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Archive for October, 2014

MAA Mentoring Social

Thursday, October 30th, 2014

October 30, 2014, Home of Dorothy Mitchell-Leef, Atlanta. For more information, visit The Medical Association of Atlanta

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N. Spencer Welch, MD

Wednesday, October 29th, 2014

Dr. Welch head shotN. Spencer Welch, MD, was born and raised in Atlanta. He received his undergraduate degree at Princeton University and then came home to Emory University for medical school. He did his internship and residency at Emory, Grady Hospital and affiliated hospitals. He did a chief residency at Crawford Long Hospital before doing a Fellowship in Endocrinology at Emory where he did research in development a method to measure insulin resistance in Type 2 Diabetes patients.

Dr. Welch wrote Diabetes Is Advancing: Are You Keeping Pace? from ATLANTA Medicine, Diabetes, Vol. 85, No. 4

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Spotlight on Hepatitis C

Wednesday, October 29th, 2014

By Helen K. Kelley

From ATLANTA Medicine, Vol. 85, No. 4

Lance Stein, MD

Lance Stein, MD

Hepatitis C, the most common blood-borne infection in the United States today, is considered a public health threat. From new medications just entering the market and clinical trials to educational efforts and a push for identifying those who have the infection, hepatitis C is a hot topic among medical practitioners in Atlanta and elsewhere.

Baby Boomers at risk; new meds have unprecedented success

Hepatitis C is most prevalent in the Baby Boomer generation – those born between 1945 and 1965 – many of whom are asymptomatic and don’t yet know they have the infection. Roughly three-fourths of the current population is now aging and falling into the targeted bracket for having the infection, according to Lance Stein, M.D., a transplant hepatologist at Piedmont Transplant Institute.

“Age is important. If you are infected with hepatitis C, it can do significant damage to the liver … and it actually takes approximately 30 years for that to happen in most patients. So, let’s say if a person was infected in 1970 and is now turning 65, that’s when we’ll begin seeing the problems,” he explains. “Hepatitis C has become a big public health issue. This is why there’s been a huge increase in the establishment of liver cirrhosis clinics and transplant clinics.”

Stein adds that the uptick in patients identified as having hepatitis C just happens, fortunately, to coincide with helpful advances in medicine.

“Hepatitis C has been ‘blowing up’ in terms of new treatment options. These new drugs are much more effective than older treatments like Interferon and Ribavirin, both of which carry significant side effects. But the new treatments are also much more expensive,” he says.

According to Stein, sofosbuvir (Solvadi), which was approved by the FDA in December 2013, is priced at about $84,000 for a three-month treatment. That equates to roughly $1,000 per day. However, the drug has been highly successful to date, with an approximate 89 percent cure rate in people with hepatitis C type 1. Stein says that the high cost upfront may actually end up saving patients and insurers money in the long run.

“The higher cure rate of sofosbuvir, along with fewer side effects than previous treatments, means fewer doctor visits and lab tests than previously required on a regimen like Interferon. It may also prevent the need for a transplant in the future,” he notes. “Some even newer drugs are currently awaiting approval later this year. This is exciting because clinical trials show cure rates for these new treatments are almost 100 percent after a three-month regimen.”

Aasim M. Sheikh, M.D., who specializes in the treatment and management of liver diseases as a gastroenterologist, hepatologist and clinical researcher with GI Specialists of Georgia, agrees that the new drugs hold great promise for people infected with hepatitis C.

Enrique Martinez, MD

Enrique Martinez, MD

“The envelope is being pushed,” he says. “Researchers – big players like Merck, Gilead, Johnson and Abbott – are looking for regimens that combine drugs to result in a minimum number of pills with the fewest side effects and shortest treatment.”

Sheikh adds that there are four different classifications of drugs that are proving to work well in combination.

“These drugs block the hepatitis C virus at different points, shutting down different enzymes that help the virus multiply,” he explains. “Together, they have a synergistic effect in controlling the virus.”

Sheikh states that the most important keys to treating and curing hepatitis C are: identifying people who have the infection; prioritizing and treating those who have the most advanced disease; the development of more effective treatments of shorter duration and fewer side effects; and analyzing the results of various treatment protocols.

