VOL. LVII • NO. 11 • 2016

VOL. LVIII • NO. 11 • 2016

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VOL. LVIII • NO. 11 • NOVEMBER 2016

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

THE ASSOCIATION President Lee Voulters, MD President-Elect William M. Grantham, MD

SCIENTIFIC ARTICLES Telemedicine in Mississippi: Can It Improve Our Last Place in Health?

Sara B. Parker, BA; Richard D. deShazo, MD; Michael Adcock, MSN, FACHE; Kathryn Rodenmeyer, BA

MANAGING EDITOR Karen A. Evers

Secretary-Treasurer Michael Mansour, MD

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

Speaker Geri Lee Weiland, MD

Clinical Problem-Solving: “I’m coughing up blood.”

Sarah E. Barowka MD; T. Ray Perrine MD; Karen Hughes MD

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Vice Speaker Jeffrey A. Morris, MD

Ten Things You Want to Know about Vaccines for Adults Saira Butt, MD and Amir Tirmizi, MD

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Executive Director Charmain Kanosky

DEPARTMENTS From the Editor – Will Trump Bring Relief to Docs and Patients?

Lucius M. Lampton, MD, Editor

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.

Reducing Barriers to 17-Hydroxprogestrone Caproate (17P) Injections to Prevent Recurrent Preterm Birth in Mississippi James A. Bofill, MD; Charlene H. Collier, MD, MPH; Meg Pearson, Pharm D; James M. Shwayder, MD; John C. Morrison, MD

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President’s Page – Free Drug Discount Card Can Help Your Patients Get Meds Lee Voulters, MD

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Commentary – Child Abuse & Neglect in Mississippi: Beginning the Conversation Stephen Beam, MD and Karla Steckler Tye, LPC

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Personals

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

Poetry and Medicine – “Autonomy” 374 James K. Glisson, MD, PharmD

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

RELATED ORGANIZATIONS MSDH – Reportable Disease Stats UMMC – Healthcare Management by Design MAFP – Foundation/Library UMMC – #AskTheHIVDoc Campaign Taps Mena’s STD Expertise

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 © 2016 Mississippi State Medical Association.

Official Publication

MSMA • Since 1959

ABOUT THE COVER

“Stop and Pray”– Martin Pomphrey, MD shot this photograph of an old rural church at a railroad crossing on Highway 45 south of his hometown, Mayhew, on the way towards Macon, MS. Dr. Pomphrey recalls taking the photograph about 20 years ago and has looked for the church recently. However, he says it must have been torn down or replaced as it no longer stands. – Ed. n JOURNAL MSMA

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F R O M

T H E

E D I T O R

Will Trump Bring Relief to Docs and Patients?

F

or many years, Mississippi physicians have felt like humorist Jerry Clower’s treeclimbing, raccoon hunter John Eubanks.

Jerry’s most famous tale was “A Coon Huntin’ Story,” set deep in the Amite River swamps with a group of coon hunters and a pack of hounds having treed what they thought was a coon in the top of a massive sweetgum tree. Jerry’s cousin John Eubanks climbed the tree planning to Lucius M. Lampton, MD punch the coon out with a sharp stick. Up Editor there, John found instead of a coon a “souped up wildcat” which proceeded to attack him! Squalling for help, John hollered to the hunters on the ground to “shoot up in here amongst us, one of us got to have some relief!”

With all the regulatory burdens and systemic disruptions of Obamacare, SGR, MIPS, Meaningful Use, and MACRA, physicians, like John Eubanks, are squalling for “some relief ” for both our patients and our profession. As this issue goes to press, Donald J. Trump’s upset election on November 8 over Hillary Clinton has shocked the world with forecasts of

significant change. Trump campaigned on repealing Obamacare, which has failed on multiple levels for both physicians and patients. He also pledged to keep many positive aspects of the legislation: allowing children to stay on their parents’ insurance until age 26 and protections for those with preexisting conditions. Like the rest of America, most physicians had been anticipating Clinton’s election and the continuation of the status quo.

It is now apparent to all that change is coming in a dramatic way for our health system.

Trump’s nomination of Dr. Tom Price, a Georgia surgeon now Congressman, to become the next Secretary of Health and Human Services certainly bodes well for patients and physicians. Price, who is personally known to most of Mississippi’s AMA delegation, has an extraordinary depth of clinical and policy experience in medicine. He has promoted health policies which focus on patient choice and has shown a genuine commitment to reduce excessive regulatory burdens for practicing physicians.

Some relief might be coming! n Contact me at lukelampton@cableone.net.

— Lucius M. Lampton, MD, Editor

JOURNAL EDITORIAL ADVISORY BOARD Timothy J. Alford, MD Family Physician, Kosy Direct Care

Bradford J. Dye, III, MD Ear Nose & Throat Consultants, Oxford

Michael Artigues, MD Pediatrician, McComb Children’s Clinic

Daniel P. Edney, MD Executive Committee Member, National Disaster Life Support Education Consortium, Internist, Medical Associates of Vicksburg

Diane K. Beebe, MD Professor and Chair, Department of Family Medicine, University of Mississippi Medical Center, Jackson Rep. Sidney W. Bondurant, MD Retired Obstetrician-Gynecologist, Madison Jennifer J. Bryan, MD Assistant Professor, Department of Family Medicine University of Mississippi Medical Center, Jackson Jeffrey D. Carron, MD Professor, Department of Otolaryngology & Communicative Sciences, University of Mississippi Medical Center, Jackson Gordon (Mike) Castleberry, MD Urologist, Starkville Urology Clinic Matthew deShazo, MD, MPH Assistant Professor-Cardiology, University of Mississippi Medical Center, Jackson Thomas E. Dobbs, MD, MPH Chief Medical Officer, VP Quality, South Central Regional Medical Center & Infectious Diseases Consultant, Mississippi State Department of Health, Hattiesburg Sharon Douglas, MD Professor of Medicine and Associate Dean for VA Education, University of Mississippi School of Medicine, Associate Chief of Staff for Education and Ethics, 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

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

Lillian Lien, MD Professor and Director, Division of Endocrinology, 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

William Lineaweaver, MD Editor, Annals of Plastic Surgery, Medical Director, JMS Burn and Reconstruction Center, Brandon

Nitin K. Gupta, MD Assistant Professor-Digestive Diseases, University of Mississippi Medical Center, Jackson Scott Hambleton, MD Medical Director, Mississippi Professionals Health Program, Ridgeland J. Edward Hill, MD Family Physician, Oxford W. Mark Horne, MD Internist, Jefferson Medical Associates, Laurel Daniel W. Jones, MD Sanderson Chair in Obesity, Metabolic Diseases and Nutrition Director, Clinical and Population Science, Mississippi Center for Obesity Research, Professor of Medicine and Physiology, Interim Chair, Department of Medicine Ben E. Kitchens, MD Family Physician, Iuka

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Michael D. Maples, MD Vice President and Chief of Medical Operations, Baptist Health Systems Heddy-Dale Matthias, MD Anesthesiologist, Critical Care Internist, Madison Jason G. Murphy, MD Surgeon, Surgical Clinic Associates, Jackson Alan R. Moore, MD Clinical Neurophysiologist, Muscle and Nerve, Jackson Paul “Hal” Moore Jr., MD Radiologist, Singing River Radiology Group, Pascagoula Ann Myers, MD Rheumatologist , Mississippi Arthritis Clinic, Jackson Darden H. North, MD Obstetrician/Gynecologist , Jackson Health Care-Women, Flowood

Jack D. Owens, MD, MPH Neonatologist, Newborn Associates, Flowood Michelle Y. Owens, MD Associate Professor, Vice-Chair of Obstetrics and Gynecology, University of Mississippi Medical Center, 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 Shou J. Tang, MD Professor and Director, Division of Digestive Diseases, University of Mississippi Medical Center, Jackson Samuel Calvin Thigpen, MD Hematology-Oncology Fellow, Department of Medicine, University of Mississippi Medical Center, Jackson Thad F. Waites, MD Clinical Cardiologist, Hattiesburg Clinic W. Lamar Weems, MD Urologist, Jackson Chris E. Wiggins, MD Orthopaedic Surgeon, Bienville Orthopaedic Specialists, Pascagoula John E. Wilkaitis, MD Chief Medical Officer, Brentwood Behavioral Healthcare, Flowood Sloan C. Youngblood, MD Assistant Medical Director, Department of Anesthesiology, University of Mississippi Medical Center, Jackson

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JOURNAL MSMA

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S C I E N T I F I C

A R T I C L E

Telemedicine in Mississippi: Can It Improve Our Last Place in Health?

SARA B. PARKER, BA; RICHARD D. DESHAZO, MD; MICHAEL ADCOCK, MSN, FACHE; KATHRYN RODENMEYER, BA Introduction The idea of work from a distance is not a new one. Physicians have been doing that by telephone for decades. Likewise, real-time audio-visual work from a distance is an old idea, but Mississippi physicians tell us they have a number of concerns about this new-fangled technological advancement and how it will affect their patients and themselves (Table 1).

FIGURE 1. A 1925 issue of Science and Invention Magazine featured Hugo Gernsback’s contraption for telemedicine called the “teledactyl.”

Table 1. Some Concerns of Mississippi Physicians about Telemedicine 1.

Quality and appropriateness of care delivered

2.

Follow-up for patients with acute medical problems treated by telehealth

3.

Role reversal of physicians by mid-level providers

4.

Loss of financial support for local primary care and basic specialty services

5.

Disintegration of existing healthcare networks

6.

Promotion of health disparities

The idea of telemedicine is not new. In 1925, the cover of Science and Invention magazine featured a drawing of a proposed robot, the Teledactyl (Figure 1). It had skinny fingers hooked up to a radio and an undefined video feed that allowed a doctor to examine a patient from a distance. That idea came from a New York inventor, Dr. Hugo Gernsback.1 Likewise, the use of telemedicine is not new. Health providers have and still use the telephone to diagnose and treat patients and monitor their progress.

New opportunities for telemedicine have appeared as video technology has evolved. The University of Nebraska developed an on-campus teaching model using telemedicine for medical students learning neurology evaluations. By 1964 they provided health services by telemedicine at the Norfolk State Hospital over 100 miles away from their campus.2 In the early 1960s, the United States (U.S.) government realized the military and public health applications of telemedicine and saw an opportunity to address the conundrum of health care for astronauts in the growing National Aeronautics and Space Administration (NASA) program. In the process, NASA developed technology applied to Space Technology Applied Rural Papago Advanced Health Care program (STARPAHC), a partnership between NASA and the Indian Health Services. This program also provided health care to Native Americans on the Papago Reservation in Arizona and subsequently to astronauts and rapidly accelerated translational research in the field.3 342 VOL. 57 • NO. 11 • 2016

With the decision of the Department of Health and Human Services (DHHS) to provide certain telemedicine services and reimbursement to Medicare and Medicaid beneficiaries, the growth of telemedicine has been explosive. In particular, support for services in health professional shortage areas (HPSA) has stimulated rural states to develop telemedicine for large underserved populations.

Mississippi became a leader in telemedicine by another route, a public-private partnership that evolved from the efforts of a former Californian who came to UMMC as a department chair and found emergency services here in a quandary. Now the American Telehealth Association (ATA) has designated Mississippi as a “telehealth friendly” state, a designation that reflects an active interest in the state to pass the necessary legislation to facilitate the practice of telehealth and provide appropriate facilities for its development.

Today, the ATA reports that there are over 200 telemedicine networks with over 3500 service sites in the U.S. The Veterans Administration alone provided over 300,000 remote consultations using telemedicine by 2011.4 This review was developed in part as fact-finding for a recent Public Broadcasting documentary, Telehealth: A Virtual Lifeline

available at www.mpbonline.org/telehealth and hopefully will provide information useful to practitioners of medicine in our region.

In this article we review the present status of telemedicine in the U.S. and how Mississippi has become a pacesetter in the application of it. We also discuss physician concerns about the potential pitfalls of telemedicine.

The Critical Access Hospital Connection Mississippi was fortunate to have received considerable federal funding for Critical Access Hospitals in order to improve healthcare for patients in rural health facilities where resources are limited. The Balanced Budget Act of 1997 created Critical Access Hospitals (CAHs) after an epidemic of rural hospital financial failures. In order to receive the Critical Access designation for reimbursement purposes, CAHs must provide 24/7 emergency services, have less than 26 inpatient beds, and be located in a rural area of the state.5 By 2003, the number of CAHs across Mississippi could no longer provide physician oversight of emergency rooms to continue successfully operating.

Robert L. Galli, MD, an academic emergency physician, internist, and Chair of the UMMC Department of Emergency Medicine, put his head together with emergency medicine nurse practitioner Kristi Henderson, DNP, and Gregory S. Hall, CNE, a computer FIGURE 2. Robert Galli, MD at TelEmergency Telemedicine Center in the UMMC Emergency Department. On this occasion, he was monitoring operations at a distant locations using audio and video access to patients and providers.

network specialist, to address the problem (Figure 2). Colleague Richard L. Summers, MD, subsequently assisted with a successful grant application to the Bower Foundation in support of a 3 hospital “TelEmergency” system using off-the-shelf electronic components and an emergency medicine training program for nurse practitioners.

The grant also supported cable installation between the UMMC Emergency Department and the three Critical Access Hospitals.

As expansion progressed, Kristi Henderson helped obtain scope of practice approval for their duties from the State Board of Nursing and became the program director. Medical Center leadership supported legislation for Mississippi Section rulings on the practice of telemedicine and helped gain support from the hospital, physician and nursing organizations and licensure boards (Table 2). Between 2003-2016, the TelEmergency program grew from three CAHs to fifteen (Figure 3).6 A partnership with an interested telecommunications company, C-Spire Inc., resulted in 6,000+ route miles of new fiber optic cable across the state as well.

Table 2. Some Mississippi Section Rules for TelEmergency Medicine Telemedicine is defined as the communication of a physician in one location with a patient in another by electronic means.

TelEmergency telemedicine is the combination of telemedicine and the consultation of a board certified emergency medicine specialist with an appropriately skilled nurse practitioner or physician’s assistant.

Only physicians licensed in Mississippi may practice telemedicine in the state and those practicing TelEmergency medicine must be located at a Level 1 Trauma Center.

A valid patient-physician relationship must be established including diagnosis and treatment and using accepted medical practices with the establishment of a medical record available to other providers.

An examination must be done prior to diagnosis but may not necessarily be done in person if technology is sufficient to collect the same information collected in face to face examinations.

Adapted from Miss. Code Ann. 73-25-34 (1972 as amended), Part 2635, Chapter 5, Practice of Telemedicine. Amended 2003, 2004, 2006, 2010.

FIGURE 3. Counties in Mississippi with present access to UMMC Telehealth (white)

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Table 3. Telehealth Providers Presently Operating in Mississippi 24/7 Dr. Help American Well Beacham/ Freedom Hospital of Magnolia ClickMedix Doctor on Demand E-Psychiatry First Stop Health FlexCare HealthTap InSight Telepsychiatry LiveHealth Online MDLive Memorial Hospital at Gulfport My Dr. Now North Mississippi Medical Center Specialists on Call St. Dominic Hospital Teladoc TelehealthONE University of Mississippi Medical Center (UMMC) – Center for Telehealth WorldClinic

the state government as a whole in the interest of patients. This was essential as the Mississippi legislature governs the scope of practice of health professionals through a series of licensure boards and other state agencies (Table 5). Thus, telemedicine was defined in the Mississippi Legislative Code as part of the TelEmergency Medicine initiative in 2003.13 Table 5. S tate Agencies Delegated Oversight of Telemedicine by the Mississippi Legislature State Board of Health1 To develop rules and regulations for the delivery of health services and to collect data on them.

State Insurance Commission2 Directs the insurance commissioner to assure that all health insurance and employee benefit plans in this state must provide coverage for telemedicine services to the same extent that the services would be covered if they were provided through in-person consultation.

Coverage for Telemedicine Services3,4 Telemedicine must be real time consultation through interactive video and does not include audio only, email, or facsimile.

Table 4. T elehealth Services Presently Provided by the University of Mississippi Medical Center

Store and forward services using the transfer of medical data through camera or other devices that record images sent via telecommunications are covered telemedicine services.

TelEmergency Medicine for Emergency Medicine and Trauma

Physician Licensure Board5

Hospital Medicine and ICU coverage, telemetry, in-patient monitoring and consultation for critical care physicians and nurses

Physicians practicing telemedicine in Mississippi must be licensed in Mississippi unless a licensed Mississippi physician has requested the consultation.

Corporate employee health programs

Standards of Practice6

Telehealth training and development

Physicians may prescribe drugs and medical supplies using the same standards of appropriate practice as those in traditional provider-patient settings.

