VOL. LVIII • NO. 10 • 2016
Your patients can enjoy a healthier life. They just need a little extra motivation. Motivated to Live a Better Life is a free six-week workshop designed to help Mississippians better manage chronic conditions and take the right steps to lead a healthier, more active life. Learn more about this evidence-based approach to health management by calling the Mississippi State Department of Health Office of Preventive Health at 601-206-1559 or visiting HealthyMS.com/MLBL.
Motivated to Live a Better Life is licensed by the Stanford University Chronic Disease Self-Management Program.
VOL. LVIII • NO. 10 • OCTOBER 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
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 Vice Speaker Jeffrey A. Morris, MD Executive Director Charmain Kanosky
JOURNAL OF THE MISSISSIPPI STATE MEDICAL ASSOCIATION (ISSN 0026-6396) is owned and published monthly by the Mississippi State Medical Association, founded 1856, located at 408 West Parkway Place, Ridgeland, Mississippi 39158-2548. (ISSN# 0026-6396 as mandated by section E211.10, Domestic Mail Manual). Periodicals postage paid at Jackson, MS and at additional mailing offices. CORRESPONDENCE: Journal MSMA, Managing Editor, Karen A. Evers, P.O. Box 2548, Ridgeland, MS 39158-2548, Ph.: 601-853-6733, Fax: 601-853-6746, www.MSMAonline.com. SUBSCRIPTION RATE: $83.00 per annum; $96.00 per annum for foreign subscriptions; $7.00 per copy, $10.00 per foreign copy, as available. ADVERTISING RATES: furnished on request. Cristen Hemmins, Hemmins Hall, Inc. Advertising, P.O. Box 1112, Oxford, Mississippi 38655, Ph: 662-236-1700, Fax: 662-236-7011, email: cristenh@watervalley.net POSTMASTER: send address changes to Journal of the Mississippi State Medical Association, P.O. Box 2548, Ridgeland, MS 39158-2548. The views expressed in this publication reflect the opinions of the authors and do not necessarily state the opinions or policies of the Mississippi State Medical Association. Copyright © 2016 Mississippi State Medical Association.
SCIENTIFIC ARTICLES Overweight and Obesity Prevalence and Trends Among Mississippi Public School Students: A Decade of Data Between 2005 and 2015 Jerome R. Kolbo, PhD, MSW; Lei Zhang, PhD, MBA; Nichole Werle, LMSW; Elaine Fontenot Molaison, PhD, RD; Bonnie L. Harbaugh, PhD, RN; Melissa Kirkup, LMSW; Evelyn Walker, MD, MPH Teen Pregnancy in Mississippi: A History and Analysis of Recent Legislative and Governmental Attempts to Address Different Aspects of this Issue in Mississippi Nycole Campbell-Lewis, PhD; Sidney W. Bondurant, MD; Freda M. Bush, MD Top 10 Facts You Should Know About Immunizations and Vaccine Exemptions in Mississippi Thomas Dobbs, MD, MPH and Paul Byers, MD, MPH Top 10 Facts You Should Know About Diagnostic Evaluation of Neonatal Cholestasis Leah Burch, BS; David Sawaya, MD; Michael Steiner, MD; Charu Subramony, MD; Michael Nowicki, MD DEPARTMENTS From the Editor – A Solution Looking For a Problem Lucius M. Lampton, MD, Editor President’s Page – Neighbor State Sees Swell in Preventable Mumps Cases: Legislature Holds the Key Lee Voulters, MD Commentary – Bariatric Surgery –A Viable Option and the Best Hope for Many Mississippians? Emma L. Willoughby, MSc; Ellen S. Jones, PhD; Deborah S. Minor, PharmD In Memoriam New Members Legalese – Government Guidelines, Practice Parameters and Specialty Standards: Swords or Shields? Stephanie Edgar, JD Una Voce – A Doctor’s Prescriptions for a Happy Family Holiday Gathering Dwalia S. South, MD
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ABOUT THE COVER
“The Old Coal Chute in McComb”– This iconic structure is located at the historic railroad yards in McComb, standing as a sentinel of the railroads of old. In 1871, Col. Henry S. McComb became president of the New Orleans, Jackson and Great Northern Railroad Company, the antebellum railroad which first went north from New Orleans to Jackson, later to become the Illinois Central Railroad. In 1872, Col. McComb built present-day McComb, which he called “McComb City,” to place his railroad shops for the southern part of the Illinois Central line, moving the yards from the distractions of New Orleans. The central structure of the railroad shops was the famous Roundhouse. Steam engines were placed on a track that would turn 360 degrees to make the needed repairs and maintenance. This old coal chute, one of the few remaining on the railroad, speaks to the coal-powered railroad era of McComb (City was later dropped), a city truly built by the railroad. McComb has an outstanding railroad museum worthy of visiting in its historic downtown depot. This photo is by Brett Tisdale, MD, of McComb. – ED. n VOL. LVIII • NO. 10 • 2016
Official Publication
MSMA • Since 1959
JOURNAL MSMA
307
F R O M
T H E
E D I T O R
A Solution Looking For a Problem
T
he Atlanta Journal-Constitution recently published a five part series asserting that there exists a national epidemic of physicians sexually assaulting their patients and that such unethical behavior is routinely tolerated by state medical boards. Although the articles received state and national notice, they were both hyperbolic and misleading, proposing as the solution the creation by state legislatures of new Lucius M. Lampton, MD criminal felony laws solely focused on Editor physician sexual misconduct. Such a proposal appears to be a solution looking for a problem. I see no epidemic of physician behavior abuse in our state. We have our bad actors, as every profession does, and when their unethical behavior comes to light, our Board of Medical Licensure takes aggressive action to protect our patients, usually taking or restricting a medical license. The proposal to create new felony laws applying only to physicians appears overly punitive and totally unnecessary. If criminal activity is uncovered, the current laws allow felony prosecution of anyone who commits rape or engages in nonconsensual sex. And don’t forget civil penalties and lawsuits
as well, which provide avenues for further punishment. Why are additional laws needed? Are we going to make it a felony for anyone in a position of trust to engage in unethical sexual behavior? What about pastors, teachers, nurses, counselors, or lawyers? We all have heard of cases in which these others have engaged in inappropriate sexual behavior with clients. What makes it different for doctors? Physicians must strongly condemn any ethical misconduct and assert the serious responsibilities entrusted to our profession. We must hold ourselves to a higher standard than anyone else. That said, physicians are frail animals, like all humans, and most cases of misconduct are tragic enough without sending someone to jail when taking their medical license and their ability to make a living accomplishes both punishment enough and patient protection. Our Board of Licensure’s current vigorous enforcement of the laws of the Mississippi Medical Practice Act is protecting the health, safety, and welfare of our patients. New laws creating a special criminal status for physicians over other professions or citizens are absolute foolishness. 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
308 VOL. 57 • NO. 10 • 2016
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
309
S C I E N T I F I C
A R T I C L E
Overweight and Obesity Prevalence and Trends Among Mississippi Public School Students: A Decade of Data Between 2005 and 2015 JEROME R. KOLBO, PHD, MSW; LEI ZHANG, PHD, MBA; NICHOLE WERLE, LMSW; ELAINE FONTENOT MOLAISON, PHD, RD; BONNIE L. HARBAUGH, PHD, RN; MELISSA KIRKUP, LMSW; EVELYN WALKER, MD, MPH
Abstract This study estimated the prevalence of overweight and obesity in Mississippi public school students in grades K-12 and examined changes between 2005 and 2015. In 2015, the prevalence of overweight, obesity, and both combined remained higher than national averages, yet the rates have neither increased nor decreased significantly since 2005 (p = 0.6904). In 2015, as with all previous years, there was no difference between boys and girls (p=0.570). As in all previous years, the prevalence of obesity in 2015 was significantly higher among black students (p < 0.001) than among white students. Similar to 2011 and 2013, there was a significant difference by grade level in 2015 (p=0.0029), with the lowest prevalence again among the elementary students. The significant linear decrease in obesity prevalence among elementary school students observed during 2013 continued to 2015 (p = 0.0209). Trends are discussed in the context of state policy and recent research. Key Words: Childhood, Overweight, Obesity, Trends Introduction Over the past decade, the prevalence of child overweight and obesity have been assessed biannually within the state of Mississippi through the Child and Youth Prevalence of Obesity Survey (CAYPOS).1-6 Data collected as part of the CAYPOS indicate the prevalence of overweight and obesity in Mississippi have not increased or decreased significantly since 2005, though it remains high and is higher than national rates. The CAYPOS data also suggest ongoing and increasing disparities between black and white students. Additionally, in recent years, the CAYPOS data offer some of the most encouraging findings in the significant decreases of overweight and obesity among elementary school level students. National trends reflect a similar stability of prevalence rates. According to the most recent National Health and Nutrition Examination Survey (NHANES), there has been no significant change in the child obesity prevalence rate among children aged 2-19 years between 2003-2004 and 2011-2012, the most recent years for which data are available.7
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Similar to Mississippi, disparities by race were observed in this national sample, with the prevalence of obesity for white youth (14.1%) being significantly lower than for black youth (20.2%). National data diverge, however, from what has been observed in Mississippi when comparing obesity rates by age. NHANES found no significant difference among age groups when comparing 6-11 year olds with 12-19 year olds but did note a significant decrease among 2-5 year old children (from 13.9% to 8.4%) between the 2009-2010 and 2011-2012 survey years. The majority of legislative attempts to intervene from a public health standpoint have focused upon public school initiatives designed to reduce obesity. Though numerous factors have been identified as contributing to the high prevalence of child overweight and obesity including early life, neighborhood, and community factors, public school initiatives are an important part of the policy toolbox. Beginning in 2006, Mississippi started implementing several public school mandates that required the creation of school wellness policies, updated beverage standards, and increased regulation surrounding nutrition, physical activity, and physical education standards.8-16 Since that time, there have been encouraging reductions in child overweight and obesity among a few, specific demographic subgroups though these outcomes have not been realized for all Mississippi students. Despite the promising changes observed over this time period, child overweight and obesity rates remain a pressing concern; this is true not only for the significant percentage of children who fall within one of these two categories but also for broader society. Overweight and obesity are associated with a number of physical and psychological comorbidities. Childhood obesity is linked to global damage to the human body, particularly to the endocrine, cardiovascular, gastrointestinal, pulmonary, orthopedic, neurological, and dermatologic systems. Obese children also have higher rates of depression, low self-esteem, and poor body image, particularly if they have been subjected to weight-based social stigmatization.17-32 Perhaps due to increased risk for negative health outcomes, the lifetime medical expenditures for an obese child has been estimated to be over $19,000 more than those of a normal weight child who maintained normal
weight throughout adulthood.33 In light of these serious ramifications and continuous public health efforts to reduce obesity rates, the 2015 CAYPOS study was intended to provide an updated landscape of the prevalence rates of child overweight and obesity and examine trends over the past decade among Mississippi public school students. Methods The 2015 CAYPOS sampling frame consisted of 478,056 students in 892 public schools offering kindergarten or any combination of grades 1 through 12 in Mississippi. As in all previous CAYPOS, the sample design was a two-stage stratified probability design.1-6 The first stage included the random selection of 95 schools. A systematic sample of schools was drawn with probability proportional to the enrollment in grades K-12 of each school. In the second stage of sampling, classes were randomly selected within the sampled schools. Classes were selected using equal probability systematic sampling. The sample was designed to result in a self-weighting sample so that every eligible student had an equal chance of selection, improving the precision of the estimates. As in each of the previous CAYPOS, the weighting process was intended to develop sample weights so that the weighted sample estimates accurately represented the entire K-12 public school population in Mississippi.1-6 In the sampling frame, every eligible student was assigned a base weight, which was equal to the inverse of the probability of selection for the student. Adjustments were made to the initial weights to remove bias from the estimates and reduce the variability of the estimates. The most recent CAYPOS (2015) was conducted in March and April 2015. The study received continued institutional review board approval through the Human Subjects Committee at The University of Southern Mississippi, as the study protocol matched the six prior CAYPOS.1-6 As with all of the previous CAYPOS, once selected schools agreed to participate and classes were chosen, a written protocol, measuring equipment (i.e., digital scales and stadiometers) and passive parental consent forms were delivered to the schools. Each school designated a school nurse or other individual who was responsible for collecting data and had been trained on the use of equipment. Approximately one week before data collection was to begin, students in the randomly selected classes were read a prepared paragraph containing information about the study. Each student was then given a passive parental consent form to take home to parents or guardians. If a parent did not want his or her child to participate in the study, the parent was instructed to indicate such on the form, sign it, and have the child return the form to the teacher. Prior to the collection of height and weight, the nurse checked with the teacher to determine if any students returned a signed form. Students who returned a signed form did not participate in the study. There were neither consequences for nonparticipation nor rewards for participation. As with all the previous CAYPOS, the protocol for making measurements required that the weight scale be placed on a hard, smooth surface; carpeted areas were not to be used.1-6 The scale was to be calibrated to zero before use and recalibrated after every 10th student. All students were to be weighed and measured in a location where the
information gathered would be confidential (e.g., nurseâ&#x20AC;&#x2122;s office). Other students were not able to read the scale or height measurement or hear a weight or height given. Nurses reported the height and weight, rounded to the nearest whole inch or quarter pound, respectively, along with age, gender, date of birth, racial or ethnic background, and the school code number. No allowance was made for weight of clothing; however, students were asked to remove belts, heavy jewelry, jackets, and shoes. No student names or other identifying information were written on the data collection forms. As in all previous CAYPOS, nurses returned the completed data forms to The University of Southern Mississippi by fax or mail.1-6 These data were then entered into Excel by a Research Assistant. The completed database was submitted for statistical analysis to identify prevalence rates and trends of the whole and various subgroups. All completed data forms were destroyed once data had been entered and analyzed. Data Analysis As in all of the previous CAYPOS, Body Mass Index (BMI) was computed for each responding student based on height (in meters) and weight (in kilograms).1-6 The height in feet and inches was first converted to meters. The weight in pounds was then converted to kilograms. BMI was calculated using the SAS program, gc-calculate-BIV. sas as follows: BMI = Weight (in kg)/[Height (in m)]2. BMI values were checked to ensure that the results were biologically plausible, using the limits developed by the Centers for Disease Control and Prevention (CDC). BMI percentiles were computed using the SAS program, gc-calculate-BIV.sas. Children and adolescents were classified into four categories: (1) underweight (BMI is less than the 5th percentile); (2) normal weight (BMI is equal to or greater than the 5th but less than the 85th percentile); (3) overweight (BMI is equal to or greater than the 85th but less than the 95th percentile); and (4) obese (BMI is equal to or greater than the 95th percentile).34 Likewise, as in all previous CAYPOS, SUDAAN 11.0135 was used to calculate weighted estimates and standard errors.1-6 Proc Crosstab procedure was used to compare prevalence of child overweight and obesity among different subgroups, such as gender, race, and grade level. Differences were assessed independently for each survey year and considered statistically significant if the p-values from the Chisquare tests were less than 0.05. For comparisons of subgroups with more than two levels (e.g., obesity by gender by race by grade, etc.), no statistical tests were conducted due to substantially decreased sample sizes and possibly unreliable estimations. The comparison of their 95% confidence intervals (CIs) was simply used for these situations; differences between estimates were considered statistically significant if their associated 95% CIs did not overlap. The estimate and its 95% CI were marked as unreliable if the sample size was less than 50. In addition, SUDAAN logistic regression procedure was used to investigate linearity of the longitudinal trends in overweight and obesity. Since elapsed time was the same between successive CAYPOS surveys, the logistic regression used orthogonal variables to model longitudinal trends while controlling for studentsâ&#x20AC;&#x2122; gender, race, and grade level. The linear coefficient (-5, -3, -1, 1, 3, 5) and quadratic coefficients (13.33, -2.67, -10.67, -10.67, -2.67, 13.33) were assigned over the years 2005, 2007, 2009, 2011, 2013, and 2015, respectively. JOURNAL MSMA
311
weight (45.9% combined). The prevalence of obesity among black students was significantly higher than among white students (p < 0.001).
