March 2011 JMSMA by Journal MSMA

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VOL. LII

2011

No. 3

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The Physicians Who Care for Mississippi

Lucius M. Lampton, MD EDITOR D. Stanley Hartness, MD Richard D. deShazo, MD ASSOCIATE EDITORS Karen A. Evers MANAGING EDITOR PUBLICATIONS COMMITTEE Dwalia S. South, MD Chair Philip T. Merideth, MD, JD Martin M. Pomphrey, MD Leslie E. England, MD, Ex-Officio Myron W. Lockey, MD, Ex-Officio and the Editors THE ASSOCIATION Tim J. Alford, MD President Thomas E. Joiner, MD President-Elect J. Clay Hays, Jr., MD Secretary-Treasurer Lee Giffin, MD Speaker Geri Lee Weiland, MD Vice Speaker Charmain Kanosky Executive Director JOURNAL OF THE MISSISSIPPI STATE MEDICAL ASSOCIATION (ISSN 0026-6396) is owned and published monthly by the Mississippi State Medical Association, founded 1856, located at 408 West Parkway Place, Ridgeland, Mississippi 39158-2548. (ISSN# 0026-6396 as mandated by section E211.10, Domestic Mail Manual). Periodicals postage paid at Jackson, MS and at additional mailing offices. CORRESPONDENCE: JOURNAL MSMA, Managing Editor, Karen A. Evers, P.O. Box 2548, Ridgeland, MS 39158-2548, Ph.: (601) 853-6733, Fax: (601)853-6746, www.MSMAonline.com. SUBSCRIPTION RATE: $83.00 per annum; $96.00 per annum for foreign subscriptions; $7.00 per copy, $10.00 per foreign copy, as available. ADVERTISING RATES: furnished on request. Cristen Hemmins, Hemmins Hall, Inc. Advertising, P.O. Box 1112, Oxford, Mississippi 38655, Ph: (662) 236-1700, Fax: (662) 236-7011, email: cristenh@watervalley.net POSTMASTER: send address changes to Journal of the Mississippi State Medical Association, P.O. Box 2548, Ridgeland, MS 391582548. The views expressed in this publication reflect the opinions of the authors and do not necessarily state the opinions or policies of the Mississippi State Medical Association. Copyright© 2011 Mississippi State Medical Association

MARCH 2011

SCIENTIFIC ARTICLES

VOLUME 52

NUMBER 3

Mississippi, America’s Most Obese State: How Can We Salvage Her Future?

Stephen D. Sudderth, MD, FACS

Treatment of Bacterial Vaginosis Does Not Reduce Preterm Birth 72 Among High-Risk Asymptomatic Women in Fetal Fibronectin Positive Patients

Christian M. Briery, MD; Suneet P. Chauhan, MD; Everett F. Magann, MD; Julie L. Cushman, RN and John C. Morrison, MD

Clinical Problem-solving: If Roosevelt Only Knew

Jeffrey Domingo Jarin, MD

PRESIDENT’S PAGE

Physicians Must Lead

Tim J. Alford, MD, MSMA President

EDITORIAL

Preventing Falls in the Hospital: How Mississippi Physicians Can Reduce This Too Common “Never” Occurrence

Steve Mack, M3, Tulane School of Medicine

RELATED ORGANIZATIONS

Mississippi State Department of Health Mississippi State Medical Association

79 94

DEPARTMENTS

Letters Physicians’ Bookshelf Images in Mississippi Medicine Poetry and Medicine The Uncommon Thread Placement/Classified

91 93 96 98 99 100

ABOUT THE COVER:

Sparrows’ Nest — C. Ron Cannon, MD photographed this bird’s nest he found on his wife’s old potting bench under their patio. The eggs are of the house sparrow species (Passer domesticus). This nest, constructed of grass from the backyard and some old plastic lying on the bench, is typical of sparrow nesting described as five or six white eggs, lightly speckled with brown, in a loose mass of grass, feathers, strips of paper, string, and similar debris placed in a manmade or natural cavity. Formerly called English sparrow, the house sparrow was purposefully introduced to the U.S. to control caterpillars. Research indicates the entire North American population of the house sparrow is descended from a few birds released in New York City’s Central Park in the 1850s. Many disagreed with the wisdom of this move and even predicted they would become pests as they fed on seeds and buds not insects. Obviously their words went unheeded; the species has prospered phenomenally. Dr. Cannon said the sparrow reminds him of a Biblical reference, Matthew 10:29-30. Dr. Cannon is in practice at Head and Neck Surgical Group in Flowood. ❒ March

VOL. LII

Official Publication of the MSMA Since 1959

2011

No. 3

MARCH 2011 JOURNAL MSMA

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JOURNAL MSMA MARCH 2011

• SCIENTIFIC ARTICLES •

Mississippi, America’s Most Obese State: How Can We Salvage Her Future?

Stephen D. Sudderth, MD, FACS

BSTRACT

INTRODUCTION Nearly three-quarters of Americans are overweight, obese, or morbidly obese. Latest results from the 2007 to 2008 National Health and Nutritional Examination Survey (NHANES) indicate that an estimated 34.2% of U.S. adults age 20 years and older are overweight (BMI, body mass index, 25.0 to 29.9). An additional 33.8% are obese (BMI 30.0 to 39.9) and 5.7% are morbidly obese (BMI greater than or equal to 40).1 While there are 9 other states with prevalence rates greater than or equal to 30%, according to 2009 Centers for Disease Control and Prevention (CDC),2 Mississippi has the highest rate of obesity at 34.4%. Today, one-third of American children are considered overweight or obese.3 Approximately 17% of these children are considered obese, meaning BMI greater than or equal to 95th 99th percentile.4 Anything over the 99th percentile in children AUTHOR INFORMATION: Dr. Sudderth is a board certified, recertified general surgeon and active member of the Fellow of the American College of Surgeons. Dr. Sudderth is a Vista certified bariatric surgeon and will complete board certification in bariatric medicine in 2011. He is a member of both the American Society for Metabolic and Bariatric Surgery (ASMBS) and the American Society of Bariatric Physicians (ASBP). Dr. Stephen Sudderth is in private practice in Vicksburg, Mississippi.

CORRESPONDING AUTHOR: Stephen D. Sudderth, MD, FACS; 188 YMCA Place, Vicksburg, Mississippi 39183 Telephone: (601) 6367222 (steve.sudderth@gmail.com).

is considered morbidly obese. During the past 30 years, childhood obesity rates have more than tripled.5 Experts believe that this generation will have a shorter lifespan than their parents by 3 to 5 years.6 In 2008, adult obesity costs were estimated at $147 billion.7 A study released by The Brookings Institute 08/12/2010 concluded that the total cost of obesity in the U.S. may exceed $215 billion annually. Of that amount, $14.3 billion is attributed to children.8 Co-morbid conditions such as diabetes mellitus Type 2, cardiovascular disease, osteoarthritis, cancer, non-alcoholic fatty liver disease, obstructive sleep apnea, gastroesophageal reflux disease, gallbladder disease, gout, infertility, pregnancy complications, and mental health issues are all well known to be caused by or worsened significantly by obesity. Obesity causes about 400,000 deaths per year and in 2001 passed tobacco smoking as the number one preventable killer in America.9 Obesity is a true chronic and stigmatized disease with genetic determinants that continues to rise in prevalence. It has a complicated multi-factorial etiology with no known absolute cure. It requires long-term treatment or recurrence is likely. Multiple treatment strategies exist and are needed due to different etiologies and physical make-ups of each obese patient. Health professionals should be familiar with and trained in these different modalities to treat effectively the bariatric patient. Drastic changes in the food industry, schools, physician training, medical licensing boards, and governmental oversight, education, and research will be required to significantly change American lifestyles to permit hope of cure or containment of this debilitating disease.

ETIOLOGY

Social stigmatization of obesity as a sign of poor self-control, laziness, character ﬂaw, or merely cosmetic issues has been a common misconception for the last 60 years. By similar inference, many researchers and health personnel were taught that overweight and obesity were simply due to energy imbalance: too much eating and too little exercise. It, therefore, seemed logical for physicians to view obesity as a lack of willpower and all

MARCH 2011 JOURNAL MSMA

too often to dispense the admonition, “Just push yourself away from the table and join a gym” – advice that persists today. Not until recently have we realized that obesity is a true chronic disease that results from interactions between our genetics, environment, and behavior. The impact of genetic influences on BMI is estimated at 40-60%. Genes play a role in an individual’s expenditure of energy, utilization of fuel, characteristics of muscle fibers, and even taste preferences. All of these, in turn, influence our behavioral responses to the environment. Personal characteristics such as age, height, gender, race, ethnicity, disease states, both medical and psychiatric, are genetically driven traits and play a major role in weight gain, but our genes have not changed appreciably during the last few decades although the rates of obesity have. It has been suggested “genes load the gun, but the environment and our behavior pull the trigger.”10 Our environment has changed dramatically in the last 60 years. Today, food is everywhere. Americans’ lifestyles are shaped by this plentiful, inexpensive food. We enjoy a “cruise boat” buffet of processed, high calorie, highly palatable, easily accessible foods and beverages containing large amounts of refined sugars, saturated fats, and salt. We can “biggie size” just about anything, and our children can receive free toys to further incentivize future sales. We can obtain these foods 24 hours per day, 7 days per week on practically every street corner in America, many with deliveries right to your door for convenience. This obesogenic environment has altered family structure

Table 1

and scheduled healthy mealtimes. Daily energy expenditure has been decreasing for the past century. Energy expenditure has been decreased by 111 kcal/day by domestic mechanization, in just 4 areas: clothes washing, dishwashing, stair climbing, and walking to work. If not compensated by food reduction, body weight could increase 10 pounds per year, an amount exceeding progressive weight gain associated with the U.S. obesity epidemic.11 More than one-half of the U.S. adult population maintains an almost totally sedentary lifestyle. Children, as well, have decreased physical activity in school due to inactivity throughout the school days and a lack of organized physical education classes. Today, children have increased sedentary activities through television time, cell phones, video games, computer, and internet usage. Other major contributory factors of obesity include stress eating, reduced sleep, hormonal imbalances (see Table 1), and prescription drugs. Although many prescription drugs can cause weight gain, common ones are listed in Table 2.

TREATMENT

Diet: Considerable controversy continues to rage over which diet is best for losing weight. There is no simple answer except to say the one that will change the individual’s lifestyle long-term to be healthy. One particular diet, however, is catching the attention of the medical community with growing scientiﬁc evidence: low carb/high protein. These diets range from highly restrictive like Ketogenic and Atkins (20 grams to 50

Common Hormonal Imbalances Lending to Weight Gain

Hypothyroidism Metabolic Syndrome Growth Hormone Deficiency

Estrogen Dominance Insulinoma Polycystic Ovarian Syndrome (PCOS)

Cushings Syndrome Male Hypogonadism

Richardson, LA, Obesity: Evaluation and Treatment of Essentials, ed, Steelman GM, Westman EC, Informa Healthcare; 2010 p 14-15

Table 2 1. 2.

3. 4. 5. 6. 7. 8. 9.

