Established in 1844, our Journal is one of the oldest in the country. To learn more about the Journal and how to submit articles, please visit https://lsms.org/page/JLSMS.
EDITOR D. LUKE GLANCY, MD
VOLUME 169 NUMBER 1 • JANUARY | FEBRUARY 2017
ESTABLISHED 1844
ASSOCIATE EDITOR L.W. JOHNSON, MD
BOARD OF TRUSTEES CHAIR, GEOFFREY W. GARRETT, MD VICE CHAIR, K. BARTON FARRIS, MD SECRETARY/TREASURER, RICHARD PADDOCK, MD ANTHONY P. BLALOCK, MD D. LUKE GLANCY, MD LESTER W. JOHNSON, MD FRED A. LOPEZ, MD
EDITORIAL BOARD MURTUZA J. ALI, MD RONALD AMEDEE, MD SAMUEL ANDREWS, II, MD BOB BATSON, MD EDWIN BECKMAN, MD GERALD S. BERENSON, MD
FEATURED ARTICLES
AMANDA STAIANO, PHD ARWEN MARKER, BA MICHELLE LIU, BS ELLERY HAYDEN DANIEL HSIA, MD STEPHANIE BROYLES, PHD
2
CHILDHOOD OBESITY SCREENING AND TREATMENT PRACTICES OF PEDIATRIC HEALTHCARE PROVIDERS
C. LYNN BESCH, MD JOHN BOLTON, MD BRIAN BOULMAY, MD MICHELLE BOURQUE, JD JAMES N. BRAWNER, III, MD BRETT CASCIO, MD QUYEN CHU, MD WILLIAM PATRICK COLEMAN III, MD RICHARD COULON, MD LOUIS CUCINOTTA, MD VINCENT A. CULOTTA, JR., MD JOSEPH DALOVISIO, MD NINA DHURANDHAR, MD JAMES DIAZ, MD, MPH & TM, D r . PH JOHN ENGLAND, MD JULIO FIGUEROA, MD ELIZABETH FONTHAM, MPH, D r . PH EDWARD FOULKS, MD BEN GUIDER, MD
DAVID TADIN, MD ROBERTO QUINTAL, MD
11
FEVER-INDUCED BRUGADA PATTERN MISDIAGNOSED AS AN ACUTE MYOCARDIAL INFARCTION
DAVID BALLARD, MD RYAN FRANSMAN, MD GUILLERMO SANGSTER, MD MATTHEW AYO, BS NAVDEEP SAMRA, MD OLUWAYEMISI OJEMAKINDE, MD ADAMWELLIKOFF CATHERINE CHAUDOIR, MD GUILLERMO SANGSTER, MD ALBERTO SIMONCINI, MD CARLOS PREVIGLIANO, MD DISHA ADELLE DESOUZA
15
JEJUNAL CARCINOID TUMORS PRESENTING AS SMALL BOWEL OBSTRUCTION
HENRY G. HANLEY, MD ELIAS B. HANNA, MD LYNN H. HARRISON, JR., MD ROBERT HEWITT, MD
18
THE NON-INNOCULOUS HILAR CALCIFICATION: RECURRENT PNEUMONIA SECONDARY TO BRONCHOLITH-ASSOCIATED ACTINOMYCES
MICHAEL HILL, MD LARRY HOLLIER, MD JOHN HUNT, MD BERNARD JAFFE, MD NEERAJ JAIN, MD
TRENTON L. JAMES, II, MD STEPHEN KANTROW, MD KEVIN KRANE, MD MAUREEN LICHTVELD, MD, MPH FRED A. LOPEZ, MD F. BROBSON LUTZ, JR., MD DAVID MARTIN, MD JORGE A. MARTINEZ, MD, JD ELIZABETH MCBURNEY, MD ELLEN MCLEAN, MD REINHOLD MUNKER, MD DAVID MUSHATT, MD STEVE NELSON, MD NORA OATES, MD DONALD PALMISANO, MD, JD, FACS PATRICK W. PEAVY, MD PAUL PERKOWSKI, MD PETERMAN RIDGE PROSSER, MD ROBERTO QUINTAL, MD RAOULT RATARD, MD, MS, MPH & TM ROBERT RICHARDS, MD
DEPARTMENTAL ARTICLES
CLINICAL CASE OF THE MONTH GROUP G STREPTOCOCCAL BACTEREMIA SECONDARY TO A BURNWOUND INFECTION
PAIGE DEICHMANN AMOL SURA CHARLES SANDERS, MD NISHA P. ARAVINDAKSHAN-PATEL, MD FRED LOPEZ, MD
20
ECG CASE OF THE MONTH CONFUSION AND A SLOW HEART RATE
D. LUKE GLANCY, MD
24
DONALD RICHARDSON, MD WILLIAM C. ROBERTS, MD DONNA RYAN, MD JERRY ST. PIERRE, MD CHARLES SANDERS, MD
RADIOLOGY CASE OF THE MONTH INTUSSUSCEPTION IN ADULTS: IS THERE A LEAD POINT?
