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Archive for January, 2013

Northeast Georgia Physicians Group Welcomes New Practices

Thursday, January 31st, 2013

Northeast Georgia Physicians Group (NGPG) recently welcomed two new practices — Heritage Obstetrics and Gynecology and Lakeside OB/GYN & Pelvic Surgery.

The physicians and midwives of NGPG Heritage OB/GYN include: Clayton Cox, MD, FACOG; Stephen Little, MD, FACOG; Holt Harrison, MD, FACOG; Francis T. Lake, Jr., MD, FACOG; Jeffrey Ward, MD, FACOG; Tiffany Tucker, CNM; and Lauren Wood, CNM. They provide comprehensive gynecological care; routine and high risk obstetric care; in-office permanent sterilization; 3D/4D ultrasounds; advanced laparoscopy and treatment for pelvic relaxation and urinary incontinence; in-office ablation for heavy menses; and robotic gynecological surgery.

The physicians at NGPG Lakeside OB/GYN are Jason Bailey, MD; Greg Martin, MD, FACOG; Jacquelyn Stone, MD; and Jameela Harper, MD. Services include: routine and high risk obstetric care; comprehensive surgery for pelvic prolapse and incontinence; evaluation and treatment of pelvic pain disorders and endometriosis; infertility evaluation and treatment; and minimally invasive hysterectomies.

Northeast Georgia Physicians Group sees patients in Gainesville and Braselton.

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Quality of Critical Health Care Delivery is Focus of Summit

Thursday, January 31st, 2013

Critical care is one of the most resource-intensive areas in U.S. health care, but despite substantial medical advances in the past decade the quality of critical health care delivery is known to vary significantly.

The 2013 Southeastern Critical Care Summit will provide targeted education to a variety of critical care medicine providers with the aim of improving care across the care spectrum. The Summit will be held Feb. 21 and 22 at the Emory Conference Center and Hotel and is sponsored by Emory University School of Medicine, Department of Medicine, Division of Pulmonary and Critical Care Medicine.

The Summit will focus on improving patient care by providing targeted education to multi-professional health care stakeholders on common critical care conditions and procedures. The program will use interactive and case-based lectures from the health care community at all levels (administrators, physicians, mid-level providers, nursing and respiratory therapy personnel), as well as hands-on teaching. Topics of particular importance (i.e. prevalence of critical care) or controversy will involve roundtable and small-group discussion, breakout sessions and procedural education.

Early Bird registration for the Summit is $135 per day or $225 for both days if registered by Feb. 6. (Feb. 7 and beyond, registration is $175/$275). Registration includes the printed Summit course syllabus, continental breakfast and buffet lunch, refreshment breaks, exhibitor interactions and other amenities to create a rewarding learning experience.

For more information and to register for the 2013 Southeastern Critical Care Summit, visit Southeastern Critical Care Summit

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Jungblut Assumes Role as WellStar Senior VP and Medical Director

Thursday, January 31st, 2013

Peter R. Jungblut, M.D., MBA, has been named senior vice president and medical director of the WellStar Medical Group (WMG).

Dr. Jungblut will assist Robert Jansen, M.D., executive vice president, WellStar Medical Group president and chief administrative medical officer, and Ellen Langford, WellStar Medical Group vice president and chief operating officer, in managing quality, clinical and operational issues and analyzing various metrics to support the development and implementation of strategic plans. He will serve on the WMG Cabinet and be responsible for physician and advance practice provider recruitment, on-boarding, performance management and alignment with WMG goals, such as the Patient-Centered Medical Home.

Prior to joining WellStar, Dr. Jungblut served as vice president of medical affairs (VPMA) for Shore Medical Center in Somers Point, N.J., for nine years and resumed an active clinical practice in internal medicine last year. As VPMA, he managed Shore’s cardiovascular, cancer, sleep, and pharmacy operations, as well as other affiliated services.

Dr. Jungblut received his bachelor’s degree in finance from New York University, his medical degree from Weill-Cornell University Medical College, and his master’s degree in business administration from the University of Washington. He did his internship and residency at Northwestern Memorial Hospital in Chicago and is board-certified in internal medicine.

