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In recent years deaths from opioid overdoses have become one of the most common injury-related deaths in North America. The continent also has the highest per capita rate of opioid prescription in the world. 

Recognizing the role that opioid prescribing plays in the national opioid crisis, a team of researchers at Lawson Health Research Institute and Western University have developed a new clinical protocol called STOP Narcotics. A study demonstrating the efficacy of their protocol was presented at the American College of Surgeons Clinical Congress in Boston, Massachusetts on October 24. 

The protocol includes a combination of patient and health care provider education and an emphasis on non-opioid pain control. The study found that they were able to reduce the overall amount of opioids being prescribed after general surgery by 50 per cent while still adequately treating a patient’s post-operative pain.   

“By significantly reducing the amount of opioids prescribed, this decreases the exposure risk and potential for misuse of narcotic medication,” said Dr. Luke Hartford, a resident in general surgery at Western’s Schulich School of Medicine & Dentistry and first author on the study. “This also decreases excess medication available to be diverted to individuals for whom it was not intended.”

The study involved 416 patients at London Health Sciences Centre (LHSC) and St. Joseph’s Health Care London who underwent laparoscopic cholecystectomy or open hernia repair. They received medication for post-operative pain through the standardized protocol, specifically acetaminophen (Tylenol) and a non-steroidal anti-inflammatory drug (Naproxen) for the first 72 hours post-surgery. 

The protocol instructs physicians to write a limited prescription of ten pills of opioids (Tramadol), with an expiry date of seven days after surgery, with instructions for the patient to fill this prescription only if adequate pain control was not otherwise achieved. There are also instructions on proper disposal of unused medication for the patient.

Dr. Ken Leslie, scientist at Lawson, associate professor in the Department of Surgery at Schulich Medicine & Dentistry, and Chair/Chief of the Division of General Surgery at London Health Sciences Centre led the implementation of the new protocol.

“We recognized that before STOP Narcotics, every surgeon had a different approach to pain control, and that most surgeons were prescribing more narcotics than are actually needed,” said Dr. Leslie. “When we looked at the data from this new protocol, we saw that the patient’s pain-control was just as good with this pathway, without a huge prescription for narcotics.”

The results showed that in the STOP narcotics group, compared to a control group, there was a 50 per cent reduction in the number of opioids being prescribed. They also demonstrated that only 45 per cent of patients actually filled their opioid prescription, compared to 95 per cent in the control group, and they were also able to increase appropriate disposal of excess opioid medication from 7 per cent in the control group to 23 per cent in the STOP Narcotics group. The levels of reported post-operative pain were the same in both groups.

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The group now hopes to expand the protocol for applications beyond general surgery.

“If we can decrease the opioid exposure risk in our patients, and decrease the amount of excess medication available for diversion, and spread this to other institutions and surgical procedures and specialties, this has the potential to significantly impact the opioid crisis,” said Dr. Patrick Murphy, a resident in general surgery at Schulich Medicine & Dentistry and co-author on the study.

The study, “The Standardization of Outpatient Procedure (STOP) Narcotics: A Prospective Noninferiority Study to Reduce Opioid Use in Outpatient General Surgical Procedures,” is published in the Journal of the American College of Surgeons.

Dr. Ken Leslie	Dr. Luke Hartford	Dr. Patrick Murphy
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Researchers in London, Ontario have been awarded $1.345 million over five years through the second phase of the Canadian Consortium on Neurodegeneration in Aging (CCNA), announced today as part of Canada’s first national dementia strategy. CCNA is a collaborative research program tackling the challenge of dementia and other neurodegenerative illnesses. 

A Dementia Strategy for Canada: Together We Aspire focuses on preventing dementia, advancing therapies and finding a cure, as well as improving quality of life for people living with dementia and caregivers. 

Clinician researchers from across the country working together 

Dr. Manuel Montero-Odasso, Scientist at Lawson Health Research Institute, is world renowned for his findings on the relationship between cognition and mobility in the elderly, and gait as a predictor of frailty and dementia. He leads the Mobility, Exercise and Cognition (MEC) Team in London, comprised of top researchers in the areas of mobility, exercise and brain health.

