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VOL. LVI • NO. 10 OCTOBER 2015

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

THE ASSOCIATION President Daniel P. Edney, MD President-Elect Lee Voulters, MD

MANAGING EDITOR Karen A. Evers

Secretary-Treasurer Michael Mansour, MD

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

Speaker Geri Lee Weiland, MD Vice Speaker Jeffrey A. Morris, MD Executive Director Charmain Kanosky

JOURNAL OF THE MISSISSIPPI STATE MEDICAL ASSOCIATION (ISSN 0026-6396) is owned and published monthly by the Mississippi State Medical Association, founded 1856, located at 408 West Parkway Place, Ridgeland, Mississippi 39158-2548. (ISSN# 0026-6396 as mandated by section E211.10, Domestic Mail Manual). Periodicals postage paid at Jackson, MS and at additional mailing offices. CORRESPONDENCE: Journal MSMA, Managing Editor, Karen A. Evers, P.O. Box 2548, Ridgeland, MS 39158-2548, Ph.: 601-853-6733, Fax: 601-853-6746, www.MSMAonline.com. SUBSCRIPTION RATE: $83.00 per annum; $96.00 per annum for foreign subscriptions; $7.00 per copy, $10.00 per foreign copy, as available. ADVERTISING RATES: furnished on request. Cristen Hemmins, Hemmins Hall, Inc. Advertising, P.O. Box 1112, Oxford, Mississippi 38655, Ph: 662-236-1700, Fax: 662-236-7011, email: cristenh@watervalley.net POSTMASTER: send address changes to Journal of the Mississippi State Medical Association, P.O. Box 2548, Ridgeland, MS 39158-2548. The views expressed in this publication reflect the opinions of the authors and do not necessarily state the opinions or policies of the Mississippi State Medical Association. Copyright © 2015 Mississippi State Medical Association.

Official Publication

MSMA • Since 1959

The Summer Food Service Program 300 and the Ongoing Hunger Crisis in Mississippi Jade A. Cobern, BS; Kathryn J. Shell, BA; Everett R. Henderson, MD; Bettina M. Beech, DrPH; Sarosh P. Batlivala, MD

Clinical Problem-Solving Case: The Weak Kid 303 Hunter Lett, MD Top 10 Facts You Need to Know about Abdominal Aortic Aneurysms 308 Joseph M. Stinson, MD and Marc E. Mitchell, MD

SPECIAL ARTICLE An Interview with 2015-16 MSMA President Daniel P. Edney, MD 313 Karen A Evers, Managing Editor

EDITORIALS Mississippi Children and Pragmatic Politics Richard D. deShazo, MD; Associate Editor

318

Segregation Then, Poverty Now: Disparities Forever? William Lineaweaver, MD, FACS

320

DEPARTMENTS

From the Editor- Send Me Your Doctor Stories 298 Lucius M. Lampton, MD MSDH MRDS- State Health Officer Dr. Currier Reappointed 306 MSMA Physician Leadership Academy 310 Images in Mississippi Medicine: South Mississippi Charity Hospital 322 Poetry in Medicine: ER Saturday Night 324

ABOUT THE COVER – TAYLOR GROCERY RESTAURANT Taylor Grocery and Restaurant continues a long village tradition of cooking catfish and serves hundreds of people each weekend with world famous food and live music. The restaurant reportedly serves the South’s best catfish. Just outside Oxford in Lafayette County, the restaurant of its name is located on a road that went nowhere-just to the left of the end of Old Taylor Road on a street named Depot Street. Parking remains a little undefined, but the faint lines begin a bit before 5pm Thursday through Sunday, just a street lane’s width past the front porch where you may have the pleasure of meeting Mr. Lynn. One might even have the opportunity to hear him play the Dobro and sing something like “Amazing Grace” or other local favorites. William Faulkner referred to Taylor as “a postage stamp of native soil.” The population of Taylor was 322 at the 2010 census. The village survived extinction, even though the train stopped running through there in the early 1980’s. By the 1990’s, over a dozen artists and writers were calling Taylor home, including potters Obie Clark and Keith Stewart, sculptor Bill Beckwith and photographer Jane Rule Burdine. The line between native and newcomer became blurred. Farmers, artists, and an increasing number of refugees from city life live side by side in neighborly harmony, visiting on front porches, working together on the volunteer fire department, attending church, and raising families. Plein Air, a concept neighborhood focusing on the arts, opened in Spring 2007 in the heart of Taylor on an old dairy farm and is bringing a distinctive flavor to the town. Plein Air has several small businesses, a Southern Living Dream Home and, in addition to the Farmers’ Market, it hosts art workshops and demonstrations, concerts, and festivals. Photo by Martin M. Pomphrey, MD; Mayhew VOL. LVI • NO. 10 OCTOBER 2015

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F R O M

T H E

E D I T O R

Send Me Your Doctor Stories

e all have them: our favorite stories of patient encounters. Such stories are bliss to share, especially with other physicians. Just as old soldiers find comfort and joy in sharing their war stories, we docs find comfort and camaraderie in sharing ours. How many times have you told or heard such stories at our physician gatherings, often of difficult or unusual cases, but other times our stories drift to surreal and humorous interactions with patients. Usually it is only another physician who understands that the absurd is a daily part of a physician’s practice and that every time we walk into an exam room, there is potential for a memorable story.

Here is one of Dr. Whites’s stories: “This is the scenario of an elderly man and his wife coming into the office, and I went into the examining room to check the lady who was a patient. I asked her what the problem was, and she said that she had a sore on her leg. I examined her right ankle, and there was a large sore approximately 2 centimeters in diameter, and you could tell that it had been there a long time. So as usual, I asked the lady what she had been doing for it, and she looked at me and said, ‘I have been soaking it in pee,’ to which I responded. ‘Urine?’ She looked up at me and then looked at her husband and said, ‘No, his-uns.’”

My friend Dr. Dayton E. Whites of Lucedale is working on a memoir of his interesting life and is writing down many of his favorite “stories” of his decades of service as a family physician. He has already written down about 80 such stories. I asked him to share them with our readers, and he has kindly assented.

Contact me at LukeLampton@cableone.net.

Whether the stories are “urine” or “his-uns,” please send me doctor/ patient stories by either slow mail (111 Magnolia Street, Magnolia, MS 39652) or email if you are willing to share with our readers. Look for more of Dr. Whites’s stories in future issues of your JMSMA.

—Lucius M. Lampton, MD, Editor

JOURNAL EDITORIAL ADVISORY BOARD Timothy J. Alford, MD Family Physician, Kosciusko Medical Clinic Michael Artigues, MD Pediatrician, McComb Children’s Clinic 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, Grenada Jennifer J. Bryan, MD Assistant Professor, Department of Family Medicine University of Mississippi Medical Center, Jackson Jeffrey D. Carron, MD Professor, Department of Otolaryngology & Communicative Sciences, University of Mississippi Medical Center, Jackson Gordon (Mike) Castleberry, MD Urologist, Starkville Urology Clinic Matthew deShazo, MD, MPH Assistant Professor-Cardiology, University of Mississippi Medical Center, Jackson Thomas E. Dobbs, MD, MPH State Epidemiologist, 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

Daniel P. Edney, MD Executive Committee Member, National Disaster Life Support Education Consortium, Internist, The Street Clinic, Vicksburg Owen B. Evans, MD Professor of Pediatrics and Neurology University of Mississippi Medical Center, Jackson Maxie L. Gordon, MD Assistant Professor, Department of Psychiatry and Human Behavior, Director of the Adult Inpatient Psychiatry Unit and Medical Student Education, University of Mississippi Medical Center, Jackson Nitin K. Gupta, MD Assistant Professor-Digestive Diseases, University of Mississippi Medical Center, Jackson Scott Hambleton, MD Medical Director, Mississippi Professionals Health Program, Ridgeland J. Edward Hill, MD Family Physician, North Mississippi Medical Center, Tupelo W. Mark Horne, MD Internist, Jefferson Medical Associates, Laurel Daniel W. Jones, MD Sanderson Chair in Obesity, Metabolic Diseases and Nutrition Director, Clinical and Population Science, Mississippi Center for Obesity Research, Professor of Medicine and Physiology, Interim Chair, Department of Medicine Ben E. Kitchens, MD Family Physician, Iuka

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

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Brett C. Lampton, MD Internist/Hospitalist, Baptist Memorial Hospital, Oxford 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 Jason G. Murphy, MD Surgeon, Surgical Clinic Associates, Jackson Alan R. Moore, MD Clinical Neurophysiologist, Muscle and Nerve, Jackson Paul “Hal” Moore Jr., MD Radiologist, Singing River Radiology Group, Pascagoula Ann Myers, MD Rheumatologist , Mississippi Arthritis Clinic, Jackson Darden H. North, MD Obstetrician/Gynecologist , Jackson Health Care-Women, Flowood

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

Got Questions MACM Risk Management has answers.

At Medical Assurance Company of Mississippi, we believe protecting our insureds from litigation is just as important as the service we provide after a suit is filed. The primary focus of our physician insureds is the health and well-being of their patients. Our responsibility is to help them keep that focus, while working on issues and topics that affect the delivery of healthcare in Mississippi. All of the programs and services listed below are offered at no cost to MACM insureds. •

Onsite Survey. Through these evaluations, our staff can analyze the risk management systems and documentation within your practice to offer suggestions for improvement.

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In-Service Education. With customized presentations and training, our staff can meet the needs of our individual insureds.

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Consultations by Telephone and Email. Our consultants are located in Mississippi and available to answer questions from insureds when they need timely assistance.

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Publications. Our insureds receive information that is timely through Risk Manager Alert email blasts, as well as more in-depth information through our Risk Manager magazine.

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Reference Materials. These written bulletins are available to our insureds and designed to help in specific circumstances that come up daily in a medical practice, such as withdrawal from patient care.

