VOL. LX • NO. 3 • 2019

VOLUME LX • NO. 3 • 2019

Regularly priced at $80, the book is on sale now!

Images in Mississippi Medicine: A Photographic History of Medicine in Mississippi

. "Lu ke" M. Lampron, MD an d Karen A. Evers Lucms

Pickup in Ridgeland for $49.95 or $57.95 includes shipping.

Order three or more to receive a discount at: http://tinyurl.com/yb7ab974 “ Images In Mississippi Medicine by Dr. Luke Lampton and Karen Evers is a handsome and impressive book, filled with stories and scenes ranging from primitive operating rooms and rows of hospitalized tornado victims a century ago to the new teaching complex at the University of Mississippi Medical Center with its modern breakthroughs.

The volume is a piece of our history that every Mississippian can appreciate.”

– Curtis Wilkie, journalist, author, and professor at Ole Miss

Images in Mississippi Medicine: A Photographic History of Medicine in Mississippi; MSMA; Jackson, MS: 2018.

OF THE MISSISSIPPI STATE MEDICAL ASSOCIATION VOL. LX • NO. 3 • MARCH 2019

SCIENCE OF MEDICINE

THE ASSOCIATION President Michael Mansour, MD

President-Elect J. Clay Hays, Jr., MD

Consults in TelEmergency: A Descriptive Analysis 111 Sarah A. Sterling, MD; Nicole R. Novotny; Michael A. Puskarich, MD; L. Kendall McKenzie, MD; Richard L. Summers, MD; Alan E. Jones, MD

MANAGING EDITOR Karen A. Evers

Secretary-Treasurer W. Mark Horne, MD

PUBLICATIONS COMMITTEE Dwalia S. South, MD Chair Richard D. deShazo, MD Sheila Bouldin, MD Wesley Youngblood, M3 and the Editors

Speaker Geri Lee Weiland, MD

SPECIAL ARTICLE

EDITOR Lucius M. Lampton, MD ASSOCIATE EDITORS D. Stanley Hartness, MD Philip T. Merideth, MD, JD

Vice Speaker Jeffrey A. Morris, MD

Top 10 Facts You Should Know About Behavioral Disturbances 108 in Dementia Sonya Shipley, MD; Ardarian Gilliam Pierre, MD; Sara Sanders, MD; Deepika Majithia, MD

Head and Neck Trauma Trends with Changing Temperature 115 and Spare Time Andrew Robichaux, MD; J. Randall Jordan, MD; Cindy Moore, MD; Christopher Spankovich, AuD, PhD, MPH

An Interview with University of Mississippi Medical Center Vice Chancellor Louann Woodward, MD 120 Margaret Cosnahan, M2; Philip Merideth, MD, JD DEPARTMENTS

Acting Executive Director Claude D. Brunson, MD

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.

From the Editor – Thank God I am a Physician!

Lucius M. Lampton, MD

106

President’s Page – Physician Wellness – A Focus on Mental Health Michael Mansour, MD

123

Letters

127

Images in Mississippi Medicine – Mississippi Baptist Hospital, 1922 Lucius M. Lampton, MD

132

Poetry and Medicine – Liquor Cerebrospinalis Merrill Moore, MD

133

INFORMATION FOR AUTHORS

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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.

ABOUT THE COVER “Wasps on Goldenrod” – Dermatologist Philip R. Loria, Jr., MD took this photograph of what appears to be five-banded tiphiid wasps, Myzinum quinquecincta Fabricius, with a Nikon D40 and a Sigma 150 macro lens at 1/400 sec F9 ISO 400. Widely known for attracting butterflies and bees, goldenrod is the source of mild debate in the plant world. Whether one considers the flower a type of wildflower or a weed, one warning that you will hear concerning this bloom is mainly a myth. People who speak of “goldenrod allergy” are usually guilty of blaming the wrong weed for their hay fever. The real culprit, in most cases, is ragweed. Dr. Loria became serious about photography at age 12, and he has used Nikon equipment ever since. About ten years ago, he switched to digital photography though he does more macro work. He also photographs birds, animals and occasionally people. He has nearly 50,000 photos on his computer. Originally from New Orleans, Dr. Loria started his private practice Oxford Dermatology about 25 years ago. He and his wife live on about 12 acres just outside of Oxford. In addition to photography, he also enjoys woodworking. n VOLUME LX • NO. 3 • 2019

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 © 2019 Mississippi State Medical Association.

Official Publication

MSMA • Since 1959

MARCH • JOURNAL MSMA

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F R O M

T H E

E D I T O R

Thank God I am a Physician!

D

r. Joe Johnston of Mount Olive, one of the state’s best family physicians, also achieved laurels for his passionate work over a decade as an editor of this Journal. Many readers remember his frank and assertive , editorials, which occasionally stirred a little controversy. However, most memorable of his tenure as Associate Editor from June 1983 - May 1993 was how he closed each and every editorial, Lucius M. Lampton, MD utilizing the phrase: “Thank God I am a Editor physician!” In those six words, Joe captured the joy and the privilege inherent in the practice of our profession.

thinning of the blood could prevent clots and thus prevent strokes; Dr. George Papanicolaou of the ‘Pap’ test; and Dr. Russell L. Cecil who wrote the ‘Textbook of Medicine’ that was used for many years in most medical schools.”

I recently asked Joe what was the origin of the phrase which became his column’s hallmark. He responded, recalling his days in medical school, “I started out wanting to be a family physician. At Cornell (University Medical College), each department wanted me to join them. They, at that time, felt that they were not just training doctors, but doctors to teach and train other physicians. Three of my professors were Nobel Prize winners including Dr. Irving S. Wright, who first found how

Now having passed the 90-year mark and having retired three years ago, Joe is still thankful to have practiced family medicine for 57 years. n

“What really cemented my feelings for family medicine was when Dr. George Reader, my professor in Internal Medicine, (on my rotation) set me up with a small office and gave me my very own group of patients to treat and follow for six weeks. I had my own nurse (student), scheduled my re-appointments, made house-calls (yes, even in Harlem at night!), and with his supervision I realized general practice (as it was called then) was perfect for me. This made me appreciate after several years of practice in Mount Olive (population: 1200) how fortunate I had been to have become a family physician...hence the ‘signature’ on all my comments and editorials...Thank God I am a physician.”

Contact me at LukeLampton@cableone.net.

— 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, M3

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

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

NEPHROLOGY Harvey A. Gersh, MD Sohail Abdul Salim, MD

ANESTHESIOLOGY Douglas R. Bacon, MD John W. Bethea, Jr., MD CARDIOVASCULAR DISEASE Thad F. Waites, MD CHILD & ADOLESCENT PSYCHIATRY John Elgin Wilkaitis, MD CLINICAL NEUROPHYSIOLOGY Alan R. Moore, MD DERMATOLOGY Robert T. Brodell, MD Adam C. Byrd, MD

GENERAL SURGERY Andrew C. Mallette, MD HEMATOLOGY Carter Milner, MD INFECTIOUS DISEASE Rathel "Skip" Nolen, III, MD INTERNAL MEDICINE Daniel P. Edney, MD Daniel W. Jones, MD Brett C. Lampton, MD Kelly J. Wilkinson, MD INTERNAL MEDICINE/EPIDEMIOLOGY Thomas E. Dobbs, MD

106 VOL. 60 • NO. 3 • 2019

OBSTETRICS & GYNECOLOGY Sidney W. Bondurant, MD Sheila Bouldin, MD Darden H. North, 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 PUBLIC HEALTH Mary Margaret Currier, MD, MPH PULMONARY DISEASE Sharon P. Douglas, MD John R. Spurzem, MD RADIOLOGY P. H. (Hal) Moore, Jr., MD RESIDENT / FELLOW Cesar Cardenas, MD UROLOGY W. Lamar Weems, MD

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Top 10 Facts You Should Know About Behavioral Disturbances in Dementia SONYA SHIPLEY, MD; ARDARIAN GILLIAM PIERRE, MD; SARA SANDERS, MD; DEEPIKA MAJITHIA, MD caregiver burden but also increased rates of caregiver psychological conditions such as depression.5 High caregiver burden is also a predictor of elder abuse risk.6 Significant patient behavioral problems contribute to earlier long-term care placement, irrespective of initial cognitive status or other risk factors for institutionalization.7 Referring caregivers to support groups or other resources such as adult day centers may help mitigate this burden. The burden of caregiving may also be relieved by the promotion of effective communication skills for the caregiver as well as education regarding the expected disease course and possible behavioral alterations. For information about communication strategies as well as a complete list of available resources, direct caregivers and patients to the Alzheimer’s Association Education and Resource Center (https://www.alz.org/careplanning/ downloads/patient-caregiver_resources.pdf ).

3 1

Always look for remediable causes of any new behavioral problem in patients with dementia. A common cause of any new behavioral problem in the geriatric population is medication side effects. Adding no more than one medication at a time and cautiously titrating the dose from low to therapeutic decreases the risk of drug side effects in the elderly. Particularly of concern are the potential side effects of anticholinergic agents: confusion, agitation, and hallucinations. Multiple agents with high anticholinergic activity are identified by the Beers Criteria as potentially inappropriate for use in the geriatric population.1 Cumulative use of such agents appears to be associated with increased risk of incident dementia.2 Whether acute or slowly developing over time, behavioral problems may be a manifestation of a process other than dementia. For instance, delirium is a common cause of behavioral changes in this population when behavioral problems occur.3,4 Finally, patients with dementia may be unable to articulate discomfort, and behavioral problems may result from these unmet needs. Therefore, a high index of suspicion is necessary, and it is prudent to look for evidence of pain, dehydration, constipation, or indolent infections as a cause of behavioral changes.

2

Behavioral problems of dementia contribute to significant caregiver burden. Severe behavioral problems, particularly early in the course of the disease, not only lead to significant

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Behavioral symptoms may be subtle in patients with dementia. Though symptoms such as severe agitation, combativeness, disinhibition, or hallucination are typically very concerning to caregivers and usually lead to prompt evaluation, more subtle behavioral issues must be addressed as well. Symptoms such as apathy, wandering, decreased appetite, insomnia, hoarding, compulsions, resistance to personal care, and psychological symptoms such as anxiety and depression also fall under the umbrella of behavioral disturbances.4 Addressing such symptoms early produces a myriad of potential benefits including lowering associated costs, delay in disease progression, and improvement in both disease morbidity and mortality.8

4

Elements of wandering behavior may be predictable. When dementia patients wander from home, they typically wander toward the dominant side, a tip that may help caregivers more quickly locate loved ones who are lost.9 Those most likely to wander share common characteristics such as feeling lost in new places or feeling restless and pacing. In the long-term care setting, patients most likely to wander are those with severe cognitive impairment, discomfort including pain, antipsychotic medication use, and lack of functional impairment.10 Up to 60% of dementia patients will wander outside of their residences. Of the patients who wander, up to half of those not found within 24 hours are at increased risk of injury and even death.11 Multiple tracking technologies, as well as national programs, are available to help locate those who wander and become lost. Mississippi’s Silver Alert System assists in locating lost individuals age 60 and older with dementia or mental impairment. A

comprehensive list of resources as well as risk factors for wandering is available at https://www.alz.org/media/kansascity/documents/ Wandering_Behavior.pdf.

5

Safety planning is a must for patients and caregivers.

Violence against caregivers of dementia patients is estimated to be greater than 20% and in fact may be the strongest predictor of long-term care placement.12 The figure is even higher for home healthcare workers who are 4 times more likely to encounter aggression if caring for a patient population that includes dementia patients. Unfortunately, caregivers typically receive minimal education about triggers for aggressive behavior. The presence of various patient characteristics may help predict aggression, including pain, sensory deprivation, environmental changes, excessive stimulation, restricted activity, limited privacy or space, and quality of relationship with caregivers.

Additional safety planning considerations include ensuring adequate safety at home to include disarming weapons, locking up medications, and securing exterior doors. Driving should also be discontinued especially if prominent visuospatial deficits are present on cognitive screening or if the patient has gotten lost or is involved in a motor vehicle accident. The physician’s legal and ethical obligation to patient safety as well as the safety of the general public must be carefully considered once potential issues are identified. Mississippi law does not require mandatory reporting of unsafe drivers, and there are no provisions for civil immunity under the law to prevent parties from seeking damages from the treating physician.13 However, HIPPA regulations do allow for reporting protected health information in the interest of public safety; therefore, reporting unsafe drivers may help protect the physician. Formal driving suitability assessments may be performed by community agencies. It is free of charge at designated Mississippi Department of Public Safety driver license locations. Testing site locations are available at https:// www.driverservicebureau.dps.ms.gov/Drivers/Driver_License_ Locations.

