BEACON Imagine the possibilities. You’ve heard of the Beacon Grant.
It’s a $14.7 million grant to the Delta Health Alliance (DHA) from the Office of the National Coordinator for Health Information Technology with goals of building and strengthening Mississippi’s Health IT infrastructure, testing healthcare innovations and improving healthcare efficiency.
What can the Grant do for my practice and my patients?
DHA has established the BLUES (Better Living Utilizing Electronic Systems) Beacon Community to work with physicians and other healthcare providers across the Delta region. Your Delta BLUES Beacon is testing innovations with over 35 Delta providers, including Clinical Decision Support, Diabetic Retinopathy Screening, Medication Therapy Management, Care Transitions and Health Information Exchange.
Imagine the possibilities!
The Delta BLUES Beacon Program is available to physicians in ten counties across the Mississippi Delta area until March 2013. How can the BLUES Beacon guide you?
Lucius M. Lampton, MD Editor D. Stanley Hartness, MD Richard D. deShazo, MD Associate Editors Karen A. Evers Managing Editor
Publications Committee Dwalia S. South, MD Chair Philip T. Merideth, MD, JD Martin M. Pomphrey, MD Leslie E. England, MD, Ex-Officio Myron W. Lockey, MD, Ex-Officio and the Editors The Association Steven L. Demetropoulos, MD President James A. Rish, MD President-Elect J. Clay Hays, Jr., MD Secretary-Treasurer Lee Giffin, MD Speaker Geri Lee Weiland, MD Vice Speaker Charmain Kanosky Executive Director
Journal of the Mississippi State Medical Association (ISSN 0026-6396) is owned and published monthly by the Mississippi State Medical Association, founded 1856, located at 408 West Parkway Place, Ridgeland, Mississippi 39158-2548. (ISSN# 0026-6396 as mandated by section E211.10, Domestic Mail Manual). Periodicals postage paid at Jackson, MS and at additional mailing offices. CORRESPONDENCE: Journal MSMA, Managing Editor, Karen A. Evers, P.O. Box 2548, Ridgeland, MS 39158-2548, Ph.: (601) 853-6733, Fax: (601)853-6746, www.MSMAonline.com. Subscription rate: $83.00 per annum; $96.00 per annum for foreign subscriptions; $7.00 per copy, $10.00 per foreign copy, as available. Advertising rates: furnished on request. Cristen Hemmins, Hemmins Hall, Inc. Advertising, P.O. Box 1112, Oxford, Mississippi 38655, Ph: (662) 236-1700, Fax: (662) 236-7011, email: email@example.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© 2012 Mississippi State Medical Association.
Tax Revenue in Mississippi Communities Following Implementation of Smoke-free Ordinances: An Examination of Tourism and Economic Development Tax Revenues Substance Use and Sexual Risk Behaviors Among Mississippi Public High School Students
James McGuire, PhD; Bo Wang, PhD; Lei Zhang, PhD, MBA
Dietary Recommendations in Ambulatory Care: Evaluation of the Southern Remedy Healthy Eating Plate
Amanda K. Smith, MD; Deborah S. Minor, PharmD; Lindsey E. Tillman, PharmD; Richard D. deShazo, MD; William H. Replogle, PhD
Just Off the Press - Info You Want to Know Prophylaxis Against Post-Stroke Depression
Eugene Lukienko, PharmD Candidate; Richard L. Ogletree, Jr., PharmD
Top 10 Facts You Should Know about Endocrine Aspects in Patients Infected with the Human Immunodeficiency Virus
Nuttha Ungnapatanin, MD; Jose S. Subauste, MD; Harold M. Henderson, MD; Christian A. Koch, MD
Why Smoke-Free? /Just What the Doctor Ordered
Steven L. Demetropoulos, MD; MSMA President
They Come Alone or in Pairs: Ta-Tas to Go Breast Cancer Survivor Creates Custom-Fit Prosthesis
Karen A. Evers, Managing Editor
And a Good Time Was Had by All
Stanley Hartness, MD
Mississippi State Department of Health
From the Editor Uncommon Thread - Doctors and Magic Asclepiad - Helen B. Barnes, MD
318 350 352
About The Cover:
Autumn Landscape – Martin M. Pomphrey, Jr., MD, who serves on the MSMA Committee on Publications, took this photograph. He writes,“When we moved into our home in 1977, there were no cypress trees here. Over the years , I have planted dozens of bald cypress in and around our pond, and many more have self-seeded. Some I transplant to less crowded areas. The cypress and the live oak are my favorite trees of the south. This photo shows them displaying their beautiful fall colors. Unfortunately, beavers have passed through periodically and seem to enjoy the cypress as much or more than I do. Every cypress in or near our pond is now protected with a wire fence which so far has repelled those nasty rodents. Also, after rebuilding the levee three or four times due to beaver and muskrat damage, there is now a chain link fence along the entire levee from the bottom of the pond to about two feet above the high water mark. There has not been one rodent incursion since our last levee reconstruction about twelve years ago.” Dr. Pomphrey is a semi-retired orthopaedic surgeon sub-specializing in sports medicine who practiced with Oktibbeha County Hospital (OCH) Bone and Joint Clinic in Starkville. r October
Official Publication of the MSMA Since 1959
Robert McMillen, PhD; Signe Shackelford, MPH
October 2012 JOURNAL MSMA 317
From the Editor
his month’s physician portrait features a Mississippi medical legend, Dr. Helen Barnes of Jackson. (see page 352) When she arrived in the hot summer of 1960 to a segregated Greenwood, Mississippi, the first person she went to see was past MSMA President Dr. Howard A. Nelson, a surgeon who was also a progressive leader of our association. Nelson not only slipped her without fanfare into the Delta Medical Society and our MSMA as our first black female member, but he also assigned her a local physician mentor to advise and counsel her, and assist her efforts as a young Mississippi physician. (A physician mentor for our young physician members: what a good MSMA tradition to return to!) Over her career, Dr. Barnes became a brilliant physician in the Hippocratic and Oslerian tradition: an artist and teacher grounded in science. She warns young physicians not to forget the “art” of medicine in our modern computer age: “There are things that technology will never tell you in medicine. We must never forget the importance of a physician’s presence and touch in the healing process.” She adds: “The laying on of the hand is the best part of medicine.” Indeed it is, and not only do we docs need to listen to our patients more, but
we also need to touch them physically, for that is a central part of the healing process. Dr. Barnes reflects: “There are some days that you walk into a patient’s room, and nothing is going right for them medically, and all you can do is hold their hand, and things get better.” Lucius M. Lampton, MD As a teacher of physicians, Dr. Editor Barnes would tell her students: “When Editor Lampton you walk into a patient’s room, don’t walk in, shuffle from one foot to with Dr. Helen Barnes another, and walk out. If you sit in the chair, and your butt doesn’t do anything but warm the chair for 3 minutes, sit!” Barnes stresses that giving the patient this time not only allows physicians to hear more from their patients, but is a critical part of the healing process. Remember, medicine is all about the physician/patient relationship. Take the time to build healing, vibrant relationships with your patients! Contact me at firstname.lastname@example.org.
Journal Editorial Advisory Board R. Scott Anderson, MD, FACR Chair, Journal Editorial Advisory Board Radiation Oncologist and Medical Director, Anderson Regional Cancer Center, Meridian Diane K. Beebe, MD Professor and Chair, Department of Family Medicine, University of MS Medical Center, Jackson Claude D. Brunson, MD Senior Advisor to the Vice Chancellor for External Affairs, University of Mississippi Medical Center, Jackson Jeffrey D. Carron, MD, FAAP, FACS Associate Professor, Department of Otolaryngology & Communicative Sciences, University of Mississippi Medical Center, Jackson Gordon (Mike) Castleberry, MD Urologist, Starkville Urology Clinic Mary Currier, MD, MPH State Health Officer Mississippi State Department of Health, Jackson Thomas E. Dobbs, MD, MPH Health Officer, District VII/VIII Mississippi State Department of Health, Hattiesburg Sharon Douglas, MD Chair, AMA Council on Ethical & Judicial Affairs Professor of Medicine and Associate Dean for V A Education, University of Mississippi School of Medicine, Associate Chief of Staff for Education and Ethics, G.V. Montgomery VA Medical Center, Jackson Daniel P. Edney, MD Executive Committee Member, National Disaster Life Support Education Consortium, Internist The Street Clinic, Vicksburg
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Owen B. Evans, MD Professor of Pediatrics and Neurology University of Mississippi Medical Center, Jackson Maxie L. Gordon, MD Assistant Professor, Department of Psychiatry and Human Behavior, Director of the Adult Inpatient Psychiatry Unit and Medical Student Education, University of Mississippi Medical Center, Jackson Scott Hambleton, MD Medical Director Mississippi Professionals Health Program, Ridgeland John Edward Hill, MD, FAAFP Residency Program Director North Mississippi Medical Center, Tupelo John D. Isaacs, Jr., MD Infertility Specialist, Mississippi Fertility Institute at Women’s Specialty Center, Jackson Kent A Kirchner, MD Nephrologist G.V. Montgomery VA Medical Center, Jackson Brett C. Lampton, MD Internist/Hospitalist Baptist Memorial Hospital, Oxford Philip L. Levin, MD President, Gulf Coast Writers Association Emergency Medicine Physician, Gulfport William Lineaweaver, MD, FACS Editor, Annals of Plastic Surgery Medical Director JMS Burn and Reconstruction Center, Brandon John F. Lucas,III, MD Surgeon Greenwood Leflore Hospital
Gailen D. Marshall, Jr., MD, PhD, FACP Professor of Medicine and Pediatrics, Vice Chair for Research, Director, Division of Clinical Immunology and Allergy, Chief, Laboratory of Behavioral Immunology Research The University of Mississippi Medical Center, Jackson Alan R. Moore, MD Clinical Neurophysiologist Muscle and Nerve, Jackson Paul “Hal” Moore Jr., MD, FACR Radiologist Singing River Radiology Group, Pascagoula Jason G. Murphy, MD Surgeon Surgical Clinic Associates, Jackson Ann Myers, MD Rheumatologist Mississippi Arthritis Clinic, Jackson Jimmy L. Stewart, Jr., MD Program Director, Combined Internal Medicine/ Pediatrics Residency Program, Associate Professor of Medicine and Pediatrics University of Mississippi Medical Center, Jackson Samuel Calvin Thigpen, MD Hematology-Oncology Fellow, Department of Medicine University of Mississippi Medical Center, Jackson Thad F. Waites, MD, FACC Clinical Cardiologist, Hattiesburg Clinic Chris E. Wiggins, MD Orthopaedic Surgeon Bienville Orthopaedic Specialists, Pascagoula John E. Wilkaitis, MD, MBA, CPE, MS Chief Medical Officer Brentwood Behavioral Healthcare, Flowood
â€˘ Scientific Articles â€˘ Tax Revenue in Mississippi Communities Following Implementation of Smoke-free Ordinances: An Examination of Tourism and Economic Development Tax Revenues Robert McMillen, PhD; Signe Shackelford, MPH
Background: There is no safe level of exposure to tobacco smoke. More than 60 Mississippi communities have passed smoke-free ordinances in the past six years. Opponents claim that these ordinances harm local businesses. Objective: Mississippi law allows municipalities to place a tourism and economic development (TED) tax on local restaurants and hotels/motels. The objective of this study is to examine the impact of these ordinances on TED tax revenues. Methods: This study applies a pre/post quasi-experimental design to compare TED tax revenue before and after implementing ordinances. Results: Descriptive analyses indicated that inflationadjusted tax revenues increased during the 12 months following implementation of smoke-free ordinances while there was no change in aggregated control communities. Multivariate fixed-effects analyses found no statistically significant effect of smoke-free ordinances on hospitality tax revenue. Conclusions: No evidence was found that smoke-free ordinances have an adverse effect on the local hospitality industry.
Key Words: tobacco smoke pollution, taxes Introduction According to the Surgeon General, there is no safe level of exposure to secondhand smoke.1 Tobacco smoke contains more than 7,000 chemicals, of which at least 69 cause cancer.2 Author Information: Dr. McMillen is an Associate Professor at Mississippi State University with a joint appointment in the Department of Psychology and the Social Science Research Center. He also serves as Investigator for the American Academy of Pediatricsâ€™ Julius B. Richmond Center of Excellence. Ms. Shackelford is at the Center for Mississippi Health Policy. Corresponding Author: Robert McMillen, One Research Park, Suite 103, Starkville, MS 39759
Acute risks of secondhand smoke exposure include sudden infant death syndrome, acute respiratory problems, otitis media, increased asthma severity, and myocardial infarction. The numerous chronic and acute harms of tobacco smoke have been documented in many literature reviews.1,2 Comprehensive smoke-free ordinances and laws reduce exposure to tobacco smoke and thereby the associated health risks. Although 62 Mississippi communities have implemented comprehensive smoke-free ordinances that prohibit smoking inside of all indoor places in which the public is allowed, opponents of these ordinances express concern that these smokefree restrictions harm local economies and businesses. The peer-reviewed literature does not support these arguments. Numerous studies from states and communities, based on objective outcomes which are examined before and after passage of comprehensive smoke-free ordinances or legislation, revealed no negative impacts on sales tax revenue and employment in the hospitality industry. Indeed, some studies have even found a slightly positive impact.3,4,5,6,7,8,9 Despite this evidence, some Mississippians remained concerned that smoke-free legislation will hurt local businesses. This study examines tax revenue for Mississippi towns to determine if local hospitality businesses in communities that implemented comprehensive smoke-free ordinances were adversely affected.
Methods There are several objective methods for assessing potential impacts of smoke-free laws on the hospitality industry.7 The most common approach is to examine trends in sales tax revenue from the hospitality sector before and after smoke-free laws and ordinances are enacted. In Mississippi, communities may choose to collect an optional Tourism and Economic Development (TED) tax that can be placed on restaurants and/or hotels/motels. This tax currently ranges from 1% to 4% of gross revenue. Most communities that collect a TED tax impose this tax on both restaurants and hotels/motels. Some communities collect the same percentage of tax from each sector, while oth-
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ers tax each sector at a different rate. Also, some communities only impose this tax on one sector of the local hospitality industry. Among the communities that collect this optional TED tax, 17 have implemented a comprehensive smoke-free ordinance and 16 have not implemented a smoke-free ordinance.* The optional tax allows us to objectively examine the impact of these smoke-free ordinances replicating the pre/post quasi-experimental design developed by Bartosch and Pope.10 Monthly sales tax collections data for municipalities are available at the local level from the Department of Revenue of the State of Mississippi. These monthly reports provide the amount of sales tax collected and the amount of TED taxes collected. Monthly revenue data were adjusted for inflation using the Consumer Price Index (CPI) with September 2011 as the base month. Descriptive Analysis The descriptive analysis examined inflation-adjusted preand post-ordinance TED tax revenue data for each of the 17 communities with comprehensive smoke-free ordinances (and at least 12 months of post-ordinance revenue data) and compares these revenue data to that from Mississippi communities without smoke-free ordinances. For each of the 17 communities with smoke-free ordinances, revenue data from these comparison communities (those without smoke-free ordinances) were aggregated across the same two 12-months periods. That is, aggregated pre- and post-ordinance TED tax revenue data for control communities were extracted for the same period as each of the 17 smoke-free communities and provide a comparison for the same time period. Note that Mississippi communities adopted their smoke-free ordinance at different times, and thus these time periods differ for the 17 smoke-free communities. Aggregated data from the 16 communities without smoke-free ordinances provide economic controls. The percent change in TED tax revenue for the smokefree community was then compared to the aggregated percent change in revenue across the comparison communities. Finally, an average percent change in revenue was calculated for the 17 smoke-free communities and compared to the average percent change in the comparison communities. Multivariate Analysis The model included 108 months (January 2004 through April 2012) of inflation-adjusted restaurant sales data for each of the 33 communities in the sample. Mixed model analysis including fixed-effects for temporal factors and repeated measures for communities were conducted using the natural logarithm of TED Tax revenue to serve as the dependent variable. The use of logged data allows the impact of smoke-free ordinances to be interpreted in percentage terms. As Bartosch and Pope note, the percentage impact on revenue following smokefree ordinances is more relevant than absolute dollar changes
given that these towns vary substantially in size.10 The model included several variables to statistically remove the influence of town characteristics while examining the effect of smoke-free ordinances on TED tax revenue. First, we created a dichotomous variable to assess potential impacts of smoke-free ordinances. All months in which aÂ smoke-free ordinance was in effect were assigned a value of one, and all months in which a smoke-free ordinance was not in effect were assigned a value of zero. Towns that had not implemented a smoke-free ordinance were assigned a value of zero for all months. This model produces an average effect of smoke-free ordinances across all towns with smoke-free ordinances, compared to towns that did not implement a smoke-free ordinance. We entered several predictor variables into this regression model to account for factors that might also affect TED tax revenue. Dummy variables for quarter of the year were included to adjust for seasonal influences. Year was included to control for variations in tax revenue over time. Finally, towns were weighted by their population size so that larger communities had more influence on the model due to their more stable tax revenue.