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Educational Opportunities. In addition to the knowledge of our in-house staff, MACM has contacts across the U.S. and makes this expertise available to our insureds through webinars and conferences.

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Presentations and Speaking Engagements. The Risk Management Staff has been a sought-after source for presentations at conferences on an array of topics related to the practice of healthcare.

If you are not currently insured by Medical Assurance Company of Mississippi, what services and educational opportunities are you missing out on?

Don’t be left out! To take advantage of the many opportunities that MACM offers its insureds, contact Tammi Arrington at (800) 325-4172 or tammi.arrington@macm.net for information and a quote on your medical professional liability needs. OCTOBER 2015 • JOURNAL MSMA

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A R T I C L E S

The Summer Food Service Program and the Ongoing Hunger Crisis in Mississippi JADE A. COBERN, BS; KATHRYN J. SHELL, BA; EVERETT R. HENDERSON, MD; BETTINA M. BEECH, DrPH; SAROSH P. BATLIVALA, MD Abstract Food insecurity is simply defined as uncertain access to adequate food. Nearly 50 million Americans, 16 million of whom are children, are food insecure. Mississippi has 21% food insecure citizens, and has the most food insecure county in the nation. Our state’s school system’s National Breakfast and Lunch Programs help combat food insecurity, but a gap still exists. This gap widens during the summer. In this paper, we describe the Mississippi Summer Food Service Program. While the program has had success in our state, it still faces challenges. Organized action by physicians in Mississippi and the Mississippi State Medical Association could significantly increase participation in these programs that are vital to our state. Key Words: Food insecurity, Child health, Food Assistance Programs Food Deserts and Insecurity

Major grocers have gradually withdrawn full-service stores from low-income communities, leaving residents of those communities to rely on corner and convenience stores—along with fast-food restaurants—to obtain the majority of their foods.1,2 Convenience stores are generally unable to offer a wide variety of fresh produce or are able to do so only with significant expense. Thus, many people in these communities live in “food deserts,” areas where nutritious food is difficult to obtain and, therefore, eat a greater proportion of the available highly processed foods with poor nutritive value.2 In addition to the lack of fresh fruits and vegetables, many who reside in food desert communities live at or below the federal poverty level and report problems accessing food, a condition termed “food insecurity.” Food insecurity is defined as “the household-level economic and social condition of limited or uncertain access to adequate food” and is now assessed in the monthly Bureau of Census’s Current Population Survey and represented in United States Department of Agriculture (USDA) reports.3 An estimated 49 million Americans were food-insecure in 2012, 16 million of whom were children. These numbers rose significantly in 2008 with the economic recession and have essentially plateaued since.4 The Dietary Guidelines Advisory Committee recently released their scientific report to the Secretaries of the Department of Health and Human Services and USDA.5 This committee is comprised of nationally recognized leaders in nutrition, and their mission is to provide the basis for federal food and nutrition policy and education initiatives. Their 2014 300

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report noted that the American diet is deficient in fruits, vegetables and whole grains, and includes too much salt and sugar.6 These problems are magnified in food deserts. Growing research demonstrates an association between living in a “food desert” and the disproportionate development of diabetes, heart disease, obesity, and other diet-related health problems.2 Hunger in Mississippi

In 2012, the USDA identified specific groups at highest risk of being adversely affected by food insecurity. Households with children, especially households with children under the age of 6, those with a single parent, African-American and Hispanic households, and those with an income less than 185% of the federal poverty level represent particularly high-risk populations.7,8 The prevalence of food insecurity is greatest in Southern states (16%) with Mississippi having one of the highest rates in the nation (20.9%).4 Feeding America is the nation’s largest hunger-relief charity, distributing 3 billion pounds of food to Americans each year through a network of more than 200 food banks.3 In 2014, this group surveyed each of the 3,143 counties in the nation and noted that 90% of food insecure counties were in the South. Feeding America noted that 93% of food insecure counties with a high percentage of African-American families had an “elevated food insecurity rate.” These African-American predominant counties also had poverty rates of 29% which is higher than the rates among all other food-insecure counties (27%) and the rate in US counties overall (16%).3 The Mississippi Delta, comprised of 18 counties, is a resource-poor section of our state and nation (Figure). In fact, more than one of every four Mississippians live in a community with limited access to a local grocer.8 Further research has shown that counties in the Mississippi Delta have, on average, only one supermarket per 190 square miles.9 Feeding America also identified Humphreys County as having the highest rate of food insecurity in the entire country. Humphreys County has an African American majority, a 41% poverty rate, a 16% unemployment rate, and a median income of $24,783 (2014 FPL was $23,850 for a family of 4).3,10 Furthermore, four other Mississippi counties were in the top ten most food insecure counties in the nation: Jefferson, Claiborne, Holmes, and Coahoma. Feeding America also specified child food-insecurity rates (CFI) to be notably higher

FIGURE. Counties of the Mississippi Delta: The Delta region includes Bolivar, Carroll, Coahoma, Desoto, Holmes, Humphreys, Issaquena, Leflore, Panola, Quitman, Sharkey, Sunflower, Tallahatchie, Tate, Tunica, Warren, Washington, andTable Yazoo1.counties. United States Department of Agriculture Food and Nutrition Services Programs in Mississippi TABLE. United States Department of Agriculture Food and Nutrition Services Programs in Mississippi. Program Name Supplemental Nutrition Assistance (SNAP) School Breakfast Child

National

Nutrition

School Lunch Summer Food Service

Fiscal Year 2013

Fiscal Year 2014

$1,018,551,943

$937,284,866

$59,505,566

$60,589,782

$162,085,512

$166,277,749

$4,934,926

$6110086

Special Milk

$2,646

$2,691

Child and Adult Care Food

$37,145,687

$37,377,076

Supplemental

WIC

$80,564,492

$75,599,290

Food

CFSP

$2,715,505

$2,885,409

Food Donation*

$9,704,984

$7,976,674

Total

$1,404,000,248

$1,323,487,017 Data from www.fns.usda.gov

*Food donation includes the Nutrition Program for the Elderly, Food Distribution Program on Indian Reservations, Donated Food, Soup Kitchens/Food Banks, and the Emergency Food Assistance Programs. Reprinted with permission from the Mississippi State Department of Health

Abbreviations- WIC: Women, infants, and children

than overall food-insecurity rates throughout the country, mirroring what has been reported by the USDA. After specifically isolating CFI, Mississippi was ranked second in the nation with a CFI rate of 28.7%.3 Hunger in Children

All stages of childhood are marked by rapid physical growth and development which are dependent on good nutrition, and disruptions in appropriate nutrient intake can have deleterious long-term effects on a child’s growth and developmental achievement.11 These issues are especially concerning for children as studies have shown an association between food insecurity and cognitive development in young children and poor school performance in older children12 as well as lower scores on mental and physical health exams later in adulthood.10 Food insecurity is also a risk factor for the development of cardiovascular disease, other chronic conditions such as hyperlipidemia and hypertension, and mental health disorders.13–15 Unfortunately, these problems disproportionately affect children in poor, food insecure counties of Mississippi. Cost-effective programs to improve the nutrition in these communities could lead to improved childhood health with significant overall positive impact on population health. The National School Breakfast and Lunch Programs, Supplemental Nutrition Assistance Program, and Summer Food Service Program (SFSP), supported by federal dollars, are some of the current efforts to address this problem in Mississippi (Table). Assistance Programs

The National School Breakfast and Lunch Programs have a significant

CSFP: Commodity Supplemental Food Program

impact on the nutritional health of our children. Both programs are federally-assisted meal programs that operate in public and non-profit schools to provide nutritionally balanced, low-cost, or free meals to school children. A 2012 USDA study reported that 31.6 million children were fed through the National School Lunch Program and that 47.3% of households receiving nutrition assistance were also food-insecure over a 12-month period.16 Only 2 million children, however, received food assistance during the summer months, significantly less participation than those utilizing the National School Lunch Program.17 The SFSP has potential to bridge this gap. Its precursor, the Special Food Service Program for Children, was launched in 1968 with the SFSP being formally created in 1975. The SFSP plans to serve more than 200 million meals to children across the nation during the summer of 2015.18 The SFSP in Mississippi has historically low participation rates. In 2010, of the 357,000 eligible children, only 26,000 children participated. This represents a penetrance of only 7.2%, well below the national average.19 The Delta has a similarly low participation rate. In 2014, approximately 98,000 children from the Delta were eligible and technically enrolled in the SFSP. Thus, the program had potential to serve 12,740,000 meals in the Delta alone last summer based on two meals served per child per day with 23 weekdays in July and 21 in both June and August. However, only 460,957 meals were served in Delta counties, representing ~3.6% participation.20 Since 2010, participation rates in Mississippi have shown overall improvement. USDA Food and Nutrition Services have targeted specific states to improve participation. Mississippi was targeted for sum-

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mer 2014 with good results. Mississippi SFSP participation increased 23% from FY 2013 to FY 2014, the third best SFSP improvement in the nation that year. In addition, this represented an increase of 41% from FY 2010. Given the low participation, small increases in overall participation rate will have dramatic results. For example, though the 23% increase in participation rate correlates with an overall participation of 8.9%, this represents an additional 6,100 children fed.

4. 5.

