ASPOM - Anesthesia, Sleep, Perioperative Medicine

The Value, Importance, and Oversight of Clinical Research

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Student [Link to top]

Anu (Thomas) Nicholas
Post-Doctoral Fellow

My work is revolving around helping develop a grant proposal about the influence of sleep disturbances and preoperative cognitive impairments in developing post-operative complications in older adults undergoing elective surgery.
The Big Picture of My Work
An understanding of this relationship can aid in highlighting the importance of screening for sleep disturbances and cognitive decline including mild early stages. Incidence of mild cognitive impairment (MCI) in patients over 65 years of age is believed to be about 3 to 22%, based on the study population. The annual rate of progression to dementia and Alzheimer's disease (AD) in people with MCI is 5% to 10% and 15%, respectively. Hence early identification can aid is early interventions to slow down the development to neurodegenerative diseases in this elderly patient cohort.
Why is This So Important?
Studies conducted among surgical patients have reported all-time highest rates of surgery among patients above 80 years; more than one in five patients. Age tends to be an independent risk factor for 30-day mortality after emergency general surgeries. Age-related changes include but are not limited to physical, emotional and cognitive alterations. Earlier prediction of underlying reasons for post-operative health decline in this patient group would help in pre-surgery interventions that can help in better post-surgery recovery and improved quality of life.
What Will This Mean for Patients?
The identification of risk factors in this patient group would help in incorporating strategies to prevent post-operative complications.
A Snap Shot of My Lab Work - Important Finding Within the Last Year
Literature searches and review of literature for the present project, grant preparation and submission.
What's Next?
Currently I am in the process of preparing a research proposal for a grant submission early this year. Success in acquiring funding will be followed by submission to the ethics board and other formalities required to start the study.

Colin Suen
Post-Doctoral Fellow

My work is focused on understanding the in-hospital outcomes associated with obstructive sleep apnea (OSA). OSA is associated with the development of several cardiovascular diseases, arrhythmias and even sudden cardiac death. As well, up to 50% of patients undergoing cardiac surgery have unrecognized OSA and may be at risk for poor cardiovascular outcomes during hospitalization. Currently, we are developing a clinical trial to study the effectiveness of non-invasive ventilation methods to prevent OSA-related postoperative complications.
The Big Picture of My Work
Determining the prevalence of OSA in the cardiac surgery population and studying therapies to prevent hypoxemia and reduce the risk of postoperative complications.
Why is This So Important?
Many patients with cardiovascular disease also have unrecognized OSA. Furthermore, between 40 to 60% of patients with OSA do not adhere to the standard therapy, CPAP, and could be at higher risk of complications when untreated.
What Will This Mean for Patients?
We may be able to use alternative methods of ventilation such as high flow nasal cannula to restore airflow and prevent complications.
A Snap Shot of My Lab Work - Important Finding Within the Last Year
Last year we looked at sleep study parameters among patients with OSA, and found that in general, lower oxygen saturation levels were associated with postoperative complications, which was published in the journal CHEST. We also examined the literature studied in-hospital outcomes of patients hospitalized for cardiac disease such as myocardial infarction and heart failure, and found that OSA was associated with increased length of stay, mortality, and markers of myocardial injury.
What's Next?
The next phase of our study will be to perform a small pilot study to determine whether alternatives such as. high flow nasal cannula is better than CPAP. This work may lead to the design of a larger clinical trial to examine whether high flow nasal cannula can be used to prevent postoperative hypoxemia, and in turn, other complications.

