Issue 41 by The Meducator

APRIL 2022 | ISSUE 41

C E L E B R AT I N G

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INTERVIEW SPOTLIGHT: ROBOTICS DR. JONATHAN IN SPINAL NG SURGERY FOUNDER OF THE R R E NR: T M E DC U CATO L I M I TAT IW O HN ES RAENIDT F U T U R E D IARLELCT B EI OG NA SN

THE EFFECT OF AUTOPHAGIC GENE INHIBITION ON EXOSOMAL TAU: A T H E RA P E U T I C TA R G E T F O R N E U R O D E G E N E RAT I O N

PRIMARY DYSMENORRHEA: E VA L U AT I N G T H E E F F E CT I V E N E S S O F N S A I D S A N D VA S O P R E S S I N R E C E P T O R A N TA G O N I S T S A S P R I M A RY DY S M E N O R R H E A T R E AT M E N T S

table of CONTENTS

M E D U CATO R

| APRIL 2022

table of contents

APRIL 2022

ISSUE 41

01 INTRODUCTION 02 MEDPULSE 04 MEDBULLETINS 06 PATHOPROFILE 08 MEDUSTORY 10 IWCH ABSTRACTS 12 FORUMSPACE 14 OPINION CRITICAL REVIEW 16 PRIMARY DYSMENORRHEA RESEARCH INSIGHT 20 ALZHEIMER’S DISEASE INTERVIEW SPOTLIGHT 24 JONATHAN NG 27 JONATHAN STOKES 29 CONTRIBUTORS

COVER ARTIST: ARIM YOO TOC ARTIST: ASEEL ABONOWARA

dear reader,

INTRODUCTION ISSUE 41

Welcome to Issue 41 of The Meducator! In continuing our celebration of the 20th year of The Meducator, we are excited to be doing so within the McMaster community, as we transition back to a modified in-person lifestyle. It has been a semester of change, continuing the tradition of interdisciplinary collaboration and revived initiatives from the past. Inspired by the connection betwen physical health and sports, Arim Yoo’s Issue 41 cover art uplifts female athletic representation and emphasizes unity in the international community. This issue’s MedPulse takes a new turn, with McMaster Friends of Médicins Sans Frontières (MSF) authoring several pieces on developments within the healthcare field, highlighting MSF’s responses to treatment inaccessibility and disease surges globally. In Pathoprofile, Shanzey Ali and Alexander Xiang take a deep dive into Kallmann Syndrome, the puberty-related genetic condition predominantly affecting males worldwide. Next, Allison Fang and Matthew Lynn highlight the MeduStory of Dr. James Makokis, advocate for Indigenous and transgender health, and winner of the 7th season of The Amazing Race. We continue The Meducator’s collaboration with the annual International Women and Children’s Health (IWCH) Conference, as well as the McMaster Health Forum. IWCH abstracts examine the impact of patient-physician relationships on patients’ mental health, the effect of racial stereotypes on Black women’s health, and the Global Midwifery Peer-to-Peer Program. In Forumspace, Vikita Mehta and Tushar Sood write about the widespread inequity in COVID-19 vaccine distribution.

introduction

We are also excited to feature an Opinion Piece, a Critical Review, and a Research Insight in this issue. Matthew Ahn and Suraj Bansal write about the efficacy of nanoparticle-based CT imaging in identifying pro-inflammatory macrophages in atherosclerosis. Nyla Syed and Thunuvi Waliwitiya then critically review NSAIDs and vasopressin receptor antagonists as primary dysmenorrhea treatments. Finally, the effect of autophagic gene inhibition on exosomal tau is explored by Philip Yu. Issue 41 concludes with two Interview Spotlights featuring Dr. Jonathan Ng, the founder of The Meducator, and Dr. Jonathan Stokes, a machine learning and novel antibiotics specialist. We are confident that The Meducator will continue to evolve in new and exciting ways in the decades to come. With the continuation of our new video initiative, MeduCares, and our new podcast, MeduCurrent, we hope to continue to shine a spotlight on our McMaster community as we navigate a new era of care in the health sciences. We are proud of our talented team for their unrelenting support and dedication not only to Issue 41, but also to the entire Meducator community during the 2021–2022 school year.

From both of us, thank you so much for an incredible milestone year of The Meducator.

| APRIL 2022

All the best,

M E D U CATO R

We would like to extend our gratitude to our executive team: Aisling, Andy, Carolyn, Catherine, Daniel, David, Eric, Jeffrey, Karishma, Madeline, Shanzey, and Yiming. We welcome our incoming 2022–2023 Editors-in-Chief, Jeffrey Sun and Madeline Chan, who we know will continue to uphold The Meducator’s mission of community building and education through knowledge translation at McMaster and beyond. We also want to extend a final thanks to you, reader, for your continued support and curiosity!

SOPHIE ZARB

Bachelor of Health Sciences (Honours) Class of 2022

MICHAL MOSHKOVICH

Bachelor of Health Sciences (Honours) Class of 2023

Lucuma (Pouteria lucuma)

MEDPULSE

AUTHORS: MCMASTER FRIENDS OF MÉDICINS SANS FRONTIÈRES (MSF) ARTISTS: NATALIE CHU & RYAN TSO

Venezuelan Migration to Brazil: A Lack of Healthcare, Shelter, and Services

Apple (Malus pumila)

By Alexia Doican

An influx of asylum seekers and migrants from Venezuela has been seen since the partial reopening of Brazil’s northern border in Roraima state. Of the hundreds of migrants arriving on a daily basis, most wind up in Pacaraima, a small town within Roraima state, awaiting legal status request processing. Clearing migration status is a slow process; the migrants are left with no healthcare or shelter accommodations from the town. This has resulted in thousands of migrants having to live on the streets during their wait. In response to this, Doctors Without Borders/Médecins Sans Frontières (MSF) has establised mobile clinics in Pacaraima and Boa Vista, offering medical, sexual, reproductive, and mental health services.1 The MSF teams cared for 14 551 patients between July and September, after the partial border opening and lifting of COVID-19 restrictions in July.1 Respiratory tract and gynecological infections were the main reason for consultation. 69% of patients consulted by the mental health team had critical symptoms of stress, depression, and anxiety due to family separation, displacement, and experienced violence.1 Health Care Inaccessibility in Central African Republic By Jasmine Parmar

The Central African Republic (CAR) is experiencing an extreme health crisis due to a severe shortage in healthcare workers, medical supplies and health facilities. This instability has led to poor health outcomes, such as a high proportion of malariadriven under-five deaths, high maternal mortality rates, and the highest prevalence of HIV in Central Africa. Additionally, a lack of access to good reproductive health care has had serious repercussions on preventing and treating sexually transmitted diseases.2 A severe shortage of healthcare workers and medical supplies, such as vaccinations, have also resulted in preventable diseases impacting public health, such as malaria and HIV/AIDS.3 Independent of any political agendas, MSF began providing general and emergency healthcare in the CAR in 1997, working to make treatment for HIV/AIDS available and running reproductive health services to address this crisis.4 In 2019, MSF ran 12 projects to host medical facilities across CAR, and in the capital, Bangui.5 MSF health facilities are free of charge, and currently one of the only treatment providers for those individuals.6

Cupuaçu (Theobroma grandiflor

MSF’s Response to the COVID-19 Pandemic in Peru By Hayley Kupinsky

Banana (Musa acuminata)

While the COVID-19 pandemic impacted all countries, it disproportionately impacted lesser-developed countries, like Peru. As of June 2021, Peru had the highest COVID-19 mortality rate in the world.7 The country experiences a large barrier to vaccine access and is struggling with an overwhelmed healthcare system. In 2020, MSF returned to Peru for the first time in over a decade to assist the Ministry of Health in their response to the pandemic.8 MSF expanded their intervention by creating a new facility in Cusco to relieve some of the pressure on the healthcare system and treat more critical COVID-19 patients.9 A team of doctors and nurses experienced in the clinical management of COVID-19 patients aimed to share knowledge acquired during COVID-19 responses in other countries. Personal protective equipment and medicines were also donated to help treat patients.10

Tuberculosis Program Implemented by MSF in Russia By Iqra Chuadhry

Tuberculosis (TB) is a bacterial infection that generally affects the lungs and respiratory system.11 TB is easily transmissible from person-toperson, which has led to several epidemics. The discovery of the antibiotic agent streptomycin in the mid-20th century significantly reduced TB cases in many parts of the world.12 However, the over-prescription of the drug has led to a surge in multiple drug-resistant tuberculosis (MDR-TB), especially in Russia.13 With no treatment available, MDR-TB cases and the associated death rate in Russia increased by 7.5% and 11% each year since 1990, respectively.14 To help the country deal with the resurgence of TB, MSF began working with the Chechen Ministry of Health to develop a TB programme.15 This programme includes the provision of appropriate medications for treatment of severe cases, training for doctors and nurses, as well as laboratory support, health promotion, and psychosocial assistance for patients and their families. This programme continues to be in effect and has since been expanded to include research and development of novel oral short-course treatment regimens for MDR-TB patients.16

Mango (Mangifera indica)

By Saathana Mathirajan

The concurrent rise of the COVID-19 Delta variant and mucormycosis infections in India had placed significant pressure on their healthcare system.17 Nearly 71% of global mucormycosis infections in COVID-19 patients were from India during the first wave of the pandemic.18 Mucormycosis, otherwise known as “black fungus,” is a rare fungal infection that can cause adverse health outcomes relating to the brain, eyes, sinuses, and nasal passages.19 If untreated, mucormycosis can be fatal in up to half of those who contract it.20 With the rampant increase in infections, several Indian states faced shortages of antifungal medications like liposomal amphotericin B, which is administered after surgically removing infected tissue.21 Along with the shortage, the cost of this medication has placed low-income families at a disadvantage for accessing treatment.22 Looking to reduce this disparity, MSF has requested the Gilead Sciences pharmaceutical corporation, a manufacturer of this liposomal amphotericin B, to promptly reduce the standard “access” price and expand the availability of this medication to all low- and middle-income countries.23 The corporation has subsequently promised to partner with the Indian government to increase access to the medication.24 Wild Loquat (Uapaca kirkiana)

rum)

Lack of Access to Antifungal Medication During India’s Surge in Mucormycosis Infections

References can be found on our website: meducator.org

Preventing and Treating Cervical Cancer in Malawi by Maheen Raja

Inaccessibility of adequate medical care remains to be the driving force of many global health concerns, including cervical cancer. While great advances for cervical cancer prevention and care have been established in high-income countries, an unequal and clear difference in curative treatments for low-income countries is noticeably observed, making it the fourth most common female malignancy.25 The alarming mortality rate in Malawi, located in East Africa, remains to be the greatest worldwide.26 To counteract this concern, MSF established five main projects worldwide, targeting Malawi with their most exhaustive approach.27 This project includes preventative and curable techniques including human papillomavirus (HPV) vaccination, visual acuity with acetic-acid screening, and various pre-cancer treatments.28 Additionally, case management strategies, including palliative care and the accessibility to surgical procedures such as extended abdominal hysterectomies, began in 2019 following the commencement of MSF’s operating theater.29 Despite MSF’s clinical approach, a greater emphasis on pharmaceutical companies creating affordable and accessible HPV vaccines is needed to overcome this global health concern.

MEDBULLETIN FIRST PIG-HEART TO

MCMASTER RESEARCHERS

AI S LING ZE NG

AISLIN G ZEN G

Currently, one treatment option for end-stage heart disease is a heart transplant, with about 3442 patients on the American transplant waiting list as of Februar y 2022. 1,2 However, for some, a human heart transplant is not an option due to underlying conditions and other factors. 3 Xenotransplantation is a solution to address the increasing organ demand and offers an alternative for ineligible transplant patients. 4

The emergence of variants throughout the progression of the COVID-19 pandemic has caused political unrest and public concern, while demonstrating the need for more long-term and robust vaccine development strategies. 1

M E D U CATO R | A P R I L 2019 M E D U CATO R | A P R I L 2022

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HUMAN

On Januar y 7, 2022, surgeons from the University of Mar yland successfully transplanted the first ever genetically modified pig heart into 57-year-old David Bennett. 4 This breakthrough surger y was not part of a clinical trial, but was rather a last ditch effort to save Bennett, who had been on cardiac support for two months. 4 The primar y cause of concern for most transplants is organ rejection, which is addressed by administering immunosuppressive medications to the patient. Bennett’s case, however, was one of the first instances in 70 years where scientists modified the donor instead of suppressing the recipient’s immune system. 5 In 2005, Dr. David Cooper, a surgeon from Har vard University, was able to use CRISPR-Cas9 technolog y to delete the gene that encodes for galactosyltransferase, an enzyme responsible for the production of galactose-α(1,3)galactose (Gal). 5 Gal is a sugar found on the surface of pig cells that is one of the major targets for human anti-pig antibodies.6 This discover y was a gamechanger in the field as it successfully prevented hyperacute rejection and led to the success of Bennett’s surger y. 5 Unfortunately, 45 days post-surger y, Bennett struggled with numerous infections and ultimately passed away 2 months after the initial operation. 7 Despite this setback, the surger y was still deemed a significant step for ward and surgeons are open to potentially conducting formal clinical trials involving xenotransplantation in the future. 7 1. 2. 3. 4. 5. 6.