Descriptive Analysis Table 1 presents the inflation-adjusted pre- and post-ordinance TED tax revenue income for the Mississippi communities that have comprehensive smoke-free ordinances, collect a TED tax, and have at least 12 months of post-ordinance revenue data. The percentage change in revenue for these towns ranges from -17% to 95%. As other researchers have noted,10 this wide range reflects the volatile nature of the restaurant and hospitality industries due to seasonality and turnover in businesses. Also, the largest changes occurred in the smaller communities. Table Results from descriptive analysis Table 1. 1. Results from descriptive analysis Town
Date of Ordinance
Percent Change in Smoke-Free Communities
Aberdeen Batesville Clinton Corinth Greenwood Grenada Hattiesburg Hernando Jackson Kosciusko Laurel Oxford Ridgeland Starkville Tupelo Pearl Pontotoc
3/22/2007 5/4/2010 8/14/2008 11/6/2007 8/17/2007 1/8/2009 1/1/2007 3/8/2007 7/1/2010 11/2/2007 12/4/2009 11/17/2006 7/19/2007 5/20/2006 10/5/2006 9/1/2010 5/1/2008
6.66% 1.84% 27.12% -2.93% 4.16% 3.29% -3.31% 94.98% -2.96% -16.86% 5.60% -0.44% 8.30% 5.14% 5.58% 5.01% 32.64%
Average Percent Change (during the same period) in the Aggregated No-Ordinance Comparison Communities 2.63% 2.75% -3.52% 0.73% 4.55% -2.31% -0.71% 1.15% 2.42% 0.73% -0.27% -2.41% 3.41% -4.72% -5.91% 0.92% -1.29%
* Aberdeen, Batesville, Clinton, Corinth, Greenwood, Grenada, Hattiesburg, Hernando, Jackson, Kosciusko, Laurel, Oxford, Ridgeland, Starkville, Tupelo, Pearl, and Pontotoc have a comprehensive smoke-free ordinance. Bay Springs, Canton, Cleveland, Florence, Holly Springs, Horn Lake, Indianola, Magee, Moss Point, New Albany, Newton, Philadelphia, Richland, Southaven, Vicksburg, and West Point served as the control communities.
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For the communities with smoke-free ordinances as a whole, inflation-adjusted TED tax revenue were 10.3% greater in the 12 months following the enactment of a smoke-free ordinance. Conversely, there was no meaningful change in TED tax revenue in the aggregated control communities (-.1%). Multivariate Analysis The results of the multivariate analysis are presented in Table 2. The implementation of a local smoke-free ordinance was associated with a non-statistically significant increase in TED tax revenue, after controlling for community, seasonality, and temporal factors. The point estimate for the implementation of a smoke-free ordinance indicates that the ordinance was followed by a 5.4% increase in revenue; however, this change was not statistically significant. Table 2. Results from multivariate analysis
Table 2. Results from multicariate analysis Predictor Variables Smoke-free ordinance First Quarter* Second Quarter Third Quarter* Year
Estimate (Standard Error) .054 (.053) -.089 (.025) .014 (.021) .071 (.016) .009 (.028)
95% Confidence Interval -.050 to .158 -.138 to -.040 -.029 to .056 .040 to .101 -.046 to .064
Discussion No evidence was found that smoke-free ordinances have an adverse effect on the local restaurant industry. Results from the descriptive analysis indicated that many communities experienced an increase in revenue following implementation of a smoke-free ordinance, and the average change in revenue was a 10 percent increase. In contrast, there was no meaningful change in the aggregated control communities. Multivariate analysis confirmed that there was no statistically significant adverse effect on revenue. These results are consistent with the numerous peerreviewed studies that have applied objective measures to examine potential impacts of smoke-free laws and ordinances.3,4,5,6,7,8,9 However, there were several potential limitations of this study. First, many communities with comprehensive smokefree ordinances do not collect the optional TED tax, and thus it was not possible to include all Mississippi communities in these analyses. Analyses, however, were based on a diverse set of communities that varied in size, region, and socioeconomic status. Second, the TED tax can range from 1% to 4% and can be applied to restaurants and/or hotels/motels. Although the tax rate was not identical across communities, it was consistent within each community over the study period. Analyses 10 addressed relative change pre- and post-ordinance, rather than 1 absolute dollar amounts, so inter-community differences in2 tax rate should not have impacted analyses. Third, analyses3 examined aggregate revenue and thus cannot address the impact4 of smoke-free ordinances on specific restaurants. Conclusions5 are therefore relevant at the community-level and may not6 necessarily apply to all venues within a community. 7 In addition to the empirical evidence presented in this8 study, the experience of the state also suggests that smoke-9
10 11 12
free ordinances are not harming Mississippi’s hospitality industry. In the past decade, 62 municipalities in Mississippi have implemented a comprehensive smoke-free ordinance, and twelve others have passed partial smoke-free ordinances that exempt bars. According to the Mississippi State Department of Health’s database of food service facilities, almost half (46%) of restaurants in this state are in one of these communities and thus are subject to smoke-free ordinances. It is doubtful that communities would continue to implement these ordinances if half of the restaurants in this state were adversely impacted.
1. U.S. Department of Health and Humans Services. The health consequences of involuntary exposure to secondhand smoke: a report of the Surgeon General. 2006. 2. U.S. Department of Health and Humans Services. How Tobacco Smoke Causes Disease: The Biology and Behavioral Basis for Smoking-Attributable Disease - A Report of the Surgeon General. 2010. 3. Edwards R, Thomson G, Wilson N, et al. After the smoke has cleared: evaluation of the impact of a new national smoke-free law in New Zealand. Tob Control. 2008;17(1):e2. 4. Pyles MK, Mullineaux DJ, Okoli CT, and Hahn EJ. Economic effect of a smoke-free law in a tobacco-growing community. Tob Control. 2007;16(1):66-8. 5. Klein EG, Forster JL, Collins NM, Erickson DJ, and Toomey TL. Employment change for bars and restaurants following a statewide clean indoor air policy. Am J Prev Med. 2010;39(6 Suppl 1):S16-22. 6. Huang P, De AK, and McCusker ME. Impact of a smoking ban on restaurant and bar revenues--El Paso, Texas, 2002. Morbidity and Mortality Weekly Report. 2004;53(07):150-152. 7. Scollo M. Review of the quality of studies on the economic effects of smoke-free policies on the hospitality industry. Tobacco Control. 2003;12(1):13-20. 8. Engelen, Farrelly M, and Hyland A. The health and economic impact of New York’s Clean Indoor Air Act. 2006. Available at: http://www.health.ny.gov/prevention/tobacco_control/docs/ciaa_ impact_report.pdf. 9. New York City Department of Finance. The State of Smoke-Free New York City: A One-Year Review. 2004. Available at: www.nyc. gov/html/doh/downloads/pdf/smoke/sfaa-2004report.pdf. 10. Bartosch W, and Pope G. The Economic Effect of Smoke-Free Restaurant Policies on Restaurant Business in Massachusetts. Journal of Public Health Management and Practice. 9(5):53-62.
Journal of the Mississippi state Med EXCELLENT MEDICAL OFFICE FOR LEASE IN THRIVING OCEAN SPRINGS, MS. Private Dr’s Office, 3 Exam Rooms, Lab, Filing, etc. Call Bill: 228-875-7224 October 2012 JOURNAL MSMA 321
Medical Assurance Company of Mississippi For nine years, MACM fought a lawsuit on my behalf. As a physician, I really didn’t think about MACM until I needed help.
The commitment and resolve that this Company has to stand behind its member physicians becomes very evident in the efforts of defending a lawsuit. I could not have asked for a kinder and more sympathetic treatment by this Company for the past 30 years that I have been insured. I realize more and more that I could not have practiced my profession had I not had your army of professionals behind me. The association can only be described as grace.
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â€˘ Scientific â€˘
Substance Use and Sexual Risk Behaviors Among Mississippi Public High School Students
James McGuire, PhD; Bo Wang, PhD; Lei Zhang, PhD, MBA bstract
This study describes the patterns of substance use and sexual risk behaviors and examines the relationships among a representative sample of Mississippi public high school students. Data were obtained from the 2009 Mississippi Youth Risk Behavior Survey. Multiple logistic regression analyses were performed. We found 61% of the participants ever had sexual intercourse and 13.4% engaged in early sexual initiation (â‰¤ 12 years). Nearly a quarter had four or more lifetime sexual partners. Onethird did not use a condom during their last sexual intercourse. Two-thirds drank alcohol. Over one-third used marijuana. Older age, being a black, drinking alcohol, or using marijuana or other drugs were associated with early sexual initiation and having multiple sexual partners. Heavy smoking was associated with early sexual initiation. Using marijuana or other drugs was associated with unprotected sex. Findings highlight the extensive substance use and engagement of sexual risk behaviors among Mississippi adolescents. Interventions that address both substance use and sexual risk behaviors may have a great impact in preventing teen pregnancy and HIV/STD transmission and curtailing substance abuse problems among Mississippi adolescents.
Key Words: substance use, alcohol use, sexual risk behaviors
High school students are at a pivotal time in their lives regarding personal decisions that impact both their current and future health.1 It is a time when the reciprocal interaction of social, environmental, and personal occurrences surface to form the foundation from which most health-related decisions evolve.1,2 In the best case scenario, students will leave the challenging time of adolescence with an abundance of knowledge and valuable life experiences while harboring minimal negative Author Information: Dr. McGuire is an Associate Professor in the Department of Community Health Sciences, College of Health, University of Southern Mississippi. Dr. Wang is an Assistant Professor at the Pediatric Prevention Research Center, Wayne State University School of Medicine, Detroit, MI. Dr. Zhang is Director of the Office of Health Data and Research, Mississippi State Department of Health, and Associate Professor, School of Nursing, University of Mississippi Medical Center. Corresponding author: Dr. Lei Zhang, Office of Health Data and Research, Mississippi State Department of Health, 570 East Woodrow Wilson, Jackson, MS 39215-1700. Phone: (601) 576-8165. (Lei.Zhang@msdh.state.ms.us).
consequences. However, in an all too common scenario, adolescents often create life-altering difficulties for themselves after adopting risky behaviors regarding substance use and/or sexual behavior3,4 or they struggle to live fulfilling lives because of underlying mental health issues.5 Based on the 2009 National Youth Risk Behavior Survey (YRBS),6 it is clearly evident that a significant number of high school students are thoroughly engaged in risky substance use and sexual behaviors. In regard to substance use, alcohol is by far the primary drug of choice. It is the most heavily used and abused substance by youth in the United States.7,8 Regardless of the fact that it is illegal until 21 years of age in all states, it is estimated that there are 11 million drinkers in the U.S. between the ages of 12-20, and they drink 11% of all alcohol consumed.9 Further, in 2008 there were approximately 190,000 emergency room alcohol-related visits by individuals less than 21 years of age.7 Nationwide, it is reported in the 2009 YRBS that 21.1% of students drank alcohol for the first time before the age of 13. Overall, 72.5% of high school students reported having at least one drink of alcohol in their life, and 41.8% had at least one drink of alcohol during the 30 days prior to the survey. Slightly over 24% had five or more drinks of alcohol in a row on at least one day during the 30 days before the survey. In addition, 4.5% of students reported at the time of the survey that they had consumed alcohol on school property at least one day during the previous 30 days. In regard to tobacco use, 46.3% of adolescents nationally reported that they had ever tried cigarette smoking. A considerable number (10.7%) reported smoking a whole cigarette before the age of 13 while 7.3% of adolescents said they smoked cigarettes on 20 days during the last 30 days and 7.8% smoked more than 10 cigarettes each day. Other substances ever used nationally include marijuana (36.8%), cocaine (6.4%), inhalants (11.7%), ecstasy (6.7%), heroin (2.5%), methamphetamines (4.1%), and injected drugs (2.1%). The 2009 National YRBS data reveal that 46% of high school students had ever had sexual intercourse. Within this percentage, 5.9% had sex for the first time before the age of 13 and 13.8% had sexual intercourse with at least four people. Slightly over 34% of students reported having sexual intercourse with at least one person during the 3 months before the survey. In addition, among the students that were currently sexually active, 21.6% said they drank alcohol before their last intercourse. When considering the above numbers regarding the areas of high school student substance use and sexual behavior, the
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link is very plausible and, therefore, has lead researchers trying to explain the connection for decades. The connection, unfortunately, is complicated and previous research yielded inconsistent findings. Research shows that there is, in fact, a strong co-occurrence of high risk behaviors among adolescents.2 This means that for every high risk behavior there is at least one additional associated high risk behavior. For example, adolescents exhibiting high risk behaviors associated with early participation in sexual intercourse have a much higher risk of substance use. There is also a high correlation between the use of the gateway drugs alcohol and marijuana and the use of other illicit drugs, delinquent behavior,10 and suicidal thoughts and tendencies.11 Other research12 has shown that it is typical for adolescents to increase in the number of associated risk behaviors over time if alcohol use continues, including more prominent risky sexual behavior, engaging in suicidal-related behavior, and neglecting responsibility. According to Miller, et al. (2007),13 current high school drinkers were more likely to be currently sexually active, drink or use other drugs before sexual intercourse, have been or gotten someone pregnant, smoke cigarettes, experience dating violence, consider or attempt suicide, and have forced intercourse. To compound this behavior, over 60% of current high school drinkers were identified as binge drinkers (> 5 drinks of alcohol in a row) and over 67% engaged in binge drinking more than one day in the past 30 days. As would be expected, the risk behaviors occurred much more often when the binge drinking occurred. A study14 explaining the role a teenager commonly plays under the influence of alcohol reported that alcohol reduces cognitive capacity, directing individuals under the influence of the drug to focus on the most prominent cues in the environment rather than the cues that require more conscious thought and reasoning. Thus, in sexual situations, intoxicated individuals will be much more aware of prominent cues such as intimacy and the immediate pleasure of the sexual contact. They are less aware of the cues requiring deeper cognition such as suspicion that the sexual partner could be HIV infected. In another study,15 it was found that using alcohol prior to sexual behavior negatively impacted motivation to use a condom as well as the performance of condom discussion with a sexual partner. The 2009 national YRBS data also reveal that there are many high school students with serious mental health issues. One indication of this is reflected in the data that 26.1% of students reported that they felt sad and hopeless. In addition, there were a significant number of high school students that have contemplated (13.8%), planned (10.9%), or attempted (6.3%) suicide. This deserves recognition, as approximately 11% of all teen deaths each year are due to suicide.16 In fact, this percentage has been consistent for over a decade and has initiated such a widespread concern that the term “suicidality,” referring to the occurrence of suicidal thoughts or suicidal behavior, is commonly used today in research regarding adolescent behavior.17 Further, the research is fairly consistent in showing that the two most important risk factors in both attempted and completed suicide are depression and substance use.9,17,18 As related to the substance use specifically among teens, alcohol is most frequently used and it, therefore, has the highest association to suicidality.17 A potential consequence, then, of teen alcohol use is the mani-
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festation of behavioral characteristics of suicide while under the influence of the alcohol. These characteristics include disinhibition, impulsivity, increased aggression, negative affectivity, and limited awareness of coping strategies.19 Although there is a strong correlation to numerous other determinants of causation closely related to attempted or actual suicide, such as other depressive disorders, family conflict, and adverse childhood experiences, it is the alcohol use that places the teen at a substantially higher risk for unplanned suicidal behavior.5,19 The alcohol becomes a solution to dealing with life issues. However, simply attributable to its depressive nature, alcohol can make the adolescent feel the discord of life even more, thus leading to a will to end it all with suicide. Unfortunately, under the influence of alcohol, the finality of suicide is not realized.18,20 Using data from a representative sample of public high school students in Mississippi, this study describes the patterns of substance use, sexual risk behaviors and mental health problems and examines the relationship between substance use and sexual risk behaviors. Gender difference in substance use, sexual risk behaviors and mental health problems were also assessed in this study.
