IMS Magazine Winter 2015

Page 1

IMSMAGAZINE THINK, LEARN, DISCOVER

WINTER 2015

THE PAIN ISSUE New treatments, discussions on chronic & cancer pain, and innovative technology.

SURP HIGHLIGHTS The Summer Undergraduate Research Program: Winners, honorable mentions, stats.

TRANSLATIONAL RESEARCH A new program oered by the IMS - what is it?

1 | IMS MAGAZINE WINTER 2015 PAIN

Student-led initiative


2 2 | IMS MAGAZINE WINTER 2015 PAIN


IN THIS ISSUE Commentary............................................4 Letter from the Editor..............................7 News at a Glance ...................................8

C A N A D I A N

CHRONIC PAIN 1/5

CANADIANS

! Pain lasting several months, or persisting

CHRONIC .

80 Approximately

of physician visits are prompted by % complaints of pain

The most common chronic pain complaints include

PAIN

Neurogenic Cancer Low back Headache Arthritis

WHO EXPERIENCES CHRONIC PAIN? Male

18%

Spotlight ...............................................28

Future Directions ..................................34

8% 4% 2%

AGE GROUP

12-17

18-24

25-34

SURP Writing Competition ...................39

OUTGOING EDITOR-IN-CHIEF

Past Events ...........................................41

EXECUTIVE EDITORS

MANAGING EDITOR JOURNALISTS & EDITORS

DESIGN EDITORS

P34

Copyright © 2015 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.

PSYCHOLOGICAL EFFECTS OF CHRONIC PAIN

60 UP TO

%

of patients with chronic pain suffer from depression.

!

CHRONIC PAIN

35-44

36-64

cancer + heart disease + HIV

APPROXIMATE COSTS OF CHRONIC PAIN PER YEAR

65+

$

costs more than

$6 BILLION

in direct health care costs

$37 BILLION

in productivity costs related to job loss and sick days

MAGAZINE STAFF CO-EDITORS-IN-CHIEF

EXPANDING HORIZONS WITH TRENDMD: An interview with founder Dr. Paul Kudlow

pharmacological NSAIDs, antidepressants, anticonvulsants, interventional nerve blocks, opioids (most prominent)

Complex, multi-faceted state that may have no obvious cause. Other types include numbness, burning, “pins and needles” sensations and shooting pain.

P14 CANADIAN CHRONIC PAIN STATISTICS 6%

SURP Feature........................................36

FUTURE DIRECTIONS

Exercise, acupuncture, transcutaneous electric nerve stimulation

0%

Percentage of group affected by chronic pain

Book Reviews .......................................30 Close-up................................................32

nonpharmacological

Self-management education, meditation, music, guided imagery, stress management

Female

10%

PAIN MANAGEMENT

psychosocial

16% 14%

Can result from sport or occupational injuries, motor vehicle accidents, repetitive strain injuries and diseases processes such as arthritis.

FEATURE GRAPHIC

BACK PROBLEMS & MIGRAIN HEADACHES

NEUROPATHIC PAIN Affects brain processing changed from injury or malfunctioning nerve fibers.

Affects bones, muscles, ligaments, and tendons.

physical

for those living in the community

12%

The most common pain-related chronic conditions of this group are

for those living in long-term care facilities

27 %

YO U T H - AD U LT S

1/10

An estimated Canadians aged 12-44 experience chronic pain.

O LD ER A D ULT S

38 %

NO DATA

Feature - Pain........................................14

MUSCULOSKELETAL PAIN

after an injury has healed, is considered

experience chronic pain on a daily basis.

Director’s Message...............................10 Special Feature.....................................12

TYPES OF NON-CANCER CHRONIC PAIN STAT I ST I CS

PHOTOGRAPHERS

Annette Ye Susy Lam Adam Santoro Nancy Butcher Sarah Gagliano Anna Badner Brittany Campbell Danielle Cha Joshua Lipszyc Kasey Hemington Katherine Schwenger Natasha Jawa Rebecca Ruddy Robert Civitarese Yekta Dowlati Cassandra Cetlin Natalie Cormier Naveen Devasagayam Ashley Hui Jerry Won Chung Ho Leung Laura Feldcamp Matthew Wu

IMSMAGAZINE

COVER DESIGN Cassandra Cetlin

THE PAIN ISSUE

FEATURE INFOGRAPHIC Natalie Cormier Ashley Hui

THINK, LEARN, DISCOVER

New treatments, discussions on chronic & cancer pain, and innovative technology.

SURP HIGHLIGHTS The Summer Undergraduate Research Program: Winners, honorable mentions, stats.

TRANSLATIONAL RESEARCH A new program offered by the IMS - what is it?

IMS MAGAZINE WINTER 2015 PAIN | 3


COMMENTARY

L I VI NG OR GA N D O N AT I O N : An Honest Perspective By Alexandra Grand On January 15th, 2014, at the Toronto General Hospital (TGH), I donated 60% of my liver to my father. Never did I imagine that at 25, I would undergo rigorous evaluation to become his living donor. The need for organ transplantation is increasing at a steady rate. Currently, 1,500 Ontarians are on organ waiting lists. These people wait in hopes of receiving a deceased donor. I could not let my dad take those chances. After hearing the devastating news of his diagnosis, I didn’t hesitate; I filled out the consent form and volunteered to give my dad my liver. For me, it was an easy decision. My father, who has given me the world, had been diagnosed with hepatocellular carcinoma, which is a fancy way of saying liver cancer. Only through the multiple CT scans and MRIs did we come to learn that he had nine tumours spread across the left and right lobe of his liver, the largest measuring six centimetres. I knew we had to act quickly. Luckily, the option for transplant was still available. The cancer was still localized in his liver, meaning the surgeon could still take out his liver entirely and put in a new one.

process. This included an MRI, CT scans, chest X‐rays, routine blood work, and psychiatric assessments. TGH does not take this process lightly. I was given a living donor manual that outlined the risks involved, what I would experience pre and post surgery, my stay at the hospital, and I was even drawn a picture to show what my incision would ultimately look like. From day one, I was treated with exceptional bedside manner and professionalism. The establishment of the donor’s safety was made so evident, and the reimbursement programs such as Trillium Gift of Life made donating an even easier decision. I knew I was in good hands from day one. In truth, it’s very difficult to articulate the days leading up to the surgery, and my days in the Intensive Care Unit. Being able

to pay it forward and give my dad the gift of life has been one of the most humbling and enlightening experiences. Recovery is an ongoing process. Losing an organ is exhausting, and having to re‐grow one is as well. All the energy you have goes in to the regeneration. Most people don’t have the awareness of living organ donation, and how you can save a life. In my case, I saved two: my dad’s, and the person who will receive the transplant from a deceased person that would have gone to my dad. I’m only 25 years old. I’m not married, I don’t have kids, and I haven’t experienced all the things in life I want him around for. Now, I can say that my dad is 100% cancer free, and has a second chance at life. For me, it was a tiny loss for a huge gain.

After I had submitted my request to donate to my father, I was contacted almost immediately to start the evaluation

4 | IMS MAGAZINE WINTER 2015 PAIN

Photo courtesy of iSt-ckphoto.com

Living‐donor transplantation has become more common over the past 20 years. A living donor puts their life at risk by giving up an organ to help save the life of another. The risk in my case was minimal, as within two to three months of surgery the liver completely regenerates.


IMS MAGAZINE WINTER 2015 PAIN | 5


is lo

IMS MAGAZINE

or ing f ok

SCIENTIFIC CONTENT

to post on the IMS Magazine website.

Whether you are a current blogger looking to cross-post your scientific musings, or just looking to give your ideas a voice through our platform, your submissions are welcome. Send an email to theimsmagazine@gmail.com for more information on how you can become involved!.

imsmagazine.com

CONNECT WITH US! facebook.com/ imsmagazine

Visit us at imsmagazine.com, and subscribe to Twitter/Facebook for updates!

theimsmagazine @gmail.com @IMSMagazine

Illustration by Natalie Cormier

We encourage our readers to send their feedback, comments, questions, corrections, and letters to the editor to theimsmagazine@gmail.com 6 | IMS MAGAZINE WINTER 2015 PAIN

Engage in dialogue with fellow IMS students and faculty. We always welcome IMS student submissions to discuss new research around the IMS, or to comment on popular/controversial topics in scientific training and research.


LETTER FROM THE EDITOR

Annette Ye & Susy Lam Co-Editors-In-Chief

Letter from the Editors

W

e’ve all stumbled across the saying, “No pain, no gain,” but beyond words of encouragement, how much discomfort is too much? In this issue of the IMS Magazine, we take an in-depth look at pain and its effects on the body. With the help of renowned experts Dr. Mojgan Hodaie, Dr. Angela Mailis-Gagnon, Dr. Jennifer Stinson, and Dr. Lucia Gagliese, we uncover pain management strategies in cancer, its effects on the brain, and avenues into web and mobile applications to help children track their pain. We’ve also sat down with Dr. Karen Davis to discuss her recent TED-Ed video, ‘How does your brain respond to pain?’ and her strong advocacy for knowledge translation. Lastly, we take a first-hand look at a patient perspective of chronic pain. We hope these articles help you gain insight and dispel myths regarding this universal phenomenon. We would also encourage you to read through our interviews with Dr. Martin McNeally and recent IMS graduate Dr. Cornelia McCormick as we get up close and personal regarding their IMS awards. Likewise, be sure to check out highlights from this year’s Summer Undergraduate Research Program (SURP) in addition to articles by our annual SURP Writing Competition winners, Elliot McMurchy and Amir Safavi. As we transition into the new year, it is our great pleasure to present Dr. Mingyao Liu’s welcome message as the new Director of IMS. We also have a special article on an exciting program IMS is launching this Fall in translational research. We would like to acknowledge Dr. Mingyao Liu and the IMS department for their ongoing support and encouragement, the IMS Magazine team on their outstanding contributions, and congratulate the incredibly talented Design Editors who have been integral in the production of this edition of the IMS Magazine. Cheers to a wonderful new year!

Photo by Chung Ho Leung

Happy reading!

