IMS MAGAZINE Summer 2019

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Global and Local Perspectives on Abortion Access

Tailoring Treatments for Breast Cancer

ESTROGENS & THE BRAIN How Hormones Student-led initiative Affect Cognition

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IN THIS ISSUE Letter from the Editors .............................. 4 Director’s Message ................................... 5 Contributor’s Page...................................... 6 Raw Talk Podcast....................................... 7 Infographic................................................. 8 Feature..................................................... 10 BMC......................................................... 18 Viewpoint................................................. 20 Travel Bite ............................................... 29 Faculty Spotlight...................................... 30 Student Spotlight..................................... 32 Past Events .............................................. 35 SURP Winners.......................................... 37 Book Review ........................................... 40 Future Directions ..................................... 42

MAGAZINE STAFF EDITORS-IN-CHIEF Beatrice Ballarin Natalie Osborne

EXECUTIVE EDITORS Jonathon Chio Krystal Jacques-Smith Mikaeel Valli Yena Lee

DESIGN EDITORS Alexander Young Chloe Ng Colleen Tang Poy Hang Yu Lin Janell Lin Julia Devorak Mona Li Roxanne Ziman Shirley Long Su Min Suh

By Shirley Long MScBMC Candidate

Copyright © 2019 by Institute of Medical Science, University of Toronto. All rights reserved. Reproduction without permission is prohibited. The IMS Magazine is a student-run initiative. Any opinions expressed by the author(s) are in no way affiliated with the Institute of Medical Science or the University of Toronto.

Colin Faulkner Kenya Costa-Dookhan Krystal Jacques-Smith Mikaeel Valli Nathan Chan

SOCIAL MEDIA TEAM Cindy Ha Sandy Lee Serina Cheung Stephanie Hulme





Abanti Tagore Alaa Youssef Alexa Desimone Ana Stosic Benjamin Liu Colin Faulkner Cricia Rinchon Erika Opingari Gaayathiri Jegatheeswaran Gökçe (Gigi) Ozdemir Grace Jacobs Jason Lau

Laura Best Mathura Thiyagarajah Meital Yerushalmi Rehnuma Islam Sabreena Moosa Sarasa Tohyama Shahrzad Firouzian Sonja Elsaid Sumaya Dano Yekta Dowlati Yvonne Bach Zahra Khanto


By Julia Devorak MScBMC Candidate




Photo credit: Jon Chio

Letter from the Editors


ow can we heal women if we don’t study them? How can we diagnose, treat, and prevent common diseases without understanding how they behave in the female body? When it comes to medicine, why does sex and gender matter? These are the questions we set out to answer in this Summer 2019 issue of IMS Magazine. The biomedical research community is awakening to the dangerous and sometimes

deadly realities of a long-standing male bias in medicine. It arose largely because researchers primarily study male cells, animals, and human subjects-assuming (often erroneously) that their findings would always be the same in females, and that females were “too complicated” to study. This “default male” thinking has far reaching consequences for women’s health. Diagnostic criteria and treatments can be less effective for women, and have more side-effects. Women’s bodies, from their brains and immune systems to the diseases that specifically affect them, are not as well studied as men’s. But this is changing, thanks to the researchers you’ll read about in this issue. For example, Dr. Gillian Einstein’s lab is investigating how estrogen (including the synthetic form found in birth control and hormone replacement therapy) influences women’s brain structure and function, particularly their memory. Dr. Maureen Trudeau is involved in multiple projects helping to advance personalized medical treatments for women with breast cancer, the most common malignancy affecting Canadian women. Dr. Robert Casper is working towards an early diagnostic test for endometriosis; a poorly understood disease affecting one in ten women that can cause infertility and significant pain. And Dr. Donna Stewart is part of an international effort to teach medical professionals how to recognize and treat the mental and physical health problems associated with intimate partner and sexual violence. IMS students further advocate for women’s health in their viewpoint articles, with perspectives on abortion (both internationally and locally) and female genital mutilation. They also reveal another type of medical bias-this time against indigenous populations. In this issue we highlight the Women’s Brain Health Initiative and several exciting past events including IMS Scientific Day, the Raw Talk Live on AI in Medicine, and an international stem cell conference in sunny California. And if you’re feeling scattered and overwhelmed, we recommend checking out our review of a rather unconventional self-help book. The articles submitted to our annual Summer Undergraduate Research Program writing contest were so impressive this year we had to pick two winners! Congratulations to Sabreena Moosa and Benjamin Liu! We are also excited to shine a spotlight on two exceptional IMS members, Director for Graduate Professional Development and Alumni Engagement Dr. Reinhart Reithmeier, and mindfulness PhD researcher Elli Weisbaum. Finally, we’d like to express our gratitude for the opportunity to serve as co-Editors in Chief of IMS magazine, and thank all the writers, editors, photographers, and designers who spent their summer holidays making this issue a reality. We hope you enjoy it, and we’d love to hear from you: you can email us at and visit our website at

Natalie Osborne

Beatrice Ballarin

Natalie is a 3rd year PhD student using neuroimaging and sensory testing to understand chronic pain under the supervision of Dr. Karen Davis. Outside the lab she loves to write about science and true crime. Twitter: @NatalieRaeOz

Beatrice is a 5th year PhD student researching the effect of a drug to promote recovery after stroke under the supervision of Dr. Michael Tymiaski. Outside the lab she is an avid reader of non-fiction books and loves running. Twitter: @BBallarina





S Photo credit: Iris Xu


Director, Institute of Medical Science Professor, Department of Surgery Senior Scientist, Toronto General Research Institute, University Health Network

ummertime is not the time only for holidays here at the Institute of Medical Science. Throughout the year, IMS researchers work on the medical issues that are vital to the wellbeing of our community locally and globally, and “Women’s Health” is no exception. We are proud of the diverse, multidisciplinary work being done at the IMS to improve the health of women and girls everywhere. In this issue you can read about Dr. Maureen Trudeau’s efforts to provide more individualized treatments for breast cancer patients, and Dr. Robert Casper’s mission to improve diagnostic tests for endometriosis, an understudied condition affecting one in ten women. You’ll learn about the important role that estrogens play in cognition in women of all ages from Dr. Gillian Einstein’s projects on brain health, and read about Dr. Donna Stewart’s work developing patient decision making aids for pregnant women with major depressive disorder as well as her efforts educating healthcare professionals on how to treat women who’ve experienced intimate partner and sexual violence. Education and training are a key component of the IMS. Every year we host a “Summer Undergraduate Research Program” (SURP) that attracts many talented young students eager to learn about the IMS graduate experience. About 100 undergraduate students from universities around the world join our laboratories and our researchers for the summer. These talented students invest their summertime in learning laboratory skills and cultivating a mindset for science. We are proud to offer this unique program at the Faculty of Medicine to foster the new generation of scientists that ends with a final competition at the SURP Scientific Day. This is a great opportunity not only for the undergraduate students, which often end up joining our program, but also for our current graduate students at the IMS as a teaching experience. Our department is growing more and more every year, and we would like to take this opportunity to welcome new faculty who have joined the IMS Core Team: Dr. Reinhart Reithmeier as Director of Graduate Professional Development and Alumni Engagement, Dr. Zhong-Ping Feng as Director of International Development, Dr. Nicole Harnett as Director of Curriculum, Dr. Marianne Koritzinsky as Director of MSC1010/1011Y, Dr. Karen Gordon as Chair of Faculty Appointments Committee, and Dr. Chung-Wai Chow as Chair of Student Awards Committee. We are excited to announce these new leaders and we look forward to the next academic year. Finally, we take this opportunity to remind the IMS Magazine readers of two important events: the welcoming of our new graduate students during the Orientation Day (on September 4th, 2019), and our prestigious Ori Rotstein Lecture on Translational Medicine, which will take place this fall. I am proud of the excellency that the IMS continues to develop and of the success of our students. I would like to commend IMS Magazine’s new Editors in Chief, Beatrice and Natalie, and all the editors, journalists, and photographers as well as the design team for the excellent production they have put together this semester. This Summer issue truly highlights the novel innovations and research being performed in the IMS, and I encourage you to read and learn something new in this Summer issue 2019! Sincerely, Dr. Mingyao Liu, MD, MSc Director, Institute of Medical Science IMS MAGAZINE SUMMER 2019 WOMEN’S HEALTH |



Summer 2019 Contributors


MS Magazine is a student-led publication. IMS students are responsible for writing, editing, and photography, while BMC students create the design. Meet some of the writers for this issue below!

Sumaya Dano is a 2nd year MSc student at IMS working under Dr. Istvan Mucsi’s supervision. She is interested in assessing patient-reported outcome measurement tools to help manage symptoms and improve quality of life for people with chronic kidney disease. In her free time, Sumaya loves traveling and learning about different cultures.

Mikaeel Valli is currently completing his PhD at the University of Toronto’s Institute of Medical Science with a specialization in neuroscience. He is working with Dr. Antonio Strafella and his lab using neuroimaging techniques to ultimately better understand the underlying pathophysiology of Parkinson’s disease.

Gokce Ozdemir is entering her second year in IMS as a master’s student studying the use of human induced neural stem cells for functional recovery after spinal cord injury under the supervision of Dr. Michael Fehlings. She would like all her free time to go to playing volleyball but ends up napping instead.

Jason Lo Hog Tian is a second year MSc doctoral stream student at IMS investigating the barriers preventing people living with HIV from seeking treatment under the supervision of Dr. Sean Rourke. He is committed to developing his scientific communication skills through writing for the magazine. Twitter: @JasonLoTweets

Sonja Elsaid is a second year IMS Ph.D. student investigating brain function and cannabis use in individuals with social anxiety. Prior to going back to school, Sonja was a clinical research and medical communications professional with nearly 20 years of experience.

Shahrzad Firouzian is an MSc student entering her 2nd year under the supervision of Dr. Karen Davis. Her research focuses on psychophysical measures of pain, specifically pain inhibition. She owns a pet cockatiel named Mango, and enjoys jazz in her spare time!

Mathura Thiyagarajah is a 2nd year Pharmacology MSc student investigating brain changes and antioxidant levels in early stages of vascular cognitive impairment under the supervision of Dr. Krista Lanctôt. She spends too much time daydreaming about traveling and talking about books, pop culture, and politics. Instagram: @inkyspines

Activist, biologist, and literary enthusiast – Colin Faulkner is deeply interested in seeking health equity for older adults. His work, which investigates individuallevel factors associated with health care use, highlights genderspecific changes that we should consider to improve the health of older women and men.

Krystal Jacques is a 2nd year IMS PhD student using human embryonic stem cells and lineage tracing mouse models to study the origins of pancreatic stem cells under the supervision of Dr. Derek van der Kooy. Outside the lab she is passionate about fine art photography, writing fiction, painting and running. Instagram: @Krystaljacques_

Alaa Youssef is an IMS PhD candidate whose thesis examines the long-term changes in health-related quality of life trajectories (HRQoL) after bariatric surgery. Her research aims to explore the psychosocial factors associated with weight regain and obesity self-management. Alaa likes listening to classics and enjoys coffee in all its forms.





Women’s Health Women in Medical Research: Understudied & Overlooked

Historically, female subjects were excluded from biomedical research due to: a) Fears that women’s menstrual cycles would introduce too much variability. b) The belief that women would respond similarly to men. c) Concerns for potential risks to a developing fetus.1 Today, major health organizations recognize that not including women in medical research has led to some treatments that are substandard or even dangerous for women.

Studies on brain disorders are 5x more likely to be conducted on male than female animals3, even though women are

70% more likely to have depression4 and 2x as likely to

have anxiety than men.5

50% more likely to be misdiagnosed after heart attack.

71% of basic research

studies using cells included only male cells.

A 2014 paper found that 76% of studies in five prominent surgical journals didn’t report the sex of the cells used. When sex was reported, 71% included only male cells.2

How does treatment differ between men & women?

Clinical trials often fail to investigate if treatments differ for men and women. Until 1988, clinical trials of new drugs were conducted predominantly on men. Government (but not industry) funded clinical trials are now mandated to include both men and women, but only 26% of studies investigate how sex influences their results.6


Heart attack symptoms can present differently in women compared to men, but many physicians are not trained to recognize them. That means heart attacks can go undiagnosed & untreated in women, which may partly explain why women are more likely to die after a heart attack than men.8 Common preventative measures, such as aspirin, were also found to be ineffective or even harmful for women.9

Women are nearly 2x as likely to develop an adverse drug reaction when compared to men.

Women absorb, metabolize and excrete some drugs differently than men. Most drug dosage recommendations are calculated based on male bodies. Eight out of 10 drugs approved by the FDA between 1997 and 2001 were removed from market due to unacceptable health risks that were more harmful to women.7


Today’s Top Women’s Health Issues

The World Health Organization (WHO) reflected over the past 20 years since the signing of the 1995 Beijing Declaration and Platform of Action that aimed to empower and improve equality for women. Significant accomplishments have been made since 1995; however, women still face many challenges, particularly with their health. The WHO has compiled a list of top ten issues10; here we show a snapshot of those issues.


References 1. Liu KA, Dipietro Mager NA. Women’s involvement in clinical trials: historical perspective and future implications. Pharmacy Practice (Granada). 2016 Mar;14(1):0 2. Yoon DY, Mansukhani NA, Stubbs VC, Helenowski IB, Woodruff TK, Kibbe MR. Sex bias exists in basic science and translational surgical research. Surgery. 2014 Sep 1;156(3):508-16 3. Beery AK, Zucker I. Sex bias in neuroscience and biomedical research. Neuroscience & Biobehavioral Reviews. 2011 Jan 1;35(3):565-72. 4. Albert PR. Why is depression more prevalent in women?. Journal of psychiatry & neuroscience: JPN. 2015 Jul;40(4):219. 5. 6. Geller SE, Koch AR, Roesch P, Filut A, Hallgren E, Carnes M. The more things change, the more they stay the same: a study to evaluate compliance with inclusion and assessment of women and minorities in randomized controlled trials. Academic Medicine. 2018 Apr 1;93(4):630-5. 7. FDA’s Office of Women’s Health 8. Wu, J et al. Impact of initial hospital diagnosis on mortality for acute myocardial infarction: A national cohort study. European Heart Journal 2016; 7:2. 9. Johannes, A.N. et al. Aspirin for primary prevention of vascular events in women: individualized prediction of treatment effects. European Heart Journal. 2011; 32:23, 2962-9. 10. Bustreo F. Ten top issues for women’s health [Internet]. World Health Organization. 2015 [cited 6 August 2019]. Available from: https://www.who. int/life-course/news/commentaries/2015-intl-womens-day/en 11. Au A, Feher A, McPhee L, Jessa A, Oh S, Einstein G. Estrogens, inflammation and cognition. Frontiers in Neuroendocrinology. 2016 Jan; 40:87-100 12. Rondon M, Stewart D. Disentangling the heterogeneity of perinatal depression. The Lancet Psychiatry. 2017;4(6):432-433. 13. Table 13-10-0111-01; Number and rates of new cases of primary cancer, by cancer type, age group and sex [Internet]. Statistics Canada. 2019 [cited 6 August 2019]. Available from: t1/tbl1/en/tv.action?pid=1310011101 14. Breast Cancer [Internet]. 2017 [cited 6 August 2019]. Available from: https://www.canada. ca/en/public-health/services/chronic-diseases/cancer/breast-cancer.html 15. Farquhar CM. Endometriosis. BMJ. 2000 May 27;320(7247):1449-52. 16. Table 35-10-0056-01; One day snapshot of types of abuse (percent) experienced by women residing in residential facilities for victims of abuse [Internet]. Statistics Canada. 2019 [cited 6 August 2019]. Available from: tv.action?pid=3510005601

Did you know that Alzheimer’s disease impacts more women than men?11 Low levels of estrogen in women has been implicated in developing Alzheimer’s.11

Perinatal mental disorders are common not only in low and middle-income countries, but also in developed countries, with an estimated prevalence of 10 out of 100 pregnant women and 20 out of 100 women postnatally.12


The number of new breast cancer cases in Canada is on

the rise: 1,600 new cases occurred between 2012 to 2016.13

1 out of 8 Canadian women are expected to develop breast cancer during their lifetime and 1 out of 31 will die of it.14 82% of breast cancer cases occur in women over 50 years of age.14


Endometriosis is a condition affecting 1 in 10

women of reproductive age in which tissue similar to the uterus lining (endometirum) grows outside of the uterus.15 Endometriosis takes an average of 8 years to diagnose, and can cause severe pain, irregular periods and infertility. There is currently no definitive cure.15



Snapshot of types of abuse (%) experienced by women residing in residential facilities for victims of abuse across Canada.16 Total 3107.

