March 2014 JMSMA

March

VOL. LV

2014

No. 3

Endangered species?

Are medical journals an endangered species? Not on your life. Scientific publications help keep your skills up to date. Your Journal of the Mississippi State Medical Association is alive and kicking with new features, a new Editorial Advisory Board, and more scientific articles than ever before. Don’t be a dodo. Read the Journal online and in print. Contact us for information on cost-efficient advertising opportunities.

Karen A. Evers, Managing Editor, 601.853.6733

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 James A.Rish, MD President Claude Brunson, MD President-Elect Michael Mansour, MD Secretary-Treasurer R. 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.

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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© 2014 Mississippi State Medical Association.

MARCH 2014

VOLUME 55

NUMBER 3

Scientific Articles The eFAST Examination for Trauma Triage

72

Brian Tollefson, MD

Prevalence and Trends in Overweight and Obesity among Mississippi Public School Students, 2005-2013 Lei Zhang, PhD; Jerome R. Kolbo, PhD; Melissa Kirkup; Elaine Fontenot Molaison, PhD; Bonnie L. Harbaugh, PhD, RN; Nichole Werle, MSW; Evelyn Walker, MD, MPH

President’s Page Towards a Smoke-Free Mississippi

88

James A. Rish, MD; MSMA President

Editorial Save the Date: Marston Symposium

100

Richard D. deShazo, MD; Associate Editor

Departments From the Editor: Access to Care Problematic in State MSMA: Nominating Committee Seeks Vacancies for MSMA Offices Poetry in Medicine Letters Una Voce: The Albatross and the Dodo

70 90 93 94 103

About The Cover:

Yard Art - Pictured is an old rotary-style hay rake, hung on the fence and repurposed as yard art. As the popularity of yard art has grown in the South, there is a whole category of sophisticated metal garden art made from the parts and pieces of old farm implements. Some artists have used the materials to design and build intricate sculptures sure to catch your eye. This photograph was taken by retired otolaryngologist Myron W. Lockey, MD, who served as Journal MSMA editor from 1983-1998. Dr. Lockey is now chair of the JMSMA Editorial Advisory Board. He and his wife Martha live in Madison. Dr. Lockey took the photo in a neighbor’s backyard adjacent to their leisure home in Ocean Springs. r March

VOL. LV

Official Publication

80

2014

No. 3

of the MSMA Since 1959

March 2014 JOURNAL MSMA 69

From the Editor: Access to Care Problematic in State

M

ost Mississippians wrongly think that difficulty with access to health care in our state is a thing of the past. It’s not, and it may have been better decades ago than now. In rural areas, access equates to rural hospitals and physician numbers, both of which are under stress. In rural Mississippi, even if one has health insurance, many patients face long drives to their physicians and hospitals. What happens if the physician has to close his office due to increasing financial stressors? What happens if many of our rural hospitals close or significantly reduce their services? A new study published in the February Southern Medical Journal asserts that if Medicaid is expanded in Mississippi, without adequate rural hospitals and physicians, such may not improve access or health status of patients. It is not as much about insurance in rural Mississippi as it is about access to caregivers.

With the creation of the physician workforce office, efforts are being made to improve rural physician numbers.

What about the status of our rural hospitals? They are in crisis in Mississippi. Most have low censuses, with poor, elderly, and vulnerable patients. Obamacare’s 20% Medicare cut for

all hospitals is going to be particularly hurtful for our struggling rural hospitals.

Most hospitals are currently reducing their staffs to anemic levels, which can barely provide the needed hospital services. As well, the so-called “onesies and twosies,” the small one or two partner primary care practices, are struggling to survive, facing Lucius M. Lampton, MD increasing costs of operation. Both rural hospitals and small medical practices must be helped, because in no uncertain terms they are our front-line of access to care in rural areas.

Etched on the lamp outside Dr. Albert Schweitzer’s jungle hospital at Lambarene, Gabon were the following words: “Here, at whatever hour you come, you will find light and help and human kindness.” Is this not what we as physicians seek for our patients? We need both physicians and rural hospitals to give this to all Mississippians.

Contact me at lukelampton@cableone.net.

—Lucius M. “Luke” Lampton, MD, Editor

Journal Editorial Advisory Board Myron W. Lockey, MD Chair, JMSMA Editorial Advisory Board Journal MSMA Editor Emeritus, Madison Timothy J. Alford, MD Family Physician, Kosciusko Medical Clinic Michael Artigues, MD Pediatrician, McComb Children’s Clinic Diane K. Beebe, MD Professor and Chair, Department of Family Medicine, University of MS Medical Center, Jackson Claude D. Brunson, MD Senior Advisor to the Vice Chancellor for External Affairs, University of Mississippi Medical Center, Jackson Jeffrey D. Carron, MD Associate Professor, Department of Otolaryngology & Communicative Sciences, University of Mississippi Medical Center, Jackson

Gordon (Mike) Castleberry, MD Urologist, Starkville Urology Clinic Mary Currier, MD, MPH State Health Officer Mississippi State Department of Health, Jackson

Bradford J. Dye, III, MD Ear Nose & Throat Consultants, Oxford Daniel P. Edney, MD Executive Committee Member, National Disaster Life Support Education Consortium, Internist, The Street Clinic, Vicksburg

70 JOURNAL MSMA March 2014

Paul “Hal” Moore Jr., MD Radiologist Singing River Radiology Group, Pascagoula

Owen B. Evans, MD Professor of Pediatrics and Neurology University of Mississippi Medical Center, Jackson

Jason G. Murphy, MD Surgeon

Surgical Clinic Associates, Jackson

Maxie L. Gordon, MD Assistant Professor, Department of Psychiatry and Human Behavior, Director of the Adult Inpatient Psychiatry Unit and Medical Student Education, University of Mississippi Medical Center, Jackson

Ann Myers, MD Rheumatologist Mississippi Arthritis Clinic, Jackson

Scott Hambleton, MD Medical Director Mississippi Professionals Health Program, Ridgeland John Edward Hill, MD Family Physician, North Mississippi Medical Center Tupelo W. Mark Horne, MD Internist, Jefferson Medical Associates, Laurel Brett C. Lampton, MD Internist/Hospitalist, Baptist Memorial Hospital, Oxford

Philip L. Levin, MD President, Gulf Coast Writers Association Emergency Medicine Physician, Gulfport

William Lineaweaver, MD Sharon Douglas, MD Editor, Annals of Plastic Surgery Professor of Medicine and Associate Dean for VA Medical Director Education, University of Mississippi School of Medicine, JMS Burn and Reconstruction Center, Jackson Associate Chief of Staff for Education and Ethics, G.V. Montgomery VA Medical Center, Jackson Michael D. Maples, MD Vice Preisdent, Chief of Medical Operations Baptist Health Systems, Jackson Thomas E. Dobbs, MD, MPH State Epidemiologist Mississippi State Department of Health, Hattiesburg

Alan R. Moore, MD Clinical Neurophysiologist Muscle and Nerve, Jackson

Darden H. North, MD Obstetrician/Gynecologist Jackson Health Care-Women, Flowood Jimmy L. Stewart, Jr., MD Program Director, Combined Internal Medicine/ Pediatrics Residency Program, Associate Professor of Medicine and Pediatrics University of Mississippi Medical Center, Jackson Samuel Calvin Thigpen, MD Hematology-Oncology Fellow, Department of Medicine University of Mississippi Medical Center, Jackson Thad F. Waites, MD Clinical Cardiologist, Hattiesburg Clinic W. Lamar Weems, MD Urologist, Jackson Chris E. Wiggins, MD Orthopaedic Surgeon Bienville Orthopaedic Specialists, Pascagoula John E. Wilkaitis, MD Chief Medical Officer Brentwood Behavioral Healthcare, Flowood

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• Scientific Articles • The eFAST Examination for Trauma Triage Brian Tollefson, MD

[This is the first in a potential series of articles on bedside clinician-performed ultrasound. Each article is intended to give the primary care provider an overview of the basic knowledge required to use ultrasound in the clinic or emergency room to facilitate rapid and accurate diagnoses and treatment decisions. After reviewing the articles and practicing the exams, even the novice sonographer should feel comfortable performing and interpreting the basic ultrasound exams. Just remember the key to success in ultrasound is practice, practice, practice.

The following topics are being considered for a primary care ultrasound series: • eFAST • Cholecystitis • AAA • Hydronephrosis • DVT • Cardiac • Ectopic pregnancy • Tendinopathy • Abscess and foreign body • Central line placement If you have an interest in further articles on bedside clinician-performed ultrasound as outlined above, please let us know. You may contact the managing editor at (601)853-6733 or KEvers@MSMAonline.com.]

—Richard deShazo, MD, Associate Editor

I

ntroduction

The use of bedside clinician-performed ultrasound in trauma began to take shape in the 1980s. Later the Residency Review Committee (RRC) for Emergency Medicine established a requirement that all emergency medicine residents receive training in ultrasonography.1 Consequently, recent emergency medicine residency graduates perform and interpret a wide variety of ultrasound exams. Unfortunately, ultrasound training is still not commonplace in most primary care residency programs.

Author Affiliation and Correspondence: Brian Tollefson, MD, FACEP, RDMS, RMSK, CAQ Sports Medicine, Director of Emergency Ultrasound, Assistant Professor of Emergency Medicine, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216. Ph: (601) 984-5144 (btollefson@umc.edu).

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Modern ultrasound machines are simple to use and relatively inexpensive to own and operate. Reimbursement for clinician-performed and interpreted ultrasound examinations can certainly offset the cost to purchase and maintain a quality ultrasound machine.

Though not currently required, it is highly recommended that a clinician obtain formal ultrasound training prior to using ultrasound to make clinical decisions. Ultrasound machine manufacturers typically offer some introductory training with the purchase of an ultrasound machine. Additional formal ultrasound training can be accomplished by attending CME courses.

Hospital credentialing committees will typically require a provider to complete a specified number of supervised ultrasound exams before granting clinical privileges to use ultrasound for patient care.

General ultrasound concepts and definitions:

1. Probe selection—probe selection is typically determined by the depth of penetration needed for a particular exam.

In general, probes are divided into high-frequency and low-frequency based on the range of frequencies produced by the probe.

• Low-frequency probes (curvilinear) allow deeper imaging but have lower resolution.

• High-frequency probes (linear) have better resolution but do not image very deeply.

2. Probe orientation—probe orientation is important to keep in mind while scanning. There is a marker on one end of the probe and on one side of the monitor (Figure 1). The markers allow the sonographer to maintain orientation of the underlying anatomy as the probe is moved across the area of interest. In general, the probe marker should point toward the patient’s right side if imaging in the transverse plane and toward the patient’s head if imaging in the longitudinal plane.

3. Echogenicity—echogenicity describes the intensity of the reflected sound waves. Highly reflected sound waves are displayed on the monitor as white (bright) whereas less highly reflected sound waves are displayed in varying

Figure 1A and B. Screen (A) and probe (B) markers: The screen marker is displayed as a small round dot (top left corner of the image). Each probe has a marker on one side of the handle (labeled in image above) that directly relates to the side of the image with the screen marker. The tissue imaged on the side of the probe with the marker is displayed on the side of the screen with the marker.

shades of gray. Non-reflected sound waves are displayed as black: • Anechoic = completely black (no reflection) • Hypoechoic = darker than surroundings (weak reflection) • Hyperechoic = brighter than surroundings (strong reflection) • Isoechoic = same echogenicity as surroundings 4. Knobology—knobology refers to the use of the ultrasound control knobs to manipulate the image displayed on the screen. Although the control panels of different ultrasound machines may appear dissimilar, all ultrasound machines have essentially the same basic functions. Learning to use the control knobs to optimize the quality of the image is an important part of scanning. Following are a few of the more commonly used controls: • Depth—this function changes the depth of the image displayed on the monitor. Depth is probably the most commonly used function. Adjusting the depth allows the area of interest to remain in the center of the viewing screen.

• Gain—this function changes the brightness of the echo signals displayed on the screen. It is a post-processing function, so it does not affect the resolution or overall quality of the image. It simply makes the image brighter.

• Freeze—as the name implies, this function freezes the image to allow the sonographer to measure, annotate and/or save the image.

• Save—this function saves the displayed image to the storage database to allow the image to be viewed or exported after the exam is complete.

