Download Lung Cancer Screening: The Benefits of Early Detection

Fall/Winter 2014
WHAT’S INSIDE
Congenital Heart Disease Specialists
Develop Nonsurgical Technique
to Correct Birth Defects
in Premature Infants . . . . . . . . . . . . . . . 2
Minimally Invasive Procedure
Designed to Treat Birth Defect
and Lessen or Eliminate Need for
Heart Surgery in Fragile Infants
Preventing Shoulder and Elbow
Injuries from Tennis and Golf . . . . . . . 3
Heart Monitoring with the
Reveal LINQ Insertable Cardiac
Monitoring System . . . . . . . . . . . . . . . . 5
FEATURED PHYSICIAN
Mark Weidenbaum, M.D.
Professor of
Orthopedic
Surgery,
Columbia
University
Medical Center
Lung Cancer Screening:
The Benefits of Early Detection
L
ung cancer remains the leading cause
of death in many countries and is
the leading cause of cancer-related
mortality worldwide. In fact, more
people die from lung cancer than colon,
breast, and prostate cancer combined. When
detected at its earliest stages, there is a high
likelihood for cure if surgically treated.
Unfortunately, once lung cancer produces
symptoms, such as cough, blood in the
sputum, or chest pain, it is often already at
an advanced stage with very few effective
treatment options available. Lung screening
looks to identify cancer at its earliest stage,
affording people the option of the most
effective treatment.
As of December 2013, the United States
Preventative Services Task Force (USPSTF),
a group of independent primary care and
preventative services experts commissioned
by the US government to make
Dr. Weidenbaum
specializes in the
surgical treatment
of spinal disorders,
deformities, and
degenerative
conditions. He
is dedicated to
delivering the best possible care for acute and
chronic conditions, as evidenced by the fact
that he has earned near-perfect reviews on all
the leading physician-rating websites, such
as Healthgrades, Vitals, and RateMDs.com.
This level of satisfaction is difficult to achieve.
surgical care for their spine turn to Dr.
Weidenbaum at Columbia Orthopedics.
Back pain affects 8 out of 10 people at some
point during their lives and usually resolves
without surgery. When non-operative
treatments fail, patients seeking the best possible
He performs a wide range of procedures on
the neck, upper back, and lower back that
include microsurgical as well as complex
spinal reconstructions. Dr. Weidenbaum is
recommendations on
national preventative
services, gave lung
screening a grade B
recommendation. The
letter grades given are
based upon evidence
available for the
potential screening
benefits and harms. Those that are given a
grade A or B represent services that are
recommended to a certain population at
risk where the benefits outweigh potential
harms. Currently, heavy smokers aged
55 to 80 and former smokers in the same
age group who have quit within the last
15 years are the population thought to most
benefit from lung screening. Heavy smokers
are defined as people who have smoked the
equivalent of 30 pack years (Figure 1).
Continued on page 6
Figure 1
an active researcher and educator with
leadership positions in national and
international spine surgery organizations.
In 1977, he graduated summa cum laude
in Chemistry as a University Scholar at
the University of Connecticut and went on
Continued on page 6
Congenital Heart Disease Specialists
Develop Nonsurgical Technique to Correct
Birth Defects in Premature Infants
Minimally Invasive Procedure Designed to Treat Birth Defect and
Lessen or Eliminate Need for Heart Surgery in Fragile Infants
Los Angeles – July 28, 2014 – A new
technique for repairing the most common
cardiac birth defect in newborns, commonly
referred to as “a hole in the heart,” has been
used successfully to mend the condition in
six premature infants without subjecting the
tiny patients to open-heart surgery.
The technique for repairing the condition,
patent ductus arteriosus, also called PDA,
was published online by the peer-reviewed
medical journal Catheterization and
Cardiovascular Interventions, the official
journal of The Society for Cardiovascular
Angiography and Interventions. The study,
published in the journal’s July print
edition, was developed by a team in the
Cedars-Sinai Heart Institute's Guerin
Family Congenital Heart Program led by
Evan M. Zahn, M.D., an expert in
congenital heart disease.
