Philip Berroll

By P.H.I.Berroll

Dr. Valentin Fuster’s workday begins at 5:00 am – but for the first fifteen minutes, he does absolutely nothing except think about the hours ahead of him. “Basically I program the day in terms of priorities,” he says, “to be sure that when I start, I know exactly where I am.”

For Dr. Fuster, the Director of Mount Sinai Heart, this approach makes perfect sense. The 67-year-old cardiologist has a load of responsibilities – as doctor, teacher, researcher, administrator and activist – that would tax the strength of many younger men. Yet he maintains his energy and his equilibrium through a mindset that is equal parts optimistic and pragmatic, detail-oriented and focused on the broader view. And despite a stunning record of achievements, honors and high-level positions, he is a modest, unpretentious man who considers himself “lucky.”

At Mount Sinai, Dr. Fuster presides over a dynamic program whose innovations in technology and research have placed it in the forefront of the cardiology field. At the same time, his interests and advocacy are global in scope. A former president of both the American Heart Association and the World Heart Federation, he is currently President for Science of the National Centre for Cardiovascular Research in his native Spain (where he spends part of each week), serves as Chair of the Committee on Preventing the Global Epidemic of Cardiovascular Disease for the Institute of Medicine (IOM), the health arm of the National Academy of Sciences, and is in demand worldwide as a speaker and advisor on medical, cardiological and related issues.

“I just want to be on the frontline – this is where I am the best,” he says. “My affinity is for dealing with the issues very pragmatically, and getting results.”

Dr. Fuster spent twelve years at the Mayo Clinic before joining Mount Sinai in 1982 as chief of the cardiology division. After a four-year hiatus in the early 1990’s when he headed the cardiac unit at Boston’s Massachusetts General Hospital, he returned to New York to be director of Mount Sinai’s Zena and Michael A. Wiener Cardiovascular Institute and later, director of the Marie-Josèe and Henry Kravis Center for Cardiovascular Health. In 2006, when the two entities were merged to form Mount Sinai Heart, Dr. Fuster was the logical choice to be its first leader.

When he talks about Mount Sinai Heart, Dr. Fuster emphasizes a number of aspects. The institute is noteworthy for integrating three disciplines – molecular cardiology, regenerative cardiology and cardiac imaging – but the doctor also praises “the integration of research, clinically applied research and clinical care.” Equally important, in his view, is that “this is a healthcare system, not a doctors’ system… we value tremendously nurses, nurse practitioners and technical people, who are very involved in what we do. We also include students who participate in projects – they are extremely helpful. And I think this is what makes this place very unique.”

He also speaks proudly of Mount Sinai’s openness to a diverse patient clientele. “This was controversial at the beginning, when we started,” he says, “but I don’t think it is anymore. I’ll never forget one day when [philanthropist] Laurance Rockefeller was sitting in the waiting area along with an ailing lady with a big hat from Harlem and he said, “I’ve never seen something more spectacular – this is absolutely fantastic what you have achieved here.”

“A Disease of Modern Times”

Dr. Fuster is serving at a critical juncture for the field of cardiology – a time, he says, when “there are so many advances, and at the same time, an epidemic.” The statistics are daunting: one in three American adults (80 million people) has one or more types of cardiovascular disease; it is the leading cause of death among women; 17 million people die from it each year around the world. And Dr. Fuster notes that it is a scourge of fairly recent origin – “Centuries ago, autopsies showed very little coronary disease. So it’s a disease of modern times.”

He is blunt in his assessment of how “modern times” have contributed to the problem:

“Of the six risk factors that lead to the disease, two we can call ‘mechanical.’ One of these is obesity, and the other is high blood pressure – a disease of the modern world, of tension, of stress – and obesity and blood pressure go together. There are two chemical problems, non-Type 1diabetes and high cholesterol, which have a lot to do with obesity. And two more factors are extremely modern: smoking and lack of exercise. All of this represents 95 percent of the epidemic.”

His studies and experience have made Dr. Fuster a passionate advocate for preventive medicine – and not just in regard to cardiovascular disease.

“I love this country,” he says, “but the concept of prevention is not part of the culture here – the feeling is, ‘It’s not going to happen to me.’ So we have prolonged life two years per decade by treating disease – but we are not preventing it. As a result, people are dying later, but at the same time, the amount of disease is increasing. This is extremely costly. For example, the cost of treating cardiovascular disease in 2006 was over $300 billion; ten years before, it was one-third of that. If you understand that you’re spending three times the amount of money as ten years ago, you can trust that the health system will break. It will not be possible to continue like this.

“What we have to do,” he continues, “is understand that preventing disease will make a significant difference. Let’s say, for instance, that we’re treating two twin brothers – one at the time he develops an infarction and the other, preventing the risk factors that may lead to the infarction – for a period of ten years. The cost of treating the infarction is four times the cost of preventing the infarction. You cannot get away from the fact that quality of life, preventing events, is very important economically.”

Learning Globally, Acting Locally

To drive home this message, Mount Sinai Heart is conducting a number of research projects in the developing world. “We have to go to this part of the world as quickly as possible,” says Dr. Fuster, “in time to help prevent what we are experiencing in Western countries – but also because developing countries can actually help nations like the United States by teaching us a lot that we do not know.”

Indeed, Dr. Fuster becomes especially energized when talking about Mount Sinai Heart’s international projects, which include an initiative in Rwanda – in collaboration with world-renowned economist Dr. Jeffrey Sachs – to help rural villagers combat cardiac disease by reducing their cholesterol and blood pressure, and a project involving 6,000 Colombian children aged three to seven, using the Spanish-language version of “Sesame Street” to teach them the importance of good health.

In another project, on the Caribbean island of Grenada, Dr. Fuster’s researchers are forming peer groups among local residents who smoke or suffer from hypertension or obesity to see whether group members can help each other develop healthier lifestyles. “The point we are trying to make,” says Dr. Fuster, “is that adults only change for two reasons: peer pressure, or the law. In Grenada, we are checking the peer pressure hypothesis.”

“The Principle of the Four T’s”

Dr. Fuster is proud of Mount Sinai Heart’s growing reputation – in U.S. News & World Report’s “America’s Best Hospitals” survey in 2009, Mount Sinai was ranked 18^th in the category of Heart and Heart Surgery, up from 41^st the previous year. “This jump took place because we are doing things that are very advanced,” he says, “in terms of technology, in terms of what we do globally. And I can predict another jump next year.”

He also expects future breakthroughs from the institute in bioimaging – “You’ll be able to see physiological processes, not just anatomy and structure, how the body works, how the mind works” – and genetics.

For now, Dr. Fuster continues to juggle his myriad interests and involvements through what he calls “the principle of the four T’s – Time to reflect, discovering your Talents, Transmitting positive feelings, and Tutoring… I have two tutors, top people in the fields in which I’m interested, who can tell whether what I’m doing is right or wrong.”

