From left to right: Michael Lewis, case manager, BRAVE; Illana Perlman, social worker, Tory Trauma Program; and Dr. Avery Nathens, surgeon-in-chief at Sunnybrook.

The repeat experience of injuries resulting from gun- or stabbing-related incidents is often the result of unmet social needs.

“We see it time and again where a patient is treated for a minor gunshot wound and then returns with a more severe injury from another shooting incident,” says Dr. Avery Nathens, medical director of Sunnybrook’s Tory Trauma Program. “We have an opportunity to intervene and prevent the second injury that may end – or significantly change – the patient’s life forever.”

Patients who experience the physical and psychological impact of violence can benefit from a hospital-based violence intervention program and approach that incorporates trauma-informed care with traditional medical care. Such programs are proven effective in reducing risk factors and optimizing the outcomes of young people negatively affected by community violence.

The Tory Trauma Program, under Trauma Services Manager Corey Freedman, launched Breaking the Cycle of Violence with Empathy (BRAVE) in October 2020. BRAVE supports people aged 17 to 30 who have been treated for a gun or stabbing injury by connecting them to a case manager to support them through their recovery for approximately six months.

“BRAVE uses the ‘teachable moment’ approach to intervene early and support the patient’s overall physical, social and psychological needs,” says Brandy Tanenbaum, injury prevention coordinator at Sunnybrook, who designed BRAVE based on models out of San Francisco and other U.S. cities.

With shooting incidents in Toronto doubling since 2014 and Sunnybrook seeing a rise in the number of violent injury patients, Dr. Nathens and Tanenbaum recognized an urgent need for this kind of program. A $100,000 grant from the City of Toronto to run BRAVE as a one-year pilot made it possible.

The BRAVE journey begins with patients still in recovery. They are visited by Michael Lewis, the program’s case manager, who brings extensive experience in community youth violence prevention. He is able to develop a rapport with patients and their families who are often looking for additional support, but do not know how to find it. Lewis continues his work after discharge by visiting patients as they continue their recovery in rehab or at home. In these visits, he learns about the patients’ circumstances.

“I get to know the patients as people and understand what their needs and goals are and begin to develop a case plan to implement over time as they are ready,” Lewis says.

Through conversations, Lewis is able to assess patients’ needs and start connecting them and their family with services. Connections can include victim services, peer support, education counselling, mental health and addiction services and more. Most important is the mentorship Lewis provides to the young patients, without the judgment or bias so often experienced by this patient population.

Support can look different for different patients, says Lewis. He recalls one young man with numerous gunshot wounds who was recovering very slowly and kept losing weight. With BRAVE, the patient was supported throughout his physical and psychological recovery. “Now back home and getting stronger, that young man has plans to study engineering,” Lewis adds.

Lewis says his job is to provide an empathetic ear, help people connect to services and nudge them to move ahead with their lives.

“When you meet people in trauma, you often run into patients who’ve been looking to make a change for a long time.”

The post Breaking a dangerous cycle of violent injury through the new BRAVE program appeared first on Your Health Matters.

Myths and misconceptions surround medical assistance in dying. This legal, highly regulated and compassionate procedure provides patients who are suffering from a life-limiting illness with a measure of control over how and when they will die.

When Annie Korus died last fall, quietly and painlessly over the course of a few minutes, her son held one of her hands, and her daughter the other. Family members filled the room, including grandchildren and her eldest great-grandchild. There were tears, but no regrets.

“We all had our opportunities to say goodbye, both individually and as a group,” says Annie’s son Russell Korus. In his last private moments, he told his 81-year-old mother how much he loved and respected her, and how he appreciated the lessons she had taught him.

Everyone was as prepared as possible when Annie closed her eyes on the afternoon of September 26, 2019, because it was a death that was requested by Annie and planned. Annie had medical assistance in dying (MAID) performed by a doctor at Sunnybrook, just as she had wanted.

Russell says his initial fears about MAID contrasted with how it brought a small degree of comfort to the family during a very difficult time. He says that for his family, knowing the when, where and how of Annie’s death was a great gift.

“It’s definitely better than getting a phone call in the middle of the night,” he says. As for his mother, Russell feels her death honoured how she lived. “It was merciful, and it was loving and caring.”

