Nov/Dec 2023 GCMS Journal

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

Co-Editors:

Jim Blaine, MD

Minh-Thu Le, MD

Junior Co-Editor: Andrew K. Le

Graphic Designer:

Dalton Boyer

Editorial Committee:

Michael S. Clarke, MD

Frank Cornella, DDS, MD

C.J. Davis, PsyD

Jean Harmison

Barbara Hover

Thomas Kuich, MD

Vu Le, MD

Victor Pace, MD

Nancy Yoon, MD

Jana Wolfe

SOCIETY OFFICERS

Sanjay Havaldar, MD

President

James Rogers, MD

President-elect

Vu Le, MD

Secretary

Jim Blaine, MD

Treasurer

Minh-Thu Le, MD

Immediate Past President

Council Members:

Matthew Green, DO

Hee Sun Kim, MD

Jennifer Lynch, MD

Kayce Morton, DO

David True, DO

Nancy Yoon, MD

Managing Director:

EDITOR'S PAGE

by Jim Blaine, MD

The cover of this issue is a painting by Jamie Jo. Jamie lives in England and works for Pokemon in Japan. Pokemon sent her to the Van Gogh museum in Amsterdam to do a live painting in front of the Van Gogh family and guests. You can view her presentation and other videos by typing: Bananajamana You Tube into your search engine.

The GCMS Journal currently has a distribution of 1500 issues in an attempt to reach all local physicians.This effort is made possible primarily through the generosity of Mercy and Cox Health Care Systems: Working Together for a Healthier Community!

This issue has many interesting articles including:

• Dr. Sanjay Havaldar’s President’s Page recapping GCMS activity over the past few months.

• Former AMA President Dr. David Barbe’s excellent article on intentional disinformation, non-intentional misinformation, their dangers to public health, and what we can do to protect our patients and the public.

• Dr. Betty Drees explores a Double Jeopardy for Health for our patients who choose to smoke and choose an unhealthy diet without adequate exercise.

• The Safe & Sober foundation celebrated their twentieth anniversary recently, and GCMS was there to cheer them on.

• Springfield/Greene County Health Medical Director Dr. Nancy Yoon updates us on prevention efforts for COVID, flu, and RSV viruses and their vaccines.

• Former School Board President Dr. Tom Prater announces a new community focused PAC.

• As physicians we attempt to prevent illness when possible, and Dr. Victor Pace’s article (Pace’s Post) reminds us that the U.S. Preventive Sevices Task Force (USPSTF) helps us prioritize those efforts.

• Brightli Medical Group President Shawn Sando writes about the challenges to address the increasing numbers of mentally ill and addicted patients in our community.

• Dr. Shannon Woods and his lovely wife Dr. Kristen Woods share their adventure together in “Spice of Life.”

• Please check out the GCMS Alliance’s update in this issue.

Finally, GCMS plans to return to Breckenridge July 21-27 to reprise last year’s Rocky Mountain Medicine Conference. Please join us for week of Category 1 CME, recreation, and collegiality. This is a family friendly event!

Sam Blaine, Greene County Prosecutor Dan Patterson, Charlie O'Reilly, Safe & Sober Founder Kurt Larson, and Dr. Jim Blaine

PRESIDENT'S PAGE

by Sanjay Havaldar, MD

The leadership of Greene County Medical Society appreciates your support over the past year.

We would like to take this opportunity to review the progress of the Society which has been helped by your investment.

Structure

Complete reorganization. Now, post-COVID, we have created a lean operational structure to focus on program, finance, membership, and communication. This includes hiring significant expansion capabilities with Club Management Services providing staffing and operational expertise.

Services

1. Greene County Medical Society Journal

We have been able to increase our readership by seven times, providing the journal to more physicians in Greene County. Our message is now reaching 95% of local area physicians and health leaders with every issue. This has increased the visibility of the Society, our message, and activities. The Journal is now reaching non-physicians and leaders, thus elevating our exposure and emphasizing the importance of health care (physicians and institutions) in our community.

2. CME activities

During this year, we have had five CME events-available to both members and non-members. One of these included a week-long conference in Colorado which was an excellent opportunity for physicians and their families to enjoy a working vacation. This went so well that plans are to continue it for next year as well.

3. Social Activities

Physician networking and burnout prevention. Every year, the Society and GCMS Alliance hosts a family night at the Discovery Center and Family Night at the Zoo for all physicians and their families. Museum night occurs in the middle of February; this is a rare opportunity for the families to interact and have a private evening with refreshments and guides present.

Zoo night in the late summer at the Dickerson Park Zoo. This is very well attended with over 450 registered last year. This year, we had new physician families who came to the Zoo the same day they had moved into town! They were excited to meet other physician families and this was a great opportunity for them to

start networking.

We have hosted and/or co-sponsored five “Happy Hours” that are short drop-ins for physicians and significant others to unwind and connect and meet others.

We have strengthened our connection with the Alliance (the organization of physician spouses for the purpose of education and physician wellness) enabling strong support by connecting mentors with new-bees.

The Physician Engagement committee has begun to explore and provide meaningful options to entice young physicians to engage in community activities.

Public Health

1. COVID

At the beginning of the COVID pandemic, GCMS partnered with the two major medical systems and other health institutions to provide guidance to the community for a coordinated response early on when little was known, a consistent message on masking and then educating on the benefit of masking and countering misinformation. As the emergency aspect of the epidemic has wound down, GCMS has helped to prepare for the transition.

2. Marijuana

As the state of Missouri has legalized first medical and then recreational marijuana, the Society has worked with other health organizations to educate the public. Knowing that the legalization of recreational marijuana will have negative and costly impacts on the legal, mental health and medical systems in the community, GCMS raised awareness of this issue and helped to pass the recent city tax on marijuana sales. We remain in contact with health and community leaders advocating for designated tax dollars for education and prevention.

GCMS Foundation

We are also excited to announce the creation of the GCMS Foundation. This will be a powerful platform for community health improvements. This allows our 501-c3 structure that oversees two separate CME funds to now apply for grants, receive donations, and collaborate with other organizations to drive health improvement efforts.

HEALTHCARE DISINFORMATION, MISINFORMATION OR DIFFERENCE OF OPINION-A CHALLENGE FOR PHYSICIANS AND THE PUBLIC

by David Barbe, MD, MHA, Regional Physician Executive Mercy Primary Care, SW MO Region

Although medical misinformation and disinformation are not new, the recent COVID-19 pandemic resulted in a dramatic increase and raised the discussion of the definition, the impact of this information, its dissemination, and how to address these difficult issues to an unprecedented level. The implications of disinformation and misinformation on both public health and the integrity of the medical profession are significant. Medical disinformation or misinformation can have serious consequences as it may lead people to make health decisions based on false or unsupported information, potentially resulting in harm to their health. This led the American Medical Association (AMA) Board of Trustees (BOT) to issue BOT report 15 at the 2022 annual meeting of the AMA House of Delegates titled: Addressing Public Health Disinformation.1

Before we go any further, let's establish a few definitions. We often think of disinformation and misinformation as interchangeable. However, there is one very important difference. Intent. There is a consensus that the term “disinformation” is used to describe false or misleading information that the author knows to be wrong and is disseminated to confuse, deceive, or manipulate those who receive the information. Whereas “misinformation” is spread unintentionally or unwittingly. The information is still incorrect or inaccurate, but the author did not intend to spread false information.

Disinformation and misinformation have been with us for literally hundreds of years. According to the AMA A-22 BOT Report 15, disinformation leading to vaccine hesitancy dates to the 1700s. ¹ Many of us remember the disinformation campaign around the DTaP vaccine in the 1970s and in the late 1990s fabricated data related to MMR vaccine. Unfortunately, even in the face of overwhelming data regarding the safety of those vaccines, we continue to see vaccine hesitancy gradually increasing. Disinformation and misinformation are not limited to vaccines. We have seen similar problems related to pain medications in the 1990s and statin therapy over the last two decades.

Both disinformation and misinformation have become an even greater problem in the past several years for several reasons, but there is no question that social media platforms

have dramatically increased the spread. An author can put out intentional disinformation (or perhaps unintentional misinformation) which is then shared and re-shared by followers, often unintentionally, thereby greatly increasing the spread of misinformation.

Further complicating this situation is that conflicting or varying research findings and differences of opinion or expert consensus. This has been a long-standing challenge for medicine. While the scientific method depends on healthy debate and discussion, it also depends on scientific and intellectual integrity in those discussions. Some instances of disinformation and misinformation stem from exaggeration of the potential risks of a given medication or treatment.