Ask
the
Doctors
2
“Just a few short years ago, the only
treatments available for these babies was an
intravenous medication regimen or heart
surgery,” said Zahn, co-director of the Heart
Institute's Guerin Family Congenital
Heart Program and a leader in the field of
nonsurgical cardiac interventions for pediatric
patients. “Yet many of these babies are so
fragile that we needed additional treatment
options to ensure that these children have a
healthy future ahead of them.”
Patent ductus arteriosus is a condition
in which a blood vessel called the ductus
arteriosus, which routes blood around
the baby's lungs prior to birth, does not
close naturally as it should within a couple
of days after birth. The opening leads to
abnormal blood flow and can cause
symptoms ranging from fast breathing
and difficult feeding to brain hemorrhage
Q
: Does radiation from X-rays or CAT
scans cause cancer?
A
: The cancer risk associated with
medical radiation is a hard question to
answer. We know that there is no lower
threshold that will eliminate risk, meaning
that there is no amount of radiation that is
considered without risk for cancer. It is
also true that the greater the amount of
radiation a person is exposed to, the higher
the risk of cancer. However, this increased
risk must be balanced with the potential
harm of missing a more life-altering
diagnosis by not having a medical
examination. When performed
appropriately, the risk associated with
and death in premature infants.
The study in Catheterization and
Cardiovascular Interventions followed six
severely premature infants who were born
with patent ductus arteriosus when they
were between 26 and 31 weeks gestation.
The babies in the study were between
16 and 80 days old and weighed between
1.9 and 4.9 pounds. All the infants in the
study had successful closure procedures
and did not experience complications.
Zahn and his team— including Alistair
Phillips, M.D., co-director of the Guerin
Family Congenital Heart Program, Ruchira
Garg, M.D., and Charles F. Simmons,
M.D., director of Cedars-Sinai's Pediatrics
Department and Division of Neonatology
and the Ruth and Harry Roman chair in
Neonatology in Honor of Larry Baum—
Continued on page 3
routine medical radiation is dramatically
outweighed by its potential benefit.
Radiation effects can be categorized into
two main types, either stochastic (chance)
or non-stochastic (deterministic). Stochastic
effects are related to radiation dose, where
an increased radiation dose increases the
probability of an adverse outcome, such as
induction of cancer. Deterministic effects
are those such as skin burns or GI upset
occurring with massive doses of radiation
(anywhere from 10 to 100 times that a
person would be exposed to from diagnostic
medical radiation) where effects only occur
after reaching a threshold dose. The major
concern that is discussed then is: What is the
risk of developing cancer?
Preventing Shoulder and Elbow
Injuries from Tennis and Golf
S
Cedars-Sinai Medical Center
cedars-sinai.edu
ummer is a great time to enjoy
sports like golf and tennis.
Unfortunately, many seasonal
athletes experience shoulder
and elbow injuries from overuse.
Most upper extremity ailments from
golf and tennis are forms of tendonitis.
Tendons are the connective tissues
that attach your muscles to your
bones, forcing your bones to move
and your joints to bend when
your muscles contract. Overuse and
repetitive stress can cause focal
irritation and pain at tendon sites.
Overuse and repetitive stress without
proper warm-up or endurance training may
lead to tendonitis. “Poor form,” or poor
body mechanics, when serving in tennis or
hitting a 9-iron can also lead to tendonitis.
Muscle fatigue and diminished endurance
can cause a lapse form and technique
that can overload certain tendons as they
insert on bones causing tendonitis.
Tendonitis feels like nagging pain near
the bony prominences of the elbow or over
side of the shoulder. Elbow tendonitis
From what we know today, calculating a
risk of cancer from a specific radiation
exposure is impossible. This is secondary to
many factors. Firstly, most data that we have
regarding the risk of cancer from radiation
are based on very high exposures, such as that
in atomic bomb survivors. We can say with
certainty that at these high doses, radiation
does cause cancer. This information, when
extrapolated to the relatively minuscule
amounts of radiation a person is exposed to
from medical tests, leads us to believe that
while there is still a tiny chance of developing
cancer, the necessity of undergoing these tests
outweighs any of these risks. To further
complicate the estimations, some of our body
parts, such as our reproductive organs, are
more sensitive to radiation than others.
