| • | SRM Collaboration Enters Second Year |
| • | The Global Burden of Cardiovascular Disease |
| • | Physician Interview with James Thrall |
| • | Preimplantation Genetic Diagnosis |
| • | Partners in the News |
SRM Collaboration Enters Second Year
Building on its successful first phase, a multi-specialty collaboration between Partners HealthCare and the SRM University teaching hospital in Chennai, India is poised for expansion. During the collaboration’s first year, a team of emergency and trauma physicians from MGH and BWH visited Chennai to assess current SRM capabilities and make recommendations to establish a Level Three Trauma Center. Under the leadership of Tobias Barker, MD, and Alasdair Conn, MD, the Partners team sponsored a trauma symposium in Chennai to introduce SRM staff to the concept of medical simulation.
Four months later, two SRM trauma physicians and a nurse traveled to Boston as clinical observers to improve their understanding of how advanced trauma centers operate. These initial interactions proved fruitful and have resulted in a plan to expand the collaboration to include the establishment of a new simulation training center at SRM in 2008.
From the start, both SRM and Partners anticipated that additional medical specialties would be incorporated into the collaboration. SRM is recruiting a new Director of Health Science and Medicine who will have a primary role in charting the future direction of the collaboration, which may include cardiology, oncology or other medical areas.
Chennai, formerly Madras, is an ancient and venerable city
in southeastern India with a population of 7.5 million. Known as an intellectual
hub for many decades, Chennai is now at the forefront of the dynamic information
technology, communications and automobile industries. Economic development
is creating demand for better health services. As one of several new private
universities, SRM is helping to inject new energy into medical education.
Through this collaboration, Partners is bringing fresh ideas and world
class standards into SRM’s teaching environment and the patient
care setting.
The
Global Burden of Cardiovascular Disease
The global burden of cardiovascular disease
will increase dramatically within the next two decades, reflecting both
the current successes and the future opportunities in preventive care. Indeed,
this evolution may present the greatest worldwide challenge for the medical
profession in the 21st century, a challenge that Partners HealthCare is
actively addressing.
As a result of technological progress, public health initiatives, and advances in medical therapy, the United States and Western Europe can anticipate continued reduction in the morbidity and mortality of cardiovascular disease. Major advances in the technology to treat cardiovascular disease – including angioplasty, coronary stents, and surgical bypass operations – have definitely advantaged individual patients in the West. Simultaneously, population-based reductions in morbidity and mortality reflect both aggressive management of risk factors for patients with established disease as well as the success of intense societal efforts at risk factor modification, including cholesterol profiling, diabetes management, blood pressure control and smoking cessation. In fact, research has shown that these societal efforts have been more important than advancements in expensive care and technology.
Looking beyond theWestern Hemisphere, however, our future prospects for conquering cardiovascular disease are anything but optimistic. Some studies have suggested that by 2025, approximately 80% of all cardiovascular disease will occur in the developing countries of Southeast Asia, Africa and the Middle East. Adults in these regions who are free of HIV infection can be expected to live longer, infant mortality among these populations will continue to decline, and the impact of conventional infectious diseases on both adults and children will decrease.
By 2025, these HIV negative populations will live to an age when cardiovascular disease becomes manifest, yet they will not have benefited from all the resources of preventive medicine that have proven so successful in the West. Many of these future cardiovascular patients will be served by healthcare systems with limited resources and organizational capabilities. Furthermore, any preventive maneuvers that are implemented in their societies today will take decades to become fully operational.
Risk factors for cardiovascular disease are surprisingly similar across diverse populations. Therefore, best practices and lessons learned in the West – particularly those relating to efficiency and prevention infrastructure – are directly applicable elsewhere in the world. Partners HealthCare is committed to playing a key role in the worldwide struggle against cardiovascular disease. While providing complex tertiary care in Boston is central to our heritage, over the past decade we have embraced a new, global responsibility in cardiovascular health.
One of our signature efforts in this regard is the annual Partners International Cardiovascular Conference Series, which emphasizes state-of-the-art practices in the prevention and treatment of cardiovascular disease. Last year, nearly 600 physicians from 34 countries attended our conferences in Buenos Aires and Dubai. By sharing our clinical knowledge overseas and conducting cutting-edge research, Partners HealthCare is demonstrating our commitment to preventive health care initiatives that will have a profound impact on all future patient populations.
by Gilbert H. Mudge, Jr., MD
Senior Cardiologist, Brigham and Women’s Hospital
Associate Professor, Harvard Medical School
SeniorMedical Advisor, Partners International Medical Services
Q&A: Dr. James Thrall
Radiologist-In-Chief, Massachusetts General
Hospital
Interview by Chris Railey, Harvard Medical
International
| CR: | You are known as a futurist within
radiology circles. Where is the cutting edge of radiology today, and
what does the future hold? |
| JT: | The future is going
to take us to smaller dimensions. Just as scientists are very excited
about nanotechnology, radiologists are very excited by our ability
to image not just at the level of the whole organ, but at the level
of molecules and cells. In fact, there is a wonderful new term –
molecular imaging – that is used to describe this trend.
