Sinai Health Magazine Fall/Winter 2018 by Sinai Health Foundation

sinai health magazine AUTUMN / WINTER 2018

th e n ew powe r tools of m e dical research What is the microbiome? Your online health toolbox Emergency medicine grows up New! Crossword puzzle

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th e cove r

Sinai Health Magazine asked Toronto-based paper-cutting artist Julia Seo to create a three-dimensional representation of an organoid (mini organ), a breakthrough technology used in Dr. Jeff Wrana’s lab to study the progression of cancer. Our cover showcases the result: an intricate and layered creation that evokes the complexity of this exciting technology.

I M A G E C R E D I T: D R . M A S A H I R O N A R I M AT S U

F A R L E F T:

A microscopic image of Dr. Wrana’s intestinal organoid which inspired the cover, next to some of Seo’s suggested colour palettes. A D J A C E N T:

Seo’s sketches reflect her explorations of the organoid shape, as she considers how to take apart and re-create the structure.

Art by Julia Seo » juliaspaper.com

Watch our cover image come to life » youtube.com/sinaihealthsystemca

@juliaspaper

V I D E O B Y: 3 0 0 4 S T U D I O S

Leadership Letter To many in our community, Sinai Health System is synonymous with world-class care for our patients throughout their lifespan. Perhaps we first helped you celebrate the birth of a child or grandchild, or treated you for cancer or inflammatory bowel disease, at Mount Sinai Hospital. Maybe we helped you rehabilitate at Bridgepoint Active Healthcare after a stroke or injury. Perhaps Circle of Care helped you care for your aging parents, keeping them at home where they can be surrounded by family. Sinai Health is all of that — and more. We don’t just offer state-of-the-art, person-centred care; we are reimagining what care will look like today and into the future. This quest to unlock the mystery of disease is at the core of the Lunenfeld-Tanenbaum Research Institute (LTRI), an incubator of scientific discovery that is the jewel of Sinai Health. For almost 35 years, with the incredible support of our donor community, the vibrant research team at the LTRI has leveraged curiosity, creativity and cutting-edge tools to redefine health care for generations to come.

David G. Cynamon

This theme of reimagining will leap off the page in this special research edition of Sinai Health Magazine, starting with our striking cover. To accompany our cover story, “The New Power Tools of Medical Research,” we asked Toronto-based paper-cutting artist Julia Seo to create an artistic representation of one of the latest technologies helping to drive our research forward: an organoid. The result: an intricate, three-dimensional paper re-creation of an organoid — a mini organ — used in Dr. Jeff Wrana’s lab to study the progression of cancer. Organoids, optogenetics, CRISPR — you’ll read about these exciting new tools that are powering the work of our researchers and leading to advances in scientific understanding and, ultimately, care for patients.

Howard Sokolowski, O. Ont.

In this issue, you will also read about how the Schwartz/Reisman Emergency Medicine Institute is driving emergency medicine research forward to reimagine best-in-class emergency care for patients around the world. And you’ll learn how genetic counselling is helping families like the Smalleys — whose lives were changed forever by a cancer diagnosis and the discovery of an inherited CHEK2 genetic mutation — take control of their health and their future. With your support, Sinai researchers will continue to ask the important questions and pursue bold ideas that promise to create a healthier future for us all. Sincerely,

David G. Cynamon Co-Chair, Board of Directors Sinai Health Foundation

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Howard Sokolowski, O. Ont. Co-Chair, Board of Directors Sinai Health Foundation

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Contents

magaz ine

Feature Stories 10

Chief Executive Officer Louis de Melo

Emergency Medicine Grows Up The Schwartz/Reisman Emergency Medicine Institute aims to be the world leader in emergency medicine research

Vice-President Brand Strategy & Marketing Danielle Donadio

Innovating Care

Want to set your own health goals? Dr. Carolyn Steele Gray has an app for that

Nature vs. Nurture: Microbiome Edition

Genetics and environment affect the gut microbiome — so, what is the microbiome?

Meet Dr. Miguel Ramalho-Santos

Editor-in-Chief Lindsey Hodgson

Co-Editor Jane Rimmer

“It’s just one little cell, but it gives rise to an entire body...” New LTRI recruit Dr. Ramalho-Santos studies embryonic development — and why and how it sometimes goes wrong

Art Director Cecilia Mok Designers Eden Biggin Grace Poon Bonnie Wong

Breaking Down Barriers Collaboration is at the centre of new models of mental health care

Past Meets Present Dr. Jon Hunter and Dr. Bob Maunder have a conversation about how a patient’s past influenced her recovery from cancer

All in the Family

The Smalley family grapples with the discovery of their shared — and a cancer diagnosis

C H E K2

Editor Sara Brown

gene mutation

Contributors Nancy Carr Heather Gibson Patricia Hluchy Marcia Kaye John Packman Jeannie Phan Julia Seo Annie Tong 3004 Studios

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The New Power Tools of Medical Research

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New biomedical technologies — organoids, optogenetics, CRISPR — are powering research at the LTRI

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News RE N E W SI NAI C E L E B RA T E S A Y EA R OF TRANSFO RMAT I ON A T M OU NT S I NA I H O SPI TAL July marked the one-year anniversary of Phase 3A of Renew Sinai, Mount Sinai Hospital’s multi-phase redevelopment campaign. The largest and most ambitious project of its kind in Canada, Renew Sinai is providing state-of-the-art upgrades to infrastructure and patient spaces throughout the hospital while our hospital and staff continue to offer a full suite of high-quality patient care services. Over the past year, the current phase of Renew Sinai has achieved many exciting milestones, including the opening of an entirely new floor of clinical and staff-related spaces on the 20th floor and creating brand-new Neonatal Follow-up and Ophthalmology Clinics. We have also begun the transformation of our Schwartz/Reisman Emergency Centre, which will double the size of our emergency department to over 24,000 square feet, increase the number of treatment bays from 37 to 52 and provide superior imaging capabilities with an advanced X-ray and CT scanner.

CY N TH IA L OY S T R E P R E S E N T I NG S I NA I H EALT H FOU N DATIO N A S NA T I ONA L A M BA S SA DO R

THE ROGERS HIXON ONTARIO HUMAN MI LK BANK ACH I EV ES ACCRE D ITA TION

Sinai Health Foundation has joined forces with television personality and relationship expert Cynthia Loyst, co-host of CTV’s “The Social” and creator of the popular online destination Find Your Pleasure. In her role as a national ambassador, Loyst will bring awareness to the worldrenowned Frances Bloomberg Centre for Women’s and Infants’ Health at Sinai Health System, including the Rogers Hixon Ontario Human Milk Bank — a cause close to her heart as both a mother and a breastfeeding advocate. “I’m proud and excited to be serving as a spokesperson and ambassador for Sinai Health Foundation,” said Loyst. “I had no idea about the Milk Bank while I was breastfeeding my son, so I want to make sure that other new moms know about this incredible service and are inspired to donate their breast milk to sick and hospitalized babies whose mothers are unable to provide their own milk.” “Cynthia is a great advocate and we’re eager to join forces to promote this important work,” said Louis de Melo, Sinai Health Foundation’s Chief Executive Officer.

Rendering of the renovated Schwartz/Reisman Emergency Centre

Our Milk Bank collects, pasteurizes and distributes donated breast milk.

The Rogers Hixon Ontario Human Milk Bank has successfully achieved annual accreditation by the Human Milk Banking Association of North America (HMBANA). Led by Debbie Stone, Manager, and Dr. Sharon Unger, Medical Director, our Milk Bank collects, pasteurizes and distributes donated breast milk for hospitalized pre-term babies in neonatal intensive care units across Ontario. Donor milk is known to reduce the rate of a life-threatening bowel infection in pre-term babies. Donor milk goes through a very rigorous safety and infection control process in our facility on the 18th floor at Mount Sinai, and the Milk Bank team achieved 100 per cent compliance for all 149 HMBANA guidelines.

SI NAI BABY SHOP NOW OP E N In September, Sinai Health System launched the brand-new Sinai Baby Shop on the 17th floor of Mount Sinai Hospital. Sinai Baby Shop was designed to help new parents quickly and conveniently find the best products to help them along their new journey. Curated by an advisory committee, including nurses, lactation consultants and educators, the shop carries a number of products to support breastfeeding and skin-to-skin contact, as well as “I’m a Sinai baby” onesies, with more products to be added soon. “We wanted to make sure there was a place located close to new parents, so that they could spend more time with their babies and find some of the products that they need without having to leave the hospital,” said Meredith Johnson, Director of Business Innovation & Development. Visit the shop on the 17th floor or shop online at SinaiShop.ca 5

NEWS

R E M E M B E R I N G T H Y RO I D CANCE R PI O N E E R DR. PAUL WALF ISH Dr. Paul Walfish, a pioneer in the treatment of thyroid disease whose prolific career at Mount Sinai Hospital spanned over 50 years, passed away on July 28, 2018. “Dr. Walfish was an icon in the field of thyroidology; an innovative and lateral thinker who established clinical and research protocols that changed the way thyroid cancer is managed around the world,” said Dr. Ian Witterick, Otolaryngologist-in-Chief for Sinai Health System. Dr. Walfish was a game-changer in the field of thyroid cancer. In 1965, after establishing the Nuclear Medicine Department at Mount Sinai, he and his colleagues pioneered studies in North America using fineneedle biopsy and ultrasound technology for the early detection of thyroid cancer. He also pioneered a new testing method that can determine whether radioactive iodine treatment is required following thyroid cancer surgery. These new techniques armed clinicians with enhanced tools and knowledge, revolutionizing the management and treatment of thyroid cancer in North America.

Accolades DR. AL LAN DET S KY A P P OI N T E D T O T H E O RDE R O F CANADA Dr. Allan Detsky, who served as Physician-in-Chief at Mount Sinai Hospital from 1997 to 2009, was recently appointed to the Order of Canada. Dr. Detsky is a trailblazer who helped to define and shape our Department of Medicine. Under his leadership, along with Dr. Michael Baker, he built the joint Department of Medicine at Mount Sinai and University Health Network, a strategic alliance that shaped and defined so much of how we deliver care to our inpatients today. As a general internist and researcher, Dr. Detsky has been a global leader in health economics and clinical epidemiology, and played a key role in applying the techniques of economic analysis to measuring the value of pharmaceutical products in Ontario and Canada.

D R. DAN I E L DRUCKE R NAM E D 2 0 1 8 MAN N I NG LAUREA TE Dr. Daniel Drucker, Senior Investigator with the Lunenfeld-Tanenbaum Research Institute (LTRI), was the Principal Award Winner of the 2018 Manning Laureate Awards, the highest honour the Ernest C. Manning Awards Foundation bestows. The accolade highlights Dr. Drucker’s achievement in revolutionizing treatment for short bowel syndrome, a disorder resulting in malabsorption of fluids and food due to a resection of the small intestine.

DR. SH OO L E E R E C E I V E S SHA NGHA I MAGNO LIA GO LD AWARD In October, Dr. Shoo Lee, Paediatrician-in-Chief at Sinai Health System, was awarded the Shanghai Magnolia Gold Award from the Shanghai government. The accolade is the highest honour given to a foreigner in recognition of contributions to the social and economic development of Shanghai. Dr. Lee established international training programs in neonatalperinatal medicine and neonatal nursing at the Children’s Hospital of Fudan University. Through a Canadian Institutes of Health Research-funded China-Canada Joint Research Initiative, he also established a national program to reduce infant mortality and morbidity in rural China by training rural health professionals to care for sick newborns.

ROYAL SO CI ET Y O F CANADA H O NO URS DR. JE F F WRA NA WITH M C LAUGH LI N M E DAL Dr. Jeff Wrana, CIBC Breast Cancer Research Scientist and the Mary Janigan Research Chair in Molecular Cancer Therapeutics at the LTRI, has been awarded the McLaughlin Medal by the Royal Society of Canada for his pivotal contributions to our understanding of biology, human diseases and treatment. Internationally recognized for his research, Dr. Wrana’s focus has been on the complex network of molecular/cellular pathways that work together to control cells, which, when disrupted, lead to diseases such as cancer. His research, and collaborations with researchers across the LTRI and beyond, aims to discover new diagnostic tests and novel targets for treatment.

