December 2009

December

VOL. L

2009

50 Years of

CONTINUOUS PUBLICATION

No. 12

E C N A I L L A A MSM

A wish for health and happiness in the coming year is being sent to you by members of the Mississippi State Medical Association Alliance!

Contributions by the following have been made to the AMA Foundation and designated to benefit the Scholars Fund at the University of Mississippi School of Medicine.

Rachel Becker Emma Borders Kathy Carmichael Peggy Crawford Valerie Davis Connie Derhgawen

Amy Gammel Shoba Gaymes Danita Horne Angela Ladner Louise Lampton Nancy Leader

Pat Lobrano Brinda ManiSundaram Eileene McRae Nell Middleton Melanie Moore Karen Morris

Sondra Pinson Mollie Pontius Susan Rish Yvette Slocum Brenda Sumrall Smith Donna Witty

Lucius M. Lampton, MD Editor D. Stanley Hartness, MD Michael O’Dell, MD AssociAtE Editors Karen A. Evers MAnAging Editor PublicAtions coMMittEE Dwalia S. South, MD Chair Philip T. Merideth, MD, JD Martin M. Pomphrey, MD Leslie E. England, MD, Ex-Officio Myron W. Lockey, MD, Ex-Officio and the Editors thE AssociAtion Randy Easterling, MD President Tim J. Alford, MD President-Elect J. Clay Hays, Jr., MD Secretary-Treasurer Lee Giffin, MD Speaker Geri Lee Weiland, MD Vice Speaker Charmain Kanosky Executive Director JOURNAL OF THE MISSISSIPPI STATE MEDICAL ASSOCIATION (ISSN 0026-6396) is owned and published monthly by the Mississippi State Medical Association, founded 1856, located at 408 West Parkway Place, Ridgeland, Mississippi 39158-2548. (ISSN# 0026-6396 as mandated by section E211.10, Domestic Mail Manual).

Periodicals postage paid at Jackson, MS and at additional mailing offices.

CORRESPONDENCE: JOURNAL MSMA, Managing Editor, Karen A. Evers, P.O. Box 2548, Ridgeland, MS 39158-2548, ph.: (601) 853-6733, FAX (601)853-6746, www.MSMAonline.com.

SUBSCRIPTION RATE: $73.00 per annum; $86.00 per annum for foreign subscriptions; $6.50 per copy, $7.00 per foreign copy, as available.

ADVERTISING RATES: furnished on request. Cristen Hemmins, Hemmins Hall, Inc. Advertising, P.O. Box 1112, Oxford, Mississippi 38655, Ph: (662) 236-1700, Fax: (662) 236-7011, email: cristenh@watervalley.net POSTMASTER: send address changes to Journal of the Mississippi State Medical Association, P.O. Box 2548, Ridgeland, MS 391582548.

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© 2009, Mississippi State Medical Association.

DECEMBER 2009

VOLUME 50

NUMBER 12

SCIENTIFIC ARTICLES A Case of Profound Weight Loss Secondary to Use of Phentermine 407 Gabriel I. Uwaifo, MD; Eugen Melcescu, MD; Angela McDonald, NP and Christian A. Koch, MD, PhD Does a Multidisciplinary Diabetes Group Education Visit Improve Patient Outcomes?

Kristi J. O’Dell, PhD, MSW; Michael L. O’Dell, MD, MSHA and James L. Taylor, PharmD

416

Clinical Problem-Solving: Halitosis: Hindrance or Hint?

Ijeoma Innocent-Ituah, MD

422

PRESIDENT’S PAGE We Have No Cabs in Vicksburg Randy Easterling, MD; MSMA President

427

EDITORIAL Like the Spartans at Thermopylae: Mississippi’s Docs Stress Need to Reform Health Reform at Interim AMA Meeting Lucius M. Lampton, MD; Editor RELATED ORGANIZATIONS Mississippi State Department of Health Information and Quality Healthcare

435 436

DEPARTMENTS Placement/Classified Una Voce

437 438

INDEX Index by Subject Index by Author

439 443

ABOUT THE COVER: “ROOFTOPS AT JACKSON SQUARE” - Charles Guess, MD, painted this oil on canvas of steeples on Jackson Square in the heart of the historic French Quarter in New Orleans. Originally known in the 18th Century as ‘Place d’Armes,’ it was later renamed in honor of Andrew Jackson. This famous landmark facing the Mississippi River is surrounded by St. Louis Cathedral, the Presbytere and Cabildo, the Lower and Upper Pontalba Apartments (the oldest apartment buildings in the U.S.) with retail shops, museums, galleries and restaurants on the ground level. A resident of Madison and retired from 35 years of private family medicine practice, Dr. Guess began painting while in medical school at the University of Mississippi. His works resemble French impressionists and reflect his serious study of the way French Masters incorporated light into their works. Most of his pieces are direct painting, without preliminary sketching on the canvas. ❒ VOL. L

December

PUBLICATION CONTINUOUS

50 Years of

No. 12

2009

December

Official Publication of the MSMA Since 1959

432

VOL. L

2009

50 Years of

CONTINUOUS PUBLICATION

No. 12

Medical Assurance Company of Mississippi With questions about a new practice, MACM gave her confidence.

“

As a physician just beginning my private practice, I did not have much experience with professional liability companies. MACM sets the bar so high that I can’t imagine being insured with anyone else.

MACM goes above and beyond to keep its insureds educated about risk management and keep them out of the courtroom. I have already attended educational seminars and completed on-line risk management training offered by MACM.

“

Being from Louisiana, I was hesitant to come to Mississippi to practice medicine. Now, I have no regrets. MACM has helped make Mississippi an easier place to practice medicine.

Louise A. Gombako-Amos, MD OB/GYN McComb, Mississippi

For over 30 years, Mississippi physicians have looked to Medical Assurance Company of Mississippi for their professional liability needs. Today, MACM is an integral part of the health care community through its dedication to sound underwriting principles and risk management education for our insureds. ȱ ȱ ěȱ ȱ ¢ ȱ ȱ ȱ ¢ȱ ȱ guarantees that the interests of our policyholders remain the top priority. This, combined with the many years of loyalty and support from our insureds, is what allows us to be the carrier of choice in Mississippi.

Please call on us to assist with your professional liability needs.

1.800.325.4172 www.macm.net

Reputation Above All Others

SCIENTIFIC ARTICLES

A Case of Profound Weight Loss Secondary to Use of Phentermine Gabriel I. Uwaifo, MD Eugen Melcescu, MD Angela McDonald, NP Christian A. Koch, MD, PhD

A

BSTRACT

Background: Obesity has become particularly prevalent in both the United States and worldwide. Mississippi continues to lead the nation in prevalence of obesity estimates. The proportion of morbidly obese subjects is increasing at a disproportionately greater rate and the burden of obesity and its complications are more prevalent among ethnic minorities. We present the unique case of a Choctaw lady with morbid obesity who has shown a profound response to pharmacotherapy with phentermine. Methods: The clinical case history of the patient; a 34-year-old Choctaw lady with morbid obesity, hypertension, hyperlipidemia, and type 2 diabetes is presented, followed by discussion of issues relevant to impacting the obesity epidemic in Mississippi.

Results: A 34-year-old Choctaw lady with 1.5 year follow up was noted to have a peak initial body mass index (BMI) of 62.6kg/m2 and weight of 176kg. Since commencement of phentermine, initially at 15mg daily and slowly up-titrated to 37.5mg daily, she has lost over 23kg (13% of baseline peak weight) with a current weight of 153 kg and BMI of 54.4kg/m2. Accompanying the weight reduction has been sustained normal blood pressure and improvement in glycemic control.

Conclusions: Phentermine is a viable and important adjunct in the medical approach to weight management in obese subjects. Its potential utility should be considered even among subjects with morbid obesity. Given its cost it could be a cost effective adjunct in comprehensive weight loss programs for Mississippi that may posiJOURNAL MSMA, December 2009 — Vol. 50, No. 12

tively impact the ongoing obesity epidemic. There remains a need for more studies of phentermine to better define its place in obesity management.

KEY WORDS:

OBeSITy, PhenTerMIne, MOrBId OBeSITy, MeTABOlIC SyndrOMe, WeIGhT lOSS, heATh dISPArITIeS,

ChOCTAW, nATIve AMerICAn INTRODUCTION Obesity is one of the major pandemics of the 21st century and has shown no signs of slowing prevalence in the foreseeable future.1-3 Obesity has a great burden of associated co-morbidities and complications associated with it that add considerably to the morbidity, mortality and cost of care associated with its management.4-6 Central to the disease burden associated with obesity is the associated increased risk for type 2 diabetes which is a second twin pandemic accompanying that of obesity.7-10 The complications and associated co-morbidities associated with obesity are broadly subdivided into metabolic (such as type 2 diabetes, hyperlipidemia, hypertension, non alcoholic fatty liver disease, insulin resistance, the dysmetabolic syndrome, focal glomerulosclerosis, polycystic ovarian syndrome, etc.) and the so called mechanical complications (such as osteoathrosis, obstructive sleep apnea, pseudotumor cerebri, reflux esophagitis, etc.).7,11 More alarming than the increasing prevalence of obesity in adults however, is the even more rapidly developing problem of obesity in 407

childhood with the same associations seen in adults along with some unique complications distinct for childhood populations such as slipped capital femoral epiphyses and Blounts disease.12,13 This raises the potential of early onset of chronic diseases previously largely restricted to adult populations in children and adolescents with the consequent increase in disease burden, morbidity and mortality that may result.14 While virtually universal in its demographic distribution there have also been clear documentations of increased prevalence of obesity and its complications among ethnic minority groups.15-17 The confluence of a significant population of ethnic minorities (African American, Choctaw native American and to a less degree hispanic), the relatively low per capita GdP and an established history of high risk nutritional habits have made Mississippi continue to have among the highest prevalence rates of obesity and type 2 diabetes in the United States.12,15,17-24 Furthermore, with the increasing prevalence of obesity and its complications, further analyses indicate that the proportions of subjects with morbid obesity (BMI >40kg/m2) is increasing as is the degree of abdominal obesity with its attendant implication for future atherosclerotic cardiovascular disease (ASCvd) risk.3,7,12,13,15,18,25 The sustained effective management of obesity is especially difficult in the present health care delivery system that is not designed to reward efforts geared towards disease prevention but rather at invasive intervention once significant complications develop.

Consequently though a multifaceted approach to obesity management involving sustained dietary counseling, physical therapy and exercise prescriptions, behavior modification and pharmacotherapy is the best strategy to achieve sustained weight loss, none of these strategies is covered by the vast majority of medical insurance plans in the United States with the problem even worse in Mississippi.5,26-30 While there is no doubt that bariatric surgery (and especially the malabsorptive procedures such as the roux en y gastric bypass procedure) remains the most effective means of achieving substantive and sustained weight loss (especially among subjects with morbid obesity and accompanying comorbidities),31,32 the sheer disease burden of obesity and the costs and human resources needed for bariatric surgery make it an unreasonable panacea for the vast majority of subjects with obesity and its complications.

The unfortunately sordid history of many prior anti-obesity agents such as aminorex, dexfenfluramine, fenfluramine, amphetamine, phenylpropanolamine, rimonabant, and ephedra has made many physicians and 408

patients very wary of using any anti-obesity medications in the management of obesity.33 The fact that there are relatively few FdA approved medications for this indication (just orlistat and sibutramine for long term use and phentermine, diethylpropion, benzphetamine and phendimetrazine for short term use) and that virtually none of these are covered by most medical insurance prescription plans make sustained access to these medications virtually impossible for most potential patients.5,26,34-36 While knowledge about the pathogenesis and pathophysiology of obesity has continued to increase exponentially, availability of effective pharmacotherapeutic options for its sustained management have lagged significantly behind.33,36-39 Consequently despite the obvious public health importance there have been no significant medications for obesity added to the clinical armamentarium since the approval of orlistat in 1999.

Phentermine (Adipex-P, Ionamin) is a sympathomimetic anorexiant that has been FdA approved for short term use (~ 12 weeks) in the management of obesity largely based on the results of the only randomized placebo controlled trial of its use which is from 1968.40 This trial demonstrated its efficacy causing weight loss of ~ 12kg from the baseline compared to the placebo group that showed a weight decline of ~4kg from baseline over the 36 week duration of the trial. The trial demonstrated the utility of phentermine adjunctive use for weight loss both in continuous and intermittent use protocols.40 Along with diethyproprion (which if far less often used), phentermine has the longest duration of use for therapy of obesity and would probably have the longest accumulated patient years in clinical experience if this prescription history could be systematically compiled. Beyond its long history of use, it is the cheapest available FdA approved anti-obesity medication which is a significant consideration as virtually all of these medications have to be paid out of pocket by most users.41 The major limitations to its more widespread use are a) the fact that it is a deA schedule 4 listed agent despite the fact that its actual abuse potential based on accumulated patient care experience history is quite small42,43 and b) the common misperception that it may be associated with cardiac valvulopathy because of these findings documented when it was combined with fenfluramine which has since been removed from the market.44-51 In fact there has been no clearly described case of so-called anorectic valvulopathy described in the setting of phentermine use alone.44-51 There are multiple small reports of various cohorts suggesting the utility of phentermine in causing signifJOURNAL MSMA, December 2009 — Vol. 50, No. 12

icant, sustained weight loss when used as a adjunct to dietary caloric reduction either as monotherapy or as part of a combination therapy protocol.30,52-57 The case presented is of a 34-year-old Choctaw lady with morbid obesity and associated co-morbidities including hypertension, type 2 diabetes and dyslipidemia. She elected for a trial of phentermine while making a commitment to change her dietary practices and had a profound clinical response that is ongoing.

CASE DESCRIPTION The patient is a 34-year-old Choctaw lady who was first seen in the endocrine service at the University of Mississippi Medical Center for evaluation of hypothyroidism and thyroid nodules. She also had an ~ 6 year history of type 2 diabetes and a long standing history of progressive weight gain which had continued to accelerate in the prior 6 months despite efforts on her part to improve her dietary habits including eliminating all intake of sweetened carbonated drinks and marked reduction in her intake of pasteries, bread and rice. She indicated that her appetite over the prior 6 months to a year was essentially unchanged though she has previously noted an increase in appetite with pregabalin (lyrica) which had been prescribed for neuopathic carpal tunnel syndrome symptoms. Because of this appetite increase she had stopped using pregabalin over a year ago. her sleep habits were quite good with no complaints of reported snoring or early morning headaches nor drowsiness. noteably she did not eat breakfast on week days because of her work schedule. review of her dietary patterns at her initial evaluation also revealed a significant amount of high carbohydrate and calorie dense fat intake. She also snacked significantly between meals and these snack choices were generally calorie rich including fruits, cookies and popcorn. Though she had already reduced significantly her intake of carbonated sweetened drinks her preferred drinks both at meal time and intervening were Kool-Aid and sweetened tea.

The patient had a significant family history of both obesity and diabetes involving all three of her brothers and her mother (who is obese but not diabetic).The medications she was on at the initial medical evaluation included; Synthroid 100 mcg daily, pioglitazone 45 mg daily, Glucovance 5/500 mg one tablet twice daily, lisinopril 20 mg daily, and topiramate 25 mg daily for migraine prophylaxis.

She had a longstanding history of irregular menstrual cycles but no history suggestive of excessive facial acne, virilization or hirsuitism. She had only one prior pregnancy which has ended in a spontaneous aborJOURNAL MSMA, December 2009 — Vol. 50, No. 12

tion.

On initial clinical examination she was noted to be morbidly obese with a weight of 167.5 kg with a BMI of 61.5 kg/m2. The rest of vital signs were normal including a blood pressure of 122/65 mm hg and a resting pulse rate of 61 beats/minute.

She was noted to have significant nuchal acanthosis nigricans but no associated skin tags. She had no demonstrable thyromegaly or palpable thyroid nodules and her throat examination revealed no tonsillar enlargement with a widely patent upper airway passage.

