Title: Academic physician quarterly
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Permanent Link: http://ufdc.ufl.edu/UF00088871/00011
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Title: Academic physician quarterly
Physical Description: Serial
Language: English
Creator: College of Medicine, University of Florida
Publisher: College of Medicine
Place of Publication: Jacksonville, Fla.
Publication Date: October 2009
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Bibliographic ID: UF00088871
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UF UNIVERSITY of
UF FLORIDA
College of Medicine
Jacksonville


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NEWS AND NOTES






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MEE YOR COLLEGE

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CHAIRMAN'S MESSAGE

Dear colleagues:

I would like to share some good news that we had received
recently. Our core residency program was reviewed by the
Residency Review Committee (RRC) and it received five year
full accreditation without any citations. Indeed, the letter of
approval mentioned accolades for the training program. Spe-
cific quotes included were "enriched educational environ- 4\
ment" and the program "generates significant enthusiasm
among the residents." In addition, the subspecialty pro-
grams that were reviewed concomitantly namely, cardio-
vascular diseases, invasive cardiology, medical oncology and infectious diseases,
all received the maximal 5 year approval. Subsequently, all these approved pro-
grams were given an unprecedented additional year of approval. This outcome
was the result of the tireless efforts of our GME leadership, program directors,
and most importantly our bright and talented trainees.

Since July 1st, the Cogent Healthcare became the hospitalist group covering the
non-teaching services. This change was initiated to enhance efficiency of patient
care and improve communications with referring physicians. In addition, this
change will help our faculty focus their efforts in resident covered patient care
areas.

The Department of Medicine continues to expand its repertoire of state-of-the-art
technology. In this issue, Dr. Samir Habashi describes the role of endoscopic ul-
trasound (EUS) in the diagnosis of gastrointestinal and non-gastrointestinal dis-
eases. This service is now available for the community.

Please let me know how we can improve the services we offer to meet your ex-
pectations.


Arshag D. Mooradian, M.D.
Professor of Medicine
Chairman, Department of Medicine


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I FOCUS 1


Samir Habashi, M.D.

Assistant Professor of Medicine


Division of Gastroenterology







Endoscopic Ultrasound

Endoscopic Ultrasound (EUS) is an important and integral
component in the diagnosis of gastrointestinal and non-gas-
trointestinal diseases. There is a relative underutilization of
the technology. It has been demonstrated that EUS with and
without FNA (Fine Needle Aspiration) has a clinical impact
in the management of certain gastrointestinal disease
processes and that FNA is cost-effective approach for staging
of malignancy.

Here are some of the examples of the clinical utility of EUS:

ESOPHAGEAL CANCER
Choice of therapy and outcome in patients with
esophageal cancer is stage dependent. One important role
of EUS is the initial triage of patients to receive neoadjuvant
therapy, undergo surgical resection or in very early stage un-
dergo Endoscopic Mucosal Resection (EMR). EUS is supe-
rior to PET scan & CT in lymph node (LN) detection. The
finding of celiac LN is considered an evidence of metastatic
spread (Ml).

Table 1: Comparison of accuracy of CT & EUS in the regional
staging of esophageal cancer
Technique No. of pts T Accuracy (%) N Accuracy (%)
CT 1154 45(40-50) 54 (48-71)
EUS 1035 85(59-92) 77 (50-90)

(Rosch T. Endosconographic staging of esophageal cancer. A review of lit-
erature results. Gastrointest Endoscop Clin North Amer 1995; 5:537-547)

Figure 1: An exam-
ple of a T3 N1
Esophageal tumor.
The tumor (5
O'clock position)
invaded the mus-
cularis propria
(T3) There is also
an evidence of
Lymph node inva-
sion (N1) (12
O'clock position)


GASTRIC TUMORS
EUS is useful for staging gastric cancer but is not an effec-
tive screening tool. Endoscopic Mucosal Resection can be
applied to gastric cancer if the lesion is well differentiated
and intramucosal (any size), or if ulcerative, with a diameter
< 3 cm. EUS & CT scan are complementary rather than com-
petitive. EUS is superior to CT scan in evaluating the struc-
ture of the gastric wall, but not accurate in assessing distant
metastasis.