Bridgepoint Active Healthcare N E W FAM I L Y PR E S E N C E P OL I C Y

DR. JORDAN PELC APPOINTED HOSPITALIST SITE LEAD

In June, Bridgepoint Active Healthcare introduced the Family Presence Policy to allow families and caregivers 24-hour access to their loved ones. The new policy was introduced after research showed that the presence of families and caregivers during a hospital stay improves outcomes, reduces the risk of falls and decreases readmissions. As part of this process, Quiet Hours were introduced from 10 p.m. to 7 a.m. so patients can get the rest they need without restricting access to families and caregivers. Each patient may designate up to two caregivers who can stay with them during these Quiet Hours, and they are issued caregiver badges from security.

Dr. Jordan Pelc has been appointed Hospitalist Site Lead at Bridgepoint Active Healthcare as part of a new Interdepartmental Division of Hospital Medicine. The new division was established this spring to ensure a cohesive academic program in hospital medicine across Mount Sinai Hospital and Bridgepoint campuses. Dr. Pelc, who joined Sinai Health System in 2016 as the first academic hospitalist working across both campuses, has led education and quality initiatives. In his new role, Dr. Pelc will focus on the complex population at Bridgepoint to provide clinical, academic and administrative leadership.

“This is a very significant change and formalizes that there is something worthwhile to family- and patient-centred care,” said caregiver Steven Reece, whose wife has been a patient at Bridgepoint for over a year.

Christine Elliott, Minister of Health & Long-Term Care, announces new funding for Bridgepoint.

M I N IST RY AN NO UNCES F UN DI NG T O O PE N 1 0 T H F LOOR

Steven Reece has a new caregiver ID badge so that he can be by his wife’s side any time 24-hours a day.

Since Bridgepoint moved into its brand new purpose-built hospital five and a half years ago, the 10th floor unit has remained unoccupied. But that will soon change. The Honourable Christine Elliott, Minister of Health & Long-Term Care — and a former Bridgepoint patient — visited our Bridgepoint campus in October to announce new health-care funding, including funds to permanently open the 10th floor — and add a total of 32 new beds — at Bridgepoint. The new funding is an exciting development that will enable us to operate the hospital as it was originally designed and to better support the needs of our community. “This is a great opportunity for Bridgepoint,” said Kate Wilkinson, Vice-President of Quality and Clinical Programs. “Over the next few months we will work with our teams and with patients and their caregivers to co-design how we will use this new space on the 10th floor.”

Circle of Care PSWs L E N D C O M F OR T A N D S U P P OR T DURI NG DI FFIC U L T TRA NS I T I ONS Circle of Care’s recent annual education event for Personal Support Workers (PSWs) focused on helping families cope with the challenges of managing end-of-life care for terminally ill loved ones who have made the decision to spend their final days at home. More than 1,000 PSWs had the opportunity to learn directly from experts at Sinai Health System’s renowned Temmy Latner Centre for Palliative Care about end-of-life nutrition and pain relief, family support and what to anticipate during the final hours of life. “PSWs are ideally positioned in the community to help patients and families during the final stage of a life-threatening illness,” said Lara de Sousa, Circle of Care’s Vice-President, Client Services. “By teaching our PSWs how they can help relieve pain and improve quality of life for a dying person, we are helping families fulfill their wish to spend their last days together in the comfort and privacy of their homes, rather than in hospital.”

Janet Afriyie, PSW; Carey Lucki, CEO, Circle of Care; Leisy Alonso Real, PSW; Dr. Russell Goldman, Director, Inter-Departmental Division of Palliative Care, Sinai Health System; and Johanne Loughrey, Clinical Practice Lead

Your Health

Incorporating appropriate daily exercise helps older adults maintain their physical and mental health and independence at home. Exercise also helps seniors avoid the risks of social isolation that can result from a lack of a sense of social belonging, minimal engagement with others and lack of high-quality relationships. In Canada, approximately 30 per cent of older adults are at risk of becoming socially isolated. Compared to socially active seniors, those who are isolated make more visits to their doctor and to emergency rooms, use more medication, fall more often and enter residential care sooner. “Simply put, older adults who are physically active are better able to manage the day-to-day tasks of independent living, such as bathing, dressing, cooking and shopping,” said Rose Lamantia, supervisor of the exercise and falls prevention programs at Circle of Care, part of Sinai Health System. “They also tend to have more meaningful relationships in the community, and a desire to stay socially connected.”

REGULAR EXERCISE PROMOTES: BETTER PHYSICAL HEALTH. Exercise reduces the risk of stroke or heart attack, and helps in the management of chronic conditions including diabetes and arthritis. If not properly managed, these conditions can lead to frailty and significant dependence on others.

BETTER MENTAL HEALTH. Studies show that physical activity can reduce the effects of anxiety and depression, and may also assist cognitive function. Some research suggests that exercise can prevent the onset of dementia later in life.

DECREASED RISK OF FALLS. Exercise can improve muscle strength, bone density, flexibility and balance — all of which help prevent falls. The Public Health Agency of Canada reports that falls remain the leading cause of injury-related hospitalizations among Canadian seniors, and between 20 and 30 per cent of older adults fall each year.

INCREASED SOCIAL ENGAGEMENT. When performed in a social setting, exercise helps forge social connections and relationships. It can also boost self-esteem and increase confidence for living independently at home.

Not sure how to get started? Circle of Care offers more than 150 free exercise and falls prevention classes across the GTA. Call 416-635-2860 to find a class that works for you.*

*As with any new exercise program, you should speak with your doctor before beginning.

ASSESS YOUR MENTAL HEALTH

Your O nline Health

Toolb

You can use a free, user-friendly online self-assessment kiosk to assess your physical and emotional health. Launched by Dr. Jon Hunter and Dr. Bob Maunder, psychiatrists at Sinai Health System, the self-assessment kiosk provides questionnaires that measure many aspects of physical and mental health as well as behaviour and personality. The questionnaires are freely accessible to all, and provide scores and feedback to help you learn about and manage your health. Visit attachmentandhealth.com

LEARN YOUR RISK FOR BREAST CANCER Thanks to funding support from Under Armour, the Marvelle Koffler Breast Centre has developed a new online self-assessment kiosk designed to empower women to understand their own level of risk for breast cancer. The Be Breast Healthy: Learn and Lower your Cancer Risk Program consists of six modules designed to provide information to women who want to know more about breast health, breast cancer risk factors and healthy lifestyle choices that may reduce breast cancer risk. Visit bebreasthealthy.ca

HELP FOR CAREGIVERS OF PEOPLE WITH DEMENTIA Dementia Advisor — a mobile app designed by the Cyril & Dorothy and Joel & Jill Reitman Centre for Alzeimer’s Support and Training — helps family caregivers learn how to deal with difficult dementia behaviours through interactive, chat-based role playing. The app can be downloaded for free from the Apple or Google Play app stores. For more information, go to dementiaadvisor.com Dementia Advisor was developed in association with Acquian, a digital technology company, and funded in part by the Government of Canada’s Social Development Partnership Program — Children and Families component.

OVER 500,000 CANADIANS are currently living with dementia, a condition associated with progressively declining cognitive function. That number is expected to nearly double in the next 15 years. The symptoms of dementia — memory loss, judgment and reasoning difficulties, and changes in mood, behaviour, visual perception and ability to communicate — affect many daily activities. Paying bills, preparing meals and keeping track of belongings all become more challenging. As a result, people living with dementia often require the daily support of family caregivers. In fact, ONE IN FIVE CANADIANS HAS EXPERIENCE CARING FOR A LOVED ONE WITH DEMENTIA. Yet, it can be hard to know how to communicate with loved ones who have in many ways become strangers, and whose moods, behaviours and capabilities may be inconsistent. Experts at the Cyril & Dorothy and Joel & Jill Reitman Centre for Alzheimer’s Support and Training at Mount Sinai Hospital recommend these simple tips for talking to loved ones living with dementia: 1

Regular short visits are best. They may need a break or time to rest

Avoid open-ended questions. Instead of “Where would you like to go?” ask, “Would you like to go to the park?”

Introduce yourself or others by your name and connection

Validate how they are feeling and reflect their feelings back to them so they feel heard

Use the person’s name and look them in the eye

Let them express their feelings without offering solutions right away

Use verbal, visual and auditory cues and gentle touch to help your loved one understand

Find a quiet place to talk and keep things calm; large groups and places with noise and distractions may confuse or overwhelm them Sit or stand at the same level as your loved one

Remember that your loved one has a life rich with history, experience, relationships, skills, hopes and dreams

EMERGENCY MEDICINE GROWS UP

The Schwartz/Reisman Emergency Medicine Institute is driving emergency medicine research forward for the community and the world BY NANCY CARR

As far as medical specialties go, emergency medicine is the kid sibling to long-established disciplines like surgery and cardiology. With a history dating back only 40 years, emergency medicine is a young specialty only now really reaching academic maturity. While several notable Canadian emergency physicians have made outstanding contributions to emergency medicine research, Canada has lacked the kind of infrastructure support required to build a large-scale academic organization specifically to advance the study of, and disseminate learnings related to, emergency medicine. 11

But when the Schwartz/Reisman Emergency Medicine Institute (SREMI) was established as a partnership between Mount Sinai Hospital, now part of Sinai Health System, and North York General Hospital in 2013, that began to change. “It’s really only now that we’re getting to the point where we, as emergency medicine physicians, start to look at the problems we face and say, ‘How do we find a better way to look after these patients?’” says SREMI Director Dr. Bjug Borgundvaag, noting that traditionally much of the focus of emergency medicine research has been on trauma, cardiac arrest and pre-hospital care. “So that’s what we’re trying to do here: generate new knowledge and then take that new knowledge and disseminate it and translate it into practice not just locally in Toronto but provincially, nationally and internationally.” That new knowledge includes how to better serve geriatric emergency patients, women with first-trimester pregnancy issues sent to the emergency department by their family doctor, people with drug and alcohol misuse problems brought in by ambulance or family members and others in our community and around the world. The Institute is the only one of its kind in Canada, and one of just three in North America. It has 10 employees, including Dr. Borgundvaag, who has practiced emergency medicine at Mount Sinai since 1995 and holds a PhD in pharmacology. It also has more than a dozen other affiliated scholars who contribute to its mission, and it’s in the process of adding two new research chairs. SREMI is able to employ its staff and fund its researchers thanks in large part to a 2013 gift from long-serving Toronto volunteers and visionary philanthropists Gerald (Gerry) Schwartz, O.C., and Heather Reisman, for whom the Schwartz/Reisman Emergency Centre was named in 1999. Their financial contribution established SREMI and has created a stable funding platform to support the development of clinician scientists and educators in emergency medicine.