And he is always finding ways to make a positive contribution to both his adopted country and his native land. He speaks with pride about bringing cardiology trainees to his wife’s home town in Spain each year, where he gives a lecture on the latest developments in the field “in the town’s movie theater – it’s like [the Italian film] Cinema Paradiso.”

“My life,” he says, “is really about giving back… because of how lucky I have been.”

Originally published in Mount Sinai Science & Medicine magazine, 2010. 

Download PDF

Laparoscopic surgery pioneer, educator, researcher – Dr. Celia Divino wears many hats, but still keeps her equilibrium.

By P.H.I.Berroll

While chatting with a visitor in her office, Celia Divino picks up a tiny plastic rake and slowly pulls it back and forth across a miniature sandbox on her desk.

“It’s a Japanese garden,” Dr. Divino explains. “When you’re stressed out, you rake it and it relaxes you. It’s kind of Zen.”

It’s easy to see how Dr. Divino would be interested in stress reduction. Her life is a kind of tightrope walk, balancing a dizzying array of responsibilities.  A pioneer in minimally invasive gastrointestinal and hernia procedures, she was one of the first practitioners to perform laparoscopic hernia surgery. And while maintaining an active surgical practice, she also serves as  Chief of Mount Sinai’s Division of General Surgery; Professor of Surgery at Mount Sinai Medical School; Program Director of the General Surgery Residency Program… and head of the groundbreaking Surgical Simulation Center (SSC), where both new and experienced surgeons learn cutting-edge robotic surgery techniques.

“When I was in medical school,” she recalls, “it was my dream to be what was called a “triple threat” – a person who does research, teaches and has an active practice. I feel fortunate to be able to do all three.”

In her work, Dr. Divino also engages in another kind of balancing act: while teaching and advocating for innovative surgical procedures, she firmly believes that no new technique should be introduced without taking issues such as patient safety and quality of care into account.

“With any new procedure, I think that people should resist a bit when they have doubts regarding safety – after all, we’re doctors, we don’t want to endanger our patients,” she says. “So there has to be quality control, and appropriate credentialing. Not everybody can just go out there and start doing this.”

From ‘Heresy’ to Standard Procedure

How does Dr. Divino keep her equilibrium? By conserving her energy, keeping her sense of humor – and practicing a kind of synergy, where her experience in one area complements and enriches her work in another.

For example, take her position at the SSC, a state-of-the-art facility where both surgical trainees and experienced surgeons can learn and practice techniques using a “virtual surgery” construct – working at a computer-based tabletop, manipulating robotic instruments as in an actual operation, while  monitoring their progress in the digital image of the “patient” on a screen. It’s a process with many similarities to minimally invasive surgery; and there is a clear overlap between Dr. Divino’s advocacy for the center, her role as an educator, her quality-control concerns and her experience performing minimally invasive surgeries such as the groundbreaking hernia procedure.

“There were a lot of pioneers across the country, but I particularly focused my interest on many aspects of hernia surgery – not just inguinal [groin] hernias but ventral [abdominal] hernias,” she recalls. “I looked into it from a more academic standpoint; I did a lot of studies on it, on the durability, safety, and outcomes of this procedure. And I still have an interest in pushing the envelope and trying to see if there are other efficient ways of doing the surgery, with better outcomes.”

She cites several advantages for laparoscopic hernia surgery over traditional procedures: “With a laparoscopic procedure, you have a smaller incision than in open surgery. You still have a dissection, of course, but with much less pulling and tearing, so there’s considerably less trauma.  And the recovery time, the possibility of wound infection, the durability – all are much better.”

Dr. Divino makes a similar case for laparascopic methods in her other major field of interest, gastrointestinal surgery.

“For gastrectomies, small bowel resections, colon resections for both benign and cancerous growths – you have the same differences in technique and in the effect on the patient,” she says. “Or look at cholecystectomy [gallbladder removal] – that’s a three, four day hospital stay if you do an open procedure. As recently as 1992, people thought the idea of doing it in such a way that the patient could go home the same day was crazy – it was heresy. But we’ve since proven that when you do it laparoscopically, it’s a four hour stay in the recovery room. Colon cancer, gastric cancer, small bowel cancer, all of them can now be approached using minimally invasive techniques with the same outcomes in terms of survival and adequacy of resection. And that is really important.”

Not surprisingly, Dr. Divino has often encountered initial objections to new techniques – and not only on the grounds of patient safety.

“It can be harder for people who have done it a certain way to adapt to what is quite a steep learning curve,” she observes. “Do you want to start from scratch again when you’re able to do this and you’ve been doing it safely for 20 years? But I think our responsibility as leaders in the field is to reassure them – to say, ‘I don’t care if you’re at this stage of your career, you can still learn it if you want to.’”

It’s in that spirit that she declares the SSC “open to everybody – not only to train new doctors, but also those who have been in the profession for some time.”

“You Have To Take Ownership of Your Patients”

Dr. Divino feels that in one regard, the current generation of surgical students does have an advantage: their experience with video games gives them a leg up.

“One of the most difficult things in doing laparoscopic surgery is that it’s you can only work in two dimensions, as opposed to three-dimensional when you’re doing open surgery,” she explains. “In laparoscopy, you have at the most 4 degrees of freedom – you go this way or that way, or up, or down. You can’t turn the instruments around there because it’s a fulcrum.

“But kids who do video games, they’re playing in two dimensions,” she continues,  “so it’s second nature to them. Studies have shown that kids who play video games have better hand-eye coordination. Even my son, who naturally has done the Wii, the Xbox, etc., has been asking to use a surgical simulator to prove to me that he would be good with it,” she says with a hearty laugh. “And I’m like, ‘We’re not having a simulator at home!’”

The educational process has changed in other ways since she began teaching. “The mass of knowledge is expanding, but we have less time to teach it in the hospital because of the regulations that have been put in,” she notes. “Interns can’t work more than 16 hours at a stretch or have too many calls. You have to supplement their operating room experience because they can’t stay there all night long anymore. So you think of innovative ways to get the message across. When we teach our curriculum, we actually give them web-based modules and reading materials to study. We are also able to teleconference our teaching conferences to other hospitals, so they don’t have to physically be here. And on balance, I think it’s for the best.”

Again, she emphasizes the importance of patient safety and the quality of care. “There’s a lot more emphasis on those factors – it’s always been there, but now there are a lot more requirements and oversight,” she says. “It’s no longer that cowboy mentality of residents operating by themselves, making crazy decisions. And that has to play a part in education.”

But there are also some unchanging lessons that Dr. Divino has always imparted to her students.

“First of all, don’t lose track of why you’re here, and that’s the patients; they come first. Two – and this goes hand-in-hand with number one – you have to take ownership of your patients. Make sure that nothing falls through the cracks, and that all the people on your team know what’s going on. Three, you have to have a passion for what you do, or else you’re not going to do a good job. Fourth, keep on learning, whether it’s on the floor or by reading. Fifth, always maintain a certain amount of professionalism, whether it’s not wearing jeans on a Saturday even if you’re so tempted, or always being respectful of the patient’s race or religion, or the way you talk to your colleagues on a different service. And finally, before you do anything, stop and think. Because medical errors are unforgivable – and if you just stop and think for a moment, it may save a patient.”

