VOL. LIX • NO. 3 • 2018

VOL. LIX • NO. 3 • 2018

10 ways

MSMA stood up for you in 2017 1.

2.

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4.

5.

6.

7.

8.

9.

10.

Protected scope of practice at State Capitol Pushed through a new stronger seatbelt law Saved vital funding for Health Department Successfully defended strong vaccination laws Added 2 new member benefit partners Promoted the economic impact of physicians Championed new Heroin & Opioid Summit Made available 277 hours of CME Spoke out against unwarranted prescribing rules Brought the AMA Pre-diabetes program to Mississippi

MSMA works hard for physicians and patients.

That’s why MSMA is the‌

largest oldest strongest best

medical association in Mississippi.

Pass the word. Tell your colleagues to join MSMA today!

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. 601-853-6733

VOL. LIX • NO. 3 • MARCH 2018

EDITOR Lucius M. Lampton, MD ASSOCIATE EDITORS D. Stanley Hartness, MD Richard D. deShazo, MD

THE ASSOCIATION President William M. Grantham, MD President-Elect Michael Mansour, MD

MANAGING EDITOR Karen A. Evers

Secretary-Treasurer W. Mark Horne, MD

PUBLICATIONS COMMITTEE Dwalia S. South, MD Chair Philip T. Merideth, MD, JD Martin M. Pomphrey, MD and the Editors

Speaker Geri Lee Weiland, MD Vice Speaker Jeffry A. Morris, MD Executive Director Charmain Kanosky

JOURNAL OF THE MISSISSIPPI STATE MEDICAL ASSOCIATION (ISSN 0026-6396) is owned and published monthly by the Mississippi State Medical Association, founded 1856, located at 408 West Parkway Place, Ridgeland, Mississippi 39158-2548. (ISSN# 0026-6396 as mandated by section E211.10, Domestic Mail Manual). Periodicals postage paid at Jackson, MS and at additional mailing offices.

CORRESPONDENCE: Journal MSMA, Managing Editor, Karen A. Evers, P.O. Box 2548, Ridgeland, MS 39158-2548, Ph.: 601-853-6733, Fax: 601-853-6746, www.MSMAonline.com.

SUBSCRIPTION RATE: $83.00 per annum; $96.00 per annum for foreign subscriptions; $7.00 per copy, $10.00 per foreign copy, as available.

ADVERTISING RATES: furnished on request. Jill Gordon, MSMA Director of Marketing, Ph: 601-853-6733, ext. 324, Email: JGordon@MSMAonline.com POSTMASTER: send address changes to Journal of the Mississippi State Medical Association, P.O. Box 2548, Ridgeland, MS 39158-2548.

The views expressed in this publication reflect the opinions of the authors and do not necessarily state the opinions or policies of the Mississippi State Medical Association.

Copyright © 2018 Mississippi State Medical Association.

Official Publication

MSMA • Since 1959

SCIENTIFIC ARTICLES Top 10 Facts You Need to Know about Pediatric Fever 128 Paul Redmond, MD; Nicholas Watkins, MD; Benjamin Dillard, MD; Melissa N Frascogna, MD Top 10 Facts You Need to Know about Inpatient Acute Kidney Injury 132 Sohail Abdul Salim, MD; Juan A Medaura, MD; Vishnu Garla; Nicki Lawson, NP; Venkataraman Palabindala, MD A Survey of Environmental and Behavioral Aspects of Human West Nile 134 Cases in Mississippi Wendy C. Varnado, PhD; Jerome Goddard, PhD Genome-Wide Association Studies (GWAS) Improve Understanding of 140 Autism Spectrum Disorders in Mississippi and Beyond: Cases in Mississippi Sabrina V. White, BS; Kristen B. Callahan, BS; Sujith Ramachandran, PhD; Dustin E. Sarver, PhD; Robert D. Annett, PhD Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy: 145 A New Treatment Modality for Primary or Secondary Peritoneal Cancer in Mississippi Wade O. Christopher, MD; Ashley H. Seawright, DNP; James J. Wynn, MD; Truman M. Earl, MD; Christopher D. Anderson, MD; W. Shannon Orr, MD DEPARTMENTS From the Editor – Magnolia Three Times 126 Lucius M. Lampton, MD, Editor Special Article – New Study Shows “Physicians Mean Business:” 154 Mississippi Doctors Boost the State Economy President’s Page: We Got “Street Cred” 157 William M. Grantham, MD MSMA – Defining Events in the Evolution of Medicine in Mississippi - 164 Celebrating the 150th Anniversary of the MSMA House of Delegates New Members 167 Letters 172 Poetry and Medicine: Turks #1 176 R. Scott Anderson, MD Images in Mississippi Medicine – Greenville Colored King’s 177 Daughters Hospital Lucius M. Lampton, MD Una Voce: Washed in the Blood 178 Dwalia S. South, MD COMMENTARY Tax Cuts & Jobs Act of 2017: A Brief Overview Michael A. Carraway, Jr., CPA Mississippi, We All Need to CHIP in on this One Lauren Friedrich, Pre-Med EDITORIAL Doctors’ Day: A Time to Reflect, Look Ahead

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RELATED ORGANIZATIONS AMA – Big Picture: Solely Focusing on Either Gestational Diabetes or 150 Hypertension Loses Site of Future Health Implications AMA Launches “Share Your Story” Campaign to Document Opioid Use 151 Disorder Barriers to Care Mississippi State Department of Health – Reportable Disease Statistics 159 Medicaid Medical Care Advisory Committee – Physician-led Medicaid 173 Group Endorses Unlimited Doctor Visits Steven Demetropoulos, MD ABOUT THE COVER This Little Light of Mine light sculpture – Stanley Hartness, MD JOURNAL MSMA

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F R O M

T H E

E D I T O R

Magnolia Three Times

A

friend once wrote me a letter by slow mail. In its opening, he confided: “I love addressing the envelope every time I send you letter: Luke Lampton, MD, Magnolia Clinic, 111 Magnolia Street, Magnolia, Mississippi. What a joy it is to write Magnolia three times!” For most Mississippians, a passion for the flowering evergreen magnolia grandiflora seems part of our DNA. Southern magnolias are as Lucius M. Lampton, MD basic to our lives and culture as red clay Editor hills or piney woods or loess bluffs. A large fragrant white magnolia flower commonly adorned my grandmother’s kitchen table in Tylertown, permeating the bright room of activity with its sweet lemon citronella scent.

Magnolia Three Times means more to me than that cherished flower and tree. Magnolia is a native place, a hometown, which also happens to be a typical small town in Mississippi. Magnolia Three Times in many ways means Rural Mississippi times three. There are wonderful things about rural small-town life in our state. The sky seems bigger here, and the people kinder. There is a small-town decency, which involves a sense

of community and shared civic dependence. And nature is always very close: opossums and raccoons are frequent visitors to our garbage cans and cat food bowls, and you fear for your outside cat the presence of owls, eagles, stray dogs, and coyotes. Missing the once weekly garbage pick-up is joked to be the most feared occurrence of all! However, never forget that poverty covers the community like kudzu on Delta field.

Rural Mississippi is struggling. I am now the only physician practicing in Magnolia: there were four in the 1950s. We are underserved medically and have little to no access to mental health services or specialty care.

Our rural hospital faces closure and the next hospital south is in another state, more than 40 miles away. Our children die driving on our roads all too frequently, as well as suffer higher rates of addiction, suicide, and unemployment. Most of our downtown store-fronts are closed. Many of our people live in crumbling mobile homes without air-conditioners and walk to the grocery store or doctor not for health reasons but because they don’t own a car. Our state needs to turn its attention to help its rural heartland, because it is withering on the vine.

Contact me by slow mail at Magnolia Three Times (Magnolia Clinic, 111 Magnolia Street, Magnolia, MS 39652) or at lukelampton@ cableone.net. n — Lucius M. Lampton, MD, Editor

JOURNAL EDITORIAL ADVISORY BOARD ADDICTION MEDICINE Scott L. Hambleton, MD

EMERGENCY MEDICINE Philip Levin, MD

MEDICAL STUDENT John F. G. Bobo, M2

ALLERGY/IMMUNOLOGY Stephen B. LeBlanc, MD Patricia H. Stewart, MD

EPIDEMIOLOGY/PUBLIC HEALTH Mary Margaret Currier, MD, MPH Thomas E. Dobbs, MD, MPH

NEPHROLOGY Jorge Castaneda, MD Harvey A. Gersh, MD

ANESTHESIOLOGY Douglas R. Bacon, MD John W Bethea, Jr., MD

FAMILY MEDICINE Tim J. Alford, MD Diane K. Beebe, MD Jennifer J. Bryan, MD J. Edward Hill, MD Ben Earl Kitchens, MD James J. Withers, MD

OBSTETRICS & GYNECOLOGY Sidney W. Bondurant, MD Darden H. North, MD

CARDIOVASCULAR DISEASE Cameron Guild, MD Thad F. Waites, MD CHILD & ADOLESCENT PSYCHIATRY John Elgin Wilkaitis, MD Nisha S. Withane, MD, Fellow CLINICAL NEUROPHYSIOLOGY Alan R. Moore, MD DERMATOLOGY Robert T. Brodell, MD Adam C. Byrd, MD

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GENERAL SURGERY Andrew C. Mallette, MD HEMATOLOGY Vincent E Herrin, MD INTERNAL MEDICINE Daniel P. Edney, MD W. Mark Horne, MD Daniel W. Jones, MD Brett C. Lampton, MD Jimmy Lee Stewart, Jr., MD

ORTHOPEDIC SURGERY Chris E. Wiggins, MD OTOLARYNGOLOGY Bradford J. Dye, III, MD PEDIATRIC OTOLARYNGOLOGY Jeffrey D. Carron, MD PEDIATRICS Michael Artigues, MD Owen B. Evans, MD

PLASTIC SURGERY William C. Lineaweaver, MD Chair, Journal Editorial Advisory Board PSYCHIATRY Beverly J. Bryant, MD June A. Powell, MD PULMONARY DISEASE Sharon P. Douglas, MD John R. Spurzem, MD RADIOLOGY P. H. (Hal) Moore, Jr., MD RHEUMATOLOGY Shweta Kishore, MD C. Ann Myers, MD UROLOGY W. Lamar Weems, MD

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Top 10 Facts You Need to Know about Pediatric Fever PAUL REDMOND, MD; NICHOLAS WATKINS, MD; BENJAMIN DILLARD, MD; MELISSA N FRASCOGNA, MD Introduction

bacteria.7, 26-28

Fever is one of the most common presenting complaints seen by pediatricians with as many as one third of all visits to the pediatric emergency department and urgent care clinics being attributable to fever.1-4 Approximately 50% of after-hours calls to pediatric group practices involve fever as part of the complaint.5 Those numbers translate to an estimated 60 million clinic visits and 8 million emergency department visits annually in the US, totaling a bill of about 10 billion dollars annually.1-7

4. Treatment of fever should emphasize comfort, not normothermia. A study of parental misconceptions of temperature showed that upwards of 50% of parents believed temperatures below 38 degrees Celsius (100.4°F) to be a fever, prompting unnecessary treatment with antipyretics.29 There is no evidence that treating fever reduces morbidity or mortality, with the exception of critically ill children with low metabolic reserve.7,26 As such, antipyretic medications, while generally safe, should be dosed with care. Ibuprofen may cause gastritis and, in overdose, nephrotoxicity. Acetaminophen, in overdose, results in hepatotoxicity. The American Academy of Pediatrics (AAP) has concluded that there is no current evidence available to recommend antipyretic use to reduce febrile temperatures in otherwise healthy children.7,26 The primary goal of antipyretic use should be to improve overall comfort rather than to achieve normothermia.26,29

In a study published in 1980, Dr. Barton Schmitt coined the phrase fever phobia to describe the misconception of the danger of fever in children. His study and more recent studies have shown that the majority of parents and pediatricians believe fever could cause physical harm such as brain damage.8,9 This so-called fever phobia leads to unnecessary office and emergency department visits, unnecessary testing, often unwarranted antibiotics, and increased health care costs.

With this in mind, here are ten facts every physician should know about fever in children.

1. Fever is definable. Fever is most commonly defined as any temperature ≥38.0°C (100.4°F).10-11 Elevated temperatures below this value are not considered fever, and parents should be educated that such temperatures are normal and appropriate in healthy children. Parents should also be educated that, in some cases, illness and infection can present with hypothermia, especially in infants and chronically ill children.

2. The most accurate temperature is the one measured rectally.

Temperatures taken rectally or orally are more accurate than those obtained using the axillary or tympanic methods, with rectal temperature being the preferred method if a child is younger than three years of age.11-12 3. Fever is generally a good sign. There is a large body of evidence that shows fever is a beneficial physiological response mechanism, is protective, and should be taken as a sign of a robust immune system.

Multiple studies have concluded that febrile temperatures will actually inhibit or significantly decrease replication and survival of bacteria, viruses, and parasites, and can hasten recovery from viral infection.17-25 Therefore, withholding treatment of fever itself may actually improve outcomes in febrile patients due to the inhibitory effects on viruses and

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5. Treating fever does not prevent febrile seizures. Febrile seizures are thought to be related to the rapid rate of temperature rise at the onset of illness, as opposed to maximum amplitude of temperature.

A child with a simple febrile seizure is not at risk for brain damage nor subsequent neurologic complications from the seizure itself. Febrile seizures typically occur in the first 24 hours of the febrile illness, and once the fever is noticed, the risk of a febrile seizure has likely already passed.30-31 6. Brain damage will not occur until 42°C (107.6°F) is reached.

Contrary to the common belief that a fever will cause brain damage, there is no evidence to suggest this in an otherwise healthy child with adequate hydration.26,33 Elevated body temperature seen with fever does not cause dangerous effects until it surpasses 42°C (107.6°F)26,32 for a prolonged period of time, at which point the body’s regulatory mechanisms are unable to balance heat loss with the increased heat production.7,33 7. The degree of fever does not always correlate with the degree of illness or likelihood of bacterial infection. Many of the common, transient viral illnesses can cause fevers of up to 40°C in otherwise healthy children.29,34 In the primary care setting, serious bacterial illness (SBI) is uncommon in immunized children presenting with fever.29 Haemophilus influenza and pneumococcal vaccination have decreased the incidence of SBI significantly.35 Immunized,

otherwise healthy children over four weeks of age who present with normal perfusion, moist mucous membranes, and appropriate mental status are unlikely to have a SBI despite the presence of fever.35 Children with more concerning signs such as tachycardia, hypotension, tachypnea, focal findings or pain, or prolonged fever may warrant further evaluation. In general, the degree or presence of fever alone should not elicit a workup in most children, rather the overall presentation. Antibiotic stewardship should also be practiced. The decision to treat with antimicrobials should be driven by evidence of bacterial infection on workup or exam rather than the presence of fever alone.

8. Always work-up and treat a febrile child who is under 28 days old. Infants in the first month of life are at very high risk for SBI.36-37 The incidence of SBI in this age group has been reported at 1-2% for bacteremia, 1-3% for meningitis, and 16-28% for urinary tract infections.36 Given this risk, the recommended practice for all febrile or ill-appearing infants ≤28 days of age is to have a full sepsis evaluation.36-38 This should include blood, urine, and cerebrospinal fluid (CSF) studies and cultures. Additional diagnostic testing to strongly consider include a chest radiograph for respiratory symptoms, a complete metabolic panel, and herpes simplex virus PCR testing on CSF. Infants having a sepsis evaluation should be admitted to the hospital and empirically treated with ampicillin, cefotaxime, and potentially acyclovir while awaiting culture results.30-33 The practice guideline for febrile neonates used at the University of Mississippi Medical Center (UMMC) is outlined in Figure 1.

FIGURE 1. Practice Guideline for Febrile Neonates 0-28 days Febrile Infant

29-­‐60d

0-­‐28d Well appearing

Ill appearing

-­‐ Admit to Hospital -­‐ CBC, CMP, UA -­‐ Routine CSF studies -­‐ CSF HSV PCR -­‐ Bld/Urine/CSF cx’s -­‐ Empiric treatment

See separate algorithm -­‐ Admit all patients to Inpatient status -­‐ May be discharged after negative growth on cultures for 48 hours, negative HSV PCR, and clinically well.

Empiric Treatment: Ampicillin 100mg/kg/dose Q8hr for ≤ 7days 75mg/kg/dose Q6hr for >7days Cefotaxime 50mg/kg/dose Q6hr ≤ 7days 75mg/kg/dose Q6hr >7days Acyclovir 20mg/kg/dose Q8hr Oseltamivir (if Flu+) 3mg/kg/dose Q12hrs PO

Additional Considerations -­‐ Transaminitis and/or thrombocytopenia: HSV PCR serum and coagulation studies -­‐ Respiratory symptoms: CXR -­‐ Diarrhea: stool culture -­‐ Flu season: Rapid Influenza A & B -­‐ No RSV testing as it will not change mgmt

* Please refer to the “Well Appearing Febrile Infant Guidelines” for more details

FIGURE 2. Practice Guideline for Febrile Neonates 29-60 days Empiric Abx: Rocephin 100mg/kg Q24hr Vancomycin (if CSF abn) 15mg/kg Q6hr Oseltamivir (if Flu+) 3mg/kg Q12hr

Febrile Infant

29-­‐60d Well appearing

Ill appearing

Resp symptoms and RSV/Flu season?

Yes

-­‐ Admit to Hospital -­‐ Bld/Urine/CSF cx’s -­‐ Empiric abx

CBC, UA, blood/urine cx Apply Rochester Criteria

Rapid RSV/Flu Positive

Urine Cx OK to d/c home No abx Tamiflu if Flu+

Negative

Low Risk

Good Follow-­‐up?

Yes

No

Rochester Criteria for Low-­‐Risk infant: d/c home Well appearing and previously healthy Admit for obs -­‐ No abx No evidence of skin, soft tissue, bone, No abx -­‐ F/U in 24hr joint, or ear infection WBC 5–15K; bands ≤1.5K -­‐ D/C when cx’s ≤ 10 WBC/hpf on urine micro -­‐ negative x 24hr ≤ 5 WBC/hpf on stool (if diarrhea -­‐ present) * Please refer to the “Well Appearing Febrile Infant Guidelines” for more details

9. Work-up in children >28 days of age is dependent on multiple variables.

There are no clear guidelines in the literature as to necessary evaluation of febrile infants from 29-60 days of life. Studies do suggest that infants in this age group can be stratified as to their risk of SBI.40 At UMMC, we employ a practice guideline based on available studies and the consensus opinion of multiple disciplines within the pediatrics department (Figure 2). The incidence of SBI in otherwise healthy, immunized children >60 days of age is low.35 When an SBI is present, UTI is most prevalent.40 Providers should have a low threshold for checking urine in infants and children aged 2-24 months with fever with no apparent source, particularly in girls and

No

High Risk

CSF Normal

Lumbar Puncture

Good Follow-­‐up?

CSF Abnormal

No

Yes Rocephin x 1 d/c home F/U in 24hr

Admit Empiric abx Discharge Criteria: Viral pos: well and cx’s negative x 24hr Viral neg: well and cx’s negative x 36hr

uncircumcised boys. The decision to perform a workup for a fever source in older infants and children should depend on the overall clinical picture. Factors to consider include age, prematurity (for infants), history of a chronic illness or an immunocompromised state, immunization status, ill-appearance, abnormal vital signs, and focal findings on exam.35

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10. It is important to educate caregivers. Good anticipatory guidance for caregivers is crucial to avoid fever phobia and to provide the tools to effectively care for their febrile child. As mentioned earlier, antipyretics can be used to improve overall comfort of the sick child. To avoid inadvertent overdose, parents should be educated on appropriate dose volume and intervals (Table 1).22 Febrile children should not be given aspirin due to the risk of Reye’s syndrome.10 Caregivers should also be educated on the expected course of illness, appropriate follow up, and worrisome signs that should prompt further evaluation.

12. El-Radhi AS, Barry W. Thermometry in pediatric practice. Arch Dis Child.

2006;91:351–6.

13. Jaffe DM. Assessment of the child with fever. Rudolph’s Pediatrics 21st ed. New York, NY: McGraw-Hill; 2002:302–309.

14. Kohl KS, Marcy SM, Blum M, et al.; Brighton Collaboration Fever Working Group. Fever after immunization: current concepts and improved future scientific understanding. Clin Infect Dis. 2004;39(3):389–394.

15. Hasday JD, Garrison A. Antipyretic therapy in patients with sepsis. Clin Infect Dis. 2000;31(suppl 5):S234–S241.

16. Adam HM. Fever and host responses. Pediatr Rev. 1996;17(9):330–331.

17. Kluger MJ. Fever revisited. Pediatrics 1992;90(6):846–850.

Table 1. Antipyretic Information Variable Decline in temperature, °C Time to onset, h Time to peak effect, h Duration of effect, h Dose, mg/kg Maximum daily dose, mg/kg Lower age limit, mo

Acetaminophen 1-2 <1 3-4 4-6 10-15 every 4 h 90 mg/kg 3

Ibuprofen 1-2 <1 3-4 6-8 10 every 6 h 40 mg/kg 6

Conclusion With studies verifying the presence of fever phobia, it is important for physicians to have a well-grounded and evidence-based understanding of fever in children and its management in order to properly treat patients and educate parents on home-care of febrile illnesses. n References 1. Alpern ER, Henretig FM. Fever. Fleisher GR, Ludwg S, Henretig FM, eds. Textbook of Pediatric Emergency Medicine 5th Edition. Philadelphia, PA: Lippincott Williams & Wilkins; 2006.295-306.

