Journal of the Mississippi State Medical Association | Volume LXI | No. 10 |October 2020

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vol. LXI • no. 10 • October 2020

Science ARTICLES

Editor Lucius M. Lampton, MD Associate Editors D. Stanley Hartness, MD Philip T. Merideth, MD, JD

The Association President J. Clay Hays, Jr., MD President-Elect W. Mark Horne, MD

Managing Editor Allison Morris

Secretary-Treasurer Joe Austin, MD

Publications Committee Sheila Bouldin, MD, Chair Dwalia S. South, MD, Chair Emeritus Thomas C. Dobbs, MD Wesley Youngblood, MD and the Editors

Speaker Geri Lee Weiland, MD Vice Speaker Jeffrey A. Morris, MD Executive Director Claude D. Brunson, MD

Journal of the Mississippi State Medical Association (ISSN 0026-6396) is owned and published monthly by the Mississippi State Medical Association, founded 1856, located at 408 West Parkway Place, Ridgeland, Mississippi 39158-2548. (ISSN# 0026-6396 as mandated by section E211.10, Domestic Mail Manual). Periodicals postage paid at Jackson, MS and at additional mailing offices.

2020 Vision: Foreseeing a New Roadmap for Mental Health Care Services in Mississippi William Silver, DO; Mohanasruthi Sanku, MD; and Philip Merideth, MD

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Teenagers as Health Screeners and Educators: The Evolution of the Mississippi State University Junior Master Wellness Volunteer Program and Results of a Pilot Study Reagan Moak, BS; David Buys, PhD, MSPH, CPH, FGSA; Ann Sansing MS, MRHF; Jasmine Harris-Speight, MS; Je’Kylynn Steen, BS, CFLE-P; and Richard D. deShazo, MD

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Top 10 Facts You Need to Know About Selective IgA Deficiency Matt hew R. Elliott , MD and Patricia H. Stewart , MD

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departments

From the Editor – Dr. Stanley Hartness: Thanks for Two Decades of Exceptional Editing at your JMSMA! Lucius M. Lampton, MD

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President’s Speech –Dr. Clay Hays’ President’s Speech Loretta Jackson-Williams

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President’s Page –Inaugural Address of the 153rd President W. Mark Horne, MD

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Editorial – Ole Miss’s Science Hall Was Utilized for Medical School Activities Until the Move to Jackson in 1955 Jack B. Campbell, MD

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Letter to the Editor – Is Therapeutic Anticoagulation the Answer in Treating COVID-19? Azad Kabir, MD

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New Members – Welcoming Our Newest Members

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

Images in Mississippi Medicine – Mississippi State Hospital, Natchez, 1870-1890, Three-Dimensional Stereoview Lucius M. Lampton, MD

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Advertising rates: furnished on request. Allison Morris, ext 324. Email: AMorris@MSMAonline.com

Poetry and Medicine – The Train Dwight McComb, MD

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Report of Consolidated Reference Committee

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CORRESPONDENCE: Journal MSMA, Managing Editor, Allison Morris, P.O. Box 2548, Ridgeland, MS 39158-2548, Ph.: 601-853-6733, Fax: 601-853-6746, www.MSMAonline.com.

POSTMASTER: send address changes to Journal of the Mississippi State Medical Association, P.O. Box 2548, Ridgeland, MS 39158-2548. The views expressed in this publication reflect the opinions of the authors and do not necessarily state the opinions or policies of the Mississippi State Medical Association. Copyright © 2020 Mississippi State Medical Association.

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A Delta Dawn at Lake Beulah — Located in Bolivar County Mississippi and Desha County Arkansas is a 1,031 acre oxbow. A line down the center of the lake forms the boundary between the two states. It was formed in 1863 when the union army dug the Napoleon cut off to avoid ambush at Beulah Bend on the Mississippi River. This changed the river’s current and allowed the oxbow to fill in forming modern day Lake Beulah. It also destroyed the town of Napoleon, Arkansas during subsequent floods.. n

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F R O M

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Dr. Stanley Hartness: Thanks for Two Decades of Exceptional Editing at your JMSMA! F

ew individuals over the last 164 years have contributed more to the success of our MSMA than Dr. Stanley Hartness, who retired as JMSMA Associate Editor in August after 22 years of exemplary service. During his 52 years of practice as a family physician in his hometown of Kosciusko and, later, Jackson, he juggled critical leadership roles at MSMA, from guidance of his North Central Medical Society to service on multiple councils and committees, to two terms on the Board of Trustees, Lucius M. Lampton, MD election as Secretary-Treasurer, a decade on Editor the Nominations Committee, and service as President (1995–96). He then began his 22 years as Associate Editor. Along the way, he received the Community Service Award, served in leadership roles at the Mississippi Academy of Family Physicians and Information & Quality Healthcare, and continues to serve as representative for the AMA Retired Physicians Section. What an unmatched legacy of service to our MSMA and our profession! Work as a JMSMA editor is a thankless task, requiring dozens of hours monthly of unpaid grunt work, which consists not only of writing copy, but

also editing and proof-reading the copy of others and directing the peer review process. Dr. Hartness remembers fondly, however, not these unseen burdens but rather “the joy of being a part of creating a publication meaningful to our members.” Over his decades of service, he, along with a talented team (Karen Evers, Dwalia South, and others), made your journal unique among medical publications, giving it a distinctive personality which was focused on its scientific mission while keeping the membership posted on the “personal aspects of medicine,” from cover photographs to personals to deaths, and the impact of politics on the practice of medicine. Dr. Hartness never took his editing responsibilities lightly. His passion for the English language, correct grammar, and a well-crafted sentence can be seen readily in his artful and concise editorials (from their titles to the last line, usually a zinger!) and also in thousands of articles his eyes improved with his careful reading. He also provided gracious leadership during difficult times when your editors and the publications committee had to fight many battles to keep your journal editorially independent and printing monthly. Bravo, Dr. Hartness, for a job well done! n Contact me at lukelampton@cableone.net. — Lucius M. Lampton, MD, Editor

Journal Editorial Advisory Board ADDICTION MEDICINE Scott L. Hambleton, MD ALLERGY/IMMUNOLOGY Richard D. deShazo, MD Stephen B. LeBlanc, MD Patricia H. Stewart, MD ANESTHESIOLOGY Douglas R. Bacon, MD John W. Bethea, Jr., MD CARDIOVASCULAR DISEASE Thad F. Waites, MD CHILD & ADOLESCENT PSYCHIATRY John Elgin Wilkaitis, MD CLINICAL NEUROPHYSIOLOGY Alan R. Moore, MD DERMATOLOGY Robert T. Brodell, MD Adam C. Byrd, MD EMERGENCY MEDICINE Philip Levin, MD

MEDICAL STUDENT John F. G. Bobo, M4

PLASTIC SURGERY William C. Lineaweaver, MD, Chair

NEPHROLOGY Harvey A. Gersh, MD Sohail Abdul Salim, MD

PSYCHIATRY Beverly J. Bryant, MD June A. Powell, MD

NEUROLOGY Mary Alissa Willis, MD

PUBLIC HEALTH Mary Margaret Currier, MD, MPH

HEMATOLOGY/Oncology Carter Milner, MD Kelly Wilkinson, MD

OBSTETRICS & GYNECOLOGY Sidney W. Bondurant, MD Sheila Bouldin, MD Elizabeth A. Lutz, MD Darden H. North, MD

PULMONARY DISEASE Sharon P. Douglas, MD John R. Spurzem, MD

INFECTIOUS DISEASE Rathel "Skip" Nolen, III, MD

ORTHOPEDIC SURGERY Chris E. Wiggins, MD

INTERNAL MEDICINE Richard D. deShazo, MD Daniel P. Edney, MD Daniel W. Jones, MD Brett C. Lampton, MD Kelly J. Wilkinson, MD

OTOLARYNGOLOGY Bradford J. Dye, III, MD

FAMILY MEDICINE Tim J. Alford, MD Diane K. Beebe, MD Jennifer Bryan, MD J. Edward Hill, MD GASTROENTEROLOGY James Q. Sones, MD GENERAL SURGERY Andrew C. Mallette, MD

INTERNAL MEDICINE/EPIDEMIOLOGY Thomas E. Dobbs, MD

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PEDIATRIC OTOLARYNGOLOGY Jeffrey D. Carron, MD PEDIATRICS Michael Artigues, MD

RADIOLOGY Justin Lohmeier, MD P. H. (Hal) Moore, Jr., MD RESIDENT/FELLOW Cesar Cardenas, MD UROLOGY Charles R. Pound, MD VASCULAR SURGERY Taimur Saleem, MD


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2020 Vision: Foreseeing a New Roadmap for Mental Health Care Services in Mississippi William Silver, DO, Mohanasruthi Sanku, MD, Philip Merideth, MD

The events of 2019 and 2020 will likely be remembered as a watershed time that brought into focus the vision of a new roadmap for the delivery of mental health care services in Mississippi. As 2019 ended and 2020 began, two separate developments were in process that will have lasting effects long after this year is over. First, the spread of a novel coronavirus that was identified in Wuhan, China in late 2019 led the World Health Organization to declare that a global pandemic was afflicting thousands of people with a deadly respiratory illness on March 11, 2020. The organization named this coronavirus “COVID-19” (an acronym for “coronavirus disease of 2019”).1 Second, a federal lawsuit that was brought by the United States Department of Justice (USDOJ) against the state of Mississippi in 2016 saw significant developments that are expected to result in mandatory changes to our mental health care delivery system.2 These events occurred in the context of an election in November 2019 that brought to the executive and legislative branches of state government many new leaders who were immediately faced with the challenge of developing a course of action to address both issues. To understand where this new mental health care roadmap may lead us, it may be helpful to consider where we are now and how we got here. Mississippi’s mental health care system is two-pronged in its approach to providing mental health services. On one end of the spectrum are community-based services, which are designed to offer evidencebased mental health services and decrease hospital admissions. On the other end, state hospitals provide care for patients who require extended hospitalization. The Mississippi Department of Mental Health (MDMH) is responsible for distributing funds, overseeing, and assisting community mental health centers (CMHC’s) in this process. The state of Mississippi is divided into 14 different regions, each with a CMHC that is tasked with providing mental health services to the counties located within its boundaries. Although Mississippi offers a number of community-based mental health services and has been moving toward a more community-based approach, the implementation of those services has been called into question by the federal government. The issues in question began with the case of Olmstead v. L.C.,3 in which two women diagnosed with mental illness and intellectual disabilities

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filed a lawsuit claiming that their rights under Title II of the Americans with Disabilities Act (ADA) were violated. Title II of the ADA states that, “No qualified individual with a disability shall, by reason of such disability, be excluded from participation in or be denied the benefits of services, programs, or activities of a public entity, or be subjected to discrimination by any such entity.”4 The two patients sought release from a state-run psychiatric facility in Georgia to pursue community-based mental health treatment. The landmark case was ultimately decided by the U.S. Supreme Court in a 6 to 3 decision in favor of the patients. The Olmstead case requires states to provide community-based services to disabled persons when (1) such services are appropriate, (2) the affected persons do not oppose community-based treatment, and (3) community-based services can be reasonably accommodated. In 2011, the USDOJ issued a letter of findings after an investigation into Mississippi’s mental health system. The USDOJ alleged that Mississippi was unnecessarily institutionalizing people with mental illness and therefore in violation of Title II of the ADA. In 2016, Mississippi found itself at the center of a lawsuit over the issue. After years of investigation and gathering evidence from both parties, the case went to trial in June and July of 2019. During the trial, the USDOJ acknowledged that Mississippi offers a number of community-based mental health services. However, the USDOJ charged that Mississippi’s move to implement those services had been too slow, thereby unnecessarily forcing individuals with mental illness into institutionalization in violation of Title II of the ADA. The USDOJ cited evidence that Programs of Assertive Community Treatment (PACT) were underutilized. Expert testimony revealed that most calls made to mobile crisis units were referred to the local police departments, crisis stabilization units were not available at all CMHCs, and supported employment services served 257 people in 2018 compared to the national average of 1266. Finally, Peer Support Services and the CHOICE housing program had low enrollment. Moreover, the USDOJ contended that the MDMH disproportionately allocates funds to state-run psychiatric hospitals. The USDOJ pointed to evidence that, excluding federal Medicaid spending, only 35.65% of Mississippi’s mental health spending went to community-based


