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VOL. LII

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Lucius M. Lampton, MD EDITOR D. Stanley Hartness, MD Richard D. deShazo, MD ASSOCIATE EDITORS Karen A. Evers MANAGING EDITOR PUBLICATIONS COMMITTEE Dwalia S. South, MD Chair Philip T. Merideth, MD, JD Martin M. Pomphrey, MD Leslie E. England, MD, Ex-Officio Myron W. Lockey, MD, Ex-Officio and the Editors THE ASSOCIATION Tim J. Alford, MD President Thomas E. Joiner, MD President-Elect J. Clay Hays, Jr., MD Secretary-Treasurer Lee Giffin, MD Speaker Geri Lee Weiland, MD Vice Speaker Charmain Kanosky Executive Director JOURNAL OF THE MISSISSIPPI STATE MEDICAL ASSOCIATION (ISSN 0026-6396) is owned and published monthly by the Mississippi State Medical Association, founded 1856, located at 408 West Parkway Place, Ridgeland, Mississippi 39158-2548. (ISSN# 0026-6396 as mandated by section E211.10, Domestic Mail Manual). Periodicals postage paid at Jackson, MS and at additional mailing offices. CORRESPONDENCE: JOURNAL MSMA, Managing Editor, Karen A. Evers, P.O. Box 2548, Ridgeland, MS 39158-2548, Ph.: (601) 853-6733, Fax: (601)853-6746, www.MSMAonline.com. SUBSCRIPTION RATE: $83.00 per annum; $96.00 per annum for foreign subscriptions; $7.00 per copy, $10.00 per foreign copy, as available. ADVERTISING RATES: furnished on request. Cristen Hemmins, Hemmins Hall, Inc. Advertising, P.O. Box 1112, Oxford, Mississippi 38655, Ph: (662) 236-1700, Fax: (662) 236-7011, email: cristenh@watervalley.net POSTMASTER: send address changes to Journal of the Mississippi State Medical Association, P.O. Box 2548, Ridgeland, MS 391582548. 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© 2011 Mississippi State Medical Association

JANUARY 2011

VOLUME 52

NUMBER 1

SCIENTIFIC ARTICLES Current Tobacco Use Trends among Mississippi Public High School Students: 1993 – 2009

Zhen Qin, PhD; Lei Zhang, PhD, MBA; Bo Wang, PhD; Erica E. Hirsch, MPH; Warren May, PhD; Roy Hart, MPH, CHES; Melanie Bishop, MPH, CHES; Rodolfo L. Vargas, MS

Top 10 Facts You Should Know: Obstructive Sleep Apnea

Sadeka Tamanna, MD, MPH and M. Iftekhar Ullah, MD, MPH

SPECIAL INSERT MSMA Public Health Report Card - 2011

PRESIDENT’S PAGE Mental Health is Everyone’s Business

Tim J. Alford, MD, MSMA President

EDITORIALS Send in the Clowns

D. Stanley Hartness, MD, Associate Editor

RELATED ORGANIZATIONS Mississippi State Department of Health MSMA MSMA Alliance

14 24 28

DEPARTMENTS Physicians’ Bookshelf Images in Mississippi Medicine Legalease The Uncommon Thread Una Voce Placement/Classified

23 25 26 30 31 32

ABOUT THE COVER: Oil on Canvas - Time Donors — R. Scott Anderson, MD is the artist who created this oil painting that led to the novel titled “Time Donors Wanted.” The book, which has received interest from several major publishers, asks the question, “If you could have a one-time affair with someone you would never see again, and no one could ever find out, would you?” Then it points out the consequences of answering yes to that question. This painting is about seeing things that may or may not be there. It’s about trying to look at desire. Most can see the woman or the man in front of them, but may miss the things that surround them? By focusing too much on the object of their desire they miss the shapes that are hiding in the shadows. You might see an emperor, penguin, or a monkey, a horse, or a woman, even a rooster, or a goldfish. Or, you may just see color. Dr. Anderson is a radiation oncologist in Meridian. January

VOL. LII

Official Publication of the MSMA Since 1959

2011

No. 1

JANUARY 2011 JOURNAL MSMA

JOURNAL MSMA JANUARY 2011

• SCIENTIFIC ARTICLES •

Current Tobacco Use Trends among Mississippi Public High School Students: 1993 – 2009

Zhen Qin, PhD; Lei Zhang, PhD, MBA; Bo Wang, PhD; Erica E. Hirsch, MPH; Warren May, PhD; Roy Hart, MPH, CHES; Melanie Bishop, MPH, CHES; Rodolfo L. Vargas, MS

BSTRACT

This study investigates trends in tobacco use based on gender, race, and grade level among Mississippi public high school students during 1993-2009. Data were obtained by combining eight weighted Mississippi Youth Risk Behavior Surveys (YRBS). Current tobacco use (cigarette, smokeless, and cigar) was selected for investigation. During 1993-2009, the prevalence of current cigarette and cigar use among Mississippi public high school students showed a significant linear decrease (p < 0.0001). A quadratic trend was also detected for current cigarette use (p = 0.0038) indicating that it increased during 1993-

AUTHOR INFORMATION: Zhen Qin, PhD, Biostatistician I, Center of Biostatistics, University of Mississippi Medical Center (UMMC), Phone: 601-815-3437, Email: Zqin2@umc.edu. Lei Zhang, PhD, MBA, Director/ Office of Health Data and Research, Mississippi State Department of Health (MSDH) Phone: 601-576-8165, Email: Lei.Zhang@msdh.state.ms.us. Bo Wang, PhD, Assistant Professor, Department of Community Health Sciences, The University of Southern Mississippi, 118 College Drive, Box 5122, Hattiesburg, MS 39406. Phone: 601-266-6507 Email: Bo.Wang@usm.edu. Erica E. Hirsch, MPH, Past Graduate Student Intern, Office of Health Data and Research, MSDH, Phone: 313-943-5479, Email: Erica.hirsch@ eagles.usm.edu., Warren May, PhD, Professor, Center of Biostatistics, UMMC, Phone: 601-984-1933, Email: wmay@umc. edu. Roy Hart, MPH, CHES, Director, Office of Tobacco Control, MSDH, 2095 Dunbarton, Suite 202, Jackson, MS 39216. Phone: 601-364-5790, Email: Roy.Hart@msdh.state.ms.us. Melanie Bishop, MPH, CHES, Bureau Director, Office of Tobacco Control, MSDH, 2095 Dunbarton, Suite 202, Jackson, MS 39216, Phone: 601-364-5790, Email: Melanie.Bishop@msdh.state.ms.us. Rodolfo L. Vargas, MS, Research Biostatistician, Office of Health Data and Research, MSDH, Jackson, MS 39215, Phone: 601-576-7369, Email: Rodolfo. vargas@msdh.state.ms.us. CORRESPONDING AUTHOR: Lei Zhang, PhD, MBA, Director/ Office of Health Data and Research, Mississippi State Health Department, Jackson, MS 39215, Phone: 601-576-8165, Email: Lei.Zhang@msdh. state.ms.us. REPRINTS should be addressed to Dr. Lei Zhang.

1995 and then decreased over the remaining period of the study. Neither linear nor quadratic trends were observed for current smokeless tobacco use. Male students were more likely to be current tobacco users. White students were more likely to use cigarettes and smokeless tobacco. Programs that target male and white students on certain products such as smokeless tobacco are needed to further decrease overall tobacco use in the state.

KEY WORDS: SCHOOL HEALTH, TOBACCO USE, TREND INTRODUCTION

Tobacco use has been recognized as the single leading preventable cause of death in the United States and is a risk factor 1-5 for six of the eight leading causes of death in the world. It has been linked to cancer of the bladder, cervix, colon, kidney, pancreas, stomach, blood, mouth and throat. Furthermore, cigarette smoking alone is a cause for 80-90% of all lung cancers and increases the risk for coronary heart disease and stroke 2 to 4 5 times. Studies have concluded that the younger one begins to smoke the more likely he or she is to suffer adverse health con4 sequences related to smoking. Every day approximately 3,900 young people between the age of 12 and 17 years try cigarette smoking for the first time in the United States, and more than 6 1,000 of those become daily smokers. Additionally, several studies report a connection between adolescent smoking, the development of alcohol-related problems, and the initiation of 1 other illegal drugs. The Youth Risk Behavior Surveillance System (YRBSS) and Youth Tobacco Survey (YTS) are commonly used by public health and education officials. The studies conducted from these surveys indicate that the overall cigarette use among U.S. high school students decreased from 28.0% in 2000 to 17.2% 7,8 in 2009, but some forms of tobacco use still remain high in

JANUARY 2011 JOURNAL MSMA

some sub-groups. When cigarette use is broken down by gender 8 and race, male and female prevalence rates are similar, and 3,8,9 whites have higher rates than blacks. However, cigar use is most prevalent in males and blacks. All types of tobacco use (cigarette, cigar, smokeless) have been shown to increase by rade level with smokeless tobacco initiation beginning the ear10 liest at the age of 12. The Centers for Disease Control and Prevention (CDC) reported in 2009 that 15.0% of high school males 8 vs. 2.2% of females used smokeless tobacco in the last 30 days. Other studies have shown that rural white males are more likely 11 to use smokeless tobacco. Knowledge of tobacco dependence and use is essential in guiding intervention programs, research initiatives, and policy decisions. The purpose of this study is to conduct trend analysis on current tobacco use among Mississippi public high school students from 1993 to 2009 to assess whether gender, race, and grade level modify the observed effects of current tobacco use. The findings will help policy makers, program coordinators, and public health advocates to better tailor policies and programs geared toward youth that are susceptible to tobacco use in Mississippi.

