FALL 2010
SUMMER 2010
A UNIVERSITY OF CALGARY Faculty of Medicine Publication
Stroke
of Geniuses
Unlocking the mysteries of stroke – a six-page special feature
Gut Feelings
An inside look at diseases that affect your insides – a four-page special feature
Outside the Comfort Zone From Afghanistan to the upper atmosphere, Dr. Andrew Kirkpatrick has practiced in some unusual places
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uCalgary
Medicine Vol 2 Issue 3 | Fall 2010
UCalgary Medicine is published three times a year by the University of Calgary Faculty of Medicine, providing news and information about our faculty, staff, alumni, students, friends and community. For more information contact:
Managing Editor Kyle Glennie T 403.210.6577 E kglennie@ucalgary.ca
Dean Dr. Thomas E. Feasby
Vice Dean Dr. Jon Meddings
Senior Associate Deans Dr. Richard Hawkes, Research Dr. Benedikt Hallgrímsson, Education Dr. Ronald Bridges, Clinical Affairs
Associate Deans Dr. Anthony Schryvers, Undergraduate Science Education Dr. Bruce Wright, Undergraduate Medical Education Dr. Jennifer Hatfield, Global Health & International Partnerships Dr. Doug L. Myhre, Distributed Learning & Rural Initiatives Dr. Joanne M. Todesco, Postgraduate Medical Education Dr. Frans A. van der Hoorn, Graduate Science Education Dr. Jocelyn Lockyer, Continuing Medical Education Dr. Samuel Wiebe (Interim), Health Research Dr. John Reynolds, Basic Research Dr. Michael Hill, Clinical Research Dr. Janet de Groot, Equity & Teacher-Learner Relations Dr. Kamala Patel, Faculty Development
Design and Production Kelly Budd, Radius Creative
Photography Carlos Amat, Robin Kuniski, Trudie Lee, James May, Janelle Pan, Bruce Perrault
Cover Illustration Hugo Dubon
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Fall 2010
FALL 2010
contents Volume 2 Issue 3 | FALL 2010
pg5 Friendship fuels philanthropy | Philanthropy
By fulfilling a pledge to a lifelong friend who passed away from lung cancer, two Calgary philanthropists have advanced lung cancer research worldwide.
Cover Story
pg6 Stroke of geniuses | Service to Society
They treat an average of four strokes each day. They are recognized as one of the leading stroke imaging facilities in the world. They’ve trained the majority of recently graduated Canadian neurologists to become stroke specialists. Welcome to the Calgary Stroke Program.
pg12 Gut feelings | Research
Superbugs, ulcerative colitis, Crohn’s disease…all in a day’s work for the Division of Gastroenterology.
pg16 Outside the comfort zone | Service to Society
From Kandahar Airfield in Afghanistan to a zero gravity laboratory 32,000 feet above the Earth, Dr. Andrew Kirkpatrick has practiced medicine in the most remarkable places.
pg18Climbing the ladder | profile
For Dr. Stuart Hutchison, the road to the Faculty of Medicine went to the top of some of the world’s tallest peaks—including a deadly night on Mount Everest.
pg20 Becoming a complete surgeon | education
Teaching surgical skills is a common practice of medical schools, but teaching someone to become a complete surgeon is a different task altogether.
pg22 The will to overcome…and inspire | profile
After a 30-year career as a surgeon, Dr. Mort Doran is looking forward to teaching anatomy at the Faculty of Medicine. He likely won’t have to cover Tourette’s syndrome, the disease he’s lived with for almost three decades.
pg23 Not your typical day at the office | Terminus
For Dr. Neal Church and Dr. Jay Cross, getting down and dirty is a family tradition.
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message from the dean
a successful
journey
This October we will celebrate a special milestone at the Faculty of Medicine: the 40th anniversary of the first class of medical students admitted into our Faculty in 1970. From our humble beginnings we have come a long way. We are respected medical educators training the next generation of physicians and health care professionals, and we are an internationally recognized research institution, innovating new treatments and therapies across the entire medical spectrum. In this issue of UCalgary Medicine magazine, we recognize two specific areas of medicine where we have reached elite status for our research and service to our community.
tremendous success and the IBD research group at the Faculty of Medicine has been ranked as one of the top five IBD research groups in the world by the Crohn’s and Colitis Foundation of Canada. As well, the IBD Clinical Trials Unit has achieved tremendous success and has been ranked as one of the top five clinical trial units in the world.
The Calgary Stroke Program is an internationally renowned stroke research and treatment program. Within the Department of Clinical Neurosciences at Alberta Health Services and the Faculty of Medicine, the program is a collaborative centre where Faculty of Medicine members and colleagues are quite literally changing the way we diagnose and treat strokes around the world. It is a special blend of clinical care, education and research.
Both of these groups of dedicated professionals improve clinical care, bring credit to our University, and help us achieve our Faculty’s vision to “create the future of health”. To that end we have compiled extended features of both in this issue. But these do not tell the whole story; they are merely a snapshot of what has been accomplished by these impressive teams. Our entire Faculty has grown and keeps growing—the stories in this issue attempt to touch on that and I hope you enjoy reading them. While our stroke research and our GI endeavours may be highlighted here, it would take several magazines over several years to tell the full story of our Faculty. It’s been a wonderful 40 years so far, and I’m thankful for the opportunity to be a part of it.
On a similar path to international recognition is the Faculty of Medicine’s Division of Gastroenterology (GI). One of the largest of its kind in the world, the GI Division’s Inflammatory Bowel Disease (IBD) Program ranks fifth internationally, just behind institutions like Harvard University and the Mayo Clinic for the number and quality of IBD research publications. As well, the IBD Clinic has achieved
Dr. Tom Feasby Dean, Faculty of Medicine
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Philanthropy
Friendship fuels philanthropy By fulfilling a pledge to a lifelong friend who passed away from lung cancer, two Calgary philanthropists have advanced lung cancer research worldwide. By Lois Epp Allen Knight (left) with Dr. Gwyn Bebb.
