rounds - cleveland clinic · 2013-12-20 · medical and surgical specialists and subspecialists...

RoundsThe laTesT news foR pRimaRy caRe physicians fRom cleveland clinicjanuary/february 2010

inside

Specially Trained Team Offers Cardiovascular Imaging

Comprehensive Services Available for the Treatment of Head and Neck Cancer

Infertility Program Receives National Distinction

Cleveland Clinic Sets International Record in Lung Transplant Volume

Celebrating 25 Years of Liver Transplantation

Cleveland Clinic Performs World’s First Single-Incision Proctocolectomy

Lifestyle 180 Brings Wellness to Patients with Chronic Conditions

Staff Notes

Coming Events

Breaking new Ground

new chronic abdominal pain clinic provides comprehensive diagnostics and treatments

cleveland clinic’s digestive disease institute and department of pain management have launched a new chronic abdominal pain clinic to provide comprehensive and cost effec-tive medical diagnostics and treatments for patients with chronic abdominal pain (cap).

an estimated 2 percent, or six million americans, have cap. But physicians find it dif-ficult to pinpoint the source of cap in many patients.

“cap, which we define as chronic abdominal pain that has been ongoing for more than six months, has always been a major health problem,” says cleveland clinic gastroenterolo-gist maged Rizk, md, director of the chronic abdominal pain clinic. “Unfortunately, due to physician frustration and patient frustration, a clear way to identify possible etiologies of cap has remained elusive.”

more common in women than in men, cap can be triggered by rare or uncommon gastrointestinal issues, visceral nerve disorders or psychological issues that may not be detected by standard diagnostic tests such as a caT scan, or endoscopic procedures to examine the stomach, small or large intestines.

at the chronic abdominal pain clinic, which opened in July 2009, cap patients undergo a thorough evaluation that includes standard and appropriate specialized medical tests to find the source or mechanism of a patient’s chronic abdominal pain. for example, sophisticated tests, such as differential retrograde epidural blocks, can determine if pain is originating from the abdomen, nerves inside the abdominal wall or the spinal cord. Recent animal research studies suggest nerve impulses from the abdomen or viscera trigger sensory pathways to the spinal cord, which in turn transmits information to the brain about pain, temperature and touch.

more importantly, the chronic abdominal pain clinic enables collaboration among medical and surgical specialists and subspecialists from a wide range of disciplines to deliver the most appropriate treatments and follow-up care for cap patients, including gastroenterology, urology, hepatology, pain management, psychiatry and clinical research.

for more information or to refer a patient, please call 216.444.5404 or 888.410.1775; or visit clevelandclinic.org/digestive. n

services for physicians

Physician Directory

view all cleveland clinic staff online at clevelandclinic.org/staff.

Physician Liaison

Referring physicians have a direct and personal link to cleveland

clinic with our physician liaison. for help with any interaction

involving cleveland clinic, contact physician liaison Kate Kenny

at clevelandclinic.org/contactKate.

criticaL care transPort WorLDWiDe

cleveland clinic’s critical care transport team serves critically ill and highly

complex patients across the globe. The transport fleet comprises mobile

icU vehicles, helicopters and fixed-wing aircraft. The transport teams are

staffed by physicians, critical care nurse practitioners, critical care nurses,

paramedics and ancillary staff, and are customized to meet the needs of

the patient. critical care transport is available for children and adults.

To arrange a transfer for sTemi (sT elevated myocardial infarction), acute

stroke, ich (intracerebral hemorrhage), sah (subarachnoid hemorrhage)

or aortic syndromes, call 877.379.coDe (2633). for all other transfers,

call 216.444.8302 or 800.553.5056.

tracK your Patient’s care onLine

whether you are referring from near or far, drconnect offers secure

access to your patient’s treatment progress at cleveland clinic. To establish

a drconnect account, visit clevelandclinic.org/drconnect or email

[email protected].

remote consuLts

Request a remote medical second opinion from cleveland clinic.

myconsult is particularly valuable for patients who wish to avoid the

time and expense of travel. visit clevelandclinic.org/myconsult, email

[email protected] or call 800.223.2273, ext 43223.

outcomes Data avaiLabLe

our outcomes books contain clinical outcomes data and information on

volumes, innovations, research and publications. To view outcomes books for

many cleveland clinic institutes, visit clevelandclinic.org/quality/outcomes.

services for patients

meDicaL concierge

complimentary assistance for

out-of-state patients and families

800.223.2273, ext. 55580, or

email [email protected]

gLobaL Patient services

complimentary assistance

for national and international

patients and families

001.216.444.8184 or visit

clevelandclinic.org/gps

General patient Referrals

24/7 hospital transfers or

physician consults

800.553.5056

clevelandclinic.org

cleveland clinic’s cardiovascular imaging lab (cvil) is one of

only a few centers in the country offering imaging of the car-

diovascular system by a team of cardiologists and radiologists

specifically cross-trained in cardiac imaging.