LORENA GARZA, MD NHAN NGUYEN, MD JEREMY NGUYEN, MD CYNTHIA HANEMANN, MD
26
OLIVER SARTOR, MD CHARLES SCHER, MD RICHARD SPECTOR, MD LEE STEVENS, MD JACK P. STRONG, MD PRAMILLA N. SUBRAMANIAM, MD KEITH VAN METER, MD DIANA VEILLON, MD HECTOR VENTURA, MD
CHRIS WINTERS, MD GAZI B. ZIBARI, MD
JOURNAL OF THE LOUISIANA STATE MEDICAL SOCIETY
Childhood Obesity Screening and Treatment Practices of Pediatric Healthcare Providers Amanda Staiano, PhD; Arwen Marker, BA; Michelle Liu, BS; Ellery Hayden, Daniel Hsia, MD; Stephanie Broyles, PhD
Obesity is characterized by a body mass index (BMI) ≥ 95th percentile and affects 17% of youth in the United States. 1 Family- based, intensive, multidisciplinary behavioral intervention has been proven efficacious to treat childhood obesity, 2 including sustainedweight lossupto10yearsafter theprogram. 3 TheUnited States Preventive Services Task Force (USPSTF) recommends that clinicians screen all children ages six years and older for obesity, then offer or refer them to an intensive and comprehensive behavioral intervention for obesity treatment if necessary. 4 The interventions should include dietary, physical activity, and behavioral counseling; be moderate (>25 to 75 contact hours) to high (> 75 contact hours) intensity; and delivered over at least six months. 4,5 This recommendation aligns with the stage 3 comprehensive multidisciplinary intervention of the four-stage treatment approach recommended by the Expert Committee convened by the American Medical Association, Centers for Disease Control and Prevention, and American Academy of Pediatrics. 6 While one survey evaluating clinicians’ screening practices for obesity was recently conducted among tertiary care hospitals, 7 this study sought to document how pediatric primary care providers and allied health professionals manage their patients’ weight and whether these primary care providers follow clinic practice guidelines. Most pediatric medical visits occur in primary care settings, 8 and the primary care setting offers an opportunity for early detection and intervention to achieve a healthy weight. Further, the extent to which health care providers screen for obesity-related comorbidities such as type 2 diabetes mellitus (T2DM) in youth is not known, despite an escalation in cases of pediatric T2DM in recent years. 9 The American Diabetes Association 10 and American Academy of Pediatrics 11 recommend screening children who are overweight (BMI ≥ 85th percentile) This study evaluated physicians’ childhood obesity screening and treatment practices. A26-question surveywas delivered topediatric providers in-personor viamail, e-mail, or fax throughout Louisiana. Fifty-sevenproviders completed the survey, themajority inprimary care clinics. Five providers met at least four of seven clinical guidelines, but no provider met all of the guidelines. Whereas 88% of providers screened for obesity, 7% met guidelines for referring patientswithobesity toweightmanagement services. Six providers offered interventions that included all recommended components (i.e. dietary, physical activity, and behavioral counseling). One intervention met intensity guidelines (i.e. >25 hours delivered over at least six months). Barriers to offering services included lack of reimbursement and poor compliance by families. Solutions to overcome treatment barriers should be identified to increase the provision of health care services for children with obesity.
and have any two additional risk factors for diabetes every three years upon reaching age 10 or puberty. Recommended screening tools are based on hemoglobin A1c criteria or plasma glucose criteria. The objective of this study was to identify pediatric healthcare providers’ current obesity and T2DM screening practices and the referral or provision of behavioral interventions for the treatment of childhood obesity.
METHODS
Participants
A survey was directly distributed to 677 health care providers located in 164 clinics in 28 cities in the United States state of Louisiana. The survey was distributed to an additional 675 stakeholders including representatives from the Louisiana chapter of the American Academy of Pediatrics, insurance groups, advocacy groups, and academia throughout the state, with a letter requesting that the stakeholder forward the survey to primary care providers. In total, 70 providers started and 57 completed the survey (26 online and 31 completed by hand), for a response rate of 10% (among providers directly solicited) and a completion rate of 81%. Pennington Biomedical Research Center’s Institutional Review Board approved the protocol and survey. No formal written consent was administered, but the following was included on the survey to notify participants that responses were collected for research purposes: “Your participation in this survey is voluntary and you do not have to participate if you do not want
2 J La State Med Soc VOL 169 JANUARY/FEBRUARY 2017
JOURNAL OF THE LOUISIANA STATE MEDICAL SOCIETY
to. By submitting this survey, you provide your consent for our research team to review and use the information you share with us. Your responses will be kept confidential.”
(4%), and a clinical psychologist also provided information. The types of physicians represented included pediatricians, pediatric subspecialists (endocrinologists and a gastroenterologist), combined internists/pediatricians, and family practitioners.
Description of Survey and Procedures
Providers’ Screening and Treatment Practices
The survey consisted of 26 multiple-choice and open-ended questions pertaining to the provider’s current practices in childhood obesity and T2DM screening and the pediatric weight management services offered at the provider’s facility. The USPSTF guidelines included: 1) screen for obesity if age ≥ 6 y; 2) if obese, refer to intervention; 3) offer obesity intervention with diet, physical activity, and behavioral counseling; 4) offer intervention lasting ≥ 6 months; and 5) offer intervention consisting of > 25 contact hours. The guidelines for T2D screening included: 1) screen for T2DM and 2) T2DM screening includes hemoglobin A1c or glucose. 10,11 The survey also queried the provider’s medical specialty and clinic location. Surveys were hand delivered, emailed, mailed, and/or faxed to recipients over a 6-month period (i.e. January to June 2015). An open-access link to the survey was listed on a website that targeted primary care providers. The online version of the survey was deployed by the Research Electronic Data Capture (REDCap) website hosted at Pennington Biomedical Research Center. Designed byVanderbilt University, REDCap uses a secure, web-based application to collect and store data for research purposes. 12 Alternatively, providers could complete a hard copy and return the survey via fax, mail, or email. Hard-copy surveys that were mailed or hand-delivered were entered into REDCap by a research assistant. Participants were informed that their responses would be used for research purposes. Providers could choose to provide personal contact information or complete the survey anonymously. Study procedures and materials were approved by the Pennington Biomedical Research Center Institutional Review Board.
The providers’ screening and obesity treatment practices are displayed in Table 1. The majority (88%) of providers reported screening for obesity via calculating body mass index (BMI) as a part of a regular child visit, and 61% used electronic medical records (EMRs) to automatically calculate BMI. Most providers (67%) indicated using multiple ICD-9 codes to bill for childhood obesity screening and treatment services. Sixty-three percent of providers reported screening for T2DM, and the most commonly used tools were hemoglobin A1c, fasting plasma glucose, and overweight/obesity.
WEIGHT MANAGEMENT SERVICES
Referral to Services
Though most providers estimated that between 20 and 39% of their pediatric patients were overweight/obese (Figure 1A), few referred children who were overweight or obese to a weight management service (Figure 1B). The majority (59%) of the providers indicated an increase in number of pediatric patients with overweight/obesity in the last 5 years, while 30% reported the number had not changed.
Provision of Services
Weight management services were provided by various departments within the providers’ facilities, including general pediatrics, nutrition, gastroenterology, and endocrinology. Fifty-five percent reported treatment delivered by multiple departments within the same facility. Out of the 31 providers who offered obesity treatment, most offered Stage 1 or 2 but few offered Stage 3 or 4 (Table 1). Among the healthcare providers and/or facilities who directly provided any weight intervention component, 64% provided multiple types of services, most commonly nutrition therapy, medical monitoring or assessment, and exercise services. Of six who prescribed medication as an additional treatment for pediatric obesity, three offered Metformin. Other prescriptions included appetite stimulants/depressants, Adderall, and Xenical/Orlistat. Two providers reported prescribing multiple medications. Thirty-three percent of the responding providers’ facilities offered multiple stages of treatment.