Jim Look was the kind of person who made lifelong, lasting friendships; the kind of friendships that inspired his friends to not just rise, but to soar to the occasion when asked for support.
rate. There are approximately 2200 patients living with lung cancer each year in Alberta. Of that group, roughly 85% will die of the disease within two to five years.
One of those friends was Allen Knight who Jim met early in his career as a geologist. That was over 30 years ago. It was during Jim’s battle with stage four lung cancer that he approached Allen about his desire to see a dedicated lung cancer database project completed. Allen responded without hesitation.
Additionally, lung cancer has a stigma attached to it which affects the ability to attract funding support. The misconception strongly exists that people with lung cancer brought it about through their own doing, like smoking. While there is a clear association with smoking, 15% of patients with lung cancer have never smoked and nearly half of those diagnosed are not smokers at the time of their diagnosis.
“I will make sure that it happens.” Soon after that conversation, Jim died of lung cancer in February 2010. Allen fulfilled his promise and together with his wife Joy made a gift of $500,000 to support the lung cancer database project Jim believed in so fervently.
One of the primary objectives of the database is to eventually have enough information about how lung cancer presents itself to then develop an effective and non-invasive screening tool, one that can detect lung cancer earlier. It was for those very reasons that another lifelong friend of Jim Look’s, Hugh Borgland, also stepped in to help.
The database is the brainchild of Dr. Gwyn Bebb, Jim’s former oncologist. A lung cancer physician with the Tom Baker Cancer Centre in Calgary, Bebb also heads up a lung cancer research group and is an assistant professor at the Faculty of Medicine and a member of the Southern Alberta Cancer Research Institute.
“I could really see the value of the database,” says Borgland. “I also think it is important to support those areas of research and medicine that don’t get that much attention.” To that end, Hugh and his wife Laureen also made a gift of $500,000 to support Bebb’s project, bringing the total contribution for the project to $1 million.
“The idea behind the database is to capture as much information about patients diagnosed with lung cancer over the last 10 years and link it to the secrets hidden in their biopsies,” Bebb explains. “This comprehensive database then provides researchers with a treasure trove of meaningful data they can access to explore their hypotheses.”
“It’s overwhelming,” says Bebb of the philanthropic investment. “I literally was expecting this project to go on for years. I am able to complete the database sooner than expected, and as such, can move forward with the next phase of the project, collecting data from lung cancer patients who are still living.”
Jim was incredulous that such a database didn’t already exist. While Bebb did have one graduate student working part-time on the project, given the scope of data he estimated it would take years before the database would be completed.
As a result of the database, Bebb and his team have since presented at several conferences and will be publishing findings in key scientific journals. The outcome of their publishing is twofold: it influences the work of other researchers, and it informs the research community that a new platform for lung cancer research is available. As such, Calgary is in the unique position of being one of the only centres in Canada to have such a comprehensive database.
Lung cancer is a difficult disease to detect. Its symptoms often go unnoticed, especially in the early stages. As a result lung cancer has a high mortality
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Service to Society
S
troke of G
Its physicians
treat about four strokes and two transient ischemic attacks every day in the emergency department. A majority of recently graduated Canadian neurologists have been trained as stroke specialists here through their fellowship program, and another 30 stroke physicians from 12 countries have also received training. They are recognized as one of the leading stroke imaging facilities in the world, and currently serve as the core imaging lab for a large multinational randomized trial funded by the National Institutes of Health. It didn’t happen overnight, but the Calgary Stroke Program has earned its international reputation as one of the leading stroke treatment and research facilities. Within the Department of Clinical Neurosciences at Alberta Health Services and the University of Calgary, the program works alongside other departments to provide quality acute, rehabilitative, and preventative care to people with stroke and their families.
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Service to Society
s e s u i n e G of
Located at the Foothills Medical Centre, the Calgary Stroke Program always has one Faculty member and one stroke fellow on call and dedicated to stroke patients at all times. And for good reason; there are approximately 5,000 strokes per year in Alberta, and it is the leading cause of adult disability and third leading cause of death across the country. “This is a tough, tricky disease,” admits Dr. Andrew Demchuk, director of the Calgary Stroke Program. “Having people focused specifically on stroke is a good thing.” In the following pages we’ll show you the research and treatment that has lifted the program to its lofty reputation, and we’ll introduce you to some of the physicians and professionals who made it all happen. As you’ll see, ‘focused’ isn’t a strong enough term.
Alana Ramsey in the virtual reality room at the Alberta Children’s Hospital.
