VOL. LVIII • NO. 10/11/12 • 2017 by Journal MSMA

OF THE MISSISSIPPI STATE MEDICAL ASSOCIATION

VOL. LVIII • NO. 10/11/12 • 2017

.__..__,""________ ____ __ ......._...... ___ -----. __...._.,....____ ........ -------. ---............._

__.. ___ _..w_.,._ __ _...,_.,. .... -"'" ....._..__

.....

..,

::.=-.=:~~:;...:.~~t;""~;.i~~ _ _ .. _ . . , _ _ _ '"""tW _ _ _ _ _ _

. ~~====~~=~ .

~~~ ..,,...,..__ .......,__~ . . ~-i--•~----...--•lr

-·

anytime, anywhere: anytime, anywhere:

download issuu to read the Journal MSMA download to read the Journal MSMA wherever issuu you go.

wherever you go.

•

ISSUU

------------

........

GET ITON

Google Play A

OF THE MISSISSIPPI STATE MEDICAL ASSOCIATION VOL. LVIII • NO. 10/11/12 • OCTOBER/NOVEMBER/DECEMBER 2017

SCIENTIFIC ARTICLES

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

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

Top 10 Facts You Need to Know about Substance Abuse 248 and Cognitive Decline Stephen Powell, MD; Netrali Patel, MD; Ashish Patel, MD Top 10 Facts You Need to Know about Hereditary Angioedema Stephen B. LeBlanc, MD; Patricia H. Stewart, MD

251

MANAGING EDITOR Karen A. Evers

Secretary-Treasurer W. Mark Horne, MD

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

Speaker Geri Lee Weiland, MD

Practice Reform and Population Health: Mississippi Physician Perspectives 258 Michael R. Korpiel, DHA; Ellen Jones, PhD; AnnaLyn Whitt, DHA, MPH; Diane K. Beebe, MD; Joshua R. Mann, MD, MPH

Vice Speaker Jeffrey A. Morris, MD

JOURNAL OF THE MISSISSIPPI STATE MEDICAL ASSOCIATION (ISSN 0026-6396) is owned and published monthly by the Mississippi State Medical Association, founded 1856, located at 408 West Parkway Place, Ridgeland, Mississippi 39158-2548. (ISSN# 0026-6396 as mandated by section E211.10, Domestic Mail Manual). Periodicals postage paid at Jackson, MS and at additional mailing offices. CORRESPONDENCE: Journal MSMA, Managing Editor, Karen A. Evers, P.O. Box 2548, Ridgeland, MS 39158-2548, Ph.: 601-853-6733, Fax: 601-853-6746, www.MSMAonline.com. SUBSCRIPTION RATE: $83.00 per annum; $96.00 per annum for foreign subscriptions; $7.00 per copy, $10.00 per foreign copy, as available. Advertising rates: furnished on request. Jill Gordon, MSMA Director of Marketing. Ph. 601-853-6733, ext. 324, Email: JGordon@MSMAonline.com POSTMASTER: send address changes to Journal of the Mississippi State Medical Association, P.O. Box 2548, Ridgeland, MS 39158-2548. The views expressed in this publication reflect the opinions of the authors and do not necessarily state the opinions or policies of the Mississippi State Medical Association. Copyright © 2017 Mississippi State Medical Association.

Osteoporosis Knowledge, Perceptions, and Self-efficacy 264 among Nursing Students in Mississippi Rita Morgan, CFNP; Vinayak K. Nahar, MD, PhD, MS, FRSPH; Amanda H. Wilkerson, PhD; M. Allison Ford, PhD; Amanda Hendricks, MS; Gurneet Bawa, MS; Martha A. Bass, PhD; Manoj Sharma, PhD

Understanding DRG 811/812 (Red Blood Cell Disorders) 270 Readmissions by Payer, Age, Race and Sex Phillip Hankins, BS; Ellen Jones, PhD; Elgenaid Hamadain, PhD; Jessica H. Bailey, PhD

Indocyanine Green Dye (ICG) Induced Hypersensitivity 274 Reaction under General Anesthesia Rachel Roberts, MD; Lakshmi N Kurnutala, MD DEPARTMENTS From the Editor – Home Before Dark Lucius M. Lampton, MD, Editor

246

President’s Page – The Professionals Who Watch the Profession William M. Grantham, MD

277

University of Mississippi Medical Center – Dedication of New Medical School Building

278

Images in Mississippi Medicine – Matty Hersee Hospital, 1902-1923

282

INDEX Subject

283

Author

287

ABOUT THE COVER

Official Publication

MSMA • Since 1959

Factors Influencing Mothers with High-Risk Pregnancies 254 and Babies at High-Risk: Exploratory Analysis from Mississippi and Implications for Breastfeeding Support Caroline Canarios, MA; Sannie Snell; John Green, PhD; Emily Turbeville; Mobolaji Famuyide, MD

“ Flocked, White, and Blue” For Dr. Stanley Hartness, his family’s traditional Saturday-after-Thanksgiving search for the “perfect” Christmas tree took a patriotic turn. The setting was the Jackson Giant Christmas Tree Sale for CARA at the MS State Fairgrounds. Never one to miss a photo op, Dr. Hartness spotted the red flocked Fraser fir and positioned the brightly decorated trash bin for an image that seemed to proclaim “Make Christmas Great Again!” (By the way, the family opted for a traditional unflocked Fraser fir.)—Ed. n

JOURNAL MSMA

VOL. LVIII • NO. 10/11/12 • 2017

245

F R O M

T H E

E D I T O R

Home Before Dark

arents often admonish their children to arrive home before dark. As the winter solstice approaches each year and daylight declines in daily increments, Mississippi physicians battle to finish their difficult work each day and get home before dark. Rarely is such accomplished by this physician in rural Mississippi, as flu and cold seasons erupt with more clinic work-ins and hospital admissions, thus Lucius M. Lampton, MD Editor longer work hours in a period of fleeting daylight. Coming home to a dark house after an exhaustive day at work and facing a cold plate of food in the fridge, having missed dinner, become the winter normal. Over 2,500 years ago, the gifted Greek poet Sappho wrote about the Pleiades (or Seven Sisters) star cluster setting in the distant sky on a winter night eliciting her awareness of the essential loneliness of the human condition. In the beautiful fragment sometimes called “Midnight Poem,” she writes: “The moon has set, and the Pleiades; it is midnight, the time is going by and I recline alone.” Physicians

frequently wage our battles alone, late into the night, to give our patients the care they need. In this time of short days and long nights, remember your fellow physicians with understanding, forgiveness, and empathy. The real heroes in our society are often front-line physicians whose good deeds go unnoticed and unappreciated to their families, friends, and yes, even their physician-peers. The solitary struggles of editors as well persist into the dark of night in our efforts to meet deadlines and provide our readers something good to read. More than a year ago, health issues of critical staff caused this journal to slip off track. To catch back up, we’ve twice combined several issues into one. Despite publishing on schedule since last January, this number remained undone and is our last “lagniappe” issue of catch-up. So, if you look closely, this extra issue, dated Oct./ Nov./Dec. 2017, completes our volume for 2017, and you will soon be getting the current volume for 2018. Expect no more combined catchup issues, and expect your Journal to maintain its monthly schedule in the future (10 issues per year, with two double issues). 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

Owen B. Evans, MD Professor of Pediatrics and Neurology University of Mississippi Medical Center, Jackson Nitin K. Gupta, MD Assistant Professor-Digestive Diseases, University of Mississippi Medical Center, Jackson Scott Hambleton, MD Medical Director, Mississippi Professionals Health Program, Ridgeland

Philip L. Levin, MD President, Gulf Coast Writers Association Emergency Medicine Physician, Gulfport Lillian Lien, MD Professor and Director, Division of Endocrinology, University of Mississippi Medical Center, Jackson William Lineaweaver, MD Editor, Annals of Plastic Surgery, Medical Director, JMS Burn and Reconstruction Center, Brandon Michael D. Maples, MD Vice President and Chief of Medical Operations, Baptist Health Systems Heddy-Dale Matthias, MD Anesthesiologist, Critical Care Internist, Madison

J. Edward Hill, MD Family Physician, Oxford

Jason G. Murphy, MD Surgeon, Surgical Clinic Associates, Jackson

Gordon (Mike) Castleberry, MD Urologist, Starkville Urology Clinic

W. Mark Horne, MD Internist, Jefferson Medical Associates, Laurel

Matthew deShazo, MD, MPH Assistant Professor-Cardiology, University of Mississippi Medical Center, Jackson

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

Alan R. Moore, MD Clinical Neurophysiologist, Muscle and Nerve, 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

Ben E. Kitchens, MD Family Physician, Iuka Brett C. Lampton, MD Internist/Hospitalist, Baptist Memorial Hospital, Oxford

246 VOL. 58 • NO. 10/11/12 • 2017

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

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

Mississippi Drug Card

a Must Have

A+

for this school year. o Mississippi Drug o PeNcils o Calculator o NoteBooks

Card

Program Highlights: families • All students and their gram are eligible for this pro t, no limits • No paperwork to fill ou trictions res h on usage & no healt

-activated • The card below is pre st any and ready to use at mo y retail chain pharmac

Sample Pricing DRUG NAME

QTY

RETAIL

DISCOUNT

SAVINGS

Dextroamphetamine XR (Adderall) 20mg

$176.99

$89.37

50%

Methylphenidate (Concerta) 18mg

$239.99

$148.62

38%

Azithromycin (Zpak) 250mg

$25.89

$12.63

51%

Montelukast (Singulair) 10mg

$50.99

$14.59

71%

Montelukast (Levaquin) 500mg

$47.98

$11.86

75%

me and • Covers both brand na y not ma t tha gs dru generic plan h covered by your healt

*Discounted prices were obtained from participating pharmacies in July. 2018. Prices vary by pharmacy and region are subject to change.

111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111ij1

Back to school time is no time to be sick! Stock up on the essentials and save up to 75%. I Prescription Pharmacy Coupon

Participating Pharmacies Include: A donation ~!Jill be made to your local

CMN hospital each time a prescription is processed using thi!i coupon.

Collpon MBR ID; Enter Year & Time (&,mp/,. r,.,,2018, r,,.,.9: 14, fnrorC/2018914/ RxGRP:

MSRX RxBIN: 6 10709

!,) 1.L

',) ,0r

,1rr,•r. ,11.-·.- =--,.,..,...,1 mi,

rrlJL~· lu , ....... t:tV\J

clt~ _ _,.,.,t

•

.1d1~·.1lo : I ;w,c:, .:1

PATIENT INSTRUCTIONS . h · t',"' , ~,.<:

Children's Miracle Network

1.,1,

i..,,,~u,1,.'. ..,.

PHAnMAC IST INSTnUCTIONS, i'",

1hnl1 1 ·,

·1

r.ar rir.~1 r<:

11vJ,_.i! IJ'l~.

Mississippi Drug Card

r,i- ,ri,.v·1 rl:1...., 1r~1n1-.r:'

is a proud supporter of Children's Miracle Network.

t>;:, prcce~~ .is s,;i,::;onc-c1r) Js ,rc ;119 lcllow -::i ph.7,r,,c, p-:x:e-:,5 rJ; ·, plr•:i,s·• c;1II 'I,. ,t ·'..-ni: 1ti11n :Ccir p·,i,,::,"; · <: q1,< •:; l 1111w, ," -' ll,l/11, .!l(Y 11~:)•f,2' 0€- i(·h.

Cu ~to n K•I' '.:,('rV-:E•

977-321-6755

r'rtarrriac1 I •e:;::-11110.

Hospitals·

800-223-2146

lllDJI '• l.i1liJ

C'JSlphannacy' wa1mart

1 :

Phtrn'IK)'

~- 0 ' SAFEWAY''-'·

PHARMACY

So,,on Q pt-.ormooy ~ '1,.7 l krno,t

&loplr&,e ..,, _ PIMlorl"Mq.

;G,....,._

IJ, G..... ~

...

iilh / ~ SH0PKO VONS ~ ACME-.,

EBZ!!9

--- ---

.c,,,,,µ 1JIUll/4 Cub

sha~

~ PAVILlONS Bl•MART FredMet'er.

» For more information or to order hard cards please contact: info@MississippiDrugCard.com JOURNAL MSMA

247

S C I E N T I F I C

Top 10 Facts You Need to Know about Substance Abuse and Cognitive Decline STEPHEN POWELL, MD; NETRALI PATEL, MD; ASHISH PATEL, MD Substance use, particularly opiates and their associated societal effects, are rising to the top of all political and health agendas as this epidemic’s death toll grows. Supported by the studies below, practitioners can be armed with the facts to communicate the dangers involved.

1 2

Chronic alcohol use causes neuronal death and effects on cognition. Alcohol’s central nervous system effects include gray/white matter volume reductions, DNA lesions causing neuronal death and decreased DNA repair.1 Clinical implications range from reduced executive function to substance-induced mood disorders affecting anxiety, mood and even chronic suicidality.2 Alcohol-use disorders may lead to increased risk of dementia in select groups. One large study with about 500,000 Swedish males studied the risk of young-onset dementia (younger than age 65) based on at least a one time hospital-treated alcohol intoxication. The men had cognitive exams serially followed for 37 years. Almost 500 of those were diagnosed with young-onset dementia, with a hazard ratio related to alcohol hospitalizations of 4.82.3 Similar findings were obtained in a study of 500 men and women followed for 23 years up through ages ranging from 65-79 with alcohol intake habits considered. Those who were carriers of the apolipoprotein e4 allele and who also imbibed in several times per month of alcohol intake in midlife showed an increased risk of dementia. Those without the genetic allele susceptibility still appeared to show general cognitive impairment.4

Cannabis use may cause neurocognitive deficits that persist after cessation of use. When compared to non-users, cannabis use is associated with impairment of attention, reduced executive functioning, worsened motor functioning, impairment of learning, and memory abilities.5 Other associations with long-term cannabis use include learning difficulties including poor retrieval of dictated words. Also, both longterm and short-term users show deficits in time-estimation, but how long these deficits persist is not yet known.6

Recurrent cannabis use beginning in adolescence appears to have a myriad of effects on cognition and educational performance. Heavy use, defined as 15 years of almost daily usage starting at age 16, resulted in decreased axonal connectivity. These brain alterations were principally in the hippocampus and corpus callosum.7 Users had decreased performance in English and mathematics, as well as higher risk of school dropout.8

When controlled for confounding factors, early and persistent cannabis use in adolescence caused neurotoxic effects across five essential domains of neuropsychological functioning. The domains affected are executive function, memory, processing speed, perceptual reasoning and verbal comprehension which collectively showed a global negative effect on users. The greatest effect was on executive function and processing speed. These effects were also noted by third-party persons, not just family, friends or research personnel and persisted after controlling for education level and the influence of alcohol, tobacco, and drug dependence.9

Chronic cocaine use appears to result in a decline in attention and memory. A study of chronic cocaine users showed decreased cognitive functioning after an inpatient washout, binge, then abstinence cycle. Cognition consistently worsened as the abstinence period lengthened. The most dramatic decline occurred in attention and recognition memory but smaller effects were seen in simple reaction times.10 Additionally, studies following CT imaging of chronic cocaine users showed cerebral atrophy that appeared to correlate with duration of cocaine abuse.11 Studies confirming the relation of these cognitive versus pathological findings are integral to future research.

248 VOL. 58 • NO. 10/11/12 • 2017

Chronic opioid use produces a decline in various cognitive areas to include memory and impulsivity. Reported long term effects include impairments in impulsivity, flexibility and short-term verbal memory.12 Other cognitive issues range from fatigue to complete disorientation, typically dose-dependent. Severe memory impairment can also occur as well as delirium, sometimes resulting in more frequent dreaming with the propensity for escalation to disturbing hallucinations. Mood disturbances can also occur with long term use which manifests often as irritability and depression.13

8 9

Chronic opioid use shows a decrease in Mini-Mental Status Exam© (MMSE©) scores in up to 33% of patients. Almost 2,000 patients with cancer who received opioids for three days or more were assessed using the MMSE© where a normal score ranges from 27 to 30. One-third of those patients showed scores at least less than 26 correlating with at least mild cognitive impairment. Factors associated with high-risk for a poor score included lung cancer, very high doses of daily opioids and older age.14 Maintenance-taper therapy or Medication-assisted Treatment (MAT) for those undergoing treatment for opioidaddiction appears to have cognitive effects as well. Both buprenorphine and methadone can cause a decline in cognitive function. When compared to each other, methadone produces more severe abnormalities. However, once the opioids are successfully tapered, the deleterious effects seen on higher doses improve. The most worrisome effects were seen in patients on maintenance therapy who operate motor vehicles. Typically, those issues mentioned become more apparent when the medication has reached peak plasma activity around one to three hours after ingestion.15 Withdrawal of opioid prescriptions in those addicted may lead to heroin use.16

Benzodiazepines pose threats to neuropsychological function after long-term use which can persist even following withdrawal. “Benzos” were first introduced in the 1960s. While their efficacy in treating anxiety disorders is profound, their side effects are worrisome. Some of the short-term effects known are decreased alertness, impaired psychomotor performance and memory dysfunction. A recent meta-analysis showed that users who had withdrawn from long-term benzodiazepine use still had significantly impaired areas of cognitive function to include visual perception, working memory and processing speed. The only domain spared was executive function. Results from this study challenge earlier ones that show that benzodiazepine users who are successful in withdrawing can have a full recovery in cognitive functioning - this may not be the case.17 Acknowledgement: The authors thank Richard D. deShazo, MD and Porter H. Wells, JD for their assistance in the preparation of this article. n References 1.

Mukherjee S. Alcoholism and its effects on the central nervous system. Curr Neurovasc Res. 2013;10:256-262.

Braillon A. Care for patients with grave alcohol use disorders. The Lancet. 2013;382:1876-1877.

3. Nordström P, Nordström A, Eriksson M, et al. Risk factors in late adolescence for young-onset dementia in men a nationwide cohort study. JAMA Intern Med. 2013;173:1612-1618. 4. Anttila T, Helkala EL, Viitanen M, et al. Alcohol drinking in middle age and subsequent risk of mild cognitive impairment and dementia in old age: A prospective population based study. BMJ. 2004;329:539. 5. Ganzer F., Bröning S., Kraft S. et al. Weighing the evidence: a systematic review on long-term neurocognitive effects of cannabis use in abstinent adolescents and adults. Neuropsychol Rev. 2016;26:186-222. 6.

Gould TJ. Addiction and cognition. Addic Sci Clin Pract. 2010;5:4-14.

Brust JC. Cognition and cannabis: From anecdote to advanced technology. Brain. 2012;135:2004-2005.

8. Stiby AI, Hickman M, Munafò MR, et al. Adolescent cannabis and tobacco use and educational outcomes at age 16: Birth cohort study. Addiction (Abingdon, England). 2015;110:658-668. 9.

Meier M, Caspi A, Ambler A, et al. Persistent cannabis users show neuropsychological decline from childhood to midlife. PNAS. 2012;109:E2657-E2664.

10. Pascual-Leone A, Dhuna A, Anderson DC. Cerebral atrophy in habitual cocaine abusers: A planimetric CT study. Neurology. 1991;41:34-38. 11. Pace-Schott EF, Stickgold R, Muzur A, et al. Cognitive performance by humans during a smoked cocaine binge-abstinence cycle. Am J Drug & Alcohol Abuse. 2005;31:571-591. 12. Baldacchino A, Balfour DJK, Passetti F, et al. Neuropsychological consequences of chronic opioid use: A quantitative review and meta-analysis. Neurosci Biobehav Rev. 2012;36:2056-2068. 13. Portenoy R, Mehta Z, Ahmed E. Prevention and management of side effects in patients receiving opioids for chronic pain. Abrahm J, ed. UpToDate. Waltham, MA: UpToDate Inc. http://www.uptodate.com Accessed on January 28, 2017.

JOURNAL MSMA

249

14. Kurita GP, Sjøgren P, Ekholm O, et al. Prevalence and predictors of cognitive dysfunction in opioid-treated patients with cancer: A Multinational Study. J Clin Oncol. 2011;29:1297-1303. 15. Pujol CN, Paasche C, Laprevote V, et al. Cognitive effects of labeled addictolytic medications. Prog Neuropsychopharmacol Biol Psychiatry. 2018;81:306-332. 16. Centers for Disease Control and Prevention Website. National Drug Control Strategy. 2016: https://obamawhitehouse.archives.gov/sites/default/files/ ondcp/policy-and-research/2016_ndcs_final_report.pdf. Accessed January 28, 2018. 17. Crowe SF, Stranks EK. The residual medium and long-term cognitive effects of benzodiazepine use: an updated meta-analysis. Arch Clin Neuropsychol. 2017;111: https://doi.org/10.1093/arclin/acx120 (e-published ahead of print). Accessed January 27, 2018.