2. Crocetti M, Moghbeli N, Serwint J. Fever phobia revisited: have parental misconceptions about fever changed in 20 years. Pediatrics 2001;107(6):1241– 1246.

3. Nelson DS, Walsh K, Fleisher GR. Spectrum and frequency of pediatric illness presenting to a general community hospital emergency department.

Pediatrics 1992;90:5-10.

4. Massin MM, Montesanti J, Gerard P, Lepage P. Spectrum and frequency of illness presenting to a pediatric emergency department. Acta Clin Belg.

2006;61:161-165.

5. Villarreal SF, Berman S, Groothuis JR, Strange V, Schmitt BD. Telephone encounters in a university pediatric group practice: a two year analysis of afterhours calls. Clin Pediatr (Phila). 1984Aug;23(8):456-458.

6. Williams RM. The costs of visits to emergency departments. N Eng J Med. 1996;334:642-646.

7. Wallenstein MB, Schroeder AR, Hole MK, et al. Fever literacy and fever phobia. Clin Pediatr (Phila). 2013;52(3):254–259.

8. Schmitt BD. Fever phobia: misconceptions of parents about fever. Arch Dis Child. 1980;134:176-181.

9. May A, Bauchner H. Fever phobia: the pediatrician’s contribution. Pediatrics 1992;90:851-854.

10. Kliegman RM, Stanton BF, Geme JW, Schor NF and Behrman RE, eds. Nelson Textbook of Pediatrics 19th Ed. Philadelphia, PA: Elsevier/Saunders; 2011.

11. Wyckoff AS. Thermometer use 101. AAP News. 2009;30;29. DOI: 10.1542/ aapnews.20093011-29a.

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18. Kluger MJ. Fever: role of pyrogens and cryogens. Physiol Rev. 1991;71(1):93– 127.

19. Roberts NJ. Impact of temperature elevation on immunologic defenses. Rev Infect Dis. 1991;13(3):462–272.

20. Nizet V, Vinci RJ, Lovejoy FH. Fever in children. Pediatr Rev. 1994;15(4):127–135.

21. Hoption Cann SA. Peak fever: helpful or harmful? Heart Lung. 2011;40:585-6.

22. Sullivan JE, Farrar HC, and the Section on Clinical Pharmacology and Therapeutics, and Committee on Drugs. Clinical report: fever and antipyretic use in children. Pediatrics 2011;127:580-587.

23. Graham NM, Burrell CJ, Douglas RM, Debelle P, Davies L. Adverse effects of aspirin, acetaminophen, and ibuprofen on immune function, viral shedding and clinical status in rhinovirus-infected volunteers. Infect Dis. 1990;162:12771282.

24. Mackowiak PA. Physiological rationale for suppression of fever. Clin Infect Dis. 2000;31(suppl 5):S185-S189.

25. E. Fields, J. Chard, M.S. Murphy, M. Richardson. Assessment and initial management of feverish illness in children younger than 5 years: summary of updated NICE guidance. BMJ 2013;346:f2866.

26. Evans O, Ingram JB. Top 10 facts you need to know about febrile seizures. J Miss State Med Assoc. 2011;52(11):346-347.

27. Nelson KB, Ellenberg JH. Prognosis in children with febrile seizures. Pediatrics 1978;61(1):720-727.

28. Schmitt BD. Fever in Childhood. Pediatrics 1984;74(5):pp.929-936.

29. El-Radhi AS. Why is the evidence not affecting the practice of fever management? Arch Dis Child. 2008;93:918-920.

30. Thompson M, Van den Bruel A, Verbakel J, Lakhanpaul M, Haj-Hassan T, Stevens R, et al. Systematic review and validation of prediction rules for identifying children with serious infections in emergency departments and urgent-access primary care. Health Technol Assess. 2012;16(15):1-100.

31. Cioffredi LA, Jhaveri R. Evaluation and management of febrile children: a review. JAMA Pediatr. 2016; 170(8):794-800.

32. Garcia S, Mintegi S, Gomez B, et al. Is 15 days an appropriate cut-off age for considering serious bacterial infection in the management of febrile infants?

Pediatr Infect Dis J. 2012;31:455.

33. Levine DA, Platt SL, Dayan PS, et al. Risk of serious bacterial infection in young febrile infants with respiratory syncytial virus infections. Pediatrics 2004;113(6):1728.

34. Yarden-Bilavsky H, Ashkenazi-Hoffnung L, Livni G, et al. Month-by-month age analysis of the risk for serious bacterial infections in febrile infants with bronchiolitis. Clin Pediatr (Phila). 2011;50:1052.

35. Hui C, Neto G, Tsertsvadze A, et al. Diagnosis and Management of Febrile Infants (0-3 months). Evidence Report/Technology Assessment No. 205. AHRQ Publication No. 12-E004-EF. Rockville, MD: March 2012. http://www.ahrq.gov/professionals/clinicians-providers/guidelinesrecommendations/index.html.

36. Jaskiewicz JA, McCarthy CA, Richardson AC, White KC, Fisher DJ, Dagan R, Powell KR. Febrile infants at low risk for serious bacterial infection--an appraisal of the Rochester criteria and implications for management. Febrile Infant Collaborative Study Group. Pediatrics 1994;94(3):390-6.

37. Arora R, Mahajan P. Evaluation of Child with Fever without Source. Pediatr Clin North Am. 2013;60:1049-1062.

38. Richardson M, Lakhanpaul M. Guideline Development Group and the Technical Team. Assessment and initial management of feverish illness in children younger than 5 years: summary of NICE guidance. BMJ. 2007;334:1163-4.

39. Shaikh N, Morone NE, Bost JE, Farrell MH. Prevalence of urinary tract infection in childhood: A meta-analysis. Pediatr Infect Dis J. 2008;27:302.

40. Subcommittee on Urinary Tract Infections, Steering Subcommittee on Quality Improvement and Management, American Academy of Pediatrics. Urinary tract infection: clinical practice guideline for the diagnosis and management of the initial UTI in febrile infants and children 2 to 24 months. Pediatrics 2011;128(3):595-610.

Author Information: Fellow in Pediatric Emergency Medicine, University of Mississippi Medical Center (Redmond). Resident in Pediatrics, University of Tennessee Health Science Center, Memphis (Watkins). Professor of Pediatric Emergency Medicine, University of Mississippi Medical Center (Dillard). Associate Professor of Pediatric Emergency Medicine, University of Mississippi Medical Center (Frascogna).

Corresponding Author: Paul Redmond, MD; Department of Pediatrics, Division of Pediatric Emergency Medicine, 2500 North State St., Jackson, MS 39216. Ph. (601)984-2195; (predmond@ *ALLIANCE HEALTH CENTER - HF PG - MS MED JOURNALqxp.qxp_Layout 1 umc.edu).

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Top 10 Facts You Should Know About Inpatient Acute Kidney Injury SOHAIL ABDUL SALIM, MD; JUAN A MEDAURA, MD; VISHNU GARLA; NICKI LAWSON, NP; VENKATARAMAN PALABINDALA, MD Hospitalists and primary care physicians encounter renal disease daily.

Although most cases of acute kidney injury (AKI) are secondary to dehydration and resolve by giving fluids, many cases of AKI are due to not uncommon but unfamiliar causes needing nephrology evaluation.

Common indications to consult a nephrologist on an emergency basis include hyperkalemia or volume overload in end stage renal disease patients (ESRD). Other cause for urgent consultation are cresenteric glomerulonephritis/and rapidly progressive glomerulonephritis in which renal prognosis of the patient depends on timely intervention.

The following are evidence-based pearls which could improve patient care and outcomes.

Key Words: Dialysis, ESRD, Renal Consultation, Glomerulonephritis, and Acute Kidney Injury 1. Use of Antacids can be problematic to patients with ESRD. Hypermagnesemia occurs with magnesium intakes as low as 281 mg/ day, which is considerably lower than the average intake in the general population. Severe and symptomatic hypermagnesemia can also be induced when exogenous magnesium is given as antacids or laxatives in usual therapeutic doses.1 Aluminum-containing antacids can cause dementia and low turnover bone disease in patients with ESRD. They are also not easily dialyzable due to high protein binding.

2. Tunneled Dialysis Catheter (TDC). Dialysis patients with TDC who are admitted with fever need urgent culture via TDC before initiation of antibiotics. The most important risk factor for tunneled catheter-related bacteremia is prolonged duration of usage.2 Human immunodeficiency virus (HIV)-positive dialysis patients are more likely to develop polymicrobial infections and infections due to gram-negative and fungal pathogens3. These patients should receive empiric coverage with antimicrobials on presentation after appropriate cultures have been obtained from the TDC. 3. Infected Arteriovenous Graft (AVG) and Fistula (AVF) can present as simple cellulitis around the area surrounding the graft/fistula.

This requires urgent ultrasound to rule out thrombosis and abscess.

Infected AVGs need to be excised completely4 and require urgent consultation to vascular surgery. Infection carries the threat of both local and systemic complications. AVGs have more risk of getting infected than AVFs.

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4. Transplant Medications including Calcineurin Inhibitors (Cyclosporine and Tacrolimus) can be the cause of AKI in renal transplant patients.5 These drugs have many interactions5 with other medications including antifungals, antiepileptics and calcium channel blockers. The initiation of transplant medications requires nephrology consultation even if kidney function is normal. Calcium channel blockers and antiepileptics can alter the level of tacrolimus, levels of which are important to prevent the rejection of a transplant.

5. Use of Gadolinium. Nephrogenic systemic fibrosis (NSF) in ESRD patients due to the use of gadolinium for magnetic resonance imaging can occur after years of contrast administration, and, if used, patients will need urgent hemodialysis. NSF can develop on hemodialysis, peritoneal dialysis, in renal transplant recipients (typically with reduced allograft function), in patients with advanced chronic kidney disease (CKD), and patients with acute renal failure not requiring dialysis.6,7 6. Resistant Hypertension. Workup for resistant hypertension should be initiated if a patient is on 3 or more drugs at adequate dosage, one of which should be a diuretic. Resistant hypertension is defined in the 2008 American Heart Association and in the 2013 Guidelines of the European Societies of Hypertension and Cardiology as blood pressure that remains above goal in spite of concurrent use of three antihypertensive agents of different classes. Use of ultrasound doppler to detect renal artery stenosis has poor sensitivity, especially if the patient is obese or has increased bowel gas. It is time consuming, technically difficult (particularly in large patient) and is operator dependent.8 7. Contrast Induced Nephropathy (CIN) is defined as ARF that occurs within 24–72 hours of exposure to intravenous or intra-arterial iodinated contrast media that cannot be attributed to other causes. In most cases, it is nonoliguric. Dialyzing patients who received intravenous contrast for a computerized tomography is not effective as the contrast is rapidly absorbed into circulation and offers no additional benefit.9,10,11 High-risk patients who may develop contrast-induced injury include patients with diabetes and preexisting dehydration.12 Several risk stratification scoring systems are available to assess the risk of developing CIN and should be used.

8. Use of Peripherally Inserted Central Catheters (PICC lines) and Midline Catheters. Neither PICC lines nor midline catheters

should be used in patients with chronic kidney disease (CKD) stage 3 and higher as they may damage veins. Avoid inserting peripheral venous catheters in a non-dominant hand and use veins as distal as possible.

The risk of venous thrombosis associated with PICC lines is two-fold higher in patients with chronic kidney disease (CKD) compared to those with normal kidney function.14 Central venous catheters inserted via the internal jugular vein are reported to be associated with an alarming 41% central venous stenosis prevalence.15 9. Vaptans. Patients treated with vaptans for euvolemic hyponatremia should not have fluid restriction.16 Greater than a 2.5-fold increase in liver enzymes is more common among patients who received tolvaptan compared with placebo. Based upon this and other data, the FDA determined that tolvaptan should not be used in patients with liver disease (including cirrhosis) because it may potentially lead to liver failure or death.17 10. Hematuria. Always check for the presence of RBCs in the urine in patients with AKI. If elevated, this should raise suspicion for cresenteric glomerulonephritis.18,19 This requires urgent consultation. Rapidly progressive glomerulonephritis (RPGN) is usually caused by one of the three following mechanisms: anti-GBM antibody disease with or without pulmonary hemorrhage, pauci-immune glomerulonephritis, or severe immune complex glomerulonephritis.19 n References 1. Randall RE Jr, Cohen MD, Spray CC Jr. Rossmeisl EC. Hypermagnesemia in renal failure. Etiology and toxic manifestations. Ann Intern Med. 1964;61:73.

2. Shingarev R, Barker-Finkel J, Michael A. Natural history of tunneled dialysis catheters placed for hemodialysis initiation. J Vasc Interv Radiol.

2013;24(9):1289-94.

12. Andreucci M, Faga T, Pisani A, Sabbatini M, Russo D, Michael A. Prevention of contrast-induced nephropathy through a knowledge of its pathogenesis and risk factors. Sci World J. 2014:823169. https://www.ncbi.nlm.nih.gov/pmc/ articles/PMC4266998/http://dx.doi.org/10.1155/2014/823169.

13. Shingarev R, Allon M. Peripherally inserted central catheters and other intravascular devices: How safe are they for hemodialysis patients? Am J Kidney Dis. 2012 Oct; 60(4): 510–513. doi: 10.1053/j.ajkd.2012.07.003 14. Marnejon T, Angelo D, Abu Abdou A, Gemmel D. Risk factors for upper extremity venous thrombosis associated with peripherally inserted central venous catheters. J Vasc Access. 2012;13:231–238.

15. MacRae JM, Ahmed A, Johnson N, Levin A, Kiaii M. Central vein stenosis: a common problem in patients on hemodialysis. ASAIO J. 2005;51:77–81.

16. Gross P. Clinical management of SIADH. Ther Adv Endocrinol Metab.

2012;3(2):61-73.

17. Higashihara E, Torres VE, Chapman AB, et al. Tolvaptan in autosomal dominant polycystic kidney disease: three years’ experience. Clin J Amer Soc Nephr. 2011;6(10):2499-2507.

18. KDIGO Clinical Practice Guideline for Glomerulonephritis. Kidney Int. 2012;2(2):209.

19. Anders HJ. Diagnosis and Management of Crescentic Glomerulonephritis: State of the Art. Saudi J Kidney Dis Transpl. 2000;11:353-61.

Author Information: Division of Nephrology (Salim, Medaura) and Division of Hospital Medicine (Malhotra, Garla, Ahuja, Lawson Sonani, Palabindala) School of Medicine, University of Mississippi Medical Center, Jackson.

Corresponding Author: Sohail Abdul Salim, MD, Department of Medicine, Division of Nephrology, University of Mississippi Medical Center. 2500 North State Street, Jackson, Mississippi 39216-4505.

Tel: 347-733-0677. (sabdulsalim@umc.edu).

3. Mitchell D, Krishnasami Z, Allon M. Catheter-related bacteraemia in haemodialysis patients with HIV infection. Nephrol Dial Transplant 2006;21(11):3185-3188.

4. Bachleda P, Kalinova L, Utikal P, Kolar M, Hricova K, Stosova T. Infected prosthetic dialysis arteriovenous grafts: A single dialysis center study. Surg Infect (Larchmt). 2012;13(6):366–370. doi: 10.1089/sur.2011.041 5. Gabriel M. Danovitch Handbook of Kidney Transplantation (Lippincott Williams & Wilkins Handbook Series) Fifth Edition - 83-89.

6. Mendoza FA, Artlett CM, Sandorfi N, Latinis K, Piera-Velazquez S, Jimenez SA. Description of 12 cases of nephrogenic fibrosing dermopathy and review of the literature. Semin Arthritis Rheum. 2006;35(4):238-249.

7. Marckmann P. Nephrogenic systemic fibrosis: suspected causative role of gadodiamide used for contrast-enhanced magnetic resonance imaging. J Am Soc Nephrol. 2006;17(9):2359.

8. Radermacher J. Use of doppler ultrasonography to predict the outcome of therapy for renal-artery stenosis. N Engl J Med. 2001;344:410-417.

9. Shuji Kawashima. Prophylactic hemodialysis does not prevent contrastinduced nephropathy after cardiac catheterization in patients with chronic renal insufficiency. Circ J. 2006;70(5): 553–558.

10. Mohammed NMA, Mahfouz A, Achkar K, Rafie IM, Hajar R. Contrastinduced Nephropathy. Heart Views: The Official Journal of the Gulf Heart Association. 2013; 14(3):106-116.

11. B. Vogt, P. Ferrari. Prophylactic hemodialysis after radiocontrast media in patients with renal insufficiency is potentially harmful. Am J Med. 2001 Dec 15; 111(9): 692–698.

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A Survey of Environmental and Behavioral Aspects of Human West Nile Cases in Mississippi WENDY C. VARNADO,PhD; JEROME GODDARD, PhD Abstract West Nile Virus (WNV) continues to persist in Mississippi with dozens of cases reported each year. A variety of ecological and behavioral factors may contribute to human WNV cases such as local weather conditions, excessive vector breeding near the home, length of time spent outdoors, and lack of personal protection measures. The purpose of this study was to survey socioeconomic, environmental, and behavioral factors in patients known to have contracted WNV disease in Mississippi. A total of 377 WNV patients were sent a questionnaire about environmental conditions around their homes as well as various behaviors such as mosquito source reduction, time spent outdoors, and repellent use. A total of 134 (36%) questionnaires were returned and analyzed. Results showed that a majority of respondents said they paid attention to mosquito breeding sites around their home and made efforts to eliminate them. This fact might demonstrate that clean-up campaigns and other educational efforts by the health department are useful. Almost all WNV patients in our study who lived in nonincorporated areas had onsite wastewater systems (septic tanks and treatment plants), but only 19% reported properly servicing and maintaining these systems. Interestingly, we found that Mississippians in WNV endemic areas do not get their information about WNV from brochures, other print materials, or radio spots. Television, newspaper, and Internet were the primary avenues for such information about WNV. Also, we found that increased amount of time spent outdoors appeared associated with WNV infection. Only one of 134 respondents in this study spent less than 2 hours outdoors one day a week. A more controlled study of outdoor activity by people living in WNV endemic areas is warranted. Paradoxically, the use of personal protection techniques such as repellents did not change from before WNV infection to after. This, too, highlights the need for continued targeted educational efforts.

Introduction West Nile virus (WNV) is a mosquito-borne Flavivirus first discovered in the Western Hemisphere in 1999 in New York City, where there was a total of 59 cases and seven deaths occurred.1,2 WNV was first documented in humans in Mississippi during 20023 and by the end of the year, the Mississippi State Department of Health (MSDH) reported a total of 192 WNV cases, with 162 of those resulting in serious encephalitis; 12 deaths occurred.4 In the decade since its introduction into Mississippi, WNV has continued to persist statewide with 2012 exhibiting the most human infections with a total of 251 cases reported and 5 deaths.5 The most common signs and symptoms of WNV 134 VOL. 59 • NO. 3 • 2018

include fever, headache, myalgia, muscle weakness, gastrointestinal disruption, and, in some cases, a maculopapular rash on the chest, back, and arms. In the U.S., WNV has become the leading cause of epidemic meningoencephalitis in humans; however, it is estimated that less than 1% of all WNV infected patients develop the neuroinvasive form of the disease.6 The irreversible neurological damage resulting from meningoencephalitis, meningitis, or acute flaccid paralysis (AFP) is often severe.7 Even for patients who recover from the disease, there may be serious and debilitating long-term sequelae such as muscle weakness, memory loss, fatigue, and difficulty concentrating.8 A variety of ecological and behavioral factors might contribute to human WNV cases. For example, local weather conditions and especially rainfall patterns may cause increases in case numbers in a given area.9-14 Contrary to what one may think, there is an inverse relationship between rainfall and WNV activity because during drought, water that remains is highly organic, favoring WNV mosquito vectors.15,16 Excessive vector breeding near the home, amount of time spent outdoors during peak mosquito activity,17 and lack of personal protection measures18,19 also can lead to WNV cases. Furthermore, there have been efforts with varying degrees of success to use landscape ecology and demographic data to try to predict WNV cases.20-25 Researchers have found that pasture lands, higher available soil water, and younger, poorer black populations were positively associated with higher WNV occurrence;9 however, there are many WNV transmission dynamics which complicate predictive modeling.26 In public health vector control campaigns, it is important to understand community residents’ understanding of personal protection measures against WNV as well as their role in reducing local mosquito populations.27,28 Although municipalities may conduct occasional clean-up days for abatement of insect vectors, community sustainability (e.g., local citizen interest and diligence concerning mosquito control) is critical for long term success. Therefore, targeted educational campaigns based upon current knowledge, attitudes, and practices of community residents are critical for prevention and management of vector-borne diseases.29 There have been surveys in several states of the socioeconomic effects of WNV,30,31 personal protective behaviors, perceptions of local mosquito control (pertaining to WNV), and sero-epidemiological factors.28,32-35 These studies have shown that people are concerned about WNV and ways to protect themselves. For example, 67% of respondents in a 2004 Mississippi survey said they used repellents to protect themselves

Figure 1. Loca6on of all human WNV occurring in MS, 2008-­‐2013 (A), and loca6on of survey respondents (B).

from mosquito-borne diseases.29 In contrast, no environmental or ecological surveys of Mississippi WNV human cases have ever been conducted. The purpose of this study was to survey socioeconomic, environmental, ecologic, and behavioral factors in patients known to have contracted WNV disease in Mississippi.

