VOL. LVII • NO. 6 • 2016
Your patients can enjoy a healthier life. They just need a little extra motivation. Motivated to Live a Better Life is a free six-week workshop designed to help Mississippians better manage chronic diseases and take the right steps to lead a healthier, more active life. Learn more about this evidence-based approach to health management by calling the Mississippi State Department of Health Office of Preventive Health at 601-206-1559 or visiting HealthyMS.com/MLBL.
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VOL. LVII • NO. 6 • JUNE 2016
EDITOR Lucius M. Lampton, MD ASSOCIATE EDITORS D. Stanley Hartness, MD Richard D. deShazo, MD
THE ASSOCIATION President Daniel P. Edney, MD President-Elect Lee Voulters, MD
MANAGING EDITOR Karen A. Evers
Secretary-Treasurer Michael Mansour, MD
PUBLICATIONS COMMITTEE Dwalia S. South, MD Chair Philip T. Merideth, MD, JD Martin M. Pomphrey, MD Leslie E. England, MD Ex-Officio and the Editors
Speaker Geri Lee Weiland, MD Vice Speaker Jeffrey A. Morris, MD Executive Director Charmain Kanosky
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 © 2016 Mississippi State Medical Association.
SCIENTIFIC ARTICLES Parasitic Infection of the Gallbladder: Cystoisospora belli Infection 174 as a Cause of Chronic Abdominal Pain and Acalculous Cholecystitis Matthew G. Martelli, MD and Johnathan Y. Lee, MD Top 10 Facts You Should Know about Mosquito Control and Zika Virus Jerome Goddard, PhD
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Electronic Cigarettes in Mississippi: Issues Facing Healthcare Providers and Policy Makers Nell Valentine, MS; Emily McClelland, MS; Jessica Bryant, MS; Robert McMillen, PhD
DEPARTMENTS From the Editor –The Coming Storm of Zika Lucius M. Lampton, MD, Editor
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President’s Page – Who is Right? Daniel P. Edney, MD, MSMA President
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Editorial– Kudos for Telemedicine Heddy-Dale Matthias, MD
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Personals
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In Memoriam
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MSMA Physicians Leadership Academy- Chasity Torrence, MD 202 RELATED ORGANIZATIONS MSDH – State-of-the-Art Thompson Public Health Laboratory 194 MSMA Component Society Meeting Schedule 199 ABOUT THE COVER “Quiet Reflection”– Billy W. Long, MD, a retired gastroenterologist, who lives on the Madison side of “The Rez,” took this photo from his boathouse deck at the Barnett Reservoir looking east toward Rankin County. He writes, “It was a late summer day when the breeze had stopped and the water was still as a mirror. The reflection of the clouds and the tree seemed in need of remembering. As I stood there for a moment, I was struck by the thought that we all need times of quiet reflection.” The Barnett Reservoir (The Rez) is an impoundment of the Pearl River between Madison and Rankin counties in Central Mississippi. This 33,000-acre lake was created as a permanent water source for the capital city of Jackson. Construction was begun in 1960, completed in 1963, and the water level reached average capacity in 1965. Today, the Rez serves as a significant water source, a major recreational area, and a stimulus for residential and economic development. There are 4,600 homes along the 105-mile shoreline. Over two million people visit the Barnett Reservoir each year for boating, fishing, water-skiing, and camping.n VOL. LV
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F R O M
T H E
E D I T O R
The Coming Storm of Zika Zika is rapidly spreading across the Americas, and the climate and biological history of our region of the country indicate that our state is ripe for the virus’s spread. Largely forgotten yellow fever, transmitted by the same mosquito vector (Aedes aegypti) along water and rail routes of travel, dominated Mississippi’s late summers up until 1905, with thousands of deaths. Elimination of yellow fever occurred then with aggressive mosquito control, public education to prevent mosquito exposure, and finally a vaccine; a century later, the control of Zika is largely the same, except sexual transmission adds another path to block. No Zika vaccine exists, and none will be on the horizon anytime soon. This viral illness presents usually with fever, rash, conjunctivitis, and joint pain. Symptoms are usually mild lasting for several days to a week after bitten by an infected mosquito. However, the virus can result in Guillain-Barre syndrome and can cause serious birth defects including microcephaly. Over 600 travel-associated cases of Zika have been reported in the U. S. by the CDC, including more
than 195 pregnant women. No locally acquired vector-borne cases have yet been reported, however 18 sexually transmitted cases have been. (Mississippi has confirmed 3 travel-associated cases.) The U. S. House and the Senate recently approved different levels of funding to combat the Zika virus, both amounts significantly less than the CDC advised and woefully inadequate for our nation to be prepared for the coming storm of Zika. Here in Mississippi, our respected Department of Health has suffered historic funding cuts over the last few years, which have resulted in multiple clinic closures, 64 employees sent home, and 89 positions unfilled. Before the cuts, the agency was already the least funded per capita health department in the country and now is operating in an emaciated and anemic condition which will impact emergency medical response. Most of the mosquito control efforts are handled by local governments, often unevenly. Mississippi physicians must be aware that Zika will emerge here, and the preparedness of our underfunded health institutions may not be as robust as needed. Contact me at lukelampton@cableone.net. — Lucius M. Lampton, MD, Editor
JOURNAL EDITORIAL ADVISORY BOARD Timothy J. Alford, MD Family Physician, Kosciusko Medical Clinic Michael Artigues, MD Pediatrician, McComb Children’s Clinic Diane K. Beebe, MD Professor and Chair, Department of Family Medicine, University of Mississippi Medical Center, Jackson Rep. Sidney W. Bondurant, MD Retired Obstetrician-Gynecologist, Grenada Jennifer J. Bryan, MD Assistant Professor, Department of Family Medicine University of Mississippi Medical Center, Jackson Jeffrey D. Carron, MD Professor, Department of Otolaryngology & Communicative Sciences, University of Mississippi Medical Center, Jackson Gordon (Mike) Castleberry, MD Urologist, Starkville Urology Clinic Matthew deShazo, MD, MPH Assistant Professor-Cardiology, University of Mississippi Medical Center, Jackson Thomas E. Dobbs, MD, MPH State Epidemiologist, Mississippi State Department of Health, Hattiesburg Sharon Douglas, MD Professor of Medicine and Associate Dean for VA Education, University of Mississippi School of Medicine, Associate Chief of Staff for Education and Ethics, G.V. Montgomery VA Medical Center, Jackson Bradford J. Dye, III, MD Ear Nose & Throat Consultants, Oxford
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Daniel P. Edney, MD Executive Committee Member, National Disaster Life Support Education Consortium, Internist, The Street Clinic, Vicksburg Owen B. Evans, MD Professor of Pediatrics and Neurology University of Mississippi Medical Center, Jackson 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 Nitin K. Gupta, MD Assistant Professor-Digestive Diseases, University of Mississippi Medical Center, Jackson Scott Hambleton, MD Medical Director, Mississippi Professionals Health Program, Ridgeland J. Edward Hill, MD Family Physician, North Mississippi Medical Center, Tupelo W. Mark Horne, MD Internist, Jefferson Medical Associates, Laurel Daniel W. Jones, MD Sanderson Chair in Obesity, Metabolic Diseases and Nutrition Director, Clinical and Population Science, Mississippi Center for Obesity Research, Professor of Medicine and Physiology, Interim Chair, Department of Medicine Ben E. Kitchens, MD Family Physician, Iuka
Brett C. Lampton, MD Internist/Hospitalist, Baptist Memorial Hospital, Oxford Philip L. Levin, MD President, Gulf Coast Writers Association Emergency Medicine Physician, Gulfport Lillian Lien, MD Professor and Director, Division of Endocrinology, University of Mississippi Medical Center, Jackson William Lineaweaver, MD Editor, Annals of Plastic Surgery, Medical Director, JMS Burn and Reconstruction Center, Brandon Michael D. Maples, MD Vice President and Chief of Medical Operations, Baptist Health Systems Heddy-Dale Matthias, MD Anesthesiologist, Critical Care Internist, Madison Jason G. Murphy, MD Surgeon, Surgical Clinic Associates, Jackson Alan R. Moore, MD Clinical Neurophysiologist, Muscle and Nerve, Jackson Paul “Hal” Moore Jr., MD Radiologist, Singing River Radiology Group, Pascagoula Ann Myers, MD Rheumatologist , Mississippi Arthritis Clinic, Jackson Darden H. North, MD Obstetrician/Gynecologist , Jackson Health Care-Women, Flowood
Jack D. Owens, MD, MPH Neonatologist, Newborn Associates, Flowood Michelle Y. Owens, MD Associate Professor, Vice-Chair of Obstetrics and Gynecology, University of Mississippi Medical Center, Jackson Jimmy L. Stewart, Jr., MD Program Director, Combined Internal Medicine/ Pediatrics Residency Program, Associate Professor of Medicine and Pediatrics University of Mississippi Medical Center, Jackson Shou J. Tang, MD Professor and Director, Division of Digestive Diseases, University of Mississippi Medical Center, Jackson Samuel Calvin Thigpen, MD Hematology-Oncology Fellow, Department of Medicine, University of Mississippi Medical Center, Jackson Thad F. Waites, MD Clinical Cardiologist, Hattiesburg Clinic W. Lamar Weems, MD Urologist, Jackson Chris E. Wiggins, MD Orthopaedic Surgeon, Bienville Orthopaedic Specialists, Pascagoula John E. Wilkaitis, MD Chief Medical Officer, Brentwood Behavioral Healthcare, Flowood Sloan C. Youngblood, MD Assistant Medical Director, Department of Anesthesiology, University of Mississippi Medical Center, Jackson
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A R T I C L E
Parasitic Infection of the Gallbladder: Cystoisospora belli Infection as a Cause of Chronic Abdominal Pain and Acalculous Cholecystitis MATTHEW G. MARTELLI, MD AND JOHNATHAN Y. LEE, MD
Abstract Herein we describe two cases of Cystoisospora belli infection of the gallbladder in patients with chronic abdominal pain and review the published literature to date. C. belli is an intracellular protozoan parasite that typically infects the small bowel of immunocompromised hosts. Little is known of the significance of C. belli infection of the gallbladder at this point as only four cases have been reported as yet, only one of which occurred in an immunocompetent patient. It is often treatable with antibiotics, and the patient’s immune status, including HIV testing, should be investigated. Neither of the patients at our institution was found to be immunocompromised, and HIV-1/2 antibody testing was non-reactive in both.
FIGURE 1. Low-power view of the gallbladder mucosa (4x). Cystoisospora belli organisms are evident even at this power (arrow).
Key Words: C ystoisospora belli, gallbladder, acalculous cholecystitis Case Presentations The first patient is a 34-year-old woman who presented to her primary care physician with epigastric abdominal pain and melena. An esophagogastroduodenoscopy (EGD) and colonoscopy were performed to evaluate for the cause of her symptoms. The colonoscopy was unremarkable, and biopsies from her stomach revealed only a mild chronic gastritis without Helicobacter pylori infection. An ultrasound of her gallbladder was ordered which demonstrated possible biliary sludge versus polyp, with no obvious calculi. There was no evidence of cholecystitis. Despite this, due to her continued abdominal pain and suspicion for cholecystitis, a cholecystectomy was performed. On routine Hematoxylin and Eosin (H&E) staining, parasitic organisms morphologically consistent with Cystoisospora belli were identified and subsequently confirmed by GMS and PAS stains (Figures 1-4). Numerous stages of parasitic development were identified including oocysts and merozoites. Her complete blood count (CBC) revealed a mild relative and absolute eosinophilia of 8% (reference range 1-4%) and 0.59x10E3/uL (reference range 0.00-0.50x10E3/uL), respectively. At her post-operative clinic appointment, she stated that her symptoms had resolved and that overall she was feeling much better. An investigation into her immune status revealed normal levels of IgA, IgG, and IgM, and antibody testing for HIV-1/2 was nonreactive. 174 VOL. 57 • NO. 6 • 2016
FIGURE 2. High-power view demonstrating intracellular C. belli organisms (20x). Numerous forms are present including oocysts and merozoites.
The second patient is a 17-year-old girl who presented to her primary care physician with a two week history of nausea, vomiting, abdominal pain, and fever. Her nausea was moderate in severity, occurred continually, and was associated with eating fatty foods. The abdominal pain was moderate in severity, constant, and located in the right upper quadrant with radiation to the back. She denied jaundice or steatorrhea. A right upper quadrant ultrasound demonstrated a normal appearing gallbladder without stones or sludge. A hepatobiliary iminodiacetic acid (HIDA) scan with cholecystokinin provocation demonstrated a slightly depressed ejection fraction of 30% (normal >40%). A pregnancy test was negative, and a CBC revealed normal blood cell counts without eosinophilia. With this information she was scheduled for a cholecystectomy, whereby C. belli organisms were discovered in the resection specimen. At follow-up, she stated that she was feeling well and had returned to school and work. Antibody testing for HIV1/2 was non-reactive. Further investigation into her immune status is pending an appointment with a clinical immunologist.
Background Cystoisospora belli (formerly Isospora belli) is an intracellular protozoan parasite that causes intestinal disease and is most common in tropical and subtropical areas of the world.1 In humans, infections typically involve the small intestine of immunocompromised hosts and cause severe watery diarrhea. The parasite is spread via the fecal-oral route, usually by ingesting mature parasites in contaminated food or water. Oral-anal contact is also a possible mode of transmission. Infected persons then shed the immature form in their feces. The parasites require 1-2 days in the environment to mature sufficiently to infect others (Figure 5). C. belli infection is treatable with oral antibiotics (trimethoprim/sulfamethoxazole).2 FIGURE 5. C. belli lifecycle.
FIGURE 3. GMS stain highlights the organisms (stained black).
FIGURE 4. PAS stain highlights the organisms (stained dark pink).
