April 2015 JMSMA by Journal MSMA

April

VOL. LVI

2015

No. 4

MMPAC

Mississippi Medical Political Action Committe

Lucius M. Lampton, MD Editor D. Stanley Hartness, MD Richard D. deShazo, MD Associate Editors Karen A. Evers Managing Editor Publications Committee Dwalia S. South, MD Chair Philip T. Merideth, MD, JD Martin M. Pomphrey, MD Leslie E. England, MD, Ex-Officio and the Editors

JOURNAL OF THE MISSISSIPPI STATE MEDICAL ASSOCIATION (ISSN 0026-6396) is owned and published monthly by the Mississippi State Medical Association, founded 1856, located at 408 West Parkway Place, Ridgeland, Mississippi 39158-2548. (ISSN# 0026-6396 as mandated by section E211.10, Domestic Mail Manual). Periodicals postage paid at Jackson, MS and at additional mailing offices. CORRESPONDENCE: Journal MSMA, Managing Editor, Karen A. Evers, P.O. Box 2548, Ridgeland, MS 39158-2548, Ph.: (601) 853-6733, Fax: (601)853-6746, www.MSMAonline.com. SUBSCRIPTION RATE: $83.00 per annum; $96.00 per annum for foreign subscriptions; $7.00 per copy, $10.00 per foreign copy, as available. ADVERTISING RATES: furnished on request. Cristen Hemmins, Hemmins Hall, Inc. Advertising, P.O. Box 1112, Oxford, Mississippi 38655, Ph: (662) 236-1700, Fax: (662) 236-7011, email: cristenh@ watervalley.net POSTMASTER: send address changes to Journal of the Mississippi State Medical Association, P.O. Box 2548, Ridgeland, MS 39158-2548. The views expressed in this publication reflect the opinions of the authors and do not necessarily state the opinions or policies of the Mississippi State Medical Association. Copyright© 2015 Mississippi State Medical Association. SIPPI ST

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The Association Claude D. Brunson, MD President Daniel P. Edney, MD President-Elect Michael Mansour, MD Secretary-Treasurer Geri Lee Weiland, MD Speaker Jeffrey A. Morris, MD Vice Speaker Charmain Kanosky Executive Director

I L A SSOC

APRIL 2015

VOLUME 56

NUMBER 4

Scientific Articles Pigmented Epithelioid Angiomyolipoma of the Kidney

Raveena Reddy, MD; Jack R Lewin, FFPath; Veena Shenoy, MD

Top 10 Facts You Should Know about Spirometry

Demondes Haynes, MD; George E. Abraham, III, MD; Terry M. Dwyer, MD, PhD; and Marcy F. Petrini, PhD

Clinical Problem-Solving Case: All’s Well That Ends Swell

William T. Brazier, MD

MSMA Health Literacy Resources

103

MSMA House of Delegates Resolutions Information

108

Nominating Committee Seeks Candidates For Vacancies in MSMA Offices 110

Editorial Public Health in Mississippi: Advances in the Last Two Decades

President’s Page There is ‘Power in Numbers’

106

Claude D. Brunson, MD; MSMA President

Departments From the Editor- Health Literacy: A Rx for Patient Success

Legal Ease- 2015 Mississippi Legislative Session Highlights

111

Una Voce- Just Doing Some Reframing

115

About The Cover: American Alligator in Mississippi JMSMA Associate Editor Dr. Richard deShazo and Mr. David Baldwin were on a trip in Pelahatchie Bay marsh on the reservoir in Jackson during the post-mating season for alligators. They came upon this textbook experience of a female alligator who had built a nest of debris just off the shoreline and assumed her nesting position while they jointly photographed the event. Female alligators remain on the nest to protect it until their eggs hatch and are not friendly during that period, or any other. They can be quite dangerous when defending their nests. April

VOL. LVI

Official Publication of the MSMA Since 1959

104

Thomas Dobbs, MD, MPH; Lucius Lampton, MD; Ellen Jones, PhD; Lydia West, MPH

2015

No. 4

April 2015 JOURNAL MSMA 89

From the Editor- Health Literacy: A Rx for Patient Success

uring last year’s annual session, Resolution 5 stressed the importance of “health literacy,” defining it as the ability of our patients to obtain, process, and understand basic health information and services needed to make appropriate health decisions and follow instructions for treatment. Many of our patients seem to understand little we are telling them. We may label them “noncompliant” but often times it is simply “health literacy,” something we as physicians can improve. A recent government study estimates that over 89 million American adults have limited health literacy skills. Studies also show this problem challenges people from all ages, races, income, and education levels. Individuals with limited health literacy incur medical expenses that are up to four times greater than other patients, costing the system billions of dollars annually. Compounding this is the fact that most patients hide their confusion because they are too ashamed and intimidated to ask for help. Outcome is no doubt improved with patient understanding and buy-in. Health literacy is not only essential for patient success but also for our future payments, as our system emphasizes more such physician performance metrics as patient satisfaction, readmissions, medication compliance, and appropriate follow-up.

Back in 2011, your JMSMA published an article focused on health literacy. [Minor DS, Lancaster WJ, Freeman, KW, deShazo RD. Improving health literacy in our patients: An opportunity to improve Mississippi health outcomes. J Miss Med Assoc. 2011;52(6):175-178]. The article provided resources for providers to help them minimize communication-related adverse events. The Board of Trustees and I encourage Lucius M. Lampton, MD you to read the article in the pressroom at MSMAonline.com as well as other health literacy resources featured on page 103 of this issue. Cultural competency is a key component of solving the health literacy problem. Physicians must remember that a high percentage of our patients don’t understand their actual diagnoses or even their physician’s name upon discharge from the hospital. Your JMSMA hopes to highlight health literacy in the future as part of a series of articles. Look for them and contribute! Contact me at LukeLampton@cableone.net. —Lucius M. Lampton, MD, Editor

Journal Editorial Advisory Board Timothy J. Alford, MD Family Physician, Kosciusko Medical Clinic Michael Artigues, MD Pediatrician, McComb Children’s Clinic

Maxie L. Gordon, MD Assistant Professor, Department of Psychiatry and Human Behavior, Director of the Adult Inpatient Psychiatry Unit and Medical Student Education, University of Mississippi Medical Center, Jackson

Diane K. Beebe, MD Professor and Chair, Department of Family Medicine, University of MS Medical Center, Jackson

Scott Hambleton, MD Medical Director Mississippi Professionals Health Program, Ridgeland

Jennifer J. Bryan, MD Assistant Professor, Department of Family Medicine University of Mississippi Medical Center, Jackson

J. Edward Hill, MD Family Physician, North Mississippi Medical Center Tupelo

Jeffrey D. Carron, MD Professor, Department of Otolaryngology & Communicative Sciences, University of Mississippi Medical Center, Jackson Gordon (Mike) Castleberry, MD Urologist, Starkville Urology Clinic

W. Mark Horne, MD Internist, Jefferson Medical Associates, Laurel

Thomas E. Dobbs, MD, MPH State Epidemiologist Mississippi State Department of Health, Hattiesburg

Ben E. Kitchens, MD Family Physician, Iuka Brett C. Lampton, MD Internist/Hospitalist, Baptist Memorial Hospital, Oxford

Philip L. Levin, MD President, Gulf Coast Writers Association Emergency Medicine Physician, Gulfport Sharon Douglas, MD Professor of Medicine and Associate Dean for VA William Lineaweaver, MD Education, University of Mississippi School of Medicine, Editor, Annals of Plastic Surgery Associate Chief of Staff for Education and Ethics, Medical Director G.V. Montgomery VA Medical Center, Jackson JMS Burn and Reconstruction Center, Brandon Bradford J. Dye, III, MD Ear Nose & Throat Consultants, Oxford Daniel P. Edney, MD Executive Committee Member, National Disaster Life Support Education Consortium, Internist, The Street Clinic, Vicksburg Owen B. Evans, MD Professor of Pediatrics and Neurology University of Mississippi Medical Center, Jackson

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Jason G. Murphy, MD Surgeon, Surgical Clinic Associates, Jackson Ann Myers, MD Rheumatologist Mississippi Arthritis Clinic, Jackson Darden H. North, MD Obstetrician/Gynecologist Jackson Health Care-Women, Flowood Michelle Y. Owens, MD Associate Professor, Vice-Chair of Obstetrics and Gynecology, University of Mississippi Medical Center, Jackson Jimmy L. Stewart, Jr., MD Program Director, Combined Internal Medicine/ Pediatrics Residency Program, Associate Professor of Medicine and Pediatrics University of Mississippi Medical Center, Jackson Samuel Calvin Thigpen, MD Hematology-Oncology Fellow, Department of Medicine University of Mississippi Medical Center, Jackson Thad F. Waites, MD Clinical Cardiologist, Hattiesburg Clinic W. Lamar Weems, MD Urologist, Jackson

Michael D. Maples, MD Chris E. Wiggins, MD Medical Director Orthopaedic Surgeon Medical Assurance Company of Mississippi, Ridgeland Bienville Orthopaedic Specialists, Pascagoula Alan R. Moore, MD Clinical Neurophysiologist Muscle and Nerve, Jackson

John E. Wilkaitis, MD Chief Medical Officer Brentwood Behavioral Healthcare, Flowood

Paul “Hal” Moore Jr., MD Radiologist Singing River Radiology Group, Pascagoula

Sloan C. Youngblood, MD Assistant Medical Director, Department of Anesthesiology, University of Mississippi Medical Center, Jackson

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April 2015 JOURNAL MSMA 91

â&#x20AC;˘ Scientific Articles â&#x20AC;˘ Pigmented Epithelioid Angiomyolipoma of the Kidney Raveena Reddy, MD; Jack R Lewin, FFPath; Veena Shenoy, MD

Key Words: angiomyolipoma, PEComa, epithelioid angiomyolipoma

cells.1 PECs are epithelioid with clear to granular eosinophilic cytoplasm and round to oval, centrally placed nucleus, and demonstrate a distinctive immunohistochemical reaction with melanocytic markers such as HMB-45, MART-1, microphthalmia transcription factor (MiTF), actin, and desmin.2 Ultrastructurally, they contain microfilament bundles with electron dense condensation, numerous mitochondria, membrane bound dense granules, pre-melanosomes, hemi-desmosomes, and poorly formed intercellular junctions.1 The PEComa family of tumors includes angiomyolipoma (AML), lymphangioleiomyomatosis, clear cell sugar tumor of the lung and clear cell myomelanocytic tumor of the falciparum ligament/ligamentum teres and unusual clear cell tumors of various other sites.1 There is a known association between PEComa and tuberous sclerosis complex (TSC).3 Epithelioid AML is a distinct variant of AML characterized by the presence of predominantly epithelioid cells with or without spindle cells or adipose tissue and thick walled blood vessels. Extensive melanin pigment deposition in an epithelioid AML is extremely rare with only ten cases reported so far.4 To the best of our knowledge, ours is the eleventh case to be reported in the literature. The aim of this paper is to describe the findings in our case and to review the literature on clinicopathologic and prognostic features of this tumor.

Background

Clinical Presentation

bstract

Extensive melanin pigment in an epithelioid angiomyolipoma, a potentially malignant and locally aggressive renal tumor, has been rarely reported. A 53-yearold, asymptomatic man with no significant past medical history underwent partial nephrectomy for a right kidney mass discovered on CT scan. Grossly, the mass was 4 cm, wellcircumscribed, dark, brown-black. Microscopically, nests of large, clear-to-eosinophilic cells with mildly atypical, vesicular nuclei and prominent nucleoli were separated by striking vascular network. Abundant, brown-black, coarsely granular pigment was noted. The tumor stained with HMB-45 and MART-1 and was negative for broad spectrum cytokeratin, CK-7, CD-10, RCC antigen, EMA, vimentin, SMA, desmin, synaptophysin, chromogranin, and S100. Fontana-Masson stain confirmed presence of melanin. Thick-walled vessels, spindle cells, and fat were absent. The patient had no family history of tuberous sclerosis. Close follow-up was recommended. It is important to differentiate this entity from melanoma, pigmented renal cell carcinoma, and pigmented paraganglioma.