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“Evidence from other countries with dementia strategies shows that coordinated, targeted efforts at the national level improves results for all aspects of dementia care and also for research,” says Dr. Montero-Odasso, also a geriatrician and Director of the Gait and Brain Lab at Parkwood Institute, a part of St. Joseph’s Health Care London. 

CCNA was purpose-built to synergize dementia research within the Canadian context. Phase I saw the creation of infrastructure fostering collaboration amongst Canadian researchers, and there are now 20 teams built around important research topics. 

“This kind of effective national collaboration by scientists and clinicians from many disciplines gives the CCNA a cutting edge in research, prevention, treatment and management of all forms of dementia,” explains Dr. Montero-ODasso. “We created a national network of researchers form west to east coast with a high level of expertise to deliver lifestyle interventions to improve cognition and slow down progression to dementia. I feel privileged working with such excellent investigators and leading this important endeavour locally.” 

Preventing dementia through lifestyle changes

The MEC team has several projects in the works, but the majority of the new funding is to complete the SYNERGIC Trial, SYNchronizing Exercises and Remedies on Gait and Cognition. 

This first-in-the-world clinical study is testing a triple intervention aimed at treating Mild Cognitive Impairment (MCI) and delaying the onset of dementia. The SYNERGIC Trial incorporates physical exercises and cognitive training, along with vitamin D supplementation to determine the best treatment for improving mobility and cognition. 

“We are looking at how interventions will work together and targeting cognitive decline at its earliest stage – individuals with MIC,” explains Dr. Montero-Odasso. “Both physical and cognitive exercises have shown promising effects for maintaining cognition, while vitamin D deficiency is associated with cognitive decline.” 

A professor at Western University’s Schulich Medicine & Dentistry, Dr. Montero-Odasso partners with researchers from across the city including Dr. Rob Bartha, imaging scientist at Schulich Medicine & Dentistry and Robarts Research Institute at Western University, and Dr. Kevin Schoemaker who leads the Laboratory for Brain and Heart Health. 

Study participants in the SYNERGIC Trial are asked to complete an individualized and progressive routine of exercises and cognitive training three times a week for six months, with one final assessment at 12 months. The main site for the study is Parkwood Institute with the physical exercises taking place at the Labatt Health Sciences Building on the Western campus.

To date, 138 research patients has been recruited across multiple sites in Canada. 

One participant’s experience 

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One day, Peter Saracino saw an advertisement about a research study. They were looking for participants who were a minimum age of 60 and had minor cognitive impairment. He felt he fit the bill and he was interested in this kind of research. 

“I have family members who suffered from forms of dementia and Parkinson’s Disease. I really understand how hard it hits and I liked that this study was about prevention,” explains Peter. 

Going into it, Peter thought he was in pretty good shape. He has two dogs and walks them regularly. “But by going to the gym and doing the exercises and faster-paced walking, I realized that I wasn’t in as good shape as I thought. My diet was under control but I was still taking blood pressure medication. I didn’t have much energy.” 

After 10 weeks in the study, he feels better than he has for over a decade. “I can garden for longer. I took two notches off my belt. I no longer take my blood pressure medication. I actually feel younger.”

He remembered that last year he slipped and fell four times, which was very unusual for him. Part of his cognitive impairment is that he had trouble with balance, and that has improved for him as well. 

Peter feels that “this is exactly the kind of research that the government should be investing in – an ounce of prevention is worth a pound of cure. This kind of research leads to keeping people independent and healthier as they get older. People are happier. They feel like doing more. There is no downside to improving someone’s health through lifestyle changes, and in fact it is cost effective and helps ease the burden on the health care system.” 

Looking forward 

“Our preliminary analysis from SYNERGIC is giving us a strong indication that a multimodal approach, combining physical exercise, cognitive training and supplementation, has a synergistic effect. It seems the whole is greater than the sum of its parts,” says Dr. Montero-Odasso. 

A major goal for the work of the MEC team in London is to translate their research findings into clinical guidelines that can be used at the front line of care. “Practitioners understand the overall importance of exercise and cognitive vitality, but we are missing more specific guidelines on what kind and how much will work for different patients. Basically, what is an effective lifestyle prescription.”