She did have a soft non radiating 2/6 ejection systolic murmur heard exclusively over the aortic area with otherwise normal heart sounds. The abdominal examination was unremarkable other than for marked anterior abdominal wall obesity. There were no visible striae and no areas of tenderness on palpation nor demonstrable hepatosplenomegaly. her diabetes control was relatively good at this time with a documented hBA1c of 6.0 and thyroid sonography revealed no significant nodular disease warranting fine needle aspiration biopsy. In view of a noted serum thyrotropin (TSh) level of 12.3 mu/ml her dose of Synthroid was increased to 150 mcg daily and this resulted in normalization of her subsequent thyroid function tests.

We had a detailed discussion with the patient regarding available strategies for weight loss (dietary changes, increased physical activity levels and formal sustained exercise program, behavior therapy and the role of pharmacotherapy). The potential utility, pros and cons of bariatric surgery was also detailed to the patient especially considering her degree of obesity. details regarding appropriate portion sizes, appropriate proportions of macronutrients in meals, need for regular breakfast, need for change to non caloric/low caloric snack options and the need to eliminate all calorie dense drinks from her diet were highlighted.

At her subsequent follow visit however, though her diabetic control remained quite good with no problems with hypoglycemic episodes she had gained an additional 8.5 kg (weight of 176 kg) with a BMI of 62.6 kg/m2 despite her best efforts at implementing the diet changing strategies we had discussed during the prior visit. The examination findings were unchanged except for the absence of the previously noted aortic murmur.

The patient was unwilling to consider possible bariatric surgery and wanted to explore addition of a pharmacotherapeutic agent to assist her diet efforts. Based on the costs and potential side effects of the main available options (orlistat, sibutramine and phentermine) she 409

elected to try phentermine which she was willing to pay for out of pocket as it was not covered by her medical insurance plan. She was aware that it was however only FdA approved for short term use and thus any long term use would have to be in an off label capacity requiring close ongoing clinical follow up. She was commenced on phentermine 15mg daily with a weight response as shown in figure 1 below and dose slowly uptitrated as shown. Associated with the weight loss has been a further improvement in her already good glycemic control (latest hBA1c of 5.6) despite reduction of her Glucovance dose to 5/500 mg one tablet daily, normal blood pressure, pulse rate profile as well as lipid profile as shown in table 2. With the reduction in her weight thus far she has noticed a significant improvement in mood and energy levels which has enabled her to now commit to regular walking up to 45 minutes daily during most week days and on weekends.

She has not been found to have any auscultable murmurs on follow up but the nuchal acanthosis nigricans has become less prominent and her menstrual periods have now become consistent and regular on a monthly basis with no accompanying complaints of significant menorrhagia or dysmenorrhea. The intended plan going forward is to discontinue glucovance and instead maintain her on metformin alone while continuing to watch the trends in her weight and overall glycemic control.

Figure 1: wEight And body MAss indEx ProfilEs on PhEntErMinE

410

Table 1: MEtAbolic And clinicAl PArAMEtErs At bAsElinE And following PhEntErMinE inducEd wEight loss Parameter HBA1c (%) Systolic blood pressure (mm hg) Diastolic blood pressure (mm hg) Resting pulse rate (beats/min) Rate-pressure product Total Cholesterol (mg/dl) HDL Cholesterol (mg/dl)) LDL Cholesterol (mg/dl) Fasting Triglycerides (mg/dl) Nuchal acanthosis nigricans

Baseline 6.0 122

Current (1.5 yrs later) 5.6 99

65

64

61

80

7442 265a 41a 180a 218a

7920 163 37 91 174

Present; 3+

Present; 1+

a; Patient was commenced on simvastatin 20mg daily immediately after baseline visit based on noted LDL level which was above desired goal of <100mg/dl.

DISCUSSION The increasing prevalence of obesity and its myriad complications is reaching pandemic proportions that requires radical change in the present strategy being used (which is clearly not working).1 While the overall prevalence of obesity is increasing the proportion of subjects with morbid obesity (BMI <40kg/m2) is increasing disproportionately58 with worrisome potential consequences. Also apparent from the ongoing obesity epidemic is a disproportionate increase among children and minority groups.7,14,17,24,58 The magnitude of the problem is even greater among lower socio-economic class populations2,12,15,59 and the confluence of all these factors have contributed to sustaining Mississippi’s position as the state with the greatest prevalence of both obesity and type 2 diabetes (http://www.cdc.gov/obesity/data/ trends.html). The dire circumstances are highlighted in even more painstaking detail in the recent report from the “Trust for America’s health” available at http://healthyamericans.org/reports/obesity2009/.

The ongoing obesity epidemic and its associated complications and co-morbidities have the potential for the first time in our nation’s history to create a generation that has a greater overall morbidity and mortality disease burden than that of their parent’s generation.1,10,19,25,58-60 Furthermore obesity and its related complications and co-morbidities have the potential to further widen the chasm of health disparities that are already apparent within the American public health system, increasing further the gap between the “haves” and “have nots” unless substantive change is implemented quickly.16,17,23 These concerns are even greater in Mississippi where the extent of the problem in adult and childhood populations as well as in minority and non-minority populations is well documented.20,22,27,61-63 What seems lacking thus far is a multifaceted system JOURNAL MSMA, December 2009 — Vol. 50, No. 12

wide program designed to provide resources for the public education, prevention and management of obesity and its complications. The Centers for disease control and prevention (CdC) has developed such a program which was created in 1999; the nutrition, Physical Activity and Obesity Program (nPAO). It is a cooperative agreement between the Centers for disease Control and Prevention’s division of nutrition, Physical Activity and Obesity (dnPAO) and 23 State health departments working to build lasting and comprehensive efforts to address obesity and other chronic diseases through a variety of nutrition and physical activity strategies. From individual behavior change to changes in public policy, these state efforts aim to engage multiple levels of society; in a comprehensive so called Socio-ecological model that involves intervention strategies in a multi-level, multi-layered approach including individual, interpersonal, organizational, community based and society based interventions (www.cdc.gov/obesity/stateprograms/index.html).

While it is unfortunate that states like Mississippi and Alabama who are among the worst hit with the ongoing obesity epidemic are not included in the present funding for this laudable program, its goals and stated objectives including decreasing obesity prevalence, increasing physical activity levels and improving dietary practices are those that should form the foundation for a similar sort of program here in Mississippi. The nPAO also provides some definite impact objectives and target areas to enable achievement of the global goals and objectives. The American Association for Clinical endocrinology; AACe has developed an initiative with valuable resources that can be used to spearhead public health preventive efforts at reducing obesity prevalence especially among children and adolescents. These resources can be accessed at www.powerofprevention. com/memberinvite.php .

While this public health blitz is paramount to substantively change the epidemiology of obesity, reduce its prevalence and reduce the increasing health disparities it engenders, there is also a need for a robust funding mechanism to provide adequate clinical care for the individual obese patient especially those with already established complications or co-morbidities. Such a program must include resources for sustained dietary counseling, behavior modification, physical activity counseling as well as access to adjunctive pharmacotherapeutic agents.4-6 While bariatric surgery remains a viable and important management option for obesity especially among morbidly obese patients it cannot be the primary or first management option even among JOURNAL MSMA, December 2009 — Vol. 50, No. 12

morbidly obese patients31,32,64 especially in a state like Mississippi with limited health care professional and other logistic resources.

The pharmacotherapy of obesity when combined with appropriate diet, behavior therapy and physical activity increase can have considerable potential in improving obesity and its complications.4,34,35,38 The presented case highlights the huge potential benefits that can result from providing access to appropriate pharmacologic agents as part of the management plan in the individual subject with obesity. The increasing realization that obesity needs to be clinically managed in the same chronic disease paradigm applied to hypertension, diabetes, dyslipidemia and ASCvd has resulted in a realization that medical therapy for obesity as in these other conditions needs to be long term (possibly life long) and may need to involve combination pharmacotherapy.4,28,35,41,65-68 In evaluating options for use in obesity management in Mississippi where sustained efficacy, safety and cost consciousness are particularly acute, phentermine has a favorable profile. It has an extended history of clinical study and use that amounts to an impressive accumulated “patient years” of clinical experience.40,53,54,69-77 While it has arguably longest record of clinical use in obesity pharmacotherapy, phentermine is one of the cheapest FdA approved medications for this indication (~ $30-45 for a months supply based on information from www.drugstore.com). In addition the available published data on its efficacy suggest a capacity to induce weight loss of 5-15% of baseline initial weight in ~ 60% of treated subjects which is at least comparable and probably somewhat superior to efficacy data reported for both sibutramine and orlistat. The major limitation to this data is that the longest documented follow up on its use remains the 36 week clinical trial from Munro and colleagues from 1968.40 This study however though clearly dated does also provide evidence of equal potency of phentermine in obesity management when administered intermittently as compared to continuous use which may be of particular importance both for cost savings and for reduction in attendant side effects.

While the product insert of phentermine lists a host of potential side effects, it is generally very well tolerated with the most common reported side effects being nervousness, dry mouth, constipation and mild hypertension.40,41,43,75,78 review of the best available published data on phentermine use in obesity therapeutics based on a meta-analysis of six randomized trials of its use demonstrated a mean weight loss of ~ 3.6kg from baseline which was comparable to the other available 411

anti obesity agents (actually only sibutramine had a mean associated weight loss that was numerically [~4.45kg] but statistically different.79,80 The same metanalyses showed a remarkably safe side effect profile with no reported adverse events pooled through the collated studies suggesting an overall side effect incidence of less than 8 events per 1000 patient treatment exposures.79,80 The combination of phentermine with fenfluramine in the past (fen-phen) has created a great deal of persistent concern and fear of using phentermine though the actual risk of both primary pulmonary hypertension and anorectic associated valvulopathy in the treated subjects was quite low and all the available evidence indicate that these complications were related to the fenfluramine or dexfenfluramine used in these combinations rather than to phentermine.44,51,81-84 There is to date no published case of phentermine use alone being associated with either of these rare complications. That said, it is important to be aware that combination of phentermine with other sympathomimetics or agents that increase circulating cathecolamine and/or serotonin levels (such as monoamine oxidase inhibitors, tricyclic antidepressants and amphetamine derivatives) is probably not advisable.38,41,85 While there are some reports of the potency of combining phentermine with selected selective serotonin reuptake inhibitors (SSrIs) in obesity and related conditions, this is generally not recommended and should only be undertaken in a clinical research setting where close clinical surveillance is assured.30,52,55,86 While there are no reported untoward side effects of such combinations reported in the literature, the mode of action of these combinations is akin to the discredited fen-phen combination with the potential for causing sustained increases in serum levels of serotonin which appear to underlie the valvulopathy associated with anorectic agents as well as that seen with ergotamine and some dopaminergic antiparkinsonian medications.47,49,50,81,83,87 Overall the recommended strategy for combination obesity phamacotherapy is to use agents with different mechanisms of action so as to reduce the potential for additive side effects from their use.38,41,88 This makes orlistat a far more appealing potential agent for combination with phentermine if required than a sympathomimetic or SSrI. It is noteable that our patient is also on topiramate (for migraine prophylaxis) and this does raise the possibility that part of the efficacy observed in this index case may be the result of a favorable combined effect of topiramate with phentermine. While possible this appears unlikely given the very small dose of topiramate the patient was on compared to the doses demonstrated 412

to have weight loss efficacy. Furthermore the patient continued to gain weight while on topiramate till phentermine was commenced.

This observation however highlights the paucity of data on phentermine use in combination with most of the newer anti-obesity agents (such as with orlistat, sibutramine, topiramate and the weight loss associated anti-diabetic agents such as metformin, exenatide and acarbose) as well as the need for well designed long term studies of its use in large populations of obese subjects. There are also various unique special populations of obese patients such as adolescents, elderly subjects and patients with accompanying psychiatric illnesses such as depression and the binge eating disorder among whom the utility and place of phentermine also needs careful study. The impact of phentermine use on important obesity associated co-morbidities like dyslipidemia, ASCvd risk, obstructive sleep apnea, osteoarthrosis, PCOS and non alcoholic fatty liver disease (nAFld) as examples are other areas of interest needing systematic study. In all these areas, making phentermine available through a statewide program for appropriate obese subjects in Mississippi could provide the clinical setting to begin to answer these questions not only for the state but the entire medical community.

CONCLUSION In summary, while the index case presented represents only one patient, the dramatic response thus far noticed with the use of phentermine without a structured dietary counseling program or significant exercise prescription highlights the potential beneficial effects that could be derived by providing all these resources to numerous obese patients in Mississippi. While the state leads the nation in the prevalence of both obesity and many of its associated co-morbidities such as type 2 diabetes, this offers the potential for great achievement and change. A targeted public health initiative modeled after the ongoing CdC sponsored nPAO initiative along with provision of basic clinical resources to enable effective management of individual obese patients can provide a narrative in Mississippi that could be an example for the rest of the nation. Such a state sponsored clinical initiative while having resources available to provide ongoing nutritional, behavioral and exercise counseling will also need to make available pharmacotheraputic agents for adjunctive use. Phentermine would be a prime consideration for inclusion in that armamentarium.

JOURNAL MSMA, December 2009 â&#x20AC;&#x201D; Vol. 50, No. 12

REFERENCES 1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

16.

17.

18.

19.

CdC director calls diabetes public health emergency. J Miss State Med Assoc. 2004;45(11):350, 344.

Ford eS, Mokdad Ah, Giles Wh, Galuska dA, Serdula MK. Geographic variation in the prevalence of obesity, diabetes, and obesity-related behaviors. Obes Res. 2005;13(1):118-122.

Ford eS, Mokdad Ah. epidemiology of obesity in the Western hemisphere. J Clin Endocrinol Metab.

2008;93(11 Suppl 1):S1-8.

Giri M. Medical management of obesity. Acta Clin Belg.

2006;61(5):286-294.

Arterburn d, delaet d, Schauer d. Obesity in adults. Clin Evid (Online). 2008.

Aronne lJ. Obesity. Med Clin North Am. 1998;82(1):161181.

Mensah GA, Mokdad Ah, Ford e, et al. Obesity, metabolic syndrome, and type 2 diabetes: emerging epidemics and their cardiovascular implications. Cardiol Clin. 2004;22(4):485-504.

Mokdad Ah, Ford eS, Bowman BA, et al. diabetes trends in the U.S.: 1990-1998. Diabetes Care. 2000;23(9):12781283.

Mokdad Ah, Ford eS, Bowman BA, et al. The continuing increase of diabetes in the US. Diabetes Care.

2001;24(2):412.

Mokdad Ah, Ford eS, Bowman BA, et al. Prevalence of obesity, diabetes, and obesity-related health risk factors, 2001. JAMA. 2003;289(1):76-79. haslam dW, James WP. Obesity. Lancet.

2005;366(9492):1197-1209.

Sherry B, Mei Z, Scanlon KS, Mokdad Ah, GrummerStrawn lM. Trends in state-specific prevalence of overweight and underweight in 2- through 4-year-old children from low-income families from 1989 through 2000. Arch Pediatr Adolesc Med. 2004;158(12):11161124. li C, Ford eS, Mokdad Ah, Cook S. recent trends in waist circumference and waist-height ratio among US children and adolescents. Pediatrics. 2006;118(5):e13901398.

Clinton Smith J. The current epidemic of childhood obesity and its implications for future coronary heart disease. Pediatr Clin North Am. 2004;51(6):1679-1695, x. li C, Ford eS, McGuire lC, Mokdad Ah. Increasing trends in waist circumference and abdominal obesity among US adults. Obesity (Silver Spring).

2007;15(1):216-224.

Murray CJ, Kulkarni S, ezzati M. eight Americas: new perspectives on U.S. health disparities. Am J Prev Med. 2005;29(5 Suppl 1):4-10.

Mensah GA, Mokdad Ah, Ford eS, Greenlund KJ, Croft JB. State of disparities in cardiovascular health in the United States. Circulation. 2005;111(10):1233-1241.

