Issue 29 by The Meducator

APRIL 2016 | ISSUE 29

Exploring AnotheR Piece of the Puzzle C o m o r b i d M e n ta l H e a lt h C h a l l e n g e s i n C h i l d r e n w i t h A u t i s m s p e ct r u m d i s o r d e r

Physician-Assisted Dying A N e w O p t i o n i n Ca n a d i a n E n d o f L i f e Ca r e

Shining Light on Biomedicine: I n t e rv i e w w i t h D r.b r u c e wa i n m a n, D i r e ct o r o f t h e E d u cat i o n P r o g ra m i n A n ato m y

WWW.MEDUCATOR.ORG

table of

contents April 2016 | I S S U E 2 9 02 03 05 07 09 11

INTRODUCTION MEDPULSE MEDBULLETIN PATHOPROFILE FORUMSPACE VIEWPOINTS

OPINION

13 Adderall and Ritalin: The New Caffeine?

table of contents

RESEARCH INSIGHT

15 Exploring Another Piece of the Puzzle: Comorbid Mental Health Challenges in Children with Autism spectrum disorder 20 INFOGRAPHIC

RESEARCH PROPOSAL

21 Vitamin D Gains: A look at potatoes, vita min D, and symbiotic relationships

CRITICAL REVIEW

25 Physician-Assisted Dying: A New Option in Canadian End of Life Care

GLOBAL PERSPECTIVE

28 Managing Chronic Diseases in the Dominican Republic 31 INTERVIEW SPOTLIGHT 34 CONTRIBUTORS

Cover Artist

m e d u cato r

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Maine Bi

Welcome to the 29th issue of The Meducator! Over the past several years The Meducator has expanded from a journal focused on research in the biomedical sciences to become a platform to discuss health science research, opinions, and current events. Accordingly, our issue covers a diverse range of topics from disease epidemiology, cancer immunology, health policy, mental health, genetically modified foods, and much more. Underlying many of our articles is the topic of healthcare delivery. As you peruse this issue, we encourage you to reflect on how the findings of each article either highlights the current failures or opportunities for improvement in the delivery of care. Issue 29 begins with the cover of our magazine designed by Maine Bi. Fundamentally, the purpose of healthcare services is to enhance both the length and quality of people’s lives. However, with the passage of time, the pills representing healthcare resources in the hourglass featured on the cover will continue to fall until there is none left unless an intervention is made. In the Pathoprofile, editors Ishan Aditya and Valerie Kim work with graphic designer Tony Chen to explore the different outcomes of interactions between the immune system and cancer. Following with their biannual Forumspace publication, the McMaster Health Forum Student Subcommittee presents an economical argument in favour of a Canadian national pharmacare program. Building on the feedback we received from last year’s Viewpoints and Round Table initiatives, we introduced the MeduCombat contest in which students across the university were asked to submit their opinions on a contentious healthcare topic. In this issue, Mobeen Mubasher and Xinglin Li present pro and con arguments respectively on the use of politically correct language by healthcare providers. In their Research Insight, Nisha Kansal and Samuel Kim discuss the mental health challenges faced by children with autism spectrum disorder. We are also excited to have Dr. Bruce Wainman, a long-time educator in the Faculty of Health Sciences and 2016 National 3M Teaching Fellow, join us for an interview to talk about his life and work. Collectively, these articles make up half of the traditional articles featured in The Meducator. We encourage you to read through all the pieces and send us your feedback on the types of articles and topics you would like to see in future issues.

introduction

INTRODUCTION ISSUE 29

dear reader,

Finally, we would like to say thank you to the amazing team we have had the pleasure to work with this year. In particular, we would like to thank Arlinda Deng, Avrilynn Ding, Eliya Zhao, and Sebastian Swic for their work as team managers. The Meducator has been a source of support and joy for both of us ever since we joined the team three years ago. As we step down from our role as Co-Editor-in-Chiefs this year, we are confident that next year’s team will continue to improve the journal under the leadership of Abi Kirubarajan and Matt Yau. With that, please sit back and enjoy our 29th issue. All the best, m e d u cato r

Maylynn ding

Bachelor of Health Sciences (Hons.) Class of 2017

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dave nidumolu

Bachelor of Health Sciences (Hons.) Class of 2017

MEDPULSE

ong m A za n e u l gees u f Inf e n R an 2016 a i r y J S

Taking the Pulse of the World

Neanderthal Genes Boost Immunity

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Zika Virus Outbreak

n tral America, Ja South and Cen specte an a million su With more th tral America, Zika is South and Cen e caused by the as to-borne dise ptoms include fever m sy d te ia Assoc le the di unctivitis. Whi pain, and conj cent research has re causes death, ation between Zika el rr co le ib ss po ital defe rious congen cephaly, a se small heads and bra with abnormal

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Southeast Asia, Jan 2016

Middle East respiratory syndrome (MERS) is a threatening and infectious disease caused by the MERS coronavirus. Symptoms include shortness of breath, fever, and cough. Earlier this year, a second case of MERS was reported in Thailand. Subsequently, health officials in Southeast Asia have quarantined 32 individuals and have been critically reviewing MERS response systems.

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MERS in Southeast Asia

India o n Mala ria Elimina tion In

dia, Feb In Feb 2016 ruary 2016, Nationa In l d ia laun tion (N Framework ched f F eliminat ME) with the or Malaria Eli the m framew e malaria by ambitious aim inaork als 2 to resurge o seek 030. The n malaria ce of malaria s to counter new NFME free status. K while mainta the ey include in endemic program strategies of ing m a the r e e a ph vivax eli t minatio argeting, and asing, high Plasmo n. dium

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ed cases in s a mosquiZika virus. r, rash, joint isease rarely s indicated a a and microect affiliated ains.

West Africa : Ebola-Free?

West Africa, J an 2016 The World H ealth Organiz has declar ation (WHO ed West ) Afr Ebola-free, st ating: â&#x20AC;&#x153;all kn ica to be own chains transmission of Guinea, Sierr have been stopped a Leone, and Liberia are no .â&#x20AC;? reported to w ha ve ze ro However, WH E O still recom bola cases. surveillance mends strong an future flare-u d response systems as ps are highly probable.

Scabies in s Indigenou ns Populati1o6

eb 20 Australia, F infection tagious skin s scabiei n o c a s, ie te Scab the Sarcop rn caused by nificant health conce g la si u p a o lian p mite, is rous Austra in indigen p of Australian resea e u th ro g g n A zi si s. e n o th ti n s eeded in sy chers succ of the parasitic scabie e p th a f m o c ti g e in n nd ge al r understa mite. Bette abiei genome is critic d n sc a s t te n p e v o pre Sarc h seeking to for researc s infections. treat scabie

Citations can be found on www.meducator.org | events occured during Spring 2016

MEDBULLETIN ZIKA VIRUS

ALZHEIMER’S

SA B RINA LIN

TAK HLI Q AMIR

A recent study published in Lancet Infectious Diseases has strengthened the current theory that the Zika virus is linked to microcephaly – a birth defect causing abnormally small heads and poor neural development in newborns. 1 This relationship was established when researchers confirmed the presence of the Zika virus in the amniotic fluid of two women displaying Zika-like symptoms during their pregnancies. 2

Alzheimer ’s disease (AD), the most common neurodegenerative disease, is defined by progressive mental deterioration. 1,2 Early research suggested AD is caused by β-amyloid (Aβ) peptide accumulation in brain tissue due to disrupted proteolytic cleavage of the amyloid precursor protein into APP-β (sAPPβ) and APP-α (sAPPα). 3 Additionally, while neurons are considered the major Aβ source in the central nervous system (CNS), the role of astrocytes has remained unclear, presenting a problem in targeting AD pathogenesis. 4 This is due to a lack of reliable methods for analyzing individual cells, an obstacle overcome by a team of researchers at Harvard, in collaboration with the Massachusetts Institute of Technology. 5

medbulletin

Zika and Microcephaly: Strengthening the Link

Over the past year, Brazil has seen a steep rise in cases of microcephaly, correlating to a rise in the number of people infected with the Zika virus. Brazil has had around 3,935 suspected cases of microcephaly, 508 of which have been confirmed, and 41 of which have been linked to the Zika virus. 2 Despite the abundance of subject-specific research being done in recent months, this is the first study to confirm the virus’ ability to cross the placental barrier. Conducted at the Oswaldo Cruz Institute in Rio de Janeiro, the research involved two women who reported experiencing fever, rash, and muscle aches during their pregnancies. Ultrasound scans revealed that their developing fetuses had microcephaly – a diagnosis suspected to be caused by the Zika virus. 1

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While the study provides strong evidence attributing microcephaly to the Zika virus, lead scientist, Dr. Ana de Filippis, has cautioned that a definitive link between the two cannot be established until specific biological mechanisms are better understood. 3 For now, the World Health Organization has declared the control of mosquito populations and prevention of mosquito bites to be the best preventative measures against the mosquito-borne virus. 3

1. 2. 3. 4.

Calvet G, Aguiar R, Melo A, Sampaio S, de Filippis I, Fabri A et al. Detection and sequencing of Zika virus from amniotic fluid of fetuses with microcephaly in Brazil: a case study. Lancet Infect Dis. 2016. Schnirring L. Microcephaly cases rise; Zika detected in amniotic fluid [Internet]. CIDRAP. 2016 [cited 25 February 2016]. Available from: http://www.cidrap.umn.edu/news-perspective/2016/02/microcephaly-cases-rise-zika-detected-amniotic-fluid Schuler-Faccini L, Ribeiro E, Feitosa I, Horovitz D, Cavalcanti D, Pessoa A et al. Possible Association Between Zika Virus Infection and Microcephaly — Brazil, 2015. MMWR Morb Mortal Wkly Rep. 2016;65(3):59-62. Zika Virus Banner [Image on the internet]. 2015 [cited 2016 February 24]. Available from: http://www. thevaccinereaction.org/wp-content/uploads/2016/02/virus.jpg

The Technology with the Potential to Revolutionize CNS Research

The new study used microengraving to examine and quantify Aβ and sAPPα secretion from individual human neurons and astrocytes by culturing these cells in nanowells. 5,6 Although initially developed to study immune cell secretions, this study is the first to apply microengraving to the CNS. 5,6 Results revealed that astrocytes do secrete high levels of Aβ and thus may be significant in AD pathogenesis. 5 Single-cell analysis further showed a new subcategory of neural cells that secrete high amounts of Aβ in the absence of sAPPα. It also noted increasing numbers of Aβ- and sAPPα-secreting cells during neural differentiation. 5 While the CNS comprises a vast variety of cells, limited methods exist to identify exact sources of cellular secretions. Microengraving presents the possibility of analyzing these underlying cellular mechanisms, thus potentially aiding in the creation of treatments targeting single cells of interest in CNS disorders. Specifically, this particular study demonstrates the potential to address neuropathology at a single-cell level, such as in AD. 5

1. 2. 3. 4. 5. 6. 7.

Bertram L, Lill C, Tanzi R. The Genetics of Alzheimer Disease: Back to the Future. Neuron [Internet]. 2010 [cited 12 February 2016];68(2):270-281. Available from: http://www.sciencedirect.com/science/article/pii/S0896627310008378 De-Paula V, Radanovic M, Diniz B, Forlenza O. Alzheimer’s Disease. Protein Aggregation and Fibrillogenesis in Cerebral and Systemic Amyloid Disease [Internet]. 2012 [cited 12 February 2016];:329-352. Available from: http://link.springer.com/chap ter/10.1007%2F978-94-007-5416-4_14 Muratore C, Rice H, Srikanth P, Callahan D, Shin T, Benjamin L et al. The familial Alzheimer’s disease APPV717I mutation alters APP processing and Tau expression in iPSC-derived neurons. Human Molecular Genetics [Internet]. 2014 [cited 12 February 2016];23(13):3523-3536. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4049307/ Zhao J, O’Connor T, Vassar R. The contribution of activated astrocytes to Aβ production: Implications for Alzheimer’s disease pathogenesis. J Neuroinflammation [Internet]. 2011 [cited 12 February 2016];8(1):150. Available from: http://www.ncbi.nlm. nih.gov/pmc/articles/PMC3216000/ Liao M, Muratore C, Gierahn T, et al. Single-Cell Detection of Secreted A and sAPP from Human IPSC-Derived Neurons and Astrocytes. J Neurosci [Internet]. 2016 [cited 12 February 2016];36(5):1730-1746. Available from: http://www.jneurosci. org/content/36/5/1730.long Love J, Ronan J. A microengraving method for rapid selection of single cells producing antigen-specific antibodies. Nat Biotechnol [Internet]. 2006 [cited 12 February 2016];24(6):703-707. Available from: http://www.nature.com/nbt/journal/v24/n6/ full/nbt1210.html Alzheimer’s Disease Banner [Image on the internet]. 2015 [cited 2016 February 24]. Available from: http://www.menshealth. com/sites/menshealth.com/files/2015/02/alzheimer’s.jpg

Huntington’s Seeds for the future in Huntington’s disease

Addiction

A Little Tetris Every day can keep the cravings away FEROZE NOORUDDIN

Huntington’s disease (HD) is a genetic disorder characterized by decreasing motor control, deteriorating cognitive functions, and ultimately death. 1 It is caused by extra repeats in the gene encoding huntingtin (HTT) protein. 2 Mutant HTT is abnormally long, so it cannot fold properly and clumps inside the brain. However, although the cause of HD is well-established, there is still little information on the role of HTT and no treatments are currently available to stop the progression of HD. 2

Tetris is a quasi-hypnotic game, in which players must organize falling puzzle pieces into rows. A recent study conducted at Plymouth University by Dr. Jackie Andrade and colleagues suggests that being engrossed in the game for as little as three minutes can reduce the strength and frequency of cravings by as much as one–fifth. 1 In the study, the researchers asked 31 undergraduate students, aged 18 to 27, to play Tetris throughout the course of seven days. It was found that playing Tetris interfered with not only cravings for food but also weakened the desire for sex and certain drugs, such as cigarettes and alcohol. It is important to note that the impact of the game was consistent throughout the week for all types of cravings. 1

While most studies explore the intracellular effects of misfolded HTT, the work of Dr. Steven Potkin and his team suggests that HTT in the cerebrospinal fluid (CSF) outside cells may also affect HD. 3 CSF is important for removing wastes in the central nervous system, so it also carries some expelled mutant HTT. 2 After “seeding” or growing neurons with CSF, the CSF from HD patients demonstrated more protein aggregation than the CSF from nonHD patients. 3 Interestingly, patients who had the genetic mutation for HD but were asymptomatic showed more CSF-related protein seeding compared to patients without HD. 3 Since the level of seeding aligned with disease progression, protein aggregation could be used to monitor progression of HD before symptoms develop. 3 Further research may lead to a better understanding of the action of HTT. While not yet explored in humans, these results suggest a potential molecular target for treatment of HD and a faster way to track changes during disease progression.

