Issue 16

McMaster’s Medical Research and Health Ethics Student Journal

New At Mac: The McMaster Health Forum

Paramedicine: Recognition Beyond Algorithms Cocaine Vaccination: A Novel Approach to Addiction Therapy

Prostate Cancer Overdiagnosis: A Product of Technological Oversensitivity

From Your System to Our System Issue 16 | Nov 2009

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Table of Contents

Issue 16 |November 2009

Research Articles Presidential Address

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MedWire

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MedBulletin

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Jaqueline Ho

MedQuiz

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Prostate Cancer Overdiagnosis: A product of Technological Over sensitivity Keon Maleki

About The McMaster Meducator The McMaster Meducator is an undergraduate medical journal that publishes articles on current topics in health research and medical ethics. We aim to provide an opportunity for undergraduate students to publish their work and share information with their peers. Our protocol strives to maintain the highest standard of academic integrity by having each article edited by a postgraduate in the relevant field. We invite you to offer us your feedback by visting our website: www.meducator.org.

Cocaine Vaccination: A Novel Approach towards Addiction Therapy Amjed Kadhim-Saleh

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Paramedicine: Recognition beyond Algorithms Karen Bilecki

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The McMaster Meducator may be contacted via our e-mail address: meducator@gmail.com or our mailing address: B.H.Sc. (Honours) Program Attention: The McMaster Meducator Michael G. DeGroote Centre for Learning and Discovery Room 3308 Faculty of Health Sciences 1200 Main Street West Hamilton, Ontario L8N 3Z5

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New at Mac McMaster Health Forum Alyssa Cantarutti

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November 2009

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s Obama strives to introduce affordable health care in the United States and swine flu gathers momentum in affecting our communities, public attention is once again focused on our health and the systems that support its maintenance. In times of change, it is the innovative minds and passionate persistence of researchers and critical thinkers that clear the way for advancement. Therefore, it is imperative that we explore novel ideas for future treatments while critically evaluating the value of current procedures and the realities of our health care system.

In this issue of the McMaster Meducator, we examine the sophisticated relationships within our own physiological systems while broadening our horizons by considering new possibilities in our health care system. Amjed Kadhim-Saleh invites us to take a detailed look into molecular interactions in his proposal to develop an unorthodox cocaine vaccine to address the vice of addiction through immunotherapy. Continuing on with the focus on our bodies, Keon Maleki draws our attention to the warning signs of excessive reliance on technology when diagnosing prostate cancer.

On a larger scale, Karen Bilecki describes the merits of self-regulation of emergency pre-hospital care practitioners and introduces her original Canadian Paramedical Process Model and its relevance to practice. Alyssa Cantarutti, our representative and co-chair of the Student Subcommittee in the newly established McMaster Health Forum, takes us on a tour of events designed to encourage dialogue between students, citizens and stakeholders on topics pertaining to our health system. The collection of articles in this offering of the Meducator captures the spirit of reinvention necessary in moving forward in light of the healthcare obstacles we encounter today.

This is my first issue as President, and I would like to extend my gratitude to everyone whose hard work eased my transition into my new role and whose collective effort helped make this issue possible. Without the hard work of the individuals in the executive team, the vision of the authors and the generous support of Dr. Del Harnish and the Bachelor of Health Sciences program, we would not have been able to produce such a high-calibre publication. Special thanks to Merry Wang for her artistic strengths in creating our intricately illustrated cover. Furthermore, I am honoured and excited to work with what has proved to be a stellar executive team. To Veronica Chan, thank you for your hard work and willingness to go over and above your role throughout this process. To the editorial team: Ahmad Al-Khatib, Alyssa Cantarutti, Randal Desouza, Randall Lau, Simone Liang, Siddhi Mathur, Navpreet Rana, Sangeeta Sutradhar, Fanyu Yang; your meticulous nature and stamina is integral to ensuring the content each article is accessible by our readers. Thank you to our creative director, Hiten Naik, for the countless hours spent looking at alignments that has given the Meducator such an aesthetically pleasing look. To our web master Keon Maleki, your efforts in maintaining our website, our portal to readers outside of McMaster, is greatly appreciated. Last but certainly not least, I would like to introduce our newest additions to the Meducator family: Mohsin Ali, Matthew MacDonald, Tahseen Rahman, Daniel Lee, Lebei Pi and Louis Winston. With new blood comes fresh perspectives, this ensures the continued growth of the Meducator.

Everything done thus far has already contributed to the ongoing success of the McMaster Meducator. With such an excellent group of personalities and dedication, I look forward to working with you all in future publications to come.

Please visit our website, www.meducator.org, to check out our past issues, MedBulletins, find information on submitting articles and to drop us a line with any comments or inquiries.

On behalf of all the writers and staff, we hope you enjoy your read.

Sincerely,

Meducator Staff President Jacqueline Ho Vice-President Veronica Chan Editorial Board Ahmad Al-Khatib Alyssa Cantarutti Randal Desouza Randall Lau Simone Liang Siddhi Mathur Matthew MacDonald Tahseen Rahman Navpreet Rana Sangeeta Sutradhar Fanyu Yang Creative Director Hiten Naik Web Master Keon Maleki Public Relations Shelly Ramsaroop Junior Graphics & Design Daniel Lee Lebei Pi Junior Editors Mohsin Ali Louis Winston Cover Design Merry Wang

Post Graduate Editors Dorina Kirilova, BHSc., MSc. (Candidate) Alba Llop-Guevara, Ph.D. (Candidate) Dr. Shana O. Kelley, B.S., Ph.D.

Jacqueline Ho B.H.Sc. IV

Walter Tavares ACP, MSc. (Candidate) www.meducator.org

Presidential Address

Dear Reader,

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MedWire

4 It has been shown that an extract found in the bright yellow curry spice turmeric can kill off cancer cells. The chemical curcumin has long been thought to have healing powers and is already being tested as a treatment for arthritis and even dementia.

Issue 16 treatment needed to prevent them from having further bone fractures in the future.

Smoking during pregnancy can significantly increase the risk of having a child with behavioural problems. Studies have shown that this behavior can be apparent as early as three years old.

A gene can explain why some women find it more difficult to stop smoking during pregnancy. In a study of 2,500 women who smoked before becoming pregnant, the “addictive gene” was associated with a lower chance of quitting once pregnant.

Scientists claim a new drug has been developed which kills leukemia cells. Researchers say the drug, PBOX-15, can destroy cancerous cells in adult patients who have not responded to other treatments.

Feeling grumpy ‘is good for you’: an Australian psychology expert has found that being grumpy makes you think more clearly. His experiments have shown that miserable people are better at making decisions and are less gullible.

Research suggests eating a diet high in processed food increases ones chance of being depressed. On the other hand, people who had diets that contained high levels of fresh fruit, vegetables and fish lowered their risk of depression.

Women not getting bone treatment: Studies at Cambridge University suggest that women who have had a fracture are not getting the

A recently released report from the Montreal Gazette calls for an overhaul of the way in which academic research is conducted in Canada. The report specifically suggested for the appointment of an ombudsman, a trusted intermediary, to oversee everything. The report was well underway when a story was released in the Toronto Star last summer about the use of ghostwriters by a McGill University professor for an academic article about hormone replacement therapy.

MED

The use of aspirin to protect against cardiovascular disease should be abandoned.

New research has found that the drug can cause serious internal bleeding and does not prevent cardiovascular disease deaths.

Researchers at North Carolina and Boston universities have used the most unlikely of subjects, drunken fruit flies, in order to identify networks of genes that play an important role in alcohol drinking behaviour. These scientists hope that these networks, also present in humans, will play as a potential drug target in treating alcoholism.

Two large, independent epidemiologic studies recently completed suggest that prostate-specific antigen (PSA), the current gold standard for prostate cancer screening, may be doing more harm than good. The studies suggest that the sensitivity of the test may

cause individuals with a false positive result to undergo unnecessary therapies with side effects such as impotence, incontinence and even death.

