HER2-positive breast cancer (HER2+) is also known as Metastatic Breast Cancer or Stage IV breast cancer. HER2+ tumours start in the breast and may spread to areas like the bone, liver or other organs, and brain. There is currently no treatment that can completely cure metastatic breast cancer. Treatments for management of the disease include neurosurgery, hormone therapy and chemotherapy, in combination with radiation therapy.

The blood-brain barrier is a protective layer of cells around the brain that prevents compounds circulating in the bloodstream from entering the brain. It also blocks potentially useful medications, antibodies, chemotherapy agents or other treatments for brain conditions.

Sunnybrook researchers have been exploring the use of focused ultrasound, a non-invasive, image-guided surgical technology to temporarily open the blood-brain barrier. It is considered to be scalpel-free, avoiding incisions to the skin. Sunnybrook is a global leader in focused ultrasound research and clinical trials.

Dr. Nir Lipsman, study principal investigator and director of Sunnybrook’s Harquail Centre for Neuromodulation explains how the research team was able to track the delivery of the therapeutic and how the findings of this innovative focused ultrasound study have the potential to change the treatment care path for patients with brain cancer and other neurological conditions in the future.

What was the goal of this study?

Our team is investigating the use of MRI-guided focused ultrasound to open the blood-brain barrier to enhance the delivery of an antibody therapy called trastuzumab to HER2+ breast cancer that spread to the brain.

Trastuzumab is highly effective at controlling breast cancer outside the brain, but very little of it gets inside the brain because of the blood-brain barrier. A safe, reversible means of opening the barrier can potentially deliver trastuzumab to where it’s needed most. Although we’ve always suspected that focused ultrasound can be used to improve drug delivery, this is the first trial that proves this by directly visualizing the drug in the brain.

How did the research team capture images of the antibody therapy crossing the blood-brain barrier?

Single photon emission computerized tomography (SPECT) imaging displaying and confirming that an antibody therapy reached tumours that spread to the brain from breast cancer.

The procedures are performed inside the MRI, which is used to help target specific areas of the brain where focused ultrasound is directed to temporarily open the blood-brain barrier. Trastuzumab is administered to trial participants during focused ultrasound, while they are inside the scanner.

In past studies, we used gadolinium, an MRI contrast agent, as an indirect measure of blood brain barrier opening. We saw contrast in areas where we opened the barrier and the following day the contrast was gone, an indication that the blood-brain barrier had safely opened and then closed.

In our current study, our team of researchers tagged the antibody therapy with a special compound. This allowed us to track and directly visualize the therapy using single photon emission computerized tomography (SPECT) imaging. This radiopharmaceutical drug was developed by Professor Raymond Reilly and his team at the Leslie Dan Faculty of Pharmacy at the University of Toronto.

In addition to showing the antibody therapy had crossed the blood-brain barrier, the SPECT scan showed it in the brain 48 hours after the procedure, well after the blood-brain barrier had closed. This is the first visual confirmation that focused ultrasound can improve the delivery of targeted antibody therapy across the blood-brain barrier in human cancer patients.

What do the study findings mean for patients?

Although still very early, the findings are promising, and with continued research have implications well beyond cancer to other brain conditions, including Parkinson’s disease and Alzheimer’s, where medications cannot cross the blood-brain barrier due to their size. Use of focused ultrasound can then help temporarily open the blood-brain barrier for better passage.

This is not a cure for HER2+ metastatic breast cancer but it is an early and critical step. With each step, we are finding new ways of potentially making treatment more feasible and tolerable for patients that could one day improve management of tumours and quality of life.

What does this mean for the field of focused ultrasound?

For focused ultrasound, this is a major step forward. We have demonstrated that a large compound can be delivered safely to the brain, beyond the blood-brain barrier, using non-invasive ultrasound. This has long been theorized in the field, but never proven, until now. It’s an exciting development but we are still very much in the early stages of research.

Sunnybrook researchers, from physicists, to engineers, to basic scientists and clinicians, are actively exploring new and less-invasive ways to enhance the delivery of a whole range of therapeutics to the brain and focused ultrasound is a major part of that effort. It’s promising, and as an innovative approach, has the potential to change the way we treat brain conditions for years to come.