On her own terms

Only a few months before her passing, Annie had been living alone in the family’s long-time, two-storey home in Toronto, her husband having passed away a few years before. A former accountant, Annie still did taxes for everyone in the family and hosted weekly family potluck dinners. An opera season ticket holder for 30 years, Annie attended the opera regularly with Russell.

“She was always fiercely independent,” he says.

Last July, Annie was admitted to hospital as a result of medication issues, and subsequently developed an infection. She spent the next few months in and out of hospital and rehabilitation facilities. By September, she was at Sunnybrook with her heart and kidneys failing, unable to move anything but her arms, and in constant pain.

“This was a life she couldn’t abide by,” Russell says. “Can you Google ‘medically assisted suicide’?” she asked her son and her daughter, Lana Lewis.

At first, their mother’s words upset them deeply. They knew nothing about MAID, and the fact that it had been legalized in Canada in 2016 and involved a rigorous assessment process that required patient consent at every turn.

Through a process of discussion and supportive dialogue with doctors and support staff at Sunnybrook, Russell says he and Lana came to accept their mother’s wishes. “I realized it was the loving and caring thing to do,” he says. In the end, Annie’s family was grateful she was able to die on her own terms.

MAID is so new in Canada that most families, like Annie’s, know little about it. They may fear the stigma around the idea of assisted dying or they may worry a loved one will change their mind, but it will be too late.

“People are concerned that marginalized or vulnerable people will fall prey to this legislation,” says Dr. Amy Nolen, a palliative medicine physician at Sunnybrook. “We know that’s not true.” In fact, MAID rules require patients to meet extensive criteria. “Some might argue it’s too restrictive,” she notes.

“There’s no one-size-fits-all reason, though it often comes down to autonomy and independence.”
– Dr. Debbie Selby, palliative care doctor at Sunnybrook, on why patients choose MAID

The doctors at Sunnybrook who administer MAID are committed to meeting their patients’ needs with compassion and care. They’re also collecting evidence for research in order to help shake off the myths around this approach to dying.

“It’s so new,” says Dr. Debbie Selby, a palliative care doctor at Sunnybrook. “That’s why we’re doing the research, both to improve our local process for patients and families, and to learn more about MAID from the perspective of patients, families and health-care providers.”

An increase in requests

Between June 2016 and the end of 2018, 6,749 people received MAID in Canada, accounting for just 1.12 per cent of all deaths. “A very small percentage of people ask for MAID,” says Dr. Selby. Sally Bean, director of ethics and policy at Sunnybrook, notes that requests for the procedure have increased since legalization in Canada came into effect. “It’s about what we’d expect based on other jurisdictions,” she says. For instance, in the Netherlands, where it’s been officially legal since 2002, medical assistance in dying accounts for 3 to 4 per cent of deaths.

Sunnybrook has performed about 150 MAID procedures since legalization. Data collected at Sunnybrook in mid-2019 for a data-focused published study shows that between July 2016 and September 2018, the hospital had 107 requests for MAID, with 97 people found eligible and 80 of those eligible undergoing the process.

General data around MAID indicates the majority of people who request it have cancer, followed by those with neurodegenerative conditions such as amyotrophic lateral sclerosis (ALS). At Sunnybrook, 78 per cent of the patients who requested MAID had cancer.

Dr. Selby was the first to receive a request at Sunnybrook in 2016. Since that time, she has passed on her knowledge to Dr. Nolen, and the two of them are the primary doctors who administer MAID at Sunnybrook. MAID can happen in various units within the hospital, always within a private space.

“We also support our oncology and ALS outpatients who want to have MAID at home,” says Bean, who helps coordinate MAID at Sunnybrook. She liaises with the people who are involved with the patient receiving MAID, providing support and information to Sunnybrook staff and family members. Bean also ensures that care adheres to government rules and the expectations of the Office of the Chief Coroner for Ontario. These deaths do get reviewed thoroughly by the coroner, she says.

The process for MAID is new to many doctors in Canada, and most patients and their families don’t know the steps or what to expect. A 2019 quality assessment study conducted by Dr. Selby and Bean exploring the experiences of caregivers and families with MAID concluded that “families reported that a lack of clarity regarding the MAID process led to unnecessary complexity and anxiety.”

A thorough and rigorous process

MAID begins with a verbal inquiry or request from a patient. Once a patient is informed about MAID, it moves to the formal consent process.