One additional factor that seems to have contributed to the increase in disinformation and misinformation and differences of opinion in the past couple of years is the current hyperpolarized political climate. What is or is not misinformation seems too often to be in the of the eye of the beholder. If one holds a particular political view or perspective, it seems to disproportionately influence one’s inclination to believe or disbelieve a particular piece of information. This has further magnified the already challenging problem of disinformation / misinformation.

Disinformation and misinformation can take many forms. Some examples are:

1. False claims about the effectiveness of alternative or unproven treatments: this can include promoting remedies or therapies that lack scientific evidence or clinical trials to support their efficacy.

2. Misrepresentation of scientific studies: Sometimes, studies are misrepresented or misinterpreted to make them seem more conclusive or supportive of a particular viewpoint than they are.

3. Conspiracy theories: Some disinformation or misinformation spreads by attributing medical issues or treatments to hidden agendas, such as claims that vaccines are part of a sinister plot or that certain treatments are intentionally discredited.

4. Discrediting legitimate sources: Some individuals or groups may try to undermine the credibility of reputable health organizations, experts, or government agencies, which can

erode public trust in accurate health information.

5. Cherry picking data: Presenting selective or outdated data to support a particular narrative while ignoring the broader scientific consensus is a common tactic used to spread disinformation or misinformation.

6. Personal anecdotes: While personal experiences can be powerful, they may not be representative of the general population, and relying solely on anecdotes can lead to incorrect conclusions about medical treatments or outcomes.

While some discussions in the field of medicine and health care may involve differing opinions, it's important to distinguish between legitimate differences of opinion based on scientific evidence and unsupported medical misinformation. As noted above, the advancement of medical knowledge depends on healthy debate and discussion of evolving research. However, differences of opinion are rooted in ongoing research, evolving medical guidelines, expert consensus, and peer reviewed literature. Health care professionals may have varying opinions based on the available evidence, but those opinions are within the bounds of established medical science and guidelines.

On the other hand, medical misinformation typically involves claims or assertions that are not supported by sound scientific evidence or are contrary to established medical knowledge. Medical disinformation and misinformation are not based on valid differences of opinion but rather on inaccurate, incomplete, or false information.

An exhaustive discussion of the potential harm that can come from medical disinformation and misinformation is beyond the scope of this short article. For that, I will refer you to the AMA BOT Report 15. However, there is one additional consideration that bears special mention: The impact on the profession. AMA A-22 BOT Report 15 states “when health professionals engage in actively spreading disinformation, there may be an overall corrosion of trust in health professionals.” It also indicates that health professionals spreading falsified research “corroded trust in health professionals which gave way to targeted harassment campaigns of those following the science.” 1

In a press release following adoption of the recommendations in AMA A-22 BOT Report 15, AMA president Gerald Harmon, MD stated the following: “Physicians are a trusted source of information for patients and the public alike, but the spread of disinformation by a few has implications for the entire profession and causes harm. Physicians have an ethical and

professional responsibility to share truthful information, correct misleading and inaccurate information, and direct people to reliable sources of health information.” 2

AMA A-22 BOT Report 15 calls for the AMA to work with health professional societies and other relevant organizations to implement a comprehensive strategy to address medical disinformation that includes the following priorities:

• Maintain AMA as a trusted source of evidence-based information for physicians and patients,

• Ensure evidence-based medical and public health information is accessible by engaging with publishers, research institutions and media organizations to develop best practices around paywalls and preprints to improve access to evidencebased information and analysis,

• Address disinformation disseminated by health professionals via social media platforms and address the monetization of spreading disinformation on social media platforms,

• Educate health professionals and the public on how to recognize disinformation as well as how it spreads,

• Consider the role of health professional societies in serving as appropriate fact-checking entities for health-related information disseminated by various media platforms,

• Encourage continuing education to be available for health professionals who serve as fact-checker to help prevent the dissemination of health-related disinformation,

• Ensure licensing boards have the authority to take disciplinary action against health professionals for spreading health-related disinformation and affirms that all speech in which a health professional is utilizing their credentials is professional conduct and can be scrutinized by their licensing entity,

• Ensure specialty boards have the authority to act against board certification for health professionals spreading healthrelated disinformation, and

• Encourage state and local medical societies to engage in dispelling disinformation in their jurisdictions. 2, 3

In summary, combating medical disinformation/ misinformation is essential to protect public health and ensure that individuals can make informed decisions about their health care choices. It is also critical to help protect the integrity of the profession. This will require an ongoing effort involving collaboration among healthcare professionals, our professional organizations, policymakers, educators, and even social media platforms. By promoting evidence-based information and fostering a culture of critical thinking, we can better protect our

colleagues and our patients from the harmful effects of medical disinformation and misinformation.

References:

1. https://www.ama-assn.org/system/files/a22-bot-reports.pdf

2. https://www.ama-assn.org/press-center/press-releases/ama-adopts-new-

GCMS FALL SOCIAL EVENT

NOVEMBER 3RD @

CMS

policy-aimed-addressing-public-health-disinformation

3. Addressing Public Health Disinformation Disseminated by Health Professionals AMA Policy D-440.914, https://policysearch.ama-assn.org/ policyfinder/detail

GCMS FALL CME EVENT

OCTOBER 11TH @

Minh-Thu Le, MD, Jacob Thomas, MD, Annette Wardel, MD, and Scott Kensel, MD

The elegant and festive "Champagne Wall"

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LOCAL RESPONSES TO MITIGATE A GROWING MENTAL HEALTH AND ADDICTION CRISIS IN OUR COMMUNITY

by Shawn Sando, MSW, MBA

The behavioral healthcare crisis across our nation is staggering and the demand for mental health and addiction services has never been higher. Nationally, 57% of people seeking behavioral healthcare are unable to connect with a provider. Of those who do, 40% had to try over 4 providers before getting an appointment –and the average wait time to receive services is around six weeks. Missouri currently meets less than 25% of the state’s mental health needs, with 57 rural counties having no psychologist or psychiatrist, creating large areas of “mental health deserts” in our state. The disparity of behavioral health resources, coupled with stigma and other socio-economic factors result in the exacerbation of the mental health and addition crisis facing Missourians. People in areas like Springfield, with a concentration of behavioral health resources, also experience excessive wait lists and workforce challenges. I am sure readers are aware of patient complaints about wait times to get into services at Burrell. While the crisis is on a national scale, the impacts to people are always local.

According to recent assessment data in our community, the behavioral health crisis in the Greater Springfield Area is trending worse than the rest of the state and the nation. For example, suicide rates in our community continue to trend above state and national averages. To help mitigate this critical problem, Burrell responds to an average of 1,430 crisis calls per month – a 45% increase since the launch of the 988 national crisis hotline. Also, our behavioral crisis center (BCC) provides adults 24/7 same day access to mental health and addiction services – serving some 300 people per month with 78% receiving a same day psychiatry or addiction medicine encounter as part of their overall care. Burrell has also increased access to outpatient mental health and psychiatry services by an average of 35% each year and expanded new interventions, like transcranial magnetic stimulation (TMS), to address the growing

trend of those reporting poor mental health and depression in our community. While the demand for services is clearly outpacing our communities’ resources, Brightli is making a significant difference for people living in the Greater Springfield Area.

Alcohol and substance use are also trending above state and national levels. Tragically, mortality associated with alcohol is on the rise, increasing 38% per 100,000; while overdose mortality continues to rise sharply, increasing 50% per 100,000. In response to the addiction crisis in our community, Brightli increased access to medication-assisted treatment services for person with addiction disorders by 150% over the past year. According to NIH, those receiving substance use treatment via telehealth were approximately 38 times more likely to receive medications for opioid use disorder compared to those who did not receive treatment via telehealth. As a result, Brightli expanded access to medication-assisted treatment (MAT) via telehealth by 150%, including services for alcohol and opioid abuse, over the past year. To further mitigate opioid deaths in our community, Brightli launched same day, walk-in access to screening and induction for opioid use, and other addiction disorders, at Burrell’s behavioral crisis center (BCC) seven days a week.

In addition to our recent expansion of care efforts, we have several new initiatives that will launch over the coming year to create additional access to care in our community: groundbreaking of youth behavioral crisis center (YBCC), addition of esketamine clinic, expansion of TMS, groundbreaking of Marshfield Clinic site, new physicians to expand access to psychiatry and addiction medicine, and continued growth of our school-based services. While no one organization can possibly meet all the needs in our community, Brightli is committed to ongoing efforts to expand access to lifesaving care with innovative services, workforce development and collaboration with community stakeholders to provide access to care when and where people need it.

