SPRING | SUMMER 18
at AUGUSTA UNIVERSITY
Waves of the Future
MCG is produced biannually by the MCG Communications Office. SPRING | SUMMER 18
Dean: David C. Hess, MD Executive Editor: Toni Baker Contributing Writer/Editor: Danielle Wong Moores Assistant Editor: Jennifer Scott Production Assistant: Laurie LaChance AU Senior Photographer: Phil Jones Design & Production: Alison South Marketing Group Cover Illustration: Ali Ennis, MSMI, Medical Illustrator Â© 2018 AUGUSTA UNIVERSITY
Waves of the Future .................................... 12 Ultrasound: “The 21st Century Stethoscope” Silencing Cancer’s Siren Call...................... 20 Mechanical Thrombectomy ...................... 26 The emerging standard of care for brain clots Roots Run Deep ............................................. 34 Drs. Drew and Kaylar Howard (’92) establish scholarship The Broken Road .......................................... 38 Profile: Dr. Douglas Lundy (’93) A Brotherhood .............................................. 40 Alums and fellow fraternity brothers establish foundation 2018 Distinguished Alumni ........................ 42 Dr. William S. Hagler (’55) and Dr. Lloyd B. Schnuck Jr. (’68) Cancer Center Receives Gift ...................... 44 Peter Knox, local businessman, donates $1 million See One, Do One, Teach One ....................... 45 Willy Hughes, Class of 2018 New Admissions Interview Process ........ 46
SECTIONS From the Dean From the President News and Views Alumni and Philanthropy News Class Notes In Memoriam
32 47 48
FROM THE DEAN It’s been quite a few years since my actual first Match Day, but this year was another first for me. It was my first official Match as dean, and I have to tell you that it was really great to stand on that stage, to look at our students, to see their enthusiasm, to hear their success. Students like Lucia Chen who matched in neurology at Vanderbilt University Medical Center, like Joel Joseph who will be studying internal medicine at Wake Forest and like Taylor Smith who will be studying OB/GYN right here. This year 210 of our students participated in Match Day, 176 from MCG’s home here in Augusta and 34 seniors attending our campus in Athens in partnership with our great colleagues at the University of Georgia. Our Class of 2018 is pursuing 22 specialties in 32 states; 25 percent will stay in Georgia for their graduate medical education. Better than 40 percent chose a primary care specialty, including nine students who chose internal medicine as a prelude to a subspecialty like hematology/ oncology. Their match rate was an outstanding 98 percent. Our 21 residency programs that participated also matched well, another tribute to the great medical education provided at Georgia’s public medical school. You will see from President Keel’s column in this issue that our GME programs got some other good news recently when an additional $10 million in support was included in the current state budget. Those additional dollars will enable us to better balance the reality that GME is expensive – but essential – and that reimbursement rates today leave us about $20 million in the hole annually. That is primarily because federal support for these programs is capped at both the number of residents and related costs back in 1996. We again thank Gov. Deal,
our state legislature and President Keel for their support. This seems like a good time to also note that our University System of Georgia’s GME Regents Evaluation and Assessment Team (GREAT), which began back in 2011 with discussions about how to grow GME programs in Georgia, has essentially doubled the number of teaching hospitals and increased GME capacity by about 40 percent in our state. MCG has been part of those important conversations from the beginning and I am pleased that Dr. Shelley Nuss, a GME expert and campus dean of our Athens partnership, chairs this committee. It is really good to see this kind of support for physician education in Georgia, a state which ranks 39th in the number of active physicians and residents and fellows per 100,000 population – although I suspect the GREAT program has whittled that some. We are also 32nd in the number of medical students based on Georgia’s large population, even with MCG’s class size being among the nation’s largest. The better news is that our state ranks 14th in the percentage of physicians retained from a public undergraduate medical education. As with many things in our lives, both physician education and practice today are a definite mixed bag. Physician burnout is real and multifaceted. There is actual and perceived loss of autonomy. The homogenization of the hospitals where we practice can be tough. The seemingly endless focus on documenting care, which ironically often takes our focus and time away from patients, is frustrating. Don’t get me wrong, electronic medical records definitely have their value, like when you want to review a patient’s chart, not for just what you have observed and treated yourself, but for his or her interactions with other physicians as well. Still somedays it feels like we stare
at a computer screen more than at our patients, even when we are in the same room with them. That particularly saddens me, because like for many of you, patients are at the heart of why we became physicians and why our students want to be physicians. Even still, I catch myself in moments when I am seeing my patients as customers, as someone to bill and collect on because of the very real financial pressures that we all face. This temptation in medicine is tremendous, and the polar opposite of why we are here. But this is also real. Like so many of you, I know in my soul that there is no better profession and certainly no better job for me. Being a doctor is an honor, being able to also teach this profession and even add to the knowledge we teach through research, is an astounding trifecta and one that I would never change. Because there are still those moments when I see a student leap with joy about their future, when I hear the amazing impact of you, our graduates, when I actually look at my patient instead of my computer. I wish for each of you the continued ability to find the magic in what you do, and the passion to continue to do it so well. And I thank you for your support of the Medical College of Georgia. Respectfully yours,
David C. Hess, MD
Dean, Medical College of Georgia Executive Vice President for Medical Affairs and Integration, Augusta University Presidential Distinguished Chair
FROM THE PRESIDENT
Augusta University is proud of its role as a research university and a major contributor to education, economic growth and innovation in the state of Georgia. We are particularly proud to be home to the Medical College of Georgia and AU Health, the state’s only public academic health system. The good work of our faculty, staff and students would not be possible without the support of those who share our mission and vision. I am grateful to Governor Deal and the members of the Georgia General Assembly for the support they have given to the University System of Georgia and Augusta University in the 2018 legislative session. Their support reflects the significance of our statewide role, and I want to highlight a few of the proposed investments from this session that are included in the budget that is awaiting the Governor’s signature: n $49.4 million in bonds for the construction of the new Math & Science Building to help us build a pipeline of health science professionals n $10 million one-time allocation in the amended budget to offset the cost of Graduate Medical Education n $1.6 million increase to support undergraduate medical education n $1.37 million to establish a new Adrenal Gland Center at MCG n $750K in state support for six fellowships in Vision (Retinal and Glaucoma); Cancer (Gynecological Oncology); Neurology (Alzheimer’s Disease and Stroke/Vascular); and Aging n An increase in state capitation for four OB/GYN residency slots - $61,320
n First-time state support for three psychiatry residency slots - $43,500 n $5 million for the Georgia Advanced Biomanufacturing Center, a collaboration between Georgia Tech, the University of Georgia and Augusta University. But as generous as these investments are, our needs remain great. The students at the Medical College of Georgia face a difficult financial burden. MCG ranks 85th out of 140 medical schools in terms of scholarships awarded. And 81% of medical school graduates leave with an average debt of $134,500. This financial burden makes it difficult to address Georgia’s physician shortage, reduces the diversity of our physician population and exacerbates shortages in specialties. As we undertake our long-term journey to reach a Top 50 designation in biomedical research, and NCI designation for our cancer center, support for new faculty is essential. To reach those goals, we must increase our population of researchers substantially over the next ten years. MCG will require resources to support new faculty members’ work in the lab, in the clinic and in the classroom. Additionally, we must have facilities that reflect current technology, provide support for high-impact teaching practices and help students move seamlessly from the classroom to the workplace. We must also be attentive to our patient experience. We must provide the environment necessary to deliver the highest-quality patient care across
the continuum. Our facilities must allow us to take full advantage of our role as an academic health center, maintaining the links between the classroom, the laboratory and the bedside. State funding alone cannot meet our needs. MCG must develop more partnerships with individuals, corporations and foundations to create a financial model that can adequately support the nation’s 10th largest medical school class. In the coming year, we will be launching a comprehensive fundraising campaign in support of Augusta University, and a centerpiece of that campaign will be fundraising for MCG. As alumni and friends of our historic institution, you will play a pivotal role in the success of this transformational effort. I will be sharing more about our campaign in the coming months. In the meantime, thank you for everything you have done and will do in support of MCG.
Brooks Keel, PhD
President, Augusta University CEO, AU Health System
NEWS and VIEWS Drs. Jin-Xiong She, left, Sharad Purohit and Ashok Sharma
SUGAR COAT IT Sugar coating on our cells is hardly icing. Rather, it is essential to cell health and ours. Now, scientists have also developed a way to identify biomarkers for a wide range of diseases by assessing antibodies to the complex sugars coating our cells. The new, highly sensitive Luminex Multiplex Glycan Array enables the kind of volume needed to establish associations between antibody levels in our blood to these complex sugars, or glycans, and conditions from cancer to autoimmune disease and dementia, they report in the journal Nature Communications. Like our cells, the beads in the new array are sugar coated. By exposing patient blood or serum to them, the
scientists can see which glycans the patient is making antibodies against and how much they are making, looking for trends that could predict disease course, even potentially one day diagnose their disease. In fact, the scientific team led by Dr. Jin-Xiong She, director of the Center for Biotechnology and Genomic Medicine at the Medical College of Georgia and Georgia Research Alliance Eminent Scholar in Genomic Medicine, has already used the array to identify a potential biomarker for high risk of ovarian cancer relapse following surgery and standard chemotherapy regimens. “While we think this new test will eventually enable us to do many things, right now we have evidence it can help
determine biomarkers for those at risk for relapse from cancer,” says She, corresponding author of the published study. “With this new technology, we can explore what is normal and what is disease. This is just the beginning.” She is also principal investigator on a new $1.6 million grant from the National Institutes of Health that is enabling another significant expansion in both the volume of patient samples and glycans the array can handle. The scientists also are beginning to make their array available to other investigators, including providing ready-made glycan beads for use in their labs.
AN EASY CATHETER FIX Dr. George Hsu, a third-year emergency medicine fellow at MCG, is the recipient of a 2018 Innovation Award from Georgia Bio, presented to individuals who are forging new ground by thinking outside the traditional paradigms to create unique technology. Hsu worked with former Georgia Institute of Technology classmates to develop a device called Cathaid to address unfortunate but common complications of medical treatment: catheter-associated infections and unintentional positional catheter shifts. Both are a major source of morbidity and mortality for patients. In certain settings, a quarter of medical catheters will experience some form of complication putting them at risk for failure, Hsu says. “Health care systems spend hundreds of millions of dollars to try and prevent these issues, and even with current best practices, they still happen,” he says. Their device is a cover that is immediately applied after a catheter is inserted. Its securement mechanism, which functions almost like a lock and key, fastens the catheter in place with an antimicrobial medical-grade adhesive to help stave off infections. Cathaid also has a small window with a colored strip that crosses the device and the catheter. Called a positional verification system, if the catheter portion of the strip has shifted, it can indicate – in real time and to any member of a patient’s care team – that the catheter has moved. “If they shift, even just a few millimeters, it can be catastrophic,” Hsu, who also serves as CEO for Cathaid, says. “Catheter shifts are usually detected when patients decompensate or the medications and fluids that are going through the catheter get backed up. Typically those things happen over
Dr. George Hsu
hours and days. This device could detect them immediately.” Hsu and his collaborators are working with the Advanced Technology Development Center, a startup incubator at Georgia Tech that helps technology entrepreneurs in Georgia launch and build successful companies. Their hope is to have Cathaid on the market and in hospitals this year.
“Health care systems spend hundreds of millions of dollars to try and prevent these issues, and even with current best practices, they still happen.” –Dr. George Hsu
NEWS and VIEWS IMPROVING LEUKEMIA OUTCOMES Patients diagnosed with the most common form of leukemia who also have high levels of an enzyme known to suppress the immune system are most likely to die early, researchers say. High levels of this enzyme, indoleamine 2,3 dioxygenase, or IDO, at diagnosis also identify those who might benefit most by taking an IDO inhibitor along with their standard therapy, they report in the Nature journal Scientific Reports. “We want to help people who are not responding to treatment and are dying very soon after their diagnosis,” said Dr. Ravindra Kolhe, corresponding author, breast and molecular pathologist and director of the Georgia Esoteric & Molecular Labs LLC in the MCG Department of Pathology. A review of 40 patients with acute myeloid leukemia, or AML, found increased IDO expression in the bone marrow biopsy, performed to diagnose their disease, correlated with lower overall survival rates and early mortality. It also indicates that IDO expression should routinely be measured when the diagnostic bone marrow biopsy is performed, Kolhe says. An early phase clinical study already is underway to begin to explore the IDO inhibitor’s clinical potential in these patients. Sites include the Georgia Cancer Center at MCG as well as Johns Hopkins University and the University of Maryland Schools of Medicine. Biopharmaceutical company NewLinks Genetics, who produces the inhibitor Indoximod, is funding the study. While everyone has the IDO gene, it’s the cancer cells in this scenario that activate the disabler of the immune response, which is also used by the fetus and solid tumors, he says. Stem cells in the bone marrow are supposed to mature into a variety of cells that enable our blood and immune system function. Instead in AML, stem cells get stuck in an in-between, undifferentiated state called blasts. “It’s very normal to go to the blast step, providing it matures from there,” Kolhe says. “In leukemia, stem cells get limboed in the blast state so you don’t get any maturation. That means there are low platelets so you get clotting problems, you have low neutrophils so you have infections, you have less red blood cells so you get anemic,” he says.
