MARCH 2014 - Donutsdocshare04.docshare.tips/files/21172/211723436.pdf · 2 SOMBRERO – March 2014....

SombreroP i m a C o u n t y M e d i c a l S o c i e t y

Home Medical Society of the 17th United States Surgeon General

M A R C H 2 0 1 4

Medical marijuana mysteries revealed Monitoring pertussis

In Memoriam: Dr. Vernor Lovett

2 SOMBRERO – March 2014

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SOMBRERO – March 2014 3

Official Publication of the Pima County Medical Society Vol. 47 No. 3

PrintingCommercial Printers, Inc.Phone: 623-4775E-mail: [email protected]

PublisherPima County Medical Society5199 E. Farness Dr., Tucson, AZ 85712Phone: (520) 795-7985 Fax: (520) 323-9559Website: pimamedicalsociety.org

EditorStuart FaxonPhone: 883-0408E-mail: [email protected] do not submit PDFs as editorial copy.

Art DirectorAlene Randklev, Commercial Printers, Inc.Phone: 623-4775Fax: 622-8321E-mail: [email protected]

Pima County Medical Society OfficersPresident Timothy Marshall, MDPresident-ElectMelissa Levine, MDVice PresidentSteve Cohen, MDSecretary-TreasurerGuruprasad Raju, MDPast-President Charles Katzenberg, MD

PCMS Board of DirectorsEric Barrett, MDDiana Benenati, MDNeil Clements, MD

Michael Connolly, DOMichael Dean, MDHoward Eisenberg, MDAfshin Emami, MDRandall Fehr, MDAlton Hallum, MDEvan Kligman, MDKevin Moynahan, MDSoheila Nouri, MDWayne Peate, MDScott Weiss, MDLeslie Willingham, MDGustavo Ortega, MD (Resident)Snehal Patel, DO (Resident)Joanna Holstein, DO (Resident)Jeffrey Brown (Student)Jamie Fleming (Student)

Members at Large Donald Green, MDVeronica Pimienta, MD

Board of MediationTimothy Fagan, MDThomas Griffin, MDGeorge Makol, MDMark Mecikalski, MDEdward Schwager, MD

Arizona Medical Association OfficersThomas Rothe, MD presidentMichael F. Hamant, MD secretary

At Large ArMA Board R. Screven Farmer, MD

Pima Directors to ArMATimothy C. Fagan, MDCharles Katzenberg, MD

Delegates to AMAWilliam J. Mangold, MDThomas H. Hicks, MDGary Figge, MD (alternate)

SOMBRERO (ISSN 0279-909X) is published monthly except bimonthly June/July and August/September by the Pima County Medical Society, 5199 E. Farness, Tucson, Ariz. 85712. Annual subscription price is $30. Periodicals paid at Tucson, AZ. POSTMASTER: Send address changes to Pima County Medical Society, 5199 E. Farness Drive, Tucson, Arizona 85712-2134. Opinions expressed are those of the individuals and do not necessarily repre-sent the opinions or policies of the publisher or the PCMS Board of Directors, Executive Officers or the members at large, nor does any product or service advertised carry the endorsement of the society unless expressly stated. Paid advertisements are accepted subject to the approval of the Board of Directors, which retains the right to reject any advertising submitted. Copyright © 2014, Pima County Medical Society. All rights reserved. Reproduction in whole or in part without permission is prohibited.

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Executive DirectorBill FearneyhoughPhone: 795-7985Fax: 323-9559E-mail: billf [email protected]

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5 Milestones: Center for Neurosciences welcomes Dr. Daniel Wee. Dr. Mateja de Leonni-Stanonik chairs Tucson Heart and Stroke Walk.

9 PCMS News: Please send us your e-mail address if you have not yet.

13 In Memoriam: Dr. Vernor F. Lovett dies at 84.

16 Medical Marijuana: Dr. Suzanne Sisley explains what the Arizona Medical Marijuana Acts means to physicians.

18 Public Health: County health department update on pertussis.

19 Valley Fever: Dr. John Galgiani helps The New Yorker explain ‘our disease’ to Easterners.

23 Makol’s Call: Still like medicine despite it all? Reasons to cheer up.

24 Perspective: Our editor holds forth on Arizona’s new judicial decisions basis law.

26 Mayo CME: Coming events from Mayo Clinic Scottsdale.

Inside


Milestones

Dr. de Leonni-Stanonik chairs heart/stroke walkMateja de Leonni-Stanonik, M.D., M.A., Ph.D. of the Center for Neurosciences, former surgeon-general of the Republic of Slovenia, has been appointed to chair the 2014 Tucson Heart and Stroke Walk, Sunday April 6 at Reid Park, the American Heart Association reported.

As chairman, Dr. de Leonni-Stanonik will “lead the charge of bringing the Tucson community together in the fight against heart diseases and stroke,” they said.

“We are pleased that Dr. de Leonni-Stanonik has accepted the challenge to lead our 2014 Heart and Stroke Walk,” said Brittany Starace, heart walk director for AHA and American Stroke Association. “Her wealth of experience and influence as a former surgeon-general, her knowledge of heart diseases and stroke, as well as her passion for the cause, will help elevate our lifesaving message and mission of building healthier lives free of cardiovascular diseases and stroke.”

Starace’s news release said that AHA-funded research has yielded or contributed to innovations such as CPR, life-extending drugs (including clot-busters), pacemakers, bypass surgery, the heart-lung machine, and surgical techniques to repair heart defects.

“People don’t understand how heart disease and stroke compare to other heath causes,” Dr. de Leonni-Stanonik said. “It’s a more significant health threat than anything else faced by our community.”

Dr. de Leonni-Stanonik said she hopes to raise significant funds to meet the event goal of $175,000, which will assist in research and educational programs. “It’s all about bringing the support in from the community. Plus, it’s a wonderful way to spend time with friends, family, and co-workers and do something wonderful at the same time.”

This year’s Heart and Stroke Walk will include a Kids Zone, Heart & Stroke Pavilion, CPP training, food and entertainment, music and interactive activities. For information about the Tucson Heart and Stroke Walk or to register, visit tucsonheartwalk.org or call 520.917.7522.

Dr. de Leonni-Stanonik is originally from the rural mountains of Slovenia close to the border of Austria and Italy. She moved to the U.S. where she graduated with a dual degree in biology/psychology, and German/political science. She received her master’s degree in cognitive psychology in 1999 and her doctorate in cognitive neuroscience in 2002 from the University of Tennessee. She completed medical school at Saba University School of Medicine in 2007 in the Netherlands, and moved to Virginia where in 2008 where she finished her internship at UVA/Carillion Clinic in medicine/psychiatry. She completed her neurology residency at George Washington University. She also

trained in vascular neurology at the Medical University of South Carolina before moving to Tucson in summer 2012.

“Although staying very busy in the world of academia, Dr. de Leonni-Stanonik has also taken time to serve her home and adopted countries,” the AHA release said. “She started in 2003, becoming vice-president of the Slovene World Congress, and in 2004 Consul from Slovenia to the United States.

“In 2009 she was appointed to be the scientific and organizing chair for the Global Health Forum for the Embassy of Slovenia in Washington, D.C. She has led numerous projects in medical and scientific diplomacy as well as cared for several politicians including the late Sen. Ted Kennedy.

“In 2010 she returned home and served as surgeon-general for the Republic of Slovenia and the chief executive for the e-Health and Telemedicine Program of Slovenia, at its Ministry of Health. She has also been involved in various executive leadership positions of the Slovene World Congress which unites all at the Slovenes in the diaspora.

“Providing medical support to rural areas around the world through the use of Telemedicine programs is close to Dr. de Leonni-Stanonik’s heart. In 2006, she served as team physician and co-director of the Amazon Virtual Medical Team, making a trip along the Amazon River to introduce telemedicine to the remotest areas of the Amazon and provide telemedicine equipment and medical supplies to villages.

“From 2007 to 2010 she also served on the Board of Directors for the International Virtual e-Hospital Foundation where she was involved in setting up telemedicine systems in the Balkans and around the world.

“She joined the Center for Neurosciences in December of 2013 as an Adult Neurologist with subspecialty in vascular/stroke neurology, headaches, and pain disorders, as well as neuro-degenerative diseases such as Alzheimer’s and Parkinson’s.

“She said she is extremely excited to be in Southern Arizona, is truly honored to be serving the community, and especially appreciative of the wonderful weather and scenery we all enjoy in here in Tucson.”

Dr. Wee joins Cornea AssociatesDaniel Wee, M.D. has joined Cornea Associates, the practice announced, and he is now accepting appointments.

Dr. Wee, who is fluent in Korean and Spanish, earned his undergraduate degree in biology at Northwestern University, and earned his M.D. at Washington University in St. Louis. Mo.

