CONSULTFALL A Newsletter for Medical Professionals

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1 CONSULTFALL A Newsletter for Medical Professionals 2017 Time is Brain Latest Stroke Interventions One Call Away A patient comes into your exam room. They have aphasia, maybe some vision problems. After an examination, you suspect they might be having a large-vessel stroke, but the timeframe is unclear. It might have been a matter of hours, or it could have been more. You can still connect with neurologists at the University of Arkansas for Medical Sciences (UAMS) so your patient can get the best in 24/7 stroke care available in Arkansas. UAMS provides consults for stroke cases in two separate ways: the Physician Call Center and AR SAVES. In instances like the one above, call the Physician Call Center number at The AR SAVES telemedicine hotline is the number for physicians at participating partner hospitals to call for cases in which the patient is within a 4.5-hour window since the onset of stroke. The Physician Call Center is staffed 24/7 by experienced telephone triage nurses who can assist with timely, appropriate consults, transfer requests and other needs. The Arkansas Stroke Assistance through Virtual Emergency Support (AR SAVES) program connects neurologists from UAMS and other partner agencies via two-way live video to 53 hospitals across the state. As of 2016, 84 percent of Arkansans lived within 30 minutes of an AR SAVES stroke hospital and 99 percent lived within an hour. Because of the success of the program, Arkansas recently fell to sixth in the nation in the number of stroke deaths per capita after many years in first place. 4.5 hours since stroke = call AR SAVES 24 hours since stroke or unclear timeline = call Physician Call Center But Sanjeeva Reddy Onteddu, M.D., AR SAVES interim medical director, always sees room for improvement. The main function of AR SAVES is to help doctors quickly assess whether a stroke patient is a candidate for tpa (tissue plasminogen activator), the clotbusting drug that can be life-saving and often restores complete function to the patient. However, tpa must be administered within 4.5 hours of a stroke s onset, a narrow timeframe that doesn t apply to every case and can sometimes be difficult to verify. (Continued on page 2)

2 (Time is Brain continued from cover) Stroke treatment is an ever-evolving field, and the neurologists at UAMS keep abreast of the latest research and options for patients, Onteddu said. Now more than ever, stroke patients have the potential for life-altering interventions, even outside that 4.5-hour window. For example, recent research indicates that for a subgroup of patients, tpa can be beneficial even up to 24 hours after the onset of a stroke. PARTNER LOCATIONS Name Spoke Sites Bap$st Health Medical Center White River Medical Center Saline Memorial Hospital Northwest Medical Center Siloam Springs Regional Hospital Great River Medical Center Benton Fulton Boone Carroll White River Medical Complex Johnson Regional Medical Center Greene Sharp Ozark Health Medical Center Lawrence Madison Newton Searcy Independence Stone Washington Johnson Franklin Ouachita County Medical Center Baxter Marion Izard Crawford Community Medical Center of Izard County Clay Randolph DewiI Hospital and Nursing Home Delta Memorial Hospital Jackson Medical Center of South Arkansas Cross White Conway Logan Crittenden Faulkner Sebastian Woodruff St. Francis Perry Yell Scott Lonoke Pulaski Prairie County Medical Center Chambers Memorial Hospital Poinsett Cleburne Van Buren Pope Conway Regional Medical Center Craighead Mississippi Ashley Lee Washington Regional Medical Center Dallas County Medical Center Sparks North Arkansas Regional Medical Center Bap$st Health Medical Center Heber Springs Helena Regional Medical Center Na$onal Park Medical Center For patients within the 4.5-hour North Metro Medical Center NEA Jonesboro window, the AR SAVES hotline Chicot Memorial Medical Center Bap$st Health Medical Center Hot Spring County is still the appropriate number Magnolia Regional Medical Center McGehee Desha County Hospital to call. But Onteddu encourages Mena Regional Medical Center physicians who encounter Drew Memorial Hospital Baxter Regional Medical Center potential stroke patients who Stone County Medical Center Howard Memorial Hospital might be outside that time Unity Health- Harris Hospital South Mississippi County Regional Hospital window to call the Physician Call Arkansas Methodist Medical Center PiggoI Community Hospital Center for a neurology consult. In Five Rivers Medical Center either case, the staff they connect St. Mary's Regional Medical Center Fulton County Hospital Receiving Sites (INTERVENTION) Receiving Facili7es (ICU CAPABLE) with at UAMS and its AR SAVES