VOLUME LXI • NO. 1 • 2020 by Journal MSMA

VOLUME LXI • ISSUE NO. 1 • 2020

A fabulous gift idea for anyone in medicine! Images in Mississippi Medicine: A Photographic History of Medicine in Mississippi

. "L uk e,, M . Lampton, M D and Karen A. Evers Lucms

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Order three or more to receive a discount at: http://tinyurl.com/yb7ab974 “Images In Mississippi Medicine by Dr. Luke Lampton and Karen Evers is a handsome and impressive book, filled with stories and scenes ranging from primitive operating rooms and rows of hospitalized tornado victims a century ago to the new teaching complex at the University of Mississippi Medical Center with its modern breakthroughs. The volume is a piece of our history that every Mississippian can appreciate.” – Curtis Wilkie, journalist, author, and professor at Ole Miss David Lewis Phares, MD (\8 17-18'lll

Images in Mississippi Medicine: A Photographic History of Medicine in Mississippi; MSMA; Jackson, MS: 2018.

OF THE MISSISSIPPI STATE MEDICAL ASSOCIATION VOL. LXI • NO. 1 • JANUARY 2020

SCIENCE ARTICLES Up-To-Date Mississippi Medicine: Advances in Immunotherapy for Advanced Melanoma Bonnie D. Hodge, BS; Caleb R. Dulaney, MD; Jeremy D. Jackson, MD

President-Elect W. Mark Horne, MD

Meningococcal Vaccination for Children with Sickle Cell Disease: An Update on Guidelines Amanda Strobel, MD; Cynthia Karlson, PhD; Clinton Carroll, MD; Anderson Collier, MD; Sandor Feldman, MD

MANAGING EDITOR Karen A. Evers

Secretary-Treasurer Joe Austin, MD

Maggot Debridement Therapy: A Suitable Treatment Option for Chronic Wound Care Emilia M. Kooienga; Jerome Goddard, PhD

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

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

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

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

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

A Pilot Study of Osteoporosis Knowledge, Beliefs, and Self-efficacy 14 of Asian-Indians in Northern Mississippi Vinayak K. Nahar, MD; Richard W. Kim, MS; Philip M. Stephens, MS; Falguni Patel, MS; Linda Pham, MS; Amanda Hendricks, MS; Mary A. Haskins, PhD; Ram Lakhan, DrPH; Allison Ford, PhD; Martha A. Bass, PhD DEPARTMENTS From the Editor – Redbud in the Woods Lucius M. Lampton, MD

President's Page – AMA Interim 2019 Highlights from San Diego J. Clay Hays, Jr., MD

Images in Medicine – Welch’s Sanitarium, Wiggins Road, Jackson Lucius M. Lampton, MD

Mississippi State Department of Health Reportable Disease Statistics

Poetry and Medicine – The Ride Less Taken (Hopefully) D. Stanley Hartness, MD

ABOUT THE COVER Tibbee School, circa 1861-1933, in Tibbee, Mississippi – Located off a rural Clay County road on Vest family property, this building on the National Register of Historic Places is one of the few remaining one-room schoolhouses still standing in the state. Billy Vest inherited something akin to a caretaker's role after his mother, Lucille, died in 1998. Saving the school that appears to have been in active use from approximately 1890 until the early 20th century had been a passion of hers, one that took root around 1975. Inside, time had paused. A black, potbelly stove stood front and center, a couple of donated vintage desks nearby. On one wall hung aged copies of student rosters from long ago, names and ages preserved in the teacher's handwriting. The late Lucille unearthed these records in her research, much of it done at the Clay County Courthouse. A table in the center of the room bore a photograph labeled as the last class of Tibbee School, dated 1933. A large map Lucille drew of what Tibbee probably looked like in the late 1800s lay next to it. The railroad tracks and depot that made it a rather thriving small community, the halfway point for travelers between Columbus and West Point, are there with the stables, school, stores and grist mill, too. Imagine when students aged 5 to 20 were all taught in the same room, as class records attest. The Bible was often one of the first books studied, along with McGuffey Readers. This is where the fortunate arrived on horses, ponies or mules, and all others had to walk; yes, often for miles. Older students helped younger ones, and when they were needed in the fields for planting or harvesting, school had to come second. Schools in the South may have often suffered from poor economic conditions, but outside of school hours these one-room hubs also provided a pulse point for many rural communities, a place where potluck suppers, spelling bees, hoedowns, political rallies and even worship services might be held. Photo by: Martin Pomphrey, MD; retired orthopedist, Mayhew. n

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Redbud in the Woods D

eep in the woods of Magnolia, along a walking trail, a large Eastern redbud tree (Cercis canadensis) has fallen over, its trunk lying horizontal and its roots torn almost completely from the ground. The upended tree resembles a cowboy sprawled backwards, perhaps toppled by too much drink. The tree’s roots enhance the image: ripped out of the earth, two large pieces of the root system Lucius M. Lampton, MD are cocked skyward as if they were the Editor cowboy’s boots pointing up. Despite this desperate position, the tree refuses to die, surviving year after year with only a small, unseen root remnant sustaining its tenuous existence. Each year, new branches with heart-shaped leaves shoot up perpendicular to the tree’s flat angle. Even more bizarre, in the annual early wave of spring, this prone, then-leafless tree, by any view dead, seems to celebrate life with a pink eruption of pea-sized flower blossoms.

medical odds but do so with tenacity and beauty. As physicians and healers, we must remember never to give up on our patients, even when we can’t heal them. Oftentimes, we simply must help them with our presence to persist and endure with dignity. Countless patients of mine have been sent back to me in their final stage after being told by their specialists that there is nothing more that can be done. The specialists are usually right: there is nothing more that they can or should do to cure the patient. The patients then frequently live meaningful lives for years. Our patients want our honesty about their slim medical chances and usually don’t have any desire for aggressive or unnecessary treatment. But they never want us to give up on them. Whether it is two days or five years that they have left, they need us to get into the ditch with them and help them fight for whatever life they have. Remember the tenaciousness of the fallen redbud in bloom, and remember that your patients will surprise you with their unexpected vitality and ability to persevere against unbeatable odds. n Contact me at lukelampton@cableone.net. — Lucius M. Lampton, MD, Editor

This supine redbud in bloom reminds me of many of my frail and fragile yet resilient patients who not only cling to life against great

JOURNAL EDITORIAL ADVISORY BOARD ADDICTION MEDICINE Scott L. Hambleton, MD

EMERGENCY MEDICINE Philip Levin, MD

ALLERGY/IMMUNOLOGY Stephen B. LeBlanc, MD Patricia H. Stewart, MD

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

ANESTHESIOLOGY Douglas R. Bacon, MD John W. Bethea, Jr., MD CARDIOVASCULAR DISEASE Thad F. Waites, MD

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

CHILD & ADOLESCENT PSYCHIATRY John Elgin Wilkaitis, MD

HEMATOLOGY Carter Milner, MD

CLINICAL NEUROPHYSIOLOGY Alan R. Moore, MD

INFECTIOUS DISEASE Rathel "Skip" Nolen, III, MD

DERMATOLOGY Robert T. Brodell, MD Adam C. Byrd, MD

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

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INTERNAL MEDICINE/ EPIDEMIOLOGY Thomas E. Dobbs, MD MEDICAL STUDENT John F. G. Bobo, M4 NEPHROLOGY Harvey A. Gersh, MD Sohail Abdul Salim, MD OBSTETRICS & GYNECOLOGY Sidney W. Bondurant, MD Sheila Bouldin, MD Darden H. North, MD ORTHOPEDIC SURGERY Chris E. Wiggins, MD OTOLARYNGOLOGY Bradford J. Dye, III, MD PEDIATRIC OTOLARYNGOLOGY Jeffrey D. Carron, MD

PEDIATRICS Michael Artigues, MD Owen B. Evans, MD PLASTIC SURGERY William C. Lineaweaver, MD, Chair PSYCHIATRY Beverly J. Bryant, MD June A. Powell, MD PUBLIC HEALTH Mary Margaret Currier, MD, MPH PULMONARY DISEASE Sharon P. Douglas, MD John R. Spurzem, MD RADIOLOGY P. H. (Hal) Moore, Jr., MD RESIDENT/FELLOW Cesar Cardenas, MD UROLOGY W. Lamar Weems, MD VASCULAR SURGERY Taimur Saleem, MD

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Up-To-Date Mississippi Medicine: Advances in Immunotherapy for Advanced Melanoma BONNIE D. HODGE, MD; CALEB R. DULANEY, MD; JEREMY D. JACKSON, MD occur and be harder to detect in people with more darkly pigmented skin color.

