“Since the onset of the COVID-19 pandemic, Sunnybrook researchers have been quick to rise to the challenge, initiating more than 100 research studies related to COVID-19 that seek to make a substantive impact in better understanding the virus or proposing solutions to the many questions posed by the pandemic,” says Dr. Kullervo Hynynen, PhD, vice-president of research and innovation at Sunnybrook.

These studies were launched thanks in large part to donor support. Close to 11,500 donors from the community stepped up to help Sunnybrook’s COVID-19 response, contributing more than $7-million.

While insights into the virus are still evolving, it appears that although COVID-19 is best known as a respiratory disease, it also has repercussions elsewhere in the body. Here is a look at some of the research projects ongoing at Sunnybrook:

What impact does COVID-19 have on mental health?

Having seen the effects of the pandemic on mental health firsthand, Dr. Anthony Levitt, chief of the Hurvitz Brain Sciences Program and medical director of the Family Navigation Project (FNP), was spurred to lead a formal study into its wide-ranging impact, with the FNP team.

“I do not think we yet fully understand the tremendous negative, and even positive, impact of the pandemic on the mental health of our society,” Dr. Levitt says. “Our study is designed to explore this and the specific effects of having contracted COVID on mental illness and addiction.”

At the end of the project, around 7,500 Ontarians will have been surveyed over a period of a year and a half. Early findings have revealed that people who have contracted COVID-19 are at a greater risk of having depression, anxiety and substance misuse, compared to those who have not. As well, the data shows that several factors are associated with higher risk of suicidal ideation during the pandemic, including younger age, COVID-19 exposure and reduced socio-economic status.

The study has revealed that greater long-term social support is potentially protective of people experiencing these kinds of challenges, says Dr. Levitt. He hopes the study’s results will assist the province in creating better supports for people experiencing mental health challenges not only from the COVID-19 pandemic, but also for future pandemics.

What is the impact of COVID-19 on the brain?

Neuroscientist Dr. Simon Graham, PhD, is leading a team looking at the longer-term cognitive effects of infection. “The brain effects of COVID-19 are somewhat under-appreciated, and we don’t know the full extent to which they’re occurring,” he says.

Using magnetic resonance imaging (MRI) and behavioural assessments, Dr. Graham’s study has already shown some patients who were on a ventilator before recovering suffered from brain micro-bleeds or mini-hemorrhagic strokes. Some recovered patients have also been found to have evidence of inflammation in the brain.

These discoveries are particularly important given the growing number of “long haulers,” patients who experience lingering problems from the virus like brain fog and poor memory, Dr. Graham adds.

“Even if their persistent symptoms have to do with shortness of breath or abnormal heart rate, those things are actually controlled by the brain, so it could be COVID-19’s impact on the brain is causing those problems, too.”

What is the relationship between COVID-19 and the heart?

Cardiologist Dr. Idan Roifman in the Schulich Heart Research Program at Sunnybrook is leading research examining how COVID-19 may lead to inflammation of the heart muscle or cause damage to the heart similar to a heart attack.

The study is building on considerable research globally showing COVID-19 increases the risk of blood clots.

Using magnetic resonance imaging (MRI), Dr. Roifman’s work seeks to find evidence of heart damage in patients who have recovered from COVID-19 and determine the type of damage that has occurred. The study is also investigating how risk factors like diabetes and high blood pressure may elevate the risk of developing cardiac complications like heart failure.

Already, the research has revealed heart function abnormalities in some patients in recovery. “That alerted us to follow them closely and led to a potential change in their long-term management,” Dr. Roifman says.

Why do COVID-19 symptoms persist in some people?

Sunnybrook’s Dr. Hubert Tsui, head of hematopathology, and clinical microbiologist Dr. Robert Kozak, PhD, are poring over blood tests and nasal swabs from patients with COVID-19 to understand why some individuals become so-called long haulers. “The research literature states as much as 50 per cent of people could have some long-term COVID symptoms,” says Dr. Tsui.

The researchers have been looking at early diagnostics from patients who became long haulers, while comparing them with other patients who have fully recovered to see if they have a different initial immune system response. “Some of our preliminary data is indeed showing that something very early on, even at the diagnostic point, is different – providing a clue in terms of risk to developing long COVID,” he adds.

