VOL. LVII • NO. 9 • 2016 by Journal MSMA

VOL. LVII • NO. 9 • 2016

Lee Voulters, MD • 2016-17 MSMA President

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VOL. LVII • NO. 9 • SEPTEMBER 2016

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

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

SCIENTIFIC ARTICLES Top 10 Facts You Should Know about “Alpha-gal,” the Newly Described Delayed Red Meat Allergy Kristen Ramey, M4 and Patricia H. Stewart, MD

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Assessment of Secondary Causes of Osteoporosis and Racial 285 Differences in Men with Normal vs. Abnormal Bone Mineral Density in a Cohort of Men Undergoing Bone Mass Measurement Khush Aujla, MD and Vikas Majithia, MD, MPH

The Spice of Life…and Death: A Case Presentation 289 and Review of Synthetic Marijuana Use in Mississippi James Wilkinson, DO; Jessica McCallister Tullos, DO; Brian Rifkin, 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 Leslie E. England, MD Ex-Officio and the Editors

Speaker Geri Lee Weiland, MD

DEPARTMENTS From the Editor – ObamaCare’s War on Small and Rural Lucius M. Lampton, MD, Editor

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Vice Speaker Jeffrey A. Morris, MD

MSMA Physicians Leadership Academy- Hossein Behniaye, MD

283

MSMA – Recap of the 2016 Session of the MSMA House of Delegates

292

MSMA – Big Discounts for MSMA Physicians

295

Legalese – Charity Care - Conner Reeves, JD President’s Page – The Inaugural Address of the 149th President Lee Voulters, MD

296 297

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

Editorial – Mississippi Health Disparities, Bias, and Social 301 Justice in Health: Mississippi Physician Leadership Is the Best Rx Richard deShazo, MD and Sara Parker, BA Editorial – Call It What You Will D. Stanley Hartness, MD

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RELATED ORGANIZATIONS UMMC – Big Problem, Bigger Award: NIH funds UMMC Obesity Research

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ABOUT THE COVER Lee Voulters, MD • 2016-17 MSMA President– The 149th president of the Mississippi State Medical Association, Lee Voulters, MD., is a neurologist practicing at Memorial Hospital in Gulfport. Dr. Voulters grew up in the United Kingdom attending medical school at the University of London and later completing his MBA at George Mason University. His training included serving as house physician and later house surgeon at the Royal Free Hospital in London and as chief resident in neurology at the University of Western Ontario in Canada. He completed his fellowship in movement disorders at the Neurological Institute, College of Physicians and Surgeons at Columbia University. He is the first internationally trained president of MSMA. In his inaugural address, Dr. Voulters pledged to diversify MSMA’s membership to better represent all physicians in the state. He plans to focus his tenure on advancing MSMA in three strategic areas: funding for stroke treatment and prevention, state-regulation for telemedicine, and improving medical coverage for all Mississippians. Dr. Voulters lives in Pass Christian with his wife, Christie.n VOL. LVII • NO. 8 • 2016

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.

Lee Voulters, MD • 2016-17 MSMA President

Official Publication

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F R O M

T H E

E D I T O R

ObamaCare’s War on Small and Rural

ne of the principal architects of ObamaCare, Dr. Bob Kocher, recently admitted that a central premise of the expansive health care act is flawed and “wrong.” [“I was wrong about ObamaCare.” The Wall Street Journal, August 1, 2016.] At the time of the act’s passage in 2010, Kocher, along with other ACA advisors, forcefully argued that the “consolidation of doctors Lucius M. Lampton, MD into larger groups” and the mergers of Editor small hospitals into larger ones were not only inevitable but “desirable.” Kocher now confesses regretfully, “Well, the consolidation we predicted has happened…Now I think we were wrong to favor it.” Why? Research is showing that innovation, savings, and quality improvement are best achieved by independent primary care physicians and small hospitals rather than those owned by large hospital-centric health systems. It gets back to the physician-patient relationship and how maintaining that old-fashioned personalized interaction best serves the patient and the system.

Last year saw 112 hospital mergers across the United States; many of these were small rural hospitals forced to merge by the ACA’s regulations in order to stay open. Medicare cuts and new rules have not only devastated rural hospitals, but also undercut fragile private physician practices. Here in Mississippi, several rural hospitals have closed and the nonpartisan Center for Mississippi Health Policy warns that of the state’s 94 hospitals, 31 are at risk of closure, most of them small and rural. Ask any small private practice physician, if you can find one, how they are faring since the rollout of the law. They will tell you they are facing closure, merger, or reinvention to keep their doors open. Now that the drafters of ObamaCare have admitted that the law declared war on small hospitals and practices, how is this tragic flaw fixed? Dr. Kocher asserts the urgent need to “write rules to make it easier” for small independent practices “to thrive…and don’t tip the scales toward consolidation.” Unfortunately, the damage has been done, the code has been called, and most of the doors are already closed in small and rural venues. For many in rural America, ObamaCare’s mea culpa has come too late.

— Lucius M. Lampton, MD, Editor

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

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

Michael Artigues, MD Pediatrician, McComb Children’s Clinic

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

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

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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

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

Lillian Lien, MD Professor and Director, Division of Endocrinology, University of Mississippi Medical Center, Jackson

Maxie L. Gordon, MD Assistant Professor, Department of Psychiatry and Human Behavior, Director of the Adult Inpatient Psychiatry Unit and Medical Student Education, University of Mississippi Medical Center, Jackson

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

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

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

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

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Top Ten Facts You Should Know about “Alpha-gal,” the Newly Described Delayed Red Meat Allergy Kristen Ramey, M4 and Patricia H. Stewart, MD Research supports a link between the bites of certain ticks and allergy to red meat. The responsible lone star ticks inhabit Mississippi. In sensitized individuals, allergy to a substance called “alpha-gal” found in red meat triggers allergic reactions several hours following red meat consumption.

1 2

Alpha-gal is short for galactose-α-1,3-galactose. Alpha-gal is a carbohydrate expressed on the surface of glycolipids and glycoproteins of most mammals.1-4 Humans lack 3-galactosyltransferase required for alpha-gal synthesis, so they cannot manufacture or express alpha-gal themselves.5 However, they are still capable of producing IgG, IgM, and IgE antibodies to alpha-gal when exposed to it.5

Tick bites appear to serve as vectors for alpha-gal and can trigger patients to make IgE to alpha-gal. This results in IgE sensitization to alpha-gal (see Figure 1).5,6 Although the exact mechanism is unknown, isotype switching to IgE is thought to occur in the skin following a bite from either larval or adult ticks. 7 Tick bites expose mammals to either tick salivary proteins, glycoproteins and glycolipids from the tick’s last blood meal, or other tick proteins. All are potential sources of alpha-gal that can trigger production of IgE and sensitization to it.5,7

Figure 1. Proposed Mechanism of Alpha-gal Sensitization

Additional supporting evidence that tick bites are the major source for production of alpha-gal specific IgE include IgE to alpha-gal increasing in humans after tick bites, reports of pruritus after tick bites correlating with the presence of alpha-gal in human serum, and IgE to alpha-gal correlating with the presence of IgE in lone star tick extract. In areas where lone star ticks are not present, IgE to alpha-gal is absent.8

Person makes IgE to alpha-gal and is thus sensi zed.

Lone star ck takes blood meal which includes alpha-gal from a deer.

The same lone star ck takes a blood meal from a person and exposes the person to alpha-gal.

Person eats meat and develops an allergic reac on.

The lone star tick, Amblyomma americanum, and the resulting “alpha gal” allergy are found in the Southeastern United States.5,7 The lone star tick, which serves as the vector for alpha-gal sensitization, is found primarily in the Southeastern United States, but over the years, this geographic distribution has expanded to as far north as Maine.5,6,8 Other ticks have also been identified as vectors in different countries.

Alpha-gal is present on the surface of glycolipids and glycoproteins (including chylomicrons), which are slowly absorbed into human circulation; therefore, the delay in symptoms after meat exposure in allergic individuals is thought to be related to slow mediator release triggered by low-density lipoproteins (LDL) and very low-density lipoproteins (VLDL), the metabolic breakdown products of these chylomicrons. 6 Alpha-gal is present on the surface of LDL and VLDL. In sensitized individuals (who exhibit IgE antibodies to alpha-gal), cross-linking IgE results in mast cell degranulation and clinical symptoms.6 Because chylomicron packaging and lipid absorption into the lymphatic system takes time, the clinical manifestations of the resulting ”alpha-gal” allergic reaction do not appear for several hours.10

History is key to suspecting delayed red meat allergy.11 Delayed urticaria, angioedema, or anaphylaxis after consuming red meat should prompt consideration for “alpha-gal” allergy as part of the differential diagnoses.11 Unlike classic food allergies which typically present between 5-30 minutes after ingestion, patients allergic to red meat because of “alpha-gal” allergy generally do not become symptomatic until 3-6 hours following red meat ingestion.12,13 JOURNAL MSMA

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Patients may have reactions that awaken them from sleep. Because the time between symptom onset and ingestion of alpha-gal may be separated by hours, the association can be difficult and may be overlooked.12 The clinical picture can be further complicated since they may tolerate red meat for years before the symptoms begin7 and every red meat ingestion might not trigger a reaction.12,13 Any time a delayed red meat allergy is suspected, questions about a history of a previous tick bite are appropriate. A americanum bites can cause intense pruritus that can continue for weeks, which makes them memorable for many patients.7,11,14.

6 7

Many animal meats that express alpha-gal fall into the “red meat” category. These animals include: beef, pork, lamb, squirrel, rabbit, horse, goat, venison, kangaroo, seal, whale.6,10,15 All of these should be avoided in patients with “alpha-gal” allergy. Patients sensitized to alpha-gal should tolerate chicken, turkey, and fish.6,7 Venison prepared by a hunter contains minimal fat and might be tolerated versus venison preparations by a butcher that might include pork fat and cause a reaction. 6

If history is suggestive of “alpha gal” allergy, testing is available but results must be interpreted with appropriate clinical correlation. The initial diagnostic approach includes obtaining both IgE levels to alpha-gal and to the suspected individual red meats containing alpha-gal.11 Serum IgE to alpha-gal should be present, but changes in titers are not directly correlated to symptom timing nor severity.13 Also, patients who have not experienced red meat allergy symptoms can test positive for IgE titers to alpha-gal and beef. This creates the necessity for clinical correlation to prevent misdiagnosis of red meat allergy. The typical patient with ”alpha gal” allergy has elevated IgE titers to galactose-α-1,3-galactose, beef, lamb and pork with negative IgE titers to chicken, turkey, and fish.11 Despite oral food challenge being the gold standard for classic food allergy, it is not currently recommended for “alpha-gal” allergy diagnosis due to the delayed nature of the reaction.11

There is cross-reactivity between alpha-gal and other proteins including those in cow’s milk3 and gelatin.15 Alpha-gal is a cross-reactive carbohydrate determinant that may cause patients to demonstrate specific IgE to cat, dog, and cow’s milk proteins; this cross-reactivity may not be clinically significant.3 On the other hand, gelatin from mammals is found in multiple foods and could serve as a covert trigger for allergic symptoms.11, 15 Gelatin-containing foods include confectioneries (marshmallows, food thickeners, glazes, icing) and fat substitutes (yogurt, mayonnaise, ice cream, sausage coatings, salami, tinned hams, meat stock).6,15 Gelatin can also be found in certain vaccines such as influenza, MMR, and varicella, but alpha-gal sensitization relative to tolerance of gelatin-containing vaccines has not been investigated.11 It is important to keep these cross-reactive foods in mind if a patient has been identified as red meat allergic and has eliminated red meats but remains symptomatic.