Figure 2: Malignant gastric ulcer where the tumor invades the muscularis
propria

PANCREATIC CYSTS
The differential diagnosis of pancreatic cystic lesions is
wide. The vast majority are pseudocysts. The detection of
mucinous neoplasms is most important as these may be ma-
lignant or have malignant potential. The combination of EUS
features, fluid cytology CEA and amylase levels can improve
accuracy in detecting potentially malignant lesions.
Figure 3: Pancre-
atic pseudocyst:
Radial EUS in a pa-
tient with a recent
episode of pancre-
atitis reveals a 3-
cm, thin-walled,
anechoic cystic le-
sion in close to the
gastric wall. Analy-
sis of the cystic
fluid showed a
high amylase level
and a low CEA
level.


Figure 4: Serous cys-
tadenoma: Typical
honeycomb appear-
ance of a 2.5 cm
microcystic serious
cystadenoma. There
are multiple small
anechoic areas.


Continued on Page 3







Focus continued from Page 2


Figure 5: Muci-
nous cystade-
noma. Numerous
solid, papillary
projections from
the cyst wall are
seen (arrow). FNA
revealed mucin-
positive cuboidal
cells, and resection
confirmed a be-
nign mucinous
cystadenoma.


PANCREATIC CANCER
EUS is the most sensitive imaging modality for the detec-
tion of pancreatic masses. It is particularly useful for the iden-
tification of tumors undetected by other methods such as CT.
A normal-appearing pancreas without a mass would essen-
tially r/o the possibility of pancreatic CA.


Figure 6: Pancreatic mass with cystic component FNA needle inside the mass


RECTAL CANCER
EUS is needed for accurate staging of rectal cancer. Patients
with locally advanced disease should receive adjuvant ther-
apy.
Figure 7: Figure 7
shows T3 rectal
Sa tumor with exten-
sion of tumor
through muscu-
laris propria (ar-
rows)









CONCLUSION
1) The primary indications for EUS are cancer staging when
there is potential additive value after CT or MRI has been
performed, assessment (usually combined with EUS-FNA) of
lymph nodes, and the evaluation of pancreatic disease and
submucosal tumors.

2) Antibiotics are recommended for prophylactic use with
EUS-FNA of a cystic lesion.

3) The risk of perforation with EUS is higher than for stan-
dard endoscopy.

4) EUS can play a role in endoscopic anastomosis & also for
chemotherapy of pancreatic cancer.


GME CORNER


Jeffrey House, D.O.

Assistant Professor of Medicine,
General Internal Medicine



Associate Program Director,
Internal Medicine Residency



The beginning of the 2009 academic year is upon us and the
new residents and fellows are in full swing. We are pleased
to bring in another strong group of trainees who will surely
contribute to what is now a very successful program. The
end of the year was marked with a wonderful graduation
dinner and accompanying send-offs to graduating residents
and fellows. This year we had a first time winner of the
Teacher of the Year Award. Dr. Laos continued the success


of the Pulmonary, Critical Care division by being this year's
recipient. Intern of the Year went to Justin Federico and Res-
ident of the Year went to Andrew Darlington, M.D., both well
deserving of this recognition. We are very proud of these res-
idents and teachers as well as all the new graduates.
After several anxious months, the core program and sev-
eral fellowships finally heard the results of the RRC site visit
and the news was great. First, the core residency program re-
ceived the news that we were accredited for a 5 year cycle.
Not only were there no citations, but the program received a
few accolades; most notably that there was an "enriched ed-
ucational environment" and the program "generates signifi-
cant enthusiasm among the residents." Not to be out done,
fellowship programs in medical oncology, infectious disease,
cardiovascular disease, and interventional cardiology were
also granted a 5 year accreditation cycle. On behalf of GME
leadership, I would like to thank the faculty, staff, and
trainees for their contribution to the success of the RRC site

