strategic priorities Archives

Brigham Team Recognized for Role in Disaster Response

When a major flood caused by a burst pipe forced the closure of the labor and delivery and neonatal intensive care units at Boston Medical Center (BMC) temporarily last year, the Brigham and several other hospitals stepped up to ensure patient care remained the priority.

During a Quality Rounds presentation in Bornstein Amphitheater last month, BMC clinicians spoke about the flood and reflected on the disaster response and lessons learned.

A critical piece to the emergency plan for BMC was the safe and timely transfer of patients out of the affected units to area hospitals, including the Brigham, for care. At the end of Quality Rounds, the Brigham was presented with an award from BMC in recognition of the assistance staff provided during the flood incident.

Karen Fiumara, PharmD, BCPS, executive director of Patient Safety at Brigham Health, said the Brigham teams that responded to this challenging situation were “nothing short of remarkable.”

“While continuing to safely care for their existing patients, they welcomed this group of BMC patients and their loved ones to the Brigham with open arms and provided them with exceptional care,” Fiumara said. “This was one of those amazing stories that makes you proud to be part of the Brigham community.”

Katherine Gregory, PhD, RN, associate chief nursing officer for the Mary Horrigan Connors Center for Women and Newborns, echoed Fiumara’s thoughts.

“The Brigham comes together in a crisis like no other, and we care—not only about our patients but also those across the city and region,” she said. “It was our privilege to care for the women and newborns who were affected by the BMC flood last year, and we stand ready to serve if called upon by our obstetric and newborn colleagues again in the future.”

Mummies Scanned at the Brigham Reveal Clues About Heart Disease

What secrets lie in the hearts of our ancestors? Signs of cardiovascular disease, for one, as a Brigham team of cardiovascular imaging experts recently helped discover.

Through a collaboration with an international team of researchers and anthropologists, Brigham faculty and staff performed CT scans on five mummies from 16th-century Greenland in the Shapiro Cardiovascular Center early last year. The team was looking for evidence of plaque in the arteries—also known as atherosclerosis—to see if the leading cause of death in the U.S. today was also prevalent centuries ago.

Sure enough, high-resolution scans of the mummified remains—belonging to four young adults and one child from an Inuit community—revealed telltale signs of the disease: hardened calcium deposits in various blood vessels in the chest.

“It’s always fascinating to look at humans who lived hundreds of years ago and see if learning about the past could teach us more about the present and future,” said Ron Blankstein, MD, associate director of the Brigham’s Cardiovascular Imaging Program, director of Cardiac Computed Tomography and a preventive cardiology specialist.

Blankstein was among the experts who scanned the mummies and interpreted the images last January, an event featured on National Geographic’s “Explorer” series this month. Other faculty and staff who helped conduct the scans included Kristen Burke, CT technologist; Marcelo Di Carli, MD, director of the Cardiovascular Imaging Program and chief of the Division of Nuclear Medicine; Abe Haboub, RT(R)(CT), cardiac CT manager; and Michael Steigner, MD, director of Vascular Imaging.

The effort was part of a broader project, led by a group of external researchers, to scan mummies from hunter-gatherer and preindustrial civilizations worldwide to search for signs of heart disease. The Brigham is one of several institutions to have participated and was approached based on the prestige of its cardiovascular imaging program, Blankstein said.

Searching the Past

From Egypt to Mongolia and now Greenland, mummies throughout the ages have shown evidence of atherosclerosis. The Greenland mummies were particularly of interest due to their diet, which would have primarily consisted of fish and sea mammals.

While increased fish consumption is commonly touted as a heart-healthy diet—which may make the findings of atherosclerosis seem surprising—Blankstein emphasized that scientists still have much to learn about its exact relationship to cardiovascular health. For example, although it is known that consuming fish rich in omega-3 fats has benefits, some types of fish can also be high in cholesterol and, in the current era, contain toxins such as mercury or polycholrinated biphenyls (PCBs) that may pose some risk, he said.

There could also have been lifestyle factors, such as exposure to cooking smoke in their dwellings, that contributed to the mummified individuals developing cardiovascular disease during their lifetimes, Blankstein explained.

With all that in mind—and the small sample sizes of these mummy scans—he noted that the team’s findings shouldn’t be taken too much to heart, so to speak.

“The question of whether fish is good or bad for you is still open-ended, and it would be unrealistic to think that we could provide a definitive answer by scanning a small number of mummies for plaque,” Blankstein said. “Our team found it fascinating that there was evidence of atherosclerosis despite the mummies’ estimated young ages, but this also doesn’t mean cardiovascular disease is inevitable. In fact, the majority of cardiovascular disease events that we see in patients is preventable with appropriate diet, weight control and lifestyle changes, such as regular exercise; at times, medication can also be used to treat various risk factors.”

A Different Kind of Patient

Although the mummies needed to travel only a few miles from a museum in Cambridge to Longwood, bringing them to the Brigham was no small feat logistically. Working closely with the hospital’s Police and Security team, Brigham faculty and staff members spent countless hours coordinating with museum officials and the researchers on how to safely transport these extraordinarily rare, delicate remains.

Once inside Shapiro, scanning the mummies wasn’t too different from work the cardiovascular imaging team normally does. In fact, they were a little easier to scan than a living patient; normally, the CT scanner must account for the movement of a beating heart.

Interpreting the images required a different perspective, however, Blankstein explained.

“This is not the same as scanning a [living] human. All of the organs are decomposed—in fact, you don’t see much of the heart at all,” he said. “The major plaque we saw was not necessarily in the arteries of the heart but in some other blood vessels in the chest, such as the aorta or some arteries of the neck.”

In addition to satisfying the team’s intellectual curiosity, Blankstein hopes their findings will inspire people to learn more about atherosclerosis and how to reduce their risk.

“It was certainly an exciting and interesting experience, and I hope we can use it to promote awareness of this mostly preventable disease,” he said.

Standing Room Only: Nursing Dreams Becoming a Reality

Many of you have already heard about the four amazing Brigham patient care assistants (PCAs) who received the inaugural Neskey Educational Opportunity Fund Scholarships, which provide full-tuition support to University of Massachusetts (UMass) Boston for PCAs who aspire to have a career in nursing. David and Sharon Neskey established the fund to honor the extraordinary care they received from a PCA here. As it turns out, the day we announced those four recipients was just one piece of what would become my One Shining Moment this year.

Weeks earlier, I had the pleasure of attending an information session about the scholarship. Considering that this was a new program, I set my expectations accordingly, thinking six to eight attendees would have been a good showing for our first year. Little did I know how incredible the response would really be. About 40 PCAs came to the session, brimming with enthusiasm about the next potential step in their careers. I was also amazed that attendees were at all stages of thinking about their future as nurses—some had completed all the academic prerequisites and were ready to start at UMass, while others who had never taken any formal steps for continued education viewed this potential scholarship as the push they needed.

Linda S. Thompson, DrPH, MPH, RN, FAAN, dean of UMass Boston’s College of Nursing and Health Sciences, was so inspired by the program that she attended the information session and spoke of how her own professional beginnings looked very similar to those in the room. The most moving part of the event, though, was that when I looked at that group of PCAs, I saw the future nurses of the Brigham, who will one day inspire the next generation that follows them. I can’t wait to see the amazing things they will do in the years to come.

Ron M. Walls, MD
Executive Vice President and Chief Operating Officer, Brigham Health

The Power of Hand Hygiene

From left: Nina Jordan, La’Lena Etheart, Michelle Lafferty and Reba Dookie

I recently went back to school for my master’s degree in Nursing Administration. I had to design a brochure as part of an assignment, and I decided to make a brochure about hand hygiene and preventing the spread of infection. I thought of the idea to have real nursing staff in my visuals, and my amazing coworkers on Shapiro 9/10 were more than willing to help! This picture is the cover photo of my brochure, which was titled “The Power Is in YOUR Hands!”

La’Lena Etheart BSN, RN, PCCN
Nurse in Charge, Shapiro Cardiovascular Center 9/10

A Shared Commitment to Improving Diabetes Care

From left: Lauren Godsoe, Margo Hudson and Maricruz Merino

I have been going annually to New Mexico with the Outreach Program with Indian Health Service since 2009, and each year gets better. I have primarily been involved with the diabetes program at Gallup Indian Medical Center in Gallup, N.M.

A former Brigham internal medicine resident, Maricruz Merino, MD, is now their chief of Medicine, and we have been working together closely over the years developing inpatient and outpatient glucose-management protocols. We are both close friends as well as colleagues, and we have shared the joys of the birth of children and grandchildren with each other in addition to seeing the growth of the diabetes program.

This past March, I had the pleasure of traveling with Brigham Health nurse practitioner Laura Godsoe, NP, for a week of lecturing and consulting on patients. I am so proud of the work we have done and thankful to Outreach Program for continuing to support this opportunity.

Margo Hudson, MD
Division of Endocrinology, Diabetes and Hypertension

The ‘Antidote to Burnout’: Helping Underserved Communities

From left: Zachary Holcomb, John Mohs, Jason Frangos, Margaret Cavanaugh-Hussey, Toby Crooks and Diana Woody

I made my second trip to Shiprock, N.M., in November 2018 as part of the Brigham and Women’s Outreach Program. Working alongside the dedicated doctors and staff at the Indian Health Service hospital in Shiprock has truly inspired and motivated me in my life and work. Contributing much-needed clinical care to the Navajo community has re-energized me with a sense of meaning and purpose as a physician. Volunteering at Shiprock has been my antidote to burnout and has revitalized my spirit.

Jason Frangos, MD
Director, Program for Infectious Diseases of the Skin
Department of Dermatology

The Heart of the Matter: Brigham Team Delivers Precious Outcome

Jasmine Taylor with her son, Jaydan

When doctors told Jasmine Taylor, 30, five years ago that pregnancy would be a life-threatening condition due to her poor health, including a complex heart defect she’s had since birth, it didn’t come as a surprise to her. It was something Taylor had heard from her care providers since adolescence. Still, as she and her husband, Damon, dreamed of starting a family, that didn’t make the news any less heart-wrenching.

Today, however, her heart overflows with love. Seemingly against all odds—and thanks to the support of Taylor’s passionate and collaborative multidisciplinary care team at the Brigham and Boston Children’s Hospital (BCH)—the Stoughton couple welcomed their son, Jaydan, to the world in July.

“When I heard him cry for the first time in the delivery room, I thought, ‘I want to protect and love him forever,’” Taylor said.

Getting to that point was a long and difficult road, one that Taylor said she doesn’t take for granted. She was born with a severe form of tetralogy of Fallot, a cardiovascular disorder that restricts the passage of blood to the lungs. By the time she was a teenager, Taylor had undergone three open-heart surgeries—the first one performed when she was just eight months old.

Upon reaching her 20s, her health continued to decline. She became overweight, diabetic and struggled with high cholesterol. On top of that, she wasn’t keeping up with the long list of medications she had been prescribed to treat these issues; at 23, she had a stroke. The frightening event was a wakeup call, Taylor said.

She began taking her medications dutifully. She adopted a healthier diet and intensive exercise regimen, leading her to drop 100 pounds in one year and safely come off most of her medications. Taylor said she did it all with one aspiration in mind: getting healthy enough to become a mother.

“There was a chance—a hope—that I could become a parent, so I was very determined to make it happen,” Taylor said.

‘We’re Going to Do This’

Even with the dramatic improvements to her health, Taylor’s weak heart would make pregnancy challenging. Among the many changes women undergo while pregnant is a significant increase in blood volume—sometimes almost doubling to nourish a fetus—which puts more stress on the heart to pump blood through the body.

“I told Jasmine, ‘It’s going to be hard work,’” recalled obstetrician Katherine Economy, MD, co-director of the Brigham’s Pregnancy and Cardiovascular Disease Program. “She just looked and me and said confidently, ‘None of this is a problem for me. My goal is to have a baby,’ and I said, ‘That is my goal now for you, too. We’re going to do this.’”

Economy is just one member of the large interdisciplinary care team that worked together over the past two years to achieve a safe pregnancy and childbirth for Taylor and baby Jaydan. But just as important as the advanced, comprehensive care they delivered was Taylor’s fierce commitment to staying healthy and starting a family, her providers emphasized.

“It takes more than a village of expert care, compulsiveness, outreach, detail, innovation, coordination and attention to quality outcomes at every step,” said cardiologist Michael Landzberg, MD, senior staff member, founder and immediate-past director of the Boston Adult Congenital Heart and Pulmonary (BACH) Program, a joint effort of the Brigham and BCH that cares for adults born with heart conditions. “That said, without identifying and utilizing her unique strengths, Jasmine could never have accomplished what she has near-miraculously done. She remains a hero to each and every one of us.”

Close Collaboration

After facing fertility challenges unrelated to her heart condition, Taylor was referred to the Brigham’s Center for Infertility and Reproductive Surgery, where she underwent two rounds of in-vitro fertilization (IVF) at the center’s Weymouth clinic. Even at this stage, her complex health needs influenced how her fertility care was planned, said reproductive endocrinologist Janis Fox, MD.

“There were definitely unique considerations in performing IVF on someone with her history,” Fox said. “I very much wanted to avoid rare but known complications such as ovarian hyperstimulation, and I absolutely wanted to avoid a multiple pregnancy, as we all felt that would be an unnecessary challenge for her heart.”

Throughout her pregnancy, Taylor’s providers were in near-constant communication and, via the Pregnancy and Cardiovascular Disease Program, met monthly to discuss her progress and anticipate possible complications. The team also involves experts from other disciplines—including anesthesiology, cardiac surgery, neonatology and nursing—to ensure they are fully prepared, said cardiologist Anne Marie Valente, MD, co-director of the program.

“We coordinated and developed a written care plan so that at any point, no matter who was on call, each of us would know exactly the potentials and treatment plan,” Valente said.

As a patient, Taylor said her providers’ extraordinary commitment, support and compassion have been remarkable: “These are priceless people in my life. They are like my extended family.”

Brigham Health’s Strategy in Action: Advanced, Expert Care
Learn more about our strategic priorities at BWHPikeNotes.org.

Nature Themes and Seating Areas Come to the Pike

An artist’s rendering illustrates the Pike’s upcoming coastal-themed area, which will be located near Bornstein Amphitheater.

You may have noticed a few changes along the Pike recently, including the addition of seating alcoves and nature-themed designs. Kicked off two years ago by the Brigham’s Planning and Construction team, the project is part of a larger effort to make it easier for patients, visitors and staff to navigate the hospital and to create a more welcoming and soothing environment.

As part of the new design, six areas are designed to correspond to a scene in nature, such as a forest, pond or wheat field. Seating alcoves within these areas will provide places for patients and families to relax in a peaceful setting as they traverse the Pike.

“We wanted to brighten up the Pike by bringing a sense of nature into the building,” said Bea Gomez, senior project manager of Real Estate. “Giving patients, families and staff a connection to the outdoors while inside was extremely important to us, as research suggests that immersion in nature makes people feel more at ease.”

The improvements are not only exciting to the team executing the work, but also to Brigham patients, families and staff.

“We’ve received feedback from people that the Pike feels more welcoming and accommodating now,” said Steve Dempsey, executive director of Planning and Construction. “We’re excited to continue to look for new opportunities to incorporate nature themes throughout the hospital.”

The team has previously worked on improving design throughout the Brigham with the addition of area platforms overlooking gardens at the Garden Café, as well as the installation of a bright green roof below the windows of the Neonatal Intensive Care Unit (NICU).

Dempsey credits Brigham Health President Betsy Nabel, MD, with supporting the team’s work to spruce up areas across the main campus. Nabel challenged the group to combine both navigational and welcoming elements in their renovations, a task that Dempsey was eager to take on.
“We’ve been able to successfully put the two concepts together,” said Dempsey. “We’re excited to make it easier for patients to find their way around the Brigham in a more comfortable and peaceful environment.”

The project is scheduled to be completed in February 2019.

Brigham Health’s Strategy in Action: Exceptional Experience
Learn more about our strategic priorities at BWHPikeNotes.org.

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Unraveling the Mysteries of Sex Differences and the Brain

Participants speak at the Interdisciplinary Neuroscience Inaugural Symposium: Sex Differences and the Brain - Implications for Research, Health and Disease.

From left: Ursula Kaiser listens as Cynthia Lemere asks a question during the first annual Women’s Brain Initiative Symposium.

In human disease biology, sex differences are as perplexing as they are pervasive. One crucial place where these differences manifest themselves is in the brain and in conditions affecting or affected by this critical organ.

There are more women than men with Alzheimer’s disease, multiple sclerosis, obesity, eating disorders, anxiety and depression, for example, while men have higher rates of Parkinson’s disease and schizophrenia. Yet the reasons for these differences remain understudied and unknown.

“Women’s health is often understood to mean reproductive health, but that’s a narrow definition for the health of half the human race,” said Charles Jennings, PhD, executive director of the Brigham’s Program for Interdisciplinary Neuroscience and Ann Romney Center for Neurologic Diseases. “We’re increasingly recognizing that many and perhaps most diseases show differences between men and women. In many cases, the effects are quite large, and if we want to understand the cause and eventual treatment of these diseases, we can’t ignore the sex differences.”

With the help of a generous philanthropic gift from Rick and Nancy Moskovitz, the Brigham-wide Women’s Brain Initiative (WBI) launched in 2017 to support research over four years into women’s brain health and the science of sex differences.

WBI-funded projects may span a range of questions from basic biology—how male and female brains became wired differently—to practical clinical questions about sex differences in disease risk and treatment responses, as well as how conditions specific to women (such as pregnancy and menopause) influence brain health. The WBI also supports community-building through an annual symposium and an ongoing Seminar Series starting Dec. 18.

“Surprisingly, there is nothing like the WBI anywhere else,” said Patti Stoll, MBA, director of the Women’s Brain Initiative. “Our goal is to attract not only investigators who are currently interested in the subject but also those who might not yet appreciate how this area could be important for their research.”

A Catalyst for Curiosity

Rosalind Lai, MD, WBI research fellow in the Department of Neurosurgery, is examining how hormones affect subarachnoid hemorrhages—which result from the rupture of an intracranial aneurysm, an abnormal dilation in a blood vessel of the brain—and why these events occur more often in women than men.

“We know that hormonal levels are altered after a head bleed, but we want to know if estrogen is a contributing factor to the rupture of an aneurysm,” said Lai. “Being a part of the WBI means being a part of a supportive community that fosters interest and curiosity about sex differences and the brain.”

Lai attended the inaugural WBI Symposium on Sept. 26 and enjoyed talks by visiting researchers. One lecture that stood out to her was given by Arthur Arnold, PhD, from the Brain Research Institute at the University of California, Los Angeles, who spoke about how chromosomal differences could affect disease risks that have previously been attributed to hormones.

“His talk made me think more about the different factors that may affect sex differences,” said Lai.

Meeting of the Minds

Another goal of the WBI is to connect researchers and clinicians at the Brigham and encourage these experts in different disease areas to think about the effects of sex differences.

Ursula Kaiser, MD, WBI-funded researcher and chief of the Division of Endocrinology, Diabetes and Hypertension, studies the effects of endocrine-disrupting chemicals, which can act similarly to estrogens, on increased risk of premature puberty in girls.

Needing guidance about how to examine the role of estrogen in Parkinson’s disease, Silke Nuber, PhD, WBI-funded researcher in the Ann Romney Center, came to Kaiser for her expertise. Kaiser invited Nuber to her lab to learn some of the techniques for examining the effects of ovarian function and estrogen levels in preclinical models.

“I think one of the wonderful things about WBI is that it brings so many multidisciplinary groups together who perhaps haven’t interacted as much in the past,” said Kaiser. “It makes all of us more aware of other research being conducted at the Brigham.”

Building on a Brigham Legacy

The WBI does not exist in isolation—it builds on and unites entities and areas of focus with a long legacy at the Brigham. One of those collaborating entities is the Mary Horrigan Connors Center for Women’s Health and Gender Biology.

Hadine Joffe, MD, MSc, executive director of the Connors Center and vice chair for psychiatry research, has encouraged researchers to join the WBI to increase funding opportunities and further advances pertaining to sex differences and the brain. One of those investigators is Katherine Burdick, PhD, of Psychiatry, whose research on predictors of cognitive impairment in postmenopausal women with major depressive disorder (MDD) has become part of the WBI’s portfolio.