Some doctors have no experience with MAID, or oppose it on conscience-based grounds. Healthcare professionals in Ontario can object to offering MAID, but must refer patients to someone who will provide it. Access to care has been a challenge, but now more professionals, including doctors, nurse practitioners and pharmacists, are gaining experience. “I think it’s getting better,” Dr. Nolen says.

Patients who find a physician to administer MAID must submit a request in writing. In Ontario, that can entail filling out a special form. This form includes a checklist that ensures the patient understands MAID, that they have a “grievous and irremediable condition,” and it must be signed by two witnesses who are independent from the patient (not family or part of their medical care team). The person administering MAID, and whoever is assisting them, also have their own corresponding legal forms.

According to the legislation set out by the Ontario Ministry of Health, a “grievous and irremediable condition” means that a patient has “a serious and incurable illness, disease or disability,” is in an “advanced state of irreversible decline in capabilities,” and has “enduring physical or psychological suffering, caused by the medical condition or the state of decline, that is intolerable to the person.” To receive MAID, a patient’s natural death must be “reasonably foreseeable.” Currently, MAID is not an option for someone who is in chronic pain or discomfort, but not at risk of death.

Prompted by a recent court ruling in Quebec during which the court invalidated the “reasonably foreseeable natural death” criteria, the eligibility requirements are currently under review by the federal government. Canada’s Department of Justice ran a public, online consultation around the eligibility criteria and safeguards for MAID in early 2020.

“It was merciful, and it was loving and caring.”
– Russell Korus says of his mother’s passing

‘Autonomy and independence’

Once a request for MAID has been formally submitted, the medical professional involved speaks to the patient to ensure they’re not being coerced, and that they understand MAID.

The issue of mental capacity is a critical part of the assessment process with MAID, Dr. Selby says. Doctors must determine whether a patient is capable of making their own health-care decisions.

Dr. Selby says she asks questions that include, “Why now?” and “What led you to know you wanted to die?” Patients often talk about losing their independence and not being able to perform basic tasks, such as eating or going to the bathroom without assistance.

There may be an assumption that people seeking MAID are driven to this choice in a desperate attempt to escape great pain, but Dr. Selby notes that pain is very rarely the motivating factor when patients choose MAID. Sunnybrook’s study showed that the majority of people who requested MAID did so over functional decline or the inability to participate in meaningful activities, followed by concerns over a loss of independence or loss of dignity. Physical suffering ranked much lower on the list.

“There’s no one-size-fits-all reason, though it often comes down to autonomy and independence,” she says.

Many patients don’t just ask for MAID, but want it passionately, Dr. Selby adds. They are often independent people who want to have a sense of control over their lives, like Annie Korus.

“Their end of life is not any different than anything else in their life,” Dr. Selby says. “Not only does it feel right, but [also] for some of them, it’s the only conceivable kind of death that makes sense to them. It’s a core part of who they are.”

Not everyone can conduct a verbal conversation. Many patients with ALS, for instance, communicate using technology or facial gestures, so Sunnybrook’s occupational therapists, speech language pathologists and other experts may help facilitate the conversation using assistive technology and speech and language therapy.

A substitute decision-maker, such as a family member with power of attorney, cannot consent on a patient’s behalf, Bean says. Consent on the day of request can only be provided by the patient themselves. And while some patients wish to put MAID in their advanced directive paperwork (also known as a living will), they cannot.

“That’s not currently legally permitted,” says Bean.

Period of reflection

Once the paperwork is done, there is a 10-day “period of reflection,” Dr. Nolen says. She notes that this requirement can present a challenge.

“If you need to have intolerable suffering to qualify, that means you need to live for 10 days with suffering that is intolerable,” she says. One family member reported to Bean and Dr. Selby in their study of families and caregivers that the period of reflection was “the longest two weeks of my life.”

Doctors can waive the 10-day period if someone is at risk of dying or losing their capacity to consent within that 10-day wait period. This happened to Annie: She filled out her paperwork for MAID on a Tuesday, but because she was losing her short-term memory and at imminent risk of losing capacity, the doctors moved up the procedure by one day.

“She was very relieved when she was told on the Thursday that it would be later that day,” recalls Russell.

When the agreed-upon day arrives, patients can delay the procedure, or change their mind entirely.

“The last thing I [am required to] say is, ‘Do you still want to go ahead? Do you understand that you will die today?’” says Dr. Selby. Consent is required so frequently that patients sometimes tire of it, she adds. On their final day, when she walks into the room, some will say to her, “Are you going to ask me again? Just get on with it.”