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Dr. Montero-Odasso adds that “as our population ages, a comprehensive strategy is vital to ensure the growing number of those living with dementia receive the care and support they deserve. Over half a million Canadians are currently living with dementia. By 2031, this number is expected to nearly double.” More than one third of dementia cases might be preventable. 

CCNA Phase II

In CCNA’s Phase II, researchers are working on analyzing the overall health of every patient in a large clinical cohort study, COMPASS-ND. This information will be used to enhance understanding of how changes in the brain affect dementia severity and ways to reduce and prevent this through lifestyle changes. Lawson is the leading recruitment site for COMPASS-ND and the London team will be instrumental in the larger lifestyle interventions moving forward. 

CCNA is funded by the Government of Canada, Canadian Institutes of Health Research (CIHR) and other funding partners. CIHR is providing $31.6 million, and partners—including provincial agencies and non-profit organizations—are providing an additional $14.4 million for a total investment of $46 million over five years. The research on dementia prevention, diagnosis, treatment and care as part of Phase II of the CCNA will support the national strategy.

Related stories

• Researchers testing triple intervention to combat dementia 
• Lawson and Western researchers suggest walking and talking can be an early predictor of dementia 
• How changes in the brain affect walking while talking in older adults 

More than 100 researchers, staff and trainees attended the third annual Parkwood Institute Research (PIR) Spring Update Half Day on April 27, 2018 to share their innovative research and learn about work from across PIR through interactive workshops and poster presentations.

A program of Lawson Health Research Institute and located at St. Joseph’s Health Care London’s Parkwood Institute, PIR represents three major research programs: cognitive vitality and brain health, mobility and activity, and mental health. The event allowed guests to hear about new studies and recent research developments from across these three themes.

“Parkwood Institute Research covers different research areas but what we want to emphasize with this event is the overlap and collaboration between our programs. Having an inter-disciplinary approach that encourages partnerships ultimately helps us to incorporate new knowledge into patient care at Parkwood Institute,” says Dr. Cheryl Forchuk, Beryl and Richard Ivey Research Chair in Aging, Mental Health, Rehabilitation and Recovery, and Assistant Director, Lawson.

Five interactive workshops were held on a variety of different topics, such as clinical trials, systematic reviews, innovation in health care, practice-based research methods and evaluating SMART technology. The workshops were led by some of Parkwood Institute’s research leaders, including Drs. Cheryl Forchuk, Robert Teasell, Michael Borrie, Dalton Wolfe, and Arlene MacDougall.

Attendees also had the opportunity to visit poster presentations on recent PIR projects.

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Ashrafunissa Janmohammad (above), Lawson research coordinator at Parkwood Institute’s Chronic Wound Management Clinic, was one of the poster presenters at the event. She presented on a study led by Lawson associate scientist Dr. David Keast, which assessed whether chitosan gelling fibre dressing could be effective in controlling bleeding after minor wound surgery. Chitosan is derived from chitin, the structural component of the cell walls of fungi and the shells of arthropods such as crabs, lobsters, shrimps and insects.

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Juweiriya Ahmed (above), a MSc candidate at Lawson and Western University’s Schulich School of Medicine & Dentistry, was another presenter. Her poster outlined a study investigating the interaction between neuroanatomical and genetic risk factors that may contribute to the development of psychotic symptoms (delusions and hallucinations) in patients with Alzheimer’s disease. Supervised by Lawson scientist Dr. Elizabeth Finger, the study could help inform the development of therapeutic targets and treatment plans.

A research team led by Lawson scientist Dr. Mamadou Diop has been awarded a Lawson Internal Research Fund to investigate whether a previously developed optical technique that can detect arthritis within one week of onset could also be used to provide early assessment of treatment response for rheumatoid arthritis (RA).

RA is a disease that causes chronic inflammation of the joints, which results in pain, reduced quality of life and loss of productivity. There is no cure for RA but a new category of drugs – biologic agents that can reduce pain and slow down or even halt disease progression – has revolutionized treatment.