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Helping children recover from pediatric strokes While strokes overall are much more common in older adults, the highest period of focused risk is the week you are born. Such strokes at or before bir th are called perinatal stroke and occur in more than 100 Alber ta children each year. Most children suf fer long-term neurological disabilities including cerebral palsy, learning disabilities, and epilepsy. Since the cause of most cases is unknown, there are currently no ways to prevent such strokes. Options for treating the lifelong disabilities that result are limited but improving. That’s where Dr. Adam Kirton, assistant professor in the Departments of Paediatrics and Clinical Neurosciences, comes in. Using a non-invasive procedure known as Transcranial Magnetic Stimulation (TMS), Kirton is taking an old technology in a new direction. “TMS has been around for 25 years, and its generally been used to map the brain and various brain pathways. But more recent evidence suggests it may be an effective therapy tool that can help guide a child’s brain development toward better function.” At the Alberta Children’s Hospital Pediatric TMS Laboratory, the first facility of its kind in Canada, Kirton is working on a study testing the effects of TMS on kids who have suffered a stroke at Page 8 | ucalgary medicine
or near birth. All of the children have some form of disability in one of their limbs and they are randomized into groups with some receiving real TMS treatment, while others receive a ‘fake’ form of TMS treatment. Some of the kids are also given a removable constraining cast on their stronger limbs to encourage use of the affected limb. While the study is ongoing, the results are already positive for Alana Ramsey. Because the trial is randomized, Ramsey does not know if she received real TMS treatments or ‘fake’ TMS treatments. Either way, the 16 year-old has already noticed some significant changes. “Before I couldn’t dribble a basketball with my weaker right hand, but now I can do it for hours. I can also throw a tennis ball with my right arm now.” Ramsey is just one Fall 2010
“The real purpose of the camp is to test our theory that these interventions are helping the brain learn,” explains Kirton. “But it only works if you give the brain a real stimulus to learn and that’s where the therapists have done a great job in setting up the camp.”
Seeing the problem close up
Dr. Andrew Demchuk in the Seaman Family MR Research Centre.
“The problem with stroke is it’s a very complex disease with multiple causes, varying severity, and it happens at different locations throughout the brain. We also need to be able to treat patients quickly, and to do that we must somehow identify groups of patients and learn how to treat them effectively.” It’s a difficult problem to answer, but Dr. Andrew Demchuk, director of the Calgary Stroke Program, has technology on his side as he and his colleagues try to decipher a solution. “One of the reasons why stroke treatment hasn’t improved more rapidly is that we’re applying a single treatment to the disease and it’s not having an impact. That’s where imaging comes in.”
This is the second TMS study that Kirton has undertaken. The first looked at TMS therapy in a group of kids who suffered a stroke anywhere from two years of age to 10. The results, published in 2008, were very encouraging. “On average we found that kids who received the TMS treatment tended to gain function in their affected limbs whereas those who received the ‘fake’ TMS treatment did not. It’s still preliminary and there is much more to research, but it’s very encouraging.” Especially for the kids.
Check out the video! Watch Alana undergo virtual reality therapy and see her progress at www.youtube.com/ucalgarymedicine
Imaging of the brain is a crucial tool in the treatment of stroke. Because time is such a factor in stroke cases, computerized tomography (CT) scans are used more often in emergency situations as they are easy to administer, and the equipment is readily available in most hospital emergency units. When dealing with cases that aren’t as time sensitive, physicians will often use magnetic resonance imaging (MRI) that offers in many ways a superior image of the brain. The Calgary Stroke Program uses both CT and MRI imaging in their stroke research, and is a recognized leader in stroke imaging. In their study looking at hemorrhagic stroke, researchers used CT angiography to effectively identify the source of bleeding in a stroke-damaged brain. These findings have spurred researchers into preparing another trial where they will test a drug normally used in hemophilia patients to see if it can stop the bleeding at the source. “In a hemorrhagic stroke, if you can stop the bleeding quickly the patient has a much better chance at recovery,” explains Demchuk. “But if that bleeding continues, the outcome is likely death or the patient is often left with a major disability.” Right now there are no effective therapies proven for hemorrhage. Another pioneering study headed by Demchuk and U of C colleague Dr. Shelagh Coutts used MRI to look at the brain and blood vessels of people who have had a mini-stroke—more technically called a transient ischemic attack (TIA)—to determine who is likely to have a major stroke. About 10% of patients who have had a TIA will have a second, more severe stroke within 90 days. This landmark study showed that MRI can more accurately predict who will have another stroke. “We’re all about establishing targets for treatment, so there is a lot of work being done here in a variety of different areas to meet that goal.”
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Service to Society
of the study’s participants; the entire group is taking part in an intensive two-week camp that includes virtual reality and physical therapy along with the TMS treatment.
Service to Society
A covert culprit They show no outward symptoms and they occur around 10 times more frequently than major strokes. Covert strokes may seem minor, but they often come with major consequences later in life. “I see the devastating effects it has and how it saps a person’s vitality and takes away their independence. So anything we can do to slow this process down or delay it to give people more quality years of life will have an impact not only on the patient, but on society in general.” Dr. Eric Smith knows what he speaks of. As a clinician and director of the Cognitive Neurosciences Clinic at the Foothills Medical Centre, Smith sees patients suffering from dementia on a regular basis. To combat this debilitating condition, Smith is researching ways to stop dementia before it starts. “Our goal is to prevent it from happening in the first place,” explains Smith, a member of the Hotchkiss Brain Institute at the Faculty of Medicine. “Part of the reason people suffer from dementia is they accumulate small strokes in the brain, which we call covert strokes because they don’t cause immediate symptoms like paralysis or loss of speech, but rather they damage the brain and cause an onset of forgetfulness and cognitive decline.”
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To identify the early warning signs of covert strokes and dementia, Smith and his colleagues have launched a study in conjunction with Harvard Medical School that will use magnetic resonance imaging (MRI) to identify whether a lack of blood flow in the brain puts people at greater risk for silent strokes. Smith will also be leading a second study that will look at the impact of covert strokes on about 600 Canadians across the country, to get a good sense of exactly how common they are in the community and in people who otherwise appear healthy. “People may be at risk for covert strokes and they don’t even know,” says Smith. “So we’re looking to ease this threat by determining who is at the highest risk.” There are approximately 500,000 Canadians currently living with dementia. A study commissioned by the Alzheimer’s Society of Canada reports that in 2008, the total economic burden of dementia in Canada (including direct health costs and lost wages of caregivers) was $15 billion. “Seeing the disabling symptoms like loss of memory and language in my patients really motivates me to keep the energy up and put in the long hours,” admits Smith. “It’s a terrible disease that affects a lot of people on many levels.
