May
Steven L. Demetropoulos, MD
VOL. LIII
2012
2012-2013 MSMA President
No. 5
Ellen, Cancer Patient
Ellen, Cancer Survivor
My L i f e i s P r o o f. A diagnosis of cancer changes everything for your patient. But today, there are more cancer survivors than ever before. At University Cancer Care, our first priority is comprehensive and compassionate care. Your patient will benefit from the collaboration of our multidisciplinary teams through specialized treatment plans. University Cancer Care has access to advanced research, technology and clinical trials that impact patient outcomes. And during the care of your patient, we communicate with you so when your patient returns to your practice, the continuum of care is seamless. To learn more about University Cancer Care, visit umhc.com/cancer or to talk doctor-to-doctor, call 866.UMC.DOCS. Dramatized to protect patient privacy
Lucius M. Lampton, MD Editor D. Stanley Hartness, MD Richard D. deShazo, MD AssociAtE Editors Karen A. Evers MAnAging Editor PublicAtions coMMittEE Dwalia S. South, MD chair Philip T. Merideth, MD, JD Martin M. Pomphrey, MD Leslie E. England, MD, Ex-Officio Myron W. Lockey, MD, Ex-Officio and the editors
MAY 2012
VOLUME 53
NUMBER 5
SCientifiC ArtiCleS Prevalence and Trends in Overweight and Obesity among Mississippi Public School Students, 2005-2011
140
Jerome R. Kolbo, PhD; Lei Zhang, PhD, MBA; Elaine Fontenot Molaison, PhD, RD; Bonnie L. Harbaugh, PhD, RN; Geoffrey M. Hudson, PhD, CSCS; Mary G. Armstrong, MD; and Nichole Werle, MSW
Top 10 Facts You Should Know about Depression
147
Shambhavi Chandraiah, MD, FRCPC thE AssociAtion Thomas E. Joiner, MD president Steven L. Demetropoulos, MD president-elect J. Clay Hays, Jr., MD secretary-treasurer Lee Giffin, MD speaker Geri Lee Weiland, MD vice speaker Charmain Kanosky executive director Journal of the Mississippi state Medical association (issn 0026-6396) is owned and published monthly by the Mississippi State Medical Association, founded 1856, located at 408 West Parkway Place, Ridgeland, Mississippi 39158-2548. (ISSN# 0026-6396 as mandated by section E211.10, Domestic Mail Manual). Periodicals postage paid at Jackson, MS and at additional mailing offices. correspondence: Journal MSMA, Managing editor, Karen a. evers, p.o. Box 2548, ridgeland, Ms 39158-2548, ph.: (601) 853-6733, fax: (601)853-6746, www.MsMaonline.com. suBscription rate: $83.00 per annum; $96.00 per annum for foreign subscriptions; $7.00 per copy, $10.00 per foreign copy, as available. advertising rates: furnished on request. cristen hemmins, hemmins hall, inc. advertising, p.o. Box 1112, oxford, Mississippi 38655, ph: (662) 236-1700, fax: (662) 236-7011, email: cristenh@watervalley.net postMaster: send address changes to Journal of the Mississippi State Medical Association, P.O. Box 2548, Ridgeland, MS 39158-2548. The views expressed in this publication reflect the opinions of the authors and do not necessarily state the opinions or policies of the Mississippi State Medical Association. copyright© 2012 Mississippi state Medical association.
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official publication of the MsMa since 1959
Just Off the Press- Info You Want to Know: Bacterial Rhinosinusitis Guidelines
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Jasmine Mckee, PharmD and Richard L. Ogletree, Jr, PharmD
PreSident’S PAge Last Random Thoughts
151
Thomas E. Joiner, MD; MSMA President
SPeCiAl ArtiCle An Interview with Steven L. Demetropoulos, MD 2012-2013 MSMA President
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Karen A. Evers, Managing Editor
relAted orgAnizAtionS Mississippi State Department of Health
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dePArtmentS Letters Una Voce Placement / Classified
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ASClePiAd Kelly Scott Segars, MD
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About the Cover:
Presidential Portrait—Pascagoula native Steven L. Demetropoulos, MD will be installed 2012-13 MSMA President during our MSMA’s 144th Annual Session, June 7-10, at the Grand Marriott Resort & Spa in Point Clear, Alabama. Dr. Demetropoulos is in the private practice of emergency medicine affiliated with Singing River Health System. He is president and group administrator of Emergency Room Group, LTD. Boardcertified by the American College of Emergency Physicians, he is a past president of the Singing River Medical Society. Dr. Demetropoulos has served MSMA as chairman of the Board of Trustees 2008-2010 and president-elect 2011-2012. He has served on the Council on Legislation (6 years); Council on Public Information (6 years); MMPAC Board member (five 2-year terms). He has served on the Medical Assurance Company of Mississippi Board of Trustees since 2002. An interview with Dr. Demetropoulos follows in this issue of the JMSMA. r May
Steven L. Demetropoulos, MD
VOL. LIII
2012
2012-2013 MSMA President
No. 5
May 2012 JOURNAL MSMA 137
From the Editor
T
he March announcement that the Encyclopedia Britannica, the world’s foremost scholarly encyclopedia, published since 1768, would no longer continue its printed editions, instead focusing on its online version, provided a sure harbinger of the death of the printed word. Not only printed books, but print journalism is struggling in our new digital age. Even more telling and local, one of the oldest daily newspapers in the country, New Orleans’s esteemed Pulitzer Prize winning newspaper The Times Picayune, recently announced plans to cease daily printing after more than 175 years as a daily, going this fall to print paper copies only three days a week. While many, including entrepreneur Warren Buffett, condemn the Picayune action as imprudent and ill-conceived, there is no doubt changes are coming to journalism; its digital transformation will continue to evolve over the next decade. This digital transformation is impacting us here at the Journal. We have been published as a monthly largely since 1891, when Drs. N. L. Clarke and Hugh H. Haralson began The Mississippi Medical Monthly at Meridian. In 1897, the journal moved to Biloxi, and within a year was renamed the Journal of the Mississippi State Medical Association. Our journal has been published monthly without a missed issue since 1929, first as The Mississippi Doctor, and since 1960 as our JMSMA. Our MSMA Board of Trustees has asked the Journal leadership to contemplate a transformation of our Journal in this digital age by developing a five-year strategic plan. Your editors and the Committee
on Publications are seeking our readers’ input on what kind of journal our members need and desire. What type articles do you find most helpful and would like to see included? Do you like our printed layout? How would you improve it? What kind of digital publication does the Journal need to be? Our current version is attractive, but not interactive. The editors feel strongly that our printed journal needs to Lucius M. Lampton, MD continue monthly, but that many of our readers might prefer instead an interactive digital version (and some may prefer both!). Let’s begin this discussion: send your suggestions on your “dream” journal to lukelampton@cableone.net or slow mail to me at JMSMA, P.O. Box 2548, Ridgeland, MS 39158-2548. This month, your Journal contains much which should interest you. Our lead article on obesity, which remains one of Mississippi’s most critical public health issues, studies the prevalence and trends of overweight and obesity among state public school students. The good news is that obesity’s prevalence in our public schools no longer appears to be increasing. However, the numbers remain staggeringly high, and there appears to be emerging a growing racial (and perhaps gender) disparity. The study suggests that many of our efforts are working, but this ongoing tragedy needs our continued focus. —Lucius M. “Luke” Lampton, MD, Editor
Journal editorial advisory Board R. Scott Anderson, MD, FACR Chair, Journal Editorial Advisory Board Radiation Oncologist and Medical Director, Anderson Regional Cancer Center, Meridian Diane K. Beebe, MD Professor and Chair, Department of Family Medicine, University of MS Medical Center, Jackson Claude D. Brunson, MD Senior Advisor to the Vice Chancellor for External Affairs, University of Mississippi Medical Center, Jackson Jeffrey D. Carron, MD, FAAP, FACS Associate Professor, Department of Otolaryngology & Communicative Sciences, University of Mississippi Medical Center, Jackson Gordon (Mike) Castleberry, MD Urologist, Starkville Urology Clinic Mary Currier, MD, MPH State Health Officer Mississippi State Department of Health, Jackson Thomas E. Dobbs, MD, MPH Health Officer, District VII/VIII Mississippi State Department of Health, Hattiesburg Sharon Douglas, MD Chair, AMA Council on Ethical & Judicial Affairs Professor of Medicine and Associate Dean for V A Education, University of Mississippi School of Medicine, Associate Chief of Staff for Education and Ethics, G.V. Montgomery VA Medical Center, Jackson Daniel P. Edney, MD Executive Committee Member, National Disaster Life Support Education Consortium, Internist The Street Clinic, Vicksburg
138 JOURNAL MSMA
May 2012
Owen B. Evans, MD Professor of Pediatrics and Neurology University of Mississippi Medical Center, Jackson Maxie L. Gordon, MD Assistant Professor, Department of Psychiatry and Human Behavior, Director of the Adult Inpatient Psychiatry Unit and Medical Student Education, University of Mississippi Medical Center, Jackson Scott Hambleton, MD Medical Director Mississippi Professionals Health Program, Ridgeland John Edward Hill, MD, FAAFP Residency Program Director North Mississippi Medical Center, Tupelo John D. Isaacs, Jr., MD Infertility Specialist, Mississippi Fertility Institute at Women’s Specialty Center, Jackson Kent A Kirchner, MD Chief of Staff G.V. Montgomery VA Medical Center, Jackson Brett C. Lampton, MD Internist/Hospitalist Baptist Memorial Hospital, Oxford Philip L. Levin, MD President, Gulf Coast Writers Association Emergency Medicine Physician, Gulfport
Gailen D. Marshall, Jr., MD, PhD, FACP Professor of Medicine and Pediatrics, Vice Chair for Research, Director, Division of Clinical Immunology and Allergy, Chief, Laboratory of Behavioral Immunology Research The University of Mississippi Medical Center, Jackson Alan R. Moore, MD Clinical Neurophysiologist Muscle and Nerve, Jackson Paul “Hal” Moore Jr., MD, FACR Radiologist Singing River Radiology Group, Pascagoula Jason G. Murphy, MD Surgeon Surgical Clinic Associates, Jackson Ann Myers, MD Rheumatologist Mississippi Arthritis Clinic, Jackson Jimmy L. Stewart, Jr., MD Program Director, Combined Internal Medicine/ Pediatrics Residency Program, Associate Professor of Medicine and Pediatrics University of Mississippi Medical Center, Jackson Samuel Calvin Thigpen, MD Hematology-Oncology Fellow, Department of Medicine University of Mississippi Medical Center, Jackson Thad F. Waites, MD, FACC Clinical Cardiologist, Hattiesburg Clinic
William Lineaweaver, MD, FACS Editor, Annals of Plastic Surgery Medical Director JMS Burn and Reconstruction Center, Brandon
Chris E. Wiggins, MD Orthopaedic Surgeon Bienville Orthopaedic Specialists, Pascagoula
John F. Lucas,III, MD Surgeon Greenwood Leflore Hospital
John E. Wilkaitis, MD, MBA, CPE, MS Chief Medical Officer Brentwood Behavioral Healthcare, Flowood
Medical Assurance Company of Mississippi An outside perspective and appreciation of MACM
“
My position on the American Board of Family Medicine’s credentials committee gives me new insight and appreciation for the critical role that MACM plays in the lives of our state physicians. MACM’s involvement with its insureds — from risk management to liability and scope of practice issues — has their best interest, and that of the public they serve, at heart. Particularly at the level of the Risk Management Committee, many of these issues are handled constructively and effectively to improve and ensure quality care for patients, while guiding physicians from potential hazards. In many states, without the commitment of an organization like MACM, physicians and patients are far less protected and similar issues result in adverse actions that often result in licensure and practice restrictions.
“
All insureds of MACM should be grateful for the role MACM and their experts in Risk Management play in keeping us (physicians and patients) safe.
Diane Beebe, MD Family Medicine Jackson, Mississippi
For over 30 years, Mississippi physicians have looked to Medical Assurance Company of Mississippi for their professional liability needs. Today, MACM is an integral part of the health care community through its dedication to risk management services for our insureds. A dedicated staff and physician involvement at every level guarantees that the interests of our policyholders remain the top priority. This, combined with the many years of loyalty and support from our insureds, is what allows us to be the carrier of choice in Mississippi. Please call on us to assist with your professional liability needs.
