Issue 5

McMMER McMaster's Medical Research and Health Ethics Student Journal

ATKINS' DIET Fad or future obesity treatment?

Kindling

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Is this m e c h a n i sm the key to the origins of epilepsy?

AIDS Stigma W h y the fear of AIDS persists Issue 5 | February 2005 www.meducator.org

February 2005 | Issue 5

MEMMER Inside Scoop Presidential Address Jennifer Clara Tang Med Bulletin Jonathan Liu Brent Mollon Med Update Jennifer Clara Tang Med Quiz

3 Atkins' Diet

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Page 8 6 20 .0

Research Article The ABCs of Atkins Based Carbohydrate-Reduction as a Treatment for Obesity Brent Mollon Providing HOPE in the Campaign Against Cardiovascular Morbidity and Mortality S a m m y H. Ali

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Cardiovascular Morbidity and Mortality Page 1 2

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The Persistence of the AIDS Stigma 15 in North America Jeannette So

AIDS Stigma Page 15

"Kindling": Origin of Epilepsy? 18 Ronald Zahoruk

Commentary Atkins' Diet Commentary Stuart M. Phillips, Ph.D

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Epilepsy Page 18

References References

Origin of

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The McMaster Meducator m a y be contacted via our e-mail address: meduadmin@leamlink.mcmaster.ca The McMaster Meducator adopts an educational approach to our publication. Despite our or our mailing address: efforts to ensure correctness, w e recognize that the publication may be subject to errors and B.H.Sc. (Honours) Programme omissions. In light of these potential errors and new developments in the medical field, we Attention: The McMaster Meducator invite you to partake in feedback and constructive discussion of the content herein for the Michael G. DeGroote Centre for Learning and purpose of furtheringyourunderstandingofthetopic-in the nameof education and discovery.

Discovery R o o m 3 3 0 8 An online discussion forum for each article is available on our website: www.meducator.org.

Faculty of Health Sciences Students and professors alike are welcome. Please enjoy the Meducator online experience!

1 2 0 0 Main Street West Disclaimer: The views represented in the articles do not Hamilton, Ontario L8N 3 Z 5 necessarily reflect those of the McMaster Meducator and http://www.meducator.org should not be substitued for medical advice.

About The McMaster Meducator

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Issue 5 | 2 0 0 5 February Dear Reader, T h e workings of the human heart are the profoundest mystery of the universe" (Charles W. Chestnutt). Scientists, poets, musicians and artists...each have their own unique way of expressing their thoughts about the human heart.

Read about McMaster researchers' efforts to help keep hearts healthy in S a m m y All's article detailing the HOPE study. A healthy diet is another part of maintaining a strong heart. Brent Mollon's article on Atkins' Diet is a must-read for those trying to keep a N e w Year's diet resolution. Wondering whether diets work at all? Consider the opinion of Dr. Stuart Phillips (McMaster's Department of Kinesiology) in his commentary. Join Jeannette So as she explores the persistence of the AIDS stigma. Finally, Ron Zahoruk navigates the origins of epilepsy in the "kindling" phenomenon. Test your understanding of the articles through the new Med Quiz concept developed by Jonathan Liu. Visit our online forum through our website (www.meducator.org) to share ideas with other readers, and continue the McMaster Meducator experience.

Our sincere thanks go to the post-graduate editors; they m a d e time to provide our student writers with feedback in spite of their busy research schedules. Special recognition is extended to the writers for their high quality of work. To Dr. Del Harnish and the Bachelor of Health Sciences Program: thank you for nurturing student learning outside the classroom by making this publication possible through your financial support. This year I have been blessed with an exceptionally talented staff. I remember at our first meeting, everyone w a s asked to n a m e a comic superhero they aspired to be. Over this term, you have all proven yourselves to be superheroes through your individual gifts that shine through in this publication. M y heart-felt gratitude goes to Jaron Chong, Vice-President, for his resourcefulness and attention to detail, S a m m y Ali and Jeannette So, VP's Medical Research and Health Ethics, for skillfully edited articles of high quality, Brent Mollon and Jonathan Liu, Jr. Editors, for creatively composed weekly MedBulletins, Anthony Collini, VP Layout and Distribution, for being the architect of a truly inspired layout, Katherine Saccucci, Director of Graphics and Imaging, for her eye-catching cover and aesthetically pleasing graphics, S h a m a Sud, VP Administration, for her wellorganized minutes, A m a n d e e p Rai, VP of Public Relations, for his innovative advertising strategies, and Edwin Ho, VP of W e b Design, for an up-to-date web page. Finally, to the founder of the McMaster Meducator, Jonathan M. Ng, thank you for your vision and innovation which has provided so many of your fellow students with an opportunity to explore their interests in medical research and health ethics.

On behalf of all the staff and writers, I would like to extend our warmest wishes to you, our readers. W e hope that the McMaster Meducator will serve as a catalyst for your personal journey in learning.

Sincerely Yours, ||JUl~w

Jennifer C. Tang www.meducator.org

President & Chief Editor Jennifer Clara Tang Vice President/Deputy Chief Editor Jaron Chong Vice President of Medical Research & Health Ethics S a m m y H. Ali Vice President of Medical Research & Health Ethics Jeannette So Junior Editor Jonathan Liu Junior Editor Brent Mollon Vice President of Layout, Production & Distribution Anthony Collini Director of Graphics and Imaging Katherine Saccucci Vice President of Administration S h a m a Sud Vice President of Public Relations A m a n d e e p Rai Vice President of Website Production & Design Edwin C.W. Ho Post-Graduate Editing Dr. Larry W. Belbeck, D.V.M. Dr. Jack Diamond, Ph.D Dr. Margaret Fahnestock, Ph.D Dr. John Lavis, M D , Ph.D Dr. Stuart Phillips, Ph.D Meducator Founder Jonathan M. N g Meducator Header Design Jay Higgerty Meducator Logo Design Shawn McGrath Meducator Website Design Karen Ho Staff Portrait Adrienne Li *

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February 2 0 0 5 | Issue 5

r

The True Beauty Behind Music

Graphic by Katherine Saccucci

R e m e m b e r the last song you listened to that w a s so good it gave you the "chills"? Or the Christmas carol that gives you nostalgic memories of hiding from your parents to try and take a peek at your gifts? Musician or non-musician, either way, music has many effects on our lives.

Over the past fifty years, scientists have been researching the relationship between music and brain activity. Preliminary studies revealed that no musical centre exists in the cerebrum. Maurice Ravel, a French composer, suffered from cerebral degeneration but priorto his death, he

I

could still remember his compositions and the sound of particular scales.

Musical interpretation requires years of training because of all the different cerebral areas it draws information from. Scientists initially hypothesized that specific frequencies picked up by hair cells in our ears were relayed, by the auditory nerve, to fixed areas in the cerebrum. A study at the University of California in the late 1980s revealed that specific arrangements of tones - known as a melody - belong to fixed areas of the brain, however, specific tones or frequencies themselves do not.

On the other hand, one's ability to feel emotions while listening to music has proven to be irrelevant to our interpretation. A patient with bilateral d a m a g e in the temporal cortex w a s unable to distinguish the difference between musical pieces but still felt emotions. Emotions are often measured by physiological changes such as heart rate, blood pressure, and respiration.

Immune System in a Bottle

the body target highly conserved viral regions.

The technology relies on honeycomb shaped cell-incubators, known as scaffolds, which can serve as a medium on which to grow live cells. O n e of the benefits of the scaffolds is they allow scientists to Graphic by Katherine Saccucci grow three-dimensional colonies, S c i e n t i s t s recently announced with all cells being exposed to the a novel way to cultivate cells, s a m e conditions. Such an approach in hopes that this new method is more like what occurs inside the can one day be used to grow an im- h u m a n body w h e n compared to the m u n e system in a bottle. This in-vitro traditional two-dimensional method grown i m m u n e system could m a k e of cell cultivation. it possible to produce flu vaccines Chemically, the scaffolds are faster and more easily. As well, this composed of inverted colloidal new technology can aid in the devel- crystals, which are also known as opment of vaccines targeting viruses photonic crystals. These crystals, with a high rate of mutation by helping which form lattices ranging from

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Jonathan Liu

|

Music education and consistent practice have shown significant effects on an individual. In the 1990s, the University of California discovered neuron re-arrangement in response to repeated or "important" sounds. Just recently, AntoineShahin, Larry Roberts and Laurel Train from McMaster University found that children, typically under the age of five, experience more auditory brain activity while playing the piano or violin. Studies around the world have confirmed the benefits of music which include hyper development in frequently stimulated structures of the brain and higher neuroplasticity.

Next time you flip on that radio in your car, remember that you're not only trying to keep awake in the traffic jam, you're also enhancing the capabilities of your brain!

[Weinberger, N.M. (2004). Music and the brain.

Retrieved November 11, 2004 from http:// www.sciam.com/article.cfm7chanl D=sa 006 &collD=l&articlelD=0007D716-71Al-1179AF8683414B7F0000]

Brent Mollon

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nanometers to micrometers, offer an environment that is flexible enough to help control the life cycle and differentiation of cells. To form the growth medium, a sol gel is poured into the photonic crystals and left to dry. Once hardened, heat is used to burn away the crystals, leaving only the three-dimensional mold used for cell growth.

[Kotov, N.A., Liu, Y., Wang, S., Cumming, C , Eghtedari, M., Vargas, G., Motamedi, M., Nichols, J., Cortiella, J. (2004). Inverted colloidal crystals as three-dimensional cell scaffolds. Langmuir, 2004, 20, 7887-7892]

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Issue 5 | 2 0 0 5 February

r

Sweet News for Those With a Sweet Tooth

Graphic by Katherine Saccucci

For those with a flu or cold this season, here is a n e w idea.

Drop those drowsy cough suppressants and have s o m e chocolate as a joint study in England has suggested.

Uncontrollable coughing is a c o m m o n symptom of colds, allergic reactions or chronic obstructive pulmonary disease. In the past, narcotic agents - such as codeine - have been used in managing severe cases of uncontrollable coughing. The side effects of narcotics, however, limit its frequency of use. O n e of the biggest issues emerging from a recent International Cough Symposium involved finding a better way to m a n a g e coughing.

Recent research has revealed that theobromine, a compound found

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in cocoa, is effective in suppressing coughs by inhibiting a sympathetic nerve - the vagus nerve. Sympathetic nerves are involved in the body's responsetostimulus, thus by inhibiting the stimulus or "depolarization" in this nerve, coughing can be stopped.

