GCMS Journal May/June 2024

MAY JUNE

2024

ARC OF THE OZARKS

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Mission Statement Bringing physicians together to improve the health of our community.

TABLE OF CONTENTS In this issue:

7

11

Editor's Page Minh-Thu Le, MD........................................................................ 4 President's Page James Rogers, MD..................................................................... 5

Vol 83, No. 3 • MAY/JUNE 2024

The Hidden Threat: Unmasking Anitbiotic Resistance Genes and Fecal Coliforms in Arkansas Water Sources Andrew Le.................................................................................. 7

Editor’s Note: All materials for the Journal must be submitted by the first of the month prior to publication.

Dyslexia: A Misunderstood Neurodevelopmental Condition José Dominguez, MD..........................................................11

Co-Editors:

An Update from the MU School of Medicine Springfield Clinical Campus David Haustein, MD...................................................................14

Junior Co-Editor:

Meeting Basic Needs: Coming Together to Help Kids Thomas Prater, MD....................................................................15

Managing Editor:

The ARC of the Ozarks: Finally, A comprehensive Autism center in Southwest Missouri Kayce Morton, DO and Kyle John, MD..................................18

Editorial Committee:

The COVID Conundrum: Board Exam Blues in the Pandemic Era Matthew Gao............................................................................20

15

Medical Student Perspective: The Springfield Clinical Campus Experience Noah Kronk................................................................................22

Jim Blaine, MD Minh-Thu Le, MD Andrew K. Le

Dalton Boyer

Michael S. Clarke, MD Frank Cornella, DDS, MD Dalton Boyer Andrew Le Jean Harmison Barbara Hover Nancy Yoon, MD Jana Wolfe

SOCIETY OFFICERS

166th Annual MSMA Convention & the 99th Annual MSMA Alliance Meeting Jana Wolfe........................................................................23

James Rogers, MD President

Rocky Mountain Medicine .............................................................25

Jim Blaine, MD Treasurer

Measles Outbreak in Missouri?

Nancy Yoon, MD.................................................................................26

Professional Directory...........................................................29

Vu Le, MD Secretary

Sanjay Havaldar, MD Immediate Past President

Council Members: David Haustein, MD Melissa Gaines, MD Steven Gradney, MD Keith LeFerriere, MD Kyle John, MD Jaya LaFontaine, MD Nancy Yoon, MD

Managing Director: Jean Harmison

On the Cover: The new ARC of the Ozarks Learning Center

The GCMS Journal is available online:

www.gcms.us

Executive Office: 4730 S. National Ave. Suite A1 Springfield, MO 65810 email: director@gcms.us www.gcms.us All communications should be sent to the above address. Those marked for the attention of a particular officer will be referred.

EDITOR'S PAGE

by Minh-Thu Le, MD

As graduations wrap up and students enjoy their summers, our journal highlights the MU-Springfield Clinical Campus as it does every year. This journal is all about medical education and also about students in our own community, patients that we may see. Additionally, our journal is about children’s services in our community. Dr. Dominguez has a semiautobiographical article about dyslexia and a resource for students in our area. Dr. Prater writes about Care to Learn, a non-profit with which our GCMS foundation is partnering to engage physicians in the “health” aspect of their 3-pronged mission. Our cover page highlights the work Arc of the Ozarks is doing with comprehensive autism treatment.

We have two medical students, Noah Kronk and Matthew Gao, both starting their fourth years at MU contributing to this journal, with Noah thanking all our faculty in Springfield and Matthew analyzing match rates for subspecialties post COVID pandemic. Dr. Haustein, the dean of the Springfield Clinical Campus, reviews the health of the campus and the students that have moved through their 3rd and 4th years here. Faculty awards were just given to your friends and colleagues who are making a significant contribution into medical education in our community.

MSMA also wrapped up another annual conference where our own past GCMS president, Dr. Brian Biggers, is tapped to be the next MSMA president. Mark your calendars now for his

4 • MAY/JUNE 2024 • GCMS Journal

inauguration and also next year’s MSMA meeting in Springfield! The Alliance has their update from the meeting this year, so please see what they are up to! Our spouses and significant others are always welcome to reach out and join the Alliance!

Dr. Yoon has a well-informed update on the measles epidemics around the country and how to protect our own children and community. It is more important now, more than ever, to encourage all our patients to vaccinate their children and grandchildren.

Andrew Le, our junior co-editor, has some original research on northern and central Arkansas drinking water bacteria and bacterial resistance genes. We strive to highlight issues that may be interesting to our readership and hope you agree and encourage and mentor students (no matter their age or background) in our community to enter this great profession of ours. If you know other students in our area doing research in medicine, we would love to highlight their research as well.

Don’t forget to mark your calendars and join us for our GCMS Summer CME meeting again in Breckenridge. Our family is looking forward to another great trip there! Also, take note of the social events coming up; I would love to see all of you there! Happy Summer!

PRESIDENT'S PAGE

by James Rogers, MD

I am convinced, more than ever, that we must transition to a “Physician Community” from a community of physicians. This means that we know each other, work and challenge all for the best patient care we can give.

Not only is this hard work, it requires effort outside of our usual schedules and spending some of our most precious resource – time. To this end, please accept my personal introduction to some of the most dedicated, busy, and devoted people – your GCMS Council. As I introduce you to them, please take the time to grow to know them and reach out to a colleague and start growing our community.

Dr. Jayaprabha LaFontaine, MD. Psychiatry, Fellowship in Child Adolescent Psychiatry specialist

Jaya was born in Central India of South Indian parents and is the second of two children, a younger sister to her older brother. At age two the family moved to the United Arab Emirates where Jaya attended a Catholic school and grew up with a myriad of religious exposures: Hinduism, Islamic, and Christian. At age 11, the family moved to New Orleans and she has called it home ever since.

After training, Jaya acquired a deep work experience in community, private clinical, VA, academic and even in tele-health service areas. Desiring to blend clinical time with administrative responsibilities we are fortunate to have her now in Springfield in the Burrell Behavioral Health system as Medical Director and Clinical Psychiatrist. Her life is very busy with a one-year-old daughter and husband that is an IT entrepreneur. They are off to Disney World for “fun” and much needed rest.

Why is she a doctor? “It was the only choice I had with both parents and older brother being electrical engineers and [me] making “B’s” in math!”

Hobbies? “[I] love to sing (trained in vocal classical music), dance, and cook. Currently I am writing a novel – a work in progress.”

Favorite color? “Deep red, especially contrasted with black or cream.”

What are your goals in next 3 years? “Increase access and reduce the stigma for mental health, and champion complete care for patients that makes sure we treat the whole person, body, and mind for all providers in the Ozarks.”

Dr. David Haustein, MD, MBA University of Missouri, School of Medicine Associate Dean

David grew up in Chesterfield, Missouri, with an older brother and younger sister, and enjoyed playing soccer, reading, and being active with various school clubs. He attended Harding University in Searcy, Arkansas for undergrad, where he was torn between a teaching career and medicine. He deferred medical school for a year to teach high school science in rural Africa before deciding that he would really enjoy a career in medicine. He then attended the University of Missouri School of Medicine in Columbia and found he loved feeling like a detective during his neurology rotation, a mechanic during orthopedics, and a wise family friend during family medicine. Combining these interests, he completed residency training in Physical Medicine and Rehabilitation (PM&R) and received certification in two subspecialties, neuromuscular medicine and electrodiagnostic medicine.

David spent his first eleven years of practice in Louisville, Kentucky, with the Louisville VA and the University of Louisville School of Medicine. He began with a full clinical practice and gradually transitioned to roles as a PM&R section chief, residency associate program director, and director of problem-based learning at the University of Louisville. He also acquired an MBA to better prepare him for administration duties, and now he is in his perfect job: running the University of Missouri School of Medicine’s Springfield Clinical Campus. This campus is a partnership between MU, CoxHealth, and Mercy hospitals, providing training for fifty-six 3rd and 4th-year medical students through the over 350 physician faculty members in our community. He also sees patients at Cox one day per week, performing nerve conduction studies and EMGs. David’s wife, Sandi, is a stay-at-home mom and the VP of Programs for the Springfield Council of PTAs. They have three teenage boys and a little girl and enjoy reading, kayaking the James River, and taking epic road trips to see national parks.

David’s goals for the next three years include building the educational infrastructure needed in southwest Missouri to have a pipeline of physicians to care for our community, as well as making memories with the family while most of the kids are still at home.

Are you interested in learning more about how you can support the physicians-in-training in our community?

Scan this code and connect with David.

MAY/JUNE 2024 • GCMS Journal • 5

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The Hidden Threat: Unmasking Antibiotic Resistance Genes and Fecal Coliforms in Arkansas Water Sources

by Andrew Le

Antibiotic resistance has contributed to 5 million hospitalizations globally in recent years, with at least 1.3 million deaths attributed to antibiotic resistance infections (Murray, 2022). Antibiotics have become commonplace in recent decades and are often overused or abused, in both medical and agricultural settings leading public health experts to conclude that this trend is unlikely to slow down. Some antibiotic resistant infections (such as Staphylococcus aureus that is resistant to methicillin and/or vancomycin) are especially dangerous in hospital and nursing homes where the rate of nosocomial (hospital-acquired) and iatrogenic (medical procedure-acquired) infections is high. Currently, Clostridium difficile, and Neisseria gonorrhoeae, and Enterobacter spp. are all known as significant public health concerns. Some strains of antibiotic-resistant bacterial species like Candida auris and Acinetobacter baumanii have evolved into panresistant “superbugs'' that are resistant to all known antibiotics (Nichols, 2019; Ademe & Girma, 2020). \There are multiple strategies that various bacteria have evolved to combat and escape different antibiotics, ranging from drug inactivation, target modification, and efflux pumps. This resistance is made possible through the evolution of antibiotic resistance genes (ARGs) that can then be transferred from parent to offspring daughter cells or between individual bacteria via methods of horizontal gene transfer that include transformation, transduction, and conjugation (Meyers, 2020). When bacteria with these ARGs, or even

Figure 1. This graph depicts the average amount of petrifilm colonies found in tap water samples.

free environmental DNA leftover from dead or dying cells that contain ARGS, are present in drinking water, it represents an unacceptable health risk for humans exposed to and ingesting that water.