Unity Health- White County Medical Center UAMS Medical Center Rock Pulaski We have LiIle a neuro-intervention care-trained Wadley Regional Medicalby Center a neurocritical Texarkana, TX Northwest Medical Center LiIle Rock Pulaski Jefferson Regional Medical Center Pine Bluff Jefferson partners will be aware of the Bap$st Health Medical Center Healthand Medical Center StuIgart Washington Regional Medical Center FayeIeville radiologist and hiswashington staff all St.ready, physician, their length ofbap$st stay Bernard s Medical Center Jonesboro Craighead Lawrence Memorial Hospital Sparks Fort Smith Sebas$an importance of speed. here waiting for the patient, outcomes are always better than Bradley County Medical Center CrossRidge Community Hospital We have our system set up in a Onteddu said. Once we get an traditional treatments, Archer way so that we can quickly assess alert of their estimated time of said. It s in the best interest for and take care of all of these arrival, the process goes like all very sick stroke patients to patients, Onteddu said. It s a clockwork from there, to the have someone like Dr. Tan on their streamlined process for us. emergency department, to the medical team. scanners, to the procedure, to the Before calling, physicians are For that patient in your exam ICU and recovery and discharge. asked to conduct a neurological room, the one who might be Saline Garland Polk Monroe Phillips Montgomery Jefferson Grant Hot Springs Howard Arkansas Jefferson Pike Sevier Clark Dallas Cleveland Lincoln Desha Hempstead Little River Nevada Drew Ouachita Calhoun Bradley Miller Chicot Lafayette exam and a head CT and a CTA head and neck, if possible, and have the information ready to show the neurologist. After the determination of whether tpa is appropriate, many of the patients are transferred to UAMS or other hospitals for further treatments. At UAMS, quick and wellcoordinated advanced neurointerventional procedures are available 24/7. Columbia Union Benedict Tan, M.D., and Lee Archer, M.D., agreed. Tan is director of neurocritical care at UAMS and is the only neurointensivist in the state. Archer is chairman of the Department of Neurology in the UAMS College of Medicine. For neurological and neurosurgical patients who are sick enough to be in the ICU, studies have shown that when they are taken care of Ashley outside the 4.5-hour timeframe connecting with the experts on the other end of the phone line is the first step in a process that could mean a world of difference for their outcome. In our business, time is brain, Onteddu said. We are here to help in a situation where every minute that goes by is equal to 1.8 million neurons lost. We help make sure that for you and your patients, every second counts. n More information about the Physician Call Center is available at UAMShealth.com/md. For more information on AR SAVES, visit arsaves.uams.edu or call

3 News to Know: Updates from UAMS Tourette s Syndrome Specialist Lotia Joins Movement Disorder Clinic Mitesh P. Lotia, M.D., has joined UAMS as a movement disorder neurologist with a special interest in Tourette s syndrome and sees patients in the Movement Disorder Clinic. Lotia came to UAMS after completing a fellowship on movement disorders and Tourette s syndrome at Baylor College of Medicine in Houston, Texas. He was a clinical stroke fellow at the National Institutes of Health Stroke Team at Washington Hospital Center in Washington, D.C. To make a referral, call OrthoNow Offers Walk-In, After-Hours Service UAMS has opened a walk-in, after-hours orthopaedics clinic OrthoNow at the UAMS Orthopaedics Clinic at 600 Autumn Road in Little Rock. OrthoNow is open 5-8 p.m. Monday through Thursday and 8 a.m. to noon Saturdays for general orthopaedics issues. Patients need not call in advance to schedule an appointment. Therapy appointments can also be scheduled during the extended hours. To schedule therapy, call Surgeons Frazier, Pearce Join Orthopaedic Clinic G. Thomas Frazier Jr., M.D., has joined UAMS as a hand and upper extremity surgeon. Charles Chuck Pearce, M.D., has joined UAMS as an orthopaedic sports medicine surgeon specializing in shoulder problems. They see patients at the UAMS Orthopaedic Clinic on Shackleford Boulevard. Frazier specializes in hand and microsurgery and has a special interest in joint replacement of the hand, wrist and elbow, and joint arthroscopy for the elbow and wrist. Pearce is experienced in performing minimally invasive shoulder and knee surgeries. He is skilled in treatment of conditions like rotator cuff tears and knee tears like those to the meniscus or anterior cruciate ligament (ACL). Both have been practicing in Little Rock for 28 years. To make a referral, call Academic Appointments Robert L. Lee Archer, M.D., has been