Soodaba Mir, MSc
University of Toronto

My work was focused on understanding the interaction between centrally acting drugs and opioids in chronic pain patients with obstructive sleep apnea (OSA) and or central sleep apnea (CSA). Chronic opioid use is now recognized to be associated with the development of sleep disordered breathing including both OSA and CSA. Centrally acting drugs with sedating properties are commonly co-prescribed with opioids in chronic pain patients, and together the two may result in respiratory events and increased risk of sleep disordered breathing. Currently, we are publishing our work on the combined use of the centrally acting drug benzodiazepine with opioids in chronic pain patients.
The Big Picture of My Work
Determining the effect of concomitant centrally acting drug use with opioids in chronic pain patients with sleep disordered breathing.
Why is This So Important?
Many chronic pain patients who are prescribed opioids have unrecognized sleep disordered breathing. Furthermore, a large percentage of these patients are co-prescribed sedating centrally acting drugs with their opioid medication despite them being contraindicated. These chronic pain patients on concomitant opioidcentrally acting drugs higher risk of respiratory depression if they have underlying sleep disordered breathing that is left untreated.
What Will This Mean for Patients?
Chronic pain patients on opioid medication should be screened for sleep disordered breathing, and at-risk patients should not be prescribed potentially detrimental centrally acting drugs with their opioid medication.
A Snap Shot of My Lab Work - Important Finding Within the Last Year
Last year we looked at chronic pain patients on opioid medication with sleep disordered breathing and found that, there may be potential to reduce the risk and severity of sleep apnea in specific chronic pain patients on opioids using certain benzodiazepine sedatives by selecting those with a low respiratory arousal threshold in whom sleep promotion may stabilize breathing. We presented our work at the World Sleep Congress 2019 in Vancouver.
What's Next?
The next phase of our research will be to potentially perform a prospective cohort study to determine whether concomitant opioid and benzodiazepine use in chronic pain patients with a low respiratory arousal threshold could be beneficial in reducing the risk of sleep apnea.

Sally Hu, MD
PGY-1 Resident Physician
Dept. of Anesthesia, University of Toronto
June 2018

I worked with Dr. Chung on a project over the course of 2 years. Dr. Chung is a fantastic research supervisor to work with. She always gave very insightful and timely feedback on the project. Under her supervision, we successfully published the project in a highly reputable journal and presented it at an international conference. Furthermore, Dr. Chung also became a mentor for me and continues to provide me with insightful guidance in my training in anesthesia. It is a pleasure working with Dr. Chung and I look forward to further collaborations with her in the future.

Thach Lam, MD
PGY-5 Resident Physician
Dept. of Anesthesia, University of Toronto
March 2018

I had the opportunity of working closely with Dr. Frances Chung throughout my Anesthesiology residency from PGY2-5. As a research supervisor, I found Dr. Chung to be very encouraging, always available, and very supportive (even when you don't have a research background like me). Most importantly, she is resident friendly - she recognizes that we have a busy residency schedule and is very accommodating with research deadlines, while being very prompt with her review and comments. She goes above and beyond to make sure your hard research work gets recognized, published and presented. I published 2 first author papers in Anesthesia & Analgesia and 2 letters to the editor with Dr. Chung. She also provided me with a stipend to present my research at an international conference. I am very grateful to have had the opportunity to work with such a dedicated mentor. I will be working in Barrie's Royal Victoria Hospital as staff anesthesiologist after I graduate.

George Ho
Medical Student | Class of 2021
University of Toronto
March 2018

I had the pleasure of working under the direct supervision of Dr. Chung as her research assistant for a period of 18 months. From the start, Dr. Chung worked closely to provide me with opportunities and resources to succeed in research. As I progressed under her guidance, I was entrusted with greater responsibility and independence to work on projects. She understood when and how to provide the right motivation and constructive feedback to build my character and skills. Under her supervision, I wrote 3 abstracts, presented at local and international conferences, and co-authored a total of 4 manuscripts, 2 of which are published

Most importantly, Dr. Chung is passionate about supporting and teaching students such as pre-meds like myself. Under her mentorship, she helped me appreciate the importance of persistence, strong work ethic and responsibility. She also connected me with medical students, residents and physicians, who provided me with invaluable guidance and advice. If it were not for Dr. Chung's continued support, I do not believe I would have gotten into medical school. I learned skills and developed competencies in her team that I continue to apply and advance as a medical student. Dr. Chung has my utmost respect, admiration and appreciation.