Data Analysis
Of the 70 providers, 13 were excluded from the analysis due to answering only one question. Fifty-seven surveys were included in the analysis. The primary endpoints were summary data of the screening and treatment practices currently offered by providers. The secondary endpoints were proportion of providers who provided screening and treatment services that met each of seven identified clinical guidelines.
RESULTS
Survey Participants
Eligibility for Services
The 57 providers were located in 17 cities across Louisiana. The majority practiced in primary care (56%) or specialty (18%) clinics. Others worked in hospitals, school health centers, a federally qualified health center, or a mobile medical unit. Most of the providers identified as physicians (75%), though nurses/ nurse practitioners (9%), dietitians (5%), exercise physiologists
To determine inclusion of children into the weight management programs, most providers used the 85th percentile (overweight) or 95th percentile (obesity) as the threshold. Twenty-four percent of the providers offered their weight management services to children as young as 5 years, and 8% to infants (0-1 years) if needed. Fifty-six percent of the providers provided these
J La State Med Soc VOL 169 JANUARY/FEBRUARY 2017 3
JOURNAL OF THE LOUISIANA STATE MEDICAL SOCIETY
TABLE 1: Pediatric weight management practices among 57 clinicians.
Number of Providers
Is body mass index (BMI) calculated as part of your regular visits with children? Yes
50
No
6 1
Did not answer
What code(s) do you use to bill for childhood obesity screening/treatment? * 278.00: Obesity, unspecified
33 26 22 21 15 13
278.02: Overweight
783.1: Abnormal weight gain
V85.54: Obesity, pediatric BMI ≥ 95th percentile for age
278.01: Morbid obesity 272.4: Hyperlipidemia 272.1: Hypertriglyceridemia 277.7: Insulin resistance
9 8 6 6 6 5 2 1 1 1 1 2 6
780.57: Sleep apnea, unspecified 790.5: Elevated liver enzymes 790.99: Elevated hemoglobin A1C
571.8: Nonalcoholic steatohepatitis (NASH) 250.00, 250.02, v58.67, 272.2, acanthosis, PCOS 278.03: Obesity hypoventilation syndrome
278.1: Localized adiposity
Weight gain
277.7 & 278 - Metabolic Syndrome
Don’t know
Not applicable/did not answer
Do you screen for type 2 diabetes mellitus in children and adolescents? Yes
16 20 21 28 22 11
No
Not applicable/did not answer
If yes, what is your primary screening tool for type 2 diabetes in children and adolescents? * Hemoglobin A1c
Fasting Plasma Glucose Overweight/Obesity
Oral Glucose Tolerance Test (OGTT) American Diabetes Association criteria
6 3 1 1 1 1
Fasting Insulin
Urinalysis
Acanthosis Nigricans presence Do not do labs on every child
Which department in your hospital/clinic provides pediatric obesity treatment? * General Pediatrics
21 15
Nutrition
Gastroenterology
8 7
Endocrinology
4 J La State Med Soc VOL 169 JANUARY/FEBRUARY 2017
JOURNAL OF THE LOUISIANA STATE MEDICAL SOCIETY
Adolescent Medicine Outpatient Services
4 3 2 2 2 1 1 1 1 1
Community Outreach and Education
Psychiatry Referred Cardiology
Sports Medicine
Surgery
Orthopedic
Exercise through wellness
None of the above
18
Not applicable/did not answer
7
What stages of obesity treatment does your hospital/clinic offer? * Stage 1: Prevention Plus
26 14
Stage 2: Structured Weight Management
Stage 3: Comprehensive Multidisciplinary Intervention
8 1 5
Stage 4: Tertiary Care Intervention
Don’t know
Not applicable/did not answer
21
What weight management services do you (or your clinic) provide for obese children? * Nutrition Therapy
34 21 19 19
Medical Monitoring
Exercise
Medical Assessment Behavior Therapy
8 2 2 1 1 1 8 5 1 2
Physical Therapy
Education, Overweight Handout, Follow-up Visits
OLOL Program Provide referral
Orthopedic diagnosis
None
Unspecified other
Don’t know
Not applicable/did not answer
What outcome(s) do you use to measure change in weight management programs? * BMI and BMI percentile
37 22 21 19 16 11 10
Blood pressure Nutrition/Diet Physical activity Labs (blood work)
BMI trajectory
Psychosocial outcomes (e.g. confidence, self-esteem)
BMI z-score
3 2 1 1
Weight
Waist circumference Body fat percentage
J La State Med Soc VOL 169 JANUARY/FEBRUARY 2017 5
JOURNAL OF THE LOUISIANA STATE MEDICAL SOCIETY
Fitness tests Don’t know
1 2
Not applicable/did not answer 17 Does your weight management program offer a maintenance phase after intensive treatment? Yes 6 Yes, follow up with provider 1 No 13 Don’t know 8 Not applicable/did not answer 29 How long do your weight management services last? 1 Week 2 6 Weeks 1 8 Weeks 2 10 Weeks 5 12 Weeks 5 18 Weeks 1 Don’t know/referred to another program 4 Not applicable/no services offered 37 How many hours of service are provided in this time? 0.5 hour 1 1 hour 7 1.5 hours 2 2 hours 1 3 hours 1 10 hours 1 Varies 1 Other 1 Don’t know 4 Not applicable/did not answer 38 What is the frequency of visits during weight management services (e.g. once a week, once a month)? Once a week 10 Once a month 6 Twice a month 2 Every other month 1 Other 1 Don’t know 4 Not applicable/did not answer 33 What are the cut-offs you use for inclusion of children into weight management/treatment programs? Overweight (≥85th percentile BMI) 12 Overweight with at least 1 comorbidity 4 Overweight with at least 1 obese parent 0 Obese (≥95th percentile BMI) 12 Don’t know 1 Not applicable/did not answer 28 * indicates that the provider was allowed to select multiple responses.
6 J La State Med Soc VOL 169 JANUARY/FEBRUARY 2017
JOURNAL OF THE LOUISIANA STATE MEDICAL SOCIETY
FIGURE 1A: Providers’ estimates of the proportion of pediatric patients under their care who are obese or overweight. Note: the remaining 5% of providers did not provide an estimate.
FIGURE 1B: Providers’ estimates of the proportion of pediatric patients with overweight/obesity who are referred to weight management services. Note: The remaining 23% of providers did not provide an estimate.
J La State Med Soc VOL 169 JANUARY/FEBRUARY 2017 7
JOURNAL OF THE LOUISIANA STATE MEDICAL SOCIETY
DISCUSSION
services to their patients through the age of 18 years, while 16% extended their care up to those aged 21 years.
