JAMES HAHN, JAN T HALEY, ROBT LEO JR HALEY, TONY O’NEAL HALFORD, HOLLIS H JR HALFORD, HOLLIS H III HALL, DANNY HALL, MICHAEL STANLEY HALTOM, THOS BRANSON HAMBY, DONALD LYNN HAMILTON, HOWARD KEN HAMILTON, JAMES RICHARD HAMILTON, RALPH S HAMLETT, JAMES M III HAMMON, JOHN W JR HANES, THOMAS EUGENE HANNA, WAHID T HARALSON, ROBT HATTON III HARDIN, ROBT ALLEN HAREN, VINCENT JAMES HARGROVE, R LESLIE HARMON, HARVEY HARRELL, THOMAS G HARRINGTON, ROBT LEE HARRIS, ARTHUR SALE HARRIS, GEORGE A HARRIS, HOYT C HARRIS, WESLEY J HARTING, DON C HARTMAN, RONALD D HARWELL, WM BEASLEY JR HASSLER, LLOYD R HAUSMANN, JAN M HAWKINS, CHAS W HAWKINS, RAYMOND JR HAWKINS, ROWLAND SPECK HAWKINS, STEPHEN S HAYES, PHILLIP WALTON HAYES, THOMAS E HAYNES, DOUGLAS BRANDT HAYS, JAMES WM HEARD, GEORGE J HECHT, JEFFREY S HEINTZ, RICHARD BRUCE HELD, GORDON R HELTON, STEPHEN LANE HEMPHILL, CHRIS B HEMPHILL, JAMES LOUIS
JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION
HENDERSON, NORMAN LEROY HENDERSON, ROBERT R HENDRIX, ERNEST LEE HERNANDEZ, GUSTAVO E HERRICK, C NEIL HERRON, BRUCE EMERSON HERRON, CHAS BURKHEAD HERTZ, CHARLES S JR HESTER, RAY WILLIS HEWGLEY, ROBERT G JR HICKERSON, WILLIAM L HICKS, BIRAM C HICKS, MACK L HIGDON, DENNIS ALAN HIGGINBOTHAM, THOS WAYNE HIGGINS, THOMAS G HIGGS, BOBBY CLARK HIGH, JAMES MARSHALL HILL, HUBERT CAWOOD HILL, ROBERT PAUL HILTON, JAMES ISAIAH HIMMELFARB, ELLIOT HARVEY HINES, LEONARD HARVEY HINES, STEPHEN L HIRE, ERVIN A HITCH, JAMES PARKS JR HIXSON, SHERMAN D HODNETT, CARY G HOFFNUNG, JACK HOLCOMB, GEO W JR HOLCOMB, GEORGE W III HOLLIDAY, H JOSEPH HOLLIER, PAUL A HOLLIS, DAVID O HOLLY, HOWARD RHEA HOLMES, ALBERT K HOLMES, GREGORY M HOLT, HUEY THOS HOOD, DEWEY WOODROW HOOD, MICHAEL T HOOD, STEPHEN THOS HOOS, RICHARD T HOPKINS, SHARON D HOPPE, GORDON PAUL HOROWITZ, DAVID HARVEY HORTON, MARSHALL HOSKINS, JOHN C HOUSE, BEN FRED HOWE, JOHN W HOWELL, MARK ALLAN HOWSER, JOHN PATTON HUA, VIN-PAUL HUBBARD, REX HUDDLESTON, CHAS IRVING HUDGENS, JAMES F JR HUDGINS, J CARMACK HUDGINS, JAMES M HUDSON, CHAS CRAIG HUDSON, LARRY D HUFF, MAXWELL E HUFFMAN, CHARLES D HUGHES, THOMAS ARTHUR HUMMEL, JOHN VERNON HUMPHREY, STEPHEN P HUMPHREY, TOM NEAL HUMPHREY, WM MERRITT HUNT, JOE