Drugs that May Promote Weight Gain

Antipsychotics: quetiapine (Seroquel), olazepine (Zyprexa) Antidepressants Tricyclics: imipramine and amitriptyline Triazolopyridines: trazadone SSRI’s : paroxetine (Paxil) Tetracyclics: mirtazapine (Remeron) MAO’s Antiepileptics: gabapentin (Neurontin), valproate (Depakote), carbamazepine (Tegretol) Mood stabilizers: lithium, lamotrigine (Lamictal) Steroid hormones: progestational steroids, corticosteroids, hormonal contraceptives Antidiabetes agents: insulin (most forms), sulfonylureas (Glucotrol,Glyburide), thiazolidinediones (Actos) Antihistamines: fexofenadine (Allegra), desloratadine (Claritin), azelastine (Astelin), centirizine (Zyrtec) Antihypertensive agents: - and β- adrenergic receptor blockers, quinazoline (Hytrin, Terazosin), propranolol (Inderal), calcium-channel blockers, dihydropyridine (Procardia) Highly active antiretroviral agents

Richardson, LA, Obesity: Evaluation and Treatment of Essentials, ed, Steelman GM, Westman EC, Informa Healthcare; 2010 p 10

JOURNAL MSMA MARCH 2011

grams per day carbohydrates) to low carbohydrate diets (50 grams to 150 grams per day carbohydrates). Patients comply for much longer periods of time when carbs are kept at 100 to 150 grams per day, not nearly enough to cause ketosis but enough to cause weight loss, improvement in insulin resistance, and metabolic syndrome (see Table 3). Numerous studies comparing outcomes of low carb / high protein diets (LCHP) with all other conceivable combinations of calorie and macronutrient diets have been done, and all reach similar conclusions. These (LCHP) diets cause greater weight loss, more loss of body fat, preservation of lean body mass, lower triglycerides, higher HDL levels, and better glycemic control than all other diets up to 2 years out. High protein amounts are just as important as the low carbohydrate portion of the diet. Protein should be 1.2 to 1.5 grams per kilogram per day ideal body weight divided equally among 3 meals. 12 Everyone can benefit from carbohydrate restriction. Individuals with normal BMI may exhibit characteristics of obesity and metabolic syndrome. Individuals with metabolic syndrome show doubling of cardiovascular risks and 5 times the risk for Type 2 diabetes mellitus. Sugar-sweetened beverages (soft drinks, tea, juice, Gatorade, energy drinks, etc.) account for 25% to 40% of American daily caloric intake. One leading cause of obesity in Mississippi is sweet tea consumed by approximately 80% of the state’s population. Each 16-ounce kitchen glass has approximately 200 calories, resulting in weight gain of 20 pounds per year with 1 glass per day! Exercise: No prescription for weight loss and healthy lifestyle would be complete without increasing one’s physical activity level. While the benefits of exercise are obvious, it is the one lifestyle change fought with the most patient resistance. The 2005 DHHS Dietary Guidelines suggest 30 minutes or more of moderate intensity physical activity on most, preferably all, days of the week. In clinical practice, my patients find even this modest amount difficult to comply with long-term. I believe this is an area where doctors need to encourage practical solutions that involve the patient and his / her family. We must evaluate each patient for time availability, home or gym equipment access, location in the home of equipment, type of equipment, child constraints, availability of a partner, season of year for outdoor activity, owning DVDs or interactive exercise video gaming, aerobic or dance classes offered near home, physical limitations due to injury, osteoarthritis, or dyspnea. Patients may simply increase

Table 3

non-exercise activity thermogenesis (NEAT), also referred to as lifestyle activity. NEAT interventions include parking the car farther away, using stairs instead of elevators, avoiding moving platforms, pacing while on cell phones, doing one’s own housecleaning, running errands, shopping, yard work, washing cars, and encouraging to use cell phones as pedometers to increase steps; all work to burn calories. Children are much less resistant to physical activity as long as it’s fun! Schools need to be leaders for intervention. Physical education should be mandatory in all schools and include not only traditional sports and gymnastics but also interactive gaming, dance clubs, self defense lessons, skills training, health education, or a variety of activities that our imaginations can design. Pharmacotherapy: Pharmacotherapy, a mainstay in obesity treatment, should never be used alone but rather in combination with diet, exercise, behavioral modification, and maintenance as a comprehensive approach. Unfortunately, barriers to using drugs for obesity treatment stem from public and professional misperceptions. A plateau in body weight or weight regain after termination of a drug should not be viewed as a therapeutic failure of the drug. Drugs for any chronic disease should not be expected to cure but rather to ameliorate symptoms of a disease. Additional barriers are regulatory rigidity that limit effective drugs to short duration, addiction potential, drug interactions, or safety issues bred out of the Dexfenfluramine and Phen-fen era. The obesity treatment guidelines for pharmacotherapy adopted by many academic medical societies follow closely the recommendations of the National Institute of Health (NIH) issued in September, 1998.13 The committee decided that diagnosis and, therefore, treatment decisions should be predicated entirely upon BMI thresholds. This opinion remains controversial because it was not based on scientific evidence. BMI, originally an epidemiological tool which correlates best with obesity mortality, is known to be an insensitive indicator of abdominal adiposity and of other typical morbidities associated with obesity, particularly cardiovascular risks.14 BMI charts do not reflect gender, body type, waist circumference, or percent and location of body fat, all considered superior predictors of obesity morbidity and mortality. Most males would find themselves significantly overweight or obese based on BMI charts alone. The American Board of Bariatric Medicine (ABBM), now considered one of the leading authorities in obesity treatment, has updated guidelines which more accurately reflect the

Metabolic Syndrome

Diagnostic Criteria (3 out of 5 of the following) Abdominal Obesity (Waist Circumference) Triglycerides HDL Blood pressure Fasting glucose

40” in men, 35” in women 150mg/dl 40mg/dl for men, 50mg/dl for women 130/80mm Hg 100 mg/dl

Steelman GM. Obesity: Evaluation and Treatment of Essentials, ed, Steelman GM, Westman EC, Informa Healthcare; 2010 p 27

MARCH 2011 JOURNAL MSMA

evidence-based criteria for pharmacotherapy (see Table 4). These guidelines are being considered for adoption by many state licensing boards. Older FDA-approved anorectic or sympathomimetic drugs like phentermine, diethylpropion, and phendimetrazine in experienced hands are usually safe, well tolerated, and somewhat effective in the short term. These drugs may be considered as ﬁrst choice unless contraindications are present. Phentermine is the most widely used weight management agent in current use. It is thought to produce anorectic effects by releasing norepinephrine that acts through alpha/adrenergic receptors centrally to reduce food intake. Three absolute contraindications are pregnancy, nursing an infant, and previous severe allergic reaction to phentermine (1 in 1000). Relative contraindications are uncontrolled hypertension, uncontrolled epilepsy, uncontrolled bipolar disease, tachyarrhythmias, mild allergic reactions, excessive stimulation, and severe anticholinergic effects of dry mouth or unmanageable constipation. Adverse side effects occur early and are usually mild and short-lived by the overwhelming majority of patients. Addiction, abuse, psychosis, pulmonary hypertension, and glaucoma have never been substantiated in 50 years of phentermine use.

• Ephedrine, once very popular, is a mild anorectic but now virtually impossible to obtain due to FDA restrictions as a precursor drug along with pseudoephedrine to produce illegal methamphetamine.

• Sibutramine (Meridia), a serotonin norepinephrine reuptake inhibitor, was an FDA long-term approved drug but had disappointing results for weight loss. It has now been banned in the United States due to cardiovascular side effects. • Orlistat (Xenical, Alli) also has long-term approval for weight loss but has not proven to be useful in clinical practice because of intolerable gastrointestinal side effects. It is an intestinal lipase inhibitor considered safe but only moderately effective. • Topiramate (Topamax), although approved for the treat-

Table 4 t t t t t t t

ment of epilepsy and migraine prevention, has long been known to cause weight loss. It is particularly useful in management of binge eating and drug-induced weight gain. It is presently being combined with phentermine as (Qnexa) and is nearing completion of Phase 3 clinical trials for obesity management. • Zonisamide (Zonegran), another anti-epileptic drug, produces similar weight loss effects as topiramate. It is being combined with buproprion as Empatic under Phase 2 clinical trials.

• Buproprion (Wellbutrin) is a norepinephrine and dopamine reuptake inhibitor chemically similar to diethylpropion (Tenuate). It is approved for depression and smoking cessation and has an added benefit of mild weight loss. It is a good choice for the depressed obese patient. It is now being combined with naltrexone (Contrave) and is concluding Phase 3 clinical trials as an anti-obesity agent. •Metformin (Glucophage) is a biguanide approved for Type 2 diabetes mellitus. It has become the first drug of choice in treating insulin resistance and polycystic ovarian syndrome (PCOS). It has mild weight loss qualities. Gastrointestinal side effects often resolve with use of the extended release form. • Exenatide (Byetta) and liraglutide (Victoza) are glucagon-like peptide 1 agents (GLP 1) approved for treatment of Type 2 diabetes mellitus not adequately controlled with oral agents. Both drugs cause good weight loss and should strongly be considered as possible alternatives to weight gaining drugs like insulin, sulfonylureas and thiazolidinediones. • Pramlintide (Symlin), a synthetic analog to amylin, is approved as a treatment adjunct in Type 1 and insulin-dependent Type 2 diabetes. It also causes weight loss due to decreased food intake. • Spironolactone plus hydrochlorothiazide (Aldactazide), carnitine, and 5 htp/carbidopa are add-on drugs which significantly reduce carbohydrate cravings.

American Society of Bariatric Physicians (ASBP) Guidelines for Prescription Drug Treatment of Obesity

BMI of 30.0 BMI of 27.0 with at least one (1) co-morbidity Current body weight of 120% of well documented, long standing, healthy weight that the patient maintained after age of 18 Body Fat of 30% in females Body Fat of 25% in males Waist-hip ratio or waist circumference such that the individual is known to be at increased cardiovascular risk and/or risk due to abdominal visceral fat Presence of co-morbid conditions aggravated by the patient’s excessive adiposity

American Board of Bariatric Medicine, Board Certification Review Course, Seattle, Washington, April 14 & 15, 2010

JOURNAL MSMA MARCH 2011

• SCIENTIFIC •

Pharmacology has been and will continue to be a mainstay of scientiﬁcally driven medical treatment. The clinician who treats the overweight and obese patient with medication must be exceptionally well informed, be keenly observant, and use sound clinical judgment in prescribing these agents.

Bariatric Surgery: Surgery is indicated for patients with BMI greater than or equal to 40 or BMI greater than or equal to 35 with obesity-related comorbidities who have failed adequate medical management programs for at least 6 months’ duration and who have undergone evaluation ruling out endocrinologic, psychiatric, or metabolic causes for obesity. Surgery has gained in popularity with now over 200,000 procedures (mainly laparoscopic) done annually. At least 90% of medical co-morbidities will be improved or resolved at 1 year post-op, and mortality rates will be lowered by at least 30%. Surgical techniques, training, instruments, and centers of excellence have clearly made these procedures much safer over the last 10 to 15 years with mortality rates 0.3% and complication rates of 10%.15 As a bariatric surgeon and bariatrician, my view is that, despite the benefits, a good surgeon understands when not to operate. These patients are at significant risk for a plethora of problems, short and long-term, and in my experience, only about 10% of morbidly obese post-op patients comply with significant lifestyle change or follow-up visits. It is not uncommon to see significant weight regain, vitamin deficiencies, and re-hospitalization related to non-compliance on the patient’s part, rather than to the type of procedure. I am encouraged by newer, safer, and less costly procedures performed by a greater number of surgeons that may make a significant impact on the U.S. morbid obesity rates. Despite growing popularity of Roux-en-Y gastric bypass and banding procedures, still only 1% of eligible patients actually have these procedures performed. Laparoscopic sleeve gastrectomy and totally endoscopic incisionless (POSE) procedures may hold future promise for patients who truly need surgery.

CONCLUSION

Obesity is a broad topic to discuss. Books have been written about every aspect of this complicated disease. The disease is treatable with diet, exercise, behavioral modiﬁcation, pharmacotherapy, and surgery but to date is not curable. Weight regain and return of co-morbidities will occur if long-term lifestyle changes are not followed. Great strides have been made in each of the topics discussed in this paper, but unless regulatory governmental authorities on the state and federal levels change the obesogenic environment in which we live, prevalence rates for obesity will continue to spiral out of control. We seem to be at that point in this epidemic that the recognition and desire for change has come. We as a state with the highest rates of obesity and the most to lose should now lead the nation in restoring our health and dignity. Mississippians are proud people who de-

serve the best possible comprehensive, multi-disciplinary approach offered to combat the problem of obesity and ultimately to improve their overall physical and mental health. Our nation and state are facing an unparalleled obesity epidemic, and it’s time to offer real life comprehensive solutions that promote weight loss and reduction in morbidity and mortality.

REFERENCES

2. 3. 4. 5. 6. 7. 8. 9.

Centers for Disease Control and Prevention NCHS Health E-Stat Prevalence of Overweight, Obesity and Extreme Obesity Among Adults: United States, Trends 1976 – 1980 through 2007-2008. June 2010 http://www.cdc.gov/nchs/data/hestat/obesity_adult_ 07_08/obesity_adult_07_08.htm; Accessed December 26, 2010. Centers for Disease Control and Prevention United States Obesity Trends, Trends by State 1985-2009, September 2010 http://www.cdc.gov/obesity/data/trends.html; Accessed December 26, 2010. Ogden C, et al. Prevalence of overweight and obesity in the United States 1999-2004 JAMA. 2006;295:1549-1555. Ogden CL, et al. Prevalence of high body mass index in US children and adolescents, 2007-2008 JAMA. 2010;303(3):242-249.