He completed his internship at St. Francis Hospital in Evanston, Ill., and his

ophthalmology residency at the University of South Carolina where he served as chief resident.

Dr. Wee then completed a cornea fellowship at Tufts New England Eye Center and Ophthalmic Consultants of Boston, where he served as a clinical instructor to the residents.


Dr. Fain honored with endowed chair in medicine

Mindy Fain, M.D, a “widely recognized leader in gerontology,” has been honored with the University of Arizona College of Medicine— Tucson’s Anne and Alden Hart Endowed Chair in Medicine, the university reported.

“Dr. Fain’s many responsibilities with the UA College of Medicine attest to her achievements in advancing healthcare for older adults,” they said.

Dr. Fain is professor of medicine and chief of the Division of Geriatrics, General Internal Medicine and Palliative Medicine in the UA Department of Medicine. She is co-director of the University of Arizona Center on Aging and Arizona Geriatric Education Center. She also is the Arizona Health Sciences Center’s executive director of practice innovation, working with the faculty of the AHSC colleges of medicine, nursing, pharmacy and public health to develop new ways to provide high-quality care at lower costs.

She recently was appointed to the Health Disparities Advisory Council, one of four councils formed by Joe G.N. “Skip” Garcia, M.D., UA senior vice-president for Health Sciences, to advance areas of excellence in health sciences research.

“Mindy Fain truly is one of our superstars,” said Steve Goldschmid, M.D., dean of the UA College of Medicine—Tucson. “Her creative vision, her clinical skills, and her commitment to improving geriatric care at all levels are recognized by her colleagues here and across the country.”

Dr. Fain said she is humbled and delighted by this new honor. “It shows such wonderful support for the work I do. And it’s not what I do, it’s what we do—because I am fortunate to work with so many people who are so outstanding in their work.”

Dr. Fain also is working with an interdisciplinary team to establish an ACE—acute care of elders—unit at UAMC—South Campus, the university reported. A patient’s care team could include, for example, a geriatrician, a nurse practitioner, a pharmacist, a social worker and a physical therapist, all specially trained in geriatric care. She also hopes to create a “virtual” ACE unit at UAMC—University Campus. Patients would be treated in more than one unit of the hospital, but with a similarly integrated care team.

The Anne and Alden Hart Endowed Chair in Medicine was made possible by a gift of real estate to the UA by Anne Hart in memory of her husband, who died in 1967, the year the College of Medicine admitted its first students, the university reported. Alden Hart began working in the telephone industry in 1906 and worked his way up until in 1940 he became president of Kansas-based United Utilities. That company evolved into United Telecommunications and, in the 1980s, became Sprint. Hart retired in 1958 and the couple moved to Tucson in 1959. Before her passing, Anne made the gift, specifying that it be used to benefit the College of Medicine.

Dr. Fain and her husband, infectious disease specialist Richard Mandel, M.D., moved to Tucson from Boston in 1984. Fain signed on for a year with a local HMO before accepting a UA Department

of Medicine position with the Veterans Administration Hospital, now part of the Southern Arizona VA Health Care System.

Her job was to provide home-based primary care—housecalls—to elders. “I rapidly fell in love with geriatrics,” Dr. Fain said. “The synergies between geriatrics and palliative care and the Center on Aging and the other programs are what make it so exciting.”

CofM Dean Steve Goldschmid accepts new clinical practiceSteve Goldschmid, M.D., who has served as dean of the University of Arizona College of Medicine—Tucson since July 2009, has been appointed associate vice- president for clinical affairs at the Arizona Health Sciences Center, the university reported.

“Dr. Goldschmid will begin his new duties March 3 and will report to Joe G.N. “Skip” Garcia, M.D., UA senior vice-president for health sciences, who now also will serve as interim dean of the UA College of Medicine— Tucson.”

In a parallel appointment, Dr. Goldschmid also will serve as vice-president of physician services for The University of Arizona Health Network, they said.

“In his new role Dr. Goldschmid will provide senior leadership in developing clinical practice strategies and opportunities for the UA’s health colleges.” He will collaborate with “AHSC deans, clinical department heads, institute and center directors and The University of Arizona Health Network executive team, providing leadership in AHSC-UAHN efforts to advance clinical practice programs and services. He also will oversee development of clinical affiliation and practice opportunities and manage existing strategic relationships with affiliates, such as the Southern Arizona VA Health Care System.

“In his UAHN role Dr. Goldschmid will serve as a key member of the UAHN executive team, with involvement in health system strategic planning, clinical quality and patient safety, monitoring and accreditation of programs and financial management and oversight. As UAHN’s vice-president of physician services, he will maintain and improve relationships among clinical departments and hospital-based operating units, contributing to the building of multi-disciplinary clinical programs and teams, and will promote professionalism standards among clinical providers and staff.”

Board certified in internal medicine and gastroenterology, Dr. Goldschmid joined the UA College of Medicine—Tucson in 2000, when he was recruited to establish a state-of-the-art gastroenterology service/endoscopy lab. He chaired the UA Department of Medicine from 2006 until July 2008, when he accepted the role of interim dean of the UA College of Medicine—Tucson. Before joining the UA, he served as director of clinical services in gastroenterology at Emory University School of Medicine in Atlanta, Ga.

“In serving as dean for the past five-and-a-half years,” Dr. Goldschmid said, “I gained a deep understanding of just how important the success of the UA Health Network is to the vitality


of the College of Medicine. I’m extremely excited to take on this new role, focusing on efforts to strengthen the performance of our clinical practice in full support of our academic mission.”

Campus honors National Solidarity DayOn Feb. 14 The University of Arizona College of Medicine honored the Fourth Annual National Day of Solidarity for Compassionate Patient Care, the university reported.

National Solidarity Day memorializes the Tucson murders of Jan. 8, 2011. “Across North America and Canada, medical schools and other health care institutions including The University of Arizona College of Medicine, stand in solidarity and undertake projects to pay tribute to all compassionate, patient-centered caregivers,” they said.

“The day is held in honor of the humanistic actions of surgeon Randall Friese, M.D., the first physician to treat Rep. Gabrielle Giffords after she was shot, and other members of The University of Arizona Medical Center—University Campus team in Tucson, who cared for the wounded and dying.”

The event was led by the Gold Humanism Honor Society (GHHS)

chapter at the University of Arizona College of Medicine, Program in Medical Humanities—Tucson, with weeklong activities beforehand. AHSC and UA Medical Center faculty and staff were invited to meet on Feb. 14, 11:45 a.m. to 1 p.m., on the AHSC Plaza just south of the medical school.

Prepatory events included students delivering baskets with information about GHHS Solidarity Day, as well as ribbons, candies and cards to units throughout The University of Arizona Medical Center—University and South Campuses, and readings of poetry and cards from display boards at Java City.

At the Feb. 14 event medical and other health sciences students, faculty and staff, formed a human chain joining hands in a circle to demonstrate standing in solidarity for compassionate patient care. This was followed by speakers from GHHS and others. Banners with the seven attributes of humanism in medicine—integrity, excellence, compassion, altruism, respect, empathy and service—were arranged in a circle and attendees asked to stand near the attribute they most exemplify.

The event concluded with a choral performance by Doc-Apella, a musical group of UA medical students who sing together to help connect with patients and to relieve stress.

Dr. Friese “struck a chord in the international medical community when he told The New York Times that his most important actions that terrible day were ‘holding her hand, speaking to her, and reassuring her that she was in the hospital and would be cared for,’” the university reported.

Dr. Friese took part in the first Tucson observance. “It is a distinct honor to have my small actions contribute to the organization of this event,” he said. “I am pleased that a message of humanism in medicine is being communicated across the state and country.” n

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PCMS News

Members must send PCMS their e-mail addressesAs of this month, the Society transitions to e-mail, a speedier, low-cost means of distributing our bulletin, legislative news and alerts, social announcements, and educational opportunities for physicians and staff.

Other than mailings required by Society bylaws, including Sombrero magazine, ballots, bylaws changes, etc., we are going strictly electronic.

For our physician e-community to work, each member must provide the Society an e-mail address to add to our membership e-distribution list. So, please email your address to Assistant Director Dennis Carey at [email protected]. Once we’ve verified or added your address, you’ll start to receive all our announcements and news via your iPhone, iPad, laptop, or desktop computer.

What do they want, blood? YesIn mid-February United Blood Services of Arizona announced public blood drives through March 31 due to rising needs.

“Arizona hospital patients require more transfusions January through March than during any other time of the year,” they said. “While donors of all blood types are needed, O-negative, the universal blood type, is always in greatest demand. Premature babies, trauma victims, as well as patients suffering from cancer, leukemia and heart disease all receive lifesaving blood transfusions.”

