August
VOL. LIII
2012
No. 8
Mississippi Physicians Don’t Miss a Thing with ONLINE CME from MSMA Now, you can earn CME credits where and when it is most convenient for you. Online courses provide the educational content you need, from a source you can trust, and without taking time away from your busy practice.
SIPPI ST
TI
IC
A
A
MED
ON
MI
S SI
E AT
S
Registering and participating in online CME is easy. Simply visit http://MSMAonline.inreachce.com, browse the MSMA catalog, and choose your courses.
I L A C O SS
Online CME from MSMA. Don’t Miss a Thing.
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 Steven L. Demetropoulos, MD President James A. Rish, 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 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© 2012 Mississippi State Medical Association.
AUGUST 2012
VOLUME 53
NUMBER 8
Scientific ArticleS
Public School Parents’ Perspectives of the Mississippi Healthy Students Act of 2007: Findings from 2009-2011
247
Linda H. Southward, PhD; Kathleen Ragsdale, PhD; Colleen McKee, MS; Anne Buffington, BS; Dorris Baggett, MS; Troy Blanchard, PhD and John Edwards PhD
Outpatient Treatment of Adults with Cystic Fibrosis by Primary Care Physicians
255
Nauman Chaudary, MD
Clinical Problem-Solving: A Common, but Unexpected, Suspect
260
Andrea Morgan, MD
Just Off the Press - Info You Want to Know Clopidogrel with Proton Pump Inhibitors
274
Hannah Gwin, PharmD; Richard L. Ogletree, Jr., PharmD
Top 10 Facts You Should Know about Diabetes
275
Rosemary J. Call, PharmD; Marion R. Wofford, MD; Daniel M. Riche, PharmD
PreSident’S PAge
Just What the Doctor Ordered
263
Steven L. Demetropoulos, MD; MSMA President
SPeciAl Article
MSMA Cosponsors First-Ever Mississippi Rx Drug Summit
267
Karen A. Evers, Managing Editor
An Interview with Charles D. “Buddy” Daughdrill, Executive Director of the Mississippi Public Health Association
278
Richard D. deShazo, MD, Associate Editor
editoriAl
Raising the Bar, but Failing to Meet the Goal: A Young Physician Reflects on Match Day and Mississippi’s Primary Care Workforce
270
P. Brent Smith, MD
My View from Second Year: Reflections of a Mississippi Medical Student
272
Emily Brandon, M2
relAted orgAnizAtionS
Mississippi State Department of Health
265
ASclePiAd
Benjamin Macklin Carmichael, MD
280
About the cover:
dAylily – Brett Tisdale, MD photographed this daylily because the morning
sun on the east-facing flower created intriguing shadows of the stamens visible through the back of the petals. He adds, “The contrast between the orange daylily and the green background (my yard) was also quite strong.” Daylilies are of the genus Hemerocallis, from the Greek hemera (day) and kallos (beautiful), and are not a true lily. Hemerocallis is a native of Asia but has been extensively hybridized in England and the United States since the 1930s producing a huge variety of forms and colors. They are adaptable to a wide range of climates, soils, and moisture conditions and thus can thrive almost anywhere. Ancient Chinese and Japanese used various parts of the plant for food and medicine: a diuretic, a pain reliever, anticancer properties, and an antidote for arsenic poisoning. (Source: National Agricultural Digital Library. Available at http://naldc.nal. usda.gov/download/39856/PDF) Dr. Tisdale practices urgent care medicine in McComb. r August
VOL. LIII
Official Publication of the MSMA Since 1959
2012
No. 8
August 2012 JOURNAL MSMA 245
From the Editor
C
entral to the art of medicine is the relief of pain. Since the time of Hippocrates, physicians have battled to treat pain appropriately yet to avoid negative consequences such as addiction and overdose. Before the Civil War, a Mississippi physician complained of the afflictions which “beset the path of humanity” owing to the “proprietors of nostrums and quack remedies.” This physician warned of the “degrading of the profession” by the abuse of “patent medicines and nostrums,” often filled with alcohol and opiates, which resulted in the addiction of masses of citizens.“The amount paid to these imposters by the people of the Mississippi Valley more than doubles the amount of sales of the regular articles of the materia medica in the Valley,” said Dr. Samuel Cartwright in 1848. Today, the abuse of prescription drugs, prescriptions written by our own pens, degrades our own profession and must be addressed. A retiring physician once commented, “It is better to be fooled by five narcotic addicts than to miss one woman with a real migraine.” I agree. We must, as patient advocates, seek to relieve the suffering and pain of our patients, and this involves trust. However, we must also realize the dangers of addiction and abuse and take necessary precautions to prescribe pain medicines with both compassion and prudence. If our efforts to end abuse result in physicians refusing to treat pain, we have failed. We, as physicians, must treat pain, but we must use evidence-based approaches and safeguards with every patient.
In this issue, our managing editor Karen Evers writes an important article on Mississippi’s recent “Rx Drug Summit.” It is obvious that if physicians don’t address and solve prescription drug abuse in our state, our legislators will, and more than likely in an onerous anti-physician, anti-patient manner. Physicians must use the tools and protocols available to treat pain more competently and solve this growing epidemic. Lucius M. Lampton, MD There are other special articles in this Editor issue. Third generation physician Emily Brandon reflects on her journey to medical school, while young physician Brent Smith, a nationally recognized physician leader, explores “Match Day” and the failure of our nation’s medical schools to attend to the primary care needs of our country. In addition to excellent scientific articles, revel in Dr. Brett Tisdale’s exemplary cover photograph, speaking to not only the beauty of nature, but also the great talents of Mississippi physicians. This Journal remains one of the few in the United States still created by physicians for physicians. It is only as good as you make it. Write an editorial, a letter, an essay, a scientific article, a case report, or take a photograph or contribute a physician portrait. Contact me at lukelampton@cableone.net.
Journal Editorial Advisory Board R. Scott Anderson, MD, FACR Chair, Journal Editorial Advisory Board Radiation Oncologist and Medical Director, Anderson Regional Cancer Center, Meridian Diane K. Beebe, MD Professor and Chair, Department of Family Medicine, University of MS Medical Center, Jackson Claude D. Brunson, MD Senior Advisor to the Vice Chancellor for External Affairs, University of Mississippi Medical Center, Jackson Jeffrey D. Carron, MD, FAAP, FACS Associate Professor, Department of Otolaryngology & Communicative Sciences, University of Mississippi Medical Center, Jackson Gordon (Mike) Castleberry, MD Urologist, Starkville Urology Clinic Mary Currier, MD, MPH State Health Officer Mississippi State Department of Health, Jackson Thomas E. Dobbs, MD, MPH Health Officer, District VII/VIII Mississippi State Department of Health, Hattiesburg Sharon Douglas, MD Chair, AMA Council on Ethical & Judicial Affairs Professor of Medicine and Associate Dean for V A Education, University of Mississippi School of Medicine, Associate Chief of Staff for Education and Ethics, G.V. Montgomery VA Medical Center, Jackson Daniel P. Edney, MD Executive Committee Member, National Disaster Life Support Education Consortium, Internist The Street Clinic, Vicksburg
246 170 JOURNAL JOURNAL MSMA MSMA
A 2012 Jugust UNE 2012
Owen B. Evans, MD Professor of Pediatrics and Neurology University of Mississippi Medical Center, Jackson Maxie L. Gordon, MD Assistant Professor, Department of Psychiatry and Human Behavior, Director of the Adult Inpatient Psychiatry Unit and Medical Student Education, University of Mississippi Medical Center, Jackson Scott Hambleton, MD Medical Director Mississippi Professionals Health Program, Ridgeland John Edward Hill, MD, FAAFP Residency Program Director North Mississippi Medical Center, Tupelo John D. Isaacs, Jr., MD Infertility Specialist, Mississippi Fertility Institute at Women’s Specialty Center, Jackson Kent A Kirchner, MD Chief of Staff G.V. Montgomery VA Medical Center, Jackson Brett C. Lampton, MD Internist/Hospitalist Baptist Memorial Hospital, Oxford Philip L. Levin, MD President, Gulf Coast Writers Association Emergency Medicine Physician, Gulfport William Lineaweaver, MD, FACS Editor, Annals of Plastic Surgery Medical Director JMS Burn and Reconstruction Center, Brandon John F. Lucas,III, MD Surgeon Greenwood Leflore Hospital
Gailen D. Marshall, Jr., MD, PhD, FACP Professor of Medicine and Pediatrics, Vice Chair for Research, Director, Division of Clinical Immunology and Allergy, Chief, Laboratory of Behavioral Immunology Research The University of Mississippi Medical Center, Jackson Alan R. Moore, MD Clinical Neurophysiologist Muscle and Nerve, Jackson Paul “Hal” Moore Jr., MD, FACR Radiologist Singing River Radiology Group, Pascagoula Jason G. Murphy, MD Surgeon Surgical Clinic Associates, Jackson Ann Myers, MD Rheumatologist Mississippi Arthritis Clinic, Jackson Jimmy L. Stewart, Jr., MD Program Director, Combined Internal Medicine/ Pediatrics Residency Program, Associate Professor of Medicine and Pediatrics University of Mississippi Medical Center, Jackson Samuel Calvin Thigpen, MD Hematology-Oncology Fellow, Department of Medicine University of Mississippi Medical Center, Jackson Thad F. Waites, MD, FACC Clinical Cardiologist, Hattiesburg Clinic Chris E. Wiggins, MD Orthopaedic Surgeon Bienville Orthopaedic Specialists, Pascagoula John E. Wilkaitis, MD, MBA, CPE, MS Chief Medical Officer Brentwood Behavioral Healthcare, Flowood
• scientific Articles • Public School Parents’ Perspectives of the Mississippi Healthy Students Act of 2007: Findings from 2009-2011 Linda H. Southward, PhD; Kathleen Ragsdale, PhD; Colleen McKee, MS; Anne Buffington, BS; Dorris Baggett, MS; Troy Blanchard, PhD and John Edwards PhD
A
bStrAct
Annual evaluations of the Mississippi Healthy Students Act of 2007 (MHSA) were conducted from 2009-2011 among four stakeholder groups: (1) parents of public school students; (2) adolescents; (3) school officials (e.g., superintendents); (4) state-level policymakers (e.g., legislators). We examine results from the first state-wide study among a randomized sample of parents (N>3,600 per year) on childhood obesity as it related to MHSA. Parents were surveyed to determine: (1) knowledge/attitudes towards MHSA; (2) knowledge/attitudes/behaviors (KAB) that influence children’s health; and (3) perceived overweight/obesity of self and child versus BMI-determined overweight/obesity. Across all three years, parents were very supportive of MHSA across a number of variables, while parents greatly underestimated obesity among self and child when compared to their BMI data. Results highlight complexities of parents’ KAB that potentially influence children’s health, including the MHSA. Policy implications are discussed.
Key WordS: Mississippi HeAltHy students Act of 2007, obesity, policy
introduction Obesity is a serious health concern affecting children and adolescents in Mississippi and the United States (U.S.) at stagAuthor informAtion: Dr. Southward, Dr. Ragsdale, Ms McKee, Ms Buffington, Ms Baggett and Dr. Edwards are at the Social Science Research Center, Mississippi State University. Dr. Blanchard is in the Department of Sociology at Louisiana State University. correSPonding Author: Linda H. Southward, Ph.D., Social Science Research Center, Mississippi State University, PO Box 5287, Mississippi State, MS 39762-0868
gering rates that have continued to increase over the past decades.1 For example, between 1996 to 2008, obesity prevalence among U.S. adolescents rose from 13.3% to 36.1%.2 From 2003 to 2007, the percent of children ages 10-17 who were overweight or obese rose from 37% to 44%.3 Overweight adolescents have a 70% risk of becoming obese adults, which is associated with risk for serious health problems such as diabetes, high blood pressure, and heart disease.4 Without considerable changes being implemented across the U.S., it is anticipated that the prevalence of obesity and chronic health problems will increase in the future, given that obesity among children and teens has nearly doubled over the past two decades and continues to climb. With an adult obesity rate of 35%,5 Mississippi ranks first in obesity in the nation, a position it has held for seven consecutive years.6,7 As of 2007, the most current state-by-state level data available indicates that, with a childhood obesity rate of 21.9%, Mississippi also ranks first in obesity among children ages 10-17.8 An important policy measure to combat rising obesity rates among Mississippi’s children began in 2007 when the state legislature passed the Mississippi Healthy Students Act of 2007 (MHSA). The implementation of this legislation highlights/reinforces the important roles and opportunities school environments have in addressing Mississippi’s high rate of childhood obesity. This legislation centers on three primary areas associated with the prevention of obesity: (1) increasing physical activity, (2) promoting sound nutrition, and (3) providing solid health education within all school districts in the state.9 Specifically, MHSA mandates 45 minutes per week of health education instruction and 150 minutes per week of activity-based instruction in Grades K-8. All students in Grades 9-12 must have completed a one-half Carnegie Unit in health education and a one-half Carnegie Unit in physical education in order to graduate. In addition, an important piece of this legisla-
August 2012 JOURNAL MSMA 247
tion includes offering healthier food choices within cafeterias (e.g., eliminating deep fat fryers) and in school-based vending machines (e.g. offering water or diet sodas and low-fat snacks).
methodS In this paper, we present the first in a series of articles based on evaluations of the MHSA that have been conducted annually during 2009, 2010, and 2011.10,11,12 The evaluations focus on four groups of stakeholders: (1) parents of public school students; (2) adolescents attending public school; (3) school officials (i.e., superintendents and school board members); and (4) state-level policymakers (i.e., legislators, State Board of Health members, State Board of Education members, and public health district officers). The evaluations examine how MHSA–relevant practices and policies have changed over time from 2009 to 2011 across a number of environmental contexts (e.g., family/home, school, and community environments) using known variables that influence weight and fitness status such as nutrition, exercise and physical activity, screen time (TV, computer, etc.,), and family activity level.8,13,14,15 For the present analysis―which is focused on parent responses―we compare survey findings from Year One (2009) to Year Two (2010) and Year Three (2011). To our knowledge, this is the first state-wide randomized sample conducted among parents of public school students on the subject of childhood obesity as it relates to the MHSA. The surveys were administered by the Wolfgang Frese Survey Research Laboratory of the Social Science Research Center at Mississippi State University (MSU) and used random digit sampling of both landline and cellphone numbers to generate phone numbers at random. To create a database of potential participants, the Mississippi Department of Education provided the phone numbers of all parents of public school students for each corresponding academic year. From the 2008-2009 database of approximately 360,000 phone numbers, a random sample of 26,000 phone numbers was drawn. We used this list from which to random digit dial (RDD) the final sample of 3,710 eligible parents in 2009, and had a 74.6% cooperation rate. From a 2009-2010 database of 491,084 phone numbers, a random sample of 34,856 phone numbers was drawn. We used this list from which to RDD the final sample of 3,755 eligible parents in 2010, and had a 67.6% cooperation rate. From the 2010-2011 database of 491,540 phone numbers, the random sample of 34,856 phone numbers was drawn. We used this list from which to RDD the final sample of 3,641 eligible parents in 2011, and had a 55.9% cooperation rate. For all studies, the sampling error for the total dataset (binomial response option with 50/50 split) was no larger than +/– 3.5%, 95% CI. The survey took approximately 15 minutes to complete, and parents who agreed to participate were not compensated for their time. The study’s protocol was approved by the MSU Institutional Review Board for each year of data collection. A key goal of the surveys was to collect data on parents’ knowledge of and attitudes toward the MHSA and related poli-
248 JOURNAL MSMA
August 2012
cies implemented in Mississippi public school systems at the time the study was conducted. This was important because schools are key venues for establishing and reinforcing health norms for school-aged children and for conveying health information to students’ parents/families.16 A second goal of the surveys was to collect data on: (1) how parents feel about a number of school health policies, (2) how parents influence school health policies, and (3) family knowledge, attitudes, and behaviors (KAB) that influence children’s health, with special emphasis on variables related to children’s weight. For each study, parents were asked the same basic series of yes/no, Likert-type, multiple choice, and rank order response items, with slight modifications in wording to improve comprehension in 2010 and 2011. Yes/no items included questions such as “State laws now require schools to offer only healthy foods to children and to increase physical education. Do you support this?” Likert-type items included questions such as “On a scale of 1 to 5, with 5 being the most important and 1 being the least important, how important do you think prevention of childhood obesity is in Mississippi?” Multiple choice items included questions such as “How many servings of fruits and vegetables should a person eat each day for good health?” Rank order responses included items such as “Please rank the following target areas that can be addressed by the Department of Education, by level of importance with 5 being the most important and 1 being the least important” and the response categories included “increasing physical activity,” “increasing consumption of fruits and vegetables,” “decreasing consumption of high-calorie, dense foods,” “decreasing children’s screen time (TV viewing, computer screen time),” and “decreasing consumption of sugary beverages.” Parents were also asked to report their own height (“How tall are you without your shoes on?” [in inches]) and weight (“How much do you weigh without shoes?”), as well as the age, gender, height, and weight of their children. We used this selfreported data to calculate the Body Mass Index (BMI) for parents and children, using standard formulas and tools available from the Centers for Disease Control and Prevention (CDC).17 Based on their BMI, parents and children were categorized as either: (1) underweight (BMI below 18.5), (2) healthy weight (BMI range of 18.5 to 24.9); (3) overweight (BMI range of 25.0 to 29.9); or (4) obese (BMI range of 30.0 or above).17 The data were analyzed using SPSS 18.0 and the level of significance was set at p ≤ .05.