US Centers for Disease Control and Prevention National Center for Health Statistics Health United States, 2003 Atlanta, Georgia US DHSS, 2003.

Olshansky SJ, et al. A potential decline in life expectancy in the United States in the 21st century. N Engl J Med. 2005; 352:11381145.

Finkelstein, EA, et al. Annual medical spending attributable to obesity: Payer-and services-specific estimates, Health Affairs 28, No. 5 September 2009; W822-W831.

Silva, C., New children’s nutritional law to improve cafeteria meals, American Medical News. December 27, 2010; 53(24):1014. Mokdad, AH, et al. Actual causes of death in the United States, 2000, JAMA. June23/30 2004;291:1238-1245 (March 2009 Reprint).

10. Price JH, Desmond SM, Krol RA, et al. Family practice physicians beliefs, attitudes and practices regarding obesity. AMJ Prev Med. 1987;3:339-345. 11. Seim, HC. Obesity: Evaluation and Treatment Essentials, ed, Steelman GM, Westman EC, New York, New York. Informa Healthcare. 2010:23. 12. Layman, D. The Optimal Diet: Is it Fat, Carbs, or Protein? Presented at the American Society of Bariatric Physicians Obesity Associated Symposium, Tampa, Florida, September 26-27, 2008.

13. NIH, Clinical guidelines on the identification, evolution and treatment of overweight and obesity in adults – The evidence report, National Institute of Health Obes Res. 1998;6(Supplement 2): 51S-209S

14. Pischon T, Boeing H, Hoffman K, et al. General and abdominal adiposity and risk of death in Europe. N Engl J Med. 2008;359:21052120. 15. Nyugen NT, Paya M, Stevens CM, et al. The relationship between hospital volume and outcome in bariatric surgery at academic medical centers, Ann of Surg. 2004;240:586-593.

MARCH 2011 JOURNAL MSMA

• SCIENTIFIC •

Treatment of Bacterial Vaginosis Does Not Reduce Preterm Birth Among High-Risk Asymptomatic Women in Fetal Fibronectin Positive Patients

Christian M. Briery, MD; Suneet P. Chauhan, MD; Everett F. Magann, MD; Julie L. Cushman, RN and John C. Morrison, MD

BSTRACT:

OBJECTIVE: Bacterial vaginosis (BV) is associated with preterm labor and may be positive in 15% of asymptomatic high-risk women. Fetal ﬁbronectin (fFN) has been shown in symptomatic women to predict infection-related preterm birth. The purpose of this study was to quantitate the relationship between BV/fFN and preterm delivery in high-risk asymptomatic women. METHODS: Women at high-risk for spontaneous preterm delivery were tested for BV/fFN between 2028 weeks gestation. Women positive for BV were treated with metronidazole, and fFN results were not used by physicians in treatment. After delivery, test results and pregnancy outcomes were entered in a deidentiﬁed database and analyzed. RESULTS: Of 232 women tested for BV/fFN over a 24-month epoch, results divided participants into 4 groups: Group A (N=12; +BV/+fFN); Group B (N=22; -BV/+fFN); Group C (N=68; +BV/-fFN); and Group D (N=130; -BV/-fFN). Demographics were the same between the 4 groups (P=NS) as was the gestational age at delivery (36.41 +/- 3.96 to 37.18 +/- 3.03 weeks). The incidence of preterm labor (P=.075), spontaneous early delivery (P=.936) and infants <2500 gm (P=.664) was also similar. CONCLUSIONS: In asymptomatic high-risk women, testing for fFN/BV during mid-pregnancy does not appear warranted.

AUTHOR INFORMATION: Dr. Briery, Willis Knighton Health System, 9111 Susan Drive, Shreveport, LA 71118; Telephone: (414) 329-5647 (Christianbriery@hotmail.com). Dr. Magann, FACOG, FRANZCOG; University of Arkansas for Medical Sciences, Division Director, Maternal Fetal Medicine, Director Maternal Fetal Medicine Fellowship, 4301 W. Markham St., Slot # 518, Little Rock, AR 72205; Telephone: (501)686-5847, Facsimile: (501)603-1716 (Everett.Magann@med. navy.mil). Dr. Chauhan, Director of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Eastern Virginia Medical Center, 825 Fairfax Ave, Suite 544, Norfolk, VA 23507, Telephone: (414)329-5647 (chauhasp@ evms.edu). Ms. Cushman (Email: jcushman@umc.edu) and Dr. Morrison, Department of Obstetrics and Gynecology, University of Mississippi Medial Center, Jackson, MS 39216 (jmorrison@umc.edu).

CORRESPONDING AUTHOR: John C. Morrison, MD, Department of Obstetrics and Gynecology, University of Mississippi Medial Center, 2500 North State Street, Jackson, MS 39216-4505. Telephone: (601) 984-5300; Facsimile: (601) 984-6904. REPRINTS WILL NOT BE AVAILABLE.

JOURNAL MSMA MARCH 2011

INTRODUCTION

Delivery before term (37 weeks gestation) complicates almost 12% of all pregnancies in the United States, and according to the latest report this figure has increased over the last 20 years from 8.9% in 1980 to over 11% in 2001.1 Preterm birth is responsible for up to 70% of serious morbidity and mortality in the neonate and is also linked to most of the neurodevelopmen2 tal defects among the neonates of such women. Unfortunately, the etiology of birth before 37 weeks gestation due to preterm labor is unknown. There is evidence, however, that upper genital tract infection and cytokine expression, particularly following bacterial vaginosis (BV) infection, are associated with preterm birth.3,4 BV, which may reside in as many as 20% of asymptomatic high-risk women, is associated with a reduction in the lactobacillus-predominant flora in which G. vaginalis, Mobiluncus species and anaerobes predominate.4 Proliferation of such flora is also associated with high rates of premature rupture of the membranes, chorioamnionitis and preterm labor, all of which lead to early delivery. 5 Randomized clinical trials as well as cohort studies have also shown a correlation with preterm labor and a reduction in preterm delivery when BV is treated, particularly in symptomatic women.6,7 Fetal fibronectin (fFN), when detected in cervico-vaginal secretions of high-risk asymptomatic women, has been associated with a sixty-fold increase in spontaneous delivery at <28 weeks gestation.8 It has been shown that intrauterine infection can cause disruption of the extracellular choriodecidual basement membrane through the action of cytokines which in turn allow the expression of fFN in the cervico-vaginal secretions.9 Although the relationship between fFN and BV has been well described in women with preterm labor symptoms, this association in high-risk asymptomatic women during the prenatal period has been inconsistent. The purpose of this study was to confirm the relationship, if any, between BV/fFN and preterm labor/delivery in a group of asymptomatic high-risk gravidas.

MATERIALS AND METHODS

Women at risk for early delivery received prenatal care in our preterm birth prevention clinic staffed by maternal-fetal

medicine specialists. High-risk factors resulting in assignment of patients to the preterm birth prevention clinic included prior preterm birth (<37 weeks gestation) due to preterm labor, episodes of preterm labor in the prior pregnancy (<34 weeks), an episode of preterm labor, preterm contractions or cervical shortening by sonography at <24 weeks in the current gestation, or cervical insufficiency. Since the BV positive rate was very high (20-25%) in our clinic, we began screening asymptomatic patients at risk for PTB with fFN and BV as part of our prenatal care protocol. Testing occurred between 20-28 weeks in these women. Since we wished to study the relationship between these tests with the timing of delivery, this retrospective analytic study was classified as exempt by the Institutional Review Board of the University of Mississippi Medical Center as it involved a chart assessment where patient identifiers were deleted. Fetal fibronectin testing was obtained during a sterile speculum exam. A Dacron swab was applied to the external cervical os and then dipped into the vaginal pool. fFN testing utilized an ELISA technique which quantitated fFN (<50Fg/mL = negative) within thirty minutes (TLi, Adeza Biomedical, Sunnyvale, California).10 BV testing was carried out by the use of the FemExam Testcard (Litmus Concepts, Inc., Santa Clara, California). A cotton-tip swab was placed in the posterior vaginal pool during the above described speculum exam, then directly placed on the pH test element on the left side of the card, and then moved to the amine test element located on the right side of the card. A vaginal pH 4.7 resulted in a plus sign (+) and, likewise, a positive sign appearing on the right side of the card signified .5 mmol of amines were present. The FemExam test card has been demonstrated to be reliable in detecting elevated pH and volatile amines in vaginal fluid with a negative predictive value of 97% and a positive predictive value of 81.5% when correlated with the gold standard of using Amsel’s criteria.11 Patients testing positive for BV were treated for seven days with metronidazole 500 mg three times per day. The charts were reviewed to gather maternal characteristics including demographic

factors and the number of patients developing preterm labor as well as women delivering before 37 and prior to 34 weeks’ gestation. Preterm labor was deﬁned as persistent contractions usually ≤ 5 minutes apart with progressive cervical dilation and effacement. Neonatal characteristics included birth weight at delivery, Apgar score, cord pH and the incidence of low birth weight (<2500 grams). Assuming the rate of spontaneous preterm delivery to be 25% among our high-risk women, 200 patients are required to demonstrate a 20% reduction in the rate of preterm delivery. Where appropriate, one-way analysis with either Tukey posttest or Kruskal-Wallis test was used. Chi square tests were also used for categorical variables. P<.05 was considered signiﬁcant.

RESULTS

During the 24-month epoch, 260 women were eligible for BV/fFN assessment in our high-risk clinic, and only two women refused testing, as they did not consent to a pelvic exam. Those entering prenatal care after 28 weeks’ gestation (n=26) were not included in this analysis. The remaining 232 women tested between 20-26 weeks were stratified by the results of BV/fFN tests into four groups: Group A (n=12; +BV/+fFN); Group B (n=22; -BV/+fFN); Group C (n=68; +BV/-fFN); and Group D (n=130; -BV/-fFN). Table I demonstrates that patient age, ethnicity, and parity were similar between the four groups (range-P=.325 – .744). Table II reveals the obstetric outcome parameters and shows that among the 232 women there were 34 parturients who developed preterm labor with no significant differences between the four groups (P=.075). Gestational age at delivery was also not significantly different (P=.475). Similarly, spontaneous preterm births (<37 weeks or those occurring <34 weeks) were not different between the four groups (P=.936, .855). Table III offers the neonatal characteristics among these patients. The infants were delivered in good condition as noted by above average Apgar scores and cord pH analysis which again did not differ between the four groups (P=.194, .894). Similarly, the birth weight by groups ranged from 2560"623 grams to 2916"696 grams and were similar across the four groups (P=.153). Table III also shows that the percentage of low birth weight infants (<2500 grams) was similar without regard to group assignment (P=.664).