1.800.325.4172 • www.macm.net
In Partnership with Insureds May 2012 JOURNAL MSMA 139
• Scientific articleS • Prevalence and Trends in Overweight and Obesity among Mississippi Public School Students, 2005-2011 Jerome R. Kolbo, PhD; Lei Zhang, PhD, MBA; Elaine Fontenot Molaison, PhD, RD; Bonnie L. Harbaugh, PhD, RN; Geoffrey M. Hudson, PhD, CSCS; Mary G. Armstrong, MD; and Nichole Werle, MSW
A
bStrACt
This study estimated the prevalence of overweight and obesity in Mississippi public school students in grades K - 12 and assessed changes in the prevalence between 2005 and 2011. In 2011, Body Mass Index was calculated using measured height and weight data for a weighted representative sample of 4,235 public school students. Additional analyses compared 2011 prevalence estimates by gender, race, and grade levels and for changes between 2005 and 2011. The prevalence of overweight and obesity among public school students no longer appears to be increasing although a significant downward trend was not observed (p = 0.0845), and rates remain higher than national averages. In 2011, the combined prevalence of overweight and obesity for all students in grades K - 12 was 40.9% as compared to 42.4% in 2009, 42.1% in 2007 and 43.9% in 2005. Significant decreases in overweight and obesity were found among white students and elementary school student groups from 2005 to 2011. White students’ combined rates fell from 40.6% in 2005 to 34.8% in 2011 (p = 0.0006). Similarly, combined rates in elementary school students dropped from 43.0% in 2005 to 37.3% in 2011 (p = 0.0045). In 2011, the prevalence of overweight and obesity was significantly lowauthor inforMation: Professor in the School of Social Work at the University of Southern Mississippi (Dr. Kolbo); Director of the Office of Health Data and Research in the Mississippi State Department of Health and an Associate Professor in the School of Nursing at the University of Mississippi Medical Center (Dr. Zhang); Associate Professor in the Department of Nutrition & Food Systems at the University of Southern Mississippi (Dr. Molaison); Associate Professor in the School of Nursing at the University of Southern Mississippi (Dr. Harbaugh); Assistant Professor of Exercise Science in the School of Human Performance and Recreation at the University of Southern Mississippi (Dr. Hudson); Medical Consultant for the Office of Licensure for the Mississippi State Department of Health (Dr. Armstrong); Research Support staff member at the University of Southern Mississippi (Ms. Werle). correSponding author: Jerome R. Kolbo, PhD, The University of Southern Mississippi, School of Social Work, 118 College Drive #5114, Hattiesburg, MS 39406, (Jerome.Kolbo@usm.edu), ph: (601)266-5913(v), fax: (601)266-4167.
140 JOURNAL MSMA
May 2012
er among white students than black students (p < 0.001) and significantly lower among white female students than black female students at all three grade levels. These findings are discussed in light of recent statewide educational initiatives and health disparities. Implications for future practice, policy, and research are presented.
Key WordS: introduCtion
childhood, overweight, obeSity
Recent data indicate that the prevalence of overweight and obesity in Mississippi children and youth has remained level since 2005.1-6 According to the Child and Youth Prevalence of Obesity Surveys (CAYPOS),1-4 a primary source of obesity data in Mississippi, 25.5% of Mississippi students in grades K - 12 were obese and 18.4% were overweight (43.9% combined rate) in 2005.2 In 2007, 23.5% were obese and 18.6% were overweight (42.1% combined).3 In the 2009 CAYPOS, 23.9% were obese and 18.5% were overweight (42.4% combined).4 Analysis revealed no significant differences in the prevalence rates between the 2005, 2007 and 2009 CAYPOS. Similar to the CAYPOS data, the Mississippi Youth Risk Behavior Survey (YRBS) revealed that self-reported prevalence of obesity in public high school students between 2007 (17.9%) and 2011 (15.8%) had plateaued. Likewise, the differences were not statistically significant.5-6 In addition, the national Youth Risk Behavior Survey (YRBS) reported no significant changes in the percentage of obesity among US students in grades 9-12 who attended public and private schools between 2005 and 2011.7-8 The most recent National Health and Nutrition Examination Survey (NHANES) also showed no significant changes in the percentage of obesity among US children aged 2 to 19 years between 2003 - 2004 and 2005 - 2006, nor between 1999 - 2010.9 The stabilization of obesity and overweight prevalence in Mississippi may be associated with recent statewide efforts aimed at improving student health. Between 2006 and 2008, the Mississippi Department of Education, in conjunction with the Mississippi State Department of Health, began implement-
ing a range of state-wide educational initiatives, including mandates for establishing school wellness policies, new beverage regulations, and more stringent nutrition, physical activity, and physical education standards.4, 10-18 While it is welcome news that the prevalence of overweight and obesity among children is no longer increasing, high prevalence rates remain a great concern. It is well documented that overweight and obesity in childhood are associated with a number of serious health conditions continuing into adulthood, including cardiovascular disease, diabetes, musculoskeletal disorders, psychological problems, and risky health behaviors.19-31 As such, the purpose of this study was to continue monitoring the prevalence of overweight and obesity as implementation of health and wellness programs is expanding in the stateâ&#x20AC;&#x2122;s public schools.17-18 Another concern noted in the 2009 CAYPOS was the increasing disparity between races. In 2005, differences in the prevalence of obesity and overweight between black and white students were not significant. However, the prevalence of obesity was significantly higher among black students than white students in 2007 (25.7% vs. 21.0%) and again in 2009 (27.4% vs.19.5%). When examined by grade level in 2009, only at the elementary level were the differences significant between the black and white students. And, when compared by gender, the prevalence of obesity was significantly higher in 2009 among black females than among white females. As such, the current study intended to assess any differences in the prevalence by gender, race, and grade level as well as changes in the prevalence by gender, race, and grade levels between 2005 and 2011.
methodS
Similar to the 2005, 2007, and 2009 CAYPOS, in the 2011 CAYPOS, the sampling frame consisted of 467,941 students in 892 public schools offering kindergarten or any combination of grades 1 through 12 in Mississippi. The sample design was a two-stage stratified probability design.1-4 The first stage included the random selection of 95 schools. A systematic sample of schools was drawn with probability proportional to the enrollment in grades K - 12 of each school. In the second stage of sampling, classes were randomly selected within the sampled schools. Classes were selected using equal probability systematic sampling. All eligible students in the selected classes were asked to participate in the survey. The sample was designed to yield a self-weighting sample so that every eligible student had an equal chance of selection, thereby improving the precision of the estimates. As in each of the previous years, the weighting process was intended to develop sample weights so that the weighted sample estimates accurately represented the entire K -12 public school students in Mississippi. Every eligible student was assigned a base weight which was equal to the inverse of the probability of selection for the student. Adjustments were made to the initial weights to remove bias from the estimates and reduce the variability of the estimates.
The most recent CAYPOS (2011) was conducted in April 2011. The study received continued institutional review board approval through the Human Subjects Committee at The University of Southern Mississippi, as the study protocol matched the four prior CAYPOS.1-4 As with all of the previous CAYPOS, once selected schools agreed to participate and classes were chosen, measuring the equipment (i.e., digital scales and stadiometers) and passive consent forms were delivered to the schools. Each school designated a school nurse who was responsible for collecting data and had been trained on the use of equipment. Two or three days before data collection began, students in the selected classes were read a prepared paragraph containing information about the study. Each student was then given a passive parental consent form to take home to parents or guardians. If a parent did not want his or her child to participate in the study, the parent was instructed to indicate such on the form, sign it, and have the child return it to the teacher. Prior to the collection of height and weight, the nurse would check with the teacher to determine if any students returned a signed form. Students who returned a signed form did not participate in the study. There were neither consequences for nonparticipation nor rewards for participation. As with all the previous CAYPOS, the protocol for making measurements required that the weight scale be placed on a hard, smooth surface; carpeted areas were not to be used. The scale was calibrated to zero before use and recalibrated after every 10th student. All students were weighed and measured in a location where the information gathered would be confidential. Other students were not able to read the scale or height measurement or hear a weight or height given. Nurses reported the height and weight, rounded to the nearest whole inch or pound, respectively, along with age, gender, date of birth, racial or ethnic background, and the school code number. No allowance was made for weight of clothing; however, students were asked to remove belts, heavy jewelry, jackets, and shoes. No student names were written on the data collection forms. As in the previous CAYPOS, nurses were sent an email with a link to a secure website developed and maintained by Qualtrics, Inc.32 to record and submit their data. These data were compiled in aggregate form by the Qualtrics software and made available in excel format to the study authors for analysis.
dAtA AnAlySiS
Body Mass Index (BMI) was computed for each responding student based on height (in meters) and weight (in kilograms). The height in feet and inches was first converted to meters. The weight in pounds was then converted to kilograms. BMI was calculated using the SAS program, gc-calculate-BIV. sas as follows: BMI = Weight (in kg)/[Height (in m)].2 BMI values were checked to ensure that the results were biologically plausible, using the limits developed by the Centers for Disease Control and Prevention (CDC). BMI percentiles were computed using the SAS program, gc-calculate-BIV.sas. Children and adolescents were classified into four categories: (1)
May 2012 JOURNAL MSMA 141
underweight (BMI is less than the 5th percentile); (2) normal weight (BMI is equal to or greater than the 5th but less than the 85th percentile); (3) overweight (BMI is greater than the 85th but less than the 95th percentile); and (4) obese (BMI is greater than or equal to the 95th percentile).33 SUDAAN 10.034 was used to calculate weighted estimates and standard errors. Proc Crosstab procedure was used to compare prevalence of child overweight and obesity among different subgroups, such as gender, race, and grade level. The differences were assessed separately for each survey year and considered statistically significant if the p-values from the Chisquare tests were less than 0.05. For comparisons of subgroups with more than two levels (e.g., obesity by gender by race by grade, etc.), no statistical tests were conducted due to substantially decreased sample sizes and possibly unreliable estimations. The comparison of their 95% confidence intervals (CIs) was simply used for these situations - differences between estimates were considered statistically significant if their associated 95% CIs did not overlap. In addition, SUDAAN logistic regression procedure was used to investigate linearity of the longitudinal trends in overweight and obesity. Since elapsed time was the same between successive CAYPOS surveys, the logistic regression used orthogonal variables to model longitudinal trends while controlling for studentsâ&#x20AC;&#x2122; gender, race, and grade level. The linear coefficient (-3, -1, 1, 3) and quadratic coefficients (4, -4, -4, 4) were assigned over the years 2005, 2007, 2009, and 2011, respectively.
Table 1: Characteristic Characteristics ofCAYPOS 2011 CAYPOS Participants, Table 1. of 2011 Participants, Grades K-12 Grades K-12 Characteristic a Gender Male Female b Race White Black Other Grade Elementary K 1st 2nd 3rd 4th 5th Middle school 6th 7th 8th High school 9th 10th 11th 12th Total a
Unweighted count
Weighted percent
2,179 2,049
51.6 48.4
2,087 1,958 186
48.5 47.2 4.3
392 336 329 406 422 352
8.9 7.5 7.9 9.5 9.6 7.9
329 352 225
7.9 8.4 5.4
395 345 201 151 4,235
10.1 8.8 4.8 3.3 100
Seven students were missing on gender.
b
Four were missing on race.
Table 2: Prevalence of Overweight and Obesity by Grade Level and Race, 2011
reSultS Characteristics of Participants from the 2011 CAYPOS Eighty-four of the 95 schools sampled participated in the study (88.4%). The student response rate was 88.1% (4,235 usable records/4,804 eligible sampled students). Thus, the overall response rate was 77.9% (product of school response rate and student response rate), which was above the threshold of 60% required to obtain weighted estimates. The final sample consisted of 4,235 students in grades K - 12, including 2,179 males (51.6%), 2,049 females (48.4%), 2,087 white students (48.5%), 1,958 black students (47.2%), and 186 students from other racial/ethnic backgrounds (4.3%) (Table 1). The number of students in other race categories was too small for separate analysis and, therefore, was not included in the comparison analyses. Results of 2011 CAYPOS Based on Subgroups of Participants As a group, 23.7% of the children and youth in grades K - 12 were classified as obese and another 17.2% of the children were classified as overweight giving a combined total of 40.9% of the children and youth at or above the 85th percentile for BMI for age and gender (Table 2).
