november March2011 2012||Issue Issue20 21||www.meducator.org www.meducator.org
Childcare as Healthcare Vitamin D enriched childhood experiences
Ciliary Dysfunction the function of microtubules
Peer Support Centres
supporting mental health at university
are current guidelines correct?
APPLYING DRAMA TO HEALTH
An interview with Hartley Jafine
issue 21 | March 2012 LETTER FROM THE EDITOR
The New Canada Health Transfer:
Increasing Disparity and Supporting Inertia?
by Adrian Tsang & Justin Neves
articles Childcare as Healthcare:
Parents’ Perceptions of Enriched Early Childhood Experiences
by Regina DeLottinville
Ciliary (Dys)function in Human Disease:
Mapping the Ciliogenesis Pathway
by Mustafa Ahmadzai
University Campus Peer Support Centres:
Benefits for Student Emotional and Mental Well-being
by Ikdip Kaur Brar, Jae Eun Ryu, Kamran Shaikh, Ashlie Altman & Jeremy Ng
The Vitamin D Gamble by Andrew Webster
INTERVIEW Hartley Jafine: The Role of Drama in the Health Sciences Conducted by Ilia Ostrovski, Brian Chin & Shelly Chopra
Editor-in-Chief Hiten Naik Deputy Editor-in-Chief Daniel Lee Strategic Advisor Ahmad Alkhatib Editorial Board Matthew Chong Mustafa Ahmadzai Khizer Amin Shelly Chopra Daniel Elbirt Keith Lee Bhavik Mistry Vaibhav Mokashi Humna Amjad Ilia Ostrovski Kimia Sorouri Andrew Webster
Graphics & Design Brian Chin Jennifer Kwan Xena Li Ellen Liang Annie Cheung Yasmeen Mansoor
Communications Aashish Kalani Mohsin Ali Tahir Ali Paul Cheon John Han
Health Forum Liaison Lebei Pi ADDRESS
The Meducator BHSc (Honours) Program Michael G. DeGroote Centre for Learning and Discovery Room 3308 Faculty of Health Sciences 1200 Main Street West Hamilton, Ontario L8N 3Z5
PRINTING Underground Media & Design
ABOUT Us: Established in April 2002 with the support of the Bachelor of Health Sciences (Honours) Program (BHSc), The Meducator is McMaster University’s undergraduate health sciences publication. Through biyearly
publications, a web page, and social media, we aim to provide a platform for undergraduate students to publish their work and share information with their peers. Our protocol strives to maintain a high 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 writing to our email: firstname.lastname@example.org
www.meducator.org Find us on Facebook! Follow us on Twitter @TheMeducator
LETTER FROM THE EDITOR: Celebrating 10 years of The Meducator This April, it will have been 10 years since the first edition of The Meducator was published in 2002. In his inaugural Letter from the Editor, Meducator founder Jonathan Ng states that the publication was established “with the vision of immersing individuals, interested in pursuing a health profession, into the world of medicine”. The issue went on to include a series of interesting pieces on topics that ranged from HIV vaccines to the health benefits of chocolate.
graduate Regina DeLottinville aptly describes in her Research Insight piece, the experiences we have during our youth can play a strong role in dictating our health habits in the future. However, there are several determinants of health that are less under our control. For example, ciliopathies are a series of disorders that have a genetic basis. In a thoughtful Critical Review, Mustafa Ahmadzai discusses the biology behind these diseases and highlights current research approaches that are used to learn more about them.
To permanently preserve the first issue and all 19 since then, we have worked with Nick Ruest at the McMaster library to integrate our publication into the university’s institutional re- Mustafa’s article is followed by two additional Critical Reviews. pository (Digital Commons). By making articles discoverable A group from the recently founded Motivation for McMaster through Google Scholar and assigning each a citation, this sys- discuss the concept of peer-to-peer counseling and how it can tem will ensure that the work of our authors remains valuable be a valuable means to deal with mental health issues while at McMaster and beyond. at university. Andrew Webster then outlines the non-classical benefits of Vitamin D and describes how the current dosage A brief perusal of all the past issues now published on our web- recommendations might be off the mark. site (www.meducator.org) reveals that our content has broadened in scope over the years and has expanded to include ar- The controversial policies and intriguing science featured in ticles—and now abstracts—based on research conducted by this issue may rightly occupy the minds of many students and students from a diverse range of fields. Medicine is truly multi- health professionals, but the arts can also be used to improve disciplinary, and the idea that health is influenced by the most our sense of perspective and regain our passions. Three memmacro and micro of factors is certainly apparent in the articles bers of The Meducator led by Ilia Ostrovski took the opportunity to interview Hartley Jafine to discuss the benefits of applyof this, our tenth anniversary issue. ing drama to health care and health education. In the coming On a national scale, the federal government can directly in- weeks, we hope to post a video of this interview on our new fluence health care delivery by providing (or not providing) YouTube channel. transfer funding to provinces. In light of recent news since their inaugural column, Adrian Tsang and Justin Neves from In closing this letter, I would like to extend a thank you to all the McMaster Health Forum Student Subcommittee discuss members of The Meducator team that have made the last two issues possible, and would like to wish next year’s staff all the this topic in the ForumSpace. best going forward. I have now been involved in nine editions But while Stephen Harper seemingly has the power to influ- of The Meducator and am confident that the next nine will ence our health care, so do our parents. As recent nursing make Jonathan just as proud.
