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JOURNAL OF THE LOUISIANA STATE MEDICAL SOCIETY VOL 175 | ISSUE 1 | SUMMER 2023
SINE DIE: 2023 LEGISLATIVE SESSION IS A WRAP!
JOURNAL BOARD K. Barton Farris, MD Secretary/Treasurer, Richard Paddock, MD Anthony Blalock, MD
VOL 175 | ISSUE 1 | SUMMER 2023 CONTENTS 4 LOUISIANA LEGISLATURE REGULAR SESSION 2023 10 2023 LEGISLATIVE SESSION BY THE NUMBERS, APRIL 10 - JUNE 8 11 2023 LOUISIANA LEGISLATURE ADJOURNS SINE DIE 12 LSMS ADVOCACY IN ACTION 14 LEGISLATIVE RECEPTION 15 WHITE COAT WEDNESDAY 16 ADNEXAL TORSION CAUSING A LARGE BOWEL OBSTRUCTION 20 CORONARY EMBOLISM: A CAUSE OF NON-ST- ELEVATION MYOCARDIAL INFARCTION 24 COMPARING PERFORMANCE OF THIRD-YEAR MEDICAL STUDENTS PRE- AND POST-PANDEMIC
L.W. Johnson, MD Fred A. Lopez, MD
BOARD OF GOVERNORS President, John Noble, Jr., MD President-Elect, Richard Paddock, MD Immediate Past President, William Freeman, MD Speaker, House of Delegates, Thomas Trawick, Jr., MD Vice Speaker, House of Delegates, Robert Newsome, MD Secretary-Treasurer, Amberly Nunez, MD Chair, Council on Legislation, David Broussard, MD Ex Officio, LAMPAC, Acting Chair, Susan Bankston, MD BOARD OF COUNCILORS
District One, Myra Kleinpeter, MD District Two, Luis Arencibia, MD District Three, Allan Vander, MD District Four, Richard Michael, MD District Five, Gwenn Jackson, MD District Six, Michael Roppolo, MD District Seven, Brian Gamborg, MD District Eight, Lance Templeton, MD District Nine, Anthony Blalock, MD District Ten, Nicholas Viviano, MD SECTION REPRESENTATIVES
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LAMPAC needs your help to ensure that the LSMS advocacy efforts have the support they need at the capitol. Our friends in the legislature need to know that we appreciate the efforts they have made, and will continue to make, on behalf of the LSMS. Contributions start at $50. For more information, please visit www.Isms.org.
Disclaimer: The author(s) of each scientific article appearing in this Journal is/are solely responsible for the content thereof; the publication of an article shall not constitute or be deemed to constitute any representation by the Louisiana State Medical Society that the data presented therein are correct or sufficient to support the conclusions reached or that the experiment design or methodology is adequate.
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2023 REGULAR SESSION – BY THE ISSUES LSMS Requested Legislation ACT 312 (HB 468) creates an infrastructure and minimum standards for health insurance issuers requiring a utilization review process for healthcare services and pharmaceuticals.
ACT 312
• Requires health insurance issuers to:
• Maintain documented PA programs utilizing evidenced based clinical review criteria.
This legislation was offered by Rep. Thomas Pressly at the request of LSMS. Our thanks to Rep. Pressly for going above and beyond in his support of physicians and this legislation! Joining him on our list of thank you’s for this Act are Senators Gary Smith and Katrina Jackson who pushed hard to keep important components of the legislation intact as it moved through the Senate.
• Acknowledge receipt of and maintain information submitted by providers throughout the appeals process.
LOUISIANA LEGISLATURE REGULAR SESSION 2023
• Provide specific clinical review criteria within 72 hours.
• Allow providers to submit requests for utilization review outside normal business hours.
• Establishes timeframes shown in chart below:
EXPEDITED
STANDARD
CONCURRENT REVIEW RETROSPECTIVE REVIEW
Before beginning a brief summary of the session, please know that LSMS did have a good session – an excellent session, in fact. Both pieces of prior authorization legislation requested by the Society were passed and have now been signed by the Governor. Congratulations and thank you to all of you who invested your time and resources to help the Society succeed! Now for that summary…
Urgent but not emergent * Medications
Knee Surgery Colonoscopy * Medications
Inpatient hospital
Service already performed
a few, there was legislation on abortion, gender affirming care, foreign property ownership and spending cap increases. These issues further impacted the session by spilling over into other debates by virtue of authors being forced to support (or oppose) or refusing to support (or oppose) varying bills. The result of this was to have legislators on edge throughout the session. In the end and over the objection of legislators from both parties, the budget bills (three in total) received a combined less than 30 minutes of debate before being finally passed and sent to the Governor. Retrospectively, how and why this was allowed to happen, as well as the impacts associated with the unknown aspects of each bill is being discussed in various legislative committees. The questions everyone is left trying to answer are:
From beginning to end, this legislative session was fast paced to the point of being manic. As a fiscal session, it is constitutionally both shorter and limited in number of general bills available to legislative authors. Specifically, a fiscal session is earmarked for: • Measures to enact a general appropriation bill; enact the comprehensive capital budget; make an appropriation; levy or authorize a new tax; increase an existing tax; levy, authorize, increase, decrease, or repeal a fee; dedicate revenue; legislate with regard to tax exemptions, exclusions, deductions, reductions, repeals, or credits; or legislate with regard to issuance of bonds.
2 business days
5 business days
24 hours
30 days
• Prohibits additional utilization review requirements during the perioperative period when a PA was not required or had already been approved.
• Prohibits claim denial based solely on failure to obtain PA when PA request is not determined timely.
• Limits the reasons for the claim denial when the PA for the service was approved (guarantee of payment).
• Establishes a process for adverse determinations.
• Establishes a “truer” peer-to-peer review.
• Requires a PA to be valid for a minimum of 3 months.
• Local bills (those that are constitutionally required to be, and have been, advertised).
Can the budget bills be fixed?
• Any other subject matter not covered above. However, any bill in this category MUST be PREFILED, and no member may prefile more than 5 such bills. Predictably, fiscal sessions see a lower number of instruments introduced for consideration. This year was no exception. Not including resolutions in the total, there were 661 House Bills and 223 Senate Bills introduced.