Introduction Melanoma, the most fatal form of skin cancer, is the sixth leading cause of cancer among both men and women. The incidence has increased 10-fold from previous decades and is now estimated at 22.8 in 100,000 people.1 In Mississippi, there were 4,275 new cases of melanoma in the years 2011-2015, with an age-adjusted rate of 26.3 (Figure 1). These cases resulted in 381 deaths.2 The risk factors are well known: fair complexion, increased sun exposure, large number of common nevi, family history, and age. While more common among people of fair complexion, it is important to remember that melanoma can also

Melanoma begins as an indolent growth confined to the epidermis. If caught at this radial growth phase, surgical resection offers excellent prognosis as the chance of metastasis is unlikely. In fact, observational studies have shown that melanomas detected by physicians are thinner than patient-detected lesions, underlining the importance of skin screening.3 Given time to progress, a melanoma will grow into the underlying reticular dermis, known as the vertical growth phase. Here, lymphatic or hematogenous metastasis may occur, which can be life-

Figure 1. Incidence of Melanoma in Mississippi by County (2011-2015)

Figure 2. ABCDEs of Melanoma

Age-Adjusted Cancer Incidence Rates in Mississippi Melanoma of the Skin | 2011 – 2015 | By County AgeAdjusted to the 2000 U.S. Standard Million Population

Mississippi Rate: 26.27 / per 100,000 Legend: 7.49 – 18.93 19.18 – 25.89 26.15 – 32.14 32.50 – 49.31 D Unstable Risk CJ Population less than 1700

All rates per 100,000. Data accessed June 16, 2018. Based on data released Feb 2018. 2018 Mississippi Cancer Registry.©

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ABCDE ’s of Melanoma A

Asymmetry | If a lesion is bisected, one half does not match the other

Border | Irregular or uneven borders that are not smooth and well-defined

Color | Variations in color can include multiple shades of brown, red, blue, black, gray, or white

Diameter | >6 mm or the diameter of a pencil eraser

Evolution | Lesion that changes in size, shape, or color over time or emergence a new lesion

Tables: Table 1. Melanoma Treatment by Stage

Table 1. Melanoma Treatment By Stage

Stage 0 I II III ‐ Resectable

Criteria

Standard Treatment

In situ (intraepithelial)

Excision Excision, with or without lymph

Localized invasive disease

node management

Invasive disease with regional nodal disease

node management, + adjuvant therapy and immunotherapy

III ‐ Unresectable IV

Excision, with or without lymph

Intralesional therapy, immunotherapy, signal transduction

Distant metastatic disease

inhibitors, chemotherapy, or

Recurrent melanoma

palliative local therapy

Adapted from the National Cancer Institute’s Melanoma Treatment (PDQ®) – Health Professional Version. https://www.cancer.gov/types/skin/hp/melanoma‐treatment‐pdq#link/_25_toc Accessed June 16, 2018.

threatening. An exception to this growth pattern is nodular melanoma which starts in the vertical growth phase at its inception and thus has increased depth at the time of diagnosis. A definitive diagnosis is determined by pathological analysis of a biopsy, which sheds light on the single most important indicator of prognosis: depth of invasion. This depth, termed the Breslow Depth, measures from the granular cell layer to the deepest invasive cell in the dermis or subcutaneous fat. As tumor depth increases, survival steadily declines the 10-year survival rate (92%) in patients with a tumor thickness <1 mm deteriorates to 50% in tumors >4 mm thick.1

There are four types of melanoma: superficial spreading, nodular melanoma, lentigo maligna melanoma, and acral lentiginous melanoma. • The superficial spreading subtype is the most common form, accounting for 70% of melanomas. 60% are diagnosed as highlycurable lesions confined to the epidermis and thus have a good prognosis. It is also the most likely type to arise from a pre-existing nevus (although up to two-thirds of melanomas arise de novo). It has a predilection for the upper back in men and the lower extremities in women. • Nodular melanomas account for 15-20% and are most often >2 mm in depth at the time of diagnosis for reasons previously mentioned. Likewise, 50% of melanomas >2 mm at time of diagnosis are found to be the nodular subtype. They appear as darkly pigmented papules or nodules. • Lentigo maligna melanoma, most commonly seen in chronically sun-damaged skin of older people, makes up 15% of melanomas, and its incidence is on the rise. It begins as a tan or brown macule that slowly

enlarges over the years and can develop foci of hyperpigmentation or color variegation. Raised areas that develop within the lesion suggest vertical growth. • Acral lentiginous melanoma is the least common subtype and accounts for 5% of melanomas. It is the most common melanoma in dark-skinned individuals and classically arises on the palms, soles, and beneath the nail plates. Occasionally, this subtype can present as amelanotic or hypomelanotic lesions that can be confused for warts, calluses, or ingrown toenails. Diagnosis Melanomas are most commonly found on the back, and patients most often present complaining of a changing mole. Advanced lesions can even present with itching and bleeding. A mnemonic well-known by both physicians and laypeople for features of melanoma is ABCDE (Figure 2). Originally just “ABCD,” the “E” was added in 2004 to include a fundamental aspect of melanoma and one of the most common chief complaints of patients with suspicious spots: evolution of the lesion over time. In patients with multiple nevi, the “ugly duckling sign” is an important diagnostic indicator as one lesion that differs in appearance from the rest, termed the “signature nevi,” is considered suspicious even if it does not meet any of the ABCDE criteria. Complete, full-thickness excisional biopsy is the standard of care for the diagnosis of suspicious lesions with a margin of 1-3 mm. This can be obtained by excisional biopsy, punch biopsy, or cauterization with a deep shave biopsy. Detailed history and clinical information, including which ABCDE criteria are met, should be provided to the pathologist to aid in histopathologic analysis. Additional information helpful to the JANUARY • JOURNAL MSMA

Table 2. Immunotherapy Drugs And Their Cellular Targets lmmunotherapy

Target

Dabrafenib

BRAF1 inhibitor

Trametinib

MEK 2 inhibitor

Vemurafenib

BRAF1 inhibitor

Cobimetinib

MEK 2 inhibitor

Pembrolizumab

PD-13

Nivolumab

PD-13

lpilimumab

CTLA-4 4

1 BRAF

is a cell signaling factor involved in the MAP kinase/ERK signaling pathway that directs cell growth. Mutation can cause constitutive action and unchecked cell growth. 2 MEK is also involved in the MAP kinase/ERK pathway, and thus its inhibition can slow growth in cancer cells. 3 PD-1 (programmed cell death protein 1) is found on the surface of cells and plays a role in "self-tolerance" by down-regulating the immune system's response to its own cells. It plays an important role in preventing autoimmune disease but can also prevent the immune system from killing cancer cells. Drugs that target PD-1 "release the breaks" on the immune system to kill cancer cells. 4 CTLA-4 is a protein receptor constitutively expressed in regulatory T cells that acts as an "off" switch on the immune response. Some cancers, including melanoma, can upregulate expression of CTLA-4 and shield itself from killing encouraging immune system tolerance. Drugs that target CTLA-4 inhibit this tolerance.

pathologist includes anatomic location, size of the lesion, and marking of any suspicious foci. Definitive diagnosis is histopathologic and based on architectural and cytological features. The four stages of melanoma and their definitive treatment options are shown in Table 1. Recent Developments The definitive management of primary melanoma is wide surgical excision. Because the primary treatment for melanoma is surgical, medical management for adjuvant therapy has typically been reserved for patients with advanced (lymph node positive) or metastatic melanoma. Patients with deep primary lesions (>4 mm) or regional

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Table 3. National Comprehensive Cancer Network Guidelines For Melanoma Treatment Based On Braf Mutation Status Mutation Status

NCCN Treatment Guidelines

+ BRAFVG00

Dabrafenib plus trametinib or Vemurafenib plus cobimetinib

- BRAF VG00 (wild-type BRAF)

Pembrolizumab or Nivolumab or Nivolumab plus ipilimumab

lymph node involvement are considered high risk as less than half of these patients will have long-term disease-free survival. Therefore, these patients (stage III or greater) are considered eligible for adjuvant therapy. A distinction in treatment direction is made by identifying whether or not the tumor has a mutation in BRAF V600 as some adjuvant medications target this signaling factor (Table 2). B-RAF is a cell signaling factor that, when mutated, is constitutively activated and voraciously promotes cell growth. As many as 40% of melanomas are found to have BRAF mutations and thus benefit from BRAF-targeted immunotherapy. In melanomas without BRAF mutation, other immunotherapies that target the immune system are available. Recently, the New England Journal of Medicine (NEJM) published three landmark trials looking at immunotherapy as adjuvant or definitive targeted therapy for stage III melanoma. With these trials have come new treatment guidelines from the National Comprehensive Cancer Network4 (Table 3). 1. For patients with BRAF V600 mutation completely resected stage III melanoma, adjuvant dabrafenib and trametinib improved relapse-free survival by almost 20% and overall survival by 10%.5 On May 1, 2018, the FDA approved this combination, making it the first oral systemic therapy regimen to prevent cancer relapse in node-positive melanoma with BRAF mutation. Both RAF and MEK are involved in an important cell signaling pathway that is hijacked in melanoma to promote uncontrolled proliferation. Dabrafenib and trametinib block this signaling cascade to inhibit tumor cell proliferation. 2. For patients with completely resected stage III-IV melanoma, adjuvant nivolumab improved recurrence-free survival by 10% and was less toxic than ipilimumab.6 Both nivolumab and ipilimumab are considered immune checkpoint inhibitors. In normal immune function, the immune checkpoint is used to prevent or suppress overactive immune cell activity—think of it as an “off switch” for the immune system. The cell receptors involved in this checkpoint identify host cells as “self ” and suppress the activity of immune cells. Melanoma takes advantage of this checkpoint to evade detection and destruction by the immune system. Nivolumab blocks the PD-1

receptor on T-cells. Ipilimumab blocks the CTLA-4 receptor on T-cells. By blocking this signaling process, the immune system can be “turned on” so that a robust immune response can be directed against melanoma cells. 3. For patients with BRAF V600 mutation in unresectable stage IIIIV melanoma, nivolumab or nivolumab plus ipilimumab improved overall survival by almost 20% compared to ipilimumab alone.7 These findings are particularly important because they demonstrate that immunotherapy is an effective treatment option in addition to BRAF targeted therapy in patients with BRAF mutations. However, BRAF targeted therapy and immunotherapy haven’t been directly compared yet.