Researchers from Johns Hopkins University School of Medicine have stumbled upon a link between medication for gonorrhoea that was used in the 1930s and its positive effect in helping to fight cancer. The drug, named acriflavine, has the ability to halt the growth of new blood vessels. How effective is the drug? Results from preliminary trials showed genetically engineered mice, if treated with daily injections of acriflavine did not develop tumours.

Tel Aviv University researchers are looking for the socalled “Prozac gene,” in order to elucidate why there is such a broad range of reaction to Prozac and other antidepressants. If successful, their research may be able to provide health care professionals with a simple genetic test that will revolutionize the treatment of depression.

A team of Alabama researchers claim that they have found the Achilles’ heel for each and every strain of the flu.

Found in many vegetables, fruits, whole grains, and even tea, antioxidants may be the key to providing an additional

November 2009

In a study from the Tufts University School of Medicine, it was found that participation in Tai Chi (Chuan) exercises caused a reduction of pain and improvement of physical movement in older patients with osteoarthritis (OA).

Doctors from Oxford University in the UK have attested that memory and language tests can be the key for reliably revealing early stages of dementia. This crucial finding allows for initiation of treatment earlier, which has shown to be much more effective in treating dementia.

In a pilot study consisting of only two patients, researchers from France used a combination of gene and stem cell therapy to treat adrenoleukodystrophy (ALD), a disease in which sufferers lose their myelin sheath. For two years, patients were given hematopoietic stem cells that were genecorrected by an HIV-derived lentiviral vector.

Scientists have shown that small metal particles have the ability to induce DNA changes across a cellular barrier without entering the cell itself. This elucidated the risk of wearing metal devices such as artificial hips or knees, but represents promise for future therapies using metal.

When do children develop accents from the place they were born? A recent study showed that babies can learn to imitate their mother tongue at three days old, suggesting this process may begin when they are in the womb.

In a pilot study undertaken at Boston University, it was found that yoga was able to improve lower back pain in minorities more than a standard treatment consisting of medication and visits to the doctor.

A new Brandeis University study of twins confirms the importance of genetic factors in age-associated hearing loss. The research, in the Journal of Gerontology: Medical Sciences, examined how genetic and environmental factors (such as harmful noise and medications with dentrimental side effects) affect hearing loss in the frequency range of speech recognition.

Researchers are working on a breakthrough in artificial limb technology – a prosthetic hand that can actually feel. The SmartHand project is funded by the European Union and is a collaboration between researchers from across the continent. It has produced motorized prosthetic hand that gives unprecedented sensory feedback.

Sugar may give you wrinkles via a process called glycation, in which excess blood sugar binds to collagen in the skin, making it less elastic. Thus, cutting back on sugar may help your skin retain its flexibility.

A study published in Human Reproduction has found that bisphenol A (BPA), a chemical commonly found in plastics, is linked to impotence.

Scientists found that male Chinese factory workers who were exposed to high levels of BPA on the job were four times as likely to suffer from erectile dysfunction and seven times as likely to have difficulty with ejaculation, compared to similar Chinese factory workers not exposed to BPA. Researchers at the University of California at Berkeley are developing the CellScope, a microscope that attaches to a camera-equipped cell phone. The CellScope can snap magnified pictures of disease samples and transmit them to medical labs across the country or around the world. The goal is to use mobile communications networks as a cost-effective way for medical personnel to screen for hematologic and infectious diseases in areas that lack access to advanced microscopic equipment.

Penguins that died 44,000 years ago in Antarctica have provided extraordinary frozen DNA samples that challenge the accuracy of traditional genetic aging measurements, and suggest those approaches have been routinely underestimating the age of many specimens by 200 to 600 percent.

A new study carried out at the University of Haifa has found that the hormone oxytocin, the “love hormone,� which affects behaviors such as trust, empathy and generosity, also affects opposite behaviors, such as jealousy and gloating.

Depression occurs in as many as one-third of patients after a stroke, and women are at somewhat higher risk than men, according to a large new review of studies. Post-stroke depression is associated with greater disability, reduced quality of life and an increased risk of death.

A new study in the journal Sleep shows that retirement is followed by a sharp decrease in the prevalence of sleep disturbances.

Findings suggest that this general improvement in sleep is likely to result from the removal of work-related demands and stress rather than from actual health benefits of retirement.

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MedWire

method, alongside vaccines, for the prevention and treatment of any flu, including the H1N1.

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MedBulletin

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Issue 16

The Effects of U.S. Health Reforms on Prescription Drugs in Other Countries

MedBulletin by Louis Winston

In 2008 the United States spent 252 billion dollars on prescription drugs. Americans paid nearly double the price for their medicine than most other developed nations. Though American drug companies can price their drugs at whatever price they deem appropriate, countries like Britain have a price control system under the National Institute of Clinical Excellence (NICE).

Some believe that countries with a price control system are benefitting from the U.S. system, inferring that U.S. drug prices have to remain substantially higher to ensure that those in the UK can remain fixed. Economist Darius Lakdawlla, director of the Bing Centre for Health Economics in Santa Monica declares: “If the United States was to substantially decrease the generosity of payment for pharmaceuticals, the resulting decrease in innovation would affect both Americans and Europeans.”

On the other hand some researchers, like Professor Donald Light, feel that the high cost of U.S. pharmaceutical industry makes them less productive than the UK system. Dr. Light states that though the UK spends less on the drug industry, it is able to put more of its profits back into research compared to American-based firms. He states, “The U.S. industry claims 17-18% of sales go into research and development but the British scheme allows up to 23% of sales to be fully recovered in British prices plus up to 22% of profits on capital.”

While the American health care reforms remain a controversial issue in the U.S., the changes that take place there in the coming months and years to come may have a deeper global impact as well.

Reference: US health reforms could hit other countries. (2009, October 12). Retrieved from BBC: http://news.bbc.co.uk/2/hi/health/8300056.stm

Transplanting Wombs

MedBulletin by Louis Winston

Surgeons from London’s Hammersmith Hospital claim that they are a step closer to carrying out the first womb transplant. The surgeons claim that they have been able to secure the womb’s intricate blood supply, which had previously served as one the major obstacles in performing the operation. Women with Rokitansky syndrome, a condition that characterizes women who lack a functional womb (due to birth defects, cancer or fibroids), may now have the option of giving birth.

However, there are many risks associated with womb transplants. The patients would be required to take numerous immunosuppressant drugs, which can lead to diabetes, osteoporosis, renal failure, cardiac arrest and cancer. For this reason, the womb would be removed after the desired pregnancies are finished. Moreover, the babies would have to be delivered by caesarean section, as the implanted womb would be unlikely to tolerate labour.

Dr. Richard Smith, who is head of the project, states that there are many ethical concerns with this method. However, he believes that that these concerns will pass: “This kind of development can make people very uneasy, but when vital fertilization was first developed many felt unhappy about making babies in test tubes”.

Reference: Giving birth to womb transplants. (2009, October 22). Retrieved from BBC: http://news.bbc.co.uk/2/hi/health/8319149.stm

November 2009

DNA Tests After Death

MedBulletin by Louis Winston

Senior doctors are calling for human tissue to be routinely preserved for genetic testing in cases where the reason for death is unknown. The doctors claim that such DNA samples may reveal an unsuspected inherited condition and possibly prevent similar deaths in relatives.

The Human Tissue Authority declared that it was “alarmed” about the public calls for practitioners to break the law. Currently in Britain and in Canada, appropriate consent is required before tissue samples can be taken from a deceased person.

Dr. Mary Sheppard, of the Royal Society of Medicine’s Pathology department and a leading expert on Sudden Cardiac Death (SCD), estimates that every year roughly 800 healthy individuals under the age of 35, die suddenly from unsuspected heart disease or without adequate reasons of explanation. She also affirms that some coroners do ask relatives already but others believe it is not part of their remit. Dr. Sheppard further states that coroners who routinely request consent at autopsies were able to find out far more about how the person died and possibly prevent other deaths in the same family.