TRANSPLANTATION

Health Resources & Services Administration. Organ procurement and transplantation network [Internet]. 2022. Available from: https://optn.transplant.hrsa.gov/data/view-data-reports/national-data/# [cited 2022 Feb 18]. Friedrich EB, Böhm M. Management of end stage heart failure. Heart. 2007;93(5):626-31. Available from: doi:10.1136/ hrt.2006.098814. Canadian Cardiac Transplant Network. Cardiac transplantation: eligibility and listing criteria in Canada 2012 [Internet]. December 2021. Available from: https://ccs.ca/app/uploads/2020/12/CCTN_Cardiac_Transplantation_Eligibility_and_ Listing_Criteria_in_Canada_2012.pdf [cited 2022 March 17]. Reardon S. First pig-to-human heart transplant: What can scientists learn? Nature. 2022;601:305-6. Available from: doi:10.1038/d41586-022-00111-9. Le Page M. The transplant revolution. NewScientist. 2022;253(3373):20-1. Available from: doi:10.1016/S02624079(22)00230-5. Cooper DKC. Modifying the sugar icing on the transplantation cake. Glycobiology. 2016;26(6):571-81. Available from: doi:10.1093/glycob/cww028. Osborne M. Patient who received a genetically modified pig heart dies after two months [Internet]. Smithsonian. 2022 Mar 10. Available from: https://www.smithsonianmag.com/smart-news/patient-who-received-a-genetically-modified-pig-heart-diesafter-two-months-180979706/ [cited 2022 March 17]

DEVELOP INHALED VACCINES

Recently, researchers at McMaster University developed a new vaccine that has just begun phase 1 clinical trials. 2 The vaccine is adenoviral-based with human and chimpanzee origins and expresses three SARS-CoV-2 antigens. 1 Thus far, it has been shown to confer protection against variants B.1.1.7 and B.1.351, commonly known as alpha and beta, respectively. 1 However, this vaccine has gained attention not for its efficacy, but for its non-traditional administration route: intranasal. Respirator y vaccines, more commonly known as inhaled vaccines, have been researched for years, though few have progressed to regulator y approval and distribution. 3 Regardless, respirator y vaccines have shown promising results, especially when addressing airborne diseases such as COVID-19. 3,4 The respirator y tract’s large surface area and high amount of antigen-presenting cells makes it the optimal target for pharmaceutical uptake and inducing an immunological response.⁴ Additionally, since COVID-19 is transmitted via aerosols and droplet spread, respirator y vaccines confer an advantage compared to traditional intramuscular vaccines, as they are delivered straight to the pathogen’s primar y site of entr y.⁴ Clinical trials are currently still under way, but if the results continue to show success, the approval and distribution of this inhaled vaccine could have huge implications for the trajector y of the pandemic and how researchers approach vaccine development in the future.

1. 2. 3. 4.

Afkhami S, D’Agostino MR, Zhang A, Stacey HD, Marzok A, Kang A, et al. Respiratory mucosal delivery of next-generation COVID-19 vaccine provides robust protection against both ancestral and variant strains of SARS-CoV-2. Cell. 2022;185(5):P896-915. E19. Available from: doi:10.1016/j.cell.2022.02.005. Donovan M. Researchers confirm newly developed inhaled vaccine delivers broad protection against SARS-CoV-2, variants of concern [Internet]. 2022 Feb 9. Available from: https://brighterworld.mcmaster.ca/articles/researchers-confirm-newlydeveloped-inhaled-vaccine-delivers-broad-protection-against-sars-cov-2-variants-of-concern/ [cited 2022 Mar 17]. Xi J, Lei LR, Zouzas W, Si XA. Nasally inhaled therapeutics and vaccination for COVID-19: Developments and challenges. Medcomm. 2021;2(4):569-86. Available from: doi:10.1002/mco2.101. Heida R, Hinrichs W, Frijlink H, Inhaled vaccine delivery in the combat against respiratory viruses: A 2021 overview of recent developments and implications for COVID-19. Expert Rev Vaccines. 2021;22(13):6937. Available from: doi:10.1080/14760 584.2021.1903878.

DA L R A J DHIL LO N

D ALR AJ DHILLON

Sickle cell disease (SCD) is a group of genetic disorders pertaining to the malformation of hemoglobin and consequent dysmorphia of red blood cells (RBCs).1 SCD is the result of a single nucleotide polymorphism to the beta-globin gene, resulting in the replacement of glutamate with valine at position 6 and the subsequent formation of hemoglobin S (HbS) instead of the normal hemoglobin A (HbA).2 At high blood oxygen concentrations, the structure of HbS appears normal, however, HbS polymerizes at low concentrations to form fibrous precipitates which alter the RBC into a crescent shape.3 These malformed RBCs tend to readily cohere, resulting in frequent clotting and associated excruciating pain crises.4 While SCD can be cured with a donor bone marrow transplant, the use of this therapy has the best chance of success in patients who have a closely matched donor, which is difficult to find for many patients.5 However, recent clinical trials have assessed the use of a viral vector gene therapy, which uses the patient's own stem cells in order to minimize rejection. This treatment, Lentiglobin, involves the transduction of CD34+ hematopoietic stem cells recovered from the patient with a lentiviral vector (BB305) that encodes for HbA.6 The single-dose reinfusion of the stem cells into the patient's blood was shown to result in sustained HbA production, reduced hemolysis, immense reduction in pain crises 4-32 months following injection, and limited adverse effects.6 While further studies will be conducted to further assess efficacy and safety, the success of this trial marks an immense step for ward in the field of gene therapy for SCD and other genetic blood disorders.

Throughout histor y, the most common practice for anterior cruciate ligament (ACL) reconstruction was through the use of a bone-patellar tendon-bone (BPTB) graft.1 The widespread use of this graft arises from its many benefits, including its similar structure and composition to the ACL, relative ease of har vesting, notable strength, and a low incidence of reinjur y. 2 Despite these many advantages, BPTB graft har vesting involves the har vesting of both the patellar tendon and part of the patella. This intrusive har vesting approach commonly leads to har vest-site morbidity, usually manifesting as diminished knee mobility and chronic anterior knee pain. 2,3 While manageable, this presents a major barrier to returning to optimal performance and function of the joint and has led to longer recover y periods for professional athletes when compared to other graft repairs.4 To alleviate these drawbacks, the use of a quadriceps tendon (QT) graft in ACL reconstruction has gained popularity. Compared to the BPTB graft, the QT graft has a 70% higher biomechanical load, and 20% more collagen fibrils per cross sectional area. 5 In addition to structural prowess of the QT, graft har vesting is ver y minimally invasive and does not involve any bone har vesting.5 A meta-analysis of clinical trials and obser vational studies revealed that QT graft ACL repairs bear no significant differences in graft failure compared to BPTB graft, yet significantly lowers the rate of donor site morbidity.6 While still gaining traction as a viable graft for ACL reconstruction, the quality-of-life benefits, coupled with a negligible difference in graft performance, may lend the QT graft as the preferred choice for orthopedic surgeons for ACL reconstruction in the future.

M E D U CATO R

CELL DISEASE

QUADRICEPS TENDON GRAFT FOR ACL RECONSTRUCTION

medbulletin

GENETIC CURE TO SICKLE

2. 3. 4. 5. 6.

Chakravorty S, Williams TN. Sickle cell disease: A neglected chronic disease of increasing global health importance. Arch Dis Child. 2015;100(1):48–53. Available from: doi:10.1136/archdischild-2013-303773. Newby GA, Yen JS, Woodard KJ, Mayuranathan T, Lazzarotto CR, Li Y, et al. Base editing of haematopoietic stem cells rescues sickle cell disease in mice. Nature. 2021;595(7866):295–302. Available from: doi:10.1038/s41586-021-03609-w. Odièvre M-H, Verger E, Silva-Pinto AC, Elion J. Pathophysiological insights in sickle cell disease. Indian J Med Res. 2011;134:5327. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3237253/ [cited 2022 Mar 17]. Columbia University Irving Medical Center. Experimental gene therapy reverses sickle cell disease for years [Internet]. 2021 Dec 13. Available from: https://www.cuimc.columbia.edu/news/experimental-gene-therapy-reverses-sickle-cell-disease-years [cited 2022 Mar 17]. Eisenstein M. Gene therapies close in on a cure for sickle-cell disease. Nature. 2021;596:S2-4. Available from: doi:10.1038/ d41586-021-02138-w. Kanter J, Walters MC, Krishnamurti L, Mapara MY, Kwiatkowski JL, Rifkin-Zenenberg S, et al. Biologic and clinical efficacy of LentiGlobin for sickle cell disease. N Engl J Med. 2022;386(7):617–28. Available from: doi:10.1056/NEJMoa2117175.

1. 2.

3. 4.

5. 6.

Dhammi IK, Rehan-Ul-Haq, Kumar S. Graft choices for anterior cruciate ligament reconstruction. Indian J Orthop. 2015;49(2):127–8. Available from: doi:10.4103/0019-5413.152393. Barié A, Sprinckstub T, Huber J, Jaber A. Quadriceps tendon vs. patellar tendon autograft for ACL reconstruction using a hardware-free press-fit fixation technique: Comparable stability, function and return-to-sport level but less donor site morbidity in athletes after 10 years. Arch Orthop Trauma Surg. 2020;140(10):1465–74. Available from: doi:10.1007/s00402-02003508-1. Hardy A, Casabianca L, Andrieu K, Baverel L, Noailles T. Complications following harvesting of patellar tendon or hamstring tendon grafts for anterior cruciate ligament reconstruction: Systematic review of literature. Orthop Traumatol-Sur. 2017;103(8):S245– 8. Available from: doi:10.1016/j.otsr.2017.09.002. Smith AH, Capin JJ, Zarzycki R, Snyder-Mackler L. Athletes with bone-patellar tendon-bone autograft for anterior cruciate ligament reconstruction were slower to meet rehabilitation milestones and return-to-sport criteria than athletes with hamstring tendon autograft or soft tissue allograft: Secondary analysis from the acl-sports trial. J Orthop Sports Phys Ther. 2020;50(5):259– 66. Available from: doi:10.2519/jospt.2020.9111. Xerogeanes JW. Quadriceps Tendon graft for anterior cruciate ligament reconstruction: The graft of the future! Arthroscopy. 2019;35(3):696–7. Available from: doi:10.1016/j.arthro.2019.01.011. Dai W, Leng X, Wang J, Cheng J, Hu X, Ao Y. Quadriceps tendon autograft versus bone–patellar tendon–bone and hamstring tendon autografts for anterior cruciate ligament reconstruction: A systematic review and meta-analysis. Am J Sports Med. 2021;036354652110302. Available from: doi:10.1177/03635465211030259.

A P R I L 2022

PATHOPROFILE PATHOPROFILE PATHOPROFILE

Kall syndro

AUTHORS: ALEXANDER XIANG & SHANZEY ALI ARTIST: MADELINE CHAN

INTRODUCTION

ann e

Kallmann syndrome (KS) is a form of hypogonadotropic hypogonadism characterized by a combination of both an inability to smell and properly regulate hypothalamic gonadotropin-releasing hormone (GnRH) pulses.1 This, as a result, affects the release of follicle-stimulating hormone (FSH) and luteinizing hormone (LH) from the pituitary gland, which in turn influences the secretion of endocrine hormones, such as estrogen and progesterone. It is found fairly infrequently, at a rate of approximately 1 in every 125,000 females and 1 in every 30 000 males.2 The inability to regulate GnRH secretion from the hypothalamus leads to a variety of consequences, including reduced sex hormone levels and the delayed onset of puberty.2

PRESENTATION AND DIAGNOSIS

The pattern of GnRH secretions from the hypothalamus continually changes throughout the stages of sexual development.3 As such, diagnosis of KS solely on the basis of GnRH levels requires an understanding of normal developmental timing. Although occasionally diagnosed during the neonatal stage, the most common period of diagnoses occurs during adolescence due to the disease’s characteristic inhibitory effects on puberty and sexual development.4 Notably, KS patients often experience stunted growth due to a lack of hormonal stimulation.1,4 Additionally, pituitary dysfunction as a result of KS often differs between males and females during sexual development, resulting in sex-specific clinical presentations.5 A study completed by Seminara et al. recruited a group of 50 males with GnRH deficiency observed that approximately 84% of patients exhibited no detectable GnRH pulses.4 Other minority groups exhibited different pulse frequencies, including abberant patterns during sleep or diminished pulse amplitudes.2,3 In contrast, the most common female GnRH secretion abnormality was a decrease in pulse frequency, occurring in approximately 40% of subjects.3 The study also observed that abnormal pulse patterns were extremely consistent within families with KS, indicating that genetic factors may also influence GnRH secretion.3

RISK FACTORS AND HERITABIILITY

The mechanism of genetic inheritance varies significantly for KS.6 GnRH pulse deficiencies have been shown to be inherited through X-linked recessive, autosomal dominant, and autosomal recessive manners.6 To this date, over 35 genes have been identified whose mutations are associated with GnRH pulse deficiencies.3 KS development has also been closely associated with other reproductive disorders, such as hypothalamic amenorrhea and constitutional delay of puberty, making these particular disorders comorbidities for the development of KS.1

One of the first genes found to be associated with KS was the Kallmann 1 gene (KAL1), located on the X chromosome.3,7 A sequencing approach conducted by Georgopoulos et al. on KS patients found nine different point mutations occurring within the exons of the KAL1 gene, which acted as a precursor to KS.3,8 The KAL1 gene is responsible for the production of anosmin-1, a protein that plays a vital role in the processes of neural adhesion and axonal migration.7 The loss of function of this protein associated with the aforementioned genetic mutations is speculated to contribute to the aberrant GnRH secretion patterns found in KS patients. Finally, it is worth noting that only about 40% of KS patients have an identifiable genetic mutation.3,7 This indicates that there are either additional genes not identified by researchers whose mutations give rise to KS, or other factors besides heritability that promote the presentation of KS.