President & Editor-in-Chief Bachelor of Health Sciences (Honours), Class of 2012
The Meducator | March 2012
SPIRITUAL HEALING & MENTAL ILLNESS
NEUOTRAUMA AND THE RESCUE PRINCIPLE
ver the last decade, the influence of religion on recovery from severe mental illness has emerged as an important idea amongst clinical psychologists. Health professionals have found that spirituality quickens recovery by playing a role in stress reduction (e.g. through prayer), improves a patient’s sense of well-being, and lends guidance or structure to afflicted individuals.1
A study conducted by Webb et al.3 investigated how positive religious support could aid recovery in 81 adults with several mental illnesses such as schizophrenia, depression, or bipolar disorder. Recovery was assessed using a Recovery Assessment Scale which comprised of 41 questions related to the participant’s personal confidence, willingness to ask for help, reliance on others and motivation to succeed. The study found that religious support resulted in a statistically significant improvement in the subjects’ mental states. The results of this study have important implications for health professionals as it encourages them to become more cognizant of spiritual issues and possibly make use of the patient’s existing religious community in treatments.4 For example, in the United States, several religious professionals and ministries with training in mental health have been able to promote recovery.5 In conclusion, spirituality and religion can be positively utilized in future therapies to help individuals recover from severe mental illness.
Sullivan WP. Recoiling, regrouping, and recovering: first-person accounts of the role of spirituality in the course of serious mental illness. New Dir Ment Health Serv 1998 Winter;(80):25-33. Huguelet P, Mohr S, Jung V, Gillieron C, Brandt PY, Borras L. Effect of religion on suicide attempts in outpatients with schizophrenia or schizo-affective disorders compared with inpatients with non-psychotic disorders. Eur Psychiatry 2007 Apr;22(3):188-194. 3 Webb M, Charbonneau AM, McCann RA, Gayle KR. Struggling and enduring with God, religious support, and recovery from severe mental illness. J Clin Psychol 2011 Dec;67(12):1161-1176. 4 Huguelet P, Mohr S, Borras L, Gillieron C, Brandt PY. Spirituality and religious practices among outpa- tients with schizophrenia and their clinicians. Psychiatr Serv 2006 Mar;57(3):366-372. 5 Stetz KM, Webb M, Holder A, Zucker D. Mental Health Ministry: Creating Healing Communities for Sojourners. Journal of Religion, Disability & Health 2011 April-June 2011;15(2):153-174. Image adapted from: http://www.time.com
he rule of rescue is “the injunction to rescue identifiable individuals in immediate peril regardless of cost”.2 The human proclivity to abide by this principle is demonstrated in accounts of sailors risking their lives to find a shipmate lost at sea. Recently, the moral implications of abiding by this principle have come into question in deciding whether or not to perform a decompressive craniectomy (DC) on patients with a severe brain injury.
The procedure, which entails removing a large section of the cranium to relieve swelling-induced pressure, is extremely expensive and often results in severe life-long disabilities for the patient. A newly derived model for indexing brain injury severity was tested to determine to what extent it could predict the outcome of patients receiving a DC. The study compared groups with above and below an 80% prediction of an unfavourable outcome. In the >80% group, only 12.5% of the patients had a favourable outcome (p<0.05). Conversely, in the <80% group, 83% of the patients returned home, with only 6% requiring nursing home care (p<0.05).2 Difficulty arises when deciding to perform a DC since the risk involved with this procedure is high. Additionally, large opportunity costs are associated with this decision-making process since consequences of the decision may not be appropriate for the patient. Physicians are put in a difficult situation since they must draw the line between morals and health benefits.