Emotional/Psychological 89% Physical 73% Financial 51% Sexual 33% Harrassment 31% Cultural abuse 7% Spiritual abuse 6% Other 5% Human trafficking: sex work 3% Forced marriage 2% Human trafficking: forced labour/other 1%



Exploring Estrogen’s Effects on the Brain By: Natalie Osborne In biology class you probably learned that estrogen is responsible for developing secondary sexual characteristics and regulating the menstrual cycle. But did you know that it also plays a key role in brain health and cognition? Understanding exactly how estrogen influences brain function could help researchers better understand disparities in brain diseases and mental health, such as why women are two to three times more likely to get Alzheimer’s disease than men1. Investigating the effects that hormones have on the brain is one of Dr. Gillian Einstein’s many specialties. Professor in the Department of Psychology, IMS member, and founder of the University of Toronto’s Collaborative Specialization in Women’s Health, Dr. Einstein is a trailblazing expert on women’s brain health and cognition. Her lab combines structural and functional brain imaging with neurocognitive and qualitative assessments to investigate how attributes like age, sex, gender, and hormones influence cognition. And the hormone they’re particularly interested in is estrogen. Or more correctly, estrogens—a family of hormones including 17-beta estradiol, estrone and estriol. They are expressed in different quantities at different times throughout a woman’s life, with 17-beta estradiol being the most prominent until menopause. Estrogen receptors can be found throughout the brains of both women and men. Two areas where they are particularly abundant are the hippocampus (a structure that’s integral for memory) and the prefrontal cortex, which is important for executive functions such as planning and decision-making. When estrogens bind to these receptors they can act like a growth factor, promoting the generation of new 10 | IMS MAGAZINE SUMMER 2019 WOMEN’S HEALTH

neurons and the sprouting of dendritic spines (the tiny branches that help neurons to communicate and make connections with each other). Estrogens can also influence the release of neurotransmitters, such as dopamine and serotonin, and even up- or down-regulate the expression of certain genes. But what does this mean for brain function? “The effects of estrogens on synapses and the growth of synaptic connections is a form of brain plasticity—it is through this plasticity that circuits for learning and memory are established,” explains Dr. Einstein. “So, in the field of aging and dementia research, ultimately the loss of estrogen is linked with the loss of the ability of certain neurons to make new connections.” A woman’s estrogen levels fluctuate across the menstrual cycle, as can her performance on certain cognitive tasks. One example is mental rotation, the ability to recognize a 3D object that has been rotated from its previous position. Men typically outperform women on these tasks. However, Dr. Einstein’s lab found this to be true only when women were tested in the luteal phase of their cycle, when estrogen levels are relatively high. When tested in the follicular phase (characterized by lower 17-beta estradiol), women performed equally to men.

Dr. Gillian Einstein Wilfred and Joyce Posluns Chair of Women’s Brain Health and Aging Professor of Psychology, University of Toronto Founder of the Collaborative Graduate Program in Women’s Health, University of Toronto, Member, Canadian Institutes of Health College of Reviewers, Adjunct Scientist, Women’s College Research Institute, Scientific Associate Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Centre

Much of what we know about estrogens’ role in the brain comes from animal studies, where researchers can directly manipulate the location and concentration of estrogens and observe how they affect cognitive abilities such as spatial navigation and memory. Studying estrogens’ effects on cognition in humans is a bit trickier. Therefore, Dr. Einstein and her lab look for opportunities where women’s estrogen levels are naturally or medically altered. One example is oral contraceptives, or “the pill”, used by over 100 million women worldwide. The pill’s exogenous supply of synthetic estrogen and/or progesterone hormones suppresses the monthly fluctuations of their endogenous counterparts. Some studies have examined the pill’s effects on mood, particularly its link to increased depression. But very few have considered how it may be influencing cognition. Einstein lab member Laura Gravelsins began addressing this serious knowledge gap in her Masters project. She asked whether the pill affects short term

Photo Provided by Dr. Einstein


Women taking oral contraceptives came into the lab and performed a classic working memory task on two separate occasions: once within one to two hours of taking their pill, and once about 24 hours after taking it (when their synthetic estrogen levels would be lowest). Naturally-cycling women did the same experiment during both the early and late follicular phase of their menstrual cycle, representing low and relatively high 17-beta estradiol levels, respectively. Somewhat surprisingly, Laura did not find a difference in task performance between high and low estrogen states in either the naturally cycling women or those taking the pill. In addition, both groups of women performed similarly on the task. “One positive thing that came out of this study was the finding that the pill’s pharmacokinetics did not influence cognition, at least in the task we looked at, which is something very surprising that had not been looked at before,” explains Laura. “There’s very limited knowledge right now on how contraception affects the brain, so I think its extremely important as women to advocate for more research on how contraception might influence a wide variety of cognitive abilities.” Now a first year PhD student in Psychology, Laura hopes to continue exploring this question. She has also joined Psychology Masters student Alana Brown in studying women positive for the BRAC1 or BRAC2 mutation who have had oophorectomies (surgery to remove their ovaries) to reduce their risk of developing ovarian and breast cancer. The ovaries are the primary producers of 17-beta estradiol. Consequently, these women experience a

Photo by Krystal Jacques

memory—the ability to maintain information in your mind and manipulate it in order to accomplish a goal. Work by another lab had previously shown that women with high circulating 17-beta estradiol levels performed better on a spatial memory task than women with low levels.2 Laura wanted to know how synthetic estradiol would interact with memory. She was particularly interested in the pill’s pharmacokinetics: a large spike in estrogen that occurs one to two hours after taking a pill, followed by a gradual decline in estrogen over the next 20 or so hours.

Graduate students Laura Gravelsins (left) and Alana Brown (right) at the Toronto Neuroimaging Facility (ToNI) “surgically induced” menopause, although some choose to take hormone replacement therapy (HRT) to restore their estrogen levels. This surgically induced menopause differs from natural menopause in two important ways. First, the drop in 17-beta estradiol from removing the ovaries is rapid compared to the slow decline in estrogens that occurs over several years in natural menopause. Second, the women undergoing oophorectomies are on average 10 years younger than the age when menopause would typically occur. “Importantly, it seems that women who have had oophorectomies may have an increased risk for developing Alzheimer’s disease” explains Alana. “So, we’re using brain imaging and neurocognitive assessments and following these women over time to try and understand what might be contributing to this increased risk.” To parse out the effects of estrogen and age, they are studying four groups of women: (1) those who had oophorectomies and are on HRT; (2) those who also had oophorectomies but are not on HRT; (3) age-matched healthy control participants; and (4) older, naturally menopausal women. Alana is using functional magnetic resonance imaging (fMRI) to study associative memory—the ability to tie previously unrelated items of information together. In the MRI scanner women are shown a series of faces with names attached and are asked to judge whether it is a “good name” or a “bad name” for the face. After the scan, they are shown the faces again, this time accompanied by two

names, and are asked to remember which name was previously linked with that face. Alana looks at the brain activity while the women are making the associative links between faces and names in the scanner and compares the brain response to facename pairs that are later correctly recalled versus those that aren’t. This gives her a pattern of brain activity that is associated with “successful” versus “unsuccessful” associative memory encoding. The research team is particularly interested in prefrontal areas, the fronto-parietal attention network, and the anterior hippocampus. Some studies show reduced activity in the anterior hippocampus of people who have a greater risk of Alzheimers, while other studies have found spikes in activity. Alana hopes to understand how the anterior hippocampus functions in post-oophorectomy women early on, and then track its activity over several years to investigate what role it has in any signs of cognitive decline that may appear. “Its very important to understand the role of estrogens in aging and dementia as well as in the presentation of other conditions such as schizophrenia, depression, and even autoimmune disorders,” says Dr. Einstein. “All of these clinical syndromes are influenced—both negatively and positively—by estrogens, and ultimately estrogens may be seen as key players in the etiology and treatment of these disorders.” References 1. Alzheimer’s A. 2015 Alzheimer’s disease facts and figures. Alzheimer’s & dementia: the journal of the Alzheimer’s Association. 2015 Mar;11(3):332. 2. Hampson E, Morley EE. Estradiol concentrations and working memory performance in women of reproductive age. Psychoneuro-



Getting personal in the fight against breast cancer:

Tools that tailor treatments to patients By: Alexa Desimone


reast cancer is the most common malignancy among Canadian women.1 In 2017, there were 26,300 new diagnoses, and approximately 5,000 breast cancer-related deaths. Breast cancer may also occur in men, who represented 230 of the new diagnoses in 2017.2 Treatments for breast cancer include surgical intervention, radiation therapy, hormonal therapy, chemotherapy, and targeted therapy. These can be used alone or in combination depending on the patient’s age and/or genetic factors.1 However, it can be challenging for physicians to narrow down the optimal treatment for each individual patient, and difficult to predict their response to a specific intervention. This means the patient may receive one or more unsuccessful courses of treatment, which are often accompanied by significant side effects. For example, approximately 8,500 Canadian patients receive chemotherapy without benefit each year.3 Delays in finding an effective treatment mean higher costs for the healthcare system and greater risks for the patient. Dr. Maureen Trudeau is one of Canada’s leading breast cancer researchers who has dedicated her career to enhancing the lives of her patients. Dr. Trudeau is a medical oncologist at Sunnybrook Health Sciences Centre, Odette Cancer Centre, and an associate member of the Institute of Medical Science. She is involved in international and interdisciplinary projects to improve the treatment of patients with breast cancer, from predicting treatment efficacy and designing novel therapies 12 | IMS MAGAZINE SUMMER 2019 WOMEN’S HEALTH

Photo Provided by Dr. Trudeau

to developing breast cancer treatment guidelines for healthcare systems in Canada and around the world. “I’m currently a part of three clinical trials, two of which are focussed on developing tests that could allow physicians to accurately predict how effective a particular treatment will be for a patient within a week or two of starting the therapy,” says Dr. Trudeau. “The third trial is developing a novel treatment for brain tumours in patients whose breast cancer has metastasized to their brain.” No single therapy regimen will result in an identical response for all patients, thus, it is important to develop methods to predict customizable therapeutic regimens. Interest in such “personalized medicine” has grown increasingly within the past few years due to its significant benefits to patients, cost, and time when treating a multitude of diagnoses. It is particularly fitting when identifying ways to develop alternative therapies or reduce chemotherapy exposure among cancer patients. Dr. Trudeau and colleagues began investigating the role of Taxotere in the treatment of metastatic breast cancer and found a 55% response rate to a first-line therapy with this specific drug.4 Later studies revealed an impressive 70% response rate to a combined treatment using both Taxotere and Epirubicin in women with metastatic breast cancer. This led Dr. Trudeau and her colleagues to investigate its use in neoadjuvant therapy – an add-on therapy given before surgery.5 Ribonucleic acid (RNA) was isolated from

Dr. Maureen Trudeau, MA, MD, FRCPC Medical Oncologist Affiliate Scientist, Evaluative Clinical Sciences, Odette Cancer Research Program, Sunnybrook Research Institute Member, Division of Medical Oncology and Hematology, Sunnybrook Health Sciences Centre Professor, Department of Medicine, Faculty of Medicine, University of Toronto Associate Member, Institute of Medical Science, University of Toronto Member of Breast Cancer Site Group, Program in Evidence-Based Care and Drug Advisory Committee, Cancer Care Ontario Chair, pCODR expert review committee, Canada tumour core biopsies taken from locally advanced breast cancer (LABC) patients prior to, during, and after this combination chemotherapy. Then, researchers analyzed the biopsies to identify each patients’ RNA integrity number—a measure of how degraded the tumour’s RNA was following treatment. They found that the RNA of tumours that responded well to chemotherapy displayed a unique pattern of bands compared to poor- or non-responders. RNA degradation analysis was able to identify 20% of patients that were chemotherapy non-responders, substantially more compared to clinical assessment alone which only detected 5%.6 This novel biomarker of chemotherapy response could allow physicians to advise patients accordingly, such that non-responding patients may be spared unnecessary toxicity from chemotherapy and be moved to alternative treatments such as surgery, radiation, or other chemotherapy regimens. Additionally, this finding led to the formation of a biotechnology firm called “Rna Diagnostics.” Dr. Trudeau serves as a clinical advisor for this innovation in personalized medicine for cancer therapy (for more information, visit Currently, Dr. Trudeau and Rna Diagnostics are collaborating on an international study developing this novel biomarker on a global scale. A second project that Dr. Trudeau is working on is assessing chemotherapy efficacy using quantitative ultrasound