Calling All Mississippi Physician-Photographers Enter the 2020 Journal Cover Photo Contest

Conclusion Melanoma is a potentially deadly skin cancer, and the incidence in Mississippi is higher than the national average. As such, early recognition by physicians is important as melanomas diagnosed with minimal thickness have excellent prognoses. Likewise, patient education on the ABCDEs of melanoma and their involvement in early detection is critical. For melanomas caught at later stages, however, tremendous advances in immunotherapy provide new hope for treatment and improved survival. Both BRAF targeted therapies and immune checkpoint inhibitors are now front-line treatment for advanced or metastatic melanoma, and the National Comprehensive Cancer Network recently updated their treatment guidelines to reflect breakthrough discoveries found in three major NEJM trials. While these treatments offer hope on one end of the melanoma spectrum, Mississippi physicians can work at the front end to both encourage prevention and provide early detection. n References

Film or Digital Shoot anything you can capture as a high-resolution image. Subjects given the highest consideration are those indicative of Mississippi. Photos of original artwork are also acceptable. The MSMA Committee on Publications will judge the entries on the merits of quality, composition, originality, and appropriateness to the JMSMA. Specifications: Vertical composition. Color slides, digital files & photos (at least 300 DPI/PPI). A hard copy print is required for judging.

4. National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology: Melanoma. NCCN. http://www.nccn.org/professionals/physician_ gls/pdf/melanoma.pdf. Accessed June 16, 2018.

Please include a brief description of the photo and information about the physician/photographer. Submit your narrative of the image to appear as “About the cover” in the magazine.

5. Long GV, Hauschild A, Santinami M, et al. Adjuvant Dabrafenib plus Trametinib in Stage III BRAF-Mutated Melanoma. N Engl J Med 2017;377:1813-1823.

For more info contact:

1. National Cancer Institute. Cancer Stat Facts: Melanoma of the Skin. https://seer. cancer.gov/statfacts/html/ld/melan.html. Accessed June 16, 2018. 2. Mississippi Cancer Registry. https://www.cancer-rates.info/ms. Accessed June 16, 2018. 3. Wolff T, Tai E, Miller T. Screening for skin cancer: an update of the evidence for the U.S. Preventative Services Task Force. Ann Internal Med 2009;150:194.

6. Weber J, Mandala M, Del Vecchio M, et al. Adjuvant Nivolumab versus Ipilimumab in Resected Stage III or IV Melanoma. N Engl J Med 2017;377:1824-1835. 7. Wolchok JD, Chiarion-Sileni V, Gonzalez R, et al. Overall Survival with Combined Nivolumab and Ipilimumab in Advanced Melanoma. N Engl J Med 2017;377:13451356.

Author Information M4, University of Mississippi School of Medicine, Jackson (Hodge). Radiation Oncology, Anderson Regional Health System, Meridian, MS (Dulaney). Associate Professor, Department of Dermatology, University of Mississippi (Jackson).

Size: Vertical format 5 x 7” or 8 x 10” Deadline: January15, 1, 2020 2020 January

Karen Evers, Managing Editor 601-853-6733, ext. 323 or KEvers@MSMAonline.com

Mail to:

P.O. Box 2548 Ridgeland, MS 39158-2548 or deliver to MSMA headquarters 408 W. Parkway Place, Ridgeland, MS 39157

Corresponding Author: Bonnie D. Hodge, 1607 Piedmont Street, Jackson, MS 39202 Ph: (601)692-6193 (bhodge2@umc.edu).

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Meningococcal Vaccination for Children with Sickle Cell Disease: An Update on Guidelines AMANDA STROBEL, MD; CYNTHIA KARLSON, PHD; CLINTON CARROLL, MD; ANDERSON COLLIER, MD; SANDOR FELDMAN, MD The Advisory Committee on Immunization Practices (ACIP) released new recommendations for the use of meningococcal vaccinations in children with sickle cell disease. The recommendations and the current standard of care will be reviewed in this article.

at 2 months of age and continued until age 5 years of age, routine evaluations by a pediatric hematologist, and vaccinations against encapsulated organisms. Recent Meningococcal Vaccination Developments

Sickle cell disease Sickle cell disease refers to a broad group of genetic disorders characterized by abnormal hemoglobin. This abnormal hemoglobin can decrease red blood cell stability by polymerizing and causing a change in cell shape, which is referred to as “sickling.” Clinically, sickle cell disease manifests as hemolytic anemia, chronic and acute pain, and functional asplenia.1 According to the Mississippi Department of Health, Mississippi has approximately 60 children born each year with some type of sickle cell hemoglobinopathy. These children are identified by a newborn screen at or near the time of birth and parents are notified by the Mississippi State Department of Health of the screening results if positive. Infection in sickle cell disease Infection is a leading cause of significant morbidity and mortality in patients of all ages with sickle cell disease, and epidemiological reports show that infection is the leading cause of death in pediatric patients.1,2 The increased infection risk in sickle cell disease stems from functional asplenia due to auto infarction over time-related to repeated sickling and compromised blood flow. The functional asplenia results in increased susceptibility to infectious agents with encapsulated organisms such as Streptococcus pneumoniae, Haemophilus influenzae, and Neisseria meningitidis.2 Before modern infection preventative protocols were implemented, patients with sickle cell disease were 30-600 times more likely to develop invasive pneumococcal disease.3 This increased risk was especially true in children less than 5 years old.1 Now due to prophylactic daily antibiotics and enhanced immunization techniques, invasive pneumococcal infections have markedly decreased.3 Neisseria meningitidis is a bacterial organism that causes meningitis, bacteremia, sepsis, and pneumonia.4 For the general population, incidence has declined since its peak in the 1990s to approximately 300-400 cases annually in the United States, in part due to immunizations.5 Current prophylactic procedures for all children with any variant of sickle cell disease include administration of twice-daily oral penicillin starting

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There are two quadrivalent meningococcal conjugate vaccines that include protection from serotypes A, C, W, and Y named MenACWY-D (Menactra) and MenACWY-CRM (Menveo). MenACWY-D (Menactra) is no longer recommended for patients with sickle cell disease under 2 years of age. This is due to their higher risk for invasive pneumococcal disease and reported immune interference with 13-valent pneumococcal conjugate vaccine (PCV13).6 This delay in meningococcal vaccination leaves young patients vulnerable to this particular infection. The new quadrivalent conjugate formulation named MenACWY-CRM (Menveo) provides coverage for serotypes A, C, W, and Y and is approved starting at age 2 months.8 The only other option for infants younger than 2 years is the bivalent formulation Hib-MenCY-TT (MenHiBrix), which contains protection against Haemophilus influenzae type b (Hib) and meningococcal serogroups C and Y.7 Notably, this formulation does not protect against serogroups A and W.7 Practice Guidelines In 2013, the ACIP released a report detailing new recommendations for meningococcal coverage for patients with increased risk of contracting the disease, including patients with sickle cell disease.8 Safety and immunogenicity data from five phase three clinical trials reviewed the use of MenACWY-CRM (Menveo) in patients aged 2 months through 23 months.8 No interferences with pneumococcal vaccines were identified.8 This new recommendation significantly broadened the coverage available to younger patients. After thorough analysis, the ACIP made final recommendations that MenACWY-CRM (Menveo) or Hib-MenCY-TT (MenHiBrix) be used in high risk infants and that they receive a four dose vaccination series with doses at 2, 4, 6, and 12-15 months.8 By providing either of these formulations, younger children are able to receive meningococcal coverage at a crucial time period of increased risk. Children with sickle cell disease should now receive the MenACWY-CRM (Menveo) or Hib-MenCY-TT (MenHiBrix) series along with their routine infant vaccinations in the first two years

Meningococcal Vaccination in Pediatric SCD Table.Recommended Recommended immunization schedule for children withCell sickle cell disease Table. Immunization Schedule For Children With Sickle Disease

Child Age

General Practice

Additional Vaccinations Meningococcal

Influenza

Routine Vaccines

MenACWY-CRM or Hib-MenCY-TT at 2, 4, 6, and 12-15 months

Annual

2-5 years

Routine Vaccines

PPSV23

MenACWY-D or MenACWY-CRM 3 years after primary series

Annual

> 5 years

Routine Vaccines

PPSV23 every 5 years

MenACWY-D or MenACWY-CRM every 5 years

Annual

Under 2 years

Pneumococcal

Note. Abbreviations used in this table include PPSV23 = Pneumococcal polysaccharide; MenACWY-CRM = Menveo; MenACWY-D = Menactra; and Hib-MenCY-TT = MenHiBrix

of life. These are covered under the Vaccines For Children program. Finally, for reinforcement of this new primary series and continued coverage, the recommendation is that MenACWY-D (Menactra) or MenACWY-CRM (Menveo) be given three years after the primary MenACWY-CRM (Menveo)/ Hib-MenCY-TT (MenHiBrix) series and then every 5 years thereafter.8 Conclusions

2010;14:e2–e12. 3. Halasa NB, Shankar SM, Talbot TR, et al. Incidence of invasive pneumococcal disease among individuals with sickle cell disease before and after the introduction of the pneumococcal conjugate vaccine. Clin Infect Dis 2007; 44:1428-1433. 4. Centers for Disease Control and Prevention. Prevention and control of meningococcal disease: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 2013;62(No. RR2):1–28. 5. Centers for Disease Control and Prevention. Meningococcal Disease: Technical & Clinical Information. http://www.cdc.gov/meningococcal/clinical-info.html. Accessed June 1, 2016.