Similar to national trends showing an increase in childhood obesity prevalence, 13 the majority of providers reported seeing an increase in number of overweight or obese pediatric patients over the past five years. The majority of providers screened for both obesity and T2DM. Yet the survey responses indicate that these patients are not receiving recommended weight management services. Most providers did not meet clinical guidelines to refer or offer weight management services, and only one of the 57 providers offered a multi-component obesity intervention that met the recommended duration and contact hours. Furthermore, few providers followed the expert committee recommended four-staged approach to childhood obesity treatment. 6 Importantly, providers noted barriers to provision of services including lack of resources to provide an intervention, lack of reimbursement for nutritional counseling services, and poor compliance by patients and families. Given88%of thesurveyedproviders reportedregularlyscreening children for obesity, there is evidence that screening practices have improved since the USPSTF recommendations were released in 2010. Based on retrospective data from the United States National Health and Nutrition Examination Survey (1999- 2008), 14 only 22% of parents of children who were overweight or obese were informed by their doctor that the child was overweight or obese. Though there was a slight increase over time in physicians notifying parents, from 19.4% in 1999-2004 to 29.1% in 2007-2008, 14 the majority of physicians either were not screening children for overweight/obesity or were not informing parents of the child’s weight status. A survey conducted in 2006 of family physicians similarly found that only 45% of physicians calculated BMI percentile at most or every well-child visit. 15 Similarly, a chart review of 255 children 2, 6, and 10 years of age identified that only 34% of those who were overweight or obese were properly documented as such. 16 The present data indicate that most providers surveyed now do regularly monitor child’s BMI, but it is not known whether these providers communicated the child’s obesity status to the parents. Many physicians were not utilizing EMRs as a tool to automatically calculate and plot BMI to facilitate obesity screening. The provision of weight management services among these predominantly primary care providers was lower than what has been previously demonstrated for tertiary care centers. In 2013, the national Children’s Hospital Association surveyed 118 children’s hospitals and identified 85 that offered comprehensive weight management services, 7 a higher proportion than the 11% who offered multi-component interventions in the present study. Nearly all of the tertiary care centers provided nutrition therapy (99% vs. 60% in the present study), behavioral counseling (86% vs. 14% in the present study), and exercise or physical therapy (80% vs. 37% in the present study). Though two-thirds of tertiary care providers stated that their programs met the USPSTF guidelines, only 40% offered programs for 6 months or longer, indicating wide variability in meeting the intensity and duration recommendations. Data from national surveys of ambulatory medical care determined that only 33%
Outcome Measures
The most frequently used outcomes to measure patient’s change in the weight management program were BMI or BMI percentile, blood pressure, nutrition/diet, physical activity, or labs (non-specified). Sixty-seven percent of the providers used multiple outcome measures.
Duration and Frequency of Services
The weight management programs ranged between periods of 1 and 18 weeks. Seven of the weight management programs included a maintenance phase after intensive treatment.
Provider Training
Forty percent of the facilities provided support and/or education about childhood obesity for providers. The offered resources included in-person continuing education (80%), lists of available resources (47%), toolkits (47%), web-based continuing education (40%), electronic health records with tools to prevent/ treat obesity (40%), quality improvement collaboratives (27%), and seminars (7%).
Identified Barriers and Needs
In an open-ended question (“Is there anything further you’d like to share related to childhood obesity management, prevention, and treatment?”), several of the providers identified a need for more supportive services including“programs [for] pediatricians [to] make quick and simple referrals without hassle.” The scarcity of insurance plans that provide for nutritional counseling was another reported obstacle. Other barriers included poor compliance by patients and their families to prescribed treatments and following through with referrals.
COMPARISON OF REPORTED PRACTICES TO NATIONAL GUIDELINES
Five of the 57 providers met at least half of the seven national recommendations examined in this study for screening and referring/providing behavioral intervention for obesity treatment (Table 2). Though one provider met six of the seven guidelines, none met all. The responses revealed that while the USPSTF guideline for screening children for obesity was commonly practiced, the recommendation to refer or offer an intervention was rarely met. Six health care providers offered an intervention that incorporated all three recommended components (i.e. dietary, physical activity, and behavioral counseling). Only one of the six programs met both USPSTF guidelines of more than 25 hours of contact time and delivery over at least six months.
8 J La State Med Soc VOL 169 JANUARY/FEBRUARY 2017
JOURNAL OF THE LOUISIANA STATE MEDICAL SOCIETY
and 18% of patients aged 2-18 years received diet/nutrition and exercise counseling, respectively, and this counseling was less frequent among socioeconomically disadvantaged children. 17 The present study found even fewer physicians in Louisiana are providing behavioral counseling, with only one program that met USPSTF intensity guidelines (i.e. > 25 hours contact time delivered over at least six months). In a 2006 survey of family practitioners, 86% said families could not afford services not covered by insurance and 55% lacked referral services for weight management programs. 15 Since then, the USPSTF recommendation for obesity screening and comprehensive, intensive behavioral intervention was rated as Grade B, indicating that the task force recommends that practitioners offer or provide this service due to the high certainty that a net benefit is moderate, or moderate certainty that the net benefit is moderate to substantial. 5 The USPSTF recommendation applies to all practitioners, not just tertiary care providers. Under the Patient Protection and Affordable Care Act of 2010, private insurance plans are mandated to cover preventive services with a USPSTF Grade A or B rating without patient cost-sharing. In spite of these recommendations and insurance mandates, providers still reported reimbursement for services as a barrier, are not providing or referring weight management services, and reported using numerous billing codes for obesity screening and treatment. Strengths of this study included responses from 17 areas that covered the major populated regions of the state of Louisiana and from a range of healthcare providers. Focusing on Louisiana providers may pose a challenge for generalizability to other
geographic regions. Yet Louisiana and the lower Mississippi delta region is one of the most medically underserved, at-risk populations living in the United States, characterized by high levels of poverty, food insecurity, obesity, and related diseases. Therefore, the state of Louisiana represents a prime opportunity to establish baseline values of childhood obesity screening and management in order to monitor changes with the enactment of policy and programmatic interventions. This study included several limitations. Despite outreach to over 1,300 providers and affiliated stakeholders and a high number of website visits to the survey, only 10% of the contacted providers participated in the survey. The sample may have been biased towards providers more interested or more active in obesity screening and treatment. Despite including “not applicable” or “do not know” as response items, some questions were skipped by providers, making it difficult to determine practices for the entire sample. In conclusion, obesity and T2DM screening practices were common but the referral and provision of weight management services for children with obesity remained rare among these pediatric healthcare providers. When offered, the interventions did not meet the recommended contact time. Despite clinical guidelines, coupled with legal requirements for insurance coverage, there is a continued lack of behavioral treatment for the most common medical disease among the nation’s youth. To address this deficit in health care access, weight management programs should be developed and disseminated and include reimbursement for services, ongoing provider training, and family input to assure patient commitment.