Instrument The YRBS was designed by the Centers for Disease Control and Prevention (CDC), in collaboration with state and local departments of education and other federal agencies, to monitor adolescent behaviors that contribute to morbidity and premature mortality among the nation’s youth and adults.21 Standardized, complex biennial surveys are administered to collect self-reported information covering unintentional injury and violence, physical activity, dietary behavior, sexual behavior, tobacco use, and alcohol and other drug use. A detailed description of the YRBS is reported elsewhere.21,22 Studies have shown YRBS data are reliable for analyzing high school students’ health-related behaviors.23,24 Additionally, another study suggests that self-reported grade point averages are highly reliable and “sufficiently adequate for research use.”25 Sampling The sampling frame for the 2009 Mississippi YRBS was obtained from the Mississippi Department of Education school enrollment database. A two-stage cluster sample design produced a representative sample of Mississippi students in grades 9-12 who attend public schools. At the first stage, 50 schools with any of grades 9-12 were selected with probability proportional to school enrollment size. The second sampling stage consisted of randomly selecting one or two intact classes (e.g., English) or a required period (e.g., second period) at each chosen school. All students in selected classes were eligible to participate in the survey. During the spring of 2009, 41 of the 50 sampled schools (82%) participated. A total of 1,795 from the 2,112 sampled students (85%) completed an 87-item questionnaire. The overall response rate (product of school response rate and student response rate) for the 2009 Mississippi YRBS was 69.7%. The overall response rate was above the threshold of 60% required to obtain weighted estimates. The weighted data were used to make
inferences concerning academic performance and substance use for all Mississippi public school students in grades 9-12. Non-Hispanic whites and non-Hispanic blacks comprised 97.4% of all Mississippi public high school students. About 45.8% of the students were non-Hispanic whites, 51.6% were non-Hispanic blacks. Due to small sample sizes, persons of other races /ethnicities were excluded from the analysis. About 49.5% of the students were male, 50.5% were female. The percentages of students in grades 9, 10, 11, and 12 were 29.6%, 26.9%, 22.7%, and 20.6%, respectively.
There are three basic steps for the statistical analysis. First, overall demographic characteristics, sexual risk behaviors (sexual initiation, multiple sexual partners, and unprotected sex), substance use (heavy smoking, alcohol, marijuana, and cocaine use), and mental health problems (suicidal thoughts and attempts) were examined using frequency distribution. A heavy smoking student was defined as one who smoked cigarettes 20 or more days during the 30 days preceding the survey. A bingedrinking student (regardless of gender) was defined as one who had five or more drinks of alcohol in a row within a couple of hours on any one occasion during the 30 days preceding the survey. Gender difference in sexual risk behaviors, substance use, and mental health problems were tested using Pearson’s χ2 (for categorical variables) or the Cochran-Mantel-Haenszel χ2 test (for ordinal variables). Second, bivariate analysis was conducted to examine the association between substance use and sexual risk behaviors. Third, multiple logistic regression model were further constructed to assess the association of substance use with sexual risk behaviors controlling for other potential demographic confounders. The independent variables included smoking, alcohol, marijuana, and cocaine use. The dependent variables were early sexual initiation (≤ 12 years), multiple sexual partners (≥ 4 partners), and condom use. Odds ratio (OR) and its 95% confidence interval (CI) were calculated. All statistical analyses were performed using the SAS 9.1 (SAS Institute Inc., Cary, NC, USA). Proc Survey procedures were used to adjust these estimates to account for differences in the complex sampling structure of the survey. A significance level of 0.05 was adopted in bivariate comparisons and multivariate analyses.
Socio-demographic characteristics and sexual risk behaviors Three quarters of the participants were aged 15-17 years. Sixty-one percent ever had sexual intercourse and 13.4% had sexual intercourse for the first time before 13 years. Nearly a quarter had sexual intercourse with four or more persons during their life. One-third did not use a condom during last sexual intercourse. Condom was the most popular method of contraception used by high school students. Twelve percent of participants had used emergency birth control pills and 7.3% used withdrawal. The prevalence of suicidal thoughts and attempts in the past 12 months were 14.3% and 8.4%, respectively (Table 1). Demographic characteristics and sexual risk behaviors were compared between males and females. There was no gender difference in age, grade, and race/ethnicity distributions.
However, higher proportions of males than females reported having sexual intercourse for the first time before 13 years (18.7% vs. 8.1%, P < 0.01) and had sexual intercourse with four or more persons during their life (30.1% vs. 17.6%, P < 0.001) and had sexual intercourse with four or more persons in the last three months (6.8% vs. 1.1%, P < 0.001). The use of condoms was significantly more common among males than among females (60.6% vs. 53.1% of sexually experienced youth). Higher proportions of females than males reported having had suicidal thoughts (19% vs. 11.9%, P < 0.001) and suicide attempt (11.9% vs. 6.4%, P < 0.001) (Table 1). Table 1: Socio-demographic characteristics and sexual risk behaviors among Mississippi high school students, table 1 socio-demographic characteristics and sexual risk behaviors among 2009 Mississippi high school students, 2009 Characteristics Sample size Age (years) ≤ 14 15-17 ≥ 18 Grade 9th 10th 11th 12th Race/ethnicity Black/non-Hispanic White/non-Hispanic Other (e.g., Asian, American Indian) Sexual initiation Never had sexual intercourse Had first sex at the age of 11-12 Had first sex at the age of 13-15 Had first sex at the age of 16-17 Number of sex partners, lifetime 0 1-3 ≥4 Number of sex partners, last 3 months 0 1-3 ≥4 Condom use, last sexual intercourse Contraceptive use No use Birth control pills Condoms Withdrawal Other (e.g., Depo-Provera) Suicidal thoughts Suicidal attempt Note: * P < 0.05; ** P < 0.01; *** P < 0.001.
8.5% 75.7% 15.8%
9.7% 74.6% 15.7%
7.3% 76.8% 15.9%
29.6% 26.9% 22.7% 20.6%
28.4% 26.8% 23.1% 21.7%
30.8% 27.1% 22.4% 19.6%
51.6% 45.8% 2.6%
52.9% 45.2% 1.9%
50.8% 47.2% 1.9%
39.0% 13.4% 33.9% 13.7%
41.8% 8.1% 34.2% 15.9%
36.0% 18.7% 33.8% 11.5%
39.2% 37.1% 23.7%
42.0% 40.4% 17.6%
36.3% 33.6% 30.1%
55.1% 41.0% 3.9% 67.2%
56.0% 42.9% 1.1% 64.2%
54.1% 39.0% 6.8% 70.2%
15.4% 12.5% 56.9% 7.3% 7.9% 15.4% 9.3%
17.8% 14.9% 53.1% 6.4% 7.8% 19.0% 11.9%
13.1% 10.1% 60.6% 8.1% 8.1% 11.9% 6.4%
Patterns of alcohol and drug use Approximately 3% of the1 participants reported heavy smoking. Two-thirds ever drank alcohol and 26.3% reported drinking alcohol for the first time before 12 years. Nearly 20% of the participants reported binge drinking. Over one-third ever used marijuana and 8.3% reported using marijuana for the first time before 12 years. About 7% of the participants used marijuana for 10 or more times in the past 30 days. The proportion of the participants who ever used cocaine, inhalations, heroin, methamphetamine, ecstasy, steroid pills or shots, and injected drugs ranged from 2% to 9.7%. In addition, 18% of the participants reported that they had been offered, sold, given an illegal drug by someone on school property in the last 12 months (Table 2). Gender differences were found in smoking, alcohol use and drug use. A higher proportion of males than females reported heavy smoking (6.6% vs. 0.2%, P < 0.001). Higher proportions of males than females reported drinking alcohol for the first time
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before 12 years (30% vs. 22.8%, P<0.01) and binge drinking (23% vs. 16.5%, P < 0.001). Higher proportions of males than females reported ever using marijuana (40.1% vs. 30.1%, P < 0.001) and using marijuama for the first time before 12 years (10.4% vs. 6.3%, P < 0.001). A higher proportion of males than females reported using marijuana for 10 or more times in the past 30 days (10.6% vs. 6.3%, P < 0.001). In addition, a higher proportion of males than females reported that they had been offered, sold, given an illegal drug by someone on school property in the last 12 months (21.5% vs. 14.6%, P < 0.001) (Table 2). Table 2: Patterns of alcohol and drug use among Mississippi high school students, 2009 table 2 patterns of alcohol and drug use among Mississippi high school students, 2009 Females Males Variables Overall 2 Sample size# 1772 917 855 Heavy smoking 3.3% 0.2% 6.6% 69.41*** Ever drank alcohol, lifetime 70.1% 70.8% 69.3% 0.44 Age at first drink of alcohol† Never had a drink of alcohol 31.4% 31.0% 31.7% 13.63** ≤ 12 years 26.3% 22.8% 30.0% ≥ 13 years 42.3% 46.2% 38.3% Frequency of alcohol use, past 30 days 0 days 60.9% 62.4% 59.3% 10.18* 1-2 days 20.0% 21.6% 18.4% 3-9 days 14.6% 12.0% 17.1% ≥10 days 4.6% 4.0% 5.2% Binge drinking 19.7% 16.5% 23.0% 10.80*** Ever used marijuana, lifetime 35.0% 30.1% 40.1% 17.58*** Age at first use of marijuana† Never used marijuana 64.6% 69.5% 59.5% 18.83*** ≤ 12 years 8.3% 6.3% 10.4% 13-17 years 27.1% 24.2% 30.2% † Frequency of marijuana use, past 30 days 0 times 82.4% 85.8% 78.8% 29.43*** 1-9 times 10.5% 10.5% 10.6% ≥ 10 times 7.1% 3.7% 10.6% Ever used cocaine, lifetime 3.7% 3.7% 3.7% 0.01 Ever used inhalations, lifetime 9.7% 10.2% 9.2% 0.46 Ever used heroin, lifetime 2.0% 2.1% 1.9% 0.12 Ever used methamphetamines, lifetime 2.7% 3.1% 2.3% 0.86 Ever used ecstasy, lifetime 5.2% 5.0% 5.4% 0.12 Ever took steroid pills or shots without a 3.3% 2.9% 3.7% 0.81 doctor’s prescription Ever used injected drugs, lifetime 2.1% 2.5% 1.7% 1.47 Offered, sold, given an illegal drug by 18.0% 14.6% 21.5% 12.81*** someone on school property in last 12 month Note: †Cochran-Mantel-Haenszel 2 test. * P < 0.05; ** P < 0.01; *** P < 0.001. #17 participants had missing data on alcohol and drug use.
Bivariate association of substance use with sexual risk behaviors Sexual initiation and multiple sex partnerships were associated with heavy smoking, drinking alcohol, drinking alco2 hol for the first time before 12 years, frequent alcohol drinking, binge drinking, drinking alcohol or using drugs before engaging in sexual intercourse, using marijuana, using marijuana for the first time before 12 years, frequent marijuana use, and using other drugs. Unprotected sex was associated with drinking alcohol for the first time before 12 years, frequent alcohol drinking, binge drinking, and using marijuana or other drugs (Table 3). Multivariate analysis of risk factors for sexual risk behaviors Multivariate logistic regression analyses indicate that older age, being black, drinking alcohol, binge drinking, using marijuana or other drugs were associated with early sexual initiation and having multiple sexual partners. Heavy smoking was associated with early sexual initiation only. Being a male was associated with having multiple sexual partners. Using marijuana or other drugs was associated with unprotected sex (Table 4). Compared to their counterparts, blacks, heavy smokers, students who drank alcohol, and those who used marijuana were
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3.7, 2.6, 3.3, 2.6 times as likely to have had sexual intercourse before 13-years-old, respectively. Blacks and the students who used marijuana were 2.1 and 2 times as likely to have had 4 or more sexual partners in their life time. High school students who drank alcohol or used drugs before engaging in sexual intercourse were 2 times as likely to have had unprotected sex during the last sexual episode.
