Journal MSMA • VOLUME LXI • NO. 2 • 2020 by Journal MSMA

volUME lXI • no. 2 • February 2020

A fabulous gift idea for anyone in medicine! Images in Mississippi Medicine: A Photographic History of Medicine in Mississippi

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Order three or more to receive a discount at: http://tinyurl.com/yb7ab974 “Images In Mississippi Medicine by Dr. Luke Lampton and Karen Evers is a handsome and impressive book, filled with stories and scenes ranging from primitive operating rooms and rows of hospitalized tornado victims a century ago to the new teaching complex at the University of Mississippi Medical Center with its modern breakthroughs. The volume is a piece of our history that every Mississippian can appreciate.” – Curtis Wilkie, journalist, author, and professor at Ole Miss David Lewis Phares, MD (1 8\7,189!

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Images in Mississippi Medicine: A Photographic History of Medicine in Mississippi; MSMA; Jackson, MS: 2018.

OF THE MISSISSIPPI STATE MEDICAL ASSOCIATION vol. LXI • no. 2 • February 2020

Science ARTICLES

Editor Lucius M. Lampton, MD Associate Editors D. Stanley Hartness, MD Philip T. Merideth, MD, JD

The Association President J. Clay Hays, Jr., MD President-Elect W. Mark Horne, MD

Managing Editor Karen A. Evers

Secretary-Treasurer Joe Austin, MD

Publications Committee Sheila Bouldin, MD, Chair Dwalia S. South, MD, Chair Emeritus Thomas C. Dobbs, MD Wesley Youngblood, M4 and the Editors

Speaker Geri Lee Weiland, MD Vice Speaker Jeffrey A. Morris, MD Executive Director Claude D. Brunson, MD

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.

Implementing an Interpregnancy Care Project among Rural and Urban Mississippi Cohorts Glen Graves, MD; Juanita Graham, DNP-RN; Lauren Ryan, MSN-RN; Changhong Wen, MPH; Lei Zhang, PhD; Michelle Y. Owens, MD

The Role of Women’s Health in Reducing Preterm Births Alfred W. Brann, Jr., MD

Radiation Dose-Volume Effects in the Esophageal Toxicity for Lung Cancer Patients Treated with Radiotherapy Rui He, PhD; Elgenaid Hamadain, PhD; Claus Chunli Yang, PhD; Hamed Benghuzzi, PhD; Donna Sullivan, PhD; Michelle Tucci, PhD; Srinivasan Vijayakumar, MD

Top 10 Facts You Need to Know about Childhood Obesity John Hanson, M4; Whitney Herring, MD, MPH

37 39

Special ARTICLE Interview: MSMA Executive Director Claude D. Brunson, MD Avani Patel, M4

departments From the Editor – Solving the Riddle of Infant Mortality Lucius M. Lampton, MD

President's Page – Physicians and the Reflective Dry-Fit Shirt J. Clay Hays, Jr., MD

Letters – Journal Praised for Becoming More Inclusive “From the Front Door to the Back Door” Robert Smith, MD, Jackson

MSMA – Welcoming Our Newest Members

Images in Mississippi Medicine – The Medical School and Hospital at Ole Miss, The Second Medical School Building, 1934–1955 Lucius M. Lampton, MD

Poetry and Medicine – Forceps Delivery Merrill Moore, MD (1903–1957)

Advertising rates: furnished on request. Karen A. Evers, ext. 323. Email: KEvers@MSMAonline.com 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 © 2020 Mississippi State Medical Association.

Official Publication

ABOUT THE COVER

“The Final Straw” – We’ve all experienced them: the final straw, the straw that broke the camel’s back, you name it. Professional burn out is indeed now a recognized entity, and opportunities for prevention and salvage are being discussed. Our cover photo was taken by Dr. Stanley Hartness, family physician and associate editor, when he was captivated by the abstract image opening a package of colorful drinking straws.n

MSMA • Since 1959

February • journal msma

F R O M

t h e

e d i t or

Solving the Riddle of Infant Mortality T

he riddle of infant mortality has stumped Mississippi physicians since territorial times. In the first American medical publication related to Mississippi, Natchez native Dr. Garrett Elliott Pendergrast recognized an increased infant mortality among slaves in the “low country” south of Natchez. Writing in his 1803 thesis from the University of Pennsylvania, he noted that “it is a very difficult thing for the planters to Lucius M. Lampton, MD raise young negroes,” and despite their Editor attentions, “at least five eighths of all that are born die…within the first two weeks after birth.” He described this finding as “curious” and attributed it to “greater inhumanity…exercised over the parents” and to “the want of proper attention in the nursing of the child itself.” [“A Physical and Topographical Sketch of the Mississippi Territory, Lower Louisiana, and a Part of West Florida.” 33-34.]

science, which included forceps use, antiseptic technique, and the coming of antibiotics. In Mississippi, the Board of Health established a Division of Child Hygiene in 1920, which began a focus on infant and maternal mortality by emphasizing midwife training. Our MSMA created a Maternal and Child Health Committee in 1942, which made ambitious recommendations, including a planned state-wide system of prenatal care. The Mississippi Regional Medical Program from 19651977 initiated a multipronged effort to improve maternal and infant health, working closely with both the Board of Health and the MSMA to create regional maternal and perinatal healthcare services.

Since the time of Hippocrates, pregnancy, childbirth, and infancy have been perilous for both mothers and their babies. Over many centuries, odds for them have improved with the evolution of better medical

Contact me at lukelampton@cableone.net.

Despite improvement over the years, Mississippi continues to be ranked by the CDC as the least-healthy state in which to be born, with 8.9 infant deaths per 1000 live births. Two brilliant physicians, Alfred W. Brann, Jr., MD, and Glen R. Graves, MD, offer articles in this issue exploring new strategies of health promotion and disease prevention to improve maternal and infant health. Their significant work in neonatal and perinatal medicine has provided them critical insight in solving the complex riddle of infant mortality. n

— Lucius M. Lampton, MD, Editor

Journal Editorial Advisory Board ADDICTION MEDICINE Scott L. Hambleton, MD

EMERGENCY MEDICINE Philip Levin, MD

ALLERGY/IMMUNOLOGY Stephen B. LeBlanc, MD Patricia H. Stewart, MD

FAMILY MEDICINE Tim J. Alford, MD Diane K. Beebe, MD Jennifer Bryan, MD J. Edward Hill, MD Ben Earl Kitchens, MD

ANESTHESIOLOGY Douglas R. Bacon, MD John W. Bethea, Jr., MD CARDIOVASCULAR DISEASE Thad F. Waites, MD

GASTROENTEROLOGY James Q. Sones, MD GENERAL SURGERY Andrew C. Mallette, MD

CHILD & ADOLESCENT PSYCHIATRY John Elgin Wilkaitis, MD

HEMATOLOGY Carter Milner, MD

CLINICAL NEUROPHYSIOLOGY Alan R. Moore, MD

INFECTIOUS DISEASE Rathel "Skip" Nolen, III, MD

DERMATOLOGY Robert T. Brodell, MD Adam C. Byrd, MD

INTERNAL MEDICINE Daniel P. Edney, MD Daniel W. Jones, MD Brett C. Lampton, MD Kelly J. Wilkinson, MD

26 vol. 61 • no. 2 • 2020

INTERNAL MEDICINE/ EPIDEMIOLOGY Thomas E. Dobbs, MD MEDICAL STUDENT John F. G. Bobo, M4 NEPHROLOGY Harvey A. Gersh, MD Sohail Abdul Salim, MD OBSTETRICS & GYNECOLOGY Sidney W. Bondurant, MD Sheila Bouldin, MD Darden H. North, MD ORTHOPEDIC SURGERY Chris E. Wiggins, MD OTOLARYNGOLOGY Bradford J. Dye, III, MD PEDIATRIC OTOLARYNGOLOGY Jeffrey D. Carron, MD

PEDIATRICS Michael Artigues, MD Owen B. Evans, MD PLASTIC SURGERY William C. Lineaweaver, MD, Chair PSYCHIATRY Beverly J. Bryant, MD June A. Powell, MD PUBLIC HEALTH Mary Margaret Currier, MD, MPH PULMONARY DISEASE Sharon P. Douglas, MD John R. Spurzem, MD RADIOLOGY P. H. (Hal) Moore, Jr., MD RESIDENT/FELLOW Cesar Cardenas, MD UROLOGY W. Lamar Weems, MD VASCULAR SURGERY Taimur Saleem, MD

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Abstract The Interpregnancy Care Project of Mississippi investigated whether primary health care and social support following very low birthweight delivery improved subsequent child spacing and pregnancy outcomes among low income black women. Two cohorts of women were enrolled following very low birthweight deliveries: an urban cohort (n=47) and a rural cohort (n=85). Subsequent reproductive outcomes were compared with retrospective control cohorts. In the urban group, pregnancies within nine months were significantly lower (p=0.05) for intervention participants. Although not significantly different, the trend for fewer pregnancies and adverse outcomes was positive at 9 and 18 months in both urban and rural intervention groups. Two important study findings include identification of implementation barriers (providers, transportation, continuity of care) and identification of previously unrecognized or inadequately managed chronic conditions (urban 62%; rural 63%) associated with adverse pregnancy outcomes. Increasing interpregnancy care implementation and primary healthcare access for low income Mississippi women will reduce very low birth weight deliveries and, subsequently, their chronic health problems and exorbitant costs. Keywords: Infant mortality, low birth weight, premature birth, interpregnancy care, preconceptual care Implementing an Interpregnancy Care Project among Rural and Urban Mississippi Cohorts In the United States, low birth weight (LBW; < 2500 grams) remains the leading cause of black infant mortality.1 Survivors of very low birth weight (VLBW; < 1500 grams) frequently experience severe chronic health problems and lifelong disability. The black vs. white disparity (2:1) in infant mortality persists throughout the United States, and the rate of VLBW is nearly 3 times greater among black infants.1,2 The societal costs of the outcomes of these pregnancies – physical, emotional, and fiscal – soar into the billions.3,4 Mississippi (MS) has the highest percentage (43%) of infants born to blacks of any state in the nation (Massachusetts-7%), and the socioeconomic and public health impacts are dramatic.5 Recent research has focused on fetal origins of adult chronic diseases such as obesity, diabetes, and hypertension.6,7 Poor pregnancy

28 vol. 61 • no. 2 • 2020

outcomes, such as VLBW, are often trans-generational problems, more common among less healthy women experiencing difficult socioeconomic conditions and lacking access to comprehensive primary health care and social support.8,9 The best clinical predictor of a VLBW delivery is a maternal history of previous VLBW delivery.10 The 2014 rate of VLBW for the general U.S. population was 1.4% of live births.11 In the same year, Mississippi VLBW deliveries accounted for only 2.3% of the 38,736 live births but 49% of infant deaths.12 After the first VLBW birth, black women have a 13.4% chance of having another VLBW birth.10 These figures double among adolescent pregnancies and progressively rise with each additional VLBW birth. Life course theory proposes that adverse pregnancy outcomes may be the product of events that occur throughout life rather than simply events incurred during pregnancy.13 Thus, addressing social, economic, and physical life course experiences prior to pregnancy could reduce adverse pregnancy outcomes. Multiple research studies suggest that strategies offering the highest potential for healthy full-term births include preconceptual and interpregnancy care.14,15,16,17 A recent opinion of the American College of Obstetricians and Gynecologists (ACOG) promotes optimizing postpartum, or interpregnancy care, as an ongoing process, rather than a limited patient encounter.18

Compliance Training) prior to approval of the project and annually. CITI training specifically addresses ethical concerns that have arisen in the past regarding medical research on vulnerable populations (such as the Tuskegee experiments on African Americans). UMMC and the Mississippi Department of Health (MSDH) require cultural and sensitivity training upon employment and annually for all staff. The lead IPCM project partners included the University of Mississippi Medical Center (UMMC) and the Mississippi State Department of Health (MSDH). The MSDH is Mississippi’s legislatively authorized public health agency, and UMMC is Mississippi’s level 4 care center for maternal and infant health.