Antibiotic resistance genes in human drinking water are far from the only water contamination concern for human health. In addition to contaminants such as pesticides and heavy metals that can cause human illness, fecal contamination is also a major source of human infection and death globally (Ashbolt 2004; Halkos & Argyropoulou 2022).

There are multiple examples of fecal-oral transmission amongst significant human pathogens, including bacteria (e.g. Vibrio cholerae, Clostridium difficile), viruses (e.g. poliovirus, norovirus), and eukaryotes (e.g. Entamoeba histolytica, Taenia solium) (Mackey et al. 2014; Temesgen et al. 2020; Cohen 2022).

Figure 2. This graph depicts the average amount of Petrifilm colonies found in well water samples.

Fecal coliforms are a subset of coliforms, a large category of bacteria. Fecal coliforms are bacteria that are commonly found in the intestines and feces of warmblooded animals. Fecal coliforms can vary in their uses, with some species being a sign of a healthy intestinal tract and other species signs of contamination (Zhang et al. 2022). Some fecal coliforms can also cause illnesses and are pathogenic. For example, Shiga toxin-producing Escherichia coli (STEC), a variant of E. coli, is associated with mild gastroenteritis, hemolytic–uremic syndrome, fevers, and thrombotic thrombocytopenic purpura (Lienemann et al. 2012). Fecal coliforms in water are typically seen as an indicator of fecal contamination, as the presence of coliforms tend to be accompanied by other bacteria that can cause viruses (Lienemann et al. 2012). Water pollution, particularly with fecal coliforms, is a major global problem that has been the leading cause of morbidity and mortality (Guatam et al.

2021). Fecal coliforms are commonly associated with E. coli, which is a well-studied bacterium that leads MAY/JUNE 2024 • GCMS Journal • 7

(Furlan, J. et al. 2020). Although E. coli has somewhat faded from the public consciousness after the epidemic of 2015, the fact that it has shown to possess many antibiotic resistance genes in order to get past most water sanitation facilities represents a health risk for humans that consume that water on a daily basis.

Figure 4. This graph depicts the average amount of Petrifilm colonies found in environmental water samples. E. coli was only found in one environmental sample.

to common illnesses such as respiratory illnesses and pneumonia.

E. coli is commonly associated with fecal coliforms due to the fact that it is commonly found in the lower intestinal tract of warm-blooded animals and discharged through feces (Jang, J et al. 2017). These feces sometimes leak into the water supply, causing the water to be contaminated with E. coli and fecal coliforms. While there are wastewater treatment plants to avert contamination of water, this does not always succeed. Different variants of E. coli can enter these water treatment plants and stay alive due to the presence of ARGs. In particular, urinary pathogenic E. coli, or UPEC, has been shown to be able to survive

With all of these implications of water contamination, it is important to know why this research is conducted.

This study’s purpose is to raise public awareness of water contaminants, particularly those that contribute to infections by pathogens: ARGs and fecal contamination. This is all driven by the question,“What is the concentration of antibiotic resistance genes and fecal coliforms in Arkansas’ water?” Three things were hypothesized: (1) Fecal coliforms (E. coli) will be present in some Arkansas drinking water, (2) Antibiotic-resistant genes will be present in some Arkansas drinking water, and (3) Water contaminants will be more prevalent in environmental and well water samples than in tap water samples.

Table 1. Primer sets used on water samples to identify presence of three different ARGs.

Methods Water Sample Collection: Volunteers filled out a form stating whether they were collecting tap or well water, where they were collecting the sample from, and their county. Volunteers then received a 50 ml test tube and collected samples of at least 45 ml of water from their home tap or well, and recorded this information on the test tube. Participants then returned the test tubes.

Figure 7. This graph depicts all of the Petrifilm colonies on water samples grouped together for comparison.

these water treatment plants (Yu, D et al. 2020). A study performed in 2020 found UPEC strains derived from wastewater carried several ARGs and survived the wastewater treatment plant (Yu, D et al. 2020). Another variant that has shown to possess ARGs and potentially be dangerous is STEC, which, according to a 2020 study, has shown to have a resistance against tetracycline, which is a common antibiotic for respiratory infections 8 • MAY/JUNE 2024 • GCMS Journal

Petrifilm Analysis: After mixing the tube contents, 1 ml of each water sample was distributed in separate petrifilms using a sterile pipette. Gloves and goggles were used to prevent unnecessary exposure to potentially contaminated water. Controls consisted of 1 ml of distilled water (negative control) and 1 ml of water with E. coli K-12 rms spiked in (positive control).

This procedure was repeated in triplicate for each water sample, and each petrifilm was closed and incubated for 48 hours to allow for growth. The amount of E. coli, non-E. coli coliforms, and non-coliforms on each Petrifilm were recorded in a lab notebook. All tools were

recorded in a lab notebook. All tools were autoclaved shortly after the experiment was done.

Figure 3: Example of a petrifilm with tap water showing coliform bacteria (red colonies with gas bubbles).

These are not a health hazard.

Figure 5: Example of a petrifilm with environmental water showing coliform bacteria (red colonies with gas bubbles) in addition to E. coli (blue colonies with gas bubbles). Presence of E. coli indicates fecal contamination of the water, which is a health hazard.

Figure 6: Example of a petrifilm with environmental water showing with non-coliform bacteria (red colonies without gas bubbles). These are not a health hazard.

autoclaved shortly after the experiment was done.

PCR and Electrophoresis: 20 µl of each sample was distributed into individual PCR tubes. A master mix comprising of 55 µl of 10x buffer, 16.5 µl of magnesium chloride, 6.6 µl of the forward primer (F) and the reverse primer (R), 8.8 µl of dNTP, and 4.4 µl of Taq polymerase was created. 4.5 µl of the master mix was distributed to each PCR tube, and was set in the thermal cycler and then left to freeze overnight. In total, three primer sets were used to look for the presence of three different ARGs (Table 1).

Samples were then retrieved and a 1% gel was created by adding 1 gram of agarose to 100 ml of 1x TAE. The gel was then microwaved in 30 second intervals until the solution was clear. SYBR Safe dye was then added to the gel and gel trays with combs were set up. Gel was then poured and 6 µl of 5x orange G dye was added to pcr samples. After the gel solidified, the combs were removed and 0.25x TAE was added on top of the gel.

5-10 µl of a 100 base pair ladder was added in the first well of each row. All samples were then loaded, and the lid was placed on top of the gel trays and set to run at 150 volts for 15 minutes, then the finished gels were placed under a UV light to visualize bands. Results were

Results Petrifilm Analysis: Petrifilm analysis allows one to distinguish non-fecal coliforms (red colonies with gas) and E. coli (blue colonies with gas), a fecal coliform commonly accepted as an indicator species for fecal contamination of water. Tap and well water samples showed no or very few coliforms, and no E. coli fecal coliforms at all (Figure 1, Figure 2). The tap water sample collected from Union County, Arkansas had the most coliforms (Figure 3). E. coli was only found in one environmental sample, a large rain puddle in a residential front yard (Figure 4, Figure 5). There were many environmental samples with multiple coliforms that were not E. coli, and thus not fecal in origin (Figure 6). Environmental water samples had far more growth on the petrifilm than well water or tap water samples (Figure 7). Analysis of Variance (ANOVA) indicated no significant differences (p > 0.05) between the types of water sources for coliforms, E. coli, or non-coliforms, due to high sample variance and a low number of available well water samples.

Antibiotic Resistance Gene Analysis: Four of twenty (20%) water samples had detectable ARGs. One well water sample from Melbourne County was positive for a tetracycline ARG (Figure 8). No water samples were positive for a penicillin ARG (Figure 9). Two water samples - one tap water sample from Lincoln County and one environmental water sample from Saline County - were positive for a ciprofloxacin ARG (Figure 10). One additional environmental sample had a band for a ciprofloxacin ARG on a separate gel (Figure 11).

Two of seven (29%) environmental samples were positive for ARGs, while only 8% of tap water samples had ARGs. Only one well water sample was collected, and it was positive for an ARG. This also partially supports Hypothesis 3.

Conclusion Hypothesis 1 was not supported by the data collected.

The absence of E. coli in these water samples is good news for human health in Arkansas, or at least in the counties where these samples were collected.

Many more water samples need to be tested to better understand the overall quality of water across the state.

Since 20% of water samples tested, including one well water, one tap water, and one environmental water sample, had detectable ARGS, Hypothesis 2 is supported. There are many more ARGs than the three tested for in this study. Since ARGs were found

MAY/JUNE 2024 • GCMS Journal • 9

frequently even amongst these samples, more testing with different primer sets for additional ARGs is warranted in all three types of water samples.