EM Cases podcast: The next level in emergency medicine education Dr. Anton Helman, SREMI’s Education Innovation Lead, is a great example of that. He is, according to SREMI’s Research Director Shelley McLeod, taking “emergency medicine education to the next level.” Dr. Helman is an emergency physician at North York General Hospital. He’s also a musician and a one-time recording engineer who almost followed that career path instead of medicine. He’s successfully married three of his passions — medicine, audio recordings and teaching — to create Emergency Medicine Cases (EM Cases), an online hub of emergency medicine podcasts, videos, quizzes, emails and in-person conferences. “There’s an idea that a lot of learning is done in hallways in emergency departments by speaking to colleagues and experts, but in real life that only happens very occasionally,” Dr. Helman says. “What EM Cases does is bring that kind of knowledge sharing and corridor learning to people’s smartphones and laptops so that learners can get access to experts in specific topics and subtopics in emergency medicine in a way that’s easily digestible and learned.” Until Dr. Helman joined SREMI, his podcasts were offered on a paid subscription basis, and he was working on EM Cases as much as he could between shifts. But with SREMI’s support, he was able to nurture and grow his brainchild, allow free access to the site and build a team of more than 20 people. “Bringing all my skills together is a lot of fun,” Dr. Helman says. “And then just knowing that I’m educating a lot of people to literally save lives and make sick people better, it’s kind of hard to beat.” The podcasts — which are the most popular element of EM Cases — are downloaded 200,000 times per month by doctors, nurses, students and others all over the world. Dr. Helman says he receives an email about once every month from a listener who used what they learned from EM Cases to improve a patient outcome or save a life. Dr. Helman is grateful to be working with SREMI. Many of the Canadian and international contacts he’s made through the Institute have contributed as guest experts on the EM Cases podcasts, and the financial assistance he’s received “frees up a little bit of my time to work a bit less in the emergency department and dedicate more time to EM Cases.” “Vital” support Gratitude is a sentiment expressed by just about everyone affiliated with SREMI. Dr. Catherine Varner, a clinician-scientist at the Institute, called the continuous funding of SREMI “vital.” Being part of a well-funded organization has created stability and allowed her to plan and carry out a coherent program of research on earlypregnancy emergencies without worrying about the challenges associated with grant money drying up and losing momentum between grants.

S I N A I H E A LT H M A G A Z I N E

“If every three months you’re having to write a new grant proposal, it’s very hard to ever concentrate on the bigger picture,” says Dr. Varner, who has been with SREMI since its inception. “And that’s really what we’re trying to do at SREMI: Focus on the priority health concerns that are important to our community and apply the research that we’re doing today to the patients who we’re seeing in the emergency department three months or six months from now.” Dr. Borgundvaag is also extremely grateful for the professional support of Sinai Health System President and CEO Dr. Gary Newton and the financial support that Schwartz, Reisman and other donors have given to SREMI during its first few years. He’s especially grateful for the level of trust that Schwartz put in him and his team when they were looking to create a new and unique educational institute.

“

Heather and I are incredibly proud to support the excellent patient care and patient-centred research underway in Mount Sinai’s emergency department.

”

— G E R A L D S C H WA R T Z , O . C . , V I C E - C H A I R , S I NA I H EA L T H S Y S T E M BOA R D O F D I R E C T O R S

“Gerry’s always been a very generous person and a benefactor to the hospital,” he says. “We’ve been so fortunate because he’s been very engaged with emergency medicine. He knows everyone here and he knows exactly what we’re doing, and it really resonates with him.” For Schwartz and Reisman, the feeling is mutual. “Heather and I are incredibly proud to support the excellent patient care and patient-centred research underway in Mount Sinai’s emergency department,” says Schwartz. Reisman adds, “We are thrilled to see SREMI raising the level of thought leadership in the field of emergency medicine and delivering evidence-based solutions that will have a tremendous impact on patient care locally, nationally and internationally.”

Changing the landscape of emergency medicine As SREMI matures, its future is even more exciting than its past. “I think we are going to completely change the landscape of emergency medicine in Canada,” says McLeod, citing accomplishments as varied as advances in emergency triage decision-making and a smart-phone app that Dr. Borgundvaag has created to detect tremors in patients suffering from alcohol withdrawal. “We are working with our community to revolutionize kind and compassionate care for all our patients in the emergency department.” The current Renew Sinai capital campaign will also have a tremendous positive impact on SREMI. It will, among other things,

double the size of the Schwartz/Reisman Emergency Centre and significantly increase the number of beds available for Emergency Centre patients.

Dr. Borgundvaag is so confident about the future of the Institute — which is poised to make some key hires in the next few months — that he can plot it on a timeline.

“In addition to being able to provide high-quality care, an adequate environment is also directly tied to our ability to do research,” Dr. Borgundvaag says. “For example, we are interested in finding ways to reduce delirium in the elderly. It’s hard to imagine being able to measure the impact of an intervention such as providing better pain relief for hip fractures when patients are kept in conditions that are noisier and more jarring than they could be for optimal care.”

“In the next year, we will hope to become the biggest emergency medicine research group in Canada. Our goal, 10 years from now, is to become the undisputed international leader in the development of new knowledge and ways to improve care for emergency department patients,” he says. “We want everyone in academic emergency medicine to know about SREMI.”

He added that a state-of-the-art emergency department will also help attract top-notch trainees to the hospital and SREMI.

B Y M A R C I A K AY E

Putting simple but innovative technologies in the hands of patients with complex care needs may lead to better health outcomes, according to new research from an innovation scientist. It can be as simple as a mobile app, says Dr. Carolyn Steele Gray, a Scientist at Bridgepoint Collaboratory for Research and Innovation, part of the LunenfeldTanenbaum Research Institute at Sinai Health System. Dr. Steele Gray studies ways to use digital technologies to improve care for individuals with several chronic illnesses — an area of focus at Sinai Health. She has been developing and testing a phone app and web portal that helps providers and patients work together to set care plans based on patients’ own personal health goals. Primary care doctors, allied health professionals, patients and families can collaboratively monitor the process and tailor care delivery to patient priorities — a very different approach from the traditional model of care. “Rather than a provider saying to a patient with five or six chronic conditions, ‘Let’s tightly manage all of those things,’ the patient comes in and says, ‘I want to get out to my social events more often,’ or ‘I want to walk my dog,’ and then the care plan gets focused on that,” explains Dr. Steele Gray. The technology helps patients track progress; for instance, for a patient whose goal is to golf three times a week, the app will ask, “How was your pain when you went golfing today?” and “How many steps did you take?” Patients check off completed tasks and receive virtual badges. The tool, called ePRO — electronic Patient Reported Outcomes — gives doctors a wealth of data.

How was your pain when you went golfing today? In an exploratory four-month trial with 16 patients in two sites, the researchers found that as patients focused on their own personal goals, their general health improved too, including lower blood pressure, healthier weight and better sleep. “A lot of health indicators were improving Dr. Carolyn Steele Gray 14

INNOVATING Dr. Carolyn Steele Gray is developing digital tools that put patients’ own health goals at the centre of care

Dr. Steele Gray says that while some techsavvy patients initially thought ePRO was too simplistic, they ultimately found it helpful and fun. Some providers were initially reluctant to add a new piece of technology to their busy schedules, but their patients’ good results won them over. It’s hoped that ePRO will save money by reducing patient visits to doctors and hospitals. The tool is now in trials with nearly 50 patients and their doctors across Ontario. Looking more broadly, Dr. Steele Gray is interested in using digital technologies to better connect patients and family doctors with specialists, home care providers and hospitals. She says that better integration of information can reduce duplicate testing and medication errors, and improve patient care. For instance, Ontario has a dozen

different types of electronic medical records, with no centralized system. In a recent study, she found that even when providers were using such technology, they were simply supporting business as usual. “Most were using it exactly like a paper filing system, but there are more innovative ways you can use that kind of information, like doing disease management planning.” She says that many technologies are developed by “very smart engineers who are often divorced from the health-care system,” which makes them challenging for health professionals to use. She says, “When we’re developing our mobile technologies, we don’t come in with a technology and say, ‘What do you think?’ We sit down with the people who would use it and say, ‘What do you need?’ And then we build it with them step by step.” She and her team are currently building a collaboration in Nova Scotia that will explore how to integrate mobile technologies on a provincially based patient health record platform. She’s also involved in the Europebased International Federation of Integrated Care (IFIC), which holds conferences and trains people in improving integration across healthcare systems. Building on her partnerships with Kaiser Permanente in Colorado and universities in Edinburgh and Glasgow, she’s starting an IFIC Special-Interest Group on digital health-enabled integration, which will build a community of practice around the development, implementation and evaluation of digital solutions that support integrated care to improve knowledge and technology sharing across countries.

ePro, an app developed by Dr. Steele Gray and her team, allows patients to record their health goals and track their progress.

P H O T O B Y: J O H N PA C K M A N

because people were engaging in activities that were meaningful to them, which can improve their outcomes over the longer term,” she says.

B Y M A R C I A K AY E

vs. Microbiome edition

The CCC-GEM Project explores how genetics and environment affect the gut microbiome — and the development of IBD Could our microbiomes be the key to our health? These mysterious communities of microbes that live on and within each of us are a hot topic of research today. Scientists are working to understand the links between our microbiomes and a vast range of illnesses and conditions, from anxiety and asthma to heart disease and obesity. While these microorganisms reside both on and in our bodies, a major focus of research at Sinai Health System is the gut microbiome and how it relates to inflammatory bowel disease, or IBD. IBD, which includes Crohn’s disease and ulcerative colitis, causes inflammation of the lining of the gastrointestinal tract, which can 16

lead to debilitating pain, fatigue and malnourishment. There is treatment but no cure. The cause of IBD is unknown, although it tends to run in families. But why do some people develop IBD while others from the same family don’t? Could it have something to do with their microbiomes? That’s what Dr. Ken Croitoru aims to find out. Dr. Croitoru, a gastroenterologist at Mount Sinai Hospital and scientist at the LunenfeldTanenbaum Research Institute, both part of Sinai Health System, is the project leader on a major global study called the Crohn’s Colitis Canada GEM

Project (CCC-GEM Project), which stands for Genetic, Environmental, Microbial determinants of Crohn’s disease. The CCC-GEM Project, funded in part by Crohn’s Colitis Canada, The Leona M. and Harry B. Helmsley Charitable Trust and the Canadian Institutes of Health Research, began in 2008. It has since recruited 5,000 people who were healthy but at risk of developing Crohn’s because they have a parent or sibling with the disease. So far 70 have developed Crohn’s. “The idea is that if you study those individuals before and after they get Crohn’s disease, and you compare their microbiome

makeup to someone who does not go on to develop the disease, you’re then in a position to identify what might be the trigger or cause.” The Sinai-led study includes participants in more than 100 sites in Canada, the United States, Israel, the United Kingdom, Australia, New Zealand and Sweden. And what have the researchers found? “We’re just beginning to peek under the hood,” says Dr. Croitoru. “We already have data that show there is a barrier dysfunction, a leaky gut, that exists before disease starts. And we’ve identified a few individual bacteria that seem to be quite

I L L U S T R AT I O N B Y: J E A N N I E P H A N • P O R T R A I T B Y: E D E N B I G G I N

different in people who go on to develop disease compared to people who don’t.” The researchers hope to learn how these important signals relate to the participants’ environmental exposures: their upbringing, diet and lifestyle. Identifying microbes in stool samples has become easier than ever due to major advances in technological expertise. When the study began 10 years ago, analysis involved putting a sample onto a gel and painstakingly examining bands of DNA fragments to identify a microorganism. But with today’s technology, state-of-the-art sequencers can produce a detailed compositional analysis quickly and cheaply. “It used to cost thousands of dollars to do DNA sequencing, but now we can do it for $70,” says Dr. Croitoru. The insights gleaned from the CCCGEM Project are especially relevant in Canada, which has one of the highest rates of IBD in the world. It’s curious that while South Asians who immigrate to Canada continue to have low rates of the disease, their Canadian-born offspring tend to develop the same high rates as other Canadian-born people. “It’s hard to imagine that genetics change in one generation,” Dr. Croitoru says. “It’s got to be something in the environment.” Another study, nicknamed GEMINI, will investigate this phenomenon. The GEMINI study, co-led by Dr. Jen Gommerman, an immunologist at the University of Toronto, and Dr. Croitoru, is currently recruiting healthy first- and second-generation South Asians to compare and contrast their microbiome makeup and study their immune response to their microbiomes. Understanding the microbiome will improve the ability to treat IBD, says Dr. Croitoru. “It’s conceivable that you could be on a microbiome pill long-term, either to prevent disease or to treat it.” He adds, “I hope we’ll have the funding to continue exploring this very precious goldmine of people who have volunteered for our study because they have a lot to teach us.”