METHODS

Data Source The YRBS was developed in 1990 by the CDC to monitor among youth in the U.S. priority health risk behaviors that evidently contribute to the leading causes of death, disability, and social problems. The YRBS includes national, state, and local school-based surveys of representative samples of 9th through 12th grade students. It is a standardized complex survey conducted biennially by local and state departments of health or education in collaboration with the CDC. The YRBS was designed to monitor trends, compare state health risk behaviors to national health risk behaviors, and to plan, evaluate, and improve school and community programs. Over the past years the YRBS questionnaires have proven to be a reliable tool for accessing and monitoring behaviors that place adolescents most at risk for pre12,13 mature morbidity and mortality.

Study Population The sampling frame consisted of all Mississippi public high schools with students in grades 9-12. The sampling design was a two-stage stratified probability design. The first stage included the random selection of schools. A systematic sample of schools was drawn with probability proportional to the enrollment in grades 9-12 of each school. In the second stage, classes were selected using equal probability systematic sampling. All eligible students in the selected classes were asked to participate in the survey. Survey procedures were designed to protect studentsâ&#x20AC;&#x2122; privacy by allowing for anonymous and voluntary par-

JOURNAL MSMA JANUARY 2011

ticipation. Parent permission procedures were followed before administration, including informing parents that their childâ&#x20AC;&#x2122;s participation was voluntary. Students completed the self-administered questionnaire during one class period, and their responses were recorded directly to a computer-scannable booklet 14 /answer sheet. Current tobacco use prevalence was assessed using the following questions: Question 1. During the past 30 days, on how many days did you smoke cigarettes?

Question 2. During the past 30 days, on how many days did you use chewing tobacco, snuff, or dip, such as Redman, Levi Garrett, Beechnut, Skoal, SkoalBandits, or Copenhagen? Question 3. During the past 30 days on how many days did you smoke cigars, cigarillos, or little cigars?

Answer choices range from 0 day to 30 days for all three questions. Respondents who reported any days (except for 0 day) of tobacco use were regarded as current tobacco users. Response rates vary among schools and from year to year. The CDC guidelines state that estimates from surveys with 60% or higher overall response rates, a product of school response rate and student response rate, can be generalized to the population. Observing this guideline, the 2005 survey data were excluded from this study due to a 43% response rate. Statistical Analysis Data from surveys conducted in 1993, 1995, 1997, 1999, 2001, 2003, 2007, and 2009 were edited to ensure consistency. Surveys of the above years all had overall response rates of 60% or higher. A weight was applied to each record to adjust for student nonresponse and the distribution of students by gender, race, and grade level. The final overall weights were scaled so that the weighted count of students was equal to the total sample size and the weighted proportions of students in each grade matched population projections for each survey year, thus making weighted estimates representative of all students in grades 914 12 attending public schools in Mississippi. Weighted data were then used to conduct statistical analyses using SUDAAN software (RTI, Research Triangle Park, NC 2008, version 9.01). SUDAAN was chosen to accommodate the complex sampling design of each survey. Prevalence, longitudinal trends for the current cigarette use, current smokeless tobacco use, and current cigar use were investigated. Effects of the following factors were evaluated: gender, race, and grade level. Subgroup-specific annual prevalence rates and 95% confidence intervals (CIs) were calculated for three different types of tobacco. Binary logistic regression was also used to assess

the longitudinal trends. The same statistical procedure was used to compute adjusted odds ratios (ORs) for the evaluation of â&#x20AC;&#x2DC;relative riskâ&#x20AC;&#x2122; of current cigarette use, smokeless tobacco use, and cigar use within subgroups (e.g., male vs. female while controlling for other characteristics such as race, and grade level). Differences between prevalence estimates were considered statistically significant if the p value was less than 0.05 for main effects of gender, race and grade level and for changes over time. Adjusted ORs were considered statistically significant if their 95% CIs did not include 1.0. Elapsed time was the same between successive surveys, except for one between 2003 and 2007. Thus, the logistic regression models used orthogonal variables to model longitudinal trends (e.g., linear term X1 = -7.5, -5.5, -3.5, -1.5, -0.5, 2.5, 4.5, 8.5; quadratic term X2 = 37.62, 9.19, -11.24, -23.68, -28.11, -24.54, 6.59, 34.16) over the year

1993, 1995, 1997, 1999, 2001, 2003, 2007, and 2009. The linear and quadratic term were hypothetically assigned to 2005 so the overall trend analysis will take into account the unequal elapsed time between 2003 and 2007.

RESULTS

Figure 1 demonstrates the longitudinal trends for current cigarette use, current smokeless tobacco use, and current cigar use among Mississippi public high school students during the period of 1993 to 2009. The percentage of current cigarette use declined from 27.6% in 1993 to 19.6% in 2009. This change was consistent with a national decrease from 30.5% to 19.5% 6,8 during the same period. The decrease in Mississippi yielded a significant linear trend (p < 0.0001) (Table 1). An uncharacteristically large increase occurred in1995 that accounted for a significant quadratic trend (p = 0.0038). The 2009 Mississippi rate was comparable to the national average but was higher than the Healthy People 15 2010 goal of 16%. The percentage of current smokeless tobacco use decreased insignificantly from 10.1% in 1995 to 8.6% in 2009. This small decrease followed neither a linear (p = 0.3371) nor a quadratic trend (p = 0.2734) and was consistent with a national pattern from 11.4% to 8.9% during the same period. The rate was similar to the national average and was higher than the Healthy People 15 2010 goal of 1.0%. The percentage of current cigar use decreased from 21.9% in 1999 to 15.4% in 2009. The change was also consistent with a national decrease from 17.7% in 1999 to 14.0% in 2009.6,8 Mississippi youth cigar use decreased faster than the nation and yielded a significant linear trend (p < 0.0001). However, the rate was higher than the national average and the Healthy People 2010 goal 15 of 8%. Table 2 displays the prevalence of current tobacco use among public high school students in Mississippi from 1993 to

JANUARY 2011 JOURNAL MSMA

2009 by gender. The prevalence for male students had been consistently higher than that of female students. Overall, male students were significantly more likely to be current tobacco users than female students. Specifically, male students were about 1.34, 19.14, and 2.40 times more likely to be current cigarettes, smokeless, and cigars users, respectively. The effect of gender was statistically significant (p < 0.0001) for all three separate regression models after adjusting for race and grade level. Table 3 displays the prevalence of current tobacco use among public high school students in Mississippi from 1993 to 2009 by race. The prevalence for Non-Hispanic white (hereafter white) students had been consistently higher than that of NonHispanic black (hereafter black) students on current cigarette and smokeless tobacco use. The percentage of current cigar use for white students was comparable to black students. Table 4 shows that white students were significantly more likely to be current cigarette and smokeless tobacco users than black students. Specifically, white students were about 3.27 and 10.37 times more likely to be current cigarette and smokeless tobacco users respectively. The effect of race was statistically significantly (p < 0.0001) for current cigarette and smokeless tobacco use regression models but not for current cigar use model (p = 0.5265), after adjusting for gender and grade level. Compared to the 12th graders, all lower grade level students were less likely to be current cigarette users. In addition, 9th graders were less likely to be current cigar users. However, the likelihood of using smokeless tobacco did not differ by grade level (Table 4).

JOURNAL MSMA JANUARY 2011

DISCUSSION

In Mississippi, overall adolescent tobacco use prevalence rates have significantly declined from 1993 to 2009 with only

smokeless tobacco remaining unchanged. Our study found a significant gender difference in tobacco use with males having higher rates of any form of tobacco use. These results are inconsistent with past studies where male and female adolescents have had fairly equivalent tobacco use prevalence rates.2, 3, 16

Adolescent males in Mississippi may be mimicking the behaviors they observe in their social environment. According to the Behavioral Risk Factor Surveillance System, adult males in Mississippi have a higher prevalence rate of smoking than adult females.17 Reasons for smoking behaviors in adolescents have been linked to lack of parental support against smoking and peer groups who smoke.16,18 A previous study indicated that youthâ&#x20AC;&#x2122;s intentions to smoke are greatly affected by their expectations of important people in their lives and the smoking habits of those people.18 Adolescent males in Mississippi smoke more often than adolescent females, maybe because their fathers or other male peers smoke. Whites in Mississippi may be more prone to smoking as it has been reported that they are more likely to have seen a parent or guardian smoke, have a friend who smokes, and have fewer restrictions on smoking in the home.3 Based on our study findings, white high school students in Mississippi have 3.27 times greater odds of cigarette smoking compared to their black counterparts and about 10.37 times greater odds of using smokeless tobacco. These results are consistent with national data where discrepancies of youth tobacco use can be seen across ethnicity.3,4 A study conducted in 2005, on 290 rural adolescents in Mississippi aged 12-16 years found that white males were more likely to report seeing a guardian smoke compared to their black 3 counterparts. Although the prevalence of current tobacco use among Mississippi public high school

