PSG Rumblings Newsletter Summer 2021

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Rumblings SUMMER 2021


President’s Message / Ravi K. Ghanta, MD, PSG President

Dear Colleagues,


Summer is officially here and things seem to be looking bright. It is hard to believe the immense socioeconomic and health manifestations that our communities have confronted over the past year or so. There seems to be light at the end of the tunnel as we have been seeing decreasing numbers of infections and less hospitalizations related to COVID-19. However, we cannot let our guard down and we must still remain vigilant and encourage our patients, family members, and friends to get vaccinated. While our work continues, we are now focused on mass vaccination efforts in hopes of achieving herd immunity. At a time when our nation seems so politically divided, it is refreshing to see our communities coming together for a common goal to end this pandemic. The PSG was also not immune to the disruption caused by the pandemic. As most of you recall, we had to cancel the 2020 Annual Scientific Conference as a precautionary measure. This was only the second time the annual conference

As my term as PSG president winds down, I look back over the past couple years and am so proud to have worked with such dedicated people navigating through immense challenges. Additionally, I am grateful to my predecessors for shaping this wonderful organization and mentoring our current members. As I transition out of my role as president in September 2021, I am eager to continue to advocate for the PSG and continued on page 2



was cancelled in our organization’s history with the other exception being after the September 11terrorist attacks. I am happy to announce this year is our organization’s 40th Anniversary. We initially planned to commemorate this milestone with a very special Annual Meeting in person. However, due to the uncertainty of the seasonal variation of the pandemic, our annual conference will be held virtually and directed by Dr. Jennifer Maranki of Hershey Medical Center. I am confident that you will find the content very valuable, so please look for our communications regarding registration.

2 President’s Message

7 S ocial Media Corner

14 Case Report

3 CME Events

8 Clinical Pearls

15 ACG Announcement

4 Editorial

11 Cast & Clay Getaway

16 Board and Staff

President’s Message

continued from page 1

look forward to Dr. David Diehl being the next president, who as many of you know, is a highly accomplished and respected physician in our field. It has been an honor to have him as a colleague and friend on the PSG board. I am proud to see that the PSG continues to grow and strengthen because of the support of colleagues and dedicated members. I would like to personally welcome

West Virginia into our organization. We are very fortunate in the great state of Pennsylvania to have a robust medical society in the specialty of gastroenterology and hepatology. After multiple discussions, the PSG wanted to open our doors to other states that may not have an organization like ours. To more efficiently utilize dues and avoid duplication of resources, it made sense to combine and expand our organization. I especially thank

Dr. Shyam Thakkar, our membership chairman of Western Pennsylvania, who had helped facilitate these discussions and who has been active in strengthening the Advanced Therapeutic Endoscopy Program at West Virginia University On behalf of the PSG, I would like to welcome our new members from West Virginia and Pennsylvania and to also thank our current members for your support and look forward to seeing you in the future.

Ravi Ghanta, MD President Pennsylvania Society of Gastroenterology



“All Disease Begins in the Gut.” —Hippocrates


CME (GI) /EVENTS/2021-22 PSG Virtual Scientific Meeting 2021

ACG 2021

AIBD 2021

Las Vegas, NV October 22-27

September 11

Orlando, FL December 9-11


Crohn’s Colitis Congress 2022

DDW 2022 San Diego, CA May 21-24

Las Vegas January 20-22 IN-PERSON IN-PERSON

COVID-19 Update Looking for up to date information and resources for COVID-19? Please check out the PAMED COVID-19 Resource Center. corona-virus


EDITORIAL: Artificial Intelligence, The Future is Now Shyam Thakkar, MD


The last few decades have

been marked by tremendous advancements in endoscopic technology, which have redefined the practice of gastroenterology and gastrointestinal surgery. Looking back, however, endoscopic innovations were initially slow to start. The first fiberoptic endoscopy, performed in 1957 by Basil Hirschowitz, first down his own throat and a few days later down that of a patient, made remarkable progress in diminishing patient discomfort by enhancing flexibility and reducing bulk. From there, video endoscopy emerged, but it did not become mainstream until the mid-1980s. Since then, though, the endoscopic world has taken flight, with advancements so remarkable that essentially any procedure the mind can imagine can be performed.