Availability of interpregnancy care services is limited in rural, medically underserved Mississippi. Socioeconomically challenged Mississippi women encounter difficulty securing health care coverage and reproductive planning in the interpregnancy period. Mississippi did not expand Medicaid, leaving Medicaid coverage for able-bodied adults as nearly non-existent.19 Mississippi Medicaid eligibility covers only the pregnancy period and up to 60 days post-partum. Consequently, many women do not receive medical care for chronic health conditions except during pregnancy when they gain Medicaid eligibility, thus decreasing the likelihood of optimal maternal health. It is well established that health care access in Mississippi remains an important issue. Mississippi is the most medically underserved state in the nation. The Health Resources & Services Administration (HRSA) federally designates at least part of all 82 Mississippi counties as medically underserved.20 Subspecialty services such as high-risk prenatal care may be difficult to acquire. Program Description The goal of interpregnancy care for women who have delivered VLBW infants is not to limit pregnancies but to increase the interval between pregnancies. This strategy is known to be safer for the woman. Specifically, the outcome of future pregnancies and the overall health and well-being of the mother should improve. Considering the contribution of VLBW to infant morbidity and mortality, and especially given the above challenges, Mississippi was deemed an optimal setting to implement an interpregnancy program modeled after the Grady Memorial Hospital program in Atlanta, Georgia.14 Following the Atlanta project model and using a similar database, forms, and program strategies, the Interpregnancy Care Project of Mississippi (IPCM) developed a pilot project to be implemented within two regions of the state. One region was the rural Mississippi Delta (aka DIME), and the other was a more urban, metropolitan region (aka MIME). These locations provide two perspectives (rural vs. urban) on implementing interpregnancy care. Since the IPCM enrolled black, low income women exclusively, issues of cultural sensitivity and ethical training of the staff were extremely important. All authors completed CITI training (Research Ethics and

At the time of discharge following the birth of a VLBW infant, women were identified and enrolled in the IPCM. Each participant established a comprehensive health plan, including reproductive planning. The goal was to delay subsequent pregnancies for a minimum of nine - 18 months, which is a well-documented benchmark for child spacing.21 The IPCM provided participants 24 months of primary, continuous health care, enhanced nurse case management, and community outreach via resource mothers. Resource mothers were a unique aspect of the project. The concept of “resource mothers” (non-professional, community health workers) was to connect them with the participant women. The resource mothers who were black, ages 22-60, and lived in the community, would provide “individualized” support to the participants (i.e., 1:1 relationships). “Individualized” meant getting to know the participant, reinforcing the importance of compliance with medications and clinic appointments, and assisting with transportation. The workers also provided social support by focusing on education, job training skills, parenthood preparedness, and safe housing through group meetings, home visits, and telephone contact. Since the resource mothers did not need to be professional social workers or registered nurses, they provided an important opportunity for cost savings. The resource mothers were recruited, trained, and supervised by the district health social workers and registered nurses. A training manual was developed by MSDH specifically for the IPC project. The authors and our consultant from Emory visited the district health offices for in-service training. Primary health care was provided by local family physicians and federally qualified community health centers (FQCHC). They addressed vital areas epidemiologically linked to VLBW delivery, including poorly managed risk factors, chronic health conditions, psychosocial issues, and short interpregnancy intervals. The first IPCM aim was to compare health outcomes among IPCM participants before and after the intervention. The second aim was to compare pregnancy outcomes among IPCM intervention and control cohorts. Across cohorts, the program compared interpregnancy intervals, birth weight distributions, birth outcomes, morbidity, and mortality among subsequent pregnancies conceived within 18 months of the index VLBW delivery. Overall, the project aimed to assess the feasibility and acceptability of delivering interpregnancy care to women in two geographic communities with differing access to medical and enabling services.

vol. 61 • no. 2 • 2020 29

Ethical and Funding Considerations The study received dual oversight and approval by the Institutional Review Boards (IRB) of UMMC and MSDH and was carried out in compliance with the approved protocol and ethical standards throughout all interactions with program participants. The consent form included all CITI training and IRB guidelines and was approved for implementation. The content was the same as the form previously approved by Emory University in the Georgia IPC project. The IPCM was funded through a combination of community and state sources. The Delta Health Alliance initially provided financing for the rural arm of the study later covered by the MSDH. The MSDH funded the primary health care component of the metropolitan arm of the project. UMMC provided the care through the West Jackson Family Medicine Clinic. A March of Dimes grant funded the resource mother in the metropolitan area. Although Medicaid transportation was available, it did not allow family members (i.e., their children) to travel. Bus vouchers were offered to these participants for transportation to clinic visits, pharmacy, group meetings, and visiting their infants. In DIME, $50 Wal-Mart cards were also available for transportation to clinics and pharmacy which were up to 50 miles away. There were no other rewards or enticements. Methods Study Design This study compared subsequent reproductive outcomes of two black, female cohorts among rural and urban arms of the study. The urban study arm, the Metropolitan Infant Mortality Elimination (MIME), included Hinds County in central Mississippi (Jackson). The rural study arm, the Delta Infant Mortality Elimination (DIME), incorporated 18 Mississippi River Delta counties. Black retrospective control cohorts, geographically and socioeconomically matched to their respective intervention cohorts, had delivered VLBW infants within 24 months prior to the initial IPCM enrollment. The study team estimated sample sizes for each of the MIME and DIME intervention and control groups to be at least 62 participants, for a total of at least 248 subjects (statistical significance level 0.05; power level 0.80). Intervention group to control group ratios were 1:1 for both the MIME and DIME study arms. The IPCM intervention was implemented and performed through UMMC’s West Jackson Family Medical Clinic, MSDH county health departments, two rural family practice clinics, and federally qualified comprehensive community health centers in the target regions. Sample Within all cohorts, enrollment eligibility criteria were identical except for county of residence. Eligibility criteria included black race, indigent care status (operationalized as Medicaid eligibility), and a VLBW infant born or treated at UMMC. Residential eligibility for the MIME

30 vol. 61 • no. 2 • 2020

required permanent maternal residence in Hinds County. DIME eligibility required permanent maternal residence in one of the 18 Delta counties. MIME and DIME enrollment occurred consecutively among consenting participants following delivery of a VLBW infant. All women who met the eligibility requirement were approached to participate. The same clinical coordinator, a women’s health nurse practitioner, consented and enrolled all participants except one. That participant was enrolled by the principal investigator. The study team identified control cohort candidates using maternal demographic information from a perinatal database of VLBW infants delivered or transferred into the UMMC Neonatal Intensive Care Unit (NICU). Inclusion criteria for the retrospective control cohort candidates included black race, county of residence, age, prior LBW or preterm delivery, and indigent status. Historical controls were matched one for one by census tracts, residing either nearest the intervention participant or a closely matching proxy census tract. Other control cohort eligibility criteria were the same as for intervention participants. Measures and Outcomes As with the Atlanta project, primary outcomes of interest were the number of pregnancies conceived within 18 months of the index VLBW delivery and the number of those pregnancies with adverse outcomes.14 In this study, the operational definition of adverse pregnancy outcome included ectopic pregnancy, pregnancies ending in late spontaneous abortion (12-20 weeks of gestation), stillbirth, or the live birth of an LBW infant (< 2,500 grams). The interpregnancy interval, expressed in months, was calculated by subtracting the date of the index delivery (ID) from the date of the subsequent delivery (SD), minus the estimated gestational age (EGA) of the subsequent delivery, divided by 30.  SD − ID − EGA      30 Data related to women’s past medical and obstetrical histories, outcomes of index deliveries and subsequently conceived pregnancies were collected by UMMC medical record review. For the intervention cohort, IPCM program records, such as personalized reproductive plans, diagnostic and treatment records, and psychosocial support service documentation provided additional data.

Data Analysis

MIME Cohort Findings

Participants’ baseline social, medical, and obstetrical characteristics were compared across cohorts. Proportions of women who became pregnant within 18 months of the index delivery were measured using Fisher’s exact test. Replicating the Atlanta project, Poisson regression evaluated intervention effect by comparing event counts that occurred more than once. Multivariable Poisson regression investigated the effect of potential confounders (number of previous terms and preterm deliveries, whether labor was spontaneous or induced, maternal age, or multiple gestations). Data analysis used SAS Version 9.2.

Twenty-nine (62%) of the 47 MIME intervention cohort participants completed 12 months of the 24-month intervention. These 29 women comprised the research sample used to determine the effectiveness of the MIME program in identifying and managing chronic and acute diseases. Among MIME participants, 24% held no high school diploma or GED, and 66% were unemployed.

Results The primary desired outcome for all IPCM program participants was the minimally desirable interpregnancy spacing of nine months, but ideally the interpregnancy spacing of eighteen or more months.21 Forty-five of 47 MIME and 79 of 85 DIME intervention participants achieved the desired nine-month interpregnancy interval.

MIME participants experienced 73% fewer pregnancies conceived within nine months of the index delivery (2 vs. 7). Using the Poisson Regression method, pregnancy numbers were significantly lower (p=0.05) within the intervention cohort. At nine months, there was one adverse pregnancy outcome (ectopic pregnancy) in the intervention group as compared with three in the control group. At 18 months, the intervention group had 43% fewer pregnancies (7 vs. 12), although not statistically significant (p=0.17). Three of the seven pregnancies had an adverse outcome, including one VLBW birth, as compared with seven adverse outcomes in the control group (p=0.20). Tables 1, 2, 3, and 4 summarize additional MIME cohort findings.

Table 1. Baseline Characteristics of intervention and control cohorts.

MIME Characteristic

IPCM cohort (n=47)

Control cohort (n=47)

Maternal Age group

DIME P-valuea

IPCM cohort (n=85)

Control cohort (n=85)

.70

P-valuea .49

Teenagers (< 20 years)

9 (19%)

6 (13%)

23 (27%)

18 (21%)

20 yrs ≤ Age < 35 yrs

37 (79%)

40 (85%)

56 (66%)

63 (74%)

1 (2%)

6 (7%)

4 (5%)

Primiparous

14 (30%)

11 (23%)

.48

25 (29%)

32 (38%)

.26

Previous term

16 (34%)

13 (28%)

.50

30 (35%)

27 (32%)

.63

Previous preterm

19 (40%)

13 (28%)

.19

22 (26%)

17 (20%)

.36

Previous abortion

16 (34%)

20 (43%)

.40

23 (27%)

24 (28%)

.86

Preeclampsia/ eclampsia

15 (32%)

9 (19%)

.16

17 (20%)

23 (27%)

.28

Hypertension

13 (28%)

7 (15%)

.13

24 (28%)

16 (19%)

.15

2 (4%)

–

.50

4 (5%)

5 (6%)

.73b

Single (marital status)

40 (85%)

–

74 (87%)

–

Illicit substance abuse

8 (17%)

5 (11%)

.37

17 (20%)

8 (9%)

.05

Tobacco abuse

11 (23%)

6 (13%)

.18

20 (24%)

9 (11%)

.03

Multiple gestation

8 (17%)

9 (19%)

.79

9 (11%)

10 (12%)

.81

Stillbirth

1/55 infants

0/56 infants

.50

5/93 infants

2/96 infants

.25

Birthweight mean (range)

1024g (454-1810g)

1055g (417-1735g)

.65

985g (360-1490g)

1028g (480-2020g)

.33c

Advanced age (≥ 35 yrs)

Diabetes

b c

P-value for Chi-square test unless otherwise specified. P-value for Fisher’s exact test. c P-value for independent t-test. a

vol. 61 • no. 2 • 2020 31

Table 2. MIME and DIME participant pregnancy outcomes at 9 and 18 months of follow-up.

MIME

DIME

Intervention

Control

Intervention

Control

Adverse outcomes

1 (2%)

3 (6%)

7 (15%)

3 (4%)

4 (5%)

6 (7%)

Live births ≥ 2,500g

1 (2%)

4 (9%)

5 (11%)

1 (1%)

4 (5%)

Unknown outcome

–

2 (2%)

4 (5%)

2 (4%)

7 (15%)

12 (26%)

5 (6%)

6 (7%)

5 (6%)

14 (16%)

Total pregnancies

Table 3. Distribution of pregnancies and adverse pregnancy outcomes within 18 months of the index VLBW. Number of women in each cohort experiencing 0, 1, or 2 pregnancies MIME DIME Intervention Control Intervention Control (n=47) (n=47) (n=85) (n=85) 0 41 36 79 76 1 5 10 6 8 2 1 1 0 1 a a c Sample mean 0.15 0.26 0.07 0.11 c No. of adverse Number of women in each cohort experiencing 0, pregnancy 1, or 2 adverse pregnancy outcomes outcomes MIME DIME within 18 Intervention Control Intervention Control months (n=47) (n=47) (n=85) (n=85) 0 44 41 82 80 1 3 5 3 4 2 0 1 0 1 b b d Sample mean 0.06 0.17 0.04 0.07 d a b Poisson Regression P-values: P-value = 0.17; P-value = 0.20; c P-value = 0.18; dP-value = 0.25 No. of pregnancies conceived within 18 months

Of the 47 women initially enrolled in MIME, 20 (43%) completed the full two years of IPCM intervention and did not become pregnant. Eight (17%) discontinued the program due to subsequent pregnancy. Four (9%) became ineligible due to relocation (n=3) or incarceration (n=1) and one (2%) voluntarily withdrew. The remaining 14 (30%) MIME participants were lost to follow-up.

Table 4. Documented health risk factors and conditions by intervention cohort.