The study involved comparing the cough-supressing effects between theobromine and codeine. The results showed a reduction in coughing as a result of both drugs; the effects (ex. suppressing duration) of the two drugs were also similar, although higher concentrations of theobromine had to be applied. With theobromine present, scientists found reduced stimulation with citric acid and capsaicin-induced coughing.

Although the resultsare promising, researchers believe more studies are still necessary. For the test trials, only w o m e n were asked to participate since previous studies have proven that they show greater reactivity to capsaicin induced coughing. In addition, high concentrations of theobromine yielded inhibitory effects on particular sensory nerves. This minor side effect, however, would still

First American 'Cloned-to-Order' Pet

Clone. Using cat ovaries purchased from spay clinics across the USA, Genetic Savings and Clone combined the D N A from the deceased Nicky with the eggs extracted from the purchased ovaries to produce the cloned pet.

To date, scientists have managed Graphic by Katherine Saccucci to clone mice, rabbits, goats, pigs, and Texas w o m a n recently became horses. Genetic Savings and Clone hopes to be the first organization to clone a dog by May of this year. the first person in the United The news of Nicky's cloning has States to purchase a 'clonedonce again sparked an ethical debate to-order' pet. This individual, w h o overcloningtechnology. As mentioned recently suffered the loss of her 17 year old cat Nicky, paid $ 5 0 0 0 0 U S in the press-release, cloning is to have the dead animal cloned. The currently viewed as an 'inexact' cloning procedure was completed by science. It often takes many tries to Sausalito-based Genetic Savings and ' TIIKr.MTKOSTATKSOr ,

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www.meducator.org

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Jonathan Liu

m a k e theobromine more practical and accessible than codeine; in fact, small amounts of theobromine are available in supermarkets!

With the continuation of research on theobromine, those with a sweet tooth will at least have something to look forward to next time they fall ill!

[Usmani, OS., Belvisi, M.G., Patel. H.J., Crispino, N., Birrell, M.A., Korbonits, M., Korbonits, D., Barners. P.J. (2004). Theobromine inhibits sensory nerve activation and cough. Retrieved November 18, 2 0 0 4 from http://www.fasebj. org/cgi/reprint/04-1990fjevl]

Brent Mollon obtain a successful clone, with failures resulting in gruesome developmental defects. Moreover, while the cloned animals may look the same, the clone will have a different personality due to different life experiences. This fact might disappoint potential investors w h o desire an exact duplicate of their deceased animal. However, Nicky's story illustrates that there is still a market for cloned animals, regardless of the ethical concerns of cloning.

[Elias, P. (2004). California company sells cloned cat. generating new ethics debate. Retrieved January 3, 2 0 0 5 from http://www.canada.com/ search/story.html?id=c446c9al-65b9-4bbl8923-lb7b35f8f71c]

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February 2 0 0 5 | Issue 5 M e d Update by Jennifer Clara Tang

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Institute for Molecular Medicine and Health Opens

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n Friday October 22, 2004, the Institute for Molecular Medicine and Health (IMMH) opened in the Michael G. DeGroote Centre for Learning and Discovery ("New advanced facilities...," 2004). The 6 3 0 0 0 sq foot I M M H is h o m e to several research facilities including: the Centre for Gene Therapeutics, Centre for Functional Genomics, and the Dr. John Mayberry Histology Laboratory. The I M M H also houses Canada's first university laboratory certified to provide gene vectors for use in patient clinical trials: the Robert E. Fitzhenry Vector Laboratory. Vectors are special D N A segments used to transport foreign genes into organisms.

Vectors have the potential to be used as therapy for diseases such as cancer, HIV/AIDS, asthma, and Michael G DeGroote Centre for Learning and Discovery gastrointestinal diseases. Not only will the opening of cutting edge research facilities in the I M M H help to recruit top researchers to McMaster and increase the cost-effectiveness of research, they will also help to speed new therapies discovered in laboratories into reality for patients w h o require them.

McMaster Named Canadian Research University of the Year

M

cMaster University w a s named Canadian Research University of the Year (under the Medical/Doctoral category) (Research Info Source, 2004). McMaster scored 9 4 points out of 100. Rankings were based on two equally weighted main categories: i) input measures: total sponsored research income, faculty research intensity, and graduate student research intensity and ii) output measures: publication intensity in leading journals. Research intensity w a s defined as "total research income per full time faculty position or graduate student". Publication intensity w a s defined as "the total number of publications (articles, reviews, notes, etc.) per full time faculty in 5 0 0 0 leading international journals covering different fields of natural science, life/health science and social science."

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Powered by people.

Fueled by knowledge.

Driven by creativity.

McMaster innovation knows no bounds. Simply put, McMaster research is

out of this world. www.mcmaster.ca/research/

RESEARCH UNIVERSITY OF THE YEAR

www.meducator.org

Issue 5 | 2 0 0 5 February

l_Reviparin: H o p e for Heart Attack Patients One of the major barriers faced by developing countries is the high Blocked blood supply cost of drugs used to prevent further complications in heart attack patients. A study led by Drs. Salim Yusuf and Shamir Mehta of the Population Health Research Institute at McMaster University presented a Occluded possible solution to this problem. The randomized control trial found that coronary the use of Reviparin, an inexpensive anti-blood clotting drug, reduced rates artery of death, reoccurrence of heart attack or stroke by 1 3 % in patients with acute myocardial infarction (heart attack) w h e n used in conjunction with reperfusion strategies and oral antiplatelet therapy (Brookes, 2004). This trial had a large sample size of 1 5 5 7 0 patients from China, India and Pakistan, 7 7 8 0 w h o were randomized to reviparin and 7 7 9 0 w h o were randomized to placebo. Reviparin is a low molecular weight heparin which enhances Damaged the effects of antithrombin (University of Illinois, n.d.). Antithrombin inhibits heart muscle factors in the coagulation cascade, thus preventing clotting. O n e safety concern the study encountered while testing Reviparin was a statistically signifi- A Myocardial infarct (Heart Attack) cant increased risk of life-threatening bleeds (0.9% of Reviparin patients experienced this compared to 0.4% of placebo patients, p < 0.001). However, one must consider that the benefits of Reviparin appear to outweigh the risks; for every 1 0 0 0 patients treated with Reviparin, 15- 2 0 patients are prevented from dying or suffering another heart attack. Only 2 per 1 0 0 0 treated are expected to experience these major bleeds (Brookes, 2004). Considering that 7 5 % of the world's acute myocardial infarction cases occur in low and middle income countries (Brookes, 2004), Reviparin m a y prove to be a cost effective solution for developing nations.

^Collaborations for Health Initiative cMaster University rang in the N e w Year with the announcement of the "Collaborations for Health" initiative headed by Susan Denburg, Associate Dean Academic of the Faculty of Health Sciences.

The goal of this initiative is to "support the McMaster community in linking excellence in health related research and education to external health needs" ("New McMaster initiative...", 2005). The n e w initiative exists to foster interdisciplinary communication and collaboration in order to address complex problems in health. Involvement of several faculties (Institute of Environment and Health, Faculty of Health Sciences, and Faculty of Social Sciences) in the West Nile Virus study commissioned by the provincial government is an example of the type of interfaculty collaboration promoted by this initiative. The completed Phase I of the "Collaborations for Health" involved a task force responsible for identifying health-related activity on c a m p u s in areas such as humanities, social and behavioural sciences and business. Phase II of this initiative begins at the end of January with a call Susan Denburg, Associate Dean for faculty submissions for ideas with regards to health related research and Academic. Faculty of Health Sciences educational collaborations. It is extremely heartening to see that the spirit of collaboration taught to McMaster students in Inquiry courses is also used by their professors to advance

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M c M a s t e r research. Seethe report on Phase I: http://www.mcmaster.ca/vpacademic/IHWG_report.pdf

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February 2005 | Issue 5

The ABCs of Atkins Based Carbohydrate-Reduction as a Treatment

^ cost of obesity in 1997 was estimated to be $1.8 billion (Birmingham, Muller, Palepu, Spinelli, & Anis, 1999).

As mentioned in a W H O report (2003b), this epidemic "reflects the profound changes in society and in behavioural patterns of communities over recent decades." While the W H O admits that genetics do play some role in predicting future risk for obesity, it stresses that one must seek to balance caloric intake with physical activity to maintain an Brent Mollon energy balance (2003a). If one consumes more energy than needed for daily activities and exercise, this excess In the early 1990s, the World Health Organization (WHO) will be stored as fat in adipose tissue. To maintain the officially recognized obesity as a worldwide epidemic. equilibrium between consumption and expenditure Despite the rigorous implementation of prevention proof calories, the American Heart Association (AHA) grams after this global awareness of obesity, the prevarecommends that individuals limit the intake of foods lence of this metabolic disease is still increasing (WHO, high in saturated fats (AHA, 2004). Instead, individuals 2003ab). It is currently estimated that 1 billion adults are overweight, with some 300 million being clinically obese should emphasize eating fruits and vegetables (at least (as determined by their Body Mass Index, or BMI). Indi- 5 servings a day), as well as grains (at least 6 servings a viduals are considered overweight if their BMI exceeds 25 day). As well, one should attempt to eat fat-free or low fat kg/m2, and obese if their BMI is higher then 30 kg/m2 dairy products and lean meats. The AHA claims that such (WHO, 2003ab). The increasing global prevalence of obe- a diet can best reduce the major risk factors for heart sity is also leading to additional health problems (see Fig- attacks: high blood cholesterol, high blood pressure, and ure 1 for the Canadian progression of obesity), as obesity excess body weight (AHA, 2004). is associated with type 2 diabetes mellitus, heart disease, THE BASIS THE NOVEL ATKINSpulmonary APPROACHdysfuncstroke, liverOF disease, sleep apnea, tion, musculoskeletal disease, female infertility, and canAcer different formForce of on dietary recommendation has been (National Task the Prevention and Treatment of Obesity, 2000). The above associations do not come sweeping across North America known as the Atkins' without cost to Canada's health care system, as the direct diet. First published in 1972 - Dr. Atkins' Diet Revolu-

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Issue 5 | 2 0 0 5 February tion - the diet has undergone several revisions in 1992, 1999, and most recently in 2 0 0 1 as the Dr. Atkins' N e w Diet Revolution. In 2003, the most recent evolution of this diet w a s published - Atkins' for Life. While the A H A diet recommends a reduction of fats, the Atkins' diet allows individuals to eat all the fat and protein they want providing they initially reduce carbohydrate intake to 2 0 g each day (www.atkins.com). The Atkins' website maintains that this approach is not to be seen as a diet, rather a lifetime nutritional philosophy that stresses the consumption of nutrient dense foods while limiting the intake of refined/ processed carbohydrates such as breads, pastas, sugars, cereals and starchy vegetables. While the low-carbohydrate approach to weight loss has been around since the 1970s, it is estimated that s o m e 2 0 million individuals worldwide are currently following the Atkins' philosophy (www.atkins.com).

