RESEARCH EXCELLENCE & DISCOVERY DAY: KEYNOTE & ORALS
Wednesday, May 26th, 2021
12:30
Keynote Address
Chair of Medicine Welcome: Dr. Mark Crowther
Research is a Team Sport: Keynote speaker Dr. Emilie Belley-Côté
1:00
Announcement of 2021 Resident Research Grant awards
Oral Presentations
1:20 – Clinician Perspectives on Caring for Dying Patients During the Pandemic – Presenter: Brittany Dennis
Background: The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has affected the hospital experience for patients, visitors and staff.
Objective: To understand clinician perspectives on adaptations to end-of-life care for dying patients and their families during the pandemic.
Design: Mixed-methods embedded study. (ClinicalTrials.gov: NCT04602520)
Setting: 3 acute care medical units in a tertiary care hospital from 16 March to 1 July 2020.
Participants: 45 dying patients, 45 family members, and 45 clinicians. Intervention: During the pandemic, clinicians continued an existing practice of collating personal information about dying patients and “what matters most,” eliciting wishes, and implementing acts of compassion.
Measurements: Themes from semi-structured clinician interviews that were summarized with representative quotations.
Results: Many barriers to end-of-life care arose because of infection control practices that mandated visiting restrictions and personal protective equipment, with attendant practical and psychological consequences.
During hospitalization, family visits inside or outside the patient’s room were possible for 36 patients (80.0%); 13 patients (28.9%) had virtual visits with a relative or friend. At the time of death, 20 patients (44.4%) had a family member at the bedside. Clinicians endeavored to prevent unmarked deaths by adopting advocacy roles to “fill the gap” of absent family and by initiating new and established ways to connect patients and relatives.
Limitation: Absence of clinician symptom or wellness metrics; a single-center design.
Conclusion: Clinicians expressed their humanity through several intentional practices to preserve personalized, compassionate end-of-life care for dying hospitalized patients during the SARS-CoV-2 pandemic.
Authors: Brittany Dennis, PGY2
Supervisor: Dr. D. Cook
1:32 – Efficacy and Safety of Tranexamic Acid in Acute Traumatic Brain Injury. A Systematic Review and Meta-analysis of Randomized Controlled Trials – Presenter: Kumait Al Lawati
Background: Tranexamic Acid (TXA) is used for a number of indications, including blunt trauma, based on evidence that it improves survival. Its role in acute traumatic brain injury (TBI) is less certain, although a recent large trial suggested it may improve head-injury related deaths. We conducted a systematic review and meta-analysis, to investigate the efficacy and safety of TXA in acute TBI.
Methods: In this systematic review and meta-analysis, we searched MEDLINE, PubMed, EMBASE, CINHAL, ACPJC, Google Scholar, and unpublished sources from inception until June 24, 2020 for randomized-controlled trials comparing TXA and placebo in adults and adolescents (? 15 years of age) with acute TBI. We screened studies and extracted summary estimates independently and in duplicate. We assessed the quality of evidence using the grading of recommendations assessment, development, and evaluation approach.
Results: Nine RCTs enrolled 14,747 patients. Compared to placebo, TXA had no effect on mortality (RR 0.95; 95% CI 0.88–1.02; RD 1.0% reduction; 95% CI 2.5% reduction to 0.4% increase, moderate certainty) or disability assessed by the Disability Rating Scale (MD, ? 0.18 points; 95% CI ? 0.43 to 0.08; moderate certainty). TXA may reduce hematoma expansion on subsequent imaging (RR 0.77; 95% CI 0.58–1.03, RD 3.6%, 95% CI 6.6% reduction to 0.5% increase, low certainty). Risks of adverse events (all moderate, low, or very low certainty) were similar between placebo and TXA.
Conclusions: In patients with acute TBI, TXA probably has no effect on mortality or disability. TXA may decrease hematoma expansion on subsequent imaging; however, this outcome is likely of less importance to patients. The use of TXA probably does not increase the risk of adverse events.
Authors: Kumait Al Lawati PGY5 Critical Care & Emergency Medicine, Hussein Al Rimawai PGY3 Emergency Medicine
Supervisor: Dr. B. Rochwerg
1:44 – A pilot study to reduce off-label telemetry on the Nephrology unit – Presenter: Meherzad Kutky
Background: Findings from various studies indicate that telemetry monitoring is often overused in non-ICU settings. The American Heart Association’s (AHA) guidelines provide recommendations on the use of telemetry outside the intensive care unit (ICU). In Canada, the Choosing Wisely campaign has identified telemetry utilization as a target for reduction and has advocated that non-ICU telemetry should only be used when indicated and systems should be in place for the discontinuation of telemetry.
Methods: We utilized an interrupted time series design to ascertain baseline telemetry data in the 16-month preintervention period, and 12-month post intervention period. Data for all telemetry orders (indication, duration) were reviewed. Shadowing was completed with telemetry and floor nurses and residents were polled to assess their familiarity with the AHA guidelines and comfort with discontinuing telemetry.
