Northeast Florida Medicine - Summer 2013 - Preventive Medicine by Duval County Medical Society

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VOLUME 64, NUMBER 2 Preventive Medicine, Summer 2013

Summer 2013

EDITOR IN CHIEF Raed Assar, MD (Chair)

Contents

MANAGING EDITOR Leora Legacy and Laura Townsend ASSOCIATE EDITORS Laura Armas-Kolostroubis, MD Abubakr Bajwa, MD Kim Barbel-Johnson, MD Ruple Galani, MD

Summer CME

Kathy Harris (Alliance) Sunil Joshi, MD (Vice Chair) James Joyce, MD Daniel Kantor, MD Neel Karnani, MD Mobeen Rathore, MD James St. George, MD

EXECUTIVE VICE PRESIDENT Bryan Campbell DCMS FOUNDATION BOARD OF DIRECTORS Ashley B. Norse, MD, President Eli N. Lerner, MD, President-Elect Neel G. Karnani, MD, Vice President Mobeen Rathore, MD, Vice President Daniel Kantor, MD, Vice President Raed Assar, MD, Secretary Sunil Joshi, MD, Treasurer Malcolm Foster, Jr., MD, Im. Past President Cynthia Anderson, MD Elizabeth Burns, MD Paul Chappano, MD Rui Fernandes, MD Ruple J. Galani, MD E. Rawson Griffin, MD Mark L. Hudak, MD TraChella Johnson Foy, MD James J. Joyce, MD Harry M. Koslowski, MD Stephen E. Mandia, MD Jesse P. McRae, MD Jason D. Meier, MD Nathan P. Newman, MD Alexander Pogrebniak, MD James St. George, MD Nathan P. Newman, MD Sanjay Swami, MD David L. Wood, MD Bouali Amoli, DMD, MD, Resident LT George Salgado, MC, USN, Resident Amit Grover, MD, Resident Monique Gray, MD, Resident Northeast Florida Medicine is published by the DCMS Foundation, Jacksonville, Florida, on behalf of the County Medical Societies of Duval, Clay, Nassau, Putnam, and St. Johns. Except for official announcements from the County Medical Societies, no material or advertisements published in NEFM are to be seen as representing the policy or views of the DCMS Foundation or its colleague Medical Societies. All advertising is subject to acceptance by the Editor in Chief. Address correspondence and advertising to: 555 Bishopgate Lane, Jacksonville, FL 32204 (904-355-6561), or email: ltownsend@dcmsonline.org.

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Evidence-Based Clinical Preventive Services Helena Karnani, MD

Preventive medicine recommendations are constantly being updated and it is important for physicians to keep current and offer appropriate clinical preventive services to their patients. This article will review the latest recommendations for clinical preventive services and immunizations from the United States Preventive Services Task Force, the American Cancer Society and the Centers for Disease Control. It will also discuss the evidence, rationale and controversies surrounding some of these recommendations.

Features The Interface Between Medicine and Public Health Robert Harmon, MD, MPH, Guest Editor

Evidence-based Community Preventive Services

From the Editor’s Desk

51 Patient Section 48 Residents’ Corner 57 New Members

From the President’s Desk

Robert Harmon, MD, MPH

The Tobacco Epidemic

Departments

Abubakr A. Bajwa, MD, FCCP; Vandana Seeram, MD; Candy Holloway; Leon Crawley and Tauseef Qureshi, MD

The Role of Physical Activity 35 in Personal and Population Health Joseph G. McQuade, MD, MS

Managing the Obesity Epidemic: A Community Perspective

Jonathan S. Evans, MD

Multi-Disciplinary Team Embarks on 47 Groundbreaking “Heat Mapping” Research Nikole M. Helvey, MS HSA

Special Articles Who Were Those Heroes in Boston?

DCMS EVP Honored as One of Jacksonville’s 40 Under 40 DCMS Hosts Dr. Ardis Hoven, AMA President-elect

Northeast Florida Medicine Vol. 64, No. 2 2013 3

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From the Editor’s Desk

Preventive Medicine: Threats and Opportunities According to Hippocrates (460 BC – 370 BC), “The function of protecting and developing health must rank even above that of restoring it when it is impaired.” Today, Hippocrates’ statement still rings true, but the overall design of the health care system is still geared toward identifying and curing illness—not preventing it. Initiatives to prevent obesity, encourage physical activity, assess risks for depression, and develop strategies to avert substance abuse have not received as much funding as new drugs and devices. Additionally, the current health care system provides care via episodic patient-physician interactions that are not ideal for prevention. This issue of the Northeast Florida Medicine echoes Hippocrates’ ancient calling. It highlights the threats to the community’s wellbeing and provides tools for physicians to improve preventive care and wellness. The cost of health insurance premiums is rising at nearly three times the rate of inflation and wages (CMS). More than 75 percent of the nation’s health care spending is on people with chronic conditions (Johns Hopkins). These conditions are also amongst the leading causes of death and disability with a tremendous impact on worker productivity. Mental illness is closely associated with chronic diseases and can itself lead to chronic illness (CDC). However, there are significant developments to note. Raed Assar, MD, MBA Editor-in-Chief Northeast Florida Medicine

America’s Outlook One significant development is the attitude of Americans seems to have changed in recent opinion surveys. About 84 percent of Americans favor public funding for chronic disease prevention (2008 National Association of Chronic Disease Directors—NACDD). Of course, questions remain regarding sources, amounts and which programs to support. More people realize that the belief that one section of the population is insulated from a certain chronic illness because they do not physically suffer from it is not valid. It turns out, all Americans share in the total costs of health care regardless of whether the conditions affect them physically. In fact, Medicare and Medicaid payments have failed to cover the cost of care for their memberships (American Hospital Association). These factors result in displacement of costs onto the working population in the form of more hidden taxes.

Physicians Should Lead the Way Outcomes over the past decades show that physicians should lead the dialogue on prevention. For example, overall heart disease and stroke death rates have declined since 1999 (Office of Vital Statistics). This would have not been possible without physicians’ leadership. It is true that disparities persist among members of racial and ethnic minority populations that contribute to higher death rates from these conditions for African Americans (CDC). This, in fact, is a threat to our community, but also an opportunity to focus efforts on this population for the desirable outcome. Progress Toward a Healthier Future Physicians made tremendous progress in developing and using effective cancer prevention, early detection and overall cancer management. Deaths caused by breast cancer and colorectal cancer decreased by two percent from 1998 to 2005, and four percent from 1995 to 2005. However, disparities remain as more African Americans are likely to die from cancer (National Cancer Institute). Also, lung cancer due to smoking remains a leading cause of mortality in this country (CDC). This challenge is great, as costs of cancer exceeded $200 billion in 2008 and are likely to continue to escalate (American Cancer Society). Physicians’ role is pivotal in managing cancer prevention initiatives and costs. Physicians also managed diabetes and prevented its complications more effectively as evident by the 21 percent decline in the incidence of end stage renal disease from 1997 to 2002 (CDC). However, poor diet and lack of exercise remain prevalent and will continue to require physician attention (National Center for Health Statistics). Arthritis, obesity, respiratory disease and substance abuse contribute to disabilities and are associated with chronic diseases. Physicians from all specialties have roles on the front line facing these conditions and should be involved in prevention strategies. In summary, the physicians’ challenge is to engage the population to raise awareness, concern and personal commitment to prevention. Costs of such conditions do not only affect the people who engage in unhealthy behaviors; they affect the entire community in the form of increased hospital costs, health insurance cost and taxes. As we learn in this issue, there are methods and opportunities on the horizon that are promising. Electronic connectivity and evidence-based decision support tools disseminate clinical information and improve availability of guidance to patients and physicians. Patient Centered Medical Homes and Accountable Care Organizations promise better results. As this issue demonstrates, physicians cannot do it alone, but they can lead the nation to a better future.

*Dr. Assar is Aetna’s Medical Director for North Florida. Articles or opinions provided by Dr. Assar do not necessarily reflect the views of Aetna. www . DCMS online . org

Northeast Florida Medicine Vol. 64, No. 2 2013 5

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6 Vol. 64, No. 2 2013 Northeast Florida Medicine

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Who were those heroes in Boston? On Monday morning, April 15th, a group of volunteer physicians, nurses, and medical support staff travelled to downtown Boston to staff the Boston Marathon Finish Line Medical Tent. As they began to set up their area to prepare for those runners suffering from dehydration, hypothermia, and other minor aches and pains after running 26.2 miles and conquering “heart break hill”, little did they know how invaluable they would become in saving the lives of over 150 people later that day. This medical tent became the triage area for those wounded in the terrorist bombing that day. But who were those heroes in Boston? Besides the professional first responders and concerned onlookers that pitched in to offer assistance, the medical personnel were comprised of healthcare volunteers who were members of the Medical Reserve Corps (MRC). The MRC is a program that falls under the Department of Health and Human Services Office of the Surgeon General. It was established after the terrorist attacks on September 11, 2001 to provide state and local governments with trained medical volunteers to assist with the public health in times of emergency. These emergencies might include responding to hurricanes, flooding, airplane crash, bird flu epidemic or immunization, or a terrorist attack. Here in Duval County, the MRC has been involved in immunization programs for the flu, staffing special needs shelters during tropical storms/hurricanes, assisting in the Haiti earthquake relief efforts, and participating in the JAXPORT airport disaster drill.

2. 1. MRC volunteers and emergency personnel assist injured people near the finish line of the Boston Marathon. 2. A better look at the MRC physician volunteers assisting with wounded victims from the bombings. Photos by Aaron tango Tang from Cambridge, MA, via Wikimedia Commons

We need more MRC volunteers here in Jacksonville so we can have a strong cadre of local heroes. The following steps will get you started in becoming an MRC: • Visit www.servfl.com • Register in SERVFL to join the FL MRC Network • Locate your local FL MRC Coordinator(s) • Review and complete the FL MRC Volunteered Required Trainings and paperwork

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Northeast Florida Medicine Vol. 64, No. 2 2013 7

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8 Vol. 64, No. 2 2013 Northeast Florida Medicine

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The Interface Between Medicine and Public Health Guest Editorial by Robert Harmon, MD, MPH The enactment the federal Affordable Care Act (ACA) and U. S. Supreme Court decision upholding it have focused new attention on the importance of improving preventive services in the practice of medicine. This edition of Northeast Florida Medicine is devoted to the timely topic of preventive medicine and public health. It seeks to promote what the practicing clinician can do, regardless of specialty, in the clinical setting and the community to help patients and populations achieve healthier lifestyles and outcomes.

help coalitions to pursue projects with proven benefits to populations in schools, worksites, churches and other community settings. In “The Tobacco Epidemic,” Abubakr Bajwa, MD and colleagues describe the ongoing epidemic of tobacco use and how Northeast Florida is responding. Joe McQuade, MD, writes about the serious epidemic of physical inactivity in his article, “The Role of Physical Activity in Personal and Population Health.” Jonathan Evans, MD, writes about the growing epidemic of obesity and its complications in his article, “Managing the Obesity Epidemic: A Community Perspective.”

It is commonly thought that medical care is the biggest determinant of how long we live. Actually, according to a report by the U. S. Surgeon General,1 medical care accounts for only 10 percent of life expectancy. Behavior and lifestyle factors account for 50 percent; social, physical, economic and environmental Robert Harmon, MD, MPH factors account for 20 percent; and biological and genetic factors account for 20 percent. The reason can be found in an analysis of the real causes of death in an article by Mokdad et al.2 They showed that the major causes of mortality in the U. S. were largely preventable risk factors, including tobacco use (435,000 deaths/year), poor diet and physical inactivity (365,000 deaths/year), alcohol misuse (85,000 deaths/year), microbial agents (75,000 deaths/year), toxic agents (55,000 deaths/year), motor vehicle crashes (43,000 deaths/year), misuse of firearms (29,000 deaths/year), unsafe sex (20,000 deaths/year) and illicit drug use (17,000 deaths/year).

These principles are taught and practiced in my specialty of Preventive Medicine, which includes the subspecialty areas of General Preventive Medicine/Public Health, Occupational Medicine and Aerospace Medicine. The challenge is that the number of actively practicing board certified Preventive Medicine specialists is less than 1% of all physicians. Therefore, it is critical that many other specialties be involved in the provision of preventive services in the office and the community. Each of the articles gives examples of successful practices that are worthy of expansion. Some involve government agencies, but many are based in the private non-profit and for-profit sectors. For example, the Duval County Medical Society has a Public Health Committee which is active in emergency preparedness and many areas of community preventive services.

So what can the practicing clinician do to reduce the risks in his/her patients and the community? This edition provides evidence-and risk factor-based approachs and the tools to improve the provision of preventive services. Helena Karnani, MD gives us the latest evidence-based guidelines on clinical preventive services from the U. S. Preventive Services Task Force in her article “Evidence Based Clinical Preventive Services.” These guidelines are now written into the Affordable Care Act and must be covered by health plans without patient cost sharing. My article, “Evidence-based Community Preventive Services for Practicing Clinicians,” describes what clinicians can do to

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The office-based provision of clinical preventive services should be enhanced by the growth in the use of electronic health records. These often have tools and reminders based on age, gender and risk factors. Expanded electronic health information exchange and direct secure messaging should also help to improve our performance in disease reporting and surveillance, immunization and other areas of public health. The American Medical Association and its component state and local medical societies have a long history of supporting public health. It is fitting that this journal is devoting an entire edition to this timely and compelling subject.

References

1. Healthy People: The Surgeon General’s Report on Health Promotion and Disease Prevention, 1979; 1-9. 2. Mokdad AH, Marks JS, Stroup DF et al. Actual Causes of Death in the U. S., 2000. JAMA. 2004; 291(10): 1238-1245.

Northeast Florida Medicine Vol. 64, No. 2 2013 9

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(Pictured left to right) We Care Jacksonville: Todd Sack, M.D., Board President, and Sue Nussbaum M.D., M.B.A., Executive Director; The Jacksonville Bank employees and We Care volunteers: Ann Van Voorst, Jennifer Hayes and Katie Perkins; and The Jacksonville Bank Medical Team Relationship Managers: Matt Wheeler, V.P., and Lou Vaccaro, S.V.P.

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Preventive Medicine Section

Evidenced Based Clinical Preventive Services Background:

The Duval County Medical Society (DCMS) strives to provide its members with the benefits that consistently meet your professional needs such as free continuing medical education (CME) opportunities in subject areas mandated and suggested by the State of Florida Board of Medicine to obtain and retain medical licensure. The DCMS would like to thank the St. Vincent’s Healthcare Committee on CME for reviewing and accrediting this activity in compliance with the Accreditation Council on Continuing Medical Education (ACCME). We would like to specially thank Helena Karnani, MD, Chair of the CME Committee; Betsy Miller, Director, Medical Staff, Quality Management; and Cindy Williamson, CME Coordinator for their work on behalf of DCMS. This issue of Northeast Florida Medicine includes an article, “Evidence Based Clinical Preventive Services” authored by Helena Karnani, MD, has been approved for 1 AMA PRA Category 1 credit.TM For a full description of CME requirements for Florida physicians, please visit www.dcmsonline.org.

Faculty/Credentials:

Helena Karnani, MD is currently the Assistant Director for the St. Vincent’s Healthcare Family Residency Program. Dr. Karnani received her degree from Birmingham University Medical School in England.

Objectives: 1. 2. 3.

Learn the most recent guidelines for preventive services. Learn the evidence and rational for preventive services recommendations. Learn most recent recommendation for immunizations in adults and children.

Date of Release: June 1, 2013

Date Credit Expires: June 1, 2014

Estimated Completion Time: 1 hour

How to Earn this CME Credit: 1. 2. 3.

Read the “Evidence Based Clinical Preventive Services” article, complete posttest following the article and fax or email your test to Patti Ruscito at patti@dcmsonline.org or 904.353.5848. Go to www.dcmsonline.org to read the article and take the CME test online. All non-members must submit payment for their CME before their test can be graded.

CME Credit Eligibility:

In order to receive full credit for this activity, a minimum passing grade of 70% must be achieved. Only one re-take opportunity will be granted if a passing score is not made on the first attempt. DCMs members and non-members have two years to submit the past test and earn the CME credit. A certificate of credit/completion will be emailed within four to six weeks of submission. If you have any questions, please contact Patti Ruscito at 904.355.6561 or patti@dcmsonline.org.

Faculty Disclosure:

Helena Karnani, MD reports no significant relations to disclose, financial or otherwise with any commercial supporter or product manufacturer associated with this activity.

Disclosure of Conflicts of Interest:

St. Vincent’s Healthcare (SVHC) requires speakers, faculty, CME Committee and other individuals who are in a position to control the content of this educations activity to disclose any real or apparent conflict of interest they may have as related to the content of this activity. All identified conflicts of interest are thoroughly evaluated by SVHC for fair balance, scientific objectivity of studies mentioned in the presentation and educational materials used as basis for content, and appropriateness of patient care recommendations.

Joint Sponsorship Accreditation Statement

This activity has been planned and implemented in accordance with the Essential Areas and policies od the Accreditation Council for Continuing Medical Education through the joint sponsorship of St. Vincent’s Healthcare and the Duval County Medical Society. St. Vincent’s Healthcare designates this educational activity for a maximum of 1 AMA PRA Category 1 credit. TM Physicians should only claim credit commensurate with the extent of their participation in the activity.

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Northeast Florida Medicine Vol. 64, No. 2 2013 11

Preventive Medicine Section

Evidenced-based Clinical Preventive Services Helena Karnani, MD

Abstract: Preventive medicine recommendations are constantly being

updated and it is important for physicians to keep current and offer appropriate clinical preventive services to their patients. This article will review the latest recommendations for clinical preventive services and immunizations from the United States Preventive Services Task Force, the American Cancer Society and the Centers for Disease Control. It will also discuss the evidence, rationale and controversies surrounding some of these recommendations.

