organized curiosity

Improving health care through research


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Now or Never: Innovation in Health Care

Health care is changing. There is an impending crisis and if we don’t solve the challenges now, they may become insolvable. It is “now or never” in health care as it is in many other aspects of life in Nova Scotia.

There is need for new approaches. Decisions about health care will be made on the basis of values. That is as it should be. The values should be spelled out but values should guide our decisions.

Unbiased data is the other pillar upon which our health care decisions should be based. Unbiased data is the essence of research. It is only by combining values and research that we can hope to make the right decisions. Research can tell us if we have met our values. For example, if our value is that people of all social classes should have equal access to health care, then we need research to see if we are living up to our values. Moreover, research can show us how to reach our values. Research can show us how to deliver health care fairly to all in the population.

One of my values is that the public should be involved in health care decisions. There is, in my opinion, an inherent wisdom in the population that can only be liberated if values are discussed and research shared.

Consequently a few months ago, I began planning the Now or Never Public Forum on health care. Dr. Danielle Martin, a family physician, Vice-President, Medical Affairs and Health System Solutions at Women’s College Hospital (WCH), as well as a regular commentator on national television. She will give her lecture on Three Big Ideas for the improvement of health care in Canada. Panelists will quiz her. About six hundred people have already signed up for her talk which will be held at Spatz Theatre in Citadel High School.  There are a few spaces left or you can watch it live streamed on the Chronicle Herald website.

Join us and discuss big ideas for health care with your friends and families.

~Dr. Patrick McGrath

Now or Never Innovation Poster_Final 1


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Marsha Campbell-Yeo

I think the most vulnerable set of patients in our health system are our sick preterm babies.

Several years ago, I spent some time in a Neonatal Intensive Care Unit (NICU) during a sabbatical in England. I was amazed by the complexity of the care that is needed and provided to these tiny patients. Those who care for sick neonates in the NICU are my heroes.

Research is the only way to improve care in the NICU. It is only with research that we can develop and carefully evaluate new ways to diagnose and treat babies that spend time in the NICU.  In the last 20 years there have been significant advances in survival of neonates. Babies who would have died 20 years ago such as those delivered as young as 25 weeks gestation, and babies weighing 500 grams (a smidge over a pound), now routinely survive.

Unfortunately, these babies require many painful procedures to monitor how they are doing and also for treatment. And unfortunately, medications don’t work all that well for procedural pain in neonates.

We have a Researcher Super Hero in the NICU at the IWK Health Centre. Dr. Marsha Campbell-Yeo is a Neonatal Nurse Practitioner who received her PhD in Nursing from McGill University in 2012. She has focused her attention on how to help parents contribute to the care of their babies. Much of her work has been on non pharmacological ways to reduce pain and distress in neonates but she also leads a large research project on medications to help with neonate breastfeeding  for moms who have not been able to produce enough milk. Marsha recently won a REAL Award for her work. She was the only Canadian honoured. The tag line for REAL Awards, “Some people entertain us, some people enlighten us, some people save our lives”. Marsha has enlightened us through her research and saved lives.

Marsha is a clinician scientist at the IWK and an Assistant Professor of Nursing at Dalhousie.

Marsha is one of several pediatric pain researchers in Halifax that makes the IWK a world leader in this area.  Please note, I have done research on pediatric pain and Marsha worked with me as a post-doc for a few months.

Her PhD was on the effects of putting twins in the same incubator to see if this would reduce their stress response to the many needle procedures that neonates experience. The thought behind this process, called co-bedding, was that it may be helpful for the twins who might be face-to-face, back-to-back or in the spooning position and could provide comfort because of the human contact, the familiar smell or just the company. She was the first to examine the effect of co-bedding on the pain response of preterm twins having routine medically indicated procedures in the NICU.   In a randomized trial, she found that co-bedded preterm twins recovered more quickly and had a more stable stress response than twins cared for in separate incubators.  She also found co-bedding had no adverse effects on either the twin who had the painful procedure or the other twin.

Marsha has also helped make major discoveries in the use of skin-to-skin contact sometimes called Kangaroo Care for pain. Kangaroo Care began in Bogota, Columbia because there was a shortage of incubators in the NICU and the neonates had to be kept warm and safe. The babies were kept skin-to- skin on the chest of their mother.  Amazingly, these babies did as well, or better, than babies in the regular incubators. Kangaroo Care is now used in many NICU’s across the world. Dr. Campbell-Yeo and her colleagues (including Celeste Johnston who was her PhD supervisor and is now Professor Emeritus at McGill and a consultant scientist at the IWK) thought it might also help with pain from needle procedures.  They tried it and later conducted several randomized controlled trials to see if it really works in very preterm infants.  The infant is placed skin-to-skin and settled before a painful procedure. This comforting process significantly diminishes pain in the neonate. She and her colleagues also found that other loved ones such as fathers or another female could help lower pain using skin-to-skin contact too. To assist others in gaining this information, Dr. Campbell-Yeo and her colleagues recently published a systematic review of all of the studies (19) related skin-to-skin contact and pain, with findings all in favour of the pain relieving effects of skin contact. Marsha is also examining the sustained effects of mothers contact provided during pain and impact on development.

