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VOLUME LXI • NO. 4 • APRIL 2020


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VOL. LXI • NO. 4 • April 2020

SCIENCE ARTICLES

EDITOR Lucius M. Lampton, MD ASSOCIATE EDITORS D. Stanley Hartness, MD Philip T. Merideth, MD, JD

THE ASSOCIATION President J. Clay Hays, Jr., MD

Prescribing Patterns and Identification of Risks with Metoclopramide in a Family Medicine Clinic Justin J. Sherman, PharmD, MCS; Ann M. Butler Kemp, MD; Tobe S. Momah, MD; James A. Cloy, MD

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The Gamma Knife Icon: Transforming Intracranial Radiation Treatments at UMMC Madhava R. Kanakamedala, MD; Roberto Rey-Dios, MD; Juan D. Uribe, MD; Satyaseelan Packianathan, MD, PhD; Chunli C. Yang, PhD, DABR; and Srinivasan Vijayakumar, MD

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President-Elect W. Mark Horne, MD

MANAGING EDITOR Karen A. Evers

Secretary-Treasurer Joe Austin, MD

Significant Declines in Overweight and Obesity among Mississippi Public 101 School Students Elaine Fontenot Molaison, PhD, RD; Jerome Kolbo, PhD, MSW; Le i Zhang, PhD, MBA; Bonnie L. Harbaugh, PhD, RN; Olivia Ismail, MSW; and Bethany Yurko , MS, RD

PUBLICATIONS COMMITTEE Sheila Bouldin, MD, Chair Dwalia S. South, MD, Chair Emeritus Thomas C. Dobbs, MD Wesley Youngblood, M4 and the Editors

Speaker Geri Lee Weiland, MD

PLA-2R(+) Primary Membranous Nephropathy Presenting as Presumptive Diabetic Nephropathy: Lessons in the Importance of a Thorough CKD Evaluation Hiroshi Hikida , DO and Harvey Gersh, MD

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Top 10 Facts You Need to Know About Referring Your Patient to Occupational and Physical Therapy Penny Rogers, DHA, MAT, OTR/L and Kimberly Willis, PT, DPT, EdD

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

JOURNAL OF THE MISSISSIPPI STATE MEDICAL ASSOCIATION (ISSN 0026-6396) is owned and published monthly by the Mississippi State Medical Association, founded 1856, located at 408 West Parkway Place, Ridgeland, Mississippi 39158-2548. (ISSN# 0026-6396 as mandated by section E211.10, Domestic Mail Manual). Periodicals postage paid at Jackson, MS and at additional mailing offices. 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. Karen A. Evers, ext. 323. Email: KEvers@MSMAonline.com POSTMASTER: send address changes to Journal of the Mississippi State Medical Association, P.O. Box 2548, Ridgeland, MS 39158-2548. The views expressed in this publication reflect the opinions of the authors and do not necessarily state the opinions or policies of the Mississippi State Medical Association. Copyright © 2020 Mississippi State Medical Association.

Official Publication

MSMA • Since 1959

DEPARTMENTS From the Editor – Sleeping Single, Sipping a Coronavirus Cocktail, Looking for PPE Lucius M. Lampton, MD Letter – Cimetidine as an Immodulator for COVID-19 Infection

90 111

Editorial – It Must Get Worse Before It Gets Better: Musings from a Physician 112 with Active COVID-19 Timothy J. Alford, MD MSMA – Committee Seeks Candidates for Vacancies in MSMA Offices

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New Members – Welcoming Our Newest Members

114

Images in Mississippi Medicine – The Ole Miss Infirmary/Hospital Interior, 1912 Lucius M. Lampton, MD

115

Poetry and Medicine – Remembering Richard Miller John D. McEachin, MD

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RELATED ORGANIZATIONS Mississippi State Department of Health –State Pushes to Stem Spread of COVID-19 Virus

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ABOUT THE COVER “Ducks in a Row”– Dermatologist Philip R. Loria, Jr., MD, took this photograph of a mother duck with her ducklings following behind. At MSMA headquarters, there is a pair of ducks residing on the lake outside the building. Every spring, like clockwork, you can find the mallard and hen searching for a place to nest. One year, after observing much courting and flirting, they chose the MSMA courtyard. The hen nested on her eggs and the miracle of birth followed with the ducklings trailing behind their mother, often in single file. Part of the reason they follow their mother has to do with early imprinting in their first few precious moments of life. However, the reason they swim in a line is thought to be for energy conservation and visual assurance. Birders aren’t absolutely sure, but the thinking is that by paddling inline, the ducklings are agitating the water, sort of setting up rotation, bringing algae and plants to the surface to eat. However, one thing is certain, while humans all across countries are facing uncertain times and are busy getting their “ducks in a row” over coronavirus, the ducks don’t have a care in the world. The ducklings’ presence every spring, along with Mississippi’s early blooming Japanese magnolias, daffodils, and narcissus are all signs of constancy. Constancy, which we have now as much of as we ever had, yet seems so much more beautiful and vital in the absence of normalcy, which is what most of us have lost. Sadly, some have lost income and work, or worse, health, loved ones or life along with the needed normalcy of gathering for school, church, recreation, and embracing loved ones. As we grieve the loss of normalcy, it seems fitting to give thanks for the bright spots in nature (the constancy of the ducks flying in a “V” formation, the dogwood and pear trees blooming), which no separation or isolation can take from us, and the unchanging truth that God is with us. Dr. Loria became serious about photography when he was 12, and he has used Nikon equipment ever since. Originally from New Orleans, Dr. Loria started his private practice, Oxford Dermatology, about 25 years ago. In addition to photography, he also enjoys woodworking. —Managing Ed. n

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F R O M

T H E

E D I T O R

Sleeping Single, Sipping a Coronavirus Cocktail, Looking for PPE “I

n case you lost track, today is March 97th,” joked a friend on the last day of last month, suggesting that March 2020 seemed to never end, each day evolving us further along this new COVID-19 life we now live. At the beginning of March, I touched each patient, running dozens through my clinic daily with my lobby overflowing. In less than a month and the arrival of this coronavirus beast, my lobby is a ghost town, manned by a masked and gloved woman armed with a thermometer Lucius M. Lampton, MD and a questionnaire. I now perform Editor telemedicine and curbside visits. Standing six feet from any patient is the norm except when an exam is required. Then hope the barriers of the N95 mask, gloves, eye-shield, and gown protect the bold from the invisible enemy. Since my first patient in mid-March, COVID has also altered my home routine. My wife and I now sleep in separate beds and social distance during our brief time together. My daily walks with my mother have ended, and she is hunkered down in my brother’s house, available only by FaceTime. When

I return from work, I take my shoes off at the door, my clothes off at the washing machine, and then head straight to the shower, where I try to wash coronavirus off. The coronavirus cocktail is now the most cherished medicinal tonic in the world: Plaquenil and Zithromax garnished with a twist of zinc sulfate or a squeeze of remdesivir. All of the science for the cocktail is anecdotal, signifying the need for randomized trials. But, like other physicians with few options, I have utilized at least Plaquenil and Zithromax with my COVID patients with apparently positive results. The world of medicine is radically different than it was just a month ago. I used to joke that wearing masks was overly dramatic, bordering on silly hypochondria. I now wear a mask everywhere. A physician friend recently participated in a webinar with a panel of frontline Chinese physicians who discussed their handling of COVID cases. “What should we be doing?” asked one of the American physicians. The response by Dr. Lei Huang, “You cannot overreact. American physicians need to get a mask and start living a COVID-19 life.” n

Contact me at lukelampton@cableone.net. — Lucius M. Lampton, MD, Editor

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

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FAMILY MEDICINE Tim J. Alford, MD Diane K. Beebe, MD Jennifer Bryan, MD J. Edward Hill, MD

MEDICAL STUDENT John F. G. Bobo, M4

PLASTIC SURGERY William C. Lineaweaver, MD, Chair

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

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

NEUROLOGY Mary Alissa Willis, MD

PUBLIC HEALTH Mary Margaret Currier, MD, MPH

HEMATOLOGY/ONCOLOGY Carter Milner, MD Kelly Wilkinson, MD

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

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

INFECTIOUS DISEASE Rathel "Skip" Nolen, III, MD

ORTHOPEDIC SURGERY Chris E. Wiggins, MD

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

OTOLARYNGOLOGY Bradford J. Dye, III, MD

GASTROENTEROLOGY James Q. Sones, MD GENERAL SURGERY Andrew C. Mallette, MD

INTERNAL MEDICINE/EPIDEMIOLOGY Thomas E. Dobbs, MD

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

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


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Prescribing Patterns and Identification of Risks with Metoclopramide in a Family Medicine Clinic JUSTIN J. SHERMAN, PHARMD, MCS; ANN M. BUTLER KEMP, MD; TOBE S. MOMAH, MD; JAMES A. CLOY, MD

Abstract Objectives: The purpose of this study was to analyze risk factors for developing tardive dyskinesia (TD) in patients at a family medicine clinic who were prescribed metoclopramide. Patients receiving metoclopramide for greater than 12 weeks (GT12) were compared to those receiving metoclopramide for 12 weeks or less (LT12). Further comparisons were made versus baseline after a brief educational intervention. Methods: Charts were reviewed retrospectively for all patients receiving at least one prescription for metoclopramide during a two-year period. Demographic data and patients at risk for TD were identified. Physician analyses of adverse effects were compared for the two groups, including the use of the Abnormal Involuntary Movement Scale or any assessment of involuntary movements. Both groups were compared again 8 months after a brief educational intervention. Results: Patients in the GT12 group were more likely to have another risk factor for TD (p < 0.05). Physician assessment for involuntary movements significantly increased (p < 0.05) 8 months after a brief educational intervention. Also, the number of patients continued on metoclopramide significantly decreased. Conclusion: Patients in the GT12 group were more likely to have a risk factor for TD. A brief educational intervention decreased the number of patients on metoclopramide and increased physician assessment of involuntary movements. Keywords: Metoclopramide, involuntary movements, tardive dyskinesia Introduction Metoclopramide is a dopamine D2 receptor antagonist that stimulates upper gastrointestinal (GI) tract motility.1 Metoclopramide also increases lower esophageal sphincter tone, intragastric pressure, and gastric emptying. It is approved by the Food and Drug Administration for short term therapy (4 to 12 weeks) of symptomatic gastroesophageal reflux disease (GERD) when conventional therapy fails, or for the relief of acute or recurrent diabetic gastroparesis, with more than two million Americans using this medication.2,3

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In 2009, the FDA created a black box warning regarding the association of metoclopramide with tardive dyskinesia (TD), the most common form of extrapyramidal symptoms (EPS).1 Symptoms include involuntary movements of the limbs, facial grimacing, rhythmic protrusion of the tongue, trismus, or dystonic reactions. Although guidelines have suggested that the frequency of TD with metoclopramide is likely to be 1 to 15%, other estimates are lower.1,4,5 The FDA suggests that treatment longer than 12 weeks generally should be avoided1 and should be discontinued in any patient developing signs or symptoms of TD. Symptoms typically decrease or subside after discontinuing medication but have not in some cases of chronic medication use. The risk of TD is directly related to the length of time the patient takes metoclopramide and the number of doses taken. Other risk factors include patients with advanced age, female gender, diabetes, renal failure, alcoholism, schizophrenia, cirrhosis, tobacco use, known organic central nervous system (CNS) pathology, and concomitant use of dopamine antagonistic neuroleptics.1,6 In 2017 the FDA approved Ingrezza (valbenazine) for treatment of TD.7 One study has examined the impact of increased awareness of TD on the prescribing patterns of gastroenterologists.8 However, the same impact on the prescribing patterns for family medicine physicians is unknown. The purpose of this study was to analyze risk factors for developing TD in patients of a family medicine clinic who were prescribed metoclopramide. Patients receiving metoclopramide for 12 weeks or less were compared to those receiving this medication for greater than 12 weeks. Further comparisons were made versus baseline after a brief educational intervention. Materials and Methods A retrospective chart review of electronic health records (EHR) was performed in August 2014 at a family medicine clinic as a pilot study and approved as exempt from the Institutional Review Board. All patients receiving at least one electronic prescription of metoclopramide between September 2012 and August 2014 were identified and included for a total of 124 patients. Data related to demographics included age, gender, race, and concomitant disease states. The patterns of prescribers, all of whom were physicians, were identified. These included diagnosis for receiving metoclopramide,


