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Archive for April, 2018

Piedmont Healthcare and Anthem Blue Cross Blue Shield Sign Agreement

Monday, April 23rd, 2018

Friday night, three days after Governor Nathan Deal announced a handshake agreement between Piedmont Healthcare and Anthem Blue Cross Blue Shield of Georgia, the two organizations put ink to paper and signed the new agreement.

The agreement ensures that Anthem Blue Cross members can see their Piedmont doctors and visit Piedmont hospitals as “in network” without incurring higher out-of-pocket costs, including covering visits and services delivered since April 1.

While Piedmont will begin calling patients – particularly those who canceled appointments for hospital-based services – all patients who canceled or delayed care during the time of disruption are encouraged to call their Piedmont doctor to reschedule.

The new contract with Anthem Blue Cross extends into 2021.

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2018 Spring Hospital Pharmacy Conference

Monday, April 30th, 2018

April 30 – May 2, 2018.  Hyatt Regency Atlanta, Atlanta. For more information, visit the Health Connect Partners website.

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An Unforeseen Threat: The Impact of Viral Hepatitis on Reproduction

Friday, April 20th, 2018
Alexis P. Calloway, M.D.

Alexis P. Calloway, M.D.

By Alexis P. Calloway, M.D.

Much focus is given to the long- and short-term impact of commonly tested sexually transmitted infections such as HIV, chlamydia, gonorrhea and HPV on reproductive health. As the medical landscape of diagnosis and therapeutic options for infertility evolve, it is just as important to focus on viral hepatitis as well, with particular emphasis on Hepatitis B and C.

Viral Hepatitis in the United States
According to the Centers for Disease Control and Prevention (CDC), there were an estimated 33,900 new Hepatitis C virus ( HCV) infections in 2015, representing a 2.9-fold increase since 2010 with 75 percent to 85 percent of infections becoming chronic. The estimated number of new Hepatitis B virus (HBV) infections in 2015 was 21,900, however these rates are decreasing.

HCV is generally acquired through IV drug use and blood transfusions until changes in screening regulation for donations in the early 1990s. HCV can rarely also be acquired through sexual transmission. Alternatively, HBV is commonly acquired through sexual transmission, particularly in heterosexuals with multiple partners and unvaccinated men who have sex with men. Other common sources of transmission for HBV include mother-to- child transmission (MTCT), intravenous drug abuse and rarely through paternal transmission. (Iqbal et al., 2015) Chronic viral hepatitis, with HCV accounting for the majority of cases, is one of the most common causes of cirrhosis in the U.S. and carries a significant burden on the healthcare system. Given the multifaceted impact to the body, it is unknown what the specific burden to reproductive health may be.

Viral Hepatitis and Male Fertility
It is already known that many chronic viruses have the ability to infect sperm and adversely impact male fertility. Specifically in the last decade, it has been found that HCV causes a statistically significant decrease in semen volume, sperm count and progressive sperm motility and an increase in abnormal sperm morphology compared with healthy controls. Furthermore, the duration of HCV infection has been negatively correlated with semen volume and sperm motility where the HCV RNA viral load was negatively correlated with sperm count and sperm motility. (Hofny et al., 2011) In a study published in 2011, it was found that couples whose male partner was infected with HBV had a higher risk of low fertility rates after IVF, a risk which was independent from the initial sperm motility. (Oger et al., 2011)

As viral hepatitis may be asymptomatic until the onset of advanced disease, these barriers may not be identified as a potential etiology for infertility in younger populations. Targeted screening in this at-risk group may be of benefit in reproductive counseling, though no clear guidelines have been established. Some literature does attempt to address the issue of disparity of screening asymptomatic men in comparison to their heterosexual partners.

In a study of 1,243 male partners of 2,400 women who attended ultrasound examinations between 2010 and 2011, 430 accepted HIV and STI testing. It was ultimately found this is an acceptable time to feasibly engage the heterosexual male partner for screening. (Dhairyawan, Creighton, Sivyour, & Anderson, 2012) Other opportunities may arise to address screening and should be pursued on an individual basis by the patient’s healthcare provider.

Table 1. Pathology Structure of female reproductive system with HBV - and HCV- infection

Kurmanova, A.M., et al. (2016). “Reproductive dysfunctions in viral hepatitis.” Gynecol Endocrinol 32(sup2): 37-40.