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Learn more about focused ultrasound at Sunnybrook: sunnybrook.ca/focusedultrasound

The post Behind the Research: Breaking through the blood-brain barrier with focused ultrasound appeared first on Your Health Matters.

Learn more about Sunnybrook’s Centre for Independent Living

Read more about Elijah’s story

More resources:

• Amputee Coalition of Toronto (ACT)
• War Amps
• Ontario Association for Amputee Care (OAAC)

The post Latest advance in prosthetics is helping some patients regain movement and independence appeared first on Your Health Matters.

Virtual reality systems are increasingly finding their place in health care. They allow patients to “see” and experience stressful medical procedures in a safe space before their actual treatment. Research has shown that by knowing what is involved in the process, this can help ease a patient’s concerns and anxiety.

New systems in development are now hoping to train future health care workers from literally anywhere.

Sunnybrook’s Collaborative Human Immersive Interaction Laboratory has been advancing virtual reality for years, and three of the experts involved provide an update on their exciting work.

• Dr. Fahad Alam, Co-Founder, Collaborative Human Immersive Interaction Laboratory (CHISIL)
• Dr. Julian Wiegelmann, Anesthesiologist, AR Development Lead
• Dr. Bill Kapralos, Associate Professor, Ontario Tech University

What is virtual reality?

Fahad: Virtual reality, or VR, creates a fully constructed world that someone can immerse themselves into by wearing a special pair of goggles. It’s different from augmented reality, or AR. While you still need special goggles in AR, it overlays customized computer graphics overtop a real-world environment, such as the space that a person is standing in. So VR is like being fully inside a video game, and AR is more like Pokemon GO, where computer generated characters and images pop up and look like they’re right there with you.

How is VR is currently being used at Sunnybrook?

Fahad: We’ve been using VR for various applications. For example, some patients who are anxious about having surgery, or certain medical procedures, can first go through the steps virtually. In our studies, we’ve found this approach decreases the anxiety that patients feel, and actually improves their outcomes.

So what’s the latest system you are working on?

Fahad: There are a lot of medical emergencies that can happen, so we’re creating an AR system called HoloSIM that will literally immerse the learner inside one of their choosing; things like cardiac arrest or anaphylactic shock. A special headset is worn that interacts with sensors in the room, so learners can walk around and control the simulated environment with their hands and movements. If a mistake is made, they can see the patient’s vital signs will react. That feedback can all be reviewed afterwards as part of the learning experience. 

Julian: Right now, HoloSIM is in the prototype stage. The idea is that any room a medical student is in can be used for training by overlaying interactive holographic resources onto it. We’re currently working on creating a platform in this system where different variables can be changed, like medical props and types of patients, and their physiology can be adjusted to any parameter to simulate almost any situation in health care.

Bill: What’s great about this is you’re not stuck to one static scene. Educators can come in and develop new scenarios or modify existing ones.

So what’s better: VR or AR?

Julian: They both have a place, as learners will use them in different ways.

How long has all this taken to put together?

Julian: There’s the coding, and then the medical content. It’s hard to tally it all, but it’s safe to say hundreds of hours have gone into development.

Are there limitations?

Julian: Right now, the HoloSIM system responds to some hand gestures and head movements, but there are still many interesting problems that need solving. For example, how do you convey a sensation like pulse when it’s something the learner can’t actually touch?

Bill: The plan is to develop a pair of gloves that deliver haptic feedback, or touch sensation. But we’re not there yet. Right now, we’re also unable to realistically convey smells that are authentic to various environments.

So how realistic is the experience a person is getting?

Fahad: It’s quite realistic, I’d say at least 80% for AR.

Bill: Yes, and with VR you definitely feel immersed in it. While there’s still work to be done on the haptic side of VR, the cognitive decision-making side is very realistic.

Sunnybrook has a Simulation Centre that uses mannequins to train students. How do VR and AR fit in?

Fahad: The SIM Centre definitely plays an important role, and in the future, maybe these two worlds can connect. For example, bringing students into the SIM Centre, and using AR to overlay different scenarios.

Bill: VR and AR technologies allow us to develop additional training tools. Since the haptic side of training still isn’t totally realistic yet, currently these tools can, for example, be used to prep students before their experience in the SIM Centre.

