Royal College of Surgeons in Ireland Student Medical Journal by Th!nk Media

Volume 6: Number 1. 2013 ISSN 2009-0838

RCSIsmjfeature

RCSI

smj Royal College of Surgeons in Ireland Student Medical Journal

Containing the Celtic gene â&#x20AC;&#x201C; Kalydeco and cystic fibrosis

In this issue: n PAR-4 â&#x20AC;&#x201C; a novel marker of luminal A breast cancer n Why are Irish doctors emigrating?

RCSIsmjcontents Royal College of Surgeons in Ireland student medical journal Executive Committee Anas Sarhan – Director Neil Fennelly – Director Rawan Alnaeimi – Executive Secretary Editorial Team Eoin Kelleher Melissa Schorr

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Editor-in-Chief Senior Editor

Staff writers Yoshihiro Katsuura – Senior Staff Writer Elizabeth Ahern-Flynn Lava Chalikonda Ramia Jameel Tara Rajiyah Education officer Sami Backley Webmaster Vincent Siu Sponsorship Co-ordinator Waasil Kareem Public Relations Lolwa Al-Obeid – Ahmad Bazarbashi Benjamin Goh Chinedum Arize Moyser Mulla

Director

Peer Review Team Mark Schwindt – Director Conor Cox – Assistant Director Aine McCarthy Alexander Johnston Alexandra Ostaszewski Daniel Cherfan Jennifer Galley Kevin May Kimberly Ng Owen Keane Peter Staunton Poornima Menon Rebecca Wolfe Sarah Pradhan Valerie Curren Acknowledgements Professor Ronán M. Conroy for the time and encouragement he has given to the RCSIsmj Journal Club. Professor McElvaney and the Department of Medicine, and Louise Sherwin and the Alumni Office, for their sponsorship. Professor McGee and the Dean’s Office for their sponsorship.

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Editorial Directors’ welcome

RCSI Ethics Challenge 6 7

RCSIsmj Ethics Challenge 2013/2014 RCSIsmj Ethics Challenge winner 2012/2013

Original articles 11 A comparison of staged and concurrent neo-adjuvant chemoradiotherapy in resectable locally advanced oesophageal carcinoma 17 An audit of patients currently using legally acquired cannabis as a means of managing chronic pain 22 Investigation of host and pathogen responses to oestrogen in cystic fibrosis 27 The inflammatory cellular constituents of foetal and infant leptomeninges – a survey of hospital-based autopsies without trauma 33 The differences in attitudes and beliefs among smokers and ex-smokers regarding the benefits of smoking cessation in Ireland 37 PAR-4 – a novel marker of luminal A breast cancer – is down-regulated by the steroid receptor co-activator SRC-1

Case reports 42 Atherosclerosis-induced aortic coarctation: a case report 45 The key is in the details: a case of disseminated histoplasmosis

Review articles 50 The MMR vaccine and autism 54 A potential cure for multiple sclerosis: the promising role mesenchymal stem cells play in the reparative process 59 Total ankle arthroplasty: the future of orthopaedic surgery? 63 Deep brain stimulation for the treatment of movement disorders 68 Development of a three-dimensional patient-specific brain model with a pineal region tumour and hydrocephalus for neuroendoscopic simulation and training

Research update 72 Changing perspectives on Alzheimer’s disease

Staff reviews 74 79 84 89 93

The abuse of stimulant drugs within the medical education setting Modulating the cystic fibrosis transmembrane regulator – breaking the basic defects Female genital mutilation and the healthcare professional in Ireland Sensory stimulation in the treatment of neuropsychiatric symptoms of dementia Why are Irish doctors emigrating?

Elective report 99 The warm heart of Africa

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Book review 102 Bad Pharma: How drug companies mislead doctors and harm patients by Ben Goldacre

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Abstract 104 Post-translational regulation of endothelial nitric oxide synthase by testosterone in the mouse penis

Please email comments to editorsmj@rcsi.ie, join our Facebook page, or follow us on Twitter @RCSIsmj to discuss journal articles. Submissions to submissionssmj@rcsi.ie Volume 6: Number 1. 2013 | Page 3

RCSIsmjeditorial Food for thought

“By far the most dangerous foe we have to fight is apathy – indifference from whatever cause, not from a lack of knowledge, but from carelessness, from absorption in other pursuits, from a contempt bred of self-satisfaction” – Sir William Osler (1849-1919), Canadian physician and founding Professor of Medicine at Johns Hopkins Hospital. 2012 was an eventful year in Irish medicine. Budget over-runs in the health service, political scandals involving the health minister and the selection of primary care centre sites in his constituency, the high-profile resignations of HSE chief Cathal Magee and Minister of State Roisín Shortall, and salary disputes involving hospital consultants and nursing graduates, all made it into the news pages. Against all of this, more health workers than ever before are leaving Ireland – not just junior doctors, but nurses, physiotherapists and other allied health professionals too. The talk among students now is not so much if you plan to leave, but rather when and where you plan on going. A future in Ireland is – for many – not on the table anymore. This depressing reality cannot and should not be ignored, and Lava Chalikonda’s article (page 93) is an interesting piece on the topic. I strongly encourage all students to read it and think about the issue, because it will affect you in just a few short years’ time. “Science is a way of thinking much more than a body of knowledge,” as Carl Sagan said, and this issue of the journal showcases many examples of stellar scientific thinking. Articles from Natasha Mehandru on stem cell therapy for multiple sclerosis (page 54), and Michael Kuhlmann on the new area of three-dimensional patient-specific models to guide therapy (page 68) are examples of this. Our journal also showcases the excellent work that is being carried out in Irish hospitals by our students. Aoife Cahalin’s paper on PAR-4 as a novel marker in breast cancer is an excellent piece of work (page 37). This year, our cover article by Ramia Jameel (page 79) discusses the exciting new research developments in cystic fibrosis (CF). Elsewhere, there is an excellent piece of original research from Moyser Mulla on the hormonal factors that influence CF (page 22). Ireland has the highest incidence of the disease in the world, and much work is carried out on CF in Irish hospitals and here in the RCSI. Ramia takes a close look at the new gene-modulating treatments for CF, which target the cause of the illness rather than the symptoms. The best known of these, ivacaftor (Kalydeco), was approved by ythe Minister for Health, James Reilly TD, in February 2013. However, ivacaftor comes with an expensive price tag that is well above the threshold cost per QALY (quality-adjusted life year). The decision to approve it, while immediately politically popular, may prove controversial in the long term as cuts have to be made elsewhere. While the journal puts a spotlight on advances in practising medicine,

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it must not be forgotten that the ethical discussions around how we practise are important too. “Education is an admirable thing”, Oscar Wilde once said, “but it is well to remember from time to time that nothing that is worth knowing can be taught”; indeed, we cannot learn ethics from a book, we must think about how we practise medicine instead. Elizabeth Ahern-Flynn provides a fascinating account on female genital mutilation (page 84), and Yoshihiro Katsuura explores stimulant abuse in education (page 74). As ever, we have our ethics prize, and we are delighted to present the winning essay from Diarmuid O’Brien (page 7). We strongly encourage students to reflect on ethics in both clinical practice and research. Some of the most significant advances in healthcare have not just been scientific; they have also been social and political, for example the passage of the Affordable Care Act (‘Obamacare’) in the US. These fields are all guided, fundamentally, by an ethical concern for people. In this hope, we invite everyone to submit for the next ethics challenge (page 6). Finally, I hope that everyone gets something of benefit from this journal: whether you have an article published, or you were involved in our peer review process, or – most importantly – you read a piece and found that it opened questions in your mind. As Carl Sagan said above, science is not a body of knowledge, it is a way of thinking. The journal seeks to stimulate and encourage that way of thinking, because all of us will play a role – for better or for worse – in the future of healthcare. We must support causes that we are passionate about, research areas that we are interested in, and share ideas that are important. “The very first step towards success in any occupation is to become interested in it.” – Sir William Osler

Eoin Kelleher Editor-in-Chief, RCSIsmj 2012-2013

RCSIsmj directors’ welcome Directors’ welcome

It is with great pleasure that we welcome you to the sixth issue of the RCSIsmj. We have no doubt that this year’s issue will provide an interesting read for students and professionals of all levels working within the Irish healthcare system. This year, once again, we have been bowled over with the high standard of diverse research and enthusiasm shown by the students of the Royal College of Surgeons in Ireland. The quality of this issue is also a testament to the talent, dedication and enthusiasm of all our staff. We would like to thank everyone who gave up much of their time amidst hectic study schedules to produce another high-quality publication this year. Over the years, the RCSIsmj has developed into a highly regarded student medical publication, not only in our own hospital system, but also among the medical schools of Ireland and abroad. The RCSIsmj as a society was founded to “increase student interest in research and scientific writing by providing a formal

structure and staff mentorship to facilitate these pursuits”. This issue marks our third year of involvement with the journal. As we look back over the years, we are pleased to see this goal realised time and again. This year, we succeeded in recruiting an exceptional staff, overseeing the development of our peer review process, and introducing a student-run journal club; all are events that we hope will continue in the years to come. As we pass on stewardship of the journal to the next generation, it is exciting to think of what further progress this publication will make in the coming issues. We have no doubt that the RCSIsmj will continue to serve our students and colleagues as a useful learning resource, a platform for their hard work, and a valued means of delving into the ever-important world of medical research and publication. Neil Fennelly and Anas Sarhan Directors, RCSIsmj 2012-2013

Volume 6: Number 1. 2013 | Page 5

RCSIsmjprize

Ethics Challenge 2013/2014 The case A granddaughter writes: “My grandmother, Joan, has always been energetic, prickly, self reliant. As a girl she loved swimming, cycling, flirting, arguing, dancing, moving. After being widowed in her early 70s she read, travelled, bought herself baubles and may or may not have enjoyed a love affair. She was one of the most active people I have encountered. And now, at 92, I would like her to die. Even those who do not remember Joan’s fierce individualism would pity the condition in which she now finds herself: tortured into living by a medical system that will not let her go. My grandmother is clearly dying, trapped in some pained transitional state. Her face and body have taken on a skeletal appearance. She sleeps most of the time. When awake, her eyes have a lost look within her stilled body, as if in appeal. She cannot hear and increasingly refuses to eat or drink. She is ready. The medical services, however, are not, and are engaged in an aggressive battle to resurrect her. The individual they are fighting would appear to be my grandmother herself. Joan has always expressed a desire to die at home, and was paying hundreds of Euro This is the fifth instalment of the RCSIsmj Ethics Challenge. The editorial staff would like to congratulate Diarmuid O’Brien on his winning essay in the 2012/2013 Ethics Challenge. Please see page 7 for his submission. We invite all students to submit an essay discussing the ethical questions raised in the case presented. Medical ethics is an essential aspect of the medical curriculum and we hope to encourage RCSI students to think critically about ethical situations that arise during their education and subsequent careers. All essays will be reviewed by a faculty panel of experts and the winning essay will be published in the 2014 print edition of the RCSIsmj. The deadline for submission of entries will be the same as the general submission deadline for the 2014 edition of the RCSIsmj. Please visit our website at www.rcsismj.com for specific dates. Please contact us at editorsmj@rcsi.ie with any questions or concerns.

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a month painstakingly saved for the privilege, nourished by those who love her in surroundings in which she felt secure. This summer she was removed from the home she has occupied since 1940 by a district nurse coup (against her wishes, those of her family and GP) and is now on a disorienting, stifling and noisy geriatric ward. Elements of dementia have increased with the confusion. We were told she would be admitted for a maximum of 48 hours. Yesterday, she saw in her fifth week. Benevolent as her immediate nursing staff are, this hijack is one of the most grotesque things I have witnessed – not merely inhumane, but inhuman. The situation I am proposing is fundamental. It involves not killing people but letting them die with dignity in conditions of their choosing”.

Questions for consideration 1. What are the ethical issues that arise in this case? 2. Do any legal considerations need to be taken into account? 3. How do you believe death with dignity should be defined?

Submission guidelines Please construct a lucid, structured and well-presented discourse for the issues raised by this case. Please ensure that you have addressed all the questions highlighted and discuss these ethical issues academically, making sure to reference when necessary. Your paper should not exceed 2,000 words. Your essay will be evaluated on three major criteria: 1. Ability to identify the ethical issues raised by the case. 2. Fluency of your arguments. 3. Academic quality with regard to depth of research, appropriateness of references and quality of sources. Good luck!

RCSIsmjethics challenge ETHICS CHALLENGE WINNER 2012/2013

Implementation of an advance directive in a case of dementia Diarmuid Oâ&#x20AC;&#x2122;Brien RCSI medical student

Introduction The 2012/2013 RCSIsmj Ethics Challenge presents the case of Mr R, a retired senior partner from a highly successful legal practice, who had drafted an advance directive (AD) with his doctor stating that his life was not to be saved if he were to become severely demented and too incapacitated to refuse treatment for himself. Having developed the aforementioned severe dementia he subsequently contracted a serious infection, which prompted a discussion of the AD among family members and medical staff. However, conflicting viewpoints were raised by both, resulting in a failure to reach a consensus. One side supported the AD but the other side contended that he was a different person now than he was then and thus his infection should be treated.1 The ethical issues surrounding ADs in the case of severe dementia are now of paramount importance, as indicated by the rapid increase in the condition worldwide. As of 2010, global figures for dementia stood at 35.6 million, but that figure is expected to nearly double every 20 years to approximately 65.7 million in 2030 and 115.4 million in 2050.2,3 Volume 5: Number 1. 2013 | Page 7

RCSIsmj ethics challenge Table 1: Definitions of relevant principles of medical ethics n Respect for persons/autonomy: to allow patients to make autonomous decisions and not to obstruct their actions unless they prove detrimental to others. Those with diminished autonomy must also be protected. n Beneficence: to promote the well-being of the patient insofar as is possible and to minimise potential harms. n Non-maleficence: to do no harm. n Justice: to ensure the equal distribution of medical resources among all persons.4

Current use of advance directives The concept of the AD was conceived in the US in the 1960s and is well established in many places such as Australia, Canada and in Europe.5-7 The legislation and implementation for each AD differs from country to country but the overall concept is the same.8 ADs are considered binding as long as the conditions outlined by each country’s legislation are met and the physician is legally bound to comply with the AD.9 Studies have found that ADs are important for both the physician and the patient. Physicians are willing to honour ADs but are reluctant to initiate discussion about them with their patients. In one study, 93% of outpatients interviewed in a Boston hospital and 89% of people from the general public said that they would desire an AD. This study also found that 77% of outpatients and 86% of the general public found making decisions for themselves easier than making decisions for incapacitated relatives or friends.10 Another recent study showed that almost 80% of people preferred independent decision making when it comes to end of life situations, and efforts are underway to increase the use of these documents.11 However, the number of people with prepared ADs is still quite low as it is still a relatively new concept. Figures are as low as 5% for hospital-based patients in Finland and 25% for Americans.9 Barriers to preparing ADs from the patient’s viewpoint included the belief that the physician should make the decisions, and the idea that ADs were only relevant to older people or those in poor health.11 From the physician’s viewpoint the time-consuming nature of discussing the AD with the patient and the lack of compensation for time and effort allocated becomes an issue.12

The advance directive as a concept The fundamental reason why ADs are becoming increasingly popular among patients is that they facilitate an expression of precedent autonomy in case of future incompetence.13 The AD is a practical extension of informed consent and thus a tool for autonomy. A person has a right to informed consent and thus a right to make an informed and voluntary decision to accept or decline treatment.14 However, while it is an excellent tool of autonomy, it can also severely compromise the ethical obligation

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of beneficence of the physician, and indeed the relatives and loved ones of the afflicted. Thus we are presented with the age-old debate between the patient’s autonomy and the physician’s beneficence, and this will be discussed in detail below.

Applying advance directives to those with dementia Dementia is a disease that progresses slowly. To confirm that Mr R’s AD is ethically valid, questions must be raised about the gaps between what effects Mr R thought the dementia would have on him and what actually transpired. Is this what he envisaged his dementia to be or is this a completely different situation to what he saw happen to his parents? His experience of dealing with his parents is, after all, the premise on which he based his AD.13 One study states that in order for a person to make an informed decision they must have a complete and genuine understanding of the experience of dementia.3 In Mr R’s case it is more than likely that he knew, insofar as anyone could grasp, the effects the dementia would have on him because of his first-hand experience with his parents, and this is what confirms its validity.

Dementia and personal identity A person who becomes severely demented undergoes deep psychological and personality changes, so much so that outside their physical bodily form they become unrecognisable to loved ones.13 The big question is: does their fundamental identity change? Is Mr R a new person in a body that is not his, or is he essentially the same complete being with an altered personality? Either way the answers to these questions have massive implications for the application of the AD. It thrusts the issue of personal identity into the spotlight when considering an AD from an ethical point of view.

Relevance of personal identity The question of the relevance of personal identity is significant because the AD can only claim moral validity if it concerns the person who drafted it. Rights-based ethics state that the AD can only have moral force if the person who drew up the AD is the same person as they are now.15 Two views of personal identity will be discussed below. One will advocate paternalism and the other autonomy.

The case for the application of soft paternalism In the Lockean/Parfitian view of the human condition, psychological continuity is inseparably linked to personal identity. Without thinking there is no consciousness and without consciousness there is no person. It is a connection to psychological states that amounts to the person.16 According to this view Mr R should be separated into a former and a current Mr R. It would then be unethical to allow former Mr R to dictate the healthcare of the current Mr R, as the current Mr R might have entirely different views on how he wants to live his life.17 The current Mr R might even be viewed as a slave to the former Mr R, which would drastically restrict his autonomy and his rights. Therefore, a physician could be justified in applying soft paternalism and

RCSIsmj ethics challenge ordering that Mr R be given antibiotics.13 However, even advocates of the psychological continuity theory advocate that although there is not enough continuity to believe that Mr R still has his original identity, they do believe that there is enough psychological continuity to give the wishes of the AD some weight in the decision concerning whether or not to treat Mr R.18

Autonomy: providing Mr R with his freedom of choice On the other hand, if Mr R, who has undergone severe and permanent neurological damage, is not the same person as before, then who is he? Is he just a shell of some other individual with no past, no life experience and no soul? Can he even be classified as a person or just a living being? Does Mr R really think or does he just exist in the shadow of his former being reacting to sensory stimuli and no longer retaining any of his former critical interests?19 Has his body acquired a different person? Body is part of the personhood. A person’s agency might be gone but personhood is ingrained in an individual’s life history and engagement with others. Therefore, it still makes sense to view Mr R as the same person.16 There are many viewpoints that support the idea that psychological continuity is not necessary for the continuity of one’s identity. From the communitarian concept of self, Mr R retains his identity because he remains important to those who were around the former Mr R. From an animalist stance he is the same person, as his animal functions of metabolism, capacity to breathe, etc., remain intact. Finally, from an embodied mind perspective, all that is required for a continued existence is persistence of cognitive processes. It is beyond the scope of this article to explore these standpoints in great detail but they are of some significance.20,21 It is similarly argued in another paper that the ability to view yourself prospectively is a necessary requirement for being a person and therefore having an inherent right to life.22 In the Dworkin view of the human condition Mr R is thought of as someone who has become demented rather than a person, or even a separate entity, who is currently demented. We could view the competent and demented stages of a person’s life as just stages within a complete life and that these stages are both equally part of the individual within the same life.13 People see themselves as one continuous person with a past and a future. Thus they have a justifiable interest in how their complete life would transpire and that it would be consistent with their former competent self in the case of future incapacity. Perceived future events contribute to the narrative unity, which is constitutive of personal identity. Indeed, surrogate decision makers would make decisions based on this same precedent.23 Psychiatrically, Dworkin’s position is supported by the fact that a patient with progressive dementia frequently has memories from his earlier life.5 It is clear then that in an overall sense Dworkin’s position has more credibility than the Locke/Parfit viewpoint and from a philosophical viewpoint Mr R’s autonomy must stand.

The advance directive from the physician and family members’ viewpoint If it is the case that Mr R is deemed to be the same person as he was before becoming afflicted with severe dementia, it strongly

conflicts with a physician’s and family’s ethical principles of beneficence and non-maleficence. Declining the opportunity to treat Mr R is unquestionably compromising the physician’s beneficence as he can clearly see that Mr R’s current demeanour is the antithesis of someone who wants his life to be ended.13 It would specifically conflict with the traditional deontological Hippocratic oath of the physician if the doctor were to let Mr R die.24 Another question must then be asked: if both courses of action are ethical, then which of the two is more ethical? The answer to that question is found in exploring the difference in Mr R’s critical interests over his current best interests.25 It is clear that superficially Mr R is currently a very contented individual, but the point of Mr R’s AD is to override the superficial appearance of his current demented personality. Mr R’s critical interests were clear. If he were to be in a situation where he had to be medically treated in order to survive he did not want to receive that treatment. Mr R, like many other people, probably wanted his critical interests to be indicative of his philosophy and attitudes to life, which would give coherence and a narrative structure to the story of said life.22,26 In this case the AD becomes a tool to help him achieve his final goal in life: not to extend his life as an incapacitated individual. Dworkin also argues that best or experiential interests have no intrinsic value. They only allow a person to live a mere pleasurable life.18 An analysis of the human condition would identify that a human being does not act simply to seek pleasure or avoid pain, but rather they act according to a moral compass and in the representation of duty, which goes beyond reacting to current emotions.27

Conclusion Although there are many ethical reasons supporting possible decisions, in this case the most ethical decision is to uphold the AD of Mr R. The autonomous decision as outlined in the AD is of greater significance than the physician’s obligation of beneficence. The following criteria assess the validity of the AD: 1. The person must have been competent when he or she formulated the AD. 2. The refusal of treatment must have been made voluntarily, unequivocally, and without duress. 3. The refusal of treatment must represent a ‘firm and settled commitment’ rather than an offhand remark that informally expresses a reaction. 4. The advance decision must have been made with reference to and intended to cover the particular circumstances that subsequently occurred. 5. The person must have known in broad terms the nature and effect of the treatment to which he or she was refusing consent.28 It is clear that Mr R’s AD is perfectly legitimate and it must be upheld. The medical staff and family members should come to a consensus that Mr R should not be given antibiotics and should be allowed to die as he intended.

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RCSIsmj ethics challenge References 1.

RCSI. Ethics Challenge. Royal College of Surgeons in Ireland Student Medical Journal. 2012;5(1):5.

Alzheimer’s Disease International. Dementia Statistics. 2010. Available

Gillick MR. Doing the right thing: a geriatrician’s perspective on medical

from: http://www.alz.co.uk/research/statistics. care for the person with advanced dementia. J Law Med Ethics. 2012;40(1):51-6. 4.

Department of Health Education & Welfare. The Belmont Report. 1979. Available from: http://www.hhs.gov/ohrp/humansubjects/guidance/belmont.

Vollmann J. Advance directives in patients with Alzheimer’s disease: ethical and clinical considerations. Med Health Care Philos. 2001;4(2):161-7.

Chan HM. Sharing death and dying: advance directives, autonomy and the family. Bioethics. 2004;18(2):87-103.

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2002;16(2):114-33. 20. Varelius J. Respect for autonomy, advance directives, and minimally conscious state. Bioethics. 2011;25(9):505-15. 21. Buford C. Advancing an advance directive debate. Bioethics. 2008;22(8):423-30. 22. Kuhse H. Some reflections on the problem of advance directives, personhood and personal identity. Kennedy Inst Ethics J. 1999;9(4):347-64. 23. Blustein J. Choosing for others as continuing a life story: the problem of personal identity revisited. J Law Med Ethics. 1999;27(1):20-31. 24. Bennett-Woods D. Ethics at a glance. 2005. Available from: http://rhchp.regis.edu/HCE/EthicsAtAGlance/EthicsAtAGlance. 25. de Boer ME, Hertogh CMPM, Dröes RM, Jonker C, Eefsting JA. Advance

Beširevi V. End-of-life care in the 21st century: advance directives in

directives in dementia: issues of validity and effectiveness. Int

universal rights discourse. Bioethics. 2010;24(3):105-12.

Psychogeriatr. 2010 [Internet];22(2):201-8. Available from:

Alzheimer Europe. The legal status of advance directives: country

http://dare.ubvu.vu.nl/

comparisons. 2009. Available from: http://www.alzheimer-europe.org/Policy-in-Practice2/Country-comparisons /Advance-directives. 9.

19. Davies JK. The concept of precedent autonomy. Bioethics.

Brauer S, Biller-Andorno PN, Andorno DR. Country reports on advance directives. 2008. Available from: http://www.ethik.uzh.ch/ibme/ veranstaltungsarchiv/2008/ESF-CountryReports.

10. Moorman SM. Older adults’ preferences for independent or delegated end-of-life medical decision-making. J Aging Health. 2011 [published online 2010 October];14;23(1):135-57. Pubmed Central PMCID: PMC3060618. 11. Emanuel LL, Barry MJ, Stoeckle JD, Ettelson LM, Emanuel EJ. Advance directives for medical care – a case for greater use. N Engl J Med. 1991;324(13):889-95. 12. Westphal C, Wavra T. Acute and critical care choices guide to advance directives. American Association of Critical Care Nurses. 2005 [Internet]. Available from: http://www.aacn.org/WD/Practice/Docs/Acute_and_Critical_Care_Choices_ to_Advance_Directives. 13. Berghmans RL. Advance directives for non-therapeutic dementia research: some ethical and policy considerations. J Med Ethics. 1998;24(1):32-7. 14. Degrazia D. Advance directives, dementia, and ‘the someone else problem’. Bioethics. 1999;13(5):373-91. 15. Furberg E. Advance directives and personal identity: what is the problem? J Med Philos. 2012;37(1):60-73. 16. Hughes JC. Views of the person with dementia. J Med Ethics. 2001;27(2):86-91. 17. Rosin AJ, van Dijk Y. Subtle ethical dilemmas in geriatric management and clinical research. J Med Ethics. 2005;31(6):355-9. 18. Rich BA. Personhood, patienthood, and clinical practice: reassessing advance directives. Psychol Public Pol Law: An Official Law Review Of The University Of Arizona College Of Law And The University Of Miami School Of Law. 1998;4(3):610-28.

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bitstream/handle/1871/31607/chapter_5.pdf?sequence=6. 26. Edwards C. Respect for other selves. Kennedy Inst Ethics J. 2011;21(4):349-78. 27. Quante M. Precedent autonomy and personal identity. Kennedy Inst Ethics J. 1999;9(4):365-81. 28. Jordens C, Little M, Kerridge I, McPhee J. From advance directives to advance care planning: current legal status, ethical rationales and a new research agenda. Intern Med J. 2005;35(9):563-6.

RCSIsmjoriginal article A comparison of staged and concurrent neo-adjuvant chemoradiotherapy in resectable locally advanced oesophageal carcinoma Abstract Introduction: Oesophageal cancer is the eighth most common cancer and sixth most common cause of death from cancer worldwide. Current overall five-year survival rates are at best 10%, largely due to the advanced stage of disease at presentation. Systemic disease requires systemic therapy, and thus the standard of care is neo-adjuvant chemoradiotherapy followed by surgery for the vast majority of patients. Aims: The aim of this retrospective study was to determine overall survival following two neo-adjuvant chemoradiotherapy regimes in patients undergoing multi-modal therapy (including oesophagectomy) for oesophageal carcinoma. Methods: One hundred and nine consecutive patients treated with neo-adjuvant chemoradiotherapy for oesophageal carcinoma between 2001 and 2011 were divided into two groups: 24/109 (22%) patients who underwent single-cycle induction chemotherapy followed by neo-adjuvant chemoradiotherapy and surgery (‘chemo-first’), and 85/109 (78%) who received concomitant neo-adjuvant chemoradiotherapy, followed by consolidation neo-adjuvant chemotherapy (‘CR-C’ group) prior to surgery. All 109 patients were followed up until the date of death or last clinical interaction. Follow-up and cause of death, if applicable, was determined by review of patient records. Results: Mean overall survival time for all patients was 50.9 (±7) months; 50.3 (±10) months for ‘chemo-first’ patients versus 43.1 (±7) months for ‘CR-C’ patients (p=0.080). Significantly higher rates of acute treatment-associated toxicity were seen in the ‘chemo-first’ patients (4/24, 16.67%) vs. the ‘CR-C’ patients (2/85, 2.3%) (p=0.001). Conclusion: There was no statistically significant difference in overall survival between the two groups. The ‘chemo-first’ treatment regime resulted in a greater number of treatment-related toxicities when compared with CR-C. Royal College of Surgeons in Ireland Student Medical Journal 2013; 6(1): 11-16.

Introduction David Brennan1 William White1 Dr Gary Bass2 Prof. Thomas N Walsh2 1

RCSI medical student

RCSI Department of Surgery, ScientificConnolly Author’sHospital, name1 1Scientific Author’s College Blanchardstown, Dublin 15

Oesophageal cancer is the tenth most common male and fourteenth most common female cancer (excluding non-melanoma skin cancers) in Ireland.1 Between 2000 and 2004, there were on average 296 male and 183 female cases of oesophageal cancer diagnosed in Ireland each year.1 During the same period, there were 296 male and 174 female deaths per year (giving an incidence:mortality ratio of 0.98).1 In men living in developed countries, only the UK has a higher incidence of oesophageal cancer than Ireland. It

is the seventh leading cause of cancer death worldwide, with a 2:1 male to female ratio. Patients will generally present with dysphagia, acid reflux, odynophagia, vomiting, loss of weight and poor appetite. Hiccups have also been shown to be a presenting symptom.2 Surgery is potentially curative in loco-regionally-advanced (i.e., early stage) oesophageal cancer, but the morbidity and mortality associated with oesophagectomy has restricted its use to a small minority of medically

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smjoriginal article RCSIsmj

fit patients.3 The majority of patients with oesophageal cancer who are initially staged as surgically curable are shown to have occult progressive systemic disease. Therefore, logically, early systemic therapy is essential. Multi-modal therapy (neo-adjuvant chemoradiotherapy followed by surgery) has been shown to have a 37% three-year survival rate compared with just 7% for those patients who received surgery alone.4 Chemotherapy, when given with radiation therapy pre-operatively, will produce a complete pathological response (cPR), with tumour eradication, in over one-third of patients.5-7 These patients would therefore no longer benefit from resection, but if operated on would be exposed to all the risks of surgery, including a risk of mortality of around 14% overall8 and 20% in the elderly,9-11 as well as a negative impact on their quality of life.12-15 Walsh and colleagues have previously shown that a complete clinical response (cCR) is 74% predictive of cPR and that surgery may even be avoided in these patients.16,17 The tumour lethality of external beam radiation therapy is related to its effects on deoxyribonucleic acid (DNA), with the introduction of single-stranded DNA breaks and, to a lesser extent, double-stranded DNA breaks. Absorption of gamma radiation in tissues leads to the immediate production of ionised atoms, which damage DNA. These in turn lead to the formation of unstable, short-lived free radicals, which interact with cellular constituents. The damage induced in a cell by ionising radiation is lethal or potentially lethal; in the latter case, the damage induced may be partially or completely repaired.18,19,20 Chemotherapy exhibits local effects that increase sensitivity of tumour cells to radiotherapy, while it is also used for its systemic killing of micrometastases. The most common chemotherapy protocol administered in oesophageal cancer treatment is ‘CF’, a

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combination of cisplatin and flurouracil (5-FU). Combining chemotherapeutic agents with radiotherapy has a multiplicative tumoricidal effect by intensifying the effect on local disease and reducing subsequent metastasis.18,19,20 Neo-adjuvant chemoradiotherapy was reported to enhance survival in a number of randomised trials4,5,19-29 and in some recent subsequent meta-analyses.22,24,30,31 The most widely used regime consists of neo-adjuvant chemoradiotherapy given initially, followed by a single one-week course of neo-adjuvant chemotherapy (‘CR-C’). The results of that study have been followed up for 15 years and are well documented. In 2000, due to logistical reasons arising from a surge in demand for radiotherapy facilities at St Luke’s Hospital, Dublin, following the introduction of the Irish BreastCheck programme, the order of the therapy was changed in Ireland. Subsequent patients were given single-cycle induction chemotherapy followed by neo-adjuvant chemoradiotherapy and surgery (‘chemo-first’). In 2012, the St Luke’s Radiation Oncology Network (SLRON) expanded to include new radiotherapy facilities in Beaumont Hospital, Dublin, and St James’s Hospital, Dublin, and the neo-adjuvant regime is to return to the initial ‘CR-C’ regime. The two regimes have never been compared. At this juncture, it would be worthwhile to evaluate whether both regimes are comparable on a non-inferiority basis, or whether the current ‘chemo-first’ regime is an improvement on the original ‘CR-C’ regime in terms of overall survival. This study reports a retrospective analysis of a prospectively accrued group of patients with oesophageal cancer in order to compare overall survival between two delivery regimes for neo-adjuvant chemotherapy and radiotherapy.

RCSIsmjoriginal article Methods From 2001 to 2011, 109 consecutive patients with a diagnosis of oesophageal cancer underwent a treatment regime consisting of neo-adjuvant chemotherapy and radiotherapy followed by surgery. A retrospective analysis of overall survival and chemotherapy-related toxicity was made, comparing 24 of these 109 patients, in whom a single course of induction chemotherapy was given prior to chemoradiotherapy and surgery (‘chemo-first’), and 85 of the 109 patients in whom a single dose was given after simultaneous chemoradiotherapy (‘CR-C’). Individual patient data was entered into an oesophageal cancer database containing demographic, clinical, operative, pathological and follow-up data. The database was locked for analysis on May 30, 2011. For the purposes of this study, all patients were followed up until the date of death or last clinical interaction. Follow-up and cause of death, if applicable, were determined by review of patient records. Overall survival was calculated from the date of diagnosis until the date of death or the last recorded clinical interaction.

Inclusion criteria The following criteria warranted inclusion into the trial: 1. Patient received the appropriate regime of neo-adjuvant chemoradiotherapy (discussed earlier). 2. Biopsy-proven adenocarcinoma or squamous cell carcinoma of the oesophagus (excluding cervical oesophagus) or the oesophageal gastric junction. 3. Leukocyte and platelet counts of greater than 3,500/mm3 and 100,000/mm3, respectively. Patients with levels outside these ranges are not deemed suitable for chemoradiotherapy. 4. Serum creatinine concentration less than 1.4mg/dL. Poor renal function is an absolute contraindication to receiving chemoradiotherapy.

Exclusion criteria The main criteria for exclusion from this study were patients who did not undergo surgery. These include patients with evidence of distant metastases, an Eastern Cooperative Oncology Group (ECOG) performance status [10] of 3 or 4, or co-morbidities contraindicating surgery. Patients who had previous chemotherapy or radiotherapy, or who had a neo-adjuvant chemoradiotherapy regime other than the one under investigation, were also excluded from this study. There was no restriction on the length of tumour or on the presence or location of lymph node metastases, as these were not considered contraindications to surgery.

Pre-operative tumour staging and classification Clinical staging of each tumour was elicited through physical examination and a combination of radiologic and endoscopic modalities. Oesophago-gastroscopy (OGD) with measurement of the longitudinal margins of the tumour was performed on all patients. Computerised tomography of the thorax and abdomen was also performed in most cases. Staging of tumours was based

on the American Joint Committee on Cancer (AJCC) guidelines for oesophageal cancer.32 Histopathology established a diagnosis of adenocarcinoma or squamous cell carcinoma in each primary case. Resection specimens were examined for the presence of metastatic lymph node deposits.

Neo-adjuvant chemoradiotherapy Each patient received one of two chemoradiotherapy regimes; they either received a single dose of neo-adjuvant sensitising chemotherapy followed by neo-adjuvant chemoradiotherapy (‘chemo-first’), or concomitant neo-adjuvant chemoradiotherapy first followed by a single dose of neo-adjuvant chemotherapy (‘CR-C’). As mentioned earlier, division of patients into either group was solely based on the time of their diagnosis with reference to the therapy protocol change in Ireland. All chemotherapy cycles followed the CF protocol – 5-FU, dosed at 15 milligrams per kilogram of body weight daily for five days, with cisplatin, 75 milligrams per square metre of body surface area on day seven. External beam photon radiation therapy (typically 40Gy, administered in 15 fractions over a three-week period, Monday to Friday inclusively) was begun concurrently with the final course of chemotherapy. All patients underwent treatment with megavoltage therapy units with 4 or 8MV photons (Cobalt model SEM100, Fairy Engineering, or Phillips model SL75-5 or Dynaray model 10, Radiation Dynamics, respectively). Radial and longitudinal margins of the tumour were defined endoscopically and radiologically, and the treatment fields extended 2-3cm and 5cm beyond the radial and longitudinal margins, respectively.

Statistics Statistical analyses were performed with Predictive Analytics Software version 18.0 for Windows. Continuous variables were expressed as mean ± standard error of the mean as appropriate, and were compared using analysis of variance (ANOVA) with post-hoc Student-Neuman-Keuls and Dunetts T3 tests for parametric and non-parametric variables, respectively. Categorical variables were compared using a chi-squared test, with Fishers exact test used where appropriate. Survival probabilities for clinical, pathological and treatment variables were estimated by the Kaplan–Meier method and pairwise comparisons were made using a log–rank test. The effect of extent of response to neo-adjuvant chemotherapy and external-beam radiation therapy (either administered sequentially or simultaneously, and then followed by surgical resection), tumour location, age, gender, WHO toxicity grading, TNM stage and time interval between chemotherapy and radiotherapy on survival were examined using logistic regression, and optimal cut-offs were determined using the maximal chi-squared method. Significant univariate factors were included in a Cox proportional hazards regression model to establish independent predictors of survival. P values of less than 0.05 were considered statistically significant.

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RCSIsmjoriginal article Table 1: Patient demographics and tumour characteristics.

Gender

Age at diagnosis

Tumour T-stage

Nodal status

Neo-adjuvant treatment regime Chemoradiotherapy (CR-C) Number % Number of patients of patients 64 75.3% 91

Male

Chemo first Number of patients 27

Female

27.0%

24.7%

25.4%

Total

100.0%

122

100.0%

>55

27.0%

15.5%

19.0%

55-67

24.3%

31.0%

28.9%

68-78

32.4%

26.2%

28.1%

78+

16.2%

27.4%

24.0%

Total

100.0%

121

100.0%

% 73.0%

All patients % 74.6%

14.3%

12.5%

13.3%

0.0%

12.5%

6.7%

14.3%

12.5%

13.3%

71.4%

62.5%

66.7%

Total

100.0%

44.4%

30.0%

36.8%

55.6%

70.0%

63.2%

Total

100.0%

Results Patient demographics Of the 109 patients studied, 24 (22%) were female and 85 (78%) were male. Twenty-four of the 109 patients (22%) were in the ‘chemo-first’ group (of whom three were female and 21 were male), while 85/109 (78%) were in the ‘CR-C’ group (of whom 64 were male and 21 were female). The mean age upon diagnosis was 66 years (ranging from 39-88 years). Patients were predominantly men in their seventies. Men tended to have received induction chemotherapy versus concomitant chemoradiotherapy, but this result was not statistically significant (p=0.091) (Figure 1). Patient demographic data are summarised in Table 1.

Toxicity In our study, 6/109 (5.5%) patients experienced acute treatment-associated toxicity. Four of the six patients had WHO Grade I toxicity, two in each of the two regimes. In the ‘chemo-first’ group, one patient experienced Grade II toxicity, while another had Grade III toxicity; there were no instances of Grade II or III toxicity in the CR-C group. Thus, significantly higher rates of acute treatment-associated toxicity were seen in the ‘chemo-first’ patients (4/24, 16.67%) vs. the ‘CR-C’ patients (2/85, 2.3%), placing these patients at a relative-risk increase of 3.43 (p=0.001) (Figure 2).

Overall survival following diagnosis The mean (± standard deviation) overall survival time for all 109

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included patients was 50.9 (±7) months. There was no detected difference in survival outcomes between the two groups; 50.3 (±10) months in the ‘chemo-first’ group versus 43.1 (±7) months for the ‘CR-C’ group (p=0.95). The results of this are summarised in the Kaplan–Meier survival curve shown, which estimates the survival function from lifetime data (Figure 3).

Discussion The management of oesophageal cancer is in constant evolution. In less than 100 years, the standard of care has evolved from hopelessness, where only palliative measures were possible, through surgery alone – constantly extending resection and refining selection criteria – to surgery following neo-adjuvant therapy, with or without the addition of adjuvant therapy, depending on the findings in the resected specimen. As more effective and targeted therapies are employed, and extended to earlier disease stages, we can anticipate a greater percentage of survivors. For squamous cell carcinoma (SCC) and adenocarcinoma (AC) of the oesophagus, neo-adjuvant therapy followed by surgery has become the standard of care in North America and parts of Europe. Ideally, complete responders (pCR) to neo-adjuvant therapy should not require surgery. A recent study of 299 patients with a pCR to neo-adjuvant therapy revealed a post-operative mortality rate of 5.7%, despite the cases being drawn from six 28 centres of excellence. Several studies suggest increased morbidity and mortality for patients undergoing preoperative 20,29,30 chemoradiation, identifying a further argument against

RCSIsmj original article P Sex Bar chart

Female 90

30 6.0

4.0

2.0

Frequency

2.0

4.0

P Tx Toxicity - WHO 1 2 3

2.0

1.5 Count

Age

Male

1.0

0.5

0.0 chemo first

6.0

simultaneous

Treatment algorithm

Frequency

FIGURE 1: Population pyramid demonstrating the patient demographics of included study patients.

FIGURE 2: Treatment-associated acute toxicity seen in patients following treatment with either ‘chemo-first’ or ‘CR-C’ (simultaneous) neo-adjuvant chemoradiotherapy. Acute toxicity was significantly more likely to occur in patients treated with the ‘chemo-first’ regime (4/24 vs 2/85 ‘CR-C’ patients, p=0.001).

submitting all these patients to resection, as well as one for ‘fine-tuning’ our neo-adjuvant chemoradiotherapy protocol.

In our study, acute treatment-associated toxicity was seen in a higher percentage of patients treated with chemo-first compared with CR-C, suggesting that combined therapy may be better tolerated if given first and, if optional, may provide a viable treatment strategy in many patients. Because of time constraints, tumour staging was not assessed in this study; this is a significant limitation as tumour stage and nodal status are known predictors of response to therapy and overall survival outcomes. Furthermore, time constraints on archive retrieval of date of diagnosis, and thus the ability to calculate accurate survival times, limited our Kaplan–Meier analysis of overall survival outcomes. Our interval analysis, presented here, failed to demonstrate a statistically significant difference in overall survival between groups. This apparent oncologic equivalence of both therapies is reassuring and may inform the logistic planning of treatment protocols in the future. A constraint of this investigation is the study design. As this study took advantage of a change in hospital protocol, it was not a 4 randomised controlled trial. Our original trial employed the CR-C neo-adjuvant treatment regime. This was then changed, for logistical purposes, to chemo-first. With the advent of the newly expanded SLRON radiotherapy capacity, we are now going ‘back to the future’ with a reversion to the originally trialled CR-C. On the basis of our limited study, we anticipate a decrease in treatment-related toxicity, and while we were unable to fully determine if a difference exists in survival between treatment protocols, our provisional data seem to suggest equivalent oncologic outcomes.

Treatment regime

100

chemo first CR-C

Overal survival (%)

40 p = 0.806

0 0

12 24

Time from first presentation (months)

FIGURE 3: Kaplan–Meier survival curve demonstrating comparison in overall survival between patients receiving ‘chemo-first’ and ‘CR-C’ regimes. While this comparison was limited by missing data, there was no statistically significant difference in overall survival between treatment groups by the log-rank method out to 100 months.

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Khorakiwala T, Arain R, Mulsow J, TN W. Hiccups: an unrecognised symptom of oesophageal cancer? Am J Gastroenterol. 2008;103(3):801.

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3-year survival in people with resectable oesophageal cancer. Cancer Treat Rev. 2004;30(1):141-4. 20. Le Prise E, Etienne P, Meunier B et al. A randomised study of squamous cell carcinoma of the oesophagus. Cancer.

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chemotherapy, radiation therapy, and surgery versus surgery for localised

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Keeling P, Gillen P, Hennessy T. Oesophageal resection in the elderly. Ann

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2005;6(9):659-68. 26. Urba S, Orringer M, Turrisi A, Iannettoni M, Forastiere A, Strawderman M. Randomised trial of preoperative chemoradiation versus surgery alone in patients with locoregional oesophageal carcinoma. J Clin Oncol. 2001;19(2):305-13. 27. Bosset J, Gignoux M, Triboulet J et al. Chemoradiotherapy followed by surgery compared with surgery alone in squamous cell cancer of the oesophagus. N Engl J Med. 1997;337(3):161-7. 28. Apinop C, Puttisak P, Preecha N. A prospective study of combined therapy in oesophageal cancer. Hepatogastroenterology. 1994;41(4):391-3. 29. Nygaard K, Hagen S, Hansen H et al. Pre-operative radiotherapy prolongs survival in operable oesophageal carcinoma: a randomised, multicentre study of pre-operative radiotherapy and chemotherapy. The second Scandinavian trial in oesophageal cancer. World J Surg. 1992;16(6):1104-9; discussion 10. 30. Urschel J, Vasan H. A meta-analysis of randomised controlled trials that compared neoadjuvant chemoradiation and surgery to surgery alone for resectable oesophageal cancer. Am J Surg. 2003;185(6):538-43. 31. Greer S, Goodney P, Sutton J, Birkmeyer J. Neoadjuvant chemoradiotherapy for oesophageal carcinoma: a meta-analysis. Surgery. 2005;137(2):172-7. 32. American Joint Committee on Cancer. AJCC cancer staging manual. Esophagus (6th ed.). New York: Springer; 2002.

RCSIsmj original article An audit of patients currently using legally acquired cannabis as a means of managing chronic pain Abstract Introduction: Chronic pain constitutes a significant challenge to healthcare today. In Canada, it is estimated that it costs healthcare over $6 billion per year. This audit investigates the medically approved use of cannabis in the treatment of chronic pain in 29 patients at the Alan Edwards Pain Management Unit of the Montreal General Hospital (MGH). Methods: Twenty-nine patient charts were accessed at MGH. Relevant patient and usage information were collected from both patient charts and Marijuana Medical Access Regulations (MMAR) documents and compiled into a spreadsheet for analysis. Results: Information gathered from 19 males and 10 females revealed that chronic back pain was the most common cause of chronic pain. In addition to cannabis, 11 were currently taking prescribed narcotic medications, five were taking synthetic cannabinoids, and five were using over-the-counter medications. The remaining eight used cannabis alone as their primary means of managing pain. All patients reported improvements in pain after using cannabis. Conclusions: This audit suggests that cannabis can be effective at managing mild to moderate levels of pain in patients suffering from a variety of pathologies. Considering the economic, psychological and physical burden associated with pain, and the growing problem of prescribed narcotic dependency around the world, the need for further research into the uses of cannabis as an alternative method of pain management is clear.

Royal College of Surgeons in Ireland Student Medical Journal 2013; 6(1): 17-21.