Table 1.  Abnormal Involuntary Scale (AIMS)a Examination Procedure – Tells the Patient What To Do The patient should be observed unobtrusively at rest before or after the examination procedure.   1) Ask the patient if anything (e.g., gum or candy) is in his or her mouth. If there is, remove it.   2) Ask if he or she wears dentures and if teeth or dentures bother the patient ‘now’.   3) Ask if the patient notices any movements in his or her mouth, face, hands, or feet. If ‘yes’, the patient should describe movements and indicate to what extent they ‘currently’ bother or interfere with ADL.b   4) Observe movements with the patient sitting in a chair with hands on knees, legs apart, and feet flat on the floor.   5) Ask the patient to sit with hands hanging unsupported, and observe hands and other body areas.   6) Observe the patient’s tongue at rest with the mouth open. Do this twice.   7) Observe abnormalities of tongue movement with the patient protruding his or her tongue twice.   8) Ask the patient to tap his or her thumb with each finger as rapidly as possible for 10 to 15 seconds, first with the right hand, and then with the left. Observe facial and leg movements during this procedure.   9) Flex and extend the patient’s left and right arms, one at a time.   10) Observe the patient in profile while standing, observing all body areas again and including hips.   11) Ask the patient to extend both arms out in front, palms down, while observing trunk, legs, and mouth.   12) Observe hands and gait twice while the patient walks a few paces, turns, and walks back to the chair. Scoring Procedure – Tells the Clinician How to Rate What He or She Observesc For movement ratings (questions 1-7), rate the highest severity observed. On a Likert scale, 0 = none, 1 = minimal, 2 = mild, 3 = moderate, and 4 = severe. Facial and Oral Movements   1) Muscles of facial expression (e.g., movements of forehead, eyebrows, or cheeks). Include frowning, blinking, or grimacing of the upper face.   2) Lips and perioral area (e.g., puckering, pouting, or smacking).   3) Jaw (e.g., biting, clenching, chewing, mouth opening, or lateral movement).   4) Tongue (rate only an increase in movement both in and out of the mouth, not the inability to sustain movement). Extremity Movements   5) Upper: arms, wrists, hands, and fingers. Include movements that are choreic (rapid, purposeless, or irregular) or athetoid (slow, complex, or serpentine). Do not include tremor (repetitive, regular, or rhythmic movements).   6) Lower: legs, knees, ankles, and toes (e.g., lateral knee movement, foot-tapping, foot squirming, or heel dropping). Trunk Movements   7) Neck, shoulders, and hips (e.g., rocking, twisting, squirming, or pelvic gyrations). Include diaphragmatic movements. Global Judgements   8) Severity of abnormal movements should be based on the highest single score on the above items.   9) Incapacitation due to abnormal movements.   10) Patient’s awareness of abnormal movements. Score as: 0 = no awareness; 1 = aware, no distress; 2 = aware, mild distress; 3 = aware, moderate distress; or 4 = aware, severe distress. Dental Status   11) Current problems with teeth and/or dentures. Score as: 0 = no or 1 = yes.   12) Does patient usually wear dentures? Score as: 0 = no or 1 = yes. a

Guy W. ECDEU Assessment Manual for Psychopharmacology: Rockville, MD, US Department of Health, Education and Welfare, Public Health Service, Alcohol, Drug Abuse and Mental Health Administration, NIMH Psychopharmacology Research Branch, Division of Extramural Research Programs, 1976: 534–7. b ADL= activities of daily living. c Scoring: Calculate total score for #1-7; #8 provides overall severity index; #9-10 provides additional information for clinical decisions; #11-12 provides information for determining lip, jaw, and tongue movements.

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dose regimen, duration of treatment, and whether the dose was changed or the medication stopped during the course of treatment. Patients at greater risk for TD were identified, including older patients (> 65 years), female gender, concomitant diabetes, and those receiving other medications known to cause and/or exacerbate TD (e.g., neuroleptics and antidepressants). Finally, data was captured regarding the analysis of adverse effects of metoclopramide, including documentation with an Abnormal Involuntary Movement Scale (AIMS)9 or a general assessment of involuntary movements. Information for AIMS can be found in Table 1. For a general assessment, the physician had to document whether the patient exhibited no involuntary movements or that movements were detected. Charts were separated into two groups according to the length of treatment. Patients receiving metoclopramide for > 12 weeks (GT12) were compared to patients receiving medication for ≤ 12 weeks (LT12). Data results were disseminated to the physicians of the family medicine clinic, and an educational intervention was provided in the form of a 1-hour presentation. Results of the retrospective chart review were discussed, along with the FDA-approved indications for metoclopramide, length of therapy, adverse effects, and the use of the AIMS as an evaluative tool. Descriptive statistics were used for demographic data. Unpaired t-tests and chi-square tests were used for comparisons between the two groups for interval and nominal data, respectively. Eight months after the educational intervention, paired t-tests and McNemar’s tests for interval and nominal data, respectively, were used to compare each group versus baseline. Significance was determined by p < 0.05.

Table 2.  Demographics and Prescribing Patterns for Patients Receiving Metoclopramide Prescriptions.

Descriptive Parameter

GT12a

LT12b

90 (72.6)

34 (27.4)

57.3 + 16.3

48.9 + 13.6

18 (72)

15 (19)d

Caucasian

31 (34.4)

15 (44.1)

African American

59 (65.6)

19 (55.9)

Prescription for metoclopramide (average in months + SD)

13.8 + 6.9

1.0 + 0.7d

Daily dose (average in milligrams + SD)

26.4 + 11

24.6 + 9.6

FDA-approved diagnosis recorded (%)

34 (37.8)

9 (26.5)

Assessment for involuntary movements (%)

15 (16.7)

2 (5.9)

Number of patients (%) Age (average number of years + SD ) c

Number of men (women)

d

Race (%)

e

d

a

GT12 = group of patients receiving metoclopramide longer than approved length of therapy (> 12 weeks). b LT12 = group of patients receiving metoclopramide for the approved length of therapy (≤ 12 weeks). c SD = standard deviation. d Statistical significance when comparing between groups (p < 0.05) with an unpaired T-test. e FDA = Food and Drug Administration.

Results A retrospective chart review of EHRs revealed that 124 patients had received at least one prescription for metoclopramide over the past 2 years within a family medicine clinic. Ninety had received prescriptions for greater than 12 weeks (GT12) and 34 had received prescriptions for 12 weeks or less (LT12). Demographics and prescribing patterns can be found in Table 2. Patients in the GT12 group had received metoclopramide for an average of 12.8 months longer (p < 0.05) compared to the LT12 group. The difference in the average daily dose of metoclopramide between the groups was not statistically significant. The EHR did not indicate any dose changes for either group. An FDA-approved diagnosis was entered into the EHR for 34.7% of the patients, 15% for diabetic gastroparesis and 85% for GERD. A general assessment for involuntary movements was noted for 13.7% of the patients, but the AIMS instrument was not used. Risk factors for developing TD were compared for patients in the GT12 group versus the LT12 group in Table 3. Patients in the GT12 group were more likely to be female; however, no other risk factor achieved statistical significance. Seven patients in the GT12 group had both psychiatric comorbidity and diabetes, while only one patient in the LT12 group had both. An AIMS test was not performed, although 13.7% of all patients were assessed for involuntary movements.

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Table 3. Risk Factors for Tardive Dyskinesia for Patients Receiving Metoclopramide Prescriptions.

Risk Factor Patients > 65 years of age

GT12a Number (%) 28 (31.1)

LT12b Number (%) 7 (20.6)

Female patients

72 (80)

19 (55.9)c

Patients with diabetes

54 (60)

16 (47)

Patients with medications potentially exacerbating for tardive dyskinesia

24 (26.7)

a

c

8 (23.5)

GT12 = group of patients receiving metoclopramide longer than approved length of therapy (> 12 weeks). b LT12 = group of patients receiving metoclopramide for the approved length of therapy (≤ 12 weeks). c Statistical significance when comparing between groups (p < 0.05) with a chi-squared test.


Table 4.  Effect of an Educational Intervention on Metoclopramide Prescriptions and Assessment for Involuntary Movements.

Pre-Intervention GT12 Number (%)

Pre-Intervention LT12 Number (%)

Post-Intervention GT12 Number (%)

Post-Intervention LT12 Number (%)

With metoclopramide prescriptions

90 (72.6)

34 (27.4)

28 (87.5)

4 (12.5)

Assessed for involuntary movements

15 (17)

2 (6)

41 (46)*

12 (35)**

With at least one risk factor for developing tardive dyskinesia

24 (26.7)

7 (20.6)

23 (25.6)*

Number of patients

4 (11.8)**

*Of the original 90 patients. **Of the original 34 patients.

A brief, but focused educational intervention was conducted as a 1-hour presentation of the data for the physicians of the family medicine clinic. Metoclopramide indications, risk factors for TD, and the AIMS test were discussed. Eight months after the intervention, charts were reviewed again and data was compared to baseline (Table 4). A total of 32 patients continued to be prescribed metoclopramide, resulting in a 74.2% reduction overall (69% and 88% reduction of patients in the GT12 and LT12 groups, respectively). Most of the patients with a GERD indication had been changed to another agent while those with diabetic gastroparesis continued to receive metoclopramide, and no dose changes were made for patients that continued on metoclopramide. Twenty-two of the 32 patients (68.8%) had a documented assessment for involuntary movements, which was a significant increase (p < 0.05). Discussion Of the 124 patients receiving prescriptions for metoclopramide, 72.6% of them had been taking it for longer than the FDA-approved length of treatment of 12 weeks. Patients taking metoclopramide for longer than 12 weeks were more likely to have an additional risk factor for developing TD. Prescribing patterns compared between the GT12 and LT12 groups were not significantly different for age, race, prescribed dosing regimen, recorded FDA-approved diagnosis, or whether an assessment for involuntary movements occurred. Dose regimens used for all patients reflected the recommended dosing for each indication, and no dosing changes were made over the course of therapy. Only one-third of all patients receiving metoclopramide had a documented indication and less than 14% were monitored for involuntary movements. This suggests that better education may be needed regarding the approved indications and the need for monitoring. A brief educational intervention significantly reduced the number of patients taking metoclopramide, especially for those without an FDAapproved indication. It also increased documented assessments for involuntary movements in patients that continued on metoclopramide.

In another study that reviewed the prescribing patterns of specialists within a health-system gastroenterology clinic, metoclopramide prescriptions decreased from 69.8% before the black box warning in 2009 to 23.7% afterward.8 Reporting of neurological side effects and TD likewise increased after the warning. Patients receiving metoclopramide were more likely to be over 50 years of age and female. Several limitations exist with this study. Since it is a retrospective chart review of a single clinic, the results may not be generalizable. A determination could not be made from the database whether patients had received prescriptions for metoclopramide prior to entering the clinic as a patient. There is an uneven number for comparator groups, which could have altered the assessment. Finally, assessments of involuntary movements could have occurred without documentation. Further research should follow this retrospective pilot study. Despite the clinical implications of adverse effects developing from this medication, there is limited research in this area and no prospective data evaluating the risk of TD. Patients identified as receiving metoclopramide for longer than 12 weeks should be formally assessed for involuntary movements with an AIMS test, and educational interventions with all healthcare team members should be studied further. Conclusion Patients receiving metoclopramide for longer than the FDAapproved length of time were more likely to have another risk factor for developing TD versus patients receiving the medication for less than or equal to 12 weeks. A targeted educational intervention was successful in changing prescribing patterns within a family medicine clinic. Further research is needed to better evaluate the risks of patients receiving metoclopramide and the effects of interventions targeted to educate providers and patients. n Acknowledgments Conflict of Interest Disclosures: The authors have nothing to disclose.

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References 1. Rao AS, Camilleri M. Review article: Metoclopramide and tardive dyskinesia. Aliment Pharmacol Ther. 2010;31:11–13. 2. Reglan® (metoclopramide) [package insert]. Baudette: ANI Pharmaceuticals, Inc., MN; 1979. 3. Lee A, Kuo B. Metoclopramide in the treatment of diabetic gastroparesis. Expert Rev Endocrinol Metab. 2010;5(5):653–662. 4. Abell TL, Bernstein RK, Cutts T, et al. Treatment of gastroparesis: A multidisciplinary clinical review. Neurogastroenterol Motil. 2006;18:263–283. 5. Parkman HP, Hasler WL, Fisher RS. American gastroenterological association technical review on the diagnosis and treatment of gastroparesis. Gastroenterology. 2004;127:1592–1622. 6. Cornett EM, Novitch M, Kayle AD, et al. Medication-induced tardive dyskinesia: A review and update. Ochsner J. 2017;17(2):162–174. 7. Ingrezza® (valbenazine) [package insert]. San Diego: Neurocrine Biosciences, Inc., CA; 2017.