Treatment recommendations for “alpha gal” allergy include avoiding consumption of all red meats and carrying an epinephrine auto-injector. As in classic food allergy, cooking methods (rare vs. well done) would not be expected to alter red meat tolerance.11 All red meats previously listed should be avoided and, if accidentally ingested, reactions should be treated accordingly. Anaphylaxis should be treated with intramuscular epinephrine. Because the natural course of “alpha gal” allergy is currently unknown, the decrease in alpha-gal titers seen over time has not been correlated to future reactivity.6,15

− − − − − − −

Tick bite avoidance is the only known method to prevent alpha-gal sensitization. Suggestions for avoiding tick bites include:6,9,11 Wear protective clothing, preferably treated with 0.5% permethrin. Use repellents with 20-30% N,N-diethy-meta-toluamide (DEET) on exposed skin surfaces. Avoid tall grass/leaf litter and travel along the center of trails. Carefully examine gear and pets and remove ticks prior to coming indoors. Bathe/shower within 2 hours of returning indoors to identify and wash off ticks that may be crawling on the body. Tumble clothes in a dryer for 1 hour using high heat to kill remaining ticks. Use extra precautions during April through September when ticks are most active.

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Figure 2. Lone Star tick, Amblyomma americanum. Image by Michael L. Levin, PhD, obtained from the Centers for Disease Control and Prevention.9 Figure 3. Geographic distribution of the Lone Star tick as of 2011. Figure obtained from the Centers for Disease Control and Prevention.9

Figure 2.

Figure 3.

Because of the complexity of “alpha-gal” allergy, consultation with an Allergist/ Immunologist should be considered.

References 1.

Galili U. The alpha-gal epitope and the anti-gal antibody in xenotransplantation and in cancer immunotherapy. Immunol Cell Biol.2005; 83:674e686.

2. Macher BA, Galili U. The Gala1,3Galb1,4G1cNAc-R (a-gal) epitope: a carbohydrate of unique evolution and clinical relevance. Biochim Biophys Acta. 2008;1780:75e88. 3. Commins SP, Platts-Mills TAE. Anaphylaxis syndromes related to a new mammalian cross-reactive carbohydrate determinant. J Allergy Clin Immunol. 2009;124:652e657. 4.

Commins SP, Platts-Mills TAE. Tick bites and red meat allergy. Curr Opin Allergy Clin Immunol. 2013;13:354e359.

Steinke J, Platts-Mills TAE, Commins SP. The alpha-gal story: lessons learned from connecting the dots. J Allergy Clin Immunol. 2015;135:589e596.

6. Tripathi A, Commins SP, Heymann PW, Platts-Mills TAE. Delayed anaphylaxis to red meat masquerading as idiopathic anaphylaxis. J Allergy Clin Immunol Pract. 2014;2:259e265. 7. Commins SP, James HR, Kelly LA, et al. The relevance of tick bites to the production of IgE antibodies to the mammalian oligosaccharide galactose-a-1,3-galactose. J Allergy Clin Immunol. 2011;127:1286e1293. 8. Platts-Mills TAE, Schuyler AJ, Tripathi A, Commins SP. Anaphylaxis to the carbohydrate side chain alpha-gal. Immunol Allergy Clin North Am. 2015;35:247e260. 9.

Centers for Disease Control and Prevention Website. http://www.cdc.gov. Accessed July 17, 2016.

10. Commins SP, Platts-Mills TAE. Allergenicity of carbohydrates and their role inanaphylactic events. Curr Allergy Asthma Rep. 2010;10:29e33. 11. Stewart PH, McMullan KL, LeBlanc SB. Delayed red meat allergy: clinical ramifications of galactose-α-1,3-galactose sensitization. Ann Allergy Asthma Immunol. 2015;115(4):260-264. 12. Commins SP, Satinover SM, Hosen J, et al. Delayed anaphylaxis, angioedema, or urticaria after consumption of red meat in patients with IgE antibodies specific for galactose-alpha-1,3-galactose. J Allergy Clin Immunol. 2009;123:426e33. 13. Commins SP, James HR, Stevens W, et al. Delayed clinical and ex vivo response to mammalian meat in patients with IgE to galactose-alpha-1,3-galactose. J Allergy Clin Immunol. 2014;134:108e115. 14. Wolver SE, Sun DR, Commins SP, Schwartz LB. A peculiar cause of anaphylaxis: no more steak? J Gen Intern Med. 2013;28:322e325. 15. Mullins RJ, James H, Platts-Mills TAE, Commins S. Relationship between red meat allergy and sensitization to gelatin and galactose-a-1,3-galactose. J Allergy Clin Immunol. 2012;129:1334e1342.

Author Information Kristen Ramey, M4, and Patricia H. Stewart, MD University of Mississippi Medical Center Department of Medicine Division of Clinical Immunology and Allergy 2500 N. State Street Jackson MS, 39216

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M S M A

This is part of a spotlight series on the MSMA Physician Leadership Academy class of 2016.

Hossein Behniaye, MD

r. Hossein Behniaye was born in Tehran, Iran, and moved to the United States after high school to pursue a career in medicine. He graduated from the University of Toledo College of Medicine in 2005 and completed his residency there in 2007. He specializes in Family Medicine with Brooklyn Family Health Clinic in Brooklyn, Mississippi. Growing up in Iran, Dr. Behniaye saw firsthand the impact healthcare disparities have on families. “The sudden death of the breadwinner of a household from an ignored or undiagnosed medical condition would deprive the next generation from fulfilling their potentials as they now have to care for the family through low-paying jobs rather than attending school,” he explains. He chose to become a physician with the hope of minimizing the effect of these disparities. After moving to the United States for school, he learned that such haunting disparities are not limited to his home country. He chose to specialize in Family Medicine as it can be applied to many medical conditions and treatments, and allows the physician to evaluate the patient’s need for and access to specialized care. “I thought by caring for entire families, this specialty would be the best fit for my goal of reducing the disparity gap.” As a physician, he believes in educating patients in non-jargon language about their medical condition. “In so doing, I cultivate compliance and empower patients to become an advocate for their own health and the health of their family,” he says.

“I

want my patients to remember me for providing the best, safest and most compassionate care. I hope my work will affect the lives of my patients and impact future generations in their families. That’s my true goal,” he explains, “to contribute to the betterment of mankind beyond and above my lifetime.” n

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Your patients can enjoy a healthier life. They just need a little extra motivation. Motivated to Live a Better Life is a free six-week workshop designed to help Mississippians better manage chronic conditions and take the right steps to lead a healthier, more active life. Learn more about this evidence-based approach to health management by calling the Mississippi State Department of Health Office of Preventive Health at 601-206-1559 or visiting HealthyMS.com/MLBL.

Motivated to Live a Better Life is licensed by the Stanford University Chronic Disease Self-Management JOURNAL Program. MSMA 284

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Assessment of Secondary Causes of Osteoporosis and Racial Differences in Men with Normal vs. Abnormal Bone Mineral Density in a Cohort of Men Undergoing Bone Mass Measurement KHUSH AUJLA, MD AND VIKAS MAJITHIA, MD, MPH Summary Osteoporosis is a condition generally associated with older women, but it is rapidly becoming a growing problem for males as well. Screening and treating men early is the only way to address this problem. The known demographic factors of osteoporosis in males such as age, race and BMI as well as secondary causes of low bone mineral density (BMD) i.e. osteoporosis, have not been well examined in the actual practice setting based on available literature. This study aims to describe the prevalence of the demographic factors and secondary causes in men with low BMD and also to assess their individual contribution to the overall prevalence. A retrospective chart review of 585 men who underwent bone density scan at the University of Mississippi Medical Center from 2005-2012 was performed. At the time of their scans, patients were also asked to complete a questionnaire assessing demographics, comorbidities, social factors, and medication use. The results suggest that racial difference and differences in secondary causes exist in the epidemiology of male osteoporosis, and this needs to be assessed further. The notion that African American males are protected from OP is unsupported in our data as well as the literature. Overall our research demonstrated that low BMI is the most important factor associated with low BMD in male patients. Introduction As the American population continues to age, there is a greater need for early prevention of traumatic medical events. Osteoporosis (OP) is the greatest risk factor for a disabling bone fracture in elderly patients, with the highest prevalence in postmenopausal females and a growing burden in the healthcare of elderly males. By the year 2030 the prevalence of OP is expected to increase by 50% in men, and by the year 2050 the number of hip fractures is expected to increase to 13 million, of which 31% will be in males.1 A surgeon general report on bone disorders in 2004 estimated that the annual direct care burden of OP was between 12 billion to 18 billion dollars.2 What is more concerning is the impact a hip fracture can have on mortality in elderly patients. A recent study looking at over 60,000 nursing home residents who had been hospitalized for hip fractures found that over

36% of these patients died within 180 days of their fracture and that men tended to have a higher annual mortality rate post hip fracture then females of similar age.3 An appreciation of the burden OP can place on an elderly male makes it imperative to have strong preventative measures. The current United States Preventative Service Task Force (USPSTF) guidelines for OP have clear recommendation for screening women, but the USPSTF recommendation for screening males for OP is a grade I, i.e. insufficient evidence to assess the balance between benefits and harms of screening and is likely due to a lack of evidence on various aspects of male OP.4 This is an unfortunate gap in preventative medicine since the predictive value of a bone density scan for osteoporosis is comparable between postmenopausal women and elderly males.5 The known demographic factors of OP in males such as age, race and BMI as well as secondary causes of low BMD have not been well examined in the actual practice setting based on available literature. This study aims to describe the prevalence of the demographic factors and secondary causes in men with low BMD at the University of Mississippi Medical Center and also to assess their individual contribution to the overall prevalence. We hypothesize that there is a difference in the prevalence of factors such as age, race, glucocorticoid use, smoking, and secondary comorbidities with low BMD in our Mississippi male population. Specifically we ask the question, which factors are most closely associated with low BMD in our UMMC male population? Methods A retrospective chart review of 585 men who underwent DEXA scan performed at UMMC from 2005-2012 was performed. Of these 585 men, 410 were Caucasian, 175 were African-American. From these records, the prevalence of low BMD was calculated using the World Health Organization (WHO) diagnostic classification to bone mass density and is as follows: normal: BMD: T ≥ -1; low bone mass “Osteopenia”: BMD: -2.5 < T < -1; Osteoporosis: BMD: T ≤ -2.5. At the time of their DEXA scans, patients were also asked to complete a questionnaire distributed to assess prevalence of the following:

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demographic factors (height, weight, Body Mass Index [BMI]), secondary causes (family history of low bone density or medical comorbidity associated with OP), glucocorticoid use, and smoking. Thyroid disorders, hyper-parathyroid disorder, diabetes, asthma/ COPD, RA, mixed connective tissue diseases, and malignancy were all analyzed separately, as well as combined category. These results were then abstracted, tabulated and analyzed using STATA software. The statistical significance of these results was assessed using T-test and Odds ratio as appropriate. Patients were divided into normal bone density and an osteoporotic group based on each variable assessed, with osteopenia patients being omitted from the analysis due to small sample size. Results The following variables were highlighted as being closely associated with low BMD in our UMMC cohort. The mean age for the normal BMD and OP group was within two years of each other, with a mean age of 57.59 years and 59.34 years respectively. In this cohort of patients undergoing DEXA scan, low BMD was seen more commonly in 53/175 African American males (30.28%) versus 90/410 white males (21.95%), and these African American males were younger (mean age 56.04) as compared to their white counterparts (mean age 62.64), though not statistically significant. There were a number of factors assessed with OP. Amongst these, low BMI had a statistically significant correlation with low BMD, with the normal bone density group having a mean BMI of 31.74 while the osteoporosis group had a BMI of 26.07. This association was present in both African American and white males. (Table 1) Table 1. The relationships between bone mineral density and demographic factors in our study demonstrate BMI as a better predictor of osteoporosis then age and race. Normal Bone Density

Osteoporosis (T-Score < -2.5)

Age (Mean)

57.59 years

59.34 years

p-NS

16.72

African Americans

55.33 years

56.04 years

P-NS

17.37

Caucasians

62.80 years

62.64 years

P-NS

16.90

BMI (Mean)

31.74

26.07*

*p<0.001

6.30

African Americans

33.18

26.63*

*p<0.001

7.66

Caucasians

30.30

25.51*

*p<0.001

5.66

Demographics

P-value

Mean Standard Deviation

Glucocorticoid use (>5 mg), was more frequent with low BMD vs. normal BMD (32.86% vs. 28.37%) but not statistically significantly. Smoking was significantly more prevalent with OP (36.06% vs. 15.15%). Table 2 Table 2. The correlation between steroid use and bone mineral density is unclear in our study, while smoking shows a negative correlation with osteoporosis.

Steroids/Smoking

Normal Bone Density

Osteoporosis (T-Score < -2.5)

Steroids >5 mg

28.37%

32.86%

p-NS

Smoking

15.15%

36.06%

*p<0.01

286 VOL. 57 • NO. 9 • 2016

P-value

Secondary medical disorders were prevalent in the cohort (>70% of patients) but had no significant difference in the prevalence in patients with low BMD when compared to patients with normal BMD (80.32% vs. 69.69%). No difference was seen in any specific disorder except asthma/COPD, which was more prevalent in those with low BMD (16.10%) when compared to patients who had normal BMD (6.75%). Of interest, rheumatoid arthritis (RA) was more prevalent in the low BMD group, 16.66% vs. 10.60%, but without statistical significance. The results suggest that racial difference and differences in secondary causes exist in the epidemiology of male osteoporosis, and this needs to be assessed further . Table 3 Table 3. The association between bone mineral density and secondary comorbidities in our study show an association between asthma/COPD and osteoporosis.

Secondary Causes

Normal Bone Density

Osteoporosis (T-Score < -2.5)

P-value

Any Disorder

69.69%

80.32%

p=0.11

Thyroid D/o

13.63%

16.39%

p-NS

Hyper-PTH

4.54%

3.27%

p-NS

Diabetes

28.78%

16.39%

p-NS

Asthma/COPD

6.75%

16.10%

*p<0.05

10.6%

16.66%

p-NS

Other Connective Tissue Disorders

7.57%

13.11%

p-NS

Malignancy

18.18%

22.95%

p-NS

Discussion To better understand an individual’s risk of fracture, the Fracture Risk Assessment Tool (FRAX) was developed to determine the importance of various demographic factors, secondary factors, and bone mineral density (BMD) in OP. The reference values for BMD is derived from data on women studied in the National Health and Nutritional Assessment (NHANES III) study.6 The original FRAX result was presented in 2008 after using multiple cohorts from around the world that included males and females. However, during the validation process only 1 out of the 9 cohorts included males. This has led many to question the value of the FRAX tool when assessing male fracture risk, and the American College of Physicians has recommended that further research is needed to evaluate OP screening in men.7 Demographic Factors One of the main goals of this study was to understand how well demographic factors like race, age, and BMI were correlated with a low BMD in our Mississippi male population. The NHANES III study, from which the United States data set on BMD for females over the age of 50 was collected, indicated that non-hispanic white women had a 1.3-2.4 higher prevalence of osteoporosis than non-hispanic African American women.8 The results from this retrospective cohort do not support the notion that African American males were protected from osteoporosis; instead, osteoporosis was seen in a higher population of African American males and at a younger age in our cohort, though it was not statistically significant. A recent study assessing race/ethnic differences in BMD assessed 5 independent cohorts and found no

difference in prevalence of OP between whites and African American males.9 Studies have shown that clinician bias towards African American women leads to a disparity in OP screening and treatment of African American women vs. white women, and the same race discrimination may also be prevalent when dealing with male OP.10 Age is believed to be one of the best predictors for fracture risk in postmenopausal females, but this was not shown in males in this cohort. The mean age for males in this cohort was around 60 years, and the majority of our patients with OP were below the age of 65 yrs. This suggests that recommended screening age of 65 for females may not be applicable to males, and the initial screening may have to occur at a different/later age. This may be due to a steady but slow decline of bone density in males as shown by KHANES IV trial.11 Since males and females undergo BMD deterioration differently, screening guidelines based on age should be based on gender. Our study suggests that the association between age and low BMD in males may only become relevant at an advanced age, though the cutoff for such an age remains unclear. Our results also showed that BMI was a strong indicator of low BMD in males regardless of race. Evaluation of clinical decision tools such as the Osteoporosis Self Assessment Tool (OST), which relies only on advanced age and a weight below 60 kg, showed BMI to be a strong predictor for osteoporosis.12 Since a low BMI is a risk factor for low BMD, this begs the question, does a high BMI protect against osteoporosis? Lloyd et al compared BMD and BMI in 3296 patients from NHANES data from 2005-2008, and showed that every unit increase in BMI provided increase BMD regardless of age, gender, and race.13 Obesity will never practically be suggested to the patient, but it highlights the importance of assessing BMI in screening patients at risk for OP and fractures. Secondary Factors Glucocorticoid use > 5mg was correlated with low BMD in our cohort, though it did not reach a statistically significant level. The role of glucocorticoid-induced osteoporosis (GIOP) has been well established in the literature, and GIOP is believed to cause fractures in postmenopausal females at a higher BMD and higher T-scores then WHO identified as OP(-1.5 vs. -2.5).14 Majumdar et al looked at preventative care for GIOP in 17,000 patients newly started on steroid therapy and found only modest increase in BMD testing and OP treatment. More troubling was their result that high quality GIOP preventative care was apparent in only 13% of men vs. 34% of women.15 Despite the understanding of GIOP, there is concern that men on these medications are being undertreated. Smoking was one of the best predictors of low BMD in our UMMC male cohort, with over twice the prevalence in the OP group. These results follow similar findings in literature, which indicated that both current smokers and former smokers had an increased risk of any location fracture, RR 2.71 and 1.66 respectively.16 Smoking cessation led to a gradual decline in the risk of fracture, though in some cases it took up to 30 years to return to normal. This supports smoking assessment in males at risk for OP, with smoking cessation being highly recommended.

For our UMMC male patients, secondary disorders were very prevalent in both the OP and normal BMD groups, but only asthma/ COPD reached statistical significance. Considering the association between smoking and COPD and steroid use in asthma patients, it is logical to correlate asthma/COPD with OP. Studies have shown very high prevalence of OP in COPD patients (upwards of 59%), and several studies suggests that COPD needs to be an important variable in OP risk assessment.17 RA is the only secondary disorder accounted for in the FRAX calculator, and our cohort showed only a minor increase in prevalence of RA in the OP group. Though RA has been associated with OP in female studies, the literature on the association between RA and OP in males remains unimpressive. The risk of OP in RA males may be age dependent, as one study showed a significant hazard ratio in women with RA under the age of 50 but not in men, HR 1.95 vs. 0.82 respectively.18 Further analysis of RA in males will be needed to determine proper guidelines for the disease. This data has significant limitations. First and foremost it is based on retrospective analysis of prospective data which introduces a number of inherent biases, including sampling or selection bias. There are possibilities of incomplete documentation, missing variables and lack of cross-verification of the medical diagnoses not done due to lack of availability of EMR and out-of-institution referrals. In addition a low number of patients with secondary causes raise doubt in validity. Nonetheless, the results provide an important insight into male osteoporosis and its potential associations on which there is limited information available and can form a strong basis for future studies. Based on our research, low BMI, smoking, and asthma/COPD are factors found to have a statistically significant association with low BMD. Age, steroid use, and RA are all factors assessed in FRAX but appeared to be poor indicators of low BMD in our population of males. Finally, the concept of African American race vs. white race being a protective factor against OP was not appreciated in our study. Conclusion These results highlight that the racial differences in prevalence and effect of underlying factors need to be better quantified in population studies of men with OP. The notion that African American males are protected from OP is unsupported in the literature and may lead to poor management of these patients. Our research demonstrated that low BMI, asthma/COPD, and smoking were found to be more prevalent in the male patients with low BMD and, therefore, are potentially of more use in determining risk. This may have significant implications on the decision to consider screening for OP in males. Currently our basis for OP screening are centered around understandings found in largely female studies, and this potentiates the issue of misinterpreting risk factors in male cohorts. Given the mortality and morbidity associated with fractures in elderly males, we recommend more studies dedicated to assessing risk factors for OP in males. When considering future studies, we kept in mind the limitations of our study, namely the retrospective design and small sample size. In the future, we hope to improve the study by extending it to include more years of data and attempting to gather more information about any possible correlation with low BMD. n

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References 1. Cosman F, de Beur SJ, LeBoff MS, et al. Clinician’s guide to prevention and treatment of osteoporosis: Osteoporosis Int; 2014; 25: 2359-81. 2. Editors office of the surgeon general. Bone health and osteoporosis: Report of the Surgeon General. 2004. 3 . Neuman MD, Silber JH, Magaziner JS, et al. Survival and functional outcomes after hip fracture among nursing home residents. JAMA Intern Med. 2014;174:1273-80. 4. Nelson HD, Haney EM, Dana T, et al. Screening for osteoporosis: an update for the U.S. preventive service task force. Ann Intern Med. 2010;153:99-111. 5. U.S. preventative task force recommendation statement. Screening for osteoporosis: U.S. preventative services task force recommendation statement. Ann Intern Med. 2011;154:356-64. 6. McCloskey E, Kanis JA. FRAX update 2012. Curr Opin Rheumatol. 2012;24:554-60. 7. Qaseem A, Snow V, Owens DK, et al. Screening for osteoporosis in men: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2008;148:680-4. 8. Looker AC, Johnston CC, Lindsay RL, et al. Prevalence of low femoral bone density in older U.S. women from NHANES III. J Bone Miner Res. 1995;10:796-802. 9. Shin MH, Zmuda JM, Cauley JA, et al. Race/ethnic differences in associations between bone mineral density and fracture history in older men. Osteoporosis Int. 2014; 25: 837-45. 10. Miller RG, Ashar BH, Schneyer CR, et al. Disparities in osteoporosis screening between at-risk-African-American and white women. J Gen Intern Med. 2005;20:847-51. 11. Kim KM, Lim JS, Lim SK. Dissimilarity of femur aging in men and women from a nationwide survey in Korea (KNHANES IV). J Bone Mineral Metabolism. 2013;31:144-52.