In concord with the ACIP guidelines to prevent meningococcal infections in vulnerable pediatric populations, the MenACWYCRM (Menveo) or Hib-MenCY-TT (MenHiBrix) vaccination series should be given to children with sickle cell disease along with their routine infant vaccinations at 2, 4, 6, and 12-15 months. (Table) According to the Centers for Disease Control, rates for routine infant vaccinations in Mississippi, last reported in 2015, were about 70%.9 In comparison, the national average was 72%.9 This ranks Mississippi 38th in the country for routine infant vaccinations.9 The rate of MenACWYCRM (Menveo) or Hib-MenCY-TT (MenHiBrix) vaccinations in Mississippi is currently unknown. The Mississippi State Department of Health has ongoing quality improvement projects assessing current meningococcal vaccination rates in order to compare them to our other infant vaccination rates. It is hoped that such quality improvement projects will lead to valuable information to guide future state-wide interventions aimed at increasing meningococcal vaccination rates in children with sickle cell disease. n

6. Centers for Disease Control and Prevention. Recommendation of the Advisory Committee on Immunization Practices (ACIP) for use of quadrivalent meningococcal conjugate vaccine (MenACWY-D) among children aged 9 through 23 months at increased risk for invasive meningococcal disease. MMWR 2011;60:1391–1392.

References

Department of Pediatrics, Division of Hematology/Oncology, University of Mississippi Medical Center (Strobel, Karlson, Carroll, Collier). Mississippi State Department of Health, Division of Immunizations (Feldman).

1. Orkin SH, Fisher DE, Ginsburg D, et al. Nathan and Oski’s Hematology and Oncology of Infancy and Childhood, ed 8, Orkin SH (ed). Philadelphia, PA: Elsevier Saunders; 2015:675, 694-696. 2. Booth C, Inusa B, Obaro SK. Infection in sickle cell disease: A review. Int J Infect Dis

7. Centers for Disease Control and Prevention. Infant Meningococcal Vaccination: Advisory Committee on Immunization Practices (ACIP) Recommendations and Rationale. MMWR 2013; 62:52-54. 8. Centers for Disease Control and Prevention. Use of MenACWY-CRM vaccine in children aged 2 through 23 months at increased risk for meningococcal disease: recommendations of the Advisory Committee on Immunization Practices, 2013. MMWR 2014;63:527–530. 9. Combined 7-vaccine Series coverage among children 19-35 months by State, HHS Region, and the United States, National Immunization Survey (NIS), 2015. (2016, October 6) https://www.cdc.gov/vaccines/imz-managers/coverage/childvaxview/data-reports/7-series/dashboard/2015.html.

Acknowledgment The authors have no conflicts of interest to disclose. Author Information

Corresponding Author: Cynthia W. Karlson, PhD; University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216. Ph: (601)984 2723 (ckarlson@ umc.edu).

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Maggot Debridement Therapy: A Suitable Treatment Option for Chronic Wound Care EMILIA M. KOOIENGA; JEROME GODDARD, PHD

Abstract Chronic, non-healing wounds due to burns, diabetes, and other injuries cost United States patients about 50 billion dollars each year. Traditionally, treatment has involved surgical debridement of necrotic tissue and frequent cleaning and changing of the wound and dressings to manage infection risk and promote healing. In the 1920s, a new method of wound debridement called maggot debridement therapy or MDT emerged and has continually developed into an effective treatment strategy. Sterile, live blow fly larvae are either placed into the wound and sealed in by gauze or held in place by a mesh bag in the wound. Secretions of the larvae kill bacteria, dissolve necrotic tissue, and stimulate healthy tissue formation. Studies have shown that MDT has the power to debride and contribute to wound healing as early as four weeks, compared to conventional therapy. With multiple benefits and few side-effects, MDT is a well-supported and increasingly accessible tool for physicians in chronic-wound treatments. Introduction Chronic wounds affect about 2% of the population of the United States, with a total cost of about 50 billion dollars annually.1 The cost of care increases in those patients with co-morbidities, complications, or other conditions related to their wounds. Traditional therapies for chronic wound care consist of surgical debridement of necrotic tissues supplemented by antibiotics. Maggot Debridement Therapy (MDT) is an alternative method of debridement in wound care that warrants further exploration. The use of maggots in wound care was first noted by William Baer at Johns Hopkins hospital in the 1920s as having a positive impact on healing soldiers’ wounds;2 however, post-World War II, maggot therapies were mostly replaced with antibiotic therapy and surgical techniques.2 In this paper, we explore traditional therapies used in debriding wounds and compare them with the merits, uses, and efficacy of MDT. Myiasis The infestation of living vertebrates with dipterous larvae is called myiasis and can be either facultative (opportunistic) or obligate. Obligate myiasis constitutes true parasitism and is a complex

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issue. The subject of this paper is facultative myiasis and how it can be used in clinical medicine. Flies, particularly those in the family Calliphoridae, lay eggs on dead animals that the developing larvae consume. Unfortunately, sometimes the adult flies mix up what is dead or alive and may lay their eggs in malodorous, pus-filled wounds on people and animals. This is sometimes termed cutaneous myiasis where fly larvae enter an open wound, feeding upon dead tissue in the wound. They do not subsequently enter into living tissue. While there are stories of people stranded outdoors after an accident with maggots in their lesions (supposedly helping prevent infection), these infestations may lead to secondary infection of the wound.3 “Wild” or naturally occurring flies and their larvae may transport a host of pathogens into the wound. For example, Staphylococcus aureus and other Group B Streptococcus organisms have been isolated from myiasis patients’ wounds.3 Types of Chronic Wounds Chronic wound care typically refers to those slow- or non-healing ulcer-like sores most often found on bedridden patients or diabetics.4 Pressure ulcers are common among bedridden patients in long-term inpatient care or who are afflicted with medical conditions that limit or prevent movement of the body.5 These ulcers develop on the less padded areas of the body with more delicate skin and less fat. In comatose patients, for example, ulcers are commonly found on the back, hips, heels and ankles.5 Patients who rely on the daily use of a wheelchair often find developing ulcers on their shoulder blades, tailbone, and back from both pressure and friction. Diabetic patients, as well as other patients with vascular diseases, are also at risk of developing pressure non-healing ulcer wounds. Decreased blood flow and nerve damage from diabetes complications mean the area, once pressure is applied, gets even less blood. This leads to tissue death as nutrition and hydration are withheld from the area. Nerve damage in the ulcer-forming area means that the patient may not feel the excess pressure or friction and will not be aware of the need to change body position to prevent injury. Complicating matters, secondary infections often occur in persistent open wounds. Methicillin-resistant Staphylococcus aureus (MRSA), in particular, is a notable concern for those with chronic wounds.

Traditional Wound Care Traditional therapies for chronic wounds include frequent dressing changes and debridement to remove and manage the amount of necrotic tissues accumulating in the wound. Debridement removes these dead and decaying tissues to facilitate the growth of new healthy tissue. Not all wounds respond well to debridement, so it is up to the discretion of the physician if this is an appropriate treatment plan. Dangers of not debriding a chronic wound include increased susceptibility to infection and inhibition of healthy tissues.6 Typically, the body is well equipped to slough off its own dead skin cells, but in instances where the area is large or particularly deep, sloughed-off tissue may not leave the wound. In such cases, intervention is required. There are two types of debridement therapies: autolytic and active. In autolytic debridement, hydrocolloids and gels increase the moisture level in the lesion, helping to both keep the wound clean and stimulate the body to degrade these tissues. Active debridement involves manual removal of tissues. In that case, surgeons precisely remove necrotized tissue with scalpel and forceps or with scissors.6 However, this often leaves an irritated and bleeding wound bed. Maggot Debridement Therapy Despite having the potential to cause harm to humans, fly larvae, or in this case maggots, do have a beneficial use. When raised on a diet of sterile media and properly handled, they are capable of debriding a wound without spreading infection or feeding on living tissues. The most commonly used larvae for MDT are Lucilia sericata, which are blow flies in the family Calliphoridae (Figure).7,8 These sterile, live, medical-grade “biosurgeon” maggots can be applied using a special “maggot cage” dressing that confines the maggots to the wound site and prevents escape. These maggots have been reared in pure culture for more than twenty-two years and are able to dissolve necrotic tissue and bacterial biofilms.9 Their excretions kill bacteria, dissolve old tissue, and stimulate generation of granulation tissue – a type of new, healthy tissue that forms in healing wounds.10 Once maggots have been applied (the dosing range for maggots per square centimeter varies from 4-10 maggots depending on the healthcare provider and species/stage maggots being used). Once they are sealed against the wound with dressings, they must be checked on every two to four hours to ensure that the outer dressing is dry, the seal is strong, and that there are no openings from which maggots can escape. The maggots can be left in the wound until the area is debrided. Once the necrotic tissue has all been dissolved and ingested, maggots will cease feeding and will leave healthy tissues alone. MDT has the potential to reduce amputation rates, speed up healing using fewer treatments, and is highly selective. Maggots will not feed on non-necrotic, living tissue and generally cause no harm the patient being treated. MDT has even been shown to remove MRSA (Methicillin-resistant Staphylococcus aureus), a topic of much current interest in the medical world. After treatment is completed, the maggots can be disposed of with normal medical waste after flushing the wound thoroughly with sterile fluid to

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Blow fly maggots such as these are used in maggot debridement therapy, most often the species Lucilia sericata in the family Calliphoridae. (Medical Maggots™ Photo by RA Sherman, courtesy of Monarch Labs).

remove any residual maggots or excretions. Besides chronic wounds, MDT can be used for patients with other difficult-to-heal malignant wounds, venous wounds, and burns.9 It may also be prescribed for patients whose condition is not stable enough to undergo surgical debridement. Patients with rapidly advancing infections or deteriorating condition should not undergo MDT. MDT can take anywhere from four days to several weeks to completely debride a wound, depending on the extent of the injury. Wounds must be open to the outside of the body, not completely dry, not near major blood vessels, and cannot include bone or tendons. MDT has been successfully studied in a case study of 18 male, diabetic veteran patients with a total of 20 non-healing wounds.4 Six were given conventional surgical and chemical debridement treatment, 6 given only MDT, and the remaining 6 given conventional therapy followed by MDT. The first two weeks of conventional therapy saw no significant debridement, whereas there was a marked decrease in necrotic tissue in those patients receiving MDT. Five weeks from the