5. Definitions commonly used in ultrasound: • Cephalad—toward the head

• • • •

• • • •

Caudal—toward the feet Longitudinal—long axis of body or organ Transverse—short axis of body or organ Hemoperitoneum—presence of blood in the peritoneal cavity Hemothorax—presence of blood in the pleural space Hemopericardium—presence of blood in the pericardial sac Sonographic artifact—something seen on the ultrasound image that does not exist in reality Acoustic window—the body tissue through which

sound waves will be transmitted.

Ultrasound in trauma

The use of clinician-performed ultrasound is well established in the setting of blunt and penetrating torso trauma. The Focused Assessment with Sonography in Trauma (FAST) exam is used to quickly examine for the presence of occult hemorrhage. The FAST exam is recommended as an adjunct to the physical exam in the last edition of Advanced Trauma Life Support (ATLS).2 The FAST exam should be performed immediately after the primary survey and can easily be completed in less than 5 minutes.3 This article will describe how to perform and interpret the extended FAST (eFAST) exam. Although the exam is very sensitive and specific for the presence of significant hemoperitoneum, hemothorax, hemopericardium and pneumothorax, it is vital to recognize the limitations of the eFAST exam. Specifically, the eFAST exam performs poorly in its ability to detect solid and hollow organ injuries as well as retroperitoneal bleeding.3 In general, the eFAST exam should be used as a triage tool to make timely treatment decisions and expedite patient movement to definitive care (Figure 11). One should not rely solely on a negative eFAST exam to rule out significant abdominal or thoracic injuries.

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Clinical Scenario

Imagine you are the sole-provider in a small emergency facility in rural Mississippi. With little warning, the paramedics rush into the ER with an unstable trauma patient. The medic reports that the 24-year-old male patient was involved in a highspeed motor vehicle accident. The patient was unrestrained and required prolonged extrication. Initially, he was mildly hypotensive and tachycardic but improved with a fluid bolus.

Vital signs on arrival to the ER are BP 90/50, P 120, and O2 Sat 100% on a non-rebreather facemask. You quickly assess the patient and determine that he has a Glasgow Coma Scale (GCS) of 15, a rapid-thready pulse and equal breath sounds.

You also note significant tenderness and ecchymosis along his left flank and left upper abdomen. The abdomen is otherwise soft and has normal bowel sounds. A portable chest x-ray reveals multiple rib fractures on the left but no evidence of pneumothorax. Next you quickly perform an eFAST exam where you identify a left-sided pneumothorax (not evident on CXR) and a significant amount of intra-abdominal free-fluid.

Less than 10 minutes has elapsed from the time the patient presented to your ER. You now have the information you need to begin care for the patient and call for helicopter transport to the trauma center in Jackson. In your report to the trauma center, you confidently state that you have a potentially unstable blunt trauma patient with a pneumothorax, multiple rib fractures and hemoperitoneum due to suspected splenic injury. Prior to transport, you successfully place a chest tube and decide to hold further fluid infusion per permissive hypotension protocol.4

The eFAST exam

The eFAST exam is very useful in the evaluation of the trauma patient, and it is a simple skill to master.6 Although the eFAST exam is highly specific for free-fluid in the abdominal cavity, the sensitivity varies widely in different studies (6396%), largely related to the skill and experience of the operator.3 For this reason it is probably more appropriate to use the eFAST exam to ‘rule-in’ rather than definitely exclude pathology.

A low-frequency curvilinear probe should be used for the majority of eFAST exams to optimize depth of imaging. Although not necessary, switching to the high-frequency linear probe to evaluate for pneumothorax will improve resolution for this more superficial portion of the exam. As you perform the eFAST exam, pay close attention to probe orientation as the probe and screen markers are directly related. This concept is somewhat difficult to grasp initially but will make sense Table1.1.eFAST eFASTexam exam overview.

Table overview.

Position Position Perihepaticview view Perihepatic Perisplenicview view Perisplenic Suprapubic Suprapubicview view Subxiphoid Subxiphoidview view Intercostal Intercostalview view

Potential findings Potential findings hemoperitoneum right hemothorax hemoperitoneum andand right hemothorax hemoperitoneum hemothorax hemoperitoneum andand leftleft hemothorax hemoperitoneum hemoperitoneum hemopericardium hemopericardium pneumothorax pneumothorax

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as you start scanning. In general, when scanning in the transverse plane, the probe marker should point toward the patient’s right side; and when scanning in a longitudinal plane, the probe marker should point toward the patient’s head. Throughout the exam, the patient must remain supine to allow free-fluid (blood) to pool in the expected dependent locations.

In the acute setting, blood in the form of free-fluid typically appears anechoic on ultrasound. Free-fluid is shapeless and formless, thus taking on the shape of its container. As time passes (1-2 hours), the blood may start to coagulate and, as a result, become more echogenic or even isoechoic.

Perihepatic view

The perihepatic view allows identification of bleeding in the intra-abdominal cavity (hemoperitoneum) and right hemithorax. Start with the probe oriented longitudinally on the patient’s right flank in the mid-axillary line at the expected location of the right kidney (Figure 2A). The probe marker should point cephalad. From this position slide the probe along the body until an image of Morison’s pouch is obtained (Figure 2B). Use plenty of ultrasound gel between the probe and skin to decrease sound wave attenuation and improve image quality.

Morison’s pouch is a potential space between the liver and right kidney. If free-fluid is present in the abdominal cavity, the fluid is most likely to accumulate in Morison’s pouch regardless of the site of injury. Fluid in Morison’s pouch will be seen as an anechoic stripe between the liver and kidney (Figure 3A).

Keep in mind that the displayed image at any given point in time is two-dimensional (similar to a single CT cut). To completely image a given region, slowly and sequentially move the probe across the entire area of interest. The dependent locations for intra-abdominal free-fluid in the perihepatic view include between the liver and kidney (Morison’s pouch), between the liver and diaphragm, and at the inferior pole of the right kidney.

Small amounts of free-fluid may not be noticed without visualizing the entire perihepatic area, especially the inferior pole of the right kidney (Figure 3B).

Next move the probe slightly more cephalad to look for free-fluid in the right pleural space (hemothorax). The normal air-filled lungs prevent the transmission of sound waves to deeper tissues. As a result, two characteristic sonographic artifacts are produced cephalad to the diaphragm: (1) a mirror image of the liver is displayed cephalad to the diaphragm and (2) the spine abruptly cuts off at the level of the diaphragm. A hemothorax would be indicated by fluid accumulation cephalad to the diaphragm, lack of mirror image artifact and continuation of the spine past the diaphragm (Figure 2B).

Perisplenic view

Similar to the perihepatic view, start with the probe oriented longitudinally along the left flank at the expected location of the left kidney with the probe marker pointed cephalad (Figure 4A). The most dependent area for free-fluid in the perisplenic

Figure 2A and B. Probe position and normal sonographic anatomy of perihepatic view. Start with the probe oriented longitudinally in the right midaxillary line at roughly the 7-9th intercostal space. The probe marker should point cephalad (as indicated by the arrow). Slowly and sequentially slide the probe along the flank to completely evaluate the perihepatic area. Look for free-fluid (blood) both above and below the diaphragm as described above. Also look for the two expected sonographic artifacts: mirror image of liver cephalad to the diaphragm and abrupt cutoff of the spine at the diaphragm. These artifacts will be absent in the presence of hemothorax.

Figure 3A and B. Perihepatic images from two different blunt abdominal trauma patients. In figure 3A, an anechoic stripe of free-fluid is clearly visible in Morison’s pouch. In the setting of trauma, this finding is assumed to represent intra-abdominal bleeding. Figure 3B shows a free-fluid collection visible only at the inferior pole of the right kidney. Again this finding is consistent with intra-abdominal bleeding. The second case demonstrates the importance of scanning the entire perihepatic area to avoid missing subtle signs of intra-abdominal hemorrhage.

Figure 4A and B. Probe position and normal sonographic anatomy of perisplenic view. Start with the probe oriented longitudinally in the left posterior-axillary line at roughly the 5-7th intercostal space (slightly more cephalad and posterior than the perihepatic view). The probe marker should point cephalad (as indicated by the arrow). Slowly and sequentially slide the probe along the flank to completely evaluate the perisplenic area while observing for free-fluid (blood) both above and below the diaphragm. Also look for the two expected sonographic artifacts: mirror image of spleen cephalad to the diaphragm and abrupt cutoff of the spine at the diaphragm. These artifacts will be absent in the presence of hemothorax.

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Figure 5A and B. Perisplenic images from two different blunt trauma patients. In figure 5A, an anechoic stripe of free-fluid is seen completely surrounding the spleen. In the setting of trauma, this finding is assumed to represent intra-abdominal bleeding. The image in figure 5B shows clear evidence of a substantial hemothorax. A large amount of anechoic free-fluid is noted directly above the diaphragm. Also note that the two expected sonographic artifacts are not present: there is no mirror image of the spleen cephalad to the diaphragm, and the spine continues cephalad to the diaphragm.

region is the splenorenal pouch between the spleen and left kidney and between the spleen and diaphragm (Figure 4B). Again, it is important to thoroughly evaluate the entire perisplenic area for free-fluid. Acute bleeding usually appears anechoic on ultrasound (Figure 5A). Novice sonographers may find the perisplenic view somewhat more difficult to obtain than the perihepatic view.7 This difficulty is mostly due to the smaller acoustic window provided by the spleen as compared to that provided by the liver. It is helpful to start with the probe positioned slightly more posterior and cephalad compared to the perihepatic view to account for the difference in kidney position.

Next, look cephalad to the left hemidiaphragm to evaluate for the presence of free-fluid in the pleural space. Again the spine should appear to abruptly end at the diaphragm and a mirror image of the adjacent organ (spleen) should be visualized above the diaphragm in a normal exam. Free-fluid in the pleural space will be indicated by (1) an anechoic layer above

the diaphragm, (2) the continuation of the spine cephalad to the diaphragm, and (3) a lack of the expected mirror image of the spleen cephalad to the diaphragm.

Suprapubic view

Like the previous two views, the suprapubic view (Figure 6A and B) is used to evaluate for hemoperitoneum. The dependent area for free-fluid to collect in the male pelvis is the rectovesical pouch which is a potential space formed by the reflection of the peritoneum from the rectum to the bladder. In the female, the dependent location is the rectouterine pouch (pouch of Douglas) formed by reflection of peritoneum from the rectum to the back wall of the uterus (Figure 6B). Overflow from the pelvic region can travel via the paracolic gutters to the upper abdomen and vice versa. Therefore, the presence of fluid in a particular intra-abdominal location does not necessarily correspond to the site of injury. It is important to do this

Figure 6A and B. Transverse probe position and normal sonographic anatomy of suprapubic view (male). Start with the probe oriented transversely just above the pubic bone and angled into the pelvis. The probe marker should be pointed toward the patient’s right side (as indicated by arrow). Look for free-fluid between the rectum and bladder (rectovesical pouch) in the male and between the rectum and uterus (pouch of Douglas) in the female.

Also look for free-fluid adjacent to the bladder and between loops of bowel. Free-fluid will typically be anechoic and in the dependent location. Also examine the area in the longitudinal plane by rotating the probe 90-degrees clockwise (probe marker cephalad).

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about 6 cm. After the heart is captured in the image, the depth can be adjusted to place the area of interest in the center of the screen.

If the stomach is full of air, scattering of the sound beam may result making visualization of the heart difficult. To avoid imaging through the stomach, slide the probe slightly to the patient’s right. This will allow imaging of the heart through the left lobe of the liver which makes a much better acoustic window than the air-filled stomach. Once the heart is found, attempt to obtain a 4-chamber image (Figure 8B). The dependent area for pericardial fluid in the subxiphoid view is the pericardial space between the liver and right side of the heart.

Intercostal view Figure 7. Transverse suprapubic image showing free-fluid (male).

This patient sustained blunt abdominal trauma and was found to have free-fluid (blood) in the vesicorectal pouch. The free-fluid is seen as an anechoic area between the bladder and rectum.

portion of the eFAST exam prior to placement of a Foley catheter if possible. A full bladder acts as an acoustic window and allows much better visualization of the deeper structures. If the bladder has already been emptied, image quality and accuracy can be improved by instilling saline into the bladder. Figure 7 shows free intra-peritoneal fluid in the vesicorectal pouch via the suprapubic view.