To make an appointment to Find the Hero in You, call 1-877-UBS-HERO (1877.827.4376) or visit www.BloodHero.com and enter your city or ZIP code.

Blood drives remaining on the schedule as of Sombrero publication were Monday March 10, 10 a.m.-2 p.m., Bloodmobile at Intuit, 2800 Commerce Center Place; and Tuesday March 11, 8 a.m.-12 p.m., UofA Campus Rec, 1400 E. 6th St. second floor Room 203.

PCMF CME dinnermeetsPima County Medical Foundation has scheduled these CME events for its Tuesday Evening Speaker series. Dinner is served at 6:30 p.m. and the presentation is at 7.

March 11: Treatments of Obesity presented by Jeffrey Monash, M.D.

April 8: Alzheimers and Other Degenerative Brain Diseases presented by Geoffrey Ahern, M.D. Also at this meeting, Timothy Fagan, M.D., Hector L. Garcia, M.D., and Jane Orient, M.D. will receive the Foundation Award for Lifetime Achievement in the Furtherance of Medical Education.

May 13: Healthcare Update 2014 presented by Timothy Fagan, M.D. Other likely speakers are Marc Leib, M.D. and Bill Mangold, M.D.

June 10: Rheumatoid Arthritis presented by Michael Maricic, M.D.

Sept. 9: Dermal fillers and Fat Stem Cells in Plastic Surgery presented by plastic surgeon Dr. John Pierce.

Oct. 14: New Medical and Surgical Treatments for Prostate Cancer presented by Rick Ahmano, M.D.

Nov. 11: Newer Anticoagulants and Their Role in A-Fib, DVT, and Pulmonary Embolism presented by Tmothy Fagan, M.D.

TMC raffle reduxJust before Sombrero went to composition, the full-color folder for TMC Mega Raffle in support of Tucson Medical Center hit Tucson mailboxes for the second year.

Calling it “the only large-scale raffle in Southern Arizona,” Michael Duran, VP and chief development officer of TMC Foundation, said that “once again, each ticket purchased gives participants a one in 20 chance of winning one of the more than 2,800 spectacular prizes, including a luxury home package, a variety of new cars, amazing dream vacations, and an array of the latest in electronics, jewelry, and home accessories.”

Tickets are $100, with limited multi-packs available at three for $250. For information see TMCmegaraffle.org or call 1800.395.8805.

Society hosts Walk With a Doc

Physicians and patients can benefit from the Just Walk/Walk With A Doc program sponsored by PCMS.

Walk With A Doc is a national non-profit organization, founded by Dr. Dave Sabgir, a board-certified cardiologist in Columbus, Ohio, designed to encourage patients to get more exercise. The Society has hosted Just Walk events since February 2012. It is the only Walk With A Doc program in Arizona.

“I endorse it,” Sombrero Editor Stuart Faxon said. “I don’t take part directly in the program, but when I was heading for 300 pounds as a Type 2 patient—not even for the first time—I had to

Leo Roop registers for the February Walk With A Doc 2.4-mile event at Rillito Park. T-shirts are available for first-time walkers.


do something. So I tried walking one hour per day and talked to my physician about it at the same time. In the last year I’ve lost 28 pounds, and with his approval no longer taking glyburide.” He is still working on it, Faxon said.

Each event begins with a brief presentation from a physician on various healthcare topics. The Arizona Chapter of the American College of Physicians provides physicians who lead the walk and presentation.

Walks are at Rillito Park on the south bank, just east of the Swan Road Bridge. The easy hike covers a 1.2- or 2.4-mile course that includes trails and paved pathways. Walkers are encouraged to interact with the physicians during the walk. The presentation begins at 8 a.m. on the second Saturday of the month. There is a summer break from May through August.

According to the American Heart Association, walking has the lowest dropout rate of any physical activity. The Walk With A Doc program is designed to get people of all ages active and reverse the consequences of a sedentary lifestyle. Walking as little as 30 minutes each day can provide the following benefits:

➢ Reduce risk of coronary heart disease.➢ Improve blood pressure and blood sugar levels.➢ Maintain body weight and lower risk of obesity.➢ Enhance mental well-being.➢ Improve blood lipid profile.➢ Reduce risk of osteoporosis.➢ Reduce risk of breast and colon cancer.➢ Reduce risk of Type 2 diabetes

Walking is low-impact, and easier on the joints than running. It is safe—with a physician’s approval—for people with orthopedic ailments, heart conditions, and those who are more than 20 percent overweight.

Just Walk/Walk With A Doc is free and open to anyone who wants to participate. Walkers are encouraged to arrive a few minutes before the event starts to register.

Physicians and walkers enjoyed the Tucson scenery and weather as part of the benefits of Walk With A Doc. Taking part were Andrew Kovoor, M.D., a resident at the University of Arizona, who led the presentation on causes and the prevention of strokes. Neurologist Nancy Bello, M.D. and Santhosh Gheevarghese-John, M.D., assisted in answering questions.

MRC Nursing Task Force at workThe Medical Rsrserve Corps of Southern Arizona’s Nursing Task Force is at work on creating a realistic disaster scenario for Arizona, reports MRC Secretary-Treasurer Steve Nash.

“It takes work,” he said, “but a statewide exercise last November posed a resource stumper: after an unusually heavy monsoon—right in the middle of summer—most of the Western power grid goes down. And it stays down for weeks. Not only do the lights not work, but ATMs are down, backup generators in hospitals run out of fuel, and there is no electricity to pump replacement fuel.”

While stakeholders wrestled with this scenario in the Pima County Emergency Operations Center, the Nursing Task Force of the MRC teamed up with nurses from the Pima County Health Department to address the functional and access needs of community members who use durable medical equipment, who are at huge risk when the power goes out. A framework for a plan was developed and tasks assigned.

In January the nurses met again, Nash said. The group decided to organize a community forum to have more comprehensive input and collaboration that would result in a more workable plan. Details about the forum will be shared with Sombrero when they emerge.

Study: Aggressive brain-wound management increases survival significantlyNine out of 10 people with gunshot wounds to the brain usually die. University of Arizona trauma surgeons, using a new aggressive resuscitation protocol for patients with gunshot head injuries, have increased survival to nearly five out of 10 victims, according to a recent study published in The American Journal of Surgery, The University of Arizona reported.

Gunshot wounds to the brain are the most lethal of firearm injuries, with survival rates of 10 percent to 15 percent. Because of the high mortality rate, aggressive management often is withheld from the most severely injured patients with low outcome scores, said Bellal Joseph, M.D., UA assistant professor of surgery and the study’s lead author.

However, military reports on the use of aggressive operative procedures for gunshot wounds to the brain have shown higher survival rates, Dr. Joseph said. Peter M. Rhee, M.D., professor and chief of the UA Division of Trauma, Critical Care, Burn and Emergency Surgery, and the study’s senior author, used this aggressive management protocol while serving as a military trauma surgeon in Iraq and Afghanistan. Drawing from these reports and Dr. Rhee’s experience, UA researchers at The University of Arizona Medical Center Level I Trauma Center began aggressively resuscitating all patients with gunshot wounds to the brain in 2008.

Irrespective of how they scored on the Glasgow Coma Scale (a neurological scale used to measure levels of consciousness in a


person following a brain injury), 132 patients with gunshot wounds to the brain received an aggressive management protocol. The protocol included blood products and hyperosmolar therapy to reduce intercranial pressure, thereby promoting long-term survival and recovery.

“After starting the new resuscitation methods, the survival rates started to improve immediately. There was an increase year after year and during the last year of the study 46 percent of those patients survived,” Dr. Joseph said.

Results of the five-year, single-site study also showed the adoption of aggressive management of gunshot wounds to the brain aided in the preservation of organs in non-survivors, increasing the number of organs procured per donor from 1.3 percent to 2.8 percent.

Dr. Rhee said, “Aggressive management is associated with significant improvement in survival and organ procurement in patients with gunshot wounds to the brain. Low outcome scores and the bias of resource use can no longer be used to preclude trauma surgeons from abandoning aggressive attempts to save these patients.”

Study authors acknowledged that an increase in survival and organ donation poses some ethical issues. While some patients had good neurologic outcomes, some were discharged in a vegetative state or in comas. Without long-term functional results, it is difficult to know long-term outcomes of survivors.

This study, funded by the UA Department of Surgery, is one of a number of research efforts by trauma surgeons at the UA Department of Surgery Division of Trauma, Critical Care, Burn and Emergency Surgery. Faculty, fellows and residents in the trauma division have published more than 35 peer-reviewed articles and book chapters this year alone, surpassing any previous year at the UA. Most level I trauma institutions have three or four research articles published annually.