Viral Hepatitis and Female Fertility
Menstrual disorders serve as the predominant cause of reproductive barriers in a patient affected with HBV and HCV due to intra- and extrahepatic pathology (as displayed in Table 1). (Kurmanova, Kurmanova, & Lokshin, 2016) Premenopausal women who are HCV positive or have chronic liver disease are at risk for premature ovarian failure impacting their lifelong fertility.

A study published in 2017 found that most new cases of HCV infection are among people who inject drugs, including reproductive-age females. Reproductive-age women who are HCV positive display markers of ovarian failure. This is associated with infertility and adverse pregnancy outcomes such as stillbirth, miscarriage, fewer live births and gestational diabetes. (Karampatou et al., 2017)

There is not much research surrounding the impact of HBV on reproduction in women specifically. One small study measuring pregnancy rates and implantation rates of HBV-sero- positive women and their partners found a higher rate of tubal blockage, often leading to signficantly higher rates of IVF and embryo transfer cycles if at least one partner was positive when compared to seronegative control couples. (Lam et al., 2010)

No matter the etiology, there are overarching impacts of cirrhosis on the reproductive health of women. Cirrhosis leading to generalized infertility and pregnancy is rare, but when it does occur specialized care is required.

Viral Hepatitis and the Pregnant Patient
Mother-to-child transmission is responsible for more than one third to one half of chronic HBV infections worldwide and can occur during pregnancy, delivery or after birth if not treated. Acute HBV infection during pregnancy is usually mild and not associated with increased mortality or teratogenicity. However, transmission rates significantly increase if acute infection occurs in the perinatal period, with rates as high as 60 percent reported. (Sookoian, 2006)

Chronic hepatitis B serves as a larger medical management consideration with emphasis on decision to treat during pregnancy with anti-retroviral therapy. This decision is generally influenced by ALT elevation greater than two times the upper limit of normal, HBV DNA levels, detection of Hepatitis B Surface Antigen (HBSAg) and anti-Hepatitis B e antibody (anti-HBe), and the presence or absence of cirrhosis.

Women with high viral loads (HBV DNA) in the third trimester should be treated even in the setting of normal ALT to decrease the vertical transmission risk to the infant. Furthermore, neonates of HBSAg-positive mothers should receive monovalent hepatitis B vaccine and HBIG 0.5ml as soon after delivery as possible (preferably within 12-24 hours) regardless of birth weight. (Committee On Infectious, Committee On, & Newborn, 2017) As perinatal transmission of HCV is unlikely, decision to treat can be deferred until after delivery. Subspecialist assistance may serve valuable in determining patient candidacy and timing for treatment.

Though HCV can be detected in maternal colostrum, this is not considered a factor associated with vertical transmission. In a study of 76 samples of breast milk from 73 chronically HCV-infected mothers, none of the samples contained HCV RNA and only one of the breastfed infants had evidence of HCV one month after birth without clear correlation to breastfeeding itself. (Polywka, Schroter, Feucht, Zollner, & Laufs, 1999) It is accepted by multiple organizations that breastfeeding is considered generally safe in asymptomatic HCV-positive mothers.

Reproductive Planning
Though initially targeted for the baby boomer population, emerging and highly effective therapies for HCV may prove beneficial to improving infertility in reproductive-age individuals burdened with this disease as well. Rates of sustained virologic response (SVR) have been found to be in the high 90th percentile for patients with common genotypes of the virus undergoing eight or 12 weeks of treatment. (Terrault et al., 2016)

Additionally, treatment is beneficial as early menopause in patients with chronic HCV was associated with low likelihood of SVR likely due to inflammatory factors and physiologic variations in estrogen that change at menopause. (Villa et al., 2011) Vaccination should also be pursued in household and sexual contacts for those with HBV.

As providers, viral hepatitis should be a part of the reproductive health discussion, with appropriate screening and treatment as indicated in this special and occasionally missed population.


