Connections: ICRH Quarterly Newsletter - Winter 2009
In This Issue:
Message from SD
Special Feature: Acute Care Challenges of H1N1
Featured Research
Featured Partners
ICRH Events
Research In the News
Upcoming Events
Announcements
Send Us Your News
Message from Scientific Director, Dr. Peter Liu
Welcome to our winter edition of Connections. I would like to extend a heartfelt Happy New Year to all!
We are pleased to dedicate this issue to critical care research. Critical illness is associated with a high morbidity and mortality. In Canada, we are fortunate to have a vibrant critical care research community, led by the Canadian Critical Care Trials Group (CCCTG).
The critical care research community has generated research findings that shape the foundation of clinical practice in critical care worldwide. The CCCTG currently has more than 300 members from pediatric and adult critical care medicine. The CCCTG includes members from Newfoundland to Vancouver and has representation from both academic and community intensive care units. Currently, the CCCTG has more than 30 research programs underway and over 80 peer-reviewed publications to its credit. A recent bibliometric analysis has shown that the impact of critical care research in Canada is way above its weight in terms of the population of the country, GDP or amount of funding.
Clearly, the driving force behind clinical research is to enhance our understanding of how complex disease processes can be safely modified or treated, thereby improving patient outcomes. The need for this type of research is exemplified by the recent H1N1 outbreak, and its attendant complications of hemorrhagic pneumonitis and myocarditis seen in the critical care units around the world. ICRH has recognized the importance of this health problem by developing a rapid response funding opportunity, encouraging the internationally recognized CCCTG to take a leading role to help address the acute care challenges of H1N1.
We are also committed to developing and sustaining critical care research through our collaboration with the Research Outcomes Consortium (ROC) an international partnership between Canada and the United States. ROC research focuses on pre-hospital cardiopulmonary arrest and severe traumatic injury. To date, ICRH has committed over $12 million to this program, together with the U.S. NHLBI and the Heart & Stroke Foundation of Canada. The NIH has renewed it commitment to the ROC to 2016.
The fall season was a very busy time for our community and our institute. In October we held an external review of our very exciting Diabetes and Cardiovascular Complications of Diabetes Consortium (CCDC). It was a very positive review with impressive progress being made amongst the Canadian and Finnish teams. ICRH also hosted a two day workshop entitled Biomarkers for Precision Medicine at the end of November, together with nine other CIHR institutes and additional partners and stakeholders. The goal of the workshop is to better understand and appreciate the gaps and opportunities of using biomarkers as one component of CIHR's Personalized Medicine Initiative, and to help us formulate an upcoming Request for Applications.
At the Canadian Cardiovascular Congress (CCC), ICRH hosted a knowledge translation workshop featuring C-CHANGE; a Canadian Cardiovascular harmonized guideline endeavor. The program aims to integrate a number of important cardiovascular prevention guideline processes, and harmonize them with implementation plans, targeted to the health care professionals, as well as the patient and the public. Our Distinguished ICRH Lecturer Eduardo Marban gave a superb lecture on Stem cells for cardiac regeneration. ICRH was also delighted to join the Heart and Stroke Foundation of Canada and AstraZeneca Canada in honoring Shelagh Coutts with the first ever Distinguished Clinician Scientist Award. ICRH also sponsored the Annual Fun Run (Outrun the Metabolic Syndrome).
At the American CHEST 2009 Conference in San Diego in November, our Distinguished ICRH Award was given to James Martin from McGill University for his outstanding work in airway remodeling. His lecture was a highlight of the meeting, and helped to kick off a series of events hosted by the Canadian Thoracic Society at the CHEST conference.
With the recent roll out of the CIHR Roadmap strategic plan, our institute will also be engaged in identifying our upcoming strategic priorities. We will be seeking your feedback and input into the planning process and will send out a survey to the community later this month. ICRH invites you to let us know about your research and outcomes, from innovation to impact, as well as your knowledge translation activities. Please let us help you to reach the world with your results, and also let us know how we can continue to serve you better.
On behalf of our entire Institute staff, we wish our entire research community a most successful 2010.