“Trauma research is really important,” Dr. Rhee said. “The successful recovery of Rep. Giffords is an example of the benefit of evidence-based treatments for the management of patients with gunshot wounds to the brain. We can impact one person at a time in the hospital, but trauma research impacts millions.”

TMC collaborates for health insurance infoBy Tucson Medical Center“Healthcare I can afford? Where can I sign up?”

Southern Arizona residents looking for information on health insurance are getting guidance from major local health care providers and other concerned organizations.

An awareness campaign should make it easier for folks to get connected with their insurance options, in light of the reinstatement of AHCCCS in Arizona, and the deadline approaching for the federal healthcare marketplace on March 31.

TMC is supporting the collaborative effort, along with other sponsors including University of Arizona Medical Center, Carondelet Health Network, Northwest Healthcare, Sinfonia HealthCare Corporation, Blue Cross Blue Shield of Arizona, and Tucson Regional Economic Opportunities, Inc. (TREO).

“This is the first time the major healthcare systems have come together for the common good and health of our citizens,” said Fletcher McCusker, CEO of Sinfonia HealthCare Corp. and Chairman of the TREO Blueprint Update Healthcare Committee. “We have many assets to position us to be a healthier region in the long run.”

“Our certified application counselors have been helping individuals navigate insurance enrollment since November,” said Judy Rich, TMC president & CEO. “We have seen the appreciation and gratitude expressed when they have secured insurance coverage for their family—sometimes for the first time in years. Our opportunity with this effort is to expand the understanding even further about the advantages provided by medical insurance.”

Thanks to this group of regional collaborators, those without insurance have new access to information—as outlined in advertising, person-to-person outreach, and the new website, www.soazcares.org. n


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Dr. Vernor F. Lovett 1929-2013

In Memoriam

By Stuart Faxon

Vernor F. Lovett, M.D., F.A.C.S., general and vascular surgeon who joined PCMS in 1966, died peacefully Jan. 20 at his

home in Tucson. He was 84. He had been an Associate Member since his retirement in 1990.

“He really was one of the good guys,” recalled Dr. Dick Dale. “He was loved by all.”

Dr. Robert Hastings, 1978 PCMS president, recalled “Vern” from both Tucson High School and Northwestern University Medical School. “He was a star on the [Tucson High] football team and on other teams,” Dr. Hastings said. “He was a great man, and a good friend.” He noted that as medical office manager of Southwestern Surgery Associates, Dr. Lovett guided all the practice’s economic decisions.

From 1922 to 1960 Dr. Lovett’s family ran Hillcrest, a TB sanatorium at North Third Avenue and Adams Street in Tucson, and he and Sarah Lovett Chatlos described that history in these pages in December 2004. It accommodated up to 28 patients, most of whom had tuberculosis. “Many of Tucson’s physicians came here in the 1920s and ’30s because they had active TB,” the authors said. They noted that at various points between 1900 and 1927, Tucson had up to nine sanatoria.

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Vernor Floyd Lovett was born April 5, 1929 in Tucson and was “proud to be a native of Tucson,” his family told the Arizona Daily Star. He graduated from Tucson High School in 1947.

He earned his undergraduate degree at the University of Arizona in 1951 and was a member of Kappa Sigma Fraternity. He went on to Northwestern University (Evanston, Ill.) Medical School, earning his M.D. in 1955. He interned at the U.S. Army Medical Service’s Letterman Army Hospital in San Francisco, and did his GS residency at Baylor University Medical Center, Dallas, Texas.

Dr. Lovett served in the U.S. Air Force for 11 years as a surgeon: as chief of general surgery at USAF Hospital Travis 1960-63, and chief of surgery and deupty commander of Evereux AFB Hospital 1963-66. He held the rank of major when he received an honorable discharge and in 1966 returned to Tucson, where he opened his GS practice office on North Country Club Road. By 1968 he had sub-specialized in vascular surgery and moved his office to North Wilmot Road. That year he associated with doctors Duncan Campbell, Donald Ewing and Mark Kartchner in Southwestern Surgery Associates, Ltd.

Dr. Lovett was “active in various communities, serving as president of the Rocky Mountain Vascular Society, and CEO of his medical group,” the family said. “He served as a founding member of MICA, as president of Sunrise Ridge Homeowner’s Association, and on the board of the White Mountain Summer Homes. Vernor loved traveling, fishing, skiing, family gatherings, and researching genealogy. He was known as ‘Reunion Man’ by his wife for the Tucson High Reunion class of 1947.”

Dr. Lovett taught in THMEP and at the UofA College of Medicine.


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He was a member of the AMA and the Arizona Medical Association, a Fellow of the American College of Surgeons, and a member of the Society of Air Force Clinical Surgeons. He was a member of St. Mark’s Presbyterian Church. He was certified by the American Board of Surgery.

In 1970 he began a three-year term as PCMS delegate to ArMA. He also served as an ArMA Southern District director 1972-77. He participated in PCMS’s radio program Prescription for Health. In retirement he served on the board of P.C.M.S. Foundation, Inc., now known as Pima Medical Foundation.

His wife of 60 years, Barbara Lent Lovett; sons Jim and Richard; daughters Patricia and Susan; and grandchildren Matthew Dyer, Sarah Dyer, Jim Lovett Jr., Brian, and Marissa Lovett survive him.

A memorial Service was given Feb. 8 at Northminster Presbyterian Church on East Fort Lowell Road. The family requests that memorial donations be made in his name to Gospel Rescue Mission, 707 W. Miracle Mile, Tucson 85705, or to a charity of the donor’s choice. n

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J O H N D . L E V I N , C L U 6 0 1 1 E . G R A N T R D . T U C S O N , A Z 8 5 7 1 2

5 2 0 . 7 5 1 . 2 0 0 0 J O H N @ W M S A S S O C I A T E S . C O M

W W W . W M S T R A T . C O M

D I S A B I L I T Y L I M I T S O N T H E R I S E YOU EXAMINE YOUR PATIENTS’ EVERY DAY, OFTEN DISCOVERING RISKS NOT OUTWARDLY APPARENT. BUT HOW OFTEN DO YOU EXAMINE YOUR OWN RISKS? IT MIGHT BE TIME TO TAKE A CLOSER LOOK.

P i m a C o u n t y M e d i c a l S o c i e t y a n d W e a l t h M a n a g e m e n t S t r a t e g i e s a r e p r o u d t o o ff e r m e m b e r s a n e w d i s a b i l i t y i n c o m e i n s u r a n c e p l a n . T h i s e x c i ti n g p l a n o ff e r s d e e p l y d i s c o u n t e d i n d i v i d u a l a n d b u s i n e s s d i s a b i l i t y p l a n s , a n d u n l i k e m a n y p l a n s , t h e s a m e l o w p r i c i n g a p p l i e s t o b o t h m e n a n d w o m e n . D e p e n d i n g o n y o u r n e e d s , y o u c a n c h o o s e a p l a n o r c o m b i n a ti o n o f p l a n s t h a t c a n h e l p y o u : � P r o t e c t y o u r i n c o m e i f y o u a r e u n a b l e t o w o r k , o r u n a b l e t o r e t u r n t o y o u r f u l l d u t i e s � C o n ti n u e r e ti r e m e n t c o n t r i b u ti o n s o n y o u r b e h a l f � C o v e r b u s i n e s s e x p e n s e s � P r o t e c t a n y b u s i n e s s p a r t n e r s � P r o t e c t y o u r r e v e n u e i f a k e y e m p l o y e e i s d i s a b l e d

Associates of Wealth Management Strategies offer securities through AXA Advisors, LLC (NY, NY 212-314-4600), member FINRA, SIPC. Investment advisory products and services offered through AXA Advisors, LLC, an investment advisor registered with the SEC. Annuity and insurance products offered though AXA Network, LLC. Wealth Management Strategies is not a registered investment advisor and is not owned or operated by AXA Advisors or AXA Network. AXA Advisors and AXA Network are not affiliated with Pima County Medical Society. PPG 69384 (07/12)

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5 2 0 . 7 5 1 . 2 0 0 0 J O H N @ W M S A S S O C I A T E S . C O M

W W W . W M S T R A T . C O M

D I S A B I L I T Y L I M I T S O N T H E R I S E YOU EXAMINE YOUR PATIENTS’ EVERY DAY, OFTEN DISCOVERING RISKS NOT OUTWARDLY APPARENT. BUT HOW OFTEN DO YOU EXAMINE YOUR OWN RISKS? IT MIGHT BE TIME TO TAKE A CLOSER LOOK.