Dr. Divino also wants her students to be knowledgeable on the subject of global health.  Born and raised in the Philippines – she came to the United States to study at University of California-Davis and UC-Berkeley – Dr. Divino is acutely aware of the differences between healthcare in the West and in the developing world. Under her leadership, surgical trainees have traveled to communities in Southeast Asia, Haiti and elsewhere to teach and help set up healthcare programs, and all senior surgical residents participate in a month-long surgical rotation in the Dominican Republic.

“Having come from that culture, I think our goal should be sustainability,” she says. “We try to go there and train the surgeons, the local people, not to do it our way, but to improve how they do it, or teach how we do it so that they’re able to do it on their own. We don’t convince them that the way to do it is using these fancy machines, because nobody there can afford them.”

The Unfinished Revolution

For all her pioneering efforts in surgical research and development, Dr. Divino has also broken new ground in another sense: as a female surgeon and surgical educator in what had long been a male-dominated bastion of medicine.

She considers it to be “revolutionary, unbelievable”  how much things have changed since she began her medical career. And while acknowledging that “there’s still a long way to go for female surgeons – we have plenty who are assistant professors, but very few who are at the tenured, full professor level,” Dr. Divino also notes that “45 to 50 percent of the applicants to surgical residency are very, qualified women from the best medical schools, some more qualified than the men. It used to be maybe 20 percent. The number of women in the American College of Surgeons, the number of women in residency programs – they’ve all gone up.”

But in her view, the rest of the country is just following Mount Sinai’s lead. “We were always ahead of the curve here,” she says, “because of Dr. Arthur Aufses [Chair of the Department of Surgery from 1974-1996], who was one of the trailblazers in bringing in a lot of women.”

Dr. Aufses, who is currently Professor of Surgery and Professor of Health Policy in Mount Sinai School of Medicine, agrees with Dr. Divino’s assessment.  “About a third of the surgical students at the medical school are women,” he notes.  “That’s real progress – though when you consider that for many, many years we’ve had 50% or more women overall as medical students, we’ve still got a ways to go to make it really equal in surgery.”

And Dr. Aufses is not surprised by the success of his former protégée.

“Every once in a while, you see somebody and you know they’re going to be a star,” he says. “She was destined to be a star from the beginning.”

“A sense of shared humanity” motivates Dr. David Nichols.

By P.H.I.Berroll

In the course of his career, David Nichols, M.D., has had no shortage of honors and acclaim. Still, upon hearing that he would receive Mount Sinai’s Saul Horowitz, Jr. Memorial Award, Dr. Nichols says he reacted with “a combination of tremendous thrill and total disbelief – because I did not expect to win.”

For all his modesty, it’s easy to see why Dr. Nichols, who is vice dean for education and professor of anesthesiology and critical care medicine at the Johns Hopkins University School of Medicine, was chosen for this honor.

The award was established in 1978 – the year after Dr. Nichols graduated from Mount Sinai School of Medicine – in memory of longtime trustee Saul Horowitz, Jr., who played a major role in the construction of the school’s facilities. It is given to alumni who have made “significant contributions as a teacher, investigator, and/or practitioner in the field of medicine.” By any definition, Dr. Nichols meets this standard.

A specialist in pediatric intensive care, Dr. Nichols has taught at Johns Hopkins for nearly three decades. He has served as director of Johns Hopkins Hospital’s Division of Pediatric Critical Care and its Pediatric Intensive Care Unit (PICU). Dr. Nichols has also trained and mentored more than 50 postdoctoral fellows, written more than 80 professional journal articles and abstracts and edited numerous textbooks on pediatric critical care medicine.

Dr. Nichols credits Mount Sinai with providing the foundation for his career. “It was a very supportive and engaging learning environment,” he says, “and it gave me a commitment to excellence. It also taught me the importance of putting the patient first.”

From Berlin to Baltimore

Dr. Nichols’ path to Mount Sinai took some unusual turns. Born in Virginia, he spent much of his childhood in Berlin, where his father, an English professor and Fulbright scholar, served as director of that city’s Freie University.After graduating from Yale with a degree in molecular biophysics and biochemistry, “I decided that I was ready for a somewhat bigger city than New Haven – and of course, nothing can compete with New York.”

It was while at Mount Sinai that Dr. Nichols chose to go into pediatrics. “I believethat it’s very important for a doctor to enjoy being around a given type of patient,” he says. “And I just loved being around children. I felt committed to and passionate about caring for them.”

That passion took Dr. Nichols even further: while doing his internship and residency at Children’s Hospital of Philadelphia, he decided to specialize in pediatric intensive care.

“There is a tremendous immediacy and energy in that situation,” he says. “All of your training, knowledge and expertise is focused on this one sick child, and you know that if you and your team can pull together to provide the right care, this child will have a chance at growing up. It’s part of what makes medicine in general and pediatrics in particular such a noble profession.

“Most of the time,” he continues, “the children bounce back, and you’re able to watch the joy, the gratitude and the relief on the faces of the family members. When it doesn’t work out, and you have to convey bad news to a family and maybe even grieve with them – that’s a moment that no parent would ever want to face. But it’s also one that exposes our common humanity, the idea that we’re all in this together. And I think it’s that sense of a shared humanity that bonds doctors and patients and families.”

That same “sense of a shared humanity” spurred Dr. Nichols to join a major overseas initiative: last year, he was involved in setting up a medical school in the Malaysian city of Serdang.The facility,Perdana University Graduate School of Medicine, is a public-private partnership for which Johns Hopkins and Ireland’s Royal College of Surgeons are helping to provide courses. Dr. Nichols describes the experience as “a wonderful, exciting journey.”

“The Next Big Challenge”

At Johns Hopkins, Dr. Nichols has worked to provide students with the same high-quality education that he received at Mount Sinai. Under his leadership, the university undertook a major updating of its medical school curriculum.

While he considers American medical education to be “probably the best in the world,” Dr. Nichols sees room for improvement in several areas: a greater emphasis on recent scientific discoveries such as genome sequencing; more inter-professional education involving doctors, nurses and other healthcare personnel; and increased use of simulation technology.

The most crucial need, he feels, is for research into the link between physicians’ education and training and patient outcomes. “We have to find a way to prove the assumption that a doctor who’s been well trained and educated will provide better care,” says Dr. Nichols, “and for poorly functioning teams, to determine what about the training and preparation of team members could have been done better.”

“That is the next big challenge in medicine,” he adds. “If there’s any task that I would like to take on in the rest of my career, it’s that one.”

Download PDF

Drs. Andrew Hecht and Sean McCance work on the cutting edge of minimally invasive back surgery.