Introduction

Alexander Constas1 Dr Mark Ware2 1RCSI medical student 2Director of Clinical Research,

Alan Edwards Pain Management Alexander Constas Unit, McGill University Health1 RCSI medical student Centre, Montreal, QC, Canada

Chronic pain is one of the most significant challenges facing healthcare today. It is defined as â&#x20AC;&#x153;pain that persists beyond the expected time of healing, or more than three to six monthsâ&#x20AC;?.1 In Canada, it is estimated that chronic pain costs healthcare more than $6 billion per year, more than cancer, heart disease and HIV combined. Lost productivity related to job loss and sick days cost an estimated $37 billion per year.2 This illustrates the immense burden of chronic pain on the healthcare system, the economy and, most importantly, the everyday life of many Canadian citizens, and suggests the need for improvement in chronic pain management. Current medical practices offer patients treatment options ranging from mild analgesics to strong narcotics, along with more invasive approaches such as nerve blocks. These options have been shown to help

many patients; however, issues such as opiate dependency and adverse pharmacological effects have led some Canadians to pursue alternative treatments. One such alternative has become a hotly debated therapy in Canada: the use of cannabis and its derivatives. A Canadian study reported that up to 15% of patients presenting to tertiary care pain management centres have used cannabis, and that 10% continue to use it as a means of managing their pain.3 One study of 30 patients using cannabis to treat various pathologies showed that 93% (n=28) of these patients reported pain relief greater than or equal to 6/10.4 Therefore, in order to accommodate patients suffering from various conditions who find cannabis an effective therapy, the Canadian Government established The Canadian Marijuana

Volume 6: Number 1. 2013 | Page 17

RCSIsmjoriginal article Medical Access Regulations (MMAR) in 2001. This programme allows Canadian patients with a prescription to apply for an exemption to Section 56 of the Criminal Code of Canada, which, if approved, would provide them with legal access to and the right to possess medicinal marijuana. However, an online survey of 607 physicians conducted by the Canadian Medical Association in June 2012 suggested that Canadian physicians have been reluctant to consider it a management option due to a lack of research and established prescribing guidelines for cannabis. The following audit will investigate the medically approved use of cannabis in the treatment of chronic pain in 29 patients at the Alan Edwards Pain Management Unit of the Montreal General Hospital (MGH). Using qualitative and quantitative data collected from medical charts, this audit will attempt to illustrate patient experiences and needs when managing chronic pain with cannabis, with the goal of providing insight into how cannabis is used medicinally in Canada.

Methods Ethical approval A proposal establishing study aims and methods was compiled and submitted to the McGill University Health Center research ethical review board for approval. Once ethical approval was granted, access to patient medical files was provided.

Study population Patient charts from the Alan Edwards Pain Management Unit were consulted. All patients currently being treated with cannabis and registered with the MMAR were included. MMAR registration was determined by cross-referencing patient files with MMAR documents and ensuring that the MMAR documents were not expired. No other patient selection restrictions such as age, sex, race, etc., were imposed.

Data collection A list was compiled (n=29) of all included patients. Their charts were then accessed and relevant patient and usage information, such as current medications, dosages, illnesses, symptoms, adverse effects, address and monthly cannabis allowance, was collected from both patient charts and MMAR documents and compiled into an Excel spreadsheet (Microsoft Excel 2010; Microsoft Corporation, WA, USA). Patient information was coded with initials and hospital chart number. Collected data never left the hospital with identifying information. Once all patient information was organised into Excel, two tables were created to clearly present patient diagnoses and patient accounts regarding symptomatic relief attributed to cannabis. Four graphs were also generated, two illustrating quantitative data, including daily frequency of cannabis use and average daily dose, and two illustrating qualitative data, including method of cannabis consumption and symptomatic relief reported by patients.

Data analysis Using the data collected regarding individual patient experience, similarities and differences that arose between reports regarding levels of pain relief, dosage requirements, frequency of use, needs of

Page 18 | Volume 6: Number 1. 2013

adjunctive pain relief, other symptomatic relief (apart from pain) attributed to cannabis use and methods of acquiring cannabis were considered. Trends observed while analysing this data were then used to form and justify relevant conclusions.

Results Patient demographics Of the 29 patients included in this study, 10 were female and 19 were male. The patient age range was 26-70 with a median age of 47.

Aetiology of chronic pain Table 1 lists the medical diagnoses responsible for the chronic pain suffered by individual patients included in this audit. This table illustrates the vast array of medical conditions causing chronic pain within this patient population, ranging from multiple sclerosis and phantom limb pain to spinal cord trauma and arthritis. Chronic back pain was the most common complaint, with a total of eight patients experiencing such discomfort.

Medication used by patients to manage pain A total of 21 patients were on medications other than cannabis to reduce pain (this includes prescription cannabinoids such as nabilone and nabiximols, over-the-counter products such as paracetamol and narcotic medications). Of these 21 patients, 11 were taking an opioid, five were on prescription cannabinoids, and five were using over-the-counter medication. The remaining eight used cannabis as their primary means of managing pain. These eight patients reported that, based on prior experience with more traditional pain medication, cannabis was comparatively the most effective remedy for their pain with the fewest adverse effects. Before cannabis was used as an intervention for pain in these patients, all of the patients included in this study had been prescribed a narcotic medication to help manage their pain. In many cases, these medications were abandoned due to adverse effects or dependency issues, factors that eventually led many of these patients to try cannabis instead.

Symptomatic improvement attributed to cannabis use Of the 29 patient charts, 20 had recorded average pain levels using a visual analogue pain scale (VAS) (0 = no pain, 10 = agonising pain), with a range of 4-9 and a mean of 7. Nine patient charts had no recorded pain levels. All patients expressed noticeable improvement in their pain after medicating with cannabis. Seven reported improvements in quality of sleep, one reported relief from nausea, two reported relief from muscle spasms, two reported relief from stress and anxiety, one reported improvement in appetite, one reported decreased diarrhoea, and one reported relief from cramps (Figure 1). Four of the 29 patients gave specific accounts regarding the degree of symptomatic relief attributed to cannabis. One reported complete relief, one indicated a five-point improvement on the VAS, one reported â&#x20AC;&#x153;greatâ&#x20AC;? relief, and the last reported a dramatic decrease in pain for three to four hours following cannabis consumption. Degree of symptomatic relief was not described in the remaining 25 patient files.

RCSIsmjoriginal article

Age (years)

Sex

Pain diagnosis

26 28 32 33

M F F F

35 37 39 41 42 43

M M M M M M

52 53 53

F M M

58 59 62 64 70

F M M M M

Pain secondary to spinal cord trauma Chronic daily headaches Complex regional pain syndrome (type 1) Chronic myofascial back pain after road traffic accident (with muscle spasms) Severe pain and muscle spasm secondary to spinal cord trauma Systemic lupus erythematosus and transverse myelitis Herniated disc Pain in legs following fracture of vertebra T3 Neuropathic pain due to nerve entrapment Trochanteric bursitis Right shoulder pain following work accident Generalised myofascial pain secondary to trauma Neck pain radiating to occipital region secondary to whiplash injury Spondylolisthesis of lumbar spine and degenerative disc disease Myofascial pain syndrome affecting face and chronic tension headaches Pain radiating from back to arms and legs secondary to cervical vertebrae fracture Lingual pain affecting jaw and face Idiopathic intestinal pseudo-obstruction Arthritis and diarrhoea associated with Crohn’s disease Post-traumatic neuropathic pain in right hand; lower back pain Iatrogenic pain (post neuroma removal) affecting head, neck, shoulders and arms Common peroneal nerve entrapment affecting left calf; lower back pain Chronic neuropathic facial pain secondary to brain tumour removal Scapular pain following concurrent humerus fracture and shoulder dislocation Multiple sclerosis Phantom limb pain Severe arthritic pain Left common peroneal nerve neuropathy Degenerative disc disease, spondylosis, stenosis of lumbar spine

32 28

Number of patients

Table 1: Pathologies causing pain in 29 patients using cannabis therapeutically. Common conditions include chronic back pain, chronic pain as a result of trauma, autoimmune conditions and various neuropathies.

24 20 16 12 8 4 0

Pain

Sleep

Nausea

Muscle spasms

Stress and Anorexia anxiety

Diarrhoea

Cramps

Symptom

FIGURE 1: Symptoms reportedly improved using cannabis. This figure shows that apart from pain relief, cannabis provided relief from other symptoms such as sleep disturbance (n=7), nausea (n=1), muscle spasms (n=2), stress and anxiety (n=2), anorexia (n=1), diarrhoea (n=1) and cramps (n=1).

Patient cannabis use Under MMAR regulations, seven patients were allowed to possess up to 30g of cannabis per month, eight were allowed to possess up to 60g/month, 10 were allowed up to 90g/month, one was allowed up to 120g/month, two were allowed up to 150g/month and one was allowed up to 450g/month. Average length of cannabis use to treat symptoms was reported in 28 patients. There was a range of one to 13 years of use and a mean of 6.3 years of use. Of these 28 patients, 25 reported daily use, two reported weekly use and one reported use as needed. Of the 29 patient charts, 25 had documented frequency of daily use (Figure 2) and four had no documentation. Grams of cannabis used per day were documented in 27 patients and ranged from less than 1g to 15g. Twenty-three patients reported using less than 3g per day, while three reported using more than 3g per day, and two had no reported daily use (Figure 3). Cannabis was consumed by smoking (pipe or joint), vaporisation, and in edible forms (Figure 4). Occasional use of cannabis for recreational purposes (use for the purpose of enhancing recreational experience and not for medicinal reasons) was reported by three patients, 21 reported using solely for medicinal purposes, and five patients did not have information regarding motivation for use documented.

Patient comments regarding their cannabis treatment Table 2 shows comments made by 17 patients regarding their treatment with cannabis. Of the 17 patient comments, 11 claimed improvement in pain when using cannabis. Some examples include: n “Cannabis decreases pain and increases sleep.” n “Cannabis decreases pain, anxiety and depression and increases functionality.” Four of the 17 patients claimed that the nature of the pain relief associated with cannabis use was best described as a disconnect or loss of focus on the pain itself: n Cannabis “disconnects pain.” n “Cannabis takes mind off pain, able to enjoy activities.” Five patients described an increased ability to participate in

Volume 6: Number 1. 2013 | Page 19

RCSIsmjoriginal article 9 8

Number of patients

7 6 5 4 3 2 1 0

PR N ot re po rte d N

Dose

ID -5 Q

D -6 TI

TI D

D -Q ID BI

D -T BI

Q D -B

Q D

1-2

2-3

Not reported

Dose (grams)

FIGURE 2: Number of times cannabis is consumed per day. This figure shows that for 11 patients in this study, consuming cannabis between once and twice daily was sufficient to manage their symptoms. Nine needed to consume more than twice a day, three consumed once daily, one consumed as needed and four had no reported frequency of use on a given day. (QD = daily, BID = twice daily, TID = three times daily, QID = four times daily, TID-6 = three to six times daily, QID-5 = four to five times daily, etc.)

FIGURE 3: Daily dose of cannabis. This figure demonstrates a wide range of dosage requirements among patients. Requirements ranged from less than 1g per day to as much as 15g per day. Two patients had no reported daily dosage.

activities of daily living, two mentioned decreased reliance on opiates to manage pain when using cannabis, two claimed that cannabis was more effective at controlling their pain than prescription cannabinoids (nabilone and nabixamols): n Pain is reduced from 8-9 to 3-4 after smoking cannabis and “cannot tolerate” prescription cannabinoids. n “Cannabis use prevents need to use morphine sulphate.” n Cannabis better than nabilone for relief and decreases opiate need. Increases appetite, prevents cramps, increases relaxation.

consumption of cannabis, detailed dosing patterns, and descriptions of side-effects, mean that it is difficult to establish a definitive position regarding the effectiveness of this treatment. An important limitation is the lack of statistical significance owing to the small sample size. This being said, studies have been conducted that provide more concrete evidence of the analgesic properties of cannabis. In a separate study of 30 patients using cannabis to treat pain, 28 reported pain relief greater than or equal to 6/10 (on an 11-point numeric scale where 0 = no relief and 10 = complete relief) following the consumption of cannabis.3 If future studies support these findings, the implications for the future of pain management are significant. Furthermore, if cannabis reduces widespread patient opioid reliance, this could lead to a reduction in drug dependency along with other unwanted side-effects. This audit indicated that of the 29 included patients, only 11 were currently consuming prescribed narcotics while also consuming cannabis. However, before adding cannabis to their treatment regimen, the majority of the patients required prescribed narcotics to manage their pain. This suggests the possibility that cannabis may have helped to reduce the need for narcotic medication to manage pain in up to 62% of the patients in this audit. However, it would be premature to attribute this dramatic decrease in use of narcotic medications solely to the effectiveness of cannabis as it was not explicitly described in patient charts as the reason for the reduction. However, this is a hypothesis that warrants further investigation. When considering the dosing of cannabis (Figures 2 and 3), it is evident that individual patient requirements in this context varied from one case to another with no observable pattern. Current research regarding marijuana dosing acknowledges this variability between patients and suggests that a patient-determined, self-titrated dosing model is recommended and relatively safe considering the low toxicity of cannabis.5 Finally, it is important to consider adverse effects associated with using cannabis and the sequelae related specifically to smoking the drug.

Reported side effects of cannabis Three patients reported side-effects associated with their cannabis use, which included decreased motivation, apathy, drowsiness, throat irritation, increased libido, palpitations and mild sadness. There was insufficient information regarding side-effects experienced by the remaining 26 patients.

Supply of cannabis Cannabis was acquired by patients from four sources: Health Canada (n=16), compassion clubs (n=9), miscellaneous underground sources (e.g., friends, dealers and other unqualified distributors) (n=5), and self-grown (n=6). Eight patients used a combination of sources. One patient did not report source of cannabis.

Discussion The data collected from 29 patients at the Alan Edwards Pain Management Unit at the MGH provides an insight into medical cannabis use in Canada. It indicates that cannabis may very well be a viable alternative or adjunctive treatment for chronic pain. The variety of the study participant pain diagnoses (outlined in Table 1) and their use of cannabis to help manage their pain, illustrates the potentially versatile applications of this drug. However, the small sample size and limited reporting of variables such as pain levels before and after the

Page 20 | Volume 6: Number 1. 2013

RCSIsmjoriginal article Table 2: Summary of patient comments on cannabis effectiveness. Patients reported reduction in pain and concentration on pain, reduced reliance on narcotic medications, increased functionality, and increased participation in daily activities.

Number of patients

Comment n Cannabis decreases pain, anxiety and depression, and increases functionality n Pain is reduced from 8-9/10 to 3-4/10 after smoking cannabis. Did not tolerate prescription cannabinoids n Cannabis helps sleep n Cannabis helps with pain n Cannabis use prevents need to use morphine sulphate n Cannabis “numbs” pain. Pain increases significantly when cannabis is stopped. Now only uses cannabis but has tried Neurontin, Voltaren, Celebrex and Vioxx in the past without much improvement. Mentioned that he doesn’t want to go out when stoned (negative side-effect) n Cannabis helps decrease pain and increase activity n Cannabis “disconnects pain”. Increased energy and communication n Feels cannabis the only prescription needed (doesn’t need prescriptions when on cannabis) n Cannabis decreases pain, increases sleep n Cannabis decreases focus on pain allowing for increased activity n Dramatic decrease in pain with cannabis. Nabiximols helped but wasn’t always effective. n Cannabis better than nabilone for relief and decreases opiate need. Increases appetite, prevents cramps, increases relaxation n Cannabis decreases hospitalisation and increases sleep n Cannabis “keeps me from going crazy” n Cannabis takes mind off pain, able to enjoy activities n Cannabis helps with pain

Smoking only

Eating only

Eating and vaporisation

Smoking and Smoking and vaporisation eating

Smoking, eating and vaporisation

Method of ingestion

FIGURE 4: Method of cannabis consumption. This figure illustrates that smoking is by far the most popular route of administration among the patients in this study. Twenty-four patients described smoking as at least one of their chosen methods of consumption.

Side-effects reported in four patient charts included decreased motivation, apathy, drowsiness, throat irritation, increased libido, palpitations and mild sadness. Due to the low number of patients reporting side-effects, it is impossible to identify the incidence and prevalence of the reported side-effects on a large scale; however, this issue will be addressed in a follow-up study where patients will answer a questionnaire. It would also be necessary to assess whether or not long-term use of cannabis can lead to dependency. Smoking cannabis is the most common method of consumption among the patients in this audit (Figure 4). Current research is divided regarding the long-term health effects of smoking cannabis such as links between smoking cannabis and the development of cancer. Considering the known consequences of smoking tobacco, it is imperative that further studies be carried out to help establish definitive conclusions. Another concern regarding long-term use of cannabis involves the development of psychiatric disorders. Studies have demonstrated links between significant adolescent cannabis use and schizophrenia, as well as cognitive impairment (such as short-term memory loss). These risks must therefore be carefully considered.

Conclusion In conclusion, data collected in this audit suggests that cannabis can be effective at managing mild to moderate levels of pain in patients

suffering from a variety of pathologies. Considering the economic, psychological and physical burden associated with pain, and the growing problem of prescribed narcotic dependency around the world, the need for further research into the uses of cannabis as an alternative to pain management is clear and definitive. With the possibility of a new and effective treatment comes hope for millions around the world who suffer every day with debilitating pain.

References 1.

Weiner DK. Office management of chronic pain in the elderly. J Medicine. 2007;120(4):306-15.

Ware MA, Gamsa A, Persson J, Fitzcharles MA. Cannabis for chronic pain:

Carter GT, Weydt P, Kyashna-tocha M, Abrams DI. Medicinal cannabis:

Schopflocher D, Jovey R et al. The Burden of Pain in Canada, results of a Nanos Survey. Pain Res Manage. In Press, 2010.

Access Regulations. J Pain Symptom Manage. 2006;32(5):497-501. 4.

Lynch ME, Young J, Clark AJ. A case series of patients using medicinal

case series and implications for clinicians. Pain Res Manage. 2002;7(2):95-9. rational guidelines for dosing. IDrugs. 2004;7(5):464-70.

marihuana for managment of chronic pain under the Canadian Marihuana

Volume 6: Number 1. 2013 | Page 21

RCSIsmj original article Investigation of host and pathogen responses to oestrogen in cystic fibrosis Abstract Introduction: A â&#x20AC;&#x2DC;gender gapâ&#x20AC;&#x2122; exists in cystic fibrosis (CF). Females acquire earlier microbial infections and have a worse prognosis. The sex hormone oestradiol (E2) has recently been highlighted as a key molecule responsible for the CF gender dichotomy. Pseudomonas aeruginosa (Ps. aeruginosa) colonises the CF lung dominating at end stages and undergoes mucoid conversion in response to E2. The aim of this project is to investigate other roles of E2 in host and pathogen, in particular its effects on the growth rate of Ps. aeruginosa and the expression of catalase and superoxide dismutase (SOD) in CF bronchial epithelial cells. Methods: Growth rate of Ps. aeruginosa (strain PA01) in the presence or absence of E2 was measured by optical density (OD600nm) and by calculating colony-forming units (cfu) per ml. Catalase and SOD gene expression in E2-treated CFBE41o- airway epithelial cells were measured using quantitative reverse transcriptase polymerase chain reaction (qRT-PCR). Results: E2 had no effect on the growth rate of Ps. aeruginosa when compared to control. The expression of catalase mRNA was not altered in CFBE41o- cells in response to E2; however, there was a two-fold increase in SOD gene expression in response to 10nM E2, at 24 hours (p=0.0057). Conclusion: Oestradiol has no effect on the growth rate of Ps. aeruginosa in vitro. In CF bronchial epithelial cells, although catalase gene expression remains unchanged, E2 increases SOD expression, potentially increasing hydrogen peroxide levels and contributing to Ps. aeruginosa mucoid conversion. Royal College of Surgeons in Ireland Student Medical Journal 2009; 6(1): 22-6.

Moyser Mulla1 Dr Catherine M. Greene2 1RCSI medical student 2Senior Lecturer in

Medicine, RCSI

Page 22 | Volume 6: Number 1. 2013

RCSIsmj original article Introduction Cystic fibrosis (CF) is a common autosomal recessive inherited multisystem disorder. Ireland has the highest incidence worldwide.1 It is caused by a mutation in the gene that encodes for the cystic fibrosis transmembrane regulator (CFTR). CFTR regulates the chloride ion (Cl-) intracellular/extracellular balance and impairment disrupts normal lung, pancreatic, reproductive and immune functions.2 This imbalance increases the production of mucus, predominately in the lungs, resulting in the formation of mucus plugs. The accumulation of such plugs impairs mucociliary clearance promoting the growth, proliferation and survival of microorganisms in the lungs. Among many of the bacteria that colonise the CF lungs, Ps. aeruginosa is the organism that dominates during the end stages of CF disease.3 Ps. aeruginosa can convert from a non-mucoid to a more harmful mucoid morphology in the lungs of people with CF; this event is associated with alginate production, biofilm formation and antibiotic resistance. Mucoid Ps. aeruginosa is associated with a 1 worse prognosis in CF. While affecting both male and female patients, recent studies have highlighted the existence of a gender imbalance. The prognosis of CF in females is generally worse than in males. Not only do women have poorer survival rates, they also tend to acquire bacterial infections at an earlier stage than men, especially with Ps. aeruginosa. However, this is observed only after puberty. Therefore, the idea of bacterial endocrinology was questioned, as there seemed to be hormonal influence on bacterial colonisation. The role of the sex hormone oestrogen became the main focus of current work by investigating its contribution, if any, to the observed gender gap in CF.2,4 Oestradiol (E2), the predominant form of oestrogen in non-pregnant females, has been shown to have an effect on various factors in the female with CF. Oestrogen plays a role in the innate immune system in both non-CF and CF lungs, and it inhibits interleukin (IL)-8 signalling and gene expression via inhibiting NF-κB activity in bronchial epithelial cells.5 It has also been established that E2 plays a major role in the Ps. aeruginosa mucoid morphology conversion through a genetic mutation in the mucA gene.1,6 This mutation is caused by E2 decreasing the activity of catalase (CAT) in the bacteria. This enzyme is responsible for degrading the DNA-damaging free radical hydrogen peroxide (H2O2). Impairing this process leads to the genetic mutation in mucA and induces the mucoid transformation of the bacterial pathogen. What has not yet been established is the relationship between E2 and the growth rate of bacteria. It also remains unclear if E2 has an effect on CAT activity in CF, and more specifically on the expression of CAT or related enzymes. The aim of this project was to study the role of E2 on the pathogen and host in a CF context. This was done through the investigation of: 1) the effect of E2 on Ps. aeruginosa growth rate; and, 2) E2’s effects on the expression of CAT and superoxide dismutase (SOD), both enzymes having a direct role in reducing H2O2 levels.

Methods The host response Tissue culture Cell line Delta F508 homozygous bronchial epithelial cells (CFBE41o-) were 2 grown in a T-75 (175cm ) fibronectin pre-coated Corning flask. o Cells were maintained in a 37 C, humidified 5% CO2 incubator and nourished with minimum essential media with earl salt (MEM) supplemented with 10% foetal bovine serum (FBS) and 1% Penicillin-Streptomycin (P/S; Gibco). Old media was replaced with 8-10ml of fresh MEM every two days.

Sub-culturing

Cells were seeded on 12 wells in a 24-well plate (1 x 10 cells/ml) and left to incubate over a 12-hour period. They were re-fed with serum free MEM medium containing 1% P/S and cultured as described above for two hours prior to treatment. The treatment was E2 dissolved in 100% ethanol (EtOH). This solution was serially diluted in serum-free MEM containing 1% P/S, and added to the serum-starved cells to achieve a final concentration of 10nM per well. As a vehicle control, EtOH was similarly diluted in the same medium and added to cells. Three wells received E2 treatment and another three received the control at the first six-hour interval. The remaining six wells received the same treatment at the second time point, 24 hours. Each treatment was carried out in triplicate. Both E2 and EtOH controls were freshly prepared prior to each experiment and used immediately. Six and 24 hours post treatment, well contents were centrifuged simultaneously – after the 24-hour treatment at 250 x g for five minutes – and the supernatants carefully discarded.

Isolating RNA At the first time point, six hours, three wells of E2 treatment were treated with 500µl TRI-reagent,7 transported into three microfuge o tubes and stored at -80 C. The same was performed for the vehicle control. This was also carried out at the second time point (24-hour). In total there were 12 wells (6hr; 3 x E2, 3 x EtOH, and 24hr; 3 x E2 and 3 x EtOH). RNA was isolated from the CFBE41o- cells using 0.1ml TRI-reagent chloroform, 0.25ml isopropanol, washed with 0.5ml of 75% ethanol (EtOH) and supplemented with 30µl of 0.1% diethyl pyrocarbonate (DepC)-treated H2O following the manufacturer’s protocol. RNA quantification was carried out using a Nanodrop 8000.

cDNA synthesis CFBE41o- RNAs were diluted with DepC H2O to make equal amounts of 5µl of each sample. There were two processes involved in copy DNA (cDNA) synthesis; a reverse transcriptase kit was used.8 The first of the two steps was genomic DNA (gDNA) elimination. This was achieved by treating each tube with gDNA wipe-out buffer (x7) and RNAse free H2O (2:7). The second was treating the samples with reverse transcriptase (RT). The 12 samples were placed in a PCR heating block for the final o step of cDNA synthesis. These were incubated at 42 C for 30 minutes o o then 95 C for three minutes and finally allowed to cool at 4 C.

Volume 6: Number 1. 2013 | Page 23

RCSIsmjoriginal article E2 versus ethanol growth curve

1.0x1010

0.9 E2 Ethanol

0.8 0.7

8.0x1009

CFU/ml

OD600

0.6 0.5 0.4 0.3

6.0x1009

EtOH E2

4.0x1009

0.2 0.1

2.0x1009

0.0 0

5 16

Time (hrs)

0 6

24 Time (hrs)

FIGURE 1: Effect of oestradiol (E2) on Ps. aeruginosa growth rate. Optical density (OD) measurements taken at hourly, six-hour and 24-hour intervals, to assess the growth rate of Ps. aeruginosa in the presence of E2 in comparison with ethanol (EtOH).

FIGURE 2: Colony-forming units (cfu/ml) were calculated measuring the growth of Ps. aeruginosa at six and 24 hours.

Catalase and superoxide dismutase (SOD) primers

Oestrogen treatment

CAT and SOD primers were designed and ordered at the start of the project. The cDNA sequence required for each enzyme was found in PubMed Nucleotides. Then it was converted into the FASTA format, a written nucleotide sequence where base pairs are represented by letters, which was needed to define the parameters of the sequence. Once the parameters were defined, they were put in an online polymerase chain reaction (PCR) analysis tool, Primer 3. During the experiment CAT and SOD primers were diluted to obtain a 10pM/µl solution using RNAse free H2O.

10µl of Ps. aeruginosa was inoculated in a 10nM solution of diluted E2 and 10nM EtOH solution (control), then both solutions o were placed to grow in an orbital shaker (200rpm, 37 C).

Quantitative reverse transcriptase-polymerase chain reaction (qRT-PCR) A PCR master mix was made containing one of the enzyme primers, CAT, SOD or glyceraldehyde 3-phosphate dehydrogenase (GAPDH). GAPDH was used as the housekeeping gene. They were distributed, each per well in a PCR well plate; 12 in total. Each well contained 18µl of the PCR master mix. Another 2µl of the E2/EtOH-treated CFBE41o- cells at either six or 24 hours was added separately to each of the PCR wells. The PCR plate was centrifuged, 2000rpm for two to three minutes, and then placed in the LightCycler 480 PCR machine o (Roche). Amplification settings were set to denaturing at 95 C for five o minutes, 45 cycles (each cycle denaturing at 95 C for 10 seconds, o o annealing at 65 C for 10 seconds and elongation at 7 C for 10 seconds). Gene expression quantification of CAT and SOD expression was calculated and statistically analysed.

The pathogen response Ps. aeruginosa isolates A colony of Ps. aeruginosa strain 01 (PA01) was cultured in 30ml of tryptic soy broth (TSB) and left to grow overnight in an orbital o shaker (200rpm, 37 C).

Page 24 | Volume 6: Number 1. 2013

Microbial enumeration measurements The growth rate of Ps. aeruginosa in the presence or absence of E2 was measured spectrophotometerically (eppendorf BioPhotometer), by recording the optical density (OD) at 600nm six times at hourly intervals, then at six-hour and 24-hour time points. However, to determine the number of live colonies that grew in the presence of +/- E2, 1:100 serial dilution method was used by plating 100µl on a o tryptic soy agar plate and leaving it in an aerobic incubator (37 C 5% CO2) overnight. Serial dilutions were used as a protocol for enumeration of bacteria in a population.9 The colony-forming units (cfu/ml) were calculated and statistically analysed.

Statistical analysis All triplicate experiments were statistically analysed using a two-tailed t-test in Graphpad PRISM 5.0.

Results E2 did not significantly affect the growth rate of Ps. aeruginosa Spectrophotometric measurements of Ps. aeruginosa (PAO1) growth showed no significant difference in the growth rate when treated with 10nM E2 compared to EtOH after six hours (Figure 1). This was confirmed when bacteria numbers were measured in cfu/ml (Figure 2). Compared to cultures grown in the presence of EtoH where there were 0.2 x 109cfu/ml after six hours, cultures similarly grown in E2 contained 0.1 x 109cfu/ml. After 24 hours control cultures contained 4.6 x 109cfu/ml. This was not

RCSIsmj original article A

0 EtOH 24hr

E2 6hr

SOD

CAT

E2 24hr

EtOH 24hr

E2 6hr

E2 24hr

FIGURE 3: Effect of oestradiol (E2) on catalase (CAT) and superoxide dismutase (SOD) gene expression. a) Illustrates the overall gene expression of CAT in CFBE41o- cells that were treated at six and 24 hours in comparison to the control EtOH 24-hour sample. b) Illustrates the overall gene expression of SOD in CFBE41o- cells that were treated at six and 24 hours in comparison to the control EtOH 24-hour sample. *p<0.01

significantly different from cultures grown in the presence of E2, which contained 4.1 x 109cfu/ml.

E2 affected the expression of SOD The expression of CAT and SOD under the influence of E2 was measured using RT-PCR. The expression of CAT at an mRNA level decreased at six hours then increased at 24 hours but showed no statistical significance (Figure 3a). In comparison the expression of SOD was significantly affected by the presence of E2. There was a significant decrease at six hours (p=0.0001) and a two-fold increase at the 24-hour interval (p=0.0057) (Figure 3b).

m las

p yto

O2 +H2O

O2e Superoxid se ta u dism

2 H 2O

Catala

Discussion In the emerging field of microbial endocrinology, which combines endocrinology and microbiology, the effect that E2 has on microbial characteristics and activity is currently being investigated.10 Oestrogen has been shown to affect bacterial morphology of Ps. aeruginosa by inducing alginate production.1 On a genetic level, it has been shown to cause a mutation in the mucA gene, which induces the production of alginate and in turn causes the mucoid conversion of Ps. aeruginosa. The relationship between E2 and the growth of Ps. aeruginosa has not yet been investigated. In our attempt to explore the effect we discovered that short exposure of E2 solely had no significant effect on the bacterial growth of Ps. aeruginosa. Little is understood of what affects the bacterial growth during the initial hours and days. Chotirmall et al. showed recently that mucoid conversion of Ps. aeruginosa in the presence of E2 happens after four weeks.6 Furthermore, the effects of E2 have also been mediated through the activation of oestrogen receptors (ERs), both alpha and beta, throughout various organs in the body.6 These receptors have effector mechanisms that are genomic, inducing gene

FIGURE 4: Oxygen reduction pathway. Illustrates the reduction pathway of oxygen free radical species. The superoxide anion (O2-) produced by partial metabolism of O2 both in the cytoplasm and mitochondria is reduced to hydrogen peroxide (H2O2) by the enzyme superoxide dismutase (SOD). H2O2 is further reduced to H2O and O2 by the catalase enzyme. In the cystic fibrosis bronchial epithelial cell, increased activity of SOD and catalase inhibition both contribute to an increased level of H2O2, a DNA-damaging free radical. transcription, or non-genomic, involving more rapid extra-nuclear pathways. Our interest was associated with the latent genomic pathway and effect that 17-Î˛ E2 had on the gene expression of two particular enzymes, CAT and SOD. These both have a role in the reduction pathway of H2O2, a toxic free radical DNA-damaging agent.5,6 Our lungs are exposed to high levels of oxidative stress, more than any other organ in the body. They are also exposed to

Volume 6: Number 1. 2013 | Page 25

RCSIsmj original article pollutants, free radical and other carcinogenic species. In the normal lung, the electron transport chain and mitochondria are the sites of the reduction pathway of oxygen. O2 is reduced to superoxide (O2-) and further reduced (to H2O2) by the enzyme

SOD.11 H2O2 is then safely reduced to H2O and O2 by the enzyme CAT (Figure 4). In the CF lung, neutrophils produce H2O2.6 Ps. aeruginosa can also produce H2O2. Oestrogen has been shown to enhance levels of H2O2 in Ps. aeruginosa after short-term exposure to E2, likely via inhibition of CAT activity. Yet the effects of E2 on the host enzyme CAT have not been made clear, nor is it known whether SOD also plays a role in the E2-mediated H2O2 reduction pathway. We investigated the genetic expression of these enzymes in the presence of E2. We found that E2 did not increase or decrease the expression of CAT. However, the presence of E2 had a significant effect on the expression of SOD. At short-term exposure, SOD expression was suppressed in CFBE41o- cells, then after 24 hours increased two-fold when exposed to E2. This would indicate the presence of oestrogen-responsive elements (ERE) on the SOD transcription genes that have a high affinity for ER-β binding.12 Yet further research needs to be done to investigate the direct effect of SOD gene expression and activity and H2O2 production and levels.

Conclusion

influence the growth rate. Further research is needed to look at the various factors that influence the initial bacterial attachment and colonisation, and to assess the likelihood of a hormonal influence. Such factors could be associated with the extra-cellular enzymes or toxins that induce the degradation, and therefore the breach, of host cell barriers.13 This project also looked at the host response of CF bronchial epithelial cells and their expression of two different enzymes, CAT and SOD, under the influence of E2. It is apparent that E2 does not affect the expression of CAT. However, previous studies have shown that E2 inhibits CAT activity in Ps aeruginosa. Whether E2 affects mammalian CAT activity remains to be tested. E2 did appear to have a significant effect on SOD genetic expression. As a result further investigations would be needed to quantify SOC protein levels, SOD activity, levels of H2O2 expressed by CFBE41ocells in response to E2, and further analysis of EREs in the SOD promoter.

Acknowledgements I would like to thank the RCSI Research Summer School and the Association of Graduates Medicine for funding this project. I would also like to thank Gillian Lavelle, Paul J. McKiernan and Irene Oglesby for their tremendous help. Finally, I would like to thank Dr Catherine Greene for giving me this opportunity, and for her generous advice and support.

The CF gender gap has opened a new research avenue to explore the hormonal association to this disorder. In this project we investigated the effect E2 had on the bacterial growth rate of Ps. aeruginosa and came to an understanding that E2 did not solely

References 1.

Chotirmall SH, Smith SG, Gunaratnam C, Cosgrove S, Dimitrov BD, O’Neill

TRI Reagent Product Information. MO USA. Sigma-Aldrich Inc. Cat No

QuantiTect, Reverse Transcription Kit. QIAGEN group. 2011. Cat No

Reynolds J. Serial Dilutions Protocol. American Society for Microbiology.

SJ et al. Effect of oestrogen on pseudomonas mucoidy and exacerbations in cystic fibrosis. N Engl J Med. 2012;366(21):1978-86. 2.

Chotirmall SC, Greene CM, Harvey BJ, McElvaney NG. The cystic fibrosis ‘gender gap’: past observations, present understanding and future

[Internet] 2005 [cited 2012 Sept 14] Available from:

Research; 2012. ISBN: 978-953-51-0287-8, InTech.

http://www.microbelibrary.org/component/resource/laboratory-test/2884-se

Lyczak JB, Cannon CL, Pier GB. Lung infections associated with cystic

Signalling in Infectious Disease and Health [monograph online]. Heidelberg

inflammation in cystic fibrosis: impact of innate immunity and oestrogen.

London: Springer; 2010. Available from: http://library.ttu.edu/about/

Chotirmall SH, Greene CM, Oglesby IK, Thomas W, O’Neill SJ, Harvey BJ et al. 17beta-estradiol inhibits IL-8 in cystic fibrosis by up-regulating secretory leucoprotease inhibitor. Am J Respir Crit Care Med. 2010;182(1):62-72.

rial-dilution-protocols. 10. Lyte M, Freestone PE (eds.). Microbial Endocrinology: Interkingdom

Chotirmall SC, Harvey BJ, McElvaney NG, Greene CM. Pulmonary Curr Med Lit – Cystic Fibrosis. 2011;1(2):37-48.

205310.

directions. In: Sriramulu D (ed.). Cystic Fibrosis – Renewed Hopes through

fibrosis. Clin Microbiol Rev. 2002;15(2):194-222. 4.

T9424.

Chotirmall SC, Smith SG, Gunaratnam C, Cosgrove S, Dimitrov BD, O’Neill

facility/face/entries/Lyte_MicrobialEndocrino.pdf. 11. Kinnula VL, Crapo JD. Superoxide dismutases in the lung and human lung diseases. Am J Respir Crit Care Med. 2003;167(12):1600-19. 12. Klinge CM. Oestrogen receptor interaction with oestrogen response elements. Nucleic Acid Research. 2001;29(14):2905-19. 13. Todder K. Pseudomonas aeruginosa. In: University of Wisconsin, Department

SJ et al. Oestrogen induces Pseudomonas mucoidy and promotes

of Bacteriology. Online Textbook of Bacteriology. Available from:

exacerbations in cystic fibrosis. N Engl J Med. In Press.

http://textbookofbacteriology.net/.

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RCSIsmj original article The inflammatory cellular constituents of foetal and infant leptomeninges – a survey of hospital-based autopsies without trauma Abstract Introduction: We investigated the possible association of leptomeningeal inflammatory infiltrates and iron deposition in neonates and infants, with the objective of deriving a baseline for reference in forensic cases. Methods: Leptomeninges derived from non-forensic deaths with atraumatic, natural causes was studied. Because of the vastly dissimilar neuroanatomy between newborn infants and older ones, 33 cases were divided into two groups, according to set age groups. Inflammatory cells and iron levels in these were quantified. Results: In group 1 there was a correlation between an increased number of inflammatory cells and the presence of subdural or subarachnoid haemorrhages. Inflammatory cells, albeit reduced in number, were also present in a number of cases in the absence of subdural or subarachnoid haemorrhages. Iron was found in the leptomeninges in several cases in similar quantities, even those without recent haemorrhage. Overall and within the two subgroups, ranges and means of the counts were wide and not significantly different. Conclusion: These findings suggest that inflammatory cells and iron in the leptomeninges can be found in a number of natural and non-traumatic conditions. Further, two cases with no reported neuropathology demonstrated the presence of inflammatory cells and iron. Thus, cautious interpretation of neuropathology found in paediatric forensic cases is recommended. Royal College of Surgeons in Ireland Student Medical Journal 2009; 1: 27-32.

Introduction

Esther Jack1 Dr Terri Haddix2 1RCSI medical student 2Stanford University Medical

Center, Stanford, CA, USA

The leptomeninges are composed of the pia and arachnoid mater connected by strands termed arachnoid trabeculae. In the young, the leptomeninges are clear, but they become gradually thickened with age.1 The leptomeninges and dura mater have been traditionally thought to contain few, if any, inflammatory cells, and any increase in cellularity is potentially equated to a pathologic condition, including inflicted trauma.1,2 At present, we do not know what constitutes ‘normal’ cellularity of infant leptomeninges and if they should be present at all in non-forensic settings. However, when indeed present under suspicious circumstances, they are often linked to inflicted trauma, such as in cases of the ‘shaken baby syndrome’.3

In order to recognise and characterise the pathologic findings in infant brains, it is important to have an understanding of the normal constituents of the various intracranial compartments. While some studies in the past, largely in rodent pups,4 have sought to evaluate and characterise the leptomeningeal cellular constituents, until now a rigorous analysis of the inflammatory cellular constituents of the leptomeninges has not been performed in human late-foetal and infant brains. This characterisation will serve as a baseline for comparison with brains of similarly aged children in forensic settings. Therefore, in addition to determining the inflammatory cellular composition and iron quantities of foetal and infant leptomeninges associated with natural disease processes, and in

Volume 6: Number 1. 2013 | Page 27

RCSIsmjoriginal article the absence of physical trauma beyond that accompanying vaginal birth, this study aims to formulate a basis of comparison of leptomeningeal cellular constituents in forensic settings, based on rigorous histological analyses of hospital-derived autopsies.

Table 1: Site and range, mean and standard deviations of lengths of leptomeninges in all cases. Sites

Materials and methods Subject selection Thirty-three foetal and infant autopsies in which neuropathologic examinations had been performed at Stanford University Medical Center/Lucille Packard Children’s Hospital were identified utilising the department of pathology database program. The cases for study were chosen in concert with the attending neuropathologist responsible for rendering the original diagnoses. The criteria for study inclusion were cases between 2005 and 2008, the age bracket of between late third trimester and one year of post-natal life, all of which have samples harvested from at least two different brain sites including the cerebral cortex, cerebellum and brainstem. Three cases within the 33 total cases that did not conform to these criteria were included.

No. of sites

Leptomeningeal

Mean (mm)

sampled

length (mm)

+/- SD

Cerebral cortex

5-41

18.8 +/- 10.5

Brain stem

10-83

28.7 +/- 17.0

Cerebellum

10-47

20.3 +/- 11.1

Analysis of results The samples were divided into infants who died beyond 33 post-natal days up to one year (group 1) and newborns who survived up to 33 days (group 2) – these represent pre- and post-natal leptomeninges.11 The mean immunoreactive cells/millimetre for CD45, CD68, and CD163 was calculated for groups 1 and 2. Iron was recorded as being either present or absent. No further statistical analysis was performed beyond demonstrating the mean values in the form of bar charts.

Leptomeningeal sample selection Each sample slide was screened on microscopy by the attending neuropathologist and only sections of brains reflecting a wide (≥5.0mm) sampling of the leptomeninges were chosen.

Sample fixing, staining and immunohistochemistry Slides of routinely processed formalin-fixed, paraffin-embedded5 sections in each case were prepared and stained with antibodies to CD45 (dilution 1:100), CD68 (dilution 1:100) and CD163 (dilution 1:200). CD45, also known as leucocyte common antigen, is uniquely expressed on the surface of all leucocytes and their progenitor cells6 – these include neutrophils, eosinophils, basophils, lymphocytes and monocytes. CD68 is expressed in monocytes and macrophages and thus represents reactive microglial activity.7 CD163 was used as an additional stain for cells of monocyte/macrophage lineage.8 Immunoperoxidase staining was performed, following microwave antigen retrieval in citrate buffer at pH 6, on an automatic stainer (Dako Autostainer, Universal Staining System).9 Iron was detected in sections utilising the standard Perl’s staining method.10

Results Demographics Of the 33 cases, 16 were male and 17 female. Thirteen were born via vaginal delivery and 19 via Caesarean section. The mode of delivery of one case was not available. Seventeen cases involved infants who died beyond the post-natal age of 33 days (group 1), and 16 cases represented either foetuses or newborns who survived up to 33 post-natal days (group 2). One child (number 7) who survived to 16 months of age, was included in group 1. There were two cases (numbers 25 and 30) involving foetuses in the 26th and 28th weeks of gestation, which were included in group 2. The general autopsy and neuropathology findings of both groups overlapped, and these included congestive heart failure, Noonan’s syndrome, micrencephaly, and pontosubicular neuronal necrosis. Table 1 demonstrates the number of slides from each brain region and the range of length, mean and standard deviation of associated leptomeninges scored per slide. Overall, 39 sites were sampled from cerebral cortices, 37 from brainstems, and 30 from cerebella. These involved leptomeningeal lengths of between 5mm and 83mm.

Group 1 Examination of samples In order to reduce inter-observer variation, the number of variously immunoreactive cells was quantified by a single observer and representative slides reviewed for accuracy by a second observer. At a microscopic magnification of x20, immunoreactive cells within leptomeninges were counted and recorded. As the length of leptomeninges evaluated varied between slides, the length of leptomeninges scored was measured in millimetres and results recorded as immunoreactive cells/millimetre. Only leptomeninges on gyral surfaces were scored as it was impossible to measure the depth of layers that were in the sulci.

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Looking specifically at the cases in group 1 (Table 2 and Figure 1), four had congenital heart disease (CHD) and two were diagnosed with Noonan’s syndrome. The mean density of CD45, CD68 and CD163 immunoreactive cells per mm of leptomeninges of the former group was 14.4, 17.5 and 17.9cells/mm, respectively, and of the latter group was 22.3, 18.6 and 21, respectively. Two cases in which sepsis or significant infection was documented (cases 22 and 8) had mean CD45, CD68 and CD163 counts of 19.3, 27.4 and 34.1 cells/mm, respectively. In group 1, 11 of 17 cases had some form of hypoxic/ischaemic event (pontosubicular neuronal necrosis, hypoxic-ischaemic encephalopathy, infarction, periventricular

RCSIsmjoriginal article Table 2: General autopsy and neuropathologic findings for infants with a post-natal age greater than 33 days (group 1). Case No

General autopsy findings

Neuropathology findings

Chronic aspiration/pneumonitis with MOSF

Oedema with herniation; HIE

Seizure disorder 4

Noonan’s syndrome

Micrencephaly; Pontosubicular neuronal necrosis

Trisomy 21 with CHD

Haemorrhagic infarct (left periventricular)

CHD

Micrencephaly

Interstitial pneumonitis (cultures negative)

PVL

Heterotaxy-asplenia syndrome

Micrencephaly; Multiple cortical and WM infarcts

Congenital pulmonary malformation

Multifocal acute HI changes

Pulmonary hypoplasia

Remote and focal acute HI changes

None (brain only)

Agenesis of CC

CHD with infarction

None

Cardiomyopathy; Sepsis with MOSF

Multiple cerebral infarctions

Foetal hydrops

PVL; Right occipital infarction

Noonan’s syndrome

Micrencephaly; Hypomyelination; Organising SAH, SDH

Liver failure

Metabolic astrogliosis; Neuronal pyknosis; bilateral subdural membranes

RSV bronchiolitis; Pneumonia

Remote occipital infarct; Subacute EDH

CHD

Cystic infarct (frontal)

CC – corpus callosum; CHD – congenital heart disease; EDH – epidural haemorrhage; GM – germinal matrix; HI – hypoxic/ischaemic; HIE – hypoxic/ischaemic encephalopathy; MOSF – multiple organ system failure; PVL – periventricular leukomalacia; RSV – respiratory syncytial virus; SAH – subarachnoid haemorrhage; SDH – subdural haemorrhage; WM – white matter

Sites

Range

Cerebellum Cerebral

9-1580

Brain stem

Brainstem

Mean

3-1193

233 +/-

0-1249 322 +/-

304 +/357

Cerebral cortex

Mean +/- SD

Cerebellum 19-1053 208 +/-

CD163

Range

+/- SD 294

cortex

CD163

CD68

CD45

219

Range 10-1213

407 +/-

4-2410

491 +/-

345

276 34-1883 344 +/-

513

385 26-1275 285 +/276

Mean +/- SD

3-1282

345 +/299

CD68 CD45 0

100

200

300

400

500

600

leukomalacia, hypoxic-ischaemic changes). The mean CD45, CD68 and CD163 positive cells/mm for this subgroup was 11.4, 15.5 and 19.0 cells/mm, respectively. Cases in the hypoxic/ischaemic subgroup incorporated cases in each of the other subgroups. Two cases had evidence of organising haemorrhages (epidural, subdural or subarachnoid; cases 26 and 28). The mean CD45, CD68 and CD163

FIGURE 1. Mean immunoreactive cells in cerebral cortex, brainstem and cerebellum (group 1). cell counts/mm in this subgroup were 33, 35.8 and 40.7, respectively. These three cases had the highest mean CD45, CD68 and CD163 counts within group 1. These three cases also contained cells in the leptomeninges with stainable iron in at least one section. An additional 12 cases in group 1 demonstrated some degree of iron staining in at least one brain section.

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RCSIsmjoriginal article Table 3: General autopsy and neuropathologic findings for foetuses and infants with a post-gestational age up to 33 days (group 2). Case No.