Annette Ye & Susy Lam Co-Editors-In-Chief, IMS Magazine IMS MAGAZINE WINTER 2015 PAIN | 7


NEWS AT A GLANCE January 13 th • IMS Lunch and Learn event 15 th • Final date to submit masters theses without fee payment for winter session 23 rd • Final date to submit doctor theses without fee payment for winter session

February 3 rd • IMS Lunch and Learn event 16 th • Family Day (University closed)

March March graduation in absentia information is posted at www.convocation.utoronto.ca

April 3 rd • Good Friday (University closed) 17 th • Final date for submission of theses for MSc degree for June convocation

May May 12 th • IMS Scientific Day 2015, Chestnut Conference Centre

8 | IMS MAGAZINE WINTER 2015 PAIN

17 th • Final date for submission of doctoral theses for PhD students for June convocation


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DIRECTOR’S MESSAGE Knowledge Translation Through Research and Graduate Education

I

t is my great honour and privilege to be the new Director of the Institute of Medical Science (IMS) at the Faculty of Medicine, University of Toronto.

IMS was established in 1968 by Dr. Jack Laidlaw and Dr. Ernest McCulloch, for graduate training in clinical departments within the Faculty of Medicine. Over several decades, IMS has trained thousands of MSc and PhD students, especially many clinician investigators. Furthermore, IMS has developed several Master of Health Science (MHSc) professional degree programs. IMS graduates have gone on to become academic leaders not only in the University of Toronto and its affiliated hospitals, but also in numerous Canadian and international universities, health care related organizations, government agencies, and pharmaceutical and biotechnological companies. Several of our alumni have been highlighted under “Future Directions” or “Close-Up” in this very publication. Under the leadership of recent directors–including Drs. Melvin Silverman, Ori Rotstein, and Allan Kaplan–IMS has become one of the largest and most unique graduate units in the University, and has received recognition at national and international levels. Finding ways on how to make this great institute even better will be the challenge of my new role as the Director of IMS. In particular, I would like to focus on knowledge translation through enhancing research collaboration and promoting graduate education. First, we need to advocate the concept of knowledge translation as an objective for research. Research is not only a tool to explore new knowledge, but can also be a process for knowledge dissemination and translation. For example, we can use our acquired knowledge (i.e. a recently developed drug, drug formulation, technique, medical device, or diagnostic tool) as a starting point, and then translate that into a clinical application, a new health policy, or a product for commercialization. To foster this way of thinking, we must aim to provide our graduate students with the right training and tools for translational research. We will be launching a new website with interactive tools to facilitate knowledge exchange and collaboration. This includes a search engine that will help new students to find supervisors, in addition to promoting collaboration amongst faculty and students. Currently, IMS students and faculty actively participate in 18 different collaborative programs, which further speaks to the enrichment of our students’ learning experience and collaborations. We will also encourage collaborative interaction between our students in MSc/PhD thesis based stream and MHSc professional streams. Second, we will further our development of new programs that lead to the dissemination of our research knowledge into new clinical practice. IMS has great experience in creating professional programs, including our newly approved Masters in Translational Research in Health Science program launching this Fall. To learn more, see our “Special Feature” article on the next pages, authored by Dr. Joseph Ferenbok, Director of the Translational Research Program in Health Science. Recently, Dean Whiteside offered IMS a new space. We will renovate it for our Translational Research and Biomedical Communication programs. This will be the first time that IMS will have its own physical presence on campus. We will use this space as a base to promote collegiality and better collaboration within IMS. 10 | IMS MAGAZINE WINTER 2015 PAIN


DIRECTOR’S MESSAGE

Mingyao Liu Director, Institute of Medical Science Professor of Surgery, Medicine and Physiology Faculty of Medicine, University of Toronto Senior Scientist Toronto General Resesarch Institute, University Health Network

Photo courtesy of http://www.istockphoto.com/vector/vector-heads-withbulbs-bridge-46672996?st=37aa7fe

Third, working with the IMS Student Association and this student-led publication, the IMS Magazine, we will promote the feeling of ‘belonging’ within our institute. Through new faculty orientation and training, establishing faculty engagement awards, recognition of IMS faculty for career achievements in graduate education, and honouring distinguished IMS alumni, we will rebuild IMS as a home for students and faculty. Last but not least, we will develop IMS as the leader in national and international graduate education in the Medical Sciences. We will organize and lead national and international conferences to develop Medical Science as a distinguished graduate training subspecialty. It is with great excitement and tremendous enthusiasm that I take on my new role as Director of the IMS. I am looking forward working with our students, faculty, staff, and alumni. Sincerely,

Photo by Chung Ho Leung

Mingyao Liu MSc MD Director, Institute of Medical Science

IMS MAGAZINE WINTER 2015 PAIN | 11


http://www.istockphoto.com/vector/medical-idea-sharing-27520792

NEW IMS PROGRAM

By Joseph Ferenbok, PhD. Director of the Translational Research Program in Health Science

RE: Thinking Translational Research

I

n the scientific community, bridging the gap between discovery and implementation has, for some time now, been acknowledged as a significant strategic aim leading to improved health care outcomes, reduced costs, and faster translation of innovations into effective health solutions. Recently, governments seem to have taken notice and have initiated programs to address the “valley of death” between bench research and bedside applications. In the United States, the National Institutes of Health’s National Center for Advancing Translational Sciences has funded over sixty regional centers as part of the Translational Science Awards Program. In Europe, the European Infrastructure for Translational Medicine (EATRIS) helps support research from “discovery to therapy” at more than 70 12 | IMS MAGAZINE WINTER 2015 PAIN

academic institutions.

WHAT IS TRANSLATION? Although many seem to espouse the virtues of translation, what they actually mean by translation can be very different. Most views incorporate the idea that translation is the harnessing of knowledge from discovery (basic science) to intervention (production of new drugs, devices, diagnosis, and treatment options). But Translational Research (TR), Translational Medicine (TM), or Translational Science (TS) can also mean the translation of research from animal models to human subjects; or the translation from human trials to clinical practice; or to populations through policy. From these perspectives, TR helps

treatments and knowledge reach the patients and populations for whom they are intended. However, TR can also mean reverse translation, or the translation of knowledge from community and clinical work back into research projects in basic science. These understandings of TR support a very wide range of activities from “bench” to “community,” and back again.

REDEFINING TR AT THE IMS At the Institute of Medical Science (IMS), the working definition of effective translation constitutes the bi-directional movement of knowledge from one context towards mechanisms, techniques, and approaches that support the prevention, diagnosis, and treatment of disease. By


generating new questions and projects and by improving access, reorganization, and coordination of systems of care, we can help scientists, clinicians, and patients change behaviors and make more informed choices. In this fashion, TR can be thought of as the bridging mechanism between knowledge and practice. Stemming from the wide range of understandings and approaches to TR is a plethora of different approaches to training TR professionals – the scientists who are able to bridge the divide between discovery and implementation. Current TM programs differ widely in focus, scope, and even target audience. Some are setup to engage with early stage medical students, while others look at dealing with MD/PhDs, residents or fellows; and others still offer a range of scientific, engineering, and/or business oriented workshops for multidisciplinary audiences in early stages of academic careers. The variation of programs and outcomes under the rubric of TR, TS, or TM mirror the diversity of approaches to the umbrella of activities they encompass. At present, no one program has come up with a secret sauce to train people who can move scientific discovery towards health care innovation.

WHAT THE IMS TRP OFFERS

The IMS TRP is designed around a central Capstone project where students identify a problem and work on a design solution that attempts to translate knowledge to people, practice, products, policy, or populations. Students will work with a Project Advisory Committee on innovative Capstone projects that focus on addressing existing needs in the health

care ecosystem and may span from wet-lab research, to product innovation, or policy development. The Capstone course and a modular Translational Research course are designed to give students the opportunity to develop breadth, depth, and integration in a portfolio to pitch to perspective employers, collaborators, investors, or other agents of change. We are looking for students who want to make a difference, who have creative and innovative spirits, and who are interested in demonstrating problem- and designoriented thinking as part of a collaborative team. We are seeking translational leaders, entrepreneurs, intrepreneurs, and innovators; for people who are willing to contribute to the larger landscape of researchers, institutions. We are calling for champions looking for the secret sauce to TR, those who aspire to enhance research and practices that progress human health in local and global contexts. This year the application deadline is June 1st, 2015, but students who apply by May 1st, 2015 will be considered for entrance awards. For more information about the program and about the Institute of Medical Sciences please visit our website at www. ims.utoronto.ca/programs/professional/ trp_home.htm.

Photos courtesy of www.istockphoto.com

On November 5th, 2014, the Ministry

of Training, Colleges and Universities approved the IMS’ proposal for a new Masters program in Translational Research in Health Sciences (TRP) for a start date of September 2015. As the first program of its kind in Ontario, our approach for the TR program, similar to others in the United States and Europe, aims to allow students to make a difference in the TR space, and establishes links into many of the global communities exploring TS. Yet it is still wholly unique because the IMS TRP is focused on learning by doing, on allowing students the opportunity, flexibility, and creative support to make a difference in medical care. The two year, course-based Master of Science program focuses on helping students to identify gaps, develop and test ideas, in addition to generating problem-solving designs in collaborative teams. Through design-oriented thinking and experiential learning, we will link students to larger networks of TR throughout the Greater Toronto Area and the world.

IMS MAGAZINE WINTER 2015 PAIN | 13


C A N A D I A N

CHRONIC PAIN 1/5

CANADIANS

STAT I ST I C S

! Pain lasting several months, or persisting after an injury has healed, is considered

experience chronic pain on a daily basis.

CHRONIC .

80 Approximately

of physician visits are prompted by % complaints of pain

The most common chronic pain complaints include

PAIN

Neurogenic Cancer Low back Headache Arthritis

WHO EXPERIENCES CHRONIC PAIN? 1/10

Male

for those living in the community

Female

16% 14% 12%

The most common pain-related chronic conditions of this group are

BACK PROBLEMS & MIGRAIN HEADACHES

for those living in long-term care facilities

N O DAT A

An estimated Canadians aged 12-44 experience chronic pain.

38 %

27 %

YOUTH - ADULTS 18%

OLDER AD U LT S

10% 8% 6% 4% 2% 0%

Percentage of group affected by chronic pain

14 | IMS MAGAZINE WINTER 2015 PAIN

AGE GROUP

12-17

18-24

25-34

35-44

36-64

65+


TYPES OF NON-CANCER CHRONIC PAIN MUSCULOSKELETAL PAIN

NEUROPATHIC PAIN Affects brain processing changed from injury or malfunctioning nerve fibers.

Affects bones, muscles, ligaments, and tendons.

Can result from sport or occupational injuries, motor vehicle accidents, repetitive strain injuries and diseases processes such as arthritis.