“It’s almost like a fingerprint” Gastroenterologist Dr. Ken Croitoru answers our most pressing questions about the mysterious microbiome

What is the microbiome? It’s a term that refers to a very complicated community of microbes that live within our guts or on our skin. Humans depend on these communities for a lot of normal health and physiology. What kinds of microbes does each person have, and how many? More than a trillion individual organisms. The focus has been mostly on bacteria, but that’s not to say that viruses and fungi and other microbes are not important. It’s just that our technology in analyzing those is a little less advanced. How unique is each person’s microbiome? It’s almost like a fingerprint. There’s probably a core of microbes that you find in everybody, and then there are very subtle differences when compared among individuals. What diseases are associated with the microbiome? The strongest links are with metabolic diseases like obesity, diabetes and inflammatory bowel disease, including Crohn’s and ulcerative colitis, which is what we focus on at Sinai Health. There are also links with colon cancer and gut infections like C. difficile. But there are data coming out on heart disease, depression, psychiatric disease, some types of arthritis. People are even looking at eczema, asthma and Alzheimer’s disease, but those are more conjecture right now. What factors determine each individual’s microbiome? We think it’s a combination of genetics and environment. The environmental factors may include the air you breathe, the water you drink, the food you eat, the pets you have, the people you live with and the medications you take, especially antibiotics.

Does where you were born make a difference? Probably, and also how you were born. A vaginal delivery allows you to be inoculated with your mother’s microbiome, and we think that sets the stage for what your microbiome is going to look like. There are studies going on now where obstetricians take vaginal swabs from the new mother and sort of swab the baby after a Caesarean section to see if that makes a difference to their future disease risk. What should we be eating to keep our microbiome healthy? Well, that’s the thing — we’re still trying to define what a normal or healthy microbiome looks like. If you take someone who’s a carnivore and put them on a vegetarian diet, you can see major shifts. The question is, is it a shift toward a healthier microbiome? And that we’re not sure of. There are huge differences in the microbiomes of people with disease and people who are healthy, but it’s a chicken-and-egg story. Does the microbiome contribute to disease or just react to disease? We don’t know yet. Should we be taking probiotics, either in food like yogurt or in supplements? Very few studies show a true benefit of probiotics supplements. One study showed a benefit of one type of probiotic for irritable bowel syndrome, but that’s a very difficult problem to define. Another study showed that a different type of probiotic worked in a very specific circumstance in patients with inflammatory bowel disease, but those results haven’t been reproduced. What about prebiotics? Prebiotics are food substances that are thought to help certain bacteria grow. At the end of the day, it’s not clear whether prebiotics are of any greater benefit than probiotics. What I tell my patients is if you take it and you think it makes you feel better, then fine. There have been no serious side effects other than the fact that it’s costing them money. 17

At the forefront of this exciting field of research is Dr. Miguel Ramalho-Santos, who was recruited this year as the inaugural Chair in Early Human Development, supported in part by a generous gift from lead donor Great Gulf Group, and Senior Investigator at the Lunenfeld-Tanenbaum Research Institute (LTRI), part of Sinai Health System. Dr. Ramalho-Santos grew up in Portugal, received his PhD at Harvard University and started his own lab at the University of California, San Francisco. He has been appointed the Canada 150 Research Chair in Developmental Epigenetics. Epigenetics is the study of how modifications in the expression of genes affect an organism’s development. 18

RAMALHO-SANTOS

Diseases that show up in adulthood may have their start decades earlier. In fact, heart disease, diabetes, neurological disorders such as Parkinson’s and Alzheimer’s disease and some cancers could have their origins in the embryo stage. And while we used to think that all the information needed to generate a human being was hardwired in the genome, there’s growing evidence that environmental factors play a critical role.

DR.MIGUEL

B Y M A R C I A K AY E

MEET

The LTRI’s newest recruit is searching for the genesis of disease — and a new band

P H O T O B Y: J O H N PA C K M A N

It’s this very development of a human being from a single fertilized egg that has long fascinated Dr. Ramalho-Santos. “It’s sort of magical if you think about it,” he says. “It’s just one little cell, but it gives rise to an entire body that has all sorts of specialized cells for different functions.” Over the past 20 years, he has been studying how that happens and why it sometimes goes wrong. His latest exciting research found that “jumping genes,” which seemed to randomly jump around the genome and were long dismissed by scientists as unimportant junk DNA, actually have a critical role in promoting development of the early embryo, even before implantation in the uterus. Dr. Ramalho-Santos is also studying the impact prenatally of external environmental factors such as chemical contaminants or maternal diet. In studying both mice and human embryonic stem cell lines, he’s found that dietary Vitamin C has critical roles in regulating development. “We might think that an embryo is sheltered from the outside world, but that’s not true,” he says. “It’s incredibly attuned to the outside world and all the positive and negative contributions from the environment.” He explains that environmental information imprinted during pregnancy — or even earlier, in the sperm or egg — may create a “memory” that leads to certain diseases in adulthood. His research will continue to shed light on the origins of these common diseases and also holds great promise for better fertility treatments, pregnancy outcomes and women’s and children’s health. Dr. Ramalho-Santos had his pick of several international career opportunities before choosing Sinai Health. “Part of the fascination of being here at Sinai Health, and one of the reasons I’m so attracted to this institution, is the great expertise in place within the maternity clinic here and all the access to clinical data,” he says. “Toronto is clearly a leader in developmental stem cell biology, and it has a community of researchers here that are leaders in their respective fields. It’s such a thriving and vibrant place.” The Canada 150 Research Chairs program, which

provides Canadian institutions with a one-time investment to attract world-class scholars and researchers to Canada, was a further incentive. Dr. Jim Woodgett, Director of Research, is delighted that Dr. Ramalho-Santos chose the LTRI as his new home. “He’s a stellar scientist, he brings expertise in stem cell research to our renowned women’s and infants’ health research group and he will help attract new research talent in the growing field of developmental epigenetics.” Dr. Ramalho-Santos, who has many creative interests, is looking forward to Toronto’s lively cultural scene. The married father of two was involved in theatre in Portugal and has published two books of creative writing. Also, wherever he’s lived, he’s been a drummer in rock bands — which makes him a rock-star scientist in more ways than one.

“

It’s sort of magical if you think about it. It’s just one little cell, but it gives rise to an entire body that has all sorts of specialized cells for different functions.

”

— D R. M I G U E L RA MA L H O - SA N T O S, C HA I R I N EA R L Y H U MA N D E V E L O P M E N T

BREAKING DOWN BARRIERS B Y M A R C I A K AY E

The idea that collaboration is integral to how we care for people has come about directly as a result of these conferences. — Dr. Mark Lachmann, Medical Lead

The way mental health care is delivered in Canada has been changing. While the old model from 20 years ago involved a primary care physician struggling to access a psychiatric consult for a patient, today the emphasis is on collaboration among a variety of health-care providers. This means that people living with mental illness, addictions or dementia, as well as their doctors, have greater access to a network of health-care support, such as social workers, psychologists, dietitians and pharmacists. This focus on collaboration is largely due to the Canadian Collaborative Mental Health Care Conference, which this year was co-planned and co-hosted by geriatric psychiatrist Dr. Mark Lachmann, Medical Lead at Bridgepoint Active Healthcare, part of Sinai Health System. (The other co-host was Toronto family physician

Dr. Abbas Ghavam-Rassoul.) Held annually since 2000, the conference aims to break down barriers and integrate mental health-care professionals into the community, where they’re most effective. “Over its lifetime, the conference has been instrumental in changing the language and the practice of supporting access to mental health care,” says Dr. Lachmann. The theme of the 2018 conference was Collaborating Across Cultures, referring both to ethnic and gender diversities as well as professional and organizational cultures. “Sinai Health made a tremendous financial contribution, and the donors certainly helped facilitate that,” Dr. Lachmann says. More than 300 people attended, from across Canada and the United States and from as far away as Argentina.

THE 2019 CONFERENCE TAKES PLACE IN VANCOUVER.

HOW SINAI HEALTH IS BRINGING MENTAL HEALTH CARE INTO THE COMMUNITY Vulnerable seniors in Toronto’s east end are receiving the supports they need to stay in their homes, thanks to a collaboration between geriatric psychiatry care and community social workers. Instead of making seniors with mental health problems go to a psychiatrist’s office, Dr. Lachmann holds weekly clinics at Woodgreen, one of the city’s largest social service agencies, and does home visits with Woodgreen’s social workers. He also mentors and supports social workers through monthly sessions to discuss complex cases.

A mindfulness meditation program at Bridgepoint is one of the first programs of its kind in a rehab hospital setting. The Interpersonal and Mindfulness (IaM) Group aims to help patients cope with the challenges of a life-changing injury or illness. Run by psychiatrist Dr. Seema Khan, spiritual care manager Iryna SolukFigol and mental health nurse Sue MacRae, the three-year-old program is a rousing success. “People love it,” says Dr. Lachmann. “It de-medicalizes people and allows them once again to be individuals.”

A program for caregivers of family members with dementia helps them not only navigate the system but receive support when they’re feeling anxious, depressed or overwhelmed by their caregiving duties. Heading up the program, which involves one-on-one and group support, is family physician Dr. Leslie Nickell, Medical Lead of Caregiver Support Services at Bridgepoint. Caregivers are encouraged to download the free mobile app Dementia Advisor (see page 8), which teaches coping skills and stress reduction.

A long-term mentoring program linking family physicians with psychiatrists and psychotherapists, in person and online, provides a team of quality care to the patients, but also supports the family doctors, for whom dealing with ongoing complex cases can be challenging and stressful. The program is led by psychiatrist Dr. Jon Hunter, Pencer Family Chair in Applied General Psychiatry at Sinai Health and Head of the Consultation-Liaison Service at Mount Sinai Hospital.

Senior psychiatry residents at the University of Toronto now receive direct experience in a primary care or community agency. While collaborative mental health care is mandatory for all psychiatry trainees in Canada, this program, run by family physician Dr. Kristina Powles, gives residents community-based training and gives sites improved access to specialist care.

I L L U S T R AT I O N S B Y: JEANNIE PHAN

BY DR. JON HUNTE R AN D D R. B O B M AU N D E R

We are psychiatrists who hear the stories of critically ill patients. As a result, we often have a unique perspective on what works well and what doesn’t for people who are treated at Sinai Health System, whether for a sudden, unexpected health event or for a chronic or life-threatening illness or injury.

prioritize self-reliance. These styles of attachment play a critical role in shaping the dynamics of all kinds of relationships, including those we form with our health-care providers and caregivers.

We listen, especially for two things — patients’ past experiences with illness and their attachment style, which means how they manage relationships with others in order to feel secure during times of fear or stress. These two things help us understand the struggles they’re having with their illness or their treatment.

Our relationships have a powerful influence on health. For one thing, whether a patient is wary of health-care providers or views them as trusted confidantes influences their care. Because patients manifest these different styles, needs and strengths at times of illness — and in fact these factors are often intensified by illness — a one-size-fits-all approach to providing health care just doesn’t work very well.

Everyone has a kind of comfort zone when it comes to attachment. In times of fear or stress — such as during an illness — people may fear being alone and seek out support and care from others, or, on the other side of the spectrum, avoid others and

For years, we have been meeting with each other every Monday to talk about our experiences with patients in order to figure out how to use these insights to improve patient care. It goes something like this… 23

S I N A I H E A LT H M A G A Z I N E

JON: There was a patient on the oncology service a while back, Arlene*. I remember her, especially because we had such a slow start. When I first went in to see her, her head was propped up on the pillows and she was just staring across the room. She didn’t acknowledge me at all. She looked frustrated and very tired. She was 43 but she could’ve easily passed for 15 years older than that. I introduced myself as the psychiatrist on the cancer team and told her they often ask me to see patients in hospital, to see if I can help. Her answer was sarcastic. She said “Great” with an obvious edge to her tone, so we had a really short conversation. I didn’t want to start our relationship by ignoring the cue to leave her alone. I was asked to assess if she was depressed, but it was quickly apparent that she wasn’t. Arlene had quite a range of feelings, but mostly she was angry — and with good reason. She mistrusted the doctors and nurses

BOB: I didn’t know that was a risk.