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. n t
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h d o r t s e
A National Issue • Stroke is the third leading cause of death in Canada. 6% of all deaths in Canada are due to stroke. • Each year, nearly 14,000 Canadians die from stroke. • Each year, more women than men die from stroke. • There are over 50,000 strokes in Canada each year. That’s one stroke every 10 minutes. • About 300,000 Canadians are living with the effects of stroke. • For every minute delay in treating a stroke, the average patient loses 1.9 million brain cells, 13.8 billion synapses, and 12 km of axonal fibres. • Each hour in which treatment does not occur, the brain loses as many neurons as it does in almost 3.6 years of normal aging.
Source: The Heart and Stroke Foundation of Canada
Always Ready Our stroke researchers are leading the way in the fight against stroke, and our communities are healthier because of it. Researchers at the Faculty of Medicine have implemented a province-wide transient ischemic attack (TIA) hotline for physicians. A TIA, which is a mini-stroke that occurs when a clot stops blood from flowing to the brain for a short period, will sometimes lead to more severe strokes in patients and time is critical when dealing with them. When an emergency physician or family doctor sees a patient who may be suffering a TIA, the hotline will connect them immediately to a stroke specialist, day or night. The specialist can help assess the suspected TIA to ensure proper treatment.
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A grey
(and white)
area
Armed with custom built lasers to view ner ve fibres that are 50 times smaller than a human hair, Dr. Peter Stys’ research is studying strokes in ways that few others on the planet can. The New York Yankees and the Boston Red Sox. The Hatfields and the McCoys. Grey matter and white matter? It may not be included on a list of great rivalries in circles outside of neurology, but the grey versus white matter debate as it relates to stroke research is a hot topic. The human nervous system is a 50-50 split between grey and white matter; grey matter—which houses the cell bodies of the neurons—is where the computations are done, and white matter is where the axons, or ‘connections’ are. “Most stroke treatments are directed at the grey matter neurons without consideration for the connections in the white matter,” explains Dr. Peter Stys, a professor in the Department of Clinical Neurosciences at the Faculty of Medicine. “If these tissues respond differently to stroke, then a drug targeted only at grey matter will not work.” In many ways white matter is the forgotten matter. Only a small number of labs around the world study it, even fewer in Canada. For the past 20 years, Stys has dedicated his research to finding out how white matter functions, and to identify the molecules, channels and proteins that function abnormally in stroke and other disease like multiple sclerosis. In order to do this, Stys and his colleagues use lasers to take three dimensional pictures deep inside tissue. “By using lasers and laser scanning microscopes, we are able to see in real time which cells are dying, how they are dying, how they are working and whether or not they are responding to treatment.” With a lab that is completely custom built from the lasers and microscopes they use, to even the table they work on, white matter is getting the red carpet treatment.
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Research
Gut Feelings Dr. Remo Panaccione (right), speaks to a patient in the Heritage Medical Research Clinic.
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It’s one of the largest divisions of gastroenterology in the world and is located in a nation that has one of the highest incident levels of Inflammatory Bowel Disease (IBD) anywhere on earth. Its IBD Program ranks fifth internationally behind institutions like Harvard University and the Mayo Clinic for number and quality of IBD research publications, and it is a world leading clinical trial centre for IBD treatments and drugs. So where exactly is this gastroenterology division? At the University of Calgary, of course.
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Research
Healing… from the inside out “Obviously I was delighted when I heard the news,” says Dr. Subrata Ghosh, recalling his reaction to hearing the Faculty of Medicine’s Division of Gastroenterology (GI) placed fifth in number of IBD research publications worldwide by institutions who receive support from the Crohn’s and Colitis Foundation of Canada (CCFC). “When the GI division was created by people like Dr. Lloyd Sutherland and Dr. Eldon Shaffer, they had the foresight to match clinical science with basic science, and that really galvanized us to where we are today.” Where they are today is quite simply a grouping of some of the best GI, and specifically IBD, researchers in the world. While the IBD program earned the top five ranking by the CCFC, Dr. Remo Panaccione, director of the Inflammatory Bowel Disease Clinic at the Faculty of Medicine, earned his own individual honour as one of the 100 most cited authors of IBD-related research papers in the world. Over the last 10 years and under his direction the clinic has grown to include six clinical IBD specialists with a variety of research interests, dedicated research personnel, and an IBD Biobank. “The CCFC is the largest funding group for IBD research in Canada, and with our clinicians and basic scientists the funding that has flowed to Calgary is five times larger than any other institution in Canada,” says Panaccione. “I think that speaks a lot about the quality of research and the amount of research that is going on here.”
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From left: Dr. Herman Barkema, Dr. Remo Panaccione and Dr. Subrata Ghosh.
It’s estimated that over 200,000 Canadians are afflicted with IBD, an incurable disease affecting a patient’s gut resulting in pain, diarrhea, bleeding, anemia and weight loss. These numbers represent one of the highest incidence levels of IBD anywhere on Earth. Right now IBD researchers at the Faculty of Medicine, along with colleagues at other Canadian universities and Alberta Health and Wellness, are trying to figure out why. They are in the first year of a five-year, $5 million team grant awarded by Alberta Innovates–Health Solution (formerly the Alberta Heritage Foundation for Medicine Research), led by Dr. Herman Barkema, department head of Production Animal Health at UCalgary Faculty of Veterinary Medicine and professor in Epidemiology of Infectious Disease. While some might question why animal researchers are participating in a study seeking to unlock the mysteries of a very human disease, Barkema says the disease crosses several species. “IBD doesn’t just affect humans, but also other species including cats, dogs and cattle. As researchers we cannot see veterinary medicine separate from human medicine because there is so much interaction between the two, with pathogens and with environmental factors. Basically, we are looking at the same thing.”