TREATMENT

The median age to begin effective KS treatment is 18 to 19 years of age in Europe.9 Although advances have been made in the field, this median age has remained unchanged for the past three decades, with timely clinical diagnosis and overall quality of patient care having barely improved.9 Receiving an early diagnosis and treatment for KS is ideal as it can prevent disease-related complications, particularly during adolescence —a critical period for secondary sexual maturation and psychological development.9,10 Genetic interruption is one solution to prevent vertical transmission of KS and can be used after detection via preimplantation genetic testing.10 For a newborn diagnosed with KS and presenting with cryptorchidism, surgical operation is the first choice at 6 to 12 months of age.10 In addition, KS patients can develop secondary sexual characteristics, maintain normal sex hormone levels, lead a healthy sexual life, and achieve fertility if provided with timely and appropriate hormone replacement therapy (HRT).10 Depending on the main goals and age of a KS patient, different HRT prescriptions support different treatment objectives.10 These treatments for physiological and biological presentations of KS can also improve the psychological health of patients.10 KS treatment is usually required for the entirety of a patient’s lifetime, but even so, 10 to 20% of patients may still undergo spontaneous reversal of reproductive function.10 Further research on a definitive diagnosis for KS is the immediate logical step in improving the quality of life for KS patients.1 1.

4. 5.

10.

Stamou MI, Georgopoulos NA. Kallmann syndrome: Phenotype and genotype of hypogonadotropic hypogonadism. Metabolism. 2018;86:124-34. Available from: doi:10.1016/j. metabol.2017.10.012. Delemarre-Van de Waal HA, Odink RJ. Pulsatile GnRH treatment in boys and girls with idiopathic hypogonadotropic hypogonadism. Hum Reprod. 1993;8:180-3. Available from: doi:10.1093/ humrep/8.suppl_2.180. Seminara SB, Hayes FJ, Crowley Jr WF. Gonadotropin-releasing hormone deficiency in the human (idiopathic hypogonadotropic hypogonadism and Kallmann’s syndrome): Pathophysiological and genetic considerations. Endocr Rev. 1998;19(5):521-39. Available from: doi:10.1210/edrv.19.5.0344. Richard-Eaglin A. Male and female hypogonadism. Nurs Clin North Am. 2018;53(3):395-405. Available from: doi:10.1016/j.cnur.2018.04.006. MacColl G, Quinton R, Bouloux MP. GnRH neuronal development: Insights into hypogonadotropic hypogonadism. Trends Endocrinol Metab. 2002;13(3):112-8. Available from: doi:10.1016/s1043-2760(01)00545-8. Topaloglu AK. Update on the genetics of idiopathic hypogonadotropic hypogonadism. J Clin Res Pediatr Endocrinol. 2017;9:113-22. Available from: doi:10.4274/jcrpe.2017.S010. De Castro F, Seal R, Maggi R. ANOS1: A unified nomenclature for Kallmann syndrome 1 gene (KAL1) and anosmin-1. Brief Funct Genomics. 2017;16(4):205-10. Available from: doi:10.1093/ bfgp/elw037. Georgopoulos NA, Pralong FP, Seidman EC, Seidman JG, Crowley Jr WF, Vallejo M. Genetic heterogeneity evidenced by low incidence of KAL-1 gene mutations in sporadic cases of gonadotropin-releasing hormone deficiency. J Clin Endocrinol Metab. 1997;82(1):213-7. Available from: doi:10.1210/jcem.82.1.3692. Swee DS, Quinton R, Maggi R. Recent advances in understanding and managing Kallmann syndrome. Fac Rev. 2021;10:37. Available from: doi:10.12703/r/10-37. Liu Y, Zhi X. Advances in genetic diagnosis of Kallmann syndrome and genetic interruption. Reprod Sci. 2021. Available from: doi:10.1007/ s43032-021-00638-8.

medustory

JAMES MAKOKIS AUTHORS: ALLISON FANG & MATTHEW LYNN ARTISTS: ASHLEY LOW & KAYLA ZHANG

For those who do not watch The Amazing Race on television, Dr. James Makokis may be an unfamiliar name. Besides being the winner of the show’s seventh season, Makokis has established himself as an Indigenous health advocate and gamechanger in transgender patient wellness.1 EARLY ROOTS Growing up in the Saddle Lake Cree Nation, Makokis knew he wanted to be a doctor at the young age of four.1,2 Having earned a Master’s Degree in Health Sciences from the University of Toronto and a Doctor of Medicine Degree from the University of Ottawa, he graduated from the University of British Columbia’s Aboriginal Family Medicine Residency program in 2012.3 A colleague once told him: “If you really want to make a difference in medicine, why don’t you start doing transgender health because there’s so few physicians who provide medical transitioning for patients? And there’s so many barriers to doing that.” This comment eventually came to reflect the essence of Makokis’ career.⁴

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MAKING A DIFFERENCE IN HIS COMMUNITY Based outside Edmonton, Alberta, Makokis runs the only clinic in the Enoch

Cree Nation that is focused on providing quality care for trans and twospirit individuals from both Cree communities and around the world. According to Makokis, “two-spirit” is a contemporary English term reflecting the substantial gender and sexual diversity commonly found in Indigenous communities.⁵ Unfortunately, over 50% of trans and/or two-spirit people have attempted or died by suicide, something which Makokis constantly strives to ameliorate.⁶ Patients often travel several hours just to visit the clinic, where he uniquely combines Western medicine and traditional Cree practices. By establishing a strong connection with his patients, Makokis has helped countless individuals feel safe and accepted.⁴ An additional goal that Makokis continues to work towards involves decolonizing health practices. With the help of grants and fundraisers, he hopes to establish a cultural healing center in Kehewin Cree Nation, alongside a birthing center based on Cree midwifery practices.1 A PERSONAL TOUCH Makokis’ unique personal background may be another reason why patients feel so connected to him. As a gay, two-spirit, and Indigenous individual, Makokis has experienced his share of discrimination, isolation, and fear that stems from being part of a marginalized group in society —feelings often shared by his patients. He states that having these personal stories helps him stay committed to his work and better empathize with those that come to him.2,6 THE AMAZING RACE From receiving an Indspire Award in 2007 to becoming the medical director of the Center for Addiction and Mental Health, there is no doubt that Makokis’ life has been filled with many notable achievements.3 However, perhaps his most memorable one to date is winning Canada’s Amazing Race 7 with his husband, Anthony Johnson. Makokis and Johnson competed with outfits that highlighted important Indigenous issues, such as the ongoing missing and murdered Indigenous women crises.⁷ Based on his contributions both outside and inside the clinic, it is clear that Dr. James Makokis is a warm-hearted individual who is passionate about making a positive impact on others. References can be found on our website: meducator.org 9

IWCH ABSTRACTS ANALYSING PATIENT-PHYSICIAN COMMUNICATION ON LIFESTYLE MEDICINE TO PROMOTE MENTAL HEALTH: A QUALITATIVE STUDY SHANIA BHOPA MSC1 , KEYNA BRACKEN MD 2 , ANNE NIEC MD 3 1

Department of Global Health, Faculty of Health Sciences 2 Department of Family Medicine, Faculty of Health Sciences 3 Department of Pediatrics, Faculty of Health Sciences

Background: Mental illness affects 1.2 million youth in Canada. In particular, female adolescents have shown to suffer significant consequences associated with mental illness. While family physicians are often the first line of contact for health-related concerns, little is known about how promotion of lifestyle medicine enhances the mental wellbeing of female adolescents. Method: Using a qualitative content analysis approach, a survey about counselling on lifestyle medicine was completed by 126 Hamilton family physicians, with a response rate of 25.2%. The data was thematically analysed to explore emergent themes.

abstracts

Results: The three themes that yielded the highest agreement amongst key informants are lifestyle medicine factors, barriers and improvements in communication to female adolescent patients. Within each theme, sub-themes were subsequently identified. Specifically, the first theme highlighted a range of lifestyle medicine factors, including familial support, physical activity, nutrition, sleep, journaling, and mindfulness, all of which influence mental health. Theme 2 considered barriers in communication, which uncovered two subthemes: trust and time constraints. Finally, theme 3 investigated potential improvements in the quality of conversation, giving rise to the four sub-themes of clinical empathy: listening skills, time, and social media. Conclusion: In this study, physicians were aware of female-specific mental health concerns, by which they were able to recognize important ways to promote inclusive communication on lifestyle medicine. Analysing the data in regards to the patient-centred care model, the prevalence of screening tools — PHQ-9 and GAD-7— and the use of communication frameworks —HEADSS and SSHADESS— were deemed supportive to patient counselling. Communication is an important factor over which physicians have the opportunity to promote the mental health consequences of female adolescent patients.

THE GLOBAL MIDWIFERY PEER-TO-PEER PROGRAM ELIZABETH HILSENTEGER1 , BRONTE JOHNSTON BHSC, MSC1,2 , LYN GUM BSN, MSN, PHD 3 AND, BETH MURRAY-DAVIS RM, PHD1,2

M E D U CATO R

| APRIL 2022

McMaster Midwifery Research Centre

Health Sciences Education, McMaster

College of Nursing and Health Sciences, Flinders

Pen-pal programs have been utilized in physician and nurse education programs, contributing to improved ability to self-reflect and greater cultural competence for students. Cultural competence is becoming a requirement of caring professions, especially in the context of global health; high cultural competence is associated with a more positive view on diversity and more open behaviour. Thus, it is imperative to nurture cultural competence in the education of future health care professionals. However, the application of pen-pal programs for midwifery students has previously not been reported. The purpose of the Global Peer-to-Peer Program is to connect midwifery students in Australia and Canada to foster conversations that expand sociocultural knowledge and aid overall learning. The effectiveness of the collaborative activity will be measured by comparing the results of two surveys: one completed prior to the intervention, and one completed after. These surveys use Likert scales to assess participants’ baseline knowledge, exposure to global health topics, and international midwifery practice. Additionally, the participating students may partake in individual interviews at the completion of the study to discuss their experience in a different forum. It is hypothesized that the pen-pal program is a feasible educational intervention that will improve student midwives’ knowledge and understanding of global health topics and international midwifery practice, including roles and scope of practice.

BLACK WOMENS’ HEALTH MATTERS: A LITERATURE REVIEW OF THE IMPACT OF RACIAL STEREOTYPICAL NARRATIVES ON BLACK WOMEN BRITTANY DAVY, BCBA 1 1

M.A. Applied Disability Studies, Specialization in Applied Behaviour Analysis

Black women are disproportionately affected by negative stereotypical narratives and complex representations of their community. The “strong, Black woman” stereotype, and many others which are contextually similar, possess diverse meanings dependent on social context and lived experiences. Studies exploring the implications of normative and stereotypical narratives of Black women on their health have revealed differences in psychological and somatic health outcomes, due to Black women’s past experiences and perception of the stereotypes.

Researchers that have previously interviewed Black women within North America found that there were several theses associated with stereotypical narratives specifically applied to Black women, including: strong/assertive, independent, educated, hardworking/ambitious, caring, and self-confident. Several Black women expressed their beliefs that internalizing and perpetuating strong, Black-women traits has been a source of empowerment, which promotes self-sufficient and resilient behaviour in this marginalized population. Contrastingly, to this population’s detriment, these narratives can be particularly debilitating and oppressive as Black women may feel objected to altering their behaviour in order to fit within the boundaries ascribed by these stereotypes. Other Black women have displayed depressive symptoms that have been correlated with their exposure to these stereotypes, thus depicting the harmful effects of social ideologies on their physical and psychological health. Predominant stereotypes and lifestyle behaviours contribute to experiences of threatened mental health, as society constantly reproduces unattainable ideals.

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Further exploration will be conducted by the researcher throughout her academic journey; her dissertation is expected to reveal differentiated yet interrelated results between the endorsement of Black women-centered narratives and health experiences. This research is crucial, as much of the current published literature is conducted within the United States of America; the deep-rooted history of slavery, culture, and covert racist treatment of Black people today may hinder the generalizability of the findings to a Canadian context. Literature regarding the impact of stereotypical narratives on Black women within the Canadian context is misrepresented within published research.

abstracts

This literature review explores a range of popular connotations and denotions meanings attributed to similar racial stereotypes. Brittany Davy, Afro-Caribbean Black doctoral student researcher in Ontario, examined published research in North America to highlight patterns in the positive and negative mental health experiences of Black women who have been exposed to common racial and gender-focused stereotypical narratives. Studies included in this review discussed the experiences of women from various age groups, from first-year college students to women approaching old age (approximately 60 years old). All studies included women that identify as Black members of African descendent populations, such as African American and Afro-Caribbean.

| APRIL 2022

FORUMSPACE The inequitable delivery of vaccines in the COVID-19 pandemic

ARTIST KATELYN MOORE

doi:10.35493/medu.41.12

TUSHAR SOOD 1 & VIKITA MEHTA 2 1 2

Bachelor of Integrated Science, Class of 2023, McMaster University Bachelor of Arts and Science (Honours), Class of 2023, McMaster University

M E D U CATO R

| APRIL 2022

forumspace

INTRODUCTION Vaccines have been shown to be effective at curbing infection rates and significantly lowering the risk of hospitalization and ICU admission.1-3 During the most recent outbreak of the Omicron variant, COVID-19 vaccines, especially after three doses, have continued to offer strong protection in minimizing hospitalization and ICU admission.1-3