MARCH 2011 JOURNAL MSMA

DISCUSSION

treatment of women with genital tract infections demonstrated a reduction in preterm birth when compared to the placebo group (4% vs 10%, P<.030). In contrast, treatment with metronidazole and erythromycin in women with a positive BV test did not reduce the incidence of early delivery compared to those treated with placebo.15 Similar results were noted by Leitich et al16 who performed a meta-analysis of 10 studies including almost 4000 asymptomatic patients for treated upper genital tract infections. Across these studies, low-risk patients without any prior or current preterm birth risk factors showed no effect of BV treatment to decrease the rate of early deliveries whereas high-risk patients had better results, particularly if they were treated for longer intervals. The addition of fFN testing in such women has offered more positive results, particularly among symptomatic gravidas. Stevens et al7 showed that a positive fFN was more often correlated with early delivery at 34 and at 37 weeks as well as a reduced birth weight when compared to BV testing among women symptomatic for preterm labor. The larger study on this subject involved almost 3000 women from the MFM Network who Group C Group D noted a correlation between a (n=68) (n=130) P-value positive fFN/BV when tested at 23-24 weeks in asymptomatic +BV/fFN –BV/fFN women and with preterm birth.8 The PREMET study15 was 11/68 14/130 .075 stopped after an interim analysis suggested a higher PTB rate in the metronidazole treated groups 36.5 + 3.8 37.5 + 3.0 .475 in addition to no reduction in PTB for those women with a positive fFN. The current study supports the literature in that the 23/68 94/130 .936 treatment of BV in fFN positive asymptomatic patients, even 8/68 12/130 .855 though they were high-risk, did not show an increased association with preterm labor, early delivery, or low-birth weight. Group C Group D The reason for the dispar(n=68) (n=130) ity across many of the studies is –BV/fFN +BV/fFN unknown. While most would P-value agree that asymptomatic BV positive women are at risk for 8.4 + 2.0 8.8 + 0.9 .194 preterm delivery, the prediction as to which of these women will 7.24 + .079 7.23 + .079 .894 have an early birth due to a spontaneous preterm labor is dif2764 + 772 2916 + 696 .153 ﬁcult. Recent studies have suggested a potential genetic susceptibility to infection medi26/68 39/130 .664 ated preterm birth. Polymor-

The notion that a combination of prenatal tests in highrisk women can predict outcome is not a novel concept. Crane et al12 studied the ability of fFN, BV and preterm birth risk scoring to predict spontaneous preterm birth in 140 asymptomatic high risk gravidas recruited between 20-24 weeks’ gestation. Although the individual tests were not predictive of spontaneous preterm birth, the combination of these three factors had a sensitivity of 44.4%, a speciﬁcity of 97.7%, a PPV of 57.1% and NPV of 96.2% for delivery prior to 37 weeks. In addition to a relatively small sample size, the BV detected among these women was not treated and therapy for BV among high-risk women in other studies yielded mixed results.3,4,13 When one separates these studies in the literature according to the subjects symptomatic vs asymptomatic for preterm labor, the results become more clear. A previous study by Stevens, et al7 showed that treatment of BV positive women conferred a beneﬁt by reducing preterm birth. Similarly, Lamont et al 14 showed that Table II. Obstetric Outcome Group A

Group B

(n=12)

(n=22)

+BV/+fFN

–BV/+fFN

2/12

7/22

36.8 + 3.4

3.6 + 4.0

<37 weeks

3/12

7/22

<34 weeks

1/12

4/22

Preterm Labor Gestational age at delivery Preterm delivery

Table III. Neonatal Statistics Group A

Group B

(n=12)

(n=22)

+BV/+fFN

–BV/+fFN

8.8 + 0.8

8.1 + 2.2

Cord pH

7.24 + .061

7.24 + .079

Birth weight (g)

2560 + 623

2567 + 768

LBW (<2500 g)

4/12

8/22

Apgar

JOURNAL MSMA MARCH 2011

• SCIENTIFIC •

phism of cytokine genes has been linked to alterations in the production of cytokines in the inflammatory cascade.17,18 Patients with different alleles produce varying amounts of cytokines in response to infection and thus have a highly specific response to infection. Women exhibiting an exaggerated inflammatory response to infection, such as BV, potentially may represent the subset of patients who will have preterm birth. There are several limitations of this investigation which must be acknowledged. First, there may have been ascertainment bias as this was not a randomized trial. However, all women who had risk factors for preterm birth were included, and therefore the likelihood of bias, at least in this population, is reduced. Secondly, testing was limited to those at 20-28 weeks; therefore, women may have benefited had they been tested earlier and/or had they received repeated testing closer to the time of delivery. Likewise, there is certainly a chance that treatment of the BV positive patients may have altered the ability of this test to predict preterm birth. This is unlikely since women in the asymptomatic high-risk category in the literature treated with placebo also did not show correlation with early delivery. Finally, the number of patients studied is modest compared to other reports. However, the number with premature births and with positive BV tests was much higher than the other reports. Based on the findings in this study, we cannot recommend fFN and BV testing in asymptomatic women at high risk for preterm labor during prenatal care.

REFERENCES

1. 2. 3. 4.

5. 6. 7. 8.

Anath CV, Joseph KS, Oyelese Y, et al: Trends in preterm birth and perinatal mortality among singletons: United States, 1989 through 2000. Obstet Gynecol. 2005;105:10841091. Bhutta AT, Cleves MA, Casey PH, et al: Cognitive and behavioral outcomes of school-aged children who were born preterm: a meta-analysis. JAMA. 2002;288:728-737.

Gibbs RS, Eschenbach DA: Use of antibiotics to prevent preterm birth. Am J Obstet Gynecol. 1997;177:375-380.

9. 10. 11. 12. 13. 14. 15.

16. 17. 18.

1996;87:643-648.

Ascarelli MH, Morrison JC: Use of fetal fibronectin in clinical practice. Obstet Gynecol Surv. 1997;52(4):S1-12.

Hussa R, Lapointe J, Marzolf G, Pong R, Jones L, Shorter S, et al: Fetal fibronectin rapid test comparison to fetal fibronectin enzyme immunoassay. Clinical Chemistry. 1998;44(6)A13. McGregor JA, French JI: Bacterial vaginosis in pregnancy. Obstet Gynecol Surve.y 2000;55(5):S1-19.

Crane JMG, Armson BA, Dodds L, Feinbert RF, Kennedy W, Kirkland SA: Risk scoring, fetal fibronectin, and bacterial vaginosis to predict preterm delivery. Obstet Gynecol. 1999;93:517-522. Andrews WW, Hauth JC, Goldenberg RL: Infection and preterm birth. Am J Perinatol. 2000;17:357-365.

Lamont RT, Duncan SLB, Mandal D, Basett P: Intravaginal clindamycin to reduce preterm birth in women with abnormal genital tract flora. Obstet Gynecol. 2003;101:516-522.

Shennan A, Crawshaw S, Briley A, Hawken J, Seed P, Jones G, et al: A randomised controlled trial of metronidazole for the prevention of preterm birth in women positive for cervicovaginal fetal fibronectin: the PREMET study. BJOG. 2006;113:65-74.

Leitich H, Brunbauer M, Bodner-Adler B, Kaider A, Egarter C, Husslain P: Antibiotic treatment of bacterial vaginosis in pregnancy: a meta-analysis. Am J Obstet Gynecol. 2003;188;752-758. Simhan HN, Krohn MA, Roberts JM, Zeevi A, Caritis SN: Interleukin-6 promoter – 174 polymorphism and spontaneous preterm birth. Am J Obstet Gynecol. 2003;189(4):915-918.

Macones GA, Parry S, Elkousy M, Clothier B, Ural SH, Strauss JF: A polymorphism in the promoter region of TNF and bacterial vaginosis: preliminary evidence of gene-environment interaction in the etiology of spontaneous preterm birth. Am J Obstet Gynecol. 2004;190:1504-1508.

PLEASE TELL

Locksmith G, Duff P: Infection, antibiotics, and preterm delivery. Semin Perinatol 2001;25(5):295-309.

OUR ADVERTISERS

McGregor JA, French JI, Parker R, et al: Prevention of premature birth by screening and treatment for common genital tract infection: results of a prospective controlled evaluation. Am J Obstet Gynecol. 1995;173;157-167.

FOUND THEM

Meis PH, Goldenberg RL, Mercer B, et al: The preterm prediction study: significance of vaginal infection. Am J Obstet Gynecol. 1995;173:1231-1235.

THAT YOU IN THE

Stevens AO, Chauhan SP, Magann EF, Martin RW, Bofill JA, et al: Fetal fironectin and bacterial vaginosis are associated with preterm birth in women symptomatic for preterm labor. Am J Obstet Gynecol. 2004;190(6):1582-1587. Goldenberg RL, Mercer BM, Meis PH, Copper RL, Das A, McNellis D: The preterm prediction study: fetal fibronectin testing and spontaneous preterm birth. Obstet Gynecol.

MARCH 2011 JOURNAL MSMA

• CLINICAL PROBLEM-SOLVING •

Presented and edited by the Department of Family Medicine, University of Mississippi Medical Center, Diane K. Beebe, MD, Chair

If Roosevelt Only Knew Jeffrey Domingo Jarin, MD

57 year-old frail-looking white female patient presented to the office with chief complaints of difficulty walking, numbness and weakness of the hands that had progressively worsened over the past 4 months. She had no known medical problems, was not taking any medications and had not seen a physician in several years. There was a history of trauma about 6 months earlier when she tripped and hit the back of her head and neck; she reported subsequent persistent neck pain. During the past few months, she noticed increased weakness and unintentional weight loss of about 38 pounds over a span of 7 months. She also reported decreased appetite with accompanying mild abdominal pains and night sweats. She had presented with these complaints to a university emergency department (ED) 2 weeks prior to her current clinic visit. Due to her history of weight loss, computed tomography of the abdomen was done and showed thickening in the ascending and proximal transverse colon, consistent with colitis. She was given pain medication and discharged to follow up with a primary care physician. Her past medical history included hepatitis 30 years ago. Her family history was positive for hypertension and gout but negative for malignancies. She reported no recent infections. She drank about one six-pack of beer per day for 4-5 years but had not consumed alcohol in the past 6 months. She had a 20 pack year smoking history. She lived with a female friend in another city with no family nearby. However, her daughter visited her intermittently, and it was the daughter who brought her to clinic concerned about the decline in the patient’s health. The patient’s overall condition is worrisome. She is defiAUTHOR INFORMATION: Dr. Jaron is working as a hospitalist in St. Dominic Memorial Hospital. He is affiliated with Cogent Healthcare, a nationwide hospitalist program. He was a third year resident in the Department of Family Medicine at the University of Mississippi Medical Center in Jackson. CORRESPONDING AUTHOR: Jeffrey Domingo Jarin, MD, 969 Lakeland Avenue, Jackson, MS 39216 Telephone: (601)200-2000. (jeffjarinmd @gmail.com).

JOURNAL MSMA MARCH 2011

nitely ill-looking, almost cachectic in appearance. With her history of recent significant weight loss and weakness, the thought of a malignancy immediately comes to mind. On general inspection, the patient looked thin and frail. She was wheelchair-borne and spoke in a weak voice. She was 63 inches in height and weighed just 108 pounds. Her pulse rate was 109 beats per minute with a blood pressure of 137/92 mmHg and a respiratory rate of 15 breaths per minute. She was afebrile. Head and neck exams were unremarkable, and her lungs were clear. She was slightly tachycardic, but no murmurs were noted. Her abdomen was soft and nontender with no masses or guarding. The patient could not lift herself from the wheel chair. Her cranial nerves appeared intact. There were some cerebellar abnormalities as the patient had noticeable dysmetria when performing finger-to-nose movements with the right hand. She also exhibited moderate to severe proximal muscle weakness. Upon attempting to stand, her legs were extremely unsteady, even with upper body support. The daughter reported that the patient was able to ambulate and work until 6-8 months ago. Upon manual muscle testing, though, her strength was 4/5 in all extremities. There was bilateral hand sensory deficit, and her reflexes were noticeably absent. While there are no acute conditions that require hospitalization, I am concerned about her family’s ability to take care of her. Given her condition, I will admit the patient for further investigation. The admitting diagnoses are ataxia with paresthesias, weight loss and neck pain. Differential diagnoses are grouped into four categories: malignancy, neurological, gastrointestinal disorders and others. Malignancy is our primary concern. With her history of smoking, lung cancer is a primary consideration. Given her abnormal CT findings, colon cancer is also a consideration. Lung and colon cancer are the 2 of the most common cancers in the United 1 States and in Mississippi. Her physical findings also raise possible clues. Stroke is a consideration. Her dysmetria suggests cerebellar disease. Her paresthesias also suggest peripheral neuropathies. The absence of reflexes and her significant ataxia point to possible demyelinating disease as well. Gastrointestinal illnesses include colitis and hepatic disease. With her acute