TABLE 2: Comparison of current screening and treatment practices to the national guidelines among 57 clinicians. Note: Values represent number of respondents unless otherwise noted. (A) includes outpatient clinic, student health center, federally qualified health center; (B) includes adolescent medicine.
J La State Med Soc VOL 169 JANUARY/FEBRUARY 2017 9
JOURNAL OF THE LOUISIANA STATE MEDICAL SOCIETY
Amanda Staiano, PhD; ArwenMarker, BA; Michelle Liu, BS; ElleryHayden; Dr. Hsia; and Stephanie Broyles, PhD are all affiliated with Pennington Biomedical Research Center in Baton Rouge, LA.
REFERENCES
1. Ogden CL, Carroll MD, Kit BK, et al. Prevalence of childhood and adult obesity in the United States, 2011-2012. JAMA . 2014;311:806-14. 2. Epstein LH, Paluch RA, Roemmich JN, et al. Family-based obesity treatment, then and now: Twenty-five years of pediatric obesity treatment. Health Psychology . 2007;26:381-91. 3. Epstein LH, Valoski A, Wing RR, et al. Ten-year follow-up of behavioral, family-based treatment for obese children. JAMA . 1990;264:2519-23. 4. Whitlock EP, O’Connor EA, Williams SB, et al. Effectiveness of weight management interventions in children: A targeted systematic review for the USPSTF. Pediatrics . 2010;125:E396-E418. 5. U.S. Preventive Services Task Force. Screening for obesity in children and adolescents: US Preventive Services Task Force recommendation statement. Pediatrics . 2010;125:361-7. 6. Barlow SE, Expert C. Expert committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: summary report. Pediatrics . 2007;120 Suppl 4:S164-92. 7. Children’s Hospital Association. (2013). Survey findings of Children’s Hospitals obesity services. https://www.childrenshospitals.org/Resources/ Report. Published May 1, 2014. Accessed December 21, 2015. 8. Bloom B, Jones LI, Freeman G. Summary health statistics for U.S. children: National Health Interview Survey, 2012. Vital Health Stat 10. 2013:1-81. 9. Dabelea D, Mayer-Davis EJ, Saydah S, et al. Prevalence of Type 1 and Type 2 Diabetes among children and adolescents from 2001 to 2009. JAMA . 2014;311:1778-86. 10. AmericanDiabetes Association. Standards ofmedical care indiabetes-2015. The Journal of Clinical and Applied Research and Education . 2015;38:S70-S6. 11. Copeland KC, Silverstein J, Moore KR, et al. Management of newly diagnosed type 2 Diabetes Mellitus (T2DM) in children and adolescents. Pediatrics . 2013;131:364-82. 12. Harris PA, Taylor R, Thielke R, et al. Research electronic data capture (REDCap)-A metadata-driven methodology and workflow process for providing translational research informatics support. Journal of Biomedical Informatics . 2009;42:377-81. 13. Ogden CL, Carroll MD, Kit BK, et al. Prevalence of obesity and trends in body mass index among US children and adolescents, 1999-2010. JAMA . 2012;307:483-90. 14. Perrin EM, Skinner AC, Steiner MJ. Parental recall of doctor communication of weight status national trends from 1999 through 2008. Archives of Pediatrics & Adolescent Medicine . 2012;166:317-22. 15. Sesselberg TS, Klein JD, O’Connor KG, et al. Screening and counseling for childhood obesity: results from a national survey. The Journal of the American Board of Family Medicine . 2010;23:334-42. 16. Reyes I. An evaluation of the identification andmanagement of overweight and obesity in a pediatric clinic. Journal of Pediatric Health Care . 2015;29:e9- e14. 17. Tanda R, Salsberry P. The impact of the 2007 expert committee recommendations on childhood obesity preventive care in primary care settings in the United States. Journal of Pediatric Health Care . 2014;28:241- 50.
Acknowledgements
Wegratefullyacknowledge the following research trainees of PenningtonBiomedical Research Center who assisted with the writing and dissemination of the survey: Neelima Gonugunta, John Hodges, Johannah Frelier, and Aimee Troxclair. We also acknowledge our funders, the Baptist Community Ministries, who provided financial support for the development and dissemination of the survey. AES is supported, in part, by the 1 U54 GM104940 grant from the National Institute of General Medical Sciences of the National Institutes of Health which funds the Louisiana Clinical and Translational Science Center. The funding sources had no involvement in the study design; the collection, analysis, or interpretation of the data; the writing of the report; or the decision to submit the article for publication.
10 J La State Med Soc VOL 169 JANUARY/FEBRUARY 2017
JOURNAL OF THE LOUISIANA STATE MEDICAL SOCIETY
Fever-Induced Brugada Pattern Misdiagnosed as an Acute Myocardial Infarction David Tadin, MD; Roberto Quintal, MD The Brugada syndrome is a rare condition associated with increased risk of ventricular tachyarrhythmias and sudden cardiac death (SCD). The Brugada pattern on electrocardiogram (EKG) is known to be revealed by several precipitants including febrile illnesses. The appearance of a Brugada pattern on EKG with fever may indicate an elevated risk of arrhythmia or sudden cardiac death. We report a case in which the electrocardiographic abnormality of Brugada pattern induced by sepsis was initially misinterpreted as a ST-segment elevation myocardial infarction (STEMI). The Brugada pattern on EKG resolved with treatment of the underlying sepsis.
