December 2009

December 2009

VOL. L No. 1250

Years ofCONTINUOUSCONTINUOUSPUBLICATIONPUBLICATION

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 Amy Gammel Pat Lobrano Sondra PinsonEmma Borders Shoba Gaymes Brinda ManiSundaram Mollie PontiusKathy Carmichael Danita Horne Eileene McRae Susan RishPeggy Crawford Angela Ladner Nell Middleton Yvette SlocumValerie Davis Louise Lampton Melanie Moore Brenda Sumrall SmithConnie Derhgawen Nancy Leader Karen Morris Donna Witty

A wish for health and happiness in the coming year is being sent to you by members of the

Mississippi State Medical Association Alliance!

MSMA ALLIANCE

DECEMBER 2009 VOLUME 50 NUMBER 12SCIENTIFIC ARTICLES

A Case of Profound Weight Loss Secondary to Use of Phentermine 407Gabriel I. Uwaifo, MD; Eugen Melcescu, MD; Angela McDonald, NP andChristian A. Koch, MD, PhD

Does a Multidisciplinary Diabetes Group Education VisitImprove Patient Outcomes? 416Kristi J. O’Dell, PhD, MSW; Michael L. O’Dell, MD, MSHA andJames L. Taylor, PharmD

Clinical Problem-Solving: Halitosis: Hindrance or Hint? 422Ijeoma Innocent-Ituah, MD

PRESIDENT’S PAGE We Have No Cabs in Vicksburg 427Randy Easterling, MD; MSMA President

EDITORIALLike the Spartans at Thermopylae: Mississippi’s Docs Stress Needto Reform Health Reform at Interim AMA Meeting 432Lucius M. Lampton, MD; Editor

RELATED ORGANIZATIONSMississippi State Department of Health 435Information and Quality Healthcare 436

DEPARTMENTSPlacement/Classified 437Una Voce 438

INDEXIndex by Subject 439Index by Author 443

ABOUT THE COVER: “ROOFTOPS AT JACKSONSQUARE” - 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. �

2009December

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2009December

VOL. L No. 12Years ofCONTINUOUSCONTINUOUSPUBLICATIONPUBLICATION

50Official Publication

of the MSMA Since 1959

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Copyright© 2009, Mississippi State Medical Association.

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JOURNAL MSMA, December 2009 — Vol. 50, No. 12 407

Background: Obesity has become particularly

prevalent in both the United States and worldwide. Mis-

sissippi 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 dia-

betes is presented, followed by discussion of issues rel-

evant to impacting the obesity epidemic in Mississippi.

Results: A 34-year-old Choctaw lady with 1.5 year fol-

low up was noted to have a peak initial body mass index

(BMI) of 62.6kg/m2 and weight of 176kg. Since com-

mencement 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. Accompany-

ing the weight reduction has been sustained normal

blood pressure and improvement in glycemic control.

Conclusions: Phentermine is a viable and important ad-

junct 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 posi-

tively impact the ongoing obesity epidemic. There re-

mains a need for more studies of phentermine to better

define its place in obesity management.

KEYWORDS: OBeSITy, PhenTerMIne, MOrBId

OBeSITy, MeTABOlIC SyndrOMe,

WeIGhT lOSS, heATh dISPArITIeS,

ChOCTAW, nATIve AMerICAn

INTRODUCTIONObesity 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 Cen-

tral 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 asso-

ciated with obesity are broadly subdivided into meta-

bolic (such as type 2 diabetes, hyperlipidemia,

hypertension, non alcoholic fatty liver disease, insulin

resistance, the dysmetabolic syndrome, focal glomeru-

losclerosis, polycystic ovarian syndrome, etc.) and the

so called mechanical complications (such as os-

teoathrosis, obstructive sleep apnea, pseudotumor cere-

bri, 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

SCIENTIFICARTICLES

A Case of Profound Weight LossSecondary to Use of PhentermineGabriel I. Uwaifo, MD

Eugen Melcescu, MD

Angela McDonald, NP

Christian A. Koch, MD, PhD

ABSTRACT

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

childhood with the same associations seen in adults

along with some unique complications distinct for child-

hood populations such as slipped capital femoral epi-

physes and Blounts disease.12,13 This raises the potential

of early onset of chronic diseases previously largely re-

stricted to adult populations in children and adolescents

with the consequent increase in disease burden, mor-

bidity 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 eth-

nic 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 com-

plications, further analyses indicate that the proportions

of subjects with morbid obesity (BMI >40kg/m2) is in-

creasing as is the degree of abdominal obesity with its

attendant implication for future atherosclerotic cardio-

vascular 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 to-

wards disease prevention but rather at invasive inter-

vention once significant complications develop.