There are people who oppose to having tissue samples taken from their deceased loved ones for a variety of reasons. This is a concern to some doctors who consider that preserving some tissue samples from the deceased could potentially prevent the deaths of others in the same family. Dr. Paul Brennan, a clinical geneticist for the Northern Genetics Service, strongly suggests all pathologists seek permission from the families to take the tissues. He states, “If consent is not given, the tissue must, by law, be destroyed. But if it is not even taken in the first place, a huge potential benefit is lost.”

Reference: Call for tests after death (2009, 7 November). BBC News, Retrieved from http://news.bbc.co.uk/2/hi/health/8346901.stm

Diagnosing Depression Through...

Balance?

MedBulletin by Mohsin Ali

Brian Lithgow, a biomedical engineer at the Monash University in Melbourne, Australia has developed a highly innovative technique for diagnosing various disorders of the central nervous system (CNS), the area of the body encompassing the brain and spinal chord. By observing the pattern of electrical activity in the brain’s vestibular system that is responsible for balance, Lithgow noticed distinct response patterns, called biomarkers, that distinguished between different CNS diseases and regular electrovestibular activity.

Due to its intimate association with the regions of the brain responsible for emotions and behaviour, Lithgow reasoned that the vestibular system is ideal as a tool for diagnosing various psychiatric disorders, such as depression and schizophrenia. The technique, called electrovestibulography, provides an unprecedented approach at measuring the presence of CNS diseases simply, quickly and inexpensively, as explained by Dr. Lithgow: “The patient sits in a specially designed tilt chair that triggers electrical responses in their vestibular system. An electrode placed in the individual’s ear canal silences interfering noise so that these meaningful electrical responses are captured and recorded. The responses are then compared to the distinct biomarkers indicative of particular CNS disorders, allowing diagnosis to be made in under an hour.”

Monash University has teamed up with a corporate partner to develop and patent the technique as EVestG™. With the technique gaining international interest, electrovestibulography may be the solution for providing health-care providers an appropriate tool for quantitatively diagnosing many mental and neurological illnesses, a tool Lithgow hopes “will eventually become standard practice in hospitals around the world.”

Reference: Monash University (2009, October 16). ‘ECG For The Mind’ Could Diagnose Depression In An Hour. ScienceDaily. Retrieved October 16, 2009, from http://www.sciencedaily.com/releases/2009/10/091015091611.htm

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MedBulletin

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MedBulletin

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Fending off Diabetes for a Decade

Issue 16

MedBulletin by Mohsin Ali

A recent follow-up study, consisting of nearly 3000 people, projected that the onset of diabetes can be delayed for a decade with regular exercise and dieting.

These 3000 individuals took part in a three year study in which they were assigned either a diet and exercise programme, a diabetes drug metformin, or a placebo as means of preventing diabetes. The diet, aimed at achieving 7% weight loss, was administered along with half an hour of exercise five days a week for the diet/exercise group.

The trial, carried out by the US-based Diabetes Prevention Program Research Group, showed that the reduction in risk of developing Type 2 diabetes was 58% for the diet/exercise group, in contrast to the 33% decline in risk in the metformin group.

After the conclusion of the main study, all three groups were given access to ongoing lifestyle coaching. Accordingly, the risk with regard to developing diabetes decreased in all three groups, but most significantly in the diet/exercise group. Their reduction in risk was one-third lower than the placebo group.

What do the experts have to say? Dr. Misra, a diabetes specialist in New Delhi, India, is concerned that the diet/exercise prescribed, though the most effective, may prove to be an unrealistic method of prevention for the disease. But as Dr. Iain Frame, head of research at Diabetes, UK describes, “With further research into the long-term benefits of good dietary advice, physical activity and, where necessary, drug therapies, we may be a step closer into helping people at high risk of developing Type 2 diabetes modify their lifestyle choices that are sustainable in the longer term.”

Reference: Dieting ‘keeps diabetes at bay’ . (2009, October 29). Retrieved from BBC: http://news.bbc.co.uk/2/hi/health/8330077.stm

Pulling the Plug on a Baby

MedBulletin by Mohsin Ali

A classic ethical dilemma in a “right-to-life” legal dispute regarding a baby has arisen. Baby RB, called so for legal reasons, was born about a year ago with a tragic case of congenital myasthenic syndrome, a rare genetic disease that adversely affects the skeletal muscle of the body. Since his birth, Baby RB has needed the assistance of a ventilator due to difficulty with independent breathing.

After much deliberation, clinicians at the hospital have resolved to withdraw the boy’s life support, a decision supported by the mother. They have stated that “Baby RB’s quality of life is so low that it would not be in his best interests to try to save him.” However, proclamations from the baby’s father on his son’s right to live have put forth the possibility of performing a tracheotomy, a procedure that creates an opening in the neck to deliver air to the lungs. The father’s lawyers further argue that the boy has no brain damage as he can still hear, see, interact and play with others, setting the stage for a legal dispute.

The baby’s physician, who openly stated that Baby RB was one of the sickest children he has ever treated, will be giving a tracheotomy assessment soon. In the meantime, the judge has ruled that the trial will continue as planned, but the results of the assessment will determine the fate of Baby RB. Reference: More tests for right-to-life baby. (2009, November 2). Retrieved from BBC: http://news.bbc.co.uk/2/hi/health/8337369.stm

November 2009

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Prostate Cancer Overdiagnosis: A Product of Technological Oversensitivity Modern

oncology suggests the risk of prostate cancer is becoming

increasingly common.

Many

other researchers contend that the dramatic

increase in the number of perceived cases of prostate cancer coincides with use of protein-specific antigen (PSA) screening as the primary tool in diagnosing these patients. Research has shown that the PSA test is overly sensitive, and

does not differentiate between men with prostate cancer, and men with higher

Keon Maleki

levels of PSA in their blood. The researchers who defend this “overdiagnosis”

of prostate cancer refer to increase in the incidence rate of prostate cancer alongside the advent of PSA testing; while there have been negligible changes in the mortality rates from prostate cancer.

This

raises the question of

whether PSA testing should be used as frequently as it is, putting patients at risk of “overdiagnosis” and receiving unnecessary treatments.

I

t is increasingly common for physicians to use screening as their primary means of diagnosing cancer, as early detection of malignant tumours is considered one of the most successful measures in cancer treatment. While routine screening can be beneficial for many cancer patients, a recent study in the Journal of the National Cancer Institute suggests that prostate cancer screening has been used in exhaustive proportions (Welch et al, 2009). This has led to what the medical community refers to as “overdiagnosis” – concluding that a patient has a certain disease, and proceeding with treatment of this disease when it is neither necessary nor beneficial for the patient (Bangma et al., 2007). Overdiagnosis is an increasingly contentious issue in the medical community. The aforementioned study further develops the justification that specific, well-defined elements must exist before one confirms the diagnosis of prostate cancer (Welch et al., 2009).

The use of protein-specific antigen (PSA) blood tests as a screening method has played a significant role in the detection

of cancer and many studies are now revealing that it may be an oversensitive tool that makes benign tumours seem fatal. Also, since the PSA test may carry risks and cause considerable discomfort that significantly outweighs its benefits, its use should be limited. The goal of researchers is to make methods of prostate cancer detection more standardized to avoid overdiagnosis.

“Research... suggests this substantial increase in cancer is deceiving” Over the last two decades, the dramatic increase in prostate cancer incidence has transformed an uncommon cancer into the third most frequently diagnosed cancer today (Bangma et al., 2007).

Research conducted by Welch et al.