8. Ehrenpreis ED, Deepak P, Sifuentes H, et al. The metoclopramide black box warning for tardive dyskinesia: Effect on clinical practice, adverse event reporting, and prescription drug lawsuits. Am J Gastroenterol. 2013;108:866–872. 9. Ganzini L, Casey DE, Hoffman WF, et al. The prevalence of metoclopramide-induced tardive dyskinesia and acute extrapyramidal movement disorders. Arch Intern Med. 1993;153:1469–1475.

Author Information Department of Family Medicine, University of Mississippi School of Pharmacy (Sherman). Family Medicine Residency Program, University of Mississippi School of Medicine (Butter Kemp). Department of Family Medicine, University of Mississippi School of Medicine (Momah, Cloy). Corresponding Author: Justin J. Sherman, PharmD, MCS Associate Professor of Pharmacy Practice, Adjunct Associate Professor, Department of Family Medicine, University of Mississippi School of Pharmacy, 2500 North State St., Jackson, MS 39216 (jsherman@

umc.edu).

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The Gamma Knife Icon: Transforming Intracranial Radiation Treatments at UMMC MADHAVA R. KANAKAMEDALA, MD; ROBERTO REY-DIOS, MD; JUAN D. URIBE, MD; SATYASEELAN PACKIANATHAN, MD, PHD; CHUNLI C. YANG, PHD, DABR; AND SRINIVASAN VIJAYAKUMAR, MD

Abstract Gamma Knife Icon is the latest version of the Gamma Knife – a stereotactic radiosurgery instrument known for its accuracy and efficiency in treating disorders and lesions of the brain. As an alternative to surgery, the Icon device enables the treatment of patients immobilized not only in a traditional frame but also in a customized “face mask.” Mask-based treatments are convenient and permit delivery of multifraction treatments that are suitable for larger lesions (>3 cm/10 cc) and lesions abutting critical brain structures, which would otherwise be unsuited for single-fraction treatment. Also, on-board cone beam CT capability and infra-red camera incorporation increase confidence in the precision of treatment delivery. The Icon increases the flexibility of the treatment process while ensuring the same level of daily accuracy. In this article, we discuss the unique capabilities of the Icon that make it a complete intracranial stereotactic radiation treatment solution and share our experience with its use at the University of Mississippi Medical Center (UMMC) over the past two years. Keywords: Radiosurgery, gamma knife, frameless Introduction The inherent quality of stereotactic radiation therapy lies in the accuracy1 of localizing the intracranial target based on external references. Stereotactic radiation therapy is typically delivered in one single treatment called stereotactic radiosurgery (SRS). When delivered in multiple fractions (usually 2-5) it is called stereotactic radiation therapy (SRT). The Gamma Knife was first designed and installed in Stockholm in 1968. The newest Gamma Knife Icon uses up to 192 precisely focused beams of radiation from individual 60Co sources. Each radiation source is low in activity in and of itself, but when multiple beams are focused onto a target, ablative levels of radiation doses are delivered while sparing maximal normal tissues. It can be used to treat malignant and nonmalignant diseases as well as vascular and functional disorders of the brain, without harming surrounding healthy tissues. In the case of

brain metastases, Gamma Knife radiation can be used in place of, or in addition to, traditional surgery or whole brain radiation therapy.2 Evolution of the Gamma Knife Lars Leksell, a Neurosurgeon, installed the first Gamma Knife in Sweden in 1968. In 1987, the first Gamma Knife in the USA was installed at the University of Pittsburgh Medical Center. In the initial models of Gamma Knife (models U, B, and C), the collimator system that shaped the 60Co-based radiation beam was external to the machine itself and held in place on a bulky attachment which also permitted immobilization of the patient’s head through the stereotactic head frame. With the introduction of the Gamma Knife Perfexion in 2006, the collimator was internalized, removing the external bulkhead to which the collimator was previously attached; however, the head frame immobilization points remained on the couch. With the internalized collimator, each radiation “shot” is composed from eight individually motorized sectors that enabled composite use of the radiation sources in each sector. Moreover, the table was also fully automated to move the patient to the treatment isocenter and back out at the completion of treatment. Since its introduction, the accuracy and efficiency of the Gamma Knife Perfexion have been well established. The latest Gamma Knife model, the “Icon”, has technological additions that include an on-board cone beam CT scanner and an infra-red camera that monitors the patient’s motion using a fiducial placed on the tip of the nose.3 Stereotactic localization can be defined based on the cone beam CT, which in turn will be co-registered to the images from the brain MRI. Increased Flexibility with Work Flow Traditionally, on the day of treatment, the patient will have a brain MRI after the frame is placed, followed by radiation planning and treatment delivery. With the introduction of cone beam CT stereotactic localization, there is more flexibility with the workflow. The MRI can be obtained, the treatment volume contoured, and the treatment planned in advance. Then the MRI can be co-registered to the cone beam CT and the stereotactic localization will be based on the cone beam CT images. This is advantageous for patients who are unable to tolerate

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the mask. For mask-based treatments, the mask can be made, the cone beam CT and MRI scans obtained, and contour planned in advance of the day of treatment. This increases the efficiency of the whole process. Cone beam CT scans can also be used to verify the patient set-up right before and during the treatment, if needed. Longer treatment times, for instance, in the case of multiple metastases being treated on one treatment plan, can now be split into two or more consecutive days, improving patient comfort and treatment tolerability. Intrafraction Motion Monitoring (IFMM) The Icon has a built-in infra-red camera at the foot of the table which can track the motion of the patient’s head via a fiducial placed on the tip of the nose. The position of the fiducial is displayed on a “real time” graphic display, and motion limits can be preselected and incorporated into the treatment system (Figure 1). If the patient were to move beyond the preset threshold for more than 3 seconds, the beam will turn off automatically. Frame vs. Mask

face mask (Figure 2). As the accuracy improves with the number of fiducials with constant relation to the intracranial target, each point in the patient’s skull can act as an independent fiducial in CT-based stereotactic localization. Traditionally, brain lesions ≤3 cm (≤10 cc) in size are amenable to single-fraction SRS. However, if the lesion size is >3 cm, the integral dose to the brain is higher with the single-fraction treatment, and these lesions are more safely treated with fractionated SRT in 2 to 5 fractions. For small lesions that are abutting critical normal structures (e.g., optical structures, brainstem, cochlea), SRT is also the modality of choice (Table). The Icon’s flexibility in allowing for fractionated stereotactic treatments as well as stereotactic radiosurgery provides a

Figure 2.  A patient immobilized by a face mask that is attached to the treatment couch through a mask adapter. This patient also has an infra-red fiducial on the tip of the nose.

Stereotaxis is the “accurate targeting technique for intracranial structures with high precision (Cartesian co-ordinates),” based on an external reference; traditionally this has been frame-based. Lars Leksell pioneered the stereotactic head frame in 1948 initially for functional neurosurgery, which was later adapted for use in radiosurgery. In the frame-based approach, fiducials in the localizer box that is attached to the frame act as external references for the intracranial structures while the frame provides rigid immobilization of the cranium. With the advent of better imaging techniques and computational power, stereotaxis can now be achieved using the patient’s skull as an external reference while the patient is firmly immobilized in a

Figure 1.  Real Time Graphic Display of Fiducial Motion Table.  Selection Criteria for Frame Versus Mask

Frame

Invasive Single-fraction SRS

Mask

Noninvasive single-fraction SRS & fractionated SRT Ideal: trigeminal, acoustic & Not for targets abutting pituitary critical structures Size: <3cm/<10 cc Larger lesions can be treated Contraindicated for lesions Fractionated for lesions abutting critical normal abutting the critical normal tissues (prescription doses > structures. tolerance limits).

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Figure 3.  Screenshot of an Inverse Plan in Progress

complete intracranial solution to treating different sized lesions, even for those lesions abutting critical normal structures.4

Figure 4.  Frame Versus Mask: Cases per Quarter in the First Year of Practice

Gamma Plan The Gamma Plan is the treatment planning system for Gamma Knife including the Icon.5 An important tool in this system is Inverse Planning. This tool allows for interactive dose sculpting and makes it possible to generate treatment plans in a matter of minutes, even for irregularly shaped targets, complex volumes, and multiple targets (Figure 3). A convolution tool provides optional heterogeneity dose correction for targets located near bone and air cavities. For patients requiring repeated Gamma Knife procedures, the dose from the previous plan can be easily derived from the previous treatment plan and displayed on the current plan. The UMMC Experience Since installation of the Icon in our department in May 2017, we have treated approximately 150 patients. The majority of our patient population had brain metastases, followed by meningioma, pituitary tumor, acoustic neuroma, recurrent glioblastoma (GBM), nasopharyngeal carcinoma, and skin cancer with cranial nerve invasion. Initially we were treating a majority of these patients using the frame, and as our confidence increased we began to use mask immobilization, even for the smaller brain metastases. With the established stereotactic

precision of the cone beam CT system, we did not need to incorporate any planning target volume margins (PTV) (Figure 4). Currently, the majority of our patients are being treated using mask immobilization. However, even with mask immobilization, the majority of the lesions were treated with SRS. Conclusion The Gamma Knife Icon ensures extreme accuracy and precision in localization during intracranial radiation treatments, even with mask

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immobilization. Fractionated treatments are possible with the mask for larger targets and lesions abutting critical structures which are otherwise not suitable for single-fraction SRS. Improved workflow flexibility with the use of cone beam CT improves patient comfort and convenience. Overall the Gamma Knife Icon is very robust and reliably provides a complete solution for intracranial SRS/SRT. As the only academic medical center in the state, UMMC is tasked with the improvement of the health of all Mississippians and we believe this is another important tool as we advance in that mission. n

2. Hamilton T, Dade Lunsford L. Worldwide variance in the potential utilization of gamma knife radiosurgery. J Neurosurg. 2016;125(Suppl 1):160–165. 3. Fu L, Perera H, Ying X, et al. Importance of CBCT setup verification for optical-guided frameless radiosurgery. J Appl Clin Med Phys. 2014;15(3):4487. 4. McTyre E, Helis CA, Farris M, et al. Emerging indications for fractionated gamma knife radiosurgery. Neurosurgery. 2017;80(2):210–216. 5. Levivier M, Carrillo RE, Charrier R, et al. A real-time optimal inverse planning for gamma knife radiosurgery by convex optimization: description of the system and first dosimetry data. J Neurosurg. 2018;129(Suppl1):111–117.

Author Information

Acknowledgments We acknowledge Dr. Eldrin Bhanat for helping edit and format the paper. Conflict of Interest Disclosures: The authors have nothing to disclose. References 1. Chung HT, Park WY, Kim TH, et al. Assessment of the accuracy and stability of frameless gamma knife radiosurgery. J Appl Clin Med Phys. 2018;19(4):148– 154.

Department of Radiation Oncology, University of Mississippi Medical Center, Jackson (Kanakamedala, Packianathan, Yang, Vijayakumar). Department of Neurosurgery, University of Mississippi Medical Center, Jackson (Rey-Dios, Uribe). Corresponding Author: Madhava R. Kanakamedala, MD, Assistant Professor, Department of Radiation Oncology, University of Mississippi Medical Center, 2500 N. State St., Jackson, MS 39216 Ph: (601) 815-6933, Fax: (601) 815-6876, Cell (312) 231-9147 (mkanakamedala@umc.edu).

