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St. Francis

Dr. Peter Wade

Hanging in the waiting room of the Mandell Center for Multiple Sclerosis at Mount Sinai Rehabilitation Hospital in Hartford is a whimsical painting of a woman, chin up, looking forward, her hair flowing behind her. According to Peter Wade, MD, the center’s medical director of neurology, the painting – commissioned for an international MS symposium held here in 2016 and aptly entitled “The Hope of Joan” – symbolizes optimism and, well, hope.

The message is a fitting one in this space: The state-of-the-art MS Center, formally known as the Joyce D. and Andrew J. Mandell Center for Comprehensive Multiple Sclerosis Care and Neuroscience Research, has indeed served as a beacon of hope for the many patients who have passed through its doors over the past decade.

The realization of a dream for Joyce and Andrew Mandell, its main benefactors, the center “allows patients ‘one-stop shopping’ for all aspects of their disease evaluation and management,” says Dr. Wade. Andy Mandell, who has MS, had traveled to multiple places for treatment and was frustrated by this piecemeal approach. “His concept was to have everything on one site,” Dr. Wade explains.

“Instead of just treating the disease, we also treat the consequences of the disease. People see that this is the right way to do it – and it’s an exciting thing that we may be changing and improving MS patient care because of this comprehensive approach.”

In addition, treatments are becoming more sophisticated, with a beneficial effect on patient outcomes. Medical therapy for MS patients is becoming increasingly targeted at specific aspects of the immune system, and clinical trials are showing that a percentage of patients are actually improving. “That wasn’t a word we used before,” he says.

A Growth Trajectory

The Mandell MS Center has come a long way since it opened in 2008. “We now have a 14-chair infusion center just for administering MS medications,” he says. “We started with only three.” Dr. Wade, who initially devoted one day a week to his work at the center, now works there full time, and an additional MS specialist, Mary Bailey, MD, joined the team in 2016.

The facility – which encompasses all aspects of MS care, from neurology to urology (MS can affect bladder function), mental health, physiatry, and rehabilitation – has treated more than 3,000 new patients since opening 12 years ago. “And we’ve never really advertised,” says Dr. Wade. “It’s pretty much just word of mouth among the MS community.”

But word appears to have gotten out. The center’s comprehensive approach to treating MS patients has recently sparked interest locally, nationally, and even abroad. A sister center is now open in at Saint Mary’s Hospital in Waterbury, Connecticut, and another is slated to open at Mercy Medical Center in Springfield, Massachusetts this year. (Saint Francis, Saint Mary’s, and Mercy Medical are all members of Trinity Health Of New England.)

Meanwhile, an exciting collaboration is developing between the Mandell MS Center and the Medical School at Oxford University in England, which is in the planning stages to open its own version across the pond. An Oxford University neurologist visited the Mandell MS Center in Hartford for the 2016 symposium and became enthralled with its comprehensive care model. The center’s relationship with that venerable British academic institution began at that time and has continued to grow.

“We now have Oxford medical students coming to do a neurology rotation at Saint Francis and spending a week here at the MS center as part of that,” he says. “And our medical students from Quinnipiac are now going to Oxford University, too, which is pretty exciting.”

Joyce and Andy Mandell, along with others associated with the center, recently went to Oxford to lay the foundation for a Mandell MS Center there, according to Dr. Wade. In addition, the two institutions are collaborating on research into the association between cardiovascular risk factors and MS. “It’s kind of amazing,” says Dr. Wade.

Treating MS – and its consequences

Still, the excitement isn’t limited to the center’s expansion: “We’re moving on to the next step with the new medications,” says Dr. Wade. Instead of the traditional chemotherapy approach – which “killed everything,” immunotherapy is more of a targeted therapy, specifically aimed at depleting certain cells in the immune system that are involved in the MS disease process.

In order to understand how immunotherapy works, Dr. Wade says, one must understand how the immune system goes awry in those with the disease. MS is a disabling disease of the nervous system in which the immune system attacks the protective covering of the nerves (the myelin sheath), disrupting the flow of information between the brain and the rest of the body. Immunomodulating drugs like ocrelizumab deplete the B cells, which are immune cells that are involved in the attack on the myelin.