6

Physical restraint is not a benign intervention. Physical restraint should be avoided at all costs. Multiple studies have shown that physical restraint, particularly in the nursing home setting, is associated with increased risk of death, most commonly due to mechanical asphyxiation, i.e. smothering, thoracoabdominal compression, or neck compression.14,15 Additional potential negative effects of physical restraint include increased risk of agitation as well as infections and physical de-conditioning.16 Physical restraint is not effective in preventing falls or wandering and is associated with an increased risk of falls.17

7

Begin management of behavioral disturbances with nonpharmacologic management. Evidence-based nonpharmacologic strategies are often underutilized tools for managing behavioral disturbances, particularly in the long-term care setting.18,19 Most patients admitted to nursing homes are likely to be placed on at least one psychotropic medication, even if no previously established psychiatric diagnosis exists. Multiple organizations including the American Geriatrics Society and the American

Psychiatric Association recommend nonpharmacologic management of behavioral problems as first-line therapy where possible.20,21 Nondrug interventions for agitation include minimizing stimulation (e.g., utilizing music & soft lighting), avoiding sensory deprivation (e.g., ensuring proper eyewear & hearing aids) as well as redirection (e.g., attempting to change the subject, offering comfort measures, avoiding arguing). Anorexia may be improved by liberalizing diet, ensuring appropriate texture, addressing poor dental hygiene/mouth dryness, and avoiding eating alone. Good sleep hygiene such as avoiding daytime naps and late evening caffeine can improve sleep, often eliminating the need for pharmacotherapy. Undiagnosed obstructive sleep apnea must also be a consideration in poor sleep as this may be present in older adults even though they have normal body habitus.4 One expert recommendation that can be easily utilized in the office setting is the DICE Approach (describe, investigate, create, and evaluate).18 In this model, a detailed description of the challenging behavior is given by the caretaker after which the clinician investigates potential causes of the troubling behavior. The clinician along with the caregiver and other members of the healthcare team develop a treatment plan, and finally, the feasibility, safety, and effectiveness of proposed interventions are evaluated.

8

Pharmacologic management with antipsychotics should be a last resort. Increased mortality has been demonstrated with antipsychotics, and as of 2005, a black box warning was placed on atypical antipsychotics (such as quetiapine or olanzapine) by the FDA. The warning was later expanded to include firstgeneration antipsychotics (such as haloperidol or clozapine) as well.

Additionally, some of the antipsychotic side effects themselves can carry an increased risk of poor outcomes, e.g., delirium, fractures, or death. This drug class has only been found to be modestly effective at managing agitation while imposing substantial risk.22 If symptoms cause significant distress or pose a risk to patient or caregiver safety, for instance, combativeness or suicidal ideation, then pharmacologic management with any indicated medication class is appropriate firstline therapy.

9

All medications are not created equally. Multiple medication caveats must be considered in the management of behavioral disturbances in an older population. Dosing of any agent should be attempted at less than the usual starting dose; older patients usually require less medication due to age-related changes in pharmacokinetics. If tolerated, quetiapine is a reasonable choice in the management of behavioral disturbances in an older patient, particularly those with Parkinson’s Disease (PD) or Lewy Body Dementia (LBD). This subgroup of patients is exquisitely sensitive to neuroleptic agents, and quetiapine is least likely to exacerbate the associated movement disorder.23,24 Antipsychotic side effects may be subtle, and identification requires an index of suspicion.

For example, acute dystonia (disordered muscle contractions) may present with swallowing difficulty, or akathisia (inner restlessness) may manifest as paradoxical excitation. The benzodiazepine of choice MARCH • JOURNAL MSMA

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is lorazepam, but caution should be exercised as this drug class can cause both cognitive and motor slowing. Citalopram is typically the SSRI of choice in the geriatric population (sertraline is a reasonable alternative), but in the subgroup of patients with PD or LBD, an agent with inherent dopaminergic activity such as bupropion may be better suited to manage depression. Of note, SSRIs can be implicated as the cause of new or worsening tremor in patients, even if no primary movement disorder is present. The presence of Parkinsonism should always prompt consideration of causes other than Parkinson’s disease as these will not respond to Parkinson’s treatment: medication side effects, advanced dementia, and other neurodegenerative conditions.

If anorexia is managed with medication, mirtazapine is a reasonable choice for appetite at low doses; megestrol should be avoided as it may cause adrenal insufficiency and thrombosis.

10

Dementia and its associated behavioral disturbances are costly. Up to 98% of dementia patients will experience neuropsychiatric symptoms across the course of the disease, placing these patients at an increased risk of institutionalization.18 The rising cost of health care will continue to be a challenge in caring for this patient population. In 2015, the Alzheimer’s Association reported that family caregivers provided an estimated 18.1 billion hours of care (up from 17.7 billion in 2013), estimated to cost more than $221.3 billion in the United States alone.8 The total cost of dementia care in 2016 was an estimated $236 billion with $117 billion of that cost covered by Medicare, $43 billion by Medicaid, and $46 billion out of pocket. For patients requiring care outside of the home, the cost is high; 2017 averaged around $45,000 per year ($43,200 in 2015) for an assisted living facility. For semi-private and private rooms, the costs ranged from $85,776 (semi-private) to $97,452 (private) per year for nursing home care ($80,300 to $91,250 in 2015).25 n Acknowledgment: Thank you to Dr. Mark Meeks, Professor of Medicine and Director of the Division of Geriatrics, UMMC Department of Medicine, for his thoughtful review and manuscript suggestions.

8. Alzheimer’s Association. 2016 Alzheimer’s disease facts and figures. Alzheimers Dement. 2016;12(4).

9. Alzheimer’s Association. Wandering Behavior: Preparing for and Preventing it. https://www.alz.org/media/kansascity/documents/Wandering_Behavior. pdf. Accessed January 3, 2018.

10. Kiely DK, Morris J, Algase DL. Resident characteristics associated with wandering in nursing homes. Int J Geriatr Psychiatry. 2000;15(11):1013-1020.

11. Alzheimer’s Association. Safe Return: Alzheimer’s disease Guide for law enforcement. https://www.alz.org/national/documents/brochure_guidefor lawenforce.pdf. Accessed January 4, 2019.

12. Wharton TC, Ford BK. What is known about dementia care recipient violence and aggression against caregivers? J Gerontol Soc Work. 2014;57(5):460-477.

13. Carr DB, Schwartzberg JG, Manning L, et al. Physician’s Guide to Assessing and Counseling Older Drivers. 2nd edition. Washington, D.C.: NHTSA; 2010.

14. Bellenger EN, Ibrahim JE, Lovell JJ, Bugeja L. The nature and extent of physical restraint-related deaths in nursing homes: a systematic review. J Aging Health.

2018;30(7):1042-1061. doi: 10.1177/0898264317704541.

15. De Letter EA, Vandekerkhove BN, Lambert WE, Van Varenbergh D, Piette MH. Hospital bed related fatalities: a review. Med Sci Law. 2008;48(1):37-50.

16. Capezuti E. Minimizing the use of restrictive devices in dementia patients at risk for falling. Nurs Clin North Am. 2004;39(3):625-647.

17. Tilly J, Reed P. Falls, Wandering, and Physical Restraints: Interventions for Residents with Dementia in Assisted Living and Nursing Homes.

Alzheimer’s Association website. https://www.alz.org/national/documents/ Fallsrestraints_litereview_II.pdf. Accessed online January 3, 2018.

18. Kales HC, Gitlin LN, Lyketsos CG. Detroit Expert Panel on Assessment and Management of Neuropsychiatric Symptoms of Dementia. Management of neuropsychiatric symptoms of dementia in clinical settings: recommendations from a multidisciplinary expert panel. J Am Geriatr Soc. 2014;62(4):762–769.

19. Molinari V, Chiriboga D, Branch LG, et al. Provision of psychopharmacological services in nursing homes. J Gerontol B Psychol Sci Soc Sci. 2010;65B:57–60.

20. American Geriatrics Society. Five things physicians and patients should question. http://www.choosingwisely.org/societies/american-geriatrics-society/.

Accessed January 3, 2018.

21. American Psychiatric Association. Five things physicians and patients should question. Choosing Wisely website. http://www.choosingwisely.org/ societies/american-psychiatric-association/. Accessed January 3, 2018.

22. Yohanna D, Cifu AS. Antipsychotics to treat agitation or psychosis in patients with dementia. JAMA. 2017;318(11):1057–1058.

References

23. Stahl SM, Grady MM. Stahl's Essential Psychopharmacology: The Prescriber's Guide. 4th ed. New York, NY: Cambridge University Press; 2011.

1. American Geriatrics Society 2015 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc. 2015;63(11):2227-2246.

24. Steffens DC, Blazer DG, Thakur ME, eds. The American Psychiatric Publishing Textbook of Geriatric Psychiatry. 5th Ed. Arlington, VA: American Psychiatric Association; 2015.

2. Gray SL, Anderson ML, Dublin S, et al. Cumulative use of strong anticholinergic medications and incident dementia. JAMA Intern Med. 2015;175(3):401-407.

25. Genworth Financial, Inc. Genworth 2017 Cost of Care Survey. Genworth website. https://pro.genworth.com/riiproweb/productinfo/pdf/179703.pdf.

Accessed January 3, 2018.

3. Reuben DB, Herr KA, Pacala JT, et al. Geriatrics at Your Fingertips: 2017. 19th edition. New York, NY: The American Geriatrics Society; 2017.

4. Medina-Walpole A, Pacala JT, eds. The Geriatrics Review Syllabus: A Core Curriculum in Geriatric Medicine. 9th Edition. New York, NY: American Geriatrics Society; 2016.

5. Gaugler JE, Kane RL, Kane RA, et al. The longitudinal effects of early behavior problems in the dementia caregiving career. Psychol Aging. 2005 Mar;20(1):100116.

6. Cohen M, Levin SH, Gagin R, Friedman G. Elder abuse: disparities between older people's disclosure of abuse, evident signs of abuse, and high risk of abuse.

J Am Geriatr Soc. 2007; 55(8):1224-1230.

7. Gibbons LE, Teri L, Logsdon R. Anxiety symptoms as predictors of nursing home placement in patients with Alzheimer's disease. J Clin Geropsychology 2002;8:335–42. doi:10.1023/A:1019635525375

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Author Information Board-certified, American Board of Family Medicine; Assistant Professor, Department of Family Medicine; Fellow, Division of Geriatric Medicine, University of Mississippi Medical Center (UMMC) (Shipley). Fellow in the Division of Geriatric Medicine at UMMC. Board certified American Board of Family Medicine (Gilliam Pierre). Board certified Internal Medicine and Geriatrics, American Board of Internal Medicine; Assistant Professor, Division of Geriatric Medicine, UMMC (Sanders). Board certified American Board of Psychiatry and Neurology; Medical Director, Geriatric Psychiatry units, Merit Health Rankin and Merit Health Natchez, Mississippi (Majithia).

Corresponding Author: Dr. Sonya Shipley, UMMC, Department of Family Medicine, 2500 North State Street, Jackson, MS 39216 (sshipley@umc.edu).

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Consults in TelEmergency: A Descriptive Analysis SARAH A. STERLING, MD; NICOLE R. NOVOTNY; MICHAEL A. PUSKARICH, MD; L. KENDALL MCKENZIE, MD; RICHARD L. SUMMERS, MD; ALAN E. JONES, MD Abstract Introduction: Little is known about patient populations seen in telemergency. Our objective was to describe a cohort of patients managed in a large TelEmergency (TE) program.

Methods: Consults from an academic TE program were recorded by the emergency medicine (EM) physician. Documented TE consults from 2011 to 2014 were included. Demographics, dispositions, and ontologies were characterized as a whole and subsequently categorized by disposition for further comparison.

Results: 4,188 TE consults were included; 44% were African American and 55% Caucasian, Median age was 50 years. Disposition of discharge home was present in 41% of patients, 34% were transferred to another facility, 23% admitted, and 2% died in the ED. Top 3 ontologies prompting consult were chest pain (11%), blunt trauma (7%), and abdominal pain (6%).

Conclusion: In a mature TE program, the most common ontologies were chest pain, blunt trauma, and abdominal pain with many patients requiring admission or transfer.

Introduction Previous investigations have shown disparities in access to specialized health care for patients in rural locations.1-3 Though research has also shown improved outcomes with prompt evaluation and treatment in many emergent conditions, timely care is often delayed for patients in rural areas. Disparate access to care has led to reports of longer total ischemic times for patients with myocardial infarctions transferred from rural hospitals to urban centers, delays in trauma interventions, and limited access to certified stroke centers.2-4 Additionally, rural areas are disproportionately affected by physician shortages and limited specialist access, further limiting access to timely, quality emergent care.5,6 In 2003, TelEmergency was developed at our institution to improve access to quality emergency care, while working in the constraints that rurality and the emergency medicine (EM) physician shortages pose,7-9 and has been described previously in detail.10-12 Since 2003, over 20 rural and critical access hospitals have participated in TelEmergency in all regions of the state. Recognizing that emergency departments (ED) in rural areas are often staffed with non-emergency medicine trained physicians or nurse practitioners

(NPs),6,7,13 TelEmergency was structured as a dual nurse-practitioner (NP) and board certified EM physician model with specially trained NPs providing on-site care at rural hospital EDs in collaboration with remote EM attending physicians practicing in an academic ED in a level 1 trauma center and tertiary referral center.10,11 Despite the growing knowledge and the increasing impact of telehealth in EM, little is known about the general population affected by its care. Improving the understanding of the general patient population likely to benefit from a tele-emergency system could inform revenue, resources and staffing decisions in rural hospital EDs as well as identify high-risk characteristics and patients likely to require transfer to a facility with a higher level of service. Additionally, identifying commonly seen conditions and complaints could help direct future training of rural hospital providers to particularly high yield fields. The objective of this analysis was to describe a cohort of a large, mature TelEmergency program and to determine patient subgroups most likely to require admission or transfer for further care.