General autopsy findings

Neuropathologic findings

CHD

None

CHD

Micrencephaly; Arhinencephaly; Neuronal necrosis, Subiculum

Harlequin ichthyosis

None

Diaphragmatic hernia; Omphalocoele

PSNN

Pneumonia

Metabolic encephalopathy; Hydrocephalus; Partial agenesis of CC

CHD

Thoracic meningomyelocoele; Hydrocephalus; Possible partial agenesis of CC

CHD

Organising SDH

Cardiomyopathy; DiGeorge syndrome

Acute HI change (focal); PSNN; Remote dural haemorrhage

Pulmonary HTN

PSNN

Foetal hydrops

GM haemorrhage extending to SA; Diffuse HIE

Tetralogy of Fallot

PSNN; BG infarct

CHD

Focal SAH; Small WM haemorrhages; PSNN

CHD

PSNN; Focal HI, cerebellum; PVL; Parietal infarct; Organising SDH, IVH, SAH

Diffuse HIE

NEC (MOSF)

Meningoencephalitis; PSNN

Multiple congenital abnormalities including CHD

GM haemorrhage with IV and SA spread; PSNN; Arhinencephaly

Pulmonary hypoplasia/HTN

GM haemorrhage with IV and SA spread; PSNN

BG – basal ganglia; CC – corpus callosum; CHD – congenital heart disease; GM – germinal matrix; HI – hypoxic/ischaemic; HIE – hypoxic/ischaemic encephalopathy; HTN – hypertension; IV – intraventricular; MOSF – multiple organ system failure; NEC – necrotising enterocolitis; PVL – periventricular leukomalacia; SA – subarachnoid; SAH – subarachnoid haemorrhage; SDH – subdural haemorrhage; WM – white matter; PSNN – pontosubicular neuronal necrosis Sites

CD45 Range

CD68 Mean +/- SD

Cerebellum Cerebral

49-1580 369 +/-

cortex Brain stem

Brainstem

388 3-1751

385 +/413

Cerebellum 29-801

CD163 Cerebral cortex

194 +/187

Range

CD163 Mean

Range

+/- SD 85-1249 476 +/-

10-1240 566 +/-

295 34-1883 358 +/413 26-1275 246 +/307

Mean +/- SD 371

8-2410

600 +/619

64-1280 292 +/307

CD68 CD45 0

100

200

300

400

500

600

700

FIGURE 2. Mean immunoreactive cells in cerebral cortex, brainstem and cerebellum (group 2).

Group 2 Looking specifically at the cases in group 2 (Table 3 and Figure 2), eight cases had CHD. The mean density of CD45, CD68 and CD163 immunoreactive cells/mm was 9.4, 16.6 and 23.2, respectively. Two cases in which sepsis or significant infection was documented had mean CD45, CD68 and CD163 counts of 31.8, 28 and 33 cells/mm, respectively. In group 2, 10 of 16 cases had some form of

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hypoxic/ischaemic event as noted above with CD45, CD68 and CD163 positive cells of 18, 20.5 and 24.6 cells/mm, respectively. Seven cases had some form of haemorrhage involving the dural surface or extending into the subarachnoid space. The number of CD45, CD68 and CD163 immunoreactive cells/mm in this subgroup was 13.5, 25.5 and 32.4 cells/mm, respectively. Five cases of seven

RCSIsmj original article

FIGURE 3. Representative case with CD45 immunostain (600x). Cells in the leptomeninges demonstrating appropriate positive staining are indicated with red arrows, and the cells and other constituents demonstrating non-specific staining are indicated with blunt black arrows. A vascular lumen containing some cells with appropriate staining is indicated by a yellow star. These intravascular cells were not included in counts. The brown blush elsewhere within the vessel represents additional non-specific staining. in this subset with associated haemorrhage also had evidence of iron staining. Two cases with no reported neuropathologic findings had CD45, CD68 and CD163 counts of 5.9, 6.2 and 11.5 cells/mm, respectively. An additional eight cases in group 2 demonstrated some degree of iron staining in at least one brain section.

Cases without reported neuropathology In two cases without neuropathologic abnormalities, all classes of inflammatory cells were found in the leptomeninges, albeit at relatively low numbers (case 17 of group 1 and case 6 of group 2).

Iron findings Of the 19 cases in which Caesarean sections were performed, 16 had positive iron findings, whereas eight cases of the 13 vaginal births were positive for iron. Four cases of each mode of delivery reported haemorrhage-related neuropathologic diagnoses. Fifteen cases of Caesarean section births were associated with some form of hypoxic/ischaemic event in contrast to seven cases involving vaginal births.

Discussion In the current study we found the presence of inflammatory cells in the leptomeninges, both overall and when segregated into two groups by age (foetal and early post-natal vs. infants beyond 33 days post-natal life) and by anatomic and neuropathologic conditions. A notable finding is that even in foetuses and infants with no neuropathologic abnormalities, inflammatory cells, and occasionally iron, were identified in the leptomeninges. This is in contrast to the widely held belief that the leptomeninges should be largely devoid of inflammatory cells and iron in children with no reported neuropathology.12 In the infant group, in fact, there was a positive association between the degree of

FIGURE 4: CD68 (panel A) and CD163 (panel B) immunostained sections (600x) from same case depicted in Figure 1. In each panel, the cerebral cortex is on the right side. In panel A, portions of two vessels (yellow stars) containing CD68 immunoreactive cells are also seen. leptomeningeal inflammation and the presence of epidural haemorrhage (EDH), subdural haemorrhage (SDH) or subarachnoid haemorrhage (SAH) (cases 26 and 28). In group 1 the presence of some form of chronic haemorrhage was associated with higher numbers of inflammatory cells compared to those without such haemorrhage. Caesarean section deliveries and vaginal births were associated with a variety of anatomic and neuropathologic diagnoses, with hypoxic/ischaemic events commonly found in both modes of delivery. Both modes of delivery also demonstrated iron deposition in the leptomeninges and haemorrhage-related neuropathology. Accordingly, it appears that the presence of iron in the leptomeninges does not necessarily equate to traumatic haemorrhage but may be found in completely naturally occurring processes, and occurs irrespective of the mode of delivery.2 There also seemed to be no recurring pattern allowing us to associate the presence of iron to a single anatomic or neuropathologic diagnosis.

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RCSIsmjoriginal article proliferate. Animal studies have demonstrated that inflammation, either introduced systemically or within the brain, causes microglial activation along with cytokine release.15 Accordingly, there is evidence to suggest that infection distant from the brain may damage developing foetal brain.13 The activation of neuroinflammatory responses may also sensitise the brain to the damaging effects of other insults, such as hypoxia/ischaemia, and amplify the effects of the latter.15 Thus there are multiple possible reasons to account for the presence of inflammatory cells within the leptomeninges early in gestation in humans outside of inflicted trauma.

Conclusion

FIGURE 5: Example of iron staining in the leptomeninges (600x) in a different case than shown in Figures 1 and 2. The leptomeninges are diagonally oriented downward from left to right and contain a large number of cells with an appropriate granular intracellular blue reaction product. In the upper right corner are some cells with non-specific staining. There are multiple mechanisms that allow the brain to sense inflammatory signals from systemic circulation,13 including interacting with circulating molecules in areas in the brain devoid of the blood-brain barrier. Microglial cells seem to migrate from the germinal matrix to the cortical layers. Early migration of microglia from the ventricular and meningeal surfaces has been observed at as early as 4.5 weeksâ&#x20AC;&#x2122; gestation in humans.14 The function of resting microglia under normal conditions is unclear. In pathologic conditions, these microglial cells are rapidly activated and

We conclude that a number of patients with various natural disease processes in this hospital-based population had significant numbers of CD45, CD68 and CD163 immunoreactive cells and iron in the leptomeninges overall and when segregated by age, and anatomic and neuropathologic diagnoses. Although we studied a larger number of cases than the dura study by Croft et al.,2 our numbers of total cases are relatively small, particularly in consideration of the varied anatomic and neuropathologic diagnoses. Our cases were derived only from hospital autopsies and these observations require comparison to actual forensic cases involving both traumatic injuries and natural disease processes. Clearly the presence of inflammatory cells and iron in the leptomeninges can occur commonly, and in significant numbers, in non-traumatic neuropathologic conditions. It has not been possible to assign a value to which the presence of inflammatory cells would be deemed arising from suspicious events. Thus, these findings support the recommendation of cautious interpretation of the findings of leptomeningeal inflammation and iron in forensic cases.4

References 1.

Sternberg SS. Histology for Pathologists (2nd ed.). New York; Raven Press, 1992. Chapter 6, Pia-arachnoid (Leptomeninges):164-7.

Croft PR, Reichard RR. Microscopic examination of grossly unremarkable paediatric dura mater. Am J Forensic Med Pathol. 2009;30(1):10-13.

Squier W. The â&#x20AC;&#x153;Shaken Babyâ&#x20AC;? syndrome: pathology and mechanisms.

Perry VH, Hume DA, Gordon S. Immunohistochemical localisation of

Acta Neuropathol. 2011;122(5):519-42. macrophages and microglia in the adult and developing mouse brain. Neuroscience. 1985;15(2):313-26. 5.

Nowacek JM, Kiernan JA. Ch 16: Fixation and Tissue Processing. Special Stains and H&E. 2010 May. pdf available online from: www.dako.com/08066_12may10_webchapter16.pdf.

Altin JG, Sloan EK. The role of CD45 and CD45-associated molecules in T

Tanaka Y, Matsuwaki T, Yamanouchi K, Nishihara M. Exacerbated

cell activation. Immunol Cell Biol. 1997;75(5):430-45. inflammatory responses related to activated microglia after traumatic brain injury in progranulin-deficient mice. Neuroscience. 2012. pii: S0306-4522(12)01143-8. 8.

2004;122(5):794-801. 9.

Kumar GL, Rudbeck L. Ch 8: Demasking of Antigens. Immunohistochemistry Guidebook (5th ed.). 2009. pdf available online from: www.dako.com/08002_ihc_staining_methods_5ed.pdf.

10. Luna L (ed.). AFIP Manual of Histological Staining Methods (3rd ed.). New York: McGraw-Hill Pub; c1968:19. 11. Squier W, Lindberg E, Mack J, Darby S. Demonstration of fluid channels in human dura and their relationship to age and intradural bleeding. Childs Nerv Syst. 2009;25(8):925-31. 12. Esiri M, Morris C. Immunocytochemical study of macrophages and microglial cells and extracellular matrix components in human CNS disease. J Neurol Sci.1990;101:59-72. 13. Malaeb S, Dammann O. Foetal inflammatory response and brain injury in the preterm newborn. J Child Neurol. 2009;24(9):1119-26. 14. Andjelkovic AV, Nikolic B, Pachter JS, Zecevic N. Macrophages/microglial cells in human central nervous system during development: an immunohistochemical study. Brain Res. 1998;814(1-2):13-25. 15. Chew LJ, Takanohashi A, Bell M. Microglia and inflammation: impact on

Lau SK, Chu PG, Weiss LM. CD163: a specific marker of macrophages in

developmental brain injuries. Ment Retard Dev Disabil Res Rev.

paraffin-embedded tissue samples. Am J Clin Pathol.

2006;12(2):105-12.

Page 32 | Volume 6: Number 1. 2013

RCSIsmjoriginal article The differences in attitudes and beliefs among smokers and ex-smokers regarding the benefits of smoking cessation in Ireland Abstract Introduction: Smoking-related diseases account for almost 5,500 deaths per year in Ireland and cost the Irish economy â&#x201A;Ź1-2 billion per year. Some 50% of all smokers will die of a smoking-related disease, and smokers on average die 10 years younger than non-smokers. The aim of this project was to assess attitudes and beliefs regarding smoking cessation in both smokers and ex-smokers. Methods: The study took place in Beaumont Hospital, Dublin. Patients who were smokers or ex-smokers were identified from the inpatient wards and respiratory outpatient department (OPD), and interviewed using a standardised questionnaire. Data regarding underlying medical history was acquired from medical records. Results: A total of 104 patients were included, comprising 50 smokers and 54 ex-smokers. There were no differences in gender or medical history. Ex-smokers were slightly older, with a mean age of 66.5 years compared to 56.9 years in smokers (p=0.0017). Current smokers had a longer smoking history; 39.14 years compared to 32.9 years in ex-smokers (p=0.047). Smokers reported lower expectations regarding the benefits of smoking cessation than the ex-smokers; only 60% believed that there would be a short-term health benefit and only 74% believed that quitting was worthwhile compared to 88.9% and 94.4%, respectively, in the ex-smoking group (p=0.0025/p=0.01). Conclusion: There is significant variation among smokers and ex-smokers regarding attitudes to smoking cessation; this is despite receiving the same smoking cessation advice and having low Fagerstrom scores. Royal College of Surgeons in Ireland Student Medical Journal 2013; 6(1): 33-6.

Sarah Byrne1 Dr Cormac McCarthy2 Prof. Gerry McElvaney2 1RCSI 2Department

medical student

of Medicine, Royal

College of Surgeons in Ireland, Beaumont Hospital, Dublin 9, Ireland

Volume 6: Number 1. 2013 | Page 33

RCSIsmjoriginal article Introduction Some 22% of the world’s population over the age of 15 smoke.1 This figure is worrying given that, on average, smokers die 10 years younger than lifelong non-smokers,2 with tobacco use killing almost six million people each year as a result of both direct use and second-hand smoke.1 This equates to almost 5,500 smoking-related deaths currently per year in Ireland.3 A study by Doll et al., which followed male British doctors for 50 years, showed that up to two in three long-term cigarette smokers will die of a tobacco-related illness, while cessation at age 50 halves the risk, and cessation at age 30 almost completely avoids it.2 As well as the financial and health-related costs to the individual, tobacco use carries huge economic costs for a country. Treating tobacco-related disease amounts to €1-2 billion a year in Ireland. Recent data indicates an average cost of €7,700 per tobacco-related hospital admission3 and smoking-related conditions account for over 7,000 hospital admissions per year in Ireland.4 In 2008/09, the Omnibus Survey identified that over two-thirds (67%) of smokers in Great Britain5 want to quit, indicating a possible deficit in the availability of smoking cessation services. The main reason given for wanting to quit was for health purposes, with 83% citing at least one health reason, 31% wanted to quit for financial reasons, 22% to protect children and 16% due to family pressure.5 However, despite the explicit warnings and dangers of smoking, people continue to start smoking and the onset of smoking now occurs primarily in adolescence.6 Beliefs and expectations regarding the outcomes of smoking cessation are important determinants in moderating an individual’s likelihood to quit and remain abstinent. Latimer-Cheung et al. found that men who received gain-framed smoking cessation advice through a state quit line and had positive outcome expectancies were more likely to quit and remain abstinent than men who were unsure of the benefits of smoking cessation. However, these findings were not replicated for females, suggesting the need for gender and individual considerations when delivering such advice.7 Magnan et al. found that both the perceived risk and worry about the medical consequences of smoking were associated with an increased motivation to quit smoking, with worry being the foremost motivator.8 Peasley-Miklus et al. also found that smokers prone to worrying were more motivated to quit smoking to reduce the negative effect, but that they also perceived greater barriers to smoking cessation.9 The aim of this study was to assess the attitudes and beliefs regarding smoking cessation between a group of current smokers and a group of ex-smokers in Ireland.

Methods Participant selection and questionnaire delivery Participants involved two patient cohorts: those attending the respiratory outpatient departments (OPD), and those in the general inpatient wards in Beaumont Hospital, Dublin. Patients were excluded if they were under 18 years of age, unable to

Page 34 | Volume 6: Number 1. 2013

provide valid consent, unable to speak English, cognitively impaired (according to information in the patient’s chart) or comatose. For the inpatient cohort, wards were selected at random and all patients on the selected wards were asked about their smoking history. Those attending the respiratory OPD were also interviewed if they were current or ex-smokers. Those who were smokers or ex-smokers were interviewed using a standardised questionnaire devised by the department of psychology in RCSI. The questionnaire was comprised of basic demographic features, smoking history including quit attempts, beliefs and expectations about smoking cessation, actual experiences of ex-smokers after cessation, and a Fagerstrom test for current smokers. Interviews lasted approximately 10-15 minutes. Data regarding the underlying medical history was acquired from medical records.

Data analysis A database was created using Microsoft Excel (Microsoft Excel 2010; Microsoft Corporation, WA, USA) to record all the data collected. This included basic demographic features, smoking history including quit attempts, professional advice received and methods used, and beliefs regarding smoking cessation. In addition, ex-smokers were also asked about the actual effects experienced following smoking cessation. Student’s t-tests were used to analyse differences between the groups. Data analysis was performed using Microsoft Excel and SPSS v. 17.0.1 (IBM Corporation, NY, USA).

Results Participant sample and smoking history The study included 104 participants: 50 smokers and 54 ex-smokers. There were no significant differences in gender (p=0.7), medical history (p=0.7), or insurance status (p=0.35) between the smoking and ex-smoking populations. The ex-smoking population was older, with a mean age of 66.5 years compared to 56.9 years in smokers (p=0.0017). Although the smoking population was younger, smokers had a longer smoking history than ex-smokers; 39.14 years compared to 32.9 years (p=0.047). However, overall ex-smokers had a higher mean pack year history than smokers, 39.6 years compared to 26.1 years (p=0.02).

Quit attempts Despite having a low nicotine dependency score as calculated by the Fagerstrom test (mean Fagerstrom score = 3.375 +/- SD 2.4), only 34% of current smokers attempted to quit in the past year, with only 18% attempting to quit more than five times. The main reason given for starting to smoke again after a cessation attempt in the past year was stress (41.2%), closely followed by social reasons, which comprised smoking on social outings or smoking with others (35.3%) (Table 1). Of the 33 smokers who had never attempted to quit, 30.3% were thinking about quitting but not

RCSIsmjoriginal article Table 1: Reasons identified by smokers for starting to smoke

Table 2: Reasons identified by ex-smokers for successful

again. (Note: some respondents gave more than one answer.)

smoking cessation. (Note: some respondents gave more than one answer.)

Reason given for smoking again

Number of participants Reason given for smoking cessation

Number of participants

Deteriorating health

29 (53.7%)

Maintain good health

7 (13%)

Advice from healthcare worker

6 (11.1%)

Increased cost of smoking

6 (11.1%)

Stress

7 (41.2%)

Social reasons

6 (35.3%)

Boredom

3 (17.6%)

Other family members smoke

2 (11.8%)

Does not really want to quit

1 (5.9%)

Family members developing

Loneliness

1 (5.9%)

smoking-related diseases

4 (7.4%)

Habit

1 (5.9%)

Just wanted to

3 (5.6%)

Pressure from family or friends

2 (3.7%)

Health messages (television,

actively planning to quit, and 51.5% were not thinking about quitting at all. Of the ex-smokers, 63% quit on their first attempt, with a further 18.5% succeeding in quitting after fewer than five attempts. The ex-smoking population also showed a slight male predominance (54%). Only 31.5% of ex-smokers used nicotine replacement therapy (NRT) or other aids to quit smoking, compared to 53% of smokers who attempted to quit in the previous year (p=0.176). The main reason cited by ex-smokers for quitting was deteriorating health, with 53.7% noting it as a reason for smoking cessation. This was followed by the desire to maintain good health (13%), advice from healthcare workers, and the increased cost of smoking (both 11.1%) (Table 2).

cigarette boxes, etc.)

2 (3.7%)

Pregnancy

2 (3.7%)

Other

2 (3.7%)

also reported higher expectations regarding the adverse outcomes of smoking cessation than ex-smokers; 52% believed that they would gain weight and 52% believed that they would find it harder to handle stress compared to only 31.4% and 29.6% in the ex-smoker cohort. When ex-smokers were asked about their actual experiences following smoking cessation, only 38.9% reported gaining weight and an even smaller 25.9% reported that stress became more difficult to manage. Regarding the benefits of smoking cessation, the reported outcomes were generally lower than the expected outcomes with only 62.9% reporting an improvement in health in the short term and 61.1% indicating an improvement in the long term. However, 96% of ex-smokers felt that overall smoking cessation was a worthwhile action to take.

Smoking cessation advice Only 43% of ex-smokers and 60% of current smokers reported receiving smoking cessation advice in the previous year (year before quitting for ex-smokers). This was irrespective of a respiratory diagnosis or other underlying medical condition. However, when asked if they would like to receive such advice, only 48% of smokers indicated that they would.

Attitudes and beliefs Smokers reported lower expectations regarding the benefits of smoking cessation than the ex-smokers; only 60% believed that there would be a short-term health benefit and only 74% believed that quitting was worthwhile compared to 88.9% and 94.4%, respectively, in the ex-smoking group (p=0.0025/p=0.01). Smokers

Discussion The main reason identified by ex-smokers for wanting to quit was deteriorating health (53.7%), with only 13% quitting to maintain their good health. This indicates that more emphasis needs to be placed on the importance of smoking cessation to protect good health rather than to slow the deterioration of already damaged health due to smoking. This lack of awareness of the importance of smoking cessation is also highlighted in that only 34% of current smokers attempted to quit in the previous year despite having a low nicotine dependency score (mean Fagerstrom score = 3.375 +/- SD 2.4). Indeed, 51.5% of current smokers are not even thinking about quitting, which demonstrates an apathy towards prevention of ill health before it occurs.

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RCSIsmj original article An important result was that only 60% of current smokers reported receiving smoking cessation advice in the previous year. It is vital that smokers are actively advised to quit, as a systematic review concluded that the provision of such professional advice has a considerable effect on the point prevalence of smoking and the continued abstinence of patients.10 Training of healthcare workers on the subject may be necessary, as the review also found that those who had received training on smoking cessation were more likely to offer smoking cessation to patients than those who were untrained.10 It has also been shown that 39.14% of physicians do not feel that they have adequate training to help patients to quit.11 The lack of provision of such advice cannot be blamed on physician time restraints, as Katz et al. concluded that emergency room staff can provide effective smoking cessation advice in a time-efficient manner.12 It seems that patients’ beliefs and expectations regarding the outcomes of smoking cessation do play a vital role in determining a patient’s likelihood to quit smoking. This is highlighted by the fact that current smokers showed lower levels of expectations regarding the positive effects of smoking cessation and higher levels of expectations regarding the negative effects of smoking cessation. Thus, educating smokers on the benefits of smoking cessation both short and long term is essential to motivate smokers to quit. It is also important to address the concerns of weight gain and stress following smoking cessation. Aubin et al. identified that on average, people who quit smoking gained 4-5kg in the first year following smoking cessation, with most weight gain in the first three months. However, there was considerable variation in weight change, as

16% lost weight and 13% gained more than 10kg.13 Thus, fluctuations in weight are not inherently linked to smoking cessation and measures can be taken to help the patient to avoid weight gain. Only 38.9% of ex-smokers in this study reported gaining weight after smoking cessation. However, as this information was taken retrospectively there could be recall bias present. It is impossible to obtain completely accurate information in this regard. There is also a possibility of selection bias as patients who were not present on the wards at the time the interviews were conducted were not questioned. Also, as all the participants were either inpatients or outpatients in Beaumont Hospital, they all have some degree of health impairment and may not be entirely representable to a group of smokers in the community.

Conclusion This study suggests that smokers’ beliefs and expectations regarding the outcomes of smoking cessation do influence their likelihood to quit smoking, highlighted by the differences between current smokers’ and ex-smokers’ beliefs. It is thus vital that healthcare professionals educate patients on the benefits of smoking cessation to motivate them to quit.

Acknowledgements I would like to thank the Alumni Beaumont Cancer Trust for the financial support received for this project. It allowed me to pursue my interest in the field of respiratory medicine. I would also like to thank Professor McElvaney and Dr McCarthy for their assistance and guidance.

Reference 1.

World Health Organisation. Global Health Observatory: Tobacco Use [Internet]. WHO; 2009 [updated 2009; cited 2012 Sept 14]. Available

counselling intervention? J Health Commun. 2012;17(9):1081-98. 8.

from: http://www.who.int/gho/tobacco/en/index.html. 2.

examination of smoking outcome expectancies, smoking motives and trait worry in a sample of treatment-seeking smokers. Addict Behav.

20QUIT.html. Health Research and Information Division (HRID). Activity in acute public hospitals in Ireland annual report, 2010. Ireland; 2010. The NHS Information Centre. Lifestyles Statistics. Statistics on Smoking: England, 2011. UK: NHS; 2011. 6.

Peasley-Miklus CE, McLeish AC, Schmidt NB, Zvolensky MJ. An

Health Service Executive. Ireland: Health Service Executive; 2011 http://www.hse.ie/eng/services/healthpromotion/QUIT/about%

Med. 2009;37(1):46-57. 9.

2004;328(7455):1519. [updated 2011 Dec 28; cited 2012 Sept 14]. Available from:

smokers on perceived risk, worry, and motivation to quit. Ann Behav

Doll R, Peto R, Boreham J, Sutherland I. Mortality in relation to smoking: 50 years’ observations on male British doctors. BMJ.

Magnan RE, Koblitz AR, Zielke DJ, McCaul KD. The effects of warning

Warren CW, Jones NR, Peruga A, Chauvin J, Baptiste JP, Costa de Silva V.

2012;37(4):407-13. 10. Carson KV, Verbiest ME, Crone MR, Brinn MP, Esterman AJ, Assendelft WJ. Training health professionals in smoking cessation. Cochrane Database Systemic Review. 2012;5:CD000214. 11. Pipe A, Sorensen M, Reid R. Physician smoking status, attitudes toward smoking, and cessation advice to patients: an international survey. Patient Educ Couns. 2009;74(1):118-23. 12. Katz DA, Vander Weg MW, Holman J, Nugent A, Baker L, Johnson S. The

Global youth tobacco surveillance, 2000-2007. MMWR Surveillance

Emergency Department Action in Smoking Cessation (EDASC) trial:

Summaries. 2008;57(1):1-28.

impact on delivery of smoking cessation counselling. Acad Emerg Med.

Latimer-Cheung AE, Fucito LM, Carlin-Menter S, Rodriguez J, Raymond L, Salovey P et al. How do perceptions about cessation outcomes moderate the effectiveness of a gain-framed smoking cessation telephone

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2012;19(4):409-20. 13. Aubin HJ, Farley A, Lycett D, Lahmek P, Aveyard P. Weight gain in smokers after quitting cigarettes: meta-analysis. BMJ. 2012;345:e4439.

RCSIsmj original article PAR-4 â&#x20AC;&#x201C; a novel marker of luminal A breast cancer â&#x20AC;&#x201C; is down-regulated by the steroid receptor co-activator SRC-1 Abstract Introduction: Prostate apoptosis response-4 (PAR-4, PAW-R, PKC apoptosis WT1 regulator) is a gene coding for a tumour suppressor protein involved in the selective apoptosis of cancer cells. Although well described in renal cell carcinomas and prostate cancer, little is known about its role and regulation in breast cancer. Methods: Western blotting techniques looked at the association between PAR-4 expression and breast cancer sub-type, and at the effects of steroid receptor co-activator-1 (SRC-1) on PAR-4 expression. Functional assays (3D cell culture and adhesion independent growth) investigated the role of PAR-4 in breast cancer cells and immunohistochemistry looked at the clinical correlations of PAR-4 positivity in our patient cohort. Results: The results show that PAR-4 is down-regulated by SRC-1 in endocrine-resistant cell lines and they validate its use as a marker of good disease-free survival, both in vitro and in vivo. In addition, the functional assays provide evidence that PAR-4 may play a role in maintaining a well-differentiated phenotype in breast cancer cell lines. Conclusion: The results suggest that PAR-4 expression is a marker of good disease-free survival, or conversely, that the loss of PAR-4 expression would signal tumour progression to a more aggressive phenotype. The identification of such markers is important in the development of more personalised forms of treatments. Royal College of Surgeons in Ireland Student Medical Journal 2013; 6(1): 37-41.

Aoife Cahalin

Dr Jarlath Bolger Dr Claire Walsh

2 2

Dr Damien McCartan

Dr Marie McIlroy

Prof. Arnold D.K. Hill

Dr Leonie Young 1

RCSI medical student

Department of Surgery,

Royal College of Surgeons in Ireland, Dublin 2

Volume 6: Number 1. 2013 | Page 37

RCSIsmj original article Introduction In 2001 a partnership between the Department of Genetics in Stanford University and The Norwegian Radium Hospital looked at variations in gene expression patterns and proposed four main classes of breast cancer.1-3 These were luminal A (mostly oestrogen receptor (ER)-positive and histologically low grade), luminal B (mostly ER-positive but may express low levels of hormone receptors and often high grade), human epidermal growth factor receptor 2 (HER2)-positive (showing amplification and high expression of many genes of the ERBB2 amplicon), and basal-like (corresponding to ER-negative, progesterone receptor (PR)-negative and HER2-negative tumours). These divisions closely correlated to those of the traditional pathological method, which was widely used, but had important implications for our understanding of the heterogeneity of breast cancer. Cell lines that represent these subtypes are now commonplace in breast cancer-associated research. Steroid receptor co-activator-1 (SRC-1) is a co-regulator protein from the p160 steroid receptor co-activator (SRC) family, and is increasingly cited as central in the switch from steroid-dependent tumours to endocrine resistance. It is also linked to a more metastatic phenotype and poorer patient survival.4-6 Steroid co-activators are expressed at low levels in a variety of tissues due to their role in the normal development and functioning of organs, but they may also contribute to cancer in those same tissues.7 With regard to breast cancer, SRC-1 protein is detected in approximately 35% of breast tumours and is associated with large, high-grade tumours and HER2 positivity.7 Initially described as an ERa co-activator, subsequent work has shown that SRC-1 may interact with a number of other transcription factors.6,8 To date, all research has focused on SRC-1 as a co-activator protein, but novel work described here identifies for the first time a role for SRC-1 as a co-repressor in conjunction with HOXc11. HOXc11 is a member of the homeobox family of proteins and has important functions in normal organ development. Previous chromatin immunoprecipitation (ChIP) sequencing and bio-informatic analysis has shown that HOXc11 may become re-activated in breast cancer and interact with SRC-1. This interaction has been identified as a feature of endocrine-resistant breast cancer.5 Combined global analysis was undertaken, which identified 54 common downstream targets of SRC-1 and HOXc11, 32 of which were known protein coding regions. PAR-4 was selected for further investigation due to its role in apoptotic pathways and because it appeared to be down-regulated in the presence of SRC-1 and HOXc11. The PAR-4 gene acts through a leucine zipper domain in the COOH terminal region that selectively induces apoptosis in cancer cells. In addition, it sensitises cells to apoptotic stimuli and causes tumour regression.9 While PAR-4 is commonly cited with regard to prostate cancer, there is little known about its role and regulation in breast cancer. The aim of this study is to investigate the relationship between SRC-1 and PAR-4 in the context of breast cancer, and to examine the viability of PAR-4 as a marker of disease-free survival.

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Materials and methods Cell lines and treatment The cell lines used in this study represent some of the phenotypical classes of breast cancer mentioned before. MCF7s are a luminal A type cell line and represent a well-differentiated and steroid-responsive phenotype. Both LetR and LY2s are luminal B cell lines, representing letrozole-resistant and tamoxifen-resistant phenotypes, respectively. The SKBR3s are a HER2-positive cell line and carry the worst prognosis of those examined here. The cells were stored in tissue culture flasks in a humidified incubator at 37°C in 5% CO2. MCF7 cells were cultured in minimum essential media (MEM) supplemented with 10% foetal calf serum (FCS), 1% L-Glutamine and 1% Penicillin Streptomycin (Pen/Strep). LY2 cells were cultured in phenol red free MEM containing 10% CDS-FCS and 10-8M 4-hydroxytamoxifen (4-OHT). SKBR3 cells were cultured in Roswell Park Memorial Institute (RPMI) media supplemented with 10% FCS and 1% Pen/Strep, and LetRs were cultured in MEM supplementation with 10% CDS-FCS, 1% L-Glutamine and 1% Pen/Strep. Cells were steroid depleted for 72 hours and stratified based on the treatments they received (vehicle, oestrogen, tamoxifen and an oestrogen/tamoxifen mix).

Western blotting Protein expression was detected using Western blotting techniques. Short interfering RNA (siRNA) directed against SRC-1 was used to knock down gene expression in LY2 cells. Primary antibodies used were rabbit anti-human PAR-4 (1:300; Santa Cruz), rabbit anti-human SRC-1 (1:150; Santa Cruz) and mouse anti-human B-Actin (1:5,000; Sigma-Aldrich). Protein was run through a 12% running gel for 2.5 hours at 120V, followed by a wet transfer for 1.5 hours. Nitrocellulose membrane was rolled overnight at 4ºC in PAR-4 primary antibody and imaged using Supersignal West DURA chemiluminescent substrate.

Immunohistochemistry Formalin-fixed paraffin-embedded tumour cores on tissue micro-arrays were used. Slides were deparaffinised and incubated in rabbit anti-human PAR-4 (1:25; Santa Cruz) or control IgG overnight at 4ºC. The slides were then incubated with the corresponding biotin labelled secondary for 30 minutes followed by incubation in avidin-biotin complex (Vector Laboratories) for 30 minutes to further amplify the signal. Sections were developed in 3,3-diaminobenzidine tetrahydrochloride (DAB) for two minutes followed by two minutes in haemotoxylin to counter-stain. Finally, the slides were dehydrated by passage through industrial methylated spirits and xylene, and mounted with DPX solution. The immunostained TMA slides were scored by two independent observers using the Allred scoring system. STAT10 data analysis statistical software was used to analyse results.This looked at the correlations of PAR-4 expression and markers of disease severity. The significance of the results were confirmed by student t test.

Adhesion-independent growth and three-dimensional cell culture assays Adhesion-independent growth looks at the ability of cells to form colonies in soft agar. Following knockdown of PAR-4 from MC7 cells

RCSIsmj original article FIGURE 1: SRC-1 down-regulates PAR-4 in endocrine resistant breast cancer. a) PAR-4 regulation at mRNA level following transient knockdown of SRC-1 using siRNA. b) Confirmation of PAR-4 knockdown using Western blotting. PAR-4 protein expression is increased in the absence of SRC-1. c) Basal expression levels of PAR-4 in MCF7, LY2, LetR and SKBR3 cell lines. High levels of PAR-4 protein expression are seen in MCF7 cells. d) Tamoxifen treatment directly suppresses PAR-4 expression in LY2 cell.

using siRNA, cells were seeded at 1x105 cells/mL into a six-well plate. They were then cultured for 14 days and the number of colonies formed was counted and compared to the control. Three-dimensional cell culture assays look at the ability of cells to polarise and hollow out a lumen, leading to the formation of an acinar-type structure. The cells were seeded at 1x103 cells/ml in 400µl of medium and 2% Matrigel (BD Biosciences) and subsequently seeded onto a Matrigel matrix in eight-well chamber slides (BD Biosciences). These were cultured for 14 days at 37ºC/5% CO2. Cells were fixed and stained with 4,6-diamidino-2-phenylindole (DAPI) and phalloidin 594, and results were examined by confocal microscopy.

Tissue samples and patient characteristics Breast tumour samples were obtained from 561 patients with breast carcinoma from the Department of Pathology, Beaumont Hospital. All patients were diagnosed and treated at the hospital between 1998 and 2006. Ethical approval was given by the Beaumont Hospital Ethics Committee.

Results SRC-1 down-regulates PAR-4 in endocrine-resistant breast cancer cell lines The results looked at mRNA levels and protein expression of PAR-4 following knockdown of SRC-1, as well as basal protein expression levels across different cell lines. They showed a significant increase in PAR-4 mRNA expression following SRC-1 knockdown (Figure 1a). This was confirmed using Western blotting, where PAR-4 protein expression was increased in the absence of SRC-1 (Figure 1b). When the basal expression levels of PAR-4 were investigated, the results of the western blots showed that the MCF7 cells expressed high levels of PAR-4 protein, with the more aggressive phenotypes, LY2 and LetR cells, not expressing PAR-4 at basal levels. A weak band was visible in SKBR3 cells (Figure 1c).

The effects of tamoxifen and oestrogen treatment on PAR-4 expression in the LY2 cell line were investigated. The Western blots showed that PAR-4 expression was increased in the oestrogen-treated sample, but that this effect was lost when combined with tamoxifen (Figure 1d).

PAR-4 is a marker of good disease-free survival in breast cancer patients Analysis of the tumour micro arrays following staining found that 45% of our patient population stained positive for PAR-4. The majority of the staining was located in the membrane and cytoplasm, with very few displaying nuclear staining. Statistical analysis that looked at the clinical correlations of PAR-4 expression found that PAR-4 was positively associated with luminal A status and ER expression. It was inversely associated with high-grade, positive nodal status, HER2 and recurrence (Figure 2a). Kaplan–Meier survival analysis revealed that PAR-4 expression is associated with good disease-free survival, which is statistically significant (Figure 2b).

PAR-4 may play a role in maintaining a well-differentiated phenotype The results of adhesion-independent growth looked at the number of colonies formed by the MCF7 cell line under normal circumstances compared with those where PAR-4 had been knocked down. The results showed that reduced PAR-4 expression resulted in significantly reduced colony formation (Figure 3a). Three-dimensional cell cultures compared the ability of cells to form acinar-type structures. MCF10A cells, a normal breast epithelial cell line, formed a well-polarised structure and the lumen hollowed out. In the MCF7 cells, there is a less defined attempt to polarise and incomplete hollowing of the lumen (Figure 3c). But when compared to the MCF7 cells following knockdown of PAR-4, there is a marked decrease in polarisation and little or no attempt to hollow out the lumen.

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RCSIsmjoriginal article FIGURE 2: Clinical correlations of PAR-4 positivity. a) Table showing the correlations (p-values) between PAR-4 expression and other markers of disease severity (*inverse correlation). b) Kaplanâ&#x20AC;&#x201C;Meier graph confirming that PAR-4 positivity is associated with good disease-free survival. c) 10x magnification of tissue micro-array stained for PAR-4. Left to right: PAR-4 positive core, PAR-4 negative core, IgG control.

FIGURE 3: PAR-4 plays a role in maintaining a well-differentiated phenotype. a) Graph showing the difference in the formation of colonies between the control and the PAR-4 knockdown cells (p=0.0038). b) 10x magnification of colonies in soft agar. c) Images from confocal microscopy of 3D structures formed by cells. MCF10A cells form well-defined acinar-type structures. MCF7 cells show some degree of polarisation and hollowing, but this is lost following knockdown of PAR-4. d) Western blotting was used to confirm the knockdown.

Discussion Prognosis and choice of adjuvant therapies for breast cancer rests on the analysis of the tumours at diagnosis. Pathological features including tumour size, stage, grade and nodal status are considered, alongside molecular markers (ER, PR, HER2), when deciding a course of treatment. But knowledge about individual prognostic factors does not take into account the vast number of genes potentially involved in controlling tumour biology, and thus their prognostic value is limited.1 The heterogeneity of breast tumours emphasises the importance of examining networks of genes and identifying potential markers to stratify patient therapies, and ultimately provide potential therapeutic targets. SRC-1 is ubiquitously expressed in tissues and is predominantly

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involved in glucose metabolism. SRC-1 itself would not make a good therapeutic target as it is a large, disorganised protein with a lack of high-affinity binding sites.10 Furthermore, its role as a nuclear co-activator makes it difficult to access and its importance in the normal functioning of a variety of tissues renders it an imperfect drug target. It is therefore essential to look at the downstream targets of this protein.7 Following identification of PAR-4 as a downstream target of SRC-1, its regulation and clinical correlations were investigated. Basal expression levels showed that MCF7 cells express high levels of PAR-4 and the more aggressive phenotypes do not (Figure 1c). A weak band was visible in the SKBR3 cell lines. Previous work from this lab has

RCSIsmj original article demonstrated that MCF7 cells do not express SRC-1, while LY2 and LetR cells do.4,6 SKBR3 cells may express some SRC-1, with cross-talk between growth factor-driven pathways and steroid pathways. This partially active steroid pathway may explain the partial suppression of PAR-4 in the SKBR3 cells. These results suggest that SRC-1 is directly suppressing the expression of PAR-4. This was validated when PAR-4 protein and mRNA expression in LY2 cells were investigated (Figure 1). The results show that when SRC-1 is knocked down from LY2 cells, PAR-4 expression significantly increases. It was also shown that treatment of these resistant cell lines with tamoxifen suppresses this marker of luminal A status. This is of significance as SRC-1 is driven by tamoxifen treatment in this cell line. This provides exciting evidence that in addition to driving the expression of oncogenes, SRC-1 may also be suppressing the expression of proteins associated with a less aggressive, more treatment-responsive phenotype. This is consistent with other studies, which have shown that down-regulation of PAR-4 may be associated with loss of the progesterone receptor, and a move to a more aggressive cancer.10 MCF7 cells represent the least aggressive phenotype of those studied here. The high basal expression levels seen in this cell line support our hypothesis that PAR-4 expression is associated with a less aggressive phenotype. Statistical analysis of the stained tissue micro-arrays revealed that PAR-4 expression positively correlates with luminal A and ER status, and inversely correlates with markers of more aggressive disease (Figure 2a). In addition, Kaplan–Meier analysis confirmed that PAR-4 positivity is significantly associated with good disease-free survival (Figure 2b). The results of the functional assays take this hypothesis a step further, suggesting that PAR-4 may play a role in the maintenance of this well-differentiated, less aggressive phenotype. The ability of cells to form colonies in soft agar is a marker of differentiation and aggressiveness. The increase in the number of colonies following the knockdown of PAR-4 qualifies its role in

maintaining a less aggressive phenotype. This is supported by the 3D assay, where the loss of PAR-4 led to a less defined attempt at forming an acinar-type structure. When taken together, the results of this research suggest a role for PAR-4 as a marker of good disease-free survival or, conversely, that the loss of PAR-4 expression would signal tumour progression to a more aggressive phenotype. The identification of multiple genes that control tumour progression would allow for stratification of patients who require specialised therapies or rigorous follow-up, which is the cornerstone of personalised medicine. It is also hypothesised that genes such as PAR-4 would ultimately be targeted, given their anti-tumorigenic nature.10

Conclusion We have shown that the master-regulator SRC-1 has a function as a co-repressor in addition to its co-activator role. We have shown that PAR-4 significantly correlates with good disease-free survival and that its expression is suppressed in tamoxifen-treated, resistant cell lines. We have begun to explore the functional role of PAR-4 and have shown that it may play a role in maintenance of a well-differentiated phenotype. These findings are significant because increasing our understanding of tumour biology and the interactions of large networks of proteins will enable more effective and specific therapeutic strategies to be developed in the future.

Acknowledgements I would like to thank Professor Arnold Hill and Dr Leonie Young for giving me the opportunity to work on this project, Breast Cancer Ireland for funding the research, and all my colleagues in the Department of Surgery in York House for their guidance and encouragement, with special thanks to Jarlath Bolger for his support and invaluable teaching throughout.

References 1.

Sorlie T, Perou CM, Tibshirani R et al. Gene expression patterns of breast

SRC-1 transcriptome identifies ADAM22 as an ER-independent mediator

carcinomas distinguish tumour subclasses with clinical implications. Proc

of endocrine-resistant breast cancer. Cancer Res. 2012;72(1):220-9. Epub

Natl Acad Sci USA. 2001;98(19):10869-74. 2.

Sorlie T, Tibshirani R, Parker J et al. Repeated observation of breast

2011 Nov 9. 7.

tumour subtypes in independent gene expression data sets. Proc Natl

receptor coactivator-1 in normal tissues and cancer. Int J Biol Sci.

Acad Sci USA. 2003;100(14):8418-23. 3. 4.

Perou CM, Sorlie T, Eisen MB et al. Molecular portraits of human breast

2012;8(4):470-85. 8.

suppresses breast cancer metastasis without affecting primary tumour

McBryan J, Theissen SM, Byrne C et al. Metastatic progression with

formation. Proc Natl Acad Sci USA. 2009;106(1):151-6. Epub 2008

coactivator SRC-1. Cancer Res. 2012;72(2):548-59. Epub 2011 Nov 22. McIlroy M, McCartan D, Early S et al. Interaction of developmental transcription factor HOXc11 with steroid receptor co-activator SRC-1 mediates resistance to endocrine therapy in breast cancer. Cancer Res. 6.

Wang S, Yuan Y, Liao L et al. Disruption of the SRC-1 gene in mice

tumours. Nature. 2000;406(6797):747-52. resistance to aromatase inhibitors is driven by the steroid receptor 5.

Walsh CA, Qin L, Tien JC, Young LS, Xu J. The function of steroid

Dec 24. 9.

Nagai MA, Gerhard R, Salaorni S et al. Down-regulation of the candidate tumour suppressor gene PAR-4 is associated with poor prognosis in breast cancer. Int J Oncol. 2010;37:41-49.

10. Zapata-Benavides P, Méndez-Vázquez JL, González-Rocha TR et al.

2010;70(4):1585-94. Epub 2010 Feb 9.

Expression of prostate apoptosis response (Par-4) is associated with

McCartan D, Bolger JC, Fagan A et al. Global characterisation of the

progesterone receptor in breast cancer. J Arc Med. 2009;40:595-9.

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RCSIsmj case report Atherosclerosis-induced aortic coarctation: a case report Abstract Acquired aortic coarctations are uncommon but potentially life threatening. They are poorly reported in the literature, primarily due to their rarity. We describe a 36-year-old Asian woman with a longstanding history of moderate hypertension. She developed atherosclerosis in her abdominal aorta, in the region of the coeliac trunk and superior mesenteric arteries. Her condition deteriorated after a motor vehicle accident, upon which her blood pressure could no longer be controlled, despite the use of several antihypertensive medications. The patient experienced claudication and weakness in both of her legs. A CT angiogram revealed a near complete suprarenal aortic occlusion, which accounted for her presentation. A left axillo-femoral bypass was performed. The benefits of the surgery were seen immediately. Her blood pressure improved and her other symptoms diminished. Aortic coarctations are most commonly derived from a congenital defect. Acquired coarctations are significantly rarer. There are a number of features that appear to be consistent with aortic coarctations such as uncontrolled hypertension, diminished lower limb pulses, and lower limb intermittent claudication. Treatment is surgical, after which the patientâ&#x20AC;&#x2122;s blood pressure and ankle/brachial indices must be closely monitored to determine success. Royal College of Surgeons in Ireland Student Medical Journal 2013; 6(1): 42-4.