Honeybul S, Gillett G R, Ho K M, Lind C R P, J Med Ethics 2011;37:707-710 Cookson R, McCabe C, Tsuchiya A. Public healthcare resource allocation and the Rule of Rescue. J Med Ethics 2008;34:540 Image adapted from: http://www.stroke.ahajournals.org/content/38/9/2506/F3.expansion 1 2
THE BIOCHEMISTRY OF LONG-TERM MEMORIES
fter numerous debunked diet fads and weight-loss plans that promised everything but failed to deliver, the Western world has come to realize the difficulties of not only losing weight, but also keeping it off.
A recent study by Dr. Joseph Proietto and colleagues at the University of Melbourne suggests that long-term biological changes in persons who are obese play a considerable role in hindering weight loss. Fifty men and post-menopausal women with body-mass indices between 27 and 40 were recruited to the study. For ten weeks, the participants were restricted to low-starch vegetable drinks, which provided 500-550 calories per day. Participants then entered the weight-maintenance phase, in which they returned to the consumption of ordinary foods, in amounts and ratios that were suggested to them by dietary experts. Follow-up occurred every two months for a span of one year. It was found that weight-loss resulted in significant alterations in levels of appetite-mediating molecules, such as leptin, insulin, and gastric and pancreatic polypeptides. These changes were a homeostatic response in order to promote the regain of weight, and were consistent with the increase in appetite that was reported by participants. The researchers found that compensatory alterations to weight loss persisted even a year after the ten-week diet, promoting the eventual regain of weight. This persistent biological transformation highlights the importance of finding diets that can be maintained permanently.
Sumithran P, Prendergast LA, Delbridge E, Purcell K, Shulkes A, Kriketos A, et al. Long-term persistence of hormonal adaptations to weight loss. The New England Journal of Medicine, 2011;365(17):1597–604. Image adapted from: http://www.emedicbuzz.com
HOMEOSTASIS: THE PRISON WARDEN OF OBESITY
he brain stores memories by forming connections between individual nerve cells. During learning, these connections, known as “synapses”, change in number and strength as a result of alterations to their protein compositions. Long-term memory formation involves maintaining these changes over long periods of time. However, how this maintenance is achieved has remained a mystery to neuroscientists.
Recently, researchers at the Stowers Institute for Medical Research discovered a synaptic protein, Orb2, in the Drosophila fruit fly that appears to be essential for the formation of longterm memory. Orb2 is a self-complementary protein, able to stack with copies of itself to form oligomers located within neurons. After determining that stimulation of neuronal synapses increases Orb2 oligmerization, the researchers tested whether oligomeric Orb2 is essential for memory formation. Introduction of a point mutation to reduce Orb2 oligmerization prevented the fruit flies from stabilizing long-term memory beyond 24 hours, a phenomenon not experienced by wild-type Drosophila. This suggests that oligomeric Orb2 plays an important role in the persistence of memory. The discovery that oligomers are involved in memory formation has numerous implications. In addition to providing insight into the complex workings of the brain, this finding also sheds light on many memory-related diseases, such as Alzheimer’s, caused by the accumulation of toxic oligomers. Further research in this area can give us a better understanding of when and how oligomers are detrimental to our health.
Majumdar A, Cesario W, White-Grindley E, Jiang H, Ren F, Khan M, et al. Critical Role of Amyloid-like Oligomers of Drosophila Orb2 in the Persistence of Memory. Cell. 2012 Jan 26. Image adapted from: http://www.newswise.com
The Meducator | March 2012
THE DEBATE OF COGNITIVE NEUROENHANCEMENT
PUBLIC HEALTH & THE DRUG RESISTANT TB Lebei Pi
ognitive neuroenhancement (NE), the process of improving one’s intellectual abilities, has been debated by the scientific community since the development of psychostimulatory drugs. At face value, the principle behind NE seems simple yet lucrative: the development of a pill to better one’s brainpower and thus one’s operative performance at school or work. However, unpacking the physiological, moral, and social implications of NE reveals how the notion is still in its infancy in the domain of non-therapeutic interventions.1
One of the largest challenges lies in the fact that many psychostimulants, acting through dopaminergic pathways, have both positive and negative effects. While dopamine is able to mediate learning and one’s intelligence quotient (IQ), overstimulation of the dopamine pathway causes addiction, a key side effect of most psychostimulants on the market today. This duality complicates research in NE and calls into question the potential benefit of psychostimulants. However, if one day the cognition-enhancing effects outweigh the counter-regulation of psychostimulants, is their marketing as neuroenhancers ethically justifiable? Social pressures to conform to the use of neuroenhancers for one’s intellectual performance parallel the manner in which athletes are often intimidated–by their opponents’ physical abilities–into using steroids. Although the average person faces many social pressures today, the key distinction between the purchase of a popular gadget and ingesting a NE drug is that the latter intervenes directly at the neurobiological level.2 One’s sense of self and self-efficacy will be affected at the neuronal level in addition to the social burdens experienced when using a psychostimulant.