reSultS
Parent Support of Current School Policies Changes in the School Environment Across all three years of the study (2009-2011), ≥96% of parents overwhelmingly supported the MHSA requirement that schools offer physical education to all students. Across all three years, ≥93% of parents also overwhelmingly supported the MHSA requirement that schools offer only healthy foods to students and that they increase physical education. Interest-
ingly, 67% of parents in 2009 reported that the role of public schools was “very important” to the prevention of childhood overweight and obesity problems in Mississippi, as compared to 66% in 2010 and 58% in 2011, which is a significant decrease from 2009 to 2011. In 2010, 34% of parents reported that their child’s school provided a “very healthy environment” in terms of offering healthy foods and opportunities for physical activity, which increased to 37% in 2011 (the question was not asked in 2009). However, when parents were asked about specific changes within their child’s school environment, only 44% reported in 2009 that they were aware of “any changes in vending machines, school lunch choices, or physical exercise requirements” at their child’s school, as compared to 37% in 2010 and 34% in 2011, which is a significant decrease from 2009 to 2011. In 2009, 26% of parents reported that their child’s school had a health committee, council or task force, as compared to 22% in both 2010 and 2011. These results are noteworthy given that all three of these domains correspond to three policy areas that are key components of the MHSA. In 2009, 50% of parents stated that only healthy snacks (e.g., low-fat and low-sugar snacks and low-sugar and non-carbonated drinks) should be offered to students in school vending machines, as compared to 47% in 2010 and 45% in 2011, which is a significant decrease from 2009 to 2011. In 2009, 27% of parents stated that both healthy and less healthy snacks should be offered to students in school vending machines and that students should be allowed to make their own snack choices, as compared to 28% in 2010 and 29% in 2011, which is a significant increase from 2009 to 2011. Likewise in 2009, 21% of parents stated that schools should not have vending machines available to students, as compared to 23% in 2010 and 25% in 2011, which is a significant increase from 2009 to 2011. Family-Level Knowledge, Attitudes & Behaviors (KAB) In 2009, 36% of parents reported serving sodas to their families 4-7 days per week, as compared to 46% in 2010 and 44% in 2011, which is a significant increase from 2009 to 2011. In 2009, 36% reported serving sodas to their families 1-3 days per week, as compared to 33% in 2010 and 35% in 2011. In 2009, 87% of parents reported that their child regularly ate breakfast, a percentage that stayed relatively the same in 2010 and 2011 (at 86% and 88%, respectively). In 2009, 41% of parents reported that their family sat down to an evening meal together seven nights per week, a percentage that also stayed relatively the same in 2010 and 2011 (at 44% and 42%, respectively). When asked, “How many servings of fruits and vegetables should a person eat each day for good health?” 18% of parents in 2009 answered this question correctly (with the response that five or more servings per day is the amount recommended). Twenty percent of parents answered correctly both in 2010 and 2011, which is a significant increase from 2009 to 2011. When asked to respond to the question, “In the past year, has the physical activity level in your own family increased, de-
creased or stayed about the same?” 47% of parents in 2009 reported that their family’s physical activity level had increased. This percentage stayed the same in 2010 and increased to 48% in 2011. In 2009, 47% of parents reported that their family’s physical activity level had stayed the same, as compared to 49% in 2010 and 47% in 2011. Interestingly, 52% of parents in 2009 reported that they had increased their child’s exercise within the past year, as compared to 44% in both 2010 and 2011, which is a significant decrease from 2009 to 2011. Self-Reported Weight Categories as Compared to Body Mass Index (BMI) Calculations As stated previously, we asked parents to report their own height and weight and the height and weight of their children, which we used to calculate the BMI for parents and children.17 Based on their BMI, parents and children were categorized as either: (1) underweight; (2) healthy weight; (3) overweight; and (4) obese.17 As Table 1 indicates, we also asked parents to selfreport which of the above four categories best described themselves and their children (i.e., underweight, healthy weight, overweight, or obese). Due to the small numbers of persons categorized as underweight, we only report this information in Table 1. In 2009, 35% of parents categorized themselves as a healthy weight, 56% as overweight, and 4% as obese, such that 60% of parents in 2009 categorized themselves as overweight/ obese. In contrast, based on BMI calculations, 29% of parents in 2009 were a healthy weight, 34% were overweight, and 36% were obese, such that 70% of parents in 2009 were overweight/ obese. In 2010, 35% of parents categorized themselves as a healthy weight, 56% as overweight, and 6% as obese, such that 62% of parents in 2010 categorized themselves as overweight/obese. Based on BMI calculations, 27% of parents in 2010 were a healthy weight, 33% were overweight, and 39% were obese, such that 72% of parents in 2010 were overweight/ obese. In 2011, 37% of parents categorized themselves as a healthy weight, 52% as overweight, and 7% as obese, such that 59% of parents in 2011 categorized themselves as overweight/ obese. Based on BMI calculations, 29% of parents in 2011 were a healthy weight, 33% were overweight, and 36% were obese, such that 69% of parents in 2011 were overweight/obese. In 2009, 75% of parents categorized their children as a healthy weight, 8% as overweight, and 9% as obese, such that 17% of parents in 2009 categorized their children as overweight/obese. In contrast, based on BMI calculations, 56% of children in 2009 were a healthy weight, 17% were overweight, and 21% were obese, such that 38% of children in 2009 were overweight/obese. In both 2010 and 2011, 77% of parents categorized their children as a healthy weight, 14% as overweight, and 1% as obese, such that 15% of parents in both 2010 and 2011 categorized their children as overweight/obese. Based on BMI calculations, 55% of children in 2010 were a healthy weight, 18% were overweight, and 21% were obese, such that 39% of children in 2010 were overweight/obese. Based
August 2012 JOURNAL MSMA 249
on BMI calculations, 54% of children in 2011 were a healthy weight, 17% were overweight, and 22% were obese, such that 39% of children in 2011 were overweight/obese. Table 1. Parents self-reported weight status for themselves and children asweight compared to BMI-based weight statustofor Tabletheir 1. Parents self-reported status for themselves and their children as compared BMI-based and weightchildren status for parents and children in 2009, and 2011. parents in 2009, 2010, and2010, 2011. Weight Status Category
Underweighta Healthy weightb Overweightc Obesed Total
Parents Weight status Self-report BMI-based % (n) % (n) 3 (108) 1 (40) 35 (1,307) 29 (986) 56 (2,092) 34 (1,167) 4 (157) 36 (1,216) 98 (3,664) 100 (3,409)
Underweighta Healthy weightb Overweightc Obesed Total
Parents Weight status Self-report BMI-based % (n) % (n) 2 (83) 1 (37) 35 (1,302) 25 (921) 56 (2,107) 31 (1,147) 6 (226) 39 (1,338) 99 (3,718) 96 (3,443) Parents Weight status Self-report BMI-based % (n) % (n) 2 (74) 1 (45) 37 (1,344) 29 (980) 52 (1,896) 33 (1,120) 7 (271) 36 (1,206) 98 (3,585) 99 (3,351)
Underweighta Healthy weightb Overweightc Obesed Total a BMI below 18.5 b BMI range of 18.5 to 24.9 c BMI range of 25.0 to 29.9 d BMI range of 30.0 or above
2009
2010
2011
Children Weight status Self-report BMI-based % (n) % (n) 7 (260) 7 (195) 75 (2,783) 56 (1,635) 8 (304) 17 (480) 9 (344) 21 (607) 99 (3,691) 100 (2,917) Children Weight status Self-report BMI-based % (n) % (n) 7 (252) 7 (205) 77 (2,902) 55 (1,677) 14 (540) 15 (555) 1 (47) 21 (635) 99 (3,741) 98 (3,072) Children Weight status Self-report BMI-based % (n) % (n) 7 (255) 7 (212) 77 (2,815) 54 (1,546) 14 (495) 17 (494) 1 (52) 22 (631) 99 (3,617) 100 (2,883)
Parent Support of Future School-based Policies Across all three studies, we found that parents were in support of schools collecting the height and weight of their child and reporting this information to the parents, although this support was not consistent across all three evaluations. In 2009, 85% of parents reported their support of this potential policy, as compared to 82% in 2010 and 80 % in 2011. Less than half (47%) of parents in 2009 reported that public school facilities were available to use for physical activity outside regular school hours, as compared to 42% in 2010 and 43% in 2011. Nearly two thirds (63%) of parents in 2009 reported having a park nearby for their child to play, as compared to 68% in 2010 and 71% in 2011, which is a significant increase from 2009 to 2011.
diScuSSion The intersection of children’s academic achievement and school-based health policy is increasingly recognized as a key issue in public health.18,19 In this paper, we compare results from three surveys delivered annually between 2009 and 2011 to a random sample of parents of public school students in Mississippi. The results highlight the complexities of parental knowledge of and attitudes toward the MHSA and related policies issues. For example, although the percentage of parents who affirmed that only healthy snacks should be offered to students in school vending machines significantly declined
250 JOURNAL MSMA
August 2012
between 2009 and 2011, there was a significant increase among parents who affirmed that schools should not have vending machines available to students. Across all three surveys, we also found that 16% of parents categorized their children as overweight/obese, yet BMI calculations indicated that 39% of children were overweight/ obese. These calculations are more in-line with finding from current national studies of childhood overweight and obesity that report an obesity rate among adolescents of 36%,2 and a combined overweight/obese rate among adolescents of 44%.3 Keeping in mind that Mississippi leads the nation in obesity rates among children,5,7,8 there is a sharp contrast between parents low estimates of overweight/obesity among their children versus BMI-based rates of overweight/obesity that are more than 2.5 times higher. This suggests that there may be a serious disconnect between parents’ perceptions that their children are a “healthy” weight versus the reality that many Mississippi children are overweight/obese. It is also noteworthy that—across all three surveys—approximately 60% of parents characterized themselves as overweight/obese, yet BMI calculations indicated that 70% of parents were overweight/obese. Although beyond the scope of the present paper, issues and implications related to this set of findings—such as why parents greatly underestimate overweight/obesity among their children as compared to themselves—are discussed elsewhere (forthcoming). Limitations The results of all surveys are subject to a variety of sources of error, such as selective non-response (e.g., parents who are perceive themselves as less healthy may have been less likely to participate in the survey), false reporting (e.g., parents may have answered questions inaccurately so as to minimize or exaggerate particular health behaviors), and unintentional false recall (e.g., parents may have inaccurately estimated their own or their child’s height or weight). However, the methodology utilizes a large, simple random sample in which these error sources are independent of one another. Each respondent had an equal probability of selection; therefore each error source had an equal probability of occurrence. It can be assumed that the error sources are normally distributed since the sample is of significant size. The large sample size reduces the margin of error within the study and increases the precision in estimating unknown parameters.20 Conclusion Results from the present study are relevant to increasing the capacity of public schools to operate as key venues for establishing and reinforcing health norms for school-aged children and for conveying health information to students’ parents/families. The findings provide useful information on parent-level barriers and facilitators to full implementation of MHSA and potential expansion of the Act. For example, the relatively low percentage of parents—an important group of key stakeholders—who reported that their child’s school had a
health committee, council, or task force (~23%) across all three years of the study suggests that many parents may be unaware of grassroots initiatives to expand health-promoting behaviors within their local public school system (e.g., eliminating deep fat fryers from the cafeteria). It is likely that to better promote healthy school environments, local school boards and school administrators need to increase ‘buy-in’ from parents to expand the reach and effectiveness of health committees at their children’s schools. Strong parental support of physical education requirements for all students (~96% across all three years of the study) suggests that the majority of parents are clearly aware of the important role that public schools play in promoting healthy lifestyles among school-aged children. Likewise, parental support of initiatives regarding healthy food options in school cafeterias (~95%) and campus vending machines (~47%) across all three years of the study suggests that the majority of parents believe public schools can make structural changes that can directly impact healthy eating among students. Finally, strong parental support of school-based BMI assessments and parental notification (~82%) across all three years of the study suggests that the majority of parents understand the important role that public schools can play in conveying vital health information to students’ parents/families and, similarly to parents in Arkansas— where an act similar to MHSA was passed into law in 2003— do not find school-based BMI assessments controversial.21 This may be of particular relevance to policymakers considering expanding the scope of MHSA to include school-based BMI assessments but are concerned such assessments may have unintended negative consequences (e.g., stigmatization of obese children by their peers). It is noteworthy that external evaluations conducted since BMI assessments were instituted in Arkansas in 2003 “have revealed none (emphasis added) of the initially feared negative consequences of BMI measurements such as teasing, use of diet pills, or excessive concerns about weight” (pg. S73).21
referenceS
AcKnoWledgement
11.
The project (Linda H. Southward, PI) was conducted by the Family & Children Research Unit, a division of the Social Science Research Center (SSRC) of Mississippi State University (MSU) and was funded by the Center for Mississippi Health Policy, with Robert Wood Johnson Foundation support. The authors would like to thank Therese Hanna, Director, Center for Mississippi Health Policy, SSRC Director Dr. Arthur G. Cosby for his support of the project, as well as the MSU Division of Agriculture, Forestry & Veterinary Medicine (DAFVM). The authors would also like to thank SSRC colleagues Ginger Cross, Sara Gallman, Heather Hanna, Jonelle Husain, and David Parrish as well as SSRC students Meghan Dunaway, Ben Fay and Trey Thompson for their invaluable contributions to the project.
1. 2.
3.
4.
5.
6.
7.
8.
9.
10.
12.
13. 14.
15.
Ogden CL, Carroll MD, Curtin LR, McDowell MA, Tabak CJ, Flegal KM. Prevalence of overweight and obesity in the United States, 1999-2004. JAMA. 2006 Apr 5;295(13):1549-55. Gordon-Larsen P, The NS, Adair LS. Longitudinal trends in obesity in the United States from adolescence to the third decade of life. Obesity (Silver Spring). 2010; 18(9): 1801–1804. doi:10.1038/oby.2009.451. Annie E. Casey Foundation. (2012). Kids Count Data Center. Accessed January 22, 2012 from http://datacenter.kidscount.org/ data/bystate/stateprofile.aspx?state=MS&cat=1078&group=Cate gory&loc=26&dt=1%2c3%2c2%2c4. US Department of Health & Human Services. (2012). The Surgeon General’s Call To Action To Prevent and Decrease Overweight and Obesity. Accessed January 22, 2012 from http://www.surgeongeneral.gov/topics/obesity/calltoaction/fact_ adolescents.htm. Centers for Disease Control and Prevention. (2011). Behavioral risk factor surveillance system, prevalence and trends data, overweight and obesity (BMI) – 2010. Accessed March 9, 2012 from http://apps.nccd.cdc.gov/brfss/list.asp?cat=OB&yr=2010& qkey=4409&state=All. Simerville, M. (2011). Miss. ranks first in obesity...again. The Daily Mississippian Online. Accessed January 27, 2012 from http://frac.org/initiatives/hunger-and-obesity/http://thedmonline. com/article/miss-ranks-first-obesityagain. United Health Foundation. (2011). America’s Health Rankings: A Call to Action for Individuals & Their Communities. Accessed January 26, 2012 from http://www.americashealthrankings.org/ SiteFiles/Reports/AHR%202011Edition.pdf. Trust for America’s Health: F as in Fat: How Obesity Threatens America’s Future 2011 (2009, July). Retrieved September 11, 2009 from http://healthyamericans.org/reports/obesity2011/release. php?stateid=MS. Mississippi Legislature, Senate. (2007, July). The Mississippi Healthy Students Act of 2007. Retrieved September 11, 2009 from http://billstatus.ls.state.ms.us/documents/2007/html/SB/ 2300-2399/SB2369SG.htm. Southward L, Cross G, Baggett D, Hanna H, Edwards J, Carmack, R, Parrish D, Buffington A, Mathews R, Thompson C. Parents’, youth and policymakers’ perspectives on the Mississippi Healthy Students Act of 2007: baseline findings. 2009. Family and Children Research Unit, Social Science Research Center, Mississippi State University, Starkville, MS. Baggett D, Buffington A, Cross G, Edwards J, Gallman S, Husain J, McKee C, Parrish D, et al. Parent, Youth and Policymaker Perspectives on the Mississippi Healthy Students Act of 2007: Year Two findings. 2010. Family and Children Research Unit, Social Science Research Center, Mississippi State University, Starkville, MS. Baggett D, Buffington A, Cross G, Edwards J, Husain J, McKee C, Parrish D, Southward L, et. al. Parent, youth and policymaker perspectives on the Mississippi Healthy Students Act of 2007: Year Three findings. 2011. Family and Children Research Unit, Social Science Research Center, Mississippi State University, Starkville, MS. Kumanyika, S. & Brownson, R., (Eds.), Handbook of Obesity Prevention. (2007). New York: Springer-Verlag. Institute of Medicine: Progress in Preventing Childhood Obesity: How Do We Measure Up? (2006, September). Retrieved September 11, 2009 from http://www.iom.edu/Object.File/ Master/36/984/11722_reportbrief.pdf90. Institute of Medicine: Childhood Obesity in the United States Facts and Figures. (2004, September). Retrieved September
August 2012 JOURNAL MSMA 251
16.