Results Characteristics of Participants from the 2015 CAYPOS Eighty-two of the 95 randomly sampled schools participated in the study (86.3%). The student response rate was 90.0% (5,222 participating students /5,808 sampled students). Thus, the overall response rate was 78.0% (product of school response rate and student response rate), which was above the threshold of 60% required to obtain weighted estimates. The final sample consisted of 5,222 students in grades K-12, including 2,644 males (50.6%), 2,578 females (49.4%), 2,057 white students (40.7%), 2,975 black students (55.4%), and 190 students from other racial/ethnic backgrounds (3.9%) (Table 1). The number of students in other race categories was too small for separate analysis, and therefore, was not included in the comparison analyses. Table 1. Characteristic of CAYPOS Participants, Grades K-12, 2015 Unweighted count
Characteristic
Weighted percent
Gender
Grade Level Among elementary level students (grades K-5), 22.6% were classified as obese, with 17.8% classified as overweight (40.4% combined). Among the middle school students (grades 6-8), 27.3% were obese and 18.8% were overweight (46.1% combined). Among the high school students (grades 9-12), 28.2% were obese and 18.5% were overweight (46.7% combined). Differences in the prevalence of obesity by grade level were statistically significant (p = 0.029). Gender In 2015, 24.7% of males were classified as obese, with another 17.3% as overweight (42.0% combined) (Table 2). As for females, 25.6% were obese and another 19.2% were overweight (44.8% combined). Differences in the prevalence of obesity by gender was not statistically significant (p = 0.570).
Male
2,644
50.6
Female
2,578
49.4
Gender and Race
White
2,057
40.7
Black
2,975
55.4
Other
190
3.9
As for gender and race, among white males, 23.5% were obese and 17.0% were overweight (40.5% combined). Among black males, 25.5% were obese and 17.6% were overweight (43.1% combined).
Race
Grade Elementary K
391
7.6
1st
440
8.3
2nd
501
9.9
3rd
480
8.4
4th
448
8.7
5th
410
8.0
6th
475
8.9
7th
368
7.2
8th
399
7.8
9th
392
7.4
10th
233
4.2
11th
344
6.9
12th
341
6.7
5,222
100
Middle
High
Total
Results of 2015 CAYPOS Based on Subgroups of Participants As a group, 25.2% of the children and youth in grades K-12 were classified as obese (Table 2). Another 18.2% of the children were classified as overweight, giving a combined total of 43.4% of the children and youth at or above the 85th percentile for BMI for age and gender. Race In terms of race, 21.8% of the white students were classified as obese, with another 18.0% as overweight (39.8% combined) (Table 2). Among the black students, 27.7% were obese and 18.2% were over-
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Among white females, 19.9% were obese and 19.1% were overweight (39.0% combined). Among black females, 29.9% were obese and 18.9% were overweight (48.8% combined). The prevalence of obesity among black females was significantly higher than among white females. Race and Grade Level Among all students, the highest rates of overweight and obesity were at the high school level regardless of race (Table 2). Among white students, 27.3% were obese and 19.3% were overweight (46.6% combined) at the high school level; 22.6% were obese and 18.8% were overweight (41.4% combined) at the middle school level; and 18.6% were obese and 17.0% were overweight (35.6% combined) at the elementary school level (Figures 1-3). Among black students, 29.2% were obese and 17.1% were overweight (46.3% combined) at the high school level; 31.1% were obese and 18.6% were overweight (49.7% combined) at the middle school level, and 25.3% were obese and 18.7% were overweight (44.0% combined) at the elementary school level. Obesity prevalence was significantly higher among black students compared to white students at both the middle (p = 0.003) and elementary (p =0.002) school levels. Gender, Race, and Grade Level When race and gender were combined at the high school level, 23.5% of white females were obese and 19.2% were overweight (42.7% combined). Among black females, 30.6 % were obese and 18.9% were overweight (49.5% combined). At the middle school level, 17.2% of white females were obese and 21.2 % were overweight (38.4% combined).
Table 2. Prevalence of Overweight and Obesity by Grade Level and Race, CAYPOS, Mississippi, 2015 All (K-12) (%, 95% CIc)
Elementary (K-5) (%, 95% CI)
Middle school (6-8) (%, 95% CI)
High school (9-12) (%, 95% CI)
All Overweighta
18.2 (17.2-19.3)
17.8 (16.6-19.1)
18.8 (16.5-21.4)
18.5 (16.3-21.0)
Obesityb
25.2 (23.3-27.1)
22.6 (20.1-25.4)
27.3 (23.5-31.4)
28.2 (24.6-32.0)
Overweight
18.0 (16.4-19.8)
17.0 (14.7-19.7)
18.8 (14.9-23.5)
19.3 (16.8-22.1)
Obesity
21.8 (19.6-24.1)
18.6 (16.0-21.6)
22.6 (17.9-28.2)
27.3 (22.9-32.3)
White
Black Overweight
18.2 (16.7-19.8)
18.7 (17.0-20.4)
18.6 (15.7-21.8)
17.1 (13.5-21.3)
Obesity
27.7 (25.1-30.4)
25.3 (21.7-29.4)
31.1 (27.2-35.3)
29.2 (23.9-35.0)
Overweight
17.3 (15.9-18.8)
17.6 (15.7-19.7)
16.5 (13.5-19.9)
17.6 (15.6-19.9)
Obesity
24.7 (22.3-27.4)
21.5 (18.5-24.9)
27.3 (23.3-31.7)
28.7 (23.4-34.6)
Male
Female Overweight
19.2 (17.5-20.9)
18.1 (16.4-19.8)
21.2 (17.7-25.2)
19.5 (15.8-23.8)
Obesity
25.6 (23.3-28.0)
23.8 (20.9-27.0)
27.2 (21.6-33.7)
27.7 (24.5-31.2)
White male Overweight
17.0 (14.3-20.0)
15.9 (12.0-20.8)
16.7 (11.5-23.7)*
19.4 (16.4-22.8)
Obesity
23.5 (20.5-26.9)
17.8 (14.1-22.1)
27.4 (21.6-34.0)
30.7 (24.1-38.2)
Overweight
17.6 (15.7-19.6)
19.5 (16.8-22.5)
16.0 (12.0-20.9)
15.2 (12.3-18.7)
Obesity
25.5 (22.2-29.1)
23.5 (19.5-28.1)
27.2 (22.4-32.6)
27.8 (20.7-36.1)
Overweight
19.1 (17.5-20.9)
18.2 (16.0-20.5)
21.2 (17.5-25.5)
19.2 (15.6-23.4)
Obesity
19.9 (17.3-22.8)
19.5 (16.2-23.3)
17.2 (12.0-24.1)*
23.5 (19.8-27.7)*
Overweight
18.9 (16.4-21.7)
17.8 (15.4-20.5)
21.0 (15.7-27.4)
18.9 (13.2-26.5)
Obesity
29.9 (26.8-33.1)
27.2 (22.9-31.9)
34.6 (28.3-41.4)
30.6 (25.7-35.9)
Black male
White female
Black female
aBody mass index (BMI) >_ 85th percentile and < 95th percentile for age and gender. bBody mass index (BMI) >_ 95th percentile for age and gender. c95% confidence interval. *Sample size is less than 50. The estimates may not be reliable.
Among black females, 34.6% were obese and 21.0% were overweight (55.6% combined). At the elementary school level, 19.5% of white females were obese and 18.2% were overweight (37.7% combined). Among black females, 27.2% were obese and 17.8% were overweight (45.0% combined). The prevalence of obesity for black females was significantly higher than white females at the middle school level. When race and gender were combined at the high school level, 30.7% of white males were obese and 19.4% were overweight (40.1% combined). Among black males, 27.8% were obese and 15.2% were overweight (43.0% combined). At the middle school level, 27.4% of white males were obese and 16.7% were overweight (44.1% combined). Among black males, 27.2% were obese and 16.0% were overweight (43.2% combined). At the elementary school level, 17.8% of white males were obese and 15.9% were overweight (33.7% combined). Among black males, 27.2% were obese and 17.8% were overweight (35.0% combined). Overweight and Obesity Trends In 2015, the prevalence of overweight and obesity among students in
grades K-12 was 43.4%, compared to 43.9% in 2005. Neither a linear (p = 0.4486) nor a quadratic change (p = 0.0531) was observed (Figure 4). However, a significant linear change was shown among the high school students (p = 0.0229), indicating an increase in obesity prevalence from 2005 to 2015. As in 2011 and 2013, a significant linear drop was observed in the prevalence of combined overweight and obesity among the elementary school students between 2005 (43.0%) and 2015 (38.0%) (p = 0.0066) (Figure 6). A separate analysis also revealed a significant linear decrease in the prevalence of obesity alone among the elementary school students during the same period (p = 0.0209). Discussion The findings of the 2015 CAYPOS suggest a continued stabilization of overweight and obesity among public school students over the past decade, with 43.9% in 2005 vs. 43.4% in 2015. The prevalence of overweight, obesity, and both combined remained higher than national averages, yet has neither increased nor decreased significantly since 2005. These findings are similar to other recent surveillance studies over time that continue to report high, yet stable, prevalence rates.7, 36
A recent movement to differentiate levels of obesity provides an opportunity to examine the stability of these rates in greater detail. Using the American Heart Associationâ&#x20AC;&#x2122;s recommendations for defining Class 2 obesity as a BMI greater than 120% of the 95th percentile and Class 3 obesity as a BMI greater than 140th of the 95th percentile allows for examining what is called, â&#x20AC;&#x153;Severe Obesityâ&#x20AC;?.37 Using the 2005-2013 CAYPOS data, severe obesity decreased significantly over time among males, whites, and elementary school students. Changes were not only noted among the severe obesity categories. Examining the underweight category in the 2005-2013 CAYPOS indicates that the prevalence of underweight increased significantly between 2009 and 2013.38 So, while the overall prevalence rates do not appear to have changed over time, several shifts in weight status distribution have occurred in the past decade. In 2015, as in all previous years, the prevalence of obesity was significantly higher among black students than among white students. Disparities, while still present between black and white students, decreased in 2015 for the first time since 2005. The decrease, however, was not necessarily due to a reduction in the prevalence among black students, but rather an increase among white students. Racial disparities have been repeatedly reported 7, 36, 37 with others suggesting that existing school-based initiatives are not sufficient to address factors associated with higher prevalence rates among black students.38, 40-43 JOURNAL MSMA
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FIGURE 1. Obesity Prevalence by Race among Mississippi High School Figure 1. Obesity Prevalence by Race among Mississippi High School Students, CAYPOS 2005-2015 Students, CAYPOS 2005-2015 40 35
Percent
30 25 20
P=0.033 25.4 19.9
p = 0.654
p = 0.007 25.9
21.9 20.1
p =0.009 25.0 21.0
19.6
55
p = 0.427
P=0.058
50
29.2 27.3
25.7
45
20.6
Percent
5 0 2005
2007
2009
2011
2013
2015
Year
Percent
30
28.429.6
25
p = 0.138
p < 0.001
p = 0.100
32.4
29.9 26.2
40.6
39.3
47.1
46.8 37.4
34.8
45.8 36.8
45.9 39.8
30 25
White
20
Black
10 5 0 2005
p = 0.003
2007
2009
2011
2013
2015
Year
31.1
28.6 26.2
23.0
21.6
19.5
20
p = 0.006
44.4
15
FIGURE 2. Obesity Prevalence by Race among Mississippi Middle Figure 2. Obesity Prevalence by Race among Mississippi Middle School School Students, CAYPOS 2005-2015 Students, CAYPOS 2005-2015 p = 0.678
46.4
35
Black
10
35
40
White
15
40
FIGURE 5. Prevalence of Overweight and Obesity by Race, K-12, Figure 5. Prevalence of Overweight and Obesity by Race, Mississippi, CAYPOS 2005-2015 K-12, Mississippi, CAYPOS 2005-2015
22.6 White
15
FIGURE 6. Prevalence of Overweight and Obesity by Grade Level, Mississippi, CAYPOS 2005-2015
Black
10 5 0 2005
2007
2009
2011
2013
2015
Year
FIGURE 3. Obesity Prevalence by Race among Mississippi Elementary Figure 3. Obesity Prevalence by Race among Mississippi Elementary School Students, CAYPOS 2005-2015 School Students, CAYPOS 2005-2015 40 35
Percent
30 25
p = 0.037 27.9 22.0
p = 0.031 27.7
p = 0.001
p < 0.001
28.2
26.8
p = 0.001 26.4
25.3
21.9 17.8
20
17.8
p = 0.002
18.6
15.8
White
15
Black
10 5 0 2005
2007
2009
2011
2013
several other studies reporting significant disparities between black and white females. 33,37,44,45
2015
Year
FIGURE 4. Prevalence of Overweight and Obesity, Mississippi, K-12, Figure 4. Prevalence of Overweight and Obesity, Mississippi, K-12, CAYPOS 2005-2015 CAYPOS 2005-2015 50 45
43.9
42.1
42.4
23.5 18.6
40.9
41.8
23.9
23.7
23.6
18.5
17.2
18.2
43.4
40 35 Percent
30
25.5
25 20
18.4
25.2 18.2
15 10 5 0 2005
2007
2009
2011
2013
2015
Year Overweight
Obesity
Combined
In 2015, as with all previous years, there was no difference between boys and girls (p=0.570). Between 2009 – 2013, however, the prevalence was higher among black females than white females, especially in middle school where 55.6% of black girls were overweight or obese compared to 38.4% of white girls. These findings are consistent with
314 VOL. 57 • NO. 10 • 2016
The prevalence of obesity was significantly higher in 2015 among black students in elementary and middle school levels. In 2011 and 2013, black students’ obesity prevalence was significantly higher at all three levels, including high school. The lack of significant difference in 2015 at the high school level was not due to the prevalence decreasing among black students but rather an increase among white students. For the first time, in 2015, the highest prevalence of obesity was among high school students. In 2015, a linear increase in overweight among high school students between 2005 and 2015 was also observed. It is somewhat difficult to speculate as to these most recent changes. However, in 2013, there was a similar statistically significant increase among middle school students, which then dropped in 2015. It is possible that students are not transitioning out of their weight status, but rather the students from the elementary grades with lower BMIs are making their way into the middle schools, while some of the middle school students with higher BMIs are making their way into high school. Recent research suggests a strong and stable association between earlier body size and adolescent overweight.18 The significant linear decrease in obesity prevalence among elementary school students observed during 2005-2013 continued to 2015.