Fahad: And there are benefits for remote students with AR and VR, as you can literally do the training anywhere. As the technology advances and gets more affordable, hopefully we’ll see more and more people at home with these special goggles and headsets.

Do you wish VR and AR existed during your own medical training

Julian: Absolutely! I recently completed my anesthesia training, and that’s why I’m creating the HoloSIM technology. You realize that you’ll never encounter all of these different crisis scenarios in real life during your training, so this software would have helped put me in the hot seat to practice in a safe environment. While HoloSIM is still in the testing phase, the hope is to roll it out to our anesthesiology residents by early 2020.

Fahad: As long as this is developed properly, it’s can be such a great training tool. Imagine as a student, during 15 minutes of downtime, popping on a headset and doing a run through of any procedure.

Bill: Plus, this is a really engaging, immersive and fun way of learning.

Why is this important to the general community?

Julian: Patients can take some comfort that, even with rare medical events, it’s something their health care teams have already rehearsed.

Fahad: And just like medicine advances, we want to ensure our teaching methods are also advancing. We’re excited to see how far this will go.

The post Using augmented reality (AR) to train health-care providers from virtually anywhere 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.

Here, some members of the team explain their roles, what getting Health Canada approval feels like, and what treating the first patient in Canada means to them.

Dr. Brian Keller, lead medical physicist (in photo below)

I have had the pleasure of being involved in this project since January 2013.

The initial version of this machine was a research version, which was eventually upgraded to a clinical version able to treat patients.

Over the years, our physics group in the cancer centre has worked closely with the company Elekta to help validate this machine for clinical use and to help produce a final product that is now able to treat patients.

Witnessing the evolution of this technology from inception to clinical validation to patient treatment is a unique experience that exemplifies how basic science and teamwork can lead to real benefits for our cancer patients.

Brian Keller testing MR-Linac.

Darby Erler, clinical specialist radiation therapy

I’ve been the radiation therapy representative on the Clinical Workflow working group within the MR-Linac consortium since 2014, participating in the development of the clinical system and definition of workflows. Through this process, I felt it was my responsibility to ensure the patient remained the central focus and not the technology itself.  As a clinical specialist radiation therapist, I am part of the multi-disciplinary clinical implementation team here at Odette that has been establishing how use the machine safely and effectively.

It has been an amazing technologic feat to combine these technologies and the MR-Linac has the potential to change the way radiation therapy treatment is delivered with the ultimate aim of improving patient outcomes.

Shawn Binda, radiation therapist and dosimetrist

As a radiation therapist, I was tasked with becoming a subject matter expert in the MR-Linac planning system, as well as training the Radiation Therapy Team.

The diverse MR-Linac Radiation Therapy Team of treatment planners and technologists has all worked together to make this day possible.

But this is now only the beginning; it’s the first step in redefining how cancer is treated in Canada and ultimately improving patient care.

The delivery team puts a part of the MR-Linac in place in 2017.

Dr. Jay Detsky, radiation oncologist

My role in implementing the MR-Linac is to help develop protocols for how are going to treat both brain tumours and prostate cancer on the MR-Linac. My expertise in magnetic resonance imaging (MRI) also means that I will help develop the best way to use the “MR” portion of the “MR-Linac” to get the best images possible so we can best see the tumours we are treating.

Approval of the MR-Linac means we can finally start pushing the entire field of radiation oncology forward. We will figure out how much better of a radiation plan can we deliver to patients with the MR-Linac compared the conventional Linac machine, to improve cure rates and minimize the side effects of treatment.

This is an exciting time, and Sunnybrook is the first centre in Canada and one of only a handful in the world with access to this new technology. We are all looking forward to the exciting possibilities it will bring to deliver the best personalized cancer care in the world.

Dr. Irene Karam, radiation oncologist

I have been involved in integrating the MR-Linac technology into our head and neck tumour site group. As a member of the consortium, I have been involved in protocol development for adaptive radiation therapy in head and neck cancers and development of head and neck delineation guidelines (to determine the best volume of radiation to deliver).