• If so, will it require a special session?
• Or could the Governor utilize line-item vetoes to make the needed changes?
• And how will what happened impact the elections this fall?
These are wait and see questions. What isn’t wait and see is outlined below in our “By The Issues” report.
What was not predictable were the highly emotional, controversial issues that were included and subsequently debated. To name
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HB 471 by Rep. Barbara Frieberg was filed at the request of corporate pharmacies. If passed, it would have allowed any licensees of the Louisiana State Board of Pharmacy (LaBOP) to give any vaccination to any child aged 7 and older. Licensees of LaBOP include pharmacists, their techs and their interns. Proponents of the legislation continue to tout this effort as an increase in access, though this has not proven true when you consider the loss of access to primary care that results from removing children
ACT 333 (SB 188) closely tracks transparency requirements proposed by the Centers for Medicare and Medicaid Services relative to Medicare Advantage organizations expected to go into effect January 1, 2026. Our thanks to Sen. Jeremy Stine for offering this LSMS requested legislation. Further thanks to Rep. Brett Geymann for handling the bill for us on the House side. ACT 333 • Requires health plans to annually report certain prior authorization metrics to the Department of Insurance including:
from a pediatric medical home. This bill went to the wire receiving three votes on the final day of the session. It died on the calendar after the House refused to approve the conference committee report which stripped two key amendments from the bill offered by Sen. Jay Morris . Thank you to Sen. Morris and to the many members who replied to our calls to action on this legislation.
• A list of all items and services requiring PA.
• Percentages of expediated and standard PA requests approved, denied, approved after appeal, approved after the review timeframe was extended and the average and median timeframes between submission and a decision.
• Requires health plans to annually publish to their website (and timely update) items and services requiring PA.
• Requires health plans to provide a list of all items and services that require PA and their policies and procedures used to make PA decisions to health care providers seeking to participate with the health plans. We’ve included a one-page pullout on our prior authorization legislation that can be found on page 11. INSURANCE Legislation
HB 599 became HB 652 when it was reported by substitute from the House Health and Welfare Committee. The original legislation was filed by Rep. Dustin Miller and encompassed components of the Global Signature Authority legislation we have fought in years past. Rep. Miller, who is an Advanced Practice Registered Nurse, met with a number of stakeholders before stripping everything but the ability for a nurse practitioner and physician assistant to “certify the existence of an illness of a teacher, school bus driver, or teaching staff for the purpose of using sick leave or extended sick leave.” All parties agreed to work with Rep. Miller outside of the legislative session to address other concerns that were removed from the bill. MEDICAL MALPRACTICE Legislation Last year, legislation was brought related to standard of care under emergency declarations. The author of the 2022 legislation, Sen. Jimmy Harris, sought to shift the burden of proof to the physician and/or other provider and tie the care specifically to the emergency. After testimony was provided in the Senate Committee, Sen. Harris agreed to pull the bill for 2022 and work with varying stakeholders to review the statutes and identify any potential areas that the parties could agree need clarifying. LSMS, LAMMICO and others did have multiple conversations on the statutes but ultimately could not arrive at a consensus. This led to Sen. Harris offering SB 139 which:
Plastic surgeon Dr. James Wade trusted LAMMICO to provide his medical malpractice insurance for nearly 20 years.
As always, the legislation introduced to impact what is covered under insurance and how insurance companies operate is varied.
“LAMMICO has been great to me. I came to them for medical malpractice insurance in 2002 and never looked back. EXPECTATIONS EXCEEDING I chose LAMMICO because of their personalized service of high quality, and because they’re policyholder-owned. They utilize talented attorneys in defense of claims. I appreciated their emphasis on risk reduction. LAMMICO gave me peace of mind. I always felt that they had my back. You cannot put a price on peace of mind.” – James Wade, M.D., plastic surgeon
In addition to our prior authorization legislation, Sen. Kirk Talbot introduced SB 110 for the Louisiana Oncology Society. It closely mirrors Rep. Pressly’s Act 312 and includes some nuanced language specific to cancer. It did pass and has become Act 254 . Unfortunately, Sen. Heather Cloud’s transparency legislation that focused on the Office of Group Benefits and mirrored Sen. Stine’s Act 333 ran out of time while in conference committee. In maternal health areas, legislation requiring coverage of doulas (Act 270) and midwifes (Act 207) did pass. There are some limitations in both bills, but we would encourage our OB/Gyn community to monitor what occurs and provide feedback on how implementation of both is affecting you and your practice. SCOPE OF PRACTICE Legislation Scope remains one of LSMS’ top priorities. This year saw two significant scope of practice bills filed. Both dealt with specific issues we’ve seen before.
• Removed premises liability (general liability).
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• Prohibited attorney chair from raising the gross negligence standard of care in review panel.
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It does still require the adoption and implementation of a policy that includes a surgical smoke plume evacuation plan aimed at mitigating and removing the surgical smoke plume. ACT 322 (SB 66) by Sen. Fred Mills changes the term “telemedicine” to “telehealth” in Louisiana statute. LSMS originally opposed the legislation and offered amendments to tighten language that now requires anyone conducting a telehealth visit on a Louisiana patient to create a written record. We have many physicians and other providers in Louisiana who have concerns related to telehealth. We did express those concerns but were met with a lack of interest in how to balance those concerns with the benefits of “easing access to healthcare.” SB 172 by Sen. Brett Allain did not get heard in committee. The legislation focused on noncompete clauses in physician contracts and focused on physicians caught by noncompetes when their employing practices are sold. However, as the bill was drafted there were unintended consequences that could not be alleviated in a compressed legislative session. ACT 358 (HB 548) by Rep. Chris Turner prohibits discriminatory practices that limit the monetary benefit that entities participating in the federal 340B Drug Pricing Program receive as result of dispensing drugs discounted by the program. RESOLUTIONS as Legislation
• Shifted the burden of proving nexus to the physician.
After two committee meetings, SB 139 failed in committee by a vote of 4 to 3.