The combined prevalence of overweight and obesity among elementary school students also showed a significant linear decline. These statewide findings in Mississippi are similar to those reported in New York City. 46, 47 While the CAYPOS is methodologically sound in the ongoing surveillance of obesity among public schools students in grades K-12, one of the limitations is the inability to determine if these significant declines noted at the elementary level in Mississippi public schools are due to something occurring at the elementary grade level or whether students are arriving in public school with BMIs that are already lower than in previous years. Numerous studies are now calling for earlier assessment and comprehensive treatment of factors associated with obesity17,18,39,41,44,45,47-49 and racial disparities41,49,51 at a time when significant declines among the pre-K population are being reported. 7,47,50-53 Factors associated with obesity include maternal (i.e., gestational diabetes, BMI and weight gain during pregnancy, smoking, gestational age of child at delivery),54-57 child (i.e., high birth weight, weight gain in infancy),58 and parenting practices (i.e., breastfeeding, age at introduction to solid foods, hours of sleep, active play vs. screen time).59-62 Associating the prevalence of obesity with such variables among a Pre-K population would provide additional insight into, and a more comprehensive understanding of, differences in race, gender and grade levels observed over the past decade in grades K-12 through the CAYPOS. n Acknowledgements Funding for this study was provided by the Bower Foundation through the Center for Mississippi Health Policy. The authors wish to thank Westat, Inc., for their assistance in the sampling and weighting of the data and to thank the staff in the Office of Healthy Schools, the Mississippi schools, school nurses and personnel who were so instrumental in collecting the data.
7. Ogden CL, Carrol MD, Kit BK, Flegal KM. Prevalence of childhood and adult obesity in the United States, 2011-2012. JAMA. 2014;311(8):806-814. 8. SB 2369, amending Mississippi Code of 1972 Annotated Section 37-13-134. Website. http://billstatus.ls.state.ms.us/documents/2007/html/SB/23002399/SB2369SG.htm. 9. United States Department of Agriculture, Food and Nutrition Services. Section 204 of Public Law 108-265-Child Nutrition and WIC Reauthorization Act of 2004. 2004. Website. http://www.fns.usda.gov/cnd/governance/legislation/historical/pl_108-265.pdf. 10. Mississippi Department of Education, Mississippi Office of Healthy Schools. Beverage Regulations for Mississippi Schools. 2006. Website. http://www. cn.mde.k12.ms.us/documents/VendingRegForMSSchools06.pdf. 11. Mississippi Legislature, Senate. The Mississippi Students Act. 2007. Website. http://billstatus.ls.state.ms.us/documents/2007/pdf/ham/Amendment_ Report_for_SB2369.pdf. 12. Mississippi Department of Education, Office of Innovation and School Improvement Office of Accreditation Mississippi Public School Accountability Standards 2012. 2012. Website. http://www.mde.k12.ms.us/docs/accreditation-library/revised-10-9-12-2012-stds.pdf. 13. Mississippi Department of Education. Mississippi Healthy Students Act Senate Bill 2369 Nutrition Standards. 2007. Website. http://www.healthyschoolsms. org/documents/MississippiHealthyStudentsActSenateBill2369NutritionStandards_000.pdf. 14. Mississippi Secretary of State, Administrative Procedures. Physical Education/Comprehensive Health Education Rules and Regulations. 2007. Website.http://www.mde.k12.ms.us/mississippi-board-of-education/ board-of-education-polic y-manual/polic y-4000-healthy-and-safeschools/policy-4012-physical-education-comprehensive-health-education-rules-and-regulations.
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26. Must A, Anderson SE. Effects of obesity on morbidity in children and adolescents. Nutr Clin Care. 2003;6(1):4-12. 27. Arens R, Muzumdar H. Childhood obesity and obstructive sleep apnea syndrome. J Appl Physiol. 2009. Website. doi: 10.1152/japplphysiol.00689.2009. 28. Daniels SR, The consequences of childhood overweight and obesity. The Future of Children. 2006;16(1):47-67. 29. Rowland K, Coffey J. Are overweight children more likely to be overweight adults? J Fam Practice. 2009;58(8):431-432. 30. Sjoberg RL, Nilsson KW, Leppert J. Obesity, shame and depression in school aged children: a population-based study. Pediatrics. 2005;116:389-392. 31. Thompson DR, Obarzanek E, Franko D, Barton B, Morrison J, Biro F, et al. Childhood overweight and cardiovascular disease risk factors: The National Heart Lung & Blood Institute Growth and Health Study. Pediatrics. 2007;150:18-25. 32. Weiss R, Dziura J, Burgert TS, Tamborlane WV, Taksali SE, Yeckel CW, Allen K, Lopes M, Savoye M, Morrison J, Sherwin RS, Caprio S. Obesity and the metabolic syndrome in children and adolescents. N Engl J Med. 2004;350:2362-2374. 33. Ning H, Labarth DR, Shay CM, Daniels SR, Hou L, Van Horn L, Lloyd-Jones DM. Status of cardiovascular health in US children up to 11 years of age: The National Health and Nutrition Examination Surveys 2003-2010. Circ Cardiovasc Qual Outcomes. 2015;8:164-171. 34. Centers for Disease Control and Prevention. A SAS program for the CDC Growth Charts. Website. http://www.cdc.gov/nccd/hp/dnpa/growthcharts/sas.htm. 35. SUDAAN (computer program). Version 10.0. Research Triangle Park, NC: 2009. 36. O gden C, Carrol M, Kit B, Flegal K. Prevalence of obesity and trends in Body Mass Index among US children and Adolescents 2011-2012. JAMA;2014:311(8):806-814. 37. Zhang L, Kirkup M, Kolbo JR. Prevalence and trends of severe obesity among Mississippi public school students, 2005-2013. Med Res Archives. 2015;3:117. 38. Kirkup M, Zhang L, Kolbo JR, Arrington A. Prevalence and trends of underweight among Mississippi public school students, 2005-2013. Online Journal of Rural and Urban Research. 2015; 5(1). Retrieved from: http://jsumurc. org/ojs/index.php?journal=ojrur&page=article&op=view&path[]=263. 39. Kumanyika SK, Swank M, Stachecki J, Whitt-Glover MC, Brennan LK. Examining the evidence for policy and environmental strategies to prevent childhood obesity in black communities: new directions and next steps. Obes Rev, 2014;15(Suppl. 4): 177-203. 40. Rossen LM, Schoendorf KC. Measuring health disparities: trends in racial− ethnic and socioeconomic disparities in obesity among 2- to 18-year old youth in the United States, 2001–2010. Ann Epidemiol. 2012; 22(10), 698-704.
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44. Huh D, Stice E, Shaw H, Boutelle K. Female overweight and obesity in adolescence: developmental trends and ethnic differences in prevalence, incidence, and remission. J Youth Adolescence. 2012;41:76-85. 45. Wang YC, Gortmaker SL, Taveras EM. Trends and racial/ethnic disparities in severe obesity among US children and adolescents, 1976-2006. Int J Pediatr Obes. 2011;6:12-20. 46. Centers for Disease Control and Prevention. Obesity in K-8 students – New York City, 2006-07 to 2010-11 school years. MMWR Morb Mortal Wkly Rep. 2011;60(49):1673-1678. 47. Farley TA, Dowell D. Preventing childhood obesity: what are we doing right? Am J Public Health. 2014; 104(9):1579-1583. 48. Pan L, McGuire LC, Blanck HM, May-Murriel AL, Grummer-Strawn LM. Racial/ethnic differences in obesity trends among young low-income children. Am J Prev Med. 2015;48(5):570-574. 49. Balistreri KS, Van Hook, J. Trajectories of overweight among US school children: a focus on social and economic characteristics. Matern Child Health. 2011;15:610-619. 50. Kimbro R, Brooks-Dunn J, McLanahan S. Racial and ethnic differentials in overweight and obesity among 3-year-old children. Am J Public Health. 2007; 97:298-305. 51. Lo, J. C., Maring, B., Chandra, M., Daniels, S. R., Sinaiko, A., Daley, M. F., & Greenspan, L. C. Prevalence of obesity and extreme obesity in children aged 3-5 years. Pediatr Obesity. 2014; 9(3), 167-175. 52. Centers for Disease Control and Prevention. Vital signs: obesity among low-income, pre-school-aged children – United States. 2008-2011. MMWR Morb Mortal Wkly Rep. 2013;62(31):629-634. 53. Wen X, Gillman MW, Rifas-Shiman SL, Sherry B, Kleinman K, Taveras EM. Decreasing prevalence of obesity among young children in Massachusetts from 2004 to 2008. Pediatrics. 2012; 129(5):823-831. 54. Nehring I, Chmitorz A, Reulen H, Kries R, Ensenauer R. Gestational diabetes predicts the risk of childhood overweight and abdominal circumference independent of maternal obesity. Diabetic Med. 2013;30(12):1449-1456. 55. Durmus B, Arends L, Ay L, Hokken-Koelega, A, Raat H, Hofman A, Jaddoe V. Parental anthropometrics, early growth and the risk of overweight in preschool children: the Generation R Study. Pediatr Obesity. 2013;8(5):339-350. 56. Linabery A, Nahhas R, Johnson W, Choh A, Towne B, Odegaard A, Demerath E. Stronger influence of maternal than paternal obesity on infant and early childhood Body Mass Index: the Fels Longitudinal Study. Pediatr Obesity. 2013;8(3):159-169. 57. Oken E, Levitan E, Gillman, M. Maternal smoking during pregnancy and child overweight: systematic review and meta-analysis. Int J Obesity, 2008;32(2):201-210. 58. Rooney B, Mathiason M, Schauberger C. Predictors of obesity in child-
hood, adolescence, and adulthood in a birth cohort. Matern Child Hlth J. 2011;15(8):1166-1175. 59. Feig, DS, Lipscombe L, Tomlinson G, Blumer I. Breastfeeding predicts the risk of childhood obesity in a multi-ethnic cohort of women with diabetes. J Matern-Fetal Neo M, 2011;24(3):511-515. 60. Seach KA, Dharmage SC, Lowe AJ, Dixon JB. Delayed introduction of solid feeding reduces child overweight and obesity at 10 years. Int J Obesity, 2010;34(10):1475-1479. 61. Flores G, Lin H. Factors predicting severe childhood obesity in kindergartners. Int J Obesity. 2013;37(1):31-39. 62. Anderson SE, Economos CD, Must A. Active play and screen time in US children aged 4 to 11 years in relation to sociodemographic and weight status characteristics: a nationally representative cross-sectional analysis. BMC Public Health, 2008;8:366-378.