“I became aware of the opportunity to apply for funding via the WBI thanks to Hadine Joffe, with whom I worked to develop the protocol for the funded study,” said Burdick. “With support from the WBI, we are trying to identify clinical and biological explanations for why some postmenopausal women with MDD develop cognitive and functional disability while others do not. This information will hopefully lead to a more personalized-medicine approach in the future.”

Brigham Health’s Strategy in Action: Discovery and Innovation
Learn more about our strategic priorities at BWHPikeNotes.org.

Investigators Present Cardiovascular Discoveries at AHA Scientific Sessions

On Nov. 10, the American Heart Association (AHA) held its annual Scientific Sessions meeting in Chicago, featuring the latest advances from major cardiovascular trials with the potential to transform clinical practice. Investigators from the Brigham led some of the most highly anticipated trials and presented their results at the conference.

Insights into Omega-3s, Vitamin D

The benefits of omega-3 fatty acids – a “good” fat largely found in fish, nuts, flax seeds and leafy greens – have been touted in recent years. But just how protective are they in cardiovascular health?

JoAnn Manson shares findings from the VITAL study.

Deepak L. Bhatt, MD, MPH, executive director of Interventional Cardiovascular Programs in the Division of Cardiovascular Medicine, presented results and insights from the clinical trial REDUCE-IT, which tested whether icosapent ethyl (a medication derived from an omega-3 fatty acid found in fish oil) could reduce the risk of cardiovascular events in at-risk patients. Participants were defined as “at risk” if they fell into one of two categories. Either they had atherosclerosis – a disease in which plaque builds up in the arteries – or they had diabetes plus at least one other cardiovascular risk factor along with elevated triglyceride levels, despite taking statins.

Participants who took the medication saw a 25 percent risk reduction in cardiovascular events and a 20 percent reduction in death due to cardiovascular causes, a result Bhatt described as “remarkable.”

“This may be the biggest development in cardiovascular prevention since statins,” he said. “The REDUCE-IT trial sets a new standard of care for these patients.”

In another presentation, JoAnn Manson, MD, DrPH, chief of the Division of Preventive Medicine, unpacked results from the VITamin D and OmegA-3 TriaL (VITAL). VITAL also examined whether omega-3 fatty acids affected a person’s risk of experiencing cardiovascular events, but Manson and colleagues studied them among a general, racially diverse population and used a lower-dose supplement that contained both of the major forms of marine omega-3s. VITAL also examined effects on cancer occurrence.

The team found that omega-3s reduced the risk of heart attacks but did not reduce stroke, major cardiovascular events or cancer. VITAL also tested the effects of taking a vitamin D supplement, which did not reduce cardiovascular or cancer outcomes except for a signal that cancer deaths were lower over time.

Diabetes Drug Lowers Heart Failure Risk

A new class of diabetes drugs known as SGLT2 inhibitors can help lower blood glucose levels in patients with diabetes. Investigators are finding mounting evidence that the inhibitors may also lower cardiovascular risk.

Stephen Wiviott, MD, of Cardiovascular Medicine, shared findings from the DECLARE–TIMI 58 trial. The multinational trial tested an SGLT2 inhibitor known as dapagliflozin. Wiviott highlighted reductions in risk of adverse heart and kidney outcomes for patients.

Separately, Elisabetta Patorno, MD, DrPH, of the Division of Pharmacoepidemiology and Pharmacoeconomics, presented initial results from the real-world EMPRISE study, which found that another SGLT2 inhibitor reduced the risk of hospitalization for heart failure in routine care.

Inflammation and Heart Disease: A Roadmap for the Future

Brigham cardiologists have been at the forefront of basic, clinical and translational research linking inflammation and heart disease for decades and presented the next chapter in the ongoing story of the inflammatory hypothesis at this year’s meeting.

Paul Ridker, MD, director of the Center for Cardiovascular Disease Prevention, delivered results from the Cardiovascular Inflammation Reduction Trial (CIRT), a large-scale trial that tested whether low-dose methotrexate – an inexpensive, generic drug widely used to treat inflammatory diseases – was effective in reducing cardiovascular risk.

Last year, the Canakinumab Anti-inflammatory Thrombosis Outcomes Study (CANTOS) showed that the high-cost drug canakinumab targeted a specific inflammatory pathway and consequently lowered rates of heart attack and cardiovascular death. By contrast, the findings from CIRT showed that low-dose methotrexate neither inhibited that same pathway nor did it reduce major adverse cardiovascular event rates.

“The results from CIRT and CANTOS, when considered together, tell us something critically important: Not all inflammation is the same, and not all drugs that target inflammation are the same,” said Ridker. “While it is disappointing that an inexpensive drug like methotrexate did not have the effects we previously saw in CANTOS, the results from CIRT shed crucial light on the underlying biology that connects inflammation with cardiovascular disease. The divergent trial results provide a clear roadmap to guide our efforts going forward.”

In a separate presentation, Brendan Everett, MD, MPH, director of General Cardiology Inpatient Service, reported that the interleukin-1β inhibitor canakinumab reduced hospitalization for heart failure and heart failure-related death. These data represent the first-large scale evidence that inflammation inhibition can improve outcomes in heart failure. The results suggest that the role of inflammation reduction in improving heart failure outcomes merits further exploration.

From a Harrowing Past Emerges a Brighter Future for Brigham Researcher

Morteza Mahmoudi displays the latest prototype of a novel skin patch designed to heal chronic wounds.

Morteza Mahmoudi, PhD, vividly remembers the fear and heartache he felt as a child growing up in Iran during the Iran-Iraq War in the 1980s. The armed conflict played out in the streets of his hometown of Tehran, where he says it wasn’t unusual to encounter a friend, neighbor or loved one suffering from traumatic injuries following a missile attack.

But just as clearly, Mahmoudi recalls what the voice inside him often said those days: Help people. Help heal their pain.

Now a biomedical investigator at the Center for Nanomedicine and the Department of Anesthesiology, Perioperative and Pain Medicine, Mahmoudi has spent the last three decades following that calling. It has propelled him to fulfill his life mission to ease suffering, no matter the obstacle.

“The war was a very hard period, but when I think about those days, I realize that kind of experience puts fuel in your motivational tank for the rest of your life,” he said. “From the time I entered university, I made the decision to use my past as a driving force for the future.”

As the winner of the seventh annual BRIght Futures Prize, Mahmoudi is especially hopeful about what tomorrow holds for patients around the world. The competition’s $100,000 award will support his project, “Time to Heal Chronic Wounds.”

Sponsored by the Brigham Research Institute, the BRIght Futures competition invites the Brigham community and the public to vote for one of three finalists whose innovative research is poised to transform medicine. This year’s competition garnered its largest-ever number of votes: 16,530. Mahmoudi was announced as this year’s winner during an awards ceremony at Discover Brigham on Nov. 7.

For the past 10 years, Mahmoudi has been working to develop a skin patch to heal chronic wounds that the body is unable to repair on its own, such as bedsores and diabetic wounds. There is no effective treatment for these types of wounds, which can easily become infected and sometimes lead to amputation or even death.

Mahmoudi’s patch is made from multifunctional nanofibers – fibers that are 1,000th the diameter of a single human hair – that mimic most of the skin’s characteristics. They are engineered to deliver a cocktail of healing biomolecules and immunotherapeutic nanoparticles to a wound site. These unique properties can help cells reach the site of a wound and create new blood vessels. Meanwhile, the nanoparticles detect and help fight infections while also lessening inflammation. The BRIght Futures Prize funding will help advance the project from the lab bench to clinical trials so that it can be rigorously tested in humans.

A Long Road

Once he got the idea for the patch, Mahmoudi soon realized how ambitious an endeavor creating it would be. It demanded expertise in four highly complex, distinct scientific fields: materials science and engineering, biomedical engineering, nanomedicine and cell biology. Undeterred, Mahmoudi earned a degree in each one (a bachelor’s, master’s, doctorate and post-doctorate, respectively).

“The time in which I was working on bachelor’s and master’s was extremely hard, as in addition to my university courses and research, I had to work over 70 hours per week as a high school teacher to support my family at the time,” Mahmoudi recalled. “The motivational fuel and my old friend – my internal monologue – gave me the stamina to make it through those days and continue my scientific activities while also taking care of my immediate family.”

He kicked off his research career at universities in Ireland, Switzerland and the U.S., advancing his understanding of science and medicine as he chipped away at the project’s protocols and prototypes.

“I was like a scientific nomad,” he said. “Ten years ago, the crosstalk between different experts was not great – not like today – so that’s why I had to train in different medical and engineering fields.”

Each part of the patch – its precise structure and physical, chemical and mechanical properties – took years to perfect.

“I would say that this was one of the hardest projects I’ve ever done because it took a lot of time, and I could have easily given up many times, but I kept going,” he said. “My long-term collaborators and I made a huge number of prototypes. We haven’t yet published anything on this topic, as I believe that the scientific community and patients would benefit from the A-to-Z story, rather than progressive reports. We needed to make sure our final prototype was error-free, and we are now at that stage.”

Being part of the Brigham’s highly collaborative clinical and research community has been a tremendous gift in advancing this work, Mahmoudi said.

Today, he is excited to see the project move one step closer to changing outcomes for patients with chronic wounds, thanks to the BRIght Futures Prize.

“If I can reduce the pain of one patient, even for one minute, I have done my share. But if these patches can help many lives, that would be my ultimate dream,” Mahmoudi said. “This prize opens the way to that.”

Brigham Health’s Strategy in Action: Scalable Innovation
Learn more about our strategic priorities at BWHPikeNotes.org.

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B-PREP Program Aims to Stop Breast Cancer in Its Tracks

From left: Mil Pierce reviews information about a clinical trial with Shivam Dua at the Comprehensive Breast Health Center.

As far as she can tell, Mil Pierce, 55, of Belmont has done everything right in terms of leading a healthy lifestyle. She never smoked. She goes to the gym twice a week and walks her dog nearly every day. She doesn’t drink alcohol in excess. And she’s eliminated red meat from her diet.

Pierce has made these choices with the knowledge that she has a strong family history of breast cancer. The disease has affected her mother, maternal grandmother and a maternal great aunt, among many other relatives.

Yet after Pierce underwent genetic testing to see if she had an inherited mutation in the BRCA1 or BRCA2 genes – an alteration that greatly increases a woman’s risk of breast cancer – the lab results showed she didn’t have the harmful mutation.

That’s why Pierce was stunned to learn two years ago, following a biopsy, that there were precancerous cells in her breast tissue. If left untreated, the abnormal cells could develop into breast cancer.

“When I got that diagnosis, it hit me like a brick. I thought, wow, there’s something else going on,” she said. “Genetically speaking, there’s no explanation for it.”

Today, Pierce is hopeful not only for her own continued health but also that of her two teenage daughters, thanks to the care, resources and guidance she’s receiving through the Breast Cancer Personalized Risk Assessment, Education and Prevention (B-PREP) Program at Dana-Farber/Brigham and Women’s Cancer Center (DF/BWCC).

Launched about two years ago and led by Tari King, MD, chief of Breast Surgery at DF/BWCC, the B-PREP Program develops a comprehensive, customized risk profile for every patient and a personalized plan aimed at reducing the likelihood of developing breast cancer. Upon entering the program, patients complete a survey that asks not only about their medical history but also a wide range of lifestyle factors that experts believe can contribute to breast cancer risk, including diet, physical activity, sleep, weight changes, whether they work a night shift and more.

“Assessing individual risk for breast cancer is complicated,” King said. “Breast cancer is not just one disease; it is a family of diseases, and the risk factors that can lead to the development of different types of breast cancer also vary.”

King emphasized that the program is open to all patients, including – and perhaps especially – those who don’t know their breast cancer risk.

“Many women think that if breast cancer is not in their family that they don’t have to worry about it, and that is not true. In fact, most women who come in with their first diagnosis of breast cancer don’t have a family history,” King said. “Our doors are open to anyone who wants to learn about their risk.”

Novel Trials

Another big misconception the B-PREP Program is working to dispel is that people at increased risk are at the mercy of their biology, King said. Based on what B-PREP’s multidisciplinary team learns from an assessment, each patient receives personalized recommendations and is connected to relevant resources, such as a referral to the Brigham’s Program for Weight Management or information about clinical trials currently enrolling patients.

One such novel trial is looking at how exercise affects breast cancer risk in women who have dense breast tissue and do not currently engage in regular exercise. Led by Jennifer Ligibel, MD, a medical oncologist specializing in breast cancer at DF/BWCC, the study pairs participants with a personal trainer for 12 weeks. Researchers will collect a breast tissue sample from participants before and after they complete the exercise program.

“We know that women who exercise more have a lower risk of developing breast cancer, but we don’t know why. We also know that denser breast tissue – that is, tissue containing more glandular elements to it and less fatty tissue – is linked to a higher risk, and, again, we don’t know why,” Ligibel said. “In a previous study we conducted looking at women who already had breast cancer, we saw that exercise actually changed the immune system within the cancer. Now, we’re looking at whether those same types of changes from exercise can be seen before a tumor has even emerged.”

Pierce learned about her eligibility for the study from her B-PREP providers and became one of the first patients to enroll. She appreciates how comprehensive the B-PREP Program is, including the opportunities to participate in clinical trials that explore wellness-based approaches to prevention.

“This breast density and exercise study was music to my ears,” she said. “I’m really excited about being on the cutting edge of research, especially since there’s a mystery here.”

Brigham Health’s Strategy in Action: Advanced, Expert Care
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Extending Access to Psychiatric Care for Pregnant, Postpartum Patients

While pregnancy, childbirth and motherhood are joyful times for many women, for others these experiences can be emotionally challenging, isolating or even traumatic. An estimated one in seven women experiences depression during pregnancy or in the first year after giving birth – making depression during this time nearly twice as common as gestational diabetes.

But unless a mother or mother-to-be already has an established relationship with a behavioral health provider, she faces multiple barriers in terms of accessing specialized care to prevent, identify and manage mental health and substance use concerns.

“Psychiatrists who are trained in and comfortable with treating pregnant and postpartum patients are an extremely limited resource. There are simply not enough,” said Leena Mittal, MD, director of the Division of Women’s Mental Health in the Department of Psychiatry. “Meanwhile, in low-resource areas like Central and Western Massachusetts, the wait time to see any psychiatrist – let alone a perinatal psychiatrist – could be three or four months. In Southeastern Mass., it could take more than six months.”

That usually leaves primary care providers and obstetricians on the front line, but they don’t typically receive the specialized training necessary to feel confident treating these patients either, Mittal said.

Helping to bridge that gap is the Massachusetts Children Psychiatry Access Program (MCPAP) for Moms, which provides free, real-time perinatal psychiatric consultations and referrals for obstetric, pediatric, primary care and psychiatric providers across Massachusetts. The Brigham serves as the Boston hub for the program, which is based out of the University of Massachusetts Medical School in Worcester.

Supporting Patients and Providers

From fluctuating hormones to sleep deprivation to a traumatic childbirth, there are a number of circumstances that can make pregnancy and motherhood a difficult time for patients.

Leena Mittal

Launched four years ago, MCPAP for Moms maintains a consultation, resource and referral phone line that providers can call to receive guidance on diagnosing, treating and prescribing medications for pregnant and postpartum women with mental health or substance use concerns. For complex cases, perinatal psychiatrists in the program conduct in-person consults with patients. The service can also help frontline providers identify other relevant community resources or help facilitate referrals to group and individual therapy or other services.

For example, if an obstetrician suspects that a patient who’s come in for a prenatal care visit is showing signs of depression, the provider could call MCPAP for Moms and ask for input on a possible diagnosis and treatment plan, explained Mittal, one of two Brigham psychiatrists who provide consults through the program.

“There’s this misconception that pregnancy is a time when women are always ‘glowing’ and happy, but it can be a complicated time,” said Mittal, who also serves as associate medical director of MCPAP for Moms. “In addition, women – and sometimes their providers – assume they have to stop all medications, including antidepressants, during pregnancy. But that’s not the case. We give providers evidence-based guidelines, and they can ask questions as needed.”

Nicole Smith, MD, MPH, of the Department of Obstetrics and Gynecology, has used MCPAP for Moms’ services in her practice and recommended it to colleagues as a novel, vital resource for providers.

“A lot of programs tend to focus on trying to increase the number of and access to therapists and psychiatrists, which is wonderful and very necessary, but that may not meet our patients’ needs,” said Smith, an unpaid obstetric consultant for the program. “Patients can receive great, timely care from their primary care doctor or obstetrician, who may just need confirmation that a treatment is appropriate or a best practice.”

MCPAP for Moms supplements the Brigham’s robust in-house psychiatric resources, she added. For example, the program makes it easy to help patients who live outside Boston find support services closer to home. “Many patients don’t want to drive to the city with a newborn, and that can be an obstacle to accessing treatment,” she said.

Looking ahead, MCPAP for Moms is expanding its services to support providers caring for perinatal patients with substance use disorders, an effort that will be based out of the Brigham and led by Mittal.

“Massachusetts is the first state in the country with a program like MCPAP for Moms, and getting to be part of something so innovative has been very exciting,” she said. “We’re moving the needle in the way that perinatal mental health is treated, and I’m thrilled to be part of that.”

Learn more at mcpapformoms.org or contact MCPAP for Moms at 855-MOM-MCPAP (855-666-6272). Providers interested in training opportunities around perinatal mental health and substance use are also encouraged to contact the program.

Brigham Health’s Strategy in Action: Timely Access
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Brigham Launches Global Health Track in Hospital Medicine

Bram Wispelwey trains community health workers in Palestine.

Thanks to a new Global Health track in Hospital Medicine, hospitalists have the support they need to practice at the Brigham and work to improve health around the world.

The first cohort of three Global Health track physicians began at the Brigham in July, with projects supporting communities in Ethiopia, Guatemala and Palestine. In 2017, Peter Rohloff, MD, PhD, an attending hospitalist, established the track to expand opportunities for his colleagues to be a part of both the Brigham and the global health community.

“The vision for this track is to help junior faculty with a strong interest in global health take the next steps in advancing their careers,” said Rohloff, who is also the founder of Maya Health Alliance, a nonprofit that addresses the health care needs of Guatemala’s most impoverished communities.

He added that the track helps clinicians connect with mentorship and development opportunities at the Brigham and have a clinical home at the hospital – a goal shared by the Division of Global Health Equity. Since its founding in 2001, the division has provided an anchor for faculty who wanted to work globally but remain active clinically and academically in the U.S.

Among those in the first cohort of physicians on the Global Health track is Bram Wispelwey, MD, MS, who completed the Brigham’s Doris and Howard Hiatt Residency Global Health Equity and Internal Medicine earlier this year. When not practicing at the Brigham, Wispelway is caring for Palestinians and helping mend fractured health care systems in Palestinian refugee camps.

To address the complex issues facing refugees in these camps – which lack dedicated local clinics or consistent access to affordable primary care – Wispelway helped launch and monitor a Community Health Worker program. This work aims to improve relationships and rebuild trust between physicians and patients, strengthen the health care delivery system and improve the health of refugee families. He now divides his time between the Brigham and Palestine.

Jennifer Goldsmith, MS, MEd, administrative director of the Division of Global Health Equity, helped establish the partnership between Hospital Medicine and the division. She described the global health track as “highly customizable to meet the needs and interests of individuals and to offer opportunities for global health research and field work, didactics and career mentorship.”

“We’re delighted to work together to build on the mentorship and global health opportunities at the Brigham by creating this new career step,” Goldsmith said.

Q&A: Reflections on Interactive Teaching, Learning from Trainees

Raymond Mak

Raymond Mak, MD, of the Department of Radiation Oncology, was honored with the 2018 Bernard Lown Teaching Award, which celebrates physicians who are outstanding clinical teachers.

In this Q&A with BWH Bulletin, Mak shares his ideas on the field of radiation oncology, effective teaching and the Socratic method.

What drew you to the field of radiation oncology?