The World Health Organization Classification of tumors defines neoplasms with perivascular epithelioid cell differentiation (PEComas) as mesenchymal tumors composed of histologically and immunohistochemically distinctive perivascular

Author Affiliations: Fellow in breast pathology, University of Chicago Medicine and Biological Sciences, Chicago, Illinois (Dr. Reddy); Associate Professor and Director of Anatomic Pathology, Department of Pathology, University of Mississippi Medical Center, Jackson, Mississippi (Lewin); Assistant Professor, Department of Pathology, University of Mississippi Medical Center, Jackson, Mississippi (Dr. Shenoy). Corresponding Author: Dr. Veena Shenoy, MD; Assistant Professor, Department of Pathology, University of Mississippi Medical Center, R 227, 2500 North State Street, Jackson, MS 39216. Phone: (601)984-1571 (Work); Fax: (601)984-1531 (Email: vshenoy@umc.edu)

Conflicts of Interest/ Funding Support: None.

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A 53-year-old African-American man with a past medical history of hypertension and chronic back pain secondary to degenerative joint disease initially presented to his primary care physician for follow up of his back pain and reported a 10 pound weight loss which he had attributed to stress. He had no other significant past medical history or any history of tuberous sclerosis. A CT scan of the abdomen and pelvis revealed a 3.2 x 3.8 x 3.9 cm, heterogeneous mass in the lower pole of the right kidney (Figure 1). Imaging was highly suspicious for renal cell carcinoma. There was no evidence of enlarged abdominal or pelvic lymph nodes or metastatic disease. A magnetic resonance imaging of the brain did not reveal any intracranial metastasis. Subsequently he underwent a right robotic converted to open partial nephrectomy.

Figure 1. CT scan with axial imaging shows a 3.2 x 3.8 x 3.9 cm right lower pole renal mass.

ion with recurrence and/or rarely metastasis. The patient did not have any complaints after the surgery and is currently doing well with no evidence of recurrence or metastasis.

Discussion

Pathologic Findings

The 32 gram partial nephrectomy specimen was a 4.0 x 4.0 x 3.7 cm irregular wedge of kidney with an intact capsule and overlying adipose tissue. A 4.0 x 3.4 x 2.6 cm, well-circumscribed, dark, brown black mass was noted 0.1 cm from the resection margin. The tumor was sampled well and the sections were submitted for processing following fixation in 10% formalin. Microscopically, the hematoxylin-eosin stained slides showed a cellular tumor with nests of large epithelioid cells, with clear to eosinophilic cytoplasm, mildly atypical, irregular, vesicular nuclei and prominent nucleoli, separated by delicate vascular network. Abundant, brown-black, coarsely granular pigment, consistent with melanin was present throughout the tumor (Figure 2a). Foci of necrosis and hemorrhage without mitoses were noted. A broad panel of immunohistochemical stains with appropriate controls was performed on select formalin-fixed, paraffin embedded tissue sections by using the peroxidase-antiperoxidase technique. The tumor was positive for HMB-45 (Figure 2b) and MART-1 and negative for broad spectrum cytokeratin, CK-7, CD-10, renal cell carcinoma antigen, epithelial membrane antigen, vimentin, smooth muscle actin, desmin, synaptophysin, chromogranin and S100 protein. Fontana-Masson stain and Prussian blue stains were also performed. Fontana-Masson stain (Figure 2c) highlighted the pigment confirming the presence of melanin. The classic features of angiomyolipoma including thick walled blood vessels, spindle cells and adipose tissue were absent. The surgical margins were free of tumor and there was no evidence of any lymphovascular invasion.

Epithelioid angiomyolipoma is an uncommon variant of AML. Most cases are benign; however, occasionally these tumors can be malignant, especially in association with tuberous sclerosis.5 Extensive pigment deposition is highly unusual and has to be differentiated from other melanin containing tumors. Only ten cases have been reported so far, ours being the eleventh case in the literature. Of the reported cases, eight occurred in women and three, including our case, occurred in men. The age range was between 12-73 years,4,6,7 and two cases reported in young children/adolescents were malignant with widespread metastases. There is no clearly documented long term followup data on any of the cases but to date three cases have been documented to have metastases, two cases have shown recurrence and three patients, including one with metastatic tumor and two with recurrent tumors, died of the disease.4 Ten out of the eleven reported tumors including ours were not associated with a history of tuberous sclerosis. All the tumors originated in the cortex with no preference to location within the kidney and ranged in size from 1.7-11 cm.4,6,7 In our case the tumor was grossly an unusual brown-black mass in contrast to other primary tumors arising in the kidney and was similar to the other reported cases. All the eleven cases showed similar histology and immunoprofile, especially with HMB-45. Figure 2a, Hematoxylin-eosin stain, 40X: Large epithelioid cells, arranged in nests separated by vascular network, are seen with clear to eosinophilic cytoplasm, mildly atypical, vesicular nuclei, prominent nucleoli, and abundant, intracytoplasmic brown-black, coarsely granular melanin pigment (arrow). 2b, HMB-45 immunostain, 20X: demonstrates the diffuse cytoplasmic staining pattern of the epithelioid tumor cells. 2c, Fontana-Masson special stain, 20X: highlights the coarsely granular melanin pigment (arrow).

Outcome

Close follow-up was recommended as these tumors can be locally aggressive and potentially behave in a malignant fash-

April 2015 JOURNAL MSMA 93

It is important to consider several other pigmented tumors in the differential diagnoses, and immunohistochemistry serves as a critical diagnostic tool. Our differential diagnoses included pigmented renal cell carcinoma, melanoma and pigmented paraganglioma. Renal cell carcinoma arises in the cortex and histologically shows nests and groups of clear cells with delicate fibrovascular septa. In our case, the tumor had similar architecture and cytomorphology, but the diffuse pigmentation was very unusual. Clear cell renal cell carcinoma would strongly express epithelial markers including low molecular weight cytokeratins, CAM 5.2, epithelial membrane antigen, CD 10, renal cell carcinoma antigen and also vimentin. Our case was negative for all these markers. Malignant melanoma in the kidney has been reported to be located in the renal pelvis8, but the possibility of a primary melanoma in the kidney has been contradictory. However, metastatic melanoma in the kidney, also very rarely reported, is usually multifocal and will be positive for all melanoma markers including S100 protein, which was negative in our case. Pigmented or melanotic paragangliomas are very rare and usually located in the uterus, retroperitoneum, lumbar spine, urinary bladder and mediastinum.9-11 The cytomorphological features overlap with that of a PEComa, but pigmented paragangliomas are positive for neuroendocrine markers such as synaptophysin and chromogranin which were negative in our case. Malignant epithelioid AML can be a very aggressive tumor with multiple widespread metastases, leading to death. Recently, Brimo et al12 studied 40 cases of renal epithelioid AMLs and developed a predictive model to report the clinicopathologic prognostic indicators of malignancy in epithelioid angiomyolipomas including (1) 70% or more atypical epithelioid cells (2) 2 or more mitotic figures per ten high power fields (3) atypical mitoses and (4) necrosis. They suggested that the presence of three or all of the above features is highly predictive of malignant behavior. This was followed by a clinicopathologic study of 41 cases of pure epithelioid PEComas by Nese et al13 to assess the morphology and risk stratification in a univariate analysis. The clinicopathologic parameters associated with disease progression included association with tuberous sclerosis or concurrent angiomyolipoma, tumor size >7 cm, necrosis, extrarenal extension and/ or renal vein involvement and carcinoma-like growth pattern. The tumor risk of progression to malignancy was stratified as: less than 2 adverse prognostic parameters = low risk (15% disease progression); 2-3 parameters = intermediate risk (64% disease progression); 4 or more parameters = high risk (100% disease progression). Extrarenal extension and/or renal vein involvement and carcinoma-like growth pattern were the only two parameters which were the most significant predictors of the outcome.13 In our case, the tumor did not demonstrate any of the above features except the close architectural resemblance to a clear cell renal cell carcinoma.

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Conclusion

Similar studies are required to analyse the clinical features, behavior and prognosis of the pigmented epithelioid AMLs. The clinicians need to be aware of this rare entity and must ensure regular and thorough follow-ups with accurate documentation of such unusual cases to better understand the clinical and prognostic features.

References 1.

Folpe AL (2002), Neoplasms with perivascular epithelioid cell differentiation (PEComa). In: Fletcher C, Unni K, Mertens F (eds) World Health Organization classification of tumors pathology and genetics of tumors of soft tissue and bone. IARC Press, Lyon, pp221-222.

Martignoni G, Pea M, Reghellin D, et al. PEComa: the past, the present and the future. Virchows Arch (2008) 452:119-132.

Fukunaga M, Harada T. Pigmented perivascular epithelioid cell tumor of the kidney. Arch Pathol Lab Med. 2009;133:19811984.

Chang H, Jung W, Kang Y, et al. Pigmented perivascular epithelioid cell tumor (PEComa) of the kidney: a case report and review of the literature. Korean J Pathol. 2012 Oct;46(5):499502. doi: 0.4132/KoreanJPathol. 2012.46.5.499. Epub 2012 Oct 25. PubMed PMID: 23136579; PubMed Central PMCID: PMC3490117.

Rasalkar DD, Chu WC, Chan AW, et al. Malignant pigmented clear cell epithelioid cell tumor (PEComa) in an adolescent boy with widespread metastases: a rare entity in this age group. Pediatr Radiol. 2011 Dec;41(12):1587-90. doi:10.1007/s00247011-2125-0. Epub 2011 May 20. PubMed PMID: 21597905.

Goyal R, Joshi K, Singh SK, et al. Melanotic clear cell epithelioid angiomyolipoma: a rare entity and a mimic of clear cell renal cell carcinoma. Histopathology 207;50: 393-4.

Ribalta T, Lloreta J, Munné A, et al. Malignant pigmented clear cell epithelioid tumor of the kidney: clear cell (“sugar”) tumor versus malignant melanoma. Hum Pathol. 2000 Apr;31(4):5169. PubMed PMID: 10821501.

Shimko MS, Jacobs SC, Phelan MW. Renal metastasis of malignant melanoma with unknown primary. Urology 2007;69:384.e9-10.

Tavassoli FA. Melanotic paraganglioma of the uterus. Cancer. 1986 Aug 15;58(4):942-8.

10. Moran CA, Albores-Saavedra J, Wenig BM et al. Pigmented extraadrenal paragangliomas. A clinicopathologic and immunohistochemical study of five cases. Cancer. 1997 Jan 15;79(2):398-402. 11. Lack EE, Kim H, Reed K. Pigmented (“black”) extraadrenal paraganglioma. Am J Surg Pathol. 1998 Feb;22(2):265-9. 12. Brimo F, Robinson B, Guo C, et al. Renal epithelioid angiomyolipoma with atypia: a series of 40 cases with emphasis on clinicopathologic prognostic indicators of malignancy. Am J Surg Pathol. 2010 May;34(5):715-22. 13. Nese N, Martignoni G, Fletcher CD et al. Pure epithelioid PEComas (so-called epithelioid angiomyolipoma of the kidney: Clinicopathologic study of 41 cases: detailed assessment of morphology and risk stratification. Am J Surg Pathol. 2011 Feb;35(2):161-76.