require the human brain, such as visual perception and decisionmaking. In recent years, the health care field has become a focus area of AI investment. In gastroenterology specifically, despite having numerous outstanding clinicians and health care providers, the quality of human performance can still fluctuate due to fatigue, interobserver variability, and lack of standardization. This is readily apparent and well-documented in screening colonoscopy. AI fills in these gaps as it has the potential to support human behavior, thereby reducing human burden while maintaining quality and reproducibility. Endoscopy provides an outstanding platform for the application of AI. With image and data driven clinical algorithms, the adoption of AI is a natural progression in the field. Currently, AI developments in polyp detection, histologic analysis, report generation, and reduction of fluoroscopy are being studied. A centralized theme among these various AI technologies is the accurate and automated predictive capacity to accomplish the necessary task. This includes AI algorithms that function as a “second observer” to aid the endoscopist in identifying on-screen lesions, such as polyps or gastrointestinal bleeds

Among the innumerable endoscopic innovations that have surfaced, Artificial Intelligence (AI), gives us the most comprehensive and complete path to the future. In its most basic form, AI is the theory and development of computer systems that can perform tasks that normally


Fig 1. Polyp detection AI algorithm placing a boundary box around a subtle polyp. (Berzin, Tyler M., and Eric J. Topol. “Adding artificial intelligence to gastrointestinal endoscopy.” The Lancet 395, no. 10223 (2020): 485.) AI is also being tested for diagnostic purposes to classify polyp histology or delineate dysplasia in the setting of Barrett’s esophagus or inflammatory bowel disease during screening or surveillance exams

Fig 2. Polyp differentiation AI algorithm predicts adenomatous pathology of detected polyp (Kudo, Shin-ei, Yuichi Mori, Masashi Misawa, Kenichi Takeda, Toyoki Kudo, Hayato Itoh, Masahiro Oda, and Kensaku Mori. “Artificial intelligence and colonoscopy: Current status and future perspectives.” Digestive Endoscopy 31, no. 4 (2019): 363-371.)

Our group has described the use of AI to measure exam quality in endoscopy by calculating the surface area and generating endoscopic thumbprints of the exams performed

Fig 3. AI algorithm heat map demonstrating quality metrics of surface area, image clarity, colonic distention, and preparation over the course of an exam (Thakkar, Shyam, Neil M. Carleton, Bharat Rao, and Aslam Syed. “Use of artificial intelligence-based analytics from live colonoscopies to optimize the quality of the colonoscopy examination in real time: proof of concept.” Gastroenterology158, no. 5 (2020): 1219-1221.) Finally, through natural language processing, AI is being used for data extraction, with a prime example being calculation of adenoma detection rates. With this heightened activity, recent clinical trials have quickly moved AI to the forefront in gastroenterology. In fact, the first FDA-approved platform, GI Genius used for polyp detection with data supporting improvement in adenoma detection rates, is now commercially available. Over time, studies are likely to measure the impact of such systems themselves on the incidence of interval colorectal cancers.

Despite the rapid progression of AI technologies, significant barriers still remain. Understanding AI algorithms is a major concern among the physician community. Many raise worries over systems that are being developed without ways to understand how the algorithms are trained and validated. Even still, most will agree that AI is in our near future, and as expected, leading GI societies including the American Society for Gastrointestinal Endoscopy (ASGE) and World Endoscopy Organization (WEO) have developed task forces and committees focused on the healthy adoption of AI. These groups are expected to guide the infrastructure by which AI grows into the world of endoscopy. Over the next 5 years, we can likely expect educational symposia, enhanced fellowship training, rigorous assessments of research quality, guidance for AI trial design, and reimbursement support. The opportunities for AI in gastroenterology, and specifically endoscopic gastroenterology, are boundless. As AI systems continue to expand their library of clinical applications and begin to have real-world applicability, the potential for improvement in procedural efficiency and accuracy could be dramatic. While clinician supervision of AI models will be necessary, it is paramount that physicians do not become dependent on AI, but rather leverage it to enhance the field and elevate patient care.