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Research
Proving grounds The U of C Inflammatory Bowel Disease Clinical Trials Unit is ranked among the top five units in the world. So who gets the kudos for that accomplishment? The patients of course. For Dr. Remo Panaccione, his passion for drug development begins with the patients. For the last decade, Panaccione has been at the forefront of 42 clinical trials testing drug therapies for ulcerative colitis and Crohn’s disease, the two most common conditions that make up the inflammatory bowel disease (IBD) family. “It’s all about the patient, and we’re trying to give the patient the best opportunity to have a favourable outcome,” says Panaccione, director of the Inflammatory Bowel Disease Clinic at the Faculty of Medicine. “They are the ones who potentially benefit as they’re receiving a therapeutic agent that is not available on the market, and one they couldn’t get outside of the centre.” The centre Panaccione is speaking of is the Calgary Centre for Clinical Research, a showpiece facility at the Faculty of Medicine. In particular, the centre houses the Heritage Medical Research Clinic, where the IBD clinical trials have been conducted. “A decade ago we were just another recruiting site where clinical trial leaders would say ‘we need two or three patients from you’,” recalls Panaccione. “Now as our expertise and our international reputation have grown, they come to us before the trial has even started to say ‘we have this drug, we think it may be useful in IBD, can we meet and discuss what you think the potential is for this?’. So our role has really expanded globally and now we help shape these clinical trials.” There role is also crucial. Less than 1% of IBD drugs that go through the clinical trial process actually make it to market; of the 42 clinical trials Panaccione has been involved with, only five received approval for public use. Of those five drugs, however, three were for the treatment of Crohn’s disease and represent the only drugs for this disease to reach the market in the last decade. “These are drugs that have changed the way we treat ulcerative colitis and Crohn’s disease, and we examined all of them right here,” says Panaccione. Improving treatment options for IBD patients is always a priority for the entire Division of Gastroenterology at the Faculty of Medicine. And there is no shortage of patients in Alberta; our province has one of the highest IBD rates in the world. For Panaccione that fact is bittersweet. “Because we have so many patients, there is always interest for participation in the clinical trials. But I think the sad thing is there are still many patients who don’t know these trials may be available to them, and they may be at the point where they have finished standard therapy and they feel they don’t have many options. It’s one of our ongoing goals to make these clinical trials accessible to everyone who has the disease.”
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Research
Doubling up against Clostridium difficile Two new studies by researchers at the Faculty of Medicine reveal new ways to prevent and protect against the deadly bacteria.
If you follow the news you’ve no doubt heard of Clostridium difficile, or C. difficile as it’s commonly known. Hundreds of patients died in Ontario hospitals after developing C. difficile infections almost five years ago; another 16 died at a hospital in Montreal, forcing a province-wide policy change on the reporting of C. difficile cases. And more recently, a C. difficile outbreak is being blamed for the deaths of close to a dozen patients at a hospital in Nanaimo, B.C. Outbreaks such as these are becoming more common and more deadly. In the US alone, C. difficile related deaths have risen by 35% each year since 1999. But researchers in the Division of Gastroenterology have just completed two studies that have scored a double blow in the fight against this emerging health threat. “In one of the studies we’ve identified a molecule that occurs in all of us naturally, and it can protect against injury caused by C. difficile toxins,” says Dr. Paul Beck, a physician and researcher at the Faculty of Medicine. “And in the other study we’ve found another molecule that seems to play an important role in causing the damage induced by C. difficile toxins.” Both studies have been published in the journal Gastroenterology, and each represents a novel approach: looking at ways to use our own bodies’ mechanisms to prevent and protect against C. difficile.
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“In the first study, we looked at something called hypoxia inducible factor, or HIF, that is found naturally in the human body,” explains Beck. “We discovered that increased HIF levels act as protection against C. difficile. Now we’re looking at ways to increase a patient’s HIF levels to both fight C. difficile and act as preventative therapy.” In the second study, Beck and his colleagues have identified a new pathway that is involved in causing toxin induced intestinal damage. “Activation of the inflammasome pathway leads to increases in interleukin-1 beta. We found that if we blocked this pathway at various points as well as blocked the action of interleukin-1 beta, we could reduce C. difficile toxin induced injury,” explains Beck. Stopping the spread of this potent bacterium is also of great concern. C. difficile spores can survive on a surface for up to a year, and alcohol-based hand sanitizers don’t kill them. Because of this it can be spread from patient to patient very easily. Add in the fact that one of the newer strains of C. difficile is 30 to 40 times more toxic than it was 10 years ago, and you have a formidable threat to hospitals. “If you can do something that is fairly benign, such as give a patient a drug to raise the level of one molecule or block another, you may be able to fight this devastating disease without the risk of creating a more resistant strain of C. difficile which can happen through regular antibiotic treatment.”
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Service to Society
By Marta Cyperling
From Kandahar Airfield in Afghanistan to a zero gravity laboratory 32,000 feet above the Earth, Dr. Andrew Kirkpatrick has practiced medicine in the most remarkable places. Formerly a full time officer and now a reservist with the Canadian Forces, Dr. Andrew Kirkpatrick is a trained surgeon and critical care specialist, disciplines that are essential in a war torn region such as Afghanistan. In 2004, he spent four weeks working at a hospital in Kabul, the scarred capital of Afghanistan. He returned in 2008, this time working at the Kandahar Airfield in Kandahar province, one of the most contested areas of Afghanistan.