Subxiphoid cardiac view

Evaluation for pericardial fluid is especially important in penetrating trauma to the chest or upper abdomen. In the acute setting, even a small amount of pericardial fluid can cause significant hemodynamic compromise. The subxiphoid cardiac view (Figure 9) can be challenging to obtain in some patients, especially the obese or those with significant abdominal pain.

To image the heart from the subxiphoid position, start with the depth set out to the maximal level. Maximal depth is necessary because the distance from the probe to the heart is typically

The anterior intercostal view is used to assess for pneumothorax (Figure 10A). Traditionally, the standard screening test for a traumatic pneumothorax is a supine chest xray. Because air trapped in the pleural space layers anteriorly, the supine chest xray is notoriously inaccurate. The anterior intercostal ultrasound exam has a much higher sensitivity than xray for the detection of a pneumothorax. The sensitivity of ultrasound for pneumothorax is similar to that of CT.8 The ultrasound technique to evaluate for a pneumothorax involves looking at the anterior pleural line between two adjacent ribs for lung sliding and comet tail artifacts. Lung sliding is the back-and-forth movement of the visceral pleura synchronized with respiration. A comet tail is an ultrasound artifact caused by the reverberation of the ultrasound wave between the two highly reflective pleural layers. A comet tail appears as a bright line projecting perpendicular and deep from the pleural line and is produced only when the two layers (visceral and parietal pleura) are in close contact (lung inflated). Lung sliding and comet tails are expected findings in a normal exam, and absence of these two findings strongly suggests the presence of a pheumothorax. A rough estimate of the size of the pneumothorax can be attained by sequentially examining the entire

Figure 8A and B. Probe position and normal sonographic anatomy of supxiphoid cardiac view. Start with the probe positioned transversely in the subxiphoid position with the probe marker pointed toward the patient’s right (as indicated by the arrow). Flatten and angle the probe toward the patient’s left shoulder. The dependent area for pericardial fluid in the subxiphoid view is between the liver and right side of the heart.

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anterior and lateral chest. Ultrasound evidence of intrapleural air laterally suggests a more extensive pneumothorax.

References 1. Moore C, Molina A, Lin H. Ultrasonography in community emergency departments in the United States: Access to ultrasonography performed by consultants and status of emergency physician—performed ultrasonography. Annals of Emergency Medicine. 2006;47:147-153.

2. American College of Surgeons Committee on Trauma. Advanced trauma life support. 8th edn. Chicago: American College of Surgeons, 2008.

3. Patel N, Riherd J. Focused Assessment with Sonography for Trauma: Methods, accuracy, and indications. Surg Clin N Am. 2011;91:195-207.

4. Geeraedts LM Jr, Kaasjager HA, van Vugt AB, et al. Exsanguination in trauma: A review of diagnostics and treatment options. Injury.

2009;40(1):11-20.

5. Natarajan B, Gupta P, Cemaj S, et al. FAST scan: Is it worth doing in hemodynamically stable blunt trauma patients? Surgery.

2010;148(4):695-700.

6. Walcher F, Kirschning T, Muller M, et al. Accuracy of prehospital focused abdominal sonography for trauma after a 1-day hands-on training course.

Emerg Med J. 2010;27:345-349.

7. Jang T, Kryder G, Sineff S, et al. The technical errors of physicians learning to perform focused assessment with sonography in trauma. Acad Emerg Med. 2012;19(1):98-101.

8. Raja AS, Jacobus CH. How accurate is ultrasonography for excluding pneumothorax? Ann Emerg Med. 2013;61(2):207-8.

Figure 9. Subxiphoid cardiac view demonstrating pericardial effusion.

A small pericardial effusion is noted as an anechoic stripe between the liver and right side of the heart. Even a small amount of pericardial fluid is significant in the setting of penetrating trauma. The patient can quickly decompensate with the development of pericardial tamponade.

Figure 10A and B. Probe position and normal anatomy of intercostal view. Start with probe positioned longitudinally on the mid-clavicular line over the 2nd or 3rd intercostal space. The probe marker should be pointed cephalad (as indicated by the arrow). Sequentially slide the probe down the anterior and then lateral chest wall stopping at each intercostal space to evaluate for signs of a pneumothorax. The ultrasound image in figure 10B shows a normal pleural line with a comet tail artifact. Lung sliding cannot be appreciated on a still image but was present in this normal exam.

Figure 11. Algorithm for blunt abdominal trauma. The algorithm is based primarily on the clinical status of the patient and eFAST findings. A single negative eFAST exam should not be used to definitively rule out significant intra-abdominal bleeding or injury. A negative eFAST exam should be followed by either a CT scan or serial eFAST exams depending on the stability of the patient. Ultrasound is most useful in the unstable blunt abdominal patient where an eFAST scan showing intraabdominal free-fluid would be an indication to take the patient directly to the OR for exploratory laparotomy without first obtaining a CT scan.5

78 JOURNAL MSMA March 2014

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• Scientific •

Prevalence and Trends in Overweight and Obesity among Mississippi Public School Students, 2005-2013 Lei Zhang, PhD; Jerome R. Kolbo, PhD; Melissa Kirkup; Elaine Fontenot Molaison, PhD; Bonnie L. Harbaugh, PhD, RN; Nichole Werle, MSW; Evelyn Walker, MD, MPH

A

bstract

This study estimated the prevalence of overweight and obesity in Mississippi public school students in grades K-12 and assessed changes in the prevalence between 2005 and 2013. In 2013, Body Mass Index was calculated using measured height and weight data for a weighted representative sample of 4,402 public school students. Additional analyses compared 2013 prevalence estimates by gender, race, and grade levels and for changes between 2005 and 2013. The prevalence of overweight and obesity among public school students no longer appears to be increasing although no significant downward trend was observed (p = 0.0862), and rates remain higher than national averages. In 2013, the combined prevalence of overweight and obesity for all students in grades K-12 was 41.8%, as compared to 40.9% in 2011, 42.4% in 2009, 42.1% in 2007 and 43.9% in 2005. Significant decreases in overweight and obesity were found among white students and elementary school students from 2005 to 2013. White students’ combined rates fell from 40.6% in 2005 to 36.8% in 2013 (p = 0.0007).

Similarly, combined rates in elementary school students dropped from 43.0% in 2005 to 38.0% in 2013 (p = 0.0002).

Additionally, 2013 marked the first year that a significant decline in obesity prevalence was noted among elementary school students, from 25.0% in 2005 to 22.0% in 2013 (p = 0.0163). In 2013, the prevalence of obesity was significantly higher among black students (p < 0.001) and middle school students (p = 0.048). These findings are discussed in light of Author Information: Director of the Office of Health Data and Research in the Mississippi State Department of Health and a Professor in the School of Nursing at the University of Mississippi Medical Center (Dr. Zhang). Professor in the School of Social Work at the University of Southern Mississippi (Dr. Kolbo). Graduate student in the Department of Social Work at the University of Southern Mississippi (Ms. Kirkup). Professor in the Department of Nutrition & Food Systems at the University of Southern Mississippi (Dr. Molaison). Professor in the School of Nursing at the University of Southern Mississippi (Dr. Harbaugh). Research support staff member at the University of Southern Mississippi (Ms. Werle).

Director of the Office of Health Promotion and Health Equity in the Mississippi State Department of Health (Dr. Walker).

Corresponding Author: Lei Zhang, PhD, MBA; Office of Health Data and Research, Mississippi State Department of Health, Phone: (601) 576-8165 Fax: (601) 576-8168 (lei.zhang@msdh. ms.gov).

80 JOURNAL MSMA March 2014

recent state-wide educational and policy initiatives and on health disparities. Implications for future practice, policy and research are presented.

Key Words: Childhood, Overweight, Obesity, Trends.

Introduction Recurring cross-sectional study of the prevalence of overweight and obesity among Mississippi public school students indicates that the rates of these conditions have remained at high and relatively stable levels since 2005. According to the Child and Youth Prevalence of Obesity Surveys (CAYPOS), 1-5 a primary source of obesity data in Mississippi, no significant differences in the combined prevalence rates of obesity and overweight were observed between 2005 (43.9%) and 2011 (40.9%).

Legislative response to this public health issue has been popular among individual states across the nation, with 475 childhood obesity-related bills enacted between 2006-2009.7 Mississippi implemented legislation aimed at combating childhood obesity through school environment modifications beginning in 2006. These multifaceted changes included mandates for establishing school wellness policies, new beverage regulations, and more stringent nutrition, physical activity and physical education standards.4,8-16 As such, alterations in the school environment may be partly responsible for the stabilization of overweight and obesity rates over time.

Trends in the overweight and obesity rates of Mississippi students mirror those documented in a nationwide sample; the most recent National Health and Nutrition Examination Survey (NHANES) also showed no significant changes in the percentage of obesity among US children aged 2 to 19 years between 2003-2004 and 2005-2006, nor between 19992010.6 Though Mississippi rates have similarly plateaued, they remain stubbornly high as compared to the nationwide 31.8% combined rate observed in the NHANES. Likewise, nationwide racial disparities identified by NHANES have also been expressed at the state level in Mississippi since 2007. The prevalence of obesity was significantly higher among black students than white students in 2007 (25.7% vs. 21.0%), in 2009 (27.4% vs.19.5%), and in 2011 (27.8% vs. 19.5%). While this racial disparity was only significant among elementary school

students in 2009, significant disparities were observed among black and white students at all grade levels in 2011, indicating a worsening in this schism. Gender by race differences in this disparity were first observed in 2009 and persisted in 2011 with significant differences observed on obesity rates between black and white females at all three grade levels. No such differences were observed between black and white males.

Encouraging findings of the 2005-2011 CAYPOS included a significant decline in obesity and overweight among white students and elementary school students. Between 2005 and 2011, the combined prevalence of overweight and obesity dropped significantly for white students from 40.6% to 34.8%, and dropped significantly from 43.0% to 37.3% among elementary school students. Despite the progress made among certain subgroups of Mississippi students, overall rates remain high. The negative health outcomes associated with obesity are well-documented. Such health risks are global in their clinical impact and include increased risk of cardiovascular disease, diabetes, musculoskeletal disorders, psychological problems, and risky health behaviors. These risks may persist into adulthood.17-29 Considering the vast implications for the public health landscape of Mississippi, the purpose of this study was to continue monitoring the prevalence of obesity and overweight among public school children amidst increased prevention efforts.

Methods The 2013 CAYPOS sampling frame consisted of 480,321 students in 889 public schools offering kindergarten or any combination of grades 1 through 12 in Mississippi. The sample design was a two-stage stratified probability design.1-4 The first stage included the random selection of 95 schools. A systematic sample of schools was drawn with probability proportional to the enrollment in grades K-12 of each school. In the second stage of sampling, classes were randomly selected within the sampled schools. Classes were selected using equal probability systematic sampling. All eligible students in the selected classes were asked to participate in the survey. The sample was designed to yield a self-weighting sample so that every eligible student had an equal chance of selection, thereby improving the precision of the estimates.

As in each of the previous years, the weighting process was intended to develop sample weights so that the weighted sample estimates accurately represented the entire K-12 public school students in Mississippi. Every eligible student was assigned a base weight which was equal to the inverse of the probability of selection for the student. Adjustments were made to the initial weights to remove bias from the estimates and reduce the variability of the estimates.

The most recent CAYPOS (2013) was conducted in March and April 2013. The study received continued institutional review board approval through the Human Subjects Committee at the University of Southern Mississippi, as the study protocol

matched the five prior CAYPOS.1-4 As with all of the previous CAYPOS, once selected schools agreed to participate and classes were chosen, a written protocol, measuring equipment (i.e., digital scales and stadiometers) and passive consent forms were delivered to the schools. Each school designated a school nurse who was responsible for collecting data and had been trained on the use of equipment. Two or three days before data collection began, students in the selected classes were read a prepared paragraph containing information about the study.

Each student was then given a passive parental consent form to take home to parents or guardians. If a parent did not want his or her child to participate in the study, the parent was instructed to indicate such on the form, sign it, and have the child return it to the teacher. Prior to the collection of height and weight, the nurse would check with the teacher to determine if any students returned a signed form. Students who returned a signed form did not participate in the study. There were neither consequences for nonparticipation nor rewards for participation.

As with all the previous CAYPOS, the protocol for making measurements required that the weight scale be placed on a hard, smooth surface; carpeted areas were not to be used.

