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Medicine 2.0

  Medicine 2.0: Promising Advances in Consumer Technology, such as 3D Printing  

By Joan Voight • Illustrations by Otto Steininger

Physicians and medical researchers are harnessing promising new advances in consumer technology, such as 3D printing and wearable sensors to improve patient care in amazing ways.

Tucked deep in the lower level of UCLA’s Center for the Health Sciences is a room that looks more like an inventor’s fantasy workshop than the medical-research facility it is. Tables are piled high with tools, electronics, prototype equipment parts and a few stray robotic arms. Posters on the wall describe pending projects in dense technical language with accompanying photos of futuristic devices. A few young graduate students toil over wires, sensors and plastic gadgets, and the only sound is the repetitive whine of a 3D printer in the back of the room, as its head shuttles back and forth, laying down layer upon layer of hot plastic.

To get here, you must make your way along several empty hallways — the entire building is in the midst of renovation — giving the feeling that one is navigating a secret passageway from the campus to reach an eccentric scientist’s subterranean lair. In fact, this hidden space is doing work that is at the very forefront of technological advances in the service of medicine. Its assemblage of smarts, parts and computers is contributing to an emerging era of personalized, tech-enabled healthcare treatment and medical research that challenges our imaginations.

THE TRANSFORMATION ALREADY HAS BEGUN. Cool inventions like replacement bones and inexpensive DIY plastic hands, fingers and other prosthetics are now being created on 3D printers like the ones at UCLA for a fraction of the cost of traditional versions. 3D bioprinting is being used to regenerate skin, blood vessels, tracheal splints and heart tissue. As you read this, somewhere a researcher is working to produce a 3D-printed heart, while another is trying to “print” functioning human kidneys.

Welcome to Medicine 2.0

At UCLA, the work toward turning these sci-fi explorations into reality is taking place in the Center for Advanced Surgical and Interventional Technology (CASIT). Through CASIT, surgeons interact with biomedical engineers to lay the foundations for new clinical interventions. CASIT facilities also include the Gonda Robotic Center, a telecommunications center, a computer-simulation facility and an integrated-operating-room suite. The overall goal of CASIT is to make healthcare more accessible by accelerating the process of turning basic-scientific research into practical medical tools and then finding companies to manufacture them.

One key project for CASIT and its 3D printers is to help prostate-cancer patients avoid the surgical removal of their prostate in favor of removing only the cancerous tumors. Gordon Deboer, a 6-foot-6- inch, 260-pound former Navy pilot, is a beneficiary of that effort. He is among a handful of test cases at UCLA for whom CASIT’s research has played a significant role in helping to guide treatment decisions. Like a lot of men, Deboer, 72, found out during a routine exam a few years ago that results of his PSA test, which measures a protein in the blood that can indicate prostate cancer, were higher than normal. He was referred to Leonard Marks, MD (RES ’73, ’78), professor of urology at the David Geffen School of Medicine at UCLA, who is known for doing advanced work with prostate tumors.

Deboer says when his tumor was identified, he considered surgery vs. less-invasive alternatives. He opted for a UCLA research project, focal laser ablation (FLA), in which a laser destroys only the tumor. The catch with FLA treatment, however, is that it’s difficult for surgeons to discern precisely the extent of the tumor based only on magnetic resonance imaging (MRI) scans. Under the clinical direction of Dr. Marks and the supervision of Warren Grundfest, MD, a surgeon and professor of bioengineering, the CASIT team came up with the idea of employing a 3D printer to assist in FLA preparation.

The approach sounds fairly straightforward. After removing a cancerous prostate from a patient, the 3D printer creates a plastic mold that wraps around the diseased organ. Doctors then can compare the two-dimensional MRI images of the prostate’s tumors to the growths in the actual glands to determine how they differ. That comparative information then is used to help future patients. “With MRI alone, we had been chasing shadows,” Dr. Marks says. “Now, we know how a spot shown on the MRI correlates to a spot on the actual prostate. It significantly increases the knowledge we have when taking biopsies and conducting laser surgery.”