99%on roomair,weight of 192kilograms, height of 6 foot 3 inches and body mass index of 53. Pertinent positives on physical exam were mild tenderness to palpation of left upper and left lower quadrants of the abdomen and tachycardia. Pertinent negatives were normal jugular venous pressure, normal lung sounds and cardiac regular rhythm. Pertinent positive labs were blood leukocytosis of 21,000/mm 3 with 3% bands. BUN was elevated at 28 mg/dL and creatinine was elevated at 3.1 mg/dL. (the baseline creatinine was 1.1 mg/dL). His serum bicarbonate level was 16 mEq/L, his TSH was normal, but a mildly elevated FT4 at 1.53 ng/dL was found. The urinalysis was abnormal with positive leukocyte esterase on dipstick. Microscopic analysis showed too many white blood cells to count and many bacteria. Other pertinent lab results were normal troponin, CKMB, CKMB%, but elevated total CPK at 885. BNP was 78 pg/mL. The patient had computed tomography (CT) of the abdomen without contrast that revealed left-sided hydronephrosis and left hydroureter secondary to retroperitoneal fibrosis. The STEMI activation was cancelled and the patient was admitted for sepsis.
CASE REPORT
A 61-year-old manwith a past medical history of hypertension, hypothyroidism, and morbid obesity presented to the emergency department due to profuse diarrhea and headaches. The patient stated that he was in his usual state of health until two days prior to presentation. The patient described 10 watery bowel movements per day. No blood or pus was noted in his stools. His headaches were located over the frontal area and non- radiating. He had associated symptoms of fever and indigestion. He denied chest pain, shortness of breath, palpitations, or edema. During his work up in the emergency department, he had an abnormal electrocardiogram (EKG), different from a prior EKG that prompted a STEMI Team activation (Figures 1,2). The patient had no known family history of cardiac problems including arrhythmias, syncope or sudden cardiac death. Vitals on presentation were: Temperature: 99.1° Fahrenheit, heart rate: 105 beats per min, 20 respirations per minute, pulse oximetry
FIGURE 1: Brugada type I EKG pattern in leads V 1 , V 2 on admission with sepsis.
J La State Med Soc VOL 169 JANUARY/FEBRUARY 2017 11
JOURNAL OF THE LOUISIANA STATE MEDICAL SOCIETY
FIGURE 2: Baseline EKG from two years ago.
FIGURE 3: EKG showing resolution of Brugada type I pattern after resolution of sepsis.
12 J La State Med Soc VOL 169 JANUARY/FEBRUARY 2017
JOURNAL OF THE LOUISIANA STATE MEDICAL SOCIETY
The patient had Enterococcus faecalis bacteremia from a genitourinary source. Hewas treatedwithappropriateantibiotics and had urologic intervention with left ureteral stenting. His hospital course was uneventful, and he was discharged with no cardiac sequelae. He had an outpatient biopsy of the retroperitoneal fibrosis indicating an idiopathic etiology. An EKG wasrepeatedonemonthlaterafterresolutionofhissepsis(Figure2).
of the sodium channel can be temperature-sensitive. 8 Fever might also impair conductance of the sodium channel.⁹
Diagnosis
Expert Consensus statement for type 1 and type 2 Brugada are defined 3 :
1. Brugada syndrome is diagnosed inpatientswith ST-segment elevation with type I morphology ≥2 mm in ≥ 1 lead among the right precordial leads V1,V2 positioned in the 2nd, 3rd, or 4th intercostal space occurring either spontaneously or after provocative drug test with intravenous administration of Class I antiarrhythmic drugs 2. Brugada syndrome is diagnosed in patients with Type 2 or Type 3 ST-segment elevation in ≥1 lead among the right precordial leads V1,V2 positioned in the 2nd, 3rd, or 4th intercostal space when a provocative drug test with intravenous administration of Class I antiarrhythmic drugs induces a Type 1 EKG morphology.
DISCUSSION
Definition
The Brugada syndrome is an autosomal dominant genetic disorder with incomplete penetrance or polygenic inheritance affecting the sodium channels. Brugada syndrome is characterized by abnormal surface EKG findings in conjunction with an increased risk of ventricular tachyarrhythmias and sudden cardiac death. EKG findings typically consist of persistent ST segment elevation in leads V1 to V3 and the presence of a pseudo-right bundle branch block. These EKG changes are dynamic, often hidden, and may reveal themselves in the presence of triggers like fever, intoxication (alcohol, cocaine, or cannabis), vagal stimulation, electrolyte imbalance, anesthetics (propofol, bupivacaine), psychotropic agents (amitriptyline, lithium), and sodiumchannel blockers. 1 Patients with typical EKG featureswho are asymptomatic andhave noother clinical criteria are said to have Brugada pattern such as the patient in this case.
Prognosis and Risk Stratification
The relation between the Brugada EKG sign in asymptomatic patients (no history of syncope, ventricular arrhythmias or SCD (sudden cardiac death)) and the future risk of developing arrhythmogenic events has been investigated. One study revealed that the cardiac event rate per year in asymptomatic patients was 0.5%, compared to 1.9% in patients with a history of syncope and 7.7% in patients with aborted SCD. 13 Multiple predictors of future arrhythmic events in patients with the Brugada pattern were studied, with male gender, mutation of the SCN5A gene and a positive family history of SCD found to be non -predictive. 13,14,15 The prognostic value of the clinical, EKG and Electrophysiology Studies (EPS) variables were analyzed in a population of spontaneous type 1 Brugada ECG patterns and no previous cardiac arrest. The cohort with negative EPS (non- inducibility of VT/VF) had a 1.8% risk of developing arrhythmic events (SCD or documented VF), compared to 14% in those with a positive EPS. 15 Further studies revealed a 0.9% rate of significant cardiac events in patients with non-inducible arrhythmias. 14,15 A positive EPS is not predictive for arrhythmic events, and data reported that the spontaneous ECG pattern and the history of syncope are the best available predictors of such events. 13,16
Prevalence
The prevalence of Brugada syndrome appears to be low in the general population. A family history is present in about 20- 30% of patients. 10 According to recent studies in Europe, the incidence of sudden death in the general population (age 7-64 years) is 1.34 per 100,000 per year. 4 Studies in heterogeneous populations suggest that the majority of patients were of Asian decent. 5 However, one article looking at Brugada pattern on EKG stated none of the patients with fever-induced Brugada were of southeast Asian origin or had electrolyte imbalance, significant bradycardia, and prolonged PR interval when their type I pattern was recognized. In addition, none of the eight patients with fever-induced type I Brugada had a history suggestive of arrhythmic symptoms. 6 The prevalence of type I Brugada pattern is 20 times higher among patients presenting with fever than in afebrile patients (2% vs 0.1%). 6
Therapies
Pathophysiology