One of the presidential initiatives of Pennsylvania Medical Society (PAMED) President Michael DellaVecchia, MD, PhD, FACS, FICS, FCPP, is to prepare physicians for the advanced technologies such as AI, robotics, nanotechnology, and biosensors that will forever change medical education and the practice of medicine. As part of this initiative, Dr. DellaVecchia is hosting several interviews with national experts in these technologies. PAMED members can learn more on the PAMED website at


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PSG Social Media Corner We have been working hard to generate meaningful content on our social channels for PSG members and other physician’s. This month we highlight Celiac disease! Keep your eye out for these great new content features and be sure to let us know what you want to see on our social pages by commenting, liking, retweeting or direct messaging us. Remember to follow @PAGastroSoc on Facebook, Twitter and Instagram to see what our Ambassador’s are up to! #PAGastro

—Neena Mohan MD, FACP

—Neena Mohan MD, FACP


An Outpatient Guide to Management of “the other” Incontinence Farid Razavi


Fecal incontinence (FI) is a relatively

common multifactorial disorder that troubles more patients than we care to admit. If we don’t ask, patients will rarely bring up the issue. Patients are much more apt to openly discuss urinary incontinence. FI is defined as the involuntary loss of any rectal contents, including solid/liquid stool, gas, or mucoid discharge. The consequences of FI are devastating with severely impaired quality of life, withdrawal, and social isolation. FI affects 8.3 percent of the U.S. population living in the community. Not surprisingly, institutionalized patients report far greater percentages, reported as high as 30 percent of all nursing home residents. Prevalence increases directly with age, ranging from 2.6 percent in younger patients to 15.3 percent in patients over 70. The actual number is likely underreported given prevailing attitudes and shame regarding FI.1

The etiopathogenesis of FI is quite diverse with the most common risk factors being obstetric trauma, anal trauma, pelvic radiotherapy, diabetes, tobacco smoking, pudendal neuropathy, copious loose stool or, conversely, impacted stool with liquid seepage, and age related changes to the pelvic floor.2 Three subtypes of FI are generally recognized: 1) passive incontinence; 2) urge incontinence; 3) fecal seepage. It is important to characterize the type of incontinence accurately before recommending management. Passive incontinence is typically due to internal anal sphincter dysfunction and peripheral neuropathy whereas urge incontinence is secondary to external anal sphincter dysfunction. Seepage is attributed to poor rectal sensation. In addition to a detailed history including a bowel diary, a high quality exam is critical in understanding the nature and severity of FI. Common telling signs on external examination include the presence of fecal debris, large prolapsed hemorrhoids (a possible source of mucoid discharge), scar tissue, or rectal prolapse. Assessing perianal sensation can be done by gently touching perianal skin. The expected reaction is immediate contraction of the external sphincter; absence would suggest neuropathy. Digital insertion should assess resting tone, elevation of the perineum, strength of sphincter squeeze, and the puborectalis sling. To better understand the causes of FI, EUS may be done to clarify the integrity of both sphincters along with the puborectalis sling. Anorectal manometry also serves an important role in helping clarify rectal


sensation and compliance. Finally, defecography (MRI or fluoroscopic) is helpful in visualizing the anorectal muscles function in concert, ruling out rectocele or internal prolapse, along with noting any abnormalities in adjacent organs. The choice of which study to pursue is dependent upon the provided history and exam. Treatment of FI should follow the clinical subtype and relative severity of symptoms. Conservative therapies such as dietary modification (withdrawal of caffeine, spicy meals, and dairy) and/or antidiarrheal agents or laxatives may be helpful in mild cases of urgency and overflow incontinence respectively. The addition of fiber may help bulk the stool and facilitate anorectal sensation.3 A recent RCT showed that psyllium significantly decreased liquid stool associated FI and was more effective than other fiber formulations including methylcellulose (Citrucel) and gum arabic.4 Amitriptyline has recently been shown to play a positive role when the above treatments fail. In recent trials, 20 mg. per night may prolong colon transit time by decreasing rectal contractions in patients with idiopathic FI.5,6 There has been limited supporting evidence to suggest clonidine or topical epinephrine improve FI symptoms substantially at the present time and therefore are rarely used in clinical practice. Biofeedback and pelvic floor exercises are the recommended next steps if conservative dietary and medication management fails. Pelvic floor exercises aim to alleviate FI symptoms by increasing the strength of pelvic floor muscles while biofeedback improves sensory-

