The Louisiana State Medical Society was formed in 1878 with the sole purpose of advancing "healthcare in the state of Louisiana. Today our mission is to be the trusted advocate for patients and physicians in the State of Louisiana. Learn more about the history of LSMS here: https://lsms.org/page/History.
JOURNAL OF THE LOUISIANA STATE MEDICAL SOCIETY VOL 176 | ISSUE 1 | FALL 2024 — 2024 LSMS — ANNUAL MEETING NEW FORMAT + NEW LOCATION = SUCCESS!
VOL 176 | ISSUE 1 | FALL 2024 CONTENTS
CHIEF EXECUTIVE OFFICER Jeff Williams
JOURNAL BOARD K. Barton Farris, MD Secretary/Treasurer, Richard Paddock, MD Anthony Blalock, MD
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2024 LSMS ANNUAL MEETING: FAMILIES, FUN, EDUCATION, POLICIES, AND SMORES, OH MY!
L.W. Johnson, MD Fred A. Lopez, MD
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PRESIDENTIAL SPEECH
8 PERIPHERAL ARTERY DISEASE: A CLUE TO POLY-VASCULAR DISEASE IN NEED OF FEDERAL LEGISLATIVE RECONSIDERATION 11 2024 LSMS LEADERSHIP 12 VANISHING PALPABLE MASS IN A YOUNG FEMALE PATIENT 15 SEBACEOUS CARCINOMA OF THE EYELID: A CASE REPORT OF A MULTIDISCIPLINARY APPROACH 18 PROCEEDINGS OF THE HOUSE OF DELEGATES, 143RD ANNUAL MEETING 26 143RD ANNUAL MEETING MINUTES 26 LOUISIANA STATE MEDICAL SOCIETY CHARTER ARTICLE VI
BOARD OF GOVERNORS President, Roderick Clark, MD Immediate Past President, Richard Paddock, MD President-Elect, Steen Trawick, MD Secretary - Treasurer, Amberly Nunez, MD Speaker, R. Reece Newsome, MD Vice Speaker, Katherine Williams, MD Col, Chair, Matthew Giglia, MD Ex Officio, Lampac, Chair, Susan Bankston, MD
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BOARD OF COUNCILORS District One, Myra Kleinpeter, MD District Two, Luis Arencibia, MD District Three, Allan Vander, MD District Four, Randall White, MD District Five, Gwenn Jackson, MD District Six, Michael Roppolo, MD District Seven, Brian Gamborg, MD District Eight, VACANT District Nine, Andy Blalock, MD District Ten, Michele Cooper, MD
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LAMPAC reasons to contribute to
1. You believe the practice of medicine is a profession , not just a job. 2. You are a patient who wants to ensure the right professional is providing the right care for your safety. 3. You want to reduce red tape, regulations, and the hassle factor so you can get back to saving lives. 4. You are tired of other professions dictating what you can and can’t do. 5. You know medical school matters.
6. You want to make
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Louisiana a better place to practice medicine.
7. You want to simply practice medicine. 8. You want to send a message that your profession matters. 9. You want your rights as a physician to be protected. 10. Because in Louisiana, if
SECTION REPRESENTATIVES Medical Student Section Member, Gregory Laborde Resident/Fellow Section Member,Omar Leonards, MD Young Physician Section Member, Ken Ehrhardt, MD Employed Physician Section Member, Clay Runfalo, MD Private Practice Physician Section Member, Lance Templeton, MD
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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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2024 LSMS ANNUAL MEETING: FAMILIES, FUN, EDUCATION, POLICIES, AND SMORES, OH MY!
Membership IT’S TIME TO RENEW More than a
On behalf of the entire LSMS team, I want to extend a warm thank you to everyone who attended our 2024 Annual Meeting on August 1, 2024 through August 3, 2024 in Destin, Florida at the Sandestin Golf and Beach Resort. There was a tremendous amount of work and even more moving parts that went into hosting a meeting in another state and we were thrilled to have you join us and we hope that you found the event valuable and informative. As this was our first meeting outside of Louisiana in our 146 years of existence, your presence made it all the more special and we are grateful for your support. We believe that the insights shared, and connections made will greatly benefit future events and/or attendees. Additionally, we are excited to see the positive impact that it has or will have on our organization. Watching physicians develop policy positions on key issues impacting them and their patients is nothing new to me as I have enjoyed that process now for almost twenty (20) years. However, getting to meet their spouses and children at our welcome reception, beach party, and smores by the fire (YES, even in 90-degree heat) was new and without a doubt was the highlight of the event for me. No one could stop talking about the “kids” owning the dance floor. Apparently, we really can mix business with pleasure! Again, thank you to those who were able to attend the event. We deeply appreciate your support, and we look forward to staying in touch. For those who could not make it this year, we hope to shortly announce that we will be back in Destin for 2025, and I anticipate everything will be bigger and even better. Mark your calendars now and save the dates – July 31, 2025 to August 2, 2025.
Lastly, I want to thank Terri, Lauren, Maria, Amy, Magan, Kristen, and Jeremy, also known as the greatest staff in the world. None of this, and so much more, would ever happen without them, they are rock stars. Also, a special shout out to all our fabulous presenters, wonderful exhibitors and sponsors, and to Katie Paganuzzi and Honey Creative for capturing all our work and fun across multiple social media channels (follow the LSMS on Instagram, Facebook, and Twitter). ■
Sincerely, Jeff
Over the past year, LSMS has remained committed to supporting Louisiana physicians through our mission to be the trusted advocate for patients and physicians throughout the state. We worked to accomplish this through our tenants of: LSMS Working for you!