“The B cell’s job is to identify the self from the non-self,” says Dr. Wade, noting that in autoimmune diseases like MS, this system fails and the immune system attacks the body’s own cells. “The B cells float around your body and ask all your organs for their ID cards,” he explains. “If an organ loses its ID card and is identified as foreign, the B cell goes back to the lymph node and gets the T cell mad, and the T cell and B cell go back and attack that organ. If your skin loses its ID card, it’s psoriasis; if your joint loses its ID card, it’s rheumatoid arthritis; and if your myelin loses its ID card, it’s MS.”

While ocrelizumab depletes the B cells that are making the mistakes, other drugs target the T cells, and still others target both. “We have 15 drugs now,” says Dr. Wade. “Some patients respond to one, some to another. The holy grail would be patient-specific immunotherapy – if you could proactively predict which one a patient was going to respond to.”

There are two main types of MS: progressive and relapsing. Those with relapsing MS, which is the more common form of the disease, alternate between remissions (periods during which they are relatively symptom free) and relapses (the sudden development of new symptoms). Progressive MS, which is more debilitating and difficult to treat, is characterized by a progressive decline in mobility. New immunotherapy drugs can slow down the decline in progressive patients, Dr. Wade says, and/or decrease the frequency of attacks in relapsing patients, thus slowing down their development of disabilities.

Meanwhile, he says, patients at the Mandell MS Center have access to a wide range of health and mental health specialists to help them to deal with the consequences of the disease. “If you are having gait difficulty, you work with PT; if you are having dexterity issues with your hands, you work with an occupational therapist; if you’re having cognitive or speaking difficulty, you deal with the speech and language therapists,” Dr. Wade says.

Physiatrists, too, are available to help patients with spasticity issues, using Botox injections or a medication called baclofen, a muscle relaxer and antispasmodic agent. “They can put in a pump – sort of like an insulin pump – that allows them to deliver the medication right into the spinal fluid so you get the medication right where it’s needed, using lower doses, and with fewer side-effects.”

Other Exciting Advances

Other exciting advances in the MS field include stem cell transplants, an even newer and more aggressive treatment approach that erases all of the body’s immune cells, with the goal of developing a completely new and improved immune system. Stem cell transplants for MS are still in clinical trials, Dr. Wade says, so they aren’t done at the Mandell MS Center.

But there is research being done at the center focusing on the rehabilitative side of MS treatment. Whereas initially, the research focused on robotic-assisted gait therapy, the center is currently working on defining motor deficits in the upper extremities of MS patients.

Another new topic in the MS literature is vitamin D, Dr. Wade says. “Lower vitamin D levels seem to be associated with an increased risk of having a child with MS – that’s probably why MS is most common in the northern, temperate climates, because there is less sun.” He says that at the Mandell MS Center, they measure everybody’s vitamin D level and supplement it when necessary.

A Safe Place

Although some patients are sent to the Mandell MS Center by their physicians, the majority of patients are self-refer, or are referred by a friend. Some have already been diagnosed with MS; others come to rule it out. Symptoms to look out for, according to Dr. Wade: “new neurologic symptoms that last more than 24 hours or evolve over time, such as loss of vision in one eye, double vision, numbness from the waist down, clumsiness, weakness on one side of the body, and, rarely, cognitive issues.”

MS is a chronic disease, so Dr. Wade tends to build long-term relationships with his patients. “Our retention level is very, very high,” he says. Indeed, the bookshelves in his office are filled with gifts and cards that patients have given him over the years – among them a book called “Curing MS,” a red crystal heart, assorted Boston Red Sox paraphernalia, and a wooden box painted with the words: Life isn’t about waiting for the storm to pass, it’s about learning to dance in the rain.

“When patients walk through those columns at the entrance to the center, they know they are in a safe place, a place where people with MS can be themselves,” says Dr. Wade, who has likened the waiting and infusion rooms in the Mandell MS Center to floating support groups. “They know that everything and anything they need is here – and that the other people they run into are going through the same thing that they are.”

Lori Miller Kase is a freelance writer living in Simsbury.

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