services in 2017. Mississippi’s state psychiatric hospital bed utilization rate is also higher compared to most states. MDMH executives responded by testifying that they were committed to providing community-based services to Mississippians. The MDMH executives noted that a shortage of qualified mental health workers is a barrier to providing these services. At the trial, experts for both parties were called to testify on the current state of community-based mental health services nationally, and whether individuals with mental illness are receiving necessary and appropriate psychiatric care in Mississippi. The USDOJ hired expert witnesses who wrote a literature review comparing the nation’s community-based mental health services with Mississippi’s services and evaluated the efficacy of Mississippi’s community-based programs. The experts concluded for the USDOJ that most of the patients interviewed could have avoided or spent less time hospitalized if they had been provided sufficient access to community-based treatment. Mississippi also retained their own expert witnesses, who were tasked with determining whether the individuals sampled were appropriate for hospital admission. Experts for the state collectively determined that all the individuals sampled were appropriate for hospital admission and, at the time of admission, could not have been sufficiently treated with community-based services. Both sides produced testimony from experts who debated the financial cost of community-based services compared with hospitalization. After a review of the evidence, the court determined that the difference in cost was negligible. The USDOJ also argued that while Mississippi had identified appropriate community-based services, there was a lack of oversight and poor management of the services. For example, PACT team utilization was often unavailable in locations with some of the heaviest users of the mental health system. The state responded that they were in fact making strong efforts in investing in communitybased services. They pointed to increased spending for communitybased services, citing a report that Mississippi had nearly doubled its investment in community-based services from 2001 to 2015. To decide whether the state of Mississippi violated the ADA, the court returned to the standards set forth in Olmstead. Ultimately, the court concluded that Mississippi’s current mental health system is not meeting the Olmstead standard. Despite the ruling, Mississippi contended that it could not accommodate the DOJ’s recommendations. Attorneys for the state pointed to an exception in Title II of the ADA, which states that a public entity may be excused from providing reasonable modifications if they can demonstrate that such changes would “fundamentally alter the nature of the service, program, or activity.”5 Mississippi contended that the changes proposed by the USDOJ would “fundamentally alter” its mental health system and the financial burden of investing in community-based services was a violation of the third tenant of the Olmstead case. The court asserted that in order to be excused from providing accommodations set forth by the ADA, a comprehensive alternative plan must be in place, which Mississippi lacked at the time of trial. The court dismissed Mississippi’s second point, as previous testimony showed community-based services cost roughly the same

as hospitalization. For these reasons, the court dismissed Mississippi’s defense and ruled in favor of the USDOJ. Moving forward, the court announced a plan to appoint a Special Master to review proposals from both parties to develop a resolution to help bring Mississippi into compliance with the ADA. Both parties submitted potential candidates for the position, and on February 25, 2020, the court issued an order appointing Dr. Michael Hogan to the role of Special Master. Dr. Hogan, a psychologist from New York, is tasked with helping Mississippi remedy the ADA violations identified during the trial in an appropriate and timely manner. Angela Ladner, the Executive Director of the Mississippi Psychiatric Association, was one of the experts who testified on behalf of the USDOJ. Concerning the most recent developments in this case, Mrs. Ladner commented, “With the naming of the Special Master, citizens of Mississippi should be optimistic that there will be a roadmap for the state to follow regarding the mental health services across our 82 counties. The purpose of the lawsuit was to create parity in accessibility to mental health services in our communities. Once the roadmap is designed by the Special Master, it should be the focus of the state to implement the suggestions and reallocate resources to make things more community accessible. This means there has to be a change in approaches that are currently being followed. We must embrace a different way of doing business to achieve success.”6 To help with efforts to improve the state’s mental health system, the Mississippi legislature passed Senate Bill 2610 during this year’s session, which was signed by Governor Reeves on July 8, 2020.7 This law creates a temporary position known as the Coordinator of Mental Health Accessibility. The coordinator, distinct from the Special Master, will be responsible for evaluating Mississippi’s mental health system, identifying its inadequacies, and eliminating shortcomings, while working in conjunction with the legislature, Governor, and appropriate state agencies. In summary, Mississippi in 2020 has seen the convergence of 3 unrelated events—the onset of the medically and economically devastating COVID-19 pandemic, significant progress in the case of United States v. Mississippi (including the appointment of a Special Master), and a transition to newly elected leaders in state government. These intersecting events have created a uniquely challenging opportunity for the state of Mississippi to move forward on the road to revising its mental health care delivery system. The end product of that effort and its date of completion are difficult to foresee. Meanwhile, the rights and wellbeing of persons with mental illness hang in the balance. Hopefully, the federal court, the USDOJ, state government leaders, the Special Master, and other key stakeholders will come together to restructure our mental health system in a way that is practical, effective, and affordable. If that occurs, the citizens of Mississippi can say that they lived in a time that saw mental health care system changes made in the face of the massive public health and economic crisis caused by the COVID-19 pandemic. It is ironic that the apocryphal Chinese curse, “May you live in interesting times” could not be a more appropriate way

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to summarize the long road that lies ahead for Mississippians who try to navigate the mental health care system in the state.  ■ References 1. World Health Organization Director-General’s opening remarks at the media briefing on COVID-19 on 11 March 2020. Accessed on May 26, 2020. https:// www.who.int/dg/speeches/detail/who-director-general-s-opening-remarks-atthe-media-briefing-on-covid-19—11-march-2020 2. United States of America v. the State of Mississippi. No. 3:16-CV-622-CWR-FKB. Memorandum and Order. September 3, 2019. 3. Olmstead v. L.C., 527 U.S. 581 (1999).

Author Information T hird-year adult psychiatry resident at the University of Mississippi Medical Center (Silver, Sanku). Professor of Psychiatry at the University of Mississippi Medical Center (Merideth). The Honorable Carlton Reeves is a U.S. District Court Judge of the Southern District of Mississippi. He is presiding over the case of United States v. Mississippi. Angela Ladner is the Executive Director of the Mississippi Psychiatric Association and a former President of the MSMA Alliance. She testified as an expert on behalf of the US Department of Justice in the case of United States v. Mississippi.

4. Americans with Disabilities Act of 1990 (42 U.S.C. Section 12101). 5. Americans with Disabilities Act of 1990, Title II (42 U.S.C. Section 12101). 6. Interview with Angela Ladner, Executive Director of the Mississippi Psychiatric Association. Jackson, Mississippi. May 26, 2020. 7. Mississippi Senate Bill 2610 from the 2020 session of the Mississippi legislature. Accessed on July 17, 2020. http://billstatus.ls.state.ms.us/documents/2020/dt/ SB/2600-2699/SB2610SG.pdf

Carlton Reeves

Angela Ladner

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Teenagers as Health Screeners and Educators: The Evolution of the Mississippi State University Junior Master Wellness Volunteer Program and Results of a Pilot Study Reagan Moak, BS; David Buys, PhD, MSPH, CPH, FGSA; Ann Sansing MS, MRHF; Jasmine Harris-Speight, MS; Je’Kylynn Steen, BS, CFLE-P; AND Richard D. deShazo, MD

Abstract In this paper, we report our experience in the development of a curriculum for the training and deployment of high school students into Mississippi communities as health screeners and health advocates. In collaboration with the Mississippi State University Extension Service (MSU ES) and the existing Mississippi 4-H program, we trained 462 high school student volunteers and 38 MSU ES agents in a new MSU ES Junior Master Wellness Volunteer (JMWV) Curriculum patterned after the University of Mississippi Medical Center (UMMC) Community Health Advocate (CHA) Program. Our program, a descendent of community-based health training initiatives in Mississippi dating to 1924, has now provided 5839 service hours to 7531 Mississippians with an estimated dollar value of $115,670.59. Although further research is needed, we feel our experience provides proof of principle that the JMWV Program successfully trains, deploys, supervises, and mentors high school students to provide health screening for common chronic illness using a curriculum developed by health professionals. Those JMWVs effectively referred individuals screened to medical professionals for evaluation, diagnosis, and treatment where appropriate, while increasing their own health literacy and interest in health professions training.

Figure 1.  Mississippi is, and has been for decades, among the

states with the worst health statistics. Mississippi is ranked 49th overall in health outcomes in the United States. This is due to a multitude of factors that need to be addressed to improve the current overall health outcomes rank of 49th. (Source. Adapted from America’s Health Rankings.com with permission)

Introduction

born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks”.1 Mississippi is at or near the bottom in all of these factors.2 Health inequalities result when the social determinants of health are lacking.3 Health literacy, the ability of an individual to understand basic human biology and master the information required for optimizing personal health, is a key social determinant of health strongly associated with good health outcomes.4

Mississippians have struggled with the complications of poor health for decades, yet our current health ranking based on factors including longevity, disability, and disease prevalence places us 49th in overall health ratings among the states (Figure 1). The social determinants of health are “conditions in the environments in which people are

Because of its key importance, many health professionals and organizations have attempted to address our state’s social determinants of health through efforts to increase health literacy among Mississippians (Table 1). There were lessons to be learned from each of them.

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Table 1.  Timeline of Some of the Attempts to Increase Health Literacy in the Southeastern United States

1924: The Era of Felix Underwood at The Mississippi Board of Health (1924-1958)6 Dr. Felix Underwood becomes Executive Officer and Secretary of Mississippi State Board of Health and addresses the role of social factors such as clean water and sanitation to decrease parasitic diseases in Mississippi with support from the Rockefeller Foundation. 1998: Initial Development of a Formal Curriculum for Community Health Workers7 Morehouse University trains medical students and interested parties, including those from Mississippi, as health educators and screeners for individuals with low health literacy. 2007: Development of the UMMC Community Health Advocate Program10 The University of Mississippi Medical Center (UMMC) faculty established the Community Health Advocate (CHA) Curriculum and Outreach Program with lay individuals as health promoters and screeners. 2014: The Faith Health Programs12 Rev. Gary Gunderson and Dr. Christina Cuffs develop a faith-based health education program using the UMMC CHA curriculum to provide posthospital discharge care and lower readmission rates at the Baptist Medical Center in Memphis, Tennessee serving Tennessee and North Mississippi. 2016: The MSU Junior Master Wellness Volunteer Program The Mississippi State Extension Center revises the UMMC’s CHA program for high school students to be used in the JMWVprogram.

Dr. Felix Underwood, the first full-time executive officer and second chairman of the Mississippi Board of Health, developed a partnership with the Rockefeller Foundation to successfully address the epidemic of roundworm infection in Mississippi children in 1930.5 He identified the social determinants of health central to that epidemic: rural status, poverty, access to healthy foods, sanitation, and health literacy. He then implemented interventions to address those social determinants and was successful in decreasing roundworm infections.6 However compared to subsequent efforts to improve health in the state, short-term funding from grants and contracts resulted in the loss of gains made over time.6 His success inspired many others, including our group, to identify a low-cost,­ self-perpetuating health literacy program.

nutritionists, physical and occupational therapists, and preventive medicine faculty interested in improving health literacy and disease prevention developed a comprehensive training curriculum for lay community health advocates (CHA) using lessons learned from the Morehouse University program. A Community Health Advocate Training Curriculum was written to be used as a training module for an interactive lecture series that included an introduction to basic human physiology and disease, disease prevention, obesity and each of its major complications (hypertension, diabetes, heart disease, and stroke), health screening for risk factors and early detection of disease, immunizations, confidentiality, and pathways to navigate the health care system and increase access to care.

A more recent example is the success of the Morehouse Community Health Worker Training Program for High School Students and Young Adults that was developed by Morehouse University faculty to improve health literacy. Morehouse University undergraduate students were trained by health professionals to perform health screenings and provide information on disease prevention to underserved populations with low health literacy. They collaborated with a network of local churches serving underrepresented minority populations to identify participants.7 Knowledge of these previous efforts to develop a written, uncopyrighted curriculum that could be shared to improve the social determinants of health led to the development of another community-based volunteer program staffed by community volunteers, medical professions, faculty, and health profession students.

An additional learning module by the same authors titled Southern Remedy Healthy Living promoted the concept of mindful changes in lifestyle as a pathway to better health and longevity.8 This module provided instructional material for community health advocates to share with interested lay participants at health screenings. Topics included basic nutrition, calorie counting and control, and the concept of body mass index (BMI). The module also included content for individuals with low health literacy adapted from the US Department of Agriculture’s (USDA) Choose My Plate Program.9 Subsequent publications to include “Dietary Recommendations in Ambulatory Care: Evaluation of the Southern Remedy Healthy Eating Plate” have validated the methodology of the CHA Program modules.8 The statewide Mississippi Public Broadcasting Radio series, Southern Remedy, promoted the availability of CHA training.