(1) Miss. Code Ann 41-3-15, (2) Miss. Code Ann 83-9-351, (3) Miss. Code Ann 83-9-351, (4) Miss. Code Ann 83-9-353, (5) Miss. Code Ann 73-25-34, (6) Miss. Code Ann 41-127-1 Conner Reeves, Esq., provided the information used for this table.

Cardiology- EKG, Holter, Echo, Stress test, and CT angiography reading services Synchronous telehealth services in real time for patient consultations in most specialties of medicine, pediatrics, and psychiatry The Center for Telehealth at the University of Mississippi Medical Center now delivers telehealth services to 213 Mississippi locations outside of the Medical Center. Courtesy UMMC Center for Telehealth

There has been explosive growth of other applications of telemedicine, especially in employee health programs. For instance, in 2016, the Mississippi Department of Finance and Administration released a request for proposals to provide telehealth services to the 190,000 members of the State and School Employee Health Plan, and over twenty private telehealth companies have entered the telemedicine market in Mississippi to date (Table 3).7 Mississippi provides an example of success on a pathway to leadership in telemedicine, now often called telehealth, despite limited resources and the difficulties of innovation and navigation of competing interests (Table 4).8,9 As a collaboration evolved between the University of Mississippi Medical Center, state political leadership, private-public partnerships, and the interest and support of the state’s physicians, nurses, and politicians to address Mississippi’s last place in health designation, telemedicine has flourished.10,11,12 On the positive side, the professional organizations have used their power to speak to 344 VOL. 57 • NO. 11 • 2016

Federal Support of Telemedicine The federal government defines telemedicine as “two-way real time interactive communication between the patient and the physician or practitioner at a distant site. This electronic communication includes, at a minimum, audio and video equipment.”14 Most federal programs such as Medicaid, the Department of Defense, and the Veteran’s Administration have been quick to embrace telemedicine.

Medicare, on the other hand, has been slower to support telemedicine with coverage varying greatly.15,16,17,18 Medicare primarily reimburses telehealth services offered by providers at distant sites to Medicare beneficiaries in Health Professions Shortage Areas. Originating sites authorized by Medicare law include 8 locations (Table 6). Medicare initially reimbursed providers for a limited number of very specific health services with strict requirements but has gradually expanded the list of reimbursable telemedicine services. Physicians, nurse practitioners, physician assistants, nurse midwives, clinical nurse specialists, clinical psychologists, clinical social workers, and registered dieticians or nutrition professionals make up the eight eligible providers for Medicare reimbursement for telehealth services.

Table 6. Telemedicine Services Reimbursed by Medicare Where provided An eligible provider not at the patient’s location may provide services for a patient seen in a doctor’s office, hospital, critical access hospital, rural health clinic, federally qualified health center, hospital-based dialysis center, state nursing home, or community mental health center Services provided Office visits, psychotherapy, consultations, “certain other services” under “certain conditions” How provided Two-way telecommunication system “like real-time audio and video” Medicare and You 2017. CMS Product 10050-17. 2016. Centers for Medicare and Medicaid Services (CMS). 7500 Security Blvd., Baltimore, MD, 21244-1850

Almost every Medicare managed plan offers at least some telehealth services, but the information presently provided to beneficiaries

by Medicare is vague.19 For instance, the beneficiaries of Medicare Advantage (managed care) plans have flexibility in using telehealth and may be reimbursed if their provider offers any of the following services: Store-and-Forward telemedicine (or medical data saved and access at a later point in time) or Synchronous, real-time, telemedicine.

However, only certain Current Procedure Terminology (CPT) and Healthcare Common Procedure Coding Systems (HCPCS) codes used with the GT modifier are eligible for Telemedicine as listed on the Center for Medicare and Medicare Services website. A Medicare physician fee schedule look-up tool provides present Medicare reimbursement rates.20 Unlike Medicare, Medicaid programs are state sponsored and are subject to state laws on telemedicine practice. States have the ability to determine what types, locations, methods, and providers of telemedicine will be reimbursed, as well as whether or not to cover telemedicine at all. States have the option to choose reimbursement levels as long as payments do not exceed the federal upper limits payment authorization. The Center for Connected Health Policy (CCHP) provides information on the status of Medicaid sponsored Telehealth.21 For example, of all of the state Medicaid programs, 46 cover Live Video, 9 cover Store-and-Forward telemedicine, 14 cover Remote Patient Monitoring, 3 cover all major types of telemedicine, and 26 cover a facility and transmission fee.

Confusing Definitions In present parlance, telehealth includes telephones, facsimile machines, electronic mail systems, and remote patient monitoring devices. While these entities do not meet the Medicaid definition of telemedicine, they are often considered to be telehealth services and may be covered and reimbursed as part of a Medicaid coverable service, such as a laboratory, x-ray or physician service. The proliferation of different types of medical services divided using audio or audio-visual communications has led to confusion over definitions. Most agree that the broad title of telehealth is the best working definition of these efforts where telemedicine specifically refers to a patient and provider

in a video chat environment. This includes the presence of software that allows the primary care provider to examine the patient, make a diagnosis, and either treat or refer the patient to a more appropriate level of care. Several specialties are among the most frequent users (Table 7).

Table 7. Early Adopters of Telemedicine Teledermatology

Telepathology

Telenephrology

Telepsychiatry

Teleophthamology

Teleoncology

Teleradiology Telerehabilitation

Telemedicine may also refer to the type of technology used. These include, networked programs providing connections between remote health facilities and multiple larger metropolitan facilities, for instance multiple academic health centers. Point-to-point connections link remote health centers to a single larger health facility. This technology is often used for obtaining subspecialty consultations for patients seen in the primary care environment. Monitoring center links allow remote patient monitoring, for example in critical care units.

Big Questions about Telemedicine Compared to Usual Care With the high demand for telemedicine, legislators and Congress are rushing to pass oversight legislation and are heavily lobbied by providers and the industry. Many telemedicine bills await consideration in state legislatures and Congress. So, what about effectiveness, acceptability, and cost of telehealth? There is great promise, especially in underserved areas like Mississippi,12 but what about the risks?

The majority of published studies, including systematic reviews, are short term, have small patient numbers and methodological deficiencies.22,23 It appears safe to say that telemedicine has great utility in the delivery of care in many military applications and in improving access to care in remote locations with few health providers.15 Available studies consistently demonstrate positive evaluations by providers and patients.24,25 Fortunately, standards have recently been established by scholars in the field on how best to perform systematic reviews of telemedicine studies using currently available statistical techniques.26 We can find no high quality scientific studies on telemedicine from Mississippi.

The Cochran Library references 13 active and ongoing systematic reviews of Telemedicine.27 Of the 13, 2 have not reached completion, 5 show some evidence of superiority over usual care, 3 show no evidence of superiority over usual care, and 3 found inadequate evidence to reach a conclusion. The most recent review in the group, “Effects on Professional Practice and Health Care Outcomes,” analyzed 93 high quality publications that included 22,047 patients.28 The authors reviewed outcomes on the use of telemedicine versus usual care in the clinical management of diabetes, mental illness, various subspecialty consultations; urogenital, gastroenterological, neurological, malignant, respiratory conditions; studies of support for parents of children in neonatal ICUs; management of co-morbidities and solid organ JOURNAL MSMA

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transplantation. There were no differences in all-cause mortality in patients who received care by telemedicine versus usual care. Hospital admission rates of patients managed by telemedicine ranged from a 64% decrease to a 60% increase compared to usual care. There was “moderate certainty” for improved quality of life, decreases in blood pressure and LDL, and a “high certainty” of lower HbA1c values.

There were no cost comparisons. The authors strongly suggested that further data are required, especially on effectiveness and cost.

It became one of 16 states that will expedite licensure for physicians who wish to practice medicine in multiple states, which will facilitate the use of telemedicine technologies.34 Such authority is given to the Board of Medical Licensure only under the authority and review of the Mississippi Legislature. The Board of Medical Licensure also regulates the collaboration requirements in physicians’ practices with nurse practitioners and physician assistants (and directly regulates the practice of PAs).

The increased use of telemedicine provides an alternate route of healthcare and has enabled more availability of care, consultation opportunities, and quality care monitoring for those who previously did not have access to these services routinely. On the other hand, telemedicine has the potential to reduce face-to-face interactions between patients and providers. For instance, since telemedicine is a virtual interaction, care of a patient with an acute illness by a medical provider using it often involves two parties unfamiliar with each other, the absence of a patient’s complete medical record, and the inability to perform percussion, palpation, and other physical examination techniques helpful to skilled diagnosticians. Also, the constantly evolving telemedicine legislation poses many opportunities for misadventure in the reimbursement of services including facility and equipment costs.29 Although best practice standards of care for telemedicine have been established by the Federation of State Medical Boards,30 the American Telemedicine Organization,31 and the American Medical Association,32,33 these have not been widely adopted (see The Mississippi Situation below). In addition, legislation, the reimbursement process, equipment costs, state licensure requirements, lack of practice standards, few high quality assessments, and scope of practice disputes among professional groups have created barriers to telemedicine.

Because of the multiple state agencies involved in telemedicine regulation in Mississippi, many differing interests have created a tempestuous telemedicine environment. As a result, sometimes supporters of telemedicine, including national fee for service companies, dialog directly with legislators on issues of oversight without including physicians in the process.

The Mississippi Situation A Complex Business, Legislative, and Medical Environment The situation in Mississippi provides a good example of the complexity of this developing environment. All of the agencies overseeing telemedicine ultimately report to the legislature which has enacted legislation delegating oversight of telemedicine to certain state agencies and commissions. State legislation on telemedicine in Mississippi includes regulations involving the State Department of Health, Department of Insurance, and the State Medical Licensure Board. Three different state legislative codes describe oversight responsibilities. These codes describe the regulations given to the Department of Health, the insurance companies, and Mississippi physicians.

The Department of Health has broad power to regulate telehealth in Mississippi. They have created draft regulations; however, the Mississippi Board of Health has yet to approve them. The insurance code includes a “Parity Law,” which mandates that insurance plans cover telemedicine services at the same rates as regular medical services.

Lastly, the code that speaks to physicians gives the Board of Medical Licensure the duty to establish the definition of the patient-physician relationship, and to assure proper documentation of medical services and licensure of all physicians using telemedicine in Mississippi.

Mississippi recently adopted the Interstate Medical Licensure Compact proposed by the Federation of State Medical Licensure Boards.

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The Texas Telemedicine Story: Implications for Mississippi With the net worth of the telemedicine industry being more than 34 billion dollars per year by 2020,35 tensions among interests in telemedicine have arisen. One example is the Texas Board of Medical Licensure v. Teladoc litigation. When the Texas Board of Medical Licensure attempted to limit the use of what they defined as voice-only telemedicine, ongoing tensions began between a for-profit telemedicine corporation and state physician licensure boards. Teledoc, the nation’s oldest and largest telehealth corporation with headquarters near Dallas, Texas, operates in 46 states. Teledoc sued the Texas Board in 2011 for constraint of trade. The Board has lost 8 appeals and dropped the appeal in November 2016. Teledoc is now working through the Texas legislature to enact legislation in their favor.36 In Mississippi, Teladoc provides telemedicine services through employee health plans to at least 51,000 citizens including directly to consumers. The Mississippi State Medical Association objected to new telehealth legislation favored by most telehealth vendors in 2016, as they were concerned that it could lead to audio-only applications, one of the same concerns expressed by the Texas Board. Teledoc contended that their “interactive audio” allows for patients without access to broadband services and should be approved.

Can Telemedicine Fix Mississippi’s Problems?

There are many reasons Mississippi has been the holder of the “Last Place in American Health” designation since America’s Health Rankings began publishing them.37 The social determinants of health have always been stacked against the state and a libertarian sentiment to correcting them has had a major effect.38 Even though over 165,000 residents under the age of 65 still have no health insurance, Medicaid expansion did not occur.39,40 Access to quality healthcare for our large African American population, 37% of whom live in abject poverty, is a major contributor to the state’s ongoing health disparities.41 Other factors include Mississippi’s lowest physician to patient ratio and its rural geography.42 A network of 21 federally qualified health centers (FQHCs) with clinics at 187 sites, pro bono care by private physicians, teaching clinics at the University of Mississippi Medical Center (UMMC), several private hospitals with teaching programs, a small number of state health department and federally designated Rural Health Clinics, and emergency departments staffed by nurse practi-

tioners in a network of Critical Access Hospitals (CAH) have not been able to fill the access gap.43 Telemedicine has already demonstrated the potential to play a role in addressing the long-term health disparities for the underserved populations in Mississippi and elsewhere. For instance, a pilot program in telemedicine-based diabetes management in the Mississippi Delta region improved clinical markers of diabetes control and strikingly decreased hospital admission rates of patients with diabetes.44 Rather than undercutting local health services programs, telemedicine consultation in critical care, asthma management, pediatric subspecialties, and TelEmergency medicine have allowed patients to receive healthcare near their homes and to continue to use their local hospitals, clinics, and providers without traveling long distances.8 In more urban areas, telemedicine promises to increase patient compliance and outcomes to treatment and provide individualized patient education and services like rehabilitation. With programs like remote patient monitoring, patients can be monitored from the comfort of their own home, while being provided education about their disease state in brief daily health sessions. Near real-time feedback can be provided by nurses directly to a patient when abnormal biometric readings are reported, instead of waiting for the next clinic visit.

used for primary care in underserved populations while economically privileged ones use private healthcare resources. All of these issues are being actively addressed by the telemedicine providers, state agencies, and professional organizations involved. n Acknowledgements Many public and private telemedicine experts provided helpful information used in the development of this paper. These include Conner Reeves, Esq, Council to the Mississippi State Medical Association and Christopher Powe, PhD of TeleHealthONE. References 1.

Telemedicine Predicted in 1925. http://www.smithsonianmag.com/history/telemedicine-predicted-in-1925-124140942/?no-ist. Accessed Sept.

2016.

2. Schleicher, John. UNMC a Pioneer in Telemedicine. UNMC a Pioneer in Telemedicine | UNMC, 10 Feb. 2015. Accessed 29 Aug. 2016.

3. Fuchs, Michael. Provider Attitudes toward STARPAHC. Medical Care 17.1 (1979): 59-68.

4. http://www.americantelemed.org/about-telemedicine/faqs. Accessed Sept.

2016.

There is a seemingly insatiable desire for convenient, quality, and lower cost healthcare by both the government and consumers.22,23 With the political forces aligned to support telehealth as a way to meet those desires, a rapidly expanding industry is shaping the course of American medicine with limited input from physicians and physician professional organizations. The Mississippi experience shows that partnerships between physicians in academic and private practice are an attractive option to protect the interests of physicians and patients.

5. Critical Access Hospitals (2015). Rural Health Information Hub. http:// www.ruralhealthinfo.org/topics/critical-access-hospitals. Accessed 15 Sept.

2016.

A bigger question is what population will be best served by telemedicine. Certainly, those with chronic illnesses should benefit from additional health coaching and monitoring. The convenience of access for medical advice and treatment of minor illnesses and injuries should be beneficial across the board. Access to specialists intuitively should be beneficial as well although the process through which that will be obtained has not been clarified.

8. Sterling SA, Seals SR, Jones AE et al. The impact of the TelEmergency program on rural emergency care: An implementation study. J. Telemed. Telecare 2016.

Present telehealth models in walk-in clinics at pharmacies or directly accessed on-line via computer or smart phone apps may or may not be available for around-the-clock service. Those that require a cash payment prior to service, computer access, or prescriptions may not solve access problems for impoverished families. The lack of a single universally-available database for healthcare providers introduces another level of complexity and risk for providers and patients with complex chronic illnesses using telehealth. The decision by the telehealth provider as to whether the patient requires a higher-level of care such as emergency or specialty care and how the patient is connected to those services is unclear and another risk for fragmentation of care. Likewise, the lack of established protocols for follow-up of patients treated by telemedicine, especially for those unattached to primary care providers, those requiring urgent evaluation by specialists, or those without health insurance, presents numerous potential pitfalls. Finally, questions of equity and health disparities could develop if telemedicine is

6. Galli, R., Keith, JC, McKenzie, K., Hall, G., and Henderson, K. “TelEmergency: A Novel System for Delivering Emergency Care to Rural Hospitals.� Ann. Emerg. Med. 2008; 51:275-284.

7. McIntosh C. Personal communication to Kathryn Rodenmeyer, 7/27/16.

Chuck.McIntosh@dfa.ms.gov.

9. Summers RL, Henderson K, Isom KC, Galli RL. The Anniversary of TelEmergency. JMSMA 2013; (Decemeber) 340-341.

10. Versel N. Senators seek Medicare telehealth parity, more rural broadband.

Med City News. 2015 Apr. 21. http://medcitynews.com/2015/04/senators-seek-medicare-telehealth-parity-rural-broadband/. Accessed 12 Sept.