Continued on Page 4







GME Corner continued from Page 3


visit. This program has a genuinely strong foundation, built
by hard work from everyone involved with the residency and
fellowships. This is certainly the impression the site visitor
took away after visiting the campus, the core program and
the individual fellowships. All this said, one person in par-
ticular stands out when analyzing the success of this site visit
as well as the overall achievements of the program. Dr. N.
Stanley Nahman, Jr. has put countless hours of work into this
program over the last five years, and I could not discuss the
recent accomplishments without recognizing the person who
is integral to all of these achievements. His devotion to the ac-
ademic mission is quite unique, and he had the foresight to
make changes to adapt to the evolving academic climate. The
residency is particularly appreciative of Dr. Nahman and his
work as program director.
Life moves pretty fast in the GME world and the upcoming
year's accomplishments, as well as challenges, are right


around the corner. New graduates are currently taking their
boards, and it won't be long before we begin the recruitment
process again for the 2010 trainees. The Fall Florida ACP
meeting is also coming up where three residents will be mak-
ing presentations. The resident "Jeopardy" team will attempt
to build on their prior success and go for their second victory.
New regulations from the ACGME are being instituted this
year and have already created changes within the teaching
services. With the support of strong leadership and energetic
residents, the program is prepared to take on the challenges
these new requirements create. These are just a few of the re-
cent events; the upcoming year certainly will be filled with
many more.
Thanks to everyone who made last year so successful and
we in the GME department look forward to working with
you again this year.


A CLINICAL CASE ]


Manish Relan, M.D., Department of Medicine
Pramod Reddy, M.D., Department of Medicine
Robert Booth, M.D., Department of Radiology
Arshag D. Mooradian, M.D., Department of Medi-
cine


Wernick's Encephalopathy Secondary
to Nutritional Thiamine Deficiency

CASE REPORT
A 45 year old woman presented to the emergency room
with the chief complaint of left sided chest pain. Patient had
a significant medical history of depression for which she was
being managed by an outpatient psychiatrist. Her chest pain
was described as intermittent, lasting for ten to fifteen min-
utes, moderated intensity and had no radiations. The pain
started 5 days ago and the patient could not describe any ag-
gravating or relieving symptoms.
The patient had lost close to twenty pounds over the last
one month and had been experiencing weakness, shortness
of breath, palpitations and was having difficulty at times un-
derstanding other people.
On admission she was alert but slow to respond to ques-
tions and had difficulty understanding commands and she
appeared malnourished. Her heart rate was 78 beats per
minute with a blood pressure of 90/74 mmHg. No ortho-


static pressures were recorded at that time. On examination
she was found to have bilateral lateral nystagmus and left
sixth nerve palsy. Her speech was fluent and clear and there
was no dysarthria. The patient had difficulty following three
step commands properly although she was able to perform
one step commands without much difficulty. There was no
facial asymmetry, no weakness of the tongue, no bulbar
symptoms and there was no motor deficit but she had dys-
metria in both upper and lower extremities with the reflexes
normal and symmetrical in upper extremity and absent at
both knees and ankles. The rest of her physical examination
was unremarkable.
Laboratory markers of cardiac injury were not elevated.
The results of the lumbar puncture showed an opening pres-
sure of 8ml of water, cerebrospinal fluid (CSF) protein was
elevated to 94 mg/dl with no xanthochromia with only three
red blood cells and no white blood cells. The CSF was nega-
tive for cryptococcal antigen, arbovirus antibody panel, her-
pes simplex virus 1/2 DNA PCR and for VDRL. The serum
concentration of thiamine was 1.2 jig/1 (normal range 4.0-
20.0). Vitamin B12 and folate were within normal range.
Wernicke's encephalopathy was suspected and patient
was treated with thiamine. A magnetic resonance imaging
of the head two days after admission showed multifocal
areas of scattered abnormalities with Wernicke's en-
cephalopathy (Figures 1).
Two-dimensional echocardiogram showed severe global
Continued on Page 5







A Clinical Case continued from Page 4


left ventricular dysfunction with an estimated ejection frac-
tion of fifteen to twenty percent with a normal left ventricu-
lar size and thickness.
The patient continued to improve with her intravenous thi-
amine therapy and at the time of discharge her mental con-
dition had markedly improved.


Figure 1: Axial magnetic resonance FLAIR images of the brain demonstrate
striking focal areas of increased signal on T2 sequences noted in the peri-
aqueductal grey matter (large arrows) and medial thalamic nucleii and tec-
tal plate of the midbrain (small arrows). The findings are consistent with a
toxic/metabolic encephalopathy notably Wernicke's encephalopathy.