The scale was calibrated to zero before use and recalibrated after every 10th student. All students were weighed and measured in a location where the information gathered would be confidential. Other students were not able to read the scale or height measurement or hear a weight or height given. Nurses reported the height and weight, rounded to the nearest whole inch or quarter pound, respectively, along with age, gender, date of birth, racial or ethnic background, and the school code number. No allowance was made for weight of clothing; however, students were asked to remove belts, heavy jewelry, jackets, and shoes. No student names were written on the data collection forms.

Nurses returned the completed data forms to The University of Southern Mississippi by fax or mail. This data was then entered into Excel by a Research Assistant. The completed database was submitted for statistical analysis to identify prevalence rates and trends of the whole and various subgroups. All completed data forms were destroyed once data had been entered and analyzed.

Data Analysis Body Mass Index (BMI) was computed for each responding student based on height (in meters) and weight (in kilograms). The height in feet and inches was first converted to meters. The weight in pounds was then converted to kilograms.

BMI was calculated using the SAS program, gc-calculate-BIV. sas as follows: BMI = Weight (in kg)/[Height (in m)]2. BMI values were checked to ensure that the results were biologically plausible, using the limits developed by the Centers for Disease Control and Prevention (CDC). BMI percentiles were computed using the SAS program, gc-calculate-BIV.sas.

Children and adolescents were classified into four categories:

March 2014 JOURNAL MSMA 81

(1) underweight (BMI is less than the 5th percentile); (2) normal Table 1. Characteristic of Participants, CAYPOS, Grades Table 1. Characteristic of Participants, CAYPOS, Grades K-12, weight (BMI is equal to or greater than the 5th but less than the K-12, Mississippi, 2013 Mississippi, 2013 85th percentile); (3) overweight (BMI is greater than the 85th but Characteristic Unweighted count Weighted percent less than the 95th percentile); and (4) obese (BMI is greater than Gender th 33 or equal to the 95 percentile).

Male 2,313 52.6 Female 2,089 47.4 SUDAAN 11.0134 was used to calculate weighted estiRace mates and standard errors. Proc Crosstab procedure was used White 1,826 41.8 Black 2,358 53.4 to compare prevalence of child overweight and obesity among Other 218 4.8 different subgroups, such as gender, race, and grade level. DifGradea Elementary ferences were assessed independently for each survey year and K 327 7.3 considered statistically significant if the p-values from the Chi1st 469 9.8 2nd square tests were less than 0.05. For comparisons of subgroups 371 8.5 3rd 346 7.3 with more than two levels (e.g., obesity by gender by race by 4th 435 9.7 grade, etc.), no statistical tests were conducted due to substan5th 294 6.3 Middle school tially decreased sample sizes and possibly unreliable estima6th 326 8.1 tions. The comparison of the 95% confidence intervals (CIs) 7th 404 9.9 8th 171 3.9 between two estimates was simply used for these situations; High school differences between estimates were considered statistically sig9th 392 8.8 10th 300 6.8 nificant if their associated 95% CIs did not overlap. The esti11th 267 6.7 mate and its 95% CI were marked as unreliable if the sample 12th 286 6.6 Missing 14 0.3 size was less than 50. In addition, SUDAAN logistic regresTotal 4,402 100 sion procedure was used to investigate linearity of the Table 2. Prevalence of Overweight and Obesity by Grade Level and Gender, Race, CAYPOS, Table 2. Prevalence of Overweight and Obesity by Grade Level and Gender, Race, CAYPOS, longitudinal trends in overMississippi, 2013 Mississippi, 2013 weight and obesity. Since elapsed time was the same All (K-12) Elementary (K-5) Middle school (6-8) High school (9-12) (%, 95% CI) (%, 95% CI) (%, 95% CI) (%, 95% CIc) between successive CAYAll POS surveys, the logistic Overweighta 18.2 (16.9-19.6) 16.0 (14.3-17.9) 21.6 (18.6-25.0) 19.3 (17.0-21.8) regression used orthogonal Obesityb 23.6 (22.0-25.3) 22.0 (19.7-24.4) 27.3 (23.8-31.2) 23.5 (20.6-26.7) variables to model longituWhite dinal trends while controlOverweight 17.1 (15.0-19.4) 14.5 (11.7-17.7) 21.5 (16.5-27.4) 17.8 (14.5-21.6) Obesity 19.7 (17.3-22.2) 15.8 (13.4-18.6) 26.2 (20.4-33.1) 20.6 (16.3-25.7) ling for studentsâ&#x20AC;&#x2122; gender, Black race, and grade level. The Overweight 19.1 (17.2-21.2) 16.9 (14.4-19.7) 21.9 (17.3-27.4) 20.8 (18.3-23.6) linear coefficient (-2, -1, 0, Obesity 26.7 (24.5-28.9) 26.4 (23.4-29.8) 28.6 (25.2-32.3) 25.7 (21.9-29.8) Male 1, 2) and quadratic coeffiOverweight 17.5 (16.1-19.1) 16.5 (14.5-18.6) 20.2 (16.0-25.1) 17.3 (14.9-19.9) cients (2, -1, -2, -1, 2) were Obesity 23.1 (21.2-25.1) 21.3 (18.8-24.0) 26.6 (22.7-31.0) 23.4 (20.1-27.1) assigned over the years Female Overweight 18.9 (17.0-21.1) 15.5 (12.9-18.6) 23.3 (20.2-26.9) 21.4 (18.1-25.3) 2005, 2007, 2009, 2011, Obesity 24.1 (21.9-26.6) 22.8 (19.6-26.2) 28.2 (23.8-33.0) 23.6 (19.0-28.9) and 2013, respectively.

Results Characteristics of Participants from the 2013 CAYPOS Eighty-three of the 95 schools sampled participated in the study (87.4%). The student response rate was 84.2% (4,402 participating students/ 5,226 sampled students). Thus, the overall response rate was 73.6% (product of school response

White male Overweight Obesity Black male Overweight Obesity White female Overweight Obesity Black female Overweight Obesity

16.8 (14.3-19.6) 21.1 (18.3-24.1)

16.2 (12.1-21.2) 15.3 (12.2-19.2)

19.1 (8.8-36.5)* 27.0 (13.7-46.3)

16.0 (13.2-19.4)* 24.7 (19.0-31.6)

18.0 (16.2-20.0) 24.3 (21.7-27.0)

16.6 (14.7-18.5) 24.9 (21.0-29.1)

21.1 (9.6-40.3)* 26.5 (16.8-39.2)

18.5 (15.1-22.6) 21.5 (16.5-27.4)

17.3 (14.5-20.6) 18.0 (15.0-21.4)

12.6 (9.1-17.1) 16.4 (12.6-21.1)

24.7 (12.9-42.0)* 25.2 (13.4-42.5)*

20.1 (13.7-28.5)* 15.4 (8.8-25.7)*

20.1 (17.1-23.5) 29.1 (26.3-32.1)

17.3 (12.8-22.9) 28.2 (23.9-32.9)

22.8 (14.1-34.7)* 30.9 (23.1-40.0)

22.7 (17.6-28.8) 29.3 (23.4-35.9)

Body mass index (BMI) > 85th percentile and < 95th percentile for age and gender.

Body mass index (BMI) > 95th percentile for age and gender. a b

95% confidence interval. * Sample size is less than 50. The estimates may not be reliable.

c

82 JOURNAL MSMA March 2014

rate and student response rate), which was above the threshold of 60% required to obtain weighted estimates. The final sample consisted of 4,402 students in grades K-12, including 2,313 males (52.6%), 2,089 females (47.4%), 1,826 white students (41.8%), 2,358 black students (53.4%), and 218 students from other racial/ethnic backgrounds (4.8%) (Table 1). The number of students in other race categories was too small for separate analysis, and, therefore, was not included in the comparison analyses.

Results of 2013 CAYPOS Based on Subgroups of Participants As a group, 23.6% of the children and youth in grades K-12 were classified as obese and another 18.2% of the children were classified as overweight giving a combined total of 41.8% of the children and youth at or above the 85th percentile for BMI for age and gender (Table 2).

Gender In 2013, 23.1% of males were classified as obese, with another 17.5% as overweight (40.6% combined). As for females, 24.1% were obese and another 18.9% were overweight (43.0% combined).

Race

In terms of race, 19.7% of the white students were classified as obese, with another 17.1% as overweight (36.8% combined). Among the black students, 26.7% were obese and 19.1% were overweight (45.8% combined). The prevalence of obesity for black students was significantly higher than white students (p < 0.001).

Grade Level Among elementary level students (grades K-5), 22.0% were classified as obese, with 16.0% classified as overweight (38.0% combined). Among the middle school students (grades 6-8), 27.3% were obese and 21.6% were overweight (48.9% combined). Among the high school students (grades 9-12), 23.5% were obese and 19.3% were overweight (42.8% combined). Differences in the prevalence of obesity by grade level were statistically significant (p = 0.048).

Gender and Race As for gender and race, among white males, 21.1% were obese and 16.8% were overweight (37.9% combined). Among black males, 24.3% were obese and 18.0% were overweight (42.3% combined).

Among white females, 18.0% were obese and 17.3% were overweight (35.3% combined). Among black females, 29.1% were obese and 20.1% were overweight (49.2% combined).

The prevalence of obesity for black females was significantly higher than white females.

Race and Grade Level Among all students, the highest rates of overweight and obesity were at the middle school level regardless of race.

Among white students, 26.2% were obese and 21.5% were

overweight (47.7% combined) at the middle school level; 15.8% were obese and 14.5% were overweight (30.3% combined) at the elementary school level; and 20.6% were obese and 17.8% were overweight (38.4% combined) at the high school level (Figures 1-3).

Among black students, 28.6% were obese and 21.9% were overweight (50.5% combined) at the middle school level; 26.4% were obese and 16.9% were overweight (43.3% combined) at the elementary grade level, and 25.7% were obese and 20.8% were overweight (46.5% combined) at the high school level.

In elementary grade level, obesity prevalence was significantly higher among black students compared to white students (p < 0.001).

Gender, Race, and Grade Level When race and gender were combined at the elementary level, 16.4% of white females were obese and 12.6% were overweight (29.0% combined). Among black females, 28.2 % were obese and 17.3% were overweight (45.5% combined). At the middle school level, 25.2% of white females were obese and 24.7 % were overweight (49.9% combined). Among black females, 30.9% were obese and 22.8% were overweight (53.7% combined). At the high school level, 15.4% of white females were obese and 20.1% were overweight (35.5% combined).

Among black females, 29.3% were obese and 22.7% were overweight (52.0% combined). A similar pattern was observed among white males compared to black males. At elementary grade level, 15.3% of white males were obese and 16.2% were overweight (31.5% combined). Among black males, 24.9% were obese and 16.6% were overweight (41.5% combined).

At the middle school level, 27.0% of white males were obese and 19.1% were overweight (46.1% combined). Among black males, 26.5% were obese and 21.1% were overweight (47.6% combined). At the high school level, 24.7% of white males were obese and 16.0% were overweight (40.7% combined). Among black males, 21.5% were obese and 18.5% were overweight (40.0% combined). At elementary grade level, the differences in rates of obesity between white and black females and between white and black males were statistically significant.

Overweight and Obesity Trends While the prevalence of overweight and obesity among students in grades K-12 has dropped from 43.9% in 2005 to 41.8% in 2013, neither a linear (p = 0.0862) nor a quadratic change (p = 0.3359) was observed (Figure 4). However, the combined prevalence of overweight and obesity for white students (40.6% in 2005 and 36.8% in 2013) has shown a significant linear decrease (p = 0.0007) (Figure 5). Also, a significant linear drop was observed in the prevalence of combined overweight and obesity among the elementary school students between 2005 (43.0%) and 2013 (38.0%) (p = 0.0002) (Figure 6). A separate analysis also revealed a significant linear decrease in the prevalence of obesity alone among the elementary school students during the same period (p = 0.0163).

March 2014 JOURNAL MSMA 83

In addition, a significant quadratic change was shown among the middle school students (p = 0.0146), indicating a decline in combined overweight and obesity prevalence from 2005 to 2007, then an increase from 2007 to 2013.

Discussion The 2013 CAYPOS data further support the previously noted trend of sustained prevalence rates of overweight and obesity among Mississippi public school students since 2005.

