Peri-Operative Wearables in Elder Recovery after Surgery (POWERS) Trial

When Karim Ladha, MD, received the IARS Mentored Research Award in 2018 for his research on “Peri-Operative Wearables in Elder Recovery after Surgery (POWERS) Trial,” he was just starting his career as a staff anesthesiologist and independent PI at University of Toronto. With no separate funding designated for junior or early-career investigators in Canada, he was finding it difficult to establish himself as an early-career investigator and progress to the next step in his research career. With the IMRA, he found the validation and mentorship he desired and the opportunity to investigate the framework of outcome assessment after surgery, an area that first piqued his interest after watching a family member undergo surgery and not be able to return to the same quality-of-life desired post-procedure. Through the POWERS Trial, he was able to begin to identify how many patients don’t return to their preoperative levels and how this might be predicted to develop interventions. Today, Dr. Ladha, in conjunction with his initial mentor for the award-funded study, co-lead a research program with 7 research staff and are undertaking an impressive 11 prospective studies. Filling a much-needed gap that he first recognized on receiving the IMRA, they have established a large research program for trainee and junior faculty members to help guide them to the next step. Below, Dr. Ladha reflects on his journey in research, his career path and his hopes that investigations will take a more holistic view of recovery, encompassing physical and psychological factors.

1. What is your current position? How long have you been in this position? What was your role when you were first funded by IARS?

I am Associate Professor in the Department of Anesthesiology and Pain Medicine at the University of Toronto and I’m a Staff anesthesiologist and Clinician Scientist at St. Michael’s Hospital. I’ve been at St. Michael’s Hospital for 4 years, and I recently got promoted to Assistant Professor last year.

Interestingly, I was at a different hospital when I initially received the IMRA. IARS staff were kind enough to transfer it over when they knew I was moving, so that was nice of them to do that.

I was the same sort of clinician investigator and assistant professor when I got the IMRA, basically the lower level in our system and at a different hospital. But really, I was just starting out my career as a staff anesthesiologist and independent PI at that point.

2. What drew you to anesthesiology and to your particular area of research? Has your research subject area evolved since the award?

I don’t know that I have a good answer for this purpose but I’ll tell you the truth. I have an older brother who is an anesthesiologist. I think the hard part about anesthesia, especially when you train as a medical student, is that you don’t get a ton of exposure to it. You don’t necessarily know what it is as a field because you’re often limited by a one-week elective, and sometimes not even that. Even as a medical student, I think it’s difficult to appreciate what anesthesiology truly is as a specialty, and what we do on a day-to-day basis. So, I was somewhat fortunate having a family member in the field. I didn’t know what I wanted to do and he told me, this is a great specialty. It’s the best one, and I don’t think he was wrong. But you know I was lucky in that sense that I could have the exposure to the field that way. That’s what sort of prompted me to do it.

The fact that we are both anesthesiologists and I’m younger, people will compare me to him and that’s okay. He’s a good older sibling, so he doesn’t make me feel bad about it.

In terms of this research, it really comes down to seeing a family member undergoing surgery. And again the surgery was deemed successful, but when they got home, they really couldn’t do all the things that they were doing before, like looking after their grandkids, taking care of themselves, being functional, and it sort of led to this idea of “well, what are we missing in our current framework of outcome assessment?” And the Apple Watch was a big thing at the time, and that’s sort of what led us to look into this, and the idea of wearables and measuring functional recovery.

There’s definitely been continued interest in wearables. What’s grown a lot is this idea of machine learning and artificial intelligence to help us predict things, which wasn’t really part of the initial project. But, we do have a lot of data now that we can probably use with these other analytic methods. So, we’ll look into this further. Our first sort of goal is to get what we had originally proposed done, and I think it’s still relevant, even though we proposed it several years ago. There’s been some data in the immediate postoperative period to show that how much patients move does affect outcomes. Our data will give us a more full-some nature of that as well. Those are 2 things that will change.

3. What was the goal of your initial research project? Was it met?

The project that was funded by IMRA was called the POWERS Study. So, what we did is we took elderly patients who were undergoing major cardiac surgery, and we placed a device called an ActiGraph on them. An ActiGraph is like a Fitbit, but it is considered medical grade.

Unlike a Fitbit, it doesn’t look very nice. It’s not very fashionable, but it allows us to keep track of data and track how much patients move before their surgical procedure, and then, following their procedure for 3 months postop as well. We look at that data to see how well it correlates to other measures of postoperative recovery and function, using standardized questionnaires. There’s a lot of work that’s been done in the perioperative period around wearables, but oftentimes it is confined to patients while they’re in the hospital. They don’t put it on before, and they don’t look at it for extended periods after surgery. So, this study will be one of the first that looks at the entire period for a long period of time, however, due to the move and COVID, things have been delayed. But we have finished recruitment, and we’re just completing the follow-ups now, and so hopefully, we’ll have everything done soon.