Ford eS, Mokdad Ah, Giles Wh. Trends in waist circumference among U.S. adults. Obes Res. 2003;11(10):1223-1231.

Ford eS, Mokdad Ah, Ajani UA. Trends in risk factors for cardiovascular disease among children and adolescents in

JOURNAL MSMA, December 2009 â&#x20AC;&#x201D; Vol. 50, No. 12

the United States. Pediatrics. 2004;114(6):1534-1544.

20. hughes Gd, Areghan GA, Knight Bn. Obesity and the African-American adolescent in mississippi: an overview.

South Med J. 2005;98(1):72-78.

21. South dS. Our children's obesity epidemic: can MSMA help legislatively mandate a cure? What's your opinion, doctor? J Miss State Med Assoc. 2003;44(12):393-394.

22. Stevenson G, Matich r. Fact sheet: obesity among Mississippi's children. Miss RN. 2004;66(1):12-13.

23. Taylor hA, Jr., Wilson JG, Jones dW, et al. Toward resolution of cardiovascular health disparities in African Americans: design and methods of the Jackson heart Study. Ethn Dis. 2005;15(4 Suppl 6):S6-4-17.

24. Bindon J, dressler WW, Gilliland MJ, Crews de. A crosscultural perspective on obesity and health in three groups of women: the Mississippi Choctaw, American Samoans, and African Americans. Coll Antropol. 2007;31(1):47-54.

25. Ford eS, Giles Wh, Mokdad Ah. Increasing prevalence of the metabolic syndrome among u.s. Adults. Diabetes Care. 2004;27(10):2444-2449.

26. Atkinson rl, hubbard vS. report on the nIh Workshop on Pharmacologic Treatment of Obesity. Am J Clin Nutr.

1994;60(2):153-156.

27. Campbell BW, Addison CC, Charles l, Thurston dA. Cardiovascular risk factors among women in Mississippi in the 1990s. J Am Med Womens Assoc. 2003;58(2):105111.

28. Atkinson rl, Blank rC, Schumacher d, dhurandhar nv, ritch dl. long-term drug treatment of obesity in a private practice setting. Obes Res. 1997;5(6):578-586.

29. hendricks eJ, rothman rB, Greenway Fl. how Physician Obesity Specialists Use drugs to Treat Obesity.

Obesity (Silver Spring). 2009.

30. Whigham ld, dhurandhar nv, rahko PS, Atkinson rl.

Comparison of combinations of drugs for treatment of obesity: body weight and echocardiographic status. Int J Obes (Lond). 2007;31(5):850-857.

31. Sjostrom l, lindroos AK, Peltonen M, et al. lifestyle, diabetes, and cardiovascular risk factors 10 years after bariatric surgery. N Engl J Med. 2004;351(26):2683-2693.

32. Sjostrom Cd, lissner l, Wedel h, Sjostrom l. reduction in incidence of diabetes, hypertension and lipid disturbances after intentional weight loss induced by bariatric surgery: the SOS Intervention Study. Obes Res. 1999;7(5):477-484.

33. Ioannides-demos ll, Proietto J, Tonkin AM, Mcneil JJ. Safety of drug therapies used for weight loss and treatment of obesity. Drug Saf. 2006;29(4):277-302.

34. Schnee dM, Zaiken K, McCloskey WW. An update on the pharmacological treatment of obesity. Curr Med Res Opin.

2006;22(8):1463-1474.

35. Mancini MC, halpern A. Pharmacological treatment of obesity. Arq Bras Endocrinol Metabol. 2006;50(2):377389.

36. Ioannides-demos ll, Proietto J, Mcneil JJ. Pharmacotherapy for obesity. Drugs. 2005;65(10):13911418.

37. Gura T. Obesity drug pipeline not so fat. Science.

2003;299(5608):849-852.

413

38. Bray GA. drug treatment of obesity. Rev Endocr Metab Disord. 2001;2(4):403-418.

39. hanif MW, Kumar S. Pharmacological management of obesity. Expert Opin Pharmacother. 2002;3(12):17111718.

40. Munro JF, MacCuish AC, Wilson eM, duncan lJ. Comparison of continuous and intermittent anorectic therapy in obesity. Br Med J. 1968;1(5588):352-354.

41. Campbell Ml, Mathys Ml. Pharmacologic options for the treatment of obesity. Am J Health Syst Pharm.

2001;58(14):1301-1308.

42. ryan dh. Use of sibutramine and other noradrenergic and serotonergic drugs in the management of obesity.

Endocrine. 2000;13(2):193-199.

43. Bray GA. drug Insight: appetite suppressants. Nat Clin Pract Gastroenterol Hepatol. 2005;2(2):89-95.

44. Kancherla MK, Salti hI, Mulderink TA, Parker M, Bonow rO, Mehlman dJ. echocardiographic prevalence of mitral and/or aortic regurgitation in patients exposed to either fenfluramine-phentermine combination or to dexfenfluramine. Am J Cardiol. 1999;84(11):1335-1338.

45. Gross SB. Appetite suppressants and cardiac valvulopathy.

Current clinical perspectives. Adv Nurse Pract.

1999;7(10):36-40.

46. Was the danger of diet pills overstated? Harv Heart Lett.

2000;10(6):4-5.

47. Bowen rl, Foreyt JP, Poston WS, 2nd, et al. echocardiographic assessment of patients receiving longterm treatment with anorexiant medications. Endocr Pract. 1999;5(1):17-23.

48. Burger AJ, Sherman hB, Charlamb MJ, et al. low prevalence of valvular heart disease in 226 phenterminefenfluramine protocol subjects prospectively followed for up to 30 months. J Am Coll Cardiol. 1999;34(4):11531158.

49. Burger AJ, Charlamb MJ, Singh S, notarianni M, Blackburn Gl, Sherman hB. low risk of significant echocardiographic valvulopathy in patients treated with anorectic drugs. Int J Cardiol. 2001;79(2-3):159-165.

50. Cheng TO. Anorectic-induced valvulopathy. Eur Heart J. 2000;21(7):593-594.

51. rothman rB, hendricks eJ. Phentermine cardiovascular safety In response to yosefy C, Berman M, Beeri r. Cusp tear in bicuspid aortic valve possibly caused by phentermine. International journal of cardiology 2006;106:262-3. Int J Cardiol. 2009.

52. rothman rB. Treatment of Obesity With "Combination" Pharmacotherapy. Am J Ther. 2009.

53. Jackson WP, vinik AI. Phentermine (duromine) for obese diabetics. S Afr Med J. 1976;50(35):1351.

54. haddock CK, Poston WS, Foreyt JP, diBartolomeo JJ, Warner PO. effectiveness of Medifast supplements combined with obesity pharmacotherapy: a clinical program evaluation. Eat Weight Disord. 2008;13(2):95101.

55. Callahan BT, yuan J, ricaurte GA. Fluoxetine increases the anorectic and long-term dopamine-depleting effects of phentermine. Synapse. 2000;38(4):471-476.

56. Torretta lK. dexfenfluramine, fenfluramine, and phentermine for the treatment of morbid obesity. J Am

414

Acad Nurse Pract. 1997;9(8):389-394, quiz 395-387.

57. valle-Jones JC, Brodie nh, O'hara h, O'hara J, McGhie rl. A comparative study of phentermine and diethylpropion in the treatment of obese patients in general practice. Pharmatherapeutica. 1983;3(5):300-304.

58. hensrud dd, Klein S. extreme obesity: a new medical crisis in the United States. Mayo Clin Proc. 2006;81(10 Suppl):S5-10.

59. li C, Ford eS, Mokdad Ah, Balluz lS, Brown dW, Giles Wh. Clustering of cardiovascular disease risk factors and health-related quality of life among US adults. Value Health. 2008;11(4):689-699.

60. Ahluwalia IB, Mack KA, Murphy W, Mokdad Ah, Bales vS. State-specific prevalence of selected chronic diseaserelated characteristics--Behavioral risk Factor Surveillance System, 2001. MMWR Surveill Summ.

2003;52(8):1-80.

61. Self-reported health of residents of the Mississippi delta. J health Care Poor Underserved. 2004;15(4):645-662.

62. davis SP, Bienemey C, ellis J, et al. A descriptive analysis of CrrIC II results: cardiovascular risks of AfricanAmerican children in Mississippi. J Cult Divers.

2003;10(3):84-90.

63. davy BM, harrell K, Stewart J, King dS. Body weight status, dietary habits, and physical activity levels of middle school-aged children in rural Mississippi. South Med J. 2004;97(6):571-577.

64. Greenway Fl. Surgery for obesity. Endocrinol Metab Clin North Am. 1996;25(4):1005-1027.

65. Atkinson rl, Blank rC, loper JF, Schumacher d, lutes rA. Combined drug treatment of obesity. Obes Res. 1995;3 Suppl 4:497S-500S. 66. Apovian CM. The use of pharmacologic agents in the treatment of the obese patient. J Am Osteopath Assoc.

1999;99(10 Su Pt 2):S2-7.

67. Glazer G. long-term pharmacotherapy of obesity 2000: a review of efficacy and safety. Arch Intern Med. 2001;161(15):1814-1824.

68. Kaplan lM. Pharmacological therapies for obesity.

Gastroenterol Clin North Am. 2005;34(1):91-104.

69. Willims rA, Foulsham BM. Weight reduction in osteoarthritis using phentermine. Practitioner.

1981;225(1352):231-232.

70. Trickett PC, Weir Jh. Clinical evaluation of chlorphentermine hydrochloride in a college population.

Pac Med Surg. 1968;76(1):35-39.

71. Sproule BC. double-blind trial of anorectic agents. Med J Aust. 1969;1(8):394-395.

72. rider JA, Moeller hC. double-blind evaluation of the use of phentermine in treating obesity. Appl Ther. 1963;5:523524.

73. Kew MC. Treatment of obesity in the Bantu: value of a low-carbohydrate diet with and without an appetite suppressant. S Afr Med J. 1970;44(35):1006-1007.

74. hadler AJ. Weight reduction with phenmetrazine and chlorphentermine a double-blind study. Curr Ther Res Clin Exp. 1967;9(11):563-569.

75. Coyne TC. Phentermine--resin or salt--there are differences. Arch Intern Med. 1997;157(20):2381-2382.

76. langlois KJ, Forbes JA, Bell GW, Grant GF, Jr. A double-

JOURNAL MSMA, December 2009 â&#x20AC;&#x201D; Vol. 50, No. 12

77.

78.

79.

80.

81.

82.

83.

84.

85.

86.

87.

88.

blind clinical evaluation of the safety and efficacy of phentermine hydrochloride (Fastin) in the treatment of exogenous obesity. Curr Ther Res Clin Exp. 1974;16(4):289-296.

Truant AP, Olon lP, Cobb S. Phentermine resin as an adjunct in medical weight reduction: a controlled, randomized, double-blind prospective study. Curr Ther Res Clin Exp. 1972;14(11):726-738. douglas A, douglas JG, robertson Ce, Munro JF. Plasma phentermine levels, weight loss and side-effects. Int J Obes. 1983;7(6):591-595.

Shekelle PG, Morton SC, Maglione M, et al.

Pharmacological and surgical treatment of obesity.

2004;no. 103:1-280. located at: evidence report/ Technology Assessment for the AhrQ; Agency for healthcare research and quality, Santa Monica, CA. haddock CK, Poston WS, dill Pl, Foreyt JP, ericsson M. Pharmacotherapy for obesity: a quantitative analysis of four decades of published randomized clinical trials. Int J Obes Relat Metab Disord. 2002;26(2):262-273. ryan dh, Bray GA, helmcke F, et al. Serial echocardiographic and clinical evaluation of valvular regurgitation before, during, and after treatment with fenfluramine or dexfenfluramine and mazindol or phentermine. Obes Res. 1999;7(4):313-322. vivero le, Anderson PO, Clark rF. A close look at fenfluramine and dexfenfluramine. J Emerg Med. 1998;16(2):197-205.

Wadden TA, Silvestry Fe, Aber Jl, Berkowitz rI, Foster Gd, Sutton MG. valvular heart disease in fenfluraminephentermine-treated patients: a comparison with control patients. Obes Res. 1999;7(3):309-310.

Wadden TA, Berkowitz rI, Silvestry F, et al. The fen-phen finale: a study of weight loss and valvular heart disease.

Obes Res. 1998;6(4):278-284.

Colman e. Anorectics on trial: a half century of federal regulation of prescription appetite suppressants. Ann Intern Med. 2005;143(5):380-385. devlin MJ, Goldfein JA, Carino JS, Wolk Sl. Open treatment of overweight binge eaters with phentermine and fluoxetine as an adjunct to cognitive-behavioral therapy. Int J Eat Disord. 2000;28(3):325-332. naqvi TZ, Gross SB. Anorexigen-induced cardiac valvulopathy and female gender. Curr Womens Health Rep. 2003;3(2):116-125.

Carek PJ, dickerson lM. Current concepts in the pharmacological management of obesity. Drugs.

1999;57(6):883-904.

AUTHOR INFORMATION: Gabriel I. Uwaifo, MD is on staff in the Division of Endocrinology, Diabetes and Metabolism in the Department of Medicine at the University of Mississippi Medical Center in Jackson and is also affiliated with the GV (Sonny) Montgomery VA Medical Center in Jackson.

JOURNAL MSMA, December 2009 â&#x20AC;&#x201D; Vol. 50, No. 12

Eugen Melcescu, MD is on staff in the Division of Endocrinology, Diabetes and Metabolism in the Department of Medicine at the University of Mississippi Medical Center in Jackson.

Angela McDonald, NP is affiliated with the Choctaw Health Department, Womenâ&#x20AC;&#x2122;s Wellness Center in Choctaw.

Christian A. Koch, MD, PhD is on staff in the Division of Endocrinology, Diabetes and Metabolism in the Department of Medicine at the University of Mississippi Medical Center in Jackson and is also affiliated with the GV (Sonny) Montgomery VA Medical Center in Jackson.

CORRESPONDING AUTHOR Gabriel I. Uwaifo, Md, FACP, FACe Associate Professor division of endocrinology, diabetes and Metabolism dept. of Medicine University of Mississippi Medical Center 2500 north State Street Jackson, MS 39216 Ph: 601-984-5525 Fax: 601-984-5769 email: Guwaifo@medicine.umsmed.edu

Mark Your Calendar! the 142nd Annual session of the MsMA house of delegates and Medical Affairs forum 2010 will be held

June 3-6, 2010 in natchez.

415

Does a Multidisciplinary Diabetes Group Education Visit Improve Patient Outcomes?

Kristi J. O’Dell, PhD, MSW Michael L. O’Dell, MD, MSHA James L. Taylor, PharmD

A

BSTRACT

Purpose: diabetes is a significant and growing public health concern, and patient education is the primary approach for self-management. The objective of this study is to assess the impact of a single session diabetes group education intervention. Methods: The design is a one-group pretest/posttest evaluation. Participants were adult outpatients with diabetes who attended a single session group education visit and volunteered to participate in the study. Survey questions include the Single Item literacy Screener and diabetes knowledge questions. The survey was mailed and collected before the group visit. diabetes knowledge was collected immediately after the group visit and again by telephone one to four months later. hemoglobin A1c (hbA1c), lipids, and blood pressure were collected from the patient electronic medical record before and, where available, three months after the group visit. data analysis includes descriptive statistics and Students t-testing to determine pre- and posttest differences of diabetes knowledge and physiological markers.

Results: Thirty-eight adult outpatients participated in the study. nearly half responded that they never needed to have someone help with written medical materials.

There was a significant increase from pretest to immediate posttest diabetes knowledge scores (n = 3; M = 5.58 to M = 7.53 out of 10), t(38) = -5.217, p = <0.001 and a significant decrease in hbA1c from pretest to posttest group education (M = 9.16 to M = 8.52), t(27) = 2.185, p = .038. Conclusions: A single session diabetes group education visit is effective in increasing patients’ diabetes knowledge and decreasing hbA1c levels.