12. Anders ME, Turner L, Freeman J. Evaluation of clinical decision rules for bone mineral density testing among white women. J Osteoporosis. 2013; 2013: 792831. 13. Lloyd JT, Alley DE, Orwig DL, et al. Body mass index is positively associated with bone mineral density in U.S. older adults. Arch Osteoporosis. 2014;9:175. 14. Mazziotti G, Canalis E, Giustina A. Drug-induced osteoporosis: mechanical and clinical implications. Am J Med. 2010;123:877-84. 15. Majumdar SR, Lix LM, Yogendran M, et al. Population-based trends in osteoporosis management after new intiations of long-term systemic glucocorticoids (1998-2008). J Clin Endocrinol Metab. 2012;97:1236-42. 16. Olofsson H, Byberg L, Mohsen R, et al. Smoking and the risk of fracture in older men. J Bone Miner Res. 2005;20:1208-15. 17. Lehouch A, Boonen S, Decramer M, et al. COPD, bone metabolism, and osteoporosis. Chest. 2011;139:648-57. 18. Amin S, Gabriel SE, Achenbach SJ, et al. Are young women and men with rheumatoid arthritis at risk for fragility fractures? A population based study. J Rheumatol. 2013;40:1669-76.

Author Information Preliminary Intern PGY 1 (Dr. Aujla); Division Chief Rheumatology, University of Mississippi Medical Center (Dr. Majithia). Corresponding Author Vikas Majithia, MD, MPH Division of Rheumatology University of Mississippi School of Medicine 2500 N. State Street, L-002 Jackson MS, 39216 Email: kaujla@umc.edu.

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288 VOL. 57 • NO. 9 • 2016

S C I E N T I F I C

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The Spice of Life…and Death: A Case Presentation and Review of Synthetic Marijuana Use in Mississippi JAMES WILKINSON, DO, PGY-2; JESSICA MCCALLISTER TULLOS, DO, PGY-1; BRIAN RIFKIN, MD

Introduction Synthetic cannabinoids are man-made drugs that are synthetic compounds of delta-9-tetrahydrocannabinol, which is the primary psychoactive cannabinoid in marijuana. They have a reputation for similar psychoactive effects as marijuana but have many more serious side effects including renal failure, seizures, various cardiovascular effects and even death. Since their initial appearance in 2008, these drugs have continued to increase in variety due to manufacturers creating new products to replace those banned by legislation. Despite the DEA and Mississippi placing these drugs as Schedule I Narcotics, there continue to be increased hospitalizations due to acute intoxication with these harmful synthetic drugs. Continued research into new chemical compositions and their clinical effects on the body, and development of rapid detection assays are needed to stem the growing epidemic of synthetic cannabinoid use. Synthetic cannabinoids, street drug abuse, drug Key Words: induced renal failure Case Presentation A 24-year-old male presented to the emergency room with status epilepticus of unknown duration. He was given IV Fosphenytoin and Lorazepam in the emergency room with resolution of his seizure activity. His past medical history was notable for closed head trauma during a motor vehicle accident 7 years prior with no residual effects. The patient did not take any medications on a regular basis. He did admit to smoking “Spice” in the 24 hours prior to admission. Workup included a head MRI and an EEG during his hospitalization, with neither result revealing significant abnormalities. Initial blood work showed a creatinine of 2.3 mg/dL and a CPK of 9,700 IU/L. A repeat CPK showed an increase to 37,000 IU/L. Urine toxicology was negative for Tetrahydrocannabinol. During the patient’s hospitalization, his creatinine peaked at 7.8 mg/dL, but he did not require dialysis. His creatinine spontaneously resolved back to his baseline of 1.1 mg/dL two weeks after his discharge. The neurologist who evaluated the patient felt that the prolonged seizure activity was most likely related to the patient’s use of Spice.

Background Synthetic Cannabinoids (SCs) are man-made drugs that are commonly referred to as “synthetic marijuana”. SCs have similar chemical makeup and share some of the same neurological effects as natural tetrahydrocannabinol (THC) found in marijuana. The man-made versions of these drugs are typically sprayed onto shredded plants or herbs and then dried and sold as incense or herbal remedies. These products can be ingested, vaporized or inhaled in e-cigarettes or other devices, similar to methods used to consume marijuana.1 SCs have varying street names including Spice, Scooby Snax, Mojo, Toxin and Anthrax.2 The effects of these drugs can be similar to traditional marijuana, but due to their ever evolving chemical formulations, symptoms can be more severe than those typically seen with acute marijuana intoxication. The degree of toxicity depends upon the amount used and the specific compound. SCs will generally not be detected by rapid urine toxicology screens because their chemical compounds do not cross-react with delta-9 tetrahydrocannabinol (THC), the chemical signature most drug screens are designed to detect.3 Epidemiology Synthetic Cannabinoids were first identified by a European drug agency in 2008.3 Not long after that, SCs began appearing in the United States. Over the last five years SCs use has increased in prevalence to the point that they are now considered to be in the top 25 drugs of abuse.3 Their prevalence in the South has been noted by federal and state agencies, and it has been reported that Mississippi has been disproportionately impacted.2 In July of 2015, the Mississippi Department of Health released a report stating that from April 1st through May 31st 2015, a total of 1,243 emergency room admissions were attributed to SCs use. These were identified with help from the Mississippi Poison Control Center and Emergency Department participation across the state. The Mississippi Medical Examiner in July of 2015 reported that 17 deaths may have been directly related to SCs.2 SCs use is quite widespread, with 54 out of 82 counties in Mississippi reporting emergency room encounters. The highest prevalence of hospitalizations occurred in the southern half of the state.2 These reports likely underestimate the true impact of SCs in the state due to a lack awareness from some healthcare professionals and the inability to perform a rapid detection test. JOURNAL MSMA

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According to the National Institute on Drug Abuse, out of 11,406 ER visits in 2010 that were associated with SCs, approximately 75% were among adolescents and young adults.1 In a survey of US high school students in 2012, SCs were found to be the third most reported substance abused, behind alcohol and marijuana.4 Because these drugs have been promoted as a “legal high,” teens appear to be less aware of the serious health effects that can often occur even with casual use. It is believed that many young adults choose SCs due to the lack of reliable drug testing and thus the ability to pass drug tests even after use. Pharmacology/Clinical Effects Over 50 chemically different SCs are known to have been manufactured. Like delta-9-THC, these substances agonize the cannabinoid receptors CB1 and CB2.5,6 CB1 receptors are the most abundant G-coupled protein receptors in the mammalian CNS and are largely responsible for the psychotropic effects of cannabinoids as well as their effects on nociception, motor activities, nausea, and vomiting.5 CB2 receptors are primarily expressed in the peripheral nervous system and effect the immune response. CB2 receptors have been a target for development of novel anti-inflammatory agents. In many cases, the SCs have a much higher affinity for the cannabinoid receptors with potencies ranging from 2 to 800 times greater than delta-9-THC.6 It is thought that SCs may stimulate other receptors, namely serotonin and NMDA, leading to their enhanced effects on the neurologic system.6,7 The most notorious of the SCs has the street name of Spice. Metabolic analyses have been performed on Spice, and several distinct active chemicals have been isolated including JWH-018, JWH-073, and AM-2201.5 Intoxication with these substances resembles classical cannabis intoxication and can manifest as tachycardia, conjunctival injection, nystagmus, vomiting, ataxia, slurred speech, lethargy, and sedation. However, intoxication with SCs is often more striking, not only secondary to their increased potency but also because of their many active metabolites that also have affinity for CB1 and CB2 receptors.5,8 Effects of SCs can last from hours to days. Unfortunately, due to a lack of a rapid assay for detection, many of the published case reports regarding SCs toxicity do not have laboratory confirmation of exposure.9 There is also the possibility that the plant matter packaged with the SCs, other street drugs mixed in with SCs, or perhaps even certain heavy metals, may play a role in the severity of SCs toxicity.5,9 More severe reactions to the SCs include acute psychosis, dystonia, hyperthermia, ischemic stroke, subarachnoid hemorrhage, seizures, rhabdomyolysis and acute kidney injury. It is not well understood why SCs can cause seizures, but it may be through decreased glutamate and GABA transmission.5,10,11 Seizures have been associated with the chemical compounds JWH-018, JWH-122, JWH-210, AM-2201.9,10 Renal manifestations of SCs toxicity are not well described in the literature. There are two case series and few case reports on the subject of renal injury associated with SCs.12,13 All patients described smoking Spice incense blends before presenting with toxic manifestations. The patients typically reported flank pain, nausea, and vomiting, with lab testing subsequently showing increased serum creatinine.5,12,13,14 Ultimately, all patient reports had improvement of kidney function, though in variable time courses, with some requiring prolonged hemodialysis. The exact mechanism by which renal involvement occurs is still unknown. The metabolites XLR-11 or UR-144 are specifically 290 VOL. 57 • NO. 9 • 2016

thought to be involved in precipitating acute tubular necrosis.13 It is interesting to note that our patient had an elevated creatinine on presentation, even before his CPK was greater than 10,000 IU/L. This suggests that something else may have precipitated his acute kidney injury, which was then exacerbated by rhabdomyolysis. Current Regulation/Legislation All SCs are currently listed as a Schedule I drugs according to the DEA. Each year chemically distinct SCs are being manufactured. They are eventually added to this schedule, but it is difficult to keep up with the ever evolving formulations of SCs. The unfortunate result is that SCs currently appear to be staying ahead of legislation, making availability more widespread. In 2014, forty-one states had placed bans on SCs.3 Mississippi was one of the first states, in 2010, to enact these sanctions.3 Despite these bans (which include possession, distribution, and manufacturing SCs), hospital admissions for SCs use have shown dramatic increases through 2015.15 These numbers may also represent more widespread recognition of SC patient’s symptoms. Summary Like cocaine and heroin before, SCs represent a major health risk to individuals. The ever-changing formulations of SCs make them potentially more toxic, as manufactures attempt to skirt current drug laws. Catastrophic neurologic, cardiovascular and renal disease may result from SCs and other impurities packaged with these “herbal products”. Ongoing education to the public about these hazardous drugs is needed to combat the fact that they are sometimes promoted as safe and natural. The epidemic of SC use must be emphasized to Mississippi physicians to improve recognition of SC symptoms until a rapid detection assay is available. n References 1. National Institute on Drug Abuse. http://www.drugabuse.gov. Nov. 2015. Accessed January 15, 2016. 2. Adverse Events Associated with the Use of Synthetic CannabinoidsMississippi, 2015. Mississippi Morbidity Report. 2015; 31(4): 1-3. 3. Brents L, Prather P. The K2/Spice Phenomenon: Emergence, identification, legislation and metabolic characterization of synthetic cannabinoids in herbal incense products. Drug Metab Rev. 2013; 46(1): 72-85. 4. CESAR FAX Synthetic Cannabinoid Series. University of Maryland Center for Substance Abuse Research. www.cesar.umd.edu. Accessed February 8, 2016. 5. Lapoint J. Goldfrank’s Toxocologic Emergencies. 10th ed. McGraw-Hill, 2015: 1042-1053. 6. Musselman M, Hampton J. Not for human consumption: a review of emerging designer drugs. Pharmacotherapy. 2014; 34:745. 7.