A slight, but not statistically significant, decline in rates since 2005 was observed (43.9% combined rate vs. 41.8% combined rate). The finding is consistent with stabilization in rates over time observed both nationwide from 1999-2010.

These combined findings represent a departure from trends of dramatic increases in the prevalence rate among children nationwide between 1980-2004.30 This indicates that dire predictions of exceptionally high childhood obesity rates based upon the assumption of steady compounded increases over time may not come to fruition.

p = 0.037

Declines in combined prevalence of overweight and obesity among elementary school students and white students remained statistically significant from 2005 to 2013. Additionally, 2013 marked the first year that a significant decline in obesity prevalence was noted among elementary school students. A quadratic change in combined prevalence rates among middle school students from 2005 to 2013 indicated an early decline from 2005 to 2007 but changed direction with an increase from 2007 to 2013. This made a significantly higher obesity prevalence rate among middle school students as compared to elementary and high school students in 2013.

Combined overweight and obesity rates declined significantly among elementary school students from 2005

p < 0.001

p =0.678

p = 0.100

28

p = 0.033

p = 0.058

25

84 JOURNAL MSMA March 2014 29 26

(43.0%) to 2013 (38.0%). Obesity rates for this group also declined during the same period (25.0% vs. 22.0%).

The structural design of CAYPOS does not allow for determination of whether continued declines in prevalence rates among elementary school students are due to schoolbased interventions at the elementary level or whether they are indicative of family and community level changes that occur prior to children entering school. However, obesity prevalence studies conducted in Oregon and Arkansas among elementary school students may lend some insight.

In 2013, researchers in Oregon observed steady increases in the prevalence of obesity among elementary school students from grades K-5.31 A similar pattern was found in Arkansasâ&#x20AC;&#x2122; 2012 comprehensive prevalence study.32 Rates of overweight and obesity steadily increased from grades K-6; rates peaked at grade 6 before declining among older middle school and high school students. A number of possibilities have been posited to explain this trajectory including increased weight gain due to pubertal changes, decrease in physical activity, and differences in lifestyle as children age.31 Trajectories such as those observed in these studies appear to indicate that family/community interventions prior to entering school may be responsible for the drop in rates as the obesity rate increased at each ascending elementary school grade level. This is counter to what would be expected if school-based interventions were responsible for the change.

Another significant finding from the 2013 study was that obesity rates among white students continued to decline since 2005 (22.9% vs. 19.7%) while rates among black students remained roughly the same over this time period (27.6% vs.

26.7%). Among elementary school students, this difference was highly significant in obesity status among black- and white females. However, the significant differences in obesity prevalence among black and white students at all three grade levels observed in the 2011 CAYPOS were not present in 2013.

Significant differences persisted only at the elementary school grade level. Though this finding suggests an improvement, racial disparities remain.

Documented racial differences in early-life factors such as lower breastfeeding rates, earlier introduction of solid foods, higher rates of excessive maternal weight gain in pregnancy, rapid weight gain in infancy, higher rates of fast food intake, and lower levels of sleep in infancy among blacks as compared to whites may predispose black children to overweight and obesity.33 Racial disparities emerging as early as pre-school have been documented in the literature and support the theory that black children may enter school at a disadvantage to their white peers in regards to weight status.34 This is a plausible explanation for the vast disparity seen between obesity prevalence rates of white and black elementary school students in the CAYPOS. The 2013 CAYPOS data reveal that obesity prevalence rates are more stable across grade level for black students

than for white students. This finding is consistent with a previous longitudinal study of over 17,000 children which found that black children, females in particular, have fewer downward transitions from overweight or obese status than do white children.35 Previous researchers suggest that becoming overweight or obese at a young age may, in turn, create favorable conditions for developing health problems that adversely affect childrenâ&#x20AC;&#x2122;s abilities or motivation to participate in health behaviors that may reduce their risk of continued overweight or obesity. Findings such as these underscore the importance of early intervention.

Emerging gender divergences in the context of racial disparity in obesity rates, first noted in 2009, continue to be apparent in data collected in 2013 with black females having a significantly higher obesity prevalence rate than white females. Though the mechanisms of this relationship are not well understood, researchers have identified differences in the responses to obesity experienced by white and black females which suggest cultural differences in the ways these racial groups ascribe meaning to obesity. For example, white obese females have a significantly higher occurrence of mental health problems including depression, suicide ideation, and risky sexual behavior tied to feelings of worthlessness than do black obese females. No significant differences were found in these relationships when comparing obese white males to obese black males.36 It is hypothesized that black obese females possess a culturally-based protective factor in which their weight status is not considered to be indicative of their personal value while white obese females possess no such factor.37 While such a factor is undeniably beneficial in preventing many of the adverse psychological effects of obesity in black females, it may also provide clemency from social pressure to maintain a healthy weight. The promotion of social and cultural norms that preserve the protective psychological benefits of self-acceptance while introducing increased emphasis on the prevention of physical ailments via pursuit of healthy weight status may be a useful intervention for this population.38-40 Broader consideration of the results of the CAYPOS study over the past decade both yields promising results and highlights areas of future concern. The stabilization of overweight and obesity rates is an auspicious development in the fight to contain and decrease rates of childhood overweight and obesity. These findings provide confirmation that Mississippi is on pace with the rest of the nation in suppressing the expansion of childhood obesity rates. Since 2005, Mississippi has seen significant drops in combined prevalence rates of overweight and obesity among the elementary school population, which may indicate positive behavioral alterations within the family or community. Yet, such gains are not enjoyed equally among all Mississippi public school students. Racial disparities between the prevalence of obesity in black and white students continue to be a cause for concern.

Though this study is methodologically strong in its use

March 2014 JOURNAL MSMA 85

of weighted, representative sampling of public school districts throughout the state, it is limited in not examining the extreme outliers on both ends of the weight spectrum. Surveillance of severe obesity is an important component of depicting accurate trends of changes in weight status over time. While comprehensive rates of nationwide childhood obesity have been stabilizing since 2004, researchers indicate that severe obesity in childhood is on the increase..41 This increase in severe obesity is primarily seen among racial minorities, a population already identified as at-risk by current CAYPOS research. On the opposite end of the spectrum, new research suggests that underweight may be on the rise among pre-school, primary school, and adolescent children in developed countries. Young underweight children have been found to have poorer measures of global health and require more special health-care needs than normal weight children.42 It is possible that increases in underweight may play a role in the sharp declines in obesity seen in elementary school students in CAYPOS research.

Undoubtedly, additional questions remain, even as current CAYPOS research has shed light on several aspects of the nature of childhood overweight and obesity in Mississippi. Inquiry into these matters is warranted in order to gain a comprehensive awareness and understanding of trends in childhood weight status across Mississippi public school students.

Acknowledgements Funding for this study was through a grant from the Bower Foundation through the Center for Mississippi Health Policy.

The authors wish to thank Westat, Inc., for their assistance in the sampling and weighting of the data and to thank the Mississippi schools, school nurses, and personnel who were so instrumental in collecting the data.

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Kolbo JR, Armstrong MG, Blom L, Bounds W, Molaison E, Dickerson H, Harbaugh B, Zhang L. Prevalence of obesity and overweight among children and youth in Mississippi: Current trends in weight status. J Miss Med Assoc. 2008;49(8):231-237.

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Kolbo JR, Zhang L, Molaison EF., Harbaugh B, Hudson GM, Armstrong MG, Werle, N. Prevalence and trends in obesity among Mississippi public school students,, 2005-2011. J Miss Med Assoc. 2012;(53)5:140-146.

6. Eyler A, Nguyen L, Jooyoung K, Yan Y, Brownson R. Patterns and predictors of enactment of child obesity legislation in the

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United States, 2006-2009. Am J Public Health, 2012;102, 22942302.

7. Ogden C, Carrol M, Kit B, Flegal K. (2012). Prevalence of Obesity and Trends in Body Mass Index among US Children and Adolescents 1999-2010. 2102. Website. http://www.ncbi.nlm. nih.gov/pubmed/22253364. Assessed December 26, 2013.

8. SB 2369, amending Mississippi Code of 1972 Annotated Section 37-13-134.

Website. http://billstatus.ls.state.ms.us/ documents/2007/html/SB/2300-2399/SB2369SG.htm. Accessed December 26, 2013.

9. United States Department of Agriculture, Food and Nutrition Services. Section 204 of Public Law 108-265-Child Nutrition and WIC Reauthorization Act of 2004. 2004. Website. http://www. fns.usda.gov/cnd/governance/legislation/historical/pl_108-265. pdf. Accessed December 26, 2013.

10. Mississippi Department of Education, Mississippi Office of Healthy Schools. Beverage Regulations for Mississippi Schools.

2006. Website. http://www.cn.mde.k12.ms.us/documents/VendingRegForMSSchools06.pdf. Accessed December 26, 2013.

11. Mississippi Legislature, Senate. The Mississippi Students Act. 2007. Website. http://billstatus.ls.state.ms.us/documents/2007/ pdf/ham/Amendment_Report_for_SB2369.pdf. Accessed December 26, 2013.

12. Mississippi Department of Education, Office of Innovation and School Improvement Office of Accreditation Mississippi Public School Accountability Standards 2012. 2012. Website. http:// www.mde.k12.ms.us/docs/accreditation-library/revised-10-9-122012-stds.pdf. Accessed December 26, 2013.

13. Mississippi Department of Education. Mississippi Healthy Students Act Senate Bill 2369 Nutrition Standards. 2007. Website. http://www.healthyschoolsms.org/documents/MississippiHealthyStudentsActSenateBill2369NutritionStandards_000.pdf.

Accessed December 26, 2013.

14. Mississippi Secretary of State, Administrative Procedures.

Physical Education/Comprehensive Health Education Rules and Regulations. 2007. Website. http://www.mde.k12.ms.us/mississippi-board-of-education/board-of-education-policy-manual/ policy-4000-healthy-and-safe-schools/policy-4012-physical-education-comprehensive-health-education-rules-and-regulations.

Accessed December 26, 2013.

15. Molaison EF, Howie S, Kolbo J, Zhang L, Rushing K, Hanes M. Comparison of the local wellness policy implementation between 2006 and 2008. J Child Nutr Manag. 2011;35(1).

16. Kolbo J, Molaison EF, Rushing K, Zhang L, Green A. The 2008 School Wellness Policy Principalâ&#x20AC;&#x2122;s Survey. 2008. Website. http:// www.mshealthpolicy.com/documents/2008_wellness_surveyFINALREPORT.pdf. Accessed December 1, 2011.

17. Baker JL, Olsen LW, Sorensen TIA. Childhood body-mass index and the risk of coronary heart disease in adulthood. N Engl J Med. 2007;357(23):2329-2337.

18. Bibbins-Domingo K, Coxson P, Pletcher MJ, Lightwood J, Goldman L. Adolescent overweight and future adult coronary heart disease. N Engl J Med. 2007; 357(23)2371-2379.

19. Farhat T, Iannotti RJ, Simons-Morton BG. Overweight, obesity, youth, and health-risk behaviors. Am J Prev Med. 2010;38(3):258267.

20. Freedman DS, Khan LK, Serdula MK, Ogden CL, Dietz WH. Racial and ethnic differences in secular trends for childhood BMI, weight and height. Obes. 2006;14(2):301-308.

21. Gordon-Larsen P, Adair LS, Popkin BM. The relationship of ethnicity, socioeconomic factors, and overweight in U.S. adolescents. Obes Res. 2003;11(1):121-129.

22. Ludwig DS. Childhood obesity â&#x20AC;&#x201C; The shape of things to come. N Engl J Med. 2007; 357(23);2325-2327.

23. Must A, Anderson SE. Effects of obesity on morbidity in children and adolescents. Nutr Clin Care. 2003;6(1):4-12.

24. Arens R, Muzumdar H. Childhood obesity and obstructive sleep apnea syndrome. J Appl Physiol. 2009. Website. doi: 10.1152/ japplphysiol.00689.2009.

25. Daniels SR, The consequences of childhood overweight and obesity. Future Child. 2006;16(1):47-67.

26. Rowland K, Coffey J. Are overweight children more likely to be overweight adults? J Fam Pract. 2009;58(8):431-432.

27. Sjoberg RL, Nilsson KW, Leppert J. Obesity, shame and depression in school aged children: A population-based study.

Pediatr, 2005,116,389-392.