Discussion At this time, little is known about the significance of C. belli infection of the gallbladder. To date, there are only four reported cases prior to the two presented herein. Dr. Benator from the Washington Hospital Center in DC published the first case in 1994 in the Annals of Internal Medicine in a patient with AIDS.3,4 This patient’s infection was discovJOURNAL MSMA
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ered incidentally postmortem during a research review of gallbladders at that institution. The role C. belli played in that patient’s demise is not clear, as he had previously cultured Entamoeba coli, Blastocystis hominis, and Endolimax nana from his stool and had been experiencing severe ongoing GI symptoms for years. A group from Brazil and a group from Yale published subsequent reports in 2003 and 2009, respectively.5,6 The Brazilian patient had known AIDS, while the patient at Yale was from West Africa with unknown HIV status. Earlier this year, a group from the Cleveland Clinic published the first case in an immunocompetent patient.7 This patient was a 47-year-old woman with vague abdominal pain for several years that gradually worsened and localized to her right upper quadrant. An ultrasound of her right upper quadrant revealed a normal gallbladder and an EGD was unremarkable. A HIDA scan with cholecystokinin provocation demonstrated a decreased gallbladder ejection fraction (EF) of 32%. On this basis, the patient was diagnosed with biliary dyskinesia and underwent an elective laparoscopic cholecystectomy, whereupon her infection was discovered. It is evident that C. belli infection/colonization of the gallbladder is capable of causing chronic abdominal pain and acalculous cholecystitis. The true significance, however, is presently unknown. It is likely that this organism will be found much more commonly in immunocompetent individuals than the immunocompromised as previously believed. Neither of the patients at our institution was found to be immunocompromised. As recognition of this organism increases and more cases are reported, we may gain a clearer understanding. We are aware that Dr. Keith Lai from the University of Arkansas Department of Pathology has been compiling a series of cases and has recently prepared a manuscript for publication that will hopefully enlighten us. At this point, however, it is wise to treat the patient (and perhaps close contacts) with antibiotics and check their immune status, including testing for HIV. Pathologists need to be aware of C. belli and look for its presence in every gallbladder specimen. The organism is intracellular and typically observed in the base of the epithelium surrounded by a clear halo on routine H&E staining. If identified, it is appropriate to alert the clinician so that treatment and laboratory investigation may commence. Even post-cholecystectomy, patients may still harbor the organisms within their small intestine or biliary epithelium elsewhere, causing continued abdominal pain and shedding of immature oocysts in their stool. Consequently, an EGD with small bowel biopsies may be appropriate as well. Because Mississippi is located within the Koppen humid subtropical region, it is likely that this parasite will be encountered again.8 Attentive pathologists and clinicians alike can serve their patients well by recognizing its presence and initiating appropriate investigation and therapy. n References
4. French AL, Beaudet LM, Benator DA, et al. Cholecystectomy in patients with AIDS: clinicopathologic correlations in 107 cases. Clin Infect Dis. 1995 Oct;21(4):852-8. 5. Frenkel JK, Silva MB, Saldanha JC, et al. Extraintestinal finding of Isospora belli unizoic cysts in a patient with AIDS: case report. Rev Soc Bras Med Trop. 2003;36(3):409-412. 6. Walther Z, Topazian MD. Isospora cholangiopathy: case study with histologic characterization and molecular confirmation. Human Pathol. 2009;40(9):1342 – 1346. 7. Takahashi H, Falk GA, Cruise M, et al. Chronic cholecystitis with Cystoisospora belli in an immunocompetent patient. BMJ Case Rep. 2015 June11;2015. 8. Climate. http://www.srh.noaa.gov/jetstream/global/climate.htm. Accessed September 24, 2015.
Author Information: Dr. Martelli is a pathologist practicing within Rush Health Systems and is based at Rush Foundation Hospital. He is board certified in anatomic and clinical pathology and recently finished a gastrointestinal, hepatic, and pancreaticobiliary pathology fellowship at the University of Florida in Gainesville, where he also completed his residency. Dr. Lee is a surgeon practicing within Rush Health Systems. He is board certified in general surgery and completed his residency at Louisiana State University Health Science Center in New Orleans. Department of Pathology, Rush Health Systems, Meridian, MS 39301
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1. Parasites – Cystoisosporiasis (formerly Isosporiasis). http://www.cdc. gov/parasites/cystoisospora/. Accessed September 23, 2015. 2. Johns Hopkins Antibiotic (ABX) Guide. http://www.hopkinsguides. com/hopkins/view/Johns_Hopkins_ABX_Guide/540152/all/ Cystoisospora_belli. Accessed September 24, 2015. 3. Benator DA, French AL, Beaudet LM, et al. Isospora belli infection associated with acalculous cholecystitis in a patient with AIDS. Ann Int Med. 1994;121:663-663.
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Top 10 Facts You Should Know about Mosquito Control and Zika Virus Jerome Goddard, PhD
1
There are many types of mosquitoes. There are at least 60 different species of mosquitoes occurring in the state of Mississippi.1 Only a few of them are significant pests of humans, while many others are quite obscure, being found in unique and limited habitats. For example, there are some species of mosquitoes that feed only on frogs2 and some that live only inside pitcher plants occurring along the coast.3 One of the common mistakes people make is thinking that all mosquitoes are the same and behave the same way.
2
Different species of mosquitoes breed in different places. Mosquitoes can be roughly grouped into categories based upon their breeding sites. Many Aedes species breed in artificial containers around the house or holes in trees. Others, like the Anopheles, breed in permanent water such as swamps or lakes. The West Nile virus vector in Mississippi, Culex quinquefasciatus, prefers water with high organic matter content such as that in septic ditches and storm drains. Some of our worst biting mosquito species come from groups such as Psorophora and Aedes which breed in floodwaters or woodland pools after heavy rains.
3
Not all mosquito species are vectors of disease agents like Zika virus. Interestingly, not all species of mosquitoes have the capability to pick up and later transmit disease agents, a concept called vector competence.4 There are lots of examples of this. In places with malaria, only Anopheles mosquitoes are the vectors despite the fact that there are many other mosquitoes in those areas. Also, after heavy spring rains, people get concerned about excessive mosquito biting from floodwater mosquitoes, but these mosquitoes are not carrying disease agents. The same is true for Zika; not all mosquitoes in Mississippi are able to transmit the virus to humans (see below).
4
Only two species of mosquitoes in Mississippi are likely competent vectors of Zika virus. Zika virus is primarily transmitted by the yellow fever mosquito, Aedes aegypti and the Asian tiger mosquito, A. albopictus. Both species are very similar in appearance and habits. Aedes aegypti is a small black species with prominent white bands on its legs and a silver-white lyre-shaped figure on the upper side of its thorax (Figure 1). It breeds in artificial containers around buildings such as tires, cans, jars, flowerpots, and gutters, and usually bites during the morning or late afternoon. It may readily enter FIGURE 1. The primary mosquito vectors of Zika virus in Mississippi: A. houses and seem to prefer human blood meals (as opposed to Aedes aegypti, and B. Aedes albopictus. Note the difference in white animals), biting principally around the ankles or back of the neck. markings on the back (Figure courtesy Mississippi Department of Health). Interestingly, in many places in the U.S. where A. albopictus was accidentally introduced, this species has virtually disappeared, apparently being displaced. Aedes albopictus is widely distributed in the Asian region, the Hawaiian Islands, parts of Europe, and much of the Americas, including the southern U.S., where it was accidentally introduced in 1986.5,6 This species is similar in appearance to A. aegypti having a black body and silver-white markings, with the major difference between the two being that A. albopictus has a single, silver-white stripe down the center of the dorsum of the thorax (instead of the lyre-shaped marking) (Figure 1). It also breeds in artificial containers such as cans, gutters, jars, tires, flowerpots, etc., and seem especially fond of discarded tires. This is an aggressive daytime-biting mosquito, often landing and biting immediately.
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5
Mosquito control of these two vectors is different from that of other disease vectors. In Mississippi, public mosquito control generally consists of spraying the town or county with a truck-mounted spray machine. While this may be fine for West Nile virus, it won’t work very well for Zika. The vectors of this disease are not readily killed by this method. Zika vectors live in close proximity to people’s houses, especially around the back porch and patio area where they breed in pots, pans, and planters. In such situations, a door-to-door effort is needed to educate homeowners about mosquito breeding and elimination (including larviciding, which means killing the larvae), combined with hand-held fogging with pesticides where needed.
6
The most important mosquito control measure around your house is to find and eliminate breeding sites. By far, the most effective mosquito control strategy for Zika virus is to search for and eliminate places where the vectors live. This is sometimes called the “tip and toss method.” People can be trained to look for trash, planters, pet dishes, and bird baths around their house where Aedes mosquitoes may live and empty the water out of them on a regular basis (Figure 2). Better yet, they can completely remove these items from the premises where possible.
FIGURE 2. The mosquito vectors of Zika virus may breed in anything that holds rainwater for more than 5-7 days. Plastic cups and garbage bags like those shown here may hold rainwater for mosquito breeding.
7
Other than eliminating breeding sites, both mosquito larviciding and adulticiding are important in controlling these two mosquito pests. Larviciding, which involves placing chemicals or other control agents in mosquito breeding habitats, is extremely effective and environmentally safe. Many of these products utilize either bacterial toxins or insect growth hormones to kill the larvae or block their development. There are also some harsh chemical larvicides available for application to water but they are rarely used these days. The bacterial or insect growth hormone larvicides are commonly available for sale at home and garden stores under a variety of brand names and are usually formulated as donuts, briquettes, tablets, or granules to be placed in water sources (Table and Figure 3).
FIGURE 3. A few mosquito control products available for homeowners.
For adult mosquito control (adulticiding), spraying around a house with a hand-held or backpack fogger works well (Table and Figure 3). Although a pest management professional can be contracted to provide this service, homeowners can do it themselves with electric or propane foggers. Certainly there might be situations where spraying with a truck-mounted machine up and down the street is also useful (but this should not be the primary mosquito control method).
8
Personal protection measures are also important in protecting yourself from mosquito-borne diseases. Other than killing the mosquitoes around your house, the best way to protect yourself from mosquito-borne diseases is to use personal protection. This includes avoiding mosquito infested areas during times of their greatest activity, wearing long sleeved shirts and long pants when outside, and using insect repellents (see next section).
9
Insect repellents are perhaps the most important tool to protect yourself. Insect repellents are a great tool for protecting the public from mosquito-borne diseases. There are several active ingredients in insect repellents such as picaridin and oil of lemon eucalyptus, but the gold standard is DEET.7 Some people have concerns about using insect repellents, but their safety is well established, especially when used according to their label directions.8 Most adverse reactions to repellents (primarily from DEET-based products) have resulted from improper application or reapplying the product too frequently. JOURNAL MSMA
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10
Remember, mosquitoes may transmit several diseases. Zika virus is not the only one. An important point to remember is that Zika is just the most recent mosquito-borne disease in a long succession of them. In Mississippi, this goes all the way back to malaria and yellow fever.9-11 Some of our more recent mosquito-borne diseases include St. Louis encephalitis and West Nile virus.12,13 There are probably other new or unknown viruses circulating in nature which could also infect people. The moral of the story is that mosquitoes may transmit several disease agents and protecting oneself from mosquito bites is a good thing. References
oddard J, Varnado WC, Harrison BA. An annotated list of G the mosquitoes (Diptera: Culicidae) of Mississippi. J. Vector Ecol. 2010;35(1):213-229. 2. Carpenter S, LaCasse W. Mosquitoes of North America. Berkeley, CA: University of California Press; 1955. 3. Goddard J, Waggy G, Varnado WC, Harrison BA. Taxonomy and ecology of the pitcher-plant mosquito, Wyeomyia smithii, in Mississippi. Proc. Entomol. Soc. Wash. 2007;109:684-688. 4. Goddard J. Mosquito vector competence and West Nile virus transmission. Infect. Med. 2002;19:542-543. 5. Lambrechts L, Scott TW, Gubler DJ. Consequences of the expanding global distribution of Aedes albopictus for dengue virus transmission. PLoS Negl. Trop. Dis. 2010;4(5):e646. 6. Rai KS. Aedes albopictus in the Americas. Ann. Rev. Entomol. 1991;36:459-484. 7. MSDH. Mosquito repellents -- types and recommendations: Mississippi State Department of Health, Jackson, MS, online article, http://msdh.ms.gov/ msdhsite/_static/14,957,93.html; 2014. 8. Fradin MS, Day JF. Comparative efficacy of insect repellents against mosquito bites. N. Engl. J. Med. 2002;347:13-18. 9. Cope SE. Yellow fever -- the scourge revealed: Florida Mosquito Control Association, Wing Beats, Winter 1996, pp. 14-26; 1996. 10. Crosby MC. The American Plague. New York: Berkley Books; 2006. 11. Hataway K, Goddard J. Malaria in Mississippi: history, epidemiology, and current status. J. Miss Acad. Sci. 2011;56:223-232. 12. Powell KE, Blakey DL. St Louis encephalitis: clinical and epidemiologic aspects in Mississippi. SMJ. 1976;69:11211125. 13. Goddard J. What is new with West Nile virus? Infect. Med. 2008;25:134-140. 1.
Corresponding Author: Jerome Goddard, PhD, Extension Professor of Medical and Veterinary Entomology, Department of Biochemistry, Molecular Biology, Entomology, and Plant Pathology, Mississippi State University, Starkville, MS, Box 9775, 100 Old Hwy 12 (Clay Lyle Building), Mississippi State, MS 39762, Ph. 662-325-2085, jgoddard@entomology. msstate.edu. n
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TABLE. Some common mosquito control products available to homeowners at local home and garden stores. Note: this is not a complete list, nor is any one of them necessarily recommended or endorsed by the author. Brand name
Insecticide
Manufacturer
Comments
Cutter Backyard Electric Powered Insect Fogger
Permethrin1
Spectrum Brands, Inc., Middleton, WI
An electric fogging machine for placement outdoors
Black Flag Propane Powered Insect Fogger
Permethrin1
The Fountainhead Group, Inc., New York Mills, NY
A propane powered fogging machine for placement outdoors
Off Mosquito Lamp2 Metofluthrin
S. C. Johnson Co., Racine, WI
A lamp for outdoors that releases an insecticide
Thermacell Patio Shield Lantern
Allethrin
Thermacell Repellents, Inc., Bedford, MA
A lantern for outdoors that releases an insecticide
Off Backyard Pretreat Spray
Lambda cyhalothrin S. C. Johnson Co., Racine, WI
A sprayer attachment for the water hose
EcoSmart Mosquito Fogger Spray
Essential Oils
Kittrich Corp., Atlanta, GA
All natural product intended to repel and kill mosquitoes in outdoor areas
Cutter Backyard Bug Tetramethrin Control (Fogger)
Spectrum Brands, Inc., Middleton, WI
A can of spray for “fogging” the backyard
Trap-N-Kill Mosquito Trap
DDVP (vapona)
Springstar Corp., Woodinville, WA
A small lethal mosquito trap to place outdoors around home
Mosquito Dunks Larvicide
Bacteria (BTI)
Summit Chemicals, Baltimore, MD
Donut-shaped product to place in water to kill mosquito larvae
Mosquito Bits Larvicide
Bacteria (BTI)
Summit Chemicals, Baltimore, MD
Treated corn cob grit to place in water to kill mosquito larvae
Pre-Strike Mosquito Torpedo
Methoprene (insect growth regulator)
Wellmark International, Shaumburg, IL
Small “tablets” to place in water to kill mosquito larvae
1 Most of these fogging machines use permethrin-based products. However, there may be other appropriately labeled insecticides for use in them. 2 Not to be confused with citronella candles or lamps.