Introduction Physicians play an important role in maintaining patients’ health and wellness and avoiding preventable diseases, yet, we could be doing a better job. A 2010 report from the Commonwealth Fund1 found that the US ranks last on measures of healthy living when compared to six other industrialized countries such as Canada, Australia and Germany. Statistics reviewed included infant mortality rates and preventable deaths before the age of 75. The US is second to last on measures of healthy life expectancy at age 60. Florida ranks 34th out of all 50 states regarding the health of its citizens, and Duval County has significantly worse statistics than the State average in areas including rates of obesity, diabetes and breast cancer.2 Many factors influence public health but, as health care professionals, we can do our part to make a difference in the health of our community and our patients. This article will focus on recent evidence-based guidelines for disease prevention for leading health issues in adults from the United States Preventive Services Task Force (USPSTF) and the American Cancer Society (ACS). It will also update recent changes for immunization recommendations in adults and children. The USPSTF is a panel of independent scientists who review scientific evidence related to clinical preventive services and make recommendation statements that weigh the effectiveness, benefits and harms of preventive interventions. These statements are published online as a guide to clinical preventive services.3 You may also download a USPSTF electronic preventative services selector (ePSS) to your PDA, mobile or tablet device which will list recommendations for patients of a specific age and sex. (Table 1)4, 5 Guidelines from the American Cancer Society may be accessed online at the Cancer Journal for Clinicians.6 Address correspondence to: Helena Karnani hkarnani@jaxhealth. com or to St Vincent’s Family Medicine Center, 2627, Riverside Ave, Jacksonville, Fl 32204 12 Vol. 64, No. 2 2013 Northeast Florida Medicine

Overview of Latest Recommendations for Leading Health Issues Cervical Cancer Screening:

Both the USPSTF and ACS updated their recommendations for cervical cancer screening in 2012. Both organizations recommend that screening with liquid based technology should start at age 21 regardless of the age of first intercourse and be performed at an interval of every three years. After the age of 30 the screening interval may be extended to every five years using a combination of cytology and HPV testing. Testing may stop at age 65 years if there are three consecutive normal PAPs and no PAPs of CIN2 (cervical intraepithelial neoplasia with moderate dysplasia) or greater in the past 20 years. PAP smears are not required after hysterectomy if there is no cervix and the woman does not have a history of CIN2 or worse in the past 20 years.7

Breast Cancer Screening:

The ACS last updated its breast screening guidelines in 20038 and recommends annual mammograms starting at age 40 and should continue annually for as long as a woman is in good health and would be a reasonably good candidate for treatment. ACS states the decision to stop screening after a certain age should be an individual decision taking into account estimated longevity and ability to be treated, as well as risks, benefits and the patient’s wishes. In 2007, the ACS recommended annual MRI screening in addition to mammograms starting at age 30 in women with life time risk of breast cancer is greater than 20-25 percent (as determined by the Gail9 or BRCA PRO10 scores). This recommendation includes women with BRCA mutations, a history of chest radiation and other high risk syndromes. The USPSTF updated its recommendations in 2009. It recommends biennial screening mammograms for women aged 50 to 74 years and notes there is insufficient evidence to assess the benefits and harms of screening after age 74. The USPSTF states that regular screening younger than the age of 50 should be an individual patient decision after discussing the specific benefits and harms. This latter recommendation caused great debate when it was first published since most physicians recommend mammograms for women in their 40’s and these women expect to have them. So, why the controversy? Even with new technology, mammography has a sensitivity (true positive rate) of 77-95 percent, and is less sensitive in younger women. It is necessary to screen 1,904 women aged 40-49 to prevent one breast cancer death. At the www . DCMS online . org

Preventive Medicine Section

Section 1: Preventive Services Recommended by the USPSTF

The U.S. Preventive Services Task Force (USPSTF) recommends that clinicians discuss these preventive services with eligible patients and offer them as a priority. All these services have received an “A” or a “B” (recommended) grade from the Task Force. For definitions of all grades used by the USPSTF, see Appendix A (beginning on p. 85). Clinical summaries of recommendations for adults begin on p. 5. Clinical summaries of recommendations for children begin 5 on p. 57.

Table 1

Preventive Services Recommended by the USPSTF Adults

Recommendation

Men

Special Populations Women

Pregnant Women

Abdominal Aortic Aneurysm, Screening1

Alcohol Misuse Screening and Behavioral Counseling Interventions

Aspirin for Prevention of Cardiovascular Disease2

Asymptomatic Bacteriuria in Adults, Screening3

Children

Breast and Ovarian Cancer Susceptibility, Genetic Risk Assessment and BRCA Mutation Testing4

Breast Cancer, Screening5

Breastfeeding, Primary Care Interventions to Promote6

Cervical Cancer, Screening7

Chlamydial Infection, Screening8

Colorectal Cancer, Screening9

Congenital Hypothyroidism, Screening10

Depression in Adults, Screening11

Diabetes Mellitus (Type 2) in Adults, Screening12 P Section 1: Preventive Services Recommended by the USPSTF (continued) 13 Folic Acid to Prevent Neural Tube Defects Gonococcal Ophthalmia Neonatorum, Preventive Recommendation Medication14

Men

Gonorrhea, Screening15

P Adults

Women

Pregnant Women

Hearing Loss in Newborns, Screening16

Special Populations P Children

Hepatitis B Virus in Pregnant Women, Screening

High Blood Pressure (Adults), Screening

HIV, Screening18

Iron Deficiency Anemia, Prevention19

P P

Iron Deficiency Anemia, Screening20

Lipid Disorders in Adults, Screening21

Major Depressive Disorder in Children, Screening22

Obesity in Children and Adolescents, Screening23

Osteoporosis, Screening24

Phenylketonuria, Screening25

Rh (D) Incompatibility, Screening

Sexually Transmitted Infections, Counseling27

Sickle Cell Disease, Screening28

Syphilis Infection, Screening

Syphilis Infection in Pregnancy, Screening

Tobacco Use in Adults and Pregnant Women, Counseling

Visual Impairment in Children Ages 1 to 5, Screening31

P P

1 One-time screening by ultrasonography in men aged 65 to 75 who have ever smoked. 2 When the potential harm of an increase in gastrointestinal hemorrhage is outweighed by a potential benefit of a reduction in myocardial infarctions (men aged 45-79 years) or in ischemic strokes (women aged 55-79 years). 3 Pregnant women at 12-16 weeks gestation or at first prenatal visit, if later. 4 Refer women whose family history is associated with an increased risk for deleterious mutations in BRCA1 or BRCA 2 genes for genetic counseling and evaluation for BRCA testing. 5 Biennial screening mammography for women aged 50 to 74 years. Note: The Department of Health and Human Services, in implementing the Affordable Care Act, follows the 2002 USPSTF recommendation for screening mammography, with or without clinical breast examination, every 1-2 years for women aged 40 and older. 6 Interventions during pregnancy and after birth to promote and support breastfeeding. 7 Screen with cytology every 3 years (women ages 21 to 65) or co-test (cytology/HPV testing) every 5 years (women ages 30-65). 8 Sexually active women 24 and younger and other asymptomatic women at increased risk for infection. Asymptomatic pregnant women 24 and younger and others at increased risk. 9 Adults aged 50-75 using fecal occult blood testing, sigmoidoscopy, or colonoscopy. 10 Newborns. 11 When staff-assisted depression care supports are in place to assure accurate diagnosis, effective treatment, and followup. 12 Asymptomatic adults with sustained blood pressure greater than 135/80 mg Hg. 13 All women planning or capable of pregnancy take a daily supplement containing 0.4 to 0.8 mg (400 to 800 μg) of folic acid. 14 Newborns. 15 Sexually active women, including pregnant women 25 and younger, or at increased risk for infection. 16 Newborns. 17 Screen at first prenatal visit. 18 All adolescents and adults and increased risk for HIV infection and all pregnant women. 19 Routine iron supplementation for asymptomatic children aged 6 to 12 months who are at increased risk for iron deficiency anemia. 20 Routine screening in asymptomatic pregnant women. 21 Men aged 20-35 and women over age 20 who are at increased risk for coronary heart disease; all men aged 35 and older. 22 Adolescents (age 12 to 18) when systems are in place to ensure accurate diagnosis, psychotherapy, and followup. 23 Screen children aged 6 years and older; offer or refer for intensive counseling and behavioral interventions. 24 Women aged 65 years and older and women under age 65 whose 10-year fracture risk is equal to or greater than that of a 65-year-old white woman without additional risk factors. 25 Newborns. 26 Blood typing and antibody testing at first pregnancy-related visit. Repeated antibody testing for unsensitized Rh (D)-negative women at 24-28 weeks gestation unless biological father is known to be Rh (D) negative. 27 All sexually active adolescents and adults at increased risk for STIs. 28 Newborns. 29 Persons at increased risk. 30 Ask all adults about tobacco use and provide tobacco cessation interventions for those who use tobacco; provide augmented, pregnancy-tailored counseling for those pregnant women who smoke. 31 Screen children ages 3 to 5 years.

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Northeast Florida Medicine Vol. 64, No. 2 2013 13

Preventive Medicine Section same time, about 100 women will have a false positive study requiring additional diagnostic testing that causes anxiety for the patient. After 10 mammograms between the ages of 40-49 years old, 50 percent of women will have had one false positive study and 20 percent will have unnecessary biopsies. There is also a concern about over-diagnosis and treatment of ductal carcinoma in situ in younger women, most of who are treated surgically, but only 50 percent are likely to become invasive. So again, the decision to have a mammogram younger than the age of 50 should take into consideration an individualâ&#x20AC;&#x2122;s risk factors for breast cancer and their wishes, weighed against the risk for harm, and should be ordered after a discussion with the patientâ&#x20AC;&#x2122;s health care professional.

Colon Cancer Screening:

Both the ACS and the USPSTF updated their recommendations in 2008 and both recommend screening beginning at age 50 in average risk people. The USPSTF recommends screening with fecal occult blood testing, sigmoidoscopy or colonoscopy. The ACS11 adds an additional test to the list - double contrast barium enema (DCBE). The ACS also recommends specific screening intervals; yearly for fecal occult testing, sigmoidoscopy every five years with or without yearly fecal occult blood testing, colonoscopy every ten years or DCBE every five years. The type of screening ordered should take into account patient preference, cost and availability of the tests, and should be an informed decision by the patient. People with increased risk of colon cancer should be screened with colonoscopy starting at age 40 for those with a family history, and earlier for some high risk familial syndromes. Subsequent frequency of testing is determined by findings at testing and patient risk factors. The USPSTF recommends against routine screening from ages 76 to 85 with decisions being made on an individual basis, and against any screening after age 85. The USPSTF concludes there is insufficient evidence to assess benefits and harms of computed colonography (virtual colonoscopies) and fecal DNA testing as screening tests.

Prostate Cancer Screening:

The ACS updated prostate cancer screening guidelines in 201012 and controversial new recommendations were published by the USPSTF in 2012. The ACS states that screening should not be performed on an individual without an informed decision making process following a discussion with their physician about the benefits and risks of screening. Men at average risk should be informed of screening options such as PSA and DRE starting at age 50, whereas men at higher risk (African Americans and men with a family history of prostate cancer before age 65) should be informed beginning at age 45. Men at very high risk (multiple family members diagnosed before age 65) should be informed beginning at age 40. Screening should not be offered to men with a life expectancy of less than 10 years. There are good patient education materials to assist with decision making at both the ACS and CDC websites and the 14 Vol. 64, No. 2 2013 Northeast Florida Medicine

ACS also has detailed talking points for physicians to assist with their discussion. The USPSTF recommended against PSA-based screening citing that many men are harmed as a result of prostate cancer screening and few, if any, benefits result. It noted that better screening tests were needed. The rationale for this statement stated that PSA testing often detects cases of asymptomatic cancer many of which would have progressed so slowly that they would not have caused harm. They said that there is no doubt that the PSA test detects prostate cancer but proof that it reduces overall mortality from prostate cancer has been limited. Studies have yielded conflicting results for outcomes after screening with, at best, an absolute risk reduction of 0.71 deaths per 1,000 men screened 13. The harms of treatment for prostate cancer have been well documented although newer surgical techniques for prostatectomy are reducing the risks of incontinence and impotence.

Lung Cancer Screening:

The ACS issued recommendations for lung cancer screening in January 201314 based on findings of the National Lung Screening Trial15 which showed a statistically significant 20 percent reduction in lung cancer mortality in a group of high risk adults randomized to receive three consecutive annual screening with low-dose computed tomography (LDCT). Screening may be offered to patients aged 55 to 74 years with at least a 30 pack per year smoking history and who currently smoke or have quit in the past 15 years. Patients should undergo a thorough discussion of the benefits, limitations and risks of screening. The risks of screening include false positive test results (39.1 percent of individuals had at least one abnormal study over three screening rounds), risk of invasive procedures (2.7 percent risk of procedures in those screened), radiation risk and over diagnosis of lung cancer. The recommendations also emphasize that the first priority for lung cancer prevention should be smoking cessation counseling. The USPSTF recommendations for lung cancer screening were last updated in 2004 and stated there was insufficient evidence to recommend screening.

Cholesterol Screening:

The USPSTF recommendations were updated in 2008, and recommendations of the American Treatment Panel (ATP3) were released in 2002 and updated in 200416 with a new guideline expected in 2013. The USPSTF recommends screening for all men over age 35 and those at increased risk for coronary heart disease (CHD) from ages 20 to 35 years. They recommend screening women aged 20 years and older only if they have risk factors for CHD. Risk factors are a history of diabetes, atherosclerotic disease, family history of premature CHD, smoking, hypertension and a body mass index more than 30. ATP3 recommends screening for all adults older than age 20 with a fasting lipid panel every 5 years. They also outline risk based cholesterol goals and treatment recommendations. www . DCMS online . org

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Northeast Florida Medicine Vol. 64, No. 2 2013 15

Preventive Medicine Section Other Recent Screening Recommendations

Abdominal Aortic Aneurysm (AAA) screening – The USPSTF recommends a one-time screening for AAA by ultrasonography in men aged 65-75 who have ever smoked. There is no evidence that screening in other groups, including women and non smokers, affects mortality outcomes. Surgical repair is recommended if the diameter of the aneurysm is more than 5.5 cm. Screening for Carotid Artery Stenosis – The USPSTF recommends against screening for asymptomatic carotid artery stenosis in the general adult population. Although a carotid ultrasound has moderate sensitivity for detecting stenosis there is only marginal benefit of treating patients with carotid endarterectomy who do not have symptoms weighed against a significant risk of post-operative stroke or death. These risks ultimately outweigh the benefits. Screening for Depression – The USPSTF recommends screening adults and children aged 12-18 years for depression if there are support systems for treatment and F/U in place. Screening involves two simple questions: In the last month have you had: 1) little interest in doing things? and 2) depressed or hopeless mood? Screening for Type 2 Diabetes – The USPSTF recommends screening for diabetes in asymptomatic adults with hypertension. The American Diabetes Association’s 2013 Standards of Care17 recommend screening all adults older than age 45 and younger than age 45 with a body mass index over25kg/m2 and one additional risk factor. Risk factors are a first degree relative with diabetes, physical inactivity, high risk ethnicity (African American, Latino, Asian American, Pacific Islander and Native American), history of gestational diabetes or having delivered a baby over nine pounds, hypertension, HDL < 35 and/or TG > 250, women with polycystic ovarian syndrome, A1C greater than 5.7 percent or impaired fast glucose on previous testing, other clinical conditions associated with insulin resistance (e.g. severe obesity, acanthosisnigricans) and a history of CHD. If the initial levels are normal, then screening should be every three years with FBG, A1C or GTT. Screening for hepatitis C – Mortality and Morbidity from hepatitis C has been increasing in the United States in recent years yet many people are unaware that they have the disease. Although people born between 1945 and 1967 represent only 27 percent of the population they account for 75 percent of the cases of hepatitis C infection. In 2012, the CDC recommended that adults born during 1945–1965 should receive one-time testing for HCV.18 Also, all persons identified with HCV infection should receive a brief alcohol screening and intervention as clinically indicated, followed by referral to appropriate care and treatment services for HCV infection and related conditions.

Adult Immunization Recommendations

Up to date immunization recommendations and tables from 16 Vol. 64, No. 2 2013 Northeast Florida Medicine

the CDC and Advisory Committee on Immunization Practices (ACIP) are published yearly and may be found on-line.18 About 50,000 adults die each year from vaccine preventable diseases (mostly influenza). The influenza immunization rate for adults in the US in 2011 was only 40 percent (while the rate was 37 percent in Duval County in 2010). Recent changes and other highlights are as follows: Tetanus, diphtheria and acellular pertussis (Tdap) – The rates of pertussis have increased remarkably in recent years with one third of cases being in adults. A dose of Tdap (which boosts immunity to pertussis in addition to diptheria and tetanus) should be given one time to all adults younger than age 65 who have not have one previously, in place of the Td shot. It may also be given older than age 65. Tdap is specifically recommended for pregnant women more than 20 weeks gestation or immediately post-partum and any other adult who will have close contact with infants less than 12 months of age. The goal of this recommendation is to reduce the risk of pertussis infection in infants who have not yet been immunized and can have severe consequences from the disease. Human papillomavirus (HPV) vaccine – A series of three shots is recommended for females at age 11-12, but may be offered up to age 26. Trials have shown that the vaccine reduces the risk of developing cervical cancer and also anal and oropharyngeal cancers that are often linked to HPV. It is also recommended for males at age 11-12 up to age 21, and may be given up to age 26. It may particularly benefit men who have sex with men (MSM). It should ideally be given before sexual activity begins, but trials have shown there is still some benefit if given after sexual activity has begun. Hepatitis B vaccine – This should be given to unimmunized adults who are sexually active, health care personnel, people with diabetes younger than age 60 and diabetics older than age 60 at the physicians discretion. It is also recommended for patients with end stage renal disease, HIV and chronic liver disease. The vaccine is recommended for all children the first dose being given shortly after birth Varicella vaccination – Varicella vaccine was introduced for routine use in children in 1995, and in 2006 a second dose at ages 4-6 years was recommended. The first dose is usually given at 12-15 months. Although adults only account for about 5 percent of all varicella cases, their disease tends to be more severe and they accounts for approximately 35 percent of mortality. Adults without evidence of immunity should be vaccinated and a second dose should be given to those who received only one previously. Evidence of immunity includes a personal history of the disease and being US born before 1980 (although healthcare workers of any age should be immunized). Other people who should strongly consider vaccination are those with close contact with immunocompromized patients, teachers, child care workers, military and those living with children. www . DCMS online . org

Preventive Medicine Section Zoster vaccination – About one in three people develop zoster (shingles) in their lifetime. Zoster vaccine is recommended for all adults (regardless of prior history of disease) older than age 60. It is, however, FDA approved to age 50. In the Shingles Prevention Study the vaccine reduced herpes zoster by 51 percent and postherpetic neuralgia by 67 percent. Zostavax is a live virus vaccine containing the same virus as the varicella vaccine but at about 14 times the dose. It should not be given to immunosuppressed patients. Measles,mumps and rubella (MMR) vaccine – MMR was first given to children in 1967, and a second dose was recommended in 1989. Children are given MMR vaccine at age 12-15 months with a second dose between ages 4-6 years.While these diseases cause relatively few infections in adults, the rates are steadily rising. Adults born before 1957 are considered immune. Adults born after 1957 should have at least one MMR immunization unless they have laboratory evidence of immunity or documented prior disease. Two doses of MMR should be given to high risk individuals such as health care workers or students. Pneumococcal Polysaccharide (PPSV) Vaccine – Adults older than the age of 65 should receive one dose only of PPSV (Pneumovax). Adults younger than age 65 should be vaccinated if they have chronic diseases such as lung disease, cardiovascular diseases, diabetes, HIV and chronic liver disease, or if they smoke. Special recommendations are given for those with cochlear implants, after splenectomy and those with sickle cell disease. People vaccinated before age 65 should receive a second dose after age 65 as long as it has been at least five years since the first dose. The vaccine is 60-70 percent effective in preventing invasive disease (meningitis and bacteremia) but does not reduce the rates of pneumonia infection. Influenza Vaccine – Is recommended annually for everyone older than age 6 months. The 2012/2013 vaccine included two new strains of the flu as well as the original H1N1 strain and despite the early start to the flu season has been pronounced to be a good match to circulating strains. Priorities for immunization should include health care workers, patients who are pregnant, the young, very old and those with chronic diseases. An intranasal vaccine may be given to healthy people younger than 50 years of age.

Vaccine Recommendations for Children and Adolescents

A comprehensive review and schedules for children and adolescents may again be accessed at the CDC website19. There are also “Catch-Up” schedules to assist with timing and dosing of vaccines in children who are behind on their immunizations.

months and 4-6 years. The large D,T and P reflect a relatively higher dose of these elements. New changes recommend an additional Tdap vaccine between ages 11-18 to boost pertussis immunity. It contains lower doses of the diphtheria and pertussis elements than DTaP. Thereafter, Td should be given every 10 years through adulthood. Pneumococcal Vaccines: – A series of 13 valent conjugated pneumococcal vaccine is given to all children stating at age two months. This replaced a prior seven valent vaccine. Children with chronic medical conditions as listed above under the adult section may receive the twenty-three valentpneumovax at the age of two. Rotavirus (RV) Vaccines – A series of three vaccines is given to children but should be initiated before age 15 weeks. Meningococcal Conjugate Vaccines (MCV4) – Is given to children younger than age 11 only if they have a complement deficiency, asplenia, are travelling to a high risk area or during an outbreak. It is also recommended for all children at age 11-12 years with a booster dose at age 16 years. The vaccine is not effective against serogroup B strains.

