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Archive for June, 2017

Urology Spotlight

Monday, June 19th, 2017

An interview with Drs. Drew Freilich, Mehrdad Alemozaffar, and John G. Pattaras

By Helen Kelley

Advancing technologies and noninvasive treatments, along with more open communication between physicians and patients, are improving the lives of people with urological conditions and diseases, from incontinence to cancer. Atlanta Medicine recently spoke with specialists who are excited to share their knowledge of the changing landscape of urology.

Minimally invasive procedures for benign prostatic hyperplasia

A growing number of older and younger adults are willing to seek out treatment for chronic conditions that have had a long-term negative impact on their quality of life, says Drew Freilich, M.D., a urologist with Urology Specialists of Atlanta.

“We’re seeing a trend of patients of all ages who are willing to be more aggressive in the treatments they want. They don’t want to continue using catheters and they are more open to accept the risks of undergoing anesthesia for procedures that can help them,” he said. “We’re also finding that cardiologists are more open to clearing older and sicker patients to go into the O.R.”

One example is men who suffer from an enlarged prostate, which causes inability to urinate and often requires them to stay catheterized and/or to take multiple medications. Freilich cites some minimally invasive procedures that are effectively reducing prostate size in cases of benign prostatic hyperplasia (BPH).

Drew Freilich, M.D

“Historically, in cases of benign prostatic hyperplasia, if the prostate grew to a certain size — over 80 grams — open surgery would be performed to remove it. Today, we use a GreenLight laser to remove prostate tissue,” he explained. “The laser technology has been around for several years now. The procedure involves inserting a small fiber into the urethra through a cystoscope and basically ‘vaporizing’ the tissue. The procedure has lower risk of bleeding than previous treatments and improves urinary flow immediately.”

Freilich says two newer procedures — UroLift and Rezūm — are also effective treatments for relieving the symptoms of BPH with minimal risks for the patient.

“UroLift is sort of a ‘glorified stapler.’ We place implants that hold the enlarged prostate tissue out of the way to relieve compression on the urethra,” Freilich said. “Rezūm is an ablation procedure that uses radiofrequency general thermal therapy, or ‘hot steam,’ to destroy the extra prostate tissue that is causing the symptoms.”

Freilich says both procedures quickly improve urinary flow and have minimal side effects.

“UroLift and Rezūm both have good long-term outcomes,” he said. “The low risks and fast recovery time make this procedure popular with both older and younger men.”

Freilich adds that a large part of his practice is comprised of people who have finally sought help after suffering long-term from conditions such as BPH, urinary incontinence and erectile dysfunction.

“Many of them don’t know there is help for their conditions or have been too embarrassed to bring it up,” he said. “As physicians, we must be more proactive about having open discussions so that patients will understand there are options available to them that can improve their quality of life.”

Robotics improve cancer treatments

“Almost every case I’ve done this week has used a scope,” says John G. Pattaras, M.D., Associate Professor of Urology at the Emory University School of Medicine and Chief of Emory Urology services at Emory Saint Joseph’s Hospital. Pattaras, who started the laparoscopic and robotic urologic surgery at Emory 17 years ago, adds that technology has evolved to make a wide variety of surgeries — including those for kidney, prostate and bladder cancers — more effective.

John G. Pattaras, M.D

“Robotics allow us to see better inside the patient. It’s not just diagnostic; it’s changed our ability to do reconstructive surgery,” he said.

Pattaras says that robotic surgery has made treatment of kidney cancer, in particular, more successful.

“In the last several years, we have seen mounting evidence that if we could remove the cancerous tumor from the kidney and spare the organ itself, the patient has a longer life expectancy. For certain size and stage tumors, removing the kidney itself has equal outcomes as far as cancer control. But this is not a good option for people who have only one kidney,” he said. “Robotic surgery gives us the precision to remove tumors, curing the cancer while preventing further deterioration of the kidney.”

For prostate cancer, the surgery that has employed robotics for years, improvements have also occurred as the technology has evolved.

“This is a very compact operation, with a complex reconstruction process to restore urination and erectile function. The robot became popular about 10 years ago as an alternative to open surgery for prostate cancer,” Pattaras said. “With today’s technology, we are able to do bigger surgeries with the same number of small holes and we’re managing more aggressive cancer. Robotics allow less invasive, lower morbidity surgeries.”