Author Information: Professor in the School of Social Work at the University of Southern Mississippi (Dr. Kolbo). Director of the Office of Health Data and Research in the Mississippi State Department of Health and a Professor in the School of Nursing at the University of Mississippi Medical Center (Dr. Zhang). Research support staff member at the University of Southern Mississippi (Ms. Werle). Chair and Professor in the Department of Nutrition and Food Systems at the University of Southern Mississippi (Dr. Molaison). Professor in the School of Nursing at the University of Southern Mississippi (Dr. Harbaugh). Licensed social worker with the Veteran’s Administration (Ms. Kirkup). Employed by United Healthcare of Mississippi (Dr. Walker). Corresponding Author: Jerome R. Kolbo, PhD, MSW, 118 College Drive #5114, The University of Southern Mississippi, Hattiesburg, MS 39406, Ph: 601-266-5913, Jerome.kolbo@usm.edu
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S C I E N T I F I C
A R T I C L E
Teen Pregnancy in Mississippi: A History and Analysis of Recent Legislative and Governmental Attempts to Address Different Aspects of this Issue in Mississippi NYCOLE CAMPBELL-LEWIS, PHD; SIDNEY W. BONDURANT, MD; FREDA M. BUSH, MD, FACOG Abstract Background. Mississippi has one of the highest teen pregnancy and birth rates in the nation. From 1991 to 2014 the birth rate to Mississippi teens decreased by 55 percent, which ranks number 35 in the rate of decline (versus 61% nationally). However, in 2014 Mississippi’s teen birth rate still kept it at number 48 out of 50 states.¹ Mississippi has implemented Healthy Teens for a Better Mississippi as a Governor’s initiative and best practice programs to reduce teen pregnancy in the state of Mississippi. Several bills have been passed into law that address various aspects of teen pregnancy prevention. Methods. Recent legislation implemented from 2011 to 2015 was reviewed and summarized. Results and Conclusions. Teen births have decreased 55 percent from 1991 to 2014. It is not possible to point to any one factor that can explain this reduction. It is likely that many factors have affected this change in teen pregnancy and birth rates. It is still too early to be able to assess the effect of the various laws that have been passed to address teen pregnancy. Introduction In 2012 newly elected Governor Phil Bryant announced that confronting and reducing Mississippi’s teen pregnancy problem would be a top priority of his administration. The Governor charged two state agencies (the Mississippi Department of Human Services and the Mississippi Department of Health) to develop an aggressive plan to address our teen pregnancy rate. The teen pregnancy rate in 2012 was 53.1 per 1,000 ages 15-19.² In 2012 Governor Bryant established the Healthy Teens for a Better Mississippi Initiative with the State Coordinator working out of the Governor’s office and reporting to him. The Governor worked with the Legislature to begin legislation that would address various particular problems that involved teen pregnancy. House Bill 999 In 2011 the Legislature passed House Bill 999. This bill established that “Abstinence Only” was the official state policy for sex education in the public schools and required each local school board to implement a 318 VOL. 57 • NO. 10 • 2016
sex-related education policy to start in the 2012 school year. Although “Abstinence Only” is designated the official state policy the legislation allowed a local school board to choose an “Abstinence Plus” policy if it desired to do so. The bill required that sex education classes be segregated by gender and prohibited the teaching that abortion was a method of birth control. Demonstrations of how to apply a condom were prohibited. The bill also required that parents “opt-in” for their child to attend the sex-education classes. The bill established the Teen Pregnancy Prevention Task Force and required it to collect data on the effects of the law’s requirements. In December of 2015 the Center for Mississippi Health Policy reported its survey of teachers of Sex-Related Education (SRE) in Mississippi. They found that, “Forty-Three percent of the SRE instructors reported that their school districts adopted an abstinence-only (AO) policy, 28 percent reported adopting an abstinence-plus (AP) policy, 5 percent adopted both AO and AP policies, 14 percent reported that their school was not currently implementing an SRE policy, and 10 percent indicated they did not know which policy the district had adopted.” They also found that despite the law requiring separation of SRE classes by gender only 71 percent of SRE teachers did this.³ House Bill 151 After Governor Bryant announced that reducing teen pregnancy in Mississippi was a priority for his administration several leaders from around the state announced that they wanted to be a part of the campaign to reduce teen pregnancy. Mississippi House of Representatives member Rep. Bryant Clark of Holmes County requested a meeting with Governor Bryant to bring some community leaders to him to discuss some possible solutions to the problem. One of those leaders was Chancery Judge Janace Goree. Data from the Mississippi Department of Health showed that in 2011 there were 135 births to mothers who were 14 years old or younger at the time of delivery. In the discussion between Judge Goree and Governor Bryant, Judge Goree told of repeatedly seeing adolescent mothers whose sexual partners were adult men.⁴ In the discussion that followed between these two Mississippi political leaders the idea of collecting umbilical cord blood evidence for use in a statutory rape investigation was born.
There is not much recent data on the age of adult men who impregnate adolescents. One 1992 report from Washington state studied 535 adolescent mothers. They found that 62% of those adolescent mothers had a history of sexual abuse or rape and that the average age of the abuser or rapist was 27 years old.⁵ We could not find any studies specific to Mississippi but anecdotal evidence such as that related by Judge Goree indicated that statutory rape was a part of the teen pregnancy problem in Mississippi. In the 2013 session of the Mississippi Legislature House Bill 151 was introduced by Rep. Andy Gipson, Rep. Jessica Sibley Upshaw, and Rep. W. Tracy Arnold at the request of Governor Bryant, passed by the legislature, and signed into law by Governor Bryant. This bill stated that, “A mandatory reporter shall make a report if it would be reasonable for the mandatory reporter to suspect that a sex crime against a minor has occurred… It shall be reasonable to suspect that a sex crime against a minor has occurred if the mother was less than sixteen (16) years of age at the time of conception and at least one of the following conditions also applies: (a) The mother of the infant will not identify the father of the infant; (b) The mother of the infant lists the father of the infant as ‘unknown’; (c) The person the mother of the infant identifies as the father of the infant disputes his fatherhood; (d) The person the mother of the infant identifies as the father of the infant is twenty-one (21) years of age or older; (e) The person the mother of the infant identifies as the father of the infant is deceased.” The bill further mandated that a specimen of umbilical cord blood would be collected at the time of delivery, a law enforcement office would be notified to collect the specimen just as is currently done with evidence collected in a “rape kit” found in emergency rooms throughout the state, and that the physician or midwife delivering the baby would be a “mandatory reporter” as defined in Miss. Code Ann. § 97-5-51. Failure of the “mandatory reporter” to make the required report could result in substantial fines or possible jail time for a second or third offense. Once the “mandatory reporter” has notified the appropriate law enforcement office the responsibility for any further legal action would rest with the law enforcement agency. The regulations for the implementation of House Bill 151 were published in late 2013⁶ but some bureaucratic delays have kept education of health care providers about the law from being fully implemented around the state. Efforts are now underway to correct this but physicians should be aware of this law and its requirements. Senate Bill 2563 This 2014 legislation was the first of its kind in the nation to combine efforts in the community colleges and universities to prevent teenage pregnancy. In 2012 Mississippi recorded 5,644 teen pregnancies (ages 10-19) out of 44,303 total pregnancies in the state. Of those pregnancies 3,919 were among young women ages 18-19.² Senate Bill 2563 identified eight issues relating to teen pregnancy among women ages 18 and 19 who were college students: (a) incorporation of unplanned pregnancy prevention into student success courses and orientation, (b) integration of information about the prevention of unplanned pregnancy into academic courses, (c) identification of opportunities to raise awareness and provide resources about
the prevention of unplanned pregnancies across the student population, (d) identification of opportunities for existing students to reach out to younger teens to serve as mentors, (e) identification of any private or federal grants available to address the prevention of unplanned pregnancy and promote student success, (f) collaboration with community health center and/or federal qualified health centers to promote access to care, (g) identification of child care, transportation, financial aid, and other challenges specific to existing single parents, (h) identification of such topics or issues relating to the prevention and reduction of unplanned pregnancies among older teens.⁷ The bill required the Institutions of Higher Learning and the Mississippi Community College Board to submit to the Governor and Legislature a plan to address unplanned pregnancies in the 18-19 year old student population. The working group was composed of representatives from community colleges, universities, the Department of Human Services, the Department of Health, Mississippi Economic Council, Women’s Foundation, and the Girls’ Health Initiative. The work plan was submitted to the Mississippi Legislature in October, 2014.⁸ Unplanned pregnancies can increase emotional and financial stress on the young men and women involved which can impede academic performance. The American Association of Community colleges reported that unplanned births accounted for nearly one in ten dropouts among female students at community colleges and seven percent of dropouts among community college students overall.⁹ Although teen pregnancy is declining in all fifty states Mississippi is number 49 in the nation in 2014 with one of the highest teen pregnancy rates.¹ There are disparities that persist in race/ethnicity and geographic locations of the teen pregnancy population.² Sixty-one percent of community college students who have children after enrolling do not complete their education.⁹ The public cost of teen childbearing in the state of Mississippi in 2010 was $137 million.¹ Senate Bill 2854 In 2015 the Legislature passed Senate Bill 2854 to fund the pregnancy initiative developed by the Senate Bill 2563 working group by appropriating $250,000 for the fifteen community colleges to implement a plan. The goal was to address pregnancy prevention in the 18-19 year old student population. Representative Herb Frierson and Senator Dean Kirby championed the funding of the bill. It passed overwhelmingly and was signed into law by Governor Phil Bryant. The money was distributed based on a formula of dividing half of the money based on enrollment numbers and the other half based on the size of the individual college campus. Hinds Community College received the most money ($41,833.00) and Coahoma Community College received the least ($7,693.00). Each community college devised its own program to address its teen pregnancy issues.¹⁰ Conclusion Teen Pregnancy has long been recognized as an important factor throughout Mississippi (Figure 2) leading to many social ills such as poor health, poverty, low educational achievements, and public
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FIGURE 1. Birth rates for females aged 15–19 years — National Vital Statistics System, United States, 2006–2014
this article. Efforts should continue to ensure a continued decline in teen pregnancy rates in order to assist our youth in achieving better health, social, and educational outcomes. The next steps to address teen pregnancy prevention in the State of Mississippi should include further research to assess the effects of the recently passed legislation and identify other approaches to build on what has been done so far. Political leaders in Mississippi should use the evidence gathered by the Teen Pregnancy Prevention Task Force to evaluate the effectiveness of the recently passed legislation described in this article and plan for future legislation based on “what works.” n References 1. Mississippi Data. The National Campaign to Prevent Teen and Unplanned Pregnancy Web site. http://thenationalcampaign.org/ data/state/mississippi. 2. Vital Statistics. Mississippi State Department of Health Web site. http://mstahrs.msdh.ms.gov/forms/pregtable.html.
FIGURE 2. Births per 1,000 females aged 15–19 years, by county of residence — National Vital Statistics System, United States, 2013–2014
3. Implementing Sex-Related Education in Mississippi – Survey of Teachers. Center for Mississippi Health Policy Web site. http:// www.mshealthpolicy.com/sre-in-ms-public-schools/ December, 2015. 4. Pettus E. Miss. Law requires cord blood from some teen moms. Yahoo! News https://www.yahoo.com/news/miss-law-requirescord-blood-teen-moms-141901161.html August 2, 2013. 5. Boyer D, Fine D. Sexual abuse as a factor in adolescent childbearing and child maltreatment. Family Planning Perspectives. 1992;24:4-11, 19. 6. Search “cord blood”. Mississippi Secretary of State Administrative Procedures Web site. http://sos.ms.gov/ACProposed/00020052b. pdf. 7. Legislation Search. Mississippi Legislature Web site. http:// billstatus.ls.state.ms.us/2014/pdf/history/SB2563.xml. Senate Bill 2563. Healthy Teens for a Better Mississippi 8. Web site. http://www.healthyteens.ms/wp-content/ upload s/2015/11/2015-Healthy-Teens -New sletter1.pd f. November 1, 2015.
Romero L, Pazol K, Warner L, et al. Reduced Disparities in Birth Rates Among Teens Aged 15–19 Years — United States, 2006–2007 and 2013–2014. MMWR Morb Mortal Wkly Rep 2016;65:409–414. DOI: http://dx.doi.org/10.15585/mmwr. mm6516a1.
assistance dependence.¹¹ Although teen pregnancy rates have decreased significantly in Mississippi (and nationwide) it appears (Figure 1) that the decline has been gradual over the past ten years and there is no one year that shows a dramatic drop. This makes it difficult to say any one factor (such as availability of birth control, abortion, educational programs or legislation) has had a definite effect on teen pregnancy. There may be effects of “cultural change” in the “social acceptability of teen pregnancy” that have come about gradually and have had significant effects although that factor is beyond the scope of
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9. Prentice M, Storin C, Robinson G. Make It Personal, How Pregnancy Planning and Prevention Help Students Complete College. Washington, DC: American Association of Community Colleges; 2012: 4-5. evine R. Senate Bill 2854. Healthy Teens for a Better 10. L Mississippi Web site. http://www.healthyteens.ms/wp-content/ uploads/2015/11/2015-Healthy-Teens-Newsletter1.pdf. November 1, 2015. 11. Teen Pregnancy Prevention. National Conference of State Legislatures Web site. http://www.ncsl.org/research/health/teenpregnancy-prevention.aspx March 29, 2016.
All websites were accessed on April 30, 2016. Author Information: Statewide Coordinator, Healthy Teens for a Better Mississippi, Office of Governor Phil Bryant, Jackson, Mississippi (Dr. Campbell-Lewis); East
Lakeland OB/GYN Associates, PA, Jackson, Mississippi (Dr. Bush); Policy Adviser and Legislative Liaison, Office of Governor Phil Bryant, Jackson, Mississippi (Dr. Bondurant). Funding/Support: None. Conflict of Interest: None.
Corresponding Author: Nycole Campbell-Lewis, PhD, Office of Gov. Phil Bryant, PO Box 139, Jackson, MS 39205, Phone (601) 359-3150, nycole. campbell-lewis@governor.ms.gov
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Top 10 Facts You Should Know About Immunizations and Vaccine Exemptions in Mississippi THOMAS DOBBS, MD, MPH AND PAUL BYERS, MD, MPH
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Vaccine preventable illnesses are still a threat. Many vaccine preventable diseases remain common worldwide. Internationally, there are approximately 20 million measles cases and 150,000 deaths annually. Similarly, approximately 16 million cases of pertussis with 195,000 deaths occur each year globally. A 2016 outbreak of 7 cases of measles in the Memphis area that resulted in 893 contacts exposed in healthcare settings and threatened many Mississippi residents requiring a 21 day home quarantine of three Mississippi infants who exposed in healthcare environments. Eighty-six percent of the cases in the Memphis outbreak were unvaccinated. An ongoing outbreak of mumps in Arkansas, with 626 cases as of October 20, 2016 could easily spill over into Mississippi. Polio has yet to be eradicated and could easily spread into the U.S. due to the ease of international travel.
2
There is no link between immunizations and autism. A 1996 Lancet publication demonstrating a possible link between MMR and autism has been thoroughly refuted. The Lancet has retracted the article and the principle author has lost his medical license due to unethical and duplicitous methods. Extensive studies, involving over one million children, have found no association with autism and MMR, any vaccine, the number of vaccine antigens or vaccine additives. Increases in autism diagnosis are attributable to a broadening of the definition (currently within DSM-5), increased awareness, and other potential factors. The impact of this deception has persisted, with thousands of unnecessary illnesses, numerous deaths, and a vocal minority of worried citizens unnecessarily wary of immunizations. A new movie “Vaxxed,” produced by the same discredited physician who wrote the Lancet article, is rekindling these same unfounded fears that have been thoroughly debunked.