This is an exciting time, and I am looking forward to further collaboration with other MR-Linac institutions to help further improve patient care and outcomes for our head and neck cancer population. This approval means we can finally start offering participation into adaptive clinical trials for our head and neck cancer patients, which will allow us to monitor tumour motion, size and position.

Members of the MR-Linac team during work in progress, 2017

Dr. Chia-Lin (Eric) Tseng, radiation oncologist

I am a CNS (central nervous system) and GU (genitourinary) radiation oncologist and have been quite heavily involved in the clinical implementation of these two priority anatomic sites as part of our MR-Linac vision. On the research side, I am the co-principal investigator of the Brain Tumour Site Group, which Sunnybrook is leading within the global MR-Linac Research Consortium. This work dates back to my fellowship in 2015.

The whole team is excited to translate years of preparatory work and research into a clinical reality for us to be able to treat patients under MR image guidance. The capabilities of the machine are transforming our way of thinking about motion management, adaptive radiotherapy, and more importantly personalized treatment via functional imaging and radiomics, which may allow us to individualize treatment strategies based on non-invasive imaging characteristics that can predict tumour behaviour and response.

Dr. Claire McCann, medical director and medical physicist

As medical director Odette Cancer Centre Clinical trials, I have been involved from the ethics and regulatory perspectives helping to ensure the testing, evaluation, implementation and research use of this system from a clinical and research perspective is conducted accordingly. I have also been involved as the Principal Investigator of the Volunteer Imaging study, the first clinical research study conducted on the MR-Linac, for which our first patient was scanned. I am also a co-investigator on the Momentum study and upcoming studies.

I have also been involved as a clinical medical physicist, working in the clinical implementation of the system in terms of creating novel workflows to build this adaptive radiation treatment paradigm that leverages the unique capabilities of this system. This has been a tremendous multidisciplinary effort involving physicians, therapists and physicists. I am part of the core physics team that will be involved in the daily clinical use of this technology for treatment and research.

My involvement from the regulatory and ethics side of things started before there was even a machine and so to see this system ready for clinical implementation after the complex steps, processes and tremendous learning opportunities is hugely exciting, especially given the potential of the system to change the way in which we see, treat, guide and adapt radiation treatment.

Angus Lau, MRI scientist

As the MRI scientist on the team, my role is to develop imaging techniques for the MR-Linac technology. These include new MRI scans to track moving tumours while patients are receiving their radiation treatment, and new scans to determine earlier if the treatment is working as planned, or whether changes to the treatment should be made.

We have been developing the new imaging methods with a separate MRI scanner used for radiation treatment planning over the past few years, so it is exciting to finally see these methods used to improve a patient’s radiation treatment with the MR-Linac.

James Stewart, research associate

I work on modelling and quantifying the treatments that the MR-Linac technology will provide. This helps us to determine how to best use this advanced technology for the benefit of our patients before we even start the very first treatment.

It was immensely gratifying to clear one of the last hurdles of Health Canada approval before we deployed the MR-Linac for our patients. It really demonstrates the value of the unique inter-disciplinary team here at the Odette Cancer Centre.

The MR-Linac – Elekta Unity at Sunnybrook

Read more:

• First patient in Canada treated on MR-Linac – Elekta Unity »
• Read more about the first MR-Linac clinical trial at Sunnybrook »
• Learn more about Sunnybrook’s Cancer Ablation Therapy Program »

The post Behind the research: Journey to MR-Linac first treatment a true team effort appeared first on Your Health Matters.

Text by David Israelson, video by Monica Matys

If you look up at the skies in Ontario’s Peel region, don’t be startled if you see a fast-moving object zipping over the tree line. It might be a drone on a life-saving mission.

This past spring, Sunnybrook launched an innovative pilot project in southern Ontario to see whether drones carrying an automated external defibrillator, or AED, can respond more quickly than emergency medical service (EMS) vehicles to cardiac arrest. An AED is an easy-to-use medical device that delivers an electric shock – or defibrillation – to re-establish a normal heart rhythm when someone is experiencing sudden cardiac arrest.

Drone delivery technology is already being deployed for everything from delivering pizzas to sending cameras down mine shafts. In reading about these applications, Dr. Sheldon Cheskes wondered: Could drones be used to improve response times for out-of-hospital cardiac arrest, particularly in rural and remote communities? 