Table 2. Prevalence of Overweight and Obesity by Grade Level and Race, 2011 All (K-12) c (%, 95% CI )
Elementary (K-5) (%, 95% CI)
Middle School (6-8) (%, 95% CI)
High School (9-12) (%, 95% CI)
All a Overweight b Obesity
17.2 (16.0-18.4) 23.7 (22.0-25.4)
15.4 (13.9-17.0) 21.9 (19.7-24.3)
19.3 (16.9-22.0) 28.6 (24.6-33.0)
18.9 (16.5-21.4) 23.1 (20.8-25.6)
White Overweight Obesity
15.3 (13.6-17.1) 19.5 (17.6-21.5)
13.2 (11.1-15.6) 17.8 (15.0-20.9)
17.3 (13.8-21.6) 23.0 (17.6-29.4)
18.5 (14.9-22.7) 21.0 (18.1-24.2)
Black Overweight Obesity
19.3 (17.7-21.0) 27.8 (25.1-30.6)
18.4 (16.0-21.0) 26.8 (22.9-31.2)
20.0 (16.8-23.5) 32.4 (28.0-37.1)
20.1 (17.3-23.1) 25.0 (22.3-27.9)
Male Overweight Obesity
17.0 (15.6-18.6) 24.4 (21.8-27.1)
15.9 (13.7-18.4) 21.4 (18.8-24.3)
18.2 (14.5-22.5) 32.0 (26.9-37.7)
18.3 (16.0-20.9) 24.2 (19.6-29.4)
Female Overweight Obesity
17.4 (15.5-19.4) 23.0 (20.8-25.4)
14.9 (12.6-17.5) 22.5 (19.7-25.6)
20.5 (17.5-23.8) 25.3 (20.5-30.8)
19.5 (15.7-23.9) 21.9 (18.1-26.3)
White male Overweight Obesity
15.3 (13.1-17.8) 21.6 (18.7-24.9)
15.0 (12.4-17.9) 18.5 (15.8-21.5)
14.2 (11.2-17.8)* 29.5 (21.1-39.7)*
16.7 (12.6-21.8)* 23.9 (17.6-31.6)
Black male Overweight Obesity
18.8 (16.8-20.9) 26.2 (22.9-29.8)
16.9 (14.7-19.3) 24.1 (22.0-26.4)
19.9 (17.3-22.8) 32.8 (27.6-38.5)
20.7 (18.1-23.5) 23.8 (20.4-27.4)
White female Overweight Obesity
15.2 (12.9-17.9) 17.1 (14.8-19.8)
11.2 (9.2-13.6) 17.0 (13.8-20.9)
20.5 (18.7-22.4)* 16.5 (9.8-26.4)*
20.4 (16.0-25.7) 17.8 (14.6-21.5)*
Black female Overweight Obesity
19.8 (17.3-22.6) 29.4 (25.6-33.5)
19.9 (17.9-22.2) 29.7 (26.5-33.1)
20.0 (18.9-21.2) 32.0 (26.4-38.2)
19.3 (15.1-24.4)* 26.4 (22.4-30.8)
a
Body Mass Index (BMI) > 85th percentile and < 95th percentile for age and gender. Body mass index (BMI) > 95th percentile for age and gender. 95% confidence interval. * Sample size is less than 50. The estimates may not be reliable. b
Gender In 2011, 23.0% of females were classified as obese, with another 17.4% as overweight (40.4% combined). As for males,
142 JOURNAL MSMA
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c
21
Grade Level Among elementary level students (grades K - 5), 21.9% were classified as obese, with 15.4% classified as overweight (37.3% combined). Among the middle school students (grades 6 - 8), 28.6% were obese and 19.3% were overweight (47.9% combined). Among the high school students (grades 9 -12), 23.1% were obese and 18.9% were overweight (42.0% combined). Differences in the prevalence of obesity by grade level were statistically significant (p = 0.008). Gender and Race As for gender and race, among black females, 29.4% were obese and 19.8% were overweight (49.2% combined). Among white females, 17.1% were obese and 15.2% were overweight (32.3% combined). The prevalence of obesity for black females was significantly higher than white females. Among black males, 26.2% were obese and 18.8% were overweight (45.0% combined). Among white males, 21.6% were obese and 15.3% were overweight (36.9% combined). The prevalence of obesity for black males was significantly higher than white males.
22
24.4% were obese and another 17.0% were overweight (41.4% combined). Race
In terms of race, 19.5% of the white students were classified as obese, with another 15.3% as overweight (34.8% combined). Among the black students, 27.8% were obese and 19.3% were overweight (47.1% combined). The prevalence of obesity for black students was significantly higher than white students (p < 0.001).
23
Race and Grade Level Among both white and black students, the highest rates were at the middle school level. Among black students, 32.4% were obese and 20.0% were overweight (52.4% combined) at the middle school level, 26.8% were obese and 18.4% were overweight (45.2% combined) at the elementary level, and 25.0% were obese and 20.1% were overweight (45.1% combined) at the high school level (Figures 1-3). Among white students, 23.0% were obese and 17.3% were overweight (40.3% combined) at the middle school level, 21.0% were obese and 18.5% were overweight 39.5% combined) at the high school level, and 17.8% were obese and 13.2% were overweight (31.0% combined) at the elementary school level. At all three grade levels, the difference in the prevalence of obesity between white and black students was statistically significant. Gender, Race, and Grade Level When race and gender were combined at the elementary level, 17.0% of white females were obese and 11.2% were overweight (28.2% combined). Among black females, 29.7% were obese and 19.9% were overweight (49.6% combined). At the middle school level, 16.5% of white females were obese and 20.5% were overweight (37.0% combined). Among black females, 32.0% were obese and 20.0% were overweight (52% combined). At the high school level, 17.8% of white females were obese and 20.4% were overweight (38.2% combined). Among black females, 26.4% were obese and 19.3% were overweight (45.7% combined). At all three school levels, the differences in rates of obesity between white and black females were statistically significant. At all three school levels, the dif-
May 2012 JOURNAL MSMA 143
ferences between black males and white males were not significant.
Figure 4. Prevalence of Overweight, Obesity, and Combined, Mississippi, K‐12, 2005‐2011
Overweight and Obesity Linear Trend While the prevalence of overweight and obesity among students in grades K - 12 has dropped from 43.9% in 2005 to 40.9% in 2011, the linear trend was not statistically significant (p = 0.0845) (Figure 4). However, the combined prevalence of overweight and obesity for white students (40.6% in 2005 and 34.8% in 2011) has shown a significant linear decrease (p = 0.0006) (Figure 5). In addition, a significant linear drop was observed in the prevalence of overweight and obesity among the elementary grade level students between 2005 (43.0%) and 2011 (37.3%) (p = 0.0045) (Figure 6).
50
43.9
45
42.1
42.4
40.9
40
Percent
35 30
25.5
25 18.4
20
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23.9
18.6
18.5
23.7 17.2
15 10 5 0 2005
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2011
Year Overweight
Obesity
Combined
144 JOURNAL MSMA
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50
45
40
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30 Percent
While Mississippi still has very high rates, the prevalence of overweight and obesity among public school students no longer appears to be increasing. This is encouraging news for the state, particularly in light of state-wide legislated school changes, publicized calls for healthy changes by influential Mississippians, grass root citizen efforts, and organizational directives aimed at child obesity reduction and prevention.35-36 In 2011, the combined prevalence of overweight and obesity for all students in grades K - 12 was at the lowest CAYPOS rate since 2005, and significant declines were found among white students and elementary school students. Since 2005, the combined prevalence of overweight and obesity has dropped significantly for white students from 40.6% to 34.8%, and has dropped significantly from 43.0% to 37.3% among elementary school students. In Mississippi, many health and wellness policy efforts have been directed towards all students at all grade levels in the public school setting.10-16 The finding that the prevalence of overweight and obesity were significantly lower at the elementary grade level is very promising and may suggest that recent state-wide educational efforts implemented in the elementary schools are making progress. However, it is important to ask whether fewer overweight or obese children are entering the public school system or whether the declines in overweight and obesity are occurring during the elementary school years. The current CAYPOS is limited to grades K- 12 and therefore cannot necessarily provide the answers to whether students are more or less obese during the preschool years. Unfortunately, there is not sufficient data related to non-low income and white preschoolers in Mississippi to answer this question adequately. However, for low-income and African-American students, the latter explanation seems plausible, since comparable CAYPOS (2005 and 2010) studies of low-income African American Head Start preschoolers in Mississippi during this period indicate that combined rates between 2005 (38.5%) and 2010 (37.8%) have not changed significantly.37
Figure 5. Prevalence of Overweight and Obesity Combined by Race, K‐12, Mississippi, 2005‐2011
46.4 40.6
47.1
46.8
44.4 39.3
37.4
34.8
25
White
20
Black
15
10 5 0 2005
2007
2009
2011
Year
Figure 6. Prevalence of Overweight and Obesity Combined by Grade Level, Mississippi, 2005‐2011
50
45
40
35
Percent
diSCuSSion
30 25 20 15 10 5 0 2005
2007
2009
2011
Year Elementary
Middle
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Another important question is why the prevalence dropped significantly for white students of all educational levels (40.6% to 34.8%), and in particular for white elementary students (39.9% to 31.0%) over the past six years. This contrasts with the prevalence of overweight and obesity for all levels of black students, which remained relatively stable (46.4% to 47.1%), including black elementary students (46.3% to 45.2%),
over the same time period. Of related concern is the finding that in 2011 the prevalence of obesity was again (as in 2009) significantly lower among white students than the black students at all grade levels while back in 2005 and 2007, the difference by race was only significant at the elementary grade level. This finding may suggest a growing racial health disparity over time. Further, when assessing both gender and race in 2011, the prevalence of obesity was significantly lower among white females than black females at all three grade levels. Previously (2009), significant differences were found between white and black female students only at the elementary grade level. This finding suggests that the increasing disparity over time by race may be tied to gender as well. Racial differences in the prevalence of overweight and obesity, particularly the disproportionately higher rates among black, Hispanic and Native American children, are well documented.9, 22-23 However, given the lack of studies finding declines in obesity rates to date, research is lacking to fully explain the apparent declines among white but not black students. One possible explanation for the racial disparities in these findings may come through a line of recent research on racial/ethnic differences and early life risk factors.38 Unlike their white counterparts, black and Hispanic preschool-aged children have been found to exhibit a higher number and range of risk factors associated with obesity (i.e., higher rates of maternal depression, more rapid weight gain in infancy, introduced to solid foods earlier, higher rates of restrictive feeding practices, more likely to have a television in their bedrooms, higher intake of fast foods, lower rates of exclusive breastfeeding, and less likely to sleep at least 12 hours/day in infancy). As such, racial/ethnic health disparities may have their origins in the earliest stages of life, long before entering the public school system. Others suggest that children with a number of these risk factors are not only more likely to develop weight problems, but a number of other adverse health conditions.39 Consequently, these complications are likely to then adversely affect the child’s adherence or motivation to adopt healthier behaviors. As such, those experiencing more risks may not be able to fully participate and/or benefit from the policies, programs and activities being implemented in the public school system. This epidemiological study of the prevalence and trends of childhood obesity in Mississippi provides essential data for informing the public as well as planning and adjusting efforts to reduce this important health risk. While overall statistics indicate that obesity and overweight rates in Mississippi school children are high, they do not appear to be worsening. The growing disparities by race, gender and educational levels do warrant further investigation. On the one hand, significant declines among elementary grade level students and among white students indicate a need to explore the factors most directly associated with the positive changes. On the other hand, further study is also needed on factors associated with the lack of change among higher grade levels and black students. For
example, are the programs currently being implemented in schools being presented to or received differently by different racial groups or grade levels? Also, are there factors outside of the school setting, both during the pre-school and school-age years, that impact the effect of the programs designed to address overweight and obesity? Given that the prevalence of overweight and obesity remains high among public school students in Mississippi (seemingly unchanged among some) and the implementation of existing educational initiatives continues to expand across the state, investigation and monitoring of the prevalence needs to continue.
ACKnoWledgementS
Funding for this study was through a grant from the Bower Foundation through the Center for Mississippi Health Policy. The authors wish to thank Westat, Inc. for their assistance in the sampling and weighting of the data and to thank the Mississippi schools and school nurses and personnel who were so instrumental in collecting the data.
referenCeS 1.
Molaison EF, Kolbo JR, Speed N, Dickerson E, Zhang, L. Prevalence of overweight among children and youth in Mississippi: A comparison between 2003 and 2005. Website. http://www. mshealthpolicy.com. Accessed December 1, 2011. 2. Kolbo JR, Penman AD, Meyer MK, Speed NM, Molaison EF, Zhang L. Prevalence of overweight among elementary and middle school students in Mississippi compared with prevalence data from the Youth Risk Behavior Surveillance System. Prev Chronic Dis. 2006;3:A84. 3. Kolbo JR, Armstrong MG, Blom L, Bounds W, Molaison E, Dickerson H, Harbaugh B, Zhang L. Prevalence of obesity and overweight among children and youth in Mississippi: Current trends in weight status. JMSMA. 2008;49(8):231-237. 4. Molaison EF, Kolbo JR, Zhang L, Harbaugh B, Armstrong MG, Rushing K, Blom LC, Green A. Prevalence and Trends in Obesity among Mississippi Public School Students, 2005-2009. JMSMS. 2010:1-6. 5. 2009 Mississippi Youth Risk Behavior Survey Surveillance Report. Office of Health Data and Research. Mississippi State Department of Health. Website. http://msdh.ms.gov/msdhsite/static/ resources/4703.pdf. Accessed April 18, 2012. 6. 2011 Mississippi YRBS Fact Sheet (unpublished). 7. Morbidity and Mortality Weekly Report. Youth Risk Behavior Surveillance - United States, 2007. Centers for Disease Control and Prevention Website. www.cdc.gov/mmwr. Accessed December 1, 2009. 8. Youth Risk Behavior Surveillance - United States, 2009. CDC Morbidity and Mortality Weekly Report. June 4, 2010 / Vol. 59 / No.SS-5. 9. Ogden C, Carrol M, Kit B, Flegal K. (2012). Prevalence of Obesity and Trends in Body Mass Index among US Children and Adolescents 1999-2010. 2102. Website. http://www.jama.ama-assn. org. Assessed on January 18, 2012. 10. SB 2369, amending Mississippi Code of 1972 Annotated Section 37-13-134. Website. http://billstatus.ls.state.ms.us/documents/2007/html/SB/2300-2399/SB2369SG.htm. Accessed December 1, 2011. 11. United States Department of Agriculture, Food and Nutrition
May 2012 JOURNAL MSMA 145
12.