3. 4.

1. 2. 3. 4.

Skorka-Brown J, Andrade J, Whalley B, May J. Playing Tetris decreases drug and other cravings in real world settings. Addictive Behaviors 2015; 85 (10): 165–70. Franken IHA, Zijlstra C, Booij J, Brink WVD. Imaging the Addicted Brain: Reward, Craving, and Cognitive Processes. Handbook of Implicit Cognition and Addiction 2010; 43(12): 185–200. Holmes E, James L, Coode-Bate T, Deeprose C Can Playing the Computer Game “Tetris” Reduce the Build-Up of Flashbacks for Trauma? A Proposal from Cognitive Science. Social Work in Mental Health and Substance Abuse 2011; 4(1): 243–57. Tetris Style Blocks Falling. 2015 [cited 2015 Oct 21]. Available from: http://s3.amazonaws.com/ spoonflower/public/design_thumbnails/0011/1325/rrrrTetrisFabricNew-58_shop_preview.png

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Lee J-M, Wheeler VC, Chao MJ, Vonsattel JPG, Pinto RM, Lucente D, et al. Identification of Genetic Factors that Modify Clinical Onset of Huntington’s Disease. Cell [Internet]. 2015 Jul [cited 2015 Jul 31];162(3):516–26. Available from: http://www.sciencedirect.com/science/article/pii/ S0092867415008405 Wild EJ, Boggio R, Langbehn D, Robertson N, Haider S, Miller JRC, et al. Quantification of mutant huntingtin protein in cerebrospinal fluid from Huntington’s disease patients. J Clin Invest [Internet]. The American Society for Clinical Investigation; 2015;125(5):1979–86. Available from: http://www.jci. org/articles/view/80743 Tan Z, Dai W, van Erp TGM, Overman J, Demuro A, Digman MA, et al. Huntington’s diseasecerebrospinal fluid seeds aggregation of mutant huntingtin. Mol Psychiatry [Internet]. Macmillan Publishers Limited; 2015 Jun 23; Available from: http://dx.doi.org/10.1038/mp.2015.81 Huntington’s Disease Banner [Image on the internet]. 2015 [cited 2015 October 21]. Available from: http://www.yourgenome.org/sites/default/files/styles/banner/public/banners/facts/what-is-huntingtons-disease/huntingtondisease-02.jpg?itok=iZGjwK4B

m e d u cato r

The act of craving involves imagining the experience of consuming a substance or indulging in a particular activity. By presenting the subjects with a visually appealing game like Tetris, brain activity is interrupted and mental processes that are designated for imagery are left without enough capacity to vividly imagine anything beyond the game. 2 The researchers suggest that the mental stimulation provided by Tetris could not only help people manage their daily cravings but also intense cravings that develop and persist over extended periods of time. The researchers have shown an interest in testing the usefulness of Tetris as an intervention for drug addicts and are currently investigating the importance of the game as a cognitive vaccine against traumatic flashbacks. 3

medbulletin

JO E LL A HO

AUTHORS: ISHAN ADITYA, VALERIE KIM ARTIST: TONY CHEN

Pathoprofile

Cancer Immunology

INTRODUCTION

Cancer refers to a complex set of diseases that stem from abnormal cells capable of sustaining proliferative signaling, evading growth suppressors, and resisting death.1 These cells may form benign tumours and may be spurred by further genetic and cellular changes to undergo carcinogenesis, thereby forming masses of cancerous tissues referred to as malignant tumours.1 This divergence from normal cells provokes immune responses, and the interactions between cancer cells and the immune system compose the dual role of immunoediting in both hindering and facilitating tumour development and progression.2,3

GENERAL IMMUNOLOGY The immune system is responsible for providing protection against substances that may disrupt the body’s normal functioning or homeostasis. It consists of nonspecific innate responses and specific adaptive responses, both of which participate in cancer recognition and control.3 The components of the innate immune system are essential for the detection of pathogens. In theory, specific ligands on cells that have undergone malignant transformation are initially recognized and destroyed by natural killer (NK) cells; uptake and processing of the remaining debris are performed by macrophages and dendritic cells, which subsequently secrete inflammatory cytokines and present antigens to the components of the adaptive immune system.3 Serving as markers that discriminate normal cells from cancer cells, tumour-specific antigens reflect abnormalities arising from the genomic instability and mutations underlying malignant transformation.1,3 These antigen-derived markers are capable of generating an adaptive immune response by binding to B cell receptors, antibodies produced by B cells, or T cell receptors.3 Following identification and attack of the cancerous cells, the adaptive responses may develop an immune memory particular to the tumour antigens, potentially to prevent their recurrence in the future.3

TNF-α IL-1 IL-12

IMMUNOEDITING

Immunoediting is theorized not only to eliminate tumours, but also to select for cells with adaptations that enable evasion of immune attack.4 Thus, the involved interactions between cancer and the immune system can either promote the development or the removal of malignant tumours.5 As the anti-tumour responses of the innate and adaptive immunity edit by removing immune-sensitive cancer cells, immune-resistant variants survive and continue to proliferate.5 This process involves the three E’s of immunoediting: elimination, equilibrium, and escape.2,4,5

REFERENCES 1. Hanahan D, Weinberg RA. Hallmarks of cancer: the next generation. Cell. 2011 Mar; 144(5):646-74. 2. Mittal D, Gubin MM, Schreiber RD, Smyth MJ. New insights into cancer immunoediting and its three component phases - elimination, equilibrium, and escape. Curr Opin Immunol. 2014 Apr;27:16-25. 3. Finn OJ. Immuno-oncology: understanding the function and dysfunction of the immune system in cancer. Ann Oncol. 2012 Sep;23(suppl B):viii6-9. 4. Grivennikov SI, Greten FR, Karin M. Immunity, inflammation, and cancer. Cell. 2010 Mar; 140(6):883– 99. 5. Shankaran V, Ikeda H, Bruce AT, White JM, Swanson PE, Old LJ, et al. IFNgamma and lymphocytes prevent primary tumor development and shape tumor immunogenicity. Nature. 2001 Apr; 410

(6832):1107–11. 6. Dunn GP, Koebel CM, Schreiber RD. Interferons, immunity and cancer immunoediting. Nat Rev Immunol. 2006 Nov; 6(11):836–48. 7. Burnet M. Cancer; a biological approach. I. The processes of control. Br Med J. 1957 Apr; 1(5022):779–86. 8. Dunn GP, Old LJ, Schreiber RD. The immunobiology of cancer immunosurveillance and immunoediting. Immunity. 2004 Aug; 21(2):137–48. 9. Teng MW, Vesely MD, Duret H, McLaughlin N, Towne JE, Schreiber RD, et al. Opposing roles for IL-23 and IL-12 in maintaining occult cancer in an equilibrium state. Cancer Res. 2012 Aug;72(16):3987–96.

ELIMINATION

In response to tumour-speciﬁc antigens, natural killer T (NKT) cells release the cytokine interferon γ (IFN-γ) to regulate anti-tumour effects of angiogenesis inhibition or cell replication inhibition.6 These antigens can also trigger various other cell populations, including NK cells, T cells, and macrophages, to contribute to the eradication of cancer cells.6,7 As a result, the elimination phase is characterized by anti-tumour immunity, driven by the elevated expression of immune cells and activity in the tumour microenvironment.7

T IFN-γ

Perforin Fas

EQUILIBRIUM NK

? T

ESCAPE IL-23

Treg

Adenosine

CD73

CD39 ATP AMP

The immune system renders the tumour functionally dormant. During equilibrium, the immune system attacks and kills some of the cancerous cells. The net effect is stasis, at which point the tumour size neither increases nor decreases.8,9 Tumour equilibrium results from a balance between cytokines that favour elimination and cytokines that favour persistence.1,8,9 While the adaptive immune system can maintain the tumour in a functionally dormant state, tumour cells subjected to constant immune pressure can evolve.8,10 Through imperfect DNA replication, cancerous cells that survive the immune responses will incur genetic lesions, developing adaptations that can enable escape from immune recognition.8,10,11 Eventually, the next generation of tumour cell variants will be capable of evading immune destruction and inducing immunosuppression, ultimately facilitating tumour growth.1,11

IL-23

The innate and adaptive immune systems detect and destroy tumours that have not acquired resistance to immune attack.

CD39

10. Schreiber RD, Old LJ, Smyth MJ. Cancer immunoediting: integrating immunity's roles in cancer suppression and promotion. Science. 2011 Mar; 331(6024):1565–70. 11. Matsushita H, Vesely MD, Koboldt DC, Rickert CG, Uppaluri R, Magrini VJ, et al. Cancer exome analysis reveals a T-cell-dependent mechanism of cancer immunoediting. Nature. 2012 Feb; 482(7385):400–4. 12. DuPage M, Mazumdar C, Schmidt LM, Cheung AF, Jacks T. Expression of tumor-specific antigens underlies cancer immunoediting. Nature. 2012 Feb; 482(7385):405–9. 13. Chao M, Weissman I, Majeti R. The CD47–SIRPα pathway in cancer immune evasion and potential therapeutic implications. Curr Opin Immunol. 2012 Feb;24(2):225-32.

ATP

The immune system fails to restrict tumour growth; cancer cells proliferate uncontrollably. Through a complex range of mechanisms, tumour cells not only evade immune recognition, but also escape immune control through acquired genetic and epigenetic changes, tipping the balance towards cancer progression.11-13 For example, cytokines, such as transforming growth factor-beta (TGF-β), and anti-apoptotic proteins, such as B cell lymphoma-2 (Bcl-2), may suppress anti-tumour immune responses and promote cancer cell proliferation.12 Uncontrolled cell division may be further aided by the evasion of phagocytosis and the dysfunction of immune checkpoints.12,13 While these mechanisms drive the process of tumor progression, they also hint at potential avenues for therapeutic exploitation. Strategies targeting the immune resistance of tumours may ultimately provide key insight into the further development and improvement of cancer treatment.12

REVIEWER Dr. Jonathan Bramson is an accomplished professor in the Department of Pathology and Molecular Medicine at McMaster University. His research is focused on re-educating immune cells to attack cancerous tumours and viral infections.

FORUMSPACE

A Case for Pharmacare in Canada: Lessons Learned from the UK Alexandra Kilian1 , Emily Fong 2 , SARA HALAWA 3 , ANNIE ZHU 4 , Matthew Hughsam 4 , Ben Li1 Bachelor of Health Sciences (Hons), Class of 2017, McMaster University, 2Bachelor of Arts & Science (Hons), Class of 2016, McMaster University, 3Master of Science in Global Health, Class of 2016, McMaster University, 4Bachelor of Health Sciences (Hons), Class of 2016, McMaster University Correspondence: kiliana@mcmaster.ca

Introduction In 2014, total drug expenditure in Canada was $33.9 billion, of which a significant proportion (85%) was spent on prescribed drugs.1 Prescription drugs have become an integral component of modern medicine as they can help treat diseases and greatly improve quality of life.2 However, unlike most other countries with a universal health system, Canada does not universally cover prescription drugs.2 While some level of public drug coverage is provided by all provinces and territories in Canada, 58% of prescription drug costs are covered by private health insurance plans or out-of-pocket payments.2 As a result, there is growing interest among the Canadian public to implement a public drug insurance program, often termed “Pharmacare,” to improve access to prescription drugs.2 The United Kingdom (UK) has had a public financing system for health coverage in place, including prescription drugs, for decades. This article explores what Canada can learn from the UK’s successful universal drug coverage program.

Prescription Drug Coverage in Canada

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forumspace

The Canada Health Act, which requires universal coverage for medically necessary care provided in hospitals and by physicians, does not provide similar requirements for prescription drugs used outside of a hospital setting. As health care in Canada is primarily a provincial responsibility, this has left provinces to determine whether and how prescription drugs are

The McMaster Health Forum strives to be a leading hub for improving health outcomes at the regional and provincial levels in Canada. Through problem-solving and discussion, they harness information, convene stakeholders, and prepare action-oriented leaders to meet pressing health issues creatively.

covered through their respective health systems. As a result, prescription drug coverage systems vary significantly between provinces, each with its own eligibility requirements, such as income or age.3 In addition to the gaps in public coverage for prescription drugs, only 66% of Canada’s population have access to private drug insurance, either purchased individually or through their employers.4 Those lacking insurance have to pay out-of-pocket for prescription drug expenses. The current patchwork of systems leaves many people without the financial means to purchase essential medications. In fact, 1 in 10 Canadians are unable to afford prescription drugs, which can lead to improperly managed conditions and worse health outcomes.5 This approach to funding prescription drugs in Canada (i.e., varied provincial drug programs coupled with private insurance and out-of-pocket payments) has contributed to inefficiencies and increased costs. A key part of the inefficiency is that prescription drug coverage in Canada involves multiple private insurers, separate from the publicly administered insurance plans. In addition to individuals incurring significant cost, this multi-payer system operates in silos and reduces efficiency by adding administrative costs. This decreases purchasing power of each payer, thereby increasing the overall cost of prescription drugs2. In contrast, singlepayer systems that pool financial risks across larger populations and consolidate purchasing power in price negotiations with drug manufacturers often incur considerably lower costs.3 Due to the complexities involved in implementing a national pharmacare system,

the UK’s model is explored as a comparison for how Canada could approach establishing its own national pharmacare program.