While this overview has focused on adults, I would direct readers to the May-June 2023 GCMS Journal and Dr. C.J. Davis’s article on Burrell’s recent responses to the growing crisis facing the youth of our community as well. As C.J. stated, we want our medical community to know that we are here to serve your patients. Our programs are accessible and yielding positive health outcomes for thousands of people each year.

If you have patients in need of mental health and/or addiction medicine services, we have several pathways to access care:

Persons experiencing a mental health or addiction crisis:

• Dial 988: Burrell is part of the national 988 crisis hotline. People of all ages experiencing a crisis can simply dial 988 for immediate assistance

• Crisis Walk-in Center (adults only): Burrell’s behavioral crisis center (BCC) is open 24/7 with walk-in access for adults experiencing a mental health or addiction crisis or who need induction for opioid use disorders. Burrell’s BCC is located at: 800 South Park, Springfield, MO 65802 or you can call (417) 893-7722.

Persons in need of mental health and/or addiction services (not in crisis):

• Connection Center (same day access): People of all ages may walk-in or schedule an appointment. Burrell’s Connection Center is located at: 1300 E. Bradford Parkway, Building A, 2nd Floor, Springfield, MO 65804 or you can call (417)761-5000. Hours are

Monday – Thursday 7:30 am to 8:00 pm and Friday 7:30 am to 5:00 pm.

For more information about these or other behavioral health services available to the Greater Springfield Area please visit our web site at www.burrellcenter.com or you can send me an e-mail at shawn.sando@burrellcenter.com

References

• Health Resources & Services Administration (HRSA), data.HRSA. gov, May 2023

• Community Mental Health and Substance Abuse Assessment, April 2019

• National Institute of Health (NIH) Research Matters, September 2022

• Exploring Barriers to Mental Health Care in the U.S., AAMC, October 2022

• National Council for Mental Wellbeing

Shawn Sando is President of the Brightli Medical Group, the medical division of Brightli, the parent company of Burrell Behavioral Health, Preferred Family Healthcare and Southeast Missouri Behavioral Health.

PACE'S POST: UNITED STATES PREVENTIVE SERVICES TASK FORCE RECOMMENDATIONS

by Victor Pace, MD

The United States Preventive Services Task Force (USPSTF) is a committee that uses gold-standard methods to systematically review the evidence on preventive services. Evidence-based recommendations are made on screenings, behavioral counseling, and preventive medications.

It would be good to review these recommendations as these are good guidelines to share with our patients and follow for our health. Some of the USPSTF recommendations may not align with specific specialty organizations. However, this is good, solid, evidence-based advice.

The USPSTF grades its recommendations based on the strength of evidence and magnitude of net benefit (benefits minus harms). Recommendations listed below are graded A, B, C, D, and I.

A. The USPSTF recommends the service. There is high certainty that the net benefit is substantial.

B. The USPSTF recommends the service. There is high certainty that the net benefit is moderate, or there is moderate certainty that the net benefit is moderate to substantial.

C. The USPSTF recommends selectively offering or providing this service to individual patients based on professional judgment and patient preferences. There is at least moderate certainty that the net benefit is small.

D. The USPSTF recommends against the service. There is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits.

I. The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of the service. Evidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined.

A Recommendations

1. Cervical Cancer Screening - cervical cytology alone every 3 years recommended for women aged 21 to 29 years. Cervical cytology alone every 3 years, high-risk human papillomavirus (hrHPV) every 5 years, or co-testing cervical cytology and hrHPV every 5 years, recommended for women aged 30 to 65 years.

2. Colorectal Cancer - recommended screening in all adults aged 50 to 75 years. Screening interval based on screening method.

3. Folic Acid Supplementation To Prevent Neural Tube Defects - recommended for all persons planning to or who could become pregnant to take a daily supplement containing 0.4mg to 0.8mg of folic acid.

4. Hepatitis B Infection Screening - recommended for pregnant women at their first prenatal visit.

5. Human Immunodeficiency Virus (HIV) Screeningrecommended for adolescents and adults aged 15 to 65 years and all pregnant persons. Younger and older individuals who are at increased risk should also be screened.

6 Hypertension In Adults - office blood pressure measurement recommended for adults 18 years or older.

7. Ocular Prophylaxis For Gonococcal Ophthalmia Neonatorum - prophylactic ocular topical medication recommended for all newborns.

8 Prevention Of Acquisition Of HIV - recommends clinicians prescribe preexposure prophylaxis using effective antiretroviral therapy to persons who are at increased risk of HIV acquisition to decrease the risk of acquiring HIV.

9. Rh(D) Incompatibility - strongly recommends Rh(D) blood typing and antibody testing for all pregnant women during their first pregnancy-related care visit.

10. Syphilis Infection In Nonpregnant Adolescents & Adultsrecommends screening in persons who are at increased risk of infection.

11. Syphilis Infection In Pregnant Women - recommends screening in all pregnant women.

12. Tobacco Cessation In Adults - recommends clinicians ask all adults about tobacco use, advise them to stop using tobacco, and provide behavioral interventions and US Food & Drug Administration (FDA) - approved pharmacotherapy for cessation to nonpregnant adults who use tobacco.

13. Tobacco Cessation In Pregnant Persons - recommends clinicians ask all pregnant persons about tobacco use, advise them to stop using tobacco, and provide behavioral interventions for cessation to pregnant persons who use tobacco.

B Recommendations

14. Abdominal Aortic Aneurysm - recommends one-time screening with ultrasonography for men aged 65 to 75 years who have ever smoked 100 or more cigarettes.

15 Anxiety Disorder - screening advised for anxiety disorders in adults 64 years or younger, including pregnant and postpartum persons.

16. Anxiety In Children & Adolescents - screening advised for anxiety in children and adolescents aged 8 to 18 years.

17. Aspirin Use To Prevent Preeclampsia - use of 81mg/ day aspirin advised as preventive measure after 12 weeks of gestation in persons who are at high risk for preeclampsia.

18 Asymptomatic Bacteriuria In Adults - screening for asymptomatic bacteriuria recommended using urine culture in pregnant persons at first prenatal visit or at 12 to 16 weeks of gestation, whichever is earlier.

19. BRCA-Related Cancer - primary care clinicians, using an appropriate brief familial risk assessment tool, should assess women 18 years and older with a personal or family history of breast, ovarian, tubal, or peritoneal cancer or who have ancestry with BRCA 1/2 gene mutations. Positive risk findings should receive genetic counseling and if indicated after counseling, genetic testing.

20. Breast Cancer Risk Reduction- clinicians should offer to prescribe risk-reducing medications to women at increased risk of breast cancer aged 35 and over and who are at low risk for adverse medication effects.

21. Breast Cancer Screening - biennial screening mammography recommended for women aged 50 to 74 years.

22. Breastfeeding - interventions to support breastfeeding recommended during pregnancy and after birth.

23. Chlamydia & Gonorrhea Screening - recommended for all sexually active women aged 24 years or younger and

in women 25 years or older who are at increased risk for infection.

24. Colorectal Cancer - recommended screening in adults aged 45 to 49 years. Screening interval based on screening method.

25. Depression & Suicide Risk In Adults - screening recommended for depression in the adult population, including pregnant and postpartum persons, as well as older adults.

26. Depression & Suicide Risk In Children & Adolescentsscreening recommended for major depression in adolescents aged 12 to 18 years.

27. Falls Prevention In Community-Dwelling Older Adults - exercise interventions recommended to prevent falls in community-dwelling adults 65 years or older who are at increased risk for falls.

28. Gestational Diabetes - screening recommended in asymptomatic pregnant persons at 24 weeks of gestation or after to improve maternal and fetal outcomes.

29 Healthy Diet & Physical Activity For Cardiovascular Disease (CVD) Prevention In Adults With Cardiovascular Risk Factors - offering or referring adults for behavioral counseling interventions recommended to promote a healthy diet and physical activity. Risk factors include hypertension/elevated blood pressure, dyslipidemia, mixed or multiple risk factors such as metabolic syndrome or 10-year CVD risk of >/= 7.5%.

30 Healthy Weight & Weight Gain In Pregnancy - offering pregnant persons effective behavioral counseling interventions aimed at promoting healthy weight gain and preventing excess gestational weight gain in pregnancy.

31 Hepatitis B Infection Screening - recommended in adolescents and adults at increased risk for infection.

32. Hepatitis C Infection Screening - recommended in adults aged 18 to 79 years; one-time screening for most adults.

33. Hypertension Disorders Of Pregnancy - blood pressure measurements recommended throughout pregnancy during each prenatal visit.