Wells D, Ott C. The “new” marijuana. Ann Pharmacother. 2011; 45:414.

8. Rajasekaran M, Brents L, Franks L, et al. Human metabolites of synthetic cannabinoids JWH-018 and JWH-073 bind with high affinity and act as potent agonists at cannabinoid type-2 receptors. Toxicol Appl Pharmacol. 2013; 269:100. 9. Gurney S, Scott KS, Kacinko S, et al. Pharmacology, Toxicology, and Adverse Effects of Synthetic Cannabinoid Drugs. Forensic Sci Rev. 2014; 26(1): 5476. 10. Havenon AD, Chin B, Thomas K, et al. The secret “spice”: An undetectable toxic cause of seizure. The Neurohospitalist. 2011; 1(4): 182-86. 11. Lutz B. On-demand activation of the endocannabinoid system in the control

of neuronal excitability and epileptiform seizures. Biochem Pharmacol. 2004; 68(9):1691â&#x20AC;&#x201C;1698. 12. Bhanushali GK, Jain G, Fatima H, et al. AKI associated with synthetic cannabinoids: a case series. Clin J Am Soc Nephrol. 2013; 8(4):523â&#x20AC;&#x201C;6. Gudsoorkar V, Perez J. A New Differential Diagnosis: Synthetic 13. Cannabinoids-Associated Acute Renal Failure. Methodist DeBakey Cardiovasc J. 2015; 11(3): 189-91. 14. Thornton SL, Wood C, Friesen MW, et al. Synthetic cannabinoid use associated with acute kidney injury. Clin Toxicol. 2013; 51(3):189â&#x20AC;&#x201C;90. 15. Health Officials Warn About Increasing Cases of Spice Hospitalization. www.msdh.state.ms.gov/msdhsite/index.cfm/23,16275,34. Mississippi Department of Health [Jackson]. April 10, 2015. Accessed February 8, 2016.

Author Information DO, PGY-2/Chief Resident, Forrest General Hospital Family Medicine Residency (Dr. Wilkinson). DO, PGY-1, Forrest General Hospital Family Medicine Residency (Dr. Tullos). MD, Division of Nephrology, Hattiesburg Clinic. Adjunct Clinical Professor for William Carey University College of Osteopathic Medicine (Dr. Rifkin). Financial or other conflicts of interest: None.

Corresponding Author: Brian Rifkin, MD Hattiesburg Clinic, Division of Nephrology 415 South 28th Ave, Hattiesburg, MS 39401 601-268-5700 (brifkin@hotmail.com)

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Mississippi State Medical Association, P.O. Box 2548, Ridgeland, MS 39158-2548 Editor (Name and complete mailing address)

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Mississippi State Medical Association

P.O. Box 2548, Ridgeland, MS 39157-2548

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Journal of the Mississippi State Medical Association (JMSMA)

August 2016

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than the Sword.

October 1, 2016

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T he Pen is Mightier

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4,025

2,795

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1,181

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3,976

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4,000

4,025

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Statement of Ownership, Management, and Circulation (All Periodicals Publications Except Requester Publications) 16. Electronic Copy Circulation

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x I certify that 50% of all my distributed copies (electronic and print) are paid above a nominal price. 17. Publication of Statement of Ownership

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September 2016 issue of this publication. in the ________________________ 18. Signature and Title of Editor, Publisher, Busin Business Manager, or Owner

Date

10/1/2016 Karen A. Evers, Managing Editor I certify that all information furnished on this form is true and complete. I understand that anyone who furnishes false or misleading information on this form or who omits material or information requested on the form may be subject to criminal sanctions (including fines and imprisonment) and/or civil sanctions (including civil penalties).

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M S M A

Recap of the 2016 Session of the MSMA House of Delegates The House of Delegates adopted 22 resolutions at MSMA’s Annual Session held August 12-13. Four resolutions were referred to the Board of Trustees. • Support of State Department of Health Immunization Policy - Resolution 2 (Adopted) MSMA salutes Dr. Currier and the State Department of Health for its strong protective vaccine policy and re-affirms the Association’s robust support for our state’s current immunization policy strongly opposing legislative attempts to remove the State Department of Health from the medical exemption process or weaken it in any way. • Update Bylaws Regarding Specialty Delegates - Resolution 3 (Adopted) Revise the MSMA Bylaws on the House of Delegates composition to include one delegate and one alternative delegate for each medical specialty recognized by the American Board of Medical Specialties (previously only specialties with an MSMA scientific section were included). • Create Licensure of Anesthesiologist Assistants - Resolution 4 (Adopted) This directs MSMA to pursue legislation to authorize the Mississippi State Board of Medical Licensure to license and regulate the practice of anesthesiologist assistants. • Allow All Members to Run for Office and Vote Electronically - Resolution 5 (Substitute adopted) MSMA will study how to best utilize technology to increase participation at all levels of the association. • Support for the Mississippi Physicians Health Program - Resolution 6 (Adopted) MSMA will work with legislative leaders and the State Board of Medical Licensure to ensure a steady and adequate revenue stream from physician licensure fees to support the Mississippi Physicians Health Program (formerly the Mississippi Professionals Health Program). • Promote Pharmacy Certification for E-prescribing Controlled Substances - Resolution 7 (Adopted) MSMA will promote the use of and encourage all Mississippi pharmacies to obtain Electronic Prescriptions for Controlled Substances (EPC) certification. • Commend Career of H. Vann Craig, MD - Resolution 8 (Adopted) The leaders and members of MSMA wish to commend the meritorious and dedicated service of Dr. H. Vann Craig, who retired from his position as Executive Director of the Mississippi State Board of Medical Licensure in March 2016. • Establish Advisory Group to Advance Disease Targets - Resolution 9 (Adopted) MSMA will establish an advisory group composed of healthcare leaders from medical societies and other partners to provide strategic and technical input to advance the 25x25 disease targets. • Study of Council Work - Resolution 10 (Referred to the Board of Trustees) The MSMA Council on Constitution and Bylaws will study and report back to the House of Delegates in 2017 whether member participation in council business would be increased and the work of the Association be expedited if standing Councils were eliminated and replaced by adhoc committees appointed as needed to study specific issues.

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• Advocate for the Expansion of Medical Coverage as Allowed by the Affordable Care Act - Resolution 12 (Adopted) MSMA has announced its support of the expansion of medical coverage as allowed under the Affordable Care Act to cover uninsured Mississippians under the age of 65. • Eliminate Pain Questions in Patient Surveys Used to Evaluate/Compensate Physicians - Resolution 13 (Adopted) MSMA will work with the Mississippi Hospital Association to reduce and eliminate the inclusion of pain management questions on patient satisfaction surveys as it pertains to payment and quality metrics so that physicians are not encouraged to over-prescribe opioids for non-cancer chronic pain. • Amend Bylaws to Change the Name of MPHP - Resolution 14 (Adopted) The Mississippi Professionals Health Program will be renamed as the Mississippi Physicians Health Program. MPHP is a confidential resource for physicians and other licensed health care professionals who suffer from potentially impairing conditions such as substance use disorders. • 150th Anniversary of MSMA House of Delegates - Resolution 15 (Adopted) The 2018 business meeting of the House of Delegates will be held August 9-11, 2018 in Jackson at a suitable facility in the metro area that will also accommodate the activities, events and other endeavors planned by the Commemorative Committee to celebrate and observe the 150th year of meetings. • Dr. Mary Currier, 2016 Recipient of the AMA Nathan Davis Award - Resolution 16 (Adopted) MSMA recognizes and extends congratulations to Dr. Mary Currier as being named the recipient of the 2016 Dr. Nathan Davis Award in the category of Outstanding Career Public Servant at the State Level during the American Medical Association’s national awards presentations held on February 23, 2016, in Washington, DC. • Support Appropriate Use of Telemedicine Technologies - Resolution 17 (Adopted) MSMA will continue to publicly support the appropriate use of telemedicine technology to extend access to physicians in a manner that replicates the traditional in-person physician-patient encounter. • Child Abuse And Neglect Awareness - Resolution 18 (Adopted) Raise awareness of child abuse and neglect in Mississippi by conducting continuing education for physicians on the topic and soliciting/ publishing related content in the Journal MSMA. • Amend State Law Limiting Eligibility for Appointment to State Board of Medical Licensure - Resolution 19 (Adopted) MSMA will work with legislative leaders and the State Board of Medical Licensure to lift the restriction that prevents a Mississippi licensed physician who graduated from a medical school outside the US/Canada to be nominated for appointment by the Governor to the State Board of Medical Licensure. • Amend State Law to Prohibit Firearms in Hospitals - Resolution 20 (Adopted as amended) MSMA will seek the necessary changes in laws and regulations governing firearms to allow public medical facilities to enjoy the same exemptions and protections as private medical facilities. • Study Requirement that MSMA Members Hold a Mississippi License to Practice - Resolution 21 (Adopted) As part of its work in 2016-2017 the Council on Constitution and Bylaws will review the categories of membership listed in the Bylaws and consider creating a path to full membership for physicians who do not hold a license to practice medicine granted by the Mississippi State Board of Medical Licensure. • Aero-Medical Ambulance - Resolution 22 (Referred to the Board of Trustees for action) The MSMA Board of Trustees will study air ambulance services in Mississippi and determine the best course of action for reducing unfair pricing practices and developing guidelines for emergency medical personnel to determine the appropriateness of air evacuation in particular cases. • Medicaid Reform - Resolution 23 (Referred to the Board of Trustees for action) The MSMA Board of Trustees will study ways to restore in-state administration capacity of Medicaid that is weighted toward the best practices of population management in Mississippi.