Comparison to the United Kingdom

Pharmacare has historically been low on the priority list in Canada’s incremental approach to reforming health care. With both social and economic changes such as an aging population and increased pharmaceutical costs on the rise, pharmacare plans are associated with increasing costs. The pharmacare system in the UK can be used as a model of an effective drug insurance coverage system to inform the design of a program that accommodates the specific needs and context of Canada. Despite financial and political barriers, it is clear that a national pharmacare plan in Canada is essential to provide coverage for prescription drugs for all Canadians and decrease long-term health care costs. Perhaps with a new Liberal federal government, steps towards implementing a national pharmacare program will soon be taken. ■

More discussions on current healthcare topics are available at http://www.mcmasterhealthforum.org/

1. CIHI. Spending and Health Workforce Prescribed Drug Spending in Canada, 2013: A Focus on Public Drug Programs [Internet]. 2015. Available from: https://secure. cihi.ca/free_products/Prescribed%20Drug%20Spending%20in%20Canada_2014_EN.pdf 2. Morgan SG, Martin D, Gagnon M-A, Mintzes B, Daw JR, Lexchin J. Pharmacare 2020: The future of drug coverage in Canada. Pharmaceutical Policy Research Collaboration, University of British Columbia; 2015. 3. Morgan SG, Daw JR, Law MR. Commentary No. 384 Rethinking Pharmacare in Canada [Internet]. Institut C.D. HOWE Institute; 2013. Available from: https://www.cdhowe.org/pdf/Commentary_384.pdf 4. Pan Canadian Drugs Negotiations Report [Internet]. 2014. Available from: http://www.pmprovincesterritoires.ca/phocadownload/pcpa/pan_canadian_drugs_ negotiations_report_march22_2014.pdf 5. Morgan S, Law M, Daw J, Abraham L, Martin D. Estimated cost of universal public coverage of prescription drugs in Canada. Canadian Medical Association Journal. 2015;187(7):491-497. 6. Boothe K. How the Pace of Change Affects the Scope of Reform: Pharmaceutical Insurance in Canada, Australia, and the United Kingdom. Journal of Health Politics, Policy and Law. 2012 Oct 1;37(5):779–814. 7. Morgan SG, Daw JR. Canadian Pharmacare: Looking Back, Looking Forward. Healthcare Policy. 2012 Aug;8(1):14.8.Ntional Pharmacare Strategy. Canadian Federation of Nurses Unions; 2014. 8. Select Science. Editorial Article: Register Now for our Free Webinar: Analysis of Elemental Impurities in Pharmaceuticals [image on the internet]. 2015 Jul 14 [cited 2016 Mar 15]. Available from: http://www.selectscience. net/editorial-articles/register-now-for-our-free-webinaranalysis-of-elemental-impurities-in-pharmaceuticals/?art ID=38007#sthash.rWLZilqB.dpuf.

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While there is no doubt that the implementation of a national pharmacare strategy would require some amount of initial investment and may likely necessitate increased federal taxes for the middle class, economic models predict that

Conclusion

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Benefits of Implementing a National Pharmacare System

forumspace

Though the Canadian health system was in part modelled from the UK’s health system, drug coverage in these two jurisdictions varies considerably.6,7 The UK implemented a singlepayer public financing scheme covering all forms of care, including prescription drugs for citizens in 1952, whereas Canada adopted a system that provides universal coverage for medically necessary care that is delivered through physicians working in private practice and in not-for-profit hospitals.3 In the UK, the budget for prescription drugs is integrated as part of the overall health care budget, which also covers all medical and hospital services.6,7 In England, a co-payment of 5% or $14.50 applies to most prescriptions, while vulnerable populations are exempt, including children and patients diagnosed with cancer.3,7 On the other hand, Wales, Scotland, and Northern Ireland require no co-payments by the patient.3 This singlepayer system allows for the achievement of lower prices for individuals. Patented and generic drug prices in the UK are 18% and 30% lower than in Canada, respectively.3 Additionally, if per capita spending matched that of the UK, the annual system savings related to prescription drugs in Canada would be approximately $14 billion.3

the implementation of this strategy would ultimately decrease long-term health care spending. For example, Pharmacare 2020 is a prominent proposal for implementing a national pharmacare plan by 2020. The financing model proposed includes a 25% contribution from the federal government, using funding mechanisms such as corporate taxes, income taxes, and/or premiums.2 This federal contribution would not increase costs for provinces and territories and would not be redirected from other essential services. The economic analysis indicates that a national plan could save the private sector up to $10 billion through decreased administrative costs, increased purchasing power, and decreased long-term health care costs due to more effective prescriptions and better management of conditions.2, 3

9. Prescription Drug Abuse [Image on the internet]. 2015 [cited 2016 March 21]. Available from: http://www. valleyrecoveryca.com/wp-content/uploads/2015/05/ prescription-drug-abuse-849x564.jpg

VIEWPOINTS PRO

Mobeen Mubasher

Bachelor of Health Sciences (Honours), Class of 2018 Correspondence: mobeen.mubasher@learnlink.mcmaster.ca

“You’re not allowed to call them dinosaurs any more, it’s speciesist. You have to call them pre-petroleum persons,” quipped Yo-less from Terry Pratchett’s novel, Johnny and the Bomb.1

Politically correct language can build rapport and trust by creating a positive relationship between patients and health care providers. Medical professionals must communicate sensitive information to patients with forethought and compassion, bearing in mind the increased emotional vulnerability that illness and fear of death can produce. It is more likely that patients in a heightened emotional state could be triggered by emotional language.2 Given medical professionals’ great influence over a patient’s healing and happiness, the use of derogatory language could further distress the patient, potentially causing them to associate the hospital environment with negativity.2

Ultimately, over many decades, negative connotations have been tied to certain words and can leave the recipient feeling both threatened and hesitant in their health care practitioners’ abilities. It is important for these words to be recognized and to instead be replaced by sensitive language to ensure a fair and comfortable environment for patients. ■

Furthermore, politically incorrect language can also engender stigma. The use of derogatory phrases against an individual’s disease status might cause them to fear the ostracization of being “different”, and thus may prevent them from seeking help. For example, stigmas of being pronounced “crazy” have surrounded mental health, and stigmas around homosexuality have prevented individuals from seeking HIV/AIDS diagnoses.3,4 Even after diagnoses have been made and treatment is available, patients may refuse treatments due to fear of humiliation. For instance, polio patients hesitated to use braces and wheelchairs in fear of being called crippled.5 By treating patients with compassion and dignity, medical professionals can reduce the judgment that patients feel.

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Despite the media’s humorous portrayal of political correctness as overly sensitive, society’s aversion towards derogatory language is anything but unnecessary. Language today can marginalize individuals of different races, sexualities, and disease statuses. As medical professionals strongly influence patient mindset, the use of politically correct language is essential in the health care field.

Moreover, it is important for health care providers to maintain professionalism in order to both gain and maintain their patient’s trust. For example, a layman’s declaration of an individual as “fat” would not only insult the patient, but would also be vague and unclear. A health care professional should use more specific clinical terminology such as “overweight”, which has a specific medical definition relating to body mass index. While both terminologies convey the same message, only one uses scientific terms that maintain the dignity of the patient as well as scientific accuracy.

1. Pratchett T. Johnny and the bomb. Brisbane: Queensland Braille Writing Association; 1999. 2. Schiedermayer D. The Healer’s Power. New England Journal of Medicine. 1993 Jan 7;328(1):67–67. 3. Shrivastava A, Johnston M, Bureau Y. Stigma of Mental Illness-1: Clinical reflections. Mens Sana Monogr. 2012;10(1):70–84.

4. Parcesepe AM, Cabassa LJ. Public Stigma of Mental Illness in the United States: A Systematic Literature Review. Adm Policy Ment Health. 2013 Sep;40(5). 5. Mahajan AP, Sayles JN, Patel VA, Remien RH, Ortiz D, Szekeres G, et al. Stigma in the HIV/AIDS epidemic: A review of the literature and recommendations for the way forward. AIDS. 2008 Aug;22(Suppl 2):S67–79.

6. Wilson DJ. Braces, Wheelchairs, and Iron Lungs: The Paralyzed Body and the Machinery of Rehabilitation in the Polio Epidemics. J Med Humanit. 26(23):173–90 7. Republican Debate [Image on the internet]. 2016 [cited 2016 March 21]. Available from: http://static2.businessinsider.com/image/56d09b0e2e52654 3008b9cba-1022-511/gettyimages-508808094.jpg

POLITICALLY CORRECT LANGUAGE IN HEALTH CARE CON

Xinglin Li

Bachelor of Health Sciences (Honours), Class of 2018 Correspondence: xinglin.li@learnlink.mcmaster.ca

Despite its importance in various situations, political correctness can have many negative consequences on the health care system. From pseudoscience to the fear-mongering present in our society, excessive consideration for political correctness by physicians decreases efficiency in health care. The propagation of pseudoscience, a belief that is marketed as scientific but does not follow the scientific method, is a prime example of the negative role of political correctness. As the impact of social media has increased, individuals are constantly swept up in the newest health care and therapeutic fads.1 Despite a clear lack of clinical evidence supporting some of these

“new age” treatments, family physicians must spend precious time listening to these ideas. This is time which could have been better spent addressing the patient’s needs through conducting medical tests.2 Instead of using politically correct language to address these ideas, physicians need to be straightforward and direct. Otherwise, politically correct language might give patients reasons to start trusting the external sources of information that purport these ideas.

Edited by TAKHliq AMIR & Abirami Kirubarajan ART BY Caberry Yu

2013 [cited 27 February 2016];126(9):755-756. Available from: http://www. amjmed.com/article/S0002-9343(13)00390-2/fulltext 3. Kata A. A postmodern Pandora’s box: anti-vaccination misinformation on the Internet. Vaccine [Internet]. 2010 [cited 17 February 2016];28(7):1709-16. 4. Plait P. Jim Carrey Makes a Series of Unfortunate Tweets. Slate Magazine [Internet]. 2016 [cited 24 February 2016]. Available from: http://www.slate.

com/blogs/bad_astronomy/2015/07/01/jim_carrey_anti_vax_is_as_anti_ vax_does.html 5. Marcotte A. Donald Trump Uses GOP Debate to Push Anti-Vaccination Myths. Slate Magazine [Internet]. 2016 [cited 24 February 2016]. Available from: http://www.slate.com/blogs/xx_factor/2015/09/16/donald_trump_ suggested_vaccines_cause_autism_during_the_cnn_gop_debate_he.html

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1. Newman, N. The rise of social media and its impact on mainstream journalism. Reuters Institute for the Study of Journalism [Internet]. 2009 [cited 27 February 2016]; 8(2):1-5. Available from: https://reutersinstitute.politics.ox.ac. uk/sites/default/files/The%20rise%20of%20social%20media%20and%20 its%20impact%20on%20mainstream%20journalism_0.pdf 2. Lien Y. Juicing Is Not All Juicy. The American Journal of Medicine [Internet].

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This is not to say that doctors should be insensitive. Just because a physician is not politically correct does not mean that they are rude. A physician can still maintain a perfectly respectful relationship with their patients and deliver information in a concise, straightforward manner. Politically correct language acts as a communication barrier between the patient and the physician. Intentions and ideas can be lost in the whirlwind of semantics and phrasings. To convey clear messages, especially concerning topics regarding pseudoscience or fear-mongering, political correctness should be eliminated. ■

viewpoints

The fear-mongering that is so prevalent in today’s society is another reason to abandon political correctness. For instance, the anti-vaccination movement has recently gained traction, and some parents fear that safe, clinically tested vaccinations will lead to the development of autism in their children. A large proponent for this rise in ignorance is the dissemination of incorrect information by prominent media personas; celebrities like Jim Carrey and Donald Trump have claimed that autism may be a result of vaccinations.3,4,5 In this case, physicians need to explicitly inform inquisitive patients that scientific papers that have undergone rigorous peer reviewing have proven, beyond a shadow of a doubt, that vaccines do not cause autism.3 They should provide current research in a straightforward, comprehensive manner (e.g. brochures and websites) that is not hindered by the specific semantic choices of being politically correct.

ARTIST CANDY NIU

Adderall and Ritalin:

The New Caffeine?

HANNA HAPONENKO Bachelor of Health Sciences (Honours), Class of 2017 McMaster University Correspondence: haponeh@mcmaster.ca

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opinion

ABSTRACT

Long gone are the days of lost motivation and fatigue. Adderall and Ritalin, two types of cognitive enhancers normally prescribed for people with Attention Deficit Hyperactivity Disorder, are now being used by Canadian undergraduate students looking to increase their productivity in a progressively fast-paced world. Praising the perks while discounting the damages caused by the nonmedical ingestion of these drugs may lead individuals down a path of dependence with a flawed perception of success. To them, it is just like coffee, but treating these drugs as such is a recipe for harm. This report provides an overview of the current issues associated with the illegal ingestion of cognitive stimulants and attempts to uncover the benefits and consequences that may arise from their use.

consuming anything dangerous. When DeSantis et al. asked 175 American undergraduate students whether they thought Adderall was harmful, the majority disagreed and refuted the notion that it was a drug at all.5 Instead, they viewed it as merely â&#x20AC;&#x153;a study toolâ&#x20AC;? like caffeine, failing to consider the medical implications of using the drug.5 Here lies a deep-rooted problem with drug misuse: many consumers know the benefits of cognitive enhancers, but few pay attention to their adverse effects. BENEFITS

Adderall and Ritalin increase dopaminergic and noradrenergic signalling in the brain, helping students with or without ADHD feel motivated and awake for longer periods of time.6-8 The active ingredient in Ritalin, methylphenidate, occupies the dopamine and norepinephrine transporters in the prefrontal cortex, thus INTRODUCTION preventing the reuptake of dopamine and norepinephrine, respectively, into the cytosol of presynaptic neurons.8 This leads to Rachelâ&#x20AC;&#x2122;s stomach sank as she furiously flipped through the higher levels of these neurotransmitters in the neuronal synapses pages of her textbook. Her gut feeling told her that she was for a longer period of time, thereby enhancing and extending going to fail the exam. Her eyes were heavy and her mind was dopaminergic and noradrenergic neurotransmission.7,8 Adderall is numb as she tried to remember every detail. Without hesitation, an amphetamine that follows a similar mechanism.7 Additionally, Rachel walked across the hallway and approached Caleb, who it also increases the release of these two neurotransmitters from was diagnosed with Attention Deficit Hyperactivity Disorder neurons mostly found in the frontal cortex, striatum, nucleus (ADHD). He also had a prescription for Ritalin, a cognitiveaccumbens, or a combination of these three regions.7 As a result, enhancing drug used in the medical management of ADHD. Adderall has longer-lasting and more pronounced cognitive enhancing effects in comparison to Ritalin.7,9 Through these Adderall (75% dextroamphetamine and 25% levoamphetamine) mechanisms, both drugs yield a heightened sense of motivation and Ritalin (methylphenidate) are the two most familiar cognitive and concentration, while boosting alertness, information stimulants among stressed students.1 In 2013, the rate of nonretention, and focus.9-12 medical use of ADHD pharmaceuticals among Canadians aged 20-24 was 9%, representing 40,000 people.2 For Canadian Upon experiencing an improvement in their ability to concentrate, postsecondary students, the rate was an estimated 3.7% - a figure some consumers of Adderall and Ritalin may suspect that the overthrown by the 7.8% our American neighbours amassed.3,4 drugs were effective because they unknowingly had ADHD.9 Although their rates of consumption differ, most of these young By increasing levels of dopamine in the synapse, the drugs adults share something in common: the belief that they are not provide the hyper-focus needed to stay on task, while their

effects on the sympathetic nervous system via norepinephrine reduce the desire to sleep.6 Therefore, these drugs are effective regardless of whether or not an individual has ADHD.9

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Dr. Jan Young Baker is the medical director at McMaster University’s Student Wellness Centre, which provides medical services, counselling options and wellness education to university students. She has been working with the Student Wellness Centre since 1989, and has thoroughly enjoyed caring for McMaster’s students.