Case report

Jonathan Shum1 Dr Robert Ting2 1RCSI 2Scarborough

medical student

General Hospital,

Toronto, ON, Canada

Page 42 | Volume 6: Number 1. 2013

This case describes a 36-year-old Asian woman who was referred to a specialist for hypertension in 1999. Previously she had two episodes of pregnancy-induced hypertension in 1989 and 1994, treated with bed rest only. She had a relevant family history, as her mother had developed hypertension at age 60. The patient had no history of alcohol consumption or smoking, and no other medical history of note. Her clinic blood pressure in May 1999 was elevated at 160/90mmHg. A 24-hour ambulatory blood pressure monitor showed that her average blood pressure was also elevated at 142/86mmHg. This was consistent with mild hypertension, and the patient was prescribed lisinopril 20mg/hydrochlorothiazide 12.5mg, which brought her blood pressure under control at 124/80mmHg. At three-month follow-up her blood pressure was 135/80mmHg and she was discharged back to her family physician for ongoing management. Five years later, in 2004, the patient was involved in a motor vehicle accident, immediately after which her blood pressure elevated to 180/100mmHg and could not be controlled with her current medication. She was hospitalised for one week after the accident. During this time, she began to experience pain in both lower extremities and had

difficulty walking. She also complained of abdominal pain. Her physicians initially attributed these symptoms to her motor vehicle accident. In 2005, the patient was referred back to the specialist for her uncontrolled hypertension. Secondary causes of hypertension such as adrenal tumour and renal artery stenosis were tested for. Tests showed a 24-hour vanillylmandelic acid (VMA) of 16, renin 5.48 and aldosterone 274, which were all within the normal range and ruled out an adrenal cause. A nuclear renal scan was performed and ruled out renal artery stenosis. Normal eGFR, creatinine, urea and electrolyte levels indicated normal renal function. An echocardiogram was ordered to check her heart function under the duress of the acute hypertension. It revealed normal left ventricular (LV) function but borderline LV hypertrophy; her LV wall thickness and interventricular (IV) septum both measured 12mm. Essential hypertension was still the diagnosis at this time. Amlodipine 10mg once daily, atenolol 100mg once daily and losartan 100mg/hydrochlorothiazide 25mg once daily were prescribed to control her blood pressure. Propylthiouracil 50mg twice daily was also prescribed to control her hyperthyroidism, which had been recently diagnosed. After one month of

RCSIsmjcase report

FIGURE 1a (left): Computed tomography (CT) angiogram showing severe atherosclerosis in the abdominal aorta at the level at T12. FIGURE 1b (above): Computed tomography (CT) angiogram showing a closer look at the severe atherosclerosis in the abdominal aorta at the level at T12.

this regimen, her blood pressure remained elevated in excess of 180/100mmHg. Consequently, her medications were titrated upwards to amlodipine 10mg bid, atenolol 100mg once daily, terazosin 4mg bid, candesartan/hydrochlorothiazide 32/25mg once daily and aliskiren 300mg once daily. After one month of this new regimen, her blood pressure still remained elevated at 170/95mmHg. Minoxidil 5mg bid and furosemide 40mg bid were added to the current regimen. Two weeks later her brachial blood pressure dropped to 135/75mmHg; however, she developed acute anuria and her creatinine levels rose dramatically (from 226 to 588µmol/L), indicating ischaemic nephropathy. The patient also complained of weakness, cramping, coldness and numbness in her feet and lower legs, and abdominal cramping. The patient’s leg and foot pulses were weak and blood pressure was unattainable in the lower extremities. Minoxidil and furosemide were ceased immediately. Her brachial blood pressure rose again to 185/105mmHg. Her creatinine level fell back to 202µmol/L, indicating that her kidney function had returned to normal. An underlying vascular problem was suspected at this point. A Doppler ultrasound was performed, which indicated irregular blood flow within the abdominal aorta. The ankle/brachial indices were 0.47 for the right side and 0.46 for the left side (values <0.9 indicate arterial disease). An abdominal aortic ultrasound indicated occlusion of the distal aorta and both common iliac arteries. A CT angiogram showed severe atherosclerosis in the abdominal aorta. The CT angiogram (Figures 1a and 1b) revealed (>90%) occlusion of the subdiaphragmatic aorta above the coeliac artery. There was extensive calcified plaque at the level of T12 with associated occlusions (90-99%) at the origins of the coeliac and superior mesenteric arteries. Collateral arteries were present. A hypertrophied inferior mesenteric

artery and the hypogastric arteries supplied the entire bowel. The inferior mesenteric artery filled the arterial beds of the coeliac and superior mesenteric arteries through collateral vasculature. Extensive collateralisation from the intercostal internal mammaries to superior epigastric arteries and abdominal wall vessels allowed retrograde refilling of the iliac vessels and anterograde refilling of the femoro-popliteal system. No significant stenoses below the origin of the superior mesenteric artery were noted. This indicated that the patient had significant atherosclerotic disease of the aorta, resulting in a coarctation of the aorta. The physicians postulated that the blunt trauma she sustained during her motor vehicle accident created shear forces that dislodged plaque, resulting in acute subtotal occlusion of her aorta and ultimately the acute elevation of her blood pressure. Blunt trauma was felt to be the case because she did not have any typical risk factors for spontaneous thrombosis, such as heavy smoking or poorly controlled diabetes. There was also a temporal relationship between the motor vehicle accident and the acute rise in her blood pressure. The patient was referred to a vascular surgeon. An aortic reconstruction would be precarious with a >20% mortality risk. There was also the risk of other complications such as paralysis, mesenteric infarction, and acute cortical necrosis of her kidneys. A left axillo-femoral bypass was performed instead. A bypass graft was placed subcutaneously along the side of her anterior chest and abdomen, joining the axillary and femoral arteries. Post-operatively, the patient’s symptoms improved considerably. Generally, she no longer has the claudication pain in her abdomen and legs. Upon exertion, she experiences claudication in her right leg due to the left axillo-femoral bypass. The right axillary blood vessels were preserved for future use in case the left graft occluded. Her physicians were able to reduce her blood pressure to 150/70mmHg without

Volume 6: Number 1. 2013 | Page 43

RCSIsmj case report precipitating acute renal failure. Her ankle/brachial indices measured 0.60 on the right and 0.66 on the left, which was satisfactory because her axillo-femoral bypass graft had a significantly smaller diameter than her native aorta. In August 2012, the patient’s blood pressure was recorded at 160/80mmHg. She currently takes five antihypertensive medications: amlodipine 10mg once daily, candesartan 32mg once daily, hydrochlorothiazide 25mg once daily, labetalol 100mg bid and doxazosin 4mg bid.

Discussion There are two types of aortic coarctation: congenital and acquired. Acquired aortic coarctations constitute only 2% of aortic coarctations.1 They can be caused by aortic dissection due to extension of a coronary artery dissection, Marfan syndrome, large-vessel vasculitis such as Takayasu arteritis, mycotic aneurysms, and severe atherosclerosis.2,3 Cases of abdominal aortic coarctations have been reported with anatomical variants, resulting in an array of clinical features.4 They do, however, commonly present with lower limb intermittent pain and ischaemia, differences in systolic blood pressure between upper and lower extremities, abdominal pain and hypertension.5,6 Other features may include spinal cord compression-like symptoms, urinary incontinence, impotence in men, inability to walk long distances, and mild sensory loss in the lower body.5,6 The variety of symptoms can make diagnosis difficult. Formation of extended collateral vasculature can maintain a basal perfusion and prevent the manifestation of acute ischaemia in the lower extremities for a long time, further delaying diagnosis.5

In the case presented, essential hypertension was originally diagnosed. The patient had two previous episodes of pregnancy-induced hypertension and a family history of the disease. Echocardiogram and nuclear renal scan tests were within the normal range. Blood and urine results were also normal. Secondary hypertension was suspected when aggressive antihypertensive treatment failed to lower the patient’s blood pressure without inducing lower body ischaemia. The absent pulses of the lower extremities indicated a vascular problem. A Doppler ultrasound and a CT angiogram revealed an atherosclerotic coarctation and its position within the abdominal aorta superior to the renal arteries. In order to get blood to the lower body, blood pressure above the coarctation had to rise. When higher doses of antihypertensives were added to the patient’s drug regimen, they caused hypoperfusion below the occlusion. This led to ischaemia of the kidneys, lower limbs and spinal cord, resulting in acute renal failure, and weakness and numbness of the lower extremities.

Conclusion Coarctations of the aorta can result from congenital or acquired conditions. Clinical features such as uncontrolled hypertension, diminished or absent lower limb pulses, and intermittent claudication present in most cases. Diagnosis can be delayed due to the various locations of aortic coarctations and the potential formation of extended collateral vasculature. Surgical treatment is required. Close monitoring of the patient’s ankle/brachial index after surgery is essential.

Further reading Warnes CA, Williams RG, Bashore TM, Child JS, Connolly HM, Dearani JA et

Twenty-two years of follow-up of balloon angioplasty for discreet native

al. ACC/AHA 2008 Guidelines for the Management of Adults with

coarctation of the aorta in adolescents and adults. Am Heart J.

Congenital Heart Disease: a report of the American College of

2008;156(5):910-7.

Cardiology/American Heart Association Task Force on Practice Guidelines.

Bowes DE, Youkey JR, Franklin DP, Benoit CH, Pharr WF. An algorithm for

Circulation. 2008;118(23):e714.

the surgical management of chronic abdominal aortic occlusion and

Teien DE, Wendel H, Bjornebrink J, Ekelund L. Evaluation of anatomical

occluded aortofemoral grafts. J Cardiovasc Surg (Torino). 1993;33:650-9.

obstruction by Doppler echocardiography and magnetic resonance imaging

Schneider J, McDaniel M, Walsh D, Zwolak R, Cronenwett J. Axillofemoral

in patients with coarctation of the aorta. Br Heart J. 1993;69(4):352.

bypass: outcome and hemodynamic results in high-risk patients. J Vasc Sur.

Fawzy ME, Fathala A, Osman A, Badr A, Mostafa MA, Mohmaned G et al.

1992;15(6):952-63.

References 1.

Daghero F, Bueno N, Peirone A, Ochoa J, Torres GF, Ganame J. Coarctation of the abdominal aorta: an uncommon cause of arterial hypertension and

Pediatr. 1998;132(6):1016. 4.

stroke. Circ Cardiovasc Imag. 2008;1:e4-6. 2.

Windham PA. Coarctation of the abdominal aorta. Tex Heart I J.

Kimura-Hayama ET, Meléndez G, Mednizabal AL, Meave-Gonzalez A, Zambrana GFB, Corona-Villalobos CP. Uncommon congenital and acquired

1993;10:269-73. 5.

aortic diseases: role of multidetector CT angiography. Radiographics. D’Souza SJ, Tsai WS, Silver MM, Chait P, Benson LN, Silverman E et al. Diagnosis and management of stenotic aorto-arteriopathy in childhood. J

Page 44 | Volume 6: Number 1. 2013

Efstratiadis G, Kirmizis D, Papazoglou K, Economidou D, Memmos D. The walking man with a completely occluded aorta. Nephrology Dial Transpl.

2010;30(1):79-98. 3.

Calhourn TR, Thumwood RG, Tennyson KB, Wright RM, Kitten CM,

2004;19(1):227-9. 6.

Bucci F, Fiengo L, Hamati S, Plagnol P. Abdominal aortic occlusion of young adults. Interact Cardiovasc Thorac Surg. 2012;14(1):99-101.

RCSIsmj case report The key is in the details: a case of disseminated histoplasmosis Abstract Case description: A 39-year-old HIV-positive Hispanic gentleman presented to the emergency department with a four-day history of altered mental status, pyrexia, mild non-productive cough, nausea and vomiting on a background of night sweats, chills, weight loss and diarrhoea. The patient had a history of non-compliance with his antiretroviral therapy, and of tobacco, alcohol and cocaine use. He was a lifelong gardener, born in Mexico but living in southern California for 19 years. On examination he was febrile, wasted and disoriented. A number of skin lesions were appreciated throughout his body. Laboratory studies demonstrated pancytopaenia and severe immunosuppression; however, imaging, serology, cultures and a bone marrow biopsy were unremarkable. Despite antibacterial, antiviral and antifungal treatment, he continued to deteriorate clinically. Thirteen days into his admission, his blood and bone marrow fungal cultures tested positive for Histoplasma capsulatum. His final diagnosis was disseminated histoplasmosis involving multiple organ systems, which responded rapidly to treatment with intravenous liposomal amphotericin B. Discussion: This case illustrates the challenges faced in the diagnosis of disseminated histoplasmosis in a patient with advanced HIV, including vague symptomatology, the presence of multiple HIV-related comorbidities, non-reactive serology, and delay due to slow-growing fungal cultures. Most importantly, this case highlights the importance of a thorough history and examination in eliciting the clues to diagnosis in the face of these challenges.

Royal College of Surgeons in Ireland Student Medical Journal 2013; 6(1): 45-9.

Sena Kilic RCSI medical student

Volume 6: Number 1. 2013 | Page 45

RCSIsmjcase report

FIGURE 1: Multiple circular, depressed, firm and non-tender plaques surrounded by erythema and with a central haemorrhagic crust were present bilaterally in his lower extremities.

FIGURE 2: Multiple similar lesions were present on his hands, shoulders, legs, head and neck.

Background Cases of histoplasmosis have been reported on nearly every continent; however, it is endemic in areas of the USA such as the Mississippi, Ohio and St Laurence river valleys. The infection is caused by the dimorphic saprophytic fungus Histoplasma capsulatum (H. capsulatum), found most commonly within 20cm of the surface of soil contaminated with bird or bat excreta. Transmission occurs via inhalation of H. capsulatum spores and persons at risk include those engaged in agriculture, outdoor construction and spelunking.1 It is the most common endemic mycosis in AIDS patients and is the AIDS-defining illness in more than 50% of patients.2 More than 90% of primary infections are asymptomatic or result in a mild influenza-like illness. Those who become symptomatic usually present with fever, headache, a non-productive cough, chills, chest pain, and also rarely with malaise, weakness, fatigue, myalgia and rheumatologic manifestations. Most symptoms resolve spontaneously, but in one out of 2,000 cases the organism grows relentlessly and affects multiple organ systems leading to disseminated histoplasmosis (DH). Most cases of DH are observed in immunosuppressed patients who are more likely to develop systemic symptoms, pancytopaenia, fungaemia and hepatosplenomegaly.3 While primary infection with H. capsulatum is not uncommon, DH is rare and, left untreated, the mortality rate is 100% in the HIV population. The challenge to diagnosis is the time it takes for fungal cultures to grow, which could take up to two weeks. It is therefore recommended that if there is an index of suspicion, the clinician should start appropriate antifungal treatment without delay.

The case This is the case of a 39-year-old HIV-positive Hispanic gentleman who presented to the University of California Irvine Medical Center complaining of a four-day history of altered mental status, pyrexia, mild non-productive cough, nausea and vomiting on a two-week

Page 46 | Volume 6: Number 1. 2013

background of night sweats, chills, weight loss and diarrhoea. His wife noted that four days prior to presentation, he began “acting drunk”. He progressed to becoming agitated, exhibiting repetitive behaviours such as turning the lights on and off, and expressing somatic delusions of anosmia, blindness and nihilistic delusions of being “dead inside”. Further questioning revealed that he had been behaving oddly for several weeks, having lacerated his own scrotum two weeks ago for no apparent reason. The patient had been diagnosed with HIV in 2004 and had a history of antiretroviral therapy (ART) non-compliance, and of tobacco, alcohol and cocaine use. He denied any recent travel, sick contacts or intravenous drug use. He had no other past medical or surgical history, and was not on any medications. He was a lifelong gardener who was born in Mexico but moved to California in 1993. His last visit to Mexico was one year prior to presentation and he had never travelled outside southern California and Mexico. On examination, he was febrile (temperature of 38.5ºC), tachycardic, wasted and disoriented. A white plaque was appreciable on his tongue and a number of circular, depressed, firm and non-tender plaques with a central haemorrhagic crust and surrounding erythema were present throughout his body (Figures 1 and 2). All other systems examinations were unremarkable and he demonstrated no focal neurological deficits or meningism. Laboratory studies demonstrated pancytopaenia, severe immunosuppression (Table 1), and extensive serology and imaging findings were negative (Table 2). A lumbar puncture was contraindicated due to severe thrombocytopaenia but a bone marrow biopsy performed on day two of admission demonstrated a normocellular marrow, budding yeast-like structures on fungal stain that failed to grow on fungal culture, and no evidence of acute lymphoma or leukaemia.

RCSIsmjcase report Table 1: Diagnostic data.

Complete blood count

Urea and electrolytes

Liver function

T-cell subsets and viral load

2.9g/dl Low

Na+

133mEq/L Low

T. Prot.

7.0g/dl

White cell count

2,900/mcL Low

Hct

28.3% Low

K+

3.1mEq/L Low

Albumin

2.8g/dl

Lymphocytes

100/mcL Low

WCC

10.2g/dl Low

Cl-

100mEq/L

Alk Phos

91IU/L

CD3+CD4+ count 3/mcL Low

Plt

26,000 Low

BUN

16mg/dl

AST

238IU/L High

Viral load

Creat

1.0mg/dl

ALT

86IU/L High

Mg2+

2.1mEq/dl

T. Bili.

1.7mg/dl High

1,730,000 copies/mL High

Inor. Phos. 3.8mg/dl Corr. Ca2+ 8.6mg/dl

Hb, haemoglobin; Hct, haematocrit; WCC, white cell count; Plt, platelets; Na+, sodium; K+, potassium; Cl-, chloride; BUN, blood urea nitrogen; Creat, creatinine; Mg2+, magnesium; Inor. Phos., inorganic phosphate; Corr. Ca2+, corrected calcium; T. Prot., total protein; Alk Phos, alkaline phosphatase; AST, aspartate transaminase; ALT, alanine transaminase; T. Bili., total bilirubin.

Table 2: Serology and imaging.

Positive serology

Negative serology

Positive imaging

Negative imaging

Other negative findings

HBsAg

Anti-HBs Ab HBV DNA HBeAg Anti-HBe Ab Anti-HCV Ab Anti-HAV Ab T. pallidum Cryptococcus Histoplasma Coccidioides EBV, CMV, HSV Toxoplasma

CT head: prominent central cerebral atrophy

Plain film chest and abdomen x-ray

Tuberculosis blood culture Tuberculosis sputum cultures

CT chest, abdomen and pelvis

Sputum acid-fast bacilli x 3

MRI brain

Stool, urine and sputum cultures

MRI L-spine

Urine histoplasma antigen

MRI T-spine

Sputum Pneumocystis jirovecii

Ultrasound scan: Liver/ gallbladder/bile ducts/ pancreas/spleen

Blood and bone marrow bacterial, viral and fungal cultures

HBsAg, hepatitis B surface antigen; HBs Ab, hepatitis B surface antibody; HBV DNA, hepatitis B virus DNA; HBeAg, hepatitis B extracellular core antigen; HCV Ab, hepatitis C virus antibody; HAV Ab, hepatitis A virus antibody; EBV, Epstein-Barr virus; CMV, cytomegalovirus; HSV, herpes simplex virus.

Volume 6: Number 1. 2013 | Page 47

RCSIsmj case report

FIGURE 3: Fungal cultures on bone marrow demonstrating H. capsulatum.

Despite being on aggressive treatment with broad-spectrum antibiotics, antivirals and antifungals (Table 3) he continued to spike daily fevers greater than 40ºC and he deteriorated clinically. He required near daily blood and platelet transfusions and developed frank psychosis with visual and auditory hallucinations. On day 10 of admission, he began complaining of severe neuropathic pain on the soles of his feet, which debilitated him further. With no diagnosis and a worsening clinical picture, a family meeting was called for a discussion regarding palliative care. Thirteen days into his admission, the first set of blood and bone marrow fungal cultures became positive for H. capsulatum (Figure 3). Guidelines by the Centers for Disease Control and Prevention (CDC), the National Institutes of Health (NIH) and Infectious Diseases Society of America recommend initiation therapy with intravenous liposomal amphotericin B and maintenance therapy with oral itraconazole.4 DH does not respond to micafungin and responds poorly to fluconazole.5 He was therefore started on a high dose of liposomal amphotericin B and became afebrile one day into treatment. From day two of treatment, the clinical picture had improved significantly (Figure 4). Not all of this patient’s symptoms could be explained by DH. While he began to improve clinically after treatment with amphotericin B, his psychosis, pancytopaenia and peripheral neuropathy failed to respond. These conditions were attributed to HIV and he was started on ARTs. While waiting for the patient to respond to ART, his HIV psychosis, pancytopaenia and peripheral neuropathy were managed with antipsychotics, packed red blood cell and platelet transfusions, and gabapentin, respectively, and responded adequately to symptomatic management. His final diagnosis was DH involving the central nervous system (CNS), liver, skin and bone marrow with concomitant HIV psychosis, pancytopaenia and neuropathy. Two weeks into his treatment, there was a dramatic improvement clinically and we were confident to begin discharge planning.

Page 48 | Volume 6: Number 1. 2013

FIGURE 4: A dramatic improvement in the patient’s skin lesions was appreciated after just two days of treatment with liposomal amphotericin B.

Table 3: Anti-microbial treatment regimen of patient. Antibacterial

Antifungal

Antiviral

Vancomycin,

Fluconazole initially

Aciclovir

ceftriaxone, and

then switched to

piperacillin-tazobactam

micafungin

Discussion DH in AIDS patients can present in a wide spectrum of clinical forms and can either be caused by a recent exposure or endogenous reactivation of latent foci. DH in AIDS most commonly presents with fever, weight loss and focal lesions on multiple organ systems including the gastrointestinal tract, endovascular structures, the CNS and the adrenal glands. Cutaneous lesions occur in 10-25% of patients with DH. These are more common in Latin Americans, ranging from 38-85%. They can either be primary, caused by direct inoculation, or secondary, caused by haematogenous spread.6 The most common cutaneous lesion is a papular eruption with crusting, but other manifestations have been reported, which are summarised in Table 4.7 This patient’s lesions (Figures 1 and 2) resemble those reported in the literature and responded rapidly to treatment with liposomal amphotericin B. The most sensitive and specific diagnostic test for DH is the detection of Histoplasma antigen in the serum, urine, cerebrospinal fluid and bronchoalveolar lavage fluid.8 If there is a high index of suspicion, direct microscopy can be performed for rapid identification on a variety of samples, including bone marrow aspirates. Standard serology has been described to be non-reactive

RCSIsmjcase report in HIV-infected patients9 and was non-reactive in this case. If treated, the prognosis remains poor among the HIV-infected patient population with DH. The overall risk of death is nearly 50%. Fungaemia, renal insufficiency and age are independent predictors of poor prognosis with odds ratios of 12.1, 11.3 and 0.9, respectively. While the vast majority of cases of DH are seen in patients with advanced HIV, defined by a CD4 count less than 50/mcl, a low CD4 count and high viral load are not statistically significant predictors of poor outcomes.10

Table 4: Cutaneous lesions of histoplasmosis reported in the literature.6 Primary

Secondary

Painless chancre with regional adenopathy

Papules

Punched-out ulcers

Plaques with and without crusts

Localised and generalised dermatitis

Pustules Panniculitis

Conclusion

Nodules Vegetations

While primary histoplasma infections are common and prevalent globally, only one out of 2,000 H. capsulatum infections progress to DH. HIV-infected individuals with low CD4 counts are at increased risk of DH and often present with vague systemic symptoms. A variety of cutaneous manifestations have been described in the literature and multiple organ systems may be involved. Non-reactive serology is not uncommon in this patient population and a definitive diagnosis by way of fungal cultures may not be possible for up to two weeks after presentation. In addition, HIV-positive patients are more likely to present with fungaemia, an independent predictor of poor prognosis despite adequate treatment. The mortality rate is 100% if left untreated, making it essential to recognise and empirically treat at-risk patients. The key to diagnosis in this case was hidden in the details. Since the patient had not visited endemic regions recently, it was concluded that his DH was due to reactivation of latent foci. Retrospective questioning revealed that he was born, raised and worked in the agricultural fields of southern Mexico, the only endemic region in the country, putting to rest the mystery surrounding his unusual diagnosis.

Mucosal ulcers Erosions

Polymorphous erythema

Keratotic plaques and papules

Erythroderma syndromes

Purpuric lesions

Molluscum contagiosum-like lesions

Acneiform eruption Rosacea-like eruption

Pyoderma gangrenosum-like lesions Diffuse hyperpigmentation Abscesses and cellulitis

References 1.

Mandell GL, Bennett JE, Dolin R (eds.). Principles and Practice of Infectious

Immunodeficiency Syndrome Clinical Trials Group and Mycoses Study

Diseases. 7th ed. Philadelphia: Churchill Livingstone Elsevier; 2010:3305-18. 2.

Group. Am J Med. 1997;103(3):223. 6.

Chang P, Rodas C. Skin lesions in histoplasmosis. Clin Dermatol.

Vasudevan B, Ashish B, Amitabh S, Mohanty AP. Primary cutaneous

Antinori S, Magni C, Nebuloni M et al. Histoplasmosis among human immunodeficiency virus-infected people in Europe: report of 4 cases and

2012;30(6):592-8.

review of the literature. Medicine (Baltimore). 2006;85(1):22-36. 3.

histoplasmosis in a HIV-positive individual. J Glob Infect Dis.

McLeod DS, Mortimer RH, Perry-Keene DA et al. Histoplasmosis in Australia: report of 16 cases and literature review. Medicine (Baltimore).

2010;2(2):112-15. 8.

Hage CA, Ribes JA, Wengenack NL et al. A multicenter evaluation of tests

Wheat LJ, Connolly-Stringfield PA, Baker RL et al. Disseminated

2011;90(1):61-8. 4.

Kaplan JE, Benson C, Holmes KH et al. Guidelines for prevention and treatment of opportunistic infections in the HIV-infected adults and

histoplasmosis in the acquired immune deficiency syndrome: clinical

adolescents: recommendations from the CDC, the National Institutes of

findings, diagnosis and treatment, and review of the literature. Medicine

Health and the HIV Medicine Association of the Infectious Diseases Society of America. MMWR Recomm Rep. 2009;58(RR-4):1. 5.

for diagnosis of histoplasmosis. Clin Infect Dis. 2011;53(5):448-54.

(Baltimore). 1990;69(6):361. 10. Baddley JW, Sankara IR, Rodriguez JM, Pappas PG, Many WJ Jr.

Wheat J, MaWhinney S, Hafner R et al. Treatment of histoplasmosis with

Histoplasmosis in HIV-infected patients in a southern regional medical

fluconazole in patients with acquired immunodeficiency syndrome.

center: poor prognosis in the era of highly active antiretroviral therapy.

National Institute of Allergy and Infectious Disease Acquired

Diagn Microbiol Infect Dis. 2008;62(2):151-6.

Volume 6: Number 1. 2013 | Page 49

RCSIsmj review The MMR vaccine and autism Abstract In February 1998, the Lancet published a study by Dr Andrew Wakefield, a British gastroenterologist, which suggested a link between the measles, mumps and rubella (MMR) vaccine as an environmental trigger, and a novel bowel disorder that led to a regressive form of autism. Despite repeated assurances from health professionals and extensive epidemiological studies, which categorically refuted such a link, the controversy sparked a huge public health scare in the United Kingdom. After a decade of controversy and investigation, Dr Wakefield was found guilty of ethical, medical and scientific misconduct in carrying out the study and publishing fraudulent data. It is important for healthcare professionals to be aware of the specifics of the controversy in this multifaceted scandal and the ongoing implications, which have led to a resurgence in cases of measles, mumps and rubella. It is also imperative to question how effectively science is being communicated to the general public to allow them to make better health decisions for their children and themselves.

Royal College of Surgeons in Ireland Student Medical Journal 2013; 6(1): 50-3.

Introduction

Zain Hasnain RCSI medical student

Page 50 | Volume 6: Number 1. 2013

The measles, mumps and rubella (MMR) triple vaccine, consisting of a live, attenuated measles virus as the immunogen, is given by injection in two doses. The first is given to toddlers aged 12-15 months, with a second â&#x20AC;&#x2DC;boosterâ&#x20AC;&#x2122; injection given to school children to safeguard the 5-10% who do not develop full immunity. The first public suggestion of a link between the MMR vaccine and autism was made by the mother of an autistic child in 1993 on a Danish television programme. This prompted an investigation in 1994 by the Danish Department of Epidemiology at the National Statens Serum Institutedence looking for a change in trend in incidence or age at diagnosis associated with the introduction of the vaccine. Although no link, either epidemiological or biological, was found at the time, fear of an association between the two inspired parents and lawyers to form anti-MMR groups.1 The possibility of such a link entered public discourse in 1998 when the Lancet published a paper suggesting a link between the MMR vaccine and the onset of autism, which has led to repercussions in healthcare and the sociopolitical arena that are still being experienced to this day.

This review will look at the extensive studies undertaken by the scientific community, which have categorically refuted any relationship between the MMR vaccine and autism.

The Lancet study by Andrew Wakefield On February 28, 1998, together with 12 co-authors, Andrew Wakefield published a study in the Lancet suggesting that the MMR vaccine could be an environmental trigger that led to the onset of developmental regression in infants. The study involved 12 children referred to the Royal Free Hospital with a history of gastrointestinal disease, in particular inflammatory bowel disease. Nine of these children were diagnosed with a regressive form of autism in which they had seemingly normal infant development before a gradual deterioration in communication and other acquired skills. The other three children had suspected encephalitis, also presenting with developmental problems.2 Histological examinations found abnormalities in the colonoscopy samples showing ileal lymphoid nodular hyperplasia (LNH) present in nine of the 12 children. Eight of these nine had mucosal

RCSIsmj review abnormalities and a distinct non-specific mild-to-moderate colitis, not classified as either Crohn’s disease or ulcerative colitis. The paper suggested that the damaged intestine triggered the regression in the children through the previously proposed “opioid-excess” hypothesis for autism. The hypothesis states that incomplete digestion of certain foods resulting from a dysfunctional gut leads to undigested ‘toxic’ peptides, which are absorbed into the bloodstream. These peptides are thought to be bound to peptidase enzymes, normally responsible for breaking down the naturally occurring opioid peptides in the central nervous system (CNS). The hypothesis suggests that the toxic peptides consequently lead to CNS disruption, which adversely affects brain development.3 The paper also reported that eight of the children’s parents or physicians said that the onset of behavioural problems was within two weeks of the vaccine administration. The authors conceded that due to a small sample size and inadequate published evidence, they could not fully substantiate a causative link. However, at a press conference following publication, Andrew Wakefield suggested that the MMR vaccine could lead to what he termed “autistic enterocolitis” and suggested that the immunisation programme be changed, with the three vaccines given separately as single injections.4 Within five years of the publication of Wakefield’s study, the rates of MMR inoculation in the UK fell from 92% to under 80%, well below the 95% rate recommended by the World Health Organisation for a population to acquire herd immunity and protect that population from an endemic.5

Reaction by the government and scientific community In response to the Wakefield paper, the Medical Research Council assembled 37 experts to thoroughly review published (and unpublished) evidence at the time, and concluded that there was no link between autism and the MMR vaccine. Despite this, Wakefield’s claim, together with widespread media coverage of the debate, meant that the controversy remained alive, especially for parents concerned with making inoculation decisions for their children.6 In 2004, an apology was issued by Richard Horton,7 the Lancet’s editor, where he described the paper as “flawed”. In addition, 10 of the 12 co-authors of the study retracted the interpretation of an MMR-autism link.8 The major remaining issue was that the paper had shown that eight out of 12 children were “previously normal” and had developed “behavioural symptoms” after receiving the vaccine. The first set of symptoms was observed to be on average 6.3 days post inoculation. Assessment of the medical reports showed several inconsistencies with the paper’s reporting of patient data regarding autism onset dates.9 The children’s parents, general practitioners and other specialists reported that some of the behavioural symptoms associated with autism were observed prior to vaccine administration and, in some cases, months after. Indeed, some of the children had been hospitalised with developmental concerns prior to inoculation.10 The suggestion of “autistic enterocolitis” as a distinct disease process of intestinal dysfunction has been refuted by the consultants at the Royal

Free Hospital who took the biopsies of the children’s colons. They concluded in pathology reports that the samples, rather than “non-specific colitis”, were not uniform but varied, and nothing out of the ordinary.11 Investigations by the press, as well as allegations of conflicts of interest, manipulation of data and ethics violations as reported by the General Medical Council led to the Lancet announcing a full retraction of Wakefield’s paper in February 2010. On May 24, 2010, Andrew Wakefield was removed from the medical register by the General Medical Council of the UK. He was found guilty of professional misconduct and having “breached fundamental principles of research medicine”, including carrying out unnecessarily invasive tests on children without the required ethical approval or paediatric qualifications, and not disclosing that he was paid to conduct the study by solicitors representing parents who believed that their children had been harmed by the MMR vaccine.12

The evidence, or lack thereof In 2005, the Cochrane Collaboration systematically reviewed 31 studies and found no credible evidence to support a relationship between MMR and autism.13 A case-control study in 2008 replicated Wakefield’s study designs to test for the presence of the measles vaccine RNA in the GI tract. The study included ileal and caecal tissue samples from 25 children with autism spectrum disorders (ASD) who had GI disturbances, and 13 children with GI disturbances with no neurological deficits as control. All children had received at least one MMR injection. The study, repeated three times in different laboratory sites, also examined the order of onset of GI disturbances and autism symptoms relative to the timing of vaccine administration.14 The study consistently demonstrated strong evidence against the autism association. Persistent measles RNA presence in the bowel after MMR inoculation was found in only five of the 25 autistic children having received the vaccine prior to GI tract disturbances. Only in those five children did the disturbances precede the autistic behavioural symptoms. The vast majority of evidence against the MMR-autism hypothesis, however, lies in the number of epidemiological studies carried out: more than 20, with large sample sizes and substantial follow-up time.

Epidemiological studies In the immediate aftermath of the Wakefield study, the Department of Health in the UK commissioned the Committee on Safety of Vaccines (CSM) of the Medicines Control Agency (MCA), working with groups internationally, to carry out epidemiological studies and review the existing ones.15 In April 2001, the MCA and CSM endorsed the safety of the vaccine.16 One of the studies conducted involved a team of Professor Brent Taylor, community paediatrician at the Royal Free Hospital, with a vaccine specialist and a statistician. The team studied the vaccine profile and medical records of 498 children, all with ASD, who were born between 1979 and 1998 in eight North Thames district hospitals.1

Volume 6: Number 1. 2013 | Page 51

RCSIsmj review MMR and measles Autism without regression Autism with regression

120

MMR stops

160

% of MMR uptake* Source: Journal of Child Psychology and Psychiatry 2005

200

MMR starts

Number diagnosed with autism by age 7 (per 10,000)

Yokohama study

80 40 0 1988

1989

1990

1991

1992

1993

1994

1995

1500

1200

900

600

300

0 1996 97 98

1996

Year of birth

FIGURE 1: The records of 31,426 children in a Yokohama district were looked at. The study noted a steady increase in the incidence of ASD from 1979 but attributed that increase to the introduction of computerised disability registers, increased recognition of the disorders, earlier and wider acceptance of diagnosis, and significant changes to the diagnostic criteria. The incidence trend of ASD did not show any sudden change with the introduction of the MMR vaccine in 1988, nor was there any data clustering of developmental regression in the immediate timeframe after MMR inoculation. The study also commented that no significant differences were found in the reporting of rates and onset of bowel problems between those vaccinated and those not. Bowel problems are common in ASD children pertaining to an unusual diet.17 A 14-year prospective study in Finland monitored 31 MMR-vaccinated children who reported mild GI symptoms or signs such as diarrhoea, vomiting and abdominal pains that lasted for 24 hours or more immediately after inoculation. Follow-ups of those 31 children lasted, on average, up to nine years. None of the children developed ASD.18 Furthermore, a population study published in 2005, of over 30,000 children in the city of Yokohama in Japan disproved the association (Figure 1).19 The study showed a rise in incidence of regressive autism (the type suggested by Wakefield as being linked to MMR), despite the discontinuation of MMR in Japan from 1993 onwards.

Cases of measles

100

99 2000 01

02 03 04

05 06 07 08

*figures relate to financial years 1996/97, 1997/98 etc

0 09

Source: HPA

FIGURE 2: Data from the Health Protection Agency, UK, shows a rising incidence of measles infections with fluctuating rates of MMR inoculation.

Table 1: The number of confirmed cases of measles, mumps and rubella in the UK from 1996 to 2012.22 Year

Measles

Mumps

Rubella

1996 1997 *1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 **2012

112 177 56 92 100 70 319 437 188 78 740 990 1370 1144 380 1086 964

94 182 121 373 730 784 500 1541 8129 43378 4420 1476 2405 7662 3965 2465 1621

3922 117 119 162 62 45 64 16 14 29 34 35 27 9 12 6 57

Data from the Health Protection Agency (UK), August 2012. *Andrew Wakefieldâ&#x20AC;&#x2122;s study is published in February 1998.

Long-term consequences of the study In April 2006, the death of a 13-year-old was the first reported mortality from measles in the UK in 14 years. By 2008, approximately 85% of all two-year-olds were reported to have received the first injection, with the second injection for children around the age of five having an inoculation rate of only 78%.20 Figure 2 (with data from the Health Protection Agency, UK) shows a rising incidence of measles infections with fluctuating rates of MMR inoculation.21 Incidences of rubella in 2012 are at a nine-year high (Table 1).

Page 52 | Volume 6: Number 1. 2013

**Provisional data from the HPA from 01/01/2012 â&#x20AC;&#x201C; 31/06/2012.

However, the HPA is now reporting more encouraging news regarding vaccine uptake (93% and 87% for first and second dose, respectively, in England). The reported cases are attributed to older children who may not have received vaccination.

Conclusion In February 2002, the polling company Independent Communications and Marketing (ICM) surveyed 1,000 adults over

RCSIsmj review the age of 18, and found that 75% of parents agreed that single vaccines should be made available by the NHS.23 Some 20% said they would be prepared to pay for single vaccines. Worryingly, 4% said they would not inoculate their children at all against any of the three diseases. However, 43% said they would agree with the scientific opinion on the controversy. A total of 63% said that they agreed with what their doctors said about the MMR. A decade later, the continuing rise in measles incidence year after year suggests that it is incorrect to presume that concerns about the link have been ameliorated.24 This may indicate a failure to effectively communicate and provide

reliable information for the public to base decisions on. The media, in reporting there to be a “controversy”, possibly led parents to believe that there is equal weight of evidence on either side of the argument, which is as disingenuous as it is factually inaccurate. With developments in recent years lowering the credibility of Andrew Wakefield’s work even further, it is critical for primary physicians and all health professionals to find a more effective way of emphasising the risks of measles, mumps and rubella, and counteract what has been described as possibly the most damaging medical hoax of the last 100 years.25

References 1.

Taylor B, Lingam R et al. Autism and MMR vaccination in North London; no causal relationship. Mol Psychiatr. 2002;(7):7-8.

Wakefield AJ, Murch SM, Anthony A et al. Ileal-lymphoid-nodular hyperplasia, non-specific colitis, and pervasive developmental disorder

3. 4.

Medicines Control Agency and Department of Health to issues raised in papers published. Adverse Drug React T. 2000;19(4) [Internet] 2001 Jan

1979;(2):174-7.

21 [cited 2012 Oct]. Available from:

Wakefield AJ. Autism, inflammatory bowel disease, and MMR vaccine.

http://www.mhra.gov.uk/home/groups/pl-p/documents/websiteresources

Deer B. How the MMR scare led to the return of measles. The Sunday http://briandeer.com/solved/st-measles-returns.htm. BBC. BBC News Research clears MMR. [Internet] 2008 Feb 8 [cited 2012 Oct]. Available from: http://news.bbc.co.uk/1/hi/health/1808826.stm.

Horton R. A statement by the editors of the Lancet. Lancet. [Internet] 2004 Feb 20 [cited 2012 Oct]. Available from: http://image.thelancet.com/extras/statement20Feb2004web.pdf.

Triggle N. Lancet accepts MMR study ‘false’. BBC News [Internet] 2012 Feb 2 [cited 2012 Oct]. Available from: http://news.bbc.co.uk/1/hi/health/8493753.stm.

association. Lancet. 1999;353:2026-9. 16. MHRA. Combined measles, mumps and rubella vaccines: Response of the

in children. Lancet. 1998;(351):637-41 (retracted).

Times [Internet] 2009 Feb 8 [cited 2012 Oct]. Available from: 6.

al. Autism and MMR vaccine: no epidemiological evidence for a causal

Panksepp J. A neurochemical theory of autism. Trends Neurosci.

(Correspondence: author’s reply.) Lancet. 1998;(363):823-4. 5.

15. Taylor B, Miller E, Farrington CP, Petropoulos MC, Favot-Mayaud I, Li J et

Deer B. Hidden records show MMR truth. Sunday Times [Internet] 2009 Feb 7 [cited 2012 Oct]. Available from: http://briandeer.com/solved/st-hidden-records.htm.

10. Deer B. How the case against the MMR vaccine was fixed. BMJ. 2011;342:c5347. 11. Deer B. Pathology reports solve “new bowel disease” riddle. BMJ. 2011;343:d6823. 12. General Medical Council UK. Dr Andrew Jeremy Wakefield;

/con2025206.pdf. 17. Potts M, Bellows B. Autism and diet. J Epidemiol Commun H. 2006;60(5):375. 18. Peltola H, Patja A, Leinikki P, Valle M, Davidkin I, Paunio M. No evidence for MMR vaccine-associated inflammatory bowel disease or autism in a 14-year prospective study. Lancet. 1998;351:327-8. 19. Honda H, Shimizu Y, Rutter M. No effect of MMR withdrawal on the incidence of autism: a total population study. J Child Psychol Psyc. 2005;46(6):572-9. 20. Triggle N. Why the NHS is facing a measles fight. BBC News [Internet] 2009 May 19 [cited 2012 Oct]. Available from: http://news.bbc.co.uk/1/hi/health/8057508.stm. 21. Triggle N. Wakefield and autism; the story that will not go away. BBC News [Internet] 2010 Jan 28 [cited 2012 Oct]. Available from: http://news.bbc.co.uk/1/hi/health/8481583.stm. 22. Health Protection Agency, UK. Measles numbers and MMR reminder [Internet] 2012 Aug 24 [cited 2012 Oct]. Available from: http://www.hpa.org.uk/NewsCentre/NationalPressReleases/2012PressRele ases/120824measlesnumbersandmmrreminder. 23. The Scotsman. MMR proving unpopular with nation’s parents [Internet].

Determination on Serious Professional Misconduct (SPM) and

2001 Feb 2 [cited 2012 Oct]. Available from:

sanction. [Internet] 2010 May 24 [cited 2012 Oct]. Available from:

http://news.scotsman.com/mmrvaccine/MMR-proving-unpopular-with-na

http://www.gmc-uk.org/Wakefield_SPM_and_SANCTION.pdf_325952 67.pdf. 13. Demicheli V, Jefferson T, Rivetti A, Price D. Vaccines for measles, mumps and rubella in children. Cochrane DB Syst Rev. 2005;(4):CD004407. 14. Hornig M, O’Leary JJ, Shiels O et al. Lack of association between

tions.2304061.jp. 24. Brown KF, Long SJ, Ramsay M, Hudson MJ, Green J, Vincent CA et al. UK parents’ decision-making about measles-mumps-rubella (MMR) vaccine 10 years after the MMR-autism controversy: a qualitative analysis. Vaccine. 2012;30(10):1855-6. 25. Flaherty DK. The vaccine-autism connection: a public health crisis caused

measles virus vaccine and autism with enteropathy: a case-control

by unethical medical practices and fraudulent science. Ann Pharmacother.

study. PLoS ONE. 2008;3(9):e3140.

2011;45(10):1302-4.

Volume 6: Number 1. 2013 | Page 53

RCSIsmj review A potential cure for multiple sclerosis: the promising role mesenchymal stem cells play in the reparative process Abstract Background: Mesenchymal stem cells (MSCs) are multipotent stem cells derived primarily from bone marrow (BM). They exert neurotrophic and immunomodulatory effects. Understanding laboratory and patient-related factors that affect MSC biology will optimise their use as a potential multiple sclerosis (MS) treatment. Methods: Eleven patients with relapsing forms of MS were enrolled in an ongoing Phase 1 trial, having met eligibility criteria (adult between 18 and 55, relapsing form of MS, currently on standard treatment, visual involvement, T2 hyperintense lesions on MRI). BM-derived MSCs were isolated, cultured and subsequently re-infused one time to assess tolerability. A literature review of MSC biology was conducted alongside this Phase I trial in order to examine the role of MSCs in MS therapy. Results: Low concentration foetal bovine serum (FBS) and specific biological factors favour MSC activity. Paracrine activity yields the majority of the therapeutic effects. Faster MSC proliferation rates were observed in cells of individuals in an earlier stage of the disease. Patient age decreases proliferation capacity. The effects of gender, MS type and disease duration are less clear. Discussion/conclusion: MSCs have great potential in MS treatment through their anti-inflammatory and reparative properties, and the trial has thus far shown that autologous MSC transplantation is safe and feasible.

Royal College of Surgeons in Ireland Student Medical Journal 2013; 6(1): 54-8.

Introduction

Natasha Mehandru1 Dr Jeffrey Cohen2 1RCSI medical student 2Director, Experimental

Therapeutics Program, Cleveland Clinic, OH, USA

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Multiple sclerosis (MS) is a chronic inflammatory neurodegenerative disease of the central nervous system characterised by neuronal demyelination and axonal loss. Autoimmune aetiology is the prevailing, though unproven, theory in which oligodendrocytes are irreversibly damaged by CD4+ T-cells, CD8+ T-cells, and macrophages.1 Available medical therapies are limited to symptomatic relief, decreased inflammation, and decreased MRI lesion activity and relapses.1 However, none of the approved therapies directly target oligodendrocyte repair or reverse accumulated damage and progressive forms of the disease in which degenerative processes are thought to dominate. Mesenchymal stem cells

(MSCs) are currently being studied in light of the great unmet need for repair-promoting strategies.1 MSCs are adult, multipotent, stromal-derived stem cells, which confer neuroregenerative and anti-inflammatory benefits, with potentially huge implications for reversing the damage seen in MS.1 This paper discusses the laboratory and patient characteristics influencing MSC behaviour based on an ongoing Phase I clinical trial to assess the feasibility and safety of autologous MSC transplantation in patients with relapsing forms of MS. This research is further explored in the context of current literature, with the aim of optimising MSC activity in the ongoing trial, and with the end goal of translational medicine in relapsing MS.

RCSIsmj review Methods Current literature regarding MSC biology was reviewed. Additionally, data from an ongoing Phase 1 clinical trial examining patient age, gender, MS type, and disease duration in relation to MSC proliferation capacity is examined.

Phase I clinical trial The primary purpose of the ongoing Phase I trial run by Dr Jeffrey Cohen at the Mellen Center for MS Treatment and Research is to assess the feasibility, safety and tolerability of autologous, bone marrow-derived, culture-expanded MSC transplantation in patients with relapsing forms of MS. The trial is funded on behalf of the Department of Defense Peer Reviewed Medical Research Program through the National Institutes of Health. Ethical approval and written consent were obtained. Twenty-four patients were to participate; half with relapsing-remitting MS (RRMS) and half with secondary progressive or progressive-relapsing MS (SPMS). Patients with primary progressive MS were excluded due to the uninterrupted and worsening nature of this subtype, which is not typically associated with relapses. Participants were between the ages of 18 and 55, on standard therapy, and were monitored for two months pre transplantation and six months post transplantation. Inclusion criteria were: documented relapse; Expanded Disability Status Scale (EDSS) 3.0-6.5; worsening impairment; MRI lesion activity in the prior two years; and, optic nerve involvement. Only patients on FDA-approved treatment for relapsing forms of MS, or those who had failed or refused approved treatment, were included. Participants are recruited predominantly from the Cleveland Clinic. Treatment consisted of a single intravenous infusion of 1-2 x 106MSCs/kg. Eleven participants have been infused to date. This ongoing trial is the first in North America to assess the activity of autologous culture-expanded MSCs in MS patients. Other trials have examined MSC and haematopoietic stem cell transplantation (HSCT) activity in the context of other pathological states in mice and human models. Allogeneic HSCTs demonstrate immunosuppressive activity through immune reconstitution of the T-cell repertoire, induced cell death of myelin-reactive T-cells, and improved functional recovery.2 Several case series and one published phase 2a trial asserting the safety of autologous MSC infusion for secondary progressive MS at the University of Cambridge have been published.1 Other trials assessing similar parameters are still in the recruiting phase.

Literature review Literature regarding MSC biology and stem cell transplantation in MS was reviewed. Articles focusing on bone marrow-derived MSCs, cellular effects of MSCs, and stem cell therapy in the context of autoimmune disease were sourced.

Results Results are divided into three categories: a literature review of MSC biology; a summary of current laboratory and patient features that affect MSC biology; and, data from the ongoing Phase 1 trial. MSC biology is first re-examined.

FIGURE 1: MSC role in immune response.4

MSC biology MSC activity MSCs are increasingly being examined as potential therapy for relapsing MS due to their inherent plasticity. They are attractive for transplantation as they can be readily isolated from bone marrow, rapidly expanded in vitro, and have a low immunogenicity.3 A number of mechanisms have been proposed as to their method of action: transdifferentiation; cell fusion; and, paracrine activity, with the latter accounting for most of the beneficial effects. MSCs release soluble factors, which stimulate adult neural stem cells (NSCs) to differentiate into oligodendrocytes. Current research holds neurotrophic activity, in the context of appropriate microenvironment, as the prevailing method of MSC action. MSCs release neurotrophic factors, such as basic fibroblast growth factor (bFGF) and vascular endothelial growth factor (VEGF), that promote proliferation, survival, and differentiation of NSCs; interleukins (IL-6,-7,-8,-11,-12,-14,-15) mediate haematopoiesis. Studies using rat MSC-conditioned media showed differentiation into oligodendrocytes by increased expression of oligodendrocyte markers galactocerebroside and myelin basic protein. Angiogenic, neuroprotective and synaptogenic effects were also seen. Non-neurotrophic factor (extracellular matrix proteins) secretion facilitates intercellular signalling and neurotrophic factor delivery. Through their suppression of innate and adaptive immunity, and dendritic cell function, MSCs demonstrate the potential to treat autoimmune and inflammatory diseases (Figure 1).4

MSC suppression of innate immunity MSCs express Toll-like receptors (TLR); immune modulation is downregulated by TLR3 and TLR4 ligands, and enhanced by IFN-Îł.5 IFN-Îł enhances MSC suppression of T-cell proliferation through the induction of indoleamine 2,3-dioxygenase (IDO) and prostaglandin E2. The degree of MSC suppression is dose dependent, with high doses having an inhibitory effect.