Dr. Cheskes, medical director of the Sunnybrook Centre for Prehospital Medicine, is leading the tests in Caledon, Ont., with the help of voluntary community CPR Responders.

“Many strategies have been tried in the past to deliver help to victims of cardiac arrest faster. But in general, surviving cardiac arrest tends to be lower in rural areas, where it’s difficult to get responders with an ambulance or a fire truck to the scene rapidly,” says Dr. Cheskes, who provides medical oversight for emergency medical services in Ontario’s Peel and Halton regions.

“Every minute of delay in response time decreases the chance of survival by 7 to 10 per cent,” he says. 

Until now, the general strategy for giving people access to AEDs has been to put them in areas where people congregate, such as public buildings, stadiums, hockey rinks and restaurants. Peel Region started a program in 2014 to put defibrillators in high-traffic locations and has placed nearly 1,200 AEDs since that time.

The problem is that you can’t put defibrillators everywhere they might be needed. An area like Caledon is a mix of town, suburbs and rural areas, including the beautiful, rugged Niagara Escarpment and the Bruce and Trans Canada trails.

In addition, while it’s important to have defibrillators in public areas, “the difficulty with cardiac arrest is that 85 per cent of cardiac arrests occur in private locations where AEDs are not readily available,” Dr. Cheskes says. 

His team put together a feasibility study and received funding from the Cardiac Arrhythmia Network of Canada (CANet) for a research proposal, which led to the first test flights in May 2019. 

“We want to find out if we can use drones to save patients in cardiac arrest,” he says of the project. 

The drones being tested to deliver defibrillators are larger and more elaborate than the recreational rigs sold to consumers. 

“They are called Sparrow Emergency Response drones,” says Greg Colacitti, vice-president of business development for Drone Delivery Canada (DDC), a partner in the pilot project and supplier of the flying machines. “Each one is approximately four feet in diameter, and with its cargo – the AED – [in place], it weighs 24 kilograms.”

The Sparrow drones can reach speeds of 80 kilometres per hour. While this may not sound all that fast, they may be able to go quicker in a straight line than an EMS vehicle speeding to a scene along a twisted or congested road. 

Under the tests, when a simulated 911 call comes in, a drone is dispatched to the mock emergency by a volunteer using an app developed by the Region of Peel. The dispatcher first decides if the emergency is easier to reach by drone than by vehicle; if it is, the dispatcher taps in the location.

Dr. Cheskes says the test also sends EMS teams by vehicle, to compare their arrival time with the drone’s delivery. In the first test, the drone travelled about eight kilometres and arrived four minutes earlier than the land ambulance, he says. 

The DDC drone uses a proprietary system to take off automatically and get to the scene. Transport Canada officials are monitoring the project, and earlier this year the federal government tightened the rules for flying drones. Requirements now include mandatory licences for drone flyers, night-flight permissions and strict safety design standards for drones that fly near the public.

“Believe me, what we go through for a launch is a lot like taking off from Pearson Airport,” Dr. Cheskes says. 

During the testing, volunteers playing the role of bystanders unpack the defibrillator from the drone and simulate deploying the equipment on a patient suffering cardiac arrest.

“In our tests, our volunteer managed to administer two [defibrillator] shocks before the EMS arrived. That’s good,” Dr. Cheskes says. “Our mathematical model suggests that we could decrease response time in an urban area by six or seven minutes, and in a rural area by 11 minutes – crucial minutes in cardiac arrest.”

The project team plans to test-fly more drones to see if they can land the units more quickly. They are also exploring ways to make it easier for bystanders to use the AEDs even if they have not been trained – for example, by including a smartphone in the drop with an app that can give simple instructions.

Dr. Cheskes says he’s convinced it’s only a matter of time before it becomes commonplace to use drones for 911 responses. 

“Using it in real life, not just testing – that’s the ultimate goal of all this,” he says. 

The post How drones could help deliver life-saving treatment in rural areas 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.

There was no question about what was at stake for Eric Furtado-Rodrigues. He became a quadriplegic after a 2009 snowboarding accident in Spain where, following the accident, surgeons there implanted a titanium plate to repair his spine. He returned to Canada, but with time the plate shifted, causing a three-by-two-centimetre hole between his spine, esophagus and trachea. By 2015, Eric was having trouble swallowing food and experiencing recurrent infections.