Risk factors

Overweight (25 ≤ BMI < 30) Obese (BMI ≥ 30) Conditions / Hypertension Diseases Diabetes Asthma Cardiovascular problems / disease Gynecological issues / STD Kidney disease Thyroid / Parathyroid problems Chronic pain (various locations) Grand mal seizures Pseudo tumor cerebri Severe vitiligo Liver problems Neurofibromatosis Sickle cell trait Psychosocial / Substance / Tobacco Behavioral use Conditions Mental illness / Stress / Anxiety Depression

MIME (n=47) 4 (9%)

DIME (n=85) 6 (7%)

10 (21%) 13 (28%) 2 (4%) 2 (4%) 1 (2%)

17 (20%) 24 (28%) 4 (5%) 2 (2%) 5 (6%)

–

5 (6%)

1 (2%) –

3 (4%) 3 (4%)

–

10 (12%)

1 (2%) 1 (2%) 1 (2%) – – – 11 (23%)

– – – 1 (1%) 1 (1%) 2 (2%) 20 (24%)

–

3 (4%)

11 (23%)

2 (2%)

DIME Cohort Findings DIME enrolled 85 participants in the intervention cohort, of which 45 (53%) completed 24 months of the IPCM intervention with no pregnancies. Among DIME intervention participants, 59 (69%) completed 12 months of IPC. Thirty-two (38%) were unemployed. Five (6%) DIME intervention participants became pregnant within nine

32 vol. 61 • no. 2 • 2020

months, as did five within the DIME the control group. At 18 months, there were six pregnancies among the DIME intervention group, as compared to 14 among the DIME control group (p=0.18). There were three adverse pregnancy outcomes among the DIME intervention cohort versus six among the DIME control. Tables 1, 2, 3, and 4 summarize additional DIME intervention and control group findings.

systems; and, 3) Intersection- transportation, insurance, education. As anticipated by the design of the project, the urban and rural settings – one highly resourced and one poorly resourced – varied in feasibility and acceptability of the intervention. Informal systems. In both MIME and DIME, women agreed to reproductive plans, stating a desire to defer pregnancy for 9-18 months. However, between 40-50% of participants missed their six-week postpartum appointment secured before discharge. These women may have been without contraception for an extended period. The clinical coordinator enrolled all participants at 24-48 hours postpartum before hospital discharge and then forwarded all information to local staff and clinics, who attempted to make contact within 2 weeks. Thirty-nine (46%) DIME participants withdrew during the 24-month intervention period. Of those participants, 15 (18%) discontinued the program due to pregnancy. Nine (11%) became ineligible due to relocation (n=8) or incarceration (n=1). Twelve (14%) voluntarily withdrew. One participant (1%) died in an accident unrelated to the program. Three (4%) were lost to follow-up. Discussion HRSA’s Maternal and Child Health Bureau leads a national collaborative improvement and innovation network (COIIN) to reduce infant mortality and identifies preconception and interconception care as one of its six COIIN strategies.24 ACOG agrees and also promotes interpregnancy care.18 This study identified challenges and barriers to implementation of interpregnancy care among low income Mississippi women. A statistically significant difference was found in the number of pregnancies at nine months in the metropolitan (MIME) cohort and also fewer adverse pregnancy outcomes. There were also fewer pregnancies and adverse outcomes in MIME at 18 months, and fewer pregnancies and adverse outcomes in DIME at 9 and 18 months. However, these findings did not reach statistical significance. The lack of statistical significance might be explained by the small sample size due to participant attrition. Strikingly, nearly two-thirds (62% in MIME and 63% in DIME) of the 132 women in both intervention groups had one or more previously unrecognized or poorly managed chronic or high-risk conditions. This finding has significant long-term implications since women who experienced preterm and particularly very preterm (<32 weeks) delivery may be at increased risk for future cardiovascular events including myocardial infarction and stroke.23 Systems-level Findings Among both MIME and DIME cohorts, barriers were found at all three levels of the health care delivery system (as described by Dr. Alfred W. Brann, Jr., 2017, personal communication): 1) Informalmother, family, community; 2) Formal- providers, institutions,

In retrospect, multiple barriers may have contributed to noncompliance with the postpartum visit. Knowledge gaps related to the significance of followup, stress associated with premature delivery and possibly critically-ill infant, ongoing treatment of medical conditions at the time of delivery, and lack of familiarity with the healthcare system may all have played a role. Additional barriers included social factors among many women living in multigenerational households with weak family support. Community support for daycare, deferring pregnancy, and encouraging education were sparse. In some instances, participants came from situations of instability and violence. Among both intervention cohorts, women continually experienced overwhelming complexities, including limited education, unemployment, housing problems, and poverty. Participants existed in double jeopardy since they were both medically and socioeconomically at risk. Formal systems. MIME and DIME groups encountered different barriers. Of note, specialized Medicaid providers remain basically nonexistent in some DIME counties. DIME is a poorly resourced, largely rural area. The Mississippi River Delta is approximately 200 miles long and some 70 miles wide. Mississippi Medicaid lists 35 obstetrical providers for the 18 counties included in the DIME project area.22 The 35 obstetrical providers are disparately distributed across the DIME counties. Fourteen of the 35 obstetrical providers are in Desoto County which is a suburb of Memphis, TN. Nine counties have no Medicaid obstetrical providers. In stark comparison, MIME is in a highly resourced urban community. Mississippi Medicaid lists more than 60 obstetrical providers in Hinds County alone, with many more in neighboring Madison and Rankin Counties.23 In MIME, one resource mother and one female family medicine physician followed all the patients. Despite 1:1 contact with the women and availability of a dedicated support system, many women were lost to followup. The lack of adequate tracking systems exacerbated this problem. Several participants who became pregnant did not initially reveal their pregnancies, citing a desire to stay in the program. However, for these women, the program did not seem to engender health-seeking behaviors, which may take a longer period of participation.

vol. 61 • no. 2 • 2020 33

In DIME, care provision obstacles were often the product of participant distribution across a poorly resourced and large geographic area. Most participants were merged into existing [and understaffed] county public health clinics, which proved problematic in consistently delivering the proposed level of individualized care. From project onset, the resource mother role had to be modified to cover the larger geographical area. The substitution was a revolving list of social work students. The intent of the resource mother role was to provide an individualized, community-based support system for program participants. The intermittent student workers could not provide consistent, individualized, maternal-like care, largely due to inexperience. Intersection of systems. Transportation has historically presented a barrier to delivering health care in Mississippi. In the Mississippi Delta, few communities have public transportation. Public programs place restrictions on who may be present when utilizing services. Medicaid transportation frequently declined to transport the mother’s children with her if the children did not have a concomitant Medicaid-covered medical appointment. Wal-Mart vouchers for gas and pharmacy were offered to facilitate access to transportation and prescription medications. Again, geographic rurality interfered, since some participants lived more than 50 miles from the nearest Wal-Mart. In MIME, bus vouchers were available but with similar barriers. Mothers were prohibited from boarding city buses with technologydependent infants. Other transportation options were explored but proved fruitless. Liability risks eliminated the use of volunteers, churches or resource mothers to provide transportation. Comparison with Atlanta project. The Atlanta study demonstrated the importance of interpregnancy care in a densely populated, highly urbanized area. All care was provided at a large, urban, county supported hospital. The pay source was not an issue. Care and pharmacy were available at this single location. Participants had access to a metro subway system, so transportation was not an impediment. Important findings were a significant reduction in pregnancies conceived within 18 months of index VLBW birth and reduction in adverse pregnancy outcomes in the intervention cohort. The Mississippi study identified barriers to implementation and potential solutions to overcome these barriers. Therefore, the studies are complementary and should benefit Mississippi, Georgia and other states wishing to implement an IPC program particularly in rural areas. In addition, a subsequent project in Georgia has initiated “Gateways,” which is a support system for IPC participants to encourage enrollment and compliance. Future Plans. Further exploration of the feasibility and acceptability of interpregnancy care among diverse communities and populations is warranted. To clarify, future plans to implement interpregnancy care may address: 1) offering long-acting reversible contraception (LARC) prior to hospital discharge; 2) deferring enrollment to provide more in-depth education and understanding of the program; 3) developing a strategy to address the special problems of distance and resources in rural areas; 4) obtaining consent at enrollment to follow the women and their offspring to determine the long-term impact of IPC on health-seeking

34 vol. 61 • no. 2 • 2020

behaviors and pregnancy outcomes; 5) establishing a primary care medical home for high-risk women; 6) funding and liability insurance for transportation by community health workers; 7) establishing a Medicaid waiver to provide primary health care to low income, medically high risk women during the interpregnancy period; and 8) engaging community stakeholders as partners to address social barriers to care. Community involvement will be extremely important to the successful implementation of future IPC programs. Obviously, professional organizations such as the American Academy of Pediatrics, the American Academy of Family Physicians, and associations of educators should coordinate their efforts. Churches, particularly in the Deep South, have been recognized as important resources. Volunteer and advocacy associations are commonly anxious to participate and support programs to improve the lives of at risk women and their children. For example, Oren Renick, JD, MPH, Th.M., Professor of Health Administration, Texas State University, supervises a student volunteer service in San Marcos which provides transportation, respite care, and home maintenance services to elderly and disabled recipients. The program is associated with the National Volunteer Caregiving Network. It is an intergenerational model called the Mutual Adoption Pact. It has found that connecting elders and youth benefits both groups. The students provide needed services, and the elders become mentors. Subsequently, hospitals, local churches, and businesses have become involved, which benefits the community (Oren Renick, personal communication, 2019). Conclusion Interpregnancy care provides a unique and potentially valuable contribution of care to a very small (2%) but very high-risk group of women. However, program administration and implementation remain fraught with challenges at all levels of the healthcare system. The IPCM enrolled 132 postpartum women, individually matched with 132 controls. Nearly two-thirds of MIME (62%) and DIME (63%) participants had at least one chronic condition or risk factor epidemiologically linked to VLBW, either previously unrecognized or poorly managed. Fortyfive (96%) MIME and seventy-nine (93%) DIME cohort participants achieved the desired nine-month child spacing. Our study identified

multiple, correctable barriers (transportation, provider access, and limited continuity of care) in the rural, underserved Delta region. Despite more easily accessible services in the urban setting, participant utilization was less than anticipated. Future implementation plans should address solutions that ameliorate primary health care and socioeconomic issues faced by high risk, childbearing aged women. Decreasing medical risks and improving child spacing have been shown to reduce long-term morbidity, mortality, and exorbitant costs associated with adverse birth outcomes.14 n Acknowledgment The authors wish to express their appreciation to Dr. Alfred W. Brann, Jr., for his consultation and continuing support for this multiyear project, the Mississippi IPC Project from its inception to the present. Importantly, Dr. Brann was the first neonatologist in Mississippi when he joined the UMMC faculty in 1969. He has continued his close personal and professional ties to Mississippi over his 50-year career in helping mothers and infants. Dr. Brann is a Professor of Pediatrics at the Emory University School of Medicine. He is Director of the Global Collaborating Center in Reproductive Health (GCC/RH) in the Woodruff Health Sciences Center of Emory University. Dr. Brann is also the Director of the Global Collaborating Center in Reproductive Health for the World Health Organization and has consulted on infant mortality reduction projects in Russia, Cuba, Mexico, Atlanta, and Mississippi. In 2014 Dr. Brann was selected as the first recipient of the Alfred W. Brann Chair in Pediatrics for Reproductive Health and Perinatal Care, designated for the person who directs the GCC/RH. This endowed chair was established by the very generous gift of Drs. Ann and Frank Critz to Emory University. The Critzes live in Atlanta. They were both graduates of the University of Mississippi School of Medicine, Class of 1969. Conflict of Interest Disclosures: The authors have nothing to disclose. Author Information Professor Emeritus, University of Mississippi Medical Center (UMMC), Jackson, MS, former attending neonatologist, UMMC Department of Pediatrics, 1978-2015 (Graves). Adjunct Nursing Professor at Maryville University McAuley School of Nursing and research consultant, Mississippi State Department of Health, Jackson Heart Study Community Engagement Center (Graham). UMMC Lactation and WIC nurse, former clinical coordinator for The Interpregnancy Care Project (Ryan). Professor, Department of Obstetrics and Gynecology, and fellowship director, Division of Maternal-Fetal Medicine, UMMC (Owens). Former epidemiologist,

