Partners Collaborates with Russians
to Reduce Bioterrorism Threat

Through an agreement brokered by the U.S. Department of State, this fall Partners physicians began collaborating with the International Science and Technology Center (ISTC) in Moscow to counter the threat of bioterrorism. Managed under the auspices of the Center for the Integration of Medicine and Innovative Technology (CIMIT), the project's goal is to transform former Soviet biological weapons research and production capacities by creating U.S.-Russian research partnerships.

Working together, CIMIT and ISTC will link Russian scientists, physicians and engineers with U.S. academic institutions and industry to identify innovative health care technologies and commercialization opportunities. To date, the group has already begun collaborating on innovative cancer therapies and an experimental, early phase HIV vaccine.

Commenting on the new Russian initiative, Dr. Jeffrey A. Gelfand, Director of CIMIT International, remarked, "This is an exciting opportunity to turn swords not into plough shares but shields. We will be working with the brilliance and talent of scientists, who, having once made weapons for the military, are now turning those weapons into agents for fighting diseases of mankind. Together, we will be combating HIV, tuberculosis, emerging infectious diseases and cancer."

Founded by Partners HealthCare System in 1994, CIMIT integrates the medical expertise of the Harvard Medical School teaching hospitals with the technological capabilities of Massachusetts Institute of Technology, the Charles Stark Draper Laboratory, and other scientific institutes. Together these groups are facilitating innovation with an emphasis on minimally invasive diagnosis and therapy, as well as new medical devices. The CIMIT consortium includes 15 institutes, 350 investigators and 45 industry partners. For more information, please visit www.CIMIT.org.

Letter from the Executive Director

Welcome to Global Health Update! In this and future issues, we plan to showcase the global health activities of Partners clinicians and hospitals and to provide information on recent advances in patient care, research and education. Our intended audience includes alumni of our training programs, other interested international health professionals, and leaders of public and private organizations involved in global medicine. Ultimately, our purpose is to make common cause in improving health for patients whoever they are and wherever they live.

Collaboration is the hallmark of great medicine and the founding principle behind the formation of Partners. Nowhere is collaboration more essential than in the area of global medicine, which the U.S. Institute of Medicine defines as "health problems, issues, and concerns that transcend national boundaries, may be influenced by circumstances or experiences in other countries, and are best addressed by cooperative actions and solutions." Given the convergence of health problems worldwide, this definition is quickly approaching redundancy.

With a broad international patient base, staff and trainees from every part of the world, the largest hospital-based research program in the U.S., the first and one of the most advanced telemedicine programs, and an unparalleled network of alumni in every corner of the globe, Partners is committed to participating actively in global medicine. While enlightened self-interest compels us to do so, in the final analysis it is a question of values. In the words of two of our physicians, Dr. Dennis Ausiello and David Shaywitz, "The quest to improve global health represents a challenge of monumental proportions: the problems seem so enormous, the obstacles so great, and success so elusive. On the other hand, it is difficult to imagine a pursuit more closely aligned with the professional values and visceral instincts of most physicians."

To paraphrase the familiar line, this publication is intended solely for the public use of our audience. Feel free to share it with others. We welcome your ideas and suggestions.

Physician Profile: Annekatheryn Goodman

For gynecologic oncologist and surgeon Annekatheryn Goodman, a typical day begins shortly before dawn, as she performs surgery to excise malignancies of the ovaries, uterus, cervix and vulva. Such a day often ends late in the evening, after she has sat with her patients, comforting them in ways that are beyond the reach of medical science.

"Part of our mission is to change what we can, but when we can't change it, we do what we can to alleviate suffering," she explains.

Dr. Goodman's sensitivity and devotion became immediately obvious to colleagues 15 years ago when she trained as a clinical fellow at the Massachusetts General Hospital. She has a passion for teaching young doctors and educates by example. Today she directs the Gynecologic Oncology Fellowship Program and serves as Associate Director of her department.

Dr. Goodman is also a former director of the MGH Colposcopy Clinic, which evaluates and treats low income women who have had abnormal Pap smears. Her fierce commitment to this work and to these women stems from her knowledge that cervical cancer can be prevented with early detection. Most of the women she treats haven't had a Pap smear in more than five years.

In her quest to do as much as she can to fight gynecologic cancers among underserved women, Dr. Goodman's work has taken her to Europe, China and the United Arab Emirates.

The Latest in Minimally Invasive
Cardiac Valve Surgery

by Lawrence H. Cohn, MD, Chief, Division of Cardiac Surgery, Brigham and Women’s Hospital and Virginia and James Hubbard Professor of Cardiac Surgery, Harvard Medical School

In the last thirty years, minimally invasive techniques have become important components of vascular, orthopedic, GI, and many other types of surgical practice. Heart surgery has been the last frontier of minimally invasive techniques, perhaps because the margin between life and death is more palpable here. However, patients who require cardiac valve repair and replacement may be candidates for a minimally invasive procedure which offers all the benefits of a conventional open procedure along with all the virtues of a more limited approach - less surgical trauma, a better cosmetic result, and a faster recovery.

A number of factors led to the development and acceptance of minimally invasive techniques for cardiac surgery. First was a philosophically different way of looking at cardiac surgery. Instead of exposing the whole heart, the surgeon only needs to look at the area where he or she will be working, making much smaller incisions feasible.

