Established in 1844, our Journal is one of the oldest in the country. To learn more about the Journal and how to submit articles, please visit https://lsms.org/page/JLSMS.
141st ANNUAL MEETING 2022 JOURNAL OF THE LOUISIANA STATE MEDICAL SOCIETY VOL 174 | ISSUE 2 | FALL 2022 H D
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VOL 174 | ISSUE 2 | FALL 2022 CONTENTS
CHIEF EXECUTIVE OFFICER Jeff Williams
JOURNAL BOARD K. Barton Farris, MD Secretary/Treasurer, Richard Paddock, MD Anthony Blalock, MD
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PRESIDENTIAL SPEECH
L.W. Johnson, MD Fred A. Lopez, MD
LSMS ALLIANCE FOR LSMS NEWSLETTER
9 DURING THE 2022 LSMS ANNUAL MEETING OF THE HOUSE OF DELEGATES, NEW LSMS LEADERSHIP WAS SELECTED 10 CHRONIC SWELLING WITH PALPABLE MASS OF THE RIGHT ANKLE IN A MIDDLE-AGED MALE 12 A CASE OF RESPIRATORY TRACT INFECTION FROM BORDETELLA HINZII IN AN IMMUNOCOMPETENT PATIENT 14 INAUGURATION LUNCH 15 GALA 16 P ROCEEDINGS OF THE HOUSE OF DELEGATES 141ST ANNUAL MEETING 21 AWARDS & ACCOLADES 21 M EMBER ANNIVERSARY & IN MEMORIAM 22 COVID VACCINE ACCEPTANCE AND HESITANCY IN PEDIATRIC PATIENTS 26 L EFT LEG SWELLING: A CASE OF MAY-THURNER SYNDROME
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
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You believe the practice of medicine is a profession , not just a job. LAMPAC reasons to contribute to
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You are a patient who wants to ensure the right professional is providing the right care for your safety. You want to reduce red tape, regulations, and the hassle factor so you can get back to saving lives.
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You are tired of other professions dictating what you can and can’t do.
SECTION REPRESENTATIVES Young Physician Member, Matthew Giglia, MD Resident/Fellow Member, Omar Leonards, MD Medical Student Member, Shivani Jain Employed Physician Section Member, John Bruchhaus, MD Private Practice Physician Section Member, Katherine Williams, MD
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You know medical school matters.
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You want to make Louisiana a better place to practice medicine. You want to simply practice medicine.
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You want to send a message that your profession matters.
AMA DELEGATION Delegate, William Freeman, MD, Chair Delegate, Luis Alvarado, MD, Vice Chair Delegate, George Ellis, MD Delegate, Donald Posner, MD Alternate Delegate, Kamel Brakta, MD Alternate Delegate, Caleb Natale, MD Member in Training, Daniel Harper, MD
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You want your rights as a physician to be protected.
Because in Louisiana, if you’re not at the table; you’re on the menu.
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LOUISIANA MEDICAL POLITICAL ACTION COMMITTEE LAMPAC
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.
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.
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PRESIDENTIAL SPEECH JOHN NOBLE, JR., MD
ON SATURDAY, AUGUST 6, 2022, THE LOUISIANA STATE MEDICAL SOCIETY INSTALLED DR. JOHN NOBLE AS THE 142 ND PRESIDENT OF THE ORGANIZATION. Dr. Noble is originally from Lake Charles, Louisiana, and has 25 years of private practice experience. He joined the Center for Orthopaedics in 2000. He earned an undergraduate degree at McNeese State University and his Medical Degree from Louisiana State University Medical School in New Orleans. Dr. Noble completed an Orthopaedic Residency at LSU Medical Center, also in New Orleans, and a Fellowship at Baylor College of Medicine in Houston, Texas. He is Board Certified by the American Board of Orthopaedic Surgeons and is a Fellow of the American Academy of Orthopaedic Surgeons. Dr. Noble is actively involved in orthopaedic research projects involving hip and knee replacement. He is involved in patient and physician advocacy and has served in multiple leadership roles at the state and regional level throughout his career. Dr. Noble’s practice is now focused exclusively on sports medicine and joint replacement.
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“THERE IS NOTHING PERMANENT EXCEPT CHANGE” - HERACLITUS
DR. NOBLE GAVE THE FOLLOWING ADDRESS BEFORE THE 2022 HOUSE OF DELEGATES IN BATON ROUGE. practice of medicine by unqualified providers. There is a stark difference in education between physicians and non-physicians. Some legislators have attempted to negate this argument, but we must never allow this fact to be circumvented or denied. The same medical schools educating our students must stand up for their mission and market their value; otherwise, they risk their existence. Education really does matter! “Winston Churchill was known for his spry humor and his many quotes. Regarding speeches he said that a good speech should be like a woman’s skirt: long enough to cover the topic and short enough to create interest. I will try to adhere to those principals today.
