Photography by David Sparks
A closer look at heart defects
3D printing is changing congenital heart disease.
By Megan Sarnacki
Every year, approximately 40,000 babies are born with a congenital heart defect in the United States, according to the Centers for Disease Control and Prevention. Because children born with heart defects require ongoing monitoring and treatments, here in West Michigan, the Congenital Heart Center at Helen DeVos Children’s Hospital aims to establish a seamless transition of care for each patient from birth to adulthood.
As co-directors for the Congenital Heart Center, Dr. Joseph Vettukattil and Dr. Marcus Haw say to improve these young patients’ lives it is necessary for hospitals to stay at the forefront of new technology. With recent additions to the Congenital Heart Center’s technological services, such as three-dimensional printing and virtual reality, Vettukattil and Haw have the chance to gain a greater detailed comprehension of each patient’s unique, complex heart defect.
“There are around 360 different diagnoses for congenital heart disease and there are about 360 different procedures that can be performed,” Haw said. “Within each diagnosis, there’s a spectrum and sometimes there can be multiple diagnoses in one patient, so there’s an infinite number of variations that can actually happen inside the heart. Even after 25 years, there are times where we haven’t seen these particular arrangements before. To actually print the heart out or have it polished holographically makes a critical impact on our performance.”
When the heart can be viewed through a 3D lens or model, doctors, such as Vettukattil and Haw, can see the structure of the heart without having to open the patient’s actual heart. Not only does this enable them to frame any part of the patient’s heart and dissect the problem virtually or through a model, but 3D printing also allows doctors to practice procedures as well as train the next generation of surgeons. “It’s like a pilot flying in a simulation plane,” Haw said. “It allows us to take surgeons who are in practice and actually watch how they’re doing with these complicated surgeries that we do in congenital heart surgery.”
It is not just the doctors who can learn from this new technology, either. Three-dimensional visualization and prototypes also provide patients and their families with a comprehensive understanding of the problem and the plan of action.
“It has a huge impact on how we deliver health care in Michigan now,” Vettukattil said. “In the past, you would need a highly-trained person to sit in front of a computer during a CT or MRI scan and try to find out what’s wrong. With 3D visualization, there is a new era of understanding medicine and simplifying complex conditions to people because once we can point out the issue, we can sit down with the patient and show them the whole scenario and how we will fix it. It demystifies the complexity of our conditions by just adding the visualization of things.”
What it means the most to Vettukattil and Haw, though, is the fact that this technology is providing them with tools to help the families who have nowhere else to go. “It is so rewarding for us because these are real people who were told there is nothing more that can be done,” Vettukattil said. “There have been nine such cases where other centers or major units in the county have told families there is nothing that can be done, but with the innovation of new devices, we can now look them in their eyes and give them what they need.”
While Vettukattil and Haw assure that future technological advancements will be even more unbelievable in terms of benefits, Haw states the effect in West Michigan already offers positive signs. “We’ve looked at a study out of Michigan Department of Health and Human Services and, sadly, congenital heart disease remains one of the major killers in early childhood and infancy,” Haw said. “Since we’ve instituted a comprehensive program here in Grand Rapids, though, the mortality (rate) in Muskegon, Ottawa and Kent counties has fallen from 11% at the age of two to 5%. We want to make sure everybody who has a problem with congenital heart disease can benefit from the highest quality of care closer to home.”
Elevating stroke recovery
New technology can mean the difference between walking or not.
By Ann Byle
Bette Alexander spent 18 days at Mary Free Bed Hospital and Rehabilitation Center after suffering a stroke and spending several days in the general hospital. She entered able to do very little; she left walking and talking.
“I couldn’t do anything,” said Alexander, 74. “But by the time I left, I could talk and get around and move. That makes me feel wonderful.”
She did hours of physical therapy, occupational and speech therapy daily, and recreational therapy twice a week. She played Jenga, swam, met with a therapy dog and played video games. The video games, however, were part of the technology so vital in returning stroke and traumatic brain injury patients back to at least partial functionality and often close to
The key to stroke recovery is repetition, according to Dr. Benjamin Bruinsma, stroke program medical director for Mary Free Bed. “Repetition enhances neuroplasticity, and that repetition can be achieved through technology,” he said.