named chair of the Department of Neurology in the College of Medicine. Archer will continue to spend about half of his time on patient care. He has trained and hired a second physician, Carolyn Mehaffey, M.D., to continue to serve MS patients in Arkansas (Continued on page 4) October 2017 Message from Dr. Jansen Dear Colleagues, I am sure that you, as am I, are a bit weary of all the changes in medicine MACRA this, ACA that and other types of health care reform. Change is never easy. It is even more difficult when our jobs are already so complex. As we learn all the new acronyms in our medical alphabet, let s be mindful of the real reason we became health care providers in the first place. Our patients have entrusted us with the most precious thing they have: their health. Hippocrates never had to deal with PQRS or meaningful use. He was consumed with understanding the human condition, including illness, and was dedicated to doing right by his patients. Even though his time has long passed, the principles by which he practiced are timeless. The next time you are in clinic or at the patient s bedside in the hospital, don t forget to step back for a moment and remember why you dedicated your life to medicine. Sincerely, Mark T. Jansen, M.D. Medical Director UAMS Physician Relations & Strategic Development CONSULT Quiz of the Month Question What is the most likely diagnosis in a person who has an erythema chronicum migrans rash (bull s eye rash) who has never left the state of Arkansas? Answer STARI (southern tick-associated rash illness) is an emerging tick-borne disease in the southern U.S. that comes from the lone star tick. Symptoms are usually mild and include low-grade fever, fatigue, muscle aches and a headache in addition to the rash. The causative agent is unknown at this time. It is self-limited, but most clinicians prescribe a short course of doxycycline. 3

4 News to Know: Updates from UAMS Physician Relations (News to Know continued from page 3) and allow the UAMS MS clinic to accept new patients. To make a referral, call John Dornhoffer, M.D., has been appointed chair of the Department of Otolaryngology- Head and Neck Surgery in the College of Medicine. Dornhoffer succeeds James Y. Suen, M.D., who stepped down after more than four decades as chairman. He continues to see patients. To make a referral, call Frederick Rick E. Barr, M.D., has been appointed chair of the Department of Pediatrics and associate dean for child health in the College of Medicine. Barr succeeds Richard F. Jacobs, M.D., who has retired after 35 years of service on the faculty at UAMS. New Physicians Breast Surgical Oncology Amelia Merrill, M.D. Gastroenterology Shashank Garg, M.D.; Sumant Inamdar, M.D. General Surgery Trauma Anna M. Privratsky, M.D. Hematology-Hospice and Palliative Care Carrie R. Hyde, M.D. Nephrology Sushma Bhusal, M.D. Neurology Nidhi Kapoor, M.D.; Krishna Nalleballe, M.D. Neurosurgery Viktoras Palys, M.D.; Analiz Rodriguez, M.D. Ophthalmology Christopher Lee, M.D. Orthopaedic Surgery Lawrence O Malley, M.D.; Steven Cherney, M.D. Pediatrics-Cardiothoracic Surgery Brian Reemtsen, M.D. Physical Medicine and Rehabilitation Antonio Howard, M.D. Pulmonary Emily Kocurek, M.D. Radiation Oncology Thomas Kim, M.D. Thoracic Surgery Jason Muesse, M.D. Urology Bruno Cancado, M.D. Vascular Surgery Christian Simmons, M.D. Physician Relations & Strategic Development Mark T. Jansen, M.D. mtjansen@uams.edu Michael Manley, RN, MNSc mmanley@uams.edu Director Melanie Meyer, M.Ed. melanie@uams.edu Manager Carla Alexander, M.Ed. carla@uams.edu Byron Jarrett, Brian Mann & Wendy Sheridan physicianrelations@uams.edu CONSULT is produced by the UAMS Office of Communications & Marketing and Physician Relations & Strategic Development. Editor Amy Widner Vice Chancellor for Communications & Marketing Leslie Taylor UAMS PHYSICIAN RECRUITMENT & PROVIDER PLACEMENT PROGRAM The UAMS Physician Recruitment & Provider Placement Program has a team of placement specialists dedicated to serving the recruitment needs of our partner communities, UAMS Regional Campuses and UAMS faculty. Physician/provider opportunities are in: Anesthesiology, Cardiology, Emergency Medicine, Family Medicine, General Internal Medicine, Geriatrics, Gastroenterology, Hematology/Oncology, Hospitalists, Nephrology, Neurology, Neurosurgery, Obstetrics/Gynecology, Ophthalmology, Orthopaedics, Otolaryngology, Pediatrics, Physical Medicine & Rehabilitation, Pulmonary/Critical Care, Psychiatry, Rheumatology, Surgery and Urology. FEATURED JOBS Medical Director, Child and Adolescent Psychiatry: Nonprofit Northwest Arkansas agency seeks medical director to serve the behavioral health needs of the community Family Medicine Opportunites: Academic and private practice opportunities available statewide Hematology/Oncology Opportunities: Three hematologist/oncologist opportunities in Central Arkansas and the River Valley Recruitment services contacts: Carla Alexander: or carla@uams.edu Wendy Sheridan: or wendy@uams.edu For a complete listing of job descriptions and opportunities, visit: MedJobArkansas.com Follow MedJobArkansas: 4