Environmental water samples had far more growth on the petrifilm than well water or tap water samples (Figure 7), partially supporting Hypothesis 3. Environmental samples also had more ARGs, further supporting Hypothesis 3. This analysis is limited in scope because only one well water sample was included in this analysis.

More well water samples across the state should be analyzed for a more conclusive understanding of well water quality in Arkansas.

Further testing should assess a larger number of samples, particularly well water samples, which were difficult to collect in this project. More antibiotics can perhaps be tested for in order to find more genes that could be antibiotic-resistant. Further testing could also perhaps examine possible sources of ARGs and fecal coliforms, and examine the differences between still water and running water on results.

Figure 8: Example of an electrophoresis gel with PCR products for tetracycline antibiotic resistance genes. One water sample had a band indicating the presence of a tetracycline ARG from a well water sample.

About the Author Andrew Le is a graduating senior at the Arkansas School for Math, Sciences, and the Arts (ASMSA), a residential high school for highly motivated 10-12th graders and part of the University of Arkansas system. His research published here is a culmination of a 2 year capstone project that won Honorable Mention at the West Central Arkansas Science Fair.

ASMSA earned the top school trophy at the Arkansas State Science and Engineering Fair this past April. He is planning on continuing his scientific endeavors at Drury University and hopes to go on to medical school and ultimately work in public health.

References Ademe, M., & Girma, F. (2020). Candida auris: From Multidrug Resistance to Pan-Resistant Strains. Infection and drug resistance, 13, 1287–1294.

Ashbolt, N. J. (2004). Microbial contamination of drinking water and disease outcomes in developing regions. Toxicology, 198(1-3), 229-238.

Cohen, M. B. (2022). Bacterial, viral, and toxic causes of diarrhea, gastroenteritis, and anorectal infections. Yamada's Textbook of Gastroenterology, 2947-3005.

Furlan, J. P. R., Gallo, I. F. L., de Campos, A. C. L. P., Passaglia, J., Falcão, J. P., Navarro, A., Nakazato, G., & Stehling, E. G. (2019). Molecular characterization of multidrug-resistant Shiga toxin-producing Escherichia coli harboring antimicrobial resistance genes obtained from a farmhouse. Pathogens and global health, 113(6), 268–274. https://doi. org/10.1080/20477724.2019.169371 Gautam, B. (2021). Microbiological quality assessment (including antibiogram and threat assessment) of bottled water. Food science & nutrition, 9(4), 1980–1988.

Halkos, G., & Argyropoulou, G. (2022). Using environmental indicators in performance evaluation of sustainable development health goals.

Ecological Economics, 192, 107263.

Figure 9: Example of an electrophoresis gel with PCR products for penicillin antibiotic resistance genes. Penicillin ARGs were absent from all water samples tested.

Jang, J., Hur, H. G., Sadowsky, M. J., Byappanahalli, M. N., Yan, T., & Ishii, S. (2017). Environmental Escherichia coli: ecology and public health implications-a review. Journal of applied microbiology, 123(3), 570–581. https://doi.org/10.1111/jam.13468 Lienemann, T., Salo, E., Rimhanen-Finne, R., Rönnholm, K., Taimisto, M., Hirvonen, J. J., Tarkka, E., Kuusi, M., & Siitonen, A. (2012). Shiga toxinproducing Escherichia coli serotype O78:H(-) in family, Finland, 2009.

Emerging infectious diseases, 18(4), 577–581.

Mackey, T. K., Liang, B. A., Cuomo, R., Hafen, R., Brouwer, K. C., & Lee, D. E. (2014). Emerging and reemerging neglected tropical diseases: a review of key characteristics, risk factors, and the policy and innovation environment. Clinical microbiology reviews, 27(4), 949-979.

Figure 10: Example of an electrophoresis gel with PCR products for ciprofloxacin antibiotic resistance genes. One water sample had a band indicating the presence of a ciprofloxacin ARG in a tap water sample.

Meyer, R. J., & Brown, S. A. (2020). Challenges of the Unseen World: A Laboratory Course in Microbiology. John Wiley & Sons.

Murray, C. J., Ikuta, K. S., Sharara, F., Swetschinski, L., Aguilar, G. R., & Gray, A. & Naghavi, M. (2022). Global burden of bacterial antimicrobial resistance in 2019: a systematic analysis. The Lancet, 399(10325), 629655.

Nichols L. (2019). Death from pan-resistant superbug. Autopsy & case reports, 9(3), e2019106.

Temesgen, Z., Baddour, L. M., & Rizza, S. A. (2020). A Rational Approach to Clinical Infectious Diseases: A Manual for House Officers and Other NonInfectious Diseases Clinicians. Elsevier Health Sciences.

Figure 11: Example of an electrophoresis gel with PCR products for ciprofloxacin antibiotic resistance genes. Two water samples had a band indicating the presence of a ciprofloxacin ARG in two environmental water samples.

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Yu, D., Ryu, K., Zhi, S., Otto, S. J. G., & Neumann, N. F. (2022). Naturalized Escherichia coli in Wastewater and the Co-evolution of Bacterial Resistance to Water Treatment and Antibiotics. Frontiers in microbiology, 13, 810312. https://doi.org/10.3389/fmicb.2022.810312 Zhang, Y., Tan, P., Zhao, Y., & Ma, X. (2022). Enterotoxigenic Escherichia coli: intestinal pathogenesis mechanisms and colonization resistance by gut microbiota. Gut microbes, 14(1), 2055943.

Dyslexia: A Misunderstood Neurodevelopmental Condition

by Phillip K. Mothersead, Ph.D., Noel Leif, BSE, CALT-ICALP, Jennifer Edwards and José M. Dominguez, M.D.

Case Study JD completed 4th grade in a suburban Baltimore public school in 1974. Unfortunately, he was unable to read at the expected level. As a result of his intellect and coping skills, he was able to hide his lack of reading skills for many years. His Father, a Child Psychiatrist, and Mother, a Registered Nurse, began to suspect there was a significant learning problem. JD underwent private testing and was formally diagnosed with dyslexia. He was transferred to a private school with a specialized curriculum to retake the 4th grade. This early intervention and continued dyslexia treatment resulted in a successful academic career. This ultimately led to becoming a Surgeon in Springfield, Missouri and JD also serves on the Board of Directors for the Springfield Center for Dyslexia and Learning. (Table 1) This underscores the importance of early diagnosis and treatment of dyslexia. As healthcare providers, we can create a major change in the life of those who struggle with dyslexia by referring them to appropriate resources and interventions.

Dyslexia The International Dyslexia Association defines dyslexia as a specific learning disability that is neurobiological in origin. It is characterized by difficulties with accurate and/or fluent word recognition and by poor spelling and decoding abilities.

These difficulties typically result from a deficit in the phonological component of language that is often unexpected in relation to other cognitive abilities and the provision of effective classroom instruction.

Secondary consequences may include problems in reading comprehension and reduced reading experience that can impede growth of vocabulary and background knowledge. The reported incidence of dyslexia is 1 in 5 individuals. Dyslexia Research over the past decade has contributed to considerable progress in understanding the key underlying causes of dyslexia as well as helping to identify effective interventions. Dyslexia is characterized by a core deficit in phonological processing (the ability to recognize and manipulate speech sounds), which

results in impairments in decoding (sounding out words), spelling, and word recognition. Dyslexia cannot be explained by poor hearing or vision, lack of attention, motivation, or opportunity.

One breakthrough in the field of dyslexia research has been the identification of specific genetic factors that contribute to this neurodevelopmental condition. These findings support the previous assumption that dyslexia, in some families, was passed down from generation to generation. In addition to genetic factors, research has helped clarify the role of brain structure and function in dyslexia. Neuroimaging studies have revealed differences in the brain regions involved in reading and language processing. These discoveries have helped to clarify the neural basis of dyslexia and have also confirmed changes in neuroprocessing with appropriate interventions.

Interventions based on the OrtonGillingham approach have been found to be effective in improving reading skills, especially when implemented with young children.

Early detection and intervention are critical in preventing significant delays in the development of independent reading acquisition. Many associated emotional and academic problems that follow poor readers can be prevented.

Missouri schools are now required to screen for dyslexia. The screening methods vary from school to school and the screening does not provide a diagnosis necessary to develop an individual education plan (IEP). More consistent research-based approaches need to be undertaken in our schools and lobbying for these services has been ongoing.

Pediatricians, Family Practitioners and other medical professionals are often on the front line working with parents to help identify neurodevelopmental disorders and refer them to local resources. Parents may report their child as struggling with reading and despite limited MAY/JUNE 2024 • GCMS Journal • 11

services provided by the school, their child does not seem to be making progress. Through careful observation and targeted questioning, the pediatrician can gain insight into a child's reading difficulties, such as their ability to recognize letters, decode words, and comprehend written text. These initial observations play a crucial role in determining if a further evaluation for dyslexia would be helpful. A clinical diagnosis is important as are services from a specialized research-based reading program, as well as accommodations in the classroom. By working together and leveraging their expertise, medical professionals can ensure that these children receive the necessary testing and diagnosis as well as appropriate intervention, paving the way for a brighter future.

with reading and writing outside the classroom. SCDL started with tutoring provided at a private home. In 2015 Steve Edwards (then President and CEO of CoxHealth ) and Jennifer Edwards saw that there was a great need in the community for this researched service / treatment.

CoxHealth donated the space and scholarship money seeding SCDL. The program has grown from 5 to 19 therapists. In addition to tutoring, SCDL provides families advocacy at their 504 or IEP school meetings as well as dyslexia screenings and evaluations. Teacher training and seminars have become a core part of the SCDL mission. Please consult the SCDL website www. dyslexiaandlearning.com and phone number 417-2690259 for further information.