13.
14.
15.
16.
17. 18.
19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30.
Services. Section 204 of Public Law 108-265-Child Nutrition and WIC Reauthorization Act of 2004. 2004. Website. http://www. fns.usda.gov/tn/Healthy/108-265.pdf. Accessed December 1, 2011. Mississippi Department of Education, Mississippi Office of Healthy Schools. Beverage Regulations for Mississippi Schools. 2006. Website. http://www.cn.mde.k12.ms.us/documents/VendingRegForMSSchools06.pdf. Accessed December 1, 2011. Mississippi Legislature, Senate. The Mississippi Students Act. 2007. Website. http://billstatus.ls.state.ms.us/documents/2007/ pdf/ham/Amendment_Report_for_SB2369.pdf. Accessed December 1, 2011. Mississippi Department of Education, Office of Innovation and School Improvement Office of Accreditation Mississippi Public School Accountability Standards 2007. 2007. Website. http:// www.mde.k12.ms.us/accred/2007_Edition.MS%20Public%20 School%20Acct.%20Stds.pdf Accessed December 1, 2011. Mississippi Department of Education. Mississippi Healthy Students Act Senate Bill 2369 Nutrition Standards. 2007. Website. http://www.healthyschoolsms.org/documents/Mississip piHealthyStudentsActSenateBill2369NutritionStandards_000. pdf. Accessed December 1, 2011. Mississippi Secretary of State, Administrative Procedures. Physical Education/Comprehensive Health Education Rules and Regulations. 2007. Website. http://www.sos.state.ms.us/busserv/Admin Procs//PDF/00014817b.pdf. Accessed December 1, 2011. Molaison EF, Howie S, Kolbo J, Zhang L, Rushing K, Hanes M. Comparison of the Local Wellness Policy Implementation between 2006 and 2008. J Child Nutr Manag. 2011;35(1). Kolbo J, Molaison EF, Rushing K, Zhang L, Green A. The 2008 School Wellness Policy Principal’s Survey. 2008. Website. http:// www.mshealthpolicy.com/documents/2008_wellness_surveyFINALREPORT.pdf. Accessed December 1, 2011. Baker JL, Olsen LW, Sorensen TIA. Childhoodbody-mass index and the risk of coronary heart disease in adulthood. N Engl J Med. 2007;357(23):2329-2337. Bibbins-Domingo K, Coxson P, Pletcher MJ, Lightwood J, Goldman L. Adolescent overweight and future adult coronary heart disease. N Engl J Med. 2007;357(23)2371-2379. Farhat T, Iannotti RJ, Simons-Morton BG. Overweight, obesity, youth, and health-risk behaviors. Am J Prev Med. 2010;38(3):258267. Freedman DS, Khan LK, Serdula MK, Ogden CL, Dietz WH. Racial and ethnic differences in secular trends for childhood BMI, weight and height. Obesity. 2006;14(2):301-308. Gordon-Larsen P, Adair LS, Popkin BM. The relationship of ethnicity, socioeconomic factors, and overweight in U.S. adolescents. Obes Res. 2003;11(1):121-129. Ludwig DS. Childhood obesity – The shape of things to come. N Engl J Med. 2007;357(23);2325-2327. Must A, Anderson SE. Effects of obesity on morbidity in children and adolescents. Nutr Clin Care. 2003;6(1):4-12. Arens R, Muzumdar H. Childhood obesity and obstructive sleep apnea syndrome. J Appl Physiol. 2009. Web site. doi: 10.1152/ japplphysiol.00689.2009. Accessed January 5, 2010. Daniels SR, The consequences of childhood overweight and obesity. The Future of Children. 2006;16(1):47-67. Rowland K, Coffey J. Are overweight children more likely to be overweight adults? J Fam Practice. 2009;58(8):431-432. Sjoberg RL, Nilsson KW, Leppert J. Obesity, shame and depression in school aged children: A population-based study. Pediatrics. 2005,116, 389-392. Thompson DR, Obarzanek E, Franko D, Barton B, Morrison J, Biro F, et al. Childhood overweight and cardiovascular disease
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31.
32. 33. 34. 35.
36.
37.
38. 39.
risk factors: The National Heart Lung & Blood Institute Growth and Health Study. Pediatrics. 2007;150:18-25. Weiss R, Dziura J, Burgert TS, Tamborlane WV, Taksali SE, Yeckel CW, Allen K, Lopes M, Savoye M, Morrison J, Sherwin RS, Caprio S. Obesity and the metabolic syndrome in children and adolescents. N Engl J Med. 2004;350:2362-2374. Qualtrics [Online Survey Software]. Provo, UT; 2009. Centers for Disease Control and Prevention. A SAS Program for the CDC Growth Charts. Web site. http://www.cdc.gov/nccd/ php/dnpa/growthcharts/sas.htm. Accessed June 1, 2009. SUDAAN [computer program]. Version 10.0. Research Triangle Park, NC; 2009. Mississippi State Department of Health. An environmental scan of childhood obesity efforts in Mississippi. 2007. Website. http:// www.msdh.ms.gov/msdhsite/resources/2482.pdf. Assessed December 1, 2011. Mississippi Department of Education’s Office of Healthy Schools. Obesity in Mississippi: A report compiled by the POWER initiative. 2009. Website. http://www.msdh.ms.gov/msdhsite/_static/ resources/3593.pdf. Assessed December 1, 2011. Harbaugh B, Kolbo J, Molaison E, Hudson G, Zhang L, Wells D. Obesity and overweight prevalence among a Mississippi lowincome preschool population: A five-year comparison International Scholarly Research Network: ISRN Nursing. 2011, Article ID 270464. Taveras EM, Gillman MW, Kleinman K, Rich-Edwards JW, Rifas-Shiman. Racial/Ethnic differences in early-life risk factors for childhood obesity. Pediatrics. 2010;125:686-695. Bennett B. Sothern MS. Diet, exercise, behavior: The promise and limits of lifestyle change. Semin Pediatr Surg. 2009;18(3):152158.
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â&#x20AC;˘ top 10 factS you Should Know â&#x20AC;˘
About Depression Shambhavi Chandraiah, MD, FRCPC
i
Major Depressive Disorder (MDD) is the 3 leading worldwide and the leading cause of disability in the Americas.1 MDD is the commonest form and has a lifetime prevalence of about 17%.2 MDD is seen about three times more often in primary care with 2/3 not being routinely detected.3 The symptoms of MDD are >= 2 weeks of depressed mood or loss of interest, changes in sleep, appetite, or energy, decreased libido or concentration, and feelings of worthlessness or suicidal ideation.4 The following facts can help in the recognition and management of depression: rd
1.
The US Preventative Services Task Force in 2002 recommended screening for depression in adults.5 Patients may not complain of depressed mood and present instead with somatic symptoms, pain, or stress. Self-report tools like the Patient Health Questionnaire (PHQ-9) can increase the likelihood of detection by three fold and can also monitor improvement with treatment.6
2.
Depression has different forms. MDD has been described above. Dysthymic Disorder is a chronic, milder, intermittent depression lasting > 2 years. Bipolar Affective Disorder has depressive but also manic (excessive energy, impulsivity, insomnia) episodes and must be treated with mood stabilizers. Adjustment Disorder follows a major life stressor like divorce, usually lasts less than 6 months, and may respond to therapy alone. Seasonal Affective Disorder consists of depression in the fall/winter and can be treated with morning bright light therapy.7 Acute grief may show some of the withdrawal symptoms of depression but usually resolves over 6 months, although 20% of patients may develop MDD.8
3.
the complications and mortality following myocardial infarction independent of its impact on depression.10
ntroduCtion
Depression is common with chronic medical illness. Hypothyroidism, anemia, and exogenous steroid treatment can all present with depressive symptoms. Depression can co-occur with cancer, diabetes, heart disease, arthritis, and especially pain. Treatment of concurrent depression improves medical treatment adherence and outcome.9 The SADHART study showed that the selective serotonin reuptake inhibitor (SSRI), sertraline, decreased
4.
Depression is also common with other psychiatric illness. Over 50% of patients with depression have concurrent anxiety,11 and their outcome is poorer despite treatment with antidepressants.12 Alcohol and opiate abuse can be primary or secondary to depression necessitating joint treatment. The pseudo-dementia of depression often occurs with dementia but also may suggest a vulnerability to future development of dementia.13
5.
The lifetime risk of suicide is 15% for MDD.14 Greater lethality (gun/hanging), active plan, and absence of a support system (church/family) increases risk. Suicide is more common in single adults, elderly males, and those with recent major losses, substance abuse, severe anxiety, chronic illness or pain, hopelessness, suicidal ideation, and past suicidal attempts. Despite the 2004 and 2007 updated FDA warning about increased risk of suicidal ideation with the use of antidepressants in adolescents and young adults, a meta-analysis of studies showed that the benefits of using antidepressants is much greater than the risks.15
6.
Depression is twice as common in women. Premenstrual dysphoric disorder, post-partum depression, and perimenopausal depression are also more common in women with MDD and vice versa.16
7.
Depression treatment should be adequate in dose, duration, and symptom relief. Generic SSRIâ&#x20AC;&#x2122;s are first line, up to maximum dosage if needed, for 4-6 weeks before considering augmentation or switching to other medications or CBT (cognitive behavior therapy). The STAR-D study showed that only 1/3 of patients improved with the first antidepressant, another 1/3 with the second, for a total of 2/3 by the end of the 4th drug trial.17 After remission is achieved, treatment must be continued for at least one year to prevent relapse.
8.
Depression is a recurrent illness. After one episode, the likelihood of recurrence is over 50%, after 2 episodes 70%, and after 3 episodes 90%. Maintenance treatment for > 2-5 years decreases the recurrence rate by three fold.18
May 2012 JOURNAL MSMA 147
9.
Therapy can be as effective as medications for mild to moderate depression. However, combined medication and therapy is better than either alone for chronic depression.19 Research suggests that CBT changes negative thought patterns and the reclusive behavior of depression. Interpersonal or problem-solving forms of therapy can also be helpful.
10. Self-care is an important part of depression treatment. Exercise,20 sleep hygiene (+/- hypnotics), and positive activities outside the home can energize and improve depressive symptoms. Family support can mitigate against depression and decrease recurrences.