5 New Machine-Guided Laser System Provides Safer Treatment Options The Navilas Laser System 577+ at the Harvey & Bernice Jones Eye Institute is specifically useful in the treatment of diabetic macular edema, says Sami Uwaydat, M.D., ophthalmologist. UAMS has acquired the Navilas Laser System 577+ at the Harvey & Bernice Jones Eye Institute. The system features a navigated, yellow 577 nm treatment laser and the option to perform tissuefriendly navigated microsecond-pulsed treatments. It is a retinal photocoagulator integrated with a digital fundus camera. The laser can be used to destroy small areas of tissue in the retina. Its imaging and navigation functions allow the physician to capture images of the problem area and use them to configure the system so that it can self-guide the laser during the procedure. The breakthrough is that you can plan the treatment on a screen, and the machine will deliver the treatment itself, said Sami Uwaydat, M.D., an ophthalmologist at the Jones Eye Institute. It has significantly improved the safety and efficacy of treatments for patients. If the patient shifts or the eye moves during the treatment, the laser beam will move along with it or not fire if it s pointed at the wrong target. It s also a great teaching tool, as you can observe the treatment on the screen while it s being completed. Uwaydat said the Navilas is specifically useful in the treatment of diabetic macular edema. Other indicated uses include proliferative diabetic retinopathy, subretinal neovascularization, central and branch retinal vein occlusion, lattice degeneration and retinal tears. It can also be used for imaging with capture, display, storage and manipulation capabilities including color, fluorescein angiography and infrared imaging. It can also aid in the diagnosis and treatment of ocular pathology in the posterior segment of the eye. To make a referral, call PHYSICIAN PROFILE J. Camilo Barreto, M.D. Assistant Professor of Surgery Surgical Oncology What inspired you to become a doctor? I always liked the sciences and found medicine to be incredibly exciting, but initially thought I would be an engineer like my father and brother. I did not realize that medicine was the path for me until later, when I took an objective look and asked myself what I really loved to do. I observed some successful doctors in their work, and the impact I saw them make really convinced me that I wanted to become a doctor as well. What do you like most about your specialty? The fact that you can cure a patient or extend their survival time or relieve disabling symptoms is extremely rewarding. I also love the practice of surgery and the technical aspects. Having a challenging case to figure out, being able to get a good outcome that helps the patient those moments make it the best job you could ask for. Treatment of cancer is constantly changing, and this provides numerous opportunities for innovation and research. What makes you unique among your peers? I have very extensive training in complex GI procedures and also have training in minimally invasive surgery. I genuinely care about the wellbeing of my patients and I pay special attention to all details during the initial workup, treatment and follow-up. Why did you come to UAMS? A good friend of mine had been working here for a few years before me and he was very satisfied with his work. I submitted my application and UAMS provided a perfect setting for a practice in a tertiary care academic center, while giving me the opportunity to treat a wide variety of conditions within my specialty. What are your clinical specialties? General surgical oncology: pancreaticobiliary tumors, gastric cancer, GIST, adrenal tumors, neuroendocrine tumors, soft tissue sarcomas, melanoma and other skin cancers, hyperthermic intraperitoneal chemotherapy for pseudomyxoma peritonei and peritoneal surface malignancies. What number can doctors use to make a referral to you? Referral number: Office number: Clinic number: JCBarretoAndrade@uams.edu 5

