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Archive for February, 2013

Use Telehealth to Expand Your Practice, A Hands-On CME

Saturday, February 23rd, 2013

February 23, 2013, Atlanta. For more information, visit Medical Association of Atlanta

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2013 Southeastern Critical Care Summit

Thursday, February 21st, 2013

February 21-22, 2013, Atlanta. For more information, visit Southeastern Critical Care Summit

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Overview of the Systemic Manifestations of Rheumatic Diseases

Tuesday, February 19th, 2013

By Kelly O. Weselman, M.D., F.A.C.R.

From ATLANTA Medicine, 2012, Rheumatology, Vol. 83, No. 3

Although many think of rheumatic diseases as causing joint pain and swelling, it is important to remember that these illnesses cause pathology in multiple other organ systems. Since these patients frequently present to primary care physicians and virtually all specialists, it is important to be familiar with the myriad manifestations of these diseases.

In patients with a known rheumatic disease and new symptoms, consider the disease or its medications as a potential cause. In patients without a known rheumatic disease, keep these illnesses in your differential. In working with your rheumatology colleagues, remember to look for objective evidence of organ involvement by carefully interpreting the history, exam, labs and imaging data. Let’s consider the effects of some of the common rheumatic diseases on each organ system.

Dermatologic Findings

Skin rashes and lesions are seen commonly in rheumatic diseases such as lupus, scleroderma, dermatomyositis and some types of vasculitis. Rashes can be specific to a disease or represent nonspecific pathology.

Eighty-five percent of lupus patients will have skin manifestations. These can include photosensitivity rashes, discoid lesions, oral and nasal ulcers, malar rashes as well as subacute cutaneous lupus. Remember that the malar rash of lupus spares the nasolabial folds and crosses the bridge of the nose, which distinguishes it from the more common rosacea and seborrheic dermatitis.

Dermatomyositis rashes may be subtle but provide important clues to the diagnosis. Particular sites of involvement are the face, eyelids, anterior chest, upper back, extensor surface of the elbows, extensor surface of the knees, and the knuckles of the hands. Erythroderma may also be present.

Findings suggestive of scleroderma include tight skin on the hands and face, areas of skin with mixed hypo- and hyper-pigmentation, and digital ulcers.

Some less-common vasculitides can also cause skin ulcers and rashes.

Hematologic Abnormalities

Abnormalities on the Complete Blood Count (CBC) are quite common in many of the rheumatic diseases. Anemia of chronic disease is especially frequent in Rheumatoid Arthritis (RA) and Systemic Lupus Erythematosus (SLE). Leukopenia and thrombocytopenia are common in SLE.

Thrombocytosis and anemia are commonly seen together in RA, Polymyalgia Rheumatica (PMR) and Temporal Arteritis. Unexplained hematologic abnormalities should prompt a careful search for not only malignancy but also a rheumatic cause. I addition, cytopenias are an important adverse effect from immunosuppressive medications. Glucocorticoids in any form commonly cause leukocytosis.

Pulmonary Disease

The lungs are commonly involved in many of the rheumatic diseases. In fact, lung disease may be the presenting manifestation. Pathology can be a direct result of the disease or medications used in treatment. It could also result from pulmonary infections associated with immunosuppression. Although most rheumatic diseases can affect the lungs, there are characteristic patterns that tend to occur with certain diseases.

Interstitial lung disease (ILD) is one of the most frequent pulmonary complications in these patients. ILD is most commonly associated with RA, SLE, Sjogren’s syndrome, scleroderma and inflammatory myopathies. Findings can include shortness of breath, dry cough, rales and a restrictive pattern on PFTs. A chest CT most commonly demonstrates ground-glass changes or honeycombing. Patients with rheumatic disease who develop a persistent cough and shortness of breath and are not responding to conventional treatment may have ILD.

Pleuritis can occur in RA and SLE and usually presents with pleuritic chest pain and dyspnea. It is often confused with costochondritis. A less common pulmonary complication is alveolar hemorrhage associated with vasculitis, SLE or scleroderma.

Polymyositis and dermatomyositis may cause respiratory muscle weakness and resultant restrictive changes on PFTs but a normal chest CT. Usually this is associated with a very high CPK and an increased risk for aspiration pneumonia.