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start of treatment, conventional treatment still saw 33% of the wound covered in necrotic tissue. At four weeks, MDT had completely debrided all wounds, increased healing rate, and encouraged the growth of the healing-indicative granulation tissue.4 Another study was conducted assessing excretions of the blow fly larvae reared for MDT. Researchers saw antiseptic activity in the wound bed of patients treated with MDT and investigated potential for these secretions to inhibit growth of Staphylococcus aureus in nonhealing wounds. Secretions from maggots were collected and tested with S. aureus both alone and with supportive ciprofloxacin antibiotic. Secretions alone showed inhibition in bacterial growth, and when in conjunction with ciprofloxacin, resulted in up to 50% reduction in S. aureus colonization.4 While MDT’s effectiveness in wound debridement and wound healing is indisputable, is it still worth the time and effort involved? Traditional surgical methods involve prep work, anesthesia, surgery time, and recovery as well as careful tending to the wound as it heals because, as previously mentioned, surgical debridement results in a raw and bleeding wound bed. Recall that MDT is usually administered by a physician carefully placing the recommended dosage of maggots in the wound, followed by extensive dressings designed to protect the maggots and keep the patient safe. It requires monitoring every two to four hours to ensure the wound and dressing are properly aligned, as one study showed that 43% of the time, maggots have escaped.11 A new method for administering MDT has recently been reported.11 The BioBag is a small mesh polyester bag with varying numbers of maggots and mesh sizes. The intention is to reduce time of setting up the wound with specialized dressings. In predetermined dosages, a BioBag can be ordered on an as-needed basis for chronic wound patients. The BioBag is placed in the wound for four days and covered with simple gauze dressing to hold it in place. The mesh allows the proteolytic enzymes, anti-microbial, anti-inflammatory, and cell-stimulating secretions to enter the wound, turning necrotic tissue into a semi-liquid that the maggots are then able to consume. A research study showed no difference in effectiveness between the BioBag and other MDT administration techniques.11 With this newfound method of administering MDT, there is less time spent changing dressings and monitoring maggot activity. Additionally, wound care can be performed by a caregiver or family member at a patient’s home upon being given instruction on sterile techniques and how to change the dressing. MDT is now faster to administer, faster to heal and debride wounds, continually getting easier to use, and puts less strain on the patient’s body than conventional therapies. A cost analysis study of MDT versus traditional debridement showed that, on average, MDT costs about 50% of conventional therapy; it reduces pain perception in patients and increases healing rate.12

increasingly accessible tool for physicians to use in treating nonhealing chronic wounds. Its low cost and relative ease of use make it a more accessible treatment to patients, while its selective, precise, and gentle debridement leaves the wound clean but not bleeding. MDT is well-supported as a suitable treatment option for non-healing chronic wounds. n Acknowledgment The authors have no conflicts of interest to disclose. Author Information Department of Biological Sciences, Mississippi State University (Kooienga). Department of Biochemistry, Molecular Biology, Entomology, and Plant Pathology (Goddard). Corresponding Author: Jerome Goddard, PhD, 100 Twelve Lane, Clay Lyle Entomology, Mississippi State University, Mississippi State, MS 39762 (jgoddard@ entomology.msstate.edu).

References 1. Fife CE, Carter MJ, Walker DH, Thomson B. Wound care outcomes and associated cost among patients treated in U.S. outpatient wound centers: data from the U.S. wound registry. Wounds. 2012;24:10-17. 2. Monarch Labs, Living Medicine; 2017, Medical maggots. http://www. monarchlabs.com/mdt. Accessed November 9, 2019. 3. Francesconi F, Lupi O. Myiasis. Clin Microbiol Rev. 2012;25:79-105. 4. Sherman RA. Maggot therapy for treating diabetic foot ulcers unresponsive to conventional therapy. Diabetes Care. 2003;26:446-451. 5. Mayo Foundation for Medical Education and Research. Mayo Clinic; 2017. Bedsores (pressure ulcers). https://www.mayoclinic.org/diseases-conditions/bedsores/symptoms-causes/syc-20355893 Accessed November 9, 2019. 6. Advanced Tissue; Understanding the different forms of wound debridement, 2014. https://advancedtissue.com/2018/10/understanding-the-different-forms-of-wound-debridement/ Accessed November 9, 2019. 7. Sherman RA, Hall MJR. Medicinal maggots: an ancient remedy for some contemporary afflictions. Ann Rev Entomol. 2000;45:55-81. 8. Williams KA, Cronje FJ, Avenant L, Villet MH. Identifying flies used for maggot debridement therapy. S Afr Med J. 2008;98:196-198. 9. Provincial Nursing Skin and Wound Committee: Maggot debridement therapy (MDT) in adults and children. British Columbia, Canada, 2012. https://www. clwk.ca/buddydrive/file/guideline-maggot-debridement-therapy/ Accessed November 9, 2019. 10. Grey JE, Enoch S, Harding KG. Wound assessment. BMJ. 2006;332:285-288.

Conclusions

11. Turner J. Debriding chronic wounds with larval therapy: the new answer for biosurgery in the outpatient wound clinic? Today’s Wound Clinic; 2017. https:// www.todayswoundclinic.com/articles/debriding-chronic-wounds-larval-therapy-new-answer-biosurgery-outpatient-wound-clinic Accessed November 9, 2019.

MDT therapy has multiple benefits, few side-effects, and is an

12. Arabloo S. Saftey, effectiveness, and economic aspects of maggot debridement therapy for wound healing. Med J Islamic Rep Iran. 2016;30:319-320.

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A Pilot Study of Osteoporosis Knowledge, Beliefs, and Self-efficacy of Asian-Indians in Northern Mississippi VINAYAK K. NAHAR, MD; RICHARD W. KIM, MS; PHILIP M. STEPHENS, MS; FALGUNI PATEL, MS; LINDA PHAM, MS; AMANDA HENDRICKS, MS; MARY A. HASKINS, PHD; RAM LAKHAN, DRPH; ALLISON FORD, PHD; MARTHA A. BASS, PHD

Abstract Introduction: Asian-Indians have a high incidence rate of osteoporosis. Assessing knowledge and beliefs is the first step towards improving health behaviors to decrease the prevalence of osteoporosis. It is in this context that the purpose of this study is to assess Mississippian AsianIndians’ osteoporosis-related knowledge, beliefs, and self-efficacy. Methods: A cross-sectional study design was utilized. Convenience sampling and snowball sampling were used to recruit participants in North Mississippi. Participants were asked to complete a selfadministered questionnaire. Descriptive statistics were performed to assess levels of knowledge, beliefs, and self-efficacy. Pearson correlation analysis and independent sample t-tests were conducted to assess the potential relationships between study variables. Results: This study had a total of 108 participants. The average age of participants was 28 years. About two-thirds (65.7%) of the participants were males. Participants demonstrated low-levels of osteoporosis knowledge, perceived severity, and perceived susceptibility. On the other hand, participants had high levels of perceived self-efficacy and moderate levels of health motivation. Moreover, results indicated that females perceived they had a greater risk of osteoporosis. Conclusion: There is a need for health education programs directed towards addressing osteoporosis-related knowledge. In addition, there is a need to change beliefs and perceptions about osteoporosis among Asian-Indians. Introduction Osteoporosis is characterized by low bone mass and structural degeneration of the tissue, which makes bones weak and fragile.1 Fragility associated with osteoporosis makes bone highly susceptible to fractures.2 Two major causes of osteoporosis have been proposed in the literature, including a decrease in estrogen, commonly related to postmenopausal women3, and a lack of calcium from the progressive aging

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of the bones.4 Furthermore, morbidity and mortality in the elderly can be linked to osteoporotic fractures.5,6 Common complications resulting from osteoporotic fractures include deep vein thromboembolism, depression, delirium, and pain.7 Therefore, it can be dangerous to suffer an osteoporotic fracture. Some populations are also more susceptible to osteoporosis and bone fractures than others. Asian-Indians are at a higher risk for bone fractures than any other population.8,9 In the United States, 2,765,155 individuals are reported to be of Asian-Indian descent.10 Both in the USA and in India, osteoporosis has high incident rates among Asian-Indians.12,13 Twentyfive million Asian-Indians were predicted to have osteoporosis in 2008, a number estimated to increase with each proceeding year. Studies have shown that compared to Western Caucasian counterparts, fractures among Asian-Indians occur 20 years earlier.6 When planning a health educational program, it is important to understand that Asian-Indians are aware of their high susceptibility to osteoporosis which can result in a higher incidence rate of bone fractures. According to the US Census, in Mississippi, the population of AsianIndians in 2010 was reported to be 5,494 individuals.11 Considering high rates of osteoporosis among Asian-Indians, it is important to design interventional programs to prevent osteoporosis in this population group. To better identify health education intervention strategies, it is significant first to understand osteoporosis-related knowledge and perceptions among Asian-Indians living in Mississippi. Hence, the purpose of this study is to assess the knowledge, beliefs, and self-efficacy of Asian-Indians living in Mississippi. The current study can guide health professionals and health educators to tailor better health intervention plans for prevention and care for the Asian-Indian population. Materials and Methods Study Design, Population, and Sampling The study utilized a cross-sectional research design. Asian-Indians