Dr. Ravindra Kolhe
In fact, bleeding is a major cause of death for patients and often, significant gum bleeding is the first indicator. The MCG researcher found one thing the blasts are producing is IDO. “The patients who died at six months had a high expression of IDO while the blasts produced relatively little IDO in the patients who lived five years or more,” Kolhe says. “Right now we know it’s high in patients who die at six months and we show that it’s an independent indicator if you adjust for other known variables.”
ANOTHER REASON TO REDUCE ANTIBIOTIC OVERUSE Antibiotic use is known to have a near-immediate impact on our gut microbiota, and long-term use may leave us drug resistant and vulnerable to infection. Now there is mounting laboratory evidence that in the increasingly
Drs. Gang Zhou and Locke Bryan
complex, targeted treatment of cancer, judicious use of antibiotics also is needed to ensure these infection fighters don’t have the unintended consequence of also hampering cancer treatment, scientists report. Dr. Gang Zhou, immunologist at the Georgia Cancer Center and the MCG Department of Biochemistry and Molecular Biology, and Dr. Locke Bryan, hematologist/oncologist at the Georgia Cancer Center and MCG are both co-authors of the study published in the journal Oncotarget. Together with their colleagues, they have some of the first evidence that in the high-stakes arena of cancer, where chemotherapy is increasingly packaged with newer immunotherapies, antibiotics’ impact on the microbiota can mean that T cells, key players of the immune response, are less effective and some therapies might be too. They report that antibiotic use appears to have a mixed impact on an emerging immunotherapy called adoptive T-cell therapy, in which a patient’s T cells are altered in a variety of ways to better fight cancer. However, they found that one of the newest of these – CAR T-cell therapy – is not affected by antibiotics, likely because it is not so reliant on the innate immune system. Human studies are needed to see whether antibiotics affect the outcomes of adoptive T-cell therapy and to give clinicians and their patients better information about how best to maneuver treatment, Zhou notes. The research was funded by the National Institutes of Health and an American Cancer Society Research Scholar Grant.
NEWS and VIEWS NOT JUST FOR BAKING A daily dose of baking soda may help reduce the destructive inflammation of autoimmune diseases like rheumatoid arthritis, scientists say. They have some of the first evidence of how the cheap, overthe-counter antacid can encourage our spleen to promote instead an anti-inflammatory environment that could be therapeutic in the face of inflammatory disease, MCG scientists report in The Journal of Immunology. They have shown that when rats or healthy people drink a solution of baking soda, or sodium bicarbonate, it becomes a trigger for the stomach to make more acid to digest the next meal and for littlestudied mesothelial cells sitting on the spleen to tell the fist-sized organ that there’s no need to mount a protective immune response. “It’s most likely a hamburger, not a bacterial infection” is basically the message, says Dr. Paul O’Connor, renal physiologist in the Department of Physiology and the study’s corresponding author. In the spleen, as well as the blood and kidneys, they found after drinking water with baking soda for two weeks, the population of immune cells called macrophages, shifted from primarily those that promote inflammation, called M1, to those that reduce it, called M2. Macrophages, perhaps best known for their ability to consume garbage in the body like debris from injured or dead cells, are early arrivers to a call for an immune response. “You are not really turning anything off or on, you are just pushing it toward one side by giving an anti-inflammatory stimulus,” O’Connor says, in this case, away from harmful inflammation. “It’s potentially a really safe way to treat inflammatory disease.”
VITAMIN D’S ROLE IN HEART HEALTH More than 80 percent of Americans, the majority of whom spend their days indoors, have a vitamin D insufficiency or deficiency that researchers say could be impacting heart health. In what appears to be the first randomized trial of its kind, they found that arterial stiffness was improved in just four months by high doses of vitamin D supplementation in young, overweight/ obese, vitamin-deficient but otherwise still healthy AfricanAmericans, they write in the journal PLOS ONE. Overweight/obese blacks are at increased risk for vitamin D deficiency because darker skin absorbs less sunlight – the skin makes vitamin D in response to sun exposure – and fat tends to sequester vitamin D for no apparent purpose, says Dr. Yanbin Dong, geneticist and cardiologist at MCG’s Georgia Prevention Institute and the study’s corresponding author. Participants taking 4,000 international units - more than six times the daily 600 IUs the Institute of Medicine currently recommends for most adults and children – received the most benefit, says Dr. Anas Raed, research resident in the MCG Department of Medicine and the study’s first author. That dose, now considered the highest, safe upper dose of the vitamin by the Institute of Medicine, reduced arterial stiffness the most and the fastest: 10.4 percent in four months. “It significantly and rapidly reduced stiffness,” Raed says.
Drs. Anas Raed and Yanbin Dong
Two thousand IUs decreased stiffness by 2 percent in that timeframe. At 600 IUs, arterial stiffness actually increased slightly - .1 percent – and the placebo group experienced a 2.3 percent increase in arterial stiffness over the timeframe. While heart disease is the leading cause of death in the United States, according to the Centers for Disease Control and Prevention, blacks have higher rates of cardiovascular disease and death than whites and the disease tends to occur earlier in life.
A BROKEN MASTER CLOCK IS BAD NEWS FOR BLOOD VESSELS What do bad sleep habits and stiff blood vessels have in common? Nothing good, say MCG scientists exploring what appears to be a direct connection between a circadian clock that isn’t working as it should and an enzyme that promotes inflammation working overtime. The connection appears to be between Bmal1, a transcription factor that senses light and drives our master circadian clock, and ADAM17, an enzyme that sets inflammationproducing proteins free from our cells to target and thicken our blood vessel walls. The scientists, both vascular biologists, are Dr. Dan Rudic, who studies the circadian rhythm that drives our sleep-wake cycle, and Dr. Zsolt Bagi, who made the connection between ADAM17 and stiff blood vessels. Now they want to know, “Is it a direct connection?” says Rudic, who is thinking that Bmal1 may directly regulate ADAM17. He and Bagi are co-principal investigators on a $2.2 million National Institutes of Health grant that is enabling them to explore the unhealthy relationship, with the goal of also identifying the best point to intervene. Drs. Dan Rudic and Zsolt Bagi
Rudic’s lab is among those that have seen the impact of a disrupted circadian rhythm on blood vessels. Mice without normal Bmal1 function have stiff blood vessels, age rapidly and die early. It essentially cuts their life span in half, from two years to one, and could potentially do the same in humans, Rudic says. “Stiff blood vessels are probably one of the best surrogates of aging other than death,” he says. In human tissue, Bagi has connected stiff blood vessels to high levels of ADAM17 and low levels of its natural inhibitor. He has watched the inflammation-producing proteins ADAM17 sets free into the bloodstream make a beeline for the heart, where they thicken and stiffen the walls of the tiny blood vessels that help feed the important muscle. Bagi’s team found the same relationship in mice that they found in human blood vessels. They wondered if these two causes of stiff blood vessels were connected. In fact, is the relationship between the two the primary mechanisms of action for a messed-up circadian clock causing stiff blood vessels? They have early evidence that downregulation of the primary clock – which naturally occurs with aging as well as habits like sleeping fewer than five hours nightly, even from regularly consuming too much caffeine – prompts the unhealthy increase in ADAM17. “This is a novel and largely unexplored signal,” Rudic says. He and Rudic are looking at clock dysfunction and ADAM17 from many angles to answer questions like whether bringing down levels of ADAM17 reduces the stiffness associated with clock dysfunction. Bagi is working again with dysfunctional human blood vessels, using biochemical assays to this time also look at clock gene expression. “You get a footprint of what was,” says Bagi, of the now disconnected blood vessels. Preliminary data indicates Bmal1 is down in this scenario, Bagi says.
Waves of Ultrasound: “The 21st Century Stethoscope”
Its beginnings can be traced to the late 1700s, when a physiologist named Lazzaro Spallanzani first studied how bats use the reflections of sound to find things. More than 200 years later, ultrasound is being called “The 21st Century Stethoscope,” and it’s changing how the Medical College of Georgia teaches future physicians and how its health system provides patient care. Ultrasound works by using a probe to transmit high-frequency sound waves into the body, collecting the bounced back waves and feeding them to a computer to create immediate images of tissues and organs. At the state’s public medical school, it’s giving students an in-depth and novel look at the organ systems they’re studying during their first two, basic science intense, years of medical school, and new and faster ways to enhance learning physical diagnosis in their clinical years. At patients’ bedsides, the use of ultrasound is also changing health care delivery by allowing MCG physicians to make important clinical decisions right there, often without expensive and unnecessary tests. Ultrasound that fits in your pocket The technology is not new – the first time it was used to make a medical diagnosis was the mid-1940s – but it has only been in the last decade or so that ultrasound machines have become portable without losing the benefit of good image quality. That development is what initially piqued the interest of Dr. Paul Wallach, MCG’s former vice dean for academic affairs who is now executive associate dean for educational affairs and institutional improvement at Indiana University’s School of Medicine. “The old ultrasound machines were big – the size of washing machines,” Wallach remembers. “What I saw happening in the world though was the technology was starting to get better and smaller, a lot like what happened with
computers and cell phones. They became smaller and smaller than ever and less and less expensive.” Today, he says, anyone can purchase a handheld ultrasound machine that produces high quality images and hooks into a tablet that fits in the pocket of a white coat, all for under $5,000. “What does that mean?,” he ponders. “Five years from now, it’s going to be smaller, it’s going to be Bluetooth compatible, and it’ll be quite affordable. That means that every health care provider is going to end up with them in their pocket. If that’s the vision and you see that happening, what’s our responsibility as an educational institution? To teach doctors how to use it.” And do it now. Wallach began thinking of ways to integrate ultrasound into the already crowded undergraduate medical school curriculum shortly after he arrived at MCG in 2012. Just before Wallach’s arrival, the Augusta University College of Allied Health Sciences announced the closure
of its bachelor’s degree level sonography program. In the meantime, its program director Becky Etheridge, was enrolled in a teaching scholars fellowship at MCG’s Educational Innovation Institute. As fate or luck would have it, the co-director of the fellowship, Dr. Chris White, an emeritus professor of pediatrics who still teaches MCG students physical diagnosis, had been reading about the Stanford Medicine 25, a list of 25 physical exam skills the Stanford University School of Medicine thought every medical student and resident should master before treating patients. Number 20 on the list was bedside ultrasound. It was like the perfect storm. “(Dr. Wallach) met with me and told me that he wanted to offer point of care (or portable) ultrasound through the medical school curriculum, and that they were going to bring me on as an instructor to do that,” Etheridge remembers. “And what he told me that
day in 2013 has been exactly what we’ve done. We’ve never strayed from that. We’ve only expanded it.” Once hired, and over the next year, Etheridge set to work laying out a way to integrate ultrasound into the first and second years of medical school. She also had to acquire the necessary equipment – ultrasound machines, high-fidelity simulators and phantoms, specially designed objects that produce ultrasound images when scanned – to teach the 190 medical students per class at MCG’s main campus in Augusta. The system she and Wallach developed offers, in the first year, ultrasound labs that correlate to the modules students are studying in class and in the gross anatomy lab. For instance, if the students are studying the musculoskeletal system, ultrasound labs are focused on scanning anatomy like shoulders and knees. In the second year, ultrasound labs correlate to skills and organ systems students are simultaneously learning in physical diagnosis workshops.