Organizing pneumonia is commonly associated with RA and can rarely be associated with methotrexate use.

Nodular disease is commonly seen in RA and Wegener’s granulomatosis. However, it is important to search for malignancy since many rheumatic diseases increase the risk of lung cancer and lymphoma.

Cardiovascular Disease

Cardiovascular disease and its prevention are increasingly important in the care of rheumatology patients. Rheumatic diseases can affect the heart in many ways, and we are learning that some are associated with a higher risk for acute cardiovascular events.

Pericardial effusion is the most common cardiac manifestation of RA and SLE. In RA patients, effusions rarely cause symptoms. Lupus patients can develop pericarditis, myocarditis and endocarditis. Both RA and SLE patients have increased risk for atherosclerotic disease. Control of risk factors should be emphasized as it is in patients with diabetes. Data in RA patients suggest fewer cardiovascular events occur with use of biologic agents and better disease treatment.

Scleroderma patients are at increased risk for pulmonary arterial hypertension. We are discovering the importance of screening these patients with PFTs and echocardiograms. The gold standard is to measure RVSP and PAP by right heart catheterization for early diagnosis and treatment.

All types of vasculitis can be important causes of cardiac and vascular symptoms. Consider temporal arteritis, Takayasu’s arteritis, Behcet’s disease and Kawasaki’s disease in patients with a vasculitis affecting the large vessels. Although these diseases can be difficult to diagnose, clues to an inflammatory process such as fever, anemia, thrombocytosis, elevated CRP and/or ESR can sometimes suggest a rheumatic cause. Additionally, an unusual presentation may be a clue to underlying rheumatic disease.

In patients with a known rheumatic disease, consider an EKG or echocardiogram for new cardiac symptoms. In new patients with an atypical presentation of cardiac disease, consider a rheumatic disease.

Renal Manifestations

Renal disease is an important manifestation of lupus and some types of vasculitis. The most common finding is severe glomerulonephritis, which can lead to renal failure. Scleroderma patients specifically can develop renovascular disease leading to renal crisis. Additionally, many of the medications used to treat rheumatic diseases can have significant adverse renal effects such as tubulointerstitial disease.

Workup for lupus or vasculitis as a cause of renal disease requires a urinalysis and urine protein to evaluate for an active sediment and proteinuria to help determine whether a rheumatic disease might be involved. Often these patients require renal biopsy to assess the effect of their disease on the kidney.

It is important to monitor kidney function in many patients with rheumatic diseases. Patients with rheumatic disease without renal manifestations must be monitored for potential adverse medication effects.

Eye Disease

The rheumatic diseases most often associated with inflammatory eye disease include Sarcoidosis, Behcet’s, reactive arthritis, inflammatory bowel disease-related arthritis, Ankylosing Spondylitis, RA and SLE. It is important for patients with a painful red eye to see an ophthalmologist promptly. Inflammatory eye diseases such as uveitis require prompt treatment and often long-term immunosuppressive medications to prevent loss of vision.

Gastrointestinal Disease

Common GI symptoms such as diarrhea, abdominal pain, hematochezia and melena can all be associated with rheumatic disease.

Inflammatory bowel diseases, reactive arthritis, spondyloarthropathies, Behcet’s disease, celiac disease and Whipple’s disease can all cause intestinal inflammation and dysmotility resulting in diarrhea.

Abdominal pain can occur with or without diarrhea and is seen in inflammatory bowel disease and vasculitic syndromes such as Henoch-Schonlein Purpura (HSP), Polyarteritis Nodosa, RA, SLE, as well as scleroderma, Behcet’s and Whipple’s disease.

Gastrointestinal bleeding is usually due to a specific lesion in the gut and can occur in ulcerative colitis, HSP, vasculitis and Whipple’s disease.

Workup up these symptoms includes EGD and/or colonoscopy. Sometimes a CT or a motility study can be helpful. Remember, many of the medications used to treat rheumatic diseases can have an adverse effect on the gut.

While this article is not meant to be a comprehensive review, it can serve as a framework to add rheumatic diseases to a physician’s thought process in the evaluation of new signs and symptoms not primarily attributed to this subspecialty.