Conclusion Offering preventive care and promotion of wellness is an important skill that we can all incorporate into our daily patient care and can also be a good way to market your practice. Ways to improve your preventive services include setting up reminder systems in your paper or electronic health records, keeping yourself and staff up to date and informed on new recommendations, and educating patients about the importance of preventive services. Measuring rates of preventive medicine services within your practice acts as an incentive to develop new protocols, introduce tracking systems, and use reminders to improve rates. The USPSTF guidelines are part of the Patient Protection and Affordable Care Act and health insurance must now cover the services without cost sharing. Reimbursement for services is gradually improving and we are beginning to see pay-for-performance programs being introduced so there is more of an incentive to provide these services. In addition, preventing illness by immunizations and earlier diagnosis of diseases can make a huge impact on the quality of patient’s lives and the health of the community.

References 1. R. Harmon, R Filipowicz, W. Livingood. Men’s and Women’s Health issues in Duval County. NE Fl Med 2009;60(1)55

Recent changes and recommendations include the following:

2. 2010 Commonwealth Fund Annual Report at www.commonwealthfund.org/Annualreports

Tetanus and Diptheria Toxoids and acellular pertussis – Children receive five doses of DTaP between ages 2

3. Guide to Clinical preventive Services at www.ahrq.gov/ clinic/uspstfix.htm

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Northeast Florida Medicine Vol. 64, No. 2 2013 17

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18 Vol. 64, No. 2 2013 Northeast Florida Medicine

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4. USPSTF electronic preventive services selector at www.epss.ahrq.gov 5. Reprinted with permission from “Section 1. Preventive Services recommended by the USPSTF” The Guide to Clinical Preventive Services, 2012: Recommendations of the US Preventive Services Task Force. (AHRQ Publications No. 12-05154). Rockville, MD: Agency for Healthcare Research and Quality, October 2012; pp. 1-3 (Available at http://www.ahrq.gov/professionals/ clinicians-providers/guidelines-recommendations/guide/ guide-clinical-preventive-services.pdf ) 6. American cancer society screening guidelines at http://online library.wiley.com/journal/10.3322/ (ISSN)1542-4863 7. ACS,ASCCP and ASCP screening guidelines for the prevention and early detection of cervical cancer. Ca Cancer J Clin 2012:62:147-172 8. American Cancer Society guidelines for breast cancer screening, Update 2003. Ca Cancer J Clin 2003;53:141-166 9. Breast cancer Risk Assessment Tool at www.cancer.gov/ bcrisktool 10. BRCA Pro Score at http://bcb.dfci.harvard.edu/ bayesmendel/brcapro.php 11. Screening and surveillance for the early detection of colorectal cancer and adenomatous polyps, 2008. Ca Cancer J Clin 2008;28:131-160 12. American cancer society guidelines for the early detection of prostate cancer, Update 2010. Ca Cancer J Clin 2010;60:70-98 13. Screening and Prostate cancer mortality in a randomized European Study. NEJM 2009;360:1320-1328 14. American cancer society lung screening guidelines, 2013 update published on line at http://onlinelibrary.wiley. com/doi/10.3322/CaAC.21172/full 15. National lung cancer trial research team. Aberle D, Adams A, et al. Reduced lung cancer mortality with low-dose computed tomographic screening. N Eng J med 2011;365:395-409 16. Third report of the expert panel on detection, evaluation and treatment of high blood cholesterol in adults (ATP final report). At http://www.nhlbi.nih.gov/guidelines/ cholesterol/atp3_rpt.htm 17. Standards of Diabetes care 2013 at http://care.diabeticjournals.org/content/36/supplement_1/511.full 18. Recommendations for the identification of chronic hepatits C virus infection in people born during 1945 to 1965 MMWR 2012;61:RR-4 19. 2013 Immunization schedules for health care professionals at http://www.cdc.gov/vaccines/schedules

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Beals and Shahin Awards Get your research ready!

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Northeast Florida Medicine Vol. 64, No. 2 2013 19



Preventive Medicine Section Evidenced-based Clinical Preventive Services CME Questions & Answers (circle one answer)/Free to DCMS Members/$50.00 charge non-members*

(Return by March 1, 2015 by FAX: 904-353-5848, by mail: 555 Bishopgate Lane, Jacksonville, FL 32204 OR online: www.dcmsonline.org.)

Which one of the following is not a recommendation for cervical cancer screening? a. Screening should start at age 21 regardless of the age of first intercourse b. Pap smears are not required after hysterectomy for benign reasons with no history of dysplasia of CIN2 or worse on the past 10 years c. Screening interval for Pap smears should be every 2 years d. Testing may stop at 65 years if there are 3 consecutive normal Paps and no abnormal Paps of CIN 2 or worse in the past 20 years

Regarding screening for prostate cancer, one of the following statements is correct: a. The American cancer society states that prostate cancer screening should not be done on an individual without an informed decision making process b. There is a clear reduction in mortality seen when PSA tests are used for screening c. Men with a family history of prostate cancer should start screening at age 40 d. The USPSTF states men at high risk for prostate cancer should be screened

Regarding MRI screening for breast cancer which statement is correct? a. An MRI should be performed in all women who have a family history of breast cancer b. An MRI should be performed in women with a life time risk of breast cancer greater than 20-25% c. The age to begin screening MRI’s is 40 d. The USPSTF has clear recommendations regarding MRI screening

Which answer is incorrect regarding screening for lung cancer? a. Recommendations are based on results from the National Lung Cancer Screening Trial b. There is a 20% reduction in lung disease in people screened with 3 consecutive annual low dose CT scans c. CT screening for lung cancer presents no potential risk to the patient d. 39.1% of patients have at least one abnormal finding after 3 CT scans

Please indicate whether the following statements are true or false.

Which answer is incorrect regarding screening for colon cancer? a. Screening in average risk people should start at age 50 b. Flexible sigmoidoscopy is an acceptable method of screening for colon cancer c. People with a family history of colon cancer should commence screening at age 40 d. Fecal Occult Blood testing should be performed yearly if used as a screening test

T / F

The USPSTF recommends screening for all men over age 35 and from ages 20 to 35 if they are at risk for CAD.

T / F

The USPSTF recommends screening every 5 years for men age 65 to 80 who have ever smoked.

T / F

The USPSTF recommends all people above the age of 50 should have screening with an ultrasound for carotid artery stenosis.

T / F

Tdap should be given to all post partum wormen and any one who will have close contact with infants aged less than 12 months.

T / F

Evidence of immunity to Varicella includes being born in the US before 1980.

Evaluation questions & CME Credit Information (Please evaluate this article. Circle one number using this scale: 1= Strongly Agree to 5= Strongly Disagree) The article met the stated objectives: 1 2 3 4 5 The article was appropriate to my practice: 1 2 3 4 5 The topic was current and well presented: 1 2 3 4 5 Comments:

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Preventive Medicine Section

Evidence-based Community Preventive Services for Practicing Clinicians Robert Harmon, MD, MPH

Abstract: Clinicians are often asked to participate in and provide guidance to community health projects. This article offers up-to-date, evidence-based tools to guide the process. Readers will learn how to use the County Health Rankings, NEFloridaCounts.org website and Guide to Community Preventive Health Services.

Introduction As mentioned in the guest editorial in this journal edition1, factors other than medical care account for most of life expectancy. This is made abundantly clear in the annual publication of the nationwide County Health Rankings, which is a joint project of the Robert Wood Johnson Foundation and the University of Wisconsin Population Health Institute2. The 2013 County Health Rankings report ranks counties according to their summary measures of health outcomes and health factors. In the Rankings model, those counties having high ranks (such as 1 or 2) are estimated to be the “healthiest.” The summary health outcomes rankings are based on an equal 50% weighting of mortality and morbidity measures. The summary health factors rankings are based on weighted scores of four types of factors: behavioral (30%), clinical (20%), social and economic (40%), and environmental (10%). The weights for the factors are based upon a review of the literature and expert input, but represent just one way of combining these factors. The 2013 rankings of six Northeast Florida counties displayed in Table 1 (page 22) show the disparities and variation caused by the health factors. St. Johns County, which has among the highest income and education levels in Florida, ranks #1 among all 67 counties in both categories. Baker and Putnam, with among the lowest levels of health factors, rank in the lowest tier in outcomes. In other words, individual, family and community factors have a major impact on health outcomes, regardless of clinical care. In fact, Duval County ranks #19 in the state in clinical factors, but ranks 31st in overall health factors and 47th in outcomes.

Address correspondence to: Robert Harmon, MD, MPH at rghmd@hotmail.com.

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Another excellent source of data and statistics on community health is the website www.nefloridacounts.org. It is sponsored by the Health Planning Council of Northeast Florida and a coalition of more than 30 organizations representing seven counties in the region. Launched in 2010, it includes dashboard indicators and up-to-date data on more than 170 measures in the areas of health, socioeconomics, environment, education and other key determinants of a healthy and livable community. The indicators also include those from the County Health Rankings. The chlamydia infection rate for Duval County is shown in Figure 1 (page 24) as an example of an indicator. When searching for evidence-based community interventions, both websites offer numerous recommendations of programs that are proven to yield positive results. The gold standard for this is called The Community Guide and is described in the next section.

Overview of The Community Guide To know what programs, services, and policies are proven to protect and improve health, decision makers in communities, companies, nonprofit organizations, health systems, and at all levels of government can rely on recommendations from the Community Preventive Services Task Force (CPSTF). The CPSTF bases its recommendations on systematic reviews of the scientific literature evidence on community preventive services. Much of the content of this article is based on the recent CPSTF 2012 Annual Report to Congress3. To date, the CPSTF has published 225 evidence-based reviews, findings, and recommendations. They are compiled in the Guide to Community Preventive Services (The Community Guide) as a reference resource for decision makers, which can be found online at www.thecommunityguide.org. CPSTF recommendations provide evidence-based options from which decision makers, including clinicians, can choose what best meets their needs. It should be noted that they are not mandates for compliance or spending. They include programs, services, and policies that have proven effective in a variety of settings—such as worksites, schools, health plans, faith-based institutions, communities, and states—and

Northeast Florida Medicine Vol. 64, No. 2 2013 21

Preventive Medicine Section Table 1

2013 Florida County Health Rankings2

can be used to promote these changes: • Protect and improve population health • Reduce future demand for healthcare spending that is driven by preventable disease and disability • Increase productivity and the competitiveness of the U.S. workforce This article summarizes the CPSTF methods, findings, products, and impact, with mention of significant research gaps and priorities for future reviews and recommendations.

Background The CPSTF is independent, nonfederal, and unpaid. Its members represent a broad range of research, practice, and policy expertise in prevention, wellness and health promotion, and public health, and are appointed by the Director of the Centers for Disease Control and Prevention (CDC). The U.S. Department of Health and Human Services established the CPSTF in 1996 to identify community preventive interventions that increase healthy longevity, save lives and dollars, and improve Americans’ quality of life. The CPSTF makes recommendations about what works to improve and protect health based on a systematic review process that evaluates existing research on community-based health programs, services, and policies. It coordinates with the U.S. Preventive Services Task Force (USPSTF)—also independent and nonfederal—which recommends clinical preventive services shown to prevent disease and injury and improve health. These guidelines are included in the article by Karnani in this publication4.

22 Vol. 64, No. 2 2013 Northeast Florida Medicine

In all aspects of its work, the CPSTF obtains input from partner organizations and agencies, and from individual policy makers, practitioners, and researchers. Many of the nation’s leading public health practice and research agencies and organizations hold official liaison status with the CPSTF. CDC is mandated to provide ongoing administrative, research, and technical support for all Task Force operations.

Current CPSTF Reviews and Recommendations The CPSTF uses a rigorous, replicable, and systematic review process to develop evidence-based recommendations for prevention programs, services, and policies. The recommendations can be used population-wide or in selected community settings, such as schools, worksites, community centers, faith-based organizations, health plans, foundations, public health clinics and departments, clinician and public health training programs, and large, integrated healthcare systems. Each systematic review encompasses an exhaustive search for and rigorous appraisal of relevant research and evaluation studies. CPSTF reviews evaluate the overall effectiveness of existing programs, services, and policies; and their applicability to different populations, settings, and contexts; and costs and return on investment to help Community Guide users select community prevention strategies that meet their needs and constraints. Evidence-based recommendations seek to reduce health and economic burdens from “missed” public health opportunities, and to prevent wasteful use of resources on programs and strategies lacking demonstrated benefit.

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Northeast Florida Medicine Vol. 64, No. 2 2013 23

Preventive Medicine Section Figure 1

Chlamydia Incidence Rate for Duval County2

Appendix A of the 2012 Report to Congress3 contains a list of all 225 current CPSTF findings and recommendations for programs, services, and policies, and lists findings based on the strength of evidence: • Strong (76) or sufficient (39) evidence of effectiveness. • Strong (2) or sufficient (0) evidence of harm or lack of effectiveness. • Insufficient evidence to determine effectiveness (108). Insufficient evidence findings mean there was not enough evidence to determine whether an intervention is, or is not, effective. This does not mean that the intervention is ineffective. It means that additional research is needed to determine whether or not the intervention is effective. Table 2 (pages 25-27) lists the recommendations with strong or sufficient evidence for the intervention. Two interesting examples of strong evidence of effectiveness are case management and disease management programs for diabetes control. If more resources could be directed to these interventions for this prevalent condition, enormous benefit could occur. An interesting example of insufficient evidence of effectiveness is firearms laws to prevent violence. Considerable political debate surrounds these interventions, but more research is needed to identify evidence-based solutions. An interesting example of strong evidence of lack of effectiveness is policies facilitating the transfer of juveniles to adult justice systems. Pediatricians have been vocal against these laws for some time.

Major Evidence Gaps Three types of evidence gaps persist and limit the CPSTF’s ability to provide decision makers with the full complement of information they need to combat their most pressing public health concerns. Evidence gaps can be filled by a combination of research studies and evaluations of real world programs, services, and policies. Some of the most important of these evidence gaps mentioned below. • Evidence to determine whether programs, services, and policies are effective in addressing particular populations or unique health concerns • Evidence to determine whether programs, services, and policies work everywhere or only in specific places or for certain groups of people • Information to help decision makers and other users select and implement effective programs, services The Task Force has identified the following “highest” priority topics for reviews in 2012-2013: • Cardiovascular Disease Prevention and Control (new reviews). • Obesity Prevention and Control (new reviews). • Promoting Good Nutrition (new reviews). • Worksite Health Promotion (new reviews). • Addressing Disparities in Health Status (Health Equity) (new reviews).

24 Vol. 64, No. 2 2013 Northeast Florida Medicine

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Preventive Medicine Section Table 2 Positive Recommendations of Community Preventive Services Task Force (adapted from reference 3)

Topic and Recommended Intervention

Strength of Evidence

Improving adolescent health • Person-to-person interventions to improve caregivers’ parenting skills

• Sufficient

Preventing excessive alcohol consumption • • • • •

• • • • •

Dram shop liability Increasing alcohol taxes Maintaining limits on hours and days of sale Regulation of alcohol outlet density Enhanced enforcement of laws prohibiting sales to minors

Strong Strong Strong Sufficient Sufficient

Asthma control • Home-based multi-trigger, multicomponent interventions for children and adolescents

• Strong

Preventing birth defects • Community-wide campaigns to promote the use of folic acid supplements • Interventions to fortify food products with folic acid

• Sufficient • Sufficient

Cancer prevention and control • • • • • • • • • • •

Reducing structural barriers for breast and colorectal cancer screening One-on-one education for breast, cervical and colorectal cancer screening Client reminders for breast, cervical and colorectal cancer screening Small media for breast, cervical and colorectal cancer screening Group education for breast cancer screening Reducing client out-of-pocket costs for breast cancer screening Multicomponent interventions Provider reminder and recall systems Provider assessment and feedback Multicomponent community-wide interventions for skin cancer Education and policy approaches in outdoor recreation and primary school settings

• • • • • • • • • • •

Strong Strong/Sufficient Strong Strong Sufficient Sufficient Strong Strong Sufficient Sufficient Sufficient

Cardiovascular disease prevention and control • Strong

• Team-based care in improving blood pressure control Diabetes prevention and control • Case management interventions to improve glycemic control • Disease management programs • Self-management education in community gathering places for adults with type 2 diabetes • Self-management education in the home for children and adolescents with type 1 diabetes

• Strong • Strong • Sufficient • Sufficient

Emergency preparedness and response • School dismissals to reduce transmission in a severe influenza pandemic

• Sufficient

Health communication and social marketing • Health communication campaigns that include mass media and health-related product distribution

• Strong

Table 2 continued next page... www . DCMS online . org

Northeast Florida Medicine Vol. 64, No. 2 2013 25

Preventive Medicine Section Table 2 - continued Positive Recommendations of Community Preventive Services Task Force (adapted from reference 3)

Topic and Recommended Intervention

Strength of Evidence

Addressing health disparities and health equity • Full-day kindergarten

• Strong

Preventing HIV/AIDS, other sexually transmitted infections, and pregnancy • Group-based comprehensive risk reduction interventions for adolescents • Youth development behavioral interventions coordinated with community service to reduce sexual risk behaviors in adolescents • Individual, group and community-level interventions for men who have sex with men • Partner notification by provider referral to identify HIV-positive people

• Sufficient • Sufficient • Strong/Sufficient • Sufficient

Improving mental health • Collaborative care for the management of depressive disorders • Home and clinic-based depression care management among older adults • Mental health benefits legislation

• Strong • Strong/Sufficient • Sufficient

Motor vehicle-related injury prevention • • • • • • • • • • • •

Alcohol sobriety checkpoints Multicomponent alcohol interventions with community mobilization Ignition alcohol interlocks 0.08% blood alcohol concentration laws Maintaining current minimum legal drinking age laws Intervention training programs for servers of alcoholic beverages Lower blood alcohol concentration laws for young or inexperienced drivers Mass media campaigns to prevent drunk driving School-based instruction programs Laws mandating child safety seats Education, distribution and incentive programs for child safety seats Community-wide information and enhanced enforcement campaigns for child safety seats • Seat belt/primary enforcement laws • Enhanced seat belt enforcement programs

• • • • • • • • • • • •

Strong Strong Strong Strong Strong Sufficient Sufficient Sufficient Sufficient Strong Strong/Sufficient Sufficient

• Strong • Strong

Promoting good nutrition • Worksite obesity prevention programs • Obesity behavior interventions to reduce screen viewing time • Technology-supported multicomponent coaching or counseling interventions to reduce weight and maintain weight loss

• Strong • Sufficient • Sufficient

Promoting oral health • Community water fluoridation • School-based or linked sealant delivery programs

• Strong • Strong

Promoting physical activity • • • • •

Enhanced school-based physical education Individually-adapted health behavior change programs Social support interventions in community settings Community-wide campaigns Creation of or enhanced access to places for physical activity combined with informational outreach activities

26 Vol. 64, No. 2 2013 Northeast Florida Medicine

• • • • •

Strong Strong Strong Strong Strong

www . DCMS online . org

Preventive Medicine Section Topic and Recommended Intervention

Strength of Evidence

Promoting physical activity • Point-of-decision prompts to encourage use of stairs • Community-scale urban design and land use policies and practices • Street-scale urban design and land use policies and practices

• Strong • Sufficient • Sufficient

Promoting health through the social environment • Comprehensive, center-based early childhood development programs for low income families • Tenant-based rental housing assistance programs

• Strong • Sufficient

Reducing tobacco use and secondhand smoke exposure • Incentives and competitions to increase smoking cessation combined with additional interventions • Smoke-free policies to reduce tobacco use • Increasing the unit price of tobacco products to reduce initiation and promote cessation • Mass media campaigns when combined with other interventions to reduce initiation and promote cessation • Provider reminders with provider education /alone • Quitline interventions • Reducing out-of-pocket costs for evidence-based tobacco cessation treatments • Mobile phone-based interventions to promote cessation • Smoking bans and restrictions • Community mobilization with additional interventions to restrict minors’ access to tobacco products

• Strong • Sufficient • Strong • Strong • • • • • •

Strong/Sufficient Strong Strong Sufficient Strong Sufficient

• • • • • • • • • • • • • •

Strong Strong Strong Strong Strong Strong Strong Strong Strong Sufficient Strong Strong Strong Strong

• • • •

Strong Strong Strong Sufficient

Increasing appropriate vaccinations • • • • • • • • • • • • • •

Multiple interventions implemented in combination Provider reminders when used alone or as system Community-based interventions implemented in combination Home visits to increase vaccination rates Reducing client out-of-pocket costs Vaccination programs in schools and organized child care centers Vaccination programs in WIC settings Vaccination requirements for child care, school and college attendance Client reminder and recall systems Client or family incentive rewards Immunization information systems/registries Provider assessment and feedback Standing orders when used alone Healthcare system-based interventions implemented in combination

Violence prevention • • • •

Early childhood home visitation Group/individual cognitive-behavioral therapy School-based programs to prevent violence Therapeutic foster care for the reduction of violence by chronically delinquent adolescents

Worksite health promotion • Assessment of health risk with feedback plus health education with or without other interventions • Interventions with on-site free or reduced cost, actively promoted seasonal influenza vaccinations among healthcare and other workers www . DCMS online . org

• Strong • Strong/Sufficient

Northeast Florida Medicine Vol. 64, No. 2 2013 27

Preventive Medicine Section

• Promoting Physical Activity (new reviews and updates to existing reviews).