@JournalMSMA

Author Information: Third-year Family Medicine resident, University of Mississippi Medical Center (Powell). Assistant Professor Departments of Medicine and Family Medicine, University of Mississippi Medical Center. Clinical Director of the MIND Center (Patel, N). Third-year pediatric cardiology fellow, Department of Pediatrics, University of Mississippi Medical Center (Patel, A). Conflicts of interest/ funding: none. Corresponding Author: Netrali Patel, MD, MIND Center, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216 (netralipatel3@gmail.com).

Like us on Facebook

Show lawmakers the face of organized medicine.

DOCTOR

OF THE DAY

Every day during the legislative session, the Capitol Medical Unit is staffed by a full time nurse and an MSMA volunteer physician who provides basic health care services to legislators and capitol staff. As a Doctor of the Day, you’ll see firsthand the everyday operations of the Mississippi Legislature and be recognized on both the Senate and House floors at the opening of each day’s session. Volunteers can choose from a half day on Monday or Friday or a full day on Tuesday, Wednesday or Thursday. Session begins in January.

250 VOL. 58 • NO. 10/11/12 • 2017

S C I E N T I F I C

Top 10 Facts You Need to Know about Hereditary Angioedema STEPHEN B. LEBLANC, MD; PATRICIA H. STEWART, MD Hereditary angioedema (HAE) is a disease characterized by recurrent episodes of swelling without itching or hives that most often involves the skin and the mucosa of the upper respiratory or GI tract. Since new treatments are now available to prevent and treat attacks of HAE, a condition that may be acute and life threatening, health professionals may find the information below helpful.

1 2 3

HAE is relatively rare. The disease has an estimated prevalence from 1:50,000 to 1:100,000 of individuals in the general population.1 It is due to a mutation in SERPING1 gene and is inherited in an autosomal dominant pattern with almost complete penetrance, though up to 25% of cases may be due to spontaneous mutation.2 Patients with HAE are frequently unable to identify a trigger for an attack. Attacks may be spontaneous or may be due to triggers such as stress, surgery or infection. Dental work is the most commonly identified trigger of attacks. During episodes, without treatment, the swelling usually increases over 24 hours and usually subsides over next 24-72 hours.3

HAE attacks can be fatal. Attacks can be life threatening when the upper airway is involved, causing asphyxiation. Up to 50% of patients with HAE will experience laryngeal edema at some point during their life.4 More commonly attacks affect skin, mucosa, upper airway and GI tract. Abdominal pain due to bowel wall edema may result in unnecessary surgeries including exploratory laparotomies, appendectomies and cholecystectomies.5

There are multiple types of HAE. Type I is most common and is due to low or absent C1 esterase inhibitor protein. It is responsible for about 85% of cases. Type II has normal or even high levels of C1-inhibitor, though the protein does not function normally and is responsible for about 15% of cases. A third, much less common Type III exists with normal C1-esterase inhibitor level and function and is believed to be due to mutation in Factor XII gene. This form is far more common in women than men and can be challenging to diagnose, often requiring genetic studies.6

5 6

Angioedema in HAE results from excessive production of bradykinin, a potent mediator of vasodilation. Sir William Osler was one of the first to recognize HAE as a distinct disease process from that of urticarial and other histaminemediated disorders.7 Mast cells and histamine are not directly involved, and thus antihistamines, glucocorticoids, and epinephrine are not usually effective in treatment. Drugs that inhibit bradykinin generation or signaling are used to manage the disease.8 Diagnosis is by careful history, especially family and medical history, as well as laboratory tests. Laboratory evaluation consists of checking levels of complement components to include C4, C1-inhibitor level and/or function as well as C1q. (Table 1). A normal C4 level during an acute attack of angioedema strongly suggests a diagnosis other than Type I or Type II C1-Inhibitor deficiency but does not exclude Type III.6 1. Complement Levels in Hereditary Angioedema (HAE) Types Table 1.Table Complement Levels in Hereditary Angioedema (HAE) Types HAE Type C4 Level C1-INH Level C1-INH Function C1q level Type I Low Low Low Normal Type II Low Normal Low Normal Type III Normal Normal Normal Normal Acquired C1-INH Low Low Low Low deficiency Idiopathic/ACEi Normal Normal Normal Normal Adapted from Middletonâ&#x20AC;&#x2122;s Allergy Principles and Practice- 8th edition. Saunders 2013; Vol. 1, 589. 7. Treatment of HAE is divided into acute treatment for attacks and prophylactic treatment for JOURNAL long-term management. Acute treatment consists of hydration, pain control, and airway MSMA management. Historically fresh frozen plasma (FFP) was used as it contains C1-inhibitor, but

251

long-term management. Acute treatment consists of hydration, pain control, and airway management. Historically fresh frozen plasma (FFP) was used as it contains C1-inhibitor, but Treatmentmay of HAE dividedparadoxical into acute treatment and prophylactic treatment foras long-term management. alsoiscause worseningfor ofattacks symptoms. Newer treatments such plasma derived Acute treatment consists concentrate, of hydration, pain control,inhibitor and airway(Kalbitor), management. frozenantagonists plasma (FFP) was used as C1-inhibitor kallikrein and Historically bradykininfresh receptor it contains (Icatibant/Firazyr) C1-inhibitor but mayare alsonow cause paradoxical worsening of symptoms. Newer treatments such as plasmasuch derived C1approved for acute treatment. Historically androgen derivatives inhibitor concentrate, kallikrein inhibitor (Kalbitor), and bradykinin receptor antagonists (Icatibant/Firazyr) are now approved for acute as Danazol and Stanozolol have been used for long term treatment, but these have risks of treatment. Historically androgen derivatives such as Danazol and Stanozolol have been used for long term treatment, but these have unwanted androgenic side effects and are increasingly difficult to access (Stanozolol is a banned risks of unwanted androgenic sidefor effects and are increasingly access (Stanozolol is a banned substance forderived competitive substance competitive athletes).difficult Newertoagents, now available including plasma C1- athletes). Newer agents, now available including plasma derived C1-inhibitor protein available in intravenous (IV) and subcutaneous (SQ) forms, inhibitor protein available in intravenous (IV) and subcutaneous (SQ) forms, are rapidly replacing 9 are rapidly replacing Danazol in patients with frequent or severe attacks. (Table 2) 9 Danazol in patients with frequent or severe attacks. (Table 2)

2. Treatment OptionsAngioedema for Hereditary Angioedema Table 2.Table Treatment Options for Hereditary Acute Treatment Fresh frozen plasma

Route IV

Recombinant C1-INH (Ruconest)

Kallikrein inhibitor (Kalbitor) Bradykinin receptor antagonist (Icatibant/Firazyr) Plasma-derived C1-INH (Berinert)

SQ SQ

Precautions Blood product, infection, transfusion reactions, paradoxical worsening Caution if rabbit sensitivity is present Anaphylaxis Injection site reactions

Thrombotic events, infection

Prophylactic Treatment Androgen derivatives (Danazol, Stanozolol) Plasma-derived C1-INH (Cinryze) Plasma-derived C1-INH (Haegarda) C1-INH= C1 esterase inhibitor IV= Intravenous

Route Oral IV

Precautions Side-effects: Virilization, weight gain, hepatotoxic, headaches Thrombotic events, infection

Injection site reactions ACEi= Angiotensin converting enzyme inhibitor SQ= Subcutaneous

8 9 10

Certain procedures require prophylaxis. 2 Patients with HAE should receive prophylaxis with IV C1-inhibitor 1 hour before planned surgical or dental procedures. Alternatively oral androgens may be used 5 days prior to and 3 days after planned procedure.3

There are several special considerations for female HAE patients. For contraception, estrogens should be avoided and progestin-only birth control is preferred. Androgen treatment is contraindicated in pregnancy but C1-inhibitor prophylaxis can be continued. C1-inhibitor is recommended prior to Caesarian section or delivery by forceps/vacuum extraction.10 There is an acquired form of HAE separate from ACE-inhibitor induced. There is an acquired form of angioedema which usually has normal levels of C1-inhibitor level plus low levels of the serum complement component C1q. This acquired form of angioedema is associated with paraneoplastic conditions, most commonly lymphoproliferative diseases. These are typically due to consumption of C1-inhibitor protein leading to relative deficiency but may also be seen in autoimmune diseases with formation of auto-antibodies to C1-inhibtor with impairment in function. Other complement values including C3, C4 and C1-inhibitor level may be normal if checked.6 n References 1.

Craig T, Aygören-Pürsün E, Bork K, et al. WAO guideline for the management of hereditary angioedema. World Allergy Organ J. 2012;5(12):182-199.

2. Pappalardo E, Cicardi M, Duponchel C, et al. Frequent de novo mutations and exon deletions in the C1 inhibitor gene of patients with angioedema. J Allergy Clin Immunol. 2000;106(6):1147-1154. 3.

Szema AM, Paz G, Merriam L, et al. Modern preoperative and intraoperative management of hereditary angioedema. Allergy Asthma Proc. 2009;30:338-342.

252 VOL. 58 • NO. 10/11/12 • 2017

Bork K, Meng G, Staubach P, Hardt J. Hereditary angioedema: new findings concerning symptoms, affected organs, and course. Am J Med. 2006;119(3):267-274.

5. Rubinstein E, Stolz LE, Sheffer AL, Stevens C, Bousvaros A. Abdominal attacks and treatment in hereditary angioedema with C1-inhibitor deficiency. BMC Gastroenterol. 2014;14:71. 6. Zuraw BL, Christiansen SC. Hereditary angioedema and bradykinin-mediated angioedema. In: Adkinson NF Jr, Bochner BS, Burks AW, et al., editors. In Middleton’s Allergy: Principles and Practice. 8th ed. Vol. 1. Philadelphia, PA: Elsevier Saunders; 2014,588-601. 7.

deShazo RD, Frank MM. Genius at work: Osler’s 1888 article on hereditary angioedema. Am J Med Sci. 2010;339(2)179-181.

Frank MM. Hereditary angioedema: the clinical syndrome and its management in the United States. Immunol Allergy Clin North Am. 2006;4:653-68.

9. Gower R, Aygören-Pürsün E, Davis-Lorton M, et al. Hereditary angioedema caused by C1-esterase inhibitor deficiency: A literature-based analysis and clinical commentary on prophylaxis treatment strategies. World Allergy Organ J. 2011;4(suppl.):S9-S21. 10. Caballero T, Farkas H, Bouillet L, et al. International consensus and practical guidelines on the gynecologic and obstetric management of female patients with hereditary angioedema caused by C1 inhibitor deficiency. J Allergy Clin Immunol. 2012;129,308-320.

Author Information: Division of Allergy and Immunology, University of Mississippi Medical Center (LeBlanc, Stewart). Conflicts of interest/ funding: none. Corresponding Author: Stephen B. LeBlanc, University of Mississippi Medical Center, 878 Lakeland Drive, LB Building, Jackson, MS 39216. Ph: (601) 815-1078.

11111111111111111111 2018 Health Care Heroes MISSISSIPPI PHYSICIANS

Michael L. Bookhardt, MD

Jolanta Roszkowska, MD

Richard D. DeShazo, MD

Robert Smith, MD

William M. Grantham, MD Rance McClain, DO

Mary B. Taylor, MD \tl"iSIS.,IPPI ...,IATf \iffitCAI ASSCX'I-\TK)~

John P.F.H. Vanderloo, MD

R. David Roberts, III MSMA GOVERNMENT AFFAIRS

given by Mississippi Business Journal

JOURNAL MSMA

253

S C I E N T I F I C

Factors Influencing Mothers with High-Risk Pregnancies and Babies at High-Risk: Exploratory Analysis from Mississippi and Implications for Breastfeeding Support CAROLINE CANARIOS, MA; SANNIE SNELL, MSW, MPH; JOHN GREEN, PHD; EMILY TURBEVILLE, BA; MOBOLAJI FAMUYIDE, MD Abstract

a FIGURE. Social-Ecological Figure. Social-Ecological Model a Model

Many factors influence a mother’s decision to breastfeed, ranging from Sociohistoric personal preferences to socioeconomic position, access to resources, and institutional policies and practices. It is important not to view these issues in a vacuum but rather to identify and consider broader Policy contexts. Using the social-ecological framework and exploratory research, we identified factors impacting mothers with medicallyCommunity and vulnerable babies. Face-to-face interviews were conducted with Organizational mothers (N = 32) who initiated breastfeeding (n = 17) and those who did not (n = 15) at the high-risk newborn follow up and high-risk Interpersonal obstetric clinics of the University of Mississippi Medical Center (UMMC) in Jackson, Mississippi. Results identify health problems, vulnerable socioeconomic positions, and transportation concerns faced by mothers. This is a pilot study conducted to inform planning Individual for the “Right! From the Start” clinical and community breastfeeding support intervention that will connect the UMMC Neonatal Intensive Care Unit with community health centers in the Delta region of the a state. The social-ecological framework of factors influencing Adapted fromforCenters forControl Diseaseand Control and Prevention, National a Adapted from Centers Disease Prevention, National Center for Chronic breastfeeding can inform intervention staff when providing lactation Center for Chronic Disease Prevention and Health Promotion, Division Prevention and Health Promotion, Division of Nutrition, Physical Activity, and Obesity. of Nutrition, Activity, and Obesity. Health EquityDisparities. Resource and social support, physicians in clinical care settings, and health care Resource Equity ToolkitPhysical for State Practitioners Addressing Obesity Toolkit for State Practitioners Addressing Obesity Disparities. policy. https://www.cdc.gov/nccdphp/dnpao/state-local-programs/health-equity/pdf/toolkit.pdf. Published https://www.cdc.gov/nccdphp/dnpao/state-local-programs/health2012. Accessed April 6, 2018. equity/pdf/toolkit.pdf. Published 2012. Accessed April 6, 2018.

Key Words: B reastfeeding; Infant, Low Birth Weight; Premature Birth; Social-Ecological Framework Introduction

The social-ecological framework provides a comprehensive approach for analyzing factors associated with health.1 The Figure examines health at the individual, interpersonal, community and organizational, and policy levels, all within the sociohistorical context of the places where people live. This framework recognizes that each level is interconnected with and shapes the others. The social-ecological framework has been used to explore social determinants of health, understand health knowledge and behaviors, and design interventions,2,3 including breastfeeding.4 Mississippi has high rates of preterm births (<37 weeks gestation: 13.0 per 100 births), low birth weights (<2,500 grams: 11.5 per 100 births), very low birth weights (<1,500 grams: 2.2 per 100 births), and infant mortality (death in first year: 9.2 per 1,000 live births), according to the Mississippi Department of Health vital records from 2011-2015.5 While breastfeeding can be beneficial for all babies, breastmilk and its health benefits may be most advantageous for those born preterm and 254 VOL. 58 • NO. 10/11/12 • 2017

at a low birth weight. Unfortunately, Mississippi’s breastfeeding rate has been one of the lowest in the nation (52.0%) with a near 30-point deficit from the US National rate (81.1%), as reported by the Centers for Disease Control and Prevention (2016) using data from the National Immunization Surveys of 2014 and 2015.6 The first step to improving the breastfeeding rates is understanding the broader contexts in which mothers are making decisions for themselves and their babies. Factors that might determine a mother’s decision to breastfeed range from personal preferences to family support, socioeconomic conditions, and access to resources, among others.7,8,9 This is a pilot study that seeks to identify the stressors and supports to as voiced by mothers themselves facing challenging risk situations. Information obtained from this study was used to structure the training and education of community health workers, social workers, and lactation consultants staffed in the “Right! From the Start” Breastfeeding Initiative (RFTS) in identifying potential issues study participants may face. Additionally, findings from these interviews aided in the design of

data collection tools used for RFTS intervention. Issues presenting at each level of the social-ecological framework are likely to be the most pronounced for mothers facing high-risk pregnancies and for those with preterm deliveries and low birth weight babies. Recognizing that all of the mothers were facing challenges in terms of the health of their babies – given that we selected them and interviewed them at high-risk clinics – it is still interesting to ask whether the Neonatal Intensive Care Unit (NICU) experience differentiated their likelihood of breastfeeding and duration of breastfeeding. The objective of this pilot study is to provide public health practitioners, providers and policy experts with a better understanding of the factors that may influence decisions about breastfeeding among mothers with babies in the most medically-vulnerable situations and to use this understanding to better equip clinical care.

1. The average age of mothers was 28 years, ranging from a low of 19 to a high of 46. The majority identified as being African American. Slightly more than half of the interviewees were either married or in a committed relationship. Approximately half had completed any college course work, and slightly more than half had incomes less than $20,000 per year. The gestational ages for their youngest children averaged 37 weeks and covered a broad range, but nearly 2 out of 5 of the babies were born preterm. Approximately 38% of respondents’ babies had been admitted to the NICU, while the rest were admitted and cared for in the intermediate care or well-baby nursery. Table 1. Demographic and Socioeconomic Characteristics of Mothers and their Babies Interviewed at High-Risk Clinics Characteristics Screening (N = 32)

Methods The interviews conducted for this project were based on an in-depth questionnaire. The items in the questionnaire, consisting of both open and closed-ended items, were informed by prior key-informant interviews and focus groups with service providers and mothers. Topics ranged from demographic and socioeconomic characteristics to pregnancy experiences, delivery and breastfeeding decisions. The final instrument and research plan were approved by the Institutional Review Board at the University of Mississippi Medical Center (UMMC) (IRB# 2015-0043). Face-to-face interviews were conducted by two trained researchers in October 2015 at UMMC’s High-Risk OB clinic and High-Risk Newborn follow up clinic in Jackson, MS. Working under the guidance of clinic staff who introduced the study during registration, researchers only approached mothers who expressed interest for interviews while they were waiting for their appointments. It was not possible to track the number of mothers who were introduced to the study by clinic staff but declined to speak with researchers, but there were only five mothers who declined to participate after speaking with researchers. Interviews were conducted in a secluded space in each clinic, and all participants received $20 gift cards to compensate for their time. In the end, 39 interviews were conducted. Seven of the mothers had not given birth to their first child yet, therefore this article is based on the remaining 32 mothers. Due to the smaller sample size, this study is indicated as a pilot study for hypothesis generation. All data from the hard-copy questionnaires were entered into the IBM Statistical Package for the Social Sciences (SPSS) for data management, further coding, and analysis. All open-ended responses were coded by a team within the University of Mississippi (UM) Center for Population Studies. Descriptive statistics from these data are presented below, drawing primarily from frequency distributions, cross tabulations and mean comparisons. Summary findings from qualitative analysis of open-ended questions are also included to add depth and nuance to the broader patterns. Results The demographic and socioeconomic characteristics of the interviewed mothers and their youngest children are shown in Table

Mother age (n = 31)*, mean (min. to max. range) [IQR], years

28 (19 to 46) [5.0]

GA of youngest child, mean (min. to max. range) [IQR], weeks

37 (27 to 42) [4.8]

Youngest child born preterm (%) Mother African American (%) Married/committed relationship (%) Any college (%) Income <$20,000 (%) Youngest child admitted to NICU (%) Mother ever tried to initiate breastfeeding for youngest child (%) Number of weeks breastfed (n = 17)**, mean (min. to max. range) [IQR] Number of weeks in NICU (n = 12)***, mean (min. to max. range) [IQR]

13 (40.6) 29 (90.6) 18 (56.3) 16 (50.0) 17 (53.1) 12 (37.5) 17 (53.1) 13.1 (.1 to 60.0) [17.4] 6.8 (.5 to 24.0) [8.0]

Abbreviations: IQR = interquartile range, GA = gestational age, NICU = neonatal intensive care unit.

One mother refused to answer question, resulting in n = 31. 17 mothers chose to breastfeed (n = 17). *** 12 mothers had infants in the NICU (n = 12). *

Half (53%) of the interviewees reported ever initiating breastfeeding, and 19% indicated they had ever pumped breastmilk. On average, mothers breastfed for just over 13 weeks. There was significant variability, with breastfeeding duration ranging from 1 day to 60 weeks. Among the mothers who decided to breastfeed but discontinued after a short time, most reported that the baby did not latch properly or that their milk supply ran out. As shown in Table 2, mothers whose babies had been hospitalized in the NICU were more likely to have ever initiated breastfeeding (75%) as compared to those whose babies had not been in the NICU (40%). However, they tended to breastfeed for shorter periods of time. Table 2. Comparison of Breastfeeding Patterns by Neonatal Intensive Care Unit (NICU) Status Non-NICU NICU Characteristics (n = 20)* (n = 12)* Ever initiated breastfeeding (%) Weeks breastfed Mean Min. to max. range Interquartile range Abbreviations: NICU = neonatal intensive care unit.