Special Feature: Acute Care Challenges of H1N1
The Global Challenge
The WHO reported in December that worldwide more than 208 countries and overseas territories or communities have reported laboratory confirmed cases of pandemic influenza H1N1 2009, including at least 9,596 deaths.1 While ongoing prevention of H1N1 infection is of paramount importance, it is also clear that to reduce the consequences of severe H1N1, a better understanding of the epidemiology and clinical biology of the disease is needed.2
The global response has been to create InFACT (International Forum for Acute Care Trialists) H1N1 Research Collaborative, an initiative in which the Canadian Critical Care Trials Group (CCCTG) has taken a significant and leading role. The InFACT Collaborative's goal is to promote a "scientifically rigorous, geopolitically inclusive, and academically collegial" response to the critical care challenge of H1N1 infected patients".3 The research strategy includes four core initiatives and five harmonized regional databases which will create a central global registry to enable real-time study of the epidemiology, natural history and treatment of severe H1N1 infection.4 The program includes three randomized clinical trials of treatment strategies that target both the virus and the host response, and initial studies will evaluate interventions that are available in both the developed and the developing world, namely corticosteroids and statins.5
These trials use adaptive designs so that the results can be quickly translated into practice and ensure that ineffective treatments are eliminated.6 This is one of the many unique ethical and logistical challenges posed by the pandemic where innovative thinking is needed. In response, the InFACT Collaborative is also developing a position paper which seeks to find ways to reconcile some of the ethical challenges posed by critical care research such as balancing the protection of, and the rights of the patient with society's need to reduce the burden of illness and to quickly find effective, evidence informed approaches to prevention and treatment.7
Canada's Response
Between March 2009 and July 2009 the largest number of confirmed cases of H1N1 infection occurred in North America.8 In December 2009, the WHO compared transmission during the current winter season in Canada and the US to transmission during the summer season, and reported 2-3 times more hospitalized cases and deaths in the United States and approximately 4-5 times more hospitalized cases and deaths in Canada during the winter season.9 During the current winter season in Canada, 52% of hospitalized cases, 60% of cases requiring ICU, and 67% of fatal cases, had a underlying chronic medical illness.10
In response to the acute care challenges to the current situation in Canada, members of the Canadian Critical Care Trials Group (CCCTG) H1N1 collaborative conducted a multicenter observational, cohort of H1N1 critically adult and paediatric Canadian patients in order to describe the epidemiological characteristics, clinical features, treatments and outcomes.11 The results of this study have been published in JAMA in October 2009.
In addition to the work described above, Dr. Rob Fowler at Sunnybrook Hospital in Toronto has developed a database on severe H1N1 infection for ongoing epidemiologic studies. Dr. Fowler is leading a global project to harmonize 5 different regional/national databases for the InFACT Collaborative with the ultimate goal of providing a comprehensive picture of severe H1N1 infection around the world; and how its epidemiology and prognosis is shaped by geographic variability.
A number of CCCTG researchers have been focussing their efforts on the H1N1 pandemic. For example, Dr. Karen Burns and Dr. John Marshall at St. Michael's Hospital in Toronto are launching a CCCTG-led RCT – the CHAT trial – to evaluate the efficacy of statins as adjunctive therapy in severe H1N1 infection. The CHAT trial is a pilot study assessing the feasibility of a large international trial and will recruit patients from Canada and many international sites under the InFACT umbrella.
Dr. Deborah Cook has led an international white paper on ethics and consent during a pandemic as part of the InFACT initiative; the paper is in press in Critical Care Medicine.
For further information on the CCCTG and related publications and projects, please contact Dr. John Marshall at MarshallJ@smh.toronto.on.ca.
References:
1. WHO Pandemic (H1N1) 2009 - update 78.
2-7. Marshall, J., et. al. The InFACT Global H1N1 Collaboration, "InFACT: A global critical care research response to H1N1", The Lancet, published online November 10, 2009, DOI: 10.1016/S0140-6736(09)6792-X
8-10. WHO Pandemic (H1N1) 2009 - update 78.
11. Kumar, A. et. al. Canadian Critical Care Trials Group H1N1 Collaborative. "Critically ill patients with 2009 Influenza A (H1N1) infection in Canada", JAMA, published online October 12, 2009.