RM: I was always interested in cancer care and patients. One of my medical school mentors, Anthony D’Amico, MD, PhD, happened to be a radiation oncologist. He introduced me to the field of radiation oncology, serving as a mentor and teacher. The field combines procedural/interventional aspects of medicine, technology and imaging, with an academic, evidence-based and patient-centered focus, which was very appealing to me.

What is the key to being an effective instructor?

RM: From my perspective, it’s about trying to put yourself in trainees’ shoes. You need to understand where they are coming from, their level of knowledge and their experience. Using this information, you need to tailor your teaching style accordingly. I focus most of my efforts here when designing a lecture or lab for trainees.

Additionally, I try to make the material as interactive as possible. Using the Socratic method, I ask a lot of questions, both rhetorical and direct, to gauge the level of understanding in the classroom or clinic. As an instructor, this is the key to understanding the needs of the learner.

Whose teaching style has influenced your own?

RM: My dad was a college professor, so growing up, I often observed him teaching and tailoring material to the needs of different people, and much of my approach now comes from him.

In the past, I considered myself somewhat of an introvert and did not really think I would be a good teacher. It was in speaking to and learning from my mentors in medical school and throughout residency that I was able to hone my craft and come out of my shell.

At Harvard Medical School, the problem-based learning curriculum set the stage for my own teaching style. Going into residency, the teaching model was Socratic as well, with the emphasis on direct questioning and audience participation. This emphasis combined with the many great teaching role models in my department and at the Brigham greatly influenced my own teaching.

How has working with trainees influenced your work as a physician-scientist?

RM: Residents teach me a lot. They have great ideas, and they don’t follow the assumptions and orthodoxies that those who have been in the field for a long time do. Between the teacher and the trainee, it’s a two-way street. I ask them questions to help them learn, and in return, they ask me questions that challenge my own thinking and customs. I always tell my residents when they’re on service with me to make sure they continually ask why I’m doing a procedure or approaching a patient’s situation in a particular way. I encourage my trainees to challenge my conventions and methods as much as possible.

Our department is an environment with such an emphasis on teaching; everyone is pushed to improve, from residents to junior faculty. There was no doubt to me that one of the most important things that I could do as a physician was to be a great teacher for residents and medical students. This has always been a primary focus for me. When everyone you’re surrounded by is focused on effective teaching and trying to do their best, you have to bring your A-game.

Brigham Health’s Strategy in Action: Teaching and Training
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AERD Center Aims to Clear the Air on an Underdiagnosed Disease

From left: Alice Maxfield speaks with David Doyle during a recent follow-up appointment.

For David Doyle, 54, taking in the flavors and aromas of food is more than his passion – as co-owner of several restaurants in Jamaica Plain, it’s also his livelihood. So when what seemed like unusually intense seasonal allergies caused his senses of smell and taste to diminish three years ago, Doyle grew concerned.

First experiencing severe nasal and chest congestion, he tried several over-the-counter allergy medications. Nothing worked – in fact, his symptoms worsened. Within a few months, Doyle not only felt miserable physically, but he was also devastated to find he could no longer smell or taste anything.

“I didn’t really want to eat because there was no joy in it,” Doyle said. “On a professional level, it was also really hard to work with these great chefs who would ask, ‘David, can you taste this?’ and all I could comment on was the texture.”

Hoping his symptoms would eventually subside, he continued taking allergy medications and pain relievers, even though their effects were minimal. It wasn’t until after suffering a frightening medical event that Doyle would learn the very medications he was taking to feel better were actually making him sick.

Doyle was on vacation with his family in Spain when he realized something was gravely wrong with his health. Suffering from a bad headache and congestion, he took some ibuprofen, a treatment he had used before without incident. This time, however, he began experiencing serious respiratory distress within a few hours and was rushed to a local hospital.

“My lungs were filled with fluid. I felt like I was suffocating,” Doyle said. “I had no idea what had prompted that reaction, but I was starting to suspect something had changed inside me.”

After returning home, he was referred by his primary care provider to Tanya Laidlaw, MD, director of Translational Research in Allergy in the Division of Rheumatology, Immunology and Allergy, who diagnosed him with aspirin-exacerbated respiratory disease (AERD). Triggered by a sensitivity to aspirin and other non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen, AERD is a chronic condition that includes severe asthma and recurrent, fast-growing nasal polyps.

Also known as Samter’s Triad, the disease often strikes otherwise healthy adults and progresses rapidly. Its cause is unknown, and effective treatments are elusive.

“This is a disease that is really not well-known and is underdiagnosed,” said Laidlaw, who also serves as director of the Brigham’s AERD Center. “It requires a multidisciplinary approach, particularly between ear, nose and throat surgeons and allergists – specialists who don’t ordinarily talk to each other about patients with these symptoms. Without that communication, an ENT surgeon is unlikely to ask about an aspirin allergy, and an allergist doesn’t typically look for nasal polyps.”

Founded five years ago, the Brigham’s AERD Center brings together allergists, ENT surgeons and researchers to explore new treatments and improve the lives of patients with AERD. The center’s clinicians diagnose and treat hundreds of patients per year, and its investigators manage an international research registry of more than 1,000 people with AERD. Combined with its robust clinical trials program, these efforts make the Brigham’s AERD Center the largest clinical and research center for the disease worldwide.

“We have an incredibly collaborative relationship between bench scientists and those of us who see this disease in patients,” Laidlaw said. “We are all in constant communication. Every patient with an aspirin allergy seen by an ENT surgeon is likely referred to us. That proves education can solve the diagnosis gap. However, there is still an enormous need for broader awareness and research funding.”

Tasting Success

Upon returning home and beginning treatment at the Brigham, Doyle enrolled in a clinical trial at the AERD Center to initiate high-dose aspirin treatment, which involves administering increasing doses of aspirin to patients and closely monitoring them for the next several hours.

After starting this daily therapy and seeing only marginal improvement, Doyle underwent two surgeries to remove nasal polyps under the care of Alice Maxfield, MD, an ENT surgeon in the Department of Otolaryngology. A third procedure adjusted the blood flow in his nose to reduce inflammation. Within days of the last surgery, Doyle said he felt dramatically better.

Today, Doyle estimates he’s recovered about 90 percent of his senses of taste and smell, and his respiratory symptoms are largely under control. Although it was a long road, Doyle said he is deeply grateful for the expert, compassionate care he has received at the Brigham.

“I feel like my experience mirrors many others with AERD. It’s really frightening to develop symptoms that don’t make sense to you, so it was a huge relief just to know what was happening,” he said. “My hope is more clinical trials will shed light on not only the causes of this disease but also treatments for it.”

Shortly after recovering from his final surgery, Doyle and his family returned to Europe to vacation in Italy. It was on this trip that he realized his senses started to return. The first food he remembers tasting? Truffles.

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‘An Amazing Gift’: Patient Receives Rare, Lifesaving Heart-Lung Transplant

Camille Frede (right), pictured with her mother, Nancy, is the first BWH patient to undergo a heart-lung transplant in more than 20 years.

When Camille Frede, 28, saw Antonio Coppolino III, MD, MSc, then a fellow in the Division of Thoracic Surgery, enter her patient room at the Shapiro Cardiovascular Center earlier this year, her heart skipped a beat as she recalled their last conversation several weeks prior.

“The next time I see you will be when we get ‘the call,’” Coppolino, now an associate surgeon in the division, had told Frede and her family at the time. “The call” would be the care team’s notification that a matched donor heart and lungs were available for transplantation. Frede received her transplant in March following two months of hospitalization at the Brigham. The 10-hour surgery was completed by a multidisciplinary team comprising nearly 60 staff members.

The rare, complex surgery – which requires the donor heart and lungs to be transplanted simultaneously – was the first performed at the Brigham in more than two decades.

For Frede, the transplant cured pulmonary hypertension, a life-threatening condition she had lived with since age 4. It causes high blood pressure in the arteries of the lungs and severe breathing problems. The condition worsens over time, progressively restricting the flow of oxygenated blood and potentially leading to heart failure. After trying numerous therapies over the years, Frede and her family grew worried as her health continued to decline.

“We would go on family bike rides, and I would be blue,” Frede said. “We were always waiting for another tragedy to happen.”

In February, she began receiving inpatient care at BWH. Within a month, she was treated with high-flow oxygen and extracorporeal membrane oxygenation (ECMO), a machine that pumps blood and oxygen for a patient when their own heart and lungs can no longer do so adequately. The therapy sustained Frede while she waited for suitable donor organs to become available.

Patients whose pulmonary hypertension worsens to the point of requiring organ transplant normally undergo a lung transplant only, explained Hari Mallidi, MD, FRCSC, section chief of Transplant and Advanced Lung Diseases in the Division of Thoracic Surgery.

But Frede also was born with an atrial septal defect, often referred to as “a hole in the heart,” which drove the need for both a donor heart and lungs, Mallidi said.

“Even though her heart function was OK, we couldn’t technically make all the connections in the right places without changing everything,” he said.

‘A Whole New Chapter’

Now six months post-transplant, Frede says every day she feels stronger and that a world of possibilities has opened up. She is hiking, biking, doing yoga and, for the first time in her life, running.

“Every time I’m doing one of those things, I pray and think of my donor and their family. Without them, none of this would have been possible,” Frede said. “It’s been an amazing gift.”

Aaron Waxman, MD, PhD, director of the Brigham’s Pulmonary Vascular Disease Program, who has treated Frede for the past 10 years, is thrilled to see her progress.

“It’s a whole new chapter of her life,” Waxman said. “My expectation is she’s going to have a completely new, healthy life.”

Frede, who recently obtained her bachelor’s in nursing, is now evaluating advanced training programs to fulfill her dream of becoming a nurse practitioner to help others – a goal inspired by her mother, Nancy, who is also a nurse. In addition, Frede hopes to dedicate her time to raising awareness about pulmonary hypertension and the importance of organ donation.

While the past year was challenging for Frede and her family, they said the remarkable, compassionate care they received at BWH helped them weather the stress and uncertainty. In ways big and small, their Brigham care team lifted their spirits and provided a supportive environment for healing.

Throughout her life, including during her hospitalization, Frede sought to remain as active as possible. While she was on ECMO, care team members helped her obtain a stationary bike for her hospital room and played YouTube videos of scenic routes while she pedaled. In the months following discharge, Frede completed several bike rides around New England with Waxman and her exercise physiologist, Julie Tracy, of the Division of Pulmonary and Critical Care Medicine.

Nancy recalled the moment she and several Shapiro nurses shed tears of joy as they watched Frede listen to her own heartbeat with a stethoscope for the first time post-transplant. She said the experience marked the first of many wonderful moments to come.

Brigham Health’s Strategy in Action: Advanced, Expert Care
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NICU Milk Analyzer Study Aims to Personalize Pre-Term Infant Nutrition

From left: Mandy Brown Belfort and Valencia Koomson, with baby Justin

During a prenatal visit for their second child, Valencia and Jude Koomson were surprised to learn Valencia had pre-eclampsia, a form of high blood pressure that can occur during pregnancy. The diagnosis, just 28 weeks into her pregnancy, led to immediate hospitalization and, within days, the premature birth of their son.

That was the best option for the health of both Valencia and baby Justin, born 12 weeks before his due date and weighing just over 3 pounds. He would require intensive support to continue to grow and develop in the Brigham’s Neonatal Intensive Care Unit (NICU).

With breathing assistance for Justin’s developing lungs and a feeding tube to deliver human breast milk to his belly, he grew and thrived. He soon graduated from the Intensive Support area to the Growth and Development area, no longer needing oxygen support and becoming strong enough to feed on his own.

One novel technology available to him was a breast milk analyzer, a device that assesses nutritional composition of human breast milk. Justin was among the first babies enrolled in a new study at BWH to examine whether knowing the exact nutrition in individual feedings of human milk, and adding the right nutrients (also known as fortification), could aid the smallest babies.

“We know that more optimal nutrition is a predictor of better growth and neurodevelopment,” said Mandy Brown Belfort, MD, MPH, of the Department of Pediatric Newborn Medicine.

Special Nutritional Needs

Human breast milk is uniquely equipped to meet nutritional needs of full-term infants. But pre-term babies – especially those born before 35 to 36 weeks’ gestation – generally require that a fortifier containing calories, protein, calcium and micronutrients such as zinc and Vitamin A be added to a breast milk diet. This aims to replicate the nutrition the baby would receive from the mother’s placenta if still in the womb.

Typically, a premature infant’s growth is followed carefully, but the fortifier is only adjusted if the baby’s weight gain slows over several days. Belfort and her team are using the milk analyzer to avoid this lag, with the goal of delivering accurate, customized fortification with each feeding.

The milk analyzer was initially developed and used in the dairy industry. Recently adapted for human breast milk, it is approved for use in Europe and Canada. In the United States, it is currently available only for research purposes. BWH is one of a few NICUs engaged in that research.

Prior research by Belfort and others has shown surprising variations in the nutritional composition of a mother’s milk throughout a given day. Nutritional makeup also varies from one mother to the next, and it is not necessarily related to the mother’s diet. It’s also known that nutritional quality can degrade as expressed milk is handled and stored.

In Belfort’s current study, each feeding of milk is sampled and analyzed using the countertop device that sits in the NICU’s milk storage room. A tiny syringe, containing less than a teaspoon of milk, is inserted into the analyzer. A readout shows within seconds the milk’s nutritional elements. The results determine how much fortifier should be added on top of the standard fortifier to ensure that nutrient targets are met.

Study results won’t be known immediately as to whether this nutritional fine-tuning will improve growth and development in pre-term babies. The first patients began in the study in spring 2018. Belfort’s team is continuing to offer NICU families the opportunity to volunteer.

Valencia, a scientist herself, was glad to know that she was giving her baby every opportunity to grow, while contributing to newborn science.

“We are thrilled and blessed that he could participate to customize his feedings to his specific nutritional needs,” Valencia said. “Particularly for NICU mothers, there is so much anxiety and uncertainty about what your baby needs. It’s a great comfort to know he’s being fed well here. A baby needs to eat to grow.”

She also expressed her gratitude for the high-quality, compassionate care that she and her family received.

“All the people here are so consistently amazing,” Valencia said. “I want to say a big thank you to the staff at Brigham and Women’s Hospital and the NICU. At all levels of staff, there are such wonderful, caring and loving people here.”

Brigham Health’s Strategy in Action: Discovery and Innovation
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iHub Celebrates 5 Years of Innovation at the Brigham

Interactive demonstrations at the ‘iHub Turns 5’ celebration showcase digital health innovation at the Brigham.

On Sept. 12, more than 200 clinicians, scientists, staff and entrepreneurs commemorated the fifth anniversary of the Brigham Digital Innovation Hub (iHub) during a celebration of innovation and digital advancement at BWH and beyond.

The half-day event, “iHub Turns 5,” featured panel discussions with BWH innovators, iHub alumni and senior leaders from the Brigham and Partners HealthCare in the Hale Building for Transformative Medicine.

Since 2013, iHub has helped innovators launch and advance projects focused on using technology to streamline hospital operations, improve care delivery and enhance the patient and employee experience. One example is the Brigham’s online wayfinding tool, which provides step-by-step directions for navigating the hospital. iHub members have also worked with Medumo, a startup co-founded by Internal Medicine and Dermatology resident Omar Badri, MD. The company’s flagship application – in use at the Brigham’s Endoscopy Center – delivers precisely timed reminders via email and text message to patients for various purposes, such as preparations for procedures.

“We are aspiring to drive the safest, most patient-centered and efficient care through the use, development, evaluation and commercialization of digital health solutions,” said Adam Landman, MD, chief information officer of Brigham Health.

Improving Lifesaving Care Through Innovation

During a panel highlighting current and former BWHers’ journeys from ideation to innovation, YiDing Yu, MD, shared her experience of working with iHub to grow a startup company from a single idea.

When she was a second-year Internal Medicine resident, Yu attended iHub’s inaugural hackathon five years ago wanting to solve a problem she had encountered firsthand, specifically the communication challenges care teams encounter when a patient is arriving via ambulance.

Due to privacy concerns, emergency medical service (EMS) responders can only transmit limited information about an incoming patient to hospital care teams over public radio channels. Yu wanted to develop a tool to bridge this gap – a technology that would provide emergency departments with timely information while protecting patient privacy.

Yu was determined to solve this problem, despite the fact that she had no experience starting a tech company. “All of us were first-time entrepreneurs. We had no idea what we were doing,” said Yu.

Yu’s application, Twiage, is now used by over 50 hospitals in 12 states. Its secure digital platform enables first responders and emergency departments to accelerate lifesaving care by sending real-time clinical data and location updates directly to hospital care teams. Yu said that while it was daunting to pivot her career path to focus on Twiage – she also practices medicine at Atrius Health a few hours a week – she believes in her startup.

Yu attributes part of her success to the support she has received from iHub and the larger Brigham community. “I came to the Brigham to train because of the culture here,” said Yu. “I think you have to be surrounded by people who support your passion – I have bosses and mentors who do that. They help ignite that fire in your belly.”

Yu was joined on the panel by Karen Fasciano, PsyD, a psychologist at BWH and Dana-Farber Cancer Institute, who discussed her work on banYAn, an app that helps young adults coping with cancer; Alexander Lin, PhD, director of the Center for Clinical Spectroscopy in the Department of Radiology, who launched a company called BrainSpec to make virtual biopsies a reality; and Scott Weiner, MD, MPH, of the Department of Emergency Medicine, who is working on several digital health projects related to the opioid crisis.

In addition to the speaking program, the celebration was a homecoming for many iHub alumni, including Lesley Solomon, MBA, who helped create iHub and was honored that evening with the inaugural Disrupting Medicine Award for her contributions and leadership.

Reflecting on iHub’s early days, Solomon said the Brigham had to chart new territory to get iHub off the ground: “You just have to go for it. You just have to start doing things.”

BWH Receives First NICU Installed MRI System in the U.S.

Work crews lower the NICU’s MRI into the Connors Center.

Arriving by crane through a roof hatch in the Mary Horrigan Connors Center for Women and Newborns on Sept. 8, a new MRI system specifically designed for safe imaging of newborns will provide high-quality scans directly in the Brigham’s Neonatal Intensive Care Unit (NICU). The system, approved by the U.S. Food and Drug Administration last year, is the first NICU-dedicated MRI in the country.

“The installation of the state-of-the-art, neonatal MRI system will greatly enhance the research capabilities of BWH and elevate and expand neurocritical care for our littlest patients,” said Terrie Inder, MBCHB, chair of the Department of Pediatric Newborn Medicine. “Locating this technology within the NICU will reduce time and patient risk associated with transporting newborns to a traditional MRI and allow MRI access from the first hours of life through the challenging, sometimes life-threatening, time within the NICU.”

Babies undergoing scans will be in a temperature-controlled, self-contained incubator bed that minimizes the patient’s movement while allowing for better control of the environment and continuous monitoring of vital signs. Information gained from the MRI can inform a care team and family as to whether brain injury has occurred and, in the future, guide which treatments may assist in preventing disability.

The self-shielded, permanently magnetic system has been specifically designed for the NICU, an area that would be typically size- and risk-prohibitive for an MRI. The system is also quieter than traditional whole-body scanners to ensure the safety and comfort of infants undergoing scans.

Manufactured by Aspect Imaging, the system, known as EMBRACE, initially will be used for research purposes.

“This new MRI system, designed with a single use – scanning of the newborn – will enhance the care we provide for our NICU patients. This empowering technology will complement our existing fleet of MRI scanners and improve efficiency by offering imaging to our tiniest patients within the controlled confines of the NICU,” said Srinivasan Mukundan Jr., PhD, MD, medical director of Magnetic Resonance Imaging in the Department of Radiology.

Brigham Health’s Strategy in Action: Advanced, Expert Care
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‘Frailty Pathway’ Leads to Safer, Standardized Geriatric Trauma Care

From left: Ann Cook, a patient on the frailty pathway, speaks with Lynne O’Mara on Tower 8B.

Older patients face a unique set of health challenges – including chronic fatigue, low muscle mass, cognitive impairment, bone fractures and reduced mobility – that can raise their risk of illness or injury during hospitalization.

Launched in 2016, the BWH Frailty Identification and Care Pathway is a multidisciplinary program addressing these challenges by providing clinicians with standardized guidelines for identifying and accommodating frailty – a complex, often age-related syndrome characterized by physical decline and increased vulnerability to stressors.

