(upbeat music) - Welcome to "At Issue," I'm H Wayne Wilson.

Thank you so much for joining us for a conversation about the ever-changing healthcare in Central Illinois.

We're going to be talking about major changes that have occurred.

And this is not a technical conversation, this is to give you a sample of some of the improvements that have occurred recently in Central Illinois, making this a healthcare center, a surprising healthcare center.

And we have five physicians and let me say first, thank you all five for being here because it is difficult to get five doctors joining in one television program.

So lemme first introduce to you, Dr. Marc Knepp.

Dr. Knepp is at the University of Illinois, College of Medicine, Peoria, where he is an assistant professor of clinical pediatrics, thank you for being with us.

- Thank you.

- And sharing the same title is Dr. Matt Bramlet.

He is at the University of Illinois College of Medicine, where he's an assistant professor of pediatrics, thank you for joining us.

- Thank you for having me.

- Dr. Jim McGee is here.

Dr. McGee is at OSF Healthcare where he is a radiation oncologist, thank you for joining us.

- Thanks Wilson.

- And Dr. Amulraj is here, Dr. Emmanuel Amulraj is at the OSF Healthcare, cardiothoracic surgeon, he's also the surgical director of the heart transplantation program, thank you for joining us.

- Thank you.

- And Dr. Vicken Chalian is here.

Dr. Chalian is with Chalian and Leak Urology based in Bloomington, although he practices in several hospitals in the area.

So thank you to all five of you.

And I'd like to turn the attention first to Dr. Amulraj because Peoria had a heart transplant center here for some time, but it terminated in 2007 and now it has returned.

And I'd like to find out first, why was there a break?

Why in 2007 did heart transplants end and now it's been resurrected.

- So it's a combination of issues at that time as how I learned it.

One was something to do with the insurance companies and the reimbursement at that time and also the retirement of the surgeon who was primarily for the heart transplantation program at that time.

The program was on hold for a while and then eventually it was closed.

So we restarted the program now and we definitely find a need for it at this stage.

- Heart transplants, what is the number that we might see in a given year?

And how important is it to Central Illinois?

- So with the longevity of the patients, especially with medical care today, the heart failure seems to be the most common presentation of most end-stage diseases of the heart, may it be valve, may be coronaries, it all ends up in heart failure.

So the heart failure population has actually increased in Central Illinois, which forces them to go to the cities which could be St. Louis Chicago to get their advanced cardiac care.

But since 2000 the advancement in the pump management as do as a cardiac assist devices has actually dramatically improved, especially after 2009, the REMATCH two trial.

Following this, I think the advancements in the technology also has changed and the effectiveness of the pump has changed.

So that brings heart transplantation as the end, what do you call, the gold standard for end-stage heart disease at this time.

- And when you say pump, I think some of us are familiar with ventricular assist device, is that what we're talking about?

That there's an actual mechanical pump?

- That is correct.

It is a mechanical pump which supports the left ventricle of the heart to improve the blood supply and get back to normal as long as the right side is good.

Now pumps have two basic types.

You have temporary pumps, which we call today as ECMO and the permanent pumps, which is commonly known as the LVADs and the L stands for the left ventricular assist device.

And yes, we do implant them by a standard operation, which involves opening the chest and implanting the pump.

- I wanna talk to Dr. Bramlet about something that is somewhat related in that before any doctor goes in to do a surgery, there might be a surprise.

And that concerned you enough that you decided that it's time to do some virtual reality so that you can see the actual organ before you ever go in and see the actual during surgery.

- Yeah, I mean, for years, we've been attempting to look inside the human with different technologies, x-ray, MRI, CT, ultrasound, and the whole purpose of this technology is to give the physician the opportunity to really see what's going on.

With the introduction of 3D printing in 2014 and to more of accessible technology, it drew out the need to actually take these CT and MRI images and build from them the 3D models that represent the anatomy, which the technology currently is not a standard capability and medicine even to this day.

And so the real value came whenever we took the existing CT or MRI data sets that had the 3D information hiding in it and in our lab, we'll take that and we'll build a digital twin of the patient, for example, that allows them to surgeon, initially in 3D print form, but now in a more advanced virtual reality form to assess that internal anatomy much as they will see it in the OR and what we're achieving is an improved mental image in the surgeon's mind before they go in there especially on these complex cases so that the surgeon can encounter the unexpected before they go to the OR.

- So there'll be fewer surprises- - Absolutely.