Understanding the basic science regarding immune response to COVID-19 could lead to identifying patients who are likely to experience long-term problems early on, Dr. Kozak notes. Research could even lead to therapeutics to prevent and treat long-hauler symptoms.

“The more we can help people now, the more they will benefit down the road,” he says.

The post Sunnybrook community steps up to support critical COVID-19 research appeared first on Your Health Matters.

“I could barely be out of bed for more than a few hours; I was so dizzy I could barely stand and I had extreme anxiety,” says the 42-year-old Toronto school teacher.

Over the course of a year, Jennifer saw a long list of specialists, including a neurologist, rheumatologist, gynecologist, psychiatrist and ophthalmologist. But none of them were able to determine the root cause of her symptoms.

It was a frustrating and challenging time, Jennifer says. Unable to work, she battled with her insurer to claim disability, because doctors couldn’t come up with a cause. “I didn’t know what was wrong with me,” she says.

Sunnybrook cognitive neurologist Dr. Matthew Burke.

Then Jennifer saw Dr. Matthew Burke, a cognitive neurologist and member of Sunnybrook’s Hurvitz Brain Sciences Program.

“Within 30 minutes of telling him everything, he said, ‘I know what’s wrong,’” Jennifer recalls.

Dr. Burke diagnosed her with persistent postural perceptual dizziness (PPPD), a complex disorder of brain network dysfunction that is treatable.

That quick, breakthrough assessment of Jennifer’s condition is a testament to Dr. Burke’s skill as a physician. It’s also an example of the creative thinking happening at one of the world’s leading hubs of interdisciplinary research and clinical care for complex brain disorders and disease.

Soon, this innovative research program will have a new home. Sunnybrook’s Garry Hurvitz Brain Sciences Centre will bring together some of the greatest minds across diverse areas of expertise in brain health, including psychiatry, neurology and neurosurgery, to encourage collaboration. The highly integrated team will develop the next generation of treatments for mental illness, dementia, stroke, neurological disorders and more.

Tearing down silos

The Hurvitz Brain Sciences Program “involves any kind of specialty in medicine that involves anything to do with the brain and central nervous system,” says the program’s chief, psychiatrist, Dr. Anthony Levitt.

Created five years ago with Dr. Levitt at the helm, the program’s mission was to encourage collaboration between psychiatry, neurology, neurosurgery, ophthalmology and otology (ear, nose and throat medicine), as well as neuropharmacology, neuroradiology and neuropsychology.

“The major brain afflictions of our time – mood disorder, stroke and dementia – are all interrelated,” Dr. Levitt explains. “So it makes sense for us to understand and treat them with meaningful collaboration between specialties that have previously functioned separately and in silos.”

An ongoing challenge, however, has been that these specialties are spread across Sunnybrook’s sprawling Toronto campuses, which can sometimes impede collaboration. The new Garry Hurvitz Brain Sciences Centre will bring Sunnybrook’s top clinical and research minds together.

Thanks to generous donations from the public and corporations, Sunnybrook raised more than $60-million for the 121,000-square-foot, three-storey facility. A matching $60-million contributed by the provincial government will help increase the capacity for adult and youth inpatient mental health care, making Sunnybrook one of the largest adolescent mental health services in the Greater Toronto Area. The building, which will house a number of Sunnybrook’s Hurvitz Brain Sciences Program treatment programs for youth, adults and the elderly (see sidebar), is specifically designed to be able to expand and accommodate additional floors in the future.

In the past, and even today, experts in mental health and neurological disease have tended to work independently, notes Dr. Levitt. But there’s a growing realization that previous distinctions between all brain-related disciplines like psychiatry, neurology and neurosurgery are increasingly blurred.

“In the last five years, for example, we’ve recognized many psychiatric disorders are not only caused by a chemical imbalance, but might also reflect circuitry issues, too,” says Dr. Levitt. “The brain is an electrical organ, and there may be specific circuits that are malfunctioning in disorders such as depression and obsessive-compulsive disorder (OCD).”