The section of cardiovascular imaging includes five clinicians

and two researchers, whose combined expertise is essential

to the work of cleveland clinic’s world-renowned sydell and

arnold miller family heart & vascular institute. for the 15th

consecutive year, U.S.News & World Report’s “america’s Best

hospitals” survey ranked cleveland clinic no. 1 in the nation

for heart care in 2009.

The cardiovascular imaging lab is equipped with state-of-

the-art computed tomography (cT) and magnetic resonance

imaging (mRi) equipment. The staff is expert in diagnosis and

treatment planning for conditions that include acquired cardiac

disease in adults, and congenital heart disease in children

and adults. specific disorders that patients may present with

include chest pain with exercise, leaky heart valves, hypertro-

phic cardiomyopathy, and defects in the size and shape of

the heart.

The cvil provides comprehensive cT, mRi and magnetic reso-

nance angiography (mRa) imaging services:

ct: fast, With exceLLent image QuaLity

The cvil is equipped with two state-of-the-art cT scanners

to expertly handle the imaging needs of your cardiovascular

patients. one scanner allows imaging of high heart rates and

the other can capture 256-slice images with every heartbeat.

with each patient, our staff is committed to using the proce-

dure that is least invasive and reduces radiation exposure to

the minimum. our cT equipment provides excellent image

quality despite high heart rates.

cTa examinations of the thoracic and abdominal aorta are

available prior to or following surgery or minimally invasive

procedures. The cT scanners in the cvil are extremely fast,

allowing for smaller contrast injections than typically used for

similar cT scans performed elsewhere.

mri/mra: for exPert carDiac anaLysis

cardiovascular mRi/mRa examinations encompassing the

breadth of acquired and congenital heart disease are per-

formed and expertly interpreted on a daily basis.

cardiovascular imaging offers two mRi scanners that are fully

equipped for cardiac analysis. The section of cardiovascular

imaging maintains close clinical working relationships with

Thoracic and cardiovascular surgery, vascular surgery and

cardiology, all within the miller family heart & vascular

institute. These collaborations aid in optimizing diagnostic

pathways and effecting cost-efficient care.

to schedule a patient exam, call 216.445.7050 or

866.223.2273, ext. 57050; or to learn more visit

clevelandclinic.org/cvil. n

specially Trained Team offers cardiovascular imaging

clevelandclinic.org/rounds 3

comprehensive services available for the Treatment of head and neck cancer

head and neck cancer is a devastating disease that occurs in

a group of patients often plagued by other diseases, putting

them at risk of significant morbidity and mortality, and loss

of quality of life. The treatment is often difficult and requires

sophisticated surgical, medical and radiotherapeutic tech-

niques, and the active involvement of a host of supportive

nurses, therapists and other patient advocates to obtain the

best results.

all of the specialties needed for the comprehensive care of

patients with complex head and neck tumors (i.e., head and

neck ablative surgeons, microvascular and reconstructive sur-

geons, dentists and maxillofacial prosthetic experts, speech

and language pathologists and dedicated nurses) are now inte-

grated into the cleveland clinic head & neck institute. Brian

B. Burkey, md, facs, is the newly appointed head of the

section of head and neck surgery and oncology.

our goal is to provide the most current leading edge treatments

for our patients, while developing new treatments and proce-

dures with an emphasis on functional preservation.

to refer a patient or for more information, call

216.444.6691. n

oral and maxillofacial surgery services now available

The cleveland clinic head & neck institute has expanded its

dental staff with the development of the section of oral and

maxillofacial surgery, headed by husam elias, md, dmd, and

joined by Joseph Krajekian, md, dmd, both oral and maxil-

lofacial surgeons, and michael huband, dds, a maxillofacial

prosthodontist.