In the House, Rep. Edmond Jordan offered HCR 57 which requested a study to solicit input, recommendations, and advice from interested stakeholders on the current effectiveness of the medical malpractice limitations to compensation and medical review panels. The make-up of the participants on the committee was very large and included twenty legislators. The resolution was referred to the House Committee on Civil Law and did not receive a hearing before the session adjourned. ABORTION Legislation Seven bills focused on abortion were filed this legislative session. LSMS has a longstanding policy to remain neutral on abortion legislation that focuses on the societal beliefs regarding the issue. However, the Society does become engaged when the legislation impacts patient safety and/or the practice of medicine. Three of the bills filed attempted to clarify last year’s legislation by developing more medically sound definitions or reducing criminal penalties associated with providing routine medical care to pregnant patients. The bills supported by LSMS this year included: • HB 461 by Mary DuBuisson would have provided to last year’s abortion exceptions through a new definition of “non- viable pregnancy.” • HB 522 by Aimee Freeman would have redefined abortion, eliminated imprisonment of physicians in favor of fines when an abortion has been performed, and reduced physician certification requirements for a determination of medical futility.
ADVOCACY • LEGISLATIVE • REGULATORY The LSMS is a good investment for physician group practices, hospitals, and other physician employers. We fill a unique role that benefits both the physician and their group or employer. The LSMS has a long history of working with our Capital Club members and leadership to address their practice needs and sharing success stories. Whether that’s coordinating on advocacy efforts, providing legislative and regulatory updates to senior leaders, or highlighting practice or hospital news and physicians, our expert staff are always one call away. Sharing Success LSMS CAPITAL CLUB
As usual, we have resolutions that are of interest which we are including if they passed.
HCR 83 by Rep. Michael Echols creates a task force within the Louisiana Department of Health to study, identify and make recommendations which address the specialist physician shortage within the state. With his resolution, Rep. Echols is continuing a multi-year effort to focus the state on physicians and highlight the need to better develop physician data and incentive programs to retain them. HCR 114 by Rep. Kenny Cox requests the Louisiana State Board of Medical Examiners to study the possible outcomes of allowing supervised practice for previously sanctioned physicians and its effects on the physician shortage in this state. SR 160 by Sen. Jay Luneau urges and requests the Louisiana State Board of Medical Examiners, the Louisiana State Board of Dentistry, and the Louisiana State Board of Nursing to make information regarding collaborative practice agreements publicly accessible to patients. To see the outcome of the full list of bills tracked by LSMS during this legislative session please click this link: Microsoft Word - 2023RS Final Report Bill List (ymaws.com)
Beyond the standard membership benefits,
THE FOLLOWING EXCLUSIVE CAPITAL CLUB OPPORTUNITIES ARE OFFERED:
• HB 598 by Candace Newell would have amended varying definitions relative to the crime of abortion.
• 25 Physician Leaders at a discounted membership rate • Physician Leaders have direct access to LSMS EVP/CEO and LSMS Advocacy Team. • Physicians can get directly involved in issues that may otherwise be seen as self-serving, such as reimbursement and scope of practice issues. • LSMS can address issues that are priority for practicing physicians but while important, may not be a priority for a system.
• Physician Leaders can gain valuable experience through the LSMS that will help them pursue leadership positions with their practice or hospital. • Practice or group logo and news is promoted on LSMS social media outlets and in e-newsletter, Capsules & Journal of the LSMS • One convenient bill to reduce staff and administrative burdens. • Easy renewal process. • Physician Spotlight across Social Media Channels
None of the bills were passed out of committee.
OTHER Legislation
In our catch all category this year, we’ve included four bills that were discussed with many of our members on multiple occasions. Please provide feedback on the ones that successfully passed. ACT 35 (SB 29) by Sen. Gerald Boudreaux was brought at the request of AORN. As introduced, the bill required licensed healthcare facilities which provide surgical procedures to adopt and implement policies for the use of a surgical smoke plume evacuation system to eliminate the surgical smoke plume. The bill was amended to remove the requirement for special systems.
Please contact Medical Group Engagement Manager, Kristen Broussard, at kbroussard@lsms.org or 225.763.2323 to discuss your Capital Club membership today!
Scan here to view the most recent legislation that affects your practice.
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2023 LEGISLATIVE SESSION BY THE NUMBERS, APRIL 10 – JUNE 8
125
Passed 2 of 2 LSMS requested bills on prior authorization
physicians at White Coat Wednesday
4 full time lobbyists
884 legislative instruments filed in the 2023 Regular Session
✔ 126 tracked ✔ 60 tracked
60
1,440 86,400
with positions
DAYS
HOURS
MINUTES
11 Call To Action Campaigns
11,178 Legislative Contacts
18 Specialty Societies working with LSMS in the Physicians Coalition
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LSMS ADVOCACY IN ACTION LEGISLATIVE RECEPTION AND WHITE COAT WEDNESDAY
On the evening of Tuesday, May 16 the LSMS in partnership with the Physician Coalition of Louisiana hosted a very successful legislative reception at the City Club in Baton Rouge for physician leaders and legislators. A special thanks to Mark Abraham, Roy Daryl Adams, Lawrence “Larry” Bagley, Stewart Cathey, Jr., Mary duBuisson, Franklin Foil, Barry Milligan, “Jay” Morris, Chuck Owens, Robert “Bob” Owens, Barrow Peacock, Thomas Pressly, IV, Mike Reece, Larry Selders, Jeremy Stine and Christopher “Chris” Turner for taking the time to meet with our members.
The next morning physicians, legislators and advocates once again gathered at the Louisiana State Capitol for the annual White Coat Wednesday physician’s day of advocacy. The 2023 event was the largest so far with over 125 physicians converging on the state capitol to meet with legislators, attend committee meetings and have their voices heard. After a briefing and breakfast at the Lt. Governor’s residence, physicians then filled the hallways and committee rooms of the capitol. This year’s day of advocacy coincided with the Senate Committee on Insurance’s vote on HB468, a bill requested by LSMS, that aims to implement new guidelines
regarding prior authorizations. Those attending were able to hear strong and impassioned testimony from their peers and see the legislative process in motion as the bill reported out of the senate committee and is now headed for final vote on the senate floor. White Coat Wednesday is an important day of grassroots advocacy where individual physicians are able to make an impact on current and future legislative efforts that benefit both their profession and their patients. The fact that this event continues to grow each year is a testament to the importance of getting involved and proof that physician voices are stronger when united.