Hosenbocus S, Chahal R. A review of longacting medications for ADHD in Canada. J Can Acad Child Adolesc Psychiatry. 2009 Nov;18(4):331–9. Government of Canada [Internet]. Canada: Government of Canada. Summary of results for 2013; 2015 Feb [cited 2016 Jan 28]. Available from: http://healthycanadians. gc.ca/science-research-sciences-recherches/data-donnees/ctads-ectad/summarysommaire-2013-eng.php American College Health Association. [Internet]. ACHA-NCHA II: Canadian reference group executive summary spring 2013. Hanover (MD): American College Health Association; 2013 [cited 2016 Jan 28]. Available from: http://www.cacuss.ca/_Library/ documents/ncha-II_web_spring_2013_canadian_reference_group_executive_summary.pdf American College Health Association. [Internet]. ACHA-NCHA II: reference group executive summary spring 2013. Hanover (MD): American College Health Association; 2013 [cited 2016 Jan 28]. Available from http://www.acha-ncha.org/docs/acha-nchaII_ReferenceGroup_ExecutiveSUmmary_ Spring2013.pdf Desantis AD, Hane AC. “Adderall is definitely not a drug”: justifications for the illegal use of ADHD stimulants. Subst Use Misuse. 2010;45(1-2):31–46. Elia J, Borcherding BG, Potter WZ, Mefford IN, Rapoport JL, Keysor CS. Stimulant drug treatment of hyperactivity: biochemical correlates. Clin Pharmacol Ther. 1990 Jul;48(1):57–66. Madras BK, Miller GM, Fischman AJ. The dopamine transporter and attention-deficit/ hyperactivity disorder. Biol Psychiatry. 2005;57(11):1397–409. Wilens TE. Effects of methylphenidate on the catecholaminergic system in attention-deficit/hyperactivity disorder. J Clin Psychopharmacol. 2008 Jun;28(3 Suppl 2):S46–53. Lakhan SE, Kirchgessner A. Prescription stimulants in individuals with and without attention deficit hyperactivity disorder: misuse, cognitive impact, and adverse effects. Brain Behav. 2012 Sep;2(5):661–77. Ilieva, I. P., & Farah, M. J. Enhancement stimulants: perceived motivational and cognitive advantages. Front Neurosci. 2013 Oct;7(198):1-6. Ilieva I, Boland J, Farah MJ. Objective and subjective cognitive enhancing effects of mixed amphetamine salts in healthy people. Neuropharmacology. 2013 Jan;64:496-505. Graf WD, Nagel SK, Epstein LG, Miller G, Nass R, Larriviere D. Pediatric neuroenhancement: ethical, legal, social, and neurodevelopmental implications. Neurology. 2013 Mar;80(13):1251-60. Schwarz A. Attention disorder or not, pills to help in school. New York Times. 2012 Oct 9 [cited 2016 Jan 28]. Available from: http://www.nytimes.com/2012/10/09/ health/attention-disorder-or-not-children-prescribed-pills-to-help-in-school. html?pagewanted=1&smid=tw-share&_r=1 Morton WA, Stockton GG. Methylphenidate abuse and psychiatric side effects. Prim Care Companion J Clin Psychiatry. 2000 Oct;2(5):159-64. Chamberlain SR, Robbins TW, Winder-Rhodes S, Müller U, Sahakian BJ, Blackwell AD, et al. Translational approaches to frontostriatal dysfunction in attention-deficit/hyperactivity disorder using a computerized neuropsychological battery. Biol Psychiatry. 2011 Jun;69(12):1192-203. Greenhill LL, Pliszka S, Dulcan MK. Practice parameter for the use of stimulant medications in the treatment of children, adolescents, and adults. J Am Acad Child Adolesc Psychiatry. Elsevier; 2002 Feb;41(2):26S-49S. The MTA Cooperative Group. A 14-month randomized clinical trial of treatment strategies for attention-deficit/hyperactivity disorder. Arch Gen Psychiatry. 1999 Dec;56(12):1073. Rubia K, Halari R, Cubillo A, Smith AB, Mohammad A-M, Brammer M, et al. Methylphenidate normalizes fronto-striatal underactivation during interference inhibition in medicationnaïve boys with attention-deficit hyperactivity disorder. Neuropsychopharmacology. 2011 Jul;36(8):1575–86. Fitzgerald KT, Bronstein AC. Adderall® (amphetamine-dextroamphetamine) toxicity. Top Companion Anim Med. 2013 Feb;28(1):2-7. Berman SM, Kuczenski R, McCracken JT, London ED. Potential adverse effects of amphetamine treatment on brain and behavior: a review. Mol Psychiatry. 2009 Feb;14(2):123–42. Drevets WC, Gautier C, Price JC, Kupfer DJ, Kinahan PE, Grace AA, et al. Amphetamineinduced dopamine release in human ventral striatum correlates with euphoria. 2001 Jan;49(2):81-96. The College of Physicians and Surgeons of Ontario [Internet]. Toronto (ON): CPSO. Prescribing drugs; 2012 [cited 2016 Mar 1]. Available from: http://www.cpso.on.ca/policies-publications/policy/prescribing-drugs Canadian ADHD Resource Alliance [Internet]. Markham (ON): CADDRA. Chapter 7: pharmacological treatment of ADHD; 2011 [cited 2016 Mar 1]. Available from: http:// www.caddra.ca/pdfs/caddraGuidelines2011Chapter07.pdf Clavenna A, Bonati M. Safety of medicines used for ADHD in children: a review of published prospective clinical trials. Arch Dis Child. 2014 Sep 19;99(9):866–72. Sharon K. Speed-like stimulants prescribed for adult ADHD part of “psychiatric fad,” risk being used for mental edge. National Post. 2015 July 23 [cited 2016 Jan 29]. Available from: http://news.nationalpost.com/health/ speed-like-stimulants-prescribed-for-adultadhd-part-of-psychiatric-fad-risk-being-usedfor-mental-edge

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Reviewed by Dr. Jan Young Baker

opinion

Although using prescription stimulants for nonmedical reasons may help them succeed in the short-term, users need to understand that chronic use can severely undermine mental wellbeing. This is especially true in cases of frequently ingested Some doctors in the United States even admit to toxic doses of amphetamine, which can prolong prescribing cognitive enhancers to children from excessive dopamine release in the dorsal striatum.20 low socioeconomic backgrounds falling behind This disruption in neurotransmitter balance in school.5,13 These physicians hope that these leads to amphetamine-induced neurotoxicity drugs may help children become academically caused by oxidative stress, which is associated competitive and “[balance] the scales a little bit”.13 with an inflammatory response.20 In other words, chronic use of Adderall at high doses can cause Given these benefits, it is no wonder that the an inflammatory reduction in the diameter of drugs are misused by those who aspire to succeed. cortical axons, a condition that may elicit psychotic However, taking cognitive enhancers does not episodes.9,20 In 2013, the American Academy of actually enhance intelligence. In fact, the subjective Neurology (AAN) published an extensive review perception of intellectual improvement after on the dangers of taking cognitive enhancers for taking a drug like Adderall conflicts with objective nonmedical reasons, advising doctors to recognize cognitive performance.10,11 This distorted perception the ethical, social, and neurodevelopmental issues is likely attributed to drug-induced feelings of mild underlying misguided prescription.12 The AAN, euphoria and heightened motivation.10,14 Thus, along with Canadian regulatory bodies like the users feel as if they perform better even when their College of Physicians and Surgeons of Ontario test scores on cognitive tasks show otherwise.10,11 and the Canadian ADHD Resource Alliance, advise that only people with disorders such as Benefits of cognitive enhancers in individuals ADHD should be taking cognitive enhancers as without ADHD are not necessarily as pronounced prescribed.12,22,23 or consistent as in those with ADHD.15 Adderall and Ritalin are reported to reduce the major CONCLUSION symptoms of ADHD within affected individuals by a clinically important level.16,17 After taking Given the dangers of Adderall and Ritalin misuse, Ritalin, people with ADHD, compared to those it is important that stakeholders understand the without, show the greatest improvement in areas potential harm of ingesting them for non-medical such as concentration and cognitive inhibition reasons. Health professionals lacking experience in since they exhibit a lower baseline ability to perform the proper diagnosis of ADHD should take caution tasks of executive function.17 This baseline deficit is in prescribing cognitive enhancers. Students must dependent upon abnormalities seen in the circuitry learn how to avoid becoming distracted and find of the frontostriatal cortex, reportedly normalized ways to naturally boost motivation. Moreover, since with ADHD drugs.15,18 As a result, there is more the long-term effects of these drugs are unknown, room for distinct change in executive function individuals need to be aware of the outcomes that may result from abusive consumption.24 Only then among users with ADHD. will users be able to detach themselves from the NEGATIVE EFFECTS idea that using stimulant medication is the optimal way to succeed during stressful times. Nowadays, Short-term side effects linked to taking cognitive it is easy to acquire ADHD medication from enhancers are varied and abundant. Common general practitioners, the Internet, or friends with side effects include tachycardia, hypertension, and prescribed drugs.12,25 The only way to guarantee insomnia, due to the exaggerated stimulation of safety is to avoid the pill entirely. Taking it may the sympathetic nervous system.19,20 Adderall and increase productivity, but it may also produce more Ritalin intake activates the mesolimbic reward problems than initially anticipated. ■ centres in the brain, producing mild euphoria.14,21 This increases the potential of addiction and may explain the frequent use among consumers without ADHD.14,21

ARTIST MICHAEL SUN

RESEARCH Insight

Exploring Another Piece of the Puzzle: Comorbid Mental Health Challenges in Children with Autism Spectrum Disorder

NISHA KANSAL, SAMUEL SEUNGHON KIM

Bachelor of Health Sciences (Honours) Program, Child Health Specialization, Class of 2016 ASD Research Team, Offord Center for Child Studies McMaster University

ABSTRACT Autism spectrum disorder (ASD) is characterized by impairments in social communication and restricted, repetitive behavioural patterns.1 In the United States, the prevalence of ASD is estimated to be 1 in 68 children.2 As children with ASD enter adolescence, they face difficulties brought on not only by the core functional impairments of their primary disorder but also by common psychiatric comorbidities, such as depression and anxiety. The prevalence estimates of these comorbidities vary widely, which may be explained by differences in assessment tools used between epidemiological studies. In this review, the most commonly used assessment tools for comorbidities among youth with ASD are presented. Out of the five tools identified, no tools had been specifically evaluated to measure anxiety among ASD youth, while only two tools had been evaluated to measure depression in this population. Across tools, there were numerous issues regarding psychometric properties, as well as differences in informants, leading to limitations when using these tools to measure comorbid psychiatric concerns in youth with ASD. Future research should aim to design better assessment tools to strengthen the quality of research in this field and better inform resource allocation and clinical practice.

INTRODUCTION

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These huge discrepancies sparked our inquiry into potential underlying causes. Heterogeneity in cognitive functioning between samples of ASD

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Particularly, depression and anxiety have widespread effects on family life and social relationships and could further affect social integration of individuals with ASD.4 Recent literature found that a significant proportion of children and youth with ASD present with comorbid anxiety and/or depression. Simonoff et al. estimated that approximately 41.9% of youth with ASD have a comorbid anxiety or phobic disorder, and 1.4% have a depressive disorder.3 Another study estimated that approximately 17% of 9-14 year-olds with high-functioning autism had clinically-relevant depressive symptoms, and 13.6% had clinically-relevant anxiety symptoms.4 A meta-analysis found that, across studies, 39.6% of youth with ASD had at least one comorbid anxiety disorder.5 Prevalence rates reported by individual studies varied significantly, ranging from 7.5% to 84.1%.5

research insight

Autism spectrum disorder (ASD) is a neurodevelopmental disorder characterized by persistent impairment in reciprocal social communication and restricted, repetitive patterns of behaviours and interests.1 Many individuals with ASD also present with psychiatric comorbidities, which is the simultaneous presence of more than one condition. One study reported that 70% of children aged 10-14 with ASD had at least one comorbid psychiatric disorder, while 41% had two or more.3 Comorbid mental health concerns compound the difficulties experienced by families, clinicians, and other stakeholders in the lives of children with ASD by increasing required services and associated impairments.

youth may lead to different rates of comorbid mental health problems. Sampling differences across studies may also contribute to variations in prevalence estimates. However, one of the starkest differences between studies is the method used to assess comorbid disorders.

research insight

To better understand these discrepancies, we investigated the current state of assessment of anxiety and depression in ASD youth. Through an extensive literature review, we identified the five most frequently used tools in our population of interest. In this review, we aimed to understand how differences in tools could be contributing to the variability in reported prevalences. We discuss implications of the current methods of understanding comorbidity in children with ASD and provide recommendations for future tool development and research.

FIGURE 1: Visual Emotional Thermometer. Used to measure intensity of emotion in order to help children evaluate their own emotions realistically and facilitate emotion regulation.20,21

How I feel

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I need some help!

I’m really upset.

I have a problem.