DISCUSSION
Most cases of thiamine (or vitamin B1) deficiency world-
wide are the result of poor dietary intake (1). In the United
States, the primary cause of thiamine deficiency is alcoholism.
Thiamin triphosphate plays a key role in integrity of the pe-
ripheral and the central nervous systems (2). The case illus-
trates the insidious nature of the clinical course of nutritional
thiamine deficiency. It is not clear whether the depression
was the primary event causing anorexia, malnutrition and
gradual thiamine deficiency while the latter in turn aggra-
vated the depression and further contributed to the emer-
gence of the encephalopathy. Many of the symptoms were
readily reversible with thiamine supplementation.
The laboratory diagnosis of thiamine deficiency is usu-
ally made by functional enzymatic assay of transketolase ac-
tivity and measurements of serum thiamine level (2).
Thiamine deficiency can present with a wide spectrum
of clinical symptoms and signs. Early manifestations of thi-
amine deficiency include anorexia, muscle cramps, paresthe-
sias, and irritability (1). Advanced thiamine deficiency can
result in lactic acidosis, chronic peripheral neuritis, gastroin-
testinal beriberi manifesting as abdominal pain, vomiting
and lactic acidosis, wet beriberi (shoshin beriberi)character-
ized by marked peripheral vasodilation resulting in high-out-
put heart failure (6) and dry beriberi that involves both the


peripheral and the central nervous systems. The peripheral
nervous system disease presents as symmetric motor and sen-
sory neuropathy associated with pain, paresthesias, and loss
of reflexes while the central nervous system involvement re-
sults in Wernicke's encephalopathy, consisting of horizontal
nystagmus, ophthalmoplegia due to weakness of one or more
extraocular muscles, cerebellar ataxia, and mental impair-
ment. When there is an additional loss of memory and a con-
fabulatory psychosis, the syndrome is known as
Wemicke-Korsakoff syndrome.
Thiamine has a central role in the metabolism of car-
bohydrates and the daily requirement of thiamine depends
on carbohydrate consumption. The DRI for thiamine is 1 to 2
mg per day. Since the liver stores only about 30 to 50 mg of
thiamine, inadequate intake can cause symptomatic defi-
ciency by depleting body stores in 4 to 6 weeks. Generally,
because of the renal excretion of thiamine, there is no known
toxicity associated with the ingestion of large doses of vitamin
B1 over prolonged periods of time.
In acute thiamine deficiency with either cardiovascular
or neurologic signs, 100 mg/d of thiamine should be given
parenterally for 7 days, followed by 10 mg/d orally until
there is complete recovery. Patients with Wernicke's en-
cephalopathy require immediate treatment with 100 mg of
intravenous thiamine, with titration of additional doses until
the ophthalmoplegia resolves. Resistance to thiamine may re-
sult from hypomagnesemia because magnesium is a cofactor
for thiamine transketolase. Eye movements sometimes begin
to improve within a few hours and, except for residual nys-
tagmus, may be normal within 1 or 2 weeks. Cardiovascular
improvement occurs within 24 hours. Ataxia tends to im-
prove less completely and more than half of patients are left
with a broad-based, unsteady gait. Drowsiness, inattentive-
ness, and apathy tend to clear with treatment, but Korsakoff's
syndrome often persists. Once established, the memory dis-
order is permanent in the majority of patients.
The case highlights the need for a high index of sus-
picion to identify thiamine deficiency in high risk patients.
The MRI findings of the brain are helpful in alerting the cli-
nician to this diagnosis.