8/20 (40.0)**

9/12 (75.0)**

7.1 .1 to 60.0 28.7

19.1 .1 to 22.0 12.4

32 mothers participated in the study. 20 mothers had babies admitted to intermediate care or well-baby nursery and 12 mothers had babies admitted to a hospital NICU. ** 8 of the 20 mothers with non-NICU babies had ever initiated breastfeeding; 9 of the 12 mothers with NICU babies had ever initiated breastfeeding. *

Many of the interviewed mothers (44%) reported health issues as a stressor during pregnancy. These issues included morning sickness, nausea and fatigue, as well as chronic conditions like high blood pressure and diabetes. Some mothers (25%) experienced depression during their pregnancy. JOURNAL MSMA

255

Mothers whose babies had been in the NICU were more likely to mention child health problems, maternal health problems and transportation constraints as challenges in caring for their babies. Pointedly, transportation problems made it difficult for one-quarter of NICU mothers to visit their babies. Half (50%) of mothers interviewed received Medicaid transportation, and most mothers reported visiting the NICU daily. For mothers who did not have transportation problems, they had their own car or were provided transportation by family members. Nearly all of the interviewed mothers (94%) reported the community being supportive toward their pregnancy, and most (87%) were pleased with the medical care they were receiving. One mother described the support she felt from her doctors, despite diagnosis of an unfavorable health condition, by stating: “Doctors here are the best, but prior, it was stressful. I feel safe here. I see three doctors and have ultrasounds. This time, bloodwork showed I was diabetic.” Individual-level health behaviors of mothers, including the decision of whether or not to breastfeed, were reportedly influenced by interpersonal and social relationships. Many mothers noted stress in their interpersonal relationships, especially with the baby’s father or their partner and other family members. Younger mothers expressed a lack of family support and increase in school stress. Community factors including workplace and school environments also impacted mothers’ stress and decision-making processes. Another young mother described depression due to stress at school, stating: “I was in high school and depressed because I was so young and got pregnant the first time I had sex.” Interestingly, respondents who had been teenage mothers relied heavily on family support and often deferred to family for decisionmaking. Financial problems and lack of support from the father placed added stress on mother. Mothers without support from father were less likely to breastfeed. One mother elaborated on these troubles by stating: “My first pregnancy I was upset because I was going through a divorce, no income, abusive relationship.” Discussion and Conclusion This exploratory study primarily reveals stressors and supports related to individual, interpersonal, community and organizational levels of the social-ecological model, including health problems, vulnerable socioeconomic positions and transportation concerns. While clinical providers may not be able to directly impact these factors, they can be taken into consideration in their approach to serving mothers, their babies, and families. Although limited in scope, conducting applied studies like the one reported here can provide important insight in this regard. Furthermore, examining institutional policies and procedures is especially important for improving clinical care. Examples of policies that impact breastfeeding include the Baby Friendly Hospital Initiative (BFHI).10 The findings from our study underscore the importance of collaborative efforts to create supportive environments for mothers considering whether to breastfeed preterm/low birth weight infants. The need for support starts prior to delivery and, as suggested by the National Perinatal Association, perinatal interventions that provide direct support and education beginning during preconception care and continuing throughout the postpartum

256 VOL. 58 • NO. 10/11/12 • 2017

period are essential.11 These interventions can occur in the provider’s office as part of a routine visit and can range from a volunteer lactation counselor discussing breastfeeding and identifying at-risk mothers, to more sophisticated involvement of a lactation consultant and social worker and/or psychologist.12,13,14,15 Neonatologists have traditionally focused on the high-risk clinical care events of the intensive care unit environment and not so much of psychosocial events beyond the relatively controlled environment of the NICU. Mothers in this study mainly reported stressors outside of the immediate purview of the medical team as significantly impacting their lives. Providing psychosocial support to parents whose infants are hospitalized in NICU can improve parents’ functioning as well as their relationships with their babies.16 Recommendations were recently published to support this model of care.17 It therefore becomes a moral imperative for the psychosocial environment of the NICU patient and family to be examined and supported in parallel to the medical care being provided. This study was designed to inform planning for the “Right! From the Start” Breastfeeding Initiative (RFTS). “Right! From the Start” is a partnership between the University of Mississippi Medical Center, The University of Mississippi Center for Population Studies, Aaron E. Henry Community Health Center and Delta Health Center. The intervention component of RFTS is a community and clinical support program created with the goals of increasing breastfeeding rates in the Mississippi Delta region. Social workers, lactation consultants and community health workers from two community health centers are staffed to support low birth weight infants and their mothers after discharge from the UMMC NICU. The intervention takes place in eight Delta counties, with four counties included for comparison. Patient enrollment for the intervention began in October 2017, and intervention activities are ongoing. The goal is for infants in the intervention to be tracked for two years to analyze the impact of the intervention on health outcomes. Findings from this study continue to inform ongoing program development and education for the social workers, community health workers, and lactation consultants providing support. Understanding the individual-level factors influencing mothers’ decisionmaking is important, but connecting those to interpersonal, community and organizational, policy and sociohistorical context is paramount to understanding how mothers make decisions about their own health behaviors for themselves and their babies, as well as informing clinicians and additional staff on areas to offer more comprehensive information, treatment and resources. Acknowledgements: This research was conducted with support from the W.K. Kellogg Foundation and the Community Foundation of Northwest Mississippi. The comments made in this article do not necessarily represent these partner organizations. The authors would like to thank Sarah Gayden Hammond and Wilson Helmhout for their involvement in data collection and analysis for this study. n

References 1. Richards L, Gauvin L, Raine K. Ecological models revisited: their uses and evolution in health promotion over two decades. Annu Rev Public Health. 2011;32:307–326. doi: 10.1146/annurev-publhealth-031210-101141. 2. Schwartz LA, Tuchman LK, Hobbie WL, et al. A social-ecological model of readiness for transition to adult-oriented care for adolescents and young adults with chronic health conditions. Child Care Health Dev. 2011;37:883-

895. doi: 10.1111/j.1365-2214.2011.01282.x. 3. Baral S, Logie CH, Grosso A, et al. Modified social ecological model: a tool to guide the assessment of the risks and risk contexts of HIV epidemics. BMC Public Health. 2013;13:1-8. doi: 10.1186/1471-2458-13-482. 4. Dunn RL, Kalich KA, Henning MJ, et al. Engaging field-based professionals in a qualitative assessment of barriers and positive contributors to breastfeeding using the social ecological model. Matern Child Health J. 2015;19:6-16. doi: 10.1007/s10995-014-1488-x. 5. Mississippi Department of Health. Mississippi Statistically Automated Health Resource System. 2015. http://mstahrs.msdh.ms.gov/. Accessed on August 2, 2017. 6. National Immunization 2014 and 2015 Surveys, Centers for Disease Control and Prevention, Department of Health and Human Services. https://www. cdc.gov/vaccines/imz-managers/nis/datasets.html. Accessed on August 2, 2017. 7. Bonuck K, Stuebe A, Barnett J, et al. Effect of primary care intervention on breastfeeding duration and intensity. Am J Public Health. 2014;104:S119-S127. doi: 10.2105/AJPH.2013.301360. 8. Sparks J. Rural-urban differences in breastfeeding initiation in the United States. J. Hum Lact. 2010;26:118-129. doi: 10.1177/0890334409352854. 9. Taveras EM, Capra AM, Braveman PA, et al. Clinician support and psychosocial risk factors associated with breastfeeding discontinuation. Pediatrics. 2003;112:108-115. 10. Taylor EC, Nickel NC, Labbok MH. Implementing the ten steps for successful breastfeeding in hospitals serving low-wealth patients. Am J Public Health. 2012;102:2262-2268. doi: 10.2105/AJPH.2012.300769. 11. Glick C, Hamlin ML, Phillips R. Breastfeeding: position paper. National Perinatal Association. 2015. http://www.nationalperinatal.org/resources/ Documents/Position%20Papers/Breastfeeding.pdf. Accessed on August 2, 2017.

12. Ross-Cowdery M, Lewis CA, Papic M, et al. Counseling about the maternal health benefits of breastfeeding and mothers’ intention to breastfeed. Matern Child Health J. 2017;21:234-241. doi: 10.1007/s10995-016-2130-x. 13. Rossman B, Engstrom JL, Meier PP, et al. “They’ve walked in my shoes”: mothers of very low birth weight infants and their experiences with breastfeeding peer counselors in the neonatal intensive care unit. J Hum Lact. 2011;27:14-24. doi: 10.1177/0890334410390046. 14. Habibi MF, Springer CM, Spence ML, et al. Use of videoconferencing for lactation consultation: an online cross-sectional survey of mothers’ acceptance in the United States. J Hum Lact. 2017; Advanced online publication:1-9. doi: 10.1177/0890334417711385. 15. Wouk K, Chetwynd E, Vitaglione T, et al. Improving access to medical lactation support and counseling: building the case for Medicaid reimbursement. Matern Child Health J. 2017;21:836-844. doi: 10.1007/s10995-016-2175-x. 16. Hall SJ, Cross J, Selix NW, et al. Recommendations for enhancing psychosocial support of NICU parents through staff education and support. J Perinatol. 2015;35:S29-S26. doi: 10.1038/jp.2015.147. 17. Hynan MT, Steinberg Z, Baker L, et al. Recommendations for health professionals in the NICU. J Perinatol. 2015;35:S14-S18. doi: 10.1038/ jp.2015.144.

Author Information: Center for Population Studies, University of Mississippi (Canarios, Green). Women and Children Health Initiatives, Inc. (Snell). Division of Newborn Medicine, Department of Pediatrics, University of Mississippi Medical Center (Turbeville, Famuyide). Corresponding Author: Mobolaji Famuyide, MD, University of Mississippi Medical Center, Division of Newborn Medicine, Department of Pediatrics, 2500 North State Street, Jackson, MS 39216. mfamuyide@umc.edu.

) ~ Mississippi Department of Rehabilitation Services Providing the freedom to live

PHYSICIANS NEEDED Internists, Cardiologists, Ophthalmologists, Pediatricians, Orthopedists, Neurologists, Psychiatrists, etc. interested in performing consultative evaluations according to Social Security guidelines.

OR Physicians to review Social Security disability claims at the

Mississippi Department of Rehabilitation Services (MDRS) in Madison MS.

DISABILITY DETERMINATION SERVICES 1-800-962-2230

JOURNAL MSMA

257

S C I E N T I F I C

Practice Reform and Population Health: Mississippi Physician Perspectives MICHAEL R. KORPIEL, ANNALYN WHITT, DHA, MPH; DHA; ELLEN JONES, PHD; DIANE K. BEEBE, MD; JOSHUA R. MANN, MD, MPH Abstract Purpose: As healthcare changes to a population health model due to the Affordable Care Act, physician practices are being forced to change the way they do business. Two studies performed at the University of Mississippi Medical Center (UMMC) examined Mississippi providers’ perceptions of care transformation and population health competencies. The first study examined physician perceptions in care transformation. The second study was a self-assessment of physician competencies in preparation for population health. Methods: Both studies used online Qualtrics survey tools. The practice transformation study posed questions to primary care physicians in Mississippi to assess perceived facilitators and barriers in practice transformation from traditional medical models of care to patient-centered care. The population health self-assessment faculty physicians at the University of Mississippi Medical Center had performed rated themselves against competencies extracted from the ACGME Milestone Project for Preventive Medicine and Family Medicine. Materials Studies: Physician responses were analyzed using Qualtrics survey and analytical tool using the Fisher Exact test for statistical significance. Results Obtained: Results of the transformational care study indicate physicians perceive their individual treatment of patients impacts overall population health. The top constructs show physicians are most concerned with accessible services for their patients, issues with reimbursement, adequate staffing and chronic disease self-management. The results of the population health assessment showed an overall aggregate score of all population health-related competencies was 3.1, slightly higher than midpoint. This indicates a gap in knowledge, skills and abilities in many population health competencies.

Population health is the design, delivery, coordination, and payment of high-quality healthcare services to manage cost, quality and patient experience for a population using the best resources available within the healthcare system.5 Managing populations, such as the employees in a company, residents of a town, or people with the same clinical diagnosis such has heart failure, requires a different payment mechanism as well as a coordinated team approach including physicians, nurses, social workers, health coaches and case managers. With a new federal administration in place in 2017, health experts believe a proactive approach to health and prevention, especially the emphasis on population health, will remain in any repeal and revision of the Affordable Care Act.6 The desire to move from a volume-based to a value-based system is a model that appears to be consistent on both sides of the aisle. Two studies performed at the University of Mississippi Medical Center (UMMC) examined Mississippi providers’ perceptions of care transformation and population health competencies. The first study examined facilitators and barriers to healthcare financing. The questionnaire consisted of constructs derived from other surveys7 and was pilot-tested by two primary care physicians in central Mississippi. The second study engaged physicians in a self-assessment of competencies related to population health management. The physicians were provided with nine specific population health competencies. The competencies were selected from the Accreditation Council for Graduate Medical Education’s (ACGME) Milestone Project that identifies competencies needed by physicians upon graduation and into private practice.8

Introduction

Both studies were granted exemption by Institutional Review Boards. The care transformation study received expedited review by the Mississippi State Department of Health (MSDH) in January 2015. The population health competencies assessment received expedited review by the UMMC Institutional Review Board on October 19, 2016.

In 2010, the federal government put in motion a reformation of healthcare in America when it passed the Affordable Care Act. This landmark legislation put into place a call to action for all involved in healthcare to focus on health and prevention for populations at large.1 This call to action includes a revised methodology for care transformation/reimbursement and a focus on the competencies and skills for physicians that will be needed to treat patients in a population health model.2,3,4

Participants in the care transformation study were primary care physicians in George, Hancock, Harrison, Jackson, Pearl River and Stone Counties in Mississippi. Email addresses were obtained from the MSDH Health Alert Network. Participants in the population health study were active physicians (MD or DO) on staff at the University of Mississippi Medical Center in the departments of Internal Medicine (IM), Family Medicine (FM), Obstetrics and Gynecology (OB/Gyn) and Pediatrics.

258 VOL. 58 • NO. 10/11/12 • 2017

Methods Both studies used online Qualtrics survey tools. In the first study, 17 constructs were posed to assess perceived facilitators and barriers to practice transformation from traditional medical models of care to patient-centered care. The survey population consisted of 335 primary care practitioners in six coastal counties. The final sample size was 288 practicing physicians with valid email addresses. The surveys were distributed through Qualtrics using the email addresses of the 288 practicing physicians. In the care transformation study, responses were recorded in a five point Likert scale. The constructs of the survey were based on domains of community health needs assessments previously conducted and best practice constructs for patient centered care.9,10 Questions were developed by the Principal Investigator with input from the Mississippi State Department of Health and the University of Mississippi Medical Center (Table 1). The second survey used an online survey to ask 181 UMMC physicians in the departments of Family Medicine, Internal Medicine, Pediatrics and Obstetrics and Gynecology to rate their own competency in population health. The assessment questions were competencies selected by the investigators from population health-related criteria established by the American College of Graduate Medical Education (ACGME) for residency training programs in Family Medicine and in Public Health and General Preventive Medicine (Table 2). The competencies were chosen based on their relevance to population health. It is noted that ACGME milestones are specialty-specific, and not all specialties incorporate specific population health milestones. Both assessments collected demographic information and practice specialty area. Responses were anonymous, and data were reported in aggregate. The population health assessment included definitions of each of the score options to provide physicians with a description of how to evaluate each of the nine levels. Each physician had the option of selecting competency levels ranging from Level 1 (scored at 1.0) to Level 5, (scored at 5.0) with each level score increasing in increments Table 1. Study 1: Primary Care Transformation Study Measures of 0.5. Based on the guidelines from the ACGME, Level 4 is designed

as the graduation target for the resident but does not represent a graduation requirement while Level 5 might describe someone who has the skills of a physician who has been in practice several years.8 The competencies selected by the investigators represent only a fraction of the total competencies used to evaluate the overall skills of the resident physician. Descriptions of competencies can be found at: http://www.acgme.org/Portals/0/PDFs/Milestones/ FamilyMedicineMilestones.pdf and http://www.acgme.org/Portals/0/PDFs/Milestones/ PreventiveMedicineMilestones-PublicHealthandGeneralPreven tiveMedicine.pdf. Measures for each study are in boxes below. Results from the Care Transformation Study Of the 34 primary care physicians that responded to the care transformation survey, 12 were family medicine, 9 were pediatricians, 8 were internal medicine, 3 were general practice and 2 were obstetrician/ gynecologists. Four of the 34 had subspecialty training, not otherwise identified, and were included in the results. Five respondents identified themselves as belonging to a practice that is recognized at any level of a patient-centered medical home (PCMH), with an additional one stating that the practice was in the process of applying. Eighteen respondents identified as not recognized and 10 did not know if their clinic was recognized as participating in any level of PCMH. Three respondents identified as actively participating in an Accountable Care Organization (ACO), four stated the practice was preparing to be in an ACO, and 17 either were not participating or did not know if they were participating. Figure 1 represents the Likert scale construct designed to answer the question â&#x20AC;&#x153;What is important to my current practice strategy?â&#x20AC;? The investigation was to discover perceptions regarding care transformation that will influence facilitators and barriers to implementation of care transformation. Frequency data was analyzed to determine the extent to which the PCPs identify facilitators and barriers.

Perceptions regarding population-based strategies that effect health outcomes influence facilitators and barriers to implementation of care transformation. Table 1. Study 1: Primary Care Transformation Study Measures Population Based Strategies of Care Frequency data regarding the opinions of Patient Care Transformation physiciansâ&#x20AC;&#x2122; roles in providing care that effects Team Based Approaches to Care population health outcomes were gathered. The Health information TableUtilization 2. Study 2:ofPhysician CompetencyTechnology Measures most agreed upon population-based indicator showed that physicians perceive that their Table 2. Study 2: Physician Competency Measures individual treatment of patients impacts overall Competencies Clinical Prevention Services (CPS): analyze evidence regarding the performance population health. Additionally, physicians state of proposed clinical preventive services for individuals and populations Partner with the patient, family, and community to improve health through disease that they are knowledgeable about public health prevention and health promotion concepts. Physicians in this investigation also Incorporate considerations of cost awareness and risk-benefit analysis in patients indicate that there are not enough healthcare and/or population-based care, as appropriate services to adequately serve the population Evaluating Health Services: evaluate population-based health services Behavioral Health or that healthcare is not affordable. Stratified Descriptive epidemiology: able to characterize the health of a community analysis by the top three responding specialties Community Health: monitor, diagnose, and investigate community health showed no difference in perceptions across the problems constructs regarding physician needs. The top Policies and Plans: develop policies and plans to support individual and community health efforts populations constructs identified related to current practice Advocates for individual and community health

JOURNAL MSMA

259

Figure 1. What is important to my current practice strategy? FIGURE 1. What is important to my current practice strategy? ■

Strongly Disagree

■

Disagree

The outcomes of my patients effect overall population health

I am knowledgeable on the

concept of public health based care

for services not provided in my clinic, I have places in the

community to refer my patients

The general population in my community cares about health and wellness

The quality of healthcare se.-vices in the community

adequately addresses the needs of the whole population There are enough healthcare

services to provide adequately for the health needs of the population

Most people can afford the health services they need

People in my community have

the access to the health services they need There are adequate wellness programs (physical activity,

healthy eating, active living, etc.) available and accessible in my

□

Neither Agree nor Disagree

■ Ag r ee

I■

□

Strongly Agree

111111111

I I I • I ■ • • I ■ ■ • • • • • I

111111111 I

111111111

■

111111111

•

community > - - - - - ~ - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - ~ 0 0/o

30%

Figure 2. What do physicians need?

40 (1/o

50%

60%

70'%,

. ,.

80%

11'

FIGURE 2. What do physicians need?

Education about pay for performance Help with electronic medical records Education about the .Affordable Care

Act (ACA) Assistance with community assessment More providers Assistance with making my office more efficient (workflow redesign) Assistance with billing codes Information on new and/or different models of care Education on reimbursement 0%

260 VOL. 58 • NO. 10/11/12 • 2017

10%

20%

30%

40%

50%

60%

strategies show that physicians are most concerned with accessible services for their patients, to have no problems with reimbursement (no rejections), to have enough staff, and to have patients manage their diseases better. This indicates that barriers to current practice strategies include access to care, reimbursement/affordability, workforce issues, and patient involvement. Figure 2 shows that half of the physicians need education on reimbursement and that the other two top needs are knowledge of new or different models of care and assistance with workflow redesign and office efficiency. This indicates that knowledge about reimbursement, models of care, and workflow redesign are barriers to clinic transformation.

7: Community health: monitor, diagnose, and investigate community health problems, with a mean score of 2.64. This competency also had the lowest number of respondents rating at a Level 4 and above. This resulted in only 19% of the respondents rating at Level 4 and above, creating the largest gap in knowledge for any competency. Table 4 Aggregate Rating for All Competencies Level 4 and Above Table 4. Aggregate Rating for All Competencies Level 4 and Above Prevention Services

3.11

Level 4 or Above Number % 12 32

Partner with Patient

3.41

Competency

Mean Rank

Gap % 68

Cost Considerations

3.61

Results from the Population Health Competency Study

Population Services

2.93

A total of 181 surveys were distributed to UMMC faculty and 51 were returned for analysis. Thirty-seven (37) assessments were returned complete, generating a 20.4% return rate. The return rates for each of the individual departments were: FM 63.2% (12/19), Pediatrics 26.7% (4/15), IM 14.4% (18/125) and OB/Gyn 13.6% (3/22). Incomplete assessments were excluded from the analysis.

