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Canada’s DI departments, universities, give birth to new technologiesBy Andy Shaw Diagnostic imaging, since its early X-ray days, has had a remarkable impact on medicine – enabling physicians to diagnose diseases more effectively and thereby hastening treatments. But better imaging doesn’t show up all by itself. Extensive investment, research, and development are needed. So is testing and commercialization. This process is by no means easy nor does it happen overnight. So how does it happen? Often in Canada, the investment comes from government, the research from hospital-connected universities, and the development usually involves partnership with a private sector company. Interestingly enough, a fair bit of this is happening in Canada when it comes to diagnostic imaging. Indeed, the country has a long and distinguished history of innovation in this area. Let’s look at some recent developments in DI, and how Canadian hospitals, universities and research institutes are generating technologies and companies. “There might be as many as 25 companies that spring up in a year, but they’re like fruit flies, hard to see, and most die off quickly,” says Dr. Ian Smith, Director General of the Institute for Biodiagnostics (IBD) in Winnipeg. The IBD, a National Research Council spin-off itself, has taken a different tack from the universities and in its 10 years of existence, the IBD has spun off five diagnostic imaging companies that are in business today. We’ll have more to say about Dr. Smith and the IBD’s innovative approach later. But beforehand, let’s take a look at how two successful diagnostic imaging companies were spun-off by hospitals in Montreal and Toronto. The imaging systems now being sold by Intelerad Medical Systems Inc., in Montreal, and Merge eFilm in Toronto, grew first from research and development done on filmless Picture Archiving and Communication Systems between 1995 and 1999 by a team at the Montreal General Hospital, one of several McGill University teaching hospitals. With backgrounds not only in medical imaging but also physics, computer systems, image-guided surgical planning, as well as electrical and biomedical engineering, Intelerad’s founders had all the necessary backgrounds to be imaging innovators. Chris Henri, now the executive vice president and an Intelerad founder, explains: “In 1995 I was working as a physicist in the department of diagnostic radiology at McGill, where the chief radiologist was Dr. Patrice Bret. When a computer systems administrator left our department, I was delegated the task of finding his replacement and ended up hiring a very talented computer engineer from McGill named Robert Cox. “We hit it off very well, and one of the things we became involved in was trying to get an ultrasound mini-PACS, which had been purchased before we arrived, off the ground and working. It had never really worked. But we had at our disposal some software from the medical physics unit that had been developed by researchers for viewing images on Macintosh computers. In a very short period of time we were able to enhance this software and demonstrate to Dr. Bret that it could do, basically, what the commercial system was supposed to do. He was very excited about that and immediately launched a clinical trial. Within two months, the Radiology department was operating and managing the ultrasound images completely digitally. “So without really intending to, we had become PACS developers. About six months later, we were asked if we could do the same for CT and MRI. We realized that the software we had patched together for the Macintosh ultrasound PACS would not hold up for those two, so we started looking and landed on Linux. “We went with Linux at the time because it was free and we really didn’t have a budget for developing PACS. It ran on PC hardware, which was much less expensive than something like a Sun server,” says Henri. “Linux was also very flexible and it had the ability to mimic some Macintosh capabilities. That was important because back then, our diagnostic imaging department was entirely Macintosh-based. “We used Linux and some public-domain software to re-develop our server architecture for acquiring, storing, archiving, and retrieving images. And by February of 1997 the department had gone live, filmless in CT and MRI. We literally ripped out all the laser cameras that were used to print film. So there was no turning back. “But eventually we got to the point where the hospital administration said that the hospitals are in the business of providing healthcare, and not operating a research and development shop, so they couldn’t afford to grow our group anymore. They said that they were grateful for the work we had done and wanted us to simply maintain it. They, in fact, encouraged us to step outside of the hospital and form a company that would allow us to continue our development efforts and grow through commercial sales. And they assured us that they would be our first client.” Thus was born Intelerad. In the meantime, Dr. Bret had been attracted by the University Health Network (UHN) in Toronto to become its chief radiologist – and had expressed the desire to build a similar team at the UHN that would share the Montreal software and continue PACS software development. Dr. Bret’s first hire for the Toronto group was Gregory Couch, PhD. He spent his first month on the job in Montreal picking the brains of Henri and his colleagues. “Gregory then developed what was the missing piece of the puzzle,” says Henri. “Partly by putting it on the Internet for other developers to add to, he developed an application called eFilm that was darn near as good as anything you could get commercially, but it