FEATURE (QUS) to predict breast cancer response to neoadjuvant chemotherapy (meaning prior to primary treatment). This project is based on the work of Dr. Gregory Czarnota and colleagues who developed and implemented QUS to determine tumour responses to radiotherapy as early as 24 hours post-treatment.9 Traditional imaging techniques lack the specificity and efficiency to determine tumour size reduction, as they often require several weeks to months of treatment administration before changes to tumours can be seen. Additionally, many chemotherapy cases may result in a cytotoxic response but no mass diminishment, and therefore would be missed with conventional imaging techniques.10 What’s more, there are early microstructural changes that occur due to tumour cell death—taking place hours to days post-treatment—that have previously been difficult to quantify. That is why the research team is testing the utility of low frequency QUS techniques to non-invasively monitor microstructural changes and determine the effects of chemotherapy on LABC patients.10,11 The QUS technique characterizes tissue abnormalities in the frequency content of the radiofrequency backscatter acquired by the ultrasound.8 Tumour cell death initiates significant alterations in nuclear structures shown through cellular changes in elasticity, viscosity, density, and the spatial organization of cell ensembles.10 All these parameters subsequently influence the pattern of ultrasound backscatter characteristics. The results of this study identify a unique sensitivity and specificity to pinpoint patients with poor response to therapy early on in their treatment onset. This study provides a step forward towards personalized cancer therapy, where an inefficient regimen can be changed to a more effective one more quickly than ever before. One of Dr. Trudeau’s more recent projects focuses on breast cancer patients whose tumours are positive for human epidermal growth factor receptor 2 (HER2+). A tyrosine kinase receptor, HER2 is associated with a poor prognosis, aggressive tumour proliferation, and poor response to chemotherapy.12 This molecular abnormality amongst breast cancer patients prompted HER2 testing

guideline in Canada to determine the appropriate treatment and sequence of treatments. Currently, targeted therapy with the agent trastuzumab, which specifically targets those HER2+ tumour cells, significantly improves diseasefree survival and mortality in patients with HER2 overexpression. However, HER2+ breast cancer patients are highly susceptible to develop brain metastases, and trastuzumab therapy is unable to cross the blood brain barrier (BBB).13 “The HER2-positive breast cancer patients are at a higher risk of developing brain metastases, so the question is how do you treat them?” explains Dr. Trudeau. “If the systemic disease is under control but you cannot access the brain, what else can you do?” Surgery, whole brain radiation, and stereotactic radiosurgery are the traditional treatment options for these brain metastases. Dr. Trudeau, Dr Nir Lipsman, Dr Arjun Saghal and their team set out to develop less invasive and more effective therapies for these patients. The utility of focused ultrasound (FUS) after a primary treatment is a promising technique aimed at inducing controlled BBB permeability in order to further treat HER2+ brain metastases. The FUS technique, originally pioneered by Dr. Kullervo Hynynen at the Sunnybrook Research Institute, is a non-invasive technique where ultrasound is used to promote movement of drugs across the BBB and into certain areas of the brain.14 Many factors, including tumour location, number of lesions, risk of bleed, and skull thickness will influence the optimization of this treatment. In the current study, patients will receive a loading dose of trastuzumab (if they haven’t been on trastuzumab already) and then receive FUS in hopes of opening the BBB to allow the drug to reach the brain tumour. In order to confirm the BBB permeability, a contrast dye will be administered. Additional amendments will be added to the clinical study to include radiolabelling on trastuzumab in order to track drug delivery to the brain and confirm its efficacy. Although this clinical study is in the beginning stages of optimization, Dr. Trudeau and her colleagues are optimistic. As a healthcare provider, Dr. Trudeau is involved in several committees focused

on healthcare delivery and guideline development. As a member of the pan-Canadian Oncology Drug Review (pCODR) and Chair of the Expert Review Committee (pERC), she is responsible for assessing cancer drugs and guiding funding decisions based on clinical and economic evidence, patient values, and adoption feasibility. Additionally, Dr. Trudeau is interested in the Ontario Cancer Data Linkage Project (cd-link), a collaboration between Cancer Care Ontario and the Institute for Clinical Evaluative Sciences. Cd-link is a data release program that provides direct access to de-identified healthcare data through a comprehensive Data Use Agreement to all researchers. Specifically, Dr. Trudeau is looking into specific chemotherapy regimens from previous clinical trials and comparing whether the real-world data is corresponding to the results of the original clinical trial. This is an important initiative to further assess the efficiency of drug allocation, and to ensure patients are receiving equitable resources in a timely fashion. References 1. Government of Canada (2017). Breast Cancer. https://www.canada. ca/en/public-health/services/chronic-diseases/cancer/breast-cancer. html 2. Canadian Cancer Society (2019). Breast cancer statistics. https:// 3. Bombard, Y., et al. (2014). Patients’ perceptions of gene expression profiling in breast cancer treatment decisions. Current Oncology, 11(2), e203-211. 4. Trudeau, M.E., et al. (1996). Docetaxel in patients with metastatic breast cancer: a phase II study of the National Cancer Institute of Canada-Clinical Trials Group. Journal of Clinical Oncology, 14(2), 422-428. 5. Pritchard, K. and Whelan, T. (2005). Clinical trial update: National Cancer Institute of Canada. Breast Cancer Research, 7(2), 48-51. 6. Parissenti, A.M., et al. (2015). Tumor RNA disruption predicts survival benefit from breast cancer chemotherapy. Breast Cancer Research and Treatment, 153, 135-144. 7. Rna Diagnostics (2017). Meet the Rna Diagnostics Team. http:// 8. Tadayyon, H., et al. (2016). Quantitative ultrasound assessment of breast tumor response to chemotherapy using a mutli-parameter approach. Oncotarget, 7(29), 45094-45111. 9. Vlad, R.M., et al. (2009). Quantitative Ultrasound Characterization of Responses to Radiotherapy in Cancer Mouse Models. Clinical Cancer Research, 15(6), 2067-2075. 10. Sadeghi-Naini, A., et al. (2013). Quantitative Ultrasound Evaluation of Tumour Cell Death Response in Locally Advanced Breast Cancer Patients Receiving Chemotherapy. Clinical Cancer Research, 19(8), 2163–74. 11. Sadeghi-Naini, A., et al. (2013). Low-frequency quantitative ultrasound imaging of cell death in vivo. Med Phys, 40(8), 082901 (13 pp). 12. Marshall, D.A., et al. (2019). Adherence to human epidermal growth factor receptor-2 testing and adjuvant trastuzumab treatment guideline in Ontario. Journal of Oncology Pharmacy Practice, 0(0), 1-7. 13. Maurer, C., et al. (2018). Risk factors for the development of brain metastases in patients with HER2-positive breast cancer. ESMO Open, 3, e000440. 14. Burgess, A., et al. (2015). Focused ultrasound-mediated drug delivery through the blood-brain barrier. Expert Review of Neurotherapeutics, 15(5), 477-491.



Shedding the


around endometriosis Using translational research to improve medical management and diagnosis of endometriosis

By: Mathura Thiyagarajah


ndometriosis affects 1 in 10 women of reproductive-age1 yet diagnosis can be delayed an average of seven years from onset of symptoms2. Despite the high prevalence, the term endometriosis is often met with a complete lack of recognition—including from women of reproductive-age. Poor awareness and understanding of symptoms related to disorders in women’s health is a common challenge in the field with real implications for patients’ quality of life. Women with endometriosis are familiar with this barrier, as symptoms of heavy bleeding during periods and pain during menstruation, ovulation, and intercourse can be falsely normalized as typical of “women’s pain’. This, coupled with the stigma surrounding menstruation and women’s sexual health, has contributed to the underfunding and underprioritizing of endometriosis research.3 Dr. Robert Casper, Scientific Director of TRIO Fertility, is determined to further our understanding of endometriosis etiology to improve medication management of symptoms and develop treatments that combat infertility associated with the disease. He explains his approach to research and clinical practice as, “do[ing] basic science that has the potential to impact women’s health directly.” Dr. Casper began his medical education at Western University in London, Ontario, specializing in Obstetrics and Gynecology. He completed his fellowship 14 | IMS MAGAZINE SUMMER 2019 WOMEN’S HEALTH

training in Reproductive Endocrinology and Infertility at the University of California San Diego, whilst studying under an international figure in the field of reproductive endocrinology, Dr. Sam Yen (M.D., D.Sc.). Upon completion, Dr. Casper spent some time at a faculty position at Dalhousie University before moving back to London to set up the city’s first in-vitro fertilization (IVF) program in 1984. Today, Dr. Casper is a Senior Investigator at the LunenfeldTanenbaum Research Institute, and his clinical and research work continues to focus on fertility, breast cancer, hormone replacement for menopause, and endometriosis. During the early days of his career, the lack of sufficient treatments available to ease the immense and debilitating pain of endometriosis patients was what originated his longstanding interest. “In fact, some of the treatments were making it worse,” he elaborates. Endometriosis is a chronic benign inflammatory disease characterized by pelvic pain resulting from deposits of endometrial cells outside of the uterus. Most women have some degree of retrograde blood flow—which is when blood flows through the fallopian tubes and ovaries at the time of the menstrual period instead of out of the cervix. For some women, these endometrium cells implant into areas of the pelvis and form lesions, causing endometriosis. The reason why endometrium implants and lesions are produced in some women and not

others is still unknown, though genetics may play a role, as women who have the disease in their family history are more likely to develop it themselves. Previously, diagnosis relied on a laparoscopy: a minimally invasive surgical procedure that allows physicians to view and then remove endometrium implants and lesions. However, a wait time of six to nine months has contributed to delayed diagnosis. Dr. Casper has seen patients in his clinic whose symptoms were relieved for just a few months after surgery and inevitably returned because some microscopic lesions cannot be removed surgically. Thus, he believes that, “medical treatment is much better as it inhibits implants in all of the cells.” Dr. Casper advocates for presumptive diagnoses based on history (unusual presentations of pain outside of the period of menstruation), physical examination (nodular tenderness behind the cervix), or ultrasound imaging (blood-filled cysts on ovaries) to initiate treatment earlier. He explains that if pain starts one to two days before the onset of bleeding and non-steroidal antiinflammatory drugs (NSAIDs) do not alleviate pain, this indicates symptoms distinct from regular cramping in the lower abdomen related to menstruation. Dr. Casper’s passion for improving medical management of endometriosis shows in his editorial in the medical journal, Fertility and Sterility, which outlines his support to replace oral contraceptives pills (OCPs)

FEATURE as the first line of treatment with oral progestin-only treatments.4 This suggestion contradicts current guidelines from obstetrics and gynecology societies around the world which posit OCPs as first line of treatment. Dr. Casper argues the excess of estrogen in OCPs is counterproductive as endometriosis implants have abnormal progestin receptors—not deficient estrogen receptors. Since the excess estrogen can worsen symptoms, Dr. Casper recommends progestin-only alternatives such as Visanne (dienogest), an oral progestin with anti-inflammatory and anti-angiogenic properties that can reduce the size of endometrium implants. He also suggests gonadotropin releasing hormone (GnRH) agonists such as Zoladex (goserelin) and Lupron (leuprolide). During his fellowship training in San Diego, he conducted original research using the first synthesized GnRH agonist, given by Dr. Roger Guillemin, the recipient of a Nobel Prize for his discovery of the GnRH structure. Initially, they thought GnRH agonists could help fertility—but learned that the drug shut down signals from the pituitary. As a result, they redirected their efforts to endometriosis because of the agonist’s ability to shut down the ovaries. While GnRH agonists work well to treat endometriosis symptoms,

Photo by Kenya Costa-Dookhan

Dr. Casper stresses the importance of co-administration with add-back estrogen therapy to alleviate any side effects associated with the resulting low estrogen. His research documenting bone density of women on Lupron with add-back therapy at 5 years and 10 years follow-up demonstrated alleviation of symptoms and no loss of bone density. Still, the drawback of both GnRH agonists and progestin-only pills is that they inhibit ovulation, which denies the option of pregnancy for women who want to conceive. Increasing knowledge on etiology of endometriosis could prove promising for developing treatments that allow for ovulation. The connection between infertility and endometriosis is strengthened in his lab by his recent discovery that endometrial lining after ovulation has to thin through compaction to promote embryo implantation instead of thickening as is commonly assumed.5 Implementing this knowledge into practice has allowed pregnancy rates at his clinic to double by excluding cycles that do not show the desired compaction. This discovery could explain the pathophysiology of infertility in endometriosis since progesterone resistance prevents the endometrium from compacting. Dr. Casper’s lab is currently investigating

the possible relationship between endometriosis and cell senescence: a state in which normal cells enter a nondividing and apoptosis-resistant phase. The cells in endometriosis implants are hypothesized to secrete an inflammatory signal that damages the cells around them, while remaining unresponsive to estrogen or progesterone and causing pain. If this research demonstrates that endometriosis implants contain an abundance of senescent cells, development of senolytics as treatments could alleviate endometriosis without inhibiting ovulation. Dr. Casper expects that there will be treatments on the market for endometriosis that do not prohibit ovulation in the next few years, which he states would be “the best of all worlds.” References 1. Bedaiwy, M. A., Alfaraj, S., Yong, P., & Casper, R. (2017). New developments in the medical treatment of endometriosis. Fertility and Sterility, 107(3), 555-565. 2. Taylor, H. S., Adamson, G. D., Diamond, M. P., Goldstein, S. R., Horne, A. W., Missmer, S. A., ... & Taylor, R. N. (2018). An evidence‐based approach to assessing surgical versus clinical diagnosis of symptomatic endometriosis. International Journal of Gynecology & Obstetrics, 142(2), 131-142. 3. As-Sanie, S., Black, R., Giudice, L. C., Valbrun, T. G., Gupta, J., Jones, B., ... & Taylor, R. N. (2019). Assessing research gaps and unmet needs in endometriosis. American Journal of Obstetrics and Gynecology. 4. Casper, R. F. (2017). Progestin-only pills may be a better first-line treatment for endometriosis than combined estrogen-progestin contraceptive pills. Fertility and Sterility, 107(3), 533-536. 5. Haas, J., Smith, R., Zilberberg, E., Nayot, D., Meriano, J., Barzilay, E., & Casper, R. F. (2019). Endometrial compaction (decreased thickness) in response to progesterone results in optimal pregnancy outcome in frozen-thawed embryo transfers. Fertility and Sterility (Epub ahead of print).

Dr. Robert Casper, MD, FRCSC, REI Scientific Director, TRIO Fertility Professor Emeritus, Division of Reproductive Sciences, University of Toronto



Photo by Mikaeel Valli

Healing One Woman at a Time by Educating Both Sides of the Doctor’s Desk By: Mikaeel Valli


ooking back within the last few decades, significant progress has been made in recognizing and improving women’s health. But this was certainly no easy feat. One aspect that positively influenced women’s health was advocacy for policy change to allow inclusion of women in clinical research, which was formally launched by the National Institutes of Health in the US in 1993, and soon after in Canada in 1997. This kind of policy pushed for researchers to educate the public and medical community on how medications, procedures, and diseases affected women differently than men. As a result of this policy change, an antidepressant drug known as nefazodone was taken off the Canadian market in 2003 after nine years, as it was discovered to cause serious liver damage especially in women, to an extent that some patients required a liver transplant to save their lives. Instrumental to this drug removal was Dr. Donna Stewart, one of Toronto’s clinician-scientists that has been playing a leading role in shaping a better future for women’s health. She is a psychiatrist at Toronto General Hospital and the Inaugural Chair of Women’s Health at the University Health Network and University of Toronto, whom the IMS Magazine had the pleasure of interviewing.

abuse and harassment.” From that point, Dr. Stewart knew it was her calling to combat such unfairness towards women and their health. Five decades later, she has worked with many colleagues and stakeholders locally and internationally to push for reform in women’s health beyond psychiatry, into medical education and public health. She tackles the challenges of women’s health from both ends of the doctor’s desk: enhancing knowledge, knowledge translation, and access to both healthcare providers and patients.