Methods We performed an analysis of all documented TelEmergency consults between March 2011 and March 2014. TelEmergency consults from 14 rural and critical access hospitals were recorded by the EM physician in real time. For each consult, the EM physician was required to document patient demographics, primary and secondary diagnoses, and disposition. Past medical history (PMH) was abstracted from the electronic medical record of each patient when available.

Due to wide variation in physician documentation in recording diagnoses, primary and secondary diagnoses were categorized into primary and secondary ontologies for comparison. An ontology refers to a set of concepts and categories in a subject area or domain that shows their properties and the relations between them. Patient demographics, PMH, dispositions, and ontologies were evaluated for the database as a whole. Patients were subsequently categorized by disposition: admission, discharge, transfer, left against medical advice (AMA), or death in the ED. Admission was defined as admission to the local rural hospital, and transfer was defined as a transfer out of the rural hospital for further care at another hospital.

Demographics, PMH, and primary and secondary ontologies were compared between the groups based upon disposition. Fisher r by c, chi-square, and Kruskal-Wallis tests were used as appropriate, with p MARCH • JOURNAL MSMA

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Table 1. Data for all documented TelEmergency consults < 0.05 considered statistically significant. Data were analyzed using StatsDirect ver 3.0.171 (StatsDirect, Cheshire, United Kingdom).

Results A total of 4,188 TelEmergency consults were documented during the study time frame and included in this analysis. For all consults, the median age was 50 years (IQR 27, 68) with an equal distribution of males and females (50%) (Table 1). The top 10 ontologies for all consults were: chest pain (11%), blunt trauma (7%), abdominal pain (6%), syncope (4%), general medical (4%), shortness of breath (4%), fracture (4%), infection (3%), dysrhythmia (3%), and nausea/ vomiting/diarrhea (3%) (Table 2). “General medical” was defined as diagnoses that did not reach a frequency to establish their own separate ontology or did not fit clearly into another ontology, and are diagnoses that would typically be managed on a general medicine ward or by a primary care physician on an outpatient basis. Common examples of diagnoses included in the general medicine ontology included anemia, generalized weakness, and hypoglycemia.

Disposition data were available on 3697/4188 (88%) of consults.

We were unable to determine dispositions on some patients due to initial work-up and plan documentation without final disposition documentation. When evaluated by disposition, 1516/3697 (41%) of patients were discharged, 1237/3697 (34%) were transferred, and 843/3697 (23%) were admitted. Two percent (65/3697) of consults died while in the ED and 30/3697 (1%) left AMA. When categorized by disposition, admitted patients were significantly older than discharged patients ((64 years (IQR 50, 80) vs (36 years (IQR 18, 56), respectively, (p < 0.0001)) (Table 3). Admitted patients were also more likely to be female (456/831 (54.9%, 95% CI 52 to 58)), while patients that died in the ED or left AMA were more likely to be male (41/64 (64.1%, 95% CI 52 to 76)) and (16/29 (55%, (95% CI 36 to 74)), respectively, (p = 0.0031). Of patients with disposition data, race data was available on 2711 of 3697 (73%) patients. When compared across all dispositions, Caucasians more often left AMA than African Americans (Table 3). Chest pain was a common primary ontology among all the dispositions, while blunt trauma and shortness of breath were common secondary ontologies (Table 4).

Table 1. Data for all documented TelEmergency consults Variable Age (IQR) Sex (%) Male Female Race (%) African American Caucasian Other Disposition (%) Admit Discharge Transfer Death in ED Left AMA

Total Consults (n = 4,188)* 50 (27,68) 2050 (50) 2055 (50) 1335 (44) 1655 (55) 31 (1) 843 (23) 1516 (41) 1237 (34) 65 (2) 30 (1)

* Missing data omitted from each category; Abbreviations: IQR: Interquartile * Missing data omitted from category; TelEmergency Table 2. Top ontologies for each all recorded Range; ED: Emergency Department; AMA: Against Medical Advice

Abbreviations: IQR: Interquartile Range; ED: Emergency Department; Table 2. Top ontologies all recorded AMA: Againstfor Medical AdviceTelEmergency consults

Top 10 Ontologies* Chest Pain 684 (11) Blunt Trauma 413 (7) Abdominal Pain 389 (6) Syncope 258 (4) General Medical 255 (4) Shortness of Breath 239 (4) Fracture 217 (4) Infection 198 (3) Dysrhythmia 181 (3) N/V/D 176 (3) * Number * Number (%); Abbreviations: N/V/D: (%); Abbreviations: N/V/D: Nausea/Vomiting/Diarrhea

Nausea/Vomiting/Diarrhea

those 1449 patients, 342 (24%) had a PMH of hypertension (HTN), 225 (16%) had a PMH of diabetes mellitus, 187 (13%) had a PMH of coronary artery disease, 127 (9%) had PMH of congestive heart failure (CHF), 109 (8%) had a PMH of chronic obstructive pulmonary disease (COPD), 102 (7%) had a PMH of malignancy, 82 (6%) had a PMH of a cerebrovascular accident (CVA), and 81 (6%) had a previous myocardial infarction. When comparing PMH by patient patients who were admitted, transferred, or discharged to home, Table 3. Comparison of patient demographic across disposition PMH data was available on 1449/4188 (35%) of the TE consults. Of admitted and transferred patients had higher comorbidity burdens Table 3. Comparison of patient demographic across patient disposition Variable Admit Death Discharge Transfer Left AMA (n = 843) (n = 65) (n = 1516) (n = 1237) (n = 30) Age* (IQR) 64 (50,80) 62 (50,80) 36 (18,56) 53 (31, 70) 43 (33, 56) Sex (%) Male 375 (45) 41 (64) 780 (52) 618 (51) 16 (55) Female 456 (55) 23 (36) 718 (48) 601 (49) 13 (45) Race** (%) African American 248 (42) 23 (38) 482 (44) 440 (47) 5 (23) Caucasian 340 (57) 38 (62) 607 (55) 484 (52) 17 (77) * Median; **Total n for patients with race data recorded= 2711; Abbreviations: IQR: Interquartile Range; AMA: Against Medical Advice * Median; **Total n for patients with race data recorded= 2711; Abbreviations: IQR: Interquartile Range; AMA: Against Medical Advice 112 VOL. 60 • NO. 3 • 2019

p value < 0.001 0.003

0.036

consu

than discharged patients. Admitted patients were more likely to have COPD (45 of 386 (11.7%), 95% CI 8 to 15, p=0.001) and CHF

to another facility for a higher level of care, or died while in the ED. These data may help tailor future educational efforts for providers Table 4. Top 3 primary and secondary ontologies for each disposition and may direct revenue, resources, and staffing for Table 4. Top 3 primary and secondary ontologies for each disposition similar tele-emergency systems.

To our knowledge, this is the largest analysis of Disposition Primary Ontologies Secondary Ontologies

a general tele-emergency consult population to Admit (%) Chest Pain 217 (26) Shortness of Breath 63 (16) date. Though other robust studies have been Syncope 49 (6) Dehydration 42 (11) performed looking at overall utilization of telePneumonia 47 (6) UTI 26 (7) emergency consults and the use of tele-emergency Discharge (%) Chest Pain 148 (10) Blunt Trauma 120 (20) consults for specialized care, little is known about Abdominal Pain 138 (9) MVC 39 (6) the average patient requiring a tele-emergency Blunt Trauma 106 (7) Chest Pain 34 (6) consult.14 While research has shown improved outcomes with the implementation of timely, Transfer (%) Chest Pain 141 (11) Blunt Trauma 78 (11) Abdominal Pain 87 (7) Shortness of Breath 60 (9) quality care in many emergent conditions, CVA 80 (7) Chest Pain 50 (7) patients in rural areas have limited accessibility Fracture 80 (7) to specialized treatment and often have delays in receiving specialized treatment.2-4,15-18 We found Death (%) Cardiac Arrest 54 (83) Cardiac Arrest 8 (40) Blunt Trauma 4 (6) Penetrating Trauma 2 (10) a large number of patients requiring consultation Respiratory Failure 3 (5) Shortness of Breath 2 (10) had high-risk complaints and often required admission or transfer to another facility. Given the Left AMA(%)* Chest Pain 5 (17) Intoxication 3 (18) limited access many rural patients have to a timely, Abdominal Pain 4 (14) Shortness of Breath 3 (18) **Top andand secondary ontologies were listed for patients that left AMAthat due left to wide variation data Top2 2primary primary secondary ontologies were listed for patients AMA due toin wide higher level of care, these data suggest that rural and low overall percentages. Abbreviations: UTI: Urinary Tract Infection; MVC: Motor Vehicle Crash; variation in data and low overall percentages.

Abbreviations: UTI: Urinary Tract Infection; and critical access hospitals remain important CVA: Cerebrovascular Accident; AMA: Against Medical Advice MVC: Motor Vehicle Crash; CVA: Cerebrovascular Accident; AMA: Against Medical Advice access points for patients. However, over the past Figure 1. Past medical history for TelEmergency consults with available past medical history several years rural, critical access hospitals, and Figure.

Past medical history for TelEmergency consults with available past medical data compared by disposition history data compared by disposition trauma centers closures have increased.19-21 Rural hospital and trauma center closures show no sign 35% of slowing per reports.19,21 Additionally, these ■ Adm it (n = 386) closures have been reported to disproportionately 30% affect vulnerable populations.19 Coupled with the ■ Transfer (n = 4 70) 25% difficulty recruiting and retaining physicians to ■ Discharge (n = 399) rural areas and the overall physician shortage, this 20% could present a potentially difficult situation for patients and health care in rural areas.5,8,9 15% TelEmergency has the potential to improve access to quality, timely care while working within the 5% constraints that physician shortages and distances from referral centers pose.11 Given the high-risk 0% nature of many of the consultations in this analysis, HTN CAD DM CVA Ml COPD CHF CA the input of EM trained and boarded physicians in p-value 0.0413 < 0.0001 0.0011 <0.0001 0.0057 0.002 0.0026 0.082 collaboration with specially trained NPs has the Abbreviations: HTN: Hypertension; CAD: Coronary Artery Disease; DM: Diabetes Mellitus; potential to improve emergent care and outcomes Abbreviations: HTN: Hypertension; CAD: Coronary Artery Disease; DM: Diabetes Mellitus; CVA: CVA:Cerebrovascular Cerebrovascular MI:Infarction; Myocardial COPD:Pulmonary ChronicDisease; Obstructive Accident;Accident; MI: Myocardial COPD:Infarction; Chronic Obstructive CHF: for patients in rural areas. Previous research has Congestive Heart Failure; cancer Pulmonary Disease; CHF:CA: Congestive Heart Failure; CA: cancer shown improved outcomes when EM trained (56 of 386 (14.5%), 95% CI 11 to 18, p<0.0001), while transferred and board-certified physicians staff EDs.22,23 Additionally, previous patients were more likely to have a history of a prior CVA (43 of 469 research has shown decreased medication errors, higher physician rated quality of care, and higher parent satisfaction scores when tele(9.1%), 95% CI 7 to 12, p=0.0002) (Figure). emergency is utilized in pediatric critical illness in rural hospitals.24,25 Discussion Though patient outcomes are outside the scope of this analysis, this analysis does suggest that rural hospitals serve as an important In this analysis of a mature emergency medicine telehealth system, access point and that many of the patients who present to rural and the most common ontologies prompting TelEmergency consultation critical access hospitals could benefit from timely emergent care and were chest pain, blunt trauma, and abdominal pain. Additionally, the stabilization. Further research is needed to evaluate these diagnoses majority of patients required admission at the local facility, transfer and the critical, emergent nature of these complaints.

10%

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Our study has several limitations. This study was conducted at an institution with a well-established tele-emergency system, and this analysis was conducted several years after the implementation of TelEmergency at our institution. Also, during the initial implementation of TelEmergency, the protocol required the TelEmergency NP to consult the TelEmergency physician on every patient seen. Later, the protocols were refined to limit consultations on low acuity patients to limit unnecessary delays in care while maintaining patient safety.26 There is a chance this may have affected our results. Finally, this analysis is of a single tele-emergency system which is well-established and robust but from a state with a large rural population and few referral centers, so our results may not be generalizable to other systems.

Conclusion In a mature TelEmergency program, the most common ontologies prompting consultation were chest pain, blunt trauma, and abdominal pain with many patients requiring admission or transfer. These data may be useful to rural hospitals attempting to tailor training for teleemergency providers and may inform revenue, resources and staffing of similar telemergency programs. n Acknowledgment: This manuscript was supported by the Federal Office of Rural Health Policy (FORHP), Health Resources and Services Administration (HRSA), U.S. Department of Health and Human Services (HHS) under cooperative agreement U6631459-01-00 as Telehealth Center of Excellence. The information, conclusions, and opinions expressed are those of the authors and no endorsement by FORHP, HRSA, or HHS is intended or should be inferred.

References 1. Carr BG, Branas CC, Metlay JP, Sullivan AF, Camargo CA, Jr. Access to emergency care in the United States. Ann Emerg Med. 2009;54:261-269.

2. Mullen MT, Judd S, Howard VJ et al. Disparities in evaluation at certified primary stroke centers: reasons for geographic and racial differences in stroke.

Stroke. 2013;44:1930-1935.