In a similar way, Heraclitus was a Greek philosopher who lived about 500 years before the birth of Christ. Two quotes attributed to him are as relevant today as they were then. He stated, “There is nothing permanent except change,” This medical society was established in 1878. It would not be inaccurate to suggest that we have seen dramatic changes in our 144 years of existence. In what was known as the Golden Era of Medicine, we witnessed the invention of antibiotics and vaccines. We saved millions upon millions of lives for a relatively minimal investment. Years ago, patients were admitted to the hospital for weeks for relatively simple surgeries. Today, we can perform heart valve replacement and joint replacement as outpatient procedures-amazing technological advances that have dramatically changed people’s lives. But we now spend billions of dollars yearly on medications with questionable and marginal benefits. Many research projects conducted today are repetitious and of dubious value. Evidence-based guidelines are currently utilized and touted by so-called experts as a way to ration care by subverting the physician’s judgment, education, and intuition. We have seen significant expansions in the scope of practice of non- physicians under the guise of improving access to rural healthcare and the fallacy of cost reduction. Our senior citizens and the physicians that treat them are locked into an anti-free market system called Medicare that fixes the fee schedule. Regretfully, even France has a better payment system more aligned with capitalism and the free market. Our reimbursement is dictated by insurance companies that have monopsonies across the country. The profession we love and honor is attacked daily by state legislatures around the country. Even in the halls of Congress, we see bills threatening physicians’ livelihood. The greatest threat to our profession is legislation passed in state capitals around the country that permits the independent
In many cases, we are learning that corporations and private equity groups initiate scope of practice battles to drive business to its stores solely for profit, often disregarding safety and best practices. They employ allied health professionals, pharmacists, and mid-level providers and shockingly offer no oversight. Harrison’s Textbook of Internal Medicine was the Bible of our profession for generations. Today the Excel spreadsheet is the guide for corporate healthcare. We should urge the Louisiana Department of Health and our State Board of Medical Examiners to look into these arrangements. Quite simply, this state should forbid the corporate practice of healthcare. In the mid-1970s, we expanded the physician team to include mid- level providers. This strategy works relatively well when deployed correctly. Most mid-level providers are happy to be part of a physician-led team. From a personal perspective, I am fortunate to work with mid-level providers who are an essential part of my team and provide excellent service to my patients. Recently we have seen various groups of practitioners attempt to practice medicine independently. Only a tiny minority, however, is lobbying for complete independence. In some cases today, we see mid-level providers practicing in a different field of medicine than their collaborating or supervising physician. The most absurd example I have seen is a cardiologist collaborating with a nurse practitioner who performs facial cosmetic injections. We now see mid-level providers advertising specialty services without reference to a supervising or collaborating physician.
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ONCE AND FOR ALL, WE MUST END THE SCOPE OF PRACTICE BATTLES IN OUR STATE LEGISLATURE.
are here because you are the best society has to offer.” So to the physicians here today, I echo that you are the best society offers. By far and away, you are some of the most educated and dedicated people in our country. So, the best and brightest of society attend college, four years of medical school, and complete a three-year residency in primary care but might earn a lower starting salary than a community college graduate with a process technology degree. Why does this occur? It happens because of soaring overhead and ridiculous reimbursement policies. This is not economic justice. But behind every storm cloud is a silver lining. I have great hope and optimism for the future. Despite the problems we face today, there is no greater privilege than that of a healer. It is an incredible honor that patients trust us enough to treat them and to share their most personal secrets. They trust us enough to perform potentially life-threatening procedures on them. There is no greater sense of accomplishment than curing a life-threatening infection or a patient’s cancer. There is exhilaration when we fix a patient’s hip or open a clotted vessel. Heraclitus also said, “big results require big ambitions.” Our staff and our physician leaders have grand ambitions. We envision a modern medical society focused on growing its membership. We will do this by providing value-added services such as affordable health insurance and improved 401{k) plans for our members. We will foster an improved business environment for our colleagues. It is my desire for us to partner with new regional and national associations focused on improving business fundamentals to support the independent practice of medicine for those who desire to remain independent. Our executive director and staff have catalyzed the growth of the physician coalition. We will continue to grow this coalition and work collaboratively with specialty societies. There are many other initiatives underway, some too premature to announce, but suffice it to say that we will work very hard for our state’s physicians. It has been an absolute honor to address such a distinguished audience this afternoon. I want to thank the House of Delegates for selecting me as the next president of our esteemed organization. I am honored and humbled. I am fortunately the beneficiary of an excellent executive director and supporting staff. I would be remiss, however, if I failed to acknowledge my family for enduring my absences over the years. Of course, this is not unique to me and is something virtually all physician families go through. My wife has tolerated my overflowing schedule for 27 years. This sacrifice has allowed my practice to flourish, allowing me to help many patients along the way and has allowed me to participate in such things as organized medicine.
The collaborative practice agreement is broken and must be reformed. We must continue to improve the standards that govern these agreements. Admittedly, some of our colleagues who collaborate must also do better. We must call on our boards and agencies to resolve this impasse. Legislators are not qualified to determine who should be practicing medicine. I know this because they say so. I have also heard them say they would love to resolve this issue permanently so that collectively we can focus on matters crucial to our state. We must emulate other states that have been successful in resolving this issue. Once and for all, we must end the scope of practice battles in our state legislature. Most physicians didn’t go to medical school to fight political battles. Many of us feel it is undignified to be involved in the political process. However, this attitude and lack of interest and engagement have allowed many groups to chip away at privileges previously felt to be sacrosanct. We must be courageous and do everything in our power to fight the push to diminish the physician’s role as the team leader. Our opponents are outraising us and outspending us, particularly when adjusted for per capita earnings. Our members must engage in political dialogue and fundraising. We must never, ever give up the fight for patient safety. Our medical society has indeed changed, which is necessary and inevitable. In years past, we had the luxury of being an organization that could be all things to everyone. But over generations, we have seen the development of specialty societies that have sometimes fractured our unity. As with all organizations today, we struggle with limited resources. We can no longer be a social organization or one consumed by frivolous tasks and objectives. We must solely focus our attention on preserving our profession so that we may better care for patients and improve the quality of life for society. How can we provide the best care for our patients if we constantly look over our shoulders? There are many political sensibilities amongst physicians, particularly those of different generations. Some organizations spend time and resources on issues that don’t affect the day-to- day business of physicians. I prefer alignment with national and regional organizations that care less about climate change and more about economic fairness for the most educated of our society. Inflation has had a devastating impact on physician earnings over the years. We’ve seen our fees reduced dramatically when compared to inflation adjusted dollars over the last 40 years. Where are our national leaders? Why are they not yelling from the rooftops to fix this travesty?