• Top 10 Facts You Should Know • About Spirometry Demondes Haynes, MD; George E. Abraham III, MD; Terry M. Dwyer, MD, PhD, and Marcy F. Petrini, PhD

ntroduction

Spirometry – an invaluable diagnostic test when performed and interpreted properly – is indicated for any patient with respiratory signs or symptoms. The test consists of the patient first inspiring as much as possible and then expiring as fast and as completely as he or she possibly can while a spirometer records the airflow. The test is then completed when the patient inspires fully and quickly. This maneuver is plotted as a spirogram with lung volume plotted versus time in Figure 1. The test is also called a flow-volume loop because this spirogram can be plotted as the flow rate versus the lung volume as illustrated in Figure 2. Contemporary spirometers are now electronic and reliable enough to be employed in many physicians’ offices. However, the full cooperation of the patient is needed in order to obtain a good test, and staff must be trained to recognize poor quality since faulty tests can mimic disease and lead to incorrect diagnoses and improper patient care.

1. A decreased FEV1/FVC is the hallmark of airway obstruction.

Airway obstruction is defined as a decrease in the ratio of FEV1 (Forced Expired Volume in 1 second) to FVC (Forced Vital Capacity), parameters measured from a spirogram. FVC is the total volume expired during a complete expiration that begins from a full inspiration, while FEV1 is the volume expired in the first second of that maneuver. A value is now defined as abnormal when the measurement is smaller than that found in 95% of a population of similar individuals who were healthy and had never smoked. In the past, two short cuts had simply been set by convention – “cutoff values” of FEV1/FVC to define airway obstruction and “percent adjustments” for race. Both of these approaches have proven Author Affiliations: Associate Professor of Medicine and Pulmonary and Critical Care Fellowship Program Director and also the Medical Director of Respiratory Therapy (Dr. Haynes). Assistant Professor of Medicine (Dr. Abraham). Professor Emeritus in the Department of Physiology and Biophysics and affiliate faculty member in the Department of Medicine (Dr. Dwyer). Professor Emeritus of Medicine (Dr. Petrini). All in the in the Division of Pulmonary, Critical Care, and Sleep Medicine at The University of Mississippi Medical Center, Jackson, MS. Corresponding Author: Demondes Haynes, MD, FCCP, Division of Pulmonary and Critical Care Medicine, University of Mississippi Medical Center, 2500 North State St., Jackson, MS 39216. Phone: (601) 984-5654 (dhaynes@umc.edu).

inadequate in practice. Instead, reference equations have been derived from populations of healthy individuals, most recently according to race, age, gender and height specific data obtained for the National Health and Nutrition Examination Survey (NHANES) III study.1 The lower limits of normal (LLNs) for spirometric parameters were then derived according to the observed scatter present in these populations.1 As a result, the use of appropriate reference equations has been more relevant to the individual’s race, gender, age and height, and LLN’s have proven to be more useful in a clinical setting than have cutoff values. One important consequence of these population studies is the recognition that normal younger lungs expire better than normal older lungs. Gender plays a role as well. For example, Figure 1. Spirogram. Three spirometric maneuvers are aligned with time (in seconds) and volume (in liters) set to zero. The forced expirations are highly reproducible as they are limited by the physical properties of the lung only; the preceding inspirations to full lung volume vary according to effort.

Figure 2. Normal Flow-Volume Loop. The maximal expiration – followed by a maximal inspiration – was taken from a spirogram and replotted with flow (Y axis) in liters per second, volume (X axis) in liters and expiration as a positive deflection.

Expiratory

Inspiratory

April 2015 JOURNAL MSMA 95

applying the appropriate reference equations, a 20-year-old female with an FEV1/FVC ratio of 76.0% has obstructive lung disease while a 70-year-old male with an FEV1/FVC ratio of 64.0% is normal.2 Thus, short cuts simply do not work in the accurate diagnosis of lung disease.

2. A normal FEV1 is not synonymous with normal lung function, but it does track the clinical course of disease.

While FEV1/FVC is decreased in obstruction by definition, FEV1 is also low in most – but not all – cases.1 Exceptions occur when FEV1 happens to be above the LLN in obstructed patients due to how variable FEV1 is in any given population, even when height, age, gender and race are taken into account. Note that it is the population that has the scatter, not the individual. For the individual, FEV1 measurement is highly reproducible. For example, consider a 40-year-old African American male, 68” tall, with an FEV1 of 4.14 L (predicted to be 3.35 L, with a normal range of 2.57 L to 4.14 L). If this particular patient acutely lost a third of his lung function with his FEV1 falling to 2.76 L, he is still considered normal; yet this change would be of great interest clinically.1 Thus, while FEV1 is not in itself a good diagnostic indicator of obstructive lung disease, it is immensely useful in following lung function over time.3

3. An isolated decreased FEV1 is not synonymous with obstruction.

A decreased FEV1 with a normal FEV1/FVC is an ambiguous finding. While FEV1 is usually decreased during obstruction – and it is used to determine the degree of abnormality – FEV1 is just a volume, and it can be decreased for three other reasons: a) Air Trapping. Emphysematous destruction of lung parenchyma can compromise the emptying of affected airways, trapping air in the lung periphery. This is particularly true for the forced maneuver of spirometry which will cause the patient to be unable to expire completely, artifactually decreasing the FVC, thus resulting in the FEV1/FVC ratio appearing to be normal. If air trapping is suspected, the patient can perform a slow vital capacity (sVC) maneuver – inspiring and expiring slowly – which may reveal more lung volume and thus a lower ratio.3 b) Obesity. Obesity may reduce the FVC, as well as the sVC, resulting in the FEV1/FVC being falsely high. c) Restriction. Frank parenchymal restriction reduces all volumes, including FEV1, but the volumes are proportionally decreased, so FEV1/FVC is preserved. A full set of pulmonary function tests, including lung volumes, diffusing capacity and some measure of resistance can help distinguish among these possibilities.3

4. Normal spirometry does not necessarily preclude a bronchodilator challenge.

While routinely performing a bronchodilator challenge is not indicated,4 it can be useful in a patient with normal spirom-

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etry and symptoms consistent with asthma or COPD. A bronchodilator response is considered positive if FEV1, FVC, or both increase. By convention, the improvement must be 12% and a minimum of 200 mL in either FEV1 or FVC.3 This response may be seen in a symptomatic patient with normal spirometry because of the wide range of normal values in an individual, as discussed in a previous section.

5. The peak flow is useful only in following the course of obstruction.

The Peak Expiratory Flow (PEF) can be used successfully to follow the course of the disease or the response to medication in motivated individuals in whom obstruction has already been diagnosed. Hand-held flow-meters are inexpensive and readily available for home use.5 Since obstructive lung disease is essentially an impairment to flow in the airways, it would seem that a direct measure of this flow – PEF – could be used to detect obstruction. However, the measurement has not been found diagnostically useful. The large variability within a population is one of the reasons, much like the case of FEV1 as discussed in the second point. For example, a 66” tall, 60-year-old Caucasian female has a predicted FEV1/FVC of 78.1% and a predicted PEF of 6.61 L/ sec; she would become abnormal when the FEV1/FVC dropped to 68.2%, a 13% decrease; however, in order for the PEF to be abnormal, it would have to decrease to 4.78 L/sec, a 28% drop, more than double the change in FEV1/FVC.1 The other reason for the unreliability of the peak flow for diagnostic purposes is that the measurement is totally dependent on maximum effort at one point in time. While PEF is usually decreased in obstruction, it can also be decreased in normal lungs with a poor or submaximal effort (see Figure 3) or when patients are unable to produce a good effort, for example in obesity or in neuromuscular disease. Figure 3. An Inadequate Effort. This flow-volume loop has a rounded peak flow, indicating that the patient performed the test with submaximal effort. In addition, the lung volume does not return to the same value at the end of the “full” inspiration (arrow).

Expiratory

t Inspiratory

6. The FEF25-75 is not a reliable diagnostic indicator of airway obstruction.

The earliest evidence of airway obstruction is the development of a slight concavity – or “scooping” – in the expiratory limb of the flow-volume loop (illustrated in Figure 4). Consequently, the Forced Expired Flow between 25% and 75% of the expired volume (FEF25-75) should be an optimal measurement for detecting early disease. Sadly this is not so, both because the finding is not specific and because of technical difficulties in performing the measurement reliably. FEF25-75 assumes a perfect flow-volume loop beginning at full inspiration with a sharp early rise and a complete expiration. However, the sharp early rise will be blunted with a poor effort (Figure 3), and it is simply not possible to always expire fully in a reliable manner, particularly with patients whose sVC is greater than their FVC (as discussed in sections 3 and 7 and in reference 3). Not only is individual variability great, but the normal range for a given population is much larger with FEF25-75 than with FEV1/FVC. Therefore, as for the case of peak flow, it becomes difficult to detect obstruction using this measurement alone. For example, a 72” tall, 50-year-old African American male has a predicted FEV1/FVC of 80.1% and an FEF25-75 of 3.53 L/sec; he would be abnormal if his FEV1/FVC fell to 69.6%, a 13% decrease; but to detect an abnormality, the FEF25-75 would have to decrease to 1.63 L/sec, a 54% decrease.1

haling forcefully. Performing a slow Vital Capacity (sVC) maneuver may unmask the gas trapping by allowing a full expiration. In this case, sVC will be significantly greater than FVC (by 12% or at least 200 mL). However, lack of improvement in sVC does not obviate the need to perform a lung volume determination because a low TLC is the hallmark of restriction and is needed to confirm it.3

8. The shape of the flow-volume curve can detect unusual causes of airway obstruction.

Intra-thoracic (tracheal mass, tracheomalacia), extrathoracic (vocal cord paralysis, supra-glottic mass) and fixed (tracheal stenosis) obstructions, while rather unusual, are best detected by the contour of the flow-volume loop (see Figure 5). These obstructions cause flattening of the expiratory limb (intra-thoracic), inspiratory limb (extra-thoracic) or both (fixed).3 These abnormal patterns stress the importance of performing a complete inspiratory limb of the flow-volume loop so that the possibilities can be distinguished. Figure 5. Flattened Patterns of Fixed Airway Obstruction. The expiratory rate reaches an upper limit when a variable intra-thoracic obstruction is present. Conversely, inspiration is limited with a variable extrathoracic obstruction while a fixed obstruction limits both inspiration and expiration.

Expiratory

Figure 4. Scooping. In patients with airway obstruction, expiration appears more concave than normal in the flow-volume loop, showing a characteristic scooping during the latter part of expiration.

Inspiratory

t 9. Appropriate reference equations are essential for correct interpretation.

Inspiratory

7. A low FVC occurs in restriction and gas trapping.

In parenchymal restriction, all lung volumes are decreased proportionally. Thus, Forced Expired Volume (FVC) is also usually decreased and, in fact, can be used to follow the course of the disease, once diagnosed.3 A second reason for a reduced FVC in obstructed patients is gas trapped in the lung preventing a full expiration when ex-

When evaluating a patient, it is imperative that the interpretation be based on predicted values that match the anthropomorphic attributes of the individual and that lower limits of normal are employed to define health and disease.3 The equations from the NHANES III study1 have become the standard of care for spirometry interpretation since they became available in 1998; they are part of the library of all standard spirometers and thus are easily implemented. They have been derived using height and age; there are separate equations for males and females, for Caucasians, African Americans and Mexican Americans, for a total of six equations for each variable. These equations also meet the recommendations of the American Thoracic Society for quality (see #10 below).6 For other races, appropriate equations have been published more recently.