JANUARY 2011 JOURNAL MSMA

students was comparable to that of national average,6,8 They did not meet the Healthy People 2010 goals. Smokeless tobacco (8.6%) had the largest gap compared to the goal of 1%. While smokeless tobacco was the least prevalent form of tobacco used by adolescents, it had not significantly decreased overtime. Public health initiatives aimed at decreasing tobacco use in youth may be focusing too heavily on cigarette use alone as it has been the most prevalent form of tobacco used by adolescents nationwide, leaving little emphasis on the negative outcomes of smokeless tobacco and cigar use. Additionally, our study found a negative association between grade level and cigarette use. Students in 12th grade were significantly more likely to be current cigarette users than those in 9th-11th grades. According to the School Health Policies and Practices Survey conducted by the CDC, the proportion of schools in the nation having policies that require the teaching of tobacco use prevention was 72.5%, 70.6%, and 74.0% for elementary, middle, and high schools respectively. As of 2006, the state of Mississippi did not have a policy that required the teaching of “tobacco use prevention” or “alcohol and other drug use prevention” in elementary or middle schools.19 Although these policies were present in high school, this may be too late to begin such initiatives as it can be seen that tobacco use has already begun in this group. Policies on tobacco use prevention, education, and mass media campaigns should be considered for implementation in middle and possibly even elementary schools in Mississippi.20 There were several limitations to our study. Known bias comes with voluntary surveying. Students who volunteered to complete the survey may have different motives, beliefs, or attitudes than students who did not participate. Even with anonymous completion, students who completed the survey may report less tobacco use than the actual in order to present themselves in a favorable light, thus possibly underreporting the true prevalence of tobacco use. Furthermore, the 2005 YRBS data were not used in this study as the response rates did not meet set criteria. This data would have been useful in gauging trends from 1993 to 2005 and also from 2005 to 2009.

JOURNAL MSMA JANUARY 2011

The cure for tobacco related health problems cannot be found in vaccines or medications but has to be tackled by the government and public society. Based on our study findings, Mississippi initiatives should focus on: (1) decreasing cigarette use as it has the highest overall prevalence rate in the state; (2) smokeless tobacco use, as it has not decreased significantly over the last decade; (3) male adolescent tobacco use as it is greater than female prevalence rates; (4) racial discrepancies in tobacco use as whites have a higher prevalence than blacks; and (5) elementary and middle school culturally appropriate tobacco education programs. If current tobacco educational programs and policies are not sustained and built upon, youth tobacco prevalence rates may rise contributing to higher prevalence in the Mississippi adult population. Continued research may consider investigating the motives, habits, and beliefs of non-smoking adolescents as this may help develop future prevention programs.16 Investigation of adult

male, female, white, and black environments, social behaviors, and tobacco use prevalence should be compared against their comparative adolescents to see if a similar pattern exists across generations. Additional exploration into grade level onset of smokeless tobacco use related to its continued use over time may unveil why there has not been a decrease in prevalence overtime and why a change has not been seen across grade level. The negative health effects associated with tobacco use are severe and can cause premature disability, morbidity, and mortality.1-5 Knowing that most smokers begin tobacco use in adolescent years makes public health initiatives that target young children and teenagers crucial.21-25 Continuous effort must be exerted to curb behaviors that may lead to initiation of tobacco use.

REFERENCES 1.

Mathers M, Toumbourou JW, Catalano RF, Williams J, Patton GC. Consequences of youth tobacco use: a review of prospective behavioral studies. Addiction. 2006;101:948-958.

Warren CW, Jones NR, Eriksen MP, Asma S. Patterns of global tobacco use in young people and implications for future chronic disease burden in adults. Lancet. 2006;367:749-753.

Muilenburg JL, Johnson WD, Annang L, Strasser SM. Racial disparities in tobacco use and social influences in a rural southern middle school. J Sch Health. 2006;76:195-200.

Warren CW, Jones NR, Peruga A, Chauvin J, Baptiste JP, Costa de Silva V, et al. Global youth tobacco surveillance, 2000-2007. MMWR Surveill Summ. 2008;57:1-28.

WHO report on the global tobacco epidemic, 2008: the MPOWER package? Geneva, World Health Organization, 2008.

Smoking and tobacco use; youth and tobacco use. Centers for Disease Control and Prevention Website http://www.cdc.gov/tobacco/data_statistics/fact_sheets/youth_data/tobacco_use/index. htm. Accessed May 07, 2010.

Nelson DE, Mowery P, Tomar S, Marucs S,Giovino G, Zhao L. Trends in smokeless tobacco use among adults and adolescents in the United States. Am J Public Health. 2006;96:897-905.

Eaton DK, Kann L, Kinchen S, Shanklin S, Ross J, Hawkins J, et al. Youth Risk Behavior Surveillance – United States, 2009. MMWR Surveill Summ. 2010;59(No. SS5).

Reddy P, Resnicow K, Omardien R, Kambaran N. Prevalence and correlates of substance use among high school students in South Africa and the United States. Am J Public Health. 2007;97:18591864.

tem. MMWR Recomm Rep. 2004 Sep 24;53(RR-12):1-13. 15. Healthy People 2010: Understanding and Improving Health. U.S. Department of Health and Human Services. 2000. 16. Kulbok PA, Rhee H, Botchwey N, Hinton I, Bovbjer V, Anderson NLR. Factors influencing adolescents’ decision not to smoke. Public Health Nurs. 2008;25:505-515. 17. Behavioral Risk Factor Surveillance System. Mississippi 2008 – tobacco use. Prevalence and trends data. National Center for Disease Control and Prevention Website. http://apps.nccd.cdc. gov/brfss/. Accessed May 10, 2010. 18. Sawatzky R, Ratner PA, Johnson JL, Marshall S. Toward an explanation of observed ethnic differences in youths’ tobacco use. J Ethn Subst Abuse. 2007;6:95-112. 19. State-Level School Health Policies and Practices: A State-by-State Summary from the School Health Policies and Programs Study 2006. National Center for Disease Control and Prevention Web site http://www.cdc.gov/HealthyYouth/shpps/2006/. Accessed May 10, 2010. 20. Centers for Disease Control and Prevention. Best practices for comprehensive tobacco control programs—2007. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health. 2007. 21. Centers for Disease Control and Prevention. The Surgeon General’s 1989 Report on reducing the health consequences of smoking: 25 years of progress. MMWR Morb Mortal Wkly Rep. 1989 Mar 24; 38 Suppl 2:1-32. 22. Giovino GA. Epidemiology of tobacco use among US adolescents. Nicotine Tob Res. 1999; 1 Suppl 1:S31-40. 23. Youth tobacco surveillance - United States, 2000. MMWR CDC Surveill Summ. 2001;50:1-84. 24. Tobacco use among young people: a report of the surgeon general. Executive summary. MMWR Recomm Rep. 1994;11;43(RR-4):110. 25. Mississippi State Department of Health, Division of Tobacco Policy and Prevention. Mississippi 2005-2010 Tobacco Control Plan. 2005; Jackson, MS.

ACKNOWLEDGEMENTS We gratefully acknowledge the CDC, Ofﬁce of Healthy School at the Mississippi Department of Education and Ofﬁces of Health Data and Research, Preventive Health, Child and Adolescent Health at the Mississippi State Department of Health for collaboration on the Mississippi YRBS Project. We also appreciate students who participated in the surveys during 1993-2009.

10. Brooks A, Gaier Larkin EM, Kishore S, Frank S. Cigars, cigarettes, and adolescents. Am J Health Behav. 2008;32:640-9. 11. Newman IM, Shell DF. Smokeless tobacco expectancies among a sample of rural adolescents. Am J Health Behav. 2005; 29: 127136. 12. Brener ND, Collins JL, Kann L, Warren CW, Williams BI. Reliability of the Youth Risk Behavior Survey Questionnaire. Am J Epidemiol. 1995;14:575-580.

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13. Brener ND, Kann, L, McManus T, Kinchen SA, Sundberg EC, Ross JG. Reliability of the 1999 youth risk behavior survey questionnaire. J Adolesc Health. 2002;3:336-342. 14. Brener ND, Kann L, Kinchen SA, Grunbaum JA, Whalen L, Eaton D, et al. Methodology of the youth risk behavior surveillance sys-

JANUARY 2011 JOURNAL MSMA

Save the Date for MSMA’s

143 Annual Session rd

May 19 – 22, 2011 Tupelo, Mississippi

Meetings at BancorpSouth Conference Center

CME and golf tournament at nearby Old Waverly Golf Course

Welcome Reception at HealthWorks, Tupelo’s new children’s health museum

Accommodations at Tupelo’s Hilton Garden Inn

For a preliminary schedule of events or to register online, visit www.MSMAonline.com!

Questions? More information? Contact Becky Wells at 601-853-6733, Ext. 340 or BWells@MSMAonline.com.

JOURNAL MSMA JANUARY 2011

President’s Reception at Tupelo Automobile Museum

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JANUARY 2011 JOURNAL MSMA

â&#x20AC;˘ TOP 10 FACTS YOU SHOULD KNOW â&#x20AC;˘

About Obstructive Sleep Apnea

NTRODUCTION:

Sadeka Tamanna, MD, MPH and M. Iftekhar Ullah, MD, MPH

Obstructive sleep apnea (OSA) has become a major public health burden in the USA. A quarter of the American adult population suffers from OSA and 80% of them remain overwhelmingly unrecognized.1 Complications of untreated OSA increase the morbidity and mortality by many folds. The classic features of OSA include fatigue, loud snoring, frequent awakenings or restless sleep at night, daytime sleepiness and headache. Knowing the clinical conditions which are associated with OSA will increase diagnosis and offer opportunities to treat or avoid these conditions.