Avenues for Improvement

The Mississippi Department of Education (DOE) and USDA have identified potential barriers to participation. These include awareness, transportation and distance to the nearest sponsor site, and lack of other activities as some of those barriers. Mississippi DOE and USDA have held two annual meetings with various stakeholders throughout the state to help address these issues and improve participation. One proposed solution is to increase awareness and outreach for enrollment in the Supplemental Nutrition Assistance Program in areas where highly food insecure individuals are eligible.21 This is particularly applicable to the Delta region. Reports have also suggested increasing the number of summer feeding sites as well as encouraging “alternative summer delivery models,” such as delivering meals rather than requiring families with limited means to obtain transportation to summer sites or allowing families to pick up a week or more of meals rather than requiring children to travel to sites each day. Many of these children, however, belong to low-income and/or single-parent homes with working parents who may have difficulty providing or accessing transportation. Some food service sites offered breakfast and lunch at separate times, requiring children to be transported back and forth, which presented further participation challenges. Consequently, in addition to recruiting more sites to decrease travel distances, some groups have also proposed creating other activities for the children so that they can remain at the site from morning through afternoon and participate in educational/physical activities in addition to receiving nutritious meals.

7. 8. 9. 10. 11. 12. 13.

14. 15. 16. 17.

Conclusions Food insecurity is a significant and often under-appreciated public health issue in the United States and especially in Mississippi. Summer months can be an especially problematic time as many children lose access to meals offered through the National School Breakfast/ Lunch Programs. The SFSP, however, has potential to significantly decrease this gap. Though the Mississippi SFSP has demonstrated recent improvement, much work can be done to improve participation rates to optimize the health of our children. Organized action by physicians in Mississippi, as well as the Mississippi State Medical Association, could significantly increase participation in these vital programs. References 1.

Woo Baidal JA, Taveras EM. Protecting progress against childhood obesity--the National School Lunch Program. N Engl J Med. 2014;371(20):1862-1865. doi:10.1056/NEJMp1409353. 2. Treuhaft S, Karpyn A. The Grocery Gap: Who Has Access to Healthy Food and Why It Matters. PolicyLink Food Trust. March 2010:1-39. 3. Gundersen C, Engelhard E, Satoh A, Waxman E. Map The Meal Gap: Highlights of Findings For Overall and Child Food Insecurity. Feed Am. 2014. http:// www.feedingamerica.org/hunger-in-america/our-research/map-the-meal-

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18. 19. 20. 21.

gap/2012/2012-mapthemealgap-exec-summary.pdf. Coleman-Jensen A, Gregory C, Singh A. Household Food Security in the United States in 2013. U.S. Department of Agriculture, Economic Research Service; 2014. http://www.ers.usda.gov/media/1183208/err-155.pdf. Millen B, Lichtenstein AH, Abrams S, et al. Scientific Report of the 2015 Dietary Guidelines Advisory Committee. February 2015. http://www.health.gov/dietaryguidelines/2015-scientific-report/PDFs/Scientific-Report-of-the-2015-Dietary-Guidelines-Advisory-Committee.pdf. Millen B, Lichtenstein AH, Abrams S, et al. Scientific Report of the 2015 Dietary Guidelines Advisory Committee. February 2015. http://www.health.gov/dietaryguidelines/2015-scientific-report/PDFs/Scientific-Report-of-the-2015-Dietary-Guidelines-Advisory-Committee.pdf. Federal Register. Off Fed Regist. 2014;79(No. 14):3593-3594. Population in low-income, low-supermarket tracks derived from: Trade Dimensions International, Inc. (2009); American Community Survey 2005-2009, ESRI Data & Maps 2009. Koprak J, Lang B. Stimulating Grocery Retail Development in Mississippi: A Report of the Mississippi Grocery Access Task Force. Philadelphia, PA: The Food Trust; 2012. Stuff JE, Casey PH, Szeto KL, et al. Household Food Insecurity Is Associated with Adult Health Status. J Nutr. 2004;134:2330-2335. Hagan JF, Shaw JS, Duncan PM, eds. Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents. Vol 3rd ed. Elk Grove Village, IL: American Academy of Pediatrics; 2008. Gundersen C, Kreider B, Pepper J. The Economics of Food Insecurity in the United States. Appl Econ Perspect Policy. 2011;33(3):281-303. doi:10.1093/aepp/ ppr022. Nelson K, Cunningham W, Andersen R, Harrison G, Gelberg L. Is food insufficiency associated with health status and health care utilization among adults with diabetes? J Gen Intern Med. 2001;16(6):404-411. doi:10.1046/j.15251497.2001.016006404.x. Seligman HK, Laraia BA, Kushel MB. Food Insecurity Is Associated with Chronic Disease among Low-Income NHANES Participants. J Nutr. 2010;140(2):304310. doi:10.3945/jn.109.112573. Heflin CM, Siefert K, Williams DR. Food insufficiency and women’s mental health: Findings from a 3-year panel of welfare recipients. Soc Sci Med. 2005;61(9):1971-1982. doi:10.1016/j.socscimed.2005.04.014. Coleman-Jensen A, Nord M, Singh A. Household Food Security in the United States in 2012. U.S. Department of Agriculture, Economic Research Service; 2013. http://www.ers.usda.gov/media/1183208/err-155.pdf. Gray KF, Eslami E. Characteristics of Supplemental Nutrition Assistance Program Households: Fiscal Year 2012. U.S. Department of Agriculture, Food and Nutrition Service; 2014. USDA Food & Nutrition Services. Summer Food Services Program. http://www. fns.usda.gov/sfsp/summer-food-service-program-sfsp. USDA FNS Office of Strategic Initiative, Partnerships and Outreach. Reaching More Mississippi Children. USDA; 2011. Wright CM. Superintendent’s Annual Report 2014. Mississippi Department of Education; 2014. USDA Food & Nutrition Services. Supplemental Nutrition Assistance Program. http://www.fns.usda.gov/snap/supplemental-nutrition-assistance-programsnap.

Author Information School of Medicine, University of Mississippi Medical Center (Ms. Cobern, Ms. Shell, Dr. Beech and Dr. Batlivala). Division of Pediatric Cardiology, University of Mississippi Medical Center (Dr. Batlivala). Division of Neonatology, Forrest General Hospital (Dr. Henderson).

Corresponding Author Sarosh P. Batlivala, MD, Division of Pediatric Cardiology, 2500 N. State Street, Jackson, MS 39216. Office: 601-984-5250 Fax: 601-984-5283 (sbatlivala@umc.edu).

C L I N I C A L

P R O B L E M - S O L V I N G

C A S E

The Weak Kid HUNTER LETT, MD

13-year-old African-American male without significant past medical history arrived by ambulance to the Emergency Department (ED) after passing out at home on a summer afternoon. The patient was accompanied by his parents and brother. The family reported that the patient was playing basketball outside with friends when he complained of sudden generalized weakness, vague chest discomfort and appeared to be confused. The patient then stumbled inside where he passed out, falling to the floor. He appeared to be coming in and out of consciousness. The very concerned family reported that this has never happened to their son in the past and he has always been generally healthy. There are several things going through my mind as there is no specific event or symptom that points to a clear cause. Of chief prominence are concerns of a seizure, dehydration leading to electrolyte abnormalities, heat stroke, cardiac abnormalities, cerebral vascular accident (CVA) or toxin ingestion. Patients with seizures usually present with shaking, confusion, altered mental status and possibly loss of consciousness. Dehydration can cause altered mental status and acute weakness. Potential cardiac abnormalities include conduction and mechanical issues such as aberrant pathways and left ventricular hypertrophy, both of which ultimately can lead to decreased cardiac output and loss of consciousness.1 CVAâ&#x20AC;&#x2122;s usually cause focal weakness and dysarthria with altered mental status depending on which part of the brain is suffering from ischemia. There is a plethora of toxins that can manifest in numerous ways but most will cause some degree of mental derailment.2 I will need to do a physical exam and consider which tests are appropriate. In the ED, the patient appeared to be calm, relaxed and in no distress. His vital signs were stable and within normal range. He was awake but seemed to be somewhat confused and drowsy. The patient only remembered playing basketball and then starting to feel weak. He did not recall coming inside the house. The family said they never saw any part of his body shaking. He remembered waking up in the ambulance; however, he could not provide specific details of what happened. He said that he felt fine in the ED. He denied chest pain, dizziness, headache, nausea, vomiting, abdominal pain or visual disturbances. There was no urinary or bowel incontinence. He was somewhat aggravated and

said that he just wanted to be left alone so he could sleep. There was some mild aphasia. He denied taking any pills or drugs and drank only some Gatorade that afternoon. His mother thought he hit his head when he fell inside the house. Pertinent physical exam findings included good skin color and turgor, moist mucus membranes, normo-reactive pupils, slowed mentation, and responses that were not completely logical to questions. His cardiac exam was unremarkable, and his reflexes were normal as well. He knew that he was in the hospital but could not accurately recall his birthdate. Finger-to-nose test was normal on the left but significantly abnormal on the right. He could stand by the bedside and walk, but he was unsteady and began to fall when he closed his eyes. There was no apparent head injury or bruising. At this point I am concerned more of a neurological manifestation of his symptoms. Specifically I am thinking that he may be post-ictal from a possible seizure, but the history does not point to typical seizure-like symptoms. I order a stat computed tomography (CT) of his head without contrast to evaluate for any signs of mass-effect, ischemia, and hemorrhage.3 I order an electrocardiogram (EKG) and place the patient on continuous cardiac monitoring to monitor cardiac function regarding arrhythmias.4 I also order a complete blood count (CBC), comprehensive metabolic panel (CMP), coagulation panel, urinalysis, urine drug screen, creatine phosphokinase (CPK), and electroencephalogram (EEG). The CBC will help identify a possible infection and anemia. The CMP will address renal function, electrolytes, acid-base status, liver function.4 The urinalysis and urine drug screen will investigate for renal abnormalities and drug toxins that may be contributing to his symptoms. The CPK is a muscle breakdown component that may be elevated with dehydration or muscle injury from either a fall or prolonged seizure activity. I obtain a chest radiograph as well to investigate for an unanticipated pulmonary abnormality. I will also order a neurology consult since there are obvious neurological manifestations involved and perform an EEG to test for brain wave abnormalities. An elevated prolactin can be secondary to a seizure if checked within a few hours of the seizure, but this is a send-off lab and is not overly sensitive or specific5; therefore, I elect not to check it. The CT head did not reveal signs of a mass, ischemia, trauma or hemorrhage. The CBC, CMP, coagulation panel, EKG, urinalysis and urine drug screen were all within normal lim-