2016.

11. Pittman D. Mississippi emerges as telemedicine leader. Med City News 2015.

Feb 26. http://medcitynews.com/2015/05/334644/. Accessed 14 Sept.

2016.

12. Versel N. Mississippi telehealth, remote monitoring, pay dividends for diabetics. 2016 Med City News. Sept 13, 2016. http://medcitynews. com/2016/09/mississippi-telehealth-remote-monitoring. Accessed 18 Sept.

2016.

13. Miss. Code Ann. 73-43-11 (1992 as amended). Part 2635. Chapter 5: Practice of Telemedicine, Rules 1-8. http://www.sos.ms.gov/ACCode/00000291c. pdf.

14. https://www.medicaid.gov/medicaid-chip-program-information/by-topics/delivery-systems/telemedicine.html. Accessed 20 Sept. 2016.

15. Poropatich RK, DeTreville R, Lappan C, Barriga CR. The U.S. Army Telemedicine Program: General Overview and Current Status in Southwest Asia.

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Telemedicine and e-Health 2006; 12: 396-408.

16. Cary MP, Spencer M, Carroll A et al. Benefits and Challenges of Delivery Tele-rehabilitative Services to Rural Veterans. Home Healthcare Now 2016; 34: 440-446.

17. Department of Health and Human Services, Center for Medicare and Medicaid Services: Medicare Learning Network. Telehealth Services. Rural Health Services. Medicare Fee for Service Program for 2016. ICN 901705. Dec. 2015. http://go.cms.gov/MLNGetinfo. Accessed 25 Sept. 2016.

18. h t t p : / / w w w. a m e r i c a n te l e m e d . o r g / d o c s / d e f a u l t - s o u rc e / p o l i cy/2016_50-state-telehealth-gaps-analysis--coverage-and-reimbursement. pdf ?sfvrsn=2. Accessed 19 Sept. 2016.

19. Medicare and You 2017. CMS Product 10050-17. 2016. Centers for Medicare and Medicaid Services (CMS). 7500 Security Blvd., Baltimore, MD, 21244-1850. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Net20. work-MLN/MLNProducts/downloads/TelehealthSrvcsfctsht.pdf. Accessed 25 Sept. 2016.

21. http://cchpca.org/sites/default/files/resources/State%20Laws%20 and%20Reimbursement%20Policies%20Report%20Feb%20%202015.pdf.

Accessed 20 Sept. 2016.

22. Mair, F., Whitten, P. Systematic review of studies of patient satisfaction with telemedicine. BMJ 2000; 320:1517-423.

23. Whitten, P.S., Mair, F.S., Hayrux, A., May, C.R. et all. Systematic Review of Cost Effectiveness Studies of Telemedicine Interventions. BMJ 2002; 324: 1434-1437.

24. Tahir D. VA and DOD give Favorable Marks to Telemedicine. http://www. politio.com/tipsheets/morning-ehealth/2016/06/ua-and-dod-give-favorablemarks. Accessed 1 Oct. 2016.

25. Ward MM, Jaana M, Natafgi N. Systematic Review of Telemedicine applications in emergency rooms. Int. J. Med. Inform 2015; 04:601-616.

26. Bashur R, Shannon G, Sapci H. Telemedicine Evaluation. Telemed. J and E-Health 2005; 11: 296-318.

27. http://onlinelibrary.wiley.com/cochranelibrary/search/. Accessed 20 Sept.

2016.

28. Flodgren G, Rachas A, Farmer AJ, et al. The Cochrane Effective Organization of Care Group. First published 7 September 2015. http://www.thecochranelibrary.com/view/2013contents.html.

29. Weinstein RS, Lopez AM, Joseph BA, et al. Telemedicine-telehealth, and mobile health applications that work: opportunities and barriers. Am. J. Med. 2014; 127: 183-187.

30. Federation of State Medical Boards Model Policy for the Appropriate Case of Telemedicine Technology in the Practice of Medicine. Http://www.fsmb. org/Media/Default/PDF/FSMB/Advocacy/FSMB_Telemedicine_Policy. pdf. Accessed 19 Sept 2016.

31. http://www.americantelemed.org/about-telemedicine/faqs. Accessed Sept.

2016.

32.

AMA Telemedicine Policy. https://www.ruralhealthinfo.org/topics/critical-access-hospitals. Accessed 11 Oct. 2016.

33. AMA Adopts New Guidance for Ethical Practice in Telemedicine. http:// www.ama-assn.org/ama/pub/news/news/2016/2016-06-13-new-ethical-guidance-telemedicine.page. Accessed 11 Oct. 2016.

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34. http://www.licenseportability.org/wp-content/uploads/2016/05/KS-MSCompact-Release_May-2016_FINAL.pdf. Accessed Oct. 2016.

35. Mordor Intelligence. Global Telemedicine Market. Growth, Trends, and Forecasts. 2015-2020. http://www.mordorintelligence.com/industry-reports/global-telemedicine-market-industry. Accessed 29 Sept. 2016.

36. Claudia Tucker, VP Government Affairs. Teledoc, with Kathryn Rodenmeyer. July 2016.

37. http://www.americashealthrankings.org/explore/2015-annualreport/measure/Overall/state/MS. Accessed 15 Sept. 2016.

38. Eberhardt, MS, Pamuk, ER. The Important of Place of Residence: Examining Health in Rural and Nonrural Areas. Am. J. Pub. Health. 2004; 94: 1682-1686.

39. “Telemedicine and Telehealth Services.” American Telemedicine Association. 2013. (http://www.countyhealthrankings.org/app/mississippi/2013/ measure/factors/85/map). Accessed 16 Sept. 2016.

40. 5 Years Later: How the Affordable Care Act is Working for Mississippi. U.S. Department of Health and Human Services. http://www.hhs.gov/healthcare/facts-and-features/state-by-state/how-aca-is-working-for-mississippi/ index.html (Last updated 11-2-2015).

41. Mississippi State Department of Health, State of the State: Annual Mississippi Health Disparities and Inequalities Report, 2015. http://msdh.ms.gov/ msdhsite/_static/resources/6414.pdf.

42. http://www.usatoday.com/story/money/business/2012/10/20/doctorsshortage-least-most/1644837/. Accessed 25 Sept 2016.

43. Critical Access Hospitals (2015). Rural Health Information Hub. http:// www.ruralhealthinfo.org/topics/critical-access-hospitals. Accessed 15 Sept.

2016.

44. UMMC Telehealth Enters Next Chapter Of Remote Patient Monitoring.

University of Mississippi Medical Center Division of Public Affairs. 12 Oct. 2016.

Author Information: Departments of Medicine and Pediatrics (Ms. Parker and Dr. deShazo).

Center for Telehealth (Mr. Adcock). The University of Mississippi Medical Center and Southern Remedy Productions, Mississippi Public Broadcasting (Ms. Rodenmeyer). Jackson, MS. Corresponding Author: Richard D. deShazo, MD, University of Mississippi Medical Center, 2500 N. State St., Jackson, MS, 39216.

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Reducing Barriers to 17-Hydroxprogestrone Caproate (17P) Injections to Prevent Recurrent Preterm Birth in Mississippi JAMES A. BOFILL, MD; CHARLENE H. COLLIER, MD, MPH; MEG PEARSON, PHARM D; JAMES M. SHWAYDER, MD; JOHN C. MORRISON, MD

In the United States about 12 percent of infants (approximately onehalf million per year) are born at less than 37 weeks gestations and such preterm births account for 85% of all perinatal morbidity and mortality.1 Treating preterm labor once it has started is difficult, and it is more effective to extend gestation before contractions and advanced cervical dilatation are established.2 Fortunately when 17-alpha hydroxy progesterone caproate (17P) is injected weekly beginning at 16-20 weeks until 36 weeks in women who have had a prior spontaneous singleton preterm birth, the risk of preterm birth can be reduced by up to 34%.3 Therefore, while the cause of preterm birth is multifactorial, we have one effective method of preventing preterm birth in certain very high-risk women.4 In Mississippi we have not reduced the preterm rate as effectively as many other states. Our efforts recently received an ‘F’ by the March of Dimes on their annual state report card (rank 49/50).5 Unfortunately, our state has the lowest per-capital income, the least education, and one of the highest rates of smoking: all factors contributing to early delivery.6 While altering any of these issues is extremely challenging, increasing the use of effective strategies, such as weekly injections of 17P, should be a top priority to reduce the burden of preterm birth for all patient populations.

It is difficult to quantify the percentage of eligible women with a prior preterm delivery who have received 17P in Mississippi. However, based on the experience of other states, it is very likely underutilized.

According to a recent study, in Louisiana only 7.4% eligible women covered by Medicaid received 17P during the calendar year 2010.7 In another investigation, Stringer et al. reported that 47 % of eligible women at two hospital systems in North Carolina received one dose of 17P, while far fewer got at least half the projected number of injections.8 In Mississippi 17P is covered by all major private insurance companies, while our two managed Medicaid plans (Magnolia and UnitedHealth Care) offer the medication to appropriately selected women. The Infant Mortality Reduction Collaborative sponsored by our legislature has been working diligently to assure that these women receive this medication.

Therefore, while the insurance coverage for 17P is not an issue, there remain challenges to accessing the medication for providers and 350 VOL. 57 • NO. 11 • 2016

patients. First, it is important to note that 17P was initially available as a compounded medication (cost about $15 per dose). The FDA approved (2010) medication, MakenaTM (manufactured by KV Pharmaceutical and marketed by Ther-Rx), was priced as high as $1500 per dose.9 Unwarranted pricing led to a severe backlash at the national level. The outrage resulted in Ther-Rx being closed.

The new company market MakenaTM (AMAG pharmaceuticals) has reduced the cost of 17P, resulting in a pricing structure acceptable to insurance companies and managed Medicaid plans. Some states and medical systems continue to provide compounded 17P in spite of an FDA ruling stating that the “FDA approved product, MakenaTM, should be used instead of a compounded drug except when there is a specific medical need (e.g. allergy) that cannot be met by the approved drug.”10 In 2013, the Mississippi Board of Pharmacy enforced the FDA policy, making compounded 17P largely unavailable to women and a risky option from a medical liability standpoint.

Despite being covered by insurance, there are different options for obtaining 17P. While private payors allow the medication to be purchased through a pharmacy and delivered to the physician’s office, some others (such as Medicaid) require the physician’s office to cover the up-front cost of the medication of an entire vial, then be reimbursed for each dose, a system called ‘buy and bill’. This can prove costly and inconvenient for many providers, leading many doctors to forego prescribing 17P. Another challenge is the delay it takes for women to be enrolled in Medicaid and then receive approval from the managed plans for 17P. Each process can take weeks in some instances. If a woman presents late in her first trimester or second trimester before having adequate insurance coverage she may miss the recommended 16 to 20 weeks gestation time frame to initiate 17P. Fortunately, while it is ideal to begin the weekly injections early in the second trimester, there is good data to support the initiation of 17P as late as 28 weeks, as it is still considered helpful in extending pregnancy to near term.11,12 There exist other patient and provider barriers to the adequate use of 17P. A weekly injection in a physician’s office can be very difficult for a patient challenged by issues like employment, transportation,

and childcare. Some providers and patients may demonstrate apathy concerning the issue of spontaneous preterm birth (particularly if the prior delivery was a late preterm birth or the infant did not experience any long-term sequelae of prematurity). Another issue is the nihilistic response; “nothing works to prevent early delivery.”2 Physicians must accept and educate patients that this is an opportunity to use the only FDA – approved medication confirmed to prevent recurrent early delivery.

Why can’t we do better in prescribing the only proven treatment to prevent preterm birth? Mississippi is particularly challenged as we have one of the highest preterm birth rates in America.

To adequately treat patients at risk for recurrent spontaneous preterm birth and eligible for 17P, it appears our approach to the problem should be three-pronged. First, an intensive educational campaign geared toward obstetricians, family physicians, and other providers who deliver prenatal care should be developed. The campaign to highlight the known advantages of 17P can be introduced at local, state, and regional meetings, as well as during professional health education sessions presented by the State Board of Health, the University Medical Center, third-party payors, and malpractice insurance providers (such as Medical Assurance).

During such educational sessions, it should be emphasized that women with prior preterm birth should receive this medication beginning as early in the gestation as possible (16-20 weeks) and even later in gestation as its use is still beneficial to prevent preterm birth.11,12 Weekly treatments should be continued until 36 weeks (the last injection) so that the maximum benefit will accrue to the patient and fetus.

Second, reducing insurance barriers to access such as removing requirements for prior authorization will expedite the approval of 17P for eligible women. Efforts should be made to discontinue the ‘buy and bill’ system that places the financial burden on the physician for purchasing the medication in advance for Medicaid patients.

Lastly, we need to consider novel solutions to attack this very difficult problem. To help overcome the inconvenience of weekly doctor visits, some states have promoted home nursing visits for the injections or developed state policies that allow for local pharmacists to provide the 17P injection. Another solution put forth by Orsulak et al.7 involves pay-for performance strategy regarding 17P therapy in appropriate Medicaid patients. In Louisiana, managed care organizations that serve these women do not receive full payment unless 17P is given to appropriate women. More recently at the 2016 Annual Meeting for the Society for Maternal Fetal Medicine (SMFM) Meeting (Atlanta, GA - Feb. 2-5, 2016) a national solution was suggested where by organizations such as the American Congress of Obstetrics and Gynecology (ACOG), Society for Maternal-Fetal Medicine (SMFM), and the Center for Medicare/Medicaid Systems (CMS) would partner to support the same pay for performance strategy as it relates to 17P. There are already rumblings of medical liability claims against physicians and managed medical organizations who have not prescribed 17P for appropriate candidates.

In summary, we all need to work together as providers and payors to make certain that women who have had a prior spontaneous preterm

birth receive weekly 17P injections up to 36 weeks. Our goal must be to significantly reduce recurrent and preventable early deliveries. n References 1. Hamilton, BE, Marin JA, Osterman MJK, Curtin CS. Births: National Vital Statistics Report 63. Hayattsville, MD: National Center for Health Statistics, 2014.

2. Haram K, Mortensen JH, Morrison JC. Tocolysis for acute preterm labor: does anything work. J Matern Fetal Neonatal Med. 2015 Mar;28(4):371-8.

3. Meis PJ, Klebanoff M, Thom E, et al. Prevention of recurrent preterm delivery by 17 alpha-hydroxyprogesterone caproate. N Engl J Med 2003;348:2379-85.

4. Society of Maternal-Fetal Medicine Publications Committee, with the assistance of Berghella, V. Progesterone and Preterm Birth Prevention: Translating Clinical Trials Data into Clinical Practice. AM Obstet Gynec. 2012.

376 – 386.

5. March of Dimes. Prematurity Campaign 2013 Progress Report. http://www. marchofdimes.org/materials/prematurity-campaign-progress-report-2013. pdf. Accessed 9/2/16.

6. Braveman PA, Heck K, Egerter S., et al. The Role of Socioeconomic Factors in Black-White Disparities in Preterm Birth. AM J Public Health. 2015. 105: 697-702.

7. Orsulak MK, Block-Abraham D, Gee RE. 17 alpha-hydroxprogesterone caproate access in the Louisiana Medical Population. Clinical Therapeutics 2015: 37: 727-32.

8. Stringer, EM. 17-Hydroxyprogesterone Caproate (17P) Coverage among Eligible Women Delivering at two North Carolina Hospitals in 2012 and 2013: a retrospective cohort study. AM J Obstet Gynecol, Volume 215, Issue 1, July 2016, Pages 105.e1–105.e12.

9. Cohen AW, Copel JA, Macones GA, et al. Unjustified increase in cost of care resulting from U. S. Food and Drug Administration approval of Mekana (17P). Obstet. Gynecol 2011; 117: 1408-12.

10. US Food and Drug Administration. Advisory Committees. www.fda.gov/ AdvisoryCommittees/Calendar/ucm279859.htm.

11. Gonzalez-Quintero VH, Istwan NB, Rhea DJ, Smarkisky L, et al. Gestational age in initiation of 17P and recurrent preterm delivery. J Mat Fetal and Neonat Med. 2007; 20(3): 249-252.