PAIN MANAGEMENT nonpharmacological physical Exercise, acupuncture, transcutaneous electric nerve stimulation

psychosocial Self-management education, meditation, music, guided imagery, stress management

pharmacological Illustrated by Natalie Cormier and Ashley Hui

NSAIDs, antidepressants, anticonvulsants, interventional nerve blocks, opioids (most prominent)

Complex, multi-faceted state that may have no obvious cause. Other types include numbness, burning, “pins and needles” sensations and shooting pain.

PSYCHOLOGICAL EFFECTS OF CHRONIC PAIN

60 UP TO

%

of patients with chronic pain suffer from depression.

!

CHRONIC PAIN

costs more than

cancer + heart disease + HIV

APPROXIMATE COSTS OF CHRONIC PAIN PER YEAR $6 BILLION

in direct health care costs

$37 BILLION

in productivity costs related to job loss and sick days IMS MAGAZINE WINTER 2015 PAIN | 15


FEATURE

NEUROIMAGING FOR FUNCTIONAL NEUROSURGERY Hodaie Lab

By Mojgan Hodaie MD MSc FRCS(C) Staff Neurosurgeon, Toronto Western Hospital Associate Professor, Department of Surgery, University of Toronto Surgical Co-Director, Joey and Toby Tanenbaum Family Gamma Knife Center Scientist, Toronto Western Research Institute multiple sclerosis, and even tumors. This surgical imaging lab uses many different brain imaging techniques in the field of functional neurosurgery–so-called because it focuses largely on disorders in which conventional magnetic resonance imaging (MRI) often fails to see any anatomical changes. Dr. Hodaie is an associate professor of surgery at the University of Toronto, and specializes in stereotactic and functional neurosurgery. One particular disorder of interest is trigeminal neuralgia, a highly debilitating disorder characterized by sudden, unanticipated, and severe facial pain. The pain can be so intense that patients have described it as “an electric surge of 10 000 volts through the face.” Surgery can result in the complete resolution of pain in most patients, but for some, the pain recurs and is more difficult to control. We simply don’t know why such individual differences exist.

Mapping the brain’s connections

(From left to right: David Qixiang Chen, Dave Hayes, Mojgan Hodaie, Brendan Behan, Danielle DeSouza)

T

he brain has been referred to as the most complex object in the universe. Unsurprisingly then, small alterations can give rise to a host of big changes in brain function. In fact, many psychiatric, movement, and pain-related disorders exist without any visually obvious changes to brain structure. 16 | IMS MAGAZINE WINTER 2015 PAIN

This is why researchers in the lab of neurosurgeon Dr. Mojgan Hodaie (www. hodaielab.com)–at the Toronto Western Research Institute, University Health Network–are looking for ways to use advanced brain imaging to help improve neurosurgical outcomes for many different types of patients, such as those with chronic pain,

Although brain imaging is an increasingly used tool in neurosurgical cases involving anatomical abnormalities (e.g. tumour resection), it has been less used in the field of functional neurosurgery. The ability to visualize the white matter pathways of the brain is a relatively new approach, and the Hodaie lab is one of the few places where the use of ‘brain mapping’ techniques is considered alongside functional neurosurgery. These techniques, such as diffusion MRI, are helping researchers to find pathway differences in those with brain disorders compared to healthy people. For instance, people experiencing chronic pain almost always have brains that appear entirely normal. “Looking at conventional brain MR imaging, we’re not easily able to


Photographs provided by Hodaie Lab

distinguish between someone who suffers from an excruciating pain disorder from someone who doesn’t,” explains Dr. Hodaie, “unless we look at the finer details of the brain.” One idea from her lab is that the experience of chronic pain may affect the microcircuitry, the white matter pathways, as well as the gray matter of the brain— these features are challenging to discern in standard brain images.

Brain-based treatments: Moving toward neuroimaging in the clinic Graduate students Danielle DeSouza (co-supervised by Karen Davis) and David Q. Chen are involved in improving the visualization of these pathways using advanced computer-based modelling which are then applied to the clinic.1–4 They showed that people with trigeminal neuralgia often have abnormalities in the trigeminal nerves on both sides of the brain, even if they only experience pain on one side. Moreover, select pathways and gray matter involved with sensory and emotional processing in the brain, but far from the trigeminal nerve, also appear to be altered—supporting the idea that chronic pain disorders may have a greater, more widespread, impact on the complex circuitry of the brain.

Beyond pain, the Hodaie Lab also focuses on technical improvements in visualization of white matter pathways. In order to understand how alterations in small brain fibers and their connections are associated with pain, it is pertinent to visualize the brain fibers in a better way than conventional methods. This is why a good portion of the lab’s effort is focused towards visualizing fine details of the brain better, and is done through technical modifications of image analysis. The techniques used in the Hodaie lab have important repercussions on how pain is studied, and hopefully they will allow for development of useful objective measures to assess pain. At the same time, these techniques are applicable beyond pain, to a variety of other conditions, including the visualization of small white matter tracts surrounding tumors, psychiatric conditions, as well as movement disorders. For example, postdoctoral fellow Brendan Behan is currently exploring better strategies to see the twists and turns of nerves pushed away from their usual paths by brain tumors, while research associate Dave Hayes has been looking at the different white matter connectivity patterns in the brains of patients who have undergone deep brain stimulation.

The ultimate goal is to improve the lives of people with challenging disorders, by using these new brain imaging strategies as a routine clinical tool for improved, highly personalized, treatments. Dr. Hodaie says that “for brain imaging to be useful in the clinic, it has to be able to help make predictions about who will benefit from surgery.” The Hodaie Lab will undoubtedly be a firm part of the future of advanced surgical brain imaging. For more information, please visit www. hodaielab.com

References: 1. DeSouza DD, Moayedi M, Chen DQ, et al. Sensorimotor and pain modulation brain abnormalities in trigeminal neuralgia: A paroxysmal, sensory-triggered neuropathic pain. PLoS One. 2013; 8: e66340. 2. DeSouza DD, Hodaie M, Davis KD. Abnormal trigeminal nerve microstructure and brain white matter in idiopathic trigeminal neuralgia. Pain. 2014;155:34–44. 3. Hodaie M, Quan J, Chen, DQ. In vivo visualization of cranial nerve pathways in humans using diffusion-based tractography. Neurosurgery. 2010;66:788–96. 4. Hodaie M, Chen DQ, Quan J, et al. Tractography delineates microstructural changes in the trigeminal nerve after focal radiosurgery for trigeminal neuralgia. PLoS One. 2012;7:e32745.

IMS MAGAZINE WINTER 2015 PAIN | 17


FEATURE ARTICLE

By Angela Mailis Gagnon, MD, MSc, FRCPC (PhysMed) Director, Comprehensive Pain Program, Toronto Western Hospital, and Chair, ACTION Ontario

Chronic Pain

The elephant in the room that no one wants to see

18 | IMS MAGAZINE WINTER 2015 PAIN

constant or in spells, at rest or only with movement, worse with weather changes, touch etc. The term is an all-inclusive “umbrella” under which many types and mechanisms of pain can be classified as follows: neuropathic pain (the result of damage or disease to the peripheral or central nervous system); nociceptive somatic pain (due to damage of the musculoskeletal system), or

nociceptive visceral pain (arising from afflictions of heart, kidneys, urinary bladder or gut), or a mix of those types. Acute pain is straightforward as in the following examples: You break a bone and it hurts. Once the fracture is stabilized in a cast, the pain stops. You have a kidney stone that creates colic. Once the stone passes, the pain stops. On the other hand,

Photo by Laura Feldcamp

C

hronic pain of one sort or another affects approximately 1 in 3-4 Canadians (depending on the statistics used). In raw numbers this corresponds to 3-4 million people in Ontario alone and 9-12 million people across the nation. Chronic pain is no “small business.” The term “chronic” means pain that is present daily or very often, for weeks and years,


FEATURE bad knee arthritis or permanent nerve damage can hurt for long periods, so this type of chronic pain has a known cause. Unfortunately, many cases of chronic pain

to develop painful conditions later in life? What is the reason that people from different cultures and races feel and express pain differently?

I do not have enough space and time to cover all these issues here. However, I want to touch on some major issues with chronic pain: The estimated annual cost of pain from all causes in the USA is approximately $61.2 billion per year and approximately $6 billion per year in Canada (estimates that are really quite small if one takes into account lost work days, health care direct costs, out of pocket expenses, are not as straightforward. What about disability and other payments, not includdisabling pain from an injury that seems ed in these numbers). Furthermore, the to be very minor and insignificant? What immense cost of human suffering cannot about ever-lasting pain from an injury, be expressed in dollar figures. Despite which for all practical purposes healed a this, chronic pain seems to be unrecoglong time ago? What about pain that seems nized and is highly undertreated in most to start in one part of the body, localized to parts of our country. When it comes to the site of a sprain or other injury, which research (how else would we know all this then spreads everywhere? Many of these difficult-to-explain pains are affected by multiple factors such as our environment, lifestyle and dietary habits, or the sufferer’s coping mechanisms and beliefs, to name a few. In most chronic pain conditions, the central nervous system plays a substantial role through changes in brain activation patterns and actual “wiring.”

What about pain that seems to start in one part of the body, localized to the site of a sprain or other injury, which then spreads everywhere?

Chronic pain can bring minor limitations, such as making us change activities, but we still go on with life. But other times, chronic pain becomes so disabling that life seems to stop and with it, our ability to work, enjoy life, and fulfill our role as spouses, parents, or friends. Chronic pain can be strange and difficult to understand on many fronts and not just where it comes from. Here is a long list of questions: Why do two people with the same injury seem to be affected very differently? Why do women seem to suffer from more painful conditions than men? Why do people with the same condition respond differently to the same treatment? Why do kids who come from homes with relatives who have chronic pain seem more prone

...other times, chronic pain becomes so disabling that life seems to stop and with it, our ability to work, enjoy life, and fulfill our role as spouses, parents, or friends.

physical and psychosocial issues that come with chronic pain. In addition, they do not have access to resources, such as pain consultants, nurses, psychologists, social workers, or manual therapists to assist them in addressing the “whole person.” From the chronic pain patient’s point of view, distance and resources that are not available or accessible, are huge issues. Many treatments for chronic pain (outside interventions such as injections and surgery) are not funded in our health system, unless you have a third party covering you, such as worker’s compensation or extended health care. Proper pain treatments not only include medications, but most importantly, physical, psychological, and “whole person” treatments in well-organized pain clinics and settings. However, these clinics are limited, and often have long waiting lists. Thankfully, in some provinces, there is a concerted effort to address the issue of chronic pain. The effort is through the National Strategy proposed by the Canadian Pain Society, which must be adopted by the federal government to work.