FIGURE 1. Location of all human WNV occurring in MS, 2008-­2013 (A), and location of survey respondents (B).

Materials and Methods Survey. With appropriate IRB approval (MSDH protocol # 011114) a 47-question survey was mailed to 400 (out of 469 total) qualifying patients who had been confirmed positive for WNV during the years 2008-2013. Those initially not qualifying for a questionnaire were either minors (total 14) or deceased (total 55). Patients were identified using the MSDH EpiTracks® system and included clinical cases confirmed by the MSDH Public Health Laboratory and/or the Centers for Disease Control, private reference laboratories, and blood banks. Questions were asked about ecologic/environmental conditions around patients’ homes, their neighboring properties as well as various behaviors such as mosquito source reduction, time spent outdoors, and repellent use. A self-addressed, stamped envelope was included with each survey for its return.

Forty-three of the 400 questionnaires were returned by the post office with no forwarding address, so we used Internet people searches in an attempt to find current addresses for them (and they were re-sent).

Twenty-three of the re-sent questionnaires were returned, leaving us to assume that at least 377 patients received the survey.

Demographic and socioeconomic data. Socioeconomic and educational level data were obtained from the U.S. Census Bureau for each tract or area where case(s) occurred with the date range of 2008 through 2013 using a previously published methodology.36,37 No attempt was made to obtain these data for each individual patient as that would entail stricter IRB review. Due to budgetary and personnel reasons, no negative control group was established since many people may become infected with WNV but remain asymptomatic, i.e., we would never know who was truly negative.

Results and Discussion Demographic and socioeconomic results. A total of 134 (36%) questionnaires were completed and returned which geographically mirrored the distribution of most human WNV cases occurring 2008-2013 (Figure 1). Analysis of patient information obtained in the questionnaires is presented and discussed below.

Incidence of WNV infection during the time period 2008-2013 by race and income (census tract data) is provided in Table 1. Interestingly, the highest WNV incidence rate occurred in whites (17.6/100,000). This is in contrast to studies in Mississippi with St. Louis encephalitis (SLE) which showed that the incidence was higher in black populations.16 Additionally, the incidence rate of all WNV cases was higher in males (18.7/100,000) compared to females (13.1/100,000), which might be due to more outdoor chores/activities in males. Other studies have shown that this disparity is even more pronounced when analyzed by neuroinvasive disease cases only (true also for our cases).38 The socio-demographic profile of those who responded is as follows: the mean age was 58.7 years (range 19-88 years) and 47.8% (52.2%) of

J

Table 1. Average median income of Mississippi WNV cases by race, 2008-2013, based on census tracts with human cases.

Race

Avg. Median Income

% Below Poverty Level

White 47,645 Black 32,110 Hispanic 42,576 Asian 98,175 Unknown 46,734 Overall $44,296 Statewide

$39,031

5.7% 20.0% 16.6% 0% 10% 9.2% 24.0%

the respondents were female (male). Racial makeup of WNV patients included 79% white, 11% black, 1% Asian, and 9% undetermined (information absent from MSDH records). Those diagnosed with WNV fever represented 59% of respondents; the remaining 41% had the more serious neuroinvasive disease. When analyzed by census data, the average median income of all WNV cases in Mississippi during the time period was $44,296.82 (Table 1), and the average percentage of patients with at least a high school diploma or higher was 83%. In contrast to one study in Texas,36 our WNV patients had a median income level above that of the general population, i.e., they were not from a lower socioeconomic class (Table 1). This is likely due to access to care and, therefore, diagnosis.

Property descriptions and environmental conditions.

Approximately two-thirds of Mississippi WNV patients in this study reported living within a town/city limit. Accordingly, one might expect some level of public works or sanitation in their areas, even mosquito control. In fact, 103/134 (76%) of respondents reported a mosquito spray truck in their city or county. This, of course, does not mean these spray trucks were being effectively utilized. A previous survey of mosquito control practices in Mississippi found that almost half of spray programs were located in towns with fewer than 3,000 people, and program managers reported limited financial resources for mosquito control.39 Ninety-three percent (124/134) of our respondents reported living in single family dwellings and 100% reported having air conditioning. Seventy four percent (99/134) reported having an open deck or unscreened porch on their house, and 104/134 (78%) reported intact screens on their windows. Most of our respondents 102/134 (76%) reported wooded areas near their houses, 119/134 JOURNAL MSMA

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(89%) said they have a yard or garden, and about a third (31%) had a storm drain nearby. Ninety percent (120/134) reported no standing water under their houses (and another 9% of them said they did not know). When asked about wildlife around their homes, 63/134 (47%) said they had a bird feeding station near their house and 57/134 (43%) said they had bird houses located on their property.

Personal protection behaviors and mosquito control activities.

Approximately 80% (109/134) of responders prior to infection reported removing trash and debris from their property and dumping containers holding water, while 72/134 (53%) reported cleaning out their gutters. As for sewage disposal, 85/134 (63%) reported being on a city sewer and 49/134 (37%) had either a septic tank or treatment plant in their yards. However, only 26/134 (19%) of respondents said they properly serviced and maintained their on-site sewage systems.

This is important because the primary vector of WNV in Mississippi, Culex quinquefasciatus, is known to breed in effluent from failing or poorly functioning on-site wastewater systems.40-42 Interestingly, respondents reported extensive outdoor activity which may have led to increased mosquito exposure (Figure 2), a finding which has been seen previously.43 Eighty-nine percent (119/134) of our WNV patients reported sitting outside on a porch or patio, and 79/134 (59%) said they spent 5 days or more per week outdoors. This may be due to patients being retired or otherwise not working.44 Of the people who said they spent time outdoors, 121/134 (90%) reported spending at least 2 hours outside. Over a third of the respondents (35%) reported being outside more than 4 hours each time. This compares with other studies including a survey of over 800 Mississippi residents which found 48% of respondents spent >30 minutes outside more than 4 days a week.29 Only about half (71/134) of the people reported avoiding mosquitoes when they were most active, and for personal protection when outdoors, 112/134 (83%) said they used repellents; 51/134 (38%) said they used outdoor fogs and sprays; 41/134 (30%) said they wore long-sleeved shirts or long pants; and 22/134 (16%) reported repairing window screens (Figure 3).

Table 2. Use of personal protection measures against mosquitoes in Mississippi.

Protection Method

Previous Survey (Slavinski and Currier 2003) 47%

Current Survey

Wear long-sleeved shirts and pants

57%

31%

Using repellents

67% 56%

84% 16%

56% 63%

54% 81%

Avoid activity when mosquitoes active

Screening of windows and doors Clean out gutters Remove standing water

Varnado and Goddard, WNV paper

Figure 3. Use of personal protec:on measures for mosquito control by WNV p ;

FIGURE 3. Use of personal protection measures for mosquito control

by WNV patients.

What personal mosquito protections techniques do you use?

Varnado and Goddard, WNV paper

Figure 4. Educa6onal avenues for persons in Mississippi to gain informa6on abou

!

FIGURE 4. Educational avenues for persons in Mississippi to gain information about WNV. Where do you get information about mosquito control and West Nile virus?

53%

Use of protective behaviors among respondents in this survey roughly matched a wider, more comprehensive MSDH survey of mosquito control among Mississippi residents (but not known to be WNV patients) (Table 2). One exception was repairing screen-wire windows and doors. The 2003 survey reported 56% repaired screens, but our survey showed only 16%. Whether or not this impacted the 136 VOL. 59 • NO. 3 • 2018

FIGURE 2. Time spent outdoors in relation to WNV cases.

How many hours per day would you estimate you spend outdoors in garden, on porch or patio during warmer months of the year?

!

risk of WNV infection is unknown. Interestingly, in our study, after having WNV infection, 36/126 (29%) of responders said that their personal protective behaviors did not change. From discussion with WNV patients (not part of this survey), we have found them to be unconcerned about repeat infection, believing that they now have lifelong immunity. However, these patients fail to realize that there are several other mosquito-borne diseases present in Mississippi. This too, highlights the need for continued targeted educational efforts.

Some live off their investments.

You live on them. land financing

When asked where WNV patients obtained their information about mosquito control and WNV, 98/134 (73%) reported television, 65/134 (48%) reported newspaper, 55/134 (41%) internet, 19/134 (14%) printed materials such as brochures, and 18/134 (13%) from the radio (Figure 4). These results are enlightening because considerable health department resources have been devoted in the past to print materials and radio spots warning residents about WNV (Liz Sharlot, Mississippi Department of Health, personal communication). Our study suggests that television would be the best medium for such announcements, a finding consistent with other studies.43,45,46 Environmentally, a majority of respondents said they paid attention to mosquito breeding sites around their home and made efforts to eliminate them. Other studies have found similar results.45,47 This fact may demonstrate that clean-up campaigns and other educational efforts by the health department have been successful. Another possible environmental factor contributing to WNV ecology identified in this study was the presence of bird feeding, nesting, and attracting devices near homes (40-47%). These factors may have brought high numbers of bird reservoirs of WNV into close proximity of patients.

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3. CDC. West Nile virus activity: United States, August 8-14, 2002 MMWR, 51: 708-709; 2002.

This study has several limitations. We depended on self-reporting to measure the frequency of environmental conditions (such as breeding sites) and personal protective behaviors against WNV. There might be a variety of reasons why some patients failed to respond, including inability to read. We made no additional efforts to re-survey these non-responders, so it is unknown if there are significant differences in responders and non-responders in risk factors, personal protection behaviors, etc. Further, due to lack of resources, we made no effort to try to validate the responses of each participant. Frequency data might be overestimated due to participant attempts to please interviewers with their answers. Despite these limitations, our study will help public health personnel achieve their goals to promote health and educate the public about personal protective behaviors for mosquito-borne diseases, and thus, reduce risk of future WNV infections. Our work will also lay the groundwork for future studies such as widespread serosurveys of populations to accurately assess WNV infection rates and visual household surveys (onsite environmental surveys) to validate responses. Also, hypothesis-driven studies of specific risk factors associated with WNV infection are in order and currently planned. n

4. MSDH. Annual summary of selected notifiable diseases -- 2002. Mississippi Morbidity Report, 18: 1-49; 2002.

References 1. Asnis DW, Conetta R, Teixeira A. The West Nile virus outbreak of 1999 in New York: the Flushing Hospital experience. Clin Infect Dis. 2000;30:413-417.

12. Shaman J, Day JF, Stieglitz M. St. Louis encephalitis virus in wild birds during the 1990 south Florida epidemic: the importance of drought, wetting conditions, and the emergence of Culex nigripalpus (Diptera: Culicidae) to arboviral amplification and transmission. J Med Entomol. 2003;40(4):547-554.

2. Mostashari F, Bunning ML, Kitsutani PT, et al. Epidemic West Nile encephalitis, New York, 1999: results of a household-based seroepidemiological survey.

Lancet. 2001;358:261-264.

13. Shaman J, Day JF, Stieglitz M. Drought-induced amplification and epidemic transmission of West Nile virus in southern Florida. J Med Entomol.

2005;42(2):134-141.

5. MSDH. Annual summary of selected reportable diseases, Mississippi 2012.

Mississippi Morbidity Report 30: 102; 2014.

6. Tesh RB, Solomon T. Japanese encephalitis, West Nile, and other flavivirus infections. In: Guerrant RL, Walker DH, Weller PF, eds. Tropical Infectious Diseases. 3 ed. New York: Saunders Elsevier Publishing; 2011.

7. DeBiasi RL, Tyler KL. West Nile virus meningoencephalitis. Nature Clin Prac Neurol. 2006;2:264-275.

8. Patel H, Sander B, Nelder MP. Long-term sequelae of West Nile virus-related illness: a systematic review. Lancet Infect Dis. 2015;15:951-959.

9.

DeGroote JP, Sugumaran R, Brend SM, Tucker BJ, Bartholomay LC. Landscape, demographic, and climatic associations with human West Nile virus occurrence regionally in 2012 in the United States of America. Geospatial Hlth. 2014;9:153-168.

10. Dohm DJ, O’Guinn ML, Turell MJ. Effect of environmental temperature on the ability of Culex pipiens to transmit West Nile virus. J Med Entomol.

2002;39:221-225.

11. Reisen WK, Fang Y, Martinez VM. Effects of temperature on the transmission of West Nile virus by Culex tarsalis (Diptera: Culicidae). J Med Entomol.

2006;43(2):309-317.

JOURNAL MSMA

137

14. Soverow JE, Wellenius GA, Fisman DN, Mittleman MA. Infectious disease in a warming world: how weather influenced West Nile virus in the United States (2001-2005). Environ Hlth Persp. 2009;117(7):1049-1052.

15. Goddard J. What is new with West Nile virus? Infect Med. 2008;25:134-140.

16. Monath TP. Epidemiology. In: Monath TP, ed. St. Louis Encephalitis.

Washington, D.C.: American Public Health Association; 1980:239-312.

17. Aquino M, Fyfe M, MacDougal L, Remple V. Protective behavior survey, West Nile virus, British Columbia. Emerg Infect Dis. 2004;10:1499-1501.

18. Gujral IB, Zielinski-Guetierrez EC, LeBailey A, Nasci RS. Behavioral risks for West Nile virus disease, northern Colorado, 2003. Emerg Inf Dis. 2007;13:419-425.

19. Loeb M, Elliott SJ, Gibson B, et al. Protective behavior and West Nile virus risk. Emerg Infect Dis. 2005;11:1433-1436.

20. Cooke WH, Grala K, Wallis RC. Avian GIS models signal human risk for West Nile virus in Mississippi. Inter J Hlth Geogr. 2006;5:36-39.

21. Gu W, Unnasch TR, Novak RJ, Katholi CR, Lampman RL. Fundamental issues in mosquito surveillance for arboviral transmission. R Soc Trop Med Hyg. 2008;102:817-822.

22. Manore CA, Davis J, Christofferson RC, Wesson D, Hyman JM, Mores CN. Towards an early warning system for forecasting human West Nile virus incidence. PLoS Currents. 2014;6:319-326.

23. Rogers DJ, Myers MF, Tucker CJ, et al. Predicting the distribution of West Nile fever in North America using satellite sensor data. Photogram Eng Rem Sens. 2002;68:112-136.

24. Wimberly MC, Hildreth MB, Boyte SP, Lindquist E, Kightlinger L. Ecological niche of the 2003 West Nile virus epidemic in the northern great plains of the United States. PLoS ONE. 2008;3(12):1-7.

25. Young SG, Tuliis JA, Cothren J. A remote sensing and GIS-assisted landscape epidemiology approach to West Nile virus. Appl Geogr. 2013;45:241-249.

26.

DeGroote JP, Sugumaran R, Brend SM, Tucker BJ, Bartholomay LC. Landscape, demographic, entomological, and climatic associations with human disease incidence of West Nile virus in the state of Iowa, USA. Int J Health Geogr. 2008;7(19):19.

27. Dowling Z, Armbruster P, LaDeau S, DeCotis M, Mottley J, Lesinhan P. Linking mosquito infestation to resident socieconomic status, knowledge, and source reduction practices in suburban Washington. EcoHealth. 2013;10:36-47.

28. Olsen LK, Castro L, Banegas M. Community residents perceptions of West Nile virus environmental health hazards. American Alliance for Health, Physical Education, Recreation, and Dance National Convention and Exposition, Ft. Worth , TX, April 8-12; 2008.

29. Slavinski SA, Jones E. Evaluation of the Mississippi ‘Fight the Bite Campaign,’ 2003. Powerpoint presentation, Mississippi State University, Mississippi Health Policy Research Center, Starkville, MS, Aprl 13, 2004. ; 2004.

30. Barber LM, Schleier JJ, Peterson RKD. Economic cost analysis of a West Nile virus outbreak, Sacramento County, California, USA, 2005. Emerg Infect Dis. 2010;16:480-486.

31. Zohrabian A, Meltzer MI, Ratard R, et al. West Nile virus economic impact, Louisiana, 2002. Emerging Infect Dis. 2004;10(10):1736-1744.

32. Bowman LR, Runge-Ranzinger S, McCall PJ. Assessing the relationship between vector indexes and dengue transmission: a systematic review of the evidence. PLoS Negl Trop Dis. 2014;8:1-11.

33. Lockaby G, Noori N, Morse W, et al. Climatic, ecological, and socioeconomic factors associated with West Nile virus incidence in Atlanta, Georgia, U.S.A. J Vector Ecol. 2016;41:232-243.

34. Slavinski SA, Currier M. Risk factors for West Nile Virus infection in Mississippi. Southeast Center for Emerging Biological Threats, Conference on West Nile Virus, a Regional Crisis, Atlanta, GA, January 14-15, 2003.; 2003.

35. Tuiten W, Koenraadt CJM, McComas K, Harrington LC. The effect of West Nile virus perceptions and knowledge on protective behavior and mosquito 138 VOL. 59 • NO. 3 • 2018

breeding in residential yards in Upstate New York. EcoHealth. 2009;6(1):42-51.

36. Rios J, Hacker CS, Hailey CA, Parsons RE. Demographic and spatial analysis of West Nile virus and St. Louis encephalitis in Houston, Texas. J Am Mosq Contr Assoc. 2006;22:254-263.

37. United States Census Bureau. American community survey, 5-year estimates summary. http://www2.census.gov/programs-surveys/acs/summary_file/ 2013/data/; 2013.

38. Murray KO, Ruktanonchai D, Hesalroad D, Fonken E, Nolan MS. West Nile virus, Texas, USA, 2012. Emerg Infect Dis. 2013;19(11):1836-1838.

39. Edwards KT, Goddard J, Varnado WC. Survey of mosquito control knowledge, attitudes, and practices among county and municipal programs in Mississippi.

J Am Mosq Contr Assoc. 2009;25:361-366.

40. Barrera R, Amador M, Diaz A, Smith J, Munoz-Jordan JL, Rosario Y. Unusual productivity of Aedes aegypti in septic tanks and its implications for dengue control. Med Vet Entomol. 2008;22:62-69.

41. Mackay AJ, Amador M, Diaz A, Smith J, Barrera R. Dynamics of Aedes aegypti and Culex quinquefasciatus in septic tanks. J Am Mosq Contr Assoc.

2009;25(4):409-416.

42. Pires DA, Gleiser RM. Mosquito fauna inhabiting water bodies in the urban environment of Córdoba city, Argentina, following a St. Louis encephalitis outbreak. J Vect Ecol. 2010;35(2):401-409.

43. McCarthy TA, Hadler JL, Julian K, et al. West Nile virus serosurvey and assessment of personal prevention efforts in an area with intense epizootic activity: Connecticut, 2000. Ann New York Acad Sci. 2001;951:307-316.

44. Gibney KB, Colborn J, Baty S, et al. Modifiable risk factors for West Nile virus infection during an outbreak--Arizona, 2010. Am J Trop Med Hyg. 2012;86(5):895-901.

45. Averett E, Neuberger JS, Hansen G, GFox MH. Evaluation of a West Nile virus ediucation campaign. Emerg Infect Dis. 2005;11:1751-1753.

46. LeBeaud AD, Kile JR, Kippes C, King CH, Mandalakas AM. Exposure to West Nile virus during the 2002 epidemic in Cuyahoga County, Ohio: a comparison of pedicatric and adult behaviors. Pub Hlth Rep. 2007;122:356-361.

47. Wilson SD, Varia M, Lior LY. West Nile Virus: the buzz on Ottawa residents’ awareness, attitudes and practices. Can J Pub Hlth. 2005;96(2):109.

Acknowledgements This study was partially funded by the Mississippi Mosquito & Vector Control Association, Jackson, MS and Methodist Rehabilitation Center, Jackson, MS. Dr. Larry Smith and Carl Haydel (Mississippi State Department of Health) provided helpful advice concerning the statistical aspects of this study.

Author Information: Office of Environmental Health, Entomology Division of Entomology, Mississippi State Department of Health, P.O Box 1700, Jackson, MS 39215, Ph. (601)576-7689, Fx.(601)576-7632 (wendy.varnado@msdh.state.ms.gov) (Varnado). Department of Biochemistry, Molecular Biology, Entomology and Plant Pathology, Mississippi State University (jgoddard@entomology.msstate.edu) (Goddard).