Dr. Stewart recalled back to the late 1960s, when she became intimately aware of how frequently women were experiencing sexual and physical violence. This was before she became a psychiatrist, when she was practicing family medicine in a small town in northern Ontario. “There was a lot of family violence and sexism,” Dr Stewart explained. “Women that worked at the local paper mill would come and tell me about terrible things that happened to them at work that included sexual

On the doctor’s side of the desk, Dr. Stewart is working on enhancing healthcare providers’ knowledge and understanding of intimate partner violence (IPV) and sexual violence (SV), particularly against women. “Prevalence rates of such violence occurs from 15 to 71% across a lifetime or 4 to 54% within the last 12 months, based on a 10-country study by the World Health Organization” she explained. Furthermore, Dr. Stewart elaborated that these numbers are


Dr. Donna E. Stewart, CM, MD, FRCPC Senior Scientist, Toronto General Hospital Research Institute University Professor, University of Toronto Inaugural Chair, Women’s Health, University Health Network probably higher because women may feel guilty, ashamed, or face social stigma if they decide to speak out. These types of violence are pressing as they can result not only in physical injury, but also mental health complications including depression, anxiety, post-traumatic stress disorder, and an array of other mental challenges. It has been estimated that upwards of 30% of psychiatric patients have been exposed to IPV and SV. Needs assessment has indicated that IPV and SV are key determinants of women’s mental health, however, “60% of mental health professionals report that they lack adequate knowledge and desire more education on this area,” Dr. Stewart said. Since these kinds of violence often do not get readily disclosed by patients or enquired about by psychiatrists or other physicians, this unfortunately takes a toll on women’s health as it impacts their diagnosis, treatment and outcome. “Healthcare physicians, including psychiatrists, must be familiar with the

FEATURE best evidence-based short- and long-term management of mental health sequalae as a result of these kinds of violence,” Dr. Stewart emphasized. Therefore, Dr. Stewart led the World Psychiatry Association, along with the World Health Organization with other colleagues across the globe, to develop an Intimate Partner Violence and Sexual Violence (IPV/SV) competencybased curriculum for medical students, psychiatric trainees and practicing psychiatrists which has now been translated into 10 languages. This curriculum includes recommendations of how to assess an array of competencies including misconceptions, health sequalae and psychiatric management of mental health trauma. In addition, the curriculum includes recommendations for psychiatric management including the initiation and monitoring of first line methods needed to treat IPV/SV psychological trauma including cognitive behaviour therapy, pharmacology intervention, or rapid eye movement desensitization. Dr. Stewart also played a role in shaping the new Canadian family violence curriculum-called VEGA-to be engaging and interactive for trainees because she has found, in her decades of teaching experience, medical students often become disengaged and uninterested with the traditional lecture format. “So, with Dr. Harriet MacMillan from McMaster University as lead, and other colleagues,

Stewart explained. The advantage with this format is that it allows trainees to receive feedback and have a chance to correct their choices. “The students love it!” Dr. Stewart said, encouraged by their responses. “We are in the process of scientifically assessing student’s learning of the new curriculum to see how effective it is in making a meaningful impact on women suffering from IPV/SV and other victims of family violence. We essentially are aiming for enhanced knowledge, attitudinal change, and skill development which provide real life competencies.” On the other end of the desk, Dr. Stewart with her colleagues helped develop a patient decision aid (PDA) for pregnant women affected with major depressive disorder (MDD). MDD is a common and serious complication associated with pregnancy. “If this condition goes untreated, it can lead to a seven-fold increased risk for postpartum depression and be detrimental to the maternal-infant attachment and child development,” Dr. Stewart cautioned. Treatment options are available to combat MDD during pregnancy, however, “treatment decisions must be guided not only by evidence, but also by how a woman values the potential benefits and drawbacks of the treatment options, which she prefers, and the extent to which she wants to be involved in the treatment,” she explained. Most women desire to play an active role in their treatment plan, but 50% of women have a decisional conflict—meaning they

...Dr. Stewart knew it was her calling to combat such unfairness towards women and their health.

the research team incorporated games and role-playing videos into the new curriculum. In the role-playing videos, for instance, the acting physician would say X, then the acting patient says Y, and then the trainee is to select from a choice of what the physician’s reply should be” Dr.

are having difficulty, discomfort and/ or uncertainty about a medical decision. Decisional conflicts can increase the chances a person will delay an important decision or make a decision that will negatively impact their health.

Evidence shows that routine clinical care or existing informational resources appear to not be enough to reduce decisional conflict. Therefore, the research team that was led by Dr. Simone Vigod, and included Dr. Stewart, developed a PDA to specifically assist expectant mothers with MDD. The PDA is an online tool that aims to educate, enhance and supplement patient-provider consultation by providing detailed-specific, and personalized focus on options and potential outcomes. The PDA works to reduce decisional conflict by helping women identify the decision in question, presenting evidence-based information about benefits, risks and side effects of available options, and clarifying patient values related to the decision. “For example, they may feel that medication is not best for them and their babies, and that psychotherapy is better. Or if the depression is severe and they are experiencing suicide ideations, then psychotherapy is not enough. We give them information about the medication— what is known and unknown about it, and we help them choose the best course of action” Dr. Stewart explains. The research team carried out a pilot clinical trial testing the utility of PDA for pregnant women with MDD. They were encouraged to find it was effective in reducing decisional conflicts, making this tool promisingly effective for women with otherwise minimal access to specialized reproductive psychiatric care. “The next stop going forward is to do a larger scale evaluation of the PDA for its impact on longer-term maternal and child outcomes, including maternal depression and anxiety symptoms during and after pregnancy, and understand the barriers and facilitators to allow PDA to be used in mainstream practice.” When asked about her legacy, Dr. Stewart says she takes greatest pleasure in seeing her former trainees become the leading women’s health researchers in Canada and internationally. Reflecting on her career and research, Dr. Stewart ultimately hopes that her contributions to the advancement of knowledge and education will lead to meaningful changes in clinical practice locally, nationally and across the globe, to allow each woman to receive the best evidenced-based and equitable healthcare possible.



Master of Science in


The following are Master’s Research Projects completed by students in the Master of Science in Biomedical Communications (BMC) program at the University of Toronto as part of their degree. Students can specialize with a focus on using animation or non-linear interactive media to address a particular communication gap in a scientific topic.


Systemic lupus erythematosus (SLE) is an autoimmune disease in which the body’s immune system attacks healthy tissue in various parts of the body. Our understanding of SLE’s causative mechanisms are poor and current treatments are sparse. Recently, researchers at the Princess Margaret Cancer Centre’s McGaha Lab, in partnership with scientists around the world, have uncovered the aryl hydrocarbon receptor (AhR) as a critical link within the process of maintaining selftolerance (the immune system’s ability to recognize self). While this is an exciting discovery with promising therapeutic potential, they need a way to communicate their complex findings in an understandable and accurate manner to various audiences, including potential graduate students. My animation project aims to highlight the forefront of SLE research by elucidating the role of AhR in immune self-tolerance and SLE development. By fully utilizing the medium of animation, this project’s ultimate goal is to fuel interest, increased attention, and hope in SLE research.







One of the many interesting and unique aspects about bats — the fact that they are the only flying mammals with many unique flight adaptations — is often not an accessible topic for the general audience; usually the information can be found only in dense research papers with complex graphs and charts.The goal of this project was to create a three to five minute 2D/3D animation on bat flight which will convey the basic information needed to understand bat flight (anatomy, aerodynamics, morphology, etc.) in an engaging and explicit way so that the general public can understand these complex concepts. This animation will further educate the public on bats in hopes of decreasing negative perceptions and myth beliefs. With an increase in knowledge, positive perceptions, and interest, hopefully the general public interest in bat conservation will also increase.


For my master’s research project, I have developed an educational 3D animation on the role of actin in cell motility as a supplementary visual learning resource for undergraduate cell biology students.This animation primarily attempts to bridge the knowledge gap in undergraduate cell biology students’ understanding of key biological concepts: (1) the fundamental characteristics of the actin cytoskeleton in cell movement, and (2) the underlying principles and mechanism regulating the dynamics of actin architecture. The ability to move is a key aspect of evolution for communication and survival by living organisms. Most motile cells rely on a dynamic system of actin skeleton for locomotion. The machinery of the cell shape changes and motility rely on the continuous assembly and disassembly of different architectures of actin skeleton. It is important to understand these concepts for those studying cell biology. However, undergraduate cell biology students have difficulties in gaining a comprehensive understanding of actin structures and the processes of cell movement due to the complexity of the topic and limited visual learning resources.



Kidney Disease and Barriers to Treatment in Indigenous Communities By: Sumaya Dano


healthcare system may provide world class medicine, but unless all of its users can access it, the system is second rate. Understanding and addressing these gaps in health care access can complement our current research discoveries and drive advancements in medicine. Canada is a global leader in Chronic Kidney Disease (CKD) research. CKD involves a gradual loss of kidney function and affects over three million adults in Canada.1 Since the emergence of dialysis machines in 1943, different dialysis options have become available to accommodate the varied lifestyles of patients. While hemodialysis requires multiple visits to the clinic each week, peritoneal dialysis can be done at home. Successful kidney transplantations from both living and deceased donors give patients with CKD the opportunity to return to their normal productive lives with a new kidney. However, the benefits of these advancements and treatment options are inaccessible for many Indigenous Canadians with CKD. The prevalence of end-stage kidney disease is approximately four times higher among Indigenous people, relative to the general Canadian population, yet Indigenous Canadians are less likely to see a nephrologist.2,3 Despite kidney transplantation being an ideal treatment for patients with end-stage kidney disease, Indigenous people are less likely to be placed on a waiting list to 20 | IMS MAGAZINE SUMMER 2019 WOMEN’S HEALTH

receive a kidney transplantation compared to other Canadian patients.4 In fact, there has been an increase in the number of Indigenous patients with CKD that need dialysis, without a corresponding increase in kidney transplantation rates. The reasons for these disparities are not fully understood, which impairs any efforts to bridge the gap for Indigenous patients to be adequately treated for CKD. One potential barrier to treatment among Indigenous patients with CKD is the geographical distance to hospitals. This limits their access to dialysis services and even necessary lab tests for kidney transplant evaluation. One solution is peritoneal dialysis treatment, which may be ideal for eligible Indigenous patients as it provides the convenience of home dialysis treatment. However, Indigenous patients with CKD are still less likely to start peritoneal dialysis compared to nonIndigenous patients with CKD.5 The disparities in treatment for CKD among Indigenous Canadians are disheartening. As part of my graduate research I’ve encountered many patients who travel far to visit hospitals in Toronto. I’ve come to learn that it’s not just the distance that makes it hard for patients to make the long drives to their appointments in big cities. Patients also face significant financial barriers. In the case of getting the lab work-up for kidney transplantation, patients have told me that it was more “cost-effective” to stay in a hotel for a few days in Toronto as opposed to going

back and forth from their hometown. However, cost-effective is nowhere near the right word for most patients, as the costs of staying in Toronto quickly add up to a significant amount of money many patients cannot afford. In addition, I never considered the financial burden kidney transplantation could pose on a person’s life insurance. This came to my knowledge after attending a conference where a mother of a patient with CKD explained how her life insurance went up after donating her kidney to her son. Surely such a selfless act of love should not be accompanied by a higher price tag in insurance rates. Hearing these different patient’s stories helped me realize there is more than just geographical distance preventing patients from pursuing kidney transplantation. I can only imagine how challenging the situation must be for Indigenous patients. Not only are many Indigenous reserves far away from urban hospitals, but for Indigenous patients to make the trip, they must leave their community and the people who appreciate and understand their culture and values. Many healthcare practitioners, including myself as a research student, do not fully appreciate nor understand the culture and values Indigenous people hold.


“ Not fully understanding the lives of our patients makes it harder to guide them to a suitable treatment option. For instance, one reason behind the high rates of CKD in Indigenous communities is an increased prevalence of diabetes and obesity.6 Healthy eating habits and exercise are two effective ways to prevent and manage diabetes and obesity. However, when healthcare providers advise their Indigenous patients to make healthier food choices, they are ignoring the fact that food insecurity and limited access to healthy food options are the reality for many Indigenous people living in remote and rural areas. Ignorance of the systemic challenges Indigenous people face everyday can make it difficult to come up with a treatment plan the patient could realistically be able to adhere to. Ultimately, understanding the barriers preventing Indigenous patients from receiving available treatment alternatives allows healthcare providers to cater health care management to these patients based on their specific needs and concerns. A study examining the association between the location of residence and likelihood of kidney transplantation reported that geographical barriers alone did not explain the lower rates of transplantation

Ignorance of the systemic challenges Indigenous people face everyday can make it difficult to come up with a treatment plan the patient could realistically be able to adhere to.

in Indigenous people. There are more complex reasons underlying inaccessible healthcare for Indigenous patients than just geographical distance. In fact, a research study exploring barriers to initiate peritoneal dialysis in Indigenous people suggested that potential factors included mental health and financial issues.5 Moreover, many Indigenous patients also express a sense of loneliness and isolation when leaving their families and friends for treatment. Clearly, there are many different factors associated with Indigenous patients not fully accessing healthcare services that require more in-depth analysis and engagement with the Indigenous communities. 7

Canadians have been at the forefront of advanced medical research, particularly regarding diabetes and kidney disease, and their work has improved healthcare outcomes for millions of patients worldwide. In the midst of the great research being done, however, it is important to understand the perspective and priorities of the patients impacted by these fundamental changes in medicine. Currently, CKD is a rising global public health issue resulting in poor health outcomes for patients.8 Disadvantaged and marginalized populations, such as Indigenous communities, have higher

rates of CKD compared to the general Canadian population but less access to effective treatments. These disparities should be addressed as they do not reflect our sophisticated advancements in medicine. As Canadians it is our responsibility to harness our considerable capacity for innovative research to understand the barriers to accessing treatment and allow everyone to benefit from our medical advancements. References: 1. Arora P, Vasa P, Brenner D, et al. Prevalence estimates of chronic kidney disease in Canada: results of a nationally representative survey. Cmaj. 2013 Jun 11;185(9):E417-23. 2. Gao S, Manns BJ, Culleton BF, et al. Prevalence of chronic kidney disease and survival among aboriginal people. Journal of the American Society of Nephrology. 2007 Nov 1;18(11):2953-9. 3. Yeates K, Tonelli M. Chronic kidney disease among Aboriginal people living in Canada. Clinical nephrology. 2010 Nov;74:S57-60. 4. Anderson K, Yeates K, Cunningham J, et al. They really want to go back home, they hate it here: the importance of place in Canadian health professionals’ views on the barriers facing Aboriginal patients accessing kidney transplants. Health & place. 2009 Mar 1;15(1):390-3. 5. Mathew AT, Park J, Sachdeva M, et al. Barriers to peritoneal dialysis in Aboriginal patients. Canadian journal of kidney health and disease. 2018 Jan 3;5:2054358117747261. 6. Collier R. Renal disease more prevalent and problematic for Aboriginal peoples. 7. Tonelli M, Hemmelgarn B, Kim AK, et al. Alberta Kidney Disease Network. Association between residence location and likelihood of kidney transplantation in Aboriginal patients treated with dialysis in Canada. Kidney international. 2006 Sep 1;70(5):924-30. 8. Garcia-Garcia G, Jha V, World Kidney Day Steering Committee. Chronic kidney disease in disadvantaged populations. Nephron Clinical Practice. 2014;128(3-4):292-6.



Crisis Pregnancy Centres The Risk They Pose to Women’s Reproductive Rights

By: Colin Faulkner


n seeking abortion care at one Toronto location, specifically in Cabbagetown, a Google Maps search for “Cabbagetown pregnancy centre” produces unexpected results. Only one result comes up, a clinic called “Aid to Women”, which advertises services such as emotional support, information on prenatal development and birth, baby clothes, pregnancy tests, medical referrals, and post-abortion referrals. The search fails to show the abortion clinic, Cabbagetown Women’s Clinic, just next door. For women seeking to end their pregnancy, only the latter clinic will provide abortion services. This close proximity is one of many strategies used by facilities called Crisis Pregnancy Centres, or CPCs, to dissuade women from obtaining abortion care. CPCs across Canada are typically Christian-based, unregulated, and can be deceptively similar to an actual abortion clinic. It is helpful to compare some facts about the average abortion clinic versus a CPC. 22 | IMS MAGAZINE SUMMER 2019 WOMEN’S HEALTH

Abortion Clinics • • • •

Located in a major health care centre or a licensed Independent Health Facility (IHF) Funded by the Ontario Ministry of Health Offers both medical abortion pills and surgical abortions up to 24 weeks Offer or refer to post-op care by professional counsellors (such as those belonging to the Canadian Counselling and Psychotherapy Association) • Subject to inspections and patient confidentiality

Crisis Pregnancy Centres • • • •

Majority have charitable tax status1 Run on charitable donations, and on occasion, government funding Do not provide abortions or refer to abortion clinics Unregulated: no substantive laws or regulations are in place to dictate how they operate. As such, CPCs are not subject to government inspection, CPC employees are not bound by confidentiality that licensed medical professionals are, and written permission is not required from a patient before releasing health information for marketing purposes • CPCs are not technically medical facilities, so they aren’t bound by the same laws • Volunteer counsellors are not accountable to professional standards or associations Although this comparison shows a distinct difference between the two venues, there are many other hidden characteristics of CPCs that go unchecked. In Toronto, women seeking abortion care during an unwanted pregnancy may be misinformed and misled by these organizations.

