organized curiosity

Improving health care through research


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Reversing the trend of antimicrobial resistance

There are few medical discoveries that have changed the course of human history more than antibiotics.  Prior to the serendipitous discovery of penicillin in 1928 a pneumonia was fatal in over 35% of infections and a simple cut leading to a skin infection would kill over 10% of people.  Since the development of antibiotics, now less than 10% of people die from pneumonia and death from skin infections are uncommon.  These miracles of modern medicine have been so successful, that by the late 1960’s physicians and policy makers were declaring victory in the war against bacteria.

Yet nature hates a void and more importantly is more clever than we will ever be.  Within 3 years of its discovery, bacteria developed resistance to penicillin. Since 1928 we have seen the introduction of multiple different classes of antibiotics, each having had the promise of protecting us from even the nastiest of bacteria.  Yet not long after each antibiotic has been introduced, the bacteria have found ways to resist its killing potential.  And where has that left us?  We now have an antimicrobial resistance (AMR) problem that has been declared a global heath emergency. Antimicrobial resistant organisms (AROs) now cause over 2 million infections and kill 23,000 people in the US each year costing 20 billion dollars in excess health care costs and over 30 billion dollars in lost productivity.  Infections like gonorrhoea (one of the Center for Disease Control in Atlanta’s three most urgent threats) were once easily treated but have become so resistant that we soon may not have any treatment options.2 In addition, the overuse of antibiotics and the elimination of “good bacteria” from our bowels have left an opening (remember nature hates a void) for opportunistic pathogens like clostridium difficile diarrhoea (the second of the CDC’s top three urgent treats), leading to increased health care cost due to prolonged hospitalizations or more dramatically, loss of your colon or death.

So how did this happen? It is a complicated problem and we have a complicated relationship with antimicrobials.  There is no question antibiotics save lives.  As we advance our ability to prolong life through toxic combinations of drugs to kill cancer or suppressing our immune systems to allow a life saving transplant to flourish, we modify the human hosts ability to fight infection increasing our reliance on antibiotics. But it is the inappropriate use of antibiotics that is probably the biggest driver of resistance.

In medicine we want to help patients and as patients we often want a pill to make us feel better.  For example, the vast majority of sore throats (and most other upper respiratory tract infections) are due to viral infections.  Antibiotics have absolutely no activity on viruses, yet antibiotics are often requested and prescribed for sore throats.  However, taking these antibiotics pressures the bacteria that normally live in you body to evolve, and adapt to survive in the presence of a chemical designed to kill them. Just as important, many of the genetic changes behind resistance can be transmitted from one bacteria to another. Bacteria can collect many different resistance genes, so eventually they have a full set that protects them from all different types of antibiotics.  In Canada you need a prescription to get antibiotic.  However in other regions of the world, antibiotic are freely available over the counter which leads to indiscriminate and inappropriate use.todd-hatchette

AMR is also the result of antibiotic use outside medicine.    We use tons of antibiotics in agriculture which is added to the feed of animals to can keep them healthy and increase production.  However, this leads to the evolution of resistance in bacteria living in these animals, which can cause infections in humans or transfer their resistance genes to other bacteria that commonly infect humans.  In addition, AMR can be an unintended consequence of obsession to ensure everything we own is clean and sterile.  We impregnate our plastic toys with triclosan to reduce bacterial contamination with the goal of making them safer. However, this chemical can turn on antibiotic resistance genes in bacteria so rather than preventing infection we are creating the potential for infections that are harder to treat.

AMR also reflects the new global reality.  We live in a global village where you can travel halfway around the world in a day. We also have a form of medical tourism where people travel to places like India for surgical procedures they cannot get in North America. AROs that develop in one region can hitch a ride on returning travellers where they can be transmitted to people within local hospitals.

So how do we address this problem?  We need to do a better job of identifying these infections and ways to prevent transmission. In the hospital AROs are transmitted to patients on the hands of health care workers. In short we need to wash our hands.  Clearly it is not just that simple. Antimicrobial stewardship programs need to be instituted in all health care settings.  We need to track resistance and we need to change how we use antibiotics. We need to use the narrowest spectrum antibiotic needed for the shortest time necessary to cure the infection.  We also need to promote the development of new antibiotics to deal with these resistant infections.  This is a challenge because it takes 10 years and billions of dollars to bring a new drug to market and how can a business lobby their share holders to back a drug which has restricted use and therefore a restricted market.  However, we need them and as importantly we need to reserve these drugs for resistant infections and not use them indiscriminately.

