Dr. Ian Gilron

ian-gilronPost-surgical pain is moderate or severe in more than 50% of the 40 million surgeries performed each year in North America. While pain is an important problem, evidence suggests that pain also contributes to other post-surgical complications. Over the past decade, continued PSI Foundation support has accelerated my study in post-surgical pain mechanisms and treatments in the Clinical Pain Research program at Queen’s University.

The findings have demonstrated that movement-related pain impairs post-surgical recovery of lung function. Despite the importance of movement-related pain, our recent systematic review showed that this outcome measure is too often neglected, and should be considered in all future post-surgical pain trials. In the interest of improving treatment, we have shown that combining two non-opioid drugs (gabapentin plus either rofecoxib or meloxicam) is superior to either drug alone for reducing pain or opioid-related side-effects. The Foundations valuable support of this program has enriched our background and expertise in the study of post-operative pain treatments and led to systematic reviews of COX-2 inhibitors and anticonvulsant drugs.

My latest PSI award involved a trial to evaluate a triple non-opioid drug combination to better treat pain after surgery. The results of this trial did not provide strong support for the superiority of a triple drug combination over a double drug combination for acute postoperative pain and illustrate the complexities of polypharmacy and multimodal analgesia.

Thanks to research expertise, resources and vision of the PSI Foundation, this research program will continue to advance and disseminate knowledge that will help guide patient-care improvements in Ontario, Canada, and beyond.

Dr. Donald Redelmeier

photo-redelmeierI was a fledgling medical student when I received my first PSI award to work on medical science. The financial amount was modest, yet the positive personal affirmation combined with the general scientific endorsement was a critical boost needed for my fragile stage of development. Indeed, most clinician scientists in Canada lead precarious professional lives and a PSI award can be distinctly more supportive of adventures than some conservative funding agencies in the United States. I applaud the PSI Foundation for this willingness to support unconventional thinking and exploration.

Over the years, support from PSI and other agencies has helped establish my laboratory as a world leader in medical decision research that applies the basic science of cognitive psychology to everyday problems in Canadian health care. The findings have helped create new laws in all Canadian provinces; changes to the fee schedule for physicians in Ontario; more effective traffic policing internationally; and new methods for health services research. The goal is to lessen human suffering, with particular attention to major trauma caused by human error. Thank you PSI for supporting this mission!

One specific study tested how physician warnings for medically unfit drivers can bring major benefits in traffic safety through integrating clinical expertise with government authority (N Engl J Med 2012). The core theory is that patients respect their physicians and respect the law; hence, the combined effect of the two forces exceeds their influence in isolation. The main finding was that physician warnings to carefully selected patients may lead to a 45% reduction in the risk of a subsequent life-threatening traffic crash (yet may also compromise a doctor-patient relationship if done tactlessly). This study informed policies and reimbursement for physician warnings in Canada (and beyond).

Our continued work in traffic medicine has had diverse applications. One of our latest studies (CMAJ 2014) highlighted how pregnant women are usually excluded from fitness-to-drive guidelines, that prenatal care is near-silent on traffic safety, and that a normal pregnancy can cause changes that might increase the risk of a crash (such as insomnia, distraction, back pain). The main finding was that pregnancy is associated with a 42% increased risk of a serious traffic crash during the second trimester that may justify a reminder for driving safety. The findings have now helped inform prenatal care guidelines.

My latest PSI award involved returning to Northern Ontario as a visiting professor for knowledge exchange among the peoples of Canada’s First Nations. As a doctor and a researcher, this experience exemplifies how thoughtful collegial dialogue allows all parties to learn from each other and improve future clinical care (and ultimately medical care throughout Ontario). It also helps highlight what is distinct to Ontario and what is shared broadly. My hope is that more physicians can partake in such opportunities in medical science supported by resources of the PSI Foundation.