Springfield Center for Dyslexia and Learning

Reference: Sanfilippo J, Ness M, Petscher Y, et al. Reintroducing Dyslexia: Early Identification and Implications for Pediatric Practice.

Pediatrics. 2020;146(1): e2019304.

The Springfield Center for Dyslexia and Learning (SCDL) began out of a need for struggling students to get help

BOARD OF DIRECTORS Mr. BJ Joplin Springfield Dyslexia & Learning Center President

Ms. Cara Erwin Director at City Utilities of Springfield

Ms. Krystal Russell Partner Spectrum Accounting LLC

Dr. José Dominguez Colon & Rectal Surgery, CoxHealth

Dr. Philip Mothersead Neuropsychologist

Ms. Jessica Johns Senior Counsel CoxHealth

Ms. Jennifer Edwards Decoding Dyslexia Missouri Co-Founder

Ms. Camille Lockhart Partner at Forvis

Mr. Keith Noble President at Commerce Bank

Ms. Shelley Marshall Merill Lynch Wealth Management Advisor

Mr. Bryan Wade Partner at Husch Blackwell

Ms. Noel Leif Springfield Dyslexia and Learning Center Executive Director

12 • MAY/JUNE 2024 • GCMS Journal

MAY/JUNE 2024 • GCMS Journal • 13

An update from the Springfield Campus

by Dr. David Haustein, MD, MBA University of Missouri, School of Medicine Associate Dean Springfield Clinic Campus

We have many things to celebrate this year at the University of Missouri School of Medicine’s Springfield Clinical Campus (SCC). As of May 2024, we have had 126 students who have graduated from this program, many of whom are still in residency and/or fellowship training throughout the country.

Many of you have contributed to the education and training of these physicians. This year’s class from the MU School of Medicine was highly sought after: 97% of the class received a residency program match. We are proud to announce the following matches for our SCC Class of 2024 students. Some students chose to not be included on the public match list for a variety of reasons. If a student is not on this list, please respect their request for privacy and do not inquire.

We are proud to see our students match into a wide spectrum of specialties from both the Springfield and Columbia campuses. Of our Springfield graduates who have completed their training, 31% are now practicing in Springfield, Lebanon and Bolivar. Some of our other graduates are teaching at Washington University, MD Anderson and other locations throughout the US. With 84% of our SCC students being from Missouri, we hope to see many return to practice here.

We are also excited to celebrate our 350 Springfield physician

faculty who volunteer their time to train with our students. The Springfield Campus hosted our 3rd Annual Faculty Appreciation Dinner on April 23rd. Thank you to everyone who came and made it a joyous evening. Please join us in congratulating the 2024 Award Winners:

We have many new developments to celebrate and to be thankful for on our campus. To all of you who give of your time and talents to raise up the next generation of physicians for Missouri, thank you. You are contributing in a meaningful way to the care of our friends and neighbors for years to come.

14 • MAY/JUNE 2024 • GCMS Journal

Meeting Basic Needs: Coming Together To Help Kids

by Thomas G. Prater, MD Mattax-Neu-Prater Eye Center I recently heard a story about a 17-year-old student enrolled in a local school district. This student was struggling to read the board and had difficulty with classes. After meeting with her, the teacher discovered that the student didn’t have the financial means to purchase a pair of eyeglasses or a way to get to an optometry appointment to obtain a prescription.

One simple need had become a barrier to her education and everyday life. Fortunately, the school had a local Care to Learn Chapter. They funded her transportation, where she received an eye exam and ordered a brand-new pair of eyeglasses. After the student received them, she teared up because she was “seeing things she didn’t know she could not see.”

Her Care to Learn Chapter shared that weeks later, the student was trying on formal dresses and teared up again. She was overcome with gratitude once more as she continued to absorb her newly improved vision.

This student is one of many facing barriers in education due to unmet health needs. According to the Missouri Department of Elementary and Secondary Education, of the 900,000 students who attend Missouri public schools, around 1 in 5 lives in poverty.

When these medical, dental, and mental health needs aren’t supported, the consequences are more than detrimental. Not only do they lead to nutritional deficiencies and higher rates of chronic conditions, but they also cause poorer mental health and emotional disparities.

Care to Learn is a nonprofit dedicated to partnering with local school districts and community members to fill these gaps and help improve the trajectory of a student’s future and overall well-being. They understand that when a child has their health needs met, they: • • • • •

Return to the classroom more quickly Experience less bullying Fit in with their peers Feel safe and secure Have more confidence and self-worth

These factors combined allow children to gain a higher education level, leading to a longer and healthier life. Ultimately, this is something we all can support.

Care to Learn has created a seamless system so simple,

intuitive, and free of red tape that it’s no wonder they’ve grown to partner with more than 45 school districts (including the eight located in Greene County) across the state of Missouri in the past 16 years. In the last three years, they’ve spent more than $213,182 to meet students’ health-related needs, and the organization has met more than 4,000+ medical needs this school year.

Beyond eyeglasses and vision exams, they help with emergency dental needs, prescriptions, assistive devices such as power chairs and hearing aids, mental health services, and support. They also cover transportation to make it to appointments.

We need organizations like Care to Learn. They ensure health, hunger, and hygiene resources are available, especially to those qualifying for Free and Reduced Lunch Rates, a key indicator of poverty.

In my time serving as a board member for Springfield Public Schools, the Springfield Area Chamber of Commerce, the Community Foundation of the Ozarks, and Care to Learn, I’ve seen firsthand the value and importance of organizations like Care to Learn and why supporting their mission is of utmost importance for the future health of our community’s youth.

Resources: 2022 poverty report. (n.d.). https://www.communityaction.org/wp-content/ uploads/ 2022/09/2022-POVERTY-REPORT-web.pdf. Missouri Community Action Network.

National Library of Medicine (2018) Social Determinants of Mental Health: Where We Are and Where We Need to Go https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC6181118/ American Academy of Pediatrics (2016, 2021) Poverty and Child Health in the United States (https://publications.aap.org/pediatrics/article/137/4/e20160339/81482/ Poverty-and-Child-Health-in-the-United-States) Centers for Disease Control (2011-2012) Health-care, Family, and Community Factors Associated with Mental, Behavioral, and Developmental Disorders in Early Childhood – United States (https://archive.cdc.gov/#/details?url=https://www.cdc. gov/ncbddd/childdevelopment/feat ures/key-finding-factors-mental-behavioraldevelopmental-early-childhood.html)

MAY/JUNE 2024 • GCMS Journal • 15

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The Arc of the Ozarks: Finally, a comprehensive autism center in Southwest Missouri

by Kayce Morton, DO, Inpatient Pediatrician, CoxHealth and Kyle John, MD, Adolescent and Child Psychiatrist, Medical Director, The Arc of the Ozarks’ Neurodevelopmental and Autism Center

As a pediatric provider here in southwest Missouri for the past 15 years, it can be sometimes frustrating with the lack of subspecialty care and limited resources for our patients.

This area isn’t considered rural by any means, and we draw from a large surrounding area, so you would think that this area would have what it needs. Despite this, we have continually improved the care options, and that is due to the tenacity for of our caregivers and families that have worked to keep the need relevant. That is why I reached out to Dr. Kyle John from Arc of the Ozarks. In case you were unaware, the newest location has opened and I personally am amazed by the forethought of this project and what it means to our Autism families as well as those with special needs.

For a little background on autism, the prevalence of autism has increased with improved diagnostic criteria and early screening. According to the Centers for Disease Control and Prevention (CDC), Missouri has a rate of approximately 1 in 48 children. This is similar to the national prevalence in the United States of approximately 1 in 44. This diagnosis includes any children identified to have autism spectrum disorder (ASD) in the state. Until now the main source of diagnosis was at diagnostic centers in Kansas City, St. Louis, Columbia and Joplin. With ECHO of Missouri, our area specifically gained 2-3 primary pediatricians that are able to diagnose autism.

Most referrals are sent to Burrell, Jordan Valley Community Health Centers as well as the Arc. Even with these resources, we are unable to accommodate initial diagnosis and 18 • MAY/JUNE 2024 • GCMS Journal

treatment and have struggled with long wait times and lack of resources.

The diagnosis of autism requires specialized training and resources. This includes screening protocols for early detection, fostering a supportive and inclusive environment within clinics, and the ability to collaborate within clinics as well as with community partners. With increasing prevalence it only underscores the importance of the need we have in our area. Furthermore, families of children with autism or ASD face numerous challenges across different aspects of life, including in schools, clinics, healthcare settings, and in daily life. There is a limited awareness and understanding leaving them to deal with issues in communication and treatment planning. Addressing these challenges often requires a collaborative approach amongst healthcare providers, educators, community organizations and support networks.

Families benefit from access to comprehensive resources, especially family centered care models that teach parents and patients to advocate for themselves. Which is why it is important to highlight the newest integrated clinic for autism with Dr John. Having a dedicated autism center that integrates care significantly improves access to services and support for individuals and their families. It is very needed in our community and will likely expand and grow in the future with continued support from us locally and via our state legislature.

Dr. John’s history and timeline: Arc of the Ozarks was established in 1964 by a group of parents around a kitchen table with a vision to connect their children to the community and create ways for them to be included, like other children.

Throughout the years, The Arc has continued to be a leader in service delivery for individuals with intellectual and developmental disabilities. Our mission and vision are to support individuals with disabilities in leading self-directed lives as members of our community. Towards that end, we employ over 1,500 staff members.