However, these new drugs are expensive and only work in 30 per cent of patients, which means many RA sufferers are treated with no benefit for up to six months – the time it takes for current monitoring methods to reliably determine whether a treatment is working or not. “This is a direct consequence of the lack of sensitivity of current monitoring methods,” says Dr. Diop, who is also an assistant professor at Western University’s Schulich School of Medicine & Dentistry.

Since their recently developed optical technique has a high sensitivity to arthritis, Dr. Diop and his team believes it could also be used as a safe and convenient method of assessing treatment efficacy in RA patients. Additionally, there are striking similarities between RA and cancer, and it has been shown that optical techniques can predict cancer in as early as one day after therapy starts.

At St. Joseph’s Health Care London, they will test this theory in a rat model of RA and compare the results of the optical technique to histology and CT imaging, other established methods of determining whether a treatment is effective.

“If successful, this project will generate a safe, low-cost technique that can detect treatment response in RA within days of starting treatment. This would reduce the risk of further joint damage experienced by many patients for whom the drugs are ineffective,” says Dr. Diop. “We hope this will enable early redirection of patients with non-responding RA to alternative treatments, such as a combination of multiple drugs and more frequent monitoring.”

Dr. Diop adds, “The Lawson IRF grant will enable us to test the validity of our hypothesis and subsequently generate valuable preliminary results to support grant proposals for larger external funding.”

The IRF is designed to provide Lawson scientists and students the opportunity to obtain start-up funds for new projects with the potential to obtain larger funding, be published in a high-impact journal, or provide a clinical benefit to patients. Funding is provided by the clinical departments of London Health Sciences Centre and St. Joseph’s Health Care London, as well as the hospital foundations (London Health Sciences Foundation and St. Joseph's Health Care Foundation).

Chronic diseases, such as chronic obstructive pulmonary disease (COPD), are complex and require thorough care to help manage the condition. Patients often need support from an integrated team of health care professionals who work in different settings. 

Dr. Shannon Sibbald, associate scientist at Lawson Health Research Institute, is leading a study to better understand integrated health care teams for chronic disease management and factors that help successful implementation. 

Integrated team-based models of care include multiple health care providers working together to support patients with complex needs, such as those with chronic disease. There are many benefits to integrated team-based models of care. Patient outcomes are improved, health care providers feel more supported in their work and services are less likely to be duplicated. 

Dr. Sibbald’s research focuses on chronic obstructive pulmonary disease (COPD), a devastating chronic disease affecting normal lung function in over 1.5 million Canadians. COPD is one example of a chronic disease where patients can benefit from team-based care. COPD is often underdiagnosed, and patients with COPD and other chronic diseases may not be receiving the ideal care for their condition. 

While integrated team-based care is important, there are currently few studies to guide implementation. In this study, Dr. Sibbald’s research team will engage health care providers and patients to gain a rich understanding of successful integrated approaches to chronic disease management, including how team-based models of care are implemented. The team will also work to better understand how patients with chronic diseases view such models, and what their hopes and expectations are for their care. 

“We want to explore innovative and successful approaches to implementing team-based models of care,” explains Dr. Sibbald. “We’re looking to learn how these methods can support practice, improve patient outcomes and spread innovation.”

The team will look at high performing integrated care teams that support current best practices at a family health team in London, Ontario. 

When models are applied to practice, context is an important part to consider. For chronic diseases, context is often broad and elaborate. They hope to gain insight into what works well and what does not in dynamic contexts, and gain a better understanding of implementation facilitators and barriers.

The ultimate goal is to build knowledge that will support implementation and sustainability of high-performing integrated health teams across our health system.

“While motivation and momentum to use integrated teams is high, there is little guidance on how to do this well,” says Dr. Sibbald. “This research will provide insight into what works and what does not, reducing our gap in knowledge.”

Dr. Sibbald received a Lawson Internal Research Fund (IRF) grant to conduct this pilot study. Once complete, Dr. Sibbald’s team hopes to expand the study to look at integrated care models at other sites across the province. 

"The IRF grant enables our team to validate our methods of evaluating the implementation of interprofessional team-based care in complex settings," adds Dr. Sibbald. "By examining the impact team-based care for patients with COPD, we hope to demonstrate the relevance of our findings, to support grant proposals."