By P.H.I.Berroll

For Sean McCance, one of the biggest innovations in his field, spinal surgery, over the last ten years has been the XLIF cage. XLIF, or lateral lumbar interbody fusion, is a minimally invasive surgical procedure performed through the patient’s side, in order to avoid the major back muscles. The cage, a small rectangular-shaped device, is inserted between the patient’s vertebrae to provide support.

“The cage is put into a very small incision,” Dr. McCance explains, “through a special tubular retractor that allows you to get a large implant into in a small space. The older approach, with a large incision, tended to cause muscle denervation [the interruption of nerve impulses to the muscles] and lead to out-pouching of the abdominal wall and maybe some scar pain. But with this technique, there’s less scarring, less risk of side effects. It can be used for older scoliosis patients who can’t tolerate a big open surgery, and can save younger patients the morbidity of a big incision.”

Dr. McCance, who is Co-Director of Spine Surgery in the Leni and Peter W. May Department of Orthopaedics, regards the XLIF cage as a major advance in his field – and a paradigm for his mission as a surgeon: “To perform the same or better surgery through a smaller incision.”

Indeed, this is the primary goal of Dr. McCance and his co-director, Dr. Andrew Hecht, who have led Mount Sinai’s spinal surgery program since 2005. For both practitioners, minimally invasive surgery has become a key component of their work. They are in the forefront of a wave of innovation that has revolutionized spinal surgery – to the point where procedures once considered high-risk are now commonly performed on both elite professional athletes and people in less physically stressful lines of work.

“Minimally invasive techniques have had a very positive impact of on our field in the last decade,” says Dr. McCance. “They’ve given us the ability to address a broader array of pathologies with less morbidity.”

The Extraordinary Tube

In addition to his work at Mount Sinai, Dr. Hecht is the spine surgical consultant to the New York Jets, the New York Islanders and numerous collegiate teams. This has given him a unique perspective on the growing popularity of minimally invasive spinal surgery, first with big-name athletes – this past May, Indianapolis Colts quarterback Peyton Manning had a microdiscectomy, which is performed through a one- to one-and-a-half-inch incision in the lower back, to relieve the pain of a pinched nerve – and now with the general public. “A lot of these techniques,” he says, “are applicable to many different groups of patients.”

Like Dr. McCance, he speaks with great enthusiasm about the use of tubular retractors – which he says “have enabled us to do some very extraordinary things” – in several types of lumbar and pelvic surgery.

Tubular retractors enable surgeons to enhance their view of the spine without the invasiveness of traditional surgery. “Instead of making a larger incision and dissecting all the way down to the spine,” Dr. Hecht explains, “we make a small incision and through a series of dilators, insert what is basically a tube. Then, with the use of a microscope, we’re able to look down the axis of this tube and see things that we normally see with open surgery. Some of these tubes at the very bottom are able to be expanded or dilated further to improve visibility.

“This allows us to avoid the extensive dissection, the tissue exposure, of open spine surgery. You’re minimizing the muscle damage, shortening the length of stay, and minimizing the post-operative pain, particularly in the short term. The patient can be out of the hospital and getting on with his life much more quickly.”

Dr. Hecht also cites prosthetic cervical disc replacement, used to treat patients suffering from herniated discs, as “a very advantageous development.” He and the other members of his team, Sheeraz Qureshi, M.D. and Samuel Cho, M.D., have frequently performed this procedure.

“It’s a big advantage over traditional fusion treatments, where the disc is removed and the surgeon performs a fusion with a bone graft and a titanium anterior fixation plate,” he says. “With prosthetic replacement, motion is preserved – patients can start moving right away, they don’t need to wear a brace. As a result, we don’t worry about problems such as muscle atrophy above or below the area where they would have had a fusion.”

From Cages to Proteins

In addition to the XLIF cage, Dr. McCance speaks highly of a similar device, the self-distracting cage (“distract” in this context means to separate or spread apart) – which, he says, “allows us to do ‘more with less.’

“When we put this cage into the spine,” he explains, “it allows us to elevate the space and restore height to the vertebrae with less maneuvering and tissue manipulation than with older technologies – because the cage itself actually jacks up, almost like a car jack. So you don’t have to do a lot of opening, spreading, etc. to expand the space, which makes it safer for the surrounding neural tissues.”

One tool about which both Dr. Hecht and Dr. McCance are enthusiastic is neither a device nor a procedure, but a substance: Bone morphogenetic protein (BMP), a molecule which can literally grow bone.

Dr. McCance, who calls himself “the largest user of BMP at Mount Sinai,” says, “It can be used as a replacement for iliac crest [a major segment of the group of bones around the pelvis, from which bone material is often used in grafts], and studies suggest that it holds up just as well. So it’s been a step forward in saving some patients the need to harvest their own bone.”

Dr. Hecht concurs: “We’re able to achieve a solid fusion through a tiny incision, only a centimeter or two long, by inserting BMP, where in the past you’d have these massive incisions. For certain types of patients, this is a very effective treatment.”

The two surgeons are closely following the development of other minimally invasive techniques that could prove useful in their work. For example, Dr. McCance predicts that more surgeons will be inserting screws in the spine percutaneously [through wires and tubes] during procedures, rather than the traditional approach of insertion through an incision.

“So if you have a sick patient who maybe can’t tolerate a full open surgery, you can do part of it percutaneously and part of it open,” he says. “That’s another minimally invasive technique that potentially is a step forward for patients.”

Dr. Hecht and Dr. McCance both feel that minimally invasive surgery has enhanced the success of their practice – and the personal satisfaction they take from their work.

“For both cervical and lumbar surgery, we’ve showed a substantial ability to help people,” says Dr. Hecht. “Mount Sinai has one of the largest spine services in Manhattan, and has emphasized treating patients with all kinds of spinal disorders, and trying to get them back to a full life. I think the kinds of surgeries we’re doing, and the outcomes we’re having, are testament to that.”

Originally published in Mount Sinai Science & Medicine magazine, 2012.

By P.H.I.Berroll

It’s one thing to research and develop a new surgical procedure. It’s quite another to put it into practice, over and over again. The surgeons of Mount Sinai have been leaders in the use of the DaVinci robotic system and other minimally invasive techniques. Here, three of them talk about how those innovations have impacted their work.

Dr. Eric M. Genden is no stranger to innovative surgical procedures – he was the first surgeon in the United States to perform a jaw transplant. So it’s not surprising that he has been a pioneer of robotic surgery in his field of specialty, cancers of the head and neck. “It’s made a remarkable impact on our ability to take care of patients with these cancers,” says Dr. Genden, “without making large incisions and doing surgeries that take up a huge amount of time and resources.” Dr. Genden, the Chairman of the Department of Otolaryngology and Chief of the Division of Head and Neck Oncology, performed his first robotic surgery in 2006 and has since done close to 250 such procedures. The biggest advantage of the robotic procedure, he says, is its relative simplicity: “In the typical open surgery, patients have to undergo a 12-to-14-hour procedure to get to the tumor, and they’re usually in the hospital for 10 to 12 days. Using the robot, we’re able to remove the tumor in about two hours – and patients usually go home the next day, eating and drinking and swallowing.” Dr. Genden notes that the robotic technique “is being adapted widely, not only across the U.S. but now in Europe and Asia – because people are seeing that this has a tremendous impact on both the quality of patient outcomes and the cost of care.”