Dr. Anthony Levitt, chief of the Hurvitz Brain Sciences Program.

Jennifer is an example of someone with a challenging health problem that doesn’t fit neatly into one medical discipline. PPPD is a disorder that involves the vestibular system, a sensory system located in the inner ear that is crucial to maintain normal balance and equilibrium. In PPPD, there is a problem with the signals sent back and forth by the vestibular system and the brain, causing a sensation of dizziness in the body.

Patients like Jennifer with functional neurological disorders – complex conditions where patients experience physical symptoms without a clear structural problem in the nervous system – are at risk of falling through the cracks, because their disorders straddle neurology and psychiatry, Dr. Burke says.

“What often happens is, they’re assessed by a neurologist, who finds no evidence of disease,” says Dr. Burke, who recently authored a groundbreaking article on the subject in JAMA Neurology entitled, “It’s All in Your Head – Medicine’s Silent Epidemic.” Says Dr. Burke: “You’ve essentially ruled out a structural – or a hardware – problem.”

But patients are left with very real symptoms, he adds, “and the message they often take from that is, ‘It’s all in your head.’”

Jennifer’s condition and similarly challenging functional brain disorders are “software” problems, Dr. Burke explains. “This means the connections between brain regions – the networks and circuits – become disrupted and dysfunctional, which doesn’t show up on structural MRI and CT scans.”

Dr. Burke notes the Garry Hurvitz Brain Sciences Centre represents a significant leap forward for standard of care for this emerging area of brain disease.

“Generally, [functional] disorders require collaboration across the brain sciences, and patients may suffer when that doesn’t happen,” he says.

Expertise and education

In addition to helping researchers collaborate and improving patient care, the centre will also be a venue for unique educational opportunities, including a new Brain Medicine Fellowship supported by the Hurvitz Brain Sciences Program.

Fellowship director Dr. Sara Mitchell, a neurologist cross-appointed within the Department of Psychiatry, says traditional fellowships often focus on one area of expertise. For instance, a psychiatry trainee might be involved in treating bipolar disorder through therapy and medication, and pay less attention to the underlying neuroanatomical basis of the disease.

“But the goal of the Brain Medicine Fellowship is to develop cross-disciplinary competencies,” she adds. “It tries to broaden perspectives and show physicians how when different brain-focused specialties collaborate, patients ultimately receive better care.”

Dr. Sarah Levitt (no relation to Dr. Anthony Levitt) was the first fellow to embark on the new training program beginning last year. Her focus is on improving care for individuals with severe mental illness who are also diagnosed with life-threatening medical conditions.

“We know people with severe, persistent mental illness – like schizophrenia – tend to die 20 to 30 years younger of cardiovascular disease, cancer and diabetes,” she says.

Dr. Sarah Levitt further notes that these patients are often best served by a multidisciplinary approach that synchronizes the efforts of many professionals toward one goal. The new centre will foster better collaboration not just through the fellowship, but also by creating a physical space for multidisciplinary clinics where patients will see a few specialists at once.

“It helps patients for them to have access to different expertise at the same time,” she says.

In short, the new centre is designed to help patients get the care they need, when they need it, in a co-ordinated space, says Dr. Anthony Levitt.

“Our goal is to have several related specialists seeing patients in the same clinic space, providing integrated care. This reduces the burden of patients and caregivers trying to navigate a complex process of specialist referrals and separate departments – in a population that is often challenged in managing these tasks as a result of the underlying illness”

Now on the mend, Jennifer says she is grateful for the treatment she received at Sunnybrook and believes the Garry Hurvitz Brain Sciences Centre will only improve care for others like her going forward.

“My hope is this new centre leads to more research, so future patients are diagnosed more quickly and get the care they so desperately need.”

The post Breaking new ground with the Garry Hurvitz Brain Sciences Centre appeared first on Your Health Matters.

Photography by Doug Nicholson

Michelle Jennett went from helping people save money to working on a device that could save lives.

In 2015, she was an investment banking analyst at a leading firm in New York. But she found herself drawn to another part of the city once she left the office.