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When Kirkpatrick is back at home in Calgary, he is kept busy as the director of the Regional Trauma Unit at the Foothills Medical Centre and as a professor at the University of Calgary Faculty of Medicine. “As much as Foothills has a fantastic trauma unit that is among the best in Canada, it’s amazing to see how great the medical treatment can be inside of the metal box of a sea-container that the mobile operating room was shipped to and contained within in Kandahar,” he says. “I’m very lucky too. I had a safe job inside the wire, unlike many of our troops who venture out beyond the wire on a regular basis.” If all that doesn’t keep him busy enough, Kirkpatrick also spends his time working on research projects with NASA and the Canadian Space Agency. Space medicine is a growing research area. Astronauts typically spend three to six months in space, with the current record held by Russian cosmonaut Valeri Polyakov, who remained on the Mir space station for 14 months. If human spaceflight is to expand beyond the moon however, Kirkpatrick insists there are many medical challenges that will need to be addressed. To travel even to Mars, Earth’s closest neighbour, the journey will take three to five years depending on the mission design. Astronauts on a voyage like this would be isolated from Earth, and need to plan for medical treatment interventions that may arise. Research into finding the most effective ways to prepare for a voyage are therefore crucial to protect the first explorers who undertake this challenge. It also has the potential to improve life for people back on earth. One of Kirkpatrick’s research projects is looking into how astronauts can better use their limited resources and equipment. He and his colleagues have explored the potential of using ultrasound, the only current diagnostic imaging technology practical for space flight, for a variety of non-traditional indications.
guide and teach medical diagnoses and procedures. The technology was originally intended for use between astronauts and medical professionals in space, but thanks to this research a tele-mentoring emergency system is in place between Calgary and Banff. “It’s an amazing system we have been fortunate enough to test and we believe we can teach almost anyone not to be an expert, but to be useful in certain emergent situations. Most importantly a technology being researched for space can be used to reach rural areas on Earth.” Making the most of medical equipment is not the only challenge in space medicine; astronauts also need to be trained in technique. At some point astronauts will need to perform surgical procedures during their mission and that’s why Kirkpatrick’s most recent research focuses on how to perform minimally invasive surgery while in zero gravity. “It’s hard to do these surgeries in weightlessness, but we’re learning new techniques to help tackle this problem.” The cost of launching spacecraft is prohibitively expensive for most zero gravity research, so space medicine researchers utilize specialized aircraft nicknamed ‘vomit comets’ in reference to both the original aircraft used by NASA, and the unfortunate side effects that can be experienced by passengers. By using a parabolic flight path—first climbing to altitude then entering a steep dive—researchers can simulate periods of zero gravity that last for up to 25 seconds before the aircraft levels out, climbs back to altitude, and begins another diving period. The aircraft that Kirkpatrick and his team use for this purpose is a specially outfitted Falcon 20 from the Flight Research Laboratory of the National Research Council in Ottawa, Ontario. “This research is helping us develop the remote operating room of the future, and if we can do it on the way to Mars we can do it in remote regions like northern Canada.” While getting to Mars may be the ultimate goal, Kirkpatrick believes the journey may be just as worthwhile. “Even if we never go to Mars, learning how to get there and developing new technologies makes the world a better place.”
“In the research process we learned that you can use ultrasound in many conditions. This is great for space travel but this has also opened our minds to how we can better use medical equipment on Earth. We are now teaching students and residents how they can use portable handheld ultrasound machines in rural or wilderness settings. 10 years ago, people never heard of this.” Kirkpatrick and his team are also investigating the terrestrial use of ultrasound teleconferencing techniques developed by NASA for their use on Earth to
Check out the video! Watch Dr. Andrew Kirkpatrick practice weightless medicine at www.youtube.com/ucalgarymedicine
From left: Dr. Andrew Kirkpatrick (right) in Afghanistan; working on an infant patient; weightless training.
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Service to Society
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“It was a real privilege to be able to go and help,” recalls Kirkpatrick. “It’s fantastic that the military allows us to go on short term rotations. We were able to provide amazing medical care to the coalition forces as well as Afghans and Afghan soldiers.” Kirkpatrick spent most of his time performing surgeries on injured Afghan soldiers and civilians, including many children who had experienced horrific injuries from the violence.
Profile
Climbing the ladder For Dr. Stuart Hutchison, the path to Calgary went through Toronto and up some of the world’s tallest peaks—including Mount Everest where he survived one the deadliest storms in the mountain’s history. He landed at the Faculty of Medicine, where KRISTA SYLVESTER caught up with him.
He’s climbed the tallest mountain peaks, he’s written several medical books and as the director of echocardiography at the Libin Cardiovascular Institute of Alberta, he’s happy to call Calgary home. “My colleagues here from physicians to nurses and technologists, they are all amazing,” beams Dr. Stuart Hutchison. “I worked with wonderful surgeons in Toronto and I work with amazing surgeons here in Calgary. I get the chance to be involved in truly advanced cardiac imaging.” A reknown cardiologist and avid mountain climber, Hutchison’s past is as intriguing as it is impressive. A McGill University graduate, Hutchison came to the Faculty of Medicine from the University of Toronto two years ago looking for new challenges. “We have a really excellent cardiology service here, it’s extremely efficient and it’s actually a lot of fun practicing here,” says Hutchison. “But there is room for growth and there is interest here to move towards a true multi modality imaging training program.” An enthusiastic educator, Hutchison says the creation of such a program, which would train residents in echocardiography, cardiac CT, cardiac magnetic resonance imaging and nuclear imaging, would help move future cardiologists away from a onetest-for-everything approach.