Corresponding Author: Jerome Goddard, Department of Biochemistry, Molecular Biology, Entomology and Plant Pathology, 100 Twelve Lane, Clay Lyle Entomology Building, Mississippi State University, Mississippi State, MS 39762.

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Genome-Wide Association Studies (GWAS) Improve Understanding of Autism Spectrum Disorders in Mississippi and Beyond SABRINA V. WHITE; KRISTEN B. CALLAHAN; SUJITH RAMACHANDRAN, PhD; DUSTIN E. SARVER, PhD; ROBERT D. ANNETT, PhD Abstract Autism spectrum disorder (ASD), a complex neurodevelopmental disorder, affects an estimated 1 in 68 children nationally. The genetic contribution of ASD has been obscure until the recent development of genome-wide association studies. This manuscript describes the application of genome-wide association studies to ASD through reviewing the known genetic variants associated with autism and the importance of genetic testing for an ASD diagnosis. Genetic testing is integral to an ASD workup, helping to determine potential etiology (e.g., copy-number variants and loss-of-function mutations) and coexisting conditions (e.g., Fragile X) as well as assisting in care planning. Genome-wide association studies may potentially identify ASD risk in individuals. Mississippi, where ASD prevalence rates differ from national data, has the opportunity to participate in SPARK, the largest national genetic study of ASD to date. SPARK and Mississippi are poised to contribute to further understanding the genetic basis of ASD. Key Words: Autism; Genome-wide association study; Copynumber variant; Loss-of-function mutation; SPARK Introduction Autism is an increasingly common condition with population estimates currently indicating that the condition affects approximately 1 in 68 individuals.1 Genetic contributions to autism have been a subject of intense scientific examination.2-4 However, only recently have healthcare providers had available tools to scan for genetic variations contributing to autism. Genome-wide association studies scan complete sets of DNA in search of genetic variations within individuals with a disease or condition, as well as an individuals without the disease/condition.

Variations including single nucleotide polymorphisms (SNPs) and copy number variants (CNVs) indicate possible genetic risk factors and contributions to complex diseases such as autism. These associated variants are not necessarily the singular cause for a disease/ condition; however, they serve as markers for identifying the region in the genome that contribute to a disease. Insights from GWAS findings provide healthcare providers with both the heritable causes of disease/ conditions as well as the ability to potentially tailor therapies based on the individual’s genetic profile. GWAS studies have been extended to the realm of psychiatric disorders, including autism. Applying a 140 VOL. 59 • NO. 3 • 2018

GWAS approach to Autism Spectrum Disorders (ASD) is expected to improve knowledge of its etiology, thereby providing information that can be further tested within ASD clinical trials research.

The purpose of the current manuscript is to describe the state of the field in the diagnostic workup for individuals suspected of ASD, including genetic screening, and the application of GWAS to the scientific understanding of ASD. We also present data on ASD in Mississippi’s children. Finally, information is provided on Mississippi’s opportunity for participation in a national ASD genome wide association (GWAS) project.

Diagnosing Autism Spectrum Disorders The diagnosis of ASD is a complex process that can be made reliably in children as young as 24 months, though national estimates indicate the median age of diagnosis to be between 48-75 months.1 A multidisciplinary team, including physicians and psychologists, use assessment procedures including reviews of the child’s development, multi-informant ratings of behavior, symptom interviews such as those based on the Autism Diagnostic Interview-Revised, and behavioral observations such as the structured Autism Diagnostic Observation Schedule, Second Edition. In addition, assessments of neurocognitive functioning, language functioning, and motor and sensory skills are critical to the assessment. Guidelines for these procedures have been described by others.5-6 Collectively, these structured and semistructured procedures assess development, social skills, behaviors, and communication skills and rule out other complex neurodevelopmental disorders.

The multi-disciplinary assessment is guided by DSM-V criteria (Table 1), which informs the diagnosis as well as interventions that can directed to the individual and family. Team members use standardized measures including direct observation of the child’s social skills, restricted and repetitive behaviors, and communication skills, along with a physical examination and assessment of motor and neurocognitive skills. A medical examination of general health and determining the presence of other coexisting conditions and conditions that are known to be related to ASD occurs and should include genetic screening for chromosomal and other genetic abnormalities. Typically, this information is summarized and provided in the form of feedback to the caregivers and a written report.

Table 1. DSM-V Criteria for Autism Spectrum Disorders Symptom Critieria

Traits

Deficits in social communication & social interaction across multiple contexts

Deficits in social-emotional reciprocity; Deficits in nonverbal communication behaviors (e.g., gestures) used for social interaction; Deficits in the development, maintenance, and comprehension of relationships

Restricted, repetitive patterns of behavior, interests or activities

Stereotyped movements, speech, and use of objects; Inflexibility to change of routines or ritualized patterns; Restricted interests with strong, abnormal attachments; Hypoor hypersensitivity to environmental factors

Symptoms must be present in early developmental period

Symptoms may not manifest until social demands exceed limited capacities

Combination of symptoms significantly impair daily functioning

Level 3 - Requiring very substantial support Level 2 - Requiring substantial support Level 1 – Requiring support

Genetic screening plays a key role in the medical examination of a child suspected of ASD, including the use of microarray to determine single point gene mutations and sequence analysis. Through this testing, families are provided with important information, including causal disease or syndrome genes, recurrence risk, and other potential complications that may arise.7 This information helps families and physicians better determine the plan of care needed for that child.

Genetic Screening Gene expression plays a complicated role in autism, as no single gene has been identified as contributing to the diagnosis of ASD. An identifiable causative genetic variant or syndrome has been estimated to be present in up to 25% of children with ASD. Still, the exact pathogenesis has yet to be determined.8 However, studies have found genomic regions, or “hotspots”, where either a SNP or a CNV is present, suggesting a strong association with ASD.9 Examination of ASD

“hotspots” (including 15q11.2q13, 10q22q23, & 17q12) among 516 neurotypical individuals and those with ASD observed a significantly larger number of CNV duplications in children with autism, while the number of deletions remained constant in both groups.4 These findings were replicated in an independent cohort examining the same hotspots. An increase in duplications, rather than deletions, appears to be a predisposition for autism. Still, CNV deletions may be of clinical importance as other large network studies involving ASD simplex families have demonstrated lower IQs in individuals with ASD with CNV deletions.10 De novo loss-of-function (LOF) mutations in the proteins CHD8, GRIN2B, POGZ, and SCN2A have also been indicated as ASD risk genes.11 In individuals with ASD, CHD8, a chromatin modifier, has the highest LOF mutation number and has proven to directly regulate other risk genes of ASD.12 Mutations in GRIN2B possibly contribute to alterations in brain function and cognition during neurodevelopment.13 POGZ, a transposable element involved in protein assembly, has been found to disrupt brain development and function if there is a deficiency.14 Clearly, there are a number of LOF mutations among individuals with ASD, indicating that there are multiple genetic factors contributing to the ASD behavioral phenotype.

ASD in Mississippi’s Children The Centers for Disease Control (CDC) Autism and Developmental Disabilities Monitoring (ADDM) Network estimates that 1 in 68 (14.7 per 1000) of children aged 8 years and 1 in 75 (13.3 per 1000) children aged 4 years have been diagnosed with ASD.15 The rate increased over the last decade before becoming stable between 2010 and 2012.

However, there is considerable variability across states, ranging from 12 to 24 per 1000.15 A point of concern is that African-American and Hispanic children are less likely to be identified as having ASD, likely reflecting health disparities affecting these populations.16 Very little information on ASD prevalence in Mississippi exists. The Mississippi Autism Advisory Committee (2015) estimates of ASD

Table 2. Percent of Children Aged 3-18 years insured by Medicaid with Developmental Disorders or Autism Spectrum Disorder by Mississippi Department of Health Regions Mississippi Department of Health Regions Region 1 Region 2 Region 3 Region 4 Region 5 Region 6 Region 7 Region 8 Region 9 Total

DD Population N (%) †

DD Prevalence Rate per 1,000

1408 (10.7) 1191 (9.0) 1094 (8.3) 715 (5.4) 3854 (29.2) 1073 (8.1) 692 (5.2) 1528 (11.6) 1648 (12.5) 13203 (100)

40 32.1 33 27.1 56.6 36.2 33.2 43.8 34.8 39.7*

ASD Population N (%) † 523 (14.2) 482 (13.1) 166 (4.5) 201 (5.5) 573 (15.6) 286 (7.8) 183 (5.0) 484 (13.2) 776 (21.1) 3674 (100)

ASD Prevalence Rate per 1,000 14.8 13 5 7.6 8.4 9.6 8.8 13.9 16.4 10.9*

Discrepancy in ASD Observed and Expected Prevalence Rate per 1,000** +0.1 -7.5 -9.7 -6.3 -9.6 -5.1 -5.9 -0.8 +1.7 -3.7

Notes: ASD = Autism Spectrum Disorders; DD = Developmental Disorders; Region 1: Coahoma, Desoto, Grenada, Panola, Quitman, Tate, Tallahatchie, Tunica, Yalobusha; Region 2:Alcorn, Benton, Itawamba, Lafayette, Lee, Marshall, Pontotoc, Prentiss, Tippah, Tishomingo, Union; Region 3: Attala, Bolivar, Carroll, Holmes, Humphreys, Leflore, Montgomery, Sunflower, Washington; Region 4: Calhoun, Chickasaw, Choctaw, Clay, Lowndes, Monroe, Noxubee, Oktibbeha, Webster, Winston;Region 5: Claiborne, Copiah, Hinds, Madison, Rankin, Simpson, Sharkey, Issaquena, Warren, Yazoo; Region 6: Clarke, Jasper, Kemper, Lauderdale, Leake, Neshoba, Newton, Scott, Smith; Region 7:Adams, Amite, Franklin, Jefferson, Lawrence, Lincoln, Pike, Walthall, Wilkinson; Region 8: Covington, Forrest, Greene, Jefferson Davis, Jones, Lamar, Marion, Perry, Wayne; Region 9: George, Hancock, Harrison, Jackson, Pearl River, Stone *Average Prevalence Rate in Mississippi **Based on CDC prevalence estimates of 1 in 68 (1/68 x 1,000 = 14.71 per 1,000) † Percentage of total DD/ASD population in Mississippi

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prevalence were calculated through extrapolation of information compiled by the CDC. Based on national estimates and a prevalence rate of 14.7 per thousand, approximately 10,700 children from Mississippi between the ages of 3-181 would be expected to be diagnosed with ASD. Mississippi’s Medicaid database provides an alternative mechanism for estimating the prevalence across Mississippi’s nine health regions. As of June, 2016 approximately 475,435 children are insured with Medicaid and CHIP, representing about 65% of Mississippi’s children.17 Inspection of Mississippi’s Medicaid data reveals a different profile than the CDC estimates. Using a combination of the enrollment data and medical claims data from the year 2015, our project sought to estimate the prevalence of ASD or developmental disorders in children from age 3 to 18 in each county, which is consistent with CDC methods. The county level data were then collapsed to the nine health regions in the state. ASD or developmental disorders were identified from the data using ICD9 codes recorded in the claims at the time of the office visit.

Our analyses determined an ASD state prevalence rate of 1 in 91 (10.9 per thousand; (Table 2), which is 25% lower than CDC estimates.

The two regions with the highest prevalence of ASD were Region 9 (George, Hancock, Harrison, Jackson, Pearl River, and Stone counties) at 16.3 per thousand and Region 1 (Coahoma, DeSoto, Grenada, Panola, Quitman, Tallahatchie, Tate, Tunica, and Yalobusha) at 14.8 per thousand. Inspection of individual county-level data revealed ASD prevalence rates ranging from 0 to 24.6 per thousand. Notably, 53 of the 82 Mississippi counties did not fall within 25% of CDC statistics, suggesting significant under-identification of ASD in Mississippi children that are qualified for Medicaid.

Collectively, these findings likely reflect challenges to ASD identification across Mississippi communities. Some have observed that child, family, physician practice, and community factors exert a significant influence upon identification and diagnosis of ASD.18,19 Within Mississippi, several issues may impact the recognition and subsequent diagnosis of ASD. For example, parent attribution about child behavior as well as knowledge of symptoms of ASD may influence the timing of diagnosis. The extent to which child behavior is viewed as a lack of discipline or behavior problems (e.g., described as being spoiled, stubborn, or disobedient) has been suggested to influence the timing for when parents seek help for their child.18 Health care provider recognition of ASD symptoms may also impact referral timing, and routine use of standardized screening instruments both reduces racial/socioeconomic detection disparities and may result in earlier identification.18,20 Childhood medical problems (e.g., seizures, GI conditions, and prematurity) have been shown to result in a later diagnoses of ASD.21 Finally, distance to health care services, including residing in a rural community, has been shown to result in later recognition of ASD.22 In sum, there are a variety of challenges to recognition and diagnosis of ASD that may be exerting influence upon the findings observed in Mississippi.

Mississippi’s Opportunity In April 2016, the University of Mississippi Medical Center helped launch the Simons Foundation Powering Autism Research for Knowledge (SPARK) study. SPARK is the largest ASD study undertaken, attempting to understand the genetic basis of 50,000 142 VOL. 59 • NO. 3 • 2018

individuals with autism and their families. Individuals of all ages with a professional diagnosis of ASD are eligible. UMMC is the only non-ASD specialty center represented among the 26 clinical research sites that are participating in SPARK. Mississippi has the opportunity to both impact and benefit from participation in SPARK. We will contribute to the recruitment of large rural and minority populations that have been markedly underrepresented in ASD genetic studies, which tend to be ethnically homogenous and Caucasian. Including broad geographic, socioeconomic, and ethnic/racial diversity is imperative to discovering the genetic etiology of complex neurodevelopmental disorders such as ASD and maximizing the representativeness of genetic analyses.

Mississippi families stand to benefit from SPARK as the genetic testing that is conducted through SPARK can be shared with the child or adult’s local physician(s). Importantly, the testing and results are made available to study participants when genetic findings are present as are a range of educational materials that provide informational resources to participants and families. Participation can be entirely online (www.

SPARKforAutism.org/UMMC) and involves registration, providing medical and family history information, and obtaining a saliva sample from a kit that is mailed to families. Compensation is provided for participation. Individuals and families can also access the SPARK online community that contains a vast library of helpful resources.

Conclusion The identification of the genetic basis of ASD through GWAS studies will provide insight into its etiology, and has potential diagnostic and treatment implications. Mississippi healthcare providers are encouraged to discuss and share information about the opportunity to participate in SPARK with families affected by ASD, including the opportunity to receive ASD-relevant educational information and ASD-specific genetic results. Our examination of Medicaid ASD prevalence rates, however, indicates a discrepancy between national and Mississippi prevalence rates, with children in Mississippi less frequently being identified as having ASD than would be expected.

While Medicaid data represents 65% of Mississippi’s children, limits to generalizability of findings remains. However, these findings underscore the imperative for early ASD screening among Mississippi primary care physicians who can provide referrals for comprehensive ASD evaluations, including genetic testing. SPARK can provide additional access resources to inform the ASD community in Mississippi. n References 1. Christensen DL. Prevalence and characteristics of autism spectrum disorder among children aged 8 years—autism and developmental disabilities monitoring network, 11 sites, United States, 2012. MMWR Surveillance Summaries. 2016;65.

2. Connolly JJ, Glessner JT, Hakonarson H. A Genome‐Wide Association Study of Autism Incorporating Autism Diagnostic Interview–Revised, Autism Diagnostic Observation Schedule, and Social Responsiveness Scale. Child Dev. 2013;84(1):17-33.

3. Girirajan S, Johnson RL, Tassone F, et al. Global increases in both common and rare copy number load associated with autism. Hum Mol Genet. 2013:ddt136.

4. Girirajan S, Dennis MY, Baker C, et al. Refinement and discovery of new hotspots of copy-number variation associated with autism spectrum disorder.

Am J Hum Gen. 2013;92(2):221-237.

5. Chawarska K, Klin A, Volkmar FR. Assessment of cognitive and adaptive skills. In: Chawarska K, Klin A, Volkmar FR, ed. Autism Spectrum Disorders in Infants and Toddlers: Diagnosis, Assessment, and Treatment. New York: Guilford Press; 2008.

6. Klin A SC, Tsatsanis K, & Volkmar F. Clinical evaluation in autism spectrum disorders: Psychological assessment within a transdisciplinary framework. In: F V, ed. Handbook of Autism and Pervasive Developmental Disorders. Hoboken, New Jersey: Wiley; 2005.

7. Baker E, Jeste SS. Diagnosis and management of autism spectrum disorder in the era of genomics: rare disorders can pave the way for targeted treatments.

Pediatr Clin North Am. 2015;62(3):607-618.

8. Hirschhorn JN, Gajdos ZK. Genome-wide association studies: results from the first few years and potential implications for clinical medicine. Annu Rev Med. 2011;62:11-24.

9. Chaste P, Klei L, Sanders SJ, et al. A genome-wide association study of autism using the Simons Simplex Collection: Does reducing phenotypic heterogeneity in autism increase genetic homogeneity? Biol Psychiatry.

2015;77(9):775-784.

10. Chang J, Gilman SR, Chiang AH, Sanders SJ, Vitkup D. Genotype to phenotype relationships in autism spectrum disorders. Nat Neurosci.

2015;18(2):191-198.

11. State MW, Sestan N. Neuroscience. The emerging biology of autism spectrum disorders. Science (New York, NY). 2012;337(6100):1301-1303.

12. Cotney J, Muhle RA, Sanders SJ, et al. The autism-associated chromatin modifier CHD8 regulates other autism risk genes during human neurodevelopment. Nat Commun. 2015;6:6404.

developmental, psychiatric, and medical conditions among children in multiple populations of the United States. J Dev Beha Pediatr. 2010;31(4):267-275.

22. Cohen P, Hesselbart CS. Demographic factors in the use of childrenâ&#x20AC;&#x2122;s mental health services. Am J Public Health. 1993;83(1):49-52.

Acknowledgements The authors are grateful for the support of the Simons Foundation Autism Research Initiative award 385076.

Author Information: Center for Advancement of Youth (CAY), Department of Pediatrics, University of Mississippi Medical Center, Jackson (UMMC) (White, Callahan, Sarver, Annett). Department of Pharmacy Administration, University of Mississippi, Oxford (Ramachandran).

Research Coordinator; SPARK UMMC (White). Research Specialist, UMMC; Research Coordinator, SPARK UMMC. Former early childhood and elementary educator (Callahan). Assistant Professor, Department of Pharmacy Administration, University of Mississippi. Research Assistant and Professor RIPS, University of Mississippi, Oxford (Ramachandran). Clinical Psychologist, Assistant Professor of Pediatrics, UMMC; Co-Investigator, SPARK UMMC. Clinical and research interests in childhood neurodevelopmental (ADHD, autism) and behavioral disorders, as well as neurocognition (Sarver). Pediatric Neuropsychologist and Professor of Pediatrics, UMMC; Principal Investigator, SPARK UMMC. Clinical and research interests in translational genetic research in pediatric oncology and the intersection of early environmental influences on brain development (Annett).

13. Kenny EM, Cormican P, Furlong S, et al. Excess of rare novel loss-of-function variants in synaptic genes in schizophrenia and autism spectrum disorders.

Mol Psychiatry. 2014;19(8):872-879.

14. Ye Y, Cho MT, Retterer K, et al. De novo POGZ mutations are associated with neurodevelopmental disorders and microcephaly. Cold Spring Harbor Mol Case Stud. 2015;1(1):a000455.

15. Caye A, Spadini AV, Karam RG, et al. Predictors of persistence of ADHD into adulthood: a systematic review of the literature and meta-analysis. Eur Child Adolesc Psychiatry. 2016;25(11):1151-1159.

16. Mandell DS, Wiggins LD, Carpenter LA, et al. Racial/ethnic disparities in the identification of children with autism spectrum disorders. Am J Public Health.

2009;99(3):493-498.

17. Mississippi Division of Medicaid. Monthly Medicaid and CHIP Application, Eligibility, Determination, and Enrollment Reports 2016. https://medicaid. ms.gov/wp-content/uploads/2016/02/2016-Enrollment-Reports.pdf.

Accessed September 2, 2017.

18. Daniels AM, Mandell DS. Explaining differences in age at autism spectrum disorder diagnosis: a critical review. Autism. 2014;18(5):583-597.

19. Fountain C, King MD, Bearman PS. Age of diagnosis for autism: individual and community factors across 10 birth cohorts. J Epidemiol Community Health.

2011;65(6):503-510.

20. Daniels AM, Halladay AK, Shih A, Elder LM, Dawson G. Approaches to enhancing the early detection of autism spectrum disorders: a systematic review of the literature. J Am Acad Child Adolesc Psychiatry. 2014;53(2):141-152.

21. Levy SE, Giarelli E, Lee LC, et al. Autism spectrum disorder and co-occurring

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Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy: A New Treatment Modality for Primary or Secondary Peritoneal Cancer in Mississippi WADE O. CHRISTOPHER, MD; ASHLEY H. SEAWRIGHT, DNP; JAMES J. WYNN, MD; Figure 1: Preoperative abdominal CT scan axial view demonstrating pseudomyxoma TRUMAN M. EARL, MD; CHRISTOPHER D. ANDERSON, MD; W. SHANNON ORR, MD peritoni. Arrow pointing to mucin.