S C I E N T I F I C
A R T I C L E
Electronic Cigarettes in Mississippi: Issues Facing Healthcare Providers and Policy Makers NELL VALENTINE, MS; EMILY MCCLELLAND, MS; JESSICA BRYANT, MS; ROBERT MCMILLEN, PHD Abstract Background: Electronic cigarettes (e-cigarettes) are currently unregulated nicotine delivery products, and use is increasing among youth and young adults in the U.S. Little is known about use in Mississippi. Design/Methods: Surveys assessed e-cigarette use among Mississippi adolescents and adults. UMMC provided data on reported cases of e-cigarette poisonings. Results: From 2010 to 2014, current e-cigarette use increased from 0.6% to 6.7% among middle school students, from 1.2% to 10.1% among high school students, and from 0.2% to 6.8% among adults. There were no reported cases of e-cigarette poisonings in 2010, 2011, or 2013. There was one case in 2012. Cases increased to 26 in 2014, and 17 cases were reported in 2015. Conclusion: E-cigarette use has increased substantially. E-cigarettes expose users and bystanders to harmful chemicals and cancer-causing compounds. Regulation of e-cigarettes at the local, state, and federal levels is needed to address the clear harms to non-smokers. Key Words: Electronic cigarettes Introduction A novel nicotine delivery product entered the U.S. market in 2007. The health community tends to refer to these noncombustible products as electronic nicotine delivery systems (ENDS) or electronic cigarettes, whereas many users apply the term vaping device. Due to their relatively recent introduction and variability across products, scientific research is not yet conclusive regarding the harms and potential benefits of these noncombustible products. Meanwhile, misleading claims that these products emit a harmless water vapor have confused the general public and many people in the health professions. On a continuum of harm for nicotine delivery devices, combustible tobacco products designed to be inhaled into the lungs are at the most harmful extreme while FDA-approved nicotine replacement therapies are at the least harmful extreme. Although it is currently unclear where e-cigarettes fall in this continuum, most scientists agree that emerging research demonstrates that these products are not without harm to users and bystanders.
Unlike cigarettes, e-cigarettes do not combust tobacco to release nicotine. Rather, a heating element heats a liquid solution to the point of aerolization, and the user inhales the nicotine-containing aerosol. The liquid solution typically contains nicotine, flavors, and a propylene glycol or glycerin base. The base is one of the primary components in the aerosol emitted by electronic cigarettes. Many users and harmreduction proponents note that most flavors, as well as propylene glycol and glycerin, have been designated by the FDA as Generally Recognized as Safe (GRAS). However, this designation applies only to ingestion of these products, not inhalation. Heating propylene glycol and other ingredients in e-cigarettes can change their chemical composition, making them unsafe as inhalants. Public Health Impacts E-cigarettes could have several potential beneficial as well as several harmful public health impacts. These products might help current smokers quit cigarettes and could be an effective harm reduction strategy for current smokers. However, e-cigarettes might also appeal to youth who would not otherwise have started using cigarettes 1 or to former smokers. 2 There are also concerns that e-cigarette users may be at an increased risk for initiating or relapsing to cigarette smoking.3 Furthermore, e-cigarettes could impact nonusers through passive exposure to emitted aerosol, and unintentional nicotine poisonings in young children. E-cigarettes and Cessation The emerging scientific research on this issue remains inconclusive with many credible scientists reaching contradictory conclusions. Although some cigarette smokers who have tried electronic cigarettes report doing so as a strategy for quitting smoking, 4,5 the limited number of studies examining the use of electronic cigarettes and cessation have found either no evidence that electronic cigarettes are effective for cessation, 4,6 that use actually reduced the likelihood of successful cessation, 5,7-10 that many smokers who use e-cigarettes continue to also smoke combustible cigarettes, 4,11 or that e-cigarettes were “modestly effective� in helping existing smokers who wanted to quit to quit. 12,13 A recent meta-analysis of 38 studies of e-cigarettes and smoking cessation
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found that smokers who used e-cigarettes had an odds ratio of quitting 28% lower than those who did not use e-cigarettes. 14 However, more well-designed randomized clinical trials with long-term follow-up are needed to sufficiently resolve this question. Complicating this issue, federal funding for conducting clinical trials using e-cigarettes as cessation drugs is not available because no manufacturer of these products has applied for FDA approval of their device as a cessation drug. Federal funds cannot support research on drugs not approved by the FDA. Due to the mixed evidence on e-cigarettes as an effective approach for quitting cigarettes, there is concern that e-cigarette use may frustrate treatment. Smokers may opt to try e-cigarettes rather than evidence-based smoking cessation treatment, and e-cigarettes are not approved or incorporated into clinical practice guidelines. E-Cigarettes As A Harm Reduction Strategy E-cigarettes are likely to be less harmful than combustible cigarettes. The absence of tar and the substantially reduced levels of toxins and carcinogens in e-cigarettes have generated excitement among some in the public health community that these products could provide a less harmful way for smokers to inhale nicotine. However, e-cigarettes are not without harm. E-cigarette emissions are primarily a toxic aerosol 15 consisting of submicron liquid droplets of glycol and many carcinogenic chemicals, such as formaldehyde, cadmium, lead, nickel, acetaldehyde, benzene, nicotine, toluene, and nitrosamines. 16 Although many of the toxic and carcinogenic byproducts of combustion are either absent or at substantially lower levels in e-cigarette aerosol than in cigarette smoke, 17-20 formaldehyde, aluminum, and nickel have been detected at higher levels in e-cigarette aerosol than in cigarette smoke. 21-23 The short amount of time that these products have been available on the market limits scientists’ ability to conduct research on their potential health impacts. However, chemical analyses of the contents of the nicotine solution, e-cigarette aerosol, and the chemical changes that occur during aerolization suggest that there is some level of harm to the user. Further evidence of potential harm to users comes from a recent analysis of 97 e-cigarette products from 24 companies, including samples from all of the leading U.S. companies. The analyses measured levels of the carcinogens acetaldehyde and formaldehyde. At least one product from 21 of these companies yielded high levels of one or both of these carcinogens. 24 Longitudinal studies with lengthy follow-up periods will be necessary to better understand the magnitude of possible health risks, but it is likely that the risks for most diseases will be lower than those for cigarettes. These products have been linked to increased risk for infectious disease. Recent research suggests that e-cigarette aerosol can weaken the immune system. Animal model studies suggest that there may indeed be short and long-term health consequences of e-cigarette aerosol exposure. Human cells forming the immune system have been found to have reduced antimicrobial activity against an antibiotic-resistant bacteria that can lead to pneumonia, while mice exposed to this bacteria were more vulnerable to death following exposure. 25
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Unfortunately, little is known about the long-term health risks of e-cigarette use. These products simply have not been available long enough for chronic disease risk to be observed. The emerging research raises concern, however. In 2014, researchers modeled the expected risks of e-cigarette use based on published studies of the chemical emissions from e-cigarettes. As might be expected, many of the toxic chemicals present in both cigarettes and e-cigarettes were at low levels in e-cigarettes and posed no significant risk for cancer. However, four of the nine chemicals tested exceeded this threshold in e-cigarettes: lead, formaldehyde, NNK, and cadmium. 15 One challenge to estimating potential risks is product variability across e-cigarettes. In the absence of federal regulation, the contents of the nicotine solution vary both within and across brands. 26,27 Gas chromatography analyses have revealed low consistency between nicotine content and the amount of nicotine on the label as well as misleading information on other ingredients in many e-cigarette solutions. Moreover, some manufacturers produce “open system” e-cigarettes or vaping devices that can be modified by the user. Modifications to the power source can increase the intensity of the e-cigarette’s heating element, thereby converting the glycerin and propylene glycol base of the nicotine solution to dangerous carbonyls such as formaldehyde and acetaldehyde. 21,28 E-cigarettes may also produce adverse health effects from inhaled heated flavorings.29 To illustrate, the chemical diacetyl meets the GRAS classification when ingested and provides products such as microwave popcorn with a butter flavor. However, the chemical is harmful when inhaled, leading to irreversible obstructive lung disease (also known as popcorn lung) among unprotected workers in manufacturing plants. 30 Furthermore, the Flavor and Extract Manufacturers Association (FEMA) warns “E-cigarette manufacturers should not represent or suggest that the flavor ingredients used in their products are safe because they have GRAS status for use in food because such statements are false and misleading.” 31 One further, albeit remote, risk for users involves potentially unstable lithium batteries in some devices. There are no federal consumer protections or regulations on e-cigarettes. A Canadian teen recently suffered second-degree burns on his face and two broken teeth when an e-cigarette manufactured in China exploded after the battery overheated. 32 According to FEMA, twenty-five incidents of explosion and fire involving an e-cigarette were reported in the United States media between 2009 and August 2014.33 Use Among Nonsmokers E-cigarettes as a harm-reduction strategy present a paradox. These products need to have sufficiently attractive features to entice smokers to switch from combustible cigarettes, but they represent a deeply flawed harm-reduction strategy if the same features attract nonsmoking adults and youth who were not likely to become cigarette smokers.34 Our recent study of U.S. adults provided evidence of the latter possibility and suggested that e-cigarettes can contribute to nicotine use among young adults who were not smokers. In 2013, almost a third of current e-cigarette users were either never smokers (12.6%) or former smokers (19.9%) of traditional cigarettes.35
Within the U.S., there is also evidence of e-cigarette use among nonsmoking youth. A recent CDC survey found that e-cigarette use has tripled among middle and high school students from 2011 to 2014. 36 Although it is not clear whether this increase occurred in youth who were diverted from smoking cigarettes or in youth who were not at risk for smoking,2 a recent survey of southern California teens found a large proportion of current e-cigarette users had never tried a cigarette.37 Initiation and maintenance of e-cigarette use among nonsmokers raises two concerns. First, there is no public health benefit of non-nicotine users using a product with unknown long-term health risks and variable quality. Second, there is the risk that use of these products among nonsmokers could be the first step on a trajectory towards established smoking. Ongoing longitudinal studies, such as the FDA’s Population Assessment of Tobacco and Health (PATH Study), will provide some insight into this possibility. Current evidence suggests that this possibility does indeed exist, at least for some adolescents. Cross-sectional studies of adolescents and young adults found that nonsmokers who had tried e-cigarettes were more open to trying smoking than those who had not tried e-cigarettes. 38,39 Moreover, three longitudinal studies found that e-cigarette use at baseline increased risk of cigarette smoking at follow-up. California and Hawaii 9th and 10th grade students who had tried e-cigarettes at baseline were found to be more likely to report use of combustible tobacco products at 12-month follow-up than those who had not tried e-cigarettes.40,41 Whereas, a national study of adolescents and young adults who were at low susceptibility for smoking found these individuals to be more likely to have initiated smoking at one year follow-up. 1 These four studies raise concerns that e-cigarettes could be a gateway to combustible tobacco use, at least among some nonsmokers. Passive Exposure As noted previously, many of the toxic or carcinogenic chemical compounds in cigarette smoke are either absent or at significantly lower levels in e-cigarettes. By the same logic that e-cigarettes are likely less harmful to users than combustible cigarettes, their aerosol is also likely to be less harmful than cigarette smoke to bystanders. However, the comparator for protecting bystanders in public spaces should be clean air and not cigarette smoke. If e-cigarette aerosol pollutes clean air with toxins and carcinogens, these products should be prohibited anywhere that cigarette smoking is not allowed. Although limited, the available research indicates that e-cigarette aerosol does indeed release toxins into the air. After releasing 100 puffs of an e-cigarette on an exposure chamber with a surface space of 100cm,2 researchers detected significant increases in surface nicotine. 42 Another study found elevated levels of airborne nicotine in homes of e-cigarette users. Although these levels were not as high as in cigarette smokers’ homes, levels were significantly higher than those observed in nonsmokers’ homes. Furthermore, levels of salivary and urinary cotinine (a biomarker for nicotine exposure) were at similar levels in bystanders of both e-cigarette and cigarette users’ homes. 43 The release of nicotine raises concerns for young children, pregnant women, and non-smokers involuntarily exposed to aerosolized nicotine. Research
with animal models indicates that this exposure can lead to adverse health outcomes. Neonatal mice exposed to e-cigarettes for the first 10 days of life were found to have modestly impaired lung growth, detectable levels of systemic cotinine, diminished alveolar cell proliferation, and a modest impairment in postnatal lung growth. 44 A follow-up study found that male mice exposed to nicotine in propylene glycol aerosol during late prenatal and early postnatal life demonstrated increased levels of behavior corresponding to ADHD behaviors in humans, suggesting that exposure to e-cigarette aerosol during a stage of rapid brain growth can lead to behavioral changes. 45 The science base on the short-term and long-term health effects of exposure to e-cigarette aerosol is growing, and initial findings indicate there is risk associated with exposure. Given health concerns about exposure to secondhand aerosol, jurisdictions have started to include the prohibition of e-cigarette use in smoke free environments. Child Poisonings Nicotine is a toxic poison and potentially lethal in sufficient doses. With e-cigarettes there is the potential for poisonings through ingestion, inhalation, or absorption of nicotine liquid; thereby creating a greater poisoning risk for e-cigarettes than combustible tobacco.46 Furthermore, e-cigarette liquid solutions typically contain up to 20mg of nicotine, while the estimated lethal dose of nicotine for a child is as little as 10mg.47 Nicotine solutions flavored like fruit, chocolate, and bubble gum increase the poison risk for young children. Several recent studies reveal increased incidents of poisonings from e-cigarettes. The National Poison Data System found a 208% increase from 2012 to 2013 in liquid nicotine reported exposures to poison centers.19 Poisoning incidents involving electronic cigarettes and liquid nicotine jumped by 156% from 2013 to 2014 and have increased more than 14 fold since 2011. More than half the calls involved a child under the age of six. 48 Policy Issues The federal government currently does not regulate e-cigarette devices, liquid nicotine flavors, or marketing. Child-proof regulations on packaging were recently enacted. On January 28, 2016, President Obama signed into a law a bill that requires child-proof packaging for liquid nicotine which will go into effect on 26 July 2016. No other federal regulations for product safety, flavors, or marketing currently exist. On April 24, 2014, the FDA released a draft of a deeming rule stating that the FDA will regulate electronic cigarettes. The FDA finalized this rule extending its authority to all tobacco products, including e-cigarettes, on May 5, 2016. This rule includes several provisions: 1) prohibition of sales to children under 18; 2) prohibition of free samples; 3) requirement that e-cigarette products have a health warning label; 4) requirement that manufactures disclose ingredients; and 4) prohibition of manufacturers making unproven health claims. These new requirements will begin to be implemented on August 8, 2016, but many provisions will not be enforced until 2017 or 2018. The finalized rule does not eliminate online sales, eliminate flavors, regulate or limit marketing, or prohibit use of electronic cigarettes in places where smoking is prohibited.