all phases of oral and maxillofacial surgery will be provided

by drs. elias and Krajekian and will include orthognathic,

TmJ, trauma, pathology, sleep apnea surgery, wisdom teeth,

dental and maxillofacial implants and maxillofacial aesthetic

and reconstructive surgery, as well as routine oral surgery and

consultative services.

as a maxillofacial prosthodontist, dr. huband specializes in

the non-surgical, or prosthetic, replacement of lost teeth and

associated oral, facial, and head and neck structures, fabrica-

tion of appliances to improve speech and swallowing, as well as

routine denture, partial denture and general prosthodontic care.

to refer a patient or for more information, call

216.444.6907. n

cleveland clinic RoUnds4

from a surgical perspective, cleveland clinic aims to pre-

serve fertility with minimally invasive techniques whenever

possible, including robotic surgery, single-port surgery, micro-

surgery, and advanced endoscopic techniques for women with

advanced endometriosis.

“couples entering the infertility program at cleveland clinic in

hopes of a successful pregnancy can expect comprehensive,

individualized treatment,” noted the medical economics article.

The article also points out that cleveland clinic had its first

two pregnancies resulting from frozen ooctyes (eggs) in 2008,

becoming one of only a handful of centers in the world able to

confidently offer this fertility preservation option to patients.

Medical Economics researches and publishes clinical centers

of excellence to be a physician’s guide to the best in various

specialties and “to recognize those hospitals that bring a little

something extra to a specialty, whether through research,

patient care, or community outreach.” The article was fea-

tured in the october 9, 2009 issue of Medical Economics,

as well as the october 2009 issue of its sister publication,

Contemporary OB/GYN.

cleveland clinic’s infertility Program has locations

throughout northeast ohio. to refer a patient, call

216.444.6601. n

infertility program Receives national distinction

cleveland clinic was one of only eight hospitals in the country

to “rise above the pack” and receive this distinction. The

magazine selected “programs offering comprehensive infertility

testing, diagnosis and treatment, complemented by participa-

tion in evolving infertility and genetic research areas” to be

noted as centers of excellence based on information received

from key opinion leaders in various specialties, through physi-

cian surveys and self-reported data from each hospital.

physicians at cleveland clinic have more than 5,700 annual

patient visits for infertility-related issues and services alone.

a multidisciplinary team from the Glickman Urological &

Kidney institute and the ob/Gyn & women’s health institute

addresses the fertility needs of both men and women, deliver-

ing personalized treatment options for every couple, including

artificial insemination, ovulation induction, intracytoplasmic

sperm injection, in vitro fertilization (ivf), and preimplantation

genetic diagnosis (pGd).

Medical Economics magazine recently recognized cleveland clinic as a “clinical center of excellence in infertility.”


on Tuesday, oct. 13, the cleveland clinic lung Transplantation and heart-lung Transplantation program performed its 129th lung transplant – 124 single-lung or double-lung transplants, two heart-lung transplants and three liver-lung transplants. The previous annual record in lung transplants was 128 in 2007.

The increasing number of lung transplants has been part of a concerted effort to expand patient eligibility guidelines, improve collaboration among cleveland clinic institutes and accept patients with complex cases who are among the sickest of the sick.

“The cleveland clinic program is gaining a reputation of accept-ing patients that may have been refused candidacy at another program and now has a firmly established track record of good outcomes with high risk cases,” says marie Budev, do, mph, medical director for the program. “it’s very rare that we decline a patient and there is an honest sadness when we do. They are truly like a part of our family.”

cleveland clinic’s lung Transplantation and heart-lung Transplantation program is a multidis-ciplinary collaboration that includes transplant surgeons, pulmonologists, infectious disease specialists, pharmacologists, nurses, social workers, physical therapists and transplant coordinators.

more patients enlisted into the transplant program means that the need for organs has increased as well. To meet the demand, cleveland clinic has broad-ened its reach, traveling up to 3,000 miles to secure lungs. cleveland clinic also is accepting and improv-ing lungs that other centers may have otherwise turned down.

another factor in the transplant program’s growth has been a streamlining of the entire process, from getting evaluated, listed and then transplanted. “There are still

people dying while waiting for a lung,” says Kenneth mccurry, md, a world-renowned cardiothoracic surgeon, who joined cleveland clinic in January, 2009. “more can be done. more donors can be utilized than are currently being utilized. more patients can receive lungs than are currently receiving them. in 2009, nearly half of our transplant recipients were turned away elsewhere.”