Table. Descriptive Statistics Of Study Variables Table. Descriptive statistics of study variables Variables Possible Range Observed Range Mean (SD) Perceived Susceptibility (n=99) 6‐30 6‐30 14.27 (5.04) Perceived Severity (n=103) 6‐30 6‐27 17.50 (4.80) Perceived Benefits Exercise (n=105) 6‐30 14‐30 24.35 (3.57) Perceived Benefits Calcium Intake (n=105) 6‐30 14‐30 23.25 (3.51) Perceived Barriers Exercise (n=102) 6‐30 6‐23 12.15 (3.87) Perceived Barriers Calcium Intake (n=105) 6‐30 6‐19 11.88 (3.28) Self‐Efficacy (n=57) 6‐30 18‐30 23.49 (3.09) Health Motivation (n=102) 6‐30 15‐30 22.76 (2.68) Knowledge (n=108) 0‐24 0‐20 11.19 (4.73)

residing in North Mississippi were considered study participants. A convenience sampling was applied. After approval from an Institutional Review Board, Asian-Indians residing in North Mississippi were invited to participate in this cross-sectional study. Potential participants were recruited via three methods: emails at the University of Mississippi, distribution of fliers on campus, and snowball sampling technique. Individuals fitting the inclusion criteria for the study had to be 18 years of age or older then were further screened for inclusion via questionnaire by three questions requiring one ‘yes’ answer: were they born in India, were both of their parents born in India or were all of their grandparents born in India. Individuals who didn’t meet the inclusion criteria were excluded from the study. Instrumentation The Osteoporosis Health Belief Scale, Osteoporosis Knowledge Test, and Osteoporosis Self-Efficacy scales were used to best compile data regarding various aspects of the health perceptions related to osteoporosis.14 The Osteoporosis Health Belief Scale is a health belief analysis tool that contains 42 questions with seven subscales measuring susceptibility, severity, benefits of exercise, benefits of calcium intake, barriers to exercise, barriers to calcium intake, and health motivation. Participants used the Likert scale to rate each item (1 = strongly disagree to 5 = strongly agree). The Osteoporosis Knowledge Test is a survey tool utilizing twenty-four questions with two subscales to assess exercise and calcium intake.14 The Osteoporosis Self-Efficacy Scale is an evaluation instrument in which the subject answers a six-question survey. Participants used the Likert scale to rate each item (1 = strongly disagree to 5 = strongly agree). Data Analysis To conclude findings and describe the variables gathered in this study, univariate statistical measures were used. The Pearson product-moment correlation was conducted to assess associations between the study variables. To conclude the probable group differences, independent sample t-tests were implemented. The analyses were all conducted using

the Statistical Package for Social Sciences (SPSS) version 21 (Chicago, IL). The significance level was established at 0.05 a priori. Results This study had a total of 108 participants. About one-third (34%) of the participants were female (n=37), and the average age of respondents was 28.7 (± 6.3) years. At the time of response recording, the average number of years respondents lived in the United States was 4.2 years ± 5.1. The table presents descriptive statistics of study variables. Participants demonstrated a low level of osteoporosis knowledge (11.2 ± 4.7). Participants also had low perceived severity (17.5 ± 4.8), low perceived susceptibility (14.3 ± 5.0), and low perceived barriers to exercise (12.2 ± 3.9). On the other hand, participants had a high level of perceived self-efficacy (23.5 ± 3.1). Participants also had high perceived benefits of exercise (24.4 ± 3.6) and high perceived benefits of calcium intake (23.3 ± 3.5) in preventing osteoporosis. Participants also indicated a moderate level of health motivation (22.8 ± 2.7). Results of Pearson correlation analysis demonstrated a statistically significant positive correlation between total knowledge and perceived benefit of calcium intake (r = 0.330, p = 0.001) and between perceived severity and barriers to exercise (r = 0.391, p < 0.001). There was also a statistically significant negative correlation between total knowledge and perceived barriers to calcium (r = - 0.363, p < 0.001) and between perceived benefit of exercise and barriers to calcium intake (r = - 0.262, p = 0.007). There were also statistically significant correlations between total knowledge and perceived susceptibility (r=0.221, p = 0.028), time spent in the United States and perceived susceptibility (r = 0.259, p = 0.012), total knowledge and benefit of exercise (r = 0.241, p = 0.013), and age and health motivation (r = 0.263, p = 0.012) at the 0.05 level. All other correlations were not statistically significant. Lastly, the results of t-test analyses determined there was only one statistically significant difference between genders in the perceptions regarding osteoporosis. Females perceived they had a greater risk of 1

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diagnosis with osteoporosis. The perceived susceptibility of males was 13.4 ± 4.8, and the perceived susceptibility of females was higher at 15.9 ± 5.1 (p = 0.014). Discussion According to the CDC, a quarter of all women in the United States aged 65 and over suffer from osteoporosis.15 Furthermore, the worldwide incidence of male hip fractures is expected to increase by 310% by 2050 when compared to 1990 rates.16 Understanding osteoporosis knowledge and beliefs of at-risk populations, such as Asian-Indians, who have among the highest rates of bone fractures in the world, could aid in reversing these negative trends and increase disease prevention behaviors.

and perceived benefits of maintaining a healthy BMI21 may also reduce osteoporosis risk in this population. Additionally, the results showed health motivation increased with age demonstrating the importance of improving health motivation in the younger population. Practitioners could use the results of this survey to implement costeffective educational tools within their clinics. For example, simple pamphlets given to Asian-Indian patients would be an effective means of improving osteoporosis knowledge, specifically severity, risk and preventative measures, and significantly decrease osteoporosis rates in this population. Limitations

The results of this study show that this population has moderate health motivation and high self-efficacy (i.e., confidence in the ability to change health behavior) and, therefore, would be receptive to osteoporosis education interventions. While the benefits of exercise and benefits of calcium intake are appreciated by this population, per the results of this study, multiple variables crucial to health disease prevention such as perceived susceptibility to osteoporosis were low.

One in three women and one in five men will suffer from an osteoporotic fracture, with an estimated 200 million women worldwide diagnosed with osteoporosis.22 Although women are at a much greater risk of developing osteoporosis, and eventually experiencing an osteoporotic fracture,23 only 39% of people in this survey study were women. The gender disparity in the sampling population and the true population experiencing osteoporosis leads to a poor ability of the data from this study to be applied to the general population and thus represents a limitation for this study. However, even though women are at greater risk for osteoporosis and fracture, men who experience osteoporotic fracture are more likely to experience mortality after fracture,22 with men’s mortality rate 6 months after fracture being about double than in similarly aged women.24 Because men still represent a large number of the population at risk for osteoporosis and tend to have worse outcomes, it is important for studies to include them to a significant degree.

Perceived susceptibility--one’s perception of the chance of contracting a health condition-- and perceived severity--one’s perception of the seriousness of a health condition’s consequences18-- both play an important role in shaping health behaviors. For example, a recent metaanalysis found patients had a significantly higher rate of vaccination with increased perceived susceptibility and perceived severity.19 These variables, along with knowledge, are essential for shaping positive health behaviors such as those increasing the prevention of osteoporosis. However, the results of this study found Asian-Indians scored significantly low in knowledge, perceived susceptibility, and perceived severity regarding osteoporosis. Osteoporosis awareness interventions targeting the Asian-Indian population should emphasize the high risk and negative consequences of developing this disease. Furthermore, healthcare professionals should focus education on increasing perceived susceptibility and perceived severity among Asian-Indian patients to effectively lower their risk of osteoporosis.

Convenience sampling was the method of collection in this study. While this sampling method has many advantages such as low cost, shorter data collection duration, and easy administration, there are also several disadvantages.25 Limitations arising from convenience sampling include sampling bias, systematic bias, and poor generalizability leading to low external validity.26 For example, in this study, the sampling bias leads to the aforementioned gender disparity. However, as stated earlier, men have a higher rate of mortality following fracture; thus, it is important to target this demographic with educational material. The cross-sectional design of the study allows for a greater survey population at a lower expense. This methodology does not allow the research team to account for past or future changes. Regardless, the data collected can be useful for shaping future health beliefs. Although convenience sampling does lead to certain limitations presented in this study, it is an invaluable method of research analysis used extensively, specifically in pilot studies.

These deficiencies are based on a lack of knowledge among this population, and results of the bivariate analysis show the intuitive relationships between various health perceptions. Our analysis showed a marked increase in perceived benefits of calcium intake, benefits of exercise, and perceived susceptibility, with deepened knowledge. We can ascertain improving other relevant health beliefs will likewise benefit this population regarding osteoporosis risk. For example, increasing perceived benefits of vitamin D consumption20

The majority of the participants in this study were young. This could also be explained by convenience sampling used in the study. Therefore, caution must be exercised while interpreting the findings of this research. In the future, researchers should consider random sampling to make findings generalizable to the Asian-Indian population. In addition, similar study should be conducted with larger Asian-Indian population living in other geographical regions of the United States.