Featured Research
The OSCILLation for ARDS Treated Early (OSCILLATE) Trial*
Dr. Maureen Meade, an Associate Professor at McMaster University, and Dr. Niall Ferguson, Assistant Professor at the University of Toronto, have received $4,000,000 from CIHR to study the effect of oscillation on severe lung disease. Oscillation is an alternative form of mechanical ventilation that is thought to be gentler with the hope of better survival and long term outcomes for adults with acute respiratory distress syndrome.
Acute Respiratory Distress Syndrome (ARDS) is a common and catastrophic complication of critical illness related to burns, motor vehicle accidents, or overwhelming infection. ARDS kills 40-70% of affected patients. Patients with ARDS require life support in the form of a ventilator to breathe for them while their lungs heal. Ironically, ventilators can cause further damage to the lungs. We propose a study comparing 2 methods to protect the lungs from further damage. One method uses standard mechanical ventilators and the other uses a new type of ventilator, called a high frequency oscillator. Building on our experience with a preliminary study that showed that this is feasible, we propose to test whether this high frequency oscillation will reduce the relative risk of dying from ARDS. A total of 1200 patients will be included from 50 intensive care units in Canada and around the world.
The primary objective of the OSCILLATE trial is to determine the effects of high frequency oscillator versus conventional ventilation on mortality in adults with severe Acute respiratory distress syndrome (ARDS). The OSCILLATE pilot trial was to assess the feasibility of the ventilation strategies and study procedures. 11 ICUs participated in the pilot trial (10 in Canada and 1 in Saudi Arabia (King fahad National Guard). The full multinational trial has started recruitment in July 09 and will continue for 5 years.
For further information on trials currently recruiting patients, please contact Maureen Meade at meadema@HHSC.CA.
* Permission obtained to reprint excerpt from CIHR grant abstract.
Featured Partners
Resuscitation Outcomes Consortium (ROC)
Sudden cardiac arrest and severe traumatic injury afflict as many North Americans as acute myocardial infarction (AMI) and heart failure (HF), but the odds of surviving an acute event are vastly different. Most AMI and acutely de-compensated HF patients survive; however, 90-95% of sudden cardiac arrest, and 60% of severe traumatic injury patients do not survive their acute event. Much of the progress in managing AMI and HF patients can be traced directly to decades of high quality, basic and clinical trials research funded by NHLBI.
The Resuscitation Outcomes Consortium (ROC) is a Clinical Research Network conducting clinical research in the areas of cardiopulmonary arrest and traumatic injury leading to arrest. This network consists of 9 Regional Clinical Centers (RCCs), three major satellites and one Data and Coordinating Center (DCC). The ROC represents a breakthrough in conducting research in the early phase of the event. The ROC investigators include national and international experts and leaders in resuscitative medicine. The ROC is the first and only large scale effort in the world to conduct clinical trials focusing on the very early delivery of interventions by Emergency Medical Services (EMS) teams in the field when there is optimal potential for patient benefit.
The ROC has passed a rigorous NIH renewal process and was successfully awarded funding to 2016. The ROC's objective is to continue conducting multiple, collaborative, clinical research trials and other types of studies to evaluate strategies for treatment of patients with cardiac arrest or life-threatening trauma with a primary focus on the out-of-hospital emergency setting. Due to the high mortality rate of out-of hospital cardiac arrest and severe trauma, ROC seeks to transform the current field of research and translate results from these trials in the pre-hospital setting. The original goal of ROC focused on the following objectives: (1) provide a knowledge base that will improve therapeutic decision-making by testing treatment approaches for cardiopulmonary arrest and life-threatening trauma (2) develop infrastructure between community EMS providers and clinical research centers to conduct efficient out-of-hospital resuscitation research and (3) facilitate the training of resuscitation and emergency medicine physicians in clinical investigation. In its first phase of funding ROC successfully developed an infrastructure, a robust scientific agenda, implemented a number of clinical studies, and facilitated training of new emergency medicine researchers. Its primary objective in the next renewal phase is to develop cutting edge translational research to increase survival in the pre-hospital setting and secondly and to capitalize and expand on their current resources of data.