Dr. Matt Lyon (’99)
“Ultrasound is the cognitive scaffolding for the learning of the adjacent basic science,” Wallach says. “We use these labs to reinforce anatomy, to reinforce pathophysiology. It makes clinical medicine come alive.” “It was very helpful for me to see in an ultrasound image the same structures that I was putting my hands on in the anatomy lab,” says fourth-year student Tahira West, who now helps teach more junior medical students in ultrasound labs. “Often, the hardest part is understanding the orientation of the anatomy in a living, breathing human being – what is posterior, anterior, for example. It’s difficult. Take the cardiac exam. The heart kind of sits diagonally in a sense. Seeing an ultrasound image of that helped me understand the anatomy better, helped me understand what I was looking at.” For two years, and mostly as a lone wolf, Etheridge taught ultrasound labs to first- and second-year medical students in the Interdisciplinary Simulation Center in the J. Harold
Harrison, M.D., Education Commons. But Wallach and she both knew the curriculum needed to expand to the third- and fourth-year clinical clerkships. They found the perfect partner to help in Dr. Matt Lyon, a 1999 MCG graduate and vice chair for academic programs and research in the Department of Emergency Medicine. Overcoming sound barriers Back during Lyon’s residency at MCG, the department had developed a fledgling ultrasound training program. While the program had a lot of stops and starts, Lyon says he knew how important and useful a tool ultrasound could be to emergency medicine physicians. He had seen it in action – being used for things like quickly diagnosing fluid on the heart, a lifethreatening pneumothorax, detecting gallstones…the list goes on. He began compiling thousands of ultrasound images and videos he had and used them to develop a lecture
“I was teaching people who had never used the technology. I had to help people overcome their initial shyness and reluctance. There’s always some of that with a new skill because they’re afraid they’re going to mess it up. You can’t mess up an ultrasound scan. This is a non-invasive look inside the body.” –DR. MATT LYON (’99)
series he could use to teach emergency medicine residents how to use ultrasound. “I went all around the Southeast teaching people how to use ultrasound at the bedside,” Lyon remembers. “Anyone who would let me come and teach a course, I would do it.” But more than teaching emergency medicine physicians and residents how to use the technology, his time on the road taught Lyon important lessons about helping people get over selfimposed barriers to using ultrasound. “I was teaching people who had never used the technology. I had to help people overcome their initial shyness and reluctance,” he says. “There’s always some of that with a new skill because they’re afraid they’re going to mess it up. You can’t mess up an ultrasound scan. This is a non-invasive look inside the body.” Back at MCG, in addition to emergency medicine residents, he still worked on an informal basis with several of the medical school’s graduate medical education programs, mostly teaching handfuls of residents here and there about how ultrasound could help guide them through procedures, like placing an intravenous line. He also developed a year-long ultrasound fellowship, which he opened to graduating emergency medicine residents, and a year-long ultrasound elective for fourth-year medical students. Knowing clinical ultrasound could and should be used across nearly every field of medicine, he began to develop an official curriculum that could translate to almost every residency program at MCG. “I designed this curriculum with the thought that ultrasound was this common language among specialties,” Lyon says. “Image acquisition and interpretation – whether the scan is normal or abnormal – is the same across disciplines. It’s how each specialty uses that information and deciding what to do with it that differs.”
For example, a scan of a patient’s leg in the emergency room that detects a deep vein thrombosis could result in different treatment than if it were discovered in the intensive care unit – but an ultrasound can be used to detect the clots in both scenarios. Lyon began to propose his “Ultrasound 101” training to residency program coordinators across the medical school in 2015. He had nearly 100 percent buy in, and still does. He runs regular resident ultrasound labs, focused on individual organ systems, that draw trainees in specialties from family medicine to surgery. And when new residents come on board in July, during their first week of training they all take a one-day crash course in ultrasound. “That crash course was amazing,” says Dr. Parker Smith, a 2015 MCG graduate who is completing his emergency medicine residency this year. “On day one as a resident in the ED, you’re using ultrasound. In the critically ill, we want and need answers immediately. Is there blood in the belly? Fluid around the heart? Ultrasound can give us those answers.” Why wouldn’t we? The experience Lyon gained throughout his years of training residents – of convincing people what a powerful tool ultrasound was and how they could integrate it into their clinical practice – became a powerful tool to demonstrate the synergy of training residents and third- and fourth-year medical students. “They were hearing a lot of ‘We don’t know how to do this,’ ‘It’s not something I do,’ ‘I can’t see how I can fit it into the curriculum,’ from clerkship directors,” Lyon says. “Those were the same barriers I’d already fought with residency program coordinators.” Wallach proposed and the university’s president and its provost created MCG’s new Center for Ultrasound Education, paired Lyon
and Etheridge, naming Lyon executive director and naming Etheridge director of ultrasound education. The two set about convincing clerkship directors that ultrasound had a place. The first step was getting emergency medicine, then an elective where ultrasound was already prevalent, designated as a required clerkship. “That gave me the ability to tell people that we were already in clerkships as we looked to expand to other clerkships,” Lyon says laughing. In 2016, students began attending labs that correlated with those resident labs, but tailored to their experience level. But Lyon, still focused on integrating ultrasound into clinical clerkships, knew if they could raise the center’s visibility, they’d be more likely to get buy in. A course, co-designed by Dr. Steven Holsten, associate professor of surgery, using ultrasound to teach and standardize the way residents place central lines (see sidebar on page 19) that reduced the complication rates to nearly zero, did just that. “We got enough notoriety from that and momentum that when we went back to clerkships, we had visibility and credentials,” he says. In the meantime, Wallach had found the money to purchase 20 Philips Lumify handheld ultrasound tablets, which are Android tablets with ultrasound probes attached. That meant Lyon and Etheridge could distribute the tablets to clerkship sites all over the state. Last July, the family medicine clerkship became the first, outside of emergency medicine, to integrate point of care ultrasound into their undergraduate training. And not just in Augusta. With the help of Dr. David Kriegel, ’98, director of medical student education for the Department of Family Medicine, and Dayna Seymore, coordinator of medical student education, the Lumify tablets and
ultrasound probes were distributed to regional campuses and 28 clerkship sites in every corner of the state. Students use the technology during their clerkships to reinforce concepts of the specialty. In the family medicine clerkship, for example, to support the national guidelines for screening patients for aortic aneurysms, students use the Lumify tablets to screen patients in the clinic. Not only are they learning the technical aspects of screening, they are also choosing the most appropriate patients who need screening. “Why wouldn’t we introduce this to our students during their clinical training?” Kriegel asks. “This is where medicine is going. I’ve seen huge developments in ultrasound just in the last 10 years. It truly is the stethoscope of the future.” Since the family medicine clerkship came on board last summer, obstetrics and gynecology has also added a point of care ultrasound component outside of the traditional sonography they have always used to perform fetal anatomy scans. Next year, internal medicine and surgery will be added to the mix, Lyon says. “By this July, we will be in all of the required core clinical clerkships,” he says. “A year and a half ago, we were only in one.” A leader in the field Integrating portable ultrasound training throughout undergraduate and graduate medical education puts MCG ahead of the game and at the front of the pack, Wallach says. According to Lyon, MCG is among the top one percent of medical schools using ultrasound in graduate medical education and in the top 10 percent that train their undergraduate medical students. MCG faculty have also shared their expertise with other medical schools. Just this spring, a team from the Center for Ultrasound Education traveled to the University of Panama to teach
undergraduate medical students and faculty there a compressed version of the ultrasound curriculum. What MCG students learn over four years, they taught in five days. “This curriculum and these training programs help us attract better medical students and residents because it’s something they can’t get at other medical schools,” Lyon says. “Our students also see how we’re training residents and they want to stay, so we end up keeping the best medical students as residents too.” “For every curricular innovation, my experience has been that there has always been a cohort of people who don’t like it and want to keep things the way they’ve always been,” Wallach adds. “I don’t think I’ve ever heard a negative comment about ultrasound. Our students appreciate that this is something that’s preparing them for their life as doctors.”
A FLUID MOTION Portable ultrasound can help nephrologists better detect fluid in the lungs of patients with end-stage kidney disease, according to a study by physicians at the Medical College of Georgia. Patients with the disease, characterized by the kidneys’ inability to work well enough to meet the body’s basic needs, can accumulate fluid all over their bodies, and commonly in the lungs, says second-year nephrology fellow Dr. Omar Saleem. The trick is knowing where the fluid is and how much needs to be removed, Saleem says. If it’s in the lungs, it can lead to complications like heart failure and high blood pressure. Saleem presented his research at the Southern Regional Meetings of the American Federation for Medical Research in February. When it comes to diagnosing “wet lungs,” the standard has been listening for chest crackling sounds with a stethoscope and measuring blood pressure – more fluid on the lungs prevents oxygen from being absorbed into the bloodstream. “But that’s quite subjective,” he says. “For instance, sometimes you can’t hear the crackling. That’s why the ultrasound adds to the physical exam.” He examined 24 end-stage kidney disease patients at Augusta University Health. As part of the normal physical exam, he placed the ultrasound probe on the patients’ chests to get a good view of the lungs. If there was fluid, he would see B-lines, which are actually reflections of the water in the lungs that appear as long, vertical white lines on an ultrasound. The higher the number of B-lines and the more intense, or bright, they were, the more fluid was present. “This is an objective marker of lung water, the accumulation of which can lead to serious complications for already fragile patients. We’re right at the edge here and we’re trying to keep people from tipping over into heart failure,” says Dr. Stanley Nahman, MCG nephrologist and director of the Department of Medicine’s Translational Research Program. “This will change the way we manage these people with dialysis.” Physicians can then better target dialysis treatments. “I can set the fluid removal goal at a higher point during dialysis,” Saleem says. “Where I might normally take off two liters of fluid, I might take three or four in someone who has water in his lungs.” “Our kidneys take all the fluid that comes from normal intake through diet and drinking and they filter the waste products, which we excrete in urine,” Nahman says. Hemodialysis uses a special filter called a dialyzer – or an artificial kidney – to filter waste, balance electrolytes and remove extra fluid. “These patients rarely urinate. They count on dialysis to keep their fluid in balance,” he says. The kidneys also help the body reabsorb essential nutrients into the bloodstream. End-stage kidney disease patients are typically receiving dialysis three times each week. Drs. Stanley Nahman and Omar Saleem
TECHNOLOGY THAT HELPS PEOPLE LIVE Dr. Ted Kuhn’s college physics professor skipped the chapter on ultrasound, telling his class at the University of North Carolina at Chapel Hill that there was no real use for it. Nearly 50 years later, Kuhn, director of international medicine in the Department of Emergency Medicine at the Medical College of Georgia, can’t keep track of the number of lives he’s helped save using the technology or the number of medical students and residents he’s trained to do the same. His interest in portable ultrasound began in the early ‘90s when he was working as a medical missionary at a small hospital in Central America, where resources were scarce. Upon walking into his bunk, his roommate, Dr. David Hunter, introduced himself. “He said ‘I’m a radiologist and I’m really useless here, but I’ll do the best I can,’” he remembers. “Turns out, not only was he a radiologist, he was ultrasound trained. He said to me, ‘If you ever need
anything, let me know.’ I told him I wanted him to teach me ultrasound. I trained with him for two years.” Kuhn, who completed a fellowship in tropical medicine after finishing medical school at Pennsylvania State University, has worked for years as a medical missionary. Those early experiences helped him realize what a valuable resource portable ultrasound could be for places where resources were extremely limited. “It was a game changer,” he says. “Physicians in the developing world are mostly using physical diagnosis to diagnose disease. Technology like CT scans, MRIs and X-rays are either not available or it’s beyond people’s ability to pay.” Realizing he could combine his training in tropical medicine and his newfound ultrasound skills, Kuhn set about using the imaging technology all over the world to better diagnose tropical diseases and alter their treatment. “It was something that was
portable and something I could use to see things in people that make a life-changing difference. I have formal training in studio art. Ultrasound, for me, is dynamic art that helps people live. Instead of painting on a canvas, I paint on a screen.” Kuhn began taking MCG students along on his mission trips, teaching them to do the same. The MCG Department of Emergency Medicine also started to develop a fledgling ultrasound training program, but for various reasons it never really got off the ground. But in the early 2000s, an excited young emergency medicine resident named Dr. Matt Lyon, ’99, helped change all of that. Lyon, who stayed as faculty after finishing his residency in 2003, cemented ultrasound’s place in residency training. Kuhn and Lyon joined forces and developed a curriculum to teach western physicians who are practicing in developing countries how to scan and diagnose tropical disease. For 15 years, they and other emergency medicine faculty and residents, have taught that curriculum all over the world – from Central to South America, in East and West Africa and in Southeast Asia. “The dream is to put this in the hands of people who need it, who can save children and adults all over the world,” Kuhn says. “But it’s not just about giving them a machine. The machine can’t interpret what it scans. We want to not only put it in their hands, but also train them so they know what they are seeing. What the mind doesn’t know, the eye cannot see.”