1. Obesity: Obesity is present in roughly 70% of patients with obstructive sleep apnea.2 Once OSA is developed, it can predispose individuals to worsening obesity from hormonal dysregulation and disrupted metabolism. All overweight/obese patients with symptoms of OSA should prompt the health care provider to screen for it. 2. Gastroesophageal Reflux Disease (GERD): Patients with OSA have a high frequency of GERD that ranges from 54% to 76%.3 Poorly controlled symptoms, especially at night, with cough and hoarseness despite adequate treatment with PPI should trigger an investigation to rule out co-existing OSA. 3. Asthma: Nocturnal asthma and OSA have been highly linked in many studies. Studies have shown elimination of nocturnal asthma attacks with CPAP therapy. 4 Co-existing OSA should be considered in cases of frequent nocturnal asthma attacks. 4. Motor vehicle accidents: Obstructive sleep apnea is recognized as a major risk factor for motor-vehicle collisions. Drivers suffering from OSA tend to have micro-sleep at the wheel and are at high risk for accidents. The prevalence of OSA among truck drivers was 26% in a large population based study.5 AUTHOR INFORMATION: Dr. Tamanna, Assistant Professor, General

Internal Medicine and Sleep Medicine, University of Mississippi

Medical Center. Email: stamanna@umc.edu. Dr. Ullah, Assistant

Professor, General Internal Medicine, University of Mississippi Medical Center. Email: mullah@umc.edu.

JOURNAL MSMA JANUARY 2011

Every commercial driver should be screened for sign/symptoms of OSA and should be sent for a polysomnography when strongly suspected. 5. Hypertension: Hypertension affects about 20% of the adult population is the US. A clear independent association between the severity of OSA and hypertension was observed in the Sleep Heart Health study. 6 Treatment of OSA with CPAP improves blood pressure in previously medically resistant hypertension.7

6. Stroke: Stroke is the third leading cause of death and long term disability. OSA is an important risk factor for development of stroke,8 and it is extremely common (43-91%) among patients who already had a stroke. Screening for the symptoms of OSA should be more vigorous for patients with stroke. 7. Congestive Heart Failure: The prevalence of OSA is 40% among patients with heart failure. The cascade of physiologic events leading to repetitive airway closure with oxyhemoglobin desaturation exerts a deleterious effect on the already compromised heart. Patients with OSA are 2.38 times more likely to develop CHF than without OSA. 9 Diagnosis and treatment of OSA in these patients will improve cardiac function. 8. Arrhythmia: Atrial Fibrillation, conduction defects and other tachy and bradyarrhythmias are highly prevalent among patients with OSA.10 Co-existing OSA in these patients is sometimes missed and patients are unnecessarily subjected to EP studies, considered for pacemaker or committed to long-term anticoagulation. These arrhythmias are often reversible with CPAP treatment. Therefore, all patients with arrhythmia and sign/symptoms of OSA should be considered for polysomnography. 9. Diabetes Mellitus: Obstructive sleep apnea has a major effect on the neuro-endocrine function of the body. Frequent arousals from sleep cause sympathetic activation and thus affect glucose tolerance and insulin resistance.11 Treatment of OSA improves overall control of diabetes by improving insulin resistance.

• SCIENTIFIC •

10. Erectile Dysfunction (ED): ED and decreased libido are found to be highly linked with OSA. Forty-eight percent of men with OSA were reported to have ED according to one study. Both short and long term treatment of OSA with CPAP showed improvement of ED.12

CONCLUSION:

Common clinical conditions are frequently associated OSA but remain undiagnosed due to lack of awareness among clinicians. Early recognition and treatment of OSA can prevent progression of many of these chronic diseases and their serious complications. Routinely asking patients about sleep related symptoms will facilitate the diagnosis of OSA. Physical examination involving assessment of neck size, BMI and oropharyngeal exam to calculate the Mallampati score (visual exam of oropharynx to assess the degree of obstruction based on visibility of the base of uvula, faucial pillars and soft palate)13 will help the physician make a decision to send appropriate patients for a sleep study. ❒

REFERENCES 1.

2. 3.

Young T, Palta M, Dempsey J, Skatrud J, Weber S, Badr S. The occurrence of sleep-disordered breathing among middle-aged adults. N Engl J Med. 1993;328(17):1230-1235.

Malhotra A, White DP. Obstructive sleep apnoea. Lancet. 2002;360(9328):237-245. Green BT, Broughton WA, O'Connor JB. Marked improvement in

4. 5. 6. 7. 8. 9.

nocturnal gastroesophageal reflux in a large cohort of patients with obstructive sleep apnea treated with continuous positive airway pressure. Arch Intern Med. 2003;163(1):41-45. Chan CS, Woolcock AJ, Sullivan CE. Nocturnal asthma: role of snoring and obstructive sleep apnea. Am Rev Respir Dis. 1988;137(6):1502-1504.

Moreno CR, Carvalho FA, Lorenzi C, et al. High risk for obstructive sleep apnea in truck drivers estimated by the Berlin questionnaire: prevalence and associated factors. Chronobiol Int. 2004;21(6):871879. Peppard PE, Young T, Palta M, Skatrud J. Prospective study of the association between sleep-disordered breathing and hypertension. N Engl J Med. 2000;342(19):1378-1384.

Logan AG, Perlikowski SM, Mente A, et al. High prevalence of unrecognized sleep apnoea in drug-resistant hypertension. J Hypertens. 2001;19(12):2271-2277.

Yaggi HK, Concato J, Kernan WN, Lichtman JH, Brass LM, Mohsenin V. Obstructive sleep apnea as a risk factor for stroke and death. N Engl J Med. 2005;353(19):2034-2041.

Shahar E, Whitney CW, Redline S, et al. Sleep-disordered breathing and cardiovascular disease: cross-sectional results of the Sleep Heart Health Study. Am J Respir Crit Care Med. 2001;163(1):19-25.

10. Gami AS, Pressman G, Caples SM, et al. Association of atrial fibrillation and obstructive sleep apnea. Circulation. 2004;110 (4):364-367.

11. Tasali E, Mokhlesi B, Van Cauter E. Obstructive sleep apnea and type 2 diabetes: interacting epidemics. Chest. 2008;133(2):496-506.

12. Guilleminault C, Eldridge FL, Tilkian A, Simmons FB, Dement WC. Sleep apnea syndrome due to upper airway obstruction: a review of 25 cases. Arch Intern Med. 1977;137(3):296-300. 13. Nuckton TJ, Glidden DV, Browner WS, Claman DM. Physical examination: Mallampati score as an independent predictor of obstructive sleep apnea. Sleep. 2006;29(7):903-908.

INTRODUCING TWO NEW SCIENTIFIC FEATURES IN OUR JMSMA:

• “Mississippi Medicine Up-To-Date” series - The purpose of this series of articles is to provide brief reviews on topics of general interest to the practicing physicians of Mississippi in areas where recent developments in diagnosis or treatment have occurred. Guidelines: 1) Articles should be practical and useful to physicians in office or hospital practice. 2) Suggested organization of manuscripts is Introduction, Recent developments, Conclusion, and References. 3) Articles will be about 6 pages (1500 words) or so in length written at a level that can be easily understood by a practicing physician of any specialty. 4) Five to eight references that will be useful to those who desire further information should be included. 5) Figures are great as are “call-outs,” i.e., boxes with key points to remember emphasizing the “take home” messages. 6) If there are specialty society guidelines on the topic, the essential features of the recommendations should be summarized in the text and the official guidelines should be cited in the references.

• “Top 10 Facts You Need to Know” series - The purpose of this series of articles is to provide referenced information on clinical management of medical conditions in a concise fashion. The submissions should be directed toward practitioners who do not have specialty training on the specific topic as a matter of general information. The author of the best “top 10” submission for each year will receive a prize. Guidelines: 1) Articles should consist of 10 numbered paragraphs. Each of the paragraphs will begin with a fact that physicians need to know and a brief explanation of why. Facts will be referenced for each of the 10 points. 2) Suggested organization of manuscript is Introduction, Point 1, Point 2, etc., Conclusion, and References. 3) Articles will be about 3 pages (about 700 words) in length written at a level that can be easily understood by a practicing physician of any specialty. 4) A reference supporting the fact offered should be provided for each of the 10 points. Citations should not be review articles. 5) If there are specialty society guidelines in the area being discussed, the essential features of the recommendations should be included in the official guidelines cited in the references.

All articles should be forwarded to the Editor for peer review using the usual guidelines outlined in the “Instructions for Authors,” found on our website or available by email: KEvers@MSMAonline.com. Contact managing editor Karen Evers: (601)853-6733, ext. 323.

JANUARY 2011 JOURNAL MSMA

â&#x20AC;˘ MSDH â&#x20AC;˘ Mississippi Reportable Disease Statistics

October 2010

* Totals include reports from Department of Corrections and those not reported from a specific district. ** Address unknown for 1 case.

For the most current MMR figures, visit the Mississippi State Department of Health web site: www.HealthyMS.com 14

JOURNAL MSMA JANUARY 2011

PUBLIC HEALTH IN MISSISSIPPI

REPORT CARD

2011

Fit or Fat?

Sources: United States Department of Health and Human Services – Centers for Disease Control and Prevention (CDC), National Center for Health Statistics, Mississippi Vital Records – Mississippi State Department of Health (MSDH), Behavioral Risk Factor Surveillance System – CDC, MSDH STD/HIV Office, National Center for Health Statistics, Henry J. Kaiser Family Foundation – State Health Facts.