(2009) at the University of Connecticut suggests this substantial increase in

cancer incidence is deceiving, largely due to the increased and widespread use of PSA blood tests. PSA is an extremely sensitive screening method that leads researchers to believe that it plays a fundamental role in prostate cancer overdiagnosis. The development of this PSA technique coincides with a significant spike in the incidence of prostate cancer; interestingly, research from Welch et al. reveals that over one million individuals diagnosed with prostate cancer are not actually at risk, and thus have not benefitted from the diagnosis (Welch et al., 2009). There is considerable evidence for the notion that prostate cancer screening may harm more people than it benefits because of the unnecessary exposure to chemotherapy and its negative side effects. Two eagerly anticipated clinical trials support this view by showing that marginal benefits are derived from PSA screening (Welch et al., 2009).

It is important to examine the underlying features of PSA blood tests in order to understand its sensitivity. PSA is a protein

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Issue 16

250

Incidence

Rate

200 150 100

Mortality

50 0 1973

1977

1981

1985

1989

1993

1997

2001

Years of diagnosis Figure 1 Incident & Mortality Rates of Prostate Cancer Per 100,000 Cases The above figure illustrates the notion that PSA testing has not been proven as a screening procedure. The use of PSA test-ing was first used in 1987, but became increasingly prevalent over time until the early 1990s, when it became a traditionally-used screening device. This temporal timeline directly coincides with the sharp spike in the incidence of PSA. However, the key is the mortality rate, which remains relatively constant with negligible changes in its rate. This demonstrates that while an increasingly large proportion of cases were being considered to be “at-risk prostate cancer patients” because of excessive PSA use, the actual levels of mortality rate have not changed too much. The obvious implication is that these patients fall under the category of the ‘overdiagnosed’ or ‘misdiagnosed’.

produced by cells within the prostate gland that can be measured by taking blood samples (Doust et al., 2000). Like many other antigens, PSA is used to detect disease and falls under a larger class of compounds known as biological markers (Welch et al., 2009). More specifically, PSA is a tumour marker and its relative levels may indicate whether or not tumours are developing (Doust et al., 2000).

Normally, men without prostate cancer have low levels of PSA in their blood.

As men age, the statistical incidence of prostate cancer naturally increases.

When examining whether a patient has prostate cancer, it is common to note that the risk of developing prostate cancer increases as PSA levels steadily rise (Doust et al., 2000). However, PSA serum levels may also be indicative of conditions other than metastatic prostate cancer . For example, rising PSA levels are also present in other prostate pathologies such as prostatitis (the inflammation

of the prostate) and benign prostatic hyperplasia (the enlargement of the prostate), both of which are increasingly prevalent (Bangma et al., 2007). Therefore, the diagnosis of prostate cancer cannot be based solely on elevated PSA serum levels. Since PSA levels alone are not sufficient to distinguish between prostate cancer and other prostate conditions, it is not surprising that an increasingly large number of physicians use PSA blood tests only for a surface analysis of a prostate condition (Bangma et al., 2007).

One characteristic of prostate cancer that makes it more difficult to detect when compared to other cancers is that the metastasizing rate for prostate cancer is highly variable (Etzioni et al., 2002). In other words, some prostate cancers grow very quickly while many develop relatively slowly. Prostate cancers are unique in that they tend to remain confined to a small region with negligible increases in growth rate (Bangma et al., 2007). In these cases,

chemotherapy and radiation treatment are not always necessary (Etzioni et al., 2002). From a physician’s perspective, it is difficult to differentiate between which treatments were required and which were unnecessary. On the other hand, a patient is faced with a difficult decision of whether to undergo treatment that may or may not be necessary. As a one of the cancers with the most side effects, with impotence and incontinence being common, the psychological consideration of neglecting prostate cancer treatment can be considered apathetic.

The question of overdiagnosing prostate cancer has many ethical implications. A counter-argument for overdiagnosis is that some prostate cancers will cause significant complications later on in life, as shown by the 2009 estimate of 27,360 fatal cases of prostate cancer out of 192,280 new cases (Welch et al., 2009). For roughly 14 percent of cases, PSA screening and treatment methods would be beneficial.

November 2009

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To argue that physicians should not attempt to treat cancer when they are able to detect a localized, malignant tumour, is to proceed with an action that compromises accepted practices in the field of oncology. This is often considered the ideal situation, as nearly all types of cancer are controlled most effectively when they are suppressed before they metastasize. Moreover, there is a compulsion in modern medicine that physicians have a moral obligation to act. We expect doctors to be proactive and explore all appropriate treatments. With this ideology, physicians must attempt to man-age prostate cancer with all the tools at their disposal, especially since it is often impossible to foresee the final outcome of not treating a patient.

Even though the Hippocratic Oath states that physicians must act in the best interest of the patient, one can argue that a physician with the patient’s best interests in mind would refrain from using chemotherapy and radiation unless absolutely necessary. The physiological and emotional side effects of these treatments are often overwhelming for patients. If men can live

with prostate cancer that does not metastasize, thus not having to worry about significant health concerns, then the advantages of avoiding treatment may outweigh the costs. Dr. Welch and Dr. Albertsen from the University of Connecticut found that out of the estimated one million men “overtreated” for prostate cancer, the majority were younger men. Specifically, there was a threefold increase in the number of men aged 50-59 who were diagnosed with prostate cancer. This is substantially less than the sevenfold increase found in men under the age of 50 (Welch et al, 2009). These statistics illustrate the urgency with which researchers are diagnosing prostate cancer with the PSA technique. The screening method must be an accurate prognostic tool in determining the probability of the cancer metastasizing.

Until then, The American Cancer Society recommends that physicians exercise caution in screening for prostate cancer and that patients be aware of the positive and negative aspects of screening. This would allow patients to make informed decisions regarding whether or not to proceed with treatment.

Postgraduate Editor in Focus Dr. Shana O. Kelley is the director of Biomolecular Sciences at the University of Toronto. Aptly listed by the Globe and Mail as Canada’s Top 40 under 40, Dr. Kelley invented the first electronic chip to sense molecular disease markers. Overseeing a team of 20 researchers at Kelley Laboratories, she continues to conduct ground-breaking research to develop nanoscale medical diagnostic technology.

References Bangma, C., Roemeling, S., Schröder, F. (2007). Overdiagnosis and overtreatment of early detected prostate cancer. World Journal of Urology, 25(1), 3-9.

Prostate cancer incidence and mortality in B.C. (2009). Retrieved October 15, 2009, from http://www.bccancer.bc.ca/HPI/ CancerManagementGuidelines/Genitourinary/Prostate/ PSAScreening/ProstateCancerIncidenceandMortalityinBC. htm Doust, J., Weller, D., Nicholson, S., Veale B. (2000). International society of technology assessment in Health Care. Meeting.

Annu Meet Int Soc Technol Assess Health Care Int Soc Technol Assess Health Care Meet , 16, 229.

Etzioni, R., Penson, D., Legler, J., diTommaso, D., Boer, R., Gann, P., Feuer, E. (2002). Overdiagnosis due to prostate-specific antigen screening: lessons from U.S. prostate cancer incidence trends. Journal of the National Cancer Institute, 94(13), 981-990.

Welch, H., Albertsen, P. (2009). Prostate cancer diagnosis and treatment after the introduction of prostate-specific antigen screening: 1986-2005. Journal of the National Cancer Institute, 101(19), 1325-1329.

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Issue 16

Cocaine Vaccination: A Novel Approach towards Addiction Therapy

Amjed Kadhim-Saleh

C

Cocaine addiction has serious social and economic ramifications. Many psychologybased therapies have been utilized to reduce cocaine- dependence. However, no medications have been developed to specifically remedy cocaine addiction.

Immunotherapy is a novel approach that might prove effective in reducing cocaine dependence. This therapy is appealing for its specificity in targeting cocaine as well as its revolutionary approach to viewing cocaine addiction as a medical illness.

ocaine addiction is a problem that has serious social, economic and health-related repercussions. According to the 2005 World Drug Report, approximately 14 million people worldwide use cocaine.