12. Mason MV, et al. Impact of 17P Usage on NICU Admission in a Managed Medicaid Population. Managed Care. 2010; 46-52.

Author Information: Professor of Obstetrics and Gynecology, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216. jbofill@umc.edu (James M. Bofill, MD). Assistant Professor of Obstetrics and Gynecology, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216, Mississippi State Board of Health, 570 East Woodrow Wilson Drive, Jackson, MS 39216, Charlene.Collier@ msdh.ms.gov (Charlene H. Collier, MD, MPH). Pharm D, Mississippi State Board of Health, 570 East Woodrow Wilson Drive, Jackson, MS 39216 Meg.Pearson@msdh. ms.gov (Meg Pearson, Pharm D). Professor and Chairman, Obstetrics and Gynecology, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216, jshwayder@umc.edu (James M. Shwayder, MD). Professor Emeritus, Obstetrics and Gynecology, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216, jmorrison@umc.edu (John C. Morrison, MD).

Corresponding Author: John C. Morrison, MD, University of Mississippi Medical Center, Department of Obstetrics and Gynecology, 2500 North State Street, Jackson, Mississippi 39216, Phone: 601-984-5300, Email: jmorrison@umc.edu.

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“I’m coughing up blood.”

SARAH E. BAROWKA MD; T. RAY PERRINE MS, MD, FAAFP; KAREN HUGHES MD

Summary An 18-year-old female presents with acute hemoptysis and rapidly deteriorates into fulminant pulmonary and renal failure. She is ultimately diagnosed with microscopic polyangiitis with pauciimmune glomerulonephritis. This case report will delineate her presentation, work-up, broad differential diagnosis, and outcome.

Key Words: anti neutrophil cytoplasmic antibody (ANCA), glomerulonephritis, hemoptysis, microscopic polyangiitis, vasculitis An 18-year-old female presents to the emergency department (ED) with the complaint of hemoptysis for one day. She describes blood-streaked sputum and mild cough the night prior which progressed on the day of presentation to shortness of breath and coughing up frank blood. She denies any recent travel or exposure to TB. Her only known sick contact is her father who has had a recent sinus infection. In addition, she complains of nasal congestion, nose bleeds, sore throat, dry mouth, generalized weakness, and ankle pain. She denies fever, chills, nausea, vomiting or diarrhea.

The differential diagnosis for hemoptysis is broad including, but not limited, to vascular, airway, parenchymal, and cryptogenic causes. In the United States, the etiology is most commonly viral or bacterial bronchitis. Worldwide, the most common cause is acute tuberculosis infection.1 In this patient, the cause is still unclear. Information that we have thus far is that this is an acute occurrence that has been progressive over the past 24 hours. She also has non-specific systemic symptoms including generalized weakness and arthralgia.

She is a full time high school student and denies alcohol, tobacco, and drug use. She has been taking a daily antihistamine and multivitamin. Her past medical history is significant for a difficult birth complicated by an intracerebral hemorrhage and a 12-day admission to the NICU resulting in persistent learning disabilities. She lives in a home that is 8 years old in a rural area.

The family has a small chicken coop. On physical exam she is afebrile, tachycardic with a heart rate of 141, tachypneic with a respiratory rate of 28, and her oxygen saturation is 94% on 2L O2 via nasal cannula. She appears to be in mild respiratory distress with shallow, rapid breathing. Her oral mucosa is clear without lesions, and her nares are clear with no signs of active bleeding.

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She has diffuse expiratory wheezes with bibasilar rales. She is tachycardic with a regular rhythm and no appreciable murmur.

Abdominal exam reveals a soft, non-tender, non-distended, abdomen with no evidence of organomegaly. No cervical or inguinal lymphadenopathy is appreciated on exam. She has no skin lesions or rashes. She does have slight tenderness to palpation of her left ankle over her Achilles tendon with mild associated erythema posterior to the medial malleolus.

At this point, her clinical presentation was most consistent with an acute viral or bacterial infection causing hemoptysis. Treatment with antibiotics to cover a potential community acquired pneumonia was initiated in the ED. In a patient with hemoptysis, appropriate laboratory work-up should include a complete blood count and coagulation studies to assess the severity of the bleeding. Renal function and urinalysis should be obtained in order to check for pulmonary-renal syndromes that may present as hemoptysis.1,2 Chest x-ray should be obtained, and computed-tomography (CT) of the chest should be considered in the work-up if there is concern for possible pulmonary embolus or arteriovenous malformation.2 Initial laboratory results reveal a hemoglobin and hematocrit of 9.8g/dL and 29.3% respectively with a white blood cell count (WBC) of 16.7 and 94% polys. Coagulation studies are within normal limits. A metabolic panel reveals a potassium of 5.4 mmol/L, blood urea nitrogen (BUN) of 45, creatinine of 4.1 and an estimated glomerular filtration rate (GFR) of 14.

Other electrolytes and a hepatic panel are within normal limits.

Urinalysis is significant for 3+ blood and 2+ protein; microscopy shows 72 red blood cells per high powered field (hpf), 8 WBCs/hpf, occasional bacteria, and WBC clumps. Chest x-ray demonstrates diffuse patchy infiltrates bilaterally consistent with a multifocal pneumonia. CT scan of the chest is consistent with diffuse non-specific alveolar infiltrates. A urine pregnancy test is negative, and her left ankle x-ray is normal.

At this point it is clear that we need to weigh the possibility that this patient’s hemoptysis is secondary to diffuse alveolar hemorrhage and part of a more complex pulmonary-renal syndrome. The decision is made to continue antibiotics for a possible bacterial infection while investigating additional potential causes of renal failure including: post-streptococcus glomerulonephritis (PSGN), systemic lupus erythematosus (SLE), Goodpasture’s syndrome, and antineutrophil cytoplasmic antibody (ANCA) associated vasculitidies (AAV) such

as granulomatosis with polyangiitis (GPA) or microscopic polyangiitis (MPA).3 She is admitted to the intensive care unit, and pulmonology, nephrology, hematology, and rheumatology are consulted.

Additional laboratory studies are ordered including blood and urine cultures, ANCA studies, anti-glomerular basement membrane (GBM) antibodies, anti-nuclear antibody (ANA), anti-streptolysin O (ASO) antibody, and HIV. Due to the amount of hemoptysis, a blood type and cross match is performed in anticipation of possible transfusion. She is continued on ceftriaxone and azithromycin to cover for possible community acquired pneumonia and placed on a non-rebreather face mask with 100% FiO2 for her increasing oxygen requirement.

On hospital day 1, bronchoscopy is performed due to her worsening respiratory status. This confirms a diagnosis of diffuse alveolar hemorrhage (DAH) directing the differential towards Goodpasture’s syndrome versus AAV including GPA (formerly known as Wegener’s granulomatosis). A renal biopsy is also performed on this day. Treatment with glucocorticoids and plasmapheresis is begun.

With the suspected autoimmune etiology of her fulminant pulmonary and renal failure, the decision is made to initiate empiric therapy for these disorders. The mainstay of treatment of autoimmune pulmonaryrenal syndromes includes glucocorticoids and plasmapheresis.4 On hospital day 2, her respiratory status begins to deteriorate.

Chest x-ray reveals an extensive left-sided pneumothorax, and the patient ultimately requires both a chest tube and intubation.

Her renal failure persists and urine output is so poor that nephrology begins dialysis. On hospital day 3, the patient continues to deteriorate despite aggressive interventions. Her oxygen saturation drops to 73-77% on full ventilator support with 100% FiO2. Transfer is not an option as the risk of complications from transport is deemed too high. In light of the patient’s poor oxygenation and pneumothorax with persistent air leak and with the lack of availability of high frequency oscillatory ventilation, pulmonology initiates inverse-ratio ventilation (IRV) in an attempt to increase her oxygenation.

IRV is defined as an inspiratory-to-expiratory time ratio greater than one. It has been demonstrated to increase PaO2 and decrease peak airway pressure, suggesting that it may improve pulmonary gas exchange while lowering risk of barotrauma.5 Various test results begin to return. FANA is negative and C3 and C4 levels are within normal limits. Meanwhile, renal biopsy reports rapidly progressive pauci-immune glomerulonephritis with anti-GBM staining negative. Anti-streptolysin O antibody also returns negative. ANCA studies are still pending.

Our differential diagnosis begins to narrow. The negative FANA with normal complement levels rules out SLE; negative ASO antibody rules

out PSGN. Lastly, Anti-GBM rules out Goodpasture’s syndrome. AAV remains at the top of the differential. AAV is classified as a necrotizing vasculitis with few or no immune deposits, predominantly affecting small vessels associated with ANCA specific for myeloperoxidase (MPO-ANCA) or proteinase 3 (PR3-ANCA) also known as p-ANCA and c-ANCA respectively.6 In some cases, ANCA studies may be negative. Both cyclophosphamide and rituximab have been indicated for treatment for the AAV in addition to corticosteroids, and these medications are started. The added benefit of plasmapheresis remains unclear; however, current recommendations advise plasmapheresis as adjunctive therapy in patients with rapidly rising serum creatinine and those with DAH.7 On hospital day 4, the patient develops a right-sided pneumothorax and requires another chest tube. Aggressive ventilation strategies are continued, and her oxygen saturation improves into the low 80s. A new macular rash is noted on her upper thighs. On hospital day 5, her oxygenation status improves further, and her oxygen saturations are now in the 90s with an FiO2 wean to 80%. Her renal failure persists and she remains on dialysis. Infectious disease is consulted in light of her new rash and increasing leukocytosis; antibiotic coverage is broadened.

On hospital day 6, the patient begins to stabilize. She continues to tolerate a wean of FiO2 to 60%. Her ANCA studies return as well. She is PR3-ANCA negative and MPO-ANCA positive. Her diagnosis is now confirmed to be microscopic polyangiitis (MPA) with pauci-immune glomerulonephritis.

There is no universal classification of ANCA-associated vasculitidies (AAV), and the clinical features of both MPA and GPA overlap. MPA is a necrotizing small vessel vasculitis with minimal immune deposits frequently associated with necrotizing glomerulonephritis, but it lacks the granulomatous inflammation seen with GPA.6 Defining the clinical manifestations is difficult as often the diagnosis of MPA is not exclusive of the other AAV. Patients may experience non-specific symptoms including fever, myalgias, and arthralgias. Renal involvement is most commonly followed by pulmonary involvement that ranges from cough to massive pulmonary hemorrhage.8 When present, DAH significantly increases the mortality of MPA with one source reporting a mortality rate as high as 30%.4 Epidemiologic data on MPA is limited because the data is frequently combined with the other AAVs. The average age of onset has a bimodal distribution striking adults most commonly around age 50 and children ages 9-12. Males and females are equally affected.8 Lab evaluation often reveals non-specific elevation of inflammatory markers. Anemia may be present. Urinalysis and renal function reflect disease progression. MPA has a high association of p-ANCA (MPOANCA) while GPA is frequently associated with c-ANCA (PR3ANCA).8 Treatment in the acute setting generally involves induction therapy for 3-6 months followed by maintenance therapy for at least 18 months. Induction therapy typically includes corticosteroids, JOURNAL MSMA

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cyclophosphamide and plasma exchange. Rituximab has traditionally been used in refractory disease. Maintenance therapy may include prednisone plus azathioprine, rituximab or methotrexate.8-9 Our patient presented with the complaint of small-to-moderate volume hemoptysis and rapidly progressed into pulmonary and renal failure. The differential diagnosis was broad but was constantly tailored to the clinical presentation and laboratory results. She required aggressive interventions including IRV, hemodialysis, and plasmapheresis. Early initiation of therapy based on clinical diagnosis was a major contributory factor to this patient’s survival as treatment was begun on hospital day 1 although diagnosis was not confirmed until day 6 by which time the patient had already begun responding to treatment.

The role of the family physician in this case should not be overlooked.

While this patient’s disease process was very complex requiring multiple consultant services, the family medicine team remained the primary service throughout. We served as coordinators of care, speaking frequently with consultants, dietary, social work, and therapy to be sure that the patient was getting comprehensive care in all areas. In addition, there was never just one patient in the room as we cared for the emotional well-being of her family during this time as well whether it involved spending a few extra minutes answering questions or simply providing a shoulder to cry on. The family medicine physician does not just treat a disease but rather seeks to provide care to the whole patient providing a very valuable service in the often specialized world of hospital medicine.

Ultimately, our patient was hospitalized for six weeks with prolonged ventilation. She then required inpatient rehabilitation for an additional three weeks for ICU myopathy. Today she is in remission and on maintenance therapy with low dose prednisone and rituximab. She has CKD stage 3a and no longer requires dialysis. She graduated from high school on schedule and has started taking college courses. n References 1. Kritek PA, Fanta CH. Cough and Hemoptysis. In: Kasper D, Fauci A, Longo DL, Hauser SL, Jameson J, Loscalzo J eds. Harrison’s Principles of Internal Medicine. 19e. New York, NY: McGraw Hill; 2015:243-247.

2. Eddy JB. Clinical assessment and management of massive hemoptysis. Critical Care Medicine. 2000;28(5):1642-1647.

3. Mohan et al. Pulmonary-Renal Syndrome. In: Jindal SK, Guleria R eds. World Clinics Pulmonary Critical Care Medicine. 2e. New Delhi, India: Jaypee Brothers; 2013.313-24.

4.

Lara AR, Schwarz MI. Diffuse alveolar hemorrhage. Chest. 2010;137 (5):1164-1171.

5. Mercat A, Graini L et al. Cardiorespiratory effects of pressure-controlled ventilation with and without inverse ratio in the adult respiratory distress syndrome. Chest. 1993;104:871-75.

6. Jennette JC, Falk RJ, Bacon PA et al. 2012 revised International Chapel Hill

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Consensus Conference Nomenclature of Vasculitidies. Arthritis Rheum.

2013;65(1):1.

7. Beck L, Bomback AS, et al. KDOQI US commentary on the 2012 KDIGO clinical practice guideline for glomerulonephritis. Am J Kidney Dis. 2013;62(3)403-41.

8. Cabral DA, Morishita K. Antineutrophil cytoplasmic antibody associated vasculitis. In: Cassidy J, Petty R, Laxer R, Lindsley CB. eds. Textbook of Pediatric Rheumatology. 6e. Philadelphia, PA: Elsevier;2016.

9. Nachman PH, Hogan SL, Jennette JC, Falk RJ. Treatment response and relapse in antineutrophil cytoplasmic autoantibody- associated microscopic polyangiitis and glomerulonephritis. J Am Soc Nephrol. 1996;7:33-39.

Author Information: Faculty physician at North Mississippi Medical Center in Tupelo (Drs. Barowka, Perrine, and Hughes).

Corresponding Author: Sarah Barowka, MD, North Mississippi Medical Center- Family Medicine Residency Center. 1665 South Green Street, Tupelo, MS 38804. Phone: 662.377.2189 E-mail: SBarowka@nmhs.net

U N I V E R S I T Y

O F

M I S S I S S I P P I

M E D I C A L

C E N T E R

Healthcare Management by Design JESSICA H. BAILEY, PHD; ELLEN JONES, PHD; ANGELA BURRELL, MSN; BRIAN RUTLEDGE, PHD Healthcare leaders today are under constant pressure from regulatory agencies, changing reimbursement issues, and shortages in the workforce coupled with an aging, more chronically ill population. This is particularly true for leaders in Mississippi, who must navigate the competing priorities of improved patient care, better health outcomes, and increased profitability in a state with an overall poor health status.

Educators at the University of Mississippi Medical Center (UMMC) realized that a gap existed in the need for an applied, practical education to prepare those involved in our ever changing healthcare environment. To meet the emerging needs in the state, UMMC designed a program that provides graduates with a unique skill set to complement those providing care to patients in the state.

First graduating cohort of DHA students with Dr. Mitzi Norris and Dean Jessica Bailey.

The School of Health Related Professions (SHRP) at UMMC is an ideal home for undergraduate and graduate programs that prepare health care administrators. SHRP has 650 students in 17 undergraduate and graduate programs. The interdisciplinary approach to education and access to faculty across the campus and beyond provide a unique opportunity to train future leaders in healthcare. Though a new medical school building is under construction on the UMMC campus, constructing interprofessional relationships and allied health partners who have studied healthcare administration is part of the vision.

Four years ago, SHRP admitted its first class of Doctor of Health Administration (DHA) students. The curriculum was created with a particular outcome in mind. Mississippi needed more professionals in the workforce who have a thorough understanding of the pressures faced by our healthcare providers. Students in the DHA program begin their coursework with an in-depth analysis of health policy combined with a critical evaluation of leadership strategies. The first semester is followed with courses in accreditation and licensure, health economics, epidemiology, fiscal responsibility, health marketing, and healthcare law.

When the program was first envisioned, SHRP dean Dr. Jessica Bailey was determined that the cohorts would be small and diverse, and would progress through the program in a true cohort fashion. This approach provides an opportunity for classmates to learn from each other, developing a broader understanding of emerging healthcare issues from different perspectives.