An Implantable Cardioverter (ICD) Device is the only proven effective therapeutic strategy for the prevention of SCD in Brugada syndrome. It is important to note that ICD’s do have disadvantages, especially young active individuals, who will require multiple device replacements during their life-time. Asymptomatic Brugada syndrome patients do not qualify for an ICD as their risk for life threatening events is very low. 17 calcium current), has proved to be useful for treatment of electrical storm in Brugada syndrome but controlled data on its therapeutic role are not available. 18 Isoproterenol (which increases the L-type
Genetic analysis in patients with Brugada syndrome has shown an association with sodium channel SCN5A mutations in about 20% of the cases. 2 This patient had Brugada Type 1 EKG pattern induced by fever. The predominance of outward ionic current (Ito) at the end of phase 1 of the action potential either because of an increase of its magnitude or because of a decrease in inward currents (INa, ICaL) causes loss of the action potential dome with marked shortening of the action potential. The greater density of the Ito current in the epicardium causes a transmural dispersion of repolarization that manifest as a J wave or ST-segment elevation. 7 Accelerated inactivation
J La State Med Soc VOL 169 JANUARY/FEBRUARY 2017 13
JOURNAL OF THE LOUISIANA STATE MEDICAL SOCIETY
Quinidine, a Class Ia antiarrhythmic drug with Ito and IKr blocker effects, has been shown to prevent induction of VF and suppress spontaneous ventricular arrhythmias in a clinical setting. Quinidine is currently being used in patients with ICD and multiple shocks; cases in which ICD implantation is contraindicated; or for the treatment of supraventricular arrhythmias. 17 It has been suggested that quinidine could also be useful in children with Brugada syndrome, as a bridge to ICD or as an alternative to it. 17 Randomized studies on the use of quinidine, however, have not been performed. Radiofrequency Ablation (RFA) of ventricular ectopy has been postulated as a therapeutic approach in Brugada syndrome patients. A recent study by Josep Brugada et al. showed prevention and treatment of Brugada syndrome by RFA. This study had pathophysiologic and therapeutic implications. Substrate epicardial mapping and ablation guided by provocative testing was considered a reproducible, safe and effective strategy to definitively treat patients with type 1 Brugada syndrome EKG pattern and risk of sudden death. 19
pathophysiological mechanism. Cirulation 1999;78:581. 6. Arnon Adler, et al. Fever-induced Brugada pattern: How common is it and what does it mean? Heart Rhythm. 2013;10(9):2-5. 7. Benito B, Brugada J, Brugada R, Brugada P. Brugada syndrome. Rev Esp Cardiol. 2009;62:1297–1315. 8. Dumaine R, Towbin JA, Brugada P, Vatta M, Nesterenko DV, Nesterenko VV, Brugada J, Brugada R, Antzelevitch C. Ionic mechanisms responsible for the electrocardiographic phenotype of the Brugada syndrome are temperature dependent. Circ Res. 1999;85:803–809. 9. Deschênes I, Laurita KR. How can a single mutation cause such arrhythmic havoc? Heart Rhythm. 2007;4:198–199. 10. Vohra Jitendra, et. al. Update on the Diagnosis and Management of Brugada Syndrome. Heart, Lung and Circulation. 2015;24:1141–1148. 11. Antzelevitch C, Brugada P, Borggrefe M, Brugada J, Brugada R, Corrado D, Gussak I, LeMarec H, Nademanee K, Perez Riera AR, et al. Brugada syndrome: report of the second consensus conference: endorsed by the Heart Rhythm Society and the European Heart Rhythm Association. Circulation. 2005;111:659–670. 12. Nguyen T, Smythe J, Baranchuk A. Rhabdomyoma of the interventricular septum presenting as a Brugada phenocopy. Cardiol Young. 2011;21:591– 594. 13. Probst V, Veltmann C, Eckardt L, et al. Long-term prognosis of patients diagnosed with Brugada syndrome. Results from the FINGER Brugada Syndrome Registry. Circulation 2010;121(5):635-43. 14. Brugada J, Brugada R, Antzelevitch C, et al. Long-term follow-up of individuals with the electrocardiographic pattern of right bundle-branch block and STsegment elevation in precordial leads V1 to V3. Circulation 2002;105(1):73-8. 15. Brugada J, Brugada R, Brugada P. Determinants of sudden cardiac death in individuals with the electrocardiographic pattern of Brugada syndrome and no previous cardiac arrest. Circulation 2003;108(25):3092-6. 16. Priori SG, Gasparini M, Napolitano C, et al. Risk stratification in Brugada syndrome: results of the PRELUDE (PRogrammed ELectrical stimUlation preDictive valuE) registry. J Am Coll Cardiol 2012;59(1):37-45. 17. Mizusawa Y, Wilde AA. Brugada syndrome. Circ Arrhythm Electrophysiol. 2012;5:606–616. 18. Priori Silvia G., et.al. HRS/EHRA/APHRS Expert Consensus Statement on the Diagnosis and Management of Patients with Inherited Primary Arrhythmia Syndromes. Heart Rhythm 2013;10(12): 1937-1940. 19. Brugada Josep, et.al. Brugada Syndrome Phenotype Elimination by Epicardial Substrate Ablation. Circulation 2015;8(6):1373-1381.
CONCLUSION
The Brugada pattern includes a pattern resembling RBBB with elevation of the ST segment in the precordial leads (V1- V2). Physicians should be aware of other causes inducing ST segment elevation. A good clinical history and a low clinical suspicion for ischemia may avoid the inappropriate utilization of emergency catheterization and of hospital resources. Fever has been described to induce a Brugada-type EKG pattern in asymptomatic patients with a negative family history. 12 The expert consensus statement from the HRS/EHRA/APHRS gives a class I indication to provide immediate treatment of fever with antipyretic drugs. 3 Furthermore, avoidance of excessive alcohol intake and drugs that may induce or aggravate ST-segment elevation in right precordial leads are class I indications. Risk stratification of asymptomatic patients with a Brugada-type EKG induced by fever and a negative family history remains a matter of debate. According to current guidelines, careful follow-up would be an appropriate option. 11 The diagnostic value of a drug challenge test as well as electrophysiological studies in this population is uncertain. Our patient was asymptomatic with a negative family history and given close follow up. REFERENCES 1. Bayés de Luna A, Brugada J, Baranchuk A, et al. Current electrocardiographic criteria for diagnosis of Brugada pattern: a consensus report. J Electrocardio l. 2012;45:433-442. 2. Probst V, Wilde AA, Barc J, et al. SCN5A mutations and the role of genetic background in the pathophysiology of Brugada syndrome. Circ Cardiovasc Genet. 2009;2:552-557. 3. S.G. Priori, A.A. Wilde, M. Horie, Y. Cho, E.R. Behr, C. Berul, et al. HRS/EHRA/ APHRS Expert Consensus Statement on the Diagnosis and Management of Patients with Inherited Primary Arrhythmia Syndromes: Document endorsed by HRS, EHRA, and APHRS in May 2013 and by ACCF, AHA, PACES, and AEPC in June 2013 Heart Rhythm, 10 (2013), pp. 1932–1963. 4. Behr ER, Dalageorgou C, Christiansen M, Syrris P, Hughes S, Tome, Esteban MT, Rowland E, Jeffery S, McKennaWJ. Sudden arrhythmic death syndrome: familial evaluation identifies inheritable heart disease in the majority of families. Eur Heart J. 2008;29:1670–1680. 5. Alings M. Wilder A. “Brugada” Syndrome: clinical data and suggested
Dr. Tadin is a cardiology fellow at LSUHSC-New Orleans; Dr. Quintal is a retired chief of cardiology at LSU and at Touro Infirmary, both in New Orleans .