17.
18.
19. 20. 21.
11, 2009 from http://www.iom.edu/Object.File/Master/22/606/ FINALfactsandfigures2.pdf. Basch CE. Healthier students are better learners: high-quality, strategically planned, and effectively coordinated school health programs must be a fundamental mission of schools to help close the achievement gap. J Sch Health. 2011;81(10):650-662. doi: 10.1111/j.1746-1561.2011.00640.x. Centers for Disease Control and Prevention. Healthy Weight - It’s Not a Diet, It’s a Lifestyle! Retrieved September 14, 2009 from http://www.cdc.gov/healthyweight/assessing/bmi/adult_bmi/ english_bmi_calculator/bmi_calculator.html. Harbaugh BL, Kolbo JR, Molaison EF, Hudson GM, Zhang L, Wells D. Obesity and Overweight Prevalence among a Mississippi Low-Income Preschool Population: A Five-Year Comparison. ISRN Nurs. 2011;2011:270464. Epub 2011 Sep 18. doi: 10.5402/2011/270464. Fiscella K, Kitzman H. Disparities in academic achievement and health: the intersection of child education and health policy. Pediatrics. 2009;123(3):1073-1080. Kutner M, Nachtsheim C, Neter J, Li W. Applied Linear Statistical Models. Fifth Ed. New York: McGraw-Hill/Irwin, 2004. Thompson JW, Card-Higginson P. Arkansas’ experience: statewide surveillance and parental information on the child obesity epidemic. Pediatrics. 2009;124 Suppl 1:S73-82. doi. 10.1542/peds.2008-3586J.
CALLING ALL Mississippi Physician-Photographers to enter the 2013
COVER PHOTO CONTEST
L
oad your camera or grab your digital. Shoot landscapes, people, animals, or anything else you can capture on film. Photos of subjects indicative of Mississippi will be given the highest consideration. Photos of original artwork are also acceptable. The Committee on Publications will judge the entries on the merits of quality, composition, originality, and appropriateness to the JMSMA. Specifications: Color slides, digital files & photos. A hard copy print is required for judging. Size: Vertical format 5 x 7” or 8 x 10”
Deadline: November 28, 2012 Mail to P.O. Box 2548 Ridgeland, MS 39158-2548 or deliver to headquarters 408 W. Parkway Place, Ridgeland, MS 39157 For more info contact: Karen Evers, Managing Editor 601-853-6733, ext. 323 or KEvers@MSMAonline.com
252 JOURNAL MSMA
August 2012
William C. Lineaweaver, MD
Tanya Oswald, MD
Meet our microsurgery specialists Our expert surgeons at Crossgates River Oaks Hospital are able to perform delicate microsurgery to treat complicated hand and extremity injuries. Using state of the art diagnostic and surgery techniques, Dr. Lineaweaver and Dr. Oswald are available 24 hours a day, 7 days a week for your patients. Some conditions our surgeons treat: • Amputation • Acute fractures • Infections
• Nerve injuries • Vascular injuries • Soft tissue loss • Burns • Multiple tendon injuries
1-877-863-9595 for referrals
350 Crossgates Blvd., Brandon, MS • CrossgatesRiverOaks.com
ROC Microvascular Hand Surgery JMSMA Ad 6-12.indd 1
6/8/12 11:19 AM
Medical Assurance Company of Mississippi For nine years, MACM fought a lawsuit on my behalf. As a physician, I really didn’t think about MACM until I needed help.
“
The commitment and resolve that this Company has to stand behind its member physicians becomes very evident in the efforts of defending a lawsuit. I could not have asked for a kinder and more sympathetic treatment by this Company for the past 30 years that I have been insured. I realize more and more that I could not have practiced my profession had I not had your army of professionals behind me. The association can only be described as grace.
“
Sadly, until a physician needs your services, MACM cannot be properly appreciated. It’s at that point that you step in and bring comfort in a physician’s darkest hour. William K. Sutherland, MD Jackson, Mississippi For over 30 years, Mississippi physicians have looked to Medical Assurance Company of Mississippi for their professional liability needs. Today, MACM is an integral part of the health care community providing a legacy of services to our insureds. level guarantees that the interests of our policyholders remain the top priority. This, combined with the many years of loyalty and support from our insureds, is what allows us to be the carrier of choice in Mississippi. Call on us to assist with your professional liability needs.
1.800.325.4172 www.macm.net
Representing Physicians August 2012 JOURNAL MSMA 253
254 JOURNAL MSMA
August 2012
• scientific •
Outpatient Treatment of Adults with Cystic Fibrosis by Primary Care Physicians Nauman Chaudary, MD [The treatment of cystic fibrosis has dramatically changed since most of us went to medical school. Dr. Chaudary, the director of the adult CF program at UMMC, has responded to our request to give us a focused update on this topic. We really can provide a better quality of life for patients with CF with the advances that have been made.] —Richard deShazo, MD, Associate Editor
A
Figure 1. Marital Status of Mississippi Adults with Cystic bStrAct
Primary care physicians now see adult patients with Cystic Fibrosis (CF) who have multi organ consequences of the disease that present a complex management dilemma. Early diagnosis and treatment of these problems is important to limit morbidity. In this article we will review common problems experienced by these patients and present approaches to their management.
Figure 1: 1. Marital Status of Mississippi Adults with Cysticwith Cysti Figure Marital Status of Mississippi Adults Fibrosis
Key WordS: AdultS, cyStic fibroSiS, treAtment introduction Cystic Fibrosis (CF) is the most common lethal autosomal recessive disorder in Caucasians resulting in clinical symptoms in lungs, the sinuses, gastrointestinal and male reproductive tracts. Dysfunction of exocrine glands leads to thick sticky mucus which may obstruct lungs and intestines. Cystic Fibrosis affects 1:3200 live Caucasian births and in 1:15,000 live African American births. It occurs equally in males and females. There are approximately 30,000 people with Cystic Fibrosis in the United States today. This number is rising as more people are diagnosed, treated sooner and living longer. One of 31 Americans is an asymptomatic carrier and 1:28 Caucasians, 10 million people, are estimated carriers in United States. According to a Cystic Fibrosis Foundation registry report of 2010, Mississippi (MS) has 232 Cystic Fibrosis patients and are leading active lives. Many are named and have achieved high levels of education. (Figures 1-2)1
Cystic Fibrosis Foundation Patient Registry. Bethesda, MD: Annual Data R Cystic Fibrosis Foundation Patient Registry. Bethesda, MD: Annual Data Report 2010:1-26. Used with permission.
Figure 2. Educational Background of Mississippi Adults
Cystic2: Fibrosis Foundation Patient Registry. Bethesda,Adults MD: Annual Data Figure Educational Background of Mississippi with Cystic Fibrosis
Figure 2. Educational Background of Mississippi Adults
Cystic Fibrosis Foundation Patient Registry. Bethesda, MD: Annual Data Report 2010:1-26. Used with permission.
Author informAtion: Dr. Chaudary is an Assistant Professor and Director of Adult Cystic Fibrosis Center in the Department of Medicine at the University of Mississippi Medical Center. correSPonding Author: Nauman Chaudary, MD, UMMC Adult Cystic Fibrosis Center, Division of Pulmonary and Critical Care Medicine, 2500 North State Street, Jackson, MS 39216 (NChaudary@umc. edu) Ph: 601-984-5650, Fax: 601-984-5658.
Cystic Fibrosis Foundation Patient Registry. Bethesda, MD: Annual Data R
PreSentAtion
Cystic Fibrosis is most commonly recognized at birth or in Cystic early infancy form) because of bowel obstruction Fibrosis (classic Foundation Patient Registry. Bethesda, MD: Annual Data (meconium ileus) or low weight gain due to digestive problems (Table 1). Most adults with Cystic Fibrosis are diagnosed due to pulmonary symptoms. Patients may have recurrent bouts of
August 2012 JOURNAL MSMA 255
sinusitis, bronchitis, and a chest x-ray may reveal bronchiectasis. Pancreatitis is also more prevalent among those diagnosed as adults (Table 2). However, males may be diagnosed during an infertility evaluation. Cystic Fibrosis may also present as a variant or non-classic form in adults in which patients have some pancreatic function and also commonly have milder lung problems.2 Table 1. Characteristics of Classic and Non-Classic CF and Non-Classic CF Table 1: Characteristics of Classic Classic CF
Classic CF Variant
No CF protein expressed
Some CF protein expressed
Chronic sinusitis
Chronic sinusitis
Severe bacterial bronchial infection
Bacterial bronchial infection (late onset, less severe)
Severe hepatobiliary disease in 5-10% of
Hepatobiliary disease not typical
patients Pancreatic exocrine insufficiency
Adequate pancreatic exocrine function (5-20% develop pancreatitis)
Meconium ileus at birth (15-20%)
Chronic constipation is common
Sweat chloride levels typically 90-110 mmol/L
Sweat chloride usually 60-90 mmol/L
CF related diabetes develops in over 40% of
CF related diabetes less common in patients
patients by age 30
with pancreatic function
Obstructive azospermia in males
Obstructive azospermia in males
Classic cystic fibrosis and classic cystic fibrosis variants. Adapted from Eileen Widerman, Barbara Palys, John R. Palys. “Now that I have CF”. Information for men and women diagnosed as adults. Solvay Pharmaceuticals. Marietta, GA; 2003:4-5. Used with permission.
Table 2: Common Signs and Symptoms of Cystic FibroTable 2. Common Signs and Symptoms of Cystic Fibrosis Adults sis Adults Recurrent sinusitis associated with headaches, postnasal drip, thick nasal discharge, halitosis and occasional epistaxis Nasal Polyps Frequent cough productive of thick sputum
Since 1989, more than 1000 mutations have been identified. Since some gene mutations cause less effects on ion transport than others, Cystic Fibrosis can be a mild disease in some individuals and a severe disease in others. To develop classical Cystic Fibrosis, a child must inherit a copy of defective gene from each parent. When both parents carry the altered Cystic Fibrosis gene, each child has a 25% chance of having Cystic Fibrosis. In this circumstance, there is also a 50% chance of having a carrier child with Cystic Fibrosis and a 25% chance of having normal child. diAgnoSiS Cystic Fibrosis may be diagnosed by measuring the amount of salt in sweat, the “sweat test.” The sweat test is easy, painless, accurate, and inexpensive but it must be done and analyzed correctly. (Table 3) Gene testing is often performed after sweat testing to identify the specific gene alterations present. Newer treatments target specific genetic mutations associated with Cystic Fibrosis. Both siblings of children with Cystic Fibrosis and siblings of parents who have a child with Cystic Fibrosis require testing since Cystic Fibrosis is inherited from parents. Siblings of parents may be carriers as well and first cousins of a child with Cystic Fibrosis should be tested for Cystic Fibrosis if they have symptoms. Additional diagnoses that should be considered in the differential diagnosis of individuals with cystic fibrosis, include primary ciliary dyskinesia, immunoglobulin deficiency, and allergic bronchopulmonary aspergillosis. When indicated, initial evaluations for these conditions include electron microscopy of ciliary structure and serum IgG and IgE levels.
Pancreatic enzyme insufficiency Table 3. Diagnostic Criteria for Cystic Fibrosisfor Cystic Fibrosis Table 3: Diagnostic Criteria
Recurrent pancreatitis
CF diagnosis can be established if a patient has:
Chronic constipation
One of these
Growth retardation Delay in sexual development Fat soluble vitamin deficiencies Cirrhosis of the liver
PLUS one of these
>1 typical phenotypic feature of CF
Elevated sweat chloride on 2 occassions
Sibling with CF
2 identified CFTR mutations
Positive newborn screening test
Abnormal nasal potential difference
Adapted/from Rosenstein BJ, Cutting GR. The diagnosis of cystic fibrosis: a consensus statement. J Pediatr. 1998;132: 589-595.
Male infertility Clubbing of the fingers Salty sweat Common signs and symptoms of CF adults. Adapted from Eileen Widerman, Barbara Palys, John R. Palys. “Now that I have CF”. Information for men and women diagnosed as adults. Solvay Pharmaceuticals. Marietta, GA; 2003:4-5. Used with permission.
PAthoPhySiology Cystic Fibrosis is caused by mutation in “cystic fibrosis trans-membrane conductance regulator” (CFTR) gene located on chromosome 7 and cloned in 1989.3 CFTR forms a channel so that salt and water can move in and out of cells, that is ion transport. The altered gene results in CFTR protein which causes abnormal ion transport in sweat and mucus glands. Thick mucus harbors resistant organisms and progresses on to bronchiectasis in the lungs.
256 JOURNAL MSMA
August 2012
treAtment In the last 4 decades, median predicted survival for Cystic Fibrosis has increased to older than 35 years. This increase 3. Approaches to pulmonary therapy into CF aggressive treatment and to inFigure survival has been attributed earlier diagnosis. Physicians caring for adults have played a major role in identification of a growing number of mild cases. By 2013, more than half of all individuals with cystic fibrosis will be18 years old or older and care givers will be increasingly likely to encounter these patients and their unique medical management. Data show that co-management of these patients Slidethe courtesy of Dr. Laurie Leclair University of Vermont at Cystic Fibrosis Used with permission. by primary careof thephysician and with anFoundation. accredited Cystic 1 Fibrosis center positively affects survival.
Pulmonary Disease Treatment Chronic pulmonary disease is the most serious complication of Cystic Fibrosis. Most patients can slow the rate of decline in lung function by adherence to treatment regimens. The goals of treatment are to clear obstructed airways and to treat or prevent infections. There are five common modalities: CFTR modulating agents, airway clearance techniques (ACT), exercise, aerosols and antibiotics. (Figure 3)
Figure 4: Flow sheet of CF commonly involved organs Figure 4. Flow sheet of CF commonly involved organs and their management and their management CF bone disease
1. 2. 3. 4. 5.
Outpatient treatment of CF adults or my
CF pulmonary disease
CF sinus disease
Figure 3. Approaches to pulmonary therapy in CF
CF Pancreatic Disease
CF Gastrointestinal Disease
Vitamin D Bisphosphonates NSAID Prednisone Allopurinol
CF related Diabetes
Figure 3: Approaches to pulmonary therapy in CF
1. 2.
3.
4.
CFTR modulator Ivacaftor in G551D Airway clearance techniques HFCC (VEST) CPT (Chest physiotherapy) and PD (Postural Drainage) Exercise Aerosols Bronchodilators (Albuterol) Mucolytics (Hypertonic saline, Mannitol, DNase) Antiinflammatory (LABA/ICS, Anticholinergic, Azithromycin) Antibiotics TOBI Aztreonam Colistin
1. 2. 3. 4. 5.
6. 7.
Inhaled steroids Montelukast Polypectomy Endoscopic drainage Antibiotics and oral steroids courses Antibiotic irrigation Saline rinses
1.
2.
3.
Pancreatic enzymes (1000-2500 lipase U/kg/meal) AquaDEK 2 tablets PO daily Calcium plus D
1. 2. 3.
4.
Miralax Lactulose DIOS Golytely Gastro grafin enema GERD therapy
1. 2.
3. 4. 5.
6.
Insulin No concentrate sweets Eye exams U/A Hypertensi on screening CKD monitoring with alb/Cr ratio
Exercise Exercise includes regular vigorous activity designed to improve physical, heart and muscle strength. Aerobic training (cycling, running) for a set time at target intensity and anaerobic training (weight or resistance training, sprinting) for short time Illustration courtesy of Dr. Laurie Leclair of the University of Vermont at at high intensity are recommended as an important adjunct to Cystic Fibrosis Foundation. Used with permission. ACT. Exercise loosens mucus in the lungs so it can be coughed up easily. Exercise can initiate coughing which can help bring Slide courtesy of Dr. Laurie Leclair of the University of Vermont at Cystic Fibrosis Foundation. Used 7 out dehydrated thick mucus. CFTR modulating agent The recent approval of ivacaftor (VX-770) marks the Aerosols beginning of new era of therapies to improve the function of Inhaled bronchodilators such as albuterol relax the airdefective cystic fibrosis transmembrane conductance regulator ways to help clear mucus and open airways. They are usually (CFTR) protein. (Figure 4) Ivacaftor is a small molecule potengiven before ACT.6 Mucolytic (DNase) thin mucus and makes tiator delivered orally that activates defective CFTR at the cell it easier to expectorate.6 Anti-inflammatories (Azithromycin/insurface. The primary target for this therapy is mutated CFTR haled steroids and bronchodilator combinations) reduce airway in which glycine has been replaced by aspartic acid at position edema and bronchoconstriction due to inflammation.5,6 Inhaled 551 (G551D) interfering with the gating of the chloride chanantibiotics help reduce the bacteria in lungs.5,6 nel. For individuals with CF 6 years of age and older, with at least one G551D CFTR mutation, the Cystic Fibrosis FoundaAntibiotics tion strongly recommends the chronic use of ivacaftor to im5 Infections are common in Cystic Fibrosis and antibiotprove lung function, quality of life and reduce exacerbations. ics are common part of therapy to prevent them. These may be Treatment is costly but manufacturer’s patient assistance progiven by the oral, intravenous or inhaled route. Antibiotics are grams are likely to make it affordable for patients. cornerstone of treatment for exacerbations of Cystic Fibrosis. The Cystic Fibrosis Foundation recommends chronic inhaled Airway clearance techniques (ACT) antibiotics such as tobramycin alternating with aztreonam in Viscous mucus in Cystic Fibrosis airways lead to chronic 28 day cycles for Cystic Fibrosis treatment when patients have infection and inflammation in lungs. ACTs such as percussion persistent pseudomonas in their cultures. Oral and intravenous and postural drainage (P&PD), positive expiratory pressure antibiotics are utilized for episodic use for symptoms during (PEP), active-cycle-of-breathing technique (ACBT), autogenCystic Fibrosis pulmonary exacerbations.5,6,8 ic drainage (AD), oscillatory PEP (OPEP) and high-frequency chest compression (HFCC) help loosen thick mucus that is then future develoPmentS removed with huffing or coughing. This may also help reduce 7 CFTR correctors, potentiators and activators are being severity of infection and assist improve lung function.