One of the major success stories is close, synchronized and collegial collaboration with multiple partners. One of the key goals has been an emphasis on a collaborative structure between the academic centers and EMS providers, utilizing a variety of communication tools, including web-based, face-to-face meetings, and staff education and training EMS in research concepts and requirements. This is unique to ROC. Traditionally EMS care has not been based on the results of randomized trials but often instead have been trained in specific, typically "local driven" care delivery. ROC has challenged many of the EMS providers by developing and implementing studies which many times have questioned existing practices. To be successful, the EMS has to be intimately involved in all stages of protocol development and implementation. ROC has been successful in creating a full partnership with their EMS providers.
The ROC's success also lies in the commitment of its funding partners. The ROC is funded by several major agencies. The Canadian Institutes of Health Research (ICRH) and the Heart and Stroke Foundation of Canada (HSFC) are excellent partners in both scientific and logistics areas. Both have also recognized the need to invest in research concerning clinical resuscitation strategies. Traumatic injuries continue to be a huge burden on the Canadian health care system, especially when leading to cardiopulmonary arrest. In those circumstances where cardiopulmonary arrest occurs outside of the hospital, early and effective resuscitation is the key to improving patient survival and rehabilitation. Both agencies have a played an important role in supporting the renewal of ROC and are committed to continue their strong support. The principal funding agency is National Heart Lung and Blood Institute (NHLBI), partnering with CIHR, HSFC, Department of Defense, Canadian Department of Defense, and the American Heart Association (AHA).
ROC has made significant progress in setting up critical infrastructure, defining new standards for quality of CPR monitoring during resuscitation trials, and applying the highest ethical and moral principles in carrying out the exception to informed consent procedures. In a relatively short period of time, ROC has built and matured into an effective planning and implementation enterprise that will continue to rapidly improve our knowledge base. ROC investigators have launched the world's largest prehospital cardiac arrest and trauma registry (Epistry). The investigators have concluded three major clinical trials (two in trauma and one in cardiac arrest) and are currently conducting two additional major clinical trials in cardiac arrest that will provide much needed evidence to determine which pre-hospital interventions yield the best outcome in patients. Over 30, 000 EMS personnel have been trained for ROC protocols. The existence of ROC has enhanced training and commitment of the entire academic emergency medicine community to resuscitation research. In fact, several of the study sites have instituted ROC-related emergency medicine fellowship training programs to ensure that the next generation of researchers can benefit from this program.
ICRH Events
ICRH at Canadian Cardiovascular Congress, October 24-28, 2009 in Edmonton, Alberta
C-CHANGE Workshop at Canadian Cardiovascular Congress
ICRH held a workshop during the 2009 CCC entitled "The C-CHANGE Project on Harmonized Guidelines: New Canadian Strategy to Maximize Impact in Cardiovascular Prevention".
The C-CHANGE workshop provided an opportunity for the community to learn more about the project. The workshop drew in approximately 70 participants. Based on the feedback received, participants enjoyed the passion behind the presentations from the content experts leading the workshop. The open forum discussion sparked a lot of questions. It appears as though the public is very eager to learn more about the program and would like even further opportunity to discuss C-CHANGE.
ICRH Fellowship Recognition Award at Canadian Cardiovascular CongressDr. Subhadeep Chakrabarti –University of Alberta
Research project title: "Role of Neuronal NOS (nNOS) on Estrogen Regulation of Endothelial Inflammation"
Subhadeep Chakrabarti is a postdoctoral fellow at the University of Alberta working with Dr Sandra Davidge. Originally qualified as a medical doctor in India, Subhadeep received his PhD in Medical Sciences from the University of Calgary for his work on neutrophil-endothelial interactions. His current research is on the endothelial inflammatory response in health and disease, with special focus on the effects of sex hormones and diabetes. In the future, Subhadeep aims to become an independent researcher in Canada in the field of vascular biology.
Special ICRH recognition also goes to:
Dr. David Kent - University of Cambridge (UK)
Research project title: "Clonal Studies of the JAK2 V617F Mutation in Myeloproliferative Disorders".
