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Archive for July, 2017

Secretary Price Appoints Brenda Fitzgerald, M.D., as CDC Director and ATSDR Administrator

Monday, July 24th, 2017

Dr. Brenda Fitzgerald

Health and Human Services Secretary Tom Price, M.D., named Brenda Fitzgerald, M.D., as the 17th Director of the Centers for Disease Control and Prevention (CDC) and Administrator of the Agency for Toxic Substances and Disease Registry (ATSDR).

“Today, I am extremely proud and excited to announce Dr. Brenda Fitzgerald as the new Director of the CDC,” said Secretary Price. “Having known Dr. Fitzgerald for many years, I know that she has a deep appreciation and understanding of medicine, public health, policy and leadership—all qualities that will prove vital as she leads the CDC in its work to protect America’s health 24/7. We look forward to working with Dr. Fitzgerald to achieve President Trump’s goal of strengthening public health surveillance and ensuring global health security at home and abroad. Congratulations to Dr. Fitzgerald and her family.”

Dr. Fitzgerald has been the commissioner of the Georgia Department of Public Health (DPH) and state health officer for the past six years. She replaces Dr. Anne Schuchat, who has been the acting CDC director and acting ATSDR administrator since January 20. Dr. Schuchat is returning to her role as CDC’s principal deputy director.

“Additionally, I’d like to extend my deep appreciation and thanks to Dr. Anne Schuchat for her exemplary service as acting director of the CDC,” said Secretary Price. “We thank Dr. Schuchat and her team for their dedication in our public health efforts to keep Americans safe and for their work to ensure a seamless transition. We look forward to continuing to work with Dr. Schuchat in her role as principal deputy director of CDC.”

Dr. Fitzgerald, a board-certified obstetrician-gynecologist, has practiced medicine for three decades. As Georgia DPH Commissioner, Dr. Fitzgerald oversaw various state public health programs and directed the state’s 18 public health districts and 159 county health departments. Prior to that, Dr. Fitzgerald held numerous leadership positions. She served on the board and as president of the Georgia OB-GYN Society and she worked as a health care policy advisor with House Speaker Newt Gingrich and Senator Paul Coverdell. She has served as a Senior Fellow and Chairman of the Board for the Georgia Public Policy Foundation.

Dr. Fitzgerald holds a Bachelor of Science degree in Microbiology from Georgia State University and a Doctor of Medicine degree from Emory University School of Medicine. She completed post-graduate training at the Emory-Grady Hospitals in Atlanta and held an assistant clinical professorship at Emory Medical Center. As a Major in the U.S. Air Force, Dr. Fitzgerald served at the Wurtsmith Air Force Strategic Air Command (SAC) Base in Michigan and at the Andrews Air Force Base in Washington, D.C.

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Rob Schreiner, M.D. Named as New President for WellStar Medical Group

Monday, July 24th, 2017

Rob Schreiner, M.D.

WellStar Health System announced the appointment of Rob Schreiner, M.D. as executive vice president and president of WellStar Medical Group (WMG). In his role, Dr. Schreiner will oversee the group’s continued growth and integration within the health system.

WellStar Medical Group, which began in 1994 with around 100 physicians, has grown to be one of the largest medical groups in the state, with 1,150 providers across 40-plus specialties at 250 locations.

“As a physician with extensive medical group leadership experience, Rob brings a unique perspective,” said Candice Saunders, president & CEO of WellStar Health System. “He has a track record of improving patient outcomes while lowering cost through a team-centered approach which will lead to better health outcomes for our patients and communities.”

Dr. Schreiner is a pulmonary and critical care physician with more than 20 years of executive-level experience in population healthcare and physician leadership development. Most recently, Dr. Schreiner served as executive medical director of the Studer Group, a healthcare consulting company which works with organizations on improving clinical outcomes and financial results. Other professional experience includes managing director of Population Health for the Huron Consulting Group and various positions with Kaiser Permanente Georgia, including chief operating officer, executive medical director, and chief of Medical-Hospitalist Services and Pulmonary Care Services.

“When I learned of this position, I thought what a great opportunity to make a contribution to physician leadership and advance the great care WellStar is known for in the community,” Schreiner said. “Our emphasis on team-based care, patient safety, and continuous improvement has enabled our success. I expect that emphasis and success to not only continue, but accelerate, into the next decade.”