August 2012 JOURNAL MSMA 257
with
studied in Cystic Fibrosis patients with the most common genetic mutation (508 del) in combination with VX-809 and ivacaftor. Ataluren promotes read through of genetic codons and is in phase 3 trials. Newer inhaled antibiotics (levaquin, amikacin), pancreatic enzymes (lipromatase), anti-inflammatory medications (sildenafil, anti-pseudomonas antibody, oral mucomyst) trials are also ongoing. Gene therapy is also being studied but is in the developmental phase.
6. 7. 8.
9.
concluSionS
CF Pulmonary Guidelines: Chronic Medications for Maintenance of Lung Health. Flume PA. Am J Respir Crit Care Med. 2007;176:957–969. Cystic Fibrosis Pulmonary Guidelines; Airway Clearance Therapies, Respir Care. 2009; 54(4):522–537. Patrick A. Flume, Peter J. Mogayzel, Jr., Karen A. Robinson. Cystic Fibrosis Pulmonary Guidelines. Treatment of Pulmonary Exacerbations. Am J Respir Crit Care Med 180. pp 802–808, 2009. Adult Cystic Fibrosis. Boyle, MP. JAMA 2007; 298 (15):17871793.
The increasing number of adults with Cystic Fibrosis and the fact that 5% of individuals with Cystic Fibrosis are diagnosed after age 16 make it important for physicians who care for adults to be familiar with Cystic Fibrosis.7 Male infertility, unexplained pancreatitis, recurrent nasal polyps/sinusitis or bronchiectasis should be red flags for this diagnosis. The Cystic Fibrosis Foundation has established guidelines for care and established centers of excellence in the diagnosis and treatment of adult Cystic Fibrosis care. Dedicated multidisciplinary teams of nurse coordinators, dieticians, respiratory therapists, physical therapists, clinical pharmacists, research coordinators, and social workers provide care and connection with new therapies that offer great promise in the future.
AcKnoWledgement
The author is grateful to Dr. Richard deShazo for his support and guidance in writing of this manuscript.
We specialize in the business of healthcare • • • • • • • •
Comprehensive Management Comprehensive Consulting Billing & Accounts Receivable Management Coding & Documentation Practice Assessments & Revenue Enhancement Profitability Improvement Practice Start-ups Personnel Management
referenceS 1. 2. 3. 4. 5.
Cystic Fibrosis Foundation Patient Registry. Bethesda, MD: Annual Data Report 2010:1-26. Eileen Widerman, Barbara Palys, John R. Palys. “Now that I have CF”. Information for men and women diagnosed as adults. Solvay Pharmaceuticals. Marietta, GA; 2003:4-5. James C. Cunningham, Lynn M. Taussig. An introduction to Cystic Fibrosis for patients and families. ed 5. Cystic Fibrosis Foundation 2003:14-17. Rosenstein BJ, Cutting GR. The diagnosis of cystic fibrosis: a consensus statement. J Pediatr. 1998;132: 589-595. Peter J. Mogayzel, Edward Naureckas, Karen A. Robinson. Cystic Fibrosis pulmonary guidelines: chronic medications for maintenance of lung health. 2012. In Press.
1600 North State Street Suite 400 Jackson, MS 39202 Telephone: 601.944.1717 WATS: 1.800.355.4231 www.mpsbilling.com
Earn free CME credit! Join The CME Institute for a live meeting on . . .
Depression, Pain, and Comorbid Medical Conditions Find out how to recognize depression in your patients with pain and effectively manage mood and physical health. Space is limited so register now! Go to PSYCHIATRIST.COM/livemeetings
September 18 Tupelo, MS Hilton Garden Inn 5:30 to 7:00pm, dinner provided
September 19 Clarksdale, MS Northwest MS Regional Medical Center 12:00 to 1:30pm, lunch provided
These meetings are provided by The CME Institute of Physicians Postgraduate Press, Inc., and are supported by an educational grant from Eli Lilly.
258 JOURNAL MSMA
August 2012
PHYSICIANS NEEDED
Internists, Cardiologists, Ophthalmologists, Pediatricians, Orthopedists, Neurologists, Psychiatrists, etc. interested in performing consultative evaluations according to Social Security guidelines.
OR Physicians to review Social Security disability claims at the
Mississippi Department of Rehabilitation Services (MDRS) in Madison MS.
Contact us at: Leola Meyer 601-853-5487 Toll Free 1-800-962-2230 (Ext. 5487) or Jo Ann Summers 601- 853-5599
DISABILITY DETERMINATION SERVICES 1-800-962-2230 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. 速 Registered Marks of the Blue Cross and Blue Shield Association, an Association of Independent Blue Cross and Blue Shield Plans.
August 2012 JOURNAL MSMA 259
• clinicAl probleM-solving •
Presented and edited by the Department of Family Medicine, University of Mississippi Medical Center; Diane K. Beebe, MD Chair
A Common, but Unexpected, Suspect Andrea Morgan, MD
A
n 8-year-old female presented to her primary care provider with complaints of low grade fevers, lethargy, and knots below her neck. During this visit she was found to have supraclavicular lymphadenopathy. Over the next week, a computed tomography (CT) to evaluate for lymphoma discovered a pericardial effusion, but the size was not reported. Lab studies performed at her initial presentation returned positive Bartonella henselae and quintana titers, and the patient was diagnosed with cat scratch disease. She was given a 5 day course of azithromycin (Zithromax) and, after completion, was prescribed rifampin (Rifadin) and trimethoprim/sulfamethoxazole (Bactrim). Ibuprofen was prescribed within 2-3 days after the pericardial effusion was discovered by CT scan. This was continued over the next two weeks, resulting in decreased lymphadenopathy but not the size of the effusion. Ibuprofen was discontinued and prednisone was prescribed. Rifampin was discontinued on day 4 due to a side effect of vaginal bleeding. An echocardiogram at the outside hospital revealed the pericardial effusion to be smaller than seen previously on CT scan even though a significant portion of the effusion remained. Approximately 6 weeks after her initial presentation, she was referred by her primary care provider to the pediatric cardiology service of a local hospital for evaluation of her pericardial effusion. On the day of admission, the patient had completed her course of trimethoprim/sulfamethoxazole but was still taking a steroid. She was directly admitted to the pediatric cardiology service for further evaluation and treatment of the pericardial effusion. Her mother reported the patient had been asymptomatic and back to her normal self for the past 10 days. Pericardial effusion is very rare in a child and must be evaluated. Our initial working diagnosis at the time of admission is a pericardial effusion due to cat scratch disease based correSPonding Author: Andrea Morgan, MD, Pioneer Community Hospital of Newton, Pioneer Family and Pediatric Clinic, 9421 Eastside Dr. Ext, PO Box 299, Newton, MS 39345. 601-683-0330 (office) Email: ammorgan35@aol.com.
260 JOURNAL MSMA
August 2012
on the positive Bartonella titers and the subsequent decrease in the size of the effusion after appropriate antibiotic treatment. A review of the literature found only one reported case of a pericardial effusion secondary to Bartonella infection. With this information, it seems possible that the pericardial effusion and cat scratch disease could be independent of one another. We must continue to test for more common causes of pericardial effusions such as viral (hepatitis, human immunodeficiency virus or coxsackievirus), fungal (histoplasmosis or coccidioidomycosis), systemic lupus erythematosus, rheumatoid arthritis, renal insufficiency, and hypothyroidism.1 The patient has also been taking a steroid, which is a common therapy in inflammatory diseases, and could be the reason for the decreasing size of the pericardial effusion. Further questioning revealed that the patient had an episode of a low grade fever of 99˚F one month ago. Since being prescribed a steroid, the patient and her mother reported increased appetite and a weight gain of one pound. The patient denied chest pain, shortness of breath, cough, muscle pain or weakness; she had no acne or purple striae. She had no drug or food allergies. Her immunizations were up to date. She was born full term without complications. The patient and mother denied any positive past medical or surgical history including previous hospitalizations or blood transfusions. She had a family history of coronary artery disease, hypertension and stroke. She was a second grade student of average intelligence and had met all developmental milestones for her age. She lived with her mother, father and sister. Her neighbor had a cat with which she had frequent contact. Her diet was appropriate for her age. This extended history does not narrow the list of possible causes. Some common side effects of steroids that the patient exhibits are increased appetite and subsequent weight gain, though minimal. Since weight gain is also a common symptom of hypothyroidism, we cannot use this symptom to further narrow our diagnosis. Since steroids are commonly used to treat inflammatory conditions such as systemic lupus erythematosus and rheumatoid arthritis, the symptoms of these conditions that are normally reported may not have been experienced due to the
use of a steroid. Without a history of blood transfusions or maternal exposure, the patient is less likely to have an effusion caused by the human immunodeficiency virus or hepatitis B or C. On physical exam, the patient had a temperature of 99.2 degrees F, a pulse of 97 beats per minute, a blood pressure of 143/95 mm Hg and a normal respiratory rate. Her weight was 27.1 kilograms. The patient had moonshaped facies. Cardiovascular exam revealed regular rate and rhythm; no murmurs or rubs were heard. No jugular venous distention was evident. Pulmonary auscultation revealed normal breath sounds. Pulses and capillary refill were normal. She had bilaterally enlarged non-tender supraclavicular lymph nodes. Her abdomen was soft, nontender, nondistended but obese. She had normal strength in all extremities, no skin changes and an afocal neurological exam. The patient’s mildly elevated blood pressure could be secondary to steroid use. Prolonged steroid use can lead to Cushing’s syndrome, which could be the cause of her moonshaped facies and obese abdomen although these findings alone are not diagnostic. The presence of supraclavicular lymphadenopathy could still be from an infectious source or lymphoma that has not yet been identified. The lack of jugular venous distention, which is the primary physical finding of a pericardial effusion, indicates the effusion is more likely to be small and not impeding cardiac function.2 Previous lab studies will be reviewed, and new lab studies such as repeat Bartonella henselae and quintana titers, a complete blood count, a basic metabolic panel and inflammatory markers will be ordered to assess the most common causes of pericardial effusions. A steroid taper will be ordered. Previous lab studies showed negative titers for rheumatoid factor, antinuclear antibody, anti-streptolysin, Cytomegalovirus antibodies, Ebstein-Barr virus antibodies and Toxoplasma gondii antibodies. Chest CT completed one month prior to admission showed a pericardial effusion without evidence of mediastinal adenopathy or mediastinal mass lesion. Echocardiogram performed 10 days before admission showed posterior effusion that was decreased to 5mm; and an anterior pericardial effusion present with no documented size. There was no evidence of cardiac tamponade. Current lab studies revealed a glucose that was elevated to 154mg/dL, a slightly elevated blood urea nitrogen (20mg/dL), but otherwise normal electrolytes and creatinine. Complete blood counts revealed no leukocytosis, anemia or thrombocytopenia. There was a left shift noted in the differential. C-reactive protein and sedimentation rate were normal. Repeat Bartonella henselae and quintana titers, as well as histoplasma antigens, were obtained with results pending. The patient was given a methylprednisolone (Solumedrol) taper at 2mg/kg/day. An echocardiogram revealed a small posterior and inferior pericardial effusion as well as mild tricuspid and pulmonary regurgitation.
The abnormal glucose and left shift again are most likely due to recent steroid use. A normal sedimentation rate and C reactive protein, in addition to a negative antinuclear antibody and rheumatoid factor, make an inflammatory cause less likely. We will await the results of the Bartonella titers as this was the initial likely cause of the effusion. We should also repeat the CT scan and echocardiogram to reassess the lymphadenopathy and pericardial effusion, respectively. According to the American College of Radiology Appropriateness Criteria, a CT scan of the neck with intravenous contrast is the second best test to an ultrasound of the neck for evaluating a child less than 14 years of age with lymphadenopathy. Except for the steroid taper, no other medications should be started since the patient is stable and an exact cause has not been identified. No drainage of the pericardial effusion will be necessary as no tamponade is evident. CT scan of the chest performed on day two revealed a persistent small to moderate pericardial effusion. CT scan of the soft tissue of the neck incidentally revealed a 1.6 cm homogeneously enhancing mass in the region of the sella turcica with suprasellar extension causing mass effect on the infundibulum and optic chiasm. No lymphadenopathy was seen in the neck or mediastinum. The patient was given a rapid steroid taper at that time. A positron emission tomography (PET) scan and magnetic resonance imaging (MRI) were ordered. Bartonella henselae and quintana as well as histoplasma titers were all negative. A differential diagnosis for the sella turcica mass includes a pituitary macroadenoma and a Rathke cleft cyst. A pituitary macroadenoma is defined as a tumor that is greater than 10mm while a microadenoma is less than 10mm. Rathke cleft cysts are benign, epithelium-lined cysts believed to originate from remnants of the Rathke pouch and can be 2-40mm in size. An MRI with pituitary protocol will be needed to further evaluate this mass. At this point, our initial diagnosis of an effusion secondary to Bartonella henselae and quintana has not been confirmed. An endocrinologic or neoplastic cause remains to be found. We should pursue hormonal testing that could be associated with a pituitary mass including, but not limited to, prolactin, adrenocorticotropic hormone and thyroid stimulating hormone (TSH) concentrations. On day 5 of admission, a PET revealed no hypermetabolic activity seen in the suprasellar mass, areas of lymphadenopathy in the supraclavicular regions or the pericardial effusion. Repeat echocardiogram revealed normal left ventricular systolic function and a trivial circumferential pericardial effusion that was essentially unchanged from the previous study. On day 6, an MRI of the brain with and without contrast demonstrated the presence of a homogenous sellar and suprasellar mass with uniform enhancement that was most typical for a pituitary macroadenoma. Endocrinology service was consulted the same day to assist with evaluating a hormonal cause of the effusion. On day 7, beta-chorionic gonadotropin hormone, cortisol and pro-
August 2012 JOURNAL MSMA 261
lactin concentrations were normal. Her adrenocorticotropic hormone concentration was low. Her TSH was 551.4 UIU/ mL with a low free T4 (0.42ng/dL). Anti-thyroid peroxidase antibody was also markedly elevated (359 IU/ml). She was subsequently given levothyroxine. We decided on day 8 that the patient could safely be discharged home with close follow-up. A definitive diagnosis of hypothyroidism is based on these results. This diagnosis could also be the cause of the modest weight gain and fatigue. An estimated prevalence of pericardial effusion in adult patients with hypothyroidism is 3%-6% and appears to be dependent on the severity of the hypothyroidism. The incidence of pericardial effusion in the pediatric population that is related to acquired hypothyroidism is even lower. Pericardial effusion is a frequent manifestation of myxedema, which is the most severe form of hypothyroidism.3,4 Treatment of the hypothyroidism typically causes complete resolution of the pericardial effusion as thyroid function tests return to normal.4,5 She will, therefore, need close monitoring by both her primary care provider and endocrinologist with subsequent TSH determinations, a repeat MRI to reassess the pituitary macroadenoma and repeat outpatient echocardiograms until resolution of the effusion. Since being discharged from the hospital, the patient continued to be monitored by her endocrinologist with normalization of her TSH and T4 concentrations within the next five weeks. A repeat echocardiogram performed 8 days after discharge still revealed only a trivial posterior pericardial effusion. A repeat MRI of her brain performed approximately 7 months later revealed complete resolution of the pituitary mass.
Key WordS: pericArdiAl effusion, HypotHyroidisM, pituitAry MAcroAdenoMA
referenceS 1. 2. 3. 4. 5.