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Significant Declines in Overweight and Obesity among Mississippi Public School Students ELAINE FONTENOT MOLAISON, PHD, RD; JEROME KOLBO, PHD, MSW; LEI ZHANG, PHD, MBA; BONNIE L. HARBAUGH, PHD, RN; OLIVIA ISMAIL, MSW; AND BETHANY YURKO, MS, RD

Abstract The 2017 biennial Child and Youth Prevalence of Obesity Study (CAYPOS) of Mississippi public school students in grades K–12 (N = 4,348) determined that the prevalence of obesity (23.7%) and the combined overweight/obesity (40.0%) remained higher than the national averages. However, between the 2005 CAYPOS and the 2017 CAYPOS, the combined overweight/obese prevalence declined from 43.9% in 2005 to 40.0% in 2017 (P = 0.040). Consistent with previous findings, the 2017 CAYPOS indicated that combined overweight/ obesity was higher among black students than white students (P = 0.019). In examining racial disparities over time, the differences in combined overweight/obesity by race peaked in 2011, yet decreased in 2013, 2015, and 2017. Grade level analyses indicated significant differences in 2017, with the lowest prevalence continuing among elementary students since 2009. Beginning in 2011 and continuing in 2017, the combined prevalence of overweight/obesity was lowest among the elementary students, and the declines since 2005 have been statistically significant. Keywords: Childhood, overweight, obesity, trends Introduction Weight status and changes in weight status over time among children and adolescents continue to vary in the United States. The 2015–2016 National Health and Nutrition Examination Survey (NHANES) results indicated that overall obesity rates of children and adolescents aged 2 to 19 years remained relatively level from 16.8% in 2007–2008 to 18.5% in 2015–2016.1 The 2017 U.S. Youth Risk Behavior Survey (YRBS) revealed that 14.8% of American high school students were obese and another 15.6% were overweight. Between 1997 and 2017, the YRBS results indicate an increase in the overall prevalence of obesity in high school students (10.6% vs 14.8%).2 Between 1995 and 2017 the prevalence of overweight in all age groups also increased significantly (27.6% vs 31.5%). The prevalence of obesity was higher among black students (18.2%) than white students (12.5%), and higher among males (17.5%) than females (12.1%). According to the biennial Child and Youth Prevalence of Obesity Study (CAYPOS), obesity trends within the state of Mississippi

between 2005 and 2015 shared similar patterns with national-level data. 3–9 Overweight and obesity rates of students in grades K–12, while consistently higher than national averages, remained stable with no significant changes over the past decade. Similar to both the NHANES (2015–2016) and YRBS (2017), the 2015 CAYPOS findings indicated the prevalence of obesity among black students continued to be significantly higher than white students since 2005 (P < 0 .001).9 Also, a significant linear change was shown among the high school students (P = 0 .023), indicating an increase in obesity prevalence from 2005 to 2015. As with the NHANES (2015–2016), the 2015 CAYPOS indicated that the prevalence of obesity remained the lowest among the youngest students. In addition, both overweight and obesity continued to decline significantly among elementary students between 2005 and 2015. The rate-leveling of overweight and obesity among Mississippi public school students and declines among the younger students for the past decade may be the result of a variety of initiatives. In 2006, nutrition standards were established for food sold in school vending machines,10 and in 2007 the Healthy Students Act, which included requirements for physical education, health education, wellness policies, and food served in the school setting was passed.11 All of these initiatives were developed in an attempt to combat overweight and obesity among Mississippi school-aged children. While these state-level initiatives may be responsible for the stabilization and reduction of the obesity rates in Mississippi, other national-level initiatives were also underway during the same period. In the early to mid-2000s, both the American Academy of Pediatrics (AAP) and the Institute of Medicine (IOM) published policy statements related to the prevention of pediatric overweight and obesity, which identified the early identification of overweight status in children as key to prevention of obesity.12,13 Further, the AAP recommended using Body Mass Index (BMI) as a tool to identify excessive weight gain related to growth and for longitudinal tracking of a child’s weight status. In 2007, the recommendation of the AAP focused on the use of primary care providers to universally assess children for obesity risk and to provide obesity prevention messages to address issues with

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excess weight. In addition to recommendations on patient-centered counseling, treatment recommendations also focused on the social and environmental changes that needed to be made to reduce rates of overweight and obesity.14,16 In 2009, not long after the AAP recommendations to focus on obesity in the primary care setting, changes to the Supplemental Nutrition Program for Women Infants and Children (WIC) were also made.15 Research on populations served by the WIC program found that participants consumed lower fat milk and foods that were lower in saturated fat. Changes in fruit and vegetable intake were not consistent, but participants had a higher intake of whole grain products.16 Since the first reported findings of the CAYPOS (in 2005), multiple state and national level initiatives have been launched, and support from leaders and practitioners in child health has been strong.12–16 The CAYPOS 2017 study was designed to continue to monitor the prevalence of overweight and obesity in Mississippi children in grades K–12 and to examine if previous trends in overweight and obesity continued by gender, race, and educational levels. Methods The sampling and data weighting process in 2017 was similar to those used in previous CAYPOS studies, ensuring every eligible student had an equal chance of selection, improving the precision of the estimates.3–9 The sampling frame consisted of 478,056 students in 892 public schools offering kindergarten or any combination of grades 1 through 12 in Mississippi.

2017 Overall Results In 2017, the overall combined rates of overweight and obesity for Mississippi public school students in grades K–12 was 40.0%. Of those, the percentage of students who were classified as obese (at or above the 95th percentile for BMI for age and gender) was 23.7%, while the percentage of those classified as overweight (at or above the 85th percentile) was 16.3% (Table 2). Race The overall prevalence of obesity for white students in all grades was 21.7% with another 16.0% classified as overweight (37.7% combined), while among black students, the prevalence of obesity was 25.4% and

Table 1.  Characteristics of Participants, CAYPOS, Grades K-12, Mississippi, 2017.

Characteristic

Unweighted count

Weighted percent

Gender  Male

2,271

52.2

Female

2,077

47.8

White

1,810

42.0

Black

2,250

51.4

Other

288

6.6

K

65

1.2

1st

307

7.5

2nd

379

8.4

3rd

398

9.3

4th

305

7.3

5th

304

7.3

6th

524

11.7

7th

335

7.3

8th

354

7.6

9th

312

6.6

10th

187

5.0

11th

312

8.1

12th

552

12.7

Total

4,348

100

Race

Grade*

Data Analysis As in all of the previous CAYPOS studies, BMI was computed for each responding student based on height (in meters) and weight (in kilograms).3–9 Children and adolescents were classified into four categories: (1) underweight (BMI is less than the 5th percentile); (2) normal weight (BMI is equal to or greater than the 5th but less than the 85th percentile); (3) overweight (BMI is equal to or greater than the 85th but less than the 95th percentile); and (4) obese (BMI is equal to or greater than the 95th percentile).17 Findings Seventy-eight of the 95 randomly sampled schools participated in the study (86.3%). The student response rate was 84.0% (4,348 participating students/5,198 eligible students). Thus, the overall response rate was 68.9% (product of school response rate and student response rate), which was above the threshold of 60% required to obtain weighted estimates. The final sample consisted of 4,348 students in grades K–12. Of the sample, 1,758 (41.0%) were in elementary (K–5), 1,213 (26.6%) in middle (6–8), and 1,363 (32.4%) in high school (9–12) (Table 1).

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Elementary

Middle school

High school

*14 were missing on grade.


Table 2.  Prevalence of Overweight and Obesity by Grade Level and Race, CAYPOS, Mississippi 2017.

All Grades (K-12) (%, 95% CIc)

Elementary (K–5) (%, 95% CI)

Middle school (6–8) (%, 95% CI)

High school (9–12) (%, 95% CI)

Overweighta

16.3 (15.1–17.7)

15.7 (14.1-17.4)

16.6 (14.4-19.1)

17.0 (14.1-20.3)

Obesity

23.7 (22.0–25.5)

21.0 (18.6–23.7)

26.1 (23.9–28.6)

25.2 (22.4–28.2)

Overweight

16.0 (14.3–17.9)

15.1 (13.1–17.5)

16.8 (14.1–20.0)

16.7 (13.2–20.9)

Obesity

21.7 (19.6–24.0)

19.3 (15.9–23.1)

21.8 (19.6–24.2)

25.5 (20.7–30.9)

Overweight

16.6 (14.9–18.3)

16.0 (13.5–18.9)

16.9 (13.3–21.2)

16.9 (13.9–20.3)

Obesity

25.4 (23.0–28.0)

22.5 (18.8–26.6)

29.0 (25.0–33.4)

25.7 (22.1–29.6)

Overweight

16.0 (14.4–17.6)

15.9 (13.7–18.2)

16.8 (14.1–19.9)

15.4 (12.3–19.2)

Obesity

22.8 (20.4–25.5)

19.2 (15.8–23.2)

26.5 (22.8–30.6)

24.3 (21.0–28.0)

All b

White

Black

Male

Female  Overweight

16.7 (15.1–18.5)

15.5 (12.8–18.6)

16.3 (13.6–19.5)

18.8 (15.4–22.6)

Obesity

24.7 (22.8–26.8)

22.9 (19.9–26.2)

25.7 (22.7–29.0)

26.2 (22.1–30.8)

Overweight

15.8 (13.5–18.3)

16.8 (13.3–20.9)

17.5 (13.2–22.7)*

13.0 (9.7–17.2)*

Obesity

22.4 (19.0–26.2)

16.7 (12.4–22.1)

25.3 (20.6–30.7)

28.6 (24.1–33.5)

Overweight

16.1 (14.0–18.5)

15.3 (12.3–18.9)

16.9 (12.7–22.1)

16.3 (12.5–21.1)

Obesity

22.8 (19.5–26.4)

20.4 (16.2–25.4)

26.8 (20.3–34.5)

22.0 (17.7–27.1)

Overweight

16.3 (14.0–18.9)

13.3 (10.3–17.2)

16.3 (12.8–20.4)*

21.4 (16.2–27.6)

Obesity

20.9 (17.9–24.3)

22.1 (17.1–28.1)

18.5 (14.2–23.6)*

21.6 (14.2–31.3)

Overweight

17.0 (14.7–19.6)

16.7 (12.7–21.6)

16.9 (12.0–23.4)

17.4 (13.9–21.6)

Obesity

28.1 (25.6–30.7)

24.6 (19.9–29.8)

31.4 (26.1–37.2)

29.3 (25.0–33.9)

White male

Black male

White female

Black female

a

Body mass index (BMI) > 85th percentile and < 95th percentile for age and gender. Body mass index (BMI) > 95th percentile for age and gender. c 95% confidence interval. *Sample size is less than 50. The estimates may not be reliable. b

prevalence of overweight was 16.6% (42.0% combined). Rates of both obesity and combined overweight and obesity were significantly higher for black than white students (P = 0.040 and P = 0.019, respectively).

females was 24.7%, with an additional 16.7% classified as overweight (41.4% combined).

Gender

In 2017, 21.0% of elementary, 26.1% of middle school, and 25.2% of high school students were obese. Combined rates of overweight and obesity were 36.7% in elementary school students, 42.7% in middle school students, and 42.2% in high school students. The prevalence

Males across all grade levels had an obesity rate of 22.8% and an overweight rate of 16.0% (38.8% combined). The rate of obesity in

Grade Level

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of obesity was significantly lower in elementary school student than high school students.

Figure 1.  Prevalence of overweight, obesity, and combined, grade K–12, 2005–2017.

Gender and Race When gender and race were combined, 20.9% of white females were obese, with an additional 16.3% classified as overweight (37.2% combined) and 28.1% of black females were obese, with an additional 17.0% classified as overweight (45.1% combined). White males had a 38.2% combined overweight and obesity, while black males had a combined rate of 38.9%. Race and Grade Level Obesity prevalence did not differ by race among the elementary school students or the high school students. However, it differed among black (29.0%) and white (21.8%) students in middle school (P = 0.004). Likewise, combined overweight and obesity rates did not differ by race among elementary students but did among the middle school students with black females having higher rates than white females (P = 0.015).

Figure 2.  Prevalence of overweight and obesity combined by race, grades K–12, 2005–2017.