to refer a patient to the Lung transplantation and heart-Lung transplantation Program, please call 216.444.6503;

or 866.ccf.Lung (223.5863). n

cleveland clinic sets international Record in lung Transplant volumeno transplant center has transplanted more lungs in a single year

By the middle of october, with more than two months remaining in 2009, the cleveland clinic had already transplanted more lungs in one year than any other transplant center in the world.


cleveland clinic in the spotlight

in 2008, the program performed 147 liver transplants, includ-

ing eight liver/kidney transplants and one liver/pancreas

transplant. our internationally renowned liver transplant sur-

geons have more experience than any other transplant team in

the nation – nine specialized surgeons with more than 100

years of combined experience.

other highLights:

• we perform the 4th largest number of liver transplants in

the nation and offer the most options for pediatric patients in

the region.

• our liver transplant one-year survival rate of 90.9 percent

exceeds the national expected rate. our three-year survival

rate of 83 percent far exceeds the national expected rate of

76 percent.

celebrating 25 years of liver Transplantation

This year, the cleveland clinic Transplant center celebrates its 25th anniversary of its first liver transplanta-tion and looks forward to additional growth and advances.

• patients on our waitlist receive transplants twice as fast as

the expected national rate, 0.79 compared to 0.37.

• our team is dedicated to helping make your patients’ liver

transplants as easy as possible. a dedicated transplant coor-

dinator, social worker, hepatologist, financial coordinator

and transplant psychiatrist all work to guide patients through

the process.

• we also provide a group patient education class, options for

transplant research, a multi-disciplinary liver Tumor clinic,

and decreased referral to listing time.

for more information on the cleveland clinic

Liver transplant program or to refer a patient, call

216.445.8473. n

cleveland clinic continues to be favorably noticed in the

national discussion of healthcare reform, more recently

in Newsweek. The article (december 7, 2009) describes

cleveland clinic’s unique model of medicine and how the

organization is able to deliver the highest quality of care at a

lower cost. The magazine describes cleveland clinic as the

place “to see high-quality, cost-effective care in action.”

for the article, “The hospital That could cure health care,”

Newsweek reporters talked to several key members of

cleveland clinic’s staff, including ceo and president Toby

cosgrove, md, and c. martin harris, md, chief information

officer, to learn about efficiencies in care and the electronic

medical record, among other things. The article says that dr.

cosgrove has “enlisted every tool of modern management,

obsessively tracking metrics of performance from blood-bank

usage to market share, even redesigning hospital gowns in an

initiative to ‘improve the patient experience.’”

to read the article in its entirety, please visit

www.newsweek.com/id/224585. n


cleveland clinic surgeons

recently used a single-port

approach to remove the

entire large intestine of a

13-year-old patient who

was diagnosed with famil-

ial adenomatous polyposis

(fap). The successful,

minimally invasive surgery

left only a coin-sized scar

on his abdomen.

The surgery, performed by

cleveland clinic colorectal

surgeon daniel Geisler, md, removed the boy’s entire large

intestine and rectum, and created a j-shaped pouch from

the small intestine to reconnect the digestive tract. The total

proctocolectomy significantly reduces the patient’s risk of

developing colon cancer.

The total proctocolectomy and ileoanal pouch procedure is

believed to be among the first in the world done through a sin-

gle-incision, laparoscopic technique, a technique that leads to

significantly reduced external scarring, decreased infection risk,

reduced postoperative pain and faster recovery for the patient.

“By operating early, we have greatly reduced the patient’s risk

for developing a difficult to treat colon cancer,” says dr. Geisler.

“patients have significantly less external scarring and recover

much faster when we use this technique.”

cleveland clinic performs world’s first single-incision proctocolectomy on 13-year-old

cleveland clinic’s innovation in minimally invasive surgery

also includes the first single-port laparoscopic colon resection

entirely through a single incision in the navel, performed in

2007 by feza Remzi, md, chairman of colorectal surgery.

for more information or to refer a patient to a colorectal

surgeon at cleveland clinic, call 216.444.5405. n

neurological institute offers several clinical Trials

if you have patients who have not responded to traditional treatments, you

can provide him or her access to the latest investigational therapies. cleveland

clinic’s neurological institute is currently offering more than 200 open,

leading-edge clinical research studies. consider offering your patient the

opportunity to enroll.