Results: Our audit showed the median percentage of class III telemetry was 56.9% and the median duration was 48 hours, 69% of calls from CCU were related to telemetry error, 48% of the calls were after 5pm and most residents (80%) were not comfortable discontinuing telemetry on-call. Post intervention 1 (changing of telemetry indications to match AHA guidelines in Dovetail) the median percentage of class III telemetry decreased to 21% and was sustained for 12 months. For intervention 2, we created a nursing driven medical directive to discontinue telemetry for the four most common indications A pilot of this directive allowed for 35% of the patients to have telemetry discontinued and was never discontinued in error.
Conclusions: Our pilot project showed a sustained decrease in the percentage of class III telemetry, and our medical directive pilot was effective without any documented adverse events.
Authors: Meherzad Kutky PGY5 Nephrology
Supervisor: Dr. S. Yohanna
1:56 – Sex Differences and Health Disparity Among Hepatitis C Positive Patients Receiving Pharmacotherapy for Opioid Use Disorder: Findings from a Propensity Matched Analysis – Presenter: Brittany Dennis
Background: The incidence of opioid-related fatality has reached unparalleled levels across North America. Patients with comorbid hepatitis c virus (HCV) remain the most vulnerable and difficult to treat. Considering the unique challenges associated with this population, we aimed to re-examine the impact of HCV on response to medication assistant treatment for opioid use disorder as well as establish sexspecific risk factors affecting care.
Methods: This study employs a multi-center prospective cohort design, with one-year follow-up. Patients aged > 18, receiving methadone for opioid use disorder were recruited from a network of out-patient opioid addiction treatment centers across Southern Ontario, Canada. Patients with ? 50% positive opioid urine screens over one year of follow-up were classified as poor responders. The prognostic impact of HCV on response was established using a propensity score matched analysis. Sex-specific regression models were constructed to evaluate risk factors for treatment response.
Results: Among participants eligible for inclusion (n=1234), HCV was prevalent in 25% (n=307). HCV patients exhibited significantly higher rates of dangerous opioid consumption patterns 35.29% (SD 0.478). Sex-specific examination revealed females with HCV incur a 3 times increased risk for dangerous opioid consumption behaviors (female OR: 2.78, 95% CI 1.09, 7.05; p=0.032).
Conclusion: Findings from this study establish the link between HCV and poor treatment response, with differentially higher risk among female patients. In light of the high potential for overdose among this population, concerted efforts are required for distinguishing the source for sex-based disparities, in addition to establishing trauma and gender informed treatment protocols.
Author: Brittany Dennis PGY2
Supervisors: Dr. Z. Samaan
2:15 – In Situ Simulation for Rapid Institution-Wide Implementation of a Protected Code Blue During Active Pandemic – Presenter: Candice Griffin
The Covid-19 pandemic has called for rapid transformation of institutional protocols to prevent viral transmission, protect healthcare workers, and preserve resources. In particular, code blue situations were high risk for aerosolization and potential PPE breaches, requiring immediate adaptation during the first wave. Our quality improvement initiative used in situ simulation (ISS) to design and implement the new protected code blue protocol at St. Joseph’s Hospital.
A code blue policy was developed, informed by American Heart Association, Heart and Stroke Foundation and Ontario Public Health Guidelines. We recognized that implementation of the protected code blue policy and judicious use of PPE would be very challenging. The initiative was thus designed to utilize ISS to train physicians, nurses and respiratory therapists across various clinical units in the hospital, and to detect the latent safety threats (LSTs) that would hinder safe implementation of the policy. Iterative PDSA (Plan-Design- Study-Act) cycles were designed and actualized, and at each stage the LSTs were identified and mitigated in the following domains: knowledge, personnel and staff, process, policy, systems issues, and medications.
Over 80 simulations were completed from March to June 2020. LSTs such as effective communication, appropriate PPE use, overcrowding, intubation procedure and safety lead roles were identified and mitigated through policy changes, training and retesting. The simulations received good feedback and resulted in increased compliance with the protected code blue policy. No Covid-19 outbreaks were traced to the simulations or to actual protected code blues.
In situ simulation is an effective QI modality, especially when rapid training is required and real-world threats must be identified and mitigated in a timely manner to optimize both patient and healthcare worker safety.
Authors: Candice Griffin PGY3
Supervisors: Dr. Z. Khalid
2:27 – Predictors of ILD development and timing of onset in systemic sclerosis: A Canadian cohort- Presenter: Jessica Kapralik
Background: Systemic sclerosis (SSc) is a connective tissue disease characterized by immune dysfunction causing vasculopathy, inflammation and fibrosis of multiple organs. Lung involvement, characterized by interstitial lung disease (SSc-ILD) and pulmonary hypertension, affect 50-70% percent of patients and together are the leading cause of death. Survival after SSc-ILD diagnosis averages 78 months therefore identifying those at highest risk for SSc-ILD is pertinent to optimizing care. The purpose of this study was to identify predictors of SSc-ILD and its early (before 5 years) versus late onset with a view to developing a future prediction rule to aid in optimizing screening for SSc-ILD.