“The cohort for our DHA program was an example of great teamwork. From the very beginning, we supported and learned from each other. The varied backgrounds and positive attitudes of each student contributed to the learning of the whole cohort.” Guy Giesecke, DHA “Personally, the most valuable player of the DHA program was the eclectic cohort design. Gaining perspective from the various disciplines has not only strengthened my leadership skills, but has made me a more attentive, informed, and efficient team member.” Mary Jane Collins, DHA, CRNA Students are required to identify an applied research topic that they will investigate over an 18-month period. Each of these capstone projects focuses on a real world problem and identifies evidence-based strategies to provide solutions. In addition to DHA faculty members, committees are comprised of subject matter experts working in the healthcare arena. The experts come from Mississippi (eg. Diane Beebe, MD, Chair of the UMMC Department of Family Medicine) and from outside the state (eg. Bill Benson, former staffer, United States Senate Committee on Aging). This interdisciplinary team approach facilitates research collaboration that is applicable to healthcare settings at the local, state, tribal and national levels.

Some of the projects completed by the first graduating class of the program included examination of top performing vs. low performing hospitals in heart failure readmission rates, innovations in a pediatric hospitalist program, primary care physician perceptions of payment reform, and financial competency of middle level managers. These and other investigations are being put to use at UMMC and partner organizations.

Swapping scrubs for a business suit is a common transition for many holding administrative positions in healthcare today. The role of healthcare administrator often follows a successful career as a healthcare provider. To date, most administrators have found themselves in a leadership position by default rather than by design. Few have had formal coursework in health policy, economics, law and administration, and DHA program coordinator Angela Burrell sums it up this way: “We were very purposeful in this design. It is a unique opportunity to develop skills and provide networking opportunities and experience in problem solving for some of the most pressing healthcare issues we face.” n JOURNAL MSMA

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Ten Things You Want to Know about Vaccines for Adults SAIRA BUTT, MD AND AMIR TIRMIZI, MD Introduction In the United States (U.S.), 50,000 people die from vaccine-preventable diseases each year.1 The Advisory Committee on Immunization Practices (ACIP) reviews and annually updates its recommended vaccination schedule for the U.S. adult (age ≥ 18 years) population. Despite these recommendations, vaccination rates fall short of target.

1

Influenza vaccine should be provided to all adults annually.

Although efficacy is not high (58%),2 it prevents hospitalizations especially in the elderly.3 Each year, an average of 226,000 people are hospitalized due to influenza and between 3,000-49,000 people die of influenza and its complications. For healthy adults up to 49 years of age, either an inactivated vaccine or live-attenuated influenza vaccine can be used. Inactivated vaccine should be used in adults ≥50 years; patients with immunosuppression or chronic cardiovascular, pulmonary, or metabolic disease; pregnant women; and those with egg allergy.4 For adults ≥65 years of age, use high-dose inactivated influenza vaccine (Fluzone high-dose) when available.4

2 3

All pregnant women should receive vaccination against pertussis with Tdap during each pregnancy.

All adults age ≥19 years who have not received Tdap (Tetanus toxoid, reduced diptheria toxoid and acellular pertussis vaccine) previously should get single dose Tdap followed by reduced diphtheria toxoid (Td) booster every 10 years. Regardless of prior tetanus and diphtheria immunization, Td should be given for severe or dirty wounds.5 PPSV23 (23-valent pneumococcal polysaccharide vaccine) is recommended for all adults ≥65 years and PCV13 (13 pneumococcal serotype vaccine) is indicated for use in adults ≥50 years.

Invasive pneumococcal disease causes 32,000 cases and about 3,300 deaths annually. PPSV23 and PCV13 are also indicated in younger patients who have cochlear implants, cerebrospinal fluid leak, sickle cell disease, asplenia, congenital or acquired immunodeficiency, malignancy, and solid organ transplant. PPSV23 is also indicated for <65 years with history of chronic heart disease, chronic lung disease, chronic liver disease, alcoholism, diabetes mellitus, and smoking.6

4

Patients do not require a prior history of varicella (chicken pox) or zoster (shingles), prior to Varicella and Herpes Zoster Vaccinations.

Two doses of varicella vaccine are recommended for all adults without evidence of immunity (4-8 weeks apart). In U.S., 1 million people get shingles annually. To prevent shingles, one dose of zoster vaccine can be given to adults >60 years of age.7 Presence of varicella antibodies is not a contraindication to get shingles vaccine. Patients on immunosuppressant medications at the time of zoster vaccination have a modest increased risk of zoster in the 42 days after vaccination.8

5

Human papilloma virus (HPV) quardivalent vaccine is recommended for adults ≤26 years for a total of 3 doses (0,2,6 months).

In the U.S., HPV causes about 17,000 cancers in women, and about 9,000 cancers in men annually. Four-thousand women die annually from cervical cancer. Catch-up vaccination should be offered for females aged 13-26 years who have not been previously vaccinated. Catch-up vaccination should be offered for males for ages of 13-21 who have not been previously vaccinated. For men who have sex with men (MSM), catch-up vaccination should be offered up to age 26. Serologic testing or HPV DNA testing is not required prior to immunization.9

6

Haemophilus Influenza B (Hib) Vaccine is Important in Patients with Asplenia.

Patients with sickle cell disease or splenectomy who have not received the childhood Haemophilus Influenza B (Hib) series should receive 1 dose of Hib conjugate vaccine. Post-successful hematopoietic stem cell transplant (HSCT): re-vaccinate adults with a 3-dose regimen beginning 6-12 months after the transplant, regardless of vaccination history. Doses should be >4 weeks apart.10

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7 8

Hepatitis A Vaccine Should be Administered for Travel to High Risk Areas.

Hepatitis A vaccine coverage (9%) is dismally low in the U.S. Hepatitis A vaccine (2 doses, 6-12 months apart) is indicated for travel to high risk countries, chronic liver disease or clotting factor disorders, MSM, illicit drug users, those with close contact to an international adoptee from an endemic area, and individuals working with virus in a research setting.1,11 Hepatitis B Vaccination is Now Recommended for Additional Populations.

Hepatitis B vaccine (3 doses at 0,1,6 months) is indicated in diabetics at age 19-59 years, pregnant females, persons born in high or intermediate endemic areas (countries with virus prevalence rate >2%), U.S.-born persons not vaccinated as infants whose parents were born in regions with high endemicity, chronically elevated aminotransferases, immunosuppressive therapy, MSM, persons with multiple sexual partners or history of sexually transmitted disease, inmates of correctional facilities, persons who have ever used injection drugs, dialysis patients, HIV or Hepatitis C patients, and family members, household members, and sexual contacts of Hepatitis B-infected persons.1,12

9

Recent Epidemics Underline the Importance of Measles Vaccine.

In 2014, the U.S. had a record 668 measles cases across 27 states, despite the fact that measles elimination was documented in 2000.

There is a current ongoing outbreak in Memphis, TN. Measles, mumps, rubella vaccine (MMR) [1 or 2 doses administered at least 28 days apart] should be given to pregnant females, college students, health care workers (HCW), international travelers, and those involved in outbreaks, household and close contacts of immunocompromised persons, HIV patients without AIDS, and persons previously vaccinated between 1963 and 1967.11,12,13

10

Not All Vaccines Should Be Given Simultaneously.

Generally, most vaccines including live vaccines can be given together same day at different sites. Exceptions to this rule are PPSV23 and PCV13, and PCV13 and meningococcal, which should not be given together. If live vaccines (live influenza, zoster, varicella, MMR) are not administered the same day, they should be given at least 28 days apart. Live vaccines (Varicella, Zoster and MMR) are contraindicated in severe immunodeficiency (malignancy, chemotherapy, congenital, AIDS, and chronic steroid use (>20 mg of daily prednisone > 2 weeks).1 MMR and Varicella vaccine should be given either 2 weeks prior or 3 months post-receiving blood products. Vaccines contraindicated in pregnancy are live influenza, Varicella, Zoster, and MMR1 Patients with leukemia, lymphoma, or other malignancies whose disease is in remission and whose chemotherapy has been terminated for at least three months may receive live virus vaccines.1,11

Table 1. Insurance Coverage of Adult Vaccines1,10 Vaccination Influenza Tetanus

Table 2. Efficacy of Adult Vaccines1,10,13

Medicare Part B

Medicare Part D

Medicaid

Private Insurance

Vaccine

Efficacy

√

√

√

√

Influenza

53-60%

Tdap

94%

PCV 13

45-75%

PPSV 23

85-90%

√

Tetanus, Diptheria,

√ √

√ √

√ √

Pertussis (Tdap) Pneumococcal vaccines

√

√

√

√

PPSV23 & PCV13 Varicella (Chicken Pox) √

Herpes Zoster (Shingles) Human Papilloma Virus

√ √ √

√ √ √

(HPV) √

Haemophilus Influenza (Hib) Hepatitis A Hepatitis B Measles, Mumps,

√

√

√

√

√

√

√

Varicella

98%

Zoster

51-72%

HPV

96-100%

HiB

>95%

Hepatitis A

79-92%

Hepatitis B

86%

MMR

89-92%

Meningococcal

80-85%

√ √ √

Rubella (MMR) Meningococcal

√

√ : Covered

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Table 3. Adult Vaccines Indications & Contraindications1,10,13,14 Condition Pregnancy

Indications

Contraindications

Influenza, Tdap (with each pregnancy), HPV*

Varicella, Zoster, MMR

Influenza, Tdap, HPV*, PCV13, PPSV23, Hib (post-HSCT)

Varicella, Zoster, MMR

AIDS CD4<200

Influenza, Tdap, HPV*, PCV13, PPSV23, HepB

Varicella, Zoster, MMR

HIV CD4>200

Influenza, Tdap, Varicella, HPV*, Zoster§, PCV13, PPSV23, HepB, MMR

None

Male who have sex

Influenza, Tdap, Varicella, HPV*, Zoster§, PCV13 (if age>50 years),

None

with male (MSM)

PPSV23 (if age>65 years), HepA, HepB, MMR

Immunocompromised host

Chronic kidney disease/

Influenza, Tdap, Varicella, HPV*, Zoster§,

Hemodialysis patients

None

PCV13, PPSV23, HepB, MMR

Heart disease, chronic lung disease,

Influenza, Tdap, Varicella, HPV*, Zoster§,

chronic alcoholism

None

PCV13 (if age>50 years), PPSV23, HepB, MMR

Asplenia

Influenza, Tdap, Varicella, HPV*, Zoster§,

None

PCV13, PPSV23, meningococcal, Hib, MMR Chronic liver disease

Influenza, Tdap, Varicella, HPV*, Zoster§,

None

PCV13 (if age>50 years), PPSV23, HepA, HepB, MMR DM2

Influenza, Tdap, Varicella, HPV*, Zoster§, PCV13 (if age>50 years),

None

PPSV23, HepB (age 19-59), MMR Health care worker

Influenza, Tdap, Varicella, HPV*, Zoster§,

None

PCV13 (if age>50 years), PPSV23 (if age>65 years), HepB, MMR Immune mediated inflammatory

Influenza, Tdap, HPV*, Zoster§, PCV13,

diseases/Patients on biologics 1st year college students

Varicella, MMR

PPSV23, HepA, HepB Influenza, Tdap, HPV*, meningococcal (one dose for age 19-21, 2 doses if HIV+),

None

HepB (if history of STD +/- multiple sexual partners), MMR *HPV (through age 26 for females & MSM, through age 21 for males) §Zoster (if >60 years)

Influenza vaccination in patients with Egg-Allergy: Inactivated Influenza vaccine is safe and is recommended in egg-allergy due to low egg protein in vaccine. If reaction to egg is hives, vaccine can be given at primary care office followed by 30-minute observation. If reaction is more than hives, it should be given by an allergist. An alternative, tri-valent inactivated egg-free vaccine (Flucevax) is also available.12 American College of Physician Immunization Advice (ACP IA) has a free downloadable application for smart phones, which enables you to identify exact vaccines for your adult patients. n References 1. Adult immunization: shots to save lives. Washington, DC: Trust for America’s Health, Infectious Diseases Society of America, and the Robert Wood Johnson Foundation; 2010.

2.

Jefferson T, Di Pietrantonj C, Al-Ansary LA, et al. Vaccines for preventing influenza in the elderly. Cochrane Database Syst Rev 2010;CD004876.

3. Nichol KL, Nordin J, Mullooly J, et al. Influenza vaccination and reduction in hospitalizations for cardiac disease and stroke among the elderly. N Engl J Med 2003; 348:1322.

4. Centers for Disease Control and Prevention (CDC). Prevention and control of seasonal influenza with vaccines. Recommendations of the Advisory Committee on Immunization Practices--United States, 2013-2014. MMWR Recomm Rep 2013; 62:1.

5. Updated Recommendations for Use of Tetanus Toxoid, Reduced Diphtheria Toxoid, and Acellular Pertussis Vaccine (Tdap) in Pregnant Women — Advisory Committee on Immunization Practices (ACIP), 2012. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6207a4.htm?s_cid=mm6207a4_e (Accessed on February 21, 2013).

6. Tomczyk S, Bennett NM, Stoecker C, et al. Use of 13-valent pneumococcal conjugate vaccine and 23-valent pneumococcal polysaccharide vaccine among adults aged ≥65 years: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep 2014; 63:822.

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7.

Gagliardi AM, Gomes Silva BN, Torloni MR, Soares BG. Vaccines for preventing herpes zoster in older adults. Cochrane Database Syst Rev 2012; 10:CD008858.

8. Cheetham, T.C., Marcy, S.M., Tseng, H.-F. Risk of herpes zoster and disseminated varicella zoster in patients taking immunosuppressant drugs at the time of zoster vaccination. Mayo Clin Proc.2015; 90: 865–873.

9. Soares GR, Vieira Rda R, Pellizzer EP, Miyahara GI. Indications for the HPV vaccine in adolescents. J Infect Public Health. 2015 Mar-Apr;8(2):105-16. doi: 10.1016/j. jiph.2014.08.011.

10. Centers for Disease Control and Prevention (CDC). Adult vaccination coverage--United States, 2010. MMWR Morb Mortal Wkly Rep 2012; 61:66.

11. Centers for Disease Control and Prevention (CDC). Notifiable diseases and mortality tables. MMWR Morb Mortal Wkly Rep. 2014; 63:277-300.

12. Webb L, Petersen M, Boden S, et al. Single-dose influenza vaccination of patients with egg allergy in a multicenter study. J Allergy Clin Immunol 2011; 128:218.

13. National Center for Immunization and Respiratory Diseases. General recommendations on immunization: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 2011; 60:1.

14. Cohn AC, MacNeil JR, Clark TA, et al. Prevention and control of meningococcal disease: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 2013; 62:1.

Author Information: Formerly Assistant Professor, Division of Infectious Diseases at University of Mississippi Medical Center. Presently, Assistant Professor, Division of Infectious Diseases, Indiana University School of Medicine, 550 N University Blvd. Indianapolis, IN (Dr. Butt). Formerly, Infectious Diseases Fellow, Division of Infectious Diseases at University of Mississippi Medical Center Presently, Hospital Medicine Physician, Major Hospital, Shelbyville, IN (Dr.Tirmizi).

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P R E S I D E N T ’ S

P A G E

Free Drug Discount Card Can Help Your Patients Get Meds

W

hen it comes to healthcare and insurance coverage many Mississippians are underserved and under the gun. Given this, we at MSMA support workable, fair solutions that increase access to healthcare. This is why your Association is a cosponsor of the Mississippi Drug Card, a simple and direct way to help Mississippians get the medicines they need.

Since its launch the Mississippi Drug Card has saved residents of the state more than $39 million. MSMA members have seen this card work firsthand. Designed for the uninsured and underinsured, the card can save a patient as much as 75 percent on prescription drugs at more than 68,000 pharmacies across the country. Almost every Mississippi pharmacy accepts the discount card.

This amazing card offers discounts on brand name and generic drugs for patients without prescription coverage. Those who do have coverage may also be eligible for discounts on drugs not covered by their insurance plan. There is no fee, no application process, no membership requirement, no income limit and no age restriction.

Patients can go online, print a free card and start using it the same day. And, there’s a digital version that can work on smartphones. Tell your patients to visit MSMAonline.com/DrugCard to print a discount card – it’s easy and it’s free.

You can also get a supply of wallet-sized cards to give out to your patients. Just email Ken Gresham at: CS@ MississippiDrugCard.com to get a free supply of the cards mailed directly to your office at no cost to you.