“Frailty and cognitive impairment are often key contributing factors in falls and accidents that lead to fractures and other injuries among older patients presenting in our Emergency Department,” said Zara Cooper, MD, MSc, FACS, of the Division of Trauma, Burn and Surgical Critical Care. “We believe that focusing on these underlying conditions is essential to optimizing the care and outcomes of these patients.”

Physician assistant Lynne O’Mara, PA-C, of the Department of Surgery, was one of many BWHers who played a key role in implementing the pathway in the Emergency Department (ED) and the Surgical, Burn and Trauma Intermediate Care Unit on Tower 8ABCD. Part of a multidisciplinary team that sought to identify and remove barriers to care for older patients, O’Mara worked closely with Cooper and Samir Tulebaev, MD, of the Division of Aging and Center for Older Adult Health, to create order sets for the pathway.

The Frail Scale

At the heart of the initiative is an assessment tool known as the “frail scale,” which is used to screen for frailty in patients over the age of 65 when they arrive at the ED. In the frail scale, “frail” also functions as an acronym, with each letter representing the constellation of symptoms and conditions that may indicate frailty. Patients are considered frail if they meet three or more of these criteria:

Fatigue (“Are you fatigued?”)
Resistance (“Can you climb one flight of stairs?”)
Ambulation (“Can you walk one block?”)
Illnesses (“Do you have more than five illnesses?”)
Loss of weight (“Is your weight loss greater than five percent?”)

It’s important to recognize these risk factors early because frail patients are more likely to experience negative health outcomes, including increased rates of morbidity, obesity and trauma, O’Mara explained.

In addition to the normal effects of aging, a patient’s circumstances at home may contribute to or worsen their frailty, O’Mara said. For example, a patient might have poor muscle mass because they’re not eating, and they might not be eating because they’re on a fixed income and don’t have the financial means to purchase food. While such challenges are not unique to frail patients, understanding this context is key to helping these patients recover smoothly, avoid injury, discharge safely and reduce readmissions, O’Mara said.

During hospitalization, frail patients are also at greater risk of experiencing delirium, an acute state of confusion that is separate from dementia. Patients who experience delirium may try to pull out their IV lines or attempt to get out of bed when they cannot safely do so, leading to a secondary injury, O’Mara said.

The frailty pathway includes standardized ways to prevent, assess for and treat delirium. Since implementing these measures, the rate of delirium has decreased by a remarkable 50 percent among patients over 65 on Tower 8ABCD. The mortality rate for the same population has dropped by 30 percent, and complications have decreased by 47 percent.

“Our main goals when we first started the pathway were to prevent delirium and preserve function for these patients, which we have since been able to achieve,” O’Mara said.

Standardizing Care

Once a patient is screened and meets the criteria for frailty in the ED, providers enter a set of admission orders to standardize the care for each patient on the pathway. Within 72 hours, the patient receives a comprehensive geriatric assessment, which includes an evaluation of medical conditions, cognition, function, nutrition, emotional status and risk for delirium, with a geriatrician, and a nutritional assessment with a nutrition consultant. This information is detailed in the patient’s electronic medical record to ensure a safe transition of care.

On Tower 8ABCD, care teams work closely with patients on the pathway to ensure they eat, get out of bed, have bowel movements and perform other self-care tasks on a routine basis.
O’Mara said collaborating with her colleagues to develop and implement the pathway – and ultimately achieve better outcomes for patients and their families – has been extraordinarily fulfilling.

“I really enjoy the personal interaction with the patients,” she said. “I like having that one-on-one time to talk with them on the floor, meet their families, discuss their diagnoses and create a personal care plan. You really become part of the patient’s family for a couple of days.”

Reiterating the importance of the frailty pathway’s multidisciplinary model, O’Mara has engaged both staff and trainees in the program. To date, she has trained 70 residents on the pathway, and she continues to offer ongoing training for new residents and providers.

“The pathway has brought the entire trauma floor together and has gotten me really excited about geriatrics,” O’Mara said.

Brigham Health’s Strategy in Action: Highest-Quality, Safe Care
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BWHer Pioneers First Neurology Fellowship in Haiti

From left: Aaron Berkowitz works with Roosevelt François, inaugural graduate of Haiti’s first neurology fellowship.

The Brigham has more than a hundred neurologists on faculty, each with their own subspecialties. Yet until recently, Haiti, a country of nearly 11 million people, had only one. Aaron Berkowitz, MD, PhD, hopes to change that.

Following the island’s devastating 2010 earthquake, Berkowitz, director of the Brigham’s Global Neurology Program, was deeply moved by what he learned from his colleagues who had traveled to Haiti to assist with medical relief efforts. The disaster magnified how the country, especially its rural areas, was in dire need of specialized care.

“Most doctors in Haiti are general practitioners because there are no specialty training programs,” said Berkowitz. “If you go to medical school in a country with few or no neurologists, you have very minimal training in neurology to help patients with neurologic conditions.”

Six years ago, Berkowitz and his colleagues, including Michelle Morse, MD, MPH, assistant program director of the Internal Medicine Residency Program and associate physician in the Division of Global Health Equity, resolved to remedy this shortage. They worked with global nonprofits Partners In Health and EqualHealth to teach neurology courses for internal and family medicine practitioners and trainees.

Following this, Berkowitz, Morse and their Haiti colleagues developed a four-week neurology rotation for five internal medicine residents at the Hôpital Universitaire de Mirebalais (HUM). Their subsequent success inspired Berkowitz and colleagues to start a new, more intensive program – thus, Haiti’s first neurology fellowship was born.

One applicant is chosen each year for the two-year fellowship, and the program is rigorous; the fellow cares for all neurology inpatients and outpatients at HUM and receives mentorship from about a dozen U.S.-based neurologists, each of whom spends one to 12 weeks teaching in Haiti annually.

Last year, the first fellow, Roosevelt François, MD, graduated from the program. He recently joined the hospital’s faculty and became director-in-training of the neurology clinical program and educational fellowship. With the second fellow set to graduate this fall and a third next year, the program is on track to reach its goal of a 500 percent increase in neurologists – from one to five – within five years.

The need for neurology care is especially critical in Haiti, Morse explained. The country has a disproportionately high rate of hypertension, which is a key risk factor for stroke, in addition to a high burden of epilepsy from neurologic infections.

Building a Pipeline

Berkowitz and Morse hope their latest milestone ignites a fast-growing, self-sustaining fellowship led by HUM faculty.

“This program is going to have an enormous impact on the next generation of health care professionals because it has this faculty pipeline built into it,” Morse said. “And, more importantly, it’s a step toward achieving what citizens of Haiti deserve: health care as a human right.”

Berkowitz expects the program will not only expand access to high-quality neurologic care in Haiti, but will also train a cohort of clinician-educators who will teach neurology to their peers and train more neurologists in Haiti. More broadly, he hopes it becomes a model that other health professionals in resource-poor settings can replicate to develop specialty training programs in partnership with visiting faculty.

“Haiti is just one country,” he said. “Around the world, patients who need specialized care often can only see their general practitioner, who has no one they can refer the patient to for specialized expertise. The need is endless, and we hope our program can inspire other clinician-educators to expand their teaching efforts beyond borders.”

Morse, who has worked on health equity initiatives in Haiti and beyond for more than a decade, said Berkowitz’s passion and dedication has positioned the project for long-term success.

“Aaron is one of my heroes for being so committed to this program,” she said. “No matter what challenge comes along, he never gives up.”

Brigham Health’s Strategy in Action: Teaching and Training
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Residents Support Local Community with ‘Wednesday Wellness’

Rich Joseph leads a class about creating a personalized health plan at Brigham and Women’s Center for Community Wellness.

When Christina Meade, MD, was invited by a fellow resident to give a talk about kidney health – one of her clinical interests – to people in the local community, she jumped at the opportunity.

“I love medicine, specifically preventive medicine, and to educate people in our local communities about their health and wellness is what makes my job so wonderful and exciting,” said Meade, a second-year resident in the Department of Medicine. “After I participated in the talk, my passion for primary care was rejuvenated.”

Last year, Rich Joseph, MD, MBA, a third-year resident in Primary Care and Population Medicine, approached Paul Ridker, MD, MPH, director of the Center for Cardiovascular Disease Prevention, about possibly launching an ongoing health and wellness series led by residents at Sportsmen’s Tennis and Enrichment Center in Dorchester. Ridker, who at the time was the board chair of Sportsmen’s, said he instantly loved the idea, knowing the series could benefit both Brigham residents and community members.

Ongoing since September 2017, the “Wednesday Wellness” series takes place twice a month at the Brigham and Women’s Center for Community Wellness, Dorchester, located within Sportsmen’s. Each course focuses on a different health- and wellness-related topic, with more than 20 sessions held to date. Courses have covered diabetes and hypertension, dementia and arthritis, among other topics.

Opened in 2015, the goal of the Brigham and Women’s Center for Community Wellness Center at Sportsmen’s is to advance health and chronic disease prevention in underserved communities of Dorchester, Mattapan and Roxbury. The facility includes both classroom space for educational activities and a full gym, free to anyone living in the area.

For Ridker, the center has been a “terrific way for the Brigham to have a positive impact on preventive health in underserved neighborhoods where so many of our patients live and work.”

Wanda McClain, MPA, vice president of Community Health and Health Equity, agreed, adding the “Wednesday Wellness” program shows the power of collaboration. “Bringing together health care providers, community residents and Sportsmen’s is a perfect trifecta for improving community health,” she said.

Toni Wiley, Sportsmen’s executive director, has seen firsthand how valuable the courses have been for attendees.

Attendees of a recent “Wednesday Wellness” course gather for a photo with Brigham resident Rich Joseph (back row, center).

“I’ve heard many success stories from our members who’ve attended the ‘Wednesday Wellness’ sessions,” Wiley said. “Some have lost a few pounds, and others have come to understand how their medications truly work. It has been truly gratifying to hear people talk about how attending these sessions has been life-changing for them.”

The series has a loyal following. William Mitchell, of Mattapan, has attended nearly every “Wednesday Wellness” session, even inviting friends to join him. A retired firefighter, Mitchell said he appreciates the residents’ thoughtful, insightful presentations.

“To me, it’s a great thing to bring health and wellness education into the local community,” he said. “I’m grateful that the Brigham and Sportsmen’s came together to bring this goodness to our community, which is helping many of us live a better life.”

The series has also benefited Brigham trainees by providing opportunities to “get outside one’s comfort zone” and talk about health and wellness in a setting other than the hospital, Joseph explained.

Since the series launched, Joseph has heard from many resident colleagues who are interested in getting involved.

“It feels good knowing our work is helping others,” said Joseph, noting the series is a collective effort and would not be possible without the support of his resident colleagues.

BWH Emergency Medicine residents and Boston Children’s Hospital pediatric residents are among those involved in the series. Since Sportsmen’s offers programs for all ages, Joseph said it has been valuable to have residents from different specialties share their expertise.

Joseph, along with a handful of other Brigham residents, including Joshua Lang, MD, MS, a third-year resident in Internal Medicine, are also teaming up with Sportsmen’s to launch related programs, including community health fairs and an educational series for children attending summer camp at Sportsmen’s. Lang said it has been wonderful to participate in this work. “I feel pretty lucky to have found out about it,” he said.

Joseph added: “Partnering with Sportsmen’s has been one of the best decisions I’ve made as a resident. For me, this is the type of work that keeps me going – it’s very motivating. I love showing people the process of discovering their own health and taking care of themselves.”

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Brigham Researchers Design Fast-Acting Cholera Vaccine

Waldor Lab members, from left: Brandon Sit, Alyson Warr, Gabriel Billings, Matthew Waldor and Troy Hubbard (not pictured: Carole Kuehl)

When an outbreak of cholera unfolds, a vaccine that offers rapid protection could mean the difference between life and death for tens of thousands of people.

In a preclinical study, investigators at the Brigham are developing a new class of vaccine that can combat cholera, a highly contagious, quickly fatal diarrheal disease with a long history of causing epidemics. The vaccine is designed to act in two ways – training the immune system to detect and destroy the bacteria in the long term and protecting a person immediately from cholera’s effects. Using mathematical modeling, the research team predicts that, if successful in humans, their highly innovative approach could change the trajectory of a cholera epidemic.

This novel therapeutic, which has been tested in a preclinical model, is made from a live strain of the disease and protects against cholera-like illness less than a day after it is administered. Traditional, oral cholera vaccines are made from strains that have been killed and take effect after about 10 days.

“Our work represents a whole new concept in vaccinology – this dual-acting agent elicits a long-term immune response and confers protection almost immediately,” said Matthew Waldor, MD, PhD, of the Division of Infectious Diseases and the study’s corresponding author. “What we’ve done is something very different than what others have done before.”

Waldor and colleagues engineered the live vaccine based on the strain of cholera that caused a large epidemic in Haiti beginning in 2010. The research team engineered the strain by removing the genetic code that gives cholera its deadly properties. They also encoded within it a system that keeps out any toxin-producing genes, preventing the strain from ever regaining toxin production abilities. The team performed additional engineering to prevent other side effects, including mild diarrhea.

Researchers tested the vaccine in a preclinical model of cholera.

The vaccine, known as HaitiV, did not elicit cholera-like symptoms and caused minimal or no fluid accumulation in the intestines after being administered, even though the vaccine colonized the small intestine. When the team exposed the preclinical experimental group to cholera 24 hours later, no signs of disease were present.

The team also performed mathematical modeling to predict the public health impact the vaccine might have compared to traditional vaccines. The researchers’ simulations showed that in a population of 100,000 people, a fast-acting vaccine could prevent 20,000 infections compared to vaccines that can take the typical 10 days to build up a host’s immunity.

“The speed with which you respond to an outbreak significantly helps your ability to control it and prevent people from getting cholera,” said lead author Troy Hubbard, PhD, a graduate student in the Waldor Laboratory at the Brigham. “We are very focused on feasibility – the idea of being able to come in with a single-dose intervention that works rapidly but confers immunity over a long period.”

The team notes that evaluating the immune response that HaitiV elicits in human volunteer studies is a critical next step.

Brigham Health’s Strategy in Action: Scalable Innovation
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BWH Ambulatory Services: Construction and Leadership Updates

An artist’s rendering of Brigham and Women’s Health Care Center – Westwood, which opens this fall

As Brigham Health advances its efforts to expand access to ambulatory care in communities around Greater Boston, BWH will open a new multispecialty outpatient clinic in Westwood this fall and is expanding the Outpatient Care Center at Brigham and Women’s/Mass General Health Care Center in Foxborough, which is slated for completion next year. To support these expansions, BWH has restructured and expanded the responsibilities of two roles in Ambulatory Services.

Ambulatory Regional Operations Expansion

Cindy Peterson

Brigham and Women’s Health Care Center – Westwood is scheduled to open this October at the University Station development. The center, which will add 30,000 square feet of outpatient care, will provide primary care through Partners Community Physicians Organization and embed Behavioral Health through the Brigham and Women’s Physicians Organization (BWPO) Department of Psychiatry. Additionally, Brigham Health providers will offer Dermatology, Obstetrics and Gynecology, Orthopaedics, Phlebotomy and Radiology services. A separate, multispecialty clinic within the center will offer Brigham Health Cardiology, Endocrinology, Gastroenterology, General Surgery, Neurology and Urology. Partners Urgent Care, an additional occupant of the Westwood site, will open later in 2019.

In Foxborough, a second, 60,000-square-foot building is being constructed across from the Outpatient Care Center at the Brigham and Women’s/Mass General Health Care Center. The additional space will double the size of its primary care practice in Foxborough, enabling further growth of the center’s nearly 30 medical and surgical specialties. Brigham Health is partnering with Dana-Farber Cancer Institute, which will occupy a floor in the new building to provide medical oncology and infusion services. The building is set to open in 2019.

New Roles and Responsibilities

Cindy Peterson, MBA, was named vice president of Regional Ambulatory Operations and Business Development. The new position will extend Peterson’s span to support and guide future ambulatory sites. She previously served as executive director at Brigham and Women’s/Mass General Health Care Center, Brigham and Women’s Health Care Center at 850 Boylston St. in Chestnut Hill and Brigham and Women’s Health Care Center – Westwood.

Julia Raymond

“Cindy has provided a regionally focused perspective, assuming ever-increasing responsibilities across the Brigham’s large off-site Ambulatory care centers in Foxborough, Chestnut Hill and soon, Westwood,” said William Johnston, MBA, chief operating officer and treasurer of the Brigham and Women’s Physicians Organization and senior vice president of Ambulatory Services. “She’s adept at utilizing external business development to grow the community’s awareness of our services in Foxborough, and her expertise will be integral to our efforts to expand regional access to ambulatory care.”

Peterson joined the Brigham in 2008 as administrative director for the Brigham and Women’s/Mass General Health Care Center in Foxborough. She received her MBA in health care management from Boston University and her bachelor’s degree from Amherst College.

In addition, Julia Raymond was promoted to director of Operations in Foxborough. She is responsible for all day-to-day operations at Brigham and Women’s/Mass General Health Care Center, and she will play a larger role in strategic planning, community outreach and supporting the Foxborough expansion efforts and new Westwood site. Raymond was previously senior operations manager in Foxborough.

“Julia has been an integral part of Foxborough operations from before our site opened in 2009,” Johnston said. “I’m excited to see how Julia will bring her unwavering commitment to continuous improvement, patient satisfaction and operational excellence to her new role.”

Raymond began her career at BWH in 2005 working with the Brigham and Women’s Physicians Organization as an application manager. Raymond received her bachelor’s degree in Health Management and Policy from the University of New Hampshire.

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Study Examines Best Way to Teach Bystanders How to ‘Stop the Bleed’

This tourniquet training class for staff at Gillette Stadium was one of many conducted by BWH researchers last year.

In the immediate aftermath of an accident or attack, can bystanders help save the life of someone who has experienced a traumatic injury? Brigham researchers recently sought to answer this question by studying how well different training methods prepared laypeople to apply tourniquets to stop uncontrolled bleeding, finding that those who underwent in-person training were most likely to successfully perform and retain this skill.

Traumatic injuries are the leading cause of death for Americans under 46, and uncontrolled bleeding is the most common cause of preventable death following a traumatic injury. Since the Boston Marathon bombings in 2013, several national initiatives, including the White House’s “Stop the Bleed” program, have emerged to empower laypeople to act as immediate responders until emergency personnel arrive on scene. These efforts have led to the development of different training methods, but it was previously unknown which type, frequency and format of training would competently prepare nonmedical personnel to conduct hemorrhage control.

To determine the best training method for tourniquet education, BWH researchers completed the PATTS Trial (Public Access and Tourniquet Training Study). The study was funded by The Gillian Reny Stepping Strong Center for Trauma Innovation and conducted in partnership with Gillette Stadium and the New England Patriots.

In total, 465 Gillette employees, who had no prior training in this area, participated in the study. The trial was designed to not only train staff in responding to uncontrolled bleeding, but also to test whether, and under what conditions, such training was effective. The results were published in JAMA Surgery this month.

Participants were randomly assigned to one of four groups. The first was provided instructional flashcards to learn about proper tourniquet application. The second group used flashcards and audio kits. The third received in-person training through the Bleeding Control Basic (B-Con) course, led by BWH instructors. The final cohort was asked to apply tourniquets with no training or instructions. Participants in the first, second and fourth groups later received in-person training.

Researchers found that in-person training, via the B-Con course, was the most effective instructional method and resulted in 88 percent of participants correctly applying a tourniquet. By comparison, participants who received no training applied a tourniquet correctly only 16 percent of the time, and participants who had access to instructional flashcards or an audio kit with flashcards experienced only small gains in effectiveness.

Looking at skill retention, researchers discovered that only about half of the participants could correctly apply a tourniquet three to nine months later, emphasizing the need for refresher training.

“Before the PATTS Trial, we didn’t know what was the best way to train the public in bleeding control,” said Adil Haider, MD, MPH, a trauma surgeon and Kessler director of the Center for Surgery and Public Health. “Now that we know, we can be more effective in creating training programs, public awareness campaigns and tools to empower people.”