References
Committee On Infectious, D., Committee On, F., & Newborn. (2017). Elimination of Perinatal Hepatitis B: Providing the First Vaccine Dose Within 24 Hours of Birth. Pediatrics, 140(3). doi:10.1542/peds.2017-1870
Dhairyawan, R., Creighton, S., Sivyour, L., & Anderson, J. (2012). Testing the fathers: carrying out HIV and STI tests on partners of pregnant women. Sex Transm Infect, 88(3), 184-186. doi:10.1136/sextrans-2011-050232

Hofny, E. R., Ali, M. E., Taha, E. A., Nafeh, H. M., Sayed, D. S., Abdel-Azeem, H. G., . . . Mostafa, T. (2011). Semen and hormonal parameters in men with chronic hepatitis C infection. Fertil Steril, 95(8), 2557-2559. doi:10.1016/j.fertnstert.2011.05.014

Iqbal, K., Klevens, R. M., Kainer, M. A., Baumgartner, J., Gerard, K., Poissant, T., . . . Teshale, E. (2015). Epidemiology of Acute Hepatitis B in the United States From Population-Based Surveillance, 2006-2011. Clin Infect Dis, 61(4), 584-592. doi:10.1093/ cid/civ332

Karampatou, A., Han, X., Kondili, L. A., Taliani, G., Ciancio, A., Morisco, F., . . . Investigators, P. (2017). Premature ovarian senescence and a high miscarriage rate impair fertility in women with HCV. J Hepatol. doi:10.1016/j.jhep.2017.08.019

Kurmanova, A. M., Kurmanova, G. M., & Lokshin, V. N. (2016). Reproductive dysfunctions in viral hepatitis. Gynecol Endocrinol, 32(sup2), 37-40. doi:10.1080/0951 3590.2016.1232780

Lam, P. M., Suen, S. H., Lao, T. T., Cheung, L. P., Leung, T. Y., & Haines, C. (2010). Hepatitis B infection and outcomes of in vitro fertilization and embryo transfer treatment. Fertil Steril, 93(2), 480-485. doi:10.1016/j.fertnstert.2009.01.137

Oger, P., Yazbeck, C., Gervais, A., Dorphin, B., Gout, C., Jacquesson, L., . . . Rougier, N. (2011). Adverse effects of hepatitis B virus on sperm motility and fertilization ability during IVF. Reprod Biomed Online, 23(2), 207-212. doi:10.1016/j.rbmo.2011.04.008

Polywka, S., Schroter, M., Feucht, H. H., Zollner, B., & Laufs, R. (1999). Low risk of vertical transmission of hepatitis C virus by breast milk. Clin Infect Dis, 29(5), 1327-1329. doi:10.1086/313473

Sookoian, S. (2006). Liver disease during pregnancy: acute viral hepatitis. Ann Hepatol, 5(3), 231-236.

Terrault, N. A., Zeuzem, S., Di Bisceglie, A. M., Lim, J. K., Pockros, P. J., Frazier, L. M., . . . Group, H.-T. S. (2016). Effectiveness of Ledipasvir-Sofosbuvir Combination in Patients With Hepatitis C Virus Infection and Factors Associated With Sustained Virologic Response. Gastroenterology, 151(6), 1131-1140 e1135. doi:10.1053/j.gastro.2016.08.004

Villa, E., Karampatou, A., Camma, C., Di Leo, A., Luongo, M., Ferrari, A., . . . Francavilla, A. (2011). Early menopause is associated with lack of response to antiviral therapy in women with chronic hepatitis C. Gastroenterology, 140(3), 818-829. doi:10.1053/j.gastro.2010.12.027

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5 Best Practices for Treating Your Muslim Patients

Friday, April 20th, 2018

By Lisa Perry-Gilkes, MD, FACS

With a Muslim population reported to be a quarter million and with 35 mosques in the metro area, Atlanta ranks as the city with the sixth largest Muslim population in the country. Cultural sensitivity in caring for the Muslim patients requires a basic understanding of Islam.

Islam, which in Arabic is derived from the word salam, or peace, is the second largest world religion with 1.57 billion Muslims worldwide. Encountering and caring for Muslim patients requires knowledge of and respect for cultural observances. Islam is based on five pillars:
1. Believing in Allah, Arabic for God, and Mohamed as his prophet (the last prophet in the lineage of prophets starting from Abraham).
2. Performing five daily prayers.
3. Fasting during the holy month of Ramadan.
4. Contributing to charity.
5. Performing the hajj or the pilgrimage to Mecca at least once.