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Using the incorrect equations can lead to misinterpretation of results; for example, a 66” (5’ 6”) tall, 65-year-old African-American male with an FEV1/FVC of 66.0% is abnormal because the lower limit of normal for FEV1 is 66.9%. However, he would be inappropriately considered normal if the reference equation for Caucasians were to be used instead, where the lower limit of normal is 65.0%.1 While easy to remember, cut off criteria fail to reliably diagnose lung disease; for instance, an error would be made in a Caucasian patient with the same results and anthropomorphic measurements if instead of using the lower limit of normal, a cut-off of 70% were to be used.2,7

10. Good quality makes valid interpretation possible.

The American Thoracic Society has established quality recommendations for pulmonary function testing with regards to individual trials, for the test as a whole, and for the appearance of the graphics from the best test. An acceptable trial should have no hesitation at the start of expiration, and the exhalation should last at least 6 seconds or reach a plateau. At least 3 trials should be performed, and testing should continue until the 2nd best FVC and the 2nd best FEV1 are repeatable within 150 mL of the best of each. The testing can stop if after 8 trials the test is not repeatable, but that seldom occurs. The contour of the flow-volume loop should be free of any “blips” caused by coughing (as shown in Figure 6), hesitation, or reinspiration that render the test unusable. These criteria are not unreasonably stringent since it is not unusual for patients to repeatedly give results that agree to within much less than 150 mL.6 When a test is not repeatable because of pain, poor cognition or unwillingness to perform, the values obtained may not be truly representative of the patient’s function. Conveniently, modern spirometers have built-in programs that provide flags for errors during the test and generate reports that detail the quality of each trial. However, the individual administering the test must be knowledgeable of these indicators and act appropriately. As part of the interpretation, the numerical components and the graphical information must be examined for quality. If patient’s performance impairs quality, this should be documented in the notes by the person administering the test. Unrecognized poor quality may result in ordering addiFigure 6. Cough Artifacts. A flow-volume loop is interrupted by characteristic “blips” when the patients coughs during the maneuver.

Expiratory

Inspiratory

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tional, expensive tests. For example, a 42-year-old, 69” tall, normal Caucasian male’s true FVC is 4.20 L, his FEV1 is 3.40 L and his FEV1/FVC is 81.0%; however, if he doesn’t expire as long as required by the guidelines, he may exhale only 3.80 L for the FVC, which is abnormal and results in a high ratio, suggestive of restriction.1,3 If the interpreter is unaware of the poor quality of the test, he would needlessly order lung volumes to confirm a non-existing restriction. Poor quality can also lead to missing a diagnosis. For example, a 50-year old, 62” tall African American woman has a normal FVC of 2.51 L and FEV1 of 1.59 L, with a low FEV1/ FVC of 63.3%, consistent with obstruction; however, if she doesn’t exhale as long as required and her FVC is measured as 2.20 L, a normal FEV1/FVC of 72.3% would result, hiding the obstruction.1,3 While most of the time poor quality results in underestimated values, this is not always the case. Coughing, shown in Figure 6, could falsely increase the FVC and may increase the FEV1, depending on when it occurs, which could mask disease. Only good quality spirometric tests can result in the correct interpretation of obstruction, suspected restriction, bronchodilator response and follow-up of function.

References 1.

Hankinson JL, Odencrantz JR, Fedan KB. Spirometric Reference Values from a Sample of the General U.S. Population. Am J Respir Crit Care Med 1999;159:179-187.

2. Culver B.H. Interpretation of Spirometry: We Can Do Better than the GOLD Standard. Respir Care 2006;51:719-721. 3.

Pellegrino R, Viegi G, Brusasco, V et al. Interpretative strategies for lung function tests. Eur Respir J 2005;26:948-968.

4. Dwyer TM, Abraham GE III. Spirometry: How Should We Order This Bedrock of Diagnosis and Management for Asthma and COPD? Respir Care 2012;57:1692-1695. 5.

Reddel HK, Taylor DR, Bateman ED. An Official American Thoracic Society / European Respiratory Society Statement: Asthma Control and Exacerbations. Am J Respir Crit Care Med 2009;180:59-99.

6. Miller MR, Hankinson J, Brusasco V. Standardization of spirometry. Eur Respir J 2005;26:319-338. 7.

Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease: NHLBI / WHO Workshop. U.S. Department of Health and Human Services, Public Health Service, National Institute of Health, NIH Publication No.2701A, March 2001.

• Clinical Problem-Solving Case • All’s Well That Ends Swell William T. Brazier, MD

57-year-old female presented to the Emergency Department (ED) with a complaint of acute-onset right leg swelling for several weeks. She also described pain in her right lower extremity (RLE) that was constant and negatively affecting her activities of daily living as well as her ability to sleep. The patient stated that she had noticed the swelling several days after she fell on her right knee approximately 1 month prior to presentation. Since that incident, she had fallen on her right knee 2-3 more times. Given her RLE swelling and pain, in addition to her history of several falls, my first concern is injury of the RLE. A vascular insult, such as a deep vein thrombosis (DVT) that may have occurred secondary to a fall is also in my differential. At this point, I also cannot rule out a possible infectious process as a cause for her symptoms. I will order imaging of the RLE, basic blood studies and acquire more history. She was evaluated in the ED approximately 1 week prior to the current presentation with similar symptoms. At that time it was noted that she had swelling from her right thigh to her right foot with a “bluish mass” noted over her right trochanter. Right hip and knee films, in addition to a RLE venous duplex scan, were unremarkable, save for an incidental finding of a right popliteal cyst. Other than elevated segmented neutrophil and monocyte counts of 77.7 x 103/mm3and 10.3 x 103/mm3, respectively, her lab results were unremarkable. She was discharged home in stable condition, given prescription tramadol (Ultram) for pain control and directions for supportive care and instructed to follow up in clinic within 2 weeks. Given the negative imaging from the previous visit 1 week ago and no history of falls since that visit, a fracture or DVT is less likely. I would not re-image the RLE at this point but would get a complete blood count, basic electrolytes, D-dimer and repeat a venous duplex scan to investigate for a DVT. I would like to get her past medical history and perform a thorough physical exam while awaiting the results of these tests. Author Affiliations: Dr. Brazier was a resident in the Department of Family Medicine, University of Mississippi Medical Center, 2500 North State St., Jackson, MS 39216. Phone: (601) 984-5250. Correspondence: William T. Brazier, MD, Family Practice Physician, 878 Lakeland Dr, Jackson, MS 39216. Phone:(601) 984-6800.

Her past medical history included chronic obstructive pulmonary disease, hypertension, dyslipidemia, chronic hip and knee pain, sciatica, acute lymphoma, anxiety and sinusitis. Vital signs on current presentation were within normal limits. Her physical exam findings were unremarkable except for the results of her RLE examination. Of note, her RLE was erythematous, warm to touch and severely swollen, with 3+ pitting edema present. The thigh, knee and leg were extremely tender to palpation. Decreased range of motion was noted at the knee, with the patient unable to perform flexion past 10 degrees. Her complete blood count and complete metabolic profile were within normal limits. Her D-dimer was 2.61 ug/mL. A venous duplex scan of the RLE showed no evidence of acute deep vein thrombosis. At this point we have an extremely tender, warm and red RLE with decreased range of motion, a positive D-dimer and a negative venous duplex scan. Certainly, the fact that she suffers from chronic hip and knee pain clouds the acute picture but would not help to explain the continued swelling. Additionally, in the process of obtaining the history, it was discerned that she had not fallen since her previous ED visit, thus effectively ruling out fracture as imaging performed during that visit was negative. Although the patient has a normal white blood count and no fever, the presentation of the RLE is concerning for possible infectious cause. It should be noted that due to its low specificity, an elevated D-dimer would not effectively confirm a DVT but can be a non-specific indicator of inflammation, infection or thrombosis.1 I would proceed with intravenous (IV) antibiotics, control her pain and admit her to the hospital for observation, in addition to pursuing other causes of her symptoms if she does not improve with the initial therapy. The patient was admitted in stable condition to the hospital service for IV antibiotic therapy (clindamycin 900 mg IV q6h) in addition to pain control with morphine 2 mg IV q4h and hydrocodone/acetaminophen (Lortab) 10/500 mg PO q4h as needed and DVT prophylaxis. On day 2 of admission, her erythema and pain had improved, although her leg showed persistent swelling with 3+ pitting edema present. Her vital signs continued to be within normal limits, and she reported that she was

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“feeling better.” Her complete blood count that morning showed a normal white blood cell count, a low lymphocyte count of 16.5 x 103/mm3and segmented neutrophils within normal limits. She did have monocytes of 14.1 x 103/mm3. Her basic metabolic profile was completely unremarkable. Physical therapy was ordered for assistance with ambulation, and IV antibiotics and pain control were continued. Initial blood cultures showed no growth. At this stage, cellulitis is a strong contender as the erythema appears to be improving with the current therapy, and her vital signs remain unremarkable. She does not exhibit a left-shift, her basic metabolic profile is normal and the initial blood culture reports are negative. She states she feels better, but how much of that is due to improving symptoms or pain control is not clear. That said, the swelling in the RLE has not improved, although it may be too early to appreciate any significant change on exam. I would continue with her antibiotics, physical therapy, DVT prophylaxis, pain control and continue to follow closely. On day 3 of admission, the patient reported that her RLE pain was increasing and that she was also having nausea and trouble sleeping. On physical exam, there was no appreciable change in the swelling, but the erythema continued to decrease. She was ambulating on her own to the bathroom. Vital signs were normal and blood cultures demonstrated no growth. She was prescribed an antiemetic and was switched to hydromorphone (Dilaudid) to attempt better pain control. Although the erythema continues to decrease, it is concerning that there has been no appreciable change in the swelling of the RLE, but again, it could be premature to expect an appreciable change. This is confounded by the fact that she is ambulating well, her vital signs remain unremarkable and blood cultures are negative. On the other hand, blood cultures have been shown to be low yield in the diagnosis of cellulitis, with positive results in less than 5% of cases.2 Her insomnia is a chronic condition, and that, in addition to the nausea, could very well be secondary to her pain. At this point, I would continue with her current management, as she seems to be improving overall. On day 4 of admission, the patient continued to complain of pain and insomnia. Her vital signs remained unremarkable. Physical exam of the RLE was unchanged from before, but the float team covering for the weekend had concerns about a “large” bruise on her right upper thigh that had not been documented previously. There have been 4 days of hospitalization with normal lab results and vital signs, decrease in RLE erythema, but no appreciable change in her RLE swelling, and pain that is waxing and waning. Given the persisting symptoms and the presence of a large unchanging area of ecchymosis on the RLE, it raises concerns for other causes that may be contributing to the RLE swelling.3 I would order a computed tomography

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(CT) with contrast of the RLE to further elucidate the source of the hematoma and continue with her current therapy. The CT RLE demonstrated diffuse cellulitis with edema throughout the subcutaneous tissue, in addition to a large mass in the right pelvis that extended from the aortic bifurcation into the right pelvis. There was also a large soft-tissue mass found superior to the right knee posteriorly. This information provides a clearer picture of a possible cause of the swelling and pain in her RLE and why her erythema was improving but the swelling continued. Interestingly, the RLE venous duplex scan performed at the ED visit prior to this admission noted a “right popliteal cyst” measuring 3.6 x 1.8 cm in diameter. Given the patient’s history of lymphoma, I would biopsy the mass and consult oncology to investigate for recurrence of lymphoma with possible metastases.4 In addition, I would order a CT chest/abdomen/pelvis to investigate for any other suspicious masses. I would continue with her current therapy while awaiting pathology results and oncology recommendations. A follow up CT of the chest/abdomen/pelvis showed prominent right iliac adenopathy but no other concerning findings. Her IV antibiotics were continued, and piperacillin/tazobactam (Zosyn) was added per oncology recommendations. Oncology and interventional radiology were consulted for biopsy and management recommendations. A lymphedema nurse was consulted to assist with control of RLE edema. Results of an ultrasound guided biopsy of the right knee mass were B-cell non-Hodgkin lymphoma, favor follicular cell lymphoma, grade 1. It was decided that since she had responded well to previous chemotherapeutic treatment they would utilize chemotherapy as a first-line treatment, and if she failed that treatment, they would next consider bone marrow transplant. She was given her first dose of rituximab (Rituxan) in the hospital and discharged to follow up with oncology for her chemotherapy. The patient had been diagnosed with follicular lymphoma 5 years prior and at that time was treated with chemotherapy followed by radiation and maintenance rituximab. The patient is now 2 to 3 years out from her initial treatment. It was concluded that this was a relapse of her disease. The majority of relapses occur during the first 2 years after completion of treatment.5 As her lymphoma responded well to rituximab previously, she was continued on that regimen as an outpatient. It has been shown that rituximab use in the treatment of non-Hodgkin’s lymphoma results in an approximately 10 to 15 percent overall increase in survival beginning at 1 year from initiation of therapy with little increase in toxicity.6,7 Key Words: Cellulitis, Lymphedema, Deep Vein Thrombosis, Follicular Cell Lymphoma, B Cell Lymphoma, non-Hodgkin’s Lymphoma, Popliteal Cyst, Erythema

References: 1.