change in strength and mobility, hepatic encephalopathy is entertained. Other possibilities include tuberculosis, thyroid disease and celiac disease. Differential diagnoses should guide further workup. To investigate for colon cancer, colonoscopy and endoscopy are planned. In the interim, serial fecal occult blood tests are ordered as initial screen. We will also order serum carcinoembryonic antigen which is a tumor marker for malignancies of the gastrointestinal tract. To investigate for lung cancer, we decided to start with a plain film chest radiograph. To differentiate among neurologic causes, a magnetic resonance imaging of the brain is ordered. This not only gives us the chance to see if there has been a cerebrovascular event but also gives us the chance to visualize other parts of the brain that may explain her symptoms. The cerebellum is of particular interest because of her dysmetria and ataxia. The MRI may also show evidence of a demyelinating process. An MRI of the Cspine and T-spine is also ordered to investigate her neck pain and upper extremity numbness. The physical exam findings and differential diagnoses direct our workup. In considering peripheral neuropathies, we start with the more common causes such as vitamin B12 and thiamine deficiencies given her history of heavy alcohol use. A metabolic profile is ordered to look for any evidence of diabetes, electrolyte imbalance or renal or kidney disease. Sedimentation rate and C-reactive protein, which are indicators of an inflammatory or vascular process, are also ordered. Electromyogram is also considered, but non-invasive tests are the priority. A neurology consult is also requested due to the complexity of this case. Other tests to be ordered include celiac antibodies, thyroid stimulating hormone, ammonia concentration and a purified protein derivative test. Initial results were unrevealing. MRI of the brain and neck showed some chronic microvascular changes but was otherwise unremarkable. There were no signs of demyelination or a cerebrovascular accident. MRI of her spine revealed multiple level spondylosis. Blood tests were unremarkable. Her chest radiograph, purified protein derivative and fecal occult blood tests were negative, and her serum carcinoembryonic antigen and thyroid stimulating hormone were normal. These results make lung and colon cancer less likely. Thus, this appears to be a neurological or a muscular problem. To differentiate, it helps to review the key differences between

a neuropathy and a myopathy. The first step is distinguishing proximal from distal muscle weakness. The progression from distal to proximal or from proximal to distal weakness is an important clue. A proximalto-distal progression suggests a myopathy or a neuromuscular junction disorder. A distal-to-proximal progression suggests neuropathies such as polio or Guillain-Barré syndrome (GBS). In this patient, her weakness started mostly with her hands and feet, then eventually involved her proximal muscles as evidenced by her difficulty in standing up and ambulating. The patient’s reflexes are also very critical. Reflexes are generally preserved in muscle disorders. In this patient, her reflexes are absent. Thus, it is becoming clearer that the patient’s problem is more of a neuropathy rather than a myopathy. Now that we have identified the pathology as a neuropathy, the next step is to determine whether it is a lower or upper motor neuron disorder. (Table 1) Simply described, a lower motor neuron travels from the spinal cord to the respective organ it innervates. When intact, lower motor neuron functions that do not have to go through the brain will work, such as the efferent portion of the reflexarc. In contrast, with lower motor neuron disorders, reflexes will be absent. In our patient, the distinct absence of reflexes, spasticity or rigidity, and the presence of muscle atrophy suggest a lower motor neuron deficit. Narrowing our diagnosis to lower motor neuron diseases, we review the more common causes. The main four disorders to be considered are post-polio syndrome, Guillain-Barré syndrome, amyotrophic lateral sclerosis and peripheral neuropathies. Postpolio syndrome is highly unlikely because polio has been virtually eradicated with the advent of polio vaccines in the 1950’s. Patients with amyotrophic lateral sclerosis usually present with a combination of upper motor and lower motor neuron signs. This patient manifested purely lower motor neuron deficits. Secondary peripheral neuropathies are unlikely due to her normal glucose, thiamine and B12 concentrations. To confirm the diagnosis of Guillain-Barré syndrome, one thing is still left to be done – a lumbar puncture to identify elevated CSF protein. A lumbar puncture on the 2nd day of admission revealed a normal glucose (72 mg/dL); normal white blood count (1/cmmm) and red blood count (1/cmmm); negative cultures for bacteria, fungi, acid-fast bacilli and Cryptococcus; and an elevated protein (167 mg/dL). We made the diagnosis of GBS.

Table 1. Lower Motor Neuron Disorders vs. Upper Motor Neuron Disorders

LOWER MOTOR NEURON Muscle Atrophy Fasciculations No spasticity No rigidity Flaccidity Areflexia/hyporeflexia

UPPER MOTOR NEURON Late muscle atrophy No fascisulations Spasticity Rigidity No flaccidity Hyperreflexia

MARCH 2011 JOURNAL MSMA

• SCIENTIFIC •

Findings of areflexia and elevated proteins in the cerebrospinal fluid are the two primary diagnostic criteria for GBS. There are 2 primary treatment modalities for GBS: plasmapheresis and high dose intravenous immunoglobulin (IVIG). Plasma exchange and high-dose IVIG are equally effective in 2 improving the rate of motor recovery in at least 60% of patients. 3 There is, however, no benefit to combining both modalities. IVIG is safer but more expensive. Plasmapheresis has more side effects, is more difficult to administer, but is relatively cheaper. Corticosteroids and immunosuppressive drugs have been proposed as possible alternatives for treatment but studies have 4 shown no benefit. On receiving a working diagnosis of Guillain-Barré syndrome, the patient underwent 5 sessions of plasmapheresis. The patient slowly showed much improved gait and strength to the point that she could stand on her own and walk with the assistance of a walker. She was discharged to her daughter’s residence near the hospital with orders to continue physical therapy as an outpatient. However, the patient insisted on returning to her own home which was miles away from the hospital and did not follow up with her primary care physician or neurologist. She did well for about a month after discharge, but she suffered a fall at her home and slowly deteriorated. She was admitted again 2 months after discharge with the same weakness. She also eventually developed severe gastroparesis. Follow up is important in patients with GBS. Plasmapheresis, while cheaper than IVIG and as effective, can take up to 3-4 weeks to achieve full benefit. Patient cooperation and motivation are also important. While a majority of these patients will show improvement, symptoms may persist for a longer period of time. Symptoms of GBS that persist for over 2 months are called chronic inflammatory demyelinating polyneuropathy 5 (CIDP). Treatment modalities for CIDP are generally the same as for those of GBS: IVIG, plasma exchange and corticosteroids. Based on a meta-analysis of CIDP studies, there appears to be no difference in the efficacy of these 3 modalities.5 Choosing which to use is largely based on cost, availability and risk for adverse effects. The patient underwent IVIG for 3 days followed by oral steroids which were continued on discharge. Again the patient showed improvement and regained her ability to ambulate albeit with assistance. In summary, this patient presented with muscle weakness and weight loss that looked like a general medical illness. But with further history and examination revealing a distal-toproximal progression of weakness, absence of reflexes and elevated proteins in the CSF, she was found to have GBS. Persistent symptoms of GBS over 2 months support the diagnosis of CIDP. Treatment modalities for these 2 diseases involve plasmapheresis, IVIG and steroids.

JOURNAL MSMA MARCH 2011

As for the title of this article, Franklin D. Roosevelt is remembered as the United States President during the Great Depression period and World War II. He was also known as the paralyzed President in a wheelchair. For a long time, it was thought that his paralytic illness and ultimate death were caused by polio. However, review of the diaries of the physicians who treated President Roosevelt led physician researchers to hypothesize that he actually had GBS instead of polio.6 This article makes you ask, “What if FDR were properly diagnosed and treatments available today had been available then, what would have happened to FDR?” More importantly, how might it have changed the course of history?

KEY WORDS: GUILLAIN-BARRÉ SYNDROME, CHRONIC

REFERENCES

1. 2. 3. 4. 5. 6.

INFLAMMATORY DEMYELINATING POLYNEUROPATHY, PLASMAPHARESIS, INTRAVENOUS IMMUNOGLOBULIN

American Cancer Society: Cancer Facts and Figures 2009. Atlanta, GA: American Cancer Society, 2009. Graeme H, Wardlaw J. Clinical Neurology. New York, NY: Demos Medical Publishing; 2002: 588-595. Immunotherapy in Guillain-Barre Syndrome. Available at http://www.aan.com/professionals/practice/index.cfm/. Accessed October 11, 2009. Hughes RAC., Wijdicks EF, Barohn WR, et al. Practice parameter: immunotherapy for Guillain-Barre syndrome: Report of the quality standards subcommittee of the American Academy of Neurology. Neurology. 2003; 61:736-740. Koller H, Kieseier BC, Jander S, Hartung HP. Medical Progress: Chronic inflammatory demyelinating polyneuropathy. N Engl J Med. 2005; 352:1343-1356. Goldman AS, Schmalstieg EJ, Freeman DH Jr, Goldman DA, Schmalstieg FC Jr. What was the cause of Franklin Delano Roosevelt’s paralytic illness? J Med Biogr. 2003; 11:232–240.

ONLINE JOB BANK Free position listings for MSMA members and for group clinics which employ at least 70% MSMA-member physicians. • List a position by visiting MSMAonlinejobs.com. • For more information, contact Anna Morris: AMorris@MSMAonline.com, 601-853-6733, Ext. 324 My solo practice listed a free position on the MSMA online job bank, and within only a couple of weeks we received several inquiries from qualified candidates and were able to fill the position quickly and easily. I highly recommend the job bank! —Tom Joiner, MD

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

January 2011

* Totals include reports from Department of Corrections and those not reported from a specific district.

For the most current MMR figures, visit the Mississippi State Department of Health web site: www.HealthyMS.com MARCH 2011 JOURNAL MSMA

• MSDH •

This Month in the Mississippi Morbidity Report

Volume 27, Number 1; January 2011

THE HEALTH EFFECTS OF SECONDHAND SMOKE

The January 2011 edition of the Mississippi Morbidity Report summarizes the evidence regarding secondhand smoke and health, including local data which show improvements in health following local implementation of smoke free air policies. What follows is a brief overview of the edition. The full report and references may be accessed at: http://healthyms.com/msdhsite/_static/resources/4169.pdf.

Introduction: The 1964 Surgeon General’s Report summarized the scientific evidence concerning tobacco smoking and health and concluded that tobacco was harmful to an individual’s health. Evidence since then has shown not only that smoking is dangerous to the smoker’s health but that secondhand smoke, or exposure to environmental smoke, is dangerous to nonsmokers’ health. Smoking rates in the U.S. have decreased markedly over the last 50 years, and social norms have changed so that public smoking has become unacceptable in many venues. However, 43% of Americans are still being exposed to environmental tobacco smoke. The 2006 Surgeon General’s Report, The Health Consequences of Involuntary Exposure to Tobacco Smoke (an update to a prior 1986 report) outlined six major conclusions concerning secondhand smoke exposure and health: 1. Children and adults are still exposed to secondhand smoke in their homes and workplaces.

2. Exposure to secondhand smoke causes disease and death in adults and children who are not smokers.

3. In children, secondhand smoke exposure increases their risk for sudden infant death syndrome (SIDS), acute respiratory infections, ear problems and more frequent and more severe asthma. 4. Secondhand smoke exposure is associated with an increased long term risk of lung cancer and heart disease but also acutely affects the cardiovascular system, having a prothrombotic effect and causing endothelial cell dysfunction. 5. There is no safe level of secondhand smoke.

6. Efforts to eliminate secondhand smoke indoors through separation of smokers and/or building ventilation do not eliminate exposure to nonsmokers.

Additionally, the 2010 Report of the Surgeon General: How Tobacco Causes Disease addresses the affects of secondhand smoke as one of its six major conclusions. “Low levels of exposure, including exposures to secondhand tobacco smoke, lead to a rapid and sharp increase in endothelial dysfunction and inflammation which are implicated in acute cardiovascular events and thrombosis.”

The Mississippi State University Social Science Research Center, Tobacco Control Unit, evaluated the health effects of public indoor smoking prohibitions implemented in Starkville in May of 2006 and in Hattiesburg in January of 2007. Hospital admissions for myocardial infarction (MI) were compared in each city prior to and after the municipal policies were put in place. Both communities showed marked decreases in MI hospital admissions compared to the time period prior to implementation of the ban. In Mississippi, however, communities with policies that prohibit smoking in indoor places or have smoke free ordinances that exempt one or more businesses cover just over 20% of the population. An October 2009 Institute of Medicine reports sums up the evidence. “Data consistently demonstrate that secondhand smoke exposure increases the risk of coronary heart disease and heart attacks and that smoking bans reduce heart attacks. Given the prevalence of heart attacks and the resultant deaths, smoking bans can have a substantial impact on public health. The savings, as measured in human lives, is undeniable.”

—Presented and edited by Paul Byers, MD, Acting State Epidemiologist, Mississippi State Dept. of Health

JOURNAL MSMA MARCH 2011

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Make plans to attend MSMA’s

143 Annual Session rd

May 19 – 22, 2011 Tupelo, Mississippi

Meetings at BancorpSouth Conference Center

CME and golf tournament at nearby Old Waverly Golf Course

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

Accommodations at Tupelo’s Hilton Garden Inn

Visit www.MSMAonline.com to REGISTER NOW! Questions? More information? Contact Becky Wells at 601-853-6733, Ext. 340 or BWells@MSMAonline.com.