Dr. Emil Schemitsch

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Aligned with a focus on research relevant to patient care, I am grateful to have been generously funded by the PSI Foundation throughout my career. These grants have been instrumental in allowing me to pursue diverse musculoskeletal research endeavors, both at the basic science and clinical levels. My first PSI Health Research Grant back in 1995 allowed for the evaluation of a clinically relevant method of bone blood flow assessment utilizing laser Doppler flowmetry, and lead to further investigations of cortical circulation and bone perfusion. More recent PSI-supported investigations of cell and tissue engineering strategies have led to the development of a successful genetic approach to stimulate fracture healing, as well as numerous publications on stem cell therapies in orthopaedics. This work continues in our basic musculoskeletal laboratory today, and a recent PSI Resident Research Grant awarded last year has allowed the application of this cell therapy to the augmentation of rotator cuff injuries as well. The PSI Foundation was instrumental in funding a pilot study examining fluid lavage in the treatment of open wounds (FLOW), and currently supports a multi-centre randomized controlled trial examining operative versus non-operative treatment of acute unstable chest wall injuries as well as an Ontario-based multi-centre prospective cohort study examining abuse and intimate partner violence surgical evaluation (PRAISE-2). As demonstrated by this diverse funding support, the Foundation remains true to their mission of improving the “health of Ontarians” through numerous health research funding opportunities, for which I am truly indebted.

Dr. Mohit Bhandari

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My collaborators and I are incredibly grateful for the support received from Physician Services Inc. (PSI) over the past 7 years. More recently, the Foundation provided funding for the highly important HIP ATTACK trial, which will provide us the opportunity to understand, and to clearly answer the question of whether early surgery for hip fracture patients will improve post-operative outcomes and quality of life. The trial is well underway at both the Juravinski Hospital and St. Joseph’s Healthcare in Hamilton with over 100 participants enrolled to date.

The support from PSI has allowed us to offset both, research personnel costs and nursing costs required to facilitate accelerated surgery for hip fracture patients at participating sites. In addition, the funding is being used to support research staff and costs associated with central coordination of the trial at the Population Health Research Institute. Ultimately, the funding received from PSI will be crucial to supporting our recruitment goal of 200 patients in Hamilton by June 2016.

The publications related to this and my other projects that are in-part funded by PSI include the following:

HIP ATTACK Investigators. Accelerated care versus standard care among patients with hip fracture: the HIP ATTACK pilot trial. CMAJ. 2014;186(1):E52-60.

Chiavaras MM, Jacobson JA, Carlos R, Maida E, Bentley T, Simunovic N, Swinton M, Bhandari M. IMpact of Platelet Rich plasma OVer alternative therapies in patients with lateral Epicondylitis (IMPROVE): protocol for a multicenter randomized controlled study: a multicenter, randomized trial comparing autologous platelet-rich plasma, autologous whole blood, dry needle tendon fenestration, and physical therapy exercises alone on pain and quality of life in patients with lateral epicondylitis. Acad Radiol. 2014;21(9):1144-55.

FAITH Investigators. Fixation using alternative implants for the treatment of hip fractures (FAITH): design and rationale for a multi-centre randomized trial comparing sliding hip screws and cancellous screws on revision surgery rates and quality of life in the treatment of femoral neck fractures. BMC Musculoskelet Disord. 2014;15:219.

Bio

Dr. Mohit Bhandari immigrated from India with his family to Canada in 1970 and has resided in Ontario ever since. He attended primary and secondary school in Hamilton, Ontario, began his Bachelors Degree in Biology at McMaster University and transitioned to the University of Toronto after 2 years as an early entry admission to Medical School in 1994. He began his sub-speciality training in Orthopaedic Surgery at McMaster University thereafter and completed a Masters Degree in Clinical Epidemiology and Biostatistics at McMaster University during his specialty training in orthopaedic surgery. He travelled for a brief period to United States to obtain super-specialized training in trauma surgery with world experts and returned to McMaster University as a Faculty member in 2004. While running a busy practice, Dr. Bhandari successfully completed his Doctorate (PhD) of Clinical Sciences at Goteburg University in Sweden.