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its. The CPK was only minimally elevated above baseline. The chest radiograph appeared to be normal. The patient was admitted to the hospital and monitored closely overnight. The EEG could not be done until the following day. The mildly elevated CPK could be elevated secondary to muscle breakdown from dehydration or a seizure, and since he does not have signs of dehydration, I am more concerned about possible atypical seizure activity at this point.6 The aforementioned lab results essentially rule out electrolyte abnormalities, infection, cardiac issues and renal issues that could contribute to the patient’s presentation. The patient was started on gentle IV hydration, and I checked on him every 1 to 2 hours during the night. Serial examinations during the night continued to reveal right arm weakness with poor coordination, somewhat improved cognitive function but persistent difficulty with word-finding. He also remained unsteady when attempting to walk or stand. In a much older person, I would be very concerned regarding the possibility of a stroke; however, in a previously healthy 13-year-old with normal CT results this is not as high on the differential. The negative CT head certainly does not rule out a stroke, especially since it is within the 24 hour window of symptom onset, but stroke is still relatively low on the concurrent differential. It can take 1-2 days for ischemic changes to been seen on a CT scan because of the time required for the tissue changes to occur; however, a hemorrhagic stroke would be revealed immediately.7 I am concerned that the patient’s weakness, poor coordination and word-finding ability have not improved during the night, which is atypical if he were post-ictal from a seizure. I would expect him to show improvement at this point, approximately 12 hours after symptom onset. I reconfirmed with the parents that he had never experienced these symptoms in the past. That following morning, I discussed the case with the neurologist, and he agreed that the symptoms were somewhat atypical for a seizure but agreed with the need for an EEG to evaluate brainwave function. The patient’s condition remained largely unchanged into the morning. The EEG revealed an abnormal awake and asleep cycle with other non-specific abnormal changes. The neurologist does not think these findings are characteristic of a seizure and may be concerning for ischemia/CVA. We decide that this warrants a magnetic resonance imaging (MRI) of the brain since the patient’s symptoms are not improving and are concerning for ischemic insult. An EEG can be sensitive for neurological changes but isn’t always specific. MRI can identify the exact size and location of the area affected by a stroke. An MRI is more sensitive than a CT scan in identifying changes caused by lack of oxygen to brain cells during the first 72 hours after a stroke. An MRI is also better for detecting strokes in the cerebellum and brain stem and is usually more accurate in detecting ischemic strokes during the first 3 days after a stroke,8 and at this point we are concerned with the possibility of a stroke that may not have been detected by the CT scan.

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An MRI of the brain with and without contrast was obtained that afternoon. The diffusion-weighted images demonstrated areas of restricted diffusion in the left basal ganglia, insular cortex, temporal lobe and left parietal lobe. This appearance was most consistent with acute ischemic insults to these areas. I am somewhat surprised at the MRI result that indicates the patient did have an ischemic CVA. Had this patient been 75 years old with a history of poorly controlled hypertension and diabetes, I would have assumed he had a stroke from the beginning until proven otherwise; however, the patient is 13 years old without any known past medical history. Some risk factors for strokes in children include arterial diseases, cardiac disorders, infection, coagulation disorders and sickle cell disease. Risk factors that are increasing in the younger population are high blood pressure, diabetes, obesity, cholesterol-related disorders, tobacco use and alcohol abuse;9 however, this patient does not have any of these risk factors. I know there has to be a significant underlying cause of the stroke, and he will need specialized care for investigation and treatment. We decide to transfer the patient to the nearby children’s hospital for further evaluation and treatment. Upon review of his records several weeks later from the children’s hospital, it was found the patient had a left carotid dissection. He was prescribed a heparin drip and bridged to warfarin for anticoagulation. Hypercoagulable studies were all negative. The patient’s aphasia and right hemiplegia improved, and he continued on warfarin. It was decided that surgical intervention for the carotid dissection was not warranted. The patient was ultimately diagnosed with fibromuscular dysplasia. I was not involved with the patient’s care after the transfer, but stoke and carotid dissection in a 13-year-old male is not common; however, this can certainly be seen in patients with fibromuscular dysplasia. Fibromuscular dysplasia is a non-inflammatory, nonatherosclerotic disorder that leads to arterial stenosis, occlusion, aneurysm and dissection. It has been observed in nearly every arterial bed. The most often involved arteries are the renal and internal carotid arteries, and less often are the vertebral, iliac, subclavian and visceral arteries.10 Disease presentation may vary widely, depending upon the arterial segment involved and the severity of disease. Common manifestations are hypertension, transient ischemic attack, stroke, headache, dizziness, tinnitus and pulsatile tinnitus. Key Words: Fibromuscular Dysplasia, carotid dissection, stroke, syncope References 1.

Massin MM, Bourguignont A, Coremans C, et al. Syncope in pediatric presenting to an emergency department. J Pediatr 2004; 145:223.

Clinical policy for the initial approach to patients presenting with acute toxic ingestion or dermal or inhalation exposure. American College of Emergency Physicians. Ann Emerg Med. 1995;25:570.

Caplan LR. Imaging and laboratory diagnosis. In: Caplan’s Stroke: A Clinical Approach, 4th, Saunders, Philadelphia 2009. p.87.

Alexander ME, Berul Cl. Ventricular arrhythmias: when to worry. Pediatr Cardiol. 2000; 21:532.

Wyllie E, Luders H, Macmillan JP, et al. Serum prolactin levels after epileptic seizures. Neurology. 1984;34:1601-1604.

Libman MD, Potvin L, Coupal L, et al. Seizure vs. syncope: measuring serum creatine kinase in the emergency department. J Gen Intern Med. 1991;6(5):408-412.

Warach S, Gaa J, Siewert B, Wielopolski P, Edelman RR. Acute human stroke studied by whole brain echo planar diffusion-weighted magnetic resonance imaging. Ann Neurol. 1995;37:231–241.

Mohr JP, Biller J, Hilal SK, et al. Magnetic resonance versus computed tomographic imaging in acute stroke. Stroke. 1995;26:807–812.

Roach ES, Golomb MR, Adams R, et al. Management of Stroke in Infants and Children: A Scientific Statement From a Special Writing Group of the American Heart Association Stroke Council and the Council on Cardiovascular Disease in the Young. Stroke. 2008;39:2644-2691.

10. Begelman SM, Olin JW. Fibromuscular dysplasia. Curr Opin Rheumatol. Jan 2000;12: 41-47.

Corresponding Author: Hunter Lett, MD East Alabama Medical Center Emergency Department 2000 Pepperell Pkwy. Opelika, AL 36801 (hunlett@aol.com)

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State Health Officer Dr. Currier Reappointed for Second Term

uring its quarterly meeting, the Mississippi State Board of Health reappointed Dr. Mary Currier for a second term as State Health Officer of Mississippi. Dr. Currier was first appointed to the position in January 2010. She began her Mississippi State Department of Health (MSDH) tenure in 1984 and has served in various capacities including two terms as State Epidemiologist, from 1993 to 2003, and again since 2007. Board Chairman Dr. Luke Lampton commended Dr. Currier saying, “The Board’s unanimous vote today clearly recognizes Dr. Currier as an exceptional leader of great integrity and competence. She is an outstanding asset not only for our agency but also for our state at large. We need her continued leadership in her role as State Health Officer for years to come.” Dr. Lampton added that during Currier’s tenure, Mississippi reduced its infant mortality rate, infectious disease rates such at tuberculosis and syphilis, and increased vaccination rates among 2 year olds. Mississippi’s strong immunization laws are now recognized as the national model.

State Health Officer Dr. Mary Currier

A graduate of the University of Mississippi School of Medicine, Dr. Currier received her master’s degree and preventive medicine residency training in Public Health from the Johns Hopkins School of Hygiene and Public Health. Currier’s bachelor’s degree is from Rice University, and she attended Trinity College in Dublin, Ireland.

She has 30 years of state service experience and more than 25 years serving in public health. Prior to serving as State Epidemiologist, Dr. Currier was a medical consultant with the MSDH where she began her career as a staff physician for the prenatal care, family planning, STD, and pediatrics programs. She is a member of the Mississippi Public Health Association, and is the Southeast Regional Representative to the Board of the Association of State and Territorial Health Officials. Currier is board certified in General Preventive Medicine and Public Health. Dr. Currier’s second term begins in January and expires in January 2022.

Calling All Mississippi Physician-Photographers Enter the JMSMA 2016 cover photo contest Load your camera or grab your 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 physician/photographer for "About the cover."