The University of Mississippi Medical Center’s Community Health Advocate Training Program and Curriculum In 2007, a group of faculty volunteers at the University of Mississippi Medical Center (UMMC) including physicians, nurses, pharmacists,

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The UMMC faculty group provided instruction in the 2 modules to lay individuals of the church, civic and other community groups, and health professions students through 4 to 6 hours of interactive training to develop community health advocates who functioned as


health screeners, health promoters, and trainers of other community health advocates for the expansion of the program across the state. At the end of the lecture component of the training, participants were taught to accurately measure blood pressure, BMI, and other indicators of health, in addition to how to best advise individuals with abnormalities to seek the assistance of medical professionals for confirmation and treatment of abnormalities detected. Over 1000 individuals were certified as CHA during the first 3 years of the program. The CHA curriculum later became a component of the medical school curriculum at UMMC and provides an opportunity to better understand the goals of population health and service-learning.10 Continuity of the program at the UMMC has been provided by support from the Division of Academic Affairs there. Data on the evaluation of the program has been previously published.11 The Faith Health Consortium Reverend Gary Gunderson and Christina Cuffs, PhD developed 2 faith-based programs in collaboration with the Tennessee Baptist Medical Center and Wake Forest Baptist Medical Center. In these programs, CHAs were trained with an expanded UMMC curriculum to successfully decrease hospital readmission and promote preventative care and compliance with medical treatment recommendations.12 The Mississippi State University Junior Master Wellness Volunteer Program Revision and Expansion of the UMMC CHA Program into the JMWV Curriculum Beginning in 2014, a group of MSU faculty cooperated with the MSU ES and UMMC to adapt the UMMC CHA curriculum for use by high school students aged 14 to 18 in health science academies and 4-H programs. The 4-H program is especially suited for this training as 4-H focuses on positive youth character and leadership development with

the pledge to use “head, heart, and hands” to promote health.13 As a first step, the working group developed objectives for the new program for teens that included measurableoutcomes (Table 2). The 10 chapters of the UMMC CHA curriculum were utilized as a starting place that would become the 15 existing modules of the new JMWV Program curriculum (Table 3). A needs-analysis by the MSU ES Review Committee identified modifications necessary to make the new program suitable for the 14 to 18 year age group. Age-appropriate topical material was added in the 5 new learning modules: asthma awareness, heat and sun safety, substance misuse, bullying, and healthy homes. The content of the 5 new modules was reviewed and approved by the UMMC CHA Program leaders, the MSU Extension Review Committee, and JMWV peer reviewers. The new JMWV curriculum materials now include the JMWV Student Guide, the JMWV Agent Guide, and the JMWV Social Media Toolkit that provides online material for activities in the classroom (Table 3). Thirty-eight MSU ES agents across Mississippi were trained as JMWV Program educators by the curriculum developers using the information in the JMWV Agent Guide and the JMWV Program curriculum. The MSU ES agents, in turn, trained high school student volunteers to become health screeners and educators. JMWVs now receive a minimum of 12 hours of instruction before their certification as a JMWV. The program requires that individual volunteers demonstrate the ability to provide health screenings and preventive health information in a confidential and culturally appropriate way under the supervision of area MSU ES agents. Their role as screeners and advisors, not health care providers, is emphasized throughout their involvement in the program. Service and Evaluation of the JMWV Program After successful completion of training and checkoffs, volunteers serve under the supervision of trained, local MSU ES agents to

Table 2.  Consensus Objectives Developed for the JMWV Program

Junior Master Wellness Volunteer Objectives

Junior Master Wellness Volunteer Implementation

Educate to empower

CHA curriculum, JMWV addendum

Provide accurate health-promotion information

Volunteers educate their communities through health fairs, presentations, and other community action plans

Develop leadership and team-building skills among volunteers

Volunteers work with other students, extension agents, teachers, and community partners to program and execute community action plans

Encourage volunteerism

Community action plans are utilized to program and organize community volunteering. These can be original ideas or preplanned action plans from the manual

Support ongoing and new programs in communities

Support and participate in community events and programs regarding health promotion and health education

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Table 3.  Chapters of the Junior Master Wellness Volunteer Curriculum with Details on Additions Made to the UMMC CHA. These JMWV curriculum additions were made in addition to the original UMMC CHA curriculum which included the following chapters: Roles and Responsibilities of CHA, What is Privacy, Health Literacy, Hypertension, Diabetes, Obesity, Portion Control, Interpreting a Health Providers Instructions on a Pill Bottle, Communicating with a Health Professional, Tobacco Use and Intervention, Cultural Competency, Oral Health, and Health Screenings.

Added Chapters in the Junior Master Wellness Volunteer Curriculum

Some Key Elements of Module

Asthma Awareness

What is asthma, diagnostics, prognostics, treatment options, how to use an inhaler, asthma action plan, how to act in case of an attack, sports

Bullying Prevention

What is bullying, types of bullying, signs of bullying, how bullying impacts health, how to intervene

Healthy Homes

Temperature and moisture control, fire and environmental safety, sanitation, ventilation, pests

Heat and Sun Safety Awareness

Skin damage protection, heat exhaustion

Opioid Misuse and Prevention

What are opioids, what is abuse, what is addiction, the biology of addiction, the psychology of addiction, sociology of addiction, who is at risk, prevention, treatment, recovery, and behavioral therapies, what to do with leftover opioids, tips for family and friends of opioid addicts

Community Action Plan Examples

Community action group, who and what, mission statement, start-up questions for discussion, action plan grid, stakeholders and community partners: community walk, self-help saving rural America conference

develop community action plans specific for health literacy in their communities. The agents and volunteers work together to select community service projects and community action plans to ensure effectiveness. This includes defining who will participate, a mission statement, start-up discussion questions, an action plan, and potential community partners. Opportunities for service are identified through social media, word of mouth, and advertisements. Volunteers program and schedule their projects, and the MSU ES agents assist with logistics. The volunteers then serve in locations across Mississippi under the supervision of that same MSU ES agent. Volunteers pledge to focus on the four 4-H values.13 Volunteers are required to complete a minimum of 24 hours of community service per school year to include approved personal initiatives that include health fairs, educational presentations, community walks, and similar activities. The 24-hour service requirement allows students to meet the 4-H goal to “Give a day of your year in service to your community.” A series of commitments were obtained from all involved before program implementation. MSU ES funded the production of highquality, full-color agent manuals and student guide manuals. MSU extension agents offered the program to 14- to 18-year-old students with an interest in service and health care beginning in 2017. Volunteers reported their community service online using the electronic database, Qualtrics.14 The template included demographic information, details of service, service hours completed, and the individuals impacted. Results were reviewed by program leaders to assess successes and opportunities for improvements each year to form an estimate of community impact.

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Once service hours from volunteers was collected, the software program Independent Sector was used for further analysis to calculate the monetary value of yearly service statewide.15 The data were also used to map participation. Written program evaluations were completed by volunteers at the conclusion of training and reviewed for evidence of leadership, content mastery, and career aspirations. This information was also used to estimate the impact the program had on the career paths of Mississippi youth. Four Years of Service by MSU JMWV During the first 4 years of the program (2014–2018), 462 volunteers from 32 Mississippi counties completed the training and performance requirements of the JMWV Program (Figure 2). They completed 5839 community service hours to 7531 Mississippians with an estimated monetary value of $115,670 (Figures 3 and 4: Map of Mississippi 2 and 3). Representative activities and comments of participants in the JMWV Program included those of N.H. from Hinds County, MS, who participated in the mammogram and hypertension clinics for the Women’s Federal Correctional Complex in Yazoo City, MS. Over 3 days of service, she provided blood pressure screenings for 27 hours to over 100 staff members while also providing health education on hypertension. A.B. from Sunflower County, MS, noted, “The Junior Master Wellness is about helping people. If you have it in your heart to help somebody find a solution and feel better, this program will give you insight into what you need to know to be able to talk to people about health.” Ten JMWVs from Winston County, MS, led a “Self-HelpSaving Rural America” conference on obesity, the impact of healthy eating, and overall hygiene for 190 Louisville High School students. Q.W. from Sunflower County wrote, “I plan to be a sports physician,


Figure 2.  Map 1 of Mississippi, showing the Junior Master Wellness Volunteer service hours 2014 through 2018. This represents the service hours completed by the JMWV in their local Mississippi communities between 2014 and 2018. These service hours were completed through health screenings, community walks, educational presentations, and a variety of other approved events.

Figure 4.  Map 3 of Mississippi, showing the monetary value of JMWV

volunteer hours between 2014 and 2018. A representation of the monetary value of the 5839 community service hours 462 volunteers completed from 2014 and 2018. This was calculated via Independent Sector.15

of volunteers expressed an interest in pursuing careers in the health profession after participation in the program. Figure 3.  Map 2 of Mississippi , showing Junior Master Wellness

Volunteer contacts during volunteer work 2014 through 2018. This map represents the community contacts made by the 462 volunteers between 2014 and 2018.

but I got my real start in medicine by becoming a Junior Master Wellness Volunteer. I’m telling students that they need to eat better, and I’m showing them how to manage their stress.” Eighty-eighty percent

Discussion The MSU ES JMWV Program was modeled after a series of communitybased activities dating back to 1924, although we are aware that there have been others of great merit in our state that we have not mentioned. Our particular effort has continued the use of face-to-face dialog with local citizens espoused by Felix Underwood, MD with community members interested in better health, while at the same time engaging local youth in service-learning in health, health professions, and social determinants of health. Research shows the positive benefits of early health education.16 We believe our initial experience reported here supports the value of carefully selected, trained, and supervised high school students as community health educators. The program also appears to promote the interest of health professions in our state where access to care has been an especially challenging social determinant of health. Regardless, the connection of high school students to community service early on will likely encourage them to become health aware and service-driven leaders in the state no matter what profession they choose going forward. We consider this experience a “pilot study” that has demonstrated proof of principle that high school students can be health educators. Possible pitfalls in our conclusions include the limited data collected as well as the quality of the data itself. During data collection, program leaders noticed difficulty in the use of the reporting software by high school students, especially in the application of the Qualtrics online electronic database. Program leaders now provide more robust training in data

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collection and the use of the software and a paper method for data collection. Agent and volunteer feedback guided these improvements. Program leaders are also reviewing that feedback to maximize the value of the curriculum and include more Mississippi-specific data in it. In the future, the program leaders plan to widen their teaching scope to educate larger, more diverse groups of teens. Program leaders will present data on the program at public health conferences in order to expand collaboration with public health officials and other health professionals interested in improving health literacy and increasing diversity and inclusion in the health professions. Conclusion Patients and physicians are continually dissatisfied with the amount of time available in the clinical setting to provide health literacy instruction, while knowing that low health literacy lessens patient compliance to recommendations for care.17 This noted combination can negatively affect clinical outcomes and patient-physician relationships. Thus, a mechanism to increase health literacy outside the clinical environment is necessary. The Junior Master Wellness Volunteer Program helps bridge that gap by educating youth on a variety of important preventive health topics while providing them a skill set to communicate that information to their families and members of their rural communities.  ■

3. Winkleby MA, Jatulis DE, Frank, et al. Socioeconomic status and health: How education, income, and occupation contribute to risk factors for cardiovascular disease. Am J Public Health 1992;82:816-820. 4. DeShazo RD, McCullouch K. Mississippi’s battle with the social determinants of health: A review and commentary. J MSMA. 2018;59:334-343. 5. Mississippi Public Health Timeline. (n.d.). Accessed on 2019. https://msdh. ms.gov/msdhsite/_static/resources/3823.pdf. 6. Lampton LM. Felix Underwood. Published April 15, 2018. Accessed on May, 2019. https://mississippiencyclopedia.org/entries/felix-underwood/2018 7. Buckner AV, Ndjakani YD, Banks B., Blumenthal, DS. Using service-learning to teach community health: the Morehouse School of Medicine Community Health Course. Acad Med. 2010;85:1645-1651. 8. Smith A, Minor D, Tillman L, et al. Dietary recommendations in ambulatory care: Evaluation of the Southern Remedy Healthy Eating Plate. J Miss State Med Assoc. 2012;53:330-333. 9. Find Resources. (n.d.). Accessed on December, 2019. https://www.choosemyplate.gov/resources. 10. Community Health Advocates Screening and Training Program Home. (n.d.). Accessed on December, 2019. https://www.umc.edu/Office of Academic Affairs/ For-Students/Office for Community Engagement and Service Learning/Community Health Advocates/Community Health Advocates.html 11. Financing Population Health Improvement: Workshop Summary. Roundtable on Population Health Improvement; Board on Population Health and Public Health Practice; Institute of Medicine. Health Care System Investments in Population Health Improvement. Chapter 3. National Academies Press (US); 2015. https://www.ncbi. nlm.nih.gov/books/NBK284859/. 12. Cutts T, Gunderson G, Carter D, et al. From the Memphis model to the North Carolina way: Lessons learned from emerging health system and faith community partnerships. North Carolina Med J. 2017;78:267-272. 13. 4-H. (n.d.). Accessed on May, 2019. https://4-h.org/about/what-is-4-h/

Acknowledgments The authors thank the many MSU and UMMC faculty and staff, the MSU Extension Service personnel, and the high school students and 4-H members whose efforts made this report possible. References

14. Qualtrics XM - Experience Management Software. (n.d.). Accessed on May, 2019. https://www.qualtrics.com/ 15. Value of Volunteer Time. (n.d.). Accessed on April, 2019. https://independentsector.org/value-of-volunteer-time-2018/ 16. Centre, INSERMCE. Health education for young people: Approaches and methods. Accessed on November, 2019. Published January 1, 1970. https://www.ncbi. nlm.nih.gov/books/NBK7118/ 17. Dugdale DC, Epstein R, Pantilat SZ. Time and the patient-physician relationship. J Gen Intern Med. 1999;14:S34-S40.