ConCluSion
Depression is predicted to become the 2nd leading cause of worldwide disability in 2030.1 The health care costs of disability from depression are similar to that from heart disease, diabetes, and back problems and are further increased if they are co-morbid.21 Screening can identify a majority of patients with primary or secondary depression. Self-care, support, psychotherapy, and medications can help treat depression, prevent recurrence, and improve quality of life. Most depressed patients have seen a physician in the month before a suicidal attempt.22
correlates. J Geriatr Psychiatry Neurol. 2007;20(4):189-198. 14. Harris EC, Barraclough B. Suicide as an outcome for mental disorders: A meta-analysis. The British Journal of Psychiatry. 1997;170:205-228. 15. Bridge JA, Iyengar S, Salary CB, et al. Clinical response and risk for reported suicidal ideation and suicide attempts in pediatric antidepressant treatment: A meta-analysis of randomized controlled trials. JAMA. 2007;297(15):1683-1696. 16. Payne JL, Roy PS, Murphy-Eberenz K, et al. Reproductive cycleassociated mood symptoms in women with major depression and bipolar disorder. J Affect Disord. 2006;99:221-229. 17. Rush AJ, Trivedi MH, Wisniewski SR, et al. Acute and longer-term outcomes in depressed outpatients requiring one of several treatment steps: A STAR*D report. Am J Psychiatry. 2006;163(11):1905-1917. 18. Keller MB, Boland RJ. Implications of failing to achieve successful long-term maintenance treatment of recurrent unipolar major depression. Biol Psychiatry. 1998;44:348-360. 19. Keller MB, McCullough JP, Klein DN, et al. A comparison of nefazodone, the cognitive behavioral-analysis system of psychotherapy, and their combination for the treatment of chronic depression. N Engl J Med. 2000;342(20):1462-1470. 20. Blumenthal JA, Babyak MA, Doraiswamy M, et al. Exercise and pharmacotherapy in the treatment of major depressive disorder. Psychosomatic Medicine. 2007;69:587-596. 21. Druss BG, Rosenheck RA, Sledge WH. Health and disability costs of depressive illness in a major U.S. Corporation. Am J Psychiatry. 2000;157(8):1274-1278. 22. Luoma JB, Martin CE, Pearson JL. Contact with mental health and primary care providers before suicide: A review of the evidence. Am J Psychiatry. 2002;159(6):909-916.
referenCeS
We specialize in the business of healthcare
1. World Health Organization. The global burden of disease: 2004 update. Available at http://www.who.int/healthinfo/global_ burden_disease/2004_report_update/en/. Accessed Dec 25, 2011. 2. Kessler RC, Berglund P, Demler O, et al. Lifetime prevalence and age-of-onset distributios of DSM-IV disorders in the national comorbidity survey replication. Arch Gen Psychiatry. 2005;62:593-602. 3. Vermani M, Marcu M, Katzman, MA. Rates of detection of mood and anxiety disorders in primary care: A descriptive, cross-sectional study. The Primary Care Companion for CNS Disorders. 2010;13(2):PCC.10m01013. 4. American Psychiatric Association. Diagnostic and Statistical manual of Mental disorders. Fourth Edition, Text Revision. Washington, DC: American Psychiatric Association; 2000. 5. U.S. Preventive Services Task Force. Recommendations and rationale: Screening for depression in adults. Available at http://www. uspreventiveservicestaskforce.org/uspstf/uspschdepr.htm. Accessed December 25, 2011. 6. Williams JW Jr, Noel PH, Cordes JA, Ramirez G, Pignone M. Is this patient clinically depressed? JAMA. 2002;287(9):1160-1170.
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7. Eastman CI, Young MA, Fogg LF, Liu L, Meaden PM. Bright light treatment of winter depression. Arch Gen Psychiatry. 1998;55:883-889. 8. Zisook S, Shuchter SR. Depression through the first year after the death of a spouse. American Journal of Psychiatry. 1991;148(10):1346-1352. 9. Katon WJ, Lin EHB, Von Korf M, et al. Collaborative care for patients with depression and chronic illnesses. N Engl J Med. 2010;363(27):2611-2620. 10. Glassman AH, O’Connor CM, Califf RM, et al. Sertraline treatment of major depression in patients with acute MI or unstable angina. JAMA. 2002;288(6):701-709. 11. Moffitt TE, Harrington H, Caspi A, et al. Depression and generalized anxiety disorder. Arch Gen Psychiatry. 2007;64:651-660. 12. Fava M, Rush AJ, Alpert JE, et al. Difference in treatment outcome in outpatients with anxious versus nonanxious depression: A STAR*D report. Am J Psychiatry. 2008;165(3):342-351. 13. Wright SL, Persad C. Distinguishing between depression and dementia in older persons: Neuropsychological and neuropathological
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• preSident’S page • Last Random Thoughts
W
ell, this is it. The last time you have to suffer through reading my thoughts. I have to admit that I am going to miss it (not the writing part) as it has been quite an honor representing MSMA the past year. Through the work of our staff, Alliance, and fellow physicians, I think that we have accomplished much at MSMA this year.
thoMaS e. Joiner, Md 2011-12 MSMa preSident
Medicine is being attacked at all levels, and we have fought hard, both here and in Washington, to protect the quality of the product you and I provide. However, the take home message is that it is an ongoing battle that is going to get worse instead of better. Just remember, we have to look out for our patients. By doing so, we will preserve our noble profession. If we start looking out for ourselves, we will become prey to the “wolves.”
We seem to be very good at protecting our patients when there is a crisis. When we were losing doctors and specialties that were critical to the care of Mississippians, we all rallied and were a potent force for tort reform. That was a great moment in MSMA history, bringing back many to provide that care. Mississippi is now a model to the whole country. Wow! Think of that! We are leading in something! However, as I said, it is always an ongoing “under the radar” battle being waged by MSMA, and I want everyone to know that our staff is the best at it of any organization in our state, something we can be proud of. And you have all heard me say that I have never been enamored with the AMA. In fact, in my inaugural speech I used two words, “sell out,” to describe how I felt about some of the AMA’s policies of the past few years. I meant it then, and I mean it now. I also was in great favor of dissolving our bonds with the AMA. However, I also said that ABC, NBC, CBS, FOX, and the Congress always ask the AMA when they want to know what the docs think. They do not ask me, you, staff, or anyone that knows what the real practice of medicine is, and if we wanted to have a say so we needed to be there. Well, this year your AMA delegation introduced and passed a resolution, by unanimous vote (and that never happens at the AMA), to delay or stop the implementation of the ICD -10 codes. This was taken to Washington by the AMA and guess what? It has been delayed and is being restudied. I strongly believe that our presence at the AMA is needed to bolster our efforts in Washington! We need to be there to voice displeasure when the AMA “sells out” again. How are we going to keep this going? MMPAC! Your PAC has been very effective over the past few years. You have heard me say that we are paying malpractice premiums at the 1999 level, thus saving someone like me $60,000! Eighty percent of the candidates we supported won in the recent election! Folks, that is worth the price of admission alone! Please do not wait until there is another “crisis” to contribute; the crisis is now! We need to remain strong! (I am sorry if I sound like your preacher on that spring fund drive Sunday, but this is serious!) And last, I have to admit that Bodemeister didn’t win the Derby or Preakness, but picking the horse that finished second in both is not bad! If you were picking to show like I do, you were a winner. And on that note we have a Triple Crown run on tap for the Belmont, and I think that I’ll Have Another has as good of a chance to take all three as any in the past 20 years. Who do you like today? I want to take this last opportunity to thank everyone for the confidence you have had in me this year. Like Bartels & Jaymes, “thanks for the support!”
May 2012 JOURNAL MSMA 151
• letterS • EHR May Not Be the Oppressor: Response to EMR End of Value Editorial
D
ear Editor,
Dr. Carl Feind’s recent guest editorial (Electronic Medical Records and the End of Value: Physicians, Nurses, and Scribes, March 2012) certainly resonated with this reader. Loss of physician autonomy, loss of our role as “master craftsman” in the practice of medicine and documentation, and loss of ancillary personnel are troubling issues of our times. However, since the focus of the editorial is the electronic health record (EHR), I would ask Dr. Feind to consider the idea that the EHR, per se, may not be the oppressor. With its failings, the EHR does have its virtues: legibility, off site access, ease in release of records, e-prescribing, all of which are mandated. EHR is just a tool. A tool should be designed to be easy for all to use and tailored to the task at hand. Efficiency is important; a large hole is best dug with a shovel, not a teaspoon.
My contention is that the tool itself is not your oppressor– the oppressor is the entity forcing you to use the wrong tool for the task at hand. Eight years ago, Jefferson Medical Associates of Laurel, a privately owned 15 member multispecialty group, reviewed all the major EHRs. Our response was to create our own system– designed by doctors, for doctors. That system, which we have found to be as efficient as possible, has since achieved “meaningful use” certification, meriting the initial incentive payments. That same system will be available to others by the time this letter is published. There are two cautionary tales in the Jefferson Medical experience: firstly, one should remain private and independent as long as possible; secondly, if we leave our fate to unbridled software developers, we will lose this craft, this practice of medicine. For those who follow us, we cannot allow this to happen! —Charles D. Cannon, Jr. MD, Laurel
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May 2012
O’Brien & Family Law Group
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P.O. Box 2623 682 Towne Center Blvd. Ridgeland, Mississippi 39158 (601) 952-0050 (Office) •(601) 952-0904 (Fax) office@jamesandobrien.net James & O’Brien Family Law Group consists of five attorneys, L.C. James, Danna A. O’Brien, David E. James, Alicia C. Baladi and Kim D. McCormack, who specialize in domestic law cases of all types, with a particular emphasis on divorce and custody. The Firm has earned and maintained an “AV” rating (very highest) in Martindale-Hubble Law Directory for more than a quarter century, and its senior member, L.C. James, is one of only 1,397 attorneys in the nation and the only family law attorney in Mississippi who has been listed in every publication of “Best Lawyers in America” since its inception in 1983. The law firm is dedicated to each client as he or she deals with divorce. We strive to earn the respect and approval of each client, for we fully understand that our reputation for excellence has been established over these many years through the judges, our peer group of fellow attorneys, but most importantly, our clients.
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• Special article •
An Interview with Steven L. Demetropoulos, MD 2012-2013 MSMA President Karen A. Evers, Managing Editor
[Each year the JMSMA interviews the incoming president. Here we go behind the scenes. Due to space limitations, the answered questions do the speaking for this interview.] —Ed.
F
amily My mother is still living and she recently remarried about a year ago. My dad died in 1999. I have two younger sisters who are both married and have children of their own. Therese and I have been married 27 years, and we have four children. Katie (24) is a nurse at Methodist Hospital in Memphis. I’m very proud of her. She is very assimilated in society, no support from the family. Ari (22) has been accepted to the University of Mississippi School of Dentistry and will start in August. Victoria (18) will attend Ole Miss and is interested in physical therapy. My youngest, son Steven, just turned 14. He’s a good student and likes hunting, fishing, and sports.
Growing up I grew up on a dairy farm near Mobile, Alabama, until I was 13, reared by loving parents who spent a lot of time with us. Working side by side with my dad on the farm, I learned how to fix pieces of equipment, work with livestock, how to build a barn and a better fence. When the dairy farm was sold, we moved to George County near Lucedale, Mississippi, where we raised cattle. There I learned a very strong work
Mr. and Mrs. (Minnie) Frank Demetropoulos on a trip to Germany, which was given to them by their son who accompanied them.
The young Demetropoulos family - Wife and mother: Therese; children: Steven, Jr. (4), Katie (14), Ari (12), and Victoria (4).
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ethic. These were things I loved, along with the beauty of the farm. I still keep the farm I grew up on, and I introduced my son to that because when you grow up in the city you aren’t exposed to loving anything like that. In fact, following Hurricane Katrina we moved back to the farm for about four months. When the schools started back in Pascagoula, the kids wanted to return to their old schools so we moved back. We found a two-story house but the bottom was gutted out. Therefore, we lived upstairs and cooked in the garage where we had a microwave and refrigerator. It was kind of rough living from about August until Christmas until the downstairs was finished. Family Horseback Outing - A favorite pastime
The Demetropoulos family at the time of Ari’s graduation - Steven, Therese, Dr. Demetropoulos, Ari, Victoria, and Katie
Demetropouloses Tailgating in the Grove at Ole MIss –They pick two games a year to make the 6-hour drive from Pascagoula to Oxford to see daughters Ari and Katie, and watch the Rebels play football. Dr. Demetropoulos calls it a “sweet thing” to see multigenerational friends sharing special times, and he enjoys meeting his children’s friends.
Priorities My faith is most important to me, and then my family is right there behind it as number two. My work and relationships fall into place underneath. If you’re only going to have one opportunity with your kids while they’re young, I want to make it count. I try to go to all of their extracurricular functions, ball games, etc. On Becoming A Doctor I thought I would like to be a doctor and was always good in science, but I didn’t have any real good role models. I really liked farming, growing things, and raising cattle. A farmer who was my good friend gave me some words of wisdom. He said, “You can be a doctor and a farmer, but you can’t be a farmer and a doctor.” That stuck with me. Around the 11th grade, I started to focus on medicine and went to college with that idea. In the summers, I’d find jobs at the hospital. I did patient transport and saw what the doctors did. That’s kind of the focal point of when my desire to become a physician started. I was fortunate to have been accepted to the University of Alabama Medical School-Birmingham where I received my M.D. Thinking back, looking how famous UAB has become, it is really an honor that I got in. It was such a good experience, not a selfish time but a time I devoted to myself. In other words, I didn’t have family, wasn’t married, didn’t have anyone who had to rely on me so I could focus on my work, I had
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no other responsibility except to get my education. After a general surgery internship at Caraway Medical Center in Birmingham, I completed my emergency medicine residency at the University Hospital in Jacksonville, Florida, and married after my first year. I ended up moonlighting a good bit and Therese would actually come with me. It was somewhat neat. Some of the older guys in the residency had a contract with the Hospital in St. Augustine, which was not too far away. A group of us inherited that and provided some coverage for them on weekends, holidays, and nights. We would go down there and they had a nice call room with a giant screen TV with HBO. For us, we were young and didn’t have much, so that was like a vacation. One Thanksgiving we went down there, and they had Thanksgiving dinner in the cafeteria. We enjoyed that. The next thing I know, we would try to watch HBO movies between patients. It was a good experience. We were just married, no kids, so it was a fun time.