— D R. BO B MA U N D E R, C HA I R I N H EA L T H A N D B E H AV I O U R A N D D E P U T Y P S Y C H I A T R I S T- I N - C H I E F

who were caring for her, and they had their doubts about her too. But I’m getting ahead of myself. All I knew after that first meeting was that she was frustrated and not keen to talk to me.

was asking for pain medication too often. Mia didn’t think so, but I could see from her facial expression and hear in the tone of her voice that she was starting to lose patience too.

So I spoke with Arlene’s primary nurse. I’ve worked with Mia* for years; she’s really experienced and very caring. She told me the nurses were concerned about Arlene, and that they needed some help. Mia told me that Arlene was crusty with everyone on the team; she tended to fend everybody off as she had me. She was fussy about the details of her care and quick to point out small errors.

BOB: So what happened?

BOB: That’s not unusual — being in hospital for cancer treatment does not bring out the best in people — but they wouldn’t call you if that was all that was going on. JON: Exactly. Something was interfering with Arlene recovering from treatment but the team couldn’t figure out what it was. Mia thought that Arlene was not putting any effort into trying to recover. That’s what made her wonder if she was depressed. Arlene was barely talking to the physiotherapist and not even attempting the exercises that she had been taught. Some of the other nurses and the surgical resident also thought that Arlene

JON: It isn’t common, but it happens. Logically, Arlene accepted that the new cancer was essentially bad luck. But once she was back in the same environment where her first cancer was treated there were a hundred reminders to trigger emotions and connect the previous experience to the current one. Without even being aware of it, out beyond the logical part of her brain, another idea was gaining strength: “You did this to me.” That idea made it hard to trust the team.

BOB: Persistence pays off.

BOB: So when things were at their most stressful, Arlene’s most comfortable position was to keep everyone at a bit of a distance. She was taking control of her circumstances as best she could by pushing back.

JON: Maybe. Later on she said that it made a difference that I seemed more interested in figuring things out with her than in defending my colleagues, so coming without an agenda of my own helped too.

JON: Right. I’ve come to know that Arlene feels most secure when she has a little “breathing space” between herself and others. She needs support — everyone does — but she is cautious about letting others get close.

Once she was talking, I learned that this was not Arlene’s first rodeo — she’d had treatment for lymphoma 20 years ago. She was a young single mother at the time and under a ton of strain. That experience was really important now because at an emotional level, she couldn’t help but cross-reference the two treatment episodes. The lymphoma had required surgical biopsy, radiation therapy and chemotherapy. The radiation played a significant role in her cure, but also had probably contributed to the development of the breast cancer she had now.

Unfortunately, there were also other factors contributing to the tension. Arlene’s medical record indicated that years before she’d had a problem with addiction to painkillers. She was proud that she had put it behind her. However, when tensions started to rise between Arlene and her nurses, her history of addiction also evoked mistrust. Some of Arlene’s care providers started to doubt the validity of her reports of pain.

JON: I went back to see Arlene a couple of times, trying not to overstay my welcome but persisting. She gradually started to share her story.

When Arlene interacted with her health-care providers, each person was a little wary of the other, which created distance in their interactions at precisely a time when Arlene needed support.

BOB: Arlene’s experience illustrates how health care is complicated because it usually takes place between people who don’t actually know each other very well. It sounds like you and Arlene figured out what was going on fairly quickly. But it would have taken longer or not happened at all without appreciating the backstory that made sense of the tense interactions. JON: Even though the tensions between Arlene and the oncology team were never dramatic, they had consequences. The anemia that explained why she was so lethargic, for example, took a little longer to discover because the team was slow to realize that her complaints of fatigue were valid and were valuable information. Mia said it helped when I told her and the physiotherapist what I thought was going on. BOB: There is no recipe for how to make it better for every patient, every time. But there are many steps we can take that improve things.

P O R T R A I T S B Y: E D E N B I G G I N

JON: Sometimes very small things can make a difference. I always think of that study where they found that if they attached a photo of a patient’s face to the requisition for a CT scan, the radiologists’ reports were more accurate. Little connections to real people make a difference.

BOB: That connection can also happen by asking about a person’s past experiences. We know that health-care professionals are hesitant to ask about harmful experiences in the past, but we also know that these experiences are very common and that they influence a person’s health throughout life, especially experiences of abuse and neglect during childhood. If we don’t ask, we don’t get to hear a part of a person’s story that might matter a lot. JON: I have been thinking about how we medicalize problems when a person comes into hospital. A guy comes into the Emergency Department because he has a life problem — say he doesn’t have the strength to climb the eight stairs between his living room and bedroom. As we investigate we start to see this as a medical problem: The tests show that his heart is not pumping blood well enough to bring oxygen to his leg muscles. We have technical terms to describe that problem, evidencebased guidelines to treat it and specific tests to know if our treatments are improving his heart function. Somewhere in that process, it can happen that people forget to ask him how he’s doing with the stairs.

to know themselves — their strengths and vulnerabilities, their coping style, how they prefer to interact. We all sort of know ourselves, but we usually have no way to know how we compare to others, or if our difficulties are severe enough to need some attention. JON: Right. Like the studies that show that if university students are given clear feedback about how their drinking habits compare to social norms and healthy limits, they tend to adopt healthier patterns. BOB: What happened with Arlene?

JON: In the end I suggested that it might help to meet with me for a few visits after she was home from hospital, just to troubleshoot anything that came up. Once at home, she felt more independent, which is how she likes it, so it was easier for her to cope. She was much more open to discussion by then, and I came to appreciate just how resilient she is. She didn’t need to see me for long but she stays in touch. She even drops in on the 11th floor to see Mia and the other nurses when she’s back at Mount Sinai for a check-up. She really appreciated their help.

BOB: Another thing that we can do is to help people

Dr. Jon Hunter holds the Pencer Family Chair in Applied General Psychiatry at Sinai Health System and is Head of the Consultation-Liaison Psychiatry Service and of Psychosocial Services at the Marvelle Koffler Breast Centre. Dr. Bob Maunder holds the Chair in Health and Behaviour at Sinai Health System and is Deputy Psychiatrist-in-Chief. Both Dr. Hunter and Dr. Maunder are shining a spotlight on the relationships between people that are at the core of all health care through research, advocacy, education and system change. Their shared goal is to improve working relationships between patients, their families and health-care professionals.

Arlene and Mia are pseudonyms. All identifying information has been omitted, changed or obscured. 25

On a fall day in 2012, 35-year-old Tara Smalley was watching “The View” when Barbara Walters introduced a topic that grabbed her attention — breast cancer screening. “I started thinking about it. A lot of people in my family have gotten cancer very young, and my grandmother on my dad’s side had breast cancer.” When she told her doctor about her family’s cancer history, Tara was quickly referred to the Marvelle Koffler Breast Centre (MKBC) at Mount Sinai Hospital, part of Sinai Health System, to have her risk assessed. Because of their strong family history, she and her sister, Nicole, were both eligible for early screening, including both mammograms and breast MRIs. Annual screening quickly became a reassuring routine. So 44year-old Nicole Smalley-Lester had no worries when she walked into the MKBC for her appointment on February 6, 2017. That started to change on February 7, when Nicole’s family doctor called on behalf of the MKBC staff team. Nicole’s mammogram had been clear, but her MRI detected a suspicious mass. “She told me it was probably nothing,” Nicole recalls. “But the fact that they reached out so quickly made me wonder.” When Nicole returned to Mount Sinai the following week, she learned that the mass was a tumour, and that it was almost certainly cancer. On February 21, she was officially diagnosed with aggressive stage 2 “triple negative” breast cancer — a type of tumour that needs to

P H O T O S B Y: J O H N PA C K M A N

BY H EATH E R GI BSON

TARA (L) AND NICOLE WITH THEIR FAITHER, MIKE

The Smalley sisters, Nicole (left) and Tara (right) with their father, Mike

be treated with aggressive chemotherapy instead of more commonly used breast cancer drugs. Nicole remembers her surgeon, Dr. Jaime Escallon, advising that they needed to start treatment quickly: “He said triple negative is a tricky one.” Nicole says she will never forget the moment she shared the scary news with her two boys Logan (now eight) and Tristan (now 10). “Tristan tried to be very brave,” Nicole recalls through tears. “But Logan was trying really hard not to cry, and asked if my cancer was ‘the dying kind.’ I couldn’t say anything, I just shook my head ‘no.’” She hoped she was right.

Searching for the trigger After Nicole’s diagnosis, both sisters underwent a blood test to look for genetic mutations that increase cancer risk. The test found that both women have a CHEK2 mutation, which is estimated to double or even triple breast cancer risk, and could also boost their chances of developing other cancers. “The majority of breast cancers are not caused by inherited genetic mutations,” says MKBC Genetic Counsellor Carolyn Piccinin. “But in Nicole’s case, given her young age, her diagnosis with triple negative breast cancer and her strong family history, we suspected that we might find a cancercausing mutation. Because our genetics

team works closely with the high-risk breast screening program, we were able see her for genetic testing quickly after her diagnosis, and identified the CHEK2 mutation.” That same mutation would also pose an ongoing risk to Tara’s health, as well as any other carriers within the family. So once the mutation was found in Nicole and Tara, the MKBC genetics team encouraged them to speak to their parents about getting tested. Knowing where the mutation came from would help others in the family to make informed health decisions. The family learned Nicole and Tara’s dad, Mike Smalley, also carried the genetic mutation.

cancer risk can be identified through ground-breaking research like this.

“When I told Nicky and Tara I was the carrier, I felt an immense amount of guilt,” says Mike. “I’m no stranger to cancer. My mother had breast cancer twice, my father died from liver cancer and my brother had leukemia and died at 44. But for some reason it’s completely different when it’s your child.” “Guilt is very, very common when parents find out they passed a mutation to their child,” says Piccinin. “As genetic counsellors, we try to explain that we don’t have any control over what genes we get or what genes we pass to our kids.” Fortunately for the Smalleys, advances in technology and research have improved genetic testing. Not long before Nicole and Tara were tested, the standard genetic test only looked at two genes linked with breast cancer — BRCA1 and BRCA2. Had the sisters been tested then, their tests would have come back negative.

“Genetic testing is constantly improving. People who tested negative just a few years ago might have a more accurate result if they got tested today. And people who test negative today might get an even more informative result in five or 10 years when we know more. We encourage all our patients to keep in touch to make sure they’ve had the most up-to-date test available,” Piccinin adds. The impact of more advanced genetic screening is potentially lifesaving for patients like Nicole and Tara whose genomes contain important information about their future health. “If I hadn’t been getting early screening at Mount Sinai, my cancer wouldn’t have been found until it was too late,” says Nicole.

Planning for her future: Tara’s story Nicole was quickly booked for surgery to remove the lump in her breast. The whole family was focused on her upcoming procedure. Like her parents, Tara was terrified for her sister. But she also felt a growing anxiety about her own health.

“For more than 20 years, most genetic testing for familial breast cancer looked at only BRCA1 and BRCA2,” says Piccinin. “Now we know there are many genes that can cause an increased risk of breast cancer, and we can offer multi-gene panels that include these newer genes like CHEK2. With panels now becoming standard practice, we’re also learning more about what mutations in these genes mean for women and families.”

“The moment Nicole was diagnosed, everything changed,” Tara recalls. “I couldn’t help but feel the day would eventually come when my mammogram would find cancer too.”

Scientists and genetic counsellors at the MKBC are collaborating on a new research project to screen the entire genome of patients who have had cancer and have a strong family history of cancer — spanning all of an individual’s roughly 20,000 genes. It’s hoped that even more genes linked with

After her exam, Tara dropped into the MKBC to ask the team about whether she’d be eligible for a prophylactic double mastectomy, the surgical removal of her breasts to prevent breast cancer.