Russel Brown MD FRCPC
Assistant professor, McMaster University
Staff anesthesiologist, Hamilton Health Sciences, Hamilton, Ontario, Canada
March 2018

As a 2nd year resident in 2012, I was fortunate enough to work on a successful project with Dr. Chung that resulted in an abstract, and we developed it further into a well cited publication. This success reflects her supportive and highly approachable nature and keen role as a mentor. Additionally it also helped me achieve my own career goals, and have since obtained an academic post as an Assistant Professor in the Department of Anesthesia at McMaster University.

Limei Zhou
PhD, molecular biology, Beijing Institute of Basic Medical Sciences
MS statistics, University of Toronto
March 2018

I am originally from China. When I was doing my Masters in Statistics from University of Toronto, I worked part-time for Dr. Chung for about half a year from September 2011 to March 2012 as a research analyst. My project was to predict postoperative adverse events based on parameters from preoperative nocturnal oximetry. As a highly accomplished clinical scientist, not only Dr. Chung is very passionate about research herself, she also encourages and challenges her team members to think independently and critically, and to achieve the highest they can do. Inspired, I was able to finish the project within a short period of time, and won the Best Abstract Award in Patient Safety in 2012 Canadian Anaesthesiologists' Society Annual Meeting, and the paper "Parameters from preoperative overnight oximetry predict postoperative adverse events" was subsequently published in Minerva Anestesiologica. Currently I work as a senior research analyst at Institute of Clinical Evaluative Sciences, Toronto.

David Lam BMSc
Medical Student - Year 3 (University College Cork)
March 2018

I was a summer research assistant for Dr. Chung in 2010 and 2011. After completing my undergraduate degree from the Medical Science Program at Western University in 2013, I worked as Dr. Chung's full-time research assistant from May 2014 to August 2015. As Dr. Chung's research assistant, I worked with a high caliber team in the Department of Anesthesia at the Toronto Western Hospital, University Health Network. I was able to develop my knowledge of writing systematic reviews and conduct clinical studies in the area of sleep apnea. While working closely with Dr. Chung, I had many opportunities to collaborate with other staff physicians and residents on various projects. Dr. Chung was very supportive and demonstrated a willingness to provide guidance throughout the different stages of project development. Dr. Chung actively encouraged and provided opportunities for her team to publish their work. In my time working with Dr. Chung, I was able to publish five papers. This experience taught me invaluable and transferable research skills that I find useful even now as a medical student. I highly recommend anyone interested in clinical research to contact Dr. Chung.

Edmond Hung Leong Chau, MD. FRCPC
Site Lead, Department of Anesthesia,
Welland Hospital Site, Niagara Health
March 2018

I am currently a staff anesthesiologist and intensivist at Niagara Health. I worked with Dr. Chung during my anesthesia residency from 2011 to 2014. I was involved in writing two manuscripts and a book chapter. Dr. Chung is very resourceful as a supervisor and she has an excellent research team. She provided me with a highly supportive environment that fosters my skills in critical thinking and writing. I also had abundant opportunities to present my work at international conferences and develop valuable connections with a wide group of experts in the field.

Matin Rashid, MD
Medical Resident
Dept. of Anesthesia, University of Toronto

I worked with Dr. Chung and want to thank her so much for giving me the opportunity to work under her leadership and allowing me to be apart of the team and it's success. Since the day she took me in, she was so kind, got me involved, teached me essential skills in research, and constantly pushed me to be a better version of myself. These lessons will stay with me forever. Once again, thank you for everything and congratulations on a well deserved achievement!

Mark Hwang, MD
Medical Resident (Class of 2023)
Dept. of Anesthesia, University of Toronto

I had the pleasure of working under the supervision of Dr. Chung over the course of 2 years. Dr. Chung is an excellent supervisor and mentor. She is exceptionally organized, supportive, and available. She was always prompt with her insightful review and feedback. It was an invaluable experience to work with and learn from a research leader in the fields of obstructive sleep apnea and perioperative medicine. She also provided generous support in publishing our work in a recognized journal and presenting at an international conference. I am grateful to have had the opportunity to work under her guidance.