28. Thompson DR, Obarzanek E, Franko D, Barton B, Morrison J, Biro F, et al. Childhood overweight and cardiovascular disease risk factors: The National Heart Lung & Blood Institute Growth and Health Study. Pediatr. 2007;150:18-25.

29. Weiss R, Dziura J, Burgert TS, Tamborlane WV, Taksali SE, Yeckel CW, Allen K, Lopes M, Savoye M, Morrison J, Sherwin RS, Caprio S. Obesity and the metabolic syndrome in children and adolescents. N Engl J Med. 2004;350:2362-2374.

30. Wang Y, Beydoun M. The obesity epidemic in the United Statesgender, age, socioeconomic, racial/ethnic, and geographic characteristics: A systematic review and meta-regression analysis.

Epidemiol Rev. 2007;29,6-28.

31. Moreno G, Johnson-Shelton D, Boles S. Prevalence and Prediction of Overweight and Obesity among Elementary School Students. J Sch Health. 2013;83,157-163.

32. Arkansas Center for Health Improvement, Year Nine Assessment of Childhood and Adolescent Obesity in Arkansas (Fall 2011-Spring 2012), Little Rock, AR: ACHI, November 2012.

33. Taveras EM, Gillman MW, Kleinman K, Rich-Edwards JW, Rifas-Shiman. Racial/ethnic differences in early-life risk factors for childhood obesity. Pediatr. 2010;125:686-695.

34. Kimbro R, Brooks-Dunn J, McLanahan S. Racial and ethnic differentials in overweight and obesity among 3-year-old children. Am J Public Health. 2007;97,298-305.

35. Rendall M, Weden M, Fernandes M, Vaynman I. Hispanic and Black U.S. childrenâ&#x20AC;&#x2122;s paths to high adolescent obesity prevalence.

Pediatr Obes. 2012;7,423-435.

36. Whaley A, Smith M, Hancock A. ethnic/racial differences in the self-reported physical and mental health correlates of adolescent obesity. J Health Psychol. 2011;16,1048-1057.

37. Granberg EM, Simons LG, Simons RL. Body size and social self-image among adolescent African-American girls: The moderating influence of family racial socialization. Youth Soc. 2009 December 1; 41(2): 256-277.

38. Klesges RC, Obarzanek E, Kumanyika S, Murray DM, Klesges LM, et al. The Memphis girls health enrichment multi-site (GEMS): An evaluation of the efficacy of a two-year obesity prevention intervention in African-American girls. Arch Pediatr Adolesc Med. 2010; 164(11):1007-1014.

39. Newton RL Jr., Han H, Anton SD, Martin CK, Stewart TM, et al.

An environmental intervention to prevent excess weight gain in African-American students: A pilot study. Am J Health Promot.

2010;24(5):340-343.

40. Robinson TN, Matheson DM, Kraemer HC, Wilson DM, Obarzanek E, et al. A randomized control trial of culturallytailored dance and reducing screen time to prevent weight gain in low-income African-American girls: Stanford GEMS. Arch Pediatr Adolesc Med. 2010; 164(11):995-1004.

41. Wang Y, Gortmaker S, Taveras E. Trends and racial disparities in severe obesity among U.S. children and adolescents, 1976-2006.

Int J Pediatr Obes. 2011;6,12-20.

MEA Welcomes Our New

42. Wake M, Clifford S, Patton G, Waters E, Williams J, Canterford L, Carlin J. Morbidity patterns among the underweight, overweight, and obese between 2 and 18 years of age: population-based crosssectional analyses. Int J Obes. 2013;37,86-93.

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xpress your opinion in the Journal MSMA through a letter to the editor or guest editorial. Letters for publication should be less than 300 words. Guest editorials or comments may be longer, with an average of 600 words. All letters are subject to editing for length and clarity. If you are writing in response to a particular article, please mention the headline and issue date in your letter. Also include your contact information.

While we do not publish street addresses, e-mail addresses or telephone numbers, we do verify authorship, as well as try to clear up ambiguities, to protect our letter-writers. You may submit your letter via email to KEvers@MSMA online.com or mail to: P.O. Box 2548, Ridgeland, MS 39158-2548.

March 2014 JOURNAL MSMA 87

• President’s Page • Towards a Smoke-Free Mississippi

I

would be remiss as your MSMA president if I did not publicly applaud the recent decision by CVS Pharmacies to remove all James A. Rish, MD tobacco products from the shelves of their retail stores nationwide 2013-14 MSMA President effective October 1, 2014. This is not only a pivotal public health statement but also an important recognition of the implied mission of the pharmacies and health care providers in general to improve the health of the patients they serve. By virtue of this new policy, CVS estimates that this will result in a loss of over a billion dollars in sales revenue for the company. That’s no small change. It is enlightening to see a company of the magnitude of CVS put social responsibility ahead of the bottom line.

It is no accident that this announcement falls on the heels of the 50th anniversary of the surgeon general’s report Smoking and Health,1 detailing some of the most harmful effects of smoking. This report was the product of the review of an estimated 7,000 documents. The report concluded that “cigarette smoking is causally related to lung cancer in men; the magnitude of the effect of cigarette smoking outweighs all other factors; and the risk of developing lung cancer increases with the duration of smoking and number of cigarettes smoked per day, and diminishes by discontinuing smoking.”1 The report was released on a Saturday so as to minimally impact the financial markets. The importance of this report has been enormous. It has fundamentally changed the way we view tobacco use in the United States. This report paved the way to the warning label required to be on every pack of cigarettes sold in the United States and has influenced the tide of public health policy relating to tobacco consumption.

Evidence of the effectiveness this report has had on tobacco consumption can be seen in the overall marked decline in prevalence of adult smoking in the United States. The prevalence of adult smokers in the United States in 1965 was about 42%. In 2012, the estimated prevalence was 18% with comparable declines in per capita cigarette consumption.2 Sadly, the prevalence in Mississippi is estimated to be the sixth highest in the nation at about 26%. Moreover, on any given day approximately 3,800 US adolescents smoke their first cigarette. Over a quarter of these adolescents will go on to become lifetime cigarette smokers. Although we have come a long way, we have a long way to go.

Being not only your MSMA president in charge of improving the health of all Mississippians, I am also a busy practicing pulmonologist in a large pulmonary group. I see firsthand the ravages of chronic tobacco use in our patients on a daily basis.

Between the nine of us, we average diagnosing a case of lung cancer every day. That’s just in our facility. There is no doubt that the societal burden of tobacco use remains enormous. MSMA has long advocated smoke-free policies for Mississippi, both at the state and municipal level. MSMA has continued to lead the charge for clean indoor air. As we have witnessed, the powerful profitdriven tobacco and casino industries have successfully thwarted our efforts at the legislative levels. We have had a great deal of success at the municipality level. Last year the Mississippi State Department of Health received a national award recognizing Mississippi having the most cities to go smoke-free in 2013.

We must continue our efforts at all levels and with all available tools including a possible statewide referendum. We simply cannot and will not ignore the fact that, according to the FDA, tobacco is responsible for 480,000 deaths in the United States alone. Tobacco use in Mississippi significantly contributes to our poor health outcomes compared to the other 49 states. We are second in the nation in the rate of cancer deaths. We have the highest rate of low birth weight babies, and we have one of the highest rates of death due to cardiovascular diseases. Smoking is at the heart of this.

88 JOURNAL MSMA March 2014

I urge each and every one of you to join the conversation and speak out to your local civic leaders and legislators for smoke free air. The battle has been raging on for over 50 years, and I suspect will continue for that many more. We must keep chipping away at this public health scourge patient by patient and city by city.

Will the CVS announcement make a big dent in the overall prevalence of smoking in Mississippi and the United States?

Unfortunately the determined tobacco consumer, who continues to ignore the loudly proclaimed health consequences of smoking, will move down the street to any number of readily accessible stores that sell tobacco products to quench their crave. However, the announcement does send a powerful message that CVS is in the business of health care, eliminating the long existing paradox of a health care enterprise the magnitude of CVS selling products that actually destroy your health. It is our sincere hope that other giant retail pharmacies across our nation the likes of Fred’s, Walmart, and Walgreens will do the socially responsible thing and follow suit.

In closing, I’d like to ask for your participation in a simple membership survey printed on pages 91-92. It’s short, and your input will help MSMA better serve you.

MSMA President James A. Rish, MD; Tupelo

References 1. US Department of Health, Education and Welfare. Smoking and Health: Report of the Advisory Committee to the Surgeon General of the Public Health Service, PHS Publication No. 1103. Washington, DC: US Dept of Health, Education and Welfare, Public Health Service; 1964.

2. Centers for Disease Control and Prevention, National Health Interview Survey. Adult Cigarette Smoking in the United States: Current Estimate. http://www.cdc.gov/tobacco/data_statistics/fact_sheets/adult_data/cig_smoking/.

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March 2014 JOURNAL MSMA 89

• MSMA • Committee Seeks Candidates for Vacancies in MSMA Offices

D

elegates attending the 146th MSMA Annual Session August 15-16, 2014 in Jackson will cast ballots to fill new terms of office for a number of association posts. The Nominating Committee is seeking input from the membership as the committee prepares a slate of nominees. The list of nominees developed by the Nominating Committee will be published to the entire membership before June 15, 2014. Eligibility: All nominees must be active members of the association.

No physician may be put forth on the ballot unless that physician has expressed a willingness to serve if elected.

Nominations for Vacancies: A chart follows listing the vacancies that will be filled by election at the 146th Annual Session in 2014. The names of incumbents, the length of each term of office and the incumbent’s eligibility to be re-elected are indicated. Nominating Committee: The Nominating Committee is composed of the nine most recent Past Presidents of the association residing in Mississippi. The Immediate Past President is the chair.

MSMA VACANCIES 2014

EMAIL NOMINATIONS to CKanosky@ MSMAonline.com or contact any member of the Nominating Committee: Steve Demetropoulos, MD; Tom Joiner, MD; Tim Alford, MD; Randy Easterling, MD; Pat Barrett, MD; Dwalia South, MD; Eric Lindstrom, MD; Helen Turner, MD and Steve Parvin, MD.

OFFICERS & TRUSTEES

INCUMBENT

COUNCILS

INCUMBENT

President-Elect

CLAUDE D. BRUNSON

Budget & Finance at large

JENNIFER GHOLSON

Trustee District 4

CLAY HAYS, JR.

Constitution & Bylaws at large

PHILIP MERIDETH

Trustee District 6

JEFFREY MORRIS

Legislation District 6

CHRIS MAULDIN

Trustee District 7`

DANIEL P. EDNEY

Legislation District 7

J. ANN REA

Trustee District 8

LEE VOULTERS

Legislation District 8

LEE VOULTERS

Trustee, Resident/Fellow

JANE BEEBE JONES

Legislation Resident

JULIA THOMPSON

Trustee, Medical Student HOUSE OF DELEGATES

SAVANNAH DUCKWORTH INCUMBENT

Legislation Student

LUKE CONNER AINSWORTH

Medical Education District 1

KATHERINE PATTERSON

Speaker of the House

R. LEE GIFFIN

Medical Education District 3

J. MURRAY ESTESS, JR.

Vice Speaker of the House JOURNAL MSMA

GERI WEILAND INCUMBENT

Medical Service District 1

ALFIO RAUSA

Medical Service District 2

BILL MAYO

Editor Associate Editor

LUCIUS LAMPTON

Medical Service District 3

LAURA GRAY

STANLEY HARTNESS

Medical Service Resident

TAL HENDRIX

Terms of Office: President-elect: 1 year 2014-2015; Officers, Trustees & Medical Service Student Councils (physicians): 3 years 2014-2017; Trustees & Councils (students & Public Information District 4 residents): 1 year 2014-2015. Speaker and Vice Speaker: 3 years 2014-2017; Journal Editor: 3 years 2014-2017; Journal Associate Editor: 2 years 2014- Public Information District 5 2016.Incumbents NOT eligible for re-election are noted as strikethrough.