Abstract Cancer involving the peritoneum has traditionally been associated with a high fatality rate. Intravenous chemotherapy (IV) has limited effectiveness due to poor penetration of peritoneal disease.

Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) has become the standard of care for certain cancer patients with peritoneal dissemination. This case report details the introduction of CRS with HIPEC in Mississippi. The patient was diagnosed with mucinous appendiceal cancer. He underwent extensive cytoreductive surgery and 90 minutes of HIPEC with Mitomycin-C intraoperatively. The patient tolerated the procedure well and remains disease free approximately 1 year later. This case report demonstrates the effectiveness of CRS and HIPEC in the setting of peritoneal cancer.

This first case laid the groundwork for HIPEC in Mississippi, and this treatment modality has been used again in subsequent cases since that time.

FIGURE 1. Preoperative abdominal CT scan axial view demonstrating pseudomyxoma peritoni. Arrow pointing to mucin.

Key Words: HIPEC, Cytoreductive Surgery, Mucinous Adenocarcinoma of the appendix Case Our patient is a 56-year-old male who presented to another hospital with a chief complaint of abdominal pain. The patient reported experiencing intermittent right lower quadrant abdominal pain which started approximately 1 year prior. He stated at that time, he thought he had appendicitis. His pain subsequently improved without seeking medical treatment, but over time he noticed his abdomen started to become diffusely swollen. He then began having difficulty drinking and eating and then developed mild diffuse abdominal pain. His workup at the outside hospital included a Computed Tomography (CT) scan, which showed multiple fluid-filled structures throughout the peritoneal cavity and small bowel distention. He was transferred to our institution for further workup.

After transfer to the University of Mississippi Medical Center (UMMC), his CT scan was reviewed. This demonstrated a ruptured appendiceal mucocele with extensive pseudomyxoma peritonei indicating the presence of a mucinous adenocarcinoma (Figure 1 and Figure 2). On paracentesis, 25 cc’s of thick yellow fluid was removed from the right mid-abdomen. Histology demonstrated acellular mucoid material

only without evidence of malignancy. Next, he underwent a screening colonoscopy which showed diverticula and one sessile polyp which was found to be a tubular adenoma. Because of the presence of pseudomyxoma peritonei on imaging, the patient was offered CRS with HIPEC and agreed to undergo the procedure. Two weeks later he underwent exploratory laparotomy with right hemicolectomy, splenectomy, cholecystectomy, partial hepatectomy, right diaphragm resection, total omentectomy, pelvic peritonectomy, bilateral diaphragm peritonectomies, bilateral abdominal wall peritonectomies, and intraperitoneal chemotherapy with Mitomycin-C for 90 minutes (Figure 3). He was found to have a peritoneal cancer index score (PCI) of 18 and was cytoreduced to completeness of cytoreduction (CC) of 0. The patient was admitted to the Intensive Care Unit overnight and then transferred to the floor the following day. His hospital course was complicated by an intraabominal abscess requiring drainage by interventional radiology. He was discharged home approximately 2 ½ weeks after surgery. After discharge, the patient has been followed in clinic with history, physical exam, laboratory evaluation and imaging every 6 months. He is doing well approximately 1 year from surgery JOURNAL MSMA

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FIGURE 2. Preoperative abdominal CT scan coronal view demonstrating pseudomyxoma peritoni. Arrow pointing to mucin.

and remains disease free (Figures 4 and 5).

Discussion Peritoneal cancer, including peritoneal dissemination from appendiceal malignancy, colorectal malignancy, and peritoneal mesothelioma, has traditionally been associated with extremely high mortality rates.1 Cancer of the peritoneum has previously been extremely difficult to treat because of the limitations of traditional intravenous chemotherapy (IV). The resistance of treatment to IV chemotherapy is due to poor peritoneal blood supply to the tumors.2 The levels of IV therapy needed to penetrate large peritoneal tumors are overwhelmingly toxic to patients and lead to detrimental side effects.

Figure 3: Intraoperative photograph of midline incision with underlying mucin.

FIGURE 3. Intraoperative photograph of midline incision with underlying mucin.

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Resection of certain metastatic cancers to specific organs has been shown to improve survival. The standard of care for colorectal metastasis to the liver and lung is surgical resection if a survival benefit is likely.3 Previously, multiple metastases to the peritoneum was a diagnosis deemed unamenable to surgery. The theory behind this was that the peritoneal lining was inherently multicentric in nature. One of the leaders in HIPEC, Dominique Elias of Paris, France, shifted the paradigm viewing peritoneal implants from colorectal cancer.

He proposed that disease isolated to the peritoneum be viewed as a single site metastasis as with isolated metastatic disease to the liver. He showed that by performing CRS and HIPEC with colorectal cancer isolated to the peritoneum, the survival rate of patients compared to standard therapy increased from a median survival of 23.9 months in the standard treatment group to 62.7 months in the HIPEC group.4,5 These results were very similar to that of liver resection for colorectal metastases. The novel approach of viewing peritoneal implants as a single site metastasis coincides with the traditional results seen with resection of isolated metastatic disease Cytoreductive surgery was first described in 1934 by Meigs et al. in New York with a report of debulking for ovarian cancer. He reported symptomatic improvement and reduction in complications such as bowel obstruction postoperatively.6 The technique was limited in use until the 1960’s when it began to be used in a more widespread approach for ovarian carcinomatosis.7 In 1969 a study reported using cytoreductive techniques applied to psudomyxoma peritonei secondary to appendiceal tumors. Administration of alkylating agents was used in this study and marked improvements in survival were seen.8 This technique remained in popularity but was not standardized with any specific metric. Intuitively it would be assumed that the lesser amount of presenting tumor burden and more complete resection of gross tumor burden, the better the outcome. An early study demonstrating this found response to therapy and survival benefits were most pronounced when largest intraperitoneal tumor implants were <2 cm.9 In the 1990’s one of the pioneers in modern HIPEC, Paul Sugarbaker, devised a scoring system for peritoneal tumor burden known at the Peritoneal Cancer Index (PCI). This scoring system divides the abdomen into 13 quadrants and stratifies tumor burden based off of gross disease in each quadrant. If all macroscopic tumor burden is removed, this is deemed a completeness of cytoreduction with an associated score of 0.10,11,12 This scoring system is used to assess the feasibility of CRS and the effectiveness of HIPEC. Prior to

FIGURE 4. Postoperative abdominal CT scan axial view demonstrating no residual tumor burden at time of follow up.

1995 there was no traditional description of the surgical technique for adequate peritonectomies. Sugarbaker et al. described six separate peritonectomy procedures: omentectomy with splenectomy, left upper quadrant peritonectomy, right upper quadrant peritonectomy, lesser omentectomy with cholecystectomy, antrectomy and stripping of omental bursa, and pelvic peritonectomy including colorectal resection.13 Hyperthermic intraperitoneal chemotherapy is heated chemotherapeutic medication that is instilled into the peritoneal cavity. It takes advantage of the separation of the peritoneal cavity from systemic circulation. The maximum tolerated dose of chemotherapy given in the peritoneal cavity is significantly higher than can be given IV. The heat is cytotoxic to the malignant cells but it also increases the chemotherapy’s penetration into the cells. The addition of heat has been shown to potentiate the chemotherapy’s cytotoxic effects.14

ure 5: Postoperative abdominal CT scan coronal view demonstrating no residual

or burden at time of follow up.

FIGURE 5. Postoperative abdominal CT scan coronal view demonstrating no residual tumor burden at time of follow up.

The technique of CRS and HIPEC requires vast resources and is limited to major medical centers and academic institutions. The logistics involved require a large support team and specialty providers.

This treatment is not new. The promise of this case report is that this technique can now be used on patients within the state of Mississippi without the time investment and financial burden of traveling long distances to receive this therapy. Since the time of this first case report, we have performed subsequent CRS and HIPEC treatment at UMMC and are optimistic about the positive results. This first case laid the groundwork for further management of peritoneal cancer in the state of Mississippi. n

References 1. Sugarbaker PH, Ronnett BM, Archer A, Averbach AM, Bland R, Chang D, et al.

Pseudomyxoma peritonei syndrome. Adv Surg 1996; 30: 233–80.

2. Steuperaert M, Falvo D’Urso Labate G, Debbaut C. Mathematical modeling of intraperitoneal drug delivery: simulation of drug distribution in a single tumor nodule. Drug Deliv. 2017;24(1):491-501.

3. Fong Y, Cohen AM, Fortner JG. Liver resection for colorectal metastases. J Clin Oncol. 1997;15(3):938-46.

4. Elias D, Goéré D, Dumont F, et al. Role of hyperthermic intraoperative peritoneal chemotherapy in the management of peritoneal metastases. Eur J Cancer. 2014; 50(2):332–340.

5. Elias D, Lefevre J, Chevalier J, et al. Complete cytoreductive surgery plus intraperitoneal chemohyperthermia with oxaliplatin for peritoneal carcinomatosis of colorectal origin. J Clin Oncol. 2009 Feb 10;27(5):681–685.

6. Meigs JV. Tumors of the female pelvic organs. New York: The Macmillan Co., 1934.

7. Munnell EW. The changing prognosis and treatment in cancer of the ovary.

A report of 235 patients with primary ovarian carcinoma 1952-1961. Am J Obstet Gynecol 1968;100:790-805.

8. Long RT, Spratt JS, Jr, Dowling E. Pseudomyxoma peritonei. New concepts in management with a report of seventeen patients. Am J Surg. 1969;117:162-9.

9. Howell SB, Zimm S, Markman M, et al. Long-term survival of advanced refractory ovarian carcinoma patients with small-volume disease treated with intraperitoneal chemotherapy. J Clin Oncol. 1987;5:1607-12.

JOURNAL MSMA

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10. Jacquet P, Sugarbaker PH. Clinical research methodologies in diagnosis and staging of patients with peritoneal carcinomatosis. Cancer Treat Res. 1996;82:359-74.

Helping you build a more secure future.

11. Esquivel J, Farinetti A, Sugarbaker PH. Elective surgery in recurrent colon cancer with peritoneal seeding: when to and when not to proceed. G Chir.

1999;20:81-6.

Harmon RL, Sugarbaker PH. Prognostic indicators in peritoneal 12. carcinomatosis from gastrointestinal cancer. Int Semin Surg Oncol. 2005;2:3.

We invest our own money alongside yours, so we are invested in your success.

13. Sugarbaker PH. Peritonectomy procedures. Ann Surg. 1995;221:29-42.

14. González-Moreno S, González-Bayón LA, Ortega-Pérez G. Hyperthermic intraperitoneal chemotherapy: Rationale and technique. World J Gastrointest Oncol. 2010 Feb 15;2(2):68-75.

Author Information: General Surgery Resident, University of Mississippi Medical Center (UMMC) (Christopher). Nurse Practitioner, Department of Transplant Surgery, UMMC (Seawright). Transplant Surgeon, UMMC (Wynn). Transplant Surgeon, Residency Program Director, UMMC (Earl), Chairman of Surgery, Transplant Surgeon, UMMC (Anderson). Surgical Oncologist, UMMC (Orr).

Corresponding Author: Wade Christopher, MD, University of Mississippi Medical Center, Department of General Surgery, 2500 North State Street, Jackson, MS 39216. Ph. 205-919-1331 (wchristopher@umc.edu).

MEDLEY & BROWN F I N A N C I A L

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148 VOL. 59 • NO. 3 • 2018

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The Heart of Hospice Difference At Heart of Hospice our mission is to serve all hospice eligible patients the way they desire to be served. We work with each patient to develop a plan of care that is unique to their specific situation.

Physical therapy, IV therapies, radiation and other comforting treatments approved by the physician may be included in the patient’s plan of care.

As always, the Heart of Hospice team will be working 24/7 to admit eligible patients who need our care.

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Transforming end-of-life care in the communities we serve

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MISSISSIPPI Northwest Delta Jackson Southern Referral Line: 1.844.HOH.0411 JOURNAL MSMA

149

A M E R I C A N

M E D I C A L

A S S O C I A T I O N

Big Picture: Solely Focusing on Either Gestational Diabetes or Hypertension Loses Site of Future Health Implications It’s well known that women who have gestational diabetes are likely to develop type 2 diabetes later, and women who have gestational hypertension will likely develop high blood pressure later. But the two are not mutually exclusive.

Recent research published in the American Journal of Epidemiology reveals that considering both conditions separately during pregnancy underestimates some key indicators for future disease.

Study results revealed that pregnant patients who have both gestational diabetes and gestational hypertension are at a greater risk of developing type 2 diabetes, hypertension and cardiovascular disease after pregnancy.

This underscores the need to identify patients at greater risk for these conditions, the importance around type 2 diabetes prevention efforts and hypertension management, and controlling the high rates of incidence associated with both types of disease.

Uncovering the link between diabetes and hypertension The study examined more than 63,000 women, between 1990 and 2007, who were mothers matched in pairs. The matched pairs were made up of women diagnosed with gestational diabetes alongside mothers who did not develop gestational diabetes.

Researchers discovered the following: Having one condition during pregnancy increased the likelihood of cardiometabolic disease, but having both conditions significantly increased the risk further. he subsequent type 2 diabetes risk for pregnant women who had either gestational diabetes or hypertension was 15 times • T higher compared to those without gestational diabetes or hypertension. But for women who had both conditions, the risk was 37 times higher.

• R isk for subsequent hypertension doubled for pregnant women with either gestational condition, however, for women with both gestational diabetes and gestational hypertension, the risk was nearly six times higher.

With both gestational diabetes and gestational hypertension present, time to subsequent cardiometabolic diagnosis was shorter.

• A type 2 diabetes diagnosis came at 4.6 years for women with both conditions vs. 5.3 years for women with one condition.

• Time to diagnosis for hypertension came at 6 years for women with both conditions vs. 9.3 years for women with one condition.

• The time to cardiovascular disease was 10.8 years for women with both conditions vs. 11.4 years for those with a history of either condition.

The study also followed up with the fathers and found that they had increased risks for these conditions as well.

Developing a big-picture strategy After birth, gestational diabetes and hypertension resolve, and since moms are more focused on the health of their babies, they tend to put their own health on the back burner, researchers observed.

These conditions are more likely to return after pregnancy when weight gain comes into play. But this gives you an opportunity to partner with patients—both moms and dads—when you notice the scales beginning to tip.

150 VOL. 59 • NO. 1 • 2018

Women with a history of gestational diabetes who are overweight or obese are eligible to participate in an intensive lifestyle change program that is part of the National Diabetes Prevention Program where participation can reduce their risk of developing type 2 diabetes by 58 percent.

The American Medical Association teamed up with the Centers for Disease Control and Prevention (CDC) to develop resources you can use to educate and manage your patient population and prevent chronic disease.

Strategies you can use to help your patients include: • Online patient risk assessment: a 1-minute quiz that determines whether a patient has prediabetes with immediate results and lifestyle tips to help lower their risk • Prevent Diabetes STAT toolkit: an online suite of tools that help you screen, test and get patients to take action to lower their risk and includes patient handouts and other resources • National Diabetes Prevention Program: a list of nationwide in-person and online lifestyle change programs the CDC recognizes • Target: BP improvement program: an online program guide to help you assess, treat and control high blood pressure within your patient population What’s at stake?

According to the CDC, the prevalence of gestational diabetes is estimated to be 9.2 percent with 2 to 10 percent of U.S. pregnancies being affected by it.

The CDC also reports that 50 percent of women with gestational diabetes go on to have type 2 diabetes. And babies of these moms have a greater risk of obesity as children or teens and are more likely to develop type 2 diabetes later on in life.

In the last 20 years, diabetes diagnoses have more than tripled in U.S. adults thanks to an aging and overweight population.

Nearly 85 million U.S. adults have high blood pressure, and 45.9 percent of adults with hypertension don’t have it under control.

These stats reveal how diabetes, hypertension and obesity continue to increase over time. This highlights the importance of strategies that prevent and offer treatment to reduce diabetes, hypertension and cardiovascular disease, which has become a national health crisis. Using key tools to partner with your patients in screening and management of these chronic conditions can have a substantial impact on improving population health. n

AMA Launches “Share Your Story” Campaign to Document Opioid Use Disorder Barriers to Care The American Medical Association (AMA) is launching a new digital tool kit as part of its ongoing efforts to improve access to high-quality treatment for patients seeking multidisciplinary pain care and for a substance use disorder. The tool kit will be used by the AMA and the nation’s medical societies to urge physicians to upload stories about their patients who encounter obstacles when seeking care for pain and/or a substance use disorder.

The “Share Your Story” campaign is part of the AMA’s work to end the opioid epidemic and is designed to highlight physician efforts as well as urge payers and policymakers to improve access to treatment.

“We know that prior authorization and other administrative practices used by health insurers can impede appropriate, necessary care—resulting in unnecessary harms and sometimes fatal consequences—for a patient with a substance use disorder,” said Patrice A. Harris, MD, chair of the AMA Opioid Task Force. “These stories will enable us to identify the unique challenges faced by patients and physicians and share them with health insurers and policymakers in support of solutions to increase access to care. Without proper treatment and access to care, this epidemic will only get worse.”

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A recent study of six large cities found that prior authorization for buprenorphine, used to treat opioid addiction, occurred 42 percent of the time, often delaying patients’ access to necessary medicine at a crucial point in their potential recovery. According to the Substance Abuse and Mental Health Services Administration, in 2016 alone, nearly 90 percent of people who need treatment for illicit drug use didn’t get it, largely due to practices such as these. Physicians agree that these practices must be discontinued, and medication assisted treatment (MAT), the gold standard in treatment for opioid use disorder, needs to Physicians can share their story here: https://www.end-opioidepidemic.org/treatment/treatment-contact-form/ The AMA Opioid Task Force recommendations to end the nation’s opioid epidemic can be found here: https://www.end-opioidepidemic.org/ n

Pain.

Why not start relief with chiropractic?

Harvard Medical School has stated that “chiropractic spinal manipulation may be helpful for back pain, migraine, neck pain, and whiplash.”

The Journal of the American Medical Association (JAMA) recently found that in “patients with acute low back pain, spinal manipulative therapy was associated with modest improvements in pain and function.”

Every day, more voices join in the call to address pain with a conservative, non-invasive, non-addicting approach.

We stand ready to contribute in overcoming the opioid crisis that is affecting millions of Americans.

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152 VOL. 59 • NO. 3 • 2018

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Oxford Treatment Center • 297 CR 244 • Etta, MS 38627 • oxfordtreatment.com An American Addiction Centers Facility JOURNAL MSMA

153

S P E C I A L

A R T I C L E

New Study Shows “Physicians Mean Business”: Mississippi Doctors Boost the State Economy Most physicians in the state have a pretty good idea of how they impact their patient’s health but are less aware of their impact the on the health of the state economy, according to MSMA President Dr. William M. Grantham. “It turns out that what is good for health care is good for the economy; and, the numbers prove it,” he said.

“I have always seen the value of physicians as movers of the economy in Mississippi,” Governor Phil Bryant said when he joined Dr. Grantham at a press conference to announce the Mississippi data. “Physicians are vital to the well-being of our citizens of the state, and they are also vital to our economy.”

The new figures populate a study commissioned by MSMA and the American Medical Association to determine state and nationwide economic impact to see how physicians are shaping the economy. The 2018 statewide report titled The Economic Impact of Physicians in Mississippi spotlights just how much medicine means to the state.

Standing with the Governor, other physicians and medical students, Dr. Grantham said, “The economic impact data presents a clear picture of how physicians and the economy work together in surprising ways.”

VITAL SIGNS: THE ECONOMIC IMPACT OF PHYSICIANS IN MISSISSIPPI1

Mississippi Jobs Created

51,305

Direct jobs .................................................................................................................................................22,461 Indirect jobs .............................................................................................................................................28,844 Average jobs supported by each physician....................................................................................... 11

Mississippi Economic Activity Generated

$8.2 billion

Direct economic output ........................................................................................................$4.7 billion Indirect economic output .....................................................................................................$3.5 billion Percent of total GSP/GDP2 ..................................................................................................................7.8% Average economic output generated by each physician................................$1.8 million

Wages and Benefits to Mississippians

$3.8 billion

Direct wages and benefits ....................................................................................................$2.8 billion Indirect wages and benefits ....................................................................................................$1 billion Average wages and benefits supported by each physician................................$810,212

Mississippi State and local tax revenue

$313.1 million

Average state and local tax revenue generated by each physician................ $67,043 1. The economic impact of physicians in Mississippi (QuintilesIMS, December 2017).

2. US Bureau of Economic Analysis: Current-Dollar GDP by State, 2015.

Mississippi physicians generate more economic output, produce more jobs and pay more in wages and benefits than higher education, nursing and community care facilities, legal services and home health.

“Many of us practice and do our best for our patients day after day and never even consider the economic impact of what we’re doing,” Dr. Grantham said. “We are privileged to help our patients, and it’s nice to know that our contribution also helps Mississippi’s bottom line.”