Future Directions

• Reducing Tobacco Use and Secondhand Smoke Exposure (new reviews and updates to existing reviews).

Demand for CPSTF recommendations is stronger now than ever before. Policy makers, the health sector, employers, third-party payers, and the public recognize the imperative to keep people healthy, productive, and independent, and to reduce the burden of healthcare costs on governments and the private sector. It has become clear that factors affected by community preventive services have even more influence on Americans’ health than does access to quality medical care.

• Improving Oral Health (updates to existing reviews). • Cancer Prevention and Control—Preventing Skin Cancer; and Increasing Appropriate Breast, Cervical, and Colorectal Cancer Screening (updates to existing reviews). As with all CFSTF reviews, these will evaluate not only the overall effectiveness of existing programs, services, and policies, but also their applicability to different populations, settings, and contexts, and their costs and return on investment—to help Community Guide users select community prevention strategies that best address their needs, preferences, and constraints. Additionally, as changes in science and resources permit, the Task Force updates existing findings and recommendations at regular intervals to ensure they are based on the current body of evidence, it has the opportunity to assess whether researchers and research funders are adequately addressing recognized research gaps.

How Communities Use the CPSTF Recommendations With 225 CPSTF findings and recommendations already available and new ones added regularly, communities, workplaces, schools, public health agencies, healthcare systems, non-governmental organizations, and all levels of government have a wide range of options for using Task Force findings. Some communities use the findings to communicate public health challenges and solutions. Others use them to address their overall health goals or a specific health problem. Still others use them as a planning tool, to help them strengthen their overall approach to improving public health practice or to optimize their resources. The Florida Department of Health in Duval County used the Community Guide as a reference to design a new immunization initiative in 2010. The agency used several evidence-based programs to focus on improving its immunization rates for two-year old clinic clients. After two years of effort, the rates were improved from under 70% to more than 90%. The agency received a Community Guide award from the Public Health Foundation for its accomplishments.

To meet the increasing demand, the CPSTF will take these future actions: • Accelerate the completion of highest priority reviews • Enhance dissemination efforts to better meet the needs of a wide range of users • Increase and refine training and technical assistance for decision makers and other users who want help in selecting and implementing CPSTF recommendations • Identify and communicate important evidence gaps, to help policy makers, funders, and scientists optimize resources for research and evaluation • Work closely with the U.S. Preventive Services Task Force and the Advisory Committee on Immunization Practices

Conclusion Clinicians should consider using the www.countyhealthrankings.org, www.nefloridacounts.org, and www. thecommunityguide.org when they are involved in the design and implementation of population health programs in their communities. Time and resources are scarce, and our efforts are best directed at evidence-based interventions.

References 1. Harmon, RG. The Interface Between Medicine and Public Health. Northeast Florida Medicine. 2013; 64(2) 2. www.countyhealthrankings.org. University of Wisconsin Population Health Institute in collaboration with the Robert Wood Johnson Foundation, 2013. 3. 2012 Annual Report to Congress, Community Preventive Services Task Force, Centers for Disease Control and Prevention, 2012 (http://www.thecommunityguide.org/ annualreport/2012-congress-report-full.pdf ) 4. Karnani, Helena. Evidence-based Clinical Preventive Services. Northeast Florida Medicine. 2013; 64(2)

28 Vol. 64, No. 2 2013 Northeast Florida Medicine

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Preventive Medicine Section

The Tobacco Epidemic Abubakr A Bajwa, MD, FCCP, Vandana Seeram, MD and Tauseef Qureshi, MD University of Florida College of Medicine/Jacksonville, Division of Pulmonary, Critical Care and Sleep Medicine.

Candy Holloway

Director of Medical Education and the Southeast Thoracic Association (SETA). Medical Section of the American Lung Association of the Southeast, Inc.

Leon Crawley

Tobacco Prevention Program, Florida Department of Health in Duval County

Abstract: Despite significant progress in battling the tobacco epidemic, millions of people continue to smoke cigarettes in the United States. Cigarette smoking continues to be the single most preventable cause of death. Smoking is linked to numerous medical, social and psychological diseases. The campaign against tobacco use has led to many global and regional initiatives including smoke free zones, product labeling and marketing and cessation programs. Health care professionals play an important role in combating this epidemic. Public education combined with regional efforts in prevention and cessations of smoking are crucial to fight this epidemic.

Introduction Since the landmark 1964 Surgeon General’s Report on the health effects of cigarette smoking, the United States has made significant progress in combating the epidemic of tobacco related illness and death. An estimated 45.3 million people, or 19.3 percent of all adults (aged 18 years or older), in the United States smoke cigarettes compared to an estimated 42 percent of all adults in 1965.1 Youth smokers have also declined since 1991 when the first survey was done in this population (Table 1 page 30).1 Cigarette smoking is more common among men (21.5 percent) than women (17.3 percent).1 Tobacco use in any form is dangerous, with cigarette smoking being the single most preventable cause of death in the United States2 and accounting for approximately 443,000 deaths, or 1 of every 5 deaths, in the United States each year.3,4 Why people start Smoking and its psychological effects: Experimenting with smoking is driven predominantly by psychosocial motives.5 Initially, smoking a cigarette is a symbolic act conveying perceived adulthood or rebelliousness. In the words of the tobacco company Philip Morris, “I am no longer my mother’s child,” and “I am an adventurer.” The desired image is sufficient for the novice smoker to tolerate the initial aversion to cigarettes, after which the pharmacological factor of nicotine dependence prevails. Phillip Morris states, “As the force from the psychological symbolism subsides, the pharmacological effect takes over to sustain the habit.”6

Email correspondence to: abubakr.bajwa@jax.ufl.edu

www . DCMS online . org

For much of the 20th century, smoking was regarded as a personal choice and socially learned habit. It is now recognized that cigarette smoking is primarily a manifestation of nicotine addiction and that smokers have individual characteristic preferences for their level of nicotine intake.7 The psychoactive drug in tobacco products that produces dependence is nicotine.8 For the vast majority of smokers, their dependence is related to nicotine.9 Nicotine dependence is the most common form of chemical dependence in the United States.10 Research suggests that nicotine may be as addictive as heroin, cocaine, or alcohol. Absorption of cigarette smoke from the lung is rapid and complete, producing with each inhalation a high concentration arterial bolus of nicotine that reaches the brain within 10-16 seconds, faster than by intravenous injection.11 Nicotine has a distributional half life of 15-20 minutes and a terminal half life in blood of two hours. Smokers therefore experience a pattern of repetitive and transient high blood nicotine concentrations from each cigarette, with regular hourly cigarettes needed to maintain raised concentrations. Overnight blood nicotine levels may drop to close to those of non-smokers. Much of the difficulty in quitting cigarette smoking is thought to result from withdrawal symptoms. Symptoms of nicotine withdrawal generally start within a few hours of the last tobacco use, and will peak about two to three days later. Symptoms may include an intense craving for nicotine, anxiety, irritability, impaired concentration and depression. Effects of Tobacco Use: Tobacco use deteriorates health throughout a person’s lifetime. These effects, which accumulate with time, result in preventable illness and, all too often, premature death. Nicotine is most efficiently delivered through smoking, resulting in death to nearly half of lifetime users.12 Over the years, other nicotine products have entered the market in a cloud of controversy and debate. Many of these new products are released with marketing that suggests that they are safer. However, no tobacco products have been scientifically proven to reduce the risk of tobacco-related disease, improve safety or cause less harm than other tobacco Northeast Florida Medicine Vol. 64, No. 2 2013 29

Preventive Medicine Section Table 1

Smoking trends among adults and high school students (modified from reference 1)

Adult smokers, National

Adult smokers, Florida

Males

Females

1965

1991

Last data available

82 million (42.4%)

N/A

45.3 million (19.3%)*

N/A

2.5 million (17.5%)†

High school student smokers

18.4%† 16%† N/A

27.5%

High school Student smokers, Florida

18.1%† 14.3%†

* Last data from 2011 † Last data from 2010

products.13 Smoking cigarettes of any variety has been scientifically proven to harm nearly every organ in the body and to increase morbidity and mortality. Moreover, smokeless tobacco products increase the risk of oral cancers. Cigarette smoke in particular contains a deadly mix of more than 7,000 chemicals; hundreds are toxic and about 70 of which have known to cause cancer.14 Smoking decreases fertility in women and when combined with oral contraceptives increases the risk of heart attack and stroke. Smoking during pregnancy is dangerous to the mother and can cause growth retardation, low birth weight and possibly death of the fetus. Secondhand smoke, also known as environmental tobacco smoke, is a mixture of side stream smoke from the burning tip of a cigarette, cigar, or pipe, and mainstream smoke, which smokers exhale. Side stream smoke is the major component of secondhand smoke, and it contains higher concentrations of carcinogens than mainstream smoke. Globally, about 40 percent of children and a third of nonsmoking adults were exposed to secondhand smoke in 2004.15 There is no safe level of exposure to secondhand smoke. Breathing secondhand smoke causes immediate harm to the cardiovascular and respiratory systems. Long-term exposure to secondhand smoke can even cause lung cancer. Women and children exposed to secondhand smoke are at particularly high risk of adverse health consequences. Sudden Infant Death Syndrome (SIDS), respiratory issues, and behavioral and learning problems can result when infants and children are exposed to secondhand smoke. An estimated 600 thousand people died from secondhand smoke exposure in 2011, with the majority occurring in women and children.16 Even limited secondhand smoke exposure delivers enough nicotine to the brain to alter its function and secondhand smoke exposure increases vulnerability to nicotine addiction.17

30 Vol. 64, No. 2 2013 Northeast Florida Medicine

Epidemiology of Tobacco Use: Nearly 20 percent of the world’s adult population smokes. Smokers consumed nearly 5.9 trillion cigarettes in 2009, representing a 13 percent increase in cigarette consumption in the past decade.18 About 800 million adult men and 200 million women worldwide smoke cigarettes. The global tobacco epidemic can be segmented into four stages: the onset of the epidemic; a dramatic increase in smoking; a decline in smoking prevalence; and, several decades later, an increase in smoking-related illnesses and disease.19 Tobacco marketing associates male smoking with masculinity, happiness, wealth, virility and power. For women, the idea has been to create an association between smoking and gender equality. Almost a century ago, the American Tobacco Company purposefully linked smoking with women’s right to vote, with cigarettes called “torches of freedom.” Overall, smoking prevalence rates are declining, but the number of smokers is increasing due to general population growth. As observed among high-income countries in the 20th century, the first stage of the tobacco epidemic occurred as the rate of smoking among men increased and surpassed 50 percent. During the next stage, smoking rates decreased among men and increased among women. The majority of smokers begin when they are in their youth. Eighty-three percent of smokers in the US begin smoking before the age of 18. Even the tobacco industry understands the importance of youth smoking, and a 1984 R.J. Reynolds document stated that “younger adults are the only source of replacement smokers.” Ways to Control Tobacco Use: Tobacco control has evolved over the last 30 years from sporadic acts by activists and isolated action by some governments to a mainstream public health issue, with known, proven, cost-effective measures. Needed now is a coherent public health strategy designed to reduce tobacco

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Preventive Medicine Section consumption, involving international, regional, national, and local actors involved in strategic planning, policy-oriented research, capacity building, funding, enforcement, and evaluation. The American Lung Association of the Southeast (ALASE) supports the CDC Best Practices for tobacco control policies of combined interventions – increasing the price of tobacco products, implementing smoke-free policies, implementing mass media advertising campaigns, restricting tobacco advertising and promotion, controlling access to tobacco products and promoting and assisting smokers to quit – are proven to significantly reduce smoking. Smoke free areas: There is no safe level of exposure to secondhand smoke. The only way to completely protect nonsmokers and the vulnerable from second hand smoke is by instituting smoke free areas. In smoke free zones, levels of smoke exposure are more than 90 percent lower than they are where smoking is permitted. A 2010 Cochrane literature review assessed 31 studies measuring exposure to secondhand smoke after smoking bans, with 19 studies including biomarkers. The review concluded there is consistent evidence that “smoking bans reduced exposure to secondhand smoke in work-places, restaurants, pubs, and public places.”20 Public support is strong for smoking bans in public places. Evidence shows that in regions where smoking bans have been mandated by law, employees, customers, and business owners report high compliance and satisfaction with the results. Independent studies consistently show no drop in employment or business revenues from the creation and enforcement of smoking bans. Product Labeling: The United States was the first nation to require a health warning on cigarettes.21 Health warnings on the packaging of all tobacco products have progressed from small, plain text warnings to strong, graphic warnings and ultimately pictorial representations of the ill effects of smoking, which was introduced in the US in 2011. The goal is for the message on a carton of cigarettes to be repeated and reinforced every time a smoker reaches for a cigarette. Although overturned by an appeals court, there is still considerable push to make such pictorial representations mandatory. Marketing Bans: In 2010, the Tobacco Control Act became law. This act not only placed new restrictions on tobacco marketing but also placed extensive constraints concerning the circulation of cigarettes and smokeless tobacco to minors. The new requirements of this law are that “audio advertisements are not permitted to contain any music or sound effects, while video advertisements are limited to static black text on a 32 Vol. 64, No. 2 2013 Northeast Florida Medicine

white background. Any audio soundtrack accompanying a video advertisement is limited to words only, with no music or sound effects.”22 Role of health professionals: Worldwide, health professionals are respected and trusted as opinion leaders and trendsetters. They have the ability to affect social norms and have led the charge for smoking cessation in high-income countries. All health professionals have the responsibility to advise patients about life-changing decisions and health matters, such as the importance of quitting smoking and how to quit. Even brief smoking cessation interventions are effective, and cessation support can double quit rates. Health professionals who are smokers are less likely to advise their patients to quit smoking. The smoking status of health professionals varies throughout the world based on socio-demographic patterns and the stages of the tobacco epidemic. Current regional efforts: In the state, the Florida Department of Health offers a number of free and convenient resources to help tobacco users quit. The Tobacco Free Florida Quit line (1-877-822-6669) offers free nicotine replacement, group classes, as well as coaching which is available 24 hours a day, seven days a week. Locally, we have the Tobacco-Free Jacksonville Coalition. It was formed in January, 1988 to provide a united front in the war against tobacco. Tobacco-Free Jacksonville is the community partnership of adults and youth working together to prevent youth tobacco use and youth exposure to second-hand smoke. The coalition’s goals are to significantly reduce tobacco use through prevention, education, cessation, and policy promotion, and decreasing environmental tobacco smoke through education and policy promotion.23 The Florida Department of Health in Duval County Tobacco Prevention Program works in conjunction with the Tobacco-Free Jacksonville Coalition on several projects. One is Students Working Against Tobacco (SWAT) , which is a youth created advocacy group with a mission to mobilize, educate, and equip Florida youth to revolt against and de-glamorize Big Tobacco. All Florida students, ages 11-17 years old, are eligible to participate. The goals of SWAT are to prevent and reduce tobacco use among youth and to protect youth from secondhand smoke. On a local level, SWAT Students participate in leadership workshops, local parades, commercial contests, art contests, writing contests, and various other anti-tobacco programming. SWAT chapters can be found in schools and communities throughout the State of Florida. Tobacco Prevention Program along with SWAT youth were instrumental in influencing the local legislators of the town of Baldwin and the city councils of Atlantic Beach, Jacksonville Beach, Neptune Beach, and the City of Jacksonville in passing resolutions to cease the sale of candy-flavored tobacco products. www . DCMS online . org

Preventive Medicine Section Other joint initiatives include reducing second hand smoke in multi-unit dwellings (apartments, condominiums) and automobiles, and providing guidance to employers/ employees regarding smoking cessation services and benefits. In partnership with these coalitions, the American Lung Association offers several options to help smokers quit. The Freedom From Smoking® program teaches the skills and techniques that have been proven to help smokers quit. Freedom From Smoking® is available as a group clinic, an online program and a self-help book. Another option is the toll-free Lung HelpLine where qualified cessation counselors provide guidance, support and coaching to smokers who desire to quit.24

Conclusion: Although the epidemic of tobacco use is far from being under control, ongoing public education combined with regional and global initiatives are certainly making an impact. Healthcare professional involvement is an essential component for this initiative. Regional organizations such as the Tobacco Prevention Program, Tobacco-Free Jacksonville Coalition and the American Lung Association are playing an important role in ongoing regional efforts to control this epidemic.

References: 1. Centers for Disease Control and Prevention. Vital Signs: Current Cigarette Smoking Among Adults Aged ≥ 18 Years—United States, 2005–2010. Morbidity and Mortality Weekly Report 2011;60(33):1207–12. 2. Centers for Disease Control and Prevention. Annual Smoking-Attributable Mortality, Years of Potential Life Lost, and Economic Costs—United States, 1995–1999. Morbidity and Mortality Weekly Report 2002;51(14):300–3. 3. Centers for Disease Control and Prevention.Annual Smoking-Attributable Mortality, Years of Potential Life Lost, and Productivity Losses—United States, 2000–2004. Morbidity and Mortality Weekly Report 2008;57(45):1226–8. 4. U.S. Department of Health and Human Services. The Health Consequences of Smoking: A Report of the Surgeon General. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2004.

NL, Curry SJ, Dorfman SF, Froelicher ES, Goldstein MG, Froelicher ES, Healton CG, et al. Treating Tobacco Use and Dependence: 2008 Update—Clinical Practice Guidelines. Rockville (MD): U.S. Department of Health and Human Services, Public Health Service, Agency for Healthcare Research and Quality, 2008. 9. U.S. Department of Health and Human Services. How Tobacco Smoke Causes Disease: The Biology and Behavioral Basis for Smoking-Attributable Disease: A Report of the Surgeon General. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2010. 10. American Society of Addiction Medicine. Public Policy Statement on Nicotine Dependence and Tobacco (PDF–92 KB). Chevy Chase (MD): American Society of Addiction Medicine, 2010. 11. Jarvis M. BMJ. Why People Smoke. BMJ 2004;328:277. 12. Tobacco Atlas, 4th Edition. 13. Tobacco Products, Health Fraud.Food and Drug Administration, US, 2011. Accessible at http://www.fda.gov/ TobaccoProducts/ResourcesforYou/ucm255658.htm 14. National Toxicology Program. Report on Carcinogens, Twelfth Edition. U.S. Department of Health and Human Sciences, National Institute of Environmental Health Sciences, National Toxicology Program, 2011. 15. Tobacco atlas 4th edition. 16. Tobacco atlas 4th edition. 17. Nora Volkow, Director, National Institute on Drug Abuse, US, 2011. NIH News. http://www.nih.gov/news/health/ may2011/nida-02.htm 18. Tobacco atlas 4th edition. 19. Tobacco atlas 4th edition. 20. Callinan JE, Clarke A, Doherty K, Kelleher C. Legislative smoking bans for reducing secondhand smoke exposure, smoking prevalence and tobacco consumption. Cochrane Database Syst Rev. 2010 Apr 14;(4). 21. Duff Wilson (21 June 2011). “U.S. Releases Graphic Images to Deter Smokers”. New York Times. http://www. nytimes.com/2011/06/22/health/policy/22smoke.html.