High school students are active exploring their world. They are inexperienced and unfamiliar with how to handle adversity. Consequently, many will make bad decisions. Substance use, involvement in sexual behaviors, and dealing with mental health issues, are three life areas topping the list of adolescent challenges. This discussion will compare the findings of the 2009 Mississippi high school student health behavior data for these areas to the 2009 National YRBS data.6 Mississippi is usually recognized as having one of the poorest overall health status ratings in the country. The state consistently has one of the highest rates for teen pregnancy and sexually transmitted disease. It is, unfortunately, a fact that the state must realize, accept, and at the same time strive to improve. In beginning the comparison of Mississippi data to the national data, however, it is important to note that Mississippi actually reflects behavior that is healthier than or similar to the national percentages in many of the three areas. The most obvious examples are in the area of substance use. Related to alcohol, it was reported that 70.1% of high school students in Mississippi had ever used alcohol, compared to the national average of 72%. In addition, it was reported that Mississippi high school students had lower, or equal percentages of use for most of the other drugs, including cocaine (3.7% vs. 6.4%), inhalants (9.7% vs. 11.7%), heroin (2% vs. 4.1%), ecstasy (5.2% vs. 6.7%), and steroids (3.3% vs 3.3%). In regard to smoking cigarettes, 3.3% of Mississippi students reported having smoked cigarettes 20 or more days during the 30 days preceding the survey, which is lower than the national level (8%).6 Unfortunately Mississippi high school students did report behavior that helped maintain the states low health status reputation. This includes data related to sexual behavior. Among Mississippi high school students, 13.4% said they had sexual intercourse before the age of 13, compared to the national average of 5.9%. Also, 23.7% of Mississippi students reported that they had sexual intercourse with four or more persons, while the national percentage was 13.8%. Another area that reflected a poor health status for Mississippi was mental health, measured by suicidal-related behavior. Among Mississippi high school students, 15.4% had seriously considered suicide, while the national level was 13.8%. Actually attempting suicide was 9.3% for Mississippi, 6.3% nationally.6 Finally, although Mississippi was below usage rates for most of the drugs, the state was recognized for poor behavioral practices regarding age of first consuming alcohol. Findings show that 26.3% of Mississippi high school students drank alcohol for the first time before the age of 13, it was 21.1% nationally. There are potential limitations in this study. First, the behavioral data were collected through self-report. Thus, it might be subject to self-reporting bias. It is possible that high school
Table 3: Bivariate association of substance use with sexual risk behavior among Mississippi high school students, 2009 table 3 Bivariate association of substance use with sexual risk behaviors among Mississippi high school students, 2009 Age of sexual initiation Lifetime sexual partners Condom use Variables No sex ≤12 ≥13 0 1-3 ≥4 Yes No 2 2 2 Sample size # 668 225 826 668 633 412 688 345 Heavy smoking 1.0% 3.3% 5.5% 20.35*** 1.0% 4.0% 6.4% 21.68*** 4.9% 5.2% 0.03 Ever drank alcohol, life time 50.7% 86.8% 82.7% 181.46*** 50.6% 80.1% 89.1% 187.84*** 82.3% 87.4% 3.65 † Age at first drink of alcohol Never had a drink of alcohol 51.8% 14.6% 19.3% 251.54*** 51.7% 21.8% 12.6% 198.29*** 20.0% 13.4% 10.07** ≤ 12 years 16.7% 54.0% 26.2% 16.9% 28.4% 38.7% 29.4% 38.2% ≥ 13 years 31.5% 31.4% 54.5% 31.4% 49.8% 48.7% 50.6% 48.3% Frequency of alcohol use, past 30 days 0 days 79.5% 36.6% 49.2% 177.38*** 79.5% 53.8% 34.4% 210.29*** 50.0% 38.6% 9.48** 1-2 days 12.7% 23.5% 26.5% 12.7% 25.8% 25.8% 24.3% 29.5% ≥ 3 days 7.8% 39.9% 24.3% 7.8% 20.4% 39.8% 25.7% 31.9% Binge drinking 9.4% 33.3% 25.6% 76.80*** 9.4% 22.0% 35.5% 97.62*** 24.80 33.16 7.14** Drinking alcohol or using drugs before NA 25.2% 15.3% 10.92*** NA 12.7% 24.6% 22.12*** 16.6% 19.8% 1.45 engaging in sexual intercourse Ever used marijuana, lifetime 14.7% 67.6% 43.9% 216.66*** 14.7% 38.7% 65.5% 247.69*** 44.4% 58.2% 15.25*** Age at first use of marijuana Never used marijuana 85.2% 32.2% 55.6% 294.32*** 85.3% 60.7% 34.3% 247.83*** 55.1% 41.4% 14.80*** ≤ 12 years 3.2% 30.1% 6.4% 3.2% 8.0% 17.5% 10.6% 13.2% 13-17 years 11.6% 37.7% 38.0% 11.5% 31.3% 48.2% 34.3% 45.4% Frequency of marijuana use, past 30 days 670 221 813 671 622 404 674 341 0 times 94.7% 58.6% 78.1% 156.48*** 94.7% 80.8% 63.1% 167.22*** 76.2% 69.4% 5.39 1-9 times 3.6% 19.8% 14.3% 3.6% 13.6% 18.2% 14.5% 17.3% ≥ 10 times 1.7% 21.6% 7.6% 1.7% 5.6% 18.6% 9.3% 13.3% Ever used drugs (e.g., cocaine, heroine, 1.4% 6.6% 5.4% 19.72*** 1.4% 5.4% 5.9% 19.04*** 4.2% 8.3% 6.70** methamphetamines) Note: * P < 0.05; ** P < 0.01; *** P < 0.001. #70 participants had missing data on sexual risk behaviors.
Table 4: Odd ratios from multiple logistic regression analysis showing risk factors for early sexual initiation,3 multiple sexfrompartners unprotected sex Table 4. Odds ratios multiple logisticand regression analysis showing risk factorsamong for early sexual initiation, multiple sex partners and unprotected sex among Mississippi high school Mississippi high school students, 2009 students, 2009 Characteristics
Early sexual initiation ORa 95% CIb 1.58 1.43~1.75
Age (year) Gender Female 1.00 (referent) Male 1.22 0.94~1.58 Race/ethnicity White/non-Hispanic 1.00 (referent) Black/non-Hispanic 3.66 2.79~4.79 Heavy smoking No 1.00 (referent) Yes 2.62 1.09~6.32 Ever drank alcohol No 1.00 (referent) Yes 3.29 2.43~4.44 Binge drinking No 1.00 (referent) Yes 1.80 1.22~2.67 Ever used marijuana No 1.00 (referent) Yes 2.62 1.90~3.60 Ever used drugs (e.g., cocaine, heroine, methamphetamines) No 1.00 (referent) Yes 2.11 1.31~3.40 Drinking alcohol or using drugs before engaging in sexual intercourse No NA Yes Notes: a OR = Odds Ratio; b CI = Confidence Interval.
Multiple sex partners OR 95% CI 1.38 1.21~1.58
1.00 (referent) 1.95 1.42~2.67
1.00 (referent) 0.73 0.53~1.00
1.00 (referent) 2.12 1.49~3.01
1.00 (referent) 0.99 0.72~1.35
1.00 (referent) 0.84 0.41~1.70
1.00 (referent) 1.06 0.50~2.26
1.00 (referent) 1.66 1.02~2.70
1.00 (referent) 1.08 0.68~1.71
1.00 (referent) 1.49 1.02~2.18
1.00 (referent) 1.12 0.77~1.63
1.00 (referent) 2.03 1.46~2.83
1.00 (referent) 1.41 1.02~1.96
1.00 (referent) 1.67 1.07~2.60
1.00 (referent) 1.93 1.29~2.89
1.00 (referent) 1.44 0.94~2.21
1.00 (referent) 0.92 0.61~1.40
OR 95% CI 1.04 0.92~1.18
students misreported or underreported their risk behaviors (i.e., substance use). Second, the cross-sectional data precludes causal interpretations of our findings. Future research is needed to describe the trends of substance use and sexual risk behaviors and subgroup comparisons among Mississippi high school students. Implications for School Health Interventions that address both substance use and sexu4 al risk behaviors may have a great impact in preventing teen
pregnancy and HIV/STD transmission and curtailing substance abuse problems among Mississippi adolescents. As indicated in this study, Mississippi public high school students are actively engaging in high-risk health behavior. Therefore, if young lives are to be spared from the negative impact, perhaps it is time for educators, legislatures, and community advocates in the state to establish clear guidelines to aggressively address the problem. For example, it is known that Mississippi has very limited health education in the schools. Although the state has a comprehensive K-12 school health framework26 to serve as a guide for teachers, it is not implemented in a comprehensive manner. In fact, the state has a mandate that requires only a nine week condensed overview of health issues in ninth grade.27 This is much too little and much too late. A more comprehensive health education curriculum (beginning in at least the middle grades), including a thorough overview of topics such as substance use, sexuality, and mental health, combined with methodology that teaches personal life skills, would more effectively assist the youth in making better decisions. In addition, as crucial as such education is to the prevention of high-risk behavior during adolescence, equally as important is the solid backing of the lawmakers and top state administrators.
We gratefully acknowledge the CDC, Office of Healthy Schools at the Mississippi Department of Education, and Office of Health Data and Research at the Mississippi State Department of Health for collaboration on the Mississippi YRBS Project. We also appreciate students who participated in the 2009 Mississippi YRBS. Any opinions implied or expressed here are those of the authors and do not necessarily reflect those of the University of Southern Mississippi, Wayne State University, Mississippi State Department of Health, and the University of Mississippi Medical Center.
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1. National center for chronic disease prevention and health promotion, division of adolescent and school health, 2009. 2. Smith, T.M., Salle, D.N. Adolescents and the co-occurrence of the early onset of sexual intercourse and drug use risk behaviors. Am J Health Stud. 2008;23(2),81-88. 3. Bandura, A. Self-Efficacy: The Exercise of Control. New York: W.H. Freeman and Company. 1997. 4. Anspaugh and Ezell. Teaching Today’s Health, (6th ed.), Needham Heights, MA: Allyn & Bacon. 2001. 5. National Institute of Mental Health. Suicide in the U.S.: Statistics and Prevention (2010). 6. Youth Risk Behavior Surveillance – United States, 2009. MMWR 2010;59(SS-5):1-42. 7. Drug Abuse Warning Network, 2008: Selected Tables of National Estimates of Drug-Related Emergency Department Visits. Rockville, MD: Office of Applied Studies, SAMHSA, 2009. 8. U.S. Department of Health and Human Services. The Surgeon General’s Call to Action to Prevent and Reduce Underage Drinking. Rockville, MD: U.S. Department of Health and Human Services; 2007. 9. Office of Juvenile Justice and Delinquency Prevention. Drinking in America: Myths, Realities, and Prevention Policy. Washington, DC: U.S. Department of Justice, Office of Justice Programs, Office of Juvenile Justice and Delinquency Prevention, 2005. 10. Lessem,J.M., Hopfer, C.J., Haberstick, B.C., Timberlake, D. Ehringer, M.A., Smolen, A.. Relationship between adolescent marijuana use and young adult illicit drug use. Behav Genet. 2006;36(4),498-506. 11. Zweig, J., Phillips, S.D., Lindberg, L.D. Predicting adolescent profiles of risk: Looking beyond demographics. J Adolesc Health. 2002;31(4),343-353. 12. Arata, C.M., Stafford, J., Tims, M.S. High School drinking and its consequences. Adolescence. 2003;38:567-579. 13. Miller, J.W., Naimi, T.S., Brewer, R.D., Jones, S.E. Binge drinking and associated health risk behaviors among high school students. Pediatrics. 2007;119:76-85. 14. Steele, CM, Josephs, RA. Alcohol myopia: Its prized and dangerous effects. Am Psychol. 1990;45:921-933. 15. Gordon, C.M., Carey, M.P., Carey, K.B. Effects of a drinking event on behavioral skills and condom attitudes in men: Implications for HIV risk from a controlled experiment. Health Psychol. 1997;16:490-495. 16. Centers for Disease Control and Prevention, National Center for Health Statistics. 2008. 17. Galaif ER, Sussman S, Newcomb MD, Locke TF. Suicidality, depression, and alcohol use among adolescents: A review of empirical findings. Int J Adolesc Med Health. 2007; 19(1): 27-35. 18. Hagedorn, J., Omar, H. Petrospective analysis of youth evaluated for suicide attempt or suicidal ideation in an emergency room setting. Int J Adolesc Med Health. 2002;14:55-60. 19. Schilling EA, Aseltine RH, Glanovsky JL, James A, Jacobs D. Adolescent alcohol use, suicidal ideation, and suicide attempts. J Adolesc Health. 2009; 44(4): 335-341. 20. American Association of Suicidology, fact sheet. 2010. 21. Sussman MP, Jones SE, Wilson TW, et al. The youth risk behavior surveillance system: updating policy and program applications. J Sch Health. 2002;72(1):13-17. 22. Zhang L, Johnson WD. Violence-related behaviors on school property among Mississippi public high school students, 19932003. J Sch Health. 2005;75(2):67-71. 23. Brener ND, Collins JL, Kann L, et al. Reliability of the youth risk behavior survey questionnaire. Am J Epidemiol. 1995;141:575. 24. Brener ND, Kann L, McManus T, Kinchen SA, Sunberg EC,
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Ross JG. Reliability of the 1999 youth risk behavior survey questionnaire. J Adolesc Health. 2002;31(4):336-342. 25. Cassady JC. Self-reported gpa and sat: a methodological note. Pract Assess, Res & Eval. 2001;7(12). 26. Mississippi Department of Education. Office of healthy schools: 2006 Mississippi comprehensive health framework, 2006. 27. Mississippi Department of Education. Office of healthy schools: Mississippi school health policies, 2008.
en is Mighter The P Than the Sword
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oad your camera or grab your digital. Shoot landscapes, people, animals, or anything else you can capture on film. Photos of subjects indicative of Mississippi will be given the highest consideration. Photos of original artwork are also acceptable. The Committee on Publications will judge the entries on the merits of quality, composition, originality, and appropriateness to the JMSMA. Specifications: Color slides, digital files & photos. A hard copy print is required for judging.
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Deadline: November 28, 2012 Mail to P.O. Box 2548 Ridgeland, MS 39158-2548 or deliver to headquarters 408 W. Parkway Place, Ridgeland, MS 39157
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For more info contact: Karen Evers, Managing Editor 601-853-6733, ext. 323 or KEvers@MSMAonline.com
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TheMedicalParkway.com October 2012 JOURNAL MSMA 329
• Scientific •
Dietary Recommendations in Ambulatory Care: Evaluation of the Southern Remedy Healthy Eating Plate Amanda K. Smith, MD; Deborah S. Minor, PharmD; Lindsey E. Tillman, PharmD; Richard D. deShazo, MD; William H. Replogle, PhD
There are few useful tools to provide dietary health education including calorie and portion control to patients, particularly in a busy ambulatory health care setting. In this report, we provide results of the evaluation of an adaptation of the recent US Department of Agriculture dietary recommendations modified for the southern diet and individuals with limited knowledge of healthy eating. Using standardized methods, we found that the “Southern Remedy Healthy Eating Plate” was well accepted by patients and can be used quickly and effectively in the outpatient setting. Moreover, the review of this placemat with easy to understand instructions for meals and snacks was associated with acceptable levels of data retention after a single visit averaging 5 minutes. Although the need for some modification of instruction techniques was identified, the Southern Remedy Healthy Eating Plate appears to be a practical and useful format for providing structured dietary counseling and education in this setting and others.
Key Words: dietary recommendations, health literacy, patient counseling, nutrition guidelines
Introduction The leading causes of death in the United States are related to lifestyle, and the most widely accepted, well-established chronic disease practice guidelines uniformly call for lifestyle change as the first line of therapy. Abundant scientific evidence has also more recently led to authoritative dietary guidelines and recommendations for healthy eating and lifestyle behavAuthor Information: Amanda K. Smith, MD is a 3rd year Family Medicine Resident at the University of Mississippi Medical Center (UMMC) in Jackson, MS. Deborah S. Minor, PharmD is a professor and clinical pharmacist in the Department of Medicine at UMMC in Jackson, MS. Lindsey E. Tillman, PharmD is a doctor of pharmacy resident at the UMMC in Jackson, MS. Richard D. deShazo is Billy S. Guyton Distinguished Professor of Medicine and Pediatrics at UMMC. William H. Replogle, PhD is a Family Medicine Research Professor and Clinical Statician at the UMMC in Jackson, MS.