HUNT, NOEL CLARENCE HURT, JOS EDWARD HUTCHERSON, WM POWELL HYDER, NAT EDENS JR HYMAN, STEVE A IGLEHART, BRYAN T IHLE, CHRISTOPHER LANGDON IKARD, ROBT WINSTON INGRAM, JOHN JACKSON III IVENS, MARK YOUNG IVEY, DONATHAN MILES IVEY, R DONATHAN JABBOUR, J T JACKSON, JAMES W JACKSON, JOHN M JR JACKSON, ROBERT C JACOBS, G JACKSON JAGGERS, JOHN S JAMES, DABNEY JAMES, DEWITT B JAMES, HAL PEARSON JAO, HENRY C
JARVIS, S CRAIG JAYNE, J LAWRENCE JR JEKOT, WILLIAM J JENKINS, JOHN M JENNINGS, JEFFORY G JENNINGS, R HUNTER III JERKINS, GERALD RAY JERNIGAN, JERRY MARSHALL JERNIGAN, JOHN FORREST JOE, PENN QUORK JOHN, JAMES THOS JR JOHNS, KARLA J JOHNS, OSCAR THOMAS JOHNSON, EDWARD DOWNEY JOHNSON, FRANK P JR JOHNSON, H KENNETH II JOHNSON, J PAUL JR JOHNSON, JAMES GIBB JOHNSON, JANET K JOHNSON, JERRY RICHARD JOHNSON, JOHN SETTLE JOHNSON, JOHN C JOHNSON, LARRY HOLLIDAY JOHNSON, ROBT MARSHALL JOHNSON, RONALD JACKSON JOHNSON, WM FRANK JR JOHNSTON, WILLIAM D JOHNSTONE, WILLIAM H JONES, DAVID W JONES, FRANK EMERSON JONES, JOE PAUL JONES, JOHN DONALD JONES, MILNOR JONES, R LUBY JONES, ROBT RILEY JORDAN, CHAS EDWARD III JOSOVITZ, MARK KANDALAFT, VICTORIA A KAPLAN, HERMAN JACOB KAPLAN, HYMAN M KASERMAN, FRED B KATTINE, ANTHONY ALBERT KAUFMAN, SETH IAN KEANE, WM SHERMAN KELLY, RONALD CLARK KENDRICK, WILLIAM RILEY KENNEDY, WM ENNIS KERLAN, ROBT ASHLEY KERLEY, HAROLD EUGENE KHATRI, HARESH H KIDD, CHARLES E JR KIDD, JENNIFER KAY KIDWELL, E R JR KILEDJIAN, VARTKES KILLEFFER, JOHN JACOB KIM, HO KYUN KIMBALL, CECIL HARRY KINCAID, WM RALPH KING, JAMES D KINNARD, JENNIFER J KIRBY, CHARLES A KIRK, CLIFFORD C JR KIRKLAND, RONALD H KIRKPATRICK, ROBT DEAN KLEIN, KARL
KLIEFOTH, A BERNHARD III KLINE, GEO LITTON KNICKERBOCKER, FRED RAY KNIGHT, JOS C KNIGHT, WILLIAM H KNOWLING, ROBT EDWARD KOCHTITZKY, OTTO M KOONCE, EDWARD D KRAUS, GORDON JEROME KRAUSE, RICHARD ALAN KRICK, JOSEPH G KRISHNAN, LALITA KROPILAK, MICHAEL D KRUEGER, SYLVIA LYNNE KUSTOFF, RALPH KUYKENDALL, SAM J KYGER, KENT KYLE, CLYDE A JR LABRADOR, DANIEL P JR LADLEY, HERBERT DEROSS LAFONT, DONALD SHARP LAMB, JOHN WM LANE, RICHARD GEOFFREY LANGDON, JAMES A JR