The IRF is designed to provide Lawson scientists the opportunity to obtain start-up funds for new projects with the potential to obtain larger funding, be published in a high-impact journal, or provide a clinical benefit to patients. Funding is provided by the clinical departments of London Health Sciences Centre and St. Joseph’s Health Care London, as well as the hospital foundations (London Health Sciences Foundation and St. Joseph’s Health Care Foundation).

A new study from Lawson Health Research Institute and Western University published in the journal Microbiome has found changes in the microbiome in multiple locations in the body are linked to the formation of kidney stones.

The human microbiome comprises trillions of microorganisms, including healthy bacteria. In recent years, research has begun to uncover its role in health and numerous diseases.

The research team examined the gut, urinary and salivary microbiomes in 83 patients who had kidney stones and compared them to 30 healthy controls. They found changes in all three microbiomes were linked to kidney stone formation.

“Kidney stone disease has been rising in recent years, affecting roughly 10 per cent of people,” says Dr. Jeremy Burton, Lawson Scientist and Research Chair of Human Microbiome and Probiotics at St. Joseph’s Health Care London (St. Joseph’s). “While previous research has shown a connection between the gut microbiome and kidney stones in those who have taken antibiotics, we also wanted to explore the connection to other microbiomes in the hopes we can advance understanding and potential treatments.”

Study participants included people who had formed kidney stones, had not had antibiotic exposure in the last 90 days and were having the stones removed surgically at St. Joseph’s.

“Our testing – called shotgun metagenomic sequencing – allowed us to discover which bacteria were present in the gut and the genetic capabilities of those bacteria, or how it functions. We also did a simpler sequencing of the oral and urinary samples,” explains Dr. Kait Al, lead author on the study and Postdoctoral Research Fellow at Western’s Schulich School of Medicine & Dentistry.

Kidney stones are most commonly formed from calcium oxalate, which is a waste product produced by the body. Historically, it was thought people with specific gut microbes, like one bacterium called Oxalobacter formigenes that breaks down oxalate, were less likely to form kidney stones. This study suggests there are other factors.

“It’s a more complex story. The microbes form a kind of network that’s stable and beneficial in healthy people, but in those with kidney stones, that network is broken down. They’re not producing the same vitamins and useful metabolites, not just in the gut but also in the urinary tract and oral cavity,” Dr. Al explains.

There was also evidence that those with kidney stones had been exposed to more antimicrobials, as they had more antibiotic-resistant genes.

“We found not only that those who got kidney stones had an unhealthy microbiome, including a gut microbiome that was more likely to excrete toxins to the kidneys, but also that they were antibiotic resistant,” explains Dr. Burton, also an Associate Professor in the Department of Microbiology and Immunology at Schulich Medicine & Dentistry.  

The research team says that although more research is needed, these initial findings shed light on the overall importance of a person’s microbiome and keeping it as healthy as possible, with a microbiome-friendly diet and minimal antibiotic use potentially part of the solution.

The study was funded in part through the Weston Foundation and supported by the American Urological Association.

Transitional aged youth in Middlesex County now have access to a free transportation resource to access mental health services. Called the County Transport initiative, it will help youth ages 16 to 25 in Lucan, Parkhill, Exeter and Strathroy-Caradoc get the mental health care they need, when they need it. 

County Transport is being coordinated by MINDS of London-Middlesex, a program of Lawson Health Research Institute, in partnership with the Canadian Mental Health Association (CMHA) of Elgin-Middlesex, Star Taxi and Middlesex County through the Lucan and Parkhill Libraries. 

“Through our collaborative work, we’ve heard from many youth that transportation is a barrier for them when trying to access mental health services when in crisis. Youth in rural areas find this very challenging since most services are not close to their location,” says Romaisa Pervez, Research Assistant at MINDS of London-Middlesex. 

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MINDS, a Mental Health INcubator for Disruptive Solution, is a social innovation lab with a mission to address the complexity of the mental health care system. Youth with lived experience, community members and researchers work together to understand and help those living with mental health challenges in London-Middlesex by designing, piloting and testing innovative solutions developed locally. 