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• Public Health Funding in Mississippi a Crisis - Resolution 24 (Adopted) MSMA will continue its support of increased funding for the essential work of the Mississippi State Department of Health. The Association will collaborate with MSDH leaders to develop strategies to increase legislative support of public health services. • Commend Dr. Tami Brooks - Resolution 25 (Adopted) MSMA acknowledges with much appreciation the brilliant work of Dr. Tami Brooks as Medicaid Medical Director and her tireless dedication to improving the agency’s delivery of medical care to the citizens of Mississippi. • Increase Membership of MMPAC - Resolution 26 (Referred to the Board of Trustees) The Board will determine appropriate ways to increase membership of the Mississippi Medical Political Action Committee. • Ban Use of Tanning Beds by Minors - Resolution 27 (Adopted) MSMA will seek the necessary changes in law or regulation to prohibit the non-medical use of tanning beds for persons under the age of 18. • Increasing Accessibility to Health Care Preceptors - Resolution 28 (Adopted) MSMA will study methods to encourage and incentivize physicians to participate as medical preceptors for health care professional students. n

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M S M A

Big discounts for MSMA physicians

Put telemedicine to work in your practice If you are looking for a way to ease telemedicine into your practice, Mend may be the answer. MSMA has partnered with Mend, an Orlando-based telemedicine company, to bring the simplest telemedicine platform on the market to Mississippi physicians. With the first month free and additional monthly discounts for MSMA members, you can put telemedicine to work in your practice using existing equipment in a flash. Mend’s telemedicine platform connects you with your patients via a real-time audio-video link and can be integrated into your practice to streamline workflow and reduce no-shows. “I’ve already signed up,” said MSMA Trustee Mark Horne, MD. “I’ve been looking for a way to connect with my patients for a virtual appointment. I chose Mend because this service utilizes my existing equipment and the Mend platform is a HIPAA-compliant, secure link.” Mend was designed by physicians so there is no complicated software for you or your patients to have to use. You and your patients can connect virtually using cell phones, tablets, laptops, or desktop computers securely when an in-person visit is not required. “Telemedicine is promising. I plan to use it to offer remote follow-up visits to my existing patients,” Dr. Horne said, “I’ve long thought that telemedicine would be an easy way for patients to check in with me; I just didn’t know how to get started.” He explained that the Mend software creates an easy way for patients to request the online video conference. There is no equipment to buy and the Mend program also facilitates scheduling, coding and billing commercial insurance and Medicaid. A few of the Mend features follow. • Audio-video consults with your existing equipment. Mend helps you connect with your patients via real-time two-way audio and video. Mend facilitates audio-video connections to replicate the face-to-face visit. Free tech support and training makes it easy for you and your staff to schedule video appointments; and, you can use the equipment you already have. • Reimbursable. Since passage in 2013 the parity law requires insurance companies to reimburse an office visit using remote technology at the same rate as an in-person office visit. Mend demonstrates the billing process and teaches your staff to code telemedicine appointments so you can be reimbursed from Medicaid and private insurance. The experts at Mend will help make this a sustainable service within your practice. • Malpractice-protected. Consult with your liability carrier about whether you are covered for practicing via telemedicine. Mend makes it easy to notify your carrier. • Inexpensive. Mend is offering MSMA members a savings of $100 per month on the service fee. Normally $500 per month per physician user, members get the reduced price of $400 per month for the first 12 months of service. Additionally, Mend doesn’t require the purchase of any equipment. All you need is a computer and video camera, which you likely already have. Mississippi enacted a parity law in 2013 that requires insurers to cover telemedicine services at the same rate as a comparable in-person office visit. More than 20 primary care physicians participated in the initial webinar offered by Mend to address the easy way to successfully implement telemedicine within an existing practice. For more information, contact Mend co-founder Nick DePriest at 919-414-8483 or visit the Mend website at www.mendfamily.com .

You asked for an easy, inexpensive way to incorporate telemedicine into your existing practice. So, MSMA found a company that can do just that. The 2015 House of Delegates adopted a resolution asking the Association to explore quality telemedicine options that a Mississippi physician could integrate into an existing practice. The House of Delegates identified certain features desired in a telemedicine service, and MSMA listened. The Association has negotiated a package of discounts and options with Mend, an Orlando-based company offering a platform that facilitates primary care telemedicine visits with your existing patients. Mend may not be right for your practice, so we ask that you do your own due diligence. More information is available at MSMAonline.com when you consider integrating telemedicine into your practice. There are many companies offering telemedicine platforms and services, and we will bring you more options as we come across good ones. *MSMA does not have any direct financial interest in Mend. Mend is one of MSMA’s Member Benefit Partners, third-party vendors and companies who offer special deals and services often at reduced rates for our members. While MSMA analyzes the quality of each Member Benefit Partner and their offerings, we do not guarantee any product or service will be right for you. Before you make a purchase, we recommend you perform your own due diligence.

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L E G A L E S E

Charity Care

Conner Reeves, JD MSMA General Counsel

any physicians across Mississippi provide charitable medical care at free clinics and in response to emergency situations such as hurricanes and floods. This is an admirable undertaking that makes a huge impact on the patients and communities being served. In an effort to remove barriers for physicians wishing to provide charitable care, MSMA worked with the state legislature in 1993 to pass a law providing immunity for such services. While physicians providing medical care during an emergency receive civil immunity automatically, physicians must obtain a medical waiver to receive immunity when providing charitable care in other settings, like a free clinic. This little-known nuance can make a sizeable impact on the defenses available in a malpractice case.

To utilize the immunity available, a physician would need to have the patient sign a written waiver in advance that explicitly states that the services are provided without the expectation of payment and that the provider shall be immune from liability. Such a waiver may already be available at the free clinic at which you volunteer, and, if not, then you should develop one immediately. Like many tools out there, they only work if you use them. Once the waiver is signed, be sure to place a copy in the patient’s file. The actual code citation follows: MS Code §73-25-38(1) Any licensed physician, physician assistant or certified nurse practitioner who voluntarily provides needed medical or health services to any person without the expectation of payment due to the inability of such person to pay for said services shall be immune from liability for any civil action arising out of the provision of such medical or health services provided in good faith on a charitable basis. This section shall not extend immunity to acts of willful or gross negligence. Except in cases of rendering emergency care wherein the provisions of Section 73-25-37 apply, immunity under this section shall be extended only if the physician, physician assistant or certified nurse practitioner and patient execute a written waiver in advance of the rendering of such medical services specifying that such services are provided without the expectation of payment and that the licensed physician or certified nurse practitioner shall be immune as provided in this subsection. The immunity from liability granted by this subsection also shall extend to actions arising from a churchutpatient xams o reatment operated outpatient medical clinic that exists solely for the purpose of providing charitable medical services to persons We are looking for physicians to join our group who are unable to pay for such services, provided that the to perform Consultative Exams in Mississippi. outpatient clinic receives less than Forty Thousand Dollars ($ 40,000) annually in patient payments. No treatment or recommendations are

PHYSICIANS NEEDED

MS Code §73-25-38(2) Any licensed physician, physician assistant or certified nurse practitioner assisting with emergency management, emergency operations or hazard mitigation in response to any emergency, man-made or natural disaster, who voluntarily provides needed medical or health services to any person without fee or other compensation, shall not be liable for civil damages on the basis of any act or omission if the physician, physician assistant or nurse practitioner was acting in good faith and within the scope of their license, education and training and the acts or omissions were not caused from gross, willful or wanton acts of negligence. n

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-N T

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P R E S I D E N T ’ S

P A G E

The Inaugural Address of the 149th President LEE VOULTERS, MD ~ 2016-17 MSMA PRESIDENT AUGUST 12, 2016 - HILTON JACKSON I am deeply honored and humbled to stand before you as the 149th president of the Mississippi State Medical Association. It’s no surprise that my background is different from most of you. I can tell because you all talk funny. England and America are – in fact – two countries divided by a common language. As you can probably see – or rather hear, I’m not originally from Mississippi. But, I got here as fast as I could … and, I can’t imagine finding a more rewarding location in which to practice medicine. Seriously, I grew up in the U.K. and attended the medical school at the University of London. I also trained in Canada. So, that makes me the first international medical graduate (IMG) to be president of MSMA. But, what I didn’t know is that more than 25% of all US physicians trained outside North America. 45% of New Jersey physicians are IMGs – International Medical Graduates.

Speaking of firsts, an outstanding individual (who I am proud to call one of my dearest friends) became the first African-American president of this association two years ago. I’m the first IMG to be president. Two firsts in three years underscores the fact that the Mississippi medical community is made up of physicians from many different backgrounds with many different experiences. At a recent strategic planning meeting our Board of Trustees looked at the demographics. We pledged to reach out to our colleagues who may look or sound different than ourselves to find the common thread that binds us physicians together in this new world of medicine.

MSMA President Dr. Lee Voulters with his wife Christie

42% of New York physicians are IMGs and in Florida IMGs make up 37% of the physician workforce. In Mississippi nearly 12% of our member physicians studied abroad. Yet, we physicians are more alike than we are different. We must recognize our differences and make it a priority to reach out. It is imperative that we - as an organization - ask how we can represent the needs and concerns of all physicians, and it is equally important that each of us speak out. If a physician’s voice is not being heard that physician has a responsibility and an obligation to speak up, to join the MSMA choir. Only then can all physicians speak with one voice to stand up for the needs of our patients which must always come first.

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Dr. Lee Voulters takes the oath of office becoming MSMA’s 149th President with his wife Christie (l.) holding the Bible by his side. Administering the oath is Board Chair Dr. Clay Hayes (r.). Standing left is Immediate Past President Dr. Dan Edney surrounded by other past presidents.

There is much we physicians can learn from our colleagues – despite our differences.

societies by organizing meetings that can unite physicians at the local level with community service projects, CME, and interesting speakers.

There is much we can teach our colleagues – despite our differences.

We must find strength in our grass roots. Enhance and expand CME programs, entice more of our colleagues to make an impact at annual session.

There is much we can accomplish with our colleagues – despite our differences. MSMA is first and foremost an Association of men and women with one thing in common – a love of medicine. That common heart for healing may have been shaped in different ways. Yet, it has never been more important that we physicians stand together – despite our differences. Benjamin Franklin said it this way, “We must, indeed, all hang together or, most assuredly, we shall all hang separately.” An example of this relates to the State Board of Medical Licensure.

We have an outstanding executive staff. We can use this experience breathe new life into local medical societies. In fact, Charmain and her staff have already started a pilot program that is helping several struggling groups re-connect at the local level. That same pilot can be replicated to unite members of a national specialty society that does not have a state chapter creating a pathway for those individual members to be an active part of the greater whole. Speaking of specialties as a neurologist, the treatment and prevention of stroke is a subject very near and dear to my heart.

Even though IMGs clearly make up an important part of our physician population, physicians nominated by MSMA for the State Board of Medical Licensure must have graduated an American medical school.

130,000 Americans die from stroke each year. Stroke accounts for one out of 20 deaths in the United States. More than 795,000 people in United States have a stroke each year. It is the third leading cause of death and the leading cause of disability.

Therefore, I introduced a resolution to update the Medical Practice Act so any physician in Mississippi with a state issued license can be considered for appointment by the Governor to the licensure board.

Mississippi has the highest prevalence of stroke in the country. Heart disease and stroke death rates together are the highest in the nation.

Another way I propose to better represent our physicians and to increase our membership is to strengthen our local component medical societies. MSMA has the infrastructure to manage struggling component

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I started working with the American Heart Association to develop a stroke system of care for Mississippi 12 years ago. I was also fortunate to join a very talented and dedicated group of healthcare professionals and hospital administrators to establish Mississippi’s first Joint Commission certified stroke center at Memorial Hospital Gulfport in 2007.