5. Jarvis M. BMJ. Why People Smoke. BMJ 2004;328:277.

22. Herington, Matthew R. “Tobacco Regulation In The United States: New Opportunities And Challenges,” Health Lawyer 23.1 (2010): 13–17.

6. 1969 draft report “Why One Smokes” to the PM board of directors. Document Bates No. 1003287836.

23. Tobacco Free Jacksonville Coalition. http://www.tobaccofreejacksonville.org/news.html.

7. Jarvis M. BMJ. Why People Smoke. BMJ 2004;328:277.

24. American Lung Association. http://www.lung.org/ stop-smoking/.

8. Fiore MC, Jaén CR, Baker TB, Bailey WC, Benowitz www . DCMS online . org

Northeast Florida Medicine Vol. 64, No. 2 2013 33

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Preventive Medicine Section

The Role of Physical Activity in Personal and Population Health Joseph G. McQuade, MD, MS

Director of Public Health, Naval Hospital Jacksonville, FL

Abstract: Scientific evidence over the past 60 years has consistently

documented clear health benefits of a physically active lifestyle. We know now that physical inactivity is a significant predictor of cardiovascular disease, type 2 diabetes mellitus, obesity, some cancers, some aspects of mental illness, overall mortality and poor quality of life. With the percentage of deaths worldwide now mostly due to non-infectious causes, health professionals now need to focus on chronic medical conditions, many of which are associated with inactivity and obesity. Physical activity should be recognized by clinicians to be as important as any medication prescribed to help patients first prevent and then treat these chronic conditions. Our fitness environment plays a key role in making our towns healthier places to live. Efforts to reach out to young people regarding the benefit of physical activity has reversed the poor trends in obesity. The US military has advanced fitness policies to help keep military recruits more lean. Physical inactivity is a multifactorial social problem with many facets, requiring joint efforts from many different fields to find effective solutions. Making our patients more active is a viable and inexpensive way to combat most of the nation’s emerging chronic diseases that are very preventable.

Introduction For millennia, exercise has been recommended by physicians and scholars. In 1953, a study was published that associated sedentary London Transport Authority bus drivers with an increased risk of coronary disease compared to their more active conductor peers. This study helped to stimulate development of research linking physical inactivity to increased risk of many chronic medical conditions.1 Physical inactivity is now considered a leading cause of premature death, disability, and numerous emerging chronic diseases. In 2008, 63 percent of deaths worldwide were due to non-communicable diseases, mainly chronic diseases of the heart and vascular system, diabetes mellitus, cancers and obstructive pulmonary disease. The large increase seen in recent years in these chronic conditions may be due to rising rates of obesity due in part to a societal shift away from regular physical activity. Physical activity is considered a cornerstone for combating non-communicable diseases by the

Please send correspondence to: Joseph G. McQuade MD MS Box 1000 2080 Child St Jacksonville FL 32214 joseph.mcquade@med. navy.mil

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United Nations. The World Health Organization recognizes physical inactivity as one of the leading global risk factors for morbidity and premature mortality.1 Finding ways to include an exercise prescription along with the countless other prescriptions written every day from doctors’ offices in our country remains an important task in improving the health of our patients.

Background For more than 30 years, excess weight, insufficient physical activity and an unhealthy diet have been considered second only to tobacco as preventable causes of disease and death in the United States. Excess weight and lack of physical activity have been linked to increased risk of cardiovascular disease, hypertension, diabetes, dementia, arthritis and many cancers.2 Regular physical activity leads to multiple physiologic and psychological benefits that can improve general health.3 Preventing chronic disease is one of the more pressing challenges facing scientists and public health policy makers in the new century. To the extent that environmental factors such as food, nutrition and physical activity influence the risk of cancer, it too is a preventable disease. Evidence has shown for example that only a small percentage of cancers are due to inheritance. Environmental factors are most important and can be modified. These include such well known cancer causing agents as tobacco use, radiation exposure and industrial agents, but also include physical inactivity and body composition. Current western medicine focuses more on the care of the sick. However, beginning in the 20th century, a major part of a physician’s duties focused on the preservation and promotion of health and the prevention of disease. This strong emphasis on health, rather than disease, dates back to Hippocrates. He wrote that “eating alone will not keep a man well: he must also take exercise. For food and exercise… work together to produce health.” Patterns of exercise have changed dramatically over the centuries. Exercise as prophylaxis promoting better health was widely preached throughout the Middle Ages and through the Renaissance in Europe. In 1769, a Scottish physician, William Buchan published a popular treatise in which he said “of all the causes which conspire to render the life of Northeast Florida Medicine Vol. 64, No. 2 2013 35

Preventive Medicine Section man short and miserable, none have greater influence than the want of proper exercise.” This belief was reformed by the early 1900’s in the US where the practice of physical education shifted in emphasis from body development and health instruction to games and leisure sports. By the time WW1 came, it was clear that physical fitness was suboptimal. Nearly one third of the three million men that were drafted were deemed unfit for service. A rekindling of interest in the role exercise played in health became intensified by data that showed an increasing number of deaths in the US were due to unhealthy lifestyles. Infectious disease no longer had the majority of US deaths, as we died from violating the rules Hippocrates had put forth. In 1979 the US Surgeon General first called for an attack on chronic disease with increased attention to physical activity and nutrition.4

Physical Activity and Personal Health Physical activity should be recognized by clinicians to be as important as any medication prescribed to help patients first prevent then treat a number of major chronic illnesses. Many mechanisms have been considered and examined to explain the observed associations between cancer and excess weight and physical inactivity. These mechanisms are complex, interrelated, and not completely understood. It has been demonstrated that excess weight and physical activity affect the synthesis and metabolism of sex hormones, insulin and related growth factors, immune responses, and oxidative stress. For example, postmenopausal obesity is related to higher exposures to free estrogens and androgens, supporting a strong role for steroid hormones in the etiology of breast, ovarian and endometrial cancers. Excess weight and physical inactivity raise levels of circulating insulin. Also, chronic hyperinsulinemia is associated with the pathogenesis of several cancers related to excess weight, including colorectal,

breast, pancreatic and endometrial cancers. Excess weight may influence the risk of cancer through effects on tumor growth regulators, including mammalian target of rapamycin (mTOR) and 50 adenosine monophosphate (AMP)-kinase, and adipokines including adiponectin and leptin. A large and growing body of in vitro and animal model studies indicates that physiologic factors linked to excess weight and physical inactivity may play a role in cancer etiology by influencing cell growth, differentiation, and apoptosis as well as tissue invasion and angiogenesis. Emerging research indicates that independent of physical activity, the amount of time spent in sedentary behaviors, such as sitting, may adversely affect health outcomes, including cancer. Physical activity alone without weight loss may reduce the risk of several types of cancer, such as cancers of the breast, colon and endometrium, as well as advanced prostate cancer and possibly pancreatic cancer.2 On the basis of results from published comprehensive meta-analyses, lack of sufficient physical activity has been associated with a 30 to 40 percent increased risk of colon cancer, postmenopausal breast cancer, and endometrial cancer.2 Sedentary behavior has been independently associated with chronic disease-related risk factors such as central adiposity, insulin resistance and chronic inflammation, which are factors hypothesized to be operative in the development and progression of breast cancer. Physical activity has been proposed as a potential modifiable risk factor for breast cancer because of its effects on circulating sex hormones and weight gain.5 The first investigators to examine if physical activity might reduce breast cancer risk were in 1985 where they found in an investigation of former women college athletes a lower lifetime prevalence of breast cancer and other reproductive cancers. There is convincing evidence that physical activity reduces the risk of breast cancer on average 25 percent when comparing the most and least active study participants in observational studies.6

Volunteers Needed - 2013 Student Athletic Screenings Join DCMS and the Jacksonville Sports Medicine Program to offer FREE athletic screenings for students on August 3 and August 10 at Nemours Children’s Clinic and Wolfson Children’s Hospital. Physician and PA volunteers are needed, including internists, family medicine, pediatricians, orthopedic surgeons, cardiologists, pulmonologists, and other medical specialists. These screenings are provided at no charge to student athletes, most from homes with limited means, and are not intended to replace annual physical exams performed by pediatricians and primary care physicians. Follow up care with individual physicians is encouraged when screenings indicate potential problems which may impact the athlete’s participation in sports activities.

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Preventive Medicine Section An association between exercise and primary incidence of prostate cancer was recently observed in a study of white men who engaged in little to no physical activity. These inactive men had a 1.7 times greater risk of prostate cancer. Physical activity had already been shown to reduce the progression to advanced prostate cancer and also to lower the risk for fatal outcomes to prostate cancer. Physical activity may influence a number of hormones hypothesized to enhance prostate cancer carcinogenesis, including insulin-like growth factor1, insulin, leptin and testosterone.7

activity in preventing progression of diabetes complications. The Diabetes Prevention Program demonstrated reduction in diabetes risk among adults with pre-diabetes through diet and exercise. A more recent study among children showed that 20 minutes of aerobic exercise per school day for just a few months showed benefits versus the control condition on insulin resistance, fitness, and fatness. Collectively, these health benefits may contribute to a reduction in the risk for long-term diabetes complications by preventing progression of the diabetic disease state.9

Obesity and physical activity, through their effects on insulin sensitivity, may be modifiable risk factors for pancreatic cancer. There is a direct relationship between body mass index (BMI) and insulin production, and there is sufficient evidence that obesity, especially intra-abdominal fat, is related to the development of insulin resistance. Physical activity may increase insulin sensitivity through reduction of intra-abdominal fat deposits and, independent of its effects on weight, has been associated with improved glucose metabolism, increased insulin sensitivity and decreased plasma insulin levels.8

A physically active lifestyle is associated with a reduced risk of heart disease and lowers risk of developing hypertension. Habitual participation in physical activity improves the lipid profile, reduces body weight and percentage of body fat, and favorably affects the prothrombic state. The risk of cardiovascular disease can be reduced by as much as 35-55 percent through adoption and maintenance of an active lifestyle.3

The World Cancer Research Fund/American Institute for Cancer Research concluded that approximately one-third of common cancers in the United States could be prevented by following healthy patterns of physical activity and diet.2 Regular physical activity helps maintain a healthy body weight and is long known to help prevent obesity, together with diet control. A rigorous review of more than 7,000 studies on the relationship between nutrition, physical activity, excess weight and cancer risk concluded that there is an association between excess weight and increased risk of several cancers, including adenocarcinoma of the esophagus, colon and rectum cancer, kidney cancer, pancreatic cancer, postmenopausal female breast cancer and endometrial cancer.2 Excess weight and lack of sufficient physical activity also may adversely affect cancer prognosis and quality of life among the increasing number of cancer survivors. Excess weight is associated with poorer survival among patients after diagnosis with breast cancer and colorectal cancer. Physical activity after diagnosis of breast or colon cancer is associated with reduced all-cause and cancer-specific mortality. Each 5-kg/m2 increase in BMI is associated with 30-60 percent increased risk of endometrial cancer, adenocarcinoma of the esophagus, and kidney cancer; the same increase in BMI yields a 13-18 percent increased risk of colorectal cancer, pancreatic cancer, and postmenopausal breast cancer. Evidence suggests that excess weight also may be associated with increased risk of other cancers, including gallbladder, liver, thyroid and hematopoietic cancers.2 Physical activity plays a crucial role in the prevention of type 2 diabetes. The American Diabetes Association has made it a central tenet of its education programs for newly diagnosed diabetic patients to be aware of the vital role of physical www . DCMS online . org

Individuals with the highest levels of cardiorespiratory fitness during middle age years were significantly less likely to develop Alzheimerâ&#x20AC;&#x2122;s disease dementia in their senior years. Greater fitness would reduce other known risk factors for dementia such as diabetes and hypertension. Fitness has also been linked to greater brain volume, and some evidence points to connections between physical activity and neural plasticity, neutrophic factors, and beta-amyloid protein deposits.10 Given the positive added effects of exercise, physical activity seems to be a reasonable prescription for providers to prescribe for dementia prevention.11 Physical activity can reduce pain and improve function, mobility, mood and quality of life for most adults with many types of arthritis including osteoarthritis, rheumatoid arthritis, fibromyalgia and lupus. Scientific studies have shown that participation in moderate-intensity, low-impact physical activity improves pain, function, mood and quality of life without worsening symptoms or disease severity. Being physically active can also delay the onset of disability if you have arthritis.

Physical Activity and Population Health Concerted efforts between healthcare and community leaders are needed to create opportunities for our patients to be able to more easily incorporate physical activity into their daily lives. The need to work with city planners is paramount to understand the contribution of the built environment to physical activity patterns. Numerous studies demonstrate the association of built and food environments with physical activity, healthful eating and obesity rates. The fitness environment plays a key role in making our cities and towns more healthful places to live. Availability of sidewalks has been shown to be positively associated with increased physical activity and walking. In many European Northeast Florida Medicine Vol. 64, No. 2 2013 37

Preventive Medicine Section cities, 30 percent or more of trips are made by cycling and walking, a figure that drops to 10 percent or less in the United States. There is substantial evidence pointing out that people who live closer to recreational facilities are more likely to be physically active overall. Physical activity in caring for young families remains a critical clinical responsibility which requires more attention. Although trends in the prevalence of excess weight and physical inactivity in the United States may seem to be stabilizing or improving, current levels, particularly the unprecedented high levels of obesity among young individuals, are concerning and can impact future disease rates. Unhealthy behaviors among young individuals may lead to unhealthy behaviors in adulthood as well as adverse health profiles and an increased risk of cancer later in life. Continued progress in reducing cancer incidence and mortality will be difficult without success in promoting healthy weight and physical activity, particularly among youth.2 Two towns in northern France undertook a regional initiative to reduce childhood obesity rates. They began by educating children about the consequences of obesity and the importance of healthy eating habits. In addition, they improved the food offerings in school cafeterias, provided nutritional family breakfasts at the schools, and started cooking classes for children and their parents. After a few years, the towns expanded their efforts by hiring dieticians and a sports educator to create programs on nutrition and physical activity in the schools. They also built new sports facilities, launched walk-to-school groups, and developed family activities to promote exercise. Furthermore, they encouraged general practitioners to identify all overweight and obese children and refer them to the initiative’s dieticians, who then put the children on programs to help them lower their BMI. The towns also undertook an aggressive social-marketing campaign to promote healthy behaviors. The results were striking. The prevalence of childhood obesity in these towns decreased substantially as it rose in nearby towns. 12 Evidence suggests that sustained breastfeeding may help protect infants and young children from becoming overweight or obese. Steps to promote lactation support within office buildings have been undertaken to allow working mothers to express breast milk and continue breastfeeding their children.13 To encourage physical activity, the National Prevention Strategy recommends encouraging community design and development that supports physical activity; promoting and strengthening school and early learning policies and programs that increase physical activity; facilitating access to safe, accessible and affordable places for physical activity; supporting workplace policies and programs that increase physical activity; and assessing physical activity levels and providing education, counseling and referrals. To monitor progress and identify opportunities for im-

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provement, the CDC has published a series of reports to provide state-specific information on current behavioral indicators as well as indicators of policy and environmental supports for fruits and vegetables, physical activity, children’s food environment, and breastfeeding support. These include strategies to promote and reinforce healthy behaviors by requiring physical education and recess in schools; state-level policies to support full-time personnel to develop, implement, monitor, and maintain physical activity interventions and programs; strategies to improve the food environment by increasing access to healthy foods; food policy councils that can support improved food environments for healthy eating through consideration of the local food system; and state regulations to support breastfeeding in childcare centers. 2 Among military clinicians, the move to standardize the care provided to overweight and obese military servicemen and women has created new treatment strategies with obesity more clearly defined as a chronic medical condition. The Department of Defense (DOD) fitness policies recently strengthened added emphasis on the food and fitness environments at our bases. The Navy Operational Fitness and Fueling Series Project (NOFFS) provides the Navy with a “best in class” physical fitness and nutrition performance resource that provides guidance to Sailors and to Navy health and fitness professionals. NOFFS instructs individuals how to physically train effectively and safely, and how to make healthy nutrition choices in both shore-based and operational environments. As the Navy is called to intensify operational tempo based on current world-wide mission requirements, it is imperative for Sailors to be physically fit. Another promising initiative is called Exercise is Medicine. Sponsored by the American College of Sports Medicine and hundreds of other organizations, including the American Medical Association, it seeks to promote the use of physical activity level as a vital sign, policy change and medical referrals to exercise professionals and facilities.14 Maintaining a healthy weight and engaging in sufficient physical activity cannot be promoted solely at the level of the individual. Supporting recommended healthy lifestyle behaviors will require concerted actions from individuals, communities, the media, federal, state, and local governments, food industries, international agencies, and sectors beyond what is usually considered public health, such as transportation and agriculture. The economic burden caused by excess weight and physical inactivity is substantial. According to recent data, per capita medical spending in the United States in 2008 for an obese individual was 42 percent higher per year compared with someone of normal weight, resulting in a national burden of $147 billion: approximately 9.1 percent of all medical spending. In addition to medical costs, indirect costs of obesity include decreased years of disability-free life, increased mortality before retirement, earlier retirement, higher dis-

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Preventive Medicine Section ability pensions, increased work absenteeism, and reduced productivity. The World Health Organization estimates that in many developed countries, obesity now accounts for two to seven percent of all health care spending. Among its other adverse economic effects are heightened absenteeism rates, reduced worker productivity, and increased food and clothing costs.2 Most past behavioral and lifestyle interventions to prevent and treat obesity have produced relatively modest and non-sustained effects on weight. One possible reason may be insufficient attention to motivational factors related to eating, physical activity and sedentary behaviors. Overeaters Anonymous provides a great source of information online for patients seeking help with these kind of behavioral issues (http://www.oa.org). Instead of emphasizing the outcomes, such as total number of pounds that may be lost, the emphasis should be on the motivation for participating in the effort. Making the patient want to participate may be more important than teaching the patient about the risks downstream of a lack of physical activity and obesity. This strategy uses something called stealth interventions to win over those who need the increased activity but may not be able to understand the benefits that lag in time sometimes as long as 20-30 years away. Engaging children in after school dance classes is an example of advancing physical activity in a stealthy way.15

Conclusion Physical inactivity is a multifactorial social problem with many facets, requiring joint efforts from many different fields to find effective solutions. It will be important to monitor and evaluate the prevalence of and trends in physical activity and disease incidence. Quality population-based risk factor and chronic disease surveillance data can be used to identify areas and populations with unhealthy behaviors and high rates of chronic disease that could benefit from targeted, effective strategies and interventions to improve physical activity and support healthy environments. It is clear today that physical activity is a viable and relatively inexpensive way to combat most of the nation’s most serious diseases that are, for the most part, preventable. Behavioral causes currently account for 40 percent of all deaths in the United States, and obesity and physical inactivity combined, along with smoking, are the top causes of premature death. In the British Journal of Sports Medicine, Steven Blair argued that “evidence supports the conclusion that physical inactivity is one of the most important public health problems of the 21st century, and may even be the most important.”4 The global challenge is clear: make physical activity a public health priority throughout the world to reduce the burden of emerging chronic medical conditions.