3. Carr BG, Bowman AJ, Wolff CS et al. Disparities in access to trauma care in the United States: A population-based analysis. Injury. 2017;48:332-338.

4. Langabeer JR, Prasad S, Seo M et al. The effect of interhospital transfers, emergency medical services, and distance on ischemic time in a rural STelevation myocardial infarction system of care. Am J Emerg Med. 2015;33:913916.

5. Burrows E, Suh R, Hamann D. National Rural Health Association Policy Brief: Health Care Workforce Distribution and Shortage Issues in Rural America.

Executive Summary. January, 2012.

6. Peterson LE, Dodoo M, Bennett KJ, Bazemore A, Phillips RL, Jr. Nonemergency medicine-trained physician coverage in rural emergency departments. J Rural Health. 2008;24:183-188.

7. Sullivan AF, Ginde AA, Espinola JA, Camargo CA, Jr. Supply and demand of board-certified emergency physicians by U.S. state, 2005. Acad Emerg Med. 2009;16:1014-1018.

8. Camargo CA, Jr., Ginde AA, Singer AH et al. Assessment of emergency physician workforce needs in the United States, 2005. Acad Emerg Med. 2008;15:13171320.

9. Ginde AA, Sullivan AF, Camargo CA, Jr. National study of the emergency physician workforce, 2008. Ann Emerg Med. 2009;54:349-359.

10.

Summers RL, Henderson K, Isom KC, Galli RL. The anniversary of TelEmergency. J Miss State Med Assoc. 2013;54:340-341.

11. Galli R, Keith JC, McKenzie K, Hall GS, Henderson K. TelEmergency: a novel system for delivering emergency care to rural hospitals. Ann Emerg Med. 2008;51:275-284.

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12. Sterling SA, Seals SR, Jones AE et al. The impact of the TelEmergency program on rural emergency care: An implementation study. J Telemed Telecare.

2017;23:588-594.

13. Groth H, House H, Overton R, Deroo E. Board-certified emergency physicians comprise a minority of the emergency department workforce in iowa. West J Emerg Med. 2013;14:186-190.

14. Ward MM, Ullrich F, Mackinney AC, Bell AL, Shipp S, Mueller KJ. Teleemergency utilization: In what clinical situations is tele-emergency activated? J Telemed Telecare. 2016;22:25-31.

15. Hsia R, Shen YC. Possible geographical barriers to trauma center access for vulnerable patients in the United States: an analysis of urban and rural communities. Arch Surg. 2011;146:46-52.

16. De LG, Suryapranata H, Ottervanger JP, Antman EM. Time delay to treatment and mortality in primary angioplasty for acute myocardial infarction: every minute of delay counts. Circulation. 2004;109:1223-1225.

17. Marler JR, Tilley BC, Lu M et al. Early stroke treatment associated with better outcome: the NINDS rt-PA stroke study. Neurology. 2000;55:1649-1655.

18. Newgard CD, Meier EN, Bulger EM et al. Revisiting the "Golden Hour": An Evaluation of Out-of-Hospital Time in Shock and Traumatic Brain Injury. Ann Emerg Med. 2015;66:30-41.

19. Hsia RY, Shen YC. Rising closures of hospital trauma centers disproportionately burden vulnerable populations. Health Aff (Millwood). 2011;30:1912-1920.

20. Wishner J, Solleveld P, Rudowitz R, Paradise J, Antonisse L. Issue Brief: A Look at Rural Hospital Closures and Implications for Access to Care: Three Case Studies. The Kaiser Commission on Medicaid and the Uninsured. July 7, 2016. https://www.kff.org/medicaid/issue-brief/a-look-at-rural-hospital-closuresand-implications-for-access-to-care/ Accessed September 19, 2017.

21. Kaufman BG, Thomas SR, Randolph RK et al. The Rising Rate of Rural Hospital Closures. J Rural Health. 2016;32:35-43.

22. Jones JH, Weaver CS, Rusyniak DE, Brizendine EJ, McGrath RB. Impact of emergency medicine faculty and an airway protocol on airway management.

Acad Emerg Med. 2002;9:1452-1456.

23. Weaver CS, Avery SJ, Brizendine EJ, McGrath RB. Impact of emergency medicine faculty on door to thrombolytic time. J Emerg Med. 2004;26:279-283.

24. Dharmar M, Romano PS, Kuppermann N et al. Impact of critical care telemedicine consultations on children in rural emergency departments. Crit Care Med. 2013;41:2388-2395.

25. Dharmar M, Kuppermann N, Romano PS et al. Telemedicine consultations and medication errors in rural emergency departments. Pediatrics. 2013;132:10901097.

26. Sterling SA, Seals SR, Jones AE et al. The impact of the TelEmergency program on rural emergency care: An implementation study. J Telemed Telecare.

2017;23:588-594.

Author Information Associate Professor of Emergency Medicine at UMMC (Sterling). Fourth-year medical student at UMMC; participant of the Medical Student Research Program partially funded through the Herrin Foundation (Novotny). Associate Professor of Emergency Medicine at Hennepin County Medical Center (Puskarich). Professor of Emergency Medicine at UMMC (McKenzie). Professor of Emergency Medicine and Associate Vice-Chancellor for Research at UMMC (Summers). Professor of Emergency Medicine and Chairman of the Department of Emergency Medicine at UMMC (Jones).

Declarations/Conflicts of Interest: Dr. Sterling discloses partial support by the National Institute of General Medical Sciences of the National Institutes of Health under Award Number 1U54GM115428. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Dr. Puskarich discloses salary support from the National Institute of General Medical Sciences (K23GM113041) and support of the NIH Loan Repayment Program. Dr. Jones discloses support through the National Institutes of General Medical Sciences (R01GM103799-01). Remaining authors have no declarations or conflict of interest to report.

Corresponding Author: Alan E. Jones, MD; Professor and Chairman, Department of Emergency Medicine, University of Mississippi Medical Center, 2500 N State Street. Jackson, MS 39216. Ph: (601) 984-5572 (aejones@umc.edu).

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Head and Neck Trauma Trends with Changing Temperature and Spare Time ANDREW ROBICHAUX, MD; J. RANDALL JORDAN, MD; CINDY MOORE, MD; CHRISTOPHER SPANKOVICH, AUD, PHD, MPH

Abstract Objective: This study set out to identify whether temperature variation or spare time correlated with an increase in observed Head and Neck Trauma (HNT) at a level 1 trauma center.

Design: Case Series with Chart Review from June 2012 to January 2015 Methods: 4,992 patients were identified using an institutional trauma database and ICD-9 codes for HNT. The temperature and temporal relationship (spare time or regular time) of the date of injury were analyzed to investigate whether either had an association with HNT as observed in this database.

Results: The majority of patients were men aged 18-75 years (peaking in the 30-50-year-old subgroup). Men also made up the largest portion (69%) of HNT compared to women and comprised a larger proportion of interpersonal violence (83%) compared to accidental trauma (65%). Over the years of inquiry, a statistically significant association between temperature or spare time and HNT was not found (p=0.598 and p=0.134 respectively).

Key Words: Head and neck trauma (HNT), temperature, spare time Introduction In the current age of evidence-based medicine and the establishment of more centralized care at major centers, predicting workload plays an integral part in ensuring proper staffing and effective delivery of care. Weather variation has been correlated to increased hospital admissions for several conditions, including respiratory, cardiovascular disease, and, more recently, trauma workload.1,2,3 In a 2015 systematic review, trauma workload was positively influenced by an increase in temperature, most notably in the pediatric population.3 Another study with 8269 trauma admissions reported that increases in temperature and precipitation were valid predictors of trauma admission volume.4 Contrastingly, a United Kingdom study refuted these findings when controlling for spare time (i.e. weekends and holidays) and noted an increase in interpersonal violence and trauma on Saturdays, Sundays, New Year, and rugby

international days.5 To the investigators’ knowledge, correlations between trauma volume and temperature or spare time have not been investigated specifically in HNT. Our study set out to identify whether temperature variation or spare time correlated with an increase in observed HNT at the University of Mississippi Medical Center’s (UMMC) Level 1 Trauma Center.

This trauma center serves the entire region of central Mississippi and bordering states, and knowledge of weather or temporal influences could potentially allow for alterations in HNT staffing for the delivery of appropriate care.

Methods Population Prior to data collection and analysis, approval was obtained from UMMC’s Institutional Review Board. Every patient that sustains a trauma-related injury treated at the University is cataloged automatically into the UMMC trauma database. Within the database, patient injuries are grouped by the Abbreviated Injury Scale (AIS), which is an anatomical scoring system that ranks the severity of injury on a scale of 1 to 6 with 6 equating to a lethal injury.6 Head and Neck injuries belong to AIS groups 1, 2, and 3 by definition.

The study period of interest was from June 2012 through January 1, 2015, and it was selected based on the introduction of the electronic health record and the completion of purely ICD-9 (International Classification of Diseases) codes for billing at our institution. After January 1, 2015, UMMC introduced ICD-10 codes for billing, but the trauma database solely collected ICD-9 codes which prohibited us from collecting accurate data beyond this time point.

Next, ICD-9 codes specifically identifying head and neck injuries that would be addressed by a team taking HNT calls were identified and others excluded. The following ICD-9 codes were included: 800-804, 807, 830, 850-854, 870-874, 900, 910, 920, 925, 929-935, 940-941, & 950-953. These criteria ensured that 4,992 HNT trauma patients had been identified.

Variables of Interest The number of trauma cases per day was calculated as a dependent variable by creating a time-series dataset. Admission date, age, gender, and injury type were recorded within the trauma dataset MARCH • JOURNAL MSMA

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upon admission. Interpersonal violence injuries were selected from the following descriptors within the trauma dataset: altercation, fall while horseplay, hanging, strangulation, hit by a blunt instrument, pistol, rifle, shotgun, and stabbed with a knife. The remainder of injury types were considered accidental or non-violent.

Using the date of injury, daily temperature (in Celsius) and humidity recordings for the Hawkins Field Airport, Jackson, MS Weather Collection Center were requested from the Archives of the National Oceanic and Atmospheric Administration. Only daily temperature apex and nadir were available for review from this station and were assigned to each patient entry. In addition, daily mean temperature data was calculated from the average of the sum of these two temperature values.

Spare time was next defined as Weekends (W), Holidays (H), and Holiday Weekends (HW) with the remaining dates considered Regular Time. W were defined as Friday through Sunday in order to capture Friday night activities. H included in this study were New Year’s Day, Valentine’s Day, St. Patrick’s Day, Memorial Day, July 4th, Labor Day, Halloween, Thanksgiving, Christmas Eve, Christmas, and New Year’s Eve. By definition, H were considered to be the date of holiday and the following 24 hours to capture the night of the holiday.

If the holiday fell on a weekend, the entire weekend was counted as the HW. If the holiday fell on a Thursday, the Thursday and following weekend were all considered HW. If the holiday fell on a Sunday, the entire weekend and the Monday were considered HW. If the holiday fell on a Monday, the preceding weekend, Monday, and Tuesday were considered a HW. The variable definitions of HW were felt to be appropriate to gather data over what is colloquially referred to as a “Holiday Weekend.” These steps were also necessary to capture the night following holidays or weekends, as the temperature data and trauma database were recorded for entire calendar days. This barred sub-analysis of diurnal temperature variation of daylight and nighttime hours.

Statistical Analyses After visually examining for nonlinear trends in the data with loess smoothers (Stata command lowess), differential daily trauma trajectories were observed. Therefore, two spline knots were placed at June 1, 2013, and June 1, 2014, using the command mkspline.

This allowed us to construct 3 distinct linear slopes within the same regression model. Time periods (TP) were defined according to trauma cases trajectory split by these spline knots: TP 1 was from June 1, 2012, to May 31, 2013; TP 2 was from June 1, 2013, to May 31, 2014; and TP 3 was from June 1, 2014, to January 1, 2015.

Descriptive analysis was used to compare the age differences by gender or injury type. Generalized linear models (GLM) with a negative binomial family and log link were constructed to examine the associations between temperature, temporal (weekend and holiday), and the daily number of trauma cases. All analyses were performed using Stata 14.0 (StataCorp. 2015. College Station, TX: StataCorp LP). Statistical significance was defined as p<0.05.

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Results A cohort of 4,992 HNT cases was identified during this 31-month study period. The age range of this population was zero to ninetynine years, mean age was 35.9 years (SD=23.4), 31.4% were female, and the majority of injuries were accidental in nature and occurred in adult males.

Table 1 depicts more details about the demographics of the HNT population and further stratify age, sex, and type of injury. Males comprised the majority of all age sub-categories except those greater than 75 years: 61% of ages [0-11)(p<0.001), 67% of ages [11-18) (p<0.001), 72% of ages [18-30)(p<0.001), 75% of ages [30-50) (p<0.001), 73% of ages [50-75)(p<0.001), and 44% of ages [75-99] (p<0.001). The largest age group was from age 30-50 (1201 patients combined) in both males (895 patients) and females (306 patients).

Stratifying injury type among all participants revealed that accidental trauma (4023 or 80.6%) occurred more frequently than trauma due to interpersonal violence (958 or 19.2%). Further stratifying sex within accidental and interpersonal violence groups revealed that males were more likely to experience trauma (65% and 83%, respectively; p<0.001) with males comprising a larger ratio within the violent group. Male accidental injuries were most common, followed by female accidental, male interpersonal violence, and female interpersonal violence in all age groups except 30-50 years and 75-99 years. The 30-50 age group had a larger component of male interpersonal violence HNT which constituted the second largest group within this age range. The 75-99 age group had a disproportionately large female accidental group.