Dr. Ted Kuhn with students in Panama
SAFETY: A CENTRAL FOCUS Standardized training on how to effectively place central lines using ultrasound has improved patient safety and quality of care at Augusta University Health by reducing central line complications to nearly zero in less than two years. In September 2016, residents and fellows who insert the lines, which are placed into a large vein and used to give medicines, fluids, nutrients or blood products over a long period of time, first attended a mandatory grand rounds training session. Then they were individually tested using a cadaver model in the university’s gross anatomy lab. Those who didn’t pass had to be retrained and retake the test. “There is always a risk associated with placing a central line,” says Dr. Matt Lyon, ’99, executive director of the MCG Center for Ultrasound Education. “And even using ultrasound incorrectly can make matters worse. But by using it correctly, that risk is dramatically decreased.” Augusta University Health was one of the first health systems in the nation to combine ultrasound training and required testing on a cadaver model, which required months of preparation, Lyon says. “We even had to come up with a unique cadaver model,” he says. “Because traditionally, the veins in cadavers are flat, but we obviously need them open for this type of training.” The cadaver veins were filled with ultrasound gel. This training is just one part of a larger effort to make patients safer, says interim Chief Medical Officer, Dr. Phillip Coule, ’96. “This continued training is an opportunity to continue to create and reinforce a culture of safety throughout the hospital.”
Dr. Daniel Kaminstein uses a portable ultrasound on an international mission
SIREN CALL BY TONI BAKER
Aggressive, deadly tumors like glioblastoma and metastatic breast cancer have in common a siren call that beckons the bone marrow to send along whatever they need to survive and thrive. Blocking production of the chemical that initiates that call could be a logical and effective new treatment target, Medical College of Georgia scientists say. “Our idea is that the most aggressive tumors have the same basic mechanisms of growth and spread,” says Dr. Ali S. Arbab, leader of the Tumor Angiogenesis Initiative at the Georgia Cancer Center and professor in the MCG Department of Biochemistry and Molecular Biology. They have evidence that an inhibitor of the chemical, 20-HETE, reduces the growth and spread of human glioblastomas and breast cancer in laboratory models. 20-HETE, or 20-Hydroxyeicosatetraenoic acid, is an important part of a healthy body. It’s a metabolite of arachidonic acid, a fatty acid we make and constantly use for a wide variety of functions like helping make lipids for our cell membranes. Its normal functions include helping regulate blood pressure and blood flow. It’s also a known mediator of inflammation, which under healthy conditions can help us fight infection and actually protect us from cancer and other invaders.
But as cancers are wont to do with our body systems, tumors enable too much 20HETE and the chemical turns on us, first by activating immune cells that will send the cytokines that become the siren call to our bone marrow, says Dr. B.R. Achyut, cancer biologist and a longtime member of Arbab’s scientific team. “There is normal function and there is tumor-associated function,” says Achyut. “Tumors highjack our system and use that molecule against us.” High levels of 20-HETE help turn bone marrow cells’ usually lifesaving functions, like making blood vessels as we develop and populating our immune system, against us, Achyut says. Instead, 20-HETE helps bolster the primary tumor site and in the case of breast cancer, for example, helps prepare remote sites – called the tumor microenvironment – for its spread. Unlike a short-lived call for help from an injury site, for example, cancer’s demand for bone marrow’s support never really ends, says MCG molecular biologist and team member Dr. Thaiz F. Borin. In this altered state, Arbab and his team have shown that 20-HETE aids activation of things like protein kinases that can change the function of proteins, their location and what cells they associate with, as well as growth factors that can make cells grow in
size, proliferate and differentiate. It can even help recruit cells that make blood vessels that enable additional growth. 20-HETE also activates signaling kinases that enable cell division. It encourages inflammationpromoting factors like tumor necrosis factor alpha and several of the interleukins, another class of proteins that help regulate the immune response. In this state, the factors are turning up inflammation to support rather than fight cancer. Growth is the cue that enables growth It’s the rapid growth of these tumors that seems to garner such support. Hypoxia, a lack of adequate blood and oxygen often associated with disease and death, is instead a survival tactic for tumors. When a glioblastoma reaches the diameter of just .1 inch, for example, the spiraling growth and cell division makes the center of this very vascular tumor hypoxic. That leads to the need to recruit from the bone marrow a myriad of factors like vascular endothelial growth factor, or VEGF, that enable blood vessel and tumor growth, which the misguided 20-HETE enables. The bone marrow cells the tumor cytokines woo also include endothelial progenitor cells to make the lining for all the new blood vessels that VEGF and myeloid cells are making. Myeloid cells are immature, multitasking cells that can drive protective inflammation that, in this case, help tumors suppress the usual immune response in addition to making blood vessels. Increased numbers of these myeloid-derived suppressor cells, or MDSCs, are recruited to both the main tumor and to its metastatic sites. Higher rates of these cells are known to be associated with higher rates of recurrence and metastasis. “We have to disconnect the tumor from the bone marrow,” Arbab says. Enter the 20-HETE inhibitor, HET0016, which was developed to learn more about what 20-HETE does. The MCG scientists are using it in their animal models as they suspect it will one day be used in humans, as an adjunct to other cancer treatments.
For one study, they gave the drug alternately with the chemotherapy drug temozolomide for three to six weeks. They found in rats with glioblastoma, for example, the rodents survived for at least six months with the tumor instead of the expected few weeks. The scientists don’t know how much longer the rats might have lived because they were euthanized at six months as part of the study. Patients with a glioblastoma have a median survival of about 14.6 months, according to the American Brain Tumor Association. When they put human breast cancer cells and mouse mammary tumor cells in the mammary fat pad of mice, waited for the cancer to take hold and begin to spread, then intravenously gave mice HET0016 five days per week for three weeks, they found HET0016 reduced the migration and invasion of tumor cells. Forty-eight hours after the drug was given, cancer cells were less able to move about in small test tubes. The drug also reduced levels of metalloproteinases in the lungs, enzymes that can destroy existing protein structures, so that, in this case, cancer cells can penetrate the area and new blood vessels can grow. It also reduced levels of other key inhabitants of the tumor microenvironment like growth factors as well as cancer protective MDSCs. “It gets rid of one of the natural protections tumors use, and tumor growth in the lung goes down,” Arbab notes. There was less communication between the tumor’s base camp and potential deadly satellite locations in areas like the lungs, liver, brain or bones. When they examined the lungs, they saw fewer cytokines to summon future bone marrow cells and fewer enzymes that also support invasiveness of the breast cancer cells, says Borin. 20-HETE inhibition quietens the cues “The drug is reducing the ability of cancer cells to create a distant microenvironment where they can thrive,” says Arbab. In what’s known as the seed and soil hypothesis, Arbab notes that cancer cells are constantly doing test runs, sending cells out into the bloodstream to see if they will
take hold at some remote site. About 30 percent of patients with breast cancer, for example, experience metastasis. Glioblastoma, on the other hand, typically does not spread to other organs rather spreads out, increasingly occupying more and more space that should be occupied by the healthy brain. Bone marrow cells’ unwitting contribution to these tumors include growing more blood vessels on their periphery to enable their growing girth. Patients can die from the pressure the tumors put on the brain. Arbab notes that with both cancers, the primary tumors also shrank with 20-HETE inhibition because they are no longer recruiting the factors that enable growth. “They are becoming static,” he adds, noting that the 20-HETE blocker does not kill existing tumor cells, rather essentially puts them on hold.
Treatment with HET0016
Animal MRIs of a glioblastoma before and after treatment with an 20-HETE inhibitor. Both the tumor volume and blood flow were significantly reduced.
The Georgia Cancer Center team notes that while chemotherapy does kill tumor cells, when the tumors start dying they actually increase their release of cytokines as yet another cry for survival and another good reason to directly target the siren call that tumors are sending, Arbab says. “Cytokines are the point of action and cancer releases a lot of them,” Borin says of these molecules well known for their role in regulating the immune response. These days find the scientists working to learn more about how the inhibitor works, including its impact on the tumor microenvironment, and more about what happens to the bone marrow cells that tumors recruit. They also are looking at exosomes, traveling packages all cells send out as a way to communicate and swap substances. In the case of cancer cells, exosomes appear to be packed with items needed to build the supportive environment for their new distant location in the lungs or elsewhere. Once exosomes establish a niche, they send back a signal to the primary site for cancer cells to join them. The scientists want to further pursue the ability of HET0016 to block these cancer-derived packages. While a 20-HETE inhibitor has not yet been used in humans, commonly used drugs like aspirin and Celebrex, which target other arachidonic acid pathways, are widely used. The scientists’ studies indicate that healthy bone marrow production is untouched by 20-HETE inhibition because it’s blocking the tumor’s signals to the bone marrow, not the bone marrow directly. And, nobody wants bone marrow cells once tumors get their attention, they note. “They are working for the tumor,” Borin says. Notables Arbab was senior author on separate review articles on metastatic breast cancer and glioblastoma in the International Journal of Molecular Sciences published in December. He and his team published a paper looking at the impact of 20-HETE inhibition on breast cancer in PLOS ONE last summer. The group is responsible for the majority of the published work on the role of 20-HETE in cancer. Research support includes funding from the American Cancer Society and the National Institutes of Health. The 20-HETE inhibitor used for these preclinical studies is made by Dr. Iryna Lebedeva, assistant professor in the Department of Chemistry and Physics at Augusta University. The MCG scientists already have identified companies that could make a clinical grade inhibitor. To date they have studied only one dose of the research drug, and Arbab has submitted a grant to the National Cancer Institute to look at escalating doses in the rat model of glioblastoma.
Dr. Ali Syed Arbab
Dr. Ali Syed Arbab, 54, was born in Bangladesh, earned his medical degree there at Dhaka University’s Institute of Postgraduate Medicine and Research, then moved to Japan when he received a scholarship to study radiological sciences. Arbab ultimately earned a PhD in that field from Yamanashi Medical University in 1998 and three years later began a postdoctoral fellowship in stem cell and cell tracking at the National Institutes of Health. Afterward, he joined the radiology faculty of Henry Ford Health System and Wayne State University School of Medicine in Detroit. Arbab came to MCG in 2013 to lead the Tumor Angiogenesis Initiative at the Georgia Cancer Center. His early interests and expertise as a physician and a scientist led him to help develop techniques for keeping up with cells, like cancer cells, as they move about. He notes that “angiogenesis” in the name of the initiative he now leads is a bit of a misnomer. Because tumors – like glioblastoma and metastatic breast cancer – first just hook up to the tributaries of nearby blood vessels. But when they grow to a significant size – usually 2-3 millimeters, or .079-.118 inches – and need their own blood vessels, they look all the way to the bone marrow for basic building blocks like VEGF, that help establish our normal vascular network during development. Healthy angiogenesis usually entails recruiting the essentials from nearby, existing blood vessels. Arbab has documented how stem cells arrive from the bone marrow at the tumor within hours of the first call. Peak accumulation occurs within 24 hours. But like a badly built house, the blood vessels that tumors rapidly grow are leaky, which would be inefficient for our organs yet are oddly effective for tumors. The leakiness means the tumors always are a bit hypoxic, which serves as that continuous cue to recruit from the bone marrow a variety of factors that ultimately enable tumor growth. The leakiness also means that drugs, like chemotherapy, are less effective at reaching the tumor. While the majority of work on 20-HETE has been exploring its normal activity, like helping regulate blood pressure, when Arbab and his colleagues first blocked the chemical in the brain tumor glioma, they were surprised to see tumors shrink in response and those leaky blood vessels normalize. It turns out that the tumor cells actually have less 20-HETE than normal cells, rather it’s the inflammatory cells tumors accumulate releasing the excessive 20-HETE and sending that siren call back to the bone marrow. Newly arriving cells also express a lot of 20-HETE. The tumor microenvironment – the place where the tumor intends to spread – also is seething with it. He hopes that the increasing evidence of how tumors are manipulating the cells of the bone marrow to grow and spread, will prompt other scientists and clinicians alike to also focus on blocking the deadly manipulation. “We turn to our bone marrow every day to make things we need to survive. Tumors do the same,” says Arbab, who is working to cut the tie so the tumor can’t thrive, but the patient can survive.
thrombectomy The emerging standard of care for big clots in big blood vessels in the brain BY TONI BAKER
He wasnâ€™t driving to work. He wasnâ€™t alone upstairs in their rambling home doing his usual morning stint on the computer. He wasnâ€™t across the country alone either as a locum tenens neurologist in North Dakota, where an aging population of less than 1 million is scattered across more than 71,000 square miles. Instead, Dr. Edward Mendoza had coaxed his wife Kay down the spiral staircase of their Martinez, Georgia, home the morning of Wednesday, July 26. He wanted to surprise her with a built-in, lighted cabinet he had made to display some of their travel memorabilia and to go over additional construction work on tap for the day that she would have to oversee while he was at work. Mendoza wondered aloud if the built-in was crooked then he kind of wandered off and became uncharacteristically quiet. Kay figured he was upset about the ongoing troubles with extensive renovations to their home. Then he began staggering, his head cocked to one side. The comparatively small woman grabbed her six-foot husband around the waist and helped him sit down. Certain now that frustration was not the problem, she called 911. The 71-year-old neurologist and retired lieutenant colonel in the U.S. Army was having a massive ischemic stroke. His clot was in the stem of the middle cerebral artery, the largest branch of the internal carotid artery and a common stroke spot. It feeds big areas of the brain important to motor and sensory skills as well as speech and language.