Perhaps unexpectedly, a difficult scenario can occur when patients become too sleepy or disoriented to consent. It can make the grief more potent for family members.

Dr. Selby recalls a circumstance where a man lost capacity before he could give his final consent to receive MAID while his two sons stood by helplessly.

“It destroyed these two boys to feel they had not honoured his wishes, and [they felt] that it was somehow their fault,” she says.

A unique experience

The standard method of administering MAID in Ontario is to give a patient a specific combination of drugs intravenously, says Dr. Selby, though patients can choose to take them orally. The first drug puts the patient to sleep, then the physician follows up with medications that cause the person to stop breathing and to stop their heart.

Although Dr. Selby tells families repeatedly that this process happens in just five minutes, they’re almost always surprised. “They can’t really conceive of how quick that feels until they’re in the moment,” she says.

People might also be surprised to know that in those rooms where patients take their last breaths, MAID offers something quite unique, Dr. Selby says.

Families and friends often hold parties with laughter and champagne. Favourite music plays.

Before one MAID procedure, one of Dr. Selby’s patients told a joke and then refused to give his pals the punchline. The man’s friends said it was so “him” to pull that kind of prank that they just had to laugh.

“Yes, these deaths are sad, but they are not sad in the way my patients who die regular deaths are,” Dr. Selby says. “[These patients] get to say their goodbyes; they say all those things that we talk about [when we say,] a ‘good death.’”

The post Uncovering myths and misconceptions surrounding medical assistance in dying appeared first on Your Health Matters.

(Photography by Doug Nicholson)

Major depression affects nearly 5 per cent of the Canadian population, and when medications aren’t helping – which happens frequently – many people struggle to do their jobs, take care of their families and have healthy relationships. Some may even develop what’s called catatonic depression, which robs them of their ability to move or speak.

There is a well-known procedure, however, that can have a dramatic impact on patients with major depression. It’s called electroconvulsive therapy (ECT) and it helps as many as 80 per cent of patients with the disorder, with 65 per cent experiencing a full remission.

“It’s life-saving in some situations,” says Dr. Peter Giacobbe, psychiatrist and associate scientist at Sunnybrook.

He’s seen people’s lives transformed by this straightforward, humane and painless treatment. But the stigma associated with ECT could make the decision to use it difficult for some patients and doctors.

“They’re so vulnerable at this moment. Their anxiety levels and their stress levels are very high,” says Dr. Fahad Alam, anesthesiologist and associate scientist at Sunnybrook.

To help patients cope with anxiety and get a sense of the procedure, Sunnybrook has developed a seven-minute virtual reality (VR) simulation video. It was filmed in 360 degrees and patients view it through a VR headset.

A calming journey

The video begins with the patient on a stretcher in the pre-procedure area. They can see the foot of the stretcher as if it was their own body lying in it. A nurse tells them what to expect when being prepped for the procedure, including getting an IV and an oxygen mask.

Next, Dr. Giacobbe appears, explaining the benefits and risks of ECT. He then wheels the bed into the procedure room. The nurse explains the equipment in this new room, and the viewer can pan around to get a closer look. Dr. Alam enters the scene to talk about the anesthetic and how it will keep the patient comfortable. The video simulates the oxygen mask coming down on the patient’s face and things fading out. Then, the video jumps ahead, showing the patient on the stretcher in the recovery room. The nurse enters again to talk about what the patient will feel like when the treatment is completed.

“[The video] reduces anxiety and stress, but also educates [patients] on the procedure,” says Dr. Alam. Ensuring that patients understand the procedure and fully consent to having it done are critical steps, he adds. The VR experience can help reinforce the information discussed by the patient and the clinical team.

Dr. Alam and Dr. Giacobbe are leading a study of 150 patients at Sunnybrook to test the technology’s effectiveness in helping people feel prepared for ECT. They want to know if VR will help people worry less about the procedure, and determine the optimal manner in which to view it. These patients will answer survey questions, report anxiety scores and also undergo tests, such as blood pressure assessments.  If the study goes well, it will become a standard offering at Sunnybrook for anyone getting the procedure.

“We know that ECT is under-utilized. Stigma and fear might be factors,” says Dr. Giacobbe. Using VR to make the therapy more palatable and dispel myths about the treatment may also inspire other centres to offer it more often.