New methods for detecting and treating cancer

Mehrdad Alemozaffar, M.D

Mehrdad Alemozaffar, M.D., urologic oncology surgeon and Assistant Professor of Urology, Emory School of Medicine, says there are several recent technologies that now allow urologists to more easily detect and successfully treat various cancers.

“Bladder cancer is a good example of how a new technology is helping us locate and treat cancers more effectively. Sometimes we have difficulty finding tumors in the bladder because they can be very small and might not be readily seen using a standard cystoscope,” he said. “But we now have blue light cystoscopy, which is an enhanced imaging procedure that increases our ability to detect cancers that might be missed under regular light. It involves injecting a fluorescent agent into the bladder an hour before the procedure. The blue light cystoscope then picks up areas where the fluorescence has been taken up, which is preferentially cancerous cells.”

Alemozaffar cites another technology, targeted biopsies, as a very important tool in diagnosing prostate cancer.

“When a patient comes in with an elevated PSA (prostate-specific antigen) level, the only way we can truly diagnose cancer is with a biopsy. Traditionally the way we have done that is to take tissue samples from 12 different areas of the prostate in a somewhat ‘blind’ method,” he said. “Today, we have the ability to target actual lesions seen on an MRI. The MRI determines the probability of cancer using the prostate imaging reporting and data system (PI-RADS). We are then able to see inside the prostate using a combination of the MRI and ultrasound imaging and can zoom in on the targeted area to obtain a much more precise biopsy.”

Alemozaffar adds that the targeted biopsy, which allows him to see three-dimensional images of the prostate lesions, has been a game changer for detecting prostate cancer.

“I’m able to find more clinically significant cancers using this technology than I did in the past with the blind sampling biopsy,” he said.

Fluciclovine PET/CT improves radiotherapy targeting for recurrent prostate cancer

A clinical investigation article in the March 2017 issue of the Journal of Nuclear Medicine demonstrates that the PET radiotracer fluciclovine (fluorine-18; F-18) can help guide and monitor targeted treatment for recurrent prostate cancer, allowing for individualized, targeted therapy.

“This is the first study of its kind demonstrating changes in post-surgery radiotherapy target design with advanced molecular imaging in recurrent prostate cancer, with no demonstrated increase in early radiotherapy side effects,” explains Ashesh B. Jani, M.D., of the Winship Cancer Institute of Emory University.

According to the American Cancer Society, one in seven men will develop prostate cancer in his lifetime. In 2017, more than 161,000 new cases of prostate cancer are expected to be diagnosed in the U.S., and about 26,730 deaths from the disease are anticipated.

For the study, 96 patients were enrolled in a clinical trial of radiotherapy for recurrent prostate cancer after prostatectomy. All patients underwent initial treatment planning based on results from conventional abdominopelvic imaging (CT or MRI). Forty-five of the patients then underwent treatment-planning modification (better defining the tumor-targeted area) after additionally undergoing abdominopelvic F-18-fluciclovine PET/CT. No increase in toxicity was observed with this process.

The Emory researchers determined that the inclusion of F-18-fluciclovine PET information in the treatment planning process leads to significant differences in target volumes (the areas to receive radiotherapy). It did result in a higher radiation dose delivered to the penile bulb, but no significant differences in bladder or rectal radiation dose or in acute genitourinary or gastrointestinal toxicity.

These are preliminary results in a three-year study, which hypothesizes that there will be an increase in disease-free survival for patients in the F-18-fluciclovine-modified treatment group over those in the standard treatment group.

This study could have implications beyond prostate cancer. Jani points out, “Our methodology is readily applicable to other novel imaging agents, and it may potentially facilitate improvement of cancer control outcomes.”

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Diabetic Retinopathy Update

Monday, June 19th, 2017

By Paul Walia, M.D. of Georgia Retina

Diabetic retinopathy affects nearly one-third of all patients with diabetes and is the leading cause of visual impairment and blindness in working-aged adults. The Centers for Disease Prevention and Control (CDC) estimates that currently the healthcare costs associated with the treatment for diabetic retinopathy is around $500 million annually. Projections forecast that from 2010 to 2050, the number of Americans with diabetic retinopathy is expected to nearly double, from 7.7 million to 14.6 million, mirroring trends with obesity and metabolic syndrome.

