Georgia Marianthe Mesbouris takes a moment to herself before a follow-up procedure at Sunnybrook.

One weekend in August 2020, on a morning when Georgia Marianthe Mesbouris and her family were planning to leave for a family vacation, the 42-year-old resident of Scarborough, Ont., woke up with an incredible pain at the back of her neck. Knowing how much this vacation meant to her kids, she took a pain reliever and hoped the throbbing and sensation of burning hot ears would go away.

It didn’t.

Georgia, a mother of two and a tech expert on a national TV channel, considers herself a healthy person. “I don’t have high blood pressure. I don’t smoke. I [rarely] drink,” she says. So it was a complete shock when – after a trip to the emergency room – she was told that the pain she was experiencing was the result of two aneurysms in her brain.

One was small, but the other was very large. Aneurysms occur when a blood vessel wall weakens and bulges out, and the largest ones, called “giant aneurysms,” are typically no more than 2.5 centimetres across. Georgia’s was 3.5 centimetres long – one of the biggest the team at Sunnybrook had ever seen.

As long as the aneurysms remained in her head, Georgia’s life was at risk. One quarter of people with a ruptured aneurysm die within 24 hours, while another 25 per cent die within six months. For those who survive, many are left with permanent neurological damage.

Fortunately, Georgia’s care was in the hands of a Sunnybrook neurosurgeon whose expertise and ingenuity led to a novel approach to treatment that saved her life.

 An X-ray shows the metal clips in Georgia’s brain following her crainotomy.

A problem with no easy solution

When faced with an aneurysm of this size, Sunnybrook neurosurgeon Dr. Leo da Costa knew he needed to come up with a unique treatment plan. Most aneurysms are berry-shaped, called saccular. But in Georgia’s case, the aneurysm was what’s called fusiformed – wide in the middle and tapered at both ends.

Another complication was that the larger aneurysm was located in the left hemisphere of Georgia’s brain, in the middle cerebral artery. This artery is responsible for providing much of the blood flow to the hemisphere, including the area of the brain responsible for speech. A rupture could have been devastating for Georgia, but she could not be treated using routine techniques.

“The easiest treatment for such large aneurysms is to close the vessel, which was not an option in this case. She could have a stroke on the left side of the brain and be paralyzed on the right side and unable to speak,” says Dr. da Costa, medical director of Sunnybrook’s Centre for Neurovascular Intervention.

Georgia says it was “surreal” to learn that her medical condition could be fatal or debilitating. But she felt hopeful that she would come through it all.

“My husband turned to me and he held my hand and [said], ‘Don’t die.’ So I told him, ‘I’m not going to die.’”

The neurovascular team’s initial treatment for Georgia was a craniotomy – brain surgery to reconstruct the affected blood vessel with metal clips. But while surgery was successful and Georgia went home, a month later an angiogram showed the aneurysm had grown again.

With Georgia’s life once again in jeopardy, Dr. da Costa decided that the situation called for another approach involving flow diverter stents. These special, tiny stents are made of mesh with very fine holes that change the way the blood flows around a vessel.

“If you imagine a tunnel, the blood goes mostly inside, and the [aneurysm] outside will slowly clot and shrink,” explains Dr. da Costa.

The problem with this approach was that Georgia’s aneurysm was far too long for these stents.

So, Dr. da Costa decided to try something unprecedented. He would telescope three miniscule stents into one another to bridge the distance of Georgia’s aneurysm.

Sunnybrook neurosurgeon Dr. Leo da Costa.

A unique approach

On October 2, 2020, Dr. da Costa and his team accessed Georgia’s brain through a small incision in her groin. Using a combination of catheters and wires, he navigated the tiny stents through her aorta and into the brain vessels where the aneurysm was located.

Dr. da Costa placed one stent from the edge of the healthy area of the blood vessel into the aneurysm, then placed another just inside that one to extend into the middle part of the aneurysm. Finally, a third stent was placed to complete the “bridge” to the other side.

“This has not been done before using these small stents; [we] were the first globally to telescope three flow diverters to successfully treat a small vessel middle cerebral artery aneurysm,” Dr. da Costa says.

In total, the surgery was just over an hour. Georgia woke up to hear a nurse complimenting her toenail polish. “That made me laugh, and when I laughed, they exclaimed, ‘She’s awake!’” she recalls.