What can you do?  Remember that not every sniffle, cough or sore throat requires an antibiotic. Similarly if your physician suggests you need it, question why to make sure you really do.  When you do make sure to take them as directed. Global consumption of antibiotics has increased 40% in the last year. Recent modeling suggests that if this disturbing trend is not reversed, by 2050 AMR infections will surpass cancer as the number one cause of death and cost the world economy 100 TRILLION dollars. But if we take action now and work together we can ensure we do not regress into a pre-antibiotic era of medicine where physicians watch helplessly as people die from infections that should be treatable.

~Dr. Todd Hatchette

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“Did you see this video on You Tube?”

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“Did you see this video on You Tube?” This is a question I over-hear or have had directed at me more times than I can count. Usually by one of my three children who want to keep me abreast of the latest post-wisdom-tooth-extraction-delirium or cute-puppies-sleeping videos. This trolling of You Tube and Instagram for entertainment is somewhat foreign to me – I’m getting old – I suppose it’s the digital age version of flipping through magazines and looking at glossy pictures. But the digital age is not going away, as a matter of fact, it is rapidly reinventing itself at a pace that I can’t keep up with. Remember podcasts? Well that was SO 10 YEARS AGO.

As much as my mind is boggled by all the social media out there, I’d like to think my learning curve has been quite steep. I’m not a You-Tuber or Instagrammer, however Twitter (as a professional tool) makes sense to me. It feels more like streaming headlines to keep me in the loop. At a recent Royal College of Physicians and Surgeons Conference http://icreblog.royalcollege.ca/ I spent a full day in a Social Media Summit where I was amazed to see the extent to which various forms of social media have planted themselves firmly in the research and medical education worlds as a tool for information exchange. Conference goers shared slides, opinions, commentaries on Twitter, Instagram and Facebook, some sessions were live-streamed, other sessions were live-Tweeted…yes, live-Tweeted…with such reach that an individual in the southern US was weighing in on topics and opinions being generated from a talk they weren’t even attending. I myself, a rather novice and slightly anti-social social media user, got caught up in the energy and tweeted points of interest and self-reflection in an effort to share with my academic and research followers. I also wanted to be as cool as all the other people who were so effortlessly and simultaneously soaking in information and Tweeting about it at the same time.

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Although the Tweeting and Instagramming activities in this particular context are likely more “social”, social media in general can serve as a very useful tool for what researchers call Knowledge Translation (knowledge dissemination, sharing, etc.). Podcasts and Tedx sessions are great sources for engaging and intellectual talks about a range of science and research topics. Want to know about a drug to slow down Parkinson’s disease? There’s a podcast for that. https://www.michaeljfox.org/foundation/news-detail.php?podcast-drug-that-may-slow-parkinson-progression-granted-23-million-from-nih-for-phase-iii

Want to know about ethical issues in HIV research? There’s a Tedx talk for that https://www.ted.com/talks/boghuma_kabisen_titanji_ethical_riddles_in_hiv_research

Social media such as You Tube can be an excellent resource for parents looking for information about a range of children’s health issues. The IWK’s Dr. Christine Chambers  http://pediatric-pain.ca/faculty/christine-chambers/ has had tremendous success with a You Tube video that has taken years of pediatric pain research and put it into a brief video designed to teach parents how to make needles less painful for their children.

In 142 characters or less, agencies like the National Institutes of Health https://twitter.com/nih and the Canadian Institute for Health Research https://twitter.com/cihr_irsc keep researchers informed about funding opportunities and the public informed about health research related topics of current relevance.

These are great, reputable sources for both health professionals and the lay person interested in hot topics related to health research in North America.

As curiosity driven beings, we are sponges for information. Social media in its various forms provides us access to a range of ground-breaking findings, trends, publications, videos and reports. A study published in the Journal of Medical Internet Research reported that 24.1% of 485 physicians surveyed used social media daily to “scan or explore medical information”. Moreover 57.5% of those physicians saw social media as beneficial, engaging, and useful for acquiring current, high-quality information. http://www.jmir.org/2012/5/e117/ . But with the sheer volume of information that’s out there, and the rapid fire speed with which we glance over that information, how can researchers and health care providers accurately assess what is “high quality information”?

In evidence-based settings (medicine, research) knowledge users engage in critical appraisal – an activity that involves a comprehensive assessment of various aspects of a research paper in order to weigh the overall pros and cons of that evidence. Criteria such as peer review, inclusion of detailed methodology, identification of limitation weigh heavily in the final assessment of overall merit. However in a digital age where knowledge is at our fingertips, there seems to be very little information about how we might critically appraise that information for validity and reliability. I can Google the most recent status of flu vaccine uptake, but is it correct?