May God bless all of you, and may God bless and protect our great profession.” ■
In the first few weeks of medical school, I had a professor who said something which has remained with me forever. He said, “You
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LSMS ALLIANCE SEPTEMBER 26, 2022
ALLIANCE
UPDATE ON STATE ALLIANCE ACTIVITIES The LSMS Alliance members have advanced to a new year, 2022-23, with President Rose Kuplesky. Now that the worst of Covid seems to be behind us, we look forward to resuming our normal Alliance activities.
Not only for 2020-2021 was Covid ravaging our state and country, but also hurricanes damaged much of our southern part of the state, especially the Lake Charles and the New Orleans areas. Many citizens in the south Louisiana did not have homes or work places for many months due to hurricane damage. We also extend condolences for all of the family members who were lost due to Covid 19 illnesses. Through the two years of Covid, your state Alliance has continued to support our local Alliances and our communities. We especially thank the local Alliances that continued to meet and collect dues and encourage the other Alliances to regroup and plan for the future. During 2020 and 2021, the state Alliance provided grants for all of the local Alliances in the form $600 each. With Covid causing many of our citizens to not be able to work and needing assistance with food cost, your state Alliance made donations of $1,000 each to five Louisiana Food Banks. Your State Alliance and local Alliances, Avoyelles, Capital Area, Orleans, and Shreveport, held fundraisers to donate $10,000 to the Louisiana “Toys for Tots”.
The State Alliance Annual Meeting was held at the Baton Rouge Hilton Capital Center on August 6, 2022 and it was a welcome event to be able to visit in person again. Our special guest was an AMA Alliance past President Sue Ann Greco. In 2020 and 2021, your State Alliance met on computer Zoom and conference calls to continue to support and encourage local Alliances to continue as much as possible. Your State Alliance delegation of Cindy Leopard, Rose Kuplesky, Marci Freeman, and Emma Borders again attended, since 2019, an in-person Annual Meeting in Chicago of the AMA Alliance on June 12-14, 2022. With William Freeman, LSMS President, we all attended the beautiful and outstanding AMA Alliance 100th Anniversary Celebration. Our state Alliance President, Rose Kuplesky, will be attending the Southern Medical Association and Alliance Annual Meeting, Pigeon Forge, TN, October 28-29, 2022. Our longtime LSMS Alliance and Society member, Donna Breen, MD, Avoyelles Parish, has had the honor of serving this year as Southern Medical Association President.
With much enthusiasm we are looking forward to returning to our Alliance activities. ■
2022-23 OFFICERS President
Second Vice-President Anita White Third Vice-President Betty DeMars
Secretary/Treasurer Emma Borders Past President Cindy Leopard
Rose Kuplesky First Vice-President Connie Boyer
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DURING THE 2022 LSMS ANNUAL MEETING OF THE HOUSE OF DELEGATES, NEW LSMS LEADERSHIP WAS SELECTED
BOARD OF GOVERNORS
JOHN NOBLE, JR., MD President
RICHARD J. PADDOCK, MD President-Elect
WILLIAM FREEMAN, MD Immediate Past President
THOMAS TRAWICK, MD Speaker
ROBERT NEWSOME, MD Vice Speaker
AMBERLY NUNEZ, MD Secretary-Treasurer
DAVID BROUSSARD, MD Chair, COL
SUSAN BANKSTON, MD Ex Officio, LAMPAC, Acting Chair
BOARD OF GOVERNORS
BOARD OF COUNCILORS
AMA DELEGATION
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Matthew Giglia, MD Young Physician Member Omar Leonards, MD Resident/Fellow Member Shivani Jain Medical Student Member John Bruchhaus, MD
Myra Kleinpeter, MD District One Luis Arencibia, MD District Two Allan Vander, MD District Three Richard Michael, MD District Four Gwenn Jackson, MD District Five
Michael Roppolo, MD District Six Brian Gamborg, MD District Seven Lance Templeton, MD District Eight Andy Blalock, MD District Nine Nicholas Viviano, MD District Ten
William Freeman, MD Delegate Luis Alvarado, MD Delegate George Ellis, MD Delegate Donald Posner, MD Delegate Kamel Brakta, MD Alternate Delegate Caleb Natale, MD Alternate Delegate Daniel Harper, MD Member in Training
Employed Physician Section Member Katherine Williams, MD Private Practice Physician Section Member
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CHRONIC SWELLING WITH PALPABLE MASS OF THE RIGHT ANKLE IN A MIDDLE-AGED MALE MITCHELL TA, BS, AHMED T. RASHAD, MD, NEEL D. GUPTA, MD, JEREMY NGUYEN, MD, FACR
HISTORY 51-year-old male presents with longstanding mass and swelling along the lateral aspect of the ankle.