As Chief of the Surgery Department’s Division of Metabolic, Endocrine and Minimally Invasive Surgery, Dr. William B. Inabnet III leads a team that has done more laparoscopic surgeries than at any other hospital in New York City. Dr. Inabnet himself performed the first robotic thyroidectomy at Mount Sinai in 2010, and is a strong advocate of both robotic and non-robotic minimally invasive procedures to remove part or all of a diseased thyroid gland. In the most common procedure, a laparoscope with a tiny, high-definition video camera is inserted into the incision made by the surgeon, so that he and his team can have a bigger, clearer view of the operation on a television screen – “which promotes teamwork,” says Dr. Inabnet, “and greatly improves patient safety.” There is also a cosmetic advantage: The patient is left with a one-to-two-inch scar on the front of the neck, as opposed to four to six inches in a traditional operation. Dr. Inabnet is so impressed with the procedure that he has posted a video of it on Facebook (www.facebook.com/msthyroid), and looks forward to its becoming more common. “Every year,” he notes, “we graduate two endocrine laparoscopic surgery fellows who know these techniques. We’re training the next generation.”

Prostatectomy – the removal of a diseased prostate gland – has long been considered one of the riskiest of medical procedures; because the prostate is surrounded by nerves which control sexual and excretory functions, the slightest error can leave a patient both impotent and incontinent. But through the use of robotics, Dr. David B. Samadi has been able to perform close to 2,200 prostatectomies at Mount Sinai, with amazing results: “97 percent of patients retain continence,” he says, “85 percent, sexual function. 95 percent stay only one night in the hospital. Pain is minimal.” As Chief of Robotics and Minimally Invasive Surgery at Mount Sinai, Dr. Samadi, a urologist, performs almost 15 robotic prostatectomies a week, using a procedure he has named with the acronym SMART (Samadi Modified Advanced Robotic Technique). The main advantages of the technique, he says, are the ability of the DaVinci system to handle the prostate without disturbing “the delicate, sensitive nerves” around it, and to give him a clear, precise view. “In open surgery, you use ‘the touch factor’ because you can’t see the detail of the procedure,” he notes. “With the SMART technique, I can see the detail – so I can perform a precise operation.”

Originally published in Mount Sinai Science & Medicine magazine, 2012.

By P.H.I.Berroll

Sol Wachtler had a grim statistic to share with his audience: “After the Vietnam conflict, we had over 200,000 veterans who went to prison.” He added, “We’re determined to see that this doesn’t happen again.”

Judge Wachtler, former Chief Judge of the New York State Court of Appeals, spoke during a panel discussion, sponsored by the Veterans Mental Health Coalition of New York City, at which speakers described efforts to steer nonviolent veteran offenders away from imprisonment and instead offer them support services and mental health treatment. One such program drew a good deal of attention: the Veterans Project, a groundbreaking North Shore-LIJ Health System initiative developed by Judge Wachtler, a lifetime North Shore-LIJ trustee.

The Veterans Project is a collaboration between North Shore-LIJ ‘s Law and Psychiatry Institute, the New York State courts, the Brooklyn, Queens and Nassau district attorneys’ offices and the U.S. Department of Veterans Affairs (VA) New York Harbor Health Care System. It is the first in the state – and the largest in the nation – to create a standardized approach to providing services and treatment to veterans involved with the criminal justice system, with the goal of preventing veterans who land in court or jail for minor offenses from getting into deeper trouble with the law. At a time when many veterans are suffering from post-traumatic stress disorder (PTSD) and depression – 20 percent of Iraq and Afghanistan veterans nationwide (300,000 men and women) have been diagnosed with those illnesses – there is an urgent need to steer them toward treatment rather than jail time.

During the panel discussion, held at Hunter College’s School of Social Work, several people involved in the Veterans Project – including Brooklyn District Attorney Charles J. Hynes, First Assistant D.A. Anne Swern, and veterans outreach specialists from New York Harbor – spoke in detail about their work. Several noted that a frequent challenge they face is convincing veterans to seek treatment; too many fail to do so, either out of embarrassment (they may worry about looking “weak” in front of their comrades) or fear that they will lose their benefits.

One way to counter this is through outreach from other veterans – the Veterans Project offers peer counseling to guide troubled former soldiers into treatment programs.  Another strategy is to reach out to veterans who have been arrested for misdemeanors such as subway fare-jumping. “We want to use the arrest,” said Ms. Swern, “as the opportunity to get them the services they need.”

Judge Wachtler and District Attorney Hynes, both of whom are veterans, spoke movingly of their desire to avoid repeating the tragedy of the Vietnam era.

“What this country did to [Vietnam veterans],” said the district attorney, “was an absolute disgrace – especially the criminal justice system.”

The Veterans Project is one of a number of innovative programs run by North Shore-LIJ’s Office of Military and Veteran’s Liaison Services (OMVLS), whose Director, Army Lt. Col. (Ret.) Randy Howard, moderated the Hunter event. Other OMVLS initiatives include a treatment program for Iraq and Afghanistan veterans suffering from PTSD and/or traumatic brain injury and programs to help returning service members find employment in the health system.

District Attorney Hynes and the other speakers touted the Veterans Project as a model that can – and should – be replicated across the country.

“If you’re in a county rather than Brooklyn, Queens or Nassau, you have a moral imperative to demand from your district attorney why such services aren’t in place,” said Mr. Hynes. “I believe that the day will come when we have district attorneys across the country committed to the proposition that no man or woman who served their country will ever be criminalized again.”

Originally published in the newsletter of North Shore-LIJ Medical Center, 2010.

Download PDF

Carol Porter, DNP, RN sees her role at Mount Sinai as “conveying the nurse’s perspective to the Medical Center, and vice versa.” As Mount Sinai’s Chief Nursing Officer – and recently appointed Associate Dean of Nursing Research and Education – she has been a strong advocate for the importance of nurses in both medical research and clinical practice.

In this regard, one of her proudest achievements has been helping to establish Mount Sinai’s Center for Nursing Research and Education (CNRE) and serving as the CNRE’s first Director since its official launch in May 2010. An ambitious collaboration between the Mount Sinai School of Medicine and the Department of Nursing, the CNRE seeks to advance “bench to bedside” research – bringing the experience and insights of clinical nurses into medical research, while integrating the results of that research into both nursing education and patient care.

Ms. Porter and the CNRE are also working with Mount Sinai’s new Global Health program, headed by Dr. Philip J. Landrigan, to share ideas in nursing research, education and practice with other medical institutions around the world. At the recent annual Global Nursing Leadership Institute (GNLI) in Geneva, Switzerland, Ms. Porter, who was in attendance, says she was impressed “to hear how Mount Sinai nurses are held in high regard globally.”