- Which might change the entire approach to the surgery.

- You're exactly right.

And the impact we've seen on the most complex cases where we started out in congenital heart, but now we're moving into cancer care, especially in pediatrics where nearly 50% of the cases that we present in this format, the most complex cases, the surgeons are changing something about their approach whether it be the incision point or how they're going to perform the procedure before they go to the OR, which is a dramatic change.

And we're using that technology in radiation oncology for the implant work, where we many times deal with very complex GYN cases.

We need to really understand what we're gonna get into and how we're going to individualize care, we 3D print the tumors and then practice implanting them before we go to the OR very much the same concept that the surgeons are using.

- Dr. McGee used an important word in my mind, individualized, you can really individualize every single surgery.

- Every single surgery and that's the direction that all cancer care is going, is very individual, very personal, down what's your genetic structure look like, what's your tumor's genetic structure look like, and how do we give treatments that are inexpensive or less expensive maybe than they are now, and how do we do that therapy so that you don't have to make very many trips to a big center for it, how do we do that so there are a few trips involved or available at home.

Also all of those things are just challenging everything that we have traditionally thought we knew about cancer care.

- And I believe Dr. Amulraj, you've also taken advantage of this virtual reality prior to a heart transplant.

- That is absolutely correct.

In fact I had a patient who had a myocardial infarction and ended up with a hole in the septum and it was a complex kind of, we call it a VSD, a ventricular septal defect.

And it was a complex case because anatomy was not typical.

So we used the 3D reconstruction and I was able to do this virtual reality to see exactly where the VSD was.

And my approach actually changed based on that.

- Dr. Knepp, you've been involved with this virtual reality as well using it for tachycardia cases, et cetera.

- Yeah, so when we think of congenital heart defects or children born with heart problems, there's a myriad of lesion.

So 18 different heart defects, and every child's a different size, shape, and form.

And so trying to do a standard approach for every child on the operation or procedure can be challenging.

And so when we've taken these cases and put them in a virtual reality or a three-dimensional model, instead of the standard flat screen, two dimensional model, we can actually make a difference and individualize the care so that during the procedure, the procedure's faster, it's smoother, complications are already predicted before they even happen.

And so it's been quite revolutionizing for our patients.

They have access to something that is on the cutting edge here in Peoria.

The other thing that I would say that we use it a lot for is actually teaching and educating both our patients and families, as well as our students and our residents.

They get the opportunity to learn from three dimensional modeling that no one else has or very few centers have.

And that has been eye-opening for me.

I remember my first patient who got to see their heart in virtual reality, walk through their heart, there were tears that were coming down her face, and she said, I never understood my heart like this.

And she'd been our patient for years and years and had met with doctors for years and years.

But that virtual reality made such a difference.

- I'm not so sure I'm ready to see my heart (inaudible) (all laugh) but nonetheless, and I wanna talk to Dr. Chalian next, but it occurs to me that there is a lot of technological advances that have made you while you're all excellent physicians, you're that much better because you have this technology available to you, including robotic surgery for you Dr. Chalian.

- Yeah, robotic surgery has completely revolutionized the practice of neurologic surgery.

We went from doing all of our cancer surgery with centrally large incisions in the abdomen, multiple days in the hospital and prolonged recoveries and prolonged time off from work and have gone to exclusively doing all of my cancer surgery robotically.

And with that, we have small little, essentially puncture incisions and then proceed with the surgery and even have gone to doing for example, prostate cancer surgery as an outpatient.

And they go home the same day as opposed to spending two days to three days in the hospital, and even our cancer surgery for kidney cancers is very similar, just overnight stays for most of them.

- I wanna follow up on that particular topic with Dr. McGee in terms of the stay in the hospital's much shorter, it might be outpatient and you use proton beam as a generic term, I assume to treat a lot of these tumors.

- Well, proton beam therapy is coming to Peoria, but right now it's a dirt hole in the ground.

We'll get there in three years.

- And I wanna talk about that in just a moment because proton beam is very rare in America.

- It is, it is.

- We'll get there, but talk about some of the advancements, because I remember a machine called trilogy.

- Yeah, so in the day we were talking about that 25 years ago, the average number of treatments that a patient received with radiation was about 30 across the board, adding everybody together, some 45, 48, some 10, but the average is around 25 to 30.

Now the average has dropped to around 12 and that's because a lot of people get one or two or three treatments.