Finally, there are many different
environmental causes of cancer and it is not
possible to determine if a specific trigger is
associated with someone developing cancer.
Clearly, in life-threatening situations,
such as in a car crash, obtaining an X-ray or
CAT scan to identify areas of injury outweighs any potential risks of cancer. This is
contrasted with some who advocate whole
body CAT scanning in an otherwise healthy
person, where the extra radiation is likely
more harmful. Therefore, medical diagnostic
radiation (X-ray or CAT scan) should only
be used when there is a medical question to
be answered and the risk of radiation
is clearly outweighed by the benefit of the
developed a catheter-based technique
that employed sophisticated imaging
technologies fluoroscopy and echocardiography to guide the physicians
through the delicate closure procedure.
“The development of new minimally
invasive techniques to treat babies with
PDA is a major step forward,” said
Eduardo Marbán, M.D., Ph.D., director
of the Cedars-Sinai Heart Institute. “The
tiny size of premature infants renders
open-chest surgery exceedingly risky;
Zahn and colleagues can now fix the
problem with a catheter, at the bedside
in the neonatal unit, without exposing
the internal organs. Lives have been
saved, and many others stand to benefit
as this new technology is disseminated.”
Health News | Fall/Winter
Spring/Summer
2014 2014
may affect the medial or lateral aspects of
the elbow, commonly referred to as “golfers
elbow” and “tennis elbow,” respectively.
Shoulder tendonitis frequently affects
the rotator cuff, muscles that power your
shoulder motions. Individuals with
tendonitis often experience no specific
injury besides overuse. A discrete feeling
of a pop, crack, or tear with bruising
on the arm is NOT tendonitis and may
indicate a completely torn tendon or
Continued on page 4
information obtained from the test.
To complicate matters further, screening,
which is diagnosing disease in otherwise
healthy people, opens the door for
irresponsible use of medical radiation and
unnecessary risks. This underscores the
importance of adherence to strict guidelines.
For example, current recommendations
for routine screening are limited to certain
diseases and in certain high-risk populations,
such as breast and lung cancer in welldefined age and risk profiles. Patients can
refuse any of these tests and should feel
comfortable discussing these risks
and benefits with their physicians.
Bradley B. Pua, M.D.
3
Charles M. Jobin, M.D.
Assistant
Professor of
Clinical
Orthopedic
Surgery,
Columbia
University
College of
Physicians
and Surgeons;
Assistant Attending, NewYorkPresbyterian
Dr. Jobin specializes in the operative and
non-operative treatment of shoulder
and elbow disorders in adults at
Columbia Orthopedics. He is an expert
in shoulder and elbow reconstruction,
minimally invasive, and arthroscopic
techniques. His particular clinical
strengths include treatment of shoulder
and elbow arthritis, joint replacement,
rotator cuff disorders, shoulder
instability, tendon and ligament
injuries, and fractures. Dr. Jobin, an
athlete himself, has cared for local
sports teams and provided orthopedic
coverage during tournaments.
Ask
the
Doctors
Q
: How should I prepare for an exotic
vacation?
A
: The most important thing to do is
seek advice from a travel clinic, especially if
4
Preventing Shoulder and Elbow
Injuries from Tennis and Golf
Continued from page 3
ligament and you should seek orthopedic
medical care.
Chronic tendonitis is characterized by
a dull but persistent soreness that feels worse
when you first start to move, and then eases
up as your muscles get warmer. Chronic
tendonitis is difficult to alleviate quickly
and may persist for several months. Selftreatment focuses on avoiding the
inciting activities and stretching, three times
daily, the muscles of the forearm and elbow
for 5 to 10 minutes per session. Acute
tendonitis causes a sharper persistent pain
that may keep you from moving the joint;
this pain usually goes away after a few
hours or days with rest, ice, compressive
wrapping, elevation, and over-the-counter
anti-inflammatory medications.