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TO OUR 2023 PARTNERS LOUISIANA STATE MEDICAL SOCIETY AMERICAN ACADEMY OF PEDIATRICS, LA CHAPTER AMERICAN COLLEGE OF EMERGENCY PHYSICIANS, LA CHAPTER AMERICAN CONGRESS OF OBSTETRICIANS & GYNECOLOGISTS, LA CHAPTER EDWARD VIA COLLEGE OF OSTEOPATHIC MEDICINE/ LOUISIANA OSTEOPATHIC MEDICAL ASSOCIATION Thank You
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20% off for LSMS members. LSMS member? Log in at lsms.org to access the MATE Act courses discounted at 20% off. • State-specific courses for local practitioners • Accreditation with Commendation by ACCME • At least 95% of CME qualifies for MOC Part II Credit • Automated reporting of earned credits to LSBME via CE Broker LA providers have trusted MI with their continuing education for over 20 years.
MEDICINE LOUISIANA LOUISIANA ACADEMY OF FAMILY PHYSICIANS LOUISIANA ORTHOPAEDIC ASSOCIATION LOUISIANA PSYCHIATRIC MEDICAL ASSOCIATION PHYSICIANS FOR PATIENTS RADIOLOGICAL SOCIETY OF LOUISIANA TULANE DOCTORS
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Reception Legislative
Wednesday White Coat
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ADNEXAL TORSION CAUSING A LARGE BOWEL OBSTRUCTION
IMAGING FINDINGS: Figure 1. Initial abdominal radiograph demonstrates no concerning abnormalities. Figure 2. Repeat abdominal radiograph 4 days after symptoms began demonstrates dilated loops of bowel in the left upper quadrant with air-fluid levels. CT of the abdomen and pelvis was recommended. Figure 3. Contrast enhanced CT of the abdomen in coronal projection demonstrates diffuse dilated fluid-filled loops of small and large bowel. Within the pelvis, superior to the urinary bladder, there is a large cystic mass in association with a soft tissue structure on the left (yellow arrow). Figures 4 and 5. Contrast enhanced axial (Figure 4) and sagittal (Figure 5) CT images demonstrate suspected transition point in the sigmoid colon (red arrow) in association with a left adnexal soft tissue structure (yellow arrow), thought to reflect the left ovary given proximity to the left gonadal vein (green arrow). Given findings, a pelvic ultrasound was recommended for further evaluation. Figure 6. Left ovary was not visualized on pelvic ultrasound. In the left adnexal region, a unilocular cystic mass with diffuse low-level internal echoes and an echogenic mural nodule (yellow arrow) was noted.
of bowel obstruction due to adnexal torsion were found in the literature: one because of an ovarian cyst in an elderly woman (5) and the other because of ovarian hyperstimulation syndrome in a woman undergoing IVF treatment (2). To the best of our knowledge, this is the first known case of an ovarian tumor with torsion resulting in a large bowel obstruction. Both large bowel obstruction and adnexal torsion are emergencies. Their overlapping clinical features may however delay diagnosis. Acute large bowel obstruction generally presents with abdominal pain, constipation, and abdominal distension (3). Adnexal torsion similarly presents with abdominal pain, often severe and sudden in onset, however symptoms are often prolonged with intermittent pain due to episodic torsion. Associated symptoms include nausea, vomiting, and fever. Leukocytosis is often present in both bowel obstruction and adnexal torsion. In our case, the patient presented 4 days earlier to the ED with similar complaints. Abdominal radiograph at time of initial visit demonstrated nonspecific air-fluid levels within both the small and large intestines. Symptoms may have been due to a transient adnexal torsion and/or related to evolving obstruction of the large bowel from the pelvic mass. On follow-up presentation, imaging studies indicated LBO and adnexal torsion due to a large cystic mass. LBO was suspected on repeat abdominal radiographs which demonstrated dilation of bowel loops and multiple air-fluid levels within the small and large intestines. Abdominal radiography is helpful to exclude complications of LBO including pneumoperitoneum, pneumatosis, and portal venous gas, while CT is used is often used to confirm the diagnosis and investigate the cause and location of the obstruction (3). Although CT may also be used in the diagnosis of adnexal torsion, ultrasound is the initial imaging modality of choice for suspected adnexal torsion and is superior in diagnosis to other imaging modalities including CT and MRI. Imaging findings suggestive of adnexal torsion include unilateral ovarian enlargement, midline position of the affected ovary, surrounding inflammatory change with pelvic free fluid, and deviation of the uterus toward the side of torsion (1). Additional findings include peripherally displaced antral follicles, an enlarged twisted pedicle, central ovarian edema, and a lead mass. Imaging findings of adnexal torsion may also be seen on CT, which can often be the first imaging modality used in diagnosis due to initially low clinical suspicion for adnexal torsion (1). The patient was taken to surgery for an emergent laparotomy and left salpingoophorectomy was performed. Intra-operative findings included adnexal torsion four times about its axis with incorporation of a portion of the colon into the twisted pedicle. The left ovary was black and necrotic, consistent with prolonged devascularization. The bowel was dilated, but otherwise appeared healthy and without injury. Pathology of the ovarian mass indicated serous borderline tumor (SBT), a rare tumor in this patient’s age group and one that is only rarely associated with cases of adnexal torsion (9).
DANIELLE HAIDARI, BS, TAYSON NGUYEN, DO, NEEL GUPTA, MD, SPENCER BARBERA, BA, JEREMY NGUYEN, MD, FACR
HISTORY: 18-year-old otherwise healthy female presented to the emergency department with 6 days of worsening diffuse abdominal pain that became severe the morning of presentation, with 3 days of associated nausea and vomiting. Additionally, patient had no passage of stool or flatus for these 6 days. She previously presented to the ED 4 days earlier complaining of similar, but less severe pain. At that time patient had a negative abdominal X-Ray and was diagnosed with constipation and prescribed stool softeners with no improvement in symptoms. Patient noted slight abdominal distension and bloating over the last several months.