Levy PY, Corey R, Berger P, et al. Etiologic diagnosis of 204 pericardial effusions. Medicine. 2003; 82(6):385-391. Gumrukcuoglu HA, Akyol A, Tuncer M, et al. Clinical and laboratory features of patients with pericardial effusion. Turk Kardiyol Dern Ars. 2010;38(7):473-479. Kabadi UM, Kumar SP. Pericardial effusion in primary hypothyroidism. Am Heart J. 1990;120(6 Pt1):1393-1395. Hardisty CA, Naik DR, Munro DS. Pericardial effusion in hypothyroidism. Clin Endocrinol. 1980; 13(4):349-354. Bhupathi R, Kothari SS, Gupta AK, Menon PS. Cardiac function in hypothyroid children: effect of replacement therapy. Indian Pediatr. 1999; 36(8):779-784.
For a bird’s eye view on medicine follow MSMA on
!
There’s a lot going on in organized medicine so it’s easy to miss something if you’re on the go. To help you stay in touch no matter where you are, MSMA is now communicating via “Twitter.” In about three minutes, you can set up a free Twitter account for yourself. Simply visit www.twitter. com and submit your name, email address and mobile phone number (optional, standard text messaging rates apply). Once you’re signed up with Twitter, you can add MSMA by going to the following web page http://twitter. com/MSMA1 and clicking “Follow” next to the MSMA icon.
Profile name: MSMA1
262 JOURNAL MSMA
August 2012
• president’s pAge •
Just What the Doctor Ordered Each month I will try to give you a different recipe for your enjoyment. I like to cook and so the recipes will be fun and easy. The first is a watermelon salad. My rendition of a watermelon salad goes like this: Take seedless watermelon. Cube it up in bite-sized pieces. Add a generous amount of feta cheese. Toss in a good handful of shredded basil leaves and toss lightly with olive oil, salt and pepper. The key ingredient in this watermelon salad is balsamic vinegar. I don’t really go by a standard oil to vinegar ratio. Gently sprinkle oil to lightly steven l. deMetropoulos, Md coat most of the watermelon. Then, since the balsamic vinegar 2012-13 MsMA president is stronger, drizzle it over the watermelon salad or over a plate of the watermelon. I like a balsamic vinegar called Fattoria Estense Aceto Balsamico di Modena. Most of the balsamic vinegar you buy in the grocery store has been aged only about two years. Even though those vinegars are good they are generally much thinner than the one I suggested to you. The one I use is aged about ten years and costs $15 or $16, and you can use this for about a month or so depending on how often you use it. The gold label is the next level vinegar by the same company. It has been aged about twelve years. As balsamic vinegar gets older it becomes thicker and sweeter and more like syrup, and it is great to use over any type of fruit-related salads or vegetables. Of course the older the balsamic vinegar, the more expensive it is. You can pay as much as you want for it. I am going to give you the web site for ordering the brand that I use. I think it is a good value, and you can certainly taste the difference. You can find it online at www.cybercucina.com. You can click on balsamic vinegar, and you can find the brand that I referenced earlier. Both are great values and very tasty, both the silver which is ten years old and the gold which is twelve. That’s my President’s Page for this month with a recipe and picture included. Bon appetit!
Steven L. Demetropoulos, MD MSMA President 2012-13 August 2012 JOURNAL MSMA 263
B lu e s
B e Ac o n
A PROGRAM OF THE DELTA HEALTH ALLIANCE
c o M M U n i t Y SOLUTIONS FOR A HEALTHY TOMORROW
Delta Health Alliance Presents the Beacon Q&A Q: What in the world is Beacon? A: Beacon is a federal grant program providing communities with funding
to build and strengthen their health care systems. The Delta Health Alliance received one of the 17 grants the federal government awarded two years ago. The total three year grant is for $14.7 million.
Q: What are you hoping to accomplish? A: We are focusing on diabetes. We want to show how physicians and
hospitals can use the latest health information technology and clinical practices in innovative ways to help get a handle on diabetes in the Delta. We want to demonstrate ways to redirect existing resources out of administration and record keeping and into patient care.
Q: Are you just focusing on physicians and hospitals? A: Good question. No is the short answer. We are also developing programs
that work directly with diabetic patients, to help them understand the causes of the disease, how it can be treated, and how it can be prevented.
Q: so, what are you actually doing? A: I’ll give you one of what could be many examples.
We have a program that works with individual patients to assess prescription drug related needs and medication experience to identify, resolve and prevent medication-related problems. the grant pays a pharmacist to work directly with patients in our partner clinics to provide education, screenings and medication management. One outcome of this project is to avoid hospitalizations in a region with some of the highest hospital readmission rates in the country. For example, one inpatient hospital day costs $1,853 for a patient with diabetes. An office visit where diabetes is the primary diagnosis costs $132. that’s a potential savings of $1,721 for one patient for one day by avoiding a hospital admission and directing care to the primary care provider’s clinic. Multiply that by the thousands of diabetic patients in the Delta and you see what Beacon can do.
for more information about Beacon in Mississippi, contact Delta Health Alliance.
Post office Box 277, stoneville, Ms 38776 • 662-686-7004
www.deltahealthalliance.org
TM
The Delta Health Alliance receives funding support for health information initiatives through the Beacon Community Program from the Office of the National Coordinator, U.S. Department of Health and Human Services.
264 JOURNAL MSMA
August 2012
• MsdH • Mississippi Reportable Disease Statistics
June 2012 Figures for the current month are provisional
*Totals include reports from Department of Corrections and those not reported from a specific district. **Address unknown for 3 cases. For the most current MMR figures, visit the Mississippi State Department of Health web site: www.HealthyMS.com.
August 2012 JOURNAL MSMA 265
• MsdH •
MS Morbidity Report - June 2012 Twelve Doses for Tuberculosis Prevention – Review of a New Evidenced Based Regimen A new directly observed treatment regimen for latent TB infections (LTBI) was presented at the American Thoracic Society International Conference in May 2011 and then published in the New England Journal of Medicine in December 2011(see reference). The new regimen consists of 12 weeks of once weekly directly observed doses of rifapentine (RPT) and isoniazid (INH) and is recommended as an equal alternative to the standard nine month INH regimen, but with potentially improved treatment completion rates. The combined twelve week INH-RPT regimen is more costly than the usual nine month INH regimen with increased costs in both nursing time and effort, and laboratory tests. However, it is projected that the initial costs will be offset by increased completion rates, decreased morbidity, and a reduction in future transmission of TB. The standard nine month regimen of INH will still be available and will remain a mainstay for LTBI treatment, but for those patients who qualify, the new regimen promises to be efficient and convenient. What follows is a brief summary of the recently published study. “Three Months of Rifapentine and Isoniazid for Latent Tuberculosis Infection” The study compared 3 months (12 weeks) of directly observed once-weekly therapy with rifapentine 900 mg plus isoniazid 900 mg, with isoniazid 300 mg daily self administered for nine months. Patients were at high risk for progression from LTBI to active disease. All subjects were required to be at least 12 years of age and have had close contact to a patient with culture confirmed tuberculosis (within 2 years before enrollment) regardless of tuberculin skin test results, or have other situations that would put them at higher risk for progression to active TB. Patients were followed for 33 months with the primary study endpoint of culture-confirmed TB in subjects 18 years of age or older, and culture-confirmed or clinical TB in children under the age of 18 years. Active TB developed in 7 of 3986 (cumulative rate 0.19%) patients in the RPT/INH group and in 15 of 3745 (cumulative rate of 0.43%) patients in the nine month INH group. Treatment completion in the INH-RPT group was 82.1% but only 69% in the INH group (P<0.001). While the rates of permanent drug discontinuation due to an adverse event were higher in the INH-RPT group (4.9%) compared to the INH alone group (3.7%), drug related hepatotoxicity was less than the INH alone group (0.4% vs 2.7%, respectively, P<0.0001). The study showed that directly observed, once weekly therapy with rifapentine plus isoniazid for 3 months was as effective as self-administered daily isoniazid for 9 months, with the rate of tuberculosis in the combination-therapy group approximately half that in the isoniazid-only group. The combination-therapy group had higher treatment completion rates and a toxicity profile similar to that of the isoniazid-only group, with lower rates of adverse events, severe adverse events, and hepatotoxicity attributable to the study drug. This simple, effective new regimen has a potential public-health benefit. The 12–dose regimen of INH and RPT is now available through all Mississippi State Department of Health clinics. The combined regimen does not replace other recommended LTBI treatment regimens; it is another effective regimen option for otherwise healthy patients aged ≥12 years who have a predictive factor for greater likelihood of developing active TB. These factors include recent exposure to contagious TB, conversion from negative to positive on an indirect test for infection (i.e. interferon-γ release assay or tuberculin test), and radiographic findings of healed pulmonary TB. Prevention of active disease is a priority among LTBI patients with recent exposure to active TB cases (within past two years) or patients with other conditions that place them at higher risk for the development of active TB. The new 12 week regimen has the potential to increase the numbers who complete treatment for LTBI. MSDH is working with CDC and other sites to follow closely implementation of this regimen. All patients with positive tuberculin skin tests or positive interferon-gamma release assays (IGRAs) may be referred to MSDH for evaluation and treatment. Please feel free to contact the MSDH Office of Tuberculosis and Refugee Health with questions at 601-576-7700 or the Office of Epidemiology at 601-576-7725. The full MMR is available at http://msdh.ms.gov/msdhsite/_static/ resources/4880.pdf. —Presented and edited by Paul Byers, MD, State Epidemiologist, Mississippi State Department of Health Reference: Sterling TR, Villarino ME, Borisov AS, et al. Three months of rifapentine and isoniazid for latent tuberculosis infection. N Engl J Med. 2011; 365: 2155-66.
266 JOURNAL MSMA
August 2012
• speciAl Article •
MSMA Cosponsors First-Ever Mississippi Rx Drug Summit Karen A. Evers, Managing Editor
MSMA joined forces with other public health and safety stakeholders to create awareness of prescription drug abuse in the state for the first-ever Mississippi Prescription Drug Summit on July 18 at the Mississippi Trade Mart. Among the speakers contemplating Mississippi’s prescription drug abuse predicament were (l. to r.) Bureau of Narcotics Commissioner Marshall Fisher, MSMA President Dr. Steve Demetropoulos; Ken Seeley, founder of Intervention 911 and interventionist on A&E Network’s “Intervention;” Stan T. Ingram, Esq., complaint counsel for the Mississippi State Board of Medical Licensure; Dr. Scott Hambleton, medical director of the Mississippi Professionals Health Program. Other presenters (not pictured) included: Safety Commissioner Albert Santa Cruz; Gregory K. Davis, US attorney, southern district; Felecia Adams, US attorney, northern district; Joe Rannazzisi, JD, deputy assistant administrator, Drug Enforcement Administration, Office of Diversion Control; Regina LaBelle, JD, policy advisor, White House Office of Drug Control Policy (ONDCP); Chris Jones, Pharm D, Centers for Disease Control; Neely Carlton, JD, MSMA general counsel; Becki Loveless, PA, Mississippi Academy of Physician Assistants; Ryan Harper, PharmD, Mississippi Independent Pharmacies Association; The Honorable Bill Skinner, judge, Hinds County Youth Court; The Honorable Joel Smith, district attorney, 2nd circuit court district; The Honorable Andrew Howorth, judge, 3rd circuit court district; The Honorable Gray Tollison, senator, district 9; The Honorable Sam Mims, representative, district 97; Randy Easterling, MD, president, Mississippi Board of Medical Licensure; Michelle McLeod, NP, Mississippi Board of Nursing; and Lt. Governor Tate Reeves.
T
miSSiSSiPPi’S firSt PreScriPtion drug Summit
he Mississippi State Medical Association (MSMA) along with many of Mississippi’s public health stakeholders joined forces with the US Attorney’s office and public safety entities to create awareness of prescription drug misuse, abuse, and diversion in the state at the first-ever summit addressing this pressing issue. The Mississippi Prescription Drug Summit on July 18, 2012 at the Mississippi Trade Mart gave over 500 state lawmakers, the medical community, and law enforcement a chance to discuss the issue and learn how to prevent it. The summit was well-covered by Clarion-Ledger investigative reporter Jerry Mitchell in an exceptional and comprehensive series Sunday, August 5, 2012. Mitchell’s series attributes the “man-made epidemic” of painkiller abuse to several factors. Among them, a decade-old push by the Joint Commission that encourages medical providers to help patients manage their pain through more liberal use of opioids, such as Vicodin, OxyContin, and Percocet. Those standards, developed in 2000 with the help of a grant from a major manufacturer of painkillers, have been called into serious question because they downplay the risks of addiction to these drugs. Mitchell, who received the 2008 MSMA Excellence in Medical Reporting Award for his expose on the State Department of Health, secured attention from the medical community with the headline: “Do no harm? Think again: Doctor shopping ignored.” The feature revealed Mississippi has an internet-based prescription drug monitoring program that officials say could halt most “doctor shopping” for narcotics, but more than two-thirds of physicians don’t use it.
August 2012 JOURNAL MSMA 267
miSSiSSiPPi PreScriPtion monitoring ProgrAm (mS PmP)
The Mississippi Prescription Monitoring Program (MS PMP) is the Mississippi solution for monitoring Schedule II-V controlled substances dispensed in Mississippi. Mississippi State Statutes 73-21-127, 73-21-97, and 73-21-103 set forth the legal requirements for reporting Schedule II-V controlled substances dispensed in Mississippi for use in the PMP system and specified non-controlled substances, such as Soma (carisoprodol), tramadol, and butalbital. The BOP website says the MS PMP solution has two main elements: • Data Submission. Information about controlled substance dispensing activities is reported regularly to the state of Mississippi through their authorized data collection vendor. Any entity dispensing controlled substances or specified non-controlled substances in or into Mississippi are required by law to provide such information to the data collection vendor in approved formats and frequencies. This includes mail order pharmacies that mail orders into the state. • Report Retrieval. Mississippi’s online report access application allows authorized users to generate customized reports 24 hours a day, seven days a week. A report shows information for all the scheduled prescriptions a specified patient has had for a specified period. An authorized user can be a prescriber for medical treatment of an existing patient, a pharmacist for pharmaceutical treatment, Mississippi licensure boards, or a law enforcement officer with an active investigation.
mS PmP rePort retrievAl
Mississippi controlled substance dispensing activity is reported regularly via the authorized data collection vendor, RelayHealth. Dispensers are required by law to provide such reporting to the data collection vendor (RelayHealth) in approved formats and frequencies. The MS PMP Report Access website allows prescribers and dispensers (and other authorized users) to request reports for a patient in their care that describes the monitored drugs dispensed to that patient during a specified period. According to the MS BOP two steps are required to gain access to the MS PMP Report Access website: 1. Submit a notarized application to the MS PMP office to request an account to use the MS PMP Report Access website. 2. Once you are notified by an email that your application is approved (which will also provide your temporary password), go to the Report Access website to complete the registration process and activate your user account. However, critics complain the PMP is far from user-friendly. MSMA immediate past-president Dr. Tom Joiner outlined the ailing system in his January 2012 President’s Page [Joiner TE. My adventure enrolling in the PMP. J Miss State Med Assoc. 2012;53(1):16-7]. Dr Joiner says it is important to note there are two programs administered by the PMP. “One is to monitor patients, and another is for those who dispense medications. Most doctors only need to register for the monitoring service, but, if you start from the top of the instruction page you will register for the wrong program!” he said. Deborah Brown, PMP manager for the Mississippi Board of Pharmacy, said “If you have any problem email me: dbrown@ mbp.state.ms.us” and offers these tips: • The person who is going to be using the system is the one who needs to sign up. If it is not the physician then the person signing up should reference the physician’s DEA number. • To download the application go to the Mississippi Board of Pharmacy website: www.mbp.state.ms.us. Click on the bottom left link to “Prescription Monitoring” and “click here for Registration Packet.” This will provide information on how to use the system before one receives a temporary password. • It is a good idea to cut and paste the temporary password. (Your managing editor adds, it is safer to copy and paste the temporary password so you will not delete it.) Confused yet? Further limitations of the electronic system include: It has a seven-day time lag. It’s reportedly timeconsuming to weed through patients with common names. Pharmacists also can access this same information, but in some chain pharmacies, employees can’t even access the Internet. Because the system is voluntary, there are no penalties for failing to comply.