Prevention is the best way to avoid the
disabling pain of tendonitis. Professional
baseball players and other professional
athletes have very specific shoulder and
elbow injury prevention training programs
to keep their joints healthy and ward off
you are going to an unusual travel
destination. If you are going to Europe, the
risk of acquiring illnesses is similar to what
you would face in the United States, but
there are different risks associated with
going to other areas of the world—Africa,
South America, Asia—and the physicians in
a travel clinic can advise what can be done
to minimize those risks.
There are illnesses such as Japanese
encephalitis that you will see in several areas
of Asia, Southeast Asia, and some areas of
Australia, but not in Africa, South America,
or anywhere else. A disease called yellow
fever is present in certain areas of South
America and certain areas of Sub-Saharan
Africa. You don’t find it in any other areas
of the world.
A very effective vaccine for yellow fever is
injury. Key elements of a prevention
program include a thorough warm-up that
gradually builds in intensity, stretching the
upper extremity and torso after warm-up,
muscle strengthening and agility exercises
that focus on proper body mechanics and
sport-specific activities. The program should
end with has a gradual cool down period.
A proper prevention program should be
repeated three or more days per week
for at least 20-30 minutes, and should start a
few weeks or months prior to the beginning
of the sporting season. A short daily
prevention program is better than a once
a week intense work out.
If shoulder and elbow pains do not
alleviate with rest or they persistently
interfere with daily activities, it is time to visit
your orthopedic doctor. Other troubling
symptoms, such as muscle deformity, feeling
a pop or snap with bruising, significant
weakness, or having the joint come out of
its socket, are indications that you should
seek expert orthopedic care.
Charles M. Jobin, M.D.
available, but you can’t get it from your
primary care doctor; it’s a live vaccine that
requires special training to monitor side
effects, so only approved clinics can provide
the vaccine. People who are going to areas
where yellow fever is endemic should seek
medical advice from a travel clinic to get
the vaccine or to decide whether or not it’s
appropriate for them because of other
health issues they may have or because the
vaccine will not be helpful in the particular
area they are planning to visit.
Travelers should also make sure that their
general overall health is stable. I certainly
do not advise someone whose chronic
condition is not under control to travel
without at least seeing their primary care
doctor and having contingency plans in case
GLOBAL CONNECTION
Heart Monitoring with the
Reveal LINQ Insertable Cardiac Monitoring System
C
apturing the electrocardiogram
(ECG) of patients who suffer
with infrequent blackouts
or palpitations was almost
impossible until the invention of the
implantable loop recorder. The original
device, the Medtronic Reveal, was the size
of a memory stick and required a surgical
implant in a hospital catheterization
lab, often requiring intravenous sedation
and post-operative monitoring. Many
patients were put off by the size of
the device, especially women, who did not
want a chest scar.
The new Medtronic Reveal LINQ™
is the smallest heart monitor on the
market—the size of two matchsticks—and
is injected through a tiny incision on the
lower part of the chest, similar to
contraceptive devices that women have
implanted in their arms. Once in place
the Reveal LINQ™ can detect and
monitor abnormal heart rhythms for up to
three years.
Implantation now takes a few
in the world with a 3G phone
minutes, with local anesthesia
signal. Profound abnormalities
alone; Dr. Oliver Segal has
generate an email or text
pioneered their implantation
message to alert the patient’s
outside of a catheterization lab
physician that something is
setting in London, using a
wrong straight away. The device
procedure room at the Harley
can also detect episodes of
Street Clinic Diagnostic Centre.
atrial fibrillation, which can
Patients are home within
be very useful in patients
Oliver Segal, M.D.
30 minutes or so and can go
presenting with cryptogenic
back to work if they wish.
stroke (a stroke not attributable
MRI scans can be performed with a
to a specific cause) or after treatments
Medtronic Reveal LINQ™ implanted.
such as catheter ablation.