In the CASIT lab, it was graduate student Alan Priester, working with Shyam Natarajan, PhD, assistant adjunct professor in the departments of urology, surgery and bioengineering, who figured out how to print a hollow plastic box within which the empty space is the shape of the diseased prostate. The box has slits that exactly match some of the slices of the gland viewed by the MRI; the slits guide the researchers to cut off slices of the gland that directly correlate to the slices visualized in the MRI. A comparison reveals exactly how the computer image is different from the actual prostate. Researchers found, for instance, that MRI images often show that a tumor is smaller than it actually is.

In Deboer’s case, the work done with the 3D-printer-created box helped surgeons to accurately interpret the MRI images of his tumor and remove only what was needed. Deboer underwent the two-hour FLA treatment in September 2014, without any disruption in his work or his life, he reports.

  Medicine 2.0: Promising Advances in Consumer Technology, such as 3D Printing  

Basic 3D printers, like the ones in the CASIT lab, work by melting hard plastic, then laying out the liquid plastic on a flat surface, similar to printing in ink. Layer upon layer of plastic is deposited, each on top of the other, cooling and hardening as it is laid down. In the end, there is a physical replica of what has been pictured in the computer and fed to the printer.

Software does much of the work, explains Priester. The operator provides the image and picks the density and resolution of the production. The computer then calculates the path required to print out the shape. It takes about six hours — and $4 worth of plastic — to print out each of those individualized prostate molds.

FOR PEOPLE WHO ARE LEARNING HOW TO USE PROSTHETIC LEGS AND FEET, a significant problem is the absence of sensation of their own weight, which throws off their balance and walking ability. CASIT researchers are coming up with a solution — a device that transfers pressure from a user’s artificial foot to the upper leg.

The 3D printers at the lab have been called into action to make the device more effective. Sensors placed in the sole of a shoe worn by a prosthetic foot measure the weight put on the foot, and that information is sent wirelessly to a cuff around the patient’s upper leg. The magic of the system comes from dime-sized balloons inside the cuff that inflate and press against the skin according to the pressure placed on the foot sensor, explains Zach McKinney, a bioengineering graduate student working on the CASIT project. For instance, pressure on a sensor in the toe area makes three balloons on the front of the thigh inflate. Weight on the heel sensor makes the balloons on the hamstring inflate.

The balloon system “takes advantage of the natural neural wiring of the body,” says Erik Dutson, MD, clinical professor of surgery and executive medical director of CASIT. Sensations from the foot, if it were there, would go up the leg where the balloons are placed to reach the brain. “So, it’s like we’re using the same telephone pole” to send touch signals to the brain, Dr. Dutson explains. “The human brain learns very quickly how to reinterpret signals on the skin to tell the person where his leg is in space and if his foot has hit the ground,” adds Dr. Grundfest.

Initial tests showed that this sensory-, or haptic-, feedback system helped about half the amputees in the program achieve a more normal gait.

The 3D printers are employed to cheaply and quickly produce tips for the balloons where they press on the skin. So far, three types of tips — from pointed to rounded — have been created to use on patients, depending on the sensitivity of their skin.
Later this year, the haptic-feedback system, including customized balloon tips, will be tested on a few dozen patients who have numb feet due to peripheral neuropathy from diabetes. “We are looking to improve their mobility and confidence and prevent worse problems down the line,” McKinney says.

HEART SURGEONS AT UCLA also are exploring how 3D printing can help them treat infants and children with congenital heart disease. In a first for the university, doctors in February prepared for the complicated surgery of a 7-monthold by studying a printed plastic replica of the baby’s heart. The model of the heart was created by a tech company in Belgium that used high-quality MRI images from UCLA and its own sophisticated software and 3D printer. “This first case was a way to learn the mechanism [of the 3D-printing process] and to explore how to proceed,” says J. Paul Finn, MD, professor of radiology and director of Magnetic Resonance Research at UCLA Radiology.

The infant had two abnormalities in the structure of his heart — a rare and complex condition. Examining the 3D-generated plastic heart helped the child’s physicians analyze how best to repair both abnormalities, says Dr. Finn and pediatric cardiothoracic surgeon Brian Reemtsen, MD (RES ’02), who is collaborating with Dr. Finn on the project.

While most 3D printing uses hard plastic, this printed heart was made of a rubbery plastic “that resembles the consistency of a gummy bear,” Dr. Reemtsen says. Because the shape of a heart changes as it beats, it is more realistic for surgeons if the plastic heart is pliable and also can change shape.