2 Things are pretty good.

Results

Of the five most common tools, the broadest measure of psychiatric comorbidity is the Child Behaviour Checklist (CBCL), a widely used parent-report measure of emotional and RESEARCH DESIGN behavioural problems in youth.10,11 There are two versions of the CBCL, one for children aged 18 Research studies measuring comorbid depression months to 5 years and the other for children aged or anxiety in youth with ASD were eligible for 6-18 years.10,11 Originally created for the general inclusion if participants were between 6-18 years population, the tool has been widely used in the old. Studies had highly diverse samples of youth ASD population. In the literature review, 23 with ASD in terms of cognitive functioning. studies utilized the tool in some capacity, mostly to assess comorbidities in various ASD samples Articles were obtained through searches in or to evaluate the efficacy of cognitive behavioural Scholars Portal, PsychInfo, Medline, Pubmed, therapy (CBT) in youth with ASD. and SCOPUS with keywords such as “autism spectrum disorder”, “autis*” “comorbid*”, Two measures of anxiety were also found among “anxiety”, “depress*”, and “obsessive compulsive the most used tools: the Anxiety Disorder disorder”. To be included, the study had to have Interview Schedule, Child & Parent Versions reviewed, validated, or utilized the tool in an (ADIS-C/P), and the Multidimensional Anxiety ASD youth sample. Based on the relevance of Scale for Children (MASC). title and abstract, the full-texts of 171 studies

Feelings Chart

were reviewed, and information on assessment tools used to measure comorbid depression and/ or anxiety were extracted. A total of 108 distinct assessment tools were identified. The five most cited are described below, followed by a discussion regarding the implications of the findings.

What I can do - Ask to take a break/use theraputty - Hold onto Luke Skywalker - Take 4 or 5 deep breaths - Ask to take a break/use theraputty - Hold onto Luke Skywalker - Take 4 or 5 deep breaths - Let a teacher know that you have a problem and need some help - Hold onto Luke Skywalker - Take 4 or 5 deep breaths - Think of your favorite things - Say “I’m going to be OK” to yourself - Take 3 or 4 deep breaths

- Enjoy the feeling! - Have fun

Feeling great!

The ADIS-C/P is a semi-structured interview of both parents and children, investigating anxiety using a framework of topics rather than the rigorous list of items used in a structured interview. The tool allows for a primary diagnosis of a childhood anxiety disorder according to the Diagnostic and Statistical Manual for Mental Disorders-IV-TR (DSM-IV-TR) in children aged 6-17.7 Clinicians must determine whether impairment warrants a diagnosis beyond the child’s autism-related difficulties.8 In the literature review, 14 studies either reviewed, validated, or utilized the tool. It is used in different contexts, such as trials of CBT for youth with ASD, case series, and epidemiological studies. The MASC is a youth self-report questionnaire that assesses four major dimensions of anxiety among youth aged 8-19: physical symptoms, harm avoidance, separation/panic, and social anxiety.8,9 A parent-report questionnaire with the same items is also available.8,9 In the literature review, 17 studies used the MASC for various purposes, such as evaluating efficacy of CBT in youth with ASD and assessing other health concerns related to ASD.8 Finally, two tools specifically developed to measure comorbidity in children with ASD were found: Autism Comorbidity Interview - Present

& Lifetime Version (ACI-PL) and Autism been psychometrically tested for use in measuring Spectrum Disorders - Comorbid for Children anxiety among youth with ASD.6,12,13 Collectively, (ASD-CC). these limitations indicate a lack of evidence-based The ACI-PL is a structured, parent interview that assessment tools for measuring anxiety among determines whether a child has had a comorbid youth with ASD, while there is potential to use disorder and/or whether a diagnosis is warranted. the ASD-CC and ACI-PL to measure depression. It can be used for most major psychiatric This finding is significant because many studies disorders based on the DSM-IV-TR, including assessing treatment outcomes and prevalence depressive and anxiety disorders.6 The tool rates have utilized the aforementioned tools. ensures that ASD-related impairments are not considered evidence of a new disorder. Within When assessing psychopathology in youth, the conducted literature review, 11 studies, mostly different informants, such as parents and youth, epidemiological, involved the ACI-PL.6 may report different levels of symptoms. The ACI-PL solely utilizes a parent informant, while The ASD-CC is an informant-based rating scale the MASC, CBCL, ADIS-C/P, and ASD-CC that asks parents or children to rate symptoms use both parent and youth informants.6-8,10 For that commonly co-occur with ASD.8 The tool youth with ASD, general concerns regarding screens for a range of comorbid psychopathology, asking youth informants about mental health such as depression, among children aged 2-18 concerns are compounded by their potential with ASD. Notably, it does not assess anxiety.12,13 deficits in verbal communication, cognitive In the literature review, 16 studies utilized the tool, functioning, and self-awareness. Children with generally to assess rates of comorbid symptoms or ASD may find self-reflection and describing diagnoses in ASD youth. feelings difficult.16 Therefore, it may be better to ask parents about the mental health of their

In the literature review, we identified tools for assessing comorbid depressive and anxiety symptoms among ASD youth. As previously mentioned, the varying tools used across studies may partly account for the differences in prevalence estimates of these comorbid psychiatric problems. Each tool uses a diverse array of items in conceptualizing and scoring comorbid symptoms, and has limitations that may hinder its ability to accurately capture comorbid symptoms.

m e d u cato r | A P R I L 2016

The most alarming finding was the lack of psychometrically-evaluated tools tailored for ASD youth. This has significant implications, as psychiatric measurement tools should be thoroughly tested for accuracy (validity) and precision (reliability) in measuring psychopathology among specific populations before use. For example, the MASC and ADISC/P have shown high validity and reliability among typically-developing youth but have not been psychometrically evaluated among children with ASD, despite their wide use in this population.7,9,14 Similarly, the CBCL was not designed specifically for ASD youth, and experts have questioned whether its broad measures can differentiate a comorbid disorder from symptoms of ASD.15 The ASD-CC and ACI-PL were developed to address such concerns but have their own limitations. Although the ASD-CC has shown high reliability and validity among youth with ASD, the tool does not assess comorbid anxiety disorders, while the ACI-PL has not

research insight

DISCUSSION: implications and recommendations

children. However, some studies suggest that children with ASD do indeed have the insight to report accurately on their feelings, maybe more so than parents.17 Mixed results across studies warrant further research into this area to decide which informants should be used.

research insight

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12.

m e d u cato r

11.

10.

13.

14.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing. Autism Speaks Canada: Facts and Stats [Internet]. Autism Speaks Canada; 2014 Mar [cited 2016 Jan 31]. Available from: http:// www.autismservicesinc.com/pdf/Autism%20 Speaks%20Canada%20Updated%20Facts%20 and%20Stats.pdf Simonoff, E., Pickles, A., Charman, T., Chandler, S., Loucas, T., & Baird, G. (2008). Psychiatric Disorders in Children With Autism Spectrum Disorders: Prevalence, Comorbidity, and Associated Factors in a Population-Derived Sample. Journal of the American Academy of Child & Adolescent Psychiatry, 47(8), 921–929. http://doi.org/10.1097/ CHI.0b013e318179964f Kim, J. A., Szatmari, P., Bryson, S. E., Streiner, D. L., & Wilson, F. J. (2000). The Prevalence of Anxiety and Mood Problems among Children with Autism and Asperger Syndrome. Autism, 4(2), 117–132. http://doi. org/10.1177/1362361300004002002 Van Steensel, F. J. A., Bögels, S. M., & Perrin, S. (2011). Anxiety Disorders in Children and Adolescents with Autistic Spectrum Disorders: A MetaAnalysis. Clinical Child and Family Psychology Review, 14(3), 302–317. http://doi.org/10.1007/ s10567-011-0097-0 Mazefsky, C. A., Oswald, D. P., Day, T. N., Eack, S. M., Minshew, N. J., & Lainhart, J. E. (2012). ASD, a psychiatric disorder, or both? Psychiatric diagnoses in adolescents with high-functioning ASD. Journal of Clinical Child and Adolescent Psychology: The Official Journal for the Society of Clinical Child and Adolescent Psychology, American Psychological Association, Division 53, 41(4), 516–523. http://doi.org/10.1080/15374416 .2012.686102 Wood JJ, Piacentini JC, Bergman RL, et al. (2002) Concurrent validity of the anxiety disorders section of the anxiety disorders interview schedule for DSM-IV: child and parent versions. Journal of Clinical Child and Adolescent Psychology 31(3): 335–342 Grondhuis S, Aman M. Assessment of anxiety in children and adolescents with autism spectrum disorders. Research in Autism Spectrum Disorders. 2012;6(4):1345-1365. Maruish, M. E. (2014). The Use of Psychological Testing for Treatment Planning and Outcomes Assessment: Volume 2: Instruments for Children and Adolescents. Routledge. Achenbach, T.M., & Rescorla, L.A. (2000a). Manual for the ASEBA Preschool forms and Profiles. Burlington, VT: University of Vermont Department of Psychiatry. ISBN 0-938565-68-0 Achenbach, T.M., & Rescorla, L. A. (2001). Manual for the ASEBA School-Age Forms and Profiles. Burlington, VT: University of Vermont, Research Center for Children, Youth, and Families. ISBN 0-938565-73-7 Matson J, Wilkins J. Reliability of the Autism Spectrum Disorders-Comorbid for Children (ASD-CC). Journal of Developmental and Physical Disabilities. 2008;20(4):327-336. Rieske R, Matson J, May A, Kozlowski A. Anxiety in Children with High-Functioning Autism Spectrum Disorders: Significant Differences and the Moderating Effects of Social Impairments. Journal of Developmental and Physical Disabilities. 2011;24(2):167-180. Silverman, W. K., Saavedra, L. M., & Pina, A. A. 2001. Test–retest reliability of anxiety symptoms and diagnoses with the anxiety disorders interview schedule for DSM-IV: Child and parent ver-

Additionally, we found that most studies first administered intelligence quotient (IQ) tests to determine study eligibility. For example, the youth self-report MASC requires the child to have adequate language and cognitive ability, which limits its use among individuals with ASD.8 Most studies end up including children with “high-functioning” ASD, with their functioning level determined only by IQ. However, IQ does not necessarily correlate with or determine a child’s level of self-awareness, emotional intelligence, or adaptive functioning, which might be more important when assessing mental health problems.18 Since socialcommunication deficits might lessen a child’s insight into their own emotions, studies have begun including visual emotional thermometers to teach children with ASD how to interpret their own and others’ emotions (Figure 1).19 Emotional thermometers might prove useful in determining a child’s true emotional awareness and ability to complete self-report measures of mental health problems accurately. There are a few limitations to our study that should be addressed. Our review did not investigate each study’s reasons for choosing a specific measure. Especially when working with ASD youth, a number of barriers to administering psychiatric assessment tools exist, including time to complete the measure, tool access, costs, and training of psychometrists to use these tools. In addition, the current review included all studies that utilized assessment tools to measure depression and anxiety in ASD youth without reviewing the specific purpose of each study - this limits the conclusions that can be drawn about the uses

of each tool identified. Future studies should aim to understand why certain tools have been used in certain types of studies - for example, clinical trials versus large-scale epidemiological studies. Further distinguishing the tools by their intended use in diagnosing mental disorders or measuring psychiatric symptoms will allow comparison of tools that have been used in both similar and differing contexts.

CONCLUSION There is evidence suggesting significant variance in prevalence estimates of comorbid depression and anxiety among youth with ASD. This may be accounted for by the wide array of assessment tools used in this population. These tools have notable limitations regarding psychometric properties, informant choice, and reduced cognitive capacities of youth with ASD, which may hinder the child’s ability to self-report their mental health status. Moving forward, future research should aim to design assessment tools that address these limitations in order to strengthen the quality of epidemiological and treatment studies of comorbidity among youth with ASD. Ultimately, improvements in research quality will support more accurate estimates of prevalence rates to guide public health resource allocation, clinical practice, and further research.

ACKNOWLEDGEMENTS We would like to thank Lorna Colli and Irene O’Connor of the Offord Centre for Child Studies as well as Margaret Secord of the Bachelor of Health Sciences Program at McMaster University for their continued guidance in the development and dissemination of this project. ■

Reviewed by Dr. stelios georgiades Dr. Stelios Georgiades is an Assistant Professor in the Department of Psychiatry & Behavioural Neurosciences and a researcher in the Offord Centre for Child Studies at McMaster University. His research focuses on the developmental pathways of children with autism spectrum disorder and the similarities and differences that may arise. Dr. Georgiades’ work has led him to collaborations with other researchers across Canada and a recent appointment to the Autism Spectrum Disorder (ASD) Clinical Expert Committee.

Edited by Joella ho sions. Journal of American Academy of Child and Adolescent Psychiatry, 40, 937–943. 15. Leyfer, O. T., Folstein, S. E., Bacalman, S., Davis, N. O., Dinh, E., Morgan, J., … Lainhart, J. E. (2006). Comorbid psychiatric disorders in children with autism: interview development and rates of disorders. Journal of Autism and Developmental Disorders, 36(7), 849–861. http://doi.org/10.1007/ s10803-006-0123-0 16. MacNeil BM, Lopes VA, Minnes PM. Anxiety in children and adolescents with Autism Spectrum Disorders. Research in Autism Spectrum Disorders.

2009 Jan;3(1):1–21. 17. McConachie H, McLaughlin E, Grahame V, Taylor H, Honey E, Tavernor L, et al. Group therapy for anxiety in children with autism spectrum disorder. Autism. 2013 Oct 7;1362361313488839. 18. Brady DI, Saklofske DH, Schwean VL, Montgomery JM, McCrimmon AW, Thorne KJ. Cognitive and emotional intelligence in young adults with Autism Spectrum Disorder without an accompanying intellectual or language disorder. Research in Autism Spectrum Disorders. 2014 Sep;8(9):1016–23. 19. Blankenship K, Minshawi NF. Behavioral Therapy

with an Individual with Asperger’s Disorder. Psychiatry (Edgmont). 2010 Aug;7(8):38–41. 20. Chuck Edgington. Emotional Regulation and Anxiety Management in Autism [Internet]. Autism Toolkit Series: Life 1st!; 2010 Sep 7 [cited 2016 Jan 31]; Oklahoma Autism Network. Available from: http:// www.okautism.org/documents/emotionalregulationanxietymanagementpresentation.pdf 21. Feelings Thermometer [Internet]. [cited 2016 Jan 31]. Available from: https://s-mediacache-ak0.pinimg.com/736x/f7/d1/57/f7d1577b9b7338912c8af140af9c2600.jpg

UNDERSTANDING DEPRESSION

AUTHOR Sarah Ge ARTIST Cathy Lu

DEPRESSION

is a mood disorder characterized by persistent feelings of sadness and low self-worth. It is a serious condition that affects the way you feel, think, and act. According to the World Health Organization

3 5 0 MILLION individuals currently suffer from depression

60% of those who commit

SUICIDE

suffer from some form of

DEPRESSION

infographic

WHO SUFFERS?