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RCSIsmj review MSC suppression of adaptive immunity MSCs direct CD4+ T-cell differentiation towards regulatory patterns of cytokine secretion, and suppress Th1, Th2 and Th17 responses. MSCs also promote the activity of Tregs, which control alloreactive T-cell responses.5 MSCs induce CD8+ regulatory cells and inhibit effector CD8+ cytotoxic T lymphocyte proliferation without being lysed. Influence on B-cell and macrophage activity is less understood.

(MSC-NPs) at the onset of the chronic phase of disease resulted in improved neurological function; a single injection had no effect.10 Reduced immune cell infiltration and demyelination, and increased endogenous nestin-positive progenitor cells were seen in EAE mice, supporting autologous MSC-NP use in MS patients.11 In summary, MSC neurotrophic activity prevails as the major mechanism of therapeutic benefit.

Effect of MSCs on dendritic cell function

B. Patient characteristics that affect MSC biology

MSCs reprogram dendritic cells to become tolerogenic by converting pro-inflammatory cytokine production (IL-12, TNF-a) to anti-inflammatory cytokines (IL-10). Dendritic cells that have encountered MSCs suppress activated T-cell proliferation.5

Effects of patient age on MSC proliferation capacity

Role of MSC transplantation The significance of the neurotrophic and immunomodulatory effects discussed above relates to the role of T-cell autoreactivity and inflammation in MS-related myelin damage. Through their potent anti-inflammatory effects, MSC-derived cytokines and interleukins downregulate T-cell activity and inflammation. MSCs also stimulate adult NSCs to regenerate damaged tissue, again supporting the theory of paracrine activity. Tissue regeneration does not occur in the normal disease-repairing process, and myelin is gradually lost. Culture-expanded MSC infusion provides the resource for adult NSCs to differentiate into myelin-producing oligodendrocytes. MSC transplantation has a huge capacity for disease improvement as MSCs exist naturally in low numbers.4

Summary of current literature A. Laboratory features that affect MSC biology in vitro Culture conditions and media Cryopreservation has no effect on MSC proliferation, secretion, or differentiation capacity,6 as evidenced by no changes in colony-forming unit fibroblast (CFU-f) numbers.7 Optimal isolation was achieved when cells were layered on Ficoll gradient, and cultured in Dulbeccoâ&#x20AC;&#x2122;s modified Eagleâ&#x20AC;&#x2122;s medium (DMEM) with low concentration (5%) foetal bovine serum (FBS).8

The effects of in vitro factors and microenvironment on MSC activity In vitro MSC environment influences lineage commitment; exposure to biological growth factors (bFGF, Wnt, and 2-ME DMSO) favoured differentiation into the neural lineage.4 However, MSC transdifferentiation into neural cells does not explain the majority of MSC activity; rather, therapeutic benefits are expected to result from trophic paracrine factor secretion. In the context of experimental autoimmune encephalomyelitis (EAE) induced in mice, NSCs and MSCs serve as bystander regulators through their neurotrophic effects.9 MSC migration from the IV administration site to the brain has been observed, where they escape immune surveillance and in some cases differentiate into cells expressing microglial and astroglial markers.9 Multiple injections of neural progenitors derived from MSCs

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Other studies have suggested that increased age correlates with decreased MSC proliferation capacity.12 MSCs undergo telomere shortening at high passage numbers limiting proliferation in vitro, but in vivo constitutive expression of telomerase maintains telomeric length.12 Induction of neuroectodermal differentiation from MSCs was completely lost with samples from old donors.12 Similarly, age-related decreases in CFU-f numbers and increases in p53 and p21 positive cells, reactive oxygen species, and lipofuscin were observed.7 Morphology changed from small spindle-like to large polygonal with successive passages.13 Growth rates peaked in the third passage, then declined.13 Growth factors and various cytokines gradually declined over time in ALS patient samples. MSCs at earlier passages are more suitable for stem cell therapy due to their stability, anti-inflammatory effects, and neuroprotective effects.13 Donor age appears to decrease MSC proliferation and differentiation capacity, and anti-inflammatory effects.13

Effect of neurodegenerative disease on MSC function The relative advantages of autologous versus allogeneic MSC transplantation are widely debated with no definitive evidence asserting oneâ&#x20AC;&#x2122;s superiority to the other. Larghero et al. support autologous MSC transplantation after showing that BM-MSCs from systemic sclerosis patients in vivo demonstrate the same proliferative and immunosuppressive properties as their healthy counterparts.14 However, Koh et al. indicate that pluripotency and trophic factor secretion capacity of BM-MSCs from amyotrophic lateral sclerosis (ALS) patients are reduced in proportion to a poorer prognosis.15 Autologous MSCs from ALS patients demonstrated reduced migration when compared to healthy donors.16 Expression of B-PIX-an intracellular factor implicated in migration was significantly reduced in ALS-MSCs. Restoring expression via genetic manipulation restored migration ability, asserting the potential role of genetic manipulation in autologous MSC transplantation.16

MSCs in other contexts MSCs have been transplanted in conjunction with allogeneic HSCTs to enhance engraftment, and as prophylaxis against graft-versus-host disease.17 As MSC therapy is still young in its therapeutic evolution, ongoing trials such as this one focus on utilising the ability of these multipotent mesenchymal cells to secrete neurotrophic factors and mediate immune effects as a source of MS therapy.

RCSIsmj review Table 1: Patient characteristics and MSC cell yield. Age Gender MS type Years since onset of symptoms Patient 1 46 M SPMS 11 2 40 F RRMS 10 3 45 F SPMS 10 4 56 F SPMS 36 5 42 F SPMS 22 6 43 M SPMS 5 7 40 F SPMS 18 8 43 F RRMS 5 9 47 M RRMS 4 10 55 M SPMS 10 11 47 F RRMS 21

Days in in culture

Passage # at harvest

Final cell yield (x10^8)

34 21 41 34 39 24 18 20 20 34 16

2 1 3 3 3 2 1 1 1 3 1

5.86 1.94 1.375 1.1 0.558 2.5 4.75 5.02 2.63 2.31 3.46

% of MSCs marker positive CD105/CD73 96.94 98.73 95.79 98.80 95.51 97.41 98.31 98.93 98.07 98.25 95.24

CD45/CD14 0.04 1.15 0.28 0.07 0.82 0.08 0.76 0.51 0.64 0.17 0.46

SPMS = secondary progressive multiple sclerosis. RRMS = relapsing remitting multiple sclerosis. MSC = mesenchymal stem cell.

MS type vs. days in culture

42 40 38 36 34 32 30 28 26 24 22 20 18 16 14

Days in culture

Age vs. days in culture

42 40 38 36 34 32 30 28 26 24 22 20 18 16 14

RRMS SPMS

MS type

Patient age (years)

FIGURE 2: Effect of each participantâ&#x20AC;&#x2122;s age on the time taken for MSCs grown in vitro to achieve target dose for infusion.

FIGURE 3: Effect of MS type on the proliferation rate of MSCs as measured by the number of days in culture to achieve target infusion dose. Each bar represents a single patient. SPMS = secondary progressive MS. RRMS = relapsing remitting MS.

Summary of patient characteristics and MSC laboratory cell culture results

from patients with autoimmune disease versus those from healthy counterparts.

A summary of data obtained for each participant who received an infusion of autologous MSCs in the Phase I trial is shown in Table 1. Duration of in vitro growth and final cell yield for MSCs is discussed in the context of age, gender, MS type and duration. The ongoing Phase I trial roughly supports current literature asserting that increased age correlates with decreased proliferative capacity, as evidenced by increased length of culture necessary to reach the target dosage (Figure 2). The target infusion dose is up to 2 x 106 cells per kg. When feasible, the number of passages was limited to the least number possible to allow for the most stable MSCs. Culture duration was shorter in RRMS vs. SPMS, suggesting a faster proliferation rate earlier in the disease (Figure 3). Most patients with MS begin with an RR course, but subsequently evolve into an SP course after about 10-15 years. Disease duration is thought to decrease overall proliferation capacity, though this was not apparent in the trial (Figure 4). Current literature is unclear about the qualitative differences of MSCs derived

Discussion Our understanding of MSC activity, although not complete, points to a dominant role in the anti-inflammatory and reparative process, primarily through neurotrophic effects. MSCs are feasible transplant options due to their ability to be readily isolated and expanded. MSCs secrete a range of factors involved in the differentiation of adult NSCs and neural tissue regeneration, although the quality of the regenerated tissue and extent of repair is largely unknown. Laboratory features such as low concentration FBS, FRP surfaces with FGF2, biological factors, microenvironment, and genetic manipulation of receptor-ligand interaction favour activity, while cryopreservation and disease time point seem to have little effect. Furthermore, patient age decreases MSC proliferation capacity and anti-inflammatory effects. Limited data from the ongoing trial limits a conclusion about the effects of gender, MS type, and disease duration on proliferation

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RCSIsmj review Years since symptom onset vs. final cell yield

Final cell yield (x10∧8)

6 5 4 3 2 1 0 0

compared to RRMS. Nonetheless, the ongoing trial achieves its primary goal of asserting that autologous MSC transplantation in MS patients is safe and feasible, as no adverse events have yet been reported. As the trial is still early in its progress, comments cannot be made on long-term effects, defined as after six months post infusion. Nevertheless, it is important to note that there have been no immediate adverse effects relating to the infusion of autologous MSCs. Confirming such tolerability will allow for the next step of MSC therapy development, which is to carry out Phase II trials assessing reparative effects and efficacy.

Years since symptom onset

Conclusion FIGURE 4: The number of years since the onset of the first MS symptom compared to the final MSC yield. capacity. Most patients with MS begin with an RR course then evolve into an SP course after 10-15 years. Therefore, it is difficult to distinguish between the effects of age, disease duration, and disease course on MSC proliferation rate in culture and eventual yield. Furthermore, as the trial is ongoing, limited data makes it difficult to identify clear patterns between patient characteristics and disease course. However, taken together, these data suggest a connection between disease course and MSC behaviour in culture – namely, slowed proliferative capacity in MSCs from patients with SPMS

MSC therapy offers a novel way to approach the treatment of neurodegenerative diseases. MSCs have promising advantages over both current medical therapy and other stem cell sources. The next step is to solidify our understanding of MSC activity and cultivate optimal MSCs capable of going one step beyond halting disease damage and ultimately reversing the disease process, providing a potential cure for MS.

Acknowledgements Thank you to Dr Jeffrey Cohen and Dr Sarah Planchon for allowing me to learn from your clinical trial and for being such fantastic teachers.

References 1.

Connick P, Kolappan M, Crawley C, Webber DJ, Patani R, Michell AW et al.

pathological effects of intrathecal injection of mesenchymal stem

progressive multiple sclerosis: an open-label phase 2a proof-of-concept

cell-derived neural progenitors in an experimental model of multiple

study. Lancet Neurol. 2012;11(2):150-6. 2.

Wijmeersch BV, Sprangers B, Dubois B, Waer M, Billiau Ad. Autologous and allogeneic hematopoietic stem cell transplantation for multiple sclerosis: perspective on mechanisms of action. J Neuroimmunol. 2008;197(2):89-98.

Maltman DJ, Hardy SA, Przyborski SA. Role of mesenchymal stem cells in neurogenesis and nervous system repair. Neurochem Int. 2011;59(3):347-56.

4. 5.

Opin Immunol. 2011;23(4):518-24. 13. Choi MR, Kim HY, Park JY, Lee Ty, Baik Ck, Chai Yg et al. Selection of cell therapy in patients with amyotrophic lateral sclerosis. Neurosci Lett.

English K, Mahon BP. Allogeneic mesenchymal stem cells: agents of

2010;472(2):94-8. 14. Larghero J, Farge D, Braccini A, Lecourt S, Scherberich A, Fois E et al.

Zhang HT, Chen H, Zhao H, Dai YW, Xu RX. Neural stem cells

Phenotypical and functional characteristics of in vitro expanded bone

differentiation ability of human umbilical cord mesenchymal stromal cells is

marrow mesenchymal stem cells from patients with systemic sclerosis. Ann

Stolzing A, Jones E, McGonagle D, Scutt A. Age-related changes in human therapies. Mech Ageing Dev. 2008;129(3):163-73. Ayatollahi M, Salmani MK, Geramizadeh B, Tabei SZ, Soleimani M, Sanati MH. Conditions to improve expansion of human mesenchymal stem cells based on rat samples. World J Stem Cells. 2012;4(1):1-8.

doubt? Regen Med. 2012;7(2):245-59. 12. Lepperdinger G. Inflammation and mesenchymal stem cell aging. Curr

optimal passage of bone marrow-derived mesenchymal stem cells for stem

bone marrow-derived mesenchymal stem cells: consequences for cell 8.

al. Stem cell therapy for multiple sclerosis: preclinical evidence beyond all

mesenchymal stem cells. J Cell Biochem. 2009;106(6):984-91.

not altered by cryopreservation. Neurosci Lett. 2011;487(1):118-22. 7.

sclerosis. J Neurol Sci. 2011;313(1-2):167-77. 11. Reekmans K, Praet J, De Vocht N, Daans J, Van Der Linden A, Berneman Z et

Liu JL, Zhuge Y, Velazquez OC. Trafficking and differentiation of

immune modulation. J Cell Biochem. 2011;112:1963-8. 6.

10. Harris VK, Yan QJ, Vyshkina T, Sahabi S, Liu X, Sadiq Sa. Clinical and

Autologous mesenchymal stem cells for the treatment of secondary

Pluchino S, Zanotti L, Brini E, Ferrari S, Gianvito M. Regeneration and repair

Rheum Dis. 2008;67(4):443-9. 15. Koh SH, Baik W, Noh MY, Cho GW, Kim HY, Kim KS et al. The functional deficiency of bone marrow mesenchymal stromal cells in ALS patients is proportional to disease progression rate. Exp Neurol. 2012;233(1):472-80. 16. Koh SH, Huh YM, Noh MY, Kim HY, Kim KS, Lee ES et al. B-PIX is critical for transplanted mesenchymal stromal cell migration. Stem Cells Dev. 2012;21(11):1989-99 [Epub ahead of print]. 17. Le Blanc K, Ringdén O. Immunobiology of human mesenchymal stem cells

in multiple sclerosis: the role of cell transplantation. Neurosci Lett.

and future use in haematopoietic stem cell transplantation. Biol Blood

2009;456(3):101-6.

Marrow Transplant. 2005;11(5):321-34.

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RCSIsmj review Total ankle arthroplasty: the future of orthopaedic surgery? Abstract The ankle is a complex joint with multiple planes of motion, which we heavily rely on for locomotion, balance and independent functioning. Thus, when arthritis affects the ankle, there are serious consequences, which underline the importance of finding a viable treatment option. One such treatment option, total ankle arthroplasty, has been garnering much attention over the past 30 years as it continues to progress towards a level of effectiveness equivalent to knee and hip replacement surgeries. After many failed generations of implant design, we are finally reaching a level of understanding of how the ankle actually works to make anatomically accurate replacements. The implant design, combined with the knowledge of the injury mechanisms leading to the need for an ankle replacement, have made the success of ankle arthroplasty more likely. For ankle replacement to have the success level of the knee or hip replacement, surgeon technique and proper patient selection must be pursued. If these areas of weakness can be overcome, the total ankle arthroplasty may soon be the first choice among orthopaedic surgeons for management of end-stage ankle arthritis. Keywords: Ankle anatomy; ankle arthritis; total ankle arthroplasty; ankle implants; arthrodesis; ankle complications; future of ankle arthroplasty.

Royal College of Surgeons in Ireland Student Medical Journal 2013; 6(1): 59-62.

Katharine Harper RCSI medical student

Introduction Anatomy

Pathology

The ankle is composed of the ankle joint proper (or talocrural joint), the subtalar joint and the inferior tibiofibular joint (Figure 1).1,2,3 The talocrural joint is a hinge joint found between the mortice formed by the malleoli and the lower end of the tibia, and the body of the talus.2 This is the location at which flexion (dorsiflexion) and extension (plantarflexion) occur.2 The subtalar joint is made up of two separate articulations: the talocalcaneal joint and the talocalcaneonavicular joint.1 This is the location at which inversion and eversion occur.2 They are referred to as one joint due to the fact that they function in unison and as a unit.1 Lastly, the inferior tibiofibular joint is an articulation between a triangular facet on the talus and the lateral malleoli (which is the inferior aspect of the fibula), the lateral aspect of which serves as the attachment point for the anterior talofibular ligament.1 With the anatomy in mind, this paper aims to review the indications, history and current status of total ankle arthroplasty (TAA), the evolution of the surgery towards the future and what variables could impact on the success of the implant.

The ankle is subjected to the highest weight-bearing force per square centimetre of any joint in the body and, as such, it is the most commonly injured.4 Primary osteoarthritis occurs much less frequently in the ankle than it would in the knee, hip, hand or spine, and is not the major contributor to end-stage ankle arthritis.4,5 Instead, post-traumatic arthritis is the most common cause of ankle arthritis requiring surgical intervention, compared with primary osteoarthritis as the main indication for hip or knee arthroplasty.4,5 Secondary post-traumatic arthritis often follows a rotational fracture or recurrent ligamentous instability5 (which commonly results in medial side arthritis specifically).5 Ankle arthritis prevalence is often difficult to quantify due to variations in clinical correlation,4 but some studies indicate that it affects up to 6% of the population.6 It often results in severe functional limitation and a decrease in quality of life.7 Unfortunately, it gets less attention than the more common and more treatable knee and hip arthritides,8 which dominate research in the area.5

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RCSIsmj review Evolution of the replacement

FIGURE 1: A coronal cross-section view of the distal lower limb, including the ankle and hind foot. The ankle joint proper (or true ankle joint) is highlighted in red, while the subtalar joint is highlighted in blue. ©Medscape

Ankle arthritis can cause significant morbidity and functional impairment in its advanced stages.7 In patients with severe post-traumatic arthritis, decreased range of motion, step length, plantarflexion power and power absorption were noted when compared to the non-affected side.6 While conservative management for ankle arthritis can be considered, it is often less effective than similar modalities used for other joints. For example, corticosteroid injections of the ankle have much shorter efficacy times than when used in the knee, often not exceeding eight weeks of pain relief.4 Patients with ankle arthritis are often younger than patients with arthritis of the knee or hip,6 and conservative management is not a sustainable option, leaving surgical management as the only long-term option for functionally disabling disease.4,5,6

Intervention Orthopaedic surgeons have achieved great results from total hip and total knee arthroplasty procedures. Unlike hip and knee arthroplasty, though, for the last 30 years complications and unsatisfactory outcomes have gone unresolved for TAA. Despite the advantages a replacement could bring in functionality and pain relief, ankle arthrodesis (fusion of the subtalar joint) remains the treatment of choice for end-stage ankle arthritis.9 At the onset of ankle arthroplasty in the 1970s, failures requiring revisions or fusions were as high as 72% 10 years post operatively.10 While TAA outcomes have vastly improved since this time,11 they still have very high revision rates (23% five years post operative).7 As failure rates continue to decrease though, the surgery will gather more interest from younger and more active patients, requiring a better understanding of how the replacements work, and where issues may arise.10

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Total ankle replacement was first attempted 40 years ago, but after poor results, it was not used extensively until the late 1980s and early 1990s.12,13 These re-attempts at ankle replacement were undertaken due to dissatisfaction in results from ankle arthrodesis, and the previous successes of hip and knee arthroplasty, combined with designs that began to more closely resemble the natural anatomy of the ankle.8,12 First generation designs originally functioned under the assumption that the ankle joint was a simple hinge joint,12 but researchers soon discovered the many complex planes in which the ankle can move.1,2,12,13 The original design had cemented tibial and talar components that were either constrained or totally unconstrained, though the unconstrained designs were quickly abandoned due to instability.13 The initial constrained device results were promising though, and thus development into a viable ankle implant was continued.8,12,13 Unfortunately, the long-term outcomes of these devices showed short-term implant survival with high failure rates. Implant design appeared to be the major contributing factor.13 Second-generation designs addressed the flaws of earlier ones and aimed to be more anatomically correct.12 They also tried to recreate the stability provided by ligaments, and reproduce the natural axis of rotation.12,13 Second generation implants were classified as “semi-constrained” and went through several stages of revision through the 1990s.13 Three major implants made contributions towards the development of semi-constrained devices: the Buechel-Pappas modification; the Scandinavian Total Ankle Replacement (STAR); and, the Agility ankle system.13 The Buechel-Pappas model developed a low contact stress implant, which contained uncemented porous ceramic tibial and talar components with a mobile “meniscal” polyethylene disc.8,13 The STAR system contained a flat tibial component, an anatomical talar cap, and a polyethylene insert that interacts with the tibial glide plate.8,13,14,15 The Agility system is unique in that it contains three components but is essentially a two-component design. The system incorporates an arthrodesis of the tibiofibular syndesmosis, with the goal of providing a larger surface area for force transfer and stability.13,16 These models remain available today, and have brought about the development of the newest generation of implants.8,13 The current generation of replacements has continued to build on the second-generation successes and can be divided into two subcategories: two-component fixed-bearing implants; and, three-component mobile-bearing implants.8,12 Figures 2a, 2b and 2c12,14 outline the different implant models over time. In recent years, trends have moved more towards the development of three-component mobile-bearing designs,8,11,12 with mobile-bearing implants being used more in Europe and fixed-bearing used more in the USA.8 The modern three-component implants have vastly improved and are currently demonstrating a 10-year survival rate of greater than 90%.17 Table 1 provides a non-inclusive overview of available brands.8,11,13,14,15,16

RCSIsmjreview A

FIGURE 2 (a, b and c): Figures 2a and 2b are examples of the first-generation unconstrained devices, which were quickly discontinued due to instability and failure rates. Figure 2c is the second-generation STARTM model, which is still in production today.

Table 1: Overview of major ankle arthroplasty implants (not inclusive). Brand name Manufacturer Type of replacement Agility8,13,16

DuPey Orthopedics

Fixed-bearing, two-component

SaltoTM Talaris8,11 STAR14,15

Tornier

Fixed-bearing, two-component

Waldermar Link

Mobile-bearing, three-component

Tornier

Mobile-bearing, three-component

SaltoTM

8,11

Buechel – Pappas11 Endotec

Mobile-bearing, three-component

Components Tibial component with associated arthrodesis of the tibiofibular joint, talar component, which slides side to side Tibial component with incorporated polyethylene and talar component Tibial component, talar component and polyethylene gliding core (6-14mm) Tibial component with hollow fin and hollow end talar facets covered by a talo-fibular facet replacement. Note: smaller medial radius of talar component allows for inversion and eversion Tibial component with stem, talar component and polyethylene gliding core

Patient selection

Complications and issues

Selecting appropriate patients for TAA is vital in trying to maximise the success of the implant in the long term.18 Currently, acceptable results have been reported in older, low-demand patients with rheumatoid arthritis or osteoarthritis.18 Rheumatoid arthritis is the number one underlying indication for performing TAA, while trauma is the indication for arthrodesis.13,19 Patients undergoing TAA are slightly older than those undergoing arthrodesis and are predominantly female.19 Research suggests that younger patients should undergo arthrodesis due to higher demands on the ankle, while older patients should consider TAA with return to low-impact activity post surgery.20 TAA is preferable to arthrodesis in patients who have established ipsilateral subtalar joint arthritis, or in patients who would be unable to tolerate long periods of immobility.13 Immobility for an extensive amount of time is required for arthrodesis.13 Absolute contraindications for TAA include avascular necrosis of the talus, Charcot’s foot, any cause of an insensate foot, poor lower limb muscle function or an acute/chronic infective state.13 Previous procedures on the ankle, including a previous arthrodesis with a malleoli excision, are also an absolute contraindication.13 Relative contraindications include long-term steroid use, vasculitic ulcers on the leg, a previous septic ankle on the affected side and a previously fused ankle.13

Complications that can arise from TAA are similar to other joint replacement surgeries and include infection, impaired wound healing, non-union and peri-operative fractures in the early post-operative period, while aseptic loosening, osteomyelitis, periprosthetic fractures, osteolysis from polyethylene wear, spacer migration and heterotropic bone formation can occur in the delayed post-operative period.21,22 TAA failure rates, as mentioned previously, remain high at 23% five years post operatively.7 This value is particularly high when compared to knee arthroplasty (0.19% annual failure and a 98.75% seven-year survival)23 and hip arthroplasty (considered one of the most cost-effective and successful operations ever introduced).24 Studies comparing arthrodesis to TAA complication rates have found that replacements have higher failure rates comparatively, with the most common complication needing revision being loosening of the prosthesis.21 Surgeon technical error was also significantly larger in the TAA subset than in the arthrodesis subset (15% and 2%, respectively).21 Technical error is equal to implant loosening as the most likely cause of failure in the TAA.21 A particularly severe complication that can result from a TAA is talar necrosis and collapse associated with the talar component of the implant (what is known as a talar “cap” in some devices).25 This complication is most commonly seen in patients who have rheumatoid arthritis and requires a total talar replacement to fix. Of note, the total talar

Volume 6: Number 1. 2013 | Page 61

RCSIsmj review replacement is capable of being integrated into the greater total ankle replacement system to salvage the replacement.25

and Drug Administration (FDA) will continue to approve new models that have built upon the basics laid out from previous generations.28

Future of the replacement

Conclusion

As TAA outcomes continue to improve, so will development of newer implant models. Studies have found TAA to be a cost-effective alternative to arthrodesis, and if models become more efficient, it may soon surpass arthrodesis as the most cost-effective treatment option.26 This will further support the use of TAA from an administrative and insurance point of view.26 From a functional standpoint, if a TAA is performed successfully there are better overall outcomes.19,27 These better outcomes include decreased energy expenditure and improved post-operative activity levels when compared to arthrodesis19,27 and will continue to make it a popular choice among certain patient populations. As more mobile-bearing implants are developed, the Food

The complexity of the ankle and the unique causes of arthritis led to initial design difficulties and high failure rates. In recent years, as implants moved from a constrained design to a mobile-bearing design, many of these flaws have been eliminated. As implants continue to be improved upon, TAA will gain popularity. The continuing focus on proper patient selection is important in the success of the surgery. For the future, the key to success will be continuing mastery of the procedure by surgeons to ensure the best possible outcomes. If these goals can be accomplished, TAA could move to the forefront of treatment of end-stage, debilitating ankle arthritis in older, low-activity adults in years to come.

References 1.

Rockar Jr PA. The subtalar joint: anatomy and joint motion. J Ortho Sports Phys Ther. 1993;21(6):361-72.

Ellis H. Clinical Anatomy: A Revision and Applied Anatomy for Clinical Students (11th ed.). Blackwell Publishing; 2006:233-5.

Medscape. Ankle Injuries. Available from: http://reference.medscape.com/features/slideshow/ankle-injuries.

Thomas RH, Daniels TR. Ankle arthritis. J Bone Joint Surg Am. 2003;85-A(5):923-36.

Saltzman CL, Salamon ML, Blanchard M et al. Epidemiology of ankle arthritis: report of a consecutive series of 639 patients from a tertiary orthopaedic centre. Iowa Orthop J. 2004;25:44-46.

Segal AD, Shofer J, Hahn ME et al. Functional limitations associated with

SooHoo NF, Zingmond DS, Ko CY. Comparison of reoperation rates

end-stage ankle arthritis. J Bone Joint Surg Am. 2012;94-A(9):777-83. following ankle arthrodesis and total ankle arthroplasy. J Bone Joint Surg Am. 2007;89-A(10):2143-9. 8.

Gougoulias NE, Khanna A, Maffulli N. History and evolution in total ankle arthroplasty. Brit Med Bull. 2009;89:111-51.

Easley ME, Adams Jr. SB, Hembree C, DeOrio JK. Results of total ankle arthroplasty. J Bone Joint Surg Am. 2011;93-A(15):1455-68.

10. Gougoulias NE, Khanna A, Maffulli N. How successful are current ankle replacements? A systemic review of the literature. Clin Orthop Relat Res. 2010;468(1):199-208. 11. Wood PLR, Clough TM, Smith R. The present state of ankle arthroplasty. Foot Ankle Surg. 2008;14:115-9. 12. Vickerstaff JA, Miles AW, Cunningham JL. A brief history of total ankle replacement and a review of current status. Med Eng Phys. 2007;29:1056-64. 13. Jackson MP, Singh D. Total ankle replacement. Curr Orthopaed. 2003;17:292-8. 14. Mann JA, Mann RA, Horton E. STARTM Ankle: long-term results. Foot Ankle Int. 2011;32(5):473-84. 15. Nunley JA, Caputo AM, Easley ME, Cook C. Intermediate to long-term outcomes of the STAR total ankle replacement: the patient perspective. J Bone Joint Surg Am. 2012;94-A(1):43-8.

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16. Criswell BJ, Douglas K, Naik R, Thomson AB. High revision and reoperation rates using the AgilityTM total ankle system. Clin Orthop Relat Res. 2012;470(7):1980-6. 17. Rippstein PF, Huber M, Coetzee JC, Naal FD. Total ankle replacement with use of a new three-component implant. J Bone Joint Surg Am. 2011;93-A(15):1426-35. 18. Clare MP, Sanders RW. Preoperative considerations in ankle replacement surgeries. Foot Ankle Clin. 2002;7(4):709-20. 19. Haddad SL, Coetzee JC, Estok R et al. Intermediate and long-term outcomes of total ankle arthroplasty and ankle arthrodesis: a systematic review of the literature. J Bone Joint Surg Am. 2007;89-A(9):1899-1905. 20. Schuh R, Hofstaetter J, Krismer M et al. Total ankle arthroplasty versus ankle arthrodesis. Comparison of sports, recreational activities and functional outcome. Int Orthop. 2012;36:1207-14. 21. Krause FG, Windolf M, Bora B et al. Impact of complications in total ankle replacement and ankle arthrodesis analysed with a validated outcome measurement. J Bone Joint Surg Am. 2011;93-A(9):830-9. 22. Bestic JM, Peterson JJ, DeOrio JK et al. Postoperative evaluation of the total ankle arthroplasty. AJR. 2008;190:1112-23. 23. Scuderi GR, Insall JN, Windsor RE, Moran MC. Survivorship of cemented knee replacements. J Bone Joint Surg Am. 1989;71-B(5):798-803. 24. Maichau H, Herberts P, Ahnfelt L. Prognosis of total hip replacement in Sweden. Acra Orthop Scand. 1993;64(5):497-506. 25. Tsukamoto S, Tanaka Y, Maegawa N et al. Total talar replacement following collapse of the talar body as a complication of total ankle arthroplasty. J Bone Joint Surg Am. 2010;92-A(11):2115-20. 26. Courville XF, Hecht PJ, Toeteson ANA. Is total ankle arthroplasty a cost-efffective alternative to ankle fusion? Clin Orthop Relat Res. 2011;469:1721-7. 27. Doets C, Vergouw D, Veeger HEJ, Houdijk H. Metabolic cost and mechanical work for the step-to-step transition in walking after successful total ankle arthroplasty. Hum Movement Sci. 2009;28:786-97. 28. Johnson AR. A closer look at the future of total ankle arthroplasty. Podiatry Today. 2009;22(5):28-32.

RCSIsmjreview Deep brain stimulation for the treatment of movement disorders Abstract Aim: To explore the principles behind deep brain stimulation (DBS), its efficacy and future uses. Method: Research for this paper was carried out using Medline, Google Scholar and UBC’s e-library. Search phrases included: deep brain stimulation, movement disorders, Parkinson’s disease (PD), essential tremor (ET), dystonia and adenosine hyperpolarisation. Papers were limited to those published in English between the years 1995 and 2011, except for adenosine-related articles. Overview: DBS has been approved to treat PD, ET and dystonia. It is an alternative to medication and has replaced ablative surgery. DBS sends electrical impulses to brain nuclei via electrodes. This causes functional inhibition, thus eliminating tremors. The mechanism of action is not known but theories include: hyperpolarisation of overactive neurons; modification of malfunctioning feedback loops; and, down-regulation of hormones and neurotransmitters. These mechanisms are target independent; thus, DBS is being studied to treat non-movement disorders. Conclusion: Despite not understanding DBS’s mechanism of action, its effectiveness is replicable and it has provided patients with clinical improvement. It is currently being studied for use in non-movement disorders. DBS is becoming safer and more effective as patient selection criteria are refined, surgical techniques are improved and patient care evolves. It is expected to become a more common intervention for ET, PD and dystonia.

Royal College of Surgeons in Ireland Student Medical Journal 2013; 6(1): 63-7.

Derek Thong RCSI medical student

Volume 6: Number 1. 2013 | Page 63

RCSIsmj review Introduction Before the advent of deep brain stimulation (DBS), treatment options for individuals with essential tremor (ET), Parkinson’s disease (PD) and dystonia were limited to medication and ablation of abnormally functioning nuclei in the brain. While effective, both of these options had significant side-effects, such as cognitive impairment and dyskinesia.1 DBS is a surgical procedure in which electrodes are implanted into specific parts of the brain. These electrodes emit electrical impulses, which cause functional inhibition of the target nuclei, thus minimising tremors. The procedure was developed in the 1990s1 and approved by the Food and Drug Administration (FDA) in the US for the treatment of ET, PD and dystonia in 1997, 2002 and 2003, respectively.2 Although DBS has helped tens of thousands of patients,1 the exact mechanism of action is not fully understood.3 Because of its target-independent mechanism of action, research is ongoing to assess its safety and efficacy in other diseases.1,3,4 Since DBS is a relatively new procedure, formal guidelines for candidate selection, assessment and post-operative care have yet to be developed and globally adopted.5 This paper aims to explore the general principles behind DBS, its efficacy and possible future uses.

diameter in the skull to allow access to the brain. To optimise the lead’s placement, the patient is kept conscious in order to provide feedback. Occasionally, a microelectrode is used to augment lead placement by stimulating and creating recordings of the target area. The permanent electrode is then implanted. Once this has been completed, the patient is put under general anaesthesia and the IPG and extension are implanted. The extension is attached to the end of the lead and runs subcutaneously behind the ear and down the neck to the IPG, which is implanted below the clavicle or, less commonly, in the abdomen.1,3,7 In the weeks post surgery, the IPG can be programmed transdermally to modify the voltage, frequency and duration of the electrical pulses sent to the lead. This programming allows the healthcare team to cater to the patient’s individual needs and to account for any changes in the patient’s disease.1,8 Typical IPG settings are 2.0-3.5V at 130Hz with a duration of 60ms.8

Mechanism of action Although the mechanism by which DBS acts is not fully understood, there are several theories, all of which are believed to be target independent (i.e., not limited to the GPi, Vim and STN).3,8 The three most widely accepted sub-mechanisms are discussed below.

What is deep brain stimulation? To deliver DBS, three components must be surgically implanted in the patient: an implanted pulse generator (IPG); an extension; and, a lead. The lead is a polyurethane-coated wire that terminates in four platinum iridium electrodes. When connected, the IPG sends electrical impulses through the extension to the implanted lead in the brain. These impulses have the effect of functionally inhibiting the desired nuclei, thus allowing the patient to be tremor free.3 In ET, PD and dystonia, the FDA-approved nuclei are, respectively: 1) the subthalamic nucleus (STN) and globus pallidus internus (GPi); 2) the ventrolateral intermedius portion of the thalamus (Vim); and, 3) the GPi and Vim.6

Interventional procedure of deep brain stimulation For DBS to be successful, the electrodes must be accurately and precisely implanted in the specified nuclei. To accomplish this, a computer-based stereotactic localising system is utilised. The patient’s head is rigidly fixed to the stereotactic frame under local anaesthesia. It is then scanned using magnetic resonance imaging (MRI) or computed tomography (CT) to determine the distances between the frame’s known geometry and the target brain structures. The data gleaned from the scan is used to create an ‘atlas’ of the patient’s brain. This atlas enables the computer to assign either Cartesian or polar co-ordinates to the target structures depending on the type of stereotactic frame being used. To ensure that the surgeon’s instrument is aimed correctly at the target nuclei’s co-ordinates, it is placed in an instrument guide affixed to high precision Vernier scales. Once this has been completed, the surgeon drills a burr hole approximately 14mm in

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Increased adenosine causing neuronal hyperpolarisation Studies postulate that tremors are caused by increased neuronal excitation and that DBS is able to normalise the neuronal activity through hyperpolarisation. DBS causes astrocytes adjacent to electrodes to release adenosine triphosphate (ATP), which catabolises to adenosine. This ligand then binds to the adenosine A1 receptor, a G-protein coupled receptor (Figure 1, #2). The ligand/receptor interaction results in the guanine nucleotide exchange factor (GEF)-mediated allosteric activation of the Gi1/2/3 protein’s α-subunit by exchanging guanine diphosphate (GDP) for guanine triphosphate (GTP) (Figure 1, #2). The G-proteins dissociate into Gα-GTP and Gβγ dimers, which activate a number of secondary signalling pathways. Most importantly, the Gβγ-mediated activation of potassium-ion channels and inactivation of P/Q- and N-type voltage-gated calcium-ion channels (Figure 1, #4) cause neuronal hyperpolarisation (Figure 1, #5). These downstream signalling events result in reduced excitatory transmission, thereby reducing uncontrolled movements.3,4 Clinical outcomes from DBS and ablative procedures are similar; however, it is important to note that DBS is easily reversed by discontinuing the electrical impulses. Confirmation that adenosine plays a main role in DBS’s efficacy was achieved by injecting adenosine A1 receptor agonists intrathalamically, which produced the same reduction in tremor.9,10

High frequency electrical stimulation alters feedback loop It is suspected that tremors may also be due to disregulation in the dopaminergic nigrostriatal system. This alteration affects the normal feedback loop of the corticospinal pathway and the sensorimotor

RCSIsmj review 1

system, causing the feedback loop to be under-dampened, leading to oscillatory neuronal firing, which manifests as tremors. In order to overcome this, DBS provides electrical pulses, which cancel out the unwanted oscillations by restoring the feedback loop to its normally critically damped state.8,11

Extracellular Space

Down-regulation of local neurotransmitters and/or hormones

GDP Intracellular Space

An in vitro study exposed isolated GH3 and PC12 culture cells to high frequency electrical stimulation (HFS). GH3 cells are found in the pituitary and normally secrete growth hormone and prolactin,12 while PC12 cells are from adrenal medulla and mediate the transport of noradrenaline13 and release dopamine.14 The study demonstrated that the cells significantly decreased their production of prolactin, dopamine and norepinephrine when exposed to HFS. The authors postulate that this down-regulation leads to local functional inhibition of the stimulated nuclei and thus elimination of the offending tremor.15

Adenosine

GDP GTP

Treatment efficacy 3

A meta-analysis of DBS’s effect on PD’s clinical manifestation conducted by Benabid et al. compared the outcomes of 18 studies. It compared the Unified Parkinson’s Disease Rating Scale (UPDRS) of patients pre- and post-operatively. Specifically, it analysed parts II and III of the UPDRS, which measure the activities of daily living and motor function, respectively. The study found that patients’ scores improved by 50% for UPDRS II and 52% for UPDRS III on average. Partial results of their findings are shown in Table 1.8

Adenosine

GTP

Adenosine G effectors

K + channel activation and Ca2+ channel inhibition

GTP

Hyperpolarized neuron

FIGURE 1: Adenosine A1 receptor activation causing neuronal hyperpolarisation. DBS causes astrocytes adjacent to electrodes to release adenosine triphosphate (ATP), which catabolises to adenosine. This ligand then binds to the adenosine A1 receptor, a G-protein coupled receptor (Figure 1, #2). The ligand/receptor interaction results in the guanine nucleotide exchange factor (GEF)-mediated allosteric activation of the Gi1/2/3 protein’s α-subunit by exchanging guanine diphosphate (GDP) for guanine triphosphate (GTP) (Figure 1, #2). The G-proteins dissociate into Gα-GTP and Gβγ dimers, which activate a number of secondary signalling pathways. Most importantly, the Gβγ-mediated activation of potassium-ion channels and inactivation of P/Q- and N-type voltage-gated calcium-ion channels (Figure 1, #4) cause neuronal hyperpolarisation (Figure 1, #5).

Indications and contraindications A formal set of candidate selection guidelines has yet to be developed and implemented. However, a set of generally accepted criteria exists and is as follows:4,5,16 n patient has medically refractory ET, PD or dystonia, which significantly interferes with quality of life; n no existing cognitive deficits; n no untreated or disabling psychiatric illness; n no cardiac pacemaker or defibrillator; n regular follow-up visits to allow for tuning of the IPG module; n realistic expectations of the surgical outcome; and, n no general surgical contraindications. If the patient had undergone previous ablative surgery for their movement disorder, DBS is still an option, provided that the target nuclei have not been destroyed. Having a history of an unsuccessful DBS surgery is not a contraindication, as DBS does not permanently alter the target structure. Even if the same nuclei are targeted, the ineffective electrode does not need to be removed provided it is at a minimum of 2mm from the newly implanted electrode.8

Risks and side effects As with any surgical procedure, complications and unwanted effects may arise. The major risks associated with DBS are: haemorrhage;

Volume 6: Number 1. 2013 | Page 65

RCSIsmjreview Table 1: UPDRS II and UPDRS III percent improvement pre and post DBS. Study

confusion; and, problems with the lead. Issues with the lead are generally due to fracture, misplacement or migration. Cognitive deficits are serious potential complications to consider when thinking about DBS as treatment. Worsening of the cognitive deficit may be caused by trauma induced by the surgical procedure itself. When considered in conjunction with the tremors, these deficits may point to atypical PD or degeneration of additional systems whose symptoms can only be temporarily warded off by DBS as the condition worsens over time.8 Fortunately, with increasing experience and improvements in patient selection, and pre-, intra-, peri-operative and long-term care, these risks have declined to the point where the mean morbidity rate is 3-4%.1 A 10-year retrospective study into the short- and long-term outcomes of DBS showed that it was a safe procedure with a low rate of adverse events (Table 2).17 Of the initial group who received DBS in this study, 7.8% had revision due to: decreased effect; low efficacy; infection; and, lead fracture or migration.

Improvement UPDRS II

UPDRS III

Krack et al.

73%

71%

Kumar et al.

30%

58%

Limousin et al.

58%

60%

Pinter et al.

N/A

45%

Houeto et al.

55%

67%

DBSPDSG

N/A

51%

Lopiano et al.

68%

57%

Volkman et al.

N/A

67%

Ă&#x2DC;stergaard et al.

64%

Simuni et al.

42%

47%

Pahwa et al.

27%

28%

Currently, DBS is only approved by the FDA for the treatment of PD, ET and dystonia. However, due to its success and target-independent nature, DBS is being studied for a number of conditions that are not limited to movement disorders (Table 3).1,3

Krack et al.

66%

Limitations

Rodriguez et al.

43%

50%

Hamani et al.

58-42%

50-49%

Fraix et al.

49%

57%

Kleiner-Fisman et al.

50%

52%

Deuschl et al.

39%

41%

Goodman et al.

30%

N/A

The future of deep brain stimulation

The most significant limitation of the studies analysed was that there were no control groups to compare against DBS. The studies compared unmedicated pre-DBS and unmedicated post-DBS patients.6,11,17 Although there was an improvement compared to the baseline, it would have been beneficial to see the gains made against conventional medication to highlight the advancements made by DBS. Additionally, many studies were conducted retrospectively, 5,7,11,18 possibly introducing bias into the results. Other studies, while they showed consistent data, were based on relatively small sample sizes or reported data from a single institution, which may mean that the findings are not generalisable.1,5,6,7,11

Table 2: Risks and side effects of DBS. Intra-operative

Peri-operative

Long-term

Vasovagal response

2.5%

Headache

15.0%

Infection

4.4%

Syncope

1.2%

Confusion

5.0%

Dysarthria

4.0%

Isolated seizure

1.2%

Hallucinations

2.8%

Cognitive dysfunction

4.0%

Severe cough

0.9%

Isolated seizure

1.2%

Worsening gait

3.8%

Intracerebral haemorrhage

0.6%

Intracerebral haemorrhage

0.6%

Transient ischaemic attack

0.3%

Large subdural haematoma

0.3%

Arrhythmia

0.3%

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RCSIsmjreview Table 3: Other conditions being studied for DBS. n Spasmodic dysphonia

n Tourette’s syndrome

n Orthostatic tremor

n Aggressive behaviour

n Meige syndrome

n Depression

n Cluster headache

n Obsessive-compulsive disorder

n Short-lasting unilateral neuralgiform headache with

n Epilepsy

conjunctival injection and tearing (SUNCT)

n Camptocormia

n Trigeminal neuropathy

n Restless legs syndrome

n Trigeminal neuralgia

n Obesity/addictions

n Chronic paroxysmal hemicranias

n Disorder of consciousness

n Chronic pain

n Alzheimer’s disease

Conclusion Over the past 20 years, DBS has provided significant clinical improvement to patients with movement disorders. Despite not completely understanding DBS’s mechanism of action, its effectiveness has been replicated in multiple studies. As a result of its success, and owing to its target-independent nature, it is being studied for use in many other non-movement disorder-related

conditions. Additionally, DBS is becoming safer and more effective as patient selection criteria are refined, DBS surgical techniques improve and DBS patient care evolves. This exciting intervention has proven highly effective and will likely become a more frequently used procedure in the future. There is promising potential to affect even more conditions that currently have no treatment.

References 1.

Lyons MK. Deep brain stimulation: current and future clinical applications. Mayo Clin Proc. 2011;86(7):662-72.

Katz M, Kilbane C, Rosengard J, Alterman RL, Tagliati M. Referring patients for deep brain stimulation: an improving practice. Arch Neurol. 2011;68(8):1027-32.

3. 4.

adenosine A1 receptors: inhibition of prolactin release, cyclic AMP production and inositol phosphate generation. Biochem J.

Fredholm BB, Ijzerman AP, Jacobson KA, Klotz KN, Linden J. International

Moro E, Albanese A, Krauss JK, Metman LV, Vidailhet M, Hariz MI. Guest editors’ introduction. Movement Dis. 2011;26:S1-S2. Savica R, Matsumoto J, Josephs K, Ahlskog JE, Stead M, Lee KH et al. Deep brain stimulation in benign tremulous parkinsonism. Arch Neurol. 2011;68(8):1033-6.

Deogaonkar M, Nazzaro JM, Machado A, Rezai A. Transient, symptomatic, post-operative, non-infectious hypodensity around the deep brain stimulation (DBS) electrode. J Clin Neurosci. 2011;18:910-15.

Benabid AL, Chabardes S, Mitrofanis J. Deep brain stimulation of the subthalamic nucleus for the treatment of Parkinson’s disease. Lancet Neurol. 2009;8(1):67-81.

movement disorders. J Neurosurg. 1996;84:203-14. 12. Delahunty TM, Cronin MJ, Linden J. Regulation of GH3-cell function via

disease: a review. Drug Des Devel Ther. 2011;5:241-54.

adenosine receptors. Pharmacol Rev. 2001;53(4):527-52.

ventralis intermedius nucleus of the thalamus as a treatment of

Hickey P, Stacy M. Available and emerging treatments for Parkinson’s

Union of Pharmacology. XXV. Nomenclature and classification of 5.

Brain. 2005;128(10):2372-82. 11. Benabid AL, Pollak P, Gao DM et al. Chronic electrical stimulation of the

Bekar L, Libionka W, Tian GF, Xu Q, Torres A, Wang X et al. Adenosine is crucial for deep brain stimulation-mediated attenuation of tremor. Nat Med. 2008;14(1):75-80.

10. Meissner W, Leblois A, Hansel D et al. Subthalamic high frequency stimulation resets subthalamic firing and reduces abnormal oscillations.