Dr. and Mrs. (Therese) Steve Demetropoulos on a trip to the Isle of Capri, Italy
Meeting your Wife, Therese Camors After I graduated from med school, a friend let me go down and use his house in Gulf Shores. I was there with one of my friends from college, and she was there with her family. We walked down the beach to lie out and saw three girls putting up a tent. I asked, “Do ya’ll need help?” Of course, I thought Therese was the really pretty one who I should try to get to know. So we met and sat on the beach. That night after my friend left, I went back out, and she invited me to come up to the house for a cocktail with her family. The rest is history. Medical Milestone In medical school everybody had to do a community health rotation. Typically, they’d go somewhere nearby to work, like for a family doctor in the area. I wondered if they Waterskiing on Lake Martin in Alabama — Dr. Demetropoulos would let me go somewhere else, maybe do one out of the says physical activity is an important part of maintaining balance country. I applied, and I was accepted for a rotation working in his daily life. in a rural health clinic back in the mountains of Jamaica. I’d flown in on a Sunday, and they took me to where the little clinic was. I found my way there, looked around and thought there was really nobody there. There was a little bunk house in the back, so I settled in, and went to bed early about 8 o’clock. About 10 o’clock, I heard a knock on the door. It was a teenager who said, “Please come with me; my father is dying.” I didn’t really know what to do, but he said, “You’re the doctor, you have to come.” While uncertain, I grabbed my stethoscope, put on my clothes, and followed him down A recent photo of the Demetropoulos ladies on the occasion of Ari’s graduation: a long trail through the jungle. I Victoria, Therese, Katie, and Arie
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arrived to find an older man, short of breath, in distress. He was sweaty and felt hot. I wondered if it was heart failure or if he might have pneumonia. I went back to the clinic and found some penicillin in the back of the refrigerator, drew up the dose I was supposed to give him, and gave him a shot. I told him I’d come back in six hours to give him another shot and keep checking on him. When I went back in six hours, he was dramatically better. And, I continued to care for him until he was well. As it turned out, he was the only guy in the community with a car. He also had a farm with a garden, and he would send fresh vegetables over to me every day so I never really had to buy any food. He even gave me a ride back to the airport when I finished up. What I learned from that whole experience was not about medical lab tests, x-rays, and equipment; it was about knowledge. It was at that point I thought, “Okay, I think I’ve become a doctor.” Anyway, that minute I felt things clicked, that I’d saved someone’s life just from what I’d learned. The man I saved was so nice to me, and I’d made a great friend in that little community. That was a great experience too. Following Residency After residency, I came to Pascagoula and joined this group (Emergency Room Group, LTD). My family lived about 45 minutes away and I wanted to be close to my mom and dad. I took this job and helped grow the group. We went from six doctors when I joined to 28 doctors now. We’re the biggest emergency group in the state. And we’re also one of the oldest continuous groups in the United States. In other words, we have the longest contract to provide emergency coverage with the hospital (45 years). So it’s been the same group, the same contract, with the same hospital. To put emergency medicine in perspective, in the early 60s there were only a few hospitals who had dedicated doctors to staff their emergency department. Ours started in ’67 so we were right there among the earliest places (like in Michigan and Washington in ’65). Here we were, right here in Mississippi, having this unique experience saying, “What if we were to have dedicated doctors just to work in the emergency department?” It’s been a nice thing for our state. Organized Medicine When I finished residency, a couple of the local guys (one of them was Jack Hoover) invited me to their component society meeting. I soon had held all of the offices within our local component society, and all of the offices within my state specialty society (American College of Emergency Physicians). Then I started going to annual session about 23 years ago, and I have gone to every one of them since they first asked me to be a delegate. I became involved, serving on several committees. I was on the Council on Public
Information and went on to chair it. Back then, they offered media training which was really neat and an exciting way to hone your leadership skills. Then I became involved with the Council on Legislation which was a very good opportunity to learn how to work better with your legislators. I served on the MMPAC Board, which was very instructive in developing relationships with politicians and discovering what gets your legislators’ attention. Serving on the Board of Trustees taught me how the Association works and is governed. I was elected to the MACM Board of Directors in 2002. That has been very educational– learning about insurance, risk management and the tort environment. They were all rewarding experiences. This is one thing I would like to advise young physicians to do: Take advantage of different leadership conferences offered to you. I participated in the AMA Leadership Conference which was very good. I attended the Legislative Advocacy Conference, and another leadership conference with the American College of Emergency Physicians. I completed a program with Volunteer Hospitals of America through our hospital. It helps you with your skill sets, dealing with other people, and handling differences of opinion with other folks. It teaches you how to disagree agreeably, and there’s a whole other component of how to present your ideas in a succinct fashion, how to run a meeting, all of the practical things which to me have been very useful. Medical Service I’m president of our E.R. group and spend a lot of time managing our group and interacting with the hospital. Being involved in hospital administration, I spend a great deal of time consulting with quality improvement, safety, and satisfaction, and all of the other things that are important there. Platform You asked me what became of the mini-internship program we used to offer. That is something I would like to see start back. This was an opportunity for community leaders outside of the medical field to see what really goes on within the healthcare realm. By allowing them to interact with the health industry, we develop meaningful association with these leaders. This allows us to establish relationships with judges, district attorneys, and others so we could mutually accomplish our goals. Dr. Rick Whitlock, a family practice doc, helped us get the mini-internship program established, and he did a great job heading it up for about 12 years. We even invited Justice C.P. “Chuck” McRae. In fact, we’ve invited everyone from our best friends to people perceived as having strong differences of opinion than us. We started with the board of directors of our hospital, we did our city council, all our board of supervisors, our state legislators, and then we went to all our local businesses. We invited CEOs from corporations like Chevron and Ingalls, then their HR departments who oversee
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health care programs. Over the years, we had a huge group go through. People really gained a lot enjoyment out of the program, but we haven’t done it in a while. It would be a good project for component societies. I think there is a missing link in many of our component societies. Other than meetings, there is not a purpose or goal to achieve. The mini-internship program would give them a purpose to bring others in and show them our profession. This creates the relationships it takes to get things done whether it is with legislators, health care decision-makers, and other people for whom it is helpful to see what doctors really do. The mini-internship program is something I would like to take back to our component societies in hopes they will implement such and benefit from it in their communities. Other parts of my platform include engaging membership and public health issues, particularly immunizations and tobacco-free indoor public spaces, restaurants, and bars. Leadership I don’t have to be the person out in front. If the committee or group gets their mission or goal accomplished, that’s where I get my satisfaction. Some people are the opposite from that. For me, there’s a goal-oriented leadership style so if somebody else wants to be in front that is fine. The main point is that our goal is accomplished and that we are pushing towards our accomplishment. Personal Philosophy Every day is a gift from God. I’m going to live each day to very fullest I can. I want to do everything with excellence. We are not promised another day. We just have the day that we have. We don’t know if we we’ll have tomorrow so I want to do everything the best that I can do and to God’s glory. I like to give everything that I’ve got to whatever I’m doing. Community Service Church: I’ve taught Sunday school for about fifteen years now. I have been an elder and deacon in the Presbyterian Church. Historical Society: I have been very involved in the local historical society in the past but not so much recently. I love history and enjoy relating to it to other people so I get pleasure from that. Cattle Associations: For a time in my life when my dad was alive, we raised purebred cattle so I was involved with the cattle associations. My kids and I showed the cattle, and we’d go to the different fairs and events. That was an exciting time when we spent the night out with the children, along with mom and dad. After dad died, we tried to hold the farm together for about a year, when we realized it was just too much. My mom stepped up. She was kind of a herdsman watching the cattle, seeing if there were any problems, and moving them to different fields. She assumed all his duties.
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We had a nice purebred cattle herd we had put together. It just became more than we could keep going with dad gone so we had a dispersal. It was truly exciting. We had the sale in Jackson. There was good crowd, and Ari, who was 11 at the time, was one of the salespeople. She was very nice and familiar with the cattle. She would talk about the different cows and that night she was still selling cattle in her sleep. It was a sweet little time! Here is another cattle story: We raised Simmental cattle and they had their own association. I took Ari, who was then about eight, and my youngest daughter, Victoria, and two heifers to a Dixie National sale. I said, “Ari, I want you to lead them in.” She said, “But daddy, there are 400 people sitting in all of the stands. I’m afraid and don’t know if I’ll be able to do it.” So, I told her, “I’m going to ask the fellow that helps us with the cows, and he is going to be right there with you. I think we have one of our best you’re leading in, and this will help sell her.” She said, “Okay, I’ll do it.” So she put on her little shirt and her cowboy hat. She led it in and the crowd went crazy, and it was the highest selling lot. Afterwards, one of the fellows said, “I wasn’t sure if we were bidding on the little girl or the cow!” She was the cutest thing in that ring. Anyway, that was the highest selling lot for that sale, and I was so proud of her. Reflections on the Hurricane Katrina Yeah, we lost pictures, along with other stuff. However, what the Hurricane did for us, and for my kids, is showed us those material things are temporary. The only thing that lasts is our relationship with God and our relationships with other people. It helped our kids understand that you can have a lot of stuff and that it can all be gone. You can try to replace it, but the main things you put value in are your relationships. Moreover, you can have difficulties, and you can get through them. You can learn from them and become a stronger person for it. We learned that even though there can be really painful moments, they can be teachable. And you can come out on the other side a better person, a more thankful person, and a person God can use to help others through their painful moments. Balance It is important for each aspect of my life to be in balance for me to function at the highest level I’m capable. On my physical side, it is important that I exercise on a regular basis. On my emotional side, it is important that we do things with our friends and family. On my spiritual side, it is important that I have a daily time of devotion and prayer. When I get out of balance with any of those, that’s when I feel like I’m under much more stress, and it’s harder for me to function at the level I’m capable of. When all of them are clicking, I’m ready to take on any challenge. r
For the fun of it— You’re most likely to see me around: The gym. On the weekends, I love to: Exercise and work in the yard. I enjoy spending special time with friends. I love music, and I like to cook for friends and family. The high school, college or pro sports teams I root for are: Ole Miss A favorite book: The Hiding Place by Corrie ten Boom If I’m listening to music, it’s probably: Neil Diamond, Carole King, 60s tunes, beach music. Lately I’ve been listening to Adelle and Allison Krause.
DiD your last meeting leave you feeling a taD
“ECTOPIC” If so, you should consider having your next meeting in Tupelo!
We’re right in the middle of the midsouth and tupelo is the headquarters of the north mississippi medical Center, the largest non-metropolitan hospital in the united states, and is a winner of the prestigious malcolm Baldrige national Quality award! And we promise you won’t feel out of place here! For information about setting up your next meeting, give Linda Elliff a call at 800-533-0611.