Torbicki A, Perrier A, Konstantinides S, et al. Guidelines on the diagnosis and management of acute pulmonary embolism. The Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC). Eur Heart J. 2008; 29(18):2276–315.

Perl B, Gottehrer NP, Raveh D, Schlesinger Y, Rudensky B, Yinnon AM. Cost-effectiveness of blood cultures for adult patients with cellulitis. Clin Infect Dis. 1999; 29(6):1483-488.

Stevens DL, Bisno AL, Chambers HF, et al. Practice guidelines for the diagnosis and management of skin and soft-tissue infections. Clin Infect Dis. 2005; 41(10):1373-406.

Pappa VI, Hussain HK, Reznek RH, Whelan J, Norton AJ, Wilson AM, Love S, Lister TA, Rohatiner AZ. Role of image-guided coreneedle biopsy in the management of patients with lymphoma. J Clin Oncol. 1996; 14(9):2427-30.

Larouche JF, Berger F, Chassagne-Clément C, et al. Lymphoma recurrence 5 years or later following diffuse large B-cell lymphoma: clinical characteristics and outcome. J Clin Oncol. 2010; 28(12):2094-100.

Sehn LH, Donaldson J, Chhanabhai M, et al. Introduction of combined CHOP plus rituximab therapy dramatically improved outcome of diffuse large B-cell lymphoma in British Columbia. J Clin Oncol. 2005; 23(22):5027-33.

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Pettengell R, Linch D, Haemato-Oncology Task Force of the British Committee for Standards in Haematology. Position paper on the therapeutic use of rituximab in CD20-positive diffuse large B-cell non-Hodgkin’s lymphoma. Br J Haematol. 2003; 121(1):4448.

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• MSMA • As the U.S. becomes more multicultural, health literacy is becoming an increasingly important issue for physicians. Over 35% of adults have serious limitations in health literacy skills. For patients, key factors affecting health literacy are: • Education • Literacy • Language

For physicians, the issue is compounded by: • Inability to speak the patient’s language or understand cultural mores • A growing expectation of patients to practice preventive health; undergo regular screenings; self-treat some chronic conditions and know when a medical or ER visit is necessary.

Health literacy is the capacity to: • Process and understand basic health information and services. • Make appropriate health care decisions and act on information provided by a healthcare provider. • Access and navigate the health care system.

Patients come to you with various levels of education or literacy and they may speak a different language. These issues may make it difficult and in some cases, impossible to understand health information. As researchers realized this was an issue, they began to talk about health literacy. Become better informed, and take advantage of these informative educational tool kits containing valuable resources to help physicians and clinicians better understand the problem of health literacy. • The AMA Foundation’s “Health Literacy and Patient Safety: Help Patients Understand” Educational Kit • Agency for Healthcare Research and Quality (AHRQ) Health Literacy Universal Precautions Toolkit • U. S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion “Quick Guide to Health Literacy”

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• Editorial •

Public Health in Mississippi: Advances in the Last Two Decades Thomas Dobbs, MD, MPH; Lucius Lampton, MD; Ellen Jones, PhD, CHES; Lydia West, MPH, RD

he American Public Health Association organizes the annual National Public Health Week (NPHW) during the first full week of every April. This year NPHW was April 6 -12. The week acknowledges the contributions made by public health organizations in their communities, while simultaneously highlighting issues that must be tackled to improve further our nation’s health. The overarching theme for this year’s week was a focus on making the United States the healthiest nation by 2030. Within NPHW’s general theme, every day corresponds with a smaller theme that can help achieve the overarching one. The five themes this year were: Monday: Raising the Grade; Tuesday: Starting from Zip; Wednesday: Building Momentum; Thursday: Building Broader Connections; and Friday: Building on 20 Years of Success. By addressing a broad range of topics, NPHW takes a holistic approach to improving the health of the nation. Since the advent of modern approaches to public health in the 20th century, life expectancy has increased 62%, from 47.3 years in 1900 to 76.8 years in 2000.1 While national public health services are known for their roles in increasing the general lifespan and vaccinating against diseases such as polio, there have been many recent advances that can be directly correlated to public health intervention. Issues such as tobacco control and maternal and infant health may be obvious issues of concern for public health services. There are lesser known issues that public health has made great strides in improving. For example, from 2000-2010 was able to increase the number of states that had comprehensive lead poisoning prevention laws from 5 to 23. After the events of September 11, 2001, national public health groups also worked to make sure the country was more prepared if another attack were to occur. The first half of the decade focused on increasing the ability of the public health systems to respond to disaster, while the second half focused on improving laboratories, epidemiology, surveillance, and response capabilities of the public health system.2 These changes resulted in rapid detection and characterization during the 2009 H1N1 outbreak. NPHW is meant to improve overall health, but it is also a time allotted to acknowledge local accomplishments. There is still much room for improvement in Mississippi public health, but achievements obtained in the last fifteen years show that the Magnolia State is committed to improving the overall health of its citizens. Mississippi’s commitment to health was no more apparent than when it established the Mississippi State Public Health Institute (MSPHI) in June of 2011. MSPHI is committed to partnerships aimed at program innovation, health resources, education, applied research, and policy development. The Institute serves as a partner and convener to promote health, improve outcomes, and encourage innovations in health systems. Essential to the daily wellbeing of every Mississippian, public health programs ensure safe food, clean drinking water, disease control, disaster response, safe medical facilities, access to critical health services, and work to reduce unnecessary deaths through maternal child health and chronic disease prevention programs. Though Mississippi leads the nation in numerous poor health outcomes such as infant mortality, obesity and cardiovascular disease, certain trends give us reason for hope. Mississippi leads the nation in school age immunizations, with 99.7% of all children entering kindergarten fully vaccinated. Tobacco prevention efforts have led to steady declines in adult and youth smoking, and 93 communities statewide have adopted smoke free ordinances that protect all from the harms of second hand smoking. Infectious disease rates, such as tuberculosis, are on the decline, with Mississippi infection rates below the national average since 2011. Public health, though lead by the state department of health, is a collaborative endeavor that depends on healthcare providers, schools, local governments, and private organizations, to name a few, and we all share in its successes and failures. In response to the 2010 Deepwater Horizon oil spill, MSDH established a coastal surveillance system to monitor for adverse health effects and worked with the Mississippi Poison Control Center to respond to reported events. Mississippi has also shown a willingness to work in conjunction with other public health centers beyond the state’s borders. After the 2010 Deepwater Horizon oil spill, both the MSPHI and the Mississippi State Department of Health District IX worked with the public health institutes of Louisiana, Alabama, and Florida in order to strengthen primary and behavioral healthcare services in oil spill impacted communities. That same year MSPHI, along with the Bristol-Myers Squibb Foundation, founded the Together on Diabetes campaign to improve health outcomes for Mississippians suffering from Type 2 Diabetes. In contrast to successes in reducing infectious disease mortality, chronic diseases are accounting for an increasing proportion of the disease burden in Mississippi. In 2011, heart disease, cancer, injuries, COPD, and stroke accounted for a remarkable

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63.4% of total deaths, a reality that necessitates enhanced focus in a state with serious infrastructure and workforce challenges. There has been some early progress. Mississippi has advanced painstaking steps not only to modernize its medical records, but also to link these records with medical providers through electronic delivery systems. Mississippi has improved its data collection, especially when it comes to one of its most dangerous public health problems: cardiovascular health. The Mississippi State Department of Health recently completed a Cardiovascular Health Examination Survey for the Delta, but after witnessing the success that was the Arkansas Cardiovascular Health Examination survey, Mississippi plans on initiating its own comprehensive statewide Cardiovascular Health Examination Survey in the coming years. This survey will hopefully result in collaborative, federally-funded, statewide programs such as hypertension control and population-wide blood pressure surveillance systems. Legislatively supported workforce initiatives, such as the Mississippi Rural Physicians Scholarship Program and the Office of Mississippi Physician Workforce, are early successes in addressing the healthcare deficits faced by a population with the lowest physician to patient ratio in the nation. As in any endeavor, achieving good health requires adequate and responsible investment. A 2011 study in Health Affairs found that for every 10% increase in local public health spending deaths from cardiovascular disease declined 3.2%, from diabetes declined 1.4%, from cancer declined 1.1%, and infant mortality declined 6.9%.3 Even though Mississippi ranks highest in numerous adverse health outcomes, per capita state funding of public health ranks 48th in the country. Mississippi invests $11.09 of state money per capita in state department of public health, compared to $43.01 in Tennessee and $63.44 in Alabama. This extremely low level of funding severely limits the scope of activities that public health partners can pursue to improve the state’s health. While MSPHI and MSDH are prominent assets to public health in Mississippi, they are far from the only providers of relief and leadership. One organization that does not get as much attention is the Mississippi State Medical Association (MSMA). Through its advocacy efforts at a state and national level, as well as its monthly journal, MSMA plays a significant role in advancing the public health of the state. Journal MSMA is the state’s preeminent medical journal, and in that capacity has provided much of the information that has affected public health policy in the state. Besides critical scientific publications, the Journal has provided a lively forum to discuss public health issues impacting the state. Other medical subspecialty organizations also play a key role in the protection and advancement of public health in the state, most especially the Mississippi Academy of Family Physicians and the Mississippi Chapter of the American Academy of Pediatrics. Of critical note, Mississippi recently became the first state in our country to establish three statewide systems of medical care: a trauma network (long established), a STEMI network for acute MIs, and a stroke network. Along with the Department of Health, the Mississippi Healthcare Alliance, constituted of many of the state’s medical leaders in cardiovascular health, has worked diligently to establish the latter two initiatives to reduce morbidity, mortality, and cost associated with cardiovascular disease in the state. In a state with limited medical and specialty resources, such coordination and facilitation of appropriate medical care are offering improved outcome for the state’s citizens in medical emergencies. Although Mississippi has high rates of many health related issues, we have many strong resources and have dramatic advances in the last century. Supporting essential public health services will help to move the Magnolia State further along, and utilizing resources and partnerships will create more momentum and sustainability of our critical public health system.