Combatting stigma

Some of the roots of ECT’s bad rap can be traced back to pop culture. Films such as One Flew Over the Cuckoo’s Nest portray it as cruel, painful and personality-changing.

But the actual treatment is very different. For an ECT procedure, the patient is put under general anesthetic and then given a muscle relaxant. Electrodes are placed on the patient’s scalp and the brain is stimulated with brief electrical pulses, resulting in tiny seizures – a process that takes less than 10 minutes. While some people experience headaches or disorientation, others don’t need much recovery time at all.

Dr. Giacobbe recalls a patient having ECT and returning to work a few hours after the procedure.

Dr. Peter Giacobbe (left) and Dr. Fahad Alam (Photography by Doug Nicholson)

Dr. Alam and Dr. Giacobbe created the content of the video with patient input last spring. “It’s based on what patients told us scared them,” says Dr. Alam.

The doctors then did a small pilot study, to make sure the video didn’t make anyone feel dizzy or nauseous, common side effects associated with VR technology.

A 2017 review study found that as many as 75 per cent of people come to ECT with anxiety about the procedure, concerned that it would cause memory impairment or brain damage. Meanwhile, Dr. Alam notes that simply being in a health-care environment causes stress. “Across the board, if anyone walks into a hospital, 90 per cent of them have some form of anxiety or stress, and up to 60 per cent have severe anxiety or stress.”

Being stressed out before a procedure causes problems. With more invasive surgeries, Dr. Alam says anxiety before being given an anesthetic is associated with higher blood pressure during surgery, the need for more medication, higher rates of infection and slower recovery times. This is likely because of stress hormones like cortisol spiking and interfering with the body’s ability to calm down and heal itself.

Teams at Sunnybrook have studied VR videos and their effectiveness for people getting general surgery. They found that viewing these short simulations reduced anxiety and gave patients extra information on the procedure and that the videos worked best if viewed just before surgery.

ECT is a non-invasive surgery, so the risk for wound infection or death are very low. But this is a vulnerable population, Dr. Alam says, because many people with depression also have anxiety.

“They have severe depression and are facing a treatment that carries a lot of stigma. It can be scary,” he says.

Sending a positive message

ECT is an outpatient procedure that is administered as a series of treatments. As many as 20 treatments may be needed, one every few days. Patients won’t feel better right away, so it’s important to reassure patients that time is needed.

The hope is this short VR video will help patients at Sunnybrook feel more relaxed and informed about their procedure before they head into their first ECT treatment, and to view machines and health-care staff as a comfort, not something to fear. It could also help send out a wider, more positive message about ECT to the health-care community, says Dr. Giacobbe, and have an impact on depression rates.

“People have an [outdated] impression of this treatment that isn’t keeping up. Our goal is to change that,” he says.

The post How virtual reality is helping patients undergoing electroconvulsive therapy (ECT) appeared first on Your Health Matters.

(Photograph by Kevin Van Paassen)

Amyotrophic lateral sclerosis, or ALS, is a devastating disease with a grim prognosis. By opening the blood-brain barrier with focused ultrasound, Sunnybrook researchers have made important progress toward new treatments and new hope.

In early 2014, Hanna Hadden noticed that something was wrong with her fingers.

The former teacher from Scarborough, Ont., was counting donations at her church. “I found I could not pick up coins,” she says.

It took several appointments with medical specialists over the next year and a half to discover what was affecting her dexterity. Hanna was in the early stages of amyotrophic lateral sclerosis (ALS), also known as Lou Gehrig’s disease.

“I was shocked at the diagnosis,” Hanna recalls. “It’s not something I ever expected.”

ALS is a degenerative brain disease that causes gradual paralysis as the motor neurons stop communicating with muscles. As these nerve cells die, gradual paralysis sets in, affecting a person’s ability to walk, talk, eat, swallow and eventually breathe. Diagnosis typically occurs between the ages of 40 and 70, with an average age of 55 at the time of diagnosis.

About 3,000 people in Canada are living with ALS and 80 per cent die within two to five years after getting diagnosed. There is no cure.

“ALS is one of the worst diseases on the planet,” says neurologist Dr. Lorne Zinman, director of Sunnybrook’s ALS clinic and an associate scientist in the Hurvitz Brain Sciences Research Program. “It’s an awful neurological disease, and currently we can only mildly slow progression.”