Consequently though a multifaceted approach to obe-

sity management involving sustained dietary counsel-

ing, 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 in-

surance 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 proce-

dure) remains the most effective means of achieving

substantive and sustained weight loss (especially among

subjects with morbid obesity and accompanying co-

morbidities),31,32 the sheer disease burden of obesity and

the costs and human resources needed for bariatric sur-

gery make it an unreasonable panacea for the vast ma-

jority of subjects with obesity and its complications.

The unfortunately sordid history of many prior

anti-obesity agents such as aminorex, dexfenfluramine,

fenfluramine, amphetamine, phenylpropanolamine, ri-

monabant, and ephedra has made many physicians and

patients very wary of using any anti-obesity medica-

tions 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 virtu-

ally none of these are covered by most medical insur-

ance prescription plans make sustained access to these

medications virtually impossible for most potential pa-

tients.5,26,34-36

While knowledge about the pathogenesis and

pathophysiology of obesity has continued to increase ex-

ponentially, availability of effective pharmacotherapeu-

tic options for its sustained management have lagged

significantly behind.33,36-39 Consequently despite the ob-

vious public health importance there have been no sig-

nificant medications for obesity added to the clinical

armamentarium since the approval of orlistat in 1999.

Phentermine (Adipex-P, Ionamin) is a sympath-

omimetic anorexiant that has been FdA approved for

short term use (~ 12 weeks) in the management of obe-

sity 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 base-

line 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 com-

piled. 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 de-

spite the fact that its actual abuse potential based on ac-

cumulated 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 signif-


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 dyslipi-

demia. She elected for a trial of phentermine while mak-

ing a commitment to change her dietary practices and

had a profound clinical response that is ongoing.

CASE DESCRIPTIONThe 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 hy-

pothyroidism and thyroid nodules. She also had an ~ 6

year history of type 2 diabetes and a long standing his-

tory 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 previ-

ously noted an increase in appetite with pregabalin

(lyrica) which had been prescribed for neuopathic

carpal tunnel syndrome symptoms. Because of this ap-

petite increase she had stopped using pregabalin over a

year ago. her sleep habits were quite good with no com-

plaints 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 carbon-

ated 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 dia-

betic).The medications she was on at the initial medical

evaluation included; Synthroid 100 mcg daily, pioglita-

zone 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 men-

strual cycles but no history suggestive of excessive fa-

cial acne, virilization or hirsuitism. She had only one

prior pregnancy which has ended in a spontaneous abor-

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 rest-

ing pulse rate of 61 beats/minute.

She was noted to have significant nuchal acan-

thosis nigricans but no associated skin tags. She had no

demonstrable thyromegaly or palpable thyroid nodules

and her throat examination revealed no tonsillar en-

largement 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 oth-

erwise normal heart sounds. The abdominal examina-

tion 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 war-

ranting 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 re-

garding 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 re-

garding appropriate portion sizes, appropriate propor-

tions 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 prob-

lems with hypoglycemic episodes she had gained an ad-

ditional 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 pharma-

cotherapeutic agent to assist her diet efforts. Based on

the costs and potential side effects of the main available

options (orlistat, sibutramine and phentermine) she


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 fur-

ther improvement in her already good glycemic control

(latest hBA1c of 5.6) despite reduction of her Glucov-

ance 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 nigri-

cans has become less prominent and her menstrual pe-

riods have now become consistent and regular on a

monthly basis with no accompanying complaints of sig-

nificant menorrhagia or dysmenorrhea. The intended

plan going forward is to discontinue glucovance and in-

stead maintain her on metformin alone while continuing

to watch the trends in her weight and overall glycemic

control.