Diabetic retinopathy often begins without symptoms. It invariably affects both eyes and is usually symmetric. If asymmetric disease is present with one eye having severe changes and the other eye not showing manifestation, the ophthalmologist must be alerted to unilateral hypoperfusion, specifically carotid artery insufficiency or blockage.

Patients may have relatively good and even perfect vision at initial presentation. However as the disease progresses, patients may experience distortion of vision, floaters and decrease of vision from mild diminution to total loss of vision.

The pathophysiology of diabetic retinopathy is complex. Hyperglycemia induces vascular pericyte deficiency, which leads to an increased vascular permeability and leakage and release of pro-inflammatory cytokines. This leads to local ischemia. Clinically, increased vascular permeability is most evident as microaneurysms, cotton-wool spots, intraretinal hemorrhages, the presence of exudates and macular edema. Ischemia is discernible as the presence of neovascularization.

Figure 1: Macular Edema

The two sight-threatening consequences are diabetic macular edema and proliferative diabetic retinopathy.  Diabetic macular edema (Figure 1) affects the macula, and thus the central vision is reduced. Focal laser treatment to photocoagulate the leaking microaneurysms has long been proven an effective therapy. Advances in pharmacotherapy have allowed intravitreal injections of medication to revolutionize the treatment paradigm. (See Figure 2.)

Medications such as anti-VEGF monoclonal antibodies and corticosteroids are vital tools in the retina specialists’ tool chest to treat diabetic macular edema. A challenge with these medications, however, is that they require multiple and ongoing injections at various intervals based on their pharmacokinetics. Promising research is ongoing about other drug-delivery vehicles, such as implantable biodegradable implants, that can allow sustained delivery of medication and reduce the frequency of injections. Additionally, there are several oral medications being studied that in conjunction with intravitreal injections may reduce the treatment burden.

Figure 2: Intravitreal Injection

Proliferative diabetic retinopathy is marked by the presence of neovascularization. (See Figure 3.) The new compensatory vessels that develop in response to ischemia lack structural integrity. They can burst and result in massive vitreous hemorrhage or fibrose and cause traction retinal detachments. Treatment options include intravitreal injection, pan-retinal laser photocoagulation of ischemic retina and vitrectomy to  remove vitreous hemorrhages and delaminate the tractional tissue from the retinal surface. Improvements in vitreoretinal surgery, including small-gauge incisions, improving viewing systems and enhancements to microsurgical instruments, have allowed retina surgeons to achieve superior outcomes.

While specialists who care for retinal diseases have a variety of treatment options to address diabetic retinopathy, prevention remains crucial. Early detection is essential to reducing the devastating consequences that can occur. Estimates suggest that a routine comprehensive dilated eye exam at least once a year can reduce the risk of eye disease by 54 percent to 76 percent and lead to the early detection of eye disease.

Figure 3: proliferative diabetic retinopathy

Of paramount importance in the treatment of diabetic retinopathy is the optimization of hyperglycemia. According to The Diabetes Control and Complications Trial, controlling diabetes and maintaining the HbA1c level in the 6 percent to 7 percent range can  delay the onset or substantially reduce the progression of diabetic retinopathy. Additional risk factors for progression of diabetic retinopathy include male sex, longer duration of diabetes, insulin use and higher systolic blood pressure as well as African-American or Hispanic ethnicity.

As the number of patients with diabetes escalates, all physicians taking care of diabetic patients will be faced with the challenge of managing this chronic disease. With early detection, systemic control and retinal therapeutics, ophthalmologists who focus on retinal care are prepared to handle the fight against diabetic retinopathy.

 

Note- Figures 1 and 3 are courtesy of the Wills Eye Manual.

 

References

Saaddine JB, Honeycutt AA, Narayan KM, et al. Projection of diabetic retinopathy and other major eye diseases among people with diabetes mellitus: United States, 2005–2050. Arch Ophthalmol 2008;126(12):1740–1747.