NEW, EXPERIMENTAL TREATMENTS

Hanna, now 70 years old, started receiving care at Sunnybrook in 2015.

From her earliest appointments, she’d ask Dr. Zinman about the possibility of experimental treatments and clinical trials.

During one appointment, Dr. Zinman told Hanna about a revolutionary trial testing focused ultrasound to open the blood-brain barrier in people with ALS.

OPENING THE BLOOD-BRAIN BARRIER

The blood-brain barrier is a network of closely spaced cells that protects the brain by keeping out toxins, viruses and bacteria in the bloodstream, but it also prevents drug therapies from reaching the brain.

“The blood vessels in this area are so small, they act like a physical barrier,” says neuroscientist Dr. Nir Lipsman, director of the Harquail Centre for Neuromodulation at Sunnybrook and team member of this clinical trial. “We need to ‘open the gates.’”

By targeting and opening the blood-brain barrier in specific regions of the brain, Sunnybrook researchers can deliver promising medications directly and try to treat diseases such as ALS.

TARGETING THE BRAIN’S MOTOR CENTRE

While Sunnybrook researchers have made huge strides using focused ultrasound, successfully opening the blood-brain barrier in patients with brain tumours and Alzheimer’s disease, the idea of using focused ultrasound to treat ALS was a first.

Never before had anyone opened the blood-brain barrier over the motor cortex, the area of the brain responsible for controlling the body’s voluntary movements.

“We had to prove the feasibility of opening this region of the brain, and that it was safe and reversible in patients with ALS,” Dr. Zinman says.

His team would need to show that the blood-brain barrier would close again after temporarily being opened after the procedure.

In spring 2018, Sunnybrook began looking for volunteers with ALS to undergo this non-invasive procedure to open the blood-brain barrier over the motor cortex. Phase 1 of the clinical trial involved a small group of patients to determine the procedure’s efficacy and safety. Follow-up studies will add the delivery of a promising therapeutic for ALS.

Illustration based on animation by Hang Yu Lin, Aubert Lab, Sunnybrook Research Institute

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How focused ultrasound (FUS) opens the blood-brain barrier

1. Focused ultrasound directs a thousand beams of energy at a low frequency to a specific area.

2. The sound waves vibrate microbubbles that have been injected into the bloodstream, causing them to expand and contract

3. The microbubbles gently push against the blood-brain barrier, causing it to open
[/mks_toggle]

VOLUNTEERING HER TIME

Hanna was one of the first to volunteer. She qualified for the trial because she was otherwise healthy and could tolerate being in a magnetic resonance imaging (MRI) machine for a prolonged period, which was a key part of the procedure. Also important was the fact that Hanna’s ALS had not yet impaired her breathing, as it often does with people in later stages of the disease.

“Because of my condition, I didn’t know what else I could do to help,” Hanna says of her decision to take part in the clinical trial. “I was quite enthusiastic, because it sounded quite innovative.”

“Patients with ALS are so altruistic and committed to finding treatments for this terminal disease.”

– Dr. Lorne Zinman,
Director, ALS Clinic at Sunnybrook

Hanna’s hands have been deeply affected by the disease. After breaking her ankle last spring and being in hospital and then rehab for weeks, she subsequently lost her ability to walk and now needs a wheelchair.

She has a personal support worker visit her home three times a day and needs two people to help her use her stair lift and get into cars. But despite these hurdles, Hanna was determined to participate in the clinical trial for the sake of furthering science.

“It may be the last good deed I can do to help other people with this disease,” she says.

Dr. Agessandro Abrahao (left) and Dr. Lorne Zinman. (Photograph by Kevin Van Paassen)

HOPE ON THE HORIZON

And so one early morning last August, with her head freshly shaved for the procedure, Hanna headed to Sunnybrook. Hanna says she didn’t sleep the night before the big day, “Anytime you’re excited about something, you don’t sleep the night before anyway.”

Three other patients from the ALS clinic had already gone through the process that summer. Sunnybrook has the largest ALS clinic in Canada, with approximately 250 new patients diagnosed each year. Dr. Zinman says many of these people are eager to contribute to medical research.

“Patients with ALS are so altruistic and committed to finding treatments for this terminal disease,” he says. “They understand that although the research study may be in its earliest stages and may not benefit them individually, they accept the potential risks to help others.”