P i m a C o u n t y M e d i c a l S o c i e t y a n d W e a l t h M a n a g e m e n t S t r a t e g i e s a r e p r o u d t o o ff e r m e m b e r s a n e w d i s a b i l i t y i n c o m e i n s u r a n c e p l a n . T h i s e x c i ti n g p l a n o ff e r s d e e p l y d i s c o u n t e d i n d i v i d u a l a n d b u s i n e s s d i s a b i l i t y p l a n s , a n d u n l i k e m a n y p l a n s , t h e s a m e l o w p r i c i n g a p p l i e s t o b o t h m e n a n d w o m e n . D e p e n d i n g o n y o u r n e e d s , y o u c a n c h o o s e a p l a n o r c o m b i n a ti o n o f p l a n s t h a t c a n h e l p y o u : � P r o t e c t y o u r i n c o m e i f y o u a r e u n a b l e t o w o r k , o r u n a b l e t o r e t u r n t o y o u r f u l l d u t i e s � C o n ti n u e r e ti r e m e n t c o n t r i b u ti o n s o n y o u r b e h a l f � C o v e r b u s i n e s s e x p e n s e s � P r o t e c t a n y b u s i n e s s p a r t n e r s � P r o t e c t y o u r r e v e n u e i f a k e y e m p l o y e e i s d i s a b l e d

Associates of Wealth Management Strategies offer securities through AXA Advisors, LLC (NY, NY 212-314-4600), member FINRA, SIPC. Investment advisory products and services offered through AXA Advisors, LLC, an investment advisor registered with the SEC. Annuity and insurance products offered though AXA Network, LLC. Wealth Management Strategies is not a registered investment advisor and is not owned or operated by AXA Advisors or AXA Network. AXA Advisors and AXA Network are not affiliated with Pima County Medical Society. PPG 69384 (07/12)


The cannabis conundrumBy Stuart Faxon

Medical Marijuana

It’s illegal. Or is it? It’s recreational. It’s medicinal. Or is it?

All marijuana areas seem to have become gray since legal, medical, and political climate change over the drug wafts over us like, well, smoke. Even smoke is not the only question in marijuana as medicine, but at least we can say no brownies were served on Feb. 11 at PCMS.

Questions abounded among the physicians attending Pima County Medical Foundation’s CME presentation by Suzanne A. Sisley, M.D., a Scottsdale IM and psychiatry physician who is assistant director of interprofessional education with the Arizona Telemedicine Program.

For this CME, she presented the Arizona Medical Marijuana Physicians Education Program, meant to educate physicians about the tenets of Arizona medical marijuana law. The program is supported through a contract with the Arizona Department of Health Services Medical Marijuana Program.

Dr. Sisley herself illustrates the changing climate, because while she is principal investigator for “a couple of research projects,” she said she’s still waiting for those to kick in because the government agency has not supplied the actual material. Could this be

because the federal agency in question is dealing with a drug still considered illegal by the federal government itself? So as not to waste time as efficiently as the feds do, Dr. Sisley has used it to become expert in Arizona medical marijuana law.

Only two states, Colorado and Washington, have legalized marijuana. About 20 states now allow medicinal use of the drug. “In Arizona,” Dr. Sisley said, “ADHS wants to make it as medical as possible.” Our law:➢ Requires registry identification cards.➢ Limits the number of dispensaries.➢ Has the support of varous medical boards.➢ Includes several requirements for

physicians who may provide qualifying patients with written certifications.

➢ Requires dispensaries to appoint an individual who is a physician to fuction as medical director.

➢ Requires dispensaries to develop, document, and implement policies and procedures for inventory control.

“Our law limits the number of dispensaries to 120 statewide,” Dr. Sisley said. “Currently we have 77.”

Even AMA ethics guidelines conflict about prescribing majijuana. So what patients qualify? In Arizona the qualifying conditions are:➢ Cancer➢ ALS—Amyotrophic Lateral Sclerosis➢ HIV➢ AIDS➢ Glaucoma

At PCMS Feb. 11, Dr. Suzanne Sisley explained the Arizona Medical Marijuana Act in a CME presentation for Pima County Medical Foundation.


➢ Crohn’s disease➢ Agitation of Alzheimer’s disease➢ Hepatitis C

But that’s really not all. Also included are debilitating diseases or medical conditions—or their treatments—that cause cachexia or wasting syndrome, severe and chronic pain, severe nausea, seizures, and severe or persistent muscle spasms. If a physician checks only one of these conditions, the physician must write in the underlying medical condition on the form.

In addition, a qualifying condition may be a debilitating or medical condition or treatment approved by ADHS under Arizona Revised Statues 36-2801.01, and A.A.C. R9-17-106, and ADHS may add new qualifying diagnoses.

After public hearings, ADHS denied as qualifying conditions PTSD, migraines, generalized anxiety disorder, and depression. “There were several more conditions ADHS received throughout the last two years that did not make it to a public hearing (for various reasons),” Dr. Sisley’s presentation noted.

ADHS accepts petitions to add to the list of debilitating conditions every January and July. A petitioner must submit contact information, name of the medical condition, description of symptoms, availability of conventional medical treatments, summary of evidence that medical marijuana will provide benefit, and peer-reviewed, scientific journal articles reporting results of research on medical marijuana benefits specific to the condition.

In order to be eligible for a card, the patient must have a written certification from a physician confirming diagnosis of a qualifying medical condition. But it may not be only an M.D. or D.O.; it may also be a naturopathic physician or a homeopathic physician.

If the patient is under 18 the situation becomes grayer still. Yes, two separate physicians must provide certification. But then parents or legal guardians must become caregivers and attest to assisting a minor patient with medical use; allowing the minor to use the marijuana; not diverting the drug to anyone not allowed to possess it; and not have been convicted of an excluded felony offense.

Dr. Sisley noted that the AMMA has a strict confidentiality statute, and ADHS cannot disclose information ao anyone about applications, cardholder names, physical addresses of dispensaries, or physicians who certify. But ADHS must disclose the names and locations of dispensaries to qualifying patients.

ADHS can also notify a physician’s licensing board if it believes a physician has committed an act of unprofessional conduct for failing to comply with program requirements. Still, ADHS neither sanctions nor has authority over physicians, so no state medical or osteopathic board authority changes.

“Every six months ADHA works with the Arizona Board of Pharmacy to examine the frequency of physician medical marijuana certifications relative to the frequency of checking the Controlled Substance Rx Monitoring Program Database. If the number of certifications exceeds the humber of times the physician has checked the database. ADHS will inform that physician’s licensing board for fllow-up or appropriate lcensing-related action. This could possibly result in licensing violations and actions taken against the physician’s license by his or her board.”

All this seems to ask, what exactly is the physician’s responsibility here? Examine the patient! Let us hope that’s nothing new. But the standard protocol is:➢ Request the patient’s previous medical records prior to

booking the appointment.➢ Examine the patient.➢ Establish a medical record.➢ Review the patient’s previous medical records➢ Make or confirm the diagnosis.➢ Discuss risks and benefits of medical use of marijuana.➢ Check the (qualified) patient’s profile in the Controlled

Substance Rx Monitoring Program Satabase.➢ Complete and sign the Physician Certification form.➢ Give the form to the (qualified) patient to submit diagnosis

to ADHS.

Presumably you have discussed alternative treatments to medical marijuana, and checked about other controlled drugs the patient is on.

For the physician serving as dispensary medical director, he or she must be on site or available by phone during dispensing hours, and if absent, he or she must appoint another physician to cover as medical director for that time. Medical directors are barred from providing written certifications for medical marijuana for any qualifying patient.

The medical direcor must provide training to dispensary agents every year about recognizing signs and symptoms of abuse; guidelines for refusing service if the individual is impaired; and providing information to Qualifying Patients on benefits, risks, side-effects, etc. The medical director must develop educational materials for Qualifying Patients and caregiver, including developing a system to help QPs track symptoms, marijuana usage and side-effects, and information on potential drug-to-drug interactions.

A complication for physicins in dosing is that tinctures of the drug are not allowed in Arizona, Dr. Sisley said.

Byzantine though it may be, the Arizona Medical Marijuana Act still has traditional limitations, barring possessing or engaging in medical use of marijuana on a school bus, on the grounds of any pre-school, primary, or secondary school, or in any correctional facility—all where we never wanted the drug to be anyway.

“Our citizenry created this system at the ballot box,” Dr. Sisley said, “so there is not a lot of data behind it.” She noted that in effect, we have been letting our citizens make diagnostic categories. n

StatisticsAs of late last year, ADHS reported that there were about 42,400 active individual qualifying medical marijuana patients, 533 active individual caregivers, and about 50 patients who were minors.

The highest numbers of applicants were aged 18-30, 31-40, and 51-60, totaling about 65 percent.