Names such as the Hocoma ArmeoSpring, ZeroG Gait and Balance System, Bionik InMotion ARM Robot, and AlterG Anti-Gravity Treadmill belie the importance of these technologies for recovering use of arms and legs. Hocoma ArmeoSpring offers motor therapy to improve grasp and release. The Bionik InMotion ARM helps with delivering high repetition motor therapy to help patients regain motor function.
According to Ken Smith, occupational therapy team leader for stroke victims, a machine can provide 600-700 reps compared to 200-300 reps that a therapist can do per session.
The machine also provides immediate feedback that tracks every move, strength of movement, and range. That’s what Bette Alexander was doing when she popped balloons on the Hocoma ArmeoSpring screen: repetitive arm movements that retrained her muscles and brain.
The brain, according to Bruinsma, will learn new pathways around the dead area caused by a stroke, and those new pathways are achieved through repetition made easier and more
productive through technology.
“There is much improvement in treatment because now people with less motor function have machines to help them improve neuroplasticity,” Bruinsma said.
The ZeroG Gait and Balance System allows patients to begin practicing and re-learning to walk. The system offers body weight support and fall protection in a harness system connected to a track in the ceiling. Therapists can assist the patient’s legs on the treadmill as they are supported on the track; improving patients can move their legs on their own, increase intensity or learn from trial and error. Several ZeroGs exist in therapy gyms at MFB, and one track runs down a long hallway for patients who are beginning to walk on their own.
Mary Free Bed offers a variety of tech therapies. Bionik InMotion ARM Robot offers motor therapy to teach grasp-and-release movements; the AlterG Pro Anti-Gravity Treadmill uses air pressure technology to reduce a user’s bodyweight so rehabbing, particularly for knee injuries, can start sooner. The LokomatPro provides gait therapy for brain and spinal cord injury patients. There’s also a mechanized golf cart to help those with spinal cord injuries stand and take a swing.
A remodeled car, donated by community members including The Daniel and Pamella DeVos Foundation, sits in a sun-lit seating area. It’s surprising how many muscles it takes to get in and out of a car. Now patients can relearn these seemingly simple tasks in an actual vehicle retrofitted with technology to assist them.
Mary Free Bed therapists still use old-school tech, too, of course. Walkers, crutches, gait belts, hand weights and exercise balls occupy space next to high-tech machines that take stroke, traumatic brain injury and amputation recovery to once-unheard-of levels.
Patients still must do their exercises, said Bruinsma, and it’s still important to get patients to rehab as soon as possible to reap long-term benefits. But he sees no downside to high-tech rehab other than the cost of the machines, which can run $150,000 to $200,000 each and require training and occasional software updates.
“It’s about better outcomes for patients,” he said. “When functional outcomes improve, there are less outpatient therapies needed later, and less burden on the family or other caregivers. And the patient may be able to go home instead of to long-term care.”
Bruinsma sees even more tech possibilities in the future. Mary Free Bed is looking at the possibility of a study on virtual rehab, where patients put on goggles and do rehab the same way gamers play virtual games.
For now, Bette Alexander’s goal is to get back home to her 40 acres. “The technology was perfect for me and helped me get stronger. It got me out of the wheelchair and walking again,” she said.
Peering into proteins
Cryo-electron microscopy is changing medical research.
By Sam Easter
Juan Du and her husband Wei Lu are two of the pioneers at Grand Rapids’ Van Andel Institute, peering into the tiniest recesses of molecular structure — in search of both better medicines and a better understanding of precisely how the body works.
The duo have been at Van Andel Institute since late 2017, by way of Germany and later western Oregon. Their research in Michigan focuses on fine, molecular processes within the body; like Lu’s work on taste, the processes behind which might reveal better medicines for certain kinds of diabetes or metabolic disorders.
“Drugs that we’re using, taking now, they’re binding to certain proteins, right? If you know how the drugs bind to the protein, it’ll help people design drugs that have higher potency, higher efficacy and are more specific to that kind of protein,” Du said. “That’s why understanding those protein structures at the molecular level and how they bind to drugs is so important.”
Du’s research in particular focuses on temperature-sensitive proteins. Understanding exactly — in fine, molecular detail — how the body’s temperature sensations work can mean better, more chemically precise treatments for ailments like fevers, and even more serious maladies, too.