“The effects when that part of the brain has interrupted blood flow are not subtle,” says Dr. Jeffrey A. Switzer, director of the Advanced Comprehensive Stroke Center at the Medical College of Georgia and Augusta University Health. “They are very dramatic.” Holly Hula, stroke program manager, saw Mendoza when he arrived, his long frame on a stretcher, his eyes deviated toward his left side, where the stroke occurred, the right side of his body paralyzed as a result. He could not talk, could not follow commands. She knew he was a neurologist and that meant he probably knew what had happened and what could result. Time means brain At 10:19 a.m., about an hour after his arrival, interventional neurologist Dr. Samuel Tsappidi punctured Mendoza’s femoral artery. He threaded a titaniumbased wire up through the clot, placed a catheter over that, then injected dye to ensure he really had made it through the clot. He then pushed the self-expanding clot retriever, which looks a bit like a piece of chain link fence, through the catheter and the clot. There is a soft pop as it expands. Tsappidi pulled Mendoza’s clot out in two pieces, but at one time, the most desired result. The neurology resident closed the groin area at 11:14 a.m. 48 hours later, Mendoza walked out of neuro intensive care. Big clots in big vessels that affect big portions of the brain occur in about 20 percent of acute ischemic strokes and mechanical thrombectomy, while still not widely available in the United States, is considered today’s standard of care, Switzer says. It’s also a point of enthusiasm and pride among MCG stroke team members. Like his patients, endovascular neurosurgeon and 2002 MCG graduate Dr. Scott Y. Rahimi likes the essentially instant results, as those vital vascular trees fill back in and brain tissue awakens. Conversely in this severe stroke scenario, 80-90 percent of patients can be left moderately to severely disabled, if
they survive, and even with tPA, the now 20-year-old clot dissolver also used to treat ischemic strokes. With mechanical thrombectomy, 4050 percent of these patients can regain their independence if not quite 100 percent of their function, Switzer says. Stroke, like trauma, appears to be a bit of an equalizer in that it can really happen to anyone. The MCG team has treated patients in their 20s and in their 80s. There are the usual risks like smoking, high blood pressure and cholesterol and obesity. But there also are risks like severe dehydration or a hole between the chambers of the heart from birth or atrial fibrillation, when the heart’s upper chambers sometimes beat randomly and out of sync with the pumping chambers below. Mendoza was diagnosed with atrial fibrillation while a student at Emory University School of Medicine right after his heart rate soared while playing basketball. He always knew the risks but was too busy to dwell. The American Heart Association says atrial fibrillation accounts for 15-20 percent of strokes. The MCG stroke team and Mendoza agree that it accounted for his. Inefficient beating can cause blood to pool in the heart, clotting
factors can pool as well and clots can form, like the fresh red one Tsappidi pulled out of Mendoza. Clots that break off from diseased arteries are more yellowish, like cholesterol, often their primary component. Risks and rewards Unlike more established trauma systems across the nation, there are still problems with patients getting to a hospital and to one that can remove those clots even in the heart of the stroke belt. Denial and delay are definitely two problems faced by EMS personnel, says Jody Stafford (see MCG Medicine, Spring/Summer 2015), a paramedic for Augusta-based Gold Cross EMS, who was attending a recent stroke assessment course taught by Hula to help address these issues. “Everybody is in denial, nobody wants to admit they are having a stroke so that puts us behind the eight ball,” he says. “This is one of those things we really can’t do anything about until we get them to the hospital,” Stafford adds. “It’s real imperative that we get them there as quick as we can.” Like with cardiac arrest, an ischemic stroke makes Stafford think about time and lost tissue.
The clot removed from Mendoza
Dr. Scott Y. Rahimi with the stent retriever
Our brain is pretty much us When he was in medical school at MCG, Rahimi thought for a time about specializing in vascular surgery because he liked the fine motor work of dealing with blood vessels. In anatomy, he can remember dissecting out all the blood vessels, even when he didn’t have to. When it was time for his neurology rotation, which at the time was combined with neurosurgery, his friends told him that he could get a better grade in neurosurgery. He believed them, swapped out his neurology spot and ended up in the operating room watching neurosurgeon Dr. James Fick operate on a gliobastoma, a super-aggressive brain tumor. When Rahimi saw the pulsing brain, the blood vessels on its surface, he found a calling and went to then-neurosurgery chair, Dr. Mark Lee, that day. “This is probably as instantaneous as it gets,” Rahimi says, looking at an angiogram of the vascular network in the brain that is restored, much like a tree revived by the spring, following mechanical thrombectomy. He was at Emory completing his neurovascular surgery fellowship, where the Mechanical Embolus Removal in Cerebral Ischemia, or MERCI, device, the first Food and Drug Administration-
approved retriever to remove clots in an ischemic stroke, was already in use. MERCI had a balloon catheter to block blood flow during the retrieval process and a coil that straightened out after it passed through the catheter and clot, recoiling on the other side to better grasp the clot. The second generation of this device worked better than the first but overall success was not great, Rahimi says. The Penumbra Aspiration System followed a few years later, which basically suctions the clot out. Stent retrievers, like the ones used at MCG and its health system, would come next. While clinical trials of all the devices reflected benefit in each, side-by-side studies ultimately showed the stent retrievers had better functional outcomes in patients. The third time can be the charm The FDA first approved the stent retrieval device in patients who did not get or did not respond to the clot buster tPA in 2012, and four years later declared it an initial therapy for ischemic stroke. The FDA cited studies that showed 29 percent of patients treated with the stent retrieval device as well as tPA and other medical management like blood pressure control, had few to no residual
Mendoza’s clot hinders blood flow in the vessel
symptoms following an ischemic stroke like Mendoza’s. That’s compared to 19 percent in patients who did not have mechanical thrombectomy. Just this February the FDA extended use of the Trevo clot retriever up to 24 hours after the onset of stroke symptoms following results of the DAWN trial, which showed 48 percent of patients treated with the device were functionally independent versus 13 percent who received medical management only. Used well, tPA could dissolve a big clot like Mendoza’s maybe 30 percent of the time, Switzer says. But when his interventional colleagues Rahimi and Tsappidi go after a clot, there is more like an 80-90 percent chance they can remove the clot and more rapidly reestablish the flow of blood and oxygen. As with Mendoza, they often use tPA as well to start to eat away at the big clot and maybe even give them more room to work inside the blood vessel. tPA can be particularly beneficial when patients are in for a long transport to the stroke center, like the rural communities MCG serves with its telestroke system, REACH, Switzer notes. “That can mean two more hours of dying brain cells.” “Time is critical following the onset of stroke symptoms,” commented
Blood flow is restored after clot removal
Dr. Edward Mendoza with wife Kay
Dr. Carlos Peña, director of the FDA Division of Neurological and Physical Medicine Devices in February. “Expanding the treatment window from 6 to 24 hours will significantly increase the number of stroke patients who may benefit from treatment.” But time matters even more for some of us. “They say you lose almost two million brain cells a minute without oxygen,” Rahimi says, referencing most of us. Those who likely will benefit most from this expanded 24-hour window are unknown until they hit the door of a stroke center, says Switzer. These are patients where the physical exam, like Mendoza’s, may indicate that a lot of brain is immediately at risk. But additional perfusion tests currently run at MCG for patients arriving beyond the six hour window, show – unlike Mendoza – that the actual infarct area in the brain is not as bad because of collateral circulation some people are fortunate to just have. These small vessels continue to provide minimal support to some brain regions that otherwise would be in immediate jeopardy. They call this at-risk region the penumbra and while no one suggests waiting any longer than necessary, this part of the brain in these individuals offers some temporary protection until the culprit clot can be removed and blood flow restored. Switzer notes that this can particularly benefit patients who wake up from a night’s sleep to find they have had a stroke, a reality for about 1 in 7 patients. “The DAWN trial gave us hope that we can help more people with clots back here,” Hula says, pointing toward the back of her 40-something head. An aging population paired with unhealthy lifestyles like high-fat diets and little physical activity, mean the demand for these kind of services will only increase, Rahimi says. But plenty of potential patients already are out there waiting for well-tuned delivery systems to develop, Switzer adds. He pragmatically notes that many of those patients are now likely dead or confined to a nursing home.
traveling the world whenever he is not working as a medical coding consultant, a neurologist at Augusta State Medical Prison or in North Dakota, or as a volunteer teacher at a Friday resident and student neurology clinic with 1964 MCG graduate Dr. James McCord. Kay so hoped that she had not lost him, too. His extremities were moving again in no time but Mendoza was still having trouble talking. He drew a triangular graph of his chances of recovery and performed his own mini-mental status exam. He looked at his pre- and post-angiogram and reasoned that this guy was devastated. He was back at work two days after leaving the hospital. Mendoza says he never needed official rehab, but did start his own regular cardio workout back in his basement near the scene of his stroke. “They did a great job,” he says of his colleagues at MCG, the day before he and Kay were heading out of town again to make room for Masters Golf Tournament visitors at their home. “Now we will see how much longer we can go,” he adds. “Every day is a miracle day.”
Because he was not driving or alone, because his wife called EMS and because the Gold Cross paramedics brought him straight to the region’s only Advanced Comprehensive Stroke Center, stroke team members met Mendoza at the Emergency Department door and got a direct briefing from the paramedics. He got a CT to first check for bleeding and the extent of early damage, and then a CT angiogram so the contrast medium could identify the offending clot. Kay had met Mendoza when her husband of nearly 28 years did not come home from a jog. David Gill was found on the roadside in a coma, but the quick EMS response did not help much that time. Horribly conflicted about ceasing life support for her 50-year-old husband, her then-chef instructor in Texas offered the wisdom of his father, neurologist Mendoza. Mendoza and Kay would actually meet a year and a half later. They would just click and soon marry. They have great fun
n Aging, gender (more women than men have strokes) and race (minorities have a higher and earlier risk) are uncontrollable risk factors. So are a family history and a previous stroke or transient ischemic attack. 20-30 percent of the time, the cause is unknown, or cryptogenic, Tsappidi says.
n About 795,000 strokes occur in the United States each year and stroke is the fifth leading cause of death and a leading cause of adult disability n 87 percent of strokes are ischemic, where normal blood and oxygen flow is stopped n Risk factors include: High blood pressure, High cholesterol, Diabetes, Tobacco use, Physical inactivity, Obesity, Heart disease and Atrial fibrillation
n Stroke can mimic hypoglycemia, seizures, alcohol intoxication, drug overdose/toxicity, cerebral infection even a brain tumor. n Most commonly used field assessment is the Cincinnati Prehospital Stroke Scale. Facial Droop: One side of face does not move at all Arm Drift: Arm does not move equally with the other Speech: Patient has slurred speech, uses inappropriate words or cannot speak. With a severe stroke, like Mendoza’s, speech is lost.
Alumni and Philant hropy News
Dear Fellow Alumni, Like many of you, I find that between a busy medical practice, a hectic family life, membership in professional or civic organizations, and country club participation, it seems that there is little time left for other endeavors or pursuits. This was exactly how I felt some years ago before I was asked to co-host a dinner with a group of freshmen medical students. The idea was to connect alumni in the Augusta area with students, and to reconnect alumni to the Medical College of Georgia. The experience was extremely rewarding on several levels. The young men and women asked insightful questions, shared their personal stories of family and undergraduate life, and expressed their anxieties about their new adventures. I was reminded of my own time at MCG and the many individuals who played such a positive role in my medical school journey. This marked the beginning of my active involvement in the Medical College of Georgia Alumni Association. My MCG story begins much earlier. I am a native Augustan and grew up several miles from campus just above Lake Olmstead. My father was a sociology professor at Augusta College, and we attended Reid Memorial Presbyterian Church, just up Walton Way from MCG. My formative years were spent in the company of friends of my parents, many of whom were physicians and graduates of the Medical College of Georgia. I enjoyed the stories that I heard of medical school classes, hospital training, long days, late nights, medical fraternities and all kinds of antics. I also heard and saw the impact that these physicians had on the lives of their patients in the Augusta community. I felt at an early age that I wanted the knowledge and skills necessary to care for my fellow man, just as my mentors were doing. I wanted to care for my community and bring healing to the sick, comfort to the dying and compassion to the grieving. Like many other teenagers, as high school approached conclusion I questioned my resolve for the many years of commitment to the course of medical studies. I chose instead to attend the Georgia Institute of Technology to study mechanical engineering. Though I loved the challenging math and science curriculum, I felt there was a humanistic void, and I began questioning my career path. Then in my sophomore year, my father was diagnosed with cancer. His eight-month battle ended in the intensive care unit where I observed the doctors and nurses, some of whom my father had taught, care for him and my family with a dedication and commitment that defied anything I had ever experienced. It was during this terrible time that I decided I wanted to be a physician, and more specifically, I wanted to be a Medical College of Georgia physician.