It is maintained that the Atkins' diet facilitates weight loss because it induces a state of ketosis in the body (www. atkins.com). A ketogenic diet stimulates the metabolism of a fasting body, and has sometimes been used as a treatment for children suffering from seizures that are not responding to medical interventions (Freemen et al., 1994). W h e n the amount of glucose available in the body is limited (by a diet in this case), fats from adipose tissue will be burned to satisfy energy requirements (Freemen et al., 1994). However, fats are not burned down completely.

Rather, remnants of fat molecules remain in the blood in the form of ketone bodies. These ketone bodies are known to have an appetite suppressing effect, which is why low-carbohydrate diets are known to work without making the dieter hungry (Freemen et al., 1994).

(Triplett, 2005)

This 2 0 0 2 abstract was one of the first pieces of literature reporting the superiority of a ketogenic diet over a low-fat, low-calorie diet. Although the American Heart Association was never mentioned directly in the article, Kappagoda and colleagues c o m m e n t that "because the study w a s funded by the Atkins' Centerfor Complementary Medicine, it swiftly became labelled as a trial of the Atkins' diet versus the A H A diet," (2004, pp 725). Additional research on this topic reported that dieters on a low-carbohydrate diet lost more weight, had lower triglyceride levels, and had higher high density lipoproteins (HDL) levels (all statistically significant) after 6 months when compared to a low-fat diet (Yancy, Jr., Olsen, Guyton, Bakst, & Westman, 2004). The authors concluded that those w h o followed a 2 4 week low-carbohydrate diet lost more weight and body fat when compared to those w h o followed a low-fat diet.

Studies then began to emerge that evaluated the COMPARING ATKINS' AND AHA'S DIETARY outcomes of this diet over a longer period of time. O n e randomized control trial (RCT) published in the New RECOMMENDATIONS England Journal of Medicine compared the Atkins' diet to a conventional low-fat diet (Foster et al., 2003). Although It is understandable that there is much confusion amongst individuals w h o are looking to change their diet to lose they found that the Atkins' diet did result in statistically weight. After all, dieters are faced with two conflicting significantly more weight loss within a 6 month period, dietary philosophies: one stressing a low-carbohydrate, these differences were not significant after a year. This high-fat diet approach and the other recommending a result was also observed in another RCT, which followed low-fat diet with plenty of carbohydrates in the form of patients for a duration of one year (Stern et al., 2004). fruits and grains (See Table 1 for the nutritional compo- While Stern et al. detected no statistical difference in nents of leading diets, including Atkins' and AHA). Setting weight loss between individuals on a low-carbohydrate aside all the marketing campaigns urging us to one side diet and those on a low-fat diet, they did report a more or the other, one must ask if there is any scientific proof favourable change in triglyceride level, HDLs and glycemic that one diet is superior with respect to health gains and control (all significant) for those individuals on the lowcarbohydrate diets when compared to the low-fat variety. weight loss.

As mentioned in Kappagoda et al., this conflict in Based on these results, the authors concluded that dietary recommendations can be traced back to a 2 0 0 2 restriction of carbohydrates in obese individuals m a y lead abstract published by W e s t m a n and colleagues (2004). to favourable metabolic changes, but it is still unknown if

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February 2 0 0 5 | Issue 5 Table 1: Comparison of Macronutrients in Two LC-HP Diets With the ADA Exchange Diet the AHA Dietary Guidelines, and IOM Recommendations (Kappagoda et al, 2004) Atkins' Diet (5) Protein Power (6) ADA Exchange (7) NECP III (4) AHA Guidelines (3) IOM/NAS (17) 1,600 1,600 1,600 1,600 1,600 1,600 220 (55%+) Carbohydrate (g) 33 (8%) 240 (60%) 220 (55%) 220 (50%+) 22 (5%) 28-72 (12%-18%) Protein (g) 149 (35%) 82 (20%) 60(15%) 90 (22%) 146 (35%) 53 (30%) 53 (<30%) Fat (g) 104 (59%) 97 (53%) 35 (20%) 40 (27%) Calories (kcal)

Saturated Fat (g) Cholesterol (mg) Dietary Fiber (g)

47 (26%)

33(19%)

11 (6%)

<7

18 (>10%)

minimize

924 4

657 11

112 22

<200

<300

minimize

20-30

>25

25 for women, 39 for men

Note only the midpoint of the ranges are quoted for IOM/NAS and NCEP III. ADA = American Diabetes Association; AHA = American Heart Association; IOM/NAS = Institute of Medicine/National Academy of Science; LC-HP = carbohydrate-high protein; NCEP = National Cholesterol Education Program.

R E S O R T I N G T O TRIED A N D T R U E

an Atkins-like diet will help prevent cardiovascular disease M E T H O D S O F WEIGHT LOSS or diabetes (Stern et al., 2004). To date, the above studies are the only RCTs following the metabolic effects of a low- The introduction of low-carbohydrates on the dieting s carbohydrate diet for at least one year. helps illustrate an important lesson: patients should be Recent reviews are also questioning the long-term wary of novel treatments when deciding on a course of benefits of low-carbohydrate diets. One paper identifies action to overcome a disease. In this case, dieters are the rather high drop-out rates due to non-compliance in exposed to a new nutritional philosophy that contradicts studies utilizing Atkins-like diets (Lara-Castro & Garvey, the low-fat, high fibre diets doctors have been traditionally 2004). This would m a k e it difficult to generalize the results recommending. It is surprising that, despite any proof of of the study to the general population and illustrate that long-term weight-loss results or understanding of health a large proportion of people may have difficulty following consequences, the Atkins' diet has 2 0 million worldwide such diets. The authors also point out that the few studies followers (www.atkins.com). Not as surprising is the numconducted thus far do not indicate that an Atkins-like diet ber of new food products introduced to capitalize on the is more effective in achieving weight loss when compared new craze. It w a s estimated that in the past two years, to a low-fat, high-fibre diet. Lastly, the long-term safety of 1558 new low-carbohydrate products have been introan Atkins-like diet has also been questioned (Lara-Castro duced to grocery stores (Kadlec, 2004). A m o n g these et al., 2004), a theme c o m m o n amongst other reviews. products are low-carbohydrate breads, soft drinks, pasta, Kappagoda et al. comment that a low-carbohydrate diet and alcoholic beverages. It is expected that these food does not fulfill all the nutritional requirements for healthy products, as well as books and guides preaching the lowindividuals with regards to vitamin and mineral intake, as carb lifestyle, will gross $ 3 0 billion in revenue this past well as dietary fibre (2002). If this is true, dieters would year(Kadlac, 2004). be forced to take vitamin and mineral supplements to In the end, no individual should be discouraged from receive nutrients they should be receiving through food changing his/her lifestyle in order to achieve and maintain consumption. In order to better understand potential a healthy body weight. After all, it was recommended that health risks, s o m e experts believe that more research all overweight or obese individuals attempt to lose weight needs to be conducted to determine if the benefits of an in order to decrease their risk of mortality from obesity Atkins-like diet outweigh the risk (Harper & Astrup, 2004). related diseases such as coronary heart disease, stroke They c o m m e n t that in order to fully understand the risks, and type 2 diabetes (Expert Panel on the Identification, research should not focus solely on cardiovascular risk Evaluation, and Treatment of Overweight and Obesity in factors, but also on bone health, renal function and cancer Adults, 1998). However, such an endeavour should not be risk - both in healthy and obese individuals. Until the undertaken without medical advice from a physician. It is risks are fully understood, Harper and Astrup c o m m e n t through such patient/physician interaction that patients that it would be "irresponsible" for a medical professional can be adequately advised on h o w to m a k e dietary and to recommend the Atkins' diet to their patients (2004). lifestyle changes that will benefit their health and wellbeing later in life. CQ

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Issue 5 | 2005 February

Atkins' Diet Commentary

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Stuart M. Phillips, Ph.D. Associate Professor, Department of Kinesiology - Exercise Metabolism Research Laboratory and Associate Member, Medicine (Graduate Faculty) - Medical Sciences, Cell Biology and Metabolism

The burden of lifestyle-related chronic disease is high; it is estimated to cost $6.3 billion in health care spending and lost productivity, and cause as many as 25,000 deaths annually in Canada due to cardiovascular disease, cancer and diabetes alone. In its October 2 0 0 2 World Health Report, the W H O also estimates that healthy life expectancy can be increased by over six years in countries such as Canada by addressing six health risk factors: 1. Blood cholesterol 2. Blood pressure 3. Overweight 4. Low fruit and vegetable intake 5. Smoking 6. Physical inactivity W e know from several large population-based studies that reductions in body weight are often associated with reductions in blood cholesterol, most notably LDL as well as triglycerides and so dieting for weight loss s e e m s like a reasonable goal. Mollon presents a nice overview of two contrasting dietary approaches to losing weight in the Atkins' and A H A diets. So what to chose? O n e approach is to look at head-to-head comparisons of the two approaches, of which Mollon notes there are relatively few. A meta-analysis of randomized controlled trials of diet-induced weight loss and their safety and efficacy, including not only weight loss but sub-clinical markers of cardiovascular disease risk, did conclude that, "There is insufficient evidence to m a k e recommendations for or against the use of low carbohydrate diets...

A m o n g the published studies, participant weight loss while using low-carbohydrate diets w a s principally associated with decreased caloric intake and increased diet duration but not [italics added] with reduced carbohydrate content," (Bravataetal., 2003).

However, the true question is whether diets work at all?

W e all know that dieting can result in weight loss, at least in the short-term, but what about long-term losses? Is weight loss maintained? Is recommending a diet worthwhile?