This year, doctors expect to use printed hearts as part of surgery preparation for another five infants. The potential is enormous, Dr. Reemtsen says. “With a physically accurate model of a heart, we can establish if only one incision is needed instead of two, or we can see if it’s possible to not just correct the problem, but also to change a baby’s anatomy to normal, which will allow the child to live decades longer than he or she would otherwise,” he says. “We can also practice a procedure beforehand with less time pressure. Cardiac surgery is a timed event.”

In addition to babies, UCLA doctors at the Ahmanson/UCLA Adult Congenital Heart Disease Center are using 3D printing to create models of adult hearts to practice surgery beforehand for procedures such as a difficult heart-valve replacement. “Harnessing 3D printing helps us better address the most complicated cases,” says Jamil Aboulhosn, MD ’99 (RES ’02, FEL ’05, ’06), Streisand/American Heart Association Endowed Chair in the Division of Cardiology and director of the Ahmanson/UCLA Adult Congenital Heart Disease Center.

Another enormous plus, Dr. Reemsten says, is that having a model of an actual heart enables surgeons to have something to show parents and heart patients when they are explaining the procedure and its risks. Later this year, researchers working on the heart program expect to start brainstorming and sharing resources with CASIT.

  Medicine 2.0: Promising Advances in Consumer Technology, such as 3D Printing  

WEARABLE GADGETS LIKE FITBIT FITNESS TRACKERS and the new Apple Watch get lots of media buzz, but the biggest impact of portable sensors that collect and analyze data will be in medicine. Devices much like Star Trek’s tricorder, the fictional sensing device that doctors used to diagnose diseases and collect information about a patient’s bodily functions, could be in our future.

UCLA medical researchers are moving the field forward, working on tools that give doctors hard information where they once had only patients’ imperfect memories. Among the most impressive efforts is the work being done with heart-surgery recovery and stroke therapy.

This year, for example, about a dozen UCLA heart-surgery patients have gone home with toolboxes that contain a pre-programmed computer tablet and wireless digital sensors that patients use to measure their weight, pulse and heart rate. These measurements are automatically transmitted to a nurse practitioner, who reviews the patient’s information and uses the tablet to hold video calls — similar to Skyping on an iPad — to discuss recovery progress and visually check on the patient.

“Everything is extremely easy for patients. They just turn on the computer tablet, and the screen asks them questions and tells them exactly what to do,” explains cardiothoracic surgeon Peyman Benharash, MD ’02 (RES ’08, FEL ’10), who oversees the heart-surgery-telehealth program. Data from this program alert the patient’s healthcare team about abnormal heart rhythm, lung problems, weight gain from fluid retention and other problems before they get to the point that the patient has to be hospitalized.

About 20 percent of heart-surgery patients in the U.S. are readmitted to a hospital within 30 days of discharge, according to researchers at Duke University Medical Center. In contrast, the readmission rate has dipped to about 6 percent among heart-surgery patients who participate in this program and other in-home web-conferencing programs, according to a recent UCLA study, Dr. Benharash says.

STROKE THERAPY STOPS TOO SOON or the goals are set too low, partly because therapists and doctors are not digging deeply enough into the scientific bases for rehabilitation, according to the UCLA Neurological Rehabilitation and Research program. Bruce Dobkin, MD (RES ’77), professor of neurology and director of the program, is trying to address that problem with networked sensors that patients wear on their ankles.

How much and what kind of physical activity patients get after they leave the hospital plays a huge part in recovering from a stroke, doctors say. The trick is to get objective information about people’s real-life exercise patterns. The ankle sensors in Dr. Dobkin’s program, which were developed with William Kaiser, PhD, professor of electrical engineering in the UCLA Henry Samueli School of Engineering and Applied Science, record accelerations and decelerations as the person moves. Then a smartphone sends the data to computer programs that analyze the type, quantity and quality of the movements. Walking speed and distance, asymmetries in leg movements and diligence in practicing particular skills can all be recorded. Twice a week, a therapist calls the patient wearing the sensors. Based on the data, the patient gets feedback on his or her activities and advice on how to improve his or her daily exercise.