“The more people we treat, the more we find out,” he says. “We hope to alter the course of their illness and keep them at a lower risk for further complications.”

Enrique Martinez, M.D., a gastroenterologist and hepatology specialist with Atlanta Gastroenterology Associates, has watched the progression of hepatitis C treatments since he began practicing in 1989.

“This is a very exciting time. It’s amazing when you consider that a disease with only an 8 percent cure rate 25 years ago is now approaching a 100 percent cure rate,” he says. “And it’s interesting that today we consider treatments with a less than 95 percent cure rate to be inferior. Pharmaceutical companies are constantly looking at new combinations of drugs that could result in better and better cure rates for hepatitis C patients.”

Martinez adds that the evolution of drug combinations also holds great promise for special populations with hepatitis C.

“People we previously thought could not be treated for hepatitis C are now being considered possible candidates for the new drug regimens,” he says. “These populations include people with immune disorders such as lupus and rheumatoid arthritis, sickle cell disease or colitis. Even people who must undergo dialysis or who are pre- or post-transplant patients have new hope for treatment.”

Lesley Miller, MD

Lesley Miller, MD

Providing care to an underserved population

The Grady Liver Clinic at Grady Memorial Hospital, established in 2002, is an innovative model for expanding access to hepatitis C care for urban, underserved patients. This population is disproportionately affected by the infection. Dr. Lesley Miller, the clinic’s medical director, says the facility is a unique and revolutionary model because it is run and staffed by general internists (rather than specialists), who work together to provide hepatitis C management – including antiviral treatment – to patients regardless of their insurance status.

“Patients without options for specialty care really benefit from this clinic,” Miller says. “We do a lot of education and counseling, and we provide immunizations against hepatitis A and B, evaluation of liver disease and medical comorbidities, and treatment options. We’re one of the only places [in Atlanta] that can offer these services to people who don’t have health insurance.”

A study of the Liver Clinic’s population for its first five years of operation showed that it was primarily African American (76 percent) and uninsured (59 percent). Patients had difficult-to-treat characteristics, including genotype 1 hepatitis C (90 percent), advanced liver fibrosis (28 percent), and high viral loads. Sixty-seven percent had comorbid medical conditions, and 40 percent had psychiatric disease. Fourteen percent of patients were treated for hepatitis C during the study period.

With those early statistics in mind, Miller is pleased with the medical advances that have made hepatitis C treatment easier for the Clinic’s current patients and is excited about the speed at which new treatment options are progressing.

“It’s unbelievable how fast the research and development in the world of hepatitis C are changing. Things I was doing last month are already different,” she says. “More of our patients are now candidates for treatment than have been in the past, because treatment duration is shorter and the regimens are easier or more relevant for people who have other chronic health problems. It’s gratifying to give patients a regimen that’s not going to make them sick and has a high probability of curing them.”

The stats on hepatitis C

In the National Health and Nutrition Examination Survey (NHANES), conducted between 2003 to 2010, researchers studied people with hepatitis C in order to estimate the prevalence of chronic HCV infection and to identify factors associated with the condition. The survey included interviews and testing of serum samples from participants aged six years and older.

Based on 273 participants who tested positive for HCV RNA:

• The estimated prevalence of HCV infection was 1.0 percent (95 percent CI, 0.8 percent to 1.2 percent), corresponding to 2.7 million chronically infected persons (CI, 2.2 to 3.2 million persons) in the U.S. non-institutionalized civilian population.

• Infected persons were more likely to be aged 40 to 59 years, male, and non-Hispanic black and to have less education and lower family income.

• Factors significantly associated with chronic HCV infection were illicit drug use (including injection drugs) and receipt of a blood transfusion before 1992; 49 percent of persons with HCV infection did not report either risk factor.

Based on the data collected, researchers estimated that approximately 2.7 million U.S. residents in the population sampled by NHANES have chronic HCV infection. The study highlighted the continued urgency of identifying the millions of persons who remain infected and linking them to appropriate care and treatment.

In the news

According to a recent article in The New York Times, “sales of the new hepatitis C drug Sovaldi reached $3.5 billion in the second quarter, a huge figure that puts it on track to become one of the world’s best-selling medicines but could intensify concerns about society’s ability to pay for it.”