She was released from the hospital shortly after the surgery and is recovering well. Last Christmas, Georgia sent Dr. da Costa a video with her two kids, thanking him for all he’d done to save her life.

“He’s so modest,” says Georgia. “He responded, ‘It wasn’t me. It was all you.’”

Less invasive and more efficient

Georgia and her children enjoy a sunny day in the park.

Dr. da Costa says the procedure will have a significant impact on how his team handles difficult aneurysms.

“Until very recently, open surgery was often the safest option for these very large aneurysms, and the procedures are often complex,” he says. “Finding out that we can add one very small stent to the other in a chain to cover longer distances will allow us to treat these aneurysms in a much less invasive and efficient manner.”

In fact, after Georgia’s treatment, Dr. da Costa said they did another similar one, using the same technique, and he is convinced more and more cases will be done in a similar fashion worldwide. That patient also did well and was discharged the next morning.

Dr. da Costa says that his team’s personalized and precise treatments work hand-in-hand with the constant evolution of technology in this space.

“Many improvements in existing devices and new, disruptive technology are launched every year, allowing us to push the boundaries of what can be treated and how we do it.”

The post Unique approach to aneurysm treatment saved this mom’s life appeared first on Your Health Matters.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Harlan Kirshenbaum says that engaging in virtual treatment for his OCD from his home has been beneficial.

COVID-19 presented a vast challenge for medical and administrative staff at Sunnybrook: How could they deliver the programs and services their patients relied on, yet still keep everyone as safe as possible? Here are just a few examples of virtual care initiatives developed at Sunnybrook through the pandemic.

Virtual OCD treatment: A better fit for some

Harlan Kirshenbaum has battled obsessive-compulsive disorder (OCD), a chronic psychiatric illness, for most of his life. Over the years, his OCD has led to the repetition of various actions, called compulsions, which have had a dramatic impact on his life.

“At one point, I couldn’t get dressed without looking at the labels on my clothes,” Harlan explains. “In recent years, I couldn’t touch my kids or my wife because I would get bad thoughts, like I would give them cancer.”

When the COVID-19 pandemic hit, Harlan’s OCD worsened. He reached out to Sunnybrook’s Frederick W. Thompson Anxiety Disorders Centre for support through the Intensive Residential OCD Program, which had recently shifted from in-house treatment to virtual care amid the pandemic.

The six-week program includes exposure and response prevention sessions guided by a therapist through video conferencing, as well as group sessions for mindfulness and cognitive-behavioural therapy. It was an intense experience, but Harlan says that virtual treatment for his OCD was even more beneficial because he was being treated while in his home, where the majority of his triggers are.

“It’s where my OCD attacks me the hardest, and the virtual program was amazing – the most effective treatment I’ve ever had,” he says.

Dr. Peggy Richter, head of the Frederick W. Thompson Anxiety Disorders Centre and director of the Clinic for OCD and Related Disorders at Sunnybrook, says that coaching people in their home environment has, for many, been advantageous over typical live treatment on-site.

The success of the virtual program has prompted Dr. Richter and her colleagues to plan for a hybrid model of care in the future, based on the positive experience of patients like Harlan. Patients would have shorter residential stays, then migrate to a virtual environment to take advantage of coaching in their home environment.

“We see all the advantages in terms of access, what can be done and how much easier it is for patients to attend our program,” Dr. Richter says. “We don’t want to lose those wonderful improvements.”

COVIDEO: A lifeline for patients

For infectious disease physician Dr. Nisha Andany, developing a virtual care model for COVID-19 was an important part of keeping patients informed about a new and unknown disease.

“Early on, it became clear that most people with COVID-19 would not need to be admitted to hospital and could be managed at home,” Dr. Andany says. “But they might be feeling alone or uncertain in terms of what to expect, what they should do or when they should seek medical attention.”

Alongside members of the infectious diseases team at Sunnybrook, Dr. Andany developed the COVIDEO program to conduct phone and video assessments of outpatients with COVID-19.

“We [also] give patients our email address and pager number and inform them there’s a doctor on call 24 hours a day for any emergencies,” she adds. “We’re often able to reassure most patients that they can stay home and guide them in managing their symptoms.”