We also explored the appropriate use of a tele-stroke system throughout the state. Since then other stroke centers have been established in Mississippi using this model.

Our new MSMA President Dr. Lee Voulters delivering his inaugural address

Development of an extensive system of stroke care has been championed by the Mississippi Healthcare Alliance – an outstanding group led by Dr. Harper Stone – to treat acute stroke and acute myocardial infarction throughout the state. As this network matures, we can better serve Mississippians with heart disease and stroke. But, significant state funding is needed. That’s where the power of physicians can truly make a difference in the health of our patients. Working closely together, MSMA and the Mississippi Healthcare Alliance can take this message – this solution – to the State Legislature. With state funding, we can develop a statewide system of stroke care that will be the envy of the nation. Protecting the practice of medicine and defending the physicianpatient relationship is central to our mission at MSMA. Every year much of our time and energy is spent at the State Capitol in endeavors to do just that. One very real threat to both the practice of medicine by Mississippi physicians and the very integrity of care delivery is the invasion by large national telemedicine corporations with poor care models. At its worst, limited technology using only a telephone is utilized to cherry-pick patients who have insurance coverage or a credit card.

We have insisted all along that telemedicine technology is a delivery mechanism that can only be good medicine when it replicates the physician-patient encounter. Medical care must be based on all the information the physician needs to make a diagnosis and determine a treatment plan. This cannot possibly be done over the phone, by a doctor who has never seen the patient when that doctor is very likely in another state or even another country – and, out of reach of our state licensing authority. Blind medicine is bad medicine. We managed to fend off a well-financed telemedicine lobby at the legislative level last session but we need to brace for a full-court press in January. This issue has recently been complicated by federal legislation.

MSMA Past President Dr. Claude Brunson (2014-15), MSMA President Dr. Lee Voulters (2016-17), and Immediate Past President Dr. Dan Edney (2015-16)

If the telemedicine corporations get their way, fundamental tort laws will be changed dramatically. These national telemedicine giants want the patient encounter to originate where the doctor is located --- not where the patient is located.

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Having grown up in London in the era of The Rolling Stones, Beatles, and Twiggy, Dr. Voulters chose a British invasion theme for his inaugural gala. The Band “Hunter Gibson and the Gators” led with their first song “Revolution.” This will pre-empt state law governing medical licensure, medical practice, professional liability, and reimbursement. What a nightmare for the courts! Initially testing in the Tri-Care system, unenforceable telemedicine across state lines - or even national borders - will compromise patient safety and make it impossible for medical boards to sanction improper or unprofessional care. MSMA has been working with our Congressional delegation for months and continues to push for state-based authority to regulate medicine. And telemedicine is MEDICINE first and technology second. Medicaid is another nightmare. MSMA has a long history with Medicaid and the legislature to provide the highest quality and most comprehensive healthcare possible through the state system. It continues to be a frustrating challenge. Medicaid is a broken system and we are nowhere near where we need to be in terms of quality and coverage. We often feel a great sense of helplessness and it appears to us that too many times our concerns fall on deaf ears.

No Governor will easily give up control of Medicaid. Therefore, we must insist on physician input. It will be much more difficult to convince the governor, legislators, state leaders, and the Division of Medicaid to go back to the old system with a Medicaid commission overseen by a board with authority and physician representation similar to the State Board of Health. This is not an easy path, and it will certainly test our mettle. These are challenging times. Now, more than ever before, we must join hands for a common purpose: to provide the highest quality health care to all Mississippians. I am confident that we can accomplish great things and improve the health of our patients. We will succeed by doing the right thing. And, as always the right thing is what’s best for our patients. Once again, thank you from the bottom my heart for giving me this highest of honors – to be your president. Now I invite everyone to join Christie and me on the dance floor for the British invasion brought to you by Hunter Gibson and the Gators.

The Medicaid Director has ignored our requests to utilize the physician advisory committee required by state and federal law. Our Governor listened to our complaints but has not acted.

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Lee Voulters, MD

E D I T O R I A L

Mississippi Health Disparities, Bias, and Social Justice in Health: Mississippi Physician Leadership Is the Best Rx RICHARD DESHAZO, MD AND SARA PARKER, BA Celebration This year’s State Medical Meeting had many things to celebrate, including a previous year of capable leadership by our first African American president, Claude Brunson, MD. Another landmark accomplishment during his period of leadership received less attention. The passage of 2015 Resolution 3, “MSMA Efforts to Improve Health Disparities” by the House of Delegates was also a major accomplishment. There will be more about that later. Some Are Misguided There is a major cause and effect connection between race and health disparities.1 Anyone who says we don’t continue to have racial problems in our country and in our state is misguided. The population of our state is moving toward a majority of people of color by 2030. Data show that fear and paranoia are to be expected during major demographic changes like those we are experiencing. 2 When the status quo changes and affects existing culture much as it did in 1964 when the Civil Rights Act was passed, social unrest can occur if not counterbalanced by positive social leadership. The attitudes expressed in letters to the editors in Mississippi newspapers, calls to radio talk shows, comments on social media, and scenes on the nightly news can be startling. More startling is the reappearance of racial hate crimes in our state. Moreover, the courts have now identified some voter-identification and voter-redistricting efforts in the South to be attempts to disenfranchise minority voters.3 Real Leadership In 2015, our House of Delegates (HOD) assumed ownership for our part in Mississippi medicine’s past racial discrimination and a commitment to address health disparities now and in the future. The HOD discussed the 2008 apology of the American Medical Association (AMA) to our African American colleagues for years of overt racial discrimination. This discrimination at the national level Figure 1. 2015 Resolution 3 of the MSMA House of Delegates became public in 1872 when the National Medical Society of the District of Columbia, a racially integrated organization, was excluded from representation at the AMA in favor of the Medical Society of the District of Columbia, an all-white one. The response was the founding of the National Medical Association (NMA), which has been multiracial from its start. The NMA and its Mississippi affiliate, the Mississippi Medical and Surgical Association (MMSA), remain physician organizations independent of the AMA. That schism between black and white physicians in our country has been demonstrated to be a factor in health disparities in the United States.4, 5 That is, physician subscription to racial discrimination has hurt the patients we serve and in Mississippi contributed to our present worst-case scenario in health. Our own Dr. Edward (Ed) Hill, as AMA President, participated in a process of racial reconciliation at the national level that eventually resulted in the AMA’s acknowledgement of racial discrimination against African American physicians, a public expression of regret and a promise to right the wrongs of past behaviors toward “African American physicians, their families, and their patients.” Dr. JOURNAL MSMA

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Ron Davis, AMA Past President, delivered a personal apology Figure 2. Members of the 2016 MSMA Physician Leadership on behalf of the AMA to a national meeting of the NMA and Academy subsequently, his apology was published in JAMA in 2008.6 The MSMA Resolution celebrated in this article, noted the growing diversity of MSMA membership, and pledged to improve dialogue between MSMA and MMSA to address health disparities. (Figure 1) There were more accomplishments. As President of MSMA, Dr. Brunson appointed a Commission on Health Equity during his inaugural address in 2014. The Commission was co-chaired by Drs. Ed Hill and Bettina Beech with members to include physicians and other stakeholders in MSMA and MMSA, the UMMC Department of Preventive Medicine, the UMMC Myrlie EversWilliams Institute, Jackson-Hinds Comprehensive Health Center, Jackson State University, and other organizations. Another positive development is the diversity among members of the MSMA Physician Leadership Academy which continues to show that we welcome inclusion (Figure 2). These multi-racial participants will soon provide leadership to break remaining racial and social barriers on our Mississippi physician side of health disparities. We should be proud that MSMA has set an example for the state in a time when others still try to divide us. More Work to Do We have now identified and moved to eliminate the explicit (conscious) bias of the past, but there is more work to do. Many health providers are not aware that, no matter how hard we try, growing up in America has inflicted another form of bias on us. That kind of bias, implicit (unconscious) bias, is even more dangerous than explicit bias. A study published in the American Journal of Public Health7 found implicit bias adversely influenced the patient-physician relationship and is present in most physicians. In this study from Johns Hopkins University School of Medicine, investigators evaluated interactions of 40 primary care physicians with 269 patients. Using two validated tests and a review of recorded encounters, the 2 FIGUREpatient investigators found evidence of implicit racial bias in 75% of primary care providers. Examples of implicit racial bias included assuming the likelihood of lower compliance to recommendations and expectations of a lower level of comprehension of disease prognosis in people of color, regardless of their socioeconomic or educational status. Unconscious assumptions resulted in less positive interactions with the patient and decreased patient satisfaction with their visits. The authors concluded, “Unconscious racial attitudes may be standing in the way of positive interactions to the detriment of health.” This was not a first. Two previous studies found bias in medical interactions between physicians and people of color and recommended similar strategies.8, 9 Treatments for Implicit Bias The authors of such studies have proposed intervention strategies to increase physician awareness and understanding of the basis of bias. 12 building in the physicianThese include more cultural sensitivity training, patient-centered communication techniques, and partnership physician and physician-patient relationships. We find the latter strategy to be the most likely to be successful of those mentioned. Writers have also identified the opportunity for health professionals “to serve as influential advocates for social justice” by openly discussing bias in healthcare and in so doing to demonstrate a commitment to “the elimination of healthcare.”7 The American Board of Internal Medicine has also called for the “promotion of justice in the healthcare system including the fair distribution of health resources and elimination of discrimination in healthcare” in their Physician Charter of 2002.10 In their report, Unequal Treatment, the Academy of Medicine of the National Academies of Science included a paper by Jack Geiger, M.D., no stranger to Mississippi. That paper recommended an increase in undergraduate and graduate education on stereotyping and bias to promote self-awareness and medical culture. He said, “The former raw discrimination and blatant racism relegating African Americans and other minority patients to all-black hospitals, charity and basement wards of white hospitals has disappeared, but scars of those past experiences remain and subtler forms of differential treatment have emerged. The preponderance of evidence strongly suggests that among the multiple causes of racial and ethnic disparities in American healthcare, provider and institution bias are significant contributors. The first task, then, is to create among providers the essence and processes of stereotypical bias and their role in the differential treatment of minority patients. Given the understandable difficulty of most physicians to recognize in themselves and their health care work places that such disparities and biases exist, and because such issues are in conflict with their consciously held egalitarian commitments, this will require a long term effort.”11

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What Does This Mean for Mississippi Physicians? So, what does this mean for Mississippian physicians of all colors moving forward? The University of Mississippi Medical Center has supported the call for increasing dialogue about racial issues between all health professionals in the college pre-professional years and extending through post-graduate training and practice. This includes an open discussion of the history of discrimination in medicine towards people of color in America and the ongoing problem of implicit bias. The Medical Center has responded with its Marston-Smith Symposium on Race and Medicine, the inclusion of the history of the struggle for social justice in health in our state in the medical school curriculum, and increasing dialogue among learners of different racial, cultural, and socioeconomic backgrounds on all health professional education. What Does This Mean for MSMA? We now stand on higher ground. As an organization, MSMA has the opportunity to lead not only our colleagues but also our state in addressing the disparities that exist in all of the social determinants of health in Mississippi. In so doing, our recent actions give us credibility to address social justice in health in our state, a state where diversity continues to be a liability rather than an asset. We have some ideas as to how we might move forward (Table 1). The big question is, will we lead or lay low? Let’s revisit the oath we took as physicians. If we don’t lead, who will? References 1. Byrd, Michael, Linda Clayton. “An American Health Dilemma: A History of Blacks in the Health System.” Journal of the National Medical Association. 84.2:189-220.