Figure 1. The spread of mumps in Arkansas and measles in Memphis places our state at risk. Mississippi has the highest vaccination rate for school-age children in the United States.
Figure 2. Andrew Wakefield the author of the article below retracted from the Lancet was also the on-camera director of Vaxxed. Actor Robert De Niro, who has an autistic son, originally lobbied, and put the controversial documentary on the schedule for the Tribeca Film Festival. After screening it with the festival team and others from the scientific community, the film was pulled amid public criticism. Additionally, the British Medical Journal (BMJ) published a detailed investigation into the research, calling it an “elaborate fraud” by Wakefield and detailing the harm it had caused and would continue to cause to the public health.
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All states have laws requiring certain childhood immunizations for schools entry. Depending on the state, various forms of exemptions from these requirements may be available, including medical exemptions, religious exemptions, and philosophical belief exemptions. All states permit medical exemptions. Forty-seven states and the District of Columbia allow religious belief exemptions. A minority of states, nineteen, allow for exemptions based solely on philosophical belief.
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Only medical exemptions are allowed in Mississippi. Three states, Mississippi, West Virginia, and California only allow for medical exemptions from school entry requirements. In 1979, the Mississippi Supreme Court ruled that religious exemptions were unconstitutional (Brown vs Stone). Following Mississippi’s example, California adopted a law removing philosophical and religious exemptions subsequent to a nationwide measles outbreak in 2014-2015 originating from a California theme park.
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Immunizations protect the individual, vulnerable populations, and the community. Not only do immunizations protect the recipient but by preventing outbreaks vulnerable Mississippians unable to be immunized (due to malignancy, immunodeficiency or other conditions) are not exposed to these deadly diseases. Population immunity, by preventing the chain of transmission, can prevent outbreaks in a community. Under-immunization and the excessive use of exemptions threaten our broad population immunity. Approximately 95% of individuals must be immune to achieve a population immunity effect. In addition, subpopulations opposed to immunizations tend to cluster in the same schools and neighborhoods, further increasing the risks of devastating outbreaks.
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Five immunizations are required for school entry in Mississippi. Proof of immunization for Diphtheria-Tetanus-Pertussis (DTaP), Polio, Varicella, Hepatitis B, and Measles-Mumps-Rubella (MMR) is required prior to kindergarten, primary or secondary school entry in Mississippi. This requirement applies to public and private schools. In addition to these immunizations, Haemophilus influenzae type B (Hib) and Pneumococcal (PCV) are required for day care entry in Mississippi.
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Tdap Immunization (tetanus, diphtheria, pertussis) booster is required for entry into 7th grade in Mississippi. Due to waning immunity to pertussis from childhood DTaP, a booster dose of Tdap is required prior to entering the seventh grade. Meningococcal and human papillomavirus (HPV) immunization should also be given to this age group.
Additional immunizations are recommended for college entry. There is no legal mandate for immunizations prior to college entry, but the Mississippi Institutions of Higher Learning and individual colleges have rules dictating which immunizations must be given before school entry. Mississippi State Department of Health does not regulate exemptions from immunization for college entry. Prior to entering college students should have received > 2 MMR vaccines and meningococcal conjugate immunization (Menactra or Menveo). Students receiving meningococcal immunization prior to 16 years of age should have a booster dose before college entry. Males and females not yet completing immunization for HPV should be given the remaining doses at this time.
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*AD - MSMAJ - 3.75X4.875_Layout 1 5/19/16 9:26 AM Mississippi is the national leader for school age immunizations. Due to numerous factors, including a strong public health immunization law, diligent physician practice, and public health leadership, Mississippi has the highest vaccination coverage for children entering kindergarten in the US (99.7% in 2014). Recent legislative efforts have been made to undermine Hope • Healing • Recovery Mississippi’s strong, scientifically based immunization laws. Laws that permit philosophical exemptions, or that undermine the integrity of the exemption process, could markedly reduce immunization rates in Mississippi and lead to preventable outbreaks. Medical Detoxification
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The Mississippi State Department of Health (MSDH) accepts all medical exemptions from Mississippi licensed pediatricians, family practice physicians, and internists. No exemption request by the aforementioned physician groups is denied, provided that a medical diagnosis is entered on the exemption request form. Exemptions submitted by out-of-state physicians are reviewed by the MSDH Office of Epidemiology and approved, given that there is an appropriate medical indication submitted by a physician providing care for the child. Please visit www.healthyms.com/immunization for additional information on how to request a medical exemption. n
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Top 10 Facts You Should Know About Diagnostic Evaluation of Neonatal Cholestasis LEAH BURCH, BS; DAVID SAWAYA, MD; MICHAEL STEINER, MD; CHARU SUBRAMONY, MD; MICHAEL NOWICKI, MD Neonatal cholestasis, characterized by jaundice with a high direct bilirubin component in the first few months of life, results from impaired bile acid synthesis or obstruction of bile flow. It is associated with a number of disorders that are individually rare, but taken as a group they make neonatal cholestasis relatively common, occurring in 1 in 2,500 live births.1 The severity of causes ranges from self-limited to life threatening. Because of the varied causes of neonatal cholestasis and the dire consequences of delayed treatment, it is important to promote awareness of this disease and the significance of rapid diagnosis, referral, and treatment.
1
Neonatal cholestasis is often overlooked. It has been estimated that greater than 50% of newborns with cholestasis are referred for specialty evaluation belatedly.1 Neonatal cholestasis is often misdiagnosed as physiologic, breast-feeding jaundice, or breast milk jaundice, often due to failure to fractionate the bilirubin when testing. The healthy appearance of some cholestatic infants may reassure parents and healthcare providers causing delay in diagnosis. Pale (acholic) stools and dark urine, findings indicative of cholestasis, may go unrecognized by parents and providers. Late diagnosis may be attributed to the well-established practice of clinical follow-up of newborns at two weeks of age and then not again until six to eight weeks of age. Some cholestatic disorders first manifest clinically during this window between visits, resulting in late diagnosis and referral.1
2
Cholestasis can be determined by testing fractionated bilirubin levels. Cholestasis is defined by direct (conjugated) serum bilirubin levels greater than 2 mg/dL or greater than 20% of the total bilirubin level if total bilirubin concentration is greater than 5 mg/dL.2 It is recommended that fractionated bilirubin levels be tested in jaundiced infants greater than two weeks of FIGURE 1. Idiopathic neonatal hepatitis as age. For breastfed infants, testing may be postponed to three weeks of age if the patient has a etiology for neonatal cholestasis. This is an otherwise normal history and can be reliably followed in the clinic.3 When cholestasis not an exhaustive list of the causes of neonatal is identified, it is important to assess for hepatic injury and synthetic function with a liver cholestasis. Rather, the graph depicts the decrease panel, PT-INR, and glucose. If coagulopathy or hypoglycemia is identified, admission to in idiopathic neonatal hepatitis as a cause of cholestasis in the newborn. In the past 40-years the hospital for treatment and further evaluation is recommended.1
3
Treatable causes of cholestasis should be promptly identified. Since the 1970s there have developed a better understanding and recognition of the etiologies for neonatal cholestasis. The percentage of cases attributed to idiopathic causes has declined significantly with the identification of new disorders (figure 1). It is imperative that treatable causes be identified quickly, as failure to initiate therapy can result in significant untoward sequelae or death. First-line investigation should include evaluation for infection (particularly sepsis and urinary tract infections), congenital infections (cytomegalovirus, herpes simplex, and syphilis), endocrine disorders (hypoor hyperthyroidism), and inborn errors of metabolism (tyrosinemia, hereditary fructose intolerance, galactosemia). The evaluation should be tailored to the individual infant based on clinical suspicion.
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Biliary atresia must be evaluated and corrected in a timely manner. Biliary atresia is the single most commonly identified cause of neonatal cholestasis, accounting for 25% of cases. Definitive treatment is to re-establish bile flow from the liver to the intestine utilizing the surgical procedure Kasai portoenterostomy. In this procedure, the atretic portion of the biliary tree is removed by dissection into the porta hepatis until bile flow is identified, followed by connection of a loop of jejunum to the porta hepatis as a Roux-en-Y. Predictors of successful primary drainage include the absence of cirrhosis on pre-surgery liver biopsy, bile duct remnant > 150 μm, experience of the surgeon, and the infant’s age at the time of surgery.4 The only predictive factor
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there has been identification of a number of new disorders associated with neonatal cholestasis, decreasing the percentage of idiopathic neonatal hepatitis. White = biliary atresia; gray = viral infection; black = metabolic disorders; red = alpha1-antitrypsin deficiency; blue = syndromic paucity of bile ducts, disorders of bile acid synthesis, progressive familial intrahepatic cholestasis; yellow = idiopathic neonatal hepatitis.
that the referring provider can influence is the age at which referral is made. Surgical intervention performed before sixty days of age is associated with the best chance of re-establishing bile flow; however, referral for cholestasis often occurs after this critical time. In patients who have bile flow established following Kasai procedure, risk for failure to maintain adequate drainage is associated with the number of episodes of ascending cholangitis.4
5
Stool color cards can help parents recognize acholic stools. Clinical features, such as degree of jaundice, hepatomegaly, splenomegaly and acholic stools, do not distinguish biliary atresia from other causes of neonatal cholestasis. However, the development of acholic stools in a neonate should prompt evaluation for biliary obstruction. Stool color in newborns with biliary atresia changes over the course of the disease, initially appearing pigmented and later becoming acholic as the degree of obstruction increases.5 Persistently acholic stools are present in up to 95% of infants with biliary atresia, but they can also be associated with severe intrahepatic cholestasis or obstruction due to choledochal cysts.2,5 Unfortunately, the accuracy of stool color reported by parents can be unreliable. To improve early detection of acholic stools, a number of stool color cards have been developed to assist parents in recognizing abnormal stool color.1 The cards consist of various stool colors separated into normal and abnormal categories to which the parents compare their infantâ&#x20AC;&#x2122;s stool. Stool color cards have been used successfully as a method of mass screening for biliary atresia. In studies, screening with stool color cards resulted in earlier recognition of biliary atresia and decreased the average age at time of portoenterostomy.2 Cards can be ordered on the Internet for distribution to parents (http://www.basca.ch/e/ vorsorge/farbenkarte/index.html).
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Imaging modalities should be used judiciously in the evaluation of neonatal cholestasis. Abdominal ultrasound is a useful tool in the evaluation FIGURE 2. Ultrasonographic evidence for choledochal cyst. Hepatic of neonatal cholestasis, particularly in its ability to show ultrasound is an important part of the armamentarium for the evaluation obstructive processes such as choledochal cyst (figure 2), of neonatal cholestasis. It can detect structural abnormalities associated cholelithiasis, and biliary sludge. However, ultrasound cannot with biliary obstruction such as a choledochal cyst. Depicted is a large with certainty confirm or exclude biliary atresia as the cause of cystic structure measuring approximately 5 cm seen in the region of the cholestasis. Findings suggestive of biliary atresia include a small porta hepatis consistent with choledochal cyst (crosses and Xs). or absent gall bladder, polysplenia, and situs inversus.6,7 The ultrasonographic finding of a triangular cord sign, an echogenic area at the porta hepatis representing fibrosis of the portal plate, has improved the sensitivity (73% to 100%) and specificity (98% to 100%) for the diagnosis of biliary atresia, but this is dependent on the experience of the operator.2 However, the finding of a triangular cord sign does not preclude definitive testing for biliary atresia. Hepatobiliary scintigraphy has been used in the past to document failure of excretion of radioactive tracer from the liver into the duodenum. While highly sensitive, scintigraphy has a low specificity for documenting biliary obstruction. In a meta-analysis regarding the accuracy of scintigraphy in differentiating biliary atresia from other causes of neonatal cholestasis, the pooled sensitivity and specificity were 98.7% (range 98.1%-99.2%) and 70.4% (range 68.5%-72.2%).8 Recent recommendations are that hepatobiliary scintigraphy not be utilized in the initial evaluation for biliary atresia.1
7
Liver biopsy is considered the most reliable method to differentiate biliary atresia from idiopathic neonatal hepatitis. Percutaneous liver biopsy has considerable diagnostic usefulness and is recommended for infants with undiagnosed cholestasis, especially when biliary tract obstruction is the presumed diagnosis. Diagnostic accuracy of liver biopsy for biliary atresia is greater than 90% in some studies; however, biopsies taken early in the course of disease (< 6 weeks of age) may be inconclusive, necessitating repeat biopsy at a later time. Biopsies should be interpreted by a pathologist experienced in pediatric liver disease. Histological features found
FIGURE 3. Histological differences in idiopathic neonatal hepatitis and biliary atresia. The distinction between neonatal hepatitis and biliary atresia can be difficult. Giant cell transformation (A, arrow heads) and extramedullary hematopoiesis (B, asterisks) are prominent in neonatal hepatitis, but can also be found in biliary atresia. Significant fibrosis and evidence for biliary obstruction, including bile duct plugs (not shown) and bile ductule proliferation (C, asterisks), are highly suggestive for biliary atresia.