When caring for a Muslim patient, being sensitive to the traditions and cultural norms can go a long way to forming a strong patient-physician relationship.

1: Approach Alcohol and Smoking Topics Sensitively
Islam strictly forbids alcohol consumption, however it is still important to inquire about alcohol use in patients with suspected head and neck cancer. Be sure to approach this topic with sensitivity. It should not be assumed that not drinking is strictly observed, and it may not be admitted to in the presence of family members.

Smoking is not encouraged, but smoking of cigarettes or the hookah is common in Islamic countries. A common belief is that since the smoke is passed through water, the smoke is filtered and made harmless. However, this form of tobacco consumption may even be worse than cigarette smoke.

It’s important to ask about chewing tobacco when discussing substance use history. Betel nut (Areca catechu) chewing is common in certain cultures such as Yemen or the Indian subcontinent. This practice has been associated with oral cancer.

2: Know When Ramadan Occurs
Ramadan is the ninth month in the Muslim calendar. Ramadan lasts for 30 days and is based on the Islamic lunar calendar, which is 10 to 12 days shorter than the solar calendar and starts at sunset. (In 2018, Ramadan starts May 15 and last through June 14.)

During this period, observant Muslims refrain from taking anything by mouth from sunrise to sunset. The fast is broken at sunset and resumes at sunrise. Islamic dietary laws can be forgiven when the individual is ill, hospitalized and required to take medication and nourishment. Islamic dietary laws allow Muslims to modify the laws to save lives. During this period you may see an increased incidence of sialadentis and sialolithiasis.

3: Understand the Islamic Dietary Code
Like many religions, Islam has a set of dietary guidelines for its believers to follow. The strict dietary code includes only eating meat that is appropriately slaughtered, similar to kosher foods in Orthodox Judaism. It is interesting to know that all kosher food is acceptable as halal, which means lawful or permitted. Halal covers more than you would expect. The term is primarily associated with food, but it also covers products that include ingredients derived from animals, such as soap, cosmetics or medicine. Things that are haram, i.e. forbidden, are:
• Swine/pork and its by-products
• Animals improperly slaughtered or dead before slaughtering
• Animals killed in the name of anyone other than Allah (God)
• Alcohol and intoxicants
• Carnivorous animals, birds of prey and land animals without external ears (i.e. bugs, snakes and lizards)
• Blood and blood by-products
• Foods contaminated with any of the above products

4: Respect the Modesty of your Muslim Patients
Modesty is one of the requirements of Islam. You may be familiar with the head covering known as the hijab. This garment, most commonly seen outside of Muslim countries, covers the head and neck with the face uncovered. Although seen in more devout members, it may cover from ankle to lower face.

It is also suggested that men are required to cover from navel to the knee, and some will wear a small head covering, called a kufi. Female patients may wear their head covering during hospitalization. A knock on the door before entering the room would give the patient a chance to cover her head.

Muslim patients will feel more comfortable with care practitioners of the same sex. At registration, the office staff should ask the patient if she is comfortable being seen by a male physician. Another way to make the patient more comfortable with a male physician is to include a female chaperone in the room, especially during a physical exam. Male patients may not feel comfortable with a female practitioner with the personal history and more commonly with the physical exam.

5: Let Your Muslim Patients Take the Lead With Shaking Hands
Some female patients will not shake hands with a male practitioner. Therefore, it is important to ask before offering a handshake, “Do you feel comfortable shaking hands?” This advice also holds true for a female physician with a male Muslim patient. Eye contact is also commonly avoided, especially in mixed-gender situations.

Accommodate Islamic Traditions About Hospitalization and End of Life
When hospital admission is required, accommodations should be made for daily prayers. This could mean a specific prayer room or making room in their hospital room. It is important for Muslims to face Mecca during prayer. For the bedridden patients who cannot fully prostrate themselves, it would show a great sign of respect to position the bed to face Mecca, which is southeast in the U.S.

Death and its preparation are very important parts of the Islamic life cycle. It is customary to perform special prays for the patient. In the case that the family members are not able to attend the hospitalized patient, the Imam (the worship leader of a mosque, similar to a priest or rabbi) should be notified of the patient’s condition to counsel and console the patient.