ADVOCACY – The LSMS works tirelessly for you! Our staff is engaged year-round on legislative and regulatory issues. We focus on protecting you and your practice so you can focus on your patients. Through the use of new events and better technology, we’ve made it easier than ever for you to interact with your legislators. Renew today to participate tomorrow! EDUCATION – The LSMS has continued to expand educational opportunities for our members. This year, we held our first Annual Meeting for physicians in Sandestin, FL which included CME, the House of Delegates & networking opportunities. Furthermore, the LSMS partnered with LAMMICO, The MSMA and Practice Management Institute to bring continuing education opportunities to our members at discounted rates.
COMMUNICATION - The LSMS is committed to keeping our members informed about the issues affecting your profession. Through our Capsules newsletters, The journal of the LSMS and timely emailed bulletins and calls to action, the LSMS ensures our members are up to date and informed. COLLABORATION – We continued our tradition of collaborating with partners to offer our members high quality benefits such as affordable healthcare benefits through the Advantage Physicians Healthcare Trust and a multiple employer 401K through Blue Chip Wealth Advisors. Find out more about your member benefits at LSMS.org.
If anyone has any questions, feedback, or suggestions, about this or any future meetings, please do not hesitate to reach out to us.
For more information about membership in the Louisiana State Medical Society, please contact Amy Tyrrell, Director of Membership at atyrrell@lsms.org J LA MED SOC | VOL 176 | FALL 2024
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PRESIDENTIAL SPEECH RODERICK CLARK, MD
Good afternoon and thank you all for being here today. I am President 144. I’d like to acknowledge and thank Dr. Paddock for his long-standing service and very successful presidency. I would also like to thank the committee headed by Dr. Williams and staff who have worked diligently and successfully to put this event together. Today we all celebrate a legacy that has endured almost one and a half centuries. The success of the Louisiana State Medical Society is a product of the devotion, creativity, pragmatism, and passion of many untold physicians and staff who have proceeded us. The memories of the particular individuals have faded with the time, but through their humility I have now the honor to serve as president of this historic organization. At this time, I’d like to introduce my family. First, Tina, my wife who is a physician and is faulty of LSU department of medicine in Lafayette. We graduated together from LSU in New Orleans. She’s the love of my life and the mother of my three children. To say she keeps me grounded is an understatement. My children, Christopher, Cassie, Chase, and his girlfriend Jessica whom I love dearly and I’m so proud of are here today. I would be remiss if I didn’t send praise to my mother, father and brother who have loved me and supported my dreams to be a doctor. In the audience, I’d like to introduce Dr. Andy Blalock and his wife Callie. Andy is about as close as you can be without being a blood relative. I would also like to mention two of my mentors Dr. Dean Griffen and Dr. Bill Vildibill, both past presidents. Their graceful nature embodied in my mind what a physician should be. First, I am going tell you a little story about myself, but I believe that it’s not a unique story. Louisiana has a history of being a very poor state and I know many in this room come from families who never had a doctor in their family or maybe never even had a family member graduate from a university. That was my case. I especially remember my grandfather and mother, ever since I was a small child always telling me “that’s my little doctor.” But I never really felt the call to medicine in my youth. Really never thought I was smart enough, but that’s not how the Lord works sometimes. I’m sure in this room many of you have either been called directly or indirectly to the practice of medicine. I recall when I gave the conference to a group of young folks wanting to go to medical school. I asked for a show of hands of those who have been either been singled out by someone or always knew in their heart they wanted to be a doctor, about 80% raised their hands. Regardless of how we are called, it is gift to serve. I’ve had the honor to be on the board of medical examiners for over 10 years and more recently, I was reappointed as president in July. What I have learned is very simple. Physicians whom have lost their way have taken their eye off of medicine and placed it on either personal or monetary gratification. They have lost their way, because they
forgot to put their patients first. Countless numbers of them have been able to get back on track. I really can’t express the emotion of the individual and of the board members when we witness these doctors humbled and find their way back home to medicine. The challenges in medicine during my lifetime have never been greater. Let me share with you another little story. For those in this room who are physicians, every clinical rotation was structured around putting your patients above everything else. I also went to business school about nine years ago and earned a MBA. I can testify to you that every class started with the professor saying that the purpose of a manager was to bring a profit to his shareholders. We now have hospital systems run by businessmen, trying to be the authorities on medicine. Hospitals are continually growing and building, because that’s what you do in business. Anyone with business skills knows that if you’re not growing you’re falling behind. The hospital corporations in the state have been given the keys by state government to provide the tools, vision, infrastructure, and medical leadership to raise us off the bottom statistically in healthcare nationally. Unfortunately, they have been unsuccessful. Louisiana still remains at the bottom of almost every category of quality outcomes. Although It’s hard to talk about the reality is physicians have not been a cohesive group and because of this, we’ve delegated some of our authority to others. Physicians have allowed themselves to be fractured by politics and Third-party players picking winners and losers. Specialties have basically turned their back on each other as long as it was not affecting them. Hopefully, we’ve learned by now that this manipulation has not served physicians or medicine well. What affects one affects all of us and we must unite around a common goal. We can never relinquish our right to be the authority of medicine in this state. Hospital systems, health insurers and some allied healthproviders have had success in diminishing our role as the authority for medicine in Louisiana. We cannot let that continue to happen. My goal is to try to develop the foundation that we can build upon from a strategic standpoint that will strengthen the Louisiana State Medical Society for the future. I plan to have a very strong relationship with Surgeon General Dr. Ralph Abraham and Governor Jeff Landry and try to incorporate their ideas and dreams into what we are trying to accomplish. I will strive for the Louisiana State Medical Society to find ways to strengthen physician advocacy, improve overall patient outcomes, and Statewide medical leadership. My hope and prayer is my efforts will enable a seamless transition to meet the challenges now and in the future.
Dr. Clark was born in Alexandria and moved to Lafayette as a young child. He received his undergraduate degree from the University of Louisiana in Lafayette. He received his Medical Degree from LSU Medical School – New Orleans. His residency in Internal Medicine was completed at University Hospital and Clinics in Lafayette prior to his fellowship in nephrology under Dr. Authur Guyton at the University of Mississippi. He is a Past President of the Lafayette Parish Medical Society and a 10-year member – and current President – of the Louisiana State Board of Medical Examiners.