Perhaps one of the biggest advances in Du and Lu’s field is the development of new techniques to see those proteins. Called cryo-electron microscopy — or cryo-EM, for short — it’s giving scientists a more powerful magnifying glass to stare into the tiniest corners of the natural world.
The advance comes over earlier x-ray crystallography techniques that were unable to render images of certain complex protein molecules; what cryo-EM does is freeze those molecules instead, take thousands of pictures, and render a three-dimensional image of the results.
The new technique has been so powerful, in fact, that the developers won the 2017 Nobel Prize in Chemistry. A report from Nature points out that a database tracking molecular shapes discovered with the method reached 10,000 entries in February, and appears on pace to surpass the older, crystallographic method by the mid-2020s.
Du refers to it as the “so-called ‘resolution revolution.’”
But there are still some hang-ups. Van Andel Institute’s researchers are remarkably lucky to have access to cryo-EM technology, which Du said is only present in two places in Michigan — Grand Rapids and at the University of Michigan. The cost of the technology ranges well into the millions, and according to Science Magazine, it can be remarkably difficult to access, with even the most privileged of researchers often forced to wait for time on a relative gem of a machine.
“The wait (to use cryo-EM) can be from three months to infinity,” Bridget Carragher, a co-director of New York City’s Simons Electron Microscopy Center, told Science. “It’s becoming the haves and the have-nots.”
Efforts are underway to build a more affordable technology, but plenty of scientists are still tapping their feet.
Not so at Van Andel Institute, which lists its own pantheon of discoveries made via cryo-EM on its website, including a remarkable one from both Du and Lu — co-senior authors on a study that lays out the structure of a temperature-regulating protein.
“You can test different drugs to see where those drugs bind to your protein, without creating or producing any crystal,” she said. “(Cryo-EM is) a big deal.”
Robots in the operating room
Robots are allowing rural patients to receive care more easily.
By Megan Sarnacki
Despite the cinematic depiction of robots taking over the world, there is one place where the increase of robotic programming is making a key difference — the operating room. According to Dr. Erich Schafer, who performs general surgeries at Spectrum Health Gerber Memorial Multispecialty Clinic in Fremont, the most common question patients have is: “What role does the doctor play in robotic surgery?”
While many people may be wary of entrusting their life to a machine, Schafer wants the community to understand that just because there is a machine in the room does not mean the surgeons are sipping coffee and reading magazines.
“The biggest thing is to know that the surgeon is in control of everything that is going on in that room — no different than prior to the advent of this technology,” Schafer said. “The biggest change is how that surgery is delivered. The robot, itself, is nothing more than a tool.”
With around 12% of all robots in Michigan, Spectrum Health has recently expanded its use of robotic programming to not only the large hospitals in downtown Grand Rapids but also smaller ones in the more rural communities of West Michigan.
For Schafer, the advancement of robotic technology is a game-changer. Because robotic surgery is minimally invasive and involves smaller incisions and less tissue trauma, the recovery rates for patients are much faster.
“Colon surgeries 20 or 30 years ago required an average of a seven-to-10-day hospital stay,” Schafer said. “But for the last four colon surgeries I have done with the robot, the patient only stayed in the hospital for an average of one-and-a-half days.”
Shorter stays may not only mean reduced pain and faster recovery to normal activities for the patient, but also significant savings for both the patient and health care system.
According to the American Hospital Association, the average hospital expenses per inpatient day range from $1,366 to $2,298 in Michigan. Schafer explained the difference between having to pay that much for seven to 10 days versus a day and a half would ease the financial burden for many patients and their families.
Adding robotics to smaller hospitals, such as Spectrum Health Gerber Memorial, also creates more access to care in populations outside of the Grand Rapids metropolitan area. “Rural populations don’t have access to this kind of technology normally, so people have to have the means to travel those distances,” Schafer said. “In Newaygo County, which we handle, the vast majority of our population is elderly and those who have limited means to make the pilgrimage to Grand Rapids to seek out this technology. It’s not possible for many people to make that long drive. Bringing this technology locally allows us to continue that community-centered care with the latest technology to ensure that our patients are going to get the same outcomes that they would if they were traveling an hour or two away to the major metropolitan areas.”
It’s not just the patient who may benefit from robotic surgery, however. Surgeons, such as Schafer, see the difference it has made in their own lives. By using robotics, surgeons are not only given a greater visualization, enhanced dexterity and greater precision, but also suffer less fatigue after completing the surgery.