The new study quantifies the economic boost that nearly 5,000 Mississippi physicians provided to the state’s economy, producing a ripple effect that is felt statewide. The study measures physicians’ impact using the four key economic indicators of jobs, economic activity, wages and benefits and state and local tax revenue.

154 VOL. 59 • NO. 3 • 2018

“The medical profession as an economic driver has become a reality in Mississippi,” Gov. Bryant said, “Physicians today are responsible for over 51,000 jobs and have a total economic output of over $8 billion annually.”

Gov. Bryant has demonstrated his commitment to putting physicians to work in the state economy by supporting the Mississippi Rural Physicians Scholarship Program at the University of Mississippi Medical Center and the William Carey School of Osteopathic Medicine. Designed explicitly to put doctors to work in Mississippi after they have completed residency training, the program was started in 2007. Each year, the number of students in the pipeline grows and now each fall more medical students make a commitment to complete medical school and to work in Mississippi after residency training.

Nationally, the AMA tipped its hat to the Mississippi economic impact statistics, noting how vital the state’s physicians are to culture, community and economy.

“The positive impact of physicians extends beyond safeguarding the health and welfare of their patients,” said AMA President Dr. David O. Barbe. “The Economic Impact Study illustrates that Mississippi physicians are woven into their local communities and have a vital role in fueling the state’s economy by creating jobs, purchasing goods and services, and supporting public services through the tax revenue they generate.”

Governor Phil Bryant joined MSMA President Dr. William M. Grantham for a news conference to announce the 2018 Economic Impact Report.

The report found that every $1 applied to physician services in Mississippi supports an additional $1.75 in other business activity. Above and beyond the clinical and administrative personnel who work inside the physician practices, an additional 6.1 jobs are supported for each $1 million in revenue generated by a physician’s practice. In addition, Mississippi physicians generate more economic output, produce more jobs and pay more in wages and benefits than higher education, nursing and community care facilities, legal services and home health care,” concluded Dr. Grantham. “Why MSMA means business!” n

Just like the river, you are strong and unstoppable.

Find your strength at the river.

If you or someone you know is struggling with addiction, call today.

(877) 654-9761

At The River www.JourneyPureRiver.com

JOURNAL MSMA

155

16TH ANNUAL

CME IN THE SAND May 25 – 29, 2018 Sandestin Golf and Beach Resort Sandestin, Florida SCHEDULE OF EVENTS: FRIDAY, MAY 25 6:00 pm Welcome Reception SATURDAY, MAY 26 7:00 am Breakfast with Exhibitors 8:00 am CME (4 hours) 2:00 pm MACM Golf Tournament SUNDAY, MAY 27 7:00 am Breakfast with Exhibitors 7:00 am Prescribing CME (5 hours) 6:30 pm Family Dinner MONDAY, MAY 28 7:00 am Breakfast with Exhibitors 8:00 am CME (4 hours) TUESDAY, MAY 29 7:30 am CME (4 hours) Register today!

Visit www.MSMAonline.com/YPS For reservations at Sandestin Golf & Beach Resort, call 850.320.8115 or BOOK ONLINE AT www.Sandestin.com 156 VOL. • NO. 3 • 2018 and enter group59 code 2382IS

TOPICS:

Antibiotic Stewardship | Alzheimer’s | Hypertension | Pre-Diabetes | Osteoporosis | Chronic Kidney Disease | Cervical & Upper Extremity Sports Injuries | Post Care of Transplant Patients | Pediatrics | Atrial Fibrillation | MACRA Update | MSMA Update | Anti-Stigma | MSBML New Rules & Regulations | Trauma and Prescribing | Suboxone Prescribing | Safe Prescribing for Chronic Pain

P R E S I D E N T ’ S

P A G E

We Got “Street Cred”

I

n this issue of the Journal we feature the 2018 Economic Impact Report which statistically illustrates something we have known for a long time. Mississippi physicians not only heal the sick but we also bring quantifiable value to our communities and our state. We physicians circulate dollars through the community by creating jobs, buying supplies, treating patients, writing prescriptions and paying taxes.

Medicine is big business. We generate more than $8 billion that circulates through the Mississippi economy. Physicians alone are responsible for nearly 8 percent of the state’s total economic output. That’s bigger than higher education, bigger than legal services. It’s larger than nursing or home care.

This knowledge gives us priority with policy makers like the Governor and the Legislature. It gives us “street cred” at the bank, at the Capitol and in Washington. And, it gives us a responsibility to isolate problems and help find the solutions. That’s where organized medicine contributes most to the value.

Back in the late 80’s physicians began to lose influence with the movers and shakers. In my opinion this was caused by health plans (payers and HMO-type companies) that stepped in and demanded that physicians see more patients for less moo-lah. We let these non-physician businesses get between physicians and patients – or at least we didn’t stop them.

The result is that we spent less time at the Chamber of Commerce event, missed more Rotary Club meetings or we just said no when asked to sit on the local bank board.

All of those community groups have carried on and flourished. They did it without physicians because we became too busy. We worked more hours and devoted less time to community. And, the most regretful scene in the picture is that we lost opportunities to influence our neighbors. They still respect physicians and maybe still ask our opinion. But, our neighbors and the community will continue.

I know I’m preaching to the choir when I tell you --- MSMA members – the value that this Association brings to the house of medicine. You ARE part of the solution. You become part of the voice and part of the answer when you call your legislator, volunteer to be the Doctor of the Day at the Capitol, serve on an MSMA council, or on a committee of the State Department of Health or the Division of Medicaid. So my personal pledge is to open my eyes to more opportunities, to influence more movers and shakers, to be a more influential playmaker. After all, we got cred and we can use it! n

William M. Grantham, MD MSMA President 2017-2018

JOURNAL MSMA

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The Mississippi State Medical Association Alliance would like to thank the physicians in Mississippi for their service and recognize the sacrifice they make every day. We appreciate your concern and compassion, and we appreciate you.

You make a difference in the lives of others!

A special thank you to those who provided this advertisement, including: Marlene Caldwell in memory of Dr. Wallace E. Caldwell Katherine Carmichael in honor of Dr. Ben M. Carmichael Lori Edney in honor of Dr. Daniel Edney Teresa Floyd in honor of Dr. Herbert Floyd Shoba Gaymes in honor of Dr. Charles H. Gaymes Lavonne Griffin in memory of Dr. T. David Griffin Beth Hartness in honor of Dr. Stanley Hartness Peggie Herrington in memory of Dr. Joe D. Herrington Jean Hill in honor Dr. J. Edward Hill Ann Hopper in honor of Dr. William C. Hopper, Jr. and in memory of Dr. John M. McRae Danita Horne in honor of Dr. Mark Horne Angela Ladner in honor of Dr. Mark E. Ladner Karen Morris in honor of Dr. Jeffrey Morris Sondra Pinson in honor of Dr. Terry Pinson Lauren Reed in honor of Dr. David Reed Carol Reeves in honor of Dr. David L. Reeves Heather Rifkin in honor of Dr. Brian Rifkin Merrell Rogers in memory of Dr. Lee H. Rogers Stacey Tsang in honor of Dr. Brian Tsang Shannon Warnock in honor of Dr. James L Warnock, Jr.

158 VOL. 59 â&#x20AC;˘ NO. 3 â&#x20AC;˘ 2018

M I S I S of SHealth I P Mississippi StateS Department Public Health Regions DeSoto

Marshall

Benton

Tishomingo

Alcorn

Tunica Tate

Prentiss

Tippah Union

Panola

Lafayette

Lee

D E P A R T M E N T Mississippi

P I

S T A T E

Coahoma

Quitman

Yalobusha

Mississippi

Calhoun

Grenada Carroll

Washington

Montgomery

Clay Webster

Sunflower Leflore Attala

Humphreys

Issaquena

January 2018

Monroe

Chickasaw Tallahatchie

Oktibbeha Lowndes

Choctaw Winston

Noxubee

Provisional Reportable Disease Statistics

Holmes Yazoo

Madison

Leake

Neshoba

Kemper

Newton

Lauderdale

January 2018

Sharkey Scott

H E A L T H

Provisional Reportable Disease Statistics*

Itawamba

Pontotoc

Bolivar

O F

*Monthly statistics are provisional. Disease totals may change depending on additional reporting statistics are investigation. provisional. Disease totals may change onthe additional reporting from healthcare providers*Monthly and public health These numbers do depending not reflect final case from healthcare providers and public health investigation. These numbers do not reflect the final counts. case counts.

Warren

Hinds

Copiah

Lincoln

Lawrence

Franklin

Amite

Clarke

Simpson

Jefferson

Adams

Jasper

Smith

Rankin

Claiborne

Pike

Wilkinson

Covington

Wayne

Jones

Jefferson Davis Lamar Marion

Forrest

Perry

Greene

Walthall

George

Pearl River Stone

Northern Region Harrison

Central Region

Jackson

Public Health District

Hancock

Zoonotic Diseases

Enteric Diseases

Vaccine Preventable Diseases

Mycobacterial Diseases

Sexually Transmitted Diseases

Southern Region

*

State Totals*

I

II

III

IV

V

VI

VII

VIII

IX

Jan 2018

Jan 2017

YTD 2018

YTD 2017

Primary & Secondary Syphilis

2

3

0

0

1

0

1

1

1

9

23

9

23

Early Latent Syphilis

3

1

2

1

1

0

0

0

0

8

32

8

32

61

75

63

61

156

61

18

68

96

659

427

659

427

130 141

134

128

284

135

57

136

157

1,302

774

1,302

774

Gonorrhea Chlamydia HIV Disease

6

6

4

7

19

3

1

7

3

56

43

56

460

Pulmonary Tuberculosis (TB)

1

1

0

0

0

0

1

1

0

4

2

4

2

Extrapulmonary TB

0

0

0

0

0

0

0

0

0

0

0

0

0

Mycobacteria Other Than TB

0

3

2

1

6

0

2

0

7

21

40

21

40

Diphtheria

0

0

0

0

0

0

0

0

0

0

0

0

0

Pertussis

1

0

0

0

1

0

1

0

2

5

5

5

5

Tetanus

0

0

0

0

0

0

0

0

0

0

0

0

0

Poliomyelitis

0

0

0

0

0

0

0

0

0

0

0

0

0

Measles

0

0

0

0

0

0

0

0

0

0

0

0

0

Mumps

0

0

0

0

0

0

0

0

0

0

0

0

0

Hepatitis B (acute)

0

0

0

0

0

0

0

0

1

1

4

1

4

Invasive H. influenzae disease

1

0

1

1

0

3

0

1

4

11

9

11

9

Invasive Meningococcal disease

0

0

0

0

0

0

0

0

0

0

0

0

0

Hepatitis A (acute)

1

1

0

0

1

0

0

0

0

3

0

3

0

Salmonellosis

2

5

0

2

6

2

0

0

4

21

45

21

45

Shigellosis

2

2

1

0

6

0

1

0

3

15

17

15

17

Campylobacteriosis

2

2

1

3

6

1

2

1

15

33

26

33

26

E. coli O157:H7/STEC/HUS

0

0

0

0

0

0

0

0

1

1

2

1

2

Animal Rabies (bats)

0

0

0

0

0

0

0

0

0

0

0

0

0

Lyme disease

0

0

0

0

0

0

0

0

0

0

0

0

0

Rocky Mountain spotted fever

0

0

0

0

0

1

0

0

0

1

4

1

4

West Nile virus

0

0

0

0

0

0

0

0

0

0

0

0

0

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

JOURNAL MSMA

159

C O M M E N T A R Y

Tax Cuts & Jobs Act of 2017: A Brief Overview MICHAEL A. CARRAWAY, JR., CPA The Tax Cuts & Jobs Act of 2017, signed into law just before the end of last year, contains many provisions affecting millions of taxpayers. It is fair to say this is, by far, the largest single revision to the federal income tax system since 1986.

Income taxes are an important consideration for physicians across all practices and specialties, so being aware of these changes is prudent, if not vital. They constitute a mixed bag of negative and positive provisions, most of which take effect in 2018, and many of which “sunset” (go back to 2017 levels) after 2025. Some of the more notable changes for individuals include: • Individual tax rates have been adjusted, with the top, marginal tax rate being reduced from 39.6% to 37%.

• The standard deduction nearly doubles from 2017 levels (to $24,000 for married taxpayers filing jointly); • Personal exemptions for dependents are eliminated; • The exemption for Alternative Minimum Tax is increased; • The Affordable Care Act individual mandate is repealed (effective 2019); • Section 529 plan funds usage is expanded; • State and local tax deductions (property and income or sales taxes) are limited; • The debt limit for home mortgage interest deductions is lowered, and home equity indebtedness interest is made nondeductible; • The child tax credit is increased; • Miscellaneous itemized deduction (“2% deductions”) are eliminated.

There are also many provisions relevant to businesses. Just a few of those include: • Corporate tax rates are set at 21% (from a previous top rate of 35%); • Corporate Alternative Minimum Tax is repealed; • Net operating loss rules are revised, and additional limitations apply; • New limits are created for business interest expense; • Like-kind exchanges can no longer be executed for personal property (equipment, automobiles, etc.), though real estate still qualifies; • Business-related entertainment expenses are no longer deductible.

• A new deduction equal to as much as 20% of “qualified business income” is created (applying to income passing through partnerships, S corporations, and/or earned by sole proprietorships/wholly owned businesses) but is inapplicable to medical service providers at certain income levels – see below; further, limitations based on wages and capital investment can apply.

The above-mentioned 20% deduction is specifically inapplicable to certain specified service trades or businesses, which does include medical services provided by physicians, nurses, etc. However, there is a taxable income threshold under which the deduction is allowed, regardless of the service provided. That threshold is $315,000 for married taxpayers filing jointly, half that for other taxpayers. Over that taxable income amount, the exclusion phases in over the next $100,000 of taxable income (for married taxpayers filing jointly; half that for others). This deduction is not available for use against salary or other reasonable compensation.

These and other changes, too numerous to list here, make it clear that reassessment of personal and business tax planning is needed for many, be it in planning for personal deductions and credits, choosing the right kind of business entity structure, or a myriad of other issues. The rules have changed, and taxpayers must act accordingly, so seeking the advice of a competent professional who understands the rules and can work with you to find the answers and actions that work for you is important.

The above does not represent tax advice. Each situation is fact-dependent, and you should seek the advice of a competent advisor. Michael A. Carraway,

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Jr. is a member of GranthamPoole PLLC. The firm is a provider of tax, accounting , advisory and strategic services, partnering with clients across a broad spectrum of industries and sizes, with a strong team of professionals providing tailored services to physicians, drawing on years of relevant industry and technical experience. n

Mississippi, We All Need to CHIP in on this One LAUREN FRIEDRICH, PRE-MED On September 30th of 2017, Congress failed to renew funding for the Children’s Health Insurance Plan (CHIP), which was passed under the Clinton Administration to provide health insurance to low-income children who are not covered under federal Medicaid benefits. CHIP covered 8.9 million children in 2016, more than 88,500 of whom live in Mississippi.1 This program has historically had widespread bi-partisan support. On September 18th, United States Senators Orrin Hatch (R-UT) and Ron Wyden (D-OR) introduced the Keeping Kids’ Insurance Dependable and Secure (KIDS) Act which would extend CHIP for five years and improve the programs by adding protections and allowing states more autonomy over their individual programs.2 Despite this attempt, September 30th passed without the passage of the KIDS Act, and actions to address CHIP’s lack of funding were not taken quickly.

Mississippi’s CHIP program covers children under the age of 19 who are Mississippi residents and ineligible for health insurance under Medicaid. CHIP funding is also used to support some children eligible for Medicaid under the Affordable Care Act within the state.3 The CHIP program is administered by the Mississippi Department of Medicaid and supported by the Mississippi Department of Health.4 As of March 2017, the CHIP program covers children who are not covered by Medicaid with income levels below 209% of the federal poverty level.5 CHIP coverage includes no premiums or deductibles but may have small co-payments for higher-income families for certain services.4 The federal government has historically provided a higher matching rate through CHIP than through Medicaid. In 2016, Mississippi received $287.5 million in funding from the federal government for CHIP.6 Mississippi is one of ten states in which CHIP is entirely federally funded.7 This support has helped Mississippi reach a level of 96% insurance coverage for children,6 slightly above the national average of 95%.8 While Congress focused on other things as September 30th approached, they failed to consider the possible ramifications of failing to renew CHIP for children and pregnant women throughout the United States. Without CHIP, the future of health care for recipients covered through CHIP would be at stake. More than 88,500 children who were covered in Mississippi in 2016 through CHIP would, if the program were not eventually renewed, lack access to health insurance. Without coverage, children would be more likely to forgo well visits and routine check-ups. In addition, without affordable co-pays, specialized or preventive health care would be unaffordable and inaccessible, forcing these populations to rely on charity care from hospital systems. Research published by Georgetown University suggested that CHIP would be a better long-term source of coverage in terms of affordability and benefits than the marketplace could provide.6 Research predicted some states would run out of CHIP funding relatively quickly.9 Estimates suggested that Mississippi would run out of CHIP funds after April 2018. The State of Mississippi reported plans to close enrollment or establish an enrollment cap for their CHIP program as a result of the lost federal support.9 In December, Congress passed a short-term measure to temporarily fund CHIP with $2.85 billion dollars through March amidst partisan disagreements over financial prioritizations.10 While this short-term measure was necessary, longer-term funding had not yet been guaranteed.

On January 22nd, Congress finally passed a six-year extension of funding for CHIP as part of a continuing resolution to fund the federal government. This extension will allow states to stably continue CHIP programs in the coming years.11 Most recently, Congress passed the Bipartisan Budget Act of 2018 which extends CHIP for an additional four years, securing the program for the next decade.12 As an aspiring pediatrician, I believe this extension of CHIP is crucial to the future of health care in America and applaud those who have advocated for the extension of funding. Without it, our kids in Mississippi and elsewhere in the United States would struggle to access adequate and necessary health care services. We all have a responsibility to provide care to the children of our state and country, and this funding is a major way that we are all able to CHIP in. n References 1. Total Number of Children Ever Enrolled in CHIP annually. Kaiser Family Foundation Web Site. https://www.kff.org/other/state-indicator/annual-chip-enrollment /?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D. Accessed January 2, 2017.

2. Hatch, Wyden Introduce Bill to Extend and Improve Critical Children’s Healthcare Program. Orin Hatch United States Senator for Utah Web Site. https://www.hatch.

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senate.gov/public/index.cfm/releases?ID=071428C9-0FD3-4C76-B3E1-734F93B46CF4. Published September 18, 2017. Accessed January 2, 2017.

3. Children’s Health Insurance Program (CHIP). Mississippi Division of Medicaid Web Site. https://medicaid.ms.gov/programs/childrens-health-insurance-programchip/. Accessed January 2, 2017.

4. Children’s Health Insurance Program (CHIP). Mississippi State Department of Health Web Site. http://www.msdh.state.ms.us/msdhsite/_static/41,0,96.html.

Accessed January 2, 2017.

5. Income Limits for Medicaid and CHIP Programs. Mississippi Division of Medicaid Web Site. https://medicaid.ms.gov/medicaid-coverage/who-qualifies-forcoverage/income-limits-for-medicaid-and-chip-programs/. Accessed January 2, 2017.

6. Mississippi Children’s Health Insurance Program (CHIP). Georgetown University Web Site. https://ccf.georgetown.edu/wp-content/uploads/2017/09/fed_ advocacy_chip_mississippi.pdf. Accessed January 2, 2017.

7. Wolfe A. Congress to consider maintaining health insurance for 79,000 Mississippi children. Clarion Ledger. October 3, 2017.

8. Health Insurance Coverage of Children 0-18. Kaiser Family Foundation Web Site. https://www.kff.org/other/state-indicator/children-0-18/?currentTimeframe=0 &sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D. Accessed January 2, 2017.

9. State Plans for CHIP as Federal CHIP Funds Run Out. Kaiser Family Foundation Web Site. https://www.kff.org/medicaid/fact-sheet/state-plans-for-chip-as-federalchip-funds-run-out/. Published December 6, 2017. Accessed January 2, 2017.

10. Collins M. Congress votes to avert shutdown, provide money for children’s health insurance. Clarion Ledger. December 21, 2017.

11. Summary of the 2018 CHIP Funding Extension. https://www.kff.org/medicaid/fact-sheet/summary-of-the-2018-chip-funding-extension/. Published January 24, 2018. Accessed February 11, 2018.

12. Earl J. What’s in the Senate budget deal? 6 quick takeaways. Fox News. February 9, 2018.3.

Lauren Friedrich is a pre-med student majoring in medicine, health and society at Vanderbilt University in Nashville, Tennessee, and will be attending medical school next fall.