Tara knew her lifetime risk of developing breast cancer was at least two or even three times higher than the average woman. The day she had her mammogram — coincidentally, the same day as Nicole’s surgery — she realized she wanted to take control of that risk.

“A preventative mastectomy is a very big decision and is not a one-size-fits-all choice, but at Tara’s level of risk, it is an option and she was quite motivated to pursue it,” says Piccinin. “We referred her to a surgeon to talk with her and help her make her decision.” “To some people it sounds dramatic, but for me, it was an easy decision to make,” says Tara, who has since undergone both a mastectomy and breast reconstruction. “All my friends get annual mammograms, and I’ll never have to do that again. But I know a few women who have been diagnosed since my surgery and I’ve had moments of feeling guilty that I got to make that choice.”

Whole-person care While Tara was getting the last mammogram she would ever have, Nicole was prepping for her surgery. But when it came time to map the tumour’s margins for a precise removal, the ultrasound technician paused. Nicole’s breast had more masses than her mammogram and MRI had found. Nicole’s scheduled surgery was a lumpectomy — intended to remove just her tumour while leaving the rest of her breast intact. In the final minutes leading up to her procedure, Nicole and Dr. Escallon discussed their choices. While Nicole realized she’d feel safer if Dr. Escallon removed her entire left breast, it was a dramatic shift in their original plan. The surgery went smoothly. But Nicole woke up feeling shocked and distraught about the unplanned loss of her breast. As her anesthetic subsided, she cried on her nurse’s shoulder. In the days that followed, she buried her sadness and steeled herself in anticipation of an aggressive schedule of chemotherapy — eight rounds under the guidance of Dr. Pamela Goodwin, Director of the MKBC and the Marvelle Koffler Chair in Breast Research. “I was in my first chemo treatment when Trisha checked in on me,” says Nicole. A social worker in the MKBC, Trisha

Woodhead had already met Nicole during her first consult with her interdisciplinary team. “She asked how I was doing, and I tried to smile. I remember feeling like, if I stopped smiling, I didn’t know what would happen to my world.” Woodhead recognized the look on Nicole’s face and the tone of her voice: “She told me I needed to let myself grieve.” To help Nicole through her experience, Woodhead connected her with Dr. Jon Hunter, a Mount Sinai psychiatrist and Head of Psychosocial Services in the MKBC who specializes in supporting patients through life-threatening health challenges. When her chemotherapy and radiation were over, Nicole went to see Dr. Hunter. “After treatment ends, you’re more on your own. Seeing Dr. Hunter then worked out perfectly because that’s when I needed it most. Dr. Hunter completed the cycle of holistic, integrated care at Mount Sinai.”

After cancer Today, with Nicole’s active treatment done, she’s considered cancer free. But she’s not done with Mount Sinai. In late 2018, Nicole underwent another surgery. Along with the reconstruction of her left breast, surgeons also removed her still-healthy right breast — which, like her left breast, will be reconstructed over time. The result of the surgeries is a dramatic reduction in Nicole’s risk of ever experiencing breast cancer again. She still sees Dr. Hunter. She also visits Mount Sinai for colorectal and thyroid cancer screening — since her CHEK2 mutation may heighten her risk for those cancers as well. But even as she prepares to move forward with her life after cancer, she knows she’s still part of the Mount Sinai family.

Nicole cherishes her two charm bracelets — one each from her sons Tristan and Logan. After surgery, Nicole’s boys each gave their mom a charm with their initial. Then the boys added a new charm for each round of chemotherapy and each week of radiation therapy. Each charm reminds Nicole of her sons’ love and support.

“I’ll never stop going back to visit the Koffler Centre,” says Nicole. “No one has told me ‘you’re done now.’ I’ll always be part of the family there. “It’s a special place,” she adds. “It’s where humanity is at its best.”

S I N A I H E A LT H M A G A Z I N E

Artist Julia Seo used layers of card stock and Korean hanji paper to create a 3-D representation of an intestinal organoid used in Dr. Jeff Wranaâ&#x20AC;&#x2122;s lab to study the progression of cancer.

B Y PA T R I C I A H L U C H Y

In the wake of game-changing developments — such as the

Peek inside the toolkit of researchers at the ltri to learn how today’s most exciting biomedical technologies — organoids, optogenetics, crispr — are powering research

Human Genome Project, which

th e n ew powe r tools of m e dical research

dramatically improved the efficiency

identified and mapped more than 20,000 individual genes in humans, and next-generation DNA sequencing, technology which and lowered the cost of genome mapping — the field of biomedical research has undergone staggering growth over the past two decades. Scientists at the LunenfeldTanebaum Research Institute (LTRI), part of Sinai Health System, are leveraging a revolution in biomedical technologies that is yielding an ever more intricate understanding of how the human body, and its diseases, work. Three of the latest technologies that are transforming research are organoids, optogenetics and CRISPR — if you haven’t heard of them yet, you certainly will in the months and years to come. Here, we talk with four world-class LTRI researchers who are using these hugely exciting innovations to answer crucial questions including: What happens when cancer starts and grows? How do brain disorders develop? And how can we regenerate tissues or develop drugs tailored to a specific patient’s disease? 31

ORGANOIDS: MINI ORGANS IN A DISH Organoids are cells grown from human or mouse organ tissues to create simplified, three-dimensional mini organs that possess some of the same structures and functions as their real counterparts. The Scientist Magazine named organoids one of the biggest scientific advances of 2013, and since then the field has snowballed rapidly. Organoids help researchers understand tissue development and study disease directly by using a patient’s own tissues, which allows for the possibility of personalized medicine.

Q: TELL US ABOUT YOUR WORK WITH ORGANOIDS.

Dr. Jeff Wrana, CIBC Breast Cancer Research Scientist and the Mary Janigan Research Chair in Molecular Cancer Therapeutics at the LTRI, aims to expose the communication networks that control how these complex structures form and how disturbances cause disease. He creates organoids to understand the progression of cancer and how to regenerate tissue.

Q: WHICH BIG QUESTIONS ARE YOU USING ORGANOIDS TO EXPLORE?

I M A G E C R E D I T: D R . M A S A H I R O N A R I M AT S U

An intestinal organoid from the lab of Dr. Jeff Wrana. Dr. Wrana’s team uses organoids like these to study how organs regenerate after injury and how colorectal cancer initiates and grows. 32

Dr. Wrana: With sequencing of the human genome, you basically went from a sailing ship trying to find new land to a satellite that showed you the entire Earth. And then the challenge became, OK, what do all the genes do and how do they all interact with each other and make a human, which led to the discovery of stem cells. And what goes wrong with cells globally and not just on a single-gene level when people get a disease? We started to study how proteins, which are the functional product of our genome, communicate between cells and instruct them on how to become a liver cell or a kidney cell. This work provided a toolkit that has driven an explosive area of biomedical research, where we can take stem cells and get them to make different kinds of organoids.

Dr. Wrana: One is how cancer initiates. The second is, how do tissues regenerate? The intestine has a tremendous turnover capacity: We turn over our intestinal lining every two to three weeks. The kidney has a limited regenerative capacity. So we’re interested in trying to compare and contrast those two tissues. We’re applying some remarkable new technologies that allow us to profile, basically, all individual cells in a tissue, and this gives us remarkable insight into how organs respond to injury. And because the organoid is in a dish, it’s much easier to do those experiments than if you were trying to do it in the context of a whole animal, like a mouse. And what we discovered, actually, is taking some cells out of a tissue and then making them grow for a couple of weeks in a dish — that’s basically regeneration. Also, you can grow an organoid in a dish and knock out a gene in the dish and see

what happens in terms of tumour initiation and regenerative capacity. What are the signals that are controlling these processes, and how can we exploit them to identify potential targets for new therapies? In our recent work, we discovered a new cell type that arises when we damage the intestine, and it seems to be critical to repair damaged intestine. Now we’re really interested in whether this cell type is also present in tissues with limited regenerative capacity, like the kidney, and whether we might be able to activate it to improve repair. Q: HOW MIGHT ORGANOIDS ONE DAY IMPROVE PATIENT CARE?

Dr. Wrana: One example of what we’re working on is glioblastoma, the devastating tumour that Gord Downie, lead singer of The Tragically Hip, recently died from. So now we’re taking human cerebral organoids — mini brains — and growing glioblastomas in them so we can understand how the glioblastoma and the normal human brain tissue are interacting with each other. This could be a really important model to screen for new therapeutics. Q: ARE THERE ETHICAL CONCERNS AROUND THE USE OF ORGANOIDS?

Dr. Wrana: With cerebral organoids, there is considerable discussion with respect to ethics. At what point does brain tissue become truly human brain-like? At what point is there consciousness, or pain? But it’s important to remember that at this point in the technology, these are really tiny pieces of tissue in a dish — they’re only a millimetre in diameter and have nowhere near the complexity of even a mouse brain, let alone a human brain. Q: WHAT’S MOST EXCITING FOR YOU ABOUT THIS RESEARCH?

Dr. Wrana: The discovery of a new cell type critical for regeneration. I gave you the analogy of going up into a satellite. Now it’s like being above the solar system, looking at this exquisite global view of tissues but also seeing it at the single-cell level. It’s blowing my mind.

OPTOGENETICS: CONTROLLING BRAIN MOLECULES WITH LIGHT The most complicated structure in the known universe, as it’s often described, the human brain is one of science’s final frontiers. Researchers still have limited understanding of the workings of its tens of billions of cells — called neurons — and the ways they communicate with each other through synapses, or of its diseases and disorders. Historically, scientists stimulated the brain with electrodes to study its activity, but that proved to be a crude tool. Now, with optogenetics, everything has changed. The technology makes targeted neurons light-sensitive and then activates those cells with light. And it has ushered in a whole new era of brain study.

Q: TELL US ABOUT HOW YOU ARE USING OPTOGENETICS TO UNDERSTAND MEMORY.

Dr. Okamoto: With optogenetics, we’re able to directly study memory function in mice at the level of neurons and synapses, which are critical for memory. In particular, we target signalling pathways, which are molecules in synapses that act as messengers between neurons. These signalling pathways are hot drug-discovery targets for brain disease. Optogenetics allows us to control the function of a target molecule with light, which means you can immediately turn critical molecules in the brain on or off, much as you would with a light switch. To do this, we inject live mice with a nontoxic virus that generates a light-sensitive molecule in the target neurons. Then we insert two optical fibres with LED lights at the tip into each hemisphere of the mouse’s brain. We do some mouse learning tests to see what happens when you break or activate signalling pathways for a specific time in the target neurons of the brain, to find out how these pathways are critical for memory. We use a unique-to-us custom microscope equipped with infrared laser light to trigger target molecules in synapses in deep regions of the brain.

Q: WHICH BIG RESEARCH QUESTIONS IS OPTO GE N ETICS H E LPI NG YOU EXPLORE?

Dr. Okamoto: Using our unique optogenetics approaches, we are trying to address the molecular mechanisms that encode learning and memory in the brains of mice and, by extension, humans. We revealed the inter-synaptic functions of these signalling molecules for the first time and are currently studying how these mechanisms function for learning and memory compared to other systems, such as computers. We hope to find out what role these molecules might have in Alzheimer’s disease, autism and schizophrenia. Q: HOW WILL OPTOGENETICS INFLUENCE CARE FOR BRAIN DISEA SES A N D D I S O R D E RS I N TH E FU T U R E?

Dr. Okamoto: Drugs that activate the signalling pathway that we are studying do exist, and they are now being used to treat heart failure. It is a critical pathway for brain function too, but the drugs don’t work well in the brain. So we are hoping to use optogenetics as a new therapeutic tool because it enables us to precisely control the timing and duration of the signalling effect. With optogenetics, we will be able to maintain the effects for a very long time compared to the more traditional chemical, pharmaceutical approach.