Researchers stress that most external hemorrhages, or bleeds, can and should be controlled by direct pressure. While bystanders were critical first responders following the Boston Marathon bombings, subsequent research indicated that all 27 improvised tourniquets administered at the scene were applied incorrectly.

Looking ahead, Eric Goralnick, MD, MS, medical director of Emergency Preparedness and lead author of this study, said clinicians and public health investigators will convene to define a common research agenda for laypeople and bleeding control.

Meghan McDonald, MSN, RN, nurse director of the Trauma Program in the Division of Trauma, Burn and Surgical Critical Care and co-author of the study, said intervention from bystanders in any situation, not just mass-casualty events, can help save lives.

“Some people hesitate, especially when it comes to tourniquets, because they are afraid of causing more harm,” McDonald said. “Educating laypeople on hemorrhage control, be it direct pressure or tourniquet application, is not only the responsible thing to do as a trauma center – it is also the right thing to do.”

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Heart & Vascular Center First in Region to Perform 1,000 TAVRs

Staff in the Brigham’s transcatheter aortic valve replacement (TAVR) program celebrate their recent milestone.

Less than a decade after performing the first transcatheter aortic valve replacement (TAVR) at the Brigham, a multidisciplinary team in the BWH Heart & Vascular Center recently became the first in New England to have completed 1,000 TAVR procedures.

Now with the largest program of its kind in the region – based on annual volume and total TAVRs performed – the Brigham’s TAVR team recently held a staff celebration in honor of its 1,000th case, which it achieved earlier this year. The program is now rapidly approaching 1,200 procedures.

“This milestone makes me realize that I am part of a progressive and talented group of individuals who have developed one of the country’s best TAVR programs,” said cardiac surgeon Marc Pelletier, MD, and the program’s surgical director. “The number 1,000 gives us pause to realize the amount of work needed to get here and how many patients and families have been helped by this groundbreaking technology.”

A minimally invasive surgical procedure performed in the Cardiac Catheterization Lab, TAVR is used to treat patients with a heart condition called aortic valve stenosis. Among these patients, blood is unable to flow freely from one of the heart’s valves to the body’s main artery, the aorta. Some patients with this condition can avoid open-heart surgery with the use of TAVR, which uses advanced imaging to help specialists guide a catheter into the heart – through a small incision in the leg, groin or chest – and insert a replacement aortic valve.

TAVR can be done without general anesthesia, and patients experience a quicker recovery than they would from a traditional open-heart valve replacement. The entire procedure takes about 90 minutes, and patients are often home within a day or two.

The Brigham performed its first TAVR in 2009 as part of a landmark, multi-institutional series of clinical trials known as the PARTNER trials. Following approval by the U.S. Food and Drug Administration, the procedure moved into clinical service at BWH in 2011.

Maximizing access to this lifesaving treatment is a major focus for the team, noted interventional cardiologist Pinak Shah, MD, who serves as the program’s medical director. The program now runs three clinics per week for patient evaluation, and TAVRs are typically done within two to three weeks of the patient’s first appointment.

“We can do this because of our ability to perform TAVR procedures five days per week, which is unusual in this field,” Shah said. “This is a testament to the dedication of everyone involved in the process – from clinic scheduling to radiology to procedure scheduling and catheterization laboratory staff.”

Pivotal to the BWH TAVR team’s success has been its focus on multidisciplinary collaboration, said cardiac surgeon Tsuyoshi Kaneko, MD.

“I am really proud of how much we’ve grown, but more than that, it’s the phenomenal teamwork,” Kaneko said. “To perform this procedure, it’s not just cardiac surgeons. It’s not just interventional cardiologists. We have an incredible team that includes anesthesiologists, nurses, non-interventional cardiologists, physician assistants, radiologists, fellows and many more. Everyone has contributed so much to the growth of this program.”

Pelletier and Shah agreed, noting that the team’s comprehensive approach and combined expertise enable them to assess referrals quickly and support faster, smoother recoveries for patients.

“It is a tremendous honor to be a part of this milestone and program, which is the ultimate example of cross-disciplinary collaboration,” Shah said. “It is very satisfying to work with such talented colleagues who have a common goal of building a successful program and providing great care for our patients.”

Brigham Health’s Strategy in Action: Advanced, Expert Care
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Helping Expand Access to Complex Care in Underserved Communities

Elizabeth Buzney demonstrates how phototherapy is performed at the BWH Phototherapy Center.

After topical treatments failed to heal a patient with a rare form of skin cancer, family physician John Mohs, MD, carefully evaluated the patient’s next steps.

Mohs practices at Northern Navajo Medical Center in Shiprock, N.M., a rural hospital operated by the U.S. Indian Health Services (IHS), which provides health care for American Indians living on or near their native homeland. Patients in this remote region of Navajo Nation are at higher risk for many diseases, yet specialty care is scarce. Northern Navajo Medical Center serves approximately 30 inpatients per day and approximately 600 outpatients per day, according to the IHS.

Diagnosed with cutaneous T-cell lymphoma – a form of lymphoma that affects the skin – Mohs’ patient was a good candidate for phototherapy, which exposes targeted areas of the body to ultraviolet light to reduce skin inflammation. Also known as light therapy, phototherapy has been proven to be safe, effective and affordable in treating a number of inflammatory skin conditions.

For Mohs and his patient, the challenge was access. Until recently, Mohs had neither the training nor equipment to provide phototherapy at his small dermatology clinic in Shiprock. The nearest phototherapy center was about 200 miles away, and his patient would need to go there three days per week for several months. The combination of barriers made it infeasible for the patient to obtain the specialized care he needed.

Ironically, the solution to their problem would be found more than 2,000 miles away – in the BWH Department of Dermatology.

Thanks to a clinical collaboration between BWH faculty volunteers and IHS clinicians through the Brigham and Women’s Outreach Program, Mohs developed and launched a phototherapy service for his patients in Shiprock based on guidance he received from BWH experts in the field.

He worked closely with Elizabeth Buzney, MD, director of the BWH Phototherapy Center, and Margaret Cavanaugh-Hussey, MD, MPH, director of Public Health and Community Outreach Programs in BWH Dermatology, who Mohs said both played a significant role in helping him get this new clinical service off the ground.

“I probably would not be using phototherapy without the guidance and assistance they provided. Dr. Buzney willingly shared many resources so that I wouldn’t have to reinvent the wheel,” Mohs said. “Thanks to all of this support, my patient was treated right at Northern Navajo Medical Center and is now in remission.”

Buzney was delighted she could help to expand access to this treatment – a cause she says is close to her heart.

“I felt like I did something that was so small – I shared resources and knowledge I already had – and Dr. Mohs has since been able to care for so many people as a result,” Buzney said. “As physicians, we typically treat patients one-to-one. To play a part in assisting many patients who are so far away is immensely gratifying.”

A Helping Hand

From left: Toby Crooks, Margaret Cavanaugh-Hussey and John Mohs

The project represents one of many collaborations established over the years between IHS clinicians and BWH faculty volunteers through the Outreach Program. Building on their latest momentum in phototherapy, Mohs and his physician assistant colleague, Toby Crooks, PA-C, visited the outpatient Dermatology clinic at 221 Longwood Ave. last month for a weeklong shadowing opportunity to observe and learn from BWH clinicians in action.

Mohs and Crooks were assigned to various specialty clinics, ranging from advanced wound care to cutaneous lymphoma – an experience that enabled them to broaden their dermatologic knowledge and strengthen relationships with experts in the field, said Cavanaugh-Hussey. In return, she added, BWH faculty had the chance to learn firsthand about the important work their IHS colleagues are doing in Shiprock.

“The BWH Outreach Program is a model for how forming meaningful relationships with primary care providers in underserved communities can dramatically increase access to high-quality specialty care,” said Cavanaugh-Hussey. “This is particularly important in dermatology, where access to care is limited in many areas of the country.”

While the Outreach Program may be best known for sending BWH faculty volunteers to Shiprock to train IHS clinicians and help care for patients, providing shadowing and observation opportunities at the Brigham are equally important to its work and mission, said Thomas Sequist, MD, MPH, medical director of the Outreach Program, a primary care physician in the Phyllis Jen Center for Primary Care, and chief quality and safety officer at Partners HealthCare. Since 2009, the program has hosted training opportunities at the Brigham for 18 IHS clinicians.

“The delivery of highly specialized, complex care is crucially needed within the IHS. However, the number of patients that require such care on a day-to-day basis is relatively low, so if we send a BWH specialist to New Mexico, it is quite likely that there will be no training opportunity with actual patients the week they are there,” Sequist said.

Mohs agreed that observing the BWH Dermatology team in person was enormously beneficial.

“We were able to see a large volume of more rare and complex conditions that we don’t see often enough to feel confident managing,” he said. “Being able to see these cases with BWH attendings and ask questions – and receive extensive answers from the experts – in real time was invaluable.”

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Innovative Video-Assisted Surgery Leads to Faster Recovery, Less Pain

From left: Wallis Urmenyhazi and Scott Swanson

Wallis Urmenyhazi, PhD, was speaking with her primary care physician by phone after a recent chest X-ray when he said four words that would change her life: “You have a lesion.”

“I didn’t know what he meant by lesion, but he told me to see a thoracic surgeon,” says Urmenyhazi, a retired professor of French literature, who had seen her physician for a persistent cough.

After meeting with a thoracic surgeon in her home state of Pennsylvania, Urmenyhazi learned that her lesion was a thymoma, a rare disease in which a tumor grows within the thymus gland, a butterfly-shaped organ that sits in front of the heart and makes immune cells. There are only 1.5 cases of thymoma for every million people each year in the United States.

The most common treatment is to remove the tumor with surgery. Accessing a thymoma can be challenging, however. The thymus sits behind the sternum, between the lungs, and is surrounded by sensitive blood vessels. A traditional surgery opens the chest by making a large incision in the breastplate.

Urmenyhazi had misgivings. It was a major operation with a long recovery process. Her tumor had been caught early; her only symptom was a cough. Through online research, she learned that some surgical procedures approached thymomas through small incisions and used less-invasive techniques aided by video or robotic technology.

“I asked my surgeon at the time if he would perform a minimally invasive procedure, but he didn’t have that expertise. He recommended the more complex traditional operation, which had no guarantee of success,” she said.

Despite her reservations, Urmenyhazi scheduled the operation – but canceled a day later. She searched online for a surgeon with experience in minimally invasive techniques for thymoma, ultimately finding Scott Swanson, MD, director of Minimally Invasive Thoracic Surgery in BWH’s Lung Center.

A member of the surgical team for Dana-Farber/Brigham and Women’s Cancer Center, Swanson is an expert in video-assisted thoracic surgery (VATS) and teaches the technique around the world.

“After meeting Wallis, I recommended VATS, a minimally invasive procedure where we insert a tiny camera and instruments into small incisions in the chest. This allows us to access the thymus without opening the chest. Compared with traditional approaches, patients can expect less pain and a quicker recovery,” Swanson said.

The procedure was performed without complications. After the surgery, Urmenyhazi had no pain. It was almost as if the surgery hadn’t happened, she said.

VATS has been available for 25 years, but not enough surgeons are trained to do it, Swanson explained. That’s why he and members of the Division of Thoracic Surgery travel to hospitals across the globe to train surgeons in minimally invasive techniques and expand access to this lifesaving procedure.

Swanson applauded Urmenyhazi for being an advocate for her own care. “Sometimes, the patient needs to seek out the physicians who are trained to perform the most cutting-edge surgical techniques,” he said.

Urmenyhazi meets yearly with Swanson for follow-up scans. “I will be forever grateful for Dr. Swanson,” she said.

Brigham Health’s Strategy in Action: Advanced, Expert Care
Learn more about our strategic priorities at BWHPikeNotes.org.

Study: Plastic Surgery Done Abroad Linked to Medical Complications

With the promise of inexpensive procedures luring patients to travel abroad for plastic surgery, medical tourism has become an expanding, multi-billion dollar industry. While the price tag for cosmetic procedures may be lower in developing countries, they can place a significant burden on U.S. public health systems when patients return with medical complications. A new study by investigators at BWH describes the magnitude of complications that can result from plastic surgery performed in destination countries.

“Many think of medical tourism as wealthy patients traveling to receive care at high-quality medical institutions abroad, but that doesn’t fully reflect what we see. We’re reporting on repercussions that can result when patients who are originally from less-developed parts of the world return to their home countries to undergo elective plastic surgery procedures at a lower cost,” said senior author Dennis Orgill, MD, PhD, medical director of the Wound Care Center. “Patients need to be very cautious when they go outside of the U.S. for elective plastic surgery. The safety and regulatory systems that protect patients in the U.S. are often not in place in a patient’s country of origin.”

In a retrospective analysis published in Plastic and Reconstructive Surgery, Orgill, along with his practice assistant, Kimberly Ross, MPH, and other colleagues evaluated patients who had been treated at BWH over the last seven years for complications or complaints associated with plastic surgery performed in a developing country.

Of the 78 patients evaluated as part of this study, the most common complications – including infections, pain and wound-healing issues – were seen following abdominoplasty (tummy tuck) or breast augmentation. None of the patients came to their Brigham appointments with their foreign medical records.

The most common destination for these surgeries was the Dominican Republic – 75 percent of the patients in the study traveled there for elective procedures. The second most common destination for medical tourism among patients studied was Colombia.

Fourteen patients arrived at BWH with infections at their surgical site, including cases of infection resulting from multi-drug resistant bacteria. Eight patients required the removal of damaged tissue or foreign objects from the wound site over a series of office visits.

The researchers found that some patients may not have received appropriate preoperative counseling and did not stay in the foreign country long enough to treat early complications. Other patients reported unwanted breast implants, showing communication issues in the consent process.

In some cases, Orgill and his colleagues attempted to contact the surgeons from outside the country, but either never received a response or were told the surgeon had never heard of any complications reported from their surgeries.

The Centers for Disease Control and Prevention and the U.S. State Department have issued numerous alerts advising U.S. citizens not to travel to the Dominican Republic, specifically, to undergo plastic surgery, as there is a high incidence of complications, rare types of infections and high rates of death associated with the procedures.

In the BWH study, researchers noted how complications can occur even when highly trained surgeons practice at the best institutions, regardless of geography, and added that there are dangers even within the U.S. from surgeons not trained or properly credentialed to perform plastic surgery procedures. They said raising patient awareness of resources available to them regarding surgeon selection and the dangers of medical tourism is necessary. Because of the continued expansion of medical tourism, the Joint Commission in the U.S. formed the Joint Commission International to accredit institutions that meet their qualifications abroad.

“We hope this study will bring attention to this emerging issue and encourage others to report any results related to medical tourism treatment and patterns,” the authors wrote.

Brigham Health’s Strategy in Action: Discovery and Innovation
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Research Program Aims to Build a Healthier World for ‘All of Us’

From left: Elizabeth Karlson and Cheryl Clark

From genealogy to genetics, BWH patient Margo Blackwell-Moquin says she has long been curious about her roots. Recently, she has been keenly interested in what her unique makeup means for her health.

“I really believe knowledge is power, and not knowing is not healthy. You can’t do anything preventive if you don’t know,” said Blackwell-Moquin. “It’s really important that we all educate ourselves about our health.”

When she learned about the All of Us Research Program – which seeks to accelerate research and medical breakthroughs that will enable individualized prevention, treatment and care – Blackwell-Moquin was immediately interested and enrolled at the Brigham. The program, part of the National Institutes of Health’s Precision Medicine Initiative, has a goal of enrolling one million or more people across the country to share their health data and samples to build the largest health database of its kind.

Partners HealthCare was selected to take part with Boston Medical Center in All of Us, making it one of several participating organizations nationwide. The BWH program, led by Elizabeth Karlson, MD, and Scott Weiss, MD, and co-investigators Cheryl Clark, MD, ScD, and Robert Green, MD, MPH, is currently enrolling participants in its pilot phase prior to All of Us’ nationwide launch.

Data that researchers obtain from volunteers – including physical measurements, medical history, and blood and urine samples – will be used to conduct thousands of studies in multiple disease areas. In addition to having the opportunity to help fuel the next medical breakthrough, some participants receive research results.

“This project will help researchers learn how individual lifestyle, environmental and genetic factors work together to affect our health so that all of us can learn how to prevent and treat disease,” Karlson said.

A cornerstone of the program is its emphasis on enrolling participants who reflect the rich diversity of the U.S., especially those who have historically been underrepresented in research, Clark explained.

“Too often, as we think about medical breakthroughs and research, the information we rely on is not always tailored to the needs of diverse communities – that can include social factors such as race, ethnicity, sexual orientation or gender identity,” Clark said. “We want to make sure the treatments we develop really do reflect the needs of every person, which makes it so important that people from all walks of life participate.”

Blackwell-Moquin, who is African-American, said she was moved by the program’s mission to improve representation in medical research and care. By enrolling in All of Us, she hopes to learn more about her own health while also supporting an effort that could uncover important information that would benefit future generations.

“I don’t know a lot of my medical family history. Sometimes there’s information that isn’t discussed in families, or the person who does know has passed on,” Blackwell-Moquin said. “And just because it’s not in your family history doesn’t mean it can’t happen to you. Doctors can’t order every test under the sun. But if African-Americans can learn, for example, that some are prone to certain diseases or disproportionately affected by specific issues, that is so important.”

Learn more about the All of Us Research Program at joinallofus.org. To find out how you can enroll as a participant at the Brigham, call 617-768-8300 or email allofus@partners.org.

Brigham Health’s Strategy in Action: Improve Health
Learn more about our strategic priorities at BWHPikeNotes.org.

‘We Are Environmental Services’: Staff Pledge Commitment to BWH’s Mission

Hospital senior leaders and Environmental Services staff unveil the department’s “We Are Environmental Services” poster.

Recently, Loay Kitmitto, CMIP, director of Environmental Services, turned an idea into reality for his team. Displayed on the wall outside the Environmental Services office on the Lower Pike is a large framed image depicting the “roof” of the Brigham’s strategy house, which outlines the institution’s mission, vision and values. Surrounding the graphic are signatures belonging to Environmental Services staff, signifying their commitment to the Brigham’s patients, their families and each other.

Kitmitto, who spearheaded the project, and his colleague Mostafa Boudal, manager of Environmental Services, wanted members of their team to understand how valued they are and the vital role they play in the patient experience. A headline above the image reflects this pride, stating “We Are Environmental Services.”

“These folks are some of the unsung heroes of our hospital. They are part of the care team for patients,” said Kitmitto, who oversees housekeeping, grounds maintenance, waste management and the unit associate program across BWH’s main and distributed campuses. “I am proud of each one of them for what they do each day to support the Brigham and make sure all areas are safe and clean.”

Earlier this month, Kitmitto and Boudal, along with several Environmental Services staff members, unveiled the framed image for senior leaders, including Ron M. Walls, MD, executive vice president and chief operating officer at Brigham Health; David McCready, senior vice president for Surgical, Procedural and Imaging Services, and Facilities and Operations; and George Player, CPE, FMA, vice president for Facilities and Operations.

Walls thanked the staff for their dedication to the Brigham. “I am so proud of our Environmental Services team members, who are role models for all of us here,” he said. “Every one of us needs to find our own way to bring the Brigham’s mission and values to life.”

McCready agreed, noting how critical the department’s role is to the entire hospital.

“Our Environmental Services colleagues are clearly proud of the Brigham, and we are all equally proud of them,” McCready said. “I’m so impressed by Loay and Mostafa’s leadership on this, and by their staff’s rock-solid commitment to our mission.”

During the brief unveiling, Environmental Services marveled at the sea of signatures and smiled as they spotted a colleague’s name or their own.

As Player admired the image, he said it’s an excellent reminder of why BWHers come to work each day: to provide patients and their families with the best possible care experience.

“It means a lot to have our employees sign their names on this board,” Player said. “I want each of them to know that we appreciate their incredible work and value their unwavering dedication to the Brigham.”

Brigham Health’s Strategy in Action: People, Education, Skills and Capabilities
Learn more about our strategic priorities at BWHPikeNotes.org.

