Thursday, March 14, 2019
Staying at the forefront of technological changes in health care is essential to improving patient outcomes, and at Virginia Commonwealth University, health sciences students are learning how to apply training, diagnostic and other medical tools in clinical settings. Below is a snapshot of how innovations in dentistry, pharmacy, medicine and other disciplines are shaping health sciences education at the university.
When Meera Doshi, a psychology major, learned about the principles of magnetic resonance imaging technology in the classroom, she was left with a lot of questions.
However, Doshi honed a deeper understanding of how the technology can be applied as a research tool while working under James Bjork, Ph.D., associate professor of psychiatry in the VCU School of Medicine who oversees the Adolescent Brain Cognitive Development Study. The longitudinal, nationwide study is aimed at increasing the understanding of how environmental, social, genetic and other biological factors affect brain and cognitive development and can disrupt a person’s life trajectory.
Doshi was able to observe a research-dedicated MRI being used to measure adolescent brain development at the VCU Collaborative Advanced Research Imaging Center, part of the university’s C. Kenneth and Dianne Wright Center for Clinical and Translational Research.
“I’ve learned a lot about imaging and when I learn about studies involving imaging in class I have more real-world understanding outside of scientific articles,” Doshi said. “MRI technology wasn’t something I fully understood before. So, actually seeing it in person was extremely helpful to my understanding of the medical technique.”
Currently, students and researchers overseeing studies in the fields of neurology, hepatology, cardiology and substance abuse use the CARI program. In addition to an MRI scanner specifically dedicated to and calibrated for research, the facility offers interview and physical examination rooms, a medication dispensary, staff to operate the MRI scanner and interpret scans, and other resources dedicated to research.
Currently, 47 studies are being conducted at the facility, most of which are focused on substance abuse, said Joel Steinberg, M.D., a research professor in the Wright Center and director of the CARI program.
Steinberg and his team are currently testing the effectiveness of Lorcaserin, a Food and Drug Administration-approved medication for weight loss, in reducing drug cravings in people with cocaine use disorder and opioid use disorder. The CARI MRI scanner would help researchers observe changes in brain physiology that may be related to improvements in patients who are in recovery for substance use disorder.
Steinberg said the CARI MRI scanner is a great tool for understanding how substance abuse disorder is related to abnormal brain physiology.
“No one knows the exact cause of substance use disorder but we’re trying to find that out,” he said. “If we can figure out the mechanisms of how the brain is disordered then perhaps researchers can create treatments targeted to the disordered brain physiology.”
Robert Cadrain, MRI manager of the CARI program, said the students, researchers and medical technologists who use the CARI MRI have a chance to participate in groundbreaking research that affects public health on a large scale. Cadrain operates the CARI MRI scanner to produce images within parameters given by researchers.
“In the clinical setting, someone may come in with an injury and you are helping that one person, but at the CARI facility you are looking at the bigger picture,” Cadrain said. “You are investigating far-reaching problems such as drug addiction and traumatic brain injury and figuring out the mechanisms behind these conditions and how to fix them.”
Victoria Allen, a fourth-year student in the VCU School of Pharmacy, works as a pharmacy technician at a local Walgreens. When the family member of someone with opioid use disorder inquired at the pharmacy about how to administer naloxone — the opioid reversal drug — Allen was ready to provide instruction.
Allen and other students in the School of Pharmacy practice mock naloxone counseling and learn how to identify opioid overdoses. The students also learn three methods to administer naloxone.
Allen said the coursework is applicable to her goal of working alongside physicians in an ambulatory care setting.
“An aspect of ambulatory care is patient education,” Allen said. “Also, as pharmacists, if you happen to see someone in need of assistance and you are carrying naloxone, you can save a life.”
Students typically use a SimMan, a patient simulator created by Laerdal Medical, to learn how to spot signs of an opioid overdose. The life-sized CPR dummies are used to learn how to administer a naloxone nasal spray, atomizer or an auto injector developed by VCU School of Pharmacy alumnus Eric Edwards.
The SimMan is also optimized for teaching naloxone administration and displays neurological and physiological symptoms related to a number of emergency medical conditions, including opioid overdose. For example, reduced or ceased respiration is a common symptom of opioid overdose and with a few clicks of a mouse and computer field inputs, the mannequin’s chest begins to rise less with each breath. His blood pressure and vital signs can be adjusted and he even has a pulse at his femoral artery and other points. People who are revived following opioid overdose often have extremely irritable moods and the SimMan can be programmed to respond verbally following resuscitation.