This article had been published in previous online forms.

information I cited earlier if it was not for research?), less than 1% of all research funds are devoted to pain research (even though Canada is a true pioneer in many research fronts including children’s pain, imaging the brain, pain genetics etc.). When it comes to waiting to be seen by doctors specializing in chronic pain, wait lists across the country vary between many months to five years. While family doctors are our “gate keepers” and manage 90% of chronic pain, they have not been trained to deal with such pain. They don’t have time or appropriate remuneration to address the complex IMS MAGAZINE WINTER 2015 PAIN | 19


Application of web and mobile technology to improve pain and symptom management in youth with chronic illness

P

ain is one of the most common symptoms reported by children with chronic (e.g. arthritis) and life threatening (e.g. cancer) health conditions. It is known to have a profoundly negative impact on all aspects of health related quality of life, including physical, emotional, social, and school functioning. The accurate and timely assessment of pain is the crucial first step in effective pain management. While there are paper-based pain diaries for children, they suffer from methodological problems such as recall bias, back-filling, and poor compliance. The use of web and mobile-based “e-diaries” can minimize recall bias by allowing patients to report how they feel “right now,” and also be designed to prevent back-filling of data. Furthermore, e-diaries are associated with heightened patient compliance, due to their portability, appeal to youth, and ease of use. While e-diaries have been widely used to assess and manage pain in adults, there has been little research evaluating their use in children and adolescents. As part of my team’s program of research, we have developed and validated several 20 | IMS MAGAZINE WINTER 2015 PAIN

multidimensional “e-diaries” for assessing pain in children and adolescents. Recently, we developed and evaluated an iPhone-based diary application called Pain Squad™, which is designed to assess cancer-related pain and symptoms in youth.

cation elements has helped us to achieve an average compliance rate of 70%. This level of compliance represents a great improvement over paper-based cancer pain diaries, which are associated with rates as low as 11%.

Pain Squad™ incorporates elements of gamification by placing the user in a fictionalized police squad with the mission of completing pain reports to achieve promotion. As the user progresses through the police ranks, they receive digital badges as well as encouragement through video clips featuring actors from Canadian television shows. The incorporation of these gamifi-

In addition to assessment of symptoms, web and mobile-based technology can also be applied to improve the self-management of illness in youth. Self-management refers to the ability of an individual to manage the symptoms, treatment, physical and psychological consequences, and lifestyle changes inherent to living with a chronic illness. Self-management inter-

Photo by Laura Feldcamp

By Jennifer Stinson, PhD, RN-EC, CPNP Nurse Clinician-Scientist, Chronic Pain Program at the Hospital for Sick Children


FEATURE ventions that provide individuals with disease-specific knowledge, strategies to manage symptoms such as pain and social support are needed to promote optimal health outcomes. My team is currently conducting a CIHR-funded, multi-centre randomized controlled trial to evaluate the effectiveness of “Teens Taking Charge: Managing Arthritis Online,” a multi-component, interactive program consisting of arthritis-specific education, self-management strategies, and social support designed for youth and their parents. This program was developed and evaluated in English and French using a sequential phased approach, including iterative development, usability testing, and outcome evaluation. Our current Teens Taking Charge trial involves a sample of 324 English and French-speaking adolescents aged 12-18 years with arthritis and one of their par-

ents/primary caregivers from 10 pediatric rheumatology centres across Canada. Participants are randomized to the experimental (internet self-management intervention) or control (attention) group. We are collecting outcome data on health-related quality of life, symptoms, treatment adherence, knowledge, and self-efficacy from both groups at baseline (T1), immediately following the intervention (T2), and at 6 (T3) and 12 (T4) months. The “Teens Taking Charge: Managing Arthritis Online” project will address several gaps in the current field of internet-based self-management interventions in youth with chronic health conditions. First, our multi-site recruitment is a significant step forward as it allows for one of the largest samples that have been used in any pediatric internet-based self-management intervention study, providing a strong test of treatment effectiveness. Second, we are using a comprehensive set of outcome

measures that exhibit sensitivity to change. Third, the extended follow-up over one year will allow for testing of the maintenance of treatment effects. Fourth, the use of a credible control condition will allow us to tease apart the effects of active treatment from those associated with increased attention given to participants. Lastly, this project has the potential to improve the accessibility and acceptability of self-management treatments for English and French speaking youth with arthritis, thereby reducing unnecessary burden and costs on the health care system and improving health outcomes. Our group is also conducting a trial of a Spanish version of “Teens Taking Charge,” which is funded by the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS). Additionally, we have adapted the program to meet the disease self-management needs of youth with cancer and hemophilia.

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By Tamara Harduwar, Rebecca Harrison, Lynn Gauthier, Lucia Gagliese Cancer Pain Research Unit, Princess Margaret Cancer Centre

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lthough cancer is associated with a broad spectrum of distressing symptoms, pain is the most significant in terms of reducing a patient’s quality of life.1 Despite advances in our understanding of cancer and its treatments, pain management has not improved significantly.2 Unrelieved cancer pain is associated with increased physical impairment,3 psychological distress,4 delirium,5 hastened diseased progression and increased morbidity.6 Cancer pain is multidimensional. It is affected by biological, cognitive and emotional factors, which all interact in complex ways. Similarly, aging involves multiple, interacting changes, which are not uniform across systems, but dramatically impact each other. We have barely begun to identify the ways in which 22 | IMS MAGAZINE WINTER 2015 PAIN

cancer pain and its effects on physical and psychological functioning differ with age. We do not know if the pharmacological and psychosocial cancer pain management strategies that are helpful in middle-aged adults are effective in older patients. We do not understand if the psychosocial barriers to obtaining medical and surgical treatment for cancer pain are similar in older and younger adults. As the population ages, it is increasingly important to understand agerelated patterns in cancer pain, in order to apply safe and effective pain management strategies. The Cancer Pain Research Lab, based at York University and the University Health Network, works from a biopsychosocial model of cancer pain to approach these issues. Our research aims to better

understand the psychological and social impact of pain on patients and family members, to determine the biological indicators of pain, and to aid in developing effective and safe pain management strategies for people across the adult lifespan. Our lab is made up of research staff, graduate and undergraduate trainees, co-operative education secondary school students, and volunteers. Our studies aim to capture the experience of cancer pain across the disease spectrum, ranging from a few weeks after diagnosis to a few days before the end of life. In our research we consider both acute and chronic pain, and study two aspects of cancer pain: that associated with the disease process itself and pain related to treatments, namely surgery. We also look at how cancer-related pain impacts (and is impacted by) the patients’ social support network.

Photo courtesy of Chung Ho Leung

The Biopsychosocial Model of Cancer Pain


FEATURE ARTICLE One of our current studies examines age-related patterns in postoperative pain in women undergoing lumpectomy or mastectomy surgery. Based on 2009 estimates, about 1 in 9 Canadian women will develop breast cancer during her lifetime.7 In addition to the women who require surgery as treatment for their cancer, many choose to undergo prophylactic surgery to reduce their risk. After surgery, many women experience moderate to severe pain, and an estimated 60% develop chronic pain.8 In this longitudinal study, we investigate how pain after breast cancer surgery differs across age groups, and how psychological and biological factors impact pain and recovery over a two-year span. Beginning prior to surgery, we measure various biological, psychological and social factors that impact the pain experience. While most studies of chronic pain must recruit patients following an injury, the unique advantage of this patient group is that it allows for examination of preinjury factors. In this way, we can identify which factors influence the development of chronic pain, and how these aspects may affect long-term outcomes for patients.

Despite advances in our understanding of cancer and its treatments, pain management has not improved significantly. By following this patient group for two years, we have the opportunity to examine the potential development of pain, the long-term recovery process, and how pain intensity, biomarkers for pain, and psychosocial well-being change over time. Biologically, aging has many interacting effects on the immune, endocrine and nervous systems, which affect how the body responds to injury.9,10,11 With age comes an increase in pro-inflammatory cytokines and cytokine responses, which may lead to an increased nervous system

response to injury, ultimately resulting in pain experienced as a result of normally non-painful stimuli.11 At the same time, estrogen and progesterone levels, which may have a neuroprotective effect on this process,12,13 decrease with age. Current research on the impact of age on postoperative cancer pain has widely varied results, likely because most studies do not examine age as a primary focus. As there are many confounding factors to account

Biologically, aging has many interacting effects on the immune, endocrine, and nervous systems, which affect how the body responds to injury. for when examining the effects of age on the disease process, our study hopes to bridge this gap in the literature by matching women based on age and surgery type.

new diagnoses of cancer. Medical Care. 2000;38(5):482-93. 4. Turk DC, Sist TC, Okifuji A, Miner MF, Florio G, Harrison P, Massey J, Lema ML, Zevon MA: Adaptation to metastatic cancer pain, regional/local cancer pain and non-cancer pain: role of psychological and behavioral factors. Pain. 1998;74(2-3):247-56. 5. Lynch EP, Lazor MA, Gellis JE, Orav J, Goldman L, Marcantonio ER: The impact of postoperative pain on the development of postoperative delirium. Anesthesia and Analgesia. 1998;86:781-785. 6. Okusaka T, Okada S, Ueno H, Ikeda M, Shimada K, Yamamoto J, Kosuge T, Yamasaki S, Fukushima N, Sakamoto M: Abdominal pain in patients with resectable pancreatic cancer with reference to clinicopathologic findings. Pancreas. 2001;22(3):279-84. 7. Advisory Committee on Cancer Statistics. (2014). Canadian Cancer Statistics 2014. Toronto, ON: Canadian Cancer Society. 8. Jung BF, Ahrendt GM, Oaklander AL, Dworkin RH. Neuropathic pain following breast cancer surgery: proposed classification and research update. Pain. 2003;104:1-13. 9. Franceschi C, Valensin S, Bonafe M, Paolisso G, Yashin AI, Monti D, De Benedictis G. The network and the remodeling theories of aging: historical background and new perspectives. Experimental Gerontology. 2000;35(6-7):879-96. 10. Straub RH, Cutolo M, Zietz B, Scholmerich J. The process of aging changes the interplay of the immune, endocrine and nervous systems. Mechanisms of Ageing & Development. 2001;122 (14):1591-611. 11. Watkins LR, Maier SF, Goehler LE. Immune activation: the role of pro-inflammatory cytokines in inflammation, illness responses and pathological pain states. Pain. 1995;63(3):289-302. 12. Sohrabji F. Estrogen: a neuroprotective or proinflammatory hormone? Emerging evidence from reproductive aging models. Annals of the New York Academy of Sciences: 1052, 2005. 13.