Dr. Clark has been in practice in Lafayette for 30 years as in nephrologist with Acadiana Renal Physicians working alongside his partners to establish nephrology and pioneer dialysis in the Acadiana area. He is a past CEO of Acadiana Renal Physicians and has served on many boards of local hospitals in the community. He is married to Tina Benoit, MD, and they have three children: Christopher, Cassie and Chase.
So my friends, let’s open our minds and ears and not fear the challenges ahead, because we the LSMS are up to the task.
Thank you, Roderick Clark M.D. MBA
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CITATIONS: 1.
6. In, et al. 18TH CONGRESS 1ST SESSION to Amend Titles XVIII and XIX of the Social Security Act to Provide for Coverage of Peripheral Artery Disease Screening Tests Furnished to At- Risk Beneficiaries under the Medicare and Medicaid Programs without the Imposition of Cost-Sharing Requirements, and for Other Purposes. 2023.
PERIPHERAL ARTERY DISEASE: A CLUE TO POLY-VASCULAR DISEASE IN NEED OF FEDERAL LEGISLATIVE RECONSIDERATION
Aday, Aaron W., and Kunihiro Matsushita. “Epidemiology of Peripheral Artery Disease and Polyvascular Disease.” Circulation Research , vol. 128, no. 12, 11 June 2021, pp. 1818–1832, https://doi.org/10.1161/circresaha.121.318535. 2. Ohman, E. Magnus, et al. “The REduction of Atherothrombosis for Continued Health (REACH) Registry: An International, Prospective, Observational Investigation in Subjects at Risk for Atherothrombotic Events-Study Design.” American Heart Journal , vol. 151, no. 4, Apr. 2006, pp. 786.e1–786.e10, https://doi.org/10.1016/j. ahj.2005.11.004. Accessed 22 Oct. 2020. 3. “Recommendation | United States Preventive Services Taskforce.” www.uspreventiveservicestaskforce.org, www.uspreventiveservicestaskforce.org/uspstf/ recommendation/peripheral-artery-disease-in-adults- screening-with-the-ankle-brachial-index. 4. Gerhard-Herman, Marie D., et al. “2016 AHA/ACC Guideline on the Management of Patients with Lower Extremity Peripheral Artery Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines.” Circulation , vol. 135, no. 12, 21 Mar. 2017, www.ahajournals. org/doi/pdf/10.1161/CIR.0000000000000470, https://doi. org/10.1161/cir.0000000000000470.
7.
“Peripheral Matters | Peripheral Artery Disease: Moving from Awareness to Action.” American College of Cardiology, www.acc.org/Latest-in-Cardiology/ Articles/2023/09/01/01/42/peripheral-matters-peripheral- artery-disease-moving-from-awareness-to-action. Accessed 25 Nov. 2023.
Authored by: Omar Leonards, MD LSUHSC-New Orleans Cardiovascular Disease Fellow
8. Scully, Rebecca E., et al. “Estimated Annual Health Care Expenditures in Individuals with Peripheral Arterial Disease.” Journal of Vascular Surgery , vol. 67, no. 2, 1 Feb. 2018, pp. 558–567, www.ncbi.nlm.nih.gov/ pubmed/28847660, https://doi.org/10.1016/j.jvs.2017.06.102. 9. Mahoney, Elizabeth M., et al. “Vascular Hospitalization Rates and Costs in Patients with Peripheral Artery Disease in the United States.” Circulation: Cardiovascular Quality and Outcomes , vol. 3, no. 6, Nov. 2010, pp. 642–651, https:// doi.org/10.1161/circoutcomes.109.930735. Accessed 21 Oct. 2020 10. U.S. Bureau of Labor Statistics. “CPI Inflation Calculator.” U.S. Bureau of Labor Statistics , www.bls.gov/data/inflation_ calculator.htm.
Peripheral artery disease (PAD) is a condition that affects approximately 236 million adults, with an estimated 8.5 million Americans being affected nationally; however, there is a need for more contemporary data.1 Though data linking race to incident PAD is limited, the lifetime estimated risk of PAD is highest amongst African Americans and non-Hispanic whites. 1 Despite the global and national prevalence of PAD, it remains underappreciated in comparison to coronary artery disease (CAD) and cerebrovascular disease (CVD). 1 Data from the REduction of Atherothrombosis for Continued Health (REACH) Registry highlights that PAD is not simply narrowed arterial vasculature but a clue of possible poly- vascular disease. 2 Despite the national prevalence of the disease and objective data from the REACH Registry, the United States Preventative Service Task Force (USPSTF) concluded there is insufficient data to screen asymptomatic individuals for PAD with an ankle-brachial index. However, supporting recommendations are found in the 2016 AHA/ACC Guidelines on the Management of Patients with Lower Extremity Peripheral Artery Disease. 3,4 This leaves millions of at-risk Americans vulnerable to the potential long-term morbidity and mortality not only associated with PAD but also potential poly-vascular disease, as the Centers for Medicare and Medicaid Services (CMS) only provides full benefit coverage for USPSTF grade A and B screening recommendations. This vulnerability in the healthcare of all Americans has ignited multiple cardiovascular disease organizations across the United States to spearhead awareness campaigns and work with federal lawmakers in supporting the introduction of legislation to address this healthcare gap. Initially founded in 2019, the Congressional Peripheral Artery Disease (PAD) Caucus was formed to educate Congress and communities about PAD and support federal initiatives in preventing PAD-related morbidity and mortality. The bipartisan caucus co-chairs include Representatives Donald M. Payne, Jr. (D-NJ) and Gus Bilirakis (R-FL). The caucus’s initiatives for this 118th Congress include the reintroduction of the Amputation Reduction and Compassion (ARC) Act, requesting the USPSTF review screening guidelines in at-risk patients, and encouraging the creation of intragovernmental workgroups to implement a comprehensive amputation prevention program for PAD patients in Medicare and other federal programs based on the US Department of Veterans Affairs Preventing Amputations in Veterans Everywhere (PAVE) program. 5