416

KEY WORDS:

dIABeTeS edUCATIOn, dIABeTeS OUTCOMeS, dIABeTeS SelF-MAnAGeMenT

INTRODUCTION Management of diabetes is a significant public health concern nationally and in the state of Mississippi.

The prevalence rate of diagnosed diabetes among adults in Mississippi is in an upward trend from 6% of the population in 1994 to 9.6% in 2005.1 If diabetes is not well managed, vital organs may be damaged over time that may lead to disability and premature death. Patient education is the primary approach for instructing patients in diabetes self-management. This is an interactive process whereby literacy, in general, and health literacy, in particular, is key. nearly half of all US adults have difficulty reading, understanding, and acting upon all types of health information. This project addresses those persons in north Mississippi with diabetes who may have difficulty reading, understanding and acting upon diabetes related health information.

A moderate amount of research regarding patient diabetes group education interventions and outcomes exists including two reviews of randomized controlled trials or quasi-experimental studies. One study reviewed the literature from 1964 through 1999 and found that diabetic patients involved with self-management education programs demonstrated reductions in hemoglobin levels (hbA1c) and improvement in systolic blood pressure.2 The other study reviewed the literature from 1980 to 2001 and found improvement in biomedical markers in all (four) studies and in self care, inJOURNAL MSMA, December 2009 — Vol. 50, No. 12

cluding diabetes knowledge, in two of four studies.3 More recently, another study compared intensive and passive diabetes education groups with patients who had hbA1c levels greater than 8.5%.4 The researchers found that both groups had significantly greater decline in hbA1c levels after receiving education than a matched control group that did not receive education.

There are few studies regarding the relationship of health literacy and diabetes education to patient outcomes. results of these studies are mixed. health literacy is “the ability to obtain, process, and understand basic health information and services needed to make appropriate health decisions and follow instructions for treatment.”5 Based on an extensive review of the literature, the Ad hoc Committee on health literacy for the Council on Scientific Affairs, American Medical Association, concluded that future research should focus on “optimal methods of screening patients to identify those with poor health literacy, effective health education techniques, outcomes and costs associated with poor health literacy, and the causal pathway of how poor health literacy influences health”.6 Baker developed a conceptual model of the domains of health literacy and the relationship of health literacy with health outcomes.7 The major domains in the model are individual capacity including reading fluency and prior knowledge, and health literacy in both oral and written forms. Wallace and lennon found that the mean Simple Measure of Gobbledygook (SMOG) grade level of American Association of Family Practice patient education materials was higher than the average reading skills of US adults.8 Two measures have been used primarily for research purposes to assess health literacy, the rapid estimate of Adult literacy in Medicine (reAlM), a 66-item word pronunciation literacy test,9 and the Test of Functional health literacy in Adults (TOFhlA).10 Shortened versions of both measures have more recently been utilized in clinical research, along with another instrument, the Single Item literacy Screener (SIlS).11 Additional testing of the SIlS is needed in clinical settings and with more diverse populations.

Morris, Maclean, and littenberg conducted a crosssectional statewide study of english-speaking adults with diabetes utilizing the Short-Test of Functional health literacy and outcome measures of hbA1c, low density lipoprotein, blood pressure and self-reported complications.12 They found no association between literacy and the outcomes measures. Kim, love, Quistberg, and Shea found that at three months from intervention both adequate and limited health literacy JOURNAL MSMA, December 2009 — Vol. 50, No. 12

groups showed improvement in hbA1c, knowledge, and self-management behaviors.13 Another group studied the influence of literacy as measured by reAlM on glycemic control and systolic blood pressure using data from a randomized, controlled trial of a comprehensive disease management program.14 At 12-month followup, among patients with low literacy, intervention patients were more likely than control patient to achieve goal hbA1c levels. Patients with higher literacy had similar odds of achieving goal hbA1c levels regardless of intervention status. Improvements in systolic blood pressure were similar by literacy status. The objective of this study is to assess the impact of a multidisciplinary diabetes group education visit for persons with poor glucose control.

METHODS The research design is a one-group pretest/posttest evaluation with follow-up. The goal of the study was to evaluate the efficacy of a group education intervention process in improving diabetes-related health literacy, that is specific knowledge, and intermediate physiologic markers of health outcomes. There were two primary research questions: 1) do physiologic measures improve, especially hbA1c, within three months of a group education visit?

2) do patients exhibit increased diabetes knowledge immediately after and in ensuing time after a group education visit?

Participants were also asked for their suggestions to improve the group education visit. The study participants were selected from the approximately 1200 adults with diabetes who get health care at the Family Medicine residency Center. Patients with poorly controlled diabetes were referred to the group. From September 2007 through June 2008, 38 adult patients with diabetes agreed to participate in the study. One hundred and fifty-eight patients were invited to attend the onetime group education visit, 56 attended the group, and 38 participated in the study for a 68% response rate among those attending the group.

The majority of participants indicated they were female (n = 28, 74%). Fifty-four percent were white (n = 20), 46% were African American (n = 17), and one missing data. Thirty-five percent indicated they were married (n = 13); 35% were divorced, widowed, or other (n = 13); 30% were single/never married (n = 11); and one missing data. Forty-five percent indicated 417

they were high school graduates (n = 17), 24% did not complete high school (n = 9), 14% completed Geds (n = 5), 11% completed technical school/some college (n = 4), 5% have college degrees (n = 2), and two missing data. number of years with diabetes ranged from one to thirty years (Mean = 7 years, Median = 5 years). Seventy-nine percent (n = 29) of participants had a family history of diabetes. hemoglobin A1c values ranged from 5.6 – 14.0 % with half of participants having values of 8.3% and higher. regarding how often participants do not fill or take prescription medications due to the cost, 18% (n = 7) responded always, 35% (n = 13) said often, 5% said sometimes (n = 2), 10% (n = 4) said rarely, and 30% (n = 11) said never, and one missing data.

Two diabetes education group sessions were initially scheduled each month with approximately five patients participating in each session. halfway through the study period, patient numbers were reduced to the point that only one group session per month was held.

The group education visit was comprised of an hourlong session on general diabetes care, medications, diet, and exercise provided by a diabetes educator, pharmacist, dietitian, and exercise physiologist. That was immediately followed by individual customized visits by the listed disciplines (other than the exercise physiologist) and each patient's physician. data collection. data were collected via a written survey and patient electronic medical record. The survey questions consisted of basic demographic information; the Single Item literacy Screener, a question intended to identify adults in need of help with printed health material; diabetes knowledge items with multiple choice responses based on AAFP and American diabetes Association patient education materials provided in the group education visit; and suggestions about improving the group education visit. data collected from the electronic medical record included hbA1c, lipids, and blood pressure. Initial data was collected before and after the group education visit. Follow-up diabetes knowledge was collected by telephone 30 – 127 days after the group education visit. Follow-up physiologic markers were collected from the electronic medical record three months after the group education visit where available. data analysis. data were analyzed using the Statistical Package for the Social Sciences (SPSS) software. descriptive statistics were used to summarize demographic data. Pretest and posttest differences of diabetes knowledge and physiological markers were an418

alyzed using Students t-tests.

RESULTS responses to the Single Item literacy Screener question, “how often do you need to have someone help you when you read instructions, pamphlets, or other written material from your doctor or pharmacy?” were: 49% never (n = 18), 3% rarely (n = 1), 19% sometimes (n = 7), 22% often (n = 8), and 8% always (n = 3), and one missing data. do patients’ physiologic measures improve within three months of the group education visit? Initial hbA1c levels ranged from 5.6% to 14.0% with a mean of 9.1%. There was a significant decrease in hbA1c (M = 9.16 to M = 8.52), t(27) = 2.185, p = .038. There was not a significant difference in systolic blood pressure (M = 135.97 to M = 136.83), t(30) = -.220, p = .827; in diastolic blood pressure (M = 80.63 to M = 83.13), t(30) = -.799, p = .431 or in lipid level (M = 90.133 to 95.07), t(15) = -.518, p = .613. does patients’ diabetes knowledge improve immediately after and at three months post a group education visit? There was a significant increase in pretest and immediate posttest diabetes knowledge scores (M = 5.58 to M = 7.53 out of 10), t(38) = -5.217, p = <0.001 and in pretest and follow-up posttest diabetes knowledge (M = 5.73 to M = 7.63 out of 10), t(30) = -4.192, p = <0.001. There was not a significant difference in diabetes knowledge from immediate posttest and follow-up posttest (M = 7.48 to M = 7.62 out of 10), t(29) = -.383, p = .705.

What suggestions do patients have about improving the group process? ninety-five percent of participants had no suggestions, but provided comments including: “everything was excellent.” “very good and informative.” “It met all my needs.” “Wouldn’t know what to change.” “help(ed) me to want to try harder in lowering my sugars level.” The two suggestions were: “explain the differences in medications for diabetes.”

“More group visits about diet and nutrition.”

DISCUSSION The limitations of the research include the one group pretest/posttest design. The setting in which the study was conducted was not amenable to a study with a control group due to the likely overlap of test interventions into a control group in a small practice. The study also had a small sample size, and there was attrition of participants in the follow-up data collection.

The primary study findings were that, after a single session group education visit, diabetes knowledge JOURNAL MSMA, December 2009 — Vol. 50, No. 12

Calling all Mississippi PhysicianPhotographers SEEKING PHOTOS TAKEN BY MISSISSIPPI PHYSICIANS FOR 2010 COVERS OF THE

JOURNAL MSMA Load your camera. Shoot landscapes, people, animals, or anything else you can capture on film.

Photos of subjects indicative of Mississippi will be given the highest consideration. Photos of original artwork are also acceptable.

The Committee on Publications will judge the entries on the merits of quality, composition, originality and appropriateness to the JOURNAL MSMA and select the best cover photos. All photos selected require the photographer and subjects contained therein to release “permission to reprint” and “publicize on the JOURNAL MSMA website.”

Specifications: Color slides, digital files and photos. Size: Vertical format 5 x 7" or 8 x 10". A print is required for judging.

Deadline: December 10, 2009 Send entries with a brief description of the subject as well as of yourself to: Karen Evers, JOURNAL MSMA, P.O. Box 2548, Ridgeland, MS 39158-2548 or deliver to: MSMA headquarters 408 West Parkway Place, Ridgeland, MS 39157 or email to: KEvers@MSMAonline.com

For more information: contact Karen Evers, ph.:(800)898-0251 or (601)853-6733

JOURNAL MSMA, December 2009 — Vol. 50, No. 12

increased and was sustained and hbA1c levels decreased among a group of adults with Type 2 diabetes.

These results support group education benefits seen in prior research.3,15,16 however, prior studies have generally involved multiple group sessions extending over weeks to years. This study demonstrates that good reductions in hbA1c and improvement in diabetes knowledge is possible with a single group education session. diabetes is a common chronic illness whose treatment is heavily dependent on patient self-management. educating patients in self-management can present a significant burden to a primary care practice due to time constraints on physician and other resources. If such education can be in a single session, this burden is lessened, and it is conceivable that many practices could enlist community resources to assist in the education, such as pharmacists, exercise physiologists, dietitians, and nurse educators as represented here. Accomplishing good reductions in hbA1c and improving health literacy occurred despite nearly onethird of participants stating they always or often need to have someone help them when they read instructions, pamphlets, or other written material from their doctors or pharmacies. In addition, this finding indicates the importance of follow-up health literacy questions and assessment of patient understanding of education materials and conversation.

While not part of the original research design, an additional finding of concern is that greater than half of participants always or often do not fill or take prescription medications due to the cost. Obviously, patient education about the importance of taking medication as prescribed will not be as effective in improving outcomes if a patient’s ability to obtain medications is lacking. disclosure of penury is predictably uncomfortable and seems unlikely to occur as freely as needed in a single visit group setting where most would be strangers to the patient in such need. Followup individual assessments for ability to obtain medication and referrals for medication assistance would require additional visits, but the office staff in many instances can assist on a one-to-one basis in this regard.

Support: American Academy of Family Physicians Foundation Health Literacy State Grant. Thanks to Edee Dull, research assistant, who participated in the data collection.

419

REFERENCES 1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

16.

Centers_for_disease_Control. Diabetes Data and Trends.

2005. apps.nccd.gov/ddTSTrS/default.aspx. Accessed October 22, 2008.

Warsi, A., et al., Self-management education programs in chronic disease. Arch Intern Med. 2004;164:1641-1649. van dam, h.A., et al., review: Interventions focusing on patient behaviors in provider-patient interactions improve diabetes outcomes. Patient Educ Couns. 2003;51:17-28. raji, A., et al., A randomized trial comparing intensive and passive education in patients with diabetes mellitus. Arch Intern Med. 2002;162:1301-1304.

Association, A.M., Health Literacy. 2006. http://www.ama-assn.org/ama/pub/category/print/8115.html Accessed October 22, 2008.

Ad hoc Committee on health literacy for the Council on Scientific Affairs, A.M.A., Health Literacy: Report of the Council on Scientific Affairs. JAMA, 1999. 281(6):552557.

Baker, d.W., The Meaning and the Measure of health literacy. J Gen Intern Med. 2006. 21:878-883.

Wallace, l. and e. lennon, American Academy of Family Physicians Patient education Materials: Can Patients read Them? Fam Med. 2004. 36(8):571-4. davis, T., et al., rapid estimate of Adult literacy in Medicine: a shortened screening instrument. Fam Med. 1993. 25(6):391-5.

Parker, r., Baker, d., Williams, M, & nurss, J., The test of functional health literacy in adults: a new instrument for measuring patientsâ&#x20AC;&#x2122; literacy skills. J Gen Intern Med. 1995. 10:537-41.

Morris, n., Maclean, C., Chew, l., & littenberg, B., The Single Item literacy Screener: evaluation of a brief instrument to identify limited reading ability. BMC Fam Pract. 2006:7(21).

Morris n, MacClean C., & littenberg B, literacy and health outcomes: a cross-sectional study in 1002 adults with diabetes. BMC Fam Pract. 2006;7(49).

Kim, S., et al., Association of health literacy with SelfManagement Behavior in Patients with diabetes. Diabetes Care 2004. 27(12):2980 - 2982. rothman, r., et al., Influence of Patient literacy on the effectiveness of a Primary Care-Based diabetes disease Management Program. JAMA 2004. 292(14):1711-1716. raji, A., et al., A randomized trial comparing intensive and passive education in patients with diabetes mellitus. Arch Intern Med. 2002. 162:1301-1304.

Warsi, A., et al., Self-management education programs in chronic disease. Arch Intern Med. 2004. 164:1641-1649.

AUTHOR INFORMATION: Kristi J. Oâ&#x20AC;&#x2122;Dell, PhD, MSW; University of Mississippi Department of Social Work

420

Michael L. Oâ&#x20AC;&#x2122;Dell, MD, MSHA; North Mississippi Medical Center Family Medicine Residency Clinic James L. Taylor, PharmD; North Mississippi Medical Center Family Medicine Residency Clinic

CORRESPONDING AUTHOR Kristi J. Oâ&#x20AC;&#x2122;dell, Phd, MSW University of Mississippi department of Social Work PO Box 1848 longstreet room 215 Oxford, MS 38677 Phone: (662) 915-7336 Fax: (662) 915-1288 email: kjodell@olemiss.edu

We specialize in the business of healthcare t t t t t t t t

$PNQSFIFOTJWF .BOBHFNFOU $PNQSFIFOTJWF $POTVMUJOH #JMMJOH "DDPVOUT 3FDFJWBCMF .BOBHFNFOU $PEJOH %PDVNFOUBUJPO 1SBDUJDF "TTFTTNFOUT 3FWFOVF &OIBODFNFOU 1SPĂśUBCJMJUZ *NQSPWFNFOU 1SBDUJDF 4UBSU VQT 1FSTPOOFM .BOBHFNFOU

/PSUI 4UBUF 4USFFU 4VJUF +BDLTPO .4 5FMFQIPOF 8"54 XXX NQTCJMMJOH DPN JOURNAL MSMA, December 2009 â&#x20AC;&#x201D; Vol. 50, No. 12

! $ ! !