The Canadian Addiction Survey revealed that 10.6% of respondents aged 15 and older reported having used cocaine in their lifetime, a significant increase from 3.8% in 1994 (2004; Collin, 2006). Cocaine abuse has been consistently associated with higher crime rates, homelessness and violence (Cruz, 2006). In the United States alone, where 2.5 million individuals are annual cocaine users, crimes associated with drug dependence amount to $67 billion annually (Martell et al, 2009; Rice et al, 1991). Health risks of drug abuse have also been well-established. For instance, 1 in 3 drug-related emergency room visits in the United States are due to cocaine abuse (Martell et al, 2009).

The health consequences of cocaine use vary greatly, including severe cardiovascular, respiratory, neurological and gastrointestinal problems (Cocaine Abuse and Addiction, 1999).

Available Therapies for Cocaine Dependence Drug-counseling and behavioral therapy are considered the most effective interventions for cocaine addiction. In addition to psychological interventions, there are certain medications that have shown clinical

“1 in 3 drug-related emergency room visits in the United States is due to cocaine abuse� efficacy, including GABA agents and agonist replacement therapy (Karila et al, 2008). For example, disulfiram, which is used to treat alcoholism, can be beneficial in individuals who use both cocaine and alcohol because of its inhibitory effect on dopamine metabolism. Among heavy users of cocaine, the GABA-B agonist baclofen is a common treatment. Antidepressants are often used in conjunction with these

drugs to mediate the mood changes that arise from cocaine withdrawal (Mechaber, 2009).

There are numerous limitations to the therapies described above. For instance, systematic reviews detailing pharmacological interventions, such as antidepressants and dopamine antagonists, cannot conclusively support their efficacy in treating cocaine dependence (Soares et al., 2003; Lima et al., 2003). Psychological interventions that encourage compliance and abstinence have been shown to be more effective in treating cocaine dependence (Mechaber, 2009). However, these interventions can be costly, lengthy, and highly unpredictable in terms of their outcome. The U.S. National Institute on Drug Abuse claims that there are no current pharmaceutical medications that specifically treat cocaine dependence (Cocaine Abuse and Addiction, 1999). As a result, other therapeutic strategies need to be developed.

November 2009

Immunotherapy Immunotherapy is viewed as a novel remedy for drug addiction. Several immunological approaches to prevent, or at least hinder, the entry of drugs into the brain have been examined.

This article focuses on the use of vaccines as an active immunization strategy, which aim to induce an immune response against cocaine. The possibility of using vaccines to combat

“Immunotherapy is viewed as a novel remedy for drug addiction”

13 addiction was shown to be effective in monkeys (Bonese, 1974). More studies were later conducted to examine the efficacy of immunotherapy in treating other drug-related addictions, such as cocaine and nicotine (Pentel, 2004).

This article centers on the mechanism of a promising cocaine vaccine that has been tested in a randomized controlled human trial. The vaccine is using a covalently-linked synthetic cocaine derivative, succinylnorcocaine, with cholera toxin B-subunit protein.

Cholera toxin, a carrier, is used because it is antigenic (generates antibodies) while cocaine is not antigenic (cocaine users do not make anti-cocaine-specific antibodies). The cocaine-antibody conjugate is then adsorbed onto an adjuvant of aluminum hydroxide (Martell et al., 2009).

Mechanism of Action The cocaine vaccine stimulates the immune system to release antibodies that specifically bind to cocaine, forming Immunoglobulin (Ig) G:drug conjugates that are unable to cross the blood-brain barrier (Figure 1). Since cocaine is prevented from reaching dopamine receptors in the brain, the drug user does not experience the euphoria associated with cocaine use.

This is pivotal in reducing the “craving”, or drug reinforcement, that often causes relapse in patients who are motivated to quit (Orson et al., 2008).

Increasing Antibody Levels

In order to inhibit cocaine-dependency, a certain level of antibodies must drug abuse was first demonstrated accumulate in the body. This level is in 1974, when a vaccine for heroin calculated using two fundamental values, antibody affinity and the total level of anti-cocaine antibody A in circulation (Orson et al., 2008).

Antibody affinity is defined as the Cocaine strength by which an antibody binds Cocaine to its targeted drug, whereas the total level of antibody in circulation refers to the quantity of IgG. Antibody affinity Anti-cocaine Antibody is calculated using the following Anti-cocaine equation Antibody Ka= [AB]/[A][B] Cocaine Antibody where (Ka) represents the equilibrium Conjugate constant; (A) and (B) refer to the cocaine drug and anti-cocaine B antibody, respectively; and (AB) Blood Brain Barrier represents the cocaine-antibody conjugate. The larger the (Ka) value, the stronger the binding (Orson et al,.

2008).

After assessing the affinity of an Cocaine-Antibody Complex antibody, it is important to calculate Dopamine Transporter drug concentration in blood circulation. For cocaine, studies have Figure 1 A) The antibody binds to cocaine forming the cocaine-antibody conjugate. B) The blood brain shown that 0.5 μM is present in the barrier prevents the complex from accessing the brain. As a result, cocaine cannot bind dopamine transblood of addicts (Orson et al, 2008). porters, leading to a lack of euphoria in drug users.

Figure 2 shows that 20 μg/ml of

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Issue 16

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Drug Dose and Binding Goal, K2 = 100 μM-1

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10 11 12 13 14 15 16 17 18 19 20

Time Since First Treatment, wk

Figure 2 The percentage of cocaine-free urine samples is represented on the Y-axis for the three groups. The X-axis shows the period of experiment in weeks. Values in weeks 9-16 show significant differences between patients with high IgG levels and the other two groups. Values in weeks 1-16 also demonstrate significant differences between groups because patients with high IgG levels had more cocaine-free urine samples than the other two groups. No significant differences were apparent in weeks 17-20 (Martell et al, 2009).

antibodies can theoretically block 90% of a drug at 0.5 μM, given that the antibody affinity is 100 μM−1 as seen in figure 3 (Orson et al., 2008).

Current Results The use of vaccines in treating cocaine-dependence show limited, yet promising results. In a controlled, double-blind randomized trial, cocaine dependence was reduced in a group of subjects who attained higher than a threshold level of 43 μg/mL cocaine-specific IgG (Martell et al, 2009). Figure 3 provides a comparison between three groups: patients with higher levels of IgG antibodies (43 μg /mL or more), patients with lower levels of IgG antibodies (below 43 μg/ mL) and a placebo group.

Patients who attained higher levels of IgG antibodies had significantly reduced levels of cocaine in their urine samples (Martell et al, 2009). Although limited, the success is promising as it indicates that those with higher levels of IgG can become abstinent if motivated to quit cocaine through counseling.

Treatment B enefits Unlike pharmacological interventions, which do not specifically target cocaine, vaccines induce the production of

90

0

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Active cocaine vaccine with high IgG levels (≥43 μg/mL) Active cocaine vaccine with low IgG levels (<43 μg/mL) Placebo

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Figure 3 Antibody level and binding goal, assuming an affinity of 100μM−1. The initial drug concentration is given as 0.5, 1, 1.5, 2 and 2.5 μM. The percentage of bound drug is given as a range from 5090% (X-axis). Target antibody level is graphed on the Y-axis (Orson et al, 2008).

antibodies which bind to cocaine molecules to prevent them from reaching the brain. Due to this specificity, vaccines are hypothesized to have fewer potential side effects or adverse events (Hatsukami et al, 2005).

In addition to the benefits conferred by the specificity of immunotherapy, this intervention changes how cocaine addiction is viewed. The use of vaccines to treat drug addicts presents cocaine-dependence from a medical perspective rather than an ethical one. Instead of viewing drug addicts as criminals, they are viewed as patients. This shift in understanding may be beneficial in reducing the social and economic implications of drug addiction (Tanner, 2009).