DISCUSSIONThe increasing prevalence of obesity and its myr-

iad 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 in-

creasing 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 prob-

lem 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 genera-

tion that has a greater overall morbidity and mortality

disease burden than that of their parent’s genera-

tion.1,10,19,25,58-60 Furthermore obesity and its related com-

plications and co-morbidities have the potential to

further widen the chasm of health disparities that are al-

ready apparent within the American public health sys-

tem, 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 Missis-

sippi where the extent of the problem in adult and child-

hood 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

Figure 1: wEight And body MAss indEx ProfilEs on

PhEntErMinE

Table 1: MEtAbolic And clinicAl PArAMEtErs At bAsElinE

And following PhEntErMinE inducEd wEight loss

Parameter Baseline Current (1.5 yrs later)

HBA1c (%) 6.0 5.6

Systolic blood pressure (mm hg)

122 99

Diastolic blood pressure (mm hg)

65 64

Resting pulse rate (beats/min)

61 80

Rate-pressure product 7442 7920

Total Cholesterol (mg/dl) 265a 163

HDL Cholesterol (mg/dl)) 41a 37

LDL Cholesterol (mg/dl) 180a 91

Fasting Triglycerides (mg/dl)

218a 174

Nuchal acanthosis nigricans

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.

wide program designed to provide resources for the

public education, prevention and management of obe-

sity and its complications. The Centers for disease con-

trol 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, Physi-

cal Activity and Obesity (dnPAO) and 23 State health

departments working to build lasting and comprehen-

sive 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 mul-

tiple levels of society; in a comprehensive so called

Socio-ecological model that involves intervention

strategies in a multi-level, multi-layered approach in-

cluding individual, interpersonal, organizational, com-

munity 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 ob-

jectives. The American Association for Clinical en-

docrinology; 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 re-

sources can be accessed at www.powerofprevention.

com/memberinvite.php .

While this public health blitz is paramount to sub-

stantively change the epidemiology of obesity, reduce

its prevalence and reduce the increasing health dispari-

ties it engenders, there is also a need for a robust fund-

ing mechanism to provide adequate clinical care for the

individual obese patient especially those with already

established complications or co-morbidities. Such a pro-

gram must include resources for sustained dietary coun-

seling, behavior modification, physical activity

counseling as well as access to adjunctive pharma-

cotherapeutic 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

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 ac-

tivity increase can have considerable potential in im-

proving obesity and its complications.4,34,35,38 The

presented case highlights the huge potential benefits that

can result from providing access to appropriate phar-

macologic agents as part of the management plan in the

individual subject with obesity. The increasing realiza-

tion that obesity needs to be clinically managed in the

same chronic disease paradigm applied to hypertension,

diabetes, dyslipidemia and ASCvd has resulted in a re-

alization that medical therapy for obesity as in these

other conditions needs to be long term (possibly life

long) and may need to involve combination pharma-

cotherapy.4,28,35,41,65-68 In evaluating options for use in obe-

sity management in Mississippi where sustained

efficacy, safety and cost consciousness are particularly

acute, phentermine has a favorable profile. It has an ex-

tended 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 ca-

pacity 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 docu-

mented follow up on its use remains the 36 week clini-

cal 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 com-

pared to continuous use which may be of particular im-

portance 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 pub-

lished 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



anti obesity agents (actually only sibutramine had a

mean associated weight loss that was numerically

[~4.45kg] but statistically different.79,80 The same met-

analyses showed a remarkably safe side effect profile

with no reported adverse events pooled through the col-

lated studies suggesting an overall side effect incidence

of less than 8 events per 1000 patient treatment expo-

sures.79,80 The combination of phentermine with fenflu-

ramine 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 sub-

jects was quite low and all the available evidence indi-

cate that these complications were related to the

fenfluramine or dexfenfluramine used in these combi-

nations 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 prob-

ably not advisable.38,41,85 While there are some reports of

the potency of combining phentermine with selected se-

lective serotonin reuptake inhibitors (SSrIs) in obesity

and related conditions, this is generally not recom-

mended and should only be undertaken in a clinical re-

search 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 litera-

ture, 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 sero-

tonin which appear to underlie the valvulopathy associ-

ated with anorectic agents as well as that seen with

ergotamine and some dopaminergic antiparkinsonian

medications.47,49,50,81,83,87 Overall the recommended strat-

egy for combination obesity phamacotherapy is to use

agents with different mechanisms of action so as to re-

duce the potential for additive side effects from their

use.38,41,88 This makes orlistat a far more appealing po-

tential agent for combination with phentermine if re-

quired than a sympathomimetic or SSrI.