Rehman HU, Masson EA. Neuroendocrinology of

female aging. Gender Medicine. 2005;2(1):41-56.

Through increased understanding of the predictors of pain, the results of the study will help identify the unique needs of older patients, and lead to the development of management interventions tailored to their special needs. In addition, the detailed pain sensitivity and psychosocial testing may allow us to identify patient subgroups who may be at a higher risk of developing chronic pain, based on their unique symptom profile. With this information, we hope to help advance breast cancer pain palliation and improve health and quality of life for cancer patients across the adult lifespan. References 1. Mercadante S, Armata M, Salvaggio L: Pain characteristics of advanced lung cancer patients referred to a palliative care service. Pain. 1994;59(1): 141-5. 2. Zeppetella G, O’Doherty CA, Collins S. Prevalence and characteristics of breakthrough pain in cancer patients admitted to a hospice. J Pain Symptom Manage 2000;20:87–92. 3. Given CW, Given B, Azzouz F, Stommel M, Kozachik S: Comparison of changes in physical functioning of elderly patients with

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FEATURE ARTICLE A NEW KNOWLEDGE TRANSLATION APPROACH: Dr. Karen Davis discusses her recent TED-Ed video ‘How does your brain respond to pain?’

Photo courtesy of Chung Ho Leung

Dr. Karen Davis is Head of the Division of Brain, Imaging & Behaviour - Systems Neuroscience at Toronto Western Hospital and world-renowned for her research on the central mechanisms of pain. Recently, she worked with TEDEd to create a TED-Ed Original lesson: an educational video professionally animated through a collaboration with animator, Brent Underhill. You can find her lesson here [http://ed.ted.com/ lessons/how-does-your-brain-respondto-pain-karen-d-davis] including the video and associated content: quizzes, additional resources, and discussion questions. TED-Ed is the educational initiative of the non-profit organization TED, and aims to expand on the TED mission of ‘spreading great ideas’ by creating short educational videos aimed at teachers and learners. I sat down with Dr. Davis to discuss the creation of the video and her passion for knowledge translation encompassing pain.

Karen Davis Senior Scientist, Toronto Western Research Institute (TWRI) Scientific Division Head: Division of Brain, Imaging and Behaviour – Systems Neuroscience By Kasey Hemington

HOW DID THE IDEA TO CREATE THE VIDEO COME ABOUT? KD: I was selected as one of six 2013-2014 fellows for The Mayday Fund’s ‘Mayday Pain & Society Fellowship: A Media and Policy Initiative’. The Mayday Fund is a foundation based in New York dedicated to alleviating pain, so the fellowship was established to train clinicians, scientists, and legal scholars to communicate effectively about their work and the field of pain management. One part of the fellowship training is defining a project you will work on for six months. One theme of the project I defined had to do with the neuroethics of developing brain imaging tools for pain diagnostics. The other theme was to disseminate the concepts that first, pain is subjective, and second, that there is a wide variety of pain sensitivities and experiences. These two themes culminate in the fact that a ‘one size fits all’ model of pain management is not effective for many types of pain, and this was the basis for the creation of the TED-Ed video. WHY IS IT IMPORTANT TO EDUCATE PEOPLE ABOUT PAIN? KD: It’s important for doctors and caregivers to understand that what the patient reports is really what they are experiencing, and it’s important for patients to know that their pain is real. The issue of patients malingering or faking pain is really played

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up. It’s more prevalent in the United States because of issues with health insurance. That’s why I also enjoy being involved in discussion with legal actors; because they don’t know whether to accept pain reports as being real or not and they’re interested in having an objective measure. TELL US ABOUT THE MAYDAY PAIN AND SOCIETY PROJECT. KD: Part of the fellowship was an intense training week in Washington DC by a team from Burness Communications. We were able to develop our projects, practice being interviewed, and learn how to get our message across. We had someone from the Huffington Post come and teach us how to blog, and someone from the New York Times teach us about writing op-eds, and journalists from the BBC and the National Public Radio help us with interview skills. We also had someone from TED-Ed come and teach us how to tell a story. I decided to take a long shot and go for the TED-Ed animation! WHAT’S THE PROCESS FOR CREATING A VIDEO WITH TED-ED AND WHAT WAS IT LIKE WORKING WITH AN ANIMATOR TO COMMUNICATE YOUR IDEAS? KD: TED-Ed is relatively new. A lot of people don’t know that it’s all animation. And it’s not just video content—I had to develop multiple choice questions related to the video as well, for example. People can go through the questions themselves or educators can take them into the


classroom, or modify them to fit their own lesson plans. Right now I have around 500 000 views of the video on Youtube, but also 3 000 questions answered! There’s also links on the site to additional resources including findings my group has published.

pain management, and some may depend on an individual’s brain circuitry and how they cope with things. Understanding the networks involved may lead to different surgical or brain stimulation targets for different people.

I created the script for the video, and I had a story line and set of visuals in mind. At TED-Ed, they first give the script to the animator without my ideas for visuals, so they have the freedom to come up with what they think will fit the script. He [animator, Brent Underhill] wasn’t familiar with animating scientific content, so he came up with a completely different approach. It took me a while to understand the way he approached animating the script because it was a lot more abstract and conceptual, but he was right; I think it made it much more accessible to a broader audience.

HOW CLOSELY DOES THE CONTENT REFLECT YOUR OWN RESEARCH?

WHAT DO YOU HOPE PEOPLE TAKE AWAY FROM THE VIDEO?

KD: It’s been tremendous. The video has

KD: Pain is experienced differently by different people, and people balance pain with other cognitive and emotional demands differently. All of this is represented by different networks in the brain. We now know that some of these networks are malleable; part of the hope for the future is that we are able to manipulate these brain networks in pain management. The bottom line has to do with personalized medicine. There are a variety of invasive and non-invasive approaches to

KD: Almost all of the content in the video is directly based on my group’s research, with some background content added in. I actually started with a talk I’d given at a conference as the framework for the video. We’ve recently published about the variable effects of distraction on pain and the tendency to mindwander during pain and how this relates to brain circuitry, which are key concepts in the TED-Ed lesson. HOW DOES THIS WORK CONTRIBUTE TO YOUR KNOWLEDGE TRANSLATION GOALS? hit many different targets for knowledge translation. In addition to being seen by hundreds of thousands of members of the general public, I’ve disseminated it to different societies—the International Association for the Study of Pain, for example—in order to reach my own peer group as well. It’s also being used as a teaching tool in undergraduate classrooms.

FEATURE

for feeling pain. Being educated can take away that stigma. Patients have also been sharing the video themselves with family and friends so they can better understand what they are going through.

Finally, through developing the video I’ve been able to reach policy makers and a legal audience. We need to get the message across that developing a diagnostic tool for pain is a difficult task because of the variability in pain responses. WHAT ADVICE WOULD YOU GIVE TO OTHER IMS RESEARCHERS ABOUT CREATING A SIMILAR KNOWLEDGE TRANSLATION TOOL? KD: It’s a great opportunity to get your message out, and the process really helps you better understand your own science. Many researchers have opportunities to do media training while working at the University of Toronto and they should take advantage of this. Learning how to communicate your work succinctly and clearly can help you convey the importance of what you do to everyone, whether it be in grant writing or explaining your lab to potential new graduate students.

On the clinical side, I’ve had clinical colleagues show it to patients in order to help open up the discussion about what pain is. A lot of people feel like it’s their fault

Animation screenshots: http://ed.ted.com/lessons/how-does-your-brain-respond-to-pain-karen-d-davis IMS MAGAZINE WINTER 2015 PAIN | 25


PATIENT PERSPECTIVE Chronic Pain By Anonymous

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s a 37 year old female registered nurse I was horrified when I was diagnosed with ankylosing spondylitis (AS) earlier this year. AS is an inflammatory arthritis and autoimmune disease in which the immune system attacks the joints in the spine resulting in pain and stiffness. I was born, raised, and completed two university degrees in Windsor, Ontario. I first started working as a nurse at Windsor Regional Hospital in the medical/surgical unit. This experience motivated me to become an operating room (OR) nurse, and after completing a perioperative program, I acquired a permanent position at Toronto Western Hospital’s (TWH) OR. After being diagnosed with AS I reflected upon my signs and symptoms over the past ten years. I experienced mild back and neck pain as well as a stiff neck, which was easily relieved by rest and exercise. At the time I attributed this pain and stiffness to the fact that I was working two jobs as well as attending school. However, in January 2014 I noticed my hands began to swell to the point where I could not close or grasp anything. This was not only difficult for my job as a nurse, but also my personal life. This was the point when I decided to visit my family doctor. After discussing my symptoms and the fact that my father has AS with my doctor, he immediately referred me to a rheumatologist. 26 | IMS MAGAZINE WINTER 2015 PAIN

After genetic testing the rheumatologist found that I tested positive for the HLA-B27 gene and presented with all the symptoms of AS, a disease that affects mostly men. At this point, I was prescribed non-steroidal anti-inflammatories, a disease-modifying agent, and regular physiotherapy, aquatic therapy, and massage therapy.

In January 2014 I noticed my hands began to swell to the point where I could not close or grasp anything Since being diagnosed in January 2014 the pain and stiffness has progressed to the point that if I do not take my medications my joints feel like they are burning, extremely stiff, and excruciatingly painful. The medications help to relieve the burning sensation, however the pain and stiffness is still noticeable. As a healthcare professional I decided to research and educate myself on the underlying causes of autoimmune diseases, specifically AS. This has provided me with insight on how to live a healthier lifestyle through a different diet and exercise program. I try to avoid eating processed foods and maintain a gluten-free diet. Flexibility is also important to maintain, because AS can cause the

spine to fuse, therefore I stretch as much as I can. One of the symptoms of AS that has dramatically changed my life is fatigue; I simply don’t have the energy to do what I used to. Long walks seem unbearable and getting a full workout means I’ve done 30 minutes of cardio and 15 minutes of stretching. This is dramatically different from the two hours of weights and high impact cardio that I’m used to. It would be a lie to say that AS hasn’t impacted my life. At this point in time, I continue to learn and manage the symptoms by living a healthy lifestyle. Aside from minimizing the symptoms of this autoimmune disease with exercise, my modified diet has many benefits, such as improving overall health and wellbeing. My low fat diet is mostly vegetarian with the exception of seafood. I no longer work in the OR. I’ve been placed on a modified work plan for the past nine months. My nursing role now consists mainly of paperwork or administrative duties. I have been working with employees in different capacities and TWH has a great multidisciplinary team. Working with different team members has enabled me to learn and provide insight into different nursing roles that I can explore.