I M A G E C R E D I T: J E L E N A B O R O VA C

An Investigator at the LTRI, Dr. Kenichi Okamoto has propelled optogenetics to the microscopic level, using infrared lasers to trigger target molecules critical for brain functions such as learning and memory. He hopes this work will lead to greater insight into a variety of neurological disorders.

A microscope image from Dr. Kenichi Okamoto’s lab of a brain slice showing expression of a light-activated protein in green. The expression of this protein was targeted to the dentate gyrus because this area of the brain is crucial for memory formation.

Q: ARE YOU WORKING ON ANYTHING ELSE IN THE REALM OF LEARNING AND MEMORY?

Dr. Okamoto: We are also trying to establish sensors to monitor target molecules in the living brains of freely moving animals. In combination with a tiny micro-camera system, we will be able to watch the effect of optogenetics to precisely determine the effective light strength or duration of the photoactivation for learning, memory and related therapeutic functions.

CRISPR: “ESSENTIALLY A PAIR OF SCISSORS” CRISPR is a powerful gene-editing tool that can change the genome in any species, including mice and humans. Science magazine’s 2015 Breakthrough of the Year, CRISPR — an acronym for the process whereby bacteria use proteins to break down the DNA of attacking viruses — allows scientists to quickly, cheaply and very precisely target and induce mutations in any of our 20,000 genes. Which means it holds the promise of treating an array of health conditions and diseases caused by genetic mutations. Dr. Daniel Durocher, Thomas Kierans Research Chair in Mechanisms of Cancer Development and Assistant Director of the LTRI and the Canada Research Chair in Molecular Genetics of the DNA Damage Response, studies how cells detect and repair damage to their DNA. He aims to understand how normal cells become cancerous. Dr. Daniel Schramek, Kierans/Janigan Cancer Research Scientist at the LTRI, focuses on the mutations and genes responsible for the development of cancerous tumours and their progression through metastasis. He has developed a new technique that uses CRISPR to weed out the random genetic bystander mutations and identify the ones critical for cancer.

Q: HOW ARE YOU USING CRISPR IN YOUR RESEARCH?

Dr. Durocher: My team is trying to disrupt the function of each gene in the human genome, one by one, and ask, “If we remove this gene, are we impacting the response to DNA damage, DNA repair and DNA damagesignalling events?” We use CRISPR to do this in a cell culture dish, and we use next-generation sequencing technologies. CRISPR is essentially a pair of molecular scissors that allows you to cut DNA at will. And we’ve been able to design a strategy to improve CRISPR. Dr. Schramek: What we’re doing is similar to what Dr. Durocher is doing, but we do it in mice rather than in cell culture. While we are limited in the number of genes we can interrogate in a mouse, the animal gives you more of a physiologic context compared to a cell culture dish. When a tumour grows in an organism such as a mouse or a human, you’ve got 20 to 30 different cell types, including immune cells, blood cells, lymph cells. So when we start to model tumours in vivo, the advantage is that we are looking at the interactions of all these cell types together. When a patient comes to the clinic with a tumour, and the tumour is excised and sequenced to see which mutations it harbours, it turns out that a normal patient’s tumour carries about 200 gene mutations. But it’s not clear which handful of these 200 mutations are actually the driver genes of this tumour and which are just passenger mutations which randomly accumulate as the tumour grows. We can take these 200 genes and destroy them one by one in an organ of a mouse and see which of them give rise to a tumour. CRISPR makes it much, much faster and cheaper to do this. Now, our team has built a system where we take a pregnant mouse and inject the embryonic sac with a virus that carries the components of the CRISPR machinery. Then we reinsert the embryo, and when the baby is born it now carries these mutated genes and the mouse develops a tumour. We can do this for about 500 genes in a single mouse. Q: WHICH BIG SCIENTIFIC QUESTIONS ARE YOU USING CRISPR TO EXPLORE?

Dr. Durocher: I’m trying to understand how cells protect their genetic information, which is essentially written on the DNA — how cells deal with broken DNA, how they repair it and how they tell the cell that there’s broken DNA. In oncology this is very important, first because you can boil down cancer to a disease of DNA that has been broken and mutated and where there have been errors in putting it back together. And second, it’s relevant because a lot of cancer therapies work by damaging the DNA. We ask a simple but important question: Which genes and gene products — proteins — are involved in repairing and signalling DNA damage? We will only understand how to defeat cancer when we understand how cells — normal cells or cancer cells — take care of their DNA because cancer is caused by changes in the makeup of the DNA. In our research we have discovered the function of proteins that are key to the efficient repair of DNA damage.

I M A G E C R E D I T: E L L E N L A N G I L L E

Watch The Making of Sinai Health Magazine » youtube.com/sinaihealthsystemca

This photo from Dr. Daniel Schramek’s lab shows a mouse infected with CRISPR viruses. The coloured patches represent clones where specific genes have been destroyed. This allows Dr. Schramek’s team to identify which genes may play a critical role in cancer development.

V I D E O B Y: 3 0 0 4 S T U D I O S

Dr. Schramek: My lab is looking at which genes in breast, brain and head and neck cancers are actually responsible for these tumours developing and metastasizing. We know that no two cases of, say, head and neck cancer have the same mutations. But we’ve discovered in 60 per cent of instances of head and neck cancers the mutations affect the same pathway, which is a sort of communication network within cells. Q: HOW DO YOU THINK CRISPR WILL IMPROVE PATIENT CARE?

Image of a human cell in culture in the process of cell division. Dr. Daniel Durocher and his team routinely use tissue culture cell in CRISPR experiments to study processes that influence cancer. I M A G E C R E D I T: D R . N I C O L E H U S T E D T

Dr. Durocher: As we uncover more and more knowledge about the making of cells and how cancer exploits this biology, there’s the possibility of new cancer treatments tailored to the exact genetic makeup of a particular tumour. Two years ago I co-founded a company, Repare Therapeutics, that is based on that premise. We think we will have products ready for trials in 2020. Q: WHAT ARE THE ETHICAL IMPLICATIONS OF THIS TECHNOLOGY?

Dr. Durocher: This kind of precision will require essentially reading the genetic makeup — the DNA — of individuals. So, it will be costly, which raises the issue of accessibility to such treatment. Then there are considerations related to the privacy of genetic information used for tailoring a treatment. I certainly wouldn’t want my genetic information to get into the hands of anyone, like marketers.

Dr. Schramek: Since we are applying the technology in mouse models rather than cell cultures, the ethics are more complex. The truth is that without animal research, we will simply not have any new cures; we wouldn’t be able to test a new drug or therapeutic strategy before going into humans. But equally important is that we conduct this research according to the highest ethical standards, which means things like minimizing the number of animals we use and avoiding any pain or suffering to them. Also, and I think everybody in Canada and the U.S. is very clear on this, CRISPR should not become a tool for creating designer babies, which scientifically we do not know how to do — yet. Q: ANYTHING ELSE YOU WANT OUR READERS TO KNOW ABOUT CRISPR?

Dr. Durocher: I read a futuristic science fiction book called Seveneves last summer. They were doing gene editing in the novel, but we’re already way past the pretty primitive way the book described it. This field is moving so fast that science fiction has problems keeping up. Dr. Schramek: Well, CRISPR technology actually comes from milk industry research into yogurt, which is a reminder that most scientific discovery comes from the unexpected.

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The professionally developed Adult Day Program is designed to support participants’ cognitive, physical, emotional, spiritual and social needs. Each day, participants are met by a compassionate and highly qualified team of nurses, social workers, recreational therapists and health-care aides. The program provides: hot, kosher meals and snacks; escorted door-to-door transportation; medication and toileting assistance; evidence-based recreational and cultural activities and counselling, education and support for caregivers.

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Support Sinai DAV I D AN D STAC E Y C Y NA M ON R E NOVAT E STAFF L O U N G E I N S C H WA R T Z/R E IS MA N E M E RG E N C Y C E NT R E

A new lounge for staff of the Schwartz/Reisman Emergency Centre opened in October, thanks to a generous donation from Sinai Health Foundation Board Co-Chair David Cynamon and his wife, Stacey. As part of Renew Sinai, the largest and most ambitious redevelopment project in Mount Sinai Hospital’s history, the Schwartz/Reisman Emergency Centre is being completely reimagined — and nearly doubling in size — to transform care for the nearly 60,000 patients treated there annually. Knowing how critical the lounge is for staff, especially in a high-traffic, high-intensity patient area like emergency, the Cynamons stepped in to provide a revitalized space for staff. “The emergency department is truly one of the busiest places in the hospital and the staff here deserve the world,” said David Cynamon. “Renovating and updating this space was the least we could do to give the incredible staff here a nice, clean space where they can relax on their breaks.” Stacey Cynamon and her colleague Celia Pasternak were very involved with the design of the space and included many thoughtful touches, including leather recliners for staff to put up their feet between busy shifts, a flat screen TV and new kitchen appliances.

David Cynamon, Board Co-Chair, Sinai Health Foundation, with his wife, Stacey, inside the new Emergency Department staff lounge.

GR EAT GULF GRO UP H E LPS ESTABLISH N EW CHAI R I N EA RLY H UMAN DEV E LO PM E NT

This year, a new Chair in Early Human Development at the Lunenfeld-Tanenbaum Research Institute (LTRI), part of Sinai Health System, was established thanks to the generosity of lead donor Great Gulf Group, co-founded by Harry Rosenbaum, Principal. Their generous gift reflects Great Gulf Group’s commitment to giving back to the health of Torontonians and the city they are helping to grow.

Great Gulf Group, co-founded by Harry Rosenbaum, Principal (above), made a lead donation that helped bring Dr. Miguel Ramalho-Santos (below) to the LTRI to study early human development. Read more about his work on page 18.

“We are building a number of residential high-rise projects in Toronto and recognize that as the city continues to grow at an unprecedented rate, it puts pressures on our hospitals to keep up with growing demand,” said Rosenbaum. “It was important to us to make an impact by supporting significant research that has great potential to make a difference in the lives of individuals.” The inaugural chair holder is Dr. Miguel Ramalho-Santos, who recently joined the LTRI from University of California, San Francisco. Here, Dr. Ramalho-Santos is part of one of the world’s largest concentrations of scientists studying women’s and infants’ health, with access to the clinical expertise of Sinai Health’s Frances Bloomberg Centre for Women’s and Infants’ Health, one of the world’s six leading centres for mother and baby care and Canada’s most comprehensive obstetrics and gynaecology program. Dr. Ramalho-Santos studies prenatal development and how and why it sometimes goes wrong. His research also looks at the prenatal impact of external environmental factors such as chemical contaminants and maternal diet. “We believe this emerging area of research is an initiative that requires support and could one day provide a breakthrough with life-saving discoveries in women’s and infants’ health,” said Rosenbaum. “We hope this gift will bring us closer to eradicating many diseases that show up in adulthood but may have had their start in early childhood. 37

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C E L E B R A T I N G 1 0 Y EA R S O F H EA L I N G A T T H E Z A N E C O H E N C E N T R E F O R D I G E S T I V E D I S EA S E S

“We are blessed to have Zane Cohen and the Centre for Digestive Diseases,” wrote Claire Van Loon, whose husband David is a longtime patient of Dr. Zane Cohen’s, in a recent letter to Sinai Health Foundation CEO Louis de Melo. Van Loon credits Dr. Cohen and his team at the Zane Cohen Centre for Digestive Diseases (ZCC) with keeping her husband alive for 45 years, since his illness required the removal of his colon and surgical replacement with a J-pouch, a procedure Dr. Cohen pioneered. According to Van Loon, Dr. Cohen’s advice to her husband at the time — “It will only change your life if you let it” — has been a guiding mantra, and today her husband remains as active and adventurous as ever.