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both in idiopathic neonatal hepatitis and biliary atresia include giant cell transformation, extra-medullary hematopoiesis, and canalicular bile plugs (figure 3A-B). Histologic features favoring biliary atresia are those of extrahepatic bile duct obstruction, including bile ductule proliferation, bile duct plugs, and portal tract edema and fibrosis (figure 3C).1 If biliary obstruction is supported by biopsy findings, referral should be made to Pediatric Surgery for an intra-operative cholangiogram to confirm the diagnosis and proceed with corrective surgery. Liver biopsy can also identify other diseases such as alpha-1 antitrypsin deficiency (PAS-positive granules), neonatal sclerosing cholangitis (necro-inflammatory lesions), Alagille syndrome (ductal paucity), and metabolic diseases (pseudoglandular formation, steatosis).3
8
Neonatal cholestasis can be caused by alpha-1 antitrypsin (A1AT) deficiency. A1AT deficiency accounts for 5% to 15% of cases of neonatal cholestasis and is clinically indistinguishable from other causes of neonatal cholestasis. Liver biopsy in the neonatal period may fail to show the characteristic PAS-positive granules as the abnormal protein may not have accumulated in sufficient quantities to be visible. As such, A1AT deficiency may be difficult to distinguish histologically from extrahepatic biliary atresia.3 Testing available for A1AT deficiency includes serum levels and protease inhibitor (Pi) phenotype. Serum A1AT levels can be misleading, as it is an acute phase reactant and may increase in response to inflammation resulting in a falsely “normal” level. The preferred method for establishing A1AT deficiency is Pi phenotype testing, which is performed by isoelectric focusing, where serum is electrically separated on a gel and the migration of the A1AT protein is documented. The normal protein is denoted “M”, and as there are two copies of the gene, the normal phenotype is denoted by PiMM. There are a number of abnormal A1AT proteins, the two most common being the “Z” and “S” isoforms, but not all lead to loss of function. The most common phenotypes associated with disease are PiZZ (10% to 15% activity) and PiSZ (40% activity).1
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Serum levels of bile acid levels and γ-glutamyl transpeptidase (GGT) can help direct further evaluation. In the face of cholestasis, serum levels of bile acids and GGT should be elevated; the finding of low or normal levels can help narrow the differential diagnosis. Low serum levels of bile acids in the cholestatic infant implies a defect in bile acid synthesis, as abnormal bile acids are not measured and the normal bile acids that are being measured are not being made in adequate quantities. Low to normal serum GGT levels in cholestasis suggests disorders of bile acid synthesis and disorders of canalicular bile acid transport, the latter referred to as progressive familial intrahepatic cholestasis (PFIC) syndromes. PFIC-1 (FIC1 protein deficiency) and PFIC-2 (bile salt export pump deficiency) both have abnormally low to normal GGT levels, while PFIC-3 (mdr3 deficiency) has the expected elevated serum levels of GGT.9 Confirmation of bile acid synthesis disorders requires specialized testing referred to as fast atom bombardment mass spectrometry, FIGURE 4. Algorithm for the initial evaluation of the cholestatic neonate. When which is performed on a urine sample; the patient should faced with a jaundiced neonate, the bilirubin must be fractionated. If there is evidence not be receiving bile acid replacement when the test is for cholestasis, defined by elevated direct bilirubin, further evaluation needs to be performed. Confirmation of PFICs is accomplished with accomplished to assess for hepatic dysfunction, rapidly identify and initiate therapy for treatable causes, and exclude biliary atresia. If there is no direct component, then microarray gene testing; this test also tests for Alagille the infant should be followed until resolution of jaundice, periodically reassessing syndrome (syndromic paucity of bile ducts) and A1AT for cholestasis. If cholestasis develops, the patient should be further evaluated deficiency.10 (CMV, cytomegalovirus; GGT, gamma glutamyl transpeptidase; H&P, history and
10
Medical management of cholestasis can alleviate symptoms and improve patients’ quality of life. Ursodeoxycholic acid (UCDA) can be used to treat pruritus and improve biochemical parameters. UCDA is a protective bile acid that improves bile acid flow and replaces a proportion of toxic bile acids. UCDA is also thought to have cytoprotective, anti-inflammatory, and antiapoptotic effects. Rifampin can also be used to treat pruritus; it enhances bile acid detoxification and bilirubin conjugation.9 Nutritional treatment is also vital to the well-being of children with cholestasis. In the presence of steatorrhea, caloric intake should be approximately 125%-150% of the recommended dietary allowance. The diet should be rich in medium chain triglycerides, which are more water soluble and can be directly absorbed into portal circulation without solubilization by bile acid micelles. Supplementation with fat soluble vitamins (A, D, E, and K) should be initiated.1
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physical examination; HFI, hereditary fructose intolerance; PT-INR, prothrombin time, internation normalization ratio).
Conclusion Neonatal cholestasis has many causes, and it is vital for healthcare providers to recognize cholestasis and refer the patient to a pediatric gastroenterologist in a timely manner. Late referral and treatment may be reduced with increased awareness of neonatal cholestasis by both primary care providers and parents. With few exceptions, direct bilirubin levels should be tested in jaundiced infants at two weeks of age in order to facilitate rapid diagnosis of cholestasis. Early treatment of biliary atresia, metabolic, and infectious causes of cholestasis can greatly improve the patient’s prognosis and quality of life. On the previous page is a proposed algorithm for the approach to the cholestatic neonate (figure 4). n References 1. De Bruyne R, van Biervliet S, Vande Veld S, van Winckel M. Clinical practice. Neonatal cholestasis. Eur J Pediatr 2011;170:279-84. 2. Benchimol EI, Walsh CM, Ling SC. Early diagnosis of neonatal cholestatic jaundice. Can Fam Physician 2009;55:1184-92. 3. Moyer V, Freese DK, Whitington PF, et al. Guideline for the evaluation of cholestatic jaundice in infants: recommendations of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition. J Pediatr Gastroenterol Nutr 2004;39:115-28. 4. Wildhaber BE, Coran AG, Drongowski RA, et al. The Kasai portoenterostomy for biliary atresia: A review of a 27-year experience with 81 patients. J Pediatr Surg. 2003;38:1480-5. 5. Lee WS, Chai PF. Clinical features differentiating biliary atresia from other causes of neonatal cholestasis. Ann Acad Med Singapore 2010;39:648-54. 6. Dehghani SM, Haghighat M, Imanieh MH, Geramizadeh B. Complarison of different diagnostic methods in infants with cholestasis. World J Gastroenterol 2006;12:5893-5896. 7. Yang JG, Ma DQ, Peng Y, et al. Comparison of different diagnostics methods for differentiating biliary atresia from idiopathic neonatal hepatitis. Clin Imaging 2009;33:439-446. 8. Kianifar HR, Tehranian S, Shojaei, et al. Accuracy of hepatobiliary scintigraphy for differentiation of neonatal hepatitis from biliary atresia: systemic review and meta-analysis of the literature. Pediatr Radiol 2013;43:905-919. 9. Balistreri WF, Bezerra JA. Whatever happened to “neonatal hepatitis”? Clin Liver Dis 2006;10:27-53. 10. McKiernan P. Neonatal jaundice. Clin Res Hepatol Gastroenterol 2012;36:253-256.
Author Information: School of Medicine medical student (M-2) employed as a research technician as part of the Department of Pediatrics Summer Research Program (Ms. Burch); Associate Professor of Surgery, Division of Pediatric Surgery (Dr. Sawaya); Assistant Professor of Radiology, Division of Pediatric Surgery (Dr. Steiner); Professor of Pathology, Department of Pathology(Subramony); Professor of Pediatrics, Division of Pediatric Gastroenterology (Nowicki). All authors affiliated with the University of Mississippi Medical Center, Jackson, MS. Corresponding Author: Michael Nowicki, MD, Division of Pediatric Gastroenterology, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216, (601) 984-5232 – office, (601) 815-1053 – fax, mnowicki@umc.edu The authors have no conflicts of interest to report.
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Contact: Susan Gladys 866-929-8766 or email susang@tsom.com
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P R E S I D E N T ’ S
P A G E
Neighbor State Sees Swell in Preventable Mumps Cases: Legislature Holds the Key
T
he number of mumps cases is swelling across the South. Arkansas is leading the country. At this time of writing, there have been more than 1,900 cases already documented there and the number is growing.
This is a stark reminder of the important role our state legislators have to support public health policy. Mississippi has the nation’s strongest and best childhood vaccination law, and we thank the Legislature for that. Working in conjunction with the Department of Health, MSMA is spearheading efforts by the Mississippi Immunization Coalition to encourage vaccinations and promote this state’s requirements for school-age children to be immunized. Your MSMA has created a website at GiveMeAShot.org where parents and policy makers can get the facts about immunizations, exemptions, vaccine schedules. We physicians can use this website as a resource for patients, parents, and policy makers.
As part of this campaign, Mississippians will also see a flurry of television ads in January that coincide with the opening of the Legislature and feature happy children who promote immunizations and every kid’s right to a safe school free from preventable diseases. You can also urge your patients to post photos of themselves, their child, or children on the website with the hash tag #ShowYourShot on Facebook. Every physician can be a part of this important campaign. This issue of the Journal features a “Top Ten Facts You Should Know about Immunizations and Vaccine Exemptions in Mississippi.” I hope you’ll take time to read it. Watch for a poster that you can hang in your office, clinic, or waiting room in a subsequent issue of our JMSMA. Many of us are on the front lines and treat a stream of patients who need to be immunized for preventable childhood diseases. Others see an older population that can benefit from vaccines that prevent pneumonia and herpes zoster. All of these are important to the public health and a robust community immunity. The Arkansas mumps outbreak is expected to exceed the 2,000 mark before Christmas and now public health officials are investigating a link from Arkansas to a number of new cases reported in Texas. The following articles provide a good snapshot of this growing outbreak. n An outbreak of mumps? Blame the anti-vaxxers http://www.star-telegram.com/opinion/editorials/article119292348.html Growing outbreak of mumps in US http://6abc.com/health/growing-outbreak-of-mumps-in-us-/1644562/ Johnson County mumps outbreak is worst Texas has seen in years http://www.dallasnews.com/news/johnson-county/2016/12/05/johnson-county-mumps-outbreak-worst-texas-seen-years
Lee Voulters, MD; Gulfport MSMA President 2016-17 328 VOL. 57 • NO. 10 • 2016
C O M M E N T A R Y
Bariatric Surgery –A Viable Option and the Best Hope for Many Mississippians? EMMA L. WILLOUGHBY, MSC; ELLEN S. JONES, PHD; DEBORAH S. MINOR, PHARMD
[Research shows that diets are ineffective in the treatment of obesity because neuro-hormonal systems to preserve excess weight are stronger than the will to keep it off. No magic pill has worked or is on the horizon. Newer, minimally invasive bariatric surgery procedures do work but may be underutilized. In this Commentary, the authors who are affiliated with the UMMC Mississippi Center for Obesity Research and one of whom trained at the London School of Economics (ELW), speak to this issue. ---Ed.] Mississippi leads the nation in overall rates of obesity as well as obesity-associated illness and chronic disease burden.1 Yet the trends of Mississippi are not unlike the rest of the United States and other countries across the globe where obesity rates continue to rise, particularly among certain racial and ethnic groups.2,3 Ideally, obesity prevention should begin early in life as study after study documents the difficulty individuals experience in not just losing weight but also in maintaining weight loss through diet and exercise regimens alone.4 For selected patients, bariatric surgical treatment for obesity management offers another option with strong evidence that the health benefits outweigh the risks.4 From another perspective, the health care costs for people classified with morbid obesity (body mass index [BMI] > 40) are estimated to be 81% higher than for those without obesity.5,6 Reducing the need for chronic medication and the risk of hospitalization by ameliorating other disease processes, bariatric surgery has been associated with not only health benefits but also lower health care costs over time.6,7 In fact, the economic case for bariatric surgery has led to changes in Medicaid reimbursement policies in most states. A 2016 report from scholars at George Washington University notes that 48 states and the District of Columbia currently cover bariatric surgery. Only Mississippi and Montana explicitly exclude bariatric surgery as a tool for chronic disease management.8