Learn more about our studies by visiting clevelandclinic.org/neurotrials. n


lifestyle 180 Brings wellness to patients with chronic conditions

well-being. once the initial one-year program is com-

plete, participants are eligible for additional follow-up

sessions as needed.

Proven benefits

previous lifestyle 180 sessions have shown impressive

results after the initial six-week immersion phase:

• one-third of our participants were able to stop taking,

avoid starting or lower the dose of medication after

10 weeks.

• They averaged an 11 percent reduction in ldl.

• participants lost an average of nine pounds.

• They lost more than two inches in waist circumfer-

ence, on average.

participants also reported improved sleep, balance,

muscle strength and mood – important benefits for

anyone living with cardiovascular disease, multiple

sclerosis, fatty liver disease (nash), ulcerative colitis,

crohn’s disease, or early prostate or breast cancer

(within two years of diagnosis).

for more information on Lifestyle 180, including

a complete list of conditions we treat and program

benefits, visit clevelandclinic.org/lifestyle180. to

refer a patient, call 877.331.WeLL (9355). n

more than 25 million americans suffer from chronic

disease, increasing their risk for death or disability. more

importantly, these people are most likely coping with

ongoing pain, fatigue, difficulty moving, sleep depriva-

tion or other obstacles to living a vibrant, healthy life.

patients with these chronic conditions may benefit from

cleveland clinic’s lifestyle 180 program, which offers a

unique, user-friendly approach to wellness based on the

principle that lifestyle management can reverse disease.

This comprehensive program involves an initial six-

week “immersion phase” followed by subsequent

follow-up visits for one year. Groups of 10 to 16 people

engage in four-hour sessions twice a week that address

the three main components of a healthy lifestyle: nutri-

tion, exercise and stress management.

cleveland clinic medical wellness experts are on-hand

to personally guide participants through the program

and help them achieve their goals for overall health and


staff notes

new staff

christine lee, mddepartment of Gastroenterology and hepatology digestive disease institute

sPeciaLty interests:

general gastroenterology

dr. lee sees patients on main campus and at the willoughby hills family health center

Phone:

216.445.0715

emaiL:

[email protected]

Joseph scarcella, mdorthopaedic and Rheumatologic institute


arthroscopic joint procedures, minimally invasive joint replacement surgery, and surgery and fracture management

dr. scarcella sees patients at medina hospital, and the Brunswick and wooster family health centers

Phone:

330.225.8886

mehdi shishehbor, doTomsich family department of cardiovascular medicine sydell and arnold miller family heart & vascular institute

sPeciaLty interest(s):

peripheral vascular intervention, cerebrovascular intervention, interventional cardiology

dr. shishehbor sees patients at main campus

Phone:

216.636.6918

emaiL:

[email protected]

Robert Zahka, mdcleveland clinic children’s hospital pediatric cardiologist


children and adults with congenital heart disease, cardiac problems in athletes, clinical research in congenital heart disease, congestive heart failure, echocardiography, education, pediatric cardiology, pediatric heart transplanta-tion, syncope, wolff-parkinson-white syndrome, abdominal aortic aneurysm, abnormal heart rhythms, angina, aorta disease, aortic regurgitation, aortic stenosis

dr. Zahka sees patients at cleveland clinic westlake

Phone:

440.899.5555


january 2010

21 ASHReview

22-25 20106thAnnualOptimizingMinimally InvasiveGynecology

Ritz carlton, fort lauderdale, fl

23 ThyroidExpo2010:AMultidisciplinarySymposium onThyroidDiseasesandThyroidCancer

cleveland clinic lerner college of medicine – ne-508 auditorium

25-28 ArabHealth2010

dubai, Uae

february 2010

3 BestofSanAntonioBreastCancerSymposium

embassy suites hotel, independence, oh

3 AdvancesinB-CellScience:ClinicianUpdate

cleveland clinic lerner Building, amphitheater

10 EndorectalUltrasonographyCourse

david G. Jagelman md conference center, cleveland clinic florida, weston, fl

13 AdvancesinB-CellScience:ClinicianUpdate

fairmont scottsdale, scottsdale, aZ

14 TransanalEndoscopicMicrosurgery(TEM) hands-on workshop

harbor Beach mariott, fort lauderdale, fl

14 EndoscopicNaturalOrificeSurgeryWorkshop (NOTES)

Biltmore hotel, coral Gables, fl

coming events – www.clevelandclinicmeded.com

The cleveland clinic center for continuing education is responsible for one of the largest and most diverse cme programs anywhere in the United states. stay informed of all the available live and online cme opportunities by signing up to receive our monthly newsflash: www.clevelandclinicmeded.com/signmeup