1. Social Determinants of Health. (n.d.). Accessed on February, 2020. https://www. healthypeople.gov/2020/topics-objectives/topic/social-determinants-of-health

Author Information

2. America’s Health Rankings United Health Foundation. 2018, America’s Health Rankings Annual National Report 2018. Accessed on May, 2019. www.ameri cashealthrankings.org/explore/annual/measure/Overall/state/MS?editionyear=2018.

Mississippi State University Food Science, Nutrition and Health Promotion (Moak, Buys, Sansing, Harris-Speight, Steen). University of Mississippi Medical Center (Moak, deShazo).

Free consult line for pediatric primary care providers Consult with a UMMC child psychiatrist or child psychologist regarding ADHD, anxiety, depression, and other mental or behavioral health concerns. • Diagnostic clarification

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S C I E N C E

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M E D I C I N E

Top 10 Facts You Need to Know About Selective IgA Deficiency Matthew R. Elliott, MD and Patricia H. Stewart, MD

Selective immunoglobulin A (IgA) deficiency is defined as a decreased serum level of IgA in the setting of normal serum levels of the other immunoglobulins.1 This immunoglobulin is found as 2 subtypes: IgA1 is the monomeric form found in the bloodstream and IgA2 is the dimeric form that is found in the secretions of mucosal surfaces (Figure 1).1 The information below may be helpful in the diagnosis and management of those with this disease. Selective IgA deficiency is the most common primary immunodeficiency and often goes undiagnosed. The prevalence of IgA deficiency is as high as 1:142 in the Middle East, 1:500 in America and Europe, and as low as 1:15 000 in Japan.2 Diagnosis is made by a laboratory test, the serum concentration of IgA. The disease can be asymptomatic, and it may be diagnosed while testing for other diseases.1 Diagnosis is generally reserved for patients 4 years of age and older, and who have normal levels

Figure 1. Models of IgA.1 The monomer is serum IgA while the dimer is secretory IgA.

of IgM and IgG (Table 1). Partial IgA deficiency patients are frequently asymptomatic and go undiagnosed, while patients with selective IgA deficiency can have a more severe disease course. Prior to diagnosis, clinicians should also rule out other causes of hypogammaglobulinemia.3 Consider selective IgA deficiency in patients with recurrent sinopulmonary or gastrointestinal symptoms. Secretory IgA coats the mucosal surfaces of the sinuses, respiratory tract, and gastrointestinal tract, and acts as a barrier to potential pathogens.1 Studies have shown that the absence of IgA results in more frequent infections of the respiratory and gastrointestinal tracts. Most commonly, these are because of bacteria in respiratory infections and giardia in gastrointestinal infections.4,5 Some patients with IgA deficiency have increased production of mucosal IgM. This is thought to be a compensatory mechanism to help reduce infections in those with decreased mucosal IgA production.6 Patients with selective IgA deficiency can have an anaphylactic reaction to blood products. This is most likely due to the production of anti-IgA antibodies in those with IgA deficiency.4 In those patients receiving red blood cells, the red cells can be washed to decrease the risk of an anaphylactic reaction. In those with an indication for plasma or cryoprecipitate, the

Table 1.  Serum IgA Levels in IgA Deficiency

IgA Deficiency Type

Serum IgA Level

Selective IgA deficiency

<7 mg/dL

Partial IgA deficiency

Two standard deviations below normal, but >7mg/dL

Adapted from Refs. 1 and 3.

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product should be obtained from an IgA deficient individual.7 IgA References before proceeding with the planned procedure is imperative. Careful deficient patients should wear a medical alert bracelet to prevent an Table 2. Five1 Star Approach to the Anesthetic Management of Trisomy 18 1. anesthetic Yel L. Selective IgA deficiency.especially J Clin Immunol. 2010; 30:10-16. and avoiding a management, airway management adverse event. Table 2. Five Star Approach to the Anesthetic Management of Trisomy 18 hypertensive crisis,pediatric is critical. Avoiding multiple procedures 2. pulmonary Stiehm ER. The four most common immunodeficiencies. J Immunotoxicol. anesthetics 2008;5:227-234. and may be helpful. n In the initial evaluation for selective IgA deficiency, the Ø Complete examination including cardiac evaluation, airway common variable immune deficiency should be excluded. 3. Conley ME, Notarangelo LD, Etzioni A. Diagnostic criteria for primary immunoassessment deficiencies. Clinical Immunology. 1999;93:190-197. Acknowledgment Multidisciplinary meeting involving anesthesiologist, There have been severalØ reports documenting thesurgeon, progression of & 1. Pre-anesthetic evaluation intensivist to discuss perioperative plan Cunningham-Rundles C. Physiology of IgA and IgA deficiency. J Clin Immunol. IgA deficiency to common variable immune deficiency. these cases, 4. We Ø Open and honest discussion with familyIn about the risks, would like to thank Khalid Altirkawi, MD, FAAP for giving us 2001;21:303-309. expectations, and treatment plan immunoglobulin replacement therapy would need to be considered to use hisMP, pictures figure. 5. permission Langford TD,to Housley Boes M,for et al.the Central importance of immunoglobulin prevent severe infections.8 A in host defense against giardia spp. Infect Immun. 2002;70:11-18. References Ø Complete anesthesia readiness, including immediate availability 6. Brandtzaeg P, Karlsson G, Hansson G, et al. The clinical condition of IgA-deficient There is an association between IgA deficiency, celiac patients is related to the proportion of IgD- and IgM-producing cells in their nasal of difficult airway equipment and emergency vasoactive drugs 2. Logistics Readiness 1.mucosa. BaumClin VC, JE. Anesthesia for Genetic, Metabolic, and Dysmorphic Ø Pediatric anesthesiologist with experience in difficult airway ExpO’Flaherty Immunol. 1987;67(3):626-636. disease, and other autoimmune diseases. management and cardiac anesthesia Syndromes of Childhood. Third edition. Philadelphia: Wolters Kluwer; 2015. The prevalence of celiac disease in patients with IgA deficiency may 7. 2.Sandler SG,A,Mallory D,The Malamut R. IgA anaphylactic transfusion Cereda Carey JC. trisomyD,18Eckrich syndrome. Orphanet J Rare Dis. 2012;7:81. Rev. 1995;9:1-8. be up to 20 times higher than that of the general population.9 IgA 3.­reactions. Transfus Meyer RE, Liu Med G, Gilboa SM, et al. Survival of children with trisomy 13 and trisomy 18: A A, multi-state population-based J Med Genet A. 2016 8. Aghamohammadi Mohammadi J, Parvaneh N,study. et al.Am Progression of selecØ “Tight” control during anesthetic, including deficiency has been associated withphysiological the development of rheumatoid 3. Intraoperative anesthesia Apr;170A(4):825-37. meticulous attention to ventilation and prevention of the tive IgA deficiency to common variable immunodeficiency. Int Arch Allergy 4,10 management arthritis, systemic lupus erythematosus, and Graves’ pulmonary hypertensive crisis disease. 4. Banka S, Metcalfe K, Clayton-Smith J. Trisomy 18 mosaicism: report of two cases.

­Immunol. 2008;147:87-92. World J Pediatr. 2013;9(2):179-181. 9. 5.Meini A, Pillan NM, Villanacci V, et al.H, Prevalence and diagnosis of celiac disease in Kosho T, Nakamura T, Kawame Baba A, Tamura M, Fukushima Y. Neonatal 4. Immediate Post-operative in intensive unit and possible Severalpost-operative medicationsØcan cause amonitoring transient IgAcare deficiency. IgA-deficient children. Ann Allergy Asthma Immunol. 1996;77(4):333-336. management ventilatory support. management of trisomy 18: clinical details of 24 patients receiving intensive Some medications known to cause IgA deficiency include treatment. Am J Med Genet A. 2006;140(9):937-944. 10. Jacob CMA, Pastorino AC, Fahl K, et al. Autoimmunity in IgA deficiency: anti-epileptics (e. g. carbamazepine, valproic acid, phenytoin, 6.­Revisiting Batees H, KA. as Trisomy syndrome: Towards balanced approach. theAltirkawi role of IgA a silent18housekeeper. J Clin aImmunol. 2008; Ø Employ “one-stop shopping” strategy: performing more than one 11-16 5. General riskcaptopril, reduction strategy proceduresulfasalazine, under one anesthetic to reduce multiple anesthesia Sudan J Paediatr. 2014;14(2):76-84. 28:56-61. lamotrigine), penicillamine, and cyclosporine. procedures 7. Boss RD, Holmes KW, Althaus J, Rushton CH, McNee H, McNee T. Trisomy 18 11 Ashrafi M, Hosseini SA, Abolmaali S, et al. Effect of anti-epileptic drugs on serum and complex congenital heart disease: seeking the threshold benefit. Pediatrics. immunoglobulin levels in children. Acta Neurol Belg. 2010;110:65-70. Patients with selective IgA deficiency have a higher 2013;132(1):161-165. 12. 8.RuffCourreges ME, PincusP,LG, SampsonR,HA. Phenytoin-induced IgAmanagement depression. Am J Dis s incidence of allergic disease. Nieuviarts Lecoutre D. Anaesthetic for Edward’ exacerbating pulmonary hypertension. Child. 1987;141:858-861. syndrome. Paediatr Anaesth. 2003;13(3):267-269. Decreased levels of mucosal immunity in those with IgA deficiency Bailey C,S, Chung R. Use of the laryngeal airway in a patient Edward’s 13. 9.Maruyama Okamoto Y, Toyoshima M, etmask al. Immunoglobulin A with deficiency appears to rigidity allow the exposure of allergens to immunocompetent Muscle after use of succinylcholine has been reported incells these ­following syndrome. Anaesthesia. 1992;47(8):713. treatment with lamotrigine. Brain Dev. 2016;38:947-949. 17 12 of this, with selective associated IgE production. 10. Miller C, Mayhew JF. Edward’s syndrome (trisomy 18). Paediatr Anaesth. However, there is noBecause known risk for patients malignant hyperthermia patients.with 1 4. Hammarström L, Smith CI, Berg U. Captopril-induced IgA deficiency. ­Lancet. 1998;8(5):441-442. IgAindeficiency predisposition to develop asthma, allergic children have witha higher Trisomy 18. Brief surgical procedures such as 11. 1991;337:436. Friesen RH, Twite MD, Nichols CS, et al. Hemodynamic response to ketamine in 18,19 rhinoconjunctivitis, contact dermatitis,byandlaryngeal food allergy. myringotomies can be managed mask airway (LMA).9 15. Farrchildren hypertension. Paediatr Anaesth. 2016;26(1):102-108. M, Kitaswith GD,pulmonary Tunn EJ, Bacon PA. Immunodeficiencies associated with sulMatsudatherapy H, Kaseno S, Gotoh Y, Furukawa K. Muscle rigidity caused Regional nerve block techniques such as an epidural catheter or single 12. phasalazine in inflammatory arthritis. BrK,J Imanaka Rheumatol. 1991;30:413-417. by succinylcholine in Edwards’ syndrome. Masui. 1983;32(1):125-128. Treatment considerations. shot caudal can be considered for lower abdominal or extremity 16. Murphy EA, Morris AJ, Walker E, Lee FD, Sturrock RD. Cyclosporine A induced Though most patients remain anesthesia. asymptomatic, with in colitis and acquired selective IgA deficiency in a patient with juvenile chronic procedures in combination with general Pain those assessment Author Information recurrent infections generally require antibiotics either older patients in the post-operative period can be challenging due to arthritis. J Rheumatol. 1993;20:1397-1398.