The most effective protection is achieved through widespread population vaccine uptake. While there has been strong uptake in many high-income countries —including Canada, where 78.7% of the total population is fully vaccinated with at least two doses— limited supply and access in many low- and middleincome countries (LMICs) has hindered similar populationlevel protection.4 For example, only 10% of people in African countries are fully vaccinated against COVID-19 (received at least two doses) and approximately 1.2 billion people in African countries have not received a single dose.5 Given the importance of an effective global response to the COVID-19 pandemic, this article explores the implications of the key legal, economic, and sociocultural factors, as well as features of the vaccine roll-out that are driving vaccine inequity. Potential options for policymakers to make vaccine access more equitable domestically and internationally are also suggested in this review. FACTORS CONTRIBUTING TO VACCINE INEQUITY There are many factors that contribute to the inequitable access of vaccines at the local, provincial/state, national, and global level, with some being legal and economic in nature. An analysis of vaccine production techniques estimates that mRNA vaccines could be mass produced for as little as $1.18-2.85 USD per dose, yet pharmaceutical companies with exclusive manufacturing rights have been charging at least five times this price.6 In October 2020, India and South Africa proposed the TRIPS Waiver, which aimed to suspend all intellectual property rights obligations related to patents.7 The goal of the TRIPS Waiver was to ensure that countries could start producing their own supplies of COVID-19 vaccines with formulas from existing pharmaceutical companies, without paying a large premium.7 While more than 100 countries are in support of the waiver, the United Kingdom, Norway, Switzerland, and the European Union (EU), which each have high vaccination rates, have persistently opposed.8 Canada remains ambiguous on its position regarding TRIPS.9 By not signing the TRIPS

Waiver, countries contribute to vaccine inequity by impeding the necessary access of vaccine technology and knowledge to LMICs, some of which have the infrastructure to start producing vaccines for their own populations at a lower cost. Vaccine inequity is also driven by sociocultural factors such as racial discrimination. When the Omicron variant was first detected in South Africa, countries including Canada and the United States were quick to implement travel bans against multiple low-income southern African countries without disclosing evidence-based reasons for their decision.10 Only two of the eight African countries banned in the United States had reported an Omicron case before the United States identified its first case on December 1 2021, whereas many other non-African countries had reported Omicron cases but were not included in the travel ban.10 This travel ban has been argued to perpetuate Afrophobia and anti-Black racism; when variants are identified by their country of origin, racist ideologies deeming racialized people as the originators of disease tend to permeate.10,11 These perceptions conceal the true reason behind new variants emerging, which is in part driven by the persistent and rapid spread of the virus. This could be slowed by the global community committing to provide enough vaccines to countries that cannot afford them. Booster programs can also contribute to the disparity in vaccination rates between high- and low-income countries. While evidence shows that a third dose provides additional protection from the Delta and Omicron variants, supplying third doses to countries that already have a high quantity of vaccines diverts necessary vaccines from poorer countries that cannot afford first doses for their citizens.12 World Health Organization (WHO) Director-General Tedros Ghebreyesus supported this argument when he declared, “blanket booster programs are likely to prolong the pandemic by giving the virus more opportunity to spread and mutate.”13 Ultimately, vaccinating the unvaccinated could incrementally save more lives than boosting those who have already received two doses.12 OUTCOMES OF INEQUITABLE DISTRIBUTION The outcomes of vaccine inequity are long-lasting and profound, with the potential to impact countries post-pandemic. The high price per vaccine, coupled with higher delivery and storage costs, has put a large financial strain on fragile health

REVIEWED BY: DR. MICHAEL WILSON Dr. Michael Wilson is the Assistant Director of the McMaster Health Forum, Associate Professor in the Department of Health Evidence & Impact, and a member of the Centre for Health Economics and Policy Analysis. His research focuses on supporting the use of research evidence by policymakers, which includes leading the McMaster Health Forum’s rapid-response program that provides evidence syntheses responding to pressing policy issues within hours, days, or weeks.

EDITED BY: ANYA KYLAS & HANNAH SILVERMAN systems.14 This burden could cause a decrease in access to routine immunizations, resulting in the resurgence of diseases such as measles and polio, as well as spikes in pneumonia infection and diarrhea.14 In addition, reducing transmission of COVID-19 through vaccination reduces viral replication, thereby decreasing the frequency of mutation and emergence of new variants of concern.15 Given this, not supporting global vaccination efforts may result in unchecked viral reproduction in some regions, possibly leading to new variants of concern.

Another important consideration involves determining how to best prioritize the delivery of vaccines to the most vulnerable and high-risk populations. Several guidelines have been published that include a focus on allocating vaccines and ancillary supplies equitably, as well as administering vaccines in ways that optimize timely uptake.22 For example, a document published on December 23 2021 outlines new actionable recommendations for equitable vaccine allocation and uptake.23 These ranged from having donors and multilateral development banks simplify access to funding for LMICs, thereby speeding up the process to linking the quick deployment of vaccines to robust monitoring and feedback.23 A rapid review published on May 22 2021 examines the risk factors for COVID-19 to inform vaccination prioritization.24 Furthermore, an important option to increase vaccine equity is for policymakers to understand vaccine accessibility and prioritization for high-risk vulnerable groups.

References can be found on our website: meducator.org

| APRIL 2022

To achieve WHO targets in global vaccination, it is imperative that all nations work collectively, with shared interests that transcend geographic borders. Countries must work together as a global community to support vulnerable and high-risk populations, protect healthcare systems, and reduce the risk of new variants emerging.

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POSSIBLE OPTIONS FOR STRENGTHENING THE GLOBAL RESPONSE COVID-19 Vaccines Global Access (COVAX) was an initiative launched by the WHO to advance equitable access to vaccines globally.16 Its goal was to make higher-income countries donate money and 2 billion surplus doses to vulnerable people and frontline workers in 92 LMICs by the end of 2021.16 This funding and vaccine supply would support the production and delivery of vaccines to countries that cannot afford them or to those that have not struck bilateral vaccine agreements with pharmaceutical companies. Of the vaccine doses donated by the world’s most advanced economies per million dollars of GDP, Germany and France are the top performers among the G7.17 As of January 17 2022, 20.58 doses per million dollars of GDP from Germany were shipped by COVAX to recipient countries, 4.37 doses per million of GDP were donated to COVAX but have not been shipped yet, and 21.7 additional doses per million of GDP have been announced but not yet donated.17 Canada and Japan are the bottom G7 performers (Figure 1).17 Additionally, as of December 2021, only 40% of the EU’s total doses donated have actually been shipped.18 The delays in shipping ready doses from COVAX stem from recipient countries rejecting doses with implications of short shelf life, the time-consuming bureaucracy involved in accepting deliveries, and a lack of capacity to absorb the doses in overburdened health systems.18 There are a number of options to strengthen the G7 COVID-19 response, for instance, prioritizing robust

FIGURE 1. COVID-19 vaccine doses donated to COVAX, per million dollars of GDP.17

forumspace

The WHO also predicts that vaccine inequity will have a dire effect on the socioeconomic recovery of LMICs.14 While richer countries are projected to vaccinate and economically recover at a fast rate, poorer countries may not achieve preCOVID-19 levels of GDP growth until at least 2024, while being unable to vaccinate frontline workers and vulnerable populations.14 Ultimately, vaccine inequity threatens to reverse significant progress made on the United Nations’ Sustainable Development Goals, a set of global goals which act as a guiding framework to achieve a better and more sustainable future worldwide. This would disproportionately harm our most vulnerable and marginalized populations.

timelines for vaccine distribution to COVAX and increasing accountability in efficient vaccine distribution.19-20 According to a strategy brief by the WHO, additional national and international financing must be mobilized from global and regional multilateral development banks to fund distribution, logistics, and staffing costs; ultimately, this will shorten delays in vaccine shipments for strained health systems.21

doi:10.35493/medu.41.14

Opinion

NANOPARTICLES The efficacy of nanoparticle-based CT imaging techniques in identifying pro-inflammatory macrophages in atherosclerosis MATTHEW AHN 1 & SURAJ BANSAL 1 1

Bachelor of Health Sciences (Honours), Class of 2025, McMaster University

ARTIST KAYLA ZHANG

M E D U CATO R

| APRIL 2022

opinion

ABSTRACT

Atherosclerosis is an inflammatory condition characterized by severe arterial obstruction by the deposits of fatty plaques along the arterial walls. Pro-inflammatory macrophages contribute to the development of atherosclerotic plaques that underlie severe cardiovascular complications like myocardial infarction, making them an attractive diagnostic target. Given their high degree of selectivity, non-invasivity, and bioavailability, nanoparticles like N1177 and AuNP have recently entered the diagnostic landscape of atherosclerosis to improve tissue resolution in conventional imaging modalities like CT scans. Nevertheless, this approach has potential limitations of cytotoxicity and carcinogenic risks. Atherosclerosis accounts for one of the leading causes for morbidities worldwide which indicates an inherent need for equitable, accessible, and proactive diagnostic procedures. The purpose of this literature review is to evaluate macrophage-targeted nanotechnologies for in vivo diagnosis of atherosclerosis and their clinical potential. This literature review was conducted according to the PRISMA-S checklist through Ovid MEDLINE and Google Scholar. INTRODUCTION Atherosclerosis is a hallmark of ischaemic cardiovascular diseases and the leading cause of mortality worldwide, with an international prevalence for increased carotid plaque accumulation of 21.1% or nearly 813.76 million individuals, aged 30 to 79.1 Atherosclerosis is a chronic inflammatory condition caused by the intramural retention of cholesterolrich apolipoprotein B-lipoproteins sequestered in vulnerable sites on the arterial vasculature. Eventually, these lipoproteins aggregate into rupture-prone plaques, leading to cardiovascular complications.2 Pro-inflammatory macrophages are immune effector cells that phagocytize pathogens in their local environment. In atherosclerosis, macrophages initiate a maladaptive, nonresolving inflammatory response to plaque accumulation in the arterial wall.3 Macrophages destabilize the extracellular matrix of arterial walls by ingesting cholesterol-rich lipoproteins, causing necrosis of the arterial wall. They secrete pro-inflammatory mediators and matrix-degrading proteases that specifically weaken the protective fibrous cap of the atheromatous core. Subsequently, tissue factor is released into the atherosclerotic plaques, accelerating intravascular thrombus formation and plaque rupture that underlies acute thrombotic vascular diseases, like myocardial infarction or cardiac failure.4 Accordingly, high densities of macrophages promote higher release of fibrous caps, and therefore correlate to increased susceptibility to ruptured plaques and thrombosis. Pro-

inflammatory macrophages are reliable biomarkers for the prevalence of atherosclerosis, making them attractive targets for diagnostic imaging in clinical practice.5 Therefore, effective noninvasive techniques for the early detection of proinflammatory macrophages are imperative to improving the diagnosis and characterization of atherosclerosis in clinical practice. The use of nanoparticles in diagnostic imaging modalities is an emerging approach to non-invasively visualize macrophages at high-resolution in vivo. In particular, nanoparticle imaging agents can be targeted to specific sites of action given the differential distribution of nanoparticles in organs according to their size. For imaging macrophages, intermediate-sized nanoparticles (10–300 nm) are found to be preferentially distributed in the liver, spleen, and bone marrow, in addition to atherosclerotic plaques where macrophage recruitment occurs.6 Further, nanoparticles are also credited for both increased bioavailability and half-life in circulation, offering an attractive opportunity for diagnostic imaging. Nanoparticles can stimulate, respond, and interact with target cells or tissues through controlled processes to produce the desired physiological responses while minimizing adverse effects.7 In the past, the gold standard for imaging pro-inflammatory macrophages in atherosclerosis has been intravascular ultrasound imaging. However, the procedure’s invasivity, resolution limitations, and demanding time requirements underscore the need for alternative imaging techniques.8 In

parallel, magnetic resonance imaging, which utilizes magnetic fields, and positron emission technology scans, which functionally assess the metabolism of radioactive biomarkers, have emerged as potential candidates for nanoparticle-based imaging due to their higher tissue resolution. However, numerous limitations associated with the negative contrast of superparamagnetic contrast agents, invasiveness, and time constraints limit their clinical translation. Another clinically robust technique is computed tomography (CT) scans, which operate through the combination of multiple X-ray images to produce cross-sectional images of localized tissue. Nevertheless, the use of CT scans in macrophage-based atherosclerosis diagnostics has practical limitations, as the high concentrations of nanoparticles that are required raises concerns of cytotoxicity, radiation exposure, and reduced cellular uptake.9 Thus, the purpose of this review is to assess the literature on the efficacy of nanoparticle-based CT imaging for pro-inflammatory macrophages in atherosclerosis and analyze its potential for clinical applications.

CONCLUSION To conclude, AuNPs and N1177 nanoparticles offer a promising frontier to broaden the diagnostic capabilities of CT imaging for early detection of macrophages involved in atherosclerosis. Nevertheless, further research is required to functionally validate these findings and determine optimal dosing for nanoparticles in clinical diagnostics. Ultimately, the integration of nanoparticles into CT imaging for atherosclerosis offers a revolutionary path in the development of nanomedicine and a leap towards greater health equity in reducing the cost of diagnostic imaging.

Kevin Zhao is a MD/PhD candidate in the Department of Medical Sciences at McMaster University and a former Meducator contributor. His current research looks to investigate age-related changes to macrophage phagocytosis.

| APRIL 2022

REVIEWED BY: KEVIN ZHAO

M E D U CATO R

RESULTS AND DISCUSSION Generally, CT scans are associated with increased spatiotemporal and density resolutions, yet require contrast agents to compensate for density and resolution requirements. Barium sulfate-based contrast agents are conventionally used in CT scans, but are clinically limited by their toxicity, high internal scattering, reduced imaging time, and overall lack of specificity. From a clinical perspective, the CT scans offer increased feasibility for widespread clinical practice because of their cost-effectiveness and efficient turnaround times for imaging results.10 Although an array of nanoparticle-imaging candidates for CT scans have been proposed, only N1177 nanoparticles and PEGylated Gold Nanoparticles have entered experimental trials. In comparison to other nanoparticle-imaging candidates for CT scans, N1177 nanoparticles and PEGylated Gold Nanoparticles have demonstrated minimal cytotoxicity, strong enhancement detected in CT scans for macrophage density, and appropriate organ distribution to advance towards in vivo studies.