Table 2 depicts the lack of a significant relationship between temperature and observed HNT. Over the entire study period, for 1 unit increase in average temperature, there was a 3% increase in the number of expected trauma cases; although this was not significant (IRR=1.028 [95% CI 0.93, 1.14], p=0.589). The analysis then approached each separate time period (TP) for further details.

Average temperature associations with HNT at the study’s starting point (June 1, 2012), TP1, TP2, and TP3 were found to be nonsignificant (IRR=1.002 [95% CI 0.96, 1.04], p=0.920), (1.017 [95% CI 0.99, 1.05], p=0.209), (0.985 [95% CI 0.91, 1.06], p=0.705), and (1.025 [95% CI 0.93, 1.12], p=0.584) respectively. This was also repeated for Tmax and Tmin which also revealed non-significant relationships (Table 2).

Table 3a depicts predicted average HNT cases for weekend, weekday, holidays and non-holidays within each TP when adjusted for temperature, and Table 3b depicts no significant association with spare time and HNT. In particular, weekend to weekday associations for our starting point, TP1, TP2, TP3, and total study period were found to be (IRR=1.476 [95% CI 0.97, 2.24], p=0.066), (IRR= 1.255 [95% CI 0.92, 1.72], p=0.155), (IRR= 1.493 [95% CI 0.69, 3.21], p=0.305), (IRR=1.436 [95% CI 0.39, 5.25], p=0.584), and (IRR=2.691 [95% CI 0.74, 9.82], p=0.134) respectively. Furthering this, when holidays were compared to non-holidays for starting point, TP1, TP2, TP3, and total study period, no significant findings were

Table 1a. Descriptive Analysis for Participant Characteristics Total Female Male [%] [%] [%] Characteristic 4,992 1,565[31.4] 3,427[68.6] Mean 35.9 37.3 (26.7) 35.3(21.6) Age & SD (23.4) 715 276 [39] 439 [61] [0, 11) 548 180 [33] 368 [67] [11,18) 1068 297 [28] 771 [72] [18,30) 1201 306 [25] 895 [75] [30,50) 1075 291 [27] 784 [73] [50,75) 385 215 [56] 170 [44] [75,99] Injury Type 4023 1394 [35] 2629 [65] Accidental [80.6] 958 167 [17] 791 [83] Violent [19.2] Table 1b. Descriptive Analysis by Sex and Injury Type Female Female Male Male Violent Accidental Violent Accidental Characteristic Total [%] [%] [%] [%] 4,992 167 1,394 791 2,629 35.9 33.9 Age & SD (23.4) 30.3 (21.1) 38.1 (27.2) (17.2) 35.7 (22.8) 715 33 [5] 242 [34] 64 [9] 374 [52] [0, 11) 548 19 [3] 161 [29] 67 [12] 301 [55] [11,18) 1068 37 [3] 260 [24] 225 [21] 546 [51] [18,30) 1201 45 [4] 261 [22] 268 [22] 626 [52] [30,50) 1075 28 [3] 261 [24] 156 [15] 624 [58] [50,75) 385 5 [1] 209 [54] 11 [3] 158 [4] [75,99]

p 0.005 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001

p <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001

SD – standard deviation

Table 2. Associations of Temperature with Trauma Cases 1 degree Celsius variation Tmean Tmax Tmin

Starting Point 1.002 p=0.920 (0.96, 1.04) 1.003 p=0.869 (0.96,1.04) 1.001 p=0.961 (0.97,1.04)

TP1 1.017 p=0.209 (0.99, 1.05) 1.018 p=0.194 (0.99,1.05) 1.014 p=0.249 (0.99,1.04)

TP2 0.985 p=0.705 (0.91, 1.06) 0.989 p=0.772 (0.92,1.07) 0.985 p=0.666 (0.92,1.06)

TP 3 1.025 p=0.584 (0.93, 1.12) 1.019 p=0.659 (0.94,1.11) 1.027 p=0.548 (0.94,1.12)

All period 1.028 p=0.589 (0.93, 1.14) 1.026 p=0.603 (0.93,1.13) 1.026 p=0.593 (0.93,1.13)

Tmean= Mean temperature; Tmax = Temperature apex; Tmin = Temperature Nadir; TP = Time period; Starting Point: 6/1/2012; Time Period 1: 6/1/2012-5/31/2013; Time Period 2: 6/1/2013-5/31/2014; Time Period 3: 6/1/2014- 1/1/2015; All Period: 6/1/2012-1/1/2015.

Tmean= Mean temperature; Tmax = Temperature apex; Tmin = Temperature Nadir; TP = Time period; Table 3a.

Average Predicted Trauma Cases

by Temporal Factors Starting Point: 6/1/2012; Time Period 1: 6/1/2012-5/31/2013; Time Period 2: 6/1/2013-5/31/2014; Time Starting Period 3: 6/1/2014- 1/1/2015; All Period: 6/1/2012-1/1/2015.

Point TP 1 TP 2 TP 3 Weekday 5.296 4.629 4.585 4.734 Weekend 7.815 6.024 5.785 6.002 Nonholiday 6.273 5.216 5.090 5.243 Holiday 8.232 5.474 5.210 5.681 Table 3b. Associations of Temporal Factors with Trauma Cases Starting TP 1 TP2 TP 3 Point 1.476 1.255 1.493 1.436 p=0.584 p=0.066 p=0.155 p=0.305 Weekend (0.97,2.24) (0.92,1.72) (0.69,3.21) (0.39,5.25) 1.312 0.979 1.453 1.306 p=0.795 p=0.548 p=0.940 p=0.628 Holiday (0.54,3.18) (0.56,1.71) (0.32,6.58) (0.17,9.81)

TP Time period.

Starting Point:Point: 6/1/2012.

TP= = Time period.

Starting 6/1/2012.

Time Period 1: 6/1/2012-5/31/2013; Time Period 6/1/2013-5/31/2014 Time Period 1: 6/1/2012-5/31/2013; Time2:Period 2: 6/1/2013-5/31/2014 Time Period 3: 6/1/20141/1/2015; All Period: 6/1/2012-1/1/2015 Time Period 3: 6/1/20141/1/2015; All Period: 6/1/2012-1/1/2015

All period 2.691 p=0.134 (0.74,9.82) 1.858 p=0.593 (0.19, 18.04)

noted {(IRR=1.312 [95% CI 0.54, 3.18], p=0.548), (IRR= 0.979 [95% CI 0.56, 1.71], p=0.940), (IRR= 1.453 [95% CI 0.32, 6.58], p=0.628), (IRR= 1.306 [95% CI 0.17, 9.81], p=0.795), and (IRR=1.858 [95% CI 0.19, 18.04], p=0.593) respectively}. This was graphically illustrated in the Figure.

Additionally, the 15 days with the most HNT observed throughout the study period are displayed in Table 4 with associated temperature. Interestingly 14 of the 15 days (93.33%) occurred on weekends, and 86.67% occurred during regular time.

Discussion The majority of patients observed in this study were male with the largest age-sex subgroup comprised of men aged 30-50 years (Table 1). Even furthering this observation is that the three largest age-sex subgroups comprised men from age 18-75 years. Finally, men made up the largest portion of accidental and interpersonal violence HNT when compared to women and made up a larger proportion of interpersonal violence HNT when compared to accidental HNT. Table 2 illustrates our investigation of temperature variation influence on observed HNT. The relationship is not statistically significant, which prohibits us from identifying positive trends observed in the data. The failure to identify a relationship may be due to the inherent nature of a retrospective chart review. Additionally, the maximum, minimum, and mean temperature for the calendar day at UMMC was used for this study. It is possible that this doesn’t appropriately account for diurnal variations in temperature across central Mississippi, but it does reinforce that our University hospital cannot base HNT staffing arrangements according to local temperature.

Additionally, it is apparent to any person who has lived in the Southeast United States that perceived humidity plays a prominent role in temperature comfort level. Humidity is such a factor in Jackson, Mississippi that historical analysis of hourly weather reports from January 1, 1980 to December 31, 2016 indicated from May 1st to October 12th, colloquially the “muggy period,” that 24% of the time the humidity comfort level is graded as muggy, oppressive, or miserable.7 Unfortunately, humidity analysis was not available in the pooled weather data from NOAA, so our investigation of this phenomenon was precluded.

It is worth discussing that the original study period included several months in the calendar year 2015. Once it was realized that ICD-9 codes were no longer solely utilized by UMMC for billing in 2015, these months and an additional 626 participants were removed from the study.

The analysis for these participants is not discussed above, but their inclusion also resulted in non-significant findings.

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Table 3a shows an expected increase in adjusted averages of Table 4. Top 15 days of Head and Neck Trauma Date Day of Week Holiday Weekend Temperature observed HNT on weekends and holidays when compared 3/1/2014 Saturday Y 18.60 to weekdays and non-holidays. Additionally, fourteen of 15 8/3/2012 Friday Y 30.00 days with the most HNT are weekend days, even though 10/13/2013 Sunday Y 24.15 4/27/2013 Saturday Y 22.75 a relationship between spare time and observed HNT was 10/4/2013 Friday Y 27.25 not established as seen in Table 3b. One such explanation 5/4/2014 Sunday Y 21.40 11/2/2013 Saturday Y Y 14.15 is that our data set is too small to capture a significant 1/26/2013 Saturday Y 11.10 relationship between spare time and HNT although trends 6/24/2012 Sunday Y 30.00 8 have been noted in smaller studies. The figure further 8/18/2012 Saturday Y 26.40 4/7/2013 Sunday Y 18.05 illustrates the non-significant correlation between spare 6/10/2012 Sunday Y 25.55 time and observed HNT and an unexpected decrease in 2/7/2015 Saturday Y 10.30 HNT throughout the study. These findings suggest that our 1/1/2013 Tuesday Y 10.30 3/13/2015 Friday Y 19.75 trauma center need not vary its HNT staffing or physician coverage depending on the day of the week, holiday, or Temperature = Mean temperature in Celsius local temperature.

Figure.

Temporal Distribution of Head and Neck Trauma Figure.

Temporal Distribution of Head and Neck Trauma

Trauma # 18 17 16 15 15 14 14 13 13 13 13 13 13 13 13

0

In a 5-year prospective study, Sivarajasingam et al.5 demonstrated that the majority of violence-related injuries were in males (72%) and that 47% were between the ages of 18-30 years. Saturdays and Sundays comprised 74/91 days with >20 violent injuries observed, and New Year days comprising 3 of these days. They also noted that 2 of the 91 days were rugby international days (World Cup).

Sivarajasingam et al.5 also found no correlation between temperature, rainfall, and sunlight hours and violent injuries, which is consistent with our findings. Finally, in contrast to our study, they noted a 114% increase in total violent injuries over the five-year study period.

Another Welsh study by Sivarajasingam, et al.9, noted that the increase of overall interpersonal violence patterns slowed over a 5-year period from May 1995 to April 2000.

Seventy-three percent of 353,442 violent injury victims were male. This study looked specifically at annual cycles and found a lower level of violence in autumn and winter for both males and females when compared to spring.

Interestingly, violent injuries affecting males aged 18-30 were not affected by seasons.

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In a database review by Atherton, et al.,8 2914 admissions for a trauma unit over a one-year-period were analyzed for possible correlations between temporal factors and local temperatures. Adult and femur fracture admissions appeared to be positively influenced by the day of the week (most notably Monday) and not temperature. Pediatric and total admissions were more likely observed in summer months and were correlated with increased daily temperatures, more daylight hours, and less precipitation.

To add to the confusion of available scientific literature, Rotton and Frey10 provided evidence of a positive correlation of daily temperatures and a negative correlation of humidity and wind speed with assaults against persons in their archival review. To further this, Carlsmith et al.11 evidenced that the conditional probability of a riot increases with increases in temperature.

118 VOL. 60 • NO. 3 • 2019

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Number of traumas observed over regular time and spare time throughout the study period

Finally, the systematic review by Ali and Willett3 found that trauma admissions were correlated with an increase in temperature and that this correlation was more strongly correlated in the pediatric population. Ultimately, the conclusions of their study were limited by the differences in methodology within the 28 included papers, and the authors were limited in stating that weather conditions may affect trauma workload independent of seasonal variation.

Limitations of our study largely stem from the nature of retrospective chart review. In particular, our dependency on a wide range of ICD9 codes that could also encapsulate non-HNT limited the accuracy of identifying sole trauma diagnoses. For instance, ICD-9-931 more often accounts for non-traumatic ear foreign bodies in our clinical experience, but due to its inclusion in the trauma database, we presumed that this code accounted for a traumatic aural foreign body.

Secondly, our local maximum, minimum, and average temperatures for calendar dates were used as the basis for potentially observing HNT trends at our trauma center. Since our database logged cases

in this manner, our efforts to investigate diurnal variation and HNT trends were impeded. Again, the inability to account for humidity and its effect on comfort level was previously mentioned.