1 Aghamohammadi Cheraghi T, Gharagozlou M, et al.Texas IgA deficiency: Correlation as severe neededmental or prophylactically. professor,A,Department of Anesthesiology, Tech University Health retardation. In more severe cases, referral to an 17. Assistant between clinical immunological phenotypes.Associate J Clin Immunol. 2009;Department 29:130-136. of Sciences Center,andLubbock, TX (Fishkin). professor, immunologist is advised. s Hospital, NCsymptoms (Sathyamoorthy). CRNA, 18. Anesthesiology, Jorgensen GH, Levine GardulfChildren' A, Sigurdsson MI, Charlotte, et al. Clinical in adults with Conclusion 8 Department of Anesthesiology, University of Mississippi Medical Center, Jackson, MS selective IgA deficiency: A case-control study. J Clin Immunol. 2013;33:742-747. Acknowledgments (Wardlaw). Professor, Department of Otolaryngology and Communicative Sciences, Janzi M, Kull I, Sjöberg R,Medical et al. Selective deficiency in early The life: authors Association to no We propose several strategies for safe perioperative management 19. University of Mississippi Center, IgA Jackson, MS (Reed). report infections and allergic diseases during childhood. Clin Immunol. 2009;133:78-85. of these patients. These patients should thorough pre- financial disclosures or conflict of interest. Conflict of Interest Disclosures: The authors haveundergo nothing toa disclose. anesthetic evaluation and be managed by a pediatric anesthesiologist Corresponding Author: Semyon Fishkin, MD; Department of Anesthesiology, with experience in managing the difficult airway and cardiac anesthesia. Texas Tech University Health Sciences Center, 3601 4th Street, STOP 8182, Lubbock, Detailed discussion with the family about treatment options and risks TX 79430. Ph: (806) 743-2981 (semyonfishkin@gmail.com).

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P R E S I D E N T ’ S

S pee c h

Dr. Clay Hays’ President’s Speech

D

ear House of Delegates,

Thank you for allowing me the opportunity to serve as the President of the Mississippi State Medical Association (MSMA). It has been an honor and privilege and something that I will never forget.

Over the past year, I wanted to set the tone with several themes. The first theme was J. Clay Hays, Jr., MD #relationships matter. To that end, I’ve MSMA President truly enjoyed the opportunity to meet 2019–2020 with physicians where they practiced all across the state. Starting last fall, my wife and I began our tour and met with physicians, hospital administrators, schools, and families. We visited with component societies in Greenwood, Indianola, Greenville, Cleveland, Jackson, McComb, Biloxi, Gulfport, Oxford, and Tupelo. Despite differences in geography, the gracious hospitality was always the same. We have a wonderful state with caring people who love their communities. They are a tremendous and treasured resource that makes Mississippi a great place to live, work, and play. I want to thank all of the component societies for being so welcoming. I was hopeful that I would visit with all of the societies around the state but obviously with the pandemic, my travels were curtailed. Please accept my apology. Establishing State Medical’s presence as the authority on the practice of medicine and the leader of the health care team was my second goal. Whether it was testifying to the legislature about the scope of practice issues, conducting television and radio interviews, having weekly calls with Blue Cross and Blue Shield about telemedicine reimbursement, or hosting weekly Facebook Live interviews with Dr. Thomas Dobbs; I wanted to make sure that State Medical was out in front of the public communicating our views and providing respected advice. I want to express my gratitude to our staff, particularly David Roberts, Becky Wells, Ashley Grant, Kathy Wade-Butler, and Kim Mathis for setting up the visits, interviews, and social media. Thanks a million! Next, the COVID-19 pandemic hit, and State Medical was ready. At the request of Governor Reeves and State Health Officer Dr. Thomas Dobbs, we were asked to set up the Governor’s medical advisory task force. Using our relationships and with the help of our executive director, Dr. Claude Brunson, I was allowed to chair the task force and work with other physicians, hospital CEOs, medical licensure board

members, nursing board members, dentists, the health department, the nursing association, MACM, the University of Mississippi Medical Center (UMMC) leadership, and the Governor’s staff. Under the direction of Dr. Steve Stogner and Dr. Harper Stone, the Mississippi Healthcare Alliance developed a COVID-19 system of care for our state. Dr. Dan Edney put together a physician volunteer workforce and the medical association was able to lobby the legislature to expand the medical liability protection. Dr. Mark Horne led regularly WebEx calls to help physicians with their outpatient practices, Dr. Jennifer Bryan set up and facilitated discussions on the PFM page on Facebook, Dr. Justin Turner worked with the mayor and city of Jackson officials on their pandemic plan, and Dr. Russell Young chaired the committee on telemedicine. At the invitation of the governor, I got to visit with Dr. Deborah Birx and express Mississippi physicians’ views and concerns about this crisis. Finally, it was fun working with my medical school classmates, UMMC’s Vice-Chancellor Dr. LouAnn Woodward and the state president of the American Academy of Pediatrics, Dr. Anita Henderson. Go Class of 1991! I can definitely testify that our bench of physician leaders is deep. Education was my next theme and the American Medical Association (AMA) was instrumental in helping us achieve our goals. With a grant from the AMA, our State Scope of Practice partnership was able to educate our legislators and high-ranking officials that Medical School Matters and nurse practitioners did not have the same training and expertise as physicians did. We were able to stop legislation allowing independent practice for nurse practitioners, physician assistants, nurse anesthetists, and optometrists. The AMA also encouraged me to pursue my MBA degree and provided an avenue for MSMA members to get a scholarship to the Brandeis eMBA program. I would encourage any member who has an interest to contact our association for further details. Finally under the education theme, we were able to safely conduct the CME in the Sand program at Sandestin over the Fourth of July weekend without any problems as we highlighted how to conduct an educational program during a pandemic. The staff of MSMA put on an excellent program and we owe them a big debt of gratitude. Wellness and Fitness was my last goal and we tried to encourage people to exercise. We printed and passed out #MSMA4Fitness T-shirts all around the state. Dr. Avani Patel assisted me in making videos and publishing interviews in AMA News. David Roberts and Dr. Katherine Pannel posted pictures on their Twitter accounts and multiple medical students showed off the swag during runs and races. I had the opportunity to break ground with Mayor Lumumba and city

vol. 61 • no. 10 • 2020 343


of Jackson officials on the Museum Trial in Jackson, and I look forward to the ribbon-cutting in October of this year. In conclusion, I have so many people to thank for their support and prayers over the past year. I would like to thank the Central Medical Society for sponsoring and supporting me over my career and development in so many positions of leadership. I want to thank the many board members who I had the pleasure of working with over the last decade. I want to thank Dr. Claude Brunson and Dr. Jennifer Bryan as well as the Staff of MSMA. I want to thank my partners and staff at

the Jackson Heart Clinic for allowing me to do this labor of love. Finally, I want to thank my family, particularly my wife, Elizabeth, for being so supportive. I could not have done this job without you! Hopefully, I leave this position in a better place and I look forward to seeing how the association prospers under the leadership of Dr. Mark Horne. May God continue to bless our association and May God Bless America!  ■ J. Clay Hays, Jr., M.D.

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344 vol. 61 • no. 10 • 2020


P r e s i d e n t ’ s

P a g e

Inaugural Address of the 153rd President

T

hank you for the great honor of allowing me to serve as the 153rd President of the Mississippi State Medical Association. It is indeed the pinnacle of my professional career.

Each of my 3 sisters has had immense influence in forming and motivating me. Their support, love, and advice have been of immeasurable value. (Thank you, Lynn, Ann, and Joy)

No one achieves success of this nature on their own. From the bottom of my heart and with the deepest sincerity I want to thank some of those who have made this possible.

In addition to being blessed with the above, wonderful and supportive family, I have been graced with a second set of parents, my mother-inlaw Kay Culbertson and late father-in-law Dan Culbertson. When I see Kay’s grace, patience, and wisdom, the source of Danita’s character is revealed. (Thank you, Kay)

First, I want to thank, Jesus. I’m aware that some of you may not share this belief, but the comfort, direction, and assurance I gain from my faith are the foundation of my very being and is a truth that I must acknowledge and embrace in good times and in times of great challenge such as those we now face. Those of you who know my wife Danita, know full well that without her, I would not be the man who stands before you. Everyone should be so blessed to have a true and trusted partner in life, someone who brings out the best, and who lovingly and patiently points out the failings. She is a planner extraordinaire, to balance my tendency to procrastinate, a gentle and caring soul to soften my often-stark view of the world in which we live. Fortunately, we are both optimistic at our core, a trait that has been mightily challenged the past 7 months. For the past 28 years, she has been optimistic about us, and I must concur. Thank you, Danita, for saying yes to my proposal, and for faithfully walking this path with me all these years. Thanks must also be given to my children, Sabine, Kiser, and Fletcher. Children are the greatest earthly treasure a parent can cherish and indeed I do greatly cherish mine. Sabine and Kiser are seniors at Ole Miss and Fletcher a high school sophomore at Laurel Christian School. There is no greater reward than the frequent complements I receive on each of them and being known as their father is an honor of the highest order. Having experienced their progression from infancy, to toddler, to adolescence and now to young adults, reminds me of the progression of my own life and career, from a young physician, energetic, confident, and eager to learn, to a position now of greater knowledge, but even greater humility, understanding the depth and breadth of the challenge and responsibility we shoulder when each of us chose to become a physician. Without my mother and late father, none of this could have ever come to pass. Not only did they provide a loving Christian home, they believed in me, challenged me, held me accountable, and instilled a solid work ethic which bears dividends for me daily. (Thank you, Mom)

Over the years, I have been blessed and challenged by many mentors, partners, and colleagues. While a complete list is impossible, among these are former presidents of this organization, Dr.’s Jimmy Waites and Eric Lindstrom. Their early insistence that I get involved with MSMA was essential to my arrival at this point in my life. (Thank you) Dr. Peter Blake was my professor for only a few months, but his mantra of “do the right thing” has been a guiding light to my career and life. Anytime I face difficulty or uncertainty as to what to do, his words quickly come to mind. Though I may yet struggle with the answer, the certainty of the guiding principle to “do the right thing” brings comfort and direction just when it is most needed. My partners and colleagues at South Central Regional Medical Center and the excellent administrative staff there, have been and continue to be trusted and invaluable assistants as we strive to provide the best care possible to our community. I particularly want to thank our CEO Doug Higginbotham for his sage advice, insights, and friendship over my career. Doug currently chairs the Board of Governors of the Mississippi Hospital Association (MHA) and I look forward to working with him and MHA to advance common goals to better health care in Mississippi. So, what are those goals? Initially, my theme for this event was to be the Art of Medicine. Though pen and paint certainly are powerful means of expressing the art of our craft, the truest expression is seen in each patient encounter. There, the essential science we have studied so hard to master meets the hopes, fears, and deepest needs of each patient that places their trust in our artistry. Will we see and hear, not just what they say, but that which is just beyond our senses of sight, sound, smell, and touch where science and our extensive technical training prove so useful.