International Medical Graduate [Link to top]

Maged Andrawes MD, FRCPC
March 2018

I am an IMG, graduated from Faculty of Medicine, Cairo university. After I finished my MCC exam, I was lacking enough research experience. I was lucky and joined the STOP-Bang research team in 2011 and worked with Dr. Chung for one year. The entire team members were helpful and understanding which created good atmosphere for new research members. During that year, I got great exposure to different research methodology and coauthored 3 papers that has been published in prestigious journals. I believe, that experience was one of the reasons I got accepted into the Anesthesia residency at University of Toronto through the Advanced Specialty Training (residency) Program in 2012. Now I am FRCPC anesthetist and currently doing Pain Medicine residency at University of Toronto.

Clinical / Research Fellows [Link to top]

Talha Mubashir MD

I had the privilege of undertaking multiple projects at the department of anesthesia under the supervision of Dr. Chung. During this time, I learned how to conduct systematic reviews, meta-analyses and writing study protocols. I was fully supported and able to present our work at various international anesthesia conferences and concurrently published our work in various reputable journals. The knowledge and skills I acquired by working with Dr. Chung will allow me to become a great future clinical scientist in the field of anesthesiology and I am very grateful for having a mentor like Dr. Chung.

Mahesh Nagappa MD
Assistant Professor of Anesthesiology,
Western University, London, Ontario.
April 2018

I came to Toronto for a Clinical Research Fellowship in "Perioperative Anesthesia" at Toronto Western Hospital in July 2013. Dr. Frances Chung was my research mentor during my two year fellowship at the hospital. Dr Chung is exceptional as a research mentor and has shaped my research career. I have been very productive in terms of academic output during my fellowship under her expert supervision. My academic tenure with her has enabled me to pursue my career as a clinical researcher at Western University, Ontario, Canada. She has incredible organizational abilities and can guide her trainees to meet various deadlines effectively. She is unique in looking out for the best interests of her trainees. I have 13 publications and nearly 50 conference presentations under her guidance. She is definitely a best mentor anybody can have.

Yamini Subramani, MD
Clinical research fellow,
Western University, London, Ontario.
April 2018

I did a clinical research fellowship in the "Perioperative Anesthesia" at Toronto Western Hospital starting January 2015 for one and a half year under the supervision of Dr. Frances Chung. Dr. Chung is exceptional as a research mentor and can bring out the best of anyone's ability in research. She has always been supportive, approachable and very clear in her expectations. My fellowship tenure was very productive in terms of academic output under her supervision with five first authored publications in high impact Anesthesiology journals like Anesthesia Analgesia, British Journal of Anaesthesia and Canadian Journal of Anesthesia. Dr. Chung has motivated me and has been instrumental in shaping my research career.

Raviraj Raveendran. FANZCA
Consultant Anesthesiologist
Palmerston North hospital
Midcentral District health board
Palmerston North, New Zealand
March 2018

It was a great experience working with Dr. Chung, who is a lead researcher in perioperative medicine. I am glad to say she is one the key persons who made some important turning points in my anesthesia career. Any clinical research should have a clear hypothesis and practically applicable for day-to-day practice, this is the most important aspect I learnt from her during my perioperative fellowship in 2012-13. My experience in perioperative smoking cessation and OSA related clinical research is helping me in my daily anesthesia practice. She has a unique capability of analyzing the potential of her fellows and guide them in the right path. Her greatest quality is, "more than a mentor, she always looks into the future of her fellows".

Raj Subramanyan MBBS, MD, MS
Associate professor
Children's Hospital of Philadelphia, PA
March 2018

I am Raj Subramanyam MBBS, MD, MS. I was a clinical research fellow with Prof. Frances Chung in 2009 and 2010. I came from India after completing anesthesia residency from a reputed institution and I had research experience. Under the mentorship of Dr. Chung, I was able to further refine my research skills and I published 4 original research articles, numerous abstracts, and was a recipient of two awards from Society for Ambulatory Anesthesia. Dr. Chung was a great mentor and her motivation always kept me going.