34. Intimate Partner Violence (IPV) - recommended screening

in women of reproductive age and provide or refer women who screen positive to ongoing support services.

35. Latent Tuberculosis Infection In Adults - screening recommended in populations at increased risk.

36. Lung Cancer Screening - annual screening recommended with low dose computed tomography (LDCT) in adults aged 50 to 80 years who have a 20 pack-year smoking history and currently smoke or have quit within the past 15 years. Discontinue screening once a person has not smoked for 15 years or develops a health problem that substantially limits life expectancy or the ability or willingness to have curative lung surgery.

37 Obesity In Children & Adolescents - screening recommended in children and adolescents 6 years and older and offer or refer them to comprehensive, intensive behavioral interventions to promote improvements in weight status.

38. Osteoporosis To Prevent Fractures - screening recommended in postmenopausal women younger than 65 years who are at increased risk of osteoporosis, as determined by a formal clinical risk assessment tool and in women 65 and older.

39. Perinatal Depression - recommend clinicians provide or refer pregnant and postpartum persons who are at increased risk of perinatal depression to counseling interventions.

40. Prediabetes & Type 2 Diabetes - recommends screening for prediabetes and type 2 diabetes in adults aged 35 to 70 years who are overweight or obese.

41. Prevention Of Dental Caries In Children Younger Than 5 Years - recommends clinicians prescribe oral fluoride supplementation starting at age 6 months for children whose water supply is deficient in fluoride. Recommends clinicians apply fluoride varnish to the primary teeth of all infants and children starting at the age of primary tooth eruption.

42 Rh(D) Incompatibility - recommends repeated Rh(D) antibody testing for all unsensitized Rh(D)-negative women at 24 to 28 weeks’ gestation, unless the biological father is known to be Rh(D)-negative.

43. Sexually Transmitted Infections (STIs) - recommends behavioral counseling for all sexually active adolescents and adults who are at increased risk for STIs.

44. Skin Cancer Prevention - recommends counseling young adults, adolescents, children, and parents of young children about minimizing exposure to ultraviolet radiation for persons aged 6 months to 24 years with fair skin types to reduce their risk of skin cancer.

45. Statin Use For The Primary Prevention Of Cardiovascular Disease (CVD) In Adults - recommends clinicians prescribe a statin agent for primary prevention of CVD for adults aged 40 to 75 years who have 1 or more CVD risk factors and an estimated 10-year risk of a cardiovascular event of 10% or greater.

46. Tobacco Use In Children & Adolescents - recommends clinicians provide interventions, including education or brief counseling, to prevent initiation of tobacco use among schoolaged children and adolescents.

47. Unhealthy Alcohol Use In Adolescents & Adults - recommends screening for unhealthy alcohol use in primary care settings in adults 18 years and older, including pregnant women, and providing persons engaged in risky or hazardous drinking with brief behavioral counseling interventions to reduce unhealthy alcohol use.

48 Unhealthy Drug Use - recommends screening by asking questions about unhealthy drug use in adults age 18 years and older. Screening should be implemented when services for accurate diagnosis, effective treatment, and appropriate care can offered or referred.

49. Vision In Children Ages 6 Months To 5 Years - recommends vision screening at least once in all children aged 3 to 5 years to detect amblyopia or its risk factors.

50 Weight Loss To Prevent Obesity-Related Morbidity & Mortality In Adults - recommends that clinicians offer or refer adults with a body mass index (BMI) of 30 or higher to intensive, multicomponent behavioral interventions.

The above recommendations apply mainly to primary care settings. I have not included the C, D, or I recommendations due to space constraints. For more detailed information, screening intervals, and the latest, most updated USPSTF recommendations, you can go to or click on the website link below.

Reference

https://www.uspreventiveservicestaskforce.org/uspstf/

VARIETY IS THE SPICE OF LIFE DOES MEDICINE ALLOW ROOM TO DIVERSIFY YOUR INTERESTS?

by Kristen Woods, OD and Shannon Woods, MD

Medicine can be wonderfully rewarding and fulfilling but can also be exhausting and all-consuming. Medicine is a calling, it is one of the professions that becomes who you are, not just what you do for a living. Do you have an escape? A place where you can breathe, lose track of time, and be free of work responsibilities? A place you can create a new you, not just Dr. “X”? A path to stave off burnout and find some life balance is acceptable. It is even necessary to endure the long and winding road of medicine.

For us, we have created that on our ten-acre property in southwest Springfield. When we bought the property, we knew we wanted to do something with it. But, as two kids from the city, we were not sure what. Raise chickens? Grow vegetables? While on vacation we stumbled upon a book featuring small farms. We read about a flower farm and knew that was it! A beautiful use of the land and something we knew nearly nothing about. Perfect. The seed was planted for our future adventure and business, Woods In Bloom, LLC.

As doctors we are lifelong learners. You may relate to the urge to learn and master something new. With so many books and websites to explore, we are fully committed to learning everything we can about flower farming. It has been a wonderful avenue to explore, involving lots of planning and problem solving. This has been a unique way that Shannon and I

have been able to cultivate a new aspect of our relationship. Our morning coffee conversations are no longer only about work, now we’re talking about soil regenerating techniques, compost, how to keep the deer out, and new seeds to try. It allows both of us to delve deeper into areas we are independently interested in and enables us to work together in a way that our medical professions would not. Missouri is an agricultural state. Many of us that have grown up here in the Ozarks have a family history steeped in agronomy. We both have grandparents that grew up in rural farming communities. Medicine

Monarch butterfly on Mexican sunflower and Mikayla Miranda Dahlia

Dr. Woods preparing to install a new greenhouse

Mexican Sunflowers

Mixed bouquet of dahlias, zinnias, celosia, gomphrena, ageratum, and marigolds

is clearly a divergence from farming, and we appreciate learning about agriculture to connect with our community and families a bit more. It is funny how as a child and teen you run away from what your family is, only to find later in life you have run full circle.

“There is something infinitely healing in the repeated refrains of nature-the assurance that dawn comes after night, and spring after winter.”-Rachel Carson.

Spring is busy and exciting, with the return of color and all the spring plantings going in the ground. And summer; it’s hot and full of abundance, a time to reap the benefits of prior work and planning. We enjoy each and repeat the cycle, but unexpected challenges will always keep it interesting. There will always be a time for career planning, a time of abundant work duties, but hopefully also a time of quiescence and rejuvenation. There are some similarities between farming and medicine.

Here’s to hoping that you find something outside of the clinic that you’re passionate about. To experience the wonder of life beyond medicine, and spend some time caring for yourself, after devoting so much to caring for others. Life in the clinics or hospitals is full, and can fill a lifetime, but sometimes you must walk out that door. When you do, I hope you look around and see all the beauty life in the Ozarks has to offer.

If you would like to learn more about our business offerings, Woods In Bloom, LLC, find us at www.woodsinbloom.com, on Instagram @woodsinbloom, or on Facebook. March-October we are at the Farmers Market of the Ozarks at Farmers Park, 2144 E Republic Rd, Springfield, MO.

Woods In Bloom allows us to enrich our lives in a different way. We are more in touch with the seasonal cycles, as the earth rotates around the sun, and the days change from season to season. Farming is merely working with nature’s original solar panels to collect energy as it falls to earth. We are more aware of the change nature brings, not just through the window of the clinic, but with the life at our feet. As we write this, our first frost is in the forecast, the growing season is near the end. But preparation for the hope of next season is under way. During this fall season, we are cleaning up, prepping the beds for next year, and planting spring crops. Winter is quiet, a time of rest, planning, and dreaming.

Kristen Woods, her mom Julie, and daughter Olivia at Farmers Market of the Ozarks

Zinnias

GCMS LAUNCHES NEW & POWERFUL TOOL TO SERVE COMMUNITY HEALTH IN S. W. MISSOURI

by JT Rogers, MD, GCMS Foundation Board Chairman

I want to share with all of you my excitement and privilege to work with this all-star group of individuals. The potential to drive community change via this “tool” at the direction of the new board is outstanding. This offers a chance for all of us to give back to the people and community that have sustained, challenged, and honored us with the privilege to provide their care in this Ozarks’ home.

Greene County Medical Society Foundation purpose: To promote community health through education, projects, and support of related charitable organizations with involvement and/ or financial support.