Think of rheumatic diseases as systemic diseases, not just causes of joint pain or arthritis. Even in a patient with no musculoskeletal symptoms, keep these disorders in the differential diagnosis. In a patient with a known rheumatic disease, consider that new signs or symptoms may be a new manifestation of the existing diagnosis. Finally, the medications used to treat these disorders should always be considered as a cause of new symptoms.

 

Dr. Weselman earned her Bachelor of Science in Biology from the College of William and Mary and her Doctorate of Medicine from Baylor College of Medicine, where she also completed her internship and residency in internal medicine. She completed her fellowship in rheumatology at Emory University School of Medicine. Dr. Weselman is a fellow of the American College of Rheumatology and a member of the Georgia Society of Rheumatology, American College of Physicians and American Medical Association. She is board certified in rheumatology and internal medicine.

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Stem Cell Techniques and Enhanced Treatment Strategies are Promising for Patients With Blood Disorders

Tuesday, February 19th, 2013

Studies of stem cell biology and transplant approaches presented at the recent Annual Meeting of the American Society of Hematology (ASH) illustrate how the use of advanced modeling techniques is optimizing stem cells to treat patients with blood disorders, as well as the potential of enhanced treatment strategies to improve the success rate of hematopoietic stem cell (HSC) transplantation for these patients.

Hematopoietic stem cell transplantation is effectively used today as a form of “replacement” therapy for patients with hard-to-treat blood conditions, providing healthy HSCs to help patients whose bodies cannot properly fight infection or disease on their own. While transplants often lead to long-term remission for many patients, researchers are now challenging traditional assumptions in an effort to further improve success rates while minimizing the remaining risks associated with transplantation.

Following are three abstracts of research findings presented at the ASH Annual Meeting.

1. Targeting Histone Deacetylases as a New Strategy for Graft Versus Host Disease Prevention

New research shows that the addition of the oral anti-cancer agent vorinostat to standard therapy given before, during, and after hematopoietic stem cell transplantation (HSCT) may safely reduce the incidence and severity of a challenging complication called graft-versus-host disease (GVHD).

HSCT is the primary form of treatment for many patients with blood disorders; it involves the transplantation of healthy blood-forming stem cells from the bone marrow, circulating blood, or umbilical cord blood to replace damaged, disease-causing cells in recipients. Despite the therapeutic benefits of HSCT, half of all patients who receive transplants from a related donor (allogeneic HCT) develop acute GVHD, a life-threatening condition occurring when the newly transplanted cells identify the recipient’s body as foreign and attack the recipient’s own cells.

Currently, HSCT patients receive prophylactic therapy before and after transplant to prepare their bodies for the procedure and to help manage their subsequent immune response. While this series of drugs is designed to help reduce patients’ risk of developing GVHD, it also compromises their immune systems, leaving them vulnerable to serious infections and complications. Recent research has sought to determine ways to improve patients’ initial immune response to transplanted cells as well as promote faster immune recovery after transplant.

Recent early-stage studies have demonstrated that a class of anti-cancer drugs known as histone deacetylase inhibitors (HDACi) may safely reduce the risk of GVHD in patients. These drugs have demonstrated an ability to “turn off” an enzyme that leads to inflammation, a major contributor to GVHD that develops as a byproduct of patients’ intense immune response to HSCT. Based on those early results, researchers initiated the current study to evaluate whether one drug in this class, vorinostat, might reduce the risk of acute GVHD when added to current regimens.

To test this hypothesis, researchers enrolled 45 patients undergoing matched related donor HSCT from transplant centers at the University of Michigan in Ann Arbor, Mich. and Washington University in St. Louis to compare results of a standard regimen with vorinostat to historical controls. The primary endpoint of the single-arm, Phase I/II trial was the cumulative incidence of grade 2-4 acute GHVD (grade 1 is mildest; grade 4 is most severe). They aimed for an incidence of no more than 25 percent, compared with historical average rates of 42 percent.

Patients participating in the study received oral vorinostat daily in addition to standard preventive treatments prior to, during, and for 100 days after transplantation. After treatment, these patients had a significantly lower incidence of GVHD than their historical controls (22 % vs. 42%) and had lower rates of severe (grade 3-4) GVHD (4% vs. 19% in controls) and transplant-related mortality at one year (13% vs. 19% in controls). There were no differences in rates of infectious complications or incidence of relapse, indicating that vorinostat helped reduce the risk of GVHD in patients without further compromising their immune systems.