Size: Vertical format 5 x 7” or 8 x 10” Deadline: December 31, 2015 For more info contact: 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

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Top Ten Facts You Need to Know: About Abdominal Aortic Aneurysms Joseph M. Stinson, MD and Marc E. Mitchell, MD

Introduction Abdominal aortic aneurysm (AAA) is one of the most common pathologies of the peripheral arteries, affecting approximately 5% of men over the age of 65. Rupture of AAA is a leading cause of death and disability, which can be nearly eliminated by early diagnosis and treatment. This article discusses the epidemiology, diagnosis and treatment of AAAs with an emphasis of early identification in order to prevent death from rupture.

n arterial aneurysm is a focal dilatation of an artery with at least a 50% increase in diameter A compared to the normal artery. The etiology of an aneurysm can be: degenerative, inflammatory, post-dissection, traumatic, infectious (mycotic), or stem from developmental anomalies. Degenerative aneurysms (incorrectly termed atherosclerotic aneurysms) are by far the most common, of which an AAA is an example.1

AAAs are the most common aneurysms. Other peripheral artery aneurysms seldom occur alone; they are usually associated with AAAs. Up to 25% of AAAs have an associated iliac aneurysm, while 90% of iliac aneurysms are associated with an AAA. 10% of patients with an AAA have a popliteal aneurysm, but approximately 50% of patients with a popliteal aneurysm have an AAA. Femoral artery aneurysms are less common than popliteal aneurysms. Aneurysms involving the visceral, cerebral, and upper extremity arteries are exceedingly rare.2

Risk factors associated with AAA include: age, gender, race, family history, smoking, hypercholesterolemia, peripheral vascular occlusive disease, and coronary artery disease. Older age, male gender and smoking are the most important risk factors for AAA development. AAAs are four to six times more common in men than women, with approximately 5% of men over the age of 65 having an AAA > 4 cm in diameter. Smokers have a five times higher risk of developing an AAA than nonsmokers. Family history of an AAA and being Caucasian increases the risk of AAA development two fold. Hypercholesterolemia, peripheral vascular and coronary artery disease increase the risk of AAA development but to a lesser extent. Hypertension is thought to increase the rupture risk in a patient with a known AAA but does not inherently increase the chance of developing an AAA. Diabetes mellitus decreases the risk of developing an AAA.3

A focused physical examination can detect AAAs. The sensitivity of the physical examination depends on factors such as AAA size, the patientâ&#x20AC;&#x2122;s body habitus, and skill of the examiner. Thin patients and those with hypertension, a wide pulse pressure, or tortuous aortas can all be falsely suspected of having an AAA. The sensitivity of physical examination for detecting AAAs is 61% for 3-3.9 cm AAAs, 69% for 4-4.9 cm AAAs, and 82% for > 5 cm AAAs.4

Ultrasound screening for and surveillance of AAAs has been shown to lower the risk of death from AAA rupture.Ultrasound is a safe and relatively inexpensive method to diagnose and follow AAAs and is the screening test of choice. Medicare now pays for a screening ultrasound in high-risk individuals. Patients with an AAA < 4.5 cm should be imaged annually and those with an AAA > 4.5 cm every 6 months. Ultrasound does have its limitations, and when an AAA exceeds 4.5 cm in maximal diameter, a CT angiogram (CTA) should be obtained. CTA more accurately measures the diameter of the AAA and provides anatomic detail necessary for planning AAA repair. The angulation of the aorta, size of the iliac vessels and distance from the renal arteries to the AAA are the major factors determining whether an endovascular AAA repair (EVAR) or open surgical repair is most appropriate.5

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Rupture of an AAA is a leading cause of disability and death. The 1 year risk of rupture for 5.5-5.9 cm AAAs is 9%, for 6-6.9 cm AAAs is 10% and for AAAs >7cm is 33%. Rapid expansion (> 0.5 cm over 6 months), saccular morphology and symptoms (abdominal or back pain) are also associated with a high risk of rupture.6 The mortality of a patient with a ruptured AAA is well over 50%, while that of elective AAA repair is less than 5%. Many patients with a ruptured AAA die suddenly and never make it to the hospital. Even with the advances in the field of vascular surgery, the mortality for emergent repair of a ruptured AAA has changed little in the past 30 years and remains between 25 and 50%. The effectiveness and safety of elective AAA repair means that most deaths from AAA rupture are preventable provided the AAA is diagnosed and treated electively.6,7

Elective repair is indicated for AAAs 5.5 cm or greater in maximal diameter. In young good risk patients AAAs 5.0 cm or greater are considered for elective repair. These numbers were obtained based on rupture risk and growth rates. AAAs < 5 cm in diameter have almost no chance of rupturing, but 5-6 cm AAAs have a 3-15% chance of rupture per year and AAAs > 8 cm have a 30-50% chance of rupture per year. The average rate of growth for AAAs is 0.26 cm/yr.5,8

9 10

All AAAs 4 cm or greater in diameter should be referred to a vascular specialist for evaluation. Early referral is key to timely and appropriate treatment for AAAs. AAAs must be closely monitored once they reach 4 cm in diameter. The vascular specialist can discuss repair options and risk factor modifications with the patient and the primary care provider.9

The majority of infrarenal AAAs are now repaired using an endovascular approach and can be done safely even in patients with significant comorbidities. EVAR can be done under local anesthesia and most patients are discharged home on the first postoperative day. Patients undergoing an EVAR usually do not require intensive care unit admission, as was the case with open AAA repair. Almost no patient is too sick to undergo an EVAR.10 Author Information: Dr. Stinson was a Vascular Surgery Resident at the University of Mississippi Medical Center and entered private practice at North Mississippi Medical Center in Tupelo in August 2015. Dr. Mitchell is Professor of Surgery at the University of Mississippi Medical Center. Corresponding Author: Marc E. Mitchell, MD, Department of Surgery, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216 (memitchell@umc.edu). References 6.

Lederle FA, Johnson GR, Wilson SE, et al. Rupture rate of large abdominal aortic aneurysms in patients refusing or unfit for elective repair. JAMA 2002;287:2968-2772.

Lederle FA, Freischlag JA, Kyriakides TC, et al. Outcomes following endovascular vs open repair of abdominal aortic aneurysm: a randomized trial. JAMA 2009;302:15351542.

Kent KC, Zwolak RM, Egorova NN, et al. Analysis of risk factors for abdominal aortic aneurysm in a cohort of more than 3 million individuals. J Vasc Surg. 2010;52:539-548.

Brady AR, Thompson SG, Fowkes FG, et al. Abdominal aortic aneurysm expansion: risk factors and time intervals for surveillance. Circulation 2004;110:16-21.

Fink HA, Lederle FA, Roth CS, et al. The accuracy of physical examination to detect abdominal aortic aneurysm. Arch Intern Med. 2000;160:833-836.

Ashton HA, Buxton MJ, Day NE, et al. The Multicenter Aneurysm Screening Study (MASS) into the effect of abdominal aortic aneurysm screening on mortality in men: A randomized controlled trial. Lancet 2002;360:15311539.

Dimick JB, Cowan JA, Stanley JC, et al. Surgeon specialty and provider volumes are related to outcome of intact abdominal aortic aneurysm repair in the United States. J Vasc Surg. 2003;38:739-744.

Chaikof EL, Brewster DC, Dalman RL, et al. The care of patients with an abdominal aortic aneurysm: the Society for Vascular Surgery practice guidelines. J Vasc Surg. 2009;50(4S):S2-S49.

Diwan A, Sarkar R, Stanley JC, et al. Incidence of femoral and popliteal artery aneurysms in patients with abdominal aortic aneurysms. J Vasc Surg. 2000;31:863-869.

10. Sicard GA, Zowlak RM, Sidawy AN, et al. Endovascular abdominal aortic aneurysm repair: Long-term outcome measures in patients at high-risk for open surgery. J Vasc Surg. 2006;44:229-236. OCTOBER 2015 â&#x20AC;˘ JOURNAL MSMA

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JONATHAN ADKINS, MD

GENERAL SURGERY • JACKSON

HOSSEIN BEHNIAYE, MD FAMILY MEDICINE • HATTIESBURG

TONDRE BUCK, MD

HEMATOLOGY/ ONCOLOGY • JACKSON

ERVIN FOX, MD

CARDIOLOGY • FLOWOOD

JONATHAN JONES, MD EMERGENCY MEDICINE • JACKSON

ANGELA SHANNON, MD PEDIATRIC GASTROENTEROLOGY • MADISON

SHARON MCDONALD, MD

CHASITY TORRENCE, MD

GERALD MCKINNEY, MD

ASTHMA/ ALLERGY/ IMMUNOLOGY • JACKSON

PEDIATRIC HEMATOLOGY/ ONCOLOGY/ CLINICAL INFORMATICS • BRANDON GENERAL SURGERY • JACKSON

PSYCHIATRY • BRANDON

DANIEL VENARSKE, MD

ANGELA WINGFIELD, MD

DERMATOLOGY • PASS CHRISTIAN

The MSMA Physicians Leadership Academy offers opportunities for our physicians members to gain experience and training in order to excel in leadership positions within organized medicine, medical practice and business. www.MSMAonline.com 310

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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.

OCTOBER 2015 • JOURNAL MSMA

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An Interview with Daniel P. Edney, MD 148th MSMA President, 2015-2016 KAREN A. EVERS, MANAGING EDITOR [Each year the JMSMA interviews the incoming president. Here we go behind the scenes. Due to space limitations, the answered questions do the speaking for this interview.] —Ed.

Family I was born in Meridian but grew up in Greenville as the youngest of four children in a working class family. I would say that we were classified as part of the working poor but I never realized that until I was grown. I have fond memories of growing up in the Delta and my first real job was “chopping cotton” as a field hand in the summers for the Mississippi State Experimental Station in Leland. The most formative event during my young life also led me into medicine. My father died of colon cancer when I was 14, and this obviously changed my whole world. It was my first exposure to the world of medicine. I suffered from some stress related GI illnesses the following two years which gave me an even closer view of medicine. I felt a call on my life at age 16 to become a physician although I had very little understanding of how the odds were stacked against me to become one then. No one in my family had graduated from college, much less medical school, and my working widowed mom now was raising me.

When I told her of what I felt God wanted me to do, her simple wise response was, “If God has called you, then He will make a way.” Had she not encouraged me as she did, despite the difficulties she knew all too well, I doubt that I’d be a physician today.