motor coordination required for continence along with correcting the ability to perceive rectal distension.8 Biofeedback and exercises in combination are more effective than either modality alone.7 Factors associated with worse outcomes for biofeedback include severe FI, pudendal neuropathy, underlying neurological conditions, overflow incontinence associated with behavioral/psychiatric disorders, decreased rectal capacity from resection, inflammation, or fibrosis, major structural damage to continence mechanisms.8 Unfortunately, at present, there is no standardization of biofeedback treatment contributing to the wide range in reported success rates of exercises with biofeedback from 38 percent to as high as 100 percent.8

attached and implanted within the labia or scrotum serves to reduce and increase pressure to allow defecation on demand. The largest case series has shown significant improvement in FI; however, longterm complications and very high revision rates within five years limit the operation to those patients with severe end-stage FI.12 The SECCA procedure is a less well known option that involves superficial destruction of the anorectal mucosa using RFA with the goal of creating scar tissue leading to remodeling/narrowing of the anal canal. There are small case series showing success with the SECCA procedure but no RCT or large scale trials.13

Perianal injection of a bulking substance offer yet another option. The most common compound used is hyaluronic acid/dextranomer (NASHA-Dx), which was approved by the FDA in 2011. In the left-lateral or prone position, 1 mL is injected into the deep submucosa through an anoscope, slightly above the dentate line. When the response is not satisfactory, a repeat injection can be administered after four weeks. Shortterm efficacy of NASHA-Dx versus sham injections for FI demonstrated that 52 percent in the NASHA Dx group and 31 percent in the sham group achieved a ≥ 50 percent reduction in FI episodes.14 Long-term data on bulking agents is limited, with repeat injections typically required to maintain continence. continued on page 10

Moving toward more invasive options, anal sphincteroplasty has had relatively poor long term outcomes with success rates ranging from 20–67 percent by 5 years, and even lower (0–40 percent) at 10 years.10 Graciloplasty is a newer option that utilizes the patient’s own gracilis muscle with one end attached to the pubis, encircling the anus, and the other end reattached to the opposite ischial tuberosity. Success rates of 38-90 percent have been shown, but there are several limitations including infection (28 percent) and steep learning curve for surgeons. Ultimately, the gracilis muscle is not a dynamic sphincter making evacuation challenging. In one study, 90 percent of patients reported constipation.11 Another surgical option is the artificial bowel sphincter (ABS), which involves implantation of an inflatable cuff within the anal canal. A pump


An Outpatient Guide to Management of “the other” Incontinence continued from page 9

Sacral nerve stimulation known as InterStim utilizes electrode placement within the S3 foramen providing low amplitude current through a battery-operated stimulator. The primary mechanism of action is neuromodulation via the visceral reflex pathway along with a direct effect on the anal sphincter complex, increasing tone and rectal sensitivity via afferent neuromodulation.15 InterStim is a two-step procedure with an initial trial percutaneous nerve evaluation (PNE) typically completed in the office under local anesthesia. This brief five to seven day trial will typically provide a good idea if permanent implant placement will be beneficial. Once PNE is completed and the patient has shown greater than 50 percent improvement in symptoms, they are typically referred to a urologist or colorectal surgeon who will place a permanent lead and an implanted battery. Most adverse events (67 percent) occurred within the first year of implantation. Common device-related adverse events are implant site pain (28 percent), paresthesia (15 percent), and changes in the sensation of stimulation (12 percent). InterStim has a proven track record, with five-year outcomes showing an 85 percent success rate in decreasing FI by 50 percent, and a 45 percent complete continence rate. Patients in the largest multicenter study reported a 3x greater quality of life improvement at five years from implantation.16

Razavi and Dr. Anirudh Masand-Rai perform the procedure at our office in Wyomissing. Dr. Razavi would be happy to discuss any challenging cases or offer input regarding the feasibility of InterStim. Please feel free to contact him directly at Patients with FI can also be referred directly to Dr. Razavi at DDA for further discussion.

8. B yrne CM, Solomon MJ, Young JM, Rex J, Merlino CL. Biofeedback for fecal incontinence: short-term outcomes of 513 consecutive patients and predictors of successful treatment. Dis Colon Rectum. 2007;50:417–427.

Bio Dr. Farid Razavi is a gastroenterologist at Digestive Disease Associates (DDA). He joined DDA in 2016 after completing his GI fellowship at NYU. He previously completed internal medicine training at Weill Cornell Medical Center and graduated from New York Medical College. Dr. Razavi has a special interest in functional bowel disorders and the treatment of fecal incontinence.