Van Loon’s sentiments are echoed by many others throughout the ZCC community — patients and donors alike — including those who gathered in the Hennick Family Wellness Gallery at Mount Sinai Hospital on June 12 to celebrate the ZCC’s 10 year anniversary and to look ahead to the future. Over the past decade, the ZCC has earned a reputation as a world leader in the care of digestive diseases including inflammatory bowel disease and hereditary gastrointestinal cancers. The ZCC team cares for 10,000 patients annually, many of whom require complex, ongoing care to manage their conditions, but the team’s impact through pioneering clinical procedures and international research projects has the potential to affect hundreds of thousands of patients worldwide in the coming years.

Dr. Robert Riddell, Pathologist, Zane Cohen Centre for Digestive Diseases, with guests at the Colon Interactive Station

Watch “How the Zane Cohen Centre for Digestive Diseases transforms care” » zanecohencentre.com

Dr. Zane Cohen, Director, Zane Cohen Centre for Digestive Diseases, and Louis de Melo, CEO, Sinai Health Foundation

Events T H E S I NA I S OI R E E W H E N : June 21, 2018 W H A T: Over 250 young

professionals gathered at The Globe and Mail Centre in the heart of downtown Toronto for a Summer Solstice-themed fundraiser. One of Toronto’s hottest summer parties, The Sinai Soiree raised $20,000 net for the redevelopment of the Schwartz/Reisman Emergency Centre at Mount Sinai Hospital. W H O : The Sinai Soiree

attendees celebrating the first night of summer together at The Globe and Mail Centre in downtown Toronto P H O T O C R E D I T: N I C K L E E

P H O T O C R E D I T: W I L L I A M S U A R E Z

P H O T O C R E D I T: G E O R G E P I M E N T E L PHOTO GRAPHY

L EADE RSH I P S I NA I P OR S C H E RA L L Y W H E N : June 8 & 9, 2018 W H A T: 70 car enthusiasts came together at Woodbine

Entertainment Centre for the third annual Leadership Sinai Porsche Rally, hosted by Downtown Fine Cars. Thanks to the incredible generosity of sponsors and participants, over $51,500 net was raised to support family reproductive health at Sinai Health System. The Event Co-Chairs were Jordy Mecklinger and Jordan Druxerman. W H O : Jordy Mecklinger, Co-Chair; Pam Mecklinger; Chris

Plater, General Sales Manager, Downtown Fine Cars; Hailey Meslin, Executive Director, Strategy & Principal Gifts, Sinai Health Foundation; Dr. Keith Jarvi, Director of the Murray Koffler Urologic Wellness Centre and Head of Urology, Sinai Health System

F AN DANGO ! BI G BAN D W H E N : October 11, 2018 W H A T: Fandango! Big Band,

led by Event Chair Janice O’Born, took place in the historic Crystal Ballroom at the King Edward Hotel with a return to the roaring ‘20s. The event has raised over $6 million net for Bridgepoint Active Healthcare since its inception, thanks to the incredible generosity of our sponsors and attendees. WHO:

1. Isadore and Rosalie Sharp 2. Performance by Toronto All-Star Big Band

T H E G REAT J EW E L L E RY H E IS T W H E N : November 1, 2018 W H A T: Over 400 guests came together in support of Bridgepoint Active

Healthcare at the eighth anniversary of The Great Jewellery Heist, presented by CIBC and Ivanhoe Cambridge. The sold-out fundraiser brought together a diverse and influential group of men and women from Bay Street and Toronto’s fashion circles for a glamorous luncheon and jewellery auction at the Ritz-Carlton hotel. The event was hosted by Jeanne Beker and has raised over $2.1 million net since its inception. WHO:

2. Laura Dottori-Attanasio, Executive Chair; Amber Choudhry, Event Chair; Jeanne Beker, Emcee; Veni Iozzo, Executive Chair; (Absent: Susan Rimmer, Executive Chair)

P H O T O C R E D I T: A N N I E T O N G

P H O T O C R E D I T: G E O R G E P I M E N T E L P H O T O G R A P H Y

1. Live auction items on display

HARRY BARBE RIAN M E MO RIAL D I N N E R W H E N : May 7, 2018 W H A T: Barberian’s Steak House closed its doors to host an

intimate, private dinner in support of Mount Sinai Hospital. Now in its sixth year, the annual Harry Barberian Memorial Dinner honours the life of Harry Barberian, an entrepreneur and family man who helped shape Toronto’s culinary landscape and played host to everyone from prime ministers to movie stars. W H O : Louis de Melo, CEO, Sinai Health Foundation;

GRATE FU L H EA R T S RA IS E S $ 1 M I L L I ON W H E N : July 12, 2018 W H A T: A celebration was held in the Mount Sinai Hospital lobby

for the Grateful Hearts program reaching $1 million fundraised. Grateful Hearts is a Foundation-led program that provides patients and families with a meaningful way to acknowledge a member of the Mount Sinai care team. Once a donation is made to recognize them, the staff member receives a thank-you card and beautiful pin. Some staff members have collected many over the years and wear them as badges of honour. W H O : Former patient and current volunteer Charlene Girt with

grateful staff members from Sinai Health Foundation

P H O T O C R E D I T: R YA N E M B E R L E Y P H O T O G R A P H Y

Dr. Jeremy Freeman, Temmy Latner/Dynacare Chair in Head & Neck Oncology, Sinai Health System; U.S. Consul General Juan Alsace; Ben Mulroney, Board Vice-Chair, Sinai Health Foundation; Arron Barberian, Event Chair; Howard Sokolowski, Board Co-Chair, Sinai Health Foundation

MOU N T SI NAI C LA S S I C GOL F T OU R NA M E NT W H E N : June 25, 2018

P H O T O C R E D I T: S T E V E S A M

W H A T: 144 ardent golfers came together at St. Georgeâ&#x20AC;&#x2122;s Golf and Country

Club for the 24th annual Mount Sinai Classic Golf Tournament, presented by Equitable Bank and Chestnut Park/Echelon Wealth Partners. Thanks to the generous support from donors, sponsors and attendees, the event raised $555,000 net in support of groundbreaking research at the LunenfeldTanenbaum Research Institute. W H O : Stephen Miller, Event Co-Chair; Louis de Melo, CEO, Sinai Health

Foundation; Jonathan Pollack; Brian Cohen, Event Co-Chair

PHOTO C RE DIT: I M AGI N E STUDIOS PHOTO GRAPHY

P H O T O C R E D I T: G E O R G E A L M A R I A

DAY AT T H E RACES W H E N : September 23, 2018

RE C OV E RY BRUN C H W H E N : May 27, 2018 W H A T: 110 like-minded young professionals came

together for the annual Recovery Brunch at Kasa Moto in Toronto. Thanks to the incredible generosity of attendees and sponsors, the event was a great success and raised $16,000 net for Bridgepoint Active Healthcare. W H O : 2018 Recovery Brunch Committee with this

yearâ&#x20AC;&#x2122;s guest speaker, Bridgepoint volunteer David Parker

W H A T: More than 100 guests joined us for a champagne reception, gourmet

lunch and horse racing at Woodbine Racetrack. With support from our generous attendees and sponsors, the event has raised over $2 million net since its inception in support of the Arthritis Research Foundation. Arthritis is an umbrella term for over 50 different, irreversible autoimmune conditions including rheumatoid arthritis, vasculitis, scleroderma, lupus and others. WHO:

1. Horses racing at Woodbine Racetrack 2. Emcee and guests enjoying a beautiful day: Razid Samdjy, Farah Nasser, Erica Vella, Matt Hall

As Seen on Instagram

@sinaihealthsystemto

...Check out the pollinator garden that students from Orde Street Junior Public School planted at the Orde Street/ McCaul Park. The planting was supported by Sinai Health’s Green Committee... #pollinatorgarden #kidsgardening

Happy National Volunteer Week! Giving our therapy dogs a special treat is a Volunteer Week tradition at Bridgepoint. Ember, one of our smallest four-legged volunteers, picked up her treat today with her handler Rebeka... #gooddog #therapydog #insidesinaihealth #healthcare #volunteers

Our Pathology and Laboratory Medicine Department... will be moving to a brand new space. It’s one piece of the largest redevelopment project in Mount Sinai’s history... Learn more at RenewSinai.ca. #RenewSinai #redevelopment #hospital #laboratory #MountSinaiHospitalTO

A patient practises walking on stairs with crutches during physiotherapy at #Bridgepoint. #physiotherapy #healthcare #hospital

Good morning! #NICU #momandbaby #toocute #mountsinaihospital

Following a stroke several years ago, Circle of Care client Ricky began folding origami cranes for his wife Julia, as a form of therapy. As his caregiver, Julia benefits from the respite provided by Ricky’s personal support worker. #seniorcare #homecare #CircleofCare #Toronto

Jacob, 17, from Orillia was one of nine students from across Ontario who visited Sinai Health System in July as part of a summer mentorship program...“...It has opened my eyes about a lot of things, not only about the field of medicine but also about myself and my future.” #MountSinaiHospitalTO

The Women’s and Infants’ Program nursing team at Mount Sinai held a diaper drive in recognition of Diaper Need Awareness Week (September 24-30)... The team collected more than 1,500 diapers for local food banks. #diaperdrive #MountSinaiHospital #MountSinaiHospitalTO

Behind the scenes at Mount Sinai Hospital in the Pathology and Laboratory Medicine Department #MountSinaiHospital #Laboratory #Healthcare #MountSinaiHospitalTO

Crossword Puzzle 1

2 5 7

4 6

8 9

11 12 13

18 19 20 21

24 26

33 35

34 36

37 38

Across

Down

Physician-developed online hub of emergency medicine information.

Absolutely necessary.

Unexpected connection between CRISPR technology and the milk industry.

Study of how modifications in the expression of genes affect an organism’s development, genetics.

Powerful gene-editing tool.

Handheld helper.

print, unique to each person.

Lunenfeld-

, Environmental, Microbial Project, or GEM Project. Research Institute, part of Sinai Health System.

Smart kid.

Digital audio series.

Philanthropist and Indigo founder.

Later life neurological disorder.

How one manages relationships with others during times of fear or stress, Attachment .

Medical care prior to birth.

Exact.

A person or family member who may pass on an alternative form of a gene.

Focus of Bridgepoint Active Healthcare’s first-of-its-kind mental health and rehab program.

Digital patient progress tool, electronic Patient Reported Outcomes, is also known as .

Digestive doctor,

Country with the highest rates of IBD in the world.

Medical discipline that focuses on the immediate needs.

-Savvy.

generation, the formation of new tissue.

enterologist.

Complicated community within our guts, or on our skin.

Metabolic disease associated with the microbiome, ulcerative

Mammography,

Treatment of a person that goes beyond just the physical symptoms of a disease.

Resistant.

The human brain has tens of billions of these specialized cells.

Inflammatory

Koffler Breast Centre at Mount Sinai Hospital.

Environmental factors — food, air,

Canada 150 Research Chair in Developmental Epigenetics, Ramalho-

Cells grown from human or mouse organ tissues.

Schwartz/Reisman Emergency Medicine Institute.

Within the living in Latin.

Current Sinai capital campaign,

Team of doctors, nurses, and support workers with a variety of knowledge sets.

. .

Resonance Imaging. Sinai.

of the breast.

Disease, or IBD.

Find the answers at supportsinai.ca/sinaicrossword 43

Create your own challenge Challenge yourself this year and help fuel groundbreaking research at Sinai Health System! It’s simple — choose your activity and personal goal, then decide when you’ll achieve your goal. Ask friends and family for support and track your progress on your personal fundraising page.

Follow these 5 easy steps to create your own challenge:

Choose your activity

Set your goal

Create your fundraising page

Choose your timeline

Start your challenge!

Your support is critical to advancing research at the Lunenfeld-Tanenbaum Research Institute. You can help our scientists push boundaries that result in groundbreaking discoveries.

race4research.ca

Sinai Health Magazine Fall/Winter 2018

Articles inside

Emergency Medicine Grows Up

The New Power Tools of Medical Research

All in the Family

Past Meets Present

Meet Dr. Miguel Ramalho-Santos

Nature vs. Nurture

Innovating Care