Photo courtesy of www.istockphoto.com

It would be a lie to say that ankylosing spondylitis hasn’t impacted my life. IMS MAGAZINE WINTER 2015 PAIN | 27


FEATURE

Recipient of the 2014 Sara Al-Bader Memorial Award: Cornelia McCormick By Rebecca Ruddy

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n the spring of 2011, the Institute of Medical Science (IMS) established an annual award to recognize the academic excellence of international students in memory of IMS student, Sara Al-Bader. Sara was a highly accomplished student from Britain. After receiving her BSc in Physics and MSc in the History of Philosophy of Science from the University of London, she moved to Toronto to pursue doctoral studies with the IMS in the area of global health. Her research was based at the McLaughlin-Rotman Centre for Global Health, where she focused on science-based health innovation in Sub-Saharan Africa. Tragically, in November of 2010, while Sara and her husband, Michael Smoughton, were driving to Montreal, they were involved in a head-on collision that took their lives. This terrible loss was felt by her family, friends, peers, and colleagues at the University of Toronto. At the time of the accident, Sara was nearing completion of her PhD thesis. While those closest to her were still mourning her loss, they also began to think about how they could honour Sara and her hard work. Following her tragic passing, friends and colleagues decided to finish what Sara had started. They were resolved to complete Sara’s doctoral thesis to the best of their ability to ensure that Sara would receive the degree she worked so hard for and so that the scientific community could still benefit from her work and research. After countless hours of hard work and dedication, her friends and colleagues completed Sara’s thesis and submitted it for external review. In November of 2011, Sara’s parents traveled to Toronto to watch as Sara was posthumously awarded her well-deserved doctoral degree. After the bestowment of her posthumous 28 | IMS MAGAZINE WINTER 2015 PAIN

degree, the Institute of Medical Science decided to preserve her memory and created an award in her honour. The Sara Al-Bader Memorial Award was established to acknowledge senior international students in IMS who display outstanding promise in academics and research. It is awarded to students who have achieved academic excellence in the department and display the promise in scientific research that Sara clearly demonstrated. To date, there have been three recipients of the Sara Al-Bader Memorial Award: Dr. Phan Sok (2012), Dr. Fabio Salamanca-Buentello (2013) and most recently, Dr. Cornelia McCormick (2014).

atmosphere and multidisciplinary environment of the IMS. At the time, Conny was studying psychology as well as pursuing her medical degree in Germany when Drs. Morris Moscovitch and Mary Pat McAndrews at the University of Toronto raised the opportunity to collaborate. Without knowing anybody and with it being her first time traveling outside of Europe, Conny came to Toronto. She immediately met new people and began a fruitful collaboration with the researchers at the IMS. She then returned to Germany to finish her medical degree and was awarded her MD in 2010. However, her work at the IMS laid the foundation for her to return to Toronto in 2010 to begin her doctoral degree with Drs. Moscovitch, McAndrews, and Taufik Valiante.

Following her tragic passing, friends and colleagues decided to finish what Sara had started. They were resolved to complete Sara’s doctoral thesis to the best of their ability to ensure that Sara would receive the degree she worked so hard for and so that the scientific community could still benefit from her work and research.

The recipient of this year’s Sara Al-Bader Memorial Award exemplifies the qualities that this award represents. Cornelia (Conny) McCormick (née Fortmeier) is an accomplished student and scientist. After corresponding with and reading about Conny, it became clear why she was chosen as this year’s recipient. She has a passion for pursuing knowledge, both through her current research and throughout her multiple degrees, where she has achieved academic excellence. It was evident that her experience at IMS was life changing both personally and professionally and has helped her work toward achieving her goals. Conny first visited Toronto in 2006, where she came to appreciate the research

Under the supervision of these three researchers, Conny was able to pursue her research interests in memory and the hippocampus. More specifically, her research focused on memory and connectivity in patients with medial temporal lobe epilepsy. Conny published in many peer-review journals and successfully defended her thesis in May. She subsequently obtained her doctorate degree in June 2014. Upon hearing the news of being awarded the Sara Al-Bader award, Conny was very


FEATURE happy and felt honored to be this year’s recipient. She had recently accepted a post-doctoral position in London and the monetary award was extremely helpful in facilitating the move overseas. Conny mentioned that for her “the Al-Bader award stands for friendship and carrying through what students started in May 2014.” She was tremendously grateful that the IMS had such esteem for her and her work to present her with this prestigious award. In the continued pursuit of knowledge and research for clinical applications, Conny is currently studying as a post-doctoral fellow at the Welcome Trust Center for Neuroimaging in London, England under the supervision of Dr. Eleanor Maguire. Conny’s research interests have always centered on the hippocampus and

memory function, which she continues to pursue. She investigates autobiographical memory and how this may be affected following hippocampal injury. Her post-doc-

she wants to continue working “on the border of clinically and theoretically relevant research.”

Enjoy your time. Have fun and don’t get too stressed about your degree. If you keep doing what you like to do, it will all fall in place.

toral studies focus specifically on studying patient populations with hippocampal damage using cutting edge neuroimaging techniques. In the future, Conny hopes her professional experience will position her to be an independent scientist. With her background in psychology and medicine

As a medical doctor and accomplished researcher at IMS, Conny offered this advice to other international IMS students: “Enjoy your time. Have fun and don’t get too stressed about your degree. If you keep doing what you like to do, it will all fall in place.”

Conny McCormick, Recipient of the 2014 Sara Al-Bader Memorial Award

IMS MAGAZINE WINTER 2015 PAIN | 29


BOOK REVIEWS

Damned Nations: Greed, Guns, Armies and Aid by Dr. Samantha Nutt, founder of War Child, McClelland & Stewart. 2012. 240 pages

Review by Susy Lam

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amned Nations: Greed, Guns, Armies, and Aid is a mesmerizing, terrifyingly truthful book about international development and aid, providing an excellent overview of the many challenges that third world countries face today. The 240 page novel covers issues such as humanitarian relief, development, health, conflict, and rule of law. As a recent medical school graduate and volunteer for UNICEF, Dr. Samantha Nutt visited Somalia and various other countries to participate in relief operations. This book vividly illustrates her observations of the aforementioned problems, which created her lifetime impetus to passionately advocate for children and families in wartorn countries across the globe. She provides a glimpse of her fifteen years providing care to some of the world’s most violent communities, while simultaneously developing her worldclass nonprofit organization, “War Child North America.” Furthermore, Nutt provides surprising truths on how multibillion dollar aid industries can go wrong in aid administration. By highlighting these problems and communicating them, her stories are stimulating changes in nonprofit organization frameworks and aid tactics. Finally, she educates readers by showcasing examples of how the public can be unknowing accomplices to these illdirected efforts while thinking it’s providing help. To address these issues, she suggests realistic solutions and directions. I highly recommend Damned Nations: Greed, Guns, Armies, and Aid to those who are new to the field of aid and international relief, as it provides a fresh perspective through a balanced mixture of anecdotes and research. It will engage you to the end, and perhaps her stories will empower you to join the field.

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Her stories are stimulating changes in nonprofit organization frameworks and aid tactics.


I Forgot to Remember: A Memoir of Amnesia by Su Meck with David de Lise, Simon & Schuster. 2014. 280 pages

Review by Rebecca Ruddy

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n Su Meck’s I Forgot To Remember, the author recounts her experience following a life-changing accident that left her with retrograde as well as anterograde amnesia. In the spring of 1988, Su Meck, her husband, and two children were in their home in Texas, when their kitchen ceiling fan came crashing down on Meck’s head. Unable to remember anything prior to the accident (no recollection of family, past experiences, and no comprehension of the simplest things like common objects), her memoir gives the reader a look into the difficulties of recovering from traumatic brain injury. She details her everyday life: where she found herself mimicking those around her, and learning along with her young children as they completed their grade school homework. It also gives insight into the difficulties of reforming past relationships, particularly with her husband who was integral in her new identity.

process following traumatic brain injury. It allows the reader to thoroughly understand the intricacies and magnitude of the injury, and the everyday struggles. I found it particularly interesting to read about how she adapted to different circumstances (such as moving to a new country and returning to school), and I realized how we often take for granted many of the small tasks that come so easily to most. The seemingly simplest task could be a huge hurdle to overcome for someone with a brain injury.

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I realized how often we take for granted many of the small tasks that come so easily to most.

Another important part of the book details what transpires immediately following the injury, while she is hospitalized. It documents the failure of the medical professionals involved to properly care for a patient with memory loss. She was discharged just three weeks following the injury, when she could not properly care for herself, let alone her two children. This treatment exemplifies only one of the many shocking aspects of her recovery. The book was an eye-opening and intriguing memoir that gives the reader a first person perspective into the difficult recovery

One inherent limitation of a memoir about amnesia is the fact that the author has no recollection of many events that she writes about. Meck acknowledges this fact immediately, but it is clear in the book that sometimes there are striking discrepancies between the medical records and what her husband remembers, as well as errors in the medical records themselves. Therefore, although she has consulted family, friends, and medical records, her stories may not always be accurate or complete. Overall, the author is able to

effectively portray her journey to recovery. She manages to successfully convey the hardships she suffered, and triumphs she accomplished in a coherent and well-written story about her life. Meck delves into very personal details that touch on very difficult parts of her recovery, which really allows the reader to gain a greater and more complete appreciation for everything she has been through and accomplished. I would highly recommend this memoir as it is a real, emotional, and eyeopening look into the painstaking process of recovery.