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Will we see the whole person, someone whose needs extend beyond anatomy and chemistry? Will we see not just the malfunctioning organ system, but the broken spirit formed by loss, addiction, or injustice? Will we have the time to attend to these needs or will the pressure to meet production and book more RVU’s win the day? Will physicians practicing the science and art of medicine drive decisions about the future of health care or will we surrender our craft to “providers” whose training and experience is but a tiny fraction of the time and toil we invest to develop our craft? This is the field on which we must strive to find a balance that allows us to be more than technically proficient, but also find the immeasurable reward of experiencing the artistry of alleviating the suffering of a human spirit. How can we move society in this direction? What should we individually and corporately strive to build, modify, improve, or devise to provide for the health of all Mississippians? 1.  We must work with our political leaders to expand access to quality health care for every person who calls Mississippi home. For many years, the debate has raged as to how to accomplish this laudable goal, only to see its achievement just beyond grasp. The current pandemic brings into ever-clearer focus the necessity of finding a means of providing access for basic health care needs for every Mississippian. Though we may differ on the approach, I believe we all hold to the same goal. Expansion of access to health care is a critical and urgent need that MSMA must continue to advance with vigor and purpose. We will not be able to achieve our goals of advancing health and quality of life for Mississippi if we leave so many behind. If there is a singular lesson to be gleaned from our current predicament, it is that we will rise or fall together.

is built. Public health is coequal to education and public safety in importance. If we are to succeed, public health funding and resources must not be neglected. 4. We must continue to strengthen MSMA and its irreplaceable position as the most trusted representative of physicians and the health care needs of the people of Mississippi. COVID-19 has revealed the essential nature of organizations such as MSMA to stand in the breach, on behalf of our patients and our profession. MSMA has been on the frontline of this pandemic from the beginning. We have tirelessly helped our members know what needed to be done to protect themselves, and their communities. We have been the most trusted advisors to our political leaders as they have struggled to do the right thing for our state. Our collective voice has been ever-present in every community and every hospital or clinic throughout the state because we are all of you. Our members have been a shining beacon of hope to all Mississippians throughout this crisis. It is the members of MSMA whose voice the legislature, governor, local school board, city councils, churches, and chambers of commerce need and want to hear. When the leadership of MSMA has called on you to stand up and spread the truth, you have done so tirelessly. It is imperative that through members and component societies, MSMA advances its mission of supporting every physician throughout the state as we advance the goal of improving the health of every Mississippian. We must look past the current uncertainty and pain to the future we know is needed for all of us to succeed. Engagement of our membership begins with each of us. Each delegate to this meeting is an invaluable resource to grow engagement of physicians throughout the state with MSMA. Your voice, your encouragement, and your example are often the only one that can help others understand the necessity of getting involved if our mission of improving health for all is to succeed.

2.  We must maintain and expand access to effective telehealth options for all Mississippians. It took a pandemic to shake loose the chains insurance companies and legislatures had placed on this critical tool in our effort to provide necessary care for our patients. Telehealth is still quite new for many patients and physicians; however, its undeniable value has been proven beyond question and will continue to grow as the technology improves and payors yield to the necessity of embracing this valuable tool in our mission to provide for the health and wellbeing of all. MSMA must be there, advocating for equal access and reimbursement for all services, regardless of the technology used to deliver the care.

The SARS-CoV-2 epidemic has yielded many lessons. Chief among these is the imperative of strong, informed, unflinching, principled leadership. Individuals, like State Health Officer, Dr. Thomas Dobbs seem to have been made for moments such as this. His steadfast leadership and public health orders (often unpopular) have saved untold lives. Members of your leadership like Dr. Jennifer Bryan, Dr. Clay Hayes, Dr. Claude Brunson, and so many others have spent innumerable hours with political leaders, on broadcast and print media interviews, and on social media promoting the science we know, and the policies we need to preserve life in this most challenging of times.

3.  Our public health system must always be supported, not just in periods of crisis. COVID-19 has revealed with irresistible clarity the necessity of a strong and robust public health system if a healthy and economically successful Mississippi is to be realized. MSMA must tirelessly advocate for and remind our state leaders that public health and education are the foundation upon which economic success

No organization but MSMA could have brought these voices together, organized the response, and effectively impacted the decisions of payors and government officials.

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Once again, MSMA has proven to be indispensable to its members and our great state.


It is essential not only for this organization but for the people of Mississippi that we continue to develop strong leaders who are experts in science, art, and the practice of medicine. MSMA stands ready to help its members develop these skills.

Medical Assurance Company of Mississippi has been a stalwart supporter of Mississippi physicians and MSMA. Thanks for all you do for MSMA and our profession. Without our exceptional staff, led by Dr. Claude Brunson, MSMA would be a pipedream.

In closing, I want to thank several people without whom this would not have been possible.

Thanks to each member of MSMA’s staff for the exceptional work you do on behalf of this organization and its members.

My nurse of over 20 years Twyla Floyd and Clinical Assistant Kenya Fortenberry keep me focused and on time (mostly!). Their loyalty and support are invaluable. Thank you for all you do.

Finally, thanks to each of you, the delegates of this House.

South Central Regional Medical Centers administrators and staff have been uniformly supportive and encouraging.

Thank you for caring, for serving, and engaging the often-difficult process of leading this organization and our profession through the challenges of the past and those we now face.

Thanks and gratitude to my many friends and mentors in MSMA over the past 28 years.

It is because of you that we can look with confidence to a bright future.

Classmates like Dr. Dan Edney and Dr. Bill Grantham kept encouraging me to remain engaged. So many others like Dr. Ed Hill, Dr. Randy Easterling, Dr. Lee Voulters, Dr. Mike Mansour, Dr. Clay Hayes, and Dr. Jennifer Bryan have been invaluable resources, advisors, and exemplars of what being a physician leader looks like. I will do my best to reflect the best of the lessons learned from these exceptional leaders.

May God continue to bless our association, the people of the great state of Mississippi, and the United States of America.  ■ Thank you. W. Mark Horne M.D. T:7”

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Ole Miss’s Science Hall Was Utilized for Medical School Activities Until the Move to Jackson in 1955 Dear JMSMA Editor, Your page is always the first one I open when my JMSMA arrives. So much nostalgia. I don’t know for sure, but I probably have one of the oldest licenses issued by Mississippi (June 1960). I was looking at “Images in Mississippi Medicine” in the latest issue [Lampton, L. “The Science Hall in July 1908: Another View of the First Medical School Building at Ole Miss.” J Miss State Med Assoc. Vol. 61, No. 6/7: 175] and was shocked to see the old Science Hall. The description below the photograph states that the “Medical School” was “moved” to Guyton Hall in 1934. I was enrolled in the Medical School in 1954, and the Science building was where we attended many classes. The concrete tank in the basement contained the cadavers that were donated to us and as described, the dumbwaiter shaft was used to hoist the bodies up to the third floor where the Anatomy lab was located. We treated the bodies with great reverence, and I will always remember my cadaver was a black female who had a Rush Pin in her fractured femur. The pin was engraved with Dr. Rush’s name and the date of insertion. Guyton Hall housed the university hospital, and we had a class or two in that building. You don’t recall of course, but all the med students grew beards. The reason was that Dr. Hogg told us we would not have time to shave and use the bathroom facilities on the same day if we intended to pass! I’ve had a beard ever since. The main reason for my letter is to assert that the Science building continued to be used as a significant part of the Medical School after 1934 since I spent many hours there in the Anatomy lab. There was an amphitheater where we were privileged to listen to Dr. Jim Ward and Dr. Ira Hogg and what we, in jest, called his “sleep machine” which was a glass slide projector with a noisy cooling fan. The Embryology class was held just after lunch and with the lights out and the sleep machine humming, the only way I could stay awake was that I had the privilege of changing the slides. I do remember that Dr. Arthur Guyton’s office and lab were in the Guyton building. I remember well his lectures using the rear projector (since he had difficulty standing at the board due to his polio and Canadian crutches), writing on the glass with a fountain pen and erasing the glass with a wet towel. He gave each of us a galley proof of his first book, its loose pages secured with a book strap. I have searched

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my belongings for years hoping to find those pages to no avail. What a terrible loss. Dr. Thomas Brooks’s office was, as I recall, in the Science building but I cannot remember on what floor. I did not “know” Dr. John Culley, but met him since he was a member of my wife’s extended family. I guess I should record some of those memories as I’m sure most of those young guys are now departed. Thanks for your stories. They bring back lots of great memories. I do have lots of stories I could tell about those days with Drs. Hogg, Tracey, Ward, Rice, Guyton, and others. Stay safe Luke and many thanks for your great articles. — Jack B. Campbell, MD, Point Clear, AL Editor’s Response: Dear Jack, I appreciate so very much your letter which clarifies from a direct participant that Science Hall remained a significant structure for the medical school in Oxford even after Guyton Hall (then called the new Medical School Building and University Hospital) was built and until the move to Jackson. The February “Images,” which featured Guyton Hall [“The Medical School and Hospital at Ole Miss, the Second Medical School Building, 19341955.” JMSMA. 2020; 61(2):55], cited a School of Medicine Bulletin of July 1941 which describes clearly that both the Science Hall and Guyton Hall were utilized for the medical school, with several medical departments


remaining at the renovated Science Hall: “Gross anatomy, neuro-anatomy, applied anatomy, histology, and embryology occupy the fourth floor of the old Medical Building (the second and third floors being occupied by the Department of Biology). Physiological chemistry and its laboratories remain in the Chemistry Building. All other departments are in the new Medical School Building.” (6) The Bulletin further indicates that on the first floor of Guyton Hall was the Pharmacology Department, with animal quarters located outside. The laboratories of Pathology, Bacteriology, and Clinical Laboratory Diagnosis were also located at Guyton Hall, on the second floor, and the Department of Physiology occupied Guyton’s third floor. By 1936,

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the Rowland Medical Library had also moved to the north wing of Guyton Hall. The University Hospital was located at Guyton Hall, with clinics also conducted in the building, and the Lafayette County Health Unit maintained its offices there. The X-Ray Laboratory was located on Guyton’s third floor next to the hospital’s operating rooms. Thank you also for your wonderful memories included in this letter of those legendary medical school professors! — Lucius M. Lampton, MD, JMSMA Editor

Pen > Sword

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

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M S M A

Welcoming Our Newest Members

FRENTZ, BRYAN, McComb, Orthopedic Surgery

SHEEHAN, CLYDE, Tupelo, Child & Adolescent Psychiatry

HARRISON, NANCY, Jackson, Rheumatology

TILLOTSON, ETHAN, Tupelo, Family Medicine

KILPATRICK, DAVID, Jackson, Ophthalmology

YOUNG, CHERYL, McComb, Obstetrics & Gynecology

LENNEP, BRANDON, Madison, Cardiovascular Disease MISSISSIPPI STATE MEDICAL ASSOCIATION MSMAonline.com The Journal of the Mississippi State Medical Association (JMSMA) has served as the voice, face and spirit of Mississippi medicine for over 61 years. We are excited to add to our growing list of Member Benefits and announce our transition from a print publication to a digital journal to provide a more beneficial user experience for our members! Stay tuned for more information regarding JMSMA’s digital shift, and how to opt into a print journal for a set annual fee for those who would prefer a physical copy.

