Gerry Banks has built his life in the Toronto Community Housing Corporation (TCHC) building he’s called home for the past 30 years. But now, at age 72, Gerry worries about his future as an older person living in social housing.

“I think about things like falling in the bathtub, and no one hears me. Or what if I need to move some furniture around – how will I do that with my bad back?” says Gerry, who shares his apartment with a dog and a cat. “There are a lot of things I have a hard time doing now, because I’m old.”

Health and safety become greater concerns for most people as they get older. But for senior tenants of social housing – who tend to be especially disadvantaged by poverty, health problems, social isolation and mobility barriers – these concerns are often magnified and, in many cases, left untended.

Sunnybrook scientists are stepping up to build and implement solutions to these urgent problems, in order to help seniors like Gerry remain in their homes safely and comfortably.

Gerry Banks in front of his home in Toronto.

In a joint project that started almost two years ago, TCHC, the City of Toronto and the Toronto Central Local Health Integration Network (LHIN) have launched an “integrated services model” that addresses the issues faced by older Canadians living in government-supported housing. Key features of this new model include greater engagement of tenants in building affairs, on-site staff dedicated to each building, access to social and wellness programs and care coordinators who connect tenants to support services.

While these features are novel for Toronto Community Housing, what’s especially unique about its development is the application of implementation science – a field of expertise at Sunnybrook that uses carefully designed frameworks to translate research into strategy, actions and, ultimately, success.

FROM ANALYSIS TO EXECUTION

“Basically, it’s the study of how to get research evidence into practice and on to the front lines,” says Sander Hitzig, PhD, a scientist at the St. John’s Rehab Research Program, a Sunnybrook Research Institute program focused on advancing rehabilitation sciences to improve patient recovery.

“We often see great ideas for a new intervention or model of care that works really well under a controlled setting, but that doesn’t work as well when you try to implement it in the real world,” Hitzig says. “By applying implementation science, you can create and put into action the best possible model based on real world evidence.”

Hitzig says the successful implementation of any project depends on five key factors: characteristics of the intervention, project setting, stakeholders’ needs, the people involved and the process for executing and evaluating the intervention.

“Without this framework, you risk looking at the trees and missing the forest,” says Hitzig, who has used implementation science to develop and launch new models of care at Sunnybrook. As an example, he cites the decision to expand the work of physiatrists (specialists in physical medicine and rehabilitation) at St John’s Rehab to include consultations in acute care.

“Everyone liked the idea, because we knew it would lead to better outcomes for patients, such as a lower need for pain medications, but there was confusion around what physiatrists should do, and whether they should be at various sites or dedicated sites,” recalls Hitzig. “We used implementation science to determine the best model and the best way to implement it.”

For the senior housing project, Hitzig and post-doctoral research fellow Christine Sheppard, PhD, worked with a team to analyze 34 social housing models in Canada, the United States and Europe. They then narrowed their investigation to five models that aligned most closely with what TCHC, the city and Toronto Central LHIN wanted to accomplish.

They also interviewed 58 senior-aged community housing residents (including Gerry Banks) and consulted with 132 diverse stakeholders who included health-care providers, social workers, geriatricians, city hall officials and community advocates.

“We learned a lot,” says Sheppard. “For instance, how [to] empower tenants by helping them improve their financial literacy in things like everyday banking, setting up direct deposits and filling out forms. Because when tenants are empowered, they feel more free to ask for help.”

A BOLD NEW MODEL OF CARE

Andrea Austen, head of seniors, services and long-term care for the City of Toronto, says that having access to Sunnybrook’s experts in implementation science has made a big difference. Their work has led to key findings that shaped the integrated services model for TCHC’s 83 seniors-designated buildings.

“Under this new model, we will have these integrated teams of care coordinators, dedicated building staff and service providers like social workers and personal support workers working together to coordinate their services and to flag any issues,” says Austen.

“We will also be upping training in many different areas related to seniors, including how to identify and support cases of elder abuse, and how to communicate with people who have mild cognitive impairment.”

In addition to conducting research and presenting their findings and recommendations, Hitzig and Sheppard created a “logic model” that outlines goals and how various actions would affect outcomes for the short, intermediate and long term. They also created a dashboard to present a visual overview of 26 indicators for a healthy building.

“We are lucky to have access to experts like Christine and Sander,” says Austen. “Through the framework they’ve created, we will be able to closely monitor this new integrated services model and see the intended impact and outcomes.”

COMMUNITY HOUSING THAT WORKS

Here are some of the elements identified by Sunnybrook researchers Christine Sheppard, PhD, and Sander Hitzig, PhD, that indicate a healthy building:

CLEANLINESS: Buildings are clean, free of pests and repairs are completed in a timely manner

ACCESS: Tenants have access to health services, social supports and community agencies right in their buildings

SAFETY: Tenants feel safe in their homes and community, resulting in reduced safety incidents and reduced calls to police and fire departments

COMMUNICATION: Frequent, proactive and respectful communication from housing staff to tenants

The post Improving life for seniors in community housing appeared first on Your Health Matters.

About 18 hours after an ambulance rushed his wife to Sunnybrook, Dean Kirkhus faced a decision that he knew could spell the difference between life and death for his partner of more than 33 years.

Tracy Kirkhus had a ruptured aneurysm, which meant that a ballooning blood vessel in her brain had burst and was leaking blood into the space around her brain. The 56-year-old was unconscious and unresponsive by the time Dr. Victor Yang, a neurosurgeon and senior scientist at Sunnybrook, took her into the operating room.

“She was in a deep, deep coma,” Dr. Yang says. “Because of the location of her aneurysm and her deteriorating condition, by the time I saw her, the options available to her were limited.”

The initial line of treatment for a brain aneurysm is endovascular coiling, which involves pushing a platinum coil through a catheter to induce clotting and prevent blood from getting through the aneurysm.

In Tracy’s case, the aneurysm occurred right against the brain stem, with a shape that makes it difficult to receive the coil at the rupture point. Though Dr. Yang tried the endovascular coiling procedure, it failed to fully repair the aneurysm, he says.

The next option was a stent, but this would require blood thinner medications because the metal in conventional stents can cause blood clots. For Tracy, who had hemorrhaged badly, blood thinners were not advisable.

“After the [initial] surgery, Dr. Yang came to me and told me it didn’t work out,” says Dean. “Then, he said he had another idea.”

Dr. Yang’s idea was to implant a flexible stent with a special polymer surface designed to mimic the natural properties of blood cells. At that time, the stent – called a Pipeline Flex Embolization Device with Shield Technology – was not approved for clinical use, so Dr. Yang needed Health Canada’s permission to use the device on a compassionate basis.

“And of course, they needed our consent,” Dean says. “I didn’t think twice. I knew we had little choice but to go ahead with this other method and I felt that we could trust Dr. Yang.”

He waited anxiously to see whether Dr. Yang’s creative manoeuvre would be successful.

A harrowing journey

The events leading up to Tracy’s surgery at Sunnybrook started in February 2019, just two days before Valentine’s Day.

She was in Toronto with Dean, an Air Canada pilot who was attending a work training course. (Tracy, a manager at an air traffic control centre, first met Dean back in the ’80s when he was a bush pilot). After taking in a movie with her daughter, who lives in Toronto, Tracy headed to her home near Minden, Ont., located about 2.5 hours northeast of the city. She was hoping to dodge a snowstorm expected to hit Toronto that night.

As Tracy drove north on Highway 400, the headache that had been bothering her all day went from tolerable to excruciating. She stopped at a roadside service centre just off the highway and went to the washroom.

She was in a stall when her aneurysm ruptured.

“It felt like the top of my head exploded and I hit the floor,” Tracy recalls. She managed to get herself up and out of the washroom, but then she fell again.

“That’s when I noticed people were looking at me strangely – they probably thought I was drunk,” Tracy says. “I went to the counter and bought myself a pop and some chips, somehow thinking that if I did that, everything would be fine.” Tracy went to her car and then began vomiting.