! $ ! !

" !#

CLINICAL PROBLEM-SOLVING Presented and edited by the Department of Family Medicine University of Mississippi Medical Center Diane K. Beebe, MD, Chair

Halitosis: Hindrance or Hint?

Ijeoma Innocent-Ituah, MD

A

44-year-old white female presented to the emergency department (ED) with recurrent epigastric abdominal pain and swelling with associated halitosis, nausea and vomiting for several months duration. Further questioning revealed that she had been admitted to the hospital 3 times in the past 6 months. Two of those admissions were for diabetic ketoacidosis, and the previous visit was for abdominal pain, halitosis, nausea and vomiting. She was subsequently diagnosed with gastroparesis and treated with intravenous fluid and pain medication. She was prescribed metoclopramide (Reglan) at discharge.

Two weeks later, she presented for the current ED visit with worsening abdominal pain, halitosis, nausea and vomiting. The abdominal pain was dull and non-radiating, aggravated by meals and relieved by vomiting. The vomiting was non-projectile and contained recently eaten meals. She had occasional associated non-bloody diarrhea. Her most recent bowel movement was on the morning of this presentation. She reported no history of travel or sick contacts.

It is very important to note the location of the abdominal pain and the patient’s age to aid in excluding unlikely causes. Abdominal pain located in the epigastrium brings to mind many surrounding abdominal organs, such as the stomach, duodenum, pancreas, liver, gallbladder and transverse colon. A chronic, non-radiating epigastric pain is more consistent with uncomplicated gastric or duodenal ulcer or cholecystitis. These are more common in the fourth and fifth decades of life; this patient falls within this age 422

group. There are some systemic diseases that may be associated with bad breath, including renal failure, respiratory tract infection, liver failure and diabetes mellitus.1 The patient’s complaint of halitosis may be associated with her history of diabetes, reflux or other underlying medical problems.

The patient had a medical history of diabetes mellitus, hypertension, fibromyalgia, gastroparesis, gastroesophageal reflux disease (GERD), coronary artery disease (with 3 cardiac stents) and depression.

She had a history of prior abdominal surgeries that included colon polypectomy, umbilical herniorrhaphy, bladder repair and appendectomy. Her current medications were insulin glargine (Lantus), insulin aspart (NovoLog), metoclopramide and hydrochlorothiazide/lisinopril (Zestoretic). She was known to be medication non-compliant largely for cost reasons. She was a smoker but did not consume alcohol. Her family history was positive for diabetes and heart disease only.

The patient’s history of uncontrolled diabetes is complicated by gastroparesis and abdominal swelling.

I am concerned that there is a decrease in gastric or intestinal motility. She states that she has had normal bowel movements until the morning she presented, inconsistent with a bowel obstruction. however, studies have shown that some patients with partial bowel obstruction do initially have normal bowel pattern that may resolve or progress to complete obstruction.2 Physical examination revealed a well developed and well-nourished, slim patient. She was anicteric, but not pale or dehydrated, and in mild pain. She had a temperature of 97.2°F, a rapid pulse of 121 JOURNAL MSMA, December 2009 — Vol. 50, No. 12

beats per minute, a respiratory rate of 18 breaths per minute, a blood pressure of 144/102 mmHg and an oxygen saturation of 98% while breathing room air.

Her head was normocephalic and atraumatic, and her pupils were equal and reactive to light.

Extraocular muscles were intact, and her mucous membranes were moist. Her neck was supple and the jugular venous pressure was not elevated. First and second heart sounds were normal, and no murmur, rubs or gallops were present. The lungs were clear to auscultation and percussion. The abdomen was full, soft, doughy with some epigastric tenderness, but no guarding or rebound tenderness. Her extremities were warm with normal strength and no edema. She was awake, alert and oriented to person, place and time.

The patient is worried that her present symptoms are similar to those during her previous myocardial infarction. Also, she thinks her reflux may be “acting up.” Though clinically the patient does not appear dehydrated, her tachycardia may be a result of fluid lost from diarrhea and vomiting. The elevated blood pressure could be due to pain or because she had not taken her medication before presentation. The epigastric tenderness with associated vomiting could be due to infection or inflammation of surrounding abdominal organs. Cholecystitis is less likely given the patient’s body habitus, negative Murphy’s sign and absence of rebound abdominal tenderness. Patients with peptic ulcer disease commonly present with epigastric pain that radiates to the back; this pain is often associated with meals. Given her history of Gerd, peptic ulcer disease is not unlikely. however, her epigastric pain is nonradiating and not related to meals. Pancreatitis is a consideration due to the recurrent nature of the pain, though her pain does not radiate to the back. The patient denied alcohol use, and her triglyceride concentration is not known. diabetic ketoacidosis (dKA) is also a consideration given her history of diabetes, medication non-compliance and multiple hospitalizations for the same presentation. I am concerned she may be presenting with atypical dKA symptoms common among female patients with diabetes.3 Laboratory results included a normal complete blood count except for a mildly elevated white cell count at 12.5 U/L with normal differentials, low potassium at 3 meq/L, mild acidosis with a bicarbonate of 19 meq/L and an elevated glucose of 233 mg/dL. The patient’s sodium, chloride, blood urine nitrogen, creatinine and calcium concentrations were within normal limits. Her liver function tests JOURNAL MSMA, December 2009 — Vol. 50, No. 12

revealed a low aspartate aminotransferase 15 U/L; her alanine aminotransferase, alkaline phosphatase, total protein and albumin were within normal limits.

Cardiac enzymes, lipase, amylase and glomerular filtration rate were also within normal limits. A plain abdominal radiograph revealed abnormal grumous material and marked distention of the stomach.

There was gas in the colon and small bowel, and no free air was identified Pancreatic disease seems unlikely given her normal lipase and amylase values. An infectious process is less likely given her white blood count that is only slightly elevated and the absence of fever. The gastric stasis evident from the plain abdominal radiograph is not unusual given the patient’s history of gastroparesis. however, with gross gastric distension, I narrow my differential diagnosis to gastric outlet obstruction and ileus. Gastric outlet obstruction is a known complication of peptic ulcer disease; this patient does not have a known peptic ulcer disease, but does have a history of Gerd. Ileus may be due to an adhesion given her history of multiple abdominal surgeries. Given the inconclusive plain abdominal radiograph, I will order an abdominal computed tomography (CT) immediately.

Abdominal CT showed marked distention of the stomach with fluid. There was an abnormal 5 cm soft tissue mass in the pancreatic head. There was dilatation of the pancreatic duct. The intrahepatic bile ducts were not dilated. The gallbladder was distended.

I am concerned that there may be a primary pancreatic head mass. Pancreatic cancer is rare before the age of 45, but the incidence rises thereafter with a male to female ratio of 1.3:1.4 About 75% of pancreatic cancers are in the head and 25% in the body and tail of the pancreas. risk factors include age, ethnicity (more common in the African-American population), obesity, tobacco use, chronic pancreatitis, prior abdominal radiation, diabetes mellitus and positive family history.5,6 This patient’s predisposing factors include diabetes and smoking. Pain is present in more than 70% of the cases and is often vague and mainly epigastric. Patients most often present with jaundice, which is usually due to biliary obstruction by a cancer in the pancreatic head.

The U.S. Preventive Services Task Force (USPSTF) does not recommend screening average-risk, asymptomatic patients with abdominal palpation, ultrasonography or serologic tumor markers.7 Although regular screening with endoscopic ultrasonography may be cost-effective in patients with a family history of pancreatic cancer,8 the USPSTF has not addressed the 423

question of screening these patients.

The patient’s epigastric pain can be explained by the distended gall bladder and duodenal obstruction.

Given the size and location of the pancreatic mass, one would expect a history of jaundice and abdominal pain radiating to the back. The patient did not report any such symptoms.

The patient was admitted to the inpatient service. She was stabilized with intravenous fluid and had a nasogastric tube placed. A surgery consultant suggested a laparotomy for possible tumor resection. At surgery, an unresectable tumor with metastasis was noted. Hence, the patient had a palliative gastrojejunostomy. An oncology consultant planned to start chemo-radiation therapy after postsurgical wound healing. The patient improved over a few days, tolerated a solid diet and was discharged home.

A few days later, the patient presented to the ED with complaints of abdominal pain and yellow eyes, first noticed by her family. On physical examination, her vital signs were normal. She was noted to be pale, jaundiced and had right upper quadrant abdominal tenderness. Laboratory studies of the liver indicated an obstructive pattern. An abdominal right upper quadrant ultrasound and abdominal CT revealed a dilated common bile duct.

She was admitted for a transhepatic drainage and stent placement. Her symptoms improved, and she was discharged home.

Several points are raised in the case. First, in evaluating a patient, a physician should take an unbiased history for each encounter. This patient had been treated several times for dKA and gastroparesis, which was assumed to be related to medication noncompliance and progression of diabetes mellitus. Second, this patient’s initial symptom of halitosis is an unusual symptom of a large pancreatic mass. She had normal liver functions without jaundice or pruritus despite CT confirmation of large, obstructing, unresectable mass on the pancreatic head with dilated common bile duct. however, this patient’s halitosis was possibly due to the location and obstructive nature of the pancreatic mass.

The patient received 2 administrations of chemotherapy. She presented to the hospital 2 weeks after her last chemotherapy with gastrointestinal bleeding and syncopal episodes. On examination she was noted to be severely pale with diffuse abdominal tenderness. She was admitted to inpatient service for blood transfusion and fluid resuscitation. She declined clinically and was transferred to the 424

For a bird’’’s s eye view on medicine follow MSMA on

!

There’s a lot going on in organized medicine med so it’s easy to miss som something if you’re on the go. T you stay in touch h no matter where you are, MSMA A is now no communicating via “Twitter.”

In about three minutes, minut you can set up a fre free Twitter account for yourself. Simply visit www.twitter. com and submit your name, email address and mobile bile phone number (optional, optional, standard text messaging essa rates apply). Once ce you’re y signed up with Twitt witter you can add MSMA by going to the following web page http://twitter.com/ MSMA1 and clicking king “Follow” next to the MSMA A icon.

3UR¿OH QDPH MSMA1

JOURNAL MSMA, December 2009 — Vol. 50, No. 12

intensive care unit. The patient eventually became unresponsive and hypotensive with respiratory compromise necessitating intubation. The patientâ&#x20AC;&#x2122;s condition did not improve, and her family eventually decided to withdraw life support. The patient died about 4 months after initial diagnosis.

KEY WORDS:

hAlITOSIS, ePIGASTrIC PAIn, dIABeTeS MellITUS

REFERENCES 1. replogle Wh & Beebe dK. halitosis. Am Fam Physician.

1996;53(4):1215-1218 & 1223-1224.

2. Jemal A, Siegal r, Ward e, Murray T, Xu J, Thun MJ. Cancer statistics, 2007. CA Cancer J Clin. 2007; 57:43-66.

3. Zhang J, dhakal I, yan h, et al. Trends in pancreatic cancer incidence in nine Seer cancer registeries, 1973-2002. Ann Onc. 18(7);1268-1279.

4. diMagno eP. Cancer of the pancreas and biliary tract. In: Winawer SJ, ed. Management of gastrointestinal diseases. new york: Gower Medical Publishing, 1992:28.1-28.

5. Fuchs CS, Colditz GA, Stampfer MJ, et al. A prospective study of cigarette smoking and the risk of pancreatic cancer.

Arch Intern Med. 1996;156:2255-2260.

6. everhart J, Wright d. diabetes mellitus as a risk factor for pancreatic cancer. A meta-analysis. JAMA. 1995;273(20): 1605-1609.

7. U.S. Preventive Services Task Force. Screening for pancreatic cancer: recommendation statement. rockville, Md.: Agency for healthcare research and Quality. http://www.ahrq.gov/ clinic/3rduspstf/pancreatic/pancrers.pdf. Accessed november 2008.

8. rulyak SJ, Kimmey MB, veenstra dl, Brentnall TA. Costeffectiveness of pancreatic cancer screening in familial pancreatic cancer kindreds. Gastrointest Endosc. 2003;57(1): 23-29.

Clinical Problem-Solving is a monthly feature of the Journal of the Mississippi State Medical Association.

Clinical Problem-Solving manuscripts are case-based and portray the sequential process of clinical decision-making when the physician is faced with a diagnostic dilemma.

Cases may be unusual presentations of common diseases or common presentations of unusual diseases. Patient problems must be based on actual patients from your practice, not contrived patients, and the problem must be solvable. Cases with interesting and educational differential diagnoses are most appropriate. Patient information is presented in segments (indicated in boldface type in the manuscript). The clinician then shares with the reader (regular type) how the new information is synthesized and the rationale for critical decisions. The decision making process continues as new information emerges until there is resolution of the problem. Authors from all medical and surgical specialties are encouraged to submit manuscripts for consideration in this monthly feature. Manuscripts and requests for Instructions to Authors should be addressed to dr. replogle at department of Family Medicine, 2500 n. State St., Jackson, MS 39216.

Review Committee: Chris R. Arthur, PhD Diane K. Beebe, MD Judy Gearhart, MD Shannon D. Pittman, MD William H. Replogle, PhD

AUTHOR INFORMATION: Ijeoma Innocent-Ituah, MD was a third year resident in the Department of Family Medicine at the University of Mississippi Medical Center.

CORRESPONDING AUTHOR: Ijeoma Innocent-Ituah, Md Ochsner Clinic Foundation dept. of Family Medicine Ochsner health Center lakeview 101 West robert e. lee Blvd, Suite 201 new Orleans, lA 70124 e-mail: innocentituah@yahoo.com

JOURNAL MSMA, December 2009 â&#x20AC;&#x201D; Vol. 50, No. 12

425

An Academic Medical Center Is Not Like An Ordinary Hospital.

As a physician, you ask more of an academic medical center.

You ask us to invent new ways to diagnose and treat disease.

To lead the medical research that can give us all better lives.

You ask more of University of Mississippi Health Care.

You ask us to offer the highest level of medical care to our mutual patients, every day.

To push the boundaries of what is possible.

This is University of Mississippi Health Care.

Your academic medical center.

Expect more.

Talk doctor-to-doctor at 866.UMC.DOCS or learn more at umhc.com.

426

JOURNAL MSMA, December 2009 â&#x20AC;&#x201D; Vol. 50, No. 12

PRESIDENT ’S PAGE WE HAVE NO CABS IN VICKSBURG

l

ike a swarm of angry yellow jackets uprooted from their earthly nest, more than 1,000 delegates and alternate delegates to the American Medical Association 2009 interim meeting descended on houston, Texas on Friday, november 6th. Armed with handbooks chocked full of tantalizing resolutions, the pervasive culinary preoccupation was whether or not the AMA was still at the health system reform table or were we now on the menu.

The proverbial stick that stirred the nest was the AMA’s support (We will come back to that word momentarily) for hr3962 less than 48 hours prior to convening the governing body of the association, The house of delegates.

On two separate nationwide conference calls, dr. Cecil randy easterling, MD Wilson, President-elect of the AMA, explained their support 2009-10 MSMa President was a strategical move precipitated by word that Speaker of the house nancy Pelosi had clear intentions on calling a vote on hr3962 by Saturday, november 7th.

The stage was set, let the games begin! hold on; allow me a moment of brief housekeeping for you AMA newbies in the audience. The interim meeting which always occurs in the Fall, and in a location known for warm weather and cool beverages (Atlanta, dallas, las vegas, hawaii, and of course houston, Texas), is dedicated solely to issues of advocacy. legislative stuff, if you will.

Well, I don’t know about you, but statutorily reshaping, redefining, and rebuilding the most sophisticated health care system in the world surely meets my criteria for advocacy.

Back to the subject at hand, the AMA support (there goes that word again) for hr3962 was predicated on the following.

1. expanding coverage: hr3962 will raise the percent of legal, non-elderly residents with insurance coverage from 83% to 96%.

2. Insurance market reform: The legislation eliminates preexisting condition exclusives and lifetime limits on total spending, does not allow insurers to vary premiums based or health status, and expands choice and access to coverage for those who are self insured or employed by small businesses.