Trends over Time The obesity prevalence for all students in grades K–12 did not change from 2005 (25.5%) to 2017 (23.7%). However, the prevalence of combined overweight and obesity rates dropped significantly (43.9% in 2005 to 40.0% in 2017, P = 0.040) (Figure 1). In terms of gender, the prevalence of obesity did not drop significantly across all CAYPOS studies for males or females but combined overweight and obesity rates were significantly lower in males between 2005 and 2017 (43.8% vs. 38.8%, P = 0.01). For race, the significant linear decline in obesity rates and combined overweight and obesity rates of whites observed during 2005–2015 did not continue in 2017 (Figure 2). In terms of changes in racial disparities, the difference in percentage of obese students by race peaked in 2011 (43.6%), dropping to 17.0% in 2017. Grade level analyses continued to show the greatest declines among elementary school students (Figure 3). The obesity prevalence among students in grades K–5 decreased from 25.0% in 2005 to 21.0% in 2017 (P < 0.01). It should be noted that this is the first time since data have been collected that there has not been a significant difference in obesity rates between black and white elementary school students. The combined prevalence of overweight and obesity in elementary school students also showed a significant decrease from 43.0% in 2005 to 36.7% in 2017 (P < 0.001). There has been no change over time in the obesity and combined overweight and obesity rates in middle school students. However, high school students’ rates of obesity increased significantly from 23.5% in 2005 to 25.2% in 2017 (P = 0.014). Discussion The prevalence of obesity and combined overweight/obesity remained higher among Mississippi public school students than

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Figure 3.  Prevalence of overweight and obesity by grade level, Mississippi, 2005-2017.


national averages. However, between the 2005 CAYPOS and the 2017 CAYPOS, the combined overweight/obese prevalence has declined significantly. As with all previous CAYPOS studies, the prevalence of obesity and combined overweight and obesity were higher in black students than among white students.3–9 Black females continued to have the highest rates of combined prevalence of overweight and obesity among all groups, with rates being significantly higher than white females in middle school. Racial disparities are found in other studies;1,3–9 however, the reduction in obesity disparity between black and white students at the elementary and high school grade levels note another trend that has not been seen in previous research. While some of the reduction appears to be due to a slight increase in obesity rates in whites, the apparent reduction in black students is noteworthy, particularly at the elementary grade level. Consistent with national data, the prevalence of obesity in Mississippi tends to be lower in younger age groups, and higher in older adolescents.1 Results from a recent prospective and retrospective analysis of BMI over time showed that children who were obese at younger ages (3–5 years) were more likely to continue to exhibit obesity into adolescence with the highest acceleration in weight seen between ages 2–6 years.18 Trends of obesity in the preschool population were also observed during the same time frame with trends being only slightly higher in Mississippi (14.2%) than national averages (13.9%).19 The longitudinal connection between early childhood obesity and adolescent adiposity may explain why elementary and middle school students are starting to show a decline in weight status. As elementary school students (who 8–10 years prior had much higher BMI) have moved into middle and high school, it is more likely that high rates will persist for some time in high school. Previous CAYPOS studies cited the Healthy School Act and other public-school initiatives as possible reasons for the decreasing rates of overweight and obesity.3–9 As with previous CAYPOS studies, the trend is to have decreasing rates of overweight and obesity in elementary and middle school students with high school rates remaining high in Mississippi. State policy in 2016 dictated that both elementary and middle school students have mandatory physical education for a minimum of 40 minutes per week while no weekly minimum was required for high school students.11 However, this initiative alone is not enough to explain the trend in weight declines in the younger student or declines in racial disparities in obesity rates and begs the question if other public health initiatives also have an impact on current weight trends in Mississippi students, particularly among the youngest children. Slightly more than a decade ago, both the AAP and the IOM made recommendations to include calculation and assessment of BMI as a required part of routine pediatric visits in a primary care setting.12,13,16 Since the recommendation was made, research was conducted on the use of BMI in the prevention, screening, and treatment of obesity in the pediatric population. Recent research shows that interventions aimed at increasing the discussion of BMI with parents and caregivers resulted in greater knowledge and discussion of BMI.20–22 Primary care providers indicated that they discussed the issue of overweight

or inappropriate weight with parents less frequently but reported increased comfort in talking about eating and physical activity habits.23 Additionally, pediatricians were more likely to discuss BMI during well visits than general practitioners, and pediatricians were reported to be more likely to have access to pediatric obesity clinics.24 With the recommendations of the AAP and IOM, the primary care site may provide an ideal setting in which to implement interventions and education to address overweight and obesity as well as the underlying causes that continue to persist in Mississippi children and adolescents.22 Barriers such as parent and child motivation, lack of family involvement, lack of time, lack of qualified providers, lack of concern, and lack of appropriate identification of overweight and obesity should be addressed in the primary care setting to improve the potential for positive outcomes.24 Health policy aims to affect the most efficient, evidence-based way to focus on present and future intervention efforts. The recommendation to assess BMI in primary care settings where health care providers can intervene with children and their families points to potential changes in policy. In addition to changes in the primary care setting, changes to WIC packages, especially changes seen in Mississippi, are leading to healthier foods being provided at a healthier age.16,25 However, limited research is available to determine if these changes have created an impact on rates of overweight and obesity. The potential to research and evaluate the impact of current food packages on overweight and obesity rates should also be explored. If evidence-based obesity prevention interventions for younger children, which include parents, can be implemented in primary care settings it may be possible to sustain and even expand the downward trends in overweight and obesity rates in Mississippi’s elementary school students. n Acknowledgments The Bower Foundation provided funding for this study through the Center for Mississippi Health Policy. The authors thank Westat, Inc., for their assistance in the sampling and weighting of the data and the Mississippi schools, school nurses, and personnel who were so instrumental in collecting the data. Conflict of Interest Disclosures: The authors have nothing to disclose. References 1. Hales CM, Carroll MD, Fryar CD, et al. Prevalence of obesity among adults and youth: United States, 2015–2016 NCHS Data Brief, no 288. Hyattsville, MD: National Center for Health Statistics. 2017. 2. Kann L, McManus T, Harris WA, et al. Youth risk behavior surveillance — United States, 2015. MMWR Surveill Summ. 2016;65:1–174. https://dx.doi. org/10.15585/mmwr.ss6506a1. 3. Molaison EF, Kolbo JR, Speed N, et al. Prevalence of over-weight among children and youth in Mississippi: A comparison between 2003 and 2005. http://www. mshealthpolicy.com. Accessed August 6, 2019.

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4. Kolbo JR, Penman AD, Meyer MK, et al. Prevalence of overweight among elementary and middle school students in Mississippi compared with prevalence data from the Youth Risk Behavior Surveillance System. Prev Chronic Dis. 2006;3:A84. 5. Kolbo JR, Armstrong MG, Blom L, et al. Prevalence of obesity and overweight among children and youth in Mississippi: Current trends in weight status. J Miss State Med Assoc. 2008;49(8):231–237. 6. Molaison EF, Kolbo JR, Zhang L, et al. Prevalence and trends in obesity among Mississippi Public School students, 2005-2009. J Miss State Med Assoc. 2010;52(3):1–6. 7. Kolbo JR, Zhang L, Molaison EF, et al. Prevalence and trends in overweight and obesity among Mississippi Public School students, 2005-2011. J Miss State Med Assoc. 2012;53(5):140–146. 8. Zhang L, Kolbo JR, Kirkup M, et al. Prevalence and trends in overweight and obesity among Mississippi Public School students, 2005-2013. J Miss State Med Assoc. 2014;55(3):80–87. 9. Kolbo JR, Zhang L, Werle N, et al. Overweight and obesity prevalence and trends among Mississippi Public School students: A decade of data between 2005 and 2015. J Miss State Med Assoc. 2016;58(10):310–317. 10. Mississippi School Board of Education. Vending Regulations for Mississippi Schools, 2006. Available at: http://sos.ms.gov/ACProposed/00013251b.pdf. Accessed September 15, 2018. 11. Mississippi Legislature, Senate. Senate Bill 2369 (as sent to governor). Jackson, MS: Mississippi Legislature; 2007. Available at: http://billstatus.ls.state.ms.us/ documents/2007/html/SB/2300-2399/SB2369SG.htm. Accessed October 18, 2018. 12. American Academy of Pediatrics. Policy statement: Organizational principles to guide and define the Child Health Care System and/or improve the health of all children. Pediatrics. 2004;113:1545–1547. 13. Institute of Medicine, Food and Nutrition Board, Board on Health Promotion and Disease Prevention, et al. Preventing Childhood Obesity: Health in the Balance. ed 1, Koplan JP, Liverman CT, Kraak VA (ed). Washington, DC: The National Academies Press; 2005. 14. Barlow SE. Expert committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: Summary report. Pediatrics. 2007;120:s164–s192. 15. The National Academy of Sciences. The WIC Food Packages: From Then to Now. Washington DC: The National Sciences Press, 2017. Print. 16. Kong A, Odoms-Young AM, Schiffer LA, et al. The 18-month impact of special supplemental nutrition program for women, infants, and children food package revisions on diets and recipient families. Am J Prev Med. 2014;46:543–551. 17. Centers for Disease Control and Prevention. A SAS program for the CDC Growth Charts. Website. http://www.cdc.gov/nccd/hp/dnpa/growth-charts/ sas.htm. Accessed August 7, 2019.

23. Holt N, Schetzina KE, Dalton WT, et al. Primary care practice addressing child overweight and obesity: A survey of primary care physicians at four clinics in southern Appalachia. South Med J. 2011;104(1):14–19. 24. Wethington HR, Sherry B, Polhamus B. Physician practices related to use of BMIfor-age and counseling for childhood obesity prevention: A cross-sectional study. BMC Fam Pract. 2011;12:80. 25. Morshed AB, Davis SM, Greig EA, et al. Effect of WIC food package changes on dietary intake of preschool children in New Mexico. Health Behav Policy Rev. 2015;2(1):3–12.

Author Information Associate Professor, The University of Alabama (Molaison). Professor, School of Social Work, University of Southern Mississippi (Kolbo). Director, Office of Health Data and Research, Mississippi State Department of Health and Professor, School of Nursing, University of Mississippi Medical Center (Zhang). Professor in the School of Leadership and Advanced Practice Nursing, The University of Southern Mississippi (Harbaugh). Project Coordinator, School of Social Work, University of Southern Mississippi (Ismail). Graduate Assistant, School of Kinesiology and Nutrition, University of Southern Mississippi (Yurko). Corresponding Author: Elaine Fontenot Molaison, PhD, RD, 2270 Old Highway 24, Hattiesburg, MS 39402. Ph: (205) 723–7560 (efmolaison@ches.ua.edu).

Helping you build a more secure future. We invest our own money alongside yours, so we are invested in your success.

18. Geserick M, Vogel M, Gausche R, et al. Acceleration of BMI in early childhood and risk of sustained obesity. N Engl J Med. 2018; 379:1303–1312. 19. Pan L, McGuire LC, Blanck HM, et al. Racial/ethnic differences in obesity trends among young low-income children. Am J Prev Med. 2015;48:570–574. 20. Shue CK, Whitt JK, Shue CB. Promoting conversations between physicians and families about childhood obesity: Evaluation of a physician communication training within a clinical practice improvement initiative. J Health Commun. 2016;31(4):408–416. 21. Polacsek M, Orr J, Letourneau L, et al. Impact of a primary care intervention on physician practice and patient and family behavior: Keep me healthy—the Maine youth overweight collaborative. Pediatrics. 2009;123:S258–S266. 22. Van Cleave J, Kuhlthau KA, Bloom S, et al. Interventions to improve screening and follow-up in primary care: A systematic review of the evidence. Acad Pediatr. 2012;12(4):269–282.

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PLA-2R(+) Primary Membranous Nephropathy Presenting as Presumptive Diabetic Nephropathy: Lessons in the Importance of a Thorough CKD Evaluation HIROSHI HIKIDA, DO AND HARVEY GERSH, MD

Abstract Currently, the nation is facing a national shortage of nephrologists, making primary care physicians essential in the initial detection and work-up of proteinuria and chronic kidney disease. Mississippi is one of the most rural states, with a significant African American population and a high percentage of people living in poverty. While diabetes is the most prevalent cause of chronic kidney disease and end stage renal disease (ESRD) in Mississippi and the nation, those lacking concurrent diabetic retinopathy need further work-up and a potential kidney biopsy after referral to a nephrologist. This report details a case wherein a patient is presumed to have proteinuria secondary to her diabetes despite lack of diabetic retinopathy when, in fact, it was due to PLA-2R(+) primary membranous nephropathy confirmed by biopsy after referral to a nephrologist. This case also serves to reinforce the importance of avoiding “anchoring bias” in the face of a presumably obvious diagnosis as well as the importance of a thorough and systematic approach to the patient with proteinuria, which frequently includes but is not limited to a referral to a nephrologist. Background Primary care physicians (PCPs) are at the front lines in the early detection and referral of chronic kidney disease (CKD). Due to the shortage of nephrologists not only in the state of Mississippi but nationwide, it is not uncommon for primary care physicians to be the first to discover proteinuria or an elevated creatinine which many times is unknown to the patient.1 The primary care physician must determine and be aware of the different causes of nephrotic syndrome and determine which diseases will require a referral to a nephrologist. In the state of Mississippi as well as the nation, diabetes is the most prevalent cause of chronic renal disease and end stage renal disease (ESRD). Despite this, there are numerous other causes for chronic kidney disease that must be considered, and now more than ever, there is a need to implement a systematic approach to working-up and diagnosing these pathologies. The following case presentation is a

common example of a patient that PCPs may see in the office on a daily basis. Case Presentation A 71-year-old Caucasian female with a history of noninsulin-dependent diabetes mellitus, hypertension, and hyperlipidemia presented with the chief complaint of recurrent swelling. On initial physical exam, she was found to be afebrile and hemodynamically stable with trace edema of her bilateral lower extremities. The remainder of her physical exam was unremarkable. Initial laboratory results showed a serum creatinine of 1.33, estimated glomerular filtration rate (GFR) of 39 mL/min (reference >60 mL/min) consistent with CKD stage 3b as well as a urinalysis showing 1–4 red blood cells (RBCs) [reference 0/high power field (HPF)], 5–9 white blood cells (WBCs) (reference 0/HPF), and > 300 mg proteinuria on dipstick (reference 0 mg/dL). A 24-hour urine protein collection showed 4,000 mg (reference <0.2 g/24 h). Further testing included negative serum and urine protein electrophoresis and antinuclear antibody (ANA) screening. Subsequent renal ultrasound showed normal renal cortical echogenicity without evidence of hydronephrosis. Although statistically diabetic nephropathy would be the most likely cause of this patient’s renal disease, there were findings that suggested the presence of an alternate pathology, such as lack of diabetic retinopathy and hematuria.3,4 It is at this stage that the primary care physician referred the patient to a nephrologist for further workup. The nephrologist then ordered a percutaneous renal biopsy which returned positive for PLA-2R antibodies on indirect immunofluorescence staining, suggesting a nondiabetic origin.4 In this case, the diagnosis was primary membranous nephropathy (PMN).5–7 The PLA-2R receptor is a receptor found on renal tissue within immune deposits in a fine capillary loop pattern.7 In PMN, there are corresponding antibodies that attack these receptor sites and are specific to this disease. This is in stark contrast to secondary membranous nephropathy where immune complexes such as IgA, IgM, and C1q would passively settle in the mesangium with or without subendothelial involvement, suggesting pathology that involves

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circulating immune complexes such as in lupus nephritis.8 The patient was started on prednisone and cyclosporine which drastically decreased her proteinuria on subsequent visits.