References 1. Sarpy, SA, et al. The south central center for public health preparedness training system model: a comprehensive approach. Public Health Rep. 2005;120 Suppl :52-58. 2. Arrieta, MI, et al. Providing continuity of care for chronic diseases in the aftermath of Katrina: from field experience to policy recommendations. Disaster Med Public Health Prep. 2009;3(3):174182. 3. Mays, GP, Smith, SA. Evidence links increases in public health spending to declines in preventable deaths. Health Affairs 2011;30(8):1585-1593. (http://content.healthaffairs.org/ content/30/8/1585.abstract#cited-by)

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• President’s Page • There is “Power in Numbers”

he adage that there’s “power in numbers” proved true last month. After hearing from MSMA members who called, texted, emailed and sent faxes asking them to vote “yes” to H.R. 2, Mississippi Senators Thad Cochran and Roger Wicker voted with the majority of the Senate to pass the historic bill which repealed the Medicare sustainable growth rate (SGR) formula.

Claude D. Brunson, MD 2014-15 MSMA President

Their votes to “Fix Medicare” followed earlier ones cast by Congressmen Bennie Thompson, Steven Palazzo, and Gregg Harper who had received similar contacts from MSMA members.

Mississippi’s Congressional delegation is to be commended for listening to physicians and helping pass this important legislation. The Medicare Access and CHIP Reauthorization Act of 2015, or “MACRA” passed by the House of Representatives on March 26 and by the Senate on April 14 permanently repeals the Sustainable Growth Rate (SGR) formula for Medicare physician payment. Passage of this legislation ends a series of 17 temporary measures since 1997 needed to prevent payment cuts resulting from the flawed SGR formula. The legislation ends a 21 percent cut to Medicare physician payments. In its place are four annual 0.5 -percent updates (or physician payment increases) in 2015, 2016, 2017, and 2018. Additionally, physician payment incentives under the meaningful use program within the HITECH (Health Information Technology for Economic and Clinical Health) Act and those under the Physician Quality Reporting System (PQRS) will end. Instead, those program incentives will be replaced with a Merit-based Incentive Payment Program, or MIPS. Under MIPS, physicians can opt for an alternative program with slightly higher payments in return for participation in certain Alternative Payment Models, or APMs. H.R. 2 will also impact physicians when the new law: •

Removes the payment cut of 21% and provides for annual increases at 0.5%. The first increase will take effect July 1, 2015, and then annually on January 1st beginning in 2016.

•

Addresses the necessity of reporting common items in multiple formats. Penalties associated with PQRS, VBM (value based modifier), and meaningful use in 2018 will be eliminated. They will be incorporated into a new MeritBased Incentive Payment System (MIPS).

•

Provides for financial incentives for providers who move to alternative payment models based on cost savings and/or quality measures.

•

Reverses the CMS decision to eliminate the use of 10 and 90 day global surgical codes.

•

Funds the CHIPS program for 2 years.

Robert Wah, MD, president of American Medical Association (AMA), broke the issue down in an interesting way in his personal blog. He outlined five ways the U.S. health care system will look different in the future: 1. Medicare and TRICARE patients will no longer face constant uncertainty over whether they might lose their access to care. The perennial threat of devastating payment cuts under SGR made it difficult for many physicians to know whether they would be able to keep their doors open for treating these patients.

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2. Physiciansâ&#x20AC;&#x2122; practices will be more sustainable. Under the new law, many of the competing quality-reporting programs in Medicare will be consolidated and better aligned. The risk of penalties also has been substantially reduced, and physicians now have potential for earning significant bonuses. 3. The path will be cleared for new models of care. The new law not only removes the financial instability caused by the SGR formula but also provides monetary and technical support for those who choose to adopt new models of care suited to the 21st-century needs of physicians and their patients. 4. Health outcomes will be improved in the clinic setting and the community. Chronic diseases have become the primary sources of poor health and death today. Treating these conditions requires new approaches, and the new law permanently requires Medicare to pay for care management of these patients. 5. Physicians in training will be taught how to practice in the new health care environment. Even as the health care system undergoes dramatic change, an AMA consortium of medical schools is exploring how to prepare the next generation of physicians for practicing in the new environment. Students will learn how to succeed in new models of care, provide high-quality but cost-effective care, and team up with other health care professionals and the community so their patients can lead the healthiest lives possible. Just as we have joined forces and spoken out over the years on key issues affecting our practices and threatening patient care, letâ&#x20AC;&#x2122;s continue to work together in the future. As I stated above, there is power in numbers. Together, we can play a vital role in this new era of health care and shape it into one in which our profession and our patients thrive.

PHYSICIANS NEEDED Internists, Cardiologists, Ophthalmologists, Pediatricians, Orthopedists, Neurologists, Psychiatrists, etc. interested in performing consultative evaluations according to Social Security guidelines.

OR Physicians to review Social Security disability claims at the

Mississippi Department of Rehabilitation Services (MDRS) in Madison MS.

DISABILITY DETERMINATION SERVICES 1-800-962-2230 April 2015 JOURNAL MSMA 107

• MSMA • Speakers Outline Requirements for Resolutions and Encourage Member Input for MSMA House of Delegates

SPEAKERS’ LETTER

April 20, 2015

TO SPECIALTY SOCIETY OFFICERS AND LOCAL MEDICAL OFFICERS Geri Weiland, MD, Speaker Jeffrey SOCIETY Morris, MD, Vice Speaker

he MSMA Annual Session is scheduled for August 14-15, 2015, at the Jackson Hilton Hotel on County Line Road in Jackson. In anticipation of spring/summer meetings of local medical societies and specialty medical societies, we MSMA House of Delegates Subject: MSMA Annual Session Resolutions and Delegates are writing to alert you of requirements and deadlines August 14-15, 2015 at the Jackson Hilton for the upcoming MSMA Annual Business Session. From: Geri Weiland, MD, Speaker of the House of Delegates

Jeffrey Morris, MD, Vice Speaker List of Localand Medical Society Delegates

Officers of all local medical societies should submit a list of annual session delegates by Friday, July 31, 2015. Fax the list to 601-853-6746 or email BWells@MSMAonline.com.

Online Forum and Printed of Reports Resolutions The MSMA Annual SessionPackets is scheduled for&August 14-15, 2015 at the Jackson Hilton Hotel To facilitate electronic submission of resolutions and online comments, resolutions will be posted online for review onAugust County Line Road in Jackson. In anticipation of spring/summer meetings of local medical 1-10, 2015. Packets of printed reports and resolutions will be distributed to delegates at the opening session of the societies and specialty medical societies, we review are writing of requirements House of Delegates at 1 pm on Friday, August 14, 2015. Please resolutionsto andalert reportsyou at MSMAonline.com prior to and the meeting. deadlines for the upcoming MSMA Annual Business Session. SPECIALTY SOCIETIES

2015 DELEGATE ALLOCATION

Anesthesiology Cardiology Dermatology Emergency Medicine EENT / Otolaryngologists Family Medicine Gastroenterology Internal Medicine Neurosurgery OB / GYN Oncology Ophthalmology Orthopaedic Surgery Pathology Pediatrics Psychiatry Public Health / Preventive Medicine Radiology Surgery Urology

1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

LOCAL MEDICAL SOCIETIES

Amite Wilkinson Medical Society Central Medical Society Clarksdale & Six Counties Medical Society Coast Counties Medical Society Desoto Medical Society Delta Medical Society East Mississippi Medical Society Homochitto Valley Medical Society North Central Medical Society Northeast Medical Society North Mississippi Medical Society Prairie Medical Society South Central Medical Society South Mississippi Medical Society Singing River Medical Society West Mississippi Medical Society RESIDENTS & STUDENTS Students UMMC Students WCC Residents

Only delegates present at the House of Delegates meeting may vote on resolutions.

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LIST OF LOCAL MEDICAL SOCIETY DELEGATES

TOTAL

1 145 3 24 4 14 22 5 4 33 11 15 12 43 15 5 16 5 20

407

MSMA Resolutions Guide

• When are resolutions due? The MSMA office is now accepting resolutions to be presented to the House of Delegates at the 2015 Annual Session August 14-15. Resolutions received after 1 pm on Friday, July 31, 2015, are considered late resolutions and must be presented at the opening session of the House of Delegates at 1 pm Friday, August 14, 2015. The Committee on Rules and Order will determine whether a late resolution is of an emergency nature and whether it will be accepted for consideration. •

Submitting a Resolution. Resolutions emailed to MSMA will be formatted and fiscal notes and/or policy references may be added. Resolutions will be posted at MSMAonline.com for comments from members via online forum for ten days, August 1-10, 2015. Online comments will only be accepted through August 10; however, any member may testify in person August 14th. To make your views known after August 10 you should plan to testify in person beginning at 1 pm on August 14th. Please limit in-person testimony to topics or points you have not already raised via online comments.

• Online Forum. Resolutions received by July 28 will be posted at MSMAonline.com August 1-10 so members may review the resolutions and submit comments to be considered by the appropriate reference committee. Any member of the Association may submit online comments and/or testify in person at reference committee hearings. Please note that resolutions received after July 28 will be posted online only after review for policy and/or financial notes which could delay posting and/or reduce the amount of time the resolution is posted for comments. •

Who can submit a resolution? Any MSMA member in good standing may submit a resolution. Any local

medical society may submit a resolution that has been approved by a majority of its members in accordance with the local society’s bylaws.

•

What information is required in a resolution? Each resolution must include a SUBJECT title, the AUTHOR (an individual physician or local medical society), at least one WHEREAS statement and a RESOLVED statement. Note: The House of Delegates only acts on the RESOLVED portion of a resolution. Each RESOLVED statement should stand on its own. The RESOLVED statement should (1) Set new MSMA Policy; (2) Modify, re-affirm or rescind current MSMA Policy; or, (3) Direct MSMA to take action. A fiscal note may be added to a resolution and related MSMA policy may be cited. A Resolution Drafting Guide Form designed to streamline the process and insure that all information is provided is available from MSMA staff.

•

Can a resolution propose changes to the MSMA Bylaws? Yes. A resolution that proposes to change the MSMA Bylaws is required to be presented to the House of Delegates one day before the day on which it is voted. So, a resolution that includes a bylaws amendment which is electronically submitted before July 31 or presented at the opening session of the House of Delegates and accepted for consideration may be deliberated the following day.

• Can a resolution propose changes to the MSMA Constitution? Yes. However, a resolution that proposes to amend the MSMA Constitution must be properly noticed. Constitutional amendments must be submitted to the membership at least 90 days before the meeting. To have a constitutional amendment considered at the 2014 meeting it must be distributed to the membership by May 14, 2015. Thus, a proposed amendment to the constitution must be received by MSMA by May 4, 2015, to ensure that it can be distributed in a timely manner as required. A proposed constitutional amendment which is not properly noticed may be laid on the table for consideration in 2016. • We can help! For assistance in drafting a resolution contact MSMA Executive Director Charmain Kanosky at CKanosky@MSMAonline.com or 601-853-6733 ext 306. April 2015 JOURNAL MSMA 109

• MSMA •

MISSISSCommittee ASMSMA IPPI STATSeeks E EDICAL in SOCIAOffices TION Nominating Candidates ForMVacancies

COMMITTEE SEEKS CANDIDATES FOR VACANCIES IN MSMA OFFICES

elegates attending the 147th MSMA Annual Session August 14-15, 2015, in Jackson will cast ballots to fill

Delegates attending the 147th MSMA Annual Session August 14-15, 2015 in Jackson will cast ballots to fill new new terms of office for a number of association posts. The Nominating Committee is seeking input from the terms of office for a number of association posts. The Nominating Committee is seeking input from the membership membership as the committee prepares a slate of nominees. The list of nominees developed by the Nominating as the committee prepares a slate of nominees. The list of nominees developed by the Nominating Committee will Committee will be published to the entire membership 30 days before the meeting. Eligibility: All nominees must be active be published the entire days before meeting. Eligibility: nominees must betoactive members of the to association. Nomembership physician may 30 be put forth on the the ballot unless that physician hasAll expressed a willingness members of the association. No physician may be put forth on the ballot unless that physician has a serve if elected. Nominations for vacancies: The chart below lists the vacancies that will be filled by election in 2015.expressed The willingness to serve if elected. Nominations for Vacancies: The chart below lists the vacancies that will be filled names of incumbents, the length of each term of office, and the incumbent’s eligibility to be re-elected are indicated. Nominating by election in 2015. The names of incumbents, each termPast of office andofthe eligibility to be Committee: The Nominating Committee is composedthe of length the nineof most recent Presidents theincumbent’s association. The Immediate re-elected are indicated. Nominating Committee: The Nominating Committee is composed of the nine most recent Past President is the chair. Past Presidents of the association. The Immediate Past President is the chair.