Public Information District 6

90 JOURNAL MSMA March 2014

EMILY BRANDON JENNIFER BRYAN DEWITT CRAWFORD CHRISTIE THORNTON

Please take time to fill out this MSMA Membership Survey In an effort to better serve our membership, MSMA will be surveying its membership and local medical societies regarding current and potential services rendered. Thank you for your time in completing this survey. We value your membership and participation in our Association. Please complete this survey and mail to Attn: Hannah Duchesne P.O. Box 2548 Ridgeland, MS 39157 1. Please place a check next to the option which best describes how many years have you been a

member of MSMA? o o o o

Less than a year 1yr-5yrs 5yrs-10yrs 10yrs+

2. What is your age? ___________ 3. In which county do you practice? _________________________

4. Which of these options best describes your practice? o o o o o o

Independent practice Employed Hospitalist Medical Officer Retired Other: _____________________________

5. Mark the frequency with which you have attended each MSMA event as a member. 

CME in the Sand



Annual Session of the House of Delegates



Local Medical Society Meetings



Doctor of the Day at the Capitol



Prescribers Summit



Foundation Cadaver Course 5K



Other: ______________________________

Every year

Every year

Every meeting

Every year

Every year

Every year

Every year

Almost every year

Once or twice

Never

Once or twice

Never

Once or twice

Never

Almost every year

Once or twice

Never

Almost every year

Once or twice

Never

Once or twice

Never

Once or twice

Never

Almost every year

Almost every meeting

Almost every year

Almost every year

6. CIRCLE: Have you attended the same MSMA event more than once?

YES

NO

March 2014 JOURNAL MSMA 91

7. Mark what type of events would you like to see more of in the future? o o o o

Social/Networking opportunities CME events Practice management classes Other: ___________________________

8. Indicate with what frequency you read each MSMA publication.  Weekly Lifeline e-newsletter Every week

Most of the time

If I happen to see it

Almost never

Always trash it

If I happen to see it

Almost never

Always trash it

If I happen to see it

Almost never

Always trash it

Almost never

Always trash it



Monthly Journal MSMA



Weekly Physicians’ Position e-blast



Weekly Advocate legislative update (January-April)

Every month

Every week

Every week

Most of the time

Most of the time

Most of the time

If I happen to see it

9. MARK: From which MSMA member service do you feel you benefit from most? o o o o o

Legislative advocacy Networking opportunities with physician colleagues CME Staying up to date with the latest medical news Practice management tools

10. What services could MSMA offer to better serve your practice? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 11. Select one of the two options below. Would you be willing to participate in a focus group to

discuss MSMA membership? o

YES! Email me at _________________________ or call me at _____________________.

o

No, thank you.

WHEN COMPLETE, PLEASE MAIL TO: PO BOX 2548, RIDGELAND, MS 39157 or FAX TO: (601)853-6746

92 JOURNAL MSMA March 2014

• Poetry and Medicine • [This month, we print another poem from “Coronary” by Benjamin A. Morris, a Mississippi born poet who lives in New Orleans. Morris is the son of Hattiesburg urologist and MSMA member Dr. Toxey M. Morris. “Sedation” provides a family view of the alien world of medicine when a loved one is hanging on for dear life. Published in 2011, “Coronary” includes 24 sonnets all centered on a similar theme: his personal experience of his father Toxey’s illness and hospitalization. (Toxey is in good health today!) The lovely volume includes original artwork by Dr. Morris on its cover. Now in its third edition, copies are available at independent bookstores in the New Orleans area and at Main Street Books in Hattiesburg. Benjamin is the author of numerous works of poetry, fiction, nonfiction, and drama. He has received many honors for his writing, including a fellowship for poetry from the Mississippi Arts Commission. More information, including how to purchase “Coronary,” is available at benjaminalanmorris.com. Any physician is invited to submit poems for publication in the journal, attention: Dr. Lampton or email me at lukelampton@cableone.net]—Ed.

Donor The blood bank called today. I can’t give blood, or even plasma, due to the shots I’m taking. Consider this: I’m O-positive, the near-universal donor, and I’m not able to give blood back to the man who gave me mine. Even though you taught me to lie on all the forms provided―no ma’am, I’ve never left the county, much less the country― the cells speak nothing but the truth. I would donate my blood, my veins, or my heart would any of it bring you back, but the cold facts stand between us. Deception is an art that meets its nemesis in science; our blood still whispers even in its silence.

—Benjamin A. Morris, New Orleans

March 2014 JOURNAL MSMA 93

• Letters • A Deafening Silence: Has Expressive Aphasia Afflicted Mississippi Physicians?

Dear JMSMA Editor:

H

istory will record that apathy and malaise brought an eerie silence to a once vibrant Association that mattered.

It was a strange time when our own arrogance trumped sound public health principles; when raw politics transcended reason and goodness and mercy; when working men and women along with their children were forsaken, an oath revoked, and an ideology prevailed.

Ticker tape rained down upon Capitol Street and snuffed out enlightenment and reason. One man’s political script was worth more than a billion dollars.

It was when we physicians became so self-important that we put ourselves beyond reach of those whom we would claim to help. Standing in the hallowed halls of Mississippi once again, quoting our abysmal state of health was enough if we were somber when we said it and wore our white coats.

It was a time when rural health systems collapsed amidst indifference and when emergency rooms filled to overflowing; a time when the working man should have just worked harder or gotten a third job – an extra route here, an extra customer checked out, a truckload on Sunday even. Come on, working man – work harder!

We promise solutions… “waivers” and help are coming, and we will create them from the dust.

It seemed that our own heart had stopped, and our soul had left our body. Silence and then a faint song was heard: “Ah, bless the child of the working man – she knows too soon who she is And bless the hands of a working man – oh he knows her soul is his!

So it goes like it goes like the river flows and truth it rolls right on And maybe what is good gets a little bit better and maybe what’s bad gets gone.”* At that moment we said, “Enough is enough” like we should have all along because finally, we heard the truth in song.

—Timothy J. Alford, MD; Past President, MSMA Kosciusko *Lyrics from theme song of Norma Rae, 1979 – David Shire/Norman Gimbel.

Dr. Alford adds as a postscript to his letter: “An article entitled ‘From Singing to Speaking’ in Stroke Connection magazine September/October 2005 states: ‘It is amazing to see stroke survivors who have lost the ability to speak suddenly produce accurate words when singing familiar songs. This phenomenon was first reported by Swedish physician Olaf Dalin in 1773. Dr. Dalin described a young man who had lost his ability to talk as a result of brain damage but who surprised townsfolk by singing hymns in church. This acquired language disorder is now called ‘aphasia.’”

94 JOURNAL MSMA March 2014

ICD-10-CM Coding Workshops o o o o o o o

March 28, 2014 April 25, 2014 May 30, 2014 June 27, 2014 July 25, 2014 August 29, 2014 September 26, 2014

Time: 9AM – 3PM

Where: McGowan Center, Holmes Community College Ridgeland, MS

The ICD-10-CM Coding Workshop will include intensive study of the ICD-10-CM diagnosis codes, guidelines, and conventions. Workshops include case studies and exercises from each section of the 2014 ICD-10-CM Manual. Each participant will be given a 2014 ICD-10-CM Manual as part of the registration fee.

MSMA Member Employee: $250 per person Non-MSMA Member Employee: $300 per person (Includes the 2014 ICD-10-CM Manual and lunch) • •

Phyllis Williams, Director of Practice Strategies 601-853-6733 Ext 322 or pwilliams@msmaonline.com

Visit www.MSMAonline.com to register online or obtain registration form.

March 2014 JOURNAL MSMA 95

Sponsored by MSMA and Holmes Community College @ the McGowan Workforce Training Center| Ridgeland, MS

Attendee Name(s) Clinic Name Office Mailing Address City, State, Zip Email

_____________ __________________

Phone MSMA Physician Member_____________________________

Do you wish to receive 4.5 hours of AAPC CEU? YES

No

Registration includes the 2014 ICD-10-CM Manual and lunch.

• •

MSMA Member Employee: $250 per person Non-MSMA Member Employee: $300 per person

Credit Card:

□ Visa □ MasterCard

□ American Express

Amount to be billed to card: ______________ Card Number:

______ ________

CVV: ____________ Expiration: _______________ Print Name on the Card: Signature:

Please indicate date you wish to attend. o March 28, 2014 o April 25, 2014 o May 30, 2014 o June 27, 2014 o July 25, 2014 o August 29, 2014 o September 26, 2014

_____________ _______

Time: 9AM – 3PM

Cancellation policy: In the event that you need to cancel your registration, your full registration fee, less $25 processing fee, will be refunded if notified less than one week prior to your scheduled workshop. No refunds will be made with less than one week notice, but you may send a substitute for the person registered or select another workshop date.

Questions: Please contact Phyllis Williams, Director of Practice Strategies 601-853-6733 Ext 322 or pwilliams@msmaonline.com

Note: A minimum of 5 people are required in order to host a class on any particular date. Additionally, the class is limited to 24 people. Should a class be cancelled due to insufficient registration or it is full, you will be offered an alternative date.

Please send completed registration form with payment to Mississippi State Medical Association, Attn: Phyllis Williams, PO Box 2548, Ridgeland, MS 39158 Or Fax to 601-853-6746

96 JOURNAL MSMA March 2014

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Schedule of Events: FRIDAY, MAY 23, 2014

SUNDAY, MAY 25, 2014

1:00 ‐ 5:00

7:30

MSMA Board of Trustees Mee�ng

SATURDAY, MAY 24, 2014 8:00 – 11:00

MSMA Board of Trustees Mee�ng

11:00 – 12:00 Management of Congenital Heart Disease

Jorge Salazar, MD 12:00

Lunch Provided During CME Session

12:15– 1:15

Orthopaedic Oncology Case Review: Missed Diagnoses and Oops Excisions Jennifer Barr, MD

1:15 ‐ 2:15

MSBML Rules and Regula�ons on Prescribing Opioids and DEA Controlled Substances Scheduling – Prescribing CME John Mutziger, DO

2:15 – 3:15

25 Tips for Maximizing Effec�veness of Controlled Substances and Minimizing Abuse – Prescribing CME Sco� Hambleton, MD

4:00 ‐ 6:00

UMC Alumni Cruise

MONDAY, MAY 26, 2014

Breakfast Provided During CME Session

7:30 ‐ 8:30

New Statewide Stroke System of Care Ruth Fredericks, MD

8:30 ‐ 9:30

Breast Reduc�on in the Obese Popula�on Peter Arnold, MD

9:30 – 11:00

Addic�on as a Brain Disease ‐ Prescribing CME Lloyd Gordon, MD

11:00

Lunch Provided During CME Session

11:15– 12:15

Strategies for the Effec�ve Management Chronic Pain and

Recommenda�ons on the use of Controlled Substances ‐ Prescribing CME Michael Cosgrove, MD

12:15 – 1:15

Mississippi Rising; The Importance of Preven�on in the Epidemic of Cardiovascular Disease Michael Mansour, MD, FACC, FACP

6:00 PM

Welcome Recep�on Co‐Sponsored by UMMC Medical Alumni

TUESDAY, MAY 27, 2014

Breakfast with Exhibitors

7:15 am

Breakfast with Exhibitors

8:00 – 9:00

Transcatheter Valve Replacement (TAVR) ‐ Two Years In William Crowder, MD

8:00 – 9:00

Risk Management Concerns and Strategies in a Changing Healthcare Environment Medical Assurance Company of Mississippi

9:30 – 11:30 am Spouse and Children Ac�vity – BINGO Amphetamines ‐ Prescribing CME Mark Williams, MD

10:30 – 11:30 Treatment of Depression: Updates in Current Care Op�ons

Greg Gordon, MD 11:30 ‐ 12:30 ICD‐10 Coding

NaTunya Johnson, Ed.S

9:00 – 10:00 A Primer on Bariatrics

Anne�e Low, MD

10:00 – 10:30 Break

10:00 – 10:30 Break

6:30

7:15 am

9:00 – 10:00

Family Dinner and Southern Medical Ice Cream Social

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98 JOURNAL MSMA March 2014

10:30 – 11:30 Diabetes Update

Marshall Bouldin, MD 11:30 ‐ 12:00

Medicine in Mississippi ‐ Legisla�ve Update Blake Bell, JD

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12th Annual CME in the Sand

May 24-27, 2014 Sandestin Golf and Beach Resort

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EVENT REGISTRATION: (All events are included in registration fee. Please check all that you plan to attend) CME Sessions – May 24 - 27

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Welcome Reception – Sunday, May 25 Family Dinner – Monday, May 26

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Please send completed registration forms with payment to: Mississippi State Medical Association, Attn: Jenny White, PO Box 2548, Ridgeland, MS 39158 or fax to (601)853-6746

March 2014 JOURNAL MSMA 99

• Editorial • Save the DateMarston Symposium

Y

ou will soon be receiving a “Save the Date” notification of an upcoming symposium at the University of Mississippi Medical Center on June 20, 2014. The First Marston Symposium at UMMC is titled, “Fifty Years After Freedom Summer, Have Physicians Healed Themselves?” The symposium has been named in recognition of the leadership of Robert Q. Marston, MD, Dean and Hospital Director at UMMC from 19611966.