The third area she has investigated is the use of small amounts of sugar-water to reduce pain from needle procedures. A small amount of sugar-water given by mouth just before the procedure is an effective analgesic in babies.  Marsha is interested in exploring the relationship between infants receiving sugar water, Kangaroo Care, or both, and how infants respond to painful procedures while in the NICU. Her hope is to identify the best methods for reducing pain in preterm infants in order to help infants have the best possible outcomes in life.

Marsha also volunteers in Africa and India teaching other professionals about neonatal care. We are lucky to have her here in Halifax.

 

Marsha Campbell Yeo

 Dr. Marsha Campbell-Yeo

 

 

 

~ Dr. Patrick McGrath


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MicroResearch: Addressing Barriers to Improved Community Health in East Africa

Submitted by Dr. Noni MacDonald and Dr. Robert Bortolussi, September 2014

“Knowledge is not enough, we must apply. Willing is not enough, we must do.” (Goethe).

In 2000, 189 countries made a promise to help citizens in the world’s poorest countries to achieve a better life by the year 2015. This promise, the Millennium Development Goals (MDGs), lead to greater funding from wealthy countries to support programs that would increase literacy, reduce poverty, and improve maternal, newborn and child health in the poorest Low Income Countries (LICs). By 2013, Ban Ki-moon, the director general of the United Nations, called the overall MDGs the most successful global anti-poverty push in history.

But improving health for mothers, newborns and children is proving to be more difficult, then the other MDG’s. For often in Africa, new knowledge gained from health research that could improve conditions has fail to be implemented in the community. The reasons are many, but chief among them is that the changes often conflict with local beliefs and culture. To paraphrase Goethe: Knowledge and good intentions are not enough, we need effective action.

One serious barrier to improving the health outcomes for mothers, newborns and children has been inadequate implementation of health knowledge at the community level. Although African health care professionals are excellent clinicians, they lack training and skills to identify critical community health problems, and to use research methods to find local sustainable solutions. Research support for health care professionals to develop and carry out their own community focused research has been neglected, since much of the donor-funded research has focused on diagnostics/treatments for infectious diseases in these LICs. For example, investigators from LICs are principal authors on only 4% of research publications dealing with health policy in LICs .

Yet health care professionals from LICs have the greatest potential to impact their own country’s health practices and policies. They understand the local culture, local languages and the local barriers to better health practices. Top down implementation has failed unless it is context and culturally appropriate. Local African health care professionals, embedded in their communities, can identify critical community problems, and apply research methods to find solutions and are in the best position to then implement change and improve health outcomes.

In 2008, Drs. Robert Bortolussi, and Noni MacDoanld from the IWK Health Centre teamed with Dr. Jerome Kabakyenga from Uganda, to develop an innovative East African-Canadian collaboration, called MicroResearch (http://www.microresearch.ca/). .  MicroResearch helps to build local African healthcare professional capacity to find local solutions for local maternal and child community health problems. MicroResearch uses five integrated components to ensure the research fits the local context, culture, and resources, is scientifically valid and is shared with local communities and local health professionals:

  • Trains multidisciplinary healthcare professional teams to identify local maternal and child health problems needing solution,
  • Coaches these MicroResearch teams to develop their research questions into scientifically valid internationally peer reviewed proposals,
  • Funds the teams to undertake these projects that will find solutions to local health problem with ongoing coaching.
  • Helps to translate the findings into action that will improve community health outcomes for mothers, newborns and children with ongoing coaching.
  • Supports sharing of research findings across an East African MicroResearch Network, through East African MicroResearch Forums.

In fact, for the past 6 years MicroResearch has already implemented the principles recently advocated by the World Health Organization as the best way to strengthen research capacity in low and middle-income countries .

The MicroResearch program has achieved remarkable success with incredibly small financial support. Between 2008 and 2013, 5 East African sites have invited MicroResearch trainers to help them increase the research capacity of local health care professionals. More than 15 workshops have been held and about 400 participants trained. Of 29 funded MicroResearch team projects ($2000 CAD each), 22 are ongoing and 7 completed . This was all done with less than $300,000. Knowledge gained from these projects has already influenced several health programs and/or government policy. For instance MicroResearch teams found that traditional umbilical cord care practices in Ugandan rural villages carry risks for sepsis; over 40% of neonatal deaths were attributable to cord related sepsis. Although we know that antiseptics may dramatically improve newborn survival, these researchers showed that WHO recommended procedures were not being followed in rural areas, and identified the root cultural barriers. As a result of their work, they are working with the Ugandan Ministry of Health, to pilot the implementiation of a chlorhexadine cord care program in rural villages in Uganda as a demonstration project and case study.