Ms. Porter notes that a recent report, “The Future of Nursing,” from the Institute of Medicine (the health arm of the National Academy of Sciences), gives credence to the CNRE’s mission.

“The report recommends that nurses should be full partners with physicians and other health professionals in redesigning health care in the US,” she says. “We’re positioned very well for this – because the Center is already partnering with physicians at Mount Sinai.”

– Philip Berroll

Originally published in Mount Sinai Science & Medicine magazine, 2011.

Download PDF

Their styles differ, but Dr. Peter Palese and Dr. Adolfo García-Sastre are focused on a common goal: a universal influenza vaccine.  

By P.H.I.Berroll

It would be hard to find two more sharply contrasting individuals than Adolfo García-Sastre, Ph.D. and Peter Palese, Ph.D. In appearance, Dr. Palese is every bit the sober, buttoned-down man of science; Dr. García-Sastre, bearded and long-haired, looks more like a rock musician, and in fact has several shelves of music cassettes – everything from Bach to Meat Loaf – stacked inside his desk. The Spanish-born Dr. García-Sastre is also an amateur entomologist with an extensive insect collection, while Dr. Palese, a native of Austria, cheerfully admits to having “very few” interests outside of medicine.

Yet for nearly 20 years, the two men have joined in a research partnership that has made them recognized leaders in their chosen field. Dr. Palese, who is Chairman of Mount Sinai’s Department of Microbiology, and Dr. García-Sastre – a professor of Microbiology and Medicine (Infectious Diseases) who also serves as Director of Mount Sinai’s Global Health and Emerging Pathogens Institute (GHEPI) – have both been in the forefront of efforts to understand and combat some of the world’s most deadly viruses. And they are now at work on a project of global import: the development of a universal influenza vaccine that can be used against multiple strains of this persistent and sometimes fatal disease.

“We can say that we have different personalities – though it depends on how you define ‘personality,’ Dr. García-Sastre says with a smile. “But motivation-wise, we are very similar. What we have in common is that we are passionate about research.”

A Vaccine for All Strains

The impact of a universal flu vaccine would be truly profound. At present, people need to be vaccinated every year at “flu season” because the virus evolves at a much faster rate than many other organisms, and pharmaceutical companies therefore have to keep updating their vaccines. And because that evolution has produced multiple strains of influenza, there is always a danger of targeting the wrong strain – resulting in an ineffective vaccine and an outbreak of epidemic proportions.

As Dr. Palese observes, “There is no other vaccine which has to be changed on a yearly basis, in contrast to things like measles or smallpox or mumps, whose vaccine strains from 50 years ago – or in the case of smallpox, 200 years ago – can still be used. So the hope is that we could get something which would be working and in use as an effective immune response against all strains of influenza.”

The two researchers and their teams have already made significant progress. “We have quite good evidence,” says Dr. Garcia-Sastre, “that when used for immunization, some types of influenza virus antigens  provide the broader immune response that can protect against multiple strains, unlike the traditional vaccines. We need to come up with better immunogens to make this a reality. But the possibilities are there.”

At the same time, they are also researching the possible development of other types of broad-spectrum antiviral drugs which could be used against viruses such as dengue, West Nile and Ebola, for which specific drugs do not currently exist. If proven effective, these antivirals could have a dramatic impact on global health not seen since the introduction of broad-spectrum antibiotics to combat bacterial infections.

“We now have solid evidence that many different viruses all use particular cellular pathways,” Dr. Garcia-Sastre observes. “And it’s possible that broad-spectrum antivirals could be effective by inhibiting those pathways.”

In addition, their work has implications for the fight against other “ever-changing” viruses such as HIV and hepatitis-C. “It’s a slightly different scenario in that these viruses have many different variants coexisting at the same time, whereas with influenza, it is a change from year to year,” says Dr. Palese. “But if we are able to succeed in making better and longer-lasting influenza virus vaccines, we could possibly try to apply that to these others.”

Working Separately and in Tandem 

Their partnership began as a student-teacher relationship. When Dr. García-Sastre came to Mount Sinai in the early 1990’s as a post-doctoral fellow, he worked in the laboratory of Dr. Palese – who soon recognized his younger colleague as “a very able and very effective and successful, imaginative researcher.”

After getting his own lab, Dr. García-Sastre continued to collaborate with his mentor on numerous research initiatives while both men also pursued independent projects, an approach which has continued to the present day. For example, Dr. García-Sastre is currently “very focused” on the body’s innate immune responses and their effect on viral replication, while Dr. Palese is researching viral packaging – the ability of a virus to package, transport, and deliver its genome to a host cell, which involves the precise manipulation of DNA throughout the life cycle of the virus.

“But in the big, overreaching aspects of influenza biology – such as influenza virus vaccines or multivirals – we fully collaborate,” says Dr. García-Sastre, “because these areas require information from multiple, specific research initiatives, resulting in a more comprehensive program. And especially in the last year, the National Institutes of Health (NIH) has put more emphasis on intercollaborative grouping between different researchers, which makes things easier from the point of view of funding.”

What was perhaps the pair’s greatest achievement to date came in 2005, when they led a team that reconstructed the virus responsible for one of history’s most devastating pandemics: the 1918 Spanish flu outbreak, which resulted in at least 40 million deaths worldwide. Their efforts earned them the 2005 Paper of the Year award from the prestigious British medical journal The Lancet.

“We decided to focus on that subjectin order to understand what made the 1918 virus so destructive – its mechanisms, its characteristics,” explains Dr. García-Sastre, “because by knowing that, we can be better prepared to fight future influenza viruses that may have the same traits.”

They began by taking the genetic material of the virus from human samples that were to some extent preserved from victims of the 1918 outbreak – “like Jurassic Park,” says Dr. Garcia-Sastre,“where they took the dinosaur DNA from mosquitos.” From there, they recovered the genetic information of the virus, which enabled them to reconstruct and study it.

Comparing the virus to that of a more recent global pandemic – the H1N1 (swine flu) outbreak of 2009 – they found enough similarities to determine that the vaccine developed to protect against H1N1 vaccine also worked against the 1918 strain. This discovery eliminated a serious concern among public health authorities about the possible use of the older strain in a bioterrorist attack.

“It was always one of our fears,” Dr. Garcia-Sastre says, “that if someone had the genetic information that was generated from the 1918 virus, they could reconstruct it for evil purposes. But now we know that everyone who gets vaccinated with the newer vaccine not only becomes protected against the 2009 virus, but also against the 1918 strain. That makes the use of the 1918 strain as a bioterrorist weapon very difficult.”

Between Complacency and Fear

Drs. Palese and García-Sastre often venture outside the lab to offer their expertise to a variety of government agencies – Dr. Palese is a member of the National Academy of Sciences (NAS), and Dr. García-Sastre is Director of the Center of Excellence in Influenza Research and Surveillance (CEIRS), which is funded by the NIH. In that capacity, both men have experienced the tendency of the public and the media to lurch between a false sense of security and unjustified panic regarding influenza outbreaks.