PEGylated Gold Nanoparticles

Gold Nanoparticles (AuNP) have been used extensively in nanomedicine given their high stability, low toxicity, high X-ray attenuation coefficients, and extended half-life in circulation. According to Qin et al., fluorescein isothiocyanate-coated dendrimer-entrapped gold nanoparticles were determined to be non-cytotoxic at high concentrations of 300 μM and stable at biological pH, as well as have high hemocompatibility and an increased half-life in circulation on murine models.13 Cumulatively, the use of AuNP produced increased quality of CT values compared to control murine trials, validating the increased resolution of CT imaging with AuNPs. Additionally, the PEGylation of AuNPs was determined to increase the halflife of the AuNPs in circulation, which further supports their integration into diagnostic imaging strategies. Nevertheless, there is a need for in vivo studies to validate the in vitro findings in support of implementing AuNP in CT scanning for proinflammatory macrophages in atherosclerosis.

opinion

METHODOLOGY This literature review was conducted according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses literature search extension statement. An electronic literature search was performed consulting the Ovid MEDLINE and Google Scholar databases. A combination of keywords including (“atherosclerosis” OR “carotid artery disease*” OR “carotid plaque*”) AND (“macrophage*” OR “monocyte*”) AND (“CT scan*” OR “Computer Tomography” OR “diagnos*” OR “detection”) AND (“nanoparticle*” OR “nanomedicine”) was applied. Results were restricted to English articles published from inception to March 2022, strictly exclusive to peerreviewed journals. Articles unrelated to nanosystems detection of macrophages in atherosclerosis were excluded, resulting in 21 relevant sources out of 185. Additionally, a grey literature search was conducted in March 2022 using the search string “macrophage-targeted nanomedicine for early detection of atherosclerosis”. The first 30 results were selected and screened, producing 7 additional citations. From the 28 sources initially identified, 12 were selected for review.

N1177 Nanoparticles

6-Ethoxy-6-oxohexyl-3,5-bis(acetylamino)-2,4,6-triodobenzoate (N1177) nanoparticles are iodinated and experimentally found to be uptaken by macrophages.11 Further, the effects of N1177 nanoparticles on phagocytic capacity and cytokine production were determined to be negligible, while N1177 nanoparticles produced high negative predictive values for eliminating the possibility of acute coronary syndromes, such as atherosclerosis.12 Moreover, the integration of N1177 nanoparticles with multislice CT (MSCT) scans has enabled increased resolution in the identification of fibrous plaques as opposed to lipid-rich plaques in atherosclerosis. However, the clinical translation of N1177MSCT is limited given a higher false-positive rate compared to angiograms and its non-negligible carcinogenic risk, both of which warrant future investigation. Specific to atherosclerosis, N1177-MSCT also has limitations in assessing the severity of coronary lesion for immediate stenosis. In clinical settings, the benefits of N1177 nanoparticles in atherosclerosis diagnosis could further support equitable access to early diagnosis and intervention for susceptible atherosclerosis patients.

EDITED BY: AARON WEN & ANNA MCCRACKEN References can be found on our website: meducator.org

CRITICAL REVIEW Evaluating the effectiveness of NSAIDs and vasopressin receptor antagonists as primary dysmenorrhea treatments

doi:10.35493/medu.41.16

NYLA SYED 1 & THUNUVI WALIWITIYA 2 Bachelor of Health Sciences (Honours), Class of 2025, McMaster University 2 Bachelor of Health Sciences (Honours), Class of 2024, McMaster University 1

ARTISTS ASHLEY LOW & CARYN QIAN

ABSTRACT Primary dysmenorrhea describes the intensely painful uterine contractions experienced during menstruation. It is associated with elevated prostaglandin production in the uterine area and primarily affects adolescents. There are several treatment options available for primary dysmenorrhea, however, there is a lapse in research assessing their efficacy and reliability. The purpose of this review is to provide an overview and evaluation of two forms of treatment for primary dysmenorrhea: non-steroidal antiinflammatory drugs (NSAIDs) and vasopressin receptor antagonists. While studies conducted on the effectiveness of NSAIDs have shown consistent results, research conducted on vasopressin receptor antagonists remains contradictory. As such, the clinical efficacy of vasopressin receptor antagonists remains inconclusive, exposing several limitations and areas that require additional research. Furthermore, this review discusses the efficacy of promising novel treatments (i.e. levonorgestrel-releasing intrauterine devices, intravaginal rings, transdermal patches) and highlights the importance of additional studies for validation.

| DECEMBER 2020

EVALUATING THE EFFECTIVENESS OF NSAIDS Given that PGs are relevant mediators in the intense, painful uterine contractions prevalent in primary dysmenorrhea, PG production is a common therapeutic target.⁸ NSAIDs aim to alleviate painful contractions by reducing PG production through the inhibition of the enzymes COX-I and COX-II. Through the abundance of supportive cost-effectiveness and harm-benefit analyses, ibuprofen, a non-selective COX inhibitor, has become the most widely

Marzouk TM, El-Nemer AM, Baraka HN. The effect of aromatherapy abdominal massage on alleviating menstrual pain in nursing students: A prospective randomized cross-over study. Evid Based ComplementAlternat Med. 2013;2013:742421. Available from: doi:10.1155/ 2013/742421. Zaidi A, Khatoon K, Aslam K. Role of herbal medicine in ussuruttams (dysmenorrhoea). J Acad Indus Res. 2012;1(3):113-7. Available from: http://jairjp. com/AUGUST/2%20ARIF%20 AU G % 2 0 M A N U S C R I PT. p d f [cited 2022 Jan 16]. Strömberg P, Akerlund M, Forsling ML, Granström E, Kindahl H. Vasopressin and prostaglandins in premenstrual pain and primary dysmenorrhea. Acta Obstet Gynecol Scand. 1984;63(6):5338. Available from: doi: 10.3109/000163484 09156715. French L. Dysmenorrhea. Am Fam Physician. 2005;71(2):285-91. Available from: https://pubmed.ncbi.nlm. nih.gov/15686299/ [cited 2022 Jan 16]. Ju H, Jones M, Mishra G. The prevalence and risk factors of dysmenorrhea. Epidemiol Rev. 2014;36:104-13. Available from: doi:10.1093/epirev/ mxt009. Dawood MY. Primary dysmenorrhea: Advances in pathogenesis and management. Obstet Gynecol. 2006;108(2):428-41. Available from: doi:10.1097/01. AOG.0000230214.26638.0c. Oladosu FA, Tu FF, Hellman KM. Nonsteroidal antiinflammatory drug resistance in dysmenorrhea: Epidemiology, causes, and treatment. Am J Obstet Gynecol. 2018;218(4):390-400. Available from: doi:10.1016/j. ajog.2017.08.108. Salmalian H, Saghebi R, Moghadamnia AA, Bijani A, Faramarzi M, Nasiri Amiri F, et al. Comparative effect of thymus vulgaris and ibuprofen on primary dysmenorrhea: A tripleblind clinical study. Caspian J Intern Med. 2014;5(2):82-8. Available from: https://pubmed. ncbi.nlm.nih.gov/24778782/ [cited 2022 Jan 16].

| APRIL 2022

M E D U CATO R

At the start of the menstrual cycle, a decrease in progesterone and estradiol concentrations in the blood upregulates transcription of endometrial collagenases, matrix metalloproteinases (MMPs), and pro-inflammatory cytokines. MMPs target endometrial tissue and subsequently break it down, allowing previously membrane-bound phospholipids to be released and converted to arachidonic acid (AA) by uterine phospholipases. AA is converted into PGs, which then undergo transformations to yield PGF2 and PGF2α. These metabolites are thought to directly stimulate uterine nociceptors to induce pain, as well as indirectly cause cramps by stimulating uterine contraction.7,8

M E D U CATO R

Primary dysmenorrhea is relatively common in adolescents, with prevalence estimates ranging from 67-90% in those aged 17-24. It is also typically more severe within this relative age group, with 41% of dysmenorrheic individuals aged 26 or under experiencing intense, daily activity-limiting pain.4 Alongside age, other risk factors for primary dysmenorrhea include beginning menstruation before the age of 11, experiencing heavy blood flow during cycles, having irregular periods, and never having given birth. In addition, menstruating individuals who are obese or underweight, have low vegetable intake, experience high stress, or have a history of smoking are at greater risk of primary dysmenorrhea.4,5

PATHOPHYSIOLOGY Advances made in the past decades propose that primary dysmenorrhea is characterized by an abnormal increase in vasoactive PGs. The increase in endometrial secretion prostaglandin F2 (PGF2) during menstruation induces abnormal uterine contractions, which subsequently cause uterine hypoxia. Thus, menstrual cramps and associated symptoms of primary dysmenorrhea are directly proportional to the amount of PGF2 released.6

critical review

CONTEXT Primary dysmenorrhea, one of the most common gynecological conditions in the world, adversely affects the quality of life of more than half of menstruating individuals.1,2 It is characterized by severe menstrual pain associated lower abdominal cramps and is often accompanied by nausea, vomiting, sweating, headaches, diarrhea, and tremulousness. It specifically refers to pain that is not caused or aggravated by an underlying pathological or physical condition, and typically persists for 2-3 days after the onset of menstrual flow. This time period is consistent with that of maximal prostaglandin (PG) release into the menstrual fluid via cyclooxygenases (COX), a process that induces uterine contractions. Alongside PGs, the hormone vasopressin is a notable uterine stimulant that induces menstrual pain.3 For this reason, COX inhibitors (commonly known as NSAIDs) and vasopressin receptor antagonists have been used to reduce dysmenorrhea symptoms.

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Csapo AI, Pulkkinen MO, Henzl MR. The effect of naproxensodium on the intrauterine pressure and menstrual pain of dysmenorrheic patients. Prostaglandins. 1977;13(1):193-9. Available from: doi:10.1016/00906980(77)90056-9. Dawood MY, Khan-Dawood FS. Clinical efficacy and differential inhibition of menstrual fluid prostaglandin F2alpha in a randomized, double-blind, crossover treatment with placebo, acetaminophen, and ibuprofen in primary dysmenorrhea. Am J Obstet Gynecol. 2007;196(1):35.e15. Available from: doi:10.1016/j. ajog.2006.06.091. Liedman R, Grant L, Igidbashian S, James I, McLeod A, Skillern L, et al. Intrauterine pressure, ischemia markers, and experienced pain during administration of a vasopressin V1a receptor antagonist in spontaneous and vasopressininduced dysmenorrhea. Acta Obstet Gynecol Scand. 2006;85(2):207-11. Available from: doi:10.1080/0001 6340500495082. Brouard R, Bossmar T, FourniéLloret D, Chassard D, Akerlund M. Effect of SR49059, an orally active V1a vasopressin receptor antagonist, in the prevention of dysmenorrhoea. BJOG. 2000;107(5):614-9. Available from: doi: 10.1111/j.14710528.2000.tb13302.x Valentin L, Sladkevicius P, Kindahl H, Broeders A, Marsal K, Melin P. Effects of a vasopressin antagonist in women with dysmenorrhea. Gynecol Obstet Invest. 2000;50(3):1707. Available from: doi:10.1159/000010319. Dalgaard F, Mulder H, Wojdyla DM, Lopes RD, Held C, Alexander JH, et al. Patients with atrial fibrillation taking nonsteroidal anti-inflammatory drugs and oral anticoagulants in the ARISTOTLE trial. Circulation. 2020;141(1):10-20. Available from: doi:10.1161/ Vazquez SR. Drug-drug interactions in an era of multiple anticoagulants: A focus on clinically relevant drug interactions. Blood. 2018;132(21):2230-9. Available from: doi:10.1182/ blood-2018-06-848747. Dansie EJ, Turk DC. Assessment of patients with chronic pain. Br J Anaesth. 2013;111(1):19-25. Available from: doi:10.1093/ bja/aet124. Campbell MA, McGrath PJ. Use of medication by adolescents for the management of menstrual discomfort. Arch Pediatr Adolesc Med. 1997;151(9):905-13. Available from: doi:10.1001/ Beatty MN, Blumenthal PD. The levonorgestrelreleasing intrauterine system: Safety, efficacy, and patient acceptability. Ther Clin Risk Manag. 2009;5(3):561-74. Available from: doi:10.2147/ tcrm.s5624.