Another Solution
Dr. Scott Hambleton, medical director of the Mississippi Professionals Health Program (MPHP), offers another possible solution to avoiding a prescription drug abuse pandemic, “Doctors, particularly primary care physicians, could screen for alcohol and drug problems by using the CAGE questionnaire: attempts to Cut back, Annoyance and criticism of drinking, Guilt about drinking, and Eye-opener morning drink. A suggestion of alcohol or drug abuse or a positive response to the CAGE questions deserves further assessment such as clarification about adverse consequences, inquiry about loss of control, determination of the patient’s perception of the substance use, and an assessment of the patient’s readiness to change behavior. Brief intervention with the patient in the clinical setting about alcohol or drug use can be effective,” he said. “A useful clinical approach, which physicians can actually charge and be reimbursed for, and is recommended for patients suspected of substance abuse is the SBIRT program, which is kind of a mini-intervention,” he explained.
continued on PAge 277 268 JOURNAL MSMA
August 2012
Rx Drug Summit “Sound Bites”
“We’ve got to change our culture. Lortab cannot be the state pill of Mississippi.” —Dr. Steve Demetropoulos, MSMA President
“It used to be crystal meth and alcohol. Now the calls we are getting at Intervention 911 are related to opioids. The opiates are turning into a cheaper form of heroin. That’s what I’m seeing all over the country.” —Ken Seeley, BRi1, RAS; Los Angeles, board registered interventionist on A&E Network’s “Intervention” “I’ve never had patients repeatedly lose their prescriptions for high blood pressure medicine or insulin, only narcotics…which is a testament to the addictive power of these medications. The pharmaceutical industry response to the present crisis is that it is still legitimate medical practice, both safe and effective, to use these addictive and dangerous medications, for chronic, benign pain conditions, as long as patients are carefully screened. This is very much like saying it is safe and effective to use a motorcycle as a means of transportation, during an ice storm at night, as long as the driver wears a helmet.” —Dr. Scott Hambleton, MPHP Executive Director “Each year, more people die from painkillers than cocaine and heroin combined. More than nine million dosage units of the painkiller hydrocodone were dispensed in Mississippi, with a big part of the problem being doctor shopping. An individual had been to 41 different prescribers in about a 14-month period. Either they have a family member who intervenes and gets into rehab, they get arrested, which is a form of intervention, and the other way it ends is, sadly, with a toe tag.” —Marshall Fisher, Mississippi Bureau of Narcotics Commissioner
“A few states have begun to require their doctors to check the prescription monitoring program before prescribing controlled substances. I check regularly before seeing patients. We and the other boards will probably get together soon to develop a regulation for all prescribers, including physicians, dentists or nursing practitioners, to require them to check the prescription monitoring program before prescribing controlled substances. That’s a better choice than having state lawmakers dictate. Doctors ought to regulate doctors.” —Randy Easterling, MD, Vicksburg, president of the state Board of Medical Licensure “If we had complete reporting on the deaths that were drug-related, it would stagger you. The sudden deaths of younger individuals who have taken prescription medications have risen dramatically … One problem is some bad doctors. The days of illicit drug overdoses have gone by the wayside. So many doctors think Xanax and Lortab are daily vitamins. I investigated two prescription drug overdose deaths, where both people had visited an Alabama doctor less than 96 hours earlier. That physician regularly prescribes 400 methadone tablets at a time... When I go by a doctor’s office in Columbus there are license plates from as far away as Jackson and Oxford. We’ve got an epidemic. It’s getting in our schools. And it’s far from just a problem for the youth. We’ve got mamas and daddies trying to act like they’re 17 or 18 using the same drugs. It’s a family problem.” —Lowndes County Coroner Greg Merchant, president of Mississippi Coroner-Medical Examiner Association
MS PMP Logo bw.AP.pdf
1
8/22/12
1:08 PM
Application for Access to the Mississippi Prescription Monitoring Program (PMP) Report Retrieval Site
Failure to read and follow instructions will result in failure to access the PMP 1.
MISSISSIPPI PRESCRIPTION MONITORING PROGRAM NOTARIZATION FORM
Go to https://rpt.pmp.relayhealth.com/MS and register at “Request Account”.
Please Print Name____________________________________________________________________ DOB ___________________________ Phone Number ________________________________ Fax Number __________________________________________________ Employer___________________________________ Street Address___________________________________________________
2. 3. 4. 5.
Sign the completed application form in the presence of a Notary Public and have them apply their seal to the signed original. Mail the original notarized form to the MS PMP office. The address is on the form. Keep a copy for yourself. Attach a copy of your Driver’s License. Do not forget to go to https://rpt.pmp.relayhealth.com/MS and register at ”Request Account.” When the proper paperwork is received, your account will be activated and you will be notified via the email address you provided.
City _______________________State _____ZIP ____________E‐mail address __________________________________________
User Type ‐‐ CHOOSE ONE:
Practitioner Practitioner Agent Pharmacist Law Enforcement State Entity Federal Entity Other (explain) _________________________________________________________________________________________ Practitioner, Practitioner Agent, or Pharmacy DEA _______________ License Number__________________ BY MY INITIALS I ACKNOWLEDGE/AGREE TO EACH STATEMENT BELOW
_____I certify that information requested from the Mississippi Prescription Monitoring program will solely be used for the purpose of providing medical or pharmaceutical treatment or evaluating the need for such treatment to a bona fide current patient. _____Approved users are limited to information concerning a current patient of the practitioner. _____Law enforcement authorities or licensing entities are limited to information concerning their current or ongoing investigation. _____Any person authorized to obtain prescription information that knowingly discloses information for misuse or purposely alters the information are subject to, but not limited to, a monetary penalty imposed by the Board of not more than $50,000.00 per violation as specified in code 73‐21‐127. _____I understand that inappropriate access or disclosure of information is a violation of Mississippi law and may result in disciplinary action by my licensing entity or loss of database access privileges. I agree to follow the policies of the Mississippi Prescription Monitoring Program and I also agree not disclose or misrepresent any data or protected health information to any unauthorized person or party. _____I agree not to share my password and realize that any other such sharing is a violation of the law as stated under “Unlawful Disclosure” and such actions will be prosecuted to the fullest extent of the law.
_____ I have read and agree to the MSPMP Data Collection Website Terms of Use Agreement on the remaining pages of this application document.
If you are with a Physician’s Office and need assistance please email: dbrown@mbp.state.ms.us If you need Technical Assistance, please call: 1‐800‐892‐0333 If you have a Policy Question please call: 1‐601‐898‐1990 Source: Adapted from Mississippi Board of Pharmacy Prescription Monitoring. Available at: http://pmp.relayhealth.com/MS/Documents/ Report%20Retrieval%20Registration%20KitV6.doc. Accessed July 19, 2012.
_____I certify that the information contained is complete and accurate without evasion or misrepresentation. _____As a practitioner, or practitioner agent, I agree to notify the Prescription Monitoring Program of any investigation or license suspension or license restrictions as it pertains to me.
Signature of Applicant______________________________________________Date_________________ Sworn to and subscribed before me this _____Day of ___________, 20_____Notary Signature_____________________ ____
Notary Seal
Mail this original form with a copy of your Drivers License to: MS PMP PO Box 1122 Madison, MS 39130‐1122
August 2012 JOURNAL MSMA 269
• editoriAl • Raising the Bar, but Failing to Meet the Goal: A Young Physician Reflects on Match Day and Mississippi’s Primary Care Workforce P. Brent Smith, MD, Cleveland
F
ew days carry as much significance to medical students nationwide as Match Day, which took place this year on March 16. For many, the day possesses more emotion than the other milestones during the long pathway to an MD, such as the Short Coat, Long Coat, and Graduation ceremonies. While most students pursue a steadfast and predictable route up to medical school graduation (notwithstanding the occasional bold soul who undertakes medicine as a second career), lives at this single point will deviate drastically based on the specialties matched and the residency locations chosen. It’s a morning of nerves and neurosis unlike any I had ever experienced before when my turn came in 2009. The day is also a telling reflection on where our priorities are for medical education in Mississippi. The day begins with remarks from the administrators of the medical school, and Dr. LouAnn Woodward, Associate Vice Chancellor for Health Affairs, related some telling statistics about this year’s class. Among the accolades detailed were off the charts Step scores (including an all-time individual high for the school), Board dr. brent sMitH scores exceeding the national average in every subject area, and a record high percentage of students matching into residencies. Dr. Loretta Jackson-Williams, Associate Dean for Academic Affairs, went on to relate how 46 members of the class enrolled in Primary Care residencies, a measure of the “social mission” for which University Medical Center’s (UMC) School of Medicine has been previously honored. It makes sense that the only allopathic medical school in a largely rural and underserved state should put a large percentage of its graduates into the specialties that provide front line care for the chronic diseases that heavily burden its population, right? A closer look at the numbers reveals the truth behind the figures, a concept being recognized nationally as “the Dean’s Lie.” Medical schools exist, at least in their mission statements, to educate the physician workforce needed for their regions, states, and country. The problem lies in how these schools are measured, funded, and collectively compared by regulatory bodies, potential applicants, and the community at large. Medical education funding is tied to large academic hospitals, such as UMC, which are inherently dependent on inpatient admissions for financial solvency and subsequently emphasize training in specialties geared towards inpatient care. Academic competitiveness between institutions leads to a reliance on measurable indicators of success, such as Step scores, Board scores, and residency match rates. The need to foster a positive image of the hospital system rises from a desire to secure funding and attract affluent patients to offset the cost of the indigent care that traditionally falls to them. Therefore, it’s in their best interest to be seen as a state of the art facility offering a plethora of rare subspecialty services. This combination of outside influences leads to a system that favors sub-specialty training and measures success by how high medical students score on their Step exams and how many match into traditionally competitive residencies. So then what happens when schools are held accountable for how well they meet the need to create a balanced, primary care driven workforce, which is the foundation of a viable healthcare system? They fall back on the “Dean’s Lie,” which is a failure to acknowledge that the accurate measure of successful workforce diversity lies not in how many enter so called “primary care residencies,” but rather in how many actually practice primary care after completing training. (The discrepancy in these numbers has been acknowledged and explained by the Council on Graduate Medical Education in its 20th report published in 2010.) When nationally ~90% of all who complete an internal medicine residency go on to specialize via further fellowship training, it becomes quickly apparent how grossly inaccurate it is to use match statistics as a metric for primary care output. At a state level, the numbers are more daunting: of the 270 JOURNAL MSMA
August 2012
2011 UMC internal medicine residency graduates, only 1 of 20 (5%) went into practice without Match Actual completing a fellowship. Internal Medicine 19 3 By measuring UMC’s 2012 IM-prelim 2 class by realistic standards, it is revealed that instead of the Pediatrics 10 4 45% claimed, only 20% of the OB/Gyn 6 6 class will enter the primary care Fam. Med. 7 7 physician workforce. What Med Peds 4 2 does become clear, however, 48 22 is that the 6.5% of the class entering family medicine makes up 1/3 of the actual primary Total matches 107 care workforce being produced *Statistics for likely percentage practicing true primary care are from the 20th report of by the state. This suggests that COGME, excepting OB/Gyn. This is from the description of the specialty provided by the we should invest more heavily American College of Surgeons. in producing family medicine residents, and also further into pediatric, Med-Peds, and OB/Gyn residents that place more graduates in actual primary care, with the goal of 40-50% of residency graduates providing primary care. How then do we fix this problem and begin producing medical school classes to fill Mississippi’s needs? The process began on a state and national level this year with key pieces of legislation introduced into our state legislature and into the US House of Representatives. In the Mississippi legislature, HB 317 authorized the creation of a Physician Workforce Office, whose purpose is to assist in starting rural site residencies in areas geographically diverse and often underserved by primary care, such as Hattiesburg, southwest Mississippi, Meridian, the Coast, and the Mississippi Delta. One mission will be assisting in the considerable work required beforehand in curriculum design and site planning before applying for graduate medical education (GME) training slots. Further, the Mississippi Physician Workforce Office will work with other government offices, such as the Mississippi Development Authority, to assist in gathering the necessary capital to cover the high startup cost incurred before programs become financially solvent 2-3 years into operation. (It is expected that state “seed money” included in the legislation will be awarded to facilitate the creation of a Family Medicine residency program in Hattiesburg at Forrest General Hospital this year.) The solution to the problem of unshackling residencies from large academic centers, and thereby opening the door for training sites in rural and underserved areas, will hopefully be deduced from the outcome The Primary Care Workforce Access Improvement Act (HR 3667), introduced in the US House of Representatives. This bill would authorize a limited number of pilot programs to test alternative funding models for primary care residencies. Currently, residencies are often forced to be associated with a teaching hospital, a scenario that adds a sense of financial security to these programs that often have relatively small numbers of residents. However, this leads to a large proportion of training time for primary care residencies being spent doing inpatient work (which earns more money for the hospital by keeping beds full), instead of training them to provide care in ambulatory settings, where they will spend 90% of their time in practice. HR 3667 would allow funding to be centered at other sites, such as Federally Qualified Health Centers, Teaching Health Centers, and groups of small rural hospitals willing to collaborate and share resources for a residency program. With residency training location being the most influential factor in final practice location, this could potentially provide a steady source of physicians for the areas that need them most. The last, and most sweeping, change needed is a cultural shift. We can no longer accept a system that bemoans poorly managed chronic disease, while condoning the training of a specialist heavy workforce. Some of these changes will take time, such as overcoming the “hidden curriculum” of medical schools that insists that high-achieving students are “too smart to do family medicine,” but others could conceivably spring from the work mentioned in this article. Students simply must spend more time away from the UMC during their training, both to get a realistic impression of the challenges and rewards of practicing in a non-tertiary care center and to develop role models and mentors in real-world practices. If we want to produce a workforce that is 40-50% primary care, it only makes sense to train our students in true primary care settings for more than the 6 week exposure they get on their current Family Medicine rotations as M3’s. Further, we have to begin to hold UMC and the School of Medicine accountable for the workforce it is producing. With roughly 15% of UMC’s budget coming from government funding, we as a state have the right to expect that they should produce medical school classes that are 40-50% primary care, measured 5 years after graduation (when they have completed residency training). If they cannot produce that workforce, perhaps we should reexamine how we spend our tax dollars. r
2012 UMC MATCH STATISTICS
August 2012 JOURNAL MSMA 271
• editoriAl •
My View from Second Year: Reflections of a Mississippi Medical Student Emily Brandon, M2, University of Mississippi School of Medicine
[Emily Brandon, a second year medical student, offers up a reflection on her path to and first year in medical school. Her grandfather is Dr. Leonard “Len” Brandon of Starkville, and her father is Dr. Steven Brandon of Starkville. She is the third generation of her family to belong to the Mississippi State Medical Association. She is currently serving on the MSMA Council on Medical Service.]—Ed.
W
hat an interesting year I’ve had over the past 12 months. It’s hard to believe that I’ve already started my second year of medical school. With both my father and grandfather being family doctors in Starkville, medicine has been a part of my life for longer than I can remember. I started working at our family’s clinic in the eighth grade, and aside from working two summers as a lifeguard at Camp Bratton Green, it’s the only job I’ve ever had. I started out filing charts and working in the front office, then I gradually made my eMily brAndon way into taking vital signs and learning how to take patient histories. When the time came to go to college, I tried to keep an open mind, but nothing sounded as appealing as medicine. During the second semester of my freshman year at Millsaps College, I chose biology as my major and started doing everything I could to prepare for applying to medical school. Throughout college, I filled my schedule with biology and chemistry classes and managed to spare some time for a few extracurricular activities. I shadowed several physicians to see what medicine was like outside of my father’s family medicine practice. For me, nothing really compared to the special relationships, trust, and variety that I had witnessed in family medicine. I decided that I was interested in staying in Mississippi as a primary care physician. During my junior year I studied for and took the MCAT and applied for the Mississippi Rural Physicians Scholarship Program (MRPSP). I was overjoyed when I was accepted into the MRPSP in the spring of my junior year; I then began preparing my application for medical school. I interviewed in September and had a suspenseful wait over the next few months, as I was not immediately accepted. In January I finally received that special email that said, “Congratulations, you’ve been accepted into the University of Mississippi School of Medicine.” I was so excited and grateful that I had finally been accepted. I had been working toward this goal for a long time and almost couldn’t believe that I had made it. I enjoyed my “last college summer” working for my father, volunteering at Camp Bratton Green, and traveling. I began school in August of last year with no idea of what to expect or how I would handle this new chapter in my life. After a week of orientation I was thrown into the infamous line up of first year classes. Biochemistry, histology, gross anatomy, physiology, and developmental anatomy consumed every minute of my first semester. Preparing for multiple tests almost every Monday while attempting to learn my way around the human body in gross lab didn’t leave me with much free time. But, I survived it. I had made it through what many say is the worst of the worst. Christmas break offered some much needed rest and relaxation, which I thoroughly enjoyed. Second semester offered its own set of obstacles however. Continuing to take histology and physiology, which both lasted about six months instead of the typical three and a half months, proved to be quite a challenge as these two classes came to a close. I was ready to start a new class with a fresh start, something I was used to having after Christmas breaks in college. I wouldn’t get this opportunity until after spring break, when we were to begin neurobiology. While I hadn’t done poorly in any of my classes, I felt as if I could have done better in some. I was determined to finish my first year on a good note, so I decided to go all out for neurobiology. I started a more intense study regimen and really tried to keep up with the material, and it paid off. I had finished my first year of medical school! I still have moments 272 JOURNAL MSMA
August 2012
that I can’t believe I’m in medical school and that in three more years I’ll graduate a doctor. There were definitely times that it was more difficult than I could have imagined and times that I didn’t know if I could make it through. I had to continually remind myself that I was there for a reason and that I could in fact do it. Even with the tough times, I think I can truly say that I enjoyed every minute of it. One of the best parts— I’m finally able to discuss medicine with my father instead of just listening and trying to keep up. This is something the rest of my family doesn’t enjoy, considering we now dominate every conversation at the dinner table. Over this past summer, I’ve learned a lot outside the classroom and the clinics. I was fortunate enough to attend three different organized medicine conferences and see first-hand how physicians can work together to improve the health of our patients and our healthcare system. It saddens me to hear my student colleagues discuss the logistics of choosing a highly paid specialty in which they don’t have to take call or will only work three days a week. While I recognize that not everyone feels that way, I hope that my fellow students recognize that primary care and a patient centered medical home are the solution to a majority of the problems we face in the healthcare industry. I’m fortunate to have grown up around primary care in a small town where I learned the importance a physician can play in a patient’s life, whether it’s in the clinic, hospital, patient home, or at the grocery store on a Saturday afternoon. No matter what specialty we end up in, it is our job as students, residents, and physicians to work together, be there for, and advocate for our patients no matter what it requires of us. I’m so grateful for all the things I’ve learned and experienced over this past year; it has all flown by so quickly, and I can’t wait for the years to come. I think that medicine is in my blood, and I can only hope that I will be privileged enough to carry on the legacy of my father and grandfather. r
MEA Medical Clinics Announces Openings for Board Certified Family Medicine Physicians in our Jackson and Laurel Area Clinics Guaranteed Base Compensation • Incentive Bonus Profit Sharing • Flexible Scheduling • CME Allowance Malpractice Insurance • Health Insurance • Life Insurance Disability Insurance • Much More!