“It’s a very interesting psychology,” says Dr. García-Sastre. “When the first deaths from H-5 [avian flu] virus were reported, even though there were very few, it made people afraid to go to countries such as Hong Kong where the flu was found. It’s very difficult to get infected with bird flu; you go to Hong Kong, you’re more likely to die in a traffic accident than from H-5 infection. But the public has an inherent fear of infectious diseases. The same thing happened with Ebola and West Nile virus. It’s the fear of the unknown, with the potential high mortality factor, which makes people very scared.”

Dr. Palese speaks of the “hysteria” surrounding the 2009 pandemic, when he was part of a committee reporting to President Obama on best responses: “This report had a possible, non-predictive scenario to help plan for the fall flu season – that many people infected, that many people symptomatic, etc. And the next thing we know, the headline on page one of USA Today reads ‘Flu Could Infect Half the USA; 90,000 Deaths, 2 Million Patients Possible.’ We made clear that this virus was probably not comparable to 1918, and that we were making vaccines for it – but that was not on page one of USA Today.”

Still, Dr. Palese does take seriously the possible use of viruses in bioterrorism: he has been on several panels advising government officials on dealing with potential bioterrorist threats.

“I’m worried about nuclear proliferation and nuclear terrorism as well,” he says, “but I feel that the biological threats are even worse, because of how easily a virus can be developed. At this point, it’s really a catch-up situation where we’re trying to ramp up the production of vaccines and other anti-bacterial, anti-viral substances.”

But both men retain a sense of optimism – based in large part on the progress that has already been made against a number of once-deadly viruses. “The impact that vaccines have had in human health has been enormous,” notes Dr. García-Sastre. “You don’t see kids dying any more from poliomyelitis, except in very rare cases. You don’t see people dying any more from smallpox. And I think that hopefully we can come up with new vaccines against some of the other agents that are still making a big impact on human health, like influenza and HIV and tuberculosis and malaria.”

They have also come to see the humor in their odd-couple partnership. Dr. García-Sastre acknowledges with a laugh that compared to his colleague, he appears “relaxed.”

And when asked about their differing styles, Dr. Palese responds, “You mean that he never wears a necktie? Well, it’s a free country.”

Originally published in Mount Sinai Science & Medicine magazine, 2011.

Download PDF

Dr. William Oh’s research aims to end the uncertainty over prostate cancer testing – and greatly reduce the number of deaths from the disease.  

By P.H.I.Berroll

Every year, across the United States, millions of men go into their doctors’ offices for a blood screening – the Prostate-Specific Antigen (PSA) test – to see if they are at risk for prostate cancer. The need for the test is clear: prostate cancer is the tenth-leading cause of cancer death in the U.S.; close to 200,000 men each year are found to have the disease, and more than 27,000 will die from it. One man in six will get prostate cancer during his lifetime, and for one man in 35 it will be fatal.

But the test’s reliability has increasingly been in dispute. A finding of high levels of PSA in the blood is often followed by a biopsy – a painful, invasive procedure with some risk of complications – to detect cancerous cells; yet in nearly two-thirds of biopsies, no such cells are found. This high rate of “false positive” test results underscores the need for a more accurate method for detecting prostate cancer.

That is the central focus of Dr. William Oh’s work.

Dr. Oh, who came to Mount Sinai last year after 12 years at Boston’s Dana-Farber Cancer Institute and Brigham and Women’s Hospital, is continuing a groundbreaking project that he began at Dana-Farber: the development of a new blood test which in combination with the PSA screening could sharply increase the accuracy of prostate cancer diagnoses – and eliminate tens of thousands of unnecessary biopsies.

“If you are biopsying 100 men and only finding cancer in a third of them, that’s a pretty poor hit rate,” he points out. “And when you multiply 100 times thousands – because there are 200,000 cases a year, which means that there are at least 600,000 biopsies a year, in the U.S. alone – we’re talking about a substantial cost to society and to individuals. So if you could reduce the number of unnecessary biopsies, it would improve quality of life, decrease health care costs and make many people happier.”

The upbeat, energetic Dr. Oh has a wide range of responsibilities at Mount Sinai – he is Chief of the Division of Hematology and Medical Oncology in the Department of Medicine, Co-Director of the Prostate Cancer Program, Associate Director for Clinical Research for the Tisch Cancer Institute, Ezra M. Greenspan, MD Professor in Clinical Cancer Therapeutics and Professor of Medicine and Urology. A native New Yorker, he returned to his home town for “the opportunity to build a program that could lead the world in developing new therapeutics for cancer patients.”

As Dr. Oh explains it, the problem with the current test lies in its focus on PSA levels rather than cancer. “It’s not a prostate cancer-specific antigen test, it’s a prostate-specific antigen test,” he notes. “So other things like infection or inflammation or enlargement of your prostate can make your PSA rise. And that decreases what we call the specificity of the test. Basically, it’s less specific for prostate cancer alone, and this leads to false positives.”

In addition, he says, the test fails to distinguish between “aggressive cancers that will prematurely end someone’s life” and slow-growing cancers that pose no threat during a patient’s natural lifespan. “We’re finding cancers in older men who are being over-treated because the cancers grow so slowly,” he says. “Let’s say a healthy man in his eighties is diagnosed with prostate cancer – the cancer is predicted, if left alone with nothing done about it, to potentially be lethal in 30 years, when he would be 110 years old. The problem is our tests right now don’t help us make those distinctions.”

The Genes Are the Key

Dr. Oh’s original study measured the accuracy of a blood test developed at Source MDx, a medical research company in Boulder, CO, which isolated six genes that, as a group, were highly sensitive in predicting which patients had prostate cancer and which were disease-free. Dr. Oh and his team found that the new test produced a dramatic jump in accuracy – especially when PSA measurements were added.

“What we found,” says Dr. Oh, “was that using the six-gene model combined with PSA, we were able to determine – more than 90 percent of the time – whether or not somebody had cancer. (Earlier studies had found that the PSA test by itself is 60 to70 percent accurate.) So we were able to greatly reduce the number of what we predict would be false positives.”

At Mount Sinai, Dr. Oh is joining researchers at other leading U.S. medical centers to determine if these findings remain valid – using a clinical trial which will involve almost 1,000 men. To date, more than 200 have enrolled in the study.

“In this trial,” the doctor explains, “men who are about to get a prostate biopsy – usually because of an elevated PSA – are going to get a blood test similar to the one in our earlier study to determine whether we can more accurately predict whether the biopsy will be positive or negative. In other words, we want to see whether or not our test will be better than the PSA test, either alone or in combination, at predicting whether somebody’s going to get a positive biopsy. We believe that we can use a test like this to get a more accurate prediction.”