accepted treatment for primary dysmenorrhea.⁴ Ibuprofen induces a significant reduction in PGF2 production when compared to placebo, which reduces self-reported pain duration and severity. It was also found that ibuprofen restores uterine hypercontractility to that of eumenorrheic menstruating individuals (those with normal menstrual cycles).⁹ A study investigating the efficacy of ibuprofen, in which participants ingested the drug on the first day of their menstrual cycle, found a reduction in pain scores when comparing pre- and posttreatment pain (pre-treatment: 5.30±2.23; first cycle: 1.48±1.62; second cycle: 1.68±2.13).⁸ Several other studies corroborated these results, reporting a corresponding reduction in total menstrual fluid PGF2 during treatment (placebo: 36.2±6.1 μg; ibuprofen: 14.8±3.0 μg).10 EVALUATING THE EFFECTIVENESS OF VASOPRESSIN ANTAGONISTS Although the role of PGs in primary dysmenorrhea is well elucidated in the literature, the role of vasopressin is less understood. Several studies have found that elevated levels of circulating vasopressin during menstruation caused dysrhythmic uterine contractions, inducing uterine hypoxia through reduced blood flow. However, few studies have employed vasopressin antagonists as a potential therapy for primary dysmenorrhea, and many findings are either inconclusive or contradictory.11 For example, studies by Liedman et al. and Brouard et al. have shown that the vasopressin/oxytocin receptor antagonists, atosiban and SR49059, may reduce uterine contractions in dysmenorrheic individuals.11,12 In contrast, a study by Valentin et al. showed that intravenous administration of atosiban during the menstrual cycle did not reduce pain or uterine contractions.13 Additionally, Valentin et al. demonstrated that dysmenorrheic individuals had levels of vasopressin comparable to non-dysmenorrheic individuals.11,13 Due to conflicting evidence, vasopressin antagonist therapies are not widely used among the public. PRACTICAL LIMITATIONS Several practical limitations hinder the advancement of therapeutics for primary dysmenorrhea, one of which is the gap in the current literature surrounding the condition’s pathogenesis. The present body of knowledge concerning the relevance of vasopressin in the pathogenesis of primary dysmenorrhea remains controversial, with several studies yielding conflicting and outdated findings. As such, the commercial use of vasopressin antagonists as a method of treatment may prove to be ineffective. Thus, researchers should continue to explore

the pathogenesis of primary dysmenorrhea to uncover novel therapeutic targets and points of intersection for the development of novel treatments. One practical limitation in using NSAIDs is the associated health risks. Although NSAIDs can be taken alongside a variety of prescription drugs, they are contraindicated with birth control medications and anticoagulants.14 Several adverse effects can be seen with the concurrent use of these medications, including an increased risk of bleeding and an increase in blood potassium levels, both of which put the patient at risk for cardiovascular complications.15 Finally, studies currently lack a well-established set of standards to measure pain and discomfort. The amendment of this issue would ensure consistently referenced metrics in literature and increased reliability, therefore opening up the opportunity for better comparisons between treatment methods in terms of pain relief.16 Furthermore, numerous studies overlook the importance of appropriate dosage size and frequency when measuring the efficacy of treatments. Studies have found that up to 25% of adolescents used less than the recommended dosage of NSAIDs and that almost half did not reach the maximum daily frequency, reducing the effectiveness of NSAIDs in treating inflammatory conditions.17 FUTURE DIRECTIONS Most existing and emerging therapies for primary dysmenorrhea, especially those concerning vasopressin antagonists, require further trials before drawing conclusions on their clinical effectiveness. Aside from vasopressin receptor antagonists and NSAIDs, another emerging treatment is levonorgestrel-releasing intrauterine devices (IUDs), which were introduced in Europe as a possible treatment for dysmenorrhea.4 Although available, utilization rates remain quite low in North America due to the Dalkon Shield intrauterine controversy during the 1970s, which continues to negatively influence the opinions of both health care providers and users.18 The IUDs decrease pelvic pain by releasing 20 µg of progesterone into the uterine cavity daily, which reduces the synthesis of endometrial PGs.19 Subsequently, this decreases menstrual blood flow and can be used as an effective contraceptive. This preferential method of pain relief for those wishing to take a contraceptive eliminates the risks associated with usage of NSAIDs and is a more suitable long-term option.20 However, for menstruating individuals not seeking to use a contraceptive, NSAIDs are currently the most effective method of reducing primary

Researchers may also choose to shift towards equally prevalent alternatives to NSAIDs and vasopressin. Recent studies have demonstrated that treatments, such as vaginal rings and transdermal patches, may have similar efficacies to oral contraceptives in the treatment of primary dysmenorrhea.21 Through differing mechanisms, both devices release estrogen and progestin in order to prevent the egg from fully developing each month, thereby preventing the onset of menstruation and the associated dysmenorrhea. Transdermal patches release progestin and estrogen daily into the systemic circulation for one week, after which it can be removed, and a new patch can be added. After the use of three patches, no patch is added for the fourth week to allow for withdrawal bleeding. Vaginal rings are flexible, transparent rings that also release estrogen and progestin into the vaginal epithelium. Patient adherence may be better with these devices because they are applied weekly or monthly, rather than daily like oral contraceptives.22

Overall, primary dysmenorrhea presents a pressing problem to menstruating individuals, and a strong, consistent treatment should be made widely accessible. Although significant progress has been made in the treatment of primary dysmenorrhea, there are still significant barriers and limitations to overcome before the widespread implementation of emerging treatments. Current research suggests that the reduction of PGs and vasopressin in dysmenorrheic individuals should reduce pain. However, further research needs to be conducted in order to determine how to improve COX inhibition through NSAIDs. Specifically, future developments need to avoid the risks associated with consuming a combination of NSAIDs, birth control, and anticoagulants, and further reduce uterine contractions through vasopressin receptor antagonists. Through an improved understanding of the pathogenesis of primary dysmenorrhea, new developments in clinical therapeutics can be made to alleviate symptoms and improve patient quality of life.

REVIEWED BY: DR. NICHOLAS LEYLAND (MD, MHCM, FRCSC)

21.

22.

EDITED BY: AARON WEN & ANNA MCCRACKEN

M E D U CATO R

CONCLUSION Overall, primary dysmenorrhea presents a pressing issue to menstruating individuals, and

20.

Ramazanzadeh F, Tavakolian Fart, Shariat M, Purafzali Firuzabadi SJ, Hagholahi F. Levonorgestrel-releasing IUD versus copper IUD in control of dysmenorrhea, satisfaction and quality of life in women using IUD. Iran J Reprod Med. 2012;10(1):41-6. Available from: https://www.ncbi. n l m . n i h . g ov/ p m c /a r t i c l e s / PMC4163262/ [cited 2022 Jan 16]. Zahradnik HP, Hanjalic-Beck A, Groth K. Nonsteroidal anti-inflammatory drugs and hormonal contraceptives for pain relief from dysmenorrhea: A review. Contraception. 2010;81(3):185-96. Available from: doi:10.1016/j. contraception.2009.09.014. Smith RP, Kaunitz AM. Dysmenorrhea in adult women: Treatment [Internet]. 2021 Dec. Available from: https:// www.uptodate.com/contents/ dysmenorrhea-in-adult-womentreatment [cited 2022 Jan 16]. Merck Manuals Professional Edition. Transdermal and vaginal ring hormonal contraceptives - gynecology and obstetrics [Internet]. 2020 May. Available from: https://www. merckmanuals.com/en-ca/ professional/gynecology-andobstetrics/family-planning/ transdermal-and-vaginal-ringhormonal-contraceptives [cited 2022 Jan 16].

critical review

Dr. Nicholas Leyland is currently Professor and Chair of the Department of Obstetrics and Gynecology at McMaster University. He graduated from the University of Toronto with his medical degree in 1983, and was awarded a Masters of Health Care Management from Harvard University in 2006. Some of his research interests include the risk of venous thromboembolism with regards to oral contraceptives, the diagnosis and management of endometriosis, and the impacts of brain-derived neurotrophic factor (BDNF) on various aspects of gynecology.

19.

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ARTIST JEFF ZHANG

RESEARCH INSIGHT The Effect of Autophagic Gene Inhibition on Exosomal Tau:

A Therapeutic Target for Neurodegeneration

ARTIST JEFF ZHANG

doi:10.35493/medu.41.20

PHILIP YU

Bachelor of Health Sciences (Honours) Class of 2024, McMaster University yup31@mcmaster.ca

ABSTRACT

Philip Yu is an undergraduate student researcher passionate about translational research in various fields. The following is an independent experimental study on genetic control of the cellular processes that regulate protein expression and transport in neurodegeneration. The study was conducted under the supervision of Dr. Derrick Gibbings in the Department of Cellular and Molecular Medicine at the University of Ottawa. Throughout the study, Philip conducted all experiments involved, in addition to collecting and processing the generated data.

INTRODUCTION

The effect of autophagic genes on the amount of tau loaded into exosomes can be determined using siRNAs to knock down the expression of autophagy-related genes ATG7 and p62 in SHSY cells and observing the amount of tau that is loaded into the exosomes of SHSY cells compared to controls. If there is a significant difference in the levels of exosomal tau between the control and treatment groups, it could indicate that tau is loaded into exosomes through an autophagic pathway. Furthermore, this finding may indicate that by inhibiting autophagy in neurons, the spread of tau can be reduced significantly or stopped —a development that may be used to advance research regarding understanding and treating AD. The ATG7 gene was chosen specifically because of its central role in autophagy, with the ATG7 protein acting as an enzyme that activates autophagic processes.7 Thus, if its activity is downregulated, autophagic activity in a cell will be reduced. The p62 gene was selected due to its role in encoding the p62 autophagic marker, which has recently been shown to deliver ubiquitinated proteins,

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Cells use a process called autophagy to maintain homeostasis in the presence of unwanted cellular

RESEARCH DESIGN

The objective of this study is to determine the effect of autophagic gene inhibition on the amount of tau in the exosomes of SH-SY5Y human dopaminergic neurons (SHSY cells). It is hypothesized that when cells are transfected with short interfering RNAs (siRNAs), which inhibit the expression of autophagic genes, the amount of tau found in the exosomes of SHSY cells will decrease significantly. siRNAs are double-stranded nucleic acids with short nucleotide sequences of around 21 base pairs. They are equipped with 3’ overhangs that allow them to bind to mRNAs at specific sequences, promoting degradation of those sites, thus preventing the translation of specific proteins.6

M E D U CATO R

Alzheimer’s disease (AD) is a neurodegenerative disease which results in the disruption of communication between neurons, ultimately resulting in cerebral atrophy.1 Upon observing the pathophysiology of the brains of patients afflicted with AD, one prominent feature is the dense aggregation of a misfolded version of the protein tau —which normally aids in the formation of microtubules —in large accumulations, known as neurofibrillary tangles, resulting in inhibited communication between neurons.2 While tau in its misfolded form can be dangerous, it requires a pathway to be propagated through the extracellular space, away from the cell of origin to aggregate. Currently, one of the increasingly widespread hypotheses regarding the mechanism behind the propagation of tau and other prion-like proteins to the extracellular space is that they are carried as cargo in extracellular vesicles known as exosomes.3

Current treatments for AD are predominantly aimed towards alleviating symptoms by utilizing biological treatments such as cholinesterase inhibitors and behavioral approaches, which do not target the underlying mechanisms of neurodegeneration.5 Thus, exploring the interactions between the autophagic pathway and exosomal export pathway involved in the propagation of misfolded tau is critical in both understanding the etiology of AD and in developing more effective therapeutics that target pathogenesis.

research insight

The misfolding of the protein tau contributes to the development of Alzheimer’s disease (AD). Misfolded tau is thought to propagate through a homeostatic degradation process known as autophagy, resulting in the export of cellular materials to the extracellular space via extracellular vesicles, called exosomes. By inhibiting the ATG7 and p62 genes necessary for autophagy to occur, the effects on the amount of exosomal and intracellular tau can be observed. Following the analysis of western blot and protein assay data, it was determined that the inhibition of the ATG7 and p62 genes results in a 70% and 60% reduction in the concentration of tau found in exosomes, respectively. These results suggest potential therapeutic applications of autophagic gene inhibition for the treatment of AD.

constituents, including misfolded tau. During this process, cytosolic components and proteins are delivered to lysosomes for degradation. Occasionally, these cellular materials may also be loaded into exosomes to be released to the extracellular environment.4

research insight

10.

11.

12.

Schachter A, Davis K. Alzheimer’s disease. Dialogues Clin Neurosci. 2000;2:91– 100. Available from: doi:10.31887/ DCNS.2000.2.2/asschachter. Iqbal K, Liu F, Gong C-X, GrundkeIqbal I. Tau in Alzheimer’s disease and related tauopathies. Curr Alzheimer Res. 2010;7:656–64. Available from: doi:10.2174/156720510793611592. Pluta R, Ułamek-Kozioł M, Januszewski S, Czuczwar SJ. Exosomes as possible spread factor and potential biomarkers in Alzheimer’s disease: Current concepts. Biomark Med. 2018;12:1025–33. https:// doi.org/10.2217/bmm-2018-0034. Baixauli F, Lopéz-Otí n C, Mittelbrunn M. Exosomes and autophagy: Coordinated mechanisms for the maintenance of cellular fitness. Front Immunol. 2014;5. Available from: doi:10.3389/fimmu.2014.00403. Lanctôt KL, Rajaram RD, Herrmann N. Review: Therapy for Alzheimer’s disease: How effective are current treatments? Ther Adv Neurol Disord. 2009;2:163–80. Available from: doi:10.1177/1756285609102724. Carthew RW, Sontheimer EJ. Origins and mechanisms of miRNAs and siRNAs. Cell J. 2009;136:642–55. Available from: doi:10.1016/j.cell.2009.01.035. Yamaguchi M, Satoo K, Suzuki H, Fujioka Y, Ohsumi Y, Inagaki F, et al. ATG7 activates an autophagy-essential ubiquitin-like protein ATG8 through multi-step recognition. J Mol Biol. 2018;430:249–57. Available from: doi:10.1016/j.jmb.2017.12.002. Liu WJ, Ye L, Huang WF, Guo LJ, Xu ZG, Wu HL, et al. p62 links the autophagy pathway and the ubiquitin–proteasome system upon ubiquitinated protein degradation. Cell Mol Biol Lett. 2016;21:29. Available from: doi:10.1186/s11658-016-0031-z. Cunnane EM, Weinbaum JS, O’Brien FJ, Vorp DA. Future perspectives on the role of stem cells and extracellular vesicles in vascular tissue regeneration. Front Cardiovasc Med 2018;5:86. Available from: doi:10.3389/ fcvm.2018.00086. Yang P-C, Mahmood T. Western blot: Technique, theory, and troubleshooting. North Am J Med Sci. 2012;4:429. Available from: doi:10.4103/1947-2714.100998. Xu J, Camfield R, Gorski SM. The interplay between exosomes and autophagy – partners in crime. J Cell Sci. 2018;131. Available from: doi:10.1242/jcs.215210. Fitzwalter BE, Towers CG, Sullivan KD, Andrysik Z, Hoh M, Ludwig M, et al. Autophagy inhibition mediates apoptosis sensitization in cancer therapy by relieving FOXO3a turnover. Dev Cell. 2018;44:555565. Available from: doi:10.1016/j. devcel.2018.02.014.

including tau, for degradation through autophagy.8 Since both ATG7 and p62 are autophagy-related genes, any widespread effect can be attributed to autophagy-related genes as a whole, and any discrepancies can be attributed to the individual genes themselves.