The 2011 Mississippi Public Health Report Card is brought to you by the Mississippi State Department of Health and the Mississippi State Medical Associa on, the physicians who care for Mississippi.

Mississippi is 1st in adult obesity & in adults reporting no physical activity in the past month • 1st in heart disease deaths • 2nd in diabetes & hypertension • 7th in adult tobacco use • 2nd in infant mortality • 1st in traffic fatalities • 4th in trauma & unintentional injuries • 1st in teen birth rate • 47th in breast cancer incidence • 9th in breast cancer mortality • 3rd in cancer mortality. • Over 39 percent of teens use alcohol & almost 18 percent use marijuana. • 31,982 new STD cases were reported last year in Mississippi including 610 HIV cases. • Mississippi ranks 49th in physicians per capita.

MISSISSIPPI STATE

MEDICAL ASSOCIAATION

SMAonline.com • 1-800-898-0251 • www.M -6733 • Fax 601-853-6746 -853 601 • 57 391 e Plac 548 • 408 West Parkway geland, Mississippi 39158-2

P.O. Box 2548 • Rid

sity; sobering. We are first in obe ort Card, and the results are in infant mortality, first in traffic Rep lth Hea lic Pub ual ann its ases second te Medical Association rele n birth rate. Mississippi is the first Public Each year, the Mississippi Stath, diabetes, and hypertension rates; and first in tee list goes on. In addition, in the three years since lth destruction The dea . hea in adult tobacco use e down this path of second in heart disease cancer death, and seventh e. Some have worsened. How long must we continu in ten top the ong am s, improv fatalitie , most statistics have yet to Health Report Card release ment to do better? patients. mit com ing these issues with their before we make the ir communities and discuss changes, and physicians should be the for les mp exa ng bei by tyle state can make a difference are preventable through lifes Physicians throughout the still listen to their doctors. Many of these diseases ts ien pat t the talk”. Evidence shows tha All g the walk” as well as “talking ediately and in future years. leading the way by “walkin us and our loved ones, imm vegetables – and our decisions ct affe t tha day ry eve and each of fried ysician, make health choices steamed vegetables instead on the path to All of us, physician or non-ph r our choices – whether to eat fruit instead of cake, orall steps day in and day out make a huge difference side Sm . con lly nds efu pou car few to a d nee lose us of lly inactive or to exercise and – whether to remain physica years to come. the in and better health now Crisis: ond-hand smoke; MAKE A MOVE to Fight the g and reduce exposure to sec okin sm pi: p sip sto s; sis ing Mis een in scr sis Health Cri . Get regular annual health family history of the disease Cancer Mortality use sunscreen; know your to exercise at least 30 le grains; make it a priority fruits, vegetables, and who in rich t die a Eat Physical Activity per week. Adult Obesity and Lack of minutes three to five times e smokefree air in your acco Quitline. Want to breath reeAirMS.com! Tob i ipp siss Mis the for e at www.SmokeF Call 1-800-QUIT-NOW the SmokeFree Air Initiativ Adult Tobacco Use community? Get involved with s three to five times per exercise at least 30 minute r doctor about reducing re; ssu pre od blo r you trol Stop smoking; con le grains; talk to you ertension fruits, vegetables, and who Heart Disease, Diabetes, Hyp week; eat a healthy diet of the risk of heart attack. Mississippi might be pregnant; call the ately if you are or think you ds immunizations, call your physician or edi imm an sici phy r you See ions 848-5683. If your child nee immunization Infant Mortality / Immunizat Pregnancy Hotline at 1-800- Mississippi State Department of Health offers more The . ent artm local health dep m. information at healthyms.co by would have been prevented of traffic deaths each year s in the US involve alcoholt cen per 50 ut Abo lt! tbe fic fatalitie Wear your sea ries drive; about one-third of traf Traffic Fatalities, Trauma Inju seat belt use. Don’t drink and impaired drivers. avior. Teens, get educated s of irresponsible sexual beh STD/HIV screenings are risk the ut abo n dre chil r . Free and private Parents, talk to you in STDs, HIV STDs/HIV before having sex Teen Birth Rate / Increase about sex, pregnancy, and department. available at your local health gs and alcohol. ate in risky behavior with dru and Kids Health ticip par not do n dre chil r Parents, do not assume you Partnership for a Drug-Free America (drugfree.org) Use Teen Alcohol and Marijuana Utilize resources such as Theto help your kids make healthy decisions. (kidshealth.org) to learn how can avoid chronic y a few adjustments now, we in our state! onl king ma By rs. avio beh t the health crisis we simply alter our ay and make a move to figh se statistics can change if The fact is that most of the es for ourselves and for our children. Join us tod health problems and diseas pi healthier, Yours in making Mississip

Fellow Mississippians,

Timothy J. Alford, MD Medical Association President, Mississippi State

lth Mary Currier, MD, MPH ippi State Department of Hea State Health Officer, Mississ

ippi. ho Care for Mississ The Physicians W

MISSISSIPPI STATE DEPARTMENT OF HEALTH

Career training. Money for college. entire And an entir e team to help you succeed. Nobody ccan Nobody an teach teach yyou ou about about cchallenge hallenge aand nd aadventure. dventure. B But ut yyou ou ccan an e experience xperience tthem hem health professional Mississippi Air Guard. ffor or yyourself, ourself, serving ser ving part-time par t-time aass a h ea lth p rofessional iin n tthe he M is sis sip p i A ir G u a rd . You’ll get excellent benefits, flexible unmatched opportunity Yo o u’ ll g et e xcellent b enefits, a fl exible sschedule chedule – aand nd aan nu n m at c h e d o ppor tunit y tto o sserve er ve yyour our ccommunity ommunit y aand nd ccountry. ountr y.

JANUARY 2011 JOURNAL MSMA

• PRESIDENT’S PAGE •

Mental Health is Everyone’s Business

had returned from a component society meeting in Natchez the night before and had arrived at the office early since I knew it was my turn to be on call. Call for twelve primary care providers can either charge your battery or run it down, but I have always felt a bit energized on call because of the density of pathology in the heart of rural Mississippi. This pathology seldom comes á la carte but as multiple mixed problems and, especially in Mississippi, often with significant associated mental health problems.

TIM J. ALFORD, MD

Because of my early arrival at clinic, the front office personnel summoned me to the 2010-11 MSMA PRESIDENT lobby restroom as one of our patients, whom I shall refer to as Smokey, was holed up in the bathroom. Smokey is one of the many patients that we share with our local community health center. As I gained entry to the restroom, I discovered that he had removed all of his possessions from his coat pocket and emptied them onto the floor. His homeless status forced him to live out of his pockets and the objects of his possession included an old battery, a comb, a chew of tobacco, half of a Snickers bar, and two bottles of pills with the labels rubbed off. This reflected the disorganized thoughts of his schizophrenia and symbolized the disarray of our mental health system. Smokey faced away from me, echoing and muttering nonsense, and my eye was drawn to the kitchen knife he was holding in his right hand. His voice raised, and the cadence of his speech picked up as he politely handed over the knife. Why Smokey? Well, he smokes a lot. He has logged sixty-pack years, which is about the number of visits he makes to our emergency room on an annual basis. His comprehensive record drawn from the ER and our office reveals that he has had numerous false starts on atypical antipsychotics and is admitted to the hospital at least once a month, occasionally to the State Hospital system but never for more than a few days. Some would say Smokey is noncompliant but, in reality, is part of a broken mental health system with which we are all too familiar. Like so many mental health patients, Smokey wanders aimlessly between community health centers, the private sector, emergency rooms, and the revolving doors of the State hospitals. Some might call this the medical equivalent of homeless.

In a recent meeting (December 3) Ed LeGrand, executive director of the State Mental Health Department, described mental health in Mississippi as comprised of the acute hospital, continued treatment services, nursing homes at Whitfield and East Mississippi, and fifteen community mental health centers. Out of the fifteen community mental health centers, five are good, five are bad, and five are ugly. There is little consistent physician oversight by the central Office of Mental Health and no policing power over these fifteen community health centers, which often serve as objects of county government supervisor fiefdoms. On the other hand, the Corinth Community Mental Health Center (Region 4) functions well— so well that it is the envy of other systems in the State, and other counties from other regions have defected to Corinth for better mental health management. Boards of supervisors have the authority to allow such transfers. Our state politicians have kept all of this at arms’ length, not wanting to challenge this highly dysfunctional system due to local politics, not to mention a population of patients who do not speak well for themselves.

In 1974 mental health services were removed from the State Department of Health to create a new agency called the Department of Mental Health. This separate agency was created as a result of the archaic view that mental health did not constitute a legitimate chronic disease state, and this Department has been adrift ever since. We now know that patients with schizophrenia and other forms of mental illness experience a rate of diabetes four times higher than the general population in addition to other associated problems, which is why mental illness cannot be considered in an isolated context. For the first time, the Department of Mental Health has a medical director who can hold up a standard of care, but there is nothing in the Mississippi statutes that provides enforcement of that standard. Imagine how our health department would function if there were no central authority directing the management of tuberculosis. This central authority of the State Health Department allows for rigor and uniformity while applying the simple and effective principle of direct monitored therapy.