3. Patient position decision making: Insures that decisions are made between physician and patient with no government intrusion.

4. Investment and quality, prevention, and wellness.

5. reduce administrative burden.

6. In addition, hr3962 authorizes incentive payments to states that adopt certificate of merit and/or early offer medical liability reforms. This, in my opinion, is an anemic attempt to placate organized medicines demand for federal tort reform…in other words, a total waste of $25 million of your and my tax dollars.

JOURNAL MSMA, December 2009 — Vol. 50, No. 12

427

It sounds good, does it not! Well, as always, the devIl is in the deTAIlS. The congressional budget office (CBO) suggests the expanded coverage would be accomplished by a combination of three vehicles.

1. Twenty-one million additional insurers through various forms of insurance exchange and/or coops.

2. expanding the Medicaid roles to include an extra 15 million.

3. And at last, but certainly not least, a PUBlIC OPTIOn. The CBO predicts that a public option would bring an additional 6 million Americans into the membership of the UnITed STATeS dISCOUnT hOUSe OF PrAyer And enTITleMenTS (Sarcasm).

If that were not enough, hr3962 did not make mention of repealing or replacing the flawed SGr. remember, that is the formula that will automatically decrease all physician Medicare reimbursement by 21.5% come January 1, 2010. repeal of the SGr is contained in Sr3961.

To make matters worse, no sooner than 6 hours following adjournment of the largely ceremonial meeting of the house of delegates on Saturday, november 7, nancy Pelosi was true to her word. At 11:00 p.m. that evening, the United States house of representatives voted 220 to 215 to pass hr3962. It is the opinion of most political pundits that the “Affordable healthcare for American Act” (3962) would have not passed had it been for AMA support.

Battle lines were drawn and the house of delegates went to work. your Mississippi delegation, along with the majority of the southeastern delegation, felt strongly that the AMA’s backing of hr3962 was tantamount to a blanket endorsement of the entire bill. It was at this point that we were educated in the fine art of “word smithing.” The AMA leadership was quick to point out that “support” was far different from “endorsement”. Supporting hr3962, the leadership explained, was nothing more than a mechanism by which to shepherd the bill through the process without giving 100% “endorsement”. dr. rohack, president of the American Medical Association, echoed time and again, that hr3962 was a bill that the association could support; but at the same time contained elements that were concerning to our organization.

Understanding full well that The United States house of representatives had spoken, a number of us (predominantly from southern states) felt it important to delineate those portions of hr3962 we supported, while at the same time isolating the egregious sections so that we might express opposition in the U.S. Senate. your Mississippi delegation played a central role in drafting additional resolutions which would direct AMA leadership to oppose a public option as the bill made its way to the United States Senate. Our efforts were in vain, we lost the vote 3 to 1.

The debate was spirited, well orchestrated and, by and large, well meaning on both sides of the issues.

Myself and your immediate past president, dr. Pat Barrett, were quite vocal concerning our opposition to a government run, government funded insurance plan. Those concerns were not shared by the majority.

I find it incredibly naïve and at the same time disappointing that a fair number of physicians in this country evidently believe that the same government that oversees Fanny Mae, Freddy Mac, the post office (which is to date $7 billion in the hole), etc… should be entrusted with efficiently managing our health care system. I am sorry, I don’t get it.

I am convinced that a public option, if adopted, will sooner or later evolve into the only option. That is the way government works. I know. I have seen it before. I am reminded of a simple analogy.

Over 20 years ago, the city of vicksburg had no cab service. A young African American in town saw an opportunity and acted. he went to the bank, borrowed some money and started a small cab service. he worked hard (after all, he had debt to repay), was responsive to his customers, and provided a vital service to the predominantly African American community in vicksburg both day and night.

Well, long story short, about two years ago the city of vicksburg decided to start a public transit system.

With grant money in hand, buses were bought and subsidies employed. now we have a city run bus system that loses money, is not nearly as responsive to the public needs, and operates only during certain hours of the day.

What we don’t have now is a cab service. For his entrepreneurism, hard work, and desire to get ahead, the government rewarded his efforts by running him out of business. he was “literally thrown under the bus” by a public option. enough said.

428

JOURNAL MSMA, December 2009 — Vol. 50, No. 12

A bill will now go to the United States Senate and then to conference. Odds are the final product will not have a public option, but who knows?

In the meantime, come see us in vicksburg. We have a beautiful, historic city with lots of things to see and do. Just remember, bring your own car.

We hAve nO CABS In vICKSBUrG. your partner in making Mississippi healthier,

Randy Easterling, MD President, Mississippi State Medical Association

Delivering healing, help and hope.

Sta-home delivers comprehensive home health services and compassionate hospice care directly to the home.

We cherish the quality of life of the patients we serve.

Customized Asset Management If you have $500,000 or more to invest, we invite your inquiry as to our investment record, background, and fee structure.

Call us at 601-982-4123 or 1-800-844-4123 or visit our website at www.medleybrown.com

Sta-home.

Clearly the best choice

for home health and hospice services.

Fee Only Financial Advisors

n

i

PV

PMT

FV

STO

RCL

%

f

g

CHS

x ><y

CLx

ENTER

MEDLEY & BROWN

sta-home.com 1-800-Sta-home

FINANCIAL ADVISORS

P.O. Box 16725 Jackson, MS 39236-6725 795 Woodlands Parkway, Suite 104 Ridgeland, MS 39157 601- Â&#x2021; -800-844-4123 Fax 601-366-0013 www.medleybrown.com

JOURNAL MSMA, December 2009 â&#x20AC;&#x201D; Vol. 50, No. 12

Family owned and operated in Mississippi.

Call to see if we can meet your needs.

Toll-free Referral Line 1-800-782-4663.

429

BlueCross BlueShield of Mississippi Committed to a Healthier Mississippi.

Celebrity Roast of

Daniel W. Jones, M.D. Chancellor University of Mississippi

Benefiting the

Mississippi A cademy o f F amily P hysicians F oundation The Inn at Ole Miss 1 Alumni Drive

Roasters for the Evening

David O. Bell, Esquire Dr. Randy Easterling Saturday, F ebruary 6, 2010 Reception 6:30 - Roast 7:00 Dr. James E. Keeton Dr. Robert C. Khayat Hotel Reservations Honorable Edward E. Patten, Jr. 1-888-486-7666 Dr. Helen R. Turner $89 Double Rate Reserve by January 16, 2010 Dr. LouAnn Woodward Tickets are $125 Individual; $200 Couple $500 Reserved Table of Five $1,000 Reserved Table of Ten

To order tickets visit www.msafp.org For sponsorship opportunities or for more information, please contact Kim Erickson at 601-853-3302 or kim@msafp.org.

430

JOURNAL MSMA, December 2009 â&#x20AC;&#x201D; Vol. 50, No. 12

JOURNAL MSMA, December 2009 — Vol. 50, No. 12

431

EDITORIAL Like the Spartans at Thermopylae: Mississippi’s Docs Stress Need to Reform Health Reform at Interim AMA Meeting

T

he 63rd Interim Meeting of the American Medical Association (AMA) house of delegates was called to order on Saturday november 7, 2009 at the George r. Brown Convention Center in houston, Texas. 464 delegates, or 85% of all delegates (and about the same number of alternate delegates), were present at the four day meeting, and Mississippi’s delegation (seven delegates and seven alternates) was present in full force, a little bleary eyed after arriving the day before and gathering at the crack of dawn Saturday to discuss pending resolutions and reports. Mississippi’s delegates were convinced as a team of the desperate need to bring the issue of health reform to the floor of the house for discussion, with hopes of influencing ongoing AMA negotiations on Capitol hill. Two late resolutions (from Georgia and Florida) expressed grass roots discontent with the AMA’s strategy in the health reform debate. As the house gathered, the national drama of health system reform evolved on television, heightening the tension of the AMA house, with the U. S. house vote on the issue occurring as the AMA met. As if the health care storm weren’t enough, Tropical Storm Ida was swirling in the Gulf and predicted to land during the meeting anywhere from Texas to Florida.

The first session of the AMA house includes special awards for community service and meritorious achievement. noteworthy was the presence of the recently confirmed U. S. Surgeon General, Alabama native regina Benjamin.

Attired in military uniform, she addressed the AMA house and notably expressed her appreciation to the AMA’s Southeastern delegation (which includes Mississippi) which had long supported her in past AMA elections. referring to the Southeastern delegation Breakfast, which traditionally includes grits, bacon, and eggs, she laughed that the “chickens contribute to the breakfast, but the pig is committed,” and added that the Southeastern delegation had been committed to her advancement. She reminded the audience of physicians: “The reason that we are here is patients come first. That is the reason that I have agreed to become the family physician of 350 million Americans.” She encouraged her fellow physicians to use their time with patients to make a difference in their lives.

The “two-ton gorilla in the room” at this AMA Interim Meeting (to use delegate dr. Pat Barrett's words) was the subject of national health care reform and the AMA’s role in that reform; the “rest is shuffling the deck chairs on the Titanic,” Pat added. Most of the delegates, and the AMA board, appeared to understand the primacy of this issue, and following Saturday’s session, a town hall-like forum was held by the house of delegates. All non AMA members were asked to leave the room, and in closed session, a frank and open discussion was engaged. referring to the current government health system as untenable, AMA President J. James rohack of Texas stressed the need for the nation’s physicians to “seize this opportunity” for reform, asking “If not now, when?” he added that “this Ponzi scheme is not going to work much longer.” delegates told the board that while they acknowledged that the status quo may be untenable, so is the proposed reform. rohack defended the AMA’s action as being in the best interests of the profession.

By being involved early in the legislative process, he said, the AMA has been able to influence it. rohack defended the AMA’s public support of h. r. 3962 (the Affordable health Care for America Act): “endorsement is like marriage; support is like engagement and we are still working on it. Words are important. We did not endorse h. r. 3962. We supported it to move the process forward.” But this nuance, a delegate countered, was not voiced nor explained to our members at the time, and all appearances were that the AMA fully supported the bill. One Georgia delegate chastised rohack that there is not “a lick of difference” between endorse and support to the average doc in the United States, and the support of the AMA should have been stated conditionally from the get-go. Another delegate from California asked “Why are we here?” And then answering his own question: “We are here because the rank and file are angry.” rohack assured the delegates that the AMA “will do a better job of communicating” with its members. rohack concluded Saturday’s forum with the following comments: “America’s doctors are being held hostage by a dysfunctional Congress... let's be clear. Congress is the problem, not America’s physicians. But we have to work with Congress because they don’t know what physicians know.” The contentious mood of the forum and the house made clear that physicians across the country have divergent opinions on varied aspects of health reform. In the midst of these AMA discussions, after a Capitol debate which lasted until the night, the house of representatives narrowly passed by a 220-

432

JOURNAL MSMA, December 2009 — Vol. 50, No. 12

215 vote its health reform bill, h. r. 3962, with only one republican vote in its favor. (Of course, repeal of the SGr formula was extracted from it!)

The health reform gorilla on Sunday became the work of reference Committee B, which discussed for hours several resolutions, including those from Georgia and Florida, regarding this issue, specifically focusing on house and Senate legislative language. This committee heard emotional debate both in support and against the AMA board’s role in the health reform battle. reference Committee B, headed by South Carolinian Boyce Tollison, crafted a fine report and synthesis of the many health reform resolutions, and much Mississippi physicians desired was accomplished by the committee’s substitute resolution 203. This resolution, supported by Mississippi and most of the Southeastern delegations, as well as several surgical specialty societies, required that the AMA “actively and publicly” support only legislation which allowed patient choice of a health plan, preserved patient choice of physician, guaranteed patients and physicians the right to contract privately, prohibited a single payer/government run health system, ensured that the medical profession determine quality of care, fixed the broken medical liability system, and did not cut one specialty’s payments to pay for increases for another specialty. Monday afternoon, the house of delegates met to debate passage of this important resolution. Mississippi’s group was on the front line of the battle in the house of delegates, working with a coalition of other like-minded states, to have the AMA outline specifically what it was for and against. Substitute resolution 203 did pass, much to the delight of our delegation.

After its passage, many delegates stressed the need to “tie the hands” further of the AMA board. however, four attempts to rescind the AMA’s stated support of h. r. 3962 , all pushed by the Mississippi delegation, failed. The first attempt to rescind this “endorsement” was introduced on the floor by dr. Barrett, who, speaking for the delegation, asked the house simply to acknowledge what AMA president rohack had told the forum audience earlier: that the AMA supported, but did not endorse h. r. 3962 (this to make it clear that the AMA did not support all parts of the house bill).

This effort failed by a vote of 350 against, 167 for. Three subsequent attempts to pass language which rescinded support for this bill each failed, averaging 35% to 65% on most votes, before the house closed down late on Monday. It is clear that there is a large minority of physicians, close to 40% of the AMA delegates, who share similar perspectives as the majority of Mississippi’s physicians. however, it is also quite apparent that to change the AMA and win these important votes at a national level, our state and region need more AMA delegates, not less.

Tuesday morning, our President dr. randy easterling discussed the AMA action on the Paul Gallo radio show back in Mississippi (via phone) before the house resumed its meeting. Gallo joked, opening up the interview, “houston, we have a problem...” randy ably explained that the Mississippi delegation had fought long and hard to remove the offensive and dangerous portions of the federal legislation on the floor of the AMA house. he stated that Mississippi made four attempts to rescind h. r. 3962 and also expressed the consensus of the Mississippi delegation that a public option would not serve Mississippi well, noting that the delegation had argued these points both in the reference committees and on the floor of the house.

At the closing session on Tuesday, after several final attempts by state delegations including Mississippi to clarify further the AMA position on h. r. 3962, past AMA president don Palmisano of louisiana stood up and expressed his frustration with the AMA’s house, commenting on the floor: “I feel like a Spartan at Thermopylae.” Thermopylae, a Greek term meaning “hot gates,” is a narrow four mile pass on the eastern coast of central Greece which holds historical importance as the site of a critical battle in ancient times. In August 480, during an invasion of Greece by Xerxes’ Persian army, a small force of 300 Spartans held the pass for three days against the mammoth Persian force of hundreds of thousands. Although the Spartan King leonidas and all of his troops perished, the battle has been celebrated in antiquity much like Texans celebrate the Alamo: an instance of heroic resistance against incredible odds. Palmisano’s comment summed up the feelings of many in our profession upon hearing of recent AMA decisions. however, the truth is that the Spartans lost because they had so few soldiers fighting to protect that pass. To change the outcome at some future Thermopylae, more Mississippi physicians must become members of the AMA to increase our region’s influence at a national level, to increase our one-third steady vote to fifty percent plus one.

At the meeting’s end, Tropical Storm Ida had gone ashore to the east, the storm in Washington had begun to calm after passage of the house bill, and the delegation returned home to Mississippi to work again in our hospitals and clinics. Mississippi’s delegates had fought the good fight for our state’s physicians. Although our delegation lost several floor battles against greater numbers, Mississippi’s arguments had been voiced in the national forum, and our AMA’s health system reform policy had been changed in a manner somewhat more palatable to the majority of Mississippi’s physicians.