Limitations of Cocaine Vaccines Immunotherapy alone may not prove effective in eradicating addiction. There has been limited success in sustaining abstinence in drug addicts using these vaccines. For example, in a randomized controlled trial, only 38% of subjects attained a higher level of IgG that are within the target level (Martell et al, 2009). Those subjects had significantly reduced cocaine use. However, those subjects only had a short-term reduction of cocaine-dependency (Martell et al, 2009). According to current guidelines, short-term reduction is insufficient to be considered abstinence (Mechaber, 2009).

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Future Direction Although immunotherapy presents a novel approach to treating cocaine-dependence, its currently limited success necessitates further research. First, better vaccines with effective boosters should be developed to increase the proportion of subjects with antibody levels that fall within the target zone, specifically 43Îźg/ml. Secondly, these

vaccines should produce a longer duration of effect. This increase in antibody levels and sustained duration may lead to a longer inhibition of cocaine-dependency. Finally, the efficacy of vaccines alone is limited; patient compliance and motivation towards abstinence should be encouraged through psychological interventions, such as counseling and cognitive-behavioral therapy, along with immunotherapy.

Postgraduate Editor in Focus Alba Llop-Guevara is an international student from Barcelona pursuing a PhD degree in the Department of Pathology and Molecular Medicine with a focus in the area of infection and immunity. Seven months pregnant with a baby boy, Llop-Guevara is currently studying the impact of initial immunological disturbances and the role of certain cytokines on the generation of allergic asthma responses in mouse models and house dust mites.Â

References Bonese, K.F., Wainer, B.H., Fitch, F.W., Rothberg, R.M., & Schuster, C.R. (1974). Changes in heroin self-administration by rhesus monkeys after morphine immunization. Nature, 252, 70810.

Volkow, N.D. (1999). Cocaine: Abuse and Addiction [Research Report Series]. Retrieved from http://www.nida.nih.gov/ PDF/RRCocaine.pdf Collin, C. (2006). Substance abuse issues and public policy in Canada: IV. Prevalence of its use and its consequences.

Ottawa, Canada: Parliamentary Information and Research Service, Library of Parliament. Retrieved from http:// www.parl.gc.ca/information/library/PRBpubs/prb0619-e. htm#anaturecocaine.

Cruz, M.F., Kalousek, K., & Fischer, B. (2006). Crack cocaine.

Ottawa, Canada: Canadian Centre on Substance Abuse. Retrieved from http://www.ccsa.ca/2006%20 CCSA%20Documents/ccsa-011328-2006.pdf.

Hatsukami, D. K., Rennard, S., Jorenby, D., Fiore, M., Koopmeiners, J., & de Vos, A. (2005). Safety and immunogenicity of a nicotine conjugate vaccine in current smokers. Clinical Pharmacology and Therapeutics, 78(5), 456-467.

Lima, M. S., Reisser, A. A., Soares, B. G., & Farrell, M. (2003).

Antidepressants for cocaine dependence.

Cochrane Database of Systematic Reviews ,(2):CD002950.

Martell, B. A., Orson, F. M., Poling, J., Mitchell, E., Rossen, R. D., Gardner, T., et al. (2009). Cocaine vaccine for the treatment of cocaine dependence in methadone-maintained patients:

A randomized, double-blind, placebo-controlled efficacy trial. Archives of General Psychiatry, 66(10), 1116-1123.

Mechaber, A., Sudak, D., Gross, D. V., & Nelson, B. P. (2009). Cocaine abuse and dependence. First Consult, Retrieved from http://www.mdconsult.com/das/pdxmd/ body/165377037-3/903715781?type=med&eid=9-u1.0_1_mt_6020120#Contributors.

Orson, F. M., Kinsey, B. M., Singh, R. A., Wu, Y., Gardner, T., & Kosten, T. R. (2008). Substance abuse vaccines. Annals of the New York Academy of Sciences, 1141, 257-269.

Pentel PR. Vaccines and depot medications for drug addiction: rationale, mechanisms of action, and treatment implications.

In: Harwood HJ, Myers TG, editors. New treatments for addiction: behavioral, ethical, legal, and social questions (pp. 65-97). Institute of Medicine Report. Washington (DC): National Academies Press, 2004.

Rice, D.P., Kelman, S., Miller, L.S. (1991). Estimates of the economic costs of alcohol, and drug abuse and mental illness, 1985 and 1988. Public Health Rep, 106, 280-292.

Soares, B. G., Lima, M. S., Reisser, A. A., & Farrell, M. (2003).

Dopamine agonists for cocaine dependence. Cochrane Database of Systematic Reviews ,(2):CD003352.

Tanner, L. (2009). Vaccine-like shots help fight cocaine addiction. Retrieved October 16, 2009, from http://w w w.google.com/hostednews/ap/ar ticle/ ALeqM5iEs1iDI4xlk0TcJAxw5UqPjddT9QD9B563F84.

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Issue 16

Paramedicine: Recognition beyond Algorithms

Karen Bilecki

Regulatory gaps exist in the provision of pre-hospital emergency care leaving both the public and paramedics at risk. The purpose of this article is to inform readers on the debate over self-regulation of emergency pre-hospital care practitioners.

This article aims to provide a background of current practice issues in paramedicine, discuss recommendations made by stakeholders, and introduce the pedagogy of the Canadian Paramedical Process Model (CPPM). The complexities and unique roles paramedics play in the arena of health care will be articulated in this original model.

I

n April 2002 at the Royal Commission Public Hearings Roy Romanow, the former head of the Royal Commission on the Future of Health Care in Canada, acknowledged “paramedics are a valuable stakeholder” in the development of healthcare. Yet, the “profession” of paramedicine is not part of the Regulated Health Professions Act (RHPA), a document that grants various healthcare professions the autonomy to govern themselves. Due to their exclusion from the RHPA, paramedics do not have their own “college”, are not considered an essential service or a profession, have no input at a national level in terms of public health research, and do not have membership in the Canadian Health Council.

The Arguments Emergency Medical Services (EMS) is an essential link in the medical care model. Aside from providing a transport system, EMS extends physician care into the community by allowing medical assessment and care to begin prior to arrival at a medical facility (Drummond, 2006). Every province with the exception of Ontario provides a means of public safeguard through professional regulation of paramedics (J. Lavis,

personal communication, November 2, 2009). A “College of Paramedicine” would allow paramedics to govern their own practice, set regulatory standards, ensure membership quality assurance, and establish a professional code of

“Emergency Medical Services (EMS) are an essential link in the medical care model”

ethics, therefore protecting the public’s interests. In 1991, the Legislative Committee for Paramedics argued that paramedics were not considered in the provision of the RHPA because, “the Ambulance Act and regulations, imperfect though they may be, [already] provide a structure to ensure adequate qualification and safety in the provision of ambulance services” (The Legislative Committee for Paramedics, 1991).

Existing legislation only regulates ambulance service delivery, leaving areas of pre-hospital care not covered by the Ambulance Act unregulated.

This puts the public and practitioners

at risk. As listed in the RHPA, there are thirteen Controlled Acts. Paramedics perform eight of them, more than any other health care profession aside from physicians. It is therefore interesting that an unregulated body performs so many controlled medical acts without being a part of the RHPA (Ontario College of Paramedics Steering Committee, 2004). In 1999, the Ontario Hospital Association made recommendations that there should be a movement for self-regulation in paramedicine. In 2002, following the inclusion of EMS into the upper tier municipalities, the Association of Municipal Emergency Medical Services of Ontario (AMEMSO) offered unanimous support for the formation of a College of Paramedics. By 2003, self-regulation of paramedicine was the key recommendation to the Ministry of Health & Long Term Care (MOHLTC) by the Provincial Base Hospitals.

a

Employment Mobility: B enefit of Inclusion into RHPA

If a paramedic desires employment with a different emergency service provider, it is likely that they must successfully complete a certification

November 2009 examination every time. Furthermore, employment mobility may present itself as a challenge due to a lack of reciprocity in many areas both within and between provinces. Registration with a self-regulatory College would include reciprocity among all provinces allowing for national licensing and remove redundant testing and certification.