CPCs ostensibly aim to help women, although this is often limited to women who choose to carry their pregnancy to term. Intentional or not, many CPCs engage in tactics that attempt to dissuade women from seeking an abortion.


CPCs ostensibly aim to help women, although this is often limited to women who choose to carry their pregnancy to term

Misrepresentation or misleading language is often employed, such as clinic names that resemble abortion clinics.1 In Toronto, two clinics-both named “Pregnancy Care Centre” (in North York and Scarborough) are easily mistaken as a government-funded clinic for pregnancy care. As alluded to before with Aid to Women, online search results can be misleading and have been gamed in the past through paid advertising to show up under searches for abortion clinics.1,2 Some CPCs are built right next to abortion clinics. Women report mistakenly entering fake health centres when attempting to visit the actual abortion clinics with which they have an appointment.3 A 2016 report of 180 CPCs by Joyce Arthur thoroughly evaluated misinformation which was disseminated online and in-clinic. For the 166 CPCs with websites, 99 clinics had no mention that they did not provide abortions. For example, Aid to Women states that they provide “honest abortion & abortion alternatives information”, but fail to mention that they do not provide the actual abortion care.1 55 clinics did not divulge that they were not a medical facility, and 39 promoted sexual abstinence as the ideal option for birth control among unwed women. 79 of the CPCs mentioned the negative psychological consequences, often termed “Post-abortion syndrome”, which is not recognized by the Canadian Medical Association.1 One of the major problems with the unregulated operation of CPCs is that in the past, some have obtained government funding and community support without disclosing their antichoice or religious affiliation. The 2016 report documented several instances of this behaviour. Earlier examples include a $64,000 grant to a CPC from the BC Ministry of Community, Aboriginal and Women’s Services. Similarly, a CPC in Sarnia, Ontario received an $83,800 Ontario Trillium Foundation (OTF) grant. It wasn’t until an activist, Fern Hill, reported their

Photo courtesy of Colin Faulkner

activity that the remaining funds were rescinded. The OTF sent Hill an explanation regarding the activity of CPCs, stating “we as a public funder, do not condone discriminatory practices and we have an anti-discriminatory policy in place to ensure that our grants do not fund such practices”.1 As recently as 2018, Canada Summer Jobs funding was offered to CPCs. Prochoice activists launched a campaign that led to a policy change: an attestation was made to ensure funded groups follow the Canadian Charter of Rights and Freedoms. It should be noted that although “abortion” is not mentioned explicitly in the Charter, multiple legal cases (like Morgentaler v R) have expanded the precedent of Charter rights, which informs future cases. As such, abortion has become a Charter right on the precedent of Section 7 of the Charter (violating anything that compromised a woman’s security of person) and past cases.4 This article supports a few key recommendations going forward. Although the CPCs are likely resistant to regulation, especially if politically motivated, it can be done in a common-sense manner. Regulation at the provincial or municipal level could ensure transparency in the operation and funding of CPCs. If a regulatory body was initiated, the following policies should be considered: 1. As ~68% of CPCs have charitable tax status, they should be required to follow CRA regulations, which cite organizations as ineligible “if they disseminate biased or inaccurate information that is disguised as “education” or “counselling”.” This would ensure CPC websites and counsellors are presenting evidencebased information, in good faith.5 2. CPCs offering similar services as abortion clinics except for actual abortion care should be scrutinized if they are in close vicinity to the abortion clinic. This practice can mislead women into entering the wrong building.

The Crisis pregnancy centre “Aid to Women” is located right next door to the “Women’s Clinic”, an actual abortion provider in the Cabbagetown neighbourhood in Toronto. 3. The regulatory body should require CPCs to display a prominent disclaimer online and at the clinic that indicates that they don’t provide abortions, and whether they are willing to point people towards an actual abortion clinic. 4. CPCs should not be publicly funded unless they adhere to the Canadian Charter of Rights and Freedoms. 5. Actions should be taken to eliminate false or misleading public advertising, as the counselling services they provide, which are neither professional nor unbiased. While CPCs claim they help countless women through the demanding and sometimes difficult process of pregnancy and motherhood, it should not be at the cost of transparency. A history of deceptive practices among CPCs further demonstrates a need for government regulation. References 1. Arthur J, Bailin R, Dawson K, Glenwright M, Reinhardt-Simpson A, Sykes M, et al. Review of “Crisis Pregnancy Centre” Websites in Canada. 2016 May;51. 2. Pro-choice advocates want crisis pregnancy centres defunded and regulated National | [Internet]. 2019 [cited 2019 Aug 7]. Available from: 3. Butler M. Fake Health Clinics [Internet]. National Abortion Federation. [cited 2019 Aug 7]. Available from: 4. January 18 DGU, 2018. Gilbert: Student jobs grant program respects Charter rights | Ottawa Citizen [Internet]. 2018 [cited 2019 Aug 7]. Available from: 5. Agency CR. How to draft purposes for charitable registration [Internet]. aem. 2012 [cited 2019 Aug 7]. Available from:



The “Heartbeat” Movement Is the World Becoming More Restrictive on Abortion? By: Jason Lo Hog Tian


bortion has been a controversial topic with a long history of changes in public opinion. Since its initial criminalization in the 1800s, attitudes toward abortion shifted to acceptance and advocacy in the early 20th century, on the back of multiple human rights movements and high-profile court cases. In 1973, the landmark Roe vs. Wade marked the culmination of shifting perspectives by lifting the ban on abortion in the United States of America (US). However, in early 2019 a wave of so called

“heartbeat” bills were put forward by several US states, restricting abortion after the detection of a fetal heartbeat.1 The new “heartbeat” bill is just the latest initiative in a long list of attempts to control abortion practices appearing globally, which begs the question: is the world becoming more restrictive on abortion? Abortion has been practiced since ancient times, but with the introduction of the legal system, abortion practices had to be refined and regulations had to be established. Countries differ on abortion

Figure 1: Legal status of abortion around the world in 2017.

Source: Global Abortion Policies Database, 2017 Map: © E. Opigez, IRD/CEPED


ideology, however there are six main grounds, ranging from most to least restrictive under which a nation would grant an abortion: ground 1 – risk to life, ground 2 – rape or sexual abuse, ground 3 – serious fatal anomaly, ground 4 – risk to physical and sometimes mental health, ground 5 – social and economic reasons, and ground 6 – on request.2 Another important factor to consider is the gestational age at which an abortion is deemed legal. Again, countries have differing opinions on the gestational

VIEWPOINT age threshold. Many countries allow abortion before 12 weeks of gestation with the highest being before 24 weeks in the United Kingdom.3 The recent “heartbeat” bills represent some of the strictest abortion criteria in history. These new policies restrict abortion after a fetal heartbeat can be detected unless there is a serious risk to the life of the mother (ground 1). Notably, appeals to amend the bills to include abortions performed on victims of rape or sexual abuse (ground 2) have been denied. With a large portion of the southern US either signing or pushing to sign similar bills, many are wondering if a ripple effect will cause a global shift of abortion laws. When considering abortion laws and criteria around the world, it is apparent that governments often take a strong stance, with most laws being either strongly for or against abortion. Strikingly, very few governments take a compromising approach. There are many possible factors influencing a country’s stance on abortion, including level of development, economic growth, religion, demographics, and culture. For example, the southern, republican identifying US states of Alabama, Louisiana, Mississippi, Ohio, Georgia, Missouri, Kentucky, Arkansas, Utah, and Iowa have all put forward some form of “heartbeat” bill.1 Figure 1 shows the legal status of abortion around the world as of 2017 and we can start to see what factors may play a role in a country’s decision on abortion. Despite gaining independence from colonizing nations, many African countries still govern with strict abortion laws, originally implemented by their colonizers. There has not been much change in abortion policy for many African nations and it remains one of the most restricted areas in the world.3 Similarly, South America has relatively restrictive laws, however this is more due to the strong influence of the Catholic Church and a highly patriarchal culture. Despite a surge of women’s rights movements, there are only a handful of South American countries that grant abortions. There does not appear to be any imminent change to this paradigm, even after the 2015 Zika outbreak, which meant potential birth defects for pregnant women

infected with the virus.4 Asia boasts a very diverse abortion landscape with some countries, such as Bangladesh and the Philippines, retaining very restrictive laws while others, such as China and India, have extremely liberal legislation in a response to high maternal mortality and to control population growth.5 In more developed regions such as Europe, North America, and Oceania, abortion is generally granted upon request. However, abortion policies are ever dynamic in these regions with initiatives such as the “heartbeat bill” representing the latest opposition to current legislation. Many fear a global overturning of abortion policy following the recent US “heartbeat” movement but, while it is powerful having numerous states presenting such a united front, it is unlikely that it will provoke change at the federal level. Without change at a national level, the ‘heartbeat’ bills will likely not have a larger global impact. Federal judges have already overturned “heartbeat” bills in many states, but abortion opponents are still hopeful that they can use the bills already in place to leverage the Supreme Court into overturning their 1973 decision. This is yet another stalemate in a growing list of movements to change abortion legislature. After the first decriminalization of abortion in the Soviet Union, many countries quickly followed suit, however this seemingly rapid switch to liberalization has just as quickly plateaued.6 Despite the ever-increasing number of women’s rights advocates, there has been little movement in abortion legislature around the world. Rather than being afraid of global abortion policies moving against whatever your agenda may be, we may have to be worried of our ability to affect change in abortion policies at all. It is important to refrain from being swept up in the politics and laws surrounding abortion. Many may get carried away with the politics and forget to consider if it will really have the desired effect. One argument against abortion is that legalizing it would lead to higher incidence of pregnancy terminations. However, this is often not the case since countries with liberal policies tend to have relatively low abortion rates, perhaps in part due to their emphasis on sexual education and access to contraception. Further, making

abortion illegal does not necessarily have the intended effect of reducing abortion rates, with many women opting to travel abroad or turning to clandestine abortion services, drastically increasing the maternal mortality rate. This is not to say that completely legalizing abortion always has its intended impact either. Many countries use liberal abortion policies to cover up poor health education or control for overpopulation, sometimes going as far as coercing women into having abortions.5 The legal system plays an important role in modern society by protecting the rights and freedoms of all people, but laws are not the only factor in affecting change. Strict abortion laws will not prevent women from terminating pregnancy and liberal abortion laws will not make up for poor sexual education and limited access to contraception. The latest “heartbeat” movement is another attempt to leverage the law to push an agenda without considering all of the consequences. There has been little movement in abortion policies in the past few decades and we may have lost our ability to affect global policies. For real change to be achieved, countries need to focus on educating the public about their rights, both sides of the abortion argument, and other important secondary factors that contribute to the decision to terminate a pregnancy. Taken together we can begin to make informed decisions and not only change the law for the better, but have a real life impact on all those affected by abortion policies, laws, and attitudes in their regions. References 1. Levenson E. Alabama’s anti-abortion law isn’t alone. Here are all the states pushing to restrict access [Internet]. CNN. 2019 [cited 2019 Jun 21]. Available from: states-abortion-laws/index.html 2. Berer M. Abortion Law and Policy Around the World: In Search of Decriminalization. Health Hum Rights. 2017;19(1):13–27. 3. Guillaume A, Rossier C, Reeve P. Abortion Around the World: An Overview of Legislation, Measures, Trends, and Consequences. Population, English edition. 2018;73(2):217-306. 4. Aiken ARA, Scott JG, Gomperts R, et al. Requests for abortion in Latin America related to concern about Zika virus exposure. New England Journal of Medicine. 2016;375(4):396–398. 5. Attané I and Barbieri M. The demography of East and Southeast Asia from the 1950s to the 2000s: A summary assessment of changes and a statistical assessment. Population, English Edition. 2009;64(1):7–146. 6. Arie S. Is abortion worldwide becoming more restrictive? BMJ. 2012;345:e8161.



Female Genital Cutting Cultural Suppression of Female Sexuality

and How to Stop It By: Gokce Ozdemir


emale genital mutilation (FGM) is a violation of the human rights of girls and women, according to UN Secretary-General António Guterres. It is performed to intentionally alter or injure the female genital organs for non-medical reasons without any health benefit. More than 200 million girls and women alive today have endured FGM1, but this doesn’t mean all girls “survive” it. A year ago, a 10-year old girl, Deeqa Dahir Nuur, died due to blood loss after her genital cutting in Somalia. In response to her death, her father said “The people in the area are content with it (FGM), her mother consented to it…” and she was “… taken by Allah …”.2 In 2015 the UN set a 26 | IMS MAGAZINE SUMMER 2019 WOMEN’S HEALTH

goal to eliminate FGM by 2030. This is a practice that has to be criminalized around the world, and the best way to do this is through education. FGM is neither new nor limited to any one specific culture. Scientific and societal beliefs towards female sexual organs – specifically the clitoris—have oscillated throughout the centuries. Italian anatomist Realdo Colombo claimed to “discover” the clitoris in 1559, describing it as “the seat of a women’s delight” and believing it was integral to a woman’s ability to conceive. Venerated Flemmish anatomist Andreas Vesalius disagreed, declaring, “You can hardly ascribe this new and useless part, as if it were an organ, to healthy women”. The “father of anatomy” stated that it

must be pathological and found only on hermaphrodites. Sixteenth century European society regarded the clitoris as either a pseudo-phallic birth defect or a growth caused by masturbation. Thus the practice of amputating it if it seemed too large began (an arbitrary judgement, as clitorises can vary in size from five to 35 millimeters long and up to 10 millimeters wide). Women and girls with large clitorises were seen as hermaphrodites or lesbians, both of which jeopardized their marriageability. Doctors performed clitoridectomies to “normalize” girls and discourage masturbation in Western Europe as recently as the Victorian era.3 It may seem surprising that cutting is currently imposed on girls mainly by their


Mostly done on girls between infancy and the age of 15, as described by WHO7, FGC has four types: 1. Type 1 (clitoridectomy), where the external clitoris, or sometimes only the clitoral hood, is partially or totally removed; 2. Type 2 (excision), where the external clitoris and the labia minora are partially or totally removed, which may or may not be accompanied by excision of the labia majora; 3. Type 3 (infibulation), where the opening of the vagina is narrowed by forming a seal through cutting the labia minora, or labia majora, and repositioning it by stitching, with or without removing the clitoris; 4. Type 4, which includes all non-medical and harmful procedures done on the female genitalia such as pricking, incising, or cauterizing the genital area.

mothers, grandmothers, and traditional female circumcisers who have central roles in their communities: grandmothers are considered the main decision-makers.4 In some communities, girls are even excited to get female genital cutting (FGC) because they see it as a joyful and proud celebration of becoming a woman; this attitude was described by Bettina ShellDuncan when she was in northern Kenya in 1996.5 It’s important to recognize however that in many societies, men will refuse to marry women who are uncut, in some cases regarding their intact genitalia as a sign of their promiscuity. If a woman has no means of making money on her own, being uncut puts her at an economic and social disadvantage, and even more vulnerable to targeted sexual assault.6 FGC is so deeply integrated in some cultures that it is seen as necessary to be a member of the community and carries no malicious intent despite it being an extreme form of suppression of female sexuality. Therefore, in this article, I will opt to use the term FGC instead of FGM. Despite how harmful and impactful the practice is, it is not done to actually “mutilate” the child, rather, as ironic as it may sound, it is done with good intentions by parents who want the best for their daughters. In my opinion, using less judgmental terms

may bring communities together and be more helpful in creating a common understanding to stop FGC, although others may argue that using the word mutilation may help people understand how extremely invasive the procedure is.

found that those with type II or III FGC were more likely to need cesarean sections, episiotomies, and suffer postpartum haemorrhage than women who hadn’t undergone FCG.8 They also concluded that “about 22% of perinatal deaths in infants born to women with FGM can be attributed to the FGM.” Why is FGC being performed today? Reasons include social pressure to conform to this “method” of preparing a girl for adulthood and marriage, to ensure virginity until marriage, to reduce libido to prevent extramarital sexual activities, increase marriageability, and for “femininity and modesty”. The practice is often upheld in the name of religion despite the lack of religious scripts demanding the procedure, and despite the fact that FGC dates back over 2000 years. In many societies where it is performed, it exists to continue a cultural tradition.7 The countries where FGC is most common today are Somalia (98% of women aged 15 to 49 have undergone FGC), Guinea (97%), Djibouti (93%), and Sierra Leone (90%).1 Since advocacy against FGC started, 22 of 28 countries in Africa, such as Egypt, Ethiopia, and Nigeria, criminalized the practice. However, it is

...using less judgemental terms may bring communities together and be more heplful in creating a common understanding to stop FGC.