Effective Savings Obesity is often accompanied by additional medical conditions, including type 2 diabetes, high blood pressure, sleep apnea, digestive issues, osteoarthritis and joint problems, and depression.4 Those living with multiple chronic conditions must adhere to complex and expensive drug and health care regimens. Having to frequently visit clinical providers interferes with work, daily life, and requires an increased reliance on others. All of these factors make disease management financially and emotionally taxing – for patients and providers alike. Economic analyses have demonstrated that costs for bariatric procedures, particularly laparoscopic, are recovered in just two years among those with morbid obesity.5 Over this time patients can expect to lose 40-50% of their excess body weight with the proper clinical support.9 Analyzing claims data from 2,235 patients with type 2 diabetes who underwent bariatric surgery, Makary and colleagues identified a decrease in total annual health care costs per person of 34% within the first two years and 71% in year three post- surgery. Cost-effectiveness analyses also show that surgical treatment for those with morbid obesity actually saves dollars compared to non-surgical treatment, which is associated with more hospital visits and readmissions, medications, and diminished quality of life.10 In short, not only is bariatric surgery ‘worth’ the price, but it actually reduces spending while achieving better health outcomes than without surgery, particularly for those with a BMI greater than 50.10,11 Although there are several types of bariatric surgical procedures, the preferred technique today is the laparoscopic vertical sleeve gastrectomy (LVSG). LVSG is less invasive than alternatives and removes only part of the stomach, but has a lasting impact.12 Currently, Medicare approves the use of LVSG for the treatment of comorbidities related to obesity since evidence supports the procedure may reverse type 2 diabetes and hypertension. The Mississippi State Employees’ Health Insurance Plan also covers various bariatric surgery procedures in addition to necessary pre-operative care and post-operative followup therapies, including nutritional counseling, psychological therapy, and physiotherapy. BlueCross BlueShield of Mississippi and other commercial payers typically cover bariatric surgery procedures and associated services through a pre-certification process. Medicaid reimbursement for those most likely to see benefit from bariatric surgery may be the next frontier in chronic disease management. In a time of shrinking state budgets, 48 states and the District of Columbia have considered the long-term savings and benefits of such preventive
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therapies and now provide coverage for bariatric surgery. Of these states, most require prior authorization (36 states) and criteria other than BMI alone (37 states) to determine eligibility. But again, Mississippi remains last – one of only two states that excludes bariatric surgery.8
Research Opportunities We still have much to learn about the physiologic processes and root causes of obesity, as research has not yet provided a full understanding of these mechanisms. We do know that the obesity epidemic is not simply a result of failing individual will but is dependent upon a range of factors, including (but certainly not limited to) hormone interactions, gut microflora, prenatal environments, chronic stress, and socioeconomic variables. While a healthy diet and exercise routine have been touted as key to maintaining weight loss, early research indicates that a ‘rewiring’ of metabolism may accompany periods of rapid weight loss that prevents individuals from keeping weight off. A recent follow-up of the first Biggest Losers participants characterizes this disheartening process.13 However, for reasons not yet understood, bariatric surgery does not seem to have the same effect and actually appears to help restore metabolic processing. Indeed, bariatric surgery has been shown to lead to remission of type 2 diabetes, hypertension, and sleep apnea.4,5,14-16 Because it may alleviate chronic disease, bariatric surgery should not only be seen as a path to weight reduction but also as a valuable, cost-saving tool for mitigating the detrimental metabolic effects of obesity. With the vision of a healthier population, Mississippi should recognize the economic and social benefits of bariatric surgery for the future health and prosperity of our state. While bariatric surgery should not be seen as a silver bullet to solving Mississippi’s chronic disease burden associated with obesity and prevention is key, the life-saving benefits can provide hope for those who are motivated to undergo this treatment as an adjunct to lifestyle changes. Expanded insurance coverage for bariatric procedures is only the first step, as we still have much to learn about the long-term physiological and psychological impact of drastic weight loss interventions. What is needed now is a comprehensive, concerted effort between those in the basic sciences and clinical programs – and support from policymakers – to ensure that effective health interventions are accessible to all Mississippians. To end on a positive note, Mississippi’s efforts in obesity prevention in early care and education settings are receiving noteworthy recognition. In reviewing the number of high impact obesity prevention standards in state licensing regulations, out of a potential 47, Mississippi met 15 in 2014 – the most of any state.17 This gives us hope for the future. n
References 1. Adult obesity prevalence maps. Division of Nutrition, Physical Activity, and Obesity, National Center for Chronic Disease Prevention and Health Promotion. Centers for Disease Control and Prevention. http://www.cdc.gov/obesity/data/prevalence-maps.html. Accessed October 24, 2016. 2. Ogden CL, Carroll MD, Fryar CD, Flegal KM. Prevalence of obesity among adults and youth: United States, 2011-2014. NCHS data brief, no 219. Hyattsville, MD: National Center for Health Statistics. 2015. https://www.cdc.gov/nchs/data/databriefs/db219.pdf. 3. Ogden CL, Lamb MM, Carroll MD, Flegal KM. Obesity and Socioeconomic Status in Adults: United States, 2005-2008. NCHS data brief, no 50. Hyattsville, MD: National Center for Health Statistics. 2010. https://www.cdc.gov/nchs/data/databriefs/db50.pdf. 4. Jensen MD, Ryan DH, Apovian CM, et al. 2013 AHA/ACC/TOS guideline for the management of overweight and obesity in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and The Obesity Society. Circulation 2014; 129 (25 Suppl 2):S102-38. 5. Cremieux PY, Buchwald H, Shikora SA, et al. A study on the economic impact of bariatric surgery. Am J of Manag Care. 2008;14:51-58. 6. Richards NG, Beekley AC, Tichansky DS. The economic costs of obesity and the impact of bariatric surgery. Surg Clin N Am. 2011;91:1173-80. 7. Makary MA, Clarke JM, Shore AD, et al. Medication utilization and annual health care costs in patients with type 2 diabetes mellitus before and after bariatric surgery. JAMA Surgery 2010;145:726-731. 8. Petrin C. Medicaid fee-for-service treatment of obesity interventions, 50 state and District of Columbia survey 2016. The George Washington University Department of Health Services Management and Leadership and STOP, Strategies to Overcome and Prevent Obesity Alliance. 2016. http://stopobesityalliance.org/wp-content/ assets/2016/04/Medicaid%20FFS%20Treatment%20of%20Obesity.%202016%20%284%29%20%281%29.pdf. Accessed June 16, 2016. 9. Brethauer S, Schauer P. “Laparoscopic Sleeve Gastrectomy – A Newcomer to Bariatric Surgery.” Obesity Action Coalition. 2016. http://www.obesityaction.org/ educational-resources/resource-articles-2/weight-loss-surgery/laparoscopic-sleeve-gastrectomy-a-newcomer-to-bariatric-surgery. Accessed May 9, 2016. 10. Chang S, Stoll C, Colditz GA. Cost-effectiveness of bariatric surgery: should it be universally available? Maturitas 2011;69:230-238. 11. Wang B, Wong ES, Alfonso-Cristancho R, et al. 2012. Cost-effectiveness of bariatric surgical procedures for the treatment of severe obesity. Eur J Health Econ. 2012;15:253-263. 12. Lentine KL, Delos Santos R, Axelrod D, et al. Obesity and kidney transplant candidates: how big is too big for transplantation? Am J Nephrol. 2012;36:575-586. 13. Kolata G. “The Science of Fat: After ‘The Biggest Loser,’ Their Bodies Fought to Regain Weight.” The New York Times. 2016. http://www.nytimes.com/2016/05/02/
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health/biggest-loser-weight-loss.html. Accessed May 12, 2016. 14. Hidalgo JE, Roy M, Ramirez A, et al. Laparoscopic sleeve gastrectomy: a first step for rapid weight loss in morbidly obese patients requiring a second non-bariatric procedure. Obes Surg. 2012;22:555-559. 15. Proczko M, Kaska L, Kobiela J, et al. Bariatric surgery in morbidly obese patients with chronic renal failure, prepared for kidney transplantation – case reports. Polski Przeglad Chirurgiczny 2013;85:407-411. 16. Freeman CM, Woodle ES, Shi J, et al. Addressing morbid obesity as a barrier to renal transplantation with laparoscopic sleeve gastrectomy. AJT. 2015;15:13601368. 17. Early care and education state indicator report 2016. National Center for Chronic Disease Prevention and Health Promotion, Division of Nutrition, Physical Activity, and Obesity. Centers for Disease Control and Prevention. 2016. https://www.cdc.gov/obesity/strategies/ece-state-indicator-report.html.
Author Information: Department of Medicine (Ms. Willoughby and Dr. Minor). School of Health Related Professions (Dr. Jones). University of Mississippi Medical Center, Jackson, MS. Corresponding Author: Deborah S. Minor, PharmD. Professor of Medicine, University of Mississippi Medical Center, 2500 North State Street, Jackson, Mississippi 39216, DMinor@umc.edu Commentaries expressed in the Journal MSMA are those of the indicated authors. News content, letters, and opinions are not expressions of the views or official policies of the JMSMA or the Mississippi State Medical Association.
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The JMSMA encourages families, friends, and our readers to submit obituaries and photos of Mississippi physicians for inclusion in the pages of our Journal. Email to KEvers@MSMAonline.com and lukelampton@cableone.net or slow mail to JMSMA.—ED. Charles Elbert Bell, MD, 86, passed away on Friday, March 18, 2016, at the Mississippi Baptist Medical Center in Jackson, MS. Dr. Bell completed his pre medical studies at Ole Miss and was a graduate of the University of Mississippi School of Medicine. Dr. Bell did his internship at the John Gaston Hospital in Memphis, TN, completed his Psychiatric Residency at the University of Louisville in Louisville, KY, and retired after 30 years of service as a dedicated and loving psychiatrist with the Mississippi State Hospital as the Director of the Male Psychiatric Service. Jewell Jerome Breeland, Jr., MD died on October 21, 2016. Dr. Breeland graduated from the University of Southern Mississippi. After serving in the United States Air Force during the Korea Conflict, he received his doctorate from the University of Mississippi Medical School. Dr. Breeland completed his internship in Savannah, Ga., in Family Practice. He opened his medical practice in Brookhaven in 1961 and continued there for 39 years. Robert Eugene Coghlan, MD passed away Friday, August 19, 2016. After graduating from Southern Mississippi University, he taught at Chamberlin Hunt Boys Academy. Shortly afterwards, he attended the University of Mississippi and University of Tennessee College of Medicine where he became a physician specializing in General Family Practice. He was one of the first persons in the state of Mississippi to earn this speciality. Robert (Bob) LaValle Donald, Jr., MD died June 9, 2016. Dr. Donald graduated with a Bachelor of Science Degree in Biology from Sewanee - The University of the South in 1958. He completed his Doctor of Medicine at the University of Mississippi Medical Center in Jackson in 1962. Upon graduation, Dr. Donald joined the United States Air Force and was stationed at Carswell Air Force Base in Fort Worth, Texas, from 1962-1965 and Camp Badaber in Peshawar, Pakistan, from 1965-1967. He began his medical practice in Pascagoula in February 1968 and had the great joy of practicing with his first cousin and mentor, Dr. Emile Baumhauer, Jr. In 1986, Dr. Donald received the Mississippi State Medical Association Community Service Award. 332 VOL. 57 • NO. 10 • 2016
James Mallard Holston, MD, 64, of Laurel died June 24, 2016. James earned a BS in biology from Millsaps College in 1972 and an MD from the University of Mississippi School of Medicine in 1976. He earned an MBA from Auburn University in 2004. Dr. Holston practiced pediatrics in Laurel for 30 years. Glenn B. Ruffin, MD of Hattiesburg died July 17, 2016. Upon graduation from high school, he entered the U.S. Navy where he served two years during World War II on an LST 865. His ship was active in the battle for Okinawa and the occupation of Japan. Following discharge from the Navy, he entered Mississippi State University, where he received his pre-medical degree. He attended Tulane University Medical School and graduated in May of 1952. He served his internship at Charity Hospital in New Orleans. He then returned to Laurel and joined the Boone Clinic in the practice of general medicine and surgery. In 1966, Dr. Ruffin returned to New Orleans to specialize in psychiatry at Tulane Medical School. After completing his residency in psychiatry, he practiced general psychiatry in New Orleans from 1969 to 2001. In October of 2001, he moved to Hattiesburg and practiced outpatient general psychiatry with the South Mississippi Psychiatric Group since that time. Paula Nicole (Nikki) ShoemakePatterson, MD of Tupelo, 40, passed away on June 1, 2016, during the birth of her daughter, Aubrey Caroline Patterson who died surrounded by family as she peacefully passed into her mother’s arms in heaven on June 8. Nikki received a Bachelor’s degree in Microbiology from Mississippi State University in 1998. Fulfilling her life-long dream, she graduated with the class of 2003 from the University of Mississippi Medical School. Upon completion of a surgical residency at St. Raphael Hospital in New Haven, CT, she joined the staff at Oktibbeha County Hospital where she became a well-respected medical colleague. In 2014, Dr. Shoemake-Patterson earned the distinction of becoming a Fellow of the American College of Surgeons.