June 21, 2023, is referred to the Subcommittee on Health. This legislation seeks to amend titles XVIII and XIX of the Social Security Act to provide coverage for PAD screening tests to at-risk beneficiaries under the Medicare and Medicaid programs without imposing cost-sharing requirements. “At-risk beneficiaries” include those listed in the 2016 AHA/ACC Guidelines on the Management of Patients with Lower Extremity Peripheral Artery Disease. 4,6 Furthermore, this legislation amends Part P of Title III of the Public Health Service Act 8 (42 USC 280g et seq.) and tasks the Secretary of Health and Human Services to work with other federal agencies and stakeholders to implement a PAD education program. The bill appropriates 6 million dollars annually from fiscal years 2024-2028 to carry out these tasks. Though the appropriations will initially cost American taxpayers 24 million dollars, the return on investment is arguably undeniable. The realized return on investment can be appreciated by understanding the fiscal strain PAD and its most severe form, chronic limb-threatening ischemia (CLTI), place on the United States healthcare system. CLTI can lead to ulcerations, gangrene, and ultimately amputation, with one-year rates of amputation reaching as high as 22% and increasing mortality rates to approximately 35-48% within one year. 7 In a review of health care related expenditure data from 2011 to 2014, the Agency for Healthcare Research and Quality Medical Expenditure Panel estimated a greater than $7000 increase in healthcare-related cost per year in each patient diagnosed with PAD in comparison to US adults 40 years of age and older without PAD when adjusted for age, gender, and race. 8 Vascular-related hospitalization in patients with PAD based on 2004 US census data was estimated to cost more than $21 billion annually, which is now greater than $33 billion annually, adjusting for inflation based on consumer price index estimates. 9, 10 Despite PAD being responsible for the highest healthcare- related cost in cardiovascular disease and worse quality of life (QOL), it continues to be underrecognized and undertreated. 7 The REACH Registry provides a clear insight into the relationship of PAD with other polyvascular diseases, and current USPSTF recommendations are incongruent with the 2016 AHA/ACC PAD guidelines. 2,3,4 This leaves millions of at-risk Americans vulnerable to the long-term outcomes of underrecognized and untreated atherosclerotic disease; thus, it is imperative that federal legislation be enacted to improve healthcare-related outcomes of the American people. ■
5. “Congressional PAD Caucus.” Congressman Donald Payne , 18 Feb. 2020, payne.house.gov/pad-caucus.
The ARC Act (HB 4261), introduced in this 118th Congress on
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The Board of Governors serves as the trustee and the administrative board of the LSMS and transacts all business for and on behalf of the Society in the interval between HOD meetings. 2024 LSMS LEADERSHIP BOARD OF GOVERNORS
RODERICK CLARK, MD President
RICHARD PADDOCK, MD Immediate Past President
THOMAS TRAWICK, JR., MD President-Elect
AMBERLY NUNEZ, MD Secretary - Treasurer
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MATTHEW GIGLIA, MD COL, Chair
KATHERINE WILLIAMS, MD Vice Speaker
SUSAN BANKSTON, MD Ex Officio, LAMPAC, Chair
ROBERT NEWSOME, MD Speaker
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SECTION REPRESENTATIVES
COUNCIL ON LEGISLATION Lance Templeton, MD Private Practice Physician Section Member
AMA DELEGATION William Freeman, MD, Chair Delegate Luis Alvarado, MD, Vice Chair Delegate
Ken Ehrhardt, MD Young Physician Member
Clay Runfalo, MD Delegate
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Omar Leonards, MD Resident/Fellow Section Member
Clay Runfalo, MD Employed Physician Section Member
Donnie Batie, MD Alternate Delegate
Gregory Laborde Medical Student Member
Ken Ehrhardt, MD Young Physician Member
Kamel Brakta, MD Delegate
Roderick Clark, MD Alternate Delegate
Clay Runfalo, MD Employed Physician Section Member Lance Templeton, MD Private Practice Physician Section Member
Omar Leonards, MD Resident/Fellow Member
George Ellis, MD Delegate
Kristin Grimes, DO Alternate Delegate
Olivia White Medical Student Member
Deborah Fletcher, MD Delegate
Smita Prasad, MD Alternate Delegate
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VANISHING PALPABLE MASS IN A YOUNG FEMALE PATIENT TIFFANY SHICK, BS, NEEL D. GUPTA, MD, JEREMY B. NGUYEN, MD FACR HISTORY
IMAGING FINDINGS Figure 1. Frontal and lateral radiographs of the right forearm in a skeletally immature patient demonstrate subtle osseous exostosis extending from the ulnar aspect of the radial diaphysis away from the radiocarpal articulation. Figure 2. Axial T1 MRI demonstrates osseous exostosis contiguous with medullary cavity of the radius with subtle suspected cartilaginous cap. Skin marker is noted superficial to the exostosis. Figure 3. Axial T2 fat saturated MRI demonstrates minor non- mass like soft tissue edema surrounding the osseous exostosis. Additional subtle marrow type edema signal involving the osseous exostosis. Figure 4. Sagittal T1 MRI demonstrates osseous exostosis contiguous with medullary cavity of the radius with subtle suspected cartilaginous cap. Figure 5. Axial T1 MRI obtained in 2012 demonstrates interval significant decreased osseous exostosis contiguous with medullary cavity of the radius with subtle suspected cartilaginous cap. Decreased mass effect on surrounding soft tissues at the level of the “regressed” osseous exostosis. Skin marker is noted superficial to the exostosis. Figure 6. Axial T2 MRI obtained in 2012 demonstrates interval significant decreased osseous exostosis contiguous with medullary cavity of the radius with subtle suspected cartilaginous cap. Decreased mass effect on surrounding soft tissues at the level of the “regressed” osseous exostosis. Skin marker is noted superficial to the exostosis. Figures 7, 8 and 9. Axial T1 MRI obtained in 2012 demonstrates significant decreased osseous exostosis contiguous with medullary cavity of the radius with subtle suspected cartilaginous cap (red arrow in Figure 7). Coursing extensor digitorum anomalous tendon slip noted near osseous exostosis (red arrows in Figure 8 and 9). Skin marker is noted superficial to the exostosis.