—Lucius “Luke” Lampton, MD Editor JOURNAL MSMA, December 2009 — Vol. 50, No. 12

433

NOW PRELEASING PROFESSIONAL OFFICE SPACE Premier Madison Office Space Highland Colony Parkway Near Baptist Complex Contact: Collier Simpson Bedford Realty 601-506-6622 bedfordrealty@att.net

R D C

Helping Mississippi Families Every Step of the Way Scott Medical Imaging and Ridgeland Diagnostic Center offer state of the art MR imaging to the people of Mississippi in a friendly outpatient setting.

s Affordable for self pay patients. s Easy Payment Option available. s Scott Medical Imaging provides mobile MRI services at several locations throughout Mississippi. s Ridgeland Diagnostic is centrally located for patients in Jackson Metro Area. s State of the art Philips 1.5 Tesla scanner. s 2EPORTS AVAILABLE WITHIN HOURS OR SAME DAY IF REQUESTED

Scott Medical Imaging and Ridgeland Diagnostic Center Phone: 1-866- 853-3856 RDC RIDGELANDMRI COM s WWW RIDGELANDMRI COM 434

JOURNAL MSMA, December 2009 â&#x20AC;&#x201D; Vol. 50, No. 12

MSDH Mississippi reportable Disease Statistics

September 2009

* totals include reports from department of corrections and those not reported from a specific district nA - not available (temporarily)

For the most current MMR figures, visit the Mississippi State Department of Health web site: www.HealthyMS.com JOURNAL MSMA, December 2009 â&#x20AC;&#x201D; Vol. 50, No. 12

435

IQH MISSISSIPPI HEALTH FIRST COLLABORATIvE A statewide effort to improve care for patients with diabetes across Mississippi, particularly for patients considered to be “medically underserved,” has been announced by the Centers for Medicare & Medicaid Services (CMS). The initiative, called the Mississippi health First Collaborative, is designed to have patients receive diabetes self-management training in their home communities. Members of the collaborative will help motivate and educate diabetes patients across the state to take preventive action against some of the complications of diabetes.

Patients will participate in diabetes self-management training classes and receive health education literature on how to control their blood sugar, blood pressure and cholesterol levels. establishing relationships with primary care providers will be a part of the program that will address better nutrition and regular exercise. The effect of housing arrangements on patients’ health and the development of support networks of family, friends, and community-based social services will be a part of the focus.

“The Mississippi health First Collaborative is a first for all of us,” said CMS’ Chief Medical Officer and director of the agency’s Office of Clinical Standards and Quality Barry M. Straube, Md. “It’s a first for patients, who will receive help managing their diabetes in community settings that are both familiar and comfortable to them. It’s also a first for CMS and our extensive network of diabetes partners in Mississippi to bring partners together in a way that lets us all reach thousands more patients than we could have possibly reached alone.”

Other federal agencies participating in the Mississippi Health First Collaborative include the Centers for disease Control and Prevention (CdC), Administration on Aging (AOA), health resources and Services Administration (hrSA), national Institutes of health (nIh), housing and Urban development (hUd), and the U. S. department of health and human Services’ Office of Minority health. national non-profit and state entities working with the collaborative include the American Association of diabetes educators, the American diabetes Association, the diabetes Foundation of Mississippi, and the national Academy for State health Policy, and the Mississippi State department of health. during the next 18 months, CMS and other collaborative members will work together seeking thousands of patients with diabetes in Mississippi, through federally qualified health centers, rural health clinics, existing and newly formed diabetes training programs, Area Agencies on Aging, the division of Aging and Adult Services, and housing authorities. CMS is mobilizing community groups, health experts, faith-based organizations, housing providers, healthcare providers, community leaders and others to reach patients across the state, including those with Medicare, Medicaid, private insurance and others without insurance. research from the U. S. Agency for healthcare research & Quality and other sources depict a bleak picture of the health of Mississippi’s population that has one of the nation’s highest obesity rates, along with high rates of diabetes, poverty, and medical need. In Mississippi, approximately one in seven African Americans has been diagnosed with diabetes, compared to one in ten whites. CdC data show that African Americans are at greater risk of diabetes and are more likely to experience disease and life-threatening complications, such as blindness and kidney failure. Many persons in the state are designated as being a part of a “medically underserved group,” which is a population group facing economic, cultural, or linguistic barriers to health care, or live in “medically underserved areas” that have shortages in the availability of personal health services.

This project borrows from the success of other projects Medicare has undertaken to improve care for patients with diabetes. Since August 2008, Medicare’s Quality Improvement Organizations (QIOs) have worked with local organizations and groups in select parts of the country to bring diabetes self-management training to their communities, and this collaborative is intended to provide similar services. QIOs such as IQh work in every state 436

JOURNAL MSMA, December 2009 — Vol. 50, No. 12

and territory to improve the quality of healthcare available to local Medicare beneficiaries. The QIOs for new york, Maryland, the district of Columbia, Georgia, louisiana, and the U. S. virgin Islands have worked with hundreds of doctors’ offices to find Medicare patients who could benefit from diabetes self-management training. To date, these efforts have helped more than 2700 beneficiaries. Through the summer of 2011, Medicare hopes to train at least 7000 more beneficiaries in these states and territories.

IQh, as the CMS Quality Organization for the state, is organizing the collaborative locally. The collaborative will help motivate and educate patients with diabetes to take preventive controls on how to control blood sugar, blood pressure, and cholesterol levels; establish relationships with primary-care providers; address better nutrition, housing, and regular exercise; and develop support networks of family, friends, and communitybased social services.

PLACEMENT / CLASSIFIED STEINWAY Mahogany Piano

Model M (1924) and matching bench; reworked in accord with Steinway certification in 2003; piano disc player; Only two owners. $28,600.

Call: 601.982.8005

PHYSiCiaNS NeeDeD Physicians (specialists such as

IQH DRUG SAFETY PROGRAM cardiologists, ophthalmologists, The IQh drug safety project continues in efforts to pediatricians, orthopedists, decrease Mississippi’s statistics in prescribing potentially neurologists, etc.) interested in inappropriate medications (PIMs) in the elderly. data performing consultative evaluations show that Mississippi ranks high in that category as well (according to social security as in drug-to-drug interactions (ddIs).

Statistics reflect that 52,573 Medicare beneficiaries guidelines) should contact the (29.98 percent) in the state received one or more PIMs Medical relations office. from July to december 2008. To assess the percent of nursing home patients receiving PIMs, the IQh analysis toll free 1-800-962-2230 staff linked nursing home patients covered by Medicare Jackson 601-853-5487 with pharmacy data. Of the 11,284 nursing home leola Meyer (Ext. 5487) residents covered by Medicare from July through december 2008, 8.5 percent received one or more PIMs. drug-to-drug interactions from July through december 2008 were found for 22,220 Medicare beneficiaries (10.23 percent). evaluation of drug-to-drug interactions in nursing home patients showed 4.4 percent.

Both the top 10 PIMs and the top 10 ddIs are shown in tables that reflect statistics from July through DiSabiliTY DeTerMiNaTiON SerViCeS december 2008 on the IQh Web site. visit www.iqh.org1-800-962-2230 -drug safety. expert panels and clinical research have shown that many of these PIM medications and ddI interaction medications have the potential to cause serious complications in the elderly. Careful reviewing of the choice of medications and weighing the risk and benefit in the elderly may help avoid these unwanted outcomes and complications.

Publication No. 9SOW-MS-OR-1436-09 Material prepared by IQH under contract with Centers for Medicare & Medicaid Services (CMS), an agency of the U. S. Department of Health and Human Services.

Contents presented do not necessarily reflect CMS policy.

JOURNAL MSMA, December 2009 — Vol. 50, No. 12

437

UNA VOCE

The Uncommon Thread

I

t started when I wrote that first column, the inflammatory invitation to try and start a dialog with America on the future of health care, Saving Lives. People asked me where I was going with this. I didn’t know. I wasn’t the regular writer for the column. dr. dwalia South would be returning after her stint as president, and in the meantime they were going to fill in with a rotating group of writers. I was just trying to r. Scott anderson, MD start another larger project. no other writers appeared, so I wrote a second column and then a third. The third returned to the subject of Saving Lives. People knew where I was going, or so they thought. Things suddenly went from Italy to irritation, with no obvious connection. And then I threw in the monkey wrench, abandoning the idea for a larger work.

Saving Lives was dead. I was committed for six more months, and I didn’t have any idea what to write about. So I just wrote.

The more I wrote, the less I was in command of what was being written. This wasn’t a novel or a screenplay, where you tried to keep to a fairly firm outline. The columns veered from here to there uncontrollably. even if I tried to re-write one of them it was likely to morph on me, and turn into something completely different than it was originally supposed to be. I started to think of my little creations as having a life of their own. I just let them do whatever they wanted for the next six months. I wrote my farewell column, and went back to work with my writing partners to try and write a stage play. Somewhere in the outline and scene development stage things changed. dr. South was diagnosed with a parotid cancer, the stage company behind the play flaked, we decided not to proceed with development without an assurance of financing, and so Una voce was once again my primary creative outlet. For the past year I’ve been back in the traces, and while I may have been the mule, I still couldn’t plow a straight furrow. The stories have continued to find their own direction as we skittered along together down my stream of conscious.

When I decided to try to put together a compilation of the columns that both dr. South and I had written over the years, I began to try to sort my little creations into some sort of order. So that they could be combined with the columns dr. South had written. But, the problems I had been having all along persisted. Stories would fuse to become one. Others wouldn’t cooperate at all, and had to be left out. Some even grew to twice their original size. dr. South would ask me, “What is our unifying theme in this?” I would say something like; “Well, they were all in the Journal.” Or “I’ve put them all in Una voce at one time or another.” Anything, so she would think I had some vague idea of where I was going with all this. “don’t ask me to explain it,” my right-brain begged, “please, please just read it. Then you can feel it.”

“But what are they supposed to feel?” My left-brain demanded. “People want things to relate to one another.

They want to know what to expect.” everybody wants a common thread.

So to make the two sides of my brain knock it off and give me some peace and quiet inside my own head, while we put together this second collection of stories, I tried to come up an explanation of what it was I wanted to do. When I did I e-mailed it to dr. South, and this is what I said: 438

JOURNAL MSMA, December 2009 — Vol. 50, No. 12

What is it about our lives that prepare us to be physicians? It can’t simply be our education, and it had to be there before medicine was our vocation? It happens all around us every day we practice, and I don’t think it will stop when we retire. We are what we are because of the millions of tiny incidents in our lives that build up like threads woven into a fabric. That fabric of what we are is what allows us to function as the physicians we can become. It is like taking thread to make a cloth, then taking that cloth and making a garment.

Medicine we think of as a white coat, but it just looks white because each thread, although a different color, shines with promise and adds to the whole.

I want to show it all, the threads, the fabric, all of it. Not just the coat.

She understood, just like I had hoped. See, it isn’t the common thread that I want to show you. It’s the uncommon thread…the many uncommon threads that we weave together to form who we are.

I hope you enjoy it, —Scott Anderson, MD, T of T (teller of tales / tangler of threads) [R. Scott Anderson, MD, a radiation oncologist, is medical director of the Anderson Regional Cancer Center in Meridian, and vice chair of the MSMA Board of Trustees. Additionally, he is an accomplished oil-painter and also dabbles in the motion-picture industry as a screen-writer and helped form P-32, an entertainment funding entity. “Una Voce” (With One Voice) is a column in the JMSMA designed by Dr. Dwalia S. South, MSMA past president and chair of the Committee on Publications. “Una Voce” features the selected prose of MSMA members. If you are a writer and would like to submit your work for consideration please send us your contribution or contact one of the editors.]—ED.

INDEx vOLUME L January - December 2009 SUBJECT INDEx The letters used to explain in which department the matter indexed appears are as follows: “A,” Abstract; “AP,” Alliance Page; “Br,” Book review; “C,” Comment; “CPS” for Clinical Problem Solving”; “d,” delegates report; “e,” editorial; “h” hardy Abstract; “I,” Images in Mississippi Medicine; “l,” letters to the editor; “lB,” looking Back; “Me,” Medical ethics; “Mle” Medical legal ease; “n,” news; “nC” numbers Count; “O” Opinion for What’s your Opinion, doctor?; “P” for Personals; “PB” Physician’s Bookshelf; “PCP” for Point-Counterpoint; “PhC,” Physicians’ health Corner; “PM,” Poetry in Medicine; “PP,” President’s Page; “S,” Special Article; “Uv” Una voce; the asterisk (*) indicates an original article in the Journal, and the author’s name follows the entry in brackets. Matter pertaining to related organizations is indexed under medical organization.

-AA Case of Profound Weight loss Secondary to Use of Phentermine [G Uwaifo, e Melcescu, A Mcdonald, C Koch], 407* A Poster for your Office... [r

easterling], 385 Acute Thermal Ulceration of the epiglottis [v Shenoy, K Chandrashekar, S Pai], 259* AMA health Insurer Code of Conduct?, 212

JOURNAL MSMA, December 2009 — Vol. 50, No. 12

-BBreast Cancer in Mississippi: What Can We do? [G houston], 299*

439

-CCase report: Gabapentin Abuse [A Polles, A Smith, C Sledge], 179* Clinical Problem-Solving [presented and edited by the dept. of Family Medicine, UMMC] A hole In One [d O’Bryan], 346CPS halitosis: hindrance or hint? [I Innocent-Ituah], 422-CPS Multiplicity [r Odom-Funches], 266-CPS The Broken heart [r Suares, Jr.], 312-CPS Things Aren’t Always What They Seem [T Perkins], 79-CPS Third diagnosis A Charm [B Simmons], 114-CPS Too Much of a Good Thing [r dyess], 44-CPS Two Falls and you’re Out [J Stephens, S Pittman], 154CPS Why the Confusion? [M Meeks], 10-CPS Community Water Fluoridation to Improve Oral health: Should Mississippi Support a Mandate? [K hammersmith, A Kranz, B Shukla, n Mosca], 143* Comparison of totally extraperitoneal vs. anterior repair of recurrent inguinal hernia in a university hospital setting [KB Boyd, dO Mcdaniel, Wl May, PM redmond, Kd vick], 377-h Compliance With and Understanding Advance directives in Trainee doctors [A Aylor, S Koen, e Maclaughlin, d Zoller], 3* Cover Photographs “All Too Familiar” [S hartness], March “Bridge in Sepia” [M howard],

440

november “Crucifix” Oil on Canvas [S Anderson], April Kosciusko with a “Z” [S hartness], August lilium “Stargazer” (Oriental lily) [B Tisdale], May Mississippi Sweet Potatoes [C Stroud], October “Old Glory” [J Kramer], July “Out to Pasture” [r Cannon], September “rooftops at Jackson Square” [C Guess], december S. randall easterling, Md: 20092010 MSMA President, June “To your health” [M Pomphrey, Jr.], January “Woman Playing Autoharp” [M Pomphrey, Jr.], February

-Ddeaths, 33 does a Multidisciplinary diabetes Group education visit Improve Patient Outcomes?

[K O’dell, M O’dell, J Taylor], 416*

-EEditorials At last [S hartness], 363-e daschle’s Solutions for America’s Broken health Care System [M O’dell], 53-e draw your Own Conclusions [S hartness], 21-e like the Spartans at Thermopylae: Mississippi’s docs Stress need to reform health reform at Interim AMA Meeting [l lampton], 432-e Medicine: Where Are you Going?