A graduate of the University of Tennessee School of Medicine, Dr. Schreiner completed his residency in Internal Medicine at Vanderbilt University Medical Center and a Pulmonary and Critical Care fellowship at the University of Colorado Health Services Center.

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Grady Opens Marcus Stroke and Neuroscience Outpatient Center

Monday, July 24th, 2017

Grady Health System’s Marcus Stroke and Neuroscience Center is expanding its care with the opening of its new outpatient center. Unveiled during ceremonies in June, the center provides a multi-disciplinary approach to care for patients with advanced neurological conditions. The outpatient center is the first phase of an expansion that will allow the Marcus Stroke and Neuroscience Center to serve more patients and expand its research capabilities.

Marcus Neuroscience Outpatient Center Opening

“Grady’s reputation as a regional destination for the advanced treatment of stroke and other neurological issues has led to significant growth. This new outpatient center will provide access to a greater number of patients who will benefit from our cutting-edge care,” said Grady CEO John Haupert.

The expansion was made possible by a $10 million gift from The Marcus Foundation, which under the direction of its benefactors, Billi and Bernie Marcus, has invested more than $50 million in Grady since 2009. A significant portion of those funds went to the creation of the Marcus Stroke and Neuroscience Center.

“We believed we could make an incredible impact on the treatment of stroke and neurological conditions here at Grady, and we have.” said Bernie Marcus, who attended Monday’s event. “Hundreds if not thousands of patients have been saved not only by the cutting edge treatment offered here, but through research that has turned into life-saving solutions. What we have accomplished – and will continue to accomplish in the future – is something we can all be very proud of.”

The new outpatient center centralizes diagnosis and treatment functions, allowing for enhanced patient care coordination.

“It is impossible to overstate the impact The Marcus Foundation has had on Grady. This health system is thriving today in large part due to Billi and Bernie’s willingness to invest in our future and challenge us not only to deliver the best possible care, but set standards that will save lives for years to come,” said Pete Correll, chair of the Grady Health Foundation.

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Newnan Dermatology welcomes Dr. Samit Patrawala

Monday, July 24th, 2017

Dr. Patrawala

Newnan Dermatology announces the addition of board-certified dermatologist Dr. Samit Patrawala to its roster of physicians.

“We’re thrilled to bring Dr. Patrawala on board with Newnan Dermatology,” said Newnan Dermatology senior partner and president Dr. Mark Ling. “With his strong history of academic recognitions and community outreach, Dr. Patrawala certainly fits well with our practice model of professionalism and compassion.”

Dr. Patrawala, a native of Michigan, graduated summa cum laude from the University of South Alabama with a Bachelor of Science in biomedical science and received his medical degree from Vanderbilt University School of Medicine. He completed an internship at University of Chicago NorthShore before completing his dermatology residency at Emory University. He is currently finishing further training in dermatopathology at Emory University. Dr. Patrawala has authored multiple publications in scholarly journals and looks forward to continuing his academic interests in skin disease.

“Being personable and forming relationships with my patients are my strong suits,” said Dr. Patrawala. “I strongly believe in personalized care. I strive to learn my patients’ goals so we can come together to craft a treatment plan that achieves their desired outcomes.”

Dr. Patrawala joins Dr. Jill Buckthal, Dr. Mark Holzberg, Dr. Steven Marcet, and Dr. Mark Ling as part of the Newnan Dermatology team, which has two locations in Newnan and Peachtree City.

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From Office Surgery to Face Lifts

Wednesday, July 19th, 2017

By Elizabeth Morgan, MD PhD FACS

“Can it be done in the office?” and “Do I need a face lift?” are two common questions that cosmetic surgery patients ask us.

Today, short-acting general anesthetics and advanced monitoring make general anesthesia very safe, safer than intravenous sedation — one reason that anesthesiologists prefer this approach. Indeed the dangers of sedation without airway control are such that the American Society of Plastic Surgeons requires members to restrict its use to accredited out-patient surgery centers. But most people dislike the cost of a surgery center, as well as the recovery from general anesthesia, and avoid it if possible.

What can a plastic surgeon today offer the patient who wants the lower cost and faster recovery of a procedure done in the office with local anesthesia, perhaps with one or two light sedative pills at most?