Mississippi State Department of Health, Jackson, MS (Wen). Director of the Office of Health Data and Research, Mississippi State Department of Health, Jackson, MS (Zhang). Corresponding author: Glen Graves, MD; University of Mississippi Medical Center, 2500 N. State St., Jackson MS 39216. Ph: (601) 6689174 (Glen.R.Graves@GMail.com). References 1. Hamilton BE, Martin JA, Osterman MJ, Curtin SC, Mathews TJ. Births: Final data for 2014. National Vital Statistics Reports. Hyattsville, MD: National Center for Health Statistics 2015;64(12). 2. Centers for Disease Control and Prevention (CDC). Infant mortality and low birth weight among black and white infants: United States, 1980-2000. MMWR. 2002;51(27):589-592. 3. Institute of Medicine [IOM]. Societal costs of preterm births. In R.E. Behrman & A.S. Butler, Eds., Preterm birth: Causes, Consequences, and Prevention, (2007:398429). Washington, DC: National Academies Press. 4. Zhang L, Hayes S, Sledge C, Wilson V, Graham J. Infant mortality in Mississippi, 1996-2005: Trend and risk analysis. Mississippi Department of Health Bureau of Health Data and Research website. http://msdh.ms.gov/msdhsite/_static/ resources/2899.pdf Published February 1, 2007. Accessed December 20, 2019. 5. Martin JA, Hamilton BE, Sutton PD, Ventura SJ, Menacker F, Kirmeyer S. Births: Final data for 2004. Natl Vital Stat Rep. 2006;55(1):1-102. 6. Barker DJP, Eriksson JG, Forsén T, Osmond C. Fetal origins of adult disease: Strength of effects and biological basis. Int J Epidemiol. 2002;31(6):1235-1239. doi:10.1093/ije/31.6.1235 7. Mohlman MK, Levy DT. Disparities in maternal child and health outcomes attributable to prenatal tobacco use. Matern Child Hlth J. 2016;20(3):701-709. doi:10.1007/s10995-015-1870-3. 8. Parham GP, Hicks ML. Racial disparities affecting the reproductive health of African-American women. Med Clinic N Am. 2005;89(5):935-943. doi.org/10.1016/j. mcna.2005.04.001 9. Browne JL, Vissers KM, Antwi E, Srofenyoh EK, Van der Linden EL, Agyepong IA, Grobbee DE, Klipstein-Grobusch KL. Perinatal outcomes after hypertensive disorders in pregnancy in a low resource setting. Trop Med Int Health. 2015;20(12):1778-1786. doi:10.1111/tmi.12606 10. Adams MM, Elam-Evans LD, Wilson HG, Gilbertz DA. Rates of and factors associated with recurrence of preterm delivery. J Amer Med Assoc. 2000;283(12):1591-1596. 11. U.S. Department of Health and Human Services [DHHS] Office of Disease Prevention and Health Promotion. Total weight infants (percent, <1,500 grams). Healthy People 2020, MICH 8.2. https://www.healthypeople.gov/2020/data/ Chart/4904?category=1&by=Total&fips=-1. Updated December 21, 2019. Accessed December 20, 2019. 12. Graham J. 2014 Infant mortality report. Health Services Office of Health Data and Research, Jackson, MS. Mississippi State Department of Health website. http:// msdh.ms.gov/msdhsite/_static/resources/6104.pdf. Accessed December 20, 2019. 13. CityMatch. MCH lifecourse tool box. CityMatCH website. https://www.city match.org/mch-life-course/ Published March 14, 2017. Accessed December 20, 2019. 14. Dunlop AL, Dubin C, Raynor BD, Bugg GW, Schmotzer B, Brann, A. Interpregnancy primary care and social support for African-American women at risk for recurrent very-low-birth-weight delivery: A pilot evaluation. Matern Child Hlth J. 2008;12(4):461-468. doi:10.1007/s10995-007-0279-z 15. Sliwa K, van Hagen I, Budts W, Swan L, Sinagra G, Caruana M, Blanco M, Wagenaar L, Johnson M, Webb G, Hall R, Roos-Hesselink J, ROPAC Investigators. Pulmonary hypertension and pregnancy outcomes: Data from the Registry of Pregnancy and Cardiac Disease (ROPAC) of the European Society of Cardiology. Eur J Heart Fail. 2016;18(9):1119-1128. doi:10.1002/ejhf.594

vol. 61 • no. 2 • 2020 35

16. Xaverius P, Alman C, Holtz L, Yarber L. Risk factors associated with very low birth weight in a large urban area, stratified by adequacy of prenatal care. Matern Child Hlth J. 2016;20(3):623-629. doi:10.1007/s10995-015-1861-4 17. Zhang L, Cox R, Graham J, Johnson D. Association of maternal medical conditions and unfavorable birth outcomes: Findings from the 1996-2003 Mississippi linked birth and death data. Matern Child Hlth J. 2011;15(7):910-920. doi:10.1007/ s10995-009-0516-8. 18. American College of Obstetricians and Gynecologists [ACOG]. ACOG committee opinion: Optimizing postpartum care. ACOG website https://www. acog.org/clinical-guidance-and-publications/committee-opinions/commit tee-on-obstetric-practice/optimizing-postpartum-care. Accessed September 13, 2019. 19. Medicaid Coverage. Who qualifies for coverage? Mississippi Division of Medicaid website. https://medicaid.ms.gov/medicaid-coverage/who-qualifies-for-cover age/. Updated 2019. Accessed December 20, 2019.

Helping you build a more secure future. We invest our own money alongside yours, so we are invested in your success.

20. Health Resources and Services Administration (HRSA). HRSA data warehouse, Find Shortage Areas, MUA find. Data. HRSA.gov website. https://dataware house.hrsa.gov/tools/analyzers/muafind.aspx. Accessed December 20, 2019.

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21. Rawlings JS, Rawlings VB, Read JA. Prevalence of low birth weight and preterm delivery in relation to the interval between pregnancies among white and black women. New Eng J Med. 1995;332:69-74.

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22. Mississippi Division of Medicaid (MDOM). Member Services, Locate a Medicaid Provider search. MDOM website. https://www.ms-medicaid.com/msenvi sion/providerSearch.do. Accessed September 13, 2019.

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23. Tanz LJ, Stuart JJ, Williams PL, Rimm EB, Missmer SB, Rexrode KM, Mukamal KJ. Preterm delivery and maternal cardiovascular disease in young and middle-aged women. Circulation. 2017;135:578-589. doi: 10.1161/CIRCULATIONAHA. 116.025954 24. US Department of Health and Human Services. Programs and Initiatives, Collaborative Improvement and Innovation Network to reduce infant mortality. HRSA Maternal & Child Health website. http://mchb.hrsa.gov/infantmortality/coiin Updated March 2018. Accessed December 20, 2019.

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318 Howard St reet • Greenwood, Mississippi 662 .453. 2114 • thealluvian.com

THE

ALLUVIAN

c o m m e n t a r y

The Role of Women’s Health in Reducing Preterm Births

“I

mplementing an Interpregnancy Care Project among Rural and Urban Mississippi Cohorts” (Graves et al.) in this issue of the JMSMA proposes a new approach to reducing infant mortality rates (IMR) in Mississippi.

There must be a focus on strategies of health promotion and disease prevention related to Women's Health to reduce rates of preterm and LBW births.

Introduction: Since my time at the University of Mississippi Medical Center (UMMC) from 1969-1975, I have Alfred W. Brann, Jr., MD continued my academic relationship with Global Collaborating Center in Reproductive Health Dr. Glen Graves and his colleagues in Woodruff Health Sciences Neonatal-Perinatal Medicine. We have Center, Emory University recognized that Mississippi and Georgia are among the five states with the highest rates of infant mortality and low birthweight (LBW) and very low birthweight (VLBW) births.1

1. The rate of LBW births in Mississippi, not being influenced by prenatal care, has not changed significantly over the past 25 years;2

Mississippi and Georgia have approached infant mortality as a complex medical problem, strongly influenced by social determinants of health. In the late 1960s, both states developed successful regional maternal and perinatal healthcare programs with dedicated neonatal transport services to ensure access to specialized hospital-based care for mothers in preterm labor and survival of their preterm infants. Both states saw an overall decline of some 50% in infant mortality rates, primarily due to increased survival of LBW and VLBW births. However, this approach to reducing infant mortality rates (IMR) and the prevalence of neurodevelopmental impairment (NDI) in surviving infants.2,3,4 is reaching its limits in the ability to provide effective care required for preterm infants approaching the limits of viability.

5. VLBW births are not random events. They are more common among women with poor underlying health status, women with poor access to quality healthcare, and African-American women;3,8,9,10,16,17

In the August 2018 issue of JMSMA devoted to Population Health, Dr. Mary Currier, then Mississippi’s State Health Officer, observed that the high rates of preterm or LBW births reflected the suboptimal status of women’s health resulting from inadequate accessibility and quality of primary health care and the availability of supportive community services. Study Design: The Graves study, in this issue, addresses one of the most important relationships within Population Health – the relationship between the status of women’s health and the rate of preterm and/or low birthweight births. The design of this study used Mississippi perinatal data and national research data, similar to that used by Dr. Anne Lang Dunlop in designing the Georgia Interpregnancy Care (IPC) study at Grady Memorial Hospital in Atlanta.5 The data used in the study design of the Graves study included:

2. Of Mississippi’s infant deaths, 54% come from VLBW births which comprise only 2.1% of Mississippi’s 37,928 annual births – only 811 women have VLBW births per year;2 3. A mother’s first VLBW birth is not predictable;6 4. Mothers who have had a VLBW birth have a known recurrence of a VLBW birth – 8% for Caucasian women, 13% for African American women, and 2x for teenage girls;7

6. Women who experience a preterm birth – independent of preeclampsia, gestational hypertension, and traditional cardiovascular disease (CVD) risk factors – are at increased risk for future cardiovascular events, including myocardial infarction and stroke;11,17 7. Postpartum Medicaid coverage – including primary health care, child spacing service, and social support for low income AfricanAmerican women who have experienced an adverse pregnancy outcome such as a VLBW birth – can promote pregnancy intendedness, optimum child spacing, and improved health status prior to the next pregnancy.5,12,13 Study Analysis: The findings of the Graves study include: 1. Nearly two-thirds of the women in both intervention groups (urban 62%; rural 63%) had one or more previously unrecognized and/or inadequately managed chronic conditions associated with adverse pregnancy outcomes. 2. Access to quality primary healthcare for low-income Mississippi women is the critical missing strategy needed to reduce chronic health problems, the associated rates of VLBW births, and subsequent exorbitant costs.

vol. 61 • no. 2 • 2020 37

3. The process of providing the integrated components of an IPC Program was confirmed by the presence of the trend of fewer pregnancies and fewer adverse pregnancy outcomes at 9 and 18 months in participants in both arms of the study. 4. Important for implementation, barriers to be corrected included:

References 1. United Health Foundation. America’s Health Ranking Annual Report -2018 https://www.americashealthrankings.org/explore/annual/measure/Overall/ state/ALL?edition-year=2018. Accessed September 20, 2019.

• inadequate urban and rural transportation; • poor retention of participants, leading to

2. Zhang L. Director of Office of Health Data and Research, Mississippi Department of Health. Infant mortality in Mississippi, 1996-2005: Trend and risk analysis. http:// msdh.ms.gov/msdhsite/_static/resources/2899.pdf Accessed September 20, 2019.

• variation in the feasibility and acceptability of IPC in both arms

3. Dunlop AL, McCarthy BJ, Freymann GR, Smith CK, Bugg GW, Brann AW. Analysis of Feto-Infant Mortality Using the BABIES Framework: Georgia 1981-83 through 2001-03. Int J Health Res. 2010; 3(3):153-163.

the incomplete provision of coordinated health care and social support; of the study;

• inadequate knowledge and skills of IPC for all participating health professionals; and

• insufficient numbers of providers of primary healthcare in the Delta arm of the study.

Summary: The Graves study – the Mississippi IPC Study – is a small, well-designed pilot study with a very tight budget. During the study, Dr. Graves, Dr. Helen Barnes, and Dr. Brann visited and talked with persons at the project sites. The findings in this study demonstrated a strong trend in their findings, similar in direction to the findings of the Georgia IPC Study.5 In spite of not achieving its primary objective, the Mississippi IPC study: a) established the need for, and b) demonstrated a strong ability to implement a statewide Interpregnancy Care Program. Because of the strength of the findings of the Mississippi IPC Study, consideration should be given to developing an 1115 Waiver in Mississippi focused on improving the health of women at risk of having a recurrent VLBW birth. The findings from the Georgia IPC study5 were central to Georgia’s development of its 1115 Medicaid Demonstration Waiver, Planning for Healthy Babies (P4HB).14 This was the first statewide program focused on improving the health of women at risk of having a recurrent VLBW birth. The results of P4HB’s Year 7 (2016), including the estimated savings of nearly $19 million in that year alone, are described in the Annual Report for Year 7.15 As of August 29, 2019, Georgia’s P4HB program has been extended for the next 10 years.