Behavioral Health

3.11

Descriptive Epidemiology

2.82

Community Health Issues

2.64

Develop Policies

3.09

Advocate for Patient

3.07

The overall aggregate score for all respondents to all of the competencies was 3.1 (slightly higher than midpoint, but below the Level 4 target established by the ACGME for residency training). The IM aggregate score was 3.0; FM 3.0; Pediatrics 3.3 and OB/Gyn 3.1 (see Table 3). The number of physicians responding to the survey by department is outlined in Table 3 in parentheses. Table 3. Score by Department (All Competencies) Table 3. Aggregate Aggregate Score by Department (All Competencies) Aggregate Score by Department (All Competencies) Score Internal Med Family Med N= (18) (12)

Pediatrics (4)

OB/Gyn (3)

3.3

3.1

Note: Number and percent are faculty responding to Level 4, Level 4.5, and Level 5 Mean was calculated using all 37 respondents.

Figure 3 identifies the specific gaps in proficiency by each of the competencies. Competency 7: Community health: monitor, diagnose, and investigate community health problems has the largest gap while Competency 3: Incorporate considerations of cost awareness and riskbenefit in patients and/or population-based care, as appropriate, had the smallest gap of all competencies. Discussion

Low response rates in survey methodology can introduce nonresponse bias. Physicians, in particular, are known to produce low response rates for surveys, with an average response rate of about twenty percent. The Aggregate data for each of the competencies are illustrated in Table 4. most often cited reasons for nonresponse are lack of time and lack of There were no mean scores of 4.0 or above for any single competency. perceived importance of the survey.11 Indeed, the response rate for Competency 3: Incorporate considerations of cost awareness and risk- both studies proved to be a challenge, as the final response rate for Figure 3 inSelf-reported assessment population competencies (Percent Responses) the care transformation study was 11.81% and response rate for the benefit patients and/orphysician population-based care, asof appropriate, hadhealth the highest mean score of 3.61. The lowest mean score was Competency population health study was 20.40%. Aggregate

3.0

FIGURE 3. Self-reported physician assessment of population health competencies (Percent Responses) 100 90 80 70 60 50 40 30 20

10 0

Comp 1

Comp 2

Comp 3

Comp 4 â&#x2013;

Level 3.5 and <

Comp 5

Comp 6

Comp 7

Comp 8

Comp 9

â&#x2013; Level 4.0 and >

JOURNAL MSMA

261

The nature of healthcare is changing due to the need for increased focus on chronic disease prevention and management as well as continued escalation of health care costs. Both governmental and private payers are promoting a greater focus on prevention and management of the health of populations. Physicians and other health care providers are increasingly being held accountable for the health outcomes of their patient populations rather than being compensated solely for the provision of clinical services. In recognition of this new model of care, the University of Mississippi Medical Center’s (UMMC) Family Medicine Department took steps to meet the national standards for patient-centered care. In 2015, the National Committee for Quality Assurance (NCQA) recognized two of the Family Medicine clinics as Patient Centered Medical Homes. By receiving this recognition, the practices demonstrated systems to better deliver proactive, continuous and comprehensive care of both health and disease, using a approach. UMMC has also taken steps to strengthen the organization’s position in population and preventive medicine research and education. In 2015, the Department of Preventive Medicine was reestablished and a Chairman was appointed.12 Additionally, in 2016, the Bower School of Population Health was approved by the Mississippi Institutions of Higher Learning, the governing body responsible for policy and financial oversight of the eight public institutions of team-based higher learning in Mississippi.13 Opened in 2017, it is only the third school of its kind in the country.14 The Bower School of Population Health will educate and train leaders prepared to transform health-care delivery and the health of Mississippians through the development of an innovative academic infrastructure uniquely designed to educate future population health scientists and clinical professionals to conduct pioneering populationbased research and provide high quality, value-driven patient-centered care delivered in an increasingly complex healthcare delivery system.15 With the creation of the new Bower School of Population Health and the reestablishment of the Department of Preventive Medicine, UMMC has put in place an opportunity for all medical students, residents and faculty to be on the cutting edge of healthcare reform. The new school will be able to teach and train new leaders who will be prepared to transform healthcare delivery and improve the health of Mississippians throughout the state.3 According to Dr. Bettina Beach, Associate Vice Chancellor of Population Health at UMMC, the University is in the process of taking a lead role in the nation to proactively prepare for the future of healthcare.3 Effectively managing patient populations requires a range of individual, practice, and system capabilities that has not been part of traditional clinical training. These include the ability to identify at-risk patient populations, to work in teams to proactively manage health risk factors and medical conditions, to collect and interpret data about individual and population risks and to assess the effectiveness of interventions, to engage patients in new methods of communication such as telemedicine and home monitoring beyond traditional office visits, and to work with partners outside the traditional health care setting to address a full range of determinants of health. It also includes the ability to be compensated for the work that is necessary to carry out

262 VOL. 58 • NO. 10/11/12 • 2017

these tasks. In the care transformation survey, 2 of the top 3 expressed needs (including the most frequently cited need) relate to reimbursement. The other is related to practice design. Clearly, physicians are concerned that their practices remain solvent in the face of the current and future challenging healthcare environment. These concerns are consistent with the national conversations at the specialty society level such as the American Academy of Family Physicians and the Family Medicine for America’s Health campaign, a collaboration between the eight leading family medicine organizations in the United States to drive continued improvement of the U.S. health care system and demonstrate the value of true primary care.16,17 In the assessment of academic primary care physicians concerning population health competencies, it is notable that the 3 areas in which respondents ranked themselves the lowest are all related to factors that are less emphasized in traditional patient care: population services, descriptive epidemiology and community health issues. Additionally, these data are not easily collected in the electronic medical record, thus making it difficult to track the utilization and effectiveness of these services. In the current healthcare volume-based model, physician practices do not have the resources to adequately deliver these services. The physicians and health systems will need to identify how to reallocate resources to address these needs, while making it budget neutral. Skills in all of these areas are needed to effectively manage the health of populations. Traditionally, physicians with these skills have often obtained them by pursuing further training outside of medical school and residency, such as a master of public health. Though such additional training can be highly valuable, for the healthcare of the future we believe that all physicians should have a fundamental understanding of these topics. It is incumbent on medical schools and residency training programs to ensure that this is the case for future graduates. Continuing medical education programs and other means of educating practicing physicians on population health concepts are also needed if we are to successfully navigate the changing landscape of healthcare. There are a number of limitations of this research that need to be acknowledged. First, the samples of the two studies are quite different: one focuses on primary care physicians in community practices in six Mississippi Gulf Coast counties while the other includes primary care and subspecialty physicians in a large academic medical center. Neither sample is likely to be representative of physicians across the state. A second limitation is that response rates were low for each survey. This raises additional questions about generalizability. Finally, each study asked only for the respondents’ opinions about their practices and practice needs and about their perceived level of competence for each population health skill. We did not conduct an objective assessment of practice needs or of physician competence. It is possible that respondents’ assessments are not entirely reflective of reality. Despite these limitations, we believe the results of these surveys provide important guidance for improving the capacity of physicians in Mississippi to better manage the health of their patient populations and thereby improve the health of the population as a whole. Additional

research is needed to identify the best approach(es) for ensuring that physicians have the necessary skills to effectively manage population health. n References 1. Walker T. Population health: Evolving under ACA. Managed Healthcare Executive. May 1, 2014. Retrieved from: http://managedhealthcareexecutive. modernmedicine.com/managed-healthcare-executive/content/tags/aca/ population-health-evolving-under-aca?page=full. Accessed February 28, 2017. 2. The Commonwealth Fund. The affordable care act’s payment and delivery system reforms: a progress report at five years. The Commonwealth FundIssue Briefs. Retrieved from: http://www.commonwealthfund.org/ publications/issue-briefs/2015/may/aca-payment-and-delivery-systemreforms-at-5-years. Accessed February 28, 2017. 3. Page L. 8 ways that the ACA is affecting doctors’ income. NEJM Career Center. Retrieved from: http://www.nejmcareercenter.org/minisites/rpt/8-waysthat-the-aca-is-affecting-doctors-incomes/. Accessed February 10, 2017. 4. Blumenthal D., Abrams M., Nuzum R. The affordable care act at 5 years. N Engl J Med. 2015; 372:2451-2458. 5. Gauthier J. Populations, population health, and the evolution of population management: making sense of the terminology in US health care today. IHI Leadership Blog. Retrieved from: http://www.ihi.org/communities/blogs/_ layouts/ihi/community/blog/itemview.aspx?List=81ca4a47-4ccd-4e9e89d9-14d88ec59e8d&ID=50. Accessed February 28, 2017. 6. Livingston S. Leaders prep for a post-ACA reality. 2016;46(50)11.

Mod Healthc.

7. Flanigan TS, McFarlane E, Cook S. Conducting survey research among physicians and other medical professionals: A review of current literature. Proceedings of the Survey Research Methods Section, American Statistical Association (4136-47). 8. Accreditation Council for Graduate Medical Education. Preventive medicine milestone project. July 2015. Retrieved from: http://www.acgme.org/ Portals/0/PDFs/Milestones/PreventiveMedicineMilestones-PublicHealtha ndGeneralPreventiveMedicine.pdf. Accessed February 28, 2017. 9. Patient-Centered Primary Care Collaborative (PCPCC). Patient centered medical homes. Retrieved from: https://wwwpcpcc.org/about medical-home. Accessed February 28, 2017. 10. Rubenstein LV, Stockdale S, Sapir N, Altman L, Dresselhaus TR, Vivell S, Ovretveit J, Hamilton AB, Yano E. A patient-centered primary care practice approach using evidence-based quality improvement. J Gen Intern Med. 29(2):589-597. 11. Van Geest JB, Johnson TP, & Welch VL. Methodologies for improving response rates in surveys of physicians: A systematic review. Eval Health Prof. 2007;30(4):303-321. 12. University of Mississippi Medical Center. Mann of the hour revises department of preventive medicine. Retrieved from: https://www.umc.edu/news_and_ publications/press_release/2015-08-27-00_mann_of_the_hour_revives_ department_of_preventive_medicine.aspx. Accessed February 28, 2017. 13. Mississippi Public Universities. What is the Board of Trustees? Retrieved from: http://www.mississippi.edu/faq/. Accessed February 28, 2017. 14. Bascom, K. UMMC to create new school of population health. News Stories, April 21, 2016. Retrieved from: https://www.umc.edu/news_and_

publications/press_release/2016-04-21-03_ummc_announces_new_ school_of_population_health.aspx. Accessed February 28, 2017. 15. University of Mississippi Medical Center. John D. Bower School of Population Health. Retrieved from: https://www.umc.edu/SoPH/. Accessed February 28, 2017. 16. Health is Primary. Who we are. Retrieved from: http://healthisprimary.org/. Accessed February 28, 2017. 17. Phillips, RL. Health is primary: family medicine for America’s health. Annals of Family Medicine Supplement 1. 12(Supplement 1). Retrieved from: http://www.annfammed.org/content/12/Suppl_1/S1.full.pdf. Accessed February 28, 2017.

Author Information Doctor of Health Administration Graduate, University of Mississippi Medical Center; President, Mercy San Juan Medical Center, Carmichael, CA (Korpiel). Practice Transformation Specialist, Aledade ACO, Aledade, Inc. (Whitt). Former Assistant Professor, Doctor of Health Administration Program, University of Mississippi Medical Center (Jones). Professor and Chair Emeritus, Department of Family Medicine, University of Mississippi Medical Center (Beebe). Professor and Chair, Department of Preventive Medicine, School of Medicine and John D. Bower School of Population Health, University of Mississippi Medical Center (Mann). Conflicts of interest/ funding: none. Corresponding Author: Michael R. Korpiel, DHA; Mercy San Juan Medical Center, 6501 Coyle Ave, Carmichael, CA 95608 (mtkorpiel@ gmail.com).

Pen > Sword

xpress your opinion in the JMSMA through a letter to the editor or guest editorial. The Journal MSMA welcomes letters to the editor. Letters for publication should be less than 300 words. Guest editorials or comments may be longer, with an average of 600 words. All letters are subject to editing for length and clarity. If you are writing in response to a particular article, please mention the headline and issue date in your letter. Also include your contact information. While we do not publish street addresses, e-mail addresses, or telephone numbers, we do verify authorship, as well as clarify ambiguities, to protect our letterwriters. You can submit your letter via email to: KEvers@MSMAonline.com or mail it to the Journal office at MSMA headquarters: P.O. Box 2548, Ridgeland, MS 39158-2548.

JOURNAL MSMA

263

S C I E N T I F I C

Osteoporosis Knowledge, Perceptions, and Selfefficacy among Nursing Students in Mississippi RITA MORGAN, CFNP; VINAYAK K. NAHAR, MD, PHD, MS, FRSPH; AMANDA H. WILKERSON, PHD; M. ALLISON FORD, PHD; AMANDA HENDRICKS, MS; GURNEET BAWA, MS; MARTHA A. BASS, PHD; MANOJ SHARMA, PHD Abstract Background: Osteoporosis is a disease characterized by excessive bone deterioration resulting in fractures. Nurses are at the center of health education for many communities particularly in clinical settings. The purpose of this study was to examine nursing students’ knowledge, perceptions, and self-efficacy related to osteoporosis to promote the development of osteoporosis prevention in relevant academic programs. Methods: This study used a cross-sectional research design. Deans and directors of twenty-two nursing schools in Mississippi were notified by phone or email and were sent a link to the online questionnaire, which was then routed to nursing students of participating programs. The questionnaire was a compilation of surveys consisting of: osteoporosis health belief scale (OHBS), osteoporosis knowledge test (OKT), and osteoporosis self-efficacy scales (OSES). The questionnaire was completed by 136 students enrolled in degree nursing programs in Mississippi. Results: A total of 136 nursing students participated in this study, which consisted of 91.9% females and 69.6% Caucasians. Results revealed a moderate level of osteoporosis knowledge, perceived benefits of calcium intake, health motivation, self-efficacy to engage in exercise and self-efficacy to calcium intake. Furthermore, the levels of perceived susceptibility and perceived severity were found to be low among participants. Conclusion: Health education and health promotion practitioners should develop, implement, and evaluate osteoporosis education programs targeting nursing students and the findings generated from this study could be used toward these efforts. Implications of this study are particularly important for nursing education, which helps shape practices of nursing students and, consequently, future nurses. Key Words: Osteoporosis, beliefs, nurses, students, Mississippi Introduction In 2008, the National Osteoporosis Foundation (NOF) estimated that low bone mass (osteopenia) or osteoporosis occurs in approximately 44 million Americans.1 Characterized by the deterioration of the bone’s internal mass, osteoporosis affects a substantial proportion of people worldwide. The decrease in bone mass results in the individual having an increased susceptibility for fractures.2 Research shows that among individuals over the age of 50 years, approximately one in every two women and one in every four men will experience a broken bone due to osteoporosis.3 The cost of care each year for osteoporotic-related 264 VOL. 58 • NO. 10/11/12 • 2017

bone fractures reaches 19 billion dollars.3 This expense is expected to be nearly 25 billion dollars by the year 2025.3 Nurses are at the center of health education for many communities, particularly in the clinical settings. In the United States, nursing is the largest healthcare profession, with more than 3.1 million registered nurses.4 Nurses are the primary providers of hospital patient care and deliver most of the long-term care.4 Few studies have been completed with nurses and particularly nursing students to assess the level of knowledge, attitudes, and practices they have regarding osteoporosis. It is in this context that the purpose of this study was to assess future nurses’ knowledge and perceptions of osteoporosis, which will potentially translate to the future of osteoporosis healthcare. Additionally, this study examined nursing students’ self-efficacy (i.e., the level of confidence that an individual has in his/her ability to engage in a particular behavior)5 to engage in primary measures for the prevention of osteoporosis (i.e., physical activity and calcium intake). Nurses are an increasing part of the outpatient health care team. Since physicians delegate much of patient education to their nurse colleagues, we were interested in developing a means of assessing preparedness of nurses for counseling patients with osteoporosis. The methodology we developed and report here may be useful in accessing what level of CME should be provided to nurses who are asked to do patient counseling in the outpatient environment. Moreover, findings generated from this study have the potential to be used to develop, implement and evaluate osteoporosis prevention intervention programs targeting nursing students. Additionally, the results of this study will be beneficial to understand and prepare the education of nursing students to best care for and prevent osteoporosis in their future patients. Methods A cross-sectional research design was used for this study. Permission to email all Directors of Nursing Programs was received by the Mississippi Institutions of Higher Learning (IHL) Director of Nursing Education, the Board of Nursing, as well as Deans and Directors of Nursing. Contact information of deans and/or directors of twenty-two nursing schools in Mississippi was provided by the director of IHL Ethics approval for this study was provided by the University’s Institutional Review Board (Protocol #15x-205) prior to data collection. In March 2015, the link to an online questionnaire was emailed to deans and directors of nursing schools throughout Mississippi. Students enrolled in each nursing school received the link from the dean or director and were given the option to participate or not participate

in this study. Informed written consent was obtained online from all individuals who participated in this study. All prospective participants were required to be at least 18 years of age. Participation by students was completely voluntary, and students could simply follow the link to the survey. The survey was completed by 136 participants from March thru May of 2015. No personal identifiers were collected, and data were analyzed as a whole. Data were collected over a period of three weeks with students receiving reminder emails in the second and third weeks. Students were given the option to answer or not answer the questions. Instrumentation Demographic information collected were gender, ethnicity, degree program, family history of osteoporosis and hip fracture, cigarette smoking and alcohol consumption habits. This study used the following questionnaires: osteoporosis knowledge test (OKT),6 osteoporosis health belief scale (OHBS)7 and osteoporosis selfefficacy scales (OSES).8,9 The OHBS contains 42 questions with seven subscales measuring perceived susceptibility (6 items; Cronbach’s alpha = 0.92), perceived severity (6 items; Cronbach’s alpha = 0.84), perceived exercise benefits (6 items; Cronbach’s alpha = 0.97), perceived exercise barriers (6 items; Cronbach’s alpha = 0.86), perceived calcium intake benefits (6 items; Cronbach’s alpha = 0.91), perceived calcium intake barriers (6 items; Cronbach’s alpha = 0.89), and health motivation (6 items; Cronbach’s alpha = 0.89). A Likert type scale was used to rate each item (1 = strongly disagree, 5 = strongly agree). For each subscale, the total score was achieved by summing item scores. A higher score indicated a higher level of the subscale. The OKT contains 24 questions measuring knowledge of general risk factors, exercise and calcium intake involved in osteoporosis, where 1 = true and 0 = false (Kuder-Richardson 20 = 0.52). Responses were summed to obtain a total knowledge score. A higher score indicates a higher level of osteoporosis-related knowledge. The OSES was comprised of two subscales. These subscales include OSESs for both exercise (6 items; Cronbach’s alpha = 0.98) and calcium intake (6 items; Cronbach’s alpha = 0.98). A Likert type scale was utilized to rate each item (1 = strongly disagree, 5 = strongly agree). For each subscale, total score was obtained by adding item scores. Higher score represents higher level of the subscale.