their cartilage-capped projections from long bones. They are slow growing lesions within immature skeletal tissue and most often do not progress in size beyond puberty (3). Many of these lesions are solitary, however roughly 15% of patients with an osteochondroma have been diagnosed with multiple tumors in the context of a rare hereditary condition called multiple hereditary exostoses (MHE) (2). While the lesions themselves are largely benign, there are potential causes for removal such as fractures, proximal structure deformity, and malignant transformation. If the patient is asymptomatic, treatment for the lesion is typically taken through a conservative approach with interval observation. Surgical treatment is more common in patients with MHE. As was shown noted in this case, an osteochondroma may be intimately associated with a tendon and may elicit pain during movement due to mechanical friction. The tendon may slide and be injured over the bony lesion (3). Additionally pathologic fractures may occur of an osteochondroma and cause significant pain. When considering potential treatment for patients with an osteochondroma, it is important to note existing cases of spontaneous regression. Although there are just a few reports of this process in the literature, available limited studies suggest that most cases of spontaneous regression have been noted in males aged 5 to 11 years old. Mechanism of regression is not fully understood; however, the causes are likely multifactorial. One proposed remodeling pathway involves regression following fracture while another model suggests bone remodeling. In such cases of tumor disappearance, complete resolution took several years (5). Reduction of bone appeared greatest during adolescence, correlating with timeline of epiphyseal arrest in development (4). While the statistical prevalence of regressing osteochondroma may remain unclear due to largely asymptomatic presentation, clinicians should take caution in considering surgical intervention versus conservative observation. In the presented case, surgery was not recommended for the patient due to the lack of significant symptoms and unnecessary surgical risks that could arise from operation. Following three years of conservative observational treatment, imaging demonstrated spontaneous regression of the patient’s bone tumor. REFERENCES 1. Galanis, N., Delniotis, I., Noussios, G., Katsourakis, A., Kitridis, D., Leidinger, B., & Givissis, P. (2020). Osteochondroma of the distal tibia in an 8‐year‐old child: Do we need to excise a benign tumor? Clinical Case Reports , 8(12), 3599–3600. https://doi.org/10.1002/ccr3.3321 2. Heyworth, P. B., & Rashid, M. (2018). Regression of a solitary osteochondroma of the distal humerus in a toddler following trauma. Radiology Case Reports , 14(2), 187–189. https://doi. org/10.1016/j.radcr.2018.10.006
14-year-old female presenting with painful palpable mass along the right radial shaft. Initial imaging was obtained in 2009 with follow-up imaging conducted in 2012.
Initial Imaging: 2009
Figure 1
Figure 2
Figure 3
Radiographs of the Right Forearm
Axial T1 MRI
Axial T2 Fat Sat MRI
Follow Up Imaging: 2012
DIFFERENTIAL DIAGNOSIS 1. Parosteal Osteosarcoma 2. Osteochondroma 3. Nonossifying Fibroma (NOF) 4. Osteoid Osteoma FINAL DIAGNOSIS Regressing “Vanishing” Osteochondroma DISCUSSION
Figure 4
Figure 5
Figure 6
Sagittal T1 MRI
Axial T1 MRI
Axial T2 MRI
We present a case of a young female patient presenting with a painful palpable abnormality of the distal right upper extremity. Three years following initial imaging, various signs of spontaneous tumor regression are evident. Osteochondromas are benign osseous surface lesions that are often asymptomatic, thus incidental diagnosis is not uncommon. Osteochondromas are the most common benign bone tumors and are defined by
Figure 7
Figure 8
Figure 9
3. Tepelenis, K., Papathanakos, G., Kitsouli, A., Troupis, T.,
Axial T1 MRI
Axial T1 MRI
Axial T1 MRI
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SEBACEOUS CARCINOMA OF THE EYELID: A CASE REPORT OF A MULTIDISCIPLINARY APPROACH
Clinical Radiology , 56(11), 877–886. https://doi.org/10.1053/ crad.2001.0795 ACKNOWLEDGEMENTS Tiffany Shick is a 2nd year Medical Student 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. ■
Barbouti, A., Vlachos, K., Kanavaros, P., & Kitsoulis, p. (2020). Osteochondromas: An updated review of Epidemiology, pathogenesis, clinical presentation, radiological features and treatment options. In Vivo , 35(2), 681–691. https://doi. org/10.21873/invivo.12308 4. Valdivielso-Ortiz, A., Barber, I., Soldado, F., Aguirre-Canyadell, M., & Enriquez, G. (2010). Solitary Osteochondroma: Spontaneous regression. Pediatric Radiology , 40(10), 1699– 1701. https://doi.org/10.1007/s00247-010-1783-7 5. Yanagawa, T., Watanabe, H., Shinozaki, T., Ahmed, A. R., Shirakura, K., & Takagishi, K. (2001). The natural history of disappearing bone tumours and tumour-like conditions.