Immediate complications of FGC can include excessive bleeding, fever, infections, shock, and death. In the longterm, FGC can cause urinary, vaginal, menstrual, sexual, and psychological problems, as well as a need for later surgeries, scar tissue, and increased risk of complications from childbirth and newborn death.7 For example, a 2006 study in The Lancet involving 28 393 mothers

these same three countries where half of all girls who have undergone FGC or are at risk of it live, highlighting the weakness of enforcement and rarity of prosecutions. The countries in Africa remaining without a law regarding FGC are Chad, Liberia, Mali, Sierra Leona, Somalia, and Sudan.9

This is not to say that FGC is limited to developing countries. According to a study IMS MAGAZINE SUMMER 2019 WOMEN’S HEALTH | 27

VIEWPOINT is crucial to include all members of the family and the advocacy against FGC...

published in 201610, in the United States alone, where FGC is illegal, approximately half a million women and girls are still at risk of FGC via vacation cutting, where girls are taken overseas for the procedure. In Canada, there has been a law against FGC since 1997 but there still haven’t been any prosecutions. Despite an estimation of more than 80,000 survivors of FGC in Canada1, there are no protocols in place to save girls from vacation cutting or to offer specialized help for survivors who immigrated to Canada after being cut. This can be compared to Britain, where the government has funded specialized clinics for survivors and training for teachers to spot girls at risk. Criminalization of the practice is not enough, it never is, whether it’s the criminalization of FGC, drugs, alcohol, or anything else. People always find a way. The problem is, when it’s done underground, it is always more dangerous and riskier. With fear of possible prosecution, people resort to practicing FGC in secret. The issue becomes the difficulty of seeking help if anything goes wrong, and with FGC, a lot can. There are many cases where the victim of FGC has serious bleeding, but the family is hesitant to take her to a hospital because they could be prosecuted for practicing FGC. Most of the time, even if the family eventually decides to seek medical help, the child dies. We need more than laws. We need support systems available for girls and women who have undergone FGC or are at risk of it. Additionally, it is crucial to create a safe space for victims because they may be hesitant to report their families to the authorities.


More importantly, to stop it from getting to a stage where kids would need to decide on reporting on their parents or not, we have to focus on education to change the harmful beliefs about women’s (lack of) rights to sexuality and bodily autonomy underlying FCG. There is growing evidence that such education can reduce the practice. A 2013 study in Egypt found that socioeconomic status, social media messages, and women’s empowerment all impacted a girl’s risk of FGC, with mother’s education and household wealth being a significant predictor of whether a girl would undergo FGC.11 A lot of work is done by international organizations to educate women about the dangers of FGC. But it is crucial to include all members of the family and society (particularly religious and community leaders) in the advocacy against FGC to 1) raise public awareness on its dangers, and 2) explain why it is considered a violation of human rights. During such discussions, it is not uncommon to find those defending the practice in the name of Islam who are shocked when they are told it is not mandated by any religion. They often take a step back when they are told to think of why God would want the bodies of his creations to be changed, as it’s a teaching of Islam that the body, like the soul, is a “gift” from God, and we are merely stewards of our bodies rather than owners. Even though initial beliefs motivating FGC (that female libido is inherently bad, that women shouldn’t get sexual satisfaction, and that women’s sexuality must be controlled or removed to fulfill their roles as wives and mothers) are all manifestations of patriarchal views

of women, FGC has now become an internalized form of misogyny and a culturally integrated issue of education. Without having conversations with the communities that discuss the role of patriarchy vs. internalized misogyny on the continuation of the practice, a legal threat will not be enough to stop it, and outsiders telling the practitioners that they’re mutilating their kids with FGC won’t help. Only if the mindset changes can the acts follow. And the mindset can only change with education that is able to counter the teachings of the communities mandating FGC. References 1. UNICEF. Female Genital Mutilation/Cutting: A Global Concern. New York; 2016 [accessed 2019 Jul 16]. Available from: https://www. 2. Barnes T. Father defends use of FGM despite death of his 10-yearold daughter. The Independent. 2018 July 23. Available from: 3. Barmak S. Closer: Notes from the orgasmic frontier of female sexuality. Coach House Books; 2016 Jul 11. 4. The Girl Generation. FGM in The Gambia: Country Briefing. 2017 January [Cited 2019 Jul 16]. Available from: https://www.refworld. org/docid/5b2baf274.html 5. Khazan O. Why some women choose to get circumcised. The Atlantic Global. 2015 Apr 8. Available from: https://www. 6. Begenal F. Mapping FGM: Building a global picture of female circumcision. Huffington Post; 2016 Sept 22. 7. World Health Organization. Female Genital Mutilation. Geneva; 2018 [accessed 2019 Jul 16]. Available from: news-room/fact-sheets/detail/female-genital-mutilation 8. Banks E, Meirik O, Farley T, Akande O, Bathija H, Ali M. Female genital mutilation and obstetric outcome: WHO collaborative prospective study in six African countries. Lancet (London, England). 2006 Jun;367(9525):1834-41. 9. 28 Too Many. The Law and FGM. Sept 2018 [accessed 2019 Jul 16]. Available from: Law%20Reports/the_law_and_fgm_v1_(september_2018).pdf 10. Goldberg H, Stupp P, Okoroh E, et al. (2016). Female Genital Mutilation/Cutting in the United States: Updated Estimates of Women and Girls at Risk, 2012. Public Health Reports. 2016;131(2), 340–347. 11. Modrek S, Liu JX. Exploration of pathways related to the decline in female circumcision in Egypt. BMC public health. 2013 Dec;13(1):921.


Science and adventures ...and science adventures!


n the last issue of Travel Bites, Beatrice described her trip to Hawaii for her first international conference, the International Stroke Conference 2019 (ISC2019). Next year, ISC will be held in Los Angeles (LA), California. Coincidently, this year’s four-day International Society for Stem Cell Research (ISSCR) conference was also hosted in LA this past June. This year, ISSCR had about 4000 attendees, a nice middle ground between the more intimate Till and McCulloch Stem Cell Meetings (about 400 attendees) and the sprawling Society for Neuroscience Conference (SFN), with upwards of 40 000 attendees. As a second-year PhD student, this year’s ISSCR was my very first international conference. I remember it like it was yesterday—I ventured to the subway, commuted to Union station, and hopped on the UP express, a train that transports you to Pearson Airport within 20 minutes. I recommend this “planes, trains & automobiles” mode of travel to anyone who wants to save money or doesn’t have someone to drive them to the airport. After arriving at the LA airport, I travelled through classic California palm trees, past the Hollywood sign visible in the far distance, and to my hotel room. The next day, ISSCR began. ISSCR focuses on all types of stem cell topics. Such examples include discussions on different human embryonic stem cell (hESC) states, differentiation of hESCs—or induced pluripotent stem cells (IPSCs)—into mature cell types or organoids, progenitor lineages, how stem cells make fate decisions, oocytes and spermatids, blastocyst complementation to generate whole organs within animals, transdifferentiation between different cell types, and ethics in stem cell research.

Despite the variety of research topics presented, this year’s major on-stage plenary talks and posters were dominated by organoid research. For those unfamiliar with stem cell research, organoids are miniature, often simplified, versions of an organ (i.e. the heart). They’re grown in vitro (e.g. in petri dishes) from tissue or stem cells, which organize to form little 3D structures resembling an organ. This year ISSCR attendees heard about a wide variety of these fascinating structures,

The great thing about large international conferences is the chance to meet “Hollywood celebrity” researchers you’ve only just read about.

By Krystal Jacques

from brain organoids, to intestines, and even the first ever non-mammalian organoid: one coming from a snake venom gland! Hot topics such as organoids become popular soon after their discovery and establishment. This year’s conference has been frequently compared to the ISSCR five years ago, where the hot topic at this time was induced pluripotent stem cells (IPSCs). IPSC research boomed after Dr. Shinya Yamanaka first revealed to the world the four Yamanaka factors (klf4, c-myc, sox2, and oct4) that had the ability to direct somatic skin fibroblast cells into induced pluripotent stem cells at the ISSCR 2006. The great thing about large international conferences is the chance to meet “Hollywood celebrity” researchers you’ve only just read about. Dr. Doug Melton’s lab, based in Harvard, publishes

prolifically in area of beta cell research, development and diabetes. After hearing one of his past students, Dr. Felicia Pagliuca, give a talk on hESC-derived beta cell transplantation undergoing clinical trials, I had the chance to ask her a few questions. During that conversation she shared some of her failures and offered me words of encouragement. While keeping in mind that every successful researcher experiences their own set of challenges, I left this amazing conference more inspired and motivated than ever to reach my own research goals. After ISCCR was over, my colleague and I decided to take an extra four-day trip to San Francisco, California, which is an hour-and-a-half flight, or a scenic eight-hour Megabus ride, from LA. The bus passes through hilly mountains and vast stretches of beautiful farm land. We chose San Francisco because there is so much to see and do there, such as riding the historical cable car, visiting the Golden Gate Bridge, Golden Gate Park, the beaches, Muir Woods, the Ghirardelli Chocolate Factory, Alcatraz, and Fisherman’s Wharf. While in Fisherman’s Wharf, we paused to enjoy San Francisco’s famous clam chowder in a sour dough bread bowl. We also took a walk through the alleyways of San Francisco’s elaborate, historically rooted Chinatown for a visit to the fortune cookie factory, and to see exactly where Bruce Lee shot many of his famous street fight scenes. Therefore, if you are travelling to California for a conference soon, I recommend going to San Francisco for an adventure! Take a tour of downtown on your first day, and always carry a phone charger and an external battery with you at all times. Last, pack a sweater or two, as LA and San Francisco can get quite cold!



Learning Forward with Dr. Reinhart Reithmeier By: Sonja Elsaid


oday, most university professors believe they ought to train the next generations of scholars to essentially create their own replacements. But, do most life science graduate students actually follow in their supervisor’s footsteps? According to Dr. Reinhart Reithmeier-the recently appointed Director for Graduate Professional Development and Alumni Engagement at the Institute for Medical Science (IMS)-only 15% of University of Toronto (UofT) PhD graduates in Life Sciences are employed as tenure-track professors. The remaining hold various leadership positions in the public and private sectors. However, their transition from academia is often difficult mainly due to the lack of guidance for the professional development they received at the university. Learning about these career transition challenges motivated Dr. Reithmeier to dedicate a part of his work towards 30 | IMS MAGAZINE SUMMER 2019 WOMEN'S HEALTH

promoting professional development. The IMS Magazine interviewed Dr. Reithmeier to gain insight on how to be successful after graduate school. In Dr. Reithmeier’s opinion, to be successful in the pursuit of an academic career, graduate students should focus on publishing their research in journals with a high impact factor. These publications should not only reflect the thesis-based work, but also the ability to collaborate in multidisciplinary teams. For those seeking an academic career in Canada, it is vital to network with Canadian scientists. On the flip side, to those wishing to follow a career outside academia, Dr. Reithmeier highly recommends staying open to a wide range of opportunities. For instance, students can learn about the non-academic professions by attending career panels or by doing informational interviews. It is also necessary to use every

opportunity to network. The networking could even take place outside school. In fact, Dr. Reithmeier has met many of his professional networks while playing golf! Thus, building and maintaining a professional network is necessary for success outside academia. Success does not always come without having to overcome adversity. According to Dr. Reithmeier, one of the main challenges graduate students face today is articulating their research to diverse audiences. Indeed, he feels so strongly that we—as the scientists—have an obligation to communicate our research to the public. For this reason, he joined the Royal Canadian Institute of Science (RCIS), which has a mission to bring the science to the public. As the Volunteer President of the RCIS, Dr. Reithmeier organizes events such as the free-style socials, during which the scientists share evidence-based information with the general public. Dr.


Photo courtesy of Dr. Reithmeier

DR. REINHART REITHMEIER, PhD, FCAHS Professor in the Department of Biochemistry and IMS Director for Graduate Professional Development and Alumni Engagement

My bottom line is that it has never been a better time to get your graduate training!

Reithmeier believes that the ability to articulate science to everyone is the most important skill one should possess to become more employable. The 3-minute thesis competition or the elevator pitch is a great example of developing good communication skills.

encouraged him to pursue research as a life-long career. Graduate students who do not have a mentor are encouraged to connect with alumni from their graduate unit. Some of these alumni can become their mentors and even help with the job search after graduation.

Dr. Reithmeier emphasizes the importance of getting a mentor shortly after becoming a graduate student. A mentor is an individual who encourages us to leverage our strengths and work on our weaknesses. In fact, Dr. Reithmeier’s first mentor was his Grade 13 biology teacher, who

Although most of Dr. Reithmeier’s careerrelated suggestions are for graduate students, he also has a few words of advice for their supervisors. He advises that the supervisors should accept that their graduate students may not want to become scholars but may want to pursue a career

in industry. Students career aspirations may change during graduate training too. Afterall, Dr. Reithmeier concluded, “My bottom line is that it has never been a better time to get your graduate training! Back in my time, there were only government and academic jobs. But now, it’s amazing! There are all these pharmaceutical and biotechnology companies, not-for-profit organizations and entrepreneurship opportunities. And, it’s fantastic!” The sky is the only limit. You just need to be prepared to seize these opportunities.



A Beautiful Mind-ful Me to We By: Rehnuma Islam


PhD student’s mindful journey takes her around the world, through the Toronto film industry, a venture into Buddhist philosophy and, many years later, on a path towards helping others to be compassionate and kind. Elli Weisbaum was born to a physician and a theatre director, who as parents sought to understand how mindfulness could impact their family. At the age of 10, Elli attended her first mindfulness retreat with her parents, led by Zen Master and Nobel Peace Prize nominee Thich Nhat Hanh. Motivated by the turmoil he experienced during the Vietnam war, he worked to translate mindfulness teachings into everyday settings and create peace within individuals and societies.

first-hand the impact of a highly pressurized work environment on mental health. To further explore this, her Master's research focused on how mindfulness impacted communication in classrooms, which is described to be a “highly stressful environment”. Seeing the beneficial impact of mindfulness within education persuaded her to consider its application in other systems, such as healthcare. To do so, she continued her training at the Search Inside Yourself program developed at Google and the University of Toronto (UofT). Designed by experts in neuroscience, business, and psychology, the program teaches mindfulness tools to reduce stress, increase focus, and improve interpersonal relationships. Elli’s ongoing goal is to integrate research, practice, and teaching to develop evidence to support bringing mindfulness into key sectors of society.