MSMA VACANCIES 2015 OFFICERS & TRUSTEES

INCUMBENT

COUNCILS

President-Elect

DANIEL P. EDNEY

Budget & Finance at large

TIMOTHY BEACHAM

Trustee District 1

CARLTON GORTON, JR.

Budget & Finance at large

SCOTT CARLTON

Trustee District 3

STEVEN BRANDON

Constitution & Bylaws at large ERIC LINDSTROM

Trustee, Resident/Fellow

JANE BEEBE JONES

Legislation District 4

MICHAEL KANOSKY

Trustee, Medical Student

JORDAN INGRAM

Legislation District 5

JOHN HALBROOK

JOURNAL MSMA

INCUMBENT

Legislation Resident

JULIA THOMPSON

Associate Editor

RICHARD deSHAZO

Legislation Student

LOGAN RUSH

Medical Education District 6

THOMAS DOBBS

Medical Education District 7

CARLOS LaTORRE

Medical Education District 8

JOHN PAPPAS

Medical Service District 6

ROBERT BRAHAN

Medical Service District 7

GERI LEE WEILAND

Medical Service District 8

JOSEPH MITCHELL

Medical Service Resident

S. TAL HENDRIX

Medical Service Student

EMILY BRANDON

Public Information District 7

JOE AUSTIN

Public Information District 8

GREG PATINO

Terms of Office: President-elect: 1 year 2015-2016 Officers, Trustees & Councils (physicians): 3 years 2015-2018 Trustees & Councils (students & residents): 1 year 2015-2016 Journal Associate Editor: 2 years 2015-2017 Incumbents NOT eligible for re-election are noted as strikethrough. DIST 1: Bolivar Coahoma Humphreys Leflore Quitman Sunflower Tallahatchie Tunica Washington Yazoo. DIST 2: Attala Benton Carroll Choctaw Desoto Grenada Holmes Lafayette Marshall Montgomery Panola Tate Tippah Webster Yalobusha DIST 3: Alcorn Calhoun Chickasaw Clay Itawamba Lee Lowndes Monroe Noxubee Oktibbeha Pontotoc Prentiss Tishomingo Union Winston. DIST 4: Hinds Leake Madison Rankin Scott Simpson. DIST 5: Clarke Kemper Lauderdale Neshoba Newton. DIST 6: Covington Forrest George Greene Jasper Jeff-Davis Jones Lamar Marion Pearl River Perry Smith Stone Wayne. DIST 7: Adams Amite Claiborne Copiah Franklin Jefferson Lawrence Lincoln Issaquena Sharkey Pike Wilkinson Walthall Warren. DIST 8: Hancock Harrison Jackson.

INCUMBENT

EMAIL NOMINATIONS to CKanosky@MSMAonline.com or contact any member of the Nominating Committee: Jim Rish, MD; Steve Demetropoulos, MD; Tom Joiner, MD; Tim Alford, MD; Randy Easterling, MD; Pat Barrett, MD; Dwalia South, MD; Eric Lindstrom, MD; and, Helen Turner, MD

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• Legal Ease •

2015 Mississippi Legislative Session Highlights R. David Roberts, III MSMA Director of Government Affairs

lection year politics ruled the day for many issues during the 2015 legislative session, and MSMA was very active promoting and protecting the profession of medicine before lawmakers. The best childhood immunization law in the nation was saved during the legislative session, scope of practice was protected, and lawmakers passed a texting ban bill for the motoring public in Mississippi that will be a positive step in reducing distracted driving and crash risks in our state.

With the good, there were also some missed opportunities by legislators to make a difference in our state by seeking ways to improve the delivery of mental health services through a mental health task force, prohibiting insurance networks from discriminating against a physician willing to accept the network reimbursement fees and meet the credentialing standards set by the health plan, and supporting over 10,000 Mississippians who signed a petition endorsing a comprehensive smoke-free law in Mississippi. Mississippi Senate lawmakers adjourned sine die on Wednesday, April 1, 2015, and House lawmakers completed their work and adjourned sine die on Thursday, April 2, 2015, wrapping up a nearly ninety day session.

Legislative Wins – Good for Medicine… • House Bill 130 – Immunization – Include Philosophical Exemption MSMA worked with a coalition led by the Mississippi Department of Health to maintain the nation’s strongest and best childhood immunization law. House Bill 130 would have allowed a philosophical exemption to childhood immunizations. Several “Call to Action” alerts were sent out to our members urging legislators to protect all children and not allow a philosophical exemption to immunizations. The bill died on the House Calendar without action.

• House Bill 215 – Physicians; authorize special volunteer medical license for those serving as active duty military or in National Guard or Reserves. Supported by MSMA, House Bill 215 provides that physicians who are currently serving on active duty in the armed forces of the United States or in the U.S. National Guard or Reserve component or who are working as physicians for the Department of Veteran Affairs may receive a special volunteer medical license under which they may donate their services for the treatment of needy persons or persons in underserved areas in Mississippi. The bill also affords the same opportunity to physician assistants that meet certain criteria. Governor Bryant signed the bill on March 17.

• House Bill 389 – Ban Texting while Driving The texting ban bill authored by Representative Bill Denny of Jackson and championed by Representative Robert Johnson and Senator Willie Simmons will prohibit any driver from writing, sending or reading a text message as well as accessing social media on a cell phone while driving. The bill passed overwhelmingly in both chambers. MSMA worked closely with the Mississippi Academy of Pediatrics and others to get this bill on the governor’s desk. It was signed March 13. MSMA members joined Governor Phil Bryant in his State Capitol office on April 21 for a ceremonial bill signing.

• House Bill 545 – Jail Diversion Program for People with Mental Illnesses Awaiting Court Hearing or during a Commitment Proceeding

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House Bill 545 contained language that will allow counties to work on improved access to mental health treatment and alternatives to jail for people with mental illnesses, through the use of holding facilities. The bill allows for the statewide establishment of a holding facility matching fund in the general fund which returns $2 from the state for every $1 set aside by a county wishing to establish a holding facility or partner with other counties in establishing a multi-county holding facility. This legislation will support local law enforcement plagued by using the county jail as the only viable place to hold mentally ill patients awaiting a court hearing or during a commitment proceeding. Ideally, the state goal is to provide resources and examples of effective reforms by connecting smaller counties or those with fewer resources to other communities that desire to successfully reduce and remove the number of people with mental illness in jails.

•

House Bill 692 – Enact the Emergency Response and Overdose Prevention Act.

Signed by Governor Bryant on March 13, the bill authorizes physicians acting in good faith and in compliance with the standard of care applicable to that practitioner to prescribe an opioid antagonist to a person at risk of experiencing an opioidrelated overdose or to other persons in a position to assist such persons at risk of experiencing an opioid-related overdose. The bill further provides liability protections for health care professionals and individuals who seek to help those at risk of experiencing an opioid related overdose. MSMA along with AMA voiced support for this legislation to the Chairs of the Public Health committees in the Mississippi State House and Senate. The bill received strong bipartisan support and passed the Mississippi House 119-0 and the Mississippi State Senate by a vote of 52-0.

Host of Scope of Practice Expansion Bills Defeated

SMA worked to defeat eight scope of practice expansion bills this session. Five of the eight bills introduced were to expand scope for nurse practitioners. One would have given authority to nurse practitioners, counselors and social workers to conduct involuntary commitments without physician oversight. Podiatrists are presently limited to treatment of the feet below the talus. They failed this year to expand authority to treat the ankle and related tissue below the knee. Highlights of scope of practice expansion bills defeated during the 2015 Mississippi legislative session include:

• House Bill 847 – Revise the definition of the practice of podiatric medicine. • House Bill 898 – Delete the requirement that practitioners of acupuncture may perform acupuncture for a patient only if the patient has received a written referral or prescription from a physician. • Senate Bill 2088 – Change the title of the Mississippi Nursing Practice Law to the Mississippi Nurse Practice Law. • Senate Bill 2096 – Delete the requirement that advanced practice registered nurses must practice within a collaborative or consultative relationship with a physician or dentist. • Senate Bill 2101 – Provide that certified nurse practitioners with over 3,600 hours of clinical practice should not be required to have a written collaborative agreement with a physician or be required to submit patient charts to a physician for review. • Senate Bill 2102 – Include licensed nurse practitioners as mandatory evaluators for civil commitment. • Senate Bill 2103 – Define the scope of practice and to revise and modernize requirements for certification as a nurse practitioner by the Mississippi Board of Nursing. • Senate Bill 2106 – Revise the scope of practice of podiatric medicine to include the treatment of the ankle, muscles, or tendons of the lower leg governing the functions of the foot and ankle. • House Bill 1047 – Tort Claims Act; revise and include the MS Charter School Authorizer Board

As originally introduced, House Bill 1047 would have required that physicians who are employees of governmental entities provide certain employment information to the tort claims board. The bill was amended to remove the reporting requirement of the physician and place the reporting responsibility for such information on the tort claims board. MSMA worked with the Chairman of the Senate Judiciary A committee and was successful in having the reporting requirement language removed in its entirety. The bill passed with language that includes adding only employees of and members of the Mississippi Charter School Authorizer Board within the scope of protection from claims under the Tort Claim Act and members of the personal service contract review board.

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• House Bill 1555 – STEMI and Stroke System Funding Mississippi Health Care Alliance - ST Elevated Myocardial Infarction Program (STEMI) received an additional $250,000 in funding for FY 2015-2016 bringing total funding to $450,000. Additionally, $250,000 was provided as a first time allocation for the Mississippi Health Care Alliance – Stroke System of Care Plan.

Additional Wins - Legislative Bills That Passed and Were Supported by MSMA… •

House Bill 204 – Health care providers; prohibit conditioning of licensure upon participation in certain health plans.

•

Senate Bill 2123 – Medical Radiation Technologist Registration Law; extend repealers.

•

Senate Bill 2407 – Community hospitals; revise provisions concerning transparency.

•

Senate Bill 2485 - Investigational drugs; authorize physicians to prescribe to certain eligible terminally ill patients.

Tort Reform Protected… • House Bill 1338 - Wrongful death; include unborn child.

MSMA opposed this legislation. If passed, the bill would have amended the Mississippi wrongful death statute to change the right to bring a wrongful death action as the result of the death of an “unborn quick child” to simply any “unborn child” and would have greatly expanded the potential plaintiff pool in wrongful death actions.

Half Loaf Victory… • Senate Bill 2847 – Funding for Rural Physicians Scholarships & Graduate Medical Education An additional $300,000 for 10 new scholarships is great news for the Mississippi Rural Physicians Scholarship program. The fiscal year 2015-2016 total will be $1.8 million for 60 medical school scholarships. Although the new $300,000 is the first increase in three years, administrative funding for the program was cut and the impact of that act is not yet known. Although the Mississippi Senate, led by Lt. Gov. Reeves, had proposed $4 million to fund existing but unfunded residency slots at UMMC, no state dollars were actually allocated to graduate medical education. The Office of Physician Workforce received level funding at $1.5 million for fiscal year 2015-2016.