ecent reports of the emergence of an incurable form of tuberculosis at the Hinduja Hospital in Mumbai, India have raised concerns regarding increasing drug resistance to the disease. Researchers in Mumbai have identified 12 patients with so-called totally-drug resistant tuberculosis (TDR-TB) that appears to be resistant to all known treatments.1 Zarir Udwadia, a physician at the Hinduja Hospital who has been treating the patients, attributes the issue of drug resistance to poor management of the disease and a failure of public health in India.1 In particular, government-run health facilities in India are viewed negatively by the public due to chronic underfunding and understaffing, effectively forcing desperate TB patients to seek care from private physicians who tend to be unregulated in both prescribing practice and qualifications.2 In fact, a study conducted in Mumbai showed that the vast majority of prescriptions written by private physicians practicing in Dharavi for hypothetical TB patients were inappropriate and would have further amplified drug resistance.3 This problem is exacerbated by poor infection control in health settings and the lack of laboratory infrastructure to identify and confirm TB diagnoses, creating a breeding ground for infection and drug resistance.1 So far, only about 1% of those who have developed multi-drug resistant TB have had access to the Directly Observed Therapy, a Short Course program that treats normal TB. However, the Indian government has failed to provide treatment for the rest of the population living with TB, due to its high cost – US$4000 per patient for TB alone, compared to the $45 the government actually spends per capita on health care in general.1,2
Although present for a number of years, the debate on the value of NE seems to have just begun. Further empirical research will determine what, if any, psychostimulants should be tested for cognition-enhancing effects in healthy individuals. Loewenberg S. India reports cases of totally drug-resistant tuberculosis. The Lancet. 2012 Jan;279(9812):205. Udwada ZF, Amale RA, Ajbani KK, Rodrigues C. Totally drug-resistant tuberculosis in India. Clinical Infectious Diseases [Internet]. 2011 Oct [cited 2012 Jan 28];0. Available from: http://cid.oxfordjournals. org.libaccess.lib.mcmaster.ca/content/early/2011/11/24/cid.cir889.full.pdf+html 3 Udwadia ZF, Pinto LM, Uplekar MW. Tuberculosis control by private practitioners in Mumbai, India: has anything changed in two decades? PloS One. 2010;5(8):1-5. Image adapted from: http://www.guardian.co.uk 1 2
Heinz A, Kipke R, Heimann H, Wiesing U. Cognitive neuroenhancement: false assumptions in the ethical debate. J Med Ethics 2012 Jan 6. Galert T, Bublitz C, Heuser I. Das optimierte Gehirn. Gehirn & Geist. 2009. Image adapted from: http://www.healthcarereformmagazine.com 1
M EDA BSTRACTS Assessing the Effects of High Sugar and Protein Diets on Reproduction and Longevity in Crickets Sohaib Amjad1, David C. Rollo2 1 Honours Biology, Physiology Specialization, Class of 2012; 2 Department of Biology, McMaster University
Studies on longevity are becoming increasingly important due to the aging population. The house cricket, Acheta domesticus, is an effective model for longevity studies due to its short lifespan of 120 days. This study explored the effects of diet on reproduction and longevity in A. domesticus. There were four treatment groups: 1) control diet with reproduction, 2) control diet with reproductive isolation, 3) high protein diet with reproduction, and 4) high sugar diet with reproduction. We began monitoring the crickets following maturity to allow for reproductive analysis. Death counts were conducted daily, followed by replenishment of food and water supplies. Egg counts and weight measurements were conducted weekly. Results showed that crickets on the high sugar diet had significantly longer lifespan than other treatments. The lowest lifespan was seen in crickets on the high protein diet. Conversely, the highest reproductive output was seen in the high protein diet and the lowest was in the high sugar diet. The reproductively isolated control group had a significantly greater longevity than the reproductive control group. Taken together, the research shows an inverse relationship between reproduction and longevity as modulated by dietary consumption of proteins and carbohydrates.