REFERENCES
1. Harper C. Thiamine (vitamin B1) deficiency and associated brain damage
is still common throughout the world and prevention is simple and safe! Eur
J Neurol. 2006; 13(10):1078-82.
2. Reuler JB, Girard DE, Cooney TG: Wernicke's encephalopathy. N Engl J
Med 1985; 312(16):1035-9









RX UPDATES


Endocrine Society Statement address-
ing the concerns of insulin glargine
(Lantus) and neoplasia:

Recently, the press has reported a potential relationship
between malignancy and the use of insulin glargine. These
reports are based on a series of five retrospective observa-
tional studies (4 papers and one letter) published on-line in
Diabetologia. The studies differ considerably in patient pop-
ulations, confounding variables, and analytic methods, as
well as in conclusions. Certain factors should be kept in mind
as one considers this new information. Obesity, diabetes (par-
ticularly Type 2), and insulin resistance all appear to be asso-
ciated with occurrence of malignancy (especially breast,
colon, and pancreas). Insulin is a dose-dependent mitogen
under various experimental paradigms, and there appears to
be a positive correlation between insulin dosage and occur-
rence of malignancy in diabetic patients. Genetic modifica-
tion of the insulin amino-acid sequence can alter hormonal
conformation and interaction with receptors, potentially lead-
ing to changes in insulin's hypoglycemic and/or mitogenic
activity, or the ratio between these two.
The index paper from Germany by Hemkens et al exam-
ined records of 127,000 individuals who began monotherapy
with a single type of insulin (native, lispro, aspart, or
glargine) and were followed retrospectively over an average
time of 1.6 years for the development of malignancy. The key
finding, determined with a Cox multiple regression model,
was that use of insulin glargine monotherapy was associated
with a statistically higher chance of malignancy, for any given
dose of insulin, than use of native insulin monotherapy; the
adjusted hazard ratio increased from 1.09 for daily insulin
doses of 10 units up to 1.31 for daily insulin doses of 50 units.
In considering these results, there are several aspects of
this study that should be kept in mind:

1) The follow-up period was very short in terms of de
velopment of malignancy, so that the investigators were
probably examining growth of pre-existing cancers rather
than initiation of de-novo malignancy;

2) The results were not adjusted for differences in weight
or BMI, factors known to be associated with malignancy;

3) There was no breakdown of the malignancy occurrence
by site of cancer.


Furthermore, it should be emphasized that this paper's
conclusion of an association between insulin glargine and ma-
lignancy was the result of a complicated statistical analysis in
which insulin dosage played a key role. Analysis of the raw
data, reflecting the real-life situation rather than the predic-
tion of a statistical model, showed that absolute cancer inci-
dence was actually 15% lower with insulin glargine
monotherapy. Furthermore, the gross all-cause mortality was
considerably lower with insulin glargine (hazard ratio 0.68;
CI 0.65-0.72). Consequently, it is difficult to assess, from this
study alone, whether insulin glargine is helpful or harmful,
compared to native insulin, in a clinical practice environment.
The other papers reported in Diabetologia, considered as a
whole, did not support a clear-cut answer to the question of
potential harm from insulin glargine, and these studies also
came to a series of perplexing conclusions. For example, a
Swedish study reported an increased risk of breast cancer
with insulin glargine (relative risk 1.99), but also showed that
women using insulin glargine had lower all-cause mortality
(relative risk 0.83). A Scottish study suggested that insulin
glargine monotherapy was associated with cancer occur-
rence, but that insulin glargine combined with other insulins
seemed to be beneficial as far as cancer incidence. One sur-
prising finding was that metformin use seemed to be strongly
protective against cancer, another plus in favor of this popu-
lar medication.
A particular concern in all of these studies is the possi-
bility of "allocation bias": differences in underlying cancer-
predisposing factors (especially weight and age) between the
insulin glargine group and the comparator group that may
not have been corrected for by the statistical methods used
and which might account for some or all of the differences
noted in purported cancer incidence.
Taken together, these studies do not clearly indicate that
inclusion of insulin glargine in a treatment regimen for dia-
betes leads to worse overall health or, for that matter, better
overall health. Nevertheless, the possibility of increased can-
cer occurrence with insulin glargine use under some circum-
stances does raise concern. Practitioners who treat diabetes
have a variety of potential treatment regimens in their arma-
mentarium, and they should continue to individualize their
recommended therapy based on each patient's situation.