Noni & Bob

 

 

 

 

 

 

 

 

~Dr. Robert Bortolussi and Dr. Noni MacDonald

 


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Now or Never: Innovation in Health Care

Health care is too important to leave to the experts (doctors, nurses, health administrators). This is why we began this blog on research and health care. We are beginning another vehicle for people to learn about and discuss health care which is the forum titled Now or Never: Innovation in Health Care. Readers in Nova Scotia will recognize the Now or Never title taken from Ray Ivany’s report on the future of Nova Scotia.

Our first forum will be on September 30th and we were lucky to get Dr. Danielle Martin to speak. She is a great thinker and a great speaker on the public health system. The poster is below. Sign up soon as tickets (which are free) are going very fast.

Now or Never Innovation Poster_Final 1


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Dr. Rudolf Uher

This is the first blog introducing you to researchers at the IWK and Capital Health, aka the QEII.

I remember vividly the first time I met Rudolf Uher.  It was late at night and I was catching up on my email.  I got a packet of CVs to review because I was on a faculty selection committee.  I sit on a lot of committees and, in a year, read hundreds of academic CVs. I had to review eight or ten CVs in preparation for a meeting the next day where the five members of the selection committee for a Canada Research Chair in the Department of Psychiatry at Dalhousie University would choose three candidates to visit and be interviewed for the job.

A Canada Research Chair is a prestigious research post. Each university has a very limited number of these federally funded positions.  They are fiercely competed for. First of all the Department has to compete with other departments to get the opportunity to offer a CRC and then the applicants compete. Once the university selects a candidate, they are vetted by another peer review committee of scientists assembled by the Canada Research Chairs Secretariat.

By 10:30pm I am usually pretty sleepy and ready to call it a night. But all of a sudden I was wide awake.  When reading a CV, I first check on basic qualifications of training and work experience, check to see what the area of research is.  Then I spend more time on publications in the scientific literature and then I look at the grants.  This set of candidates was exceptional and one stood out as being amazing in an exceptional group.  Rudolf Uher’s CV was how I first met him and it was exciting.

Dr. Rudolf Uher studied medicine and neurosciences at Charles University in Prague, the Czech Republic  and trained in Psychiatry at the Maudsley Hospital in London, England.  These are outstanding centres of training and research.

Dr. Uher’s research was broad but all focused on severe mental illness.  His research included psychiatric genetics, pharmacogenetics, the interplay of genes and environment in the causation of mental illness, classification of psychopathology, treatment of depression, and use of clinical assessment and biomarkers to personalize treatment.

He had worked on some major international efforts and already had provided leadership in areas such as investigation of genetic based drugs for depression.   He had published over a hundred scientific papers. WOW, I thought. He had only finished his training about a year before in 2010.

He interviewed brilliantly.  He looked younger than he was and was quiet, personable and thoughtful.

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His science was impeccable.  Rudolf was offered the CRC and came to Halifax in 2012.  Since that time he has shown all of us how to do great science. He set up a major new project, Families Overcoming Risks and Building Opportunities for Well-being (FORBOW), a very ambitious longitudinal cohort study, initially with funding from Capital Health but now funded by the Canadian Institutes of Health Research and the Canadian Foundation for Innovation.  FORBOW explores the unfolding of severe mental illness which exacts a huge personal and financial toll on thousands of individuals and families in Nova Scotia. Serious mental illness is expensive to society because of very high treatment costs, social services costs and unemployment. FORBOW will continue for many years with different substudies examining specific issues.

Uher is trying to figure out how to prevent what happens before severe mental illness arises and is developing early interventions to promote mental health in youth.  Some of these interventions are skills and others may be specific drug approaches that specifically fit each person.  These are ambitious, groundbreaking ideas that build on his previous work.  Dr. Uher has assembled a team of co-investigators to help him and he has attracted a star studded international advisory board to guide the research.

But Dr. Uher is also busy doing other things. He co-leads the Maritimes Depression Hub of the Canadian Depression Research and Intervention Network (CDRIN) and is active in half a dozen other studies as well as supervising trainees and teaching.  He consults with patients at Capital Health and IWK.

His science is very well received internationally. He was named associate editor of the prestigious journal Depression and Anxiety and in 2014, he was awarded the International College of Neuropsychopharmacology, Max Hamilton Memorial Prize for his research.  Last year his research was cited in over 900 other research papers and he published 19 articles in the international research literature.  I would estimate that his scientific productivity is in the top 1% of scientists in the world (not Nova Scotia, not Canada but across the world).

Dr. Uher is an international star, bringing the latest science to help patients in Nova Scotia, discovering new knowledge that is of interest internationally and creating well paid research jobs here in Nova Scotia. Most importantly, he is giving hope and practical evidence-based assistance to families who have had to deal with major mental illness.

We are very lucky to have him here.

~Dr. Patrick McGrath