JOURNAL MSMA JANUARY 2011

Currently in Mississippi, of the $335 million budgeted for the Medicaid formulary, $78 million goes to behavioral drugs.1 Recent studies show that atypical antipsychotics are being prescribed in up to 60 percent of cases of non-FDA approved diagnoses. These inappropriate diagnoses include insomnia, dementia-related psychosis, attention deficit disorder and anxiety.2,3 This is not to mention the weight gain, diabetes, lipid abnormalities, and irreversible movement disorders brought about by these drugs. The rampant non-evidence-based use combined with adverse safety and efficacy point to one of the greatest marketing campaigns in modern pharmaceutical history and a capitulation by some who care for the mentally ill to such marketing pressure.

The Governor’s announced 15 percent cut to the Department of Mental Health amounts to $68 million in lost state funds that would be used to draw down the federal match. In FY 2010, the Division of Medicaid had expenditures of over $150 million to the fifteen regional community health centers. The Governor and many legislators feel that mental health care should be handled at the community level, but the inherent inefficiencies and the lack of central authority will continue to lead to displaced patients and cost overruns. The State Medical Association provided leadership a few years ago when the Health Department was suffering the consequences of a lack of central direction. There is currently legislation being advanced in conjunction with the State Department of Mental Health, and one key ingredient to this legislation must be the empowerment of the central office and its medical director so that sound principles of chronic disease management can apply. Smokey echoes, “It is cold outside!”

REFERENCES: 1. 2. 3.

Salzeman C, Jeste DV, Meyer RE, et al. Elderly patients with dementia-related symptoms of severe agitation and aggression: consensus statement and treatment options, clinical trials methodology, and policy. J Clin Psychiatry. 2008;69(6) 13e1-e10:889-898. Schneider LS, Dagern KS, Insel P. Risk of death with atypical antipsychotic drug treatment for dementia: Meta analysis of randomized placebo-controlled trials. JAMA. 2005;294(15):1934-1943. Schneider LS, Tariot PN, Dageman KS, et al. CATIE- AD Study Group. Effectiveness of atypical antipsychotic drugs in patients with Alzheimer’s disease. N Engl J Med. 2006;355(15):1525-1538.

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(601) 856-7200 WWW.CCTB.COM JANUARY 2011 JOURNAL MSMA

• EDITORIAL •

Send in the Clowns D. Stanley Hartness, MD, Associate Editor

“The truth won’t help me now I’m falling, free falling The answer’s very clear, the end is almost here I’m falling, free falling”

nterior chest pain…dyspnea on exertion…his symptoms sounded for the world to me like coronary artery disease so arrangements were made for the forty-something black male with no risk factors to see a cardiologist. The cardiologist was similarly impressed and even proceeded with catheterization following a negative treadmill. Again clean coronary arteries although the cardiologist noted a mild anemia he thought unusual for this gentleman who appeared the picture of health. The patient re- surfaced several months later with an office visit for an upper respiratory infection. On questioning, he was still experiencing anterior chest pain and shortness of breath. I remembered the cardiologist’s comment about anemia and rechecked a CBC, the results of which were sobering and no doubt accounted for his angina: hemoglobin 7.0/hematocrit 21.0. My interrogation intensified revealing that he had indeed noticed bright red rectal bleeding for some time. And then the bombshell: “About two years ago I had an operation for a spot on my colon.” I was to learn that the gastroenterologist who had performed the diagnostic colonoscopy had moved from the area shortly thereafter and the patient had, in effect, been lost to followup. “I’m falling, free falling” The appointment notation read innocently enough “blood pressure followup,” but things didn’t seem quite kosher: The new, relatively young patient seemed oblivious while his medication regimen (clonidine, metoprolol, diltiazem, furosemide) hinted at a more ominous history—and still his blood pressure was significantly elevated. As it turned out, he had just been hospitalized for more than a week because of long-standing severe hypertension with chronic renal failure. When his followup appointment was made from the hospital to see me for the first time ever, no medical records were forwarded. “I’m falling, free falling”

The implications of this “new patient” visit were daunting: Ostensibly I was to determine if the young female was able to resume operating a motor vehicle…following a motorcycle accident in which she had sustained fractures of the left superior and inferior pubic rami; zone 2 sacral fracture; left clavicle fracture; left rib fractures 2-7; transverse process fractures T1, T4-T6, L5; closed head injury; diplopia; herpetic keratitis; and C. diff colitis requiring hospitalization followed by several week of in-patient rehab and a neuropsychiatric followup. All this on a Friday afternoon at 3:45 p.m. Is it just me or does there seem to be something wrong with this picture? “I’m falling, free falling”

With retirement from fulltime practice a year ago (my, how time flies when you’re having fun), this older dog thought—and hoped—he’d be spared the new trick of electronic medical records. But now that I’ve recycled myself and work three days a week, I can almost hear the ringmaster shouting, “And now direct your attention to the center ring where Dr. Hartness will jump through flaming cyber hoops!” But when I think about it, EMR represents just the safety net that may make the difference between life and death for hapless patients like the three described and provide a cordon between me and that “for the people” outfit. Ctrl…Alt…Delete…ever so slowly but even less surely I’m learning the ropes of this techno trapeze. In fact, it’s time for me to sign off. My eight-year-old granddaughter is here to give me my next lesson! ❒

JOURNAL MSMA JANUARY 2011

• PHYSICIAN'S BOOKSHELF •

“My Own Country – A Doctor’s Story” by Abraham Verghese reviewed by Philip L. Levin, MD

o read recent history is to relive your life, to bring back not just the memories, but your joys, sorrows, and fears too. One of the most dramatic stories of the 1980’s was the recognition of the disease caused by the HIV virus. Dr. Verghese (Dr. V) relates this history through the eyes of a Tennessee infectious disease specialist, a story poignant with personal incidents.

The book opens with a 1985 scene of the first AIDS patient arriving at the Tennessee medical center hospital, “The Miracle Center,” where Dr. V was just beginning his career. The story brings back the mood of those days, the stigmata of being homosexual, the fear of the contagion, and the inevitability of death. Dr. V tells that the ventilator used on that patient became a symbol of the fear; no matter how hard the staff sterilized it, no one would ever allow it to be used again.

This fear of contagion echoes through the early pages of the book, bringing back memories of my early experiences with AIDS patients. In the mid-eighties, the HIV infected patients from New York and San Francisco came home to the rural hospital where I worked, just as described in the book. Some of my nurses refused to treat them, as did some of the surgeons. We knew each patient by his or her name at first, until their numbers began to climb.

As illustrated by incidents in the book, the announcement of the discovery of the cause of AIDS, the HIV virus, seemed to offer promise for a cure. After all, we had developed vaccines for so many viruses. Yet “My Own Country” expresses the frustration Dr. V felt, fighting so hard against a disease without effective treatment, hoping that any day there were be a new drug, some sort of miracle that could stop this incredible scourge. He tells of how HIV changed the gay men culture, the bathhouses, and anonymous sex of the eighties giving way to

Vintage Books (1994) Paperback - 432 pages ISBN 0679752927 List price: $16 the paranoia and safe sex campaigns. The book focuses on a few of these men, giving personal tales that were so foreign in the early eighties but, because of HIV, became commonplace within a decade. It’s a reminder of how a generation of some of our most creative men was lost and how Americans acted as if they somehow deserved it. Interlaced with his professional story is Verghese’s personal life, the story of being a foreign-born doctor in a community of southern whites. He tells of his marital issues, the unhappiness of a wife frustrated by an overly busy

JANUARY 2011 JOURNAL MSMA

specialist devoted to his practice. That, too, is a picture of history, now a fading one, as twentyfirst century physicians have come to push the balance of their lives more towards having time for family life.

The book ends the last day of 1989, just as the early ARV drugs were coming onto the market. For the first time the death sentence associated with an HIV diagnosis had been offered a glimmer of hope. The stigmata of being homosexual had begun to fade. The fear of treating these patients had yielded to the necessity of caring for the ill.

It’s said we all have a story to tell. “My Own Country” does an excellent job of relating an era when doctors had just begun to believe they could cure anything and were faced with a disease we couldn’t. It was a simpler time, a more humane time, a more idealistic time. It’s worth remembering.❒

DR. PHILIP LEVIN— Philip L. Levin, MD, an emergency physician practicing at Memorial Hospital in Gulfport, serves as president of the Gulf Coast Writers Association, a regional writing group with over a hundred members. His newest novel manuscript, “Andrew Comes Home,” took first place in the contemporary romance division of the New Orleans Romance Writers of America Dixie Kane Classic contest. In addition, it also received the Grand Prize, the award given to the highest scoring manuscript of the seven top place winners. His other publications include a murder mystery, “Inheritance,” and a children’s photo book, “Consuto and the Rain God.”

• MSMA •

Committee on Publications Selects 2011 JMSMA Cover Images

he MSMA Committee on Publications met December 3 at MSMA headquarters to select the most preeminent images for 2011 JMSMA covers. “The fact that we met for four hours before finally reaching a consensus speaks volumes for the number of photos we mused over,” said chair of the committee Dr. Dwalia South. “In the end we could select only twelve winners.” This year marks the 12th annual cover photo contest for physician/photographers. Photos of subjects indicative of Mississippi are given the highest consideration. The committee judges entries on the merits of quality, composition, originality and appropriateness to the JOURNAL MSMA. For instance, “We prefer vertical pictures over horizontal ones because they are more graphically suitable for the cover,” said Dr. South. “We also try to use as many images from different doctors as possible. However, at the end of day, it comes down to the photos we all can agree are fitting to grace our covers for the coming year,” added editor Dr. Luke Lampton. This managing editor remembers the very first image selected in the premiere cover contest. A snow-scene photo of the cemetery at Chapel of the Cross Episcopal Church in Madison, taken by Dr. Cathy Stroud, was selected for the January 1998 cover. If you want to participate in the contest for 2012 mark your calendar. The deadline is usually right after Thanksgiving each year.