DIFFERENTIAL DIAGNOSIS: 1. Serous Borderline Tumor 2. Serous Ovarian Cystadenoma 3. Ovarian Cystadenocarcinoma 4. Ovarian Teratoma 5. Ovarian Cyst
FINAL DIAGNOSIS: Serous borderline ovarian tumor with adnexal torsion causing a large bowel obstruction DISCUSSION: We present a case of a serous borderline ovarian tumor in an adolescent complicated by adnexal torsion in association with a large bowel obstruction. Large bowel obstruction (LBO) is often due to underlying colonic malignancy (60-80%), followed by volvulus (11-15%) and diverticulitis (4-10%) (3). Extrinsic compression from adjacent mass is an uncommon cause of LBO (3). Large bowel obstruction secondary to adnexal torsion is even far more uncommon. Cases of adnexal torsion resulting in bowel obstruction have been reported in the neonatal period, although only as related to ovarian cysts. In a 2010 literature review of 19 cases of neonatal ovarian cysts resulting in bowel obstruction, 10 cases were due to adhesions of portions of the bowel due to an adjacent necrotic ovary secondary to torsion. Remaining cases of bowel obstruction were secondary to mass effect from a large ovarian cyst (4). Furthermore, only two related adult cases
FIGURE 1: ABDOMINAL RADIOGRAPH
FIGURE 2: ABDOMINAL RADIOGRAPH
FIGURE 3: CONTRAST-ENHANCED CT
FIGURE 4: CONTRAST-ENHANCED AXIAL CT FIGURE 5: CONTRAST-ENHANCED CT
FIGURE 6: PELVIC ULTRASOUND
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on histologic characteristics, conventional and micropapillary/ cribif3orm SBT (8). A study examining the imaging findings of the two types of SBT found that conventional SBT are cystic masses that commonly exhibit an intracystic mural nodule on imaging, as seen in this case (6). Due to the potential for recurrence, intraperitoneal seeding, and lymph node involvement with SBT’s, follow-up surveillance is recommended as with other ovarian tumors (8). 6. Nakai G, Yamada T, Yamamoto K, Hirose Y, Ohmichi M, Narumi Y. MRI appearance of ovarian serous borderline tumors of the micropapillary type compared to that of typical ovarian serous borderline tumors: radiologic-pathologic correlation. J Ovarian Res. 2018 Jan 10;11(1):7. doi: 10.1186/s13048-018- 0379-y. PMID: 29321056; PMCID: PMC5764013. 7. Park SB, Kim MJ, Lee KH, Ko Y. Ovarian serous surface papillary borderline tumor: characteristic imaging features with clinicopathological correlation. Br J Radiol. 2018 Jul;91(1088):20170689. doi: 10.1259/bjr.20170689. Epub 2018 Jun 21. PMID: 29888983; PMCID: PMC6209462.
Serous borderline tumors of the ovary account for approximately 15% of all serous ovarian tumors, and present epithelial proliferation with an intermediate degree of nuclear atypia and no stromal invasion (7). SBT’s are associated with intraperitoneal and lymphatic implants and are a potential precursor to low grade serous carcinoma. (7, 8). SBT’s vary in morphology including papillary, solid, and cystic components. World Health Organization classification of SBT’s is divided into two types based REFERENCES: 1. Dawood MT, Naik M, Bharwani N, Sudderuddin SA, Rockall AG, Stewart VR. Adnexal Torsion: Review of Radiologic Appearances. Radiographics . 2021;41(2):609-624. doi:10.1148/ rg.2021200118 2. Lazaridis A, Maclaran K, Behar N, Narayanan P. A rare case of small bowel obstruction secondary to ovarian torsion in an IVF pregnancy. BMJ Case Rep . 2013;2013:bcr2013008551. Published 2013 Feb 15. doi:10.1136/bcr-2013-008551 3. Jaffe T, Thompson WM. Large-Bowel Obstruction in the Adult: Classic Radiographic and CT Findings, Etiology, and Mimics. Radiology . 2015;275(3):651-663. doi:10.1148/radiol.2015140916 4. Jeanty C, Frayer EA, Page R, Langenburg S. Neonatal ovarian torsion complicated by intestinal obstruction and perforation, and review of the literature. J Pediatr Surg . 2010;45(6):e5-e9. doi:10.1016/j.jpedsurg.2010.02.118 5. Murgugesan RKS, Ross K, Prabakar J. A case of ovarian cyst torsion causing intestinal obstruction. International Surgery Journal . 2020, 7(12):4228-4230. ACKNOWLEDGMENTS: Danielle Haidari is a 4th year Medical Student at Tulane University School of Medicine. Tayson Nguyen, DO is a 4th year Tulane Radiology Resident. Neel Dewan Gupta, MD is a clinical and academic musculoskeletal radiologist in New Orleans and serves as a clinical assistant professor within the Department of Radiology at the Tulane University Medical Center. Spencer
The state’s vaccine database, Louisiana Immunization Network (LINKS), is a tool that helps providers ensure kids are healthy and have received all recommended age- appropriate vaccines. The utilization of LINKS reduces the risk of vaccine-preventable illnesses resulting in major outbreaks. Entering all of your patients’ vaccination records in LINKS is not only a legal requirement in Louisiana, it also helps prevent diseases from spreading in our communities. The Louisiana Department of Health Immunization Program reminds all providers that all vaccinations must be entered into LINKS within one week after administration.
8. Sharma
A,
Lastra
RR.
Serous
borderline
tumor.
PathologyOutlines.com https://www. pathologyoutlines.com/topic/ovarytumorserousborderline. html. Accessed August 4th, 2022. website. 9. Xu M, Wang B, Shi Y. Borderline ovarian tumor in the pediatric and adolescent population: a clinopathologic analysis of fourteen cases. Int J Clin Exp Pathol. 2020 May 1;13(5):1053- 1059. PMID: 32509078; PMCID: PMC7270684.
Barbera is a 3rd year Medical Student at Tulane University School of Medicine.
Jeremy Nguyen MD, FACR is a clinical radiology professor within the Department of Radiology at the Tulane University Medical Center.