Chronic Swelling with Palpable Mass of the Right Ankle in a Middle-Aged Male Mitchell Ta, BS, Ahmed T. Rashad, MD, Neel D. Gupta, MD, Jeremy Nguyen, MD, FACR HISTORY 51-year-old male presents with longstanding mass and swelling along the lateral aspect of the ankle.
Figure 1
Figure 2
Figure 2. Axial T1 and T2 FS MRI
Figure 1. AP radiograph at the level of the lateral malleolus.
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Figure 3. Sagittal T1 and T2 FS MRI
Figure 4. Coronal T1 and T2 FS MRI
Figure 4. Coronal T1 and T2 FS MRI
Figure 1. AP radiograph at the level of the lateral malleolus. Figure 2. Axial T1 and T2 FS MRI Figure 3. Sagittal T1 and T2 FS MRI Figure 4. Coronal T1 and T2 FS MRI IMAGING FINDINGS Figure 1. Frontal radiograph of the ankle demonstrates soft tissue prominence immediately superficial and inferior to the lateral malleolus with interspersed soft tissue heterogenous radiolucency as noted by the red arrows.
of peroneal tenosynovitis with prominent frond-like tissue containing fat signal. IMAGING FINDINGS Figure 1. Frontal radiograph of the ankle demonstrates soft tissue prominence immediately superficial and inferior to the lateral malleolus with interspersed soft tissue heterogenous radiolucency as noted by the red arrows. IMAGING FINDINGS Figure 1. Frontal radiograph of the ankle demonstrates soft tissue prominence immediately superf and inferior to the lateral malleolus with interspersed soft tissue heterogenous radiolucency as not the red arrows. Figure 2. Axial T1 and T2 FS MRI images demonstrate a large amount of fluid within the peroneal tendon sheath reflective of peroneal tenosynovitis with prominent frond-like tissue containing fat signal. Figure 3. Sagittal T1 and T2 FS MRI images demonstrate a large amount of fluid within the peroneal tendon sheath reflective of peroneal tenosynovitis with prominent frond-like tissue containing fat signal. Figure 4. Coronal T1 and T2 FS MRI images demonstrate a large amount of fluid within the peroneal tendon sheath reflective of peroneal tenosynovitis with prominent frond-like tissue containing fat signal. Figure 2. Axial T1 and T2 FS MRI images demonstrate a large amount of fluid within the peroneal tendon sheath reflective of peroneal tenosynovitis with prominent frond-like tissue containing fat s Figure 3. Sagittal T1 and T2 FS MRI images demonstrate a large amount of fluid within the peronea tendon sheath reflective of peroneal tenosynovitis with prominent frond-like tissue containing fat s Figure 4. Coronal T1 and T2 FS MRI images demonstrate a large amount of fluid within the peronea tendon sheath reflective of peroneal tenosynovitis with prominent frond-like tissue containing fat s Figure 3. Sagittal T1 and T2 FS MRI images demonstrate a large amount of fluid within the peroneal tendon sheath reflective of peroneal tenosynovitis with prominent frond-like tissue containing fat signal. Figure 4. Coronal T1 and T2 FS MRI images demonstrate a large amount of fluid within the peroneal tendon sheath reflective of peroneal tenosynovitis with prominent frond-like tissue containing fat signal.
Figure 2. Axial T1 and T2 FS MRI images demonstrate a large amount of fluid within the peroneal tendon sheath reflective
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DIFFERENTIAL DIAGNOSIS 1. Lipoma Arborescens
DIFFERENTIAL DIAGNOSIS 1. Lipoma Arborescens
DIFFERENTIAL DIAGNOSIS 1. Lipoma Arborescens 2. Pigmented Villonodular Synovitis (PVNS) 3. Synovial Chondromatosis 4. Rheumatoid Arthritis 5. Intra-articular Synovial Liipoma FINAL DIAGNOSIS Lipoma Arborescens of the Peroneal Sheath
intensity on T1 weighted images and varying signal intensity on T2 weighted images, depending on the extent of ossification. Intermediate T1 and T2 signal intensity noted with rheumatoid arthritis due to areas of fibrosis. Additionally specific laboratory values are noted with rheumatoid arthritis. REFERENCES 1. Sanamandra SK, Ong KO. Lipoma arborescens. Singapore Med J. 2014;55(1):5-11. doi:10.11622/smedj.2014003 2. Babar SA, Sandison A, Mitchell AW. Synovial and tenosynovial lipoma arborescens of the ankle in an adult: a case report. Skeletal Radiol. 2008Jan;37(1):75-7 3. A. Hoffa, “The influence of the adipose tissue with regard to the pathology of the knee joint,” The Journal of the American Medical Association, vol. 43, no. 12, pp. 795–796, 1904. 4. Meyers SP. MRI of bone and soft tissue tumors and tumorlike lesions, differential diagnosis and atlas. Thieme Publishing Group. (2008) ISBN:3131354216. 5. Y. Dogramaci, A. Kalaci, T. T. Sevinç, E. Atik, E. Esen, and A. N. Yanat, “Lipoma arborescens of the peroneus longus and peroneus brevis tendon sheath: case report,” Journal of the American Podiatric Medical Association, vol. 99, no. 2, pp. 153–156, 2009. 6. Vilanova JC, Barceló J, Villalón M, Aldomà J, Delgado E, Zapater I. MR imaging of lipoma arborescens and the associated lesions. Skeletal Radiol. 2003 Sep;32(9):504-9. doi: 10.1007/s00256-003-0654-9. Epub 2003 Jun 17. PMID: 12811424. 7. Patil PB, Kamalapur MG, Joshi SK, Dasar SK, Rao RV. Lipoma arborescens of knee joint: role of imaging. J Radiol Case Rep. 2011;5(11):17-25. doi: 10.3941/jrcr.v5i11.783. Epub 2011 Nov 1. PMID: 22470770; PMCID: PMC3303421.