By 2012, Dr. Bhandari was a full Professor and Academic Chair of the Division of Orthopaedic Surgery at McMaster University and a distinguished Canada Research Chair in Musculoskeletal Trauma.
His research interests include the management of patients with traumatic injuries, and most recently, he has shifted his focus to identifying and assisting women with these injuries resulting from intimate partner violence. Most regard Dr. Bhandari as the foremost authority in the translation of knowledge from orthopaedic research to clinical practice (Evidence-Based Orthopaedics).

Dr. Charmaine Lok

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The Physician’s Services Incorporated Foundation (PSI) has positively influenced my career path and has had a significant impact on direct patient care through the research they have supported.

I was first encouraged to pursue clinical research as an internal medicine resident when I was awarded a Resident Research Award from PSI for “The Accuracy and Interobserver Agreement in Detecting the ‘Gallop Rhythm’ by Cardiac Auscultation”1. Through this research, the importance of evidence based evaluation of patient bedside diagnostic manoeuvres and tests were highlighted.

Later on, the PSI supported “The Hemodialysis Infection Prevention with Polysporin Ointment (HIPPO) Study” – a double blinded multi-centre, randomized control trial that I designed and implemented in conjunction with my degree in Clinical Epidemiology at Harvard University. In this way, the PSI contributed in a significant manner to my continuing education. More importantly, however, this study has impacted not only patients in Ontario, but worldwide. This study evaluated the effect of a topical polyantibiotic ointment, Polysporin Triple ointment (PTO), on preventing catheter-related infection in patients on hemodialysis. Why is this important?

The prevalence of endstage kidney disease requiring dialysis or transplantation is increasing. Once on hemodialysis, patients depend on a vascular access (central venous catheter, arteriovenous fistula or synthetic graft) to connect their blood to the dialysis machine so it can be “cleaned” and processed. This vascular access is their lifeline; as such, vascular access complications can have a dramatic impact on their quality of life and overall survival. Catheter related infections are a leading cause of morbidity and mortality in hemodialysis patients. The HIPPO Study demonstrated that only 1 in 7 patients needed to be treated with prophylactic application of PTO to prevent a serious bloodstream infection and only 1 in 8 patients needed to be treated to prevent a death2. Subsequent related studies have found these findings to be both long lasting with continual low rates of infection as well as cost effective3, 4. The use of prophylactic polyantibiotic ointment to prevent hemodialysis catheter related infections is a Grade “A” recommendation in the Canadian Society of Nephrology and other Hemodialysis Practice Guidelines and it is supported by Infectious Diseases Societies with a recommendation in CDC guidelines.

Since the publication of this early research, I have continued to focus my research efforts on practical strategies to improve clinical outcomes of patients with chronic and endstage kidney disease. This work would not have been possible without the generous and continual support of the PSI.

This blog is an opportunity for me to thank the PSI for all their tremendous support of my research – for enabling both new and established researchers to conduct clinically relevant and necessary research through a fair and rigorous peer review process, and for helping patients who have benefitted directly from this research.

  1. Lok CE, Morgan CD, Ranganathan N: The accuracy and interobserver agreement in detecting the ‘gallop sounds’ by cardiac auscultation. Chest, 114: 1283-1288, 1998
  2. Lok CE, Stanley KE, Hux JE, Richardson R, Tobe SW, Conly J: Hemodialysis Infection Prevention with Polysporin Ointment. Journal of the American Society of Nephrology : JASN, 14: 169-179, 2003
  3. Battistella M, Bhola C, Lok CE: Long-term follow-up of the Hemodialysis Infection Prevention with Polysporin Ointment (HIPPO) Study: a quality improvement report. Am J Kidney Dis, 57: 432-441, 2011
  4. Daisy Kosa S, Lok CE: The economics of hemodialysis catheter-related infection prophylaxis. Semin Dial, 26: 482-493, 2013

