RIC Technologies (now Cortian Medical) at Neuro Nexus 2019 Demo Day. From Left: Ryan Rosentreter, Noam Anglo, Brittney Herrington, Dr. Aravind Ganesh, Maliyat Noor, and Kyle Guild
Meet the interviewees Cortian Medical Technologies is improving the outcomes of stroke by leveraging a phenomenon known as ischemic conditioning; where briefly occluding blood flow in the limbs induces the production of agents that allow the body to protect itself. Cortian Medical Technologies, first formed at Neuro Nexus 2019 under the guidance of champion Dr. Aravind Ganesh, are now in the SPARK incubator at W21C in Calgary. We caught up with Ryan, Noam, Kyle, Brittney, and Dr. Ganesh to learn about their technology, plans, and where they see the field heading.
Key terms: remote ischemic conditioning, digital health telemetry, democratization of technology, wearables, artificial intelligence, machine learning
Neuro Nexus So what is remote ischemic conditioning?
Ryan Rosentreter So, essentially remote ischemic conditioning, and I'll be specific to the way we're using it, is a potential treatment for ischemic stroke that can be used pre-hospital, as we wanted to use it in the ambulance settings. It works by occluding a blood vessel with an inflatable cuff to create a low-oxygen environment downstream. And during that time that the blood vessel is occluded, in response, the body builds up different molecules and factors that when you release the cuff, allow blood flow to continue or reperfuse. Those factors can travel through the bloodstream and exert a protective effect downstream such as at the brain, and that short bout of ischemia can actually be protective, rather than harmful.
Brittney Herrington Basically using the body to protect itself.
Neuro Nexus Could you talk about the solution that you've developed and the technologies that went into building it?
Noam Anglo Yeah, sure, I can take this one. So as Ryan mentioned, the only real requirement is to have induced ischemia, or to have cut off blood flow somehow. We leverage the basic concept of ischemic conditioning and reprogrammed a blood pressure cuff, except instead of one cuff we use 4 - for four-limb RIC. So the main technology is a reprogrammed blood pressure cuff, with some microcontrollers and other electronics that allow us to control it and do whatever sort of cycle that we want to realize. Some of the technologies that we have been focusing on nowadays have been for diagnosing the patient, so one of the things that we're trying to add into it is an array of sensors that allow us to do more than just provide therapy.
Neuro Nexus So you all come from very different backgrounds. What do each of you feel you brought to the team early on, and how have your roles and knowledge changed since the competition?
Kyle Guild I would say that our roles overlap a lot right now just with what we're doing and the stage that we're at. For the competition, I was able to provide two different skill sets; one was on the business side so essentially how to create a pitch, because that's one of the core skills you learn as a business student. Every student takes an entrepreneurship class where you learn how to take an idea and build a startup, so I was able to use those skills that I learned through Haskayne. And then the other role was using my experience as a paramedic where I had knowledge about what the back of an ambulance looked like and how our product needed to function and what would be easy for paramedics to use versus what might be more difficult and make it so they don't want to use this device. I would say that was my role at the start, and now it's kind of amalgamated and changed depending on what our needs are at the time.
Noam Anglo Going off Kyle's point, one of the things about working in such a small team and wanting to do so much means that all of us have to be flexible in what we're doing. So, as an example, when we first started the program, the focus I had was purely engineering and I didn't really want to do anything else. I helped do the pitch at the start, but Kyle did the entire like one-minute pitch by himself and I didn't really want to do anything like that. But as time has progressed, the focus that I have has gone well beyond just manufacturing the prototype. Nowadays what I'm actually doing with most of my time working on Cortian is not only designing and making things but also talking to advisors, reaching out to different contacts, and doing presentations like we did at SPARK recently. Whether or not I'm better at it is arguable, but I think I'm definitely way more confident.
Dr. Aravind Ganesh Oh, I can confirm that he is better at it! That's been quite nice to see all of them grow in different aspects. Noam for one, absolutely. The first day that I met him he was very much interested in the technical side of the product but of his own volition he also got involved in pitching. On the last day of the competition it was actually him and Kyle that did the pitch together, so that was really cool. And he clearly did a great job, as we won!
Ryan Rosentreter I would say at the start my role was primarily focused on providing a perspective based on my neuroscience background, and was to try to communicate the science and what we were trying to do with remote ischemic conditioning in the context of ischemic stroke and how we were going to deal with that problem. I think my role, like everybody else's, eventually transitioned and moved into something more. I think I took charge on getting in touch with different groups, or contacts that we could reach out to get more information like Innovate Calgary. Moving forward, my role has transitioned to managing all the little pieces and I've been working with Aravind on some grants. It definitely has transitioned from doing something like translation of science to the public, to learning how to manage something bigger. Like Brittany has said, I have no experience in business really, and I've learned a lot about that side of things. Developing a medical product has been an area that's very new for me and a very exciting one as well. Overall I've really enjoyed it!