References
1. http://www.endo-society.org/media/press/
2008/SocietyRespondstoRecentInsulinGlargineLantusStudy.cfm








NEWS & NOTES


* Dr. Andrew Darlington was the recipient of the 2009
Outstanding Resident Clinician Award. The award was
presented to him at the resident graduation ceremonies
on June 17, 2009. The Edward Jelks Outstanding Resi-
dent Clinician Award is given annually to the resident
who through dedication, diligence and compassion, or
through innovation in patient care, is considered to
have contributed the most to the improvement of pa-
tient care at Shands Jacksonville.
Dr. Darlington is currently one of the two Chief Resi-
dents in the Department and he is planning to stay on
as a fellow in Cardiology starting July 1st, 2010.

* Dr. Linda R. Edwards was the recipient of the 2009
Russo Professionalism Award. The award was pre-
sented to her at the resident graduation ceremonies on
June 17, 2009. The Louis S. Russo Award for Outstand-
ing Professionalism in Medicine is presented annually
to an individual with the highest standards of medical


professionalism, substantiated by a commitment to per-
sonal behavior that reflects the core values of the con-
summate physician.

Dr. Edwards' contributions to the clinical excellence in
this institution are widely recognized. She has effec-
tively led the Division of General Internal Medicine for
many years and has served the Department and the In-
stitution in multiple capacities. Her academic achieve-
ments have earned her a national recognition. She is a
dedicated educator and a role model for our faculty and
trainees.

SDepartment of Medicine Awards: Dr. Luis Laos of the
Division of Pulmonary, Critical Care & Sleep Medicine
was the winner of Teacher of the Year Award. Intern
of the Year recognition was given to Dr. Justin Federico
and the Resident of the Year was Dr. Andrew Darling-
ton. Congratulations to all awardees.


MEET YOUR COLLEAGUES


HANDS BRAND


Shands Jacksonville on Social
Networking Scene
Facebook and Twitter began as a way for individuals to
connect with one another. It is also quickly becoming a place
for companies to communicate with various audiences.
Shands Jacksonville has recently joined the social media
scene with organizations such as Motrin, Baskin-Robbins,


Coca-Cola, and even the White House.
Social networking sites like these are rapidly changing the
way businesses market and advertise their products and
services to potential consumers. Healthcare organizations,
including Shands Jacksonville, are no different than the or-
ganizations mentioned above. Our environment is becom-
ing increasingly competitive, and for hospitals to survive, we


Continued on Paae 8









SHANDS BRAND continued from Page 7


must consider non-traditional means of reaching our audi-
ences.
A good Web site provides in-depth information about a
company's products and services and it is continually up-
dated with new content. Using social networking sites en-
ables us to share updates on jax.shands.org with fans on
Facebook and followers on Twitter and pushes them to our
Web site. In addition to updates on service line pages, fans
and followers are informed of new patient spotlights as well
as healthcasts with physicians. Recent healthcasts include in-
terviews with Christopher Williams, MD, about prostate can-
cer, and Scott Silliman, MD, on stroke.
Social networking is not a trend -it is here to stay. It is es-
timated that two-thirds of all Internet users visit social net-
working or blogging sites. Last year, Facebook recorded 1.2
billion visits a month, making it the top-ranked social net-
work site. Twitter ranked third with 54.2 million visits.
And it's not just for teens and young adults. The audience
has become broader and older. This shift has primarily been
driven by Facebook, whose greatest growth has come from
people aged 35-49 years of age (+24.1 million). From Decem-
ber 2007 through December 2008, Facebook added almost
twice as many 50- to 64-year-old visitors (+13.6 million) than


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it added under 18-year-old visitors (+7.3 million).
For Shands Jacksonville, the future of social networking
will be to continue offering pertinent information (latest
news, breakthroughs in treatment and clinical trials) to exist-
ing and potential customers that will keep them informed
and returning to the site. Healthcare organizations maximize
their social networking sites by allowing patients from the
community and around the globe to connect with others liv-
ing with the same illnesses, while physicians can share infor-
mation with one another and learn about the latest treatment
options and research. The site incorporates the existing brand
and marketing strategy, as well as serves as an extension of
the organization's outreach programs.






If you're interested in following us on these sites, go to
Facebook.com or Twitter.com and type Shands Jacksonville
Medical Center in the search box to find the official page, or
visit jax.shands.org/news and click on the Facebook or Twit-
ter links.


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