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New Cardiac Pump Improves Long-Term Outcomes for Heart Failure Patients

Mandeep Mehra

BWH investigators have found that heart failure patients who received a novel circulatory heart pump had lower rates of pump-related blood clots and stroke after two years compared to patients who had received a commercially available model. Mandeep R. Mehra, MD, executive director of the Center for Advanced Heart Disease and medical director of the Heart & Vascular Center, presented findings from the clinical trial known as MOMENTUM 3 at this year’s American College of Cardiology meeting in Orlando, Fla. Results were simultaneously published in The New England Journal of Medicine.

“This is a pivotal study in the field of advanced heart failure,” said Mehra. “Left ventricular assist devices have been in development for 40 years, and while there have been improvements in their technology, several challenges exist, including problems of blood clots forming in these devices, requiring device replacement. The field has been trying to engineer devices that could make these devices more compatible with blood, and we’re reporting on some important advances.”

The trial, sponsored by the HeartMate’s manufacturer, Abbott Inc., evaluated the performance of the HeartMate 3 left ventricular assist system versus its predecessor, the HeartMate II. The HeartMate 3, which includes several technological adaptations intended to reduce risk of complications, consists of a fully magnetically levitated, continuous centrifugal-flow circulatory pump. This means the device runs like a bullet train – its rotor contains no mechanical bearings, pushes blood using only magnetism and is thus frictionless. It is designed to reduce a form of mechanical strain on blood elements known as shear stress, which is thought to cause blood clots to form in pumps.

By comparison, the HeartMate II uses an axial-flow pump, which uses a rotor that spins on a central ruby bearing to pump blood from the heart throughout the body.

The trial evaluated how many participants had not suffered a disabling stroke or had an operation to replace or remove a malfunctioning device after two years. Researchers reported that about 78 percent of patients who received the HeartMate 3 did not experience a disabling stroke or need a reoperation compared to approximately 56 percent of those on the HeartMate II.

Only three people who received the newer pump needed a reoperation – and none of those due to blood clots – compared to 30 with the commercially available implant.

Improving Access to Novel Therapies

MOMENTUM 3 launched in 2014 and was designed to dramatically reduce the overall timeline for clinical trials. All patients with refractory heart failure who needed a cardiac pump were eligible for the trial, regardless of whether the pump was intended as bridge to transplantation or the primary therapy.

“Traditional trials must first complete safety testing, followed by testing in populations of healthier transplant eligible patients, and it can be more than a decade before the broader advanced heart failure population has access to such therapies,” said Mehra. “Removing restrictions based on transplant status resulted in a unique study that has been extremely successful in its enrollment and highly expeditious in delivering results.”

In its next phase, MOMENTUM 3 will evaluate 1,028 patients at the two-year mark to further validate the current findings. Results of the full cohort are expected in 2019.

Brigham Health’s Strategy in Action: Discovery and Innovation
Learn more about our strategic priorities at BWHPikeNotes.org.

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Study: Surgery May Offer Better Outcomes for Obesity, Diabetes Control

Donald Simonson

Patients with worrisome levels of obesity and poor control of their Type 2 diabetes face two dramatically different options to improve their health: surgery or significant lifestyle changes. In a randomized controlled clinical trial, scientists from BWH and Joslin Diabetes Center found that patients who underwent a form of weight-loss surgery known as Roux-en-Y gastric bypass did significantly better after three years than those who followed an intensive diabetes- and weight-management program.

“Our study demonstrates that in patients with mild-moderate obesity and Type 2 diabetes, gastric bypass surgery leads to a sustained reduction in weight, improvement in glycemic control and decrease in cardiovascular risk, compared to a medical diabetes- and weight-management program,” said lead author Donald Simonson, MD, ScD, MPH, of the Division of Endocrinology, Diabetes and Hypertension.

Other BWH contributors to the research include Florencia Halperin, MD, medical director of the Program for Weight Management, and Ashley Vernon, MD, a member of the Center for Metabolic and Bariatric Surgery.

The paper, which will be published the April issue of Diabetes Care, provided the results from the SLIMM-T2D (Surgery or Lifestyle with Intensive Medical Management in the Treatment of Type 2 Diabetes) study, which randomly assigned 38 obese patients with Type 2 diabetes to Roux-en-Y gastric bypass surgery at BWH or an intensive lifestyle management program at Joslin. Initially, participants had an average weight of 230 pounds and body mass index (BMI) of 36.3.

After three years, patients who underwent surgery experienced far more weight loss, dropping 55 pounds on average. Those in the lifestyle-management intervention lost an average of 11 pounds over the same period.

Additionally, patients in the surgery group lowered their blood sugar to a greater degree, seeing hemoglobin A1c levels drop 1.79 percentage points. In comparison, patients in the lifestyle-management program experienced a 0.39 percentage point decrease. Those who received surgery also showed significantly lower risk of coronary heart disease and stroke.

‘A Viable Option’

Although patients given the lifestyle-management program made encouraging initial progress in both weight loss and diabetes control, investigators noted that those improvements dropped noticeably over time.

“Patients who had the gastric bypass procedure had superior ability to sustain changes both in weight and blood sugar, and they did so requiring less medication for their diabetes, their blood pressure and their lipids,” said Allison Goldfine, MD, head of clinical research at Joslin during the trial and senior author on the paper.

Participants from both groups reported improvements in overall quality of life. Those who were assigned the surgical intervention experienced greater improvement in physical functioning, self-esteem and work performance, and weight loss had a significantly higher effect on their quality of life compared to the other group.

“As a result of these findings, we expect that more physicians will consider gastric bypass surgery as a viable option for patients with Type 2 diabetes and mild to moderate obesity when previous attempts to lose weight and improve glycemic control have not been successful,” said Simonson.

The Roux-en-Y gastric bypass procedure is done laparoscopically through small cuts in the abdomen. Surgeons form a small pouch at the top of the stomach and connect the pouch to the middle of the small intestine.

Joslin’s 12-week intensive lifestyle-management program included a change in diabetes medications to enhance weight reduction, structured dietary intervention with lower carbohydrates and higher protein and meal replacement, an exercise program with emphasis on strength training, and weekly educational and support sessions.

Goldfine emphasized that treatment must be personalized for all patients with obesity and diabetes, as gastric bypass surgery may not always be the best option. She noted that today’s surgical procedures and intensive lifestyle-management techniques both take advantage of major medical advances achieved in the past decade or two.

“Older surgical procedures were much more invasive, with much higher surgical risk and complication rates, and older types of procedures had higher failure rates over time,” she said. “Laparoscopic surgery made the biggest impact on the surgical experience and recovery, but we have improved surgical techniques all the way from preoperative evaluations to better postoperative care.”

Brigham Health’s Strategy in Action: Discovery and Innovation
Learn more about our strategic priorities at BWHPikeNotes.org.

New Angiography Imaging System Comes to Hybrid OR

From left: Michael Belkin, Felicity Billings and Edwin Gravereaux, beside the ARTIS Pheno imaging system in BWH’s hybrid OR.

BWH surgeons and interventionalists working in the Michael J. Davidson, MD, Hybrid Operating Room are among the first clinicians in the Northeast to use the new ARTIS Pheno angiography imaging system.

The powerful, robotically controlled device delivers high-end imaging for patients undergoing certain cardiac, endovascular or thoracic surgeries or procedures.

The Brigham has a rich history of pioneering technologies and imaging tools in the hybrid operating room (OR) to deliver the most advanced care to patients. Some interventions that once took place over several days – historically in multiple operating rooms and diagnostic labs – can now be done over the course of one visit in the hybrid OR. BWH was the first hospital in the U.S. to use the ARTIS Zeego system, the Pheno’s predecessor, in the OR.

Known as “C-arms” for their C-shaped design, the Zeego and Pheno perform real-time X-ray imaging during angiograms and therapeutic procedures. Both are designed to rotate completely around a patient’s body, making it easier to diagnose a condition in the OR and, if necessary, immediately operate.

BWH clinicians are using these imaging systems to guide increasingly complex procedures, such as aortic valve replacements and transcatheter aortic valve replacements (TAVRs). These require high-quality, granular imaging – an area in which the Pheno offers several improvements, according to Michael Belkin, MD, chief of the Division of Vascular and Endovascular Surgery.

“The Pheno algorithms will allow us to better perform these procedures,” he said. By better, Belkin means faster imaging, less radiation exposure for patients and interventional surgeons, and higher-quality images. Resolution for two-dimensional imaging in Pheno is four times higher than in the older device.

Last month, BWH clinicians began enrolling patients in a clinical trial for transcatheter mitral valve replacement, a study the Pheno will support, said cardiac surgeon Tsuyoshi Kaneko, MD, of the Division of Cardiac Surgery.

“This trial requires a thoracotomy – a surgery to open the chest wall – which we will perform in the hybrid OR. It’s a perfect example of where the Pheno will be really useful,” Kaneko explained, as the newer system will provide better visibility and resolution with less contrast load.

Improving Quality and Safety

In addition to the new system’s advanced capabilities, parts of its design are expected to improve care quality and safety for patients in the hybrid OR, providers said. Pheno’s wider-space robotic C-arm moves more easily in and out of the patient field without interrupting the sterile surgical field. And as a more closed system compared to the Zeego, the Pheno is easier to keep sterile.

“The Zeego moves like an old-generation robot, whereas Pheno will be silky smooth when the arm moves and will make our procedures much, much easier,” Kaneko said.

The new device also enables clinicians to obtain images faster. “We want to see the image in a matter of seconds, especially when working on an urgent or complex case,” said Kaneko. This isn’t only a matter of convenience; it also concerns patient safety. Because the Pheno scans up to 15 percent faster than earlier systems, images are produced with less IV contrast – an added benefit, as contrast can tax the kidneys.

While the Pheno likely won’t be used for conventional open cardiac, thoracic or endovascular procedures, Belkin is enthused about the device’s potential benefits for patients for whom its use is appropriate.

“We are already doing hundreds of cases every year in the hybrid OR now,” Belkin said. “With this newest machine, we can deliver even better care to our patients.”

Brigham Health’s Strategy in Action: Advanced, Expert Care
Learn more about our strategic priorities at BWHPikeNotes.org.

‘My Heart Is Full of Love’: Patient Grateful for Care, Compassion

From left: Ann Washington, Cindy Washington and Darien Clark

At age 25, Cindy Washington and her heart have been through a lot: two cardiac arrests, the installation of a pacemaker and, most recently, the implantation of a left ventricular assist device (LVAD). But the Roxbury native says there’s one thing that has kept her heart going through all the hard times: love.

“From the amazing care team at the Brigham to my fiancé, mom, siblings and friends, I am so grateful for all the support I receive from them every day,” Washington said. “If it weren’t for these people in my life, I don’t know where I’d be today. Because of them, my heart is full of love.”

In 2011, Washington was diagnosed with dilated cardiomyopathy, a type of heart failure due to an enlarged heart that has an impaired ability to pump blood. Despite having an implantable defibrillator placed in her chest in 2014, her heart grew weaker. In 2016, she needed to have an LVAD implanted. The LVAD, a mechanical pump that supports heart function and blood flow in patients with heart failure, is a “bridge to transplant” as Washington awaits a donor heart.

On Valentine’s Day, Washington came back to BWH with her mom, Ann Washington, and fiancé, Darien Clark, to visit with members of her care team and thank them for all they’ve done for her and her family.

Ann, who saved her daughter’s life twice by performing CPR on Washington when she suffered the cardiac arrests, said she’s forever grateful for the incredible, compassionate care provided at BWH.

“I know Cindy might not be here today if it wasn’t for the extraordinary team of experts at the Brigham that has never given up on my daughter,” said Ann, as she wiped tears from her eyes.

‘A Special Patient’

After Washington first became sick, she had to drop out of college because she was too weak to attend classes and keep up with the workload. She became depressed and isolated from family and friends. Today, her life looks a lot different. She feels great and is taking online courses, with hopes of one day becoming a health policy lawyer. Washington said she’s gotten through the tough times because of her support system, both at the Brigham and at home, and by maintaining a positive outlook.

“Heart disease hasn’t beaten me yet,” Washington said. “I’ve always told myself that I’ve never had a broken heart; it’s just been a little sick. My will is strong, and I refuse to let anything get me down.”

Michael Givertz, MD, medical director of BWH’s Heart Transplant and Mechanical Circulatory Support Program, is a member of Washington’s care team. He described Washington as a “very special patient” who, from a young age, has remained hopeful, joyful and positive.

“Cindy is a shining example of a patient who is living life as fully as she can,” Givertz said. “She’s independent, strong and determined. She’s a true pleasure to care for, and I feel fortunate that I’ve had the opportunity to get to know Cindy and her family.”

Knowing that returning to school was important to Washington, Givertz wrote her a letter of recommendation for a college scholarship.

Another person who has been instrumental in Washington’s life is her fiancé, who has stood by her side through everything. Clark said he wouldn’t have it any other way. Although it has been difficult to see his loved one hurting, he knew they’d get through it – together.

“Cindy is my world,” Clark said. “She’s my valentine today and every day. We’ve overcome so many obstacles together, and I will never leave her side.”

Brigham Health’s Strategy in Action: Advanced, Expert Care
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Study: Stroke Risk Factors Unique to Women Identified

Kathryn Rexrode

Stroke disproportionately affects more women than men. It’s the fourth leading cause of death in women in the U.S., a prominent cause of disability and affects 55,000 more women than men each year. But what causes the disparity?

Investigators from BWH are looking to answer this question by exploring the effects of risk factors that are unique to women, including hormone levels, hormone therapy, hormonal birth control, pregnancy, first menstrual period and menopause.

In a paper published in Stroke earlier this week as part of a special issue focused on women’s health in honor of American Heart Month, investigators highlight these risk factors as well as areas where future research is needed, including the effects of hormone therapies for transgender people.

Corresponding author of the paper Kathryn Rexrode, MD, MPH, chief of the Division of Women’s Health, said that many people don’t realize that women experience a stroke more frequently than men and that mortality is much higher among women.

“As women age, they are much more likely to have a stroke as a first manifestation of cardiovascular disease rather than heart attack,” said Rexrode, who led a team that delved into the scientific literature to investigate evidence behind this finding. “We want to better understand susceptibility: Why are women more susceptible to strokes than men? What factors are contributing and disproportionately increasing a woman’s risk?”

Considerations for Clinicians

In this review, researchers reported on several hormonal factors that elevate the risk of stroke among women, including experiencing first menstruation and menopause at an early age, having low levels of the hormone dehydroepiandrosterone (DHEA) and taking oral hormones, whether as estrogen oral contraceptives or postmenopausal hormone therapy.

The team noted that while many of these factors are extremely common, the absolute risk in younger women is relatively small. However, Rexrode emphasizes it’s important for clinicians to consider these factors when evaluating a female patient’s risk of stroke. Additional factors unique to women include a history of pregnancy complications, such as gestational diabetes, pre-eclampsia or hypertension during or immediately following pregnancy.

“These women should be monitored carefully, and they should be aware that they are at a higher risk, and motivated to adhere to the healthiest lifestyle to decrease the risk of hypertension and subsequent stroke,” Rexrode said.

Certain risk factors, such as taking transdermal estrogen or progestogen-only contraception, need further research, according to the authors. The team also conducted a search of the literature for studies on the impact of hormones on stroke risk in transgender individuals, but reported there is scant evidence on the effects of medical treatment with estrogens, anti-androgens or a combination of both.

Brigham Health’s Strategy in Action: Discovery & Innovation
Learn more about our strategic priorities at BWHPikeNotes.org.

Digital Tool Helps Patients, Staff Find Their Way

From left: Helen Thompson, Josie Elias and Ashley Buckley look at directions provided by the BWH wayfinding tool.

Have you ever started walking to a meeting or tried to give someone directions to an unfamiliar part of the Brigham, only to realize you weren’t entirely sure how to get there? Thanks to a group of in-house innovators at BWH, a new online wayfinding tool is helping patients, visitors and staff get to where they need to go around the main campus.

Accessed through a web browser on any internet-connected device, the wayfinding tool is designed to help users navigate the hospital several different ways. Available at maps.brighamandwomens.org, the web-based tool can provide directions to a location in the Brigham from an outside site, such as a person’s home address. To get from one place to another within the hospital, users receive step-by-step walking instructions alongside a map that illustrates their path.

The wayfinding tool’s robust directory includes far more than the locations of clinics and conference rooms. It can also help patients, visitors and staff find various services within and outside the hospital, such as the BWH Shop on the Pike or a nearby restaurant. In addition, the tool allows users to search locations by the name of the clinic, conference room, service line, patient floor and much more.

For about two years now, an interdisciplinary team at BWH has been working diligently to build and test the online navigation tool. Josie Elias, MBA, MPH, program manager for Digital Health Initiatives at the Brigham Digital Innovation Hub (iHub), who has led the project since its inception, said she’s proud of what the teams have accomplished and hopes people find the tool to be useful.

“We wanted to alleviate the stress of trying to locate a specific area in the hospital,” Elias said. “The Brigham is a very large institution and sometimes it can be difficult for people, including staff, to locate their destination.”

This tool is designed in a way that enables the team to easily modify and add locations if, for example, an office relocates or there’s demand to include locations not currently in the directory, Elias added.

Using wayfinding is simple and intuitive, said Cassandra Lee, a marketing specialist at iHub. A starting location can be entered manually – bringing up a list of options as you type – or, for internal locations, selected by browsing the directory. When starting from somewhere outside the main campus, the tool can also identify your current location using GPS.

Among the many BWHers who collaborated with iHub to design, build and test the tool was Andrew Shinn, a planner in BWH Real Estate and Facilities. Shinn has worked closely with Elias and the team to make sure the directions provided in wayfinding are up to date and match signage throughout the hospital. Shinn said it’s wonderful to see the technology come to fruition in the hospital setting.

“It’s exciting to produce a tool that will provide a better experience for our patients, visitors and staff,” Shinn said. “I’m looking forward to continuing to work with the group to discuss feedback and make sure the tool reflects what users want to see.”

As early adopters, Helen Thompson, manager of Patient Access Services, and Ashley Buckley, a supervisor in Patient Access Services, have worked with Elias and the team to develop and refine content and naming conventions in the web-based tool. Buckley and Thompson said they’re eager to share its capabilities with patients, visitors and staff.

Buckley said she’s enjoyed being involved in so many aspects of the project, from design to implementation. She’s looking forward to seeing the tool evolve over the coming months.

“I know this tool will have a positive impact on patients, families and staff,” Buckley said. “I’ve found that I use wayfinding so often now, especially when I’m running from one meeting to another. I know my colleagues are going to enjoy using it as well.”

Thompson agreed, adding that it’s an exciting time to be at the Brigham.

“The wayfinding tool is another example of how the Brigham is moving forward with technology that is designed to make life easier for our patients, their families and our colleagues,” Thompson said. “I’m grateful that Josie and the team have put so much thought into the design of this tool. It’s really something special.”

To submit feedback and questions about the wayfinding tool, email BWHWayfinding@partners.org.

Brigham Health’s Strategy in Action: Exceptional Experience
Learn more about our strategic priorities at BWHPikeNotes.org.

Innovative Pilot Improves ED Access, Reduces Walkouts

Emergency Department staff gather to celebrate a year of a sustained reduction in walkout rates.

A cornerstone of any emergency department (ED) is to see the sickest patients first – a practice that has saved countless lives. But it has the unintended side effect of leaving patients with less-acute symptoms waiting to be seen by a physician when the department is at capacity.

“Previously, some patients waited several hours to be seen for an issue that takes five or 10 minutes to address, such as a medication refill or wound evaluation that doesn’t need an intervention,” said Christopher Baugh, MD, MBA, medical director of the ED in the Department of Emergency Medicine.

When the ED is at capacity, some patients leave after being seen by a triage nurse, but before being seen by a physician. When a “walkout” occurs – often due to long wait times – it not only leads to a poor patient experience, but it is also a safety concern, as nearly 30 percent of patients who receive care in the Brigham’s ED are sick enough to be admitted.

Over the past year, a multidisciplinary team has piloted a care delivery model that reduced door-to-physician time and sustained lower ED walkout rates. The intervention centered on turning two sections of the ED known as surge areas – nonclinical spaces that were temporarily used to see patients during high-volume periods – into regularly staffed areas where patients could be seen by a physician within about 20 minutes of arrival. In addition, ED Radiology partnered with the team to flag certain imaging orders to expedite a patient’s evaluation.