Brittney Herrington A lot of my role is kind of overlapped with Ryan, as we have very similar backgrounds. So at the start, my role was contributing mostly from the scientific side, delving into the literature seeing what's already been done with RIC and using that to kind of guide the development of our project. I also had a lot of experience with science communication and presenting and I really enjoy doing that. But I've wanted to take a step back recently to let other members of the team build those skills as well.
Dr. Aravind Ganesh I've got to say that was a really interesting thing to see was how Ryan and Brittany ended up delineating or overlapping the roles over the course of the project. Of course, when you put together the team, at the start of the challenge, you don't really know what how people are going to gel together, right? You just know a little bit about their background and stuff. And so it was quite neat to see Ryan come into his own in the way of delegating skills and managerial skills because. And Brittany, I think it was it was quite nice that she took a step back to allow other members of the team to also hone their presentation skills. That's a key thing that everybody is able to now take home from the project.
Neuro Nexus Yeah, that is very important and it's really great to get that feedback fresh from the audience or the advisors; there's definitely nuance and context that gets losts when one tries to explain that feedback after the fact.
Neuro Nexus (humorously) And so Dr. Ganesh, you are a full medical doctor at this point. So I don't know if you could have learned anything anymore during this project!
Dr. Aravind Ganesh Yeah, right! You know, every time I talk to folks in my department or I talk to junior colleagues about this, I always say that one of the highlights of my residency training in Calgary was actually being part of [Neuro Nexus] over the course of a few months. And I actually wouldn't have gotten into it, if a medical student that I was mentoring, Nicole Burma, hadn't encouraged me to get involved in Neuro Nexus. So it's kind of like the student had become the master! By participating in this, I learned that I absolutely want to involve graduate students and undergraduate students in my research work because, as somebody that's kind of starting out as an independent researcher, that's always something that you wonder... "Is this something that's cut out for me? Is taking on students something that I'll enjoy?" And well I completely enjoyed it!
The other thing that it taught me was that some of the best relationships that you can have with your students can be with students that aren't from your own academic background. That's something you struggle with as a research advisor or research mentor, is knowing if you want to take on folks that are from a completely different field. So until then, I had had students on the wards and also in some research projects, but they were all medical students or, sometimes neurology residents, so people from pretty much the same neck of the woods. Ryan and Brittney were a bit close to what I was doing but still removed because they were from the physiology side rather than the clinical side. Noam and Maliyat were engineers, and Kyle at the time was doing his MBA. I'd like to think that I was able to provide something meaningful to each of them, but even setting that aside, each of them certainly taught me a ton of stuff too. As Kyle mentioned already, his paramedic experience and his experiences with Haskayne were quite helpful for the group. Both Brittany and Ryan raised some very critical questions along the way about making sure that we had certain things checked off for safety. And then Noam and Maliyat were giving us all a crash course in engineering design! They're still teaching us stuff there.
Noam Anglo I think it was more like we were taking the crash course with you! And just to add to that, one of the main things I learned from this project is how useful it is to be student going into the field and trying to make something by yourself, you realize that there's so much more to it than just you know. In engineering, you just think, ‘all I need to know is how to make this thing’. But all the peripheral things around it make you realize that your job is just one small piece of the puzzle. I think it's really valuable for students in general to get that sort of hands-on practical experience outside of the field. These guys have really helped me broaden my perspective.
Neuro Nexus The persistent issue among engineers, and I can say it because I am one!
Neuro Nexus How do you envision your device integrating with existing health telemetry infrastructure?
Dr. Aravind Ganesh I think that's the right question, actually, for where the team is at the moment, because something that we've bee talking about in our meetings is precisely "What are we able to do right now versus where would we like to be in the future?" And while we started out with the problem of providing a pre-hospital treatment for acute stroke, one of the things that we also realized is that, at the present time, there's also quite a lack of information flow in the pre-hospital period before somebody arrives to a stroke center. And so we've realized that with the way that we've set up our device, we can actually use it to gather relevant clinical information while a patient is in transit. One of the things that we wanted to do right off the bat was have a device that would fit in well in the ambulance setting and not get in the way of the paramedics and maybe make some aspect of their job easier. And in the process of trying to fulfill that need, we naturally ended up creating a device that was able to monitor certain kinds of physiological parameters. Like Noam was saying it's basically a modified blood pressure cuff, and as you're transporting a patient, you have to measure the blood pressure anyway. So the device kind of checks off that box, is able to check heart rate, and we've added a few additional physiological parameters, as well as some variable features that can be added to the device in a modular fashion, depending on how high end or low end one wanted to go. And so it doubles as a device that can that can monitor A) regular physiological aspects of a patient while they're being transported, and keep an ongoing log of that and facilitate ongoing analysis or even remote monitoring of that, as well as B) track the clinical progression of a stroke when a patient is in transit because that is something that we presently are not able to do in clinical practice. I might know that a patient is coming in from Medicine Hat, but they might be one way when the story is told to me while the patient is in Medicine Hat, and they might look completely different by the time they come through the door to me, and having a way to keep track of how the patient changed in that time, from a neurological standpoint is something that we see as a promising aspect of what we're doing at the moment.