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L E T T E R

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Is Therapeutic Anticoagulation the Answer in Treating COVID-19? Dear JMSMA Editor: Patients with COVID-19 have numerous coagulation abnormalities including elevated factor VIII, elevated fibrinogen, circulating prothrombotic microparticles, and hyper-viscosity.1-2 This indicates there is hypercoagulability among patients with COVID-19. Though COVID-19 has similar laboratory findings as disseminated intravascular coagulation (DIC), including a marked increase in D-dimer and mild thrombocytopenia, other coagulation parameters in COVID-19 are distinct from DIC. In the case of COVID-19, there are high fibrinogen and high factor VIII activity, indicating that major consumption of coagulation factors is not occurring.1 Rather COVID-19 has massive microscopic thromboembolism throughout the body among all the major organs. An autopsy study of 21 individuals with COVID-19 showed prominent pulmonary emboli (PE) in 19% of cases and microthrombi in alveolar capillaries in 45% of cases. Interestingly, the primary cause of death in each of the cases was found to be respiratory failure due to exudative diffuse alveolar damage and massive capillary congestion accompanied by microthrombi.3 Another autopsy study showed significantly more predominant severe endothelial injury (endotheliosis), widespread thrombosis with microangiopathy, and alveolar-capillary microthrombi in the lungs of the patients who died of COVID-19 compared to the lungs of individuals who died of influenza or other causes.4 Venous thromboembolism (VTE) is seen in up to one-third of the intensive care unit (ICU) patients with COVID-19 even when a prophylactic dose of anticoagulation is used. A recent study conducted on 44 ICU patients also found a high rate of kidney failure and thromboembolic events among the study subjects.5 This study suggested the need for early therapeutic anticoagulation (not prophylactic dose) or fibrinolytic therapy to address this state of fibrinolysis shutdown or massive thromboembolism. If physicians utilize full anticoagulation among all the intensive care units or hospitalized patients or those that are treated on an outpatient basis, then could we prevent all the thromboembolic events which are the predominant cause of death among patients with COVID-19? Autopsy studies are considered the “gold standard” for diagnostic accuracy and diagnostic and therapeutic error prevention. Developing a treatment strategy to prevent mortality based on what is seen

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in autopsy studies should be the guiding principle in developing treatments for COVID-19. This author, who treated more than 50 COVID-19 patients in 3 months on the hospital COVID floor (and also in an outpatient setting), found that early initiation of therapeutic anticoagulation (without any remdesivir or convalescent plasma or hydroxychloroquine) has significant mortality and morbidity benefit. It has been frequently reported that patients with a positive COVID-19 diagnosis present with strokes or transient ischemic attacks (TIA), especially 2 weeks after their diagnosis with COVID-19. The author also observed significant mortality and morbidity reduction among patients who were already on therapeutic anticoagulation for atrial fibrillation or history of PE or deep vein thrombosis (DVT) if diagnosed with COVID-19. Anecdotal evidence including this author’s hospital experience on the COVID floor suggests that evaluation of therapeutic anticoagulation is essential to reduce mortality and morbidity in COVID-19 patients. It is apparent that the timing of the initiation of full anticoagulation is the key to prevent mortality in the case of COVID-19. If patients have already developed widespread thromboembolism, then can anticoagulation stop the hypercoagulable cascades? So, the question is whether we should start full anticoagulation upon diagnosis or start full anticoagulation among high-risk populations even before the diagnosis of COVID-19 (given COVID diagnostic tests are at times not reliable)? These questions need to be addressed through welldesigned clinical research to reduce mortality and morbidity related to COVID-19. A randomized control clinical trial will need at least 1-year to get the results. During the 1 year waiting period, thousands will die worldwide due to mistreatments. A quick study with a similar impact can be done by evaluating the patient population who are already taking oral therapeutic dose anticoagulation (apixaban, rivaroxaban, delteparin, betrixaban, or warfarin) for chronic medical conditions (like atrial fibrillation, DVT, PE, or mechanical valves). We need to evaluate whether these subsets of patients develop acute respiratory distress syndrome (ARDS), stroke, PE, or DVT, or have a decreased death rate when diagnosed with COVID-19. This author observed almost zero ARDS, stroke, or any major complications among several patients who are on therapeutic anticoagulation (when diagnosed with COVID-19). These observations may indicate that due to


therapeutic anticoagulation, patients are protected from microscopic thromboembolism related COVID-19 complications.

References 1. Panigada M, Bottino N, Tagliabue P, et al. Hypercoagulability of COVID-19 ­patients in intensive care unit: A report of thromboelastography findings and other parameters of hemostasis. J Thromb Haemost. 2020;18:1738-1742.

Based on autopsy studies and the author’s personal experience in working on the COVID floor, the death rates are negligible among patients with COVID-19 who are taking therapeutic anticoagulation. It is essential to design further studies in this regard to demonstrate the effect of early initiation of therapeutic anticoagulation. In addition, such studies should also aim to evaluate the need to initiate prophylactically therapeutic anticoagulation, preferably oral anticoagulation, among front line workers (including physicians, nurses, healthcare employees, essential services, teachers, students, and other high-risk individuals). Given that the accuracy of COVID-19 tests is often questionable and that 50% of the time COVID-19 is completely asymptomatic (hence we fail to diagnose it), some of these patients will present with strokes or other thromboembolism if not treated with therapeutic anticoagulation. Thus, therapeutic anticoagulation may be the answer to the COVID-19 pandemic.

2. Maier CL, Truong AD, Auld SC, et al. COVID-19-associated hyperviscosity: A link between inflammation and thrombophilia? Lancet. 2020;395:1758-1759. 3. Lévesque V, Millaire É, Corsilli D, et al. Severe immune thrombocytopenic purpura in critical COVID-19. Int J Hematol. 2020. 4. Ackermann M, Verleden SE, Kuehnel M, et al. Pulmonary vascular endothelialitis, thrombosis, and angiogenesis in Covid-19. N Engl J Med. 2020;383:120-128. 5. Wright FL, Vogler TO, Moore EE, et al. Fibrinolysis shutdown correlation with thromboembolic events in severe COVID-19 infection. J Am Coll Surg. 2020;231:193-203.e1.

Author Information Azad Kabir, MD, MSPH, ABIM; Lighthouse Clinics, 1120 Beach Blvd, Biloxi; MS 39530; Email: azad.kabir@gmail.com.

— Azad Kabir, MD Biloxi

Date of Submission: August 15th, 2020

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MISSISSIPPI STATE HOSPITAL, NATCHEZ, 1870-1890, THREE-DIMENSIONAL STEREOVIEW — This albumen doubleimage print stereoview, a so-called “portrait for the stereoscope,” presents two similar yet different images of the “Mississippi State Hospital at Natchez,” which is hand-written on the stereoview’s back. These 2 images appear to date from 1870 to 1890. These images emphasize the high bluff on which the hospital was built above the Mississippi River and the local cemetery, to which locals would say one was “rolled down the hill” after dying to be buried. Before the age of radio and television, the viewing of a stereoview or stereoscopic photograph (also called a stereograph) through a stereoscope or viewer was a popular form of home entertainment. A nineteenth-century family would often own a large box of stereoviews, each depicting an exotic place or interesting subject. Stereoviews usually measured 3½ × 7 inches and were created by a special camera to give a three-dimensional effect when viewed. Natchez Charity Hospital, originally established in 1805 for the care of indigent boatmen, received state funding as a hospital from its inception. In 1837, Natchez was selected as 1 of 7 sites for a national marine hospital to be built from the standardized plans of architect Robert Mills, who had also designed the Washington Monument. (The lone surviving sister hospital of this one erected from those plans still stands in Louisville, Kentucky.) Construction began in 1849 and was completed by 1852. This hospital represents a rare early federal effort in health care, although its management appears to have remained in local and state hands as it continued to be called the Mississippi State Hospital at Natchez. State law of 1858 outlined the operation of the hospital by a “house surgeon” assisted by 3 unpaid resident students of medicine “who shall reside in said hospital.” This appears to be the first clinical postgraduate medical training established in the state of Mississippi. (The site also fostered the first formal nurse training program in the state and the creation of the Mississippi Nurses’ Association.) After the Civil War, the hospital returned to its usual hospital status, although from 1877 to 1883 the Natchez Seminary (the ancestor of Jackson State University) occupied the structure. After becoming a hospital again in 1883, it remained a state charity institution until closing for repairs in the early 1980s. The structure burned on August 4, 1984. The hospital was noted for its curving main stairs rising 5 stories to its 8-sided cupola. If you have an old or even somewhat recent photograph which would be of interest to Mississippi physicians, please send it to me at lukelampton@cableone.net or by snail mail to the Journal. — Lucius M. “Luke” Lampton, MD; JMSMA Editor

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Edited by Lucius Lampton, MD; JMSMA Editor

[This month, we print a poem offered by W. D. “Dwight” McComb, MD, who practices internal medicine, pediatrics, and wound care in Amory. His poem, “The Train,” reveals his broad literary talent, taking on a subject close to the heart of all of us who live close to the rattle of the tracks and the roar of a passing train. His inspiration for the poem is tied closely to the background of his community. He comments: “Amory exists for one reason—because it was the midpoint between Memphis and Birmingham. The railroad wanted to establish a station at the halfway point between those two hubs, and in 1887, a stopping point became a town. Our town celebrates its first lifeblood with an annual Railroad Festival, multiplying in size by fivefold for one weekend each year. To commemorate our origins, a locomotive (photo below) rests in Frisco Park, where the festival takes place. I mention our town’s history only as a backdrop for the thoughts formed one day as I waited at one of our railroad crossings. As I watched impatiently while one of our trains started from a standstill, then picked up the pace until each car raced on by, I suddenly saw the rail cars as the years of life passing by. Irritatingly slow at first, then faster and faster, until they fly by for a time without distinguishing one from the other. Then the end comes, perhaps more quickly than anticipated. Even though I still consider myself a relatively young man, I have seen enough in my life and practice to acknowledge I don’t know how many rail cars are around the bend. Though it is a work in progress, I am learning how to not be in such a hurry, to be content to sit and watch the train. The caboose will arrive soon enough.” After obtaining a chemical engineering degree at Mississippi State, Dwight graduated from the University of Mississippi School of Medicine in 1999. Recently, he began writing fiction. His debut novel “The Truth That Lies Between” was highly acclaimed and was nominated for several awards. He’s also published two short stories, “The Recruit” and “They Roam Those Hills,” and his second novel “Anatomy of the Truth” will be released in November. He notes: “Writing is something I began doing about five years ago for a release. Most of that time has been on novels, but I play around with poetry a bit if an idea strikes me.” I encourage one to access his website at www.wdmccomb.com. Dwight McComb is writing some of the best literature coming from a physician’s pen in the state. This Aberdeen native continues to practice medicine in northeast Mississippi, where he lives with his wife and three children. Any physician is invited to submit poems for publication in the Journal either by email at lukelampton@cableone.net or regular mail to the Journal, attention: Dr. Lampton.]—Ed.

The Train

There! It is alive! Subtle stirrings, first turns Of steely wheels come to life, burgeoning sounds Of new motion, anticipation, begetting yearns For haste, O hurry! As a fox ‘fore the hounds!

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Too slowly growing in momentum and speed, No, never enough, not enough, why so slow? Languid one then the next, each planting the seed Of wonder - how many, how fast will it go? Counted as they pass, crawl to five, rush to twenty, A dozen more seem the same, rolling by faster, More hidden ‘round the bend, but surely too plenty For the deadlines of time, always the master. Warm sun, lulling rhythms, yet hastening pace, Now what’s that? Sudden content, less distraction? Why the rush, might it slow? Why always a race? The finale soon enough, impatience redaction. But there it must lurk, down the tracks, out of sight, Its harbingers fleeting, too swift, specks on wind, Get ready, ready to cross, and pray for delight When the caboose races by, there at the end. —Dwight McComb, MD Amory

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REPORT OF CONSOLIDATED REFERENCE COMMITTEE To: House of Delegates Presented by: Candace Keller, MD Chair Dr. Speaker, the Consolidated Reference Committee has considered each of the items referred and presents the following report: I. The Address of the President Dr. Speaker, your Consolidated Reference Committee recommends the Remarks of the President be filed and Dr. Hays be commended for outstanding leadership during the 20192020 year. Dr. Hays’ speech highlighted his past year as MSMA’s 152nd President. Over the past year, Dr. Clay Hays had several themes for his presidency year. The first being #relationshipsmatter, he met with physicians, hospital administrators, schools, and families throughout the state. He visited with component societies in Greenwood, Indianola, Greenville, Cleveland, Jackson, McComb, Biloxi, Gulfport, Oxford, and Tupelo. Establishing MSMA’s presence as the authority on the practice of medicine and the leader or the healthcare team by testifying in the legislature, conducting radio and TV interviews, holding weekly telehealth calls and hosting weekly Facebook Live interviews with Dr. Thomas Dobbs, was his second goal. Addressing the COVID-19 pandemic, MSMA, at the request of Governor Tate Reeves and State Health Officer Dr. Thomas Dobbs, set up the Governor’s Medical Advisory Task Force which Dr. Hays chaired. MSMA and Dr. Hays worked tirelessly along with countless MSMA members to develop a COVID 19 system of care for our state as well as a physician volunteer workforce. MSMA also lobbied to expand medical liability protection.