DISCUSSION Lipoma arborescens, also known as synovial lipomatosis, is a rare, benign lesion characterized by diffuse proliferation and infiltration of sub-synovial connective tissue by mature adipose cells forming hypertrophic synovial villi 1 . Lipoma arborescens was first described in 1904 by Hoffa 3 and named for its macroscopic treelike morphology. Typically unilateral, it most often involves the suprapatellar pouch and presents between the 5th to 7th decades as an insidious onset of intermittent exacerbation of pain and swelling. Isolated involvement of the tenosynovial sheath is exceedingly rare – in such cases, there is often preferential involvement around the ankle joint 2,5 . While most often occurring without any antecedents, lipoma arborescens is often associated with inflammation, joint disease and trauma 4 . Although typically monoarticular, bilateral involvement has been reported in approximately 20% of patients with lipoma arborescens 6 . Rare cases of lipoma arborescens of the synovial joints presents with intermittent insidious swelling, followed by pain caused by trapping of the frond-like projections within the joint space 5 . As the clinical presentation of lipoma arborescens is often nonspecific, other pathologies must be ruled out through evaluation of laboratory values as well as sampling of synovial fluid through joint aspiration. MRI often is sufficient to make the diagnosis, given its pathognomonic appearance of an ill-defined, nonencapsulated synovial mass with frond-like configuration and concurrent joint effusion 6 . Both T1 and T2-weighted sequences demonstrate high signal intensity frond-like tissue, with saturation on fat suppressed sequences noted. Lipoma arborescens is characterized by soft tissue prominence, as demonstrated by radiographs of the ankle in our case. Histopathological analysis demonstrates villous papillary proliferation with replacement of subsynovial tissue by mature adipocytes 7 . Imaging differential diagnosis includes pigmented villonodular synovitis (PVNS), synovial chondromatosis, rheumatoid arthritis, and intra-articular synovial lipoma. While PVNS manifests as joint swelling in a similar age group, on MRI PVNS is characterized by low signal intensity on all sequences due to hemosiderin deposition (characteristic blooming on gradient echo) 8 . Synovial chondromatosis demonstrates intermediate to low signal
8. Garner H, Ortiguera C, Nakhleh R. Pigmented Villonodular Synovitis. RadioGraphics. 2008;28(5):1519-23.
ACKNOWLEDGEMENTS Mitchell Ta is a 4th year Medical Student at Tulane University School of Medicine in New Orleans, La. Ahmed T. Rashad MD is a PGYIV Resident in the Department of Radiology at Tulane University School of Medicine in New Orleans, La. 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. Jeremy Nguyen MD, FACR is clinical radiology professor within the Department of Radiology at the Tulane University Medical Center. Donald Olivares, Digital Imaging Specialist and Graphic Designer. ■
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A CASE OF RESPIRATORY TRACT INFECTION FROM BORDETELLA HINZII IN AN IMMUNOCOMPETENT PATIENT
Sangya Sharma - Edward Via College of Osteopathic Medicine, Blacksburg, Virginia
Correspondence to: Kamal Masri, MD Pulmonary Disease/Critical Care Medicine Willis Knighton Health System, Shreveport, Louisiana Email: kmasrimd@gmail.com Phone: (318) 212- 8159
Kamal Masri - Department of Pulmonary Disease/Critical Care Medicine, Willis Knighton Health System
ABSTRACT Bordetella hinzii is a primarily zoonotic organism and rarely affects immunocompetent individuals. We report the case of a healthy 45 year old male who presented with chronic cough and dyspnea and was diagnosed with Bordetella hinzii infection of the lower lungs from imaging and bronchoscopy. He was then discharged on a course of antibiotic treatment.