1988;255:69-77. 13. Zhu MY, Ordway GA. Down-regulation of norepinephrine transporters on PC12 cells by transporter inhibition. J Neurochem. 1997;68(1):134-41. 14. Zhu WH, Conforti L, Millhorn DE. Expression of dopamine D2 receptor in PC-12 cells and regulation of membrane conductances by dopamine. Am J Physiol. 1997;273(4):C1143-C1150. 15. Xia R, Berger F, Piallat B, Benabid AL. Alteration of hormone and neurotransmitter production in cultured cells by high and low frequency electrical stimulation. Acta Neurochir. 2007;149:67-73. 16. Lang AE, Houeto JL, Krack P et al. Deep brain stimulation: preoperative issues. Movement Dis. 2006;21(14):S171-S196. 17. Kenney C, Simpson R, Hunter C, Ondo W, Almaguer M, Davidson A et al. Short-term and long-term safety of deep brain stimulation in the treatment of movement disorders. J Neurosurg. 2007;106:621-5. 18. Leksell Stereotactic System® [photograph]. Stockholm: Elekta AB (publ); c2011. 1 photograph: colour, 700x450 pixels. 19. Figure 1: Neuronal Hyperpolarisation [diagram]. Dublin: Derek Thong; 2011. 1 diagram: colour, 282x772 pixels.

Volume 6: Number 1. 2013 | Page 67

RCSIsmjreview Development of a three-dimensional patient-specific brain model with a pineal region tumour and hydrocephalus for neuroendoscopic simulation and training Abstract Patient-specific modeling (PSM) is a growing field of research into computational models specific to patient data. It aims to develop both virtual computer models and, more recently, physical 3D models of patient tissue and organ dynamics for a variety of medical training and practice purposes. It has shown promising results in a number of areas such as the brain, blood vessels and other internal organs (for example the liver and kidneys). The aim of PSM is to improve diagnoses and clinical outcomes for the patient population. In the past, PSM projects have seen the brain modelled for areas of research and clinical practice such as deep brain stimulation, but to date a working 3D physical model of a paediatric brain with a pineal region tumour has not been constructed. While previous neuromodulation and deep brain stimulation models have focused on virtual models, PSM has commenced a movement towards a physical 3D model that can be used in an array of medical fields, whether training, neuroendoscopic preparation or actual surgical practice. We attempted to construct that model using conjoint CT and MRI images from a four-month-old male patient. We were able to successfully create a realistic 3D model of a pineal gland tumour in a four-month-old male patient, which was successfully used on a trial basis in neuroendoscopic training and simulation.

Royal College of Surgeons in Ireland Student Medical Journal 2013; 6(1): 68-71.

Introduction

Michael Kuhlmann1 Prof. James Drake2 1RCSI medical student 2University of Toronto,

ON, Canada

Page 68 | Volume 6: Number 1. 2013

Patient-specific modelling (PSM) is a relatively new technology and a fast-growing field of research. Neal et al. define it as the “development of computational models of human pathophysiology that are individualised to patient-specific data”.1 This is accomplished through the use of detailed image data sets specific to an individual patient, and the subsequent creation of tissue and organ dynamics, often in a 3D model format. In early stages of research, PSM has shown promising potential to improve diagnoses, treatment and

clinical outcomes.2 In present day medicine, many therapeutic options for patients are based on clinical trials of the overall population and a limited amount are based on specific patient data. PSM has the advantage of allowing more individualised treatment options for patients – a type of ‘tailored’ therapeutic management plan for each patient. Thus PSM, as an alternative, has the potential to optimise treatment and have a huge role as a ‘theranostic’ tool (a portmanteau of therapeutic and diagnostic). On the whole, PSM has seen huge progress over

RCSIsmjreview FIGURE 1: Pineal region tumour adjacent to the third ventricle in Magics.速

the last 15 years. It is now used as a tool in the modelling of blood vessels and blood flow, bones, the heart, the brain, skeletal muscle and the modelling of tumours. We aimed to construct a 3D model of a pineal region tumour in a four-month-old male patient pre operatively. This patient was chosen by an experienced neurosurgeon on the basis that the images the model would be based on displayed a very typical picture for this type of condition. The patient had hydrocephalus secondary to the tumour. This model will be used to aid in simulation and training. In addition, it will be used as a tool for evaluating surgical technique, with a specific focus on third ventriculostomy. If successful, the model can be further used to validate surgical robots and image-guided therapies. If this model proves successful in aiding neuroendoscopic training techniques, it will open the door for the discussion of creating these surgical models prior to surgeries for residents to practice their surgical technique on an exact model of the surgery they will be performing.

Production of the patient-specific model Production of computational model from image data sets The development of the brain model begins with obtaining the patient MRI. The reason MRI is chosen is because it highlights the inner brain structures more clearly than CT and is therefore more accurate in the segmentation process. Once this is obtained, the images can be converted for use with a specialised imaging software program known as Mimics (Materialise NV; Leuven, Belgium). A process of segmentation is then completed to create a surface model of the organ of interest. In this specific case, the brain, ventricles and pineal tumour were segmented separately. A CT image of the head taken two days prior to the MRI was used for segmentation of the skull. CT was used for the skull because there are pre-determined threshold values to ease the segmentation of bone from an image.

Creation of 3D computational mould Magics (Materialise NV; Leuven, Belgium), a data preparation software package, was used to create a mould from the organ surface file that was then fabricated using 3D printing technology (Figure 1). The brain was positioned within a block approximately

5mm larger than the organ in all directions. The block was made semi-transparent so that the organ surface could be visualised and positioned within the block and an appropriate cut line could be selected to create the proper sections of the mould. The cut line undertook a developed process to ensure stability of the organ after printing, ease of extraction and assembly of the mould pieces for filling and curing. After a cut line was chosen, the program underwent a Boolean operation, which subtracts the organ surface from the block, leaving a space in each mould section. Later, this space was filled with a silicone mix to create the organ.

The 3D printing and mould creation process Finally, these mould files are saved in stereolithography (STL) format and manufactured using our 3D printer (ZCorp Z510) with zp速 131 powder, which is a combination of plaster, vinyl, polymer, carbohydrate and sulfate salt. The ventricles were printed in their entirety so as to create the hollow space in the completed brain mould. The tumour underwent a process similar to the brain, but the completed mould was created with a different silicone mix ratio so as to better reflect the density of the tumour compared to the brain tissue. We chose a platinum-cure silicone rubber (Dragon Skin 30; Smooth-On Inc., Easton, PA) available as a liquid that is separated into two components. When the components are mixed in a 1:1 ratio by weight or by volume, they undergo additional curing that takes anywhere from two to three hours for a small part to 16 hours for a large part, to form a flexible solid. Slacker additive, consisting of polyorganosiloxanes, may be mixed into the silicone rubber solution to modify the mechanical properties of the final product. In the case of a brain phantom, a higher amount of slacker is added to the silicone rubber when compared to other organs, such as a kidney or liver. The higher the concentration of slacker additive used, the softer the final product. We determined the concentration of silicone rubber to slacker by volume. Because the final product in a brain phantom requires more slacker, it is difficult to remove the organ without tearing or losing its form. To overcome this obstacle, we began by applying a thin layer to the outer sections of the

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RCSIsmjreview FIGURE 2: Suspension of ventricles in mould to create negative space.

mould and let this layer cure. Afterwards, the high slacker mixture is added and allowed to cure. The brain phantom was then more structurally sound and removed with ease. Pigment may also be added to the solution during mixing to give the product a desired colour, which aids in the realism of the phantom. In this specific case, we ensured that different pigments were used to better represent the colour of the brain versus the tumour. Once the appropriate amounts of silicone rubber and slacker additive were thoroughly mixed, the solution was degassed using a vacuum chamber and vacuum pump assembly to remove air bubbles. The degassed solution was poured into the mould and allowed to cure. The ventricles and tumour were suspended into the mould in appropriate positioning to keep the proper negative spaces (Figure 2). In order to achieve correct positioning of the ventricles, one half of the mould was allowed to cure first with the ventricles in place. Once the first half was fully cured, the second half was positioned with the ventricles and first half of the mould on top, but suspended 2mm so the two sides would not cure together. Once the second half was fully cured, the ventricles were removed from the brain mould and the two halves were cured together with the tumour in place. We did not need to apply any releasing agent to the mould.3 The final obstacle was creating the membrane at the base of the third ventricle so that it would be a realistic model for neurosurgical trainees to refine their neuroendoscopy skills. In order to do this, special attention was paid to separately segment the third ventricle from the basal cisterns (which lie beneath) and attempt to insert a practical membrane in that space. Upon conclusion of the moulding process, it was found that the full 3D ventricle model caused a small membrane to remain, which sufficed as an appropriate representation. A full patient-specific brain, including ventricles and a pineal tumour, along with the moulds used to make them are shown

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(Figure 3). This model was inserted into the developed skull three days after completion.

Outcome of the patient-specific model A life-sized MRI-compatible brain model with a pineal region tumour and resultant hydrocephalus was created. In addition to its use in simulation and training, we were also able to image the brain model using MRI (Figure 4). This illustrated the multi-faceted success of PSM in the areas of medical imaging, diagnostics and therapeutics. Following this project, the method was developed further. On the secondary method, the process of the PSM design was reformed. A cured mould of the ventricles was made first. This was then filled with simple melted candle wax and allowed sufficient time to harden. Once the moulded ventricles were complete, they were placed into two uncured halves of the brain mould and left inside. A small hole was left and the entire structure was boiled at 100oC. As a result, the moulded ventricles melted, leaving the negative space within the brain. This model was more successfully used for neuroendoscopic training, in particular third ventriculostomy.

Discussion Much of PSM with regard to the brain has to date been focused on deep brain stimulation (DBS)4 for patients with Parkinsonâ&#x20AC;&#x2122;s disease and other movement disorders. Other areas of research have included brain deformations as a result of craniotomy procedures, needleâ&#x20AC;&#x201C;tissue brain interactions and intracranial pressure dynamics in traumatic brain injury patients. This specific model represents a successful attempt to model an intracranial tumour and to subsequently practice a neuroendoscopic third ventriculostomy on the model. This has the potential to be advantageous for surgery residents in training and for experienced surgeons operating on difficult and complex cases, as it opens the door for 3D brain

RCSIsmjreview FIGURE 3: Completed brain mould with pineal region tumour.

modelling. Despite being case specific, we can be hopeful that this technique will be beneficial across the board for similar patients. Previous authors have stressed and focused on the need for more accurate segmentation and registration methods for brain structures. This includes being more precise with certain structures, including white versus grey matter and the pia mater and meninges, as these can be difficult to discern on current imaging techniques and may represent a potential obstacle to PSM. This project has shed light on potential opportunities available with brain modelling and advanced this field of research. Being able to accurately segment a pineal region tumour based on MRI images of a four month old opens the door to other opportunities that can arise with brain modelling. Specifically, the use of PSM in brain tumours could help surgical trainees and aid in complex surgical cases in the future. Hopefully the obstacles faced in this project, such as the difficulty in the primary methodology with creating a suitable PSM for neuroendoscopic training, can help to aid further advancements in this field of research.

FIGURE 4: Sagittal MRI of brain model with pineal region tumour.

Further reading Hamani C, Moro A. New frontiers in brain and spine stimulation. Int Rev Neurobiol. 2012;107:5-22.

References 1. 2.

Neal NL, Kerckhoffs R. Current progress in patient-specific modelling. Brief

of multimodality anthropomorphic silicone rubber phantoms for validating

Bioinform 2009;2(1):111-26.

surgical robots and image-guided therapy systems. The Hospital for Sick

Arts T, Lumens J, Kroon W, Donker D, Prinzen F, Delhaas T. Patient-specific modelling of cardiovascular dynamics with a major role for adaptation.

Children. 4.

Wittek A, Miller K, Kikinis R, Warfield SK. Patient-specific model of brain

Springer J. 2010;12:21-42.

deformation: application to medical image registration. J Biomech.

Cheung C, Looi T, Drake J, Kim P. Magnetic resonance imaging properties

2007;40:919-29.

Volume 6: Number 1. 2013 | Page 71

RCSIsmjresearch update Changing perspectives on Alzheimer’s disease

Royal College of Surgeons in Ireland Student Medical Journal 2013; 6(1): 72-3.

Rachel Mattson RCSI medical student

Page 72 | Volume 6: Number 1. 2013

Alzheimer’s disease presents a major challenge to the ageing population in Europe due to its high morbidity, mortality, and burden on the health system.1 Alzheimer’s disease is traditionally accounted for by the aggregation of misfolded structural proteins including β-amyloid peptides. An increasing body of evidence describes its aetiology from a metabolic perspective, as a result of impaired brain glucose utilisation and insulin sensitivity. Biochemical measures of insulin and insulin-like growth factor (IGF) resistance, oxidative stress, and metabolic dysfunction should be considered alongside β-amyloid neurotoxicity in the pathophysiology of Alzheimer’s disease.2 Currently, the diagnosis of Alzheimer’s disease in clinical practice is based upon criteria such as those found in the Diagnostic and Statistical Manual of Mental Disorders (4th edition) (DSM IV). More sophisticated centres include neuropsychological and performance-based

functionality testing, genetic screening, neuroimaging, and a panel of biomarkers proven to have limited predictive value.3 The limitation to timely and accurate diagnosis of Alzheimer’s disease is exemplified by the fact that post-mortem examination is the diagnostic gold standard.4 Advances in understanding the pathogenesis of this neurodegenerative process beyond the abnormal accumulation of β-amyloid precursor protein allow for exploration of novel diagnostic and therapeutic modalities.3 As mentioned, a growing body of research supports the notion that Alzheimer’s disease occurs as a result of metabolic dysregulation. Neuronal survival and signalling pathways within the brain depend upon tightly regulated glucose metabolism. Hence, brain insulin and IGF resistance allow for the initiation of a neurodegenerative cascade. Impaired IGF signalling and brain insulin resistance activate

RCSIsmjresearch update kinases that phosphorylate tau and lead to expression and accumulation of β-amyloid precursor protein-Aβ.2 The accumulation of abnormal proteins leads to endoplasmic reticulum and mitochondrial stress, the generation of reactive oxygen species and activation of inflammatory cascades, which promote apoptotic pathways within neurons.3 Reduction in cerebral glucose utilisation is evident in early stages of Alzheimer’s disease.2 Suppression of brain insulin receptors within in vivo models leads to cognitive impairment, neurodegeneration, and features of Alzheimer’s disease exemplifying the detrimental consequences of impaired glucose uptake by neurons.5 Regions of the brain most vulnerable to neurodegeneration in Alzheimer’s disease are those with the highest expression of insulin and IGF receptors, such as the temporal lobe. Metabolic dysregulation including hyperinsulinaemia with or without diabetes mellitus along with peripheral insulin resistance has been shown to correlate with the development of Alzheimer’s disease. This phenomenon is supported by evidence of increased β-amyloid precursor protein-Aβ, elevation of inflammatory indices, formation of advanced glycation end products and reactive oxygen species within the brains of patients with hyperinsulinaemia.3

Metabolic syndrome and Alzheimer’s disease The development of both metabolic syndrome and Alzheimer’s disease occurs as a result of similar genetic, environmental and lifestyle predispositions.4,6 For example, Grodstein et al. found that type II diabetes mellitus correlated with lower neuropsychological test scores and an increased duration of time with type II diabetes mellitus was associated with even poorer scores. However, hypoglycaemic therapy seemed to improve cognitive scores.7 Similarly, midlife obesity was found by Kivipelto et al. to correspond with elevated risks of dementia and Alzheimer’s disease in late life, which was further increased by vascular risk factors.8 Such observations are crucial in guiding clinicians towards the aetiology of Alzheimer’s disease in order to

develop more effective therapies to reverse or halt this neurodegenerative process. Diagnosis of Alzheimer’s disease may be improved by including biochemical markers of peripheral insulin resistance, hyperglycaemia, hyperinsulinaemia, the accumulation of reactive oxygen species, and advanced glycated end products. Collectively, such abnormalities elucidate the potential for ongoing neurodegeneration. Dynamic functional plasma insulin tests and cerebrospinal fluid (CSF) assays of raised insulin levels have been shown to be elevated in Alzheimer’s disease compared to normal age-matched controls.3 This relationship is correlative to the severity of dementia, which strengthens its validity as a prognostic method. Logical approaches to preventing Alzheimer’s disease from a metabolic perspective have been shown to be effective in several circumstances. Evidence suggests that insulin treatment delivered intranasally improves cognition and memory in clinical trial participants with mild cognitive impairment.2 Additionally, insulin-sensitiser drugs such as peroxisome proliferator-activated receptor (PPAR) agonists (which also possess anti-inflammatory and anti-oxidant properties in addition to enhancing glucose uptake and insulin receptor sensitivity) decrease cognitive impairment and neurodegeneration in diet-induced obesity and type II diabetes mellitus patients. However, a multifaceted approach to diminish oxidative stress and metabolic dysfunction along with insulin and IGF resistance will be required to truly ameliorate cellular injury imparted upon neurons by the progressively toxic cascade, which leads to dementia and subsequently Alzheimer’s disease.3 Identification of novel pathophysiological processes implicated in the development of Alzheimer’s disease directs further studies towards ascertaining improved diagnostic and prognostic methods. Additionally, early experiments show promising results for preventing the onset and progression of Alzheimer’s disease through tight glycaemic control in type II diabetics and obese patients with insulin and IGF resistance.

References 1.

Blendon RJ, Benson JM, Wikler EM, Weldon KJ, Georges J, Baumgart M

Metabolic changes in rat brain following intracerebroventricular

et al. The impact of experience with a family member with Alzheimer’s

injections of streptozotocin: a model of sporadic Alzheimer’s disease.

disease on views about the disease across five countries. Int J Alzheimers Dis. 2012;903645. 2.

Acta Neurochir Suppl. 2010;106:177-81. 6.

De la Monte SM. Contributions of brain insulin resistance and

Nitrosamine exposure causes insulin resistance diseases: relevance to

deficiency in amyloid-related neurodegeneration in Alzheimer’s disease.

type 2 diabetes mellitus, non-alcoholic steatohepatitis, and Alzheimer’s

Drugs. 2012;72(1):49-66. 3.

De la Monte SM. Brain insulin resistance and deficiency as therapeutic

Frisardi V, Solfrizzi V, Seripa D, Capurso C, Santamato A, Sancarlo D et

disease. J Alzheimers Dis. 2009;17(4):827-44. 7.

targets in Alzheimer’s disease. Curr Alzheimer Res. 2012;9:35-66. al. Metabolic-cognitive syndrome: a cross-talk between metabolic 5.

Tong M, Neusner A, Longato L, Lawton M, Wands JR, De la Monte S.

Grodstein F, Chen J, Wilson RS, Manson JE. Nurse’s Health Study – type 2 diabetes and cognitive function in community-dwelling elderly women. Diabetes Care. 2001;24:1060-5.

Kivipelto M et al. Obesity and vascular risk factors at midlife and the

syndrome and Alzheimer’s disease. Ageing Res Rev. 2010;9:399-417.

risk of dementia and Alzheimer disease. Arch Neurol.

Labak M, Foniok T, Kirk D, Rushforth D, Tomanek B, Jasinski A et al.

2005;62(10):1556-60.

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RCSIsmj staff review The abuse of stimulant drugs within the medical education setting Abstract The rising abuse of stimulant drugs â&#x20AC;&#x201C; traditionally reserved for the treatment of attention deficit and hyperactivity disorder (ADHD) â&#x20AC;&#x201C; as cognitive enhancers in academic environments has serious implications in medical education and practice. In this article we report on the nature of these drugs, and the prevalence of their abuse in relation to ADHD diagnosis in Europe and abroad. We also highlight the ethical pitfalls of neuroenhancement in medicine to help forecast cultural and administrative changes that may be necessary to protect the integrity of the medical field in the future.

Royal College of Surgeons in Ireland Student Medical Journal 2013; 6(1): 74-8.

Yoshihiro Katsuura

Dr Kilian McGrogan 1

RCSI medical student

Department of General Practice,

RCSI, and Mercer Medical Centre

Page 74 | Volume 6: Number 1. 2013

RCSIsmjstaff review Mesocorticolimbic pathway Reuptake Dopamine Catecholamine

MAO

VTA NAcc Stimulants

FIGURE 1: The neuropharmacology of stimulants: stimulants exert their effects on the mesocorticolimbic pathway augmenting dopamine and catecholamine transmission by blocking reuptake and degradation by MAO as well as promoting vesicle fusion. MAO – monoamine oxidase; NAcc – nucleus accumbens; VTA – ventral tegmental area.

Introduction Stimulant drugs (amphetamine and methylphenidate) used widely to treat attention deficit and hyperactivity disorder (ADHD) have come under scrutiny for their pervasive use as academic enhancers – reportedly as high as 35% in college-aged adults.1 While their seemingly ubiquitous use in high school and college settings across the United States has gained attention recently in the media,2 little is known about their use in our area of particular interest, medical education and practice. This is especially true within Europe. In this article we explore the pharmacology and abuse of stimulant drugs, as well as providing a discussion on the relationship of abuse to ADHD prevalence. We highlight the potential dangers behind such use in a medical academic setting in order to draw attention to a problem that is not widely recognised in Europe.

coeruleus and projecting to the median forebrain bundle, the limbic system, and generally throughout the brain.5,6 This system arbitrates selective cognitive functions including the orienting response (an organism’s reaction to a gradual change in the environment), selective attention and vigilance.5 The deregulation of the noradrenergic system has been implicated in the pathogenesis of ADHD corresponding with the therapeutic effect of stimulants for this condition.7,8 Stimulants have the ability to dramatically improve patient performance in sustaining attention – especially for tedious or monotonous tasks.9 While the therapeutic impact of stimulants on ADHD can be significant, it is clear that their effects would be desirable for anyone wishing for an increased ability to sustain focus. Thus, their potential for illegitimate use as so-called academic doping agents is broad.

The properties of stimulants The stimulants methylphenidate (Ritalin) and amphetamine (Adderall) are two common and highly efficacious treatments for ADHD, a neuropsychiatric disorder.3 These drugs act through the augmentation of catecholamine and dopamine neurotransmitters by driving their release from the synaptic cleft, inhibiting their reuptake, and inhibiting the catabolic monoamaine oxidase (MAO) system.4,5 The dopaminergic effects of these drugs are mediated mainly by the mesocorticolimbic system, originating from the ventral tegmentum of the midbrain and projecting to the nucleus accumbens, as well as most of the cortical mantle – the function of which is the mediation of response reinforcement (reward).5 More importantly, the noradrenergic effect of these drugs is exerted primarily on the central noradrenergic network originating in the locus

Adverse effects of stimulants While stimulants such as methylphenidate and amphetamine are effective treatments of ADHD, and are generally well tolerated in the short term, they do have similar reinforcing properties to cocaine, with a potential for dependence.10,11 In addition, while the long-term effects of protracted stimulant use are not known, they may contribute to sensitisation to dependence on other substances or trigger psychiatric disorders such as panic, aggressive behaviour and increased risk of suicide (particularly at high doses).11,12 Furthermore, stimulant abuse has been shown to have adverse cardiovascular effects, as well as causing insomnia, anorexia, hypertension and headache.13 Withdrawal effects of stimulants, while well characterised in amphetamine, are less understood in

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RCSIsmj staff review methylphenidate use.14 Nonetheless, in their study on rats, Ferreira et al. showed an increase in anxiety secondary to sensitisation of an anxiety-provoking brain region after methylphenidate infusion.14 In spite of these adverse effects, stimulants are generally considered safe and their narrow side-effect profile, coupled with their augmentation of focus and concentration, make them ideal for intellectual enhancement. While the distinction between the term misuse, or improper use of prescription drugs, and the term abuse, implying the use of the drug outside of a prescription, may be made, for simplicity, the term abuse will be used for both of these definitions for the remainder of the article.

ADHD: the world-wide problem The easy accessibility of stimulant drugs such as methylphenidate stems from the high prevalence of ADHD.1 ADHD is a worldwide problem, but there is no consensus on prevalence. US studies suggest that ADHD affects 6-8% of children and 4-5% of adults.15 By contrast, in 2008, the influential UK-based National Institute for Health and Clinical Excellence (NICE) published a clinical summary of best practice in the UK for ADHD, which included the following statement: “Based on ICD-10, hyperkinetic disorder is estimated to occur in about 1-2% of children and young people in the UK. In contrast, using the DSM-IV, ADHD is thought to affect about 3-9% of school-age children and young people in the UK, and about 2% of adults worldwide”.16 The discrepancy in prevalence rates between the US and the EU stems from differences in diagnotic and cultural methodology (discussed below). ADHD is associated with a high level of comorbid psychopathology and has significant deleterious impacts on a patient’s functional life.17 Moreover, while many cases of ADHD can persist into adulthood, symptoms tend to decrease by 50% every five years from ages 10-25,18 suggesting that prescription rates should also experience a concurrent plateau. Nonetheless, the manufacturing of methylphenidate for medical use has increased by 40% since 1993 in the US.19 Originally, ADHD was thought to be most prevalent in the US due to pathogenesis models, which implicated societal factors common in America as triggers for the disease – some studies even citing a 20-fold greater prevalence in America.15,20 This purported discrepancy in prevalence was largely the result of several technical and societal factors. Foremost, ADHD has historically been much more readily diagnosed in the US owing to the extensive research conducted on the subject in the country, and thus a heightened awareness on the topic compared to European countries.15 In addition, several methodological differences have extenuated the inconsistency in prevalence rates of ADHD between the US and Europe. For example, variation in diagnostic paradigms such as the use of the DSM criteria for ADHD in the US, which utilised a broad, more inclusive diagnostic category, and its ICD equivalent of hyperkinetic disorder in Europe – which has a narrower, less inclusive criteria – have likely contributed to lower reported levels of ADHD in Europe as reported by the NICE summary.15,16 Moreover, these criteria systems tend to be less strictly applied to patient populations in Europe.15

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Finally, cultural dynamics such as misconceptions of the severity of adverse effects of ADHD as well as apprehension towards the use of stimulant treatment in Europe have simulated lower prevalence rates.15 It is also worth pointing out that some of the medications commonly used in North America are either not licensed in Europe or are not licensed for the treatment of adults. Nonetheless, in their meta-analysis comparing the prevalence rates of ADHD in the USA and other countries, Faraone et al. indicate that initial differences in prevalence of ADHD were due primarily to confusion regarding the diagnostic criteria and that the rates of ADHD may be as high in other countries as in the USA.15 As stimulant abuse stems indirectly from the prevalence of ADHD and the availability of stimulant drugs,14 this information would suggest that a similar potential for abuse of stimulant drugs used to treat ADHD exists in Europe as it does in the USA.

The abuse of stimulants In their American review, Wilens et al. reported a non-prescription stimulant abuse rate for both academic enhancement and recreation to be 5-9% in grade school- to high school-aged children, and from 5-35% in college-aged adults.1 The highest rates of abuse were found in studies that focused on individual academic institutions (as opposed to multiple), which suggests that the competitiveness of a college environment may predict which groups are likely to abuse the drugs.1,21 Demographic studies reported that men are more likely to abuse than women,12 and that the Caucasian race is more likely to abuse and divert (illegally sell prescriptions) stimulants than other races.1 Further information concerning the social classes and academic disciplines most likely to abuse stimulants remains unknown.1,21 McCabe et al. report that the majority of those who abuse stimulants obtain them from their peers.21 Thus it would appear that the growing prescription of these drugs by physicians has directly contributed to their availability for abuse.19 In a separate report, Jardin et al. document that as many as 11% and 22% of those ADHD patients with legitimate prescriptions sell or abuse their medications, respectively.1,22 Teter et al. reported that of college students who misuse stimulants, 58% did so to concentrate, 43% for alertness, and 43% to get high, showing that the majority of abuse within the academic sphere is for performance enhancement.12 The rates of abuse in graduate and professional school (i.e., schools awarding postgraduate doctorate degrees such as PhD, MD and JD) are less well characterised. White et al. describe similar patterns but with lower rates of abuse of methylphenidate in graduate students respective to college students at the University of New Hampshire.19 A study conducted at a medical school in Iran showed that 8.7% of students questioned had taken methylphenidate at least once on their lifetimes.23 Given the significant abuse in the undergraduate setting, more rigorous and multi-geographical studies are needed to determine the true prevalence of stimulant abuse within medical schools worldwide, as no research into this has currently been conducted. In addition, as many of these studies base their analysis on anonymous internet-based surveys, more rigorous sources of data such as

RCSIsmj staff review prescription databases should be studied. Finally, there is little written in the standards of good practice either within the UK General Medical Council or the Irish Medical Council specifically offering guidelines regarding the abuse of stimulant drugs within the medical workplace.24,25

The dangers of stimulant abuse in the medical education setting As new methods of neuroenhancement are likely to become more available in the future (related to advancements in the treatment of Alzheimer’s disease),26 it is important to determine how medical students may use these drugs and how that will impact on their education. Practically speaking, stimulants improve a student’s ability to perform in academic situations – they increase IQ scores on neuropsychological measurement tests,27 enhance focus for the preparation of examinations, and allow increased wakefulness for prolonged writing or study.19 Within the US, stimulants are used by college students both with and without a diagnosis of ADHD to enhance academic performance.1,28 This data raises several questions about the use of stimulants: 1. Are overachieving students trying to push their capabilities and should this be constituted as cheating? 2. Are students who have not been diagnosed with ADHD simply and appropriately self-medicating for an undiagnosed (but real) ADHD? 3. Are stimulants any different from other forms of psychiatric medication, which treat disabling mental illness and potentially improve academic outcome? 4. What are the professional ramifications of stimulant abuse to the practice of medicine? In the following discussion, we offer a cursory evaluation of these questions, acknowledging the limitations of a rhetorical discussion in determining an absolute right or wrong answer. The initial question with regard to stimulant abuse is whether it can be constituted as cheating, much as doping is for athletic competitions. Students who misuse stimulants may gain an unfair advantage over students who refrain from misuse.2 However, in their study examining print media, public health literature and other sources, Forlini et al. reported ambivalence in regard to whether this can be construed as cheating.26 Many sources cited likened stimulant abuse to access to private tutors, or any resources only available to a select group of students, which improve academic outcome. In this regard a better understanding of the cognitive benefit delivered by stimulants vs. tutorial and their relation to long-term clinical performance is needed. For example, private tutorial is typically undertaken to improve comprehension of material, and thus an increased clinical performance is expected as a result. It is unclear if stimulants purely offer a temporary cognitive enhancement and improved concentration, or if they actually improve understanding, and long-term retention. Secondly, given the high incidence of ADHD, it is possible that subsets of students who abuse stimulants are treating an

undiagnosed ADHD. This confounds the argument that stimulant abuse in the academic setting may represent dishonest behaviour, as a proportion of these abusers may in fact be returning to a baseline cognitive status, as may be considered for a depressed patient benefiting from antidepressants. However, this argument can only apply to a fraction of those students taking these medications. If we were to accept the upper level estimate of 5% of the entire young adult population having ADHD, then any figure in excess of this implies misdiagnosis or misuse. Furthermore, stimulant abuse differs from the treatment of other psychological disorders such as depression and anxiety in that they are directly nootropic – or neuroenhancing. Antidepressant or anxiolytic medication would not improve the cognitive function of a student with pre-existing mental illness. For example, a student taking antidepressants for depression would typically never exceed his intellectual potential, while it is easily conceivable for some students using stimulants for the treatment of ADHD to supersede their baseline cognitive ability. Finally, our particular interest is in students of the health sciences, especially medical students. There are some obvious and important moral factors that are more likely to apply to clinical students, namely, that the transition to direct clinical responsibility is immediate upon graduating, with licensed access to prescribing. Both undergraduate and postgraduate medical studies are notoriously intense and competitive, with the potential for very long clinical hours, stress,29 and the need to achieve academically present long after graduation. For these reasons, most medical schools give considerable emphasis to the use of sets of professional examinations as indicators of competence and fitness to practice. Stimulant use may blur the effectiveness of such instruments as they enhance the users’ ability for focus and concentration.9 At one extreme, students who may have initially failed an exam, but who pass with the aid of stimulants and are allowed to progress in their careers, may become liabilities in future practice. More likely is a scenario where a student who uses this type of medication may rightly or wrongly be convinced that their examination success is dependent on the stimulant, which raises questions about their confidence as future medical practitioners. By abusing these drugs, students may be committing to lifelong use of stimulants to perform in the medical setting. While many medical students may gain temporary enhancement from the use of such drugs, the consequences of withdrawal and return to normal cognitive function also raises ethical questions regarding patient care. It is possible that students may return to an even lower cognitive ability once the effects of the drugs have worn off due to physiological anxiety, dependence and other cognitive side-effects of the drugs.11,13 These factors are likely to decrease their clinical judgment as well as their ability to cope with stressful situations in a medical setting.

Conclusion In conclusion, it is possible that neuroenhancement may become commonplace in the future as many drugs in development for the

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RCSIsmjstaff review treatment of disorders such as Alzheimerâ&#x20AC;&#x2122;s disease may have the potential to augment cognitive ability.26 Even current medications for cognitive enhancement are generally so ubiquitous, and well tolerated over long-term courses, that they might seem a smart choice for a struggling student. As competition becomes more intense, stimulants could seem a realistic option for improving chances of success. Nonetheless, the use of stimulants by individual medical students and healthcare professionals remains fraught with

both medical and ethical issues. Future studies into the prevalence of stimulant abuse on medical school campuses are required. Many of the current studies examining this problem make use of potentially biased internet-based surveys to determine level of use and thus have limitations on the impact of their evidence. In addition, further studies exploring the ethical qualitative and quantitative impact of attention-enhancing medication on healthcare are required.

References 1.

Wilens T, Adler L, Adams J, Sgambati S, Rotrosen J, Sawtelle R. Misuse and diversion of stimulants prescribed for ADHD: a systematic review of the literature. J Am Acad Child Adolesc Psychiatry. 2008;47(1):21-31.

Schwarz A. Risky rise of the good grade pill. The New York Times. 2012 June.

Abikoff H, Hechtman L, Klein R et al. Symptomatic improvement in children with ADHD treated with long-term methylphenidate and multimodal psychosocial treatment. J Am Acad Child Adolesc Psychiatry. 2004;43(7):802-11.

Feldman R, Meyer J, Quenzer L. Principles of Neuropsychopharmacology. Sunderland: Sinauer Associates Inc; 1997.

Solanto V. Neuropsychopharmacological mechanisms of stimulant drug action in attention-deficit hyperactivity disorder: a review and integration. Behav Brain Res. 1998;94(1):127-52.

Kostowski W. Noradrenergic Interactions Among Central Neurotransmitters. New York: SP Medical and Scientific Books; 1980.

Arnsten A, Steere J, Hunt R. The contribution of alpha 2-noradrenergic mechanisms of prefrontal cortical cognitive function. Potential significance for attention-deficit hyperactivity disorder. Arch Gen Psychiatry. 1996;53(5):448-55.

Pliszka S, McCracken J, Maas J. Catecholamines in attention-deficit hyperactivity disorder: current perspectives. J Am Acad Child Adolesc Psychiatry. 1996;35(3):264-72.

Biederman J, Spencer T. Attention-deficit/hyperactivity disorder (ADHD) as a

15. Faraone S, Sergeant J, Gillberg C, Biederman J. The worldwide prevalence of ADHD: is it an American condition? World Psychiatry. 2003;2(2):104-33. 16. NICE-Guidelines. Attention Deficit Hyperactivity Disorder. Guidelines, NHS National Institute of Health and Clinical Excellence. 2008. 17. Goldman L, Genel M, Bezman R, Slantez PJ. Diagnosis and treatment of attention-deficit/hyperactivity disorder in children and adolescents. JAMA. 1998;279(14):1100-7. 18. Hill J, Schoener E. Age-dependent decline of attention deficit hyperactivity disorder. Am J Psychiatry. 1996;153(9):1143-6. 19. White B, Becker-Blease K, Grace-Bishop K. Stimulant medication use, misuse, and abuse in an undergraduate and graduate student sample. J Am Coll Health. 2006;54(5):261-8. 20. Taylor E, Sandberg S. Hyperactive behaviour in English schoolchildren: a questionnaire survey. J Abnorm Child Psychol. 1984;12(1):143-55. 21. McCabe S, Boyd C. Sources of prescription drugs for illicit use. Addict Behav. 2005;30(7):1342-50. 22. Jardin B, Looby A, Earleywine M. Characteristics of college students with attention-deficit hyperactivity disorder symptoms who misuse their medications. J Am Coll Health. 2011;59(5):373-7. 23. Habibzadeh A, Alizadeh M, Malek A et al. Illicit methylphenidate use among Iranian medical students: prevalence and knowledge. Drug Des Devel Ther. 2011;5:71-6. 24. UK General Medical Council. Good Medical Practice: Health [Internet]. 2012. Available from:

noradrenergic disorder. Biol Psychiatry. 1999;46(9):1234-42.

http://www.gmc-uk.org/guidance/good_medical_practice/health.asp.

10. Kollins S, MacDonald E, Cush C. Assessing the abuse potential of

25. Irish Medical Council. A Guide to Ethical Conduct and Behaviour. Dublin:

methylphenidate in nonhuman and human subjects: a review. Pharmacol Biochem Behav. 2001;68:611-27. 11. Vitiello B. Long-term effects of stimulant medications on the brain: possible relevance to the treatment of attention deficit hyperactivity disorder. J Child Adolesc Psychopharmacol. 2001;11(1):25-34. 12. Teter C, McCabe S et al. Prevalence and motives for illicit use of prescription

Irish Medical Council; 2008. 26. Forlini C, Racine E. Disagreements with implications: diverging discourses on the ethics of non-medical use of methylphenidate for performance enhancement. BMC Med Ethics. 2009;10:9. 27. Biederman J, Fried R, Petty C, Henin A, Wozniak J, Corkum L et al. Examining the association between stimulant treatment and cognitive

stimulants in an undergraduate student sample. J Am Coll Health.

outcomes across the life cycle of adults with attention-deficit/hyperactivity

2005;53(6):253-62.

disorder: a controlled cross-sectional study. J Nerv Ment Dis.

13. NIoD. NIDA InfoFacts: Methylphenidate (Ritalin) [Internet] 2012. [cited 2012]. Available from: http://www.drugabuse.gov/publications/drugfacts/ stimulant-adhd-medications-methylphenidate-amphetamines. 14. Ferreira R, Bassi G, Cabral A, Nobre M. Withdrawal from methylphenidate

2012;200(1):69-75. 28. Butcher J. Cognitive enhancement raises ethical concerns. Lancet. 2003;362(9378):132-3. 29. Chang E, Eddins-Folensbee F, Coverdale J. Survey of the prevalence of

increases neural reactivity of dorsal midbrain. Neurosci Res.

burnout, stress, depression, and the use of supports by medical students at

2010;68(4):290-300.

one school. Acad Psychiatry. 2012;36(3):177-82.

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RCSIsmjstaff review Modulating the cystic fibrosis transmembrane regulator – breaking the basic defects Abstract The defective allele responsible for cystic fibrosis (CF) is found in one in 19 people in Ireland. Historically, treatment of CF comprised ameliorating patient symptoms, but recently there has been much progress in CF therapy, not least of which are the CFTR gene modulators. These target specific basic defects in the disease: that of deficient or abnormal synthesis; and, processing of the CFTR channel, thus treating the disease, for the first time, systemically. These compounds have implications for targeted CF therapy and mark a large step forward in the field. So far, three targets have been overcome, with varying degrees of success. There are six mutation classes in CF; Class I is most severe, but patient presentation depends on the specific combination of alleles. Kalydeco was developed for the class III G551D mutation, and demonstrated efficacy in homozygous patients, but the high cost of the drug remains an issue. Lumacaftor and VX-661 were developed to address the ΔF508 Class II mutation; lumacaftor was effective when used in conjunction with Kalydeco, and VX-661 is as yet undergoing trials. Lastly, investigations are ongoing to assess Ataluren as a modulator of the effects of the premature termination codons caused by Class I CF mutations; two of three phase II studies showed varied improvement in patient symptoms following treatment with Ataluren and a phase III trial is currently underway. This article discusses the progress in CF-modulating therapy hitherto. Royal College of Surgeons in Ireland Student Medical Journal 2013; 6(1): 79-83.

Introduction

Ramia Jameel

1 2

Dr Emer Reeves

Dr David Bergin

Prof. Gerry McElvaney 1

RCSI medical student

Department of Medicine, RCSI, Beaumont Hospital, Dublin 9, Ireland

Cystic fibrosis (CF) is a disorder that results from mutations in the cystic fibrosis transmembrane regulator (CFTR) gene. It causes a build-up of mucus with resulting cycles of inflammation and infection, and primarily affects the lungs and digestive system.2 The disease was so named due to the cyst formation in the pancreas after pancreatic ducts became blocked in the course of the disease’s pathology. The disorder is also termed mucoviscidosis as a result of the thick mucus that plugs the airways in its pulmonary pathology. It has even been dubbed ‘65 roses’ by those patients too young to pronounce its name or understand its significance (Figure 1). CF is a multisystemic hereditary disease with protean manifestations and an autosomal recessive pattern of inheritance. Since the discovery of the CFTR gene in 1989,3 hopes of clinicians and researchers have been focused towards the time when knowledge of its effects could be built upon to cure CF, but until just three years ago there had been no significant progress.

CF has particular importance in Ireland, where 2.98 in 10,000 individuals have CF and one in 19 of the population is a carrier of a defective CFTR allele.4 The incidence of CF in Ireland is the highest in the world – nearly four times the rate in other European countries and in the USA.4 Reflecting this, much work has been done in Ireland directed towards individuals with the disease, ranging from the RCSI Department of Medicine’s significant participation in the CF therapy trial of VX-7705 to the building of dedicated CF centres in hospitals nationwide.6 To date, the majority of treatment for CF has been symptomatic, not curative, involving the use of hypertonic saline, dornase alfa, pancreatic enzymes, albuterol and inhaled antibiotics.7 These are given to improve airway surface liquid volume, break down mucus build-up, aid nutrient absorption in the gastrointestinal tract, relax bronchial muscle, and prevent and combat infection. Life expectancy for CF patients has increased and is now approaching 40 years,8 and

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RCSIsmj staff review

FIGURE 1: ‘65 roses’ is how some young patients first learn to say ‘cystic fibrosis’.1

FIGURE 2: CFTR mutation classes and common mutations. Mutation class correlates more closely to pancreatic function than to pulmonary pathology.9,15

exciting new developments are underway as more discoveries are being made with regard to the gene and its effects. Mutation-specific CFTR-modulating therapy is among these advances along with gene therapy and newer, more effective antimicrobials. This article discusses the upcoming therapeutic CFTR modulators.

The presentations of CFTR mutation classes I-VI (Figure 2) range from most severe to sub-clinical, respectively: n Class I mutations result in a premature termination codon (PTC). This causes the production of a truncated form of CFTR that is degraded before it reaches the plasma membrane – thus it results in a complete absence of CFTR on the membrane.9 n Class II mutations include the most common ΔF508 mutation. This class causes abnormal post-translational modifications to the complete protein – in this class, too, the mutated protein is degraded before it can reach the cell membrane.9 n Class III mutations result in defective regulation of CFTR channel function. This occurs due to impaired ATP binding and hydrolysis, which stops energy-dependent channels from opening. In Class III mutations there is a normal amount of CFTR on the cell membrane but it is non functional.11 A prominent example of this class is G551D (incidence of 4% worldwide, 10% in Ireland).12 It is the second most prevalent mutation in Ireland.13 The G551D mutation has recently received much media attention as its respective modulator treatment, Kalydeco, was, as of January 2012, approved by the FDA for use after an accelerated Phase III trial.14 n Class IV mutations lead to a defective CFTR channel pore. These mutations result in decreased protein function, and include the relatively common R117H mutation.9 n Class V mutations cause a reduced amount of functional CFTR protein to be present at the membrane.9 n Class VI mutations cause altered regulation of channels other than the chloride channel. There is overlap of this class with other classes, such as for the ΔF508 mutation, which is both a Class II and Class VI mutation (Figure 2).9

CFTR channel and function The CFTR gene encodes for a chloride channel found in the apical membrane of secretory epithelia in respiratory, gastrointestinal, reproductive and other exocrine glands.9 Its structure consists of two transmembrane domains (of six α-helices each), two cytoplasmic nucleotide binding domains (NBDs) and a regulatory domain (R domain) containing protein kinase A and P phosphorylation sites.9 The channel through which the chloride molecules pass is formed by the two transmembrane domains.9 The CFTR protein is a member of the ATP-binding cassette (ABC) family, a group of proteins that bind ATP in order to transport molecules across cell membranes.9

The importance of CFTR – ion transport regulation One of CFTR’s main functions is to allow the exit of Cl- ions from epithelial cells into the lumen.10 However, it is a multifunctional protein and many of its additional functions have only recently been described. In addition to facilitating chloride transport, CFTR also regulates transport of ions such as Na+ and CO3-, predominantly through interactions involving its NBD.9 Thus, normal CFTR function is essential on several levels to prevent duct blockage, mucous build-up, infection and inflammation.

Mutation classes Many of CF’s clinical presentations result from the varied effects on ion conductance. The severity of the disease, in turn, depends upon the extent to which CFTR function is impaired.9 There are six classes of CFTR mutation based on their effects on the CFTR protein.9 The CFTR modulators are an attempt at treatment specific to mutation class, and thus understanding these mutations is key to understanding many of the ongoing therapeutic advances in the disease.

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The phenotypic presentation of these mutations depends upon the combination of an individual’s alleles. If both the alleles are of the more severe genotypes (classes I-III), the individual is likely to present with the classic CF phenotype, i.e., pancreatic insufficiency, gastrointestinal symptoms and sinopulmonary infections.9

RCSIsmj staff review Correcting and potentiating CFTR Drugs that correct the problem of early degradation (as in Class I) are called CFTR ‘correctors’.11 Those that correct aberrant trafficking or gating of the channels once at the membrane (as in Classes II and III) are known as CFTR ‘potentiators’ (Figure 3).11 Three different mutation targets are currently being addressed by two pharmaceutical companies: 1. PTC124 (Ataluren) by PTC Therapeutics,7,8 to overcome Class I mutations that result in PTCs. 2. VX-809 (Lumacaftor) by Vertex Pharmaceuticals,7,8 to correct CFTR trafficking defects in Class II mutations. 3. VX-770 (Kalydeco/ivacaftor), also being developed by Vertex Pharmaceuticals,7,8 which potentiates CFTR at the membrane in Class III mutations. PTC suppression and correction of aberrant CFTR trafficking are both more difficult objectives to reach as they involve modulation issues on several levels: n PTCs can result from several mutations, which need to be targeted individually; n restoration of translation is also required; and, n the functional protein must then be trafficked to the cell membrane. The three upcoming treatments are discussed here in order of discovery, which also (understandably) reflected the targeting of the least to most severe class.