BRANDON BYRAM CANTON CLINTON JACKSON LAUREL MADISON PEARL RICHLAND RIDGELAND
We look forward to hearing from you! Toni Jordan 601-898-7535
Rachel Williamson 601-898-7527
1-800-844-6503 Recruiter@mms-ms.com
www.meamedicalclinics.com
en is Mighter The P Than the Sword
Express your opinion in the JMSMA through a letter to the editor or guest editorial. The Journal MSMA welcomes letters to the editor. Letters for publication should be less than 300 words. Guest editorials or comments may be longer, with an average of 600 words All letters are subject to editing for length and clarity. If you are writing in response to a particular article, please mention the headline and issue date in your letter. Also include your contact information. While we do not publish street addresses, e-mail addresses or telephone numbers, we do verify authorship, as well as try to clear up ambiguities, to protect our letter-writers. You can submit your letter via email to KEvers@MSMA online.com or mail to the Journal office at MSMA headquarters: P.O. Box 2548, Ridgeland, MS 39158-2548.
August 2012 JOURNAL MSMA 273
• Just off tHe press - info you WAnt to KnoW • Clopidogrel with Proton Pump Inhibitors Hannah Gwin, PharmD; Richard L. Ogletree, Jr., PharmD
B
methodS
AcKground
In 2009, the FDA added a new warning to the clopidogrel After search of MEDLINE, EMBASE, and Cochrane label discouraging co-administration of the medication with Controlled Trials Register, 19 studies with a total of 4,693 subomeprazole. The warning has been strengthened and now says jects met the inclusion criteria and by evaluation of platelet to avoid concomitant use of clopidogrel with either omeprafunction in patients given clopidogrel alone or together with zole or esomeprazole. The warning is also on the labeling for a PPI. Accepted platelet function tests included adenosine diomeprazole, but currently not on the insert for esomeprazole. phosphate/maximal platelet aggregation, vasodilator-stimulatClopidogrel is metabolized to its active metabolite ed phosphoprotein platelet reactivity index, VerfiyNow® ADPJust off the Press Info You cytochromeWant to Know: Clopidogrel with Protonunits, Pumpand Inhibitors through a two-step transformation via– hepatic platelet reactivity inhibition of platelet aggregation. P450 enzymes, particularly CYP2C19. Some medications inHannah Gwin, Pharm.D.; Richard L. Ogletree, Jr, Pharm.D. terfere with the activity of these enzymes and could theoretireSultS Background: In 2009, the FDA added a new warning to the clopidogrel label discouraging cocally block this process. There is increasing debate regarding Six studies compared omeprazole with pantoprazole. administration of the medication with omeprazole. The warning has been strengthened and now says to the efficacy of clopidogrel when given with concomitant proton Three of these studies showed a on greater attenuation of the The warning is also the avoid concomitant use of clopidogrel with either omeprazole or esomeprazole. pump inhibitor (PPI) therapy, particularly when using a PPI that labeling for omeprazole, but, currently not on the insert forclopidogrel’s esomeprazole. antiplatelet effect when given with omeprazole. is known to inhibit CYP2C19 and other hepatic enzymes. The other three, which had limited sample size, did not show a Clopidogrel is metabolized to its active metabolite through a two-step transformation via hepatic statistically significant difference. cytochrome-P450 enzymes, particularly CYP2C19. Some medications interfere with the activity of these enzymes and could, theoretically block this process. There is increasing debate regarding the efficacy of Kwok CS, Loke YK. Effect of proton pump inhibitors on inhibitor concluSion clopidogrel when given with concomitant proton pump (PPI) therapy, particularly when using a that is known to inhibit CYP2C19aand other hepatic enzymes.The authors of this systematic review platelet function inPPI patients receiving clopidogrel: systematic
Article
concluded that the evidence included fails to establish definitively a consistent or Article: Kwok CS, Loke YK. Effect of proton pump inhibitors on platelet function in patients receiving predictable decrease in clopidogrel’s antiplatelet activity and clopidogrel: a systematic review. Drug Saf. 2012 Feb 1;35(2):127-39. objective PPIs using platelet function tests. This review did not assess data on platelet in patients receiving clopidogrel either To synthesize availablefunction To synthesizeObjective: the available data ontheplatelet in function clinical outcomes with PPI administration. alone or concomitantly with a PPI. patients receiving clopidogrel either alone or concomitantly Design: Systematic review of randomized controlled trials controlled studies with a PPI. rand evieWer ’S cobservational omment The heterogeneity of the studies and different observed Methods: After search of MEDLINE, EMBASE, and Cochrane Controlled Trials Register, 19 studies deSign results makeofit platelet difficult to come to a firm conclusion. However, with a total of 4,693 subjects met the inclusion criteria and by evaluation function in patients Systematic review of randomized controlled and what interaction was seen adenosine seems to be more likely with omepragiven clopidogrel alone or together with atrials PPI. Accepted platelet function tests included diphosphate/maximal platelet aggregation, vasodilator-stimulated phosphoprotein reactivity controlled observational studies. zole. Since the FDAplatelet warnings have not been proven to be false, index, VerfiyNow® ADP- platelet reactivity units, and inhibition of platelet aggregation. it may be prudent to avoid omeprazole or esomeprazole in patients receiving clopidogrel. r Results: review. Drug Saf. 2012 Feb 1;35(2):127-39.
Comparison PPI exposure vs. no exposure Omeprazole
vs. placebo
Pantoprazole vs. placebo Esomeprazole vs. placebo Omeprazole
vs. Pantoprazole
Esomeprazole vs. Pantoprazole
# of Trials
Significant difference in platelet interaction
No difference in platelet interaction
5
2
3
9
5
4
6
1
5
6
0
6
6
3
3
3
0
3
Six studies A compared omeprazole with pantoprazole. 274 JOURNAL MSMA ugust 2012
Three of these studies showed a greater attenuation of the clopidogrel’s antiplatelet effect when given with omeprazole. The other three, which had limited sample size, did not show a statistically significant difference.
• top 10 fActs you sHould KnoW •
About Diabetes Rosemary J. Call, PharmD; Marion R. Wofford, MD; Daniel M. Riche, PharmD
introduction
Diabetes affects 25.8 million Americans and is a national healthcare concern. It is a major cause of cardiovascular disease (CVD) and stroke and the leading cause of kidney failure, nontraumatic lower limb amputations, and new cases of blindness among adults. Diabetes was the 7th leading cause of death in 2010. In 2007, the estimated direct and indirect medical costs of diabetes were $174 billion. These costs may rise as more Americans become diabetic. Between 2005 and 2008, 35% of American adults aged 20 years or older had prediabetes (50% of those aged 65 years or older). Applying this percentage to the entire 2010 population projected that roughly 79 million Americans aged 20 years or older have prediabetes.The risk of developing diagnosed diabetes is higher in minorities compared to non-Hispanic white adults: 18% higher among Asian Americans, 66% higher among Hispanics, and 77% higher among non-Hispanic blacks.1 Mississippi significantly contributes to the national burden of diabetes. In 2010, 12% (261,000) of Mississippians had diagnosed diabetes.2 Education, medication, and lifestyle modification are necessary to improve patient quality of life, prevent complications, and reduce healthcare costs related to diabetes. 1.
EARLy DIAGNOSIS OF DIABETES CAN REDUCE COMPLICATIONS AND IMPROvE PATIENT OUTCOMES. Diabetes is diagnosed using one of the following criteria: a hemoglobin A1c (A1c) ≥6.5%, fasting plasma glucose ≥126 mg/dL (fasting is defined as no caloric intake for at least 8 hours), 2-hour plasma glucose ≥200mg/dL during a 75-gram oral glucose tolerance test, or a random plasma glucose ≥200 mg/dL in a patient with classic symptoms of hyperglycemia (polydypsia, polyphagia, polyuria) or hyperglycemic crisis. Repeat testing if patient does not have unequivocal hyperglycemia. Screening for diabetes should be considered in all asymptomatic adults who are overweight (BMI ≥ 25 kg/m2) with one or more additional risk factors: history of CVD, hypertension (blood pressure ≥140/90 mmHg or on antihypertensive medication), physical inactivity, first-degree relative with diabetes, high-risk race/ethnicity (e.g., African American, Latino, Native American, Asian American, Pacific Islander), women who delivered a baby weighing >9 lb or who were diagnosed with gestational diabetes, women with polycys-
2.
3.
4.
tic ovary syndrome (PCOS), high density lipoprotein (HDL) <35mg/dL and/or triglycerides >250mg/dL, A1c ≥5.7%, impaired glucose tolerance or impaired fasting glucose on previous testing, and/or other clinical conditions associated with insulin resistance (e.g. severe obesity, acanthosis nigricans). In the absence of the above criteria, testing for diabetes should begin at age 45 and repeated every 3 years.3 GLyCEMIC CONTROL HELPS REDUCE MICRO- AND MACROvASCULAR COMPLICATIONS. Glycemic goals include: A1c ≤ 7%, fasting plasma glucose 70 to 130mg/dL, and post-prandial plasma glucose <180mg/dL. Perform A1c testing in patients twice yearly who are at goal and quarterly in patients who have changed therapy or who are not meeting goals. Most monitoring parameters should be assessed annually, including: fasting lipids, urine albumin excretion, serum creatinine, neuropathy screenings, dilated eye examinations, and comprehensive foot examinations (10-g monofilament plus any one of the following: vibration using 128-Hz tuning fork, pinprick sensation, ankle reflexes, or vibration perception threshold).3 SELF-MONITORING BLOOD GLUCOSE (SMBG) IS NECESSARy FOR EvALUATING PATIENT RESPONSE TO AND EFFICACy OF THERAPy. Patients should SMBG 3 to 4 times daily if they use multiple injections of insulin daily or use an insulin pump. SMOG should also be used by patients on oral or other injectable agents such as incretin therapy. While hand-written blood sugar logs are frequently used many new glucometers can record information electronically. Continuous glucose monitoring is an option for patients who are unaware of hypoglycemia and/or who have multiple episodes of hypoglycemia. Continuous glucose monitors allow patients to know their blood sugar at any time during the day, anticipate and avoid rises or falls in glucose, and identify trends in glucose patterns. These devices can also be blinded and data can be downloaded by the provider.4 METFORMIN SHOULD BE GIvEN TO EvERy TyPE 2 DIABETES AND MOST PRE-DIABETES PATIENTS UNLESS CONTRAINDICATED. Metformin decreases hepatic glucose production, decreases intestinal absorption of glucose, and improves
August 2012 JOURNAL MSMA 275
5.
6.
7.
8.
insulin sensitivity. It can lower A1c between 1.5 and 2.5% and can be used in combination with all other diabetes medications, including insulin. Titrate as tolerable to the maximum effective dose of 1000mg twice daily.3,5 SULFONyLUREAS STIMULATE INSULIN SECRETION AND CAN LOWER A1C BETWEEN 1 AND 2%. When choosing a second generation sulfonylurea note that glipizide works more quickly than glyburide or glimepiride but has a shorter duration of action. Glipizide does not produce active metabolites; glyburide and glimepiride both do and can last up to 24 hours. Glyburide is the most potent agent and is associated with higher rates of severe hypoglycemia. Sulfonylureas should be used cautiously with insulin, if at all. Make sure to counsel patients appropriately on the risk of hypoglycemia with all sulfonylureas.6 INCRETIN THERAPy EFFECTIvELy LOWERS POST-PRANDIAL BLOOD GLUCOSE. Incretin hormones, primarily glucagon-like peptide-1 (GLP-1) and glucose-dependent insulinotropic polypeptide (GIP), are released by the intestines in response to a meal. GLP-1 and GIP, which increase insulin secretion and reduce hepatic glucose production, are inactivated by the enzyme dipeptidyl peptidase IV (DPP-4). Incretin therapy includes DPP-4 inhibitors and GLP-1 receptor agonists. DPP-4 inhibitors, sitagliptin, linagliptin, and saxagliptin, are oral tablets that slow the inactivation of GLP-1 and GIP. These agents can lower A1c approximately 0.5%.7,8,9 GLP-1 receptor agonists, liraglutide and exenatide, are subcutaneous injections. Daily injections can lower A1c up to 1% while the once weekly exenatide may lower A1c up to 1.6%. These agents also slow gastric emptying and can promote weight loss. Incretin products can be used in combination with metformin and insulin to lower post-prandial glucose.10,11,12 THIAZOLIDINEDIONES INCREASE INSULIN SENSITIvITy, DECREASE HEPATIC GLUCOSE PRODUCTION, AND LOWER A1C BETWEEN 1 AND 1.5%. Pioglitazone is the only available agent in this class and can be used in combination with all other diabetes medications, including insulin. It should be noted that patients on pioglitazone for more than 1 year may have an increased risk of developing bladder cancer. The benefits of using pioglitazone should be weighed against this potential risk when initiating or continuing therapy.13 INSULIN IS AN EFFICACIOUS TREATMENT OPTION BUT ONLy ABOUT 26% OF ALL DIABETES PATIENTS USE INSULIN THERAPy.1 According to the 2005 Diabetes Attitudes, Wishes, and Needs (DAWN) study providers in the United States are more likely to delay insulin therapy in patients. Providers can reduce self-blame by avoiding telling patients that insulin is a consequence of poor diabetes control.2 Improving the attitudes of both patients and providers towards insulin therapy can improve dia-
276 JOURNAL MSMA
August 2012
betes management. Maintaining glucose levels to as close to normal as possible, reaching A1c goals, and preventing hypoglycemic episodes should be the major focus of diabetes treatment. 9. HyPERGLyCEMIA IN HOSPITALIZED PATIENTS CAN LEAD TO INCREASED COMPLICATIONS, MORTALITy, AND HEALTHCARE COSTS. According to the most recent guidelines for management of hyperglycemia in hospitalized patients in the non-critical care setting, all patients, regardless of whether they have been diagnosed with diabetes, should have a laboratory blood glucose test on hospital admission. Consider obtaining an A1c from diabetes patients admitted to the hospital if it has not been performed in the previous 2-3 months. The majority of hospitalized patients with non-critical illness should have a premeal glucose target of < 140mg/dL and a random blood glucose <180mg/dL. It may be reasonable to allow a higher target range (blood glucose <200mg/dL) for patients with a terminal illness and/ or with limited life expectancy or at high risk for hypoglycemia. Reassess antidiabetic therapy when blood glucose is <100mg/dL to avoid hypoglycemia.15 10. RISk FACTOR MODIFICATION IN DIABETES PATIENTS INCLUDES THE USE OF STATINS AND AN ANGIOTENSIN CONvERTING ENZyME (ACE) INHIBITOR OR AN ANGIOTENSIN II RECEPTOR BLOCkER (ARB). Statin therapy should be initiated regardless of baseline lipids levels in diabetes patients with overt CVD or without CVD but are over the age 40 and who have one or more other CVD risk factors. CVD risk factors include cigarette smoking, hypertension (BP≥140/90 mm Hg or on antihypertensive medication), low HDL (<40 mg/ dL), family history of premature coronary heart disease (CHD in male first-degree relative <55 years of age; CHD in female first-degree relative <65 years of age), and age (men ≥45 years; women ≥55 years). For patients at lower risk, statin therapy should be considered if low density lipoprotein (LDL) remains >100mg/dL. Measure fasting lipid panel at least yearly with goal of attaining: LDL <100mg/dL (<70mg/dL in patients with overt CVD), triglycerides <150 mg/dL, and HDL >40 mg/dL in men and >50 mg/dL in women. An ACE inhibitor or an ARB should be initiated in patients with micro- or macroalbuminuria.2 These agents reduce the rate of progression from micro- to macroalbuminuria and end stage renal disease. While tight blood pressure control itself can reduce the risk of developing nephropathy it is recommended that patients with hypertension and diabetes be treated with an ACE inhibitor or an ARB. Treatment with these classes may also delay the onset of microalbuminuria.16,17 Direct renin inhibitors (Tekturna® containing products) have not shown similar benefits and should not be used with an ACE inhibitor or an ARB in diabetes patients with renal impairment. Target blood pressure to <130/80mmHg.2,18
referenceS 1.