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Quality control is also an issue. Electronic cigarettes are not addressed by the Consumer Products Safety Commission. Many electronic cigarettes have unknown levels of nicotine, unknown ingredients, technical flaws, and variable quality.26,27,47,49-54 Mississippi restricted the ability to purchase these products to adults who are at least 18 years of age, but no other state regulations exist. To date, 72 Mississippi municipalities include e-cigarettes in their local ordinances prohibiting smoking in indoor public places. There are no other restrictions on the manufacture, use, or marketing of e-cigarettes.
sample characteristics would match those of the population of public middle and high school students within the state. Weight = W1 * W2 * f1 * f2 * f3 * f4 W1 = inverse of the probability of selecting the school W2 = inverse of the probability of selecting the classroom within the school f1 = a school-level non-response adjustment factor calculated by school size (small, medium, large)
Summary
f2 = a class adjustment factor calculated by school
E-cigarette use is increasing, there are many unknown and contested potential risks and benefits of these products, and little is known about the social penetration of these products in Mississippi. The purpose of this study is to provide healthcare providers and policy makers with data on the prevalence of e-cigarette use among adolescents and adults in Mississippi, as well as incidents of poisonings from e-cigarettes.
f3 = a student-level non-response adjustment factor calculated by class
Methods Results presented in this article are from three data sources. The Mississippi Youth Tobacco Survey provides data on youth e-cigarette use, while the Mississippi Social Climate Survey of Tobacco Control provides data on adult e-cigarette use. Both surveys are administered by the Mississippi State University Social Science Research Center. The Mississippi Poison Control Center at the University of Mississippi Medical Center provides data on reported exposure cases of poisonings from e-cigarette ingestion. The Mississippi Youth Tobacco Survey The Mississippi Youth Tobacco Survey (YTS) is a comprehensive tobacco survey administered annually to Mississippi public middle and high school students. The YTS measures students’ attitudes, knowledge, and behaviors concerning tobacco use. Questions about electronic cigarette use were added in 2010. Cross-sectional data on e-cigarette use are available for 2010-2014. Procedure
f4 = a post stratification adjustment factor calculated by gender and grade Statistical analyses were conducted using SPSS 22.0 and complex sampling procedures. The use of complex sampling procedures was required because standard statistical analyses are based on the assumption that the data were obtained through simple random sampling. Statistical procedures completed with the assumption that the data were obtained with simple random sampling would have underestimated the error variance due to the homogeneity of students within the same school and the same classroom. Measures Respondents were provided with this definition of e-cigarettes, “Electronic delivery devices that produce a vapor and often contain nicotine are called by many names. Some of these are electronic cigarettes, e-cigs, hookah pens, e-hookahs, vape pipes, or vape pens. For the purposes of the following questions, we will call them e-cigarettes.” Then respondents were asked, “How many times have you used an e-cigarette in your entire life?” Those who did not select the response, “I have never used an e-cigarette” were classified as ever users. Students were also asked about their use of e-cigarettes during the past 30 days. Those who reported using this product on at least one of the past 30 days were categorized as current users of that product.
The Institutional Review Board at Mississippi State University approved these annual surveys. Public middle and high school students in the state of Mississippi were selected for participation using a multistage sample design. All public schools containing students in 6th, 7th, or 8th grades for the middle school sample and 9th, 10th, 11th, or 12th grades for the high school sample were included in the first sampling stage. In order to produce a representative sample of students, schools were selected with a probability proportional to enrollment size. Once a school agreed to participate, classrooms were chosen randomly and all students in selected classes were eligible for participation. Parents were informed of the nature and intent of the survey via permission forms that provided the opportunity for them to opt their child out of participation. Teachers used standardized procedures to group administer the anonymous, self-administered questionnaires during a normal class period.
Mississippi Social Climate Survey of Tobacco Control
A weighting factor was applied to each student record to adjust for non-response at the school, class, or student level. Weighting the data ensured that all schools would be represented equally and that the
Respondents were asked, “Have you ever heard of a product called electronic cigarettes or e-cigarettes, or brands such as Smoking Everywhere, NJOY, Blu, or others?” Respondents who had heard of
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The Mississippi Social Climate Survey of Tobacco Control (SCSTC) is an annual cross-sectional survey. The survey is administered to a representative sample of Mississippi adults who are interviewed by telephone. The sample represents the civilian, non-institutionalized, adult population over age 18 in Mississippi. In order to provide a probability-based sample representative of all households in the state, a dual-frame RDD (Random-Digit-Dialing) sampling methodology was employed, whereby both landline and cellular telephone numbers were used to contact eligible adults. Telephone numbers were dialed a maximum of eight (8) times before being retired. The sample was weighted to reflect selection probabilities of households and with respect to specific demographic characteristics. The Institutional Review Board at Mississippi State University approved these surveys. Measures
electronic cigarettes were asked, “Have you tried Electronic Cigarettes or E-cigarettes, even just one time?” Respondents who reported yes were classified as having tried electronic cigarettes. Those who had tried electronic cigarettes were asked, “How often do you now vape or use e-cigarettes? every day, some days, or not at all.” Respondents who reported every day or some days were classified as current users. All current users were asked a set of questions about why they used e-cigarettes. Mississippi Poison Control Center The Mississippi Poison Control Center provided data on the number of reported exposure cases of e-cigarette ingestion in 2010-2015. Results Youth E-Cigarette Use Overall response rates range from 65% to 78%. Tables 1 and 2 provide the school, student, and overall response rates for each year. Sample characteristics for each year did not vary significantly across years. Table 1. Response Rates, Middle School Samples Table 1. Response Rates, Middle School Samples Table 1. Response Rates, Middle School Samples School Student Overall 2010
85.4%
81.8% Student
2011 2010
87.5% 85.4%
80.2% 81.8%
70.2% 69.9%
2012 2011
82.0% 87.5%
83.7% 80.2%
68.6% 70.2%
2013 2012
90.0% 82.0%
87.6% 83.7%
78.8% 68.6%
2014 2013
80.0% 90.0%
84.9% 87.6%
67.9% 78.8%
2014
80.0%
84.9%
67.9%
School
Overall
69.9%
Table 2. Response High School Samples School Samples Table 2. Response Rates, High Rates,
not vary by sex. Although middle school students who smoked cigarettes were more likely to report current e-cigarette use (63.9%) than nonsmokers (2.6%), p<.05, many current e-cigarette users were not cigarette smokers (44.8%) and 14.2% had never smoked a cigarette.
Among high school students, Table ever3.use of e-cigarettes increased from Trends in E-Cigarette Use among Youth 1.9% to 21.6% and current use increased from 1.2% to 10.1% from Ever Use, High Ever Use, Middle Current Use, Year 2010 to 2014 (Table 3). School Student School Students Middle School Students
Perce Weighted Percent In 2014, ever and current use did not differ across sex or grade. How-Weighted & 95% CI & 95% CI Weighted & 95%and ever, white students were more likely to report ever usePercent (31.0%) CI current use (13.6%) than African American students (11.1% and 1.9% (±1. 2010 0.9% (±0.6) 0.6% (±0.4) 6.4%) p<.05. Although high school students who smoked cigarettes 2011 (±0.7) were more likely to report current e-cigarette2.0% use(±0.9) (36.0%)1.0% than non- 5.9% (±2. 3.5% (±1.4)e-cigarette 1.1% (±0.6) smokers (5.4%,) p<.05, more2012 than half of current users 8.4% (±3. (51.9%) were not current cigarette smokers and 18.2%1.5% had(±0.7) never 9.7% (±2. 2013 3.2% (±1.2) smoked a cigarette. 2014
Adult E-Cigarette Use
10.7% (±3.0)
6.7% (±2.6)
Table 4. Trends in E-Cigarette Table 4. Trends in Adults E-Cigarette Use among Adults among Cooperation rates ranged Use
from 67.5% to 90.3%. From 2010 to 2014, ever use of e-cigarettes use among Mississippi adults increased from 0.3% to 20.1% and current use increased from 0.2% to 6.8% (Table 4). In 2014, ever and current use varied by sex, age, race, and education level (Table 5).
Year
Ever Use
Current Use,
Weighted Percent & 95% CI
Weighted Percent & 95% CI
2010
0.3% (±0.6)
0.2% (±0.4)
2011
4.5% (±0.9)
0.5% (±0.7)
2012
9.6% (±1.4)
4.0% (±0.6)
2013
12.1% (±1.2)
5.7% (±0.7)
2014
20.1% (±3.0)
6.8% (±2.6)
School Samples Table 2. Response Rates, High School
Student
2010
88.0%
84.4% Student
2011 2010
90.0% 88.0%
78.7% 84.4%
70.8% 74.3%
Ever User
Current User
2012 2011
82.0% 90.0%
82.6% 78.7%
67.8% 70.8%
Weighted Percent &
Weighted Percent &
95% CI
95% CI
School
Overall Overall
74.3%
2013 2012
80.0% 82.0%
82.4% 82.6%
65.9% 67.8%
2014 2013
88.0% 80.0%
83.3% 82.4%
73.3% 65.9%
2014
88.0%
83.3%
73.3%
Overall, ever use of e-cigarettes among middle school students increased from 0.9% in 2010 to 10.7% in 2014, while current use increased from 0.6% to 6.7% (Table 3). In 2014, ever and current use did not differ across race or grade. However, males (14.7%) were more likely than females (6.7%) to report ever use, p<.05. Current use did
Ever Use, Middle School Students Weighted Percent & 95% CI
Current Use, Middle School Students Weighted Percent & 95% CI
Ever Use, High School Students Weighted Percent & 95% CI
Current Use, High School Students
30
Weighted Percent & 95% 30 CI
2010
0.9% (±0.6)
0.6% (±0.4)
1.9% (±1.1)
1.2% (±0.8)
2011
2.0% (±0.9)
1.0% (±0.7)
5.9% (±2.0)
2.3% (±1.1)
2012
3.5% (±1.4)
1.1% (±0.6)
8.4% (±3.6)
2.7% (±1.2)
2013
3.2% (±1.2)
1.5% (±0.7)
9.7% (±2.6)
2.9% (±1.0)
2014
10.7% (±3.0)
6.7% (±2.6)
Table 4. Trends in E-Cigarette Use among Adults Year
Ever Use
Current Use,
21.6% (±3.0)
Sex
p<.05
10.1% (±2.0)
p<.05
Male
24.5% (±3.1)
8.9% (±2.1)
Female
16.2% (±2.5)
4.9% (±1.5)
Race
p<.05
p<.05
African American
12.2% (±2.8)
3.9% (±1.6)
White
24.2% (±2.8)
8.8% (±1.8)
Age
Table 3. Trends in E-Cigarette Table 3. Trends in E-Cigarette Use among Youth Use among Youth Year
Table 5. Demographic Predictors of E-Cigarette Use Table 5. Demographic Predictors of E-Cigarette Use among Adults, 2014 among Adults, 2014
p<.05
p<.05
18-24
31.9% (±6.3)
8.5% (±3.7)
25-44
29.6% (±4.1)
11.2% (±2.8)
45-64
14.7% (±3.0)
5.1% (±1.8)
5.2% (±2.6)
1.5% (±1.4)
65+ Education
p<.05
Less than HS Degree
18.1% (±5.2)
4.3% (±2.6)
HS Degree or GED
21.8% (±3.7)
7.0% (±2.3)
Some College
25.1% (±3.6)
9.0% (±2.5)
College Degree
11.9% (±3.9)
4.9% (±2.3)
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21.6% (±3.