Hanna soon found herself being fitted with a special helmet lined with a thousand tiny ultrasound transducers, which convert electrical energy into sound energy. Then, she was placed into an MRI machine, so researchers could map out the motor cortex for precise targeting by the ultrasound waves.

That’s when doctors turned on the focused ultrasound inside the helmet. Thousands of low-frequency ultrasound waves converged on key points, hitting right near the blood-brain barrier of the motor cortex. “The frequency is so low, it’s harmless to the brain,” Dr. Lipsman says.

Tiny microbubbles are injected intravenously, and the ultrasound waves cause them to vibrate at the targeted brain regions. As they expand and contract, the microbubbles gently push against the sides of the tiny blood vessels around the motor cortex, eventually creating a small opening in the blood-brain barrier. Intravenous contrast is then injected to observe the blood-brain barrier opening on MRI.

After this four-hour procedure, Hanna stayed overnight in hospital to be closely monitored and had an MRI the next morning to determine if the blood-brain barrier had closed again. It had.

“The blood-brain barrier has an important function which needs to be restored. We want this therapeutic window to be opened only temporarily and then repair itself over a few hours,” says neurologist Dr. Agessandro Abrahao, a fellow at Sunnybrook with the ALS clinic who’s part of the research team.

“It’s been incredibly exciting for me to be involved in this world-class research. We are so pleased that this non-invasive procedure has been safe and well tolerated by all the trial participants,” Dr. Abrahao says.

MOVING FORWARD

The team at Sunnybrook is now moving ahead with plans to start Phase 2 of the trial. This study will include the use of a therapeutic agent and Drs. Abrahao, Zinman and Lipsman hope to begin in the fall.

Over time, researchers will likely develop therapies for ALS designed for this type of direct-to-the-brain use. Antibodies, gene or viral therapy, for instance, might be ideal.

Antibodies directed to specific targets can be used to decrease toxic proteins or reduce harmful inflammation. Gene therapy can involve replacing a mutated gene that causes disease with a healthy copy of the gene, or knocking out a mutated gene that is functioning improperly. Viral therapy can involve reprogramming viruses in the lab into therapeutic agents that can be used to kill harmful cells.

It is believed that these kinds of therapies could potentially improve, or even reverse, the damage caused by ALS, resulting in better motor function and a longer life span for people with the disease.

Being able to open up the blood-brain barrier around the motor cortex could also eventually lead to more effective treatments for other neurological diseases that impact movement, such as Parkinson’s disease and Huntington’s disease.

Once the process for opening the blood-brain barrier is refined and effective drugs are developed, Dr. Lipsman says it will be possible that focused ultrasound could be used in any hospital for ALS treatment.

“There are upfront costs for equipment,” he says. But because opening the blood-brain barrier helps medication get to the brain more effectively, hospitals could cut down on the dosage they need to administer.

“And if you can slow ALS progression and reduce disability in these patients, there is the potential to not only develop a much needed therapy, but [also] save our health-care system significant expense,” Dr. Lipsman adds.

And while it’s uncomfortable to lie in an MRI machine, this can be a painless and side-effect-free procedure for patients like Hanna.

To help others one day receive a truly effective treatment for this devastating disease, Hanna says undergoing the procedure as one of the first study participants was worth it.

“I would do it again,” she says.

The post ALS: researchers take a big step forward with focused ultrasound appeared first on Your Health Matters.

He never completed the word. A car ahead of him had stopped to turn left. Steve swerved into oncoming traffic, colliding head-on with another vehicle.

Paramedics concluded the 28-year-old had suffered a severe brain injury, and that one of his thighbones was broken in two places. With his life on the line, Steve was airlifted to Sunnybrook’s Tory Regional Trauma Centre.

The trauma centre, now celebrating its 40th anniversary, was Canada’s first regional trauma centre and it remains the country’s largest. The centre’s expert team cares for over 1,600 injured patients annually, many of whom are at risk of losing life or limb, usually from a motor vehicle collision, shooting, stabbing, severe fall or industrial incident.

While patients with injuries like Steve’s are a rarity at many hospitals, they’re a daily reality at Sunnybrook. Tory Regional Trauma Centre’s success at saving lives place it amongst the top 10 per cent of all North American trauma centres, according to a recent report by the American College of Surgeons.

Sunnybrook’s trauma team saves 94 per cent of the most severely injured patients who come through the centre’s doors. They can do so because they harness the latest advancements in trauma care, some of which have been spurred by their own cutting-edge research.