Dr. Ada Tang –University of British Columbia
Research project title: "Aerobic training after stroke: is there a dose-response relationship?"
Dr. John Ronald - Stanford University (California)
Research project title: "Multi-modality cell trafficking imaging using optical bioluminescent imaging, positron emission tomography (PET) and magnetic resonance imaging (MRI)".
In partnership with Astra Zeneca Canada Inc, ICHR hosted the 3rd annual "Outrun Metabolic Syndrome" delegate Fun Run at this year's CCC. Despite near freezing temperatures in Edmonton almost 40 participants turned up at 6:30 am for a 5k jog. We hope to see everyone again next year in Montréal!
Distinguished Lecture Awards 2009
Distinguished Lecture in Cardiovascular Sciences
Dr. Eduardo Marbán, Director, Cedars-Sinai Heart Institute and holder of the Mark Siegel Family Foundation Endowed Chair, Cedars-Sinai Medical Center, Los Angeles was awarded the ICRH Distinguished Lecture Prize in Cardiovascular science at the 2009 Canadian Cardiovascular Congress (CCC). Dr. Marbán's presentation focused on his ground breaking research, how his findings have led to greater understanding of stem cells for cardiac regeneration, and how the technique may lead new ways to repair damaged hearts.
Dr. Marbán's earlier research into how the heart's electrical system works was seminal, and now his new research on how one can accelerate the healing of damaged hearts with stem cells is just as astounding. This research offers so many new possibilities for patients with major heart attacks, heart failure and stroke. With heart disease being the leading cause of death in Canada, Dr. Marbán's research may fundamentally change how we approach these conditions.
Distinguished Lecture in Respiratory Sciences
CHEST Conference
November 2nd, San Diego
On behalf of ICRH and the Canadian Thoracic Society (CTS), we are pleased to announce that Dr. James Martin, Director, Montreal Chest Institute, was chosen as this year's Distinguished Lecturer in Respiratory Sciences. Dr. Martin delivered a one hour address on the topic of Airway Remodeling in Asthma: Implications for Disease Severity at the CHEST Conference on November 2, 2009 in San Diego, CA.
His research area is the immunopathology of asthma which he has addressed through cellular and animal models. These models provide the opportunity to explore T cell cytokines in allergic airway inflammation as well as the potentially important intracellular signalling pathways involved.
Biomarkers Initiative
ICRH led and hosted the Biomarkers for Precision Medicine Initiative National Workshop, along with eight CIHR Institutes, the Regenerative Medicine and Nanomedicine and the Canadian Longitudinal Study on Aging initiative. The workshop was held in Toronto on November 19-20, 2009, with over 70 registered national and international participants (experts and stakeholders) in attendance.
The vision of the workshop was to define and refine the focuses of biomarker research and development that could underpin a Request for Applications (RFA) to be launched by ICRH and partners in 2010. Such an RFA will be issued to the Canadian health research community with the intent of enabling excellence and distinction in Canada's biomarker solutions aimed at more precise personalized health care.
Overall, participants were very satisfied with the workshop and its outcomes, commenting that they enjoyed the multi-faceted presentations from experts from diverse fields of biomarker research. In addition, participants valued the opportunity of exchanging ideas and networking with many individuals.
Research In the News
Women have same heart attack symptoms as men
ScienceDaily (November 3, 2009) – The gender difference between men and women is a lot smaller than we've been led to believe when it comes to heart attack symptoms, according to a new study by cardiac nurse Martha MacKay.
Scientists record first injured human donor lungs repair with gene therapy
The Guardian (November 5, 2009) – For the first time in the world, transplant surgeons at Toronto General Hospital, University Health Network, Canada, used a new technique to repair an injured donor lung that was unsuitable for transplant, and then successfully transplanted it into a patient. They said the use of this technique could significantly expand the lung donor organ pool and improve outcome after transplantation.
1 in 4 Ontario hospitals change cardiac care policies after public report cards released
ICES (November 18, 2009) - "An interesting finding from our study was the observation that 30-day heart attack mortality rates were lower in the patients treated at the early feedback hospitals. While we cannot be certain as to whether this finding was due to the report cards or due to other unknown factors, we believe the EFFECT study data likely stimulated some important local hospital-specific changes in delivery of care that may have contributed to the better outcomes observed at early feedback hospitals," says Dr. Tu, lead researcher and senior scientist at ICES.