The FDA-approved drug, manufactured by Gilead Sciences, is for patients with hepatitis C virus (HCV) genotypes 1, 2, 3 or 4 infection.

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Diabetes Is Advancing: Are You Keeping Pace?

Wednesday, October 29th, 2014

By N. Spencer Welch, MD

From ATLANTA Medicine, Vol. 85, No. 4

Dr. Welch

N. Spencer Welch, MD

Diabetes is not going away. As America becomes more sedentary and more overweight, and as developing countries “ westernize” their diets, the incidence of diabetes – especially Type II – is skyrocketing.

While the incidence of the disease is increasing at an alarming rate, we are continuing to advance our knowledge into the pathophysiology of both Type I and Type II diabetes, leading to new forms of therapy. Our technology to detect and monitor these diseases has advanced as well. Hopefully our advances in pathophysiology, treatment and technology will both prevent future cases of diabetes as well as make the lives of those who have diabetes healthier and happier.

Right now the incidence of diabetes in the U.S. is about one in 10, and there are dire predictions that unless we do something to change our course, one in three Americans may have diabetes by the year 2050. Diabetes and obesity are closely linked, so as the incidence of obesity goes up the incidence of diabetes goes up.

Unfortunately, this starts at an early age. When I was growing up in the 1960s, the overweight child was the exception. Now in America’s elementary school, every third desk is occupied by an overweight child. Today, in children under the age of 12 presenting with diabetes, the likelihood that it will be Type II Diabetes instead of Type I is 45 percent.

To combat these rising rates, we must educate both parents and children about proper nutrition and exercise. These skills are just as important as any other life skills to ensure that the life expectancy of future generations is just as high as or higher than it is right now.

footDue to the efforts of such great researchers like Dr. Ralph De Fronzo, our knowledge of the pathophysiology of Type II diabetes, the most prevalent form, has increased dramatically. Researchers have been peeling away the layers of the onion to get to the core defects of the disease so that we develop specific treatments to target each of these core defects.

In the early 1990s, Dr. De Fronzo outlined the triumvirate of insulin resistance, impaired insulin secretion and increased hepatic glucose output as the basic pathophysiology behind Type II diabetes. However, new research has led Dr. De Fronzo to expand from the triumvirate to the ominous octet.

This means eight separate areas can be targeted therapy. 1) The pancreatic beta cell because of decreased insulin secretion. 2) The pancreatic alpha cell because increased glucagon secretion. 3) Incretin hormones because Type II diabetics are to some degree both incretin deficient and incretin resistant. 4) The kidney because it is responsible for reabsorption of glucose from the urine. 5) The sympathetic nervous system because increased sympathetic tone increases blood glucose. 6) The muscles because insulin resistance decreases glucose uptake in the muscles. 7) The liver because of increased hepatic glucose output and lastly 8) Adipose tissue because increased lipolysis is toxic to the beta cell and increases insulin resistance.

The ominous octet is just our latest stopping point in understanding Type II diabetes, but our understanding of this disease is ever widening.

When I started practice more than 25 years ago, human insulin had just recently become widely commercially available and the sulfonylureas were the only class of oral agents available in the U.S. Now there are five new analog insulins, three rapid acting, two long acting and an inhaled form of human insulin on the way.

Welch and patientThe classes of oral agents have expanded from one to nine. In addition to the sulfonylureas, we now have biguanides like metformin that decrease hepatic glucose output, thiazolidinedione like pioglitazone that increase insulin sensitivity in muscle and fat, nateglinides that increase insulin secretion, alpha-glucosidase inhibitors that block carbohydrate absorption in the gut, GLP-1 agonists that give pharmacologic levels of activation of the incretin GLP-1 receptors, DPP-4 inhibitors that decrease the enzymatic degradation of GLP-1, dopamine agonists that decrease sympathetic tone, and the latest class of new anti-diabetic therapy, the SGLT2 transport blockers that decrease the kidney’s ability to reabsorb glucose. Each one of these therapies targets a specific arm of Dr. De Fronzo’s ominous octet. (See page xx for more on how Dr. Jonathan Ownby puts these agents to appropriate clinical use.)

In the 1980s, home glucose monitors were the size of cassette tape recorders, required a large hanging drop of blood to produce a glucose reading and the test time was two minutes. Insulin pumps were in their infancy, with Auto-Syringes, nicknamed the “blue brick” due to its large size and weight, that could give only a single basal insulin rate.