6 MEDICAL CASE STUDY Hand Reattachment The patient severed his left hand across the palm. INITIAL CONTACT A 29-year-old male patient presented to a hospital in Texarkana, Arkansas, with his left hand severed across the palm from a sawmill accident. UAMS has a hand surgeon on call 24/7 and is the tertiary referral for the region for hand trauma. John Stephenson, M.D., provided a telemedicine consult to the Texarkana hospital and advised that the patient be transported to UAMS. The patient s coworkers had placed the amputated hand on ice immediately after the accident, and it had been professionally iced and gauzed by staff at the Texarkana hospital. He arrived at UAMS about six hours after the accident, within the ideal window for a hand reattachment, which is 12 hours. ASSESSMENT UAMS hand trauma surgeons Stephenson; John Bracey, M.D.; and Mark Tait, M.D., assessed the trans-metacarpal amputation and determined that the patient was an excellent candidate for replantation. 6 With many of the hand trauma cases that the team encounters, the tissue has been crushed or stretched in a way that prevents replantation. But in this case, the type of blade had not ripped or stretched the skin. The cuts to the bones were clean, almost surgical in nature. The team discussed the options with the patient: the replantation attempt, or a proximal amputation. While he was an ideal candidate for replantation, it was important to the surgeons that the patient understood that the reattached hand would never function at 100 percent. It would never be normal again, but it would likely regain some function and sensation and be able to serve as a helper hand. It would also likely be easier and more intuitive for him to learn to work with than a prosthetic hand. The patient agreed to the replantation surgery. PROCEDURES Bracey, Tait and Stephenson spent almost 12 hours on the surgery. They reattached bones and tendons, microscopically repaired vessels to return blood flow, and completed nerve grafts to restore feeling. They worked in shifts, with two surgeons under the microscope at any given time. The surgery cannot be completed alone because of the exhaustive detail work involved and the duration of the procedure. Before UAMS was able to recruit the minimum number of hand surgeons necessary to offer this procedure on call, such patients were sent to hospitals in St. Louis, Missouri, and Louisville, Kentucky. The surgery began with sterilization of both the hand and the residual stump to decrease the risk of infection. To establish stability, the surgeons wired the bones into place. Then their priority was to restore some blood flow to the hand. They reattached some of the arteries before moving on to tendons, veins and nerves. The case presented some ideal conditions and some challenges. Because of the clean nature of the cut, the quality of the tissues on each side was good, and the team did not have to resect back or remove healthy tissue. The nerves had received minimal damage, and what damage there was, they patched with nerve tube. Despite the relatively clean cut, the team did encounter some vessels that were stretched, so they had to creatively plan different vessels to anastomose to the distal vessels. The surgery took almost 12 hours. They amputated the little finger. The saw cut was at an angle and went through the bottom edge of the small finger, causing it to be particularly at risk of becoming stiff and unusable after replantation. The surgeons fashioned that side to resemble the natural outer curve of the hand, so (Hand Reattachment continued on page 7)

7 (Hand Reattachment continued from page 6) The team examines the patient about seven months after the surgery. the missing finger would be less obvious at first glance. While the patient was an ideal candidate for the surgery in many ways, the location of the cut caused it to be one of the most challenging and time-consuming of hand replantation surgeries. The amputation severed the palmar arch, where many blood vessels branch off to take blood supply to the fingers, which increases the number of individual reattachments that are necessary. Compared to other amputation locations, where, for example, only two arteries have been severed, the location of this amputation multiplied the amount of detail work to be done many times over. The patient did very well during surgery and during the immediate post-operative three days in intensive care on blood thinners and under close observation. FOLLOW-UPS Initially, the team monitored blood flow and saw the patient often after he was released from the hospital. The team moved slowly and cautiously to re-introduce motion, careful not to stress or rupture the blood vessels. The vessels stabilized after a few weeks, and the team re-introduced light motion. At six weeks, the X-rays reassured them that the bones were healing, and they started being more aggressive with the re-introduction of motion. At six weeks, the tendons are also in a good position to support more motion. Since that time, the patient has been working aggressively in occupational therapy, with the surgeons monitoring. The priorities shifted from blood flow to motion, then strength and