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Aside from his educational endeavours, Hutchison would also like to see a wide range of equipment upgrades for the cardiology division, establish disease-specific scanning protocols, and develop links with sites in Edmonton and other areas of Alberta. After only a few minutes with Hutchison, though, it’s quite clear he truly enjoys teaching. He was awarded a Provincial Association of Residents Association Excellence in Teaching Award this summer, the first for cardiology in Calgary. He’s also written three cardiology books and has five more on the way, all directed towards meeting the needs of cardiology residents, who he says have been extremely validating to work with. So what does a cardiologist/author/educator do in his spare time? He climbs the tallest mountains in the world including Mount Everest, K2 and Mount McKinley, naturally. Hutchison’s brush with Everest in 1996 is one that has been told in a number of books, including Jon Krakauer’s bestseller Into thin Air; he survived an amazing ordeal that took the lives of eight people in one of the deadliest storms in the mountain’s history.
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Main photo: the northeast face of Mount Everest Above: Dr. Stuart Hutchison (left) with climbing partner and friend Jeff Hall, on the summit of Mount Denali in Alaska Below: ascending the Lhotse Face of Mount Everest
While he will always cherish his climbing experiences, Dr. Hutchison says he focuses on lower risk hobbies since becoming a parent to four-year-old and eight-month-old boys. “Like fishing, hiking and golfing,” he jokes. Five years ago was the third and last time Dr. Hutchison climbed Mount McKinley, and he says he’s okay with watching from the sidelines for now. “Climbing is something you do when you’re younger, and now that I’m not and have kids I have other priorities,” he admits. “Last night I got home from the hospital at 1:00 am. The moon was clear and just huge and it lit up the mountains beautifully. While I may not get to be on top of them, I get to see them every day and night.” Hutchison loves spending time with his wife and kids, the older of which already has a love for water and the curiosity of his father. “On the first day at the beach in Tofino, he was trying to command the waves to stop because they were knocking him around.” Like father, like son, perhaps.
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Education
Becoming a
Complete Surgeon Teaching surgical skills is a common practice of medical schools, but teaching someone to become a complete surgeon is a different task. And as KYLE GLENNIE found out, the Faculty of Medicine’s unique Surgical Skills program is one of kind in Canada. The needle slowly punctures the top of the bottle and draws a small amount of local anesthetic into the syringe. Sterile green cloth is draped around the patient’s chest, leaving only a small square patch of skin showing. After identifying the target area, the needle is delicately inserted into the soft tissue. “Uh oh I think I hit the lung, I hope it doesn’t pop.” Pop? Well that’s what could happen when the lung in question is really a red balloon, and the tissue is synthetic skin placed over pork ribs. It’s just another day in the surgical skills program for residents at the Faculty of Medicine. “I think this course tries to simulate what it’s like in a real surgical atmosphere,” says Dr. Alicia Ponton-Carss, co-director of the Core Surgical Skills Curriculum and the person who developed the program. “In the real world during surgery you are interacting with many people like nurses, anesthesiologists and students. You need to be in command.” The course isn’t unique in that it trains medical residents to become surgeons; that type of instruction is available at many medical schools. What makes the program distinct is that it teaches surgical skills along with other crucial abilities that are needed to become a complete physician, as declared by the Royal College of Physicians and Surgeons of Canada (RCPSC). These abilities, known by the RCPSC as CanMEDS roles, are core competencies used by physicians on a daily basis. There are seven in all: medical expert, communicator, collaborator, manager, health advocate,
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scholar, and professional. When Ponton-Carss set out to develop the program, incorporating these roles was a top priority. “Dr. John Kortbeek, the head of the Department of Surgery, asked me to develop a core surgical skills program and I thought ‘well if we’re going to do it I’d like to add the CanMEDS roles’,” remembers Ponton-Carss. “I know when I went through training I wish I had people to teach me these competencies.” The program, which began its second year in late August, has earned PontonCarss a nomination for the RCPSC/American Medical Services Inc. Donald R. Wilson award, given to a medical educator who has demonstrated excellence in integrating the CanMEDS roles into a health related training program. “Before, I think most surgeons would learn these competencies on the job and you would more or less model your attitudes from the faculty and professors. But if you learn the roles at the same time as your surgical skills, they are more ingrained and you can develop these roles much better than if they have to be taught years later.” At the Faculty of Medicine, all surgical residents must complete the program regardless of their surgical specialty. Last year 24 students took the course; this year 28 are enrolled. The students practice surgical skills on everything from pig’s hoofs to synthetic skin, bench models and more sophisticated human simulators. Ponton-Carss also developed models for the student to practice various surgeries on, including one for a chest tube insertion. Utilizing plastic moulds made into the shape of a human chest, she attached synthetic skin to some regular, raw pork ribs and then bolted both to the plastic moulding. Inside the moulding are two balloons to act as the patient’s lungs.
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“This is a good representation of what an actual chest tube insertion into a human patient is like. The pork ribs simulate the human ribs of course, and the residents have to be sure not to pop the balloons as this would be like puncturing a patient’s lungs.” In the same session, students practice a treatment called thoracentesis, for which Ponton-Carss also developed a model. This time she used a large Tupperware container and partially filled it with a yellow liquid. She then places some saran wrap, pork ribs and synthetic skin over the container and the students’ task is to drain the liquid. For the students the benefits of the program are obvious; they learn the surgical skills they need and get a jump on obtaining the core competencies that will make them complete physicians. But for Ponton-Carss, the program is just as rewarding. Designing the course is part of her efforts to obtain her PhD in medical education, and it also gives her a chance to give back. “I love education and the residents teach me so much as well. I’m happy to help find ways to pass on surgical knowledge, and it allows me to reflect on my own experiences.”
Check out the video! See medical students practice surgical techniques in the anatomy lab at www.youtube.com/ucalgarymedicine
medicine.ucalgary.ca/magazine
Learning the basics and so much more. Medical residents in the core surgical skills curriculum at the Faculty of Medicine.