After death, traditionally the family and/or friends wash the body to prepare it for burial, which will occur as soon as possible. Embalming should be avoided unless required by civil law, and cremation is not allowed by Islamic law.

Atlanta has a very diverse population. We need to keep in mind that our Muslim community is not homogeneous. Our Muslim patients come from diverse and varied backgrounds, from the Indian subcontinent to those born in the United States.

Keeping this in mind, we should avoid stereotypes and assumptions. With all patients, the care should be crafted to fit the individual. Using a culturally sensitive approach to all of our patients is a best practice with improved, welldeserved, better outcomes.

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Clearview Regional Medical Center Becomes Piedmont Walton Hospital

Thursday, April 19th, 2018

Clearview Regional Medical Center is officially Piedmont Walton Hospital, the eleventh hospital in the Piedmont Healthcare system. Leaders cut a ceremonial ribbon and unveiled a sign displaying a Piedmont Walton marquee, which now adorns the entrance of the hospital.

Founded in 1959, Piedmont Walton is a 77-bed acute care hospital that offers a wide range of medical services and procedures to the Monroe, Ga. area.

At the Piedmont Walton ceremony was newly-appointed Piedmont Walton CEO Larry Ebert. Ebert has been the executive director of strategic operations at Piedmont Athens Regional Medical Center in Athens, Ga. since 2017, serving as an integral part of many strategic projects, including Piedmont and Clearview’s recent partnership.

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Dr. Charles DeCook Opens New Arthritis & Total Joint Specialists Office in Braselton

Friday, April 20th, 2018
Dr. Charles A. DeCook

Dr. Charles A. DeCook

Arthritis & Total Joint Specialists announced a new location in Braselton. Dr. Charles A. DeCook returned to the Northeast Georgia community and began seeing patients at the new office April 16.

With locations in Braselton, Alpharetta, Canton and Cumming, Arthritis & Total Joint Specialists specializes in treatment of chronic joint pain of the hip and knee. Dr. DeCook and his partners – Dr. Jeffrey P. Garrett, Dr. Kenneth J. Kress and Dr. Jon E. Minter – are all board-certified physicians in orthopedic surgery.

The office provides services including non-invasive care, stem cell therapy and minimally invasive, same-day joint replacement.

Dr. DeCook specializes in knee and hip replacements and has performed more than 5,500 total-joint replacements and 3,500 anterior-hip replacements. He works with the joint-replacement industry to improve surgical techniques and design implants and tools that result in better patient outcomes. Dr. DeCook has travelled internationally to teach other surgeons and improve the technique of hip and knee replacements and has served as a lecturer at some of the most esteemed symposiums in the world. He recently was recognized with the Leaders in Joint Replacement award by Orthopaedics Today.

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Emory Eye Center Opens New Expanded Clinic in Johns Creek

Thursday, April 19th, 2018

Emory Eye Center, Georgia’s largest eye care facility, opened a new office at Emory Johns Creek Hospital on April 4. The clinic is located at the Physicians Plaza at Emory Johns Creek Hospital.

Petra Jo, OD, provides comprehensive eye care to patients, by conducting eye exams, contact lens exams and prescribing glasses. Dr. Jo joined the Emory Eye Center team in 2014.

The clinic also offers diagnostic tests such as optical coherence tomography (OCT) for patients who need more specialized scans. An OCT shows an image of the tissue layers within the retina.

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Children’s Healthcare of Atlanta to Open Its First Urgent Care Center Inside The Perimeter

Thursday, April 19th, 2018

Children’s Healthcare of Atlanta opened the doors to the Children’s at Chamblee-Brookhaven Urgent Care Center, the not-for-profit pediatric healthcare system’s first Urgent Care location within the perimeter.

Located at the corner of Peachtree Boulevard and Clairmont Road, the new Children’s at Chamblee-Brookhaven will have 12 exam rooms and two procedure rooms that will allow Children’s to treat minor illnesses and injuries while also providing convenience for families.

Children’s at Chamblee-Brookhaven has board-certified pediatricians and a pediatric-trained staff. The Chamblee-Brookhaven location offers onsite laboratory and X-ray services.