Additionally, the temperature used for analysis is local and does not account for the temperature at which the HNT occurred. This ultimately would not be of concern to UMMC as local temperature models would be used to predict HNT workload if such a correlation had existed. Therefore, it is possible that temperature at the geographic location of injury could be correlated to HNT trends. It is also possible that HNT patients are being managed appropriately in the community, which may be evidenced by the decrease in observed HNT at our institution throughout the study period.

There are potential future directions with this dataset. One possibility is to prepare a predictive model based on the available data from the trauma dataset and prospectively observe HNT for any correlation. Further analysis of more variables including humidity, socioeconomic status, and type of intervention required would also shed light on this population.

Conclusion In summary, we did not find a statistically significant association between temperature or spare time and HNT. To the authors’ knowledge, there have been no studies investigating possible correlations between temperature and spare time with HNT specifically. As prior papers have set out to accomplish, we have found no statistical evidence that would suggest our trauma center need to vary its HNT staffing depending on temperature or holidays.

As stated previously, our inability to detect an association between temperature and HNT may be limited by our study design and the inherent deficiencies of retrospective chart review, but it does raise a particular point of interest to our University. UMMC is no less than 190 miles away from the nearest major tertiary care facility, and with varying degrees of meteorological factors within that radius, our attempts to vary staffing based on local temperature are precluded. n Acknowledgment: Special thanks to Michael Griswold, PhD for his work with analysis and interpretation and Dan Su, MPH for her work with analysis, interpretation, and revising of this manuscript.

6. Brohi, K. Abbreviated Injury Scale (AIS) Score. Overview of the anatomical scoring tool. http://www.trauma.org/index.php/main/article/510/.

Published March 10, 2007. Accessed May 20, 2017.

7.

Humidity: Average Weather in Jackson, Mississippi, United States.

WeatherSpark Web site. https://weatherspark.com/y/11879/AverageWeather-in-Jackson-Mississippi-United-States. Accessed October 17, 2017.

8. Atherton WG, Harper WM, Abrams KR. A year’s trauma admissions and the effect of the weather. Injury. 2005;36(1):40-46.

9. V Sivarajasingam, J.P Shepherd, Matthews K, Jones S. Trends in violence in England and Wales 1995-2000: an accident and emergency perspective. J Pub Health Med. 2002;24(3):219-226.

10. Rotton J, Frey J. Air pollution, weather and violent crimes: concomitant timeseries analysis of archival data. J Pers Soc Psychol. 1985;(49):1207-1220.

11. Carlsmith JM, Anderson, CA. Ambient temperature and the occurrence of collective violence: A new analysis. J Pers Soc Psychol. 1979;37(3):337-344.

Author Information Resident, Department of Otolaryngology Head and Neck Surgery and Communicative Disorders, University of Mississippi Medical Center (UMMC) (Robichaux, Moore). Professor, Department of Otolaryngology Head and Neck Surgery and Communicative Disorders, UMMC (Jordan). Associate Professor, Director of Clinical Research and Clinical Audiologist, Department of Otolaryngology Head and Neck Surgery and Communicative Disorders, UMMC (Spankovich).

The authors disclose no conflicts of interest.

Corresponding Author: Cindy Moore, MD, 5155 McCoy Dr., Jackson, MS 39211 (cmmoore4@umc.edu).

Helping you build a more secure future.

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

2. Chau PH, Wong M Woo J. Ischemic heart disease hospitalization among older people in a subtropical city – Hong Kong: does winter have a greater impact than summer? Int J Environ Res Public Health. 2014;11(4):3845-3858.

••••• ••••• iiMfai• II

3. Ali AM, Willett K. What is the effect of the weather on trauma workload? A systemic review of the literature. Injury. 2015;46(6):945-953.

MEDLEY & BROWN

References 1. Shiue I, Muthers S, Barman N. The role of cold stress in predicting extra cardiovascular and respiratory admissions. Int J Cardiol. 2014;172:e109-e110.

4. Rising WR, O'Daniel JA, Roberts CS. Correlating weather and trauma admission at a level I trauma center. J Trauma. 2006;60(5):1096-1100.

5. Sivarajasingam V, Corcoran J, Jones D, Ware A, Shepherd J. Relations between violence, calendar events and ambient conditions. Injury. 2004;35(5):467473.

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S P E C I A L

A R T I C L E

An Interview with University of Mississippi Medical Center Vice Chancellor Louann Woodward, MD MARGARET COSNAHAN, M-2; PHILIP MERIDETH, MD, JD

What’s a typical day as Vice Chancellor for Health Affairs and Dean of The School of Medicine?

This might be the hardest question on the list. There really isn’t a “typical” day, and that’s the fun of it. There is my internal work with the medical center - interacting with the students, residents, faculty, and the administrative team. And then there’s the work I do externally- interacting with people in our community, around the state, and outside of it.

Margaret Cosnahan (M2) interviews Dr. Woodward

The entering class this August had 165 students. Ten years ago, we set this target by analyzing the workforce in Mississippi, GME positions available, retention rates, and our application pool. Mississippi is ranked last in physicians per capita right now, and we want to move up that curve and be somewhere What innovations and technologies does the new medical between the lower-third and the halfway mark. We wanted to school offer to students? put Mississippi in a different place. Since we did that analysis, a lot of those variables have changed. We now have to consider The new medical school allows us to grow the class size and the D.O. School and the merging of D.O. and ACGME establish an academic home. In 2003 or 2004, Dr. Dan Jones residency programs in our and I had a conversation analysis. With this in mind, about increasing the class we will need to do another size of the medical school. At analysis over the next five to this time, we were admitting six years to determine the around 100 students per right number going forward. year. It became clear to me We also must determine what that if we wanted to grow our clinical capacity is on this the class size, we needed campus. All of our schools a new building. We now have grown alongside our have a modern educational medical school class. We space dedicated to medical take in more than a thousand Photograph of UMMC showing New School students that allows them to students per year in the form of Medicine Education Building learn in a more modern wayof visiting medical students, through simulation labs where nursing students, and PA students can practice clinical skills, small group rooms, and students. We must consider all of these factors when thinking larger lecture halls. Student involvement in the planning of this about the future expansion of our class size. building was unprecedented, and I am proud of that fact. We wanted it to be the kind of place that the students just loved and If you could give one piece of advice for medical students could call home. It was a long journey and a lot of fun, but now I and future physicians, what would it be? think the upper-level students are like, “Really….?”

It’s hard for me to distill it down into a single piece of advice.

Can you comment on the medical school’s newly broken No matter the specialty or the practice environment, whether admission record? Do you project growth in the class size you work at an academic medical center such as this or you’re a in the next five years? solo practitioner—it’s hard work. There is an increased sense of 120 VOL. 60 • NO. 3 • 2019

urgency with all of the technology that we have now, and I think this adds to the pressures you feel. Most people can’t imagine a world without e-mail, but when I was a resident and a young faculty member, we would actually get memos—that’s where they type it up and send it to you. We had more time to digest information and think about it, and now there is an expectation of quick responses. When you order a scan or a test on a patient, you get answers back immediately. The pace at which we are expected to work has increased. Ultimately, my advice is to be sure you have a way to remember why you’re doing what you’re doing. Because that's what motivates everybody and keeps it fresh and fun. When people lose sight of this, that balance gets out of whack, and the frustrations become greater than joy.

What are your thoughts on “physician burnout”?

Burnout is a national problem, and it's broader than just physicians. A couple of years ago, I asked Josh Mann and Alan Jones to form a team to examine how other academic medical centers around the country confronted this issue.

After looking at several different models, we created The Office of Well-Being which kicked off at the start of the new academic year. I want this office to ensure that the services and activities we offer are addressing the main pain points of our employees and students. We have already found that the electronic health record is a big point of dissatisfaction, especially for people around my age who didn’t grow up with a phone in their hand. How can we make the electronic health record less intrusive and less difficult? We all know it’s not going away. As I said earlier, the pace of work is faster, the pressures are more significant, and I think all of these things contribute to the frustrations, and eventually the burnout.

I am excited that we will have a concentrated focus on this issue here at UMMC.

able to support them by utilizing telemedicine and after-hour providers.

What are some of the individual needs of rural communities? In what ways does UMMC reach via telehealth?

Our first telehealth venture was telemergency, which is near and dear to my heart. I actually ran the first code using telemergency.

When we started telemergency, there were many emergency departments across the state supported by our physicians here at UMMC. We now offer telepsychiatry, teleneurology, telepathology, and teledermatology to communities in our state. These examples are viewed as more traditional types of telemedicine, whereas now we are moving towards a directto-consumer type of telemedicine. For example, if you are working at BankPlus and you don’t feel well, you can schedule an appointment with a physician during your break. All of this takes place on a computer without leaving your desk or your job. One of the things I am most excited about is remote patient monitoring. I believe this will be a big part of our future. We've done a large pilot program involving primary care physicians and individuals with uncontrolled diabetes.

Using a tablet, patients can keep a closer check on sugar levels, and physicians can intervene when a trend is heading in the wrong direction. This type of patient monitoring also allows for increased patient education. Patient education and monitoring will not only help us manage chronic disease, which is good for the patient, but it will also help us improve in areas like readmissions.

“Be sure you have a way to remember why you’re doing what you’re doing.”

What role does UMMC play in supporting rural hospitals in Mississippi?

Our role in the state has changed a lot in the last ten years, and it’s still changing rapidly. I hope that we continue to be an organization that supports healthcare in our rural communities in a way that works best for them individually. Over the last few years, we have partnered with many different communities. In January, we started a partnership in Gulfport where we run the NICU and manage their pediatric practices. We also participate in a similar pediatric focused partnership with North Mississippi Medical Center. After the hospital closed in Belzoni, we were

Why practice in Mississippi? Why did you stay in your home state?

That’s an easy one. There is such a need in Mississippi. The need here is great. If you’re looking for easy, this isn’t it. If you want to practice in a place where you are taking care of basically healthy people, this is not it. If you want to practice in a place where there are plenty of resources, this isn’t it. If you are driven by the mission of taking care of patients where there is a great need and you know you can make a difference, then boy, have I got a job for you. You never have to walk away from your day of work in a place like this and wonder if what you did mattered. It always matters in a place like Mississippi. Until we get to a better place in our state, as far as our health outcomes and physicians per capita, we need to stack the deck as much as we can. We need MARCH • JOURNAL MSMA

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students that are committed to Mississippi and have the desire to practice in the rural parts of our state.

“You never have to walk away from your day of work in a place like this and wonder if what you did mattered. It always matters in a place like Mississippi.”

What book have you read recently and what did you like about it?

I love to read. The only time in my life when I didn’t read for fun was during medical school and my residency. Now, I keep a basket of books at home that I’ve ordered but haven't gotten to yet. I just finished a book called, The Emperor of All Maladies. It provides a historical review of cancer and cancer treatment. I was drawn to the book after my mother passed away from cancer about a year ago. The book was not an easy read, and I found it very dense. As I was reading it, I kept thinking to myself, if I didn’t have a background in healthcare and medicine would I be able to follow this? However, as a healthcare provider, it's a great book that highlights how far we’ve come in the treatment of cancer but reminds us that we’re not quite there yet.

One of my favorite books is called Mom’s Marijuana by Dan Shapiro. About ten years ago, we sent this book to the medical students the summer before they started school. The author, Dan, is a psychologist and friend of mine. As a teenager, he was diagnosed with lymphoma, and after a couple of relapses, everybody wrote him off. They just said, “There’s nothing else to do.” Mom’s Marijuana is about his journey during that time, and it is an incredibly wonderful work. I read it in about 4 hours.

What value do you see in the Journal of the MSMA? We are great storytellers in Mississippi, and everybody likes to feel connected. That’s part of it, I think, this state is special because of its level of connectivity. You can go to a town where you’ve never been before, talk to a group of people, and before you leave you’ve made some connections. “Oh, you know so and so”... I think the Journal finds a wonderful balance between that connectedness and being a scientific publication. If you think about all of the journals that we read, nothing else has that feel of being a legitimate scientific type of journal while still maintaining that connectedness to Mississippi. n 122 VOL. 60 • NO. 3 • 2019

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P R E S I D E N T ’ S

P A G E

Physician Wellness – A Focus on Mental Health

R

ecent concerns with burnout have pushed physicians to rethink how they approach physician well-being which has led to more concern for physician’s mental health and how they approach a mental health diagnosis and treatment in general.1 The American Medical Association has called physician burnout a precursor to more serious mental health problems. Stress, burnout, and vulnerability to ill health are commonplace among physicians. Many physicians lack the opportunity for exercise and lack the time to eat properly.

Sleep deprivation is a common finding among physicians that contribute to poor health. Increased bureaucracy is also a common contributor to the pressures physicians feel.2 The control or lack thereof that physicians have over their work environment plays a significant role in predisposition to burnout. A broader awareness may better equip physicians in their capacity as leaders to improve circumstances for those with whom they work.3

asking applicants about treatment for mental health conditions and focus on screening only for current impairment.6 The Federation of State Medical Boards recently issued recommendations that licensure boards remove questions on applications that ask about past Michael Mansour, MD or current mental health conditions.

The Mississippi State Board of Medical Licensure is to be commended for adopting this position.