For now, Dr. Oh rejects what he calls the “nihilistic” view that because of the PSA test’s shortcomings, men should avoid having it. “Our findings are very encouraging,” he says, “but until we can verify them, it is important to recognize that the PSA test, despite its limitations, is still the best test available for diagnosing prostate cancer at this time.”

But looking to the future, Dr. Oh predicts, “We will look at prostate cancer the same way we now look at certain infectious diseases such as tuberculosis or syphilis” – illnesses that a century ago were often fatal, but were conquered when doctors “figur[ed] out ways of diagnosing them early and then figuring out how to treat them or at least control them.”

And what Dr. Oh has learned about the complexities of prostate cancer can be applied, he feels, to other forms of the disease. “People have spoken of a ‘war’ on cancer, but it is much more like battling terrorists – you can’t always see them, they’re all over the place, and they may use different techniques to fight you,” he says. “The mistake that was made 40 or 50 years ago was to think of cancer as one disease; what we’ve learned is that there isn’t a single thing driving most cancers – there are many different pathways that the cancers can take to grow. Armed with that understanding, I think that we are really making progress. And I believethat in the future, this will continue – we’ll be able to cure more people, keep them alive longer and give them a better quality of life.”

Originally published in Mount Sinai Science & Medicine magazine, 2010.

Download PDF

By P.H.I.Berroll

When asked about the impact of cardiovascular disease on world health, Jagat Narula, MD, PhD replies calmly but bluntly: “It is the most important scourge against mankind – the same for developing countries as for developed countries, and the same for men as for women.”

Dr. Narula does not make such pronouncements lightly. A dedicated researcher, educator and clinician – he is Philip J. and Harriet L. Goodhart Professor of Medicine and Cardiology and Associate Dean for Global Health at Mount Sinai School of Medicine, and in May of this year was named Director of Cardiovascular Imaging Program in the Zena and Michael A. Wiener Cardiovascular Institute and the Marie-Josée and Henry R. Kravis Center for Cardiovascular Health – he has devoted his professional life to studying and combating heart disease. In his current research, he is working to develop potent new tools for cardiologists worldwide: sophisticated molecular imaging techniques which can provide a window into the heart – and predict and prevent heart attacks before they occur.

“The levels are becoming epidemic,” he says, “and basically, prevention is the only way that we will be able to reduce them. I think that prevention through personalized medicine will have the biggest influence on cardiology in the next ten years.”

From detection to prevention

Dr. Narula emphasizes prevention because heart disease is often a “silent killer,” undetected until it is too late. “The disease, in its most serious form, is asymptomatic,” he explains. “More often than not, patients don’t come to you and ‘declare themselves’ or present with chest pains – instead, there can be an acute coronary event, including sudden cardiac death.”

Over the years, researchers have pinpointed the most common factors that put people at high risk for the disease, such as smoking, diabetes, high blood pressure and hypertension. When those factors are treated and modified, the incidence of the disease is reduced.

However, Dr. Narula notes, some people are more in need of preventive measures than others. “In the United States and Western Europe, you could say the population is divided into three tiers,” he says. “About 50% are at low risk for coronary disease; 10% are at high risk; but 40% are intermediate – they may have a problem, or they may not. So we need to glean them further, into those who are low-risk and those who are high-risk. Basically, I would like to have a two-tier rather than a three-tier system. You want to identify those who have a problem. And imaging can enable us to do this.”

In his research, Dr. Narula focuses on cost-effective measures that are especially suitable for this intermediate group – in his view, costly, time-consuming procedures such as MRIs and angiographies are not necessary in these cases – and can be used to screen large groups of people.

One technique involves taking an ultrasound image of the carotid arteries, which supply blood to the brain, or blood vessels in the iliofemeral region of the legs, in order to find signs of atherosclerosis – a condition, commonly known as “hardening of the arteries,” which if left untreated can eventually cause cardiac infarctions or strokes. A second procedure is taking a CT scan of a patient’s heart and using the scan to determine the amount of calcium in the coronary artery. “If the calcium is more than what is good for your age and gender,” says Dr. Narula, “that’s a very good indication that [coronary] disease is there.”

Dr. Narula says that advances in coronary disease studies in recent years have helped open the door to new avenues of research.

“There’s been a gradual evolution in the knowledge of the disease,” he notes. “For example, until a few years ago, we used to see a chest pain as just a simple strangulation of the coronary arteries. Now we have started to realize that atherosclerosis, which affects the blood vessel walls, is equally important when it comes to acute coronary events.”

The next step, in Dr. Narula’s view, is to subject imaging procedures to “rigorous clinical and outcome-based trials” so that cardiologists have a better idea of how to apply the results of imaging to specific preventive measures.

“As the knowledge is evolving,” he says, “that kind of investigation or studies need to be there before we are able to say, ‘this is the way we should be evaluating our patients,’ and then suggesting means of prevention.”

Fighting ‘diseases of affluence’ 

Dr. Narula is also working on a global scale to prevent heart disease, through his involvement in international-oriented programs such as the Heart Attack Prevention Program for You (HAPPY). Co-founded by Dr. Narula and Dr. Leonard Hofstra of the University of Maastricht in The Netherlands, HAPPY provides free cardiovascular screenings for people in developing countries. He is also the founding Editor-in-Chief of a new journal – Global Heart, published by the World Heart Federation – which aims to narrow the coronary disease research gap between the West and the developing world. Heart disease has increased sharply in those countries in recent years, as rapid urbanization has led to the erosion of traditional diets and the spread of Western habits like smoking cigarettes and consuming high-fat meals.

“In these countries, where we were used to dealing with things like infectious and post-infectious diseases and child health issues, there is now a tremendous increase in diabetes, hypertension and other coronary risk factors,” Dr. Narula observes. “These countries already are burdened with the diseases of poverty; now they also have the diseases of affluence.”

Asked about his goals for the future, Dr. Narula says simply: “I want Mount Sinai to be the world’s best imaging center – the hub of imaging.” He adds, “I’m very keen to develop the imaging fellowship here, so that we can bring in cardiologists from outside and train them in integrated cardiovascular imaging, so that they can use imaging tests to improve the quality of patient care. Then they can become the partners of the invasive cardiologists, the surgeons, etc.,   to help them deliver the best results.”

In addition, he would like to see imaging training become an integral part of the basic medical school curriculum, both at Mount Sinai and other schools.

“Imaging has got to become part of a patient’s standard physical examination,” he asserts. “Therefore, I feel that imaging should be taught from day one of medical school.  Because I believe, and I have often said – though people have not always liked to hear it – that if you’re not an imager, you’re not a physician.”

But in terms of his specific research, Dr. Narula prefers not to speak of short- and long-term goals. “Your goals are driven by your strategy, and my strategy is the use of imaging for better definition, management and prevention of a disease,” he says. “That’s what I’ve been working towards for many years now – and the sooner I get there, the better.”

Originally written for Mount Sinai Science & Medicine magazine, 2011.

Download PDF