And yet the number of people getting treated is greater than it was in the day when we were doing 45 treatments.

And that's just because radiation has become much more applicable in many situation as curative with a little side effect for things like early stage lung cancers where no operation's needed and patient can make three outpatient visits and have radiosurgery to a primary lung cancer with expectation, total expectation of cure without side effects and the same goes on.

But there are different approaches now to many different cancers.

And that's why there are different tools that are developed like the high dose rate radiation implants that are given in a matter of minutes.

And we're moving down the line to flash therapy with the protons where one to three treatments will be given and the time for any treatment would be about a millisecond because that causes the same reaction in tumor tissues as it does now with standard dose rates where a treatment takes five minutes.

But when you do it in a millisecond, rather than over minutes, the normal tissue doesn't react nearly like it used to.

And so we're getting a great separation developing between how we're doing therapy now and what we can look forward to in five and 10 years.

But right now we're already at the point where the number of treatments that people are getting has collapsed, the application is greatly expanded and the side effects happily are continuing to drop.

- And the beam's actually more precise?

- Yeah, now we have CAT scanners built into our linear accelerators so we can see right where the beam's gonna go, we're not guessing anymore.

It used to be, you put marks on the scan and you thought, man, this is kind of close.

Now we take into account with daily adaption the amount of urine in the bladder or stool in the colon.

And all of that just has changed on the fly and treatment's given and you're right on target.

So yeah, it's a different world.

- And there's a term flash therapy, is that some of what we're talking about?

- That's the research that we're in, OSF is part of the The FlashForward Consortium, about 12 institutions around the world and we're starting to move in that direction with clinical research.

This is very early on, but that's the future.

And that combined with immune therapy largely replacing the toxic systemic therapies that we're used to, just really changes the whole landscape for cancer therapy going forward.

- The preciseness of what you're doing, I want to follow up on that with Dr. Bramlet, because the virtual reality, the three dimensional appearance, you're so much more precise, less time in on the operation, et cetera.

- Absolutely, the primary work that occurs prior to actually getting in and seeing this in VR is translating what the radiologist sees when they look at those images into that digital 3D model.

Once you have the digital 3D model, it unlocks all of the opportunities that allow us to pinpoint from a computer standpoint, the computer's understanding of which the different tissues are.

And I think a lot of people in Central Illinois don't know the rarity of this technology between the University of Illinois College of Medicine and OSF, we've really combined to bring incredible cancer care to the forefront here in this area that they can't go elsewhere and find.

The best they could go elsewhere with would still not, is still behind where we currently sit with much of the digital reproduction of this complex anatomy for surgical planning and future computer planning for these complex procedures.

- Dr. Amulraj, as a heart surgeon, a heart transplant surgeon, recovery time is a lot less and I remember the first person who got a heart transplant in Peoria, I believe it was 1987, a woman by the name of Doris.

- That's correct.

- I believe she's still alive.

- Yes, sir, she is.

- But she was in the hospital maybe seven weeks or something like that recovering from a heart transplant surgery.

You just had a surgery late February, how long was that patient in?

- Approximately about two weeks.

- Two weeks down from seven weeks.

- Pretty much, yeah.

- What can you attribute the reason for that?

Why was it so much shorter?

- So there were different stages in this surgery.

So when he first came, when we saw him for the first time, it was actually in the middle of the COVID crisis on Easter morning.

And it was, I got a code saying that a patient 23 year old gentleman who basically is in crisis needs the temporary pump.

And that's when we put him on ECMO.

Eventually the next day we did an echocardiogram and we found that he had a clot in his heart.

So we had to go in and take it out.

So we put him on temporary pumps, recovered him and then at that time we put a permanent pump eventually at one stage in the surgery.

And that was a long recovery time, which he had to go through on the first time around.

By then, after that, he progressed well but his right ventricle started failing all the time.

And when this happened, I think it's a combination, it's not, I think, sorry, let's put it this way, it is a combination of early good diagnosis early in the game, we brought him in the hospital, we tuned him up, we put him on the wait list and as soon as he got a heart, he was pretty much ready to go.

His kidneys were in good condition, his rest of his organs was in great condition.

It was just the heart that needed to be fixed.

And so we put a temporary pump in addition to his permanent pump column to support his right side.

So it was very well optimized at the time of surgery, at the time of the transplantation.

So the transplant recovery was very smooth.

- So Dr. Chalian, what I'm hearing so far is that it's all this preparation in advance and the technological tools that we now have that make the surgery that much more quick, that much easier and with better outcome.