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Physicians Day at the Capitol

Wednesday, January 30th, 2013

January 30, 2013, Atlanta. For more information, visit Physicians Day at the Capitol

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MAA Board Meeting

Thursday, January 24th, 2013

January 24, 2013. For more information, visit Medical Association of Atlanta

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Atlanta Medical Center Consolidates with South Fulton Medical Center

Thursday, January 24th, 2013

Atlanta Medical Center (AMC) and South Fulton Medical Center have consolidated into one hospital with two campuses. South Fulton Medical Center has been renamed Atlanta Medical Center – South Campus. Atlanta Medical Center is owned by Tenet Healthcare Corporation.

Now licensed as a 762-bed acute care hospital, Atlanta Medical Center is the second largest licensed-bed hospital in Georgia. With its main campus located in downtown Atlanta, the hospital’s South Campus in East Point, GA provides care to the surrounding communities of East Point, College Park, Hapeville and Camp Creek.

“Both of these hospitals have a long history of serving our communities,” said William T. Moore, president and CEO of Atlanta Medical Center. “We are pleased to provide even greater service to our patients by combining our strengths, providing quality health care to a larger region and offering a choice of location.”

The consolidation has been in the works since last spring, as the two hospitals explored ways to ensure long-term stability. On Dec. 31, 2012, the Georgia Department of Community Health issued a licensing permit recognizing Atlanta Medical Center as a 762-bed acute care hospital.

An academic medical center, AMC has been serving the community since 1901. With the consolidation, the hospital now has almost 3,000 employees and contractors; 580 physicians on its medical staff; and handles more than 21,000 inpatient admissions and 162,000 outpatient visits each year. Atlanta Medical Center offers comprehensive health care, including 24-hour emergency services, Level 1 trauma care, stroke treatment, women’s services, medical imaging, orthopedics, sleep center, pulmonary, cardiac care and bariatric surgery for weight loss.

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Breast Cancer Update

Friday, January 18th, 2013

By Colleen Austin, M.D. and Lynn Baxter, M.D.

From ATLANTA Medicine, 2012, Women’s Health, Vol. 83, No. 1

The diagnosis and management of breast cancer has evolved dramatically since the declaration of the War On Cancer 40 years ago and especially during the past decade.  In addition to the developments in diagnosis and treatment, there has been a major paradigm shift in our understanding of the disease such that we increasingly focus on the intrinsic molecular subsets of breast cancer rather than viewing the disease as one entity.

There are over 200,000 cases of breast cancer per year in the United States with 40,000 deaths (1). After an increase in incidence during the 1990’s attributed to the increased use of screening, there has subsequently been a decrease. This has been attributed to the decline in use of hormone replacement therapy in part driven by the results of the Women’s Health Initiative (2). The decrease has largely been in estrogen receptor positive tumors with little decline in the incidence of ER negative malignancy.

During the past decade the mortality from breast cancer has also been declining. This decrease has been attributed to the benefits of screening and adjuvant therapy; thus far treatments for metastatic disease have had little impact on mortality. Unfortunately while having a lower incidence of breast cancer, African American women continue to experience higher mortality from the disease (3).

Risk factors for which adequate evidence exists include age, gender, race, family history, reproductive history, diet and lifestyle, alcohol use, smoking and exposure to radiation. A recent report from the Institute of Medicine extensively reviewed evidence for environmental factors contributing to breast cancer risk. Inadequate data exists for many suspected risks, and a focus on exposures in early prevention should include a healthy diet limiting fat and alcohol, avoiding weight gain especially after menopause, avoiding exposure to cigarette smoke and radiation, and limiting use of hormone therapy.

Germline mutations account for less than 10% of all breast cancer cases. In addition to BRCA 1 and 2 mutations, Li-Fraumeni, Cowden and Chek 2 mutations are important. All are autosomal dominant and include the risk of other malignancies as well. Obviously family history is an important consideration in determining the appropriateness of genetic testing. However referral for genetic testing should be considered in patients 45 or younger regardless of family history, in patients less that 50 with a limited family history and in patients less that 60 with triple negative breast tumors (5).

While there are many types of imaging used to evaluate for breast cancer, mammography is the gold standard. As Dr. Dan Kopans of Harvard likes to point out, it is the only test of any kind ever proven to reduce mortality from breast cancer.