WAYS TO GET HELP

Depression affects all individuals, regardless of culture, race, age, sexual orientation, or gender.

Depression can be diagnosed and treated by primary health care workers.

are more affected by depression compared to

1. World Health Organization. Depression [Internet]. 2015 [Updated October 2015; cited 19 October 2015]. Available from: http://www.who.int/mediacentre/factsheets/fs369/en/ 2. Lesage AD, Boyer R, Grunberg F. Suicide and mental disorders: a case-control study of young men. Americal Journal of Psychiatry. 1994;151:1063-8.

3. Cavanagh JT, Carson AJ, Sharpe M. Psychological autopsy studies of suicide: A systematic review. Psychological Medicine. 2003;33:395-405.

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M E N 29% versus 17%

Apart from talking to their doctors, individuals can also cope by being more ACTIVE, connecting with FRIENDS AND FAMILY, and LEARNING more about mental illness.

m e d u cato r

W O M E N

4. Singleton N & Lewis G (2003) Better or worse: a longitudinal study of the mental health of adults living in Great Britain. London: The Stationery Office

ARTIST Michael Sun

RESEARCH PROPOSAL

Vitamin D Gains:

A look at potatoes, vitamin D, and symbiotic relationships.

Gurrattan Chandhoke1 , Jennifer Herman1 , Avika Misra 1 , Eric Ferreira 2 Honours Health Sciences, Class of 2018 McMaster University

Bachelor of Technology, Class of 2018 McMaster University

ABSTRACT

Vitamin D deficiency is a health issue that affects millions of people worldwide. In 2013, one in ten Canadians were reported to have a vitamin D deficiency. Recent research proposes that vitamin D deficiency can be addressed by creating a vitamin D-rich food source. Plant species contaminated with fungi contain traces of vitamin D, suggesting that vitamin D may be transferred from fungal organisms to plants in a mutualistic symbiotic relationship. This relationship exists between arbuscular mycorrhizae and Solanum tuberosum, a common potato plant that provides food security for millions living in Africa, Asia and South America. We propose that the pathway of radioactively labelled vitamin D from fungi to host plant can be followed in order to identify the protein responsible for transporting vitamin D. Once the genomic sequence of the transporter protein is identified, the gene can be upregulated to increase protein expression and consequently, vitamin D content in S. tuberosum crops. Understanding the specific vitamin D transfer process from fungi to plants will enable sustainable and large-scale production of vitamin D-rich food sources.

Vitamin D3 (cholecalciferol)

Chemical Composition

C28H44O7

C27H44O7

Primary Mode of Acquisition

Dietary vegetable sources and oral supplements9

Skin exposure to ultraviolet B radiation in sunlight, ingestion of food sources (oily fish, milk, juices, margarines, yogurt), and oral supplements9

Presence in Environment

Found in plant life7

Synthesized within the body7

Potency in Humans

Less Potent8

More Potent8

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Vitamin D2 (ergocalciferol)

TABLE 1: CONSTRASTING VITAMIN D2 and D3 Both forms of vitamin D vary in their chemical composition, yielding differences in their potency, primary mode of acquisition in humans, and their presence in the environment. Lower potency of vitamin D2 will allow for the delivery of vitamin D in a controlled manner that limits adverse toxic effects while minimizing major deficiencies.

m e d u cato r

Vitamin D deficiency is a global health problem that afflicts over one billion people. In Canada, one in ten people are either deficient or do not possess sufficient levels of vitamin D, demonstrating the nature of the condition as a growing epidemic.1,2 Vitamin D exists in two distinct forms: Vitamin D3 (cholecalciferol) is synthesized endogenously in the skin via the photochemical conversion of 7-dehydrocholesterol (provitamin D3), while vitamin D2 (ergocalciferol) is produced in certain fungi and yeasts, by the conversion of provitamin D2 (ergosterol) through UVB-exposure. Given the inability for humans to synthesize vitamin D2 The mutualistic symbiotic relationship between independently, it is generally acquired through fungi and plants can be exploited in the potato nutritional intake.7 Both vitamin D2 and D3 crop S. tuberosum to increase vitamin D content have various key biological actions that include in this important food source. Potatoes are enhancing calcium and phosphorus absorption, highly adaptable plants that are able to grow in as well as stimulating insulin production.3 many different climates; therefore, they play a Disruption of these functions may lead to fundamental role in food security, particularly in 2 consequences such as muscle weakness and Africa, Asia and South America. Small amounts decreased bone density. By extension, osteopenia of free vitamin D3 are present within potatoes, 10 and osteoporosis may be exacerbated, resulting in while vitamin D2 is limited. By transporting increased risk of fractures in adults, and growth the abundant supply of vitamin D contained retardation and rickets in children.11 Deficiency within fungi to the potato plant via a specific of vitamin D leads to a domino effect in which vitamin D2 transporter, a food source rich in many other biological processes like these are both vitamin D2 and D3 can be created in order disturbed, ultimately resulting in improper to combat worldwide deficiencies. However, plants are not consistently effective in uptaking growth and compromised disease prevention. molecules from fungi in plant-fungal symbiotic Soil arbuscular mycorrhizae are a type of relationships.7 Identifying the transporter

research proposal

mycorrhizal fungi that commonly form mutualistic symbiotic relationships with the roots of vascular plants.4 The fungus forms long branches of filamentous structures known as hyphae, which penetrate through the cell wall of root cortical cells and release nutrients into the apoplast, a free diffusion space outside the plasma membrane of these cells.5 Water and solutes from the hyphae are transported through the plasma membrane and into root cortical cells, providing the host plant with a variety of nutrients and increasing their potential for biotic and abiotic stress resistance.4,5

INTRODUCTION

responsible for the transportation of D2 is similar in structure and genomic sequence to that of vitamin D-binding protein given the structural similarities between vitamin D2 (C28H44O) and vitamin D3 (C27H44O); the only substantial difference is the attachment of a methyl group to the 24th carbon and the presence of a double bond between the 22nd and 23rd carbons in vitamin D2.15 Given that arbuscular mycorrhizal fungi are naturally capable of transporting vitamin D, it is reasonable to presume that a gene similar to that of GC gene in humans must exist in fungi.

research proposal

Radioactively labelling vitamin D2 with carbon-14 and observing its transport from fungus to host plant is a method by which the vitamin D2 transporter can be more specifically identified.16 This process has been demonstrated to be feasible, as Carbon-14 has been used previously as a label for vitamin D2 to uncover other proteins involved in its transport.10 Overall, the strong indication of a vitamin D-binding protein-like transporter in mycorrhizal fungi and the suitability of this experimental technique renders the identification of the vitamin D2 transporter an important and achievable task. Methodology In order to understand the pathway of vitamin D absorption in fungi, we propose the use of molecule that enables the movement of vitamin carbon-14 to radioactively label vitamin D D2 into plants such as S. tuberosum is therefore and analyze transmembrane protein content. imperative to improving the natural efficiency of Ultimately, we aim to identify the specific protein this process and eliminating vitamin D deficiency. that transports vitamin D2 from arbuscular mycorrhizae to S. tuberosum.

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A P R I L 2016

Research Design

REVERSE PHASE CHROMATOGRAPHY The reverse phase chromatography works by using a hydrophobic phase to adsorb like molecules. This differs from normal phase chromatography which focuses on hydrophilic molecules X-RAY CRYSTALLOGRAPHY X-ray crystallography uses x-rays to obtain three dimensional images of crystal structures. Visualized structures are most often biological macromolecules and proteins

Hypothesis We aim to investigate the transporter protein involved in distribution of vitamin D2 throughout fungal cells. We hypothesize that by radioactively labelling vitamin D2 with carbon-14 and observing its transport from fungi to host plant, we will be able to identify this protein and upregulate its function.12 Upregulation of its function will increase the transport of vitamin D to plants in plant-fungal symbiotic relationships. Rationale Although the transporter protein for vitamin D3 has been discovered, the vitamin D2 transporter protein remains unidentified. The vitamin D3 transporter is encoded by the GC group-specific gene sequence in humans, which codes for the general vitamin D-binding protein, also known as gc-globulin.13,14 It is possible that the protein

Creating a Mycorrhizal Relationship: A symbiotic relationship between a S. tuberosum host plant and arbuscular mycorrhizal fungi will be developed in a laboratory climate of SATP (Standard Ambient Temperature and Pressure) conditions. Labelling Vitamin D with Carbon-14: Vitamin D2 and provitamin D2 will be radioactively labelled with carbon-14 to allow observation of vitamin D within the fungi.12 Injecting Radiolabeled Vitamin D2 into Arbuscular Fungi: The mycorrhizal fungi will be injected with carbon-14 labeled vitamin D2, allowing its direct entry into the fungi. Tracking the Vitamin D Pathway: Time will be allotted for observation to ensure

that radioactive vitamin D reaches its binding proteins. Gel Electrophoresis Extraction: Fungi tissues will be collected and run through gel electrophoresis to separate and extract radiolabeled proteins.12

would involve determining a mechanism for upregulating this protein using various biotechnology techniques.

2. 3.

6. 7.

10. 11.

Experts in the field Assistant Professor Department of Biotechnology McMaster University gengf@mcmaster.ca

This research proposal has been peer reviewed by Dr. Fei Geng, an alumnus of McMaster and Assistant Professor of The Bachelor of Technology Program. Dr. Geng is a member of the American Society of Cell Biology and the American Association of Cancer research. Prior research includes novel breast cancer cell death pathways and prognostic biomarkers for lung cancer. Edited by SHARON YEUNG

13. 14.

15. 16. 17.

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Reviewed by Dr. Fei Geng

12.

m e d u cato r

Dr. Fei Geng

Holick MF, Chen TC. Vitamin D deficiency: a worldwide problem with health consequences. The American journal of clinical nutrition. 2008 Apr 1;87(4):1080S-6S. Strange R, Scott P. Plant Disease: A Threat to Global Food Security. Annu Rev Phytopathol. 2005;43(1):83-116. Holick M, Binkley N, Bischoff-Ferrari H, Gordon C, Hanley D, Heaney R et al. Evaluation, Treatment, and Prevention of Vitamin D Deficiency: an Endocrine Society Clinical Practice Guideline. The Journal of Clinical Endocrinology & Metabolism. 2011;96(7):1911-1930. Smith S. Mycorrhizal Fungi Can Dominate Phosphate Supply to Plants Irrespective of Growth Responses. Plant Physiology. 2003;133(1):16-20. Bucking H, Liepold E, Ambilwade P. The Role of the Mycorrhizal Symbiosis in Nutrient Uptake of Plants and the Regulatory Mechanisms Underlying These Transport Processes. Plant Science. 2012. Russell P. Biology. Toronto: Nelson Education; 2009. JĂ¤pelt R, Jakobsen J. Vitamin D in plants: a review of occurrence, analysis, and biosynthesis. Frontiers in Plant Science. 2013;4. Aburjai T, Al-Khalil S, Abuirjeie M. Vitamin D3 and its metabolites in tomato, potato, egg plant and zucchini leaves. Phytochemistry. 1998;49(8):2497-2499. Holick M, Chen T. Vitamin D deficiency: a worldwide problem with health consequences. The American Journal of Clinical Nutrition. 2008;87:1080S-6S. Chalk K, Kodicek E. The association of 14 C-labelled vitamin D 2 with rat serum proteins. Biochem J. 1961;79(1):1-7. Haddad J, Matsuoka L, Hollis B, Hu Y, Wortsman J. Human plasma transport of vitamin D after its endogenous synthesis. Journal of Clinical Investigation. 1993;91(6):2552-2555. Carpenter T, Zhang J, Parra E, Ellis B, Simpson C, Lee W et al. Vitamin D binding protein is a key determinant of 25-hydroxyvitamin D levels in infants and toddlers. J Bone Miner Res. 2012;28(1):213-221. Vitamin D. Alternative Medicine Review. 2008;13(2). Britz-Cunningham S, Adelstein S. Molecular Targeting with Radionuclides: State of the Science. The Journal of Nuclear Medicine. 2003;44(12):1945-1961. Kissinger P. Reverse-phase ion-pair partition chromatography. Comments. Analytical Chemistry. 1977;49(6):883-883. Smyth M, Martin J. x Ray crystallography. Molecular Pathology. 2000;53(1):8-14. Grada A, Weinbrecht K. Next-Generation Sequencing: Methodology and Application. Journal of Investigative Dermatology. 2013;133(8):1-4.

research proposal

Once the vitamin transport protein is identified in S. tuberosum, this specific protein can be more easily identified within other organisms. With the advancements in next generation [1][2] Protein Analysis: sequencing, these proteins will be cheaper and Extracted proteins will be observed with reverse- faster to map.19 Following the gene sequencing, phase paper chromatography and viewed with Polymerase Chain Reaction (PCR) technology a Hanovia short-wave ultraviolet lamp to will amplify the gene across several orders of quantify the radioactive material.12 Additionally, magnitude, and the product will be integrated a biological assay, used to estimate the back into the S. tuberosum genome. In further concentration of biochemically active materials, understanding the metabolic pathways of will be performed on extracted protein in order to naturally occurring vitamin D production, we can give a qualitative analysis of radioactive content.12 help create a new industrial bioprocess to cultivate and transfer vitamin D in large quantities for Protein Identification: food fortification. This would help expand off of Once separated, the proteins will be analysed efforts currently being made to move agricultural using x-ray crystallography.. The images will be biotechnology away from harmful chemical used to determine shape, specific regions of the processes. protein.18 A portion of the isolated protein will be sent away for analysis in order to identify the Requirements for optimal proliferation of the specific DNA sequence. S. tuberosum, arbuscular mycorrhizae symbiotic relationship, in conjunction with the upregulated Gene Expression: transport protein, must be established to allow Once the DNA sequence of the transporter for the development of this naturally enriched protein is identified, the gene will be upregulated S. tuberosum crop. Finally, before the crop can to increase expression of the protein. This will be available for consumption, assessment of its consequently increase the vitamin D2 content in toxicity must be completed in order to ensure S. tuberosum. Ultimately, an increased amount of vitamin D levels within the plant are safe, and the vitamin D2 in host plants will allow consumers to symbiotic relationship used during plant growth have access to a natural and safe vitamin D-rich does not have any potentially dangerous effects food source. on humans. The process outlined in this paper has the potential to remedy vitamin D deficiencies, which continue to be problematic in both Discussion and Conclusion developed and developing societies, where many This research proposal outlines initial steps in do not have access to pharmaceutical vitamin developing a S. tuberosum crop that is naturally D supplements. Given the newly discovered enriched with vitamin D and that can be correlations with autoimmune diseases, infectious grown and consumed worldwide. Following disease and even common cancers, novel the identification of the protein responsible biotechnologies addressing vitamin D deficiency for transporting vitamin D, further research must be a biomedical research priority. â&#x2013;

ARTIST MAINE BI

CRITICAL REVIEW

Physician-Assisted Dying A New Option in Canadian End of Life Care

David Bobrowski1 and Faizan Bhatia 2 Bachelor of Health Sciences (Honours) - Biomedical Sciences Specialization, McMaster University Bachelor of Health Sciences (Honours), McMaster University Correspondence: bobrowd@mcmaster.ca, bhatiaf@mcmaster.ca 1

ABSTRACT

Healthcare in Canada is undergoing a major transformation as patients obtain the right to request for and be granted physician-assisted dying (PAD). 1 This legal reform represents a paradigm shift in Canada’s approach to end of life care. In February 2015, the Supreme Court of Canada (SCC) struck down laws that made it illegal for individuals to assist others in ending their own lives. The ruling on PAD has been held in suspension for 16 months to allow for amendments to health policy. 2 The SCC’s ruling only applies to competent adults with persistent, intolerable suffering, who consent to ending their lives. 1 In this article, we aim to coalesce several opinions on the implementation of PAD, highlight the challenges, and critically evaluate recommendations of several policy-influencing bodies.