CELL CULTURE

A fully confluent 10 cm plate of SHSY cells raised in Dulbecco’s Modified Eagle Media was split into seven new plates: two control plates, two ATG7 knockout plates, two p62 knockout plates, and one plate for the passage of the cell line. Following incubation, each plate was transfected with its respective siRNA treatment (control, ATG7, and p62 siRNAs). Three days post-transfection, the media in each plate was replaced with culture lacking fetal bovine serum (FBS), after being washed with phosphate buffer saline (PBS) to remove the exosomes found in FBS. The plates were incubated for another day to allow for the release of sufficient amounts of exosomes. The media for each treatment group was collected to procure cell lysates and exosome samples. The supernatant from the collected media underwent serial centrifugation. After the complete removal of the supernatants, the exosome pellets for each sample were resuspended in 50 μL of PBS and stored at four degrees Celsius.

EXOSOME QUANTIFICATION

Using the ZetaView particle tracker machine and software, the particle sizes from the diluted pellets were determined and recorded in Table 1, confirming their identification as exosomes.9

PROTEIN QUANTIFICATION

The micro BCA protein quantification assay is a method used to normalize the amount of protein taken from each sample,

so that any change in the amount of tau and other loading controls can be attributed to the siRNA treatment and not loading error. The cell lysates and exosome samples were serially diluted in cell lysis buffer and pipetted into a 96-well plate and in duplicate to ascertain protein assay results. The plate was placed in the Synergy H1 Hybrid Reader for analysis, where the signal given off by the bovine serum albumin (BSA) solutions of known concentrations were used as standards to compare with solutions of cell lysates and exosomes. This method allowed the concentrations of protein in the cell lysate and exosome solutions to be determined. Using this information, the corresponding amounts of PBS and lysis buffer for each cell lysate and exosome sample for each group was ascertained. A western blot was used to visualize the amount of specific proteins in cells and exosomes. Proteins from the samples were separated by molecular weight through gel electrophoresis and subsequently transferred to a membrane. Antibodies for the protein in question were then bound to the membrane. A substrate was applied to the membrane that activates chemiluminescent markers on the antibodies, which were then imaged with the LG ImageQuant LAS, which captured the emitted chemiluminescent signals. Using the intensity of the signals within a given area, the amount of tau in each sample was quantified.10 The membrane was washed again so that it was stripped of antibodies. It was then cut to test for the presence of the loading controls —TSG101 and flotillin-2 for exosomes, and tubulin and ALIX for cells. It was also tested for the autophagy marker LC3, and the protein SOD1 (implicated in ALS) using the same immunoblotting method.10 Leftover cell lysates were tested for the ATG7 gene to confirm its knockdown.

M E D U CATO R | A P R I L 2022

TABLE 1. ZetaView exosome size, dilution, and particle concentration readings.

TABLE 2. Percent reduction in exosomal tau for p62 and ATG7 gene knockdowns as compared to a control siRNA treatment group and standard deviation in loading controls.

RESULTS AND ANALYSIS

Using Fiji, the relative intensity of chemiluminescence from the blots was quantified. From the processed data in Table 2, it can be noted that the inhibition of ATG7 and p62 caused a significant decrease in the amount of exosomal tau (70% and 60% reductions, respectively).

FIGURE 1. Results for western blot for tau with loading control. The western blot depicts bands of varying intensity representing varying concentrations of tau within the cells and exosomes of the control and knockout groups. Loading control confirms elimination of attribution of results to loading error.

DISCUSSION

The results of this study prompt further research into the relationship between the autophagy pathway and the spread of tau and other prion-like proteins; through the relatively unchanged expression of SOD1 in the exosomes of both the control and treatment groups, it is demonstrated that not all prion-like proteins responsible for other neurodegenerative diseases are spread via an autophagic pathway. Hence, the results of this study may only reflect a unique downregulation in the loading of tau into exosomes, possibly affecting the progression of AD. There are, however, factors other than misfolded tau that contribute to the onset and progression of AD. Although p62 and ATG7 are crucial autophagic genes, the assumption that their effects are representative of all autophagic genes was made. Moreover, only one complete trial was performed. More replicates of the experiment are required to ascertain the trends exhibited. Despite the visible reduction in exosomal tau following the inhibition of ATG7 and p62 in SHSY cells, the inhibition of autophagy can lead to increased levels of apoptosis, which may be damaging in other ways.12 Hence, while therapeutic applications of these results are still distant objectives, the significance of the interplay between autophagic genes and the loading of tau into exosomes lends itself to further research.

CONCLUSION

TABLE 3. Additional western blots for other proteins and loading controls.

ACKNOWLEDGEMENTS

I would like to thank my supervisor, Dr. Derrick Gibbings, for providing me with the training, support, and facilities necessary to conduct this research project.

REVIEWED BY: ATREYEE DE

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Atreyee De is a pre-doctoral student at Dr. Bhagwati Gupta’s lab in McMaster University. She is currently studying the insulin signaling and Wnt signaling pathways of model organisms nematode Caenorhabditis elegans and Caenorhabditis briggsae to understand the role of these pathways in the development, metabolism, and longevity of the worms. She will begin her PhD in fall 2022.

M E D U CATO R

With two other loading controls in Table 3 confirming the results for exosomal tau, the trends exhibited in the exosomes are quite reliable. Contrarily, the loading controls show uneven loading of cellular protein; therefore, no conclusive trend can be drawn from the data for protein expression in SHSY cells. In the exosomes, SOD1 showed no significant difference following Fiji analysis, providing evidence that this phenomenon is not applicable towards all prion-like proteins and that SOD1 may not be loaded into exosomes via the autophagic pathway. LC3 is an autophagic marker that has two forms with different molecular weights; depending on the activity of autophagy, one form can be downregulated while the other is upregulated, but this cannot be discerned with the blot performed as the band for LC3 had not yet separated.11 In future trials, a lower-percentage resolving gel for faster separation of protein bands should be used to allow the two bands of LC3 to be distinguished, permitting the amount of autophagy occurring to be more directly measured. Multiple controls were used to reduce random error, including a control siRNA, blotting for loading controls, and quantifying and standardizing protein concentrations using a protein assay.

The inhibition of the autophagic genes ATG7 and p62 in SHSY cells caused a 70% and 60% reduction in the amount of tau that is loaded into exosomes, respectively. If applied to the development of therapeutic treatments, this procedure can inhibit the spread of misfolded tau and prevent the formation of neurofibrillary tangles —potentially slowing down or even halting the progression of AD.

research insight

Figure 1 demonstrates visible reduction in exosomal tau following the inhibition of ATG7 and p62 in SHSY cells, confirming the hypothesized reduction in the loading of tau into exosomes through autophagic processes.

A western blot was also performed to test for the presence of ATG7 in the leftover cell lysates of the control group and the cells that underwent the ATG7 siRNA treatment, confirming the knockdown of this autophagic gene.

EDITED BY: SEPEHR BAHARESTAN KHOSSHAL & MEERA CHOPRA

I NS TP EO RT V L I I EG WH

DR. JONATHAN NG

WHERE IT ALL BEGAN

MADELINE CHAN 1 & JEFFREY SUN 2 1

Honours Life Sciences, Class of 2024, McMaster University Bachelor of Health Sciences (Honours), Class of 2024, McMaster University

As a celebration of our 20th anniversary, we introduce you to Dr. Jonathan Ng, founder of The Meducator. As a Health Sciences student in 2002, Dr. Ng started The Meducator in hopes of giving undergraduate students the opportunity to be involved in academia. Two decades later, we bring Dr. Ng back to discuss his original visions for The Meducator, how it compares to where we are now, and how we hope The Meducator will continue to grow in the next 20 years. Dr. Ng is currently a family physician who provides primary healthcare to the Ottawa community. Let this interview be an opportunity for us to reconnect with our roots. WHY DID YOU START THE MEDUCATOR? The idea for The Meducator came when I attended a journal club at McMaster, and I was really interested in getting involved in research. I attended the first meeting and nobody had article[s], nobody was actually talking about research, and I sat there feeling really dissatisfied. I wanted more out of the [McMaster] experience, and so I left that group wondering, ‘What could fill that need?’ There was nothing at McMaster that bridged that gap, because as a first-

year coming in, you’re green. You haven’t had experience with research. You’re lacking the knowledge, the expertise, and the contacts. The medical research establishment is out there and, as a first-year, you have no bridge to that. The Meducator came about as a bridge, giving [students] that chance to get into [research] hands-on. A big focus of Health Sciences was [about] understanding where knowledge comes from. Before university, I didn’t have an understanding of how knowledge [gets] generated. How does research happen? How do [facts] come about? My first-year inquiry professor was the late Del Harnish, the Dean at the time, and he instilled that idea of peer review in me. I thought, ‘Hey, why don’t we use that idea for The Meducator?’ It met the students’ needs because they got to get in touch with researchers, [...] write a scientific article, [...] learn, [...] and be curious. They got something to show for it after they finished, and the researcher [could also] share their passion with students and the community. [BHSc] can say, ‘Hey, our students did this, look at this amazing thing.’ WHAT WAS THE PROCESS OF STARTING THE MEDUCATOR LIKE? The McMaster Student Union at the time required clubs to submit a constitution. We needed to decide [on] the rules: there was a Word document with four or five bullet points for the responsibilities of each position. I thought, ‘What would this person need to do at a bare minimum? If they did this, would we end up with a publication?’

We’d need someone editing the articles. For medical research, we’d need someone for health ethics, and then we’d need someone to look after the layout design. We only had one person: Kianosh Keyvani, who [did] the yearbook at her school. [She] single-handedly put [the issues] together. [There] were also my friends, Terry Ng and Kapilan Kugathasan. We [were] excitedly discussing what The Meducator could be like. The Meducator sells itself in health science: it’s a rich experience that is beneficial for everyone. The experience of managing people and creating something [is] a great thing. There were a lot of people excited to be a part of it; [recruiting people] was never really a big issue. The bigger issue was finding writers. [They] come and go.

WHAT DID YOU DO AFTER LEAVING THE MEDUCATOR? After The Meducator, I did medical school at McMaster for three years, and then I went to Queen’s University to do radiation oncology, a research-intensive medical specialty. Three years into the program, there was a job crisis in radiation oncology, where it was unclear whether you’d be able to practice where you wanted, even if you [were qualified]. I had to do a bit of soul-searching. I wanted to practice medicine and [balance] family life. I had always been interested in medical research and the science of the human body. How do you mix that with caring for people? Radiation oncology was a great way to do that, because people were coming [in] with cancer, and you were using radiation to treat or cure them.

HAS STARTING THE MEDUCATOR INFLUENCED YOUR INTERESTS AND PERSONAL DEVELOPMENT? The Meducator taught me how to respond to life’s challenges. When life isn’t the way that you need it to be, you can accept it and be unhappy; or, you can try to forge a new way and [create] the thing that you want. I was so fortunate to meet so many talented and amazing people, [and I learned] to trust that people [who] come together with a shared vision can make amazing things happen. The Meducator teaches you how humbling it is to pull back the curtain [and] realize that knowledge [is not] as certain as you might have thought. When you start looking at things, like 95% confidence intervals and statistics, you realize [that] there’s so much variability to the conclusions. [Knowing] where the data came from gives you more confidence, and also a humbleness about the knowledge that we have. There really are no 100% certainties in family medicine. Every intervention has a range of effectiveness for different people. It teaches you the importance of follow-up, to make sure that you’re not overconfident. You’re aware that weird things can happen, so that you can be flexible. If you’ve ever been engaged in primary research, and you’ve noticed that you got a data point that was not expected, [... ignoring] that [means] you’re probably not doing good research. COULD YOU ELABORATE ON THE IMPORTANCE OF INVOLVING UNDERGRADUATE STUDENTS IN ACADEMIA? The importance of involving students in academia is to give them first-hand experience. It’s one thing to read about [research]; it’s another thing to engage in it. A quote from Del Harnish: “Learning is a contact sport.” The Meducator gives students that opportunity to engage in writing an article. You learn about how [research] is

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[Family medicine] is totally not where I expected, and yet I couldn’t be more happy with how things have turned out. The experience of caring for people never grows old. [It’s about taking] someone in a position of suffering, using

Yes, some. Pulling all-nighters, trying to get stuff done, finishing the editing… it forms a bond. Terry Ng is actually in Ottawa. He’s a medical and college oncologist and researcher. We hang out; we’re still in touch. Terry was the [vice-president]. He started The Meducator with me.

M E D U CATO R

After three years of radiation oncology, I finished my family medicine residency at Queen’s University, and then went into practice in Ottawa. The joy of family medicine is the relationship with your patients. Much like how The Meducator can be a bridge between first-year students and the medical research community, family doctors are a link between patients and the medical practice community. It involves bridging that gap to a specialist where you involve their expertise, whether we’re applying [their] recommendations or explaining some of the complex things that they said.