The Arc staff provides direct care services to hundreds of clients and families across the region, including Springfield, Branson, Joplin, Monett, Bolivar, Mountain Grove, and Kansas City. These services allow clients to remain in their family home or to move into a supportive living facility. In addition to direct care, The Arc also has innovative partners which allow for some individuals to be remotely monitored, affording even more independence.

Current services provided at The Arc include: autism assessment and diagnostics, counseling therapies – individual, group, family, marriage, psychiatric and interventional psychiatric care, medical therapies – speech to include feeding and augmentative/alternative communication, occupational, physical, aquatic, and school-based.

The Arc team also provides family advocacy to help guide patients and families throughout the evaluation and diagnostic process. These community experts are knowledgeable regarding therapeutic services available in Southwest Missouri.

Future goals for The Arc include continued robust diagnostics at the Springfield center along with expansion of therapy locations in the region, perhaps in Bolivar and Lebanon, as well as continued growth in Joplin and Branson. Additionally, we hope to expand medical services to include basic medical screening and care for patients on the spectrum, to avoid visits to emergency facilities.

Our interventional psychiatric team will soon provide both traditional Transcranial Magnetic Stimulation (TMS) for the treatment of depression, obsessive-compulsive disorder, nicotine cessation, as well as Magnetic Resonance Therapy (MeRT), a cutting-edge, EEG-guided form of TMS specific for patients with Autism, PTSD, traumatic brain injury, depression, and anxiety, among others.

Since our 50th anniversary, the Arc team has continued to listen to the needs of the disability community and have expanded our reach to serve more children and families with disabilities. These accomplishments would not have been possible without the support of our Board of Directors, donors, grantors, community partners, friends, and dedicated team members.

MAY/JUNE 2024 • GCMS Journal • 19

The COVID Conundrum: Board Exam Blues in the Pandemic Era

by Matthew Gao, University of Missouri School of Medicine

The COVID-19 pandemic has posed challenges to medical education and training throughout our country. As a medical student, I am familiar with the sudden shifts to virtual learning platforms and the cancellation of hands-on clinical experiences. The pandemic created difficulties for medical trainees and professionals of all levels. Fellowships represent an integral part of medical training, offering specialized education and experience in various subspecialties following residency. The fellows are actively trying to hone their skills and knowledge under the guidance of experienced mentors, with their focus on delivering patient centered care.

Fellowship board exams are typically taken after completion of a fellowship program, which can vary in duration but often lasts two to three years. These exams serve as a milestone for fellows, assessing their readiness to practice independently in their subspecialty. Among the many areas affected by the pandemic, medical board examination pass rates have become a point of concern. In this article, I explore the trends in board exam pass rates, challenges, and strategies for adaptation.

Cardiology Board Exams Over the past three years, there has been a notable drop in pass rates for the American Board of Internal Medicine (ABIM) subspecialty examination in cardiovascular disease. In 2021, 2022, and 2023, the pass rate for first-time test takers fell to 86%, marking a significant decline from the typical pass rates hovering around 93%.1 Cardiology fellowships typically span three years. Graduates in 2021 had 12 to 18 months of training overlap with the pandemic, while those in 2023 navigated through the entire fellowship amidst pandemic challenges.

stable, with 84% and 89% respectively.

However, a significant dip occurred in 2021, where only 74% of candidates passed. This trend persisted in 2022, with another 74% pass rate, indicating ongoing challenges. Although there was a slight uptick in 2023, with 82% of candidates passing, the fluctuating pattern underscores the persistent hurdles faced by examinees.1

Allergy and Immunology Board Exams The pass rates for first-time candidates in the Allergy and Immunology board exams have shown resilience and stability over the years, even amidst the challenges posed by the COVID-19 pandemic. From 2016 to 2023, these rates have generally remained high, with minor fluctuations observed.3 In particular, there was a slight decrease in 2021, followed by a notable increase in 2022 and 2023, demonstrating the adaptability and perseverance of candidates and training programs.

The cardiovascular disease certification examination is not graded on a curve. Instead, the minimum passing score reflects a standard that is independent of the performance of any group of candidates.2 The passing score is a consistent benchmark and decreasing pass rates reflect poorer preparation for the exam.

Impact of the Pandemic on Education and Training

Endocrinology Board Exams Similarly, the Endocrinology written board examination pass rate witnessed a rollercoaster ride in first-time test taker pass rates. Initially, in 2019 and 2020, the pass rates were relatively 20 • MAY/JUNE 2024 • GCMS Journal

Reflecting on the impact of the COVID-19 pandemic, it's evident that fellowship and residency education underwent significant structural changes, affecting various aspects of learning. These changes included shortened physical examinations, abbreviated rounds, reduced patient volumes limiting physicians’ exposure to diverse cases and hands-on experiences.

Additionally, the shift to virtual conferences due to canceled in-person events diverted attention away from didactic

learning. Those who contracted the virus lost valuable training time. Faculty education and engagement also declined, resulting in a ripple effect on learning experiences. Travel restrictions and the cancellation of national conferences further disrupted the exchange of innovative ideas and therapies.

Compounded by existing burnout, these challenges contributed to high levels of faculty turnover, commonly observed among senior physicians who traditionally played a significant role in fellowship education. As a result, graduating fellows experienced setbacks in both procedural and didactic education.

The psychological toll of the pandemic, coupled with fears of contracting COVID-19, heightened anxiety among healthcare workers, impacting their ability to engage in self-directed learning. The disruption of routine schedules, concerns about personal health and safety, and witnessing the overwhelming impact of the pandemic on patients and healthcare systems have all contributed to the burden experienced by trainees.

Strategies for Mitigation and Adaptation Residency programs have responded with a wide range of strategies to mitigate the pandemic's impact on board examination pass rates. These include virtual learning platforms, telemedicine experiences, modified curriculum delivery, and adjustments to examination formats. Additionally, efforts were made to bridge disparities in access to resources, with some endocrinology fellowships implementing early acquisition of

board review materials, structured didactics covering relevant content, periodic case conferences focusing on high-yield board topics, and funding additional board review options like inperson courses.4 Conclusion In the face of many challenges brought forth by the COVID-19 pandemic, medical trainees have exhibited remarkable resilience and adaptability. Despite disruptions to education, training, and board examination preparations, they have remained firm in their commitment to serving their communities. Their ability to persevere in the face of adversity, whether it be through long hours, challenging conditions, or personal sacrifices, exemplifies the true spirit of medicine.

References 1. American Board of Internal Medicine. Internal medicine and subspecialty certification examinations: 2019-2023 first-time taker pass rates https://www.abim. org/Media/yeqiumdc/certification-pass-rates.pdf 2. https://www.abim.org/certification/exam-information/cardiovasculardisease/scoring-results 3.

https://www.abai.org/statistics_exam.asp

4. https://www.apdem.org/program-director-corner/a-commentary-on-the2021-endocrinology-subspecialty-exam-abim-pass-rates/

Oncology Updates with ASCO Highlights Saturday, June 22, 2024

Saturday, June 29, 2024 DoubleTree by Hilton Hotel Springfield, MO

DoubleTree by Hilton Hotel Chesterfield, MO Presented By

Department of Medicine, Division of Oncology Washington University School of Medicine in St. Louis

Course Chairs

Katherine K. Clifton, MD Brian A. Van Tine, MD, PhD In support of improving patient care, Washington University School of Medicine in St. Louis is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

Credit Available for this activity American Medical Association (AMA): This activity has been approved for AMA PRA Category 1 credits.

American Nurses Credentialing Center (ANCC): This activity has been approved for ANCC contact hours.

Accreditation Council for Pharmacy Education (ACPE): ACPE credit will be awarded for this activity.

Interprofessional Continuing Education (IPCE): This activity has been approved for IPCE credits.

Washington University School of Medicine in St. Louis - Continuing Medical Education MAY/JUNE 2024 • GCMS Journal • 21 (314) 362-6891 (800) 325-9862 Website: cme.wustl.edu Email: cme@wustl.edu

Medical Student Perspective: The Springfield Clinical Campus Experience

by Noah Kronk, University of Missouri School of Medicine

Greetings everyone, my name is Noah Kronk, and I have the privilege to serve as the class president for the Springfield Class of 2025. I wish to take this opportunity to share a glimpse of my personal journey here in Springfield.

Through this, I hope to convey the appreciation our students hold for your tireless dedication and hard work in educating us.

Upon entering medical school at Mizzou, I was certain that the Springfield Clinical Campus (SCC) was where I wanted to be. My prior experience working as a tech in the Emergency Department at Mercy during my undergraduate years, along with being a simulated patient at the school, gave me a firsthand glimpse into the exceptional learning environment provided by the Springfield campus for our third and fourth-year medical students. It was a nobrainer for me to eagerly sign up.

Despite my excitement for the learning experiences awaiting me during my clinical years in Springfield, I couldn't shake off the nerves as the moving day drew closer. Thoughts of whether I had made the right decision crept into my mind. With the upcoming move from Columbia, the Step 1 exam looming over my head, and various other life stressors, doubt began to cloud my thoughts.

Once orientation started, all my doubts faded into the background, replaced by excitement, and from that moment on, I never looked back. I owe a heartfelt thank you to Dr. Haustein, Jill, Jennifer, Trayce, Eden, Dee, and the entire SCC family. Your dedication to us students is evident, and your efforts to connect with and understand us make an immense difference in our experience here.

The SCC wouldn't be what it is without your support and investment in our success.