Surprisingly we can offer a lot of safe office operations. This isn’t just our ingenuity but our response to patients wanting solutions to a wider range of cosmetic issues. Today I can safely offer my patients 50 such procedures with continuous monitoring of pulse, blood pressure and pulse oxygenation to ensure the surgery is in fact safe.

Such operations include small-volume liposuction, small-volume fat transfers, lip lifts, lip implants, buccal fat reductions, face lift revisions, skin-only tummy tucks, ear lobe repairs and reductions, chin implants, elbow lifts, buttock lifts, upper lid lifts, lower lid lifts, correction of nipple eversion and inversion, labiaplasties, brow lifts, alar nose reduction, ear setbacks, implant exchanges and much more.

Figure 1A

Figure 1B

Not every patient or problem is suited for local anesthesia surgery, but what can be done is remarkable. Incremental advances in our understanding of local anesthetics and cosmetic surgery have expanded our patients’ options while making these procedures almost painless.

Indeed the pain from many of these operations is much less than for filler, Botox or Kybella injections. For instance, pain from local anesthesia for a lip lift (see Figure 1 A and B) is two spot skin injections or four seconds, compared to the severe pain from Kybella fat injection of the neck (see Figure 2 A and B),which lasts five minutes. This is 75 fold less pain!

Figure 2A

Figure 2B

Indeed the ease and recovery from such procedures makes patients want all cosmetic surgery done this way. The day may come — but it’s not here yet. Why not? Office surgery should take not much more than two hours for patient comfort, cannot be safely done in a hypertensive or hyper-anxious patient or if there is a risk of fluid shifts, unexpected bleeding, unsafe levels of local anesthetic or damage to vital structures. Major surgery with these risks belong in an accredited surgery center.

Although mini-face lifts can be done in the office, surgery tends to be limited and results less durable. So far in my practice, an in-office mini-face lift seems a poorer choice than a well-done standard face lift in a surgery center, which will typically produce good to outstanding durable results with a low risk of complications. (See Figure 3A and B.)

Figure 3A

Figure 3B

This leads to the question — what is a standard face lift? It is a ‘bespoke’ or ‘designer’ lift, based on the patient’s facial changes and the available techniques. Here is how that approach is evolving.

From the early 1910s to 1968, face lifts just tightened skin. By the late 1960s, all of the neck skin and much of the facial skin was being raised off the deep layers beneath. Results could be good but were unpredictable.

In 1968, Tord Skoog, a Norwegian plastic surgeon, introduced his deep layer face lift. By raising and tightening the deep layer of the face — a fascial layer he called the submusculo-aponeurotic system (SMAS) — he improved face lift results and durability. But the SMAS flap was often fragile and hard to suture. Facial nerves travel under the SMAS and could be injured. So face lifting branched in two directions, less and more. Which approach a modern plastic surgeon uses depends on her/his assessment of risk and of the patient’s needs.

Doing less led to SMAS excision or plication — tightening with SMAS without lifting it. Nerve injuries were rarer, and results were very good. This then led to the ‘mini-lift,’ which uses a short incision in front of the ear to tighten just the SMAS. The results are less durable and eventually led to ‘suture’ and ‘thread’ lifts, a recurring ‘face lift’ fad with little durability.

Doing more led to sub-periosteal face lifts, which lifted the facial tissues off the bone, now largely replaced by the composite face lift championed by Dr. Hamra. This procedure leaves the skin attached to the SMAS and extends further into the mid-cheek and lifts the lower lid and brow as well. Results can be superb, but the extent of surgery, longer recovery and greater risk led many surgeons to only incorporate elements of this lift into their face lifts, as needed.

Figure 3

Meanwhile back in the lab, plastic surgeons were dissecting cadaver faces to understand facial aging. Why do our faces age differently from those of all other animals? Faces of the dog and cat, mandrill and camel do not sag as ours do. (See Figure 3.) Here’s what we learned.

First we learned that aging causes loss of facial fat, deflating the face. The advent of fillers, fat injections and soft solid silicone implants allows us to restore some of this youthful facial fullness. But this is only part of a fascinating story.

Another part is that our muscles of facial expression differentiate us from other animals. These muscles lie in the SMAS, kept in place with ligaments that attach skin and SMAS to bone beneath along a line going from lateral brow to angle of the jaw. These ligaments separate the mobile, expressive front of our face from the immobile sides.