4. Durkin MS, Benedict RE, Christensen D, Dubois LA, Fitzgerald RT, Kirby RS, Meanner MJ, Van Naarden Braun K, Wingate MS, Yeargin-Allsopp M. Prevalence of Cerebral Palsy among 8-year-old children in 2010 and preliminary evidence of trends in its relationship to low birthweight. Paediatr Perinat Epidem. 2016 Sep; 30(5): 496–510. Published online 2016 May 23. doi: 10.1111/ppe.12299 5. Dunlop AL, Dubin C, Raynor D, Bugg Jr. GW, Schmotzer B, Brann AW Jr. Interpregnancy Primary Care and Social Support for African-American Women at Risk for Recurrent Very-low-birthweight Delivery: A Pilot Evaluation. Matern Child Health J 2008; 12:461–468. Published online 2007 Aug 22. doi: 10.1007/ s10995-007-0279-z 6. Lockwood, CJ. (2002). Predicting premature delivery-no easy task. New Eng J Med. 2002 Jan 24;346(4):282-4. 7. Adams MM, Elam-Evans LD, Wilson HG, Gilbertz DA. Rates of and factors associated with recurrence of preterm delivery. JAMA 2000 Mar 22-29;283(12): 1591-6. 8. Martin JA, Hamilton BE, Sutton PD, Ventura SJ, Menacker F, Kirmeyer S. Births: Final data for 2004. National Vital Statistics Report. 2006;55(1):1-101. 9. Adams MM, Sarno, AP, Harlass, EE, Rawlings, JS, & Read, JA (1995). Risk factors for preterm delivery in a healthy cohort. Epidemiology 1995;6(5):525-532. 10. U.S. Department of Health and Human Services [DHHS]. Total weight infants (percent, <1,500 grams). Healthy People 2020, MICH 8.2. https://www.healthy people.gov/2020/data/Chart/4904?category=1&by=Total&fips=-1. Accessed September 20, 2019. 11. Tanz LJ, Stuart JJ, Williams PL, Rimm EB, Missmer SB, Rexrode KM, Mukamal KJ. Preterm delivery and maternal cardiovascular disease in young and middle-aged women. Circulation 2017;135:578-589. doi: 10.1161/CIRCULATIO NAHA. 116.025954 12. Klerman, LV, Cliver, SP, & Goldenberg, RL (1998). The impact of short interpregnancy intervals on pregnancy outcomes in a low-income population. Am J Pub Health. 88, 1182–1185.

Conclusion: The major contributions of the Graves study include the recognition of the following:

13. Conde-Agudelo, A, Rosas-Bermudez, A, & Kafury-Goeta, A. (2006). Birth spacing and risk of adverse perinatal outcomes: A meta-analysis. JAMA. 2006;295(15):1809-1823. doi:10.1001/jama.295.15.1809

• The central role of women’s health and its profound influence

14. State of Georgia government, Georgia Medicaid, Planning for Healthy Babies. https://medicaid.georgia.gov/planning-healthy-babies-0/planning-healthybabies-program-overview Accessed September 20, 2019.

on the occurrence of preterm and/or low birthweight births.

• The

next major reduction of infant mortality and neurodevelopmental impairment will involve strategies to reduce the number of preterm and LBW births.

• The need for an organized postpartum health plan for all women with a previous VLBW birth should include Interpregnancy Care and long-term cardiovascular disease (CVD) surveillance; and

• The

Medicaid cost savings that will accrue from an Interpregnancy Care Program. n

38 vol. 61 • no. 2 • 2020

15. State of Georgia government, Georgia Department of Community Health Annual Reports, FY 2018 Annual Report & Auxiliary Charts. https://medicaide.georgia. gov/sites/medicaid.georgia.gov/files/related_files/document/Annual%20 Report%20Year%207%FINAL%2012%2027%2018.pdf Accessed September 20, 2019. 16. Dunlop AL, Salihu HM, Freymann GR, Smith CK, Brann, Jr AW. Very low birth weights births in Georgia, 1995-2005: Trends and racial disparities. Matern Child Health J 2011;15:890-898. 17. Hobel CJ, Dolanc SM, Niree A, Zhonge HN, Menon R. History of the establishment of the Preterm Birth International Collaborative (PREBIC) Placenta 2019;79: 3-20.

S C I E N C E

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Radiation Dose-Volume Effects in the Esophageal Toxicity for Lung Cancer Patients Treated with Radiotherapy Rui He, PHD; Elgenaid Hamadain, PhD; Claus Chunli Yang, PhD; Hamed Benghuzzi, PhD; Donna Sullivan, PhD; Michelle Tucci, PhD; Srinivasan Vijayakumar, MD

Abstract This paper reviewed the current status of dose-volume effects on radiation-induced esophagitis for lung cancer patients treated with radiation therapy in combination with chemotherapy. The importance of radiation techniques and chemotherapy drugs is emphasized. It pointed out that there are dose-volume related dosimetric predictors related to esophagitis. However, it indicated some challenges in clinical practice, such as the difficulties in determining definitive dosimetric predictors from the published data which involves the variety of volumetric metrics of the esophagus. Furthermore, lack of standardization in esophagus delineation causes lack of consensus of radiation dosimetric predictors in esophagitis. The treatment outcome review and analysis is encouraged at each individual institution. Meanwhile, normal tissue complication probability (NTCP) modeling, especially one of the most useful NTCP model of Lyman Kutcher Burman (LKB), is introduced and could be used in predicting the potential esophagitis. Keywords: Radiation therapy, lung cancer, esophagitis, radiation dose-volume effect Introduction Radiation therapy is a type of cancer treatment that uses ionizing high energy radiation such as X rays, gamma rays or electron beams to destroy cancer cells.1 Although radiation is beneficial at killing the tumor cell, it is harmful to the detriment of the healthy organ.2 Radiotherapy involves optimization of treatment plans to maximize the radiation dose to a tumor and minimize the dose to the critical organs around the tumor. Unfortunately, this is often impossible due to the anatomic distribution and the limitation of the radiation beam delivery. The aim of radiation therapy is to deliver enough radiation dose to a tumor to destroy it without irradiating normal tissue to a radiation dose level that will lead to serious complications.3 In other words, the aim of radiation therapy is to achieve an uncomplicated local and regional control of cancer.4 In order to reach this goal, the precise knowledge of

tumor control radiation dose and the tolerance dose (TD) of normal tissue to radiation is required.5 In the past, radiation therapy (RT) doses were selected empirically, largely based on the physician’s clinical experience. These empiric guidelines were imprecise and did not fully reflect t he u nderlying a natomy, p hysiology, and dosimetry.6 The q uestion “ What r adiation d ose i s b est f or c ancer treatment?” has been asked by radiation oncologists, radiobiologists and medical physicists since the onset of radiation therapy in the 19th century. In 1991, Emami et al. published the tolerance doses (TDs) of most various normal tissues to radiation therapy based on both literature review up to the year 1991 and the opinions of the experienced radiation oncologists.4 The purpose of their work was to give the therapeutic dose guidance to the clinical practice of radiation therapy and in the meantime, pointed out that the extensive and comprehensive research was needed. In 2013, Emami et al. published updated TDs of normal tissue to therapeutic radiation based on some of the modern radiotherapy developments and 3 dimensional (3D) conformal techniques in radiotherapy, and he pointed out again that more enhanced research work is needed in this area.2 “In 2015, it is continued to refine what is the ‘optimal’ fractionation for head and neck, prostate, lung, breast, and many other cancers within the clinical trial design and for individual patients.”7 A group of physicians and researchers noticing the aforementioned difficult, co mplex an d ob vious ne eds jo ined to wo rk on th e so called “Quantitative Analysis of Normal Tissue Effects in the Clinic (QUANTEC).” QUANTEC published a series of papers on organ-specific radiation doses dealing with the extremely complex and multifactorial issues in the field of normal tissue tolerance to therapeutic radiation. Despite these efforts, many questions still remain unanswered. It will continue to be an urgent need for comprehensive and collaborative research.2 QUANTEC encourages each individual institute of cancer treatment to perform the treatment outcome analysis.8 Big data science in radiation oncology research is coming.9 There will be many types of important radiation oncology questions that can be addressed in the data set which will expand our knowledge tremendously.

vol. 61 • no. 2 • 2020 39

Esophagitis in Lung Cancer Patients Treated by Radiotherapy

Dosimetric parameters in treatment planning

Since the late 1980s, radiation therapy was considered the standard of care for patients with lung cancer. Combined concurrent chemo-radiotherapy is the standard treatment for locally advanced, inoperable non-smallcell lung cancer patients.10 For patients with small-cell lung cancer, it is advantageous to give RT first followed by chemotherapy (sequential chemo/radiation therapy) in the treatment course or concurrently with chemotherapy (concurrent chemo/radiation therapy). The esophagus is one of the critical organs at risk (OAR) when lung cancer is treated by radiation therapy. Acute esophageal toxicity is seen as one of the main complications for lung cancer radiation treatment, and it is known to be a significant dose-limiting factor.8 Severe esophagitis can cause hospitalization and breaks in treatment, which will reduce tumor control probabilities. The late esophageal complication of stricture formation is an abnormal narrowing of a bodily passage and ulceration.

In current clinical treatment plan for lung treatment, the esophagus dose constraint is set as mean dose less than 34 Gy.2 Emami et al. in their 1991 published paper listed esophagus tolerance of TD5/5 for 1/3, 2/3 and 3/3 of volume as 60 Gy, 58 Gy, and 55 Gy respectively; and TD50/5 as 72 Gy, 70 Gy and 68 Gy.4 Definitions of treatment planning parameters in dosimetry and other terminologies used here, e.g., TD5/5 and TD50/5, are listed in Table 2. The previously reported dosimetric predictors for acute radiation-induced esophagitis are percentage of esophageal volume receiving dose larger than 45 Gy (V45), V50, V60, length of esophagus in the treatment field, maximal esophageal point dose, mean esophageal dose (Dmean), hyperfractionated RT, and esophageal surface area receiving 55 Gy.12 However, these predictors are too varied to unify them.12 The results include a total of 12 studies published between 1999 and 2009 that assessed the dose-volume outcome in more than 90 patients treated for non-small cell lung cancer were reviewed.8 The endpoint in this paper was based on radiation therapy oncology group (RTOG) Grades. These studies found a correlation with these endpoints for a variety of dose-volume factors, such as V20, V35, V60 and V70. They found that a variety of clinical and dosimetric parameters have been associated with acute and late toxicity. However, several studies have provided information to estimate the incidence of esophagitis to dosimetric parameters, which seems to be dose-volume response related, although the inter-study variations have been large.8 The main difficulty in determining definitive dosimetric predictors from the published data is the variety of volumetric metrics of the esophagus. For instance, some used the absolute volume of the esophagus and some used relative volume. It indicated that the esophagus delineation is lacking standardization. As a result, it lacks of consensus of radiation dosimetric predictors in esophagitis. Nevertheless, the paper stated that the data are somewhat consistent with rates acute Grade 2 or greater esophagitis increasing to more than 30% when V70 exceeds 20%, V50 exceeds 40%, and V35 exceeds 50%.8 Further study is necessary as many studies led to different and sometimes even contradictory results.13 It is also important to analyze the dose (not the final treatment dose) at which the acute esophagitis starts to develop.8 It is necessary to do one more step further to determine the radiation sensitivity of cephalad, middle and caudal of the esophagus by analyzing the dosimetric parameters related.

The esophagus is about 25 cm in length and is a muscular tissue connecting the throat to the stomach. Anatomically, the heart, trachea, and lungs are nearby. In radiotherapy, the esophagus is contoured/drawn by a radiation oncologist on the axial computed tomography (CT) image slice, and the entire length of the esophagus, from the cricoid cartilage to the gastroesophageal junction is identified in the planning CT scan. The main challenges of defining the esophagus in CT images are listed in Table 1. Clinical data indicate that both patient-related and treatment-related factors contribute to esophageal toxicities.5 Factors such as height, weight, gender, race, age, personal health condition, cancer stage, esophagus length, treatment technique, dosimetric parameters, dose per fraction, overall treatment time, volume of tumor/normal tissue irradiated, concomitant use of chemotherapy, etc. are correlated to treatment outcomes.2 In this review, we will focus on the three major key risk factors: dosimetric parameters in treatment planning, treatment techniques and RT combined with chemotherapy. Table 1. Challenges of Defining the Esophagus in CT Images and Consequent Dose Calculating Inaccuracy

Visibility Tube structure

Mobility Mobile Movement up to 9 mm11

Very difficult to determine the lumen

Cause inaccuracy of dose volume calculation in CT image based treatment planning8

Might cause uncertainty of dose calculation due to high electronic density of barium paste

40 vol. 61 • no. 2 • 2020

Dose volume histogram, commonly used cumulative DVH: relative volume (%) versus absolute dose (Gy) Highest dose that encloses v% organ volume, e.g. D5: dose to 5% of volume received

Dmax

Maximum dose in an organ (Gy)

Volume (%) receiving ≥ dose D, e.g. V20: volume in % receiving ≥ 20 Gy

Dmean

Mean dose (Gy)

TD5/5

Tolerance dose (Gy) for 5% complication probability at year 5

DVH

Closed when no swallowing activities

Barium paste administrated to locate esophagus in CT image

Table 2. Definitions of Treatment Planning Parameters in Dosimetry

TD50/5 Tolerance dose (Gy) for 50% complication probability at year 5

Treatment technique

Normal Tissue Complication Probability (Ntcp) Model

The treatment techniques of radiation therapy for lung cancer treatment used in a conventional way are to use Anterior-posterior/Posterioranterior (AP/PA) beam arrangement to the target dose of 45 Gy with 1.8 Gy per fraction daily, then to use off spinal cord beams (or oblique beams to avoid irradiating the cord) to boost target dose to a total of 59.4 Gy. With the technological developments, the low modulated intensitymodulated radiotherapy (IMRT) and 4 dimensional (4D) motion management are gradually implemented in the lung cancer radiation treatment with better tumor dose conformation at the University of Mississippi Medical Center, Radiation Oncology. Acute toxicity and oncologic outcomes in a large cohort of lung cancer patients treated with IMRT or 3-dimensional conformal radiotherapy (3D-CRT) have been compared.14 They identified no differences in any measures of acute toxicity by treatment technique. But there was a nonsignificant trend toward lower rates of grade 2 esophagitis among IMRT patients compared to 3D-CRT patients. A comparison of once-daily radiotherapy to 60 Gy and twice-daily radiotherapy to 45 Gy for limited-stage smallcell lung cancer concluded that esophagitis was more common in the twice-daily group.15 Although the differences in overall survival and local-regional recurrence free survival were not significant between the once-daily and twice-daily groups, there was a trend toward to improving local control in the twice-daily group. Hypofractionated RT offers good disease control for patients with advanced stage non-small cell lung cancer with acceptable toxicity rates.16 At a recent ASTRO (American Society for Radiation Oncology) meeting (October 23, 2015), IMRT for lung cancer treatment which results in less inflammation and better tolerance of chemo was presented. This study pointed out that the treatment modality can be an important factor associated with the severity of the normal tissue toxicities.