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PROFILE
The will to overcome…. and inspire Dr. Mort Doran isn’t your typical associate professor of anatomy. He doesn’t do email, he doesn’t have an assistant, and the only way we got a hold of him was calling his home phone number. Oh, and he also overcame Tourette’s syndrome to practice surgery for more than 30 years. But as COLLEEN BIONDI found out, chatting with Doran is well worth the effort. For over 30 years, Dr. Mort Doran was an accomplished surgeon in Williams Lake and Cranbrook, British Columbia. Today he teaches the anatomy curriculum—on blackboards with coloured chalk—to first and second year students at the University of Calgary Faculty of Medicine. He is a licensed pilot with his own four-seat Cessna and bikes 50 kilometers a day.
helps with OCD behaviors. But as far as the distractibility, reduced attention span, non-compliance and impatience associated with ADHD are concerned, Doran finds one strategy very successful. Avoiding environments which are demanding, aggressive and overwhelming and people who are arrogant and incompetent reduces Doran’s vulnerability. “I can’t stand stupid,” he admits.
There is another unique credential that sets him apart from most other retired surgeons. Doran is the subject of a chapter in Dr. Oliver Sacks’ renowned book An Anthropologist on Mars because he has Tourette’s syndrome.
When Doran was operating, tics were a non-issue. “Tourette’s is not like Parkinson’s where you can’t stop. I can stop,” he explains. Rather the sensation is like an itch or a tag on the back of your shirt. If Doran felt the urge in the operating room, he would simply step back for a moment and take a quick break or twist to release the tension.
Tourette’s is a neurological disorder with a questionable genesis. There is no cure and treatments consist of à la carte drug combos to control individual symptoms and behaviors. Upper body tics are common. “They are essentially the purposeless firing off of nerve pathways indiscriminately and without provocation,” says Doran. For some, “phonic” symptoms—like grunting or hooting—are present. Although he had tics as a child, Doran didn’t think much of it. “I thought that was just who I was,” he says. But one day he was listening to a neurologist talk about a condition on CBC Radio’s Quirks and Quarks program when the penny dropped. “I felt like they were talking about me.” What followed was a diagnosis; Doran was 37 and already a practicing surgeon. What often accompanies Tourette’s is both attention deficit hyperactivity disorder (ADHD) and obsessive compulsive disorder (OCD). Doran has both of these and over the years has found ways to reduce their impact on his life. A low-dose selective serotonin reuptake inhibitor (SSRI)
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“I’ve never slipped in surgery. I would never zig where I should zag,” he says. “I knew what had to be done and I did it.” Rather it was incessant, interruptive or irrelevant intercom messages, for example—as opposed to the difficulty of the procedure—which heightened his anxiety and triggered episodes. For many living with Tourette’s, symptoms abate over time. Not with Doran. He has been dealing with the condition his whole life and has found creative ways to adapt, to manage, to cope. And he recommends this plan to others facing medical challenges. “If you think you can do something, don’t let anyone tell you that you can’t,” says Doran, who acknowledges that an early diagnosis might’ve thwarted his plan to become a surgeon. Next up on Doran’s to-do list? More teaching, biking and flying. And continuing to inspire others to pursue their dreams, despite challenging circumstances, one day at a time.
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Not your typical day at the office For Dr. Neal Church and Dr. Jay Cross, getting down and dirty is a family tradition. “Hereford’s are usually red with a white face and they’re known to be quiet. An Angus though is either solid black or solid red.” It’s not the kind of conversation you’d expect to have with a surgeon. But when you’re at the Calgary Bull Sale—an annual event that attracts ranchers from all over western North America and is now in its 110th year—it’s all bulls, all the time. “Well it’s a lot different than my day job that’s for sure,” admits Dr. Neal Church, an upper gastrointestinal surgeon and a member of the Faculty of Medicine. “But it’s a nice escape, and I enjoy using a different part of my brain.” The bull sale is a gathering place for the ranching community and amongst the crowd you can also find Dr. Jay Cross, a researcher in animal health, molecular genetics and stem cells. Both Faculty of Medicine members have spent months preparing cattle from their family ranches for the sale, and have dedicated their time during the showcase.
medicine.ucalgary.ca/medicine
By Marta Cyperling Church’s family has been ranching north of Calgary for over 100 years. The bulls at the sale are bought exclusively for breeding purposes and are chosen based on the traits that the rancher wishes to have in the young calves, such as easy birthing or general temperament. The rancher must go into the sale knowing his cows and their traits, so he can match them most effectively with the bulls on sale. Cross also participates in the event each year, and ranching has been an important part of his family history since 1883. “It’s a marketplace for selling the best, and it’s a social event for Alberta ranchers where we can exchange ideas and discuss issues.” Ranching is now an ultra modern discipline that encompasses a huge scientific component relating to genetics and veterinary care. “It’s like a science conference in that there are lots of important exchanges happening, formal and informal.”
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Gairdner med ad 09.08.10.pdf 1 10/5/2010 11:55:31 AM
Ucalg Med 40th ad 09.08.10.pdf 1 9/8/2010 2:41:45 PM
The University of Calgary presents the 2010 Gairdner Foundation Lectures Nationally supported by the Canadian Institutes of Health Research
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Please join us on: October 25, 2010 at 2:30pm In the Libin Lecture Theatre at the Health Sciences Centre PM AGREEMENT NO. 41095528 RETURN UNDELIVERABLE CANADIAN ADRESSES TO: University of Calgary Faculty of Medicine Communications & Fund Development Health Sciences Centre 3330 Hospital Drive NW Calgary, Alberta T2N 4N1