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References: 1. Hallal, P. C. (2012). Physical Activity: more of the same is not enough. Lancet , 190-191. 2. Eheman, C. P. (2012). Annual Report to the Nation on the Status of Cancer, 1975-2008, Featuring Cancers Assoiciated With Excess Weight and Lack of Sufficient Physical Activity. Cancer, 1-29. 3. American Association of Diabetes Educators. (2012). Diabetes and Physical Activity. The Diabetes Educator, 129-132. 4. Berryman, J. (2010). Exercise is Medicine: A Historical Perspective. Current Sports Medicine Reports , 195-201. 5. Patel, A. V. (2003). Recreational physical activity and risk of postmenopausal breast cancer in a large cohort of US women. Cancer Causes and Control vol 14, 519-529. 6. Friedenreich, C. (2012). Can living a less sedentary life decrease breast cancer risk in women? Women’s Health vol 8, 5-7. 7. Singh, A. A. (2013). Association Between Exercise and Primary Incidence of Prostate Cancer. Cancer, 1-6. 8. Giovanucci, E. L. (2005). A Prospective Study of Physical Activity and Incident and Fatal Prostate Cancer. Archives of Internal Medicine/ Vol 165, 1005-1010. 9. Davis, C. P. (2012). Exercise Dose and Diabetes Risk in Overweight and Obese Children. JAMA 308(11), 1103-1111. 10. Verdelho, A. M. (2012). Physical activity prevents progression for cognitive impairment and vascular dementia: results from the LADIS study. Stroke: Jornal of the American Heart Association, DOI 10.1161. 11. DeFina, Laura F. (2013). The association between midlife cardiorespiratory fitness levels and later-life dementia: A cohort study. Annals of Internal Medicine , 158:213-214. 12. Algazy, J. M. (2010). Wny governments must lead the fight against obesity. Health International, 89-101. 13. US Department of Health and Human Services. The Surgeon General’s Call to Action to Support Breastfeeding. Rockville, MD: US Department of Health and Human Services, Office of the Surgeon General; 2011. 14. www.exerciseismedicine.com, American College of Sports Medicine, March 12, 2013 15. Robinson, T. N. (2010). Stealth Interventions for Obesity prevention and Control: Motivating Behavior Change. In L. Dube, Obesity Prevention: the Role of Brain and Society on Individual Behavior (pp. 319-327). New York: Elsevier Academic Press.

Northeast Florida Medicine Vol. 64, No. 2 2013 39

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Preventive Medicine Section

Managing the Obesity Epidemic: A Community Perspective Jonathan S. Evans, MD Abstract: We are in the midst of an obesity epidemic. Personal responsibility and choice are a necessary starting point, but alone are insufficient to resolve this problem. Other variables beyond our immediate control influence our choices and responses, such that a multi-tiered approach including medical, political and societal efforts is advocated to address this disease. In this article the community’s response in Northeast Florida is reviewed with an emphasis on children, perhaps our most vulnerable population. Since 2001, the Healthy Jacksonville Childhood Obesity Prevention Coalition has undertaken a successful and sustained effort connecting more than 150 local organizations, resulting in evidence-based policy recommendations, multiple community grants and assistance to the public school system. The medical community’s response is also reviewed with practical recommendations for the physician. The present obesity epidemic is ongoing and will require a sustained, coordinated and collaborative approach at all levels of our society, such as that undertaken in Northeast Florida.

Introduction and Scope of the Problem It is now recognized by the medical community that we are in the midst of an obesity epidemic. It affects Americans of all ages and walks of life. At least 68 percent of adults are either overweight or obese and adult obesity rates have more than doubled to 35 percent in the past 30 years.1,2 The state of Florida now ranks 32nd among all states, with an obesity rate of 27 percent.3 Numbers are even worse for our children, with obesity having tripled in the past 30 years. At least 32 percent, or 23 million children ages two to 19 years old, are now overweight or obese.4 Healthy-weight Americans are also affected by the obesity epidemic through increased insurance premiums, health care costs and taxes to pay for the un- and underinsured. The annual medical burden of obesity increased to 10 percent of all medical expenses and was estimated at $147 billion in 2008.5 Solutions to this epidemic are not expected to be simple nor immediate. This is perhaps due to the insidious and complex nature of a problem that took years to develop and come to our attention. In this article, our community’s response to the obesity epidemic will be examined with an emphasis on our children and what can be done locally. Opportunities for improvement, as well as local efforts and successes, will

Please send correspondence to: Jonathan S Evans, MD, Division of Pediatric Gastroenterology and Nutrition, Nemours Children’s Clinic, Jacksonville, FL 32207, jevans@nemours.org

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be highlighted along with specific recommendations and practical resources for the health professional.

The Obesity Epidemic: A Multi-Tiered Approach It is often stated that the solution to the obesity epidemic comes down to personal responsibility and choice: to eat less and exercise more. Although this is a necessary starting point for all individuals, our choices are often influenced by factors beyond our immediate control. It is accepted that control of one’s health and body weight is not only a medical issue, but also involves complex factors that permeate all levels of society. Multiple reports support a multi-tiered view and approach to the obesity epidemic, including recent reports that adopt both a broad perspective,6,7 but also address specific issues such as the economics and politics of soft drinks.8 Beyond these published reports are many real-life situations which we encounter daily as health care professionals, and these situations emphasize the need for a multilevel approach with a strong community basis. An example is described in the inset. A real-life example of the multiple societal factors that play a role in the development of obesity. The example is taken from the author’s medical clinic. A single mother of two school-aged children lives in Jacksonville’s health zone 1, which includes the city’s urban core and bears the burden of significantly higher infant mortality, chronic disease and crime rates. The mother works downtown. One child is obese (BMI for age >95th percentile) and the other is overweight (BMI for age between the 85th and 95th percentile). The children attend different public schools (elementary and middle) and qualify for the free and reduced meal programs at their schools where they eat both breakfast and lunch. The younger child has only one physical education class weekly. The older child has none. Upon release from school the children return home and stay inside until mother returns from work, often 3-4 hours later. During that time the children have a prepackaged purchased snack, complete their homework and watch TV. They are not allowed outside. The mother admits that she picks up dinner at a nearby fast food outlet approximately three nights per week. She feels this is convenient and allows her children to eat a hot meal upon her return, especially if she is running late. The nearest supermarket is a significant detour from her home commute. The remainder of the evening is spent finishing homework, preparing for the next day and playing video games or watching TV. The mother estimates that each child spends 3-4 hours daily in screen time. She describes her neighborhood as unsafe. She will only let the children play in front of the house or at the local park with adult supervision.

Northeast Florida Medicine Vol. 64, No. 2 2013 41

Preventive Medicine Section Table 1 A multi-tiered approach to the obesity epidemic: Where efforts should be applied and areas of concern.

Individual

Eating more and exercising less

Family

Parental role-modeling Family centered meals

Community City Government

Funding for playgrounds and parks Food deserts

Schools

Enforced daily/weekly PE quotas Food Service management

Employers

Employee health management Health insurance coverage for clinical preventive services

Medical

Obesity screening Outcome based, cost-effective management

Neighborhood

Need more health-based initiatives

Community organizations

Need more health-based initiatives Health policy for children and schools Enforcement of weekly school PE requirements

State National Government

Farm Act legislation to subsidize healthier foods Enactment of Hunger Free, Healthy Kids Act legislation

Business

Health-negative legislative lobby efforts

Media

Health-negative messaging Health-negative children-targeted marketing

Table 1 examines the different levels of this tiered societal approach and identifies several key areas of concern. Figure 1 attempts to describe the interactions between the major stakeholders that influence our local obesity prevention efforts. It is obvious that these interactions are multiple and complex without a single major influential partner. It can be concluded that while the individual and family should remain central to our concerns, no single effort will be successful without collaboration and coordination amongst the numerous stakeholders. An example of coordination and collaboration of resources is described below, followed by a description of the efforts by the medical community. Employer and community-based organizations also play important roles in addressing obesity rates along with city government and schools. Their initiatives will be highlighted as examples throughout the text.

Figure 1 A multi-tiered approach to the obesity epidemic uncovers multiple and complex relations that ultimately affect the individual and families.

Healthy Jacksonville Childhood Obesity Prevention Coalition Since 2001, there has been a successful and sustained effort to stem the rise of childhood obesity in northeast Florida. Under the auspices of the Duval County Health Department and its Healthy Jacksonville initiative, the Healthy Jacksonville Childhood Obesity Prevention Coalition has engaged citizens, health professionals and local organizations to make 42 Vol. 64, No. 2 2013 Northeast Florida Medicine

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Preventive Medicine Section Table 2 Seven focal points central in addressing local issues relating to obesity by Healthy Kids, Healthy Jacksonville Call to Action10

Call to Action

Example of Recommendations Made

1. City of Jacksonville

Incorporate public health priorities in land use plans and decisions.

2. Health care systems and providers

Educate and train health care providers in effective obesity prevention and treatment methods. Adopt a core message for use by providers in prevention and treatment of obesity.

3. Schools

Support and implementation of the District Wellness Police. Support efforts to meet state mandates for physical activity.

4. Early childhood

Expand breast feeding education. Disseminate instructional materials for early childhood care providers that emphasize health.

5. Community/ faith/youth organizations

Implement youth-led peer involvement campaigns supporting healthy living.

6. Media and marketing

Adopt a core message and media campaign to support healthy lifestyles

7. Employers

Support worksite wellness programs. Support employee efforts to be health role models.

Figure 2

Community Garden

a lasting and positive impact on the health of local children, families and county residents. Since its inception it has met monthly and connected more than 400 interested individuals and 150 local organizations from not only city government, the business community, academia, health care, public and private schools, but also faith-based organizations, philanthropic entities, and community associations. Under the coalition’s direction, evidence-based policy recommendations applicable to our community were formulated in 2006 and 2009 and made available to the public and city leaders.9,10 This further defined the coalition’s mission around seven action plans that focus on nutrition, active living, advocacy and youth empowerment (Table 2). Direct outcomes have included 56 community grants awarded over three years and funded by the Blue Cross and Blue Shield of Florida Foundation for a total of $560,000. These grants have included community garden projects (Figure 2), extra-scholastic physical activities for youth, active living urban design projects, and healthy nutrition classes. Other direct outcomes from the coalition’s agenda have included an educational research grant from the Robert Wood Johnson Foundation and the formation of the Duval County Food Policy Council. The Food Policy Council’s advocacy has provided technical assistance on two bills which will be introduced to the Florida legislature in 2013. The coalition’s members, recognized as subject matter experts, have been able to assist the Duval County Public Schools (DCPS) formulate healthier policies on soft drinks and the selection of the food service management company supplying meals for the county’s 125,000 students. They meet monthly with the food service vendor to review federally sponsored breakfast and lunch menus and to continue advocating for healthier food venues and projects. The members of the coalition have also been instrumental in the implementation of a wellness policy and program for the county’s public schools. Further details about the coalition’s efforts can be found in Table 3 (page 44) and on its website.11

The Medical Community Response The health professionals’ response to the obesity epidemic is essential to its resolution. It is most often the physician who first alerts the patient about any overweight and health-related issues. It is also to the physician that the patient turns for a remedy when the diagnosis or discovery of a complication is made. Consequently, all levels of the medical community, from the primary care physician, to multispecialty clinics, to hospitals and medical societies, should be prepared to deal with obesity and its consequences.

The Bridge of Northeast Florida community garden project in the Springfield neighborhood of Jacksonville. An example of the Embrace a Healthy Florida grants funded by the Blue Cross and Blue Shield Foundation of Florida.

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The primary care physician’s role is crucial and should focus on screening, diagnosis and treatment. All children should be screened at least annually with a height, weight and body mass index (BMI) for age. Children diagnosed as overweight are defined as having a BMI for age between the 85th and 95th percentile, while obese children have a BMI for age greater than the 95th percentile. Additionally children with

Northeast Florida Medicine Vol. 64, No. 2 2013 43

Preventive Medicine Section Table 3 The Healthy Jacksonville Childhood Obesity Prevention Coalition Policy Accomplishment

Policy Recommendations 2006

Duval county evidence-based policy for the prevention of childhood obesity (9)

2009

Healthy Kids, Healthy Jacksonville: A Community Call to Action (10)

Grants 2008

Embrace a Healthy Florida, Blue Cross and Blue Shield Foundation of Florida. ($160, 000/cycle year)

2009

Healthy Kids, Healthy Communities, The Robert Wood Johnson Foundation ($360, 000/4 years)

2011

Healthy Equity Grant, Hillsborough County Health Dept, CDC ($20, 000)

Advocacy 2010

Duval County Food Policy Council

2012

Youth Advisory Council

Education 2009- Present

Over 40 workshops held training for more than 410 health care professionals

2013

Jacksonville Childhood Obesity Prevention Coalition website (11)

increasing BMI for age and crossing percentiles towards the 85th percentile should be considered at risk. Adults should be screened with a BMI and waist circumference. A BMI from 25-29.9 kg/m2 defines adult overweight, 30-39.9 kg/ m2 defines adult obesity and above this as morbid obesity. Furthermore a waist circumference ≥40 inches in men and ≥35 inches in women defines obesity. Once a patient has been identified as at risk, overweight or obese, they should be further evaluated and appropriate treatment options recommended. Description of further diagnostic testing to screen for complications and treatment options that can be monitored from the primary care setting or require referral are beyond the scope and purpose of this article. Excellent and comprehensive guidelines however have been published by national and local medical societies for both children12 and adults.13-15 Faced with an overweight child, adult and/or family, the primary care practitioner often feels helpless to provide meaningful and effective guidance during an often too short clinical encounter. Working key messages into anticipatory guidance at each well care visit helps to ensure the acquisition of healthful dietary and lifestyle habits. The practitioner can prepare for the already overweight patient with helpful handouts, trained staff to provide ongoing education, and support and access to outside resources such as registered dieticians, local gyms, parks and produce markets (e.g. Beaver St. and Riverside Arts Market), health oriented community organizations (e.g. YMCA, Girls on the Run), nutrition classes, etc. 44 Vol. 64, No. 2 2013 Northeast Florida Medicine

Simple and consistent messages that are adopted by both practitioners and their communities may be effective preventive measures. The “5, 2, 1 Almost None” program (Figure 3) is an example of such a message that can be incorporated into medical practices and their communities with positive results.16,17 In Delaware this core message has been used in medical practices and distributed through schools, supermarkets and the media. Large medical centers have also recognized the need to join with the community to prevent and treat obesity. Locally, The Players Center for Child Health at Wolfson Children’s Hospital in Jacksonville18 has developed programs for the community that focus on childhood healthy nutrition and lifestyles. These include “I can eat a rainbow” (ages 3-7), “Mission Nutrition” (grades 4-5), and recently “Kidz Bite Back” (grades 4-5). “Kidz Bite Back” is a novel concept that is created and led by student leaders and introduces their peers to educated consumerism and healthy choices.

Future Directions The efforts of a multi-tiered approach to the obesity epidemic are beginning to show positive results nationally.19 Successes in Northeast Florida are also becoming apparent but need further support and expansion both locally and beyond. Some specific areas where these efforts should be applied are outlined in Table 1 (page 42). From a federal government level further implementation of the Healthy,

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Preventive Medicine Section Figure 3

5 - 2 - 1 - Almost None Program

The 5 - 2- 1- Almost None program is an example of a healthy living core message that can be used by medical practices, the media and community organizations.

Hunger Free Kids act of 2010 will include all foods (including snack foods and drinks) consumed in school but also development of subsidies for healthy foods (e.g. fresh produce) through the Farm Bill should be promoted. At a state level, existing quotas for weekly physical activity for students of all ages need strengthening and enforcement and ongoing development of farm to school programs should be pursued. City government is encouraged to pursue infrastructure policies that support healthy active lifestyles (e.g. safe parks, bike lanes and sidewalks to school) and elimination of food deserts in our most disadvantaged neighborhoods. Business incentives that promote healthy lifestyles for employers and employees need further development. Schools, both public and private, need further development of their wellness policies and programs in regards to nutrition and physical activity. The medical community, www . DCMS online . org

from solo practices to clinics and hospitals, need programs in place to routinely screen, diagnose and counsel their patients in regards to overweight and obesity. Finally clear messages that encourage personal responsibility for healthy choices should come from all levels to help the individual and families. In conclusion, it is clear that the present problem of obesity is multifactorial and complex. To achieve positive outcomes, a coordinated and collaborative approach, such as that undertaken locally by the Healthy Jacksonville Childhood Obesity Prevention coalition, is necessary but will require ongoing effort, expansion and support.

References: 1. Flegal KM, Carroll MD, Ogden CL, et al. Prevalence and trends in obesity among U.S. adults, 1999-2008. Journal of the American Medical Association, 303(3):235-241, Northeast Florida Medicine Vol. 64, No. 2 2013 45

Preventive Medicine Section 2010 2. Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of Obesity in the United States 2009-2010. NCHS data brief no 82. Hyattsville Md: National Center for Health Statistics, 2012. 3. http://www.cdc.gov/obesity/data/adult.html 4. Ogden CL, Carroll MD, Curtin LR, Lamb MM, Flegel KM. prevalence of high body mass index in US children and adolescents 2007-2008 Journal of the American Medical Association. 303(3):242-249, 2010 5. Finkelstein EA, Trogdon JG, Cohen JW, Dietz W. Annual medical spending attributable to obesity: payer and service specific estimates. Health Affairs, 28 (5): w822-w831, 2009 6. F as in Fat: How obesity threatens Americaâ&#x20AC;&#x2122;s future. Sept 2012; http://healthyamericans.org/assets/files/TFAH2012FasInFat18.pdf 7. Trudnak T, Melton ST, Simpson L, Baldwin J. The childhood obesity response in Florida: where do we stand? Child Obes. 8:237-242, 8. 2012 Breaking down the chain: a guide to the soft drink industry. Public Health Law and Policy 2011. http://www. foodpolitics.com/wp-content/uploads/SoftDrinkIndustryMarketing_11.pdf 9. http://www.docstoc.com/docs/92498540/childhood-obesity-final-report-5-4-06 10. http://www.hjcopc.org/site-docs/aboutus/2009_Community_Call_to_Action.pdf 11. http://www.hjcopc.org/ 12. Spear BA, Barlow SE, Ervin C, et al. Recommendations and treatment of childhood and adolescent overweight and obesity. Pediatrics 2007;120:S254-S280. http://pediatrics. aappublications.org/content/120/Supplement_4/S254.full (with updates andservices) 13. Lyznicki MS, Young DC, Riggs JA, et al. Obesity: Assessment and management in primary care. Am Fam Physician 2001; 63:2185-2196 14. Waldron, A. Obesity and obesity-related complications. Screening of of adults and children in the primary care office. NE Fl Med 2007;5821-29 15. Moyer VA. Screening for and management of obesity in adults: U.S. preventive services task force recommendation statement. Ann Intern Med 2012;157:373-378 16. Feinson,J, Atkinson A, Hassink S. How a primary care quality improvement initiative is implementing the expert recommendations on childhood obesity. Del Med J 2010; 82:57-65 17. Chang DI, Gertel-Rosenberg A, Drayton VL, et al. A statewide strategy to combat child obesity in Delaware. Health Aff 2010;29:481-490 18. www.wolfsonchildrens.org/theplayerscenter 19. Sekhobo J, Edmunds LS, Whaley S, et al. Obesity prevalence among low income, pre-school aged children: New York City and Los Angeles County 2003-2011. MMWR 2013;62:17-22 46 Vol. 64, No. 2 2013 Northeast Florida Medicine

We hate lawsuits. We loathe litigation. We help doctors head off claims at the pass. We track new treatments and analyze medical advances. We are the eyes in the back of your head. We make CME easy, free, and online. We do extra homework. We protect good medicine. We are your guardian angels. We are The Doctors Company. The Doctors Company is devoted to helping doctors avoid potential lawsuits. For us, this starts with patient safety. In fact, we have the largest Department of Patient Safety of any medical malpractice insurer. And, local physician advisory boards across the country. Why do we go this far? Because sometimes the best way to look out for the doctor is to start with the patient. To learn more about our medical professional liability program, call us at (800) 741-3742 or visit www.thedoctors.com.