Traditionally, stroke patients see a doctor a month after being released and then two or three months after that. “Crucial recovery time is wasted if the patient isn’t active between these doctor visits,” Dr. Dobkin says. Currently, researchers at UCLA and the University of Miami are examining whether or not the data collection and feedback from the sensors increase daily exercise, improve walking and reduce risk factors for repeated stroke or heart attack. They expect to have an adequate sample by fall 2016.

  Ralph and Shirley Shapiro  
 

Ralph and Shirley Shapiro
Photo: Courtesy of UCLA School of Dentistry

Why I Give

Shirley and Ralph Shapiro and their family are generous philanthropists who have supported many areas across UCLA, including endowing four chairs in UCLA Health Sciences.

The Shapiros recently made a gift of a 3D printer to the David Geffen School of Medicine at UCLA in honor of Drs. Richard Shemin, William Suh, Tamara Horwich, Karen Cheng and Benjamin Ansell.

The printer will help advance the clinical, research and educational activities of the physicians and scientists working in cardiovascular medicine at UCLA.

“Shirley and I are gratified to help UCLA’s talented physicians leverage the latest technology to ensure the best possible outcomes for patients.

“Our family made this gift in honor of the doctors in UCLA’s heart program. We are proud to support their research.”

– Ralph Shapiro

When the California Rehabilitation Institute — a partnership among UCLA Health, Cedars-Sinai and Select Medical — opens in Century City next year, “the plan is to have recovering stroke patients wear these activity sensors both in the hospital and at home,” Dr. Dobkin says.

BECAUSE SURGERY SHUTS DOWN THE DIGESTIVE SYSTEM, determining when a person’s digestive tract can accept food again has been a hit-or-miss proposition. With a new device — a pair of disposable, one-inch sensors that people wear on their abdomens to sense and record the vibrations of the digestive tract — based on research by a UCLA physician and engineers at the UCLA Wireless Health Institute, that no longer is the case.

“Working intestines have very specific vibrations as they function, which we can now measure. That information tells us when the patient is ready to eat full meals and can be released from the hospital,” says Brennan Spiegel, MD (FEL ’04), professor of gastroenterology. A computer at the patient’s bedside analyzes the information to tell doctors when and how the person should eat, he says. Clinicians asked for a simpler system, so the team organized the data into a “stoplight” with three colors — red for “no feeding,” yellow for “start liquids” and green for “start solids.”

The research by Dr. Spiegel and Dr. Kaiser, who is co-director of the UCLA Wireless Health Institute, which is an interdisciplinary collaboration of experts from engineering, medicine, nursing and public health, has been licensed, and a device, AbStats, is in the final stages of Food and Drug Administration approval. The process of getting a device in the marketplace “means we have to do everything perfectly — the design, manufacturing and costs — and it has to be usable and be easily wearable,” Dr. Kaiser says. “Then the final hurdle of getting regulatory approval is critical.” The start-up developing AbStats, GI Logic, expects to launch the device in hospitals by September 2015, with plans to sell to consumers in 2016.

Eventually, cheap, disposable wireless AbStats sensors and a simple smartphone app could monitor the millions of people with irritable bowel syndrome and allergies to gluten, lactose and other substances. “We have invented a new vital sign — your intestinal rate — a measure of how quickly your intestines are moving,” Dr. Spiegel says.

IN THE BEST CASES, TECHNOLOGY AND MEDICINE should have a symbiotic relationship that reinforces each other, CASIT’s Dr. Grundfest says. But all the excitement from emerging technology in health needs to be tempered with consideration of the human side of medicine. “First, we need to listen to patients and clinicians in the trenches about their unmet needs and then decide if more tech and digital data would really help,” Dr. Spiegel says.

Indeed, in the field of bioengineering, Dr. Grundfest says, it is clinicians who set the goals that UCLA engineers in the lab then work to achieve. With that mindset, possibilities abound. Soon, medical teams at UCLA will be fabricating custom devices and making models of body parts in-house, thanks to 3D printing. And with big data, they will be able to help high-risk patients through telehealth, mobile health applications, wearable biosensors and even social media. As Dr. Spiegel puts it: “That is the path forward.”

Bay Area freelance writer Joan Voight’s articles, blog posts and columns have been published in Wired, Adweek and on CNBC and CBS Interactive websites.

 





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