The device automatically detects episodes
The Medtronic Reveal LINQ™
of bradycardia (heart rate slower than
is changing the landscape of diagnostic
normal) or tachycardia (resting heart rate
ECG monitoring and lowering the
faster than normal) and wirelessly transmits
threshold for using implantable devices
this information every night to a monitor
to diagnose patients correctly. Dr. Oliver
kept in the patient’s bedroom; additional
Segal and the Harley Street Clinic are
transmissions can be made manually
pioneering outpatient implantation
if the patient has symptoms. The
of this device, raising the acceptability of
information is then transmitted to a
this technique even further.
secure website accessible only to the
Oliver Segal, M.D.
cardiologist; the monitor works anywhere
things happen overseas.
Diabetes is a chronic illness that can be
affected by travel. A diabetic is more prone
to infection and is subject to fluctuating
blood sugar depending on diet, and traveling
to exotic locales will likely involve a change
in diet. A well-formed plan on how to
manage diabetes while traveling is a must.
People who are immuno-compromised,
perhaps from having received a transplant in
the past, or as a result of taking medication
for rheumatoid arthritis or Crohn’s disease,
are also more susceptible to infections that
are endemic and their response to these
infections is significantly different because
their immune system is weakened. Even
healthy people can have conditions
to be concerned about—pregnancy is a
consideration. I always recommend that
pregnant women who are going to an area
with malaria discuss it with their obstetricians
and make sure that they are aware of the
risks associated with malaria in pregnant
women. It really involves being aware of the
place you are going to, being aware of your
own body and what is going on there and
seeking the appropriate medical care. It is a
three-pronged approach before travel.
Travelers should be sure to pack a sufficient
supply of any medication that they take
normally and a small first aid kit: an antiinflammatory (ibuprophen, naproxen, or
aspirin) band-aids, disinfectant, gauze,
Benadryl, hydrocortisone cream, and
depending on the destination, a mosquito
repellent can be very crucial. In general we
Health News | Fall/Winter 2014
recommend something that has between
20 and 30 percent Deet. Those of us who
live in the northeast or in areas with tickborne illnesses know that these can be very
helpful and sometimes life saving. If one will
be primarily outdoors in areas where there is
a high risk of mosquito-borne illnesses they
should definitely take a mosquito netting,
available from any camping store; some
are even sprayed with a chemical called
permethrin, which helps kill mosquitoes.
If the purity of the water is in question,
I always recommend drinking bottled water,
brushing teeth with it and using it to make
ice in their hotel room. Alternatively, a
filter from a camping store can be used to
purify water.
Joseph El Khoury, M.D.
5
Mark Weidenbaum, M.D.
Continued from page one
to earn his medical degree at Columbia
University College of Physicians and
Surgeons in 1981. He then trained for
two years in General Surgery at Roosevelt
Hospital (New York), after which
he completed a residency in Orthopedic
Surgery at Columbia’s Presbyterian
Medical Center (New York) and a
Fellowship in Scoliosis and Spine Surgery
at Rush-Presbyterian–St. Luke’s Medical
Center in Chicago.
Dr. Weidenbaum has received several
prestigious grants from the Orthopaedic
Research and Education Foundation,
the National Institute of Health, and the
Carroll Foundation to support his clinical
and basic science research.
Recognized internationally for his work on
spinal deformity, Dr. Weidenbaum actively
participates in the American Association
of Orthopaedic Surgeons, the Scoliosis
Research Society (SRS), and other leading
professional organizations. He is a member
of the SRS Board of Directors, and has
been selected as the SRS Secretary.
Dr. Weidenbaum is also a highly active
Faculty Member and Course Co-Chair
for the SRS, participating in numerous
training courses held in Sarajevo, Bosnia;
Valencia, Spain; and Calcutta, India.
With an extensive number of peerreviewed publications in Spine, the
Journal of Orthopedic Research, and
the Journal of Biomechanics, as well as
several textbook chapters to his name,
it is no wonder that Dr. Weidenbaum is
frequently invited to lecture and operate
in locations throughout the United States,
Europe, the Middle East, South America,
and Asia. He has consulted for the
New York Yankees and appeared several
times on NBC’s The Today Show to
discuss spine issues.