“I was always volunteering Saturday nights in the emergency room,” she says. “So in the back of my mind, there was this passion for [medicine].”

Those evenings of cleaning hospital beds and giving out warm blankets to patients were fulfilling in a way the financial realm wasn’t. Jennett decided to move back to her home province of Ontario to pursue pre-medical school, a move that ultimately led her to Sunnybrook’s Medventions program.

Medventions was founded through the Schulich Heart Program in 2016 as a way to put technological innovations on the path to commercialization. The program connects aspiring medtech entrepreneurs with scientists, clinicians and engineers to develop medical devices that address very specific problems in the hospital environment.

Jennett went through the Medventions program as a fellow in 2018, and subsequently co-invented one of the program’s most promising innovations – a commercially viable medical device called RescuBeat, designed to improve life-saving measures in critical care environments.

RescuBeat has the potential to overcome a number of challenges associated with administering cardiopulmonary resuscitation (CPR) to patients in cardiac arrest in the catheterization (cath) lab.

Cath labs are specialized examination and treatment rooms equipped with diagnostic imaging equipment.

While most patients brought to the cardiac cath lab have a relatively low risk of complications, some patients, emergent cases in particular, are at a higher risk of cardiac arrest, says  Dr. Brian Courtney, an interventional cardiologist at Sunnybrook and co-inventor of RescuBeat.

CPR compresses the chest and pumps blood from the heart to the rest of the body to prevent irreparable damage to critical organs. With the right amount of pressure and consistency, compressions can save a patient on the verge of dying, but CPR is difficult and exhausting to administer by hand, even for trained health professionals.

And while mechanical CPR devices already exist, which can help eliminate human error and fatigue, “their use is unfavourable in situations like the catheterization lab for heart attack patients,” Jennett says.

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In the back of my mind, there was this passion for [medicine].”

– Michelle Jennett

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“The problem in the lab is  you do not want to have a person standing in the path of X-rays while administering manual CPR because they will get exposed to unwanted radiation,”  Dr. Courtney says.

The X-ray exposure may be necessary for a patient who may die without the help of an angiogram. During an angiogram, a hollow, thin tube called a catheter is inserted into the cardiac blood vessel through the skin, allowing doctors to examine how well the heart is working. And while one-time exposure is unlikely to lead to lasting harm, health-care providers would inevitably be exposed multiple times during the course of a career performing CPR in the lab on several occasions.

Mechanical CPR devices prevent this kind of exposure. But devices currently on the market can block X-rays that allow cardiologists from viewing the vessels of the heart during an angiogram, a necessity during a heart attack.

Jennett witnessed this problem first-hand while shadowing Dr. Courtney as part of her Medventions learning experience.

“One of the existing [CPR] devices was placed on the patient and it blocked views of the arteries during the angiogram, making it very difficult to proceed with the procedure,” she says. “That’s when we realized there must be a better way.”

The moment served as a critical juncture in the development of RescuBeat. Jennett and the team – which consisted of herself, Dr. Courtney and engineers Reniel Engelbrecht and Miles Montgomery – had identified a major problem worth solving. And that’s a key part of the Medventions process, says Ahmed Nasef, Medventions program manager.

“We immerse multi-disciplinary teams of clinicians, engineers and people from a business background in the clinical environment at Sunnybrook where they spend a substantial amount of time trying to identify challenges that impose a significant medical burden,” Nasef says.

The Medventions Internship Program gives participants the chance to find these sorts of problems by letting them shadow health-care professionals at Sunnybrook for the first half of the four-month program.

“This really is the most important phase,” Nasef says. “Because if you get this stage right, chances are you will likely develop a solution that has high commercialization potential.”

Dr. Courtney points out that medical devices comprise a multi-billion-dollar industry, yet Canada accounts for a small fraction of this economy. 

“We import $8 billion in medical devices and export $3 billion in medical devices,” he says. “We know we have great engineering talent, research infrastructure and clinicians, so why is it we don’t develop a lot of good medical technology?”

Dr. Courtney came to Sunnybrook to be part of the answer. He was driven by his experience at Stanford University as an early student in the pilot phase of the Biodesign Program, which was instrumental in building the booming medical device industry in the U.S.