14 J La State Med Soc VOL 169 JANUARY/FEBRUARY 2017
JOURNAL OF THE LOUISIANA STATE MEDICAL SOCIETY
Jejunal Carcinoid Tumors Presenting as Small Bowel Obstruction David Ballard, MD; Ryan Fransman, MD; Guillermo Sangster, MD; Matthew Ayo, BS; Navdeep Samra, MD
Carcinoid tumors are themost common formof gut neuroendocrine tumors, however, they rarely present with small bowel obstruction. We present a case of a 65-year-old woman without prior abdominal operations who presented with symptoms of small bowel obstruction. Computed tomography (CT) showed multiple air fluid levels and a transition point in the left mesentery with two soft tissue densities at the same level. The patient was taken to the operating room for surgical exploration, which showed two intramural masses in the mid and distal jejunum, which surgical pathology showed to be stage IIIB carcinoid tumor.
FIGURE 1A: Axial noncontrast CT image of the mid abdomen demonstrates two irregularly marginated solid mesenteric masses (arrows) causing mild proximal small bowel dilatation.
INTRODUCTION
Although carcinoid tumors are rare, they are the most common form of gut neuroendocrine tumors. The annual incidence of carcinoid tumors is 4-5 cases per 100,000 people, increased from the previous estimation of 1.5 per due to better diagnostic tests and tumor detection techniques. The most common locations for gut carcinoid tumors in descending order are small intestine, rectum, stomach, colon, and appendix. The peak incidence of carcinoid tumors is in the sixth decade of life. 1-4 Carcinoid tumors are often asymptomatic and rarely cause obstructive symptoms. We present a case of a patient with a virgin abdomen presenting with small bowel obstruction due to carcinoid tumors of the jejunum.
FIGURE 1B: Multiplanar coronal reconstruction of the abdomen and pelvis show two mesenteric masses (arrows).
CASE PRESENTATION
A 65-year-old female presented to the emergency department with abdominal pain, vomiting, and constipation. These symptoms were present for approximately one month and acutely worsened over the past four days. The sharp, periumbilical pain was exacerbated by eating and relieved by vomiting. Past medical history was remarkable for peptic ulcer disease and she denied previous surgeries, recent travel, sick contacts, or abdominal trauma. Vital signs were within normal limits. Physical exam revealed tenderness in the periumbilical region. Metabolic panel was remarkable for elevated alkaline phosphatase, mild hyponatremia, and hyperkalemia; electrocardiogram showed normal sinus rhythm. Hematologic parameters, lipase, urinalysis, and lactic acid were all within normal limits. Upright abdominal radiograph revealed multiple air fluid levels and paucity of gas within the rectum and throughout the colon. Subsequent non-contrast CT revealed two irregularly marginated solid mesenteric masses (Figure 1A, 1B) causing proximal small bowel dilatation and a collapsed small bowel loop (Figure 1C) distal to the mesenteric mass consistent with mechanical obstruction. Following resuscitation, the patient was taken urgently to the operating
FIGURE 1C: Axial noncontrast CT Image immediately distal to the previous section shows a collapsed small bowel loop (arrow) distal to themesenteric mass consistent withmechanical obstruction.
J La State Med Soc VOL 169 JANUARY/FEBRUARY 2017 15
Page 1 Page 2 Page 3 Page 4 Page 5 Page 6 Page 7 Page 8 Page 9 Page 10 Page 11 Page 12 Page 13 Page 14 Page 15 Page 16 Page 17 Page 18 Page 19 Page 20 Page 21 Page 22 Page 23 Page 24 Page 25 Page 26 Page 27 Page 28 Page 29 Page 30 Page 31 Page 32 Page 33 Page 34 Page 35 Page 36 Page 37 Page 38 Page 39 Page 40 Page 41 Page 42 Page 43 Page 44 Page 45 Page 46 Page 47 Page 48 Page 49 Page 50 Page 51 Page 52 Page 53 Page 54 Page 55 Page 56 Page 57 Page 58 Page 59 Page 60 Page 61 Page 62 Page 63 Page 64 Page 65 Page 66 Page 67 Page 68 Page 69 Page 70 Page 71 Page 72 Page 73 Page 74 Page 75 Page 76 Page 77 Page 78 Page 79 Page 80 Page 81 Page 82 Page 83 Page 84 Page 85 Page 86 Page 87 Page 88 Page 89 Page 90 Page 91 Page 92 Page 93 Page 94 Page 95 Page 96 Page 97 Page 98 Page 99 Page 100 Page 101 Page 102 Page 103 Page 104 Page 105 Page 106 Page 107 Page 108 Page 109 Page 110 Page 111 Page 112 Page 113 Page 114 Page 115 Page 116 Page 117 Page 118 Page 119 Page 120 Page 121 Page 122 Page 123 Page 124 Page 125 Page 126 Page 127 Page 128 Page 129 Page 130 Page 131 Page 132 Page 133 Page 134 Page 135 Page 136 Page 137 Page 138 Page 139 Page 140 Page 141 Page 142 Page 143 Page 144 Page 145 Page 146 Page 147 Page 148 Page 149 Page 150 Page 151 Page 152 Page 153 Page 154 Page 155 Page 156 Page 157 Page 158 Page 159 Page 160 Page 161 Page 162 Page 163 Page 164 Page 165 Page 166 Page 167 Page 168 Page 169 Page 170 Page 171 Page 172 Page 173 Page 174 Page 175 Page 176 Page 177 Page 178 Page 179 Page 180Made with FlippingBook Digital Publishing Software