When students have properly applied one of the three treatments, the SimMan’s vitals begin to normalize. Sensors in the mannequin’s body can report when students have used the auto injector, which is applied to the thigh similarly to how an EpiPen is used for allergies, or the atomizer and nasal spray that are administered nasally. The students are also taught that before administering naloxone to an unconscious patient, they should rule out signs that low blood sugar is the cause.
The SimMan can also be used to mimic the fact that naloxone only circulates in the body for roughly five minutes, said Laura Morgan, Pharm.D., associate professor in the School of Pharmacy and an opioid education specialist.
“Since naloxone only stays in the system for a few minutes, the patient will often wake up minutes later and go unconscious again, so the caregiver will have to readminister the naloxone,” Morgan said. “Part of the simulation process is the student assessing whether the patient has started to respond to the naloxone appropriately.”
Learning to identify the signs of overdose and how to use naloxone have been part of the pharmacy school’s efforts for nearly four years to prepare students to effectively treat patients amid the opioid crisis. In 2017, the school bolstered these efforts with a laboratory activity for its third-year students focused on Virginia’s prescription monitoring program, naloxone counseling, opioid prescriptions and pain management.
Loud whirs are heard in the background at the School of Dentistry’s digital dentistry lab where computer-aided design/computer-aided manufacturing machines are used to mill custom-made crowns and 3D printers are printing dental appliances.
The lab, headed by Sompop Bencharit, D.D.S., Ph.D., the school’s first director of digital dentistry, was created to apply new technology in the classroom and clinical settings. Bencharit teaches students how to use digital technology to create dental prosthetics and models that a decade ago most dentists and technicians cut and molded by hand.
Now, a growing number of dental practices expect graduates to have experience in using CAD/CAM technology including digital prosthetic design and milling, and 3D printing.
“CAD/CAM technology is the new disruptive innovation,” Bencharit said. “As many as 30 years ago, the industry-changing innovations were adhesive dentistry and modern implants. We’ve come a long way.”
Digital fabrication often has the advantage of being more precise and having more consistent quality than prosthetics created by hand, he added.
“There are so many studies that show that digital fabrication of prosthesis is the same or better than conventional techniques,” Bencharit said. “It gives a good baseline for quality and levels the playing field.”
Henrique Silva is one of several third- and fourth-year students who are learning oral scanning techniques and how to design and mill crowns from Bencharit as well as digital lab technician Marithe Baclagon and digital lab manager Robert Armstead. The students then apply that knowledge to patient care at VCU’s dental clinics.
Silva said one of the greatest benefits of having access to CAD/CAM technology is the ability to make assessments and create and fit crowns within a day in many cases.
“Same-day crowns are great for the patient and a good experience for us,” Silva said. “We are able to prove to potential employers that we have done cutting-edge dentistry.”
While many private dental practices have the scanning technology required to create the final crowns, outside labs frequently design and mill the crowns using the scans. This requires a longer wait for patients, who often have to wear a temporary crown until a permanent crown is milled.
“Our patients come in in the morning, we’ll anesthetize them, prepare the tooth and design and mill the crown,” Silva said. “Then we will place the crown, cement it and they go home with a brand new tooth that same day. No one wants to walk around with something temporary that is often uncomfortable.”
Bencharit also has reduced patient wait times by implementing intraoral scanning and digital impressions in the clinic and teaching students to use the technology. The digital impressions take roughly five minutes and are made using a handheld scanner. The scanner is able to take 1,400 to 1,500 pictures to create a digital model that can be viewed on screen for designing a CAD/CAM crown, which is later milled into the final crown product. Traditional impressions require a molding material that is mixed and must harden in a patient’s mouth.
This month, the lab was expanded to a larger space that includes additional milling machines and 3D printers capable of creating not only porcelain crowns, but dentures and other dental prosthetics and appliances that require either metal, wax or plastic materials. Bencharit said the improvements will allow more services to be performed in-house, which could eventually translate to lower costs for patients.
“We are hoping to be able to lower the cost of dental care so that people in the community can receive the best treatment,” he said. “The students will also be able to expand their knowledge of dentistry in the digital world.”
Training for surgery
Jeremy Powers, M.D., a plastic surgery resident in the VCU School of Medicine, has spent numerous hours practicing anastomosis, a suturing technique for connecting blood vessels.
Specifically, Powers is working to perfect a type of anastomosis used during DIEP flap surgery, a breast reconstruction technique for women who have had mastectomies. He has spent his residency shadowing attending physicians before peering through the scopes himself.
“For the first several you do, you help only with the vein, then you assist with the artery,” he said. “They [the attending physicians] might let you put one or two stitches in the artery while they observe how you work under the scope and get more comfortable with your skills. It’s a graded progression of doing more and more.”