Accreditation Council for Graduate Medical Education (ACGME) has added to its common program requirements that call for residency programs to provide residents “with immediate access at all times to a mental health professional.”1 Between 2000 and 2014, 324 physicians died while in residency. The leading cause of death for male residents was suicide and for female residents was Health systems should promote healthy lifestyles for malignancies. Resident death rates were lower than in physicians. Licensure boards must make sure all questions the age- and gender-matched general population.6 The about mental health comply with the American with depressive symptoms that increase during internship are Disabilities Act and only ask questions about current greater for women. Work-family conflict is an important 4 conditions causing impairment. Privacy and confidentiality potential modifiable factor that is associated with increased of a physician’s health and treatment history are important depressive symptoms of physicians in training. Given that to allow those in need of help to come forward without depression among physicians is associated with poor patient fear of punishment. While information about a physicians care and career attrition, efforts to alleviate depression health status may be essential to a State Board’s solemn duty among physicians have the potential to reduce negative to protect the public, the Federation of State Medical Boards consequences associated with this disease.7 Data also has noted that a history of mental illness or substance suggest a higher risk for individuals early in their training 3 abuse does not reliably predict future risk to the public. and during vulnerable periods in the first quarter of the The Consensus Statement on Confronting Depression academic year and after the winter holiday season.6 The and Suicide in Physicians recommends transforming Association of American Medical Colleges encourages professional attitudes and changing institutional policies schools to offer and promote mental health services for 5 to encourage physicians to seek help. The AMA has students and faculty. Promoting a sense of community recommended that all state medical boards refrain from support free of threats of repercussion from licensing boards MARCH • JOURNAL MSMA

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is critically important to normalizing the conversation regarding treatment of mental illness in physicians and the community as a whole.1 It is a common misconception that physicians are more susceptible to suffering from burnout in later stages of their career, presumably from fatigue and aging. In fact, physicians in the middle of their careers are at the highest risk for burn out.8 Physicians speaking retrospectively toward the end of their careers frequently find difficulty in achieving a sustainable balance of work and home commitments. Medical careers are getting longer, and retirement ages are increasing. Physicians in the latter stages of their careers may have to adapt the makeup of their work to reflect the best use of their skills experience and abilities.2 The drivers of both burnout and high professional fulfillment fall into three major domains: efficiency of practice, a culture of wellness, and personal resilience.

Efficiency of practice and a culture of wellness are primarily organizational responsibilities, whereas maintaining personal resilience is primarily the obligation of the individual physician. Physicians have suffered a reduction in their sense of professional autonomy, experienced a significant increase in clerical duties, and are beholden to a growing array of imperfect and inconsistent quality and productivity metrics. The World Health Organizationâ&#x20AC;&#x2122;s definition of health is an optimal state of physical, mental, and social well-being, and not merely the absence of burnout. It is counterproductive to ask physicians to heal themselves through superhuman levels of resilience.4 Medical school curricula and residencies must educate students about the risk of psychosocial distress, particularly suicides, and take steps to address this problem. Healthcare institutions should consider a strategy to ensure that physicians have appropriate access to the mental health services they need. Confidentiality is widely regarded as a barrier to physicians access to mental health services.9 Healthcare organizations must embrace their responsibility to build an efficient practice environment and to foster a culture of wellness while also supporting physician efforts to improve resilience.4 Some solutions proposed to avoid burnout in physicians in training include adequate sleep, adequate supervision to know there will always be someone to answer a question, 124 VOL. 60 â&#x20AC;˘ NO. 3 â&#x20AC;˘ 2019

and being part of a well-functioning team. These all can contribute to a sense of job satisfaction that mitigates against stress and burnout.10 Easily accessible and brief web-based cognitive behavioral therapy is associated with reduced likelihood of suicidal ideation among medical interns.

Prevention programs with these characteristics could be easily disseminated to medical training programs.11 Physicians, in turn, maintain a professional obligation to nourish their personal resilience while simultaneously playing key roles in helping to build a culture of wellness and to improve the efficiency of practice.4 Physicians need to accept the notion that professional competence allows for compassion toward other professionals and toward themselves. Recognizing distress in others, offering support and assistance to those in distress and reducing the conflict between work-life and family-life can further address these concerns of maintaining good mental health. n

Michael Mansour, MD President, Mississippi State Medical Association

References 1. Castelluci M. Healthcare industry takes on high physician suicide rates, mental health stigma. Modern Healthcare News. Sept 29, 2018.

2. Smith F, Goldacre MJ, Lambert TW. Adverse Effects on helath and wellbeing of working as a doctor: views of the UK medical graduates of 1974 and 1977 surveyed in 2014. J R Soc Med. 2017;110(5):198-207.

3. Physician Wellness and Burnout. Report and Recommendations of the Workgroup on Physician Wellness and Burnout. Adopted as a policy by the Federation of State Medical Boards, April 2018.

4. Bohman B, Dyrbye L, Sinsky CA, et al. Physician well-being: the reciprocity of practice efficiency, culture of wellness, and personal residence. NEJM Catalyst.

Aug 7, 2017.

5. Center C, Davis M, Thomas D et al. Confronting depression and suicide in physicians. a consensus statement. JAMA June 18, 2003(289)23:3161-3166.

6. Yaghmour NA, Brigham TP, Richter T, et al. Causes of death of residents in ACGME-accredited programs 2000 through 2014: implications for the learning environment. Acad Med. 2017;92(7):976-983.

7. Guille C, Frank E, Zhao Z, et al. Work-family conflict and sex difference in depression among training physicians. JAMA Intern Med. 2017;177(12):17661772.

8. Dyrlye LN. Burnout among U.S. medical students, residents and early career physicians relative to the general U.S. population. Acad Med. 89(3):443-451.

9. Goldman ML, Bernstein CA, Summers RF. Potential risks and benefits of mental helath screening of physicians. JAMA Dec 25, 2018;(320)24:2527-2528.

10. Paice E, Hamilton-Fairley D. Avoiding burnout in new doctors: sleep, supervision and teams. Postgrad Med J. Sept 2013;89(1055):493-494

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Images in Mississippi Medicine: A Photographic History of Medicine in Mississippi

Images in Mississippi Medicine

publishing and Advertising. Fascinated with graphic design, advertising, the University of Mississippi with a B.S. in Journalism sales and Karen A. Evers, a native of Jackson, graduated from Hippocrates and Health. After 10 years in advertising working with such magazines as Better Homes & Gardens, a position she’s and media, she went from Ole Miss to New York City of the Mississippi State Medical Association (JMSMA), In 1995, she became managing editor of the Journal distributed magazine publishing, she returned home to Mississippi. editing and production to the printed and online magazine publishing process from content acquisition, writing, Journal volumes containing more than held since, overseeing and coordinating the Journal’s bound 20 than more produced has Karen and the MSMA Committee on Publications, for Most Improved in members’ mailboxes. With her physician editors Association Trends All-Media Contest Silver Award including Best One-Person-Produced Magazine, an 250 issues. She is the recipient of several APEX awards issue “From Doc on Horseback to Managed Care.”

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HOT OFF THE PRESS! Mississippi State Medical as Editor and Associate Editor of the Journal of the Dr. Lucius M. “Luke” Lampton of Magnolia, has served national awards for of articles on medicine and health care and receiving Association for more than two decades, writing thousands Encyclopedia, authoring multiple as Medical Editor of the recently published Mississippi excellence in writing and journalism. He also served primary care textbook Conn’s recently contributed a chapter to America’s leading entries on the history of medicine in Mississippi. He and served as chairman of 2006 since of the Mississippi State Board of Health Current Therapy. Dr. Lampton has also served as a member nursing homes, geri-psych, hospital, clinic, settings: multiple in Medicine Family in the Board from 2007-2017. Dr. Lampton specializes MAFP, alumna of the year as Mississippi’s “family physician” of the year by the long-term acute care, and hospice. He has been recognized citation for his hospice work. by his Tulane medical students, and has received national by his medical school, professor of the year nominee Clinical Instructor Medicine, of Community Medicine at Tulane University School He serves as Clinical Assistant Professor of Family and of Family Medicine at William School of Medicine, and as Adjunct Clinical Professor in Family Medicine at the University of Mississippi of Mississippi Lampton also serves as President of the Foundation Dr. Hattiesburg.

Medicine, Osteopathic of Carey University College Museum. of Mississippi History and the Mississippi Civil Rights History and helped oversee the creation of the Museum

ASSOCIATION

$80.00 ISBN 978-0-692-12459-8

58000>

126 VOL. 60 • NO. 3 • 2019

MSMA

9 780692 124598

Lucius “Luke” M. Lampton, MD and Karen A. Evers

IMAGES IN MISSISSIPPI MEDICINE: A PHOTOGRAPHIC HISTORY OF MEDICINE IN MISSISSIPPI

Get your copy today @ msmaonline.com

An old idiom asserts that a picture speaks a thousand the words, and the hundreds of images which follow tell story of medicine with texture, color, and depth words a often can’t convey. Mississippi has always possessed distinctive medical sense of place, with its history strongly and native as well as climate sultry influenced by its was imported diseases. The long struggle of physicians arduous in their efforts to battle the state’s significant an health challenges, which included poverty, race, and often-malignant climate.

Written by Lucius “Luke” Lampton, MD and Karen Evers, longtime editors of the state’s respected monthly medical journal, Images in Mississippi Medicine: provides Mississippi in A Photographic History of Medicine an extraordinary and unrivaled account of the evolution today’s of medicine in Mississippi from territorial times to latest technology. This magnificently illustrated book offers a unique array of rare photographs and historical images as well as compelling essays by Dr. Lampton which reveal the untold story of Mississippi’s medical history, a largely forgotten drama peppered with forgotten larger but brilliant medical heroes who helped shaped the history of the state in both political and social terms.

Over two decades in the making, this book will prove essential to anyone interested in medicine in the state.

The story of medicine is the story of men and and patients their for care to women and their endeavors advance their profession. The book’s chapters explore of with fascinating narrative and vivid imagery the rise the hospitals and medical institutions, physician pioneers, emergence the illness, history of the treatment of mental and of public health, the crusade for medical education, the accomplishments of organized medicine.

Jacket/Book Design: Adrienne C. Dison

L E T T E R S

Editor spot on with “Secret Sauce” editorial: What is organized medicine doing about it?

Dear JMSMA Editor, I just read your piece in the Journal of the Mississippi State Medical Association about the “secret sauce” of medicine. [Lampton, L. “Medicine’s ‘Secret Sauce’.” J Miss State Med Assoc. Vol. 59, No. 9: 390.] You are spot on. I am sure many other physicians know this.

The question is “What are the state and national medical associations doing to stand up for physicians and tell the corporations how health care will be delivered?” Informing me that there is a problem does little to help me.

Jeff Burns, MD; Hattiesburg

Editor “nailed it” with recent editorial: However, have we become a profession of salmon swimming upstream, helpless to effect necessary change?

Dear JMSMA Editor, I am retired; you nailed it! [Lampton, L. “Medicine’s ‘Secret Sauce’.” J Miss State Med Assoc. Vol. 59, No. 9: 390] However, in the Journal, you are indeed preaching to the choir. I have felt for the last 10 years of practice that I was a salmon swimming upstream, and I felt helpless to effect any change. We who love history know that if you study the past, you avert the disasters of the future. If only from the past we had an avenue to change the future of medicine, maybe we would maintain the advocacy and compassion for our patients for which all of us entered medicine.

Thank you for the job that you do!

William Spencer, MD; Oxford

Commemorative issue “a beautiful record”: A memory of the legendary Dr. Henry Holleman Dear JMSMA Editor, What a beautiful record you gave us with the Commemorative Edition. [J Miss State Med Assoc. Vol. 59, Nov./Dec. 2018] Trivia: In January 1962 I was drafted into the USAF following my first 6 months of pediatric residency at the University of Tennessee in Memphis. I was stationed at Columbus, Mississippi AFB, a Strategic Air Command Base housing B-52s, and KC-135 refuelers. Dr. Henry Holleman, then a 47-year-old in surgical practice in Columbus, periodically came to visit our small staff of about a dozen MDs. On one occasion he gave a lecture —with vivid photos— on his time in Korea! MASH! I diagnosed my very first pyloric stenosis — ever— in mid ’62. At my request, Henry Holleman came out and performed the Fredet/Ramstedt surgical surgery! Great guy! Fine surgeon! An American hero!