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iors.1-3 Most physicians and patients do not follow these recommendations, and obesity rates continue to increase despite these guidelines and evidence.1-4 Recent national data show that almost 70% of American adults are either overweight or obese, and 35.7% are obese. Mississippi consistently leads the nation in the prevalence of obesity as well as associated unhealthy behaviors and co-morbid diseases.1,5-6 Though many factors contribute to and sustain unhealthy behaviors, this does not eliminate the duty of physicians and other providers to assist patients in making appropriate changes.2 Most patients need nutritional guidance, and recommendations suggest that providers offer counseling. However, many barriers exist to counseling patients about nutrition and other lifestyle interventions.4 Physicians cite inadequate confidence, lack of knowledge and skill, and time constraints as major barriers to providing adequate education. Providers often lack the training or effective models to guide their efforts.4,7 In one survey, only 49% of family physicians felt competent in prescribing weight loss programs for obese patients.2 Lack of patient readiness for change and poor health literacy are also barriers to addressing diet in provider-patient encounters.4 Effective initiatives to promote healthy behaviors and address the epidemic of obesity require the involvement of many public and private groups working together. Mississippi Public Broadcasting (MPB) and the University of Mississippi Medical Center (UMMC), under the Southern Remedy branding, have recently developed a series of health promotion programs addressing health literacy and lifestyles. One of these programs, Southern Remedy Healthy Living, includes a 7-inch Healthy Eating Plate (HEP) reproduced on a laminated placemat. The placemat serves as a guide for patient teaching and review of the new United States Department of Agriculture (USDA) dietary guidelines and recommendations.3,8 It attempts to address barriers to dietary counseling by facilitating provider-patient communications using a format that can be effective to quickly teach patients with a low level of health literacy. The HEP is designed to be used by health professionals in their practices, community health advocates in their churches, civic and other
of the Healthy Eating Plate” was used by the clinician investigators to review the HEP with participants and guide the discussion.8
Fruit 17 grapes 1/2 banana
Whole Grain/ Starchy Vegetables
1 1/4 cup whole strawberries
1/3 cup cooked rice
3/4 cup pineapple
1/3 cup cooked pasta
1 1/4 cup watermelon
1 slice of bread
3/4 cup blueberries
1/2 cup sweet potatoes
1 small baked potato
1/2 cup corn
4 oz fruit juice
1/2 cup English peas
~60 calories per serving
1/2 cup beans (pinto or kidney)
1/4 cup dried fruit
1 low carb tortilla
1/2 cup servings green beans broccoli asparagus tomato okra squash zucchini carrots lettuce turnip greens
Development of Materials The initial survey consisted of the patient’s self-reported educational level and an assessment of health literacy, using the validated Newest Vital Sign (NVS) instrument.9 The HEP placemat, instructions for use, and other dietary guides in the Southern Remedy Healthy Living program were developed by clinicians (physicians, pharmacists, dieticians, nurses) using the USDA guidelines and ChooseMyPlate.gov “food plate” initiative.3,10 Modifications and adaptations to the USDA “food plate” included simplification of the caloric recommendations and increasing the “preferred language and pictorial depiction for communicating” the dietary guidelines.11 The HEP placemat pictures a 7-inch salad plate and healthy food choices, along with approximate serving sizes and calorie content (Figure). If the HEP instructions are followed, three meals and two snacks provide between 1400-1600 calories per day. A standardized approach adapted from the Southern Remedy “Guides for Use
~80 Calories per serving, low fat or fat free 1 oz cheese (size of 2 dominoes) 1/4 cup cottage cheese 1 cup milk 4 - 6 oz yogurt
2 oz= 1/4 cup 3 oz= 1/3 cup 4 oz= 1/2 cup 5 oz= 2/3 cup 6 oz= 3/4 cup 8 oz= 1 cup
Snacks ~120 calories
A combo of a carb and protein is a good choice.
~25 calories per serving
pork tenderloin - 40 calories/oz boneless, skinless chicken breast - 30 calories/oz sirloin - 50 calories/oz flank steak - 40 calories/oz grilled fish - 40 calories/oz shrimp - 25 calories/oz 1/4 cup mixed nuts - 160 calories 1 tbsp peanut butter - 80 calories
~90 to ~160 calories per serving
• 1/2 cup carrots & 1/4 cup hummus • 6 crackers & 1 oz low fat cheese • apple & 1 tbsp peanut butter • 17 grapes & 1 oz low fat cheese • small serving of cereal and milk • 2 tbsp raisins & 1 oz almonds • 4 - 6 oz Greek yogurt (0% fat) & 1/2 cup fruit • 1/2 cup light ice cream
1 cup edamame (soy) beans - 115 calories
Study Design This study was submitted and approved by the UMMC Institutional Review Board prior to initiation. Over approximately 6 weeks, adult patients aged 18 years and older in a family medicine ambulatory care clinic were invited to participate during their normal clinic visit. Patients were asked if they would like to complete two surveys and review new dietary guidelines with a health care provider. Individuals unable to read or speak the English language or unwilling to answer survey questions were excluded. Those patients who agreed to participate were first given a survey to complete. After survey completion, a health care provider (AS or LT) gave the participant a HEP placemat and used this as a guide to review dietary recommendations. Following the review, participants were asked to complete a second survey. A health care provider documented the total time spent discussing the HEP, patient demographics, and any participant comments or questions. Participants were allowed to keep the HEP placemat and were provided with copies of other Southern Remedy dietary guides.
Whole Grain/ Starchy Vegetables ~80 calories per serving
3 oz serving of meat size of a deck of cards
An Original Production of
Your Logo here
Lunch & Dinne r Fruit
2 tbsp raisins
Healthy Eating Plate
lose weight with the
One selection from each of the sections of the plate for breakfast, lunch and dinner plus 2 snacks provides about 1,400 calories per day. Adjust calories up as needed to lose only the recommended 1-2 pounds per week.
• 1/2 oz almonds
groups, and individuals who wish to use it on their own.8 The Southern Remedy Healthy Living program is distributed at no cost to health providers and the general public for use in professional offices, churches and other community settings, including training of community health advocates (http://www. southernremedy.org).8 Although the HEP is being used in the training of community health advocates with apparent success, it has not been evaluated in a health care setting. The purpose of this initial study was to review the usefulness of the HEP in providing dietary health education in an ambulatory health care environment, to identify modifications needed to make the HEP more effective, and to determine whether health literacy influences the time required for review or responses to the information provided.
~ approximately equal to Copyright ©2011 Mississippi Public Broadcasting®. All rights reserved. To order copies of this placemat, contact MPB
0 calories - unsweetened • tea
• diet soda
The second survey (post-survey) consisted of 11 questions including those testing recall of objective information and subjective assessments of the review. Seven multiple-choice questions assessed recall. Questions included the daily recommended number of servings of protein, fruits and vegetables; recommended portion sizes of protein (meat) and a starchy vegetable; number and variety of meals and snacks for a balanced, healthy diet; and the recommended plate size for portion control. Patients were neither encouraged nor discouraged from using the placemat as a reference. One question assessed the subjective usefulness of the HEP placemat as a guide for healthy eating using a 1–10 point scale. Two open-ended questions allowed the patient to indicate what they thought were the most helpful and most confusing about the placemat and the review. A final question asked the patient if they felt that they needed to change their diet or eating habits and if so, their readiness for initiating changes: ready to start today, may be ready but still thinking about it, or not ready.4 Data Analysis The NVS assessed baseline levels of health literacy. A score of 0-1 suggests high likelihood (50% or more) of limited health literacy, a score of 2-3 indicates the possibility of limited health literacy, and a score of 4-6 almost always indicates adequate health literacy.9 Objective and subjective post-survey responses were analyzed to determine the usefulness of the HEP in providing dietary health education and modifications that might be needed to the placemat or the review. NVS scores of health literacy were correlated with the number of correct postsurvey responses, time spent on the HEP review, the usefulness of HEP placemat rating, and readiness to change response.
Results The 51 participants were 76% female and 63% black, with a mean age of 52 years and body mass index (BMI) of 33.5 (Table 1). The majority (74%) of participants were obese (BMI > 30 kg/m2). Most participants had a high school edu-
October 2012 JOURNAL MSMA 331
12. U.S. Department of Health and Human Services. Decision Memo for Intensive Behavioral Therapy for Obesity (CAG-00423N). Centers for Medicare and Medicaid. http://www.cms.gov/medicare-coverage-database/details/nca-decisiondiet, 71% chose the USDA recommendation of 3 meals with 2 cation or less (68%) and a high probability of limited health optional snacks. An appropriate portion size for a starchy vegliteracy (55%) based on NVS scores. The average review time memo.aspx?&NcaName=Intensive%20Behavioral%20Therapy%20for%20Obesity&bc=ACAA was identified by 57% of participants. was 5AAAAIAAA&NCAId=253& minutes (reported in 0.5 minute increments, range 3.5-10 . Published Novemberetable 29, 2011. Assessed February 1. 2012.On the contrary, minutes). Only 6 reviews were over 6 minutes in length, with most of these in the first 10 reviews, indicating clinician familiarity with the process. Very few participants asked questions Figure: Healthy Eating Plate (attached) at the end of the HEP review. The questions asked concerned exercise, specific foods, and dietary changes needed for diabetes and hypertension.
Participant Characteristics Gender Female Male Race African American Caucasian Hispanic Education High school or less Any college Omitted response Health Literacy Poor (score 0-1) Limited (2-3) Adequate (4-6) BMI (kg/m2) Age, years
Number (%) 39 (76%) 12 (24%) 32 (63%) 18 (35%) 1 (2%) 35 (68%) 15 (30%) 1 (2%) 9 (18%) 19 (37%) 23 (45%) 33.5 (range 17-76) 52 (range 21-72)
Table Table22. Objective Post-Survey Responses Participants - % Correct Balanced meal selection 94 Protein (meat) serving size 92 Plate size for portion control 88 Servings of lean protein/day 78 Number of meals/optional 71 snacks/day Starchy vegetable serving size 57 Servings of fruits/vegetables/day 20 The majority of participants (57%-94%) answered 6 of the 7 post-survey objective questions correctly, with a positive correlation based on NVS scores (Table 2). Out of the 4 sample meals listed, 94% were able to identify a healthy balanced meal. The correct serving size of protein (meat) for a balanced meal was answered correctly by 92% of participants. Most participants (88%) identified a salad plate as the best size to use for help with portion control, and 78% correctly identified the recommended number of protein servings per day. When asked how many meals should be eaten in a day for a healthy
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80% of participants failed to recall the minimum recommended number of fruit and vegetable servings per day. Rather than the correct number of 5 servings a day, most participants (71%) answered 3 servings with the remaining (9.8%) answering 7.3 Subjective post-survey questions included a rating of the HEP, comments concerning the HEP placemat and review, and an assessment of the participant’s personal readiness for changing their diet or eating habits. The HEP review was rated as very helpful by 82% of participants and helpful by 14%, with only 4% reporting it as not helpful. Participants identified that they most liked the emphasis on portion sizes, the colorful display, and the placemat layout. They also liked the variety of examples and felt that the HEP was easy to understand and follow. Few participants responded to the question asking what was “the part that is most confusing” about the HEP. Two participants commented that the HEP placemat and review did not directly address the number of fruit and vegetable servings needed each day (corresponding with the incorrect answers on the post-survey). Three participants stated they were confused about adequate portion and/or serving sizes and 2 were confused about calorie intake. The majority (66%) of participants indicated a readiness to change their diet or eating habits (starting today), with another 20% stating they may be ready but were still thinking about it. One participant answering that they were not ready to make changes added a comment that the HEP “makes you think.” There was a significant Pearson correlation between NVS scores and the number of correct post-survey responses (r=0.43, p=0.002). As NVS scores increased, the number of correct post-survey responses tended to increase. We failed to find significant correlations between NVS scores and time spent on the HEP review (r=-0.19, p=0.16), the usefulness of HEP placemat rating (r=0.004, p=0.98) and readiness to change response (r=0.25, p=0.07).
Discussion The principal finding of this pilot project was that the Southern Remedy HEP appears to be a useful format for providing dietary education in a timely manner in a busy ambulatory health care environment. Most participants found the HEP placemat and review to be very helpful. We were also able to identify changes needed both in the placemat and the manner of presenting. The positive subjective feedback and high objective recall scores confirmed that most participants found the HEP easy to understand. While a patient’s level of health literacy did affect overall recall of the information presented, it did not appear to influence time spent on the HEP review or subjective responses regarding the usefulness of the review or participant reported readiness to change. Through participant comments and responses, we identi-
fied that the HEP placemat and review needed clarification in the areas of daily protein intake and recommended number of servings of fruits and vegetables. The USDA recommends approximately 6 ounces protein daily.3 If taken literally, the HEP suggests at least 9 ounces of protein daily: 3 ounces with each meal and additional protein with the optional snacks. Since most of our patients likely take in well over that amount daily, the plate would still guide them toward a reduction; however, this should be presented more clearly. There was also some confusion regarding the serving size of protein on the breakfast plate depiction. Based on the picture, some patients interpreted that approximately half of the plate should be meat, too large of a portion size. Instead of the leaner meats suggested, many patients may choose more fatty options typical of the Southern diet. The recommended daily number of fruit and vegetable servings was confusing to many participants. As with the protein, this issue needs to be addressed in future reviews and HEP revisions. The HEP program does not address dietary recommendations for patients with special needs. If these needs are identified, they can be addressed by the provider in the discussion of the HEP and with follow-up visits after the initial instruction. The average time spent per discussion was approximately 5 minutes. Because even this minimal amount of time can be considerable in a hectic and time-conscious clinical environment, a shortened presentation of the HEP may be beneficial for some. Pairing the HEP with an assessment of current diet and eating behaviors using practical tools such as the Rapid Eating Assessment for Participants (REAP-S) may be a useful approach and allow for more personalized and specific discussions.4 Use of an interdisciplinary team and clinic support staff to help with dietary education can also have a positive effect of patient health behaviors. Although initial assessment of the patient’s readiness to change is an extra step, it may provide clues as to the effort that should be invested at any given time.4 For obese patients needing intensive behavioral and dietary counseling for weight loss, Medicare will now cover physician face to face visits in a primary care setting under certain conditions.12 Limitations of this study include the small sample size and the limited time for enrollment. We also had no assessment of the baseline knowledge or awareness of dietary guidelines and recommendations or eating behaviors. Our post-survey assessment recorded immediate recall only. Participant follow-up was not a part of this study but is highly recommended.
mat for providing structured dietary counseling and education in a busy ambulatory care clinic. We also identified changes needed for the placemat and areas for increased focus during the HEP review. Future assessments will help define the role of the HEP and other programs in effecting and sustaining behavioral changes and beneficial health outcomes.
1. Roger VL, Go AS, Lloyd-Jones, et al. Heart Disease and Stroke Statistics-2012 Update: A report from the American Heart Association. Circulation 2012;125:e2-e220. 2. Lianov L, Johnson M. Physician competencies for prescribing lifestyle medicine. JAMA 2010; 304(2):202-203. 3. U.S. Department of Agriculture and U.S. Department of Health and Human Services. Dietary guidelines for Americans, 2010. 7th Edition, Washington, DC: U.S. Government Printing Office, December 2010. 4. Rao F, Burke LE, Spring BJ, et al. New and emerging weight management strategies for busy ambulatory settings: A scientific statement from American Heart Association. 2011; 124(10):11821203. 5. Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of obesity in the United States, 2009–2010. NCHS data brief, no 82. Hyattsville, MD: National Center for Health Statistics 2012. http://www.cdc.gov/nchs/data/databriefs/db82.pdf. Accessed March 1, 2012. 6. U.S. Obesity Trends. Centers for Disease Control and Prevention. http://www.cdc.gov/obesity/data/trends.html Accessed March 1, 2012. 7. U.S. Preventive Services Task Force. Screening for obesity in adults: recommendations and rationale. Ann Intern Med. 2003:139:930-932. 8. deShazo R, Minor D. Southern Remedy’s Healthy Living: A Portion and Calorie Control Program for Mississippi. J Miss Med Assoc. 2011;52(12):390-393,395-402. 9. Weiss BD, Mays MZ, Martz W, et al. Quick assessment of literacy in primary care: the newest vital sign. Ann Fam Med. 2005;3(6):514–22. 10. United States Department of Agriculture. ChooseMyPlate Initiative. http://www.choosemyplate.gov. Accessed March 1, 2012. 11. U.S. Department of Agriculture. Development of 2010 dietary guidelines for Americans: consumer messages and new food icon. Center for Nutrition Policy and Promotion. Washington, DC: U.S. Government Printing Office, June 2011. 12. U.S. Department of Health and Human Services. Decision Memo for Intensive Behavioral Therapy for Obesity (CAG00423N). Centers for Medicare and Medicaid. http://www.cms. gov/medicare-coverage-database/details/nca-decision-memo. aspx?&NcaName=Intensive%20Behavioral%20Therapy%20 for%20Obesity&bc=ACAAAAAAIAAA&NCAId=253&. Published November 29, 2011. Accessed February 1, 2012.