91.9% of the respondents, and 69.6% were white. Approximately 22% of the participants indicated family history of osteoporosis, and 18.1% had family history of hip fracture. Sixteen participants were identified as smokers and 19 participants reported consuming at least one Table 1. Demographic characteristics of the study participants

Table 1. Demographic characteristics of the study participants Variables

n (%)

Gender Male Female Other

9 (6.6%) 125 (91.9%) 2 (1.5%)

Race/Ethnicity White Black or African American Hispanic or Latino Asian/Pacific Islander American Indian, Alaskan Native, Native Hawaiian Bi-Racial or Multi-Racial Other

94 (69.6%) 31 (23%) 5 (3.7%) 1 (0.7%) 1 (0.7%) 2 (1.5%) 1 (0.7%)

Degree Program Two-year Associate Degree in Nursing Diploma in Nursing Master of Science in Nursing Doctorate in Nursing Practice Bachelor of Science in Nursing

57 (42.5%) 4 (3.0%) 4 (3.0%) 4 (3.0%) 65 (48.5%)

Program year 1st year 2nd year 3rd year 4th year 5th or more year

49 (37.1%) 45 (34.1%) 13 (9.8%) 23 (17.4%) 2 (1.5%)

Family history of osteoporosis

25 (21.6%)

Family history of hip fracture

21 (18.1%)

Smoking cigarettes

16 (13.9%)

Alcohol consumption in a sitting 0 1 2 3 4+

59 (51.8%) 19 (16.7%) 22 (19.3%) 8 (7.0%) 6 (5.3%)

Table 2. Knowledge of risk factors of osteoporosis

Table 2. Knowledge of risk factors of osteoporosis Statements

Correct response n (%)

Exercising on a regular basis

5 (3.8%)

Statistical Analyses

Eating a diet high in dark leafy vegetables

17 (13.1%)

Descriptive statistical analyses summarizing means and standard deviations of metric variables and frequencies and percentages of categorical variables were conducted to describe the data. A one-way ANOVA was performed to assess whether differences existed in OKT, OHBS and OSES scores across years of nursing education. A p-value of less than 0.05 was considered statistically significant. All data analyses were performed using SPSS Statistics for Windows software, Version 23.10

Having big bones

50 (38.5%)

Having ovaries surgically removed

83 (63.8%)

Being a white woman with fair skin

98 (75.4%)

Eating a diet low in milk products

112 (86.2%)

Having a mother or grandmother who has osteoporosis

111 (85.4%)

Taking cortisone (steroids, e.g., Prednisone) for long time

115 (88.5%)

Being menopausal; "change of life"

123 (94.6%)

Results A total of 136 nursing students participated in this study. Characteristics of study participants are presented in Table 1. Females comprised

alcoholic beverage in a sitting. With regard to osteoporosis knowledge, approximately two-thirds of the participants (61.5%) did not know that a person having big bones JOURNAL MSMA

265

Table 3. Frequency and percentages of osteoporosis related perceptions and self-efficacy Statements

Disagree n (%)

Neutral n (%)

Agree n (%)

Perceived Susceptibility Your chances of getting osteoporosis are high Because of your body build, you are more likely to develop osteoporosis It is extremely likely that you will get osteoporosis There is a good chance that you will get osteoporosis You are more likely than the average person to get osteoporosis Your family history makes it more likely that you get osteoporosis

58 (45.7%) 75 (59.1%) 78 (53.8%) 64 (50.4%) 83 (65.4%) 85 (66.9%)

28 (22%) 20 (15.7%) 28 (21.9%) 27 (21.3%) 25 (19.7%) 17 (13.4%)

41 (32.3%) 32 (25.2%) 22 (17.2%) 36 (28.3%) 19 (15%) 25 (19.7%)

Perceived Severity The thought of having osteoporosis scares you If you had osteoporosis you would be crippled Your feelings about yourself would change if you got osteoporosis It would be very costly if you got osteoporosis When you think about osteoporosis you get depressed It would be very serious if you got osteoporosis

47 (37%) 100 (78.7%) 68 (53.5%) 46 (36.2%) 89 (70.1%) 50 (39.4%)

24 (18.9%) 17 (13.4%) 30 (23.6%) 36 (28.3%) 29 (22.8%) 28 (22%)

56 (44.1%) 10 (7.9%) 29 (22.8%) 45 (35.4%) 9 (7.1%) 49 (38.6%)

Perceived Benefits of Exercise Regular exercise prevents problems that would happen from osteoporosis You feel better when you exercise to prevent osteoporosis Regular exercise helps to build strong bones Exercising to prevent osteoporosis also improves the way your body looks Regular exercise cuts down the chances of broken bones You feel good about yourself when you exercise to prevent osteoporosis

14 (11%) 14 (11%) 15 (11.8%) 13 (10.2%) 17 (13.4%) 13 (10.2%)

9 (7.1%) 14 (11%) 4 (3.1%) 10 (7.9%) 11 (8.7%) 9 (7.1%)

104 (81.9%) 99 (78%) 108 (85%) 104 (81.9%) 99 (78%) 105 (82.7%)

Perceived Barriers to Exercise You feel like you are not strong enough to exercise regularly You have no place where you can exercise Your spouse or family discourages you from exercising Exercising regularly would mean starting a new habit which is hard for you to do Exercising regularly makes you uncomfortable Exercising regularly upsets your everyday routine

95 (80.5%) 101 (85.6%) 112 (94.9%) 61 (51.7%) 98 (83.1%) 79 (66.9%)

9 (7.6%) 10 (8.5%) 4 (3.4%) 16 (13.6%) 11 (9.3%) 14 (11.9%)

14 (11.9%) 7 (5.9%) 2 (1.7%) 41 (34.7%) 9 (7.6%) 25 (21.2%)

Perceived Benefits of Calcium Intake Taking in enough calcium prevents problems from osteoporosis You have lots to gain from taking in enough calcium to prevent osteoporosis Taking in enough calcium prevents painful osteoporosis You would not worry as much about osteoporosis if you took in enough calcium Taking in enough calcium cuts down on your chances of broken bones Feel good enough when taking enough calcium to prevent osteoporosis

20 (16.1%) 9 (7.3%) 32 (25.8%) 35 (28.2%) 11 (8.9%) 10 (8.1%)

24 (19.4%) 11 (8.9%) 35 (28.2%) 38 (30.6%) 15 (12.1%) 29 (23.4%)

80 (64.5%) 104 (83.9%) 57 (46%) 51 (41.1%) 98 (79%) 85 (68.5%)

Perceived Barriers to Calcium Intake Calcium-rich foods cost too much Calcium-rich foods do not agree with you You do not like calcium-rich foods Eating calcium-rich foods means changing your diet which is hard to do In order to eat more calcium-rich foods you have to give up other foods that you like Calcium-rich foods have too much cholesterol

97 (82.2%) 98 (83.1%) 104 (88.1%) 98 (83.1%) 98 (67.6%) 92 (78%)

11 (9.3%) 9 (7.6%) 7 (5.9%) 9 (7.6%) 12 (10.2%) 22 (18.6%)

10 (8.5%) 11 (9.3%) 7 (5.9%) 11 (9.3%) 8 (6.8%) 4 (3.4%)

Perceived Health Motivation You eat a well-balanced diet You look for new information related to health Keeping healthy is very important for you You try to discover health problems early You have a regular health check-up even when you are not sick You follow the daily recommendations to keep you healthy

39 (33.1%) 23 (19.5%) 11 (9.3%) 17 (14.4%) 40 (33.9%) 36 (30.5%)

30 (25.4%) 23 (19.5%) 16 (13.6%) 14 (11.9%) 13 (11%) 40 (33.9%)

49 (41.5%) 72 (61%) 91 (77.1%) 87 (73.7%) 65 (55.1%) 42 (35.6%)

Self-efficacy to Exercise Begin a new or different exercise program Change my exercise habits Put forth effort required to exercise Do exercises even if they are difficult Exercise for the appropriate length of time Do the type of exercises that I am supposed to do

21 (18.1%) 18 (15.5%) 18 (15.5%) 19 (16.4%) 18 (15.5%) 18 (15.5%)

15 (12.9%) 14 (12.1%) 13 (11.2%) 18 (15.5%) 20 (17.2% 15 (12.9%)

80 (69%) 84 (72.4%) 85 (73.3%) 79 (68.1%) 78 (67.2%) 83 (71.6%)

Self-efficacy to Calcium Intake Increase my calcium intake Change my diet to include more calcium-rich foods Eat more calcium-rich foods as often as I am supposed to do Select appropriate foods to increase my calcium intake Stick to a diet which gives an adequate amount of calcium Obtain foods with adequate calcium even when they are not readily available

12 (10.3%) 11 (9.5%) 14 (12.1%) 12 (10.3%) 17 (14.7%) 19 (16.4%)

11 (9.5%) 13 (11.2%) 16 (13.8%) 11 (9.5%) 16 (13.8%) 20 (17.2%)

93 (80.2%) 92 (79.3%) 86 (74.1%) 93 (80.2%) 83 (71.6%) 77 (66.4%)

266 VOL. 58 â&#x20AC;˘ NO. 10/11/12 â&#x20AC;˘ 2017

is less likely to get osteoporosis. Additionally, slightly over one-third of the participants (36.2%) did not know that having ovaries surgically removed can increase the risk of developing osteoporosis. However, more than 75% of the participants correctly identified that being a white woman with fair skin, eating a diet low in milk products, having a family history of osteoporosis, taking cortisone and being menopausal can increase a person’s chances of acquiring osteoporosis. Table Table 4. Descriptive statistics of study variables Table 4. Descriptive statistics of study variables Variables

Possible Range

Observed Range

Mean (SD)

Knowledge

0 - 24

6 - 21

15.99 (2.87)

Perceived Susceptibility

6 - 30

15.01 (5.62)

Perceived Severity

6 - 30

6 - 28

15.70 (4.90)

Perceived Benefits of Exercise

6 - 30

24.00 (6.58)

Perceived Barriers to Exercise

6 - 30

12.04 (4.64)

Perceived Benefits of Calcium Intake

6 - 30

21.33 (5.08)

Perceived Barriers to Calcium Intake

6 - 30

11.49 (4.27)

Perceived Health Motivation

6 - 30

20.57 (5.43)

Self-efficacy to Exercise

6 - 30

21.85 (6.33)

Self-efficacy to Calcium Intake

6 - 30

22.35 (6.04)

2 illustrates participants’ knowledge concerning osteoporosis risk factors. Table 3 presents frequency and percentages of responses to osteoporosis-related perceptions and self-efficacy questions. Table 4 presents the descriptive statistics of the primary study variables. Two-thirds (66.9%) of the participants disagreed that family history makes it more likely to acquire osteoporosis. Nearly 40% of the participants did not perceive osteoporosis as a serious condition. However, 80% of the participants believed that exercise is beneficial for preventing osteoporosis. Participants also indicated a moderate level of osteoporosis knowledge (15.99 ± 2.87 units on a scale of 0-24), perceived benefits of calcium intake (21.33 ± 5.08 units on a scale of 6-30), health motivation (20.57 ± 5.43 units on a scale of 6-30), self-efficacy to calcium intake15(22.35 ± 6.04 units on a scale of 6-30) and self-efficacy to engage in exercise (21.85 ± 6.33 units on a scale of 6-30). The level of perceived susceptibility (15.01 ± 5.62 units on a scale of 6-30), severity (15.70 ± 4.90 units on a scale of 6-30), barriers to exercise (12.04 ± 4.64 units on a scale of 6-30) and barriers to calcium intake (11.49 ± 4.27 units on a scale of 6-30) were low among participants. Moreover, there were no statistically significant differences in OKT, OHBS, and OSES scores across years of nursing education. Discussion Epidemiological findings indicate that a substantial proportion of people worldwide are affected by osteoporosis; yet, contributing influences are often controllable through lifestyle modifications.11 In the current study, osteoporosis-related knowledge, health beliefs, self-efficacy and lifestyle factors were explored. Investigating nursing students’ knowledge, self-efficacy and health beliefs provides a

significant function in health care and health education programs. The most effective osteoporosis reduction strategies have been found through health education and health promotion.12 A recent study conducted to evaluate osteoporosis awareness and knowledge of nursing students resulted in the need for osteoporosis-related continuing education to provide the knowledge needed prior to clinical internship.13 Educational programs significantly increased the knowledge, health beliefs, and self-efficacy of nursing students (p < 0.001).10 However, due to saturation of curricular content, significant challenges exist among health professionals, practitioners and researchers in health education.14,15 Research has shown that nursing education has been inundated with content saturation for several years.14 Similarly, in narrowing curricular content, nurse educators struggle to determine which aspects of traditional nursing practice should be retained, which content should be alleviated and which current medical knowledge should be integrated.14 In the prevention, diagnosis and treatment of osteoporosis, a multidisciplinary approach is required. One of the first steps for raising awareness is to examine how much is known about osteoporosis by health care providers involved in prevention and treatment. Results of the current study indicated that participants have adverse attitudes with regard to low perceived seriousness and low susceptibility of osteoporosis. Similarly, results of previous studies indicated that participants believe osteoporosis is an inevitable component of aging and do not believe it is a serious disease which may cause death.16,17 Although knowledge is an essential element in promoting self-care, knowledge alone cannot result in the habit of behavior prevention or positive attitude.18 Considering participants of the current study were students enrolled in a Mississippi nursing education program, the low level of knowledge relating to family history and osteoporosis is of concern. An encouraging observation common among participants was that a majority knew exercise and calcium are beneficial toward osteoporosis prevention. The nursing students reported moderate levels of self-efficacy of exercise (21.85 units on a scale of 6-30) and calcium intake (22.35 units on a scale of 6-30). However, there is still room for improving these constructs through educational interventions. Self-efficacy can be built by breaking down the behavior into small steps, having a role model demonstrate the behavior, using persuasion and reinforcement and reducing stress.19 The constructs of perceived susceptibility (15.01 units on a scale of 6-30) and perceived severity (15.7 units on a scale of 6-30) were at the middle of the possible range signifying the need to build these constructs further through educational interventions. The health belief model provides definitive guidelines developing perceived susceptibility through elaborating negative consequences, and personalizing the risk.19 Likewise, perceived severity can be altered through mention of serious negative consequences and personalizing the seriousness of risks.19 The challenge remains in changing knowledge gained from health education into lifelong practices and adopting new health behaviors. Further research geared toward the follow-up of attained knowledge and behavioral change over time is needed. Implications of this study are particularly important for nursing education, which helps shape knowledge and practices of nursing students and, subsequently, future nurses. Before nursing students emerge into nursing roles and occupy

JOURNAL MSMA

267

responsible positions in the community, school health and within the healthcare system, theory-based education regarding the magnitude of osteoporosis should be emphasized.20 Limitations Although the findings from this study present important information regarding nursing students’ knowledge and attitudes related to osteoporosis, these findings must be considered within the context of several limitations. First, the sample consisted predominantly of white female students attending one of twenty-two nursing schools in Mississippi. Consequently, generalizability of findings to other nursing students in the United States is limited. Future studies should therefore explore osteoporosis knowledge and attitudes among more diverse samples of nursing students. Although the sample was predominantly female (91.9%), this is representative of the demographics among nurses currently licensed in the United States, where only 11% of nurses licensed from 2010 to 2013 were male.21 Additional limitations to the present study include the collection of self-reported information and the cross-sectional design of the study, which prevents determination of cause and effect. The study was furthermore exploratory and descriptive in nature, thus limiting interpretation of the study findings.22 Conversely, the exploratory nature of the study provided a springboard for future research to further explore the relationship between nursing students’ knowledge and attitudes concerning osteoporosis and patient care practices. Finally, this study did not attempt to measure the understanding of osteopenia vs. osteoporosis among nursing students. This should be investigated in future studies since the treatment and approaches are different between osteopenia and osteoporosis. Conclusions The findings from this study identified that among a sample of nursing students, participants indicated a moderate level of osteoporosis knowledge, perceived benefits of calcium intake, health motivation, self-efficacy to calcium intake and self-efficacy to engage into exercise. However, it is concerning that two-thirds of participants did not recognize the relationship between family history and osteoporosis and almost half of participants did not perceive the disease as serious. Health education and promotion practitioners should develop, implement, and evaluate osteoporosis education programs targeting nursing students, and the findings generated from this study could be used in these efforts. Moreover, the findings from this study are useful in the professional preparation of nursing students in order to provide the best care and prevention for osteoporosis in their future positions in the healthcare field. n References 1. Lewiecki E, Baim S, Siris E. Osteoporosis care at risk in the United States. Osteoporos Int. 2008;19(11):1505-1509. 2. Svedbom A, Hernlund E, Ivergård M, Compston J, Cooper C, Stenmark J, Kanis J. Osteoporosis in the European Union: a compendium of countryspecific reports. Arch Osteoporos. 2008;8(1-2):137. 3. National Osteoporosis Foundation website. What is Osteoporosis and

268 VOL. 58 • NO. 10/11/12 • 2017

What Causes It? https://www.nof.org/patients/what-is-osteoporosis/2018. Accessed December 7, 2017. 4. Chard, R. The personal and professional impact of the Future of Nursing Report. AORN. 2013;98(3):273-280. 5. Bandura, A. Self-Efficacy: The Exercise of Control. New York, NY: W.H. Freeman Publishers; 1997. 6. Gendler P, Coviak C, Martin J, Kim K, Dankers J, Barclay J, Sanchez T. Revision of the osteoporosis knowledge test: reliability and validity. West J Nurs Res. 2015;37(12):1623-1643. 7. Taggart H, Connor S. The relation of exercise habits to health beliefs and knowledge about osteoporosis. J Am Coll Health. 1995;44(3):127-130. 8. Kim K, Horan M, Gendler P, Patel M. Development and evaluation of the osteoporosis health belief scale. Res Nurs Health. 1991;14(2):155-163. 9. Horan M, Kim K, Gendler P, Froman R, Patel M. Development and evaluation of the osteoporosis self-efficacy scale. Res Nurs Health. 1998;21(5):395403. 10. Kirkpatrick L, Feeney B. A simple guide to IBM SPSS for Version 23.0, 14th Ed. 2015 IBM® SPSS. Boston, MA. 11. Bokhari S, Khan A. Growing burden of noncommunicable diseases: The contributory role of oral diseases. Eastern Mediterranean Region perspective. East Mediterr Health J. 2009;15(4):1011-1020. 12. Strope M, Nigh P, Carter M, Lin N, Jiang J, Hinton P. Physical activity-associated bone loading during adolescence and young adulthood is positively associated with adult bone mineral density in men. Am J Mens Health. 2015;9(6):442450. 13. Zhang Y, Li X, Wang D, Guo X, Guo X. Evaluation of educational program on osteoporosis awareness and prevention among nurse students in China. Nurs Health Sci. 2012;14(1):74-80. 14. Giddens J, Brady D. Rescuing nursing education from content saturation: the case for a concept-based curriculum. J Nurs Educ. 2007;46(2):65-69. 15. Mailloux C. Using “The essentials of baccalaureate education for professional nursing practice” (2008) as a framework for curriculum revision. J Prof Nurs. 2011;27(6):385-389. 16. Von Hurst P, Wham C. Attitudes and knowledge about osteoporosis risk prevention: a survey of New Zealand women. Public Health Nutr. 2007;10(7):747-753. 17. Reventlow S. Perceived risk of osteoporosis: restricted physical activities? Qualitative interview study with women in their sixties. Scand J Prim Health Care. 2007;25(3):160-165. 18. Khan Y, Sarriff A, Khan A, Mallhi T. Knowledge, attitude and practice (KAP) survey of osteoporosis among students of a tertiary institution in Malaysia. Trop J Pharm Res. 2013;13(1):155-162. 19. Sharma M. Theoretical foundations of health education and health promotion. 3rd ed. Burlington, MA: Jones and Bartlett; 2017. 20. Sayed-Hassan R, Bashour H, Koudsi A. Osteoporosis knowledge and attitudes: a cross-sectional study among female nursing school students in Damascus. Arch Osteoporos. 2013;8(1-2):149.

21. American Nurses Association. The nursing workforce 2014: growth, salaries, education, demographics & trends; 2014. 22. Powell J, Inglis N, Ronnie J, Large S. The characteristics and motivations of online health information seekers: cross-sectional survey and qualitative interview study. J Med Internet Res. 2011;13(1):1-11.

Author Information Department of Health, Exercise Science & Recreation Management, Bone Mineral Density Laboratory, School of Applied Sciences, University of Mississippi, Oxford (Morgan, Ford, Bass). Center for Animal and Human Health in Appalachia, College of Veterinary Medicine, DeBusk College of Osteopathic Medicine, and School of Mathematics and Sciences, Lincoln Memorial University, Harrogate, TN (Nahar). Department of Health and Exercise Science, College of Arts and Sciences, The University of Oklahoma, Norman, OK (Wilkerson). School of Mathematics and Sciences, Lincoln Memorial University, Harrogate, TN. (Hendricks, Bawa). Behavioral & Environmental Health, School of Public Health, Jackson State University, Jackson, MS; Health for all, Omaha, NE (Sharma). Conflicts of interest/ funding: none. Corresponding Author: Vinayak K. Nahar, MD, PhD, MS, FRSPH; Lincoln Memorial University, 6965 Cumberland Gap Parkway, Harrogate, TN 37752. Ph: (423) 869-7179 (naharvinayak@gmail. com).

@JournalMSMA Like us on Facebook

JOURNAL MSMA

269

S C I E N T I F I C

Understanding DRG 811/812 (Red Blood Cell Disorders) Readmissions by Payer, Age, Race and Sex PHILLIP HANKINS, BS; ELLEN JONES, PHD; ELGENAID HAMADAIN, PHD; JESSICA H. BAILEY, PHD Abstract Purpose: Hospital readmissions within thirty days are a costly burden on the healthcare system. This investigation examines readmissions for Diagnostic Related Group 811/812 (red blood cell disorders), primarily represented by sickle cell disease, at the University of Mississippi Medical Center (UMMC) for 2015 and 2016. Approach Used: The study was a retrospective analysis to compare readmissions at <= 7 days to readmissions >7 and <=30 days and 30 day readmission rates by payer, age group, race, and sex. Materials Studied: Admissions data from calendar years 2015 and 2016 was analyzed using QlikView business intelligence software and SPSS for statistical significance. Results Obtained: Statistical differences existed for readmissions due to DRG red blood cell disorders by payer, age, and between <= 7 day and >7 and <= 30 day readmissions. There was not a significant difference for readmission by sex or race. Conclusion: Diagnosis Related Group 811/812 (red blood cell disorders) readmissions remain high in Mississippi for readmissions >7 day and <=30 day. For these patients community level supports are of critical importance.