Human V-ATPase a2 P405L Mutation Results in Cutis Laxa by Affecting V-ATPase Assembly and/or Stability Ravi Kumar1, A. Bhargava2, M. Manolson2 1 Bachelor of Health Sciences (Honours), Class of 2014; 2 Faculty of Dentistry, University of Toronto
Cutis Laxa is a genetic disorder in which a patient’s skin becomes loose and inelastic. The autosomal recessive variant of this disorder has been linked to a genetic mutation in vacuolar-type H+-ATPase (V-ATPase). This enzyme contains a cytosolic domain, responsible for hydrolyzing ATP, and a membrane-bound domain that actively transports protons across intracellular and plasma membranes. Proton pumping regulates housekeeping functions inside the cell, resorption of bone, and acidification of urine. A human missense mutation in one of the V-ATPase subunits (a2 P405L) that causes Cutis Laxa was recreated in the yeast V-ATPase to elucidate why a single amino acid change could affect enzyme activity. The mutation recreated in the yeast V-ATPase disrupted activity based on the inability of yeast to acidify their vacuoles. The membrane domain of the mutant V-ATPase was correctly assembled and targeted to the yeast vacuole but the cytosolic domain was not attached explaining why the vacuoles were not acidic. These results suggest that the loss-of-function mutation present in cutis laxa leads to decreased V-ATPase stability and/or assembly. Further experiments will be designed to assess if the mutation results in a conformational defect, and if so, therapeutics assisting in protein folding can be explored. Such therapeutics not only hold promise for cutis laxa, but also for other V-ATPase genetic diseases such as osteopetrosis, distal renal tubular acidosis and male sterility.
The Impact of HIV/AIDS Criminalization on Awareness, Preventiuon and Stigma in the GTA Karen Chung1, Brittany Greene1, Jessica Lax-Vanek1, Sofija Rans1, Allyson Shorkey2, Michael Wilson3 Bachelor of Health Sciences (Honours), Global Health Specialization, 1Class of 2012; 2Class of 2013 3 Program in Policy Decision-Making/Centre for Health Economics and Policy Analysis, McMaster University
In Canada, the exposure and/or transmission of HIV is punishable by criminal law. Deficiencies in Canadian-focused research about the implications of criminalizing HIV exposure demonstrate a need for locally applicable research evidence. This study aims to investigate the impact of HIV/AIDS criminalization on awareness, prevention, and stigma in the Greater Toronto Area through a scoping review and stakeholder interviews. Eleven databases were searched and the results were reviewed for relevance. Search yielded 1301 results, 148 relevant articles. Primary research is limited to 12 articles, while the remainder is comprised of case reports, editorials, commentaries and essays (n=136). Literature highlights confusion regarding behaviours constituting “significant risk”, resulting in difficulties in the application of legal precedent and uncertainty regarding HIV knowledge in the general public. Some evidence suggests that criminalization contributes to disincentives for testing and disclosure, strained therapeutic relationships, HIV related stigma, and barriers to promoting shared responsibility for safer sex. Stakeholders (policy/content experts, executive directors and front-line workers from community-based HIV/AIDS organizations) were identified, and a purposive sample invited to participate in one-on-one, semistructured interviews. Interviews depict the negative impact of criminalization on prevention efforts, heightened community awareness of prosecutions, and increased stigmatization of people living with HIV/AIDS. Participants recommend guideline development to optimize the use of criminal law pertaining to HIV/AIDS non-disclosure. These findings will significantly contribute to increasing primary research on the impact of HIV/AIDS criminalization in the Greater Toronto Area. Further research is necessary to characterize the impact from the perspective of people living with HIV/AIDS.
The Meducator | March 2012
F O RU M S PAC E The New Canada Health Transfer: Increasing Disparity and Supporting Inertia? Adrian Tsang1 and Justin Neves2 McMaster Health Forum Student Subcommittee Bachelor of Health Sciences (Honours), 1Class of 2012; 2Class of 2013 The current Canada Health Transfer which distributes $27 billion in cash and $13.6 billion in tax points to the provinces to support health care, will expire in 2014. Near the end of 2011, the Harper government surprised Canadians with a take-it-or-leave-it deal, whereby the Canada Health Transfer would be delivered with no-strings-attached and a decline in the rate of increased spending starting in 2017. The proposed deal reflects a growing hands off approach to healthcare in federal politics, furthers the divide between “have” and “have-not” provinces and represents a missed policy window for implementing significant healthcare reforms.