Author: Robert P. VanHoy, Edward Via College of Osteopathic Medicine
tumor that was immunohistochemically BerEp4 positive, and it was diagnosed as a “basal cell carcinoma(BCC), incompletely excised.” The patient was referred for pre-op consultation and decided to proceed with excisional surgery, with intraoperative frozen section controls to optimize chances for clear margins. The surgery was more extensive than planned, with the surgeon removing essentially 100% of her lower eyelid to gain negative margins, a significant deviation from the projected 40%. A Hughs Tarsoconjunctival flap stage I from the right upper lid was performed, as well as a free skin graft from the retroauricular area to repair the excised area(Figure 1B). The excision specimen with frozen sections were sent to the pathology department and assessed by a dermatopathology subspecialist. The tumor demonstrated intraepidermal pagetoid tumor spread in addition to invasion, the former being a key difference between SC and BCC. Further, the tumor showed positivity for epithelial membrane antigen(EMA), Androgen receptor(AR) and adipophilin through immunohistochemical staining. This constellation of features, along with recognition of scattered atypical sebocytes amid intraepidermal and an invasive tumor, allowed reliable histologic diagnosis of poorly differentiated sebaceous carcinoma in this case. The patient was counseled on the updated diagnosis and future treatment included performing further excision of the medial and lateral canthal margins during the second stage of the lid sharing procedure. The lid sharing procedure achieved good eyelid function and cosmetic results(Figure 1C) and the re- excisional biopsy yielded negative margins. The patient was followed postoperatively and it was decided that she would receive conjunctive radiation treatment. Radiation oncology was consulted and the patient was treated with 5000 cGy in 200cGy fraction energy with six MV electrons for 25 treatments over 36 days. Radiation treatment was targeted to the eyelid with minimal orbit involvement. Over a year later the patient, unfortunately, had a recurrence. A positive conjunctival biopsy and staging was conducted by MRI and showed isolation to the same lower lid. Patient was offered exenteration but she declined. It was then planned to place the patient on mitomycin C drops 0.04% four times daily (.04mg/cc) one week on and one week off for a total of four weeks. After completion of the mitomycin C, the patient had a clinically successful cure. Two years later, the patient presented with a suspicious skin lesion on the lower right eyelid. Biopsy was taken and it was confirmed a local skin recurrence of SC. The patient was treated with 5-fluorouracil (5-FU) 1% twice daily for two weeks. Regular follow ups and treatment over the past three years have successfully retained her bilateral sight and preserved her cosmetic appearance(Figure 1D). Coauthors: Dr Michael A. Redmond at Louisiana Eye and Laser and Dr. George R. Collins at Delta Pathology group Alexandria LA
ABSTRACT Sebaceous carcinoma (SC) is a rare malignancy that can arise from the sebaceous glands in the skin. The case presented below is of an 87-year-old caucasian woman who originally presented with a nodular growth on the lower eyelid, which was initially diagnosed on biopsy as basal cell carcinoma. Only after additional staining was the final diagnosis of SC made. Incorrect pathological diagnoses have been reported in 45-75% of SC cases 1 , most commonly being mistaken for squamous and basal cell carcinoma. Clinical recognition of SC of the eyelid is also challenging due to its resemblance to common eye pathologies such as blepharitis and chalazion. Treatment of SC can vary depending on location of the tumor and metastasis but involves surgical removal, radiation, and chemotherapy 1,2 . This case report aims to add to the current literature by highlighting the difficulty in diagnosing SC and offering options for conservative treatment plans. INTRODUCTION Sebaceous carcinoma (SC) is an aggressive tumor that can form anywhere there are sebaceous glands on the skin. Approximately 80% of SC present in the head and neck region and 40% on the eyelid, with a two to three times higher prevalence on the upper eyelid due to the higher number of sebaceous glands 2 . Diagnosis is difficult because the malignancy resembles many pathologies on appearance and is even difficult to distinguish on histology without close attention to subtle morphologic features and characteristic ancillary staining methods 3 . Treatment is surgical excision and is, many times, combined with chemotherapy and/ or radiation 2 . This case report demonstrates that SC is a rare and difficult diagnosis to make, requiring a multidisciplinary approach. CASE REPORT An 87-year-old white woman presented to the ophthalmologist with irritation and lid lesion on her lower right eyelid(Figure 1A). The lesion had been present for two weeks and was described as enlarging and itchy; an earlier visit for the same complaint resulted in antibiotic treatment, giving the patient temporary relief. Upon ophthalmic exam, a lesion was identified on the medial lower right eyelid and meibomian gland dysfunction bilaterally. Previous ocular history only involved cataract removal OU. The differential diagnosis was originally between blepharitis and unknown neoplasm of the skin. The plan was to treat the patient with bacitracin 500unit/gram ointment and erythromycin 5mg/gram ointment applied to the right eyelid and bilateral warm compresses with lid scrubs. Follow up was scheduled in two weeks to remove the lesion if the patient showed no improvement. The patient presented to two week follow up with no reduced symptoms so the lesion was biopsied and sent to pathology. Four days later, pathology results revealed a basaloid
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SC show positive for epithelial membrane antigen(EMA), BerEp4, Androgen receptor(AR). BCC is negative for EMA and SCC is negative for BerEp4, as well as AR. 3 Using these stains looking for focal sebocytic morphologic features will most likely lead to diagnosis of SC, however there is overlap. If diagnosis is still unclear, additional staining with adipophilin renders both high sensitivity and specificity for SC 10 . This stain requires careful scrutiny at high power since only the characteristic cytoplasmic microvesicular membranous rimming pattern in atypical sebocytes is considered a positive staining pattern, whereas granular cytoplasmic staining is nonspecific and can be seen in BCC, SCC, and other tumors 12 (Figure 2D). The recommended treatment for sebaceous carcinoma of the eyelid is either surgical with complete circumferential peripheral and deep margin assessment or Mohs micrographic surgery, with or without radiotherapy 1,2 . The recognition, rapid biopsy and start of treatment is critical in achieving better outcomes for SC patients. A primary care physician or specialist should always maintain a high index of clinical suspicion for SC in regards to presenting lesions on the eyelid or periorbital region. Likewise, the pathologist must maintain a high index of suspicion for possibility of SC when confronted with this anatomic region, with a low threshold for ancillary staining studies when any ambiguity exists. Along with recognition, treatment is difficult and cosmetic results are often not fully successful due to the cancer’s location. CONCLUSION This case showcases how this rare masquerading malignancy can be so difficult to diagnose. In order to effectively and efficiently diagnose and treat SC patients, all clinicians involved must expand their differential and pay close attention to detail in effort to not prevent delay of therapy. Treatment of SC on the eyelid is further complicated by how it can affect the patient functionally and cosmetically, therefore, collaboration with the patient and other specialists should be included in the care plan. Achieving a rapid, reliable diagnosis with optimized patient prognosis and clinical outcome is difficult but can be achieved with utilization of the most up-to-date pathologic diagnostic modalities, a high index of clinical and pathologic suspicion, and a multidisciplinary team approach. SOURCES 1. Ling M, Silkiss R. Diagnosis and Management of Sebaceous Carcinoma of the Eyelid. Fekrat S, Scott I, eds. EyeNet. Published online August 2013:33-35.