Many of us believe that there are ongoing issues between black and white physicians in Mississippi that are yet to be resolved. These issues may adversely affect our ability to recruit and retain physicians and to address our epidemic of bad health. We are hopeful that this symposium will provide the environment to generate new ideas and approaches for racial reconciliation going forward.

Robert Q. Marston, MD

Space for this symposium will be limited. If you are interested in coming, please adjust your calendar so that you can attend as a registration announcement will follow in about a month.

Hopefully the information below will give you further insight into the plan and purpose of this symposium.

Who was Robert Q. Marston and why is the University of Mississippi Medical Center holding the Marston Symposium on June 20, 2014?

Who? Virginia native Robert Q. Marston, MD, became Director of the University of Mississippi Medical and Dean of the School of Medicine in 1961 at the age of 38. He became Vice-Chancellor of the University of Mississippi in 1965 and remained Dean of the School of Medicine until 1966. He then served first as Associate Director and subsequently as Director of the National Institutes of Health until 1974. At that time, he became President of the University of Florida, which he led until his retirement in 1984. During retirement, he served in many roles, including those of consultant, advisor, and board member to governmental and national medical organizations. He was highly respected and successful in all these roles and remained active until his death in 1998.

The time of Dr. Marston’s service as leader of the Medical Center, only established in 1955, was a period of social turmoil in the United States. Much of that turmoil was centered in Mississippi. The US Supreme Court’s Brown vs. Board of Education decision in 1954 had set into motion integration of public education and statewide voter registration efforts for African Americans that resulted in Mississippi becoming a civil rights battleground. A riot on the Ole Miss campus following the admission of James Meredith to the University of Mississippi occurred during his first year in Mississippi. The riot greatly troubled many of the UMMC students and house staff and required strong leadership by the faculty.

Implementation of Title VI of the Civil Rights Act of 1964 required that all medical center facilities, including University Hospital and its clinics, be integrated quickly or lose federal funding critical to research and educational programs. As leader of the medical center, Dr. Marston received pressure from the governor, legislature, White Citizens Council, and others to resist federal directives. At the same time, he received pressure from civil rights leaders, the physicians of the Medical Committee for Human Rights and the government to comply with the new laws.

The Medical Center staff did not escape the violence of the era. Many injured and ill civil rights workers were treated at the Medical Center in the emergency room and clinics during this period. In 1963, the Medical Center provided trauma care services to the dying Medgar Evers, NAACP Director for Mississippi. In 1964, autopsy services were provided for Freedom Summer

100 JOURNAL MSMA March 2014

volunteers James Chaney, Mickey Schwermer, and Andrew Goldman after their murders, and controversy arose that adversely affected the national image of the institution and the faculty.

Dr. Marston carefully and thoughtfully navigated the Medical Center through this difficult period by close personal dialogue and positive relationships with black and white physicians, community leaders, politicians, and a continuing series of federal auditors and visitors. As a result, the Medical Center retained its federal and community support and moved forward with its mission.

Why? The Civil Rights Era issues have historically estranged black and white physicians in Mississippi. For years black physicians were set apart in state medical directories by their designation “S” for “scientific” status until the mid 1960s.

Civil rights struggles and events in the education and practice of medicine by black physicians in our state have resulted in parallel professional lives for black and white physicians which persist. With the state still leading the country in poor health, health disparities, and the critical shortage of physicians in the US, the University of Mississippi Medical Center has chosen to take a positive leadership role in moving forward. One of these efforts is a partnership with the University of Mississippi Winter Institute for Racial Reconciliation to sponsor the Marston Symposium. This symposium will be held at the Medical Center during the 50th anniversary of Freedom Summer of 1964.

What and When?

As the state’s only academic medical center, UMMC seeks to improve and expand relationships among all physicians in Mississippi who share the desire to address Mississippi’s epidemic of poor health. The Marston Symposium will be an all-day event on June 20, 2014. It will provide an opportunity for Mississippi physicians to better understand the history of medical practice in the state, update their knowledge on Mississippi’s health status, and develop new partnerships to improve the health of those we serve. We anticipate an exciting and meaningful event which will hopefully be the first of an ongoing series. CME will be provided, and Dr. John Dittmer, author of the book The Good Doctors, will provide the luncheon lecture.

—Richard D. deShazo, MD, Associate Editor

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ree online access to the Journal MSMA is available to current members of the Association. If you would prefer to receive only the online version and not the print version of the JMSMA let us know. If you would like to opt out of receiving the print version, please contact Managing Editor Karen Evers, KEvers@MSMAonline.com or 601.853.6733, ext. 323.

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102 JOURNAL MSMA March 2014

• Una Voce • The Albatross and the Dodo

P

erhaps you recall my December missive titled the “Interloper,” the derogatory assignation that I gave my corporate issued laptop computer whose use is now mandated in our clinic. I know I am not alone on this sea of electronic misery, and that is why this Ancient Mariner continues to harp on it. I firmly believe that it helps to know that other physicians share in our present grief.

Dwalia S. South, MD

Is it a blessing or a curse that we Baby Boomer medical doctors are being forced to bridge the chasm which lies between the ‘Golden Age of the Physician’ and the ‘Digital Age of Healthcare Providers?’ Some more adventurous physicians than me plunged headlong into the realm of Electronic Medical Records (EMR/EHR-whichever is the preferred acronym du jour). I, however, am still being dragged kicking and screaming from my comfortable perch into this brave new world…a Dodo, a species facing extinction or at least obsolescence.

The current shift to the Digital Age in our whole society is nothing less than tectonic. The advent of computers for our generation equates to the giant leap that came for mankind with the invention of papyrus about 5000 years ago. While papyrus represented an advance over engraving on stone, it certainly was not cheaper, more permanent, or more readily available than a rock wall. However, the inherent portability of papyrus brought a semblance of ‘user friendliness’ to the human species. Prior to this time, the daily carryings-on of our pre-historic ancestors simply went unrecorded. (Regrettably, now we have Facebook and everybody knows just about every inane thing there is to know about everybody else.) True paper was not seen until 104 A.D. when those clever Chinese folks first perfected its mass production. In 1450, communication really began to pop when Gutenberg perfected and mechanized the moveable printing press in Europe. This invention heralded the Age of Enlightenment, the Renaissance, the Reformation, and the Scientific Revolution of the Middle Ages.

When and why did physicians begin keeping medical records? The ‘when’ is uncertain because many of the earliest physician records consisted simply of lists of names, accounts, recipes for cures, and treatments. Even without the threat of a HIPAA violation, most medical diaries remained private and therefore are not extant. According to my research (granted, done magically during the construction of this article by simply ‘Googling’ the “history of medical record-keeping”), I learned of “The Casebooks Project,” outlining Foreman and Napier’s medical records from 1596-1634. These are perhaps the most extensive surviving set of patient charts from before 1700, pre-dating all modern medical records.

Knowing ‘why’ physicians first began keeping medical records is self-evident; it was good for the patient and made our work easier. Between 1700 and the dawning of this millennium, latter day medical records primarily focused on the individual and the cure of his disease. Clinical hospital charts in America were pioneered in the 1800’s but only began to be used in ambulatory settings in the early 20th century.

I have now been completely immersed, baptized if you will, into the modus operandi of the EHR. After somewhat mastering the navigational systems of my laptop and having to learn a whole new way of approaching my patient in the exam room, I can say with certainty that the present electronic medical record keeping system under which we labor does not fulfill this earlier nobler goal. It does not make my work easier by any reckoning, and furthermore, despite government research projections to the contrary, I am firmly convinced that it does not lead to better patient care or better outcomes.

What it does do well is to allow the front office to charge more for what we do, and allows ‘Big Brother’ (the government and big insurance) to scrutinize every move physicians make.

March 2014 JOURNAL MSMA 103

Call me a stupid old fogey, but I thought the point of enduring all this angst was efficiency, better communication, and improved patient safety. It simply isn’t happening. No matter what the gurus say, the present incarnation of the EHR is cutting down on productivity at a time when we need to be seeing more patients and not fewer. There are literally about a thousand different commercially available EHR systems to choose from out there.. There are about 15 big name brands, and every doctor’s office I know has a different one. And guess what, they can’t talk to each other. If I need a patient’s emergency room record from the previous night, I have to fax a signed release form, and in turn, I am faxed back reams of literal gobbledy-gook which is far more indecipherable than the one-page handwritten note of yore.

Here is one example from recent days: A patient is in my office to follow up an ER visit. I sent for the notes from the previous night. The patient’s chief complaint was “headache.” Buried in all the jargon was this nonsensical notation…

“Behavioral: no tobacco use, tobacco non-user, not a current smoker, non-smoker, never smoked, social drinker, six-pack a day, smoking status: never smoked, eats chocolate, cola: one can per day, coffee: yes” And this embarrassing stuff becomes a part of the permanent record. A patient’s 30 minute visit to the emergency room for a ‘headache’ requires 12 pages of documentation which ends up with a negative CT scan and a $5,000 bill with a diagnosis of “HEADACHE” and the admonition to “follow up with PCP tomorrow if not better.”

I’m sorry, but after reading this mess, I am the one with a headache: and I could use that cigarette and some caffeine right about now. I still have to figure out what is causing the headache and dole out the prescription for the pain medication which in reality was their prime motivation for seeking treatment in the first place. Then I have to sit down and type up a ream of nonsense about this patient and their probable hangover headache for our own office records.

At times like this, I yearn for the days of my youth and the 5 by 7 inch note cards that were our records at the saintly old Ripley Medical Clinic. “ Jan. 7. 12 Y/O WF. NKA Dx Strep Pharyngitis. 1.2 Million CR Bicillin IM.” It was 1981. The patients were all griping because the office visits had just gone up to $8.00 from the $5 they had been charged for the prior ten years.

Sometimes these days, the chart when printed out weighs more than the actual person but somehow does not serve to distinguish them from any other patient. I have noticed how much more difficult it is now for me to visualize John Jones’s face from what is now being written into the EHR….every patient has a cookie cutter sameness on the screen. Like many family physicians, I always used to write notes in the margins about his hobbies, children’s names, etc. to help me form a bond with my patient and a few days later to aid me to pull his face up on the gray screen of my brain when he calls me for test results. There is no place for information like this in the present , and I feel this depersonalization is a serious deficiency.

Another big problem is the decrease in my actual productivity in terms of patient volume. This fat, slow, and awkward Dodo bird can only manage to see and document semi-coherently about half my usual patient load. Here I am slaving away with flawed tools, being totally inefficient, laboring in a mode that I have insufficient background to understand. Some days I don’t even feel like a doctor anymore, rather a glorified scribe or secretary.

There are a few things that this old Dodo bird will say positively about the Electronic Albatross I bear during my day at work. It has forced the calcifying corridors of my cranium to actually learn something new. I was heartened to know that I don’t yet have dementia. And I love being able to pull up information on the computer to share with the patient during their visit. One color photo of a black tar laden lung at autopsy is worth ten-million “don’t smoke” admonitions to my patient who has consumed three packs a day for 30 years.

Since EHRs have invaded the world of medicine, there truly is more paper clutter on my desk than I can ever recall.

Most of it consists of reams of the same type of nebulous crap generated and faxed from other doctor’s offices, hospitals, home health, hospice agencies, insurance company denial letters, and mail order pharmacy requests ad infinitum.

The biggest bright spot I see in all this is that as long as we have “paperless medical systems,” my pine tree plantation remains a sound financial investment.

“T

he best moments in reading are when you come across something – a thought, a feeling, a way of looking at things – which you had thought special and particular to you. And now, here it is, set down by someone else, a person you have never met, someone even who is long dead. And it is as if a hand has come out, and taken yours.” — Alan Bennett

104 JOURNAL MSMA March 2014

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