To hone their skills, the residents also practice on the Advanced Microsurgical Trainer developed by collaborators from the School of Medicine, College of Engineering and School of Arts. The trainer simulates blood flow, vessels, cardiac distress and a chest cavity.
Santosh Kale, M.D, assistant professor in the School of Medicine, developed the idea for the trainer. Kale wanted to address an absence of realistic models for teaching anastomosis. Students have traditionally learned on animal models and tabletop models made of rubber tubes that simulate blood vessels.
“A human is much larger than an animal, so there are more three-dimensional constraints in humans to consider,” Kale said. “There are also intricacies that are unique to human physiology that may be subtly different from animal physiology.”
Co-primary investigators included Morgan Yacoe, an alumna of the VCU School of the Arts sculpture program; and Peter Pidcoe, D.P.T., Ph.D., director of the Engineering and Biomechanics Lab. Pidcoe, a professor and assistant chair in the Department of Physical Therapy in the College of Health Professions, also holds an appointment in the Department of Biomedical Engineering in the College of Engineering.
Yacoe created the torso model while Kale provided guidance on anatomical accuracy. Pidcoe engineered a pump within the chest cavity that simulates blood pressure levels. The pump also simulates the flow of oxygenated blood out of the heart and oxygen-depleted blood into it. Pidcoe also created an Android application that controls the system.
Powers said the trainer helped him build confidence in his surgical skills.
“Our training is greatly enriched by having opportunities to practice with a simulator, so that in the operating room, the process is faster and more efficient,” he said. “As we know from several studies, less time under anesthesia leads to better outcomes for our patients.”
VCU researchers and students across multiple disciplines are using AR technology to improve health outcomes and conduct innovative research.
AR superimposes digital information onto real-world surroundings and is currently used in a number of applications, most popularly for gaming. Researchers and students in the lab of Dayanjan “Shanaka” Wijesinghe, Ph.D., assistant professor in the Department of Pharmacotherapy and Outcomes Science in the School of Pharmacy, are working with physicians to use AR to plan complex cardiac surgeries. They have developed the MedAR program, which renders 2D stacks of a patient’s CT and MRI scans into 3D hologram-like images that can be viewed while wearing the Microsoft HoloLens headset and manipulated via gesture and voice commands.
The 3D images are often more effective than 2D MRI scans for planning surgical approaches, said Daniel Tang, M.D., the Richard R. Lower Professor in Cardiovascular Surgery in the VCU School of Medicine.
Tang recently partnered with Wijesinghe’s lab to use MedAR to plan the removal of a tumor surrounded by heart tissue. The surgical team was able to use 3D models of the patient’s MRI scans to view the whole heart and remove portions of the organ to isolate the tumor before starting the surgery.
“It really gives you a sense of where structures lie in relation to other structures while planning operations,” Tang said.
MedAR was developed by Wijesinghe in partnership with Tang; graduate student Vasco Miguel Pontinha from the School of Pharmacy; Ali Panahi from the College of Engineering; Vigneshwar Kasirajan, M.D., the Stuart McGuire Professor and chair of the Department of Surgery; Alex Valadka, M.D., a professor and chair of the Department of Neurosurgery; and the VCU da Vinci Center.
Currently, two teams of students are refining the technology as part of the College of Engineering’s Vertically Integrated Projects program, which allows undergraduate students to participate in multiyear, multidisciplinary, team-based projects under the guidance of faculty and graduate students.
Raghav Saravanan, a student in the College of Engineering, is on MedAR’s biomedical team, which uses 3D slicer software, commonly part of 3D printing processes, to combine multiple 2D MRI and CT scans into single 3D renderings.
“Our work with MedAR is practical and I enjoy learning that goes beyond books and the classroom,” Saravanan said. “We are applying knowledge from the classroom to change the lives of people around us.”
Joseph Hamlett, also a student in the College of Engineering, is part of a computer science team that programs voice commands for MedAR and the code that enables the 3D images to be displayed on the HoloLens.
“I aspire to work in the virtual reality industry so when I found out about this team, I had to be on it,” Hamlett said. “There are not a lot of other classes and programs that are teaching applications for augmented reality in this way.”
Shirley Yu, a first-year student in the School of Medicine, is also training to segment the medical images. Yu, who is interested in radiology, said she would like to see AR technology applied in the field.
“I feel like this technology could improve how radiologists read scans,” she said. “I’ve always been fascinated by augmented and virtual reality and would like to apply these technologies to medicine.”