“While GVHD remains a challenging complication that affects a large proportion of patients who receive stem cell transplants, we are encouraged by the significant reduction in both the incidence and severity of this life-threatening condition that we observed in this trial,” said Pavan Reddy, M.D., senior author and Co-Director of the University of Michigan Bone Marrow Transplant and Hematologic Malignancies Program. “In order to increase the use of transplants and make them safer for more patients who need them, we need to see if this treatment approach may be successful in patients who receive stem cells from unrelated donors, and whether it may work among patients who are at high risk for severe GVHD. Moreover, we would like to confirm our findings in a larger, Phase III clinical trial.”

 

2. No Survival Advantage after Double Umbilical Cord Blood (UCB) Compared to Single UCB Transplant in Children with Hematological Malignancy: Results of the Blood and Marrow Transplant Clinical Trials Network (BMT CTN 0501) Randomized Trial

A study evaluating the efficacy of hematopoietic stem cell (HSC) transplants using single versus double units of transfused umbilical cord blood (UCB) for children with hematologic malignancies finds that the single unit approach remains the gold standard, refuting the notion that “more is better” in this clinical setting.

UCB contains a high concentration of HSCs with a unique immune profile that permits a high degree of human leukocyte antigen (HLA, proteins on white blood cells that determine compatibility between donor and recipient) mismatch, making it an increasingly popular source of HSCs for transplants. Questions remain, however, regarding the optimal quantity of transplanted umbilical cord stem cells. Previous research has found that double UCB transplant (the co-infusion of two partially HLA-matched units) is effective, particularly for adults for whom a single UCB unit is inadequate. Since prior research has connected cell quantity with survival, researchers hypothesized that a double UCB transplant may be superior to the use of a single unit in children with blood cancer for whom two units were available.

For this study, a team of researchers within the Blood and Marrow Transplant Clinical Trials Network examined whether the use of two units of UCB would offer a significant advantage in overall survival and other transplant outcomes such as blood and marrow recovery time, risks of acute and chronic graft-versus-host disease (GVHD), and transplant-related mortality and relapse.

As part of the multi-center, Phase III trial, 224 pediatric acute leukemia patients were randomized to receive either a single- or double-unit UCB transplant. After a median of 25 months of follow-up, nearly all patients (92%) in both study arms were in remission, with similar overall survival rates at one year post transplant between the groups (71% vs. 66% for the single vs. double unit, respectively). Overall, outcomes were similar between the groups, including disease-free survival (68% vs. 64% in single vs. double) and rates of relapse (12% vs. 14%), suggesting the double UCB transplant did not offer additional therapeutic benefit. While both study arms had the same overall rate of GVHD (57% each), patients who received a double UCB transplant experienced a higher risk of severe (grade 3-4) GVHD (23% vs. 14% for single unit patients), possibly attributed to the greater number of transplanted HSC.

“Our findings, though unexpected, affirm that the standard transplant approach of a single umbilical cord blood unit is optimal so long as the unit offers a sufficient number of cells. The study also demonstrated that a double umbilical cord blood transplant, while not better than a single cord blood transplant, can be an effective strategy among mainly adult patients for whom a single unit of cells is insufficient,” said John Wagner, M.D., lead author and Director of the Pediatric Blood and Marrow Transplant Program at the University of Minnesota in Minneapolis. “With this in mind, we need to focus our efforts on the development of new strategies that will enhance the speed of engraftment and immune recovery – and the double umbilical cord blood model may be a useful tool for achieving that goal.”

 

3. Prolonged Strenuous Exercise Expands the Population of Developmentally Early Stem Cells in Bone Marrow (BM) and Mobilizes them into Peripheral Blood — Novel Evidence that Strongly Supports a Positive Effect of Physical Activity on Extension of Life Span at the Level of Stem Cells

Researchers have demonstrated through a mouse model study that the beneficial effect of exercise on lifespan may be specifically related to the increase of a certain type of primitive stem cell believed to play an important role in tissue and organ regeneration.