was for free, and you didn’t need to buy a six-figure workstation to run it. He really shook the foundations of the imaging world with that.” For more than a year, the development groups in Montreal and Toronto tried to form a single business entity in order to bring their systems to market. But by February of 2000 they agreed to go their separate ways. Since then, a Milwaukee-based company has bought control of the Toronto interests, with Couch serving as Merge eFilm’s chief technology officer working out of the company’s Toronto office. Now, Intelerad and Merge eFilm are in effect PACS competitors. But they remain friendly. Intelerad even distributes the eFilm software. “We have slightly different strengths,” says Henri. “Intelerad’s strengths are definitely in the technical back end for handling archiving and distribution. And we’re focused on 24-hour-a day support.” On the other hand, Merge eFilm developers have produced what they regard as a quantum leap in the flexibility, scalability, and workflow capacity of a PACS system at the front end. The company’s Fusion Server 1.0 is a single software platform that minimizes the hardware needed while delivering clinical quality PACS, as well as teleradiology and Web distribution. It readily integrates databases and image storage with a whole range of overriding HIS applications. As such, the company says its software is a stepping-stone to both a filmless environment and a fully electronic patient record. For its part, Intelerad’s IntelePACS is a highly scalable, fault-tolerant system that works on PCs or workstations running Linux and that conforms with the DICOM 3.0 standard. But more importantly to its developers, it is affordable. Somewhat like “buying” certain cell phones, you don’t pay for the tangible IntelePACS product. In effect, it’s free. What you pay for, besides the off-the-shelf hardware needed, is Intelerad’s standard support package for the first year. It includes round-the-clock remote technical support, daily system watch-dogging by Intelerad’s proprietary InteleMonitor system, any software updates, and follow-up onsite visits after installation. Intelerad’s current client list of over 20 hospitals and other users spans three continents and stretches from the Perth Radiological Clinic on Australia’s west coast, to Radiology Imaging Associates in Denver, Colo., St. Paul’s Hospital in Vancouver, the University Health Network and Mount Sinai Hospital in Toronto, the McGill University Health Centre and the Centre Hospitalier de l’Université de Montréal (CHUM) and on over to the Ernest Müller Research Institute in Bern, Switzerland. Meanwhile, in Manitoba, there’s an alternative approach to diagnostic spin-offs that’s also in the picture. At the Institute for Biodiagnostics (IBD) in Winnipeg, they’re spinning off companies based on research in four core areas: magnetic resonance imaging, spectroscopy, physiology, and bioinformatics. The stated goal of the National Research Council (NRC)-backed IBD is to develop non-invasive diagnostic instruments and techniques that can be commercialized. IBD is not associated directly with any university or hospital. IBD’s best known spin-offs sound like a trio of space aliens: Novadaq, IMRIS, and MRV. Scientists and programmers at IBD spent three years developing the cardiac imaging system now commercialized by Novadaq Technologies Inc. Novadaq’s SPY(tm) Imaging System enables cardiac surgeons to check the outcomes of coronary artery bypass procedures on the fly. SPY can instantly spot kinks or twists restricting blood flow in new artery grafts. SPY is awaiting FDA approval in the United States but is already on sale in Canada and Europe . Similarly, IBD researchers conceived the original design for the patented IMRIS inter-operative magnetic resonance imaging system made for neurosurgeons. The IMRIS magnet at the heart of the system can move repeatedly over the patient and then retract to allow surgeons unrestricted access to the patient. Brain surgeons are currently using an IMRIS system at the Foothills Hospital in Calgary. The magnetic resonance technology used by MRV Systems is specifically designed for use on our four-footed friends. Winnipeg veterinarian Dr. Gordon Goodridge triggered IBD interest in developing an affordable MRI to meet the strong demand for veterinary diagnostic imaging. Traditionally, the cost of owning MRI equipment and being trained in its use has been too high for veterinary clinics and hospitals. So they have had to negotiate with regular hospitals for after-hour access to MRI or use lower resolution X-ray and ultrasound systems. Nonetheless, the estimated North American spending on pet examinations, pregnancy testing of livestock, and soundness evaluation of race horses is nearly $700 million annually. To exploit this major market, MRV has on trial in Saskatoon a mobile veterinary MRI that is about a tenth the cost of a fit-for-humans model. IBD’s ability to spin-off new companies received a further boost last year when the NRC announced a $10 million contribution as part of its nation-wide innovation program. The money will help finance a new Industrial Partnership Facility (IFP). To be built alongside the IBD building, the IFP will be a small business incubator for IBD diagnostic spin-offs and other start-ups. The entrepreneurs of those fledgling companies will be able to draw on and work alongside IBD’s top medical technology researchers. Smith believes the dedicated nature of the IBD is more productive in creating spin-off companies than either the hospital/university or big company environments. He says university researchers are focused mostly on their individual career paths and getting them to collaborate on research is challenging at the best