Normal tissue complication probability (NTCP) modeling plays an important role in treatment plan evaluation, optimization, and predicting normal tissue radiation injury.19 Lyman Kutcher Burman (LKB) model is probably the most useful method of NTCP modeling in radiotherapy.20 Several publications have reported using LKB to predict the normal tissue complication in radiotherapy, such as the pneumonitis in lung cancer treatment; esophagitis in lung cancer treatment, xerostomia in head and neck cancer treatment; and rectal complication in prostate cancer treatment.10, 20, 21, 24

Radiotherapy combined with chemotherapy The combination of chemotherapy and radiation resulted in an improved local and regional control and increased survival by 5% to 10% in patients with locally advanced non-small cell lung cancer (NSCLC) and small cell lung cancer (SCLC).17 For locally advanced lung cancer, concurrent chemoradiotherapy showed consistent improvement in survival compared with sequential chemoradiotherapy but at the cost of increasing in the toxicity.18 The toxicity of adding chemotherapy to radiation therapy is mainly dermatitis, mucositis, esophagitis, and pneumonitis. Radiation-induced esophagitis occurs in 30% of patients receiving chemoradiotherapy and is dose-limiting acute toxicity.17 The rate of severe esophagitis varies depending on the factors of the radiosensitizing effect of the chemotherapy drug and the radiation dose delivered to the esophagus, and the esophagus volume irradiated.17 In addition, the interruption of radiotherapy due to toxicity results in a significant reduction in local-regional control, overall survival, and metastasis-free survival. Clearly, modern radiation oncology is facing the challenges of interactions between different radiation techniques and the many chemical and biological agents used for cancer therapy. How to quantify and model or predict the normal tissue complication is a very urgent need for modern radiotherapy to treat cancer.

The LKB model21 allows partial volumes of homogenous dose to be achieved and adapted for conventional radiotherapy using the histogram reduction work of Kutcher et al.22 Parameter values of Emami et al.4 and Burman et al.23 were fitted in the model. There are four parameters in the LKB model which are NTCP, TD50, m and n. TD50 represents the dose for a homogenous dose distribution to a full organ at which 50% of patients are likely to develop defined toxicity. m is related to the standard deviation of TD50 and describes the steepness of the dose-response curve and n indicates the volume effect of the organ being assessed. Following are the equations used in the model: n

  EUD = ∑v i D1i /n   i  EUD −TD50 t= m TD50

...(1) ...(2) 2

NTCP =

1 t −2x ∫ e dx 2 −∞

...(3)

Equations (2) and (3) represent a sigmoidal curve that is determined by three parameters, TD50, m and n. Equivalent Uniform Dose (EUD) is the dose at which a given uniform dose to the entire organ would produce the same normal tissue complication probability as the original dose distribution by assuming that any two dose distributions are equivalent if they cause the same radiobiological effect. For each organ, the normal tissue complication probability (NTCP) depends in a very complex way on the dose and the irradiated volume. Determination of the relationship between the NTCP and tumor control probability (TCP) with the dose volume distribution has been the goal of many researchers and clinicians over the past few years. Clinical radiobiology focuses on the relationship between a given radiation dose and the resulting biological effect on tumors and normal tissues. The injury of several organs, including heart, liver, lung, rectum, and parotid gland, from radiation is assessed and these organs’ updated TD data are listed based on the LKB model.24 Conclusions Tumor control probability (TCP) is a sigmoid curve with the increments in dose increasing the tumor-killing. Similarly, NTCP is a sigmoid curve sitting hopefully at the right side of the TCP curve, as illustrated in the figure. If the two curves are close together, the increments in dose will cause the increases of both TCP and NTCP. If the two curves are

vol. 61 • no. 2 • 2020 41

Figure. Illustration of Therapeutic Ratio to be Increased by Different Means5 Therapeutic Ratio 1.2

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100

150

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separated largely with NTCP at the right side of TCP, the increases in dose will cause only TCP increase but keep the NTCP to be relatively low. All efforts in radiation therapy are aimed to separate the two curves farther apart. The ratio of the doses to cause the same TCP and NTCP is defined as the therapeutic ratio. In other words, the goal of radiation therapy is to increase the therapeutic ratio. Unfortunately, over the 100 years of radiation therapy practice, besides the current technological progress, the knowledge of TCP and NTCP are kept limited due to the complexity of the subjects. The radiobiology is likewise revolution; however, the current radiation therapy is far more influenced and changed by the technological developments than the radiobiology insights. The concept and the availability of 3DCRT shifts the NTCP curve farther to the right of TCP curve, making the radiation dose to the tumor more conformal and avoiding normal tissue receiving high radiation dose. The treatment recording system has improved qualitatively, which will enhance the model prediction. Although there are limitations in this research area, looking forward more reasonable parameters related to normal tissue complications will be established. n Conflict of Interest Disclosures: The authors have nothing to disclose. Author Information From the University of Mississippi Medical Center, Jackson, Mississippi. Medical Physicist, Assistant Professor, Department of Radiation Oncology (He). Biostatistician, Professor, Department of Diagnostic and Clinical Health Sciences (Hamadain). Medical Physicist, Professor, Department of Radiation Oncology (Chunli Yang). Professor, Department of Diagnostic and Clinical Health Sciences (Benghuzzi). Professor, Department of School of Medicine (Sullivan). Professor, Department of Orthopedic Surgery (Tucci). Radiation Oncologist, Professor, Department of Radiation Oncology (Vijayakumar). Corresponding author: Rui He, PhD; Department of Radiation Oncology, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216. Ph: (601) 815-6893 (rhe@umc.edu).

42 vol. 61 • no. 2 • 2020

References 1. Khan FM, Introduction: Process, Equipment, and Personnel, in Khan’s treatment planning in radiation oncology, ed 4, Khan FM, Gibbons JP and Sperduto PW (ed). Philadelphia, PA: Wolters Kluwer; 2016:3-11. 2. Emami B, Tolerance of normal tissue to therapeutic radiation. Rep radiother o ncol. 2013;1:35-48. 3. Johns HE, Cunningham JR, Radiobiology in The Physics of Radiology, ed 4, Springfield, IL: Charles C Thomas Publisher; 1983:670-718. 4. Emami, B, Lyman J, Brown A, et al. Tolerance of normal tissue to radiation irradiation. Int J Radiat Oncol Biol Phys. 1991;21:109-122. 5. Bradley J, Deasy JO, Bentzen S, et al. Dosimetric correlates for acute esophagitis in patients treated with radiotherapy for lung carcinoma. Int J Radiat Oncol Biol Phys. 2004;58:1106-1113. 6. Marks LB, Yorke ED, Jackson A, et al. Use of normal tissue complication probability (NTCP) models in the clinic. Int J Radiat Oncol Biol Phys. 2010;76(3 Suppl):S10–S19. 7. Bentzen SM, Constine LS, Deasu JO, et al. Quantitative analyses of normal tissue effects in the clinic (QUANTEC): An introduction to the scientific issues. Int J Radiat Oncol Biol Phys. 2010;76(3 Suppl):S3-9. 8. Werner-Wasik M, Yorke E, Deasy J, et al. Radiation dose-volume effects in the esophagus. Int J Radiat Oncol Biol Phys. 2010;76(3 Suppl):S86–S93. 9. Bentzen S, Supersize it: Big data comes to radiation oncology research. ASTROnews, fall 2016;14. 10. Rodriguez N, Algara M, Foro P, et al. Predictors of acute esophagitis in lung cancer patients treated with concurrent three-dimensional conformal radiotherapy and chemotherapy. Int J Radiat Oncol Biol Phys. 2009;73:810-817. 11. Dieleman EM, Senan S, Vincent A, et al. Four-dimensional computed tomographic analysis of esophageal mobility during normal respiration. Int J Radiat Oncol Biol Phys. 2007;67:775–780. 12. Takeda K, Nemot K, Saito H, et al. Dosimetric correlation of acute esophagitis in lung cancer patients treated with radiotherapy. Int J Radiat Oncol Biol Phys. 2005;62:626-629. 13. Billiet C, Peeters S, De Ruysscher D, et al. Focus on treatment complications and optimal management: radiation oncology. Transl Lung Cancer Res. 2014;3:187-191. 14. Ling DC, Hess CB, Chen AM, et al. Comparison of toxicity between intensitymodulated radiotherapy and 3-Dimensional conformal radiotherapy for locally advanced non-small-cell lung cancer. Clin Lung Cancer. 2016;17:18-23. 15. Han D, Hao S, Tao C, et al. Comparison of once daily radiotherapy to 60 Gy and twice daily radiotherapy to 45 Gy for limited stage small-cell lung cancer. Thorac Cancer. 2015;6:643-648. 16. Agoli L, Valeriani M, Bracci S, et al. Hypofractionated image-guided radiation therapy (3Gy/fraction) in patients affected by inoperable advanced-stage Nonsmall-cell lung cancer after long-term follow-up. Anticancer Res. 2015;35:5693-5700. 17. Yazbeck VY, Villaruz L, Haley M, et al. Management of normal tissue toxicity associated with chemoradiation (primary skin, esophagus, and lung). Cancer J. 2013;19:231-237. 18. Fournel P, Robinet G, Thomas P, et al. Randomized phase III trial of sequential chemoradiotherapy compared with concurrent chemoradiotherapy in locally advanced non-small-cell lung cancer: Groupe Lyon-Saint-Etienne d’Oncologie Thoracique-Groupe Francais de Pneumo-Cancerologie NPC 95-01 Study. J Clin Oncol. 2005;23:5910-5917. 19. Deasy JO, Niemierko A, Herbert D, et al. Methodological issues in radiation dose-volume outcome analyses: Summary of a joint AAPM/NIH workshop. Med Phys. 2002;29:2109–2127. 20. Gulliford SL, Partridge M, Sydes MR, et al. Parameters for the Lyman Kutcher Burman (LKB) model of Normal Tissue complication Probability (NTCP) for specific rectal complications observed in clinical practice. Radiother Oncol. 2012;102:347-351. 21. Lyman JT, Complication probability as assessed from dose–volume histograms. Radiat Res Suppl. 1985;8:S13–S19. 22. Kutcher GJ, Burman C, Brewster L, et al. Histogram reduction method for calculating complication probabilities for three-dimensional treatment planning evaluations. Int J Radiat Oncol Biol Phys. 1991;21:137–146. 23. Burman C, Kutcher GJ, Emami B, et al. Fitting of normal tissue tolerance data to an analytic function. Int J Radiat Oncol Biol Phys. 1991;21:123–135. 24. Kukolowicz P, Clinical aspects of normal tissue complication probability. Rep Pract Oncol Radiother. 2004;9:261-267.