Dean had texted his wife earlier to check that she had made it home safely. She responded after midnight, but her text came through as jumbled letters. When Dean called her, she told him she was at a service centre along the 400, but could not tell him which one. He immediately got in his car and went from service station to service station, searching for his wife.

“When I found her, I thought she was having a stroke, so I drove her to the nearest urgent care clinic,” he says. The doctor who saw Tracy ordered a CT scan of her brain. At around 4:30 a.m., she was taken by ambulance to Sunnybrook.

Tracy Kirkhus and her husband, Dean, at their home near Minden, Ont. (Photography by Kevin Van Paassen)

‛Cutting-edge approaches’ that save lives

The Pipeline flex shield stent is made with a synthetic version of an organic compound found in the outer membrane of red blood cells. This mesh-like biomaterial prevents blood cells from reacting to the stent implant. Once implanted, the Pipeline flex shield stent acts as a scaffold and helps rebuild the damaged blood vessel.

To get the Pipeline flex shield stent to Tracy’s brain, Dr. Yang used a flexible catheter, inserted into an artery in the groin region and sent up through the body. He also employed innovative imaging technology called Doppler Optical Coherence Tomography (OCT), which uses infrared light waves to create images of tissue, cells and molecules.

With OCT to guide him, Dr. Yang was able to see and accurately position the stent in the damaged blood vessel.

“My research lab was the first in Canada to do OCT research 20 years ago, and at Sunnybrook we are still the only group in the world capable of doing Doppler OCT in neurovascular patients,” says Dr. Yang.

Sunnybrook was also the first in Canada to implant the Pipeline flex shield stent, which is now Health Canada approved. To date, says Dr. Yang, Sunnybrook is one of the leading hospitals in the country for treating complex ruptured aneurysms using this technology.

“As part of the hospital’s mandate to innovate and stay at the forefront of treatment technology, Sunnybrook has led research in brain sciences with cutting-edge approaches to treating neurovascular diseases,” Dr. Yang says. “At the same time, Sunnybrook has also advanced its application of image-guided, minimally invasive therapies.”

By combining these two strategic directions, doctors at Sunnybrook have been able to treat more and more patients who would have previously been quite difficult to treat, he adds.

For Tracy Kirkhus, Sunnybrook’s innovations in neurovascular treatment have meant a second chance at life.

After spending 25 days in intensive care at Sunnybrook, Tracy spent another five months in hospital, both in Toronto and in Lindsay, Ont. By August 2019, she was able to return home, where she continued to receive physiotherapy and occupational rehabilitation. Now, she is able to walk and goes to rehab sessions twice a week.

Tracy says her vision is still impaired, and sometimes she forgets things. Talking at length can take a toll on her.

“But I’m alive, and I’m home,” Tracy says. “Dr. Yang and all the great people at Sunnybrook are my heroes.”

The post Leading-edge stent technology for aneurysms gives Sunnybrook patient a second chance at life appeared first on Your Health Matters.

(Photography by Kevin Van Paassen)

Mary Buchan Jarvis learned to drive virtually any kind of car, bus or off-road vehicle when she served as a driver in the Canadian Women’s Army Corps in the Second World War. But when her children gave her a mobile phone to help her stay in touch, Mary resisted. 

“It’s just one of those things I can’t seem to get used to,” says Mary, who has been living at Sunnybrook’s Veterans Centre for about four years. 

But when staff at the Centre announced a pilot program seeking volunteers to use an iPad-based communication app, Mary decided to give it a test drive. At the time, she didn’t even know what an iPad was.  

“The way it was described to [me] sounded like a great idea, so I said, ‘Alright, I’m up to the challenge,’” recalls Mary, who turned 95 this year. 

The mobile app, called Connections, was developed by the University of Toronto’s Technologies for Aging Gracefully Lab (TAGlab) and software company Famli.net Communications. It allows users to send text, voice, picture and video messages – all from a single interface – simply by tapping on the photos of the people they’ve added to the app. Recipients get all messages by email, regardless of whether they’re sending a text, voice memo or photo.

“We know from studies and from our work at Sunnybrook that seniors’ health, function and mood are better when they’re engaged,” says Dr. Jocelyn Charles, medical director of the Veterans Centre at Sunnybrook. “Veterans using the app are definitely more engaged, connected and enjoying a better life experience.” 

The pilot program, which started three years ago with 10 participants, was expanded last year to include 40 veterans.

Sunnybrook volunteers, most of them retirees or university students, provide one-on-one and group training sessions for the veterans on a weekly basis. The majority of participants have so far reported feeling more connected since they started using the app, Dr. Charles says. 

The Connections app is a step towards universally accessible communication for older people, says Robert Arn, chief technology officer at Toronto-based Famli.net, the mobile communications software company that worked with Sunnybrook and U of T on the pilot project. Robert points to TAGlab research that looked into the many communication challenges faced by older people. 

“The problems are multifaceted and include issues such as accessibility – for seniors with hearing and eyesight problems, for example – and in some cases also cognitive challenges and language barriers,” Robert says.  

App developers worked to create a way for people to communicate that is independent of any disabilities the users might have and that doesn’t require anyone to be particularly tech-savvy, he says. “For example, if you have poor eyesight and are sending a voice message to someone who’s hard of hearing, your message would be automatically converted to text.” 

Mary’s daughter, Karen Evans, says her mother’s ability to communicate through a device she’s comfortable with has made all the difference for the entire family. Mary is even taking photos of flowers and vegetables in the Veterans Centre garden and sending them to the youngest members of the family.  

“It used to be so hard to get in touch with her because she doesn’t like using her phone, but it’s been amazing the way she’s adopted the iPad,” Karen says. “It’s been a lifeline for me and for my brothers, but the absolute benefit has been for her grandchildren and great-grandchildren because now she’s maintaining email correspondence with them.”  

The post A mobile app is helping veterans stay connected to loved ones appeared first on Your Health Matters.

Since 2013, Sunnybrook’s Family Navigation Project has helped thousands of youth and their families find the mental health care and addiction services they need. Now, Sunnybrook is sharing its knowledge by collaborating with Humber College on a unique graduate program.

For years, the health-care system was a frustrating maze to Cathy Walsh.

She first faced difficulties finding the right kind of help for her daughter who grew up with developmental challenges. Then, when her younger daughter began grappling with mental health problems, Cathy again struggled to find the right programs and care for her child.

“The mental health care system is really complex,” says Cathy, who lives in Ajax, Ont., with her husband and two children. “And with mental health, there needs to be the correct fit between client and service provider for treatment to be successful.”

The situation took a turn for the better about two years ago, when Cathy connected with the Family Navigation Project (FNP) team at Sunnybrook. Within days, a family navigator at FNP found a residential placement with services and programs that matched her daughter’s needs.

“We had exhausted all resources in our jurisdiction,” she recalls. “By using FNP’s navigation services, we were able to find this residential placement outside of our region. Their help made a huge difference.”

Since launching in September 2013, FNP has helped more than 2,500 youth and their families, like the Walshes, find the health-care providers and programs best suited to their needs.

Growing to meet demand

The idea of FNP began with a group of families committed to make it easier for other families to get help for their loved ones. Over the years, the program has grown from two navigators to a team of 20, including an intake coordinator, a parent advocate with lived experience and 10 navigators – all working with Sugy Kodeeswaran, the executive director, and Dr. Anthony Levitt, the medical director. Navigators at Sunnybrook have diverse educational backgrounds and work experience, from social work to psychology to child development.

“Our goal since the project’s inception has been to provide direction for patients and their families, and at the same time act as a beacon for education and the dissemination of health-care system information,” says Dr. Levitt.

“We have excellent health-care services in this province, and there is a great deal of information available, but often people don’t know how to access the services or what to do if things don’t work out – or what to do if the youth themselves are not motivated to receive care. Too frequently the youth and their families get lost trying to understand and find resources in the system,” he says.