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Jackson, MS • Oxford, MS • Madisonville, LA • 877-759-5765 • www.MWGEmployerServices.com JOURNAL MSMA

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M I S S I S S I P P I

S T A T E

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A S S O C I A T I O N

Defining Events in the Evolution of Medicine in Mississippi - Celebrating the 150th Anniversary of the MSMA House of Delegates KAREN A. EVERS

M

any of you remember celebrating our association’s sesquicentennial at annual session in Vicksburg (2006), having been relocated from the Gulf Coast by Hurricane Katrina in 2006. Now it’s time to celebrate the 150th anniversary of our MSMA’s House of Delegates in Jackson where the first meeting was held December 15, 1856. Wait a minute, that doesn’t add up, and we just inaugurated William Grantham 150th MSMA President last year. Let me explain the intricacies of our association’s cause for more celebration.

According to the original report of the proceedings of the December 1856 medical convention, the minutes end with plans to meet at the end of the next year. However, no record of another meeting prior to 1869 has been found, and apparently, like so many things in the South, the destructive winds of the Civil War retarded further growth of organized medicine in the state. Thirteen years after the founding fathers1 established the MSMA, pursuant to a call made by the Vicksburg Medical Society, physicians from around the state assembled in Jackson for the purpose of reestablishing the association.2 One-hundred and fifty years later, we will gather again in downtown Jackson for the 150th Anniversary of the MSMA House of Delegates, August 16-17, 2018. This time we will meet at The Westin Jackson, a new world class Starwood property.

RESERVATIONS AND SPECIAL EVENTS A block of rooms at $139 plus tax is available at the hotel, 407 S. Congress Street. July 17th is the cutoff date for this rate. For reservations, call the Westin Jackson: 601-9688200.

An outstanding commemorative program is planned beginning with an opening reception at the Two Mississippi Museums. Guests will receive a glimpse of the medical holdings in the Museum of Mississippi History before heading across the street for the awards ceremony and Inaugural Gala at the Old Capitol Inn. Michael Mansour, MD, a cardiologist from Greenville, will be installed as the association’s 151st president.

Other aspects of the program include the following:

164 VOL. 59 • NO. 3 • 2018

CONVENTION OF PHYSICIANS — After the December 15, 1856 medical convention met and established the MSMA, Jackson’s The Daily Mississippian ran a brief summation of the event.

EDUCATIONAL PROGRAM FRIDAY, AUGUST 17, 2018 6:00 7:30

Reception at Museum of Mississippi History Awards, Reception & Inaugural Gala at Old Capitol Inn

SATURDAY, AUGUST 18, 2018 7:00 KICK OFF BREAKFAST – Emcee Dr. J. Edward Hill, MD 8:00 Arthur P. Guyton, MD – John Hall, PhD 8:30 Civil War Medicine in Mississippi – Sid Bondurant, MD 9:00 MS Medicine and the Civil Rights Struggle – Claude Brunson, MD 9:30 Yellow Fever in Mississippi – Deanne Nuwer, PhD 10:00 Images in Mississippi Medicine – Lucius “Luke” Lampton, MD 10:30 MSMA: From Education to Advocacy – Mike Trotter, MD 11:00 William Faulkner: Nobel Laureate or Town Drunk? – Randy Easterling, MD 11:30 James D. Hardy, MD – Marc Mitchell, MD 12:00 KEYNOTE LUNCHEON: Governor Haley R. Barbour – My Perspective: Tort Reform, Hurricane Katrina, and Mississippi Medicine CME A REPORT OF THE PROCEEDINGS — This is the title page to The Mississippi State Medical Association is accredited by the Accreditation the only known surviving copy of the book which included the Council or Continuing Medical Education (ACCME) to provide continuing minutes, constitution, and by-laws of the original 1856 meeting medical education for physicians. The MSMA Foundation, Inc. designates of the MSMA. It was published in Vicksburg in 1871. This copy belonged to president William M. Compton, MD, who died in this live activity for a maximum of 4 AMA PRA Category 1 Credit(s)™.

1878. Two commemorative books, an updated MSMA history Physicians should claim only the credit commensurate with the extent of and “Images in Mississippi Medicine,” are being published and their participation in the activity. will be available at the meeting.

SPONSOR OPPORTUNITIES MSMA is seeking corporate partners to sponsor specific components of the educational programs such as commemorative books, special issues of the Journal MSMA, and scientific lectures. All sponsors will be recognized; corporate partners donating at the $10,000 level will receive special recognition.

REFERENCE COMMITTEES ARE GOING GREEN All delegates should bring an electronic device to the meeting. Any laptop, iPad or smart phone will allow you to access the event app with the full text of reports and resolutions. Plus, all reports and resolutions will be posted at MSMAonline.com for comment prior to the meeting. Please note that we WILL NOT PRINT packets of reports and resolutions. We will only print a summary of the RESOLVE statements from resolutions that require a HOD vote. If you require a printed copy of the entire resolution, please do so from the website and bring the printed copy with you to the meeting.

VENUE: THE NEW WESTIN JACKSON — 150 years after physicians from around the state assembled in Jackson for the purpose of reestablishing the association we will convene downtown again. Call the Westin for reservations: 601968-8200. Reserve online: http://www.starwoodhotels.com/ westin/property/rooms/index.html?propertyID=3903.

REGISTRATION Register for the meeting at: https://www.msmaonline.com. Go to EVENTS, drop down to ANNUAL SESSION. For more information contact Becky Wells: (601)853-6733, ext. 340. n References 1. From a letter by Dr. J M Taylor, president in 1873-4, published in the 1893 Transactions. In: Hall JC, Sutherland HL, Howard, EF. The History of the Mississippi State Medical Association, Vicksburg, MS: Mississippi Printing Company; 1910:9.

2. Lampton LM. The original report of the proceedings of the December 1856 medical convention: MSMA’s newly discovered first minutes, constitution, and by-laws.

J Miss State Med Assoc. 2006;47(6):183.

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Celebrating Years

150

House of Delegates MSMA ANNUAL SESSION 2018

FRIDAY AUGUST 17, 2018 8:00

MSMA Board of Trustees meeting [Time for specialty society meetings]

10:00 House of Delegates

SATURDAY, AUGUST 18, 2018 7:00 8:00

SPECIAL COMMEMORATIVE CELEBRATION KICK OFF BREAKFAST Emcee J. Edward Hill, MD CME: Arthur P. Guyton, MD. John Hall, MD

11:30

Candidate Forum (box lunch available @ 11:30)

8:30

CME: Civil War Medicine in Mississippi.

Sid Bondurant, MD

12:30

Reference Committee Hearings

9:00

CME: Mississippi Medicine and the Civil Rights Struggle. Claude D. Brunson, MD

Caucuses

9:30

CME: Yellow Fever in Mississippi Deanne S. Nuwer, PhD

3:30

Shuttle from the Westin to museum & Old Capitol Inn back to Westin afterward.

Reception 6:00 Commemorative at Museum of Mississippi History Enjoy hors d’oeuvres and beverages while exploring the new Mississippi Civil Rights Museum and Mississippi History Museum. Then, walk one block to the Old Capitol Inn for the Gala.

7:30

Inaugural Gala, Old Capitol Inn

Gala Dinner Dance includes the official inauguration of 151st President Michael Mansour, MD; Leadership Awards program and dancing.

166 VOL. 59 • NO. 3 • 2018

10:00

Break

10:15

CME: Images in Mississippi Medicine Luke Lampton, MD

10:45

CME: MSMA from Education to Advocacy Michael Trotter, MD

11:15

CME: William Faulkner Nobel Laureate or Town Drunk? Randy Easterling, MD

11:45

CME: James D. Hardy, MD. Marc Mitchell, MD

12:15

KEYNOTE LUNCHEON The Honorable Haley Barbour

2:00

House of Delegates

4:00

MSMA Board of Trustees Meeting

M S M A

N E W

M E M B E R S

ALLEN, J. CLAYTON, Hattiesburg; Hematology/Oncology

INGRAM, BRANDON, Hattiesburg; General Surgery

BLACKWELL, KORY, Hattiesburg; Family Medicine

MAPLES, JOHN, Starkville; Emergency Medicine

BRITT, BLAINE, Brookhaven; Internal Medicine

MARTIN, WILLIAM, Hattiesburg; Family Medicine

COLVILLE, AMBER, Ocean Springs; Internal Medicine

MUSHTAQ, FARAH, Hattiesburg; Endocrinology

COOLEY, CHAD, Flowood; Obstetrics & Gynecology

OLMSTED, BLAKE, Hattiesburg; Allergy Immunology

CURRIE, WILLIAM, Ellisville; Family Medicine

ROYALS, KATHERINE, Purvis; Family Medicine

DENNEY, LAYSON, Flowood; Obstetrics & Gynecology

TORRES, TIMOTHY, Hattiesburg; Anesthesiology

ESTARIS, ROLAND, Hattiesburg; Internal Medicine

WALLACE, JAMES, Meridian; General Surgery

GANTZ PANNEL, SARAH, Winona; Psychiatry

WEBSTER, JOHN, Pascagoula; Anatomic/Clinical Pathology

HARVEY, MEGAN, Hattiesburg; Pediatrics

WILLIAMS, JOSHUA, Flowood; Internal Medicine

HAY, WILLIAM, Brookhaven; Family Medicine

WE L VE OUR MSMA DOCTORS HAPPY DOCTORSâ&#x20AC;&#x2122; DAY FROM YOUR MSMA TEAM

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Charmain Kanosky

Conner Reeves

Executive Director

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Debby Batzing

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Data and Technology

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David Roberts

Government Affairs

Karen Evers

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Becky Wells

Jill Gordon

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Communications

Mail Clerk

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MSMAonline.com

JOURNAL MSMA

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Doctors’ Day: A Time to Reflect, Look Ahead

O

n March 30, 1933, the Barrow County Medical Alliance of Winder, Ga. observed the first Doctors’ Day. Eudora Brown Almond, wife of Dr. Charles B. Almond developed the idea and timed it to occur on the anniversary of the first administration of anesthesia by a Barrow County doctor. Since then, the day has been a time to hit pause and reflect on the contributions of physicians to health and to communities.

“Doctors’ Day is an opportunity to recognize the dedication of physicians who care for Mississippi’s patients,” said MSMA President William Grantham, MD. “There are many demands on physicians striving to give their patients the best quality health care in an increasingly complex world.”

In 1990, legislation was introduced in the United States House and Senate to establish a national Doctor’s Day. Following overwhelming approval by the United States Senate and the House of Representatives, on October 30, 1990, President George Bush signed S.J. RES. #366 (which became Public Law 101-473) designating March 30th as “National Doctor’s Day.” As we take time to acknowledge the importance of physicians in our nation, it’s helpful to look ahead as well. Technology and automation are changing health care rapidly, and doctors must stay mindful of how these innovations will affect the delivery of medicine. The physician must remain the leader of the health care team, and this includes overseeing the machines. Doctors also must continue to organize and speak with one voice on the subjects that vitally affect their profession and their patients best interests. n

Navigating the Business of Healthcare 2018 iPASS

Insurance Payment Advocacy Solutions Summit MSMA will help you navigate the business of healthcare at our annual iPASS summit. Topics include:

• Challenges of MACRA • Issues with healthcare payers and handling prior authorization denials • Changes to Medicaid and MississippiCAN • Networking and open forums to answer your questions See www.MSMAonline.com/iPASS for more information.

168 VOL. 59 • NO. 3 • 2018

iPASS Summit Dates Hattiesburg: Friday, May 4 Jackson: Wednesday, May 9 Oxford: Friday, May 11

The Following Is Not For Print/For Information Only

In Honor of Doctors’ Day 2018 “In nothing do men more nearly approach the gods than in giving health to men.”

— Marcus Tullius Cicero “Wherever the art of medicine is loved, there is also a love of humanity.”

— Hippocrates

“As any doctor can tell you, the most crucial step toward healing is having the right diagnosis. If the disease is precisely identified, a good resolution is far more likely. Conversely, a bad diagnosis usually means a bad outcome, no matter how skilled the physician.”

— Andrew Weil

“In the sick room, ten cents’ worth of human understanding equals ten dollars’ worth of medical science.”

— Martin H. Fischer

“He is the best physician who is the most ingenious inspirer of hope.”

— Samuel Taylor Coleridge

“The first duty of the physician is to educate the masses not to take medicine.”

— William Osler

“The good physician treats the disease; the great physician treats the patient who has the disease.”

— William Osler

“The art of healing comes from nature, not from the physician. Therefore, the physician must start from nature, with an open mind.”

— Paracelsus

“Only the healing art enables one to make a name for himself and at the same time give benefit to others.”

— Chinese Proverb

“A physician is obligated to consider more than a diseased organ, more than even the whole man – he must view the man in his world.”

— Harvey Cushing JOURNAL MSMA

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anytime, anytime, anywhere: anywhere:

downloadissuu issuu to to read read the download theJournal JournalMSMA MSMA whereveryou you go. go. wherever

170 VOL. 59 • NO. 3 • 2018

ABOUT THE COVER This Little Light of Mine light sculpture — When Mississippi’s Civil Rights Museum and the Museum of Mississippi History opened on December 9th of this year, tourism officials projected 180,000 visitors in the first year, with an annual economic impact of $17 million. Our cover photo features a dramatic light sculpture at the heart of the Civil Rights museum: a central space lit by this soaring figure that plays the museum’s theme song, “This Little Light of Mine.” As more visitors gather and interact with the sculpture- adding their own “light”- it shines brighter and the music grows stronger.

VOL. LIX • NO. 3 • 2018

2018

Distinguished Population Health

lectureship presented by

Fred Goldstein, M.S. Founder and President of Accountable Health, LLC. entitled

SpaceX, Moon Shots and Diabetes in Mississippi at 12:00 Noon on Friday, April 13, 2018 in the School of Health Related Professions, room 1B University of Mississippi Medical Center Lunch available for the first 50 guests FRED GOLDSTEIN is the founder and president of Accountable Health, LLC, a healthcare consulting firm focused on population health. He has over 30 years of experience in population health, disease management, HMO and hospital operations. He is an expert in population health, care management, risk management, health information technology (HIT) and health system design and development.

During his career, Mr. Goldstein founded a disease management company that provided services to 11 State Medicaid programs and numerous employer groups, operated an HMO that was ranked the highest quality Medicaid Health Plan in Florida, developed an award winning mobile health app and worked with health systems and vendors to develop population health programs and platforms. He was also directly responsible for the inclusion of the Medicare Annual Wellness Visit in the Affordable Care Act.

If current attendance rates hold, the Civil Rights and Mississippi history museums are set to surpass attendance and could see up to 300,000 visitors in 2018. Museum officials are almost halfway there with more than 80,000 visitors since the opening.

That would top almost all the civil rights museums in the South.

This issue of the JMSMA features the latest economic impact study of physicians in Mississippi. It measures the direct and indirect contributions of Mississippi physicians in terms of overall economic impact, job creation, wages and benefits paid and state and local taxes. The story illustrates a fundamental fact of medicine and economics – every patient-care physician is a job and economic output generator.

Each Mississippi physician generates an average economic output of 1.8 million. See page 154 for other statistics from the new study.

Photo by MSMA Past President and Associate Editor, Stanley Hartness, MD — Ed. n

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L E T T E R S

Has Mississippi’s refusal to expand Medicaid doomed the state’s rural hospitals?

Dear JMSMA Editor: In a recent editorial, Dr. Lampton identified a grim prospect for health care in Mississippi. As many as 31 of the state’s 94 hospitals are reported to be “at risk of closure.”1 Such closures compromise the advantages of accessible local care as well as threaten to overload other hospitals and specialty centers.

Dr. Lampton proposes that these possible closures are consequences of a “war on small hospitals” intrinsic to the implantation of the Affordable Care Act. While elements of this legislation offered some incentives to consolidations and elimination of duplicate services, the law does not clearly create any circumstances mandating the closing of smaller facilities. None of the ACA replacement proposals clearly recognizes hospital closures as a problem, and none of them explicitly offers any defined relief.2,3 I work in a practice that accepts referrals from all over all our state, ranging from the smallest health centers to the state’s Level I trauma center. In addition, I serve on state trauma committees and subcommittees. In the capacities, I have heard many hospital administrators describe difficulties facing their facilities.

Such discussion almost always includes the financial burdens associated with providing uncompensated care. As of 2012, 15% of Mississippi’s citizens did not have health insurance.4 Costs of such care can be crippling to large institutions, and they can be fatal to smaller facilities with fragile budgets.

Medicaid expansion, a provision of the Affordable Care Act, can provide substantial reliefs to hospitals that could critically benefit from reductions in losses and increases in revenue. A study of 19 states that expanded Medicaid in January, 2014, showed that hospitals in those states reduced mean annual compensated care costs by $2.8M ($1.6M-4.1M) and increased mean annual Medicaid income by 3.2 M ($0.9M-5.6M).5 Hospitals in states without Medicaid expansions showed no decreases in cost or increases in revenue.

Mississippi, despite a high uninsured population and woeful health statistics, has declined to implement Medicaid expansion.4 Could such an expansion, with possible increases in budget balances of $6M annually, provide critical relief for Mississippi’s at risk hospitals? n —William C. Lineaweaver, MD

Chair, JMSMA Editorial Advsiory Board Jackson

References

1. Lampton L. Obamacare’s war on small and rural. J Miss Med Assoc.

2016;57:276.

2.

Obama B. United States health care reform. JAMA 2016;316:S25-532.

3. Carroll AE. A look at Republican plans for repealing and replacing Obamacare. JAMA 2017;317:348-349.

4. Lineaweaver W. Segregation then, poverty now: Disparities Forever? J Miss Med Assoc. 2015;56:320-321.

5. Blavin F. Association between the 2014 Medicaid expansion and U.S. hospital finances. JAMA 2016;316:1475-1483.

Editorial regarding politics of opioid crisis “right on point” Dear JMSMA Editor: Your editorial [Lampton LM. The politics of public health crises. J Miss Med Assoc. 2017;58(6/7):182] regarding the politicallydriven urgency over the “opioid crisis” in Mississippi was right on point. There are many more pressing health problems in our state.

Thank you for clearly articulating my thoughts! n —Margaret (Peggy) Davis, MD Jackson 172 VOL. 59 • NO. 3 • 2018

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A D V I S O R Y

C O M M I T T E E

Physician-led Medicaid Group Endorses Unlimited Doctor Visits STEVEN DEMETROPOULOS, MD

“N

ow we can get results,” MSMA President Dr. William M. Grantham said about a mandated advisory committee that the Division of Medicaid failed to convene for more than five years, despite being required by state and federal law. “Your MSMA has been working diligently to get Medicaid to engage physicians,” Dr. Grantham said. “Finally, the agency is hearing your concerns and recommendations.”

The Committee is chaired by Dr. Steven Demetropoulos of Pascagoula and includes nine physicians and three hospital executives. “Physicians and other providers have a lot of valuable information that would improve Medicaid,” Dr. Demetropoulos said, “and I’m pleased with the progress the committee has made and the recommendations in our report.”

The MCAC met six times in 2017 and the following report was provided at the end of the year summarizing the activities and providing recommendations to legislative leaders.

What we learned about low-birth weight babies.

Prematurity is the leading cause of infant mortality in Mississippi. Mississippi has the highest infant mortality rate in the country (about 9 babies die for every 1000 babies born live each year). 17 Hydroxyprogesterone (17P or 17OHP) is the only medical intervention shown to decrease the risk of preterm births (birth before 37 weeks’ gestation) in women who have had a previous preterm birth.

It is a hormone that is recommended to be injected once a week for weeks 16 through 36 of pregnancy. Having a previous preterm birth is the only good predictor of preterm birth. 17P is recommended for women who have had a previous preterm, singleton (not twins or triplets) birth.

This hormone treatment is quite costly; however, it decreases the risk of preterm birth by ⅓ to ½. In women who still deliver prematurely, the pregnancy often lasts weeks longer than with her previous preterm delivery. We learned that while 17 Hydroxyprogesterone is a covered Medicaid benefit, the method by which it is obtained varies by each Coordinated Care Organization (CCO) and the Medicaid program. The Division of Medicaid reported that only 11.6% of the 560 OB-GYNs enrolled in the Medicaid program prescribed this treatment.

Another issue with preterm birth and poor birth outcomes in general is the health of the mother prior to pregnancy. In Mississippi many of our women of child bearing age are obese or overweight and have associated chronic diseases such as hypertension and diabetes.

Duties of the Medicaid Medical Care Advisory Committee • Advise the division with respect to amendments, modifications and changes to the state plan for the operation of the Medicaid program; • Advise the division with respect to issues concerning receipt and disbursement of funds and eligibility for Medicaid; • Advise the division with respect to determining the quantity, quality and extent of medical care; • Communicate the views of the medical care professions to the division and communicate the views of the division to the medical care professions; and Gather information on reasons that • medical care providers do not participate in the Medicaid program and changes that could be made in the program to encourage more providers to participate in the Medicaid program.

These chronic diseases can affect the pregnancy and lead to increased preterm births as well as other associated health problems in the newborn infant. Access to regular healthcare for the women of childbearing age who have had a previous preterm birth would help alleviate this problem. If Medicaid coverage, which extends to 60 days’ post-partum, were extended to one-year post-partum, women would have the ability to be healthier when they are next pregnant, thereby decreasing preterm births.

The Family Planning Waiver program (which all women who have Medicaid during pregnancy are eligible for and are automatically enrolled in) does not cover disease care, only the provision of family planning services. We believe will result in overall cost savings.