10. A nandam JL. Surgical management for fecal incontinence. Clin Colon Rectal Surg. 2014;27:106–109.

With the appropriate evaluation and realistic treatment strategy, FI can become a manageable and approachable disorder. Digestive Disease Associates (DDA) offers InterStim as an option for our most challenging FI patients. Both Dr. Farid

6. E hrenpreis ED, Chang D, Eichenwald E. Pharmacotherapy for fecal incontinence: a review. Dis Colon Rectum. 2007;50:641–649.

References 1. K ang HW, Jung HK, Kwon KJ, Song EM, Choi JY, Kim SE, Shim KN, Jung SA. Prevalence and predictive factors of fecal incontinence. J Neurogastroenterol Motil. 2012;18:86–93. 2.. M adoff RD, Parker SC, Varma MG, Lowry AC. Faecal incontinence in adults. Lancet. 2004;364:621–632. 3. E swaran S, Muir J, Chey WD. Fiber and functional gastrointestinal disorders. Am J Gastroenterol. 2013;108:718–727. 4. B liss DZ, Savik K, Jung HJ, Whitebird R, Lowry A, Sheng X. Dietary fiber supplementation for fecal incontinence: a randomized clinical trial. Res Nurs Health. 2014;37:367–378. 5. W ang JY, Abbas MA. Current management of fecal incontinence. Perm J. 2013;17:65–73.

7. N orton C, Cody JD. Biofeedback and/or sphincter exercises for the treatment of faecal incontinence in adults. Cochrane Database Syst Rev. 2012;7:CD002111.


9. N orton C, Chelvanayagam S, Wilson-Barnett J, Redfern S, Kamm MA. Randomized controlled trial of biofeedback for fecal incontinence. Gastroenterology. 2003;125:1320–1329.

11. C hapman AE, Geerdes B, Hewett P, Young J, Eyers T, Kiroff G, Maddern GJ. Systematic review of dynamic graciloplasty in the treatment of faecal incontinence. Br J Surg. 2002;89:138–153. 12. S ystematic review of safety and effectiveness of an artificial bowel sphincter for faecal incontinence. Mundy L, Merlin TL, Maddern GJ, Hiller JE Br J Surg. 2004 Jun; 91(6):665-72 13. F rascio M, Mandolfino F, Imperatore M, Stabilini C, Fornaro R, Gianetta E, Wexner SD. The SECCA procedure for faecal incontinence: a review. Colorectal Dis. 2014;16:167–172. 14. E fficacy of dextranomer in stabilised hyaluronic acid for treatment of faecal incontinence: a randomised, shamcontrolled trial. Graf W, Mellgren A, Matzel KE, Hull T, Johansson C, Bernstein M, NASHA Dx Study Group. Lancet. 2011 Mar 19; 377(9770):997-1003. 15. T he effect of sacral nerve stimulation on distal colonic motility in patients with faecal incontinence. Patton V, Wiklendt L, Arkwright JW, Lubowski DZ, Dinning PG Br J Surg. 2013 Jun; 100(7):959-68. 16. Long-term durability of sacral nerve stimulation therapy for chronic fecal incontinence. Hull T, Giese C, Wexner SD, Mellgren A, Devroede G, Madoff RD, Stromberg K, Coller JA, SNS Study Group. Dis Colon Rectum. 2013 Feb; 56(2):234-45.

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Reserve Your Spot Today! Proceeds will support pancreatic research and program grants under the guidance of Dr. Shyam Thakkar, the Pennsylvania Society of Gastroenterology, and WVU Medicine. GI 21TM Foundation is a tax exempt organization under Section 501(c)(3) of the Internal Revenue Code. Contributions to GI 21 Foundation are tax deductible for federal income tax purposes (less the value of any goods or services, if any, provided by the organization in return for the contribution).








EUS-guided Measurement of Portosystemic Pressure Gradients (PPG) Followed by EUS-liver Biopsy: The Emergence of the Field of Endo-Hepatology David Diehl, MD The patient underwent EGD and EUS in the endoscopy unit. The EGD did not demonstrate esophageal varices or portal gastropathy. The echotexture of the liver under EUS was homogenous, and not consistent with cirrhosis.