$ per capita
he Canada Health Act and its predecessor legislation explic- areas, which are usually identified during Health Accord negotiaitly declare that “the primary objective of Canadian healthcare tions.2 Canada Health Transfer payments—currently worth $27 policy is to protect, promote and restore the physical and mental billion in cash and $13.6 billion in tax points—will increase at well-being of residents of Canada and to facilitate reasonable ac- the present rate of 6% per annum until 2017, at which point cess to health services without financial or other barriers.”1 State- increases will be tied to economic growth with a guaranteed floor ments such as these have resonated with Canadians for decades, of a 3% increase per annum until approximately 2024.3 Health creating a strong sense of national pride in a health system that care spending has increased by 6.1% per annum over the last few values fairness over privilege and need over the ability to pay. With years, meaning provinces will now have to find ways to limit this that being said, as the global economy continues to struggle and increase to ensure that their health systems are sustainable.3 the baby boomer generation begins to retire, there is a growing concern that our healthcare system may require significant reform. At first glance, the rich provinces will become richer and the poor will become poorer. Under the terms of the proposal, the federal In the First Ministers’ Accord of 2004, the prime minister and government will eventually distribute money from public coffers the premiers of each province and territory agreed upon a fund- to the provinces and territories on a strict per-capita basis, which ing strategy to increase federal support for healthcare through will exacerbate the wealth disparity across Canada in two ways. yearly cash and tax point transfers, known as the Canada Health First, tax revenues from wealthier provinces are usually greater Transfer. The ministers also agreed upon priority funding areas to than those from poorer provinces on a per capita basis because improve healthcare, such as embracing information technologies they are tied to residents’ incomes. In fact, Alberta will signifiand reducing wait times.2 With the Accord expiring in 2014, pol- cantly benefit from the proposed per-capita transfer because their icy entrepreneurs and health professional associations have been tax points are so “strong” in comparison to the rest of the country anxiously waiting for new negotiations to commence to push (Figure 1).4 onto the agenda important health system policies on home care, 250 prescription-drug insurance and a variety of other issues. They are 200 going to have to continue waiting. 150 100 This past December, the Harper government surprised the provin50 cial and territorial governments as well as the general public when 0 Finance Minister Jim Flaherty announced a take-it-or-leave-it deal, -50 whereby the Canada Health Transfer would be delivered with no-100 strings-attached and a decline in the rate of increased spending -150 N.L. P.E.I. N.S. N.B. Que. Ont. Man. Sask. Alta. B.C. starting in 2017. At the moment, the government’s proposal will also remove the equalization formula that balances Canada Health FIGURE 1: Per Capita Difference in Total CHT Entitlement between Current and Transfer payments between “have” and “have-not” provinces. The Equal-per-Capita Cash Transfer, 2011-2012. Adapted from http://parl.gc.ca/Content/ LOP/ResearchPublications/2011-02-e.htm#a6 proposal includes no statement about national priority funding
Second, increases in economic development upon which the transfers will be based, will be led primarily by the west. In 2018 the Canada Health Transfer will begin to be tied to the growth in nominal gross domestic product (GDP), which is a measure of GDP without adjustment for inflation. While inflation increases the cost of delivering health services, the economic development of resource-rich provinces will significantly overshadow growth in resource-poor provinces.5 Without an equalization payment to re-distribute wealth across the country, this will negatively affect “have-not” provinces like Ontario and Quebec and positively affect a “have” province like Alberta.
Cooperation and Development (OECD), Canada ranked second (behind only the United States) in the amount spent on prescription drugs. In fact, Canada’s total expenditure on pharmaceuticals is about thirty percent higher than the OECD average8 and now exceeds physician-based care, making it the second largest health expenditure in Canada’s health system (Figure 2).9 Despite high costs, Canada still has the lowest rates of public drug coverage amongst OECD countries and eight percent of Canadians are still unable to fill their doctors’ prescriptions due to cost.8 In order to reduce the inequality in access to medicines, it may be beneficial to unite the formularies of the thirteen provinces and territories into a single evidence-based national formulary. Doing so could Under the new plan, Stephen Harper threatens to narrow the al- reduce prescription drug costs by $10.7 billion dollars, or 43% of ready limited input that the federal government has in a domain the $25.1 billion Canadians currently pay for drugs.8 where it makes substantial annual investments. Ottawa has in a sense become a hands-off benefactor, while leaving responsibility to the provinces to continue to provide essential healthcare services that Canadians have come to expect on terms guaranteed by the Canada Health Act.