We alumni were all brought to MCG from different cultural backgrounds, different geographic regions, different socioeconomic levels and for different personal reasons, but the fact is we were privileged to receive one of the finest medical educations in the country. Today, residency program directors across the United States report that MCG graduates are some of the most knowledgeable and most prepared for postgraduate training. MCG residents receive comparable accolades as they enter fellowships and private practices. Our alma mater instilled in us the tools and talents needed to positively impact the world around us. Our medical school, the Medical College of Georgia, whose name, emblem and ring will always be part of our, and future graduates’ identity, has now one of the largest medical school classes in the country. We are part of a comprehensive research university that garners national and international attention, and over the next few years we will see our school expand even more to meet the needs of the citizens of the rapidly growing state of Georgia. For many of us, the years have flown by since our hooding ceremony and graduation, or our ceremony concluding residency or fellowship training, but it was at that time that we all became forever bonded as alumni of the Medical College of Georgia. I look at my oldest son who is a pre-med student at the University of Georgia and who very much wants to follow in his father’s footsteps at our alma mater. My hope is that he experiences the influences of engaged alumni as he, like all the rest of us did, prepares for a life of dedication to knowledge and service to others. I challenge you over the next 12 months to reach out to the Medical College of Georgia Alumni Association and ask how you can positively impact the lives of our young medical students and young physicians through the many programs and scholarship opportunities sponsored by the association. I encourage you to say “yes” when I, or another member asks if you would like the opportunity to pay forward the many blessings that the Medical College of Georgia bestowed upon us, to another group of future alumni. Yours, respectfully and sincerely,
Alan Milledge Smith, MD (’95)
Drs. Kaylar and Drew Howard (â€™92)
Alumni and Philant hropy News
BY DANIELLE WONG MOORES
Drs. Drew and Kaylar Howard (â€™92)
have established an MCG scholarship to attract the best and brightest to underserved parts of Georgia.
At Harvard University, it’s the Presidential Scholars program. At Emory, it’s the Woodruff Scholarship. And at Johns Hopkins, it’s the Bloomberg Scholarship. At most major universities, transformative gifts from alumni have made it possible to attract the highest-caliber students and catapult that university into a top 10 or top 20 institution. Drew and Kaylar Howard, both class of 1992, want to do the same for the Medical College of Georgia. “I can’t give billions, but I can start,” said Drew. “I want MCG to continue to be a world-class medical school and a leader because it was that for me…But it’s also not Harvard or Johns Hopkins or Stanford right now. So we thought, let’s start doing our part. The way to do that is to give.” “And if I do it, maybe other people will follow suit.” Back Home Today, Drew and Kaylar own The Howard Center, the OB/GYN practice they opened in July 2001. It’s a large practice of 12 physicians, and the 19,000-squarefoot facility supports state-of-the-art care including obstetrics, gynecology and anti-aging, all in a beautifully designed, relaxing setting, just the way the Howards envisioned it. It’s a practice that would fit right in at a big city, but it’s in Tifton, Georgia, smack dab in the middle of rural Southwest Georgia. Drew hails from only a few miles down the road in Sycamore, a spit-and-you’ll-miss-it community of less than 300. He grew up on a farm, where his parents did a little of everything—corn, peanuts, cotton, soybeans, even cattle—and they
Gra du t a d r a w o H aylar Drew and K MCG 1992
“MCG gave me the education and
gave me that desire to go back to
underserved areas and to give back a portion of what they gave me to a community.”
–DR. DREW HOWARD
believed their son would go into the family business. “But for whatever reason, as a child, 3rd, 4th grade, I just really liked our family doctor,” said Drew. “He was a country doctor who did everything from surgery to delivering babies. He took care of all of us and I just really liked him and I wanted to be like him.” Accidental Insight Growing up just two hours north, in the slightly larger rural town of Jasper County’s Monticello, Kaylar hails from a farm family too. But that’s where her story takes a different turn. She majored in animal science at the University of Georgia and had landed her first job as a quality control manager at a ground beef company in Norcross when tragedy struck. Her mother and brother were in a car wreck on the Jasper-Newton county line and were life-flighted to Atlanta. While her brother was released after just a few days in the hospital, during her mother’s three-month recovery, Kaylar drove back and forth to help take care of her. “I just kind of got intrigued with medicine when I was doing that,” she said. Kaylar’s plan was originally to become an RN, like one of her aunts. But when she saw that she needed only a few more classes in order to qualify for medical school, she thought, “Why not?” Meanwhile, Drew worked hard, and the community around him worked hard to help prepare him—with the result that he was the first in his family to receive a college education, much less attend medical school. Drew and Kaylar met their first day at MCG and quickly became friends as they discovered they came from such similar backgrounds. As they studied together, did laundry together and were drawn to the specialty of obstetrics and gynecology together, they also shared
a dream: to one day go back to rural Georgia to practice. For them, there was never the question of doing anything else. For Kaylar, the terrible car accident that her mother and brother experienced shed a light on the great need for clinicians in rural areas of the state. And for Drew: “MCG gave me the education and gave me that desire to go back to underserved areas and to give back a portion of what they gave me to a community. We never faltered in that thought.” Giving Back Drew and Kaylar were both led to MCG for financial reasons—the school was at the time one of the more affordable options. Drew himself had attended Emory University as an undergraduate on a Coca-Cola scholarship designed to attract students from underserved areas of Georgia. It was a tough choice between his college alma mater and the state’s medical school, but once he got to Augusta, “It was awesome. I came to MCG and just absolutely loved it. I excelled there…Later, when I was applying to residencies, everywhere I went [it was], ‘We love students from MCG because they hit the ground running…At MCG, they’re doctors and they’re ready to perform.’” Kaylar had much the same experience. “For me, it was very difficult to go to college and to medical school, financially…MCG was the most affordable medical school in the state for sure,” she said. “And I think the training at MCG is really, really good, both from the basic science and clinical standpoint…I just felt like I could do anything after there.” Both always thought that they’d give to MCG. But it was when their own children were applying to universities like Harvard and Princeton and Emory
and being offered scholarships that the Howards realized that the time to give back to their alma mater wasn’t in 10 or 20 years, but right now. An endowment is often thought of as a gift that alumni give when they are further along in their careers. “What I realized was how Emory for instance has gone from a normal university, fairly prestigious in Georgia, to a world-class university by its alumni giving back,” said Drew. “That is what does it, when you can support students and attract students that you couldn’t otherwise get.” Those high-caliber students are what’s needed to drive a university to the top of those academic rankings— which in turn bring more bright students, new faculty, advanced research and more. The Dr. Drew Howard and Dr. Kaylar Greer Howard Scholarship also has a twist: Along with merit and financial need, preference will be given to students who want to practice in Southwest Georgia. Those roots, after all, are strong. “The high cost of malpractice insurance has become such a problem that it’s very difficult to attract physicians at all to rural areas, which often present lower salaries,” said Drew. “What we’re trying to attract is world-class, brilliant people who want to come do underserved work.” “We had talked about it forever,” added Kaylar. “As far as our state goes, there are two big needs. One is K-12 education and we’re way behind on that, and two is medical care, and we’re way behind on that. Both of those need to be provided in certain parts of the state… there was a burning desire to see that taken care of.”
Alumni and Philant hropy News
The Broken Road BY DANIELLE WONG MOORES
Dr. Douglas Lundy (’93)
If Plan B had happened, it would have been Douglas Lundy, PharmD or Douglas Lundy, DVM. But it wouldn’t have been Plan A. Not that there is anything wrong with a career in pharmacy or in veterinary care, if they’re your first choice. But Lundy—who today is an orthopaedic trauma surgeon and co-president of Atlanta’s Resurgens Orthopaedics—had always imagined he’d be a doctor. Even after his friends told him, “You’ll never get in, it’s too hard.” Even when he was rejected from his first-choice medical school, the Medical College of Georgia—first, then a second time. Still, hard work and determination run in his Irish veins. “My father was a first-generation Irish immigrant, and an electrician and an engineer,” said Lundy. “He was the first in his family to be born in America. He worked as hard as any doctor—70, 80 hours a week, all the time. He’s who I modeled myself after.” Making It Happen Lundy’s mornings often start early, in the dark of 4 a.m., unless he doesn’t sleep at all because of an emergency case. Even before he gets out of bed, he’s on his phone, checking emails and texts, planning out his day. Although he has held the role of co-president of Resurgens—which has more than 20 locations and 100 physicians across the greater Atlanta area—since 2014, he continues to see patients and operate three days a week and many weekends. The clinical piece is something he would never give up. “It’s the best job in the world,” he said. The success and where he is today continue to surprise him, since it wasn’t something he necessarily pursued. In 2012, Lundy was elected to the American Board of Orthopaedic Surgery, where he served as treasurer and chair of ABOS’ Oral Examinations Committee, until he was tapped to be president-elect this year. He is also chief financial officer-elect of the Orthopaedic Trauma Association and was chair of the American Academy of Orthopaedic Surgeons Council on Advocacy.
“I didn’t have any expectations,” said Lundy. “I just came and worked and put my head down and did stuff. Looking around now, I’m like, ‘How did this happen?’ It was not planned.” But in many ways, that rejection from medical school was a wakeup call. After graduating from North Georgia College under a military scholarship and receiving his first medical school rejection letter, Lundy went into the U.S. Army’s Infantry Basic Officer Leader Course and completed his initial training. After moving back to the reserves, he applied again to medical school, veterinary school, pharmacy school, even masters programs and got into them all—all except medical school. So he took a deep breath and chose an option. Yet after a short time in pharmacy school, Lundy realized, “This isn’t me.” At the same time, his friends who had remained active in the army full-time were moving up in the ranks and other friends who had entered masters programs were well on their way to earning their diplomas—“And here I was doing something I didn’t want to do.” Still, many would have just stuck with their choice. Not Lundy. “I really threw down and studied hard in pharmacy school,” with a goal of making the grades so he could apply one more time. It would take another two years of work, but he was accepted into the Medical College of Georgia Class of ’93. “I was one of the last people to be accepted, three to four weeks before class started,” admitted Lundy. Lundy was in Yakima, Washington, doing a joint command exercise with the Marine Corps and Army combat ops when his mother called with the news. “I had to suddenly and quickly separate from the army and get to Atlanta, then get to Augusta.” Medical School, Full Blast At MCG, Lundy poured 100 percent of himself into the work. Chalk it up to his time in the infantry, where it was full blast, all the time, with no sleep and no time even to complain about the lack of sleep. And he loved it. Every rotation appealed to him too. But he kept coming back to his first thought: orthopaedics. “The only doctor I ever saw growing up was an orthopaedic surgeon,” he said. “I never got sick. I was always breaking or spraining or twisting something, so it was off to Dr. Chip Pendleton.” When he rotated on the trauma rotation, he knew immediately: This is what I want to do. The days and often long nights of jumping in to take care of fractures and lifethreatening injuries appealed to that “go full blast” side of his personality. “It selects you,” he said. “The frenetic lifestyle chooses those of us that it appeals to…We just do such cool stuff…I’m 53 now, and it never gets old.” MCG was also where he developed the mindset about his life and his career. “Being a doctor is a calling. It’s more than a job. It’s what sets you up in terms of how you treat people and why you do what you do. We see a lot of entitled doctors
and surgeons out there…and that’s against what we learned at MCG. [There, it was] ‘It’s not about you, dummy.’ It’s about everybody else. That’s why you’re here. Just get up, do your thing, figure this out and stop the problem.” Rapid Fire
After graduating near the top of his class and completing a residency in orthopaedics at Georgia Baptist Medical Center in Atlanta, followed by an orthopaedic trauma/foot and ankle fellowship at Vanderbilt University Medical Center, Lundy went for a time to practice in Fort Collins, Colorado, with his family, wife Peggy and sons Zack and Ryan. Still, Atlanta was home. After his mother-in-law died, he and Peggy both realized that their sons were growing up without knowing the rest of their family. So when an opportunity came available at Resurgens, he signed up, with a goal of just doing his thing—fixing fractures. But when you’ve been a combat infantry officer in the army, leadership tends to come naturally. The previous leadership at Resurgens recognized that. Lundy was brought on as part of a succession plan. Since becoming co-president of one of the state’s leading orthopaedic clinics, Lundy’s focus has been on building on the success of those previous leaders. “My job was to stand on their shoulders and take the practice to the next level.” Resurgens’ rapid growth came in part from merging several practices into one. As difficult and challenging as that process was, it was just as hard to consolidate the cultures in order to make the practice seamless and consistent, from the policies, forms and the type of furniture to patient outcome measures. “We wanted everything to be identical,” he said. “It’s worked really well.” So well, in fact, that the Atlanta Journal-Constitution last year ranked Resurgens the number 3 large workplace in metro Atlanta. The work is never done—and that’s the way Lundy likes it. But in his free time, he spends every moment with his wife and now older sons who will soon be graduating college and most definitely not attending medical school. With one son’s goal to attend Auburn and work at Walt Disney Corp. and another to work with animals, the medical profession is not their Plan A. In between, Lundy frequently travels to Africa for medical missions work, where he is working to train African doctors to become surgeons. Sometimes too, he will speak at his sons’ schools. And the story’s not about a high-powered doctor, not really. It’s about that kid who just graduated college in 1986, with a medical school rejection letter in his hand. “The whole thing is, never give up. Just continue to improve your position and continue to push. Don’t let anybody tell you you can’t. If I had listened, I would have stopped way before this.”