Health-care navigation originated in New York in 1990 to help cancer patients, and in Canada programs have also largely focused on cancer care. However, at Sunnybrook, FNP was established to help families who have a youth dealing with mental health and addiction challenges.

As with any start-up, seed funding was essential to the early success of FNP. Sunnybrook was fortunate to partner with RBC to launch the program, and it has continued to provide critical support through the annual RBC Race for the Kids.

“There are so many reasons people don’t talk about mental health or addiction, so it is often even harder for them to know what to do and what particular services to seek,” Dr. Levitt says.

“That’s why it’s so important to have someone who can help ensure you’re going down the right care pathway.”

This means much more than just handing patients a list of health-care providers and asking them to sort out which to contact. Effective navigation requires in-depth knowledge of the health-care system and a dedication to understanding the unique needs of each client. It also requires empathy for families as they juggle the logistics of getting the proper care, while coping with the physical and psychological challenges of a serious illness, and their own health, family and financial issues.

“Navigation also involves ‘getting in the boat’ with families to make sure they really do connect with the services we provide as options,” Kodeeswaran explains.

Navigator education

FNP’s first wave of navigators trained with Dr. Levitt, a psychiatrist, and with therapeutic placement professionals in the United States. Today, FNP has the depth of family navigation knowledge and experience to provide its own in-house training for new team members.

“Family navigators come into FNP with varied experience in supporting clients and families finding their way through the system. Even with this background, it takes several months of on-the-job training to become a skilled family navigator,” Dr. Levitt says.

Their education doesn’t stop there, adds Kodeeswaran.

“Our navigators are constantly learning from each other, learning about and sharing new resources daily,” she says. “We have our finger on the pulse of the system, so our knowledge is real-time and not restricted only to a database. Our focus is being on the ground, finding out about programs and constantly sharing information with each other.”

Cathy Walsh (left) in class with Sunnybrook navigator and Humber College instructor Miriam Blond (right). (Photograph by Kevin Van Paassen)

Collaborating with Humber

This commitment to sharing systems navigation knowledge expanded even further last year, when Toronto’s Humber College reached out to FNP for help in developing a new Systems Navigator graduate certificate program.

Launched this past September with a cohort of 24 students, the one-year program – which combines in-class learning with 240 hours of field work – is designed to build skills for guiding patients and families through complex health-care and social care systems. Admission into the program requires a bachelor’s degree or diploma in health, social and community service or other health-related or human-services field.

“When our committee came together to design the program, one of the first things we asked was, ‘Does it have to be just health care? Or could it also address navigation needs in other systems, such as social, housing, Indigenous and criminal justice?’” says Colin MacRae, coordinator for Humber’s Systems Navigator program.

Students learn how to work with interdisciplinary teams in hospitals, medical centres, community services organizations, correctional facilities and other public and private entities, all while keeping the needs of patients, clients and their families front and centre.

With three representatives at the table, Sunnybrook’s family navigation team had a “large presence” on the Humber program development committee, MacRae notes. “After the committee was dissolved, we went back to Sunnybrook again and asked if any team members would be interested in helping us write the curriculum,” he says.

When the program was ready for launch, FNP clinical and research staff stepped up to teach six courses: systems theory, health literacy, professional self-care, professional communication, strength-based approaches to service and a field-based internship.

“We were thrilled when the folks at Sunnybrook agreed to help us draw up and teach the program,” MacRae says.

Teaching and learning

For Miriam Blond, one of two Sunnybrook navigators now teaching at Humber, the opportunity to share her knowledge with future system navigators was too good to pass up.

She teaches a strength-based approach to service course, which she explains is a relatively new approach in the field of health. “It focuses on resilience and a positive approach to concerns, rather than focusing on pathology,” says Blond. She came to family navigation from a background in social work and community mental health. “It’s looking at what people can bring to a solution and what’s working well for them that we can bring forward to achieve better outcomes.”

Like the other courses in the program, Blond’s teachings apply to systems beyond health care. But the students aren’t the only ones learning from the program, she says.

“I’m also able to bring the theories back to Sunnybrook, which helps to improve our practice,” she says. “My team has asked me to bring in academic material that we can use to review and evaluate our navigation model at Sunnybrook and potentially to translate into training material for our staff.”

Continued expansion

Patient navigation continues to expand, becoming part of the gold standard of care for chronic conditions such as cancer, diabetes, cardiovascular disease and mental illness – as evidenced by the creation of the Humber certificate program. Yet while the growing number of such programs means improved access to care for more patients, a lack of common standards for navigation itself could also lead to a fragmented navigation system in the future, says Dr. Levitt.

This is why Sunnybrook recently began speaking and working with stakeholders to explore building a system that ties together the disparate navigation services across the province.

“There’s a need to create a cohesive system of navigation,” Dr. Levitt says. “With our years of experience in family navigation, we’d like to contribute to this integration.”

Full circle

For Cathy, working with the FNP team at Sunnybrook has translated into a smoother journey through the health-care system and better solutions for her daughter. Cathy remembers how the navigator, having identified the right health-care facility, contacted the doctor in charge of the facility and explained her daughter’s medical and care history.

“By the time we talked to the doctor and the facility staff, they had a good background of what we were coming for,” says Cathy. “So it took away the stress of having to tell our story over and over again.”

For Dr. Levitt, “Cathy’s family journey is an example of how navigation is not simply about putting a bandage on a fragmented system, but rather that navigation is an integral part of an effective system. Navigation takes a family-focused approach to improve access to and transitions through the system, even when all the services are actually in existence. So there’s lots to teach our community and lots still to learn.”

For Cathy, her positive experience with FNP inspired her to pursue a new career.

After being out of the workforce for a decade, she had been thinking about rebooting her career but wasn’t sure what she wanted to do. Then, a navigator at Sunnybrook mentioned the new program at Humber.

“I said to my husband, ‘That’s the program I’ve been waiting for,’” says Cathy, who has a psychology degree and work experience in the insurance industry.

“I applied that same day.” 

The post Helping families navigate the health-care maze appeared first on Your Health Matters.

Soon doctors at Sunnybrook’s Odette Cancer Centre will be able to watch a beam of radiation move through a patient’s body in real time, directing that beam precisely at a tumour.

This groundbreaking technology is called the MR-Linac. “MR” refers to MRI (magnetic resonance imaging); “Linac” refers to linear accelerator, the machine that delivers the radiation.

The MR-Linac is the first machine to combine radiation and high-resolution magnetic resonance imaging. Thanks to the machine’s real-time imaging, it lets doctors and radiation therapists at the Odette Cancer Centre target tumours and monitor their response to radiation with unparalleled precision. They will be able to see immediately whether a tumour is responding to radiation.

Sunnybrook is the first hospital in Canada to install this machine, which promises to be a game changer in the way cancer is treated.

[mks_dropcap style=”letter” size=”42″ bg_color=”#ffffff” txt_color=”#000000″]2012[/mks_dropcap] Sunnybrook becomes a founding member of the seven-member international MR-Linac Consortium. Member hospitals are hand-picked for their expertise by Elekta and Philips – the MR-Linac’s manufacturers – to refine, test and use the machine to treat patients.

[mks_dropcap style=”letter” size=”42″ bg_color=”#ffffff” txt_color=”#000000″]Fall 2016[/mks_dropcap] Construction starts on the specialized radiation bunker that will house the MR-Linac. Major tweaks had to be made to the existing room to reinforce the floor (so it could support the MR-Linac’s six-tonne weight), a hole was cut in the ceiling to lower the machine in, and the room was lined with lead to make it safe to use radiation in the space.

[mks_dropcap style=”letter” size=”42″ bg_color=”#ffffff” txt_color=”#000000″]Fall 2017[/mks_dropcap] Set-up and calibration on the massive machine continues. In September 2017, a beam of radiation in the MR-Linac is turned on for the first time in Canada.