Should scientific content distributed across social media as a form of knowledge exchange be subject to the same sort of critical appraisal as traditional forms of scholarly knowledge sharing? Journal publications are peer-reviewed. Conference presentations undergo a review process before accepted. However, as researchers we can Tweet our opinions about our (or others) research, Instagram a photo of a table or chart or You Tube a video of a lecture and there it is, out in the digital world to be consumed. And who’s to say any of this is accurate, reliable or valid? Can the retweet, the favorite and the like be considered a virtual form of peer review?

One side of the coin is that perhaps knowledge exchange on social media is nothing more than the new casual conversations around the proverbial water cooler. Brief snippets of information and videos can keep you up to date on the current issues in your research area.

The other side of the coin is that perhaps we should start considering critical appraisal tools – with either intuitive or formal processes – to apply to various forms of social media. Although I doubt very much that any good researcher would expect his or her audience to accept the “trust me” defense and accept a tweet, podcast or Instagram as gospel, I often wonder if the knowledge consumer doesn’t stop to assess the information. Even where links are provided to support posts with journal articles, charts and data, I would bet very few of us dig deeper when all we’re looking for is the digital version of a sound bite.

So where does this leave us as critical thinkers? I believe we should apply the same critical lens to knowledge that is disseminated through social media as we apply to traditional forms of knowledge dissemination. Perhaps the same rigor we apply to systematic critical appraisal is not required, but I would suggest the grain-of-salt approach. Is the source reputable? Does the source provide additional reputable links for more detailed information? Is the information based on evidence or opinion? These are just a few high level considerations.

There’s a lot of information out there and separating the good from the bad can be a cumbersome process. At least when things get overwhelming, there will always be cute-puppies-sleeping videos…guaranteed to be a valid and reliable source of stress relief.

~  Dr. Jill Hatchette


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10 Reasons Why I Hate Research

 

Why I Hate Research

I should tell you, there was a time when I hated research enough that I nearly quit. When I finished my PhD (in the last century), I hated research. I had become a psychologist because I wanted to help kids. Although I did well in my PhD, I was so fed up that I didn’t publish my PhD research which was a series of studies on the measurement of social skills. I felt it didn’t do any good and would only be read by a few other scientists.

I applied only for clinical jobs. Unfortunately, the clinical job I applied for required I do a bit of research. I started some research on children with recurrent abdominal pain because no one could figure out what to do with these patients. It related directly to my patients and within three years, I was hooked on research.  During my career, I have spent thousands of hours doing my research, supervising student research, and I have published hundreds of scientific papers.  Although my days are now spent as Vice President of Research and Innovation, I can’t imagine how I could live without doing research.

But I still hate research at times.  Here are 10 reasons why.

  1. Research crushes some of the best and the brightest young minds. Research funding is so tight that some outstanding young scientists don’t get funding. For example, in the regular Canadian Institute of Health Research competition, there was about an 85% failure rate. With low success rates for grants, it takes an almost insane devotion to science to continue in research.
  2. Research doesn’t get enough attention in the media. Maybe this is unseemly whining, but I wish that instead of the focus we have on celebrities and athletes we had a bit more focus on my brilliant colleagues who are scientists. Did you ever notice that the newspaper has a large section on sports but only a few columns on science and research. If you look up what is trending on Twitter, it is never science. Not that I think scientists should be pursued by papparazi, but more attention would be good.
  3. Research fails a lot of the time. Many of my research ideas and those of other researchers fail. It is necessary. In fact, if you don’t fail in your studies, you are not being adventuresome enough. Failure of a study, if designed right, is just another data point. My first study when I started my research career was a failure and it taught me a lot. But it can be miserable to spend months working on a project to see it fail.
  4. Sometimes partners you choose are not good collaborators. This is fortunately rare and most collaborators are outstanding. Because research often requires multiple investigators with different skills, collaborators who don’t deliver can devastate a study.
  5. Sometimes it takes longer than I think it should to do a study. The most common problem in clinical research is enrolling participants with most trials not meeting their planned level of participants.
  6. Research takes a lot of your personal time and is often done outside of regular work hours. I don’t know of any top flight researcher who does not spend many extra hours on research.
  7. Sometimes research doesn’t go anywhere – findings not used, papers not published.
  8. It is hard to keep up with the rapidly changing field – must stay current by reading a lot of journals, attending international conferences etc.
  9. Research is sometimes not valued.  Even though there is great research evidence for a decision, this may not be acted on by policy makers and others.  This can be frustrating.
  10. Grant reviewers sometimes just don’t get it and give poor ratings to my proposal. But it is probably not their fault.  It is likely that I have not done a good enough job explaining the research or the potential value of the research.

 

~Dr. Patrick McGrath