64-year-old woman was seen in the nutrition/bariatric medicine clinic for consideration of RYGB surgery. An ultrasound was done for routine pre-operative bariatric workup and the liver showed a heterogenous echotexture and slightly nodular contour. The radiologist felt that both findings raised the possibility of early cirrhosis. The FIBROSIS 4 score (calculated from a formula using age, AST, ALT, and platelet count) was calculated at 2.85, suggesting the potential for significant fibrosis. A FibroScan was done and showed a fibrosis score of 9.7 kPa, which would be interpreted as F2 fibrosis. Because of the worrisome ultrasound findings of possible cirrhosis, the elevated FIB-4 score, and the discordant FibroScan results, it was decided to pursue a liver biopsy as well as EUS-guided assessment of the portal pressure gradient.

To accomplish measurement of the portosystemic pressure gradient (PPG), a 25-gauge (G) needle connected to a manometer was used (EchoTip Insight portosystemic pressure gradient measurement system, Cook Medical, Bloomington IN). A small branch of the middle hepatic vein (HV) was identified in the left hepatic lobe, and its identity confirmed with Doppler (FIG 1).

The 25G EUS needle was inserted into the vessel using a needle trajectory that went through liver parenchyma before reaching the vein (FIG 2).

After the pressure stabilized, three pressure measurements were taken with 30-60 seconds between measurements. After this, the needle


was removed, and the needle track monitored with Doppler imaging to confirm that there was no bleeding (FIG 3).

Next, a small branch of the portal vein (PV) in the left lobe was identified by EUS and Doppler (FIG 4).

The 25G needle was inserted into the PV through the liver parenchyma (FIG 5),

and three PV pressure measurements were taken. The PPG is the difference between means of PV and HV pressure. In this case, the PPG was 2.3 mmHg (normal is less than 5 mmHg).

Following PPG measurements, EUSguided liver biopsy was done from the left and right lobes with a 19G FNB needle, returning several long tissue cores (FIG 6).

The patient awoke from the procedure without any abdominal pain. She was observed for one hour without any adverse events noted. The liver histology showed no minimal steatosis without NASH or increased fibrosis. With the above information, the patient has been cleared for further consideration for RYGB bariatric surgery.

Discussion: There is an emerging field of endo-hepatology, which expands the role of endosonography for the evaluation and treatment of liver diseases. Up until recently, the intersection of endoscopy and hepatology was limited to diagnosis and treatment of varices. The technique of EUSguided liver biopsy (EUS-LB) is seeing increased use and has been the initial basis of endo-hepatology. EUS-guided management of gastric varices is another important advancement. EUS-guided injection of coils followed by tissue glue may decrease risks of glue embolization that may be seen without coil use, and also has the potential for better varix eradication.

2020. It is likely that expanded use of EUS-guided portosystemic pressure gradient (EUS-PPG) assessment will increase, and hopefully minimize the need for transjugular access for wedged portal pressures. The ability to perform a comprehensive liver evaluation with EUS-guided biopsy and portal pressure assessment in one setting allows a more efficient approach to the liver patient, while at the same time keeping the patient within the care of the gastroenterology/ hepatology service. We expect to see expansion of the field of endo-hepatology in the future as gastroenterologists and hepatologists become more familiar with these diagnostic tools.

Efforts to develop methods for measuring portal pressures with EUS guidance have been underway for several years, and FDA clearance of the EchoTip Insight was achieved in

In June, we began the election process for the position of Governor in Eastern Pennsylvania. The election process recently ended, and the winner of the election is the incumbent, Joyann Kroser, MD, FACG.

Joyann Kroser, MD, FACG

Dr. Kroser will serve for a second three-year term commencing at the conclusion of the College’s Annual Meeting this October. Regards, Amy S. Oxentenko, MD, FACG ACG Secretary





Ravi K. Ghanta, MD Digestive Disease Associates (610) 374-4401



David L. Diehl, MD Geisinger Medical Center Gastroenterology/Nutrition 570-271-6856



Karen Krok, MD Penn State Hershey Gastroenterology (717) 531-4950



Manish Thapar, MD Thomas Jefferson University Hospital (215) 955-8900


Rumblings EDITOR

Neilanjan Nandi, MD, FACP University of Pennsylvania 215-662-8900



STAFF Cindy Warren Operations Jessica Winger Meeting Manager Jill Bennish Member Service Specialist Tom Notarangelo Design Manager

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