Epub 2020 Sep 9. PMID: 32907843; PMCID: PMC7854832
5. Sargen MR, Cahoon EK, Lynch CF, Tucker MA, Goldstein AM, Engels EA. Sebaceous carcinoma incidence and survival among solid organ transplant recipients in the United States, 1987–2017: a registry-based cohort. JAMA Dermatol 2020;In Press 6. Desiato VM, Byun YJ, Nguyen SA, Thiers BH, Day TA. Sebaceous Carcinoma of the Eyelid: A Systematic Review and Meta-Analysis. Dermatol Surg. 2021 Jan 1;47(1):104-110. doi: 10.1097/DSS.0000000000002660. PMID: 33347004. 7. Lanoy E, Dores GM, Madeleine MM, Toro JR, Fraumeni JF Jr., Engels EA. Epidemiology of nonkeratinocytic skin cancers among persons with AIDS in the United States. AIDS 2009;23:385–93
8. Gall R, Ortiz-Perez S. Sebaceous Gland Carcinoma. [Updated 2023 Aug 14]
Figure 1
Figure 2
(A)Presenting nodule. (B)Postoperative Hughs Tarsoconjunctival flap Stage 1. (C)Postoperative Hughs Tarsoconjunctival flap Stage 2. (D)Fully healed
(A)Basaloid invasive nodular SC at low power(40x) (B)SC at medium power(100x). Red arrows- intraepidermal spread of atypical sebocytes in SC (C)High power(400x) atypical sebocytes (D)Adophilin stain(400x). Red arrows-perivesicular staining
9. Johnson S, Nerad JA, Syed NA. Sebaceous Cell Carcinoma: A Masquerade Syndrome. EyeRounds.org. January 23, 2007
10. Plaza JA, Mackinnon A, Carrillo L, Prieto VG, Sangueza M, Suster S. Role of immunohistochemistry in the diagnosis of sebaceous carcinoma: a clinicopathologic and immunohistochemical study. Am J Dermatopathol. 2015 Nov;37(11):809-21. doi: 10.1097/DAD.0000000000000255. PMID: 26485238.\ 11. Esmaeli B, Nasser QJ, Cruz H, Fellman M, Warneke CL, Ivan D. American Joint Committee on Cancer T category for eyelid sebaceous carcinoma correlates with nodal metastasis and survival. Ophthalmology. 2012 May;119(5):1078-82. doi: 10.1016/j.ophtha.2011.11.006. Epub 2012 Feb 11. PMID: 22330966; PMCID: PMC3869195. 12. Shalin SC, Lyle S, Calonje E, Lazar AJ. Sebaceous neoplasia and the Muir-Torre syndrome: important connections with clinical implications. Histopathology. 2010 Jan;56(1):133- 47. doi: 10.1111/j.1365-2559.2009.03454.x. PMID: 20055911; PMCID: PMC2805836. 13. Dourmishev LA, Rusinova D, Botev I. Clinical variants, stages, and management of basal cell carcinoma. Indian Dermatol Online J. 2013 Jan;4(1):12-7. doi: 10.4103/2229-5178.105456. PMID: 23439912; PMCID: PMC3573444. 14. Yanofsky VR, Mercer SE, Phelps RG. Histopathological variants of cutaneous squamous cell carcinoma: a review. J Skin Cancer. 2011;2011:210813. doi: 10.1155/2011/210813. Epub 2010 Dec 29. PMID: 21234325; PMCID: PMC3018652.