Dr. Charmaine Lok is a Professor of Medicine, Faculty of Medicine, at the University of Toronto and Senior Scientist at the Toronto General Hospital Research Institute. She is also associated with the Department of Clinical Epidemiology and Biostatistics, Faculty of Health Sciences, McMaster University. Dr. Lok is the medical director of both the chronic kidney diseases and hemodialysis programs at the Toronto General Hospital, Toronto, Canada. She is active in raising awareness of CKD and ESRD and its importance in population health. Dr. Lok is involved in a variety of local and international scientific and educational programs, including CIHR, KFOC, DOPPS, NKF, ASN, VASA and ASDIN.

Dr. Robin Green and Dr. David Mikulis

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In a series of papers focusing on volumetric imaging, DTI and neuropsychological correlates, they demonstrated that the brain shows progressive losses during the chronic stages of injury, and moreover that such losses are ubiquitous across patients. They also showed that some of these losses (in the hippocampi in particular) are correlated with reduced cognitive stimulation, which opens new avenues of research for offsetting these losses and improving clinical outcomes, on which they are currently focused. They have also recently uncovered behavioral correlates of hippocampal losses and a further mechanism of volume loss, leading again to novel avenues of treatment to improve patient outcomes. Finally, the funding has also helped to create a database that is unique in the world – a longitudinal database of neuroimaging, cognitive and functional findings of nearly 200 patients assessed from 2 months to 2 years post-injury. The database is leading to a much clearer picture of the evolution of change in moderate-severe TBI patients in Canada, including, for example, increasing depression and anxiety across time. The database also allows for excellent retrospective research opportunities for trainees in the field of brain injury. Some of our findings have policy implications, including a redistribution of resources to encompass the chronic stages of injury, where there is scope for offsetting the accelerated aging and poor clinical outcomes currently seen, and which have importantly shown response to treatment. The findings also support a need for novel approaches to the delivery of treatment to patients in the chronic stages of injury in order to get treatment to patients all over Canada after they have left in-patient therapies, regardless of where they live.

These achievements were made possible by early work on the part of Dr. Mikulis who established one of the first functional neuroimaging labs in Canada in 1993. His lab embraced and supported numerous investigators including Dr. Green, who went on to develop a very successful neuroimaging lab focused on neurotrauma. Both researchers have “veteran” labs with unique strengths and capabilities. However, in today’s research environment, information growth is presenting significant challenges to this model of individual principle investigator driven research. In addition, it is becoming increasingly difficult to acquire and maintain all of the necessary skills to remain competitive. Furthermore, duplication of skills is expensive and inefficient. Forming collaborations has therefore become a key element to success. This is exactly the opportunity Dr. Green and Mikulis pursued enabled by PSI funding. Once started, it soon became obvious that the sum of their capabilities was greater than that of the individual parts. It did not take long for the collaboration to show productivity with 7 publications in only 2 years. This is a terrific example of how support for this paradigm of collaborative research can enhance the efficiency of the financial commitment all of which was made possible by support and sponsorship on the part of the PSI. Dr. Mikulis and Dr. Green are most grateful for the continuing support of the PSI.

Dr Green is a Canada Research Chair (tier II) in traumatic brain injury (TBI) and a senior scientist at Toronto Rehab – University Health Network, where she is head of the Brain Recovery and Discovery Team; she is also a clinical neuropsychologist. Her research focuses on the causes and treatments of neurodegeneration and its behavioural correlates in chronic TBI.

Dr. Mikulis is a Professor in the Dept. of Medical Imaging at the University of Toronto and the University Health Network, Director of the Functional Neuroimaging Research of the Joint Department of Medical Imaging. He is most recently Past President of the American Society of Functional Neuroradiology. His research has focused on translating advanced structural, functional, and neurovascular imaging methods into clinical applications. Several PSI grants have allowed for a very productive collaboration between Drs. Green and Mikulis. Their primary area of joint research funded by PSI has focused on a reconceptualization of traumatic brain injury as a progressive and neurodegenerative disorder.