Now glucose monitors fit in the palm of your hand and require less than 0.5 microliters of blood. There are even smart monitors that can spot trends in blood glucose and can be programmed to calculate insulin doses. Insulin pumps are smaller and smarter. Basal insulin requirements can now be programmed hourly. The pumps can be programmed to calculate mealtime insulin when the patient feeds in their glucose and carbohydrate data.

There are now continuous glucose sensing devices that give a glucose reading every five minutes in real time to help patients on insulin pumps and multiple daily insulin injections avoid lows and combat highs to achieve better control. (See page xx for Dr. Chris Newton’s view on the latest in these technology advances and how to apply them to your patients.)

The incidence of diabetes is advancing, and we are trying to keep pace with advancing our knowledge, technology and treatment strategies. However, all of these advancements will fall short of their potential unless we have educated patients. Education is still the cornerstone of diabetic therapy because the more our patients know about what diabetes is and the more they know about how treat it, the more adherent our patients will be. Our most sophisticated therapies will be ineffective unless we give our patients the tools to implement healthy lifestyles that incorporate diet, weight loss and exercise.

 

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Norman Gitlin, MD, Named a Fellow of the American Association for the Study of Liver Disease (AASLD)

Tuesday, October 28th, 2014

Norman Gitlin, MDAtlanta Gastroenterology Associates recently announced that one of its physicians – Norman Gitlin, MD – was named a Fellow of the American Association for the Study of Liver Disease (AASLD) as part of the 2014 inaugural class of AASLD fellows. Founded in 1950, and now an international society, the AASLD is the leading organization of physicians, scientists, researchers, and health care professionals committed to preventing and curing liver disease, as well as to promoting liver health and quality patient care. The Fellow designation is considered one of the most prestigious for AASLD members. It is awarded to those who have made a significant contribution to studying and caring for patients with liver disease and who are considered leaders in the field.

For decades, Dr. Gitlin has played a key role in both the clinical research and treatment of liver diseases. A native of South Africa, his medical career began in England as a student of world-renowned hepatologist Dame Professor Sheila Sherlock (co-founder of AASLD), and went on to earn many other distinctions in the medical community, including Fellow of the Royal College of Physicians and Fellow of the American College of Gastroenterology. He previously held various academic appointments at the University of California in San Francisco and was named chief of hepatology and professor at Emory University School of Medicine in Atlanta. He has authored three textbooks on liver disease and published numerous papers on the subject, as well as served on the editorial boards for several national journals and medical societies.

For the past 15 years, Dr. Gitlin has been in private practice with Atlanta Gastroenterology Associates and sees patients at the Emory Midtown location. In addition, he serves as the Medical Co-Director of Atlanta Gastroenterology Associates’ Liver Center. His specialty includes liver transplantation, and he is an authority on drug-induced liver disease and herbal/traditional therapies used in the treatment of liver disease and hepatitis C. He is actively involved in a number of research studies, including the treatment of hepatitis C and B and non-alcoholic steatohepatitis.

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New CEO Joins Eastside Medical Center

Tuesday, October 28th, 2014

Scott SchmidlyScott Schmidly, FACHE, has been named chief executive officer (CEO) at Eastside Medical Center. Schmidly brings over 19 years’ experience in the healthcare industry in adult and pediatric hospitals as well as academic teaching institutions.

“I am honored to be a part of the Eastside family and the community we serve,” said Schmidly. “This is an exciting opportunity to collaborate with our medical staff, our caregiving team and community partners as we build momentum around expanding and enhancing our services. Because of our most valuable asset, our people, Eastside is uniquely positioned to become even more integral to advancing the way we care and deliver services across the region.”

Before joining Eastside, Schmidly served as CEO at Saint Joseph’s Hospital in Atlanta, Ga. He has also served as the chief operating officer (COO) of Medical City Dallas Hospital – Medical City Children’s Hospital in Dallas, Texas and Medical Center of Arlington in Arlington, Texas.

“Scott’s proven track record in relationship building and leadership is exactly why we asked him to be a part of Eastside’s team,” Steve Corbeil, president of HCA’s TriStar Division, said. “I’m confident in his ability to lead the team of medical professionals at Eastside to meet the healthcare needs of the community.”