4. How did your findings impact patient care?

When we think of outcomes after surgery, the traditional way we think about it is, “Did someone have a heart attack? Did they have a stroke? Did they have a major complication? Yes or no?” And if they didn’t, we sort of move on and pat ourselves on the back, thinking that we did a good job.

In reality, from a patient perspective, recovery after surgery means a lot more, and one of the things we want to look at is how well people function after their surgical procedure. And a key part of that is, can we get them back to the level that they were functioning at before their surgery or even above that level after their procedure? A lot of the work we’ve done before shows that there’s a large proportion of patients who don’t meet that functional goal. This study will really help us identify not only how many patients don’t get back to their preoperative level, but how do we predict who that is, and that will help us design interventions to make sure that patients can get back to their functional status that they were at before, if not better. It really helps change the paradigm of postoperative outcome assessment and makes it more patient-centered. This study plays a very important part of that. And so in and of itself, it’s probably a small part, but it will definitely lead to bigger and greater things that will improve patient care.

5. How did your findings impact the field of anesthesiology?

This study is part of a larger movement to make anesthesia research more patient-centered. So, focusing on what matters to patients and why and how do we, as researchers and clinicians, adjust our care to make sure that we keep the patient first and foremost.

Obviously, outcomes such as having a stroke and heart attack are relevant to patients. But what can we do that encompasses more of what they want, what they want to achieve, and what their goals are for having surgery.

6. How did the award affect your research/professional trajectory?

It affected it immensely. Even all of these years later, I’m very, very grateful for the support that it provided. As a resident doing research, and even as a fellow, you don’t have a lot of support from mentors and PIs to do research without your own independent funding, and I think the hard part is when you transition to becoming staff. The expectation is you’re going to be an independent scientist. There’s sort of a plot there in the middle. And oftentimes those mentoring relationships aren’t necessarily formalized. Everybody’s very busy, and you’re sort of left alone, and it’s a hard place to start.

One of the things I tell people is, it’s always hard to get your first grant. It means a lot to get your first one, because it is a bit of a risk. No one’s really seen what you can do. And if they have a choice between giving it to someone who’s never had funding before and someone who has an established lab, you know, they’re going to choose someone with a more established lab, especially in a place like Canada. Our funding strategy is a little different than it is in the US; there’s no separate funding for junior or early-career investigators. It’s a very difficult place to establish yourself as an early-career investigator. And I think the award, because it focuses on mentorship, is key because it’s focused on early career. It helps you establish that career and gives you a platform to say, “Hey, look, I’ve gotten this big grant. I’ve gotten my first one!” It establishes you on a different plane. And to reiterate it’s just immensely important.

What’s interesting is my mentor and I were not at the same hospital. We had worked together on projects sort of peripherally. But this was sort of our first endeavor together. And now we co-lead a research program where we have 7 research staff. We’re basically undertaking 11 prospective studies. And we have a very large research program for trainee and junior faculty members. We coordinate all their research from within our Department of Anesthesia at our hospital. Looking back at the first thing that we did together really started with this grant. There’s been a huge impact not only on our careers, but we’re passing it along and trickling it down to other junior faculty members as well. It’s been huge.

7. How do you feel about having received the IARS Mentored Research Award?

This is going to sound funny but I can tell you exactly where I was when I got the award email. When I received it, it was a big moment, and again, having been rejected a couple of times from other funding competitions, this was the first real, big grant that I’d ever gotten. It was a tremendous moment in my career, and like I said, one that I don’t think I’ll ever forget.

8. What is something that someone would be surprised to learn about you?

I did a triathlon this summer only because I don’t think anybody would expect me to be athletic at all. And so, I think that was a big thing. I do think being active is an important thing, and I hit a milestone birthday last year, and I sort of was having my mid-life crisis. Instead of getting a fancy car, I decided to do a triathlon.

9. What is your vision for the future of anesthesia research?

I know this question is not necessarily related to the award, but one of the interesting things that we’ve embarked on is really just a more holistic view of recovery, which includes not only physical recovery, but also psychological recovery. We start looking at outcomes related to mental health. As a result, we’ve also started looking at the use of anesthetics on mental health conditions. The most interesting thing is that anesthesiologists can get involved with mental health, both in the perioperative period, postoperative period and beyond. When we look at what’s happened before COVID and with COVID, mental health has become a huge public health issue, and that affects numerous people. I can’t tell you how often I give a talk on this and people come up to me after and tell me about their colleague, their son, their family member that suffers from mental health issues asking for help. I had no idea how prevalent this was, even amongst the people around me, who have been affected by this. And I think what’s interesting is there’s some data on how ketamine can make a difference. But, we’re doing a study on nitrous oxide as well, which also has potential to treat conditions like depression. It’s an important area that we can potentially get involved in, and also make a difference for patients outside of the operating room as well – it’s a big thing that we’re looking into now.

We’ve got some cool studies underway. We just got funding actually from the Canadian equivalent of the NIH, to look at those guides for chronic pain. There’s going to be some cool, interesting studies down the line.