LANGFORD, MICHAEL D LAPIS, JAMES L LARD, JANET KAYE LASKY, RICHARD SAML LASSITER, LAWRENCE H LATOUR, DANA L LATOUR, PAUL A LAW, WILLIAM M SR LAW, WILLIAM M JR LAWRENCE, HARRY M JR LAWRENCE, ROY FINCH LAWRENCE, THOMAS L LAWSON, JOHN FULLER LAY, JOHN DANL LAZAR, RANDE H LAZARUS, STEPHEN M LEAVELL, SANDRA REESE LEDBETTER, BUFORD B LEDBETTER, WILLIAM HENRY LEE, ANTHONY JOEL LEE, ROBT HENRY LEISY, MARILYN LEMINGS, STEPHEN LESTER, THOMAS EDWARD LETT, JAMES C LEVENTHAL, MARVIN R LEVITCH, MELVYN ABRAHAM LEVITT, MICHAEL J LEW, IRA EUGENE LEWIS, ALLEN DAVID LEWIS, MALCOLM R LEWIS, RODGER PATRICK LEWIS, W MICHAEL LEWIS, WILLIAM I LEY, JOSEPH ANTHONY LEYEN, ROBT F LILLY, JAMES AARON LIMBACHER, JOHN P LINDSAY, JACK WASSON LINDSAY, JAMES LINDSEY, CHARLES HUGH LIPSCOMB, ALBERT BRANT JR LIPSCOMB, ALBERT BRANT LITCH, MELVIN JR LITTLE, FRANK B JR JR LITTLE, JAMES P
LITTLE, WILLIAM R JR LIU, CHUNG-YUEN LLOYD, KENNETH MICHAEL LOCKE, JOEL R LONG, DAVID DALE LONG, IRA MORRIS LOUGHEED, JOS C LOVE, VARNA MAE LOVEN, KEITH H LOVVORN, HAROLD N JR LOWE, JERE W LOWE, REGINALD S JR LOWERY, EDWIN RAY JR LOWRY, FRANK H LOWRY, ORLANDA R III LOYD, JAMES ALAN LUBOW, LAWRENCE D LUCKMANN, KENNETH F LYMBERIS, MARVIN LYNCH, EVERETTE G LYNCH, KENNETH CLYDE LYNCH, PENNY BETH MACHIN, JAMES ELLIOTT MACK, JOHN W JR MACKEY, WM FREDERICK MACKLER, DONALD F MADDEN, JAMES JOS JR MAGGART, MICHAEL L MAHAN, BEN BOB MAHESH-KUMAR, A P MAJEED, SHAHUL J MALEY, BRUCE B MANDELL, ALAN I MANI, VENK MANNING, RICHARD 0 MANSON, JAMES EDWARD MANUGIAN, ARSEN MARCELO, BERNARDINO D MARCELO, JOSEFINA Q MARCY, JOHN SAML MARIENCHECK, WM IRVIN MARMON, KENNETH WALDO MARSH, CLARENCE BRUCE
JANUARY, 1990
MARSHALL, MICHAEL RALPH MARTIN, DANIEL C MARTIN, RAYMOND S III MASSINGALE, H LYNN MATHES, WM T JR MATHEWS, CARL LESLIE MATTHEWS, JOHN T MAVES, BARRY V MAYFIELD, RUSSELL W MAYS, KIT SANFORD MAZZOLINI, J MICHAEL MCADOO, MICHAEL A MCALEAVY, JOHN C MCCALL, CHARLES MCCALLEN, PERRY BOIES MCCALLUM, OSCAR M MCCLELLAN, ROBERT E MCCLURE, JAMES G MCCONNELL, CONN M MCCONNELL, DAVID H MCCOY, SUE
MCCOY, WILLIAM JOHN III MCCRAVEY, JOHN WELLS MCCULLOUGH, BILLIE S MCDONALD, CHARLES D JR MCEWAN, ROBERT C JR MCGINNIS, CHARLES W MCGOWAN, LESLIE R MCGOWAN, RONALD L MCILWAIN, WILLIAM A MCINNIS, JOHN CAMERON MCKAY, CHARLES E MCKEE, DAVID EARL MCKENZIE, JEROME F MCKISSICK, WILLIAM R MCKNIGHT, DAVID THOMAS MCLEAN, GEORGE WALLACE MCLEMORE, WAYNE L MCMAHON, CLETUS JOSEPH MCMILLIN, RODNEY M MCMURRAY, JOHN MARK MCMURRY, JOSEPH SEARLE MCNEELEY, HOWARD B MCNEIL, DAVID WYATT MCNEILL, THOMAS PINCKNEY MCNULTY, JOHN STEPHEN MCPEAKE, WILLIAM T MCPHERSON, WARREN F