Dr. Avery Nathens

nathens-photoMy history with the PSI foundation dates back to 1994, when I received my first grant as a doctoral student in the Surgical Sepsis Laboratories at the Toronto General Hospital in the Surgical Scientist Training Program at the University of Toronto. At that time I was studying the host response to infection and the inflammatory response. The success in that environment led me to pursue an academic track focusing on traumatic injury and emergency surgical care.

I moved on to start my career in Seattle, WA where I pursued an MPH and refocused my efforts on health services research and injury. I returned to Canada in 2006 and shortly thereafter collaborated with Dr. Vicki Leblanc, a psychologist with an interested in how stress among health care providers might impact clinical performance. This was a perfect opportunity to study the resuscitation of severely injured trauma patients, a high stakes, high pressure clinical setting. We received funding from PSI in 2007 to study the stress response in trainees in simulated trauma scenarios. We demonstrated that critically injured patients provoke a considerable stress response as demonstrated by high levels of circulating cortisol. Further, this level of stress was associated with impaired performance. This work resulted in the two publications below and set the stage for an interest in evaluating performance in the trauma bay using novel technologies.

1. Harvey A, Bandiera G, Nathens AB, LeBlanc VR. Impact of stress on resident performance in simulated trauma scenarios. J Trauma Acute Care Surg. 2012
Feb;72(2):497-503.

2. Harvey A, Nathens AB, Bandiera G, Leblanc VR. Threat and challenge: cognitive appraisal and stress responses in simulated trauma resuscitations. Med Educ. 2010
Jun;44(6):587-94.

I also have an interest in injury prevention and to this end, PSI funding has been used to evaluate risks for recurrent intentional injury among youth. My personal experience and that supported by several lines of evidence indicate that many patients who are victims of interpersonal violence have prior visits to the emergency department. In 2008, Dr. Carolyn Snider and I were interested in designing brief interventions to prevent this cycle of violence among youth and received a PSI grant to study this further. We first used a mixed methods approach (concept mapping) to evaluate what type of interventions and/or services would offer the most value from the perspective of high risk youth and their community partners. This work laid the foundation for conceptualizing a hospital based violence prevention intervention and to identify outcomes relevant to the community. Next, we evaluated the optimal hospital setting to implement these programs. Our work in this domain demonstrated that over 80% of injured person present to non-trauma centres. This finding is important as most injury prevention programs are implemented in trauma centres, but this work clearly demonstrated that violence prevention initiatives implemented in this environment will not achieve the goals of preventing recurrent injury on a population basis.

1. Snider CE, Nathens AB. Where should we implement emergency department secondary prevention programs for youth injured by violence? J Trauma. 2010 Oct;69(4):991-4.

2. Snider CE, Kirst M, Abubakar S, Ahmad F, Nathens AB. Community-based participatory research: development of an emergency department-based youth violence intervention using concept mapping. Acad Emerg Med. 2010 Aug;17(8):877-85.

As part of my research program evaluating emergency surgical care, my doctoral student, Dr. Charles de Mestral received PSI funding to evaluate strategies related to the management of acute cholecystitis. This work, carried out at the Institute for Clinical Evaluative Sciences allowed us to follow a cohort of Ontario residents with this common diagnosis. We demonstrated significant benefit to patients receiving early surgical intervention with fewer complications, better quality of life, less health care resource utilization and lower costs. This work caught the attention of the MOHLTC, where incentives to perform earlier operation are being considered. This work resulted in the the 4 publications below, with one more in press:

1. de Mestral C, Rotstein OD, Laupacis A, Hoch JS, Zagorski B, Alali AS, Nathens AB. Comparative operative outcomes of early and delayed cholecystectomy for acute
cholecystitis: a population-based propensity score analysis. Ann Surg. 2014 Jan;259(1):10-5.