Board of Trustees 2023

Dr. Patricia Dix, High Risk Maternal-Fetal Medicine: Decades of direct patient care with unfaltering dedication. She has received countless praise and gratitude from her patients and recognition by colleagues and public alike. She received honors as a Missourian of the Year, board member of Cox Health, and numerous teaching and leadership positions. To this day she continues to place the welfare of her patients first.

Dr. Vu Le, Psychiatry; Regional 23 Clinical Hub Director -Dept of Veteran Affairs: Very humble beginnings created a tremendous work ethic and desire to succeed. His talents for goalsetting and clear, concise communication to staff have created tremendous success in building a virtual network for the VA health system. His talent for creating and sustaining these work efforts has continued to expand duties and responsibilities at work and in community assignments.

Dr. Keith LaFerriere, Otolaryngologist, Facial Plastic Surgeon (retired): Strong personal involvement. He is a unique leader by example with broad skills. An accomplished surgeon, businessman, teacher, and advocate for political change he has an amazing number of talents and experiences. Serving on several boards including OTC Foundation and Drew Lewis Foundation he has been invaluable. Most remarkable his participation in Safe to Sleep (overnight sheltering and feeding for homeless women) has him personally spending nights keeping watch over their safety as they rest.

Dr. Kayce Morton, Pediatrician, Pediatric Hospitalist: To say that she has a passion for healing sick kids is an understatement. Early on she declared that health care requires far more than just practicing medicine. Her desire to heal and not just treat has led her to advocate for mental health, environmental health, and poverty interventional measures. She has incorporated these attributes personally in her teaching, leadership roles, and public advocacy.

Dr. Jake Thomas, Ophthalmology: Loved by all his patients for his personal concern and genuine interest in them. As a teacher and leader, he has been recognized by the University Missouri School of Medicine as an outstanding young physician of the year. He is busy balancing his dedication for patient care and love for his young family. This is giving him perspective on judging impact for his valuable time.

Dr. Jim Blaine, Emergency Medicine, Primary Care (retired): He has sustained an unblemished track record for advocacy and public change. His talent for bringing individuals together to help drive a particular initiative or task is phenomenal. His successes

Left to Right: Jim Blaine, MD, Jean Harmison, Kayce Morton, DO, J.T. Rogers, MD, Patricia Dix, MD, Jacob Thomas, MD, FACS, Keith LeFerriere, MD, and Vu Le, MD

are based partly on people skills and largely on his instincts to recognize issues and address them with a pure desire to help. While his motives are always clear no one should underestimate his tenacity.

Mrs. Jean Harmison, Owner Club Management Services: We are fortunate to have individuals who can thrive in chaos, channel strong-willed personalities, and remind us of the exciting potential possibilities when working together. Her operational oversight for dozens of other civic, business, and board driven organizations has given her experience, perspective, and a tremendous advantage to us as we start this journey.

“New beginnings from a rich history”

The foundation fund was first created in 1960 by the signature of GCMS President Dr. Leo Wyrsch. This created a home for donated funds dedicated to providing focused medical education and establish loans to medical students.

Why create the new board?

This 501(c)(3) status allows us to receive donations (tax deductible), apply for grants, and collaborate with other organizations to pursue our “purpose” by direction of the board.

Twenty years ago, attorney Kurt Larson was a member of the GCMS DWI Task Force, and asked for our support in forming a new organization that he named Safe & Sober. Kurt was concerned that high school students frequently were forced through peer pressure to drink alcohol on Prom night. His idea was to minimize the impact of that peer pressure by encouraging Springfield students to enter into a written contract with their parents promising not to drink alcohol on Prom night. I was proud to represent GCMS on Kurt’s first Safe & Sober Board.

Twenty years later, Safe & Sober’s mission to prevent

What can I do?

Give direction – contact us with service ideas, talk to a board member, share this story with a friend.

Donate – in honor of a colleague, loved one, an idea, or project. Make your investment for community health this year and challenge the new board members to start to work, for all of us! `

To donate online just scan the QR Code above or you can mail a donation. Please make checks payable to the GCMS Foundation and send to 4730 S. National Suite A1, Springfield, MO 65810. Please include any special instructions and an email address for receipt.

by Jim Blaine, MD

substance misuse has evolved to include students age 12-18, and the program delivers compelling prevention education content that is new and relevant each year. The current contract between teens and their parents promises abstinence from alcohol, drugs, smoking, vaping, and now marijuana until age 21. The Safe & Sober program currently includes schools and after-school organizations throughout the State of Missouri, and it has been used in schools in thirty-two other states. The program is delivered to hundreds of thousands of students each year.

The twentieth anniversary annual Safe & Sober “Rise and Shine” Breakfast fundraiser was held in Springfield on October 24, and involved presentations of the “Past, Present, and Future of Safe & Sober. Kurt asked GCMS to present the Future component. GCMS President Dr. Sanjay Havaldar, Dr. Jake Thomas, Dr. Vu Le, former Health Department Director Harold Bengsch, former Health Department Director Kevin Gipson, and Barbara Blaine were present at the GCMS table.

We are very proud of the success of the Safe & Sober program and the impact it has had.

Kurt Larson speaking about Safe & Sober

The following is the transcript of the GCMS “Future of Safe & Sober” presentation that followed a compelling video featuring former DEA agent Brian Townsend addressing the devastation of Fentanyl and its threat to our youth.

"So what is Fentanyl? Fentanyl was originally a new synthetic opioid pain reliever approved by the FDA in 1968; it is up to fifty times stronger than heroin, and a hundred times stronger than morphine.

So there are now two types of fentanyl: legal pharmaceutical fentanyl and illegally made fentanyl. Pharmaceutical fentanyl is prescribed by doctors to treat severe pain, especially during anesthesia for surgery and for advanced-stage cancer.

However, almost all cases of fentanyl-related overdose are linked to illegally made fentanyl, which is distributed through illegal drug markets for its heroin-like effect. Fentanyl is cheap and it is easy to produce.

According to the CDC, deaths involving opioids killed 2600 people in 2011; only ten years later over 70,000 opioid overdose deaths (mostly Fentanyl) were reported in the U.S. Stimulants such as cocaine and meth added another 30 thousand overdose deaths that year. These people did not

Jake Thomas, MD and Vu Le, MD

intend to kill themselves. Some were simply seeking a higher high, and many did not even know that they were taking Fentanyl because it was laced into a counterfeit Percocet, or into a Marijuana gummy bear.

According to the CDC, Fentanyl overdose is the number one cause of death in people from 18 to 45. That is an amazing statistic!

So what can be done: Well, our global, national and state governments need to act to decrease the deaths; this is a public health emergency! But, additionally, we can minimize the effect ourselves by talking to our kids, and Safe & Sober can assist with that communication!

Another increasingly concerning drug is THC. THC is the psychoactive drug in Marijuana. Missouri recently voted to legalize recreational Marijuana. Was this a good idea? The medical community doesn’t think so. The AMA, MSMA and GCMS all opposed it. The reason we opposed it is because the smoked pot of the nineties contained 4% THC, and was not much of a problem. Current smoked pot contains up to 25% THC, and concentrated versions can be up to 90%.

Three in ten of every day pot smokers now develop Marijuana Use Disorder and will have trouble stopping.

According to the Addiction Center using THC can cause IQ loss if used on a regular basis before the brain is fully developed at age 25. The degree of cognitive decline depends on the frequency and potency of the THC use, and how early the use began.

When I was an emergency physician in Cox and Mercy in the 70’s, and 80’s, I never saw a Marijuana overdose, now, according to Cox Emergency Department Director Dr Howard Jarvis, they are seeing a lot of Hyperemesis cannabis (vomiting and abdominal pain) as a result of higher potency pot. This is not your Dad’s weed! Colorado legalized recreational marijuana over ten years ago and has seen a 138% increase in highway fatalities linked to marijuana use during that time.

Continued on page. 23

Former Health Dept Director Kevin Gipson, Judge Todd Myers, and former Health Dept Director Harold Bengsch

SOUTHWEST MISSOURI HEALTHCARE COMMITTEE OCTOBER LEGISLATIVE EVENT

Dr. Bryan Finke, and GCMS President Dr. Sanjay Havaldar

State Representative Bill Owen, Burrell Behavioral Health SW Region President Clay Goddard, and Cox President Max Buetow

Cox Executive VP and General Counsel Charity Elmer, and Dr. Alex Hover

Fmr. Director of Health and current Burrell Behavioral Health SW Region President Clay Goddard, and Cox Chief of Staff, VP Government Relations Teresa Cohen

Senator Curtis Trent and Springfield Mayor Ken McClure

Dr. Kayce Morton, Lt. Governor Mike Kehoe, and Dr. Tim Swearingen

UNITED SPRINGFIELD: AN INNOVATIVE LOCAL SOLUTION TO A COMMUNITY PROBLEM

by Thomas G. Prater, MD, Mattax-Neu-Prater Eye Center

Are you tired of strident voices and negative advertising in our local elections? Do you want to see quality candidates running for the nonpartisan seats on our school board and city council? Having been on the local ballot twice, I feel your pain! Here is our solution.