The majority of current e-cigarette users were also cigarette smokers (63.8%,) whereas 16.2% were not smoking cigarettes when they initiated e-cigarette use. These adults were either never smokers or former smokers who quit smoking without the use of e-cigarettes. One fifth of current users (20.0%) were former smokers who reported using e-cigarettes as a means for quitting cigarette smoking. Among cigarette smokers who report current e-cigarette use, 60.4% report using e-cigarettes because they can use these products where smoking is not allowed, 68.1% report using e-cigarettes because they might be less harmful than cigarettes, and 62.5% report using them to try to quit smoking. E-cigarette Poisonings The Mississippi Poison Control Center provided data on reported exposure cases of e-cigarette ingestion for 2010 through 2015. There were no reported cases in 2010, 2011, or 2013. There was one case in 2012. The number of cases increased to 26 in 2014, and 17 cases were reported in 2015. Of all of these cases, 25 involved children 6 years of age or younger. The remaining occurred in teens or adults. 55 Discussion Mirroring national trends, 35,36,56 e-cigarette use among Mississippi youth and adults increased substantially from 2010 to 2014. Results from our 2014 surveys reveal that many current e-cigarette users are not smoking cigarettes, suggesting that these emerging products are indeed having an impact on public health. Supporting the potential of e-cigarettes for cessation, our self-reported, cross-sectional data indicated that some adult users were former smokers who quit smoking by switching to e-cigarettes. However, our surveys also highlighted a public health harm from these products. About half of youth who use e-cigarettes are not cigarette smokers, and more than 15% of adult users were not smoking cigarettes when they started using e-cigarettes, suggesting these products can contribute to nicotine use among people who would not have initiated use of combustible tobacco products. The finding that approximately half of adolescents who use e-cigarettes do not smoke cigarettes is alarming, in the context of recent studies finding non-smoking youth who use e-cigarettes are more open to trying smoking 38,39 and to actually initiating smoking. 1,40 It is difficult to conclusively determine from our data if susceptible nonsmoking youth who use e-cigarettes were diverted from smoking by e-cigarettes or were youth who were at low risk for smoking cigarettes but attracted to e-cigarettes. The concurrent decline in cigarette smoking and rise in e-cigarette use could be interpreted as providing support for the former option. However, closer analysis of the absolute number of fewer smokers and increased e-cigarette users suggests that many current e-cigarette users are not simply students who were diverted from cigarettes. Among high school students, cigarette smoking decreased from 18.1% to 13.3%, leading to 6,549 fewer high school smokers while e-cigarette use increased from 2.7% to 2.9%, leading to 273 more e-cigarette users. If students substituting e-cigarette use for smoking cigarettes was responsible for the decline in cigarette smoking, then we would expect the number of new e-cigarette users to be similar to the number of fewer smokers. In the absence of longitudinal data, it is difficult to make inferences about tobacco use 186 VOL. 57 • NO. 6 • 2016
trajectories, but these data do not support the hypothesis that smoking rates among high school students are dropping because would-be smokers are substituting e-cigarettes for cigarettes. The issue of whether or not e-cigarettes facilitate or interfere with cessation remains unresolved with contradictory research findings. Moreover, little is known about the short and long-term health risks of e-cigarette use. Chemical analyses of e-cigarette aerosols reveal lower levels of many toxins and carcinogens, 17-20 and a recent review commissioned by Public Health England concluded that e-cigarettes pose only a small fraction of a health risk compared to combustible cigarettes. 57 This report, however, has been criticized for reliance on weak data on the harms of most products and for a conflict of interest on the part of one of the authors who also consults for an e-cigarette company. 58,59 Moreover, other studies have found that e-cigarette aerosol causes lung damage in animal model studies, 44 and more time will have to pass for the risk-potential of e-cigarettes in long-term diseases to be properly assessed. At this point, there remains considerable scientific uncertainty over the issue of potential long-term harm reduction benefits of e-cigarette use rather than smoking and the potential but uncertain risk of serious disease. 29 This study is subject to the limitations of cross-sectional and self-report surveys. Longitudinal surveys are needed to provide detailed information on trajectories of cigarette and e-cigarette use in order to determine if nonsmoking e-cigarette users were diverted from cigarettes or are people who were attracted to nicotine use through e-cigarettes. Our finding that some former smokers report quitting cigarettes through the use of e-cigarettes is also limited by the nature of our data. Longitudinal studies or better randomized clinical trials that verify cessation would provide stronger evidence. Finally, self-report data may not provide accurate e-cigarette data from all respondents. However, our finding that many adult e-cigarette users and a large proportion of youth who use e-cigarettes are non-smokers is consistent with findings from a national survey of adults 35 and a southern California survey of 11th and 12th graders.37 Whether future research supports or contradicts the harm reduction benefit of e-cigarettes to smokers, the obvious public health harm of nonsmokers initiating and maintaining e-cigarette use should be addressed. Regulation of e-cigarettes at local, state, and federal levels is needed to address the clear harms to non-smokers. The FDA should expand its proposed deeming rule to address the product features, flavors, and marketing strategies that appeal to teens. Potential Policies for Mississippi At the local and state level, the use of e-cigarettes should be prohibited in places where smoking is not allowed. There is no objective evidence that e-cigarette aerosol is harmless to bystanders. The precautionary principle of requiring proof that a plausibly harmful action is not harmful supports the initiatives of local and state level restrictions on e-cigarette use where smoking is prohibited. Currently, 72 of Mississippi’s 121 municipalities with comprehensive smoke-free ordinances also include e-cigarette restrictions. In addition to restricting where people can use e-cigarettes, Mississippi has several other regulatory opportunities to reduce the likelihood that nonsmokers will use e-cigarettes. New York City, the state of Hawaii,
and numerous municipalities have increased the age of sale of tobacco to 21 from 18 years of age. An increased age of sale for tobacco breaks the distribution cycle by reducing minors’ ability to buy from other high school students. Adults who purchase cigarettes for distribution to minors are typically under 21.60 High school students typically do not have 21-year-olds in their social circles and thus have less access to tobacco from older buyers.61 This approach has been shown to impact adolescent smoking rates. Needham, MA, was one of the first places to implement this policy and experienced larger declines in current smoking than comparison communities in the same region of the state. 62 Moreover, the majority of Americans, including smokers and adults aged 18-20, support this approach. 63 Mississippi could consider legislation to increase the age of sale for tobacco products and include e-cigarettes in this legislation. Our research demonstrates strong support in this state for raising the age of sale to 21. More than three-quarters of Mississippi smokers and nonsmokers (77.8%) support this initiative, including 53.3% of adults between the ages of 18 and 20. 64 Taxation is another strategy for making e-cigarettes less attractive to nonsmokers. The lack of a state tobacco tax on e-cigarettes represents a missed opportunity for reducing use among nonsmokers. Mississippi currently has one of the lowest state cigarette taxes. At 68 cents per pack, this rate is substantially lower than the national average of $1.61. 65 A change to the tax structure that increased the state cigarette tax to the national average and also taxed e-cigarettes would be one approach to decreasing cigarette smoking and making e-cigarettes unattractive to nonsmokers. Finally, there is a lot of misinformation about e-cigarettes. Truth in Advertising reviewed more than 150 e-cigarette ad websites and found that half made false or unsubstantiated claims regarding the health benefits of e-cigarettes, while one-third of ads claimed that these products could be used anywhere. 66 This claim is false; many states and municipalities are including e-cigarettes in smoke-free ordinances and laws. Counter-marketing campaigns should debunk false or premature claims about e-cigarettes so that Mississippians have more accurate information about the toxins and carcinogens that are in e-cigarette aerosol and understand the local and private restrictions on where these products are allowed to be used. References 1. Primack BA, Soneji S, Stoolmiller M, Fine MJ, Sargent JD. Progression to Traditional Cigarette Smoking After Electronic Cigarette Use Among US Adolescents and Young Adults. JAMA Pediatr. 2015;1-7. doi:10.1001/jamapediatrics.2015.1742. 2. Kalkhoran A, Glantz S. Modeling the health impact of expanding e-cigarettes sales in the United States and United Kingdom: A Monte Carlo analysis. JAMA Intern Med. 2015. doi:10.1001/jamainternmed.2015.4209.
5. Vickerman KA, Carpenter KM, Altman T, Nash CM, Zbikowski SM. Use of electronic cigarettes among state tobacco cessation quitline callers. Nicotine Tob Res. 2013;15(10):1787-91. doi:10.1093/ ntr/ntt061. 6. Bullen C, McRobbie H, Thornley S, Glover M, Lin R, Laugesen M. Effect of an electronic nicotine delivery device (e cigarette) on desire to smoke and withdrawal, user preferences and nicotine delivery: randomised cross-over trial. Tob Control. 2010;19(2):98-103. doi:10.1136/tc.2009.031567. 7. Grana RA, Popova L, Ling PM. A Longitudinal Analysis of Electronic Cigarette Use and Smoking Cessation. JAMA Intern Med. 2014. doi:10.1001/jamainternmed.2014.187. 8. Popova L, Ling PM. Alternative tobacco product use and smoking cessation: a national study. Am J Public Health. 2013;103(5):92330. doi:10.2105/AJPH.2012.301070. 9. Al-Delaimy WK, Myers MG, Leas EC, Strong DR, Hofstetter CR. E-Cigarette Use in the Past and Quitting Behavior in the Future: A Population-Based Study. Am J Public Health. 2015;105(6):12131219. 10. Borderud SP, Li Y, Burkhalter JE, Sheffer CE, Ostroff JS. Electronic cigarette use among patients with cancer: Characteristics of electronic cigarette users and their smoking cessation outcomes. Cancer. 2014. doi:10.1002/cncr.28811. 11. Polosa R, Caponnetto P, Morjaria JB, Papale G, Campagna D, Russo C. Effect of an electronic nicotine delivery device (e-Cigarette) on smoking reduction and cessation: a prospective 6-month pilot study. BMC Public Health. 2011;11:786. doi:10.1186/1471-245811-786. 12. Bullen C, Howe C, Laugesen M, et al. Electronic cigarettes for smoking cessation: a randomised controlled trial. Lancet. 2013; doi:10.1016/S0140-6736(13)61842-5. 13. Brown J, Beard E, Kotz D, Michie S, West R. Real-world effectiveness of e-cigarettes when used to aid smoking cessation: a cross-sectional population study. Addiction. 2014. doi:10.1111/add.12623. 14. Kalkhoran S, Glantz SA. E-cigarettes and smoking cessation in real-world and clinical settings: a systematic review and meta-analysis. Lancet Respir Med. 2016. doi:10.1016/s2213-2600(15)00521-4. 15. Offerman F. The Hazards of E-Cigarettes. ASHRAE Journal. 2014;2014( June). Available at: http://bookstore.ashrae.biz/journal/download.php?file=2014June_038-047_IAQ_Offerman_ rev.pdf. 16. Goniewicz ML, Knysak J, Gawron M, et al. Levels of selected carcinogens and toxicants in vapour from electronic cigarettes. Tob Control. 2013. 17. Czogala J, Goniewicz ML, Fidelus B, Zielinska-Danch W, Travers MJ, Sobczak A. Secondhand Exposure to Vapors From Electronic Cigarettes. Nicotine Tob Res. 2013. doi:10.1093/ntr/ntt203.
Lindblom E. Effectively Regulating E-Cigarettes and Their Advertising and the First Amendment. Food Drug Law J. 2015;70(1):57-94.
18. Goniewicz ML, Knysak J, Gawron M, et al. Levels of selected carcinogens and toxicants in vapour from electronic cigarettes. Tob Control. 2013. doi:10.1136/tobaccocontrol-2012-050859.
4. Adkison SE, O’Connor RJ, Bansal-Travers M, et al. Electronic nicotine delivery systems: international tobacco control four-country survey. Am J Prev Med. 2013;44(3):207-15. doi:10.1016/j.amepre.2012.10.018.
19. Schober W, Szendrei K, Matzen W, et al. Use of electronic cigarettes (e-cigarettes) impairs indoor air quality and increases FeNO levels of e-cigarette consumers. Int J Hyg Environ Health. 2013. doi:10.1016/j.ijheh.2013.11.003.
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20. Schripp T, Markewitz D, Uhde E, Salthammer T. Does e-cigarette consumption cause passive vaping? Indoor Air. 2013;23(1):25-31. doi:10.1111/j.1600-0668.2012.00792.x. 21. Kosmider L, Sobczak A, Fik M, et al. Carbonyl Compounds in Electronic Cigarette Vapors-Effects of Nicotine Solvent and Battery Output Voltage. Nicotine Tob Res. 2014. doi:10.1093/ntr/ntu078. 22. German Cancer Research Center, Heidelberg. Electronic Cigarettes--An Overview.; 2013. 23. Williams M, Villarreal A, Bozhilov K, Lin S, Talbot P. Metal and silicate particles including nanoparticles are present in electronic cigarette cartomizer fluid and aerosol. PLoS One. 2013;8(3):e57987. doi:10.1371/journal.pone.0057987. 24. Cox C. A smoking gun: Cancer-causing chemicals in e-cigarettes.; 2015. Available at: http://www.ceh.org/wp-content/uploads/CEH-2015report_A-Smoking-Gun_-Cancer-Causing-Chemicals-in-E-Cigarettes.pdf. 25. Hwang JH, Lyes M, Sladewski K, et al. Electronic cigarette inhalation alters innate immunity and airway cytokines while increasing the virulence of colonizing bacteria. J Mol Med (Berl). 2016. doi:10.1007/ s00109-016-1378-3.
creasing In Both Smokers And Nonsmokers. Tob Control. 2014. doi:10.1093/ntr/ntu213. 36. Arrazola RA, Singh T, Corey CG, et al. Tobacco use among middle and high school students, United States, 2011-2014. MMWR Morb Mortal Wkly Rep. 2015;64(14):381-5. 37. Barrington-Trimis JL, Berhane K, Unger JB, et al. Psychosocial Factors Associated With Adolescent Electronic Cigarette and Cigarette Use. Pediatrics. 2015. doi:10.1542/peds.2015-0639. 38. Coleman BN, Apelberg BJ, Ambrose BK, et al. Association Between Electronic Cigarette Use and Openness to Cigarette Smoking Among U.S. Young Adults. Nicotine Tob Res. 2014. doi:10.1093/ntr/ntu211. 39. Bunnell RE, Agaku IT, Arrazola RA, et al. Intentions to Smoke Cigarettes Among Never-Smoking U.S. Middle and High School Electronic Cigarette Users, National Youth Tobacco Survey, 2011-2013. Nicotine Tob Res. 2014. doi:10.1093/ntr/ntu166. 40. Leventhal AM, Strong DR, Kirkpatrick MG, et al. Association of Electronic Cigarette Use With Initiation of Combustible Tobacco Product Smoking in Early Adolescence. JAMA. 2015;314(7):700-7. doi:10.1001/jama.2015.8950.
26. Cheah NP, Chong NW, Tan J, Morsed FA, Yee SK. Electronic nicotine delivery systems: regulatory and safety challenges: Singapore perspective. Tob Control. 2012. doi:10.1136/tobaccocontrol-2012-050483.
41. Wills TA, Knight R, Sargent JD, Gibbons FX, Pagano I, Williams RJ. Longitudinal study of e-cigarette use and onset of cigarette smoking among high school students in Hawaii. Tob Control. 2016. doi:10.1136/tobaccocontrol-2015-052705.
27. Trtchounian A, Talbot P. Electronic nicotine delivery systems: is there a need for regulation? Tob Control. 2011;20(1):47-52. doi:10.1136/ tc.2010.037259.
42. Goniewicz ML, Lee L. Electronic Cigarettes Are a Source of Thirdhand Exposure to Nicotine. Nicotine Tob Res. 2014. doi:10.1093/ntr/ ntu152.
28. Jensen RP, Luo W, Pankow JF, Strongin RM, Peyton DH. Hidden Formaldehyde in E-Cigarette Aerosols. N Engl J Med. 2015;372(4):392394. doi:10.1056/NEJMc1413069.
43. Ballbè M, Martínez-Sánchez JM, Sureda X, Fu M, et al. Cigarettes vs. e-cigarettes: Passive exposure at home measured by means of airborne marker and biomarkers. Environ Res. 2014;135C:76-80. doi:10.1016/j.envres.2014.09.005.