As the COVIDEO program was rolling out, the team also began to send out blood oxygen monitors to higher-risk patients. That way, the COVIDEO team could obtain a more objective assessment of someone’s condition from home.

“Now, patients will call us and say ‘my oxygen level is at a certain level’,” Dr. Andany says. “It allows us to more reliably determine how sick someone is. If a patient has a normal oxygen level, we will typically reassure and advise them to remain home and keep monitoring. However, for those with low oxygen levels, even if they say they feel okay, we know they actually need to come into the hospital for treatment.”

Virtual post-operative physiotherapy

For patients recovering from hip or knee replacement surgery, virtual post-operative physiotherapy offered by the Holland Centre has given patients all over the province greater choice, says Amy Wainwright, manager of the Holland Bone and Joint Program.

“For some patients, the possibility of virtual care removes some barriers to receiving care at the hospital such as arranging transportation, long travel times, paying for parking, as well as family members to accompany them,” Wainwright says.

Throughout the pandemic, physiotherapists have been hosting rehab sessions by video to safely guide patients in their post-surgical recovery.

Going forward, the Holland Bone and Joint Program will continue to offer virtual care for outpatient physiotherapy, as well as virtual options in other areas of the program such as pre-admission and post-operative follow-up clinics. Wainwright says the expansion of virtual care has been something of a silver lining among the challenges caused by COVID-19.

“We now have a virtual care model that would have taken years to get to and may have been challenging to implement if it wasn’t for the pandemic pushing us all into a new arena,” she says.

Bringing the ED to the community

When Sunnybrook physician Dr. Justin Hall saw patients avoiding the Emergency Department (ED) due to fears around contracting COVID-19, he saw the need to provide another option.

“People delayed their care and were more unwell when they eventually came in,” Dr. Hall explains. “In some cases, there was permanent or irreversible damage because of this delay.”

Along with members of ED leadership, Dr. Hall developed Sunnybrook’s Virtual ED. Focused on addressing acute but non-life-threatening issues, it launched thanks to provincial funding as a six-month pilot in December 2020, and it has since been extended with ongoing provincial and hospital support. Patients can book a same-day appointment to see a physician through video conferencing app Zoom if they’re unable to visit their regular family doctor.

“It’s not a replacement for the in-person ED,” Dr. Hall notes, as emergency departments are still open and are safe to visit. People experiencing life-threatening issues like a heart attack or stroke should still go to the hospital. But issues such as skin conditions, some mental health concerns or sprains and strains can now be assessed through a video appointment.

As with many departments at Sunnybrook, there are plans to incorporate a hybrid model of virtual and in-person care in the ED post-pandemic, says Dr. Hall, making it easier for patients to access treatment in an integrated manner.

“We estimate that 30 per cent of in-person visits could be seen virtually,” he says. “There’s an increasing recognition of the value of virtual care and that patients like it and are willing to use it.”

Learn more about the Virtual ED »

Staff members of the Virtual Emergency Department Team (from left): Toni Alevantis, patient administrative associate; Steffanye Michaelson, patient care manager; Dr. Aikta Verma, chief of emergency medicine; Dr. Justin Hall, emergency room physician and virtual emergency department lead.

The post Ushering in a new era in medicine: Sunnybrook creates virtual care programs in response to COVID-19 appeared first on Your Health Matters.

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

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

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

What impact does COVID-19 have on mental health?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Why do COVID-19 symptoms persist in some people?

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

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

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

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

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

Mark Opauszky exercising on the streets of Toronto (photograph by Kevin Van Paassen)

In February 2019, Mark Opauszky flew down to New York for what he thought would be a quick business trip. The Toronto-based CEO and founder of a rapidly growing marketing automation company was scheduled to present at a conference and take in a few sales meetings.

Two days in, Mark fell suddenly, severely ill. With a fever spiking and on the brink of losing consciousness, his business partner rushed him to a Manhattan hospital. Mark emerged several weeks later from a medically induced coma to discover he had developed necrotizing fasciitis, more commonly known as “flesh-eating disease,” and it had brought him to the brink of death.

“I found out later that my probability rate of survival had been in the 5 per cent range,” says Mark, now 51.