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12/11/12 10:33 AM

Multi-Disciplinary Team Embarks on Groundbreaking “Heat Mapping” Research Nikole M. Helvey, MS HSA

When a patient is discharged from a hospital stay for a medical condition in the United States, there is a 16% chance that he or she will be readmitted for that same condition within 30 days. For patients with congestive heart failure the likelihood increases to 21.2%; and for acute myocardial infarction to 25.3%.1 Hospital readmissions among Medicare patients alone are attributed to costs that exceed $26 Billion annually in the United States, and it is estimated that at least $17 Billion of those costs result from return trips to the hospital that may have been avoided if the patients had the appropriate resources, understanding, and motivations related to their condition following their initial discharge. It is widely accepted that readmissions which occur within 30-90 days following a hospital discharge are considered an undesirable outcome for all involved including patients, hospitals, and physicians – and as such this issue has received an increasing amount of scrutiny and attention during recent years. Yet even with a widespread swell in the development and adoption of quality metrics, evidence-based treatment protocols, and reimbursement penalties for hospitals nationally, little progress has been made in moving the needle on this issue over the past five years.2 The Robert Wood Johnson Foundation (RWJF) has been conducting ongoing research on this topic in the U.S. since 1979 and defines Jacksonville’s Hospital Referral Region to encompass Baker, Nassau, Duval, and parts of Clay County, as well as a small region of southeast Georgia. RWJF reports hospital readmissions among Medicare beneficiaries in this region to average 15.8% for medical conditions and 13.8% for surgeries; compared to national averages of 15.9% and 12.4% respectively. In comparison, the rates for the St. Johns County to Ormond Beach hospital region average 15.2% for medical readmissions and 11.1% after surgeries.3 Multiple research studies show that patients with similar illness have very different chances of hospital readmission depending on where they live.4 “Every patient’s story about his or her hospital readmission is complicated, unique, and hard to characterize. Yet there are common traits across the stories...”5 The Health Planning Council of Northeast Florida is embarking on a groundbreaking research project for our region in partnership with St. Vincent’s Healthcare, Orange Park Medical Center, the Duval County Health Department, an Urban Economist from the University of North Florida, Cen-

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tury Ambulance Service, and ELM (a planning, architecture landscape, architecture, and environmental graphics firm) to determine where patients who utilize the most (and most costly) health care live, and/or what other characteristics they share. In its first phase, the Health Planning Council and partners will utilize GIS mapping technology with datasets from public and private health insurance claims to identify “hot spots” or areas and neighborhoods where the patients who are the highest utilizers of hospital services live. In the second phase, the partners will apply advanced analytics across a wide variety of socioeconomic, environmental, and other available datasets to create complex algorithms that will identify significant patterns in the data from those areas. While healthcare heat mapping has already been conducted in several cities around the country, the Health Planning Council’s research agenda is unique in that it will include broader socioeconomic variables and conditions, along with sophisticated geo-spatial environmental data to analyze the correlation between healthcare utilization, health disparities, mortality rates/life expectancy, socio-economics, and the environmental conditions in which people live. Ultimately it is intended that the findings from this leading edge research will assist health system planners, providers, and communities develop policies and initiatives that will successfully identify and address key factors that are correlated to a higher risk of hospital readmission for patients in Northeast Florida.

References: 1. Goodman, Fisher, and Chang. After Hospitalization: Readmissions Among Medicare Beneficiaries. Dartmouth Institute for Health Policy and Clinical Practice, 2012. 2. Leveraging Advanced Analytics to Successfully Reduce Hospital Readmissions. SAS, Health Data Management. 2013 3. Dartmouth Atlas of Health Care. (www.DartmouthAtlas. org). Accessed on April 24, 2013. 4. Robert Wood Johnson Foundation. The Revolving Door: A Report on U.S. Hospital Readmissions. February, 2013 5. Perry, Michael. Hospital Readmissions from the Inside Out: Stories from Patients and Health Care Providers. PerryUndem Research and Communication, 2012.

Northeast Florida Medicine Vol. 64, No. 2 2013 47

Residents’ Corner: University of Florida-Jacksonville Residency Program Editor’s Note: In an effort to connect more Duval County Medical Society members with residents, in each 2013 issue there will be a “Residents’ Corner” with information about a residency program in the area, details about research being done and/or a list of achievements/accomplishments of the program’s residents. This “Residents’ Corner” features the University of Florida- Jacksonville Residency Program.

Overview of the Program The University of Florida and Shands Jacksonville is a 695 bed hospital home to 32 accredited GME programs and more than 330 residents and fellows. The residency programs are accredited by the allopathic boards and generate numerous certified physicians who go on to work in a variety of clinical settings globally. During their time at UF & Shands Jacksonville, residents have the opportunity to train in the Center for Simulation Education and Safety Research (CSESaR), one of the nation’s largest non-military simulation training centers. They also work and train with third year medical students from UF’s College of Medicine and fourth year medical students from various schools. UF & Shands Jacksonville is also home to the first Level 1 trauma center in Florida and the only Level 1 trauma center in the region. University of Florida’s Proton Therapy Institute is the first in the southeast and currently one of nine operating in the United States. The University Health System Consortium rated the institute 19 out of 116 academic medical centers labeling UF & Shands Jacksonville a “rising star.”

Resident Research • Paul Maraj, MD of Internal Medicine presented a case report about coccidioides meningitis in an immunocompetent man in Northeast Florida at the American Federation of Medical Research Southern Section Annual Meeting in New Orleans, LA in February 2013. • Ryan Wilson, MD of Internal Medicine recently completed a manuscript entitled “An Algorithm for Identification of ST-Elevation Myocardial Infarction Patients by Emergency Medicine Services” that is to be published in the American Journal of Emergency Medicine. • Craig Erker, MD of Pediatrics is currently investigating recurrent pancreatitis during maintenance chemotherapy for pre-B acute lymphoblastic leukemia.

Jason Hew, MD, Internal Medicine

• Kerry Nagee, MD of Pathology is investigating the presence of the KRAS mutation in benign pancreatic cells and precursor lesions of pancreatic ductal adenocarcinoma. Concurrently Dr Nagee is also investigating the mononucleotide and dinucleotide markers currently in use in the MSI assay for colorectal carcinoma and also looks at the frequency of homozygosity and loss of heterozygosity of these markers in the Northern Florida population. • Kristin McKee, DO of Emergency Medicine is investigating the use of ultrasound for confirmation of central line placement in lieu of imaging that exposes patient to radiation in an effort to shorten time before treatment. All three post-graduate year Internal Medicine residents are participating in a problem based learning and quality improvement project involving peer chart reviews. Aisha Khan, DO, presented this project as an oral presentation titled “Institution of a Sustainable Chart Review System at an Internal Medicine Program” at the Florida American College of Physicians in Orlando in March 2013.

Back row L to R: Rohan Samon, MD, Ryan Wilson, MD, Internal Medicine Chief Resident, Sanjay Hedge, MD, Vishal Jaikaransingh, MD. Front row L to R: Jeff House, DO, Internal Medicine Program Director, Sarada Jaimungal, MD & Chandrikha Chandrasekharan, MD 48 Vol. 64, No. 2 2013 Northeast Florida Medicine

L to R: Jean Touchan, MD, Jason Hew, MD, Bilkisu Gaye, MD, all of Internal Medicine and Vinoo Ramsaran, Pulmonary/Critical Care Fellow

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DCMS EVP honored as one of Jacksonville’s 40 Under 40! By Karen Pan, DCMS Membership Director Duval County Medical Society (DCMS) EVP, Bryan Campbell was honored in April as one of the Jacksonville Business Journal’s “40 Under 40” awardees for 2013. Mr. Campbell was selected from close to 200 well-qualified nominations, according the newspaper’s editor John Burr. Since becoming the EVP of DCMS in early 2012, Mr. Campbell has effectively worked with the DCMS President and Board of Directors to accomplish many goals. Immediately following his arrival, Mr. Campbell led DCMS to create its first strategic plan and adopt a revised mission statement: “Helping physicians improve the health of our community.” He also placed a renewed focus on marketing and communication, while simultaneously working with community partners to increase member value and benefits. Consistent with Mr. Campbell’s vision, most of his accomplishments have directly benefited DCMS members. Several new DCMS membership meetings have been created, specifically designed to meet the educational and social needs of physicians, ranging from retirees to residents to employed doctors and everything in between. As a result, hundreds of DCMS members have attended a DCMS event who had never done so before. Additionally, Mr. Campbell’s leadership resulted many other accomplishments for the Society including: an increase in membership for the first time in six years, an increase in revenue, the creation of a new DCMS Membership Benefits program, the formation of strategic partnerships with the Florida Times-Union and other media outlets, and an increase in both membership and revenue for the four affiliate County Medical Societies managed by DCMS staff. In addition to his DCMS responsibilities, Mr. Campbell is also dedicated to community involvement. During the past year he has led the Mayor’s Council for Fitness and

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DCMS EVP, Bryan Campbell and his wife Sarah at the 40 Under 40 luncheon.

Well-Being to reimagine the Mayor’s Seal, and helped to develop a plan to use the Seal to move Jacksonville closer to becoming a “Let’s Move City.” This year he also became the first county medical society executive to be named to the Florida Medical Association Political Action Committee (FMA PAC). He also serves on the Board of Directors for the North Florida chapter of the Public Relations Society of America (PRSA) and Challenge Enterprises in Clay County, as well as the Finance Committee for the Jacksonville Juniors Volleyball Association. DCMS Staff, Bryan’s wife Sarah, and several colleagues attended the “40 Under 40” Awards Luncheon to celebrate this distinct honor. Please join us in congratulating Mr. Campbell!

Northeast Florida Medicine Vol. 64, No. 2 2013 49

DCMS Hosts Dr. Ardis Hoven, AMA President-elect By Laura Townsend, DCMS Communications Coordinator/Managing Editor The Duval County Medical Society was honored to continue a 20 year tradition of hosting the President-elect of the American Medical Association (AMA) in May. Dr. Ardis Hoven’s visit to the First Coast included a tour of UF & Shands’ Center for Simulation Education & Safety Research, a panel discussion with the editorial board of The Florida Times-Union, speaking at the Rotary Club of Jacksonville, a visit with the Naval Hospital Jacksonville and a visit with the leadership of Florida Blue. Dr. Hoven’s visit concluded with a DCMS Membership Dinner where members, state represen-

tatives and Dr. Hoven enjoyed a delicious dinner at Epping Forest Yacht Club. Dr. Hoven presented an update about the AMA which includes a multi-year improving health outcomes initiative, a $10 million grant to a school who presents an innovative training for medical students, and the AMA’s continued efforts to physicians understand and adapt to the changing healthcare system. We look forward to continuing this tradition with the AMA in the future. If you were unable to attend, please take a look at the photos from the event and more at www.dcmsonline.org.

1. Dr. Alan Harmon, Dr. Ardis Hoven and Dr. Eli Lerner enjoying dinner at Bistro Aix. 2. Dr. Ardis Hoven speaking at the Naval Hospital Jacksonville. 3. Florida House Representative Dr. Ronald “Doc” Renuart and Dr. Ardis Hoven. 4. Florida Representative Mia Jones, Dr. Ardis Hoven and Mayor Alvin Brown. 5. Dr. Ardis Hoven chats with guests at the dinner reception at Epping Forest Yacht Club.

50 Vol. 64, No. 2 2013 Northeast Florida Medicine

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Patient Section

2013 Recommended Immunizations for Children from Birth Through 6 Years Old HepB

DTaP

Hib

PCV

IPV

DTaP

Hib

PCV

IPV

DTaP

Hib

PCV

Hib

PCV

DTaP

MMR

IPV Influenza (Yearly)*

HepB

Varicella

HepB

IPV

HepA†

MMR

Varicella

NOTE: If your child misses a shot, you don’t need to start over, just go back to your child’s doctor for the next shot. Talk with your child’s doctor if you have questions about vaccines. FOOTNOTES: * Two doses given at least four weeks apart are recommended for children aged 6 months through 8 years of age who are getting a flu vaccine for the first time and for some other children in this age group. † Two doses of HepA vaccine are needed for lasting protection. The first dose of HepA vaccine should be given between 12 months and 23 months of age. The second dose should be given 6 to 18 months later. HepA vaccination may be given to any child 12 months and older to protect against HepA. Children and adolescents who did not receive the HepA vaccine and are at high-risk, should be vaccinated against HepA. If your child has any medical conditions that put him at risk for infection or is traveling outside the United States, talk to your child’s doctor about additional vaccines that he may need.

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Northeast Florida Medicine Vol. 64, No. 2 2013 51

Patient Section

Vaccine-Preventable Diseases and the Vaccines that Prevent Them Disease:

Vaccine:

Disease spread by:

Disease symptoms:

Disease complications

Chicken Pox

Varicella vaccine protects against chickenpox.

Air, direct contact

Rash, tiredness, headache, fever

Infected blisters, bleeding disorders, encephalitis (brain swelling), pneumonia (infection in the lungs)

Diphtheria

DTaP* vaccine protects against diphtheria.

Air, direct contact

Sore throat, mild fever, weakness, swollen glands in neck

Swelling of the heart muscle, heart failure, coma, paralysis, death

Hib

Hib vaccine protects against Haemophilus influenzae type b.

Air, direct contact

May be no symptoms unless bacteria enter the blood

Meningitis (infection of the covering around the brain and spinal cord), intellectual disability, epiglottitis (lifethreatening infection that can block the windpipe and lead to serious breathing problems), pneumonia (infection in the lungs), death

Hepatitis A

HepA vaccine protects against hepatitis A.

Direct contact, contaminated food or water

Hepatitis B

HepB vaccine protects against hepatitis B.

Contact with blood or body fluids

Flu

Flu vaccine protects against influenza.

Air, direct contact

Measles

MMR** vaccine protects against measles.

Air, direct contact

MMR**vaccine protects against mumps.

Air, direct contact

Pertussis

DTaP* vaccine protects against pertussis (whooping cough).

Polio

IPV vaccine protects against polio.

Pneumococcal

May be no symptoms, fever, stomach pain, loss of appetite, fatigue, vomiting, jaundice (yellowing of skin and eyes), dark urine

Liver failure, arthralgia (joint pain), kidney, pancreatic, and blood disorders

May be no symptoms, fever, headache, weakness, vomiting, jaundice (yellowing of skin and eyes), joint pain

Chronic liver infection, liver failure, liver cancer

Fever, muscle pain, sore throat, cough, extreme fatigue

Pneumonia (infection in the lungs)

Rash, fever, cough, runny nose, pinkeye

Encephalitis (brain swelling), pneumonia (infection in the lungs), death

Swollen salivary glands (under the jaw), fever, headache, tiredness, muscle pain

Meningitis (infection of the covering around the brain and spinal cord), encephalitis (brain swelling), inflammation of testicles or ovaries, deafness

Air, direct contact

Severe cough, runny nose, apnea (a pause in breathing in infants)

Pneumonia (infection in the lungs), death

Air, direct contact, through the mouth

May be no symptoms, sore throat, fever, nausea, headache

Paralysis, death

PCV vaccine protects against pneumococcus.

Air, direct contact

May be no symptoms, pneumonia (infection in the lungs)

Rotavirus

RV vaccine protects against rotavirus.

Through the mouth

Diarrhea, fever, vomiting

Severe diarrhea, dehydration

Rubella

MMR** vaccine protects against rubella.

Air, direct contact

Children infected with rubella virus sometimes have a rash, fever, swollen lymph nodes

Very serious in pregnant womenâ&#x20AC;&#x201D;can lead to miscarriage, stillbirth, premature delivery, birth defects

Tetanus

DTaP* vaccine protects against tetanus.

Exposure through cuts in skin

Stiffness in neck and abdominal muscles, difficulty swallowing, muscle spasms, fever

Broken bones, breathing difficulty, death

Mumps

Bacteremia (blood infection), meningitis (infection of the covering around the brain and spinal cord), death

* DTaP combines protection against diphtheria, tetanus, and pertussis. ** MMR combines protection against measles, mumps, and rubella.

52 Vol. 64, No. 2 2013 Northeast Florida Medicine

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Patient Section

2013 Recommended Immunizations for Children from 7 through 18 Years Old

Tdap vaccine is combination vaccine that is recommended at age 11 or 12 to protect against tetanus, diphtheria and pertussis. If your child has not received any or all of the DTaP vaccine series, or if you don’t know if your child has received these shots, your child needs a single dose of Tdap when they are 7 -10 years old. Talk to your child’s health care provider to find out if they need additional catch-up vaccines.

All 11 or 12 year olds – both girls and boys – should receive 3 doses of HPV vaccine to protect against HPV-related disease. Either HPV vaccine (Cervarix® or Gardasil®) can be given to girls and young women; only one HPV vaccine (Gardasil®) can be given to boys and young men.

Meningococcal conjugate vaccine (MCV) is recommended at age 11 or 12. A booster shot is recommended at age 16. Teens who received MCV for the first time at age 13 through 15 years will need a one-time booster dose between the ages of 16 and 18 years. If your teenager missed getting the vaccine altogether, ask their health care provider about getting it now, especially if your teenager is about to move into a college dorm or military barracks.

Everyone 6 months of age and older—including preteens and teens—should get a flu vaccine every year. Children under the age of 9 years may require more than one dose. Talk to your child’s health care provider to find out if they need more than one dose.

A single dose of Pneumococcal Conjugate Vaccine (PCV13) is recommended for children who are 6 - 18 years old with certain medical conditions that place them at high risk. Talk to your healthcare provider about pneumococcal vaccine and what factors may place your child at high risk for pneumococcal disease.

Hepatitis A vaccination is recommended for older children with certain medical conditions that place them at high risk. HepA vaccine is licensed, safe, and effective for all children of all ages. Even if your child is not at high risk, you may decide you want your child protected against HepA. Talk to your healthcare provider about HepA vaccine and what factors may place your child at high risk for HepA.