In front of each ligament is a ‘potential space,’ a glide plane that allows the muscles to move. We move them constantly! This repetitive motion plus aging and sun damage will stretch the skin, subcutaneous fat and SMAS, causing them all to bulge out over the ligaments, forming the jowls, facial folds, saggy cheeks and bulgy lower lids of “age.”

Further, aging causes thinning, weakening and absorption of tissue in every layer of the face, from skin and fat to periosteum and bone. By our mid-20s, signs of aging are seen in Caucasian women. Because of men’s thicker tissues, these changes are seen later, in the early 30s. Those with even thicker facial tissues have even later visible signs of aging, as is evident in many Americans of Asian and African descent.

But no worries for early agers, right? Now that we know the anatomy in detail, can’t we just tighten those SMAS tissues around the ligaments? Not so fast! The nerves lie in the ligaments. Releasing ligaments can cut those nerves.

But our new knowledge does provide an answer. We now know how to find the glide planes between the ligaments — these are safe spaces where SMAS and skin can be tightened away from ligaments and nerves. This approach provides a limited dissection, less risky composite face lift, an approach being incorporated in face lifts today — yet another important incremental step forward.

Meanwhile, plastic surgeons and others are exploring another avenue: stem cells and other biotechnology to rejuvenate aging tissues. The ultimate irony for plastic surgeons would be if our own research leads to pills, creams or safe injections that restore the face to a youthful appearance permanently without surgery, injections or implants.

While we await this Fountain of Youth, we have ever better face lifts and a panoply of office procedures to offer our patients. It’s astonishing progress from the introduction of general anesthesia in 1844 and local anesthesia in 1888!

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Gynecology Spotlight

Wednesday, July 19th, 2017

By Helen K. Kelley

Atlanta Medicine recently spoke with some Atlanta-area gynecologists to learn about new effective surgical techniques, comparisons of surgeries in terms of costs and advantages, and how conversations about family planning and contraception choices are reducing the number of unintended pregnancies among their patients.

New tissue removal techniques for hysterectomy

Algernon O. Steele, a board-certified gynecologist with Southeast Permanente Medical Group, says that new techniques for removing tissue have allowed a return to minimally invasive surgery for hysterectomies.

Dr. Algernon Steele

“One of the problems we had in the progression of minimally invasive gynecological surgery was the ability to remove larger uteruses and fibroid tumors from the body,” he says. “This tissue removal was greatly facilitated by the use of a power tissue morcellator, which allowed us to cut the tissue into smaller pieces that could then be removed through a small laparoscopic incision. However, in the last three years, the FDA discouraged its use for uterine procedures, issuing a warning that morcellators may spread occult cancer in the course of surgery. As a result, some hospitals chose to completely ban the device.”

With the morcellator out of commission for gynecological use, what would have been laparoscopic hysterectomies in some cases became total abdominal hysterectomies. The abdominal surgeries included longer recovery times, larger blood loss and higher morbidity rates.

Steele says that new tissue removal techniques have allowed gynecologists to return to performing minimally invasive hysterectomies.

“We can now use tissue containment bags that can be used through a small incision to manually remove a larger uterus or fibroid in a contained way,” he says. “We put the specimen in the bag, use a scalpel to cut it into smaller pieces and remove them through the incision.”

Newer devices are being developed that will allow power morcellation to take place within a bag. Steele adds that the banning of the tissue morcellator is still a controversial topic.

“For women under age 50, the known risk of spreading cancer by using a morcellator is very low,” he says. “However, the data is still being collected. And if it happens to even one person, there are people who would say that is one too many.”

 

Comparative study of vaginal, abdominal and robotic laparoscopic hysterectomy

During a presentation at the 65th annual meeting of the American College of Gynecology in May, Magdi Hanafi, M.D., a board-certified gynecologist with Gyn & Fertility Specialists, spoke about a comparative study he conducted among vaginal, abdominal and robotic laparoscopic hysterectomies. The study, which included 122 patients with symptomatic leiomyomata at Saint Joseph’s Hospital of Atlanta (now Emory Saint Joseph’s Hospital) took place from February 2007 to June 2009. Participants underwent either robotic-assisted laparoscopic myomectomy or abdominal myomectomy.