Dr. Weidenbaum is part of a family of
enthusiastic healthcare providers: his wife,
Lisa Berke-Weidenbaum, is a nurse
practitioner, and his middle daughter,
Emily M. Weidenbaum, is a first year
medical student at Columbia’s College of
Physicians & Surgeons.
6
Lung Cancer Screening:
The Benefits of Early Detection
Continued from page one
Over the past few decades, many
studies have looked at the optimal imaging
technique to screen for early lung cancer.
Early studies in the 1980s, conducted
throughout the US and Europe, failed to
demonstrate any benefit to screening
with chest X-ray, sputum analysis, or the
combination. In the late 1990s and early
2000s advances in computed tomography
(CT) allowed for several studies to be
performed that first demonstrated utility
of CT in screening for lung cancer. In the
US, this has culminated in the National
Lung Screening Trial (NLST), a multicenter
trial, which concluded that low dose CT
(LDCT) was superior to chest X-ray in
detecting early-stage lung cancer. In that
study, screening with LDCT in a highrisk population led to 20% fewer deaths
from lung cancer than screening with
chest X-ray. This remarkable difference
was thought secondary to the ability of
CT to detect more early stage cancers.
Today, lung-screening programs perform
CT scans of the chest with a low dose
technique of radiation equivalent to
only a few chest x-rays.
What should you expect from joining a
lung-screening program? Lung-screening
programs will have dedicated staff
members who can provide you with a
risk assessment and advise you as to the
potential risk and benefits of undergoing
a low dose CT scan for detection. The
LDCT examination takes about 5 minutes
to perform, with the scan itself being
done in a single breath hold. The scan is
evaluated by an experienced radiologist
and is given a suspicion score and
recommendations for follow-up.
Suspicion is based on the size of a nodule,
its consistency, and any associated growth
noted on follow-up examinations. The
vast majority of the studies will be negative
with recommendations for annual followup. It is important to understand that up
to 15 to 20% of these studies may be
considered “positive.” A positive study
does not mean that a lung cancer was
detected, but that an abnormality
was identified on the CT that requires
additional testing or a follow-up period
shorter than one year. Only a small
fraction of positive studies will represent
cancer. (Figure 2)
Positive studies that do not actually
represent cancer (false positives) are a
point of controversy in screening. It is the
false positive examinations, the potential
for unnecessary additional testing, and
the possibility of treatment of cancers
that would never have proven to be lifethreatening that need to be minimized to
allow full adoption of lung screening.
Lung Cancer Prevention & Risk Factors
Whereas early detection allows for
optimal therapy with the highest likelihood
for cure, primary prevention should not
be ignored. While controversy surrounds
several potential risk factors of lung
cancer, the link between lung cancer and
smoking is clear, accounting for 80 to
90% of lung cancer deaths. For current
smokers, cessation is the best method to
not only lower risks of developing lung
cancer, but also lowering the risk of
stroke and heart disease. The process
of quitting is very difficult and many
screening programs will either have
counselors available to help or be able to
direct you to one.
Additional risk factors for development
of cancer include environmental factors
such as contact with asbestos and radon
as well as genetic factors such as a strong
family history of lung cancer. Personal
history of other cancers or lung diseases
such as chronic obstructive pulmonary
disease (COPD) also appear to be related.
A link between lung cancer risk and
second-hand smoking is related to the
amount of exposure. As the amount of
exposure to second-hand smoke is
difficult to measure, the actual risk may
not be easily known. These factors, if
they apply to you, should be discussed with
your physician when deciding on screening.
Where should I go for screening?
Your primary physician can help you
decide and evaluate your risks for lung cancer.
Many centers will require a prescription from
your doctor for screening. Centers that do not
require a prescription will have physicians
available to discuss whether or not you are a
candidate. A thorough review of your family
and individual medical history, smoking
history, and environmental exposures will be
used to make this determination.
Your screening center should follow an
organized plan or protocol for follow-up.