Kalydeco – potentiating at the plasma membrane The story of the first CFTR-modulating drug to be approved in the therapy of CF, Kalydeco (also known as VX-770 and ivacaftor), is an interesting one. This compound was a result of a commitment on the part of the Cystic Fibrosis Foundation to, based on the knowledge of CFTR accumulated to date, treat CF as a multisystem disorder and to invest in the search for new therapies targeting basic CFTR defects.16 A collaboration with Vertex Pharmaceuticals led to high-throughput screening with CF lines to evaluate 228,000 molecules, from which VX-770 was discovered.16 It demonstrated ability to potentiate CFTR in homozygous G551D (Class III) and heterozygous G551D/ΔF508 (ΔF508 being of Class II) mutations. The exact mechanism by which Kalydeco exerts its effects is as yet unknown, but it has demonstrated positive results in all its pivotal studies to date: one Phase II and two Phase III trials.17,18 It resulted in notable and sustained improvements in forced expiratory volume in one second (FEV1), which, it has been noted, is “the most well studied and validated surrogate end point for patients with cystic fibrosis and reflects airways obstruction”.16 A 10.6% increase in FEV1 from baseline was demonstrated as compared with placebo, as well as improved sweat chloride levels and nasal potential difference (NPD); the latter reflects chloride transport.18 However, it would be valuable to measure quantitative chest imaging and lung clearance index in future investigations as they have been noted to be more sensitive as measures of pulmonary disease in CF.16 Accurso et al. conducted a two-part Phase II trial evaluating Kalydeco’s

FIGURE 3: Targets of upcoming drugs.2

safety.17 The adverse events profile of Kalydeco was similar to placebo, with serious adverse events being fewer in the treatment group (24% vs. 42%).17 Ramsey et al.’s Phase III STRIVE study of 2011 was conducted in patients over 12 years old. It demonstrated a significant increase in FEV1, a decrease in sweat chloride levels (some out of the threshold of CF diagnostic), a decrease in pulmonary exacerbation rate and an increase in weight from baseline.18 This study was followed by the two-year-long PERSIST open-label study, in which the long-term safety and efficacy of Kalydeco were examined; the benefits of the drug remained significant.19 The ENVISION study in six- to 11-year-olds demonstrated that Kalydeco was also safe and effective for this age group.20 The weight gain in these trials’ results remains unexplained and warrants further investigation – postulations include that improvement in CFTR function in the digestive tract may augment nutritional absorption.7 Although Kalydeco is a potentiator, it has its use in patients with the ΔF508 mutation. On its own it has no efficacy in ΔF508 homozygous patients21 but trials are ongoing to investigate its efficacy when combined with other CFTR modulators. Further research gaps include the appropriateness of its use for other Class III (gating) mutations, for patients two to five years old, and for patients with one or more copies of the Class IV R117H mutation.7 Kalydeco, approved by the FDA in January 2012, costs $294,000 per year for its twice-daily regimen, though Vertex Pharmaceuticals has programmes that allow patients with no insurance and a household income of less than $150,000 per year to obtain the drug for free. Those with insurance can receive up to 30% of the drug’s list price.22 After being approved by the European Medicines Agency in July of this year for individuals over the age of six years with at least one copy of the G551D mutation,21 Kalydeco is currently being reviewed for use in Ireland by the drug regulatory authorities.23 Kalydeco was approved by the Irish Minister for Health, Dr James Reilly, in February 2013.24

Correcting ΔF508 – Lumacaftor and VX-661 Class II mutations result in abnormal CFTR folding and degradation of the protein before it reaches the cell membrane. The ΔF508 mutation, the most common mutation in Ireland (found in approximately 66% of CF patients)25,26 belongs to this class. There is no CFTR present on the cell membrane as a consequence of homozygous ΔF508

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RCSIsmjstaff review mutations. Class II mutations therefore require more regulation – they require a correctly formed protein to be produced as well as translocation of the CFTR channel to the cell surface. Due to the hypothesis that there may be residual defective ΔF508 CFTR at the membrane, Kalydeco was trialled in isolation for patients homozygous for the ΔF508 mutation but, as discussed, did not prove clinically effective. A Phase II randomised controlled trial (RCT) in a similar group was conducted for VX-809, also known as Lumacaftor, and it demonstrated safety and modest efficacy in reducing sweat chloride, and concluded that Lumacaftor is a viable candidate for further investigation.25 A Phase II RCT investigating the combined effect of Lumacaftor and Kalydeco was conducted in 2011. In combination, the two drugs work together to remedy the defect: Lumacaftor corrects the folding and processing of CFTR and thus aids in transporting the protein to the membrane, and Kalydeco then supports its function.2 The 62-participant study concluded that the combination improved CFTR function significantly in patients homozygous for the ΔF508 mutation and recommended further clinical investigation.27 In June 2012, the results of a second part of that combination trial were announced, enrolling 109 people over 18 years of age. Improvement in pulmonary function was dose dependent, with those who received the greatest dose of VX-809 demonstrating most improvement, and homozygous individuals benefiting more than heterozygotes. A pivotal trial of the Kalydeco–VX-809 combination is planned for homozygous and heterozygous ΔF508 CF patients in 2013.28 Another drug is being investigated called VX-661, which is postulated to increase CFTR trafficking to the membrane in the ΔF508 mutation.8 An exploratory Phase II clinical trial is in progress to evaluate the safety and effects of VX-661 alone and in combination with Kalydeco. The study is due to be completed in August 2013.29

Terminating PTCs – Ataluren Class I comprises the most severe forms of mutation and represents 10% of CF genotypes.7 It consists of nonsense mutations that cause the production of a truncated or unstable form of CFTR, which is detected by chaperone proteins at the ER and degraded before it reaches the cell surface. This class is associated with complete lack of CFTR protein at the apical membrane of epithelial cells. G542X is the most common of these mutations.2 Gene therapy and aminoglycosides such as gentamicin30,31,32 are currently being investigated for a therapeutic approach to Class I mutations.33 Aminoglycosides allow the attachment of a near-cognate tRNA to the defective template, allowing a full-length protein to be produced. This

has been shown to be efficacious in vitro, in animal studies of CF and muscular dystrophy, and in small numbers of CF patients.8 Of more relevance to this discussion of CFTR modulators, an orally bioavailable non-glycoside compound specifically developed to promote ribosomal read-through of nonsense mutations is under review, designated PTC124 and also known as Ataluren.34 Ataluren binds to eukaryotic ribosomes and suppresses PTCs in cell- and animal-based disease models. There have been three randomised open-label dose-ascending Phase II trials in CF. The results of all showed tolerability to Ataluren in the short term. Improved function of CFTR (measured by NPD) was seen in two.8 One study showed that CFTR localisation to the nasal cell membrane was improved, and another’s results demonstrated a reduction in cough over three months.35,36 However, the third study did not demonstrate an improvement in NPD and limitations of all studies included the small sample size and lack of placebo controls.15 Concerns about Ataluren include its potential to permit oncotic change, as its read-through capabilities could potentially allow native mutations to go undetected.7 Adherence may also be an issue, as the medication needs to be taken thrice daily.7 A Phase III RCT is in progress to determine the drug’s safety, efficacy and tolerability for the duration of 48 weeks, to be completed in October 2012.37

Conclusion The advances made in CF therapeutics are many and encouraging, but several questions remain to be answered. The long-term efficacy of these medications is yet to be elucidated and more than 1,600 disease-associated mutations3 have to be tackled before CF can be known as a curable disease. These drugs also provide the hope that the damage CF can cause can be stopped in its early stages. Use of Kalydeco has improved quality of life, for those who can afford it, with decreased cough and sputum production and a reduced burden from conventional treatment. Progressive lung disease and premature death do not seem as imminent with the advent of such potentially curative therapies, though longer-term studies remain to be conducted. The issue also arises as to whether investment should focus solely on the G551D patients by subsidising the drug or whether interventions catering for all CF patients should be allocated the limited healthcare budget – the ever-present ‘distribution problem’.38 It remains to be seen whether PTC- and ΔF508-targeting modulators are potent enough to have clinical effectiveness. Despite, or even because of, these uncertainties, CFTR modulators, coupled with the introduction of newborn screening in Ireland in July 2011,39 highlight the area of CF therapy as one to watch in the near future.

References 1.

Flickr.com. Purple Rose by wenzday01 [image on Internet]. Accessed from:

http://www.flickr.com/photos/wenzday01/5018527216/. 2.

gene: cloning and characterisation of complementary DNA. Science.

Ashlock MA, Beall RJ, Hamblett NM, Konstan MW, Penland CM, Ramsey BW et al. A pipeline of therapies for cystic fibrosis. Semin Respir Crit Care Med. 2009;30(5):611-26.

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Riordan JR, Rommens JM, Kerem B et al. Identification of the cystic fibrosis 1989;245(4922):1066-73.

Farrell PM. The prevalence of cystic fibrosis in the European Union. J Cyst Fibros. 2008;7(5):450-3.

RCSIsmj staff review 5.

Beaumont Hospital. Beaumont Hospital Annual Report 2010. Beaumont Hospital, Dublin, Ireland [cited 2012 Aug 26]. Available from: http://www.beaumont.ie/media/Beaumont_Hospital_Annual_Report_201 01.pdf.

6. 7.

VX-809, an investigational CFTR corrector compound, in subjects with

Centre Updates. Spectrum. 2012;28:2.

cystic fibrosis homozygous for the ΔF508-CFTR mutation. Thorax.

Pettit RS. Cystic fibrosis transmembrane conductance regulator-modifying 2012;46(7-8):1065-75.

http://www.irishtimes.com/newspaper/breaking/2013/0202/breaking5.html. 25. Clancy JP, Rowe SM, Accurso FJ et al. Results of a phase IIa study of

CF Ireland. Cystic Fibrosis Unit in St Vincent’s University Hospital Open. CF

medications: the future of cystic fibrosis treatment. Ann Pharmacother. 8.

Ireland. Spectrum. 2012;28:10. 24. Irish Times. February 2013. Available at:

Kumar V, Abbas AK, Fausto N, Aster JC. Robbins and Cotran Pathologic

2012;67(1):12-18. 26. Lommatzsch ST, Aris R. Genetics of cystic fibrosis. Semin Respir Crit Care Med. 2009;30(5):531-8. 27. Boyle MP, Bell S, Konstan MW, McColley SA, Wisseh S, Spencer-Green G.

Basis of Desease (8th ed.). Philadelphia: Saunders; 2010:465-70.

VX-809, an investigational CFTR corrector, in combination with VX-770, an

Greger R, Schreiber R, Mall M et al. Cystic fibrosis and CFTR. Pflugers Arch

investigational CFTR potentiator, in subjects with CF and homozygous for

2001;443(Suppl 1):S3-7. 10. Kerem E. Mutation-specific therapy in cystic fibrosis. Eur J Respir Dis. 2008;4(1):41-4. 11. The Cystic Fibrosis Association of Ireland. European Medicines Board approves Kalydeco (formerly known as VX770 – also known as ivacaftor) [Internet] [cited 2012 Sept 29]. Available from: http://www.cfireland.ie/index.php/news/14-mainarticles/196-update-kalyde co-vx770-gets-european-approval. 12. Vertex Pharmaceuticals. Ethnic and geographic patterns of CFTR mutations. CFTR Science [updated 2011; cited 2012 Aug 26]. Available from: https://www.cftrscience.com/epidemiology.php. 13. Ledford H. Drug bests cystic fibrosis mutation. Nature. 2012;482(7384):145. 14. Boyle M. Do these patients have CF? Recognising and diagnosing late presentations of cystic fibrosis [presentation slides]. Johns Hopkins Medicine Continuing Medical Education Session, 35th ECFS Conference, Dublin, Ireland, 2012. 15. Clancy JP, Jain M. Personalised medicine in cystic fibrosis: dawning of a new era. Am J Respir Crit Care Med. June 21, 2012 [Epub ahead of print]. 16. Sanders DB, Farrell PM. Transformative mutation-specific pharmacotherapy for cystic fibrosis. BMJ. 2012;344:e79. 17. Accurso FJ, Rowe SM, Clancy JP et al. Effect of VX-770 in persons with cystic fibrosis and the G551D-CFTR mutation. N Engl J Med. 2010;363(21):1991-2003. 18. Ramsey BW, Davies J, McElvaney NG et al. A CFTR potentiator in patients

the ΔF508-CFTR mutation (abstract) Pediatr Pulmonol. 2011;(Suppl 34):287. 28. Cystic Fibrosis Foundation. Final Results from Phase 2 Combination Study of Kalydeco and VX-809 show significant improvements in lung function [updated 2012 Jun 28; cited 2012 Aug 26]. Available from: http://www.cff.org/aboutCFFoundation/NewsEvents/2012NewsArchive/6 -28-Final-Results-Phase-2-Kalydeco-and-VX-809.cfm. 29. Vertex Pharmaceutical Incorporated. Study of VX-661 alone and in combination with VX-770 in subjects homozygous to the ΔF508-CFTR mutation. ClinicalTrials.gov [updated 2012 Aug 23; cited 2012 Aug 27]. Available from: http://www.clinicaltrials.gov/ct2/ show/NCT01531673?term=vertex+661&rank=1. 30. Bedwell DM, Kaenjak A, Benos DJ et al. Suppression of a CFTR premature stop mutation in a bronchial epithelial cell line. Nat Med. 1997;3(11):1280-4. 31. Wilschanski M, Yahav Y, Yaacov Y et al. Gentamicin-induced correction of CFTR function in patients with cystic fibrosis and CFTR stop mutations. N Engl J Med. 2003;349(15):1433-41. 32. Rowe SM, Clancy JP. Pharmaceuticals targeting nonsense mutations in genetic diseases: progress in development. BioDrugs. 2009;23(3):165-74. 33. Rowntree RK, Harris A. The phenotypic consequences of CFTR mutations. Ann Hum Genet. 2003;67(Pt 5):471-85. 34. Welch EM, Barton ER, Zhuo J et al. PTC124 targets genetic disorders caused by nonsense mutations. Nature. 2007;447(7140):87-91. 35. Sermet-Gaudelus I, Boeck KD, Casimir GJ et al. Ataluren (PTC124)

with cystic fibrosis and the G551D mutation. N Engl J Med.

induces cystic fibrosis transmembrane conductance regulator protein

2011;365(18):1663-72.

expression and activity in children with nonsense mutation cystic fibrosis.

19. McKone EF, Borowitz D, Drevinek P et al. Long-term safety and efficacy of investigational CFTR potentiator, VX-770, in subjects with CF (abstract). Pediatr Pulmonol. 2011;(Suppl 34):284. 20. Aherns R, Rodriguez S, Yen K, Davies JC. VX-770 in subjects six to 11 years with cystic fibrosis and the G551D-CFTR mutation (abstract). Pediatr Pulmonol. 2011;(suppl 34):283. 21. Flume PA, Liou TG, Borowitz DS et al. Ivacaftor in subjects with cystic fibrosis who are homozygous for the ΔF508-CFTR mutation. Chest. 2012 Mar 1 [Epub ahead of print]. 22. Gever J. FDA approves cystic fibrosis drug. MedPage Today [updated 2012 Jan 31; cited 2012 Aug 26]. Available from: www.medpagetoday.com/Pulmonology/CysticFibrosis/30936. 23. CFAI. Letter from CFAI: Re Kalydeco To the Drug Regulatory Authorities in

Am J Respir Crit Care Med. 2010;182(10):1262-72. 36. Kerem E, Hirawat S, Armoni S et al. Effectiveness of PTC124 treatment of cystic fibrosis caused by nonsense mutations: a prospective phase II trial. Lancet. 2008;372(9640):719-27. 37. PTC Therapeutics. Study of Ataluren (PTC124™) in cystic fibrosis. ClinicalTrials.gov [updated 2012 Aug 6; cited 2012 Aug 26]. Available from: http://clinicaltrials.gov/ct2/ show/NCT00803205?term=ataluren&rank=5. 38. Hope T. Medical Ethics: A Very Short Introduction. New York: Oxford University Press; 2004. 39. HSE. Newborn Screening for Cystic Fibrosis (CF) [updated 2011 Sept 8; cited 2012 Aug 26]. Available from: http://www.hse.ie/eng/about/Who/ONMSD/practicedevel.

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RCSIsmj staff review Female genital mutilation and the healthcare professional in Ireland Abstract Female genital mutilation (FGM) involves the cutting and/or suturing of a girl or womanâ&#x20AC;&#x2122;s external genitalia for varying cultural reasons. It may result in serious long-term physical and mental health sequelae, and has an estimated worldwide prevalence of between 100 and 140 million females. It is practised to varying degrees in parts of Africa, the Middle East and South-East Asia. It has recently become an issue in Ireland due to immigration from these areas, with an estimated 2,500 women and girls in Ireland living with FGM. The United Nations, Amnesty International and other human rights and advocacy groups consider FGM a serious violation of women and girlsâ&#x20AC;&#x2122; human rights, including the rights to life, health and physical integrity. Ireland recently passed a bill outlawing the practice of FGM, as well as the removal of women and children outside the country for the purposes of conducting FGM. The ethical issues healthcare professionals may encounter when treating patients who have undergone FGM include requests for reinfibulation post partum, requests to perform FGM on the daughters of parents from cultural groups where it is practised, and requests by consenting women to perform FGM on themselves. The WHO and other international health organisations reject any involvement in FGM by healthcare professionals. Healthcare professionals should be well informed regarding this issue to provide the best care for patients, both medically and culturally. Royal College of Surgeons in Ireland Student Medical Journal 2013; 6(1): 84-8.

Elizabeth Ahern-Flynn RCSI medical student

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RCSIsmjstaff review Table 1: WHO classification of female genital mutilation.

Type I

Partial or total removal of the clitoris and/or the prepuce (clitoridectomy).

Type II

Partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora (excision).

Type lll

Narrowing of the vaginal orifice with creation of a covering seal by cutting and appositioning the labia minora and/or the labia majora, with or without excision of the clitoris (infibulation).

Less than 10% 10.1%–25%

Type IV

All other harmful procedures to the female

25.1%–50%

genitalia for non-medical purposes, for

50.1%–75%

example pricking, piercing, incising, scraping

75/1% or more

and cauterisation.

missing data or FGM not widely practised

FIGURE 1: Prevalence of female genital mutilation in Africa and Yemen (women aged 15-49). Source: MICS, DHS and other national surveys, 1997-2006. Map developed by UNICEF, 2007.

Introduction The road to women’s liberty and bodily autonomy has been paved with traditional notions of women’s roles as homemaker and child-rearer, their duties to their husbands, and attempts to subvert their femininity in order to deny them their freedom and sexuality. Several waves of feminism in Ireland have culminated in relative equality between men and women in terms of voting rights, employment law, availability of contraception and societal regard.1 A growing challenge of increasing importance facing certain groups of women in Ireland is female genital mutilation (FGM), as immigration from countries in which FGM is routinely practised increases. This article will discuss the measures the Irish State has taken to combat FGM, the role of the healthcare professional in treating women who have undergone FGM or who wish to undergo it, and the ethical issues that may arise for healthcare professionals interacting with communities in which FGM is the cultural norm.

Female genital mutilation: an introduction FGM is defined by the World Health Organisation (WHO) as “all procedures involving partial or total removal of the external female genitalia or other injury to the female genital organs for non-medical reasons”2 (Table 1), and is usually carried out between birth and 15 years of age. Irish law defines FGM as “any

act the purpose of which, or the effect of which, is the excision, infibulation or other mutilation of the whole or any part of the labia majora, labia minora, prepuce of the clitoris, clitoris or vagina of a girl or woman”.3 FGM is recognised internationally as violating the human rights of women and girls.2 The WHO estimates that between 100 and 140 million women and girls worldwide have undergone some form of FGM2 and AkiDwA, the Irish migrant women’s network, estimates that more than 2,500 women in Ireland may be living with FGM, although this figure may be an underestimation due to reluctance of some to participate in the census.4 As FGM is a culturally bound and values-laden practice, the terminology used when discussing it with patients can have powerful connotations. The WHO uses the term “mutilation” to emphasise the gravity of the act; however, this has been criticised as stigmatising women who have undergone FGM who do not think of themselves as mutilated or their families as mutilators.2,5,6 “Female genital cutting”, “circumcision” and “closed” are terms that may be used in lieu of “female genital mutilation” when speaking with patients.4,6 FGM is primarily carried out in North-Western and North-Eastern African countries and certain parts of the Middle East and South East Asia (Figure 1).

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RCSIsmjstaff review Table 2: Reasons for the practice of FGM put forth by AKiDwa and Dr Fuambai Ahmadu.

Table 3: Short and long-term complications of FGM.4

Why FGM is practised

complications of FGM can

The short-term

include: 1 Tradition.

n injury or trauma to adjoining areas, such as the

2 Rite of passage into womanhood.

urethra and anus; n infection and failure of the

3 Religion (practiced by Christians, Jews, Muslims and tribal religions in Africa, although none of these religions specifically require it and the practice of FGM pre-dates these religions).

wound to heal; n haemorrhage, which may lead to shock; n transmission of HIV and

4 Preservation of virginity until marriage. 5 Social acceptance (among peers, as well as for marriage).

other viruses; and, n death.

The long-term complications of FGM can include: n psychological trauma; n dyspareunia (painful intercourse); n decrease or loss of sexual sensation; n dysmenorrhoea; n difficult and complicated childbirth; n incontinence or difficulty urinating; n pelvic inflammatory disease (PID) and infertility; n scarring, causing constant

6 Cultural and aesthetic reasons.

pain around the genital area; and,

7 Removal of the clitoral tissue is intended to reduce sexual

n sebaceous cyst development.

pleasure and thereby reduce promiscuity among women.

The reasons behind the practice of FGM are varied, but all are a function of gender inequality, rooted in male-dominated systems that seek to control and suppress women’s power over their body and sexuality to preserve male dominance and power in the cultures in which it is practised.2,4,7 A joint paper by AkiDwA and the Royal College of Surgeons in Ireland (RCSI) identifies six key reasons FGM is continued4 and Dr Fuambai Ahmadu of Sierra Leone, a post-doctoral fellow at the University of Chicago, and proponent and advocate of FGM, identifies another (Table 2). Ahmadu argues that the type of FGM in which clitoral tissue is removed spares 75% of the clitoris, leaving behind a dense network of nerves that allows a woman to experience sexual pleasure.8 Women may be ostracised from their communities and considered unmarriageable if they do not undergo the procedure.2 In many countries where FGM is performed, women are excluded from positions of power and economic independence, and so marriage is crucial to survive in society. Parents are therefore eager for their daughters to be considered marriageable and this, combined with a lack of appreciation of the negative health consequences of FGM (Table 3), contributes to the perpetuation of the practice in these countries.2,4 Although the potential short- and long-term complications of FGM may cause profound morbidity and mortality, there is very little evidence regarding the prevalence of these complications. One review concludes that medical complications of FGM are the exception rather than the rule,9 and another finds large disparities

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between the reported rates of complications, as well as no clear pattern of a lower frequency of long-term complications among less severe forms of FGM.10

Ireland’s response to FGM In 2007 the Irish Medical Organisation (IMO) called for doctors who encounter FGM to report it to the relevant authorities, although no legislation specifically against FGM had been enacted at that time.11 Although there have been no confirmed cases of FGM taking place in Ireland to date,8,12 the Irish Government has taken the proactive step of enacting specific legislation prohibiting the practice. In March 2012 the Seanad passed the Criminal Justice (Female Genital Mutilation) Bill, which prohibits the practice of FGM anywhere in the country, and specifically identifies parental consent, consent of the girl or woman in question, and customary or ritual reasons as insufficient defence for the practice. Under this new bill it will be illegal for an Irish citizen, or a person ordinarily residing in Ireland, to remove a girl from the country for the purposes of carrying out FGM and, should this occur, they would be subject to criminal proceedings upon returning to Ireland. Violation of this law can be punished with up to 14 years’ imprisonment as well as potentially a fine. This piece of legislation clearly represents the Irish Government’s condemnation of FGM and commitment to preventing girls in Ireland from being subject to the practice or removed from the country for such purposes.

RCSIsmjstaff review FGM and the healthcare professional While the law protects girls and women in Ireland from future FGM, there are still those living with FGM and its sequelae, or seeking FGM, in this country as immigration to Ireland from areas where FGM is routinely practised continues.4,7,12 There are numerous circumstances under which a woman with FGM may contact a healthcare professional in Ireland. These include, but are not limited to, seeking maternity services, seeking FGM for themselves or their daughters, help due to medical complications of FGM, and domestic abuse.4 Healthcare professionals, therefore, must be well equipped to deal with the issue of FGM and its sequelae by being aware of the numerous ethical issues surrounding FGM, the requests they may receive from women who have undergone FGM and their families, and the communication skills necessary to address these issues with understanding and cultural sensitivity. Dealing appropriately with established FGM, and requests for reinfibulation and performance of FGM will be discussed in turn.

Medicalisation of FGM and harm-reduction strategies ‘Medicalisation’ of FGM refers to the practice of FGM by a healthcare professional, including reinfibulation at any point in a woman’s lifetime.5 Within communities in some African countries there has been a trend towards healthcare workers carrying out FGM.10,13 The WHO is unequivocal in its position regarding the medicalisation of FGM, stating that “health professionals must never perform female genital mutilation” and recognising those who do so as violating girls’ and women’s rights to life, health and physical integrity.5 The International Federation of Gynaecology and Obstetrics (FIGO) holds a similar position; in 1994 it passed a resolution at its general assembly formally opposing “any attempt to medicalise the procedure or to allow its performance, under any circumstances, in health establishments or by health professionals”.14 Ireland’s National Plan of Action to Address FGM, an interagency committee, also rejects the medicalisation of FGM.7 The issue of medicalisation raises the moral challenge as to whether we should take measures to protect women’s and girls’ health at the expense of legitimising a harmful and misogynistic practice. The argument could be made that we allow needle exchange programmes to operate based on the pragmatic stance that the harm will never be eradicated, but should be reduced, so why then do we prevent healthcare professionals from carrying out FGM using surgical techniques and sterile equipment? Some healthcare professionals hold the utilitarian belief that medicalised FGM constitutes a safer form of FGM and thus is a legitimate harm-reduction strategy, and that medicalisation is an essential step in the process of full abandonment of FGM.7 However, the WHO denies that medicalised FGM is any safer than if done by non-medical members of the community, and that there is no evidence to suggest that medicalisation has an effect on abandonment of the practice.7 They further argue that the medicalisation of FGM legitimises the practice and may give the

impression of its being medically beneficial for girls, as healthcare professionals often hold positions of power and authority in society.7 In their view, the principled argument for upholding the rights of girls and women supersedes any argument for medicalisation. Shell-Duncan et al. argue that medicalisation leads to a substantial reduction in post-FGM complications and so medicalisation provides an acceptable and appropriate course of action where cultures are not yet willing to abandon the practice.10 However, this analysis may not be as valid when applied to rejecting medicalisation of FGM in Western cultures, as the cultural impetus to perform FGM may not be as strong because it is confined to minority cultures, and attempts to promote eradication may be more successful. Studies investigating the success of promoting abandonment of FGM are lacking but would be helpful in guiding further policy on medicalisation. The case for respecting and facilitating cultural customs and practices has also been made by healthcare professionals to defend their involvement in FGM. However, both the WHO and Irish law maintain that preservation of cultural practice is insufficient grounds for contravening the human rights of girls and women by allowing FGM to be carried out, as their bodily autonomy, one of the most fundamental principles of medical ethics, takes precedence over cultural norms.3,7

FGM and consent Healthcare professionals may find that they are requested to reinfibulate a post-partum woman who had been deinfibulated in order to give birth. In this circumstance the request is likely to be made by a consenting adult who is exercising her right to bodily autonomy. By requesting this of the healthcare professional, the case for preserving her rights to health and physical integrity becomes more challenging as she has provided consent. In such instance, does the medical professional have legitimate grounds to perform a re-infibulation at the woman’s request, and further to this, may a healthcare professional ethically perform FGM on an adult, consenting woman? There is another question: does the doctor have an ethical obligation to perform the procedure at the woman’s request, despite the law being against them? The recent Irish FGM Bill prohibits any form of FGM, even if the woman has given consent.3 This may seem at odds with the traditional liberal values of states allowing their citizens control over their bodies provided that such control harms no other person. It may be noted that while FGM is criticised as an expression of society controlling women’s bodies, to specifically legislate against women consenting to this practice is also denying them agency and choice, the main principles on which feminism is based, and which generations of women have fought for. This problematic inconsistency has been criticised by some as a function of cultural imperialism by Western liberal democracies, as Western countries have been the most vocal in condemning FGM and campaigning for its eradication.15 Even the term ‘female genital mutilation’ is itself implicitly condemnatory, as it casts women’s families and communities as mutilators16and implies

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RCSIsmj staff review that a woman’s agency has been violated. Sheldon and Wilkinson of the departments of law and philosophy at the University of Keele in the United Kingdom provide analysis of what stands as valid informed consent from a woman seeking FGM.15 They ask the question: “can a woman who is adequately informed of the possible sequelae of FGM validly consent to the procedure when the alternative is social exclusion?” They identify two forms of coercion that may render even informed consent invalid: “direct pressure” – in which women are persuaded by family and members of their community to undergo the procedure – and “indirect pressure” – where women feel compelled by deep-seated societal expectations. The issue of consent is further complicated where these pressures exist, but education about human rights and the potential sequelae of FGM are lacking.15 So in what circumstances then may we deny a woman the right to exert control over her body? Sheldon and Wilkinson argue that “when an intervention seeks to impose significant limitations on individual freedoms, such an intervention must always be carefully considered, rationally justified and fairly applied”.15 Such justification is put forward by Cook et al. in their argument that, as FGM is a socially contrived, medically unnecessary procedure (i.e., is performed for cosmetic and/or cultural reasons and provides no physical health benefit to the woman, indeed, actively harms her), it should not be given respectability by medicalisation.16 It could be argued, however, that it is socially

acceptable to perform medically unnecessary procedures such as breast augmentation or reduction, or even cosmetic genital surgeries such as labioplasty for mental health or lifestyle reasons. The crucial difference between these examples and FGM is that FGM by its very nature may result in profound physical harm to the woman, whereas the above procedures typically do not. The WHO argues that as re-infibulation recreates the same problems as the original infibulations, it is a procedure that increases the suffering of women, and so should not be performed, even at the request of a woman.5 This raises the further question, is a woman’s consent rendered invalid by potential future medical sequelae?

Conclusions and future directions A joint paper by the RCSI and AkiDwA recommends that healthcare professionals notify social workers and a public health nurse if a daughter is born to a woman who has undergone FGM.4 At the time of writing this article, the Irish Medical Council (IMC) has not issued guidelines for healthcare professionals in Ireland regarding the care of patients who have undergone FGM or who may request FGM for themselves or their daughters. Ethical guidelines issued by the IMC would be helpful in equipping healthcare professionals to address the challenges that may arise from such patients in a culturally sensitive and appropriate manner, while upholding human rights by protecting some of the most vulnerable in our society.

References 1.

Irish Statute Book. Equal Status Act 2000. Dublin: The Stationery Office; 2012.

UNAIDS, UNDP, UNECA, UNESCO, UNFPA, UNHCHR, UNHCR, UNICEF, UNIFEM, WHO. Eliminating female genital mutilation: an interagency statement. Geneva: World Health Organisation; 2008.

Irish Statute Book. Criminal Justice (Female Genital Mutilation) Act 2012. Dublin: The Stationery Office; 2012.

The Royal College of Surgeons in Ireland, AkiDwA. Female Genital Mutilation: Information for Healthcare Professionals Living in Ireland. Dublin; 2008.

UNAIDS, UNDP, UNFPA, UNHCR, UNICEF, UNIFEM, WHO, FIGO, ICN, IOM, MWIA, WCPT, WMA. Global strategy to stop healthcare providers from performing female genital mutilation. Geneva: World Health Organisation; 2010.

Odemerho BI, Baier M. Female genital cutting and the need for culturally competent communication. J Nurse Pract. 2012;8(6):452-7.

The Irish Family Planning Association. Ireland’s National Plan of Action to Address Female Genital Mutilation. Dublin: The Irish Family Planning Association; 2008.

Ahmadu F. “Ain’t I a woman too?” Challenging myths of sexual

Brunswick: Rutgers University Press; 2007:278-310. 9.

Obermeyer CM. Female genital surgeries. Med Anthropol Q. 1999;13:79-106.

10. Shell-Duncan B. The medicalisation of female “circumcision”: harm reduction or promotion of a dangerous practice? Soc Sci Med. 2001;52(7):1013-28. 11. Lynch P. Doctors urged to report female genital mutilation. Irish Medical News. 2007 Sep 9. 12. The Women’s Health Council. Female Genital Mutilation/Cutting: A Literature Review. Department of Health and Children: Dublin; 2008. 13. Njue C, Askew I. Medicalisation of female genital cutting among the Abagusii in Nyanza Province, Kenya. New York, NY, Population Council: Frontiers in Reproductive Health Program; 2004. 14. International Federation of Gynaecology and Obstetrics. Resolution on Female Genital Mutilation. (Accessed 2012 July). Available from: http://www.figo.org/projects/general_assembly_resolution_FGM. 15. Sheldon S, Wilkinson S. Female genital mutilation and cosmetic surgery: regulating non-therapeutic body modification. Bioethics. 1998;12(4):263-85. 16. Cook RJ, Dickens BM, Fathalla MF. Female genital cutting

dysfunction in circumcised women. In: Hernlund Y, Shell-Duncan B (eds.).

(mutilation/circumcision): ethical and legal dimensions. Int J Gynaecol

Transcultural Bodies: Female Genital Cutting in Global Context. New

Obstet. 2002;79(3):281-7.

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RCSIsmj staff review Sensory stimulation in the treatment of neuropsychiatric symptoms of dementia Abstract The prevalence of dementia in Ireland is predicted to more than double over the next 25 years. As this population grows, cost-effective interventions must be implemented. While pharmacological therapies are effective in slowing disease progression, especially in the case of Alzheimerâ&#x20AC;&#x2122;s disease, they are not as effective in treating neuropsychiatric symptoms. Neuropsychiatric symptoms increase healthcare costs, caregiver burden and patient comorbidities. This article explores the use of stimulation-oriented therapies to prevent and alleviate these neuropsychiatric symptoms. Interventions such as Sonas Activating Potential for Communication, cognitive stimulation therapy, aromatherapy and music therapy are promising; however, sound evidence is lacking and stronger studies must be conducted before evidence-based recommendations can be provided. Royal College of Surgeons in Ireland Student Medical Journal 2013; 6(1): 89-92.

Introduction: dementia and its role in Ireland

Tara Rajiyah RCSI medical student

Dementia is an umbrella term for all acquired diseases that cause a progressive and often irreversible decline in memory and cognitive functioning; it is characterised by both cognitive and non-cognitive symptoms.1 In Ireland, the approximately 41,740 people suffering from dementia is predicted to more than double by 2036.2,3 The current annual cost of providing informal and formal care to people with

dementia is estimated to be â&#x201A;Ź1.69 billion.2 With the ever-growing elderly population, these financial demands will only grow.2 Therefore, it is important to utilise cost-effective and efficacious dementia treatment. Dementia patients are often unable to find bearings in their current reality as a result of their memory impairment and thus become agitated. Agitation is one of the main neuropsychiatric symptoms

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RCSIsmj staff review associated with dementia and encompasses a wide array of manifestations ranging from sleep disturbances, irritability, stubbornness and excessive anger, to wandering, pacing, flailing and kicking.1 If caregivers learn to recognise the early signs of behavioural disturbances, they can calm patients and improve the quality of life for the caregiver and patient alike.4,5 While pharmacological interventions help to slow the progression of dementia,6 endeavours must also be made to treat neuropsychiatric symptoms that might arise. Non-pharmacological treatments in dementia can be classified as being emotion oriented, cognition oriented, behaviour oriented and stimulation oriented.7 Stimulation-oriented therapies aim to engage various senses and, while useful in all patients, are particularly beneficial in patients with severe dementia and neuropsychiatric symptoms.7 Many neuropsychiatric symptoms stem from problems within the environment itself.1,7 This article will explore various stimulation-oriented therapies that are used in Ireland, or could be implemented as adjunct therapy. These interventions include multisensory environments, Sonas Activating Potential for Communication (Sonas APC), cognitive stimulation therapy (CST), aromatherapy and music therapy.

Standard pharmacological approaches to dementia While no cure exists for dementia, pharmacological treatments that slow disease progression are available.8 According to the United Kingdom’s National Institute for Clinical Excellence (NICE) guidelines, Alzheimer’s disease, one of the main causes of dementia,9 can be treated with the acetylcholinesterase (AChE) inhibitors and memantine, an N-methyl-D-aspartic acid (NMDA) receptor agonist. An important consideration in the treatment of dementia is the presence of neuropsychiatric symptoms.4,10 These symptoms are associated with increased length of hospital stay and increased costs.4,10 Sink et al. (2005) conducted a systematic review and found that only the atypical antipsychotics risperidone and olanzapine were effective in the management of neuropsychiatric symptoms.4 According to a 2008 Cochrane review, the typical antipsychotic haloperidol shows a decrease in aggression among dementia patients.11 However, the extrapyramidal side effects, somnolence, and stroke risk associated with these drugs may outweigh any benefits.4,11 Therefore, non-pharmacological approaches may be of benefit in this regard.

Sensory interventions Multisensory environments Snoezelen rooms (Figure 1) have been established in some nursing homes in Ireland as well as worldwide. These multi-sensory rooms engage the senses through fibreoptic lights, touch, colours, sound, smells, and obstacles to help engage a participant’s cognitive function and perception.12,13 The environment allows patients the chance to interact with staff members and helps staff to recognise what types of stimuli might provoke neuropsychiatric symptoms.12

Page 90 | Volume 6: Number 1. 2013

Figure 1: Snoezelen Rooms engage the senses through fibreoptic lights, touch, colours, sound, smells, and obstacles to help engage a participant’s cognitive function and perception.

According to Ball et al. (2005), even after as little as 12 hours of sensory deprivation, patients develop an acute psychotic-like state. These symptoms were not responsive to medications but improved following sensory stimulation, suggesting that stimulation via Snoezelen rooms might be effective.12 However, a Cochrane systematic review performed in 2008 found that Snoezelen room sessions did not provide any effects on behaviour.13 As Snoezelen rooms are expensive to implement,12,14 require a great deal of staff attention,12,14 and have minimal supportive evidence,15 they seem to have been largely phased out in Ireland.

Sonas Activating Potential for Communication Sonas APC is a therapy that was developed 20 years ago in Ireland.16 The programme requires participants to interact and communicate with a small group of people and incorporates a signature tune, opening and closing songs, relaxing and dance music, exercise, percussion instruments, sensory stimulation, proverbs and poetry.16 People with dementia who participated in Sonas APC had improved cognitive scores, reduced depression scores, reduced activity of daily living disturbance scores and reduced communication disturbance scores compared to their baseline.16 Another study trained carers in Sonas techniques. While communication between carer and patient and carer quality of life improved after six weeks, 12-week follow-up showed that the effect was not sustained. Despite the lack of supporting evidence, Sonas APC is offered to nursing home residents across the nation and training is offered frequently in Ireland because it is inexpensive compared to similar interventions, and is readily accessible.17

Cognitive stimulation therapy CST is a form of mental exercise that has proven beneficial in patients with mild to moderate dementia.18,19,20 It incorporates both cognitive-oriented and stimulation-oriented therapies, and

RCSIsmjstaff review involves a wide range of mental exercises aimed at keeping the mind active and oriented as well as engaging memory through stimulation. Activities include discussion of past and present events, word games, puzzles, music and practical activities.18,19,20 Granzino et al. (2005) found that CST improved communication skills and cognition but had no effect on anxiety, depression or activities of daily living compared to baseline.21 The authors also found that the number needed to treat to garner an improvement in cognition and quality of life was comparable to those of anticholinesterase drugs.21 A Cochrane systematic review on CST found that while it improved quality of life, cognition and communication skills as is evidenced most readily by the Mini Mental State Examination (MMSE), no changes were seen in mood or self-care.19 Coen et al. (2011) conducted a study on the efficacy of CST on an Irish sample population in Dublin. Participants who completed CST showed increases in MMSE scores and improvements in quality of life.19,20 Currently, the Irish Health Information and Quality Authority (HIQA) advocates reminiscence and reality orientation in dementia; CST makes use of the principles of reality orientation therapy and elaborates upon them.20 However, it is unclear as to what extent CST is being practised in Ireland. Providing this service for patients being cared for in the community is a challenge. One study offered carers training in reality orientation. Patients enrolled in the study were all on anticholinesterase inhibitors. Those patients whose carers took part in CST training showed an increase in both MMSE score and Alzheimer’s disease assessment scores, while those whose carers were not enrolled in the training showed a decline in these scores over the 25 weeks.22 Based on these findings, CST likely provides a more durable effect when implemented at home than Sonas APC.22

activate memories.24 When compared to those who received regular oil massage or aromatherapy alone, dementia patients who received aromatherapy massage yielded the strongest decline in agitated behaviour.25 Fung et al. (2012) performed a meta-analysis that explored the effects of aromatherapy in dementia. This showed that aromatherapy improves cognitive functioning and decreases the frequency of neuropsychiatric symptoms.26 While the review made use of one study (Burns et al., 2011) that looked at the effects of aromatherapy in home-based practice, the study lacks power.26 Therefore, further investigation is required before recommending it to carers.

Music therapy

As 63% of people with dementia live in the community,2,3 therapies that can be facilitated by family members and carers must be established.

Both musical ability and listening to music have an effect on steroid hormones.27 Oestrogen and testosterone decrease β-amyloid, a pathological finding in Alzheimer’s disease, as well has having other neuroprotective effects against dementia disease processes.27 Fukui et al. (2012) investigated the effects of music and music therapy on 17 β-oestradiol concentrations and testosterone concentration. Therapy consists of discussing health and emotion while music entails listening to favourite songs. Music therapy incorporates aspects of both music and therapy sessions. Both music and music therapy increased 17 β-oestradiol concentrations but music therapy was the only intervention that yielded a significant increase in testosterone levels. Carers additionally reported a decrease in problematic behaviour that lasted for 24 hours after the music therapy session.27 Given the protective effect of testosterone and oestrogen, these findings might suggest that music therapy has the potential to slow disease progress in Alzheimer’s disease as well as reducing neuropsychiatric symptoms.27 Music therapy can also be used by carers to reduce agitation and apathy.7 Live music has the greatest effect on positive engagement and apathy reduction; however, it might not always be a feasible option in community care.7 Playing a patient’s favourite prerecorded songs has immediate effects on present agitation but is not found to have long-term ones.7

Aromatherapy

Discussion and conclusions

Aromatherapy is quickly becoming a mainstay for complementary and alternative therapies.22 Essential oils contain terepenes, which are absorbed through the lungs and cross the blood-brain barrier; they have cholinergic activity and act on γ-aminobutryic acid (GABA) receptors.4 Lemon balm and lavender oil are the most widely used.22 Topical application of lemon balm to a patient’s face twice a day was found to reduce physical and verbal aggression, irritability and aberrant behaviour compared to those who were treated with a placebo.24 The effects of lavender oil on behaviour were observed when diffusers were placed on either side of a patient for an hour during sleep.25 A significant reduction was seen in agitation and improvements were seen in night-time waking.25 Touch and massage can also be incorporated with aromatherapy to enhance its effects. They provide a reassuring, non-verbal form of communication and are believed to stimulate oxytocin release and

Non-pharmacological sensory approaches to dementia may help in the prevention of neuropsychiatric symptoms. They are also not accompanied by the troublesome side-effects of pharmacological agents. Sonas APC, CST, aromatherapy and music therapy, especially, demonstrated favourable effects on neuropsychiatric symptoms, reducing aggression and improving quality of life. However, while current results are promising, larger trials, more stringent protocols and comparisons to the current mainstay pharmacological treatments are necessary to ensure the efficacy of these approaches. Given the current state of evidence, sensory approaches to dementia can, at best, be recommended as adjuvants to the current standard of pharmacological and behavioural therapy. Despite the lack of conclusive literature, the 2011 NICE guideline recommends cognitive stimulation, multisensory stimulation, music therapy, aromatherapy and massage.6 Central to these

Sensory therapies at home

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RCSIsmj staff review recommendations is the focus on patient-centred management based on preferences and skills. All interventions should be carefully monitored and adapted based on the patient’s growing and evolving needs. Therefore, despite the lack of substantial evidence, the use of sensory-based therapy methods in dementia might be considered on a patient-by-patient basis.

Acknowledgements Dr Siobhan Kennelly, Consultant Physician in Medicine for the Older Person; Melissa Ryan, Liaison Nurse, CLT/Connolly Hospital Liaison Team for Older Persons Elm Green Nursing Home, Castleknock; and, Rena O’Hara, Ryevale Nursing Home.

References 1.

Howard R, Ballard C, O’Brien J, Burns A. Guidelines for the management of agitation in dementia. Int J Geriatr Psychiatry. 2001;16:714-7.

Cahill S, O’Shea E, Pierce M. Creating Excellence in Dementia Care: A

communication through multisensory stimulation. In: Jones GMM, Miesen,

Living with Dementia Research Programme, School of Social Work and

BML (eds.). Care-giving in Dementia Research and Applications. Volume 3.

Cahill S. Developing a National Dementia Strategy for Ireland. Int J Geriatr

Sink KM, Holden KF, Yaffe K. Pharmacological treatment of

Psychiatry. 2010;912-6.

Available from: http://www.sonasapc.ie/workshops/training-faq.html. 18. Spector A, Thorgrimsen L, Woods B, Royan L, Davies S, Butterworth M. Efficacy of an evidenced-based cognitive stimulation therapy programme

2005;293(5):596-608.

for people with dementia: randomised controlled trial. Br J Psychiatry.

Brodaty H, Arasaratnam C. Meta-analysis of non-pharmacological 2012;169:946-53. National Collaborating Centre for Mental Health. Dementia: supporting people with dementia and their carers in health and social care. NHS: National Institute for Health and Clinical Excellence; March 2011.

United Kingdom: Brunner-Routledge; 2004:120-37. 17. Sonas APC: training Ireland: Sonas APC Ltd [Internet]. [cited 2012 Oct 4].

neuropsychiatric symptoms of dementia: a review of the evidence. JAMA.

interventions for neuropsychiatric symptoms of dementia. Am J Psychiatry. 6.

a feasibility randomised controlled trial. Clin Rehabil. 2011;25(7):607-16. 16. Hamill R, Connors T. Sonas APC: activating the potential for

Research Review of Ireland’s National Dementia Strategy. Ireland: DSIDC’s Social Policy TCD, Irish Centre for Social Gerontology, NUIG; 2012.

multisensory stimulation to improve balance in individuals with dementia:

Kverno KS, Black BS, Nolan MT, Rabins PV. Research on treating neuropsychiatric symptoms of advanced dementia with non-pharmacological strategies 1998-2008: a systematic literature review. Int Psychogeriatr. 2009;21(5):825-43.

2003;183:248-54. 19. Woods B, Aguirre E, Spector AE, Orrell M. Cognitive stimulation to improve cognitive functioning in people with dementia. Cochrane Database Syst Rev. 2012;2:Art No. CD005562. 20. Coen RF, Flynn B, Rigney E, O’Connor E, Fitzgerald L et al. Efficacy of a cognitive stimulation therapy programme for people with dementia. Ir J Psych Med. 2001;28(3):145-47. 21. Grazino O, Zanettia O, Giacobini E, Frisoni GB, Bartorelli L, Carbone G et al. Reality orientation therapy combined with cholinesterase inhibitors in Alzheimer’s disease. Br J Psychiatry. 2005;187:450-5.

Blass DM, Rabins PV. Dementia. Annals Int Med: ITC. 2008;(4):ITC2-16.

Stephan BCM, Brayne C. Vascular factors and prevention of dementia. Int

neuropsychiatric symptoms of advanced dementia with

Rev Psychiatry. 2008;20(4):344-56.

non-pharmacological strategies; 1998-2003: a systematic literature review.

10. Wancata J, Windhaber J, Krautgartner M, Alexandrowicz R. The consequences of non-cognitive symptoms of dementia in medical hospital departments. Int J Psychiatry Med. 2003;13:248-56. 11. Lonergan E, Luxenberg J, Colford J. Haloperidol for agitation in dementia. Cochrane Database Syst Rev. 2002;2:CD002852. 12. Ball J, Haight BK. Creating a multisensory environment for dementia: the goals of a Snoezelen room. J Geront Nurs. 2005;31(10):4-10. 13. Chung JCC, Lai CKY. Snoezelen for dementia. Cochrane Database Syst Rev. 2002;4:Art.CD003152. 14. Anderson K, Bird M, MacPherson S, McDonough V, Davis T. Findings from a pilot investigation of the effectiveness of a Snoezelen room in residential care: should we be engaging our residents more? Geriatr Nurs. 2010;32(3):166-77. 15. Kiages K, Zecevic A, Orange JB, Hobson S. Potential of Snoezelen room

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22. Kverno KS, Black BS, Nolan MT, Rabins PV. Research on treating

Int Psychogeriatr. 2009;21(5):825-43. 23. Smallwood J, Brown R, Coulter F, Irvine E, Copland C. Aromatherapy and behaviour disturbances in dementia: a randomised controlled trial. Int J Geriatr Psychiatry. 2001;16:1010-13. 24. Holmes C, Hopkins V, Hensford C, MacLaughlin V, Wilkinson D, Rosenvinge H. Lavender oil as treatment for agitated behaviour in severe dementia: a placebo-controlled study. Int J Geriatr Psychiatry. 2002;17:305-8. 25. Nguyen Q, Paton C. The use of aromatherapy to treat behavioural problems in dementia. Int J Geriatr Psychiatry. 2008;23:337-46. 26. Fung JK, Tsang HWH, Chung RCK. A systematic review of the use of aromatherapy in treatment of behavioural problems in dementia. Geriatr Gereontol Int. 2012;12:372-82. 27. Fukui H, Arai A, Toyoshima K. Efficacy of music therapy in treatment for the patients with Alzheimer’s disease. Int J Alzheimer’s Dis. 2012;1-6.