Gaining a better picture of lung disease
Western News (November 20, 2009) - Chronic obstructive pulmonary disease (COPD), a respiratory disease commonly known as chronic bronchitis or emphysema, is the fourth leading cause of death worldwide, but a University of Western Ontario researcher is providing new insight into the disease. Chronic obstructive pulmonary disease (COPD), a respiratory disease commonly known as chronic bronchitis or emphysema, is the fourth leading cause of death worldwide, but a University of Western Ontario researcher is providing new insight into the disease.
Upcoming Events
CIHR Primary Healthcare Summit: 'Patient-Oriented Primary Care – Scaling Up Innovation': Institute of Circulatory and Respiratory Health (ICRH) C-CHANGE Workshop
January 18-19, 2010
Hilton, Toronto
The workshop will provide an opportunity to learn about C-CHANGE as a systematic, evidence based, approach to harmonization and integration of cardiovascular risk factor treatment guidelines such as hypertension, diabetes, smoking, and lipids. The workshop seeks feedback from the primary care community on the harmonized guidelines and clinical strategies as well as implementation tools to promote uptake of the harmonized guidelines.
Presenters include: Drs Denis Drouin, Janusz Kaczorowski, Rick Ward, Peter Lin and James A. Stone
If you would like to attend the C-CHANGE workshop, please contact Caitlin Burgess at cburgess@uhnresearch.ca or 416-340-4962 to register free of charge.
To register for the entire summit, please visit the website.
Café Scientifique: Links Between Mental Health and Cardiovascular Disease
Tuesday, March 2, 2010
Windsor, Ontario
ICRH is holding a Café Scientifique in partnership with the Mental Health Commission of Canada in Windsor on Tuesday, March 2, 2010 at Mezzo Ristorante. Please visit our website shortly for more information. The event is free and open to the public.
Café Scientifique: Aboriginal Health and Risk Factors in Cardiovascular and Respiratory Disease
Tuesday, May 4, 2010
Vancouver, BC
ICRH is holding a Café Scientifique in partnership with the Aboriginal Health Strategic Initiatives in Vancouver on Tuesday, May 4, 2010 at the UBC Longhouse. Please visit our website shortly for more information. The event is free and open to the public.
YI Forum, May 5-7, 2010
The YI Forum is a major training and educational initiative of CIHR's Institute of Circulatory and Respiratory Health. Each year, the YI Forum provides young investigators and trainees with an opportunity to showcase their research; interact with senior researchers and faculty; learn about career development and state of the art research and technologies.
This year the institute has teamed up with the Providence Heart + Lung Institute at UBC to co-host the 2010 YI Forum in Vancouver, British Columbia. The 2010 meeting will take place from May 5-7th, at the Pan Pacific, a downtown Vancouver waterfront hotel.
The deadline for abstract submissions is January 15, 2010!
Announcements
Of Note…
The following CIHR Sponsored Award Lectures were given in recognition of excellent contributions to Proteomic Sciences at HUPO 2009 in Toronto, Ontario:
Dr. Daniel Levy, NHLBI
Dr. John Yates, TSRI
Dr. Michael Siu, York University
Dr. Rolf Apweiler, EBI/EMBL
Dr. Ralph Bradshaw, UCSF/MCP
Dr. Jay Cohn was presented with Academy's Lifetime Achievement Award in Cardiovascular Science and Medicine by Naranjan Dhalla on September 25/09
"Dr. Cohn's lecture was "A Strategy For Everyone To Live Past 100!"
Dr. Naranjan Dhalla and Dr. Jay Cohn
Send Us Your News
The Institute of Circulatory and Respiratory Health would like to hear from you. There is a wonderful story to tell about the results and benefits of health research in Canada, but we need your help to truly make this a page turner. And, we need to keep telling this story. So, we encourage you to let us know when you have or, better still, are close to publishing the results of research funded by CIHR. Please drop us a line at cburgess@uhnresearch.ca.