Eight large, randomized controlled trials beginning in the 1960s showed a 20-30% decrease in mortality for women offered mammography (6) — and this was using technology from the 1960s and 70s! Digital mammography is rapidly becoming the new standard. It allows computer manipulation of the images and can reveal fine details not seen on film. Digital imaging has been demonstrated to be superior to film for cancer detection in women with dense breasts and women under age 50 (7). However, digital mammography still has some of the same limitations as film mammography. Things such as dense tissue and implants can obscure underlying cancers, and approximately 10% of patients having screening mammograms are recalled for additional imaging. Most of these patients do not have cancer, and the false positive recalls can be stressful. These limitations have led some people to advise against routine mammography, despite its proven benefits.

Fortunately, new technology is beginning to address these issues. The latest advance in mammographic imaging is digital breast tomosynthesis (also known as 3D mammography). In tomosynthesis, multiple images are obtained in an arc around the breast and then reconstructed in 1 mm slices. This allows radiologists to view the internal structures of the breast unobscured by overlapping tissue. In traditional 2-D mammography, tissue in one part of the breast can be superimposed on tissues from another to mask cancers or create the illusion of a mass. Tomosynthesis can overcome this problem, allowing us to detect more cancers and reduce recall rate. In fact, in studies that have been published so far, the recall rate has decreased by up to 40 % (8).

However, tomosynthesis still has limitations. It cannot find all cancers. For example, lobular cancers that do not create a mass or calcify will not stand out on tomosynthesis. Cancers that are equally dense with surrounding tissue can also be missed. Also, tomosynthesis will not eliminate all recalls. Patients with cancer will still need to be recalled and patients with real but benign lesions such as fibroadenomas will still need additional evaluation to exclude malignancy.

Like 2D mammography, tomosynthesis requires breast compression and radiation.  In fact, the standard combination exam of 2D and 3D mammography delivers two to three times the radiation dose of a 2D mammogram. The radiation dose is still extremely low and well within FDA guidelines. The FDA also points out that the marked decrease in recalls for the extra views should offset the additional radiation from the initial exam. The combination exam has been shown to find the most cancers, and calcifications are still best evaluated with 2D digital mammography (9). Therefore, only the combination exam is approved by the FDA.

Another major advance in breast cancer imaging is the use of MRI. MRI has long been the gold standard for evaluating the integrity of silicone implants. It is now also increasingly being utilized to evaluate for breast cancer. MRI uses no compression or radiation, and it not only shows anatomy, but also uses intravenous contrast to evaluate physiologic changes in bloodflow patterns. Invasive cancers alter bloodflow patterns through angiogenesis and other mechanisms. MRI can identify these changes with great sensitivity. In fact, published studies show an almost 100% detection rate for invasive cancers (10). Unfortunately, MRI is not as sensitive for non-invasive cancers, since they do not reliably alter blood flow. In addition, benign lesions such as fibroadenomas, fibrocystic tissue, and papillomas can enhance with patterns that can mimic cancer. Bloodflow patterns can even change during different phases of the menstrual cycle. For these reasons, MRI cannot replace mammography, but is useful as a compliment in many situations.

MRI is now frequently used to evaluate patients with a new breast cancer diagnosis. It identifies additional unsuspected cancers in the ipsilateral breast in up to 1/3 of patients and finds unsuspected contralateral cancers in 4 to 6 percent of patients. It can find primary tumors in 90 percent to 100 percent of patients whose cancer is initially detected in an axillary lymph node (11). It is also useful for following patients on chemotherapy since its physiologic evaluation of blood flow can show a response earlier than anatomic studies such as mammography or ultrasound. In high risk screening patients, MRI finds unsuspected cancers in approximately 4 percent (12).

With all of the new tools available for breast imaging, what are the current recommendations for breast screening? The America Cancer Society recommends annual screening mammography for all women ages 40 and older.  Annual MRI is recommended in addition to mammography for high- risk patients (those who are BRCA + or have a 20 percent greater lifetime risk of breast cancer). Screening for these high-risk patients should begin at age 30. Intermediate risk patients (15 to 20 pwecent lifetime risk) may wish to consider yearly MRI in addition to mammography. Research is ongoing in this population, which includes patients with a personal history of breast cancer. MRI screening is not recommended for average risk patients, since in a population with a low prevalence of cancer, the number of false positives would be unacceptably high.