Now operational and staffed every weekday during peak times, the surge spaces consist of the “front end” – a curtained-off section of the waiting room – and one hallway inside the ED, where eight stretchers are separated by opaque dividers.

Faster Access to Care

Prior to the intervention, a patient who checked into the ED would be seen by a triage nurse and have their vital signs checked. If the patient wasn’t identified as critically ill and there was not an available treatment space, further care – such as lab testing, imaging or pain medication – was delayed until a room was available.

Lower-acuity patients, such as those who come in with a sore throat or sprained ankle, are now often able to be seen in the front end shortly after arrival. When in use, the area is staffed with a physician, nurse, nursing assistant and medical scribe. The area can accommodate four to five patients at a time. Most patients seen in the front end can be treated and safely discharged from there.

“It’s definitely a different way of doing things, and it’s much quicker,” said Sue Botsch, RN, an ED nurse who staffs the front end. “You’re not waiting for things to happen because the team is right here. I like that it’s a real-time application of care, and patients appreciate going home in an hour.”

Staff Support Drives Success

Prior to the intervention, ED walkout rates ranged from about 2.5 to 4 percent, with some individual days reaching as high as 8 or 9 percent. Since implementing the new model in December 2016, the walkout rate has consistently remained under 2 percent since January 2017, with one month as low as 0.7 percent.

“As soon as we opened this surge capacity as a regular practice every weekday, we saw the walkout rate drop dramatically and immediately,” said Jonny McCabe, BSN, RN, operations director in Emergency Medicine.

Pivotal to the initiative’s success has been a cultural change among ED staff, said Janet Gorman, MM, BSN, RN, executive director of the ED.

“We owe it to our community to be available for them, and if there’s no access, we’re doing them a disservice,” Gorman said. “I’m so proud of our staff, who truly took ownership of this work to improve how we care for our patients.”

Anna Meyer, DNP, RN, interim ED nursing director, said the pilot’s success reflects the team’s commitment to multidisciplinary collaboration.

“We definitely stepped outside our comfort zones, but everyone’s continued hard work has paid off for our patients,” Meyer said. “The sustained success shows how well we work together.”

Looking Ahead

Still, the team sees room for improvement. In monthly Press Ganey surveys, some ED patients report concerns regarding privacy and comfort – feedback the team takes to heart, Baugh noted.

“There is certainly a tradeoff,” he said. “Hallway and surge-area care are short-term interventions that improve patient safety by lowering our waiting room census and walkout rate. We track these metrics and share them with hospital leadership because we need everyone to understand how hospital crowding affects ED care.”

Although the upcoming ED expansion will add 30 beds and alleviate some of the current challenges, Baugh underscored the importance of taking what the team has learned from the pilot and incorporating those efficiencies into the new design.

“We have to change the way we engage with our patients – not just add more treatment rooms,” he said. “We think we can borrow from this process and continue to refine it to get even better use out of our new space.”

Brigham Health’s Strategy in Action: Timely Access
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DF/BWCC Opens New England’s First Adult Cancer Diagnostic Service

From left: Cancer Diagnostic Service team members Luke Arney and Louise Schneider

Sometimes, a routine medical examination leads to more questions than answers. But for patients with suspicious and complex symptoms that point to cancer, not receiving concrete answers right away about their diagnosis can be especially scary.

Take, for instance, a patient who met with her Partners HealthCare-affiliated primary care physician (PCP) for a routine lung cancer screening. While a chest CT scan didn’t show signs of lung cancer, it did reveal a bone lesion and pathologic rib fracture, a form of rib injury caused by disease rather than blunt trauma. Additional tests suggested cancer, but her doctor wasn’t sure.

Such a patient poses an unusual challenge. A referral to an appropriate oncologist is difficult because a cancer diagnosis has not been made, but the next steps in the diagnostic workup aren’t always clear either for PCPs. Yet the prospect of a cancer diagnosis also creates stress, so everyone wants answers as soon as possible.

The Cancer Diagnostic Service (CDS) at Dana-Farber/Brigham and Women’s Cancer Center (DF/BWCC) aims to alleviate that uncertainty and make the determination of a cancer diagnosis faster and simpler for patients and their providers. Initially piloted as a virtual clinic to help Partners-affiliated PCPs streamline and expedite a diagnosis for patients with suspected cancer, the CDS recently graduated from its pilot phase and began seeing patients in its new physical space on the main campus.

While the service’s biggest users at the moment are PCPs within Partners, including those at the Brigham, it is expected to grow into a regional resource for referring physicians at other health care organizations as well.

“When there is a strong suspicion of cancer without a definitive diagnosis, it can be difficult for patients and physicians,” said Lindsay Carter, MD, MBA, medical director of the Cancer Diagnostic Service. “As doctors order additional diagnostics test for their patients or seek input on the appropriate next steps, there can be significant delays and unnecessary tests. We created the Cancer Diagnostic Service to streamline the process to help doctors reach a timely diagnosis so that treatment can begin without delays.”

The patient with suspicious findings on her lung CT was referred to the CDS, where she was diagnosed with adenocarcinoma – a form of cancer – following a CT-guided biopsy. She was then seamlessly transferred to a thoracic oncologist at Dana-Farber Cancer Institute (DFCI) to begin treatment.

A More Seamless Approach

During the center’s six-month pilot, which began in October 2016, providers used Epic’s E-consult function to consult virtually with CDS staff. Of the 82 cases evaluated by the clinic’s staff – an internist, physician assistant and consulting BWH and DFCI oncology specialists – 70 percent of patients were recommended for and received a full diagnostic work-up. Among that group, nearly two-thirds were ultimately diagnosed with cancer and referred to oncologists or surgeons.

The pilot generated an overwhelmingly positive response from PCPs. “It’s scary when your patient has cancer, and it was really nice to have someone guide you as you make diagnostic decisions,” wrote one physician in a feedback survey. Others praised the rapid response and seamless process in reaching a diagnosis.

With funding from the Brigham Care Redesign Incubator Startup Program (B-CRISP) and DFCI, the CDS opened its physical space on Oct. 20 in the Brigham Medical Specialties Suite at 45 Francis St. The team sees patients on Wednesday mornings and Friday afternoons. Patients are scheduled for an appointment within five business days of the referral.

“After a referral, the CDS takes ownership of each patient’s case and coordinates the diagnostic work-up. We communicate detailed results and a suggested treatment plan to both patients and referring providers,” said Ryan Leib, MBA, administrator for the CDS and director of Ambulatory Practice Management at DFCI. “Now that we have an established physical location, we are reaching out to the referring physician community to inform them about this unique service.”

To refer a patient the Cancer Diagnostic Service, call 857-307-5775. Partners HealthCare physicians may also submit an Epic order to Ambulatory Referral to DF/BWCC Cancer Diagnostic Service.

Brigham Health’s Strategy in Action: Timely Access
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Town Meeting Highlights Efforts to Improve Access, Enhance Safety

Betsy Nabel addresses BWHers during Town Meeting.

Overcoming challenges through collaboration, innovation and expansion was a theme echoed throughout Town Meeting, held in Bornstein Amphitheater on Dec. 1.

Among these challenges is the unusually high patient census BWH has experienced in recent months. While high volume is a testament to the quality of care at the Brigham, it can cause undue pressure on patient flow, requiring the use of Code Help and sometimes Code Amber to reduce the number of boarders in areas such as the Emergency Department (ED) and the Post-Anesthesia Care Unit (PACU), said Brigham Health President Betsy Nabel, MD.

“We’ve been very busy this fall, and that is a real sign of confidence that patients have in the care we deliver,” Nabel said. “But that also presents a challenge for us: We must continue to deliver safe, exceptional care every day, including when we have high occupancy rates.”

While there are long-term plans to build a new inpatient tower at 45 Francis St. to accommodate a greater number of patients, that is still several years away, Nabel explained. A more immediate solution is needed to optimize our existing resources, she added.

Charles Morris, MD, MPH, associate chief medical officer, and Eric Goralnick, MD, MS, medical director of Emergency Preparedness and the Brigham Health Access Center, announced a new initiative launching in January to address these challenges. Every weekday at 9 a.m., clinical staff and members of the senior leadership team will gather for a daily safety huddle. These focused meetings will provide an opportunity to proactively identify obstacles to managing patient care in a safe, timely manner.

“It’s a chance to increase the situational awareness of where we are each day at an institutional level,” Morris said. “At the same time, we’ll be able to do near real-time problem-solving so that we can get patients the care they need.”

At the heart of these efforts is greater communication at all levels, said Ron M. Walls, MD, executive vice president and chief operating officer.

“We need to learn from providers on the front lines – and not just people at the bedside but also those registering or transporting patients. We need all of your ideas about what things we can fix, and we’re very committed to fixing them,” Walls said.

Identifying Efficiencies

In addition, a project is underway in the ED to double its size – adding 30 patient rooms, larger trauma bays, a second CT scanner and areas dedicated to oncology and behavioral health patients.

During the question-and-answer portion of Town Meeting, one BWHer asked how the ED expansion will affect wait times and boarder volume without a concurrent expansion of inpatient beds in the short term. Walls explained that a redesign of BWH’s care continuum management program – a blend of care coordination and utilization management – is underway to better support both the ED and inpatient areas as well as imaging, transport, procedural areas, operating rooms and more.

“We know that we don’t have space to accommodate additional patients in the beds that we have, nor can we ask people to work any harder because it is plain to see how hard everyone works here,” Walls said. “Our goal is to provide teams with the support they need to be more effective, efficient and empowered to identify solutions.”

Community hospitals will also play an important role in streamlining patient flow.

Goralnick explained that the Access Center, launched earlier this year, provides a centralized system to facilitate timely, safe patient transfers across Brigham Health. Part of its goal is to identify which transfer requests from referring hospitals can be safely directed to community hospitals like BWFH or Newton-Wellesley Hospital. This improves access to care for more tertiary and quaternary patients at BWH.

“The idea is to find the right bed for each patient to support the best care,” Goralnick said.

Brigham Health’s Strategy in Action: Highest-Quality, Safe Care
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‘An Unbreakable Bond’: BWHers Partner with Indian Health Service Providers

From left: Hanni Stoklosa, Mardi Chadwick, Annie Lewis-O’Connor, Jacqueline Savage Borne and Jessica Loftus

For several BWHers, including Srini Mukundan, MD, PhD, of the Department of Radiology, being able to work with care providers at Northern Navajo Medical Center in Shiprock, N.M., and Gallup Indian Medical Center in Gallup, N.M., through the Brigham and Women’s Outreach Program with Indian Health Service (IHS) has been an educational and transformative experience they will always cherish.

Mukundan, who has trained IHS staff on-site in Shiprock and remotely from BWH, said his experiences with the program provide an antidote to burnout and remind him why he chose this path in medicine.

“The Outreach Program opportunities have been one of the greatest rewards of being a BWHer,” Mukundan said. “After meeting the wonderful patients and witnessing firsthand the work of our remarkable colleagues at Shiprock, it is clear how important the essence of the physician-patient relationship is, especially in light of the limited resources available in Shiprock.”

Since 2009, BWHers have collaborated with the Navajo Area IHS – the federal agency responsible for delivering medical and public health services to members of federally recognized Native American tribes in the region. Through the Brigham and Women’s Outreach Program with IHS, BWH faculty, nurses, trainees and other providers volunteer their time and expertise to provide specialized care and training – on the ground at IHS hospitals and through remote teaching – in rural New Mexico and Arizona.

Advancing Care

Over the past year, BWHers across multiple disciplines have helped establish critically needed and sustainable services that would have otherwise been unavailable in these resource-poor areas.

Earlier this year, a BWH team traveled to Shiprock to teach IHS staff about human-trafficking in addition to screening and intervention strategies for domestic violence in the health care setting. Because of that visit, a BWH/IHS Trauma-Informed Care working group has been established with the goal to implement a trauma-informed care model in Shiprock by late 2018.

“During our time there, I learned new things from my Brigham colleagues as well as from the IHS staff. The whole experience challenged me to think more broadly about my interactions here with patients in the Emergency Department,” said Hanni Stoklosa, MD, MPH, an attending physician in the Department of Emergency Medicine and a member of the Division of Women’s Health, who trained IHS staff in human-trafficking awareness.

Annie Lewis-O’Connor PhD, MPH, NP, director of the C.A.R.E. Clinic and a member of the Division of Women’s Health, provided staff with techniques for incorportating trauma-informed care into practice, emphasizing the need for self-care, patient autonomy and meeting patients where they are at.

Also on the team was Jacqueline Savage Borne, LICSW, hospital program manager for the Passageway program in the Center for Community Health and Health Equity, who said working with the program was a professional dream fulfilled.

“The providers at Shiprock are so deeply committed to holistic, trauma-informed care for their patients,” Savage Borne said. “The resiliency in this community and its network of care providers is nothing short of inspiring.”

The collaboration between BWH and IHS providers results in dramatic, lasting improvements in care. Because of the radiology training provided by Mukundan, a neuroradiologist and medical director of Magnetic Resonance Imaging at BWH, along with other faculty members and house officers from the Department of Surgery, Shiprock providers are now able to screen patients for stroke based on head CT scans. Prior to this, they had no ability to provide this service.

Also in the works is a live, interactive remote video-training program to license IHS clinicians to be able to administer buprenorphine, a medication to treat opioid use disorder. Joji Suzuki, MD, director of the Division of Addiction Psychiatry, provides the same training in Boston and will lead the new remote course. Such support is needed to help IHS clinicians combat the opioid crisis in their remote and resource-poor communities.

“I have a lot of respect for the clinicians in IHS. I have visited and taught remotely, and I’ve seen firsthand how they work under very difficult conditions due to their limited resources,” Suzuki said. “I’m pleased we’ll be able to help them have access to training that would have otherwise not been readily available.”

Thomas Sequist, MD, MPH, a primary care physician in the Phyllis Jen Center for Primary Care and medical director of the Outreach Program with IHS, said he believes the Outreach Program is a vital resource for the region.

“Access to specialty care services is particularly challenging in more rural parts of the country, often limiting the treatment options for patients in these areas,” said Sequist, who also serves as chief quality and safety officer at Partners HealthCare. “We are extremely proud of the work of our BWH clinical community – physicians, nurses and other staff working together to fill important gaps in care. This work is built on the premise of establishing long-lasting relationships that represent a sustainable approach to delivering advanced and high-quality care in these native communities.”

Brigham Health’s Strategy in Action: Improve Health
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BWH Celebrates Achievement of Comprehensive Stroke Center Certification

From left: Ali Aziz-Sultan and Steven Feske

The Stroke and Cerebrovascular Diseases Center received advanced certification as a Comprehensive Stroke Center from The Joint Commission and the American Heart Association/American Stroke Association on Nov. 15. This highly selective designation – awarded to only a small fraction of institutions in the U.S. – recognizes hospitals that meet the standards to treat the most complex stroke patients.

“This certification reflects our ability to care for these patients from the moment they come into our ED until they are discharged from our specialized unit,” said Linda Bresette, DNP, NP-C, director of the Brigham Health Stroke Program. “Our highly trained, multidisciplinary staff worked together to showcase how our stroke patients receive advanced, individualized care that’s grounded in science and delivered with compassion.”

To become certified, BWH underwent a rigorous on-site review by Joint Commission experts who evaluated all aspects of complex stroke care. This includes the initial assessment, treatment protocols, advanced imaging, and state-of-the-art facilities for urgent intervention and intensive care. The certification reflects that BWH meets advanced standards of stroke care and has provided evidence of successful performance on more than 18 quality measures. All BWH clinicians demonstrated advanced education and competency.

“This certification recognizes our multidisciplinary team of specialists who deliver the best in stroke care. It acknowledges our advanced diagnostic and treatment capabilities, and allows us to provide the most comprehensive medical, interventional and surgical therapies,” said Steven Feske, MD, chief of the Division of Stroke and Cerebrovascular Diseases and medical director of BWH’s Comprehensive Stroke Center.

Stroke is the fifth-leading cause of death and a leading cause of adult disability in the U.S., according to the American Heart Association/American Stroke Association. On average, someone suffers a stroke every 40 seconds; someone dies of a stroke every four minutes; and 795,000 people suffer a new or recurrent stroke each year.

To improve outcomes for stroke patients, BWH provides pre-arrival evaluation and treatment planning, accelerating treatment for patients transferred to BWH for advanced stroke care. The center also offers remote physician consultations via telemedicine. Once at the Brigham, patients receive rapid assessment by expert clinicians who have access to neuro-interventional suites and a dedicated neuroscience intensive care unit. Additionally, BWH researchers investigate groundbreaking approaches to stroke management in several national clinical trials.

“Stroke is a life-threatening emergency, and the greatest chance for recovery from stroke occurs when treatment is started immediately after the onset of symptoms,” said Ali Aziz-Sultan, MD, Neurosurgical director of BWH’s Comprehensive Stroke Center. “Newer stroke therapies offered at BWH, such as endovascular treatments, can rapidly reestablish blood flow and restore patients’ health.”

Brigham Health’s Strategy in Action: Advanced, Expert Care
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Harnessing the Power of Artificial Intelligence to Diagnose Ovarian Cancer

BWH and Dana-Farber Cancer Institute (DFCI) researchers are using artificial intelligence to detect ovarian cancer early and accurately with a simple blood test.

The team looked at a set of molecules called microRNAs, which help control where and when genes are activated. With the aid of an advanced computer algorithm, researchers identified a network of microRNAs that are associated with risk of ovarian cancer and can be detected from a blood sample.

Artificial intelligence, also known as AI, is a branch of computer science in which machines are trained to identify patterns and make predictions after analyzing large amounts of data.

“When we train a computer to find the best microRNA model, it’s a bit like identifying constellations in the night sky. At first, there are just lots of bright dots, but once you find a pattern, wherever you are in the world, you can pick it out,” said Kevin Elias, MD, of BWH’s Department of Obstetrics and Gynecology, and lead author of the study, published in eLife.

Unlike other parts of the genetic code, microRNAs circulate in the blood, making it possible to measure their levels from a sample.

“MicroRNAs are the copyeditors of the genome: Before a gene gets transcribed into a protein, they modify the message, adding proofreading notes to the genome,” said Elias, who collaborated with Dipanjan Chowdhury, PhD, chief of the Division of Radiation and Genomic Stability at DFCI.

Need for Early Detection

Most women are diagnosed with ovarian cancer when the disease is at an advanced stage, at which point only about a quarter of patients will survive for at least five years. But for women whose cancer is unexpectedly found at an early stage, survival rates are much higher.

Existing early-detection blood tests frequently report false positives and have shown no meaningful effect on survival rates. With this in mind, BWH and DFCI researchers sought to develop a tool that would be more sensitive and specific in detecting cases of early-stage ovarian cancer.

To do this, the team investigated the microRNAs in blood samples from 135 women before they underwent surgery or chemotherapy. These samples were used to train a computer program to look for differences in microRNA that indicated the presence of ovarian cancer and to accurately distinguish samples from harmless non-cancerous masses.

When the computer program predicted cancer, it was right more than 90 percent of the time. Similarly, a negative test reflected absence of cancer about 80 percent of the time, which is comparable to the accuracy of a Pap smear test.

“The key is that this test is very unlikely to misdiagnose ovarian cancer and give a positive signal when there is no malignant tumor. This is the hallmark of an effective diagnostic test,” said Chowdhury.

To move the diagnostic tool out of the lab and into the clinic, the research team will need to monitor patient samples further. They are particularly interested in determining if the tool will be useful for women at high risk of ovarian cancer as well as the general population.

Brigham Health’s Strategy in Action: Scalable Innovation
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Just Around the Bend: Rehab Services Relocates to Shapiro

Physical therapist Caitlin Guzy supports patient Luis González during his physical therapy session in the clinic’s new space.

Sunlight, street-level visibility and greater privacy – these are just a few upgrades providing a better experience for Ambulatory Rehabilitation Services patients, families and staff in the department’s new clinic in the Shapiro Cardiovascular Center.