Recently we’ve also developed the capacity to
watch organs process signals from the outside world. This is particularly
important in the brain. By watching the changes in the energy metabolism
of the brain, and changes in the blood flow to different parts of
the brain, we are actually able to watch the brain think. If we
expose a subject to a visual stimulus, the parts of the brain that
process the signals in the eyes will light up on the scan. Or if
we play a musical note, a different part of the brain that’s
involved in auditory processing lights up. And if we ask you to
think of a word, then the part of the brain that processes words
lights up, and we can actually tell what you’re thinking. |
| CR: | How are advances in IT
impacting radiology? |
| JT: | Think about recent improvements in television.
First we gained the ability to record in high definition. And then
someone developed a picture tube that could display high definition.
And then the picture tube suddenly became a flat panel display. And
it suddenly became not just a cathode ray tube but an LCD panel or
a DLP panel or a plasma panel. The same thing is happening in imaging
- every component of everything we do is simply getting better, so
we can see finer detail, higher resolution. |
| CR: | You’re the Radiologist-in-Chief
at a top academic medical center. How would you describe the interplay
between MGH and industry when it comes to bringing IT advances into
practical application? |
| JT: | Typically industry does the engineering
and physics and comes to us and we do what’s called translational
research. So we have to take every new product and demonstrate its
usefulness clinically. In fact, the FDA of the US requires that
some level of clinical testing is done with all new products and
all new drugs. So there’s actually a partnership between industry
and the academic world because the only place you can do that kind
of clinical research is in a hospital. You cannot do that in a research
laboratory at a company. |
| CR: | PET/CT has become the gold standard
for oncology. How do you see its use expanding in the future? |
| JT: | It’s terrific, because the
combination of positronic tomography and computed tomography brings
metabolic information about what’s going on in a particular
tissue with high-resolution anatomic information. And before we could
put those two together, we couldn’t say with a high degree of
certainty that a particular metabolic abnormality was matched up with
a specific structure in the body. With PET/CT we can do that, and
it allows us to be more accurate in our diagnoses. |
| CR: | Will we soon see a PET/MRI modality? |
| JT: | We will. In fact, here at MGH we
are installing a PET/MRI device this month in one of our research
laboratories. |
| CR: | What’s the potential for that?
What will that allow us to do? |
| JT: | We’ll be able to meld the functional
imaging capacity of MRI with the metabolic information coming from
PET scanning. This has tremendous potential and tremendous implications,
mostly directed at continuing to understand how the brain functions.
I am less certain what the impact will be for day to day clinical
practice, but in terms of mapping the brain and determining how it’s
wired, and what causes it to behave one way or another, PET/MRI is
going to be unbelievable. |
| CR: | How has the move
from analog to digital image recording impacted radiology? |
| JT: | The switch from analog recording of images
to digital recording has been pivotal in the modern age of imaging.
When we recorded the image on a piece of X-ray film, we could not
process or manipulate that image after the fact. We could measure
a few things, but we could not re-project the tumor in three dimensions
to allow a surgeon to study it and understand how best to approach
it in the operating room. We could not do something called tissue
segmentation, which allows the separation of different kinds of tissue
using digital image processing. We could not use computer aided detection
algorithms. Human beings tire during the day; computers don’t.
And many of us believe that computer aided detection – where
there is a partnership between man and machine – is going to
be very effective. The ability to extract quantitative parameters
from the data, the ability to do 3-D representations of the data,
and the ability to do computer aided detection all are contingent
upon having the data in digital form. |
Irene Souter, MD
Director, Preimplantation Genetic Diagnosis Program,
Massachusetts General Hospital Fertility Center;
Clinical Instructor, Harvard Medical School
Colored light micrographs of an IVF human
embryo during
preimplantation genetic testing.
In 1980, a team of researchers performed the first preimplantation genetic diagnosis (PGD) to select a female embryo because a male would have had a 50% chance of inheriting a serious disease. In 1992, the first PGD baby screened for a single-gene mutation (cystic fibrosis), rather than for an X-linked disease, was born. Today, a single cell extracted from an embryo can be screened for any disorder for which a reliable genetic test is available.
The PGD process involves leaving embryos to divide for three
days, ideally resulting in an eight-cell embryo. At this point a hole
is created in the zona – the membrane that temporarily surrounds
an embryo in its early stages – and a single cell is extracted that
can
then be prepared for genetic testing or fixed for chromosomal analysis.