Latest splurge: Traveling, taking the girls to Rome. I am passionate about: Faith, my family, and friends. Something about me not everyone knows: I have two black belts. I started out in Shodakan karate and switched to the martial art of Akido. Do you prefer to go out or stay in? Both. Perfect meal: Something Mediterranean. I made a great salad the other night, and you can share my recipe. It’s blood oranges with avocado, a little purple onion, fresh mint, and feta cheese with a little olive oil, balsamic vinegar, salt and pepper. Perfect day: Swimming and water skiing at the lake house, followed by inviting four or five couples over for dinner. The guys serve the girls cocktails, then salad, a second course of maybe pasta, then dinner. It’s important for me to have just the right music, like Burt Bacharach, and to see everyone have a great time. Favorite color: Red. Text, email, or cell phone: Phone, I prefer to talk to someone. Pets: An English bulldog, Therese adopted as her last child. MSMA member since: 1987 May 2012 JOURNAL MSMA 159
Steven L. Demetropoulos, MD; MSMA President 2012-13
What they say about him... “I’m proud to say in all humility that I taught Steve everything he knows about organized medicine. Unfortunately, it was while we worked together in the AMA Young Physicians Section House of Delegates about 100 years ago so none of it is valid as he becomes President of MSMA. However, I was able to see then and now that Steve was a compassionate yet strong physician and leader which is what we need as he takes on the mantle of leadership for MSMA. Thanks Steve for putting up with me then and now and being a good friend to me in organized medicine. I look forward to serving with you as we work to protect our profession.” —Dan Edney, MD, Vicksburg “Dr. Demetropoulos has always been passionate about providing quality care to patients that he sees in the ER, and serving as President of the Mississippi State Medical Association will give him a new platform to promote the message of quality and affordable healthcare for all of Mississippi. As a member of the MACM Board of Directors, he has been compassionate and fair in his decision making, and he represents his constituents, the physicians of South Mississippi, well. We are pleased to congratulate him in this new role with MSMA.” —Michael D. Houpt, President and CEO Medical Assurance Company of Mississippi “A nine-year-old female finds a turtle and adopts it as a pet, paints its shell and nails pink. The next day it bites her on the lip and won’t let go. She comes to the ER and sees ‘Demo.’ He says, we are going to have to kill it, and then all of a sudden she is no longer its best friend, and fine with euthanasia. Demo says “this is going to be messy, I am going to have to cut its head off,” then he tries to saw and cut its head off. It retracts into the shell and pulls her lip with it. He finally gives it a paralytic (succynlcholine) and it dies, and lets go. “A thug/drug addict guy comes into the ER in police custody fighting, biting, grabbing testicles, just took an overdose. Demo finally loses patience with him, grabs him by the shirt, and yells at him, demanding to know what pills he took. Demo is a big guy, and the thug was
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quite intimidated. Then 20 minutes later he felt guilty, went back, and apologized to him.” —Ben Hudson, MD, Pascagoula “Fair and balanced are the qualities Steve has brought to the presidency. Thank you for your leadership.” —Don Q. Mitchell, MD, Jackson “Having known Dr. Demetropoulos for several years, and watching him mature as a person and a leader in the medical community, has been very rewarding. He stands out as a person committed to his family and his profession. His most outstanding characteristic is that, in every endeavor, he evidences his sincerity and makes decisions based on good facts and his heart. The Coast and medical community are blessed by his leadership and presence.” —Bob Montgomery, General Counsel Medical Assurance Company of Mississippi “I count Steve Demetropoulos as one of my best friends. We work, worship, play and travel together. Since we are often mistaken for each other (not!), I am fortunate that he is kind, gracious, and generous. He is a loving son, husband, and father, caring physician, and gourmet cook. Mississippi physicians are privileged to have Steve represent us. They can expect a bold agenda that will benefit our profession for years to come.” —Paul H. (Hal) Moore, Jr., MD, Pascagoula “Dr. Demetropoulos has been a member of MACM’s Board of Directors since 2002. During his tenure we have developed a close personal and professional friendship. We value his participation and his thoughtful consideration on matters that affect our Mississippi Physicians. Congratulations on his new role as president of Mississippi State Medical Association!” —William A. Whitehead, MD, FACS Chairman, Board of Directors, Medical Assurance Company of Mississippi
• JuSt off the preSS - info you want to Know •
Bacterial Rhinosinusitis Guidelines Jasmine McKee, PharmD; Richard L. Ogletree, Jr, PharmD
A
rticle: Chow AW, Benninger MS, Brook I, Brozek JL, Goldstein EJC, Hicks LA, Pankey GA, Seleznick M, Volturo G, Wald ER, File TM. Executive Summary: IDSA Clinical Practice Guideline for Acute Bacterial Rhinosinusitis in Children and Adults. Clin Infect Dis. 2012 Apr;54(8):1041–1045. Introduction: The Infectious Diseases Society of America (IDSA) recently updated their clinical practice guidelines for acute bacterial rhinosinusitis (ABRS). The following is a quick review of their recommendations.
3. Worsening signs and symptoms after illness (fever, HA, increased nasal discharge) after previous bout of sinusitis seemed to improve some (evidence of “double-sickening”).
If any of these three situations are present, it is important to start an antibiotic immediately (strong recommendation with moderate quality evidence). What antibiotics should I use to treat these patients? First line therapy:
· Amoxicillin-clavulanate (Augmentin®) in both chil-
When should I start an antibiotic in a patient? Three specific situations (strong recommendation with low to moderate quality evidence):
dren (strong recommendation, moderate evidence) and adults (weak recommendation, low evidence).
· High dose amoxicillin-clavulanate (90 mg/kg/day po
1. Persistent signs and symptoms (lasting ≥ 10 days)
BID up to a max of 2 g po BID) is recommended in areas where endemic rates of invasive S. pneumoniae are ≥ 10%, those in daycare, immunocompromised, severe infection (temp of ≥ 102°F and signs of systemic toxicity), recent hospitalization, age < 2 years or > 65 years (weak recommendation, moderate evidence).
with no clinical improvement. 2. Severe signs and symptoms (temp ≥ 102°F and either purulent nasal discharge or facial pain) lasting 3-4 days.
Table 1. Antimicrobial Regimens for Acute Bacterial Rhinosinusitis in Children Indication Initial empirical therapy β-lactam allergy Type I hypersensitivity
First-line (Daily Dose) Amoxicillin-Clavulanate (45 mg/kg/day po BID)
Second-line (Daily Dose) Amoxicillin-clavulanate (90 mg/kg/day po BID)
Levofloxacin (10-20 mg/kg/day po every 12-24 hours)
Clindamycina (30-40 mg/kg/day po TID) plus cefixime (8 mg/kg/day po BID) or cefpodoxime (10 mg/kg/day po BID) Amoxicillin-clavulanate (90 mg/kg/day po BID) Clindamycina (30-40 mg/kg/day po TID) plus cefixime (8 mg/kg/day po BID) or cefpodoxime (10 mg/kg/day po BID) Levofloxacin (10-20 mg/kg/day po every 12-24 hours) Severe infection requiring Ampicillin/sulbactam (200-400 mg/kg/day IV every 6 hospitalization hours) Ceftriaxone (50 mg/kg/day IV every 12 hours) Cefotaxime (100-200 mg/kg/day IV every 6 hours) Levofloxacin (10-20 mg/kg/day IV every 12-24 hours) aResistance to clindamycin (around 31%) is found frequently among serotype S. 2neumonia serotype 19A isolates a- Resistance to clindamycin (around 31%) is found frequently among S. pneumoniae 19A isolates in different regions in of the US different regions of the US Non-type I hypersensitivity Risk for antibiotic resistance or failed initial therapy
May 2012 JOURNAL MSMA 161 Table 2. Antimicrobial Regimens for Acute Bacterial Rhinosinusitis in Adults
Levofloxacin (10-20 mg/kg/day IV every 12-24 hours) a- Resistance to clindamycin (around 31%) is found frequently among S. 2neumonia serotype 19A isolates in different regions of the US
Table 2. Antimicrobial Regimens for Acute Bacterial Rhinosinusitis in Adults Indication Initial empirical therapy
First-line (Daily Dose) Amoxicillin-clavulanate (500 mg/125 mg po TID, or 875 mg/125 mg po BID)
β-lactam allergy
Risk for antibiotic resistance or failed initial therapy
Severe infection requiring hospitalization
Second-line (Daily Dose) Amoxicillin-clavulanate (2000 mg/125 mg po BID) Doxycycline (100 mg po BID or 200 mg po daily) Doxycycline (100 mg po BID or 200 mg po daily) Levofloxacin (500 mg po daily) Moxifloxacin (400 mg po daily) Amoxicillin-clavulanate (2000 mg/125 mg po BID) Levofloxacin (500 mg po daily) Moxifloxacin (400 mg po daily) Ampicillin-sulbactam (1.5-3 g IV every 6 hours) Levofloxacin (500 mg po or IV daily) Moxifloxacin (400 mg po or IV daily) Ceftriaxone (1-2 g IV every 1224 hours) Cefotaxime (2 g IV every 4-6 hours)
Another option: What else should I recommend for these patients? How long should I use antibiotics in these patients? Doxycycline—a good alternative for adults. Shows great · Intranasal saline irrigations are recommended to For uncomplicated cases, adults should be treated for 5-7 days and children for 10-14 days (weak recommendation, low to pharmacologic properties and is active against respiratory relieve symptoms in adults and children, but many moderate evidence). pathogens. children may find this more uncomfortable than the benefits warrant (weak recommendation, low to modSecond line therapy: erate evidence). 2nd and 3rd Generation Cephalosporins—activity against · Intranasal corticosteroids are recommended to help S. pneumoniae is variable. Third generations cefpodoxime or treat symptoms, especially in those with a history of cefixime can be used in combo with clindamycin as an alterallergic rhinitis (weak recommendation, moderate native for children with non-type I allergies to penicillin. evidence). Not as highly recommended:
· Fluoroquinolones—associated with multiple adverse effects (dysglycemia, CNS events, QT prolongation, skeletomuscular complaints, photosensitivity, peripheral neuropathy) and has shown no additional benefit over a β-lactam.
· Macrolides—(clarithromycin and azithromycin) S. pneumoniae and H. influenzae show resistance.
How long should I use antibiotics in these patients? For uncomplicated cases, adults should be treated for 5-7 days and children for 10-14 days (weak recommendation, low to moderate evidence).
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· Topical and oral antihistamines and decongestants
are not recommended to help treat symptoms—they have shown no added benefits in addition to antibiotic therapy (strong recommendation, low to moderate evidence).
What if my patient is non-responsive to therapy?
· If no improvement in 3 to 5 days or a worsening in
symptoms after 48 to 72 hours of empiric antimicrobial therapy, switch to an alternative regimen (strong recommendation, moderate evidence).
· Evaluate patient for noninfectious cause, resistant
pathogens, compliance to treatment, or a structural abnormality (strong recommendation, low evidence).
Figure 1. Acute Bacterial Rhinosinusitis Treatment Algorithm
Used with permission from Chow AW, Benninger MS, Brook I, Brozek JL, Goldstein EJC, Hicks LA, Pankey GA, Seleznick M, Volturo G, Wald ER, File TM. Executive Summary: IDSA Clinical Practice Guideline for Acute Bacterial Rhinosinusitis in Children and Adults. Clin Infect Dis. 2012 Apr;54(8):1041â&#x20AC;&#x201C;1045.
May 2012 JOURNAL MSMA 163
â&#x20AC;˘ MSdh â&#x20AC;˘ Mississippi Reportable Disease Statistics
April 2012 Figures for the current month are provisional
Totals include reports from the Department of Corrections and those not reported from a specific District. For the most current MMR figures, visit the Mississippi State Department of Health website: www.HealthyMS.com.
164 JOURNAL MSMA
May 2012
• una voce •
The Tattoos of Life
L
et’s call her Lydia, not the name on her chart. I knocked on the door of the exam room and entered to see this otherwise strikingly beautiful young woman seated with legs crossed nonchalantly and with hands busy texting at hyper speed. When I spoke, her limbs unfolded. I could then view rising above the horizon of her halter top a vivid color image of a dying Christ on the cross, His arms spread eagled across her entire upper body. The unfinished portraiture was so remarkable I had to restrain my curious nature to address the actual medical problem for which she came to the clinic that day. I later learned the reason for the incompleteness of this prodigious display of ‘body art.’ When the tattoo artist began work atop her tender breast bone, this ultra slim young lass dwalia S. South, Md found the pain quite unbearable. She called a time-out, then decided to come back and try it again another day. Before our visit was over I simply had to see the whole thing. The crucifix extended from the base of her neck all the way to her navel, Jesus’ toes pointing in the direction of a metal bar pierced through her belly button. And I could only ask her, “Why? Why?” Her answer, “To get the message across to the world.” I wondered if it was necessary for one’s entire skin to be martyred in the name of Christendom. When back at my desk, I began to ponder that any man who someday becomes intimate with her will also by necessity come to know Jesus Christ as his close personal Saviour. I marveled at my imagined vision of how bowlegged Jesus would appear when someday distorted by the ninth month of gestation. I then pondered how pitifully the Lord might seem to fade and sag a half century or so in the future. What’s up with this exploding modern day tattoo phenomenon? It seems more than just a passing fancy to me, something more along the lines of a basic societal shift. As a family practice physician, I see more of folks’ skin than the general public is privy to. From my observations it appears that about half the 18-35 age group have at least one tattoo. The tattoos seem to be getting larger, bolder and less discrete. Why do so many people of seemingly normal intelligence want to get tattooed? When you ask them (and believe me, I do ask them) the responses vary: “I wanted to pay tribute to the most important things and people in my life.” “It shows that I am really Me and in control of MY body.” “Man, I don’t remember…I was wasted, I guess.” “I just think they are SOOO COOOL! Tattoos rock!” “I just wanted to be different; I wanted to be really unique.” The sad contradiction is that in that masochistic attempt to be somehow seen as ‘special’, these young people are simply running with the herd. Sadly, fads and fashion change, but like it or not, tattoos will go on forever. Tattoos are not a new or isolated phenomenon and their history is nothing short of fascinating. From Paleolithic Japan to Pre-Christian northern Europe, we humans have been applying tattoos for various reasons for tens of thousands of years. One example, Otzi, the mummified Neolithic Iceman who dates back to the fourth to fifth millennium BC, sported approximately 57 tattoos scattered over his body. The Alpine Iceman’s simple carbon tattoos were primarily a series of dots and lines adorning his lower spine, left knee and right ankle. Anthropologists speculate that Otzi’s tattoos were applied as a form of healing ritual because their appearance closely resembles the acupuncture patterns we see today. Like the tattoos themselves, it seems that people have been suffering from low back pain and arthritis of the knees throughout the centuries. Amazingly, the islands of Great Britain even take their name from the practice of tattooing, with the term ‘Britons’ literally translating as ‘the people of the designs.’ The British people continue to be the most tattooed folks in Europe. And throughout world history, people have been forcibly tattooed for identification purposes in every culture which practiced human bondage.