Reflections on Medical School Being a medical student was an absolute joy. I loved everything about it and especially loved being a member of the class of ‘88. Our class was comprised of a bunch of great men and women that I appreciate and respect even today. Our class has roamed far and wide as physicians but I especially enjoy seeing, referring to, and working with my former classmates. Great memories! They range from living in the “ghetto” of married student housing and the birth of my first child while a M3 on UMC Surgery A (yes, we flunked family planning), to being a sub intern as a M-4 for VA Medicine A in the “good ole days,” to working with Dr. John Estess at the Hollandale Clinic for my family medicine away block, to playing alto saxophone for our class rock band “The Bottom Third.” After finishing my residency in internal medicine at the University of Virginia, I returned to Mississippi, as I always wanted to practice medicine in “small town Mississippi.” I was offered a great job opportunity at the old Street Clinic in Vicksburg and have loved practicing, living there, and raising my family with Lori since 1991. I’ve been with my current partners with Medical Associates of Vicksburg since 2009 and the five of us now run a physician-owned private internal medicine practice where we all do full general medicine including primary care clinic, hospital, LTAC, and nursing home care. Milestones My most fulfilling role in life has been that of husband to Lori for 32 years and father of my three children: Daniel who is a young practicing attorney in Vicksburg (one of the good guys); Meredith Salmon, a newlywed who is a public school teacher for third grade in Birmingham; and Meg, who is a junior at William Carey University in Hattiesburg. Lori has been by my side since 1983, through my years of medical school, residency, and of building a new practice. She deserves a great deal of the credit for anything I’ve been able to accomplish in life.

Dr. and Mrs. (Lori) Daniel Edney celebrate the marriage of their daughter, Meredith, to Jared Salmon with their other daughter Meg and son Daniel.

Nepal Honduras

Passion The most fulfilling accomplishment in professional life has been to establish the First Baptist Medical/Dental Ministry in Vicksburg. This faith-based, evangelistic, free clinic specifically serves the working poor of West Mississippi by providing free physician and dental services as well as lab and a full pharmacy. Founded about 20 years ago out of my church, this ministry is fully staffed, administered by volunteers, and serves as the primary source of medical and dental care for the majority of our patients.

I am passionate about my disaster medicine work and the other volunteer medical service I do but see our medical ministry as part of my legacy of serving as a physician in Vicksburg. I truly thank God for allowing me to do this for His glory.

Organized Medicine I joined MSMA as soon as I started work at The Street Clinic. I was told by the partners it was expected-not optional. I remember reading about something that was coming up called “Annual Session” and I asked my senior partner then, Dr. Joe Ross, what that was all about. He told me he hadn’t been in a while and that we both just needed to go, so we did. Then I found out that West Mississippi Medical Society had nominated me to run for the Council on Constitution and Bylaws. I had no clue what it was but I learned quickly at the meeting that MSMA was THE organization that represented the physicians of our state, and that as a young doctor facing the brand new issue of managed care and RBRVS that I’d better get involved. So I ran, and ran hard, and lost! However, I was hooked and made a decent impression on the older guys that year so the next year I got to serve on a reference committee and was elected to the Council on Medical Service and have been grateful to the HOD for electing me each time I ran for MSMA offices going forward. I also was selected to serve as Young Physicians Section (YPS) chair around that time which was not difficult because back then, in the early 90s, there weren’t many young physicians participating at the state level. I remember that at my first YPS meeting at Annual Session there were three of us: Mary Gayle Armstrong, Steve Demetropoulis, and a few others. I decided to try to jump start YPS and thankfully we had some talent coming behind us like Clay Hays, Luke Lampton, Tim Beacham, Jim Fuller, and others to build on our early work. Now MSMA has a solid Young Physicians Section with an excellent annual program for families at Sandestin which is well attended each year. It’s critical for the sake of the profession that MSMA cultivate and encourage its younger leadership as it did with me. Another formative experience was serving as a MSMA representative to the AMA-YPS House of Delegates and getting some early exposure on the national scene. There I experienced firsthand how important it is for MSMA to be actively represented at the AMA as there are many doctors around our country that don’t think or practice like we do at home. It led me into wanting to serve on our AMA delegation from MSMA. Those were wonderful years of service with much hard work involved and time away from home and practice but were critical to protecting our interests in Mississippi.

Two great highlights were: giving Dr Edward Hill’s nomination speech to the full AMA HOD the year he was elected AMA president, and having the honor of serving as chair for our AMA delegation. OCTOBER 2015 • JOURNAL MSMA

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Disaster Life Support and Response Most recently, I have been asked to respond in Northern Iraq in October 2014 as part of a Baptist Global Response (BGR) initial response team and in February 2015 leading the medical disaster response team for Mississippi Baptist Disaster Response as we served the Iraqi civilians displaced by ISIS. In May 2015, I was asked by BGR to serve on the initial assessment team evaluating the earthquake disasters in Nepal. This was to evaluate and make recommendations regarding the scope of disaster and need for mobilization of medical teams to Nepal following this disaster. Disaster Response medicine has been a calling for me as a result of training I underwent following 9-11. The AMA developed Basic Disaster Life Support training to prepare physicians as first responders in time of disaster. Thankfully, this training has not been needed due to a domestic terror event, but I realized that it would be useful for natural disaster response as well. That led to my working in Indonesia after the tsunami, South Lebanon after the Israeli war, our own Gulf coast with Katrina, the Haitian earthquake, and now Iraq and Nepal. This is a fascinating field of volunteer medicine requiring us to use our full diagnostic skills and troubleshooting abilities to care for serious illness and injury with limited resources in remote areas of the world. If I can do it, then believe me, anyone can do it. “On Call with Dr. Dan Edney” The radio show is a project that developed out of a frustration of patients being subjected to various bogus “medical” reports, misleading medical reporting in the media, and direct to consumer marketing issues that often mislead patients, not to mention sensational reporting on the internet. I had a friend and patient who owned a radio station in Vicksburg and produced his own morning radio program. Often he invited me to be interviewed on various medical topics on his show. There was a very favorable response, and we developed a separate radio show that covers the current event topics in medicine, periodic medical updates with disease management education, and treatment updates. This show takes on the various medical social, political, and economic issues of the day from a Christian worldview. Volunteerism in Medicine I am a big believer in volunteerism in medicine. “To those whom much is given, much is required.” We as physicians have been blessed in many ways, and much of our education, whether in medical school or residency/fellowship or both, has been subsidized by the taxpayer. Because of this, I feel that I have an obligation to serve our society in ways not connected with my income. 316

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Nepal

Medical volunteerism, in whatever form a physician feels led, is a wonderful way to fight against burnout and becoming jaded. As I serve in my various modes as a volunteer doctor, it reminds me of the main reasons that I became a physician: to serve others through the practice of medicine. Medical Volunteerism My first real experience with medical volunteerism was when I felt led to develop and open a free medical (and later dental) ministry to serve the working poor of our community that I could see as a young doctor were struggling to afford access to quality medical care on an ongoing basis. I also felt led to develop this as an extension of my faith as an evangelistic ministry of our church. For over 20 years, the FBC medical/dental clinic ministries has been fully staffed by volunteers and funded with private donations accepting no remuneration from patients. Every month we serve about 80 patients by providing free medical and dental care, lab services, and free medications for our patients who are screened to insure that they meet the financial needs criteria. This has been a labor of love that over time has been embraced and supported by the entire Vicksburg community. I’ve also been able to use it as a great resource for teaching medical students, PA and NP students about the medical needs of this segment of our population, the importance of altruism in medicine, and how to provide quality medical care to patients with only limited diagnostic testing. Currently, we have medical students from UMC and William Carey as well as PA students from MC and NP students from UMC who rotate through with us. Physician Health and Wellness A major issue I’d like to promote is the issue of physician health and wellness. Iraq Doctors sacrifice a significant part of our lives for training and then continue to make sacrifices of time and resources usually at the expense of our families and our health for the sake of the profession. Statistics show that we suffer from burn out, psychological and psychiatric illnesses including depression, suicide, and substance use disorders, and are notorious for not taking care of our own health. MSMA has been working very hard on the problem of a limited physician work force on the front end by training more doctors, but we also need to improve retention rates in the profession to help the work force. When doctors die young for any preventable reason, retire early due to burnout, or become physically or psychologically disabled, our workforce and the state’s economy suffer. I hope to shed an encouraging light on health and wellness challenges facing physicians, and what we can do as a profession to improve these issues.

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

DISABILITY DETERMINATION SERVICES 1-800-962-2230 OCTOBER 2015 • JOURNAL MSMA

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Mississippi Children and Pragmatic Politics RICHARD D. DESHAZO, MD; ASSOCIATE EDITOR

hat’s Old is New Again

In this issue of the Journal [Batlivala SD et al. The Summer Food Service Program and the ongoing hunger crisis in Mississippi. J Miss State Med Asoc. 2015; 56:300-302.] there is a mind-boggling article by Cobern and colleagues on federal programs, available to states, to address food insecurity. One overwhelming part of the article is that 21% of Mississippi families are unsure of their next meal. In a society as rich as ours, how can we still have hungry children and families who are unsure of their next meal? Physicians in Mississippi have a long history of trying to remedy this problem. Back in 1967, a group of pediatricians supported by the Marshall Field Foundation came to Mississippi, traveled the state, and found large numbers of black children in Head Start programs were hungry, undernourished, and developmentally delayed.1 Governor Paul B. Johnson, Jr., the Mississippi legislature, Archie Gray, MD, the chair of the State Board of Health, other Mississippi leaders including United States Senators Eastland and Stennis, and United States Representative Jamie Whitten, were actively involved in Head Start politics. They were at the same time, trying to kill Head Start programs in general, and those in Mississippi in particular.2, 3 They said the physicians’ findings were not only “false” but “libelous.”4 Several more physician groups, including a physician group impaneled by Governor Johnson himself, visited Mississippi and found the Field Foundation physicians’ findings, later published as Hungry Children: Special Report, to be true.5 The problem was more than racial, as poor white children were hungry, out of sight and ignored too.6 Denial did not make the problem better, only worse, but Head Start provided one pragmatic approach because of the feeding programs that came with it.