JOURNAL MSMA MARCH 2011

President’s Reception at Tupelo Automobile Museum

Preliminary Schedule of Events Thursday, May 19 (Registration: 10 am - 5 pm; Exhibit Set Up: 10 am - 1 pm) 10:30 – until 11:30 – 1:30 12:30 – 2:00 3:00 – 5:00 6:00 – 8:00 8:00 – 10:00

Lunch & Learn (2 hrs CME) and MACM-Sponsored Golf Tournament (1 pm); Old Waverly Golf Course Committee on Publications Luncheon Reference Committee Orientation / Briefing Medical Affairs Forum (2 hrs CME) MSMA Welcome Reception; HealthWorks MSMA Board of Trustees Meeting

Friday, May 20 (Registration: 7 am - 5 pm) 7:00 – 9:00 8:00 – 9:00 9:00 – 11:00 11:00 – 12:00 11:30 – 1:30 1:00 – 1:30 1:30 – 3:30 3:30 – 4:00 4:00 – 5:00 4:00 – 5:00 4:00 – 6:00 5:00 – 6:00 6:00 – 8:00 8:00 – 9:00

Breakfast with Exhibitors Q&A Panel with MSMA/AMA Delegation (1 hr CME) House of Delegates Medical Affairs Forum (1 hr CME) Pizza Party Lunch with Exhibitors MSMA Board of Trustees Meeting Reference Committee Hearings Staff Presentation: MSMA Online Tools MMPAC Board Meeting YPS Business Meeting Women in Medicine Meeting Council on Medical Education Meeting President’s Reception; Tupelo Automobile Museum Southern Medical Association Ice Cream Social

Saturday, May 21 (Registration: 6:30 am - 5 pm) 6:30 – 8:30 7:15 – 12:30 11:00 – 1:00 12:30 – 1:30 1:30 – 3:30 3:30 – 5:30 6:00 – 7:00 7:00 – 8:00 8:00 – 11:30

Breakfast Medical Affairs Forum (5 hrs CME) MPCN Annual Meeting Luncheon Specialty Society Luncheons for all members Candidate Speeches to Combined Caucuses MSMA Board of Trustees Meeting Reception Honoring President-Elect MSMA Alliance Silent Auction President’s Inaugural Dinner Dance

Sunday, May 22 (Registration: 7 am - 11 am) 6:00 – 7:00 7:30 – 8:00 7:00 – 9:00 7:00 – 9:00 8:00 – 9:00 9:00 – 11:00 11:00 – 11:30

Friday, May 20 Saturday, May 21

Sunday, May 22

Sunrise Cycling Bike Ride Worship Service Continental Breakfast and Voting VIP Breakfast: 50-yr members and Past Presidents MSMA Board of Trustees Meeting House of Delegates MSMA Board of Trustees Meeting

MSMA Alliance Schedule of Events 11 am – 2:30 pm 8:30 am – 11:30 am 12 pm – 2:30 pm 8:30 am – 10:30 am

Alliance Pre-Convention Board Meeting / Luncheon Alliance House of Delegates Alliance Installation Luncheon; Park Heights Restaurant Alliance Past President’s Breakfast; Home of Susan Rish

Just for Kids Events

Friday, May 20 10:30 am – 2:30 pm Outside Fun Day 6 pm – 10 pm Black Light Elvis Party Saturday, May 21 8:30 am – 2:30 pm “Tame the Wind” Kite-Building Activity 6 pm – 11 pm Sports Under the Stars

MARCH 2011 JOURNAL MSMA

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• PRESIDENT’S PAGE •

Physicians Must Lead

he February Journal article of Dr. Richard D. deShazo, “Mississippi, How Did We Get to This Place?,” arrived on your desk only one week after the advanced nurse practitioners made a serious move in our Mississippi Legislature toward seeking independent practice. According to Dr. deShazo, it is our inescapable cultural heritage and fragile economy coupled with poverty and health workforce shortages that continue to assure our bottomdwelling status among other states. Dr. deShazo’s eloquent historical account of the social determinants of many of our major health indicators ends with the challenging question, “Who will lead?” Clayton M. Christensen in his book The Innovator’s Prescription explains the process by which complicated and expensive goods or services in a free market are transformed into simple, more affordable ones (i.e. nurse practitioners). Full engagement of disruptive technologies and transformative business model TIM J. ALFORD, MD innovations are both necessary conditions for survival of any industry including 2010-11 MSMA PRESIDENT health care. In other words, those who espouse the free market should be prepared to die by it unless they can produce sufficient value therein. The recent hearings at the Mississippi Legislature on the proposed quest of nurse practitioners to seek independent practice provide a prime example of the debate over who shall lead. It was obvious at the hearing that there is animosity toward the stereotypical indignant physician. If we are to claim leadership of the healthcare team, then it must be evident to the extenders and our communities that we are indeed willing to lead. The following is a portion of my statement to the Public Health Committee on this issue:

“ A

Chairman Holland,

s President of the Mississippi State Medical Association, I thank you for the opportunity to speak to you this afternoon about the ongoing quest of advanced practice nurses to end collaboration and seek independent medical practice.

First, I would like to commend you and your Committee for the work that you have done to advance the cause of primary care through Mississippi’s own Rural Scholars Program, one that was recently nationally recognized. More medical students are declaring their intent to enter primary care in a state that ranks fiftieth in the nation in numbers of primary care doctors per thousand patients.

I have practiced my specialty of Family Medicine now for twenty-five years in Kosciusko, twenty of which I have enjoyed working in a collaborative way with nurse practitioners, and I can tell you from personal experience that this model of care works. By that I mean it is safe, of high quality, allows all related professionals to utilize their highest level of training in the most cost effective way, and if we are doing what we are supposed to be doing, there is the side benefit to the local economy. I am speaking to you not in theoretical terms but as someone who along with eight family physicians, a pediatrician and three advanced family nurse practitioners, carries out over one thousand outpatient visits per week.

MARCH 2011 JOURNAL MSMA

Collaboration has been a key ingredient that allows us to take care of our patients safely and with high quality. We collaborate with one another as physicians as well as with the advanced practicing nurse and all care extenders. In Kosciusko, we even collaborate with our neighboring group and their nurse practitioners. Guess who wins? The patient. This team approach allows both groups – nurse practitioners and doctors – to function at their highest level of training and, as I have said, reduces costs. Uncertainty in medicine often equals more tests … more costs. Lack of collaboration or communication equals duplication of expensive services …. more costs. Besides that, often in medicine two heads are simply better than one. One of my younger colleagues pointed out a finding on an x-ray just this morning that I had not seen. Collaboration with one another is to be cherished and valued, not resented and shunned. As long as there is a discipline called medicine there will be experiences some have not had and pathways that need appropriate leadership and direction. Working together makes us all better caregivers. Shouldn’t this be our goal? We have serious problems in this State. We are losing ground in many areas. One-half of our children entering kindergarten will develop diabetes and for the first time in modern history, we face a generation that will live sicker and die younger than its preceding generation. We cannot afford to have two separate teams. If we are ever going to lift off of the bottom, it will be because we have one team playing together, not two playing against one another.

The side benefit of playing as one team has a tremendous economic impact. For the University Medical Center, literally billions of dollars. In Kosciusko, our physician-driven health care system is the single largest employer in central Mississippi and accounts for over 800 health-related jobs. So you could say that the 12 physicians in our area stimulate over 70 jobs per physician.

The issue of variability in training relates directly to the cost of care, a difference of 21,500 hours of clinical training according to my own specialty society versus 630 hours of clinical training according to the UMC nurse practitioner website, is stark and real. In addition, compare 11 to 17 years of medical school and residency versus six years for the advanced nurse practitioner. For the MD to be, often through the night, through the whole spectrum of care from the emergency room to the operating room – the point is that no book or computer or remote site can teach one to recognize the subtleties of a young infant’s illness or an elderly patient’s dimming of signs, symptoms and features of a disease. The true art of medicine, if you will, Mr. Chairman, requires the dimension of time and exposure. As the late Dr. James D. Hardy, one of the great pioneers of surgery, put it, “The only thing wrong with every other night call is that you miss half the cases!” As for access to medical care, you have heard that if nurse practitioners could only practice without restrictive collaborations more Mississippians could have access to care. Studies of the distribution of nurse practitioners in states that have granted independent practice show that this is not the case. Arizona, Minnesota and North Carolina indicate that nurse practitioners tend to cluster where physicians are located even if they are “independent” of them.

Finally, I mentioned Mississippi’s Rural Scholarship program earlier. A shorter route to independent practice for advanced practicing nurses is a discouragement to prospective medical students. Why go through ten to twelve years of medical school, residency and fellowship, rack up six digit student loans, when you can arrive at the same endpoint with half the time and cost? At a time when we have the essential ingredients in place to grow new primary care doctors, we do not need to take such a step backward. Let’s keep collaboration because collaboration works.

”

Dr. Currier and I will present the health report card here on the rotunda steps Thursday morning at 11a.m. This is not a report card you would want to bring home to mama! We must work as a team to improve grades.

Physicians must lead!

JOURNAL MSMA MARCH 2011

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MARCH 2011 JOURNAL MSMA

• EDITORIAL •

Preventing Falls in the Hospital: How Mississippi Physicians Can Reduce This Too Common “Never” Occurrence

Steve Mack, M3, Tulane School of Medicine

alls are a significant cause of morbidity and mortality for older adults who are at higher risk because of accumulating comorbidities as well as a natural decline in gait and balance. Nearly one in three adults aged 65 or older is predicted to have a fall this year, with that number increasing to greater than half for those above 80 years old.1 Falls are particularly devastating among inpatients and are estimated to occur in up to 20% of hospitalizations with an additional average hospital charge of more than $4,000. With our rapidly aging population, the number of older adults at risk for falls is set to skyrocket in the coming years. Costs associated with falls on a national level were estimated to be $19 billion in 2000 and are expected to almost triple to $54.7 billion by 2020.2 In response to the financial burden of falls in inpatients, in 2008 The Centers for Medicare and Medicaid Services (CMS) designated hospital falls as a “never event” and stopped reimbursing for falls sustained in hospitals, leaving the institutions to absorb these large costs.3 Because of this, there has been an increased effort to discover the most effective means of preventing falls in a hospital setting. During my family medicine clerkship in rural Mississippi, I worked with many geriatric patients in a variety of clinical settings, including inpatients. As part of my rotation I attempted to apply evidence-based medicine to find ways to reduce falls at the local hospital. Unfortunately, I soon realized that the evidence was unclear and incomplete. The evidence shows that multifactorial and individualized fall prevention plans are vastly superior to single interventions although, due to the heterogeneity of the proposed programs, it is difficult to render judgments about specific components of proposed multifactorial programs with high levels of certainty.4 Until formalized and widely accepted evidence-based medicine guidelines become available, we must rely on expert opinion and clinical reasoning. The following interventions are those that I have found either supported by the most promising evidence or commonly used components of the more successful programs. These are reducing the use of bed rails as physical restraints, vitamin D supplementation at 800 IU/d, exercise and physical therapy, a medication review, and attempts to reduce environmental hazards. Unfortunately, one of the most common practices for high-risk patients is the use of bed rails as physical restraints. Bed rails are dangerous, and during a twenty year period 691 incidents of side rail entrapment were reported to FDA, 413 of which resulted in death. For cognitively impaired patients, the rails are “invariably perceived as a barrier” and lead to more injurious falls from greater heights. There is no evidence that bed rails decrease falls, and when their use is reduced, multiple studies have failed to show an increase in fall rates (some have even shown a decrease in fall rates when restrictive bed rails are withdrawn).5 The evidence against using bed rails to prevent patient falls is clear, although it is still a widespread practice. As a medical student I have witnessed it in several different institutions and hospitals as common practice, despite these findings and federal mandates. Vitamin D supplementation has been a controversial topic in the falls literature, especially following the recent 2011 Institute of Medicine (IOM) report and updated recommendations. The IOM report recently updated the RDA from 600 IU/day to 800 IU/day for those aged 71 and older, although these numbers were based on the benefits to bone health effects only.6 Many studies suggest that vitamin D may have effects on balance, attention, and muscle strength that can help reduce falls, particularly in those who are vitamin D deficient, in addition to strengthening bones. The IOM committee concluded that the evidence for fall reduction from vitamin D supplementation was insufficient and inconclusive. This is in contrast to a recent meta-analysis that concluded that there was a significant effect of fall reduction with vitamin D supplementation. In fact, a 14% decrease was found.7 The elderly are obviously at risk for vitamin D deficiency due to decreased cutaneous synthesis, and hospital inpatients are certainly not exposed to a sufficient level of sunlight. Those studies demonstrating its efficacy have shown that there is little difference between standard vitamin D and active forms of the vitamin and that there appears to be a dose-dependent effect with levels below 800 IU/day largely ineffective. It seems to me that vitamin D supplementation at 800 IU/day is safe (the IOM committee also raised the upper limits from 2,000 IU/day to 4,000 IU/day), cheap, and may have the ability to decrease falls. Therefore, it should be a part of any falls prevention program until strong evidence shows that it is harmful. Exercise has been shown to have a protective effect on elderly who live in the community. However, the evidence is not conclusive on its effects in reducing hospital falls. This is most likely due to the delayed effects of exercise and the relatively short length of hospital stays.4 Physicians should recognize the fact that after hospitalizations these patients will return either to