8. Fries JWU, Mendrick DL, Rennke HG. Determinants of immune complex-mediated glomerulonephritis. Kidney Interna. 1988;34(3):333–345.

Discussion

10. Salim SA, Medaura JA, Malhotra B, et al. Nephrology key information for internists. J Community Hosp Intern Med Perspect. 2017; 7(2):70–72.

Membranous nephropathy is the most common cause of nephrotic syndrome in nondiabetic patients, comprising approximately one-third of renal biopsies.9 These patients present with nephrotic range proteinuria with stigmata of nephrotic syndrome. Even though spot urine protein creatinine ratio is sufficient for monitoring the progression of renal disease, a 24-hour urine protein is preferred for confirming a diagnosis of nephrotic range proteinuria.10 In this case, the PCP could have ordered a serum PLA-2R antibody test prior to the referral to a nephrologist. The result may have been useful in the workup of primary membranous nephropathy and reduced the delay in definitive diagnosis. Primary membranous nephropathy is a potentially reversible disease that must be considered whenever a patient presents with significant proteinuria. In this case, the patient was presumed to have diabetic nephropathy despite atypical findings in her work up including a lack of diabetic retinopathy.3,4 She underwent a percutaneous renal biopsy to obtain the final diagnosis of primary membranous nephropathy. Biopsy in these cases enables the nephrologist to stage the disease and consider immunotherapy in patients without high grade fibrosis. Finally, less than 10% of patients with primary membranous nephropathy will develop ESRD over the subsequent decade with proper management.11,12 In this case we highlight the importance of a systematic approach for those presenting with proteinuria to their primary care physician to ensure an early and accurate diagnosis in the face of easier explanations. n Acknowledgment

9. Rivera F, López-Gómez JM, Pérez-García R. Clinicopathologic Correlations of Renal Pathology in Spain. Kidney Internat. 2004;66(3):898–904.

11. Ponticelli C, Zucchelli P, Passerini P, et al. A 10-year follow-up of a randomized study with methylprednisolone and chlorambucil in membranous nephropathy. Kidney Int. 1995;48:1600–1604. 12. Jha V, Ganguli A, Saha TK, et al. A randomized, controlled trial of steroids and cyclophosphamide in adults with nephrotic syndrome caused by idiopathic membranous nephropathy. J Am Soc Nephrol. 2007;18:1899–1904.

Author information Internal Medicine Resident PGY-2, Merit Health Wesley (Hikida). Board-certified nephrologist and medical director, Hattiesburg Clinic (Gersh). Corresponding Author: Hiroshi Hikida DO, 5001 Hardy St., Hattiesburg, MS 39402. Ph: (808) 286-1608 (hiroshi.hikida@ gmail.com).

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References 1. Sharif MU, Elsayed ME, Stack AG. The global nephrology workforce: Emerging threats and potential solutions!. Clin Kidney J. 2016;9(1):11–22. 2. Salim SA, Zsom L, Cheungpasitporn W, et al. Benefits, challenges, and opportunities using home hemodialysis with a focus on Mississippi, a rural southern state. Semin Dial. 2019;32(1):80–84. 3. KDOQI Clinical Practice Guidelines and Clinical Practice Recommendations for Diabetes and Chronic Kidney Disease. Am J Kidney Dis. 2007;49(2):S12–S154. 4. Dong Z, Wang Y, Qiu Q, et al. Clinical predictors differentiating non-diabetic ­renal diseases from diabetic nephropathy in a large population of type 2 diabetes patients. Diabetes Res Clin Pract. 2016;121:112–118. 5. Salant DJ, Cattran DC. Membranous nephropathy. Chapter 20. In: Comprehensive Clinical Nephrology, ed 5, Floege J, Johnson RJ, Feehally J (ed). St. Louis, MI: Saunders; 2015:239–251. 6. De Vriese AS, Glassock RJ, Nath KA, et al. A proposal for a serology based ­approach to membranous nephropathy. J Am Soc Nephrol. 2017;28(2):421– 430.

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Conflict of Interest Disclosures: The authors have nothing to disclose.

7. Kumar V, Ramachandran R, Kumar A, et al. Antibodies to m-type phospholipase A2 receptor in children with idiopathic membranous nephropathy. Nephrology (Carlton). 2015;20:572–575.

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318 Howard St reet • Greenwood, Mississippi 662 .453. 2114 • thealluvian.com


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Top 10 Facts You Need to Know About Referring Your Patient to Occupational and Physical Therapy PENNY ROGERS, DHA, MAT, OTR/L AND KIMBERLY WILLIS, PT, DPT, EDD

Introduction Occupational and physical therapists are reliant on physicians as a primary source of referrals.1 This trend has not changed over the past 20 years. As with all referral services, the quality of service depends on information obtained from the patient and the referring health care provider. Often the provider and the patient are unaware of the scope of services in our area, thus this Top Ten Facts. What does the medical professional need to know regarding patient referral to occupational therapy (OT), physical therapy (PT), or both? Physical therapy addresses rehabilitation with a focus on prevention of impairments, activity limitations, participation restrictions, and environmental barriers related to movement, function and health.2 Occupational therapy addresses areas of occupational performance, injury prevention, participation, role competence, and wellness.3 Many physicians do not identify areas such as substance abuse, oncology, neonatology, and cardiology as practice areas of OT and PT.1 Furthermore, early referrals can result in positive patient outcomes.4,5 International Classification of Diseases (ICD-10-CM) is the most widely used source for diagnoses coding in all United States healthcare treatment settings. As of October 1, 2015, Centers for Medicare Services implemented the required use of ICD-10 codes to all documentation to aid in reimbursement of services including OT and PT services.6 Specific patient diagnosis is key. The medical professional (e.g. physician or nurse practitioner) can expedite the referral process by sending the OT and PT professionals the patient diagnosis(es). This allows the therapist the opportunity, if needed, to communicate with the physician and payment sources prior to the patient’s visit to therapy. A physician’s referral is essential for most payment sources to reimburse for occupational or physical therapy intervention.3,5

Personal factors and/or comorbidity documentation is imperative. As of January 1, 2017, current procedural terminology (CPT) evaluation codes for OT/PT have changed. For the therapist to bill the correct CPT code, a list of personal factors and/or comorbidities is helpful for correct coding.7,8 Comorbidities may be physical or mental conditions that coexist with a primary disease but also stand alone as a specific disease. An example is that someone may have high blood pressure and not have diabetes; however, it is not uncommon for someone who has diabetes to also have hypertension (HTN).9 Patient referrals may include many diagnoses and patient types. Patients with low back pain, congenital disorders, chronic diseases, injury, limited physical activity, integumentary (skin and wound) conditions, and progressive neuromuscular disorders are only a small sampling of those who may benefit from rehabilitation services. Patient populations may be referred due to injury on the job, athletic injuries, or pelvic floor disorders. Residents in long term care facilities, and children who have life-long disabilities may also be referred.10 There are many options for OT or PT evaluation/ examination7,8 and treatment. Based on the patient’s needs, a physician may choose to refer to one or the other rehabilitation disciplines, or both concurrently. Options for consultations may state as follows: OT evaluate and treat, PT evaluate and treat, or OT/PT evaluate and treat. The physician has the choice to allow the rehabilitation professional to utilize their own skills to treat within the scope of practice or to clearly define the required course of treatment. Early referral to rehabilitation can make a difference in patients with neurodegenerative diseases and may prevent or delay some disabling aspects of the disorder.5 According to traditional opinions on the treatment of neurodegenerative conditions, many feel that therapy and exercises can have little affect or may escalate the progression of the disease. However, others believe

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that the promotion of education and early referral to rehabilitation services is beneficial to this patient population. The Parkinson’s Disease Foundation is one organization that promotes education and early referral to occupational and physical therapy. Patients of all ages who have been diagnosed with Parkinson’s disease can profit from OT, PT, and home based exercise programs. Occupational and physical therapy are established as a means to improve the quality of life and delay the disabling aspects of the disorder.5 The rehabilitation professional is encouraged to work as a multi-disciplinary team with the physician.2,3,10 According to the American Physical Therapy Association and the American Occupational Therapy Association, communication and open dialog between the rehabilitation team and the physician enhances patient outcomes. Physicians who wish ongoing dialog with their patients’ therapists should request updates. An electronic medical record and system has the possibility of enhancing communication between the occupational and physical therapy professional and improving patient outcomes.11 This option is presently underutilized. Centers for Medicare and Medicaid Services (CMS) and maintenance treatment: Occupational and physical therapy can treat and bill for services that maintain/manage a person’s current status, even if no functional improvement is expected, as long as SKILLED services are required by the patient.12,13 Skilled therapy according to Centers for Disease Control (CDC) is defined as “inherent complexity of the service is such that it can be performed safely and/or effectively only by or under the general supervision of a skilled therapist.”13 Collaboration between the physician and occupational and physical therapists in addressing multifactorial screening strategies has the potential to identify conditions that benefit from further physician care.14 In a recent study of 78 patients, twenty of the patients were referred back to the physician secondary to the therapist’s recognition of symptoms that had no relation to the initial referring diagnosis.14 These referrals offer evidence to the collaboration between the rehabilitation professional and physician. Acknowledgment Conflict of Interest Disclosures: The authors have nothing to disclose.

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References 1. Deitch CJ, Gutman SA, Factor S. Medical residents’ education about occupational therapy: Implications for referral. Am J Occup Ther. 1994;48(11/12):1014–1021. 2. Lovato A. 2013. When to refer rheumatology patients to physical therapy The Rheumatologist. 3. Caceres V. 2014. Occupational therapy can benefit rheumatology patients The Rheumatologist.org. Accessed March 2, 2017. 4. Keus SHJ, Munneke M, Nijkrake MJ, et al. Physical therapy in Parkinson’s disease: Evolution and future challenges. Mov Disord.. 2009;24(1):1–14. 5. Parkinson’s Disease Foundation 2008. www.pdf.org. Accessed February 12, 2017. 6. CMS. ICD-10 Next steps for providers assessment & maintenance toolkit. http:// www.the-rheumatologist.org/article/occupational-therapy-can-benefit-rheuma tology-patients/. Published October 1, 2015. Accessed March 2, 2017. 7. American Physical Therapy Association. Quick guide to the 3 levels of physical therapy evaluation: Physical therapy evaluation reference table. https://www.apta. org/uploadedFiles/APTAorg/Payment/Reform/NewEvalCodesQuickGuide. pdf. Published 2016. Accessed April 6, 2017. 8. CPT® Assistant. New Occupational Therapy Evaluation Codes. https://www. aota.org/~/media/Corporate/Files/Advocacy/Reimb/Coding/AOTA%20 CPT%20Assistant%20Article.pdf. Published 2017. Accessed February 16, 2017. 9. Centers for Disease Control (CMS). Comorbidities: What does comorbidity mean? https://www.cdc.gov/arthritis/data_statistics/comorbidities.htm. Published 2016. Accessed February 16, 2017. 10. American Physical Therapy Association. Today’s physical therapist: A comprehensive review of a 21st-century healthcare profession. https://www.apta.org/ uploadedFiles/APTAorg/Practice_and_Patient_Care/PR_and_Marketing/ Market_to_Professionals/TodaysPhysicalTherapist.pdf. Published January 2011. Accessed January 19, 2017. 11. Hillestad R, Bigelow J, Bower A, et al. Economics of health information technology: Can electronic medical record systems transform health care? Potential health benefits, savings, and costs. Health Aff. September 2005;24(5):1103–1117. 12. American Physical Therapy Association. FAQ: Skilled maintenance: What constitutes skilled maintenance? http://www.apta.org/Payment/Medicare/Coverage Issues/SkilledMaintenance/ Updated October 13, 2015. Accessed February 13, 2017. 13. CMS Manual System, Department of Health & Human Services. https://www. cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/ R179BP.pdf Published January 14, 2014. Accessed February 13, 2017. 14. Boissonnault WG, Ross MD. Physical therapists referring patients to physicians: A review of case reports and series. J Orthop Sports Phys Ther. 2012;42(5):446–454.