Now, Medventions is becoming a blueprint for other medical centres. Sunnybrook recently received a $49 million investment from the federal government to help spearhead medical technology commercialization across Canada.

While the potential economic spinoffs are massive, even more important is the potential to solve health-care challenges and improve the lives of patients.

With a provisional patent filed earlier this year, RescuBeat is well on its way to commercialization. It’s also the first Medventions device accepted by MaRS Innovation, which provides seed funding and other supports to fledgling medical startups.

Although a work in progress, the device may one day not just save lives in the cath lab. It could be used anywhere cardiac arrest occurs.

“Our hope is to bring a device to market that will ultimately save many, many lives,” Jennett says.

The post Michelle went from an investment banker, to inventing a device that could save lives appeared first on Your Health Matters.

Raysha Rivany and Billy Kurniawan on their wedding day. (Photograph by Christopher Liando)

Nerve injuries to the shoulders and arms can be severe and complicated, impairing a person’s quality of life. Sunnybrook’s new Complex Combined Upper Extremity Clinic takes a team approach to provide patients like Billy Kurniawan with a leading model of care.

Billy Kurniawan awoke last May not knowing how he ended up at Sunnybrook.

Told that he been unconscious for a number of days, he had no memory of the motorcycle crash that had brought him to Canada’s busiest trauma centre.

What the 39-year-old could recall, however, was that he was to be married to his fiancée, Raysha, in two months.

Billy soon realized he faced a challenging recovery from a long list of injuries. Because of his neck injury, he needed to wear a halo brace – a medical device that clamps around the head and attaches to the shoulders to stabilize the spine.

“But the real major [injury] was to my brachial plexus – a root of the nerves that attach to the spinal cord,” he explains. “Basically, the nerves that control my arm, hand and fingers were detached from my spinal cord.”

The injury, called a root avulsion, meant Billy had lost much of the sensation and use of his left arm. Suddenly everything in his life now seemed up in the air: the wedding, his job and whether he’d ever be able to use his arm again.

What was certain, however, was that Billy needed specialized care, and Sunnybrook was the right place. A year before his crash, Sunnybrook’s Complex Combined Upper Extremity Clinic opened with a mandate to treat serious nerve injuries like his.

Dr. Paul Binhammer, plastic surgeon, Complex Combined Upper Extremity Clinic at Sunnybrook. (Photograph by Kevin Van Paassen)

“I am one of those lucky people – to be at Sunnybrook,” he says. “I am thankful to be alive and still able to walk.”

Billy is among several dozen Ontarians who have undergone treatment at the Complex Combined Upper Extremity Clinic since it opened in June 2017.

Plastic surgeon Dr. Paul Binhammer, one of the clinic’s specialists, says the idea for a specialized unit evolved out of the realization that care for patients with serious nerve injuries to their arms and hands was not as good as it could be.

“I felt like these patients weren’t being well served,” says Dr. Binhammer, one of Canada’s leading specialists for procedures to repair nerve injuries to the upper extremities.

Before Sunnybrook’s innovative new clinic, patients might have had to see several specialists at different locations over a number of weeks.

“I’m a positive person, so I wake up each day hoping for the best.”
– Billy Kurniawan

“That often would prolong the recovery process because patients go back and forth between specialists as they tried to solve the problem,” Dr. Binhammer says. “The clinic came about with the aim of having all the specialists for the patients in one place, so we can come up with solutions much more quickly.”

Time is a big factor with these kinds of injuries, he explains. The longer patients wait for care, the longer their recovery will be. Also, as time passes, the damage is more likely to become permanent, as muscles atrophy and joints become progressively more rigid.

Raysha and Billy at home in Toronto. (Photograph by Kevin Van Paassen)

The Complex Combined Upper Extremity Clinic aims to provide fast-tracked care. Patients first meet with the team, three specialists who include Dr. Binhammer, Toronto Western Hospital hand surgeon Dr. Heather Baltzer and physiatrist Dr. Larry Robinson. (Physiatrists are nerve, muscle and bone experts who diagnose and treat illnesses or injuries that affect movement.)