S C I E N C E

O F

M E D I C I N E

Top 10 Facts You Need to Know about Childhood Obesity John Hanson, M4; Whitney Herring, MD, MPH Introduction Despite national trends in decreasing pediatric obesity numbers for certain age groups, the incidence remains alarmingly high with Mississippi still staying at the top. Obesity in children is estimated to be responsible for $14.1 billion in additional healthcare costs1 with profound effects from obesity-related co-morbidities. It is important for primary care providers to be aware of these co-morbidities but also the most current developments in obesity pathology, prevention and treatment. Childhood obesity rates in Mississippi remain above the national average. Studies of Mississippi public school students in grades Kindergarten through 12th show an even higher obesity rate at 25.2% with a combined total of overweight and obese children found to be a staggering 43.4%.2 This is compared to 18.5% of children considered obese in the same age groups nationwide.3 There are monogenic, syndromic and polygenic causes of obesity; however obesity is most commonly caused by an interplay of genetics, epigenetics and environmental factors. Around 40-70% of obese patients have an underlining genetic component that is inherited.4 Monogenic causes of obesity are extremely rare and mostly located in the leptin-melanocortin pathway. Syndromic obesity may be due to a single gene change or by several genes within a chromosomal region with phenotypes including intellectual disability, dysmorphic facies and abnormalities specific to organ systems.5 Fat acts as an endocrine organ, further contributing to obesity. Adipose tissue is the primary storage for excess energy with an additional role in appetite regulation, body weight homeostasis and glucose and lipid metabolism. It also secretes many substances such as adipocytokines which, if production is unbalanced in obesity, may be a factor in the development of metabolic syndrome. Some secreted factors include tumor necrosis factor-α, leptin, and IL-6.6 Risk factors for obesity begin as early as the prenatal state, as well as continuing into infancy and beyond. Specifically, a strong association between Gestational Diabetes Mellitus (GDM)/maternal obesity and childhood obesity exists. Both conditions elevate birth weight risk that then increases adolescent elevated BMI risk. It has been estimated that as the birth weight of a

newborn increases by 1kg increments, one sees an additional 30% increase in childhood obesity prevalence.7 Screening for the presence of overweight and obesity should be performed at every clinic visit. Body Mass Index should be plotted on growth charts during visits and BMI percentiles noted. Overweight BMI is defined as 85-94% and obesity as > 95%. Class II obesity is 120% of the 95th percentile, and class III obesity is 140% of the 95th percentile. According to the US Preventive Service Task Force (USPSTF), children should also be evaluated for specific risk factors including parental obesity, improper nutrition, poor sleep, low socioeconomic status and sedentary lifestyles.8 Recommended weight change differs with age and body mass index percentile. Weight goals may include maintenance of weight, slowing of weight velocity or even weight loss. This depends on age, health risks and weight classification.9 (Table) Primary care physicians should utilize motivational interviewing as first-line treatment. The goal is to prevent future gain in weight and promote an increase in physical activity. This includes goal-setting, self-monitoring and stimulus control. Most evidence suggests that familial-based behavioral interventions show the greatest evidence of weight change and reduction in behavioral rebound.10 After failure of primary care interventions over 3 to 6 months, referral to a weight management specialist is indicated. Progression through treatment stages is based on readiness for change.11 Intensive interventions should be utilized by multidisciplinary teams, including a pediatrician, nutritionist, and a pediatric obesity specialist. Treatments start with calorie deficits that provide high protein with low fats and carbohydrates. Pharmacotherapy can be used adjunctively.12 Evidence shows that early detection and ≥26 clinical contact hours using intensive behavioral interventions result in the greatest weight improvement over a 12-month period.8 Bariatric surgery should be considered in adolescents with class II obesity along with obesity-related co-morbidities, or with class III obesity. Clinically significant co-morbidities include obstructive sleep apnea (Apnea hypopnea index >5), type 2 diabetes, idiopathic intracranial hypertension, non-alcoholic steatohepatitis, Blount’s disease, slipped capito-femoral epiphysis, gastroesophageal reflux disease or hypertension.9

vol. 61 • no. 2 • 2020 43

Table. Recommended Weight Change by Age and BMI Category

Age

BMI Category

Weight Goal to Improve BMI Percentile

<2y

Weight for height

N/A

2-5 y

5th-84th percentile or

Weight velocity maintenance

85th-94th percentile with no health risks 85th-94th percentile with health risks >95th percentile

Weight maintenance or slow weight gain Weight maintenance (weight loss of up to 1 lb/mo may be acceptable if BMI is >21 or 22 kg/m2

6-11 y

5 -84 percentile or 85th-94th percentile with no health risks 85th-94th percentile with health risks 95th-99th percentile th

>99th percentile 12-18 y 5 -84 percentile or 85th-94th percentile with no health risks 85th-94th percentile with health risks 95th-99th percentile >99th percentile th

Weight velocity maintenance

Weight maintenance Gradual weight loss (1 lb/mo or 0.5 kg/mo) Weight loss (maximum is 2 lb/ wk) Weight velocity maintenance; after linear growth is complete, weight maintenance Weight maintenance or gradual weight loss Weight loss (maximum is 2 lb/wk) Weight loss (maximum is 2 lb/wk)

Quality of life for obese children deserves focus. It has been shown that obese children and adolescents report lower health-related quality of life and have a similar quality of life to children and adolescents with cancer. Parent proxy reports show that BMI z score was inversely correlated with physical, social and psychosocial functioning.13 Conclusion With increasing rates of childhood obesity in Mississippi, it is important to screen, prevent, and treat the pediatric population, actively. Even with limited clinical research on the topic of childhood obesity, it is imperative that more focus goes into this area to help with this everincreasing epidemic. n Acknowledgment Conflict of Interest Disclosures: The authors have nothing to disclose.

44 vol. 61 • no. 2 • 2020

Author Information From the Department of Pediatrics, University of Mississippi Medical Center, Jackson, MS. Fourth-year medical student, University of Mississippi Medical Center (Hanson). Director of Pediatric Obesity Medicine and Nutrition at the Mississippi Center for Advanced Medicine, Madison, MS (Herring). Corresponding Author: John Hanson, University of Mississippi Medical Center, 2500 N. State St. Jackson, MS 39216 Ph: (229) 5471077 (jbhanson@umc.edu). References 1. Finkelstein EA, Graham WCK, Malhotra R. Lifetime direct medical costs of childhood obesity. Pediatrics. 2014;133(5):854-862. doi:10.1542/peds.2014-0063 2. Zhang L, Kolbo JR, Kirkup M, et al. Prevalence and trends in overweight and obesity among Mississippi public school students, 2005-2013. J Miss State Med Assoc. 2014;55(3):80-7. 3. Hales CM, Carroll MD, Fryar CD, Ogden CL. Prevalence of obesity among adults and youth: United States, 2015-2016. NCHS Data Brief. 2017;(288):1-8. 4. Wardle J, Carnell S, Haworth CM, Plomin R. Evidence for a strong genetic influence on childhood adiposity despite the force of the obesogenic environment, Am J Clin Nutr. 2008;87(2):398-404. doi: 10.1093/ajcn/87.2.398 5. Thaker VV. Genetic and epigenetic causes of obesity. Adolesc Med State Art Rev. 2017;28(2):379-405. 6. Coelho M, Oliveira T, Fernandes R. Biochemistry of adipose tissue: an endocrine organ. Arch Med Sci. 2013;2:191-200. doi:10.5114/aoms.2013.33181 7. Gillman MW, S. Rifas-Shiman S, Berkey CS, Field AE, Colditz GA. Maternal gestational diabetes, birth weight, and adolescent obesity. Pediatrics. 2003;111(3). doi:10.1542/peds.111.3.e 8. US Preventive Services Task Force. Screening for obesity in children and adolescents: US preventive services Task Force recommendation statement. JAMA. 2017;317(23):2417-2426. doi:10.1001/jama.2017.6803 9. Pratt JSA, Browne A, Browne NT, et al. ASMBS pediatric metabolic and bariatric surgery guidelines, 2018. Surg Obes and Relat Dis. 2018;14(7):882-901. 10. Kirk S, Scott BJ, Daniels SR, Pediatric obesity epidemic: treatment options, J Am Dietetic Assn. 2005;105(5):44-51. doi:10.1016/j.jada.2005.02.013. 11. Barlow SE. Expert committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: summary report. Pediatrics. 2007;120 (supplement 4). doi:10.1542/peds.2007-2329c. 12. Yanovski JA. Intensive therapies for pediatric obesity, Ped Clinics North Amer. 2001;48(4):1041-1053. doi:10.1016/s0031-3955(05)70356-4 13. Schwimmer JB, Burwinkle TM, Varni JW. Health-related quality of life of severely obese children and adolescents. JAMA. 2003;289(14):1813–1819. doi:10.1001/ jama.289.14.181

S p e c i a l

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INTERVIEW EXCLUSIVE Avani Patel, M4

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DR. C AUDE BRUNSON, MSMA EXECUTIVE DIRECTOR

vol. 61 • no. 2 • 2020 45

“We are the indispensable organization that represents physicians and thereby represents represent healthcare in the state. My vision is that we will continue that strong legacy and continue to adapt to a modern healthcare environment and that Mississippi physicians stand up and take their rightful place in leading Mississippi to a healthier state where we are providing access to care to all Mississippians and helping our state policy makers come up with a healthcare delivery system that works for Mississippians.”

Want to hear more information from your Executive Director of MSMA? Check out our YouTube video series.

MISSISSIPPI STATE MEDICAL ASSOCIATION

Q: Q:

WHAT IS YOUR VISION FOR MSMA?

46 vol. 61 • no. 2 • 2020

PLEASE TELL US A LITTLE BIT ABOUT YOUR TRANSITION FROM A MEMBER, PAST PRESIDENT, PAST CHAIRMAN OF THE DELEGATION, AND PAST CHAIRMAN OF THE BOT TO EXECUTIVE DIRECTOR?

Claude D. Brunson. MD l.1ecu 1lwc Olrcclor

WHAT HAVE YOU LEARNED FROM THIS PROCESS?

Want to hear more information from your Executive Director of MSMA? Check out our YouTube video series.

“When I look back over my career, I’ve had a number of different roles in MSMA. At the same time, I was also working at the University of Mississippi medical medical center. I've also worked at a rural hospital in Brookhaven. When you of these, these, it I've had combine all of has given me the opportunity to the opportunity to experience experience almost every almost every aspect of a aspect of a physician’s physician’s professional life. It professional It allows me allows me aslife. Executive Director as Executive Director come to come up with ideastoand up with ideas and programs programs that actually work for that actually work for practicing physicians.” practicing physicians.”

“All the different things that I have done gives me the ability to relate to physicians and understand what frustrations they may be undergoing in a complicated health delivery system and then asking the state medical association to partner with them to make their lives easier so that they can do what they are trained to do—take care of patients and make Mississippi healthy.”

vol. 61 • no. 2 • 2020 47

WHY IS IT IMPORTANT FOR ALL PHYSICIANS TO BE MEMBERS, INCLUDING ACADEMIC AND HOSPITAL-EMPLOYED PHYSICIANS?

"EACH ONE OF US BRINGS AN INDIVIDUAL AND UNIQUE VOICE TO THE CONVERSATION ABOUT HOW WE IMPROVE HEAL TH IN OUR STATE. THAT'S IMPORTANT WHETHER WE ARE IN PRIVATE PRACTICE OR HOSPITALEMPLOYED PRACTICE." “I was an academic medicine physician for 30 years. I’ve always thought that of all doctors, it is the academic physician who ought to be the first physician that runs to join this organization. The reason I say that is because our product is more physicians—bright minds we’re bringing into medicine and training them to go out and take care of patients. Anybody else who is producing a product will market that product, be proud of that product and by extension creating a legacy—physicians to go out and practice medicine. If I truly believe in what I am doing, I have a responsibility to make sure the environment I’m sending them out into is conducive to practice their art and take care of patients. So I think it is most important for me and my colleagues to become members of this association because this is where we go to protect the profession and make sure that Mississippians have access to high quality health care.”

48 vol. 61 • no. 2 • 2020

“That is one of the things I have thought about long and hard across my years as a member of the association and being in practice as a physician anesthesiologist. What is the importance of organized medicine and membership in this association? In my mind, it’s a professional responsibility because this is the association that represents physicians and the potential that we have as physicians to affect policies that make healthcare in the state better, that helps us move medicine forward, move healthcare forward.”

Want to hear more information from your Executive Director of MSMA? Check out our YouTube video series.

WHAT DO YOU ENVISION AS THE ONE SINGLE THREAT YOU SEE IN ORGANIZED MEDICINE IN MISSISSIPPI?