Summary Poor diet and other unhealthy behaviors are the leading cause of disease and death in adults. Though there are many factors and barriers, the potential benefits of improving the diet and other lifestyle changes necessitate that clinicians take leadership in promoting healthy behaviors as a foundation for medical care, disease prevention, and health promotion. This pilot project helped establish the HEP as a practical and useful for-
October 2012 JOURNAL MSMA 333
• President’s Page •
his month I would like to talk about one of my agenda items for the upcoming year and that is for our state to be smoke-free in public spaces. According to the Center for Mississippi Health Policy, Mississippi is one of only seven states without any kind of statewide law restricting smoking in private indoor workplaces, restaurants or bars. Mississippi ranks number four in the nation in smoking with 23% smokers in 2010. The health links to secondhand smoke are very strong and have been reported in the literature. There is a strong linkage between secondhand smoke and increased asthma episodes. The link to cardiovascular disease is very Steven L. Demetropoulos, MD strong as well. There is about a 25 to 30% increase in cardiovascular disease associated with exposure to secondhand smoke. We have 2012-13 MSMA President a good example of this with the implementation of smoke-free ordinances in Hattiesburg and Starkville. In Starkville there was a 22% reduction in the rate of heart attack admissions after the implementation of the smoke-free ordinance. The cost of those admissions was estimated at $288,000 over the 5-year study period. In Hattiesburg over a two and a half year period, the reduction was 13% in heart attack admissions after their smoke-free ordinance was implemented. In Hattiesburg the estimated cost savings was $2,367,909 over the 4 year study period. This information is from the Mississippi State University Social Science Research Center. Other complications from secondhand smoke include otitis media, increased respiratory infections, decreased lung function, increased injury secondary to household fires, increased numbers of SIDS deaths, and premature and low birth weight deliveries just to name a few. The good news is that we have made some headway in the state. We enacted a cigarette tax. We enacted laws to prohibit tobacco use on school property and school sanctioned events. We enacted laws to prohibit smoking at any youth related events. The social climate seems to be changing as well. More than three-fourths of Mississippi adults favor a state law prohibiting smoking in most indoor places including workplaces, public buildings, offices, restaurants, and bars, and fewer than one in six adults oppose the state law. There are 62 communities in the state of Mississippi that are already smoke-free and these include almost every major metropolitan area in the state–Jackson, Tupelo, Hattiesburg, Laurel, Meridian, and Oxford, to name a few. There are 13 communities that are partially smoke-free. The people that live in these cities actually represent about 23% of our state population that is already smoke-free. So what are the barriers to the whole state becoming smoke-free? One is the potential economic impact to restaurants, bars, and hotels. However we have good data that show that as a whole, inflation adjusted tax revenues for communities with smoke-free ordinances were 10% greater in the 12 months following the enactment of a smoke-free ordinance. Even casinos have seen a similar experience. In 2011 the Palace Casino in Biloxi underwent a $50 million dollar renovation and reopened as a smoke-free facility. Because there is not yet a year-to-date data to compare, it is too early to assess the full impact of the policy on the casino; however, the third quarter data from 2011 immediately following implementation, showed no change in the casino’s market share or number of employees when compared to the end of the third quarter of the past year. With that economic data looking positive instead of negative, I think we could reassure businesses that they would not be hurt by going smoke-free especially looking at the experiences in cities that are already smoke-free like Jackson, Hattiesburg, Meridian, and Laurel. 334 JOURNAL MSMA
I want our organization to be firmly committed to enacting a secondhand smoke law in which smoking is prohibited in indoor places including workplaces, public buildings, offices, restaurants, and bars. This would be the biggest impact that we could have on both our patients and our state from the cost of the illnesses that we treat, the negative impact on our patientsâ€™ health, and the negative impact on all employees that have to work in a smoking environment. Our state ranks number one in heart disease death rate and number three in cancer death rate in the United States. This law would have a tremendous impact on those statistics. Now is the time for every physician in the state to talk to their state representatives both in the Senate and the House of Representatives and encourage them to move forward with supporting this law. Fully 24% of the state is already covered with the smoke-free communities, and so the next step is covering the other small towns and rural areas throughout the state. If we were to do one big thing that would have long-lasting effect for all our patients in this next year, this is it. We as doctors all know the consequences of smoking, and now we have the opportunity to actually do something about it by encouraging our legislators to pass this law allowing for smoke-free indoor places.
Steven L. Demetropoulos, MD MSMA President 2012-13
Just What the Doctor Ordered EGGPLANT TOMATO TOWER
ere is my take on a caprese salad. I call it the Eggplant Tomato Tower. I like to take an eggplant, peel it, and cut it in slices that would hold up nicely on the grill. Do the same thing to green tomatoes and to a purple onion. Then lightly coat the vegetables with olive oil and salt and pepper. Place them on the grill. When you have good grill marks on both sides, they are done. Then remove them and build the tower. I start first with mozzarella cheese on the bottom and top with onion and the green tomato. Add another slice of eggplant and another slice of mozzarella cheese and the same combination again. I top the salad with fresh basil and olive oil and drizzle with balsamic vinegar. The warm vegetables seem to melt the cheese some, and you can serve this as a slightly warm salad or you can serve it cool. It is a delicious heavier salad that is a nice accompaniment with a grilled steak or grilled pork loin or lamb chops. Bon appetit!
October 2012 JOURNAL MSMA 335
A HIGHER LEVEL OF SUCCESS
MILLSAPS COLLEGE EXECUTIVE MBA:
336 JOURNAL MSMA
• Earn a Millsaps MBA degree in 16 months • Attend class every other weekend • Keep your career on track while you study • Learn from nationally ranked faculty Top accreditation
601-974-1253 • emba.millsaps.edu
• MSDH • Mississippi Reportable Disease Statistics
August 2012 Figures for the current month are provisional
*Totals include reports from Department of Corrections and those not reported from a speciﬁc district. For the most current MMR ﬁgures, visit the Mississippi State Department of Health web site: www.HealthyMS.com.
October 2012 JOURNAL MSMA 337
Your MSMA is listening.
MSMA members said:
we need to reach out and make it easy for more physicians to be involved. Our strength is in the unity of physicians, medical students, residents, retirees and spouses.
Starting next year, Annual Session will be in August in Jackson.
A central in-state location will shorten the drive for most delegates and high-tech capabilities will make it easy for those who can’t attend to monitor the House of Delegates proceedings online.
A fresh 2-day format will streamline the business meeting.
Start at 1:30 on Friday afternoon with the House of Delegates and Reference Committee hearings. Suit up for the official inaugural of MSMA’s 2013-2014 President Dr. James A Rish of Tupelo. Have lunch Saturday with the MSMA candidates for 2013-2014 vacancies. Then, vote for candidates before opening the House of Delegates to vote on resolutions. That’s right. Get in and get it done. A streamlined two-day agenda will get business done and still include popular social events like the President’s Inaugural Gala and Alliance activities. Plus, connect with fellow physicians and spouses at a Reunion Reception.
What about CME?
MSMA’s family-friendly CME-IN-THE-SAND will be expanded to five days at the Sandestin Golf and Beach Resort. Earn 15 hours CME over the Memorial Day weekend and only miss two days of clinic. Oh, and we’ll throw in a Free CME Saturday in February for another 6 hours. Watch for dates and details.
The new format is member-friendly and fiscally responsible.
Keeping the business meeting of the House of Delegates in Jackson will save thousands of dues dollars each year. It’s closer, shorter and easier to get to. And, there’s still time to visit with classmates and colleagues at the Inaugural Gala, the Alliance fundraiser and the Reunion Reception.
Your practice. Your voice. Your MSMA.
Let us hear from you! Visit MSMAonline.com to join the online discussion. And, be on the lookout for more details in coming weeks! 338 JOURNAL MSMA
Internists, Cardiologists, Ophthalmologists, Pediatricians, Orthopedists, Neurologists, Psychiatrists, etc. interested in performing consultative evaluations according to Social Security guidelines.
OR Physicians to review Social Security disability claims at the
Mississippi Department of Rehabilitation Services (MDRS) in Madison MS.
Contact us at: Leola Meyer 601-853-5487 Toll Free 1-800-962-2230 (Ext. 5487) or Jo Ann Summers 601- 853-5599
DISABILITY DETERMINATION SERVICES 1-800-962-2230 www.bcbsms.com
Blue Cross & Blue Shield of Mississippi, A Mutual Insurance Company, is an independent licensee of the Blue Cross and Blue Shield Association. 速 Registered Marks of the Blue Cross and Blue Shield Association, an Association of Independent Blue Cross and Blue Shield Plans.
October 2012 JOURNAL MSMA 339
• Special Article •
They Come Alone or in Pairs: Ta-Tas to Go Breast Cancer Survivor Creates Custom-Fit Prosthesis Karen A. Evers, Managing Editor
or a breast cancer survivor, waiting for a custom prosthesis is more than an inconvenience. MSMA Alliance member Christina Riad faced countless challenges through the course of treatment for her disease. One of those, with consequences that are more emotional than physical, was the selection of a breast prosthesis following a mastectomy. Post-mastectomy patients want a breast form with the look, fit, and comfort of a natural breast, and Mrs. Riad has created a convenient, affordable solution with her newly patented “Ta-Ta’s to Go.” Ta-Ta’s to Go, LLC is a breast prosthesis company geared mostly towards breast cancer mastectomy patients/survivors. The enterprise makes easy slip-in prosthesis bra forms to fit all bra types. Sizes range A, B, C, and D. “Our prosthesis is not pre-formed. It is more of a bra-filler and might be described as beanbag-like.” It simply fills and takes the shape of any bra you choose to wear,” Mrs. Riad says. “For special sizes, we customize prostheses, and we are more than happy to assist.” “I came up with the idea after trying many different items, basically anything I could stuff in my bra to make them equal. Being a surgical nurse I used many surgical type dressings; however none had the correct weight of breast tissue. In that case, the elastic Ta-Ta’s to Go logo - October is of the bra does not stay National Breast Cancer Awareness around the ribs and Month, and the pink ribbon is an tends to ride up under international symbol of awareness for the disease. the arm. My sister, who is a nurse also, and I were brainstorming in my bathroom, and came up with using pantyhose and white rice,” Mrs. Riad explains. “It was the perfect weight and moved similarly to my other breast. The problem was water, no swimming, or washing! I would have to change the rice frequently. I used glass beads to swim however; this is both very heavy and very expensive. I then decided to do research to find a material that was shaped like rice and weighed the same as rice,” she said. Mrs. Riad found a company in Houston that works with plastics and is a strong supporter of women starting their own businesses. “I happened to be in Houston at an appointment in the radiology department, and the radiologist happened to see my ‘rice bag boob.’ She said that if she were me, she would run not walk to a patent office, which I did the following week!” With that, “Ta-Ta’s to Go” was born in New Orleans, Louisiana, in November 2011. “I was originally diagnosed in March of 2010 with a lump under my arm. It was read as normal but it was decided to send it to Vanderbilt University where it was read as malignant. I am from Houston, Texas, and received my nursing degree from there. My mother and sister still live there so I decided to go to MD Anderson for care. I was already stage III when Breast cancer survivor and former surgical nurse Christina diagnosed. I was extremely scared and cried often. I have three (Tina) Riad shows her breast prosthesis, Ta- Ta’s to Go, on a dress form. young children, ages 14, 12, and 7 at the time of diagnosis and
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A close-up shot of the product
After experimenting and researching, Christina Riad has produced a custom-made prosthesis that is more lifelike and lighter weight than other breast forms available.
was mostly scared for them,” she reflects. Married to anesthesiologist Ashraf E. Riad, MD, Mrs. Riad was a traveling surgical nurse when she met him in New Orleans where he was doing his residency at Tulane University Hospital. Dr. Riad received his M.D. from Thomas Jefferson Medical College in Philadelphia, Pennsylvania. He is the director of anesthesia at Southwest Mississippi Medical Center in McComb, where they have lived the last 16 years. “What we learned from all this is that breast prostheses are not easily obtained and available without invasive and embarrassing interventions,” said Mrs. Riad. “What is offered to us is the silicone prosthesis which can only be obtained with a prescription and an appointment to be measured. You can go to some drug stores or other mastectomy stores to be measured. This is six months after surgery. Quite honestly, I was not ready to peel my bra off and show a stranger my horrible looking scar! It is humiliating and tears start rolling down your face at the devastation of it all– not to mention the cost of the prosthesis and bra, which runs from $400 to $500. I started thinking of all the people I see who don’t put anything in their bra following a mastectomy, and I’m sure it has to do with the high cost and the unavailability of the prosthesis.” Mrs. Riad’s mission is to make the bra filler/breast prosthesis affordable and available. Ta-Ta’s to Go are priced $40-$50. “My company is in the beginning stages but hopefully will be able to help thousands of ladies like myself that just needed something simple to make me feel confident again,” she said. “Plus, growing hair back helped,” she adds. For more information on Ta-Ta’s to Go, LLC contact Christina Riad, PO Box 727, McComb, MS 39649 or email: tatastogo@ For packaging, customers are sent gmail.com. You may also check them out on Facebook and Twitter or visit Tatastogo. boxes with the Ta-Ta’s to Go logo via U.S. Mail, including instructions on Christina Riad and her daughter, Victoria com. washing and care.
October 2012 JOURNAL MSMA 341
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342 JOURNAL MSMA
• Editorial •
And a Good Time Was Had by All Stanley Hartness, MD
’ve never been one to buck a current trend.
Since my associate editor buddy, Dr. deShazo, has the journal in a “Top Ten This” and “Top Ten That” mindset, it was only a matter of time before I followed suit. Following are my “Top Ten” observations from this past summer’s MS Academy of Family Physicians Scientific Assembly in Sandestin: 1. Beth Embry, our crackerjack MAFP chapter exec, and her capable staff (which included a cadre of enthusiastic medical student volunteers) staged yet another outstanding meeting from the timely scientific program to the energized exhibit hall to the fun-filled, family-oriented social functions. 2. I was surprised to learn in a dermatology lecture that studies have shown a relationship between pityriasis rosea and HSV and that its course can be significantly ameliorated by prescribing Valtrex. 3. It was stressed that the importance of the November Supreme Court elections cannot be over-emphasized. The stability of Mississippi’s civil justice system is at risk: two of our balanced justices are opposed by candidates backed by trial lawyers, and a court vacancy opens the door for a new member on the Court. Not only must WE support qualified candidates, we must educate our patients about the best persons for the job so that the significant tort reforms enacted some 10 years ago will remain in force. 4. For a worthy cause, family physicians (and coerced family members) are willing to make absolute fools of themselves. Case in point: an outrageous lip sync contest to raise funds for the Jackson Free Clinic. In case you’re interested, I’m sure the performances can no doubt be found on You Tube. 5. Surprise! Hydrocodone is the #1 dispensed prescription in the United States…enough for every man, woman, and child to take 4 a day! 6. Dr. David Dzielak, personable executive director Division of Medicaid, was impressive with his insightful and plausible “Medicaid Update” which even he admitted ultimately raised more questions than it answered. 7. An innovative recommendation, at least to me, is the use of periodic urine drug screens to determine whether a patient has been taking a prescribed narcotic rather than engaging in drug trafficking. In other words, in this instance a negative drug screen is a bad thing! 8. It was reported that cases of hidradenitis suppurativa (bane of patients and physicians alike) previously recalcitrant to antibiotics responded favorably to a course of finasteride (Proscar); this treatment is contraindicated in pregnancy. Also mentioned was the use of zinc gluconate as well as a decreased intake of dairy products. 9. The “New Drug Update 2011-2012: Parts I and II” occupied a whopping 39 pages of the syllabus. C. Wayne Weart, PharmD of the Medical University of South Carolina, led us masterfully through an exhaustive review of newly FDA approved medications, warnings, and label changes along with comparisons and contrasts of these newer agents to existing therapies. Whew…almost too much of a good thing! 10. In a moving presentation with family, friends, and partners in attendance, Dr. Gary Holdiness of Kosciusko was named posthumously “MAFP Family Physician of the Year.” This meeting brought to mind the familiar round, “Make new friends but keep the old…one is silver and the other gold.” While renewing acquaintances with valued colleagues and their families was certainly a highlight, meeting bright young faces enthusiastic about the practice of medicine left me feeling reassured about our profession. r October 2012 JOURNAL MSMA 343
• Just off the Press - Info You Want to Know • Prophylaxis Against Post-Stroke Depression Eugene Lukienko, PharmD Candidate; Richard L. Ogletree, Jr., PharmD
The risk of developing depression is six times higher in patients after a stroke compared to patients with no prior history of cerebrovascular accident (CVA). Development of depression may serve as an impediment to recovery of functional and cognitive status. It may also increase mortality risk and reduce patients’ quality of life. Because of the impact of depression on patients, caregivers, and society, the possibility of prevention of depression after CVA has received much recent attention.