JOURNAL MSMA MARCH 2011

the community or to a long-term care facility and thus should use the opportunity to extol the benefits of exercise to their patients while they are under their care. Early rehabilitation and physical therapy within the hospital should be part of any falls reduction program, and teaching appropriate exercises during the hospitalization can slow age-related health decline and aid in lifelong gait and balance strengthening. The risk for falling increases with the number of medications a patient is taking, making medications a significant risk factor for most geriatrics. Drugs affecting the CNS, particularly sedatives and hypnotics, antidepressants and benzodiazepines, have been shown to significantly increase the risk of falling.8 It would be useful to undergo a medication review for any patient who is identified for a high fall risk, although it is important to view falls within the framework of particular medical conditions and the reasons those medications were prescribed in the first place. Medication lists should be reviewed for unnecessary medications or dangerous drug interactions. Psychotropic drugs, if being discontinued or reduced, should be tapered slowly to avoid withdrawal or adverse effects. Falls are complex events that occur when a variety of accumulating risk factors put a patient at an increased likelihood of losing balance from a precipitating event, such as a loose shoelace or a slippery floor. Just about every single successful fall program has elements of altering the local environment in order to prevent falling. A lot of these are common sense and expert opinion and, because of the inconsistency in these interventions across individual studies, it is virtually impossible at this point to identify which are the most useful.4 Nonetheless, lowering the bed height, installing handrails and non-slip mats in the bathrooms, clearing the path from the bed to the bathroom, reducing bedside clutter to have items such as glasses and any walking devices within easy reach, ensuring that the call button is accessible and that its use is actively encouraged when the patient leaves the bed, and providing night lights for better visibility in the dark are all good suggestions for environmental interventions and are all used commonly in the literature. Also, nursing staff should increase the frequency of bedside visits if possible in order to reorient patients and detect falls sooner should they occur, and high fall risk patients should be placed closer to nursing stations if the facility can accommodate this. Encouraging family members to spend time with the patient during their stay or to provide bedside sitters when they are unable to stay can help reduce the nursing burden and provide another level of safety. continued on page 90

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â&#x20AC;˘ EDITORIAL â&#x20AC;˘ continued from page 89 Falls are a significant problem among hospitalized patients in unfamiliar environments, and even though deemed a â&#x20AC;&#x153;never event,â&#x20AC;? it is naĂŻve to think that falls can be completely eliminated. Not all studied fall prevention programs appear to make a significant reduction on fall rates, but even those that are successful are capable of accomplishing only modest reductions of 2030%. The CMS, in my mind, is correct â&#x20AC;&#x153;that [falls] should not occur after admission to the hospital,â&#x20AC;? but as there is yet no reliable manner in which to eliminate or drastically reduce falls, it seems imprudent merely to shift these costs to smaller hospitals when falls can occur even in the face of the best medical care.9 However, due to the significant morbidity and mortality associated with falls and the approaching profound shift in age demographics, we must do all that we can to prevent falls while awaiting more conclusive research. Multifactorial programs incorporating those elements discussed above appear to have the best chance of success at reducing falls. REFERENCES

2. 3.

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

Rubenstein LZ, Josephson KR. Falls and their prevention in elderly people: what does the evidence show? Med Clin North Am. 2006;90:807824. Centers for Disease Control and Prevention. Costs of Falls Among Older Adults. Accessed December 27, 2010. <http://www.cdc.gov/ncipc/ factsheets/fallcost.htm>. Kolin, MM, Minnier, T, Hale, KM. Fall Initiatives. Redesigning Best Practice. J Nurs Adm. 2010;40(9):384-391.

Cameron ID, Murray GR, Gillespie LD, et al. Interventions for preventing falls in older people in nursing care facilities and hospitals. Cochrane Database Syst Rev. 2010; (1):CD005465.

Capezutti, E, Wagner, LM, Brush, BL, et al. Consequences of an intervention to reduce restrictive side rail use in nursing homes. J Am Geriatr Soc. 2007;55:334-341.

Ross, AC, Manson, JE, Abrams, SA, et al. The 2011 report on dietary reference intakes for calcium and vitamin d from the institute of medicine: what clinicians need to know. J Clin Endocrinol Metab. 2011 January; [Epub ahead of print]. Kalyani, RR, Stein, B, Valiyil R, et al. Vitamin D treatment for the prevention of falls in older adults: systematic review and meta-analysis. Journal of the American Geriatrics Society. 2010;58:1299-1310.

Woolcott, JC, Richardson, KJ, Wines, MO, et al. Meta-analysis of the impact of 9 medication classes on falls in elderly persons. Arch Intern Med. 2009;169(21):1952-1960. Inouye, S K, Brown, C J, and Tinetti, M E. Medicare nonpayment, hospital falls, and unintended consequences. NEJM. 2009;360(23): 23902393.

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JOURNAL MSMA MARCH 2011

• LETTERS •

Groundhog Day

ear JMSMA editor, Mao Tse-tung perfected the technique of making the truth out of false facts simply by repeating them often enough. He did not invent the technique, but he perfected it enough to enslave 25% of the planet. Thus it is with some medical economics. Many medical false facts are repeated so often by media that much of the lay public believes U.S. health care is substandard and inferior. Unfortunately, too many doctors also believe this propaganda. I am fortunate to have practiced a long time in this country and previously in Canada in a single payer universal system (SPUN) i.e., government-controlled medical system. The Canadian SPUN is similar to all of those in Europe. In the last few years I have tried to warn my colleagues that despite media propaganda, the U.S. system is still by far the best in the world, far better than any SPUN. Many of my articles have been printed in journals, some in this very journal. But I often feel like reporter Phil Connors in Groundhog Day. I keep repeating myself and making no progress. So it is in the guest editorial, “Creating a Better Climate for the Nation’s Health Care Could Make Champions of all Physicians,” by Dr. William Lineaweaver [J Miss State Med Assoc. 2010;51(12):360-361]. He tells us that: 1) U.S. healthcare has “staggeringly high costs caused by insurance company overhead and profits.” 2) U.S. healthcare has “depressingly low outcomes including infant mortality and life expectancy.” 3) Obamacare is acceptable because “it does not dismantle or socialize anything; the act serves as a regulation of the insurance industry.” Wow, I don’t know where to start, but let’s start with the classic definition of socialism: public (government) control of the means of production of services and goods. That can happen in a number of ways: violent takeovers, a la Mao Tse-tung; nationalization, a la Venezuela; or by oppressive hyper-regulation so oppressive that insurers cannot make profits and simply go out of business to be replaced by big government. That’s called socialism. It has already happened, of course, with the elderly and now children since insurers can no longer afford to insure “children” to age 26. The 2700 pages of Obamacare will so hyper-regulate that government will take over the rest of us. Apparently, profit is ipso facto obscene except when a doctor makes a profit. It is true that compared to other Organization for Economic Co-operation and Development (OECD) countries, the U.S. spends about 16 % of our GNP on medical care, whereas most others spend 10% (including Canada). So it appears we are much more expensive. But the devil is in the details: 1) Money to run any medical system must be collected. In a SPUN this is done by tax agencies and given to the SPUN. In private systems (including our offices) cost of collection is about 25% of operating costs. So SPUNs appear to operate 25% cheaper because they don’t have to collect. 2) The burden of disease in this country is much higher because the U.S. has cohorts that NO OTHER OECD has: a) 10% illegal immigrants (1% or less in the OECD) b) 28% minorities (black, Hispanic) who have 50% higher burden of very expensive cardiometabolic disease; many OECD’s are monocultural (Scandinavia, Japan) c) 8% military veterans who suffer from more physical and psychiatric disease (OECD-1% or less) d) a long open border with a third world country across which pours drugs into the inner cities causing death and disease; many OECD’s are islands with no borders. Infant mortality in the U.S. is about 7/1000 which ranks us about 30th in the world. But: 1) we alone count still births and missed abortions in our figures -about 25% of the total. 2) we count anchor babies, most of whom have never had prenatal care before or after crossing our border illegally. 3) Black or Hispanic teenagers are 50% more obese than Scandinavian teenagers, for instance, so their pregnancies are 50% more morbid. Therefore, when these factors are taken into account, infant mortality in the U.S. is among the best in the world. Last but far from least, every SPUN country has a method to control the cost of frivolous law suits: a “loser pays” legal system. The Institute of Medicine in 2008 reported that defensive medicine may increase medical costs by as much as 30%. Thirty percent of 2 trillion is a lot of money. The U.S. is the only OECD country that does not have a “loser pays” system. The cost of medical care in SPUN countries is reduced by as much as 30% by a “loser pays” system which prevents barratry and champerty. continued on page 95

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• PHYSICIANS' BOOKSHELF • The Intern Blues: The Timeless Classic About the Making of a Doctor By Robert Marion, MD New York, NY: Harper Collin Publishers, 2001. Paperback. 492 pages. $15.99

hen many physicians think about the hardest part of their professional (and often personal) lives, they recall their internship. Some note that this time was marked with anxiety, confusion, frustration, depression, anger, chronic sleep deprivation, endless hours without food – and that was on the good days. In his book The Intern Blues, Dr. Robert Marion, director of the Pediatrics program in Bronx, New York, writes about the experiences of three new medical school graduates who begin their intern year in July 1985. The young doctors - Andy, Amy, and Mark - receive tape recorders to document their experiences and thoughts during their internships. Dr. Marion then compiles their recordings into monthly journal entries. What follows is a narrative of the trials and tribulations Andy, Amy, and Mark endure throughout their internship. The Intern Blues begins as the new, overwhelmed, fearful doctors are thrust into a chaotic hospital environment, caring for new patients with complicated medical histories, doing novel procedures, and surviving the first calls of their careers. As the book progresses, their fears dissolve as they gain confidence in their abilities. Moreover, the book also brilliantly captures how each intern develops bouts of depression as they care for dying patients who cannot be saved even in the age of modern medicine. It articulates the frustrations doctors face while working with incompetent hospital staff (from lab techs to nurses and even other interns and residents) who seem disinterested in providing efficient and quality medical care. The book contrasts these moments by showing the bonds that develop be-

tween like-minded doctors, nurses, and hospital staff who are committed to the care of their patients. Interestingly, The Intern Blues delves into the personal lives of Andy and Mark who note how difficult it was for them to maintain their relationships with their girlfriends, family, and friends while working nearly 100 hours a week. And a unique perspective is provided by Amy, a doctor juggling her internship with the demands of caring for her husband and their two month old daughter. The book is skillful at highlighting the good, bad, serious, and funny moments of each intern’s life. It is surprisingly vivid, and the reader will certainly feel as though he/she is trying to survive internship with Andy, Amy, and Mark. The success of the book lies in its honesty. At no point will the reader feel that the narration is censored to suit the delicate sensibilities of the audience. Rather it captures the raw emotions each young doctor feels with every success and failure. This is a truly terrifying book for medical students who see their internship looming in the horizon (as a third year medical student myself I experienced bouts of tachycardia and respiratory distress as I read this book). And for seasoned physicians who have successfully completed their internships and are practicing comfortably, the book will be a trip back to intern year, a time that many doctors may have forced themselves to block from their memories. Yet, it helps both the student and veteran physician realize how through this rite of passage scared, incompetent medical graduates transform into intelligent, confident, and efficient physicians. Perhaps, the real strength of The Intern Blues, however, is its ability to relate the intern experience to the public who often find it difficult to understand the challenges doctors face during their training. It is especially recommended to the families and friends of new interns who often suffer through the rigors of medical training as much as the new doctor. Therefore, the book offers something to the future intern, the former intern, and for people wanting to understand the life of an intern. The Intern Blues is recommended for any brave soul willing to live the intern experience in this lengthy book. You can pick up a copy at your local or online bookstore today. — Shweta Sood, M3, Tulane Medical School Class of 2012