United Springfield, a not-for-profit organization, has been formed to support individuals running for nonpartisan office who will unite our Springfield children, citizens, and community. It will work to protect what makes Springfield so unique. We are a statewide and regional leader because of our strong community partnerships, life changing educational opportunities, and welcoming environment for innovation. To continue building a stronger Springfield for tomorrow, United Springfield will work to protect civil discourse, community partnerships, and the welcoming culture of innovation. This group will include members from all walks of life who recognize the need to preserve a united nonpartisan local government.

Long-time community leaders Jim Anderson, a Democrat, and Terri McQueary, a Republican, co-chair the group. Anderson brings decades of experience in the business world and has dedicated his life to making Springfield the best it can be. He spent his career building strong community partnerships and pioneering our welcoming culture of innovation. Terri McQueary brings decades of community involvement and leadership. McQueary, a longtime small business owner, has engaged in philanthropy and community leadership most of her life. Debbie Shantz Hart will serve as the group’s treasurer. She is a business leader who works every day to improve the Springfield community and has held many Springfield leadership positions.

In a press release, Jim Anderson was quoted as saying,

“United Springfield is an innovative local solution to a community problem. There has never been an independent entity solely focused on nonpartisan elections. We know economic and work force development are directly impacted by strong and nonpartisan local leadership. Now is the right time to unite as a community.” “The beauty of United Springfield is that it is nonpartisan. As partisan politics get more divisive, nonpartisan office holders must focus on uniting our community.” said Terri McQueary. “United Springfield is truly a place for Republicans, Democrats, and Independents to come together, put aside political disagreements, and focus on making our community better for everyone.”

The United Springfield steering committee embodies the community wide effort of the organization including community educators, businesspeople, religious leaders, and long-time community volunteers. Steering committee members include Raylene Appleby, Orin Cummings, Jeff Johnson, Julie Leeth, Alina Lehnert, Tom Prater, and Gail Smart.

Want to help? There are several ways you can use your influence to foster a more United Springfield. Have some extra cash, send it our way. Check the United Springfield website at sgf.vote. Contact me if you have any questions. I always welcome good advice from our engaged medical community.

Thomas Prater served six years on the Springfield Board of Education, including two years as President. He represented zone 2 on the Springfield City Council.

HONORING THE LEGACY OF THE GCMS ALLIANCE, 1924-2024 CENTENNIAL

CELEBRATION

by Jana Wolfe, co-President GCMS Alliance

Barbara and I are reflecting on our past, trying to preserve our present, and contemplating our Alliance’s future.

Several loyal members rejoined our Alliance for the 2022-2023 year. We truly are grateful for you. To show our appreciation, we are extending your membership for 20232024 year for GCMS Alliance in honor of our upcoming centennial. This appreciation extension is for our local Alliance only.

If you join the MSMA Alliance and/or the AMA Alliance, we will include links to how you can continue to join or rejoin those organizations.

GCMS Alliance has a rich history of accomplishments in our community: promoting health education, assisting in programs that have improved the health and quality of life of our community, and providing support to our physician families.

Barbara and I are reaching out to our members and the hundreds of spouses of physicians who are not members yet who have enjoyed our couple and family events the last several years: the summer events, “Physician Family Picnic," “Physician Family Night at the Zoo” and the spring events, “Physician Family Night at the Museum” and the physician couples’ events, “Taking Care of Our Own” from 2016-2019.

SAFE & SOBER

We NEED YOU!

The medical society, in honor of our Centennial Celebration, is offering a FREE membership to all spouses of NEW GCMS members.

We need ACTIVE Alliance members who are willing to join as leaders, and serve on committees, programs, and projects to honor the legacy of our Alliance.

We are reaching out to ALL of you in this Centennial Membership Drive for ACTIVE members to say “YES."

Join us in Honoring Our Past, Making A Difference in Our Community, and Our Physician Families, and Soaring into Our Future…

Please contact Barbara and Jana NOW through September 2024, at which time the membership will decide the future of GCMS Alliance.

To join/renew MSMA Alliance membership visit: msma. org/Alliance.

To join/renew AMA Alliance membership visit: amaalliance.org

If you have any questions about the above links, please feel free to contact Jana for assistance.

Continued from page. 20

Clearly we need better regulation on Marijuana! However, we are fortunate to live in a community that has a reputation of working together for the benefit of all; especially children! We all know and support each other. The upcoming Burrell Youth Resiliency Center is one excellent example and will provide help for teens with a mental health crisis.

There are dozens of other examples including Safe & Sober. I remember a young attorney joining the Greene County Medical Society’s DWI Task Force over twenty years ago. He had a passion to protect teens from the peer pressure of using alcohol on Prom night and avoiding the well known potential consequences. He developed a written pledge between kids and their parents. The contract evolved into a promise for complete abstinence from Alcohol, drugs and tobacco until age 21! That pledge helps provide cover for the peer pressure faced by teens as they continue to mature, and become more self confident.

We as parents seek to protect our children, and deliver them safely into adulthood. That’s our job, but it is becoming

increasingly more difficult with stronger opioids and stronger marijuana.

The written contract Kurt developed binds parents and children, and empowers kids to stay on the path, and resist peer pressure. Although the increase in impaired driving deaths, drug overdose deaths, and suicides in young people is scary, the Safe & Sober approach can be a great tool.

But let me make something clear, that tool does not cure any bad things, it prevents bad things from happening, and it is that that makes it special.

The more kids and parents that sign up, the easier it is for individuals to stay strong. Much like herd immunity.

This breakfast is the primary fundraiser for Safe and Sober, and, like any other nonprofit, fundraising is critical to carry out its mission. Please help Safe and Sober prevent alcohol and drug dependence in children and join us in making an investment in the health of our kids and our community.

We appreciate you for showing up to support such an important project as Safe & Sober. Thank You!"

METABOLIC SYNDROME AND SMOKING: DOUBLE JEOPARDY FOR HEALTH

by Betty M. Drees, MD, FACP, FACE Professor, University of Missouri-Kansas City President, Graduate School of the Stowers Institute for Medical Research

Introduction

Tobacco use and the metabolic consequences of obesity are the two leading causes of preventable death in the United States. Both contribute to increased morbidity and mortality due to cardiovascular disease (CVD), as well as cancer and other chronic diseases. What may be underappreciated is the additive risks of adverse health effects of both conditions occurring together in individuals, as well as the impact of the presence of one on the management of the other. These relationships are important when addressing primary and secondary prevention of disease from both a public health perspective as well as in caring for individuals.

Nearly 20% of adults in the United States (US) use tobacco products, with cigarette smoking the most common use.1 The annual costs of tobacco use are $300 billion, with $225 billion for direct health care costs and the remainder lost productivity. There are nearly half a million deaths annually due to tobacco-related causes. In Missouri2, over 17% of adults smoke cigarettes; annual costs are $3 billion; and there are 11,000 tobacco-related deaths each year. In Missouri youth, e-cigarette use is more prevalent than traditional combustible cigarette smoking. Approximately 5% of youth are current cigarette smokers, but 20% are current e-cigarette users. Approximately 10% are “frequent” e-cigarette users.

Metabolic Syndrome (MetS) is a constellation of physiological, hemodynamic, inflammatory and metabolic changes that increase the risk of developing type 2 diabetes mellitus (T2D) five-fold and double the risk of CVD.3 MetS is also associated with increased risk for cancer, polycystic ovary disease, and dementia.4 The condition is made up of five components including hypertension, insulin resistance, abdominal obesity, high levels of triglycerides (TG), and low levels of high density lipoprotein (HDL). Three of the five components must be present for diagnosis. MetS is a public health concern as its prevalence among US adults has been increasing in the past decade, resulting in over one-third of adults currently having MetS.5 Prevalence of MetS increases with age, but alarmingly MetS is increasing in adolescents and young adults, such that 20% of young adults ages 20-39 now have MetS. Primary prevention and early detection of MetS are of highest importance as early lifestyle interventions and risk factor modification can

significantly decrease risk of CVD. The pathophysiology of how MetS devel-ops is unclear; however, it’s linked to lifestyles, especially diet and physical activity and the resultant insulin resistance. Annual health care costs for people with MetS are 60% higher than for people without the condition.6 Even excluding costs for medical care for T2D or a cardiovascular event, health care costs for people with MetS are greater than for those without MetS.