- Yeah, when the patient comes in prepared for the surgery and see their medical doctor, make sure all their other comorbidities or other health issues are addressed in advance, they come in just well-prepared for their surgery and then doing minimally invasive surgery, they almost don't require any narcotics during their recovery, which makes their recovery even faster with fewer side effects.

- Dr. Bramlet, can we talk about Enduvo.

- Sure.

- And explain Enduvo, I mean, because it's expensive to do virtual reality or at least it has been.

- Yes, yeah and the main problem is with this newest, the new technology, it's very difficult to bring in a set of developers to come in and create very specific tools.

And in my lab at the university of Illinois, in a jumped simulation, we said, well, what if we built the tool itself rather than building a bunch of custom items, we built the actual, I don't know, authoring tool that allows any one of us to, without coding skills to go in and interact and create these 3D models in an education and training platform, which in medicine, education is how we communicate with one another and so, Enduvo, the company that I founded and spun out of my lab at the University of Illinois.

- And because you work very closely with him, can you talk about the advantages of all of this?

I mean, we've touched on it, but how important is it that we have this more accessible, cheaper process that's going to help surgery in the future?

- I think it's just gonna improve the quality of care that can be delivered, being a, have that accessibility to the best technology will make bypass times and recovery times for our youngest patients so much faster, it'll make education for them better.

But we have actually been getting requests from all over the United States for Dr. Bramlet and his lab to actually put this together for other major congenital heart program.

So it's fun to see how medicine has evolved even in the 10 years that I've been here, how we have changed our philosophy when we go to taking care of each of these kids.

- And you touched earlier on the teaching aspect of this that virtual reality makes it easier to teach.

- Yeah, when you're first starting to learn and you see everything in two dimensions, it takes you a while to recreate how the valve set in the heart or where the holes are in the heart and what parts of the heart there are.

When we can put it in three dimensions and you see the spatial relationships, it makes it so much easier and so much real, so much more real for the learners.

And we've seen our residents and students who have gone through the education process, we've actually done a little bit of research on it, showing the standard teaching versus using the three-dimensional teaching.

They catch on quicker.

- And Dr. McGee, I jumped the gun earlier in regard to the proton beam.

And now you have an opportunity to explain proton beam and for the viewer's benefit, there's a big hole where allied agencies used to be behind OSF.

Could you explain proton beam and this cancer center that's being developed?

- So the cancer center being developed is designed to bring together imaging and very precise radiotherapy of different types.

In a center where patients would come occasionally, this is not a type of equipment they're gonna need, 100 times, it's something where they'll have an episode of care that would be otherwise impossible without really great distance of travel.

And so it's really designed for the people of Central Illinois.

The center also is going to emphasize multi-specialty, multidisciplinary in that interaction around the patient's care.

So it's not just about technology, it's about getting doctors together to discuss with the patient their situation, some of that with a virtual presence that Dr. Bramlet's also pioneering with to really help a doctor far away to feel like they're in the room with the patient.

And we're also then emphasizing who these people are that we take care of here in Illinois.

We're really trying to understand what's different about the cancer risks, what's different about how patients deal with cancer in our environment, because all the studies that have been done have largely been based in large metropolitan areas and really aren't that relevant to what we encounter in large numbers and have encountered in large numbers for decades.

So we have a very formal program where we're looking at that.

But the proton unit in particular is a packet of energy that comes in and stops and explodes in the tumor and that's it, it doesn't go all the way through, just treats the tumor.

- And with that we're out of time.

But I might point out that we're all concerned about the cost of healthcare, but healthcare is one of the best offerings that Central Illinois has, $300 million for the cancer center behind OSF.

I wanna say thank you to Dr. Marc Knepp at the University of Illinois, College of Medicine, Peoria, and his also assistant professor at the same organization, UICOMP, Dr. Matt Bramlet.

Dr. Jim McGee, thank you so much for joining us.

He is with OSF Healthcare.

Dr. Amulraj also at OSF Healthcare, thank you for being with us and Dr. Vicken Chalian who is with Chalian and Leak Urology in Bloomington and practices at several hospitals, including Pontiac, Carle BroMenn, Carle Eureka, et cetera.

Thank you all for being with us on "At Issue."

We'll be back next time with another edition of "At issue."

We're gonna talk about state finances with the person who knows them best, the state comptroller, Susana Mendoza.

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