Alumni and Philant hropy News
BY JENNIFER HILLIARD SCOTT
Drs. Jonathan Jarman (’86), left, and Sam Richwine (’77)
To learn more about the Cloverhurst Benevolent Foundation, visit cloverhurst.org
The motto of the Phi Gamma Delta fraternity is “Not for College Days Alone,” solidifying the idea that the brotherhood and support that come with joining lasts well beyond college years. On its recruitment website, they boast, “You may graduate from your college, but you never graduate from Phi Gamma Delta.” The irony is not lost on Drs. Sam Richwine, ’77, and Jonathan Jarman, ’86. Both joined the fraternity as undergraduates at the University of Georgia, and together with some of their fellow brothers they have recently founded the Cloverhurst Benevolent Foundation, to assist brothers who suffer with substance abuse, clinical depression, family, professional or financial problems. The story of how and why starts with Facebook. After graduating from UGA in 1979, Jarman headed to medical school, then residency, got married, then moved to New Orleans and started a family. He returned to Atlanta to settle down permanently and before he knew it, it had been nearly 30 years since he’d had any real contact with his fraternity brothers, who are affectionately called Fijis. “And then Facebook popped up,” he remembers. “I joined, started a page, and started making connections with Fijis I hadn’t seen or thought about in years.” One of his former brothers – a new Facebook friend – encouraged him to attend the UGA Chapter’s Pig Dinner that year, the annual alumni dinner that reunites graduated Fijis and their undergraduate brothers. They could even ride together, the friend suggested. “He said you’re not going to recognize me when you come to pick me up, but I’ll tell you all about it on the way to Athens. He was right,” Jarman remembers. “I wasn’t that close to him in college, but I remembered him as this tall, thin guy with wiry blonde hair. When I got there to pick him up, I found a heavyset bald man with glasses that looked nothing like him. He might have looked like what I imagined his grandfather looked like.” Over the hour-and-a-half drive, his fraternity brother told him how his life had fallen apart. He’d graduated college, gotten a master’s degree in business and become a successful corporate executive. But his executive job title came with many after-hours commitments, where the alcohol flowed and he’d started drinking, socially at first, but then more and more. “He became an alcoholic,” Jarman said. “To cut to the chase, eventually, he lost his marriage, he lost his job and he became homeless. When he said homeless, I assumed he meant he lost his house in the divorce, but he had lived on the streets. He had no one to turn to.” When they arrived at the dinner and he began asking about other brothers he remembered fondly from college days, similar stories played out over and over again. “I heard, ‘He’s dead. He’s dead too. Him too,’ over and over,” he says. “I began to find out that a lot of these early deaths were from things like drug and alcohol abuse and suicide.”
He was stunned. How could these things have happened to his brothers – members of a fraternity famous for producing U.S. Presidents, Vice Presidents, even Pulitzer Prize winners, he wondered. How could they have had no support system to turn to? “Even from our ‘Not for college days alone’ fraternity?” Jarman, who practiced emergency medicine, but had a deep, abiding interest in psychiatry, decided it was time to do something to help. “I began to think about an organized way to help guys that have fallen by the wayside and have no other support system,” Jarman says. “I went to the (undergraduate) chapter and gave a talk on depression and alcoholism, but it just wasn’t the right time. It just fizzled out.” But two years later, the group found out about another brother in crisis – going through a divorce, suffering from severe alcoholism and having tremendous financial problems. They set up an intervention and were able to get him into a rehab facility. The timing was right. He talked to Richwine, a Gainesville plastic surgeon, and a few other UGA Phi Gamma Delta brothers and together they created the foundation – aptly named after their fraternity house, which still sits on Cloverhurst Court in Athens. “After he got out of rehab, we brought this guy in as our first ‘client,’” Jarman says. “We helped get him a job, financial counseling, legal counsel and then we met with him weekly and gave him homework assignments. After about three months, we stepped back. We learned a lot through that – what we were doing right what we were doing wrong.” It was a beginning. “We’ve identified about a dozen people from our chapter that have had problems (in the past). Those are the ones that we know of. Maybe there are others that had support systems,” Jarman says. “We want to create this organization as a model for other (Phi Gamma) chapters. We want this to spread to other Greek organizations outside of Phi Gamma Delta, too.” There are no requirements to get help from the foundation and their work is confidential. The focus until they find their next client, Richwine and Jarman say, is getting the word out that the foundation exists and building its finances. “We want to really get out the word that if you’re having trouble, it’s part of life, if you need a good support system, we’re here. We just want people to understand that we’re available, we’re sort of on call,” Richwine says. “We have a lot of very successful brothers, but the reality of it is that even if you’ve got a group of high-functioning folks, somebody is not going to get to that level. Someone is going to have trouble. To deny that is coming is just sticking your head in the sand.”
Alumni and Philant hropy News
2018 MCG Distinguished Alumni A retinal ophthalmologist who created the first retina service between Baltimore and Miami, bringing new sight-saving procedures to people in eight Southeastern states, and a longtime MCG Department of Radiology and Imaging faculty member who is active in the MCG Alumni Association and on the MCG Foundation’s Board of Directors, are recipients of the 2018 MCG Distinguished Alumni awards.
Dr. William S. Hagler (’55)
Dr. William S. Hagler, (see MCG Medicine Fall 2017/ Winter 2018) a 1955 graduate, is MCG’s Distinguished Alumnus for Professional Achievement. After his graduation from MCG, he completed an internship at Parkland Memorial Hospital in Dallas, Texas, and his residency in ophthalmology at the Emory University/Grady Memorial Hospital program in Atlanta in 1959. He was then awarded a Heed Foundation Fellowship to study retinal surgery at the Massachusetts Eye and Ear Infirmary in Boston. After fellowship, he returned to Atlanta to become the first full-time faculty member in the Department of Ophthalmology at Emory University School of Medicine, where he trained residents and established a fellowship program, eventually training some 37 ophthalmologists in medical and surgical diseases of the retina. Having arrived at Emory in a time of great racial turmoil, he initiated efforts to integrate Emory Hospital by insisting that his African-American patients be operated on there. Throughout his career, he never turned away a patient because of inability to pay, nor did he receive financial compensation for his teaching and research activities. In 1971, he, along with Drs. William Jarrett and Alvin North (’58), established the first multispecialty ophthalmology group in Atlanta and he served as its president for many years. This group subsequently became Eye Consultants of Atlanta and now employs 29 ophthalmologists practicing in 10 locations in Georgia. In 1973, he and Jarrett were appointed Clinical Associate Professors in the MCG Department of Ophthalmology. Ophthalmology residents from MCG spent a three-month rotation with them in Atlanta during their three years of residency training. In 2015, Hagler established the William S. Hagler, M.D. Distinguished Chair in Ophthalmology at MCG to support teaching of medical students, residents and research fellows, lectures and pilot programs in vision science. Hagler has served as president of the Atlanta Ophthalmological Society and was the first president of the Georgia Society of Ophthalmology. He was a charter member of the Retina Society and served on its credentials committee
Dr. Lloyd B. Schnuck Jr. (’68)
and represented the Retina Society on the Council of the American Academy of Ophthalmology. In 1975 he received the Academy’s Award of Merit. In 1980 he was elected to the prestigious American Ophthalmological Society. He was largely responsible for instituting an interim meeting of the Georgia Society of Ophthalmology in which residents from both Emory and MCG were encouraged to present papers on their research. He co-authored many papers with his residents and fellows over the years. He published over 90 scientific papers and gave over 180 presentations during his 37-year career. Hagler was also active in various international organizations. He was on the medical advisory board of Project Hope, and served on the Hope Ship in Sri Lanka, Brazil, Jamaica and Tunisia. He and his colleagues were the first to train native ophthalmologists in these developing countries in the modern techniques of retinal surgery. He and his fellow, Dr. Harry Taylor, made a clandestine trip to communist Cuba in 1967, where he operated on an American missionary who had been imprisoned by Fidel Castro.
Dr. Lloyd B. Schnuck Jr., a 1968 graduate of the state’s public medical school, is the recipient of the Distinguished Alumnus Award for Loyalty. After graduating from MCG, Schnuck completed his internship at University Hospital before returning to MCG for his radiology residency, serving as chief resident from 1973-74. Schnuck also served in the United States Army, as a captain battalion surgeon in the Fifth Special Forces Group. He was awarded the Combat Medics Badge, Parachutist Badge, Bronze Star, Air Medal, Vietnam Campaign Medal and National Service Defense Medal. He has worked at hospitals and schools all over the state of Georgia, but always returned to Augusta. From 1974-75, he served at Doctors Memorial Hospital in Atlanta. From 1975-80 – and again from 1993-95 – he served at Liberty Memorial Hospital in Hinesville, Georgia. He served on the Advisory Committee for Armstrong State University’s School of Radiologic Technology from 1982-95 while simultaneously acting in different positions at Candler Hospital, including chair of the Department of Radiology, vice chair and radiation safety officer. In 1995, Schnuck moved back to Augusta for good. From 19962012 he practiced medicine at the Charlie Norwood VA Medical Center and taught at MCG. He has been an assistant professor of radiology at the medical school since 1996. Since his return to Augusta he has served on the MCG Foundation Board of Directors, currently as treasurer. He has been an active member of the Alpha Omega Alpha Honor Medical Society and has been a recipient of the MCG Distinguished Faculty Award, American Medical Association’s Physicians Recognition Award with Commendation, Republic of Vietnam Community Service Award, the Milton Antony Medical History Award from MCG, and the Instructor of the Year Award from Candler Hospital’s School of Radiological Technology. He is a former councilor and a fellow of the American College of Radiology. He and his late wife Barbara funded the sculpture in front of the Children’s Hospital of Georgia in 1997 and the Lloyd B. Schnuck, Jr., MD School of Medicine Scholarship began in 1999. Dr. Schnuck founded the Barbara Schnuck Endowed Chair in 2005.
Alumni and Philant hropy News
Georgia Cancer Center: Augusta philanthropist gives $1 million in support Augusta businessman and philanthropist Peter Knox has given a $1 million gift to the Georgia Cancer Center to help support its future director. The gift creates a discretionary fund, which the director can use to address critical areas he or she identifies. Examples could include new equipment or recruitment and/or retention of faculty. The Medical College of Georgia and the university are in the final stages of the director search, with the aim of having someone in place this fall. “Cancer is a great equalizer that can and has touched everyone’s lives. It is my hope that this gift will help the center’s future director continue putting the focus on finding new treatments and cures for this horrible disease right here in this community,” Knox said of the gift, which he hopes inspires more giving. “Making Augusta a destination for the best patient care and research is another wonderful way to put this city on the map. What a grand mission for a community.”