2.
3. 4. 5. 6.
7. 8.
Centers for Disease Control and Prevention. National diabetes fact sheet: national estimates and general information on diabetes and prediabetes in the United States, 2011. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 2011. Murphy SL, Xu J, Kochanek KD. National vital statistics reports: deaths: preliminary data for 2010. Atlanta (GA): Centers for Disease Control and Prevention (US); 2012 Jan. Report No.: 4. 69 p. American Diabetes Association. Standards of medical care in diabetes- 2012. Diabetes Care. 2012;35(suppl 1):S11-S63. Continuous glucose monitoring system. Medtronic, Inc. Web site. http://www.medtronicdiabetes.net/Products/guardiancgm. 2011. Accessed April 4, 2012. Glucophage [package insert]. Princeton, NJ: Bristol-Myers Squibb Company; 2009. Micromedex Healthcare Series Web site. http://www.thomsonhc. com/micromedex2/librarian/ND_T/evidencexpert/ND_PR/ evidencexpert/CS/C91BBF/ND_AppProduct/evidencexpert/ D U P L I C AT I O N S H I E L D S Y N C / C C D D C E / N D _ P G / evidencexpert/ND_B/evidencexpert/ND_P/evidencexpert/ PFActionId/pf.HomePage. Accessed April 4, 2012. Januvia [package insert]. Whitehouse Station, NJ: Merck and Co, Inc; 2011. Onglyza [package insert]. Princeton, NJ: Bristol-Myers Squibb Company; 2011.
9. 10. 11. 12. 13. 14.
15.
16. 17. 18.
Tradjenta [package insert]. Ridgefield, CT: Boehringer Ingelheim Pharmaceuticals, Inc; 2011. Victoza [package insert]. Princeton, NJ: Novo Nordisk; 2011. Byetta [package insert]. San Diego, CA: Amylin Pharmaceuticals, Inc; 2011. Bydureon [package insert]. San Diegot, CA: Amylin Pharmaceuticals, Inc; 2012. Actos [package insert]. Deerfield, IL: Takeda Pharmaceuticals America, Inc; 2012. Peyrot M, Rubin R, Lauritzen T, et al. Resistance to insulin therapy among patients and providers: results of the cross-national Diabetes, Attitudes, and Wishes (DAWN) study. Diabetes Care. November 2005;2811:2673-2679. Umpierrez GE, Hellman R, Korytkowski MT, et al. Management of hyperglycemia in hospitalized patients in non-critical care setting: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. January 2012;97:16-38. Remuzzi G, Macia M, Ruggenenti P. Prevention and treatment of diabetic renal disease in type 2 diabetes: the BENEDICT study. J Am Soc Nephrol. 2006;17(Suppl 2):S90-S97. Haller H, Ito S, Izzo JL Jr, et al. ROADMAP Trial Investigators. Olmesartan for the delay or prevention of microalbuminuria in type 2 diabetes. N Engl J Med. 2011;364:907-917. Novartis announces termination of ALTITUDE study with Rasilez®/ Tekturna® in high-risk patients with diabetes and renal impairment. Novartis Web site. http://www.novartis.com/ newsroom/media-releases/en/2011/1572562.shtml 20. Dec 2011. Accessed April 4, 2012.
MSMA Cosponsors First-Ever Mississippi Rx Drug Summit continued from PAge 268 Screening, brief intervention, And referrAl to treAtment (Sbirt)
The idea behind the Substance Abuse and Mental Health Services Administration’s (SAMHSA) Screening, Brief Intervention, and Referral to Treatment (SBIRT) program is to stop drinking and substance abuse problems before they became serious enough to destroy people’s lives. The basics of SBIRT are the same no matter where the services are provided. All patients in participating emergency rooms, primary health clinics, campus health centers, or other health care venues automatically undergo a quick screening to assess their alcohol and drug use. If they’re at risk of developing a serious problem, they receive a brief intervention that focuses on raising their awareness of substance abuse and motivating them to change their behavior. Patients who need more extensive treatment receive referrals to specialty care. More information on SBIRT, including financing, training, CME, screening, and training resources, can be found on the SAMHSA-HRSA Center for Integrated Health Solutions (CIHS) website: http://www.integration.samhsa.gov/clinical-practice/sbirt. Additionally, MSMA president Dr. Steve Demetropoulos, suggests physicians institute a pain policy. “What we really need is an attitudinal shift that pain doesn’t have to be treated with opioids — both in the medical community and in U.S. society as a whole. There are other over-the-counter pain relievers and non-addictive meds like ketorolac and other NSAIDs. An individual with severe arthritis pain does not need an addiction, too.” He suggests, “When writing a legitimate opioid prescription, only prescribe a small quantity with no refills.” Studies indicate Americans consume an estimated 99 percent of the world’s hydrocodone but represent less than 5 percent of the world population. Dr. Demetropoulos also reminds physicians, “The Joint Commission is warning hospitals about the risks of adverse events associated with opioid drugs and is urging providers to take action to prevent opioid-related harm or death.” In an alert (PDF found at http://www.jointcommission.org/assets/1/18/SEA_49_opioids_8_2_12_final.pdf) issued to Joint Commission-accredited organizations, the commission noted that opioid pain drugs “rank among the drugs most frequently associated with adverse drug events” such as respiratory depression and aspiration pneumonia. Prescription errors as well as providers’ lack of knowledge about different opioids’ potencies and inadequate patient monitoring are among the factors behind adverse events, according to the commission. Dr. Hambleton concludes, “As a fellowship-trained and board-certified physician in addiction medicine and family medicine, I am amazed by the current national prescribing practices. We are prescribing painkillers to non-life-threatening conditions, and we have ended up causing these patients to become addicted or die. Prescription drug abuse is a serious issue. Medications that were once reserved for cancer patients or trauma cases are now being prescribed for unpleasant but benign conditions such as chronic lower back pain,” he added. “My hope is that physicians and other prescribers will carefully consider the risks versus the benefits and take the lead in effecting change in the current prescribing practices. After all, you cannot have a prescription drug crisis without prescriptions.” r
August 2012 JOURNAL MSMA 277
• speciAl Article • An Interview with Charles D. “Buddy” Daughdrill, Executive Director of the Mississippi Public Health Association Richard D. deShazo, MD, Associate Editor
What is your present position? I currently serve as the Executive Director of the Mississippi Public Health Association, a statewide non-profit association with over 600 members whose mission is to promote personal and public health in the state of Mississippi and to promote professional development of public health workers through advocacy and education activities. I have served in this position since 2008. What is your background in healthcare? Prior to my current position, I served as the District Director with the Mississippi State Department of Health in the Hattiesburg area for 26 years managing all public health programs, staff, and finances for a nine-county area. Tell us about public health in Mississippi. Public health is population-based health care that has the responsibility to protect and promote health, and to prevent disease and injury. There are three core functions of public cHArles d. “buddy” health which include assessment, policy development, and assurance. Every day, public health professionals work to prevent the spread of disease, protect your food and water, and help dAugHdrill ensure your community is healthy. Each day, every day, public health impacts the life of every single citizen of Mississippi. The successes and efforts of public health are often taken for granted. As we brush our teeth with clean water, as we serve safe milk to our child and leave them with a licensed day care center, as we eat our meals in an inspected restaurant or visit a family member in a licensed hospital or nursing home, as we live without fear of polio or other illnesses capable of disabling healthy children and workers, and when a disaster such as Hurricane Katrina and the Gulf Oil Spill occur and emergency healthcare providers quickly respond to us, public health plays a significant role. All of these actions and many more are in place to protect our family, our community, and us. Every day, public health touches our life and is an under-appreciated component of our health care system. In Mississippi and across the country, our current public health infrastructure is fragile and is in urgent need of all our support. Can you give us an update on funding of public health in Mississippi? Historically, our public health system in Mississippi, with the Mississippi State Department of Health as the backbone, has been underfunded to maintain an adequate infrastructure and to provide services to assist in addressing the myriad of health issues facing our state. Based on a 2010-2011 report by Trust for America’s Health, a non-profit, non-partisan organization dedicated to saving lives by protecting the health of every community, Mississippi ranked 48th in state funds to meet our public health needs. The Department received $8.72 per person in state funding to operate public health services. In context, our neighboring states received their own state funding to support public health as follows: • • • •
Alabama #8: $70.19 per person, Arkansas #12: $51.37 per person, Louisiana #14: $49.70 per person, and Tennessee #17: $43.87 per person.
During 2012, the Legislative session initially proposed a $23 million state funding level for the Mississippi State Department of Health that would have represented a 12 percent reduction from the current level. This reduction would have been in addition to the $10 million in cuts sustained during the past four years. The Department stated during official testimony a minimum of $32.5 million dollars is required to maintain basic, essential public health services. This funding equals about $10.90 per Mississippian.
278 JOURNAL MSMA
August 2012
Through our efforts to educate state legislators regarding the impact of these cuts and the need for adequate funding, the Department was ultimately funded at the $32.5 million level, which prevented devastation to the critical functions of the Department. This level of funding, however, allows public health to continue to operate at a basic, functional level and requires all of our continued support to assure adequate funding of the Department. What problems have arisen from the lack of funding of public health in the state? I feel the overall infrastructure of the public health system has been marginalized with the lack of state funding. I think we have seen this result in the inability to improve many of the health indicators we face including infant mortality, teenage pregnancy, obesity, chronic illness issues such as diabetes and hypertension as well as STD/HIV and TB. We also face a declining public health workforce and many skilled, educated public health professionals who are eligible for retirement which obviously diminishes capacity. According to a July 2011 study published in Health Affairs, researchers found that for each 10 percent increase in local public health spending, there were significant drops in infant deaths (6.9%), cardiovascular deaths (3.2%), diabetes deaths (1.4%), and cancer deaths (1.1%). Based on Mississippi’s 2010 statistics, this means today there would be: • 27 more infants celebrating their second birthday • 314 more families not affected by cardiovascular disease • 69 more cancer survivors. Going forward in a period of austerity, what needs to be done? First, I think we need to thank the legislators for approving the funding at a level that at least maintains the current public health infrastructure given the financial challenges facing the state. However, the current $10.90 per capita state funding level remains woefully inadequate as compared to the need and the funding provided to our neighboring states. I would ask that the entire medical community recognize the important role public health plays as a partner in healthcare in our state and join us to educate policymakers as well as all of our citizens on the need for a strong public health system. Financial decisions faced by the Legislature to fund state services are difficult. Yet, to ensure healthy children to educate, healthy adults to work, and healthy communities to develop economic opportunities, the Department of Health must receive adequate state funds. The bottom line is we have to educate our citizens on the importance public health plays in improving our daily lives…. Develop a stronger, louder voice to convince our policy makers that public health activities should not be taken for granted and to fund them adequately. r
PERFORMANCE It is one of the most important things to consider when selecting an investment advisor. Our past performance can be seen on our website...right now.
www.medleybrown.com
23
years
1989-2012 MEDLEY & BROWN, LLC F I N A N C I A L
A D V I S O R S
601-982-4123
M&B Perf MSMA Feb'12.indd 1
August 2012 JOURNAL MSMA 279AM 2/6/12 10:58
• AsclepiAd •
B
ENJAMIN MACkLIN CARMICHAEL, MD, OF HATTIESBURG— Benjamin M. “Ben” Carmichael, MD, a Hattiesburg cardiologist for 34 years and long a member of our MSMA, retired from the practice of medicine in 2008. A native of McDonough, Georgia, Dr. Carmichael was Hattiesburg’s first board-certified cardiologist. He was inspired to enter medicine by his grandfather, Dr. H. C. Ellis, a general practitioner. He completed college and medical school at Emory University, like his grandfather, and then entered the Army in 1965, doing an internship and internal medicine residency at Walter Reed Army Medical Center in Washington, D.C. He completed a cardiology fellowship at and served on the staff of Brooke Army Medical Center in San Antonio, Texas. He had the opportunity to treat two United States Presidents during his career. He attended President Dwight Eisenhower while at Walter Reed, where the President was recovering from a heart attack, and he attended President Lyndon Johnson while at Brooke Army Medical Center. Following his service in the Army, Carmichael was recruited (by then Forrest General Hospital Administrator Lowery Woodall and Hattiesburg Clinic representatives Dr. Fred Tatum and Dr. Richard Clark) to establish a cardiology program for Hattiesburg. Prior to his arrival, the hospital’s only service for heart patients consisted of a four-bed coronary care unit. Patients who required cardiac catheterization or bypass surgery were transferred to Jackson or New Orleans. “The opportunity to start a program, develop it, and bring heart surgery to south Mississippi greatly appealed to me,” he recently said. Carmichael tirelessly worked with area leaders to design the hospital’s new cardiology unit, and by February 1978, he established heart catheterization capability at the hospital similar to what he had performed in the Army. Under his leadership, Forrest General became the first south Mississippi hospital to install a pacemaker via the Swan-Ganz method, and in 1985, it was the first area hospital to perform angioplasty (by Drs. Gerald Lowrimore and Carmichael). Carmichael’s leadership fostered the evolution of cardiac services at Forrest General Hospital and Hattiesburg Clinic, two institutions now leaders in the field equipped with the latest medical technology and a full staff of cardiologists and cardiovascular surgeons. Carmichael was there at the beginning of cardiology in south Mississippi, literally building great things from “nothing.” This leadership was commended by our MSMA House of Delegates, in Resolution No. 126, which honored him for “a legacy of service to the medical community exemplified by outstanding leadership, dedication, and prudent judgment.” Carmichael, who started playing the piano in the second grade, remains a talented pianist and enjoys music and the arts. He played a season for the Hattiesburg Concert Band as well as filled in as a substitute organist at Trinity Episcopal Church. He was the founding president of Partners for the Arts and is a recognized leader in the arts community of Hattiesburg. In addition to his involvement at our MSMA (serving on the Board of Trustees), Carmichael has long been a leader at Southern Medical Association, currently serving as Mississippi’s Councilor (the highest ranking state leader). His wife, Kathy, is a past president of the Southern Medical Association Alliance and is one of the longtime leaders of our MSMA Alliance. They have two sons, Ben, who works for R.J. Young Company in Hattiesburg, and David, who is associated with an accounting firm in Gulfport. They have four grandchildren: Katelyn, Matthew, Gunner, and Lake. This photo is by Karen Evers. —Lucius M. Lampton, Editor and Karen Evers, Managing Editor.
280 JOURNAL MSMA
August 2012
What’s Your Specialty? Our specialty is NETWORKING... TPAs Physicians
Hospitals
M
I
S
S
I
S
S
I
P
P
I
Physicians Care N E T WO R K
Employer Groups
Ancillary Providers Insurance Companies
MPCN - THE OBVIOUS CHOICE Change Networks. Not Doctors. 601-605-4756 • www.mpcn-ms.com Sponsored by the Mississippi State Medical Association
Have You Considered a Life Settlement For Your Old Life Insurance Policy? What is a Life Settlement? A life settlement is the sale of an existing life insurance policy on the secondary market to a third party investor.
Who or What May Qualify? If the person insured by the policy is age 70 or older If the person insured has any major medical conditions If the policy has a death benefit of $250,000 or more Policies including, but not limited to, universal life, term insurance, variable life insurance or whole life insurance If any cash value exists in the policy, the amount is relatively small
For More Information on Life Settlements, contact: H. Larry Fortenberry, CPA, CLU, ChFC Executive Planning Group, PA 1640 Lelia Drive, Suite 220 PO Box 16566 Jackson, MS 39216 (601) 982-3000
Why Use a Life Settlement? Term life insurance policy will expire Old policy that is no longer needed or premiums cannot be paid A policy that was purchased for a business buy/sell and is no longer needed A policy was purchased for a business that has been sold or is not needed There may be a better policy available at a lower cost
Estate value has changed and the policy is no longer needed
Securities Offered Through ValMark Securities, Inc. Member FINRA, SIPC Investment Advisory Services Offered Through ValMark Advisers, Inc. a SEC Registered Investment Advisor 130 Springside Drive, Suite 300 Akron, Ohio 44333-2431* 1-800-765-5201 Executive Planning Group is a separate entity from ValMark Securities, Inc. and ValMark Advisers, Inc. In a life settlement agreement, the current life insurance policy owner transfers the ownership and beneficiary designations to a third party, who receives the death proceeds at the passing of the insured. As a result, this buyer has a financial interest in the seller’s death. When an individual decides to sell their policy, he or she must provide complete access to his or her medical history, and other personal information, that may affect his or her life expectancy. This information is requested during the initial application for a life settlement. After the completion of the sale, there may be an ongoing obligation to disclose similar and additional information at a later date. A life settlement may affect the seller’s eligibility for certain public assistance programs, such as Medicaid, and there may be tax consequences. Individuals should discuss the taxation of the proceeds received with their tax advisor. ValMark Securities considers a life settlement a security transaction. ValMark and its registered representatives act as brokers on the transaction and may receive a fee from the purchaser. A life settlement transaction may require an extended period of time to complete. Due to complexity of the transaction, fees and costs incurred with the life settlement transaction may be substantially higher than other securities.