[mks_dropcap style=”letter” size=”42″ bg_color=”#ffffff” txt_color=”#000000″]July 2017[/mks_dropcap] The MR-Linac installation begins. It took a team of a dozen people and one very large crane a full day to lower the giant machine in parts into its bunker through a hole in the ground along the Odette Cancer Centre’s west wall.

[mks_dropcap style=”letter” size=”42″ bg_color=”#ffffff” txt_color=”#000000″]What’s next?[/mks_dropcap]
Once Health Canada approves the MR-Linac for research use, the Sunnybrook team will start several clinical trials with the machine to help perfect its use. Sunnybrook is the lead site in the development of the machine’s use in brain cancer.

Photography by Doug Nicholson and Kevin Van Paassen

The post The MR-Linac: Game-changing radiation technology appeared first on Your Health Matters.

Three innovative radiation technologies mean faster and more effective treatments for multiple types of cancer.

Photography by Doug Nicholson

Kasia Moroniewicz’s treatment last September in Sunnybrook’s new MRI-brachytherapy suite made her one of the first patients in the world to experience an innovation that has dramatically changed cervical cancer therapy.

But being the suite’s first user didn’t matter much to Kasia. What impressed her most was how the designed-in-Sunnybrook super-suite cut down her time in hospital to about two hours from an entire day and made the treatment significantly more comfortable.

“It was literally night and day,” she says. “I woke up and that was it.”

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“It was literally night and day. I woke up and that was it.”

– Kasia Moroniewicz, diagnosed with cervical cancer

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Before the suite was built, Kasia had gone three times for MRI-guided brachytherapy treatments to destroy tumours from her cervical cancer. The procedure involves magnetic resonance imaging of the cervix to find the tumours. This also involves the insertion of a tube-shaped vaginal applicator, where a radiation seed is positioned via a wire to emit radiation directly into the tumours.

During these first three treatments, the discomfort of having the vaginal applicator inserted for as long as eight hours, combined with the anxiety she experienced as she lay in the MRI machine, pushed Kasia, an elementary-school teacher in Brampton, Ont., to a few tears, she admits.

“You have those moments to think about what you’re going through and it feels very scary,” says Kasia, who learned last year she had cervical cancer just nine months after her first child was born. “And there are parts of the procedure that are just unpleasant. When they remove the applicator, that’s the most uncomfortable part for me.”

Kasia Moroniewicz (with son Nigel) was the first patient to experience a new designed-in-Sunnybrook Suite for treating gynaecological cancer. Photography by Kevin Van Paassen

The new all-in-one operating room has a built-in MRI and radiation treatment bunker to treat patients who are under general anaesthetic.

“In the short span of six months, we’ve revolutionized how we treat cervical cancer,” says Ananth Ravi, a medical physicist and one of the Sunnybrook scientists who led the MRI-brachytherapy suite project. “We’ve minimized the discomfort and trauma from the treatment.”

The MRI brachytherapy initiative is among the next-level innovations now available through Sunnybrook’s Cancer Ablation Therapy (CAT) Program – a specialized unit within the hospital’s Odette Cancer Centre that uses precision therapies to target tumours without invasive surgery.

Over the last two years, the program has brought in three first-in-Canada radiation technologies, including the MRI-brachytherapy suite for gynaecological cancers. The other two are the Gamma Knife Icon, used to treat brain tumours, and the MR-Linac, which combines radiation with MRI for real-time imaging during procedures and is now in the testing phase. Each of these technologies is designed to deliver precise treatment while advancing research in cancer ablation therapy.

“Sunnybrook is in a unique position to work with the companies that make these technologies because we are recognized as world leaders in cancer care and research,” notes Dr. Arjun Sahgal, a radiation oncologist and scientist at Sunnybrook. “For the people we treat at Sunnybrook, this means access to advanced precision instruments that are in the hands of some of the best oncologists and radiosurgeons in the world.”

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How has the MRI-brachytherapy suite changed the treatment of cervical cancer?

Radiation oncologist Dr. Eric Leung, the other lead in bringing the suite to Sunnybrook, describes what radiation treatment for cervical cancer was like before.

In the operating room, the patient is given an anaesthetic to go to sleep and then implanted with a vaginal applicator. She wakes up later in the recovery room and waits – often in discomfort – to be taken to the imaging department for an MRI. After the MRI is done, the patient is taken back to the recovery room where she waits while her doctors map out her treatment.

When the doctors have completed their treatment plan, she is then wheeled to the radiation bunker. A team of brachytherapy radiation therapists helps connect the brachytherapy unit to the applicator, where a high-dose radiation seed is moved into the applicator via a wire and positioned to emit radiation directly into the tumours revealed by the MRI.

Medical physicist Dr. Ananth Ravi (left) and radiation oncologist Dr. Eric Leung were integral to the development and implementation of the MRI-Brachytherapy Suite. Photography by Kevin Van Paassen

“We have MRI images of where the brachytherapy applicators are in the pelvis, and we have marked out where the cancers are,” explains Dr. Leung. “The radiation seeds are connected to wires that go into the applicator tube, and they stay inside for maybe 10 seconds at a time, emitting radiation at each position in the applicator.”

Once the radiation procedure is finished, the patient is taken again to the operating room for removal of the applicator. Her last stop is the recovery room, where she will spend the final hour of a long day that can extend to as long as 10 hours.

Compare this experience to treatment in Sunnybrook’s new MRI-brachytherapy suite, where patients are anaesthetized and implanted with the applicator in the operating room, then placed immediately after in the MRI machine in the adjoining room before going back to the operating room for radiation. Patients are asleep the entire time.

“It’s a faster procedure, taking about two-and-a-half hours compared to eight to 10 hours,” Dr. Leung points out. “When the MRI machine and operating room are right in the same suite, it gives patients an optimal experience because we can do the applicator implant, wheel them into the MRI and then plan and do the treatment right away.”

According to Dr. Leung, the suite opens the way toward real-time imaging during radiation. The MRI is housed in a radiation bunker, allowing patients to be treated while they’re in the machine. “Right now, not all of our radiation equipment is compatible with MRI, which contains a very powerful magnet,” he says. “But full MRI compatibility is currently in the works.”

The suite can be used in future for other types of cancer that are typically treated with brachytherapy, including prostate, breast and gastrointestinal, notes Dr. Ravi. A number of hospitals in other Canadian provinces and in the U.S. have approached Sunnybrook about the suite, he adds.

“We’ve had queries about the suite. There is definite interest and there’s even a book that’s been published that includes a chapter on our particular design,” says Dr. Ravi. “When we first started to do this, it seemed like an outlandish idea, but in the short span of six months, we’ve revolutionized how we treat cervical cancer, so it makes sense to expand that to other types of cancer.”

First-in-Canada technology provides precise cancer treatment

First-in-Canada technology at Sunnybrook made it possible for Andrew Stewart to undergo radiation surgery, known as radiosurgery, to heat and destroy the cancer cells in his brain, and show up at his workplace the next day.

Radiation oncologist Dr. Arjun Sahgal (left) with Andrew Stewart, who was treated for brain cancer with the Gamma Knife Icon, a precision-radiation delivery tool. Photography by Kevin Van Paassen

Last June, the 78-year-old entrepreneur – whose melanoma skin cancer had spread to his lung and later to his brain – came to Sunnybrook for treatment with the Gamma Knife Icon, a new frameless, high-precision tool that delivers effective doses of radiation to target tumours while sparing the surrounding healthy brain tissue. “I came out of the procedure with no side effects. I could have driven myself home,” says Andrew, who lives in Caledon, just outside Toronto. “I was back at work running my business the very next day.”

The Gamma Knife Icon is used for brain stereotactic radiosurgery treatments by focusing hundreds of low-dose radiation beams on a single tumour. The beams are emitted by 192 radiation sources set out in a conical pattern – an arrangement that causes the beams to converge when they hit their target. This allows for the delivery of a concentrated dosage of radiation that effectively destroys cancerous tissue.