Author Information University of Mississippi Medical Center, School of Health Related Professions (Rogers, Willis).


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Cimetidine (Tagamet) as an Immunomodulator to Block Cytokine Storm in the Reactive Phase of COVID-19 Infection Dear JMSMA Editor: There appears to be a two-phase immune response in COVID-19 as there is in many viral infections. The first is the body’s response directly to the viral infection. This involves the local involvement of ACE2 receptors and the adjacent infected tissues. This is followed by a second, reactive stage of COVID-19 infection, which is a result of a cytokine release syndrome similar to other viral infections including SARS, MERS, and even influenza. It is a consequence of the host’s reaction to the infection precipitating a cytokine activation cascade with resultant auto-immune induced damage to lung, vascular endothelium, gastric mucosa, and other sensitive structures. This is mediated by non-T leukocytes and is found to be associated with lymphocytopenia, rising ferritin levels, a decreasing platelet count, and an elevated erythrocyte sedimentation rate.1 This response is felt to be a result of Interlukin-6 (IL-6) overexpression.2 Literature out of China suggests that IL-6 blockade may be of benefit in this stage of the infection. Other products including IL-1 and tumor necrosis factor (TNF) may be involved as well. If we could suppress these factors, we could substantially reduce subsequent lung damage.3 Data from Wuhan, China, indicate a lymphocyte response of a decrease in absolute T lymphocytes with specific reductions in both helper (CD-4) T-cells and suppressor T-cells (CD-4, CD-25 hybrid).4 Cimetidine (Tagamet) is available as an over the counter medication for heartburn relief. It is also an extremely powerful immunomodulator. Cimetidine is an H2 receptor antagonist, and its cellular consequences in normal healthy individuals include reduction of CD8+ (cytotoxic/ suppressor) cells and a corresponding increase in CD4+ (helper/ inducer) cells, with resultant reduction in hypersensitivity response.5

and immune modulated gastropathy are both seen as consequences of cytokine storm and are in themselves a justification for consideration of cimetidine therapy. A prudent starting dose would be 800 mg BID and increasing from that level. Cimetidine alters the metabolism of many drugs by decreasing their metabolism. One drug in particular which raises a concern is chloroquine,8 which may require substitution with hydroxychloroquine, dose reduction, tapering, or discontinuation. In the situation we face in terms of the COVID-19 pandemic, if we can reduce mortality with a relatively simple, inexpensive means with few side effects, we should try to do so. There is no clinical data yet, but this appears to be something we as a state and as a nation should consider. — R . Scott Anderson, MD Medical Director, Anderson Cancer Center, Meridian References 1. Mehta P, McAuley D, et al. COVID-19: Consider cytokine storm syndromes and immunosuppression. Lancet March 28 2020;395(10229):1033–1034. 2. Tanaka T, Narazaki M, Kishimoto T. Immunotherapeutic implications of IL-6 blockade for cytokine storm. Immunotherapy 2016;8(8):959– 970. 3. Ascierto P, Fox B, et al. SITC Statement on anti-IL-6/IL-6R for Covid-19. Posted March 24, 2020, pending publication in the J Immuno Therapy Cancer (JITC). 4. Qin C, Zhou L, et al. Dysregulation of immune response in patients with COVID-19 in Wuhan, China. Clin Infect Dis. 2020;Mar 12:pii: ciaa248. 5. Brockmeyer NH, Kreuzfelder E, et al. Immunomodulation of cimetidine in healthy volunteers. Klin Wochenschr. 1989;67(1):26–30.

Cimetidine has been shown to be an immunostimulant with a propensity to increase IL-2 and suppress IL-6; it increases IL-2 directly and inhibits IL-6 via the H2 receptor by inhibiting histaminic stimulation of IL-6 production.6

6. de Oliveira PA, de Pizzol-Júnior JP, et al. Cimetidine reduces interleukin-6, matrix metalloproteinases-1 and -9 immunoexpression in the gingival mucosa of rat molars with periodontal disease. J Periodontol. 2017;88(1):100–111.

As far as dosage, the Physicians' Desk Reference (PDR) recommendations are that a maximum dose is less than 2,400 mg in a 24-hour period, and can be administered as p.o. or IV dosing.7 Erosive gastritis

8. Ette EI, Brown-Awala EA, Essien EE. Chloroquine elimination in humans: Effect of low-dose cimetidine. J Clin Pharmacol. 1987;27:813– 816.

7. PDR.net Cimetidine, Dosage and Administration. https://www.pdr. net/drug-information/cimetidine. Accessed March 26, 2020.

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It Must Get Worse Before It Gets Better: Musings from a Physician with Active COVID-19 TIMOTHY J. ALFORD, MD, MSMA PAST-PRESIDENT, KOSCIUSKO

I

n times of drought we seek water, and we want our water to be pure and drinkable. In times of a public health crisis, we expect prompt deliverance from the plague.

worse before it gets better. I am five to six days into my current infection and so far have escaped pneumonitis. I am hopeful that this old fashioned and crude vaccination that I am receiving now will allow me to return and care for patients soon. Please let’s all listen to the experts and do our best to echo and amplify their words. n

Let’s be honest—before the year 2020, issues of surveillance, contact tracing, and virus jumping were not foremost in our minds. This is not to say that the constantly underfunded public health community wasn’t keeping constant pressure on the subject. There has always been a balance between making a case for public health and being completely expunged from the legislative appropriations process. As Bill Gates says, “This is the moment”. This is the kick in the head for the United States. Over the past three years, our pandemic readiness capacity has been decimated and defunded. As a consequence, we have reacted with lethargy and incompetence to the current viral crisis. The messages from the public health community have been clarion clear, yet undermined by those who refused to consider the seriousness of the moment.

[At press time, our dear friend dr. Alford has fully recovered and is back at work caring for patients.] —Ed.

As for me, I have tested positive for the novel COVID-19 as of Saturday evening March 28 at 10:30 p.m., as did a good friend and colleague. My work in the emergency room and his hospital led to the encounter with a mutual patient. We are now part of the “curve” and not apart from it. I must have done something wrong along the way to get the virus, but for the life of me, I cannot say what that was. In the process, I have placed family, friends, and patients at risk. Who am I to offer advice? We need to echo the experts of the moment, Dr. Thomas Dobbs from Mississippi, and nationally, Dr. Anthony Fauci with his calm prescriptive truths. I am prayerful as I write this, with some considerable fatigue, fever, headache, and loss of taste, that my friends, family, and patients will be spared. I do so with the understanding that we have failed to feel the full gravity of the 2020 pandemic. It must get

112 VOL. 61 • NO. 4 • 2020


Committee Seeks Candidates for Vacancies in MSMA Offices Delegates attending the 152nd MSMA Annual Session August 14-15, 2020, in Jackson will cast ballots to fill new terms of office for a number of association posts. The Nominating Committee is seeking input from the membership as the committee prepares a slate of candidates. The slate developed by the Nominating Committee will be published to the entire membership in June. All nominees must be active members of the association. No physicians may be put forth on the ballot unless that physician has expressed a willingness to serve if elected. The chart below lists the vacancies that will be filled by election in 2020. The names of incumbents and the incumbent’s eligibility to be re-elected are indicated. Terms of office follow. The Nominating Committee is composed of the nine most recent Past Presidents of the association residing in Mississippi. The Immediate Past President is the chair. Only names in black are eligible for reelection.

OFFICERS & TRUSTEES President-elect at large Speaker Trustee District 4 Trustee District 6 Trustee District 7 Trustee District 8 Trustee Resident/Fellow Trustee/Student Vice Speaker YPS Representative

INCUMBENT W. Mark Horne Geri Lee Weiland Loretta Jackson-Williams Steven Stogner Carlos A. Latorre John F. Pappas Chelsea Rick Candice Bailey Jeffrey A. Morris John Cross

COUNCILS Accreditation at large Accreditation at large Budget & Finance at large Constitution & Bylaws Ethical & Judicial Affairs Ethical & Judicial Affairs Student Legislation District 6 Legislation District 7 Legislation District 8 Legislation Resident Legislation Student Medical Education District 1 Medical Education District 3 Medical Service District 1 Medical Service District 2 Medical Service District 3 Medical Service Resident Medical Service Student Public Information District 4 Public Information District 5 Public Information District 6 JOURNAL MSMA Journal Editor Journal Associate Editor

INCUMBENT Mary G. Armstrong Shawn McKinney Lori Marshall Mary G. Armstrong Sharon P. Douglas William Ross William L. Waller Dedri M. Ivory David N. Sawyer Mitchell Moffett Elizabeth Wicks Katherine T. Patterson Barbrette Clayborn Abhash C. Thakur Hubert E. Spears, Jr. Ann Chancellor Roberson Johnny Lippincott Hannah Wikoff Angela Shannon Deanna Price J. Stephen Beam INCUMBENT Luke Lampton D. Stanley Hartness

Terms of Office: President-elect: 1 year 2020-2021; Officers, Trustees & Councils (physicians): 3 years 2020 – 2023; Trustees & Councils (students & residents): 1 year 2020-2021. Journal Editor: 3 years 2020 – 2023; Journal Associate Editor: 2 years 2020-2022. Incumbents NOT eligible for re-election are noted in gray type. Email Nominations to kwadebutler@MSMAonline.com or any member of the Nominating Committee: Michael Mansour, MD; William M. Grantham, MD; Lee Voulters, MD; Daniel P. Edney, MD; Claude D. Brunson, MD; James A. Rish, MD; Steve Demetropoulos, MD; Thomas E. Joiner, MD; Timothy J. Alford, MD.

VOL. 61 • NO. 4 • 2020 113


M S M A

Welcoming Our Newest Members

ALTHEEB, ZAID, Meridian, Cardiovascular Disease

LEE, JONATHAN, Madison, Family Medicine

BISWAS, MOUMITA, Yazoo City, Family Medicine

MAIBAM, AMITA, Tupelo, Internal Medicine

COTTER, GREGORY, Natchez, Radiation Oncology

SAHA, KALLOL, Southaven, Other

HOBBS, MITCHELL, Jackson, Pediatrics

WILLIAMS, JAMES, Tupelo, Surgery

MISSISSIPPI STATE MEDICAL ASSOCIATION MSMAonline.com

RightTrack

MEDICAL GROUP

Katherine G. Pannel, DO

Psychiatrist & Medical Director ®

Quality outpatient mental healthcare in Mississippi ✔ PSYCHIATRIC EVALUATION ✔ MEDICATION MANAGEMENT

✔ INDIVIDUAL & FAMILY THERAPY ✔ COPING SKILLS GROUPS

e m a i l : i n f o @ R i g h t Tr a c k M e d i c a l . c o m

114 VOL. 61 • NO. 4 • 2020

CLINIC LOCATIONS:

• Oxford • Tupelo • Corinth • Olive Branch • Starkville


I M A G E S

I N

M I S S I S S I P P I

M E D I C I N E

THE OLE MISS INFIRMARY/HOSPITAL INTERIOR, 1912 — This image from 1912 features the interior of the Ole Miss Infirmary, also called the Hospital, which served as the student infirmary and hospital from 1906 to 1934. Typical of a student infirmary of that period, multiple beds, I count nine, were utilized in an open ward-like setting, with chairs for the attendants or care-givers. This was the first official infirmary on the Oxford campus and would eventually be named Brady Hall in honor of Minnie Brady, the university nurse. It housed the Department of Journalism for many years before it was razed in 1979 to make room for Coulter Hall, which is home to the Department of Chemistry and Biochemistry and adjacent to the Thad Cochran Research Center. A 1967 map places Brady Hall set back on the corner of University Avenue (which it faced) and Fraternity Row, with the Power Plant behind it on the right. The Infirmary was built in 1906 as part of the original plan for the two-year Ole Miss Department of Medicine, which opened in 1903. (See related Images for November/December 2019, February and March 2020.) Inset is a later view from the 1920s of the exterior of the Infirmary, which reveals ivy growing on its walls and extensive planting and trees on the grounds. If you have an old or even somewhat recent photograph which would be of interest to Mississippi physicians, please send it to me at lukelampton@cableone.net or by snail mail to the Journal. — Lucius M. “Luke” Lampton, MD; JMSMA Editor VOL. 61 • NO. 4 • 2020 115


P O E T R Y

A N D

M E D I C I N E

Edited by Lucius Lampton, MD; JMSMA Editor

[This month, we print an inspiring and insightful poem by John D. McEachin, MD, FAAP, a Meridian pediatrician and the Journal’s unofficial poet laureate. He recently penned this brilliant remembrance and tribute to the legendary pediatric surgeon Richard Charles Miller, MD (1929–2018), who served the University of Mississippi Medical Center for 43 years, not only teaching two generations of medical students and residents, but also caring and saving the lives of countless patients. Dr. Miller was the first surgeon in Mississippi specializing in pediatrics. His wife of 56 years, Dr. Suzanne Thorne Miller, also significantly impacted the practice of pediatrics in Mississippi through her service as the state’s first pediatric pulmonologist. McEachin writes: “My experiences with pediatric surgeons were always beneficial, enlightening , and excitingly instructive. I had the pleasure of association with Bob Allen and Earle Wrenn, at Le Bonheur and St. Jude Hospitals, respectively, in Memphis in the early 1960’s. Richard Miller matched these two and became my mentor, my friend, and chief pediatric surgical consultant until my retirement in 2003. He was available, reliable, and predictably correct in his surgical assessments. Sue certainly supported all the state physicians with her devotion to the care of children with cystic fibrosis!” For more of Dr. McEachin’s wonderful poetry, see past issues of JMSMA. To contact the poet, email him at mceachinmd@bellsouth.net. Any physician is invited to submit poems for publication in the Journal either by email at lukelampton@cableone.net or regular mail to the Journal, attention: Dr. Lampton.] —Ed.