The clinic is part of a growing trend in health care acknowledging the importance of multidisciplinary treatment for patients with multifaceted injuries, Dr. Robinson says, who serves as chief of St. John’s Rehab at Sunnybrook.

“A big piece of doing that well is offering all the care in one place,” he says. “Because the surgeons and others – [including] physiatrists like myself – can have that interdisciplinary discussion, we’re bringing multiple viewpoints to the table, which allows us to reach a thoughtful recommendation much faster.”

Often Dr. Robinson’s role comes first in the care plan. He helps discover the extent of a patient’s injury by testing nerve function using electromyography, or EMG for short.

“In Billy’s case, using EMG, we were able to establish he had a complete injury because there was no signal getting through to his arm,” he says.

(Illustration by Trevor Johnston)

[mks_toggle title=”Image description” state=”close “]Mapping the damage

The initial electromyography test (EMG) shows the degree of injury to a nerve. Post-surgery, it measures how the nerve is growing.
The exam involves placing thin electrode needles into the muscle. These needles are wired to a device that receives electrical impulses from the nerve, measuring its functionality.
The nerve’s ability to conduct is measured by the machine below which displays the strength of the electrical signals.
In a muscle without a working nerve, there is no voluntary activity seen despite a full effort to contract the muscle. This reading is typical in a muscle with no nerve supply.
Above are electrical recordings of muscle fibres that are just starting to recover after a nerve injury. The three large spikes represent voluntary muscle activity from individual nerve fibres.
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With the severity of Billy’s injury established, his surgical team could swiftly determine the next course of action: a nerve graft.

The aim of this surgical procedure was to restore most – but not all – movement and feeling to his left arm and hand.

“Typically with these complex cases, we can’t entirely make the limb and hand as it once was,” Dr. Binhammer says. “So we focus on things that are most important – like the fingers being able to flex and extend.”

Billy had to wait a few months for the surgery while his other injuries healed. In the meantime, his doctors gave him the go-ahead to walk down the aisle.

“We asked if we could remove the halo, but the doctors said it would be too dangerous, so it made for some interesting wedding photos,” Billy says with a laugh.

After the wedding, the procedure to repair the tear to his brachial plexus went ahead as planned. It involved Dr. Binhammer removing several centimetres of the sural nerve from Billy’s left leg.

“We steal that chunk of nerve and graft it like you’d splice an electrical wire to repair a damaged cord,” Dr. Binhammer explains. The sural nerve is often the ideal choice for grafts because patients can lose its function without affecting their quality of life much.   

“They can still run, jump and lead active lives,” he says.

Once complete, the graft procedure does not restore function immediately because the grafted nerve fibre cannot carry signals from the spine down the arm just yet. Rather, it serves as a bridge for sprouting nerves in the spine to cross the gap to the brachial plexus and regrow down the arm.

“With this pathway in place, the nerves grow about a millimetre a day,” Dr. Binhammer says. “So my job, post-surgery, is to find out how the nerve is growing.”

For Billy, it will be a long recovery, involving a lot of hard work for both him and his wife. She helps with his daily exercises and with common tasks he used to take for granted, like zipping up his jacket.

“I’m so happy she’s by my side,” he says.

While it can be challenging to accept that his recovery may take up to three years, “I realize most motorcycle crashes of this nature have far worse outcomes,” Billy says.

“I’m a positive person, so I wake up each day hoping for the best.”

Illustration by Trevor Johnston

[mks_toggle title=”Image description” state=”close “]The brachial plexus, a complex freeway interchange

Sunnybrook’s Dr. Larry Robinson, who specializes in severe injuries to upper extremities, has an apt description for the brachial plexus: “It’s like the most complex freeway interchange you could ever imagine – one with multiple exit and entry ramps.”
Located where the shoulder connects to the spine, it is a nexus for five important nerve roots controlling sensation and movement in the shoulders, arms and hands. These nerves branch into three main neural circuits, or cords, that route signals to more than a dozen peripheral nerves.
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The post How Sunnybrook helped a newlywed recover from a traumatic nerve injury appeared first on Your Health Matters.