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Northeast Florida Medicine Vol. 64, No. 2 2013 53

Patient Section

Vaccine-Preventable Diseases and the Vaccines that Prevent Them Diphtheria (Can be prevented by Tdap vaccine) Diphtheria is a very contagious bacterial disease that affects the respiratory system, including the lungs. Diphtheria bacteria can be passed from person to person by direct contact with droplets from an infected person’s cough or sneeze. When people are infected, the diptheria bacteria produce a toxin (poison) in the body that can cause weakness, sore throat, low-grade fever, and swollen glands in the neck. Effects from this toxin can also lead to swelling of the heart muscle and, in some cases, heart failure. In severe cases, the illness can cause coma, paralysis, and even death. Hepatitis A (Can be prevented by HepA vaccine) Hepatitis A is an infection in the liver caused by hepatitis A virus. The virus is spread primarily person-to-person through the fecal-oral route. In other words, the virus is taken in by mouth from contact with objects, food, or drinks contaminated by the feces (stool) of an infected person. Symptoms include fever, tiredness, loss of appetite, nausea, abdominal discomfort, dark urine, and jaundice (yellowing of the skin and eyes). An infected person may have no symptoms, may have mild illness for a week or two, or may have severe illness for several months that requires hospitalization. In the U.S., about 100 people a year die from hepatitis A. Hepatitis B (Can be prevented by HepB vaccine) Hepatitis B is an infection of the liver caused by hepatits B virus. The virus spreads through exchange of blood or other body fluids, for example, from sharing personal items, such as razors or during sex. Hepatitis B causes a flu-like illness with loss of appetite, nausea, vomiting, rashes, joint pain, and jaundice. The virus stays in the liver of some people for the rest of their lives and can result in severe liver diseases, including fatal cancer. Human Papillomavirus (Can be prevented by HPV vaccine) Human papillomavirus is a common virus. HPV is most common in people in their teens and early 20s. It is the major cause of cervical cancer in women and genital warts in women and men. The strains of HPV that cause cervical cancer and genital warts are spread during sex. Influenza (Can be prevented by annual flu vaccine) Influenza is a highly contagious viral infection of the nose, throat, and lungs. The virus spreads easily through droplets when an infected person coughs or sneezes and can cause mild to severe illness. Typical symptoms include a sudden high fever, chills, a dry cough, headache, runny nose, sore throat, and muscle and joint pain. Extreme fatigue can last from several days to weeks. Influenza may lead to hospitalization or even death, even among previously healthy children. Measles (Can be prevented by MMR vaccine) Measles is one of the most contagious viral diseases. Measles virus is spread by direct contact with the airborne respiratory droplets of an infected person. Measles is so contagious that just being in the same room after a person who has measles has already left can result in infection. Symptoms usually include a rash, fever, cough, and red, watery eyes. Fever can persist, rash can last for up to a week, and coughing can last about 10 days. Measles can also cause pneumonia, seizures, brain damage, or death. Meningococcal Disease (Can be prevented by MCV vaccine) Meningococcal disease is caused by bacteria and is a leading cause of bacterial meningitis (infection around the brain and spinal cord) in children. The bacteria are spread through the exchange of nose and throat droplets, such as when coughing, sneezing or kissing. Symptoms include nausea, vomiting, sensitivity to light, confusion and sleepiness. Meningococcal disease also causes blood infections. About one of every ten people who get the disease dies from it. Survivors of meningococcal disease may lose their arms or legs, become deaf, have problems with their nervous systems, become developmentally disabled, or suffer seizures or strokes. Mumps (Can be prevented by MMR vaccine) Mumps is an infectious disease caused by the mumps virus, which is spread in the air by a cough or sneeze from an infected person. A child can also get

54 Vol. 64, No. 2 2013 Northeast Florida Medicine

infected with mumps by coming in contact with a contaminated object, like a toy. The mumps virus causes fever, headaches, painful swelling of the salivary glands under the jaw, fever, muscle aches, tiredness, and loss of appetite. Severe complications for children who get mumps are uncommon, but can include meningitis (infection of the covering of the brain and spinal cord), encephalitis (inflammation of the brain), permanent hearing loss, or swelling of the testes, which rarely can lead to sterility in men. Pertussis (Whooping Cough) (Can be prevented by Tdap vaccine) Pertussis is caused by bacteria spread through direct contact with respiratory droplets when an infected person coughs or sneezes. In the beginning, symptoms of pertussis are similar to the common cold, including runny nose, sneezing, and cough. After 1-2 weeks, pertussis can cause spells of violent coughing and choking, making it hard to breathe, drink, or eat. This cough can last for weeks. Pertussis is most serious for babies, who can get pneumonia, have seizures, become brain damaged, or even die. About two-thirds of children under 1 year of age who get pertussis must be hospitalized. Pneumococcal Disease (Can be prevented by Pneumococcal vaccine) Pneumonia is an infection of the lungs that can be caused by the bacteria called pneumococcus. This bacteria can cause other types of infections too, such as ear infections, sinus infections, meningitis (infection of the covering around the brain and spinal cord), bacteremia and sepsis (blood stream infection). Sinus and ear infections are usually mild and are much more common than the more severe forms of pneumococcal disease. However, in some cases pneumococcal disease can be fatal or result in long-term problems, like brain damage, hearing loss and limb loss. Pneumococcal disease spreads when people cough or sneeze. Many people have the bacteria in their nose or throat at one time or another without being ill—this is known as being a carrier. Polio (Can be prevented by IPV vaccine) Polio is caused by a virus that lives in an infected person’s throat and intestines. It spreads through contact with the feces (stool) of an infected person and through droplets from a sneeze or cough. Symptoms typically include sudden fever, sore throat, headache, muscle weakness, and pain. In about 1% of cases, polio can cause paralysis. Among those who are paralyzed, up to 5% of children may die because they become unable to breathe. Rubella (German Measles) (Can be prevented by MMR vaccine) Rubella is caused by a virus that is spread through coughing and sneezing. In children rubella usually causes a mild illness with fever, swollen glands, and a rash that lasts about 3 days. Rubella rarely causes serious illness or complications in children, but can be very serious to a baby in the womb. If a pregnant woman is infected, the result to the baby can be devastating, including miscarriage, serious heart defects, mental retardation and loss of hearing and eye sight. Tetanus (Lockjaw) (Can be prevented by Tdap vaccine) Tetanus is caused by bacteria found in soil. The bacteria enters the body through a wound, such as a deep cut. When people are infected, the bacteria produce a toxin (poison) in the body that causes serious, painful spasms and stiffness of all muscles in the body. This can lead to “locking” of the jaw so a person cannot open his or her mouth, swallow, or breathe. Complete recovery from tetanus can take months. Three of ten people who get tetanus die from the disease. Varicella (Chickenpox) (Can be prevented by varicella vaccine) Chickenpox is caused by the varicella zoster virus. Chickenpox is very contagious and spreads very easily from infected people. The virus can spread from either a cough, sneeze. It can also spread from the blisters on the skin, either by touching them or by breathing in these viral particles. Typical symptoms of chickenpox include an itchy rash with blisters, tiredness, headache and fever. Chickenpox is usually mild, but it can lead to severe skin infections, pneumonia, encephalitis (brain swelling), or even death.

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Patient Section

2013 Recommended Immunizations for Adults

FOOTNOTES: (Influenza vaccine) 1. There are four different types of flu vaccines available—talk to your doctor or nurse about which flu vaccine is right for you. (Tdap vaccine) 2. Pregnant women are recommended to get Tdap vaccine with each pregnancy to increase protection for infants who are too young for vaccination but at highest risk for severe illness and death from pertussis (whooping cough). (HPV vaccine) 3. There are two different kinds of HPV vaccine but only one HPV vaccine (Gardasil®) can be given to men. Gay men or men who have sex with men who are 22 through 26 years old should get HPV vaccine if they haven’t already started or completed the series. (MMR vaccine) 4. If you were born in 1957 or after, and don’t have a record of being vaccinated or having had these infections, talk to your doctor or nurse about how many doses you may need. (Pneumococcal vaccine) 5. There are two different types of pneumococcal vaccine: PCV13 and PPSV23. Talk with your doctor or nurse to find out if one or both pneumococcal vaccines are recommended for you. If you are traveling outside of the United States, you may need additional vaccines. Ask your doctor or nurse which vaccines you may need.

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Northeast Florida Medicine Vol. 64, No. 2 2013 55

Patient Section

Vaccine-Preventable Diseases and the Vaccines that Prevent Them Diphtheria (Can be prevented by Tdap vaccine) Diphtheria is a very contagious bacterial disease that affects the respiratory system, including the lungs. Diphtheria bacteria can be passed from person to person by direct contact with droplets from an infected person’s cough or sneeze. When people are infected, the diptheria bacteria produce a toxin (poison) in the body that can cause weakness, sore throat, low-grade fever, and swollen glands in the neck. Effects from this toxin can also lead to swelling of the heart muscle and, in some cases, heart failure. In severe cases, the illness can cause coma, paralysis, and even death. Hepatitis A (Can be prevented by HepA vaccine) Hepatitis A is an infection in the liver caused by hepatitis A virus. The virus is spread primarily person-to-person through the fecal-oral route. In other words, the virus is taken in by mouth from contact with objects, food, or drinks contaminated by the feces (stool) of an infected person. Symptoms include fever, tiredness, loss of appetite, nausea, abdominal discomfort, dark urine, and jaundice (yellowing of the skin and eyes). An infected person may have no symptoms, may have mild illness for a week or two, or may have severe illness for several months that requires hospitalization. In the U.S., about 100 people a year die from hepatitis A. Hepatitis B (Can be prevented by HepB vaccine) Hepatitis B is an infection of the liver caused by hepatitis B virus. The virus spreads through exchange of blood or other body fluids, for example, from sharing personal items, such as razors, diabetes blood sugar monitors, or during sex. Hepatitis B causes a flu-like illness with loss of appetite, nausea, vomiting, rashes, joint pain, and jaundice. The virus stays in the liver of some people for the rest of their lives and can result in severe liver diseases, including fatal cancer. Human Papillomavirus (Can be prevented by HPV vaccine) Human papillomavirus is a common virus. HPV is most common in people in their teens and early 20s. It is the major cause of cervical cancer in women, as well as anal cancer and genital warts in both women and men. The strains of HPV that cause cervical cancer and genital warts are spread during sex. Influenza (Can be prevented by annual flu vaccine) Influenza is a contagious viral infection of the nose, throat, and lungs. The virus spreads when an infected person coughs, sneezes, or talks and can cause mild to severe illness. Typical symptoms include a sudden high fever, chills, cough, headache, runny nose, sore throat, and muscle and joint pain. Extreme fatigue can last from several days to weeks. Influenza may lead to hospitalization or even death, even among previously healthy children and adults. Measles (Can be prevented by MMR vaccine) Measles is one of the most contagious vaccine-preventable diseases. Measles virus is spread by direct contact with the airborne respiratory droplets of an infected person. Measles is so contagious that just being in the same room after a person who has measles has already left can result in infection in a susceptible person. Symptoms usually include a rash, fever, cough, and red, watery eyes. Fever can be high rash can last for up to a week, and coughing can last about 10 days. Measles can also cause pneumonia, seizures, brain damage, or death. Meningococcal Disease (Can be prevented by MCV vaccine) Meningococcal disease is caused by bacteria and is a leading cause of bacterial meningitis (infection around the brain and spinal cord) in children. The bacteria are spread through the exchange of nose and throat droplets, such as when coughing, sneezing or kissing. Symptoms of meningitis include sudden onset of fever, headache and stiff neck, often with nausea, vomiting, sensitivity to light, and confusion. Meningococcal disease also causes blood infections. About one of every ten people who get the disease dies from it. Survivors of meningococcal disease may lose their arms or legs, become deaf, have problems with their nervous systems, become developmentally disabled, or suffer seizures or strokes. Mumps (Can be prevented by MMR vaccine) Mumps is an infectious disease caused by the mumps virus, which is spread in the air by a cough or sneeze from an infected person. A person can also

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get infected with mumps by coming in contact with a contaminated object, like a toy. The mumps virus causes fever, headaches, painful swelling of the salivary glands under the jaw, fever, muscle aches, tiredness, and loss of appetite. Severe complications for people who get mumps are uncommon, but can include meningitis (infection of the covering of the brain and spinal cord), encephalitis (inflammation of the brain), permanent hearing loss, or swelling of the testes, which rarely can lead to sterility in men. Pertussis (Whooping Cough) (Can be prevented by Tdap vaccine) Pertussis is caused by bacteria spread through direct contact with respiratory droplets when an infected person coughs or sneezes. In the beginning, symptoms of pertussis are similar to the common cold, including runny nose, sneezing, and cough. After 1-2 weeks, pertussis can cause spells of violent coughing and choking, making it hard to breathe, drink, or eat. This cough can last for weeks. Pertussis is most serious for babies, who can get pneumonia, have seizures, become brain damaged, or even die. More than half of children under 1 year of age who get pertussis are hospitalized. Pneumococcal Disease (Can be prevented by Pneumococcal vaccine) Pneumonia is an infection of the lungs that can be caused by the bacteria called pneumococcus. This bacteria can cause other types of infections too, such as ear infections, sinus infections, meningitis (infection of the covering around the brain and spinal cord), bacteremia and sepsis (blood stream infection). Sinus and ear infections are usually mild and are much more common than the more severe forms of pneumococcal disease. However, in some cases pneumococcal disease can be fatal or result in long-term problems, like brain damage, hearing loss and limb loss. Pneumococcal disease spreads when people cough or sneeze. Many people have the bacteria in their nose or throat at one time or another without being ill—this is known as being a carrier. Rubella (German Measles) (Can be prevented by MMR vaccine) Rubella is caused by a virus that is spread through coughing and sneezing. In children rubella usually causes a mild illness with fever, swollen glands, and a rash that lasts about 3 days. Rubella rarely causes serious illness or complications in children, but can be very serious to a baby in the womb . If a pregnant woman is infected, the result to the baby can be devastating, including miscarriage, serious heart defects, mental retardation and loss of hearing and eye sight. Tetanus (Lockjaw) (Can be prevented by Tdap vaccine) Tetanus is caused by bacteria found in soil, dust, and maure. The bacteria enters the body through a wound, such as a deep cut. When people are infected, the bacteria produce a toxin (poison) in the body that causes serious, painful spasms and stiffness of all muscles in the body. This can lead to “locking” of the jaw so a person cannot open his or her mouth, swallow, or breathe. Complete recovery from tetanus can take months. Ten to 20% of people who get tetanus die from the disease. Varicella (Chickenpox) (Can be prevented by varicella vaccine) Chickenpox is caused by the varicella zoster virus. Chickenpox is very contagious and spreads very easily from infected people. The virus can spread from either a cough, sneeze. It can also spread from the blisters on the skin, either by touching them or by breathing in these viral particles. Typical symptoms of chickenpox include an itchy rash with blisters, tiredness, headache and fever. Chickenpox is usually mild, but it can lead to severe skin infections, pneumonia, encephalitis (brain swelling), or even death. Zoster (Shingles, Herpes Zoster) (Can be prevented by the zoster vaccine) Shingles is caused by the varicella zoster virus, the same virus that causes chickenpox. After a person recovers from chickenpox, the virus stays in the body in a dormant (inactive) state. For reasons that are not fully known, the virus can reactivate years later, causing shingles. Almost 1 out of every 3 people in the United States will develop shingles, also known as zoster or herpes zoster. About half of all cases occur among men and women 60 years old or older. People who develop shingles typically have only one episode in their lifetime. In rare cases, however, a person can have a second or even a third episode. Herpes zoster is not caused by the same virus that causes genital herpes, a sexually transmitted disease.

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DCMS Membership Applications These physicians’ applications for membership in the Duval County Medical Society are now being processed. Any information or opinions you may have concerning the eligibility of the applicants listed here may be directed to Karen Pan, Membership Director (904-355-6561 x107).

Vaqar Ali, MD Interventional Cardiology/Cardiovascular Disease First Coast Cardiovascular Institute Medical Degree: Rawalpindi Medical College Residencies: St. Vincent’s Medical Center-Staten Island & Christian Cardiology Fellowships: University of Kentucky & New York Hospital Queens Pachavit Kasemsap, MD General Surgery MCCI Medical Degree: Washington University Residency: University of Illinois Pamela A. Lindor, MD Pediatrics University of Florida Medical Degree: University of Massachusetts Medical School Residency: Yale-New Haven Hospital Fellowship: Rhode Island Hospital Marc Litt, MD Cardiology Baptists Heart Specialists Medical Degree: Univ of Cincinnati College of Medicine Residency: Johns Hopkins Hospital Rajul Parikh, MD Neurology/Clinical Neurophysiology First Coast Cardiovascular Institute Medical Degree: B.J. Medical College, Gujarat University Residencies: Jamaica Hospital Medical Center & Medical Center of Wisconsin Saswata Roy, MD Otolaryngology Jacksonville ENT Surgery Medical Degree: University of Nebraska Residency: University of Minnesota Hospital

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Anwer Siddiqi, MD Anatomic Pathology / Cytopathology University of Florida Medical Degree: Dow Medical College Residency: Emory University Fellowship: University of Florida Jacksonville Carlos Sotolongo, MD Cardiology Baptists Heart Specialists Medical Degree: Wayne State University School of Medicine Residency: University of Iowa Hospital and Clinics Merrill Stass-Isern, MD Ophthalmology Nemours Children’s Clinic Medical Degree: Universidad De Zaragoza Residency: University of Missouri Fellowship: Children’s Mercy Hospital Daniel Thielemann, MD Sleep Medicine/Neurology First Coast Cardiovascular Institute Medical Degree: University of Mississippi Medical Center Residencies: Allegheny General Hospital Fellowship: University of Nebraska Medical Center William Wallace, MD Plastic Surgery Coastal Cosmetic Center Medical Degree: University of Oklahoma Health Science Center Residency: Ohio State University RESIDENTS Bilkisu Gaye, MD Internal Medicine Medical Degree: Ross University School of Medicine Residency: Shands Jacksonville Hospital

Northeast Florida Medicine Vol. 64, No. 2 2013 57

From the President’s Desk

It is a pleasure to be writing this report to you. We have had an extraordinary beginning of the year with many new programs under way and more to come. Most importantly we are all beginning to realize the importance of DCMS in our practice lives. We are engaged in one of the most comprehensive health care changes in the history of American medicine, and DCMS is working very hard to help all of us find our way through the new maze of legislation and health care delivery systems. Dr. Ardis Hoven, the President-Elect of the American Medical Association (AMA), visited with us and brought forward the AMA’s plan to navigate through the health care changes and addressed the problems of Accountable Care Organizations (ACO) Eli Lerner, MD on a national basis, as well 2013 DCMS President as patient care under the oncoming changes. She left a positive impression, stressing the role of physician leadership in ACO’s, quality metrics, and studies leading to a change in the way physicians are trained. Dr. Hoven pointed out that the AMA has been successful in advocating Centers for Medicaid and Medicare Services (CMS) to dramatically improve the ability of physicians to form up and lead ACOs. The organization has established a $170 million advance payment option to help physicians cover start-up costs of ACO’s. As a result, almost half of the 250 ACO’s that have been established are physician led. She was of great help in helping us formulate plans for our next big event: a meeting focusing on ACO’s and their impact on local practice in Duval and other surrounding counties which is planned for the same day as the DCMS Annual Meeting on December 4, 2013. Dr. Daniel Kantor, appointed to the countywide Search Committee for a new Public Health Director for Duval County, has made a very positive impact on behalf of all of us and assures that we are deeply engaged in this very important effort.

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We have met with Daniel R. Wilson, Dean of UF College of Medicine-Jacksonville and are putting together a joint educational program for Residents going into practice for the first time. The program is designed to make the business aspect of practice more meaningful with attention placed on contracts, partnerships, privileging and other building blocks of a successful practice. This program will debut soon. We continue to engage members and potential members in small meetings all over town, offering business topics and how they relate to physicians. These are ongoing and continue to engender interest from the members who attend. Financial topics are presented, as well as practice tips for practicing physicians. I have spoken to several of the practice managers who have attended our practice manager luncheons and have gotten very positive feedback on the value of those sessions. With these sessions, we try to make the practice of medicine easier for our members and their office staff. Since the beginning of the year, Bryan Campbell and the DCMS Staff have worked hard to bring new member benefits to the group. To cite a few, members may enjoy a reduced rate on Income Protection Insurance as well as substantial cost discounts on Long Term Care Insurance from Mass Mutual. Our medical malpractice insurance program continues for members through The Doctors Company. Another recent addition is HIPAA compliant payment processing from World Pay, which is very important looking forward. Office Product discounts are available from My Office Products, and to be sure that relaxation is not neglected, the Jacksonville Boat Club is offering three free months of membership to us which is a $1,200 value. To learn more about benefits that help save you money, please visit www.dcmsonline.org/ content.php?page=MembershipDeals. We have had a wonderful start this year and look forward to even greater strides in the months to come. Get involved with your Medical Society. Call DCMS Headquarters and find out how you can become more involved in the structure of DCMS. See you at the ACO meeting and the Annual Membership Meeting on Wednesday, December 4. To register for this meeting, please visit www.dcmsonline.org/calendar.php.

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