Article Salter KL, Foley NC, Zhu L, Jutai JW, Teasell RW. Prevention of Poststroke Depression: Does Prophylactic Pharmacotherapy Work? J Stroke Cerebrovasc Dis. epub May 2012; Available from: http://www.sciencedirect.com/science/article/ pii/S1052305712000894
Objective There are a number of studies with conflicting evidence regarding early initiation of antidepressant therapy for prevention of post-stroke depression (PSD). The purpose of this study was to examine the evidence from published randomized controlled trials (RCTs) and to provide pooled analysis of data to determine usefulness of early pharmacotherapeutic interventions in post-stroke prevention of depression.
Design Meta-analysis of randomized controlled trials.
Methods Databases such as PubMed, CINAHL, EMBASE, PsychINFO, Cochrane, and Web of Science were included in search for RCTs with adult human participants. Inclusion criteria included RCTs utilizing pharmacotherapy for prevention and control of depression in post-stroke patients, utilization of valid rating scales to determine presence or absence of depression, and lack of clinically identifiable PSD at baseline. Pooled analyses were conducted and odds ratios were reported. Fixed effects models were utilized in this analysis.
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Results The search resulted in 377 citations. Fifteen articles were reviewed. After discarding seven of them because they did not meet pre-determined criteria, eight studies, which included 776 participants, were included in the meta-analysis. Treatment duration ranged from 3 months to 1 year in most studies. Of the eight studies, five examined the use of SSRIs (fluoxetine, sertraline, and escitalopram); with additional studies examining tricyclic (nortriptyline) and tetracyclic (mianserin, mirtazapine) antidepressants, as well as an SNRI (milnacipran). One study utilized two different classes of antidepressants. Although statistical significance was not demonstrated in each of the individual studies, pooled analysis of data showed an inaggregate statistically significant reduction in risk for depression associated with pharmacotherapeutic intervention (OR 0.34, 95% CI 0.22-0.53, p<0.001). Statistical significance was also achieved when looking at studies involving SSRI antidepressants only (OR 0.37, 95% CI 0.22-0.60, p<0.001). This analysis was not intended to determine the most appropriate recipients and timing of pharmacotherapeutic intervention for prevention of PSD. Examination of relative risks of adverse events was not included in this meta-analysis due to lack of consistent reporting in the included RCTs.
Conclusion There appears to be sufficient evidence, based on pooled analysis, that early initiation of antidepressant therapy in poststroke patients may reduce the odds of developing depression.
Reviewer’s Comment This pooled analysis of RCT’s seems to indicate that early initiation of antidepressant therapy after a stroke could prevent post stroke depression. The analysis did not look at adverse effects of the antidepressants in these patients.
Supplemental information This analysis reported its findings as Odds Ratio information. However, since each of the trials was prospective in nature, Relative Risk could be utilized, as well. r
Supplemental information: This analysis as Odds Ratio However, information. Howeve Supplemental information: This analysis reportedreported its findingsitsasfindings Odds Ratio information. since each of the was prospective in nature, could Risk be utilized, since each of trials the trials was prospective in Relative nature, Risk Relative could as bewell. utilized, as well.
Table 1:Results Results ofof SSRI studies Table 1: of SSRI studies Table 1: Results SSRI studies
Patients Taking SSRI Patients Taking Placebo Patients Taking SSRI Patients Taking Placebo Developed Total Developed Total Developed Total PSD Developed Total PSD
Narushima et al. (2002) Narushima et (2003) al. (2002) Rasmussen et al. Almeida et al. (2006) Rasmussen et al. (2003) Robinson et al. (2008) Almeida et al. (2006) Chollet et al. (2011) Robinson et al. (2008) Pooled Results
3 6 8 5 4 26
17 70 48 59 57 251
5 15 11 13 17 61
3 17 5 67 16 6 70 15 51 67 8 48 11 58 51 56 5 59 13 58 248 Relative Risk, Chollet et al. (2011) 4 57 17 Risk, Relative Risk, Absolute Absolute Risk, Number Number56Needed Needed to to Treat Treat Pooled Results 26 251 61 248 Relative risk Relative risk is is the the probability probability of of an an event event occurring occurring with with an an exposure exposure to to a a factor factor when when com com Figure 1: Pooled analysis of SSRI studies lack of exposure. lack of exposure. Figure 1: Pooled analysis of SSRI studies
Figure 1: Pooled analysisIt of SSRI studies It is is usually usually used used for for prospective prospective studies studies or or cohort cohort studies. studies. It It is is calculated calculated by by dividing: dividing:
Probability Probability of of PSD PSD when when taking taking an an SSRI SSRI đ?‘…đ?‘…đ?‘…đ?‘… đ?‘…đ?‘…đ?‘…đ?‘… = = Probability of PSD when taking placebo Probability of PSD when taking placebo 26/251 26/251 10.4% 10.4% = 0.42 đ?‘…đ?‘…đ?‘…đ?‘… = 0.42 đ?‘…đ?‘…đ?‘…đ?‘… = = 61/248 = = 61/248 24.6% 24.6%
This This means means that that a a person person taking taking an an SSRI SSRI is is only only 42% 42% as as likely likely to to develop develop depression depression as as a a taking placebo â€“ or has 58% decrease in risk. taking placebo â€“ or has 58% decrease in risk.
Adapted from: Salter KL, Foley NC, Zhu L, Jutai JW, TeasellisRW. Prevention of poststroke depression: does Absolute risk calculated by subtracting risks AbsoluteZhu riskL,reduction reduction is Teasell calculated by Prevention subtracting the the risks for for each each group. group. Adapted pharmacotherapy from: Salter KL, Foley Jutai JW, RW. of poststroke prophylactic work?NC, J Stroke Cerebrovasc Dis. depression: does prophylactic pharmacotherapy work? J Stroke Cerebrovasc Absolute risk risk reduction reduction = risk risk for for those taking takingDis. placebo âˆ’ âˆ’ risk risk for for those those who who take take an an SS Absolute = those placebo Relative Risk, Absolute Number Needed to Treat JustRisk, Off the Press Bonus: How Relative Risk, Absolute Risk, Absolute risk Relative Risk, Absolute Risk, Number Needed Treat Absolute risk reduction reduction = = 24.6% 24.6% âˆ’ âˆ’ 10.4% 10.4% = = 14.2% 14.2% and NNT Usedtoin This Series is Calculated Adapted from: Salter KL, Foley NC, Zhu L, Jutai JW, Teasell RW. Prevention of poststroke sk is the probability of an event occurring with an exposure to a factor when compared to Relative risk is the probability of anNumber event occurring Number Needed to Treat (NNT) is the numberDis. oftreat patients Needed to Treat (NNT) is the number of patients required to to Number Needed to Treat (NNT) is the number of patients required to treat to see see an an effec effec depression: does prophylactic pharmacotherapy work? J Stroke Cerebrovasc sk is the probability of an event occurring with an exposure to a factor when compared to osure. with an exposure to a factor when compared to lack of required to treat to see an effect. osure. exposure. Two Ways to Calculate NNT NNT used for prospective studies or cohort studies. Two Ways to CalculateTwo Ways to Calculate NNT used for prospective studies or cohort studies. It is usually used for prospective studies or 1. cohort studies. 1. One One way way to to calculate calculate number number needed needed to to treat treat (NNT) (NNT) ted by dividing: 1. risk O nereduction way to is calculate number needed decimal to treat Step 1: The absolute converted from Step 1: The absolute risk reduction is converted from percent percent to to decimal ted by dividing: It is calculated by dividing: (NNT) Step 1: The absolute risk reduction is Probability of PSD when taking an SSRI converted from14.2% percent 0.142 to decimal đ?‘…đ?‘…đ?‘…đ?‘… = Probability of PSD when taking an SSRI 14.2% = = 0.142 Probability of PSD when taking placebo đ?‘…đ?‘…đ?‘…đ?‘… = Probability of PSD when taking placebo 14.2% = 0.142 Step Step 2: 2: This This number number is is inverted inverted to to show show NNT NNT Step 2: This number is inverted to show NNT 26/251 10.4% đ?‘…đ?‘…đ?‘…đ?‘… = 26/251 = 10.4% = 0.42 1 đ?‘…đ?‘…đ?‘…đ?‘… = 61/248 = 24.6% = 0.42 1 = 7.04 đ?‘ đ?‘ đ?‘ đ?‘ đ?‘ đ?‘ 61/248 24.6% 7.04 đ?‘ đ?‘ đ?‘ đ?‘ đ?‘ đ?‘ = = 0.142 = Thistaking meansanthat a person SSRItoisdevelop only 42% as 0.142 that a person SSRI is only taking 42% asanlikely depression as a person likely todecrease develop depression as aas person taking placebo â€“ thatâ€“ aorperson taking an SSRI is only 42% likely to develop depression as a person ebo has 58% in risk. or has 58% decrease in risk. 2. Alternatively, the absolute risk reduction can be left ebo â€“ or has 58% decrease in risk. 2. Alternatively, Alternatively, the the absolute absolute risk reduction reduction can be left in in percent percent form and the the numera numera 2. risk left and in percent form andcan thebe numerator wouldform be 100% isk reduction is calculated by subtracting the risks for each group. be 100% instead of 1. Absolute risk reduction is calculated by subtracting be 100%the instead of 1. instead of 1. isk reduction is calculated by subtracting the risks for each group. risks for each group. olute risk reduction = risk for those taking placebo âˆ’ risk for those who take an SSRI 100% 7.04 đ?‘ đ?‘ đ?‘ đ?‘ đ?‘ đ?‘ = = 100% = olute risk reduction = risk for those taking placebo âˆ’ risk for those who take an SSRI đ?‘ đ?‘ đ?‘ đ?‘ đ?‘ đ?‘ Absolute risk reduction=risk risk for those taking placeboâˆ’ 14.2% = 7.04 14.2% = 24.6% âˆ’ 10.4% = 14.2% risk Absolute for thoserisk whoreduction take an SSRI Absolute risk reduction = 24.6% âˆ’ 10.4% = 14.2% That means that we would need to give an SSRI to around eeded to Treat (NNT) is reduction the number of patients required to treat to see an effect. after a stroke to prevent 1 case of PSD. Absolute risk = 24.6% âˆ’ 10.4% = 14.2% 7 people eeded to Treat (NNT) is the number of patients required to treat to see an effect. to Calculate NNT October 2012 JOURNAL MSMA 345 to Calculate NNT way to calculate number needed to treat (NNT) way to calculate number needed to treat (NNT) 1: The absolute risk reduction is converted from percent to decimal
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• Top 10 Facts You Should Know •
Endocrine Aspects in Patients Infected with the Human Immunodeficiency Virus Nuttha Ungnapatanin, MD; Jose S. Subauste, MD; Harold M. Henderson, MD; Christian A. Koch, MD
Data of the World Health Organization report 33 million people living with the human immunodeficiency virus-1 (HIV) and 1.8 million dying from AIDS in 2009.1 HIV infection is still considered endemic in some geographical areas. Basic demographic data on patients infected with HIV in Mississippi show that in 2009, MS ranked sixth nationally in HIV infection case rates among the 40 states with confidential reporting. In 2010, about 10,000 persons in MS were living with HIV according to data obtained from the MS State Health Department, and 73% of these persons were African-American. In 2010, MS reported 550 new cases of HIV: 76% of cases in 2010 were male, 78% were African-American. Almost half of these new cases (48%) were between the ages of 25 and 44. Direct infiltration of a respective organ, such as the adrenals, gonads, thyroid, bone, and others, with HIV and/or an opportunistic agent, can potentially impair that organ’s function. With antiretroviral therapy, HIV patients have now a longer life expectancy when compared to previous decades. Treating patients with HIV infection can exacerbate or induce various endocrine conditions. Recognizing these potential adverse effects of antiretroviral therapy can decrease complications in HIV-infected patients.2 1. HIV Lipodystrophy syndrome (HIVLD) is now the most common form of lipodystrophy and is caused by certain types of antiretroviral therapy, such as Ritonavir (protease inhibitor), Stavudine (nucleoside reverse transcriptase inhibitor), and others, resulting in subcutaneous lipoatrophy in face and limbs of patients infected with HIV. Such patients can also develop central fat accumulation with visceral organ and dorsocervical fat pads (buffalo hump). These features can resemble Cushing’s syndrome. However, other physical signs of Cushing’s syndrome such as proximal muscle weakness and violaceous striae are rarely present. HIVLD patients have an increased risk of metabolic syndrome and should be screened for this problem.3,4 Author Information: Dr. Ungnapatanin is a Fellow at the University of Mississippi Medical Center. Dr. Subauste is Professor and Fellowship Program Director in the Division of Endocrinology, University of Mississippi Medical Center. Dr. Henderson is a Professor in the Division of Infectious Diseases, University of Mississippi Medical Center. Dr. Koch is a Professor in the Division of Endocrinology, University of Mississippi Medical Center. Corresponding Author: Nuttha Ungnapatanin, MD, Endocrine Fellow, Division of Endocrinology, University of Mississippi Medical Center, Jackson, MS 39216, Email: email@example.com
2. Insulin resistance: The prevalence of impaired glucose tolerance and diabetes mellitus type 2 in patients with HIVLD is 35% and 7%, respectively. Insulin resistance is a risk factor for cardiovascular disease (CVD). This should prompt health care providers to screen for it and to treat accordingly. Pentamidine, used for pneumocystis carinii prophylaxis, has been known to be beta-cell toxic.4,5 3. Dyslipidemia: HIV infection by itself is associated with a higher prevalence of hypertriglyceridemia, hypercholesterolemia, and decreased HDL levels with increased oxidized LDL concentrations. In chronic untreated HIV infected patients, HDL remains low. With the use of some antiretroviral therapies including Ritonavir, Nelfinavir, Stavudine, Didanosine, and others, the lipid profile in HIVinfected patients can significantly worsen with an increased risk of CVD in this group of patients. The fasting lipid profile should be measured 3 months after starting antiretroviral therapy and be regularly monitored. Statins represent the drugs of choice in most patients, although various drug interactions should be considered. Fibrates are the second choice of therapy.4-6 4. Thyroid dysfunction: The rate of abnormal thyroid function tests related to non-thyroidal illness has decreased with increasingly restored CD4 cell counts. On the other hand, with antiretroviral therapy, the prevalence of subclinical primary hypothyroidism is up to 12% with approx. 80% of such patients having positive anti-TPO antibodies.5,7 In HIV-infected children, an increased TSH level is associated with failure to thrive and grow. Growth rates increase in response to thyroid hormone replacement. HIVinfected children with failure to thrive should be screened for hypothyroidism by measuring TSH and free thyroxine (T4). 5. Immune reconstitution syndrome with thyroid dysfunction: upon improvement of the immune status by using antiretroviral therapy, HIV-infected patients can develop thyroid dysfunction secondary to immune reconstitution syndrome. Graves’ disease is most often reported in this context. Thyroid function tests (TSH, free T4) should be checked if clinically indicated (symptoms and signs of hyperthyroidism). 6. Adrenal gland function can be impaired by direct infiltration with HIV and/or opportunistic agents. Usually, more than 90% of the adrenal cortex has to be destroyed before adrenal insufficiency occurs.8 Many medications used in HIV-infected patients can affect adrenal gland function.2 Ketoconazole decreases cortisol and tes-
October 2012 JOURNAL MSMA 347
tosterone synthesis; rifampin increases cortisol clearance. Using these medications can induce an adrenal insufficiency crisis in a patient with impaired adrenal reserve. Inhaled, topical, local, and systemic glucocorticoids can lead to secondary adrenal insufficiency after overexposure, especially when considering pharmacokinetics and 窶電ynamics of the protease inhibitor ritonavir. Megace (Megestrol acetate) also exerts glucocorticoid effects with potential suppression of ACTH secretion and the risk of secondary adrenal insufficiency. It also suppresses gonadal function causing hypogonadism. Abrupt discontinuation of megace in chronic users can precipitate an adrenal insufficiency crisis. Megace should be slowly tapered once patients do not need it anymore. 7. Hypogonadism IN HIV: Fifty percent of men with AIDS and 20% of HIV-infected men have hypogonadism.2,9 Their sex-hormone binding globulin can be increased, therefore causing falsely elevated or normal total testosterone levels in hypogonadal patients. If hypogonadism is strongly suspected, free testosterone and LH (luteinizing hormone) levels should be checked at 8.00 am on 2 different days. Ketoconazole not only reduces cortisol but also testosterone production. Opiates and megestrol acetate can lead to central hypogonadism. The effects of testosterone replacement therapy on insulin resistance and cardiovascular risk are uncertain.10,11 8. Bone: Osteoporosis or osteopenia, or both, are seen in 73% of HIV-infected versus 30% of HIV-negative patients of similar age.12 A number of endocrine factors can contribute to reduced bone density in HIV-infected patients, such as hypogonadism, vitamin D deficiency, and excessive inflammatory cytokine release. Screening and treatment of these conditions can improve bone density. Alendronate, a bisphosphonate agent, can be used for idiopathic bone loss if there is no contraindication. 9. Hyponatremia (Na < 135 mmol/L) occurs in up to 50% of HIV-infected patients.13,14 SIADH (secretion of inappropriate antidiuretic hormone) is the most common cause of euvolemic hyponatremia in such patients. SIADH can be secondary to the HIV infection, other infections, tumor, or medications. Hyponatremia in the setting of SIADH can be corrected by treating the underlying infection and by adjustment of an inciting medication if possible. Vasopressin V2-receptor blockers such as tolvaptan (oral) or conivaptan (intravenous) can raise serum sodium levels in hyponatremic patients. Full-blown adrenal insufficiency including lack of mineralocorticoids can occur in HIV-infected patients once more than 90% of the adrenal cortex is destroyed. 10.Growth hormone deficiency: Growth hormone (GH) secretion is impaired in states of chronic inflammation such as AIDS/HIV.15 GH deficiency usually leads to a change in body composition with increasing fat mass and decreasing lean body mass, thereby increasing insulin resistance. GH treatment can facilitate CD4(+) T cell recovery and increase thymic mass in patients infected with HIV.16
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Early recognition and treatment of endocrine conditions in HIV-infected patients can reduce cardiovascular risk and improve quality of life. Health care providers should be aware of possible adverse effects of medications used in HIV-infected patients and how to combat side effects, for instance, changing/ withdrawing certain drugs, using statins and/or fibrates in hypertriglyceridemia, levothyroxine in hypothyroidism, vitamin D and bisphosphonates in osteoporosis, tapering megestrol to avoid adrenal insufficiency, considering testosterone for chronic opiate users (still under investigation), and GH to improve immunfunction and body composition in selected patients.