Missed Opportunities by Legislators for Medicine… • House Bill 442 – Any Willing Provider Election year politics killed Any Willing Provider… MSMA pursued legislation to prohibit insurance networks from discriminating against a physician willing to accept the network reimbursement fees and meet the credentialing standards set by the health plan. House Insurance Chairman Gary Chism championed Any Willing Provider legislation for MSMA by introducing House Bill 442. A fresh approach was employed this year as MSMA worked with a coalition of supporter groups including specialty societies. The insurance lobby opposed the bill and the House leadership deemed the bill controversial and asked for a roll call vote of the Republican coalition before moving the bill out of the House Insurance Committee. MSMA rallied members by conducting CALL TO ACTION on House Bill 442 and also worked the Democrat vote as well. Chairman Chism recorded fifty-four Republican supporters on the bill, but after the bill was “whipped” the vote count dropped to forty-four and House leadership deemed the bill too controversial to move forward in fear of fracturing the coalition vote on the House floor.

• Senate Bill 2481 / House Bill 868 / House Bill 957 – Mental Health Task Force

Even with Lt. Gov. Tate Reeves taking the lead, the state legislature refused to create a task force to review the entire system of delivery for mental health care. Senator Brice Wiggins, of Pascagoula, led the effort saying that Mississippi’s mental health system is broken from top to bottom. MSMA President Dr. Brunson put mental health reform high on the MSMA legislative priority list noting that much assistance will be needed to implement the federal mandates. The U.S. Department of Justice targeted Children Services and Adult Services identifying inadequacies that need to be addressed. Despite overwhelming support and passage out of the Mississippi State Senate, the bill met strong opposition in the Mississippi House where Senate Bill 2481

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and House Bill 868 died. MSMA worked and was successful in having the mental health task force language amended to House Bill 957 to keep the legislation alive and sent to conference. Unfortunately, House conferees would not agree with Senate conferees and the bill died. A task force of health care professionals and leaders could have helped write the blueprint to improve the entire system of delivery of mental health services in Mississippi.

House Bill 770 & Senate Bill 2054 – State-Wide Smoking Ban In All Public Places After a valiant effort, including an impactful press conference at the State Capitol with the unveiling of a scroll containing over 10,000 signatures from Mississippians, as well as an attempt to attach smoke free bill language to another bill in different committee, both versions of the smoke free legislation, House Bill 770 and Senate Bill 2054, did not pass out of the committee this session. If passed, the bill would have made a state-wide ban on smoking in all public places.

New Laws to Monitor… • House Bill 952 - Co-pay Parity for Oral Cancer Meds Designed to ensure that cancer patients covered by the State Employees Health Plan, House Bill 952 was hi-jacked to allow a middleman to decide which surgeons and facilities can treat more than 187,000 state employees and dependents. MSMA actively supported the parity legislation until the House added an amendment to require the State Employees Health Insurance Board to accept bids for surgical services that included “assistance in locating a board-certified surgeon, setting up initial consultation, travel, a negotiated single case rate bundle and payment for orthopedic, spine, bariatric, cardiovascular and general surgeries.” Fearful that state employees would have no access to local surgeons with whom they have a doctorpatient relationship, MSMA opposed the amendment and the narrow network it would create. Finally, the amendment was changed in conference and replaced with language that only “allows” the State Employees Health Plan Board to accept bids for surgical services. The board certification requirement was removed and language was added to say that only Mississippi surgeons and facilities could treat state employees – UNLESS otherwise provided by the board. MSMA will stay on top of the Health Plan Board and will work to prevent the exclusion of Mississippi physicians.

• Senate Bill 2441 - Ground work for ProviderSponsored Health Plan Set The Mississippi Legislature has paved the way for the Mississippi Hospital Association to establish a non-profit health plan for Medicaid patients with the passage of Senate Bill 2441. The provider-sponsored health plan would compete with Magnolia Health Plan and United HealthCare for the Medicaid managed care program known as MississippiCAN. MSMA President Dr. Claude Brunson said, “We are just not comfortable the proposal. The concept is too vague for MSMA to endorse.” The MSMA Board of Trustees asked the Mississippi Hospital Association to pledge that its members would support several key issues so that the majority of members on all governing boards of any PSHP would be composed of physicians. MSMA opposed the plan based on the decision of the Council on Legislation chaired by Dr. Ann Rea of Summit. After five months of meetings with hospital association leaders the MSMA Board of Trustees took a stand when Mississippi Hospital Association refused to agree on a governance model that put physicians in the majority to determine administrative and clinical issues.

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• Una Voce •

Just Doing Some Reframing

few years ago I learned a valuable strategy for coping with a ‘pet peeve’ shared by virtually every practicing small town physician…the sneak-attack medical consultation by patients outside the office setting. One example of this is when a fellow church member regularly brings a diary of her blood pressure readings for my perusal during Sunday school. A waitress at a favorite Chinese restaurant might ask for treatment for her recurrent yeast infection while we are enjoying the egg drop soup. I have written prescriptions on the back of a Dwalia S. South, MD lunch counter ticket or a paper napkin more than once, I’m afraid. When folks walk briskly toward me in the grocery aisle yelling, “Hey there, Doc!”… I know what’s coming next. First is the small town small talk, followed by an inevitable request for medical advice or a prescription refill. There goes a chunk of my thirty-minute lunch break. To refuse to listen or attend to these inappropriate requests seems impossible for me. I simply don’t want to be perceived as a snobbish jerk of a doctor. Very often, feeling that I had been used or abused in some fashion, I would get back in my truck fuming as I returned to the office. One of my old colleagues in practice commented that when patients did this to him he had the perfect out. He smilingly recalled a bank teller asking him about her recent bout of lumbago to which he replied, “Well, dear, just strip to the waist from both ends, and I’ll examine you right here.” I am simply not that brazen. I confess that once I did carry on a fake conversation on my cell phone for several minutes while shopping in Walmart to avoid another inane play-by-play consult with a notoriously long-winded patient. I chatted with no one, pointing at my phone, waving and smiling at her as I pushed my cart down the aisle and out of her sight. Later, I felt a pang of guilt for having carried on this ruse to avoid a sweet elderly lady. The valuable lesson I later learned came one Saturday morning when I was rushing to get to my income tax preparation appointment. I briefly stopped at a convenience store to buy gas and a snack before the dreaded annual ordeal. A big mistake! The young clerk who waited on me picked up a small flashlight from the counter and asked me to look down her sore throat please and to call her in a script for some Amoxil… “Both my kids have had strep, and I can’t get off work to come to the clinic!” I acquiesced to her dilemma and did as she requested. “Thank you, Doc, you’re a lifesaver!” she said as I hurried out the door sublimating my frustration as best I could. The lecture I had just attended about practicing ‘evidence based medicine’ went out the door with me. I arrived at my CPA cousin’s accounting office a tad late. Van didn’t mind, but he did notice and remark on the steam coming out of my ears that morning. As I pulled all my 1099’s, W2’s and other sundry tax files out for him, I recounted the source of my irritation. I began to vent as he blithely moved through my papers and skillfully tapped at his keyboard while listening to me gripe. Van then gifted me with a bit of wise counsel. He said, “You know, this happens to me, too, sometimes. I used to really let it bother me when I would meet an acquaintance out in public somewhere, and before they could get the ‘hello, how have you been?’ out of their mouth, they would ask me a tax question. A man last week at church asked me if he could deduct the cost of building a swimming pool as a medical expense since he and his wife both have arthritis and been recommended to do water aerobics. And you know what, I don’t even do his taxes! I decided a long time ago that the best way to deal with that situation is to take the question as being complimentary instead of letting it irritate me. People recognize us out in public and in a small town professional people are sort of like celebrities in a way. These people want

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to interact socially with you, and in their minds, what you do for a living is simply an extension of you as a person. They are not going to think of conversing with you about the weather. To them, your mind is on Medicine at all times. Sometimes they are being opportunistic, and using us; but many times they simply want to connect with someone whose opinion they truly respect. I have learned to spin the situation around in my mind and think that this person views me as an expert, values my judgment and I should take that question as an honor. Of course, that isn’t always the case, but doing this keeps my blood pressure down. Just like when I tell you today how big a check to write Uncle Sam, you should think how fortunate you are to have made enough money to have to pay these income taxes. Sounds silly, I know, but it eases the pain a bit.” My accountant’s advice did not fall on deaf ears. I think the experts in the field of psychology refer to this as “reframing” a negative emotion into a positive one. It is akin to the experience of taking a once cherished old photograph that has hung on the wall for years and become tired-looking, dust-covered, and mostly ignored, and then mounting it in a nice new mat with a fresh frame. The picture then becomes viewed with quite different eyes and appreciated anew. I recall the days when as a medical student, I would come home on the weekends and relatives would ask me for medical advice or for an explanation of what their doctor had diagnosed. “Just what exactly is DIE-VER-TICKLE-ITIS, Doc?” When I wasn’t yet quite a bona fide physician, being called ‘Doc’ was kind of an ego-boost, not perceived with the inflammation it had come to bring after many years of hearing the moniker. As a young doctor, being asked for help or advice outside the clinic gave me a sense of pride that I had indeed earned a place of trust in my community. It was a visceral response which I had to consciously relearn to evoke after my many years in practice had callused my ears and my heart. We signed onto this life of practicing medicine to ease suffering, and we must keep ourselves whole in order to do so. Nowadays, I attempt to cultivate an attitude of gratefulness instead of hatefulness when these daily trials inevitably occur. In certain scenarios managing a heartfelt smile seems to require a Herculean effort, but the act of smiling rather than grimacing will doubtless reduce a physician’s hypertension and heartburn. Next week, I’m planning to get my sagging 35-year-old med school diploma down from the wall and get it ‘reframed.’ It’s high time. —Dwalia South, MD; Ripley “I therefore…beseech you that ye walk worthy of the vocation wherewith ye are called, With all lowliness and meekness, with longsuffering, forbearing one another in love…” Ephesians 4:1-2

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116 JOURNAL MSMA

April 2015

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MPCN - THE OBVIOUS CHOICE Change Networks. Not Doctors. 601-605-4756 • www.mpcn-ms.com Sponsored by the Mississippi State Medical Association

T H E

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M I S S I S S I P P I

M E D I C A L

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P R E S E N T S

The Second Robert Q. Marston Symposium on Race and Medicine

Is Race Still a Factor in Mississippi’s Health? Target Audience: Practicing and Retired Physicians, Residents and Fellows, Medical Students

Content: • The 1967 Wheeler Physicians Report on Child Health, “Hungry Children,” and the Visit of Senator Robert Kennedy to the Delta

• Facilitated discussions about race and health in Mississippi: The William Winter Institute for Racial Reconciliation

• Construction of a plan of action to address health disparities in Mississippi • Opportunities for cross-talk between representatives and cosponsors: the Mississippi State Medical Association, the Mississippi Medical and Surgical Association, the William Winter Institute for Racial Reconciliation, the Myrlie Evers-Williams Institute for the Elimination of Health Disparities, and the Mississippi Humanities Council

Credit: AMA The University of Mississippi School of Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to sponsor continuing medical education for physicians. The University of Mississippi School of Medicine designates this live activity for a maximum of 5.5 AMA PRA Category 1 Credit(s)TM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

To register for this conference, visit

www.umc.edu/marston

8 a.m. – 3 p.m. • Friday, June 5, 2015 UMMC Conference Center • Jackson Medical Mall • Jackson, Mississippi