Formerly located on the ground-level Pike at 45 Francis St., Rehab Services’ outpatient team began seeing patients in its new main campus space on Oct. 23. The department relocated to the first-floor area of Shapiro formerly occupied by the Great Living Café.

While the previous location used curtains to separate patient areas, the new clinic space contains five private exam rooms. Frosted glass on the windows ensures patient privacy for the Francis Street-facing open treatment and gym space.

“The new rehabilitation space is wonderful,” said patient Luis González, who has been receiving physical therapy at the Brigham following surgery. “I like how there is so much natural light. It’s nice to be able to look out the windows when I’m doing my therapy. I enjoy every minute when I’m here. I’m feeling better each time I come for therapy, thanks to the great therapists who spend time working with me.”

In addition to providing a better overall experience, the exam rooms will enable the department to expand its service line at the main campus to provide pelvic floor and lymphedema care soon, said Reg Wilcox III, PT, DPT, MS, OCS, who was recently named executive director of Rehab Services. Until now, pelvic floor care was only available at the department’s other ambulatory clinics: 850 Boylston St. and the Brigham and Women’s/Mass General Health Care Center in Foxborough.

The relocation to Shapiro offers other benefits for patients. Aside from being easier to find, the new space is more centrally located within the hospital – and closer to other clinics Rehab Services patients often visit when they come in, such as the Orthopaedic and Arthritis Center, Wilcox said.

“We provided excellent care in the old space, but this new location offers many opportunities to better serve our patients and staff in a convenient and expanded healing environment,” he said.

Wilcox, who has been with the department for 17 years, said one of his short-term goals as the new executive director is ensuring the Rehab Services team uses the new space effectively to meet the needs of patients seeking ambulatory rehabilitation care on the main campus.

Patients from Orthopaedics, Rheumatology, the Neurosciences and Internal Medicine and Primary Care are often referred to Rehab Services for outpatient care. As patient volume in those areas grows, it is important that Rehab Services is well-positioned to serve those patients, Wilcox said. This new space will assist with those plans.

“My big strategic goal is to have rehabilitation resources and staff, both ambulatory and inpatient, in the places they need to efficiently and effectively meet the needs of patients,” he said. “It’s about providing the right care for the right patient at the right time in the right location.”

The clinic’s former space at 45 Francis St. – also vacated by Orthopaedics and Rheumatology when they moved into the Building for Transformative Medicine last year – will be used in the upcoming Emergency Department (ED) expansion. A construction project expected to last several years, the ED expansion will add 30 patient rooms, larger trauma bays, a second CT scanner and areas dedicated to oncology and behavioral health patients.

Brigham Health’s Strategy in Action: Exceptional Experience
Learn more about our strategic priorities at BWHPikeNotes.org.

DF/BWCC to Offer Groundbreaking CAR-T Cancer Therapy

CAR T-cell therapy uses T cells (illustrated above) from a patient’s own immune system to attack cancer.

What if the key to a cure for cancer is already inside our own bodies?

Scientists at BWH and Dana-Farber Cancer Institute have asked that question over the past several years as they studied an immunotherapy – that is, a treatment that uses a person’s own immune system – for adult cancer patients.

Now, following a successful clinical trial and recent approval from the U.S. Food and Drug Administration (FDA), Dana-Farber/Brigham and Women’s Cancer Center (DF/BWCC) is one of a few locations nationwide certified to offer the first chimeric antigen receptor (CAR) T-cell therapy for a form of non-Hodgkin lymphoma.

CAR T-cell therapy, like all forms of cancer immunotherapy, seeks to sharpen and strengthen the immune system’s inherent cancer-fighting powers. It involves giving patients modified versions of their own immune system’s T cells – white blood cells that help protect the body from disease.

“Treating patients with CAR T cells has been one of my most exciting professional experiences, and the FDA approval of this therapy offers hope and optimism to a subset of patients whose other treatments have failed them,” said Caron Jacobson, MD, medical director of the Immune Effector Cell Therapy program at DF/BWCC. “It is extremely rewarding to be able to offer a new therapy to patients who had virtually no other options just 12 to 24 months ago.”

Clinical Trial Demonstrates Safety, Effectiveness

The drug, known as Yescarta (axicabtagene ciloleucel), was developed by Kite Pharma and can be used to treat adults with refractory aggressive B-cell non-Hodgkin lymphoma.

Over the past couple of years, Jacobson and her team have been testing Yescarta in a clinical trial at DF/BWCC, the only facility in the northeast that was part of the trial.

The FDA ruling is based on the results of this nationwide trial, which showed the therapy to be safe and effective. Of the 101 patients who received Yescarta, 82 percent responded to the treatment, with 54 percent having a complete response to therapy. Thirty-six percent of patients remain in complete remission six months after treatment.

“This therapy requires just a one-time infusion for patients, and the results are evident within one month,” Jacobson said. “It is our goal as clinicians to help patients and improve their quality of life. Seeing these patients return to work, their families and their livelihoods so quickly is an important reminder of how far we have come. It is also inspiration for the work we still need to do.”

The initial clinical trials of CAR T-cell therapy have involved pediatric and adult patients with blood-based cancers such as leukemia, lymphoma and multiple myeloma. Based on the therapy’s success so far, CAR T-cell therapy trials are now opening for certain types of solid tumors as well.

“The successful development of CAR T-cells as a therapy for cancer is a testament to the progress we have made in understanding how our immune system is regulated and how cancer evades the immune system,” Jacobson said. “It is a perfect example of how basic science research can fuel clinical progress. Now we need to take what we can from the clinic back to the laboratory to make this therapy even better.”

Brigham Health’s Strategy in Action: Advanced, Expert Care
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Here Comes the Bride – and Baby: Nurse Officiates Wedding in NICU

Ashley and Zachary Thompson had planned to get married with a low-key courthouse ceremony on Oct. 10, one month before the couple expected to celebrate the birth of their son. But baby Jack, it seems, did not want to miss the party, arriving just a few days before his parents intended to say “I do.”

Thanks to a BWH nurse, Ashley and Zack were still able to say their vows on Oct. 10, albeit in an unanticipated setting – the Brigham’s NICU – and with a very special “best man” in their arms.

Shortly before Ashley’s C-section on Oct. 6, Matt Medina, MSN, RNC-OB/EFM, a nurse in the Center for Labor and Delivery, learned about the engaged couple’s situation. Medina, who is also a lay minister, offered to perform the ceremony before their son was born, but the couple had not yet obtained their marriage license.

On Oct. 10, Medina was in a nurse midwifery class in Springfield when he received a text message from the Labor and Delivery nurse-in-charge that Ashley and Zack had their marriage license and wanted Medina to officiate the ceremony that day.

In between an exam and his other classes, Medina was in contact with staff from the NICU, Spiritual Care Services and the Center for Patients and Families to ensure everything was ready for the celebration.

That evening, the couple and Medina gathered in Jack’s room in the NICU, which was decorated for the occasion by NICU nurses. Holding her newborn son in one arm, Ashley joined hands with Zack as Medina pronounced them husband and wife.

“I’m so excited to have been connected to you both during the unexpected delivery of this handsome little man,” said Medina during the ceremony. “Our meeting and our connection is a perfect reminder to cherish and savor those serendipitous moments that come up. As your love grows, remember to follow these moments that will write the story of your life. Spontaneity is one of the many seeds of a strong marriage.”

Suzanne Fernandes, MSN, RN, nurse director of the Growth and Development Unit and Special Care Nursery, noted that the ceremony would not have been possible without Medina going above and beyond for the couple.

“Not only did Matt help bring Jack into the world, but he also united his parents in marriage. It was beyond the call of duty and exemplified the true art of nursing,” she said.

Ashley described the experience as unforgettable, thanking Medina and the Brigham for “helping our dreams come true” as a family.

“Being able to hold Jack in our arms as Zack and I committed to forever together was something so unbelievably special,” she said. “It’s a moment we will cherish for the rest of our lives.”

Brigham Health’s Strategy in Action: Exceptional Experience
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Room to Grow: Center for Child Development to Provide Post-NICU Care

From left: Carmina Erdei, Michalia Root, Lianne Woodward (seated), Pamela Dodrill, Jennifer Benjamin and Nicole DePalma

Critically ill newborns often spend the first several months of their lives in the Neonatal Intensive Care Unit (NICU) at BWH. After hospital discharge, these vulnerable patients remain at risk for ongoing complications, yet providers have no formal mechanism for continuing care or tracking the progress of patients and families during this formative period. A new center opening at the Brigham is poised to change all of that.

Located at 221 Longwood Ave. and scheduled to open in the coming weeks, the new Center for Child Development will provide a comprehensive, team-based approach to outpatient care of infants and children at risk for developmental delay and/or ongoing medical problems following NICU discharge.

The center encompasses three discrete, but intertwined, areas of focus: the Research Suite, led by Lianne Woodward, PhD, director of Research in the Department of Pediatric Newborn Medicine; the NICU Follow-up Program, run by Jennifer Benjamin, MD, attending neonatologist and infant follow-up specialist; and the Feeding Program, directed by Pamela Dodrill, PhD, NICU feeding therapist.

The new center at BWH will advance the department’s vision to provide long-term support for NICU patients and families by addressing clinical needs and filling gaps in research. The latter will allow Pediatric Newborn Medicine to track and analyze the short- and long-term outcomes of the care provided in the NICU and identify ways to improve care delivery in the future.

“Our responsibility as care providers for this fragile patient population is not only to provide the highest quality of medical and developmental care during their NICU hospitalization, but also to ensure that ongoing issues at the time of discharge are addressed for the long term,” Benjamin said. “We need to learn from our own patients, which will allow us to optimize the care we provide to future NICU babies and families.”

Holistic, Patient-Centered Care and Research

BWH neonatologists will identify which infants in the NICU will be best served at the center, with appointments in the Follow-up Program typically occurring every four to six months during the child’s first three years of life.

“We not only focus on the assessment and management of a child’s developmental progress at regularly scheduled intervals, but we also evaluate other areas of concern, including overall growth and nutrition, behavior management and social and family issues, such as parental well-being,” Benjamin said.

According to Dodrill, depending on an infant’s needs, there may be a clinical assessment to identify feeding issues, monitor related therapies, measure infant growth and recommend interventions to improve feeding and nutrition.

In addition to the care of infants and toddlers, the longer-term goal of the center is to create opportunities for wider family support, such as providing in-center access to a mental health specialist and/or social worker who can help families directly with any difficulties they may be experiencing.

On the research side, Woodward said investigators will now be able to track the outcomes of NICU babies from discharge through early childhood. The initial areas of focus include the influence of early nutrition, maternal mental health factors and brain injury during the neonatal period on a child’s brain and behavioral development.

Specifically, Woodward said the suite offers opportunities for state-of-the-art evaluations of a child’s cognitive, language, behavior and motor development, in addition to family assessments.

In combination with the new neuroimaging research platform in the Brigham’s Building for Transformative Medicine, the opportunities to study the effects of pregnancy complications and early neonatal risk on children’s long-term brain and behavioral development is immense, Woodward said. “This will open up collaboration and partnership opportunities not only within the center but across the hospital and country, all of which will be key to our success.”

Woodward said she’s excited about what the new space will offer to patients, families and staff.

“A major focus in our design was to make this a very child- and family-friendly space,” Woodward said. “From the beginning, we had a vision to create a center that was developmentally supportive. Every decision was made with our patients and families in mind. We can’t wait until we can officially open our doors and begin offering these services.”

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BWHers Study How to Best ‘Stop the Bleed’

Pablo Uribe Lietz (center) demonstrates for Harvard Medical School students how to properly apply a tourniquet.

Even if you have no medical training, you might be able to save the life of someone experiencing a heart attack if there’s an automated external defibrillator (AED) nearby. Designed to be used by those with minimal or even no training, these devices automatically detect an abnormal heart rhythm and administer an electrical shock after sensors are applied.

Now, a group of BWHers plans to develop a similar kit for treating uncontrolled bleeding that anyone can use during an emergency before medical personnel arrive. The project is part of Stop the Bleed, a national awareness campaign about how to stop life-threatening bleeding.

In this Q&A, Eric Goralnick, MD, medical director of Emergency Preparedness, discusses the innovative ways BWH is contributing to Stop the Bleed in partnership with The Gillian Reny Stepping Strong Center for Trauma Innovation, Gillette Stadium and several local partners.

What gave rise to this initiative?

EG: Stop the Bleed was started in the wake of the Sandy Hook shootings by a group of clinicians, the Hartford Consensus, whose goal was to find what we can do as a society to minimize preventable deaths after mass shootings or other mass-casualty events.

To do that, they looked at the success the military has had in preventing deaths from extremity injuries by training many ground forces in trauma combat casualty care. The focus is on teaching lay individuals to recognize life-threatening bleeding and intervene – either applying pressure to a wound, packing a wound and then applying pressure or, if it’s an extremity, applying tourniquets. From this, the Hartford Consensus recognized the need to empower laypersons to intervene.

How is the Brigham contributing to the campaign?

EG: Where we think Brigham can particularly add value is in innovation, education and operationalizing the concepts of Stop the Bleed.

We’re working to identify the equivalent of the defibrillator for hemorrhage control, starting with trials of a few commercial “just-in-time training” kits for bleeding control. Potentially, we may design our own.

We’re also developing training programs. When we look at these horrible events, they have traditionally occurred in places like stadiums, public transportation hubs, schools and shopping malls. We want to work with these organizations to train their staff in bleeding control.

This program’s success is possible thanks to our collaboration with the Department of Emergency Medicine and Trauma Service at BWH and Massachusetts General Hospital, the Center for Surgery and Public Health, Fallon Ambulance, South Shore Hospital and Boston MedFlight.

Tell us more about the research and training.

EG: At our first event, we trained more than 50 health care professionals, followed by a series of similar events in the community.

We also launched a randomized study at Gillette Stadium, where we’ve enrolled more than 560 staff, including security officers, vending station operators, parking attendants and others. Each staff member was randomly assigned to one of four groups comparing the effectiveness of tourniquet application after receiving traditional training, “just-in-time training” kits with audio or diagrams or no advance training.

Through focus groups, we’re learning how to design a more intuitive kit. Roughly 90 percent of the people got it right after in-person training, and we think we can develop a kit that’s equivalent.

In addition, Stepping Strong and Gillette purchased 525 first-aid kits that will be worn by personnel who have been trained. They’ve also purchased public-access tourniquet kits that are hung next to AEDs.

Next, we will retest and reevaluate these individuals to gauge how often they should be retrained. Finally, we’ll describe best practices for training a stadium’s workforce, as this is the first Stop the Bleed program in a professional sports stadium that we’re aware of.

This is an opportunity for science to guide us, and the science we have is from the battlefield – and the many soldiers, sailors, airmen and Marines whose lives have been saved because of tourniquets.

‘Stop the Bleed’ at HUBweek

BWH is participating in HUBweek, a weeklong festival celebrating innovation in Boston. On Wednesday, Oct. 11, 3-5 p.m., explore innovation at Brigham Health through an interactive scavenger hunt, which includes a training session with BWH’s Stop the Bleed project. The event is free to attend and open to all staff. Register and learn more here.

Brigham Health’s Strategy in Action: Scalable Innovation
Learn more about our strategic priorities at BWHPikeNotes.org.

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Ground Control to STRATUS: Simulating Medical Emergencies in Space

From left: Gregory Porretto, Abdulrahman Sabbagh and Kara Brown simulate a scenario in STRATUS’ mock spacecraft medical bay.

With funding and support from NASA, the Neil and Elise Wallace STRATUS Center for Medical Simulation recently collaborated with experts from McMaster University and Northern Ontario School of Medicine (NOSM) in Canada to design and construct a simulated spacecraft medical bay – a first-of-its-kind facility researchers will use to study how astronauts can best manage medical emergencies in space.

That’s one small step for man, one giant leap for health care simulation at the Brigham.

Based on the International Space Station’s (ISS) medical bay, the simulator will serve as a testbed where BWH researchers can implement a nontechnical skills training program they’ve developed for astronauts on human-exploration missions to Mars, near-Earth asteroids or the moon. The simulator was designed by Thomas Doyle, PhD, MESc, an associate professor of Electrical Engineering at McMaster.

“The most exciting part of this project is that we’ve been successful in creating an environment that mimics the medical facilities that might be available to astronauts on a long-duration mission. This allows us to create scenarios where crew members face a variety of medical emergencies,” said Jamie Robertson, PhD, MPH, assistant director of Simulation-Based Learning at STRATUS. “By studying the behavior of the team in these situations, we can identify the behaviors that might increase survival and mission success. Hopefully, this research will lay the groundwork for the training programs that will train the first Mars astronauts.”

A mission to Mars, which NASA hopes to launch in the 2030s, would take several years. That creates a very different dynamic than a five-day trip to the ISS, explained Steven Yule, PhD, director of Education and Research at STRATUS and principal investigator (PI) of the project. The longer trip makes it far more likely the crew will experience a medical emergency. In addition, there will be relatively limited supplies on board, and there may only be one or two astronauts with medical training among a crew of scientists, engineers and military service members.

Communication with Mission Control also becomes more difficult. Whereas ISS crews experience a one-second delay, the time delay between Earth and Mars can reach 20 minutes – each way.

These conditions are similar to those faced in remote areas during medical emergencies, which led Yule to team up with a longtime collaborator, David Musson, MD, of NOSM, who specializes in simulating medical event management in rural and remote locations and serves as co-PI of the NASA project.

“The first few minutes of a medical event can be really critical. If something occurs, the crew has to be able to deal with some of that themselves,” Yule said. “They can ask for assistance from the ground, but they’re not going to be available to immediately help.”

Developing Nontechnical Skills Training

While BWH researchers also hope to help NASA determine the medical capabilities needed for these missions, their immediate focus will be on skills such as situation awareness, decision-making, communication, leadership and teamwork.

The interdisciplinary team at STRATUS – which also includes postdoctorate fellow Roger Dias, MD, MBA, PhD – and the Center for Surgery and Public Health, as well as experts from McMaster and NOSM, has worked with NASA for the past year. Together, they are developing a behavior observation system, training programs and checklists to teach astronauts these skills. The simulator itself allows researchers to test and document the program’s effectiveness in various scenarios. From there, BWH will help develop the nontechnical skills training programs for eventual integration with NASA’s astronaut training in Houston.

“The work that Steve, Jamie and the rest of the team have done on this important project with NASA is another indication of how much STRATUS and BWH have contributed to the growth of medical simulation and highlights the importance of nontechnical skills in the practice of medicine – even on a mission to Mars,” said Charles Pozner, MD, executive director of the STRATUS Center.

‘More Than Just a Prop’

Although it looks like a movie set, the simulator offers the most realistic environment possible for research and training, Yule said. In addition to its authentic appearance, the simulator mimics many other characteristics of a spacecraft medical bay – minus, of course, zero gravity. Alarms, lights, smoke machines and vibrations provide a greater sense of immersion for simulation participants.

“It’s more than just a prop,” Yule said. “The psychological fidelity is really important for simulation training.”

Researchers themselves also look the part. Next to the simulator is a rack of NASA astronaut flight suits. Though amid all the realism, STRATUS added one fictional, but fun, detail: The name badges on the flight suits include Ash, Ripley and Brett – characters from the 1979 film Alien.

Become an ‘Astronaut’ During HUBweek

BWH is participating in HUBweek, a weeklong festival celebrating innovation in Boston. On Wednesday, Oct. 11, 3-5 p.m., all staff are invited to explore innovation at Brigham Health through an interactive scavenger hunt, which includes a stop at STRATUS’ state-of-the-art spacecraft medical bay.

Step into a flight suit and experience “blast-off.” A fellow “astronaut” will complain of chest pain and difficulty breathing. Under the guidance of a physician, you’ll respond as a team to the mock medical emergency.

The event is free to attend and open to all staff. Register and learn more here.

Learn About Simulation at Pop-up STRATUS

Celebrate Healthcare Simulation Week with the STRATUS team on Tuesday, Sept. 12, 9 a.m.-1 p.m., at an information table on the Tower 2 mezzanine and learn about medical simulation, explore skills training equipment and simulation gadgets, and get an up-close look at the manikins (patient simulators) used at STRATUS.

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