Before stereotactic radiosurgery came along, tumours that had spread to the brain were generally treated with whole-brain radiation, which often affected memory and other cognitive functions because it also damaged healthy tissue. Sunnybrook had acquired the Gamma Knife Icon last November but, this year, upgraded to the fully integrated unit with a mask-based safety system.

“At that point, the unit became exactly what we wanted, which was a fully-integrated, image-guided brain radiosurgery instrument, where you no longer have to put the patient’s head into a frame,” says Dr. Sahgal, whose team consists of radiation doctors, neurosurgeons, radiation therapists and radiation physicists.

Before Sunnybrook got the new unit, patients undergoing brain radiosurgery needed to get their heads immobilized with a frame that was, essentially, screwed on to the skull. Dr. Sahgal says the screws punctured the skin and often caused pain and discomfort for patients. “Depending on the number of tumours or lesions they had, some patients would have to be in the frame for several hours,” he says. “It’s a painful experience, and patients need time for the punctures to heal.”

With the new unit, a plastic mask moulded to the patient’s face is used to keep the head still. Throughout the treatment, an infrared positioning device watches for the slightest head movement. “From an outside console, we watch in real time to make sure there’s no motion because if there is, we stop the beam,” Dr. Sahgal explains. “That’s what makes it so safe and precise.”

Sunnybrook treats an average of five people a day with the Gamma Knife Icon, he says. This work also feeds research with Sunnybrook’s medical physicists and the Sunnybrook Research Institute to improve various aspects of stereotactic radiosurgery, such as treatment planning, imaging quality and MRI response.

“We have a major research program centred around this machine,” Dr. Sahgal notes. “We are building new trials in order to ask and answer questions about the treatment of brain metastases that can only be asked and answered with the Icon. We also lead a North American Icon research group, and this is something we are very excited about.”

The post These first-in-Canada technologies are improving cancer treatment appeared first on Your Health Matters.

They awaken to stiff joints and spend their days fighting pain as they go through the usual motions of living.

An estimated 4.6 million Canadians suffer from osteoarthritis, a degenerative joint disease – and the most common form of arthritis – that starts with the breakdown of the cartilage that protects joints and keeps the bones from rubbing against each other. This chronic disease results in joint pain, stiffness and swelling, often becomes disabling, and is more prevalent among older people.

The implications are troubling for an aging country like Canada, where there are now more people over the age of 65 than there are children and where seniors will account for two out of 10 residents by 2024.

A number of studies in recent years have highlighted the growing prevalence of osteoarthritis among Canadians, and the greater burden this places on the country’s health-care system.

One study published in 2011 by the Arthritis Alliance of Canada – in a report entitled “The Impact of Arthritis in Canada: Today and Over the Next 30 Years” – predicts that by 2040, one in four Canadians will have osteoarthritis. With a new diagnosis of osteoarthritis every 60 seconds, almost 30 per cent of Canadian workers will have difficulty working because of the disease, the study’s authors wrote.

“Now more than ever, we need to look at how we can best serve the needs of Canadians with osteoarthritis in ways that will also be more optimal for the health-care system,” says Dr. John Murnaghan, interim medical director of the Holland Centre, part of Sunnybrook’s Holland Musculoskeletal Program.

Sunnybrook is leading the way in this effort. About 12 years ago, the Holland Centre introduced an innovative model of care for hip and knee arthritis. As part of its Hip and Knee Arthritis program, the centre pioneered a Central Intake and Assessment process that today continues to improve access and quality of care. Two patients from the Centre share their stories.

For Mary Lou Nawrocki, it was a great relief to learn she didn’t need joint replacement surgery. (Photograph by Kevin Van Paassen)

Mary Lou Nawrocki: non-surgical treatment

Life changed the day Mary Lou Nawrocki’s knees buckled as she was walking about with a friend. Diagnosed shortly after with knee osteoarthritis, the retired elementary- school teacher could no longer take long walks or exercise because of the pain and stiffness in her legs. She became less active and gained weight, which put more pressure on her knees and added to her pain.

“I tried physiotherapy and then a chiropractor, but nothing worked,” recalls Mary Lou, who is 67 and lives in Toronto with her husband. “The osteoarthritis would just flare up and my knees would swell.”

Her life changed again last year, this time for the better, when her doctor sent her to the Holland Centre. Within the month of getting a referral, Mary Lou walked into the Centre’s Assessment Clinic.

A distinctive feature of the Holland Centre Assessment Clinic is that it is led by advanced practice physiotherapists (APPs) and advanced occupational therapists (APP/OTs) – clinicians with extensive credentials that include solid backgrounds in orthopaedics and specialized training from the surgeons.

Instead of immediately putting patients in a long queue to meet with an orthopaedic surgeon, the Holland Centre’s intake process connects them first with an APP/ OT, who works with them on a treatment strategy and, when needed, refers the patient on to an orthopaedic surgeon.

The process starts with a detailed assessment by an APP/ OT that includes a thorough clinical examination and a review of X-rays of the affected joints, as well as functional testing that gives information about a patient’s ability to carry out everyday activities. As part of the assessment, they are asked to do a six-minute walk test.

Using this information and a scoring system developed by the Centre’s experts, the APP/OT determines if the patient needs to see a surgeon about hip or knee replacement surgery or can carry on with non-surgical strategies such as exercises to strengthen weak muscles, weight loss to reduce joint loads, walking aids or other adaptive devices to help with everyday functions.

“Our APP/OTs give patients the tools, confidence and peace of mind to carry on with their daily activities,” says Susan Robarts, an advanced practice physiotherapist and team leader at the Holland Centre. “Many of our patients are pleasantly surprised to learn they don’t have to rush into surgery and that there’s a lot they can do to maximize their ability to move and function well.”

According to Dr. Albert Yee, chief of the Holland Musculoskeletal Program, the Central Intake and Assessment model provides a more efficient triage process because it ensures that only patients who need and want surgery are sent to an orthopaedic surgeon.

Today, about 30 per cent of Holland patients do not go on to see a surgeon. “Everyone’s immediate needs are addressed within a much shorter period,” says Dr. Yee. “Those who need surgery get to see a surgeon sooner and those who don’t need surgery can learn about their other options for treatment.”

Dr. Albert Yee is the chief of the Holland Musculoskeletal Program. (Photograph by Kevin Van Paassen)

For Mary Lou, it was a great relief to learn she didn’t need joint replacement surgery. Instead, her advanced practice physiotherapist recommended a 12-week education and exercise program, which taught her movements to strengthen her damaged joints and muscles and lessen her pain.

“It’s all about strengthening the good muscles you have to support the bad joints,” explains Mary Lou, who signed up for physiotherapist-led education sessions at the Holland Centre. “At the end of the 12 weeks, I saw improvement. I could walk without pain, I had more stamina, I could climb stairs without apprehension. I was even doing knee presses on one of the machines at the Centre, and I was able to press a much greater amount of weight than I thought I ever could.”

Since it started collecting data in 2007, the Holland Centre has managed 20,000 patient visits using the Central Intake and Assessment model. Today it’s widely considered to be the gold standard in hip and knee arthritis care.

“We were the first Centre of Excellence in Ontario for hip and knee replacements,” says Dr. Jeffrey Gollish, a former Holland Centre medical director who was instrumental in the development of the Central Intake and Assessment model. “One of our first mandates was to develop a new model of care delivery to improve access to care for patients with hip and knee arthritis, so a group of us went to Glasgow and Edinburgh in Scotland to study what they were doing there, and we incorporated key elements of their model to form the basis for what we have at the Holland today.”

Dr. Jeffrey Gollish was instrumental in developing the Central Intake and Assessment Model. (Photograph by Kevin Van Paassen)

Other health-care institutions in Canada have adopted similar models of care. Doctors and health administrators from other countries have also shown interest in the Holland Centre model.