It is noteable that our patient is also on topiramate

(for migraine prophylaxis) and this does raise the pos-

sibility 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 ap-

pears unlikely given the very small dose of topiramate

the patient was on compared to the doses demonstrated

to have weight loss efficacy. Furthermore the patient

continued to gain weight while on topiramate till phen-

termine 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 sub-

jects. 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 im-

portant obesity associated co-morbidities like dyslipi-

demia, ASCvd risk, obstructive sleep apnea,

osteoarthrosis, PCOS and non alcoholic fatty liver dis-

ease (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.

CONCLUSIONIn summary, while the index case presented rep-

resents only one patient, the dramatic response thus far

noticed with the use of phentermine without a structured

dietary counseling program or significant exercise pre-

scription highlights the potential beneficial effects that

could be derived by providing all these resources to nu-

merous 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 di-

abetes, 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 ef-

fective management of individual obese patients can

provide a narrative in Mississippi that could be an ex-

ample 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 pharma-

cotheraputic agents for adjunctive use. Phentermine

would be a prime consideration for inclusion in that ar-

mamentarium.


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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.

Eugen Melcescu, MD is on staff in the Division of

Endocrinology, Diabetes and Metabolism in the


Mississippi Medical Center in Jackson.

Angela McDonald, NP is affiliated with the Choctaw

Health Department, Women’s Wellness Center in

Choctaw.

Christian A. Koch, MD, PhD is on staff in the Division

of Endocrinology, Diabetes and Metabolism in the


Mississippi Medical Center in Jackson and is also

affiliated with the GV (Sonny) Montgomery VA

Medical Center in Jackson.

CORRESPONDING AUTHORGabriel 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: [email protected]

Mark

Your

Calendar!

the 142nd Annual session of

the MsMA house of

delegates and Medical

Affairs forum 2010

will be held

June 3-6, 2010in natchez.


Purpose: diabetes is a significant and growing

public health concern, and patient education is the pri-

mary approach for self-management. The objective of

this study is to assess the impact of a single session di-

abetes group education intervention. Methods: The

design is a one-group pretest/posttest evaluation. Par-

ticipants were adult outpatients with diabetes who at-

tended a single session group education visit and

volunteered to participate in the study. Survey ques-

tions include the Single Item literacy Screener and di-

abetes 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. hemoglo-

bin A1c (hbA1c), lipids, and blood pressure were col-

lected from the patient electronic medical record before

and, where available, three months after the group visit.

data analysis includes descriptive statistics and Stu-

dents 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 imme-

diate 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 dia-

betes group education visit is effective in increasing pa-

tients’ diabetes knowledge and decreasing hbA1c levels.

KEYWORDS: dIABeTeS edUCATIOn,dIABeTeS OUTCOMeS,

dIABeTeS SelF-MAnAGeMenT

INTRODUCTIONManagement 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 pop-

ulation 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 ed-

ucation 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 re-

viewed the literature from 1964 through 1999 and found

that diabetic patients involved with self-management

education programs demonstrated reductions in hemo-

globin levels (hbA1c) and improvement in systolic

blood pressure.2 The other study reviewed the literature

from 1980 to 2001 and found improvement in biomed-

ical markers in all (four) studies and in self care, in-

Does a Multidisciplinary DiabetesGroup Education Visit ImprovePatient Outcomes? Kristi J. O’Dell, PhD, MSW

Michael L. O’Dell, MD, MSHA

James L. Taylor, PharmD

ABSTRACT


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 out-

comes. 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 re-

view of the literature, the Ad hoc Committee on health

literacy for the Council on Scientific Affairs, Ameri-

can 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 asso-

ciated 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 Sim-

ple Measure of Gobbledygook (SMOG) grade level of

American Association of Family Practice patient edu-

cation materials was higher than the average reading

skills of US adults.8

Two measures have been used primarily for re-

search purposes to assess health literacy, the rapid es-

timate 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 re-

cently been utilized in clinical research, along with an-

other 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 cross-

sectional 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 lit-

eracy and the outcomes measures. Kim, love, Quist-

berg, and Shea found that at three months from

intervention both adequate and limited health literacy

groups showed improvement in hbA1c, knowledge,

and self-management behaviors.13 Another group stud-

ied 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 follow-

up, among patients with low literacy, intervention pa-

tients 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 multidiscipli-

nary diabetes group education visit for persons with

poor glucose control.

METHODSThe 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 educa-

tion visit?