The full extent of Mark’s ordeal reads like the plot of a horror movie. Necrotizing fasciitis is a disease in which bacteria infects the connective tissue, or fascia, under the skin. The disease rapidly kills the tissue, causing it to peel, blister and turn black as it dies. Most often caused by Group A streptococcus bacteria (the same bacteria that causes strep throat), it usually enters the body through a break in the skin like a cut or scrape.

Mark’s strain of necrotizing fasciitis resulted in septic shock, a worst-case scenario where the major internal organs begin to shut down and blood pressure dips dangerously low. In order to save his life, surgeons were forced to cut away a vast quantity of Mark’s muscle and flesh to remove damaged tissue, exposing some limbs down to the bone.

The New York team had saved Mark’s life. But by the time he arrived via air ambulance at Sunnybrook’s Ross Tilley Burn Centre four weeks later, Mark says he was in extremely rough shape.

“They did what they did [in New York] and then they sort of shipped me back to Toronto in pieces,” he says.

Mark in his room at Sunnybrook’s Ross Tilley Burn Centre, a few days after his arrival.

THE JOURNEY BEGINS

Mark’s arrival at Sunnybrook was the beginning of a long healing process that would involve multiple surgeries on his limbs, extensive rehabilitation and an extreme level of determination. Mark went through eight surgeries over four weeks at the Ross Tilley Burn Centre, including the amputation of several fingers and toes. He was then transferred to Sunnybrook’s St. John’s Rehab to begin the next phase of recovery.

St. John’s Rehab is renowned in Canada for its personally tailored programs that incorporate multidisciplinary teams to treat complex medical traumas, such as burns, falls, limb loss and vehicular accidents.

Multidisciplinary teams at St. John’s Rehab include physicians, nurses, physical and occupational therapists, prosthetists, speech-language pathologists and dietitians to support patients back to previous daily functioning. Equally important are psychologists, social workers and spiritual care providers to support the mental and emotional aspects of recovery.

“We use a holistic approach to care that focuses on the mind, body and spirit of each person,” says Dr. Amanda Mayo, physiatrist (rehab specialist) at St. John’s Rehab. “It’s one thing to save a life, and it’s another to rebuild that life in a way that is meaningful for that person.”

Mark’s program involved a rigorous schedule of cardio and calisthenics designed to rebuild atrophied muscle. Physiotherapy and occupational therapy helped him start walking again and learn how to use his injured hands. He also required regular massage and stretching for his limbs due to the volume of skin grafts he’d received – an extremely painful procedure.

For the entire duration of his stay at Sunnybrook, Mark says he didn’t once turn on his phone or watch TV. A tech entrepreneur who had previously been perpetually plugged in, Mark transitioned to a near meditative state that allowed him to focus on healing.

“It was me and my brain and my time, and that’s all I did,” he says. “I would spend hours just picking one body part at a time to concentrate on. Or I would open and close my fist because I was trying to get my fingers to work again.”

Doctors anticipated Mark’s in-patient stay at St. John’s Rehab would take eight weeks. He walked out the front door two weeks later. Mark says his quick recovery time was a combination of the outstanding care he received and the extreme discipline he had maintained in his previous life as a high-functioning CEO.

“I would get up in the middle of the night, get my walker and do laps around the nurses’ station at 2 a.m.,” Mark says of his time in rehab, noting that he was motivated by his desire to get back home to his wife, Danielle, and his two children.

ONE MORE STEP

In October, Mark returned to the Ross Tilley Burn Centre for a final amputation of his lower left leg. He had a bone infection, his left foot wounds weren’t healing and despite a top-of-the-line orthotic to offload his painful foot, he was in constant pain.

Dr. Mayo says she recognized that Mark’s left leg below the knee might need to be amputated due to the extensive damage back when he first arrived at the Ross Tilley Burn Centre. But she also understood how important it was to his emotional recovery to give him the opportunity to make that decision on his own time.

“Limb loss is a life-changing event. A lot of patients with chronic infections have to go through this journey and they go through multiple treatments or surgeries that can become quite draining,” says Dr. Mayo, who led Mark’s limb-loss rehabilitation team. “And then they realize, ‘I’m actually better off not having the foot. The foot is painful. This foot has wounds. I can’t walk on this foot.’ And Mark came to that decision.”

The left below-knee amputation surgery, led by plastic surgeon Dr. Alan Rogers, proved successful and has improved his quality of life, Mark says.