Studies of the long-term efficacy of diets are remarkably sparse; however, those that are published show a rather paltry rate of success. A meta-analysis of the long-term effectiveness of lifestyle interventional approaches in persons with type 2 diabetes in induction and subsequent

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maintenance of weight loss found that the pooled weight loss for any lifestyle-based intervention, in comparison with usual care, w a s 1.7 kg or 3.1% of baseline body weight (Norris et al., 2004). Follow-up times ranged greatly in the study from 1 to 5 years, but the overall message is rather disappointing. In fact, at the recent 8th annual Nutrition Workshop run by Dr. David Armstrong of McMaster's Gastroenterology Unit, Dr. Ayra Sharma, a Professor in Medicine and a Canada Research Chair for Cardiovascular Obesity Research & Management, gave a thought-provoking presentation entitled "Why diets don't work." His distilled message was that obese patients, like the rest of us, can easily lose weight while dieting and in fact the majority of them do so numerous times throughout their life, but it doesn't last. Interestingly, Dr. Sharma presented what he called a very typical case report in which a 5 0 year old obese w o m a n weighing 4 5 0 lbs had lost the equivalent of her body weight while on numerous weight loss diets during her lifetime. Similar experiences have to eventually force clinicians to truly evaluate whether diet-only approaches to 'treating' obesity are valuable, or even ethical - Dr. Sharma's o wn words. Given m y views on physical activity I feel obliged to mention that while data w a s only available from 5 3 patients, that in the s a m e meta-analysis those who received a more intense physical activity intervention lost 3.9 kg, or 3.6% of baseline body weight, more than those w h o received a less intense or no physical activity intervention.

What appears obvious from available data is that no one approach alone, in particular reduced energy diets like Atkins' or the myriad other schemes, is effective in the treatment of obesity. In all likelihood, a multifaceted approach involving lifestyle changes including physical activity, behavioural counseling, diet modification, and pharmacological support for appetite, mood, and other conditions, m a y be successful. To date, however, no trial of any one therapy, particularly reduced energy diets, has been long enough to provide data to provide an evidencebased recommendation for this approach as a treatment.

Ultimately, the realization that prevention of weight gain is m u c h more effective rather than treatment after the fact must prevail (Avenell et al., 2004). M y conclusion is based on analyses of preventable deaths and comorbidities associated with all chronic disease including obesity (7/10 of the top ten killers of Canadians are chronic diseases and are amenable to prevention) (DesMeules et al., 2004). These analyses show that prevention would cost substantially less and yield greater dividends from a health standpoint than end-stage treatment. Viewed from this perspective, the amount of resources and energy, not to mention attention, being invested in the treatment of obesity and it related complications, rather than prevention, indicates a mismatched set of priorities. No doubt, obesity is a serious health problem and one that requires substantial attention, and soon. The answer will, I predict, not be found in the Atkins' diet! ESI -

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February 2 0 0 5 | Issue 5

Providing H O P E in the Campaign Against Cardiovascular Morbidity and Mortality

S a m m y H. Ali Hope describes precisely what Dr. Salim Yusuf, McMaster researcher, cardiologist and chair of the Heart Outcomes Prevention Evaluation (HOPE) study has uncovered for populations at high risk for cardiovascular death.

Dr. Salim Yusuf, McMaster researcher, cardiologist and chair of the Heart Outcomes Prevention Evaluation (HOPE) study

THE HOPE STUDY Studies demonstrate that Angiotensin Converting Enzyme Inhibitors (ACE-lnhibitors) reduce morbidity and mortality in patients with low ejection fraction with and without heart failure (Yusuf et al., 1992). However, the impact of ACE-lnhibitors on preventing heart failure in patients without pre-existing heart failure, low ejection fraction, or hypertension remains unexplored. The primary purpose of the H O P E study w a s to evaluate the usefulness of Ramipril, an ACE-lnhibitor, in the reduction of cardiovascular events in high risk patients without pre-existing heart failure or low ejection fraction.

The outcomes evaluated by this multi-center randomized controlled trial are a composite of myocardial infarction (heart attack), stroke and cardiovascular death. The H O P E study w a s conducted over six years and included 9 2 9 7 high risk patients (55 years of age or (http://www.med-ars.it/galleries/heartl.htm)

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older) with evidence of vascular disease or diabetes, from nineteen countries across North America, South America and Europe. This study has the distinction of being one of the largest clinical trials to address cardiovascular disease prevention for high risk patients, such as diabetics.

The H O P E study demonstrates the effectiveness of ACE-lnhibitor regimens in the prevention of cardiovascular events in high risk patients. A total of 6 5 1 patients randomized to treatment with Ramipril (14%) reached a primary outcome in comparison with 8 6 2 in the placebo group (17.8%). Furthermore, treatment with Ramipril reduced the rates of cardiovascular death, myocardial infarction, stroke, cardiac arrest, heart failure and complications related to diabetes (HOPE Investigators, 2000b). The benefit of Ramipril was at least as great as that observed with other proven secondary prevention measures, such as beta-blockers (Yusuf et al., 1985), aspirin (Antiplatelet Trialists' Collaboration, 1994) and lipid-lowering agents (Law, 1998).

ANGIOTENSIN CONVERTING ENZYME ( A C E ) INHIBITORS ACE-lnhibitors are a class of drugs originally developed to lower the blood pressure of hypertensive patients. Their function is to interfere with one of the body's blood pressure and blood volume regulatory pathways, the renin-angiotensin system. The key to understanding the activity of ACE-lnhibitors is to understand the physiology underlying the renin-angiotensin system.

Renin-Angiotensin System The renin-angiotensin system is a series of reactions designed to regulate blood pressure and extracellular volume. It consists of the following steps: 1) When blood pressure drops, the kidneys release the enzyme renin into the bloodstream 2) Renin splits angiotensinogen, a large protein that circulates in the blood stream, into pieces. O n e piece is angiotensin I. 3) Angiotensin I, which is relatively inactive, is split into pieces by angiotensin-converting enzyme (ACE). O n e piece is angiotensin II, which is very active.

4) Angiotensin II, a hormone, causes the muscular walls of small arteries to constrict, increasing blood pressure. Angiotensin II also triggers the release of the horm o n e aldosterone from the adrenal glands which are located above the kidneys. www.meducator.org

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February 2 0 0 5 | Issue 5 and 3 5 7 7 of the participants were diabetic. After investigating separately the data from those patients with diabetes, investigators found that Ramipril significantly lowered the risk of major cardiovascular outcomes by 2 5 - 3 0 % in a range of high-risk middle-aged and elderly people with diabetes mellitus (HOPE Investigators, 2000a).

Blood A more effective approach to preventing these pressure rises complications would be to prevent the development of diabetes. Many recent trials suggest that lifestyle changes lead to a reduced risk of diabetes (Pan et al., 1997); however the long-term adherence to these regimens remains questionable.

The H O P E investigators subsequently analyzed the effects of Ramipril on the incidence of new cases of diabetes in their study population. They found that treatment with Ramipril decreased the risk of developing diabetes by 3 3 % (Yusuf et al., 2001b). While these findings Angiotensmogen are promising, they require further confirmation. They will Blood be studied in the upcoming D R E A M (Diabetes REduction pressure Assessment with ramipril and rosiglitizone Medication) falls Figure 1: The Renin-Angiotensin System (www.merck.com) study.

5) Aldosterone causes the kidneys to retain salt (sodium) and excrete potassium. The sodium increases plasma oncotic pressure. This causes water to be retained, thus increasing blood volume and consequentially blood pressure.

ACE-lnhibitors interfere with the cleavage of the relatively COST EFFECTIVENESS OF HOPE inactive angiotensin I into the active hormone angiotensin II by ACE. In the absence of angiotensin II, the renin-angioA treatment regimen should be cost effective, in additio tensin pathway is unable to mediate any corresponding to improving clinical outcomes. In the United States and increases in blood pressure or alterations to the vascuCanada, the use of Ramipril based on the approach of lature. the H O P E trial is a realistic strategy. It not only improves clinical outcomes, such as cardiovascular death, myocarCONUNDRUM OF THE STUDY dial infarction, and stroke, but also greater than 9 0 % of the cases fall into a cost-saving or cost-neutral situation The beneficial treatment effect observed in the HOPE (Lamyetal., 2003). study was much greater than could be accounted for by the small reduction in blood pressure induced by Ramipril CLINICAL IMPLICATIONS OF THE HOPE STUDY (3/2 m m Hg). The investigators hypothesized that antagonizing alternative actions of the renin-angiotensin system The results of the HOPE study have made available yet may account for the treatment effect. They have focused upon antagonizing the direct effects of angiotensin II on another powerful tool in the battle against cardiovascuvasoconstriction, rupture of plaques and thickening of lar events in high risk patients. Subsequent to the trial, blood vessels, all of which contribute to cardiovascular the use of Ramipril in a clinical setting experienced a substantial increase. Yusuf has attributed this increase to its morbidity (Lonn et al., 1994). ease of use, proven cost effectiveness and the very clear effect in reducing myocardial infarction, stroke and death, ADDITIONAL HOPE FOR DIABETICS in addition to heart failure and diabetes (Taubes, 2002).

In regards to the larger goal of eradicating the threat Individuals with diabetes mellitus are at high risk of carof cardiovascular disease, Yusuf believes that "we now diovascular disease. Epidemiological studies have shown have the knowledge to do it, but w e have to implement it. that the risk of cardiovascular mortality is two to three By that I m e a n getting the smokers to stop smoking-right times greater in m e n with diabetes (Stalmer et al., 1993) there you can reduce the risk of future heart attack by 40and three to five times greater in w o m e n with diabetes 5 0 % . Getting people to lose weight. If they lose four to five (Manson et al., 1991) than in persons without diabetes. kilograms, that can have a big effect...Targeting obesity Although the H O P E study was not restricted to patients will be a big issue for the future but we're not there yet" with diabetes, it was an inclusion risk factor for the trial (Taubes, 2002). M

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The Persistence of the AIDS Stigma in North America and tuberculosis (Lloyd, 1988). Even substantiation of Louis Pasteur's Germ Theory, which posited the role of microscopic pathogens in causing disease, did not halt the .*V--j persistence of prejudice (Davison et al., 2002; Valdiserri, 2002).

Scientists discovered that the disease originated from a virus that migrated from chimpanzees and mutated into Jeannette So the h u m a n immunodeficiency virus-1 (HIV-1) to infect humans. However, the emergence of AIDS was not entirely The Acquired Immunodeficiency Syndrome (AIDS) a virological event - h u m a n behaviour, namely changes pandemic is one of the biggest contemporary to sexual mores and intravenous drug use, enhanced global health concerns. Although the majority of pathogenicity (Washer, 2004). Since such underlying cases are in Africa, the prevalence of AIDS grows steadily factors were perceived to be controllable, PLHA were within the populations of Canada and the United States. blamed and held personally responsible for the disease.