sensation. Seven months after the surgery, the patient was able to move his fingers, grasp a pen and scribble on a piece of paper. Since then, the main gains he has made have been in sensation, with the return of some protective sensation: the ability to differentiate between hot and cold, sharp and dull. Nerve recovery is the longest part of the process, and will continue to improve over time on a scale of years rather than months or weeks. He will also be able to work on refining his movements to manipulate increasingly smaller objects. For consult or transfer, call To make a referral, call Mark Tait, M.D. Assistant professor Department of Orthopaedic Surgery UAMS College of Medicine Education Medical Degree, University of Missouri Residency Orthopaedic surgery, UAMS Fellowship Hand and microsurgery, OrthoCarolina in Charlotte, North Carolina Brachial plexus and nerve injury traveling fellowship with Christophe Oberlin, M.D., Paris John W. Bracey Jr., M.D. Assistant professor Department of Orthopaedic Surgery UAMS College of Medicine Education Medical Degree, UAMS Residency Orthopaedic surgery, UAMS Fellowship Hand and upper extremity, OrthoCarolina in Charlotte, North Carolina Brachial plexus surgery training with Jayme A. Bertelli, M.D., Brazil EpicCare Link is a secure, web-based portal for referring physicians to track patient progress and treatment while at UAMS. It provides secure messaging for electronic consults. First Access allows users to add patients to their accounts. It is free of charge, convenient to use and signing up is easy. How to register: Log onto UAMShealth.com/md Complete the EpicCare Link access request form UAMS IT will your user name and password Please visit our website for referring providers: UAMShealth.com/md Content includes: CME Outreach LearnOnDemand EpicCare Link Find a Physician Online Appointment Requests Physician Call Center Physician Recruitment & Provider Placement UAMS Library 7

8 4301 W. Markham St., #727 Little Rock, AR NONPROFIT ORGANIZATION U.S. POSTAGE PAID LITTLE ROCK, AR PERMIT NO ADDRESS SERVICE REQUESTED Learn on Demand A resource of the UAMS Center for Distance Health (CDH), the LearnOnDemand.org web portal offers health care professionals the flexibility of earning continuing education (CE) credits on their own schedule, through an expanded array of teleconferences and online courses. n Track all educational hours and credits earned inside or outside the program n Ensure compliance with the CE requirements for the national accrediting organizations for physicians and nurses n Earn certificates of attendance for a variety of other disciplines LearnOnDemand.org For information on LearnOnDemand, contact: cdheducation@uams.edu or To request speakers or topics or to learn more about how the UAMS Physician Relations & Strategic Development team can help you, visit UAMShealth.com/md OCTOBER 3 Chronic Kidney Disease Manisha Singh, M.D. Department of Internal Medicine OCTOBER 10 Medication-Assisted Treatment for Opioid Use Disorders Michael Mancino, M.D. Department of Psychiatry OCTOBER 17 Pancreatitis Benjamin Tharian, M.D. Department of Internal Medicine OCTOBER 24 Trauma/ER Tuesday Coagulopathy, Massive Transfusion Protocol JR Taylor, M.D. Department of Surgery OCTOBER 31 Professional Development Interviewing Patients Mary Cantrell & Faiza Khan, M.D. UAMS MASTER s Champions NOVEMBER 7 URI and Strep Pharyngitis: Medication Regimens, Strep Testing/Treatment, Complications Phani Durvasula, M.D. Department of Otolaryngology NOVEMBER 14 Trauma/ER Tuesday Massive Orthopaedic Trauma: Controlling Hemorrhage Regis Renard, M.D. Department of Orthopaedics NOVEMBER 28 Professional Development Independent vs. Integrated Michael Cash, MHSA, FACMPE SVMIC DECEMBER 5 GERD and Barrett s Esophagus: What s New? Sumant Inamdar, M.D. Department of Internal Medicine DECEMBER 12 Adult Sickle Cell Update Pooja Motwani, M.D. Department of Internal Medicine DECEMBER 19 Biomechanics of Obesity Antonio Howard, M.D. Department of Physical Medicine & Rehabilitation Learn on Demand services are FREE in October. In support of improving patient care, University of Arkansas for Medical Sciences is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC) to provide continuing education for the health care team. The University of Arkansas for Medical Sciences designates this live activity for a maximum of 1.0 AMA PRA Category 1 Credits TM. Physicians should claim only the credit commensurate with the extent of their participation in the activity. The University of Arkansas for Medical Sciences designates this live activity for a maximum of 1 ANCC contact hour. Nursing contact hours will be awarded for successful completion of program components based upon documented attendance and completion of evaluation materials.