Not all solutions are simple, easy and innovative. The Mississippi Drug Card is. We support it and promote it here at MSMA. We’re proud to help you help your patients get the medicines they need at a cost they can afford. n

Lee Voulters, MD; Gulfport MSMA President 2016-2017

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Child Abuse & Neglect in Mississippi: Beginning the Conversation STEPHEN BEAM, MD AND KARLA STECKLER TYE, LPC Abstract The Mississippi State Medical Association House of Delegates passed Resolution 18 in 2016 to bring attention to child abuse and neglect in Mississippi. This descriptive article is the first of a number of articles that will be included in the Journal MSMA to educate further the medical community on a problem that impacts individuals throughout their life. Research has shown that our medical professionals, just like many other disciplines that encounter child abuse, are unprepared to identify and respond to the issue of child abuse. This article outlines the magnitude of child abuse in Mississippi as well as the life-long ramifications of that abuse. Lastly, this article outlines two current initiatives in Mississippi attempting to make systemic changes to identification and response to cases of child abuse. hild abuse and neglect, Children’s Advocacy Key Words: C Centers, Child Advocacy Studies Training Introduction The following vignettes are an amalgamation of literally thousands of events that occur in Mississippi each year. There is a plague of child abuse and neglect today that has been with us since antiquity. A few dedicated and hardworking, medically trained professionals in our state strive tirelessly to address these issues but the numbers are few and most of their efforts go largely unnoticed by the general public and by many medical professionals. It is estimated that, at best, only ten percent of child abuse/neglect cases are reported. Some estimates indicate an even lower percentage. Medical providers in our State who work in clinical medicine areas exposing them to infants and children should always be aware of the possibility of the presence of these hellish problems and be willing to report suspected cases of child abuse and neglect. These children are living a nightmare everyday of their young lives and have no way of escaping without help.

Case Scenario 1: I am three years old and have spent most of my life in a car seat in a bedroom with the windows taped so no light can see through it. My mom sleeps a lot. She forgets to change my diaper, sometimes for hours. She has men friends who visit her but none ever stay very long. I can’t walk because I am almost always in my seat. My grandparents also live in the house but I don’t see them very much. My mom took me to the doctor today after my aunt saw that I could not walk. The doctor checked me and said I need to see another doctor in Jackson. I hope someone can help me to walk so maybe my mom will let me out of my car seat.

Case Scenario 2: My little sister who is four cries a lot, especially when our mom’s man friend gets in her bed. He has been here about six months and sometimes hits my mom and makes her cry. My mom sleeps a lot especially after she takes her medication. She goes to work and leaves us with “Uncle Ted.” He sometimes makes us both get in bed with him while my mom is gone.

I am six years old and miss a lot of school, and neither my sister nor I have friends who can come and visit.

Today Uncle Ted was hurting my little sister again so I jumped on him to see if I could make him stop. He grabbed my arm and twisted it so hard that it made a popping noise and hurt real bad. He threw me against the wall, and I did not remember anything for a while. Later, I woke up and my sister was crying and calling my name. I hugged her and told her to quit crying. Uncle Ted was gone so we got dressed and waited for our mom. My arm still hurts but I know Mom will take us to the doctor and he will help us.

Case Scenario 3: I am thirteen years old, and I have a terrible secret. When I was little my family and I lived on a farm near my uncle and his three kids.

The oldest boy, Freddy, was about fifteen and we all played together. I was seven that summer and pleased that Freddy wanted to spend time with me since I was so much younger. There were times when it was just the two of us and sometime during that summer he began to do things to me. I was scared and cried but did not tell anyone. I started wetting the bed again and having bad dreams. That fall we moved from the farm but sometimes I wake up scared after a bad dream.

About six months ago a new family moved in next door. They had a six year old boy who came over to our house to play with my younger brother. He was just a little kid but we began spending time together when my brother was not there. I have started touching him in bad ways. I know I should stop but I keep doing it. He has stopped coming over and my brother says he is sick and his parents are taking him to the doctor. What if he tells? I hope no one asks.

Where Are We Today The state of Mississippi, as with every state in the United States, has long been in a crisis regarding the protection of children from abuse and neglect. The statistics are grim. Although the prevalence rate varies slightly by study, commonly accepted national statistics inform us that 1 in 7 girls and 1 in 25 boys will be a victim of sexual abuse before their 18th birthday.1 Complicating the issue, the greatest risks to children are not strangers, but rather family and friends. In 90% of sexual abuse cases, the child and family know and trust the abuser.2,3 In 2014, Mississippi had 27,967 total reports of child abuse and neglect,

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22,706 of which were referred for investigation. A total of 8,435 children were substantiated to be victims of abuse or neglect, a rate of 11.5 per 1,000 children. Of these children, 75.7% were neglected, 17.5% were physically abused, and 11.8% were sexually abused.4 Notably, children that are being seen for one form of abuse frequently disclose subsequent forms of abuse during their child advocacy center forensic interviews.

In 2014, 22 children were confirmed to have died in Mississippi because of abuse or neglect.5 The situation regarding child deaths from child maltreatment has reached such a high that the U. S. Congress developed The Commission to Eliminate Child Abuse and Neglect Fatalities. Their final report highlighted the need for multidisciplinary efforts by stating “a number of children who die were not known to child protective services but were seen by other professionals (e.g., health care), highlighting the importance of coordinated and multisystem efforts.”6 The impact of abuse has long-reaching tentacles that can impact someone throughout their lifetime if they do not receive appropriate treatment. The Adverse Childhood Experiences (ACE) Study found that adverse childhood experiences, including child abuse, are common and that there is a strong link between adverse childhood experiences and adult onset of chronic illness. Those with ACE scores of 4 or more (four or more adverse childhood experiences) had significantly higher rates of heart disease and diabetes. Chronic pulmonary lung disease increased 390%, depression increased 460%, and suicide increased 1,220%.7 People with six or more ACEs died nearly 20 years earlier on average than those with a zero ACE score.8 Those who had experienced child maltreatment were more likely to engage in risky health-related behaviors during childhood and adolescence such as early initiation of smoking, sexual activity, illicit drug use, adolescent pregnancies and suicide attempts. Additional lifetime implications for those with a history of child sexual abuse are at a higher risk for alcoholism, fetal death, intimate partner violence, sexually transmitted diseases, and unintended pregnancies.9 These outcomes present a serious and daunting problem to all citizens of the state, extending beyond the moral concerns associated with abuse of a child to include increased health care costs, long-term social consequences, and ongoing increased public service spending.

Every year nearly 3,000 of these courageous Mississippi children walk through the doors of a child advocacy center to tell the details of their felonious abuse and receive services to help them heal from that abuse. Importantly, these victims, as well as thousands of others, are also walking through the doors of your medical practices either as a child or later in life as an adult, in every community and economic demographic across the state. The outcome of that visit can be dramatically impacted by the efficacy of your training to recognize and care for these victims.

The Role of Children’s Advocacy Centers™ Children’s Advocacy Centers of Mississippi’s 11 member child advocacy centers provide critical services to children that are the victims of the most severe felony abuse: all sexual abuse, severe physical abuse (ex: burns, choking, permanent injury, broken bones, 364 VOL. 57 • NO. 11 • 2016

etc.), drug endangered children, trafficking victims, and children who have witnessed a homicide or similarly violent crime. The core foundation of the child advocacy center is to work collaboratively with law enforcement, medical personnel, child protective services, prosecutors and other key professionals during the investigation, prosecution, and treatment of child abuse cases. That collaboration begins with training programs for all members of the multidisciplinary teams that emphasize recognition, competency, and cooperation to manage their individual roles throughout a child abuse investigation.

Prior to the advent of children’s advocacy centers, abused children faced a maze of entities in reporting the abuse and getting appropriate therapeutic care. All too often the professionals involved with the case – no matter their profession – were not adequately prepared or trained to respond to child abuse and were unfortunately learning on the job how to respond to these child victims. Families often faced frustration with the system and withdrew from the process, resulting in no conviction for the perpetrator and no healing for the child.

The overriding benefit of the child advocacy center model is that the case investigations are coordinated from the onset. They begin more timely, fewer cases are missed, families receive appropriate referrals for the proper medical exams, children receive evidenced-based therapy sooner, and the CAC collaborative model reduces duplication of resources.10 The collaborative approach is instrumental in assuring that all services provided by the team are performed at the highest level and that the entire team works efficiently for the benefit of the child and their non-offending family members.

At the local child advocacy centers, a child can relate his or her experience one time, in one place. Rather than being shuffled between doctors, police, counselors, and child advocates, the model strives to bring these professionals together while minimizing trauma to the victim. We strive to provide a comfortable, child-friendly setting in which a child can feel safe telling what has happened to him or her. Our multidisciplinary teams are made up of trained professionals whose primary goal is to reduce the burden on children and help facilitate their recovery.

Education is Imperative There is a growing body of research documenting the poor undergraduate and graduate training addressing the multifaceted and complicated issues surrounding child maltreatment. The United States Attorney General’s Task Force on Children Exposed to Violence has recognized the need to improve undergraduate and graduate training in this area and has called for a “national initiative to promote professional education and training on the issue of children exposed to violence at home, in their neighborhood, and schools.” The Task Force included sexual abuse in the definition of violence and they specifically urged academic institutions to “include curricula in all university undergraduate and graduate programs to ensure that every child and family serving professional receives training in multiple evidence-based methods for identifying and screening children for exposure to violence.”11 The training provided to medical professionals across the country is

similarly inadequate to the undergraduate and graduate schools. When it comes to medical schools, the reality is that “more than 40 years after the diagnosis of battered child syndrome entered the literature, our pediatric residency programs do not have significant education requirements for preventing, recognizing, or managing child abuse.”12 There is a need for extensive training about child abuse and neglect for professionals who work with children and families. The absence of effective training in institutions of higher learning necessitates that professionals must learn important skills through on-the-job training while the lives of children are at stake.

As a result of this lack of effective training, egregious errors occur. As 2002 study that compared the Emergency Department physicians with assessments of physicians trained in child abuse evaluation revealed very concerning discrepancies.13 In a 2012 summary of that 2002 study, the researchers noted that, “Only 8 of 46 (17%) children identified as having abnormal genital findings, interpreted

by Emergency Department physicians as signs of sexual abuse, were found on re-examination by child abuse specialist actually to have abnormal findings. The examination findings of the remaining 38 children were either normal or showed a condition other than abuse indicating potential errors made by the Emergency Department physicians in both identification and interpretation of genital findings.”14 Of importance, these researchers emphasized the implications of these types of errors, “In a clinical setting, mistaking a normal anatomic variant, a condition other than abuse, or an injury caused by an accident as being due to sexual abuse has serious adverse consequences. Even one mistake of this type can be devastating for the child and family. Physicians not specializing in child abuse evaluation, Advanced Practice Nurses and Sexual Assault Nurse Examiners who examine fewer than five children monthly for suspected sexual abuse all performed poorly on this survey. For those less experienced providers, review of every case by an expert in child sexual abuse evaluation could decrease the likelihood of a misdiagnosis of child abuse.”15 Identification and screening for abuse and neglect, identifying risk factors in families, and prevention efforts are critical for maximizing prevention of abuse and neglect in Mississippi. One-time training is not enough. These training needs extend to ongoing training for the existing workforce. For example, physicians and other medical personnel need training on mandated reporting laws. As these laws are revised frequently, it is important that physicians receive routine training on mandated reporting as well as the latest research on child maltreatment. This is a very basic training requirement that could directly benefit the lives of thousands of children annually.

Child Advocacy Studies Training This year, the Department of Family and Children’s Services, Attorney General’s Office, and Children’s Advocacy Centers of Mississippi joined forces to request that colleges and universities in Mississippi implement Child Advocacy Studies Training (CAST) designed to ensure that our future workforce will be skilled in recognizing and addressing abuse cases prior to entering their career fields. CAST is an interdisciplinary program for students entering the fields of criminal justice, social work, sociology, human sciences, education, nursing,

psychology, law, medicine, or seminaries. This program involves a multidisciplinary approach that allows the various disciplines to learn to work together to prevent, identify and address situations involving child abuse and neglect. CAST is a unique program that can be catered to the needs of each university, and it brings academia into application by teaching students the skills necessary to work effectively as part of the team that reflects the real world experience.

While Mississippi has already become a national leader of the statewide model of the CAST curriculum, we still have a ways to go to reach our goal of implementing CAST in 100% of the public universities and colleges. It is also our hope and expectation that many of the community colleges and private colleges will also adopt the training program. We recognize that institutions of higher education are an important key to changing lives and, for that reason, the CAST program has the potential to be the most important dynamic to impact child maltreatment. Child maltreatment has far-reaching implications for communities that affect education, economics, healthcare, and many other systems, which will directly assist college students in their further professions.

In Summary The days are gone where we can accept that we can work individually when responding to a child victim of abuse. We must think about how we can collectively work together to gain momentum in solving this issue. Children who have endured abuse deserve to have us– the people charged with the responsibility of responding to their needs during this critical time- coordinating with each other. We are making a commitment to do this work together: Not my part and your part, but instead, our part. We together will find the best path to help move victims to survivors. The Mississippi State Medical Association should be commended for passing the resolution this year committing to increasing the awareness of child abuse and neglect in Mississippi. Over the next year, we challenge each of you to consider how you expand your knowledge in this field and be a champion for child victims of abuse. Whether it is attending a mandated reporting training, serving on a local multidisciplinary team, or receiving further training on managing child abuse cases, you have a choice to become a champion for child victims. n References 1. Townsend, C. & Rheingold, A.A. Estimating a child sexual abuse prevalence rate for practitioners: A review of child sexual abuse prevalence studies. Charleston, S.C., Darkness to Light. Retrieved from www.D2L.org/1in10. 2013.

2. Finkelhor, D. & Shattuck, A. Characteristics of crimes against juveniles. Durham, NH: Crimes against Children Research Center. May 2012.

3. Whealin, J. Child Sexual Abuse. National Center for Post Traumatic Stress Disorder, US Department of Veterans Affairs. 2007.

4. U.S. Department of Health & Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children’s Bureau. Child maltreatment 2014. Available from http://www.acf.hhs. gov/programs/cb/research-data-technology/statistics-research/childmaltreatment. 2016.

5. U.S. Department of Health & Human Services, Administration for Children

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and Families, Administration on Children, Youth and Families, Children’s Bureau. Child maltreatment 2014. Available from http://www.acf.hhs. gov/programs/cb/research-data-technology/statistics-research/childmaltreatment. 2016.

14. Adams, J., Starling, S., Frasier, L., Palusci, V., Shapiro, R., Finkel, M. & Botash, A. Diagnostic Accuracy in Child Sexual Abuse Medical Evaluation: Role of Experience, Training, and Expert Case Review, Child Abuse & Neglect.

2012;36(5).

6. Commission to Eliminate Child Abuse and Neglect Fatalities. Within our reach: A national strategy to eliminate child abuse and neglect fatalities. Washington, D.C.; Government Printing Office. 2016.

15. Adams, J., Starling, S., Frasier, L., Palusci, V., Shapiro, R., Finkel, M. & Botash, A. Diagnostic Accuracy in Child Sexual Abuse Medical Evaluation: Role of Experience, Training, and Expert Case Review, Child Abuse & Neglect 2012; 36 383, 392.

7. Felitti, V. The Relation Between Adverse Childhood Experiences and Adult Health: Turning Gold into Lead. The Permanente Journal, Winter 2002; 6 (1).

8. Brown, D.W., Anda, R.F., Tiemeier, H., et al. Adverse Childhood Experiences and the Risk of Premature Mortality, American Journal of Preventive Medicine, 2009; 37 (5).

9. Brown, D.W., Anda, R.F., Tiemeier, H., et al. Adverse Childhood Experiences and the Risk of Premature Mortality, American Journal of Preventive Medicine, 2009; 37 (5).

10. Lalayants, M., & Epstein, I. Evaluating multidisciplinary child abuse and neglect teams: a research agenda. Child Welfare, 2005; 84(4).

11. Report of the Attorney General’s National Task Force on Children Exposed to Violence. Defending Childhood. Available from https://www.justice.gov/sites/ default/files/defendingchildhood/cev-rpt-full.pdf. 2012.

12. Botash, A.S., M.D. From Curriculum to Practice: Implementation of the Child Abuse Curriculum, Child Maltreatment. 2003; 8(4).

13. Makoroff, Brander, Meyers, & Shapirol, Genital examinations for alleged sexual abuse of prepubertal girls: findings by pediatric emergency medicine physicians compared with child abuse trained physicians. Child Abuse & Neglect. 2002; 26.

Author Information: Stephen Beam, MD is boarded in Family Medicine and serves as the Medical Director of Work Well (occupational medicine clinic) and also Medical Director of VA primary Care clinic in Hattiesburg. He is a member of Medical Staff at Wesley Medical Center and serves as a clinical instructor for William Carey Medical School. He serves as Medical Director of Edwards Street Fellowship Clinic, a free clinic, located in Hattiesburg and recently completed five years as an officer in South Mississippi Medical Association.