DISCUSSION SC is a rare malignant disease only affecting one to two per 1,000,000 per year 1,2 . It is the third most common malignancy of the eyelid after basal cell(BCC) and squamous cell carcinoma(SCC) 1,3 . SC develops from the sebaceous cells of sebaceous glands which are most concentrated on the face and scalp. Development of SC is thought to be multifactorial with several risk factors. Genetic risk factors have been seen in the loss of expression in the mismatch repair genes MSH2, MSH6, PMS2, and MLH13. This is why SC is found more often in the autosomal dominant Muir-Torre syndrome, a varient of Lynch syndrome. Ultraviolet exposure has been seen to increase risk for SC shown by its geographic predication and increased incidence in races with less melanin 3 . Immunosuppressed patients have been shown to be at increased risk of SC. People with AIDs show an eightfold increase 3 and solid transplant recipients showing as high as a 25 fold increased incidence 5 . Clinically patients will most commonly present as older and white with an enlarging nodule most often in the upper eyelid, where basal cell and squamous cell carcinoma typically present in the lower eyelid 1,3,6 . The five year survival rate for SC has been recorded as low as 70% with a metastasis rate as high as 18%. SC accounts for only 1% of all eyelid tumors but 4.7% of eyelid malignancy. It also shows high rates of local aggression and recurrence and can metastasize to regional lymph nodes or other organs 11 . Historically, much like the case presented, these cancers have been difficult to diagnose. Earning the name the “Great Masquerader, ‘’ SC cases clinically appear similar to many pathologies of the eye such as a chalazion, blepharoconjunctivitis or other eyelid
malignancies 1,2,9 . Not only is SC a clinical masquerader, but even when the lesions are biopsied, they can resemble other skin cancers like BCC and SCC. Incorrect original pathological diagnoses have been reported in 45-75% of SC cases 1 . SC tumor cells’ morphologic characteristics show atypical sebocytes, with scalloped nuclei and multivacuolated clear cytoplasm with hematoxylin and eosin stained sections. Although these atypical cells can be focal in a given tumor, which can contribute to difficulty in diagnosis 12 (Figure 2C). At low power — where sebocytes are often inconspicuous — SC tumors share a similar appearance to BCC by showing invasive nodules of basaloid cells(Figure 2A). Rarely, BCC can contain sebocytes, but BCC will additionally show diagnostic areas of classic BCC morphology, such as peritumoral cleft formation, peritumoral stromal mucin, lack of intraepidermal pagetoid spread, and peripheral palisading of basaloid cells at periphery of tumor nests 13 . A lack of this typical diagnostic constellation of features of BCC in H&E stained histologic sections should alert the pathologist to the possibility of SC and careful study of the tumor for sebocyte differentiation, which can be focal. A single focus in a basaloid tumor, particularly poorly differentiated examples, can serve to distinguish SC from BCC. An important and reliable feature distinguishing SC from BCC is the presence of pagetoid intraepidermal spread of tumor cells with basaloid and sebocyte tumor cells, a feature universally absent in BCC but not present in all SC 12 (Figure 2B). SCC, specifically the clear cell variant, can mimic the clear cell appearance of SC but will show keratinization, lack of true adipocytic vacuolization, and different immunohistochemical staining pattern 14 . Sebocytes in
2. Gall R, Ortiz-Perez S. Sebaceous Gland Carcinoma. [Updated 2023 Aug 14]
3. Patterson JW, Hosler GA, Prenshaw KL, Weedon D. Weedon’s Skin Pathology. Elsevier; 2021.
4. Sargen MR, Starrett GJ, Engels EA, Cahoon EK, Tucker MA, Goldstein AM. Sebaceous Carcinoma Epidemiology and Genetics: Emerging Concepts and Clinical Implications for Screening, Prevention, and Treatment. Clin Cancer Res. 2021 Jan 15;27(2):389-393. doi: 10.1158/1078-0432.CCR-20-2473.
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LOUISIANA STATE MEDICAL SOCIETY H D2024
PROCEEDINGS OF THE HOUSE OF DELEGATES 143RD ANNUAL MEETING
CALL TO ORDER Thomas Trawick, Jr., MD, Speaker of the House called the opening session of the Annual Meeting to order at 3:30PM on Friday, August 2, 2024 at the Baytowne Conference Center in Sandestin, Florida. The Pledge of Allegiance and Physicians Prayer were both recited by attendees. RECOGNITION OF DECEASED LSMS MEMBERS Physician members passing August 2023 through July 2024 include: William Bundrick, Sr., MD, Stephen Breaud, MD, Pedro Cazabon, MD, John Finn, Jr., MD, William Glenn, MD, Rozelle Hahn, MD, Thomas Kramer, MD, James Phillips, MD, Frederick Price, MD, and Prentiss Smith, Jr., MD. RECOGNITION OF 50-YEAR PHYSICIANS Physician members who graduated medical school in 1974 include: Don Bell, MD, Ronald Bombet, MD, Leonard Bourgeois, MD, David Bryan, MD, Zach Buckalew, III, MD, Vincent Culotta, Jr., MD, Robert Dawson, III, MD, Daniel Dupree, MD, March Eschete, MD, Carl Fastaband, MD, Thomas Ferguson, MD, Rajendra Gandi, MD, Joseph Heard, MD, Sheldon Johnson, MD, Alfonso Lebron- Berges, MD, F. Brobson Lutz, Jr., MD, Brian Matherne, MD, Weston Miller, III, MD, Glenn Mills, MD, Stephen Person, MD, Edwin Ross, MD, Robert Ryan, MD, Lawrence Schneider, MD, Alan Sheen, MD, Charles Simonson, MD, Robert Wallace, III, MD, Kermit Walters, Jr., MD, Charles Williams, Jr., MD, and Michael Zambie, MD. 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 Sandestin. 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. 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 near the front 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. REPORT OF THE CREDENTIALS COMMITTEE Charles Nunez, MD, Committee Chair, reported that a quorum of certified delegates was present and seated.
50 YEAR PHYSICIANS
YEARS
Don Bell, MD Ronald Bombet, MD Leonard Bourgeois, MD Richard Bourgeois, MD David Bryan, MD Zack Buckalew, Ill, MD Vincent Culotta, Jr., MD Robert Dawson, Ill, MD
Carl Fastaband Thomas Ferguson, MD
Stephen Person, MD Edwin Ross, MD Robert Ryan, MD Lawrence Schneider, MD Alan Sheen, MD Charles Simonson, MD Robert Wallace, Ill, MD Kermit Walters, Jr., MD Charles Williams, Jr., MD Michael Zambie, MD
Rajendra Gandi, MD Joseph Heard, MD Sheldon Johnson, MD Alfonso Lebron-Berges, MD F. Brabson Lutz, Jr., MD
Brian Matherne, MD Weston Miller, Ill, MD Glenn Mills, MD
Daniel Dupree, MD Mary Eschete, MD
In Memoriam
William Bundrick, Sr., MD John Finn, Jr., MD William Glenn, MD Rozelle Hahn, MD
Thomas Kramer, MD James Phillips, MD Frederick Price, MD
Stephen Breaud, MD Pedro Cazabon, MD Prentiss Smith, Jr., MD
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