Suspicious findings may require further
testing, such as tissue biopsy; thus, centers
should also have access to physicians
experienced with this. In addition to strict
quality control to decrease screening harms,
easy access to a multidisciplinary team of
physicians comprised of pulmonologists (lung
doctors), thoracic surgeons, and radiologists
who can help direct your care is essential.
Bradley B. Pua, M.D.
Figure 2
CONTRIBUTORS
Charles M. Jobin, M.D.
Assistant Professor of Clinical Orthopedic Surgery
Columbia University College of Physicians and Surgeons
Assistant Attending
NewYork-Presbyterian
Joseph El Khoury, M.D.,
Massachusetts General Hospital
Bradley B. Pua, M.D.
Assistant Professor of Radiology
Program Director, Interventional Radiology Fellowship
Director, Lung Cancer Screening Program
NewYork-Presbyterian/Weill Cornell
For questions and membership
information, please call
1-212-472-4444 or
1-800-634-3932
Oliver Segal, M.D.
Consultant Cardiologist & Electrophysiologist
The Harley Street Clinic Diagnostic Centre
Health News | Fall/Winter 2014
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California, Los Angeles
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Chile, Santiago
Clinica Las Condes
China, Beijing
Peking Union Medical College Hospital
China, Shanghai
Hua Shan Hospital
England, London
The Harley Street Clinic
The Lister Hospital
London Bridge Hospital
The Portland Hospital
The Princess Grace Hospital
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Florida, Miami
University of Miami
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The American Hospital of Paris
Germany, Munich
Stadt. Krankenhaus Munchen-Bogenhausen
Hong Kong, Hong Kong
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Physician Affiliate Sites
India, Mumbai
P.D. Hinduja National Hospital and
Medical Research Center
Ireland, Dublin
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Israel, Jerusalem
Hadassah-Hebrew University Medical Center
Israel, Tel Hashomer
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Rome American Hospital
Japan, Kamakura
Shonan Kamakura General Hospital
Jordan, Amman
Al Khalidi Medical Center
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Severance Hospital
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Subang Jaya Medical Center
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Massachusetts General Hospital
Mexico, Mexico City
The American British Cowdray
Medical Center
New York, New York
NewYork-Presbyterian, The University
Hospital of Columbia and Cornell
North Carolina, Winston-Salem
Wake Forest Baptist Medical Center
Phillipines, Queson City
St. Luke’s Medical Center
Poland, Poznan
MSW Hospital
Portugal, Lisbon
Clinica Medica Internacional de Lisboa
Puerto Rico, Santurce
Pavia Hospital
Russia, Moscow
European Medical Center
Saudi Arabia, Jeddah
International Medical Center
Singapore
Mount Elizabeth Hospital Ltd.
National University Hospital
Glen Eagles
Spain, Barcelona
Centro Medico Teknon
Clinica Quiron
Institut Dexeus
Spain, Madrid
Complexo Hospitalario Juan Canalejo
Switzerland, Bern
University Hospital of Bern
Switzerland, Zurich
University Hospital
Taiwan, Taipei
National Taiwan University Hospital
Thailand, Bangkok
BNH Medical Center, Ltd.
Turkey, Istanbul
American Hospital of Istanbul
UAE
American Hospital Dubai
Alaska, Anchorage
Amsterdam
Arizona, Phoenix
Bolivia, La Paz
Canada, Ottawa, Toronto, Vancouver
Costa Rica, San Jose
Czech Republic, Prague
Dominican Republic, Santo Domingo
Ecuador, Quito, Guayaquil
Egypt, Alexandria, Cairo
Finland, Helsinki
Florida, Naples
Germany, Cologne, Frankfurt, Munich
Hawaii, Honolulu
Illinois, Chicago
India, New Delhi
Indonesia, Jakarta
Italy, Florence
Japan, Tokyo
Kenya, Nairobi
New Zealand, Wellington
South Africa, Johannesburg
Spain, LaCoruna, Madrid
Sweden, Stockholm, Goteborg
Texas, Houston
Ukraine, Kiev
Vietnam, Hanoi