Ultrasound screening is not generally recommended except for high-risk patients who cannot tolerate MRI (such as those with pacemakers). While ultrasound is quite useful as a diagnostic tool to evaluate a mass seen on mammography or palpated on clinical exam, it is hampered in the screening setting by issues of both sensitivity and specificity. While screening ultrasound can find some additional unsuspected cancers, it only finds 0.4% more than mammography (13), as opposed to 4 % more for MRI. Comparative studies have shown that ultrasound does not add any increased cancer detection to the combination of mammography and MRI. Moreover, ultrasound has a high rate of false positive recommendations for biopsy (14).

We’ve come a long way with breast imaging since those first mammography trials. Challenges still remain, and no current imaging test or combination of tests is perfect. However, with continued advances, we will hopefully be able to address current issues, decrease false positives, and find ways to identify more cancers at treatable stages. With improved tools for screening, earlier diagnosis is possible with opportunities to modify the extent of treatment. Breast conserving surgery is now the standard of care for patients with early malignancy. Acceptable margin width has declined, and neoadjuvant systemic therapy can often be used to reduce larger tumors making them amenable to breast conservation. Radiation therapy is a critical adjunct to breast conserving surgery, reducing recurrences by 25% (15).

Node sampling has also evolved in the direction of “less is more.” Sentinel node biopsy is now the standard of care, and two studies have demonstrated that complete axillary node dissection can be avoided when two or fewer nodes are involved in patients receiving subsequent radiation therapy (16, 17.)

The use of IMRT (Intensity Modulated Radiation Therapy) has improved the accuracy and uniform dosing of treatment. Although a five-week course of whole breast irradiation remains the standard, hypo fractionated regimens (Canadian Regimen) permit completion of treatment in half the time. Accelerated partial breast irradiation techniques (PBI) limit the treatment volume to the tumor bed and 1-2 cm surrounding margin. Treatment can be completed in five days. Although gaining in popularity, PBI is subject to continuing evaluation in clinical trials and its use is limited to patients over 45 years old with small node negative tumors (18).

Finally there are patients who may avoid radiation after breast conserving surgery: women over 70 with small ER positive tumors who are receiving adjuvant hormonal therapy (19). The use of radiation after breast conserving surgery for non-invasive tumors (DCIS) is also being reconsidered, and molecular profiling of the tumor may help predict which patients can avoid therapy (20). The evolving paradigm of the intrinsic tumor subtypes in breast cancer has had a major impact on the use of systemic treatment in this disease. Therapy is now individualized for hormone sensitive, HER 2 amplified, and “triple negative” tumors. The use of systemic treatment prior to surgery, so-called “neoadjuvant therapy” initially focused on patients with locally advanced disease. While no survival benefit has been associated with this approach, it is valuable in assessing response to systemic treatment and can be used to evaluate new therapies prior to large-scale trials.

Genomic studies of patient tumors have also helped individualize systemic therapy choices. Gene expression profiling provides a molecular signature of a patient’s cancer, which can be used to classify the risk for relapse and the benefit of a variety of treatment strategies. Many patients have avoided the toxicity of treatments, which would likely have contributed little to reducing their risk of recurrence.

Central to the paradigm shift in the management of breast cancer has been the elucidation of the molecular pathways critical for cell growth. Targeting these pathways has led to some of the most important advances in treatment (e.g. Traztuzumab for HER 2 overexpressing tumors). Among the large number of agents in the pipeline, many if not most will target critical steps in these pathways and hopefully will lead to significant progress including for those patients with metastatic disease.

With the rapid evolution in technology for diagnosis and treatment of breast cancer, it is likely that our approach to this disease will increasingly reflect the unique aspects of each tumor rather than a global approach to the disease. The results of many prior studies are likely compromised by our lack of understanding of this complexity. Fortunately in many instances tissue banking of tumor specimens from older studies has allowed the reevaluation of some of these issues, often with very different conclusions.

Perhaps the most gratifying aspect of the progress we have made in this disease is the increasing focus on“Survivorship.” Even patients with metastatic disease often live years, and programs directed at managing the aftermath of cancer treatments are receiving increased attention.

Lynn Baxter, M.D., is a board-certified radiologist who specializes exclusively in women’s imaging. She received her undergraduate degree from Duke University and her medical degree from the University of Pennsylvania. She completed her Radiology residency at Harvard’s Beth Israel Hospital and a Breast Imaging fellowship at Emory University. She is Director of Breast Imaging for Northside Radiology Associates and Chair of the Northside Hospital Breast Care Committee.