MARCH 2011 JOURNAL MSMA

• SPECIAL • ARTICLE • MSMA • MSMA & MSDH Release 3rd Annual Public Health Report Card & MSMA Alliance Hosts CSI VI Karen A. Evers, Managing Editor

ealth Awareness Day, Thursday, January 20, was eventful at the state Capitol building as the MSMA Alliance hosted the sixth annual Capitol Screening Initiative (CSI VI) targeting the 174 members of our state Legislature and a media press conference was held to release the 3rd annual public health report card. The report card, issued by MSMA in collaboration with the Mississippi State Department of Health, appeared in the January 2011 issue of the JMSMA. The prior evening, Wednesday, January 19, the Mississippi Medical Political Action Committee (MMPAC) held a legislative briefing in preparation for a reception honoring state legislators at The South Warehouse downtown. The MSMA Council on Legislation provided an overview of MSMA’s 2011 legislative agenda. The cocktail reception afterwards gave members an opportunity to discuss Health Awareness Day— Press conference to release the pending bills and legislative issues with their state 3rd Annual Public Health Report Card senators and state representatives. Guests were entertained with a special performance by a troupe their communities and discussing these issues with their of political impersonators whose satire shined a new light on patients. “Evidence shows that patients still listen to their the government affairs in Washington. doctors. Many of these diseases are preventable through All of the activities planned were to get legislators’ attention and let them know our MSMA wants to help them stay lifestyle changes, and physicians should be leading the way by ‘walking the walk’ and ‘talking the talk,’” he said. in the best physical and mental condition to make the critical “All of us, physician or non-physician, make health decisions they are faced with during the legislative session, choices each and every day that affect us and our loved ones, particularly the health issues on MSMA’s legislative agenda. immediately and in future years. All of us need to consider A variety of health screenings were offered at no charge to carefully our choices – whether to eat fruit instead of cake, or elected officials and staff. Members of our Alliance were on steamed vegetables instead of fried vegetables – and our hand to meet and direct legislators through the screenings as decisions – whether to remain physically inactive or to exercise well as to provide healthy snacks (bananas, granola bars and and lose a few pounds. Small steps day in and day out make a juice) for consumption after the tests. Both events, the report huge difference on the path to better health now and in the years card press conference and CSI VI, showed the Legislature the to come,” Dr. Alford said. medical community cares about them. To further enhance MSMA’s advocacy efforts members Each year, MSMA releases its annual Public Health are asked to display the report card by hanging it in a prominent Report Card, and the results are sobering. Mississippi ranks place. Physicians can use the poster to inform patients, prompt first in obesity; second in heart disease death, diabetes, and dialogue, and encourage those who seek their advice. The 2011 hypertension rates; and first in teen birth rate. Mississippi is Public Health Report Card can be viewed and downloaded from second in infant mortality, first in traffic fatalities, among the the MSMA website, MSMAonline.com, by clicking on the top ten in cancer death, and seventh in adult tobacco use. “View PDF” icon below the news article. If you did not save In the three years since the first Public Health Report Card the insert from your January Journal, you can also call MSMA release, most statistics have yet to improve. Some have headquarters and request a reprint of the poster. worsened. MSMA President Dr. Tim Alford asked physicians —Karen A. Evers, Managing Editor throughout the state to make a difference by being examples for

JOURNAL MSMA MARCH 2011

Top left: MSMA President Dr. Tim Alford was interviewed by Lindsey Slater, Fox-40 news reporter. Top right: Alliance members did an excellent job coordinating CSI VI, answering questions and manning the hospitality table. Lunch was distributed courtesy of MMPAC to all exhibitors, Alliance members and their spouses. They were honored to have AMA Alliance President Emma Borders join them for the day. Middle left: Medical students in the Mississippi Physicians Rural Scholarship Program participated. Middle right: District 11 (Panola, Tate) Rep. Joe C. Gardner was one of about 200 people who received a screening from over 20 exhibitors. Screenings included BMI, blood pressure, glucose, cholesterol, EKG, glaucoma, and diabetic retinopathy. Flu shots were given by the Mississippi State Department of Health. Bottom left: A University of Mississippi Health Care resident measures District 115 (Harrison) Rep. Randall Patterson's blood pressure.

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• LETTERS •

Therefore, comparison between the U.S. and OECD or other countries is not valid because of different counting methods and much different burden of disease. The large number of U.S. born physicians who refuse to believe that the U.S. health system is “the world’s greatest” always embarrasses me. This naturalized citizen who practiced and lived and fled a government system care can tell you that, despite all its problems, the U.S. is still the best in the world. So, help me out, Dr. Lineaweaver. Make my Groundhog Day end. Tell me I don’t have to keep repeating myself. We can’t stop bad facts by the media, but we can seriously question them. We are far too educated to fall into the Mao Tse-tung trap. It is possible to compare apples and oranges, but such a comparison is not valid. The U.S. system is by far the best in the world considering the awesome burden of disease and all the confounding factors in this magnificent country. —Calvin S. Ennis, MD, Escatawpa

MARCH 2011 JOURNAL MSMA

• IMAGES IN MISSISSIPPI MEDICINE •

A DELTA CHILD, 1907 — The negative impact of tobacco on health is proven and severe. Premature disability, morbidity and mortality all result from tobacco use, and physicians know that the habit is often established in childhood or adolescence. This old photograph bespeaks the huge efforts still needed by the medical community to eliminate long entrenched tobacco dependence from our state’s population. On the photo’s back, someone has written “A Delta Child. May 21, 1907. J. D. Upshaw, Jr. 18 months old.” The photo, which also has a reference to Yazoo City written on it, appears to have been taken in front of an old rural mercantile store. Note the sign behind young Mr. Upshaw which promotes “Cherry Smoking Tobacco,” underscoring the dangers of tobacco advertising for youth. January’s JMSMA featured an excellent article on current tobacco use among public high school students in Mississippi. The authors did find a significant decline in tobacco use from 1993 to 2009. So perhaps things are starting to improve in Mississippi in regard to childhood and adolescent smoking. However, such is not true elsewhere. Last summer, a photograph of a smoking obese 2-year-old Indonesian child named Ardi Rizal became an internet sensation. That child had started smoking at 18 months as well and by the age of 2 was smoking 40 cigarettes a day. Data from Indonesia reveals that there are many children there under the age of 5 who smoke. If you have an old or even somewhat recent photograph which would be of interest to Mississippi physicians, please contact the Journal or me at lukelampton@cableone.net.

JOURNAL MSMA MARCH 2011

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• POETRY AND MEDICINE •

[This month we print a poem by John D. McEachin, MD, a Meridian pediatrician. This poem, written in November, offers up another proverbial “pearl” from his many years of pediatric practice. Writes Dr. McEachin,“‘Nursemaid’s Elbow’ has undergone a couple of name changes, more dignified and specific anatomically. First was ‘Radial Head Subluxation;’ more recently the designation has been ‘Annular Ligament Displacement.’ My recent concern has been the reported charges to patients for this simple office reduction—- $250 to $1500. (It was, on occasion, embarrassing to charge the routine office visit fee.) If the history by phone was believable, parents could be easily taught the maneuver of reduction, and a dangling arm became a high grasp for a lollipop!” The prolific Dr. McEachin holds a special place at the Journal as our unofficial poet laureate. For more of Dr. McEachin’s poetry, see past JMSMAs and look for more in coming months. Any physician is invited to submit poems for publication in the journal, attention: Dr. Lampton or email him at lukelampton@cableone.net.]—ED.

“Pediatric Pearl: Quick Fix” (with apologies to Gilbert and Sullivan)

I am about to educate, I promise I won’t overstate A therapy now in debate; relax, don’t hyperventilate! “Nursemaid’s Elbow,” we can state, is caused by jerk- a real pronate. The surest cure I can relate is simply pull- and supinate. This treatment’s not to irritate, but here I will not moderate. There is no method at this date that’s better than to supinate. Why do we oft initiate alternatives that aggravate? The “old” is fine- in fact it’s great, so fast there’s no need to sedate!

Hope this will serve to stimulate- it’s not to make you palpitate! Please think and simply meditate: “Which way shall I manipulate?” Remember now, before too late, do not your fee over-inflate, ‘Cause texting you can delegate: Tell Mom and Dad, “Just Supinate!” —John D. McEachin, MD Meridian

JOURNAL MSMA MARCH 2011

• THE UNCOMMON THREAD •

Bits of Lint

or the most part that’s what the things that pass across these pages I write are. See, I’m a lot like the Scottish botanist Robert Brown: I put my eye to my microscope and describe what it is I see at the moment. In 1827 Brown described the way that pollen grains jiggled under his microscope when they were floating in water. (We will have to assume that he wasn’t tapping his foot against the table leg at the time.) He wasn’t really the first person to notice the R. Scott Anderson, MD phenomenon. Lucretius as early a 60 B.C. rhapsodized about it in his poem “On the Nature of Things.” In a bit of remarkable prescience, Lucretius postulated that the motion was the result of invisible atoms colliding with the tiny specks of dust suspended in the sunlight. Well, it wasn’t really too prescient. That’s where the name atom came from in the first place, so prediction it wasn’t. Now old Dr. Brown may have made a great cream soda, but he didn’t know much about atoms. His concern was to determine if the pollen particles were actually living things that were going about making volitional movements. It was all of the guys that followed him that led to a real description of what we now think of as “Brownian Motion.” And for those of you that only know Albert by his E=mc2 , he also came up with D = kBT/b to describe the Brownian motion of a particle at thermodynamic temperature T. Worthless lint. But what a fuss was made of it.

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MARCH 2011 JOURNAL MSMA

• UNCOMMON THREAD •

If you somehow made a mistake and showed up here accidentally, don’t get scared. They don’t give me anything sharp, save wit and tongue. Given enough time, I do eventually come to the point although I am usually the one skewered by it. If you came here looking for sense, I’m afraid that you’re lost. There’s little enough of that here. It’s not that I don’t make sense; it’s more that the sense I make is not much more than pollen jiggling. Truth around here isn’t so much something that we see as it is a process of discovery. So what have we discovered? A gem of a story told to me by my friend Ed Holmes who is a local pulmonologist. This is a kind of old story in that it comes from the dawn of time before cell phones could fit in your pocket. See, back then cell phones came in kind of a bag, like a mini-suitcase. There was a plug that went into your cigarette lighter (that’s what we called the power outlets we had in cars back then) and an antenna thing that you stuck on the roof of your car. Needless to say, nobody carried them around in their pocket. The way the folks in your office got hold of you if they needed you was to call the floors that they knew you were going to be rounding on and leave messages for you there. Well, Ed was in the ICU taking care of a sick patient when a call came in for his new partner, a young fellow who had arrived in town driving a fancy new Infinity and without a wife. Since he didn’t have a wife, it was the car that decided to give him trouble, and the message that the nurse took for him had to do with that situation. As Ed continued to work, the original nurse went to eat, and shortly after that his new partner called to check on things. “Hold on, Doctor,” the unit secretary added before she passed his call on to the nurse of the patient he was calling about. “Suzy took a message for you a while ago. The infertility clinic called about a half-hour ago. They said your parts were in.” The moral of that story? Write it so they can read it, I guess. If you come up with something else, let me know. Thanks to Ed for sharing his story with me. If you have a funny story or something that I can stick onto the end of the column, let me know. Send it to KEvers@MSMAonline.com and label it “Uncommon Thread.” She’ll make sure I get it, or you can send it to me at RSAnderson@JARMC.org. See you next time, R. Scott Anderson, MD, a radiation oncologist, is medical director of the Anderson Regional Cancer Center in Meridian and past vice chair of the MSMA Board of Trustees. Additionally, he is an accomplished oil-painter and dabbles in the motion-picture industry as a screen-writer, helping form P-32, an entertainment funding entity.

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