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GHA Subsidiary Partners with IllumiCare to Help Physicians be Better Stewards of Healthcare Spending

Friday, April 20th, 2018

Seeing prices and calorie counts on a restaurant menu allows consumers to make better choices when eating out. In the same way, physicians make better choices when presented with the financial cost and potential risks of medications, labs and radiology tests when inside the electronic medical record (EMR) making treatment decisions.

Georgia Hospital Health Services (GHHS), the shared services subsidiary of the Georgia Hospital Association (GHA) is partnering with IllumiCare, a pioneer in point-of-care healthcare information technology, to offer Georgia hospitals its Smart Ribbon solution so clinicians can make better choices. The Smart Ribbon is a non-intrusive ribbon of information that appears within or momentarily hovers over a hospital’s EMR to display real-time cost, risk and other data. This empowers clinicians to practice more clinically efficient medicine, while also being better stewards of resources.

Inside the hospital, the Smart Ribbon shows not just how much radiology tests cost, but also the cumulative amount of medical radiation exposure to that patient and the associated cancer risk. When ordering a lab test, physicians see not only the cost, but also the amount of phlebotomy blood loss and the associated anemia risk. For medication ordering, they have powerful insight into the associated risk of c. difficile (if on antibiotics) or a fall (if on sedatives or opioids), and other adverse events, in addition to seeing the wholesale cost to supply the amount of medication in each scheduled order. The Smart Ribbon displays different information based on context and user, so when used in an outpatient setting, providers are given the necessary information for that type of user.

“We are uniquely aware of the challenges of hospitals within our state and nationally in selecting the most ideal and informed course of treatment for their patients. As healthcare leaders, we understand the importance of using innovative and cost-effective technology to improve care. Our partnership with IllumiCare is our latest initiative to arm hospitals with influential tools to increase transparency and awareness for physicians,” said GHA Senior Vice President of Business Operations, Bill Wylie.

The EMR-agnostic Smart Ribbon uses existing data feeds to gather clinical data and piggybacks on existing authentication and permission infrastructure. It was designed for physicians by a physician so it does not disrupt clinical workflow, appearing only in the upper portion of the screen, and if a provider does not interact with it, it automatically minimizes.

In 2016, IllumiCare partnered with the Texas Hospital Association (THA), and Texas hospitals produced incredible results. Initial pilot hospitals provided safer care for patients while they saved $112 to $202 in direct costs per inpatient admission. As a result, there are now 52 Texas hospitals participating in the initiative, with many others in the adoption process. The goal is to bring the same value to Georgia hospitals and their patients.

“It is paramount that hospital care be value-driven and fiscally efficient,” said GT LaBorde, CEO of IllumiCare. “GHA is helping to set a new standard of efficiency for hospital systems not only in Georgia, but across the country, to ensure all decisions made add value to the care of patients. In a short period of use, these hospitals will see measurable, hard dollar reductions in the cost of medications, labs, and radiological procedures.”

With signups underway, GHA and IllumiCare have created an early-adopter incentive for the first five participating Georgia hospitals or healthcare systems.

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Northside Vascular Surgery Opens Second Office in Sandy Springs

Friday, April 20th, 2018
Dr. Brooks Whitney

Dr. Brooks Whitney

Dr. Brooks Whitney has joined the staff of Northside Vascular. Dr. Whitney is board-certified in vascular surgery and general surgery and has more than two decades of experience practicing in the Atlanta area.

Prior to joining Northside Vascular Surgery, Dr. Whitney was a member of Georgia Vascular Clinic. He is a pioneer in adopting stenting and other endovascular treatments and is extensively experienced in serving patients with minimally invasive vascular surgery and endovascular therapy procedures. In 1997, Dr. Whitney was the first physician to perform carotid stenting at St. Joseph’s Hospital, and later was among the first to perform an aortic stent graft repair in the Southeast.

Dr. Whitney serves all forms of vascular treatment for his patients, including medical management, stenting and surgery. He tailors medical management and interventional techniques based on each patient’s specific needs.

Northside Vascular Surgery specializes in the diagnosis and treatment of disorders of the veins and arteries and has locations in Canton, Cumming and Sandy Springs. Dr. Whitney sees patients at the group’s Cumming location and at its new, second location in Sandy Springs.

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