adjusting reimbursements based upon an organization’s readmission performance compared to the national average. The Hospital Readmission Reduction Program (HRRP) took effect in 2013 and established reimbursement penalties for hospitals with excessive readmissions for specific diagnoses. Although Diagnostic Related Group 811/812 (red blood cell disorders) is not included in the diagnoses that are subject to penalties, the health burden and cost to Mississippi hospitals and families is high. Sickle cell anemia is the most common condition found under the DRG red blood cell disorder and was the highest percent readmitted index diagnosis in 2010 with 87,326 index admissions that produced 27,837 (31.9%) readmissions (Table).4 Research Design

Table. All-cause 30-day Readmission Ranked byHighest Conditions with Table All-cause 30-day Readmission Ranked by Conditions with the Readmission Ratesthe in U.S. hospitals, 2010 Highest Readmission Rates in U.S. hospitals, 20104 4

30-day all-cause readmissions Rank

Principal diagnosis for index hospital stay

Sickle cell anemia

Gangrene

Introduction

Hepatitis

One of the major issues hospitals currently face is avoidable readmission rates. The causes of patient readmission vary. Research shows that a large number of readmissions are preventable.1 The fact that these readmissions are preventable means that there is room for improving overall health, enhancing the quality of healthcare provided, and reducing the cost of healthcare. An investigation into readmissions at the University of Mississipi Medical Center (UMMC) revealed that red blood cell disorders were the second leading index admission Diagnosis Related Group that was readmitted for calendar years 2015 and 2016.

Disease of white blood cells

Chronic renal failure

On a national level, one in 12 adults is readmitted within thirty days of discharge and one in five is readmitted within six months.2 These one in twelve readmissions add an estimated $16 billion additional costs to the already high cost of healthcare. The estimated cost for these readmissions is $26 billion per year. An estimated $17 billion of the total cost was for readmissions that could have been prevented.3 The additional cost associated with readmissions is a topic that the Centers for Medicare and Medicaid Services (CMS) has attempted to tackle by establishing readmission guidelines and

270 VOL. 58 • NO. 10/11/12 • 2017

Number of readmissions

Number of index stays

27,837

87,326

10,693

33,786

11,593

37,480

16,771

54,861

4,766

17,394

Percent readmitted

31.9 31.6 30.9 30.6 27.4

This study was a retrospective analysis of all readmission data from the University of Mississippi Medical Center (UMMC) hospital for calendar years 2015 and 2016. The data utilized for this research were extracted from EPIC, the electronic health record currently in use. The data represents index admission and readmission of patients age 19 and over. DRG 811/812 includes sickle cell disease and these two DRG are used as a proxy for sickle cell disease in this study.5 The analytics and visualizations were produced using QlikView (Qlik Technologies Inc. Radnor, PA), business intelligence analytics and visualization software. Graphs and analytical analysis can be produced inside the Glick application using expressions/formula. Expressions/ formula typically follow a pattern such as: SUM([LOS]) where [LOS] is a field with a number value; the values will be summed based upon the current data set or selections in the data set. Graphs and analytical analysis were produced that showed the basic difference in total number and percent of total values for readmissions by payer class, age, race, and sex. Data associations were made between tables using

index and readmission DRGs. Descriptive statistics and frequency distribution tables were generated for readmissions. The data were exported as an excel file and imported into SPSS for statistical tests of significance. The Kruskal Wallis one-way analysis of variance and the Mann Whitney Test were used to determine significance at the 5% level of significance (p = .050). The UMMC Institutional Review Board (UMMC IRB) approved the protocol for the investigation on 2/1/2017. Results Results of the data extraction produced 22,535 discharges for 2015 that resulted in a 14.67% readmission rate. In 2016, there were 24,144 admissions that resulted in a 14.65% readmission rate. The national rate for the same time period ranged from 8.7% (privately insured) to 17.2% (Medicare).6 The most common causes in absolute numbers by rank for the two-year period were chemotherapy, red blood cell disorders, other antepartum medical diagnoses with medical complications, heart failure, and septicemia/ severe sepsis.

Age Only patients 19 and older were included in the study. The Age Group 19 - 30 had the most red blood cell disorders index admissions (362) and the most readmissions (128). Age Group 31 – 40 had 318 red blood cell disorders index admissions and 122 readmissions. Age Group 41 – 50 had 115 red blood cell disorders index admissions and 30 readmissions. Ages 51 – 65 had 98 index admissions and 20 readmissions. Age Group >= 66 had 82 red blood cell disorders index admissions and 9 readmissions (Figure 2). The Kruskal Wallis oneway analysis of variance did show a significant difference between the age groups for red blood cell disorders readmission rate (P-value = 0.010). The Mann Whitney Test showed significant differences between >= 66 and 19 - 30 (P-value = 0.007) and >= 66 and 31 – 40 (P-value = 0.000). No other significant differences between age groups were detected using Mann Whitney Test. FIGURE 2. 30 Day Readmissions by Age Group for Index Admission DRGs for Red Blood Cell Disorders #

Payer Class Analysis by payer type revealed that at UMMC, Medicare/Medicare Advantage had the most red blood cell disorders index admissions (456) and the most readmissions (168). Medicaid had 350 red blood cell disorders index admissions and 116 readmissions. BCBS had 50 index admissions and 9 readmissions. Commercial had 20 red blood cell disorders index admissions and 4 readmissions. Other payer type had 21 red blood cell disorders index admissions and 6 readmissions. Self-pay group had 1 index admission with 0 readmissions. The unknown group had 77 index admissions and 6 readmissions (Figure 1). The Kruskal Wallis one-way analysis of variance did show a significant difference between the different payer groups for red blood cell disorders readmission prevalence (P-value = 0.025). The Mann Whitney Test showed significant differences between Medicaid and Unknown Payer (P-value = 0.000) and Medicare/Medicare Advantage and Unknown Payer (P-value = 0.002). No other significant differences between payers were detected using Mann Whitney Test.

of Discharges

30 Ddy Redclmis,;iu11s l,y Aye Group fur Index Admission DRGs for RED BLOOD CELL DISORDERS

I 4UU :Jti1

350

40%

38.36%

JODayReaamns Discharges % Readmit

···"35_

300

30%

250 200

20%

150 100

10%

50 0%

Race Black or African American race had the most red blood cell disorders index admissions (889) and the most readmissions (294). White or Caucasian had 80 red blood cell disorders index admissions and 15 readmissions. Other races had 5 index admissions and 0 readmissions.

FIGURE 1. 30 Day Readmissions by Payer for Index Admission DRGs for Red Blood Cell Disorders 30 Day Readmissions by Payer for Index Admission DRGs for RED BLOOD CELL DISORDERS

# of Discharges

I 500

40%

30 Day Readmits Discharges %Readmit

36.84'11l56

450

35%

400 30%

350 300

25%

250

20%

200

15%

150 10%

100 5%

50 0

Blue Cross & Blue Shield

Commercial

Medicare/Medicare Advantage Medicaid other

Self Pay

Unknown

JOURNAL MSMA

271

Hispanic had 1 admission and 0 readmissions (Figure 3). The Kruskal Wallis one-way analysis of variance did not show a significant difference between races for red blood cell disorders readmission rate (P-value = 0.379). FIGURE 3. 30 Day Readmissions by Race for Index Admission DRGs for Red Blood Cell Disorders

FIGURE 5. 7 Day to 30 Day Readmissions Compare for Index Admission DRGs for Red Blood Cell Disorders # of Discharges

7 Ddy lo 30 DciY Red<.lr11issio11s Compdr"e for Index Admission DRGs for RED BLOOD CELL DISORDERS ■ <= 1 Dav Reaamns • <= 7 Dav %Readmit

3511 1000 1--- - - - - ----J 30%

#of Discharges

30 Ody Redllmissioro, l,y Rd<:e foc Index Admission DRGs for RED BLOOD CELL DISORDERS

1000 1--- - - - - - - - - - - - - - - - - ----l 35% ,J.U M 9

Discharges

%Readmit

JODayReadmRs

800

25'11,

600

2011

■ >7 <=30 Dav Readmits >7 <= 30 nay o. Readmit ■ O::= 30 Day RJ!iadmit§ + <- 30 Day II Readmit ■ Di5charge5

15'1i

4UU

800

101\

200 93

20%

---- - ·- ·-

15%

400

or race. There were also statistical differences between <= 7 day and >7 and <= 30 day readmissions for index admission Diagnosis Related Group 811/812, approximately two thirds of 30 day readmission occurring >7 days after discharge (Figure 5).

10%

200 5 '11,

wnne or cauc...

Hispanic

Black or African American

O'lo

Other

Mann Whitney Test The female sex had 595 red blood cell disorders index admissions with 196 readmissions. The male sex had 380 red blood cell disorders index admission with 113 readmissions (Figure 4). The Mann Whitney Test did not support a significant difference between female and male in readmission prevalence (P-value = 0.685). FIGURE 4. 30 Day Readmissions by Sex for Index Admission DRGs for Red Blood Cell Disorders # of Discharges

1000

30 Ody Redllmissior o, l,y Rd<:e foc Index Admission DRGs for RED BLOOD CELL DISORDERS

1----------------------' 35%

cfJ.U M 9

800

Discharges

%Readmit

JO Day Reaan1ns

- - - - - - - - - - - - - ---' JUI\

600 18.75~

20%

15%

400

10%

200 5 '11,

wnne or cauc...

Hispanic

Black or African American

Uo/o

O'lo

Other

Seven to 30 Day Readmission Comparison for Red Blood Cell Disorders

Through this study, Qlikview software demonstrated an ability to handle big data sets and an ability to analyze many different variables at one time. The results of this study point to a need to differentiate readmissions within the first week and those that occur on days eight to thirty. David Chin and colleagues at the University of California, Davis, studied Medicare readmissions in four states for three conditions: myocardial infarction (MI), congestive heart failure (CHF), and pneumonia (PN). The study results showed unplanned readmission rates of 17.5%, 23.6% and 17.6% for MI, CHF and PN respectively. Hospital level variation in readmission rates for all three conditions dissipated after the first week, indicating that the hospital itself had the most control over readmission risk in days one to seven. The authors report that the hospital level effect is strongest within the first week of an index admission. Further, the study suggests that community level factors (smallest and most rural counties) and household characteristics may be more influential in eight to thirty days readmissions.7 The implications of the Chin study support previous literature that question the fact that penalties do not take into account poverty level, language barriers, and cultural barriers that affect compliance. In addition, inability to pay for prescriptions and fewer care options at discharge are factors outside the hospitals’ control. Discharge plans and community connections may be especially important for UMMC patients that have high ER and hospital utilization and a diagnosis of red blood cell disorder.

Discussion

This study was limited by including only data for index admissions of patients age 19 and older, as approved by the UMMC IRB. Diagnosis Related Groups were not broken into individual complication groups but were grouped together into the main diagnosis name. Some red blood cell disorder principal diagnoses were not sickle cell disease. The data from outside institutions are not available to combine with the data from UMMC and 24 months of data may not be long enough to establish trends.

Analysis of data from calendar years 2015 and 2016 found statistical differences existed for readmissions by payer and age for Diagnostic Related Group 811/812. No statistical differences were found for sex

Mississippi would benefit from future studies in at least four areas. Initially, further studies on the differences between 7 and 30 day readmissions will identify hospital affected readmissions.6 Research

There were 975 total discharge DRGs related to red blood cell disorders. Of the 975 discharges, 93 were readmitted <= 7 days (9.54%), 216 were readmitted >7 and <= 30 days (22.15%) for a total of 309 readmissions within 30 days (31.69%) (Figure 5). The Mann Whitney Test did show a significant difference between readmissions <= 7 days and >7 <= 30 days (P-value = 0.010).

272 VOL. 58 • NO. 10/11/12 • 2017

to date on community supports including patient navigators, mental health, and aging services will facilitate better continuum of care. Development of a team for high risk readmissions and deploying the team early in the hospital stay should be investigated. Finally, studies of transitions of care in Mississippi and mechanisms for reimbursement will be important to improved care for patients with red blood cell disorders. Examples of future research include quantitative analysis of ICD primary diagnosis codes for Diagnosis Related Group 811/812 and identification of multiple readmissions by individual patients. Qualitative assessments about facilitators and barriers to recovery by geographic area in Mississippi could assess areas with room for improvement at the community support level. Understanding the trends, internal, and external contributors to readmissions will allow for better quality of care to be delivered to patients with Diagnosis Related Group 811/812. n References 1. Kruzikas D, Jiang H, Barrett M, et al. Preventable hospitalizations: a window into primary and preventive care, 2000. Agency for Healthcare Research and Quality. September 2004. http://archive.ahrq.gov/data/hcup/factbk5/ factbk5.pdf. Accessed October 14, 2016. 2. Regenstein M, Andres E. Reducing hospital readmissions among Medicaid patients: A review of the literature. Quality Management in Health Care. 2014;23:203-225. 3. Sommers A, Cunningham P. Physician visits after hospital discharge: implications for reducing readmissions. National Institute for Healthcare Reform. December 2011. http://nihcr.org/wp-content/uploads/2016/07/ Reducing_Readmissions.pdf. Accessed October 13, 2016. 4. Elixhauser A, Steiner C. Readmissions to U.S. hospitals by diagnosis, 2010. Agency for Healthcare Research and Quality. April 2013. http://www.hcupus.ahrq.gov/reports/statbriefs/sb153.pdf. Accessed October 14, 2016. 5. Draft ICD-10-CM/PCS MS-DRGv28 Definitions Manual. Centers for Medicare and Medicaid Services. February 2011. https://www.cms.gov/ icd10manual/fullcode_cms/p0304.html. Accessed October 15, 2016. 6. Hines A, Barrett M, Jiang J, et al. Conditions with the largest number of adult hospital readmissions by payer, 2011. Agency for Healthcare Research and Quality. April 2014. https://www.hcup-us.ahrq.gov/reports/statbriefs/ sb172-Conditions-Readmissions-Payer.jsp. Accessed October 20, 2016.

Calling All Mississippi Physician-Photographers Enter the 2018 JMSMA Cover Photo Contest

Film or Digital Shoot anything you can capture as a high-resolution image. Subjects given the highest consideration are those indicative of Mississippi. Photos of original artwork are also acceptable. The MSMA Committee on Publications will judge the entries on the merits of quality, composition, originality, and appropriateness to the JMSMA. Specifications: Color slides, digital files & photos (at least 300 DPI/PPI). A hard copy print is required for judging. Please include a brief description of the image and information about the physican/photographer.

7. Chin D, Bang H, Manickam R, et al. Rethinking thirty-day hospital readmissions: shorter intervals might be better indicators of quality of care. Health Affairs. 2016; 35:1867-1875.

Author Information Quality Administration (Hankins). Doctor of Health Administration Program (Jones). Professor and Biostatistician (Hamadain). Professor Health Administration and Dean (Bailey). All in the School of Health Related Professions at the University of Mississippi Medical Center, Jackson. Conflicts of interest/ funding: none. Corresponding Author: Phillip Hankins, Quality Administration, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216.

For more info contact:

Size: Vertical format 5 x 7â&#x20AC;? or 8 x 10â&#x20AC;? Deadline: January 6, 2018

Karen Evers, Managing Editor 601-853-6733, ext. 323 or KEvers@MSMAonline.com

Mail to:

P.O. Box 2548 Ridgeland, MS 39158-2548 or deliver to MSMA headquarters 408 W. Parkway Place, Ridgeland, MS 39157

JOURNAL MSMA

273

S C I E N T I F I C

Indocyanine Green Dye (ICG) Induced Hypersensitivity Reaction under General Anesthesia RACHEL ROBERTS, MD; LAKSHMI N KURNUTALA, MD Abstract Hypersensitivity reactions remain one of the major causes of morbidity during general anesthesia. There are two main types of hypersensitivity reactions including anaphylaxis and anaphylactoid reactions, also known as nonimmunologic anaphylaxis. There are several common causes of peri-operative hypersensitivity reactions. In this article, we discuss a much less common cause of hypersensitivity reactions, indocyanine green (ICG) dye. Key Words: H ypersensitivity, anaphylaxis, indocyanine green, anesthesia Introduction Hypersensitivity reactions are an uncommon cause of morbidity and mortality in the operating room. These reactions can be further divided into anaphylaxis or anaphylactoid reactions. Although they have a similar presentation including signs and symptoms of skin rash, hypotension, tachycardia, angioedema, bronchospasm, they can usually be differentiated by laboratory testing. Regardless of the type, hypersensitivity reactions require early recognition and treatment. Case report A 67-year-old Caucasian male (BMI-34) with ameloblastoma of the jaw was scheduled for a tracheostomy, segmental mandibulectomy neck exploration, and fibular free flap under general anesthesia. His medical history was significant for hypertension, coronary artery disease, multiple coronary stents, chronic rate controlled atrial fibrillation, hyperlipidemia, neuropathy in bilateral hands and feet, frequent otitis externa infections, and psoriasis. His most recent echocardiogram showed LVEF (Left Ventricular Ejection Fraction) of 65% with concentric left ventricular hypertrophy, mild left atrial enlargement, and heart valves within normal limits. Current medications included atorvastatin, biotin, carvedilol, gabapentin, lisinopril, rivaroxaban, and multivitamins with no known medication and food allergies. In the operating room, the patient was connected to standard ASA (American Society of Anesthesiologists) monitors. After induction, intubation was performed orally with a Macintosh #4 direct laryngoscope with grade 2 view of the glottis. A 7.5 mm cuffed endotracheal tube (CETT) was placed and secured after confirming bilateral air entry and end tidal CO2. A right radial arterial line was placed for continuous intraoperative blood pressure monitoring and blood sampling. The patient’s surgery began at 0800. At 0900, a 7.5 mm reinforced CETT was placed through a new tracheostomy. Air entry and ET CO2 were confirmed. Vital signs remained within

274 VOL. 58 • NO. 10/11/12 • 2017

normal limits for the next 11 hours. At 1900, he was given 25 mg indocyanine green diluted in normal saline (IC-GREEN® Akorn, Inc. Lake Forest, IL) through peripheral venous access to confirm the integrity of vascular anastomosis. Within 60 seconds of the injection, the patient became hypotensive with mean arterial pressures in the 40s, hypoxemic with arterial saturations in the low 90s, and atrial fibrillation with a rapid ventricular response with a heart rate in the 130s. End tidal CO2 minimally changed to 31 mmHg from 35 mmHg with peak airway pressures of 36 mmHg (initially 21- 23 mmHg) and plateau airway pressure 32 mm Hg with bilateral decreased air entry. He received 100 mcg of phenylephrine initially followed by 4 more doses of 100 mcg phenylephrine and a total of 500 mcg phenylephrine and 1 liter fluid bolus (normal saline) given for management of hypotension. Once hypersensitivity to ICG was suspected, 100 mcg of epinephrine, 50 mg diphenhydramine, 200 mg hydrocortisone were given intravenously, followed by 4 more doses of 100 mcg of epinephrine. An infusion of epinephrine at 1 mcg/kg/min was started to support the blood pressure. The patient continued to be in atrial fibrillation with a rapid rate, and his saturations increased to 92% on 100% O2. End tidal CO2 at this time was 32 mm Hg. Blood pressure was increased, and MAPs (Mean Arterial Pressures) were greater than 70 mm Hg. Over the next 2 hours, the epinephrine infusion was slowly weaned and was discontinued by the end of surgery at 2130 with stable vital signs. The surgery was completed, and the patient was transported to the Surgical ICU (Intensive Care Unit) with a tracheostomy tube on spontaneous respiration for post-operative monitoring given the prolonged surgery and multiple medical comorbidities. He continued to have atrial fibrillation similar to the preoperative period, but he had a new onset rapid ventricular rate (RVR) at a rate of 130/min in EKG (electrocardiogram). Postoperative laboratory values including cardiac enzymes were within normal limits. The postoperative course was uncomplicated, and he was discharged home 8 days after surgery. The patient was advised to follow up with the allergy clinic for further evaluation of ICG allergy. He was lost without allergy followup and did not have postoperative skin testing for medications used intraoperatively to confirm the specific allergy. His reaction was diagnosed clinically and the onset of his cardiorespiratory compromise associated with immediately following ICG injection. Discussion Indocyanine green (ICG) is a cyanine dye, composed of lyophilized green powder and no more than 5% of sodium iodide, which is used in multiple medical diagnostics to identify intraoperative vascular

anastomotic leaks, determine cardiac output, hepatic function, and liver blood flow, and for ophthalmic angiography. ICG has a half-life of 3-4 minutes and is removed from the circulation exclusively by the liver via biliary excretion. ICG is available as 25 mg sterile powder form with 10 mL of aqueous solvent. There are few reports of hypersensitivity reactions, either anaphylaxis or anaphylactoid reactions, to ICG in the literature.1,2,3,4,5 In 1994, Hope-Ross et al. published a study assessing the adverse reactions to ICG during ophthalmic imaging. In their study of 1226 consecutive patients, 1923 intravenous ICG video angiography tests, 3 (0.15%) mild adverse reactions, 4 (0.2%) moderate reactions, and 1 (0.05%) severe adverse reaction were observed without any deaths reported.6 Olsen et al. reported one case of presumed ICG related anaphylaxis requiring CPR (Cardiopulmonary Resuscitation) for stabilization during an ophthalmology case.7 Definitions of anaphylaxis and anaphylactoid reactions. Anaphylaxis is defined as a life-threatening hypersensitivity reaction with a rapid onset.8 It may be allergic or non-allergic; Allergic reactions involve specific immunologic mechanisms including IgE, IgG, or immune complex/complement-related.9 Approximately 70 percent of intraoperative hypersensitivity reactions are IgE mediated.10 Therefore, anaphylactic reactions require previous exposure to a foreign substance. Contrastingly, anaphylactoid reactions, which are triggered by direct stimulation of mast cells with histamine release and compliment activation, do not require IgE or previous exposure to the offending agent. Causes of hypersensitivity reactions. Although ICG is not a common cause of hypersensitivity reactions in the operating room, few cases have occurred in literature.1,2,3,4,5 The more common causes of intraoperative hypersensitivity are neuromuscular blocking drugs, latex, and antibiotics.9,11,12 Of the commonly implicated agents involved in intra-operative hypersensitivity reactions, neuromuscular blocking agents account for up to 70% of the reported cases.7 Rocuronium and succinylcholine are the most commonly implicated agents.13 Because several drugs are administered during general anesthesia, it can be difficult to identify the definitive cause of hypersensitivity reactions. Analysis of anesthetic records for details regarding clinical manifestations, drugs are given, and the timing between each drug can Table.