From day one of my first rotation I was given the opportunity to have hands-on experience and dive right 22 • MAY/JUNE 2024 • GCMS Journal

into patient care. Let me tell you I was nervous, clueless, and had no idea how to write a note or be a productive member of the team. Fortunately for me, with time and support from those who taught me I was able to gain confidence in myself. The physicians I worked with are so patient, passionate about their craft, and had a burning desire to teach and help mold the next generation of physicians. All of those things foster such a positive learning experience for our students. Every day I was able to come onto my rotation and work alongside such talented physicians and I was able to observe examples of the type of physician I aspire to be one day.

I'll provide a few examples of the exceptional preceptors I've had the privilege of encountering to better illustrate this. In observing Dr. Moore I saw compassion in the way he cares for and knows his patients and how much trust they have in him. In Dr. Ayeni I saw her commitment to lifelong learning and her passion for teaching. In Dr. Robbie I observed his graceful and softhearted approach to delivering devastating news to a family who had lost a loved one and how impactful a warm hug and a box of tissues can be. In Dr. Rice I saw how to unconditionally care for a group of patients in the federal prison that many in society had given up on. He taught me to never place judgment on a patient for decisions they have made in the past. In Dr. Hernandez I saw what it looks like to truly find joy in your work and how to bring out the best in those around you. I saw patience in many surgeons as they watched me attempt for the first time, maybe with some shaking and some technique that needed improvement, suturing up their patients' port sites.

There are so many more moments I could mention. Most importantly I want to thank all of the physicians here in Springfield for dedicating their precious time to teaching and mentoring us. I think I speak for every student here when I say the Springfield campus would not be what it is today without all of you. We know that your time is limited and that teaching us takes energy, patience, and thoughtfulness. We also understand having a student on your service might not always be the most efficient thing in the world but all of the effort you put into shaping us and helping build us into future physicians means so much to us. You’ve inspired us. On our most challenging days, your unwavering support has given us belief in our own capabilities and a desire to excel in this field. Thank you for providing us the freedom to make mistakes, to grow, to navigate the complexities of medicine, and to ultimately stride forward with the confidence that we can confront whatever lies ahead. Thank you all.

166th Annual MSMA Convention & 99th Annual MSMA Alliance meeting

by Jana Wolfe, co-president GCMSA

On April 5th, the revolving doors to the Renaissance St. Louis Airport Hotel transported the MSMA Alliance back to the beginnings of the Woman’s Auxiliary to the Missouri State Medical Association in 1924, when Mrs. George Hoxie welcomed the attendees to their first annual meeting. Who knew, then, that we would be gathering again in St. Louis a century later to celebrate our Centennial!

On Friday afternoon, the MSMA Alliance proudly began setting up the antiquities and displays of one hundred years’ worth of memories. It was humbling to see archives, never seen by many of us; the original documents establishing our organization, hand-written minutes, financial records, notes to members marking important moments in their lives.

Left to Right: MSMAA President Donna Corrado, MSMA Past-President Dr. Lancer Gates, AMAA President Racheal Kunesh and MSMAA Past-President Sana Saleh

Many of you may be unaware of the huge contributions physician spouses have made over the years. The state auxiliary presented programs and projects to members and encouraged them to be implemented at the local auxiliaries.

These projects would make huge differences across the state of Missouri, attracting the attention of the Auxiliary to the American Medical Association many times.

The State Auxiliary began health education programs and implemented higher standards for rural schools, sanitation and community health information, immunization clinics for children, typhoid, TB, and cancer education in the early years. During the war years, the spouses promoted legislation for birth certificates, informed communities of the Social Securities Act, and organized the Committee of Health Defense.

The medical auxiliary recorded over 92,000 hours of volunteer service, educating Missouri communities on the health issue on elimination of rats, started the AMA Education Foundation, focused on aging, nutrition & seatbelt safety, taught disaster

preparation... the list goes on.

Fast forward to our latest programs: "STOP America’s Violence Everywhere", "Pills Are NOT a Party", opioid abuse education, organ/tissue donation, human trafficking education, DeNOVO committee formation, medical marriage/physician burnout programs, Prescription Drug Monitoring Program advocacy, “Stop the Bleed” education and many more educational programs and physician/patient advocacy issues have been brought to our state legislators.

The auxiliary (now Alliance) is not a white-glove organization of women sitting around sipping tea. We never have been. We are a physician spouse and partner-based organization. . We are men, women, and families of physicians (& physicians, too) actively involved in our communities, our state, and our nation. We promote and advocate for the health and welfare of our spouses, our families, the physicians, and the patients in our communities.

The treasure trove of one hundred years’ worth of the MSMA Alliance antiquities was proudly displayed in a room just outside the meeting rooms and Inauguration and Presidential Reception rooms. The MSMA & MSMA Alliance members and guests were able to enjoy browsing through the Auxiliary and Alliance Presidential memoirs and members’ keepsakes.

On Friday evening a wonderful reception was held marking the opening of the 166th MSMA Convention and the 99th MSMA Alliance Annual Meeting. As always, the Alliance collected contributions for the MSM Foundation.

On Saturday morning, MSMA Alliance 2023-24 President Sana Saleh presented an informative year-end report to the MSMA House of Delegates. She received a standing ovation.

The Nomination Committee, chaired by Barbara Hover, presented and elected the following officers: President Donna Corrado; President-Elect Gill Waltman; Foundation VPs Kathy Weigand and Gill Waltman, Health VP Angela Zylka, Legislation VP Kirk Doan, Membership VPs Jana Wolfe and Sue Ann Greco, Recording Secretary Diana Corzine, and Treasurer Debora Snyder.

We had an outstanding speaker, Kathie Thomas-Deitz, Executive Director & Founder of Hope Creates. Kathie created this organization during her intense journey, seeking assistance for her family and one of her daughters suffering from addiction. Hope Creates was born out of her belief that creation is the opposite of self-destruction and that positive self-expression builds self-confidence and self-esteem. We also had another inspirational speaker, Racheal Kunesh, AMA Alliance 2023-24 President. She reminded us of all the benefits of being an AMA Alliance member and the importance we are and the differences we make in our communities, our state, MAY/JUNE 2024 • GCMS Journal • 23

and our nation.

Saturday’s meeting concluded with our Awards, Recognition, and Officer Installation luncheon. Mr. Kirk Doan received the prestigious Jean Wankum Spirit of the Alliance Award, Mrs. Mary Shuman received the inaugural Lizabeth Starnes Fleenor Literary Award, and Heather Ramsey, Dr. & Mrs. James Wolfe’s daughter, received MSMA Alliance Honorary Membership for her support, dedication, and enthusiasm to the MSMA Alliance.

The 99th MSMA Alliance Annual Meeting was a wonderful event, concluding with the installation of Donna Corrado.

The evening was spectacular with the MSMA & Alliance Presidential Reception.

Next year, the 167th MSMA Convention & 100th MSMA Alliance Annual Meeting, will be held in SPRINGFIELD!! Get your party shoes ready!

Greene County Medical Society Alliance Members who have served as Missouri State Medical Association Alliance Presidents Mrs. U. J. Busiek, 1931-32* Mrs. Paul F. Cole, 1939-40* Mrs. Anne (W. Carey) Cheek 1951-52* Mrs. Marjorie (Stanley S.) Peterson, 1959-60* Mrs. Pat (William M.) Walker, 1970-71*

James Rogers, MD, Alex Hover, MD, Jim Blaine, MD, Brian Biggers, MD and James Wolfe, MD (standing.)

Mrs. Joan M. (Charles) H’Doubler, 1996-97* Mrs. Judy (Frank) Corry, 1998-99 Mrs. Julie (J. David) Gipson, 2010-2011 Mrs. Barbara (Alexander) Hover, 2013-14 Mrs. Jana (James) Wolfe, 2016-17 Mrs. Barbara (Alexander) Hover, 2021-22 *Deceased

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AR license #235655 Certified Financial Planner Board Standards owns the certification marks CFP® , CERTIFIED FINANCIAL PLANNER™ and CFP (with Investment advisory products andofservices areInc. made available through Ameriprise Financial Services, LLC, a registered investment adviser. plaque in the U.S. Board of Standards Inc. owns the certification marks CFP®, CERTIFIED FINANCIAL PLANNER™ and CFP (with Certifieddesign) Financial Planner Ameriprise Financial plaque design) in thecannot U.S. guarantee future financial results.

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SIPC. Financial cannot guarantee futureFINRA financial 24 • MAY/JUNE 2024 • GCMS Journal © 2023 Ameriprise rights reserved.

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GCMS Journal Co-editor Jim Blaine, MD, GCMS President James Rogers, MD, and MSMA President-Elect Brian Biggers, MD

From left, Carlin Ridpath, MD, Louis DelCampo, MD, Betty Drees, MD, Charles Van Way, III, MD, and William Drees.

Front row from left: James Wolfe, MD, Springfield; George Hruza, MD, Chesterfield – Chair; standing from left: Basia Michalski-McNeely, MD, Young Physician Section; George Mansour, MD, St. Louis; and Keith Ratcliff, MD, Washington

MSMAA (Missouri State Medical Association Alliance) Left to right: Jana Wolfe, Barbara Hover, MSMAA President Donna Corrado, Kay Johar, AMAA President Racheal Kunesh

director@gcms.us (417) 887-1017 4730 S. National #A1 Springfield, MO 65810

MAY/JUNE 2024 • GCMS Journal • 25

26 • MAY/JUNE 2024 • GCMS Journal

MEASLES OUTBREAKS IN MISSOURI?

by Nancy Yoon, MD MPH, Chief Medical Officer Springfield-Greene County Health Department

Scope of the Problem As of April 26, 2024, a total of 128 measles cases have been reported in the U.S. this year. From January 1, 2020–March 28, 2024, CDC was notified of 338 confirmed measles cases; 97 (29%) of these cases occurred during the first quarter of 2024, representing a more than seventeen-fold increase over the mean number of cases reported during the first quarter of 2020–2023. Among the 338 reported cases, the median patient age was 3 years (range = 0–64 years); 309 (91%) patients were unvaccinated or had unknown vaccination status.