I am now at Children's Hospital of Philadelphia, PA where I am an Associate Professor of Anesthesiology and the Director of Quality Improvement. I continues to do my research on Pediatric Obstructive Sleep Apnea and other public health problems.

Edwin Seet, MBBS, MMed
Adjunct Associated Professor
Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
Adjunct Assistant Professor, Yong Loo Lin School of Medicine, National University of Singapore
Senior Consultant
Khoo Teck Puat Hospital, Singapore
March 2018

The Ambulatory Anesthesia fellowship in Toronto Western Hospital, under the mentorship of Professor Frances Chung, was an extremely fruitful, perspective-changing and rewarding experience for me. I spent a year undergoing a well-organized and clinically-orientated Fellowship program about a decade ago and still have fond memories of the time there. More importantly, the networking from the stint was a professional springboard for research and educational opportunities many years after. Drs Frances Chung, David Wong and Jean Wong are key opinion leaders of a wide range of clinical fields - including obstructive sleep apnea, airway management, perioperative medicine, pain management and other important topics. I'm currently working as a Senior Consultant Anesthesiologist and contributing as an Associate Professor with a Medical School in Singapore.

Balaji Yegneswaran MD, FACP
Intensivist, St Peter's University Hospital
Associate program director of the internal medicine residency program
Rutger's Medical School, New Jersey, USA
March 2018

I completed my medical school from the All India Institute of Medical Sciences, New Delhi, India in 2004. Then I worked as a research fellow in the Department of Anesthesia at Toronto Western Hospital, University Health Network under the guidance of Dr. Frances Chung from 2005-2007. Under her mentorship, I had six publications, multiple abstracts, and poster presentations. I won the best poster award in 2007 Society For Ambulatory Anesthesia Annual Meeting.

After my research fellowship, I completed medical residency at Drexel College of Medicine / Saint Peter's University Hospital followed by a fellowship from the University of Pittsburgh in Critical Medicine. I have continued to do research and have over 30 publications.

During my research fellowship with Dr. Chung, she was reasonable with the workload and gave insightful feedback. She was always polite and considerate. She taught me research methodology, grant and manuscript writing. Even though I moved on from her lab a decade ago till date, she continues to serve as a mentor and role model. I am most grateful and appreciative of her help in my career as an International Medical Graduate.

Dr. Chung has changed the landscape of diagnosis of sleep apnea through the STOP-BANG questionnaire, Her work on how blood test should not be ordered for routine surgeries (such as cataract or ambulatory surgery) have resulted in the whole idea of Choosing Wisely Campaign by the ABIM Foundation. In the past decade via her research, Dr. Chung has remarkably changed the landscape of perioperative medicine and has advanced patient safety greatly.

Hairil Rizal Abdullah
Clinical Director,
Perioperative Services,
Singapore General Hospital.
March 2018

I did my Perioperative fellowship at Toronto Western Hospital in 2012. My fellowship year was an eye-opener to academic medicine. The fellowship turns out to be extremely productive for someone who had no previous experience in research - I managed to publish all six papers written that year! Frances and team, including Jean and David, were very nurturing and provided the guidance and opportunity to learn and experience a matured academic system. Furthermore, the mentorship continues long beyond the fellowship year, and we are working together even until now! The program was such an inspiration to me that I am currently pursuing clinician-scientist career track back home in Singapore.

Denis Correa
Assistant Professor
Department of Anesthesiology, Universite de Sherbrooke
Edmundston Regional Hospital
Edmundston, NB, Canada
March 2012

I joined Toronto Western Hospital as a clinical/research fellow in 2012 and had a lifetime opportunity to work with Prof. Frances Chung. She is an excellent supervisor. Her depth of knowledge in research, dedication, networking, and hard work is exceptional. Being a lead researcher, she has remarkably changed the views in perioperative medicine and advanced patient safety. She is the best mentor one can have and can bring out the best of anyone's ability in research. The fellowship program at Toronto Western Hospital turned out to be extremely productive as I got involved with research where Prof. Chung and Dr. Jean Wong were pivotal in my project. I published a highly cited review in Anesthesia & Analgesia with 77 citations.