29. Barrington-Trimis JL, Samet JM, McConnell R. Flavorings in Electronic Cigarettes: An Unrecognized Respiratory Health Hazard? JAMA. 2014. doi:10.1001/jama.2014.14830. 30. Kreiss K, Gomaa A, Kullman G, Fedan K, Simoes EJ, Enright PL. Clinical bronchiolitis obliterans in workers at a microwave-popcorn plant. N Engl J Med. 2002;347(5):330-8. doi:10.1056/NEJMoa020300. 31. Gf K. Methodological Papers, Presentations, and articles on KnowledgePanel. 2014. Available at: Knowledge Networks, 2010, http:// www.knowledgenetworks .com/ganp/reviewer-info.html. Accessed April 4, 2014. 32. A 16-Year-Old Teen Suffered Second Degree Burns When an E-Cigarette Exploded in His Face. A 16-Year-Old Teen Suffered Second Degree Burns When an E-Cigarette Exploded in His Face. Yahoo Health. https://www.yahoo.com/health/16-old-teen-suffered-second-211900580.html. Published January 28, 2016. Accessed February 4, 2016. 33. Electronic Cigarette Fires and Explosions. Electronic Cigarette Fires and Explosions.; 2014. Available at: https://www.usfa.fema.gov/downloads/pdf/publications/electronic_cigarettes.pdf. 34. Maziak W. Harm reduction at the crossroads: the case of e-cigarettes. Am J Prev Med. 2014;47(4):505-7. doi:10.1016/j.amepre.2014.06.022. 35. McMillen RC, Gottlieb MA, Shaefer RM, Winickoff JP, Klein JD. Trends In Electronic Cigarette Use Among U.S. Adults: Use Is In-
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44. McGrath-Morrow SA, Hayashi M, Aherrera A, et al. The effects of electronic cigarette emissions on systemic cotinine levels, weight and postnatal lung growth in neonatal mice. PLoS One. 2015;10(2):e0118344. doi:10.1371/journal.pone.0118344. 45. Smith D, Aherrera A, Lopez A, et al. Adult Behavior in Male Mice Exposed to E-Cigarette Nicotine Vapors during Late Prenatal and Early Postnatal Life. PLoS One. 2015;10(9):e0137953. doi:10.1371/journal.pone.0137953. 46. Cobb NK, Byron MJ, Abrams D, Shields PG. Novel nicotine delivery systems and public health: the rise of the “e-cigarette”. Am J Public Health. 2010;100(12):2340-2. doi:10.2105/AJPH.2010.199281. 47. Cobb NK, Abrams DB. E-cigarette or drug-delivery device? Regulating novel nicotine products. N Engl J Med. 2011;365(3):193. doi:10.1056/NEJMp1105249. 48. Poisoning Calls About E-Cigarettes and Liquid Nicotine More Than Doubled in 2014 – FDA Must Act to Protect Kids. Poisoning Calls About E-Cigarettes and Liquid Nicotine More Than Doubled in 2014 – FDA Must Act to Protect Kids.; 2015. Available at: http://www.tobaccofreekids.org/press_releases/post/2015_01_13_poisoning. 49. Cameron JM, Howell DN, White JR, Andrenyak DM, Layton ME, Roll JM. Variable and potentially fatal amounts of nicotine in e-cigarette nicotine solutions. Tob Control. 2013. doi:10.1136/tobaccocontrol-2012-050604.
50. Trehy ML, Ye W, Hadwiger ME, Moore TW, et al. Analysis of Electronic Cigarette Cartridges, Refill Solutions, and Smoke for Nicotine and Nicotine Related Impurities. J Liq Chromatogr Rel Technol. 2011;34(14):1442-1458. doi:10.1080/10826076.2011.572213. 51. Williams M, Talbot P. Variability among electronic cigarettes in the pressure drop, airflow rate, and aerosol production. Nicotine Tob Res. 2011;13(12):1276-83. doi:10.1093/ntr/ntr164. 52. Cobb NK, Brookover J, Cobb CO. Forensic analysis of online marketing for electronic nicotine delivery systems. Tob Control. 2013. doi:10.1136/tobaccocontrol-2013-051185. 53. Eissenberg T. Electronic nicotine delivery devices: ineffective nicotine delivery and craving suppression after acute administration. Tob Control. 2010;19(1):87-8. doi:10.1136/tc.2009.033498. 54. Cheng T. Chemical evaluation of electronic cigarettes. Tob Control. 2014;23 Suppl 2:ii11-7. doi:10.1136/tobaccocontrol-2013-051482. 55. The Mississippi Poison Control Center. Reported exposure cases of e-cigarette ingestion. 2015. 56. King BA, Alam S, Promoff G, Arrazola R, Dube SR. Awareness and ever-use of electronic cigarettes among u.s. Adults, 2010-2011. Nicotine Tob Res. 2013;15(9):1623-7. doi:10.1093/ntr/ntt013. 57. McNeill A, Brose L, Calder R, Hitchman S, Hajek P, McRobbie H. E-cigarettes: an evidence update. A report commissioned by Public Health England; 2015. 58. E-cigarettes: Public Health Englandâ&#x20AC;&#x2122;s evidence-based confusion. Lancet. 2015;386:829. doi: http://dx.doi.org/10.1016/S01406736(15)00042-2. 59. McKee M, Capewell S. Evidence about electronic cigarettes: a foundation built on rock or sand? BMJ. 2015. doi:10.1136/bmj.h4863 . 60. DiFranza R. Sources of tobacco for youths in communities with strong enforcement of youth access laws. Tob Control. 2001;10(4):323-328. doi:10.1136/tc.10.4.323. 61. Ahmad S. Closing the youth access gap: the projected health benefits and cost savings of a national policy to raise the legal smoking age to 21 in the United States. Health Policy. 2005;75(1):74-84. doi:10.1016/j.healthpol.2005.02.004. 62. Kessel Schneider S, Buka SL, Dash K, Winickoff JP, Oâ&#x20AC;&#x2122;Donnell L. Community reductions in youth smoking after raising the minimum tobacco sales age to 21. Tob Control. 2015. doi:10.1136/tobaccocontrol-2014-052207. 63. Winickoff JP, McMillen R, Tanski S, Wilson K, Gottlieb M, Crane R. Public support for raising the age of sale for tobacco to 21 in the United States. Tob Control. 2015. doi:10.1136/tobaccocontrol-2014-052126. 1
2 64. Raising the age of sale for tobacco to 21. 2015. Available at: http://mstobaccodata.org/wp-content/uploads/2015/08/Age-of-Tobacco3 Sales-Factsheet.pdf. Accessed September, 2015. 4 65. Boonn A. State cigarette excise tax rates & rankings .; 2015. Available at: 5 https://www.tobaccofreekids.org/research/factsheets/pdf/0097. 6 pdf. Accessed September 3, 2015. 7
Author Information Project Coordinator, Social Science Research Center, Mississippi State University. Nell Valentine leads the Mississippi Youth Tobacco Survey and is the Co-Principal Investigator for the Tobacco Surveillance project for the Office of Tobacco Control of the Mississippi State Department of Health (Ms. Valentine). Data Management Coordinator, Mississippi Health Policy Research Center, Social Science Research Center, Mississippi State University. Emily McClelland performs analyses and manages various datasets and projects related to the prevalence of youth and adult tobacco use in Mississippi. These datasets and projects are surveillance services for the Office of Tobacco Control of the Mississippi State Department of Health (Ms. McClelland). Graduate Research Assistant, Social Science Research Center, Mississippi State University. Jessica Bryant performs analyses and works with various datasets and projects related to youth and adult tobacco use in Mississippi, including aiding with the administration of the Mississippi Youth Tobacco Survey (Ms. Bryant). Associate Professor, Department of Psychology & Associate Director, Social Science Research Center, Mississippi State University. Robert McMillen serves as the Principal Investigator for the Data Sets Project of the American Academy of Pediatrics Julius B. Richmond Center of Excellence and provides surveillance services for the Office of Tobacco Control of the Mississippi State Department of Health (Dr. McMillen). Corresponding Author: Robert McMillen, One Research Park, Suite 103, Starkville, MS, 39759 (rcm19@msstate.edu). Support for this article has been provided in part by the Office of Tobacco Control of the Mississippi State Department of Health. The information, views, and opinions contained herein are those of the authors and do not necessarily reflect the views and opinions of this organization. Acknowledgments: The authors would like to thank Malcolm Huell, Miranda Dempewolfe, and Schuyler Jones for the assistance with administering the Youth Tobacco Survey.
Journal of the Mississippi State M The University of Mississippi Medical Center Nephrology Division in Jackson, MS is seeking BC/BE two Nephrologists. Faculty candidates should submit a CV via fax to 601-984-5608. EOE, M/F/D/V.
66. Smoking out e-cigarette ad claims. Smoking out e-cigarette ad claims. 8 Smoking out e-cigarette ad claims. Available at: https://www.truthinad9 vertising.org/smoking-out-e-cigarette-ad-claims/. Accessed Septem10 ber 3, 2015.
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P A G E
Who is Right? One very special duty that I have enjoyed more than I initially thought has been speaking to the various component society meetings. I have literally traveled from Tupelo to Gulfport and a great many points in between. At the beginning of my term as your president, I saw this as an important duty mainly in being able to communicate the major advocacy issues that MSMA was working on behalf of the physicians of Mississippi. However, now that I have completed these visits, I have come to appreciate the importance of hearing directly from our members while I am on their home turf regarding the issues they are facing. I have been encouraged and challenged by the penetrating questions posed to me from around the state. I have developed a much better appreciation for how medicine in Mississippi looks and feels from different parts of the state. As I have shared at these meetings, after 25 years of full-time active practice in Vicksburg, I am a certified expert in being a doctor in west Mississippi. I am well versed in the challenges faced by physicians and their patients from the south Delta down to Claiborne and Jefferson Counties. I truly don’t think there is much more I can learn about the nuances of practicing medicine in my neck of the woods. However, I fully understand after making all of these visits that I cannot speak with authority on what practice life is like in the rest of Mississippi except as I have learned by listening to my colleagues from around the state. Medicine in the Delta is very different from Southwest Mississippi, which is different from Tupelo or Oxford, which is uniquely different from that in Jackson, Hattiesburg, Meridian, or the Gulf Coast. We are indeed a small state with less than 2.5 million residents but we have at least nine different medical regions of our state and they all face unique challenges in delivering the best healthcare possible, as they would like. I also have learned that the opinions of doctors in all of these various regions are quite different based on the challenges they are facing. I have learned that the opinion of our members regarding Medicaid expansion is quite varied. Doctors in the Delta, Southwest Mississippi, and other rural areas have voiced to me the need to provide some form of coverage for the uninsured in their areas while doctors in Jackson, on the Gulf Coast, and other more metropolitan areas are very wary of further government intrusion into their practice lives. Which opinion is correct and what should MSMA do regarding this critical issue? Therein lies the dilemma. Both opinions are valid and important and deserve due deliberation. The leadership of MSMA must listen to all viewpoints and weigh all of the issues discussed in order to lead the association in developing and advocating a policy that benefits the doctors and patients all over this state. There are many issues that unite our members such as fighting to maintain our strong laws regarding school age vaccinations or preserving and promoting the role of the physician as the head of the healthcare team, and MSMA excels in advancing these issues. However, the only way for us to move forward in developing and promoting healthcare policy on issues where there is a diversity of opinion is to be the leaders our profession demands. We must all be willing to subordinate our individual desires and be willing to listen thoughtfully to the opinions and positions of our colleagues from other areas of the state who are facing very different challenges from our own. We must be willing to consider, at least for a moment, that our opinion may not be the best one for the entire profession. We must be willing to listen to our colleagues every bit as much as we listen to our patients and be willing to sacrifice our own interests for those of the greater good of medicine when indicated. In order to do this we must all stay engaged. We need to stay informed by every means possible, and we need to come together when possible. That includes talking to each other about key professional issues in our clinics, doctor’s lounges, component and specialty society meetings, and very importantly coming together as the House of Medicine at the MSMA Annual Session. Annual Session is where we as physicians from different practices, races, genders, specialties, and political affiliation from all over Mississippi discuss, deliberate, debate, and finally decide what the best positions for our MSMA to take are. Once we do this, we must come together on those issues where professional unity is critical, irrespective of our individual agenda, to strengthen our profession. Developing consensus and a unified voice is a very difficult challenge for our MSMA but since when have we physicians not faced difficult challenges? What I have learned in my varied travels this year is that we as “the physicians who care for Mississippi” are more than equal to that challenge.n
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School of Medicine Reunions August 26 & 27, 2016
Honoring Classes of
1966, 1971, 1976, 1986, 1991, 1996, 2006
Make plans now to attend!
Registration will be available in June. Hotel information and event updates are available now on umc.edu/alumni. Questions? Concerns? Please contact us at 601-984-1115 / 800-844-5800 or alumni@umc.edu
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
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Kudos for the Center of Telemedicine
I
was recently fortunate to visit the University of Mississippi Medical Center’s (UMMC) Center for Telehealth. Administrator Michael Adcock gave me a thorough tour and interview, explaining, in detail, the various aspects of the program. It was an astonishing experience.
Heddy-Dale Matthias, MD Madison
I knew little about the Center, other than a few articles I had seen in local papers. I work for a telemedicine company myself and was curious about the program at UMMC. Additionally, the Mississippi Legislature was debating the Telemedicine bill at the time. Unlike many practicing physicians in the state, I am a hospital-based physician without a clinic. For better or worse, the daily difficulties of running a clinic, especially in a rural area of this state, do not constitute my life.
However, I encounter many rural patients, especially in my anesthesia practice at the Jackson Eye Institute with Dr. James Bruce, performing cataract surgeries. For over twenty years, I have been very frustrated in dealing with the many medical problems of this elderly population, many of whom are poor African Americans with a myriad of the usual problems of poorly-controlled hypertension, diabetes, renal disease, and cardiovascular disease. The poor control of these problems has led me to many over-the-phone conversations with the patients’ primary and specialty-care physicians. Diabetes control and education are the most difficult problems which, I suspect, comes as no surprise to my colleagues. That’s why I was especially interested and impressed with UMMC’s Telehealth Center’s programs in diabetes, cardiovascular care, dermatology, and mental health. The Telehealth Center’s diabetes program, which has already demonstrated its ability to save millions of dollars in healthcare costs, enrolls diabetic patients at the request of their PCP. After this request is made, the patients are given a HIPAA-compliant tablet and record their blood sugars. The patients are then followed on a daily and monthly basis by a team of diabetic nurses. In turn, these nurses call or video the patients when problems appear, coach the patients, and call the PCP with their findings and discuss problems, recommendations, and solutions. The Center also runs the same types of programs with tablets and electronic scales that can follow premature neonates as they return home to distant areas with the same offerings of nurse monitoring and consultations with ultimate reporting to the patients’ physicians. The Center has elaborate video-conferencing directly in many rural emergency rooms, providing real-time patient assessments by on-call physicians and immediate recommendations for the treatment of stroke, myocardial infarction, and other acute illnesses that a rural hospital might not treat on a routine basis, offering state-of-the-art medical care to these areas. In the emergency rooms, the Center has placed (“free of cost”) teleportals that allow video-conferencing, transmission of heart sounds, faceto-face videos of patients and providers. This direct face-to-face is vitally important as we physicians know “a picture is worth a thousand words.” The ability of face-to-face audiovisual transmission became a significant issue in this year’s legislative battle, with the insistence of the Mississippi Board of Medical Licensure (MSBML) and MSMA that audiovisual (not audio only) medical care was the sine qua non of the standard for licensing of a telemedicine company in the state. Mr. Adcock, who has many years’ experience as a pediatric critical care nurse, hospital administrator, telemedicine administrator and innovator, was gracious in demonstrating other important programs available to any requesting Mississippi physician. Imagine that a PCP wishes to have his cardiac patients seen and interviewed once a month by a cardiologist and that his/her recommendations and assessments can be discussed directly with the PCP. Imagine the same convenience for a PCP by having his/her patients with worrisome skin lesions seen via video-conferencing by a dermatologist. The Center can set up these programs in the PCPs office, avoiding long travel and wait times for patients. The Center can also provide off-site “hospitalist” services to small hospitals unable to afford their own in-house physicians, thereby offering care in a cost-effective manner to rural hospitals and patients in real time.