For more information about vaccine reporting, visit LaLINKS.org
18 J LA MED SOC | VOL 175 | SUMMER 2023
CORONARY EMBOLISM: A CAUSE OF NON-ST-ELEVATION MYOCARDIAL INFARCTION
more commonly a coronary thrombus with bystander coronary atherosclerosis 1. If a coronary thrombus is identified, aspiration thrombectomy should be considered to reduce cardiovascular mortality and to identify the thrombus’s origin 4,8 . After managing the acute presentation, one’s attention should focus on determining the etiology of the embolic material. Utilization of transthoracic or esophageal echocardiogram is essential in evaluating causes such as atrial and ventricular thrombus, valvular abnormalities, and anatomic defects 5, 8. Thrombophilia evaluation can be considered outpatient if it will change management; however, inpatient evaluation is often flawed 1,8 . SUMMARY: This case highlights the importance of recognizing non- atherosclerotic causes of non-ST-segment elevation myocardial infarctions. It is important to understand the broad differential of type 2 myocardial infarctions and the predisposing factors that can lead to coronary embolism. The combination of oral contraceptives used to treat dysmenorrhea, in addition to the incidentally noted papillary fibroelastoma, are the most plausible etiologies of the patient’s presentation. Though intravascular ultrasound or optical coherence tomography was not used, in the setting of no traditional risk factors, a lack of antecedent angina or anginal equivalents, and angiographically normal coronary arteries it is most plausible that coronary embolism, rather than a primary plaque rupture event, was responsible for the patient’s presentation. CITATIONS: 1. Al-Taweel O, Sami F, Pinsky S, Wineinger T, Berbarie RF. Coronary Embolism Presenting as NSTEMI in a Patient with Splenectomy. Kans J Med. 2021 Apr 19;14:111-113. doi: 10.17161/ kjm.vol1414823. PMID: 33903812; PMCID: PMC8060067. 2. Busti, A. J. (2015, October 1). The Mechanism of Oral Contraceptive (Birth Control Pill) Induced Clot or Thrombus Formation (DVT, VTE, PE) . Evidence Based Medicine Consult. Retrieved November 11, 2022, from https://www.ebmconsult. com/articles/oral-contraceptive-clotting-factors-thrombosis- dvt-pe 3. De Lemos, J. A., Newby, L. K., & Mills, N. L. (2019, September 6). A Proposal for Modest Revision of the Definition of Type 1 and Type 2 Myocardial Infarction . Circulation. Retrieved November 11, 2022, from https://www.ahajournals.org/doi/full/10.1161/ CIRCULATIONAHA.119.042157 4. Jolly SS, James S, Džavík V, Cairns JA, Mahmoud KD, Zijlstra F, Yusuf S, Olivecrona GK, Renlund H, Gao P, Lagerqvist B, Alazzoni A, Kedev S, Stankovic G, Meeks B, Frøbert O. Thrombus
demonstrated no wall motion abnormalities or pathologic findings. The patient was initiated on dual antiplatelet therapy and started on a heparin infusion. She was subsequently taken to the cardiac catheterization lab. A coronary angiogram demonstrated no coronary artery disease but identified a filling defect in the posterolateral branch of the right coronary artery. The finding was felt to be most consistent with a coronary artery embolism rather than distal embolization of a primary plaque rupture event. Given the patient’s lack of traditional coronary artery disease risk factors, antecedent angina before presentation, family history of premature coronary artery disease, and in the setting of suspected coronary artery embolism on coronary angiogram, a transesophageal echocardiogram was performed to evaluate for predisposing pathologic risk factors. Transesophageal echocardiogram with bubble study demonstrated a mobile echo density on the A2 segment of the mitral valve consistent with potential papillary fibroelastoma. No left atrial appendage thrombus, left ventricular thrombus, or patent foramen ovale were identified. The patient was discharged with standard medical therapy in the setting of a non-ST-segment elevation myocardial infarction and was in good health at the time of outpatient follow-up. DISCUSSION The most common etiology of a non-ST-segment elevation myocardial infarction is a type 1 NSTEMI which results from an atherosclerotic plaque rupture event followed by coronary thrombus formation causing subtotal occlusion and subendocardial ischemia. In the absence of angiographically demonstrated coronary artery disease one’s differential should expand to include causes of type 2 myocardial infarctions. The etiologies of type 2 myocardial infarctions can be divided into primary coronary or secondary causes from acute related illnesses 5. Coronary embolism, an infrequent cause of type 2 myocardial infarction, is responsible for approximately three percent of acute coronary syndrome events according to a retrospective analysis by Shibata et al. Though relatively protected by the acute angle take-off, the coronary arteries remain vulnerable to embolic insults. Understanding the causes of these embolic events can be directly related to Virchow’s triad and anatomic predispositions. Examples of predisposing factors include malignancy, hormonal therapy-induced hypercoagulability, endothelial injury following angioplasty, and stasis of normal flow because of atrial fibrillation or aneurysmal dilation of the left ventricle. Additionally, classic anatomic predispositions include an atrial septal defect and a patent foramen ovale 8 . The initial presentation of coronary embolism is difficult to distinguish from an acute coronary syndrome event secondary to type 1 physiology and is often managed similarly. It is distinguished by coronary angiogram which may demonstrate a heavy thrombus burden without coronary artery disease, or
OMAR LEONARDS, MD, XAVIER DIAZ-HERNANDEZ, MD AND SHAHRUKH KHAN, MS-3
INTRODUCTION Acute myocardial infarctions are a known cause of morbidity and mortality worldwide. The most common acute form is a type 1 myocardial infarction related to atherosclerotic plaque rupture and thrombus formation 1,7 . Though rare, a cause of type 2 myocardial infarction, defined as a supply-demand mismatch of myocardial oxygenation, is a coronary artery embolism, which may be responsible for up to three percent of acute coronary syndrome events 3,5,9 . The most common causes of coronary embolism are atrial fibrillation, prosthetic valve thrombi, infective endocarditis, and iatrogenic causes 5,9 . This manuscript will highlight hypercoagulable states and benign cardiac tumors as a cause of acute coronary syndrome in a patient without typical risk factors. CASE REPORT In July of 2022 a 47-year female with class I obesity, depression, and dysmenorrhea being treated with oral contraceptives, presented with a chief complaint of acute onset bilateral arm pain with associated diaphoresis and nausea while leisurely walking. She denied symptoms of gastroesophageal reflux, emesis, new skin changes, hemoptysis or pleuritic chest pain, dyspnea, recent illnesses such as viral infections, or a family history of premature atherosclerotic coronary artery disease or myocardial infarction. She participated in aerobic and resistance training daily without angina or anginal equivalents.