RCSIsmjstaff review Why are Irish doctors emigrating? Abstract The emigration of Irish-trained doctors is not a new phenomenon, but in recent years it has begun to have a greater impact on the efficiency and stability of the Irish healthcare system. With the highest number of doctors working abroad and more than half of those working in Ireland being non-Irish nationals, this is an issue not to be taken lightly, and it has led to a critical shortage in non-consultant hospital doctor (NCHD) numbers. Causes of this problem include falling income levels in Ireland, a better workâ&#x20AC;&#x201C;life balance available abroad, excessive working hours and an uncertain career pathway, among others. Australia, New Zealand, the UK and the USA are the most attractive destinations for doctors emigrating from Ireland as they address the above issues better than Ireland does. It is critical that all involved parties, including the Health Service Executive (HSE) in Ireland, solve this problem, as further decline will have negative consequences for Irish healthcare provision.

Royal College of Surgeons in Ireland Student Medical Journal 2013; 6(1): 93-8.

Lavanya Chalikonda RCSI medical student

Volume 6: Number 1. 2013 | Page 93

RCSIsmjstaff review Introduction Since the end of the 19th century, Irish-trained doctors have been emigrating to countries outside Ireland to practise medicine.1 Ireland currently has the highest number of doctors working abroad, with 47.5% of our doctors outside the country.2 The Irish Medical Organisation (IMO), the sole representative of NCHDs in Ireland, conducted a benchmark survey in 2011, questioning NCHDs about their medical training, career intentions and current working conditions. According to the report, 61% of NCHDs rated their morale as low. The low morale among NCHDs has been blamed for difficulties in NCHD recruitment and retention by the HSE. A total of 58% of NCHDs stated that there is an insufficient number of training (as opposed to service) positions, and 74% believe that there is a lack of consultant posts. In addition, 70% of NCHDs stated that they would like to work overseas, with 60% stating that they are unlikely to return to Ireland due to the lack of consultant training posts. Other reasons for low morale that may be contributing to recruitment and retention hindrance include long working hours, difficult working conditions, and non-application of contractual entitlements, among others.3 In 2004, a questionnaire compiled by the Medical Education and Training Group and UCD was sent to 893 medical graduates of 1994 and 1999. It investigated current postings, postgraduate training, demographic characteristics and future career intentions.4 Of the 95% remaining in medical employment, 45.6% were working outside of Ireland. Findings from these and other similar studies clearly indicate that a great number of NCHDs are indeed emigrating or planning to emigrate from Ireland, and that this figure has increased in passing years.4 NCHDs are very important within the Irish health system. These are doctors who have completed their intern year and are now in postgraduate training, after which they can progress to consultant level, which is the highest rank of medical practitioner.5 Falling levels of NCHDs could result in a further increase in the already long hospital waiting lists, reduction in emergency department (ED) opening hours, and increased stress for the remaining doctors who will be under pressure to meet a growing workload. According to the Health Service Executive (HSE) in Ireland, the principal destinations of emigration for Irish medical graduates (IMGs) are Australia, New Zealand, the UK and the USA.3 The HSE must implement a strategy as to how they are going to either retain IMGs or recruit more foreign doctors to replenish the depleting numbers. This article aims to outline the reasons why IMGs are emigrating, the appeal of foreign countries to IMGs, and to suggest what can be done to either retain IMGs or attract foreign-trained graduates to Ireland.

The problem There is a considerable shortage of NCHDs in Ireland, and the number of applications for Medical Council registration is decreasing each year.6 The continuing depletion of NCHDs is now beginning to have a more profound effect on healthcare provision, in particular EDs, where there is severe overcrowding and an insufficient number

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of hospital staff.7 According to a survey conducted by the Irish Association of Emergency Medicine (IAEM), approximately 29% of the positions in EDs around the country are vacant.8 The emigration of doctors is impacting heavily on the health system in general, which may contribute to decreased efficiency, lengthy waiting lists and, consequently, increased mortality.9 One of the strategies Ireland had implemented in 2011 was the recruitment of foreign doctors, predominantly from India and Pakistan, in order to make up for the shortfall.10 However, this has a financial impact, as a substantial sum of money is spent hiring foreign-trained doctors from abroad in order to replenish the diminishing numbers.9 Ireland is currently relying on the recruitment of foreign-trained doctors in order to make up for these discrepancies.10 In 2006, it was estimated that around 54% of NCHDs working in Ireland were non-Irish nationals.11 In 2011, close to 300 doctors were recruited from India and Pakistan. In addition, the number of non EU-trained physicians increased from 972 in 2000 to approximately 4,740 in 2010.12

Reasons for emigration Working hours Working conditions contribute significantly to overall job satisfaction, and it has been found that current conditions are playing a role in emigration. This has also been noted by the HSE, which has conducted an audit on NCHD working hours for the purpose of evaluating implementation of the European Working Time Directive (EWTD).13 The EWTD was introduced in 2004, and was to be fully implemented by August 1, 2009. It dictates that workers are prohibited from working in excess of 48 hours per week with a cap of 24 consecutive hours at any one time, and are entitled to 11 hours of uninterrupted rest per day.14 In relation to NCHDs, this excludes training periods as a means to protect education, income levels, and health and safety. The HSE has yet to implement the EWTD in all workplaces across Ireland. The EU Commission has issued warnings to Ireland regarding the continued violation of the EWTD, where doctors are sometimes working in excess of 61 hours per week, with some shifts exceeding 36 hours without a break.15 The current working week is 9.00am to 5.00pm from Monday to Friday, with overtime commencing for any additional hours worked outside this time frame and on weekends, with a maximum limit for total work of 48 hours per week.16 However, due to the economic recession, many hospitals have unpredictable policies regarding payment for unrostered overtime and many NCHDs end up without compensation for time they have worked.17 Furthermore, the HSE has recently announced an extension of working hours for doctors, making it from 8.00am to 8.00pm Monday to Friday, and 8.00am to 7.00pm on weekends, hence further reducing overtime hours and, consequentially, income levels.17

Work–life balance Achieving a good work–life balance is a priority for many people, with doctors being no different. A work–life balance is very important for

RCSIsmjstaff review Table 1: A comparison of income levels between Ireland, the UK and Australia. Income per annum

Working week

Tax (single)

Ireland

€38,839-€54,746

48 hours

20% on first €32,800 41% on the remaining balance

United Kingdom

£22,412-£29,705 (€26,494-€35,116)

40 hours

20% on first £34,370 (€40,360) 40% from £34,751-£150,000 (€41,081-€177,324). 50% on income over £150,000 (€177,324)

Australia

Aus$60,000-Aus$75,000 (€46,313-€57,891)

38 hours

The first 30% of income is tax free. Remaining 70% is taxed at $3,572 + 32.5% for income levels between $37,001 and $80,000

overall health and wellbeing, not only in medicine, but in any career.18 Working excessively long hours has adverse effects on both physical and mental wellbeing. Stress, burnout and fatigue are just some of the effects that overwork has on the body.18 If subject to continuously long hours, the susceptibility to burnout increases.19 Burnout was initially used to describe the negative emotional reactions of those working in a client-based industry. It is characterised by emotional exhaustion, depersonalisation and a decreased level of personal accomplishment within one’s job.20 The Maslach Burnout Inventory (MBI) is a recognised system for measuring burnout, and has been used in extensive research for 25 years post publication.21 It evaluates all the three key features of burnout: emotional exhaustion by work; depersonalisation, where one becomes detached and aloof towards the recipients of the service; and, personal accomplishment, which involves the levels of success and competence felt at work. Doctors suffering from burnout can become detached from patients and will not experience the same level of fulfilment that they used to in their job.21 Cognitive function and clinical decision-making are also impaired, which can increase the risk of medical error.19 Over time, the burnout will not only affect the doctor but also the patient. The risk of medical errors, ill health and lower levels of patient satisfaction due to doctors’ lack of interpersonal skills are some of the effects that burnt out doctors have on patients.19 Being overworked can also lead to fatigue, stress and poor health. A study on work-related factors among Japanese paediatricians found that longer working hours, overtime and no days off contribute to job stress, while more work days without overtime and periodic breaks have the opposite effect.22 Doctors’ long working days contribute to fatigue, one of the major causes of medical error in hospitals. This is truer in the ED, where quick reaction time, sound judgment and concentration are required. Sleep deprivation and fatigue result in poor concentration levels and impaired judgment. One night of missed sleep decreases cognition by as much as 25%, with two missed nights reducing cognition by 40%. Lower levels of motivation and initiative, altered mood and reduced morale are just some of the other side-effects that can result from lack of sleep.23

According to the Clinical Indemnity Scheme there were 83,611 reported errors in 2011 (compared to 55,058 in 2007) in Irish hospitals throughout the country.24 Although medical errors happen across the world, it would contribute greatly to the quality of Irish healthcare if efforts were made to reduce these errors. Burnout is not just a factor that causes ill health; it may play a role in prompting doctors to go to a place where the workload and stress are lighter. Experiencing continuous stress, strain and fatigue, not deriving a desired amount of satisfaction from work, and both physical and emotional exhaustion, are detrimental to overall health and wellbeing. Poor working conditions, one of the reasons for emigration, are also thought to contribute to burnout.25 Australia, one of the prime destinations for Irish doctors, has been found to have the highest quality of life in the world with regard to income, housing, jobs, education, health, work–life balance and environment.26 The average working week for a doctor in Australia is 38 hours.27 As a result, these countries have increased in popularity among Irish doctors,3 with numerous job advertisements in medical newspapers such as the Irish Medical Times and the Irish Medical News.

Income levels Due to the current economic recession in Ireland, NCHDs have been subjected to cuts to their overtime pay, as well as to any bonuses or allowances, as described above.17 There are considerable discrepancies in terms of income, working hours and cost of living when comparing Ireland with Australia, the prime destination for Irish doctors, and the UK, Ireland’s closest neighbour (Table 1). In Ireland, the salary for NCHDs ranges from €38,839 to €54,746 per annum for a 48-hour working week.28 As described above, overtime is paid for hours worked outside the normal working week and at weekends.28 However, in recent times, the HSE has ceased paying unrostered overtime to NCHDs in a number of hospitals in Ireland.17 All income is taxable at 20% on the first €32,800 and 41% on the remaining balance for single taxpayers.29 In Australia, the salary is Aus$60,000-Aus$75,000 (€46,313-€57,891) for a 38-hour working week.27 The first 30% of

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RCSIsmj staff review income is tax free, while the remaining 70% is taxed at $3,572 + 32.5% for income levels between $37,001 and $80,000.27 Doctors in Australia are paid overtime for hours worked outside the 38-hour window, as well as for night shifts, weekends and public holidays. Overtime is usually double the standard rate of pay.27 In the UK, a foundation year 1 doctor earns around £22,412 (€26,494) per annum for a basic 40-hour week. This rises to £27,798 (€34,269) in foundation year 2, and up to £29,705 (€35,116) for a specialist in training.30 If they work more than 40 hours per week outside 7.00am to 7.00pm, Monday to Friday, then there is overtime pay of between 120 and 150% of basic salary.31 In the UK, tax rates are similar to that of Ireland, with 20% on all income earned below £34,370, (€40,360), 40% from £34,751-£150,000 (€41,081-€177,324), and 50% on income over £150,000.30 However, salary levels must be interpreted in light of the cost of living. In order for one to live comfortably, income levels must be in proportion to the cost of living. Dublin, although a rather expensive city, ranks lower than Australian cities such as Melbourne and Perth, and UK cities such as London and Manchester.32 However, other cities in the UK such as Glasgow and Aberdeen have a significantly lower cost of living.32 The generally higher cost of living in Australia and the UK may partially explain the higher salaries.

Career pathway Another important reason NCHDs are leaving Ireland is an uncertain career pathway.6 For doctors, postgraduate training opportunities are crucial for advancing in their career and are a basic requirement for specialisation.33 In Ireland, junior doctors can remain as juniors for more than 10 years due to a limited number of places for higher specialty training (HST) schemes.6 Many doctors state that an insufficient number of consultant posts is one of their reasons for emigrating.34 Some 62% of doctors working in Ireland had finished their medical training in ten years, but only 16% of them were in consultant posts.34 In Ireland, after graduating from medical school, a doctor must undertake one year of internship in order to gain recognition with the Irish Medical Council.5 Immediately after completing the internship year, a doctor can either apply for basic surgical training (BST), basic medical training (BMT), the GP training scheme, or spend up to a maximum of two years abroad in non-training posts before applying. But if the doctor practises for longer than two years in a non-BST/BMT post upon completing their internship, then application to a training scheme can no longer be made.5 After completing the basic training scheme, application can be made for HST. This lasts for five to six years and includes assessments to attain a Certificate of Satisfactory Completion of Specialist Training, which allows the doctor to be eligible to apply for a consultant post.5 However, the number of places for postgraduate training has increased in Ireland from a total of 1,793 posts in 2010-2011, to 2,087 posts for BST in 2011 and 2012.5 In the UK, a two-year foundation programme is taken upon graduation from medical school in order to attain registration with the General Medical Council (GMC). Following this is another two years of core

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medical or core surgical training.35 Afterwards, if the doctor wishes to, they can apply for the HST programme or specialist registrar scheme, lasting four to five years, or the GP training scheme, which is three years in duration. Following the completion of the specialist training programme, a doctor can apply for a consultant post.35 Surgical training is around 11-12 years in duration before becoming a consultant. Every year, there are about 9,000 training posts in the UK, for which 15,000 applicants apply across 60 different specialties.36 The Health Minister in Ireland, Dr James Reilly TD, stated that such an uncertain career pathway has become a huge problem in Ireland and has led to frustration among those who wish to advance in a linear manner through their medical career. At present, there are some 450 NCHDs in Ireland with contracts of indefinite duration.37 This leaves many doctors unsure as to where their career may take them next.

Consequences Medical emigration is affecting the Irish healthcare system in many ways. One key issue is waiting lists. Due to the current shortage of specialists, waiting lists to see consultants are unacceptably long, and can be up to three years from referral from a GP in some specialties.38 A recent report from the HSE stated that around 350,000 patients are currently on waiting lists, with roughly 200,000 waiting for more than one year.39At present, there are 3.2 doctors practising medicine per 1,000 of the population.40 In the UK, however, there were 2.7 doctors practising medicine per 1,000 people as of 2010, which includes both specialists and general physicians.40 However, in the UK, the maximum length spent waiting to see a consultant upon referral from a GP is 18 weeks or six months.41 Should the number of doctors diminish further due to emigration, waiting lists may become longer than they already are; this would significantly decrease the overall efficiency of healthcare provision in Ireland.

Efforts to address the issue The Postgraduate Medical Education and Training Group (MET) in Ireland published a report in 2005, which addressed the state of postgraduate medical training in Ireland as well as the issue of medical emigration.34 The report was compiled with the former Minister for Health, Mary Harney, members of the MET and government departments. The chairperson of the MET, Jane Buttimer, stated that the reduction of working hours, reformation of medical education and the improvement of medical care are among the strategies laid down in order to improve the Irish health system. Also contained in the report are factors that have influenced doctors to emigrate, which are not unlike the ones discussed above. These include, but are not limited to, shorter working hours, acceptable workload, better working conditions, better pay, and location of medical posts. These are the results of a survey on two cohorts of medical graduates from 1994-1999. This report shows that these issues are known and efforts are being made to address them. The report gives a detailed description of the plan of action for the Minister for Health and the HSE on improving the overall quality of the Irish health system. Accommodating NCHD training within the

RCSIsmj staff review 48-hour working week, safeguarding training and service delivery, implementing the National Flexible Training Strategy to retain graduates, establishing a strong Medical Education and Training Programme by the HSE (HSE-MET), and creating a funding base for postgraduate education and research are among the numerous strategies detailed in the report. In relation to the health of doctors, the HSE is also considering integrating modules on dealing with illness, stress and understanding the systems available to doctors who are ill, into undergraduate and postgraduate training. Further measures include the following: ensuring that occupational health services are made available to doctors, including those in rural areas; providing assessment and retraining after long illness or absence from work; and, creating a mentoring network to meet the retraining needs among doctors.34 Increasing the number of postgraduate training posts is another factor that needs to be considered, as it is contributing to the emigration of doctors.34 The IMO is aware of the problems regarding NCHDs and hospital care, and has implemented a plan of action for retaining NCHDs: a

training fund; two-year NCHD contracts; EWTD implementation; public holiday leave; professional competence; overtime payments; career plans; improved working conditions; education and training; a 39-hour core working week; and, GP travel allowance.42

References

Jones, G. ‘Strike out Boldly for the Prizes that are Available to You’: Medical Emigration from Ireland 1860-1905. Med Hist. 2010;54(1):55-74.

García-Perez AM, Amaya C, Otero A. Physicians’ migration in Europe: an

Available from: http://www.emn.ie/files/p_20100715122609 mamanges%20Migration%20and%20the%20Labour%20market_the%hea

Submission to Oireachtas Joint Committee on Health and Children.

McEntee E, Daly L, Clarke A, Fitzpatrick P. Career tracking study: factors

Public Health Medicine & Epidemiology, UCD; 2005. Available from: http://www.lenus.ie/hse/bitstream/10147/43361/1/3330.pdf. Health Service Executive. Annual Assessment of NCHD Posts July 2011 to June 2012. Medical Education & Training Unit, Health Service Executive, Dr Steevens’ Hospital, Dublin 8, Ireland: HSE-MET Unit; 2010. Bruce-Brand R et al. Diagnosing the doctors’ departure: survey on sources of dissatisfaction among Irish junior doctors. Ir Med J [Internet].

lth%20sector%20in%20Ireland.pdf. 11. The Royal College of Surgeons and Trinity College Dublin. The Doctor Migration Project. 2012. (Accessed: 2012 Nov 24). Available from: http://www.doctormigration.com/the-project.html. 12. McGreevy R. Highest number of overseas doctors may be in Ireland. The Irish Times [Internet]. 2012 Feb 7. 13. Irish Medical Organisation. IMO meets with HSE on EWTD amd NCHD retention. 2012. (Accessed 2012 Oct 6). Available from: http://www.imo.ie/specialty/nchd/live-issues/imo-meets-with-hse-on-ewt/. 14. Department of Health and Children. Plan for Implementation of EWTD in Ireland – Doctors in Training. Dublin: Department of Health and Children. 2012. (Accessed 2013 Jan 2). 15. Kelly A. Ireland must reduce doctors’ working hours or face legal action

2012;105(1):7. Accessed 2012 November 22.

warns European Commission. Irish Central [updated 2011; cited 2012 Aug

Irish Association for Emergency Medicine. Completed national emergency

4]. (Accessed 2012 Nov 22). Available from:

medicine workforce survey reveals a 25% deficit in Emergency Department

http://www.irishcentral.com/news/Ireland-must-reduce-doctors-working-h

junior doctor staffing from 11th July 2011. Dublin: Irish Association for Emergency Medicine. 2011. (Accessed: 2012 Nov 22). Available from: http://www.iaem.ie/images/stories/iaem/press_releases/2011/iaem_press_r elease_re_ed_manpower_survey_which_confirms_extent_of_the_ed_nchd_ crisis_160611.pdf. 8.

factsheets/ fs301/en/index.html. 10. Quinn E. Managed Migration and the Labour Market – The Health Sector

http://www.biomedcentral.com/1472-6963/7/201.

Postgraduate Medical Education and Training Group and Department of

2012 Nov 24). Available from: http://www.who.int/mediacentre/

in Ireland: European Migration Network. 2005. (Accessed: 2012 Nov 22).

affecting career choices and retention of Irish medical graduates.

World Health Organisation. Migration of health workers. 2010. (Accessed

[Internet]. (Accessed 2012 Nov 22). Available from:

Health and Children. October 20, 2011.

There is room for improvement within the Irish health system. The economic recession is still affecting Ireland, so enhancing the health system may prove to be a challenging endeavour due to financial limitations. However, it is important in order to prevent the health service from deteriorating further. The reports written by the MET and the IMO show that the HSE and the IMO are fully aware of the problems within the health sector, and are currently in the process of improving the health system and the working conditions for doctors working within Ireland. Although recruiting large numbers of doctors from abroad to fill the vacancies left by Irish graduates has helped the Irish health system in the short term, it is not a long-term measure. The retention of Irish graduates is also important in improving the efficiency and quality of healthcare provision in Ireland.

overview of the current situation. BMC Health Serv Res. 2007;7:201

Non-Consultant Hospital Doctors: Hearing before the Joint Committee on 4.

Conclusion

ours-or-face-legal-action-warns-European-Commission-130936268.html. 16. Citizens Information. The Working Week. 2012. (Accessed 2012 Nov 20). Available from: http://www.citizensinformation.ie/en/employment/ employment_rights_and_conditions/hours_of_work/working_week.html. 17. Irish Medical Organisation. Unrostered Overtime. 2011. (Accessed 2012

Feely M. Almost one third of emergency department NCHD posts vacant.

Oct 6). Available from: http://www.imo.ie/specialty/nchd/live-issues/

Irish Times, February 6, 2012.

unrostered-overtime/index.xml.

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RCSIsmjstaff review 18. OECD. Work–Life Balance. 2012. (Accessed 2012 Dec 29). Available from: http://www.oecdbetterlifeindex.org/topics/work-life-balance/. 19. Finn F, Armstrong C. Junior doctors’ extended work hours and the effects on their performance: the Irish case. Int J Qual Health Care [Internet]. 2011;23(2):201. (Accessed 2012 Oct 6). 20. Dahlin M. Burnout in doctors. BMJ Careers [Internet]. 2012. (Accessed 2012 Oct 6). 21. Maslach C, Jackson SE, Leiter MP, Schaufeli WB, Schwab RL. Maslach

http://www.nhscareers.nhs.uk/explore-by-career/doctors/pay-for-doctors/. 31. Burr S. A Guide to Overtime Pay. 2012. (Accessed 2012 Dec 29). Available from: http://www.uknetguide.co.uk/Employment/Article/ A_guide_to_overtime_pay-105690.html. 32 Mercer. Worldwide Cost of Living Survey 2012. 2012. (Accessed 2012 Nov 23). Available from: http://www.mercer.com/press-releases/cost-of-living-rankings. 33. National Health Service. Postgraduate Medical Training in Ireland. 2012.

Burnout Inventory (MBI). 2005. (Accessed 2012 Nov 23). Available from:

(Accessed 2012 Oct 23). Available from:

http://www.mindgarden.com/products/mbi.htm.

http://www.medicalcareers.nhs.uk/postgraduate_doctors/medical_training

22. Umehara K, Ohya Y, Kawakami N, Tsutsumi A, Fujimura M. Association of work-related factors with psychosocial job stressors and psychosomatic symptoms among Japanese paediatricians. J Occup Health [Internet]. 2007;49(6):467-81. (Accessed 2012 Oct 6). 23. Ashish KJ, Bradford WD, Bates DB. Fatigue, sleepiness, and medical errors. In: Kaveh GS, Bradford WD, McDonald KM, Wachter RM. (eds.). Making Health Care Safer: A Critical Analysis of Patient Safety Practices. University of California at San Francisco (UCSF)–Stanford University: U.S. Department of Health and Human Services; 2001:592. 24. Hunter N. Stats may hide real medical numbers. 2012. (Accessed 2012 Oct 6). Available from: http://www.irishhealth.com/article.html?id=15376. 25. Sedgwick E. How to achieve a work–life balance. BMJ Careers [Internet]. 2007;1752(8526). (Accessed 2012 Dec 29). 26. White G. These countries have the best quality of life in the world.

_abroad/medical_training_in_ireland.aspx. 34. The Postgraduate Medical Education and Training Group. Preparing Ireland’s Doctors to meet the Health Needs of the 21st Century. Ireland: Health Research Board; 2008:17,30,68-82. 35. NHS. Doctors Specialty Training. 2012. (Accessed 2012 Nov 24). Available from: http://www.nhscareers.nhs.uk/explore-by-career/doctors/ specialty-training/. 36. Howes, J. Recruitment into specialty training in 2013. BMJ Careers [Internet]. 2012. (Accessed 2012 Nov 22). 37. Barron, D. Up for discussion. Irish Medical News. 2012 May 28:20. 38. HSE. Supplementary Report. Ireland: Health Service Executive. 2012. Available from: http://www.hse.ie/eng/services/Publications/ corporate/performancereports/March_2012_Supplementary_Report.pdf. 39. The Journal. “Too many people waiting far too long” – 200,000 on

Business Insider [Internet] 2011 [cited 2012 Aug 15]. Available from:

hospital waiting lists [Internet] 2012. (Accessed 2012 Oct 6). Available

http://www.businessinsider.com/oecd-better-life-index-2011-5?op=1.

from: http://www.thejournal.ie/too-many-people-waiting-far-too-long-

27. International Medical Recruitment. Salaries in Australia. 2012. (Accessed 2012 Nov 22). Available from: http://www.imrmedical.com/ australiasalaries.htm. 28. HSE. NCHDs basic salary and allowances as of 1 January 2010. 2011. (Accessed 2012 Oct 6). Available from: http://www.hse.ie/eng/staff/nchd/benefits/salary.html. 29. Citizens Information. How your income tax is calculated. 2012. (Accessed 2012 Dec 29). Available from: http://www.citizensinformation.ie/en/ money_and_tax/tax/income_tax/how_your_tax_is_calculated.html. 30. NHS. Pay for doctors. 2012. (Accessed 2012 Nov 22). Available from:

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200000-on-hospital-waiting-lists-477500-Jun2012/. 40. The World Bank. Physicians (per 1,000 people). 2011. (Accessed 2012 Nov 24). Available from: http://data.worldbank.org/indicator/SH.MED.PHYS.ZS. 41. NHS. Guide to waiting times. 2011. (Accessed 2012 Nov 23). Available from: http://www.nhs.co.uk/choiceintheNHS/Rightsandpledges/ Waitingtimes/Pages/Guide%20to%20waiting%20times.aspx. 42. IMO. IMO NCHD Strategy. 2012. (Accessed 2012 Oct 6). Available from: http://www.imo.ie/specialty/nchd/imo-nchd-strategy/.

RCSIsmjelective RCSI medical students PETER STAUNTON, ELIZABETH TATRO, OWEN KEANE, JOANNE LENNON, NIALL TIERNEY, EMMA CARMODY, ELIZABETH KEANE, SEAN FITZGERALD and BRENDAN Oâ&#x20AC;&#x2122;KELLY embarked on an elective experience last summer in Kamuzu Central Hospital (KCH) in Lilongwe, Malawi, South Central Africa.

The warm heart of Africa

Behind the warm smiles and kind greetings of the Malawian people lies a country ravaged by poverty, HIV, malaria, and abysmal maternal and infant mortality rates. It has a population estimated at over 15 million, and with one of the highest birth rates in the world the population is expected to triple in size by 2050.1 The health system is based around 21 district hospitals and four central

hospitals, which act as tertiary referral centres. Kamuzu Central Hospital (KCH), a one-thousand-bed hospital, is the centre for the central region of the country and has a catchment population of over five million people. During our time in Malawi we were afforded the opportunity to join the specialty of our choice within the hospital and we have attempted to provide insight into each.

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RCSIsmjelective Internal medicine The bulk of our group chose internal medicine, with five students allocated to the four general medical teams. The general medical wards were overcrowded, with countless numbers of patients spilling out onto the verandas, and only a few patients lucky enough to secure a bed inside. With limited nursing staff, patients were required to bring a ‘guardian’ – a friend or family member who was responsible for providing food, helping them to dress and providing for all of their hygiene needs. The first piece of advice shared with us was that our best resources would be our five senses, which was not lost on us once we became familiar with the smells of the wards. This was also driven home by the fact that a full blood count (FBC) and a partially worn x-ray machine were the only two freely available investigation modalities. It was clear that careful history taking and the clinical exam were going to be the most useful diagnostic tools and this was made all the more challenging by a considerable language barrier. History taking in Chichewa came more naturally to some of us than others, with most histories based around ‘Mkuvu Kuwawa?’ (‘Do you have pain?’) and plenty of hand gesturing. Morning meeting started the day for most of the specialties in the hospital. It was in essence a handover meeting, which discussed developments overnight. The meeting was generally followed by a day rounding the wards or an attachment to the ‘short stay unit’. Visiting and local physicians alike were eager to teach and expose students to most aspects of medical care within the hospital. As in any hospital, there were daily tasks to be performed on the wards, such as blood draws, pleural or ascitic taps and lumbar punctures, and the opportunity presented itself to the group to perform these procedures. Because simple tests like renal and liver function tests or cytology were not readily available, some of the group took it upon themselves to get tests done, whether it be paying out of pocket for a liver function test (LFT) to differentiate between the causes of painful jaundice or persuading the visiting pathologist to take a particular interest in a possible case of leukaemia. The ‘short stay unit’, which is essentially the medical Accident and Emergency (A&E), provided great opportunities to work up patients from initial presentation. Huge emphasis was also placed on utilising the history and exam to guide management as confirmatory testing was not always available. The necessity to consider unfamiliar underlying pathologies added to the difficulties when assessing the semi-conscious patient. The common Irish presentations of heart failure, liver disease and diabetes were no less common in Kamuzu and daily rounds provided evidence of this. However, malaria and HIV were probably the two conditions that set a hospital day in Malawi apart from one in Ireland. Daily exposure to the management of these conditions provided a great basis for becoming familiar with the diseases. Alongside HIV were all of the conditions associated with immunosuppression, commonly seen in older patients who had not been treated with anti-retroviral medication early in the course of their illnesses. Feeling the tree bark skin of Kaposi’s sarcoma or

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seeing the distinctive presentation of cerebral malaria were among some of the experiences that made the elective invaluable.

Surgery As a lone student attached to the surgical team, there was a great freedom afforded as regards daily activities. Days typically began, like the other specialties, with a morning meeting, reviewing overnight cases and the inevitable deaths over the past 12 hours. Following this, the options were to either spend the day in theatre, partake in daily rounds or spend some time in the surgical A&E, where a constant stream of patients presented themselves, many having travelled for days from the districts. There was always work to be done in surgical A&E. The more senior surgeons really enjoyed the opportunity to teach and basic triaging was something they gave particular attention to. They focused on highlighting the skills involved in managing patients with next to no diagnostic investigations. Surgical chest drains, endless wounds to be sutured and fracture reductions were among the daily tasks for the enthusiastic student. The surgical wards consisted of multiple cramped, dimly lit rooms with bare cement floors. The overpowering smell of sepsis was noticeable before the sight of the purulent and often completely open wounds responsible for it. Despite the potential to be deterred from returning to the wards, they were the place where most was learned. The rounding surgeons took great pride in their knowledge and attempted to impart it, with daily simulated final medicine objectively-structured clinical examinations. Signs like massive splenomegaly and advanced wound infections, which are rare in Ireland, made spending time there very worthwhile. The operating theatre was the highlight of the attachment with the opportunity to scrub in for a wide range of cases daily, most often as first assistant, a level of exposure that would take many months in theatre at home. While the resource-starved nature of the hospital was difficult to forget, KCH had adequate resources to perform most major surgeries. Scrubbing for up to eight cases daily meant that over the course of four weeks, the variety of cases was quite considerable. Laparotomies were the most common procedures, but there were many others, including burr holes, guillotine amputations, and a rare craniotomy.

Paediatrics Daily activities for the two students in this department began with a very brief round of the main ward and the High Dependency Unit (HDU). The morning meeting that followed was an excellent source of learning and guidance during the elective. It involved detailed discussions of all HDU patients, as well as a thorough debriefing on all child deaths in the previous 24 hours. These led to focused teaching sessions on the relevant clinical topics, with full participation from students expected. The bulk of the day was spent on twice-daily rounds throughout the various departmental areas and wards. Staff and students were split into two consultant-led teams with the aim of assessing as many

RCSIsmj elective children as possible. With plenty of work to be done, students set about monitoring vital signs, checking blood glucose levels, carrying out malaria rapid diagnostic tests, and performing lumbar punctures and finger-prick haemoglobin tests, to name but a few. Seeing many cases of malaria, one quickly developed an appreciation for the urgency required when dealing with the severely anaemic child, and there was many a rushed venture across to haematology sourcing the appropriate blood products needed for transfusion. Being able to assist by carrying out the simple tasks of retrieving, logging and starting the transfusion freed the senior physicians to focus on the numerous other patients awaiting assessment. With personnel numbers stretched to the limit at times, students were frequently presented with the opportunity to assist senior clinicians in the management of acutely unwell patients. The most common, and arguably most important, intervention in this setting was ventilation. Skills in oxygen delivery, learned during the early stages of the elective, enabled the students to divide up scarce oxygen supplies and start patients on the appropriate mode of oxygen supplementation, be it simple nasal prongs or a novel form of non-invasive positive pressure ventilation called â&#x20AC;&#x2DC;bubble CPAPâ&#x20AC;&#x2122; (continuous positive airway pressure). In more critical cases involving severe respiratory distress, or failure of a patient to maintain an adequate airway, students would employ bag-mask ventilation under the guidance of a consultant intensivist, and provide assistance during rapid sequence induction and subsequent intubation. This represented a unique opportunity to receive expert tuition and guidance on airway and ventilation management procedures in the acute setting.

Obstetrics and gynaecology The most striking aspect of obstetrics and gynaecology was the modern new building that housed the specialty within the otherwise dull confines of KCH. Despite the relatively affluent appearance, conditions for patients seemed no less desperate. Morning teaching began each day in KCH with a focus on reviewing current literature and imparting learning points for the day. Daily rounds and the outpatientsâ&#x20AC;&#x2122; clinic allowed the student to see and assess first visit patients and was probably the best way to see the wide range of cases that presented to the hospital. HIV-positive patients with pelvic inflammatory disease, genital herpes, warts, post-operative wound infections, and even sexual abuse of children as young as four years old were the types of cases found on the wards of KCH. Active participation in rounds and discussion of the appropriate patient management was an invaluable source of learning. This learning also extended to the

operating theatre, where there were many opportunities to participate. Part of the attachment was spent in the local district hospital, in an attempt to gain more obstetrics experience, as the amount of obstetrics in KCH was quite limited. While the design was for two women per birthing room, it was not uncommon to see one woman in between the two trolleys delivering on the floor, a stark contrast to the comfortable, quiet warm rooms of the labour ward in the Rotunda. Days in the district essentially consisted of non-stop deliveries and because there were simply not enough hands to cope with all the deliveries, a medical student became a valuable commodity. The experience of being relied upon to oversee deliveries was quite daunting initially, but confidence came with each delivery until getting stuck in from first thing in the morning till late in the evening was expected.

Reflections Our visit to Malawi was an incredibly valuable experience and for that we have all the people we encountered to thank, as well as each other for making it that much more enjoyable. While the experience gained within the hospital in terms of symptoms and signs seen, odours inhaled and hands-on practical exposure will stay with most of us, the country itself, the people, and seeing the quality of life they live is something that will probably resonate for longer within us. That above all is what separates this elective from any other we have had the chance to undertake. There are stand out differences in the practice of medicine in a resource-starved country, from the unavailability of basic medical supplies and the failure of systematic management within the hospital, to the basic lack of health education within the community. These factors lead to many different problems, the most relevant for students being those arising when assessing patients. The barrage of tests often afforded to those in Irish hospitals is simply not available, and management needs to be based on the most likely diagnosis. Because of these restrictions, nowhere is the importance of good clinical acumen more apparent. A poor history or examination can easily result in incorrect assessments and hence poorly directed management, often resulting in unnecessary deaths. Four weeks of exposure to this generated a huge appreciation within the group for the value of strong history and examination skills. Not only this, but hopefully we took with us a long-lasting appreciation for the value of laboratory and radiological testing, something that is becoming more relevant every day on the wards in Ireland.

Reference 1.

World Health Organisation. World Health Organisation Country Profile:

http://www.who.int/countries/mwi/en/.

Malawi; 2009. Cited November 20, 2012. Available from:

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RCSIsmjbook review Bad Pharma: How drug companies mislead doctors and harm patients by Ben Goldacre

Reviewed by Eoin Kelleher, RCSI medical student Paperback: 448 pages Publisher: Fourth Estate, London Published 2012 ISBN: 978-0-00-735074-2

Dr Ben Goldacre earned his reputation for his 2008 book Bad Science and his column in the Guardian newspaper of the same name. In both he provides an entertaining, accessible and well-researched exposé of poor scientific practices. Compared to his first book, which played charlatans such as Gillian McKeith and homoeopathists for laughs, Bad Pharma is a much more sombre read. However, as a piece of investigative journalism, and a resource for students, doctors and patients, it is invaluable.

Food for thought Goldacre opens by making a claim that: “Drugs are tested by the people who manufacture them, in poorly designed trials, on hopelessly small numbers of weird, unrepresentative patients, and analysed using techniques which are flawed by design, in such a way that exaggerate the benefits of treatments. Unsurprisingly, these trials tend to produce results that favour the manufacturer. When trials throw up results that companies don’t like, they are perfectly entitled to hide them from doctors and patients, so we only ever see a distorted picture of any drug’s true effects”. It’s quite a statement. He goes on to explain that the problems run deeper, into the heart of academic medicine. Doctors’ continuing education is often provided by these very companies: at conferences by their colleagues – who are given ‘honorarium’ payments (without disclosure) by companies; or, through sales reps who have been proven in studies

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to affect doctors’ prescribing habits (although most doctors claim that their own practices have never been affected, just those of their colleagues). Even journals, which are considered to be an unbiased source of medical knowledge, are not free from this – journal articles are regularly ghost-written by employees of drug companies and an eminent academic is invited to put their name to it; this appears in the journal, again without disclosure.

Drugs are tested by the people who manufacture them, in poorly designed trials, on hopelessly small numbers of unrepresentative patients, and analysed using flawed techniques. Critique The title suggests that this book is a critique of the pharmaceutical industry – and it is. It is also critical of a medical establishment that co-operates with the industry in perpetuating practices (such as ghost-writing) that ultimately harm patients. But this book is not full of conspiracy theories and stories about evil people. People who work in the pharmaceutical industry, and those who work in medicine in general, want to help people; they are good people. But incentives are often perverse and encourage practices that

RCSIsmj book review seem normal because they are familiar, but are proven to harm patients. The ultimate aim is that pharmaceutical companies should be regulated and transparent to the extent that academics can feel enthusiastic rather than ashamed to work in collaboration with them. It is shocking that an industry that makes products to improve people’s health and has given huge benefit to humanity over past decades, has managed to erode its good will to the point where it lies somewhere among bankers and politicians in the public estimation.

Defining ‘normal’ The theme of normality is one that crops up throughout the book. No one bats an eyelid at sales reps handing out free pens and coffee mugs; no one finds much cause for concern at industry-sponsored conferences; no one cares too much if negative trials get buried and never published, or if the papers themselves have been ghost-written by the industry and an academic’s name attached. The practices described are so widespread and so, well, normal, that it is only when you look in from the outside that you realise they are perverse. Goldacre draws parallels to the MPs’ parliamentary expenses scandal in the UK, where politicians believed that the levels of expenses were normal (one enterprising MP memorably claimed for a moat). Similarly, closer to home, a common defence of banking practices in Ireland in the lead up to the crash was that everyone was doing it, and that such practices were normal. And so it is for medicine. As Goldacre says: “Just because you think something is normal – just because everyone you know is doing it – that doesn’t mean outsiders will agree, when they find out”.

“Just because you think something is normal – just because everyone you know is doing it – that doesn’t mean outsiders will agree, when they find out.” The mystery of the missing data The dodgy marketing tactics of these companies (who spend twice as much on marketing drugs as they do on research and development), which involve dishonest advertisements, secret payments and spin, have already received widespread press coverage. The real issue however, Goldacre states, is missing data. Half of all clinical trials are never published, for a variety of reasons, and these are most likely to be the trials with negative results for a company’s drug. However, unlike sales reps or trade advertising, which one can ignore, this misleads everybody without anyone being aware. Goldacre uses the example of reboxetine, an antidepressant. Seven trials were conducted comparing reboxetine against a placebo, but only one had a positive result. This was the only trial published. Furthermore, ten trials were carried out

comparing reboxetine against other antidepressants. Only three showed it to be as good as these other drugs, and these were the three that were published. Seven studies showed it to be worse than comparable antidepressants, but these studies remained unpublished. What is more, the unpublished data also showed that patients on reboxetine were more likely to suffer side effects than those on other drugs. This matters because if you are a doctor prescribing reboxetine, if you have read the published papers and critically appraised them – i.e., if you have practised evidence-based medicine – you would think that reboxetine is an effective treatment for depression. You have no way of knowing that the drug is no better than a placebo because the information has not been made available to you. Doctors and patients need all the information to make an informed decision about the best treatment, but if it is not available they cannot do that. Furthermore, is it ethical to tell participants in trials that they are contributing towards medical knowledge and improving treatment for future patients if over half of these trials are not published and the data goes unused?

Doctors and patients need all the information to make an informed decision about the best treatments, but if it is not available they cannot do that. Green shoots? Academic journals and drug companies have pledged to stamp out publication bias, but as Goldacre shows, in reality little has changed. The history of responses to bad practices in the pharmaceutical industry is littered with false starts and broken promises because no one checks up on them to see if commitments to change have been kept once the press fanfare dies down. Ben Goldacre’s book is timely and needed to be written. It has transformed a topic that, to many, is impenetrable – statistics and research methods – into one that is engaging and engenders a sense of incredulity and disappointment that such practices have been able to carry on. But it is not an entirely negative book; at the end of each section he offers ways to fix the problems highlighted. And developments such as the Sunshine Act in the US (which will compel companies to publish how much money they give individual doctors and for what), and a commitment from GlaxoSmithKline to make all of its trial data available, are promising. Bad Pharma is an easy read. Goldacre has earned his reputation as a very good popular science writer through his engaging style and ability to communicate complex ideas in a simple manner. Although the book is not as entertaining as Bad Science, it is still very accessible and – arguably – more important. It is definitely one that everyone involved in healthcare should read.

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RCSIsmj abstract Post-translational regulation of endothelial nitric oxide synthase by testosterone in the mouse penis Elaine Harris1 Prof. Arthur Burnett2 1RCSI medical student 2Department of Urology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA

FIGURE 1: Hypothesis: testosterone acting through the Akt pathway positively regulates eNOS phosphorylation at Ser-1177, and the subsequent increase in NO production promotes penile vascular homeostasis and penile erection.

FIGURE 2: Total mice serum testosterone (T) levels following three days of vehicle or testosterone treatment at the indicated doses. Each bar represents one mouse.

Introduction Nitric oxide (NO) is the main mediator of penile erection.1 In endothelial cells, NO synthesis is catalysed by endothelial NO synthase (eNOS). eNOS phosphorylated at Ser-1177, a positive regulatory site, constitutively increases NO production, which, via vasorelaxation of the cavernosal smooth muscle cells, maintains penile erection.2 eNOS phosphorylation at Ser-1177 is stimulated by several stimuli including shear stress, oestradiol, vascular endothelial growth factor and, potentially, testosterone.3 Testosterone is essential for the normal structure and function of penile cavernous tissue.4 In hypogonadism, low levels of testosterone are associated with erectile dysfunction and treatment with testosterone improves erectile function.4 Recent

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studies have shown that testosterone beneficially regulates the vasculature.5 However, the precise vasoprotective mechanisms of testosterone in the penis are unknown. We hypothesise that testosterone acting through the Akt pathway positively regulates eNOS phosphorylation at Ser-1177, and the subsequent increase in NO production promotes penile vascular homeostasis and penile erection (Figure 1).

Methods Eight-week-old wild-type mice were used (n=15). Twelve mice were castrated and split into four groups of three. Pellets were implanted subcutaneously, releasing 1.2µg, 12µg or 70µg of testosterone or

smjabstract RCSIsmj

FIGURE 3: Western blot demonstrating p-eNOS (Ser-1177) and eNOS protein levels in the penises of non-castrated control mice, and castrated mice treated with vehicle, 1.2µg, 12µg or 70µg of testosterone (T)/day for three days. Lower panels represent quantitative analysis of P-eNOS (Ser-1177)/eNOS in penises in the same treatment groups. Each bar represents the mean ± SEM of three mice.

FIGURE 4: Western blot demonstrating eNOS and β-actin protein levels in the penises of non-castrated control mice, and castrated mice treated with vehicle, 1.2µg, 12µg or 70µg of testosterone (T)/day for three days. Lower panels represent quantitative analysis of eNOS/β-actin in penises in the same treatment groups. Each bar represents the mean ± SEM of three mice.

FIGURE 5: Western blot demonstrating p-Akt and Akt protein levels in the penises of non-castrated control mice, and castrated mice treated with vehicle, 1.2µg, 12µg or 70µg of testosterone (T)/day for three days. Lower panels represent quantitative analysis of p-Akt/Akt in penises in the same treatment groups. Each bar represents the mean ± SEM of three mice.

FIGURE 6: Western blot demonstrating p-VASP and VASP protein levels in the penises of non-castrated control mice, and castrated mice treated with vehicle, 1.2µg, 12µg or 70µg of testosterone (T)/day for three days. Lower panels represent quantitative analysis of p-VASP/VASP in penises in the same treatment groups. Each bar represents the mean ± SEM of three mice.

vehicle per day in each group. Three non-castrated mice were used as controls. After three days, total serum testosterone levels were measured by radioimmunoassay, and protein levels of phosphorylated-eNOS (p-eNOS), eNOS, phosphorylated-Akt

(p-Akt) and phosphorylated vasodilator-stimulated phosphoprotein (p-VASP) were investigated by western blotting in the penises excised at baseline. All results were expressed relative to non-castrated mice.

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RCSIsmjabstract Results Treatment with 1.2µg of testosterone p/day resulted in physiological serum testosterone levels (1.6pm/ml), whereas 12µg of testosterone p/day and 70µg of testosterone p/day resulted in supraphysiological serum testosterone levels (7.9pm/ml and 13.5pg/ml, respectively) (Figure 2). Consistent with our hypothesis, testosterone deficiency showed a trend towards reduced eNOS phosphorylation at Ser-1177 (p=0.1124), while administration of low and medium doses of testosterone increased eNOS phosphorylation above castrated levels (Figure 3). Testosterone deficiency showed a trend towards increased eNOS protein expression levels (p=0.3807), while different testosterone doses showed no effect on eNOS protein expression compared to non-castrated mice (Figure 4). P-Akt levels exhibited changes similar to p-eNOS (Ser-1177) in response to castration and

testosterone replacement, suggesting that testosterone-induced eNOS phosphorylation at Ser-1177 occurs through the p-Akt pathway (Figure 5). Testosterone did not affect protein expression of p-VASP, a marker of NO signalling (Figure 6).

Conclusion In the mouse penis, testosterone may induce eNOS phosphorylation at Ser-1177 via the p-Akt signalling pathway. This may promote penile vascular homeostasis and positively influence penile erection.

Acknowledgments Funded by The James Buchanan Brady Summer Urological Research Experience at Johns Hopkins Medical Institutions.

References 1.

Burnett AL. Novel nitric oxide signalling mechanisms regulate the erectile response. Int J Impot Res. 2004;(16 supp 1):S15-19.

penis. J Androl. 2009;(30):352-62. 4.

Hurt KJ, Musicki B, Palese MA, Chrone JK, Becker RS, Moriarty JL et al.

morphologic remodelling at penile and cardiovascular levels: a common

Akt-dependant phosphorylation of endothelial nitric-oxide synthase mediates penile erection. PNAS. 2002;(99):4061-6. 3.

Mirone V, Imbimbo C, Fusco F, Verze P, Creta M, Tajana G. Androgens and piece in complicated puzzles? Eur Urol. 2009;(56):309-16.

Perusquia M, Stallone JN. Do androgens play a beneficial role in the

Musicki B, Ross AE, Champion CC, Burnett AL, Bivalacqua TJ.

regulation of vascular tone? Nongenomic vascular effects of testosterone

Posttranslational modification of constituitive nitric oxide synthase in the

metabolites. Am J Physiol Heart Circ Physiol. 2009;(298):H1301-H1307.

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smjlast laugh RCSIsmj

Illustration by Eoin Kelleher.

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