The Wills Eye Manual : Office and Emergency Room Diagnosis and Treatment of Eye Disease. Sixth Edition. Philadelphia :Lippincott, Williams, and Wilkins. 2012.

King P, Peacock I, Donnelly R. The UK Prospective Diabetes Study (UKPDS): clinical and therapeutic implications for Type 2 Diabetes. Br J Clin Pharmacol. 1999. 48: 643-8.

Nathan D. The Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications Study at 30 Years: Overview. Diabetes Care. 2014. 37: 9-16

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Dr. Darrell Carmen receives Father of the Year award

Friday, June 9th, 2017

Darrell J. Carmen, MD

Dr. Darrell Carmen of Georgia Urology may be a noted physician, but first and foremost he’s a father. The Father’s Day Council, a philanthropic nonprofit, recognizes this. On June 29 at the College Football Hall of Fame in Downtown Atlanta, Dr. Carmen will be one of a handful of Georgia-based recipients honored at the Father’s Day Council’s Father of the Year Awards benefitting the American Diabetes Association.

This ceremony salutes men in Georgia who keep their families as the number one priority in their lives while simultaneously juggling challenging careers and community interaction. These annual awards, which take place in select cities across the country, attempt to heighten awareness of the importance of fatherhood.
“Often times we’re defined by the professions we choose,” said Dr. Carmen, “or the degrees and career accomplishments we attain along the way. At the end of the day, the gift of fatherhood is the greatest honor and privilege I’ll ever receive.”
In addition to receiving the Father of the Year Tribute Trophy, Dr. Carmen will be celebrated as a community leader and devoted dad in the form of a video presentation. He will be sharing the spotlight as part of a quartet of distinguished honorees, who also serve as forerunners in their respective communities. In addition to Dr. Carmen, the Father of the Year Awards honors Vince Dooley, former University of Georgia head football coach and director of athletics; David V. Martin, Ph.D, former executive director of the Georgia Council on Economic Education; and Thomas Carroll, head of division wealth management at SunTrust Bank.
Proceeds from event ticket sales help support the American Diabetes Association. This organization strives to prevent and cure diabetes, and improve the lives of all people affected by the disease. Together since 2000, the Father’s Day Council and the American Diabetes Association have raised more than $40 million for the American Diabetes Association.
“As a urologist, I frequently see ailments caused or complicated by diabetes,” Dr. Carmen said. “While my goal is to be the best father I can be, I also hope to leave the world a bit healthier than I found it. I’m happy to see this fundraiser attempting to do just that.”
Dr. Carmen, a married father of two, is a member of the American Urological Association, National Medical Association, American Association of Clinical Urologists, and American College of Surgeons. With specialized training in robotic surgery and InterStim therapy, Dr. Carmen has urologic expertise in prostate cancer, erectile dysfunction, penile implant surgery, urinary incontinence, and kidney stones.
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Emory among first in U.S. and first in GA to use FDA-cleared device to protect patients from stroke risk during TAVR

Monday, June 19th, 2017

Since 2007, Emory Heart & Vascular Center has offered a minimally invasive treatment option for patients with aortic stenosis. The Emory Healthcare team has performed almost 2,000 Transcatheter Aortic Valve Replacement (TAVR) procedures to date, more than any other provider in the Southeast.

Sentinel Cerebral Protection SystemEmory is now among the first in the United States to offer a newly FDA-cleared device to help protect patients from the risk of stroke during TAVR procedures. The device, called the Sentinel Cerebral Protection System, is the first FDA-cleared device of its kind available in the country.

Studies have shown that during TAVR procedures, and other endovascular procedures, calcium deposits or surrounding tissue can dislodge and travel to the brain, increasing the risk of a stroke.

The Sentinel device, manufactured by Claret Medical, is designed to filter, capture and remove this debris before it reaches the brain. It has been shown to reduce strokes by 63 percent during the procedure and in the first 72 hours after it, when most strokes occur.

During the procedure, the Sentinel device is delivered percutaneously via catheter in the radial artery of the right arm before the TAVR procedure begins. The device’s two cone-shaped filters are positioned and deployed in two vessels connecting the heart to the brain – the brachiocephalic artery and the left common carotid artery – where it can begin to trap dislodged debris. After the TAVR procedure, the device and its contents are completely removed from the vessels.