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Dr. Martin McKneally, MD, PhD Professor Emeritus of Surgery, Department of Surgery, University of Toronto

Close-up with Dr. Martin McKneally By Chelsea Lowther

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his past summer I sat down with the 2014 Institute of Medical Science (IMS) Course Director Award recipient Dr. Martin McKneally to find out more about his two highly regarded IMS courses—Practical Bioethics (MSC1052H) and Foundations 2: Teaching Bioethics (MSC3002Y). It came as no surprise that Dr. McKneally had a wealth of experience to draw on when designing these two courses. He completed both his cardiothoracic surgical training and PhD at the Uni32 | IMS MAGAZINE WINTER 2015 PAIN

versity of Minnesota and was thereafter appointed Professor of Surgery and Chief of the Division of Cardiothoracic Surgery at the Albany Medical Center in Albany, New York. In 1990, the University of Toronto was fortunate to gain Dr. McKneally as a faculty member and today he is Professor Emeritus of Surgery at the IMS, the Joint Centre for Bioethics, and the Toronto General Hospital. Dr. McKneally’s move from the United

States to Canada came with a shift in his research focus from applied immunology in surgery to surgical ethics, specifically the area of informed consent during what he calls the “surgical transaction.” This has included qualitative investigations of patients’ views of informed consent, and more recently an exploration of how surgeons and patients preoperatively discuss life-sustaining treatments when patients are undergoing moderate to high risk operations. In collaboration with surgeons at

Photo by Matthew Wu

“Always do the right thing. It will please some people and astonish the rest.” -Mark Twain


CLOSE-UP Harvard and the University of Wisconsin, cardiothoracic surgeons at the University of Toronto have played a significant role in this project. Dr. McKneally asserts that “as surgeons push the boundaries, operating on older and sicker patients, intensive care units fill up in North America and it becomes important that we have explicit conversations with our patients about potential adverse outcomes.” Dr. McKneally has been a member of the Joint Centre for Bioethics at the University of Toronto since its founding, and in 1999 he helped create the Masters of Health Science (MHSc) program in bioethics. According to Dr. McKneally’s colleagues, several of whom nominated him for the 2014 IMS Course Director Award, his continuing commitment to the MHSc program has been “an instrumental contribution” to the program’s success. Several of his previous students wrote letters of support detailing his unmatched commitment

“as surgeons push the boundaries, operating on older and sicker patients, intensive care units fill up in North America and it becomes important that we have explicit conversations with our patients about potential adverse outcomes.” to their individual learning and his ability to integrate philosophical theories with modern day clinical practice. After spending just an afternoon with Dr. McKneally discussing several hot button ethical issues, including whether it is ethically sound to give experimental drugs to patients with Ebola, I can certainly echo this sentiment. Faint memories of my own experience as a student in an undergraduate bioethics class remind me that ethics are, as Dr. McKneally teaches, “sets of values, principles, beliefs, and standards of conduct that guide the behavior of specified groups, such as doctors, lawyers, journalists, Mafiosi, and pirates,” and that bioethics is the field of study concerned with the ethical and philosophical implications of certain medical procedures, technologies, treatments, and research. I asked Dr. McKneally how he

conceptualizes the teaching of bioethics. I momentarily imagined how challenging it must be to teach this process to students. “It’s like teaching surgical judgement. The judgements you make are not based on authority. Instead, it is a process of deter-

“I really believe that the discussion is what makes the experience intellectually stimulating and the discussion really depends on the students.” mining a well-reasoned, thoughtful, and reflective argument to support a decision or a plan of action.” When asked about the popularity of the Practical Bioethics course (also known as the “Capstone Course”), Dr. McKneally attributes its reputation to the students. “I really believe that the discussion is what makes the experience intellectually stimulating and the discussion really depends on the students.” One of Dr. McKneally’s teaching strategies is to set up class debates—assigning students to positions that they may not personally agree with. “The goal is to teach them how to develop a reasonable way to think about a problem and not focus on finding the single right answer to a multiple choice question. I try to put emphasis on clarity of presentation and proper use of persuasive argument, very important skills for the bioethicist.” By the time students finish the course they have completed a term-long project intended to prepare them to serve as entry

“a lot of coaching goes on, I put emphasis on writing because writing is thinking—you must think clearly in order to write clearly.” level professionals in the field of bioethics. “A lot of coaching goes on during the course. I am fortunate to be teaching it with my talented co-director, nurse-psychotherapist and bioethicist Sue MacRae,” says Dr. McKneally.

course Dr. McKneally teaches is equally as hands on; students are required to design their own bioethics teaching curriculum. “The ability to apply bioethical theory and reasoning to a wide array of real-life situations is a critical skill for bioethicists to learn.” Dr. McKneally argues that you can’t arrive at a situation and say “that’s not my area of interest; you need to be able to at least apply a framework when trying to help solve a problem.” A true testament to Dr. McKneally’s famed teaching style is the broad range of students attracted to his classes, varying from physicians and midwives to lawyers and administrators, each bringing a collection of rich personal experience. “One of the advantages of teaching at the University of Toronto is the wide array of international students. They

“It’s like teaching surgical judgement. The judgements you make are not based on authority. Instead, it is a process of determining a well-reasoned, thoughtful, and reflective argument to support a decision or a plan of action.” add yet another perspective to each class that enriches discussion.” I laugh knowingly when I ask Dr. McKneally to describe his teaching style and he replies: “a lot of coaching goes on, I put emphasis on writing because writing is thinking—you must think clearly in order to write clearly.” In the realm of science, filled with manuscripts and grant proposals, no truer words have ever been spoken. If anything has come across during my meeting with Dr. McKneally it is just how important sound training in bioethics is to essentially every realm of science, whether it be clinical, research, or administrative domains. I’ve quickly grown accustomed to Dr. McKneally’s humbleness and am not surprised when he says that learning from the students has been the best part of his teaching career. Clearly, the students have not forgotten him either. Congratulations on your award, Dr. McKneally.

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MESSAGE FROM SURP DIRECTOR Dr. Vasundara Venkateswaran

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he 2014 Summer Program commenced on June 2nd with the orientation and introduction of the program to the summer students. Truly, I have had a gratifying summer with over 90 exhilarating and enthusiastic students who participated in the Summer Undergraduate Research Program (SURP). It has been extremely gratifying to serve as “Director” of SURP for the past four years. Every year has been an exciting experience and I am looking forward to upholding the standards, eminence, and success of this program in the years to come. The SURP has now completed its 38th year. This program is presently the largest summer program at the University of Toronto, facilitated through the Institute of Medical Science (IMS). This program gives undergraduate and medical students an opportunity to acquire research knowledge and skills, inspiring them to pursue a career in translational research. Participants spend the summer in a laboratory, working on a research project. In addition, students are encouraged to participate in individual 36 | IMS MAGAZINE WINTER 2015 PAIN

laboratory meetings, data analysis sessions, journal clubs, and appropriate clinical research rounds at the various affiliated teaching hospitals. As part of the SURP, the IMS offers a weekly lecture series rendered by our world renowned graduate faculties to complement the students’ research. Students also get an insight into the graduate program offered at IMS as well as interaction with faculties and graduate students. It is mentionable that this year the participation/interaction from the summer students was phenomenal. The SURP concluded with the research day on August 13th, 2014. This was an all-day event providing students an opportunity to showcase their research findings through an oral or poster presentations. The presentations were thoroughly impressive. It was rewarding to see students beam with excitement when they presented their research; the enthusiasm they exhibited clearly demonstrated their productive summer experience in the laboratories or clinics. Students showcased their work with confidence and pride and responded to the

challenging questions posed by the judges. Highlights of the Research Day included a stimulating keynote address by Dr. Shaf Keshavjee. Dr. Keshavjee is a thoracic surgeon and a scientist in the McEwen Center for Regenerative Medicine at UHN. He is Surgeon-in-Chief, James Wallace McCutcheon Chair in Surgery at University Health Network (UHN) in Toronto, Professor in the Division of Thoracic Surgery and Institute of Biomaterials and Biomedical Engineering at the University of Toronto, and Director of the Toronto Lung Transplant Program. Dr. Keshavjee has a passion for surgery and innovative research. His experience in the pioneering days of lung transplantation in Toronto stimulated him to develop a career in lung transplantation. His current work involves molecular diagnostics and gene therapy strategies to repair organs and to engineer superior organs for transplantation. Dr. Keshavjee inspired us with his superb lecture entitled, “The future of Transplantation: Personalized Medicine for the Organ.”


SURP FEATURE

DIVERSITY: PARTICIPATING DOMESTIC AND INTERNATIONAL UNIVERSITIES

Participating universities: Columbia University, Dalhousie University, McGill University, McMaster University, Queen’s University, Shandong University, St Bonaventure, University of British Columbia, University College London, University of Guelph, University of Ottawa, Trent University, University of Toronto, University of Western Ontario, Victoria College Funding partners: University of Toroto Undergraduate Research Opportunity Program, Faculty of Medicine, Division of Surgery, University Health Network, St. Michael’s Hospital, Merck

PARTICIPANTS 2014

72%

Illustrations by Jerry Won

18%

Undergraduate

Medical

10%

SEMINAR SERIES SPEAKERS Name

Research Area

Dr. Nick Woolridge

Biomedical Communications

Mr. Neil Winegarden

Genomics

Dr. Muhammad Mamdani

Pharcoepidemiology

Dr. Badru Moloo

Animal Ethics

Dr. Cindi Morshead

Stem Cell Biology

Dr. Jennifer Gibson

MicroRNA

Dr. Urban Emmenegger

Urology

Ms Yekta (PhD candidate)

Post Partum Depression

International

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Photo courtesy of CCarlos J M. Garate

WINNERS

Eric Yung, Magdalene Au, Maya Deeb, Melissa Galati, Nima Jaberi-Lashkari, Hannah Kozlowski, Alexandra Majerski, Elliott McMurchy

HONORABLE MENTION

Alexandra Hudson, Lauren Chan, Michael Dzingala, Ya Gao, Adam Katz, Johnathan Lau, Christie Liang, Andrew Purssel The Research Day concluded with an address from Dr. Allan Kaplan, Vice Dean, Graduate and Life Science Education, followed by presentation of awards. Several students were recipients of cash awards as winners of the “First Place” and others received certificates of “Honourable Mention” in recognition of their fantastic research work. All students received a certification of participation on the successful completion of the Summer Program. I would like to thank all the supervisors who have played a significant role in contributing their valuable time and effort, providing students with the environment, motivation and guidance in their research. I would like to convey my sincere appreciation to all our funding partners

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for providing their support, the faculties and students who served as judges at Research Day, as well as to the distinguished researchers for rendering lectures at the weekly seminars. Most importantly, I would like to thank Elena Gessas, Departmental Assistant, for her excellent effort in coordinating this program and Ms. Kamila Lear, Business Officer, for her continued support. On behalf of all the faculties and staff at IMS, I would like to congratulate the summer students on their research achievements and wish them the very best in all their research endeavours!