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The Center has an in-house staff of highly-trained and experienced critical care nurses who spend 8-10 hours a shift monitoring multiple patients in UMMC’s many critical care units. They use highly advanced and technical software programs that allow monitoring of critical events and trends and oversight of these patients, trends and events that might have been overlooked by their primary physician and nurse, allowing early interventions and solutions. Mr. Adcock was clear in the Center’s mission: to provide advanced, convenient, cost-effective medical care, monitoring, and consultation to areas of Mississippi that are underserved in order to improve the overall health of the state. He was adamant that the Center was not interested in obtaining new patients for UMMC or siphoning patients from PCPs in the state. Rather, he assured me that UMMC wished to help provide PCPs/specialists and their patients the most convenient, cost-effective, and “best practices” medicine no matter where they worked, lived, or practiced. The Center has some “for-profit” services in order to sustain the “not-for-profit” aspect of its other programs. They supply video-conferencing portals for private corporations in and out of Mississippi for out-patient services. They comply with the face-to-face requirements suggested by the Legislature, MSBML, and MSMA. I admit that prior to my visit I was skeptical of the Center for Telemedicine. I, as I suspect many other physicians, thought it might be a political organization bent on a mission of consolidating UMMC’s control of medical services in the state. However, Mr. Adcock’s detailed interview assured me that this is not the case; rather, it is providing the best of what a university medical center can offer a community: a cost-effective, convenient, state-of-the-art program to extend medical expertise to any requesting physician in Mississippi and Mississippi’s citizens. I suggest that my colleagues learn more about the Center, avail themselves of its services for themselves and their patients, and ask them how they can help. The future possibilities are unlimited in what the Center can do to improve healthcare for the state. Kudos to the Center for Telemedicine! Author Information: Heddy-Dale Matthias, MD is an anesthesiologist in Jackson and a member of the Journal MSMA Editorial Advisory Board.
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State-of-the-Art Thompson Public Health Laboratory Now Open for Business
T
he Mississippi State Department of Health (MSDH) held a ribbon-cutting in April for the Dr. F.E. “Ed” Thompson, Jr. State Public Health Laboratory on its central office campus in Jackson. Construction began on the $36 million laboratory in 2010. The 80,000 square foot facility provides state-of-the-art lab space that now allows the agency to more efficiently monitor and respond to public health threats. The MSDH laboratory’s 85-member staff moved into the facility in January 2016. “This new facility gives Mississippi the capacity to prepare and respond to all types of public health emergencies and to test for numerous diseases,” said MSDH State Health Officer Dr. Mary Currier. “Our previous lab was built in 1959 and was no longer adequate to support the technology used today to protect our citizens from disease outbreaks, harmful environmental contaminants, and emerging health threats.” The MSDH laboratory has assisted health authorities in the prevention and control of public health threats in Mississippi since 1917. As the state’s only public health laboratory, the facility serves the citizens of Mississippi by performing more than 175 different tests on the more than 600,000 samples received each year. The facility routinely performs a wide range of tests that detect biological, toxicological, chemical, and radiological threats to the health of the population including testing for Zika virus in recent travelers, rabies in animals, Salmonella or E.coli in food, and contaminants in drinking water. The laboratory also has capabilities to respond rapidly to public health emergencies such as novel strains of flu, suspicious substances containing anthrax or ricin, and unusual events like widespread flooding or hurricanes. “This sophisticated, 21st century lab was a dream for Dr. Thompson,” said State Board of Health Chairman Dr. Luke Lampton. “He was a true public health champion in every sense and was incredibly instrumental in getting this project off the ground. I am certain Dr. Thompson would be especially pleased with the final result.” Unlike the former facility, the Thompson lab meets the national standards established for laboratories that work with highly infectious substances. The laboratory is equipped with more than 3,000 square feet of Biosafety Level 3 containment areas, which allow the laboratory staff to work safely with highly infectious agents such as multi-drug resistant tuberculosis or newly emerging pathogens such as Ebola. n 194 VOL. 57 • NO. 6 • 2016
We’re proud to say
BLUE that we’re
Blue Distinction+ is the new standard for demonstrating quality care in hip and knee surgery programs.
Rush Foundation Hospital is the first and only hospital in our region to achieve this distinction.
The Knee and Hip Replacement Programs at Rush Foundation Hospital have been designated as a Blue Distinction Center+ (BDC+) by Blue Cross & Blue Shield of Mississippi. Blue Distinction Specialty Care is a national designation program recognizing healthcare facilities that demonstrate expertise in delivering quality specialty care – safely, effectively, and cost efficiently. The goal of the program is to help consumers find both quality and value for their specialty care needs, while encouraging healthcare professionals to improve the overall quality and delivery of care nationwide and providing a credible foundation for local Blue Plans to design benefits tailored to meet employers’ own quality and cost objectives.
What does BLUE mean to our patients? It means that the physicians and staff at Rush Foundation Hospital are working to provide our patients with: • Expertise in delivering quality specialty care; • Quality measures focused on improved patient health and safety; • Cost-efficiency in delivery of quality care.
Thanks to the four skilled, experienced orthopaedic surgeons and the multi-disciplinary, expert team of caregivers comprising Rush Foundation Hospital’s Hip and Knee Replacement programs, we are BLUE – and that’s a great thing for our patients!
Irvin Martin, M.D.
David Pomierski, M.D.
Gus A. (Sonny) Rush, III, M.D.
James R. Watson, M.D.
Knee & Hip Replacement
Blue Distinction Centers (BDC) met overall quality measures for patient safety and outcomes, developed with input from the medical community. A Local Blue Plan may require additional criteria for facilities located in its own service area; for details, contact your Local Blue Plan. Blue Distinction Centers+ (BDC+) also met cost measures that address consumers’ need for affordable healthcare. Each facility’s cost of care is evaluated using data from its Local Blue Plan. Facilities in CA, ID, NY, PA, and WA may lie in two Local Blue Plans’ areas, resulting in two evaluations for cost of care; and their own Local Blue Plans decide whether one or both cost of care evaluation(s) must meet BDC+ national criteria. National criteria for BDC and BDC+ are displayed on www.bcbs.com. Individual outcomes may vary. For details on a provider’s in-network status or your own policy’s coverage, contact your Local Blue Plan and ask your provider before making an appointment. Neither Blue Cross and Blue Shield Association nor any Blue Plans are responsible for non-covered charges or other losses or damages resulting from Blue Distinction or other provider finder information or care received from Blue Distinction or other providers.
Visit rushhealthsystems.org for more information.
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Jeff D. Almand, MD; Trevor R. Pickering, MD; Brian P. Johnson, completed his medical degree from the University of Mississippi MD; Robert. K. Mehrle, Jr., MD and Walter R. Shelton, MD at School of Medicine in Jackson, and his general surgery residency at Mississippi Sports Medicine and Orthopaedic Center (MSMOC) the University of Mississippi Medical Center. Dr. Cauthen joins the are pleased to announce their partnership with Blue Cross & Blue team of specialists at the NMMC Bariatric Center that has helped Shield of Mississippi (BCBSMS) as the first and only surgical clinic hundreds of patients lose tons of weight since 2007. Insurance in the state to perform total knee and hip replacement surgery in an covers weight loss surgery for most patients, including teachers and outpatient ambulatory setting. BCBSMS has also recognized the state employees. Open since 2007, NMMC’s Bariatric Center is center’s facility, Madison Outpatient Surgery Center, as the state’s accredited as a Comprehensive Center by the Metabolic and Bariatric only outpatient Orthopaedic Center of Excellence. Surgery Accreditation and Quality Improvement Program. For more Traditionally, total hip and knee replacement surgeries have information, visit www.nmhs.net/bariatric_center or call (662) 377been performed in an inpatient (hospital) setting. Due to clinical SLIM(7546) or 1-866-908-9465. advancements MSMOC has perfected over time in the hospital setting, their Network Surgeons are now able to deliver an optimal experience for qualified patients in the ambulatory outpatient setting. Performing knee and hip procedures in the ambulatory outpatient setting is more cost effective and allows the patient to have surgery and begin recovery at home all within the same day. In addition to improving patient experience, BCBSMS and MSMOC are moving beyond traditional fee-for-service payment models to a value-based, episode of care payment model that puts the focus on the patient and the quality of care provided. The value-based payment model (bundled billing) provides a single payment to MSMOC for Reminder: 2016 PQRS GPRO Registration Open all services rendered to the patient for orthopaedic through June 30, 2016 services, including anesthesia and physical therapy, Groups of two or more Eligible Professionals (EPs) can avoid the -2.0% CY 2018 Physician and is tied to quality outcomes and cost-effective Quality Reporting System (PQRS) payment adjustment by meeting the satisfactory care. Many patients may qualify for an additional reporting criteria through the 2016 PQRS Group Reporting Option (GPRO). The Physician benefit of a reduced deductible and co-insurance by Value - PQRS (PV-PQRS) Registration System is now open through June 30 for groups to select a GPRO reporting mechanism: selecting outpatient surgery at Madison Outpatient Surgery Center. Will Cauthen, MD, general surgeon, has joined the medical staff of North Mississippi Medical Center’s Bariatric Center. He joins Terry Pinson, MD, and Vivian Rogers, DNP, NP-C, at the Bariatric Center. Dr. Cauthen has been practicing with Surgery Clinic of Tupelo and on staff at North Mississippi Medical Center in Tupelo since 2014. In addition, he is serving a three-year appointment as cancer liaison physician for NMMC Cancer Care. He earned a bachelor’s degree in biological science from Mississippi State University in Starkville. He 196 VOL. 57 • NO. 6 • 2016
Qualified PQRS Registry Electronic Health Record (EHR) via Direct EHR using certified EHR technology (CEHRT) or CEHRT via Data Submission Vendor Web Interface (for groups with 25 or more EPs only) Qualified Clinical Data Registry (QCDR) Consumer Assessment of Health Providers and Systems (CAHPS) for PQRS Survey via a CMS-certified Survey Vendor (as a supplement to another GPRO reporting mechanism)
Avoiding the CY 2018 PQRS payment adjustment by satisfactorily reporting via a PQRS GPRO is one of the ways groups can avoid the automatic downward payment adjustment under the Value Modifier (-2.0% or -4.0% depending on the size and composition of the group) and qualify for adjustments based on performance in CY 2018. Alternatively, groups that choose not to report via the PQRS GPRO in 2016 must ensure that the EPs in the group participate in the PQRS as individuals in 2016 and at least 50 percent of the EPs meet the criteria to avoid the CY 2018 PQRS payment adjustment. For More Information:
2016 PQRS GPRO Registration Guide PQRS GPRO Registration PQRS Payment Adjustment Information CAHPS for PQRS Made Simple
Information & Quality Healthcare 385 B Highland Colony Parkway, Suite 504, Ridgeland, MS 39157
Dr. Viswanath “Vishwa” Gajula, MD, assistant professor of pediatric critical care at the University of Mississippi Medical Center (UMMC), is caring for seriously ill pediatric patients at the North Mississippi Medical Center Women’s Hospital. Since January UMMC has been providing pediatric hospitalist services in Tupelo 24 hours daily. The pediatric hospitalist consults with pediatric patients in the Emergency Department and provides hospital care for children on the Pediatrics unit. Dr. Gajula works with pediatric hospitalist Dr. Jana Sperka. Dr. Gajula holds a master’s degree in environmental health management at the University of Findlay in Ohio, degrees in medicine and surgery from Gandhi Medical College and Hospital/NTR University of Health Sciences in Hyderabad, India, and degrees in biology and physics from Sri Chaitanya University in Vijayawada, India. A pediatric critical care fellow at Children’s Hospital of Michigan/ Wayne State University School of Medicine, Dr. Gajula did his pediatric residency at Michigan State University-Kalamazoo Center for Medical Studies. His areas of specialty are hospitalist medicine, pediatric critical care, and emergency care. Experienced as a researcher and principal investigator in pediatrics, Gajula is a member of the Society of Critical Care Medicine, the American Academy of Pediatrics, the Educational Commission of Foreign Medical Graduates, the Medical Council of India, and Andhra Pradesh State Medical Council of India. William (Bill) Pontius, MD recently visited the radiology department at Biloxi Regional, from where he retired (now Merit Hospital). The department has held a permanent exhibit of his photography for years. Dr. Pontius and his wife, MSMA Alliance Past President Mollie Pontius, were surprised to see Merit reframed his collection and placed the photographs as a grouping to brighten the radiology registration area. Mollie notes Bill became an octogenarian last month. Woody Sistrunk, MD of Jackson Thyroid & Endocrine Clinic has been asked to serve a three year term on the Rare Tumors Task Force of the Head & Neck Cancer Steering Committee for the National Cancer Institute, Bethesda, Maryland. Dr. Sistrunk’s practice, Jackson Thyroid & Endocrine Clinic, is one of very few thyroid-only endocrine practices in the country.