George Faison Smith, MD died October 19, 2016. He graduated from the University of the South at Sewanee, Tennessee, in 1950. Following two years of graduate school at Ole Miss, he entered the University of Mississippi Medical School and received his two year medical certificate in 1954. He continued his medical education at Tulane University School of Medicine in New Orleans, receiving his MD degree in 1956. His early medical career included an internship at Charity Hospital in New Orleans, a one year general practice residency at Huey P. Long Charity Hospital in Pineville, Louisiana, and three years in general practice in Ocean Springs, Mississippi. Dr. Smith completed an anatomic pathology residency at University of Mississippi Medical Center. He practiced at St. Dominic Hospital until 1970 when he accepted a position at the V. A. Medical Center where he practiced until his retirement in December of 1999. During his tenure at the V. A. he also had an appointment as assistant professor of pathology at University of Mississippi Medical Center. From 1974 to 1997 Col. Smith served in the Mississippi Army National Guard including 14 years in the 134th Combat Support Hospital with four years as hospital commander and seven years in the 213th Medical Brigade which included duties as deputy state surgeon. Robert Sidney Tarver, MD, 64, passed away on September 6, 2016. Bob went to the University of Tennessee and graduated with honors and a Bachelor of Science degree in Zoology. He then attended the University of Mississippi Medical School. A residency in General Surgery was completed, followed by a teaching appointment in the Department of Surgery at the Veteran’s Hospital in Jackson. Bob left academics and began a career of General and Vascular Surgery in Jackson. Horton G. Taylor, Jr., MD, 76, of Ripley, passed away on July 5, 2016. Dr. Taylor graduated from Rutgers University and received his MD degree from Emory University. He completed a general surgery/family practice residency in Atlanta following which he reported to Fort Hood Army Hospital, Killen, TX, and then headed a MASH hospital. Later he began private practice in Ripley, MS, where he practiced for over 45 years. At age 65, Dr. Taylor, also known as Col. Taylor, assisted in the pre-combat set up of Mobile MASH Army Hospitals during the Desert Storm operation following 9-11, one of his most treasured accomplishments. John Clark Williams, MD died on July 9, 2016, in Orlando, Florida. Dr. Williams served in the United States Army Infantry in the Philippine
Islands in 1945. He attended Mississippi College and graduated from Louisiana State University Medical School, New Orleans, receiving his Medical Degree in 1957. Dr. Williams’ medical experiences included an internship and residency at University of Mississippi School of Medicine. In 1960 Dr. Williams began a lifetime of service to the community when he joined Dr. Benson Martin’s Vicksburg Infirmary. He later conducted a solo practice. Still later he joined the Street Clinic, Department of Internal Medicine. William (Bill) B. Wilson, MD, Jackson, died June 23, 2016. He attended Vanderbilt University and Vanderbilt School of Medicine. Bill trained in Internal Medicine and Anatomic Pathology and served two years as a shipboard medical officer in the Navy. In 1964, he moved his young family from Nashville to Jackson to become the director of laboratories at the Mississippi Baptist Medical Center, a position he held until his retirement in 1998. n
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N E W
M E M B E R S
ABED, HUSAM, Jackson; Obstetrics & Gynecology
GHAFOOR, HAFIZ USAMA BIN, Hattiesburg; Internal Medicine
ALUR, PRADEEP, Jackson; Nephrology
GILMORE, APRILE C., Hattiesburg; Pediatrics
ARMSTREAD-WILLIAMS, CASSANDRA, Jackson;
GOEBEL, MICHAEL A., Hattiesburg; Gastroenterology
Anesthesiology
GONZALES, MICHAEL RAYMUND C., Hattiesburg;
AWAN, AHMED ARSLAN YOUSUF, Hattiesburg;
GONZALEZ, MARIA F., Jackson; Anatomic Pathology
Internal Medicine
Endocrinology, Diabetes & Metabolism
BAJESTANI, SAEED, Jackson; Clinical Pathology
GUSA, WLLIAM E., Jackson; Anesthesiology
BANDA, KEERTHI, Hattiesburg; Internal Medicine
HAND, JOSHUA PETER, Petal; Family Medicine
BAUTISTA, LEODY C., New Albany; Obstetrics & Gynecology
HARBARGER, CLAUDE F., Jackson; Pediatric Otolaryngology
BERGER, INES, Jackson; Anesthesiology
HASSELL, JESSICA M., Jackson; Pediatrics
BETHEA, LAUREN A., Hattiesburg; Obstetrics & Gynecology
HENDERSON, JOHN M., Jackson; General Surgery
BLACK, JASON L., Ocean Springs; Emergency Medicine
HOLDER, MICHAEL G., Jackson; Pediatric Emergency Medicine
BYNUM, STEPHANIE D., Hattiesburg; Family Medicine
HOLDER, NNEKA A., Jackson; Adolescent Medicine (Ped)
CABRAL, MARIA DEMMA I., Jackson;
HOLLINGER, JASMINE C., Jackson; Dermatology
HONG, TAO, Jackson; Anesthesiology
Adolescent Medicine (Int. Med)
CARROLL, CLINTON M., Jackson; Pediatrics
HOWARD-CLAUDIO, CANDANCE M., Jackson;
CASTANEDA, JORGE, Jackson; Nephrology
CAUDILL, JONATHAN SHEPHERD CROSS, Jackson;
HURT, JAMES ALBERT, Jackson; Orthopedic Surgery
Pediatrics
ILIEV, DESSISLAVA, Jackson; Anesthesiology
CHANDLER, DERRICK L., Meridian; Anesthesiology
ILIEV, PETER B., Jackson; Anesthesiology
CHAROLOTTE, HOBBS, Jackson; Pediatric Infectious Disease
INAGAKI, KENGO, Jackson; Pediatrics
CHOUFANI, DANI I., Jackson; Neurology
JABARI, DUAA, Jackson; Neurology
CLARK, SONYA, Jackson; Orthopedic Surgery
JONES, CANDICE, Iuka; Family Medicine
CLEMENTE, ETHEL G., Jackson; Pediatric Endocrinology
JONES, KELLY L., Jackson; Pediatrics
DARBY, MARIE M., Hattiesburg; Obstetrics & Gynecology
KAPLAN, JULIE D., Jackson; Pediatrics
DAVIS, DERRICK, Jackson; Pediatrics
KENCY, JASMINE T., Jackson; Pediatrics
DAVIS, JUSTIN R., Jackson; Pediatrics
KRUSE, JOHN, Hattiesburg; Neurosurgery
DAVIS, KASEY I., Jackson; Pediatric Critical Care Medicine
KURNUTALA, LAKSHMI N., Jackson; Anesthesiology
DESAI, JAGDISH B., Jackson; Pediatrics
LEVESQUE, VANETTA L., Jackson; Anesthesiology
DHARMAPURI, SADHANA K., Jackson;
LOPEZ, MAX R., Jackson; Hospitalist
LOVEJOY, JOHN REIMBOLD, Hattiesburg;
Adolescent Medicine (Ped)
Diagnostic Radiology
DOUGLAS, CHRISTOPHER, Hattiesburg;
MAHESHWARI, ANSHU, Jackson; Pediatric Gastroenterology
Interventional Cardiology
Cardiovascular Disease
DOUGLAS, LAURIE E., Hattiesburg; Hematology/Oncology
MAHOWALD, MICHAEL A., Jackson; Clinical Pathology
DRAMBAREAN, PAUL, Hattiesburg; Internal Medicine
MALHOTRA, BHARAT K., Jackson;
DZUGAN, SERGEY SERGEYEVICH, Hattiesburg;
MANN, JOSHUA R., Jackson; Preventive Medicine
Orthopedic Surgery
Internal Medicine (Hospice & Palliative)
EL JAMAL, SIRAJ M., Jackson; Anatomic/Clinical Pathology
MANUCHA, VARSHA, Jackson; Anatomic Pathology
FARINO, JETHER CHRISTIAN, Ocean Springs; Psychiatry
MBEO, GILBERT O., Jackson; Neurology
GAJULA, VISWANTH, Jackson; Pediatrics
McCOLLUM, CHARLES R., Hattiesburg; Pulmonary Disease
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MEHTA, AVANI T., Jackson; Pulmonary Disease
SENDRA, FIDEL FABIAN, Hattiesburg; Cardiothoracic Surgery
MOORE, BENJAMIN CHARLES, Hattiesburg;
SHRADER, MICHAEL W., Jackson; Orthopedic Surgery
SIMPSON, LAUREN STEELE, New Albany; Pediatrics
Obstetrics and Gynecology
MORRIS, SEGER S., Corinth; Internal Medicine
SIMPSON, SCOTT A., Jackson; Pediatrics
MORRISON, GERALYNN G., Hattiesburg; Internal Medicine
SOHAL, DAWINDER SINGH, Vicksburg; Nephrology
NAYLOR, YAKEYLA N., Hattiesburg; Pediatrics
STEMPAK, LISA M., Jackson; Clinical Pathology
NEAVES, BRITTANIE INGRAM, Caledonia; Internal Medicine
STEWART, JAWAUNA, Hattiesburg; Internal Medicine
NORDNESS, PAUL JORGEN, Brandon; General Surgery
SUKUMARAN, ANJU P., Jackson; Pediatrics
OSEI, FRANK ABROKWAH, Jackson; Pediatric Cardiology
TALWAR, HARPREEK K., Jackson; Radiology
PALABINDALA, REMEN, Jackson; Internal Medicine
TANAWUTTIWAT, TANYANAN, Jackson; Cardiovascular Disease
PANDE, LEENA, Gulfport; Radiology
THURMOND, PATRICK R., Jackson; Internal Medicine
PARKER, ELLEN E., Jackson; Radiology
TIEU, BRIAN C., Jackson; Ophthalmology
PATEL, NETRALI, Jackson; Geriatric Medicine (Family Medicine)
TULIP, HANS HUNT, Meridian; Vascular Surgery
PATEL, RIDDHIBEN S., Jackson; Pediatrics
TURNER, JAMES, Hattiesburg; Emergency Medicine
RAAB, STEPEHN S., Jackson; Clinical Pathology
TURNER, SHERRY DENISE, Hattiesburg; Emergency Medicine
RAO, DEEPKIA S., Jackson; Anesthesiology
VINSON, JANELL, Vicksburg; Pediatrics
REED, LORI K., Jackson; Orthopedic Surgery
WALLACE STEVENS, ALICIA L., Poplarville; Internal Medicine
RODGERS, SCOTT M., Jackson; Psychiatry
WEBER, EMILY S., Jackson; Pediatrics
RODRIGUEZ, GRETTEL R., Hattiesburg; Internal Medicine
WEBSTER, MARILYN, Hattiesburg; Internal Medicine
SAN LUIS, CHRISTA Oâ&#x20AC;&#x2122;HANA V., Jackson; Neurology
WESTERVELT, JUSTIN D., Hattiesburg; Nephrology n
JOURNAL MSMA
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Academy
2016-17
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Contact us at: Gwendolyn Williams 601- 853-5449
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L E G A L E S E
Government Guidelines, Practice Parameters and Specialty Standards: Swords or Shields? The paramount question in any medical malpractice case is whether there was a breach of the standard of care. But what is the standard of care? In every medical malpractice case tried before a Mississippi jury, the jury is instructed that the standard of care is what a reasonably prudent minimally competent physician in the same field of practice, and having available the same general facilities, services, equipment and options, would not have done under the same or similar circumstances or the failure to do some act such a physician would have done under the same or similar circumstances. Stephanie Edgar, JD Legal Counsel Medical Assurance Company of Mississippi
Now, putting the legalese aside, the standard of care is a medico-legal term which, at least in Mississippi, sets the level at that which a minimally competent practitioner would practice under similar circumstances. Hopefully, you recognize that both the official legal definition and my attempt to simplify that definition are riddled with tons of subjectivity.
This is why expert witnesses are such vital components in medical malpractice cases. Both sides designate experts to refute what the other side’s expert claims is the standard of care. When the jury begins its deliberation, both sides hope that their expert was more believable to the jury than the other side’s expert. But what happens when there is a government guideline, a practice parameter, or a specialty standard present that addresses the precise situation which led to your being sued? For example, assume that you treat chronic pain patients with opioids. Further assume that one of your patients overdoses on hydrocodone, a medication that you prescribed, and you get sued. The plaintiff ’s lawyer, unless he’s had his head under a rock for the last several years, will be well aware of the opioid epidemic in this country. Likewise, he’ll be armed with authorities such as the CDC’s Guideline for Prescribing Opioids for Chronic Pain. So, it should come as no surprise to anyone when the central issue in the case becomes whether you effectively and timely evaluated the risks and benefits of opioid therapy with this particular patient. As the discovery process unfolds, everyone in the case learns that you started this patient on hydrocodone, and she was scheduled for a return visit to your office six weeks later. Unfortunately, the overdose occurs during week five—one week prior to her scheduled return visit and one week after the CDC says you should have seen her back in clinic. What ends up occurring is that the plaintiff ’s lawyer and his expert will try to make what’s in this guideline be the standard of care. And both will use it in such a way that it’s almost like a recipe. So, if you’re baking a cake and the recipe calls for an egg and a stick of butter, unless you’re a whiz in the kitchen, you’re going to mindlessly follow these steps and presumably, end up with the perfect cake. Applying that same rationale to medicine, because the CDC’s Guideline for Prescribing Opioids for Chronic Pain (the recipe) says that “[C]linicians should evaluate benefits and harms with patients within one to four weeks of starting opioid therapy for chronic pain…”, and you hadn’t planned to see this patient again until six weeks after starting hydrocodone, you botched the recipe. The plaintiff ’s lawyer will argue and his expert will testify that this amounts to a breach of the standard of care. The result is that the very recommendations which were created with the best of intentions to assist you in managing chronic pain patients will be used as a sword against you. Practice parameters and specialty standards are often used similarly, although many of these contain decent disclaimers which state that the recommendations are simply that—recommendations that are not intended to establish the standard of care. While such a disclaimer is never fool-proof, it can be used by a medical malpractice defendant to explain to a jury that practice parameters and specialty standards are tools designed to assist practitioners; however, ultimately, a physician’s treatment must be individualized for each patient and must be based on sound clinical judgment. Simply put, this is the method by which the plaintiff ’s attorney’s sword is converted to your shield in the courtroom. n Information contained in this publication is obtained from sources considered to be reliable. However, accuracy and completeness cannot be guaranteed. Information herein should not be regarded as legal advice. Source: The Risk Manager, Medical Assurance Company of Mississippi JOURNAL MSMA
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A Doctor’s Prescriptions for a Happy Family Holiday Gathering DWALIA S. SOUTH, MD ‘Happy Family Holiday’ sounds like something you would order from a Chinese restaurant menu, doesn’t it? Since dysfunctional and fragmented families are pretty much the status quo these days, we offer some common sense advice on having a less traumatic annual gathering. This information may prove helpful for both the host/hostess and the attendees. 1. There are various types of family gatherings, most involving rampant feasting and gifting. Since the Christmas season now begins before the Halloween candy has been eaten, it is good to project to your family early in the season about when, where and how the event will take place. Don’t be disappointed if there are conflicts and everyone on your list can’t come when you plan. There is always next time! 2. Gifts are a perennially touchy issue and exchanging them can get quickly out of hand and financially stressful for many. Now that Christmas has become a celebration of the birth of an infectious viral commercialism, you want to make it clear early on how things will be done. Depending on the size of your group, you may want to draw names the old-fashioned way. You might plan to have an exchange only for the children and perhaps the grandparents. For heaven’s sake, don’t plan on doing that odious Dirty Santa thing at any gathering other than perhaps an office party. Dirty Santa can be fun, but very young and the most senior family members don’t ‘get it.’ I have actually seen grown women in tears when someone greedily snatches away their gift. 3. Hostesses, do not spend much time perusing your December “Southern Living” or “Martha Stewart” magazines when planning your get-together. These folks work all year to set holiday standards that only exist in a fantasy world. Be as natural and simple as you can. Forget perfection, it ain’t happening. 4. Hostesses, don’t be afraid to ask for the help you need from your guests, such as bringing a particular dish, or to ask for help in clearing things away. Guests: if your hostess says ‘don’t worry about bringing anything,’ she is just being coy. Bring something anyway, some simple dish, or a small gift for the person hosting the gathering…preferably something that will not require dusting in the future. 5. Set a slightly flexible time span for arriving at your gathering unless you are planning a formal sit-down dinner. If you are a guest, do NOT arrive early unless you have been asked to help. Give the already frazzled hostess a little breathing room. Guests, the same goes with leaving the party. If you can stay and help clean up, please do so. If not, do NOT be the last person to leave. And be sure to thank your host family when you depart. 6.
Be mindful of special diets; diabetics are guaranteed to be present. Have a sugar free dessert or two available.
7. Limit or possibly omit alcohol from the gathering. Perhaps a punch bowl, rather than a bar to defray uninhibited mayhem. Consider inviting an outsider, perhaps even your minister to be there if a certain family member notorious for misbehaving has been a problem in the past. 8. If you have pre-planned activities and games, please be sure there is something for every one. The more folks can be involved the better. Have Christmas music going softly in the house somewhere. So soothing! If someone plays guitar or keyboard ask them to bring it to your gathering. Nothing seems to bring people together more harmoniously than group singing. 9. Avoid having discussions of politics, religion, family money business, conflict resolution, and war and peace-making among family members at all costs. It never works and always makes things worse. 10. Lower your expectations for the Happy Family Holiday. Form some new traditions. If you anticipate that things will NOT go as planned, that everything will NOT be sweetness and light, with hugs and kisses all around, you’ll be so much better off. If your gettogether ends without blood being shed, you can then declare it the best family gathering ever! Above all, remember what the poet said, “You can’t go home again.” Traditions are wonderful, but realistically cannot be maintained forever. Family members pass away and leave great voids that will be someday filled by new arrivals to the fold. Folks will leave us, but their love always remains. n
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