Public Health

Help deal with pertussis increaseBy Anissa Taylor

In the past year Pima County experienced a significant increase in pertussis cases. There were 97 cases of confirmed and

probable pertussis reported in Pima County for 2013, compared to 46 confirmed and probable cases in 2012.

Year-to-date cases for January 2014 show there are seven confirmed and probable cases. The 2013 case investigations revealed that the majority of cases have occurred in those younger than 19 years old.

Our investigations at the Pima County Health Department determined the cases that had history of pertussis containing vaccine tended to have a shorter duration of cough. These cases also experienced a less severe course of illness than those without a history of pertussis containing vaccines.

The steady increase in reported cases over the years parallels the increases seen in Arizona and across the nation. This may be due to a combination of increased vaccine refusal, lower vaccination rates, and a less-than-desired length of post-vaccination immunity. PCHD’s epidemiologists continue to track and characterize the changing incidence of pertussis in the community.

We encourage notification to our epidemiology office, and testing and treatment when pertussis is suspected. Recommended testing includes a Polymerase Chain Reaction test (PCR) or culture. These are the only tests acceptable for “confirming” a case of pertussis.

The specimen should be obtained either by aspiration or with Dacron swabs (cotton, rayon or calcium alginate swabs should not be used), collected within three weeks of the onset of

symptoms, and prior to antibiotic use. Testing should not be done if symptoms are not present. It is unlikely that the organism will be recovered through testing if no symptoms are present.

Specimens must be placed into universal transport media for PCR and Regan-Lowe media for culture. Clinicians should consult with their contracted laboratory for the media. If culture or PCR is not available through your contracted lab, the Arizona State Laboratory may be able to assist in testing on a case-by-case

basis. Do not delay either treatment or reporting to the health department while waiting for laboratory results.

For treatment or chemoprophylaxis, the antimicrobial agents of choice are azithromycin, clarithromycin and erythromycin. Exposed household members are considered close contacts and should be offered chemoprophylaxis. Administer a course of chemoprophylaxis to close contacts within three weeks of exposure. Close contacts are administered the same doses as in the treatment schedule. Please remind cases to remain home until treatment completed.

Clinicians should consider “cocooning” newborns by boosting all adults and adolescents in your practice who may come into contact them. We also recommend that you take steps to assure your staff received a booster for pertussis, particularly if there are infants in your practice.

Please do your part to assure that levels of circulating pertussis remain as low as possible in our community.

Anissa Taylor is an epidemiologist with the Pima County Health Department. n

Algorithm for Pertussis Laboratory Testing (Cough Illnesses)

Typical characteristics of pertussis include a worsening coughin a non-toxic and afebrile patient.

In addition to cough, does the patient report having any paroysms, whoop, or episodes of post-tussive vomiting?

Notify the local health department immediately. Pertussis should be suspected. Please add a nasopharyngeal swab for pertussis testing* (Culture and/or PCR) in addition to other clinically indicated tests. Negative lab results should not rule out a diagnosis of pertussis.

Notify the local health department immediately. Pertussis should be suspected. Please add a nasopharyngeal swab for pertussis testing* (Culture and/or PCR) in addition to other clinically indicated tests.

Was the patient a close contact to another case of pertussis?

Continue to monitor patient. Clinical judgment should be used to determine appropriate testing* and interventions. If pertussis is suspected, notify the local health department immediately.

Yes

Yes

No

No

*Serologic testing is not the preferred method of testing for pertussis.Updated 3/1/2011


Valley Fever

Dr. Galgiani, cocci go-toBy Stuart Faxon

When Dana Goodyear, staff writer for The New Yorker, wanted to become familiar with valley fever, she was

quickly pointed to Tucson, Dr. John Galgiani, and the Valley Fever Center for Excellence at the University of Arizona, of which he is director.

“It’s our disease,” Dr. Galgiani has said. Two-thirds of the nation’s cases happen here, and it was the second-most reported Arizona disease in 2012. This Sombrero department is usually authored by Dr. Galgiani. But New Yorker readers pay little attention to Arizona once the highway leads away from Scottsdale. Say “California,” however, and they look up from their lattes. Hyper-population makes New York and California the bread of the American geographical sandwich, and the rest of us the meat.

So in the Jan. 20 New Yorker, the story’s hyperbolic headline was Death Dust—The Valley Fever Menace, and began with Central California in 1977, when a 5,000-foot dust cloud “blotted out the sun” as it blew from the Great Basin through the Tehachapi Mountains, Goodyear wrote.

Coccidioidomycosis—“cocci” to docs and valley fever to lay folks—is hardly about to come stalking Manhattanites, but the 1977 incident was deadly to the extent of six deaths and more than 100 cases in Sacramento County, Goodyear reported. “In the previous 20 years there had never been more than half a dozen cases a year.”

But mainly the story was a report to readers who have never heard of “our” disease, that has no preventive vaccine, and in its worst cases, no cure. “The population of Phoenix has grown by 10 percent in the past decade and newcomer have no acquired immunity,” Goodyear reported. “The elderly and the immune-compromised, including pregnant women, are most susceptible” and for reasons unkonwn “otherwise healthy African-Americans and Filipinos are disproportionately vulnerable to severe and life-threatening forms of the disease,”

she reported. But she added that one specialist told her that “if you breathe, and you’re warm-blooded, you can get this.”

Microscopic Coccidioides immitis spores live in soil and break up easily when disturbed, such as by housing and business development. When we breathe the spores in, we can’t breath

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them out, Goodyear was told, as they are small enough to reach the bronchioles at the bottom of our lungs.

“Once in the lung, the spore circles up into a spherule, defined by a chitinous cell wall and filled with a hundred or so baby endospores. When the spherule is sufficiently full, it ruptures, releasing the endospores and stimulating an acute inflammatory response that disrupts blood flow to the tissue and can lead to necrosis. The endospores, each of which will become a new spherule, travel through the blood and lymph systems, allowing the cocci to spread” anywhere.

Cocci is notorious for being sneaky. In a typical scenario, an Eastern person will return home from the desert Southwest and go to his or her physician complaining of fever, cough, and exhaustion as if it were flu. The unsuspecting Eastern physician will proceed to miss the true diagnosis, and that’s just in patients with symptoms, because 60 percent of cocci victims are asymptomatic.

“In recent years,” Goodyear reported, cocci “infections have risen dramatically. According to the CDC, from 1998 to 2011 there was a tenfold increase in reported cases. Officials there call it a ‘silent epidemic’” that is “far more destructive than had been previously recognized.

“Its circumscribed range has made it easy for policymakers to ignore. Thogh it sickens many more people than West Nile virus, which affects much of the country”—and is closely monitored by the Pima and Maricopa county health departments—“it has received only a small fraction of the funding for research.”

“The impact of Valley Fever on its endemic populations is equal to the impact of polio or chickenpox before the vaccines,” Dr. Galgiani told Goodyear. “But chickenpox and polio were worldwide.”

“Fluconazole, the medicine most commonly prescribed to cocci patients, can cost up to $3,000 a month, and doesn’t destroy the fungus but mnerely keeps it in check,” Goodyear reported. “At the University of Arizona in Tucson, John Galgiani is attempting to develop a drug that will actually kill it. Trim and avid—a youngster, at 67—Galgiani is a partner in a company that is trying to ready a molecular byproduct of the bacteria streptomyces, called nikkomycin Z, for the marketplace. It works by destroying the spherule’s ability to make chitin, which forms the protective wall” without which the disease stalls.

“Nikkomycin Z was discovered in the 1970s and is still several years and millions of dollars away from being available,” Goodyear reported. “A corporate partner could accelerate” it, “but as long as VF is perceived as a regional disease, the market will likely seem too small” for attention of Big Pharma.

“We sometimes talk about wishing a President or former President would get cocci,” Dr. Galgiani told Goodyear, who noted that for now, the most likely source of a celebrity case is Major League Baseball, in which thousands of players annually Spring-train in Arizona.

Unfortunately, cocci is another consideration that has come with international jihadist and other terrorism. “Until last year,” Goodyear reported, “C. immitis was listed as a Select Agent. After culturing it, lab technicians had seven days to report to the Department of Homeland Security that it had been destroyed.”

Dr. Galgiani led Goodyear on a visit to the UofA’s Bio Safety 3 lab, where he and others deal with hazardous pathogens such as cocci. “In the 1950s,” he said, “both the U.S. and the Russians had bio-warfare programs using cocci. Generals can’t control agents that rely on air current to disperse them, and it was difficult to use the vector precisely, so it fell out of favor. But terrorists don’t care about that stuff—all they care about is perception. A single call can cause disease, and you can genetically modify it to make it more powerful.”

Back in daily medical practice world, several studies have indicated that 15-30 percent of community-acquired pneumonia in the hyper-endemic population centers of Southern Arizona is caused by cocci. In 2007 the Arizona Department of Health Services recommended that all patients presenting with community-acquired pneumonia in these areas be tested for cocci.