Recognizing the legal implications of PAD, the CMA recommends that the SCC must legally protect the doctors who either agree or refuse to provide PAD services.5 However, the CMA has reported that its members are divided on the possibility of being responsible for ending the lives of their patients.1,5,6 Many doctors argue that patients should self-refer to independent third parties if their physician is unwilling to provide PAD, whereas others argue that this would prolong and exacerbate patient suffering.5,7 For its part, the CMA’s official stance is that patients referred to a third party should consider other options as well, including palliative and spiritual care.5,8

these sections “infringed on the rights to life, liberty and security of persons suffering terminal illness in a manner that is…not justified under the Canadian Charter of Rights and Freedoms”

m e d u cato r | A P R I L 2016

In Canada, PAD continues to serve as a controversial medical ethics issue. The Canadian Medical Association (CMA) defines PAD as: “A physician knowingly and intentionally providing a person with the knowledge or means or both required to end their own lives, including counseling about lethal doses of drugs, prescribing such lethal doses or supplying the drugs”.1 A number of There are a number of challenges with legal cases involving terminally ill patients, providing PAD services. Physicians have including Carter v. Canada, have gained stressed that efforts to broaden access to national headlines. These cases propelled the palliative care in Canada should be prioritized issue of PAD into mainstream thought and ahead of PAD.1,5,8 A patient might feel inclined eventually to the Supreme Court of Canada to opt for PAD because of limited access to (SCC) in February 2015.2 The SCC struck down palliative care centres. Indeed, valid consent portions of sections 14 and 241 of the Criminal is the core principle of PAD, and the lack of Code of Canada (CCC), which prohibited access to quality palliative care may threaten PAD for competent, consenting adults with a the validity of consent by placing unwarranted “grievous and irremediable medical condition pressure on the patient.5,9 Furthermore, that causes enduring suffering”.2 The SCC safeguards must be present with PAD to determined that these sections “infringed on protect patients who are most vulnerable.1,9,10 the rights to life, liberty and security of persons In particular, the interests of individuals at risk suffering terminal illness in a manner that of attempting suicide for alternative reasons is…not justified under the Canadian Charter

critical review

In North America, only a small number of jurisdictions allow physician-assisted dying (PAD).3 These include the American states of Washington, Oregon and Vermont, as well as the Canadian province of Quebec. Quebec’s Bill 52 is similar to European laws pertaining to patients experiencing “unbearable suffering”, whereas the United States follows a more time-based approach that considers the number of months until death.3,4 Since their inception, laws on PAD have evolved throughout the years in Europe. The pioneers were the Dutch and the Belgians in 2002 and many countries have since followed suit.4

of Rights and Freedoms”.2 This decision serves as a paradigm shift for the Canadian medical community in its approach to end of life care. To allow sufficient time for public deliberation and policy changes, the ruling was suspended for 16 months.2

must be protected. Physicians are expected to follow the Code of Ethics outlined by the CMA in providing life-support measures to individuals who have attempted suicide.9,10 In addition, suicide-prevention programs should continue to be implemented across Canada. To ensure that PAD is delivered appropriately, medical regulatory authorities should establish guidelines for physicians and ensure that their education covers patient eligibility criteria for PAD.8

critical review

6. 7.

m e d u c a t o r | A pril 2 0 1 5 m e d u c a t o r | april 2 0 1 6

10.

11.

12.

The Canadian Broadcasting Cooperation. Quebec end-of-life law can’t take effect until Criminal Code is changed, court rules [Internet]. 2016 [cited 3 March 2016]. Available from: http:// www.cbc.ca/news/canada/montreal/ quebec-end-of-life-care-1.3345572 The Guardian. Euthanasia and assisted suicide laws around the world [Internet]. 2014 [cited 3 March 2016]. Available from: http://www.theguardian.com/ society/2014/jul/17/euthanasia-assisted-suicide-laws-world Canadian Medical Association. Euthanasia and assisted death [Internet]. 2016 [cited 13 January 2016]. Available from: https://www.cma.ca/Assets/assets-library/document/en/advocacy/ EOL/cma-policy-euthanasia-assisteddeath-updated-2014-e.pdf Supreme Court of Canada. Carter v. Canada (Attorney General) - SCC Cases (Lexum) [Internet]. 2015 [cited 13 January 2016]. Available from: https:// scc-csc.lexum.com/scc-csc/scc-csc/ en/item/14637/index.do Canadian Medical Association. A Canadian approach to assisted dying: CMA member dialogue [Internet]. 2016 [cited 13 January 2016]. Available from: https://www.cma.ca/Assets/assetslibrary/document/en/advocacy/Canadian-Approach-Assisted-Dying-e.pdf Godard E. Is physician-assisted death in anyone’s best interest?: No. Can Fam Phys. 2015;61(4):316. Canadian Medical Association. End of life care [Internet]. 2016 [cited 14 January 2016]. Available from: https://www. cma.ca/assets/assets-library/document/en/advocacy/englishreportfin Vogel L. Many doctors won’t provide assisted dying. CMAJ. 2015;187(13):E409-E410. Gibson J, Taylor M. Provincial-territorial expert advisory group on physicianassisted dying [Internet]. 2016 [cited 13 January 2016]. Available from: http:// www.health.gov.on.ca/en/news/bulletin/2015/docs/eagreport_20151214_ en.pdf The College of Family Physicians of Canada. A guide for reflection on ethical issues concerning assisted suicide and voluntary euthanasia [Internet]. 2016 [cited 14 January 2016]. Available from: http://www.cfpc.ca/uploadedFiles/Health_Policy/_PDFs/Guidefor%20Euthanasia_EN_FInal.pdf Canadian Nurses Association. Physician-assisted death [Internet]. 2016 [cited 13 January 2016]. Available from: https://www.cna-aiic.ca/~/medi a/cna/page-content/pdf-en/physi cian-assisted-death_brief-for-the-government-of-canadas-external-panelon-options-for-a-legislative-responseto-carter-v-canada.pdf?la=eal.pdf Buchman S. Physician-assisted dying - Bringing the family physician perspective to the table. Can Fam Phys. 2012;58(10):1169.

Physican-assisted dying is unique but not drastically different in the umbrella of end of life care care providers should be sufficiently educated about PAD to be able to inform patients about available end of life options.9,12

Regardless of geographic location, PAD should be readily available to patients.9 An effective The future of PAD now lies in the hands PAD framework should include patient of the physicians’ colleges, Parliament, and navigators who have knowledge of health provincial legislatures.2,5 The SCC recognizes care providers and end of life care options.9 that a physician’s decision to participate in Patient navigators would possess the resources PAD is one that bears ethical weight, and and legal authority to guide patients across in some instances, may be informed by the continuum of care. In the context of PAD, religious principles. With that being said, an patient navigators would act as the “middle increasing number of experts believe PAD man” between PAD-eligible patients and should be considered as one appropriate health care providers willing to participate.9 medical service within a spectrum of options available in end of life care.2,5

safeguards must be present with Physician -assisted dying to protect patients who are most vulnerable

The problem with this matching system is that certain areas of Canada could become hubs for PAD, thus undermining the original notion of accessibility.9 Physicians are thus calling for a pan-Canadian approach where the federal government would work collaboratively with provinces and territories to develop PAD rules, regulations, and expectations for health professionals.9,11 A provincial-territorial expert advisory group has noted that this initiative will require extensive training in health institutions, which could bring reform to university curricula and hospital protocols.9 Even though certain health professions may be more responsible for end of life care than others, all health

However, it is important to recognize that PAD is unique in the umbrella of endof-life care. We must recognize that the principle of patient autonomy, together with physicians’ morals, has the potential to render the principle of care “equity” to be empty promises to the public.1,9,10 It is likely that there will still be many unanswered questions in the immediate future, outlining the need for a coalition directed at advancing Canada’s healthcare system. In the near future, we should expect to see the development of guidelines for PAD – and certainly more discussion about this contentious issue. ■

Reviewed by DR. JOSHUA SHADD Dr. Joshua Shadd is the Director of the Palliative Care Division at McMaster University. Previously, Dr. Shadd was Medical Director at St. Joseph’s Hospice of London and an adjunct professor at the Schulich School of Medicine and Dentistry at the University of Western Ontario. Edited by MAXWELL TRAN

Managing Chronic Diseases in the Dominican Republic Xue (Shirley) Jiang, Shicheng (Tony) Jin, Salmi Noor, Raiya Suleman, Tanishq Suryavanshi Bachelor of Health Sciences, Global Health Specialization Level III McMaster University

meducator

D e c e m b e r 2013

global perspective

GLOBAL PERSPECTIVE

ARTIST Candy Niu

Introduction

m e d u cato r

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global perspective

Chronic conditions and diseases, such as heart disease, stroke, and cancer significantly influence health status around the world.1 By 2020, an estimated 75% of deaths will be caused by chronic diseases, with an estimated 80% of these deaths occurring in low to middle-income countries (LMICs).1,2 Furthermore, problems with chronic disease are exacerbated by socioeconomic and geopolitical factors.3

tical factors that impede the provision of chronic disease management in La Romana, Dominican Republic. Through our embedded experiences, we learned about several important issues preventing the management of chronic diseases in the bateyes, as well as potential solutions implemented by local and foreign teams.

Care aversive behavior: issues and solutions

A primary cause of care-aversive behavior by Haitians An example of an LMIC burdened with chronic in the bateyes is a strong belief in Vaudou - a religion diseases is the Dominican Republic (DR), where which suggests that illness is caused by evil spirits and non-communicable diseases account for about 70% can be cured through rituals or traditional medicines. of deaths each year.4 The DR is located on the island Thus, Haitians suffering from diseases will often attriof Hispaniola, which is shared with Haiti. Despite bute their symptoms to spirits and seek the attention of their geographical proximity, the two countries are a traditional healer. Some patients may journey to Haiti vastly different with regards to development, with to receive traditional treatment, which can delay pathe DR placing over 50 countries above Haiti on the tients from seeking medical services. Some patients are United Nations (UN) Human Development Index.5 dissuaded from obtaining care from foreign and local This disparity leads to the migration of many Haitian teams practicing Western medicine for fear of receiving negative judgement. Furthermore, batworkers to the DR. A large portion ey residents generally recognize acute of the Haitian migrants work in the and chronic diseases through their sugar industry as laborers. In fact, â&#x20AC;&#x153;However, batey community physical manifestations. In the case approximately 85% of sugarcane members are often uninterested of asymptomatic chronic diseases, pa6 workers in the DR are from Haiti. [in health education] because tients will often deny that they have the they see a lack of practicality or disease and refuse to accept treatment. The sugarcane workers are primarily housed in batey communities. A applicability of the information batey is an underdeveloped village to their day-to-day lives. Thus, In order to address the batey commulocated near sugar cane fields, it is important to explore nity membersâ&#x20AC;&#x2122; gaps in knowledge rebuilt by large multi-national sugar different ways to deliver garding chronic disease care, local and production companies. These engaging education programs. foreign groups provide education programs in the community about chronvillages are severely underfunded, ic care management. These education which gives rise to a variety of programs are delivered door-to-door health and quality of life issues. in the bateys by trained healthcare professionals. HowCommon conditions found among batey inhabitants ever, batey community members are often uninterested include gastroesophageal reflux disease, hypertension, because they see a lack of practicality or applicability 7 and upper respiratory infections. Given that many of the information to their day-to-day lives. Thus, it is Haitian residents are paid extremely low wages and important to explore different ways to deliver engaging have limited access to many social services, the burden education programs. In addition, because educational of these health problems is amplified greatly. There have been many attempts to address these problems programs are in the early stages of implementation, by both local and foreign aid teams. However, it is difficult to measure their long-term effectiveness. many factors complicate the provision of chronic Continuity of Care: disease management, such as care aversive behavior issues and solutions and difficulties with achieving continuity of care.

Personal experience and health topics Insights discussed in this article were derived from the observations of a group of five Bachelor of Health Sciences students in the Global Health specialization while on their three-month Extended Learning Experience (HTH SCI 3A15). As observers in the community, we had the opportunity to work with community members and local health leaders in these bateyes to gain a better understanding of the cultural and logis-

In addition to the care-aversive behaviour seen in the bateyes, problems regarding the management of chronic disease is further complicated by a poor care-delivery model. Care in the bateyes was primarily provided by short-term volunteer teams from the United States. These teams, each operating according to their own protocols, would visit sporadically for one week at a time. This led to disjointed care, as patients were prescribed different treatments at each visit. Moreover, since these foreign teams did not follow a specific timeline for their medical visits, follow-up care was poorly planned. Fi-

nally, the power dynamic between batey community members and foreign medical teams led to several problems. For example, many patients were hesitant to disclose accurate information about medication adherence, fearing judgement from health care providers. These barriers compromise the quality of care in the bateyes, given that continuity of care is vital to achieving optimal health outcomes with chronic diseases.