Protection of the profession of paramedicine would be included in the RHPA. Each of the Regulated Health Professions specifies the protection of title by preventing unqualified persons from declaring themselves a member of the profession. With the protection of a professional name, patients can rest assured that any person calling themselves a paramedic has met the standards set out by that profession.

Development of legislation that guarantees any person who claims to be qualified and licensed with

17 the â&#x20AC;&#x153;College of Paramedicsâ&#x20AC;? has met professional regulatory standards or risks criminal prosecution (Ontario College of Paramedics Steering Committee, 2004).

Putting Practice into Knowledge Acquiring a self-regulated governing body tempered with the need to provide quality, evidence-based practice in prehospital emergency care is challenging.

Drawing from current practice, insights incorporated into a process map that focuses on client-centred care, inherent in paramedical practice, is critical to the argument for self-regulation. Without a solid foundation of knowledge and collaboration between academia, practitioners and the public forum, there is little capacity for professional development in advancement of theory.

If a profession, such as paramedics, does not own its own body of knowledge,

Figure 1 Philosophical theory in paramedicine

there is no clear direction for changes in practice, no defined theory on which to derive meaning from practice, no descriptions of how paramedicine bases its fundamental concepts, no philosophic beliefs, and no basic values of the profession. It can be argued that paramedicine has adopted a biomedical model from the medical profession, or that paramedics have come to practice under a quasi-nursing model of care, but what of the unique and essential role pre-hospital practitioners play in the delivery of primary health care that emulates the principles of Canadaâ&#x20AC;&#x2122;s Health Act? (Health Canada, 2002)

Philosophical Theory Development One strategy to rectify outstanding issues and better define the profession of Paramedicine is the Canadian Paramedical Process Model (CPPM).

The CPPM is an integrated theory that uses a systematic approach to evaluate the interactions between the client and paramedic in the context of a therapeutic relationship. This model can be integrated into a philosophy, goalsetting, learning objectives, quality assurance programs, job descriptions, and essential legal documentation (Figure 1). Once goals are set and priorities are identified interventions are critically analysed and selected, while ongoing systematic evaluations of outcomes are carried out. The CPPM, unlike a hierarchy of tasks, draws parallels with a continuum of care. The CPPM has been adapted from the Roy Adaptation Model by Sr. Callista Roy and Heather Andrews (Roy, Andrews, 1991, with permission). The model is based in part, on an integrated approach to the client as a person. Utilizing three frameworks, systems and adaptation level theory as scientific paradigms, and humanism as a philosophic paradigm (Roy, Andrews, 1991). A systems www.meducator.org

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Issue 16 Third, the concept of Paramedical Practitioner encompasses the concept of The Person but also maintains attributes that incorporate altruism and paternalistic behaviours.

Paramedicine has moral and ethical boundaries and responsibilities, contributes knowledge, scholarly dialogue and specialized skill-sets.

Figure 2 Paramedics at work

approach encompasses holism, information feedback, and the complex nature of living systems. An adaptation level approach considers behaviour as an adaptive process in which ineffective coping strategies must be modified in order to achieve a successful result. From a philosophic framework, humanism demonstrates creativity, purposefulness, holism, and interpersonal processes as having individual meaning (Roy, Andrews, 1991). There are four major concepts that comprise the CPPM. First, the concept of The Person that is central to the paramedic-client therapeutic relationship and the centre of the process itself. The Person is viewed as a holistic adaptive system. As part of a complex adaptive system, The Person has the capacity to adjust effectively to changes within their environment. A system functions interdependently upon each component within their sphere. Input, output, control and feedback mechanisms are vital as responses to factors affecting environment creates various levels of adaptation within the person (adaptive or ineffective responses). How these levels are achieved are through individual coping strategies (Roy, Andrews, 1991).

Second, the concept of a Paramedical Process relates to the practices of paramedics in the field and includes identification of need areas, collection of data, assessment of stimuli, the development of a provisional diagnosis. From there, client and paramedic collaboratively set goals and prioritize interventions. Through synthesis and analysis of information, implementation of interventions takes place to form of emotional, physical, supportive care.

Fourth, the concept of Cognator and Physicality is more linear and comprises eight dimensions of the human experience that are central to knowing and valuing; (1) collaboration between paramedic and his or her community, (2) lived experience of the paramedic, (3) communication techniques for establishing therapeutic, (4) perception attitudes and judgments of situations, (5) diversity understanding cultural contexts of persons and community, (6) environment physical, emotional atmosphere, (7) resources financial, physical, and emotional assets, and (8) knowledge.

Putting Theory into Practice Through qualitative research and integrative study, the Canadian Paramedical Process Model provides a philosophical paradigm that is useful in the provision of optimum clinical practices in client-centred, evidence-based pedagogy. The CPPM utilizes an individualized client-centred approach to a plan of care that identifies particular needs, and influences best practices.

Recommendations Paramedical practitioners need to be included into the RHPA and given the opportunity to develop their own professional College to bridge the self-regulatory gap.

Professional paramedicine should utilize action strategies that support ongoing processes of theory development in the context of pre-hospital care, yet articulate scholarly dialogue through knowledge translation, and development of structural paradigms that are inherent to Paramedicine in Canada today. Paramedicine is more than just performing algorithms, paramedics provide comprehensive prehospital emergency medical, and ethical care that effectively demonstrate knowledge, skill, and ability. Lobbying efforts to government officials, key stakeholders and paramedics on the front line need to continue in order for paramedicine to be reserved a seat at the legislative table. A clear and unified voice for change and inclusion into key national health care legislation is paramount in establishing valued partnerships with government officials.

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Postgraduate Editors in Focus Walter Tavares is a Masters candidate in Health Research Methodology at McMaster and an education research fellow in the faculty of medicine at the University of Toronto. Tavares serves as program coordinator for the paramedic program at Centennial College and University of Toronto (Scarborough) and is the Ontario direction for the Society of Prehospital Educators of Canada. An internationally trained and certified advanced care paramedic, Tavares’ current research evaluates factors affecting clinical performance in prehospital care and education.

Dorina Kirilova is a Masters candidate in Health Research Methodology at McMaster. Working at the centre for Health Economics and Policy Analysis, she is currently researching “Public Engagement into Health Care Decision making regarding Technologies”. In the future, she hopes to pursue a PhD in health policy and become an analyst.

References Alligood, M. R., Tomey, A. M. (2002). Nursing Theory Utilization & Application. 2nd ed. St. Louis, MS: Mosby Inc. Canadian Emergency Health Services Research Consortium.

(2004). About The Canadian Emergency Health Services Research Consortium. Retrieved from http://cerc.paramedic.ca/index.php?option=content&task=view&id=15 &ltemid=40.

Canadian Institutes Of Health Research. (2004). About Knowledge Translation. Retrieved from http://www.cihrirsc.gc.ca/e/29418.html.

Canadian Institutes Of Health Research. (2004). Knowledge Translation Strategy 2004-2009. Innovation In Action.

Retrieved from http://www.cihr-irsc.gc.ca/e/26574.html.

Health Canada. (2002). About Health Canada. Canada’s Health Care System At A Glance. Retrieved from http:// www.hc-sc.gc.ca/ahc-asc/media.nr-cp.2002/2002_caresoinsbk5_e.html.

Kenty, J. R. (2001). Weaving Undergraduate Research Into Practice-Based Experiences. Nurse Educator. 26(4). pp.

182-186.

Ontario College Of Paramedics Steering Committee. (2004).

Paramedic Regulation Today. Retrieved Oct. 21, 2006 from http://www.ontariocollegeofparamedics.ca/over_ regulated.htm Parker, M. (2001). Nursing Theories And Nursing Practice.