On initial presentation, the patient’s vital signs were a temperature of 36.1º Celsius, a heart rate of 72 beats per minute, a blood pressure of 107/71, a respiratory rate of 16, and a weight of 90 kilograms. The patient’s physical examination was unremarkable for any pertinent findings. Laboratory evaluation was remarkable for stable iron deficiency anemia, marginal thrombocytosis, brain natriuretic peptide of 9, high sensitivity troponin of 44 that peaked at 10,830 twelve hours after presentation, and a negative urine drug screen. Serial electrocardiograms were performed and demonstrated normal sinus rhythm without ST-T wave abnormalities. A chest radiograph performed at the time of presentation did not demonstrate pulmonary edema or widening of the mediastinum. Point of care ultrasound obtained at the time of consultation and formal transthoracic echocardiogram
FIGURE 1. ECG DEMONSTRATING NORMAL SINUS RHYTHM.
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Infarction Patients: Mechanisms and Management. Circ Cardiovasc Interv. 2018 Jan;11(1):e005587. doi: 10.1161/ CIRCINTERVENTIONS.117.005587. PMID: 29311288. 8. Raphael E. Claire, John A. Heit, Guy S. Reeder, Melanie C. Bois, Joseph J. Maleszewski, R. Thomas Tilbury, David R. Holmes. Coronary Embolus: An Underappreciated Cause of Acute Coronary Syndromes. JACC: Cardiovascular Interventions. Volume 11, Issue 2, 2018. Pages 172-180. ISSN 1936-8798. https://doi.org/10.1016/j.jcin.2017.08.057. 9. Shibata T, Kawakami S, Noguchi T, Tanaka T, Asaumi Y, Kanaya T, Nagai T, Nakao K, Fujino M, Nagatsuka K, Ishibashi-Ueda H, Nishimura K, Miyamoto Y, Kusano K, Anzai T, Goto Y, Ogawa H, Yasuda S. Prevalence, Clinical Features, and Prognosis of Acute Myocardial Infarction Attributable to Coronary Artery Embolism. Circulation. 2015 Jul 28;132(4):241-50. doi: 10.1161/ CIRCULATIONAHA.114.015134. Epub 2015 Jun 25. PMID: 26216084.
Aspiration in ST-Segment-Elevation Myocardial Infarction: An Individual Patient Meta-Analysis: Thrombectomy Trialists Collaboration. Circulation. 2017 Jan 10;135(2):143-152. doi: 10.1161/CIRCULATIONAHA.116.025371. Epub 2016 Dec 9. PMID: 27941066. 5. Lacey MJ, Raza S, Rehman H, Puri R, Bhatt DL, Kalra A. Coronary Embolism: A Systematic Review. Cardiovasc Revasc Med. 2020 Mar;21(3):367-374. doi: 10.1016/j.carrev.2019.05.012. Epub 2019 May 22. PMID: 31178350. 6. Newby, K. Type I and type II myocardial infarction . European Society of Cardiology. Retrieved November 11, 2022, from https://www.escardio.org/Sub-specialty-communities/ Association-for-Acute-CardioVascular-Care-(ACVC)/ Education/type-i-and-type-ii-myocardial-infarction 7. Popovic B, Agrinier N, Bouchahda N, Pinelli S, Maigrat CH, Metzdorf PA, Selton Suty C, Juillière Y, Camenzind E. Coronary Embolism Among ST-Segment-Elevation Myocardial
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22 J LA MED SOC | VOL 175 | SUMMER 2023
COMPARING PERFORMANCE OF THIRD-YEAR MEDICAL STUDENTS PRE- AND POST-PANDEMIC
same time, there was no statistically significant difference ni their final grades (Table 1). Figure 1 shows the box-plot diagram summarizing the results. The quiz and NBME scores showed a weak positive correlation in both groups (Figure 2). DISCUSSION: Our finding was contrary to previous reports. Anderson et al.4 reported a 22.4% reduction in NBME shelf exam performance for the COVID-19 pandemic cohort. Hanson et al. ( 7 ) noticed that students who completed their core pediatric clerkship during the COVID-19 pandemic were significantly more likely to fail their end-of-clerkship NBME shelf exam. They attributed the increased failure rates to issues with acquiring and retaining pediatric medical knowledge. In another study, Aaraj et al. ( 8 ) noted no effect of the COVID-19 pandemic on the end-of-clerkship scores. One of the reasons for better performance on quizzes and NBME shelf exams could be the availability of more time for self-study. During the true pandemic, students saved traveling time as they mostly practiced remote learning. The other reason could be explained by the e-learning format. Experience reported in pre-clinical clerkships has shown that students who engaged with electronic books (eBooks) performed significantly better in objective assessments ( 9 ) . In another study, Faner et al. ( 10 ) reported no significant difference in scores among pre-clinical students using video calls ( zoom) and on-campus teaching. In a recent study, Guluma and Brandl ( 11 ) described that transitioning to virtual learning allowed students to adapt their own study strategies, and they were able to reduce group study time and increase self-study time. Our findings suggested that the student’s performance in the standardized examination at our academic institution was improved during the COVID-19 pandemic favoring remote learning. Educators have used the flip ped -classroom (FC) model as an alternative to in-person learning ( 12 ) . FC model consists of teaching modules, where students receive lectures in the format of PowerPoint slides format or recorded lectures. After reviewing the assignment, students meet with faculty to discuss the topic and interact with questions and answers flip ped instead of faculty giving the lecture in the hall and students reviewing the topic remotely and then engaging in active learning on-site- the lecture hall or class. Xiong et al. 12 agreed that in addition to engaging students in active learning, no clinical core rotation should be designed to be completely virtual. The acquisition of clinical skills involves hands-on experience. In our program, the subjective score consists of 65% of the final grades. As these scores included the evaluation provided by the supervising faculty and residents, these could be used as a surrogate of students’ engagement during rotations in the wards, clinics, and newborn nursery. Quizzes and NBME shelf exams evaluate students’ medical knowledge, not clinical skills. The final grade, on the other hand, assesses the medical students’ performance more comprehensively as we evaluate their communication skills, patient care and bedside manners, medical knowledge,
grade records of medical students’ evaluations were accessed to obtain the exam scores.