The re-negotiation of the Health Accord should have been the time to build on the initiatives from the previous agreement that are still in their infancy. Perhaps the most essential of these initiatives was primary healthcare reform, which was mandated to ensure equitable access to seven important areas: health promotion, illness prevention, health maintenance, home support, long-term care, community-based rehabilitation and pre-hospital emergency medical services. There is also a need to continue successful initiatives, such as shifting non-acute resources from hospitals to FIGURE 2: Total Health Expenditures by Use of Funds, 2010. Adapted from http:// secure.cihi.ca/cihiweb/products/drug_expenditure_2010_en.pdf community-based primary healthcare clinics with inter-professional teams and disease-oriented collaborative practices. Finally, it is important to continue to improve access to care through the implementation of successful wait-time initiatives stemming from The Canada Health Act and the Canada Health Transfer remain the activities of provinces from the previous agreement.6 two of the most important policy levers to develop and implement lasting healthcare reform. As pressure begins to mount on The Health Accord could also have provided an opportunity to one of the most cherished pieces of the Canadian identity, there is expand the Canada Health Act beyond hospital and physician a need for national leadership, not political trepidation. Universal services. The most significant of the potential expansions is argu- and equitable healthcare is important to all Canadians. A Canada ably the creation of a national pharmacare program, which was Health Transfer without federal guidelines or equalization payfirst recommended in 1964 by the Royal Commission on Health ments raises the possibility of creating a patchwork system with Services and for which evidence and support has only continued no strategic priorities and no efforts to address inequities across to grow.7 Of all countries within the Organization for Economic the country.
Canada Health Act. Department of Justice Canada. 1985.
First Minister’s Meeting on the Future of Healthcare 2004. Health Canada. 2004.
Matier, C. Renewing the Canada Health Transfer: Implications for Federal and Provincial-Territorial Fiscal Sustainability. Ottawa: Office of the Parliamentary Budget Officer. 2012.
Gauthier, J. The Canada Health Transfer: Changes to Provincial Allocations. Ottawa: Office of the Parliamentary Budget Officer. 2012.
Coulombe S. Economic growth and provincial disparity: A new view of an old Canadian problem. 2009.
Postl B.D. Final report of the federal advisor on wait times. Health Canada. 2006.
Romanow, R.J. Building on Values: The Future of Healthcare in Canada. Ottawa: Commission on the Future of Healthcare in Canada. 2002.
Gagnon, M.A & Hebert, G. The Economic Case for Universal Pharmacare: Costs and Benefits of Publicly Funded Drug Coverage for All Canadians. Canadian Centre for Policy Alternatives. 2010.
Drug Expenditure in Canada, 1985 to 2010. Canadian Institute for Health Information. 2010
The Meducator | March 2012
R ESEARCH I NSIGHT Childcare as Healthcare: Parents’ Perceptions of Enriched Early Childhood Experiences Regina DeLottinville Bachelor of Science in Nursing, Class of 2011 Regina is a Registered Nurse and a recent graduate from the Bachelor of Science in Nursing Program. Her research project largely concerned social determinants of health, and more specifically, early childhood development. She has spent the past year exploring local parents’ perceptions and opinions about the importance of enriched early childhood experiences. The focus of this research was to describe health benefits of enriched early childhood development that may shape health behaviours later in life.
CHILDCARE AS HEALTHCARE: WHAT DO PARENTS THINK?