“We do not have the exact numbers of transitional aged youth living in rural Middlesex who would benefit from access to the County Transport Initiative, but we know that mental health services in rural communities are limited and that access to the services available in larger city centres is challenging due to transportation difficulties,” explains Cathy Burghardt-Jesson, Warden for Middlesex County.

“Transportation from Middlesex to London, where the majority of mental health resources are located, is underdeveloped as there are limited bus routes and schedules. This leaves little in the way of affordable transit options for youth in crisis.”  

Youth in crisis who connect with CMHA’s Reach Out 24/7 line at www.reachout247.ca or by phone at 519-433-2023 will be supported and assessed by the Crisis Line staff. If it is determined that a visit to the London Crisis Centre is needed, the CMHA Crisis worker will ensure a smooth transition from the Crisis Line to the Star Taxi Service. The youth will be provided with free transportation to and from CMHA’s Mental Health and Addictions Crisis Centre located at 648 Huron Street.  

To ensure the safety and wellbeing of the youth accessing this service, Star Taxi drivers have received training developed by CMHA regarding mental health and crisis de-escalation, as well as suicide prevention training by Living Works. 

Funding for the initiative has been provided by St. Joseph’s Health Care Foundation and the generous support of individual donors in the community. 

“With additional funding, the initiative could be scaled up to reach as many youth as possible in Middlesex County and beyond. We want to see all youth in rural areas who want to access mental health services able to do so, by removing the barriers of location and transportation,” adds Pervez.

They will be collecting information regarding use of the transportation service and youth experience to refine and improve the initiative.

For patients with kidney stones, ureteral stents (hollow devices placed in the ureter – the tube between the kidney and bladder) can be used temporarily to relieve urinary obstruction. Despite the use of antibiotics, ureteral stents often become encrusted with minerals and coated with bacteria. This can lead to complications like infection and the need for replacement surgery. 

Published today in Cell Reports Medicine, researchers at Lawson Health Research Institute and Western University conducted a novel microbiome study to examine bacteria associated with ureteral stents. They found that nearly all the stents, whether visibly coated or not, had unique bacterial profiles that were most associated with a patient’s medical condition rather than antibiotic use. For patients with ureteral stents, they may benefit from a personalized approach to care and antibiotic treatment. 

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The study included 241 patients from St. Joseph’s Health Care London. The research team collected and analyzed patient urine samples and ureteral stents following surgical removal, as well as relevant patient information such as antibiotic use and history of infections.  

“We wanted to know which bacteria were present and whether the bacteria found in urine samples corresponded to the bacteria found on a patient’s stent,” explains Dr. Kait Al, Postdoctoral Fellow at Lawson and at Western’s Schulich School of Medicine & Dentistry. “We found that there was a bacterial community present on almost all stents, even if they were not visibly affected, and that it differed from the bacterial community found in a patient’s urine.”

These findings challenge long-held beliefs that the urinary tract is a sterile environment devoid of bacteria.

The study revealed that the bacteria present were determined by an individual patient’s medical condition. They differed significantly based on comorbidities like irritable bowel syndrome, obesity and hypertension. Antibiotic use within the past 30 days did not seem to have an effect on the types of bacteria detected on the stents. 

“While more research is needed, our study suggests that antibiotic use during the placement of these stents could one day be more conservative or targeted based on each patient’s condition,” says Dr. Jeremy Burton, Lawson Scientist and Associate Professor at Schulich Medicine & Dentistry.

The team also discovered that in patients needing multiple stents, the bacterial community remained stable over time, suggesting that infections on a patient’s previous stent could direct the course of treatment for their future device placements. 

“This is the largest study of its kind, investigating bacteria both in urine and adhered to ureteral stents,” states Dr. Hassan Razvi, Urologist at St. Joseph’s, Lawson Associate Scientist and Professor at Schulich Medicine & Dentistry. “We hope this will be the first step towards personalized care, ultimately leading to fewer stent-associated infections.” 

The study was made possible through the generous support of The W. Garfield Weston Foundation and St. Joseph’s Health Care Foundation.

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Dr. Kait Al, Postdoctoral Fellow at Lawson and Schulich Medicine & Dentistry