Second was miniaturization of the cardiopulmonary bypass set-up. Using smaller tubes and assisted venous suction, and gaining access percutaneously through the femoral vein, we can achieve the same flow and drainage characteristics we could with the conventional set-up, with a much smaller incision.

Finally, the emergence of transesophageal echocardiographic (TEE) technology and three-dimensional reconstruction has been essential to minimally invasive cardiac surgery. TEE allows the surgeon to visualize tube placement, to monitor removal of air from the heart, and to assess intraoperatively the adequacy of valve repair. This is a critically important piece, and in my opinion, it is not possible to do minimally invasive valve surgery without it.

My BWH colleagues and I have performed approximately 1,000 minimally invasive cardiac valve surgeries since 1996, and in 1999, we reported on a series of 300 patients undergoing minimally invasive aortic or mitral valve surgery at the Brigham between 1996 and 1998. We found that these patients experienced low operative mortality and postoperative morbidity, less use of pain medication and blood transfusions, and reduced length of stay, as compared with patients undergoing conventional valve repair or replacement. Most importantly, these patients recovered and returned to their normal activities faster. A surgical team experienced in valve repair can offer the patient results equal to those obtained in open surgery, except that instead of a 23-centimeter scar, the patient has a 6-centimeter scar, less pain, and a more rapid recovery. In our center, we perform about 80% of isolated valve repair or replacement surgeries using minimally invasive approaches, and only rarely have we needed to convert to an open procedure.

Of course, not every patient is a good candidate for minimally invasive valve repair surgery. We do not currently offer this approach for patients who also require coronary artery bypass, but any patient with isolated valve disease may be referred for minimally invasive valve surgery.

An exciting addition to our minimally invasive armamentarium is the
da Vinci Robotic Surgical System, which debuted at the Brigham in 2001. I first used the system in 1997 while it was in development, and I was convinced that da Vinci had the potential to revolutionize minimally invasive cardiac surgery.

The surgeon operating with robotic assistance sits at a console across the room from the patient and works through an eyepiece optical field that provides 3-D reconstruction. The image on the monitor expands the field of vision and actually provides a better view of the operative field than does the unassisted eye. From the console, the surgeon operates two levers attached to arms which enter small ports in the patient's chest and are equipped with a variety of surgical tools. Another mechanical arm is equipped with optical equipment, lights and a video camera.

Computer software interprets the movements of the surgeon's hands and translates them so that the mechanical hands mimic the actual ones, only better. Robotic assistance eliminates tremor, and the robotic wrists have more degrees of freedom than human wrists, allowing the surgeon to perform maneuvers that would not otherwise be possible.

In the future, I anticipate that robotic assistance will be invaluable in coronary artery bypass.

Working as part of an FDA protocol, BWH surgeons have used robotic tools to dissect the left mammary artery from the chest wall. Under a new protocol, we expect soon to be allowed to perform a complete single vessel bypass using minimally invasive techniques and robotic assistance. Then, we will be able to offer patients with left anterior descending coronary artery disease the gold standard therapy in terms of duration of graft patency along with the benefits of a minimally invasive approach.

Another advance that will aid immeasurably in minimally invasive cardiac surgery is the development of sutureless techniques featuring surgical sealants, clips, or magnets. Suturing is perhaps the most laborious and time-consuming aspect of any surgery. There are already a number of devices available, and when these are fully developed and clinically available, they will cut surgery times significantly.

Minimally invasive surgery is here to stay, and robotic technology will play a significant role in selected patients in the future. We are poised to add further to this evolving field given our considerable expertise and access to emerging technologies.

Partners in the News

Dr. Nawal Nour, founder of BWH's African Women's Health Center, and Dr. Jim Yong Kim, co-chief and co-founder of BWH's Division of Social Medicine, were recently awarded prestigious "genius grants" by the MacArthur Foundation. Dr. Nour was named a MacArthur Fellow for creating the only medical center in the U.S. that focuses on the physical and emotional needs of women who have experienced female circumcision. A native of Sudan, Dr. Nour established the clinic in 1999. Dr. Kim, who is currently serving as a senior advisor to the director general of the World Health Organization, was chosen as a Fellow for his work treating and containing major diseases in the world's most underprivileged countries. Dr. Kim is one of the world's leading experts on drug-resistant tuberculosis and continues to work to eradicate this fatal disease.

Dr. Paul Farmer, division chief and co-founder of the Division of Social Medicine and Inequalities at BWH, is the subject of a new book entitled Mountains Beyond Mountains. Written by Pulitzer Prize winning author Tracy Kidder, Mountains Beyond Mountains chronicles Dr. Farmer's life, from his initial pursuit of medicine to his altruistic mission of treating AIDS, tuberculosis and malaria among the world's most impoverished populations. In addition to bringing essential medical care to countries such as Haiti, Peru, Mexico and Guatemala, Dr. Farmer has worked tirelessly to fund continued research and to train local health workers across the globe. According to a recent book review in The New York Times, "If any one person can be given credit for transforming the medical establishment's thinking about health care for the destitute, it is Paul Farmer."

The Global Health Update is published three times per year by the International Program of Partners HealthCare System, Inc. The International Program 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 01 (617) 724-6420.

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