PGD for single-gene disorders
The patients who most obviously benefit from PGD testing are those who
are carriers for or affected by single-gene disorders such as cystic fibrosis,
Tay Sachs disease, muscular dystrophy, sickle cell anemia or Huntington’s
disease. However, PGD is not covered by most insurance companies, and
even when it is, the in vitro fertilization (IVF) cycle needed to obtain
the embryos is covered only if the couple is also being treated for infertility.
As a result, the cost of PGD and IVF presents a barrier for many couples.
Another consideration is that PGD for a single-gene mutation
can take several months, beginning with genetic counseling, identification
of parental mutation(s), seeking insurance coverage and finally the IVF-with-PGD
cycle. Faced with a daunting and expensive process, some couples prefer
to forgo PGD, and instead undergo prenatal diagnosis and consider terminating
the pregnancy if serious anomalies are detected.
Balanced translocation: another application
A second use of PGD with clear advantages is when either partner’s
balanced translocation is the cause of infertility, recurrent miscarriage
or a chromosomally abnormal pregnancy. A balanced translocation can cause
these problems when chromosomes break and become unbalanced during meiosis.
In this case, PGD can be used to screen embryos that have inherited the
resulting unbalanced translocation.
PGD for advanced maternal age
The use of PGD to test for aneuploidy in embryos from patients with advanced
maternal age (AMA) could apply to the greatest patient population; however,
this use is also the most debated application of the technology. Although
PGD for aneuploidy can substantially decrease the risk of trisomy 21 or
trisomies commonly seen in spontaneous abortuses, the patients who would
be candidates for this testing are undergoing IVF, most likely for infertility.
Therefore, the possible damage to embryos during PGD, and what effect
it might have on the chance of pregnancy, must be weighed against the
benefit of eliminating the relatively small risk of trisomy.
Another argument used in favor of routine PGD for aneuploidy is that some evidence suggests that screening embryos for chromosomal abnormalities will increase the chance of pregnancy, particularly among women who produce many eggs, referred to as high responders. However, this data is hotly debated in the scientific community, and often AMA patients who are undergoing IVF for infertility do not produce many eggs.
The PGD program at the Massachusetts General Hospital Fertility
Center was started in 2005. In this short time, the Fertility Center has
already faced many of the challenging scientific and ethical questions
posed by this new technology. There is little doubt, however, that PGD
will play an increasingly important role in patient care.
Bermuda Hospitals Board Visits Partners
Hospitals
Executives from the Bermuda Hospitals Board visited Boston on October 30-31 to explore future opportunities for a new collaboration between Bermuda and Partners HealthCare.
Partners International Cardiovascular Conference
Buenos Aires – May 16-17, 2008
The next Partners International Cardiovascular Conference, which will
take place in Buenos Aires, will emphasize state-of-the-art practices
in the prevention and treatment of cardiovascular disease. In addition
to formal presentations, the conference will include interactive panel
discussions and informal “meet the professor” sessions. Certificates
of attendance will be awarded by Harvard Medical International. The Partners
International Cardiovascular Conference Series is supported by an educational
grant from Pfizer. Attendance is by invitation only.
From
left to right: David Jones, Partners International; Don Vincenzo D'Arenzo, Casa Sollievo; Fr. Marciano Morra, Casa Sollievo; Dr. Massimo Ferrigno, BWH |
Casa Sollievo and Partners International Announce Oncology Collaboration
Partners
International and Casa Sollievo della Sofferenza, a large Vatican-owned
hospital, have signed an agreement outlining plans to accelerate the development
of three clinical programs – a pre-operative testing center and
tertiary services for breast and thoracic cancer – at Casa Sollievo’s
facility in southern Italy. Under the terms of the one-year agreement,
Partners physicians will provide consulting services on-site at Casa Sollievo,
and the Partners hospitals will also host several Casa Sollievo clinicians
for short-term observerships in Boston.
The Global Clinic 2008:
Healthcare Management for Physician Executives
Boston – June 26-28, 2008
Leaders from industry, government and academia will gather in Boston next
June to discuss best practices in international corporate medical and
occupational health programs at Partners International’s 2008 Global
Clinic Conference. Led by faculty from Harvard Medical School, the conference
will address strategies to improve workforce health and promote productivity
while meeting new business challenges brought on by globalization. Online
registration is now available on Harvard Medical School's CME website.
Executive
Director |
Medical
Editors Timothy Guiney, MD Gilbert H. Mudge, MD |
Executive
Editor Elizabeth A. Nolan |
| Corporate
Manager of International Business Development Edwin J. McCarthy |
Design Jackrabbit Design |
The Global Health Update is published twice per year by Partners International Medical Services, a division of Partners HealthCare System, Inc. Partners International develops opportunities for Partners staff to contribute to the improvement of health care around the world.
This publication provides medical news. It is not intended to provide
medical advice, which should always be obtained directly from a physician.
To subscribe, request additional copies or make comments, please contact
us via email at partersinternational@partners.org
or by phone at +1 (617) 724-6420.
©2007. Partners HealthCare System, Inc.