Established research cites the benefit of exercise in reducing the risk of disease and managing chronic conditions, and studies have already shown that physical activity helps to mobilize stem cells, or move them from the bone marrow into the bloodstream. Taking this one step further, researchers focused their study on investigating the activity of the primitive stem cells (known as very small embryonic-like stem cells or VSELs) to directly assess whether strenuous exercise could increase the presence of a pool of developmentally early and highly potent stem cells in the blood stream. They hypothesized that the increased presence of these stem cells in the blood stream may enhance the rejuvenation of organs and tissues and potentially extend the lifespan.

To test their hypothesis, the team exposed the mice to various periods of strenuous exercise on rotating wheels (short-term at 1 day, mid-term at 14 days, and long-term at 6 months). The length of exercise was positively correlated to the counts of these primitive cells in their bone marrow and circulating blood, with the greatest increase in overall counts being in the group with the longest exercise exposure. The team also found similar correlations between the rates of exercise and the active function of genes that assist in organ and tissue regeneration. The data show that prolonged, strenuous exercise in mice is associated with the increased quantity of these important primitive stem cells in the bone marrow and their movement into the bloodstream.

“These data makes a compelling argument that exercise may not only prevent health issues that tend to emerge as people age, but may also help improve the body’s ability to heal damaged tissue and organs,” said Mariusz Ratajczak, M.D., Ph.D., senior author and Director of the Stem Cell Institute at the James Graham Brown Cancer Center of the University of Louisville in Kentucky. “Additional studies need to be conducted to better define the role of these early stem cells in healing tissue damage, extending the lifespan, and maintaining health during the aging process, as well as to understand how we might be able to harness them for further therapeutic benefit.”

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Drs. Wolfe and Winston Participate in eSVS® Mesh Clinical Trial at NGMC

Tuesday, February 19th, 2013

J. Alan Wolfe, M.D., and A. Daniel Winston, M.D., cardiovascular surgeons with Northeast Georgia Physicians Group Cardiovascular & Thoracic Surgeons, recently implanted new technology that could improve the quality of life for patients who need heart bypass surgery as part of an initial feasibility clinical trial. The surgery was performed at Northeast Georgia Medical Center (NGMC) on February 5, 2013, with a second patient treated as part of the trial on February 13.

“We are very early in the process and still have a lot to learn, but, if this product performs like many in the clinical world think it will, it could be the biggest game-changer heart surgery has seen in decades,” says Dr. Wolfe.  “We’re talking about improving a basic principle of the way bypass surgery has been performed since the late 1960’s.”

Heart bypass surgery is typically performed when one or more of a patient’s coronary arteries are blocked, which makes it difficult for the heart to pump blood to the rest of the body.  The surgeon will take healthy arteries or veins from other parts of the patient’s body and attach them to the blocked artery in a way that allows blood flow to “bypass” the blockage.

Saphenous veins are most commonly used to bypass blockages, because they are readily available in most patients, but using them presents two key issues:

1)    Saphenous veins are also more likely to degenerate following surgery because they have thinner, less rigid walls than arteries.

2)    Veins have a normal blood pressure of 10, which is significantly less than the blood pressure of 120 in arteries.

That’s where the eSVS Mesh comes in. It’s an extremely thin, flexible tube of knitted mesh metal (nitinol) that is placed around the saphenous vein, like a sheath, to make the vein stronger and prevent enlargement. Medical research suggests that the sudden enlargement of the vein bypass graft often results in a buildup of plaque within the graft that ultimately causes it to narrow and stop working.

“Recent studies confirm that as many as 30-40 percent of saphenous vein grafts are closed within one year after surgery, which means patients may have to come back for a second surgery down the road and are put at risk for future heart attacks,” says Dr. Wolfe.  “As a clinician, our goal is to devise a way to make the vein perform more like an artery.  If the eSVS Mesh proves to help accomplish that goal, it may help spare patients the pain and expense of future heart problems.”

Dr. Wolfe says the first eSVS patient treated at NGMC is doing well and recovering normally at home. Although NGMC is currently the only hospital in the United States participating in the clinical trial, several other  cardiac surgery centers from across the nation – including Cleveland Clinic, Mayo Clinic and Emory University – are expected to join the clinical trial.

The trial site at Northeast Georgia Medical Center is coordinated by the research department of Northeast Georgia Heart Center, a private cardiology practice affiliated with Northeast Georgia Health System.