Remembering Richard Miller

It was Saturday, about noon; The three-week-old boy was asleep! I’d just felt his pyloric mass; I jumped from my stool with a leap! I got a surgeon on the phone! He would be “on call” two more days;

116 VOL. 61 • NO. 4 • 2020


His answer was kind, and to the point,

*Richard called back that afternoon:

“You’ve never referred me a case!

“He came through surgery just fine!

I’ve not performed this surgery.” (His rapid response which was true.) It was two whole days ‘til Monday,

Pyloric, as you expected; Send home, A.M. about nine!”* —John D. McEachin, MD, Meridian

And shuffling our feet wouldn’t do! I called Ped. Surgery, U.M.C.; A Resident came to the phone. He was thrilled, beyond excited; This pyloric would be his own??!! The parents found no objection; They left Meridian, post haste!

**The episode just related represents my final conversation with Richard Miller, the date sometime in the decade before the year 2000. I left pediatric residency at UT in Memphis to begin pediatric practice in Meridian in 1965. Richard came to Jackson to the University of Mississippi Medical Center in 1969. He was a terrific surgeon and a wonderful person. I sought his counsel on numerous occasions, and with each session, I was impressed by his knowledge, skill, and clinical wisdom.

When would they do the surgery? To them, not a minute to waste!

The lessons to be learned from this specific event are as follows:

Thought I should call back and check,

1. Pyloric “olives” can be difficult to palpate. Experience is the best teacher, accompanied by patience, persistence, tenacity, and the conviction that diagnostically, “you are on the right track.” (I hated, stubbornly, to yield to ultrasound or barium swallow.)

Sunday A.M., I dialed their room—

2. Pediatricians always get the first “shots” at diagnosis.

With their intense anxiety,

Mother in tears, a screaming wreck! “It’s not pyloric stenosis! They are going to ship us out! They will not do the surgery! (Lo! I did not have time to pout!) “Wait a minute, they’re coming back! Now a new Doc— bald head– is here!!” “Ma’am, let me speak to this person!” Richard and I were loud and clear!

3. Fredet-Ramstedt pyloromyotomy is best performed by surgeons with previous experience and successful results utilizing this technique. 4. The honesty of the surgeon who had not been afforded the opportunity of personal intervention (re: this surgery) is refreshing and indeed honored. 5. Trust on the parts of both the referring and the consulted physician is noteworthy. 6. The young pediatric surgical resident learned during this experience, and his future was enhanced through his association with Dr. Miller. 7. All of the physicians, plus the parents and their infant son, were ultimate beneficiaries!

VOL. 61 • NO. 4 • 2020 117


M I S S I S S I P P I

S T A T E

D E P A R T M E N T

O F

H E A L T H

State Pushes to Stem Spread of COVID-19 Virus State Health Officer Dr. Thomas Dobbs (seated left) addressed the press at the health department on Thursday, March 12, 2020. It was the first of many daily press conferences in response to the novel (new) coronavirus COVID-19. The Mississippi State Department of Health (MSDH) held the presser to announce significant updates on novel COVID-19 and new community recommendations. The MSDH is actively working with doctors and hospitals to identify cases and respond effectively to limit this outbreak quickly. The national Centers for Disease Control and Prevention (CDC) and the MSDH continue to monitor the outbreak of respiratory illnesses caused by COVID-19 closely. They are working to limit the spread of cases nationally and in Mississippi. Dr. Dobbs announced expanded access to the Public Health Laboratory’s COVID-19 testing procedures, saying all primary-care providers in Mississippi have access to courier services to send potential COVID-19 samples to the state’s testing facility or private facilities capable of confirming a possible infection.

Public health officials announced the first confirmed case of COVID-19 in Mississippi as the disease was declared a global pandemic by the World Health Organization. At the Mississippi Department of Health, state leadership called for extraordinary caution for all residents and outlined proper procedures for seeking testing. The news came as nationwide school and college closures began to spread across Mississippi, and numerous public events were postponed or canceled. It is all part of a push to stem new cases of the illness caused by the virus. Mississippi COVID-19 Case Map Cases of COVID-19 continue to be identified in the U.S. and Mississippi. This is a rapidly changing situation that is continually being monitored by the CDC and the MSDH Top left to right (standing): Sign language interpreter Greg Goldman, the Honorable as new cases are identified. Lieutenant Governor Delbert Hosemann, and House Speaker Philip Gunn. Left to right (seated): State Health Officer Dr. Thomas Dobbs, State Epidemiologist Dr. Paul Byers, Cases and deaths are reported daily and shown in an and Mississippi Emergency Management Agency Executive Director Greg Michel. interactive map on the health department's COVID-19 web page available at healthyms.com. Charts and graphs provide additional statistics and relevant data. n

118 VOL. 61 • NO. 4 • 2020


M I S S I S S I P P I

S T A T E

D E P A R T M E N T

O F

H E A L T H

Mississippi

Mississippi ProvisionalMississippi Reportable Disease Statistics* Reportable Disease Statistics* ProvisionalProvisional Reportable Disease January 2020 Statistics* January 2020

January 2020

*Monthly statistics are provisional. Disease totals may change depending on additional reporting from healthcare providers and public health investigation. These numbers do not reflect the final case *Monthly statistics arecounts. provisional. Disease totals may change depending on additional reporting

from healthcare providers and public health investigation. These numbers do not reflect the final case Public State counts. Health District Totals*

I

II

III

Gonorrhea

4

Early Latent Syphilis

HIV Disease

9

8

8

Gonorrhea Chlamydia

Mycobacterial Diseases

1

137 131

Extrapulmonary TB

317 209

4

7

11

4

1

8

8

4

11

3

4

318

133

64

510

3

03

0

0

0

8

1

0

00

Extrapulmonary TB

Tetanus

0

0

0

00

0

8

1

0 Mumps

0

0

0

1

640

1

1

0

00

01

0

0

0

00

00

1

4

0

0

0

0

10

2

Tetanus

Invasive H. influenzae disease

0

0

0

Invasive Meningococcal disease

0

0

Hepatitis A (acute)

0

4

Zoonotic Diseases

0

0 0

0

00

00

1

1

10

00

0

1

0

1

0

3

2019

2020

51 2,323552,544 51 2,544 2,323 43 103

5060 43

10350

1 0 1 1,104 1,386

0 1,104

267

2,544 2,323 2,544 2,323

0

0

1

4

05

324

1

4

0

5

0

0

00

00

0

0

0

0

0

9

0 0

0

44

0

050

0 43 0

0

0

0

0

29

00

1

0

40

0

0

0 0

0

12

37

400

33 0

0 1

0

0

0

1

04

1

1

0 0

3

0

55

6

4

6

0

2

2

3

13

0

0

00

0

0

0

00

01

00

1

0

1

02

53

23

1

2

3

0

1

8

0

12

30

38

0

1

1

2

0

0

2

1

0

2

0

5

4

0

0

0

0

0

0

0

2

E. coli O157:H7/STEC/HUS

0

0

1

0

0

0

0

4

0

Animal Rabies (bats)

Invasive Meningococcal disease

Lyme disease

Hepatitis A (acute)

Rocky Mountain spotted fever

0

00

1

0

0

00

0 0

0 0

1 1

0 0

0 1

0

00

00

1

0

10

10

4

0

0

0

0

0

00

0

18

0 0

5 4

0

00

12

3

370

5

0

0

0

0

118

0

0

0

0

0

05

0

0

0

00

0

80

44

0

1

0

0

29

5

10

0

0

44

40

0

00

0

29

11

00

0

0

44

0

0

3

9

0

10

0

0

430

5

0

3 0

0

0

0

02

0

2019

0 1,386

0

0

51

1,386 1,104 1,386 1,104

605

5

55

0 0 199 0 163

0

0

55 324

10 12610267 228

51

103YTD 60 YTD 103

0

0

0

0

199

60 Jan

0

10

0

0

163

YTD 2019

0 0 Salmonellosis 1

Invasive H. influenzae disease

0

0

IX

YTD 2020

0

Campylobacteriosis

Hepatitis B (acute)

0

VIII

Jan

State 2019 Totals*

0

Shigellosis

0

14

0

Hepatitis B (acute)

0

0

14

30

0

00

4

50

0

4

0

0 15 0

Pertussis

Mumps

4189 640 1

228 126

0

0

Measles

VII

189

0

0

104

244

Pertussis

Poliomyelitis

VI

137

Pulmonary Tuberculosis (TB)

0

137

641

1

0

V

415

2

Measles

1

1330

4

Poliomyelitis

VIII

33

Diphtheria

55

Jan3 2020

VII

7 20911 244 317

HIV Disease

10

10

VI

2 11 1

Pulmonary Tuberculosis (TB)

10

V

137 131 44

Jan 2020

IV

Health District

IV

IX

IIPublicIII

0 0318 0 104

Mycobacteria Other Than TB

Enteric Diseases

Vaccine Preventable Diseases

Early Latent Syphilis

9

7

Diphtheria

Enteric Diseases

7

Chlamydia

Mycobacteria Other Than TB

Zoonotic Diseases

Primary & Secondary Syphilis

Primary & Secondary Syphilis

Vaccine Preventable Diseases

Mycobacterial Diseases

Sexually Transmitted Diseases

Sexually Transmitted Diseases

I

6

6

00

3

0

0 0

50 0

29 0

4

5

5

5

0

4

0

6

0

0 37

0

5

3 23

5

30

5 38

4 0

5 0

6 0

43

4 37 4

3

0

0

2

Shigellosis

0

0

0

0

1

0

1

1

2

5

23

5

23

Campylobacteriosis

2

3

2

0

1

8

0

2

12

30

38

30

38

E. coli O157:H7/STEC/HUS

1

1

0

0

1

2

0

0

0

5

4

5

4

Animal Rabies (bats)

0

0

0

0

0

0

0

0

0

0

0

0

0

Lyme disease

0

0

0

0

0

0

0

0

0

0

0

0

0

Rocky Mountain spotted fever

0

0

0

0

0

1

0

3

0

4

4

4

4

0

0

0

0

8

3

13

40

0 0 0 0 0 0 0 0 0 West Nile virus *Totals include reports from Department of Corrections and those not reported from a specific District.

33

3

40

2

2

0

0

1

West Nile virus *Totals include reports from Department of Corrections and those not reported from a specific District.

3

0 33

0

Salmonellosis

0

0

0

0

0

40

0

4 0 0 4

33 0

VOL. 61 • NO. 4 • 2020 119


Cold or Allergies

Flu

Coronavirus

Itchy Eyes Stuffy Nose Sneezing Fever Fatigue Body Aches Shortness of Breath Coughs History of Travel Exposure Worsening Symptoms Sources: CDC, Mayo Clinic. For more information: www.cdc.gov/COVID19-symptoms

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