May 2012 JOURNAL MSMA 165
Dermatologists by necessity have a vested interest in tattoos and today classify them into five basic sub-groups. There are the ‘amateur or homemade tattoos.’ Examples of this risky, unsanitary, and disfiguring practice can be seen in ex-convicts and wannabe gang members. Often they are of a ‘teardrop’ configuration (which is said to mark a death or murder) and are done with cigarette ashes or ink salvaged from pens. The most mainstream group these days are the ‘professionally applied/ artistic tattoos’ which may range from a simple butterfly or star on the ankle to the very large, vividly ornate themed tattoos displayed on multiple body parts. Thankfully most are now done under hygienic conditions in trendy tattoo parlors. There are the ‘post-traumatic tattoos’ such as can be seen from a remote encounter with asphalt (road burn) or the common grade-school scuffle which leaves permanent pencil lead marks. The two final categories, the ‘cosmetically applied tattoos’ (permanent facial make-up) and the ‘medical tattoos,’ are applied by professionals in clinical facilities. As a med student, I first encountered serious tattoo art in my VA hospital rotations, veterans bearing permanent mementoes of tours of duty from every military theater since the turn of the century. They were particularly de rigueur among the Navy men. They were casually observed and remarked upon as identifying features of the physical exam and no negative significance was attached to them or the men who bore them. Big grey battleships, colorful US flags, and the ubiquitous naked pin-up girls were the norm, all serving to tell the story of my patient’s former incarnation. Thirty years ago I recall inheriting my first tattooed female patient in private practice. She was 98 then and was languishing in our local nursing home, stricken with advanced dementia. In stark contrast to all my other little old ladies, she had several godawful, washed out tattoos on both her arms…undecipherable names and unrecognizable symbols. I wondered when and under what circumstances she had acquired these frightful markings but never learned their origin. She never had any visitors, and her vocabulary consisted of two words repeated endlessly, “Kah, kah, kah-meer….kah, kah, KAH-MEER!” Interestingly, the Latin word for tattoo is ‘stigma’ and indeed that is what this elderly woman’s markings implied to me. Her mysterious history became a constant source of speculation as I tried to envision the rough and rowdy ways of her past lifestyle back around the turn of the century. Had she been a drug addicted prostitute? Had she done prison time? These days the sheer volume of “body art” that I view daily has desensitized me somewhat, but for the most part I still find that people are sadly stigmatized by their mostly ill-advised tattoos. There is nothing cute, classy, sexy or macho about having more tattoos than you do teeth. I strain to be open-minded but find it almost impossible not to feel consternation when someone with a 400 buck “tramp stamp” on her tush moans about not having the money to buy her diabetes meds. Though I have seen plenty of patients with intriguing tattoos in medical practice, I have only very rarely met a ‘tattooed lady.’ One dear older friend of mine recently called my attention to her tattooed-on permanent eyebrows, almost indistinguishable from the real thing. She had them done when after years of fashionably plucking them. “My eyebrows just seemed to disappear on me.” Most recently I saw a tattooed lady whose story piqued my interest. A fortyish African-American woman who had just undergone a complete mastectomy and breast reconstruction asked if I wanted to see her new tattoo. My eyes must have displayed some disapproval for she immediately said, “Oh, but you will really like my tattoo!” She then proudly displayed for me her newly acquired aureola on the reconstructed breast. Her plastic surgeon did a marvelous job for it was a perfect match to the nipple of her healthy breast in size shape and color. The most singularly memorable tattoo I have encountered throughout my medical career…a ghostly blue series of six numbers on the forearm of an elderly German woman who was branded by the Nazis in an Auschwitz prison camp. Now there was a tattooed lady. Truly there are as many types of tattoos are there are personalities. The fascination for those of us unadorned has to lie within the life stories they evoke, whether they are expressed to us audibly or simply inferred from observation. When I named my patient Lydia I was paying homage to a Groucho Marx song in the wildly funny “At the Circus.” Lydia, oh Lydia, say, have you met Lydia? Lydia the Tattooed Lady? When her muscles start relaxin’ Up the hill comes Andrew Jackson Lydia, oh Lydia, that encyclopedia Lydia the queen of tattoo. For two bits she will do the mazurka in jazz With a view of Niagara that nobody has And on a clear day, you can see Alcatraz You can learn a lot from Lydia! My patient, my Lydia, accomplished her goal that day in the clinic. She captured my rapt attention and shared the take-home message of her life story with me. I learned a lot from Lydia. The tattoos of life. Everyone has them. I possess some very special patients with tattoos. My rapidly diminishing World War II veteran population bears what I term ‘progressive tattoos,’ a hybrid of those acquired 60 years ago overlaid and disfigured
166 JOURNAL MSMA
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by the ravages of time and ill health. Most of the guys are on blood thinners that cause their crepe paper skin to bruise at the slightest bump. I touch the wrinkled thinning hide of these my heroes and have to fight a teary eye. I watch their eagles and anchors mutate and mottle over time through a succession of blue and purple shades. That lovely blonde bombshell tattooed on an upper arm now appears to have a good case of varicose veins. Many of the old military emblems once worn so proudly have finally evolved into an unidentifiable rusty brown conglomeration, altered by stains caused by the iron in his blood, a testament to a half century of manual labor. These are the tattoos of a hard but well-lived life. Then I realize that we all acquire tattoos sooner or later...tattoos which bear witness to the slings and arrows of our outrageous misfortunes. My older brother had a big blue-black tattoo on the crown of his head. While playing as a child he was accidentally struck by a hatchet. Our grandmother staunched the rapidly bleeding scalp laceration by putting fireplace ashes in it. This old country remedy stopped the hemorrhaging, but the ashes and soot never left his scalp. I remember last noticing my brother’s ‘tattoo of life’ some 30 years later on the day he was buried. I inspect my skin for my own tattoos of life. I am acquiring a veritable constellation of them. There is a rusty scar on my calf from an encounter with a barbed wire fence. There are brown spots and white stretch marks that came with pregnancy and never quite went away. There are some permanent radiation burn discolorations on my neck, a residual from cancer treatment. I have one blue leg vein which for all the world resembles a topographical map of the Mississippi River. Our bodies are already something of a masterpiece, a truly one of a kind piece of artwork. These tattoos of life are the indelible souvenirs of our fantastic journey on this planet. The tattoos of our lives make us unique, make us special, make us ‘cool.’ They tell our stories like nothing else can. And they come to us soon enough in life. There is no need to pay extra for them. r [“Una Voce” (With One Voice), is a column in the JMSMA featuring the prose of Dwalia South, MD. Her new book Una Voce, a collection of selected JMSMA columns, will soon be available. Having served as an associate editor of the JMSMA, she currently chairs the MSMA Committee on Publications. A past president of the MSMA and the Mississippi Academy of Family Physicians (MAFP), Dr. South is a family physician in Ripley affiliated with North Mississippi Primary Care Associates, Inc. She is a past recipient of the MSMA James C. Waites Leadership Award, the MAFP “Family Physician of the Year Award,” and was named one of America’s Top Family Doctors of the Year: 2004-2005. She has served on the Mississippi State Board of Medical Licensure and the Mississippi Foundation for Medical Care Board of Trustees. In addition to writing, Dr. South enjoys the art of oral storytelling and operating her family farm business, Green Hills Farm, producing Quarter horses, Longhorn cattle, and pine trees. This poem, “Hen Scratch,” is an JNLMSMed-BW2 epithalamium to her new husband, musician Roger Yancey, whom she married October 2, 2011.] —Ed.
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May 2012 JOURNAL MSMA 167
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Dear Kay:
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Express your opinion in the JMSMA through a letter to the editor or guest editorial. Letters for publication should be less than 300 words. Guest editorials or comments may be longer, with an average of 600 words All letters are subject to editing for length and clarity. If you are writing in response to a particular article, please mention the headline and issue date in your letter. Also include your contact information. While we do not publish street addresses, e-mail addresses or telephone numbers, we do verify authorship, as well as try to clear up ambiguities, to protect our letter-writers. You may submit your letter via email to KEvers@ MSMA online.com or mail to: P.O. Box 2548, Ridgeland, MS 39158-2548.
ThisThank forum is intended primarily forinyoung you for your interest the physicians beginning their practice though all members of the JOURNAL MSMA. Your ad is typeset MSMA are invited to attend. Its purpose is to convey for a 8 information line b/w ad at rate ofknowledge $4.00 and up-to-date to the promote line plus an additional skillsper that will($32.00) better enhance patient care and practice typesetting charge of is $25 for a rate of operations. The conference designed to provide an avenue for learning through formal lectures, informal $57.00 for the May insertion; $44.00 discussions with course faculty and exchange of ideas thereafter. among peers related to issues of interest to young physicians.
This ad will run in the May 2012 issue and thereafter until you notify us to discontinue the ad. Please proof, sign off, fax back (FAX 601-853-6746) or call if you have questions, 601-8536733, extension 323. You will also need to include your full billing information to mail an invoice with a copy of the magazine featuring your ad. All cancellations must be received in writing by the first of the month for the following month’s issue.
PHYSICIANS NEEDED Many thanks,Neurologists, Psychiatrists, etc. Internists, Cardiologists, Ophthalmologists, Pediatricians, Orthopedists, interested in performing consultative evaluations according to Social Security guidelines.
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DISABILITY DETERMINATION SERVICES 1-800-962-2230 168 JOURNAL MSMA
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May 2012 JOURNAL MSMA 169
Delta doctors, don’t get left behind. Does your practice need electronic health records but you’re putting it off until tomorrow?
MSMA and the Delta Health Alliance can help Delta physicians achieve better health outcomes for your patients and earn federal incentive payments through meaningful use of electronic health records…
AT LITTLE COST TO YOU! Contact MSMA for more information! 601.853.6733
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170 JOURNAL MSMA
May 2012
K
• aSclepiad •
ELLY SCOTT SEGARS, SR., MD, OF IUKA— This month’s physician portrait is of Dr. Kelly S. Segars, Sr., a family physician legend of Iuka, current member of the Mississippi State Board of Health, past MAFP Family Physician of the Year (2002), and a longtime member of our MSMA. Segars is also renowned for his renaissance interests, which range from founding a bank to operating radio stations to flying airplanes. Born in Red Bay, Alabama (a small hamlet located near the state line 30 miles south of Iuka), Segars obtained his pharmacy degree from Auburn University. At the end of college, he married his high school sweetheart, Martha Thompson. Additionally, he was commissioned a second lieutenant and served in the Korean War. His experience there at a battalion aid station would foster his interest in medicine as a career. In February 1956, Kelly entered the newly created four-year School of Medicine at UMMC, where he was in the first class to start and finish in Jackson. Kelly graduated in 1959, heading to Norfolk, Virginia, for a one-year internship with the U.S. Public Health Service. Kelly and Martha then brought their young family back to Mississippi, choosing the bustling rural city of Iuka, located in Tishomingo County. Here he would practice family medicine for decades and rear his three children. Originally in a three man practice, he worked long hours seeing clinic and hospital patients, performing surgeries, delivering over 500 babies in his career, and eventually becoming board certified in geriatrics. In 1982, he started a private clinic, now operated by his son, Scott. As far as his philosophy of medicine, Kelly advises: “Treat everybody like you would like to be treated. You will never go wrong if you do.” Early in his practice, Kelly built a “call room” at his house which had everything he needed to care for most patients: an exam table, blood pressure cuffs, suture material, meds, and most supplies and equipment for patient encounters short of x-rays. When he was on call, patients would drive up to his house to be seen. Kelly remembers the terrible 1964 flu epidemic as especially onerous. One day he started at 5 am with house calls, had a full day at the clinic and hospital, and then had six cars with patients waiting at his house at day’s end. When he wrapped up at 11 pm, he had seen 110 patients total. Commenting on modern medicine, Kelly says that “the technology is amazing, but the politics are horrible.” Kelly has passionate interests and grand successes outside of medicine. “My favorite pastime was flying,” he relates, revealing that he learned to fly solo while a student at Auburn. Kelly flew until the age of 70. He also opened a bank in 1964, and he still serves as president and chairman of the board. That bank, First American National, has become quite successful over the years, with nine offices in four counties. This photo is by Sue Elam, courtesy UMMC public relations. For more on Dr. Segars’s amazing life, see Mississippi Medicine, Spring 2012 (pages 21-25). — Lucius M. Lampton, JMSMA Editor
May 2012 JOURNAL MSMA 171
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