John McEachin, MD; Meridian MARCH • JOURNAL MSMA

127

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I M A G E S

M

I N

M I S S I S S I P P I

M E D I C I N E

ISSISSIPPI BAPTIST HOSPITAL, FROM NORTH STATE STREET, 1922 – After its modest beginnings in a frame home on Manship Street in 1909 (and as a Baptist eleemosynary institution in December 1910), Jackson’s Mississippi Baptist Hospital constructed in 1914 a 50-bed two-story (three with basement) brick, fire-proof structure at the corner of North State and Manship Streets [See Lampton, L. “Mississippi Baptist Hospital, Jackson, 1914,” January 2019 (60:1), page 34]. The coming of World War I slowed growth briefly, but by 1919 hospital census began to rise, making expansion imperative. Proposing to add a maternity ward, an x-ray unit, a laboratory, a steam laundry and thirty-five more hospital beds, the hospital trustees initiated in 1920 construction of another story to the original building with a threestory wing to be built at the hospital’s rear. By early 1922, the new hospital construction was completed (see image above) with bed capacity increased to 120, including the screened porches. The first x-ray machine was purchased by the hospital in November 1921 for $15,000 and installed in the operating room on the new fourth floor. A second piece of x-ray equipment “a deep therapy machine” was also purchased at that time for $11,000, revealing an early use of radiotherapy to treat cancer and tumors. The much-anticipated maternity ward was also placed on the hospital’s fourth floor. After these additions and having met all the modern hospital requirements, the institution was placed on the list of hospitals “approved” by the American College of Surgeons in October 1923. Its School of Nursing (later the Gilfoy School of Nursing) continued to thrive and produce generations of the state’s nurses. This Jackson landmark would be razed in 1985. If you have an old or even somewhat recent photograph 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

132 VOL. 60 • NO. 3 • 2019

P O E T R Y

A N D

M E D I C I N E

EDITED BY LUCIUS LAMPTON, MD; JMSMA EDITOR [This month, I continue a multi-issue focus on the poetry of the late physician-poet Merrill Moore, MD (1903-1957), a noted American psychiatrist and neurologist who also achieved fame as a poet and sonneteer. Born and educated in Tennessee, he received his MD from Vanderbilt School of Medicine in 1928. While always a prolific poet, he specialized in psychiatry and neurology, conducting a large psychiatric practice while teaching at Harvard Medical School and publishing research on alcoholism, addiction, suicide, and the psychoneurosis of war. “Liquor Cerebrospinalis” is the Latin phrase for the colorless fluid which bathes the brain and spinal cord. This fascinating poem was delivered in 1935 at a dinner held in honor of the legendary pioneer neurologist James Bourne Ayer, MD (1882-1963; Neurology Chief at Massachusetts General, 1927-1946) at The Tavern Club (a private club) in Boston. Moore tipped his hat in his sonnet review not only to his mentor Ayer, but also to his fellow Vanderbilt alumnus Harvard-based physician H. Houston Merritt (1902-1979), who with Frank Fremont-Smith, had just finished a lengthy book on cerebrospinal fluid. (Ayer wrote the book’s foreword.) Merritt collaborated with his friend Moore on many neurological publications and became one of the most significant academic neurologists of the 20th century. Expect more Moore sonnets in coming months. Any physician is invited to submit poems for publication in the Journal either by email at lukelampton@cableone.net or regular mail to the Journal, attention: Dr. Lampton.] — Ed.

LIQUOR CEREBROSPINALIS (A Sonnet Review of the Literature on Cerebrospinal Fluid with Special Reference to Three Important Events) Cotugno1 saw the way that Spinal Fluid

But then---was Yankee ingenuity

Filled up the space between the Brain and Bone;

And gentlemanly scholarship to keep

Scientists since his day are overjoyed

Its finger out of this important pie?

To add to Humors still another one.

No---it is only mete and only fair4 And Quincke2 with his quiet precision made

To keep reminded of the work of Ayer

More manifest what he had done himself

Who tapped a Cistern that is mighty deep!

Since when the published Articles parade And Books on Spinal Fluid3 fill the shelf.

References 1.

Contugno, Domenico: de Ischiade Nervosa Commentarius, Neapoli, 1764.

2.

Quincke, H.: Arch. f. Anat. u. Physiol., 1872, 153.

— Merrill Moore, MD (1903-1957)

3. Merritt, H. H., and Fremont-Smith, F.: The Cerebrospinal Fluid, Philadelphia, 1937.

4. Ayer, J. B.: Puncture of the Cisterna Magna, Arch. Neurol. And Psychiat., 1920, iv, 529.

MARCH • JOURNAL MSMA

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• INSTRUCTIONS FOR AUTHORS • The Journal of the Mississippi State Medical Association (JMSMA) welcomes material for publication submitted in accordance with the following guidelines.

Address all correspondence to the Editor, Journal of the Mississippi State Medical Association, P.O. Box 2548, Ridgeland, MS, 39158-2548. Contact Karen Evers, managing editor, with any questions concerning these guidelines: (601) 853-6733, ext. 323.

STYLE: Articles should be consistent with JAMA/ JMSMA style. Please refer to explanations in the AMA Manual of Style: A Guide for Authors and Editors. 10th ed. New York, NY: Oxford University Press; 2007. JAMA and JMSMA style differs from APA style. JAMA: https:// jamanetwork.com/journals/jama/pages/instructions-for-authors A quick reference guide is available upon request. Any manuscript that does not conform to the AMA Manual of Style, 10th edition will be returned for revision.

MANUSCRIPTS should be limited to 3000 words with ≤5 tables and/or figures and ≤25 references, due to JMSMA policy to feature concise but complete articles. (Some subjects may necessitate exception to this policy and will be reviewed and published at the Editor’s discretion.) The language and vocabulary of the manuscript should be understandable and not beyond the comprehension of the general readership of the Journal. The Journal attempts to avoid the use of medical jargon and abbreviations. All abbreviations, especially of laboratory and diagnostic procedures, must be identified in the text. Manuscripts must be typed, double-spaced with adequate margins. (This applies to all manuscript elements including text, references, legends, footnotes, etc.) The original manuscript hard copy should be submitted by mail. The Journal also requires manuscripts be supplied in Windows OS-compatible digital format. You may email digital files as attachments to KEvers@MSMAonline.com or supply them on a portable memory storage medium. All graphic images should be included as individual separate files in TIFF, PDF, or EPS format. An accompanying cover letter should designate one author as correspondent and include his/her address and telephone number. Provide title/affiliation for up to six authors for author information. Manuscripts are received with the explicit understanding that they have not been previously published and are not under consideration by any other publication. Manuscripts are subject to editorial revisions as deemed necessary by the editors and authors are to make such modifications to bring them into conformity with Journal style.

The authors clearly bear the full responsibility for all statements made and the veracity of the work reported therein.

REVIEWING PROCESS: Each manuscript is received by the managing editor, and reviewed by the Editor and/or Associate Editor and/or other members of the MSMA Committee on Publications and its review board. The acceptability of a manuscript is determined by such factors as the quality of the manuscript, perceived interest to Journal readers, and usefulness or importance to physicians. Authors are notified upon the acceptance or rejection of their manuscript. Accepted

manuscripts become the property of the Journal and may not be published elsewhere, in part or in whole, without permission from the Journal MSMA. TITLE PAGE should carry [1] the title of the manuscript, which should be concise but informative; [2] full name of each author, with highest academic degree(s), listed in descending order of magnitude of contribution (only the names of those who have contributed materially to the preparation of the manuscript should be included); [3] a one- to two-sentence biographical description for each author which should include specialty, practice location, academic appointments, primary hospital affiliation, or other credits; [4] name and address of author to whom requests for reprints should be addressed, or a statement that reprints will not be available.

ABSTRACT, if included, should be on the second page and consist of no more than 150 words. It is designed to acquaint the potential reader with the essence of the text and should be factual and informative rather than descriptive. The abstract should be intelligible when divorced from the article, devoid of undefined abbreviations. The abstract should contain: [1] a brief statement of the manuscript’s purpose; [2] the approach used; [3] the material studied; [4] the results obtained. Emphasize new and important aspects of the study or observations. The abstract may be graphically boxed and printed as part of the published manuscript.

KEY WORDS should follow the abstract and be identified as such. Provide three to five key words or short phrases that will assist indexers in cross indexing your article. Use terms from the Medical Subject Heading list from Index Medicus when possible.

Available at: http://www.nlm.nih.gov/mesh/authors. html.

SUBHEADS are strongly encouraged. They should provide guidance for the reader and serve to break the typographic monotony of the text. The format is flexible but subheads ordinarily include: Methods and Materials, Case Reports, Symptoms, Examination, Treatment and Technique, Results, Discussion, and Summary.

REFERENCES must be double spaced on a separate sheet of paper and limited to no more than 30. They will be critically examined at the time of review and must be kept to a minimum.

You may find it helpful to use the PubMed Single Citation Matcher available online at: http://www.ncbi.nlm.nih. gov/ entrez/query/static/citmatch.html to find PubMed citations. All references must be cited in the text and the list should be arranged in order of citation, not alphabetically. Reference numbers should appear in superscript at the end of a sentence outside the period unless the text cited is in the middle of the sentence in which case the numeral should appear in superscript at the right end of the word or the phrase being cited. No parenthesis or brackets should surround the reference numbers.

Personal communications and unpublished data should not be included in references, but should be incorporated in the text.

MARCH • JOURNAL MSMA

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References must conform to proper style to be eligible for review.

Contact managing editor Karen Evers for an easy-to-follow guide with examples of how to use JMSMA/ JAMA reference citation format. The following form should be followed: Journals: [1] Author(s). Use the surname followed by initial without punctuation. The names of all authors should be given unless there are more than three, in which case the names of the first three authors are used, followed by “et al.” [2] Title of article. Capitalize only the first letter of the first word. [3] Name of Journal. Abbreviate and italicize, according to the listing in the current Index Medicus available online at http://www.nlm.nih.gov/bsd/aim.html.

[4] Year of publication; [5] Volume number: Do not include issue number or month except in the case of a supplement or when pagination is not consecutive throughout the volume. [6] Inclusive page numbers. Do not omit digits. Do not include spaces between digits of the year, volume and page numbers.

Example: Bora LI, Dannem FJ, Stanford W, et al. A guideline for blood use during surgery. Am J Clin Pathol. 1979;71:680-692.

Books: [1] Author(s). Use the surname followed by initials without punctuation. The names of all authors should be given unless there are more than three, in which case the names of the first three authors are used followed by “et al.”

[2] Title. Italicize title and capitalize the first and last word and each word that is not an article, preposition, or conjunction, of less than four letters. [3] Edition number, [4] Editor’s name. [5] Place of publication, [6] Publisher, [7] Year, [8] Inclusive page numbers. Do not omit digits.

Example: DeGole EL, Spann E, Hurst RA Jr, et al.

Bedside Examination, in Cardiovascular Medicine, ed 2, Smith JT (ed). New York, NY: McGraw Hill Co; 1986:23-27.

FIGURES require high resolution (at least 300 dpi) individual digital scans to be provided. Legends should be typed, double-spaced on a separate sheet of paper.

Photographic material should be high-contrast glossy prints.

Patients must be unrecognizable in photographs unless specific written consent has been obtained, in which case a copy of the authorization should accompany the manuscript. All illustrations should be cited in the body of the text. Omit illustrations which do not increase understanding of text.

Illustrations must be limited to a reasonable number. (Four illustrations should be adequate for a manuscript of 4 to 5 typed pages). The following information should be typed on a label and affixed to the back of each illustration: figure number, title of manuscript, name of corresponding author, and arrow indicating top.

TABLES should be self-explanatory and should supplement, not duplicate, the text. The brief descriptive title, usually written as a phrase rather than a sentence, appears above to distinguish the table from other data displays in the article. Data should be aligned horizontally not to exceed 6.5".

Tables should be numbered and supplied on individual pages separate from manuscript body text. Tables should be cited in the manuscript text. If no more than one, use (Table.)

136 VOL. 60 • NO. 3 • 2019

with placement indicated within. See Section 4 of the "AMA Manual of Style" for specific Figure and Table components and proper presentation of data.

ACKNOWLEDGMENTS are the author’s prerogative; however, acknowledgment of technicians and other remunerated personnel for carrying out routine operations or of resident physicians who merely care for patients as part of their hospital duties is discouraged. More acceptable acknowledgements include those of intellectual or professional participation. The recognition of assistance should be stated as simply as possible, without effusiveness or superlatives.

SUBMISSIONS TO JMSMA SCIENTIFIC SERIES Top 10 Facts You Need to Know Series The purpose of this series of articles is to provide referenced information on clinical management of medical conditions in a concise fashion. The submissions should be directed toward practitioners who do not have specialty training on the specific topic as a matter of general information. The author of the best submission for each year will receive a prize.

Guidelines: 1) Articles should consist of 10 numbered paragraphs. Each of the paragraphs will begin with a fact that physicians need to know and a brief explanation of why. Facts will be referenced for each of the 10 points. 2) Suggested organization of manuscript is Introduction, Point 1, Point 2, etc., Conclusion, and References. 3) Articles will be about 3 pages (about 700 words) in length written at a level that can be easily understood by a practicing physician of any specialty. 4) A reference supporting the fact offered should be provided for each of the 10 points. Citations should not be review articles. 5) If there are specialty society guidelines in the area being discussed, the essential features of the recommendations should be included in the official guidelines cited in the references (≤12).

UpToDate Series The purpose of this series of articles is to provide brief reviews on topics of general interest to the practicing physicians of Mississippi in areas where recent developments in diagnosis or treatment have occurred. Guidelines: 1) Articles should be practical and useful to physicians in office or hospital practice. 2) Suggested organization of manuscripts is Introduction, Diagnosis, Recent developments, Conclusion, and References. 3) Articles will be about 6 pages (1500 words) or so in length written at a level that can be easily understood by a practicing physician of any specialty. 4) Only include those references useful to physicians who desire further information in the area. Five to eight references that will be useful to those who desire further information should be included. 5) Figures are great as are “call-outs,” i.e., boxes with key points to remember emphasizing the “take home” messages. 6) If there are specialty society guidelines on the topic, the essential features of the recommendations should be summarized in the text and the official guidelines should be cited in the references.

GALLEY PROOF - The principal author will receive a PDF via email to review. It is the author's responsibility to proof and approve it. Corrections should be clearly marked and returned promptly. If you desire reprints, inquire about prices to order. ❒

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