JOURNAL MSMA JANUARY 2011

In this digital era, the committee hopes more doctors will participate next year. Shoot landscapes, people, animals, or anything else you can capture on film. Photos of original artwork are also acceptable. Congratulations to this year’s winners! • February – Dr. Randy Easterling / Sugar, Spice and Snow at Cedars by the Lake • March – Dr. Ron Cannon / Bird’s eggs in a nest • April – Dr. Dwalia South / Battle of Shiloh Monument • May- Dr. Martin Pomphrey / Bumblebee on Purple Coneflower • June- (Reserved for portrait) 2011-12 MSMA President Thomas E. Joiner, MD • July - Dr. Martin Pomphrey / Bicyclist on the Natchez Trace • August – Dr. Hannelore H. Giles / Church in Nova Scotia • September – Dr. Martin Pomphrey / 9-11 Remembered • October – Dr. Dwalia South / “Boil them Cabbage Down” fiddler at the National Storytelling Festival • November – Dr. Thomas E. Sheffield / Fawn in deer seaeson • December– Dr. Joe R. Bumgardner / Law library of U.S. Sen. James Z. George, author of the Mississippi Constitution of 1890 • January 2012 - Dr. D. Stanley Hartness / Ice-laden tree branches over the Yockanookany River at sunset —Karen A. Evers, Managing Editor

• IMAGES IN MISSISSIPPI MEDICINE •

1927 MISSISSIPPI FLOOD, GREENVILLE— The spring

1927 Mississippi flood was one of the greatest natural disasters ever to hit our state. It was the Hurricane Katrina of its day, with thousands of Mississippians displaced for extended periods under economic and physical stress. Such resulted in significant medical disasters as well. The above two images feature common sites during the flood: first, refugees in downtown Greenville seeking higher ground and escape from the rising waters; and second, a refugee camp in Greenville packed to its gills with fleeing citizens seeking aid and assistance. Over 16 million acres were flooded in 170 counties in seven states along the Father of Waters. Over 162,000 homes were flooded, and an estimated 500 people died during the flood. As the poor fled for their lives, the Red Cross established 154 camps feeding hundreds of thousands of the displaced. The water took months to recede, and in the camps pellagra erupted due to the nutritional deficiencies of the diet given, which was largely salt pork, molasses, cornbread, and coffee. Dr. Joseph Goldberger, who had discovered the cause of pellagra in Mississippi more than a decade earlier, came to the state to advise the Red Cross how to stop the pellagra outbreak. For more on the 1927 flood, see John M. Barry’s “Rising Tide: The Great Mississippi Flood of 1927 and How It Changed America” (1997). If you have a photograph or image related to Mississippi medicine, which would be of interest to your fellow physicians, please send as a high-resolution jpg file to Dr. Lampton at lukelampton@cableone.net or contact the Journal. —Lucius Lampton, MD, Editor Magnolia

JANUARY 2011 JOURNAL MSMA

• LEGALEASE •

How to Avoid Legal Liability for Online Activities

“If you can’t say something nice, don’t say anything at all.”

ur mamas told us this adage growing up; and in today’s world of constant contact, this is possibly the one lesson we need to remember most!

Recently, MSMA General Counsel has been asked, in different ways, to answer the question: “Can I really be liable for comments posted on the internet?” Well, actually, the answer is, “Yes.” Facebook, Twitter, MySpace, as well as unlimited blogs and commentaries allow us instantaneously to voice our opinion. Indeed, MSMA has recently launched “Online Forums” on its website to help physicians share information across practice, political, and other interests.

Unfortunately, though it feels anonymous at times, participation in social networks and other internet statements can create liability issues for physicians, clinics, and possibly MSMA. That’s why MSMA adopted a Social Media Policy which all users are required to accept before blogging. As it turns out, the Medical Assurance Company of Mississippi (MACM) had enough concern about this newly-emerging area of professional liability that it also prepared an article on the subject which I respectfully submit below for your careful consideration. (Oh, and, “Yes, mama, you were right.”) Taking the steps below will help in preventing legal and other problematic incidents arising out of social networking sites. —Neely C. Carlton, JD General Counsel and Chief of Staff

From MACM: In Your Face(Book)! Social Networking & Clinic Liability 1 It starts out innocently: a staff member letting off steam at the end of the day, venting about anonymous patients or coworkers in an unnamed clinic entity in some Mississippi town. Pretty soon the Internet is brimming with enough information to pinpoint the town, the clinic, and the patient or co-worker. In military security training, this is called talk around… trying to convey a message through code words or vague references to the subject. It doesn’t work. However much we think we hide identities and facts, those closest to the subject can put everything together to make the story. Yes, we had that scenario.

Or, being the caring people we are here in the South, we want to let friends and relatives know what their kinfolk may be doing during their treatments for whatever ails them. After all, the family has set up a CaringBridge page for dissemination of information and for well-wishers to post notes of encouragement. Surely a comment from clinic personnel encouraging their patient in his treatment would be welcomed. Yes? Well, maybe not. A posting from a family member or a friend may be welcomed but only in their personal capacity, not in their capacity as a member of the patient’s health care team. Confidentiality pitfalls with the technology of the Internet are not new issues, but the proliferation of social networking sites has added a new twist to the problem. People sometime forget the line that must be drawn between their personal lives and

JOURNAL MSMA JANUARY 2011

their professional lives. The absolute stickler for protecting patient’s privacy by day may morph into the social butterfly of the Internet by night — without realizing what he or she has done. A September 2009 issue of the Journal of the American Medical Association (JAMA) 2 published an article in which they reported that of the medical school deans who responded to a survey, 60 percent of them reported incidents involving unprofessional posting on social networking sites, with 13 percent reporting violations of patient confidentiality. Some of these postings resulted in expulsion of the student from the medical school.

What are some of the things a clinic can do to help prevent these transgressions and demonstrate that, in accordance with HIPAA regulations, it is taking the required steps to assure patient privacy? •

• • • 1.

Establish written policies regarding the security of patient information and include policies on photos (don’t for get those cell phone cameras!) and social networking sites. Also include all clinic personnel— physicians, too. In clude in your policies prohibition against posting of clinic business or day-to-day clinic issues. Outline procedures for obtaining permission in cases of clinic marketing efforts or media involvement.

Establish for new hire a strong orientation program which includes the security and privacy policies. Reinforce security and privacy policies through periodic training of all personnel. Post security reminders in clinic personnel areas.

Inform all clinic personnel of the consequences of violating the policies, including the possibility of termination. Have them sign a confidentiality statement upon hire and annually thereafter.

Originally featured in Risk Manager published by the Medical Assurance Company of Mississippi, Second Quarter 2010.

Chretien, KC, Greysen, SR, Chretien, J, Kind, T. “Online posting of unprofessional content by medical students,” JAMA. 2009; 302(12):1309-1315.

Feel the Burn Exercise at a moderate intensity to get the most benefit from your workout. A light sweat, faster breathing and some strain in your muscles are all good indicators you’re exercising effectively. If you have a health condition or any other physical barrier, it’s a good idea to talk to your doctor before you begin. be healthy. exercise.

www.bcbsms.com Blue Cross & Blue Shield of Mississippi, A Mutual Insurance Company, is an independent licensee of the Blue Cross and Blue Shield Association. ® Registered Marks of the Blue Cross and Blue Shield Association, an Association of Independent Blue Cross and Blue Shield Plans.

JANUARY 2011 JOURNAL MSMA

• ALLIANCE SPOTLIGHT •

Past President’s Spotlight: Mrs. Ben (Kathy) Carmichael MSMA Auxiliary President, 1992-1993 • Hattiesburg

Kathy Carmichael

here did you grow up? I was born at Walter Reed Army Medical Center as my father was in the United States Army until I was 16-years-old. He was stationed at Fort Bragg, North Carolina; Fort Knox, Kentucky; Japan, and San Francisco. After he retired, we moved to Charleston, West Virginia, where I graduated from high school. I attended Mary Washington College in Fredericksburg, Virginia, for two years and Louisville General Hospital School of Radiological Technology. How did you meet your physician spouse? I then moved to Arlington, Virginia, where I took a job as an x-ray technologist at Walter Reed General Hospital. There I met Ben, who was finishing his internship and would soon begin an Internal Medicine residency. We were married at Walter Reed and our first child Ben was born there. Our second son, David, was born in San Antonio, Texas, at Brooke Army Medical Center where Ben did his Fellowship in Cardiology. What are the names and ages of your children? We have two children, Ben and David. We have four grandchildren, all living in Hattiesburg: Katelyn-13; Gunner10; Matthew-10, and Lake-8.