Dr. Magda Hana

The study compared short-term surgical outcomes of robotic and abdominal myomectomy and analyzed the factors affecting the short-term outcomes. The variables investigated included the type of surgery, age, body mass index, gravity, parity, number of leiomyomata, diameter of largest tumor size, total operative time, estimated blood loss and length of hospital stay.

“The study found there were no significant differences between the two groups regarding age, gravity and parity. However, BMI, numbers of leiomyomata and tumor sizes were significantly higher in abdominal myomectomy compared with robotic-assisted laparoscopic myomectomy,” Hanafi says. “While the total operative time was significantly longer in robotic-assisted laparoscopic myomectomy compared with abdominal myomectomy, estimated blood loss and length of hospital stay were significantly lower. We concluded that blood loss, post-operative pain, length of hospital stay and cost were significantly higher for abdominal hysterectomy versus all other methods.”

Hanafi adds that robotic surgery has many advantages for both patient and surgeon.

“First, robotic surgery has reduced the number of open surgeries. We have improved visibility and are able to do more precise work as surgeons,” he says. “This results in an improved quality of post-operative care and better outcomes for patients.”

 

Long-acting contraceptive methods, family planning

Long-acting reversible contraceptives (LARC) – methods of birth control that provide effective contraception for an extended period without requiring user action – include intrauterine devices (IUDs) and subdermal contraceptive implants. According to Fonda Mitchell, M.D., a gynecologist with Southeast Permanente Medical Group and clinical assistant professor at the department of obstetrics and gynecology for the GRU/UGA partnership at Medical College of Georgia, LARC have made a significant impact toward decreasing the number of teenage and unintended pregnancies.

Dr. Fonda Mitchell

“Intrauterine devices and subdermal implants have minimal side effects, can be placed in the physician’s office and can provide good contraception for three to five years,” she says. “These methods have proved very successful for our younger patients who want a reliable form of contraception that they don’t have to think about daily or for those who may not necessarily be compliant with taking medication.”

Mitchell adds that opening up a dialogue with patients provides an opportunity to educate them and help them make an informed decision about contraception and even their future.

“In our practice, most of our conversations with reproductive-age women now center around the question, ‘Are your plans to conceive this year or not to conceive this year?’” she says. “We talk about options for contraception and their ability to actively participate in family-planning goals. And we tell them [that] if their desire is to complete high school and/or college, we can offer them a contraceptive that will allow them to focus on their future. When a young woman has that conversation with her clinician, she has the opportunity to learn about all of the alternatives available to her to help ensure she achieves her goals.”

Fellowships in family planning are now available in obstetrics and gynecology programs at many medical schools around the country. Mitchell says that the additional two years of study allows residents to hone their knowledge of family-planning alternatives.

“As the millennials are completing residency training, they’re telling us that they are enhancing their fund of knowledge in the family planning arena,” she says. “They are learning more about how to counsel patients, as well as how to identify good candidates for various forms of contraception. And they are running clinics in areas that have a high-risk population for unintended pregnancy.”

 

Conflicting advice regarding pelvic exams

Two physician associations have released differing opinions when it comes to annual pelvic exams for women.

The American College of Obstetricians and Gynecologists (ACOG) recommends an annual pelvic examination for women age 21 and older as “a fundamental part of medical care,” and that it is “valuable in promoting prevention practices, recognizing risk factors for disease, identifying medical problems and establishing the clinician–patient relationship.” The exam is recommended regardless of whether the woman shows any symptoms of disease or not.

Meanwhile, the American College of Physicians (ACP) recommends against performing screening pelvic examination in asymptomatic, nonpregnant, adult women. The ACP cites harms, including overdiagnosis, overtreatment, diagnostic procedure–related harms, fear, anxiety, embarrassment, pain and discomfort as the reasons for its recommendation.

A recent study published in the American Journal of Obstetrics & Gynecology found that when women were informed that one prominent medical association recommended against the yearly exam, it substantially reduced their desire to have one.

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2017 Georgia Society of Plastic Surgeons Annual Scientific Meeting

Friday, July 28th, 2017

July 28 – 30, 2017. The Ritz-Carlton Reynolds Plantation. Greensboro, Georgia. For more information visit, gsps.info

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Columbus CME Dinner

Thursday, July 20th, 2017

July 20

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Columbus CME Dinner

Thursday, July 20th, 2017

July 20, 2017. For more information visit, choa.org

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