Philadelphia, PA: F.A. Davis Co.

Democracy Centre. (1997). Lobbying-The Basics. Retrieved from http://www.democracyctr.org/resources/lobbying. html.

Regulated Health Professions Act. (1991). Statutes Of Ontario, 1991. Chapter 18. Queens’ Printer For Ontario. Current to January 30, 2006.

Drummond, A. (2006). About Canadian Association Of Emergency Physicians Advocacy: Committees and Policies. Romanow Commission. Retrieved from http://www. caep.ca/template.asp.

Roy, SR. C., Andrews, H. A. (1991). The Roy Adaptation Model: The Definitive Statement. Norwalk, Conn: Appleton & Lang.

Engelke, M. K., Marshburn, D. M. (2006). Collaborative Strategies To Enhance Research And Evidenced-Based Practice. Journal Of Nursing Administration, 36(3), 131- 135.

Walker, J. A. (2004). Paramedics: Canada’s Front-Line Health Care Provider. The Paramedic Association Canada & Canadian Emergency Health Services Research Consortium.

Retrieved from http://www.paramedic.ca/cerc.

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Issue 16

New at Mac The McMaster Health Forum

Alyssa Cantarutti

A

s a member of the editorial board in the McMaster Meducator, I act as a liaison between undergraduate writers and post-graduate editors as an article moves through the editing process prior to publication. As of September this year, I also became the Meducator representative on the McMaster Health Forum. The Health Forum’s Student Subcommittee provides students with the opportunity to express their opinions regarding health policy on all levels, ranging from global to local communities, such as here on campus.

Being a part of the Health Forum as a second-year Biochemistry student and a member of the McMaster Meducator, I have thus far been able to expand my knowledge and familiarity with many diverse aspects of health care. I am a Co-Chair of the Student Subcommittee, along with MSU president Vishal Tiwari.

Together, we lead the committee that represents the student body. This means that we organize Health Forum events that incorporate student involvement, chair meetings with other representatives from student organizations, and try to bring forth the opinions of McMaster students wherever to the Health Forum dialogue.

Joining this committee as a representative of a student group is a significant responsibility as the Health Forum requires a marked amount of time and energy. However, this experience also provides the opportunity to explore many interesting areas of health care provision that students often overlook.

We are not often exposed to issues surrounding health policy and health care accessibility in resource-limited settings that currently affect millions of people around the world, and the Health Forum has been a fantastic way for me to become much more familiar with such

“This experience also provides the opportunity to explore many interesting areas of health care provision” topics. It has also sparked my personal interest in related areas. Furthermore, the Health Forum does not only represent and target its messages towards Science or Health Sciences students. Students not involved in science courses are also encouraged to partake in the forum dialogue as active and engaged citizens by attending presentations and events so that they too can be aware of the personal and global implications of health policy.

The McMaster Health Forum provides a platform for discussion among public health figures at the international,

provincial and regional levels, as well as among McMaster students, faculty, and Forum fellows. Forum events are meant to encourage debate among its stakeholders with regards to current challenges in health care. The vision of the Forum is to “be a world-leading hub for improving health outcomes through collective problem solving.” Its mission is to use current evidence, informed and concerned citizens and influential thinkers to meet the challenges presented by health care needs around the world.

Some examples of these challenges include pandemic preparedness, such as that which we are experiencing with regards to H1N1, as well as the HIV/AIDS epidemic.

Forum events focus primarily on knowledge translation and the dissemination of ideas. The intention behind this sharing of information is to transform insight into action, with the ultimate goal of improving research and education, as well as promoting awareness. The topics of discussion at these events are decided based on pressing health dilemmas that need

Figure 1 Dr. John Lavis

November 2009

International Advisory Board

Managing Director

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Steering Committee Director

Scientific & Educational Sub-Committee

Student Sub-Committee

Community Sub-Committee

Figure 2 Organization of the McMaster Health Forum

to be addressed at all levels of leadership. There are several types of events held: dialogues lead by faculty and students, stakeholder dialogues, citizen panels, and public talks. Studentled dialogues and debates allow students to interact with toplevel health officials. These are focused on health challenges that concern individuals at the grass-roots level. An example of a past event was a faculty debate on the topic of healthcare expenditures. McMaster students are encouraged to take part in these events and to develop informed opinions about the state of health care globally.

â&#x20AC;&#x153;The intention ... is to transform insight into action with the ultimate goal of improving research and education as well as promoting awarenessâ&#x20AC;?

The Forum is composed of three subcommittees, a steering committee, advisory board, adjunct faculty, fellows, and staff.

The three subcommittees consist of a Scientific and Education Subcommittee, a Community Subcommittee, and a Student Subcommittee. The Forum is under the direction of Dr. John Lavis, a professor in the Department of Clinical Epidemiology & Biostatistics, as well as an associate member of the Department

of Political Science. The Student Subcommittee, chaired by MSU president Vishal Tiwari and myself, is designed to represent the interests and opinions of students at McMaster. The remainder of the committee is comprised of students representing healthrelated groups on campus, including: McMaster Meducator, McMaster Graduate Students Association, McMaster Medical Student Society, Bachelor of Health Sciences Society, McMaster University Nursing Student Society (MUNSS), MacDebate Society, Health, Aging and Society Student Association, and McMaster Students for Health Innovation. Students wishing to represent their organizations within the Health Forum at this level should see the Health Forum website (below) for more information about who they can contact. Representatives that sit on the Student Subcommittee are all members of campus groups with interests in health issues.

The McMaster Health Forum will be hosting events in November that are open to students. For more information about how you can attend or participate, please keep an eye open for posters around campus and posted on LearnLink, as well as events on Facebook! Additionally, there will be an upcoming event in Winter/Spring 2010 regarding barriers to health care access. Students are encouraged to contribute their opinions regarding the access they have to health care in Canada, as well as the availability of health care in other nations and its comparative quality. More information about the McMaster Health Forum can be found at http://healthforum.mcmaster. ca/index.php.

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Issue 16

Get in touch with your world!

Look out for the next issue of the McMaster Meducator A collaborative eďŹ&#x20AC;ort with the Global Citizenship Conference

Out in February 2010!

CALL FOR WRITERS Do you have an article idea?

Would you like to write for us?

Want to see your work published?

Visit our website or e-mail us to submit an article, learn more about writing, or discuss ideas with our editors!

www.meducator.org meduemail@learnlink.mcmaster.ca

November 2009

23

Have you read all the articles? Test yourself and see how well you understood the articles by answering the questions below.

MedQuiz

MedQuiz 1. What does PSA stand for? a) Protein-specific antigen b) Probability sensitive analog c) Phospholipid screening antigen d) Protein-specific antibody

5. The profession of paramedicine is regulated under: a) The Regulated Health Profession Act b) The Legislative Committee for Paramedics c) The Ontario College of Paramedics Steering Committee d) None of the above

2. What characteristic of prostate cancer makes it difficult to diagnose? a) Size b) Location c) Metastasizing rate d) Demographic it affects

6. The Canadian Paramedical Process Model is an integrated theory that uses:

3. What brain receptors does cocaine act upon? a) Dopamine b) Serotonin c) Acetylcholine d) Epinephrine

7. McMaster students are given the opportunity to voice their opinions about health policy through: a) The Silhouette b) McMaster Health Forum c) Facebook d) MacInsiders Forum

4. Cocaine vaccines prevent cocaine from: a) Binding to dopamine receptors b) Binding to serotonin receptors c) Crossing blood brain barrier d) Entering bloodstream

a) A systematic approach to evaluate client-paramedic relationships b) A hierarchy of tasks c) Utilizes two framework systems d) Employs the concept of the paramedic

8. The profession of paramedicine is regulated under: a) McMaster University b) North America c) Around the world d) All of the above

Answers:: A, C, A, C, A, A, B, D

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