Colleen Austin, M.D., is a board-certified medical oncologist with a special interest in breast cancer. She received her undergraduate degree from Vassar College and her M.D. from State University of N.Y Upstate Medical School. She completed her residency in Internal Medicine and fellowship in Hematology and Oncology at Emory University School of Medicine. She currently chairs the Cancer Committee at Northside Hospital.

References
1. Kohler BA, et.al. Annual report to the nation on the status of cancer 1975-2007. J Natl Cancer Inst 2011;103:714.

2. Ravdin PM, et.al. The decrease in breast-cancer incidence in 2003 in the United States. N Engl J Med 2007; 356:1670.

3. Carey LA, et. Al. Race, breast cancer subtypes, and survival in the Carolina Breast Cancer Study. JAMA 2006l295(21): 2495.

4. Institute of Medicine: Breast Cancer and the Environment: A Life Course Approach. www.iom.edu/Reports/2011/Breast-Cancer-and-the -Environment-A-Life-Course Approach.aspx (Accessed on January 1, 2012.

5. National Comprehensive Cancer Network (NCCN) guidelines available online at www.nccn.org (Accessed on January 1,2012).

6. Kopans, DB, Breast Imaging, 3rd Edition, Lippencott-Raven, 2007

7. Pisano, ED, et al. Diagnostic Performance of Digital versus Film Mammography for Breast Cancer Screening. NEJM 2005; 353(17):1773-83

8. Poplack, SP, et al. Digital breast tomosynthesis: initial experience in 98 women with abnormal digital screening mammography. AJR 2007; 189:616-623

9. Spangler ML, et al. Detection and classification of calcifications on digital breast tomosynthesis and 2D digital mammography: a comparison. AJR 2011; 196:320-324

10. Morris EA. Diagnostic breast MR imaging: current status and future directions. Radiol Clin N Am. 2007;45:863-880

11. Ibid.

12. Liberman L & Morris EA, Breast MRI: Diagnosis and Intervention, Springer, 2005

13. Berg WA et al. Combined Screening With Ultrasound and Mammography vs Mammography Alone in Women at Elevated Risk of Breast Cancer. JAMA 2008; 299(18):2151-2163

14. Sardanelli F, Podo F, D’Agnolo G, et al. Multicenter comparative multimodality surveillance of women at genetic-familial high risk for breast cancer (HIBCRIT study): interim results. Radiology 2007;242:698-715

15. Fisher B, et.al. Twenty-year follow-up of a randomized trial comparing total mastectomy, lumpectomy, and lumpectomy plus radiation for the treatment of invasive breast cancer. N Engl J Med 2002; 347 (16):1233.

16. Giuliano AE, et.al. Axillary dissection vs no axillary dissection in women with invasive breast cancer and sentinel node metastasis: a randomized clinical trial. JAMA 2011; 305:569.

17. Galimberti V et. al. Update of Internalional Breast Cancer Study Group trial 23-01 to compare axillary dissection versus no axillary dissection in patients with clinically node negative breast cancer and micrometastases in the sentinel node. SABCS abst. S3-1, 2011.

18. Smith BD, et.al. Accelerated partial breast irradiation: Consensus statement from the American Society for Radiation Oncology (ASTRO) Int J Radiot Oncol Biol Phys 2009:74:987.

19. Hughes KS, et.al. Lumpectomy plus tamoxifen with or without radiation in women age 70 or older with early breast cancer. J Clin Oncol 2010; 28:69s

20. A quantitative multigene RT-PCR assay for predicting recurrence risk after surgical excision alone without irradiation for ductal carcinoma in situ (DCIS): A prospective validation study of the DCIS score from ECOG E5194. SABCS abst. S4-6, 2011.

 

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Sanda Will Oversee Prostate Cancer Center at Winship

Friday, January 18th, 2013

Martin G. Sanda, MD, an internationally recognized prostate cancer surgeon and scientist, has been appointed chair of the Department of Urology at Emory University School of Medicine and service chief for Emory Healthcare. He will also serve as director of the Prostate Cancer Center, which will be established within Emory’s Winship Cancer Institute.