Eric now needed a feeding tube and a tracheostomy tube, which made it difficult to speak and impossible to eat or drink anything by mouth. He wanted the best quality of life possible, something he expressed profoundly to Dr. Danny Enepekides, Sunnybrook’s otolaryngologist-in-chief and chief of surgical oncology.

At just 37, Eric still had much to achieve. He would push his doctors to think outside of the realm of possibility, so that he could once again do the simple things that used to bring him joy, from being a world-class athlete to enjoying fine food, including his wife’s cooking. To get Eric to that place, Dr. Enepekides and his colleagues were inspired to do everything they could.

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“It was one of the most rewarding things I’ve ever experienced. He reminded me why I do what I do.”

– Dr. Danny Enepekides, otolaryngologist-in-chief and chief of surgical oncology

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They would need to repair the hole and perform intricate microsurgery to mend his damaged trachea. It was a challenging prospect. “If the procedure failed, I would make him worse,” says Dr. Enepekides.

One of Eric’s goals was to earn a spot on the Team Canada Wheelchair Rugby Team. His high expectations, determination and optimism inspired Dr. Enepekides to think of ways to get this young man back to playing sports again.

Over multiple appointments (30 to 40 in total leading up to the surgery), a deep relationship – one marked by trust, caring and mutual respect – formed between doctor and patient.

“When I met Eric, my heart went out to him, his wife, Susana, and his family,” recalls Dr. Enepekides. “He is a genuine person. Despite all of the challenges he faced, he always had a very positive attitude. He was full of life – very inspirational.”

Eric was confident that  Dr. Enepekides could successfully repair the hole in his trachea surgically. “At that point, I was fed up,” recalls Eric. “I had nothing to lose. My quality of life wasn’t good. And even though [the surgery] had never been done before, I just had a good feeling everything would work out.”

It took almost a year to plan the surgery. Dr. Enepekides and his surgical colleague, Dr. Kevin Higgins, spent countless hours meticulously mapping out every step of the procedure to mend the hole that was causing so many problems for Eric. In the back of their minds was the fact that Eric wanted to pursue his love of athletics once again and compete at an international level.

Dr. Danny Enepekides (left) and Dr. Kevin Higgins successfully innovated a surgery that had never been done before, which restored Eric’s ability to eat and drink.
Photography by Kevin Van Paassen

Both doctors understood there was a lot riding on the success of the surgery and they had never seen a case where there was so much damage. After much analysis, Dr. Enepekides believed he had a solution that would work to fix Eric’s cricoid (the ring-shaped cartilage around the trachea that also forms part of the voice box) and save his larynx. He would harvest a small amount of tissue from the patient’s scalp and transplant it to repair the hole in the cricoid.

“It’s an area that is quite tricky,” explains Dr. Enepekides. “Because of where he was injured, the option most likely to succeed would have been to remove his voice box. If I did that, he would lose his ability to speak. Instead, I opted for techniques I’ve used before in cancer surgeries.”

One of those techniques was the use of a fluorescence imaging system, a high-tech tool that allows physicians to visualize microvascular blood flow. Patients are injected with the special dye indocyanine green (ICG), which causes blood vessels to glow brightly when exposed to a laser beam attached to a digital camera recording how and where the dye is moving. It’s invaluable to surgeons looking for a highly detailed map of a patient’s vascular system.

Sunnybrook’s fluorescence imaging system was donated by a former patient to the Division of Plastic Surgery. Though the imaging system is often used in breast reconstruction, the surgical team was able to take a customized approach and utilize it in Eric’s procedure.

“The system helped increase our confidence going into his surgery,” says Dr. Enepekides. “It is a very useful tool.”

On the day of the surgery, Dr. Enepekides had covered the wall of the operating room with a large chart, precisely outlining each step of the surgery to ensure its success. It took more than 10 hours to complete the intricate procedure that included splitting Eric’s voice box to get to his trachea. Now, it was watch and wait, allowing time to heal.

At Eric’s follow-up appointment with Dr. Enepekides, the question remained if Eric would be able to drink and eat normally again. While his feeding tube and trach tubes were still in, a barium swallow suggested the hole had been sealed and both were feeling optimistic.