With the continued increased incidence of thyroid nodules and specifically thyroid cancer, the practice focuses on the evaluation of thyroid nodules including an on-site CLIA certified lab, physicianperformed ECNU certified, AIUM accredited thyroid ultrasound lab with FNA biopsy, and physician performed, thyroid-specific ICANL accredited nuclear medicine lab. Long term surveillance of patients with thyroid cancer has become the largest part of Dr. Sistrunk’s practice. As a part of this task force, Dr. Sistrunk will give input in the development of phase 2/3 trials, help refine ideas for specific thyroid cancer trials, and give input for clinical trial planning meetings. J. Martin Tucker, MD of Jackson was elected secretary of the American Congress of Obstetricians and Gynecologists (ACOG) assuming office at their May meeting. Dr. Tucker received his undergraduate, medical, and residency training at the University of Mississippi. He completed his MFM fellowship at the University of Alabama at Birmingham. He has been in private practice with Jackson Healthcare for Women since 1990. He is affiliate faculty at the University of Mississippi (MS) School of Medicine. Dr. Tucker has served as Chief of Staff of Woman’s Hospital and Medical Director of Obstetrical Services at St. Dominic Hospital in Jackson, MS. He is a past president of the Winfred Wiser Society, the Jackson Gynecologic Society, and the UM Medical Alumni Chapter. He has chaired the MS Infant Mortality Task Force and the MS State Medical Association Council on Legislation. He is currently a member of the steering committee of the MS Perinatal Quality Collaborative. After serving as Secretary-Treasurer, Vice Chair, and Chair of the MS Section, Dr. Tucker was Secretary, Vice Chair, and Chair of ACOG District VII. He is Immediate Past Chair of the Council of District Chairs. Dr. Tucker has served on numerous ACOG Committees at the section, district, and national levels, chairing several of those committees. He was a member of the AMA CPT Editorial Panel and a McCain Fellow. LouAnn Woodward, MD, vice chancellor for health affairs and dean of the School of Medicine at the University of Mississippi Medical Center, is on track to direct the organization setting medical education standards across the United States and Canada. On July 1, she becomes chair-elect of the Liaison Committee on Medical Education (LCME) for 12 months before taking over as chair of the accrediting body in July 2017 for a oneyear term. JOURNAL MSMA
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Dr. Woodward was appointed in 2013 to a three-year membership to the LCME and was reappointed this year. She has served on its executive committee and chairs its subcommittee on International Relations. Sponsored by the Association of American Medical Colleges and the American Medical Association, the LCME establishes benchmarks for U.S.- and Canadian-chartered medical education programs operated by universities or medical schools. “Across the country, there are many changes in the way we teach medicine and in the profession itself,” Dr. Woodward said. “It’s an exciting time to be involved in medical school accreditation. I’m honored to receive this opportunity and humbled that my colleagues have confidence in me to take it on.” The U.S. Department of Education recognizes the LCME for its role in accrediting medical degree education programs in the United States. Established in 1942, the agency is also acknowledged by the World Federation for Medical Education. Most state boards of licensure require that medical schools earn accreditation from the LCME, signifying that they meet national standards for the awarding of an M.D.
Dr. Woodward serves as one of 18 members of the LCME, currently chaired by Dr. John Fogarty, professor and dean of the Florida State University College of Medicine in Tallahassee. “LouAnn has done a great job in her time on the board, reviewing and making recommendations on some of our most difficult cases that come before our committee,” Fogarty said. “We were very pleased that she accepted our invitation to run for chair-elect, and she was confirmed unanimously by our board.” Dr. Woodward, also a professor of emergency medicine, is a native Mississippian. She earned her undergraduate degree from Mississippi State University and received her medical education at UMMC, where she also completed her residency training. She served for several years as associate vice chancellor for health affairs and vice dean of the medical school under her predecessor, Dr. James Keeton. During Dr. Woodward’s year of service as chair, the LCME will observe its 75th anniversary. “The LCME is a well-respected organization in setting the standards for medical education,” Woodward said. “I feel fortunate to be in a leadership role as we celebrate this important milestone in its history.” n
The JMSMA encourages members to submit news of personal awards, accomplishments, and promotions with photos of MSMA members for inclusion in the Personals column of our Journal. Email to KEvers@MSMAonline.com. —Ed.
CME with Mickey Mouse
November 19-22, 2016
Walt Disney World®
Earn up to 10 CME credits at the happiest place on earth with MSMA! For registration, housing reservations and more information, visit: www.MSMAonline.com/CMEDisney. DISNEY PROPERTIES/ ARTWORK: © DISNEY 198 VOL. 57 • NO. 6 • 2016
2016 Component Society Meetings
JULY 12 North MIssissippi Medical Society
(location TBA)
AUGUST 4 South Mississippi Medical Society at Cotton Blues 12-13 Annual Session at the Hilton Hotel in Jackson
SEPTEMBER
OCTOBER
1 Northeast Mississippi Medical Society
4 Central Medical Society at River Hills
13 Prairie Medical Society at Old Waverly 13 South Central Medical Society at
12 Delta Medical Society (location TBA)
at Tupelo Country Club
Country Club
Fernwood Country Club
Dates and locations to be announced: Singing River Medical Society North Central Medical Society Coast Counties Medical Society
Homochitto Valley Medical Society
East Mississippi Medical Society
Delta Medical Society
Clarksdale & 6 Counties Medical Society Please check www.MSMAonline.com for updates on meeting dates and times. JOURNAL MSMA
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The JMSMA encourages families, friends, and our readers to submit obituaries and photos of Mississippi physicians for inclusion in the pages of our Journal. Email to KEvers@MSMAonline.com or slow mail to JMSMA.—ED. William Ray Callender, Jr., MD, of Bogue Chitto, died Saturday, April 23, 2016, at King’s Daughters Medical Center. He was born March 29, 1951. He served in the United States Air Force from 1980 to 1988, where he received the Merit Medal of Honor. He was a family practice doctor at Southwest Mississippi Regional Medical Center.
Whitman B. Johnson, Jr., MD, of Clarksdale, died on March 4, 2016, while surrounded by his family and several colleagues, following a short illness. Whit was born on December 2, 1928, in the Clarksdale Hospital, which he ultimately purchased many years later as the office from which he practiced. After graduating from Clarksdale High School, he attended college and the first two years of medical school at the University of Mississippi in Oxford. He finished his medical education at the University of Pennsylvania in Philadelphia, following which he did a five-year surgical residency in Memphis, TN. He returned to the hometown he loved and began practicing medicine at Baptist Hospital on July 1, 1960. He practiced many years as a surgeon and then in his later life as a family practice physician, working all the way up until the day before he entered the hospital for his final illness. Dr. Johnson was a well-respected as a physician on the local, state, and national level. He was a member of the American College of Surgeons and served as the President of the Mississippi State Medical Association in 1983-84. Glenn Allen McCrory, MD, of Madison, died May 6, 2016. ,A native of Jackson, Dr. McCrory received his premed degree from Delta State University, earned his medical degree from the University of Mississippi and served his residency in Obstetrics and Gynecology at Tulane University. Following in his father’s footsteps, Dr. McCrory became an OB-GYN and began practice at Women’s Health Associates in April 2002.
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Norman C. Nelson, MD, of Brandon, who led the University of Mississippi Medical Center during 21 years of its most dynamic growth, died at his home on April 21, 2016. He was 86. Dr. Nelson began his career in academic medicine at Louisiana State University Medical Center in New Orleans, LA, rising through the ranks to become medical school dean. He came to Mississippi’s health sciences campus in 1973 as vice chancellor for health affairs and dean of the School of Medicine. At the beginning of his remarkable tenure, the Medical Center consisted of two health professional schools, a teaching hospital, and a small research program. When he retired in 1994, he had transformed the institution into a nationally respected health sciences campus with four health professional schools, a major teaching hospital, a robust research program - and the largest, funded physical plant expansion package in the state’s educational history. That package of eight new buildings, added to the 10 authorized and constructed during his tenure, essentially gave the Medical Center a new physical plant. Dr. Nelson first came to Mississippi at five when his father, an attorney, bought the National Park Hotel in Vicksburg. His family also lived briefly in Biloxi before moving to Houston, Texas, where he completed primary and secondary school. From Texas, he went to Tulane University in New Orleans, where he earned his BS in 1951 and the MD in 1954 and was tapped for membership in the academic honor societies of Sigma XI, Phi Kappa Phi, and Alpha Omega Alpha. He interned at Charity Hospital of New Orleans, then spent a year in private practice before serving from 1956 - 1958 on active duty as a Captain in the Medical Corps, USAR 101st Airborne Division. He took his residency in general surgery at Charity Hospital from 1958-1962, then held a US Public Health Fellowship at Harvard and Massachusetts General Hospital as a clinical research fellow from 1962-1963. He joined the LSU surgery faculty in 1963, became the medical school’s associate dean in 1969 and dean in 1971. From 1965-1970, Dr. Nelson held a prestigious John and Mary R. Markle Fellowship, one of the most coveted honors in academic medicine. Among his other recognitions were the 1969 Arthur M. Shipley Award from the Southern Surgical Association; eight awards for teaching excellence during his years at LSU; the 1985 (and first) Herman Glazier Award as the Outstanding Public Administrator from the Mississippi Chapter of the American Society for Public Administrators; the 1989 Outstanding Alumnus Award from the Tulane School of Medicine; and a 2013 Hall of Fame election by the Medical Alumni Chapter of the University of Mississippi Alumni Association.
But no honor meant more to Dr. Nelson than the designation of the student union at the Medical Center in his name. He frequently told his faculty and staff that the “only reason we have a job is because of our students” because the institution’s principal mission is “to train health professionals for Mississippi.” Isaac “Ike” Alton Newton, Jr., MD, 83, of Greenville died on March 8, 2016. Born in Bolton, his family moved to Fayette in 1941 where Dr. Newton graduated from high school. He entered Millsaps College in 1949 and transferred to the University of Mississippi where he graduated. In 1953 he entered medical school at the University of Mississippi which at that time only offered two years of medical training. Dr. Newton continued his training at the University of Tennessee Medical School in Memphis and graduated from there in 1955. He completed his internship at John Gaston Hospital in Memphis, Tennessee. In 1962 he fulfilled his residency in Internal Medicine which had been interrupted by serving as a Captain in the United States Air Force. Dr. Newton was stationed at the 6038th Military Hospital in Misawa, Japan where he served as Chief of Internal Medicine. At John Gaston Hospital he completed fellowships in both Gastroenterology and Cardiology. Dr. Newton moved to Greenville in 1963 to practice at the Gamble Brothers and Archer Clinic. In 1969 he went into private practice. He served as Chief of Medicine at both The King’s Daughters Hospital and Delta Regional Hospital and was Chief of Staff at the King’s Daughters Hospital. He was a member of the Delta Medical Society, the MSMA, and the AMA. Dr. Newton retired from active practice on April 1, 2004.
Carl Chapman Welch, MD of Corinth died on April 3, 2016, in Memphis, TN. Born December 2, 1931, in Raymond, he began his career in journalism and later he became general manager of radio station WHSY in Hattiesburg and was also involved in ownership of a station in Corinth. Welch interrupted his career in radio to join the U.S. Army, where he served for two years and then attended Hinds Community College in Raymond. After completing his courses, Welch began pursuing a life-long dream to become a medical doctor. He enrolled as a part-time student at Little Rock University where he fulfilled educational prerequisite requirements and was immediately accepted into the University of Arkansas for Medical Sciences. He graduated with Honors (Alpha Omega Alpha) in 1968 and then completed a three-year residency in Anatomical and Clinical Pathology. He then moved his family back to Corinth to become director of laboratories at Magnolia Regional Health Center and the Tishomingo County Hospital in Iuka. In 1975, Welch began his private practice in family medicine through which he lovingly and unselfishly served the community of North Mississippi until 2015, at which time he continued to work as the medical director for five local programs including the hospice program for Magnolia Regional Health Center, Whitfield Nursing Home, Alcorn County Regional Correctional Facility, and Alcorn County Jail and Region IV Crisis Center. n
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This is part of a spotlight series on the MSMA Physician Leadership Academy class of 2016.
Chasity Torrence, MD
Dr.
Chasity Torrence is a life-long Mississippian with unwavering dedication to her community and state, but most importantly, to the patients who occupy it. Growing up on a small horse farm and competing in rodeo events, patience and compassion toward all creatures were instilled in Dr. Torrence throughout her childhood as she aspired to become a veterinarian. As high school came to a close, she decided to direct her compassion toward serving people and perused a career in medicine. Dr. Torrence’s interest in psychiatry originated during her third year of medical school at UMMC. As she participated in a psychiatry inpatient clerkship, she discovered a passion for helping the very special patient population she encountered. Now in her fourth year of residency in general psychiatry, the patients she sees daily are the source of her inspiration. “Because I truly enjoy and love what I do, I do not feel like I am actually working. Psychiatry is such as vast field entailing cutting edge neuroscience research, psychopharmacology, somatic treatments, forensics, and addiction medicine. The opportunities are endless, and the research is vast,” Dr. Torrence explains. “Even last week, I told several medical students, ‘There is your miracle,’ as a patient made a remarkable 360 degree improvement. Psychiatry provides an opportunity that is more than prescribing medications; it combines compassion with medicine and allows the physician to establish an ongoing therapeutic relationship.” Even at such an early stage in her career, Dr. Torrence has plenty of achievements of which to be proud. She is an active advocate for medicine, psychiatry, and patients on both state and national levels. She has served as an MSMA Doctor of the Day at the Mississippi State Capitol and met with US Senator Thad Cochran and Senator Roger Wicker at the United States Capitol to advocate on behalf of mentally ill patients as a member of the American Psychiatric Association. She was the recipient of the Junior Resident of the Year Award during her first year of residency at UMMC and the Gold Humanism Excellence in Teaching Award during her second year. Most recently, she received the 2015 Quality Care Recognition for House Staff in Psychiatry Award at the G.V. Sonny Montgomery VA Medical Center and the 2015 Nina Moffitt MD Award from the University of Mississippi Medical Center. “However,” Dr. Torrence insists, “the most significant honor that I have obtained as a physician is being blessed with the opportunity to help and treat so many people in my community and surrounding areas.” As of July 2016, Dr. Torrence will be practicing as a full-time psychiatrist at the Mississippi State Hospital in Whitfield and as an assistant professor at the Behavioral Specialty Outpatient Clinics with the Department of Psychiatry at the University of Mississippi Medical Center. n
202 VOL. 57 • NO. 6 • 2016
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148TH ANNUAL SESSION OF THE HOUSE OF DELEGATES Featuring: • The inauguration of President-Elect Lee Voulters, MD • Guest speaker Andrew W. Gurman, MD, President-Elect of the American Medical Association • CME sessions both mornings
August 12−13, 2016 The Hilton Hotel
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