Head Start The Head Start program, the idea for which came from the Freedom Schools of Mississippi Freedom Summer 1964, was funded by the Economic Opportunity Act of 1964. The purpose was to better prepare economically disadvantaged children to succeed in the first grade of elementary school. But perhaps more importantly for Mississippi children, many of whom had never seen a physician or dentist, it provided medical and nutrition evaluations, referrals for any health problems identified, and a minimum of one nutritious meal per day to begin to address the hunger issue. The governor, legislators, and the Mississippi congressional delegation encouraged local leadership to stay clear of Head Start programs and services as they claimed the requirements for participation violated states’ rights by assuming the prerogatives of state agencies, promoted socialism, and could cost the state money. These concerns were frequently raised as threats by Mississippi politicians when the state’s status quo was threatened.7 Sound familiar? The back story on their objections to Head Start (and federally funded programs in general) lurked in the shadows. Political leaders feared that black Mississippians who received federal grants to run these programs would become politically and socially empowered to threaten local white power structures and segregation itself. Governor Johnson, therefore, had refused to sign off on any Head Start applications in Mississippi. But the first Head Start in Mississippi, Child Development Group of Mississippi (CDGM), used a loophole in the funding mechanism by applying in partnership with a college. They received 1.3 million dollars to start up their program. In this case, funds went directly to the Head Start grant applicants in the Delta. Since most of Mississippi’s black children met federal poverty guidelines, they were the major participants in Head Start and the major benefactors of its programs.8 Governor Johnson was furious and with the legislature and Mississippi’s Congressional delegation, coordinated their opposition. Senator Eastland, who at the time had unprecedented power over congressional funding, mercilessly attacked Sergeant Shriver and the Office of Economic Opportunity in Head Start’s Congressional hearings and in the press.9

Some Physicians Stood Up Participation in any federal program brought suspicion, scrutiny, and criticism to those who supported such programs, even when there were obvious benefits. In this case, the benefits were food and medical care for hungry children. Appropriately, much has been written to record how a small group of black physicians worked to initiate Head Start Programs in Mississippi.7 Much less has been written about the smaller group of white physicians who did the same. One of these was Dr. Jim Hendrick, the chair of the largest private pediatric group in the state, Children’s Medical Group in Jackson (Figure). Jim Hendrick, a southerner, decorated veteran, and a deeply committed Baptist, was neither active nor interested in politics. But, he saw attempts by Governor Johnson and the Congressional delegation to block funding of a new program that would provide desperately needed health and nutrition assistance to be immoral and lacking pragmatism, regardless of the politics. He and a small group of physician friends accepted referrals of sick children from black physicians, including Drs. Robert Smith, Aaron Shirley, and James Anderson, who provided health screenings when no one else was available to do so in many CDGM Head Start centers. In 1967, Hendrick volunteered to serve as the medical director of a new Head Start program in the city of Jackson. The Mayor and the Citizens’ Council publicly criticized him. His family were the targets of numerous efforts at intimidation. Dr. Hendrick’s 318

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efforts as a civil libertarian were rewarded by threats delivered by mail, phone and in person. He went out each morning to pick up threatening letters thrown onto his driveway before his children arose, knowing what happened to Medgar Evers in his driveway. When a bomb wrecked the home of his neighbor, Rabbi Perry E. Nussbaum, a fellow signer of the Statement of Belief and Intention, friends rushed to the Hendrick’s house thinking it was the Hendrick family who had been bombed. The good-natured pediatrician replied that he was “protected” as his next door neighbor was a leader in the White Citizens’ Council.10

History Repeats Itself In this month’s JMSMA, Ms. Cobern and colleagues provide documentation that not only do we have ongoing health and nutrition problems, many of Mississippi’s children are still not benefitting from federal programs like the Summer Food Program, designed to help states with large numbers of children in poverty, like ours. The Healthy HungerFree Kids Act of 2010 -2015, now up for renewal in Congress, provided an opportunity to move from school meals filled with high fat and empty calories to one with nutritious foods for all school children (Table).11 The program also facilitated support for food from local groceries as well as locally prepared food for breakfast and lunch programs. It supported educational programs to help families learn how to cook and eat healthy foods in appropriate portions. Covered by the present short term federal budget extension, who knows what will happen to this program in the long term? But we do know not funding it would hurt Mississippi children.

The New Malnutrition in Mississippi

FIGURE. Jackson, Mississippi pediatrician Jim Hendrick, MD. Dr. Jim Hendrick had served in the US Army Medical Corps in World War II, received a Bronze star, and came to practice in Jackson in 1948. Hendrick’s experience in the military and his understanding of Christianity made him uncomfortable with his church’s continued segregation. After church members turned away blacks at a service during a “kneel-in,” in response to the murder of Medgar Evers, Hendrick and his family joined others to form an inclusive new church composed of conservatives and progressives trying to understand the ethics of the civil. His wife, Mary Ferrell and several of her friends dared to take food and personal items to civil rights protesters at the Mississippi State Fairgrounds in 1965.

Poor nutrition associated with low BMIs of the past has been replaced by the poor nutrition of high BMIs of the present and an explosion of metabolic syndrome in children and young adults. Conservative estimates suggest that Mississippi will soon lead the United States into an era of a new form of disability, one associated with large numbers of young adults who are unemployable because of obesityassociated complications to include diabetes, heart disease, stroke, cancer, and osteoarthritis. Meanwhile, we in the medical community remain silent about our state’s reluctance to participate in federal health programs like those supported by the Healthy Hunger Free Kids Act, programs that could be lifesavers for our children.

Likes of Jim Hendrick

TABLE. Federal Food Programs Supported through the Healthy, Hunger-Free Kids Act of 2010-2015 (Presently Up For Reauthorization by Congress)11

School Breakfast National School Lunch Child and Adult Care Food Summer Food Service Fresh Fruit and Vegetable WIC

Somewhere there are physicians like Jim Hendrick who can help others see through the dust storm that is our present politics to the most important issue of all, the needs of our children. Such leadership is pragmatic, and can include Republican, Democrat, and Independents. Today, more than ever physicians need to find the courage to accept whatever labels non-pragmatists throw at us in the process. Such pragmatism reaffirms the principles to which we have already committed, “I will remember that I remain a member of society, with special obligations to all my fellow human beings, those sound of mind and body as well as the infirm.”12 Pragmatic physicians can become pragmatic activists and Jim Hendrick was a great model for that.

References 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12.

Kota N. Let them Eat Promises. The Politics of Hunger in America. Prentice-Hall, Inc. Englewood Cliffs, New Jersey 1969, pg. 8-10. Edelman, P. So Rich, So Poor. Why is it So Hard to End Poverty in America. The New Press, Ny, NY. 2012, pg. 7-18. Drew, EB. Going Hungry In America. The Atlantic Monthly. December 1968: 53-61. Robertson N. Stennis and Eastland Reject “Libel” in Mississippi Attack Testimony at Hearing that States White Try to Drive Out Negroes. New York Times, July 12, 1967:22. Wheeler R, et al. Hungry Children: Special Report. 1967 Southern Regional Council, Atlanta, Georgia 1-27. Owen GM, Garry PJ, Kram KM, Nelsen CE, Montalvo JM. Nutritional status of Mississippi preschool children. A pilot study. Am J Clin Nutr. 1969 Nov;22(11):1444-58. Dittmer, J. The Good Doctors. The Medical Committee for Human Rights and Struggle for Social Justice in Health Care. Bloomshaw Press, NY, NY 2009, pg. 126-129. http://pollygreenberg.net/civilrights/description.htm. Accessed October 6, 2015. Loftus, JA Poverty Hearing Set In Mississippi; Senate Inquiry On Today— Police Brace for Crowds. New York Times. April 10, 1967: 13. deShazo interview with Becky Hendrick April 27, 2015. Healthy Hunger Free Kids Act. Updates to the Healthy Hunger Free Act of 2010-2015. http://www.fns.usda.gov/school-meals/healthy-hunger-free-kids-act Accessed October 6, 2015. Tyson P. The Hippocratic Oath Today. NOVA 2001. http://www.pbs.org/wgbh/nova/body/hippocratic-oath-today.html. Accessed October 6, 2015. OCTOBER 2015 • JOURNAL MSMA

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Segregation Then, Poverty Now: Disparities Forever? William Lineaweaver, MD, FACS

n January of 1963, George C. Wallace was inaugurated as governor of Alabama. His speech concluded with an attempt to enshrine racism as a political and social ideal:

“Today I have stood where once Jefferson Davis stood, and took an oath to my people. It is very appropriate then that from this cradle of Confederacy, this very Heart of the Great Anglo-Saxon Southland…..we sound the drum for freedom….In the name of the greatest people that have ever trod the earth, I draw the line in the dust and toss the gauntlet before the feet of tyranny….and I say…segregation now…segregation tomorrow… segregation forever.”1