NOTE:Allcoursesareatthespectacularstate-of-the-artInterContinentalHotel&ConferenceCenterontheClevelandCliniccampusinCleveland,OH,unlessotherwisenoted.

february 2010 continueD

15 SurgeryoftheForegutSymposium

Biltmore hotel, coral Gables, fl

24-27 DiastologyandNewEchoTechnologiesSummit

hyatt Regency Bonaventure conference center & spa, weston, fl

march 2010

4-6 5thAnnualPerioperativeMedicineSummit2010

eden Roc Resort, miami Beach, fl

6-10 12thAnnualPainManagementSymposium

loews coronado Bay Resort & spa, coronado Bay, ca

13 FrontierinNewAnti-AtheroscleroticTherapies

The Georgia world congress center, atlanta, Ga

15-20 ComprehensiveAnesthesiologyReview

19-21 InnovationsinPlasticSurgery

Ritz carlton, fort lauderdale, fl

aPriL 2010

9 6thAnnualContemporaryIssuesinPituitary Disease:Case-basedManagementUpdate

cleveland clinic lerner Research institute cleveland oh

10 UveitisUpdate

22-24 PediatricEthics2010: AdvancingtheInterestsofChildren

Renaissance cleveland hotel, cleveland oh

At Cleveland Clinic, a complimentary online program called

Drconnect bridges the communications gap. By provid-

ing real-time patient updates, the program makes referring

physicians a part of the care team and takes professional

collaboration to a whole new level.

“Drconnect is a godsend,” says Loretta Isada, MD, an Akron-

area cardiologist. “The information it provides is incredibly

helpful. I have operating notes, discharge summaries, medi-

cation lists, lab results and everything else I need at my

fingertips.”

Cleveland Clinic’s Drconnect program is utilized by thousands

of physicians in more than 30 countries around the world.

These professionals are linked to a sophisticated electronic

medical record (EMR) system that unifies the main campus

hospital complex and its many other facilities into what is

essentially a common practice environment.

Designed to meet the needs of busy medical practices,

Drconnect generates a single, daily email notification to

alert physicians each time something new is added to their

patient’s EMR. These emails contain no private patient

information, and only the physician or authorized personnel

can view them.

Healthcare institutions without an EMR system often depend

on patients to keep track of their own medical information.

The Cleveland Clinic Foundation 9500 Euclid Avenue / AC311 Cleveland, OH 44195

Drconnect: Making You Part of the Care Team

Online program empowers referring physicians

RoUnds | JanUaRy/feBRUaRy 2010 | The laTesT news foR pRimaRy caRe physicians fRom cleveland clinic

09-CCR-004

“People are sent home from those hospitals with stacks of

papers, including copies of lab reports and so forth, which

patients often misplace,” says Dr. Isada.

With the Drconnect program, there is no need to wade

through stacks of papers or place calls to hospitals to request

information. “The program offers instant communication and

continuous updates,” says Dr. Isada. “It’s easy and nicely

organized, and you can select information relevant to you.

Signing up is really simple. You just fill out a brief form and

make up a password. That’s basically it.”

The Drconnect site is secured using 128-bit encryption

between Cleveland Clinic and the user’s computer. All it takes

is access to the Internet for physicians who are not a direct

part of Cleveland Clinic to feel like active members of the

treatment team.

“My patients in Canton have the mindset that Cleveland Clinic

is far away,” says Loretta Isada, MD. “You’d think I was

sending them to Siberia. But for me, it’s only a click away –

a computer mouse click, that is.”

to register for Drconnect, please email us at drconnect@ccf.

org or call 877.224.736; or clevelandclinic.org/drconnect

for more information. n

rounds - cleveland clinic · 2013-12-20 · medical and surgical specialists and subspecialists...

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