As such, AIDS is not simply a disease, but an illness in Prejudice was especially focused due to the association of which social and psychological contexts greatly influence the disease with marginalized social groups, in particular the experience of those afflicted. AIDS is essentially a gay m e n and intravenous drug users. disease with triple stigma: it is a terminal disease, it Duringthe initial years of the epidemic when little was is associated with other stigmatized groups, and it is known about the cause and transmission of the disease, most commonly sexually transmitted, which implies the fear of AIDS virtually bordered on hysteria (Conrad & responsibility on the part of the individual. A stigma is Kern, 1990). After more than two decades since the onset an undesirable characteristic that, according to others of the epidemic, there remains much to learn about both who do not have it (the majority), reduces the status of the biological mechanisms and the social impact of AIDS. individuals wh o possess it and marks them as deviant The uncertainty that surrounds AIDS is closely related to (Brown et al., 2003). This allows the majority to define fear and the overestimation of the risk of casual contact and reaffirm their identity by discrediting and demeaning in the transmission of the disease (Herek et al., 2002). those who have AIDS. This process of "othering" is the AIDS stigma is one way of coping with fear, and allows most c o m m o n form of discrimination experienced by for the externalization of evil and badness (Aaronovitch, People Living with HIV or AIDS (PLHA); however, AIDS 2003). Misconceptions about casual social contact are stigma includes all types of prejudice and stigma related pervasive. Exaggerated and irrational fears manifests in to HIV and AIDS (Brown et al., 2003). It is these three a phenomenon called magical contagion, where people aspects, the fear or uncertainty, the other associated believe that contact with objects touched by a person with stigmas, and the tendency to hold individuals responsible AIDS will result in HIV contagion (Herek et al., 2002). for their disease, which account for the persistence of AIDS stigma in North American society.

IS AIDS UNIQUE? Nonetheless, this fear of AIDS did not derive solely from the infectious and deadly nature of the disease. The of Severe Acute Respiratory Syndrome (SARS) The stigma of certain diseases and the discrimination outbreak and exclusion of people w h o had those diseases were not new in 2 0 0 3 caused widespread panic. People wore masks, phenomena and did not pertain exclusively to AIDS. In the used hand sanitizer compulsively, shunned Asian stores early 19th century, hospitals in Canada and the United and communities, and quarantined individuals suspected States used moral worthiness as the criteria to determine of infection. To s o m e extent, however, the fear of S A R S the admission of patients. They denied medical treatment was justified. The novelty of S A R S meant that there was to patients with venereal diseases, w h o m they deemed no cure, and alarmed even the experts in the field. S A R S immoral and undeserving (Lloyd, 1988). Individuals with was also fairly communicable, and infected many in a cholera were ostracized and condemned as "intemperate, short period of time. Yet, unlike AIDS, the fear of S A R S lazy, and vice ridden" (Valdiserri, 2002). Hospitals also was temporary and dissipated shortly after the last patient refused admittance to contagious, chronically ill, and recovered. Perhaps this was due to the development of a incurable patients, which included those with smallpox vaccines, but s o m e believed that the previous experience HISTORICAL PERSPECTIVE

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February 2 0 0 5 | Issue 5 from AIDS w a s only reason for the exaggerated fear because it allowed the public to conceptualize S A R S on the s a m e scale. Along with the uncertainty and fear, other associated stigmas rendered AIDS not simply a disease that attacked physiological systems, but an illness that involved social and psychological phenomena, and contributed to the continuation of the othering of PLHA (Conrad, 1990).

Global estimates of HIV/AIDS epidemic as of end 2004

North America 1 000 000

Caribbean 440 000 Latin America 1 700 000

AIDS AND ASSOCIATED STIGMAS

Eastern Europe & Central Asia 1 400 000

Western Europe 610 000 North Africa & Middle East 540 000

Sub-Saharan Africa 25 400 000

East Asia & Pacific 1 100 000 South & South-East Asia 7 100 000 Australia & N e w Zealand 35 000

Total: 39.4 Million Although the first cases of AIDS appeared in North America in 1981, there wa s little coverage in the press Figure 1: Global estimates of HIV/AIDS epidemic as of until 1 9 8 3 because the majority of those inflicted were end 2004 (www. una ids. org) m e n w h o had sex with other m e n and drug users, which therefore did not concern average citizens (Washer, 2004).

Association with these marginalized groups provoked disposition) or external influences (i.e. the situation). intense, value-laden reactions in response to PLHA Unfortunately, people often commit the fundamental (Valdiserri, 2002). Allen (2002) argued that the use of attribution error, which is the tendency for observers to the plague metaphor "contributed to the normalization of underestimate situational influences and overestimate an ideological dichotomy between alien, less than h u m a n dispositional influences, in their evaluation of others 'others'...and everyone else...during the initial stages of (Myers & Spencer, 2004). As a result, individuals are held the moral panic..." In fact, the early designation of the more personally responsible for outcomes in situations disease w a s Gay Related I m m u n e Deficiency Syndrome where they are perceived to have control. If the outcome (GRID) (Conrad, 1990). Healthy individuals used othering is negative, the person receives more blame, but less to establish exclusion barriers in attempt to protect the sympathy, pity, and offers of help (Cobb & de Charbert, social order (Ungar, 1998). The general population (i.e. 2002). With HIV and AIDS, those infected or have the those w h o were not PLHA) successfully extricated from disease attract increased anger and decreased empathy the negative connotations of the disease and shifted because the public consider their illness a product of the blame of AIDS onto the "other people." They sought personal decisions. reassurance from the irrational notion that the differences between the "others" and the "us" sufficiently rendered FEAR AND UNCERTAINTY OF AIDS AIDS as "nothing more than a hypothetical threat" (Washer, 2004).

The fear of AIDS breeds prejudice. One man is reported to Even when AIDS spread to groups that had no attached have advised other PLHA over the radio against revealing stigma, the hostility resisted correction (Smithurst, 1990). their seropositive status: "...say absolutely nothing. It will The Canadian government initially refused to allocate ruin your career, and your family life, and it will destroy any money from the federal budget for education and yourfriendships" (Smithurst, 1990). The public considers prevention of AIDS because they were afraid to be seen the high level of consumption of healthcare resources by as condoning homosexuality and extramarital sexual PLHA an economic burden that the rest of society do not activity (Edginton, 1989). Since such behaviours are want and should not have to tolerate. This implies that regarded as "moral weaknesses" on the part of the PLHA, PLHA cannot be productive individuals and the services the government did not act to curb the AIDS stigma. and resources they require would be better spent on healthy m e m b e r s of society (Silvers, 2001).

ATTRIBUTION OF AIDS In 1991, public opinion overwhelmingly favoured coercive policies that d e m a n d e d quarantine of PLHA, mandatory Attribution theory describes how people perceive others'testing of individuals in high-risk groups, and disclosure behaviour and situation, which determines their reactions of disease status (Herek et al., 2002). Such punitive and attitudes toward those individuals (Myers & Spencer, policies disguise the violation of h u m a n rights of PLHA 2004). The behaviour and condition of others can either under pretences of protecting the health of the public be attributed to internal influences (i.e. motives and (Herek etal., 2002).

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C O N S E Q U E N C E S O F AIDS STIGMA While overt and violent displays are rare, subliminal forms of discrimination can spread and reinforce AIDS stigma. People w h o do not experience AIDS stigma and othering often have no interest in advocating for those who do because they are afraid that the stigma would extend to include them and they would lose their identity with the "us" group. PLHA themselves m a y internalize such negative attitudes that have profound impact on self-perceptions and self-efficacy (Myers & Spencer, 2004). PLHA begin to attribute personal blame for their disease and see themselves as inferior. This self-fulfilling prophecy, in which they conform to the misconceptions and stereotypes created by the mainstream of society w h o are not HIV-positive or have AIDS, can lead to increased risky behaviour like multiple sexual encounters and alcohol/ drug use in order to seek self-validation (Valdiserri, 2002).

AIDS stigma can also affect people indirectly associated with HIV and AIDS. Family, friends, and even healthcare workers of PLHA often experience secondary stigma where they are subjected to the s a m e kind of prejudice and exclusion as those w h o have the disease (Brown et al., 2003). It is not surprisingthat AIDS stigma is currently evident even a m o n g health care professionals.

Despite superior medical expertise and experience, health care professionals are not wholly i m m u n e to the apprehension and stereotypical beliefs when treating patients with AIDS. S o m e healthcare workers, including physicians and dentists, refuse to care for and treat PLHA (Brown et al., 2003). Hospital workers in San Francisco who were ordered to attend to a patient with AIDS wore masks, gowns, and goggles for "protection" (Conrad & Kern, 1990). S o m e physicians w h o are willing to treat PLHA still m a k e assumptions regarding sexual orientation based on patients' Al D S d isease status. The effects of Al D S stigma generate s h a m e and embarrassment for patients, who would be more averse to disclosing information that potentially valuable in deducing an accurate diagnosis.

Scientific knowledge and mastery of clinical skills do not provide sufficiently effective preparation. Lack of respect toward patients with AIDS exposes the negative attitudes, fears, and anxieties that arise from ignorance. Neither specialty nor previous experience influence whether or not healthcare professionals discriminate against patients with AIDS, or the extent to which othering occurs. As a result, patients often receive less empathy from reluctant caregivers.

In addition totreatingthe physical ailments, physicians, nurses, and other healthcare workers must administer

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to the emotional and psychological distress of patients w h o receive a diagnosis for HIV or AIDS. The attitudes and beliefs regarding PLHA determine the ability and effectiveness in which the needs of the patients are met.

If the actions of physicians and nurses reinforce the AIDS stigma, discrimination and othering of PLHA will persist while the quality and accessibility to adequate health care for these patients will deteriorate.

CONCLUSION With increased visibility and prevalence of HIV and AIDS in populations w h o are neither homosexual nor intravenous drug users, one m a y have expected the abolishment of AIDS stigma. However, this is not the case.

The ambiguity of the disease and lack of a cure maintains an environment of fear and ignorance, which allows discrimination to thrive. Despite increased tolerance, and even the legalization of same-sex marriages in Canada, the stigmas of homosexuality and intravenous drug are still associated with AIDS and bring negative connotations to the disease. Responsibility of AIDS is therefore attributed to the afflicted individuals, and they are denied sympathy and pity for their suffering. These prejudices, fears, and misconceptions contribute to the persistence of stigma, and must be overcome before comprehensive and effective m a n a g e m e n t of AIDS can be attained. EB

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February 2 0 0 5 | Issue 5

'Kindling": Origin of Epilepsy?