This proclamation not only epitomized a spectrum of sophisticated and visceral racial politics but also defended a social system that excluded citizens defined as “black” from credible access to education, health care, housing, and employment, consigning them to poverty and exploitation. Already at the time of Governor Wallace’s speech, his advocacy of segregation was being critically undermined. Integration of the United States Armed forces, Supreme Court decisions striking down legal structures of segregated education, and a growing social consensus against the forms of racial inequality were transforming the political, educational, and economic landscapes of the county into a society free of the clumsiest, most oppressive trappings of official racism.2-4 In 1964, with the passage of the Civil Right Act, racial segregation was outlawed throughout the r ealms of interstate commerce and equal protection under the law.3 This journal has recently joined the repudiation of segregation through a series of historical studies describing the extraordinary exploits of the brave individuals who began the ultimately successful overthrow of segregated health care and medical education in Mississippi.5-6 The achievement of the end of formal racism in Mississippi medicine was acknowledged in an editorial, “An apology long overdue”. 7 These revelations and sentiments are not expressed at the same level of risk as experienced by Medgar Evers, James Chaney, Michael Schwerner and Andrew Goodman fifty years ago. Still, it is never untimely to speak out against racism. Can such sentiments be directed to a contemporary consequence of segregation? Poverty, a lasting and destructive footprint of the politics of racial inequality, plays an ongoing role in this state by denying great numbers of citizens access to medical insurance and adequate health care.8 In 2006, Governor Mitt Romney of Massachusetts signed into law a comprehensive health care reform for his state. This plan had broad bipartisan political support, including endorsements from such diverse actors as Senator Jim DeMint and Senator Ted Kennedy. Governor Romney’s health care reform included organization of a health insurance exchange to facilitate access to competitive rates for private insurance, expansion of Medicaid, and a mandate that all citizens enroll in health insurance.9 The effects to date of Governor Romney’s health care innovation include a 60% drop in the uninsured population of Massachusetts to 4% of the state’s occupants (table 1).10 Life expectancy during the decade of Governor Romney’s health care reform has increased 3 years to 81 years, one the of the highest in the nation (table 2) 11-12 Governor Romney’s plan was the prototype for the Affordable Care Act, legislation identified with President Obama. This federal legislation would have extended the basic provisions of Governor Romney’s health care plan to the nation as a whole.13 Through a Supreme Court decision and legislative technicalities, however, the federal legislation has been unevenly applied. Mississippi has declined to organize a state insurance exchange or expand Medicaid. Some of the consequences of these policies are depicted in Tables 1 and 2. The state’s rate of uninsured occupants has decreased but most recently was estimated at 15% nearly 4 times the rate in Massachusetts. Life expectancy in Mississippi has had a minimal increase and is 6 years less than in Massachusetts. Among the many health indices where Mississippi ranks last in the nation, one of the saddest is infant mortality, where the death rate is twice that of Massachusetts (table 3). 14-15 320

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It took 50 years from the passage of the Civil Rights Act for this journal to publish a critique of segregation and health. By this essay, I bring the issue of poverty and health to these pages only 5 years after passage of the Affordable Care Act. The barricades of the classic civil rights movement are now more monuments than front lines. While legal segregation enforced health disparities 50 years ago, poverty does so now.8,16 Possibly, the Affordable Care has already played a role in Mississippi by being a factor in the slight increase in life expectancy and measurable decrease in uninsured inhabitants. One survey has shown that premiums for specific health insurances plans have decreased 24% (before tax credits) in the Jackson area in 2015, allowing lower income applicants better access to insurance.17 Without expanding Medicaid or organizing a state-run insurance exchange, however, the state of Mississippi has limited the impact the Affordable Care Act could have on the woeful health statistics of this state, statistics that translate into dead children and dead adults who could have otherwise expected longer, healthier lives with access to care resources. The arguments against fully implementing the Affordable Care Act have ghostly resemblances to Governor Wallace’s championing of segregation. In both cases, partisan and specious arguments fade before the realities of disease and death that could be alleviated through legislated change. It really is time for this journal and this state’s medical profession to confront the consequences of health care disparities in this state, initially by expanding Medicaid and organizing an insurance exchange under the Affordable Care Act.18 and further by examining expansion and reorganization of public health expenditures, maternal and infant health resources, trauma care, and tertiary care at the state’s only academic medical center. References 1. Carter DT. The Politics of Rage. New York, Simon and Schurter, 1995, p. 11

TABLE 1. Rate of uninsured citizens, Mississippi and Massachusetts

2. Clifford C. Counsel to the President. New York, Random House, 1991, pp. 208-212.

YEAR

MISSISSIPPI

MASSACHUSETTS

YEAR 2006

MISSISSIPPI 20%

MASSACHUSETTS 10%

YEAR 2006 2008

MISSISSIPPI 20% 18%

MASSACHUSETTS 10% 5%

2006 2008 2010

20% 18% 17%

10% 5% 6%

5. Dittmer J. Race and health care in Mississippi during the civil rights years. J Miss State Med Assoc. 2014;55:358-362;367-368.

2008 2010 2012

18% 17% 15%

5% 6% 4%

6. DeShazo R, Smith R, Skipworth LB. The meeting. J Miss State Med Asoc. 2014;55: 370-376.

2010 2012

17% 15%

6% 4%

7. Lampton L. An apology long overdue (editorial) J Miss State Med Assoc. 2014,55:370-376.

YEAR 2012

MISSISSIPPI 15%

MASSACHUSETTS 4%

8. Azevedo M (ed). The state of healthcare in Mississippi Jackson. U Press of Mississippi, 2015; pp 138-139.

YEAR 2000

MISSISSIPPI 74

MASSACHUSETTS 78

9. Halperin M, Heilemann J. Double down. New York, Penguin Book, 2014, pp 106-108.

YEAR 2000 2010

MISSISSIPPI 74 75

MASSACHUSETTS 78 81

2000 2010

74 75

78 81

YEAR 2010

MISSISSIPPI 75

MASSACHUSETTS 81

YEAR 2012

MISSISSIPPI 8.8

MASSACHUSETTS 4.3

YEAR 2012

MISSISSIPPI 8.8

MASSACHUSETTS 4.3

2012

8.8

4.3

TABLE 2. Life expectancy (years) in Mississippi and Massachusetts

TABLE 3. Infant mortality (Deaths per 1000 live births)

3. Powe L. The Warren Court and American politics. Cambridge, Harvard University Press, 2000, pp. 27-74; 217-302. 4. Egerton J. Speak now against the day: The generation before the civil rights movement in the South. Chapel Hill, UNC Press, 1994.

10. Wikipedia. Health insurance coverage in the United States. http://en.wikipedia.org/wiki/Uninsured -acccessed 2/9/15. 11. The State of Health: Life expectancy (2000), http:// statehealth.newamerica.net/node/77-accessed 4/20/15. 12. The Henry J. Kaiser Family Foundation: Life expectancy at birth. http://kff.org/other/state-indicator/life-expectancy/accesses 4/20/2015 13. Lineaweaver W. Life. liberty, the pursuit of happiness, and the Patient Protection Affordable Care Act. J Am Coll Surg. 2012; 69: 593-594. 14. MS Depart of Health: Infant deaths (table C11). Vital statistics Mississippi, 2012. 15. Mass Dept. Health: Massachusetts deaths 2012, table 29, p. 58. 16. Khuller O, Gillespie T, Nickleach D et al: Socioeconomic risk factors for long term mortality after pulmonary resection for lung cancer. J Am Coll Surg 2015; 220: 156-168. 17. Kaiser Family Foundation: Premium changes in the ACA’s health insurance marketplace, 2014-2015. JAMA 2015; 313:557. 18. Lineaweaver W. Medicaid expansion. J Miss State Med Assoc. 2013;54:352.

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I M A G E S

I N

M I S S I S S I P P I

M E D I C I N E

OUTH MISSISSIPPI CHARITY HOSPITAL, LAUREL, 1920—

This 1920 image of South Mississippi Charity Hospital, also known as Laurel Charity Hospital, opened in 1917 as a 125-bed hospital funded by the state of Mississippi. It served the needs of charity patients in the Pine Belt for 72 years, before closing in 1989. Besides serving as an early training ground for many of the state’s physicians, the hospital also operated a School of Nursing from 1919 to 1964, producing two generations of nurses in the area. The name changed in 1966 to the South Mississippi State Hospital. In 2011, the Mississippi Department of Archives and History placed a historic marker at the hospital site at 100 Buchanan Street. In 2004, much of the structure was destroyed by fire. The state’s charity hospital system dates to the early nineteenth century and included hospitals at Vicksburg, Laurel, Meridian, Natchez, and Biloxi. Although UMMC’s opening resulted in the closure of the Jackson Charity Hospital, others remained in operation until 1989, when Governor Ray Mabus proposed the closure of the last three remaining hospitals. Mabus asserted that the poor would be better served if the hospital money went into Medicaid and received the quite favorable federal funding match. If you have any old stories or factual data about the Laurel’s Charity Hospital, please contact me. Also, 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 MSMA. —Lucius M. “Luke” Lampton, MD; JMSMA Editor

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P O E T R Y

A N D

M E D I C I N E

his month, we print another poem by Robert Ray “Bob” McGee, MD, a Clarksdale internist. McGee writes under the pseudonym of Thomas Browne, MD. He recently published a lovely and brilliant volume of poetry entitled “Case Reports and Other Epiphanies,” printed by the Old Man’s Press of Clarksdale. He’s an accomplished and talented poet, publishing poems as early as 1980 in such publications as the “Annals of Internal Medicine” and “The Pharos.” A selection of his writing was also included in Dr. Trey Emerson’s “Avocation of Compassion,” published in 1989. To obtain a copy of his poetry collection, go to lulu.com or write to Dr. McGee directly at 303 Cypress Avenue, Clarksdale, MS 38614. This poem offers up a reflection on an ER happening in rural Mississippi, probably a full moon type of night, with physicians trying to survive the arduous, late-night work with gallows humor and glimpses into the lives of our varied patients. Tickets to paradise frequently get one there, but often in a prompt and unintended fashion. Look for more of his poems in coming journals. Any physician is invited to submit poems for publication in the journal, attention: Dr. Lampton or email me at LukeLampton@cableone.net.)—Ed.

ER Saturday Night — Robert Ray “Bob” McGee, MD, Clarksdale

He had a neat, round hole In the center of his head. He lay on the table Stone cold and dead. In his pockets we found A pair of dice. I rolled them once, rolled them twice, Just to be sure, I rolled them thrice. Sevens and elevens, nothing more, Were the only numbers They would score. Don’t know whose gun Put the lead dead center in his head, But I’ve wondered since If the pair of dice Had been his ticket to paradise. –Thomas Browne, MD Clarksdale

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