of times, never mind getting them to go all the way and form a new company. And the large-scale market leaders in diagnostic imaging keep their focus on the large scale. “These guys are not interested in one-offs, two-offs, three-offs or even 10-offs. They’re interested in 1000s-off. They can’t make money unless they have a large volume,” says Smith. “But the real breakthroughs are made by the small companies like ours doing one- to three-offs. Then when they have demonstrated that it works in a hospital or two, they sell it to a Siemens or a GE, who say we didn’t want to invest in it before because it was too risky. But now that you have shown that it works, we want to buy it off you.” Smith says there are exceptions out there to his rule of thumb, citing the development work being done at Sunnybrook Hospital in Toronto and the spin-offs created by the Robarts Institute in London, connected with the University of Western Ontario. “I would rank Robarts right behind us” says Smith. As to other sources in future for spinoffs, here’s one hitherto off-the-beaten-track spot to watch: Saskatoon. For two reasons: first, it is the site of the soon to be operational synchrotron at Canadian Light Source Inc. And, in case you have to ask, a synchrotron is an accelerator that spins atomic bits about the circumference of a 400-metre loop and is used for a wide variety of research. Among its talents, the synchrotron can spin-off and focus the X-ray end of the light spectrum with unequalled clarity and brilliance. The other reason to keep an eye on the place is the outfit’s newly appointed president. In a remarkable recruiting coup, Dr. Bill Tomlinson was snared from the European Synchrotron Radiation Facility in Grenoble, France, where he was head of the medical research group. During earlier research in his distinguished career, Dr. Tomlinson helped invent and patent a diffraction-enhanced imaging technique. BACK TO TOP OF PAGE
York Central among first in Canada to use endoscopic ultrasoundBy Jerry Zeidenberg RICHMOND HILL, ONT. – A gastroenterologist trained at the Mayo Clinic in Minnesota is now using endoscopic ultrasound technology at York Central Hospital, in Richmond Hill, Ont., to more accurately diagnose lesions found in the GI tracts of patients. The technology also enables the physician to gauge how far cancers have developed, and to determine the best course of therapy for patients. “It’s an excellent way of identifying cancers and other illnesses – quickly, accurately, and in a non-invasive manner,” said Dr. Pardeep Nijhawan, who recently completed a five-year residency and research fellowship at the Mayo Clinic, specializing in gastroenterology. While EUS is used in many medical centers in the U.S., York Central Hospital is one of the first facilities in Canada to employ the technology. Like other forms of diagnostic imaging, it may become a standard practice across the country as word of its effectiveness spreads. For his part, Dr. Nijhawan is thrilled that his hospital is able to offer the advanced technique to patients. “It’s nice to see that a community hospital can take the lead in introducing this to Canada,” he said. Endoscopic ultrasound (EUS) works by attaching an ultrasound probe to the tip of a narrow catheter, which is carefully guided through the digestive system of the patient. The ultrasound device not only creates images of structures on the surface of the GI tract, but also identifies problems in the walls of the stomach, duodenum and intestines. Moreover, it can be used to image nearby structures, such as major blood vessels, the pancreas, liver, gallbladder and lymph nodes. “Endoscopic ultrasound can tell us what type of lesions we’re dealing with, even if they are submucosal (beneath the surface layer),” said Dr. Nijhawan, who has been using the technology to diagnose patients at the hospital since August, after the hospital acquired a $220,000 EUS system in July. He said endoscopic ultrasound is most useful for patients who have had a regular endoscopy, during which a lesion was found. An EUS can help the specialist determine the nature of the mass without the need for exploratory surgery. “It can tell us if it’s a benign or malignant cancer, a pool of blood vessels or even a fat collection,” explained Dr. Nijhawan. In each of these cases, the images will appear differently on the computer screen, which the physician watches as he or she performs the procedure. “It’s a matter of pattern recognition,” noted Dr. Nijhawan. The technology is also extremely useful for cancer staging, he said. “If you can look at the lesion using ultrasound, and you see that it’s in an advanced stage, you might decide that extensive surgery is unnecessary for the patient.” For example, in cases of advanced esophageal cancer, removal of a large part of the esophagus could be more traumatic to the patient than foregoing the surgery and allowing the person to live out his remaining days, months or years with the ability to eat and drink relatively normally. Dr. Nijhawan predicts that enhancements to EUS technology will appear in the near future, such as narrower catheters, making it easier for the patient to swallow and reducing the risk of tearing the GI tract. As well, he foresees developments in the area of fine needle aspirants – the devices that allow physicians to take tissue biopsies while they are conducting the endoscopic ultrasound. All in all, Dr. Nijhawan says endoscopic ultrasound is an extremely useful technology: “It’s an excellent method of determining what’s going on inside the GI tract, and for making an accurate diagnosis.” BACK TO TOP OF PAGE
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Canada’s DI
departments, universities, give birth to new technologies