Emory participated in the U.S. clinical trial, published in the Journal of American College of Cardiology, which showed that the Sentinel device captured debris in 99 percent of TAVR cases.

Emory Heart & Vascular Center’s comprehensive, cross-functional program is a one-stop destination for all types of cardiac valve and defect treatments, from medical management to traditional and minimally invasive surgical care.

emoryhealthcare.org/rightdirection

404-778-5050

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Prospective parents can now be screened for more than 200 genetic diseases

Wednesday, June 14th, 2017

On the heels of March 2017 recommendations by the American College of Obstetricians and Gynecologists (ACOG) that encourage physicians to discuss expanded carrier screening with their patients, JScreen increased its testing panel from 100 to more than 200 disease genes that could affect a couple’s future children.

JScreen, which is based at Emory University School of Medicine’s Department of Human Genetics, provides convenient, affordable access to help singles and couples throughout the United States plan for healthy families before pregnancy.

Through a simple, at-home saliva test, JScreen allows prospective parents to find out if they are carriers for severe and often lethal diseases, such as Tay-Sachs, Spinal Muscular Atrophy and Duchenne and Becker Muscular Dystrophy, that could be passed on to their children. Participants register online for screening kits and mail their saliva samples to the lab for testing.

With JScreen, prospective parents have a unique opportunity to access screening at a low cost. JScreen’s test is significantly more comprehensive than other tests that can be ordered online. And, in contrast to other screening programs, JScreen functions under the direction of an MD specializing in genetics, and the cost includes genetic counseling via phone or secure video-conference. Through genetic counseling, couples found to be at increased risk gain an understanding of their risks and available options to help them have healthy children.

“Genetic testing alone is not enough. Counseling is a necessary part of the process. Labs that report results directly to consumers put people at risk for misinterpreting the information they need to make family planning decisions,” says Karen Grinzaid, Emory University Genetics faculty, and JScreen’s Executive Director.

The JScreen test uses state-of-the-art genetic sequencing technology to determine carrier status for diseases common in many ethnic groups and is the national leader in providing easy access to comprehensive genetic testing for people of Ashkenazi, Sephardic and Mizrahi Jewish backgrounds. In addition, JScreen’s test includes genetic diseases common in the general population, making the test applicable to everyone

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Sam Gold, M.D. named Childhood Immunization Champion for his work to create immunization policies

Tuesday, June 13th, 2017

Dr. Samuel Gold, Physicians Group

Sam Gold, M.D. has been named Georgia’s 2017 Center for Disease Control & Prevention Childhood Immunization Champion for his work to create immunization policies.

Thanks in large part to WellStar pediatrician Sam Gold, M.D., WellStar Health System created immunization policies to screen children for vaccinations at every well visit. As a result of the program’s success, the Center for Disease Control (CDC) named Dr. Gold Georgia’s 2017 CDC Childhood Immunization Champion.

“Dr. Gold is an incredible pediatrician and has made it his mission to make sure families know the importance of keeping up with vaccinations as children grow,” said Avril Beckford, M.D., chief pediatrics officer of WellStar Health System.

As the 2017 CDC Childhood Immunization Champion for the state of Georgia, Gold has shown leadership for advocating child immunizations by implementing critical immunization guidelines set by the American Academy of Pediatrics.

“Our Champions’ dedication is crucial to creating community partnerships, working towards policy advancements, finding creative solutions to immunization challenges, counseling parents and educating and raising awareness of the importance of childhood immunization,” said Nancy Messonnier, M.D., the director of the National Center for Immunization and Respiratory Diseases, in a letter notifying the Health System of the honor.

This isn’t the first time WellStar and Dr. Gold have been recognized for this work. The System was also awarded the Walt Orenstein Champions for Immunization Award for its Standards for Child Adolescent and Adult Immunization Practices award in 2015 by the Georgia Department of Public Health for demonstrating Standards for Child Adolescent and Adult Immunization Practices.

WellStar utilizes all clinical encounters to screen and immunize patients when appropriate and follows immunization guidelines set by the American Academy of Pediatrics to protect America’s children against vaccine-preventable diseases.