Dr. Enepekides handed him him a glass of water and asked him to take a sip. Eric held the cup to his lips, then drank. He was able to swallow for the first time in nearly a year and a half.

“[The water] felt so cool going down,” he remembers. “It was the best feeling. Dr. Danny and I just looked at one another and we smiled.”

Post-surgery, Eric was able to enjoy eating again. He remembers his first full meal after the surgical procedure fondly – Susana’s homemade shepherd’s pie. Once he had finished healing, he was able to focus on earning a spot on Canada’s wheelchair rugby national team.

When he was selected in March 2017, one of the first e-mails Eric sent out was to Dr. Enepekides. “I’m officially a member of the team!” it said and included a photo of himself in action at the tryouts. Dr. Enepekides still has that message.

Eric has been attending rugby training camps in preparation to compete at the 2018 Wheelchair Rugby World Championship of the International Wheelchair Rugby Federation (IWRF), to be held in August in Sydney, Australia. Says Eric, “There’s no way I’d be doing what I am right now without what Dr. Danny did for me. He’s a special guy. I’ve dealt with a lot of doctors throughout this experience and he is in a class of his own. I was so fortunate to be taken care of by him and such an incredible team.”

Meanwhile, Dr. Enepekides and his team continue to use the knowledge gleaned from Eric’s surgery for other Sunnybrook patients.

“I was incredibly thankful to be able to help Eric,” notes Dr. Enepekides. “It was one of the most rewarding things I’ve ever experienced. He reminded me why I do what I do.”

The post How a trail-blazing surgery transformed this Canadian athlete’s life appeared first on Your Health Matters.

I can’t speak for anyone else, but for me, it’s an extreme level of sadness. It’s so difficult to get out of bed, and almost impossible to manage day-to-day functioning.

It’s constant despair.

It wasn’t always like this, but in 2011, I went through a traumatic experience that completely changed my life. It’s left me struggling with treatment-resistant major depression. This means, while I’ve tried various treatments out there, they haven’t worked. It’s frustrating because, there’s no magic pill. There’s no magic to make this better. No one wants this.

Every aspect of my life is affected. Depression makes it difficult for me to navigate friendships and family dynamics. It also takes a huge toll on self-care. Things like hygiene, diet and sleep, all suffer because of depression. It decimates my self-worth. Depression fuels hopelessness.

Treatments for depression

I’ve done so many different types of therapy and treatments. Whether it’s cognitive behavioural therapy, dialectic behavioural therapy, talk therapy, medication, therapy for PTSD – none of it seems to work.

I’ve even tried repetitive transcranial magnetic stimulation, or rTMS, which uses a magnetic field to alter brain activity, but there was no change. The depression remained.

After multiple treatments, medications, group therapy, and other programs – I feel like I’ve tried everything I can. Through the constant struggle, I’ve given a lot of effort and feel like I’ve exhausted my options.

Scalpel-free brain surgery

I am taking part in a study, to be one of the first patients in a North American clinical trial, to be treated with focused ultrasound (FUS) for depression. It’s still very early and this trial is investigating the safety of FUS. There’s no guarantee this is going to work and I understand the risks involved, however, this possible new treatment gives me a tiny spark of hope that there’s going to be a time in my life where I don’t hate myself and that I am not worthless.

I have a son at home. He means the world to me. He’s the only reason I am still alive. I take care of him and am fortunate to have supportive family and friends who help me make sure he has everything he needs. It’s easier for me to be on autopilot and make sure that I live my life for him because he deserves that. But, at what point do I say, “Wait a second, I need to live my life for me”? Maybe, this surgery is a way for me to say to myself, “Now, is a chance for you to be better.”

I have no idea. The one thing I do know is, I have tried so many therapies, so many treatments and none have made it better. None of them have lifted the blanket of depression that weighs on every aspect of my life. I really have nothing to lose.

To me, the potential to be even a little bit “okay,” is huge. If it does work, then I could go back to work, and I could be more active in society. I’m trying to hold out hope that it’s going to make a difference for me. That life won’t be so bleak.

The post ‘What I will do to try and beat depression’ appeared first on Your Health Matters.