Mindfulness is the awareness of what is happening inside and around you in the present moment.

As a physician and school teacher respectively, Elli’s parents aimed to use mindfulness in their daily lives. Inspired by her parents, Elli’s interest in the application of mindfulness flourished. Continuing in the footsteps of her mother, Elli did her Bachelor of Fine Arts in film production at York University. She worked as a film producer in Toronto where she experienced 32 | IMS MAGAZINE SUMMER 2019 WOMEN'S HEALTH


An interest in both research and knowledge translation drew her to the Institute of Medical Science at UofT. For her PhD research, she is exploring how mindfulness impacts physician well-being in the context of their daily lives. Elli collects field notes as a participant observer during a fiveweek mindfulness training program at SickKids. She also conducts post-program

qualitative semi-structured interviews with participants, using qualitative scales such as the Maslach burnout inventory and the five facets of mindfulness questionnaire; evaluating behaviours such as observing, describing, acting with awareness, non-judging of inner experience, and nonreactivity to inner experience. By bringing together the physicians’ perspective and her own mindfulness understanding, she seeks to help inform how mindfulness can be integrated to support physician’s individual mental health, and the potential broader systemic impact of mindfulness within healthcare. Elli recognizes that, “Mental health and well-being is a call in our society right now, across many sectors. We can use mindfulness to build supportive communities, because how often are we surrounded by people, yet still feel isolated?” The constant need to focus, produce results, deal with masses of emails, and participate in challenging conversations are a daily part of a graduate student’s life, Elli’s included. Even with all these known stressors, burnout is viewed as a serious faux pas. Yet, how many of us feel it? In her graduate work, Elli not only conducts research on mindfulness, but tries to apply it to take care of herself. While stress and anxiety are inevitable in grad school, it is important to realize you are not alone in it. The key is for each of us as graduate students is to find a path towards well-being by having compassion and kindness towards ourselves and others. As Elli puts it, “when we take care of ourselves, we take care of others; and when we take care of others, we take care of ourselves”. She recommends students acknowledge the need to slow down our pace of life throughout the day and give ourselves a proper break from work. Finding others that are also kind and compassionate can help build a community of support, such as the community within the Mindful Moments drop-in program at UofT. Mindfulness practice is a lot like physical fitness, we need to discover what works best for us as individuals, whether that be mindful walking, eating or sitting. What is gained in exchange, is a beautiful mind-ful me to we. References 1. Hyland T. Mindful nation UK–report by the mindfulness all-party parliamentary group (MAPPG)What is mindfulness?


Just A Mindful Minute! What is Mindfulness? An All-Parlimentary report1 put out by the UK government in 2015 defines mindfulness as the ability to “pay attention to what’s happening in the present moment in the mind, body and external environment, with an attitude of curiosity and kindness”. This skillset can bring about a greater sense of personal well-being and can be developed by practicing bringing one’s attention to experiences occurring in the present moment. The ability to focus on the thoughts and sensations in the present (rather than replaying the past or worrying about the future) is the foundation of many mindfulness-based therapies. Let’s try a simple breathing exercise that takes only a few minutes. Focused Attention Practice: Finding Your Anchor 1. Set the intention to take a break from your thoughts/worries about the future or past for the next 5-10 breaths while sitting, standing or walking. 2. To help focus your attention select an anchor, like your breath or a bird if you are sitting outside. One way to do this, is to think ‘in’ when you breath in and ‘out’ when you breath out. 3. Have an attitude to be kind and curious towards yourself. Your mind will naturally wander when you try this, so the mindful moment is simply to notice when the mind wanders and then the skill building is to bring it back to the anchor of the breath (or whatever anchor you have chosen). Continue to bring the mind back as often as you can, being kind to yourself each time. Post-Practice Inquiry: Even a short mindfulness moment is an opportunity to collect some important data about our internal states. This data can help inform how we interact with ourselves and others throughout our day. For example, if we notice that a specific worry keeps popping up, or there is a difficult conversation we are replaying, this might mean we are more distracted or irritated throughout the day. With this information, we can try to be more understanding towards ourselves, and in turn this will impact our interpersonal communication with others. The following questions can help you reflect on your mindful moment to collect some data on yourself: Important tip: remember there is no “right” or “wrong” answer to any of these questions, just an opportunity to collect some data to have greater understanding of yourself. • During your mindful moment was your mind busy or calm? • Did you notice when your mind wandered or did it just run away? • If you noticed your mind wandering, were you able to bring it back to your anchor? • Did you notice yourself judging how “well” you practiced mindfulness? Or were you able to be kind and curious towards yourself? How might these different attitudes towards yourself impact you outside of a mindfulness practice? • What have you noticed about the quality of your mind today that informs how you might behave towards yourself and others?

Photo courtesy of Elli Weisbaum

ELLI WEISBAUM Institute of Medical Sciance PhD Student



Medicine Meets Machine: The Emerging Role of AI in Healthcare By: Alaa Youssef


oday, artificial intelligence (AI) is the big hype in science. It is shaping the world’s economy, education, health, and policy. AI, a broad term used to describe a wide range of machine learning approaches, is used to process large datasets to discern meaningful knowledge. While advances in AI bring infinite possibilities to understand inherently complex phenomena, these technologies pose new questions for society to address. This year, on May 7th, Raw Talk Podcast hosted ‘Medicine Meets Machine’, a live podcasting event at JLABS Toronto, attracting audiences and experts from diverse backgrounds to discuss the challenges AI poses to healthcare. AI is transforming medicine in a myriad of ways by solving complex problems across a wide range of clinical domains. In this context, speakers in Raw Talk’s first panel discussion provided a glimpse into some of the ways AI is transforming medicine. Dr. Oren Karus, Co-Founder Phenomic AI, described how advances in computer vision and deep learning techniques had transformed clinical imaging to a new realm, to enable image reconstruction, noise reduction, quality assurance, triage, segmentation, computer-aided detection, computeraided classification, and radiogenomics. Notwithstanding these advances, there exist some challenges to harnessing the low hanging fruit AI affords. As Dr. Jason Lerch, Senior Scientist at the Hospital for Sick Children, highlighted “The ripe of AI in brain imaging and neuroscience 34 | IMS MAGAZINE SUMMER 2019 WOMEN’S HEALTH

research is yet to rise. While complex AI algorithms are slowly replacing classic models, the capacity of AI to elevate our understanding of complex imaging structures is yet to flourish as the process of data interpretability remains unknown.” Ongoing research efforts to understand the decision-making processes behind these complex algorithms promise to expand our understanding of complex and rare diseases to an unprecedented level. Application of AI algorithms in other clinical domains, such as critical, neonatal, and geriatric care, promises to bridge wide existing gaps in healthcare systems. Growing evidence demonstrates that developing AI algorithms utilized in acute care outperform current clinical scoring systems, showing a higher level of accuracy monitoring and predicting changes in patients’ vitals. Thus, AI may offer practical solutions to many prevailing care delivery dilemmas, enhancing care efficiency and quality. Most importantly, as Dr. Marzyeh Ghassemi, Assistant Professor in the Department of Computer Science and Medicine, noted that “AI will transform medicine by allowing clinicians to focus on patient care” as these systems aid professionals with better evidence-based recommendations, and treatment options—augmenting clinician decision-making processes. Dr. Sunit Das, Neurosurgeon and Scientist at the St. Michael’s Hospital and The Hospital for Sick Children, noted that “AI is simply a tool to assist patients in making their decision…… and that the weight of that

decision still lies in the communication between myself and my patient.” The conversation in the second panel tackled some of the ethical and safety concerns AI may impose on society. Specifically, the discussion centered around the potential benefits and risks of using AI algorithms to leverage accessible population health data. A key take away from this panel was that purposefully integrating AI systems, at the population level, might be the breakthrough to bridge the ‘Quality Chasm’ in healthcare, addressing the complexity of comorbid disease management and promoting preventative medicine. Conversely, the oblivious generalization of nonrepresentative consented data could exacerbate societal health disparities and inequities. Thus, as Dr. Alison Paprica, Vice President of the Health Strategy and Partnerships at the Vector Institute put forth, harnessing existing population health data and mitigating societal ethical concerns will require “engaging with the public in genuine ways [to translate] data into knowledge of what they value and what they agree with.” The message from this event was clear–AI in medicine is to enhance evidencebased decision making to answer critical questions, ‘why’ and ‘what if ’’, and not to replace experts. Thus, it is incumbent on us to foster interdisciplinary collaborations to enact AI systems safely and equitably to promote societal benefits and growth.


The 2019 IMS

SCIENTIFIC DAY By: Shahrzad Firouzian


n May 14, 2019, the Institute of Medical Science (IMS) at the University of Toronto (UofT) held another successful scientific day, showcasing student and faculty achievements in research. It was a day of engaging talks, poster presentations, student competitions, and celebrating research achievements. As usual, the morning was a busy time of poster set-up; many students were at their posters, practicing their presentations for the Alan Wu Poster Competition. This competition awards the two most outstanding posters, as determined by a team of judges who review and rank the presentations. This year’s winners are Lina Elfaki and Sara Mirali—Congratulations! The first talk of the day was given by the IMS Director, Dr. Mingyao Liu, who spoke of the recent five-year external review of IMS, and the new strategic plan that resulted, whereby a new active strategic planning committee and associated strategic planning working groups will be launched. His talk was a great reflection of the collective effort from students and faculty in enhancing IMS programs. For this annual event, the keynote lecture was created in honour of Dr. Bernard Langer. Dr. Langer was the Chair of the Department of Surgery at UofT, and during this time, he established the Surgeon-Scientist training program. This year, Dr. Dongeun Dan Huh presented the keynote talk. Dr. Huh is the Assistant Professor and the Wilf Family Term

Endowed Chair in the Department of Bioengineering at the University of Pennsylvania. He is internationally recognized for pioneering “organ-on-achip” technology, and his lab develops microfabricated devices to mimic human cells, structures, and environments. His research team developed devices to mimic lungs, in the form of human-breathing lung-on-a-chip, which has allowed them to study lung disease models. Additionally, his cancer immunotherapy project involved mimicking the vasculature necessary to perfuse tumour cells. His lab also engineered human blinking-eyeon-a-chip to study dry eye disease which mimics the blinking behavior of humans. Although the “organ-on-a-chip” requires a lot of data, it can be used to study a multitude of different disease states and paves the way to personalized medicine by using patient cells as part of the bioengineering technology. In the course of his educational training, Dr. Huh transitioned from mechanical engineering to biomedical engineering, which require different mindsets. The combination of the two however allowed his team to engineer a robotic hole-punching device that assisted their bioengineering goals. His team’s work led him to receiving the Lush Science Prize from the Lush cosmetics company, which acknowledged his work supporting alternatives to animal testing. However, questions may arise on how investigators can determine if testing on chips is biologically valid with respect to the human body. Nevertheless, his work is clear evidence that Dr. Huh has

made a great impact on the scientific community, so much so, that funding from NIH allowed him to launch his organon-a-chip devices to the International Space Station! In early May 2019, Dr. Huh was able to watch his chips launch from earth. The purpose of this project is to address infections in space, because immunosuppression in space is a concern for astronauts. The chips are to be infected in space, and then returned to Dr. Huh’s lab for analysis of results. Following lunch, the Jack Laidlaw Manuscript Competition was held and won by Uswa Shahzad. This competition was created to honour Dr. Jack Laidlaw, who was the first director of IMS. The competition was followed by Data Blitz Talks, which consisted of three concurrent sessions, each consisting of a presentation from an IMS faculty and five short talks from IMS students. The data blitz sessions covered a wide range of insightful topics: neuroscience and brain health chaired by Dr Voineskos; cancer, health services, and education chaired by Dr Zimmermann; and regenerative medicine, cardiovascular, and stem cells by Dr Yau. The day closed with the presentation of awards for deserving competition finalists who gave excellent presentations. Our own executive editor Jonathon Chio is this year’s winner of the Roncari Book Price, while the Sara Al-Bader Memorial Award goes to Tahani Baakdhah. Dr Liu’s closing remarks were a reflection of yet another successful IMS scientific day filled with science that leaves scientists inspired to continue in their efforts of scientific discovery. IMS MAGAZINE SUMMER 2019 WOMEN’S HEALTH | 35


Photo courtesy of IMS

IMS Scientific Day: Students presenting at the Alan Wu Poster Competition.

Photo courtesy of IMS

IMS Scientific Day: Dr. Dongeun Dan Huh presents the 2019 keynote address, “Microengineered physiological biomimicry: Human organs-on-chips.”

Photo courtesy of IMS

IMS Scientific Day: PhD student (and current IMS Magazine Executive Editor) Jonathon Chio accepts the Roncari Book Prize.


Photo courtesy of IMS

IMS Scientific Day: IMS Director Dr. Mingyao Liu and award donor Dr. Leticia Rao present the inaugural Dr. LG Rao/Industrial Partners Graduate Award to PhD student (and current IMS Magazine Co-Editor in Chief) Natalie Osborne, pictured with her advisor Dr. Karen Davis.