T h e Truth A b o u t Epilepsy

• 181 000 new cases of epilepsy are diagnosed each year • Incidence is highest under the age of 2 and over 6 5 • 4 5 0 0 0 children under the age of 15 develop epilepsy each year • Prevalence of active epilepsy (history of the disorder plus a seizure or use of antiepileptic medicine within the past five years) is estimated as approximately 3 million in the United States • Prevalence tends to increase with age Ronald Zahoruk • Trend shows decreased incidence in children, but A s i d e from the triggers that m a y potentially induce an increased incidence in the elderly 5 0 percent of people epileptic seizure, very little is actually understood with new cases of epilepsy will have generalized onset seizures about the origin of the disorder. As a matter of fact, (Epilepsy Foundation, n.d.) for 7 0 % of all seizure cases, there is no discernable cause

even with the most sophisticated equipment (Wikipedia, n.d.). In addition, approximately 2 0 - 3 0 % of those w h o suffer from epilepsy are resistant to drug treatment (Epilepsy Foundation, n.d.). Yet, there is hope in the form of the many dedicated researchers across the globe w h o are attempting to decipher, through extensive empirical inquiry, the possible mechanisms of causation.

Here at McMaster, Dr. Gautam Ullal is currently researching the kindling phenomenon along with Dr. Ron Racine and Dr. Margaret Fahnestock. Dr. Ullal has spent over a decade in Bangalore investigating the causes of epileptic seizures in manipulating their onset by "kindling", and how this relates to a unique form of epilepsy: "hot water epilepsy" (HWE) - a potential model for how epilepsy originates. Kindling is the repeated chemical or electrical stimulation of the brain or a particular brain region that eventually leads to seizures. Along with many others, Dr. Ullal believes that "kindling" provides a mechanism by which the actual origins of epilepsy can be viewed. He has also tried to explain the possible mechanism of kindling by using a paradigm of neural-network modelling.

Epilepsy is generally characterized as the suffering of recurrent seizures, temporary or prolonged alterations in electrical brain activity that cause dysfunction in cerebral structures (Wikipedia, n.d.). Seizures c o m e in two forms focal and generalized. Focal seizures are local to a neural region and m a y cause abnormal perception (e.g. flashes of light) or aberrant muscle movements. In contrast, generalized seizures actually disrupt cerebral activity in the whole of the cortex. Seizures are further classified as being either simple or complex. Simple seizures are those that do not undermine one's consciousness, whereas complex seizures directly interrupt it. This does not necessarily m e a n that a complex seizure will result in fainting and loss of consciousness. A partial complex seizure m a y simply manifest in the unconscious repetition of speech or motor movements. The terms petit mal and grand mal are used in describing generalized seizures.

Petit mal generalized seizures are characterized by a loss

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of consciousness for up to 30 seconds, along with muscle twitching. Grand mal seizures (or tonic-clonic) involve an initial contraction of the muscles (tonic phase), which m a y involve tongue biting, urinary incontinence, and the absence of breathing. This is followed by rhythmic muscle contractions (clonic phase). These are also seemingly accompanied by intense visions or hallucinations, often of a mystical or religious nature (Wikipedia, n.d.).

H W E is a type of reflex epilepsy distinguished by seizures that are triggered by stimuli (in contrast to spontaneous seizures). In H W E , seizures are induced by the pouring of hot water within the range of 3 5 to 5 0 degrees Celsius over the head during bathing (in many parts of the world, bathing is done by pouring hot water over one's body rather than bathing in a tub). W h a t is peculiar about this kind of epilepsy is that although cases have been described in the United States, Australia, Canada, UK, Japan, and other places, the majority of H W E are reported in South India (Satishchandra et al., 1998).

The significance of this class of seizures is that they initially start as reflex seizures, but ultimately progress into generalized non-reflex (spontaneous) seizures (Satishchandra et al., 1998). Therefore, studying such seizures as precursors to chronic epilepsy have proven quite useful.

Kindling wa s originally discovered by G.V. Goddard in 1 9 6 7 at the University of Waterloo. Short electrical bursts were supplied to the brain's limbic system once a day for a period of time, and though initially no activity w a s seen, partial focal seizures were the eventual result, followed by clonic seizures (Goddard et al., 1969).

Since then, m u c h work has been done in utilizing kindling and its proposed effects on neural plasticity (the ability of the brain to adapt to change, which provides the foundation for learning and memory), one of the fundamental properties of neurophysiology. Since neural plasticity is a feature considered universal throughout the central nervous system, this suggests that changes www.meduclftorTbTg

Issue 5 | 2 0 0 5 February prompted by kindling within one part of the central nervous system m a y occur throughout the body as well (Sutula, 2004). With this in mind, many have viewed kindling as most notably affecting the neuronal cells of the hippocampus and via a Hebbian Learning mechanism (synaptic strength is increased the more frequently it is active), these cells becom e altered permanently. This may be the mechanism by which spontaneous seizures are generated. Although kindling-induced alterations are seen most strikingly in the hippocampus and the limbic system, repeated stimulation of the pathways of the limbic, cortex, subcortical and brain stem regions (either chemically or electrically) induces a progressive sequence of long-lasting cellular and molecular alterations at all levels of biological organization in neural circuits, from gene transcription to patterns of neuronal connectivity (Sutula, 2004). Therefore, it can be assumed that seizures have an effect on the entire body, commensurate with the idea of neural plasticity.

For the last ten years Dr. Ullal conducted empirical studies with animal models for HWE-rats that were seizureprone. In one experiment, he studied the relationship of varying the inter-stimulus interval on progression of seizure (kindling). This progression appeared to be coupled with a rapid increase in temperature within the organism. Ullal and his colleagues suggested that this form of seizure induction was the result of "hyperthermic kindling" (Satishchandra et al.,1998). W h e n comparing this trend in h u m a n epileptics, temperature recordings taken from the auditory canal also showed a rapid temperature increase. Furthermore, autopsy studies of patients with H W E also demonstrated pathological changes in the hypothalamus that could be related to a disturbed thermostat mechanism. According to Dr. Ullal, these results were "very exciting", and have since led to further study biochemical and genetic investigations.

The findings of Dr. Ullal and his collaborators are being further validated through other research. Regarding the functional changes Ullal proposes in the temporal lobe, a recurrent pattern in H W E patients' MRIs shows infolding heterotopic gray matter along a cleft in the left temporoparietal region, as well as other regions where focal seizures occur (Diehl et al., 2003; Lee et al., 2000; Oshiro & Fukushima, 2003). The idea of hyperthermic kindling and the observation that temperature increase is altered in those with H W E have been extrapolated to the function of the blood-brain barrier, where increased permeability to certain proteins, like GLUT-1 (a glucose transporter protein), loss of permeability to other serial proteins, and altered transport of certain ions has been noted in H W E rats (llbay et al., 2003). Finally, Dr.Ullal's manipulation of the intervals between seizure induction is proving to be quite valid in terms of whether seizures will progress to www.meducator.org

Figure 1: Comparison of a normal brain scan with that of a person With epilepsy (Source: ADEAR) more complex, spontaneous ones. Though H W E is only one specific type of epilepsy, greater insight will ultimately aid the scientific community in understanding epilepsy in general.

Sutula (2004) notes that inducing seizures with increased frequency actually reduces later seizure activity, something he calls the 'neuroprotective' effect of kindling.

Although Goddard (as cited in Sutula, 2004) observed a similar effect. Kindling is only now being understood through complex neural computational models. In a set of collaborated studies, Ullal's group formulates for the first time a computational model for kindling phenomenon (Mehta etal., 1993).

There are still many obstacles to comprehending the "kindling" phenomenon. One of the most perplexingfacets of this neurological disorder, as mentioned previously, is that roughly 2 0 - 3 0 % of epileptics are drug-resistant.

Dr. Ullal believes that this is part of epilepsy's elusive nature, and it is also confirmed in many other studies (Malagon-Valdez, 2004; Stefan, 2004).

Even when s o m e researchers believe that they can account for the drug-resistance, their findings prove invalid. A very good example is a paper published by Zimprich and colleagues (2004), claimingto have discovered a gene locus, A B C B 1 , responsible for the apparent pharmacoresistance many epileptics exhibit. Specifically, they believe that the homozygous halotype of A B C B 1 encodes P-glycoprotein, a protein responsible for transporting drugs in the central nervous system, and ultimately leads to a diminished response to epilepsy drug treatment. However, Tan and colleagues (2000) conducted a similar study yielding results inconsistent with Zimprich's findings.

Despite the debate that continues, m u c h more is now known regarding the origins of epilepsy in comparison to the late 1 9 6 0 s whe n Goddard first uncovered the p h e n o m e n o n of kindling.

While epilepsy remains pharmaceutical^ untreatable in m a n y patients, with researchers like Dr. Ullal, it is only a matter of time before the origins of this mysterious neurological disorder are revealed, and effective treatments can be administered.EB

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February 2 0 0 5 | Issue 5

N 'Z HAVE You BEEN "MEDUCATED"? ^ y S e e how well you have retained the information from the articles in this issue. S o m e of these questions (1 and 2) are based on facts but others (3 and 4) will require the application of what you now know (take a meducated guess!). ^ 2 Answer the questions and email them to medcontest@learnlink.mcmaster.ca by March 1st. The individual with the highest score will win a prize!

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The A B C s of Atkins Based Carbohydrate-Reduction as a Treatment for Obesity: 1) N a m e three health consequences of obesity.

2) H o w do the Atkins and A H A diets differ?

3) W h y would a Ketogenic Diet aid children suffering from seizures?

4) Other than suppression of appetite, what are s o m e other effects of Ketone bodies in the blood?

Providing HOPE in the Campaign Against Cardiovascular Morbidity and Mortality: 1) What is an ACE-lnhibitor?

2) What was the purpose of the H O P E study?

3) What effects do ACE-lnhibitors have on blood pressure?

4) What is the 'conundrum' of the H O P E study results?

AIDS Stigma in North America: 1) What are the three main reasons for the persistence of AIDS stigma?

2) What was the original n a m e for AIDS? 3) What makes AIDS different from other infectious diseases?

4) H o w does the fundamental attribution error explain the persistence of AIDS stigma?

"Kindling": Origin of Epilepsy? : 1) What distinguishes reflex seizures from spontaneous ones?

2) W h y would "kindling" foreshadow a seizure?

3) Aside from H W E , n a m e three examples of reflex seizures and briefly describe the stimulus involved.

4) What would cause patients to be resistant to antiepileptic drugs?