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Keywords: Bordetella pertussis, Bordetella hinzii, immunocompromised
CASE PRESENTATION A healthy 45 year old male presented with an ongoing history of cough and shortness of breath for four months. He had a history of recurrent sinusitis and seasonal allergies. He was placed on multiple course of oral antibiotics and steroids with partial improvement in his symptoms. His overall labs and urinalysis were unremarkable. Immunology/serology were negative for Aspergillus, Cryptococcus,
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Tracheobronchial Tree
Figure 1. Ultrasound-guided bronchoscopy visualizing bilateral endobronchial segments
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Left mainstem bronchus
Left mainstem bronchus
Left lower lobe
Trachea
Figure 1. Ultrasound-guided bronchoscopy visualizing bilateral endobronchial segm Figure 1. Ultrasound-guided bronchoscopy visualizing bilateral endobronchial segm
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Trachea ltrasound-guided bronchoscopy visualizing bilateral endobronchial segments rtarsaos uo nu dn -dg- ug iudi edde db rbor no cnhc oh socsoc po yp yv ivsius aulai zl iizni gn gb ibl ai l taetrearla el ne dn od bo rbor no cnhc ihai la sl esge mg me ne tnst s 12 J LA MED SOC | VOL 174 | FALL 2022
Right mainstem bronchus
Right upper lobe
Right lower lobe
The Bordetella species can be subdivided into classical and non classical subspecies. The classical subspecies include Bordetella bronchiseptica , B ordetella pertussis , and Bordetella parapertussis . 9 The nonclassical species include Bordetella hinzii , among many others. 4 Classical bordetellae cause disease of the respiratory tract of their natural hosts, whereas nonclassical species may also cause wound infections and bacteremia. 4 Bordetella hinzii is known to cause respiratory disease in poultry and rodents. 4 It has been associated with infections in immunocompromised humans, including bacteremia, septicemia, respiratory disease, and chronic cholangitis. 4 In the United States as of November 2021, there have been 18 reported cases of B. hinzii primarily in patients with cystic fibrosis, HIV/AIDS, and those undergoing immunosuppressant therapy. 3 Humans may become infected by aerosols from the avian reservoirs and may develop pulmonary infection long after exposure. 4 Survival in the digestive tract is another specificity of B. hinzii among the Bordetella species. 4 Studies have shown positive culture results from rectal swab samples of those infected. 4 Thus, this pathogen is likely to be transmitted by the oral route, possibly after ingestion of contaminated poultry products or swallowing of respiratory secretions. 4 Recent studies have shown that soil may also serve as an environmental niche for this pathogen. 5 SUMMARY Bordetella hinzii is an uncommon cause of pulmonary infections in immunocompetent patients. The infection does not prefer a particular location of the lungs. Its mode of transmission is through droplets or ingestion. It is primarily a zoonotic infection, most commonly caused by rodent and/or avian exposure. Lung infection has not been reported in healthy individuals such as the patient in this case report. REFERENCES 1. Donato GM, Hsia HLJ, Green CS, Hewlett EL. Adenylate cyclase toxin (ACT) from Bordetella hinzii: characterization and differences from ACT of Bordetella pertussis. J Bacteriol . 2005;187(22):7579-7588. doi:10.1128/JB.187.22.7579-7588.2005 2. B hinzii Pneumonia and Bacteremia in a SARS-CoV-2 Patient. Medscape. Accessed August 7, 2022. https://www. medscape.com/viewarticle/961650
Coccidiocides, and Histoplasma antibodies. Histoplasma antigen was negative in both serum and urine. His expectorant was negative for any acid-fast bacilli. The patient’s chest x-ray and CT angiography were unremarkable. The CT scan of the lung with contrast ( Figure 1 ) showed bronchial wall thickening and tree-in-bud infiltrate predominantly involving the lower lobes, hinting at possible malignancy or atypical infection. The patient subsequently underwent ultrasound-guided bronchoscopy. Findings included thick endobronchial mucus with diffuse inflammation of the airway. Bronchioalveolar lavage ( Figure 2 ) was performed in the right upper lobe apical segment and sent for cell count and bacterial/viral/fungal analyses. There were no malignant cells, but sample cultures were positive for Bordetella hinzii . The patient was administered IV piperacillin/tazobactam and discharged after 2 days with PO amoxicillin/clavulanate 6.5 mg BID for 10 days. qfrueiqnuoelonntleysr. esistant to many antimicrobial drugs, including β-lactams, cephalosporins, and 2 Reported isolates have been susceptible to piperacillin/tazobactam, ceftazidime, tigecycline, and meropenem. 9 /18/22 9:53:00 PM The presence of a novel beta-lactamase gene in B. hinzii makes it less susceptible to amoxicillin. 3 In this case, amoxicillin/clavulanate was prescribed for outpatient use. However, the choice of antimicrobial drugs and treatment duration have not been standardized. 4 The Bordetella species can be subdivided into classical and non classical subspecies. The classical subspecies include Bordetella bronchiseptica , Bordetella pertussis, and Bordetella parapertussis . 9 The nonclassical species include Bordetella hinzii , among many others. 4 Classical bspoercdieetsemllaaeycaalusosecdauisseeawseooufntdheinrfeescptiiorantsoarnydtrbaaccttoefrethmeiiar. natural hosts, whereas nonclassical 4 Bordetella hinzii is known to cause DISCUSSION B. hinzii is a species of gram-negative coccobacilli that exhibit weaker virulence than B. pertussis because of the reduced activity of the adenylate cyclase toxin (ACT). 1 This is due to decreased binding affinity of B. hinzii to calmodulin, the eukaryotic activator of the B. pertussis ACT and due to the lack of the cyaC gene needed to acylate the ACT. 1 Additionally, B. hinzii is frequently resistant to many antimicrobial drugs, including β-lactams, cephalosporins, and quinolones. 2 Reported isolates have been susceptible to piperacillin/tazobactam, ceftazidime, tigecycline, and meropenem. 9 /18/22 9:53:00 PM The presence of a novel beta-lactamase gene in B. hinzii makes it less susceptible to amoxicillin. 3 In this case, amoxicillin/clavulanate was prescribed for outpatient use. However, the choice of antimicrobial drugs and treatment duration have not been standardized. 4 Figure 2 . Axial image of chest computed tomography of lower lobes of the lung with infiltrates as labeled. Discussion B. hinzii is a species of gram-negative coccobacilli that exhibit weaker virulence than B. pertussis because of the reduced activity of the adenylate cyclase toxin (ACT). 1 This is due to decreased binding affinity of B. hinzii to calmodulin, the eukaryotic activator of the B. pertussis ACT and due to the lack of the cyaC gene needed to acylate the ACT. 1 Additionally, B. hinzii is Figure 2. Axial image of chest computed tomography of lower lobes of the lung with infiltrates as labeled.