Relationships Between MetS and Smoking

A number of studies have reported an increased risk of MetS in smokers.7-13The specific components may vary across studies, but consistently demonstrate adverse effects on lipids with increased TG and decreased HDL. The reported increased risk of MetS in smokers ranges from 30% higher to twice as high. These effects persist over time even in former smokers. In some reports, former smokers may have an even higher risk of MetS than current smokers, which may be attributed to weight gain after stopping smoking.12 There are fewer studies of e-cigarettes and MetS; however, use of e- cigarettes are reported to have about the same increased risk of MetS as traditional combustible cigarettes.13 Passive exposure to cigarette smoke also increases risk adverse metabolic effects and MetS.14-16 The relationship of smoking and risk of MetS is dose-dependent, with increasing risk associated with heavier smoking and longer duration.17-19 The co-occurrence of MetS and smoking increases cardiovascular risk more than either condition alone, which may be nearly double that of either risk factor by itself. 20-21 Furthermore, those who smoke may be less likely to respond to interventions to reverse MetS.21

Implications for Clinical Care

The associations between smoking and MetS combined with the demographics of both MetS and tobacco use have important implications for clinical care. The increased risk of MetS in smokers is dose-dependent, persists over time in former smokers, includes secondhand smoke and e-cigarettes. MetS prevalence increases with age, but the risk of cardiovascular disease associated with MetS (or T2D) is higher the younger the age of onset of MetS.21,22 Younger individuals are more likely to use e-cigarettes, which appears to have the same negative metabolic impact. For the health of both individuals and the general population, screening for tobacco abuse—including e-cigarettes--and metabolic

risk factors (obesity, hypertension, insulin resistance, lipid abnormalities) is important for early intervention for lifestyle modification and attention to component risk factors for CVD in both children and adults.23,24 Recognition of the association between smoking and MetS should raise the awareness of the increased risk of MetS in smokers (especially abnormal lipids), the adverse metabolic effects of smoking that may persist even after smoking cessation, and the potential for smoking to reduce effectiveness of interventions to reverse MetS.

There are associations between tobacco use and MetS that are unique to adolescents and young adults that deserve special attention for three reasons. First, since adverse metabolic effects are dose dependent, including duration, earlier onset of tobacco use (including e-cigarettes) may increase the duration of tobacco exposure. Second, children and adolescents may be exposed to secondhand smoke from adults even if they are not smokers themselves. And third, MetS and its components have a higher risk of CVD the earlier the age of onset. Both primary and secondary prevention to reduce smoking and exposure to cigarette smoke, and to promote healthy nutrition and physical activity are especially important in adolescents and young adults.

Lifestyle interventions to reverse MetS in adults include healthy eating and increased physical activity. Behavioral and habit changes are difficult, but if there are limited number of changes an individual might make, perhaps the two most important are to reduce added sugars in the diet—especially sugar-sweetened beverages—and to increase physical activity. Both of these actions address the insulin resistance that is central to MetS, and both lend themselves to specific goals, such as decreasing the number of sodas per day or taking a walk everyday after dinner. Nutrition should focus more on metabolic health and healthy eating patterns than weight loss or specific diets,26 but weight loss does require a reduction in caloric intake and cannot be accomplished by increasing physical activity alone. Physical activity is extremely important in improving insulin sensitivity, maintaining muscle mass, and reducing all- cause mortality. Increasing physical activity may reduce mortality by 20%-50%.25 Attention to physical activity is critical in individuals who are losing weight through any approach because weight loss is associated with loss of muscle mass. Physical activity may mitigate this loss of muscle mass with weight loss.27 Any amount of increase in physical activity is beneficial to metabolic health and it is beneficial at any age.

In summary, tobacco use and MetS are modifiable risk factors

for CVD and other chronic diseases and contribute to excess morbidity, mortality, and health care costs. Smoking and MetS have important relationships that exacerbate the adverse health effects of each other. Addressing both risk factors through primary and secondary prevention strategies and lifestyle changes are important in both younger and older populations to improve metabolic health and reduce CVD risk. It is never too early to start or too late to try to intervene to improve health and reduce risk. In addition to medical care of individuals, physicians have a role in advocacy in public health and policy to promote metabolic health through access and availability of healthy foods and spaces for physical activity, and to promote reduction in tobacco exposure in any form.

References:

For a complete copy of references from this article please email director@gcms.us.

FALL AND WINTER VIRUS OVERVIEW

by Nancy Yoon, MD,. MPH

The most effective way to protect yourself from the worst outcomes of this season's viruses is to get your fall vaccines now! This year marks the first fall and winter virus season where vaccines are available for the three viruses responsible for most hospitalizations – flu, COVID-19 and RSV. Everyone is also encouraged to minimize virus spread by staying home when sick, practicing good handwashing, and seeking testing when ill to identify the infection. Here is an overview of the respiratory viruses that will be circulating during the 2022-2023 fall and winter season, and recommendations for vaccinations and treatment.

COVID-19

The risk of COVID-19 varies by age and underlying health conditions. COVID-19 burden is currently lower than at previous points in the pandemic, however there are still thousands of hospitalizations and hundreds of deaths each week. The majority of the U.S. population has some level of immunity due to infection, vaccination, or both. Vaccine and infection-induced immunity wane and new variants have emerged, suggesting that susceptibility remains and may increase over time.

Updated COVID-19 Vaccine Recommendations:

• People 5 years and older without immunocompromise: 1 dose of 2023-4 COVID-19 vaccine, regardless of prior vaccination history

• People ≥ 6 months who are moderately or severely immunocompromised:

• Initial COVID-19 vaccine series

• At least 1 2023-2024 COVID-19 vaccine dose

• May receive 1 or more additional 2023-2024 mRNA COVID-19 vaccine doses

New requirements are now in place to receive a COVID-19 vaccine. Due to changes in vaccine funding, the Health Department will only administer COVID-19 vaccines to those who are underinsured or uninsured. CDC’s Bridge Access Program provides no-cost COVID -19 vaccines to adults 18 years and older without health insurance and adults whose insurance does not cover all COVID -19 vaccine costs. Those with private or commercial insurance should visit Vaccine417.com to view other vaccine offerings in the community.

COVID-19 antiviral medications

Don't Delay: Treatment must be started within days of

when you first develop symptoms to be effective. There are several FDAauthorized or approved antiviral medications used to treat mild to moderate COVID-19 in people who are more likely to get sick. Several options are available for treating COVID-19, including Nirmatrelvir with Ritonavir (Paxlovid), Remdesivir (Veklury) and Molnupiravir (Lagevrio).

Influenza (Flu)

The highest rates of hospitalization for influenza in 20222023 were among the adult population 65 years and older, which is typical for most flu seasons. Adults 65 and older bear the greatest burden of hospitalizations and deaths associated with flu. One multiseason study found that this group accounted for 54-70% of hospitalizations and 71- 85% of deaths.

Flu Vaccine Recommendations:

• All persons aged ≥6 months who do not have contraindications are recommended to receive a flu vaccine.

• Adults aged ≥65 years should preferentially receive a higher dose, recombinant, or adjuvanted flu vaccines.

Treatment with flu antiviral medications is recommended as soon as possible for any patient with suspected or confirmed flu who is hospitalized; has severe, complicated, or progressive illness; or is at higher risk for flu complications (including those 65 years and older). Treatment should not wait for lab confirmation of flu.

The Missouri Department of Health and Senior Services (DHSS) has a new Influenza Surveillance Report, available

as an interactive online dashboard. Using laboratory and outpatient data, the dashboard displays the counties that have reported flu cases each week, the weekly number of cases statewide as compared to the previous four flu seasons, the percentage of hospital emergency department visits that included patients with influenza-like illness (fever and a cough and/or sore throat), and the number of new flurelated hospital admissions by week.

2022-2023 U.S. Flu Season Burden Estimates:

RSV

Respiratory syncytial virus (RSV) is recognized as one of the most common causes of childhood illness and is the most common cause of hospitalization in infants. It can also cause serious illness in older adults. In most regions of the United States, RSV season starts in the fall and peaks in the winter, but the timing and severity of RSV season in a given community can vary from year to year.