Measles is highly infectious; one person with measles can pass it on to 9 out of 10 people who are unvaccinated or do not have natural immunity. It spreads through the air when a person with measles coughs or sneezes and the virus can live in the air for up to 2 hours. A person with measles is contagious from 4 days before the rash appears until 4 days after the rash appears.

Measles is almost entirely preventable through vaccination with the MMR vaccine. The standard immunization schedule recommends that children receive their first dose of the MMR vaccine at 12 months of age. The MMR vaccine is safe and highly effective, with two doses being 97% effective against the disease. Even one dose provides a high level of protection at 93%.

Worldwide, measles is still the leading cause of vaccinepreventable deaths in children. Measles was declared eliminated in the US in 2000 after a successful vaccination campaign. However, there has been a resurgence of measles due primarily to waning vaccination rates, and measles was no longer able to be declared eliminated in the U.S. in 2019.

Vaccination coverage of over 95% is needed for a community to be considered protected through herd immunity.

From 2000–2022, estimated measles vaccination prevented approximately 57 million deaths worldwide. However, millions of children missed vaccinations during the COVID-19 pandemic, resulting in an 18% increase in estimated measles cases and a 43% increase in estimated measles deaths in 2022 compared with 2021.

Measles in Missouri In Greene County, there have been 3 confirmed cases of measles in the last 20 years. All three of these cases

occurred in 2010 and were linked to international importation. The only reported measles case in Missouri in 2024 occurred in Liberty, Missouri and is believed to have been contracted during international travel. No person-toperson transmission has occurred in the state thus far.

Locally, we remain above the national average for school vaccination rates with Springfield Public Schools (SPS) reporting a steady historical vaccination rate at or around 97%. For the 2023-2024 school year, SPS had a 3% exemption rate. Nationally, vaccination coverage among kindergartners decreased from 95.2% during the 2019–2020 school year to 93.1% in the 2022–2023 school year. Continuing vaccination rates at or above this percent in children will help us mitigate outbreaks.

Complications • About 1 in 5 people in the U.S. who get measles will be hospitalized.

• About 1 out of every 20 children with measles gets pneumonia, the most common cause of death from measles in young children.

• About 1 out of every 1,000 people who gets measles will develop encephalitis.

• Nearly 1 to 3 of every 1,000 people with measles will die from respiratory and/or neurologic complications.

Recommendations for Healthcare Providers • All U.S. residents older than age 6 months without evidence of immunity who are planning to travel internationally should receive MMR vaccine prior to departure.

• Consider measles as a diagnosis in anyone with fever (≥101°F or 38.3°C) and a generalized maculopapular rash with cough, coryza, or conjunctivitis who has recently been abroad, especially in countries with ongoing outbreaks.

• When considering measles: o Isolate the patient o Notify the state or local health department o Test: Collect either a nasopharyngeal swab, throat swab, and/or urine for reverse transcription polymerase chain reaction (RT-PCR) and a blood specimen for serology o Manage: In coordination with local or state health departments, provide appropriate measles post-exposure prophylaxis (PEP) as soon as possible after exposure to close contacts without evidence of immunity, either with MMR (within 72 hours) or immunoglobulin (within 6 days).

MAY/JUNE 2024 • GCMS Journal • 27

COVID-19 Pandemic Effects on Routine Vaccination CDC is launching a new initiative Let’s RISE - Routine Immunizations on-Schedule for Everyone

Routine vaccine orders and administration are rebounding but unevenly. The rebound may be insufficient to catch up everyone that missed a vaccine dose in 2020 and 2021.

The COVID-19 pandemic caused disruptions in routine health services including vaccinations for adults and children.

While we continue to investigate, CDC is prioritizing getting everyone caught-up on routine immunizations that were missed or delayed and continuing to strengthen adult vaccination rates above pre-pandemic levels.

The full impact of the COVID-19 pandemic on routine vaccination coverage will take time to determine.

LEARN MORE:

Routine Immunizations on Schedule for Everyone | 2022 Data Review www.cdc.gov/vaccines/partners/routine-immunizations-lets-rise.html

Vaccine Hesitancy In general, there has been a growing trend of misinformation and disinformation being spread about the safety and efficacy of vaccines. This has resulted in changed perceptions about the need to get vaccinated among patients and parents, as well as some being unwilling to follow quarantine requirements to prevent the spread of communicable diseases. Unfortunately, if this trend continues, we will continue to face increased threats of outbreaks, and may lose progress in the global efforts to eliminate vaccinepreventable diseases and their consequences.

The CDC’s Routine Immunizations on Schedule for Everyone (Let’s RISE) initiative provides community leaders, health care professionals, and partners with strategies, examples, and data to support efforts to catch up on routine childhood vaccinations.

All providers can play a role in addressing vaccine hesitancy by being trusted messengers, and making sure their patients are up-to-date on all recommended vaccines. The CDC has several resources to help with vaccine conversations with patients:

28 • MAY/JUNE 2024 • GCMS Journal

https://www.cdc.gov/vaccines/hcp/conversations/index. html https://www.cdc.gov/vaccines/schedules/hcp/resources. html

References CDC “Measles Cases and Outbreaks.” www.cdc.gov/measles/casesoutbreaks.html Mathis AD, Raines K, Masters NB, et al. Measles — United States, January 1, 2020–March 28, 2024. MMWR Morb Mortal Wkly Rep 2024;73:295–300.

Minta AA, Ferrari M, Antoni S, et al. Progress Toward Measles Elimination — Worldwide, 2000–2022. MMWR Morb Mortal Wkly Rep 2023;72:1262– 1268.

CDC Health Alert 0504 – 3/18/2024: Increase in Global and Domestic Measles Cases and Outbreaks: Ensure Children in the United States and Those Traveling Internationally 6 Months and Older are Current on MMR Vaccination Center for American Progress (2023). Rosenthal J. Reversing the Decline in Routine Childhood Immunization Rates is Good Health, Equity, and Economic Policy

professional directory

To Advertise in this directory call Jean Harmison at the Society office: 417-887-1017.

Please Note: Changes to ads will be made quarterly and must be submitted in writing.

H Denotes GCMS Membership “A” Denotes GCMS Applicant GCMS Member Ad Rates: $10.00 per 2” sq. • Non-Member Ad Rates: $13.75 per 2”sq.

Direct Primary Care ASCENT DIRECT PRIMARY CARE, LLC MATTHEW GREEN, DO H

Mission Statement

Bringing physicians together to improve the health of our community.

Dermatology, Procedural

Family Medicine www.ascentdpc.com 417-595-0956 413 N McCroskey, Ste 2 Nixa, MO 65714

Internal Medicine

Family Medicine

MERCY CLINIC– INTERNAL MEDICINE WHITESIDE

COXHEALTH FAMILY MEDICINE RESIDENCY FAMILY MEDICAL CARE CENTER

RAJ ANAND, MD JAMES T. ROGERS, JR. MD, FACP H Board Certified in Internal Medicine

MARIA DELA ROSA, MD

3800 S National Ste 700 Springfield, MO 65807 (417) 269-8817

NELSON DELA ROSA, MD

American Board of Family Medicine

Eye Surgery/Ophthalmology EYE SURGEONS OF SPRINGFIELD, INC.

C. BYRON FAULKNER, MD H

Comprehensive Cataract Ophthalmology

JUDD L. McNAUGHTON, MD H

Comprehensive Cataract Ophthalmology Diplomates, American Board of Ophthalmology 1330 E. Kingsley St. • Springfield, MO 65804

Marc Carrigan, MD Cameron Crymes, MD Kristin Crymes, DO Kristen Glover, MD Kyle Griffin, MD Shelby Hahn, MD Laura Isaacson, DO Evan Johnson, MD Katie Davenport-Kabonic, DO Michael Kabonic, DO Jessica Standeford, MD

3850 S. National Ave, Suite 705 Springfield, MO 65807 (Located inside Hulston Cancer Building-7th floor) 1240 E. Independence Springfield, MO 65804 Phone: 417-888-0858 • Fax: 417-889-0476 www.swanndermatology.com Hollister Location 590 Birch Rd, Ste 2c Hollister, MO 65672 PH. 417-690-3858 Fax 417-690-3862 Monett Satellite Location (Inside CoxHealth Urgent Care) 2200 E. Cleveland Ave Monett, MO 65708 Phone: 417-888-0858 • Fax: 417-889-0476

Eye Surgery/Ophthalmology MATTAX • NEU • PRATER EYE CENTER

JAMES B. MATTAX, JR., MD, FACS …

American Board of Ophthalmology

LEO T. NEU III, MD, FACS H

ALEJANDRA ROA, MD KELLY TRYGG, MD GABBY BONNER, NP STEVEN BOWLIN, MD

Board Certified in Internal Medicine

STEPHANIE HOVE, NP CARRIE KUGLER, PA COURTNEY WEATHERFORD, PA JENNIFER WHITE, PA

Phone 417-887-1965 • Fax 417-887-6499 417eyecare.com

MICHAEL H. SWANN, MD H BRETT NEILL, MD MICHAEL KREMER, MD JOHN CANGELOSI, MD AUTUMN BERTHOLDI, PA-C PATSY DUGGAN, PA-C LORI MILLER, NP-C HANNAH LEE, FNP-BC