Methods: We performed a retrospective review of the Canadian Scleroderma Research Group patient registry. All patients 18 years or older were included in the analysis. Ordinary least squares and forward stepwise regressions with Bonferonni correction were used to determine predictors of both ILD diagnosis and early onset.
Results: 1505 patients were included, of which 227 developed SSc-ILD. Development of SSc-ILD was associated with increased in mortality (OR 1.74 [1.44, 2.10; 95% CI]). We identified 14 factors associated with increased odds of developing SSc-ILD independent of age and sex. Additionally, our forward selection model revealed 6 independent and significant predictors of SSc-ILD including baseline DLCO, anti-centromere-antibody, baseline FVC, anti-topoisomerase-antibody, hemoglobin and age at Raynaud’s onset. Age at SSc diagnosis was the only predictor of development of early SSc-ILD.
Conclusion: In a large Canadian cohort we confirmed that development of SSc-ILD significantly increases the risk of mortality in patients with SSc. Six factors were significantly and independently associated with a greater risk of developing ILD, and age was the main predictor of earlier versus later onset.
Authors: Jessica Kapralik PGY5 Respirology
Supervisors: Dr. N. Hambly
2:39 – Exploring Trauma in Medical Training: The Impact of Patient Death during Residency – Presenter: Wendy Ye
Introduction: Patient death is an inevitability of medical training. Subsequent distress, decreased empathy, and worse learning outcomes have been reported amongst physicians. While debriefing provides space for reflection, this infrequently occurs. Early trainees often feel underprepared to manage death. We aimed to ascertain the impacts of patient death, debriefing opportunities, and coping strategies employed by residents at McMaster University.
Methods: Trainees across residency programs that completed an internal medicine rotation at McMaster were invited to participate. Semi-structured interviews were conducted to understand circumstances, emotional responses, support, coping mechanisms, and preparedness regarding the patient death. Interviews were transcribed and coded to identify themes using thematic analysis and constructivist grounded theory.
Results: At the time of submission, 13 interviews were completed and 18 participants recruited. Three main themes were categorized: 1-patient death circumstances; 2-personal and professional impact; 3-trainee support. Pronouncing death, communicating with families, and unexpected/unknown deaths were common challenges. Feelings of guilt, helplessness, regret and grief often followed events, amplified by lack of debriefs. Perceived medical culture, power imbalances, and fear of appearing unprofessional contributed to emotional consequences including difficulties sleeping, intrusive thoughts, and emotional distancing. Respondents universally felt underprepared for the experience. Some residents were aware of formal supports, although none accessed these services. While these experiences are congruent with effects of psychological trauma, they were consistently normalized by trainees.
Conclusion: Patient death in medical training can be traumatic for trainees and may perpetuate loss of empathy, changes to practice, and residual emotional effects. These experiences are normalized by medical culture, and residents themselves. Further focus is needed to better prepare trainees for this phenomenon and examine the culture in which physicians operate.
Authors: Wendy Ye PGY2, Candice Griffin PGY3
Supervisor: Dr. D. Brandt Vegas
2:51 – Maintenance therapy in transplant ineligible adults with newly-diagnosed multiple myeloma: A systematic review and meta-analysis – Presenter: Aram Karkar
Multiple myeloma (MM) is an incurable malignancy characterized by clonal proliferation of plasma cells. Treatment consists of induction therapy, consolidation with autologous stem cell transplantation for eligible patients, followed by maintenance therapy. The role of maintenance therapy in the transplant-eligible population is well established; however, its role in transplant-ineligible MM patients is less clear.
We conducted a systematic review and meta-analysis of all RCTs examining maintenance therapy versus observation in newly diagnosed transplant-ineligible MM patients to assess efficacy and toxicity.
We performed a comprehensive search of MEDLINE, Embase, and Cochrane database up to February 28, 2020. Two authors screened studies for eligibility, extracted data, and assessed risk of bias. The outcomes of interest included progression free survival (PFS), overall survival (OS), and adverse events. We performed meta-analyses using a random effects model and assessed certainty using GRADE methodology.
5 RCTs with a total of 1139 patients were included in the meta-analysis. Patients receiving maintenance therapy vs observation had improved PFS (Hazard ratio [HR] 0.48, 95% confidence interval [CI] 0.38-0.62, high certainty). There was no difference in OS (HR 0.96, 95% CI 0.76 to 1.2, moderate certainty). Patients receiving maintenance therapy had higher rates of hematologic adverse events (RR 3.67, 95% CI 1.51-8.93, low certainty), infections (RR 2.21, 95% CI 0.61-8.0, very low certainty), and second primary malignancies (RR 1.46, 95% CI 1.04-2.04, moderate certainty).
In conclusion, this systematic review and meta-analysis demonstrates that, in newly diagnosed transplant-ineligible patients, maintenance therapy improves PFS; however, higher toxicity rates were also observed. While maintenance therapy may present a therapeutic option for this population, additional studies are required to identify patients who would benefit the most from this approach.
Authors: Aram Karkar PGY2
Supervisor: Dr. H. Mian