Karla Steckler Tye, LPC has specialized in the field of child abuse and neglect for over 17 years and she currently serves as the Executive Director of the Children’s Advocacy Centers of Mississippi. Early in her career, Mrs. Tye became committed to addressing child maltreatment investigations through a multidisciplinary team approach and she currently serves on the State’s Child Death Review Panel. Mrs. Tye received her Masters of Science in Art Therapy from Eastern Virginia Medical School.

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MAFP Foundation announces Dewitt G. Crawford, MD Memorial Scholarship Fund The Mississippi Academy of Family Physicians Foundation (MAFPF) is pleased to announce the establishment of the Dewitt G. Crawford, MD Memorial Scholarship Fund. Dr. Dewitt G. Crawford from Louisville, MS, attended the University of Mississippi Medical Center and began his family medicine career in 1961 with his father, Dr. John Albert Crawford, in his hometown of Louisville. He served as President of the Mississippi Academy of Family Physicians in 2008-2009 and was a member of the American Academy of Family Physicians (AAFP) and the Mississippi Academy of Family Physicians (MAFP) from 1988 until his death in January, 2016. In 1994, he was honored by the MAFP as the Family Physician of the Year. Over the course of his career, he served in a variety of MAFP leadership positions on numerous committees and board offices, including Treasurer, before becoming President in 2008.

A financial endowment was given to the MAFP Foundation in Dr. Crawford’s memory by Mrs. Dewitt G. Crawford to provide scholarship funding for deserving residents to attend the Mississippi Academy of Family Physicians (MAFP) Annual Scientific Assembly held each year.

The MAFP Annual Meeting provides opportunities for family physicians from across the state to connect with each other, network with those in collaborative roles and earn continuing medical education credits.

The Dewitt G. Crawford, MD Scholarship will be awarded each year to a deserving resident who best demonstrates the character qualities of leadership gained through life experience in their job, education, and/or service or volunteer opportunities and shows a commitment to future involvement as a leader with the MAFP. The Mississippi Academy of Family Physicians Foundation (MAFPF) secures resources to enhance Family Medicine education and training to promote wellness of all Mississippians. The Foundation is the philanthropic arm of the Mississippi Academy of Family Physicians (MAFP). The MAFP has over 1,000 members consisting of physicians, residents and medical students. For more information about this organization, go to www.msafp.org. n

MAFP Library dedicated in honor of Dr. and Mrs. Dewitt G. Crawford Additionally, the Mississippi Academy of Family Physicians announced the dedication of its family medicine library in honor of Dr. and Mrs. Dewitt G. Crawford. Dewitt G. Crawford, MD, a Louisville, MS, family physician was a member of both the American Academy of Family Physicians (AAFP) and the Mississippi Academy of Family Physicians (MAFP) from 1988 until his death in January, 2016. Over the course of his medical career, Dr. Crawford served in a variety of leadership roles for the MAFP, including Treasurer and eventually President (2008-2009).

Dr. Crawford and his wife, Peggy, donated numerous medical books to the MAFP library over the years including Dr. Crawford’s personally inscribed 1st edition hardcover Textbook of Medical Physiology written by Arthur C. Guyton, MD, Professor and Chairman of the Department of Physiology and Biophysics at the University of Mississippi Medical Center. Dr. Guyton’s inscription to Dr. Crawford reads in part “You will recall how much it meant to me to work with you and also that I proposed very seriously to you to join us permanently in our department and the world of research physiology.” In addition to a variety of medical books, the Crawfords also donated several antique framed prints including Aesculapius and Hippocrates, the Father of Medicine which now hang in the MAFP corporate office in Ridgeland, MS. The prints were recovered from the old Fox Drugstore on Main Street in Louisville, MS, purchased by the Crawfords’ at a church auction and donated to MAFP in 2012. n

Mrs. Dewitt Crawford displays the plaque presented to her and her late husband Dewitt G. Crawford, MD on behalf of the Mississippi Academy of Family Physicians for the dedication of the MAFP library. The MAFP Library was formally dedicated July 19, 2016. An engraved plaque in honor of Dr. and Mrs. Dewitt Crawford was placed at the entrance to the library and reads as follows: The MAFP Library is dedicated to Dr. and Mrs. Dewitt G. Crawford in appreciation for their exemplary service to the MAFP and to the profession of medicine in Mississippi.

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John Cross, MD, a Jackson internist, has been appointed to fill the vacant slot for a young physician on the MSMA Board of Trustees by MSMA President Lee Voulters, MD. Dr. Cross is an associate professor of internal medicine at UMMC and practices at University Physicians: Grants Ferry in Flowood. He is board certified in internal medicine and is a fellow of the American College of Physicians. Dr. Cross is the current president of Central Medical Society and past president of the MSMA Young Physicians Section.

Mary Currier, MD, MPH, state health officer for the Department of Health, won the McCormack Award for outstanding service at a state agency. The Association of State and Territorial Health Officials presents the award each year at its annual meeting. The award is given to a public health official who has “demonstrated excellence and has made a significant contribution to the knowledge and practice of the field.”

Michael Diaz, MD, Biloxi plastic surgeon, brought duffel bags full of medical supplies on his second trip to Cuba this year and returned with a commitment from Cuba’s top doctor to speak at Louisiana State University in the fall. Dr. Diaz was accompanied by his father Albert Diaz, MD, an OB/GYN, along with gastroenterologist Darrell Finlay, MD, and said he believes this is one of the first open medical exchanges between the United States and Cuba in 60 years.

Charles R. Griffith, MD, recently joined Hattiesburg Clinic Family Medicine where he will provide family medicine services.

Griffith also will be working with the Forrest General Residency Program. As a faculty member of the residency program, Griffith assists in the supervision of the resident physicians at FGH Family Medicine Center, located on the first floor of Hattiesburg Clinic.

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Griffith received his medical education at Louisiana State University in Shreveport. He is a certified medical director and is board certified in Family Medicine and Hospice and Palliative Medicine by the American Board of Family Medicine.

He holds professional memberships with the American Academy of Family Physicians, American Academy of Hospice and Palliative Medicine, Mississippi Academy of Family Physicians, American Medical Association and The Society for Post-Acute and Long-Term Care Medicine.

Richard D. deShazo, MD has been included in Marquis Who’s Who. As in all Marquis Who’s Who biographical volumes, individuals profiled are selected on the basis of current reference value.

Factors such as position, noteworthy accomplishments, visibility, and prominence in a field are all taken into account during the selection process.

Dr. deShazo’s busy career has included service as a practicing medical consultant, educator, researcher and academic administrator; public broadcasting producer and on air host; and author. Born in Birmingham, Ala. in 1945, he earned a Bachelor of Arts in chemistry and religion from Birmingham Southern College before attaining an MD at the University of Alabama in 1971. Dr. deShazo then completed an internship in pediatrics, a residency in internal medicine, a fellowship in immunology and microbiology, and a fellowship in clinical immunology. He further prepared for his career by becoming board-certified by the American Board of Internal Medicine, the American Board of Allergy and Immunology, the American Board of Rheumatology, the American Board of Geriatrics and the National Board of Medical Examiners. He has published over 300 original scientific articles in peer reviewed literature.

Having completed a residency and fellowships at the Walter Reed Army Medical Center, Dr. deShazo spent eight years in the U.S. Army Medical Corps reaching the rank of lieutenant colonel. He was awarded the Distinguished Service Medal by the Department of the Army. He also began his career as a medical educator, starting as a clinical assistant professor of medicine at the University of Colorado School of Medicine. He was then an assistant professor of medicine and pediatrics at the Uniformed Services University of the Health Sciences before spending nine years with Tulane University School of Medicine. While at Tulane, Dr. deShazo advanced from associate professor to full professor of medicine and pediatrics, and also served as vice chair of clinical operations. In 1989, he left Tulane University to become a professor and chairman of the Department of Medicine at the University of South Alabama College of Medicine. After eight years in this role, he accepted the position of professor of medicine and pediatrics and chairman of the Department of Medicine at the University of Mississippi Medical Center. He stepped down from his

chairman role in 2010, but he continues to teach at the university as a Billy S. Guyton Distinguished Professor of medicine and pediatrics.

In addition to teaching, Dr. deShazo has been a producer of radio and television health documentary programming for Mississippi Public Broadcasting since 2010. As such, he leads a daily radio series called “Southern Remedy,” during which experts discuss current and relevant health issues and topics. The program can be heard on Mississippi Public Broadcasting’s Think Radio from 11 am until noon, as well as online at http://www.mpbonline.org/programs/radio/listen-live. He was associate editor of the Southern Medical Journal from 1995 to 2013.

He now serves as an associate editor of the American Journal of Medicine and is on the editorial boards of numerous medical journals.

Dr. deShazo has remained an active member of the medical community through affiliations with the American College of Physicians, the American College of Rheumatology, the American College of Chest Physicians, and the American Academy of Allergy, Asthma and Immunology, among numerous other organizations.

He was elected a Master of the American College of Physicians and a Distinguished Fellow of the American College of Allergy, Asthma and Immunology. He has taken on a number of leadership roles within these organizations and has received formal honors from them as well. Some of his most recent honors include a 2015 Southeast Emmy Award nomination and a 2015 and 2016 Telly Award for his work on “Southern Remedy.” In 2013, he received the Mississippi Humanities Council Commercial Media Award, as well as media and communication awards from the Association of American Medical Colleges. He also received the Martha Meyers Physician Role Model Award from the University of Alabama School of Medicine. Dr. deShazo and his wife, Gloria, have 3 children and 6 grandchildren. Dr. deShazo has been featured in the 59th through 70th editions of Who’s Who in America, the 7th and 8th editions of Who’s Who in American Education, the 2nd through 8th editions of Who’s Who in Medicine and Healthcare, the 11th and 12th editions of Who’s Who in Science and Engineering, the 27th through 42nd editions of Who’s Who in the South and Southwest, and the 26th through 33rd editions of Who’s Who in the World.

Scott Hambleton, MD, Director of the Mississippi Physicians Health Program, and Randy Easterling, MD, MSMA past-president and member of the Mississippi State Board of Medical Licensure, have both been appointed to the state’s opioid task force. Governor Phil Bryant has created the new task force to study opioid abuse and addiction in Mississippi and propose recommendations that will help address the issue.

Stanley Hartness, MD, of Jackson, has been elected to the IQH board of directors for a three-year term ending in 2019. He joins Dr. Danny W. Jackson of Rolling Fork, Dr. Helen Turner of Madison and Gerald Wages of Tupelo, board members serving through 2017.

Members serving terms on the board through 2018 include Dr. Michael D. Maples of Jackson, Beth Embry of

Ridgeland, and Bo Bowen of Jackson. Serving through 2019 will be Dr. Thomas N. Skelton of Jackson, Dr. Frank C. Wade Jr. of Magee, and Dr. Hartness. Dr. Skelton serves as board chair. Bo Bowen is vice chair, and Gerald Wages, treasurer.

“Dr. Hartness is no stranger to IQH,” said Becky Roberson, CEO. “He has served in numerous capacities throughout the years, including board chair. It is a pleasure to welcome him back.”

Dr. Edward Hill, MD, FAAFP, of Tupelo and distinguished State Board of Health member was recently honored by the Mississippi Public Health Association with a prestigious award for his dedication to the field of public health in Mississippi.

The Felix J. Underwood Award is named for the “father of public health in Mississippi,” Felix J. Underwood, who served as the State Health Officer from 1924 to 1958. Those who receive this award are known to share Dr. Underwood’s passion for protecting the health of all Mississippians.

Dr. Hill was first appointed to the State Board of Health in 2006 by former Governor Haley Barbour. Hill has seen the Mississippi State Department of Health through several periods of transition.

“History remembers Dr. Felix Underwood as the ‘man who saved a million lives’ through his brilliant public health career in Mississippi.

Dr. Edward Hill is deserving of the same sobriquet for his decades of dedicated service to the citizens of his state, his country, and his world,” commented Dr. Lucius Lampton, Chairman of Mississippi’s Board of Health, of Magnolia.

“Dr. Hill has been a longtime proponent of public health and educating the public about health for decades. We are proud and lucky to have him as a Board member,” said State Health Officer Dr. Mary Currier.

He was named Vice Chairman of the Board in 2011 and has served on numerous Board work groups and committees, including most recently the Primary Prevention and Health Education committee. Dr. Hill has also served as president of the American Medical Association and board chairman for the World Medical Association, as well as a variety of leadership roles in other state, regional, and national medical organizations.

Carlos A. Latorre, MD of Vicksburg has been elected the Mississippi Academy of Family Physicians Foundation 2016 president. He served as the foundation’s vice president in recent years. Latorre is a board-certified family physician in Vicksburg. He received his medical degree from the University of Puerto Rico School Of Medicine and completed his residency at the University of Mississippi Medical Center, while serving as chief resident for the Department of Family Medicine. Latorre has bachelor’s and master’s degrees in geology from the University of Southern

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Mississippi and is a registered professional geologist in the state of Mississippi. He has practiced medicine with River Region Health Systems in Vicksburg since 2011 and serves as medical director of Clinical Integration and Physician Orientation, and as secretary of the Medical Executive Committee. He serves as a preceptor to medical students. Latorre is also the Reference Committee Chairman for the Mississippi State Medical Association.

Latorre and his wife of 19 years, Nalini, live in Vicksburg and have one daughter, Alana, 13. They are members of St. Michael’s Catholic Church. In his spare time, Dr. Latorre enjoys spending time with friends and family, attending local dance and theater productions, and sporting events at St. Aloysius Catholic School. He also volunteers for the Miss Mississippi Pageant Corporation, serving as patron chairman in 2016 and judge for The Quality of Life Scholarship for the 2014 through 2016 pageants. He also serves as a volunteer physician at the First Baptist Church Free Clinic, Walk with the Doc Vicksburg, International Ballet Competition in Jackson, Sanderson Farms Championship PGA tour, Doctor of the Day at the State Capitol, and is involved in the Rotary Club in Vicksburg.

Almois Mohamad, MD has joined Merit Health Medical Group as a board certified interventional cardiologist. “Dr. Mohamad’s skill set is vital to Mississippi residents who need improved access to quality cardiovascular care,” said Dr. Greg Oden, Chief Medical Officer, Merit Health. Dr. Mohamad has been practicing interventional cardiology in the Jackson area for the last three years and to-date, has performed over 1,000 cases.

He completed his cardiology fellowship, residency and internal medicine internship at the Medical College of Georgia where he also served as Chief Cardiology Fellow. Dr. Mohamad is an active researcher in both the basic and clinical sciences.

His work was recently published in several peer-reviewed journals including The Annals of Thoracic Surgery, The Texas Heart Institute Journal and The Journal of Clinical & Experimental Cardiology. He is a member of the American College of Cardiology, American College of Physicians, AMA, SMA, Society of Cardiovascular Angiography and Interventions, American Society of Nuclear Cardiology, and Sudanese Doctors’ Union. “With five accredited Chest Pain Centers, Merit Health is thrilled Dr. Mohamad will be treating our patients and lending his expertise to our expanding cardiovascular service line,” said Dr. Oden.

Merit Health Central and Merit Health River Region are accredited as Chest Pain Centers with PCI, and Merit Health Madison, Merit Health Rankin and Merit Health River Oaks are accredited as Chest Pain Centers by the Society of Cardiovascular Patient Care, an institute of the American College of Cardiology. Merit Health Rankin is also accredited for Heart Failure (HF) v2.0. Dr. Mohamad will be performing catheterization laboratory procedures at Merit Health Central and is now seeing patients in Flowood and Brandon.

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P. H. “Hal” Moore, MD of Pascagoula was named president of the Ole Miss Alumni Association when they announced officers for 2016-17 on Saturday, Oct. 1, as part of Homecoming festivities on campus. Dr. Moore is president of Singing River Radiology Group. He serves on the board of directors of the Merchants & Marine Bank and formerly served on the boards of the Mississippi State Medical Association and Belhaven University.

“What a great honor it is to represent the Ole Miss Rebel nation,” said Dr. Moore.

Michelle Y. Owens, MD has been appointed to the Mississippi State Board of Medical Licensure (MSBML) by Gov. Phil Bryant. Dr. Owens replaces Dr. John C. Clay, who resigned earlier this year. Dr. Owens’s appointment is effective immediately and ends June 30, 2020. The MSBML is responsible for the regulation and licensure of medical and osteopathic physicians, podiatrists, physician assistants, radiologist assistants, acupuncturists, and the permitting of limited x-ray machine operators who practice in a physician’s office or clinic. Dr. Owens is currently a practicing obstetrician and gynecologist at the University of Mississippi Medical Center. She has been a member of the faculty at the University of Mississippi School of Medicine since 2007. She currently serves as the director of the Division of Maternal Fetal Medicine Master’s Program in Biomedical Sciences for UMMC and is the past vice-chairman of the Department of Obstetrics and Gynecology.