This state-of-the-art care was there for Steve when it mattered most. Comatose and bleeding, he was rushed to the trauma bay and treated by a multidisciplinary team of surgeons, anesthesiologists, nurses, respiratory therapists, imaging specialists, blood bank technologists and others.

They stabilized him over the course of nearly three hours by getting the bleeding from his leg under control and treating his life-threatening brain swelling.

Steve had won the opening round of his long fight to return to his daily life. He went on to spend the next 52 days in the Intensive Care Unit. Next came in-patient rehab, and then more from home.

Steve is still living with the residual effects of his permanent brain injury, which has prevented him from pursuing his career path, but he feels fortunate to be alive. “The trauma centre saved my life. I owe so much to them,” he says.

A history of innovation

The advent of computed tomography (CT) imaging – a technology that was crucial to Steve’s care – is one of the major ways trauma care has improved since the Tory Regional Trauma Centre opened four decades ago. CT imaging can visualize nearly all parts of the body, and it is particularly well-suited for rapid evaluation of brain injuries and internal bleeding.

With the introduction of this technology, Sunnybrook developed protocols for its optimal use to assess injuries and come up with effective treatment strategies. A recent addition to the team – dedicated emergency and trauma radiologists who conduct CT imaging – is yet another Sunnybrook innovation.

Advancement in blood transfusion science is another area where trauma care has improved in recent decades, thanks in part to contributions by Sunnybrook. For instance, the hospital’s Massive Hemorrhage Protocol is a comprehensive, multidisciplinary protocol that has been used as a model for hospitals worldwide.

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Sunnybrook’s trauma team saves 94 per cent of the most severely injured patients who come through the centre’s doors

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Developed by Dr. Jeannie Callum, Sunnybrook’s director of transfusion medicine and tissue banks, and Dr. Barto Nascimento, a trauma specialist, the protocol stipulates how and when blood products – for instance, red cells, platelets, plasma – should be transfused in cases of massive bleeding. It also speaks to the use of medications to stop bleeding, and advises on various factors that can impact bleeding such as maintaining normal body temperature, using blood warmers for all blood products and frequent tests of clotting factors.

Dr. Callum’s team reviews every resuscitation involving massive transfusion. Their goal is improving the protocol and saving lives, while carefully and efficiently using scarce blood products. Many patients who survive the early hours and days of a trauma can die later because of a blood clot in the legs or lungs. This is because immediately after trauma, the blood clotting system goes into high gear to stop injury-related bleeding. This process can also lead to abnormal blood clots. Sunnybrook’s Dr. Bill Geerts has led research to enhance prevention and treatment of such clots.

Dr. Geerts, director of the hospital’s Thromboembolism Program, leads a team that assesses every trauma patient for this risk, often prescribing low doses of clot-preventing drugs. His team has dramatically reduced deaths and is considered a world leader in this aspect of trauma care.

Sunnybrook’s chief of surgery, Dr. Avery Nathens, says the Tory Regional Trauma Centre’s innovative care wouldn’t be possible without its talented staff. “We’ve brought in the right people, all of whom are here because of their commitment to the injured patient,” he says.

Sharon Ramagnano is one of those people. She was brought on this year as manager of trauma services and will lead quality improvement and strategic project work in order to make processes better and foster more alignment across all clinical areas that are involved with trauma patient care. She is also focused on patient and family education to both prevent trauma and support those going through the continuum of trauma care.

“We are very proud of the work we do saving lives,” says Dr. Nathens. “We also realize the importance of improving the quality of life of our trauma survivors. This focus – bringing together the experience of our surgical teams, rehabilitation medicine specialists and mental health physicians – to get patients back on their feet to the lives they’ve had before injury – will be our next advancement.”

An important innovation on the horizon is the construction of Sunnybrook’s first hybrid operating room (OR). At twice the size of a standard OR, the hybrid OR will bring advanced imaging and surgical equipment into the same room. This will, for instance, enable one surgeon to operate to stop abdominal bleeding, while another surgeon operates on the brain.

“A hybrid OR means we will never have to compromise in our approach,” says Dr. Nathens, adding that the facility, which will be built with the assistance of donors, is evidence of Sunnybrook’s commitment to inventing the future of trauma care.

For trauma patients like Steve, it’s all quite remarkable. “There’s so much work that goes into saving one person,” he says. “I think it’s just amazing.”

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