When addressing the need for a standardized protocol of treatment, the situation becomes more complex. Standardizing practices is a political task which requires the approval and initiative of key stakeholders. One possible solution would involve engaging local organizations to take the lead of coordination due to their strong influence on foreign teams. However, this is something that could be difficult given the imbalance of power between foreign and local teams. This is a task that must be focused on in the future, in order to ensure optimal care in the bateyes.7

Achieving proper management of chronic diseases is difficult in LMICs due to limitations emerging from cultural, financial, and logistical barriers.These limitations were manifested in the Dominican Republic, as seen by differences in the perspectives of those providing treatment and those receiving it, as well as the difficulties with coordinating care in LMICs. As third year students on an extended learning experience in the DR, we tried to address some of these limitations by developing a standardized hypertension protocol with the local hospital. We investigated the current practices of health providers and their gaps in protocols, as well as what the perception of disease of those receiving care. Overall, this information is being used to ensure protocols for hypertension in the DR achieve adequate quality of care in the bateyes. Aside from working with protocol standardization, this can also be addressed by investigating the way short-term trips are organized or the way financial aid is allocated. By acknowledging and responding to the barriers to care in the bateyes, we can more effectively reduce the burden of chronic diseases in the DR, and use this system as a model for chronic disease management in other LMICs.

acknowledgements

global perspective

One possible solution involves collaboration between foreign and local teams to ensure continuity of chronic disease care, through regular check-ups with patients and standardized provision of medication. Most healthcare groups working in La Romana bateyes face major barriers to providing care. Often, local teams are confronted with a lack of resources whereas foreign teams are unable to dedicate consistent and sustained time to batey communities. To address this, foreign teams often help local organizations find sponsors and local teams provide regular visits in the period of time between foreign visits. This ensures consistent visits by care providers and provision of consistent medication, resulting in a sustainable chronic disease program.

Conclusion

We would like to acknowledge the BHSc Program at McMaster University for allowing us to take part in this experience through the Global Health Specialization. We would also like to thank the 53rd Week, a non-profit organization that we worked in collaboration with while in the Dominican Republic. ■

Reviewed by Dr. Henry Lin Dr. Henry Lin is the executive director of The 53rd Week and a pediatric hepatologist at the Childen’s Hospital of Philadelphia, interested in healthcare advocacy and community development. With the 53rd Week, he has focused heavily on improving the impact of short-term volunteer work on the community through collaborative efforts. m e d u cato r

Edited by Nicole falzone

2. WHO | 2. Background [Internet]. WHO. [cited 2016 Jan 29]. Available from: http://www.who. int/nutrition/topics/2_background/en/ 3. Paradis G, Chiolero A. The Cardiovascular and Chronic Diseases Epidemic in Low- and MiddleIncome Countries, A Global Health Challenge⁎. J

Am Coll Cardiol. 2011 Apr 26;57(17):1775–7. 4. WHO | Global status report on noncommunicable diseases 2014 [Internet]. WHO. [cited 2016 Jan 29]. Available from: http://www.who.int/ nmh/publications/ncd-status-report-2014/en/ 5. Hdr.undp.org. | Human Development Reports [Internet]. 2016 [cited 10 February 2016]. Available from: http://hdr.undp.org/en/countries 6. Refworld | World Directory of Minorities and

Indigenous Peoples - Dominican Republic: Haitians [Internet]. Refworld. [cited 2015 Nov 2]. Available from: http://www.refworld.org/ docid/49749d2e21.html 7. Ferrara BJ, Townsley E, MacKay CR, Lin HC, Loh LC. Short-Term Global Health Education Programs Abroad: Disease Patterns Observed in Haitian Migrant Worker Communities Around La Romana, Dominican Republic. Am J Trop Med Hyg. 2014 Nov 5;91(5):871–5.

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1. Strong K, Mathers C, Epping-Jordan J, Beaglehole R. Preventing chronic disease: a priority for global health. Int J Epidemiol. 2006 Apr 1;35(2):492–4.

INTERVIEW SPOTLIGHT

DR.BRUCE WAINMAN Wainman shows the way JACK ZHANG

Bachelor of Health Sciences (Honours), Class of 2017, McMaster University Correspondence: zhangzy3@mcmaster.ca

 DR. BRUCE WAINMAN IS AN ASSOCIATE PROFESSOR OF PATHOLOGY

AND MOLECULAR MEDICINE AT MCMASTER UNIVERSITY. HE IS ALSO THE DIVISION DIRECTOR OF ANATOMY AND THE CURRENT DIRECTOR FOR THE EDUCATION PROGRAM IN ANATOMY. ADDITIONALLY, DR. WAINMAN SERVES AS THE COORDINATOR FOR BIOLOGICAL SCIENCES FOR THE ONTARIO MIDWIFERY CONSORTIUM. HE TEACHES PHARMACOLOGY, ANATOMY AND PHYSIOLOGY, AND REPRODUCTIVE PHYSIOLOGY AT MCMASTER UNIVERSITY. IN FEBRUARY 2016, DR. WAINMAN WAS AWARDED THE 3M NATIONAL TEACHING FELLOWSHIP – CANADA’S MOST PRESTIGIOUS UNDERGRADUATE TEACHING AWARD. DR. WAINMAN’S CURRENT RESEARCH INTEREST INCLUDES HOW ENVIRONMENTAL CONTAMINANTS IMPACT HUMAN REPRODUCTIVE HEALTH. SPECIFICALLY, DR. WAINMAN AIMS TO IDENTIFY THE RELATIONSHIP BETWEEN EXPOSURE TO ENVIRONMENTAL CONTAMINANTS AND THE ALTERATION IN MENSTRUAL CYCLE FUNCTION. DR. WAINMAN OBTAINED HIS UNDERGRADUATE DEGREE IN BIOCHEMISTRY FROM LAURENTIAN UNIVERSITY, A MASTER’S DEGREE IN MEDICAL SCIENCES FROM MCMASTER UNIVERSITY, AND A PHD IN BIOLOGY FROM YORK UNIVERSITY.

Edited by ellen he and Sebastian Swic



HI DR. WAINMAN, THANK YOU FOR HAVING US. YOU’VE HAD AN INCREDIBLE LIFE STORY. YOU WERE A FIRST-GENERATION UNIVERSITY STUDENT AND ALSO A RUNNER ON THE CANADIAN NATIONAL TEAM WHILE ATTENDING UNIVERSITY. CAN YOU GIVE US A LITTLE MORE BACKGROUND REGARDING YOUR EDUCATION AND HOW YOU BECAME A PROFESSOR AT MCMASTER? It’s a different experience when no one in the family has received any type of higher education. You have almost no expectations, but it also means you have almost no preparation. So, you go into it practically blind. You don’t really know [what to expect], except maybe what you see in movies and on TV. So for me every day at university was really a new experience. I was really allowed to find my own way and discover what I really enjoyed. It turned out that only after a few days of school, I saw professors doing research with all these interested - and interesting students, and working with some pretty great people, and I

be really aware of people’s emotions and the impact that you have on them. It is very difficult from a medical point of view, constantly making decisions about acceptability of bodies that have been donated. And there are also legal considerations; people get into a lot of trouble if you do the wrong thing around dissecting bodies, so you end up learning quite a lot. After I ran the anatomy lab for a while, we decided that we would develop more surgical skills, so we developed the surgical skills facility. That was fantastic! Sometimes you cannot predict what’s going to happen in your career but all of your experiences will still be meaningful.

 YOUR RESEARCH FOCUSES ON THE IMPACT

OF EXPOSURE TO ENVIRONMENTAL TOXINS ON REPRODUCTIVE HEALTH. YOU HAVE PUBLISHED MANY PAPERS IN THIS FIELD. RECENTLY, YOU CONDUCTED A STUDY ON HOW EXPOSURE TO PERSISTENT ORGANOHALOGENS AND CERTAIN METALS AFFECT THE MENSTRUAL CYCLE OF CREE ABORIGINAL WOMEN LIVING IN JAMES BAY. CAN YOU TELL US MORE ABOUT THE STUDY?

thought that looked like a pretty great job, you know? All of a sudden you see something that you really like... It’s like falling in love. You just had this feeling, you just knew it was something that you wanted to do.

 THANK YOU FOR SHARING THE RESULTS OF YOUR RESEARCH. WHAT ARE SOME FUTURE STEPS YOU WOULD LIKE TO EXPLORE? IN ADDITION, WHAT ARE THE CHALLENGES YOU HAD TO OVERCOME WHILE CONDUCTING THIS RESEARCH?

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Running an anatomy program is a very special and different sort of thing because I was trained as a researcher. When you start running the anatomy program, all of a sudden you have to deal with the public in a very important way. These are people who have donated a loved one’s body to the program and that’s almost like a clinical situation where you have to

We confirmed that there were some changes in these women’s menstrual cycles, particularly in the luteal phase. It was very complex to figure out because there’s so many contaminants and there’s so many different possible measures of menstrual function. That’s why it was such a hard study to publish because it was just so difficult, not to do, but to explain. Science doesn’t work if you can’t explain what you’re doing; if you can’t explain it, it’s like you didn’t do it. It was by far the most complex study that I have ever been a part of. Now I do more education research, look at metal contamination in students, and other fascinating topics. m e d u cato r

So I came to Mac, I did my master’s and I enjoyed that. Then, I took some time and went to work for Environment Canada. Afterwards, I decided I would finish the whole deal, and pursued my PhD and postdoctoral fellowship, followed by a research associate position at Guelph. They needed people to teach within the midwifery program, so I started teaching a course. Then suddenly, I was teaching almost all the courses in the midwifery program while designing new programs and courses. Soon after, I received a few grants. One day, someone said I should run the anatomy lab so…here I am.

interview spotlight

We know that people who consume a lot of aquatic mammals will get lots of organic contaminants. What we didn’t realize is that many people in aboriginal communities were getting high exposures to some of these organic contaminants. In the early work we did about 20 years ago, we started to find that these women living in James Bay had high levels of contaminants including certain metals. We know that the menstrual cycle is hormonally regulated, so our study was really looking at how different levels of contaminants altered menstrual cycle hormones and length. So we broke that all down, working with colleges from the Centre for Disease Control, and found some very interesting results.

There’s so many challenges in research, one of which is funding. We had to convince the Canadian Institute for

“I’M NOT AFRAID OF TRYING DIFFERENT THINGS AND I’M ALSO NOT AFRAID OF MAKING A BIT OF A FOOL OF MYSELF.”

m e d u cato r

A P R I L 2016

interview spotlight table of contents

Health Research that this was a worthwhile study. Thus we found a bit of money to complete a pilot study and found significant results. It can be difficult to find time to write the grant proposals and complete other research tasks because I teach so much. Regardless of these issues, we eventually got the funding which was great!

Our research in James Bay can get really complicated. You have no idea how small the population in Ontario is once you get outside of Toronto. When you get to James Bay after flying straight north for four hours, there are not even 10,000 people. When you have to find women that are of a certain age, fulfill all of the study characteristics, are willing to provide you with samples every day for 40 days, have blood taken, and have all sorts of extensive questionnaires it can be very difficult to enroll participants. You can see why these things become very difficult. I mean, even getting to our study site was like a day and a half of work. So it’s always complex, but that’s what makes it interesting. Since it was a difficult population to reach, it made it fascinating to find such a unique group. Part of the reward is that we can go back to them and say: “We found certain problems with these particular contaminants and not with these. We think in general your health is pretty strong, let’s go on and talk about other issues like better sewage treatment and better education for the kids.”

 YOU ARE THE CURRENT DIRECTOR OF THE EDUCATION PROGRAM IN ANATOMY, TEACHING ANATOMY TO BACHELOR OF HEALTH SCIENCES, MIDWIFERY, NURSING, AND ENGINEERING STUDENTS. YOU RECENTLY RECEIVED THE 3M NATIONAL TEACHING AWARD FOR YOUR EXCELLENT SERVICES IN HIGHER EDUCATION. WHAT IS IT ABOUT YOUR PEDAGOGY THAT MAKES YOU SUCH AN EXCEPTIONAL EDUCATOR?

I think I’m just really into it. I do generally find what I’m doing interesting and I’m not really the most knowledgeable person. I’m not the greatest anatomist, but I’m really good at conveying the knowledge I have. I’m pretty clear that I don’t know a lot of things and the reason why that’s useful is that I try never to say anything I’m not sure about. The worst thing you can do is give people false information. It’s like learning a piece of music incorrectly and never remembering the original song. I’m not afraid of trying different things and I’m also not afraid of making a bit of a fool of myself. It’s not about me when I’m up in front of a class. I have only one goal, and that’s to try to make people understand what I’m saying. I’m just there to help you learn the material the best way that I can. I think when you’re younger, you want many things. Perhaps a new car, or a vacation, but what you really want is to find meaning. You realize that a lot of those things are meaningless. I mean, shoes are nice, but after you’ve got a couple of pairs, it doesn’t really matter as much. And for me at least, what provides meaning is what I do: helping people understand and discover what I find fascinating about science, and life to a certain degree. But mostly science.

 I AM SURE YOUR TEACHINGS HAVE INSPIRED

MANY STUDENTS TO BECOME INTERESTED IN SCIENTIFIC AND SPECIFICALLY BIOLOGICAL RESEARCH. WHAT ADVICE WOULD YOU GIVE TO ASPIRING YOUNG RESEARCHERS?

I think that you have to understand the amount of work and difficulty. I was so lucky early in my career because I had no idea, no preconceived notion, of how much work this would be. I just knew what I didn’t want to do. I didn’t want to wash cars for a living anymore. The amount of work you have to put in is considerable, and it’s not every day that you finish and say “fantastic”. There are a lot of days where you feel like you’re pushing against this giant rock, and some days, somehow it moves. It’s dispiriting because you think it’s not going anywhere. But you have to be faithful. You’re getting better at what you’re doing, but it’s not always obvious. You have to keep trying. You can’t win if you quit and you will certainly lose if you quit, and so you have to keep pushing. And that’s hard because a lot of time, everyone, especially in modern culture, is really excited about how you’re doing. “Are you happy every day?” “I’m going to find myself every day.” But really you can’t find yourself every day, and you can’t be happy every day. You in fact need to have something better than that. You have to be fulfilled. You have to find long-term meaning. ■

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