“Our Central Intake and Assessment model functions very well,” says Dr. Murnaghan. “Going forward, our hope is to play a key role in working with Ontario’s health-system leaders to help other centres adapt it for their own settings, and to extend this model to other areas of musculoskeletal care, for example, for spine and for shoulders.”

Patricia Petersen: surgical treatment

Getting a referral to the Holland Centre also marked the beginning of the end of four years of pain for Patricia Petersen. In 2006, at age 66, she started feeling pain and tightness in her right leg and hip. Two years later, she was finally diagnosed with hip arthritis.

“I’ve always been very active. I used to hike, cross-country ski, kayak and do a lot of walking, until the pain began to limit my physical activities,” says Patricia, a retired University of Toronto professor and former director of the school’s Urban Studies Program. “Then in 2010, there was significant deterioration and my doctor looked at my X-rays and said, ‘You don’t have a hip joint there anymore.’ That’s when I was sent to Holland [Centre].”

A week after her doctor made the referral, Patricia got a call from the Holland Centre scheduling her for an assessment the following week. Within three weeks, she met with a Holland orthopaedic surgeon.

“I saw the surgeon in mid- May and they had a cancellation in June, but I was scheduled to teach in Germany, so the surgery was scheduled for my return in September. What I found so amazing was that within a month of seeing my own doctor, I had the assessment and was seen by the surgeon and could have had my hip replaced the next month,” Patricia recalls.

This optimal pathway from referral to surgery can be attributed directly to the intake process, says Dr. Richard Jenkinson, an orthopaedic surgeon at the Centre.

A study published last March in the international peer-reviewed BMJ (formerly the British Medical Journal) highlights the importance of joint replacement surgery for those who need it the most.

The study looked at about 4,500 patients in the U.S. between the ages of 45 to 79 and found that patients with severe knee osteoarthritis gained significant quality-of-life benefits from total knee replacement surgery, while those with less severe progression and symptoms of the disease experienced minimal improvement in quality of life after surgery.

“Now we’re only seeing patients who stand to benefit the most from surgery,” says Dr. Jenkinson. “At the same time, all patients are benefiting from a longer discussion about their options with an APP/OT, which typically takes more time than most orthopaedic surgeons are able to commit to in their clinic.”

Patricia resumed hiking, kayaking and other physical activities after her hip surgery.

Last May, she returned to the Holland Centre, this time with a referral for her left hip. While she’s less than thrilled about having a second hip replacement, she’s happy her doctor once again sent her to the Centre.

Says Patricia, “Based on my experience with my right hip replacement and on my recent assessment, I know I’m in good hands.”

To operate or not to operate

Will I need a knee operation right away? Should I stop going to the gym? Patients who are diagnosed with osteoarthritis in the knee are often confused about what it means to have this degenerative joint disease. With so much information available online and through other sources, it can be hard to separate fact from misinformation. Dr. Richard Jenkinson, an orthopaedic surgeon of Sunnybrook’s Holland Musculoskeletal Program, discusses some of the most common myths around knee osteoarthritis.

MYTH: My osteoarthritis is bone-on-bone. I need a knee replacement.

FACT: Not necessarily. While the most reliable surgical treatment for bone-on-bone arthritis is a knee replacement, the key issue is the severity of a patient’s symptoms. Knee replacement is most beneficial for patients experiencing pain, stiffness and functional limitation that significantly diminish their ability to engage and enjoy their daily lives.

MYTH: Knee surgery is the only option.

FACT: Even if a person has severe knee arthritis, non-operative treatment can alleviate the symptoms. The most effective non-operative strategies to relieve symptoms include strengthening the muscles that support the knee joint and decreasing the forces across the knee through weight loss. A program of low-impact exercises, possibly including formal physiotherapy, can be very helpful. Medications, injections, braces and other treatments can also play a role in improving function.

MYTH: I’ve been told that I should have knee surgery now when I’m younger, so I can have a better recovery.

FACT: The time to have knee replacement surgery is when the symptoms are severe enough that a person cannot manage a regular lifestyle without severe limitation. Anyone considering a knee replacement should first make sure they’ve given non-operative strategies a full attempt. Weight loss and exercise can do wonders for knee symptoms. Surgery can be considered for younger patients, but only if their symptoms are severe enough to warrant a significant operation.

MYTH: Knee replacements only last 10 years. My surgeon says I am “too young” for the surgery.

FACT: The vast majority of modern knee replacements can be expected to last longer than 20 years. Surgery should not be rushed into, however, if someone has not fully explored nonoperative treatments and is having severe symptoms. On the other hand, they should not be suffering for many years, to the point where their function and mobility become severely limited before getting a knee replacement.

MYTH: If I can’t have surgery, I should just take pills for the pain.

FACT: Strengthening the muscles around the knee and adding even light physical activity to one’s routine can greatly improve knee arthritis symptoms. Medications such as acetaminophen and ibuprofen, which are over-the-counter drugs, can help manage arthritis symptoms. Stronger narcotic painkillers are not usually recommended to manage arthritic pain due to potential side effects and the risk of addiction. For the minority of those with inflammatory arthritis, like rheumatoid arthritis, medications are very effective and are an important part of the treatment. Injections, braces and other options can also help people manage their symptoms if surgery is not possible.

The post Determining the best treatment for hip & knee problems appeared first on Your Health Matters.

It’s been almost two years since Everett Mullen’s legs were burned from ankle to groin as he was burning leaves in the yard of his Sudbury home. That day in April 2015, Everett was flown by air ambulance to Sunnybrook, where doctors performed two operations – one to repair his legs and another to graft skin from his back onto his singed limbs. He was in hospital for about one month. Everett has never returned to Sunnybrook.

All his follow-up appointments with Dr. Marc Jeschke, director of Sunnybrook’s Ross Tilley Burn Centre, have happened via a secure mobile phone app at his local hospital, which is only 15 minutes away from his home. During these appointments, Everett puts on a hospital gown and sits in a room equipped with a big-screen television and small video camera.

Dr. Jeschke examines him through the camera, which a nurse holds and moves over his legs and back. This form of videoconferencing is known as telemedicine and allows for virtual screen-to-screen interactions between patients and their health-care providers.

“It’s an 800-kilometre round trip between here and Toronto. It’s a lot of driving and if I had to fly, it would be costly,” says Everett, a 78-year-old snow plow operator who returned to work just a few months after his injury.

“At the start especially, it would have been really hard for me to travel because [the doctors] took the skin off my back, from the top of my shoulders to my waist, to graft onto my legs.”

Dr. Jeschke says telemedicine enables close and continuous follow-up without the necessity of travelling. “It’s independent of the weather, saves huge amounts of time and can be done at all times of the day. Everett had access to specialized care 24-7 without being at the burn centre.”

Telemedicine’s roots in Ontario can be traced back to Sunnybrook, one of the four sites where telemedicine was launched in the province in April 1998. This virtual private network – set up to protect patient confidentiality – is operated by the Ontario Telemedicine Network (OTN), a not-for-profit organization funded by the Ontario Ministry of Health and Long-Term Care. OTN now works with about 1,300 health-care organizations and more than 8,000 health-care providers in nearly 1,750 sites across Ontario.

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“It’s been a gift because everything happens close to home”

– Olive Climo, patient

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Telemedicine is making a significant difference in health care, where patients who need access to medical specialists often have to travel long distances for diagnosis, treatment and follow-ups.

According to the OTN, more than 637,000 patients in the province received care and health education through telemedicine in 2016. This has saved patients almost 260 million kilometres in travel and significantly reduced appointment wait times, emergency room visits and hospital admissions.

“When I started in telemedicine in October of 2001, there were less than 20 communities with telemedicine in their local hospitals under the NORTH [Northern Ontario Remote Telehealth] Network telemedicine program, which had a home at Sunnybrook,” says Valerie Sutherland, Sunnybrook’s telemedicine clinical coordinator.