He began outpatient rehab at St. John’s Rehab to learn how to use his new prosthesis. Esther Chung, Mark’s physiotherapist, says that Mark’s dedication was a key factor in his specific recovery.

“Mark is very strong mentally, and I think it helped him progress,” she says. “He also had a strong support network of family and friends, which is important to maintain motivation over the long run.”

Dr. Mayo agrees that mindset and attitude are crucial aspects of the rehab process at St. John’s Rehab.

“A patient’s perseverance is very important,” she says. “Somebody who’s very active and doesn’t have any other medical comorbidities should be going back to most of the activities they did before, [only now] wearing a prosthesis or maybe [using] some adaptive equipment.”

Today, Mark is thriving. He is adjusting to a new normal that seems much closer to his previous life than he had initially imagined.

“I lift weights. I have a treadmill. I started [martial art] Muay Thai again. I’ve been learning to be a bit more agile on my limb,” he says. “I don’t even walk with a limp anymore. Some people can’t even tell that I’ve lost a leg.”

Feeling immense gratitude to his Sunnybrook team, Mark says he is inspired to give back.

“I would very much like to transition from just being a patient to being somebody who can contribute to the [organization] in some way, shape or form,” he says.

HEALING THROUGH MINDFULNESS

How much does your state of mind dictate how well you heal?

At his Sunnybrook lab, physiatrist and researcher Dr. Robert Simpson develops mindfulness and yoga programs for patients with disabling long-term conditions, including multiple sclerosis, stroke and amputations.

“There’s now robust, high-quality evidence for mindfulness improving mental health outcomes – mainly stress, anxiety and depression. There’s also fairly robust evidence that it leads to beneficial changes in cognitive function and probably pain,” says Dr. Simpson, who is trained to teach both mindfulness and Hatha yoga.

Mindfulness can be defined as the act of paying attention to the present moment, non-judgementally. It is often taught through guided meditation practices that focus on the breath and sensations within the body.

The concept hit the North American mainstream in the late 1970’s when a program called Mindfulness-Based Stress Reduction (MBSR) began to infiltrate medical and wellness circles as a treatment for chronic pain and stress. The program had been adapted from Buddhist and Yogic principles by U.S. medical professor Jon Kabat-Zinn.

Dr. Simpson says he considers a host of factors when deciding who might benefit from a mindfulness-based intervention (MBI). For example, someone with an amputation who also has conditions like diabetes, high blood pressure and depression may face more challenges with rehab than someone without these conditions.

That’s why a combination of personalization, education and support are key to improved results, he says.

“Humanistic factors like encouragement, empathy, compassion, understanding – I think these are all really important factors, and different people likely need different ‘doses’ of these things.”

The post One man’s journey after a battle with ‘flesh-eating disease’ appeared first on Your Health Matters.

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

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

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

Sunnybrook cognitive neurologist Dr. Matthew Burke.

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

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

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

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

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

Tearing down silos

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Expertise and education

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

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

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

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

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

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

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

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

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

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

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

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

But he never loses sight of the big picture.

“Each aspect of my work informs the other,” says Dr. Wijeysundera.

In Sunnybrook’s Schulich Heart Program, Dr. Wijeysundera is part of a team that leads the country in minimally invasive treatments for patients, many of whom cannot withstand open-heart surgery. Among his specialties is the transcatheter aortic valve implant (TAVI) procedure, which involves repairing the aortic valve, responsible for pumping blood to the heart. Dr. Wijeysundera threads a catheter through a small incision in the leg up to the heart, then deploys a mesh replacement valve in the narrowed aortic valve, relieving shortness of breath and chest pain often immediately.

When Dr. Wijeysundera isn’t treating patients in the catheterization lab, he leads an impressive research program that evaluates how health technologies like TAVI can be used to treat even more patients.

“As physicians, we have responsibilities to the patient in front of us, but we also have bigger responsibilities as caretakers of the health-care system,” he says.

Dr. Wijeysundera and his team analyze large amounts of data involving patients who have received devices like TAVIs in order to put forward policy recommendations to key provincial decision-making groups about how such life-saving technologies can be optimized for more patients across the health system. His efforts have been recognized with multiple awards, including his most recent honour, the Distinguished Clinician Scientist Award from the Heart and Stroke Foundation of Canada.