The pediatric clerkship is a 6-week rotation. Third-year medical students rotate through inpatient and outpatient services to get a global view of children’s healthcare. During the rotation, they are taught by faculty attendings using didactic lectures and bedside teaching. Performance was assessed by the total scores and grades. We compared the two groups’ quiz scores, National Board of Medical Examiners (NBME) scores, and clerkship final grade scores. The NBME Clinical Science Pediatric Shelf exam ( 6 ) , which assesses third-year medical students’ ability to treat children and adolescents, was administered on the last day of the sixth week. The NBME score constitutes 30% of the total score. The quiz consists of 50 multiple-choice questions with a one- best-answer format, extracted from an intradepartmental pool of clinical vignettes, which students took online, being proctored by the clerkship coordinator. There is no cutoff grade for passing/ failing, but students understand that the quiz score represents 5% of their final grades for the clerkship. The subjective score constitutes 65% of the total score. The final grade of the clerkship comprised a cumulative 360-degree evaluation score, including objective evaluations like the quiz and NBME shelf exam, and a subjective component which included assessments of their clinical performance and evaluation scores from residents and attendings during the rotation through wards, clinics, and nursery. Group A comprised the medical students from graduating class of 2022 who took pediatrics during the acceleration phase of the pandemic (true pandemic phase). Group B included the class of 2023, which took pediatrics during the deceleration phase (control phase). The data was collected from July 1st -June 30th of their third academic year cycle (The data collection year was a year prior to the graduating year- the class was identified as the year of graduation). The Pediatric clerkship is a 6-week rotation. Annually, there are eight blocks of a 6-weeks rotation. The total number of students reflects the annual numbers. The number of students varies during each block (ranging from 14-22). We did not look at the names or individual scores to comply with the student’s privacy. The mean cumulative score for the whole class was compared between the groups. We used the Microsoft excel program for data analysis and conventional statistics. We use a two-tailed test student (t-test) for comparative analysis. RESULTS: The true pandemic group comprised 134 students, while the control group had 147 students. The average overall final grade was greater than 90, which is cataloged as an honor grade in our institution. We noted a statistically significant difference in the quiz and NBME scores between the true pandemic phase and control phase groups, 74.97 + 8.11 vs. 70.00 + 8.60, p =< 0.001, 80.35 + 7.09 vs. 78.58 + 7.10, p = 0.03, respectively. At the
Shabih Manzar, MD, MPH 1 Patricia Pichilingue-Reto, MD 2 1 Director, Pediatric Clerkship 2 Co-director, Pediatric Clerkship Department of Pediatrics
Correspondence to: Shabih Manzar, MD, MPH Louisiana State University Health Sciences Center at Shreveport 1501 Kings Hwy, Shreveport, LA, 71103 Phone: 318-675-7275 Fax: 318-675-6059 Email: shabih.manzar@lsuhs.edu
Louisiana State University Health Sciences Center, Shreveport, LA Ochsner LSU Health, St. Mary Medical Center, Shreveport, LA
KEYWORDS: COVID-19, Performance, Medical Students FUNDING AND FINANCIAL SUPPORT: None
the control group had 147 students. We noted a statistically significant difference in the quiz and NBME scores between the true pandemic phase and control phase groups. The mean quiz score of group A was 74.97 + 8.11 versus group B of 70.00 + 8.60, p = < 0.001. The mean NBME score of group A was 80.35 + 7.09 versus group B of 78.58 + 7.10, p = 0.03. The mean final grade scores between groups A and B were not statistically significant, 90.46 + 3.01 and 90.64 + 2.49, p = 0.58. Conclusions: We noted improved performance, assessed by examination scores, among students during the pandemic phase. Further studies would be needed to look at the effect of virtual learning on skill acquisition and clinical performance. pandemic medical education ( 1 ) . Questionnaire-based studies have shown that medical students were more motivated during the pandemic ( 2 ) and learned equally with the virtual learning process ( 3 ) . These studies looked at motivation and learning as qualitative data. On the quantitative side, earlier studies have demonstrated the impact of COVID-19 on academic INTRODUCTION: The COVID-19 has impacted performance and personal experience among pre-clerkship medical students 4,5. Anderson et al. ( 4 ) noted that during the COVID-19 pandemic, preclinical first-semester students did not score above the national average as much as first- semester students pre-COVID -19 . Chang et al. ( 5 ) observed that the NBME scores of the intra-pandemic preclinical class were significantly higher than the pre-pandemic class. We planned this study to compare the performance of medical students during their pediatric clinical clerkship pre- and post-pandemic. METHODS: The study protocol was presented to the institutional review board (IRB). The IRB determined that the proposed activity is not research involving human subjects as defined by the Department of Health and Human Services and Food and Drug Administration regulations. For this study, the examination performance and
CONFLICT OF INTEREST: None
ACKNOWLEDGMENT: Authors would like to thank Ms. Shirley Turner for providing the data. DISCLOSURE: The result of this study is published as a comment in Medical Teacher. Manzar S. Study adaptation and NBME scores [published online ahead of print, 2023 Feb 25]. Med Teach . 2023;1. doi:10.1080/0142 159X.2023.2182661
ABSTRACT: Background:
The COVID-19 pandemic has impacted medical education. We planned this study to look at the performance of medical students pre- and post-pandemic during their pediatric clinical clerkship. Methods: We compared the quiz, National Board of Medical Examiners (NBME), and clerkship final grade scores of the two groups. Group A comprised the medical students from graduating class of 2022 who took pediatrics during the acceleration phase of the pandemic (true pandemic phase). Group B included the class of 2023, which took pediatrics during the deceleration phase.
Results: The true pandemic group comprised 134 students, while
24 J LA MED SOC | VOL 175 | SUMMER 2023
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