Schmidly earned his bachelor’s degree from Stephen F. Austin State University in Nacogdoches, Texas before going on to complete a master’s degree in healthcare administration from Trinity University in San Antonio, Texas. He is a fellow in the American College of Healthcare Executives (ACHE) and a recipient of ACHE’s Executive Regent’s and Governor’s Awards.

 

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Georgia CAPUS Care Portal a One-Stop Online Connection to Care for HIV Positive Georgians

Tuesday, October 28th, 2014

The Georgia Department of Public Health recently announced the launch of the Georgia CAPUS Care Portal, a clearinghouse for all information related to HIV/AIDS in the State of Georgia. The portal is administered by the HIV Prevention program of the Georgia Department of Public Health (DPH) and is the result of two years of planning and creation.

CAPUS, which stands for Care and Prevention in the United States, is a cross-agency project led by the Centers for Disease Control and Prevention (CDC) that aims to create more efficient and more effective systems to improve HIV testing, linkage to and retention in care, specifically targeting highest risk minority populations. Georgia was one of only eight states in the U.S. to be awarded a portion of a $44.2 million dollar grant from the CDC. Georgia DPH received $7.5 million to be used in part for the design and implementation of the CAPUS Care Portal.

There are more than 50,000 people living in Georgia who are HIV positive, 45 percent of those people are not in care. One out of five HIV positive people in Georgia don’t know they are HIV positive. Finding sustainable HIV treatment and care is the single, most important connection HIV positive individuals can make. But for many, navigating through different systems can become so frustrating, that a connection to care is never made.

“HIV information currently available online can be confusing or conflicting. The CAPUS Care Portal cuts through the haze, bringing HIV positive individuals and providers closer to the truth – treatment is prevention,” said Patrick O’Neal, M.D., director of health protection for the Georgia Department of Public Health. “We know that an HIV positive individual receiving, and adhering to, an appropriate treatment regimen is 96 percent less likely to pass HIV to someone else.”

By answering five simple questions in the easy-to-use Eligibility Portal, users will learn immediately whether they may be eligible for Ryan White services. The Ryan White Program is federally funded and works with cities, states, and local community-based organizations to provide HIV-related services to people who do not have sufficient health care coverage or financial resources for coping with HIV disease.

Continuing toward care is even simpler. Users indicated as eligible for Ryan White services in the portal can request that a provider in the nearest Ryan White clinic contact them directly and discreetly to arrange for a clinic appointment. At the clinic, a Ryan White caseworker will help determine individual care, often at no cost.

The Mapping and Testing Tool provides important data everyone can use to connect more Georgians with quality HIV treatment and care. The public component features a testing map, which lists testing event dates and locations across the State of Georgia, along with a graphic display of HIV/AIDS incidence in our state. Community Based Organizations (CBO) and health care providers can use the HIV Continuum Visualizer – a specialized map for health care professionals to make better decisions on testing, outreach, and linkage-to-care by using current surveillance, or incidence data.

Normal web searches can’t match the portal’s Resource Directory – an online tool to help locate local services for people living with HIV and AIDS. By selecting an area of our state, users are connected with essential services in the most important categories: HIV testing, medication assistance, oral health, food assistance, case management, treatment, housing assistance, mental health, substance abuse, primary care, family planning, shelters, funeral services, legal services, spiritual resources, LGBTQ friendliness, and transportation.

The Medical Information Pates cut through confusing or conflicting information and provide relevant, fact-based information for people living with HIV or AIDS, for service providers, and for anyone wanting to know more.

You can see and explore the features of the CAPUS Care Portal at gaCapus.com.

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Northside Hospital Healthcare System Announces New Robotics Procedures

Tuesday, October 28th, 2014

Northside Hospital Healthcare System recently announced the introduction of three advanced robotic surgery technologies: The Magellan Robotic System, the da Vinci Xi Surgical System and the MAKOplasty surgical arm.

Northside Hospital is the first healthcare institution in the state of Georgia to utilize the Magellan Robotic System. The Magellan Robotic System, designed to perform a myriad of minimally invasive endovascular procedures, will be available at both the Atlanta and Forsyth campuses.