Dr. Wolfe received his medical degree from Duke University and completed his residency at Brigham and Women’s Hospital, Bellevue Hospital and New York University Hospital. In addition to being the first surgeon in the nation to implant the eSVS Mesh in a patient, Dr. Wolfe has developed his own technique of minimally invasive heart valve reconstructions.

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Piedmont Welcomes Urologist J. Maxwell White, Jr., M.D.

Tuesday, February 19th, 2013

J. Maxwell White, Jr., M.D. has joined Piedmont Physicians Urology Specialists practice, which also includes Rajesh Laungani, M.D., associate director of Piedmont Atlanta Hospital’s robotics and minimally invasive surgery program, Nikhil Shah, D.O., chief of minimal access and robotic surgery at Piedmont Healthcare, and Matthew Sand, M.D.

Previously, Dr. White was in private practice for more than 20 years.  He also was an assistant professor in the Division of Urology at Emory University.

Dr. White earned his bachelor’s and medical degrees from Emory University. He completed his internship in surgery and residency in urology at the Naval Medical Center, and served as a medical officer in the U.S. Navy.

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Emory Healthcare Acquires Paces Plastic Surgery Center

Tuesday, February 19th, 2013

Emory Healthcare has acquired the plastic surgery practice of Roderick Hester, MD, and Foad Nahai, MD, along with the Paces Plastic Surgery Center, located in Buckhead. Both Hester and Nahai are associate professors of surgery, Division of Plastic and Reconstructive Surgery, at Emory University School of Medicine.

Drs. Hester and Nahai offer plastic surgery, including breast reconstruction; ocular-plastics and ophthalmology; facial plastics and otolaryngology (including head and neck reconstruction; and hand and upper extremity reconstruction.

The acquisition will be finalized in Spring 2013, at which time the Paces Plastic Surgery Center will change its name to Emory Aesthetics Center, and the practice will become part of The Emory Clinic’s Division of Plastic and Reconstructive Surgery.

Hester founded what was then called Paces Plastic Surgery and Recovery Center in 1993. It is a comprehensive center for the care of plastic surgery patients, and includes clinical areas, operating rooms, overnight recovery suites. The center will offer an array of nonsurgical support and treatment services including CoolSculpting, photofacials, hydrafacials, laser hair removal, chemical peels and more.

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Kenney Employs Minimally Invasive Surgery Technique at Northside-Forsyth

Tuesday, February 19th, 2013

Dr. Patrick Kenney recently performed Northside Hospital-Forsyth’s first Single-Site™ (single-incision) surgery, a gallbladder removal, using the da Vinci® Surgical System, as part of its robotic surgery program.

Minimally invasive robotic surgery has given surgeons better tools to perform more complicated procedures with great precision and achieve better outcomes for their patients. In traditional laparoscopic and robotic surgery, surgeons make several small incisions for the tools and camera needed to perform the procedure. However, Single-Site technology allows surgeons to eliminate multiple incisions and place all the instruments through a single 2-to-2.5-centimeter port, often at the bellybutton, to reduce the appearance of scarring.

“Single-Site allows me to operate with perfect ergonomics, enhanced 3-D visualization and fine instrument control,” said Dr. Kenney, adding that patients benefit from the advantages of minimally invasive surgery with less pain and blood loss, a quicker recovery and an almost invisible scar once healed. “My robotic patients have faired just as well postoperatively as my non-robotic patients, with the notable difference that their operative times were significantly shorter with the robot.”

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New Physical Therapy Clinics Open in Underserved Areas of Atlanta

Tuesday, February 19th, 2013

The need for advanced physical therapy expertise in underserved areas has led BenchMark Physical Therapy to add two clinics in East Point and Douglasville.

Aaron Honeycutt, PT, DPT, serves as clinic director of the East Point clinic and offers expertise in sports medicine, orthopedic manual therapy and dry needling, which are specialized techniques aimed at relieving pain and increasing mobility.

Melinda Elder, PT, DPT and Shane Anthony, PTA, treat patients at the Douglasville clinic and offer advanced training in orthopedics and worker’s compensation.

 

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GPPA 2013 Winter CME Meeting

Friday, February 15th, 2013

February 15-16, 2013, Atlanta. For more information, visit Georgia Psychiatric Physicians Association

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