JOURNAL MSMA JANUARY 2011

Dr. and Mrs. Ben (Kathy) Carmichael

How do you spend your free time? I sing in our church choir at Trinity Episcopal Church where I also volunteer one morning a week in the church office. I have just retired from the “Boutique” at Steinmart after 13 years. I enjoy yard work, tennis, University of Southern Mississippi (USM) football, travel, and the many programs USM offers to the community. How did you come to join the Alliance? I had been a member of the Officer’s Wives Medical Board in San Antonio so as soon as we moved to Hattiesburg and I was invited to join the County Auxiliary I joined and became progressively involved. At that time, our local and State Auxiliary was very active with many members. What are the highlights of your presidential year? The highlights of my year as President of MSMA Alliance would be travelling around the state, staying in many wonderful homes, and forming lasting friendships. We did change our name from the Auxiliary to the Alliance following the AMA’s example. Do you have any advice for fellow physician spouses? The Alliance has been a big part of my life and has opened many doors for me. It’s the best way to meet and get to know the medical community. It is a unique opportunity to become involved with young and old medical spouses who truly care for one another and their community. ❒

(Standing) Mary Al Alford, Amy Gammel, Kathy Brandon, Angela Ladner, Jane Preston, Dede Lewis, Louise Lampton, Brinda Manisundaram, Martha Clippenger, Shoba Gaymes, Eileene McRae, Marian Kennedy, Kathy Carmichael, Jean Hill, (front) Nancy Smith, Peggy Crawford, Sondra Pinson, Susan Rish, Karen Morris, Nancy Lindstrom

A wish for health and happiness in the coming year 2011 is being sent to you by members of the Mississippi State Medical Association Alliance JANUARY 2011 JOURNAL MSMA

• THE UNCOMMON THREAD • My Top Ten on Nutrition

was at the December Publications Committee meeting and heard about the idea that the editors were hatching about a Top Ten List of things physicians should know on various health care subjects. I think it’s a great idea so I’m going to take on what we all have on our minds in the New Year– losing weight. So without further ado lets jump to:

# 10.

R. Scott Anderson, MD

DOC A’S TOP TEN LIST ON NUTRITION

For all of you moms out there - Cheetos are not a vegetable. A sandwich and Cheetos is not a balanced meal.

# 9.

Kids – Although it may look like it, broccoli is not really poisonous. I’m sure your mother isn’t really trying to kill you by making you eat it.

# 8.

Okay, Dads, it’s your turn– A diet that is primarily bacon may possibly be too high in fat and sodium.

# 7.

This one is a pretty universal rule – If you eat enough calories to support a six hundred pound hog for long enough, you may start to look like one after a while.

# 6.

There are some things about eating healthy you need to be aware of – Fresh vegetables can lead to the occasional gaseous social blunder.

# 5.

Couples need to be aware that weight loss may do more for your sex life than Viagra can.

# 4.

If you eat too much salt, you get high blood pressure, and although your eyes may not actually shoot out of your head like your mom said, it still isn’t good for you.

# 3.

If folks in Mississippi ate only what they needed, the extra food left over could end hunger in most average size African countries.

# 2.

While most Chinese people aren’t fat, what the average Mississippian eats at a Chinese buffet would feed a family in China for more than a week.

# 1.

I can see my picture too, and even though I’m much thinner in two-dimensions, I’m still too fat. I guess I better go back through the other nine a few more times myself. Happy New Year

R. Scott Anderson, MD, a radiation oncologist, is medical director of the Anderson Regional Cancer Center in Meridian and past vice chair of

the MSMA Board of Trustees. Additionally, he is an accomplished oil-painter and dabbles in the motion-picture industry as a screen-writer,

helping form P-32, an entertainment funding entity.

JOURNAL MSMA JANUARY 2011

• UNA VOCE •

Dwalia S. South Bitter, MD

A Pox upon Ye!

or the New Year, the “Una Voce” column once again departs from the norm to share a brief but important message. My adopted brother and dear friend, certified travel companion and literary muse, Mr. Tommy Covington, has written this “letter to the editor” to several regional publications regarding his recent experience with shingles and the beastly disorder we physicians label postherpetic neuralgia (PHN). He was besieged by this ailment in July while I was away with my family in Destin at the Mississippi Academy of Family Physicians annual meeting. The diagnosis was made over the phone, and treatment was begun quickly by calling in the appropriate anti-viral meds to his local pharmacy. He responded rather well at first, the rash was drying nicely when I first viewed it, but a few weeks later the burning pain escalated into an endless mind-bending bit of hell on earth. It panged me just to watch him suffer with this electric agony and grab at his side when he was playing the organ for us at church. We tried several modalities, and he has finally found some semblance of relief at last, many months after its beginning.

Tommy e-mailed me one morning and said, “It seems I might be cursed with this forever, but if there is a vaccine available to prevent someone else from being stricken with it, I want people to know about it. Therefore, I am sending this to the Southern Sentinel and the North Mississippi Daily Journal. What do you think?” When I read his letter to our local newspapers prior to publication, I felt a pang of another sort, deep regret that I didn’t suggest the preventive vaccine to him long ago and that I don’t do it often enough in my daily primary care practice. I don’t think very many physicians do, and this is a sad commentary about us. We like to think we are good at preventive medicine, but we are actually pretty lousy at it. We are too busy putting out the string of daily fires that appear in our exam rooms dozens of times a day. I also lamented the fact that a suffering patient was the one who felt led to be the “town crier,” warning and informing the local public about the shingles vaccine. After his letter appeared in our local paper, dozens of patients have asked for and received this vaccine. Countless others who need it simply are unable to afford its exorbitant price. I haven’t found an insurance plan yet that covers it nor does Medicare. However, the federal government and other private insurances then spend millions each year paying for endless and repeated office visits, expensive antiviral medications, creams, and narcotics required to treat this scourge once our patient is struck with this very common malady, costly in terms of both money and quality of life. As always, it seems our health care system and those of us who provide medical care continue our feeble efforts at closing the barn doors only after the horses have gotten out. To paraphrase a popular, comedic buzz-phrase: “Dear Feds... Here’s your sign!” Please read the following eye-opening letter which is pertinent to literally every physician specialty that treats adult patients, feel free to send it for publication as a letter to your local newspaper under your authorship if so desired, and finally take to heart this admonition for your own personal health as well. —ds

SHINGLES VACCINE nyone who has ever had chickenpox carries the virus for the rest of his or her life. This varicella-zoster infection, which most of us view as an innocuous childhood illness, can cause a painful outbreak of herpes zoster in our later years. Commonly known as shingles, this reactivated virus erupts in blisters along the course of a major nerve. Some unfortunate patients go on to develop a nightmarish condition called postherpetic neuralgia (PHN). Until I had shingles, I thought that shingles was only a simple skin condition that was itchy and painful. Now that I have had shingles followed by a severe case of PHN, I know that the condition can attack the body at any number of places and even begin without any skin eruptions at all. It can be a pain which may mimic heart trouble, kidney trouble or affect various other internal organs. When shingles occurs on the face around the eyes, it can be especially dangerous possibly causing blindness.

JANUARY 2011 JOURNAL MSMA

At the onset of my attack, I believed I was having another kidney stone. Five days later the telltale blisters developed and the offending culprit was made known. Once the shingles diagnosis is established, the treating physician will most likely prescribe an anti-viral drug to begin as soon as possible. In my case, the drug cleared up the blisters and reddened skin within three weeks. I then developed PHN of the whole right side of the mid-section of my body. It is definitely a torment which is now in the fifth month. I cannot stand for my clothes to lightly touch my side and I wear a soft velour cloth snuggly wrapped around my waist. Sleeping can be a real challenge. At times during the first three months, it felt like a whole nest of wasps was stinging me at the same time! During the fourth month that turned into soreness as if my side had been burned. Postherpetic neuralgia pain requires trying different drugs including analgesics which may not entirely control the intense pain that is experienced. Skin creams and lotions are of little help after the shingles blisters have dried up. The pain is from the damaged internal nerves. I want to give this warning that there is a shingles vaccine (Oka/Merck) [Zostavax] that may help to prevent those 60 years or older from having shingles and enduring unnecessary pain and misery. Please consult your doctor. There are a few situations where one should not take the vaccine. There are a lot of unknowns about the vaccine and I have found the best information on the Internet from the Centers for Disease Control:http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5705a1htm and The Shingles Foundation: http://www.vzvfoundation.org/faq.html. Some people have recurring cases of shingles and one question is whether vaccination is a preventative measure. Physicians have different opinions concerning that situation. At some point, I plan to be vaccinated just on the possibility that it might prevent or lessen a second case. The CDC agrees it is okay to do so. The vaccine will not be of help with a current case of shingles or PHN. The shingles vaccine is recommended for those 60 and older only. The vaccine is expensive (between $150 and $175), and may or may not be covered by insurance. I will say that regardless of any out of pocket cost, I only wish that I had been given this warning and been vaccinated before developing this excruciating and life-altering condition. â&#x20AC;&#x201D;Tommy Covington, Ripley [Una Voce (With One Voice), is a column in the JMSMA featuring the prose of Dwalia South, MD. Having served as an associate editor of the JMSMA, she currently chairs the MSMA Committee on Publications. A past president of the MSMA and the Mississippi Academy of Family Physicians (MAFP), Dr. South is a family physician in Ripley affiliated with North Mississippi Primary Care Associates, Inc. She is a past recipient of the MSMA James C. Waites Leadership Award, the MAFP â&#x20AC;&#x153;Family Physician of the Year Awardâ&#x20AC;? known as the John B. Howell Memorial Award, and was named one of Americaâ&#x20AC;&#x2122;s Top Family Doctors of the Year: 2004-2005. She has served on the Mississippi State Board of Medical Licensure and the Mississippi Foundation for Medical Care Board of Trustees. In addition to writing, Dr. South enjoys the art of oral storytelling and operating her family farm business, Green Hills Farm, producing Quarter horses, Longhorn cattle, and pine trees.] â&#x20AC;&#x201D;ED.

JOURNAL MSMA JANUARY 2011

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