“At that time, there were two other telemedicine programs in the province providing health-care services to patients in the southwest and eastern areas. In 2006, the three programs came together to become OTN.”

“Looking at telemedicine today, more health-care professionals in many disciplines and programs have adopted it as a means to provide health-care services to patients,” she says. These professionals include specialists and other practitioners, such as family physicians, speech-language pathologists, occupational therapists, physiotherapists, nurses, communicative-device assistants, pressure garment therapists and social workers.

“On average each month, about 35 health-care professionals at Sunnybrook consult with patients through telemedicine,” says Sutherland. These professionals come from a wide range of programs at Sunnybrook, from cardiology and endocrinology to dermatology, urology and psychiatry, to name a few. “Telemedicine has allowed Sunnybrook’s specialists to help patients not only in Ontario but in other provinces as well,” she adds.

“From time to time, we provide very specialized health-care services to patients who live in other provinces in Canada, thanks to a national adoption of this medium for delivering care.” says Sutherland.

James Heap was one of those patients who needed specialized care for his essential tremor disorder. Sunnybrook was the first site in Canada to offer MRI-guided focused ultrasound – a non-invasive surgical treatment that uses heat to burn away the area of the brain that causes abnormal movements of the hands and arms.

James’ hands shook so badly that everyday tasks such as eating and drinking became difficult.

“I was dropping everything and couldn’t do simple things like cut my food,” says the 84-year-old Ottawa resident. “My local doctor gave me pills to control the shaking, but it didn’t really help.”

From diagnosis to treatment, telemedicine allowed Dr. Michael
Schwartz, right, a neurosurgon at Sunnybrook, to provide health care to Ottawa resident James Heap, left. (Photo by Kevin VanPaassen)

Everything changed last year after James was referred to Dr. Michael Schwartz, a neurosurgeon at Sunnybrook and principal investigator on the MRI-guided focused ultrasound trial to treat tremors.

James had his first consultation with Dr. Schwartz through telemedicine. Under the supervision of a nurse, he went through a series of tests that included drawing spirals, drinking water from a glass and pouring water from one glass to another.

“I have a large screen that allows me to see the patient easily,” says Dr. Schwartz, who does all his initial consultations with potential MRI-guided focused ultrasound patients through telemedicine for those who cannot easily travel to Sunnybrook. “I can see if their hands are trembling when they’re doing the various tests or even if their hands are just resting on the desk.”

Based on the telemedicine consultation, Dr. Schwartz concluded that James was a good candidate. Last September, James underwent the procedure to treat the tremors in his right hand. He now reports that he goes to restaurants, shaves with a blade and plays golf.

Thanks to telemedicine, James had to come to Sunnybrook only twice – for MRIs – before his procedure.

“Technology is at a point where the communication and tests via TV monitors are the same as if I had been in Dr. Schwartz’s office,” he says. “And in my mind, these tests were as important as the operation.”

The field of telemedicine is also opening up new avenues for cancer patients like Olive Climo. The first time she drove to Toronto to meet Dr. Natalie Coburn, a surgical oncologist at  Sunnybrook, she left her home in Port Hope at 5 a.m.

Cancer patient Olive Climo of Port Hope, Ont., (seated, at right) used to leave home at 5 a.m. to get to appointments at Sunnybrook with surgical oncologist Dr. Natalie Coburn. Now, through telemedicine, her progress can be monitored from her local hospital with nurse Patricia Ley (at left) and Dr. Coburn (on screen), saving time, money and stress. (Photo by Kevin VanPaassen)

“It’s easy to be anxious on the highway,” says Olive, who was diagnosed last year, at the age of 69, with gallbladder cancer. “There’s all this construction and traffic, and when you’re worried about your health the drive is even more stressful.”

Thankfully, she hasn’t had to make that long drive very often since last August. Her initial consultation with Dr. Coburn and the operation that followed called for two trips to Sunnybrook. Since then, all other appointments with Dr. Coburn, including follow-up appointments to monitor the progress of her chemotherapy, have been through telemedicine.

“I go to a local hospital for chemo, and after 18 weeks of chemo, I’ll get a CAT scan there and then have a telemedicine appointment with Dr. Coburn to discuss results,” says Olive. “It’s been a gift because everything happens close to home.”

Dr. Coburn, who started using telemedicine about three years ago, says her “aha” moment came one snowy day in February when a patient who had come in for a 2 p.m. appointment told her that she had driven in from Temiskaming in northeastern Ontario, and the journey to Sunnybrook had started at 5 a.m.

“And I said to myself, ‘There’s got to be a better way to do this,’” Dr. Coburn recalls. “Often, people are coming in, feeling unwell, or just after a surgery, so the trip is really quite a burden.”

Telemedicine also keeps her schedule on track, notes Dr. Coburn. Given the complex web of sites involved, she may be seeing patients located in Timmins, Oshawa, Wiarton, Lindsay and Midland within the same hour. As each site has an assigned time to be linked with Sunnybrook, it is important to start appointments as scheduled.

“There are so many benefits to telemedicine,” says Dr. Coburn. “But in the end, it’s about offering better care for patients.”

The post Telemedicine connects patients to their care teams in new ways appeared first on Your Health Matters.

Brain scientists at Sunnybrook looked at the brain scans and overnight sleep study results of 26 patients who had a stroke or transient ischemic attack (TIA), also commonly referred to as a mini-stroke. They found that these patients had enlarged perivascular spaces – which can be seen on 3-D MRI brains scans – suggesting blockage of these channels.

These findings are the first to show, in humans, a link between poor quality sleep and enlarged perivascular spaces – the fluid-filled channels that surround the brain’s blood vessels to drain toxins and waste products, especially during stages of deep sleep.

“We looked at the volume of perivascular spaces on their MRI scans and correlated them with markers of sleep fragmentation from their sleep studies,” says Courtney Berezuk, the study’s co-lead author and a neuroimaging analyst in the L.C. Campbell Cognitive Neurology Research Unit at Sunnybrook, directed by Dr. Sandra Black. “In those with poor-quality sleep, the enlarged perivascular space volumes were larger than those with healthy sleep patterns.”

Previous studies have shown a cause-and-effect relationship between fragmented sleep and a higher risk of cognitive diseases such as Alzheimer’s and dementia.

“Sunnybrook’s work with enlarged perivascular spaces are an extension of these studies,” says Dr. Mark Boulos, the study’s principal investigator and stroke and sleep neurologist in the Hurvitz Brain Sciences Program at Sunnybrook.

“These findings could be particularly important for patients suffering from stroke or dementias such as Alzheimer’s disease, which are thought to arise from the build-up of toxic amyloid protein in the brain, as sleep may be an important factor in their development,” says Dr. Boulos.

The post Could sleep affect your Alzheimer’s disease risk? appeared first on Your Health Matters.

His mother, an aunt and three uncles: in the previous generation alone, Ted has lost five close family members to Alzheimer’s disease. Another uncle – one of the six out of nine siblings who were diagnosed with the disease – is now in long-term care.

So it felt especially cruel when Ted’s doctor told him eight years ago, at the age of 44, he had autosomal dominant Alzheimer’s disease (ADAD), also known as early onset familial Alzheimer’s disease. It was the same condition that had claimed the lives of his mother and her siblings when they were in their 60s.

“That’s the scariest part,” says Joanne, Ted’s wife. “They died so young — it’s really frightening when you think about it.”

Since the diagnosis in 2008, Joanne and Ted have lived in a state of anxious anticipation – watching and waiting for worsening symptoms of ADAD, a disease caused by rare, inherited gene mutations whose effects typically start to appear when patients are in their 30s and 40s.

But the Toronto-area couple is also hopeful. Earlier this year, Ted, a former entrepreneur (who asked to be identified only by his first name), became one of the first Canadians to participate in a global study looking at the potential of antibody drugs to prevent or slow down the development of early onset ADAD, a rare form of Alzheimer’s found in less than one per cent of patients with the disease.