DO YOU STILL KEEP IN TOUCH WITH YOUR MEDUCATOR COLLEAGUES?

interview spotlight

I had no idea how we were going to fund this. My initial idea was ads, like any other publication. [At] the later end of the year, I met with the Dean and asked him for funding, and he agreed. But for the first part, we attempted to find ads and [sponsors], and our funding pool was very low. I was ready to just print it on [office] paper and hand them out, if that’s what The Meducator needed. When we actually had that first publication in hand, it was something special.

your knowledge and resources to help them make sense of what’s happening, and [giving] them the reassurance that they’re gonna be okay. You’re going to be there for them; even if things don’t go well medically, you’re able to support them. [The ability] to care for people in that way has been the joy of family medicine for me.

conducted, and where information comes from. That gives you a deeper learning experience, and an appreciation for research itself. I don’t think that you can really learn that without getting your hands dirty. The Meducator involves students by putting them into contact with [the researcher] as well. If they form a good connection, then they [get] welcomed into the lab, [and] that may help them dive into that passion. For people to [...] figure out what they like is helpful for individuals to find their own path. BACK IN 2002, WHAT HAD YOU ENVISIONED FOR THE MEDUCATOR TO BECOME? HOW DOES IT COMPARE TO THE MEDUCATOR IN 2022?

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interview spotlight

I envisioned The Meducator to be a way for students to explore a research topic that they were interested in. How that [issue] would look like in physical form mattered less than the experience of having fun.

The heart of that process is still alive and well, and expanded upon by the editors. The process has become much more rigorous, and I think that’s good for students and The Meducator. I am floored by the quality of the Critical Reviews, [...] what kinds of articles are coming out, and imagining what kind of experience the student is getting from the process of writing. I’m happy that you have been able to expand on that and make it a more rich process. I really like that the idea of [...] experiencing things in the medical community is the theme of the various subprojects. I like MeduCollab, [MeduCurrent], the YouTube videos, [and] the interviews. [...] The Meducator is giving a great service to the people who are part of it, because if you’re a first-year student and you go to someone, you’re like, ‘Hey? Can I just talk to you?’ It’s not as easy to access as if you go, ‘Oh, I’m with The Meducator and I’m doing an article.’ It can open doors for you. [It] is such a visceral thing how beautiful The Meducator has become. I want to hug the issues! I haven’t had that feeling of holding The Meducator, and that sense of amazement for a long time. I had not envisioned how well art would integrate into The Meducator, and I really like how that can merge with the writing to create something beautiful and engaging. That’s also what was missing for me from the journal club. Even if I would have been talking to other students, there wouldn’t have been any real authority in the room. After we finish talking, it just evaporates into [thin air]. I didn’t get to share my understanding in a community. There’s no tangible thing that’s there! It wasn’t as rich of an experience as if there was an end product.

WHERE DO YOU THINK THE MEDUCATOR WILL BE IN 2042? I expect to be tasting my articles in 2042! So long as The Meducator has students engaging, [it] may expand and contract in whatever way it needs. So long as that heart is still there, The Meducator is willing to publish on [office] paper if we have to, and it continues to be beneficial, then there will be value and people will continue to [participate]. WHAT IS THE BEST MEMORY YOU HAD BEING ON THE MEDUCATOR? The best memory would be every time we had an issue printed and you’re holding the physical copy. You’re really [appreciating] what everyone did to make this happen. My other favorite memories were all the moments where I got to see people act with passion and excellence. When I created the Meducator constitution and set the roles, there was so much freedom for people to go do something great with this. It was always a joy for me to see what people have done, and to go, ‘Oh, wow! That’s a great idea, that’s fantastic! Oh, that’s gonna be amazing!’ WHAT WAS YOUR FAVORITE PLACE ON CAMPUS? Health Science Library. WHAT DID YOU EAT DURING EXAM SEASON? Whatever was in the Commons at the time, on the meal plan… [like] pasta. I think there was a Teriyaki Experience on campus. There was Subway, Pizza Pizza… you know, all this really healthy stuff. YOUR BHSC EXPERIENCE IN 3 WORDS? Inquiry was awesome. WHAT DO YOU MISS ABOUT BEING A STUDENT? The exciting sense of possibility. The Health Science community felt [like] there were open doors, and that the world lay in front of you. You’re not sure where your life is going to go.

INTERVIEW SPOTLIGHT

MACHINE LEARNING & NOVEL ANTIBIOTICS ERIC ZHANG 1 , NATALIE CHU 2 , & YIMING ZHANG 1 1

Bachelor of Health Sciences (Honours), Class of 2024, McMaster University Bachelor of Arts & Science (Honours), Class of 2025, McMaster University

Dr. Jonathan Stokes is an Assistant Professor in the Department of Biochemistry and Biomedical Sciences at McMaster University. He received his BHSc in 2011 and his PhD in antimicrobial chemical biology in 2016, both from McMaster University. He then completed a postdoctoral fellowship at the Broad Institute of MIT and Harvard. In 2021, Dr. Stokes established his lab back at McMaster University, which, in part, leverages machine learning approaches to discover new antibiotics. The Stokes Lab also seeks to determine the molecular mechanisms underlying antibiotic tolerance and resistance. Furthermore, he is the co-founder of the non-profit Phare Bio, dedicated to navigating earlystage antibiotics through preclinical trials.

The project that I was given as an undergraduate thesis student with Dr. Brown was to look for small molecule

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I was remarkably lucky since I was able to start working in laboratories at McMaster as a high school student. My entry into the lab began, oddly enough, as a gardener for world-renowned hematologist Dr. John Kelton at McMaster. As I was finishing grade 12, I guess he saw it fit to ask whether I wanted to spend

WHAT WERE SOME OF YOUR PAST PROJECTS, AND WHAT ARE YOU CURRENTLY WORKING ON NOW?

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AS A HEALTH SCIENCES GRADUATE, HOW DID YOUR TIME AT MCMASTER INFLUENCE YOUR CAREER AND INTEREST IN THE BIOMEDICAL SCIENCES?

a summer in his academic lab. At the time, I wasn’t sure what to expect, but I ended up loving it and thought that it was the coolest experience. I was drawn to the laboratory environment and the camaraderie that existed within labs. Dr. Kelton was kind enough to also let me study under him through my first three years of undergrad. When fourth year came around, I ventured to explore a different field of study, and that’s when I got into contact —through Dr. Kelton, actually— to Dr. Eric Brown, who is a world expert in bacterial cell physiology and antibiotic discovery. I did my fourth-year thesis with Dr. Brown, and that’s when I realized that I truly loved studying infectious disease, antibiotics, and bacterial cell biology. I was just hooked. It was a pure chance that I happened to stumble into this field, but I was fortunate. Three weeks into my fourth-year thesis project, I realized that I wanted to do this forever, so I asked Dr. Brown if he’d allow me to do my Ph.D. with him, and he kindly agreed. [...] I suppose the question I asked myself, as an undergraduate student thinking about embarking on a Ph.D., was whether I could see myself doing this type of work every day for five years. The answer to that was, unquestionably, yes. That was all the self-convincing I needed before diving in. [...] Being in Health Sci was useful because there was a lot of elective space in the curriculum, so I was able just to fill up all my time with stuff that would enable me to spend more of it in the lab and explore topics that deeply interested me.

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DR. JONATHAN STOKES

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interview spotlight table of contents

inhibitors of bacterial ribosome biogenesis. The ribosome is this big ribunucleoprotein complex that is responsible for translating mRNA into protein. We have a ton of antibiotics that inhibit translation, but we don’t have any molecules that specifically inhibit the assembly process of the ribosome. So, the question was, can we find the molecules? In my undergrad thesis, I performed a chemical screen of roughly 30,000 molecules for those that inhibited the assembly process. Then, I spent the next two-and-ahalf years —well into my Ph.D.— following up on one specific molecule that we were interested in and showing that it was a specific inhibitor of ribosome assembly. Proving that this molecule was inhibiting ribosome assembly and not translation, which is a tightly coupled biological process, took years of work. Indeed, those were tedious and complicated experiments. Then, after that, I felt like investigating a different biological system in bacteria. Through my work studying the ribosome, I got interested in the question, “How do you get antibiotics physically make their way past the bacterial cell envelope and inside bacteria?” This is called the permeability problem. Investigating the molecular features of antibiotic permeability made the second half of my Ph.D. After this, I wanted to expand my research into systems biology and machine learning-type work, so I went to Dr. Jim Collins’ lab at MIT, where I spent about 4 years before luckily being recruited back to McMaster. Indeed, it was at MIT where I started to get really interested in the application of artificial intelligence in new antibiotic discovery, which is what we’re studying a lot in my lab now. We’re trying to leverage the utility of machine learning to more rapidly get us to novel structural classes of antibiotics that we then have the ability to validate in the wet lab. [...] Antibiotic drug discovery is inherently a multiproperty optimization problem. For example, it’s really easy to find molecules that kill bacteria in a petri dish. However, it’s really hard to make an antibiotic that can be used in the clinic. That’s because anything that’s generally cell-toxic will kill bacteria, but it will also kill human cells, which is not ideal for a human medicine. So, when we’re looking to use machine learning algorithms to predict new antibiotic molecules, or design new antibiotic molecules, these models need to be trained on a bunch of different molecular properties in order to satisfy all the molecular requirements that define a good human drug. These models are only as good as the data that we generate to train them on, so we take a lot of care to gather our own wet lab data to build the most robust models in the world. GIVEN THAT YOUR RESEARCH CONCERNS DISCOVERING NEW ANTIBIOTICS, CAN YOU DESCRIBE TO US THE PROCESS OF CREATING A NEW ANTIBIOTIC FOR PUBLIC USE? To develop an antibiotic in this space, soup-to-nuts, is about $1.5 billion. That’s what it costs to develop any

human medicine. However, for antibiotics, there’s a fundamental economic problem in that there are very few financial incentives to develop antibiotics. That’s because it’s challenging to make a good return on your investment, relative to something like an anticoagulant that a lot of people are going to take daily for many years. However, to try to overcome some of the economic hurdles associated with antibiotic drug development, my previous professor, Jim Collins, and I co-founded this non-profit called Phare Bio. We built this non-profit entity to absorb a lot of the risk associated with expensive late preclinical antibiotic development. Our goal [at Phare Bio] is to take potentially useful antibiotic candidates from the academic laboratory and provide a viable economic path to get them through the preclinical drug-discovery process. By doing this, it will decrease the financial barriers to entering Phase I clinical trials. HOW DO YOU BELIEVE THE FUTURE OF ANTIBIOTIC DEVELOPMENT AND RESEARCH WILL CHANGE BASED ON THE EMERGING INTERDISCIPLINARY NATURE OF THE FIELD? In antibiotic discovery, I think that the widespread application of computational approaches will enhance the ability of my field to make significant progress. At least I hope so; I’m kind of betting my career on it. I think biology in general is becoming a data-driven science. You’re always hearing about “big data” in biology-centric fields of investigation. For example, we are gathering genomics datasets at unprecedented rates that we are still trying to understand how to optimally analyze. Our ability to make sense of the vast quantities of data we generate will be important to make impactful discoveries. The challenge of having truly interdisciplinary work is that you have these teams of people, computer scientists, biologists, chemists, physicists, who don’t speak the same scientific language. I mean, you talk to a computer scientist and they might not know the details of what a gene is, then they try to talk to me as a biochemist [primarily], and I don’t understand the intricacies of graph neural networks. So, there’s a language barrier, and overcoming that is not trivial. There’s a lot of hard work on everyone’s part that goes into making a truly interdisciplinary team that works collaboratively. But I think that will slowly happen naturally as the edges of all these scientific disciplines become blurred. ARE THERE ANY MISCONCEPTIONS ABOUT ANTIBIOTICS THAT YOU WOULD LIKE TO ADDRESS? Don’t take them if you have a viral infection. They’re useful if you have a bacterial infection, but if you have another type of infection, like the common cold, you aren’t going to feel any better.

STAFF

VIDEO TEAM Managing Video Editor David Klitovchenko

EDITORS-IN-CHIEF Michal Moshkovich & Sophie Zarb EDITORIAL BOARD Managing Editors Jeffery Sun & Yiming Zhang

GRAPHICS & DESIGN Creative Directors Andy Zhu & Madeline Chan Graphic Designers Arim Yoo Aseel Abonowara Ashley Low Caryn Qian Jeff Zhang Katelyn Moore

Akash Mehta David Jin Leena Ghani

Kayla Zhang Manreet Dhaliwal Natalie Chu Ryan Tso Samantha Cheng

MEDUPROMO Director Carolyn Wang Medupromoters Mike Cho Richard Cheng Shib Bal

MEDUCURRENT Directors Aisling Zeng & Catherine Hu

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M E D U CATO R

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Bachelor of Health Sciences (Honours) Program

contributors

Editors Aaron Wen Hargun Kaur Aisling Zeng Matthew Ahn Alexander Xiang Matthew Lynn Allison Fang Meera Chopra Anna McCracken Nick Teller Anya Kylas Rida Tauqir Dalraj Dhillon Sepehr Baharestan Eric Zhang Shanzey Ali Gurleen Bhogal Suraj Bansal Hannah Silverman Taaha Hassan

Video Sub-Team Leads Erin Lin Ken Yu Diane Kim

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Issue 41

Articles inside

JONATHAN NG

ALZHEIMER’S DISEASE

PRIMARY DYSMENORRHEA

MEDBULLETINS

INTRODUCTION

FORUMSPACE

MEDUSTORY

IWCH ABSTRACTS

MEDPULSE

PATHOPROFILE

OPINION