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Recommendations: The Committee recommends that the Division of Medicaid direct the CCOs to educate physicians on the availability of this hormone treatment and work to make the process of obtaining the drug easier. It would also be feasible for the Division and CCOs to allow for home administration by a licensed healthcare professional to provide an opportunity for patients to receive the medication when travel is a barrier. We believe the use of a similar or same process for distribution among all Medicaid payers would benefit the program and allow for more appropriate use of the treatment to reduce preterm births.

What we learned about prior authorization and the implications of service limits.

Prior authorization are the two words that provoke more frustration among prescribers than just about any other. The reason is that this requires the physician or other prescriber and/or their staff to spend a great deal of time away from patient care and on the phone or computer trying to get a reply as soon as possible so as not to delay treatment. The Committee heard from the CCOs and the utilization management contractor for the Division of Medicaid regarding the processes to obtain a prior authorization for medications and services from each.

Both CCOs stated they were working to ensure a prior authorization was obtained only when necessary and they continually looked at the data to see where this requirement could be removed. They also reported that they offer a web portal for ease in obtaining a prior authorization.

The CCOs also discussed their programs for exempting certain prescribers from the prior authorization requirement based on past performance. In some instances this is called a “Gold Pass” or a means to simply report the procedure and then reviews are done retrospectively to ensure appropriateness. This type of program rewards those prescribers who ensure medical necessity based on evidence-based guidelines prior to any service/procedure.

Proper and accurate clinical documentation has always been important, but in today’s healthcare environment, it has become even more imperative. Physicians and other prescribers understand the need for appropriate documentation to support the medical necessity for certain services. The Division of Medicaid and the managed care plans reported that some documentation is lacking necessary information for them to handle prior authorization requests in a timelier manner. For this reason, we believe education is needed to help prescribers understand what they are doing today and where there are areas for an opportunity to do a better job documenting.

Composition of the Medicaid Medical Care Advisory Committee The MCAC is a public advisory group established in accordance with federal and state law to advise the Division of Medicaid about the impact of Medicaid policy and help the agency plan programs.

The MCAC is composed of geographically diverse members who are vested in improving health and healthcare in Mississippi. Appointed by the Governor, Lt. Governor, and Speaker, the MCAC is advisory and does not set policy.

Members: Dr. Steven Demetropoulos of Pascagoula, Chair: Dr. William Grantham of Clinton; Dr. Mary Currier of Jackson; Dr. Allen Gersh of Hattiesburg; Dr. Edward Hill of Oxford; Dr. Jerry Martin of Oxford; Dr. Shannon Orr of Madison; Dr. Vicki Pilkington of Jackson; Dr. James Rish of Tupelo; Chris Anderson of Jackson; Dave Estorge of Gulfport; and, Brad Mayo of Oxford.

We also learned that service limits such as physician visits and pharmacy benefit limits were designed to control costs; however, the benefit limits with the Coordinated Care Organizations are higher in those programs. The higher benefit limits allow more consistent care at a lower level such as the physician level and reduces the need for some Medicaid fee-for-service beneficiaries to use the emergency department at hospitals for basic health needs due to the fact they have used all their physician benefits. The same argument applies to pharmacy benefit limits. If a person can access their medications, then this may reduce inpatient hospitalizations as their condition may not worsen.

Providers also reported to the committee the frustrations with credentialing and the delays in allowing physicians and others to provide services. It was stated that each system is different and the approval dates may vary from one payer to another.

Recommendations: The Committee recommends that the Division of Medicaid provide more education for all prescribers including hospitals, physicians, dentists, nurse practitioners, and physician assistants, on proper documentation and the various means to obtain a prior authorization. In addition, we want to encourage the CCOs to educate prescribers on the formal “Gold Pass” process to allow more physicians to participate once they have reached the appropriate approval rates. We would like the legislature to consider removing or at the least increasing the physician benefit limit and increasing the pharmacy benefit limit to a minimum of eight prescriptions per month.

Finally, it is believed that if the credentialing process were standardized among the four Medicaid payer systems (Division of Medicaid, Magnolia Health Plan, Molina, and United Healthcare) to provide for standard information and streamlined approval dates, services to the Medicaid population would be more readily accessible.

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What we learned about hospital reimbursement.

Hospital providers reported that in the Spring of 2016, CMS notified the Division of Medicaid that its methodology for distributing supplemental hospital payments through the Mississippi Hospital Access Program (“MHAP”) did not comply with federal law. These supplemental payments amount to $533 million and are a significant part of the hospital’s compensation for providing services to Medicaid patients. The state’s share for these payments is funded entirely by hospital taxes. The Division of Medicaid has been directed by CMS to include hospitals in the development of a compliant model. To date, the Division of Medicaid has not met with hospitals to develop a new complaint methodology.

The current model uses the same distribution methodology that was used for distributing Upper Payment Limit payments in SFY 2015 which was based upon a model developed in 2010 before Medicaid changed from cost based reimbursement to a DRG fee schedule. UPL payments are no longer allowed by CMS as the Division of Medicaid voluntarily surrendered the State Plan Amendment necessary for the operation of a UPL program during SFY 2016 Additionally, the MHAP program operates in tandem with the supplemental payment program that provides cost reimbursement to hospitals for services provided to the uninsured (Disproportionate Share Hospital or DSH). Each program, both MHAP and DSH, operate in a manner whereby payment decisions made in one of the programs (MHAP or DSH) has a significant impact on the operation of the other program (MHAP or DSH).

The viability of Mississippi’s hospitals, including rural hospitals, can be protected only if the programs operate in a manner that assures an appropriate level of cost recovery for healthcare services delivered to uninsured and Medicaid patients for all Mississippi hospitals.

Recommendations: The Committee recommends that the Division of Medicaid solicit input from Mississippi hospitals regarding a preferred methodology for distributing supplemental payments. The goal of the supplemental payment programs is to ensure access for patients covered by Medicaid programs. To that end, the Division of Medicaid and/or the Mississippi Legislature should ensure that both the Disproportionate Hospital Share (DSH) payments and MHAP are allocated to hospitals so that no hospital receives less than its federally defined need for such payments (OBRA Limit).

What we learned about physician reimbursement.

The committee learned that Division of Medicaid and the Coordinated Care Organizations would like to change reimbursement to physicians.

No details or plans were provided except to say that they wanted to pay physicians based on performance quality measures. This methodology is very concerning to the committee as no information was provided leading us to think it has not been thought out sufficiently.

It is unclear how these entities plan to evaluate the performance quality of physicians. Such as the current two Coordinated Care Organizations use two different sets of criteria to evaluate inpatient hospital admissions, the two plans – soon to be three plans - could more than likely use varying degrees of performance quality measures. For example, one plan may say a physician excels in quality measures while another says that same person is not meeting performance measures.

Recommendations: The Committee recommends that the legislature allow the plans to develop pay-for-performance programs currently allowed for in-state law (43-13-117(H)(1)(c)) and to evaluate the effectiveness of those programs, but not allow the Division of Medicaid or the CCOs to lower the reimbursement below 90% of the current Medicare rate to any physician. We feel strongly that as the Division of Medicaid considers any pay-for-performance methodology that all programs/plans should be presented both to the Medical Care Advisory Committee and be open for statewide comment by Mississippi Providers before any final decision is made. Furthermore, the insurance providers must provide evidence that these standards have been shown to improve patient outcomes.

Summary The Committee learned a great deal over the past year and look forward to learning more in 2018. We think that this is an important committee that could contribute to better functioning of the Division of Medicaid. In the coming year, as we learn more about the Medicaid program, we hope the Division of Medicaid will recognize the value of this committee and will actively seek our input prior to developing policy, not afterwards. We believe our efforts this past year have shown our desire and interest to be a partner and advise the Division on issues from the entire Medicaid provider community. n

—Steven Demetropoulos, MD; Chair Mississippi Medicaid Medical Care Advisory Committee January 2018

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P O E T R Y

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Turks #1 [R. Scott Anderson, MD, is a radiation oncologist in Meridian. He serves as the Medical Director of Anderson Cancer Center there. He is well-known to readers of the Journal as the author of the column “The Uncommon Thread.” He is the author of two books of fiction under the pseudonym Russell Scott as well as a collection of essays. He currently edits the literary journal “China Grove,” which focuses on Southern poetry and literature. All of his writing can be accessed at www.chinagrovepress.com. He has also served the Journal as the Chairman of the Editorial Advisory Board. He writes of this poem: “It’s about the importance of having a vacation, to get away from the daily routine, and to allow us to remember who we are and where we come from. In my case in this poem it is about my time as a Navy diver and my affinity for the sea, something I miss as a radiation oncologist in Meridian!” Such is a lovely image: the need to always seek what gives our lives meaning as we go about “collecting” our diseases! Any physician is invited to submit poems for publication in the JMSMA, attention: Dr. Lampton or email me at lukelampton@cableone.net.]—Ed.

I have swum with the dolphins as one of their pod.

It is only when I return,

I have been a thing in the water that people had a reason to fear.

sitting silently suicidal,

that I reflect on the manner

in which I have ordered my days.

But now older, collecting my diseases,

Constrained, contained, confined.

Everything must fit within the cube.

A cube of my own design,

a construction from a drawing board

loving the feeling of the water

as it flows along my skin.

And even when I know I’m pushing into the current,

to show the world

I am just a moving thing

the thing I say is “me.”

All my effort spent at merely standing still I push on.

But away I was the things, the things I was before.

Simply for the joy

And perhaps in some ways the things I’ve never been.

of the feeling of waves,

the fingers of the ocean.

I miss a boat on the ocean

I wonder if my heart is still strong enough to sustain the exertion,

and swimming across a reef

or should I succumb, giving myself to the joy of this moment?

in fins and mask.

And I am in her hands again.

Peering into that world

from which we all arose.

Then after, kicking along parallel to the beach, I remember.

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—R. Scott Anderson, MD Meridian

I M A G E S

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REENVILLE COLORED KING’S DAUGHTERS HOSPITAL, 1905-1953— These images are related to

what was called “Greenville Colored King’s Daughters Hospital,” officially King’s Daughters No. 4. As the inset cornerstone states, it was organized in 1905 by K. S. Lewis and erected in 1908 by S. R. Raines, President, D. Brown, Tres., D. Daniels, Secty., with a motto stated on the cornerstone of “Doing Good” and laid by the Grand United Order of Odd Fellows, a fraternal order founded in 1843 with its membership principally African American. This order was an active force in the black community in the early years of the twentieth century, and African American fraternal orders often played key roles in the erection of similar hospitals in the South during the Jim Crow era. Medical historian Dr. Mike Trotter located this stone at the site of the original hospital lying on the ground next to an air conditioner compressor. (The original site was on the 300 Block of Alexander Street.) The 65-bed charity surgical hospital appears to be the first hospital opened after the Civil War dedicated to the care of African Americans. Trotter, who provides the cornerstone photograph, has arranged for the stone to be stored safely in a warehouse and legally donated to MSMA, with hopes of arranging display at the new Civil Rights Museum, as well as place a historic marker at the original site. Also seen above is a photograph taken in front of the hospital provided by Dr. Hugh Gamble which dates from the early 1950s. He writes: “In the front row wearing a suit is my grandfather, Dr. Hugh A. Gamble. In the back row on the far right with her head down is Mrs. Doolittle who was the director of nursing.” The photo must have been taken at Christmas time, note the Santa hidden on the steps. The photo reveals genuine camaraderie of a biracial staff. After his arrival in Greenville in 1907, Gamble, with his physician brother Paul, played an instrumental role in developing the “Colored King’s Daughters,” even providing funding support and recruiting colleagues to provide care. When the Washington County General Hospital (Delta Regional Medical Center) opened in 1953, Doolittle became their director of nursing. The Colored King’s Daughters closed the day that “The General” opened, with black physicians joining the staff slowly because of the new concept of “ER call,” according to Gamble. The original building was razed in 1971, although as seen the cornerstone survives. If you have an old or even somewhat recent photograph or image which would be of interest to Mississippi physicians, please send it to me at lukelampton@cableone.net or by snail mail to the Journal. n

— Lucius M. “Luke” Lampton, MD; JMSMA Editor

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Washed in the Blood DWALIA S. SOUTH, MD MSMA PAST PRESIDENT AND COMMITTEE ON PUBLICATIONS CHAIR

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y earliest recollections of my Daddy are not pleasant ones. Most of those have lain buried for years in the grave of my forgetfulness. Events of recent days have somehow resurrected them. My ears have slid down some passageway near my soul’s memory and I am straining to hear. I must listen hard.

It was a mild and bright Sunday morning in the spring of 1962. I know that I was six years old because I only ever confided this story to my first grade school teacher, Mrs. Bessie Morton. My Daddy was still drinking gin and was still quite drunk from the night before. He and Mother had had another one of those loud shouting matches that unfailingly always seemed to occur around Saturday midnight culminating in my Daddy getting a brown paper grocery bag or a cardboard box, and cramming some clothes in it, bellowing the promise of leaving home and never coming back. I recall several prior instances of being awakened by this drama, of crying and holding to his pants legs, and begging him not to go.

South

I remember that awful day watching him staggering around in the yard in an attempt to do the usual morning farm chores…feeding the chickens and milking the cows. My hyperactive cocker spaniel was with me, ripping and jumping with the unrestrained reckless abandon of her breed. Her name was Whitey, my beloved and beautiful friend, Whitey. She was running around generally making a nuisance of herself by torturing Mother’s cats, hopping and weaving back and forth between my legs as I walked.

As my Daddy was straining to stay upright in the worn path from the barn carrying buckets of fresh milk, Whitey made a joyous leap in front of him.

Daddy fell sprawling, dumping all the milk and planting his face in the muck. When he was able to get on his feet, he went roaring after my precious companion. Whitey apparently sensed impending danger and ran for the protection of her bed on the front porch. Somehow my Daddy was able to catch her. I watched in horror as he grabbed both of her hind legs and carried her wiggling and thrashing to the large silver-gray painted propane tank beside our house. Cursing, he maniacally slung my poor Whitey over his head and began to smash her brains out on that big gas tank. Her blood sprayed in all directions as he repeatedly bashed her now limp white and black speckled body against the unforgiving metal. His rage ended only with his complete exhaustion. He leaned breathlessly against the tank and glanced in my direction. I was paralyzed by the shock of what I had just seen, and perhaps may have had the thought that I was next in line.

When I could bring my legs to move, I ran into the house to Mother screaming about what I had just witnessed. Memories seem a little blurred after that. I don’t think my mind could really process what had just happened in those few moments of his sudden drunken fury. Apparently, that was the last straw for Mother. She found the courage to lock the doors, and make a call to the Sheriff asking him to come.

The Tippah County Sheriff, Robert Estes, lived and farmed about 8 miles from us. He was a contemporary of my parents and long time family friend, a tall and handsome man with a solemn countenance. More than once he had been to our house in the past to talk to Daddy about some plumbing or electrical problem that needed fixing. As a child he inspired a little trepidation in me because he had a mechanical left arm that he could control well enough to smoke his Pall Malls. He was a World War II veteran and former POW, but his arm had fallen victim to a farm accident with a silage machine. I remember being fascinated by his ‘artificial hand’, something I had never seen before. In the past when Mr. Robert had noticed me staring at it, he would quietly point it in my direction, snap it open and closed it in rapid succession, and give me a sly grin.

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On this day, he was not coming to my Daddy to ask for help, but to give it. Time seemed to pass quickly and he arrived in our driveway. The Sheriff got out of the car, and came to the front door. I heard him talking to my Mother but could not decipher the conversation through my huffing sobs and tears. He went around the north side of the house to look for Daddy. I watched them talking through the window as both sat on some big unsplit blocks of firewood. I watched Mr. Robert because I thought that I didn’t want to see or look at my Daddy ever again. I remember that he did not seem to be a lawman to me at all in his khaki pants, brown fedora hat, and with no visible badge or firearm. I remember him calmly and constantly smoking his cigarette with the metal claws that intrigued me so, and the motion of Daddy repeatedly nodding his lowered head towards him. After a while and without any ruckus, unbelievably my Daddy willingly got in the car with the Sheriff and they drove away.

The memory of that day ends there for me. Of course this episode did not ever become a fond family topic of discussion. Only as an adult did I learn that the Sheriff had taken Daddy and put him in the county jail. I suppose Daddy must have slept it off for a day and a night. While the horror of the previous day was vivid to me, Daddy apparently was so toxically inebriated that he had no memory of doing any of it. I learned later that when Daddy came to his senses the next morning, he found himself alone in a jail cell with no recollection of why he was there. He was still dressed in the stinking clothes he had been wearing for three days, caked in mud and dried black blood for which he was offered no explanation. He was left to stew in his anguish for several hours and came to believe that he must have killed someone. But …who?

Mr. Robert Estes, the wise High Sheriff, let my Daddy continue to believe that he had committed murder for the next several hours without telling him what had really happened.

His traumatic awakening that morning in reeking bloody clothes made enough of an impression on Daddy that he literally never took another drink again in his life. My Mother had never learned to drive, so Mr. Robert delivered him home personally that Monday afternoon.

My parents did not mention the incident in front of me ever again. The loud episodic nocturnal rages and threats subsided and became somehow unremembered. Oh, they still fussed with each other until their dying day, but they always seemed to thrive on it.

I don’t know who buried my dog Whitey or where. I know that scores of dried rivulets of her life’s blood stained that big propane tank for many, many years… a constantly seen and terrible reminder of the madness of that morning. Someone at some point repainted the tank and I could once again make use of it when topped with an old saddle. Oh, the hours I’d spend on it pretending that I was riding a beautiful race horse!

I don’t remember seeing Mr. Robert much after that morning. Our paths didn’t cross except when he might make an occasional stop by our house to request some plumbing help or to buy some blue channel catfish from Daddy. They would converse with each other away from my view or earshot. When he would leave, Daddy would remark that Robert Estes could do more with one hand than most men could do with two.

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Then, in the spring of 1982, I was able to get deeply acquainted with Mr. Estes. I was a very young doctor and he had been admitted to our hospital during his last days of dealing with metastatic lung cancer. He was only 66, but the Pall Malls, the L&Ms, and the Vantage (he called them ‘hollow points’) cigarettes which he smoked over the years had finally taken their toll. I remember that he didn’t point and click his artificial hand at me during that long and final hospital stay. I truly can’t recall if he even bothered wearing it then. Mr. Robert Estes was dying, extremely sick and weak, but we were able to really talk. It was only then that I learned the backstory of that dreadful spring morning of twenty years earlier.

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30

Through the last resort efforts of my Mother’s quick thinking and bravery, by way of Sheriff Robert Estes’ kindness, patience, and friendship and because of the untimely and terrible sacrifice of my little 1 dog, Whitey, my Daddy was able to become the remarkable man and 2 3 father that I will forever cherish and remember. He was truly washed in 4 the blood. n 5 Dwalia S. South, MD 6 Journal of the Mississippi State 7 Ripley 8 9 Infectious Diseases  Clinical Physician 10 The University of Mississippi Medical Center 11 Infectious Disease Division is seeking BC/BE 12 Clinical Physician. Faculty candidates should 13 submit a CV via fax to 601-815-4014. EOE, 14 M/F/D/V. 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30

Region 8 offers support, compassion and effective treatment for individuals and families seeking to overcome the destructive nature of alcohol and drug use. Services are provided in Copiah, Lincoln, Madison, Rankin and Simpson Counties. ê Male and Female Residential Treatment (Located in Simpson and Copiah County )

ê Intensive Outpatient Treatment Program ê Family Treatment

ê Substance Use Prevention Services ê Recovery Support Services ê Employee Assistance Program

For information, contact 601.824.0342 or www.region8mhs.org

180 VOL. 59 • NO. 3 • 2018

Articles and editorials expressed in the Journal are those of the indicated author. Comments and opinions are not expressions of the views or official policies of the Mississippi State Medical Association. We encourage our membership to submit comments for publication regarding any opinion expressed or information contained in the Journal. Email to KEvers@MSMAonline.com or mail to Lucius Lampton, MD, Editor, 111 Magnolia St., Magnolia, MS 39652-2825.

WeJournal encourage your comments. of the Mississippi State Medi Ob/Gyn Hospitalists Join an established academic medical center!

University of Mississippi Medical Center, Department of Obstetrics and Gynecology is currentlyAssociation accepting applications for Ob/Gyn Medical Hospitalists. Candidates will work with residents and students and care for a diverse population.

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Competitive compensation.

If interested,Partner please Keith Robinson, Assoc HR-Service contact Bretta Blackman, BS, MSM UMMC Talent Acquisition Department Administrator at Center 601-984UniversityBusiness of Mississippi Medical 5391 submitState CV to bcblackman@umc.edu.

2500orNorth Street Equal Opportunity Employer, M/F/D/V Jackson, MS 39216-4505

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August 17-18, 2018 The Westin Jackson

Defining Events in the Evolution of Mississippi Medicine 182 VOL. 59 â&#x20AC;˘ NO. 3 â&#x20AC;˘ 2018