“This technology will grant an unprecedented level of precision to Northside vascular surgeons navigating the extremely complex anatomy of peripheral blood vessels,” said Dr. Joseph Ricotta, chair of vascular surgery & endovascular therapy at Northside Vascular Surgery, medical director of vascular services, Northside Hospital Heart & Vascular Institute and the lead Northside physician for the procedure.

The Magellan Robotic System is able to robotically shape endovascular catheters during the procedure, so that a single catheter may be used instead of exchanging for various pre-shaped catheters during the procedure.  Magellan Robotic Catheters can rotate 360 degrees, and bend 180 degrees in any direction.  This may lead to fewer catheter exchanges during the procedure, more predictable procedure times and may help facilitate navigation through very complex anatomy, potentially leading to less radiation and contrast exposure, making the procedure safer for the patient.

Magellan allows doctors more control and precision while navigating catheters through small blood vessels in complex vascular procedures. This leads to higher procedural success rates and enables more patients to be treated by less invasive endovascular methods rather than open surgery.

The da Vinci Xi Surgical System, the latest version of the da Vinci robot, is already being utilized for complex procedures like partial nephrectomy (kidney removal). Dr. Scott Miller performed the first surgery with this device in Georgia on October 1. The Xi is the newest iteration of the robotic system and comes with a whole suite of improved patient outcomes. The Xi provides multiple benefits like better visualization and multi-quadrant access (a boom overhead that gives the surgical team more room around the patient).

The MAKOplasty procedure at Northside Hospital-Forsyth has helped improve the surgical outcomes of patients requiring hip and partial knee replacements. Through 3D models, motion capture and real-time virtual views of the patient’s anatomy, doctors are able to provide more accurate fittings and ensure that post-procedure pain is reduced significantly for patients.

“MAKOplasty provides hip and partial knee replacement patients that qualify with a more appealing solution,” said Dr. Jon Minter, orthopaedic surgeon at Northside Total Joint Specialists and lead MAKOplasty physician. “The system allows surgeons to fine-tune the implant’s positioning and shape, making the most accurate joint replacements available and increasing patients’ mobility faster than ever before.”

 

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Transforming Clinical Practice Initiative to Award $840 Million to Fund Collaboratives and Practice Transformation Networks

Monday, October 27th, 2014

A new initiative, recently announced, is expected to deliver stronger health outcomes by giving medical practices the technical assistance and peer-level support they need to deliver efficient patient-centered care.

As a new model of the Centers for Medicare & Medicaid Services (CMS), the Transforming Clinical Practice Initiative will award $840 million for the creation of evidence-based, peer-led collaboratives and practice transformation networks to support physicians in providing high-quality care.

“The Transforming Clinical Practice Initiative will achieve a number of important goals,” said American Medical Association (AMA) Board Chair Barbara L. McAneny, MD, who participated in a CMS call announcing the initiative. “It will foster collaboration among a broad community of practices of various sizes, including collaboration between primary care physicians and specialists. It will also develop a network for sharing information among medical societies as well as multi-stakeholder regional collaboratives to support practice transformation.”

The networks, which will be announced in the late spring, are expected to support 150,000 clinicians beginning May 1. Anticipated strategies include giving physicians better access to patient information, expanding how patients can communicate with their health care team and improving coordination of care.

The AMA has been urging CMS to assist physician practices in their efforts to adopt new payment and delivery models under physician leadership, a primary goal of this new model.

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American Medical Association Provides Online Ebola Resource Center

Thursday, October 23rd, 2014

The Centers for Disease Control and Prevention (CDC) confirmed the first U.S. case of Ebola on September 30 and developments associated with the virus continue to unfold. Prepare your practice and your patients with resources developed by Ebola experts and assembled by the AMA in one convenient location.

Visit the AMA’s online Ebola Resource Center at http://www.elabs10.com/ct.html?ufl=9&rtr=on&s=x8pbgr,21u7z,43mj,ljml,gti3,dlm2,loql for information from the CDC and other public health groups.

Resources cover:

  • Understanding the virus
  • Preparing your hospital or practice
  • Screening and diagnosing Ebola
  • Treating patients with the virus

The resource center will be updated regularly to give you, your practice staff and your patients the most up-to-date information you need.

 

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