The University of Arizona Valley Fever Center for Excellence provides free continuing medical education (CME) on cocci. The CME is available online at the VFCE website. A CME event is given each year, usually in Fall, in Tucson or Phoenix. This event is held in conjunction with the annual Valley Fever Awareness Week. Please check the center’s webpage for updated information. A recorded version of the CME is also available in Spanish. n

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Makol’s Call

Type A-PositiveBy Dr. George J. Makol

Is it just my impression, or are doctors becoming

pessimistic?

It would be hard to blame any medical doctor who feels that way, considering the changes in insurance, lowered reimbursement for more work, and interference in patient management by medically uneducated bureaucrats.

On the contrary, my feelings about the practice of medicine, having participated in it for

about 35 years, are still amazingly positive. We doctors are still afforded great respect, and looking back, I have enjoyed many a moment taking care of patients and some moments not directly related to patient care.

During my med school and postgrad training in the 1970s, I volunteered with a group called “Switchboard of Miami.” We were a group of doctors, nurses, and paramedics that served at all Orange Bowl games, including at that time games played by the World Champion Miami Dolphins, who at one point had 17 wins and no losses. I was able to see quite a bit of each game, except when predictably, one of the 50,000 cheering fans would have a heart attack right in the middle of the third quarter or so (perhaps they just realized how much they had paid for a playoff game ticket). Then we were called into action.

The switchboard also served at most of the big concerts, so I was backstage at some of the most historic ’70s rock concerts. On Aug. 4, 1974, I worked the Eric Clapton concert at the West Palm Beach Raceway. We had a huge medical tent behind the stage, and we treated about 160 fans for various drug-related symptoms—some obviously believed it was still the 1960s—and evacuated by air one pregnant fan who went into labor. She was not about to miss this concert for anything! Near the end of the prepared set, my fellow docs, knowing I was a rock’n’roll fan, told me to climb up on stage and watch the show with the roadies, hidden behind the stage’s side curtains.

I was perhaps 20 feet from Eric Clapton, and I asked the roadie next to me who were the funny looking guys backing him up. He replied, “Are you kidding? That is Peter Townshend of the Who on guitar, and Keith Moon of the Who on drums.” Needless to say, I was in rock’n’roll heaven for the next 45 minutes while they jammed “Layla,” a song written by Clapton for George Harrison’s wife Patty, who he later married.

Then the “roadie” sitting right next to me asked me to pass him the Fender Stratocaster in the stand behind me. He ran onstage, plugged into Eric Clapton’s amplifier, and began to jam. I turned again to the guy on my right, who by now thought I was from

some other planet, and he replied before I could ask “That’s Joe Walsh from the Eagles”! For those of you from another generation, this was like being in the orchestra pit while Frank Sinatra sang with the Tommy Dorsey band.

I later moved to Tucson for my allergy/immunology fellowship, much to the dismay of my family who were still in Miami. I used to commute back and forth for the Christmas holiday, and in my first year away, I showed up at TIA around Dec. 20 to fly to Miami. The distinguished older gentleman at the counter checked me in, and asked if I was Dr. Makol the allergy specialist. I replied that I was, and he asked me if I had ever flown First Class. I had once sat just behind the driver on a Greyhound bus, but on a training salary flying First Class was not an option. He commented that I took care of his granddaughter, and that I had her previously uncontrolled asthma under control, and she no longer had to go to the ER. Next thing I knew, I was in a comfy leather seat, being attended by a lovely stewardess (now to gender-specific a term) and eating off real china.

I for years have consulted with the University of Arizona athletic medical staff, and have worked with some incredible and motivated athletes. Hence, a few weeks ago my wife and I were invited to a private showing and cocktails at the new $75 million Lowell-Stevens football training facility. I found myself rubbing elbows with major donors and discussing their thoroughbred horse purchases and private workouts with the team. Luckily, no one asked me about my end-zone seats!

Years before I had worked with a UofA basketball player with asthma. He was playing about five minutes a game, and then raising his hand so Coach Lute Olson could pull him out. He came in to see me with a trainer and in a couple of visits we had him ready to play in a big interconference game. Famed sportscaster Dick Vitale was giving his usual colorful comments during the nationally televised contest, and I was watching TV with my extended family as my patient played for 25 minutes and scored 25 points.

Vitale commented after our player scored a spectacular dunk, “Hey baby, I heard this guy has a new doctor, and wow, can he play now! Thanks, Doc.” Everyone in the room cheered, although no one else in the country had the faintest idea what Dick Vitale was talking about. But it did not matter to me. I had just done my job like each of you does every day.

So maybe reimbursements could be better, and insurance companies temporarily rule the roost, but we are still afforded respect by our fellow citizens, and sometimes get special treatment, even if it is just getting a great table and service in a restaurant owned by one of our patients.

Cheer up!—and let us know your stories.

Sombrero columnist George J. Makol, M.D. practices with Alvernon Allergy and Asthma, 2902 E. Grant Rd., and has been a PCMS member since 1980. n


Perspec�ve

Is fear really our protection?By Stuart Faxon

The essentially silly idea among some hard-Left locals to create the 51st American state, called Baja Arizona, by seceding from the rest of the 49th state, is still the plainest example of the historic divide between the Arizona political Left and Right, between Pima County and Maricopa County, between Tucson and Phoenix.

“Baja Arizona” is still on bumperstickers around here. I saw another that said, “I’d rather live in denial than live in Phoenix.”

I always tell non-Arizonans that Tucson is to Arizona as Austin is to Texas, or Madison is to other parts of Wisconsin. I also tell them that Phoenix/Mesa/Maricopa is so big at this point—almost four times the population of Tucson/Pima County—that the Democrats we send up there just don’t have the numbers to mean anything in opposing the Republican juggernaut.

I’m no Democrat, but certainly no Republican. I’m an independent, the fastest-growing electorate in our age of American cynical political alienation. I consider myself a conservative at 65, but no one else would who includes a religious test for conservatism. As an atheist since my 20s, I have that foot in the liberal camp from which I evolved.

When one is raised in or near New York City, it would be hard not to become a standard-issue Roosevelt Democrat. My first presidential vote was for George McGovern, and next time Jimmy Carter. I voted for John Anderson, not Ronald Reagan.

I could not bring myself to endorse such snake-oil vendors as Clinton, Gore, Kerry, and Obama, all of whom are still at it because we buy our politicians emotionally the same way we buy our cars. I vote against Rep. Raul Grijalva (D-7-Ariz.) every two years like clockwork. I used to vote for Sen. John McCain, but I fear the ancient mariner is losing his mind. Calls for congressional term limits have no better current example.

Both my sides come together in my hatred for the focus of evil in my modern world: jihadism, murder/suicide in the name of faith, in this case faith in some imaginary guy called Allah and his sword-wielding prophet. Since 2001 most Americans have at least a notion of what makes up this deadly retrograde phenomenon. Most of our planet’s wars and rebellions now consist of Islamists who can’t get along with their neighbors. Yet it’s still a subtle distinction for many that “Islamist” means jihadism or political Islam, as opposed to merely Islam itself and Muslims. The same people probably don’t know Arabs from Persians, or Sunni from Shiite from Sufi.

The American Left naturally hates jihadism, but tempers it with concern for political correctness, usually when issue front-people present a guise of civil rights. Terrorism apologists CAIR love to take advantage of this American gullibility.

The American Right also hates jihadism, but with a Christian edge to its hatred. Of course nobody likes murder and suicide, any more than they like airliners as missiles. Yet it’s still Christianity that drives much American anti-jihadism.

Similar religious fervor drives the Arizona Legislature not to murder, but to forever try to get their Bible into everyone’s public schools, and their law into women’s bedrooms to restrict women’s reproductive rights because they can’t do anything about federal law set forth in Roe v. Wade. So much for small, unobtrusive government when they get their God involved. Our capitol building even says “God Rules” (Ditat Deus, the state motto). Do most of our state legislators think Arizona is a theocracy? There would certainly be a First Amendment issue there if state mottos caused litigation.

Islamists say they know what their god wants. Most often they yell it. Similarly, political Christians say they know what their god wants, and since God-fearing people exalt fear, fear is their great motivator. Fear is not a great legislator.

Since 2010 Arizona and five other states—Kansas, Louisiana, Oklahoma, South Dakota and Tennessee—have enacted legislation barring judges from considering foreign law in their decisions, including Sharia (Islamic) law, which is the nub of the matter. At least 25 states have introduced such measures, according to the Pew Research Center’s Religion and Public Life Project, as reported by Janet Loehrke and Kimberly Railey in USA Today.