2) do patients exhibit increased diabetes knowl-

edge 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 partic-

ipants were selected from the approximately 1200

adults with diabetes who get health care at the Family

Medicine residency Center. Patients with poorly con-

trolled diabetes were referred to the group. From Sep-

tember 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 one-

time 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


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 miss-

ing data.

number of years with diabetes ranged from one

to thirty years (Mean = 7 years, Median = 5 years). Sev-

enty-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 val-

ues of 8.3% and higher. regarding how often partici-

pants 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 miss-

ing data.

Two diabetes education group sessions were ini-

tially scheduled each month with approximately five pa-

tients 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 hour-

long session on general diabetes care, medications, diet,

and exercise provided by a diabetes educator, pharma-

cist, dietitian, and exercise physiologist. That was im-

mediately followed by individual customized visits by

the listed disciplines (other than the exercise physiolo-

gist) and each patient's physician.

data collection. data were collected via a written

survey and patient electronic medical record. The sur-

vey questions consisted of basic demographic informa-

tion; 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 dia-

betes Association patient education materials provided

in the group education visit; and suggestions about im-

proving 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 Sta-

tistical Package for the Social Sciences (SPSS) soft-

ware. descriptive statistics were used to summarize

demographic data. Pretest and posttest differences of

diabetes knowledge and physiological markers were an-

alyzed using Students t-tests.

RESULTSresponses 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 im-

mediately after and at three months post a group edu-

cation 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 knowl-

edge (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 fol-

low-up posttest (M = 7.48 to M = 7.62 out of 10), t(29)

= -.383, p = .705.

What suggestions do patients have about improv-

ing the group process? ninety-five percent of partici-

pants 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.”

DISCUSSIONThe 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 inter-

ventions into a control group in a small practice. The

study also had a small sample size, and there was attri-

tion of participants in the follow-up data collection.

The primary study findings were that, after a sin-

gle session group education visit, diabetes knowledge


increased and was sustained and hbA1c levels de-

creased 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 gen-

erally involved multiple group sessions extending over

weeks to years. This study demonstrates that good re-

ductions 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-man-

agement. educating patients in self-management can

present a significant burden to a primary care practice

due to time constraints on physician and other re-

sources. 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 physiolo-

gists, dietitians, and nurse educators as represented

here. Accomplishing good reductions in hbA1c and

improving health literacy occurred despite nearly one-

third of participants stating they always or often need

to have someone help them when they read instruc-

tions, pamphlets, or other written material from their

doctors or pharmacies. In addition, this finding indi-

cates the importance of follow-up health literacy ques-

tions 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 pre-

scription medications due to the cost. Obviously, pa-

tient education about the importance of taking

medication as prescribed will not be as effective in im-

proving outcomes if a patient’s ability to obtain med-

ications 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. Follow-

up individual assessments for ability to obtain med-

ication 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 re-

gard.

Support: American Academy of Family Physicians

Foundation Health Literacy State Grant. Thanks to

Edee Dull, research assistant, who participated in the

data collection.

SEEKING PHOTOS TAKEN BYMISSISSIPPI PHYSICIANS FOR2010 COVERS OF THE

Calling allMississippiPhysician-

Photographers

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JOURNAL MSMA

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

Deadline: December 10, 2009


REFERENCES1. Centers_for_disease_Control. Diabetes Data and Trends.

2005. apps.nccd.gov/ddTSTrS/default.aspx. Accessed

October 22, 2008.

2. Warsi, A., et al., Self-management education programs in

chronic disease. Arch Intern Med. 2004;164:1641-1649.

3. 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.

4. raji, A., et al., A randomized trial comparing intensive and

passive education in patients with diabetes mellitus. Arch

Intern Med. 2002;162:1301-1304.

5. Association, A.M., Health Literacy. 2006.

http://www.ama-assn.org/ama/pub/category/print/8115.html

Accessed October 22, 2008.

6. 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):552-

557.

7. Baker, d.W., The Meaning and the Measure of health

literacy. J Gen Intern Med. 2006. 21:878-883.

8. Wallace, l. and e. lennon, American Academy of Family

Physicians Patient education Materials: Can Patients read

Them? Fam Med. 2004. 36(8):571-4.

9. davis, T., et al., rapid estimate of Adult literacy in

Medicine: a shortened screening instrument. Fam Med.