Call For Article Submissions: Issue 6

The McMaster Meducator is currently accepting article submissions for Issue 6 (released in April 200 Articles (1000-2500 words) about medical research, health ethics or health policy are welcome. Detailed article guidelines ma y be found on our website www.meducator.org. Articles must be submitted by early March. Writing for the McMaster Meducator combines exploration of medical research and health ethics with the excitement and prestige of publishing work for the McMaster community to read. The opportunity is ideal for those considering a future in medical research, health ethics, or any profession within the health care field. The McMaster Meducator provides quality educational feedback through post-graduate editing of selected articles. If you are interested in writing or wish to submit your article, please e-mail us at: medwriter@learnlink.mcmaster.ca.

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Issue 5 | 2 0 0 5 February

Press Release Contest The McMaster Meducator ran the Biology 1A03 Press Release Contest in mid-November. The editorial board received a variety of entries with topics ranging from cancer cell communication to rare diseases like Timothy Syndrome. Our winners c o m e from a diverse set of faculties and are as follows; Congratulations to E m m a Love (Arts and Science II), winner of our Press Release Contest. E m m a was awarded a gift certificate to Titles Bookstore. You can read E m m a ' s article entitled "Transport of D-Fructose in the Small Intestine is Linked to High Blood Pressure in Rats."

Honourable Mentions go to: Ryan Henderson (Science I): Acid Sensing Ion Channels and Brain D a m a g e Anjori Pasricha (Health Sciences I): Tracking Cancer: One Cell at a Time Alvin Pilobello (Chemical Engineering and Bioengineering II): Calcium Channel Protein Mutation: The Cause of Timothy Syndrome

Thank you to all contest participants. For an additional opportunity to win prizes, check out our Med Quiz secti test your knowledge of this issue!

Transport of D-Fructose in the Small Intestine is Linked to High Blood Pressure in Rats was noted in absorption rates of D-fructose, the cells from the hypertensive rats had a maximal transport capacity of the monosaccharide that was 5 3 % lower than normal.

The hypertensive rats' cells also had approximately 5 1 % fewer GLUT5 transport proteins than the normal cells.

Furthermore, the hypertensive rats had a 5 2 % decrease in GLUT5 m R N A , the genetic information responsible for producing GLUT5 proteins. These results suggest that DE m m a Love fructose transport is inhibited in hypertensive rats due to M e d Contest Winner February 2 0 0 5 a reduction in GLUT5 m R N A , which causes a reduction H y p e r t e n s i o n , also known as high blood pressure, is in quantities of GLUT5 protein, which in turn reduces the one of the most c o m m o n diseases worldwide, but cells' ability to move D-fructose. It is not yet known whethits causes are not fully understood. Research has er these defects result from hypertension or are genetishown that defects in the intestinal cells may be linked cally linked to its onset. Regardless, knowledge of both to hypertension. The digestive system breaks down the the causes and the consequences of hypertension is escarbohydrates w e consume into smaller pieces which sential. Hypertension can d a m a g e vital organs and is a are subsequently absorbed into the body by the small in- risk factor of heart disease and stroke. Determining the testine. These pieces are known as monosaccharides, causes and effects of hypertension will help to treat and of which there are three major types: D-glucose, D-galac- m a n a g e this devastating disease. tose, and D-fructose. The suppression of D-glucose and D-galactose transport by intestinal cells has already been (Mate, A.. Barfull, A., Hermosa. A.M.. Planas, J.M. & Vazquez. CM. (2004). Regulation of D-fructose transporter GLUT5 in the ileum of linked to hypertension. D-fructose is allowed into the spontaneously hypertensive rats. Journal of Membrane Biology, 199 cell by a different transport protein called GLUT5. This 173-179.) study compared the transport of D-fructose in the intestinal cells of hypertensive and normal rats. The rate and the amount of D-fructose absorbed were measured using simulated intestinal linings. Although no major change

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February 2005 | Issue 5

Yancy, W. S.. Jr., Olsen, M. K., Guyton, J. R., Bakst, R. P., & Westman, E. C. (2004). A low-carbohydrate, ketogenic diet versus a low-fat diet to treat obesity and hyperlipidemia: a randomized, controlled trial New advanced facilities allow for cutting-edge medical development (2004.

(Electronic Version], Annals of Internal Medicine, 140, 769-777.

October 22). Retrieved January 15, 2005, from http://www.fhs. mcmaster.ca/pubrel/facility.htm Stuart Phillips - Atkins' Diet Commentary McMaster University named Canadian Research University of the year (2004, November 22). Retrieved January 15, 2005, from http://dailynews.

Avenell, A., Broom, J., Brown, T. J., Poobalan, A., Aucott, L., Stearns, S. C. mcmaster.ca/story.cfm?id=2981 Systematic review of the long-term effects and economic consequences Research Info Source. (2004) "Top 50 Research Universities Report 2004". of treatments for obesity and implications for health improvement. Health Retrieved January 15, 2005, from http://www.researchinfosource.

Technology Assessment, 8, 1-182. com/top50.shtml Bravata, D. M.. Sanders, L., Huang, J„ Krumholz, H. M., Olkin, I., Gardner, C. D. et al.

Low cost drug helps reduce deaths, repeat heart attacks (2004, November 8).

(2003). Efficacy and Safety of Low-Carbohydrate Diets: A Systematic Retrieved January 15, 2005, from http://www.fhs.mcmaster.ca/pu Review. Journal of the American Medical Association, 289, 1837-1850. brel/reviparin.htm DesMeules, M., Manuel. D„ Robert, C. (2004). Mortality: life and health expectancy Brookes. Laura (2004) "CREATE: Clinical Trial of Metabolic Modulation in Acute of Canadian women. B M C Women's Health, 4, S9.

Myocardial Infarction Treatment Evaluation". Retrieved January 15, Norris, S. L, Zhang, X., Avenell, A„ Gregg, E., Bowman, B„ Serdula, M. et al. (2004).

2005. from www.medscape.com/viewarticle/494544 Long-term effectiveness of lifestyle and behavioral weight loss interven University of Illinois-Urbana/Champaign Carle Cancer Center, (n.d.) "Reviparin". tions in adults with type 2 diabetes: A meta-analysis. American Journal of Retrieved January 16, 2005, from http://www.admin.med.uiuc. edu/hematology/Medications.htm Medicine, 117, 762-774.

New McMaster initiative fosters cross Faculty research teams (2005. January Sammy H. Ali - Providing HOPE in the campaign against cardiovascular morbidity 14). Retrieved January 15. 2005, from http://dailynews.mcmaster. ca/story.cfm?id=3098 and mortality Jennifer Clara Tang - MedUpdate

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Brent Mollon - The ABCs of Atkins Based Carbohydrate-Reduction as a TreatAIDS epidemic update: December 2004 North America, Western and Central Europe ment for Obesity 13. Retrieved January 23, 2005 from http://www.unaids.org/wad2004/ EPIupdate2004_html_en/Epi04_28_en.gif American Heart Association. (2004). Dietary guidelines: at-a-glance [Electronic Antiplatelet Trialists' Collaboration. (1994). Collaborative overview of randomised tri Version). Retrieved September 6, 2004 from http://www.american als of antiplatelet therapy. I. Prevention of death, myocardial infarction, heart.org/presenter.jhtml?identifier=810 and stroke by prolonged antiplatelet therapy in various categories of Birmingham. C. L, Muller, J. L, Palepu, A., Spinelli, J. J.. & Anis, A. H. (1999). patients. BMJ, 308, 81-106.

The cost of obesity in Canada [Electronic Version]. Canadian Medi Bosch, J. Yusuf, S., Pogue, J., Sleight, P., Lonn, E. et al. (2002). Use of ramipril in cal Association Journal, 160, 483-488. preventing stroke: double blind randomized trial. BMJ. 324, 699.

Expert Panel on the Identification, Evaluation, and Treatment of Overweight and Heart Outcomes Prevention Evaluation (HOPE) Study Investigators. (2000a). Effects of Obesity in Adults. (1998). Executive summary of the clinical guide ramipril on cardiovascular and microvascular outcomes in people with lines on the identification, evaluation, and treatment of overweight diabetes mellitus: results of the HOPE study and MICRO-HOPE substudy. and obesity in adults [Electronic Version]. Journal of the American The Lancet, 355, 253-259.

Dietetic Association, 158, 1855-1867.

Heart Outcomes Prevention Evaluation Study (HOPE) Investigators. (2000b). Effects Foster. G. D., Wyatt, H. R., Hill, J. 0., McGuckin, B. G.. Brill, C, Mohammed, B. of an Angiotensin-Converting-Enzyme Inhibitor, Ramipril, on Cardiovascu S. et al. (2003). A randomized trial of a low-carbohydrate diet for lar Events in High-Risk Patients. NEJM, 342, 145-153. obesity [Electronic Version]. New England Journal of Medicine, 348, Lamy, A., Yusuf, S., Pogue, J. & Gafni, A. (2003). Cost Implications of the Use of 2082-2090.

Ramipril in High-Risk Patients Based on the Heart Outcomes Prevention Freeman, J.M.. Kelly, M.T.. Freeman, J.B. (1994). The epilepsy diet treatment: an Evaluation (HOPE) Study. Circulation, 107, 960. introduction to the ketogenic diet. New York: Demo Publications.

Law M. (1998). Lipids and cardiovascular disease. In: Yusuf S, Cairns JA, C a m m AJ, Harper, A. & Astrup, A. (2004). Can we advise our obese patients to Fallen EL, Gersh BJ, eds. Evidence based cardiology. London: BMJ Books, follow the Atkins diet [Electronic Version]? Obesity Reviews, 5, 93191-205.

94.

Lonn. E.M., Yusuf, S„ Jha P. et al. (1994). Emerging role of angiotensin-converting Kadlec, D. (2004, May 3). The low carb frenzy. Time, pp. 34-40. enzyme inhibitors in cardiac and vascular protection. Circulation, 90, Kappagoda, C.T., Hyson, D.A., & Amsterdam, E. A. (2004). Low-carbohydrate2056-2069. high-protein diets: Is there a place for them in clinical cardiology?

Malcolm J., Arnold, 0„ Yusuf, S., Young, J., Mathew, J., et. al. (2003). Prevention of Journal of the American College of Cardiology, 43, 725-230.

Heart Failure in Patients in the Heart Outcomes Prevention Evaluation Katzmarzyk, P. T (2002). The Canadian obesity epidemic, 1985-1998. Cana (HOPE) Study. Circulation, 107, 1284. dian Medical Association Journal, 166, 1039-1040.