Profile text by Ishani Nath. Photo by Kevin Van Paassen.

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“Everything needs maintenance, and we provide 24-7 support across all systems,” says Nick Poulidis, chief operating engineer. “It’s wonderful to be able to serve and help our patients, families and staff every day. This is a real group effort, and we’re lucky to have the expertise of such great engineers and specialists.”

Because the power plant is always running, so is the team. Fifteen staff members work day and night to make sure all of the systems relied upon by patients, families and staff are there when needed. Here are some highlights of the main utilities:

1. FULL STEAM AHEAD

Sunnybrook has four large steam boilers that support all heating in the hospital, including that needed to sterilize medical equipment. Each boiler is about 2,000 times the size of a home water heater and produces a maximum of 60,000 pounds of steam per hour. The exhaust passes through an impressive 178-foot chimney, equivalent to a 16-storey building.

2. COOL IT

About 300,000 litres of water are continually filtered through chillers in this closed water system. A total of seven chillers keep water temperatures at five degrees Celsius, providing air conditioning and keeping everyone comfortable during the warmer months.

3. POWER SOURCE

Six generators provide backup power in the case of an outage. Collectively, these provide about 9,500 kilowatts of power, which is more than enough to keep essential services at the hospital running in the case of an emergency or a blackout.

4. AIR-HANDLING SYSTEMS

Every area of the hospital is affected by the heating, ventilation and air conditioning (HVAC) systems to ensure an optimal patient care environment. Having enough air changes in an operating room, for example, helps keep the space safe and clean. Maintenance of these systems is led by six HVAC mechanics who work within the power plant group.

5. NEXT GENERATION

This cogeneration plant is a new installation at Sunnybrook with construction currently underway. It has a gas turbine generator, which is powered by natural gas and produces both electricity and waste heat that is used in a boiler to produce steam. The cogeneration system produces electricity and steam more cost effectively than through traditional means. When completed later this year, this new addition will allow Sunnybrook to generate about 85 per cent of the electricity it needs in-house. It will be equivalent to removing approximately 6,000 single homes off the power grid.

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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

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On Thanksgiving weekend in 2019, a senior arrived at Sunnybrook’s emergency department with rib fractures after suffering a fall. She was in stable condition, but needed a new walker to get around. So, the woman was admitted.

The problem? No available beds.

“She spent the whole weekend with us in our hallway in emergency,” remembers Will Thomas-Boaz, advanced practice nurse for Sunnybrook’s emergency department and trauma program.

Fortunately, change was already in the works to address this all-too-common problem. Sunnybrook had begun developing a new team of emergency department healthcare workers with one main goal: helping seniors avoid long stays in the hospital by giving them the supports they need to go back home to the community safely.

On October 28, 2019, Sunnybrook launched the ED One Team. In its first five months, the team showed a decrease of 323 admissions, or 2.1 per day, compared to the same time period the previous year, says Thomas-Boaz, who develops quality improvement initiatives with ED One.

The ED One Team consists of both a hospital and community social worker, geriatric emergency medicine nurse, physiotherapist, occupational therapist, community care coordinator, psychogeriatric case manager, a community mental health specialist and staff from home-care service agencies. After a daily huddle to discuss cases, they usually work with an average of eight to 10 patients a day.

To further support seniors care, the ED One Team works together with the Slaight Senior Care Navigation Pilot, a project supported by the Slaight Family Foundation Seniors Fund. The pilot places a trained navigator from SPRINT Senior Care in Sunnybrook to help facilitate safe discharges into the community.

Natalie Coyle, the ED One Team coordinator, says using a holistic, team-based approach to patient care makes all the difference. She pulls up a letter from one patient, Terry, a senior living alone who arrived in emergency with a hip fracture. ED One Team members ordered his new walker, helped him learn how to use it, made sure he could easily return to his home in community housing and scheduled a home cleaning, too.

“I’m a very proud person and I’ve never accepted this kind of help before, but she really made me feel safe and was always pleasant and professional,” he wrote of his experiences with the ED One psychogeriatric case manager.

With a high number of seniors in the community, the ED One Team will be kept busy, but that’s precisely the point.

“Now that we have [ED One], I can’t imagine not having it,” says Coyle.

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