Noam Anglo We've considered a lot of ways that we can most easily get into the healthcare system, and into ambulances specifically, and one of the strategies that we're considering is by piggybacking off somebody who's already worked out that problem.
Neuro Nexus What trends would you recommend watching in the digital health telemetry space? What exciting changes are happening in the sensorification of health?
Dr. Aravind Ganesh I suspect that each of these guys probably has a bit of a different angle of the problem that they're interested in. I certainly have my ideas, but I don’t want to want to spill everything right up front!
Noam Anglo Okay, I can give it a shot. Because Maliyat and I have been thinking a lot about what sensors you can actually put on a device, the most exciting thing we've found is that we're at a point in technology where, for pretty much any disease you want to diagnose, there are hundreds of sensors that you can use to do that, and not all of them have been tried yet. There's always new approaches coming out. Until very recently, for example, analysis with machine learning wasn't as common as it is today. We're at a point of technology where everybody's just trying everything, and there are now plenty of ways to diagnose something that we've never seen before. From an engineering perspective, it's really exciting that researchers are getting very creative with solutions and using obscure or esoteric techniques to further diagnosis and treatment.
Ryan Rosentreter I think I can build off that answer... In my Master's, there's been a strong focus on using physiological instruments to measure all sorts of things like heart rate, blood pressure, ECG, transcranial Doppler ultrasound (TCD) for brain blood flow velocity, and I can definitely agree with Noam that there is just so much you can measure physiologically. I think it'd be really interesting to know what's one: clinically possible, particularly in an ambulance setting, or in a surgical setting or something that's more acute, and two: what's clinically relevant. So for example it might not be relevant to measure certain standard parameters, but there may be others ways to look at the data that reveal important information.
Neuro Nexus So from what I've heard so far, would you agree that the building blocks are all in place, and people are finding ways to connect them creatively, but you would not expect crazy innovations on the hardware side.
Noam Anglo I think a really good example of this is the development of pulse oximetry - it applies a very basic piece of common technology to measure something in an innovative way. I think the reason that sensors and wearables are seeing so much success and interest nowadays is because anyone is able to find the information to understand how they work, and apply those principles on their own. In the next decade or so, I think we're really going to start seeing novel ways of diagnosing something, just because so much information and technology has become accessible to nearly anyone.
Kyle Guild To expand on what Noam and Ryan have said, less relevant to our project, but more to some of the general trends that I've been seeing as well are taking the sensors and putting them into everyday devices. So like in wearable technology, or in phones, where people are able to track their physiological data themselves, and some of that has diagnostic value for their clinicians. As well, more on the software side, artificial intelligence is playing a bigger role now in being leveraged for better clinical outcomes.
Brittney Herrington Going back to what you said Kathryn, about not necessarily expecting "crazy innovations" because the technology is already there, but I think Aravind had mentioned last week in a different meeting, that medicine is still living in the 70s. We're using very old technology because it works, so the attitude is "why change something that works?" But it could be better. So it's worth our time to bring something new into the medical field.
Dr. Aravind Ganesh Yeah, I mean, that's kind of been the story of my life for the last five years is that on the one end there's this incredible kind of cutting edge of, 21st century technology that we're using for our day to day communication in our daily life. Our patients are already beginning to use wearable technology to keep track of, even their own fitness goals at home and those types of things. And then you walk into the hospital and in some ways it's almost like going through, like a wormhole or something into the past because all of a sudden now people are applying these old school cuffs on you and they're using probes on you that were that were designed before the dawn of wearables, and then a doctor comes up to you with a clunky stethoscope to listen to your heart. And if that wasn't odd enough, then your doctor gets called away because she gets a page! The pager is like the loud cousin of the fax machine, and that's still how we communicate with doctors. It's really strange, right? So I think the big part of the challenge of modern medicine is to try to bridge those two worlds, that disconnect within medicine. On the one hand, because I work in a comprehensive clinical and research institution, I'm able to easily take a patient to get endovascular thrombectomy, a treatment for acute stroke that didn't exist when I started training. But at the same time, there's potentially simpler things that I seem to struggle to do when it comes to communicating with my patients or keeping track of them when they're outside of the clinic, or outside of the hospital.