3. Gregory S, Gregory IS, Fleckenstein J. Three Cases of Bordetella hinzii, United States. Published online 2021:7.
4. Fabre A, Dupin C, Bénézit F, et al. Opportunistic Pulmonary Bordetella hinzii Infection after Avian Exposure - Volume 21, Number 12—December 2015 - Emerging Infectious Diseases journal - CDC. doi:10.3201/eid2112.150400 5. Hamidou Soumana I, Linz B, Harvill ET. Environmental Origin of the Genus Bordetella. Front Microbiol . 2017;8:28. doi:10.3389/fmicb.2017.00028 ■
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INAUGURATION LUNCH The House of Delegates was recessed and members attended the Inauguration Lunch in the Heidelberg room. John Noble, Jr., MD was installed and past presidents in attendance were introduced.
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GALA Delegates and guests danced the night away to the Rewind band while enjoying hors d’oeuvres and cocktails. A champage toast was presented by Katherine Williams, MD. President-Elect Richard Paddock, MD performed Mustang Sally for the group - what a night!
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PROCEEDINGS OF THE HOUSE OF DELEGATES 141ST ANNUAL MEETING H D
CALL TO ORDER Thomas Trawick, Jr., MD, Speaker of the House called the opening session of the Annual Meeting to order at 9:00AM on Saturday, August 6, 2022 at the Hilton Baton Rouge Capitol Center in Baton Rouge, Louisiana. Trenton James, II, MD offered the invocation then the Pledge of Allegiance was recited. RECOGNITION OF DECEASED LSMS MEMBERS Physician members passing August 2021 through August 2022 include : David Aiken, MD, Robert Albrecht, MD, James Ball, MD, Thomas Canale, MD, Charles Cefalu, MD, Milton Chapman, MD, Patricia Cook, MD, John Cooksey, MD, Erwin Engert, MD, David L. Glancy, MD, Henry Hollenberg, MD, Jill Lindberg, MD, and Patrick Unkel, MD.
Any delegate has the right to extract any item from either the proceedings of the HOD or BOG to be debated. If anything was extracted from those proceedings, debate on those items only would occur immediately. Additionally, the Speakers reminded delegates that minutes from BOG meetings cannot be changed. Dr. Trawick reminded the delegates of the process by which resolutions are numbered and categorized. He reiterated the Speakers make only minor editorial changes to the resolve segment of resolutions to clarify their structure prior to publication and mailing to the House. He emphasized most are grammatical or procedural in nature and do not reflect any change to the intent of the resolution. He noted any portion of a resolve can be amended during debate. Because the WHEREAS portions of resolutions are dropped once resolves are adopted, each resolve should always be in a form which can stand alone after adoption. Dr. Trawick noted the procedure for offering amendments. Amendments should be submitted to the designated LSMS staff member in the back of the House. When the author wishes to introduce an amendment, he will say so then the coordinating amendment will be displayed on the screens. Dr. Trawick explained that the meeting would follow the rules of Sturgis. Dr. Trawick reminded attendees that when speaking at the microphones to identify yourself, who you represent, and state whether you support or oppose the resolution or amendment.
REMARKS OF THE SPEAKER Thomas Trawick, Jr., MD, Speaker of the House began his remarks by welcoming all participants and thanking them for making the trip to Baton Rouge.
Dr. Trawick announced that the procedure for elections for offices elected by the House of Delegates would be outlined by the Committee on Rules and Order of Business. The Speakers prepared election sheets for all elected offices and previously announced candidates for each office as a slate of candidates which will be presented to the House. As each position comes up for election, the Speakers will indicate the announced candidate(s) and call for any additional nominations from the floor.
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REMARKS OF THE PRESIDENT Dr. Trawick introduced William Freeman, MD to give him an opportunity to address the House.
Thanks to you, White coat Wednesday and the legislative reception the night before were the largest attended in many years. We had over 100 doctors in attendance which is a huge increase from the 20 doctors we had present several years ago. In February, LSMS put on its first “Boot Camp” - Candidate School for physicians. We brought in some of the most successful, brightest minds and instructors to teach physicians how to become a candidate, run, finance, and ethically manage a campaign. It was very well attended, and we plan to continue this educational conference in the future. We expect great things as a result of this conference and can’t wait to celebrate when a physician once again walks the hallowed halls of our state legislature.