Table 1. Commonly Implicated Agents Involved in Intra-operative Hypersensitive Reactions 1,13,14 1

Neuromuscular blocking agents – succinylcholine, rocuronium

Latex

Antibiotics – penicillins and cephalosporins

Hypnotics – thiopental, propofol

Opioids – morphine, meperidine

Colloids – gelatin, dextran

Hemostatic agents

Chlorhexidine

Contrast dyes

NSAIDs

aid in the identification process.9 (Table 1) Presentation of hypersensitivity reactions. Signs and symptoms of hypersensitivity reactions include new onset of rash, flushing, urticaria, erythema, angioedema, gastrointestinal manifestations, respiratory issues such as bronchospasm, and cardiac collapse including hypotension and tachycardia.9 Skin manifestations occur less often in the peri-operative setting. Patients on beta blockers do not have the same increase in heart rate that other patients may have.14 Differentiating anaphylaxis and anaphylactoid reactions. Although the initial diagnosis consists of clinical manifestations and the patient’s history, serum tryptase levels can be obtained for further diagnosis. Tryptase is a marker of mast cell degranulation, and a tryptase level above 25mcg/L suggests an IgE related anaphylaxis.9,10 Tryptase has a half-life of 2 hours and returns to baseline after 12 hours.9 The ideal time to draw a tryptase lab is 1-6 hours after the onset of a reaction.15 Although an elevated tryptase would have been a useful laboratory test, a normal level does not refute a diagnosis of anaphylaxis. Plasma histamine levels could also be used as a marker for anaphylaxis or anaphylactoid reactions. These levels peak within minutes of a reaction, but they have a short half-life and are difficult to handle, so they are often not used. We were unable to draw these labs in our patient intraoperatively, and are therefore unable to differentiate between an anaphylactic and an anaphylactoid reaction. In an outpatient setting, allergies may be confirmed by pinprick test to specific antigens and RAST (radio-allergosorbent test) with referral to an allergist. Although there are published protocols for skin testing, they have not been validated. Management of hypersensitivity reactions. Management and treatment of hypersensitivity reactions include investigating and eliminating potential causes, maintaining or establishing an open airway and administering 100% oxygen, elevation of lower extremities to increase venous return, crystalloids should be given quickly (5001000cc in 10-20 minutes for adults), and vasopressors should be used if needed to maintain an appropriate blood pressure.9,10 Epinephrine is the drug of choice due to its alpha and beta properties as well as its inhibition of mast cell degranulation; adult doses range from 10200mcg IV, or 200-500mcg IM.9,10 Infusions can be used if patients require repeated boluses. It is important to begin epinephrine as quickly as possible, as delayed administration is the main factor associated with mortality from anaphylaxis. Glucocorticoids can be given to prevent the second phase of biphasic reactions, but their use remains controversial.16-17 Finally, in the event of cardiac arrest, ACLS (Advanced Cardiovascular Life Support) protocols should be applied for resuscitation.10 There are a number of published protocols for pretreatment of patients with known hypersensitivity reactions such as intravenous contrast agents; these protocols consist of oral or intravenous steroids, usually prednisone or methylprednisolone, with combinations of antihistamine like diphenhydramine given before the injection of agent with known mild to moderate allergy but still need to be ready for unexpected emergencies. If the patient had a severe allergy, it is recommended to avoid the agents. In adults in elective cases, the pretreatment recommendations include JOURNAL MSMA

275

50mg Prednisone PO 13, 7 and 1 hour before the injection, and 50mg Benadryl (Diphenhydramine) IV/PO within 1 hour of the injection. In an emergency situation, 200mg Hydrocortisone IV 4 hours before injection, and 50mg Benadryl (Diphenhydramine) IV/PO within 1 hour of the injection but the effect is less proven.18 Given the possibility of severe hypersensitivity reactions to ICG, caution is advised during the administration of ICG to all patients including those without a prior history of allergic reactions. Recognition of allergic reactions and appropriate equipment to secure the airway and medications should immediately be available to treat the condition. Early recognition and treatment prevented the severe morbidity and avoided the mortality in our patient. n References 1. Wolf S, Arend O, Schulte K, Reim M. Severe anaphylactic reaction after indocyanine green fluorescence angiography. Am J Ophthalmol. 1992;114:638-639. 2. Benya R, Quintana J, Brundage B. Adverse reactions to indocyanine green: a case report and a review of the literature. Cathet Cardiovasc Diagn. 1989;17:231-233. 3. Speich R, Saesseli B, Hoffmann U, et al. Anaphylactoid reactions after indocyanine-green administration. Ann Intern Med. 1988;109:345-346.

anaphylactic reaction. Adv Clin Exp Med. 2012;21:403-408. 16. Ellis AK, Day JH. Incidence and characteristics of biphasic anaphylaxis: A prospective evaluation of 103 patients. Ann Allergy Asthma Immunol. 2007;98: 64-69. 17. Lewis J, Foex BA. BET 2: In children, do steroids prevent biphasic anaphylactic reactions? Emerg Med J. 2014;31:510-512. 18. Mervak BM, Davenport MS, Ellis JH, et al. Rates of breakthrough reactions in inpatients at high risk receiving premedication before contrast-enhanced CT. AJR Am J Roentgenol. 2015;205:77-84.

Author Information Assistant Professor, Department of Anesthesiology, University of Mississippi Medical Center & G.V. (Sonny) Montgomery Medical Center (Roberts). Associate Professor, Director Neuroanesthesiology, Department of Anesthesiology, University of Mississippi Medical Center, Jackson (Kurnutala). Conflicts of interest/ funding: none. Corresponding Author: Lakshmi N Kurnutala, MD, University of Mississippi Medical Center, 2500, N State St, Jackson, MS. 39216. Ph: (601) 984-5900 Fax: (601)984-5939 (lkurnutala@umc.edu).

4. Garski TR, Staller BJ, Hepner G, et al. Adverse reactions after administration of indocyanine green. JAMA. 1978;240:635. 5. Michie DD, Wombolt DG, Carretta RF, et al. Adverse reactions associated with the administration of a tricarbocyanine dye (Cardio-Green) to uremic patients. J Allergy Clin Immunol. 1971;48:235-239. 6. Hope-Ross M, Yannuzzi L, Gragoudas ES, et al. Adverse reactions due to indocyanine green. Ophthalmology. 1994;101:529-533. 7. Olsen T, Lim J, Capone A, et al. Anaphylactic shock following indocyanine green angiography. Arch Ophthalmol. 1996;114:97. 8. Johansson SG, Bieber T, Dahl R, et al. Revised nomenclature for allergy for global use: Report of the Nomenclature Review Committee of the World Allergy Organization, October 2003. J Allergy Clin Immunol. 2004;113:832836. 9. Galvão VR, Giavina-Bianchi P, Castells M. Perioperative anaphylaxis. Curr Allergy Asthma Rep. 2014;14:452. 10. Mertes PM, Malinovsky JM, Jouffroy L, et al. Reducing the risk of anaphylaxis during anesthesia: 2011 updated guidelines for clinical practice. J Investig Allergol Clin Immunol. 2011;21:442-453. 11. Kannan JA, Bernstein JA. Perioperative Anaphylaxis: diagnosis, evaluation, and management. Immunol Allergy Clin North Am. 2015;35:321-334. 12. Laxenaire MC, Charpentier C, Feldman L. Anaphylactoid reactions to colloid plasma substitutes: incidence, risk factors, mechanisms. A French multicenter prospective study. Ann Fr Anesth Reanim. 1994;13:301-310. 13. Caimmi S, Caimmi D, Bernardini R, et al. Perioperative anaphylaxis: Epidemiology. Int J Immunopathol Pharmacol. 2011;Jul-Sep;24(3 Suppl) :S21-6. 14. Mertes PM, Lambert M, Guéant-Rodriguez RM, et al. Perioperative anaphylaxis. Immunol Allergy Clin North Am. 2009;29:429-451. 15. Michalska-Krzanowska G.

Tryptase in diagnosing adverse suspected

276 VOL. 58 • NO. 10/11/12 • 2017

Express your opinion in the JMSMA through a letter to the editor or guest editorial. The Journal MSMA welcomes letters to the editor. Letters for publication should be less than 300 words. Guest editorials or comments may be longer, with an average of 600 words. All letters are subject to editing for length and clarity. If you are writing in response to a particular article, please mention the headline and issue date in your letter. Also, include your contact information. While we do not publish street addresses, e-mail addresses, or telephone numbers, we do verify authorship, as well as clarify ambiguities, to protect our letter writers. You can submit your letter via email to KEvers@ MSMAonline.com or mail it to the Journal office at MSMA headquarters: P.O. Box 2548, Ridgeland, MS 39158-2548.

P R E S I D E N T ’ S

P A G E

The Professionals Who Watch the Profession

ome jobs are thankless, yet they still have to be done. This is why I want to thank publicly the women and men who have accepted appointments for serving on the State Board of Medical Licensure.

Nine physicians serve on the Licensure Board. It’s prestigious only in the medical community, and even there the reward can be far out of proportion with the time, care, worry and just plain hard work required. The physicians get a $40 per diem when they attend a meeting in exchange for the privilege to lose hundreds of dollars a day in income. The time, effort and expertise the Licensure Board members bring to the job can be taxing. They tackle tough issues and guard the professionalism and integrity of their chosen careers. For most Mississippians, the composition of the Licensure Board is not top-ofmind stuff. That’s because the board does a pretty darn good job of using its power and authority to protect the public. The licensure boards that oversee nurses, dentists, pharmacists, and other health care professionals have board members from those respective professions. That’s good because those who work in a given profession are best suited for the job. They know when a colleague has stepped out of bounds and what’s expected, which is often the “standard of care.” An engineer won’t know whether a physician prescribed the right drug and proper dose, but another physician will. Likewise, a dentist won’t know whether the engineer used enough concrete to span a particular distance or carry the likely load; another engineer will. Given the years of training and continuing education medicine requires, the physicians themselves are best suited to make regulatory and disciplinary decisions. This is common across the country for most professional licensing boards. In Mississippi, this professional board makeup is standard because it works. And it works because the individual members take their positions seriously. So, while licensure boards aren’t often table conversation topics, I want to shout out to the professionals who sacrifice time and money to make the hard decisions. I want to thank the physicians who serve on the State Board of Medical Licensure; and, I applaud their integrity, commitment, and sacrifice. They help keep medical care healthy. n

William M. Grantham, MD MSMA President 2017-2018

JOURNAL MSMA

277

U N I V E R S I T Y

O F

M I S S I S S I P P I

M E D I C A L

C E N T E R

Dedication of New Medical School Building Bodes Well for Health Care’s Future

The new School of Medicine at the University of Mississippi Medical Center stands five floors high and has square footage of about 151,000 feet.

Elected officials and other dignitaries attending the dedication of the University of Mississippi’s new, $76 million School of Medicine building celebrated a new era in medical education and health care for the state. The breadth of the 151,000 square-foot facility on the University of Mississippi Medical Center campus means more space for students, more students for each class and, consequently, more doctors for Mississippi. “This remarkable building will be filled with students endowed with the seeds of greatness,” said Gov. Phil Bryant, who addressed a gathering of an estimated 200 officials, students, faculty members and other guests in the ground-level entrance lobby, prior to the formal ribbon cutting. The facility presents these students with “the greatest opportunity for success,” Bryant said. For many of those who worked for and supported the construction of the building, this is part of the story that resonates the most: The dimensions allow for a boost in the size of each entering class, and larger classes mean more physicians will be trained each year in Mississippi, a fact noted by Dr. Jeffrey Vitter, chancellor of the University of Mississippi. Adding physicians to the state’s workforce, he said, will “improve access to quality health care for the citizens of Mississippi.” Mississippi ranks last, at roughly 185 doctors per 100,000 residents, as reported in 2015 by the Association of American Medical 278 VOL. 58 • NO. 10/11/12 • 2017

Pictured above, prior to cutting the ceremonial ribbon are, from left, UMMC chaplain Doris Whitaker, U.S. Rep. Gregg Harper, Dr. James Keeton, Gov. Phil Bryant, Dr. LouAnn Woodward, Johnny Lippincott, Dr. Loretta Jackson-Williams, Lt. Gov. Tate Reeves, Chancellor Jeffrey Vitter and Dr. Ford Dye

Colleges. The only other medical school in the state is at William Carey University in Hattiesburg, which opened in the fall of 2009 and awards the Doctor of Osteopathy degree. The hope is that many of the school’s graduates will stay here, which U.S. Rep. Gregg Harper encouraged them to do in his address: “I say this to the medical students. ‘There’s no place like Mississippi … There’s no place better.’” With the new school building, plans are to expand entering class sizes from around 145 students to 155, and to eventually top off at approximately 165 – the total considered necessary to meet the state’s goal of 1,000 additional physicians by 2025. “This is a project that had unanimous support in the Mississippi Legislature,” said Lt. Gov. Tate Reeves. “Everyone in the legislature recognized the need.” Located on the north side of the campus, between the Student Union and the Learning Resource Center, the site is the educational core of the Medical Center: The building’s neighbors include the schools of dentistry, pharmacy and the health related professions, along with the emerging School of Population Health housed in the new Translational Research Center. The two other schools represented on campus are nursing and graduate studies in the health sciences. Financing of the new medical school included state funds and a $10 million Community Development Block Grant awarded through the Mississippi Development Authority and administered through the Central Mississippi Planning & Development District for site and infrastructure work. Construction was the job of general contractor Roy Anderson Corp., headquartered in Gulfport. Two architectural firms worked in tandem: Cooke Douglass Farr Lemons Architects and Engineers, P.A. in Jackson; and Eley Guild Hardy Architects, P.A., which has offices in Jackson and Biloxi and designed the Robert C. Khayat Law Center at Ole Miss. In Jackson, the task was to build and design the replacement for a school housed in the original Medical Center complex which opened in July 1955 and, at 490,000 square feet, was considered one of the biggest, and most modern, buildings in the state. Over the years, demands for space grew, and, as the Medical Center spread out, the medical school splintered into a network of disconnected sites, including some makeshift offices and labs. JOURNAL MSMA

279

On top of that, by the early 2000s, the AAMC had predicted a nationwide doctor shortage and asked medical schools across the country to pump up class sizes by about 30%. Accreditation standards were also changing, and in order to meet them, the School of Medicine would need more room, an increase and upgrade in simulation facilities, additional classrooms that accommodate interactive group learning, and more. It was clear to Medical Center officials that a new, state-of-the-art facility was more likely to meet the future needs of medical students. A succession of vice chancellors, including Woodward, guided the venture, starting with Dr. Dan Jones and Dr. James Keeton. Promoted by administrators as a potential economic development boon, the project gained the support of lawmakers and Bryant, who was lieutenant governor at the time. After years of planning, on January 7, 2013, UMMC officials staged a ceremonial groundbreaking in the parking lot that has been transformed into a new medical school. “Who would think you would have an emotion about a building?” said Keeton, a 1965 medical school alumnus who retired with emeritus status this year. One of those emotions is “joy,” he said. As for the new crop of medical students arriving next week, he said, recalling his own first days as an first-year medical student, “Let me tell you what their emotion is right now: fear.” Students were among the members of a steering committee that brought back ideas from other medical schools when this one was being planned. For instance, the twin amphitheaters, which function as lecture halls, are modeled after Emory University’s and offer advanced AV equipment, integrated sound systems and sound-dampening features. Overall, in the words of architect Rob Farr, the design is “student-focused.” The building’s southern face overlooks a courtyard and brings in natural light to student work and study areas.

First-year medical student Peyton Thigpen of Jackson, left, and second-year medical student and Class President John Bobo of Clarksdale view one of the new School of Medicine’s two auditoriums. 280 VOL. 58 • NO. 10/11/12 • 2017

The second level is organized for “student movement,” while the upper floors are focused on teaching stations and support areas that frame a space-organizing central atrium. Some architectural details are homages to tradition as well as to the medical profession: Certain areas are appointed with glass etched with rolling lines simulating an EKG; on the floor of the lobby where the dedication was held is a representation of the great seal of the university: a human eye surrounded by the sun; a wall of the student lounge is decorated with medical terms. The cutting-edge simulation training area has a dedicated floor and was made possible in great part Dr. Michael Holder, left, associate professor of pediatric emergency medicine and executive by grants totally nearly $5 million director of simulation and interprofessional education, shows Gov. Phil Bryant how to play from the Hearin Foundation. It is a game that simulates performance of surgery. equipped with a mock operating theater – funded by the UMMC Alliance and the Manning Family Foundation – virtual reality spaces with high-fidelity task trainers, a clinical skills center, flexibleuse spaces and more. “Over the course of the next 50 years, we’re going to deliberately wear it out,” said Dr. Loretta Jackson-Williams, professor of emergency medicine and vice dean for medical education, referring to the building as a whole. Fourth-year medical student Johnny Lippincott, president of the class of 2018, said he’s particularly proud of the way the building’s technological components are designed to be able to adapt to future updates. In his remarks, he also praised the facility’s spaciousness and homage to “natural light.” Ultimately, though, he said, “this is all about what we do for our future patients.” The upshot, from the ground up: Ground floor: Office space, student lounge, café, storage lockers First floor: Classrooms, group studies, twin amphitheaters, Legacy Wall (bearing the names of donors and relating the history of UMMC) Second floor: Classrooms and group studies (mostly repeats first-floor layout) Third floor: Basic and Advanced Cardiopulmonary Resuscitation Training Center, wet and dry labs, training and group study rooms, expandable conference rooms Fourth floor: Office of Interprofessional Simulation Training Assessment Research and Safety, exam and simulation rooms, Standardized Patient training (with actors who portray patients) n

JOURNAL MSMA

281

I M A G E S

Matty

I N

M I S S I S S I P P I

M E D I C I N E

Hersee Hospital, Meridian, Miss.