Sanda joins Emory from Harvard Medical School, where he is professor of surgery in urology, and from Beth Israel Deaconess Medical Center, where he currently serves as director of the Prostate Cancer Center. He is also co-leader of the Prostate Cancer Program at the Dana Farber Cancer Center. He will begin at Emory on Feb. 28, 2013.

Sanda is principal investigator of three multi-center consortium studies funded by the National Cancer Institute and the Prostate Cancer Foundation that seek to develop urine tests for detecting prostate cancer; to develop benchmarks for improving quality of life among cancer survivors; and to develop innovative prostate cancer vaccines. These studies have enrolled over 4,400 patients with findings published in leading medical journals including the Journal of the American Medical Association and the New England Journal of Medicine.

Sanda’s clinical practice, which includes robotic prostatectomy and robotic cystectomy, is focused on developing new surgical and non-surgical approaches to cancer care and to improving the quality of life among cancer survivors.

After receiving his BA in molecular biophysics and biochemistry from Yale University , Sanda went on to receive his MD degree at Columbia University. He then trained as a general surgery resident at the Medical College of Virginia and as a surgical oncology fellow at the National Cancer Institute. He completed his urology residency at Johns Hopkins Hospital.

Sanda has served as chair of the Prostate and Genito-Urinary Collaborative Group of the National Cancer Institute’s Early Detection Research Network, has spearheaded two nationwide, NCI Cooperative Group prostate cancer clinical trials, has served on numerous federal funding review panels, and has served on the Research Council of the American Urological Association since 2011. Sanda has more than 150 peer-reviewed publications, and his work has been cited more than 5,000 times in biomedical literature.

 

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GMGMA Board Meeting

Friday, January 18th, 2013

January 18, 2013, Brasstown Valley Resort. For more information, visit Georgia Medical Group Management Association

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Gwinnett Heart Specialists Staff Includes Sreeni Gangasani, M.D., Michael Lipsitt, M.D. and Marc Unterman, M.D.

Thursday, January 17th, 2013

Gwinnett Medical Center has opened Gwinnett Heart Specialists of Gwinnett Medical Group. This new medical practice is staffed by Sreeni Gangasani, M.D., Michael Lipsitt, M.D. and Marc Unterman, M.D., three experienced cardiologists who have served the community for 30 years.

Gwinnett Heart Specialists provides services for both the prevention and treatment of cardiovascular disease. Services include:
•    Stress testing
•    Echocardiography
•    Vascular services
•    Coronary interventions, including cardiac catheterization and angioplasty
•    Peripheral interventions, including percutaneous stenting
•    Pacemaker implantation

Dr. Gangasani, who has served as the chief of the Department of Internal Medicine at GMC, completed his residency in internal medicine and a fellowship in cardiovascular diseases from William Beaumont Hospital. He served as President of the Georgia association of Physicians of Indian heritage (GAPI) in 2010 and currently is co-director of the GAPI volunteer clinic which serves the uninsured people of metro Atlanta. Dr. Gangasani is currently the Chairperson of the International Medical Graduates section of the Medical Association of Georgia (MAG).  In 2012, he received the Circle of Hope award from MAG. His interests include cardiac catheterization, pacemaker implantation and echocardiography. He is board certified in internal medicine, cardiovascular disease, echocardiography and nuclear cardiology.

Dr. Lipsitt, named a top doctor for the southeast region by Money Magazine, completed his internal medicine residency and cardiology fellowship at the Emory Affiliated Hospitals in Atlanta. He is a Fellow of the American College of Cardiology and member of the Medical Association of Georgia. His special interests are interventional cardiology, which include cardiac catheterization, coronary angioplasty, intracoronary stents, peripheral vascular angioplasty and pacemakers. He is board certified in internal medicine, cardiology and interventional cardiology.

Dr. Unterman, a Fellow of the American College of Cardiology and a member of the American Society of Echocardiography and the College of Nuclear Cardiology, completed his internal medicine residency Grady Memorial Hospital in Atlanta, and his cardiology fellowship at the University of Cincinnati. His special interests are interventional cardiology, including cardiac catheterization, coronary angioplasty, coronary atherectomy, intracoronary stents, and peripheral vascular angioplasty. He is board certified in internal medicine, cardiovascular diseases and interventional cardiology.

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