[M Pomphrey], 54-e Old habits Will eventually Break Us [S hartness], 126-e reflections [S hartness], 252-e Shame on Us [l Weems], 277-e Thanksgiving [M O’dell], 397-e The Adventures of a novel

Influenza A virus among Medical virgins at a Time near the end of the World [l lampton], 204-e The Grits report 2009: America’s Physicians Face Their d-day and Mississippi’s docs Tell Obama that “Caps Work!” [l lampton], 324-e Window dressing [M O’dell], 167-e elderly Suicide and risk Assessment Strategies [S hart-hester, K Crockett, P Smith, W rudman], 107* emergency room demographics diagnoses, and Frequency of Use among Mississippi Medicaid Beneficiaries [A Crudden, J Cossman, W Sansing, h Burson], 219* evidence-based Medicine Guidelines in Obstetrics/Gynecology and Trauma Surgery [J Morrison, K Paulson, v Berghella, e Magann, S Chauban, d Siddiqui], 302*

-Hhypertension in Mississippi: We Can do Better [d Jones], 39*

-IImages in Mississippi Medicine American Medical Association (AMA) Annual Meeting, June 1990, 367 dr. John Stone (1916-2008), Mississippi-Born Physician Poet [l lampton], 101-I Memphis hospital Medical College Professors’ Ticket 1890-91 [l lampton], 64-I Identifying Strategies for reducing Mississippi Infant Mortality Utilizing an Analysis of Trends and racial disparities [l langston, J Graham, l Zhang], 71*

JOURNAL MSMA, December 2009 — Vol. 50, No. 12

Immediate mobilization following open reduction and internal fixation of mandibule fractures [B Persons, S Jacob, M Germany, J Sledge, M Walkinshaw], 380-h Immunizations in Mississippi [M Currier], 262* IQH dr. Peeples receives derrick Quality Award, 287 how to Get Stimulated! [J. McIlwain], 206 IQh Annual Session, 287 IQh drug Safety Program, 437 IQh receives Champion Award from Mississippi health Information Association, 400 Medicity to Power the Mississippi Coastal health Information exchange [J. McIlwain], 27 Mississippi health First Collaborative, 436 Mississippi Providers rank Second for Prescribing Potentially Inappropriate Medications for the elderly, 128 new electronic Prescribing Incentive Program [J. McIlwain], 27 “Shovel ready” [J McIlwain], 169 Toolkit encourages health Information exchange, 168

-LLetters to the Editor A doctor’s Adventures in Patient land [d South], 22-l A record $2 Million Plus [J hill], 396-l Anti-vaccine legislation Threatens Immunity [T Brooks], 23-l Avoid visit to licensure Board by Properly renewing license Online [v Craig], 170-l Burn Care in Mississippi: A Measure of Competence in health Care and education [W lineaweaver], 129-l ed Utilization by Medicaid Beneficiaries [J Blackston],

360-l Join MSMA in leading White Coat day in Washington [P Barrett], 170 MPCn notification [S dennis], 395-l numbers do Count [C ennis], 393-l The death of Unification [l Weems], 395-l The lost Art [h Giles], 129-l To Agree to disagree is only Professional [J Blackston], 393-l Universal health Care - Be Careful What you Wish For [r Boronow], 171

-MMAFP Medical Legal Ease Just When We Thought It Was Safe to Go Back in the Water..., 98-Mle recovery Audit Contractors: Mississippi Physicians and Medicare Audits [P Stokes], 292-Mle Mississippi Burnout Part I: Personal Characteristics and Practice Context [J Cossman, d Street], 306* Mississippi Burnout Part II: Satisfaction, Autonomy and Work/Family Balance [J Cossman, d Street], 338* MSDH doctors Asked to be vigilant in Following novel h1n1 vaccination recommendations, 317 Groundbreaking held for new Public health laboratory, 93 Mississippi reportable disease Statistics October 2008, 25 Mississippi reportable disease Statistics november 2008, 60 Mississippi reportable disease Statistics december 2008, 92 Mississippi reportable disease

JOURNAL MSMA, December 2009 — Vol. 50, No. 12

Statistics January 2009, 117 Mississippi reportable disease Statistics March 2009, 165 Mississippi reportable disease Statistics April 2009, 203 Mississippi reportable disease Statistics May 2009, 229 Mississippi reportable disease Statistics June 2009, 270 Mississippi reportable disease Statistics July 2009, 316 Mississippi reportable disease Statistics August 2009, 399 Mississippi reportable disease Statistics September 2009, 435 new Mobile Field hospital Means Immediate Care for disasterStricken Mississippians, 26 State health Officer receives national Award, 271 MSMA Former State Senator Joins MSMA Staff, 272 MSMA & MSdh Issue First Annual Public health report Card, 57 MSMA house of delegates vote to Make AMA Membership Optional, 390 Presidential Address of 2008-09 MSMA President J. Patrick Barrett, Md to the MSMA house of delegates, 238 report and highlights of the 141st Annual Session of the MSMA house of delegates & Medical Affairs Forum 2009, 231 MSMA Alliance, 384 Multi Modal Approach in the Management of liver Metastasis from Colo-rectal Cancer [M Keller, C lahr, B Blondeau], 224*

-Nnew Members, 29

441

News Former AMA Trustee dr. Benjamin nominated to be Surgeon General, 364 Numbers Count how does health Care Correlate to America’s Budget?, 366nC numbers Count, 95-nC Public health report Card Stats, 134-nC The Physicians’ Perspective: Medical Practice in 2008, 61nC

-OOutcomes in neonatal gastroschisis: a single center experience [r Seetharamaiah, J. Manley, r Caskey, r roy, d Sawaya, C Blewett], 381-h

-PPermanent sacral nerve stimulation for bladder control: clinical results and quality of life measures [eh rutland, AM haraway, PC White], 381-h Personals, 135, 208, 288 Physician’s Bookshelf Hospital Medicine 2nd edition [robert M. Wachter Md, lee Goldman Md, harry hollander Md. lippincott Williams & Wilkins, Philadelphia, 2005] [reviewed by r rahim], 91PB Poetry in Medicine days not Forgotten — Memory diamonds [J Mceachin], 63PM he Makes A house Call [J Stone], 99-PM Popliteal artery injuries in an urban trauma center with a rural

442

catchment area [Jd Simmons, re Schmieg, Jd Manley, JW Gunter, FW rushton, hB Mcdaniel, Tr Bilski, JM Porter, Me Mitchell], 382-h President’s Page A Start Toward a healthier Mississippi [P Barrett], 15PP Change is Constant [P Barrett], 200-PP I Think It Just Stopped raining [r easterling], 383-PP Improving the “Business of Medicine” [P Barrett], 51-PP Inaugural Address - 141st Annual Session, Oxford [r easterling], 242-PP Making darwin Proud (The evolution of Medicine) [P Barrett], 163-PP One Picture Is not Worth a Thousand Pages [r easterling], 321-PP The Final Battle (Medical Armageddon) [P Barrett], 119-PP The Trojan horse of healthcare reform [P Barrett], 83-PP We have no Cabs In vicksburg [r easterling], 427-PP We need to reform healthcare reform [r easterling], 351PP Where Were you? [r easterling], 274-PP Public health in Mississippi report Card 2009, 17

-Rreport Card on Tobacco Use in Mississippi, 2009 [d rogers, r vance Sr.], 371* role of FdG PeT Imaging in the Management of Pediatric hodgkin’s disease: An Assessment of Stagemigration, response Comparisons with CT and

Correlation to Clinical Outcomes [v vijayakumar, M Kanakamedala, W. Mourad], 184* routine use of epidural anesthesiadoes it improve patient outcomes? [lM nicols, Jd Simmons, W replogle, n Fayard, d Snyder], 379-h

-SSingle institution results of the transobturator tape procedure for the treatment of femail stress urinary incontinence [TC davenport, MW Koury, Wr Cazayoux, Cl Secrest], 378-h Special Articles A year Ago in Mozambique - The African Medical Mission Trip [P levin], 278-S An Interview with randy easterling, Md, 2009-2010 MSMA President [K evers], 190-S “economic Impacts of Physicians on Mississippi’s County economies [B Blair], 8-S More Than Just drainage [S Moak], 356-S

-TThe end of the free flap? Use of laser assisted fluorescence angiography in perforator flap reconstruction to the lower extremity [M Burgdorf, A Johnson, A Kochevar, M Walkinshaw], 378-h Total percutaneious endovascular aneurysm repair using perclose A-T suture-mediated closure device [MA Berry, h Mcdaniel, W Cauthen], 376-h Trauma in Mississippi: A Public health Issue [J Porter, A Kyle], 150*

JOURNAL MSMA, December 2009 — Vol. 50, No. 12

-UUMC School of Medicine A new year at the Medical School [l Woodward], 353 UMHC Match Madness [J Mazurak], 281 UMMC Batson hospital Partners with leading Pediatric hospital to Create “homegrown” Cardiac Surgery Program, 173

Una voce According to Plan [S Anderson], 139-Uv Caught [S Anderson], 214-Uv County 60 [S Anderson], 175-Uv danger-Genius at Work [S Anderson], 402-Uv Portrait of a Two-lane road [S Anderson], 254-Uv Squirrel Story [S Anderson], 34Uv The One about the Warthogs [S Anderson], 102-Uv The Uncommon Thread [S

Anderson], 438-Uv Where I Fit in the Food Chain [S Anderson], 67-Uv Urgent versus emergent laparoscopic appendectomy in children with acute appendicitis: Our experience over a 5-year span [Jl Altomar, C Ouwubiko, S Milbourne, d Sawaya, C Blewett], 375-h

INDEx vOLUME L January - December 2009 AUTHOR INDEx The letters used to explain in which department the author’s matter indexed appears are as follows: “A,” Abstract; “AP,” Alliance Page; “Br,” Book review; “C,” Comment; “CPS” for Clinical Problem Solving”; “d,” delegates report; “e,” editorial; “h” hardy Abstract; “I,” Images in Mississippi Medicine; “l,” letters to the editor; “lB,” looking Back; “Me,” Medical ethics; “n,” news; “O” Opinion for What’s your Opinion, doctor?; “P” for Personals; “PB” Physician’s Bookshelf; “PCP” for Point-Counterpoint; “PhC,” Physicians’ health Corner; “PM,” Poetry in Medicine; “PP,” President’s Page; “S,” Special Article; “Uv,” Una voce; the asterisk (*) indicates an original article in the Journal.

A Altomar, Jl, 375-h Anderson, r. Scott, 34-Uv, 67Uv, 102-Uv, April cover, 139-Uv, 175-Uv, 214-Uv, 254-Uv, 402-Uv, 438-Uv Aylor, Arden l., 3*

B Barrett, J. Patrick, 15-PP, 51-PP, 83-PP, 119-PP, 163-PP, 170-l, 200-PP Berghella, vincenzo, 302* Berry, MA, 376-h Bilski, Tr, 382-h Blackston, Joseph, 360-l, 393-l Blair, Benjamin F., 8-S Blewett, C, 375-h, 381-h

Blondeau, Benoit, 224* Boronow, richard C., 171-l Boyd, KB, 377-h Brooks, Tami, 24-l Burgdorf, M., 378-h Burson, herbert I., 219*

C Cannon, C. ron, September cover Carron, Jeffrey d., 331* Caskey, r., 381-h Cauthen, W, 376-h Cazayoux, Wr, 378-h Chandrashekar, Kiran Bettaiah, 259* Chauhan, Suneet P., 302* Cossman, Jeralynn S., 219*,

JOURNAL MSMA, December 2009 — Vol. 50, No. 12

306*, 338* Craig, h. vann, 170-l Crockett, Kathy l., 107* Crudden, Adele, 219* Currier, Mary, 262*

D davenport, TC, 378-h dennis, Scott, 395-l dyess, renee O., 44-CPS

E easterling, randy, 242-PP, 274PP, 321-PP, 351-PP, 383-PP, 385 ennis, Calvin, 393-l evers, Karen, 57, 190-S

443

F Fayard, n, 379-h

G Germany, M., 380-h Giles, hannelore h., 129-l Graham, Juanita, 71* Guess, Charles, december cover Gunter, JW, 382-h

H hammersmith, Kimberly J., 143* haraway, AM, 381-h hart-hester, Susan, 107* hartness, Stanley, 21-e, March cover, 126-e, 252-e, August cover, 363-e hill, Jean, 396-l houston, Gerry Ann, 299* howard, Martin, november cover

I Innocent-Ituah, Ijeoma, 422-CPS

J Jacob, S., 380-h Johnson, A., 378-h Jones, daniel W., 39*

K Kanakamedala, Madhava, 184* Kandathil, Cherian, 331* Keller, Michael, 224* Koch, Christian A., 407* Kochevar, A., 378-h Koen, Sophia, 3* Koury, MW, 378-h Kramer, James J., July cover Kranz, Ashley M., 143* Kyle, Amber, 150*

L lahr, Christopher, 224* lampton, lucius, 64-I, 101-I, 204-e, 324-e, 432-e langston, ledon, 71* levin, Philip l., 278-S

444

lineaweaver, William C. , 129-l

M Maclaughlin, eric J., 3* Magann, everett F., 302* Manley, J., 381-h, 382-h Mazurak, Jack, 215 May, Wl, 377-h Mcdaniel, dO, 377-h Mcdaniel, h, 376-h, 382-h Mcdonald, Angela, 407* Mceachin, John d., 63-PM McIlwain, James S., 27, 169, 206 Meeks, W. Mark, 10-CPS Melcescu, eugen, 407* Milbourne, S, 375-h Mitchell, Me, 382-h Moak, Samuel, 356-S Morrison, John C., 302* Mosca, nicholas G., 143* Mourad, Waleed F., 184*

N nicols, lM, 379-h

O O’Bryan, deborah S., 346-CPS O’dell, Kristi J., 416* O’dell, Michael l., 53-e, 167e, 397-e, 416* Odom-Funches, rhonda, 266CPS Ouwubiko, C, 375-h

rogers, deirdre B., 371* roy, r., 381-h rudman, William J., 107* rushton, FW, 382-h rutland, eh, 381-h

S Sansing, William, 219* Sawaya, d, 375-h, 381-h Schmieg, re, 382-h Secrest, Cl, 378-h Seetharamaiah, r., 381-h Shenoy, vishwanath n., 259* Shukla, Bhavarth S., 143* Siddiqui, danish, 302* Simmons, Barby J., 114-CPS Simmons, Jd, 379-h, 382-h Sledge, Chapman, 179* Sledge, J., 380-h Smith, Austin, 179* Snyder, d., 379-h South, dwalia, 22-l Stephens, James W., 154-CPS Stokes, Peter A., 292-Mle Stone, John, 99-PM Street, debra, 306*, 338* Stroud, Catherine h., October cover Suares, Jr., robert n., 312-CPS

T Taylor, James l., 416* Tisdale, Brett, May cover

U

P Pai, Sneha, 259* Paulson, Kari A., 302* Perkins, Todd h., 79-CPS Persons, B., 380-h Piazza, elizabeth, 331* Pittman, Shannon d., 154-CPS Polles, Alexis, 179* Pomphrey, Jr., Martin M., Janu ary cover, February cover, 54-e, Porter, JM, 382-h Porter, John M., 150*

Uwaifo, 407*

v vance, Sr., ralph B., vijayakumar, vani, 184*

W Walkinshaw, M., 378-h, 380-h Weems, W. lamar, 277-e, 395-l White, PC, 381-h Woodward, louAnn, 353

Z

R rahim, robby, 91-PB replogle, W., 379-h

Zhang, lei, 71* Zoller, dennis, 3*

JOURNAL MSMA, December 2009 — Vol. 50, No. 12

using technology to get you the right protection, right away!

Shave three to four weeks off the old way of doing business Call1-888-285-9477 or visit MSMAqui MSMAquicklife.com Group can give you straight answers you need to make informed decisions.

If you prefer person personal nal service, Larry Fortenberry Forten and The Executive Planning Life IInsurance. Quickly.

and your loved ones. right decisions for yourself information you need to make the We provide the important through the application process. objectives and then guide you questions about your specific Apply on online. We ask the right competitively priced policies. life insurance quotes for Online. Fast. Itâ&#x20AC;&#x2122;s easy to get free Executive Planning Group. and offered by MSMA and The rated life insurance companies insurance quotes all from highlyselection of personalized life Quick Life offers an excellent

is the answer.

Life Insurance. Quickly.

insurance protection for your family - fast.

Sometimes you need to get quality life

Faster is better.

Faster is better.

Sometimes you need to get quality life insurance protection for your family - fast.

Life Insurance. Quickly.

is the answer.

Quick Life offers an excellent selection of personalized life insurance quotes all from highlyrated life insurance companies and offered by MSMA and The Executive Planning Group.

Online. Fast. Itâ&#x20AC;&#x2122;s easy to get free life insurance quotes for competitively priced policies.

Apply on online. We ask the right questions about your specific objectives and then guide you through the application process.

We provide the important information you need to make the right decisions for yourself and your loved ones.

Life IInsurance. Quickly.

If you prefer person personal nal service, Larry Fortenberry Forten and The Executive Planning Group can give you straight answers you need to make informed decisions.

Call1-888-285-9477 or visit MSMAqui MSMAquicklife.com

Shave three to four weeks off the old way of doing business using technology to get you the right protection, right away!