AMANDA MCALISTER, MD

VICTOR GOMEZ, MD

Board Certified in Internal Medicinee

Gynecology

2115 S. Fremont, Suite 2300 Springfield, MO 65804

WOMAN’S CLINIC www.womansclinic.net

Phone 417-820-5600 Fax 417-820-5606

Leaders in Minimally Invasive Gynecology & Infertility

Urology

DONALD P. KRATZ, MD, FACOG H

MERCY CLINIC UROLOGY (FREMONT)

American Board of Ophthalmology

American Board of Obstetrics and Gynecology

DAVID NASRAZADANI, MD

AMY LINN, FNP-BC American Academy of Family Nurse Practitioners

ERIC P. GUILLIAMS, MD, FACS H

THOMAS PRATER, MD, FACS H

VANESSA MCCONNELL, APRN, DNP, FNP-C

ROBERT D. JOHNSON, MD, FACS H

JACOB K. THOMAS, FACS, MD H

1135 E. Lakewood, Suite 112 Springfield, MO 65810

TYRUN K RICHARDSON, MD

DREW A. YOUNG, MD American Board of Ophthalmology American Board of Ophthalmology

BENJAMIN P. HADEN, MD H American Board of Ophthalmology

MICHAEL S. ENGLEMAN, OD MARLA C. SMITH, OD MATTHEW T. SMITH, OD 1265 E. Primrose Springfield, MO 65804 417-886-3937 • 800-995-3180

Located inside Tri-Lakes Family Care 1065 Hwy 248 Branson, MO 65616 Phone 417-887-5500 Fax 883-8964 or toll free 877-966-2607 Monday-Thursday 8am-4:30pm Friday 8am-12pm

American Board of Urology

American Board of Urology American Board of Urology

MARK J. WALTERSKIRCHEN, MD, FACS American Board of Urology

Phone 417-820-0300 Fax 417-882-9645 1965 S Fremont, Ste. 370 Springfield, MO 65804

MAY/JUNE 2024 • GCMS Journal • 29

Internal Medicine ADULT MEDICINE & ENDOCRINOLOGY JONBEN D. SVOBODA, MD, FACE, ECNU American Board of Endocrinology JAMES T. BONUCCHI, DO, ECNU, FACE American Board of Endocrinology NICOLA W. GATHAIYA, MD, ECNU, FACE, CCD American Board of Internal Medicine American Board of Endocrinology STEPHEN M. REEDER, MD, FACP American Board of Internal Medicine ANA MARCELLA RIVAS MEJIA, MD, CCD American Board of Internal Medicine American Board of Endocrinology JACQUELINE L. COOK, FNP-BC, CDCES, CCD KELLEY R. JENKINS, FNP-C, CDCES ALINA CUMMINS, PA-C STACY GHOLZ, FNP-C SHELLEY L. CARTER, DNP JESSICA A. CROUCH, FNP-C Phone (417) 269-4450

960 E. Walnut Lawn, Suite 201

Springfield, MO 65807

Nephrology

Neurosurgery SPRINGFIELD NEUROLOGICAL AND SPINE INSTITUTE West Tower • 3801 S National, Ste 700 Springfield, MO 65807 • 417-885-3888

Neurosurgery:

H. MARK CRABTREE, MD, FACS EDWIN J. CUNNINGHAM, MD MAYUR JAYARAO, MD

J. CHARLES MACE, MD, FACS H CHAD J. MORGAN, MD

MICHAEL L. MUMERT, MD

SALIM RAHMAN, MD, FACS ANGELA SPURGEON, DO ROBERT STRANG, MD

Interventional Neuroradiology MICHAEL J. WORKMAN, MD

Physiatry:

TED A. LENNARD, MD KELLY OWN, MD

Physician Assistants:

JOSHUA BARBIERI, PA-C MARK BROWN, PA-C ERIC CHAVEZ, PA-C

BLAKE MARTIN, PA-C

HEATHER TACKETT, PA-C

Nurse Practitioner:

EMILY CROUSE, NP-C

BILL HAMPTON, ANP-BC ROZLYN MCTEER, FNP

ALYSSA CHASTAIN, FNP

Obstetrics/Gynecology

1911 South National, Suite 301 Springfield, MO 65804 Phone 417-886-5000 • Fax 417-886-1100 www.springfieldnephrology.com

STEPHEN E. GARCIA, MD H American Board of Internal Medicine American Board of Nephrology

ETHAN T. HOERSCHGEN, MD American Board of Internal Medicine American Board of Nephrology

GISELLE D. KOHLER, MD H American Board of Internal Medicine American Board of Nephrology

DAVID L. SOMMERFIELD, MD American Board of Internal Medicine American Board of Nephrology

SUSAN A. WOODY, DO H

American Board of Internal Medicine American Board of Nephrology

30 • MAY/JUNE 2024 • GCMS Journal

SPRINGFIELD OB/GYN, LLC

CoxHealth Jared Neuroscience

BRANDON RUBLE, ACNP-AG

SPRINGFIELD NEPHROLOGY ASSOCIATES, INC.

Obstetrics/Gynecology

COXHEALTH PRIMROSE OB/GYN MARCUS D. MCCORCLE, MD, FACOG Diplomate, American Board of Obstetrics and Gynecology

THOMAS M. SHULTZ, MD, FACOG Diplomate, American Board of Obstetrics and Gynecology

GREGORY S. STAMPS, MD, FACOG Diplomate, American Board of Obstetrics and Gynecology

P. MICHAEL KIDDER, DO, FACOOG Diplomate, American Osteopathic Board of Obstetrics & Gynecology

Phone 882-6900 1000 E. Primrose • Suite 270 Springfield, MO 65807

MATTHEW H. TING, MD, FACOG H American Board of Obstetrics & Gynecology

909 E. Montclair, Suite 120 Springfield, MO 65807 Phone 417/882-4466 • Fax 417/890-5631

Oncology/Hematology ONCOLOGYHEMATOLOGY ASSOCIATES OF SPRINGFIELD, MD, P.C.

Otolaryngology MERCY CLINIC– EAR, NOSE & THROAT BENJAMIN L. HODNETT, MD, PHD H ERICH D. MERTENSMEYER, DO, FAOCOO AARON R. MORRISON, MD A. DANIEL PINHEIRO, MD, PhD, FACS H RAJEEV MASSON, MD MARK J. VAN ESS, DO, FAOCOO Diplomates, American Board of Otolaryngology

SHELBY BRITT, PA

WILLIAM F. CUNNINGHAM, MD, FACP

MELISSA COONS, FNP

JIANTAO DING, MD H

ELIZABETH (BETSY) MULLINGS, FNP

American Board of Internal Medicine American Board of Medical Oncology American Board of Internal Medicine American Board of Hematology American Board of Medical Oncology

ROBERT J. ELLIS, MD, FACP American Board of Internal Medicine American Board of Hematology American Board of Medical Oncology

BROOKE GILLETT, DO

American Board of Internal Medicine American Board of Medical Oncology

V. ROGER HOLDEN, MD, PhD American Board of Hematology American Board of Medical Oncology

DUSHYANT VERMA, MD, FACP American Board of Internal Medicine American Board of Hematology American Board of Medical Oncology

Springfield Clinic 3850 S. National, Ste. 600 Springfield, Missouri 65807 Monett Clinic 802 US Hwy 60 Monett, Missouri 65708 Phone 882-4880 Fax 882-7843 Visit our website: www.ohaclinic.com

Rheumatology 417 RHEUMATOLOGY

Independent rheumatology care and infusion services DAVID TRUE, DO, FACR H

Board Certified in Internal Medicine and Rheumatology by American Board of Internal Medicine

Phone 417-501-2644 Fax 877-540-0429

909 E. Republic Rd., Building D200 Springfield, MO 65807 www.417ra.com

TAHRA LOCK, NP

PAUL STRECKER, FNP Audiology

JASON BOX, AuD, CCC-A MAMIE JAYCOX, AuD, CCC-A JENNIFER PLOCH, AUD ALLISON WHITE, AUD, CCC-A Phone 417-820-5750 Fax 417-820-5066 1229 E. Seminole, Ste. 520 Springfield, MO 65804

Plastic Surgery

MERCY CLINIC– FACIAL PLASTIC SURGERY MATTHEW A. KIENSTRA, MD, FACS American Board of Facial Plastic & Reconstructive Surgery

American Board of Otolaryngology

Phone 417-887-3223

1965 S. Fremont, Ste. 120 Springfield, MO 65804 facialplasticsurgeon.com

Psychiatry JAMES E. BRIGHT, MD H

Diplomate, American Board of Psychiatry & Neurology.

Practice Limited to: Adult Psychiatry Phone 882-9002 1736 E. Sunshine, Ste. 400 Springfield, MO 65804

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MAY/JUNE 2024 • GCMS Journal • 31

GREENE COUNTY MEDICAL SOCIETY 4730 S NATIONAL AVE, SUITE A1 SPRINGFIELD, MO 65810 Change Service Requested

32 • MAY/JUNE 2024 • GCMS Journal

PRSTD STD U.S. POSTAGE PAID PERMIT NO. 816 SPRINGFIELD, MO.