While additional, racially inclusive prospective studies are needed to better understand the effects of race/ethnicity on bone loss, research indicates osteoporosis-related fractures occur at a younger mean age among African Americans and Hispanics compared to Caucasians.17 Further, non-white populations with osteoporosis are more likely to also report a chronic illness or condition with lower survival rates post fracture.17

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Conclusion Osteoporosis is a debilitating disease affecting millions of men and women worldwide, with people of Asian-Indian descent at great risk of diagnosis. Although this population is high risk when surveyed, they have low perceived susceptibility and perceived severity-demonstrating their lack of knowledge regarding their risk and the consequences of this condition. Efficacious interventions addressing the aforementioned variables, administered by providers, would be cost-effective. The Asian-Indian population will likely be very receptive to interventions due to their high self-efficacy and moderate health motivation, thus potentially decreasing overall osteoporosis rates in the population. To the best of authors’ knowledge, this is the first study to assess osteoporosis knowledge and perceptions among Asian-Indians in Mississippi. These findings can be used by health professionals and educators to tailor care and education to the Asian-Indian population, specifically in Mississippi. The scope of knowledge obtained from researchers will enhance to specificity of delivery, information, and medical intervention towards reduction of prevalence of osteoporosis. n Acknowledgment The authors have no conflicts of interest to disclose. Author Information Department of Dermatology/Preventive Medicine, School of Medicine/John D. Bower School of Population Health, University of Mississippi Medical Center, Jackson, MS (Nahar). DeBusk College of Osteopathic Medicine, Lincoln Memorial University, Harrogate, TN (Kim, Patel, Pham). School of Mathematics and Sciences, Lincoln Memorial University, Harrogate, TN (Hendricks). School of Health Sciences, Stephens College, Columbia, MO (Haskins). Department of Health and Human Performance, Berea College, Berea, KY (Lakhan). Bone Mineral Density Laboratory, Department of Health, Exercise Science & Recreation Management, School of Applied Sciences, University of Mississippi, Oxford, MS (Ford, Bass). Corresponding Author: Vinayak K. Nahar, MD, Department of Dermatology School of Medicine University of Mississippi Medical Center, 2500 North State Street – L216 Jackson, MS 39216. Ph: (601) 815-5876 (naharvinayak@gmail.com).

6. K eramat A, Patwardhan B, Larijani B, Chopra A, Mithal A, Chakravarty D, Adibi H, Khosravi A. The assessment of osteoporosis risk factors in Iranian women compared with Indian women. BMC Musculoskelet Disord. 2008; 9:28-32. 7. C olon-Emeric CS, Saag KG. Osteoporotic fractures in older adults. Best Pract Res Clin Rheumatol, 2006;20(4):695-706. 8. G eorge JA, Micklesfield LK, Norris SA, Crowther NJ. The association between body composition, 25(OH)D, and PTH and bone mineral density in Black African and Asian Indian population groups. J Clin Endocrinol Metab. 2014;99(6):2146-2154. 9. M akker A, Mishra G, Singh BP, Tripathi A, Singh MM. Normative bone mineral density data at multiple skeletal sites in Indian subjects. Arch Osteoporos. 2008;3(1-2), 25–37. 10. D aniel, M., Wilbur, J., Marquez, D., & Farran, C. (2013). Lifestyle physical activity behavior among South Asian Indian immigrants. J Immigr Minor Health. 2013;15(6):1082-1089. 11. U nited States Census Bureau. Population 2010. http://www.census.gov/ . Accessed July 30, 2017. 12. Jha R, Mithal A, Brown EM. Pilot case control investigation of risk factors for hip fractures in the urban Indian population. 2nd Joint Meeting of the European Calcified Tissue Society and the International Bone and Mineral Society, Geneva; 2005. 13. K handewal S, Chandra M, Lo JC. Clinical characteristics, bone mineral density and non-vertebral osteoporotic fracture outcomes among post-menopausal U.S. South Asian Women. Bone. 2012;51(6):1025-1028. 14. K im KK, Horan ML, Gendler P, Patel MK. Development and evaluation of the osteoporosis health belief scale. Res Nurs Health. 1991;14(2):155-163. 15. N ational Center for Health Statistics. Osteoporosis. https://www.cdc.gov/nchs/ fastats/osteoporosis.htm. Accessed July 30, 2017. 16. G ullberg B, Johnell O, Kanis JA. World-wide projections for hip fracture. Osteoporos Int. 1997;7:407-413. 17. S terling R. Gender and race/ethnicity differences in hap fracture incidence, morbidity, mortality, and function. Clin Orthop Relat Res. 2011; 469:1913-1918. 18. U niversity of Twente. Health Belief Model. https://www.utwente.nl/en/bms/ communication-theories/sorted-by-cluster/Health%20Communication/ Health_Belief_Model/. Accessed September 4, 2017. 19. B rewer NT, Chapman GB, Gibbons FX, Gerrard M, McCaul KD, Weinstein ND. Meta-analysis of the relationship between risk perception and health behavior: the example of vaccination. Health Psychol. 2007;26(2):136-145.

References

20. I nternational Osteoporosis Foundation. Preventing Osteoporosis. https://www. iofbonehealth.org/preventing-osteoporosis. Accessed July 30, 2017.

1. N ational Osteoporosis Foundation. Physicians guide to prevention and treatment of osteoporosis. Excerpta Medica, 1998.

21. D e Laet C, Kanis JA, Odén A, Johanson H, Johnell O, Delmas P, Eisman JA, Kroger H, Fujiwara S, Garnero P, McCloskey EV, Mellstrom D, Melton LJ 3rd, Meunier PJ, Pols HA, Reeve J, Silman A, Tenenhouse A. Body mass index as a predictor of fracture risk: a meta-analysis. Osteoporos Int. 2005;16(11):13301338.

2. M ithal A, Bansal B, Kyer CS, Ebeling P. The Asia-Pacific regional auditepidemiology, costs, and burden of osteoporosis in India 2013: a report of international osteoporosis foundation. Indian J Endocrinol Metab. 2014;18(4):449-454. 3. A ssessment of fracture risk and its application to screening for postmenopausal osteoporosis. Report of a WHO Study Group. Geneva, World Health Organization, 1994 (WHO Technical Report Series, No. 843).

22. F acts and Statistics. International Osteoporosis Foundation. https://www. iofbonehealth.org/facts-statistics#category-15. Accessed July 30, 2017. 23. C awthon PM. Gender differences in osteoporosis and fractures. Clinical Orthop Relat Res. 2011;469(7):1900-1905.

4. R iggs BL, Wahner HW, Seeman E, Offord KP, Dunn WL, Mazess RB, Johnson KA, Melton LJ. Changes in bone mineral density of the proximal femur and spine with aging. Differences between the postmenopausal and senile osteoporosis syndromes. J Clin Invest. 1982;70:716-723.

24. K anis JA, Oden A, Johnell O, De Laet C, Jonsson B, Oglesby AK. The components of excess mortality after hip fracture. Bone. 2003;32(5):468-473.

5. K anis JA, Delmas P, Burckhardt P, Cooper C, Torgerson D. Guidelines for diagnosis and management of osteoporosis. Osteoporos Inter. 1997;7:390-406.

26. E xplorable. Convenience Sampling. https://explorable.com/conveniencesampling. Accessed July 30, 2017.

25. B ornstein MH, Jager J, Putnick DL. Sampling in developmental science: situations, shortcomings, solutions, and standards. Dev Rev. 2013;33(4):357-370.

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AMA Interim 2019 Highlights from San Diego

ississippi was well represented at the Interim American Medical Association meeting in San Diego on November 15-19, 2019. I was joined by other members of our Mississippi delegation including Dr. Jennifer Bryan, Dr. Sharon Douglas, Dr. Katherine Pannel, Dr. Randy Easterling, and Dr. Lee Voulters. Our medical student delegation included Taylor Christian, Luke Leary, Candise Johnson, Savannah Walker, Mariam Ebeid, Niki Patel, Sara Bolen-Parker, and Bobby May. Dr. Candace Keller (Anesthesia) and Sabra Sullivan (Dermatology) also attended. MSMA Staff included Dr. Claude Brunson, Dr. Scott Hambleton, Avani Patel, and David Roberts. President Dr. Patrice Harris from Georgia gave a wonderful speech to the House of Delegates and drew attention to mental health issues, burnout, and women in medicine. Dr. James Madara, AMA CEO, spoke about AMA goals, including high-quality care, access to care, affordable care, and physician wellness. He also talked about social determinants of health and what the AMA is doing with new programs to treat hypertension and diabetes. Dr. Sharon Douglas represented us at the reference committee on the Council on Medical Education. Highlights included a suggestion for using only a pass/fail system for the first 2 years of medical school, supporting residents and fellows when a hospital closes, and health insurance coverage for medical students after a needle stick. The AMA continues to work closely with American Board of Medical Specialties (ABMS) and all boards to find ways to eliminate high stakes recertification exams. The AMA is giving feedback about changing the United States Medical Licensing Exam STEPS exam to a pass/fail, reviewing issues related to the residency match, and how best to follow up on abnormal lab tests to promote better patient outcomes. This was also the first official meeting for Dr. Douglas as a newly elected member of the AMA’s Council on Medical Education. Dr. Jennifer Bryan gave a wonderful presentation at the Southeast Delegation breakfast on MSMA’s Women in Medicine program that occurred at our last Annual Session.