2. de Mestral C, Laupacis A, Rotstein OD, Hoch JS, Haas B, Gomez D, Zagorski B, Nathens AB. Early cholecystectomy for acute cholecystitis: a population-based retrospective cohort study of variation in practice. CMAJ Open. 2013 May 16;1(2):E62-7.

3. de Mestral C, Gomez D, Haas B, Zagorski B, Rotstein OD, Nathens AB. Cholecystostomy: a bridge to hospital discharge but not delayed cholecystectomy. J Trauma Acute Care Surg. 2013 Jan;74(1):175-9.

4. de Mestral C, Rotstein OD, Laupacis A, Hoch JS, Zagorski B, Nathens AB. A population-based analysis of the clinical course of 10,304 patients with acute
cholecystitis, discharged without cholecystectomy. J Trauma Acute Care Surg. 2013 Jan;74(1):26-30.

Dr. Aziz AlAli is another one of my graduate students who as a neurosurgeon, was interested in exploring strategies related to care of the patient with brain injuries. As the director of the American College of Surgeons Trauma Quality Improvement Program, I had an interest in how we can capitalize at exploring variations in practice to evaluate optimal care strategies. In work funded through the PSI foundation, we used data from almost 200 trauma centres across North America to explore the impact of tracheostomy timing in patients with severe traumatic brain injury. This is an area of considerable controversy where biases are so great that randomized controlled trials are almost impossible. We demonstrated a significant benefit to early (within 7 days) tracheostomy. This work was cited as one of the top 10 publications that are likely to change practice at the largest trauma conferencesin the world (Annual Las Vegas Trauma, Critical Care & Acute Care Surgery, March 2015, 
Las Vegas, NV). The PSI funding was also used to explore other variations in practice to gain insights into other care strategies that might improve outcomes in this critically ill population. Altogether, PSI funding led to the three publications below:

1. Alali AS, Scales DC, Fowler RA, Mainprize TG, Ray JG, Kiss A, de Mestral C, Nathens AB. Tracheostomy timing in traumatic brain injury: a propensity-matched
cohort study. J Trauma Acute Care Surg. 2014 Jan;76(1):70-6; discussion 76-8.

2. Alali AS, Fowler RA, Mainprize TG, Scales DC, Kiss A, de Mestral C, Ray JG, Nathens AB. Intracranial pressure monitoring in severe traumatic brain injury:
results from the American College of Surgeons Trauma Quality Improvement Program.
J Neurotrauma. 2013 Oct 15;30(20):1737-46.

3. Alali AS, Naimark DM, Wilson JR, Fowler RA, Scales DC, Golan E, Mainprize TG, Ray JG, Nathens AB. Economic evaluation of decompressive craniectomy versus barbiturate coma for refractory intracranial hypertension following traumatic brain injury. Crit Care Med. 2014 Oct;42(10):2235-43.

The PSI Foundation has been remarkably supportive and as is evident above, not only provided funding to begin my career, but also initiated the career of several promising graduate students and/or junior faculty under my supervision in fields as diverse as emergency medicine to neurosurgery. The Foundation is critically important in supporting physicians’ asking the right scientific questions to improve the quality of care and bringing innovation to the bedside.

Dr. Nathens is a trauma surgeon and the Surgeon in Chief of Sunnybrook Health Sciences Centre, Canada¹s largest Level 1 trauma centre. He is also an epidemiologist with a focus on trauma system design. He is an active member of the American College of Surgeons Committee on Trauma and is Director of the American College of Surgeons Trauma Quality Improvement Program. He holds the DeSouza Chair in Trauma Research and has published many landmark peer-reviewed papers in the Lancet, NEJM and JAMA focusing on trauma system design and implementation. Dr. Nathens has had extensive experience evaluating quality of care and trauma system effectiveness and translated much of this work into tangible changes at the patient level.