RSV vaccines are available to protect older adults from severe RSV. RSV vaccines (administered during pregnancy) and monoclonal antibody products (administered to the infant) are also available to protect infants and young children from severe RSV. A healthcare provider’s recommendation is one of the most important factors influencing a patient’s choice to accept a new prevention product or vaccine.

Vaccination recommendations:

• Adults ages 60 years and older may receive a single dose of RSV vaccine, using shared clinical decision-making

• Co-administration with RSV and other adult vaccines is acceptable

• RSV Immunization to Protect Infants during RSV Season: Because of the high incidence of severe RSV disease in the first months of life, RSV prevention products focus on passive immunization of young infants through maternal immunization or immunoprophylaxis with monoclonal antibodies.

• Maternal RSV vaccination at 32-36 weeks of gestation. ----- OR ------

• Nirsevimab (RSV immunization), which is a long-acting monoclonal antibody for passive immunization to prevent RSV-associated lower respiratory tract disease among infants and young children.

There is currently a limited supply of nirsevimab. In this context, the CDC recommends prioritizing available nirsevimab 100mg doses for infants at the highest risk for severe RSV disease: young infants (age <6 months) and infants with underlying conditions that place them at highest risk for severe RSV disease. CDC further recommends that providers suspend using nirsevimab in palivizumab-eligible children

aged 8-19 months. Prenatal care providers should discuss potential nirsevimab supply concerns when counseling pregnant people about RSVpreF vaccine (Abrysvo, Pfizer) as maternal vaccination is effective and will reduce the number of infants requiring nirsevimab during the RSV season.

Each year in the U.S. in children < 5 years, RSV is associated with:

References:

Clinic tools and handouts: www.immunize.org

CDC 2023-2024 Fall and Winter Virus Season Playbook (October 2023)

CDC Health Advisory Oct 23-2023: https://emergency.cdc.gov/ han/2023/han00499.asp

IF WE ARE NOT TAKING GOOD CARE….

by Patricia Dix, MD, ACOB/GYN, MFM Regional Perinatal Center, Cox Health

There is a reasonable and prevalent perception in the medical community and among pregnant women that medication is dangerous for the baby. This caution is completely reasonable. However, if she gets a cold, she does not need to take medicine! Common colds are rarely serious, and famously, there is no cure for them anyway!

HOWEVER, if a woman has a medical condition that requires medication for control during pregnancy, she should take the safest medication that has been effective. These conditions include, but are not limited to, diabetes, hypertension, seizure disorder, psychiatric illness, asthma, and autoimmune diseases. IF WE ARE NOT TAKING GOOD CARE OF THE MOTHER, WE ARE NOT TAKING GOOD CARE OF THE BABY.

There are of course, medications which should always be discontinued during pregnancy such as ACE and Arbs for hypertension. There are better, safer alternatives during pregnancy including calcium channel blockers, and beta-blockers.

Statins should never be used because the baby’s organs, especially the brain, require cholesterol to grow. Short term absence of statins does not affect the long term benefit.

Asthma is also common in young women. Most asthma medications such as albuterol inhaler and budesonide are safe; even prednisone for short periods is safe in pregnancy. These medications are much safer than uncontrolled asthma which can lead to status asthmaticus. If an asthma attack does not respond to treatment or bronchitis is diagnosed, a chest x-ray can and should be done to exclude the possibility of pneumonia.

Psychiatric medications are also usually safe in pregnancy. This is one of the classes of drugs which are most often stopped due to pregnancy. Once again, we have to weigh the risk of the medication for the fetus against the risk of NOT treating the mother. Since untreated depression, anxiety, schizophrenia, etc. can lead to suicide, the treatment should not be stopped. If she is well controlled on a medication, it can usually be continued. The drug of choice for bipolar disorder during pregnancy is lamotrigine. The dose may need to be increased during pregnancy to maintain therapeutic

levels and then decreased after delivery to avoid toxicity. The SSRI of choice during pregnancy is sertraline because there is a lengthy experience with it, and, following delivery, it is also safe during breastfeeding. The safest medication for treatment of anxiety during pregnancy is buspirone. Always start small and increase to therapeutic levels to avoid side effects. It is safe during breastfeeding as well.

There is a National Pregnancy Registry for Psychiatric Medications at Harvard. They will speak to any pregnant woman with a history of psychiatric regardless of medication status. However, the patient must register. They are also happy to provide written material for patients. Phone: 866-961-2388. Such registries are the only way we learn the true incidence of birth defects associated with any given medication.

Seizure disorder is another illness for which medication is often discontinued with pregnancy. Valproic acid has been well known for years to be teratogenic, and It should be discontinued before pregnancy if possible. We also try to avoid topiramate if possible. Lamotrigine and levetiracetam are both acceptable alternatives. There is also a registry for anti epileptic drugs at Harvard. The patient must register by calling 888-233-2334.

Rheumatoid arthritis and systemic lupus erythematosus are diseases that are common in women of child bearing age. The safest medication is hydroxychloroquine. Prednisone may be used to treat flares.

All autoimmune patients should be on ASA 81 mg enteric coated tablet daily from 12 weeks gestation until delivery.

Once again, the principal rule of treating any disease during pregnancy is IF WE ARE NOT TAKING GOOD CARE OF THE MOTHER, WE ARE NOT TAKING GOOD CARE OF THE BABY.

This is only an overview of medication risk/benefit for treatment of chronic diseases common in pregnancy. If there is ever a doubt about medication safety please feel free to call me at 417-269-4037.

professional

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

H Denotes GCMS Membership “A” Denotes GCMS Applicant

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

Mission Statement

Bringing physicians together to improve the health of our community.

Dermatology, Procedural

Eye Surgery/Ophthalmology

MATTAX • NEU • PRATER

EYE CENTER

JAMES B. MATTAX, JR., MD, FACS H

American Board of Ophthalmology

LEO T. NEU III, MD, FACS H

American Board of Ophthalmology

DAVID NASRAZADANI, MD

DREW A. YOUNG, MD

THOMAS PRATER, MD, FACS H

American Board of Ophthalmology

JACOB K. THOMAS, FACS, MD H

American Board of Ophthalmology

BENJAMIN P. HADEN, MD H

MICHAEL H. SWANN, MD H

AUTUMN COURTNEY, PA-C

PATSY DUGGAN, PA-C

WESLEY N. WORMINGTON, PA-C 3850 S. National Ave, Suite 705 Springfield, MO 65807

Phone: 417-888-0858 • Fax: 417-889-0476 www.swanndermatology.com

Direct Primary Care

ASCENT DIRECT PRIMARY CARE, LLC

MATTHEW GREEN, DO H

Family Medicine www.ascentdpc.com 417-595-0956

413 N McCroskey, Ste 2 Nixa, MO 65714

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

Family Medicine

COXHEALTH

FAMILY MEDICINE RESIDENCY

FAMILY MEDICAL CARE CENTER

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

AmericAn BoArd of fAmily medicine

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

Gynecology

Call 887-1017 to list your practice here! Urology

WOMAN’S CLINIC www.womansclinic.net

Leaders in Minimally Invasive Gynecology & Infertility

DONALD P. KRATZ, MD, FACOG H American Board of Obstetrics and Gynecology

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

VANESSA MCCONNELL, APRN, DNP, FNP-C 1135 E. Lakewood, Suite 112 Springfield, MO 65810

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

MERCY CLINIC UROLOGY (FREMONT)

ERIC P. GUILLIAMS, MD, FACS H American Board of Urology

ROBERT D. JOHNSON, MD, FACS H American Board of Urology

TYRUN K RICHARDSON, MD

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

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

SPRINGFIELD NEPHROLOGY ASSOCIATES, INC.

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

Neurosurgery

SPRINGFIELD

NEUROLOGICAL AND SPINE INSTITUTE

CoxHealth Jared Neuroscience

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

BRANDON RUBLE, ACNP-AG

ALYSSA CHASTAIN, FNP

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

Obstetrics/Gynecology

SPRINGFIELD OB/GYN, LLC

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.

WILLIAM F. CUNNINGHAM, MD, FACP

American Board of Internal Medicine

American Board of Medical Oncology

JIANTAO DING, MD H

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

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

MELISSA COONS, FNP

TAHRA LOCK, NP

ELIZABETH (BETSY) MULLINGS, FNP

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

CONNECTED.

We believe when we work together, big change happens. Families get healthier. Communities grow stronger. Lives change. Right now, side by side, our providers are shaping our future –strengthening it and making it a little bit brighter for everyone. coxhealth.com 417-269-INFO CoxHealthNow

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