Then about three months ago, according to the Right-wing source National Report, the Dearborn (Mich.) City Council voted 4-3 to become the first U.S. city to “officially implement all aspects of Sharia law. The tough new law … addresses secular law including crime, politics, and economics as well as personal matters such as sexual intercourse, fasting, prayer, diet and hygiene.”

The same source claims Dearborn is “a well-known and safe haven for Muslims and Muslim sympathizers. With a population of around 98,000 people, roughly 30 percent of its residence [sic] are Muslims, making them the largest concentration of Muslims in the U.S.”

I never trust a source that can’t write and edit properly for publication. But if this Dearborn information is correct, it’s small wonder that the six states enacted the laws they did.

But it was only six.

I also recalled the 2004 controversy in Hamtramck, Mich. (pronounced “ham TRAM ik”), the city of 23,000 surrounded by Detroit, in which a local mosque requested permission to air two-minute Arabic calls to prayer by loudspeakers five times per day. According to a CBS News report, Hamtramck Muslims said it was no different from Christians ringing church bells. Many local Christians objected to the loud message that Allah is the one and only God, which makes sense when each religion has its own god.

I have always thought the phenomenon of sects in monotheism was just more proof that gods are man-made, culture by human culture. Anyway, I suspect the monotonous noise alone would grate on me, and I don’t even have a god, just a conscience.

This conflict had to happen somewhere as America becomes a


greater percentage Muslim, and given that, a greater percentage jihadi. Hamtramck used to be about Poles, pierogi and polka, but all the newer residents are Bosnian, Yemeni, and Bangladeshi, all with their corresponding mosques.

Like any other “conservative” reactionism, the state law reactions are mainly about fear. “Does Islamic law, Sharia, have a place in American courts?” asks UPI Senior Legal Affairs Writer Michael Kirkland. “A lot of state legislatures don’t think so, and there is a movement to ban its application in domestic courts, state and federal. It’s one of those national issues that for now is not before the Supreme Court, but almost inevitably will be before the Justices somewwhere down the line, even if just in the petition stage.”

The Pew Forum notes that the laws enacted in Arizona, Kansas, Louisiana, South Dakota, and Tennessee are more neutral than the Oklahoma law, and do not cite Sharia or other religious laws in particular. But last summer an Oklahoma federal judge struck down that state’s law—a constitutional amendment approved by 70 percent of Oklahoma voters in 2010—on the basis that it discriminated among religions. You can guess who opposed it: the ACLU on behalf of the executive director of the state chapter of CAIR, the Council on American-Isamic Relations. No one is more clever than CAIR at using American courts against gullible America. Expect them in every such case.

According to the UPI report, the appeals court said supporters of the Oklahoma law do not “identify any actual problem the challenged amendment sought to solve. Indeed, they admitted at the preliminary injunction hearing [that] they did not know of even a single instance where an Oklahoma court had applied Sharia law or used the legal precepts of other nations or cultures, let alone that such applications or uses had resulted in concrete problems in Oklahoma.”

“So what’s the big deal with Sharia?” asks Omar Sacirbey of Religion News Service. “Many Americans think of Sharia as an Islamic legal system characterized by misogyny, intolerance, and harsh punishments. Some anti-Semitic activists warn that Muslims are trying to sneak Sharia into the American legal system in ways that do not reflect U.S. legal principles and beliefs” while “many Muslim Americans counter that Sharia is essential to belief, and that any harsh punishments or unconstitutional aspects associated with Islamic law have either been exaggerated, abrogated, or are superseded by American law.”

Sacirbey notes that some nations, such as Saudi Arabia, Pakistan, Malaysia, Nigeria, and Egypt, have Sharia systems with a high degree of influence on the legal system in family law, criminal law, and in some places personal beliefs, including penalties for apostasy, blasphemy, and not praying.

There are even Muslim-majority nations in which Sharia plays no role, such as Mali, Niger, Tunisia, the “stans” of Kazak, Kyrgyz, Tajiki, Turkmeni and Uzbeki, and Turkey. In Turkey, those engaged in recent unrest and calls for new elections charged popular, thrice-elected Prime Minister Recep Tayyip Erdowan with imposing an Islamic agenda against Turkey’s 90-year rule of secularism.

Mixed systems such as in Algeria, Morocco, Somalia, Bangladesh, Jordan, Kuwait, and Syria generally cover family law, while secular courts cover everything else.

Of course in the U.S. there are no Islamic courts, but Sacirbey notes that judges sometimes have to consider Islamic law in their decisions, such as a judge recognizing the validity of an Islamic marriage contract from a Muslim country in order to grant a divorce in America. I’m sure this is common, as we do not consider women as chattel here. In Tucson Atheists, the local group I attend, there are several women who have experienced what by American standards is the female prison that is Islam. Sequestration by gender is bad enough, but when a woman steps out of line it’s far worse.

The upshot here is, Sharia law is so intently unAmerican that it is not likely to take root here. But how solid are our traditions among a historically ignorant populace? Jamilah King, writing for the Left-wing Color Lines News For Action calls the state bills “useless” and asks, “Are you ever afraid the fundamentalist Muslim extremists will take over your state courthouse? That’s the idea behind the radical Right’s peddling of the myth that … Sharia law will somehow make its way to the United States.”

Ah but it has, snotty Lefty! The point is to what degree. Another Left source, Think Progress, characterizes Arizona’s law, HB2582, the Arizona Foreign Decisions Act, as “banning the implementation of Sharia law” and also “canon law, halacha, and karma.”

In its definitions section our bill actually says, “Religious sectarian law means any statute, tenet, or body of law evolving within and binding a specific religious sect or tribe” including “Sharia law, canon law, halacha and karma, but does not include any law of the United States or the individual states based on Anglo-American legal tradition and principles on which the United States was founded.”

Wouldn’t it be funny if a judge, citing karma, told you that you get what comes around because it goes around?

Halacha was new to me as a member of the Long Island Goyim. With all the Hebrew and Yiddish familiar to me, I went 65 years without hearing of halacha, or halakhah. I had to look up Judaism 101 to find that it refers to Judaism’s set of beliefs about rules and practices that affect every aspect of a comprehensive way of life, including food, clothing, grooming, conducting business, whom you can marry, how to treat other people, and how to observe the holidays.

So we’re afraid of Jews as well as the other Semites? That’s hardly useful, nor is the feared event likely. Heck, if a jihadi became a Jew he’d certainly be better off, rather than needing mental health treatment. This alleged issue about the basis for judicial determinations is fear for the fearful and nothing else. Tucsonans like to think they’re smarter and less fearful than Phoenicians. The Left says this is paranoia on the radical-Right. The Right says wait until it confronts you and then see what you do.

What I fear is the Supreme Court. These unaccountable nine, each owned by one of the two ruling parties, have done Americans dirty in several ways in recent years: Citizens United. A corporation is a person. A penalty is a tax. Medicine is interstate commerce. Money is speech. Where is money in the First Amendment? This set of Justices turns the joint upside down in every session, yet we turn to them because we apparently cannot unite legislatively as Americans, giving the Court unwarranted power. And don’t get me started on the Imperial Presidency.

I sure hope the Court makes the right decision about foreign law under American law—if by that time the Justices’ overpowering party loyalty allows allow them to remember what American law is.

Stuart Faxon is Sombrero editor. n


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MarchMarch 27-29: Tackling Problematic Chronic Rhinosinusitis: A Conclave of Global Experts is at Mayo Clinic Education Center, 5777 E. Mayo Blvd., Phoenix; phone 480.301.8000. Accreditation AMA, AOA, AAFP.

Mayo Clinic presents “the first symposium on managing your most challenging sinusitis patients.” Global leaders in otolaryngology-rhinology, allergy-immunology, and basic sciences brainstorm in highly interactive sessions. Symposium goal is to synthesize its information into innovative strategies and tips on medical and surgical management of the recalcitrant chronic rhinosinusitis (CRS) patient. Bring together your challenging cases to discuss.

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AprilApril 4-5: The Southwest Laryngology and Voice Rehabilitation Conference is at Mayo Clinic Education Center on the Mayo Clinic Hospital campus, 5777 E. Mayo Blvd., Phoenix 85054; phone 480.515.6296. Accreditation 17 AMA PRA Category 1.

Course targets practicing otolaryngologists, PAs, and speech-language pathologists for a “state-of-the-art program based on a multidisciplinary team approach. Agenda includes a wide variety of voice considerations, including diagnostics, surgical procedures and therapeutic management of a wide spectrum of pathologies, such as functional voice disorders, cancer, post-surgical voice reconstruction and post-laryngectomy voice rehabilitation.” Format uses expert lectures, panel discussion, case presentations, audience participation, and live demonstrations.

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