20 VOL. 61 • NO. 1 • 2020

She highlighted the women physician pioneers of our state including Dr. Helen Barnes, Dr LouAnn Woodward, and Dr Shawn McKinney. Dr Bryan encouraged other states to start similar events. Dr Bryan also represented us at the reference committee on the AMA’s governance and finance. Pertinent topics of discussion included moving JAMA J. Clay Hays, Jr., MD and related journals to digital printing, improving childcare at the AMA meetings to help delegates with young families, and appropriate compensation for the AMA officers. Dr. Katherine Pannel attended her first AMA event as part of our delegation and was featured on one of the AMA banners in the House of Delegates. She used her skills with social media to communicate with the folks back home and also connect with other delegations. She did great as our state representative to the Council on Constitution and Bylaws. Dr. Randy Easterling provided testimony at the Council on Public Health reference committee. The Council on Science and Public Health gave reports on cannabis and cannabinoid products, improving our emergency response for infectious diseases, and the importance of health surveillance. The AMA board of trustees reported on distracted driver education and advocacy. The AMA House of Delegates agreed with the reference committees’ recommendations to expand our AMA’s campaign against smoking to including vaping products, improve healthy food options at all medical facilities and prisons, and ensuring appropriate treatment at schools for children with sickle cell anemia. Dr. Lee Voulters participated in discussions at the reference committee on legislation. Topics of debate included scope of practice issues, Veterans Courts, the importance of having physicians at the bedside when doing radiation therapy treatments, and opioid addiction treatment. The reference committee affirmed the AMA’s commitment to oppose efforts by organizations to board certify non-physicians who mislead

“

The Mississippi delegation resolution to have the AMA develop model state legislation regarding copay accumulators for all pharmaceuticals, biologics, medical devices, and medical equipment passed the House of Delegates. This resolution will help

“

our patients with the burden of out-of-pocket costs related to drugs, devices, and equipment needed for their care.

the public to believe such board certification is equivalent to medical specialty board certification. Reports dealing with potential financial penalties related to MIPS, as well as the burdens of EHR, were referred to the AMA Board of Trustees for further study with report back to the House of Delegates at the annual meeting in 2020. The Mississippi delegation resolution to have the AMA develop model state legislation regarding co-pay accumulators for all pharmaceuticals, biologics, medical devices, and medical equipment passed the House of Delegates. This resolution will help our patients with the burden of out-of-pocket costs related to drugs, devices, and equipment needed for their care. In the reference committee related to medical service, I deliberated in discussions where prior authorization was the hot topic. The AMA continues to fight against the amount of cost and time related to this burden. The AMA also continues to be a champion against drug price escalation,

for transparency in pharmaceutical benefit manager rebates to insurance companies and pharmacies, for improving risk adjustments in alternative payment models and protecting physicians on hospital medical staffs. Our AMA continues to support pluralism, access to care for all, freedom of choice, and freedom of practice. Our AMA also pointed out that we are stronger when we have a significant percentage of physicians join our organization. Congress looks at how many physicians are part of our organization when making policy. The Mississippi delegation is proud to support the Southeast delegation in recruiting new members to the AMA. If an additional 251 Mississippi physicians join the AMA, our allotment of delegates to the House of Delegates will increase to 4 delegates and 4 alternate delegates. This will put us on par with Alabama and Oklahoma. Georgia, Kentucky, Louisiana, Maryland, South Carolina, and Tennessee all have 5 delegates while Arkansas, Delaware, West Virginia, Puerto Rico, and D.C. all have 3 or less. Other interesting facts heard at the meeting included our AMA projecting a physician shortage of between 46,000 and 121,000 physicians by 2032 and the successful use of drug courts in West Virginia and Indiana in handling the opioid crisis. Our delegation heard talks on the State Scope of Practice Initiative, how to deliver messages in a public forum, and what’s new about the 2021 E/M code update. Your Mississippi delegation to the AMA worked well as a team, and we were productive in expressing the views of Mississippi physicians. Our AMA continues to grow with over 250,000 members. The future is bright for American medicine, and your Mississippi delegation is proud to represent our state. n

J. Clay Hays, MD President, Mississippi State Medical Association

JANUARY • JOURNAL MSMA

I M A G E S

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I N

M I S S I S S I P P I

SANITARIUM ,

WIGGINS

ROAD ,

JACKSON ,

M E D I C I N E

MISSISSIPPI

WELCH’S SANITARIUM, WIGGINS ROAD, JACKSON – This postcard from the late 1930s features Welch’s Sanitarium, Inc., operated by Russell Ransom Welch, MD, who served as its medical director. On the back of the card is a description of the sanitarium: “a beautiful, twostory home, located amid quiet, restful surroundings — about 300 ft. back from the Wiggins Road, just off Clinton Boulevard, near Jackson, Mississippi… It answers a long-felt need for a private sanitarium devoted to the cure of drug and alcoholic patients as well as mild nervous and mental disorders.” It was located just off of Clinton Boulevard, which is the continuation of Jackson’s West Capitol Street. This type of residential sanitarium for “nervous” disorders was quite common in that era. The Jackson City Directories reveal the sanitarium in full operation by 1940. Dr. Welch was born July 10, 1884, and died January 21, 1941. A well-known psychiatrist, Dr. Welch was a native of Kola in Covington County, a graduate of Mississippi State, and later Tulane Medical School in 1908. He practiced general medicine at Norfield in Lincoln County for many years, working as the company physician for the Denkmann Lumber Mill there, before focusing on psychiatry, coming to Jackson after the mill closed down to become assistant superintendent of the State Insane Hospital in Jackson and then became superintendent of the East Mississippi Insane Hospital at Meridian by 1935. In the late 1930s, he established Welch’s Sanitarium west of Jackson. Besides being a pioneer in psychiatry in the state, he also was prominent in the Mississippi golfing community. He helped create a course at Norfield and was a recognized golfer along with his son. His brother, Dr. James Welch, was also an early psychiatrist, serving as superintendent of Louisiana’s state mental hospital at Pineville. He and his wife Helon Duncan Welch (1888-1944), whom he married in 1910, are buried in Lakewood Memorial Park not far from the location of the sanitarium. If you have an old or even somewhat recent photograph or image 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

22 VOL. 61 • NO. 1 • 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

Mississippi Provisional ReportableDisease Disease Statistics* Provisional Reportable Statistics Provisional Reportable Disease Statistics* February2019 2018 October October 2019 *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

Sexually Transmitted Diseases

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

Early Latent Syphilis Gonorrhea Chlamydia

Mycobacterial Diseases

Sexually Transmitted Diseases

Primary & Secondary Syphilis

Early Latent Syphilis

Gonorrhea I Chlamydia

HIV Disease

100

57 0

199 149

166

113 0

2 0

Pulmonary Tuberculosis (TB) Extrapulmonary TB

Pertussis

Tetanus

0 Poliomyelitis 1 0 0

0 0

Invasive H. influenzae disease

0 0

1 0

1 1

0 1

188 0

0 222 4

086

7 0

851 0

280

430

02 0

2 2

846 0

867

09,7690

780

8,130 0

039 5 0

0 407 0

4580

3 0

8 0

034

0 274 0

2650

0 6 21

160

078

0 0

Rocky Mountain spotted fever

West Nile virus

0 7

0 2

0 4

0 0

0 0 0

100

0 0

3 13 15 and6 those not 5 reported 14 from13 Totals include10 reports25 from Department of Corrections a specific104 District.

1,668 2,045 20,88545 18,675 3 44 81 24

0 142 0

1521 100 6

560

Shigellosis

Lyme disease

680

Animal Rabies (bats)

YTD

Invasive H. influenzae disease

YTD

603 954 2018 52720191274 2018 1,529 859 2,842 1,633 55 483 385

Measles

E. coli O157:H7/STEC/HUS

Campylobacteriosis

Salmonellosis

Hepatitis B (acute)

9379 1 0

0196 0

Oct

Hepatitis A (acute)

362 2

Oct

56 82 VIII 21 IX 60 2019 133 68 175 196 3 3 27

YTD 2017

Poliomyelitis

131 VII

YTD 2018

0 0 0 Invasive Meningococcal disease Enteric Diseases

69 V 66 VI57 175 139 3 4 155 2126

III

Tetanus

Salmonellosis

61 IV

Hepatitis B (acute)

Zoonotic Diseases

Vaccine Preventable Diseases

VIII

Diphtheria

Hepatitis A (acute) Enteric Diseases

VII

Mumps

Invasive Meningococcal disease

Zoonotic Diseases

Measles

Mumps

Mycobacteria Other Than TB

Pertussis

Vaccine Preventable Diseases

Mycobacterial Diseases

Extrapulmonary TB

III

Primary & Secondary Syphilis

Public 0 Health 3 District 0 2

Diphtheria

Pulmonary Tuberculosis (TB)

Feb 2017

State 13 Totals* 20

Mycobacteria Other Than TB

HIV Disease

Feb 2018

7 31

0 0

189

3 0

20 75

384

660

1 0

1,044

1,090

Shigellosis

137

232

Campylobacteriosis

536

522

E. coli O157:H7/STEC/HUS

108

Animal Rabies (bats)

Lyme disease

Rocky Mountain spotted fever

106

150

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.

JANUARY â&#x20AC;˘ JOURNAL MSMA

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, Stanley Hartness, MD, our brilliant and multi-talented associate editor, offers a poem. “Meet me/ Where the shadows cross…” is how he begins, bringing us into the morbid world of tobacco abuse. Dr. Hartness notes, “As current chair of the Information & Quality Health Care (IQH) board, I was gratified to learn that in 2018, Mississippi’s Tobacco Quitline had the highest quit rate in the nation. Sparked by the memory of my own father’s death courtesy of unfiltered Camel cigarettes and the current rash of untimely deaths related to vaping , I tried to capture the frustrations of nicotine addiction in this unmetered piece of poetry. Enjoy the ride.” Any physician is invited to submit poems for publication in the Journal either by email at lukelampton@cableone.net or regular mail to the Journal, attention: Dr. Lampton.] — Ed.

The Ride Less Taken (Hopefully) Meet me Where the shadows cross “Confluence” I think I heard them call it I never knew I’d signed on for the ride Signposts signaled unsettling destinations: Chest CT, Bronchoscopy, PET Scan, Biopsy The cost of a carton of smokes as prohibitive as a tank of fuel and I’ll probably have nothing to show for it when they both burn out. — D. Stanley Hartness, MD Jackson

24 VOL. 61 • NO. 1 • 2020

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VOLUME LXI • NO. 1 • 2020

Articles inside

Maggot Debridement Therapy: A Suitable Treatment Option for Chronic Wound Care