Table 1. Proposal for a 5-Year Diversity Initiative by MSMA 1. Appoint a MSMA task force to implement a 5-year program to lead in addressing Mississippi’s health disparities and diversity among health professionals. That program could include any or all of the additional proposals to follow. 2. Have a presentation on diversity, race relations, cultural sensitivity, bias, or related topics as a plenary session in each annual MSMA meeting. 3. Develop a plan to support UMMC’s and William Carey School of Osteopathic Medicine’s efforts to increase minority applicants to health professions programs in the state. 4. Include the issues of diversity and health disparities in all policy considerations of MSMA including programming. 5. Support, include, and value MMSA and Mississippi Osteopathic Medical Association as equal partners in addressing Mississippi’s Health Disparities.

2. Pinderhughes, Charles A. “Psychological and Physiological Origins of Racism and Other Social Discrimination.” Journal of the National Medical Association. 63.1(1971):25-29. 3.

Fausset, Richard. “North Carolina Exemplifies National Battle Over Voting Laws.” The New York Times. 10 March 2016.

4. Perez, Thomas E. “The Civil Rights Dimension of Racial and Ethnic Disparities in Health Status.” Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington, D.C.: National Academy, 2003. 5. Shavers, Vickie L. and Brenda S. Shavers. “Racism and Health Inequity among Americans.” Journal of the National Medical Associations. 98.3(2006):386-396. 6. Davis, R.M. “Achieving Racial Harmony for the Benefit of Patients and Communities: contrition, reconciliation, and collaboration.” JAMA. 2008; 300: 323-325. 7. Cooper, Lisa A., Debra L. Roter, Kathryn A. Carson, Mary Catherine Beach, Janice A. Sabin, Anthony G. Greenwald, and Thomas S. Inui. “The Associations of Clinicians’ Implicit Attitudes About Race With Medical Visit Communication and Patient Ratings of Interpersonal Care.” Am J Public Health 102.5 (2012): 979-87. 8. Green, Alexander R., Dana R. Carney, Daniel J. Pallin, Long H. Ngo, Kristal L. Raymond, Lisa I. Iezzoni, and Mahzarin R. Banaji. “Implicit Bias among Physicians and Its Prediction of Thrombolysis Decisions for Black and White Patients.” J GEN INTERN MED Journal of General Internal Medicine 22.9 (2007): 1231-238. 9. Sabin, Janice A., Frederick P. Rivara, and Anthony G. Greenwald. “Physician Implicit Attitudes and Stereotypes About Race and Quality of Medical Care.” Medical Care 46.7 (2008): 678-85. 10. “Medical Professionalism in the New Millennium: A Physician Charter.” Annals of Internal Medicine. 2002;136;243-246. 11. Geiger, Jack. “Racial and Ethnic Disparities in Diagnosis and Treatment: A Review of the Evidence and a Consideration of the Causes.” Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. The Institute of Medicine. The National Academies Press; 2002: 417-450. 12. Adler, Nancy E. and Katherine Newman. “Socioeconomic Disparities in Health: Pathways and Policies.” Health Affairs. 21.2(2002):61-76. 13. Burgess, Diana, Michelle Van Ryn, John Dovidio, and Somnath Saha. “Reducing Racial Bias Among Health Care Providers: Lessons from Social-Cognitive Psychology.” Journal of General Internal Medicine 22.6 (2007): 882-87. 14. Pettus, Gary. “Conspicuous Absence.” Mississippi Medicine. University of Mississippi School of Medicine. Summer 2016. 15. Rowley, William R., Clement Bezold, Yasemin Arikan, Erin Byrne, and Shannon Krohe. “Diabetes 2030: Insights from Yesterday, Today, and Future Trends.” Population Health Management.

Author Information From the Departments of Medicine and Pediatrics, University of Mississippi Medical Center (Dr. deShazo and Ms. Parker).

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Call It What You Will

hroughout my 47 year career, the phenomenon has occurred countless times. Early on I chalked it up to pure coincidence or serendipity, but in recent years I’ve been forced to rethink that idea. Most recently a middle-aged female patient (referred by one of her co-workers whom I’d seen several months earlier) presented to our walk-in clinic complaining of longstanding GI symptoms for D. Stanley Hartness, MD which she’d been unable to get any answers: early satiety, abdominal bloating, epigastric discomfort, JMSMA Associate Editor and constipation. After I had exacted a history and performed an exam of her abdomen, “something” prompted me to sit her up for a more detailed look-see. “Is that a nodule in the left lobe of her thyroid?” I asked myself. Unsure, I purposely didn’t inform the patient of my suspected finding but included a thyroid ultrasound along with an abdominal study. When the report arrived, there it was: solid 2.5 nodule left lobe thyroid; malignancy should be considered. By the way, the abdominal ultrasound was cold normal. I took a deep breath as I reached for the phone to inform my patient of these findings and the need for referral for further investigation. It had happened once again. A patient had come in with one problem only to have a more serious—perhaps even life-threatening— condition discovered. At the risk of being labeled politically incorrect, I have come to the conclusion that divine intervention lies at the heart of these somewhat miraculous turns of events. In a recent sermon, my minister corroborated my feelings when he quoted Nobel physicist Albert Einstein who said, “Coincidence is God working anonymously.” And I’ve always felt that if it was good enough for Al, then it’s certainly good enough for me! n

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Big Problem, Bigger Award: NIH funds UMMC Obesity Research

KAREN BASCOM

he University of Mississippi Medical Center has received its largest single award ever to confront one of the state’s largest health issues.

The five-year, $19.9 million award from the National Institutes of Health will fund the Mississippi Center for Clinical and Translational Research (CCTR). Supported by the NIH’s Institutional Development Award (IDeA) program, the CCTR’s mission will be the prevention, diagnosis and treatment of obesity and related health conditions. “Mississippi has the highest rate of obesity in the United States,” said Dr. James Wilson, professor of physiology and biophysics and the project’s lead investigator. The Centers for Disease Control and Prevention reports that 35 percent of Mississippi adults are obese. “High blood pressure, diabetes, chronic kidney disease and cardiovascular disease are all associated with this one preventable cause,” Wilson Wilson said. Obesity also increases a person’s risk of multiple cancers, neurological disorders and stroke. The CDC estimates that obesityrelated illnesses cost the United States $150 billion annually. To address the problem, UMMC scientists and health-care professionals need an approach that brings their research from the laboratory bench to the greater population. “Translational research takes basic science findings and uses them to develop interventions that will affect treatment options and public health,” Wilson said. Example interventions could be community engagement programs or pharmaceutical drugs. The new award, announced by the office of U.S. Sen. Thad Cochran, enhances UMMC’s capability to conduct clinical and translational research. The CCTR’s task is to invest in people who will make those solutions a reality. “A significant mission of the program will be to train junior faculty into established investigators,” Wilson said. That training will come through CCTR’s Professional Development Core, whose members will mentor junior faculty conducting obesityrelated research. In addition, the Pilot Projects Program will fund promising projects while the researchers seek additional outside funding to sustain their activities.

UMMC research officials receive a tour of the new Translational Research Center from Jimmy Peacock, project manager with Fountain Construction Company. From left are Dr. Richard Summers, associate vice chancellor for research, Cari Fowler, director of sponsored programs, and Leslie Musshafen, executive director of research. The building, one of the assets in UMMC’s translational research portfolio, is scheduled for completion in summer 2017. Dr. Richard Summers, UMMC associate vice chancellor for research, emphasized the importance of developing new talent to spur obesityrelated clinical research - a theme present throughout UMMC’s history. “When the Medical Center was built in 1955, most of the faculty who formed our early clinical research programs were young investigators,” Summers said. Organ transplant pioneer Dr. James Hardy was 37 in 1955; cardiovascular physiologist Dr. Arthur Guyton was 36. “With the CCTR, our goal is to build a pipeline of investigators and clinical research for years to come,” Summers said. Dr. Jeffrey Vitter, University of Mississippi chancellor, thanked Summers Cochran for championing health sciences research and extended his congratulations to the research team at the Medical Center.

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“We are honored by this NIH investment to substantially enhance our capacity and success in translating research discoveries and innovations to better health outcomes,” Vitter said. UMMC has a reputation for strong basic research on cardiovascular function and disease, Wilson said. This will provide a starting point for creating clinical applications. In recent years, UMMC has built the infrastructure needed to advance its clinical and translational research capabilities. The Center for Bioinformatics and Biostatistics, Enterprise Data Warehouse and Clinical Research Support Program are three important parts, Wilson and Summers said. When two campus construction projects - one nearly complete and the other in the planning stages - wrap up, UMMC will have a full set of physical tools needed to achieve these goals. “The timing of this magnificent grant couldn’t be better as it coincides with the development of our Translational Research Center and Clinical Research Unit in the University Hospital, facilities that will be crucial to our success in clinical and translational research,” said Dr. LouAnn Woodward, UMMC vice chancellor for health affairs. “We look forward to putting these assets to work in the cause of discovering tomorrow’s treatments and cures,” Woodward said.

The other center is based at the Mayo Clinic in Rochester, Minn. UMMC and Mayo entered into a collaborative agreement in 2014 that allows the institutions to share data tools and trial participants. Close ties have already developed around cancer research. The National Institute for General Medical Sciences funds IDeA awards, which support biomedical research programs in states with limited history of federal funding. The Clinical and Translational Research program enhances research on health issues impacting medically underserved populations and health concerns specific to those states. Wilson said that after five years, “We hope to have ten or more junior investigators successfully funded as a direct result of this grant” and on a trajectory to independent obesity research programs. In addition, other CCTR core infrastructure such as regulatory, logistics, epidemiological and evaluation support will be operating. “As an additional result, we hope to recruit senior-level population and clinical investigators with the ability to collaborate with each other,” Wilson said. Summers said he is “very proud of Wilson and his efforts so far.” Now, he looks forward to the future. “This award has the potential to be transformational for us,” Summers said. n

The Translational Research Center, scheduled for completion in 2017, is just one new resource that will serve UMMC scientists across disciplines. “All of these pieces brought together give UMMC the infrastructure to enhance clinical research,” Summers said. However, UMMC cannot solve the obesity epidemic in Mississippi on its own. Tougaloo College and the University of Southern Mississippi will also collaborate in the CCTR. “Those institutions will be key in community outreach efforts,” Wilson said. The CCTR will also pursue extensive collaborations with two NIH-funded clinical and translational -research centers. Pennington Biomedical Research Center in Baton Rouge, La., has expertise in nutrition and metabolic disease, valuable to UMMC’s obesity efforts, Wilson said.

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