Summer Undergraduate Research Keynote: Program Dr. Allan S. Kaplan

Research Day

Vice Dean, Graduate & Academic Affairs Professor of Psychiatry

9:00 Welcome 9:15 Keynote 10:30 Podium Presentations Noon: Lunch 1:00 Poster Presentations 3:00 Awards Ceremony

August 14 2019

Genes or Jeans? The Etiology and Treatment of Anorexia Nervosa

Hart House Great Hall 7 Hart House Circle




The evaluation of education as an intervention for concussion treatment

By: Sabreena Moosa


oncussions affect more than 150,000 people in the sole province of Ontario every year.1 Such findings often lead to questions about how much people really know about this form of mild traumatic brain injury and what its treatment plan constitutes. This summer I had the privilege to work under the supervision of Dr. Mark Bayley at the Hull Ellis Concussion and Research Clinic at Toronto Rehab Institute. There is some current research related to finding the best approach to treating concussion symptoms and improving recovery trajectory, however, early education remains the most critical intervention post-concussion.2,3 My project involved looking at the education provided at the Hull Ellis Concussion and Research Clinic. Patients recruited at this rapid access concussion clinic completed an education questionnaire at week 1 and week 8 of injury. The objective of this study was to evaluate the effectiveness of the education provided to concussion patients, factors predicting their receptiveness to education and aspects which can be modified to standardize physicians’ approaches to providing patients with more knowledge about recovery and symptom management. 38 | IMS MAGAZINE SUMMER 2019 WOMEN’S HEALTH

Preliminary results have aided in identifying effects of various knowledge on patients’ anxiety and symptom-reporting, as well as questions which require rephrasing. Some factors might also be affecting prior knowledge about concussion, which could then be used to individualize physicians’ approach to concussion treatment and ensure maximum effectiveness. This is especially important as most past studies have focused on athletes and youths, thus often involved preventative education provided in case of injury and was aimed to increase successful identification of a concussion. Looking at the education provided to concussion patients of the general population would be a step in the long journey towards identifying areas of education that directly affect recovery. Working on this project provided me with many exciting opportunities such as interacting with patients and analyzing the raw data collected. This not only taught me about research study design and implementation, but also critical statistical, data interpretation, communication and problem-solving skills. Partaking in the entire progress of a project helped me realize how common challenges, unexpected results, and limitations are in research. It is normal to experience recruitment difficulties

and unexpected results, and that it is important to take them in stride and try again, while learning more in the process. I am grateful for the support and mentorship provided to me at the lab, which taught me about clinical research and provided me with lifelong skills. More than anything else, this summer project taught me the importance of varying individual skills in a research team and the effort that goes into refining a project before the finished product comes about as a published paper. With the findings of this project, I hope that a standardized clinical approach to providing education for treatment of concussion can be personalized to improve patients’ recovery trajectory. Perhaps some findings can also be generalized to other disorders in order to seek a more effective approach to education when used as an intervention in any healthcare setting. References 1. Langer L, Levy C, Bayley M. Increasing Incidence of Concussion: True Epidemic or Better Recognition? J Head Trauma Rehabil. 2019 Jun 25; 2. Borich MR, Cheung KL, Jones P, Khramova V, Gavrailoff L, Boyd LA, et al. Concussion: current concepts in diagnosis and management. J Neurol Phys Ther JNPT. 2013 Sep;37(3):133–9. 3. Consensus statement on concussion in sport—the 5th international conference on concussion in sport held in Berlin, October 2016 | British Journal of Sports Medicine [Internet]. [cited 2019 Jul 31]. Available from:


A message in a bottle: how extracellular messages can help babies breathe again

By Benjamin Liu


efore joining the Zani lab, I – like many people – had never heard of congenital diaphragmatic hernia (CDH). Therefore, I was surprised to learn that CDH is an extremely deadly congenital disease, with a mortality rate of 40%1. As a congenital disorder, CDH occurs during fetal life, whereby abdominal organs migrate through a hole in the diaphragm to physically block lung development2. While some CDH babies never take their first breath, others slowly and painfully suffocate within the first days of life. For the survivors, many suffer life-long morbidities. However, despite this high mortality, there is no established therapy. For the healthcare team, supportive care is the only option as the parents wait for the baby to live – or die from suffocation2. The absence of a cure drew me into the Zani lab at Sick Kids Hospital and made me excited to come back for a 2nd summer because the Zani lab is pursuing a novel stem-cell-based therapy for CDH. Not just a cool sounding name, stem-cell-based regenerative medicine has attracted a lot of attention regarding its capabilities and its efficacy. However, like a plot twist in a good movie, amniotic fluid stem cells (AFSCs) have shown regenerative potential in

lung underdevelopment not by directly transforming themselves into lung cells, but rather by sending regenerative messages to the dysregulated lung cells3. Our lab had previously hypothesized that the key mediators of these cell-to-cell regenerative messages are extracellular vesicles. As a result, my current project was to investigate this hypothesis in the setting of fetal lung underdevelopment. To date, I have demonstrated that AFSC extracellular vesicles (AFSC-EVs) could be administered to underdeveloped rat lungs to rescue the production of surfactant protein. This summer, I continued to advance the project by staining AFSCEVs to visualize their entry into lung epithelial cells. I also observed that AFSCEVs exhibit a greater beneficial effect on underdeveloped lungs when compared to the EVs from mesenchymal stem cells. While I have learned a lot about EVs and lung development, the biggest lesson I learned is to keep the bigger picture in mind. Sometimes experiments fail and you may find yourself stressed and fatigued from working much longer than anticipated. However, the results that we discovered could lead to exciting and novel lung regeneration therapies. Whereas before newborns would suffocate to death after being born with CDH, my involvement in creating a potential new therapy could save these young lives.

Finally, EVs may not only be the cure for lung underdevelopment, but they may also be the next big innovation. During my research, I learned about applications for EVs in therapies beyond lung regeneration, including cardiac regeneration after myocardial infarctions or treating spina bifida4,5. EVs are also potential biomarkers for different types of cancer, as cancer cells release their own EVs for their nefarious purposes7. Unlocking the secrets behind these recently discovered messages could unlock a whole new field of medicine, where we could literally tell cells to get their act together and identify when they are not! References 1. Harting MT, Lally KP. The Congenital Diaphragmatic Hernia Study Group registry update. Semin Fetal Neonatal Med. 2014 Dec;19(6):370–5. 2. Chandrasekharan PK, Rawat M, Madappa R, Rothstein DH, Lakshminrusimha S. Congenital Diaphragmatic hernia - a review. Matern Health Neonatol Perinatol. 2017 Mar 11;3:6–6. 3. Pederiva F, Ghionzoli M, Pierro A, De Coppi P, Tovar JA. Amniotic fluid stem cells rescue both in vitro and in vivo growth, innervation, and motility in nitrofen-exposed hypoplastic rat lungs through paracrine effects. Cell Transplant. 2013;22(9):1683–94. 4. Sahoo Susmita, Losordo Douglas W. Exosomes and Cardiac Repair After Myocardial Infarction. Circulation Research. 2014 Jan 17;114(2):333–44. 5. Kumar P, Becker JC, Gao K, Carney RP, Lankford L, Keller BA, et al. Neuroprotective effect of placenta-derived mesenchymal stromal cells: role of exosomes. The FASEB Journal. 2019 Feb 12;33(5):5836–49. 6. Tai Y-L, Chen K-C, Hsieh J-T, Shen T-L. Exosomes in cancer development and clinical applications. Cancer Sci. 2018 Aug;109(8):2364–74.



By Beatrice Ballarin


s scientists we generally study addiction by focusing on the addicted individual. This means we can sometimes fail to see the broader social and emotional consequences of addiction, especially if there is a child involved. In his inspiring graphic memoir, Hey, Kiddo: How I lost my mother, found my father, and dealt with my family addiction, Jarrett Krosoczka visualizes what it means to be raised by a dysfunctional family struggling with addiction, and still love them unconditionally and survive their imperfections. Hey, Kiddo is a coming-ofage graphic memoir written and illustrated by Jarrett, describing his own experience. The book is told from the perspective of an adolescent, and its panels poignantly capture the travails of a childhood touched by addiction and absent parents. This IMS Magazine issue’s book review is different from our usual repertoire of non-fictional books. It narrates Jarrett’s childhood from his own understanding of the time. The vignettes combine a series of happy moments that every 3 years old is

How I lost my mother, found my father, and dealt with my family addiction entitled to, such as snuggles and bath time. But we also see little Jarrett fixing his own breakfast: “as a 3-year-old, I was getting my cereal on my own because I was waking up in an empty house”. While it is clear to the reader that his mother has substance abuse issues, it seems that little Jarrett is not aware of it. It’s only much later that he discovers the truth about his mother and her heroin addiction. Most of the text is expository, mirroring the fact that Jarrett’s familial circumstances weren’t often acknowledged in conversation. It’s the illustrations, rendered in thick black lines and grayscale watercolour, that allow the reader to feel the kaleidoscope of Jarrett’s experience. Even though a harsh reality is narrated, the book remains approachable for kids for its simplicity and directness. Unlike most narrative accounts of addiction, if there’s any homily in Hey Kiddo, it’s the healing power of art. Indeed, graphic art plays an important role both in the book and in Jarrett’s life: “When I was a kid, I’d draw to get attention from my family,” he says in the first vignette.

“In junior high, I drew to impress my friends,” says another. “But now that I am in my teens, I fill sketchbooks just to deal with life. To survive.” Later, art provided the backbone of a successful career: adult Jarrett is the writer-illustrator of many well-loved children’s books, including the Platypus Police Squad and Lunch Lady series. This is a brave story. And a heartbreaking one. And even if there is a happy ending this time, experience tell us that many of those kiddos raised in an unstable home tend to follow the same path. Adult Jarrett is still paying the price of the neglect he experienced. Perhaps in the remarkable story of Hey Kiddo, there is the wish of every child to be seen and loved by their parents. Perhaps there is the wish for a normal childhood. And perhaps the story doesn’t only represent Jarrett’s childhood, but also all those other kiddos that are dealing with addiction, isolation, and abuse in their families. Yet ultimately, this is also an inspiring story about channeling the craziness of this life into drawings. And transforming that pain and suffering into art that can heal and help others. *Illustration adapted from book cover






hen I picked up this book last January at Indigo, besides being attracted by the bright orange colour of the cover, I have to admit that I was a bit frustrated with how things were going in my life. It was a new year, but my experiments were a never-ending story, and the lab was not always an easy environment to work in: the typical life of a senior PhD candidate! When I entered Indigo, the rather compelling title, The subtle art of not giving a f*ck, intrigued me. I had to read it! I thought maybe my problem was that I cared too much about everything. I am a perfectionist after all, and perhaps I need to learn to let things go. I had envisioned this book was about learning to let go, to not care. I thought the book would teach me how to reach a perfect and peaceful indifference to everything around me. Basically I thought this was one of those typical self-help books, one in which you already know what you should do by yourself, but somehow it is always nice and encouraging if someone else tells you and charges you 20 bucks for it—oh gosh, I was so wrong about this!!

The real lesson was in fact to care deeply about the things that you find important,

but learn to care less about everyone else’s opinions. I, too, have felt that “I have given a fuck about too many people and too many things”. I have also heard, maybe from the book of Hermann Hesse, that the key to success in life is simply “not to give a fuck”. As well, I have heard stories of people making an impulsive and radical decision, without a care in the world, and excelling. This book made me think of a friend of mine, Regina, who made a sudden decision in her life—quitting a stable job and going back to grad school—simply deciding “not to give a fuck”. By taking a chance, she; finished grad school at UPenn, met the love of her life, got married, found a better job in California, and is now expecting a baby. Regina went on to accomplish amazing things, because she didn’t let fear hold her back. Fear of what others thought, or would think if she failed. As Mark Manson would say: “Fucks given? None, just went and did it”. But the point of the book is not to make crazy life changing decisions that you hope work out through sheer serendipity. On the contrary, the author wants you to focus on what you really like, what you feel deep-deep down is the most important thing in your life, and disregarding all the rest. Only by doing that, being honest with what you feel, and thus directing your

“fucks” to what really matters, is possible to accomplish great things. In a way, Regina decided what to give a fuck for—deciding what was really “fuckworthy”. It was a scary decision for sure, but she made the choice to focus only on going-back-to-school. And it was this singular focus that made the goal to get her degree more attainable. My friend reminded me of what this book is about: deciding what is “fuckworthy” and pursuing it wholeheartedly and without reservations. Life could be easier, less scary, rejections less painful, and failure may not be as terrifying if we could only learn to give a few less and “legitimate fucks”. Thus, the point of the book is to realize that “not giving a fuck” is a fine art of learning what you don’t want, so you can focus your attention on what you do want. I am personally still working on learning to control, manage and direct “the fucks” that I want to give, as Mark Manson would say. Nevertheless, the time when I did follow the advice of the book, “the fucks” I have not given have made a big difference in my life. I have felt stronger and more empowered with my decisions. So, if you feel like me, I offer a few words of advice: stop “fucking” around and get your “fucks” together! And of course, read this “fucking” book!

We all have a limited number of fucks to give; pay attention to where and who you give them to. - MARK MANSON



Sex, Gender & Brain Health Why We Can’t Forget to Factor in Females

By: Laura M. Best


f you’ve ever completed a Canadian Institutes of Health Research (CIHR) grant application, then you’re familiar with these questions: Is sex as a biological variable and is gender as a socio-cultural factor taken into account in your research? On the surface, this seems like an obvious consideration. Personally, I run a neuroimaging trial in humans, so I recruit equal numbers of men and women and then inquire about non-binary gender considerations–easy. Digging deeper, however, the concept influences how you write your protocol, how you recruit and conduct your research methods, how you interpret and communicate the data; essentially, how you are operating as a scientist. Being mindful of sex and gender in both basic and clinical research can have critical effects on the outcomes and can also guide new research directions. Many diseases affecting the brain and mental health, for example, are more prevalent in women. 42 | IMS MAGAZINE SUMMER 2019 WOMEN'S HEALTH

Consider dementia: two-thirds of those affected in Canada are female.1 Even after taking into account differences in life-span, women are at a significantly higher risk for dementia compared to men, and we now know that sex differences exist in amyloid and tau protein accumulation.2 Despite these differences, however, research has historically used male subjects. This neglects the nuances that are specific to females, including differences in brain structure and function, immune system functioning, and hormones, to name a few. While modern scientific research is making strides in this area, there is still work to be done. One charity that is making an impact in this space is Women’s Brain Health Initiative (WBHI),3 and I have had the pleasure of serving as the Vice-Chair on their Young Person’s Cabinet, a board of appointed young-achievers, for two years. Founded in Toronto in 2012, WBHI is solely dedicated to protecting the brain health of women. Through the motivation to help women stay connected longer

to a meaningful life, WBHI has funded research and founded education programs across North America. Their advocacy work has even led to the very questions that we are all too familiar with regarding sex and gender factors on our applications. In partnership with CIHR, WBHI established and currently funds the world’s first Research Chair in Women’s Brain Health and Aging, which was awarded to Dr. Gillian Einstein, a neuroscientist investigating the effect of sex and gender in dementia and depression at the University of Toronto. The charity has also partnered with the Canadian Consortium on Neurodegeneration in Aging, a group of 350+ clinicians and researchers across Canada dedicated to advancing research in age-related neurodegenerative diseases, to support their Women, Gender, Sex and Dementia program within the affiliated 350+ research labs across Canada. A jarring finding from recent research is that neurodegeneration and plaque accumulation can occur decades prior to the first symptoms of dementia in both


Photo courtesy of Arthur Mola Photography

Members of Women's Brain Health Initiative's Young Person's Cabinet The mandate and goal for the Women’s Brain Health Initiative Young Person’s Cabinet is to inspire millennials to protect their brain health.

Being mindful of sex and gender in both basic and clinical research can have critical effects on the outcomes.

men and women.4 While this reality is not lost on the charity or it’s Young Person’s Cabinet, it is not common knowledge among young adults and millennials; the general population may not be aware of the connections between sex, gender and dementia, let alone how lifestyle choices during young adulthood can influence one’s risk of dementia and other diseases affecting the brain. In an effort to communicate new and reliable research discoveries such as these, WBHI hosts educational events across Canada, such as the Engaging Millennial Minds series, which pair scientists with refreshments and fun activities to facilitate an engaging, accessible learning environment.

From my involvement with the charity, and my own research, I have learned that this landscape is not barren or hopeless. Rather, we are on the cusp of exciting discoveries that can empower millennials and women to engage in neuroprotective lifestyle choices such as eating a healthy diet, scheduling regular physical activity and adequate sleep, staying socially active and reducing the effects of stress through mindfulness and yoga. But this and other reliable research needs to be conducted in such a way that it considers our entire population, specifically women. As students, young adults, young clinicians, and young scientists, we are in the perfect position to make an impact in the broader

context of women’s health when we choose to take gender and sex differences into consideration on multiple levels within science, medicine and research. Oh, and be sure to take care of your brain, too! References 1. Public Health Agency of Canada. Dementia in Canada, including Alzheimer’s Disease: Highlights from the Canadian Chronic Disease Surveillance System. 2017. 2. Buckley R, Mormino E, Rabin J, et al. Sex Differences in the Association of Global Amyloid and Regional Tau Deposition Measured by Positron Emission Tomography in Clinically Normal Older Adults. JAMA Neurol 2019; 76(5): 542-51. 3. Women’s Brain Health Initiative. 4. Younes L, Albert M, Moghekar A, Soldan A, Pettigrew C, Miller MI. Identifying Changepoints in Biomarkers During the Preclinical Phase of Alzheimer’s Disease. Frontiers in Aging Neuroscience 2019; 11(74).