“Laparoscopic (small incision) involves me contorting myself into odd positions in order to accommodate the equipment, which is incredibly fatiguing,” Schafer said. “I used to go home after doing five or six cases laparoscopically in the operating day and not have
any energy to spend time with my family.”
But by placing the robotics in those contorting poses, instead of himself, Schafer can control the tiny incisions in the patient from a comfortable ergonomic position, giving him more energy at the end of the day. “Now, I feel good at the end of the day. I’m ready to keep going. Yesterday was a perfect example — I did five cases, went home and took my son out for small game hunting — that’s something that before robotics was not possible for me to do.”
Beating breast cancer
AI technology enhances cancer screenings.
By Justin Dawes
New artificial intelligence software is significantly improving the way doctors at Metro Health-University of Michigan Health diagnose breast cancer.
Late last year the health system fully implemented the FDA-approved ProFound AI product developed by New Hampshire-based medical technology company iCAD, according to Dr. Mark Traill, a radiologist at Metro Health.
Prior to Metro Health’s implementation, iCAD had donated the technology so Traill could use it on a research basis with the University of Michigan. Now, iCAD has the technology at more than 600 sites in the country — only a few of which are in Michigan.
The software uses an algorithm to spot abnormalities in 3D mammography images more accurately than doctors, reducing false positives, false negatives and unnecessary patient callbacks for additional testing.
Doctors detect cancers about 80% of the time, Traill said, or much worse depending on the doctor or any number of factors. The algorithm can detect malignant and nonmalignant tumors about 7%-9% more often, he said.
For this reason, Traill expects the technology to be “massively disruptive” in the field.
“It’s made my job a lot easier,” he said.
Spotting abnormalities is more of a reflex than a cognitive process, kind of like playing “Where’s Waldo?” he said.
“It’s like when you see your friend on the street. When you see them, the process of recognizing them occurs in a tenth of a second. If he’s got a hat on and it’s out of context, you may or may not recognize him,” Traill said. “That’s exactly the same process that we deal with finding these cancers.”
He said it’s easy for even several doctors to completely overlook abnormalities in a screening — and staring at the images longer typically doesn’t help much.
“Nobody finds them all,” he said. “One, in particular — I really don’t think I ever would have seen it.”
While the patients may not understand the difference in what tools are being used, they appreciate hearing that AI and other advancing technologies are elevating what providers can do, Traill said.
“These patients are moms with kids and wives. There’s something about breast cancer that is just a little more rotten than other cancers, I think, because of the people that it takes out,” Traill said. “So, you want to do the best you can, and this technology is helping.”
Traill said he remembers the excitement when MRI technology was introduced because of the changes it brought in diagnoses.
“This is going to be a lot bigger than that,” he said.
“There’s been a lot of hype, but I don’t think it’s overdone for this. I think this is something that is really going to have a huge impact on radiology and across the board in medicine.”
Google Health developed a similar system and had its performance results published in the science journal Nature. Though Google’s system is based on the same model as ProFound AI, Google’s isn’t quite ready for clinical use.
“I think because they’re Google, they’re able to present it as they’re the first ones to do this, but that’s not the case,” Traill said. “We’re doing it now.”
When iCAD rolled out the technology in 2018, Forbes called it one of the year’s biggest moments in AI.
Other companies have developed similar systems for diagnosis of lung, brain and other cancers. Systems are regularly being granted FDA approval, and the results of some have been published in Nature.
Traill said he has been attending conferences and following advances in this technology for about four years, and the progress has been “surprisingly fast” and seems to be somewhat outpacing its utilization for now.
The technology overall is in the early stages. In the next decade, he said he expects it may even be able to make diagnoses, not just find abnormalities that radiologists then diagnose.
He sees this as a solution to the developing shortage of radiologists nationally, especially in rural areas. The reason for the shortage in this area of practice may come in part due to development of this technology, however, he said, citing a recent study.
“It’s scared some people away because it basically has potential to automate what you do,” he said.
Despite that apprehension, Traill doesn’t see the advancing technology displacing radiologists but rather changing their role a bit. He argues that radiologists who use the technology no longer have to spend time reading mammograms but instead will be able to offer more valuable care.
“AI is not going to replace radiologists, but radiologists who use it and embrace it are going to replace those that don’t,” Traill said.