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Murphy receives highest physician honor from Emory Saint Joseph’s

Tuesday, June 13th, 2017
Dr. Doug Murphy

Dr. Doug Murphy

Emory Saint Joseph’s Hospital cardiothoracic surgeon Douglas Murphy, MD received the E. Napier “Buck” Burson, Jr., MD Physician Award of Distinction, the hospital’s highest honor for physician service. The award is named for the late Burson, former chief of staff at Saint Joseph’s Hospital, and a leader in the field of gastroenterology who pioneered the diagnostic tool of GI endoscopy.

Burson Award recipients are selected for their adherence to the Mercy philosophy and contribution to the Mercy mission in Atlanta; contribution to the quality of medicine practiced at Emory Saint Joseph’s; and leadership as a member of the medical staff.

“For more than 30 years, Dr. Murphy has been a tireless and compassionate advocate for our patients at Emory Saint Joseph’s, and the Burson Award is a well-deserved honor in recognition of his service and commitment,” says Heather Dexter, CEO of Emory Saint Joseph’s.

An associate professor of surgery at Emory University School of Medicine, Murphy serves in two roles at Emory Saint Joseph’s: as the chief of cardiothoracic surgery, a position he has held since 1995; and since 2010 as the director of robotics.

Murphy received his medical degree from the University of Pennsylvania School of Medicine, followed by the completion of his internal medicine and general surgery residencies at Massachusetts General Hospital.

After completion of his cardiothoracic surgery fellowship at Emory, he joined the Department of Surgery faculty and established the Emory Cardiac Transplant Team. In 1987, he was appointed director of cardiac transplantation at Saint Joseph’s Hospital, and performed the facility’s first heart transplant. That year, Murphy and his team completed 47 heart transplants, making it one of the highest volume programs in the U.S.

Murphy’s approaches in cardiac care also extend to the field of robotics. An early advocate of minimally invasive cardiac surgery, Murphy is a pioneer in the field, leading one of the first U.S. cardiac surgery teams as the principal investigator in clinical trials using the Intuitive da Vinci Surgical System for atrial septal defect repair and coronary bypasses prior to FDA approval. Murphy performed the state’s first robotic heart surgery at Emory Saint Joseph’s in 2002, and due to his achievements, the hospital was named the exclusive cardiac southeastern training center for the daVinci system in 2004.

Since that time, Murphy has trained surgical teams around the world in the LEAR technique (Lateral Endoscopic Approach using Robotics). The technique, developed by Murphy’s team, allows open heart surgery to be performed through five small holes in the right chest. Murphy has published many scientific papers on the use and success of robotic cardiac surgery, and remains active in performing, researching and teaching.

Most recently, he achieved a world record after completing his 2,000th robotically assisted mitral valve surgery at Emory Saint Joseph’s.

Murphy’s leadership and community involvement includes serving as the chair of the Heart and Vascular Institute from 2007 to 2009 and providing longtime support to Mercy Care and more recently, the Atlanta Police Foundation. In 2005, Murphy was the recipient of the American Heart Association’s Distinguished Physician Award.

Accepting the Burson Award, Murphy acknowledged this honor is the result of a team effort. “The successful patient outcomes we have had are all due to our team — from the nurses to anesthesiologists to perfusionists,” says Murphy.

Murphy performs minimally invasive robotic surgery using a specially-designed computer to control surgical instruments on thin robotic arms. This requires the skill, support and organization of his team, including first and second surgical assistants Ted Cocian and Jeannette Karstensen, who have a combined 37 years of experience working with Murphy. “When I am working at the robotic console, I rely on the team for their invaluable assistance with sutures and instruments at the operating table,” he described.

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Georgia College of Emergency Physicians Annual Meeting

Friday, June 9th, 2017

June 9 -11, 2017. Kiawah Island, South Carolina. For more information, visit Georgia College of Emergency Physicians.

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American Medical Association Annual Meeting Information for Sections

Thursday, June 8th, 2017

June 8-13, 2017. In Chicago. For more information, visit American Medical Association.

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Medical Association of Atlanta Annual Meeting

Saturday, June 17th, 2017

June 17 at the Wimbish House, Atlanta. For more information, visit Medical Association of Atlanta.

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