A positive test for any one of three ADAD gene mutations virtually guarantees the onset of Alzheimer’s disease, and also means there’s a 50-50 chance of passing on the gene mutation to children.

“(ADAD) is quite aggressive, so it’s important to have these trials going on,” says Ted, now 52. “We want to help and be part of finding a cure.”

Ted (left), who was only 44 when diagnosed, relaxes at home with his wife Joanne.

The Dominantly Inherited Alzheimer Network Trials Unit (DIAN-TU) study is one of two research projects at Sunnybrook investigating the use of drugs to prevent or slow memory loss caused by Alzheimer’s disease, which currently affects an estimated 750,000 Canadians.

Both studies are using therapeutic drugs to target betaamyloid, a toxic brain protein, which can deposit in amyloid plaques outside the nerve cells, damaging the brain leading to memory loss, word-finding difficulty and other cognitive problems.

The studies hold exciting promise for patients in the early or presymptomatic stages of Alzheimer’s: a chance to live life with their memories and intellectual abilities intact, for much longer than they would likely have been able, if the anti-amyloid antibody drugs work.

The studies are international in scope. DIAN-TU, led by the Washington University School of Medicine in St. Louis, Mo., has sites in the United States, Canada, the United Kingdom, Germany, Australia and Argentina.

The second study – called Anti-Amyloid Treatment in Asymptomatic Alzheimer’s, or A4 for short – has site locations in the U.S., Canada and Australia, all coordinated through the University of Southern California’s Therapeutic Research Institute.

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“It’s important to have these trials going on. We want to help and be part of finding a cure.”
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DIAN-TU’s focus is on early onset familial Alzheimer’s, while the A4 study is focusing on late-onset Alzheimer’s disease (AD), testing participants aged 65 to 85 who have family or other risk factors for AD, but do not yet have the disease.

“If we can start removing the beta-amyloid early enough, we hope to postpone this pathology from expressing itself. Maybe we can control this rogue protein before it spreads its toxic effects through the brain,” says Dr. Sandra Black, director of Sunnybrook’s Hurvitz Brain Sciences Program and lead investigator of the A4 trial at Sunnybrook, which is looking to study 10 elder volunteers who are at risk of AD, often because of a family history.

Scientists believe amyloid build-up outside nerve cells can cause inflammation and prevent cells from communicating with each other. It may also lead to deposits within nerve cells, called tangles, made up of the second major misfolded protein seen in Alzheimer’s, called tau.

Normally, tau stabilizes channels that transport nutrients and proteins from the nerve cell body to the nerve endings, where they make contact with other nerve cells.

These PET scans show the remarkable difference in amyloid levels between individuals. The left image shows a 77-year-old woman with low amyloid burden. The right image belongs to an 89-year-old woman who is amyloid positive.

“In diseases like Alzheimer’s, the tau starts to misfold and deposit inside cells. This abnormal form spreads from one nerve cell to other nerve cells that are functionally connected, degrading that functional network,” explains Dr. Black. “We’re not quite sure how amyloid and tau work together, but it seems that if you have beta-amyloid deposits, you are more likely to have tau deposits as well. Mobilizing and removing the amyloid may remove an inciting factor that promotes the tau tangles.”

The A4 study is testing the antibody drug solanezumab, while DIAN-TU is testing both solanezumab and a second drug, gantenerumab. Both drugs are designed to bind to amyloid – each drug targeting a different part of the protein – to help move it out of the brain.

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There have been some reports about the unsuccessful results of the drug Solanuzemab from a study that tested the therapy in mild Alzheimer’s Dementia, which means these individuals are no longer independent and require help with day-to-day functioning.

While the drug appeared to be well-tolerated and safe, the treatment did not significantly slow cognitive decline.

In the A4 study being conducted at Sunnybrook and other sites, our researchers are targeting individuals who are still cognitively normal, and still may be many years before symptoms begin, when the burden of disease is at a much earlier stage. In the DIAN-TU study, genetic forms of the AD in their early stages are being targeted, and these forms may be different from the more common late onset forms in response to this medication.

Our researchers have reason to hope that Solanuzemab immunotherapy at this very early stage may still be helpful in slowing disease progression.

» Learn more about these studies
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While previous studies have looked at ways to treat Alzheimer’s disease at various stages when it is already causing problems, DIAN-TU and A4 are groundbreaking, because they focus on individuals who are at risk of developing Alzheimer’s, but show no symptoms of the disease at the start of the trial.

DIAN-TU is also the first to focus on prevention or delayed development of early onset familial Alzheimer’s. In addition to cognitive testing, biomarkers such as amyloid levels in the cerebrospinal fluid and in the brain are being used as outcome measures.

“Traditionally, studies of Alzheimer’s disease will just use memory tests to measure outcomes,” says Dr. Mario Masellis, lead investigator for the DIAN-TU site at Sunnybrook. “The problem with this is that people with early stages of the disease often don’t have a measurable deficit.

With DIAN-TU we looked at developing something that can act as a surrogate measure of the benefits of the drugs being tested – something more sensitive and indicative such as amyloid uptake in the brain.”

DIAN-TU will follow an “adaptive clinical trial” approach, testing two drugs simultaneously to allow researchers to advance quickly if one drug shows more promise than the other, or, conversely, to stop testing a drug that produces adverse side effects without halting the entire study. With this adaptive model, new drugs may be added as they become available, says Dr. Masellis.

The use of advanced imaging technology also sets DIAN-TU and A4 apart from other studies on Alzheimer’s prevention. For example, in both studies, participants undergo an amyloid PET scan, which uses a radioactive tracer designed to bind to amyloid in the brain to quantify the extent of amyloid deposits in the brain. In A4, if the amyloid scan is positive, the participants are then randomly assigned to get solanezumab or placebo infusions monthly for three years.

“It used to be that you could only detect deposits of brain amyloid in the brain in an autopsy, but now you can see this in people while still alive,” says Dr. Black. “Also, in the two to three years since the study started in the U.S., a radio-tracer has been developed that can detect tau in the brain, so that’s now also offered to participants of both studies.”

Getting people to sign up for the studies is not an easy task. With both A4 and DIAN-TU, being accepted into the treatment trial essentially confirms what most people don’t want to hear: that they’re likely to develop Alzheimer’s.

“The majority of people don’t want to find out,” says Dr. Masellis. “It can affect their insurance, career or job, or their outlook on life, but if a new therapy is developed then maybe more people would want to be tested.”

One participant in the A4 trial at Sunnybrook, a retired nurse whose parents both had serious memory-loss problems – although they were never officially diagnosed with Alzheimer’s – said she signed up for a number of reasons.

“For me it’s to get information on what’s going on with Alzheimer’s, and to get myself prepared for the future,” says the woman, a Toronto resident who asked not to be identified. She said she is selling her house and getting her affairs in order in the event she becomes debilitated by loss of cognitive function down the road.

She hasn’t told anyone in her family she’s part of the A4 study, although she did mention to a sibling that she was getting tested for amyloid build-up.

“And my sister told me she wouldn’t want to know,” says the woman.

“I am extremely hopeful that Ted is receiving the drug and that it will slow down his symptoms.” – Joanne, Ted’s wife (left), pictured above with Ted

With the A4 and DIAN-TU studies, by luck of the draw, one group gets monthly infusions of antibody, while the other group gets infusions containing no active drug. For Ted and Joanne, this means taking a chance – and embracing an opportunity.

So far Ted remains functional in his day-to-day life, but his short-term memory has deteriorated over the last eight years and he tends to repeat himself. As a result, he tends to be anxious in social gatherings, notes Joanne.

“I am extremely hopeful that Ted is receiving the drug and that it will slow down his symptoms,” says Joanne. “And then there’s the next generation – if this trial goes well and there’s a cure 10 years down the road, there’s hope for our two children and Ted’s many cousins who are younger than him, as well as for other people who may unfortunately inherit the gene for this disease.”

All photography by Tim Fraser

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