Education was his next theme and with a grant from the AMA, the State Scope of Practice partnership was able to educate legislators and highranking officials that Medical School Matters. Wellness and Fitness was his last goal. Dr. Hays printed and passed out #MSMA4Fitness T-shirts all around the state encouraging people to exercise. Each goal was accomplished with the help and support of State Medical leadership, partners and staff at Jackson Heart Clinic, MSMA staff, and countless others. II. Report A of the Board of Trustees Dr. Speaker, your Consolidated Reference Committee recommends Report A be filed with commendation and appreciation to our Board of Trustees. Report A thoroughly summarizes and documents MSMA’s activities during 2019-2020 association year and the disposition of all actions taken at the 151st Annual Session including the recommendations of the President; the 2019 Reports of the Board of Trustees regarding action on items referred to the Board; the Report of the SecretaryTreasurer; the Report of the Delegates to the AMA; the Report of the Executive Director; the Report of the Council on Public Information; the Report of the Council on Medical Education; the Report of the Council on Medical Service; the Report of the Council on Constitution and Bylaws; Report on the Council of Accreditation; Resolutions 1 through 22; and MSMA subsidiaries. III. Report C of the Board of Trustees Dr. Speaker, your Consolidated Reference Committee recommends Report C of the Board of Trustees be filed with

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commendation to the staff and the Council on Budget and Finance. Report C summarizes the annual independent audit of MSMA financial statements. The audit reflected total assets of $3,412,564 and total liabilities of $1,326,338 with net assets of $2,086,226. No irregularities were noted in the audit which is available for review at the association headquarters. IV. Report D of Board of Trustees Dr. Speaker, your Consolidated Reference Committee recommends Report D of the Board of Trustees be filed. Report D of the Board of Trustees summarizes the location and dates of past and future annual sessions noting that positive comments have been received regarding the Jackson location and specifically the ease of having all activities on the same property. The Board noted that attendance of students and residents is one of the strongest reasons to continue meeting in the Jackson area. It is noted that the 2021 session of the House of Delegates continue to be held in the Jackson metropolitan area. V. Report of the Council on Public Information Dr. Speaker, your Consolidated Reference Committee recommends the Report of the Council on Public Information be filed. This report summarizes the Council’s activities for the 2019-2020 year. The Council continues to promote the annual Excellence in Medical Communications and Health Promotion and MSMA Community Service Award. The recipient of the 2020 Excellence in Medical Communications and Health Promotions award is Dr. Jaleen Sims. Dr. Christopher Boston is the recipient of the 2020 MSMA Community Service Award. VI. Report of the Council on Accreditation Dr. Speaker, your Consolidated Reference Committee recommends the Report of the Council on Accreditation be filed. This informative report outlines the Council’s activities in 20192020 to accredit organizations that sponsor intrastate continuing medical education activities for physicians. MSMA accredits 15 CME providers, which sponsored over 3,500 hours of AMA PRA Category 1™ in 2019-2020. These activities provided MS and TN physicians with over 16 000 hours of CME and included online hours offered through InReach online CME services accessible at MSMAonline.com. VII. Annual Report of the Secretary-Treasurer Dr. Speaker, your Consolidated Reference Committee recommends the Annual Report of the Secretary Treasurer be filed.

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This report summarizes the MSMA membership for the year ending December 31, 2019 and is compared to membership at the end of the three previous years. On December 31, 2019 MSMA’s total membership was 4765 members. The report also notes that, as required by the Bylaws, the Board of Trustees conducted an annual performance evaluation of the Executive Director. VIII. Report of the Executive Director Dr. Speaker, your Consolidated Reference Committee recommends the Report of the Executive Director be filed with commendation and appreciation to all the MSMA staff. The Report of the Executive Director summarizes MSMA’s efforts over the course of the last year, highlighting the shift in priorities at the onset of the COVID-19 pandemic. Prior to the coronavirus outbreak, MSMA began its focus with the State Scope of Practice Partnership (SSOPP) campaign in collaboration with the AMA to use the survey results touting Mississippians preferred a physician-led healthcare team. Utilizing taglines such as #physicianledteamcare and #medicalschoolmatters, the overwhelming success made MSMA a program template for states and specialty societies across the nation. MSMA was also successful in using the SSOPP campaign to block an initiative by CRNAs to opt-out of being supervised or having a collaborative physician agreement as well as defeating all efforts at the Mississippi State Capitol during the 2020 legislative session to expand scope of practice for midlevel providers. In response to the COVID-19 pandemic, MSMA became a key leader in multiple arenas for the state. The Capitol Medical Clinic became a COVID testing clinic at the request of the Lt. Governor. We also partnered with State Health Officer (SHO) and Mississippi State Department of Health (MSDH) to distribute timely, relevant COVID-19 information to physicians and the public through Facebook live interviews, press releases, op-eds, and the other marketing campaigns. Two campaigns of note are the on-going Prepared to Care campaign, in partnership with the Mississippi Hospital Association, aimed at educating patients on how physicians, clinics and hospitals are ready to care for them, and the Vaccination campaign, in partnership with the Mississippi ChapterAmerican Academy of Pediatrics, encouraging parents to maintain vaccination schedules through the pandemic. Governor Reeves established a COVID-19 Medical Advisory Committee appointing President Dr. Clay Hays to serve as an advisor to the COVID-19 response, and Dr. Hays appointed several MSMA members to serve on this committee as well. Dr. Hays established a Physician Workforce Mobility subcommittee chaired by Dr. Dan Edney to respond to areas of physician shortage. Internally, MSMA’s BOT Chair Dr. Jennifer Bryan established three specialty committees to address the pandemic; COVID-19 Outpatient Clinic Operations Committee (Chaired by President-Elect Dr. Mark Horne), Telehealth Committee (Chaired by Dr. Russell Young) and the MSMA/MHA COVID-19 Committee (a joint committee of MSMA leadership and MHA/Hospitals CEOs; Chaired by BOT Chairman Jennifer Bryan,


MD). As the pandemic progressed, it was noted that many physicians were beginning to feel burned out and stressed. In response, MSMA BOT member, Dr. Katherine Pannel established a “Physician Support Group” where Mississippi physicians could in a confidential and secure manner receive any mental health support that could assist them through these very challenging times.

be filed and that the House commend the Mississippi Delegation for its dedication and work during the 2019-2020 year. This report describes the activities of the Association’s delegation to the AMA at the 2019 Interim Meeting and the 2020 Annual Meeting. XIII. Report of the Council on Constitution and Bylaws

Partnerships were also formed with AZOVA, a telehealth platform, waiving physician licensing fees to join and creating the Mississippi Physicians Telehealth Network. MSMA is also actively vetting a Health Information Exchange (HIE) platform to further improve health of all in Mississippi.

Dr. Speaker, your Consolidated Reference Committee recommends the Report of the Council on Constitution and Bylaws be filed with commendation to the staff and the Council.

IX. Report B of the Board of Trustees

The Report of the Council on Constitution and Bylaws is a summary of matters considered and actions taken by the Council during its annual meeting.

Dr. Speaker, your Consolidated Reference Committee recommends that Report B of the Board of Trustees be filed. Report B summarizes MSMA’s efforts during the 2020 Regular Session of the Mississippi State Legislature and the activities of the Association’s Council on Legislation. The report notes the association’s success in defeating legislation to expand scope of practice for multiple midlevel providers, preservation of the best childhood immunization law in the nation, securing an additional $100,000 in appropriated funding for the Mississippi Physician Health Program, passage of legislation to curb the vaping epidemic in our state, securing over $7 million dollars of CARES Act funding for PPE legislation to protect our private practice physicians on the frontlines during the pandemic and passage of legislation to protect physicians with immunity protections from frivolous lawsuits during and up to one year after the state of emergency for the pandemic has been lifted. X. Report of the Council on Medical Service Dr. Speaker, your Consolidated Reference Committee recommends that the Report of the Council on Medical Service be filed. This informative report summarizes the Council’s work during the 2019-2020 year. XI. Report of the Council on Medical Education Dr. Speaker, your Consolidated Reference Committee recommends the Report of the Council on Medical Education be filed. This informative report summarizes the Council’s work during the 2019-2020 year. XII. Report of the Delegates to the AMA Dr. Speaker, your Consolidated Reference Committee recommends that the Annual Report of the Delegates to the AMA

Resolution 2, Training Designation Dr. Speaker, your Consolidated Reference Committee recommends that Resolution 2 be adopted. RESOLVED, that MSMA opposes any actions (writings, advertisements, websites, or other communications), regardless of intent, likely to confuse the public about the unique credentials of American Board of Medical Specialties(ABMS) or American Osteopathic Association-Bureau Osteopathic Specialists (AOA-BOS) board certified physicians in any medical specialty; and BE IT FURTHER RESOLVED, that MSMA opposes any action, regardless of intent, by organizations providing board certification for nonphysicians that is likely to confuse the public about the unique credentials of medical specialty board certifications or take advantage of the prestige of medical specialty board certification for purposes contrary to the public good and safety, and BE IT FURTHER RESOLVED, that MSMA advocates that all health care professionals, including those in training, wear during patient encounters, name tags clearly signifying the type of license they hold, and BE IT FURTHER RESOLVED, that MSMA advocate for appropriate training designation of nonphysician training programs as well as participants thereof. Resolution 2 highlights how the designation of nonphysician programs of study as residency or fellowship programs along with the designation of those nonphysician students as residents or fellows and or the use of the term board certification when applied to nonphysicians is misleading and confusing to patients and the public. The committee reviewed and had a thorough discussion and noted strong support received for the resolution. It was noted by the committee that there is an existing Truth in Advertising Law and that the third resolve did reaffirm existing MSMA policy.

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Resolution 3, Alzheimer’s Caregiver Assistance Program Dr. Speaker, your Consolidated Reference Committee recommends that Resolution 3 be adopted. RESOLVED, that the MSMA will work with the Alzheimer’s Association of Mississippi Chapter, the Mississippi Osteopathic Medical Association and the Mississippi Psychiatric Association to advocate for legislation to create an Alzheimer’s assistance program to provide support services for informal caregivers of individuals with Alzheimer’s disease or related dementia and those living with Alzheimer’s and related dementias. Resolution 3 highlights the often excessive financial and personal costs for families caring for a loved one with Alzheimer’s and the need to advocate for legislation to create an Alzheimer’s assistance program to provide support services for informal care givers of individuals with Alzheimer’s disease. The committee reviewed and had a thorough discussion of the resolution, including the comment received. The committee noted that MSMA and MOMA would be representative of all specialties who would be engaged in working to advance legislation to create an Alzheimer’s Caregiver Assistance Program. Resolution 4, Telemedicine Parity Dr. Speaker, your Consolidated Reference Committee recommends that Resolution 4 be adopted. RESOLVED, that the MSMA work with the Mississippi Legislature to advocate for passage of telemedicine parity laws that require private insurers to cover telemedicine-provided services comparable to that of in-person services. Resolution 4 notes the increased use of telemedicine by physicians during the COVID-19 pandemic and the increased challenge that many physicians have faced with not being properly reimbursed for telemedicine encounters for 99214s or above and being forced to down code based on private insurance policy. The committee reviewed, had a thorough discussion of the resolution and noted that the resolution would be an additional complement to the work already being undertaken during the pandemic to bring appropriate reimbursement to physicians for the work they are doing through telemedicine. The committee further noted that the resolution was a strong and appropriate statement for the House of Medicine to come together and support.

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Resolution 5, Reduce Perinatal Morbidity and Mortality by Promoting Existing Programs Dr. Speaker, your Consolidated Reference Committee recommends that Resolution 5 be amended by insertion of an additional resolve and be adopted as amended. RESOLVED, the MSMA will promote these programs so that they are appropriately utilized and coordinated with the medical home to reduce modifiable risk factors and address the psychosocial determinants of health that may affect subsequent pregnancies and improve the health of women and children in Mississippi. RESOLVED, the MSMA take a leadership role in forming a task force to begin work to increase awareness of available programs to physicians and all interested parties and report back to the 2021 House of Delegates. Resolution 5 highlights the need to improve pregnancy outcomes and improve infant and maternal mortality, by MSMA collaborating with all Mississippi entities related to perinatal and postpartum care and physicians in the state to promote the increased utilization of programs in the state available to offer access to care for the women and infants of Mississippi. The committee reviewed and had a thorough discussion of the resolution and noted strong support for the resolution. The committee further discussed the need for MSMA to take a leadership role with immediate action through the creation of a task force to bring awareness of the programs available to physicians and interested parties with a report back to the 2021 House of Delegates. The committee agreed with the recommendation and adoption of the additional resolve. Dr. Speaker, your Consolidated Reference Committee wishes to thank the delegates and other members of the association who participated in the hearing and presented testimony on the various matters that were considered and to the capable MSMA staff who assisted us in the preparation of our report. AUTHORIZED ELECTRONICALLY BY: þ Candace Keller, MD, Chair

þ Lee Giffin, MD

þ Lee Voulters, MD

þ Dan Edney, MD

þ John Gaudet, MD

þ Hays Walker (Student)

þ Manjot Kaur Mashiana (Student)


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