1993. 25(6):391-5.

10. Parker, r., Baker, d., Williams, M, & nurss, J., The test

of functional health literacy in adults: a new instrument

for measuring patients’ literacy skills. J Gen Intern Med.

1995. 10:537-41.

11. 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).

12. 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).

13. Kim, S., et al., Association of health literacy with Self-

Management Behavior in Patients with diabetes. Diabetes

Care 2004. 27(12):2980 - 2982.

14. 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.

15. raji, A., et al., A randomized trial comparing intensive and

passive education in patients with diabetes mellitus. Arch

Intern Med. 2002. 162:1301-1304.

16. Warsi, A., et al., Self-management education programs in

chronic disease. Arch Intern Med. 2004. 164:1641-1649.

AUTHOR INFORMATION:

Kristi J. O’Dell, PhD, MSW; University of Mississippi

Department of Social Work

Michael L. O’Dell, MD, MSHA; North Mississippi

Medical Center Family Medicine Residency

Clinic

James L. Taylor, PharmD; North Mississippi Medical

Center Family Medicine Residency Clinic

CORRESPONDING AUTHORKristi J. O’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: [email protected]

We specialize in the business of healthcare


CLINICALPROBLEM-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

A44-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

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


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 non-

radiating 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

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


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 post-

surgical 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

medicine follow MSMAFor a bird’

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matter where you you stay in touch no if you’re on the go.

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intensive care unit. The patient eventually became

unresponsive and hypotensive with respiratory

compromise necessitating intubation. The patient’s

condition did not improve, and her family eventually

decided to withdraw life support. The patient died

about 4 months after initial diagnosis.

KEYWORDS: hAlITOSIS, ePIGASTrIC PAIn,

dIABeTeS MellITUS

REFERENCES1. 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. Cost-

effectiveness of pancreatic cancer screening in familial

pancreatic cancer kindreds. Gastrointest Endosc. 2003;57(1):

23-29.

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: [email protected]

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

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.



like 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

Wilson, President-elect of the AMA, explained their support

was a strategical move precipitated by word that Speaker of the

WE HAVE NO CABS

IN VICKSBURG

PRESIDENT’S PAGE

randy easterling, MD

2009-10 MSMa President

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.


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.


A bill will now go to the United States Senate and

then to conference. Odds are the final product will not

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Dr. LouAnn Woodward



EDITORIAL

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

The 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-


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

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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



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 community-

based social services.

IQH DRUG SAFETY PROGRAMThe IQh drug safety project continues in efforts to

decrease Mississippi’s statistics in prescribing potentially

inappropriate medications (PIMs) in the elderly. data

show that Mississippi ranks high in that category as well

as in drug-to-drug interactions (ddIs).

Statistics reflect that 52,573 Medicare beneficiaries

(29.98 percent) in the state received one or more PIMs

from July to december 2008. To assess the percent of

nursing home patients receiving PIMs, the IQh analysis

staff linked nursing home patients covered by Medicare

with pharmacy data. Of the 11,284 nursing home

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

december 2008 on the IQh Web site. visit www.iqh.org-

-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.

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UNAVOCE

The UncommonThread


It 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

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:

r. Scott anderson, MD


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 LJanuary - 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.

-A-

A 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

-B-

Breast Cancer in Mississippi: What

Can We do? [G houston],

299*


-C-

Case 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], 346-

CPS

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], 154-

CPS

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],

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: 2009-

2010 MSMA President, June

“To your health” [M Pomphrey,

Jr.], January

“Woman Playing Autoharp” [M

Pomphrey, Jr.], February

-D-

deaths, 33

does a Multidisciplinary diabetes

Group education visit

Improve Patient Outcomes?

[K O’dell, M O’dell, J

Taylor], 416*

-E-

Editorials

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*

-H-

hypertension in Mississippi: We

Can do Better [d Jones], 39*

-I-

Images 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*


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

-L-

Letters 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

-M-

MAFP

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


Statistics november 2008, 60


Statistics december 2008, 92


Statistics January 2009, 117


Statistics March 2009, 165


Statistics April 2009, 203


Statistics May 2009, 229


Statistics June 2009, 270


Statistics July 2009, 316


Statistics August 2009, 399


Statistics September 2009,

435

new Mobile Field hospital Means

Immediate Care for disaster-

Stricken 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*

-N-

new Members, 29


News

Former AMA Trustee dr. Benjamin

nominated to be Surgeon

General, 364

Numbers Count

how does health Care Correlate

to America’s Budget?, 366-

nC

numbers Count, 95-nC

Public health report Card Stats,

134-nC

The Physicians’ Perspective:

Medical Practice in 2008, 61-

nC

-O-

Outcomes in neonatal

gastroschisis: a single center

experience [r

Seetharamaiah, J. Manley, r

Caskey, r roy, d Sawaya, C

Blewett], 381-h

-P-

Permanent 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], 91-

PB

Poetry in Medicine

days not Forgotten — Memory

diamonds [J Mceachin], 63-

PM

he Makes A house Call [J Stone],

99-PM

Popliteal artery injuries in an urban

trauma center with a rural

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], 15-

PP

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], 351-

PP

Where Were you? [r easterling],

274-PP

Public health in Mississippi -

report Card 2009, 17

-R-

report 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 Stage-

migration, response

Comparisons with CT and

Correlation to Clinical

Outcomes [v vijayakumar,

M Kanakamedala, W.

Mourad], 184*

routine use of epidural anesthesia-

does it improve patient

outcomes? [lM nicols, Jd

Simmons, W replogle, n

Fayard, d Snyder], 379-h

-S-

Single 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

-T-

The 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*


INDEx

vOLUME LJanuary - 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,” dele-

gates report; “e,” editorial; “h” hardy Abstract; “I,” Images in Mississippi Medicine; “l,” letters to the edi-

tor; “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 Cor-

ner; “PM,” Poetry in Medicine; “PP,” President’s Page; “S,” Special Article; “Uv,” Una voce; the asterisk (*)

indicates an original article in the Journal.

AAltomar, Jl, 375-h

Anderson, r. Scott, 34-Uv, 67-

Uv, 102-Uv, April cover,

139-Uv, 175-Uv, 214-Uv,

254-Uv, 402-Uv, 438-Uv

Aylor, Arden l., 3*

BBarrett, 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*

CCannon, 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*,

306*, 338*

Craig, h. vann, 170-l

Crockett, Kathy l., 107*

Crudden, Adele, 219*

Currier, Mary, 262*

Ddavenport, TC, 378-h

dennis, Scott, 395-l

dyess, renee O., 44-CPS

Eeasterling, randy, 242-PP, 274-

PP, 321-PP, 351-PP, 383-PP,

385

ennis, Calvin, 393-l

evers, Karen, 57, 190-S

-U-

UMC 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], 34-

Uv

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


FFayard, n, 379-h

GGermany, M., 380-h

Giles, hannelore h., 129-l

Graham, Juanita, 71*

Guess, Charles, december

cover

Gunter, JW, 382-h

Hhammersmith, 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

IInnocent-Ituah, Ijeoma, 422-CPS

JJacob, S., 380-h

Johnson, A., 378-h

Jones, daniel W., 39*

KKanakamedala, 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*

Llahr, Christopher, 224*

lampton, lucius, 64-I, 101-I,

204-e, 324-e, 432-e

langston, ledon, 71*

levin, Philip l., 278-S

lineaweaver, William C. , 129-l

MMaclaughlin, 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*

Nnicols, lM, 379-h

OO’Bryan, deborah S., 346-CPS

O’dell, Kristi J., 416*

O’dell, Michael l., 53-e, 167-

e, 397-e, 416*

Odom-Funches, rhonda, 266-

CPS

Ouwubiko, C, 375-h

PPai, 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*

Rrahim, robby, 91-PB

replogle, W., 379-h

rogers, deirdre B., 371*

roy, r., 381-h

rudman, William J., 107*

rushton, FW, 382-h

rutland, eh, 381-h

SSansing, 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

TTaylor, James l., 416*

Tisdale, Brett, May cover

UUwaifo, 407*

vvance, Sr., ralph B.,

vijayakumar, vani, 184*

WWalkinshaw, M., 378-h, 380-h

Weems, W. lamar, 277-e, 395-l

White, PC, 381-h

Woodward, louAnn, 353

ZZhang, lei, 71*

Zoller, dennis, 3*

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is the answer.Quick Life offers an excellent selection of personalized life insurance quotes all from highly-rated life insurance companies and offered by MSMA and The Executive Planning Group.

Online. Fast. It’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.

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Documents

December 2009