Want to hear more information from your Executive Director of MSMA? Check out our YouTube video series.

most important importantthreat threatisis “The single most everybody that that we we APATHY. We need everybody can train to be participating in the train to be participating in the healthcare healthcare delivery delivery system, system,but but physicians physicians are are the the natural naturalleaders leaders and the the head head of ofthose thosehealthcare healthcare delivery teams. teams. As Aswe've we'vecontinued continued to see these these scope scope battles, battles,what whatI think have done is is we I thinkphysicians physicians have done have tried stay outto ofremain that fray to stay out ofto that fray remain professionally above that fray. professionally above that fray. But But we have toinvolved. be involved. we have to be We We cannot cannot be apathetic; we cannot sit be apathetic; we cannot sit back back because the system will because the system will change. change. If we truly that believe that If we truly believe there is there is something unique abouthow how something unique about physicians physicians are are trained trainedand andhow howitithas put at level treat, has them put them at atolevel todiagnose, treat, and formulate for patients that diagnose, and plans formulate plans for is unique,that theniswe have a patients unique, then we responsibility to PROTECT this have a responsibility to PROTECT profession and those patients. this profession and those patients. Physicians cannot cannot be be apathetic; apathetic;they have to ENGAGE. We have have they have to ENGAGE. We to have to their lending into theinto chorus have VOICES their VOICES blending of it’s so thewhy chorus ofimportant why it’s sophysicians important lead the healthcare and that physicians lead the team; healthcare team; medical provided physicians and thatcare medical care by provided by in an organized manner makes a physicians in an organized manner difference to Mississippians in makes a difference to Mississippians getting thethe highest quality andand best in getting highest quality care. Another thing—we needneed to best care. Another thing—we stand up up andand take ourour rightful place to stand take rightful of being leaders in healthcare and place of being leaders in healthcare make sure sure we are for and make weadvocating are advocating what will make it better for us tous to for what will make it better for provide that that care care to toour ourpatients patientsand and Mississippians.” Mississippians.”

vol. 61 • no. 2 • 2020 49

WHY IS PHYSICIAN PARTICIPATION CRITICALLY IMPORTANT TO THE VIABILITY OF ORGANIZED MEDICINE IN MISSISSIPPI?

A: “We have an organized association where we come together as physicians and talk about healthcare policy to make our communities and our state better. We learn from each other. This is the place where physicians of every specialty and every kind of work environment come together as one organized profession to debate and talk about those things, the future of medicine, what we can do collectively to improve the healthcare environment in our state which improves the care for our patients. That’s what organized medicine does.”

“ T H E T H R E AT T O T H AT I S I F W E D O N ' T A S S O C I AT E , W E L O S E T H AT M I X O F D I V E R S E I D E A S A N D S O L U T I O N S T H AT A D D S T O O U R COLLECTIVE INTELLIGENCE. AS WE COME TOGETHER, WE CAN COME UP WITH BETTER, MORE COMPREHENSIVE SOLUTIONS IMPROVING CARE ACROSS THE SPECTRUM."

50 vol. 61 • no. 2 • 2020

Want to hear more information from your Executive Director of MSMA? Check out our YouTube video series.

WHAT IS THE SINGLE MOST IMPORTANT RETURN ON INVESTMENT FOR MEMBERSHIP AT THE MSMA?

A: "In my mind, it’s the COLLEGIALITY and getting to be an engaged member of the most respected profession on the planet. That’s a return on investment that I don’t think you can get from any other place if you’re a physician. Another “Anotherreturn return on on investment investment is you step up and take your rightful place as a leader in healthcare. Our Hippocratic Oath requires us to be leaders—to go forward and lead and to reach back and bring other physicians forward. We have to PROTECT the environment of healthcare, and we do that through organized medicine. When I came into practice, I came into a good healthcare environment to practice medicine, and the physicians who came before me did that. They advocated for sound policy, and you do that through an association like MSMA. My predecessors did that for me, and they believed that was a part of their Hippocratic Oath responsibilities: responsibilities; to to protect protectthe the profession thereby protecting healthcare for our patients. I have a responsibility to do that also, especially for the younger physicians that I have trained, coming out into to practice.

It was “It was protected protected for for me, me, and and now now II have have to to help help maintain that good environment for physicians to follow, follow. I think is one of main the main reasons weneed all need Iand think that that is one of the reasons we all to to be members of the association. If you think that there there are things that can be improved in the healthcare health care system, then you you have have even even more more of of aa delivery system, responsibility to be a member, engage, engage, bring us those solutions that will make make the environment environment better, better, and and continue to move the healthcare delivery system in our state forward. It’s going to take take us us all to do it collectively, and the best place to start is by by joining joining this this association.” association.”

Want to hear more information from your Executive Director of MSMA? Check out our YouTube video series .

vol. 61 • no. 2 • 2020 51

P R E S I D E N T ’ S

P A G E

Physicians and the Reflective Dry-Fit Shirt

ood, fun, and fellowship are common staples of our Mississippi culture. We just love to get together and eat and enjoy each other’s company. Unfortunately, a major byproduct has been the often quoted epidemic of obesity, diabetes, and hypertension in our state. So what are we to do?

As physicians, we look to solve problems and change behavior. The problem of obesity is no different. We must change the way we eat and exercise. We must eat healthier foods and reduce our calorie intake while increasing the amount of exercise that we do. Obviously, this is easier said than done. J. Clay Hays, Jr., MD

The most recent guidelines from the American Heart Association recommend 150 minutes of exercise per week. This is mostly through aerobic exercise, although we should do resistance training twice a week as well. I often discuss this with my patients, as well as other community groups. As physicians, we have the opportunity to set the example by hitting the pavement or working out in a gym. In Mississippi, we are blessed to have wonderful weather from October through mid-June to get outside and exercise. We have many 5k, 10k and longer distance races all over the state. By getting involved with these races, we highlight how fitness can be a meaningful part of our own lives.

longer. Sometimes we go slower. We talk about current events and the challenges of medicine. It’s a great time of encouragement, and I always regret it when I can’t make it. To help us get through our jaunt, we often will wear various types of apparel. Whether it’s a shirt from a recent race, a pullover for warmth, shorts with lots of pockets, or colorful compression socks, we enjoy looking and feeling our best. The dry-fit material is an excellent type of clothing when exercising as it keeps moisture away from your body. My compadres all have some type of this wonderful swag, and I thought I might encourage others to exercise by producing a dry-fit shirt for the medical association. Working with our friends from Fleet Feet Jackson, we have produced a light blue dry-fit shirt with reflective lettering on the front. #MSMA4Fitness is emblazoned across the chest to alert the viewer of our message and to also protect the wearer of the shirt by reflecting the lights back in traffic. Many physicians and medical students have already started wearing these shirts, and the response has been very positive. If you would like a shirt, please contact Becky Wells at BWells@ msmaonline.com. She will be happy to help you. As one of our previous Governors stated, “Let’s go walkin’ Mississippi!” I hope to see you on a trail somewhere. n

I have found exercise to be a wonderful stress reliever and try to practice what I preach by jogging, cycling, or hiking. Every week I get together with a group of friends (including physicians) in the early morning hours to run/walk our 3-4 mile route. Sometimes we go

RightTrack

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52 vol. 61 • no. 2 • 2020

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L E T T E R S

Journal praised for becoming more inclusive “from the front door to the back door” Dear JMSMA Editor, I had planned to write you a letter for some time and reflect on the Journal of the Mississippi State Medical Association becoming more inclusive in the last several years, from the front door to the back door. Looking at the In Memoriam section, you included the lives of Dr. James Anderson, Dr. Walter Robert Jones, Jr., and Dr. Richard C. Miller, people who were very helpful to me, especially Dr. Anderson, another minority and colleague of mine. Dr. David Lee Clippinger was,

of course, another excellent primary care physician. [“In Memoriam.” JMSMA, Vol. LX, No. 4, April 2019, 159-160.] It made me increasingly proud to be a Mississippian for there was a time in my life where minority physicians were overlooked and some not included, even in the In Memoriam section of the Journal. With appreciation and regards, — Robert Smith, MD

Jackson

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vol. 61 • no. 2 • 2020 53

M S M A

Welcoming Our Newest Members

BHESANIA, NATALIE, Jackson, Pediatrics

WOOD, JOANN, Southaven, Pediatrics

JOHNSON, AMANDA, Tupelo, Radiology

WOODS, JOHN, Hattiesburg, Obstetrics & Gynecology

MORGAN, CARA, Brandon, Family Medicine MISSISSIPPI STATE MEDICAL ASSOCIATION MSMAonline.com

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DISABILITY DETERMINATION SERVICES 1-800-962-2230

54 vol. 61 • no. 2 • 2020

I M A G E S

I N

M I S S I S S I P P I

M E D I C I N E

THE HOSPITAL OF THE UNIVERSITY OF MISSISSIPPI, OXFORD, MISSISSIPPI

0 • 4,U3

THE MEDICAL SCHOOL AND HOSPITAL AT OLE MISS, THE SECOND MEDICAL SCHOOL BUILDING, 1934-1955 — This postcard image, which is dated May 5, 1946, features the second Medical School Building at the University of Mississippi, built in the early 1930s on the far western edge of the Oxford campus. Constructed over several years at a cost of $125,000, this depression-era Classic Revival style brick structure would not open until 1934, with further work continuing until 1937. Called both the Medical School Building and the University Hospital Building, it would house the School of Medicine until it moved to Jackson in 1955, as well as the university’s campus hospital. The medical school suffered a gloomy period in the 1920s and 1930s after efforts nationally to close two-year schools almost resulted in its demise. The school was placed on probationary status in 1927 by the Association of American Medical Colleges (AAMC) for among other reasons its poor facilities. A special legislative appropriation pushed by Governor Theodore Bilbo was passed in 1928 to address this deficiency. This massive three-story structure would be built to replace the first medical school building, which was called Science Hall. [For more on Science Hall, see Lampton, L. “The Science Hall at Ole Miss, The First Medical School Building, 1906-1934,” JMSMA. November/December 2019 (60:11/12), page 364.] On the first floor of the new building was the Pharmacology Department, with animal quarters located behind the building. Laboratories of Pathology, Bacteriology, and Clinical Laboratory Diagnosis were located on the second floor, and the Department of Physiology occupied the third floor. By 1936, the Rowland Medical Library moved to the north wing of the building. The University Hospital, led by University Physician John C. Culley, MD, handled “normal situations” of hospital admissions there with two registered nurses assisting. Clinics were also conducted in the building, and the Lafayette County Health Unit maintained its offices there. The X-Ray Laboratory was located on the third floor next to the hospital’s operating rooms. The School of Medicine’s Bulletin of July 1941 indicates that some medical departments remained at Science Hall, which had been renovated: “Gross anatomy, neuro-anatomy, applied anatomy, histology, and embryology occupy the fourth floor of the old Medical Building (the second and third floors being occupied by the Department of Biology). Physiological chemistry and its laboratories remain in the Chemistry Building. All other departments are in the new Medical School Building.” In 1961, this building would be named Guyton Hall after Dr. Billy S. Guyton, who served as dean of the School of Medicine from 1935-1944. It later housed the Student Health Service, Air Science Tactics, and the Departments of Aerospace Studies and Military Science. After a full renovation in 2003 and the addition of an annex in 2010, it currently houses the School of Education. If you have an old or even somewhat recent photograph which would be of interest to Mississippi physicians, please send it to me at lukelampton@cableone.net or by snail mail to the Journal. — Lucius M. “Luke” Lampton, MD; JMSMA Editor vol. 61 • no. 2 • 2020 55

P o e t r y

a n d

M e d i c i n e

Edited by Lucius Lampton, MD; JMSMA Editor

(This month, I resume a multi-issue focus on the poetry of the late physician-poet Merrill Moore, MD (1903-1957), a noted American psychiatrist and neurologist who also achieved fame as a poet and sonneteer. This poem’s subject is a forceps delivery. Obstetric forceps consist of two separate blades (positioned around the head of the fetus), providing a means of extracting the fetus when the mother is unable to complete the delivery. Forceps have proven critical in medicine’s ability to decrease infant and maternal mortality over the last three centuries. The principle of assisting a difficult delivery with traction was first described by Hippocrates. However, the invention of obstetric forceps in the 17th century by maverick barber surgeon Peter Chamberlen (1560-1631) represented an important technical advance in the management of childbirth. There have been over 600 modifications of Chamberlen’s original prototype. In this poem, Moore expresses a physician’s common fear of encountering a problematic birth and also his belief that a difficult delivery was part of nature’s defense against mankind. The poet seems to enjoy the alliteration of the curve of Carus (kar′ŭs), an imaginary arc corresponding to the pelvic axis. This curve is postulated to have evolved in humans from walking on all fours to standing upright on two. Such caused the spine to slant, the pelvis to bend, and the birth canal to curve. This curve is named for Carl Gustav Carus (1789-1869), a brilliant German physician (who taught obstetrics in Dresden), psychologist, and painter. This poem is from “M: One Thousand Autobiographical Sonnets” published in 1938 (see page 924). Any physician is invited to submit poems for publication in the Journal either by email at lukelampton@cableone.net or regular mail to the Journal, attention: Dr. Lampton.) — Ed.

Forceps Delivery “Remember the curve of Carus as you go!” Was all he said as he handed them to me, And I took them, stopping only a moment to see That they were in good shape, and I found they were. The phone had rung no more than an hour ago, And the street address they gave could not be far, So I hurried toward it, wondering what I’d find, With fears of every description crossing my mind. Mother in labour; child stuck in the canal A good many hours; waiting has become tense, And nothing to do but try to recompense A lack that Nature had caused, maybe in defense Against so-called civilization, whatever that is— The forceps work: The matter stands as is. — Merrill Moore, MD (1903-1957)

56 vol. 61 • no. 2 • 2020

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Journal MSMA • VOLUME LXI • NO. 2 • 2020

Articles inside

Implementing an Interpregnancy Care Project among Rural and Urban Mississippi Cohorts