ATTY HERSEE HOSPITAL, 19021923— These images, which are post-marked 1905

and 1920, are of the important 40-bed Meridian charity institution Matty Hersee Hospital. Originally located at 2310 Poplar Springs Road (now Poplar Springs Drive), Matty Hersee Hospital was organized in 1902 and built by 1903 by a group of civic-minded citizens led by philanthropist Martha “Matty” Waller Hersee Wright (1853-1915) and named in her honor. Born in October 1853 in New York and married to wealthy Meridian bank president John Herbert Wright (1854-1916), Wright (along with her husband) appears to have financially supported the early operations of Meridian’s first hospital. With a population of 23,562 in 1904, Meridian was the most populous city in the state at the time of the hospital’s birth. The 1905 image lists its first address as “North 23rd Avenue” and the postcard writer notes that the freshly constructed hospital “building is in the woods.” In April 1906, state Senate Bill 79 provided $2000 a year for support of the charity work of the Hospital, with the requirement that the city of Meridian and Lauderdale County each contribute an additional $1000. This institution would make history not only for its charitable health work but also as a pioneer educational site for physicians and nurses. When Mississippi’s first four-year medical school was organized in Meridian in 1906 as the Mississippi Medical College, its clinical training would be performed here. Sadly, this ambitious medical school, which admitted two women in its first class, fell victim to severe criticism in the 1910 Flexner report, which resulted in its closure by 1913. A more enduring school of nursing was associated with the hospital by 1910, with the census revealing two “pupil nurses” that year and a diploma surviving issued on June 8, 1913 to a graduate of the Matty Hersee Training School for Nurses. Wright and her husband resided near the hospital, apparently to facilitate her work there. Also residing near the hospital in the new Poplar Springs Road development was Dr. William W. Reynolds, who appears to have been among the first and most instrumental physicians working at the institution, becoming its Superintendent by February 1939. By 1920, the facility was conveyed to the city of Meridian and Lauderdale County jointly, see larger image of hospital in its ascendency. By 1923, the hospital had outgrown this rambling structure, and a new hospital would be constructed at a different site, soon to achieve official status as one of the state’s charity hospitals under the jurisdiction of the Board of Trustees for State Eleemosynary Institutions. Wright is buried with her husband in Meridian’s Magnolia Cemetery. If you have an old or even somewhat recent photograph which would be of interest to Mississippi physicians, please send it to me at lukelampton@cableone.net or by snail mail to the Journal. n

— Lucius M. “Luke” Lampton, MD; JMSMA Editor 282 VOL. 58 • NO. 10/11/12 • 2017

• Index • Volume LVIII January - December 2017

Subject Index

The letters used to explain in which department the matter indexed appears are as follows: “E,” Editorial; “L,” Letters to the Editor; “PB,” Physician’s Bookshelf; “PM,” Poetry and Medicine; “PP,” President’s Page; “S,” Special Article; “UV” Una Voce; the author’s name follows the entry in brackets. Matters pertaining to related organizations are indexed under the medical organization. -A-

A Retrospective Analysis of Thyroid Cancer Prevalence among Thyroid Nodules at the University of Mississippi Medical Center [J Taylor, S Ahmad], 192 Advances in Dementia Care Using Telemedicine [N Patel, A Marya, D Lafferty, A Majeste], 112 An Interview With William M. Grantham, MD, 150th MSMA President, 2017-2018, [K Evers], 236-S

-C-

Cervical Spine Immobilization Associated with an Increased Risk of Death in Patients Transferred to the University of Mississippi Medical Center with Gunshot Wounds to the Head [J Garagliano, A Turnock, R Saunders, W Vanderlan], 190 Change In Meropenem Utilization Following the Implementation of a Targeted Antimicrobial Stewardship Audit and Feedback Program [D Cretella, S King, J Parham, K Stover], 162 Congenital Lobar Emphysema Can Mimic Tension Pneumothorax [P Amolenda, D Maposa, M Sathyamoorthy], 224 Connective Tissue Disease May Be a Significant Risk Factor for

Development of Nonuremic Calciphylaxis [S Kishore, M Harrigill, A Fowler, V Majithia], 226 Clinical Problem-Solving [presented and edited by the Dept. of Family Medicine, UMMC] Comments MACRA: How to Prepare for the Unknown [E Fry], 55 Cover “Claiborne County, MS Landscape” [R Easterling], January “Come into my parlor...” [S Hartness], June/July “Dr. William M. Grantham - 201718 MSMA President”, August/ September “Flocked, White, and Blue” [S Hartness], October/ November/December “Hibiscus Bloom” [J Bumgardner], March “Lantana camara (Verbenaceae)” [M Davis], May “Osprey Nest” [B Alexander], February “State Flower” [M Davis], April

-E-

Economic Impact of Medicare Physician Payment in Mississippi [C Robertson, D Maposa], 50 Educational Debt in Mississippi’s

Emerging Health Care Workforce [S Lirette, R Didlake], 122 Emergency Physician-Performed Bedside Ultrasound in the Evaluation of Acute Appendicitis in a Pediatric Population [B Tollefson, J Zummer, P Dixon], 10 Establishing A Continuum of Care for Evidence-Based Behavioral Treatment for Youth with Disruptive Behavior [K Parisi, N Sarver, D Scattone, D Sarver], 158 Editorials An Assessment of the Affordable Care Act: What we Have that we Could Lose [W Lineaweaver], 94-E Are Insurance Companies Keeping Physician Payments in Line with the Rising Costs of Medical Practice? [S Demetropoulos], 91-E Changing Gears [S Hartness], 96-E Has the Time Come for Democracy at our MSMA? [M Artigues], 204-E Medical Student of the Day [J Cobern], 93-E Primordial and Primary Prevention: Addressing Noncommunicable Diseases in Mississippi [J Mansour, M Mansour], 17-E The State of Special Education in Mississippi [B Saunders], JOURNAL MSMA

283

97-E You Can Change a Village: Lessons Learned on a Medical Mission to Honduras [P Merideth], 205-E

-F-

Factors Influencing Mothers with High-Risk Pregnancies and Babies at High-Risk: Exploratory Analysis from Mississippi and Implications for Breastfeeding Support [C Canarios, S Snell, J Green, E Turbeville, M Famuyide], 254 From the Editor [L Lampton] Home Before Dark, 246 Is Nurse Staffing “the” Quality Issue?, 214 Lifting the Veil, 110 Physician for the Island of Misfit Toys, 34 The Lost Art of Nursing, 150 The Politics of Public Health Crises, 182 There is no Capital in the System to Waste, 66 Word Salad: What Our Patients Hear, 2

-I-

Indocyanine Green Dye (ICG) Induced Hypersensitivity Reaction under General Anesthesia [R Roberts, L Kurnutala], 274 Interstitial Lung Disease in Patients Hospitalized for Acute Illness: Is Thoracoscopic Lung Biopsy Worth the Risk? [J Moremen, C Greenleaf, S Stokes, A Tom, P Rao, C Sears, T Birdas, D Ceppa], 40 It’s “Normal to be Normal” in Child Sexual Abuse [K Farst], 68 Images in Mississippi Medicine “East Mississippi State Insane Asylum, Meridian” [L Lampton], 147 “Historical Marker Erected at Blue Mountain for Dr. Jessie 284 VOL. 58 • NO. 10/11/12 • 2017

Mauney” [L Lampton], 106 “Kuhn Memorial State Hospital in Vicksburg” [L Lampton], 62 “Matty Hersee Hospital, 19021923” [L Lampton], 282 “Newton Sanitarium, 1908” [L Lampton], 25 “The Biloxi Sanatorium, 1904, Gulf Coast Health Resort, 1913” [L Lampton], 243 “The New Hospital, Beauvoir, 1907” [L Lampton], 177 “The Second Hospital, Beauvior, 1924-2005” [L Lampton], 211

-L-

Legalese Mississippi Medical Professionals Feel Drug Enforcement Heat [S Gilbert], 142 The Framework of a Board Investigation [B Reardon], 100 Letters A Man of Grace Remembered [M Deren], 103-L Charity Hospital, Vicksburg [M Holman], 140-L Dr. deShazo’s Response to Dr. Ford’s Letter [R deShazo], 141-L Letter in Response to “Hammering Physicians Not the Answer to State’s Opioid Crisis” [R Weierman], 139-L Is Medicaid Expansion and Universal Healthcare Based on a Ponzi Scheme Our Grandchildren Will Have to Pay For? [C Ennis], 138-L Physicians Remain on the Sidelines Again as the Future of Medicine is Decided [W Weems], 139-L Physicians Should Support Universal Healthcare [D Smith], 21-L Racial Bias of White Physicians Not to Blame for Health Disparities [W Ford], 141-L Remarkable Journal [W Lineaweaver], 140-L

Rural Hospital Survival Depends on Infusion of Monies, Especially to Cover Uncompensated Care: Could Medicaid Expansion Provide Critical Relief? [W Lineaweaver], 20-L Sandbagging Medicaid is a Futile Weapon Against the ACA and Short-Changes Mississippians Hundreds of Millions [W Weems], 21-L What Our Patients Hear: Dr. Bondurant Recalls a Favorite Patient Story [S Bondurant], 103-L What Our Patients Hear: Smiling Mighty Jesus [J Sones], 103-L -MMississippi Hospital Stroke Readiness [M Conner, E Hamadain, E Jones], 198 MACM Telemedicine Checklist: How to Get Started [K Stone], 178 MMPAC Thanks to the 2017 I.V. League Members, 171 MSDH Department of Health Earns Coveted National Accreditation, 209 Mississippi Provisional Reportable Disease Statistics January 2017, 15 Mississippi Provisional Reportable Disease Statistics February, 2017, 45 Mississippi Provisional Reportable Disease Statistics March, 2017, 77 Mississippi Provisional Reportable Disease Statistics April, 2017, 131 Mississippi Provisional Reportable Disease Statistics May, 2017, 170 Mississippi Provisional Reportable Disease Statistics July 2017,

208 Mississippi Provisional Reportable Disease Statistics August 2017, 230 State Board of Health Elects New Leadership, 231 MSMA Committee Seeks Candidates for Vacancies in MSMA Offices, 26, 35 Grantham Inaugurated New MSMA President, 232 Mansour Names President-Elect, Board of Trustees Welcomes New Members, 234 MSMA House of Delegates, 233 New Members, 210 Physician Leadership Academy Ann Roberson, MD, 176 Physician Leadership Academy Charles Richardson, MD, 90 Physician Leadership Academy Justin Turner, MD, 90 Physician Leadership Academy LaFarra Young, MD, 176 Physician Leadership Academy Meredith Travelstead, MD, 54 Physician Leadership Academy Peggy Boles, MD, 133 Slate of Candidates Announced for 2017 Annual Session, 67 STAT Students Receive Awards, 235 -NNonketotic Hyperglycemic ChoreaHemiballismus, A Unique and Treatable Manifestation of Diabetes Mellitus [A Buice, T Rizvi], 168 New Members, 22 -OOsteoporosis Knowledge, Perceptions, and Self-efficacy among Nursing Students in Mississippi [R Morgan, V Nahar, A Wilkerson, A Ford, A Hendricks, G Bawa, M Bass, M Sharma], 264

-P-

Pelvic Synovial Sarcoma of Unknown Primary Origin [C Theriot], 114 Practice Reform and Population Health: Mississippi Physician Perspectives [M Korpiel, E Jones, A Whitt, D Beebe, J Mann], 258 Precision Medicine in Cancer Prevention: Exploring Applications in Mississippi and Beyond [S Vijayakumar, P Roberts, S Packianathan], 4 Physician’s Bookshelf The Mississippi Encyclopedia Finally Published, Lampton Served as Associate Editor of Medicine [K Evers], 136-PB Physician’s Health Corner Poetry and Medicine Alpha to Omega (A True Story) [J McEachin], 212-PM Anytime: A Meditation for the Wounded Healer [D South], 244-PM Doc Hill [E Masters], 180-PM Doctor Meyers [E Masters], 105-PM Dr. Siegfried Iseman [E Masters], 146-PM Our Little Blind Boy [D South], 28-PM President’s Page “Hammering Physicians not the Answer to State’s Opioid Crisis” [L Voulters], 89-PP MSMA Supports Immunizations with GiveMeAShot.org [L Voulters], 16-PP Opioid Abuse: A Comprehensive Problem Demands a Comprehensive Solution [L Voulters], 53-PP, 175-PP The Address of the 2017-18 MSMA President Lee Voulters, MD [L Voulters], 202-PP The Inaugural Address of the 150th MSMA President, William M. Grantham, MD, 240-PP

The Professionals Who Watch the Profession [W Grantham], 277-PP The Value of Membership [L Voulters], 132-PP

-QQuality Management in Surgical Pathology [V Manucha, V Shenoy, M Vargas, I Akhtar, D Shenoy, J Lewin], 119 -R-

Repeated Cardiac Arrests due to Undersensing of Temporary Epicardial Pacer after Coronary Artery Bypass Grafting and Maze Procedure [S Bahadur, B Ham, S Chamarti, T Hong], 222

-S-

Special Article A Pediatrician, Antifreeze, and the FDA [O Evans], 134-S The 2017 Nancy O’Neal Tatum Lecture: Does Mississippi’s Health Status Reflect Ethical Shortcomings? [R deShazo, D Jones], 57-S

-T-

The Trouble with IVC Filters [A Jayaraj, E Murphy, S Raju], 36 Top 10 Fertility Myths You and Your Patients Should Know [J Parry], 128 Transcatheter Aortic Valve Replacement in Treatment of Aortic Stenosis [J Schmidt, J Laite], 195 Top 10 Facts You Should Know About ADHD [B Saunders], 152 About Anesthesia for Neonates, Infants, and Children [T Hamilton, M Sathyamoorthy], 126 About Bloodstream Infections [J Brock, J Parham], 78 About Carotid Artery Disease [D Robbins, M Mitchell], 8

JOURNAL MSMA

285

About Chest Radiography of Lines and Tubes in the Intensive Care Unit [J Brewer, D Pepper, C White], 154 About Contact Dermatitis [H Badon, S Helms], 187 About Eosinophilic Esophagitis in Children [P Giroux, M Nowicki], 81 About Feeding Disorders [D Scattone], 216 About Hereditary Angioedema [S LeBlanc, P Stewart], 251 About Lung Cancer in Women [J Courtney, D Hansen, J Pressler], 46 About Negative Aspects of Treatment with Benzodiazepines [R Reeves, S Gleason], 184 About Palliative Care [C Paine, A Klar, C Ward, J Mansel, K Swetz], 218 About Substance Abuse and Cognitive Decline [S Powell, N Patel, A Patel], 248

-U-

Understanding DRG 811/812 (Red Blood Cell Disorders) Readmissions by Payer, Age, Race and Sex [P Hankins, E Jones, E Hamadain, J Bailey], 270 Usefulness of CT-MR Fusion in Target Delineation of Radiotherapy Planning for Prostate Cancer Patient with Bilateral Hip Replacements [R He, J Suggs, P Kumar, Y Hu, C Yang, E Hamadain, S Vijayakumar, S Giri], 72 UMMC Dedication of New Medical School Building, 278 Una Voce [Dwalia S. South] Patients Say the Darndest Things, 63-UV Throat Mopping and Other Lost Arts of Medicine, 107-UV

286 VOL. 58 â&#x20AC;˘ NO. 10/11/12 â&#x20AC;˘ 2017

-W-

Will Toad Venom Ingestion be the next Mississippi Poisoning Epidemic? [J Henry, W Aldred, J Spurzem, R Cox], 86

Volume LVIII January - December 2017

Author Index

The letters used to explain in which department the author’s matter indexed appears are as follows:“E,” Editorial; “I,” Images in Mississippi Medicine; “L,” Letters to the Editor; “PB,” Physician’s Bookshelf; “PM,” Poetry and Medicine; “PP,” President’s Page; “S,” Special Article; “UV” Una Voce. A

Ahmad, Shema, 192 Akhtar, Israh, 119 Aldred, Wesley L., 86 Alexander, Belinda B., February Cover Amolenda, Patricia, 224 Artigues, Mike, 204-E

Badon, Hannah R., 187 Bahadur, Sachin, 222 Bailey, Jessica H., 270 Bass, Martha A., 264 Bawa, Gurneet, 264 Beebe, Diane K., 258 Birdas, Thomas J., 40 Bondurant, Sidney W., 103-L Brewer, J. Michael, 154 Brock, James B., 78 Buice, Ashley, 168 Bumgardner, Joe R., March Cover

Canarios, Caroline, 254 Ceppa, Duykhanh P., 40 Chamarti, Sirivalli, 222 Cobern, Jade A., 93-E Conner, Mary Helen, 198 Courtney, Jeremy D., 46 Cox, Robert D., 86 Cretella, David A., 162

Davis, Michael, April Cover, May Cover Demetropoulos, Steve, 91-E Deren, Mike, 103-L deShazo, Richard D., 57-S, 141-L Didlake, Ralph H., 122 Dixon, Phillip, 10

E Easterling, Randy, January Cover Ennis, Calvin, 138-L Evans, Owen B., 134-S Evers, Karen A., 136-PB, 236-S F

Famuyide, Mobolaji, 254 Farst, Karen, 68 Ford, Allison, 264 Ford, William, 141-L Fowler, Amanda H, 226 Fry, Edward T. A., 55

Garagliano, Joseph, 190 Gilbert, Scott, 142 Giri, Shankar, 72 Giroux, Parker, 81 Gleason, Sara H., 184 Grantham, William M., August/ September Cover, 240-PP, 277-PP Green, John, 254 Greenleaf, Christopher E., 40

Ham, Ben, 222 Hamadain, Elgenaid, 72, 198, 270 Hamilton, Thomas, 126 Hankins, Phillip, 270 Hansen, Derek T., 46 Harrigill, Max, 226 Hartness, Stanley, 96-E, June/July Cover, October/November/ December cover He, Rui, 72 Helms, Stephen E., 187 Hendricks, Amanda, 264 Henry, Jason S., 86 Holman, Melvin R., 140-L Hong, Tao, 222

Hu, Yida, 72

J Jayaraj, Arjun, 36 Jones, Daniel W., 57-S Jones, Ellen, 198, 258, 270 K

King, S. Travis, 162 Kishore, Shweta, 226 Klar, Angelle L., 218 Korpiel, Michael R., 258 Kumar, Pullatikurthi, 72 Kurnutala, Lakshmi, 274 L Lafferty, Denise, 112 Laite, Josiah, 195 Lampton, Lucius M. “Luke”, 2, 25, 34, 62, 66, 106, 110, 147, 150, 177, 182, 211, 214, 243, 246, 282 LeBlanc, Stephen B., 251 Lewin, Jack, 119 Lineaweaver, William, 20-L, 94-E, 140-L Lirette, Seth T., 122

McEachin, John D., 212-PM Majeste, Andrew, 112 Majithia, Vikas, 226 Mann, Joshua R., 258 Mansel, J. Keith, 218 Mansour, Jennifer, 17-E Mansour, Michael, 17-E Manucha, Varsha, 119 Maposa, Douglas, 50, 224 Masters, Edgar Lee, 105-PM, 146PM, 180-PM Mayra, Anuj, 112 Merideth, Philip, 205-E Mitchell, Marc E., 8 JOURNAL MSMA

287

Moremen, Jacob R., 40 Morgan, Rita, 264 Murphy, Erin, 36

Nahar, Vinayak K., 264 Nowicki, Michael, 81

Packianathan, Satyaseelan, 4 Paine, C. Christian, 218 Parham, Jason J., 78, 162 Parisi, Kathryn E., 158 Parry, J. Preston, 128 Patel, Ashish, 248 Patel, Netrali, 112, 248 Pepper, Dominque J., 154 Powell, Stephen, 248 Pressler, Jr, Joe M., 46

Raju, Seshadri, 36 Rao, Pavan K., 40 Reardon, Ben, 100 Reeves, Roy R., 184 Rizvi, Tanvir, 168 Robbins, Daniel J., 8 Roberts, Paul Russell, 4 Roberts, Rachel, 274 Robertson, Charles M., 50

Sarver, Dustin E., 158 Sarver, Nina Wong, 158 Sathyamoorthy, Madhankumar, 126, 224 Saunders, Barbara S., 97-E, 152 Saunders, Rachel N., 190 Scattone, Dorothy, 158, 216 Schmidt, John, 195 Sears, Catherine R., 40 Sharma, Manoj, 264 Shenoy, Divya, 119 Shenoy, Veena, 119 Smith, David L., 21-L Snell, Sannie, 254 Sones, James Q. “Jim”, 103-L South, Dwalia, 28-PM, 63-UV, 107UV, 244-PM Spurzem, John R., 86 Stewart, Patricia H., 251 Stokes, Samantha M., 40

288 VOL. 58 • NO. 10/11/12 • 2017

Stone, Kathy, 178 Stover, Kayla R., 162 Swetz, Keith M., 218 Suggs, Jeanann, 72

T Taylor, Jeremy, 192 Theriot, Christie, 114 Tollefson, Brian, 10 Tom, Alan, 40 Turbeville, Emily, 254 Turnock, Adam, 190 U V

Vanderlan, Wesley B., 190 Vargas, Mirna, 119 Vijayakumar, Srinivasan, 4, 72 Voulters, Lee, 16-PP, 53-PP, 89-PP, 132-PP, 175-PP, 202-PP

Ward, Carole A., 218 Weems, W. Lamar, 21-L, 139-L Weierman, Robert, J., 139-L White, Charles S., 154 Whitt, Annalyn, 258 Wilkerson, Amanda H., 264 Y Yang, Claus Chunli, 72 Z Zummer, Jaryd, 10

What’s Your Specialty? Our specialty is NETWORKING... TPAs Physicians

Hospitals

Physicians Care N E T WO R K

Employer Groups

Ancillary Providers Insurance Companies

MPCN - THE OBVIOUS CHOICE Change Networks. Not Doctors. 601-605-4756 • www.mpcn-ms.com Sponsored by the Mississippi State Medical Association JOURNAL MSMA

289

MISSISSIPPI STATE MEDICAL ASSOCIATION MISSISSIPPI STATE MEDICAL ASSOCIATION 408 W. Parkway Place 408 W. Parkway Place Ridgeland, MS 39157 Ridgeland, MS 39157

anytime, anytime, anywhere: anytimei anywhere: download download the the issuu issuu app app to to read read the the Journal Journal MSMA MSMA wherever wherever you you go. go.

â&#x20AC;¢

ISSUU

..... GETITON

,...... Google Play