SURP FEATURE

Overprescribing Antibiotics to Children By Elliot McMurchy, SURP Essay Competition Winner

Photo courtesy of www.istockphoto.com

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he discovery of antimicrobial drugs (antibiotics) is regarded as one of the greatest scientific breakthroughs of the 20th century. Before this discovery, many simple infections were fatal to young children.1 With drug companies creating dozens of antibiotics, physicians have been taking advantage of this effective means of treatment for many ailments, prescribing high levels of antibiotics to children. In a ten year study (2000-2010), researchers from Boston Children’s Hospital and Harvard Medical School studied children ranging in age from three months to 18 years and found that children aged from three to <24 months were the highest utilizers of antibiotics.2 Recent research studies have hypothesized that the use of antibiotics in infants may lead to several long-term health risks including inflammatory bowel disease, celiac disease, and infant obesity. While the chief cause in this linkage remains to be elucidated, many studies are pointing to a change in the gut microbiota, which is highly dynamic during the early years of life.3 As a summer undergraduate research student with the Institute of Medical Science in an immunology lab that specializes in researching the gut microbiota, the effects of antibiotics on the microbiota was a focal area of investigation

using mouse models. It is well documented in the literature that a change does occur in the gut microbiota after antibiotic use, with a conclusive link between antibiotic use and antibiotic resistance. Ghosh et al. concluded that this is a global health problem having found “an alarmingly high abundance of antibiotic resistance genes in two infant gut microbiomes.�4 Researchers are now working to better understand the link between antibiotic use, a change in the microbiota, and long-term health problems. Although prescriptions of antibiotics seemed to have leveled off in the latter part of the 20th century with the finding of antibiotic resistance, this issue remains controversial since, as noted in the Harvard study, overprescribing of antibiotics by physicians persists.2 A 2013 ParentsCanada survey showed that 8% of parents pressure their doctors to provide antibiotic prescriptions, and a 2006 Centres for Disease Control study showed that 65% of doctors prescribed antibiotics when they felt the parent expected them to compared with only 12% when there was no pressure.5 Until parents become more informed about the accumulating evidence of long-term harms from over-prescribed antibiotic use, they will continue to pressure physicians into prescribing antibiotics to their children.

While researchers, including those at the University of Toronto, have found an association between overuse of antibiotics and changes in the microbiota of young children, research must continue in this field as the stakeholders in the medical and healthcare field remain divided: parents eager for access to antibiotic medications, physicians pressured to service their clientele, and researchers not yet having the conclusive evidence to support the hypothesized microbial changes due to overuse of antibiotics. References 1. The history of antibiotics. [Internet] 2006 Nov 1 [updated 2014 Mar 31; cited 2014 Aug 12]. Available from: http://www.healthychildren.org/English/health-issues/conditions/treatments/Pages/The-History-of-Antibiotics.aspx. 2. Vaz LE, Kleinman KP, Raebel MA, et al. Recent trends in outpatient antibiotic use in children. Pediatrics. 2014;133(3):375-85. 3. American Gastroenterological As sociation. Tricky balancing act: antibiotics versus the gut microbiota. [Internet]. ScienceDaily. 2014 [updated 2014 Mar 10; cited 2014 Aug 12]. Available from: http://www. sciencedaily.com/releases/2014/03/140310111539.htm. 4. Ghosh TS, Gupta SS, Nair GB, et al. In silico analysis of antibiotic resistance genes in the gut microflora of individuals from diverse geographies and age-groups. PLoS One. 2013;8(12):e83823. 5. Dourcet J. Are parents hooked on antibiotics? ParentsCanada. [Internet]. 2014 Feb 10 [cited 2014 Aug 12]. Available from: http://www. parentscanada.com/health/are-parents-hooked-on-antibiotics.

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Physician-Assisted Death: Facing the Challenges of a New Reality in Canadian Healthcare By Amir Safavi, SURP Essay Competition Winner

It is ironic that Canadian medical professionals advocate for personalized medicine on a biological level but exhibits selective reluctance for it on a social level. Countless Canadians must concurrently struggle with a merciless, incurable medical condition and a lack of support given by the healthcare system when they wish to die on their own terms. The official policy of the Canadian Medical Association (CMA) states that physicians should not participate in assisted suicide1. On August 19th, the general council of the CMA voted to “support the right of all physicians, within the bounds of existing legislation, to follow their conscience when deciding whether to provide medical aid in dying.”2 While this position provides more flexibility than the official policy, it remains insufficient because it would allow physicians to withhold the option of physician-assisted death from a patient and refuse to transfer the care of a patient asking for physician-assisted death, even if assisted suicide were decriminalized. The late Dr. Donald Low, head of microbiology at Mount Sinai Hospital and the Department of Laboratory Medicine and Pathobiology at the University of Toronto, was one physician who believed that Canadians should have the option to pursue physician-assisted suicide. Eight days before succumbing to a terminal brain cancer, Dr. Low shared his feelings

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in a video produced by the Canadian Partnership Against Cancer: “I’m just frustrated not to be able to have control of my own life. Not being able to have the decision for myself when enough is enough.”3 Dr. Low addressed the reluctance of physicians to support assisted suicide: “A lot of physicians have opposition to dying with dignity. I wish they could live in my body for 24 hours and I think they would change that opinion.”3 Perhaps some of these physicians would willingly choose to endure unimaginable suffering and relinquish agency over their lives, even if they were in Dr. Low’s condition. Ultimately, that choice, informed by a lifetime of values and experiences, must be made by individuals for themselves. In an article recently published in the Canadian Medical Association Journal, Dr. James Downar and colleagues raise important questions that must be addressed to prepare the healthcare system for the Supreme Court of Canada’s seemingly inevitable ruling against the law banning assisted suicide. What criteria must patients meet to be eligible for physician-assisted death? How will we ensure that vulnerable and incapable patients are protected from involuntary physician-assisted death? How can we ensure that legalizing physician-assisted death will not detract from efforts to improve palliative care?4

Answers to these questions must be elucidated sooner rather than later; the chapter on whether physician-assisted suicide should be allowed is nearing its end. A large proportion of physicians may have strong reservations about physician-assisted death, but the reality is that physician assisted suicide will likely become legal in the immediate future. Failure to proactively engage the critical issues involved in practicing physicianassisted suicide will endanger both physicians and the public. Physicians, medical ethicists, legal scholars and ordinary citizens must engage in discourse to clarify a fair set of standards so that all Canadians may receive care that is truly patient-centered and exercise their right of self-determination in the face of terminal illness. References

1. Canadian Medical Association. Euthanasia and assisted suicide (updated 2007). [homepage on the Internet]. 2007 [cited 2014 Aug 22]. Available from: http://policybase.cma.ca/dbtw-wpd/Policypdf/ PD07-01.pdf 2. Picard A. Canadian Medical Association softens stand on assisted suicide. [homepage on the Internet]. 2014 [cited 2014 Aug 22]. Available from: http://www.theglobeandmail.com/news/national/ canadian-medical-association-softens-stance-on-assisted-suicide/ article20129000/ 3. CBC News. SARS doctor Donald Low’s posthumous plea for assisted suicide. [homepage on the Internet]. 2013 [cited 2014 Aug 22]. Available from: http://www.cbc.ca/news/canada/toronto/sars-doctordonald-low-s-posthumous-plea-for-assisted-suicide-1.1866332 4. Downar J, Bailey TM, Kagan J, Librach Sl. Physician-assisted death: time to move beyond yes or no. CMAJ 2014; 186(8):567-68.

Photo courtesy of www.istockphoto.com

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physician should be in the service of the patient, treating not only disease but also the totality of a person. The physician is an integral component of a complex system of individuals, communities, and social structures that facilitate patient-centered care. Every decision that a physician takes with regards to a patient must be personalized by the patient’s unique medical and personal needs.


PAST EVENTS “I feel that science and music share many things in common: both require rigorous dedication, creativity, and passion.”

James Hong, MSc student at IMS supervised by Dr. MIchael Fehlings

IMSSA Talent Show: The Collaboration of Art and Science By Katherine Schwenger

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he Institute of Medical Science (IMS) Student Association holds an annual end of year talent show to highlight the artistic diversity within the department. A wide array of IMS students and faculty showcased their hidden talents, while raising money for a local charity. On a Thursday evening in July seven acts took stage, including IMS Student Association’s president Rageen Rajendram who rapped a freestyle inspired by IMSSA and the charity, as well as two other original songs. IMS students and faculty filled the event space and enjoyed an evening mesmorized by their peers’ creative abilities. This year’s winner for the talent show was a second year Master’s student graduate, James Hong. During his performance he captured the audience’s attention with his violin, by performing the 3rd movement of Seitz’s 4th violin concerto. James currently conducts research at the Toronto Western Research Institute under the supervision of Dr. Michael Fehlings. At age 10 James’s mother decided to enroll him in violin lessons, and the rest is history. Not only is he a proficient violinist, but he also plays the piano. When asked if he currently performs, he responded that he “frequently plays Argentian tangos and jazz piano for de-stressing after a long day.

[He is] fascinated with the 19th century evolution of both genres.” Although James is passionate about the arts, science has always been his main focus. His goal is to complete a combined MD-PhD degree and become a clinician scientist. His research focuses on identifying the cellular cues that are responsible for the distinct neural stem cell fate specifications between cervical and thoracic spinal cord injury. James’s career path is driven by science, but when asked how he has been able to integrate his devotion for music he stated, “I feel that science and music share many things in common: both require rigorous dedication, creativity, and passion. Thus, I’ve been fortunate enough to be able to start my career in the sciences with a primed mentality of what is expected of me.” When reflecting upon how the violin changed his outlook with regards to science, James found that “after meeting so many colleagues with a passion for music, I have noticed that there is undeniable evidence that music is linked to success in both science and medicine. I feel that studying music or any other creative discipline (e.g. dance or visual arts) is beneficial for the cognitive development of an individual.”

The collaboration between science and art has the potential to generate a new way of thinking, understanding, and approaching to research—which has the potential to benefit both fields. When asked if there is a future for the collaboration between arts and science James declared that, “it is already happening! Many scientists are interested in the cognitive processes of musicians, and many musicians are exploring the impact of music and how it stimulates different parts of the brain. This shared passion for a common goal has the potential to evolve our understanding of both art and science.” The IMS has created an environment that cultivates future scientists to work alongside artists, thus providing both fields with an exciting collaborative future. Keith Tyson, a British artist, eloquently describes this collaboration: “If you attempt to marry and equate art with science, then you fail. If you allow what is not similar about art and science, and their different methods and processes, to co-exist and thrive, then a real art/science collaboration and aesthetic will emerge. But at the end of the day, art and science are united by one logic and one impulse—both are attempts to understand what it is to be human and the world around us.” IMS MAGAZINE WINTER 2015 PAIN | 41


PAST EVENTS

Visiting the AGO

Hart House Farm

IMS Pub Night

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IMS HOLIDAY PARTY 2014

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