1. World Health Organization. HIV/AIDS Data and statistics, http:// www.who.int/hiv/data/. 2. Brown TT. The effects of HIV-1 infection on endocrine organs. Best Pract Res Clin Endocrinol Metab. 2011;25(3):403-413. 3. Freitas P, Carvalho D, Souto S, et al. Impact of lipodystrophy on the prevalence and components of metabolic syndrome in HIVinfected patients. BMC Infect Dis. 2011;11:246. 4. Anuurad E, Semrad A, Berglund L. Human immunodeficiency virus and highly active antiretroviral therapy-associated metabolic disorders and risk factors for cardiovascular disease. Metab Syndr Relat Disord. 2009;7(5):401-410. 5. Brown TT, Glesby MJ. Management of the metabolic effects of HIV and HIV drugs. Nature Rev Endocrinol. 2011; Sep 20;8(1):11-21. 6. Mikhail NE. Lipid abnormalities in patients infected with human immunodeficiency virus. Endocr Pract 2008;14(4):492-500. 7. Madeddu G, Spanu A, Chessa F, et al. Thyroid function in human immunodeficiency virus patients treated with highly active antiretroviral therapy. Clin Endocrinol 2006;64:375-383. 8. Koch CA, Pacak K. Abnormal ACTH-stimulation test in a patient with AIDS: adrenal insufficiency or toxoplasmosis? Endocr Regul. 2001 Jun;35(2):91-3. 9. Rochira V, Zirilli L, Orlando G, et al. Premature decline of serum total testosterone in HIV-infected men in the HAART-era. PLos One 2011;6(12):e28512. 10. Bhasin S, Parker RA, Sattler F, Haubrich R, Alston B, Umbleja T, Shikuma CM. Effects of testosterone supplementation on whole body and regional fat mass and distribution in human immunodeficiency virus-infected men with abdominal obesity. J Clin Endocrinol Metab 2007;92(3):1049-1057. 11. Ullah MI, Washington T, Kazi M, Tamanna S, Koch CA. Testosterone deficiency as a risk factor for cardiovascular disease. Horm Metab Res. 2011 Mar;43(3):153-64. 12. Brown TT, McComsey GA, King MS, et al. Loss of bone mineral density after antiretroviral therapy initiation, independent of antiretroviral regimen. J Acquired Immune Deficiency Syndromes. 2009;51(5):554-561. 13. Upadhyay A, Jaber BL, Madias NE. Incidence and prevalence of hyponatremia. Am J Med. 2006 Jul;119(7 Suppl 1):S30-5. 14. Bevilacqua M. Hyponatraemia in AIDS. Baillieres Clin Endocrinol Metab. 1994 Oct;8(4):837-48. 15. Koutkia P, Eaton K, You SM, Breu J, Grinspoon S. Growth hormone secretion among HIV infected patients: effects of gender, race and fat distribution. AIDS. 2006 Apr 4;20(6):855-62. 16. Napolitano LA, Schmidt D, Gotway MB, et al. Growth hormone enhances thymic function in HIV-1-infected adults. J Clin Invest. 2008 Mar;118(3):1085-98.
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October 2012 JOURNAL MSMA 349
• The Uncommon Thread •
Doctors and Magic R. Scott Anderson, MD
o you believe in magic? Sure, no, yes, maybe, it depends on how you define magic are all acceptable answers. But for the most part I think we, as physicians, tend to be skeptical. It comes from a lifetime of requiring proof in making the decisions that affect our patients’ lives I suspect. I wrote about my own personal loss of magic some time ago, and yes I believe in the magic of love. I believe in the magic of innocence and beauty of the tenderness of Christmas mornings and tooth fairy nights. However, I don’t much worry about wizards, or witches, or vampires, or evil magicians pitted in old feuds from Arthurian times. Maybe I’m just obtuse. I have a group of e-friends I enjoy very much. I don’t know any one of them personally, but if I have the opportunity on M-W-F from 3-4 pm CST I log into #LitChat and share with other writers and readers from around the globe. Last week we had begun discussing the book The Night Circus by Erin Morgenstern. One of the participants allowed that in her book club, which was primarily composed of physicians, no one seemed to get it. I felt bad. I’d started the book when it was first published, and here it was three months later, and I still hadn’t gotten a third of the way through it. The problem was, I didn’t know why. Why had I stalled out? It was beautifully written with luxurious description that creates a magical world straight out of a Tim Burton movie. The plot revolves around two children selected as participants in an ancient feud bound to one another in a battle to the death; no matter how long the contest takes. They both receive different arcane training in the ways of magic until they are grown and then set on a collision course in the contest venue of the night circus, a magical circus that appears and disappears from place to place around the world. That’s about as far as I got. It was kind of like surgeons and internal medicine residents on night call appearing mysteriously in the various wards of the hospital to battle with one another over the true manner of healing. I can hear the voices thundering through those cold gray green halls. Zanziber, resplendent in his blue scrubs with contrasting Betadine stains cascading down his thighs declared, “The only way to heal is with cold steel. Surgery is the only way. He has a perforated ulcer.” And then, Mortimer, rheumy eyes dull, places his stethoscope in the pocket of his yellowed white coat and responds to the challenge, “You wouldn’t know healing if it bit you on the ass. It’s pancreatitis. Look at his blood chemistries.” Fire flies from Zanzibar’s eyes, “Chemistries be damned, there is rebound, and where there is rebound is a surgical abdomen.” And that was my problem with the book. While it might have been magic for some, it was learned ritual for me, the IV or the blade. You want arcane magic get a psychiatry resident involved in a case. A life and death struggle that involves death by exhaustion is nothing to an old-school surgery resident. The book didn’t take me anywhere that I hadn’t already been intellectually, but now that I had been called out I was damned and determined that I was going to finish it. I will spare you any further details, to keep from ruining the plot for you. Suffice to say, in the end, it all returned to my own personal viewpoint on magic. It exists in the relationships we pursue and the love we share with one another along the way. Overall, it was worth the read. It is a triumph of descriptive writing with a plot worthy of Shakespeare. Perhaps a plot derived from Shakespeare. But that doesn’t detract from the writing.
350 JOURNAL MSMA
P.O. Box 2548 • Ridgeland, Mississippi 39158-2548 • 408 West Parkway Place 39157 • 601-853-6733 • Fax 601-853-6746 • 1-800-898-0251 • www.MSMAonline.com
PRESIDENT steven L. demetropoulos, Md Pascagoula
PRESIDENT-ELECT James a. Rish, Md Tupelo
PAST PRESIDENT thomas e. Joiner, Md Jackson
SECRETARY-TREASURER J. Clay Hays, Jr., Md Jackson
SPEAKER R. Lee giffin, Md Vicksburg
BOARD OF TRUSTEES Claude d. Brunson, Md Chair, Jackson daniel p. edney, Md
Vice Chair, Vicksburg
william M. grantham, Md Secretary, Clinton s. Carlton gorton, II, Md Belzoni
Bradford J. dye, III, Md Oxford
steven C. Brandon, Md Starkville
dwight s. Keady, Jr., Md Meridian
Jeffrey a. Morris, Md Hattiesburg
Lee Voulters, Md Pass Christian
andrew weeks, Md
Richard C. Robertson, Jr. Medical Student, Jackson
October 1, 2012 Dear MSMA members,
Your MSMA is listening.
Active members want MSMA to reach out and make it easy for more physicians to be involved. You understand our strength is in the unity of physicians, medical students, residents, retirees and spouses. So, to meet these member goals of participation and engagement, we will have a new annual meeting format in 2013. Beginning next year, MSMA’s Annual session will be in august in Jackson. With a central in-state location providing high-tech capabilities, delegates can attend easily and members across the state can monitor proceedings online. A streamlined two-day agenda will get business done while still including popular social events like the President’s Inaugural Gala, the MSMA Alliance annual fundraiser, and a newly-added reunion reception. For those physicians interested in MSMA’s offering of CME, we have expanded the young physician section CMe In tHe sand in Sandestin, Florida. Now, you earn up to 16 hours CME and miss a maximum of only two days of clinic at this family-friendly conference on Memorial Day weekend. The new format is member-friendly and fiscally responsible, saving thousands of member dollars each year.
This is your practice, your voice, your MSMA.
we want to hear from you! Visit MSMAonline.com to join the online discussion through our members-only forums. And be on the lookout for more details in coming weeks.
Thank you for your support and membership in MSMA.
Claude Brunson, MD Chair
October 2012 JOURNAL MSMA 351
• Asclepiad •
ELEN B. BARNES, MD, OF JACKSON— This month’s physician portrait is of Dr. Helen Beatrice Barnes, MD, of Jackson, a Mississippi medical legend and teacher who became a member of our MSMA in 1960. Born in Jackson near Millsaps College (in a delivery overseen by a “granny midwife”), Dr. Barnes spent her first years in the capital city. A critical influence of her life was her grandmother Harriet Barton Watson, who had been a nanny for the Ross Barnett family in Jackson. As a small child, Helen moved to New York with her mother and brother, where she was enrolled in excellent Catholic schools in both New York and Pennsylvania. After graduating from New York’s Hunter College, she worked at the clinical chemistry labs at Howard University College of Medicine at Washington, D. C., then was accepted to Howard’s School of Medicine. She was one of the few women in the class, and in that earlier era, she remembers being called by professors and classmates by her last name only, “Barnes,” a tradition extended to most of the other women in the class. After graduating, she performed a rotating internship at Kings County Hospital in Brooklyn, spending an additional year there emphasizing pediatrics and urology. Years earlier, Dr. Barnes applied for and received a full medical school scholarship from the state, which included a promise to return to Mississippi to practice medicine. Dr. Barnes arrived in Greenwood, Mississippi on July 1, 1960, beginning a four year period of intense work as a rural general practice physician. She describes her early practice environment in the 1960s Delta as “medieval conditions”: brutal poverty, rampant malnutrition, oppressive segregation, and a feudal plantation system. And, she remembers working nonstop, being “as busy as a one armed paper-hanger.” In 1964, she left Greenwood, returning to New York to complete an Ob/Gyn residency back at Kings County Hospital, passing her boards and becoming certified by 1968. Dr. H. Jack Geiger of Tufts University then contacted her and asked her to help set up the first federally funded rural comprehensive community health center in the nation at Mound Bayou, Mississippi. At the Tufts-Delta Health Center, she directed maternal and child health, which led to a dramatic decrease in infant mortality. In October 1969, she was hired to serve on the Ob/Gyn faculty at the University Medical Center (UMC), becoming the first black faculty member at the institution. She served generations of Mississippi patients, medical students, and residents as a beloved and admired professor of obstetrics at UMC. (The physician-artist Kim Sessums, MD, trained with her as both a student and resident, later using her as the subject of one of his works of art.) She also long served on UMC’s Admissions Committee and was appointed by Governor William Winter in 1980 for a six year term on the Statewide Health Coordinating Council, leading it as chairperson from 1983-86. Now retired, Dr. Barnes, one of the first African American members of our MSMA, reflects: “The laying on of the hand is the best part of medicine.” She adds, “The foremost thing we can do as physicians is to form relationships that allow us to help people.” For more on Dr. Barnes, see “From the Editor,” page 318. This photo is by Crawford Lampton. 352 JOURNAL MSMA
—Lucius M. Lampton, MD, JMSMA Editor
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Published on Oct 18, 2012
Published on Oct 18, 2012
The Journal MSMA has a circulation of 5,000, which includes the membership of the Association and paid subscribers. The year 2012 represents...