The American Cancer Society estimates that nearly 1.7 million new cases of cancer were diagnosed in the United States and a little more than 600,000 people died from the disease, last year alone. “I can’t think of a better way to begin 2018 than with the announcement of such a crucial gift, one that will allow us to continue the tradition of the world-class work of our Georgia Cancer Center,” said Augusta University President Dr. Brooks Keel at the January announcement. “The faculty and staff at the GCC are making a difference every day for people in Augusta, in Georgia and around the world. If we are to achieve our ultimate goal – finding new cures and treatments for this disease – we need the support of our community.” “The timing could not be more perfect,” added MCG Dean Dr. David Hess. “This generous gift from Mr. Knox will help ensure the best possible leadership for the Georgia Cancer Center. This new leader will be charged with making Augusta and the GCC
a destination cancer center, not just for this region, but for the entire Southeast.” That happens, Hess said, by expanding clinical and basic science research and providing access to novel cancer therapies. He is working with cancer center leaders to also grow clinical operations by recruiting more frontline physicians, particularly hematologists/oncologists and radiation oncologists. Physical growth at the Georgia Cancer Center also will continue with the upcoming opening of the M. Bert Storey Cancer Research Building expansion, the first phase of an integrated, single center that combines clinical cancer care and research programs. The additions include approximately 72,000 square feet of new construction and approximately 6,000 square feet of renovated space, including a five-story expansion of the research building and an elevated connector that spans historic Laney Walker Boulevard, connecting the treatment and research facilities to enhance collaboration.
“See one, do one, teach one.” I’ve heard this mantra of medical education many times over the past two years, and as a recent graduate, I have a new appreciation for it. The hierarchy of training built into traditional medical campuses can make this method difficult, but at the Southwest Campus these words still ring true. In Albany, and the surrounding south Georgia clinical sites, there were no residents to crowd me out of the operating table or send me to fetch faxed documents. It was just me and my attending, and together we learned medicine. She taught me about the energy, empathy and efficiency that go into great doctoring, and once in a blue moon I could shine by reminding her how ferritin levels relate to anemia in chronic disease. Now finished with clinical rotations and enjoying my precious remaining free time, I am realizing that spending my clinical years at the Southwest Campus was the best decision I made since applying to the Medical College of Georgia. Regional campuses are a blessing that many medical students are not afforded, and one that I believe has enhanced my training and medical perspective. Initially the idea was somewhat intimidating: “You expect me to leave 90% of my classmates behind and move to a small town in south Georgia?” “Will I have to work in a different city each month?” “Will I see a wide range of pathology?” All of these concerns were ultimately unfounded. During our first week we were welcomed with a low country boil by Dr. Stephen Russ, a 2012 MCG graduate who regularly hosts gatherings for Southwest students. Visiting clinical sites in different cities was a welcomed perspective on the variety of health care settings, and I found myself enjoying time away from the competitive mindset of the Augusta campus. While we may not see as many medically complex and complicated procedures as those that pass through the halls of Augusta University Medical Center, the “meat and potatoes” of medicine abounds down here. Research projects, large clinical responsibilities, and the demands of managing residents can be overwhelming for attendings and leave medical students grasping for crumbs. But the Southwest campus faculty are neither required to teach nor financially compensated for their efforts. Those who choose to, like Dr. Kathy Hudson, ’98, in Albany, Dr. Dixie Griffin, ’05, and Dr. Eric Paulk, ’06, both in Tifton, selflessly devote their time and energy to passing their knowledge on to the next generation. Additionally, working with MCG graduates has been a confidence-boosting reminder of the quality of training our medical school has provided for generations. One final question often lingers in the minds of those considering a regional campus: “Will this experience make
me a more competitive residency applicant?” I personally didn’t achieve AOA status or finish top of my class. However, I did manage to match into my top choice urology program, and for this the Southwest Campus deserves recognition. Several interviewers remarked about the collection of unique, highly-personalized rotation evaluations in my application. This was the direct result of spending my rotations working one-on-one with my attending physicians. The closeness of our professional relationships allowed my educators to more critically evaluate my strengths and help me improve my weaknesses. The same comments were made about my dean’s letter, written by our regional campus dean. Dr. Doug Patten is a tremendous student advocate and is passionate about his students becoming a part of the local community. When two devastating tornadoes passed through Albany in early 2017, Dr. Patten invited us to participate in a large community relief effort. One year later we joined the community in planting hundreds of trees to rejuvenate a large local park affected by the storms. Opportunities like these provided a unique perspective into the importance of physicians being active members of their local community. For me, the Southwest Campus was not just a choice, it was an investment. Now two years in, I feel at home here. As I look forward to beginning residency training, I have a wealth of memories to look back upon fondly, and a few good reasons to consider bringing my future practice back to South Georgia.
Willy Hughes MCG Class of 2018
Dr. Kelli Braun (’04) Associate Dean for Admissions
A more efficient, effective admission process Applicants for admission to the Medical College of Georgia Class of 2023 will be the first to go through the medical school’s redesigned interview process. The old process required each potential student to go through two, 30-minute-long one-on-one interviews. That system created scheduling challenges for admissions committee members, heavier workloads for the faculty who volunteer to interview potential students, and delays in completed applicant files and ultimately admission decisions. Applicants to the state’s public medical school will now go through a Multiple Mini Interview, or MMI, a style created at McMaster University that evaluates noncognitive skills and draws multiple samples of applicants’ abilities to think on their feet, critically appraise information, communicate ideas and demonstrate that they’ve thought about issues that are important to the medical profession. An MMI interview process consists of eight stations that are each eight minutes in length. Each station has a dedicated theme to assess applicants’ personal characteristics that are important to MCG. Some examples include a station that addresses critical thinking and assesses the applicant’s strengths and weaknesses; or a teamwork station that allows applicants to demonstrate how they can work collaboratively, share information and knowledge with others and put team goals ahead of individual goals.
“MMI performance has been shown to be predictive of how students will perform clinically,” says MCG Associate Dean for Admissions, Dr. Kelli Braun, ’04. “They also allow us to be consistent in how we assess candidates.” The new process will also lessen the time commitment of the traditional system. The 2017/18 admissions cycle required faculty to commit to 66 days of interviews – many times performing multiple interviews each day. With the new system, Braun says up to 16 students per day can be interviewed, shortening the number of interview days to 38. In addition to participating in MMIs, applicants will also be required to take a CASPer test, an online screening tool designed to evaluate key personal and professional characteristics that make for successful students and graduates. CASPer measures traits like professionalism, ethics, communication and empathy. In addition to the changes to the interview process, the Admissions Committee will reduce its membership from 29 to approximately 14. They will continue to screen applicant files, review candidates who will be presented to the full committee for possible admission and attend voting sessions. Individual interview responsibilities, which have fallen exclusively to committee members, will be opened up and could include patients, students and faculty not on the committee and even community members.
Dr. Irving Victor (’45) received the second-ever Eminent Alumni Award from Armstrong State University, recognizing his service to Armstrong, his profession and his community. Dr. William B. Butch Mulherin (’61) is the 2017 Bill Hartman Award recipient from the University of Georgia. Dr. John House (’67) has published a novel, Rancor.
Dr. Brooks Ficke (’11) joined the practice of Resurgens Orthopaedics in Roswell, Georgia. Dr. Kathryn Echols (’12) joined the Heart of the Rockies Regional Medical Center in Salida, Colorado. Dr. Julien Norton (’12) joined the team at Charleston Ear, Nose, Throat & Allergy, in Charleston, South Carolina.
Dr. Willie Nell Bryant-Pitts (’83) is celebrating more than 20 years of working for the state of Oklahoma, including service to the Northern Oklahoma Resource Center of Enid, Sulphur Veterans Nursing Home, and most recently for the Department of Corrections at the James Crabtree Correctional Center.
Dr. Shavonda Thomas (’12) joined Erlanger Southside Community Health Center in Chattanooga, Tennessee.
Dr. Neal Simmons (’83) has joined Radiology Associates of Macon in Macon, Georgia.
Dr. Alicia Daniels (’14) and Dr. Trey Dyer III (’14) joined the CHI Memorial Medical Group in Chattanooga, Tennessee.
Dr. Steven Kitchen (’85) was appointed to the Georgia Board for Physician Workforce by Gov. Nathan Deal. Dr. James Kenneth Smith (’85) joined WellStar Medical Group as a rheumatologist at the New WellStar Vinings Health Park in Smyrna, Georgia. Brig. Gen. Ronald T. Stephens (’90) received the National Defense University’s Certificate of Appreciation. Mercer University has named Dr. Natalie Hogan (’93) chair of pediatrics at Dwaine and Cynthia Willett Children’s Hospital of Savannah at Memorial Health University Medical Center.
Dr. Alex Caten (’14) joined Sierra Nevada Ear, Nose & Throat, which has offices in Carson City, Gardnerville, and Fallon, Nevada.
Dr. Puja Chebrolu (’15), who is completing her internal medicine residency at Barnes-Jewish Hospital in St. Louis, Missouri, has received a three-year Weill Cornell Global Health Research Fellowship, which includes field-based research, courses in research methods, and teaching and clinical service at Weill Cornell NewYorkPresbyterian Hospital. The majority of time over the three years will be spent conducting mentored research at international sites in Haiti, Tanzania, Brazil or India.
Dr. Matthew George Erickson (’96) appeared on Caravan to Midnight with John B. Wells, a cyber talk show, in January to discuss his sepsis treatment kit, which is based on a metabolic cocktail developed by Dr. Paul Marik at Eastern Virginia Medical School. Dr. Roni Bollag (’04, ’07) has been named to the Board of Directors of Xytex, global provider of cryoservices. Dr. Wesley Davis (’05) is division chief of pediatric cardiology at the Children’s Hospital at Erlanger in Chattanooga, Tennesee.
Dr. Frederick Mitchell Bell Jr. (’53) – March 2 Dr. James Harvey Beall Jr. (’55) – March 3 Dr. James W. Carter (’86) – March 11 Dr. Thomas Edgar McLemore Jr. (’53) – March 11 Dr. Hal McNair (’60) – March 13 Dr. E. Anthony “Tony” Musarra II (’69) – March 15 Dr. Shelley Melinda Sneed (’83) – March 18 Dr. Oland Garrison (’50) – March 21 Dr. Donald Bass (’61) – March 26 Dr. Robert Alexander Wynn Sr. (’65) – March 28 Dr. William E. Coleman (’51) – April 3 Dr. Thaddeus L. Chapman (’91) – April 16 Dr. Waldo E. Floyd (’59) – April 20 Dr. Stanley Jackson Self (’66) – April 24 Dr. Barbara Ann Powell (’62) – May 23 Dr. Luther Rice Mills IV (’65) – May 1 Dr. William “Bill” Smith Jr. (’51) – May 4 Dr. Perry Hudson (’43) – June 3 Dr. Charles Deaton Maddox (’66) – June 14 Dr. Ashbury Clark Robinson (’61) – June 30 Dr. Dearing Nash (’51) – July 10 Dr. John Yarbrough (’84) – July 11 Dr. Tommy Jordan (’70) – August 13 Dr. Caren Chaknis (’92) – August 28 Dr. Leonard Cotts (’56) – September 19 Dr. Darrell Murray (’58) – September 24 Dr. Marcella Wood (’53) – September 26 Dr. Roger Millwood (’78) – September 29 Dr. K. Allen Harper (’63) – October 8 Dr. Hugh Gibson (’61) – October 25 Dr. Jack Lawler (’61) – November 1 Dr. Mell Bridges (’92) - November 2 Dr. John Ezzard (’61) - November 2 Dr. Thomas Sturkie (’58) – November 3 Dr. Sheldon Cohen (’51) – November 9 Dr. Perry G. Busbee (’51) – November 22 Dr. Stephen D. Mullins Jr. (’49) – November 24 Dr. George Batayias (’60) – November 29 Dr. Michael Garrett (’91) – December 7 Dr. Rex E. Stubbs (’57) – December 30
Dr. William A. Threlkheld (’58) – January 9 Dr. Richard D. Miller (’57) – January 14 Dr. Roy E. Joyner (’50) – January 24 Dr. Miriam Chambless (’50) – January 30 Dr. T. Conrad Williams, Jr. (’56) – February 1 Dr. Gloria Anne Dixon (’53) – February 11 Dr. George L. Echols (’59) – February 11 Dr. Byron F. Deen (’02) – February 28 Dr. Jack M. Bates (’63) – April 2
MD/PhD student Bianca N. Islam and Dr. Darren D. Browning, cancer researcher in the MCG Department of Biochemistry and Molecular Biology, made quite an international media splash this spring with their published study that showed a small, daily dose of Viagra significantly reduces colorectal cancer risk in an animal model predetermined to have this third leading cause of cancer death. The researchers are pursuing clinical trials for patients considered at high risk for reasons like a strong family history or multiple previous polyps, abnormal and often asymptomatic clumps of cells on the lining of the intestines that may become cancer. A Viagra dose similar to the one given babies for pulmonary hypertension cut polyp formation in half in their study published in Cancer Prevention Research. MCG MEDICINE
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