“I want to start out by saying thank you! Thank you all for the support you have provided me over the past year. It has been an absolute pleasure and honor to serve as your President. I want to personally thank the Board of Governors, the other officers and especially the LSMS Staff for their support and guidance over the past year. Jeff, Maria, Lauren, Terri, Sarah and all the LSMS staff, you have been absolutely amazing in all you have accomplished and in your support for us as a board and for the membership of the LSMS. I want to thank my wife, Marci Freeman, for her continued love and support during my tenure as your president. Thank you for being there, supporting me, and helping me be the best president and husband I can be. Most of all I want to say thank you to all the physicians present here today and our members across the state. Last year, I put out a call to action declaring that the house of medicine was under attack. I challenged each of you to get out of you comfort zones, step up, and fight for the practice of medicine. And step up you did! Legislatively our team of lobbyists have worked diligently this session on 6 scope bills, 38 antivaccine bills, 4 noncompete bills, 2 medical malpractice bills, and 1 antitrust bill along with supporting several other bills that we put forth. This list does not include the many other bills they followed and tracked during this session. They were also diligently involved in passing a package of bills aimed at relieving the administrative burden on our practices. It was a very busy and hectic session this year. They worked to streamline the text and email messaging to our members to get us involved at the right time and with the right message to our legislators. This was extremely helpful in both passing and defeating several pieces of legislation this year. Thank you for responding when the texts and emails went out. Under LSMS leadership we continue to maintain our coalition of 21 specialty societies and their legislative efforts this past year. If you have not read the latest edition of The Journal, I would strongly encourage you to read it and learn first-hand of the success stories of our Council on Legislation, the LSMS, our team of lobbyist, and most importantly the difference your individual contacts and contributions made in the process. Through LAMPAC we have been able to raise money to support those legislators who most supported our causes. With your help and financial contributions this past year, we put on 2 extremely successful fundraisers for our candidates and definitely caught the attention of the legislature. Through your efforts we raised right at $100,000 for their campaigns. Thank you for your donations to LAMPAC and the candidates that support our efforts.
I leave you with one thought told to me by Maria, “In order to get politics out of medicine, doctors have to get involved in politics.”
While our recruiting efforts could have been better, we did increase our membership by a small percentage this past year. I challenge you to continue to recruit your colleagues and tell them the reasons why their participation is important to the practice of medicine. We need to continue to strengthen our recruiting efforts in the specialty organizations and encourage those physicians to join the LSMS as well. This way we can put forth a united front in the challenges we face. It has been a very fast paced year on all fronts for your Board of Governors. Through the direction of the HOD, we added an employed physician and an independent practice physician to help us address the unique needs and problems that these providers face on a daily basis. We also addressed the issues sent to the board from the HOD last session. Your board has been working on a peer-to-peer wellness program for its members. We continue to finalize the plans for a health insurance plan for the members through the Advantage Physicians Health Trust and should be available very soon. We formed two task forces to address scope of practice issues and the corporate practice of medicine in Louisiana. We as your board have traveled to Lafayette and to Lake Charles for our board meetings and will be going to Monroe in September. We look forward to a reception the Tuesday night before our meeting and would welcome any member from the area to attend. Jeff and I and other members of the LSMS staff have attended several parish society meetings to provide them with updates on the LSMS and on our legislative efforts. Fortunately, the majority of our meetings have been in person and not on Zoom! It has been great being able to travel and meet face to face once again. As you can see your BOG and LSMS Staff have been very busy on your behalf. In conclusion, I would challenge each of you continue the fight for the house of medicine. Get involved. Join LAMPAC. Run for office. Be an active member. Run for the Board of Governors. Run for leadership
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IN ORDER TO GET POLITICS OUT OF MEDICINE, DOCTORS HAVE TO GET INVOLVED IN POLITICS.
the floor for one minute for the purpose of rebuttal or to summarize his/her position.
positions of the LSMS. Do your part! Continue to fight for the house of medicine.”
REPORT OF THE CREDENTIALS COMMITTEE Trenton James, II, MD, Committee Chair, reported that a quorum of certified delegates was present and seated.
2. Election packet was approved as presented.
3. Recommends there shall be no unauthorized audio or video recordings nor any live audio or video transmission of the proceedings of the HOD. The only exceptions will be for the address of the outgoing president and the inauguration speech of the incoming president. 4. Late Resolutions L-1, L-2 and L-3 were submitted by the Board of Governors and do not need approval from this Committee.
REPORT OF THE COMMITTEE ON RULES AND ORDER OF BUSINESS
Anthony Blalock, MD, Chair, presented the report of the Committee on Rules and Order of Business which met earlier in the day. The Committee recommended the following rules for use by the 2022 House of Delegates: 1. Limitation of Debate: The tradition of previous meetings regarding limitation of debate be as follows: Each speaker addressing an item brought to the floor for a vote is limited to two minutes of debate. Each delegate may return to
The report and recommendations of the committee on Rules and Order of Business were approved by the House of Delegates.
ELECTIONS: THE FOLLOWING MEMBERS WERE ELECTED TO SERVE: BOARD OF GOVERNORS Position Name Term President-Elect Richard Paddock, MD 2022 Speaker, House of Delegates Thomas Trawick, Jr., MD 2022 Vice Speaker, House of Delegates Robert Newsome, MD 2022 Secretary-Treasurer Amberly Nunez, MD 2022 Chair, Council on Legislation David Broussard, MD 2022 Medical Student Member Shivani Jain 2022 Resident Member Omar Leonards, MD 2022 Young Physician Member Matthew Giglia, MD 2022 Employed Physician Member John Bruchhaus, MD 2022 Private Practice Physician Section Katherine Williams, MD 2022
AMA DELEGATION Position
Name
Term
Delegate Delegate
George Ellis, MD Donald Posner, MD Daniel Harper, MD
2022-2024 2022-2024 2022-2023
Alternate Member in Training
COUNCIL ON LEGISLATION Position
Name
Term 2022 2022 2022
Medical Student Member
Paige Wilson
Resident Member
Omar Leonards, MD Matthew Giglia, MD
Young Physician Member
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