“Dr. Owens’s experience and distinguished accolades make her the perfect appointee for the position,” Gov. Bryant said. “She has separated herself numerous times as a physician and professor of great skill and merit. I am pleased to appoint her to the State Board of Medical Licensure.”

Owens attended the University of Alabama at Birmingham for her undergraduate studies and graduated from the Virginia Commonwealth University School of Medicine.

“I am deeply honored by Gov. Bryant’s appointment,” Dr. Owens said. “I look forward to working to ensure that we continue to have outstanding healthcare professionals providing care to all Mississippians.”

She received post-graduate medical training as a resident and fellow at Johns Hopkins University and the University of Mississippi Medical Center.

Owens has received the Central Association of Obstetricians and Gynecologists President’s Certificate of Medal Award, Mississippi Medical and Surgical Society President’s Award, Mississippi Medical

and Surgical Society Physician of the Year, and the University of Mississippi Center Department of Obstetrics and Gynecology CREOG National Faculty Award.

She is a diplomate of the American Board of Obstetrics and Gynecology and a member of the American College of Obstetricians and Gynecologists, Howard Kelly Society, Association of Professors of Gynecology and Obstetrics and the Mississippi Medical and Surgical Society, among many others.

Owens is currently licensed to practice medicine in Mississippi and Wisconsin.

She and her husband have three children.

Raman Palabindala, MD loves his job as a hospitalist for many reasons, but one especially stands out.

“We talk to the families every day, and multiple times in a day if needed. We take the time to establish that relationship with patients and families. We take care of patients as a team,” said Palabindala, an assistant professor of medicine. “We are there in the hospital 24 hours when patients and families need us.”

That’s his role as a hospitalist, a physician who exclusively cares for adult inpatients, whether they’ve recently had surgery, come through the Emergency Department, or were admitted for other reasons. “We are the one and only attending-based service for the entire hospital, unlike other services that have residents and fellows,” said Palabindala, who came to the Medical Center in December 2015. “We don’t have a clinic outside the hospital.”

His dedication to his patients and his excellence in medicine have been recognized by ACP Hospitalist magazine. Palabindala is among the Top Hospitalists for 2016, one of 10 physicians chosen from dozens of nominations nationwide by the editorial board of the publication of the American College of Physicians. At age 35, he’s one of the youngest honorees in the program.

“I work really hard in life,” said Palabindala, the Medical Center’s lead hospitalist. “I knew when I was in my residency that I wanted to be a hospitalist, and I made contacts with national leaders to learn as much as I can.”

He was nominated by his colleagues at Southeast Alabama Medical Center in Dothan, where he joined the staff in 2012 as a hospitalist in the Department of Internal Medicine. He served on the department’s clinical teaching staff at the Alabama College of Osteopathic Medicine, and in 2015, he took on additional duties at SAMC as a home health director and clerkship director.

He is a graduate of the Kamineni Institute of Medical Sciences in Narketpally, India. Palabindala completed residency training in internal medicine at the Greater Baltimore Medical Center, serving as chief

medical resident from 2011-12.

Ronald L. Schwartz, MD, director and principal investigator at Hattiesburg Clinic’s Memory Center, and Imaging departments are collaborating on a study aimed at improving the method of care for people with Alzheimer’s disease.

The Imaging Dementia – Evidence for Amyloid Scanning Study goes by the acronym IDEAS. It focuses on brain images that may help physicians diagnose Alzheimer’s disease sooner. Images of the brain are taken via amyloid PET scans. These images show physicians if there is a significant amount of amyloid plaque build-up, which Dr. Schwartz says could be a strong indicator of a person eventually being diagnosed with Alzheimer’s disease. “Amyloid plaques are sticky clumps of protein in the brain, which are associated with this disease. Whether or not these plaques are present could help us determine the likelihood that a patient’s symptoms are caused by Alzheimer’s disease.” PET imaging will highlight any plaque present. A follow-up visit will be scheduled with the patient, during which the specialist will discuss the scan results and use that information in helping the patient plan his or her future.

“Ultimately, the goal is to show how important the PET scans are in the early diagnosis of Alzheimer’s disease,” Schwartz said. “Although there is no cure yet, early treatment can slow the progression of the disease, and that is the standard of care we are aiming for through this study.” To learn more about the IDEAS Study, including eligibility requirements, visit www.hattiesburgclinic.com/memorycenter, or call 1-877-91-MEMORY (1-877-916-3667). n

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#AskTheHIVDoc Campaign Taps Mena’s STD Expertise Leandro Mena, MD considers himself a shy person. He doesn’t do Facebook, and he barely tweets.

But his international reputation as an expert in the field of sexually transmitted infections has placed him in a sweeping social media spotlight. He’s one of three “smart and sexy docs” answering questions on an array of topics in #AskTheHIVDoc, a YouTube-based series of short-form, question-and-answer videos in English and Spanish produced through the initiative Greater Than AIDS. Mena, a native of the Dominican Republic and associate professor of infectious diseases at the University of Mississippi Medical Center, and HIV/AIDS experts Dr. David Malebranche and Dr. Demetre Daskalakis give frank and information-packed answers to questions about sexually transmitted diseases - questions that many men who have sex with men (MSM) might never feel comfortable asking their own providers.

“We do it in a straightforward, simple way,” said Mena, who joined the duo of Malebranche and Daskalakis in December 2015 and can be seen in the second season of #AskTheHIVDoc that debuted June 1 on YouTube.

That’s 23 English videos and an additional 11 narrated by Mena in Spanish. The nonprofit Kaiser Family Foundation created the branded campaign Greater Than Aids; #AskTheHIVDoc is a part of that brand.

“We just fell in love with him,” said Tina Hoff, the Kaiser Family Foundation’s senior vice president and director of health communications and media partnerships. “He’s not only incredibly knowledgeable and skilled as a clinician, but he’s a warm person who feels so deeply passionate about what he’s doing. He connects with his patients. He’s everything we were looking for.”

The trio takes on topics that include “Can I Get HIV if My Partner is Undetectable?” “Herbal Treatments?”

Leandro Mena, MD “Can I Still Have Sex?” and “How Can I Find Help?” At the beginning of the season two videos, a smiling Mena tells viewers: “We’re going to give you what you need.”

The tone of the videos is sometimes playful and always engaging, but the underlying messages are tough in a society that’s experiencing an HIV/AIDS epidemic. In the United States, Mena says, one out of every two black MSM will become HIV positive in their lifetime. Among Latino men, that’s one out of four.

And, a recent Emory University study shows four of 10 MSM in Jackson have HIV - the highest rate in the nation. “That right there tells you that there’s a need for this information,” said Harry Hawkins, field organizer for the Jackson office of the Human Rights Campaign, a civil rights organization dedicated to achieving LGBT equality.

“There’s an urgency to act and do something to change what might seem inevitable for a significant portion of the population,” Mena said.

Using social media as the platform for the videos “gets the message across in a very effective way for the times we live in,” Hawkins said. “A lot of people who are infected are between the ages of 15 and 24.” The first season of #AskTheHIVDoc received 731,141 views on YouTube and another 405,302 on other social and digital platforms, Kaiser Family Foundation statistics show.

The #AskTheHIVDoc messages empower not just MSM, but the caregivers whose lack of expertise in HIV and AIDS treatment leaves them struggling to answer their patients’ questions and manage their overall health.

“We’re in a health-care system where many clinicians don’t regularly ask their patients about their sexual behavior,” Mena said. “They’re uncomfortable about having a conversation about sex, and uncomfortable about discussing behaviors to decrease their risk.”

But at the same time, Mena said, clinicians like himself are trying to improve access to health care, especially to those most vulnerable to sexually transmitted infections.

The videos encourage discussions that can never be too basic - for example, the difference between AIDS and HIV, or how people can become infected when they have sex. “We talk about how often you should be tested for HIV, and what tests gay or bisexual men should have when they go to the doctor, and when they should start treatment,” Mena said. “We talk about how safe certain practices are.

“In clinic, I start by talking very frankly with my patients, and breaking things down into the language that makes them comfortable. If you do that, you have a better chance to address their health needs,” Mena said.

The three doctors also talk about PrEP, short for pre-exposure prophylaxis, a medication that works to keep the HIV virus from establishing a permanent infection. A pill that’s taken once daily, PrEP targets those with an ongoing, substantial risk of HIV infection and, when taken consistently, can reduce risk of HIV in people who are at high risk by 92 percent, the Centers for Disease Control and Prevention says.

“I’ve talked to folks in my job and outside of my job that have been to doctors in this area who just don’t know anything about PrEP,” Hawkins said.

“There’s a need for education when you have a patient coming to you who says I’m a sexually active gay male, and I want to get on this to protect myself.”

Brandon Brazzle of Jackson, one of Mena’s patients, agrees.

“People think you have HIV, rather than these drugs trying to prevent it,” said Brazzle, 27, who is taking Truvada, the brand name of the drug that gained federal approval in the United States. “I had to explain to my family members that I wasn’t HIV positive.”

He regularly talks to friends about PrEP because it can help them with their sexual health. “It’s kind of hard sometimes to take it up with your doctor, because they might not be used to seeing that kind of patient,” Brazzle said.

The first #AskTheHIVDoc videos featured just Malebranche, an internal medicine physician with Georgia-based Wellstar Health Systems who also cares for inmates at the DeKalb County Adult Detention System in Marietta, a suburb of Atlanta; and Daskalakis. But Daskalakis, assistant commissioner of the

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Bureau of HIV Prevention and Control at the New York Department of Health and Mental Hygiene, approached Mena about joining the team last fall when the two served as co-presenters at the U.S. Conference on AIDS. “It was a no-brainer,” said Malebranche, who has specialty training in HIV, AIDS and health needs of the LGBT community. “The additional bonus is him being from the Dominican Republic. He can not only do this in English, but in Spanish so that we can reach a whole different audience.”

Mena said yes to #AskTheHIVDoc, but not without hesitation. “I’m kind of a shy person, but this is something important to reaching many people who might not otherwise have access to this information in a format that people can understand,” he said. “If people are educated, they will make better-informed decisions and in turn will have better health outcomes.”

“We really like each other, and it’s not super subtle,” Daskalakis said. “Although we come from different perspectives, we all come to the same conclusion to give medical information related to HIV and sexual health in a way that’s digestible, fun and brief. Leandro gets it, and his comfort level on #AskTheHIVDoc is great.”

How education on MSM sexual health is delivered greatly needs improvement, said Dr. Thomas Dobbs, state epidemiologist with the Mississippi Department of Health. That agency runs the Crossroads Central Clinic in Jackson, which offers HIV testing, counseling and medical referral services. Mena serves as medical director at Crossroads, the only publicly funded clinic of its kind in the state.

“There’s been a lot of effort to get the word out,” Dobbs said. But one of the challenges, he said, is that many doctors see treatment of HIV patients as a specialty field. “It really needs to be addressed as part of core health. There’s a role for every doctor in the state in HIV care. Everyone should be able to provide testing and have an awareness of the options in care.”

That includes PrEP, Dobbs said. “It’s probably not making a big impact right now,” he said of the drug. “Not enough people are on PrEP, but it holds a lot of promise. It’s an underutilized opportunity.”

Brazzle is a former Crossroads patient. “It was like my second home,” he said. “I feel comfortable in that environment, and they won’t think my questions are silly or stupid.”

“The fact of the matter is, with HIV and patients’ adherence to their medications, it’s very personal,” Malebranche said. “You have to scrap the old notions of being stoic and not giving patients your cell phone number. All of us embody that spirit. Dr. Mena’s patients absolutely love him.”

In a state where the LGBT community often must struggle with discrimination, “Dr. Mena is a warrior to me,” Malebranche said. “There aren’t that many experts there who would be approachable and non-judgmental.”

His role in #AskTheHIVDoc “may be just a small contribution,” Mena said. “But, it’s an important component of what must take place to end the HIV epidemic in our country.”

“It’s hard for us sometimes to reach that community, and there’s stigma here, too, but flash back to Leandro,” Daskalakis said. “Nothing we are doing in New York is nearly as heroic and community loving as what Leandro is doing in Mississippi.”

Leandro Mena, MD devotes a significant part of his waking hours to public health, but also is a researcher, educator, and clinical partner with a number of organizations devoted to sexual health and HIV prevention in gender and sexual minorities.

He has vast experience in clinical and epidemiological research in the area of sexually transmitted infections including HIV, with special interest in the dynamics of transmission and the role social determinants play in the HIV epidemic in ethnic and racial minority populations.

An associate professor of medicine in the Medical Center’s Division Helping you build a more secure future of Infectious Diseases, Mena joined the Medical Center faculty in 2003. He We’re a firm that’s invested in your success serves as director of the Center for HIV/AIDS Research, Education and and are committed to delivering: Policy in the Myrlie Evers-Williams Institute for the Elimination of Health Disparities.

A long-term, value-driven investment strategy.

Mena helps his patients to develop a plan to manage the risks of their HIV infection or likelihood of becoming infected. He takes into account their Thoughtful, carefully-vetted investment selections. culture and lifestyle in coming up with a plan that works for the patient, with sexual health education playing a key role.

Friendly, conscientious client service.

Mena serves as medical director for the Crossroads Central Clinic, a Proven, positive investment results. state Department of Health-run clinic for HIV testing and counseling. It’s the only publicly funded clinic of its kind in the state. Mena supervises a clinical We believe in the investments we recommend and and epidemiologic research team in conjunction with the clinic. invest our money alongside yours in the same manner.

He is medical director of Open Arms Healthcare Center, a communitySo let’s work together to achieve your financial goals. based clinic that offers primary care and mental health services with an emphasis in the health-care needs of LGBT populations in Jackson. Mena also is associated with My Brother’s Keeper, a Jackson-based community outreach organization that works to improve the health and well-being of minorities.

My Brother’s Keeper also is committed to HIV prevention among racial and ethnic minority populations.

He earned his medical degree from the Universidad Nacional Pedro MEDLEY & BROWN, LLC F I N A N C I A L A D V I S O R S Henriquez Urena in Santo Domingo, Dominican Republic, and his master of public health from Tulane University School of Public Health and Tropical Call us at 601-982-4123 www.medleybrown.com Medicine in New Orleans. n

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Autonomy [This month, we print a poem by James K. Glisson, MD, PharmD, of Jackson. Dr. Glisson is an internist who works at St. Dominic Hospital. His poem “Autonomy” was inspired by his own clinical experience and his pursuit of a “good death” for his patients who faced end of life. Glisson states, “I wrote [“Autonomy”] after caring for a patient who only wanted to go home and die. The surgeon wanted to keep doing things despite him having a terminal diagnosis. I talked with the patient and family who decided against additional surgeries.” Glisson feels physicians in our region often do poorly with end of life care: “I find that many physicians do not listen to what the family wants and often don’t give the family time to make their wishes known.” Glisson concludes, “I hope the culture of medicine changes and physicians discuss all options of care with patients, even hospice. In my opinion helping a patient die comfortably is one of the noblest actions of a caregiver/physician along with saving a life.” Any physician is invited to submit poems for publication in the journal, attention: Dr. Lampton or email me at lukelampton@cableone.net.]—Ed.

Mr. Blue is tired.

His brain won’t sleep; his gut won’t wake.

The surgeon says, “I have a plan, six weeks of TPN, better yet, a PEG. LTAC will tune you up.

Just one more operation, Mr. Blue.

I’ll cauterize those adhesions.

This time I’ll win!”

The son says, “Your call dad.”

Mr. Blue replies, “I gave my consent.

The PICC team is here.

I’ve a belly full of contrast the CT tech awaits.

But, I am so tired doctor.

I’m wasting away.”

I say, “There is another way.

No more scans or surgeries. No TPN. And YOU say when to begin and end.

Your drowsy bowel can finally lay down to rest.

The rigid snake in your nose can be excised.

Consent can be reversed by a single word.

You choose your path, on your terms, not mine nor by the surgeon’s pride.”

He soaked in my words.

They spread from cell to cell soluble in lipid and water.

And with a sharp mind, a rolling tremor, and a shuffling gait, he spoke from a six-foot, fifty-four-kilogram weight.

“Doc, I’d like to go home, to be with family and enjoy the wait.

374 VOL. 57 • NO. 11 • 2016

I’m now just a raisin and all my life I’ve been a grape.”

In the lung it began, then stalked out the liver and bone.

The cancer has won, but Mr. Blue chose his fate.

He jettisoned the surgeon and welcomed the hospice embrace.

—James K. Glisson, MD, PharmD Jackson

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