Manson, J.E., Coldlitz, G.A., Stampfer M.J., et al. (1991). A prospective study of matu Lara-Castro. C. & Garvey, W. T. (2004). Diet, insulin resistance, and obesity: rity-onset diabetes mellitus and risk of coronary heart disease and stroke Zoning in on data for Atkins dieters living in South Beach [Electronic in women. Arch Intern Med, 151, 1141-1147.

Version). Journal of Clinical Endocrinology & Metabolism, 89, 4197Ostergrena, J., Sleightb, P., Dagenaisc, G., Danisad, K„ Bosche, J„ Qilonge, Y, & Yusuf, 4205.

S. (2004). Impact of ramipril in patients with evidence of clinical or sub National Task Force on the Prevention and Treatment of Obesity. (2000). clinical peripheral arterial disease. Eur Heart Journal, 25, 17-24.

Overweight, obesity, and health risk [Electronic Version). Archives of Pan, S.R., Li, G.W., Hu, Y.W., et al. (1997). Effects of diet and exercise in preventing Internal Medicine, 160, 898-904 NIDDM in people with impaired glucose tolerance. Diabetes Care 2 0 Stern, L., Iqbal, N.. Seshadn, P., Chicano, K. L, Daily, D. A., McGrory, J. et al.

537-544.

(2004). The Effects of Low-Carbohydrate versus Conventional Stamler, J., Vaccaro, 0.. Neaton J.D., & Wentworth, D. (1993). Diabetes, other risk fac Weight Loss Diets in Severely Obese Adults: One-Year Follow-up of tors, and 12-yr cardiovascular mortality for m e n screened in the Multiple a Randomized Trial [Electronic Version). Annals of Internal Medicine, Risk Factor Intervention Trial. Diabetes Care, 16, 434-444.

140, 778-785.

Taubes, G. (2002). In-cites: an interview with Dr. Salim Yusuf. Retrieved January 3rd Triplet!, G. The Pennsylvania Gazette. Retrieved January 23, 2005, from http:// from http://www.in-cites.com/scientists/DrSalimYusuf.html www.upenn.edu/gazette/0703/images/gaz05.gif Teo, K„ Mitchell, B„ Pogue, J„ Bosch, J„ Dagenais, G„ & Yusuf, S. (2004). Effect Veech, R. L. (2004). The therapeutic implications of ketone bodies: The effects of Ramipril in Reducing Sudden Deaths and Nonfatal Cardiac of ketone bodies in pathological conditions: Ketosis, ketogenic diet, Arrests in High-Risk Individuals Without Heart Failure or Left Ventricular redox states, insulin resistance, and mitochondrial metabolism Dysfunction. Circulation, 110, 1413-1417.

[Electronic Version). Prostaglandins Leukotrienes & Essential Fatty Yusuf, S„ Peto, R„ Lewis, J., Collins, R., & Sleight, P. (1985). Beta blockade during and Acids, 70, 309-319. after myocardial infarction: an overview of the randomized trials Prog World Health Organization. (2003a). Diet, nutrition and the prevention of chron Cardiovasc Dis, 27, 335-371. ic disease [Electronic Version). Retrieved September 6, 2004 from Yusuf, S„ Pepine, C, Garces, C. et al. (1992). Effect of enalapril on myocardial http://www.who.int/hpr/NPH/docs/who_fao_expert_report.pdf infarction and unstable angina in patients with low ejection World Health Organization. (2003b). Obesity and overweight [Electronic Ver fractions. Lancet, 340, 1173-1178. sion). Retrieved September 6, 2004 from http://www.who.int/diet Yusuf, S„ Bourassa, M „ Yi, Q., Bosch, J., Lonn, E., Kouz, S„ Dagenais, G„ & Grover J physicalactivity/media/en/gsfs_obesity.pdf (2001a). Effects of Ramipril on Coronary Events in High-Risk Persons ' Results of the Heart Outcomes Prevention Evaluation Study. Circulation 104, 522.

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Issue 5 | 2005 February

Yusuf, S., Gerstein, Hâ&#x20AC;&#x17E; Hoogwerf, B., Pogue. J.. Bosch, J., Wolffenbuttel, B., & Zinman,Ron Zahoruk - "Kindling": The Origin of Epilepsy?

B. (2001b). Ramipril and the Development of Diabetes. JAMA. 286, 1882Diehl. B., Salek-haddadi, A., Fish. D.R.. & Lemieux. L. (2003, December). Mapping of 1885. spikes, slow waves, and motor tasks in a patient with malformation of cortical development using simultaneous EEG and fMRI. Magn Reson Jeannette So - The Persistance of the AIDS Stigma in North America maging, 21(10), 1167-73.

Aaronovitch, D. (2003. April 6). Fever pitch: once it was the chicken virus,Epilepsy then Ebola, Foundation, (n. d.). Epilepsy and Seizure Statistics. Retreived November 3, now it's SARS. W e worry too much. The Observer. 29.

2004, from http://www.epilepsyfoundation.org/answerplace/statistics. cfm Allen. S. (2002). Media, risk and science. Buckingham: Open University Press.

Alzheimer's Disease Education & Referral Center (ADEAR). Retrieved January 20, Goddard, Graham V, Mclntyre, Dan Câ&#x20AC;&#x17E; & Leech. C. K. (19691. A permanent change in 2005 from http://www.alzheimers.org/unravelling/07.htm brain function resulting from daily electrical stimulation. Experimental Brown, L, Maclntyre, K. & Trujillo, Lea. (20031. Interventions to reduce HIV/AIDS Neurology, 25(3), 295-330. stigma: what have we learned? AIDS Education and Prevention, 15(1), Grosso, S., Farnetani. M. A., Francione, S.. Galluzzi, P.. Vatti. G., Cordelli. D. M., 49-69. et al. (2004). Hot water epilepsy and focal malformation of the parieta Juan, C.W., Siebers, R.. Wu, F.F-S, Wu, C-J, Chang, Y-J, & Chao. C. (2004). The cortex development. Brain and Development. 26(7), 490-493. attitudes, concerns, gloving practices and knowledge of nurses Ilbay, G., Sahin. D.. & Ates. N. (2003). Changes in blood-barrier permeability during in a Taiwanese hospital regarding AIDS and HIV. International Journal of hot water immersion-induced seizures in rats. Neurological Science, 24, Nursing Practice. 10. 32-38.

232-235.

Cobb, M. & de Charbert, J.T (2002). HIV/AIDS and care provider attributions: who's to Lee. Y.C., Yen, D.J., Lirng. J.F., & Yiu. C.H. (2000). Epileptic seizures in a patient by blame? AIDS Care. 14. 545-548. immersing his right hand into hot water seizure. 9(8). 605-7.

Conrad, P. (1990). The social meaning of AIDS. In The Sociology of Health and Illness Malagon-Valdez. J. (2004). The new anti-epileptic drugs: their indications and side (pp. 285-292). New York: St. Martin's Press, Inc. effects. Revista Neurologia, 39(6). 570-5.

Conrad, P. & Kern, R. (1990). The Sociology of Health and Illness. New York: St. Mehta, M.R., Dasgupta. C. & Ullal, G.R. (1993). A neural network model for kindling of Martin's Press, Inc. focal epilepsy: basic mechanism. Biol Cybern, 68(4), 335-40.

Davison, G.C., J.M. Neale, K.R. Blankstein, & Flett, G.L. (2002). Abnormal Psychology Oshiro. S.. & Fukushima. T. (2003, May). Two adult cases of unilateral schizencephaly Canadian Edition. Etobicoke: John Wiley & Sons Canada, Ltd. manifesting as minor neurological signs- importance of radiographic CT Edginton, B. (1989). Health, Disease and Medicine in Canada. Toronto: Butterworths assessment. No to Shinkei. 55(5). 431-4.

Canada Ltd. Satishchandra. P., Ullal. G.R.. & Shanka. S. K. (1998). Trigger Mechanisms in HotHerek, G.M., Capitanio, J.P. & Widaman, K.F. (2002). HIV-related stigma and knowl Water Epilepsy. Advanced Neurology, 75, 283-93. edge in the Sayin, U., Osting, S.. Hagen. J.. Rutecki, P., & Sutula, T (2003). Spontaneous seizures United States: prevalence and Trends. 1991-1999. American Journal of Public Health, and loss of axo-axonic and axo-somatic inhibition induced by repeated 92(3), 371-377. brief seizures in kindled rats. The Journal of Neuroscience: The Officia Lloyd, R. (1988). Looking back and forward: hospital responses to epidemics and Journal of the Society for Neuroscience, 23(7), 2759-2768.

Stefan. H. (2004). How to diagnose and treat epilepsy. M M W Fortschr Med, 24(146), AIDS. In The Social Impact of AIDS in the U.S. (pp.51-66). Cambridge: Abt Books Inc. Myers. D.G. & Spencer, S.J. (2004). Social Psychology Second 41-46.

Canadian Edition. Toronto: McGraw-Hill Ryerson Limited.

Sutula, T P. (2004). Mechanisms of epilepsy progression: current theories and perspectives from neuroplasticity in adulthood and development. Epilepsy Silvers, A. (2001). Prescribing multi-functionalism to achieve equality in a world of Research. 60(2-3), 161-171. difference. Health Ethics Today 12(1).

Tan. N. C. K., Heron. S. E., Scheffer, I. E.. Pelekanos, J. t, McMahon, J. M., Vears. D. Smithurst, M. (1990). AIDS: risks and discrimination. In AIDS - a moral issue (pp.99et al. (2000). Failure to confirm association of a polymorphism in ABCB1 111). New York, St. Martin's Press, Inc. with multidrug-resistant epilepsy. Seizure. 8(9). 605-607.

Ungar, S. (1998). Hot crisis and media reassurance. British Journal of Sociology, 49.

Zimpnch, F. Sunder-Plassmann. R,. Stogmann, E.. Gleiss, A., Dai-Bianco, A.. Zimpnch.

36-56.

A. et al. (2004). Association of an ABCB1 gene haplotype with Valdiserri, R.O. (2002). HIV/AIDS stigma: an impediment to public health. American harmacoresistance in temporal lobe epilepsy. Neurology, 63, 1090-1091.

Journal of Public Health, 92(3), 341-342.

Washer, P. (2004). Representations of SARS in the British newspapers. Social Science & Medicine, 59, 2561-2571.

The McMaster Meducator Executive 2005

Top Row (Left to Right): Jonathan Liu, Brent Mollon, Anthony Collini, Amandeep Rai, Sammy H. Ali, Edwin Bottom Row: Jeannette So, Shama Sud, Jennifer Clara Tang, Jaron Chong, Katherine Saccucci www.meducator.org

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