growing interest in analyzing the short-term and long-term beneficial effects of early childhood development programs. 5
he concept of social determinants of health is widely consid- Although there are emerging public health initiatives that recogered to be the cornerstone of practice in the emerging and nize favorable outcomes from early childhood development progrowing fields of public healthcare and health promotion. Health- grams, some aspects remain unclear. Do parents view access to care professionals along with the general public are becoming in- early childhood development programs as an important determicreasingly aware that good health is not simply a matter of good nant of child health? How do parents perceive the significance genes and the availability of healthcare resources. Rather, it is a of enriched childhood experiences (such as the ones obtained by summative outcome of many interrelated social, economical and attending Ontario Early Years Centers) in contrast to other health societal factors, such as income, housing, employment conditions, determinants? Although there are many factors that influence a child’s enrollment and attendance, the final decision to introduce education and nutrition. the child to these programs is made by their primary caregivers. So far, early childhood development has been clearly identified As such, it is important to understand how parents prioritize the as one of the major social determinants of health. Although the opportunities for their child’s growth and development. So far, health benefits and value of early childhood education may not be the results are not particularly optimistic. A survey conducted by as obvious as other social determinants (such as income or hous- Toronto Child Development Institute found that “less than half ing conditions), many of today’s public health researchers agree of the parents [interviewed] are knowledgeable about providing that experiences during pregnancy as well as early childhood have enriched, sensitive environments for their young children”.6 a profound effect on health behaviour and outcomes later in life.1 Not surprisingly, positive stimulation early in a child’s life can The introduction of the Ontario Early Years Centers (OEYCs) iniprovide a solid foundation for healthy choices and practices that tiative is an attempt to bridge the gap between the differing levels can continue into adulthood. From a primary health perspective, of positive developmental stimulation children receive at home. investing in early childhood development can be a powerful tool Currently, there are over a hundred OEYCs in Ontario that prothat has the potential to prevent adolescent pregnancies, tobacco vide a wide range of services to parents and their children from 0 use and substance abuse in adulthood, and a number of learning to 6 years of age free of charge. The initiative is fully funded by disabilities.2 Many beneficial health habits, such as eating sensibly the Ontario government and offers educational and informational and exercising, are strongly influenced by exposures in early child- resources for parents, as well as opportunities for their young chilhood, and in turn may have the potential to reduce the risk of dren to learn through play.7 Public Health Nurses, as well as allied diabetes and cardiovascular disease in adults.3 Particularly among healthcare professionals, play a very important role in articulatchildren from low-income families, high quality childcare helps ing and delivering a strong message about health promotion to to address many social inadequacies by promoting intellectual families that visit OEYCs. As such, sufficient knowledge regarding and interpersonal stimulation. In turn, children exposed to the the role of early childhood development and social determinants beneficial effects of enriched development may feel empowered of health is a cornerstone of public health practice. Today, health and enabled to make healthy choices as adults.4 Currently there is advocacy and policy development initiatives strongly benefit from
deepened knowledge of the participants’ perspective of key determinants of health. In fact, research that examines participants’ perspectives can be meaningfully used to develop effective health policies.
STUDY METHODS: QUALITATIVE FRAMEWORK It is evident that parents play a crucial role in introducing children to enriched early childhood experiences, and this, in turn, may have a powerful effect in shaping a child’s positive health behaviours later in life. The focus of the current research project is to explore local parents’ opinions and perceptions about early childhood education and its importance. The author used a qualitative study design because it serves as an effective source of evidence in public health practice.9 Within the qualitative framework, the method of interpretive description was utilized to describe and increase existing understanding of the phenomena. This simple yet unrestrictive method facilitates deeper understanding of the healthcare issue, as well as explores research participants’ values and beliefs.10 A total of 12 parents whose children attend OEYCs were interviewed for this study, and the participants were purposefully recruited from three centers that serve demographically, culturally and socioeconomically diverse neighbourhoods in Hamilton, Ontario. Data were collected during the course of approximately 30-40 minute long interviews, which were audio-recorded, transcribed verbatim and later analyzed using NVivo 8.0 software.
RESEARCH FINDINGS: SOCIAL AND HEALTH BENEFITS OF ENRICHED EARLY CHILDHOOD DEVELOPMENT The parents who participated in the research study unanimously stressed that they perceive early childhood development as very important. Such findings could be due to the fact that the participants were recruited and interviewed while their children were attending specialized child development centers. Nonetheless, one of the goals of the study was to describe the specific ways that early childhood experiences can benefit child health and development, as viewed by the parents. According to the participants, the developmental benefits of early childhood experiences were limited to mainly social and intellectual aspects, while health benefits were much broader and included health education regarding nutrition and hygiene, opportunities for activity and exercise, improved immunity through exposure to other children, and access to health services. The examples of such benefits are summarized in Table 1.
Development - Social
Opportunity to interact with other children; expansion of social support network for the parents
Development - Intellectual
Value through learn and play; “Domino effect” of staggered intellectual benefits
Health - Nutrition
Education about healthy food choices for children; nutritious snacks supplied by child development centers
Health - Hygiene
Hygiene education and reinforcement amongst children, particularly handwashing
Health - Immunity
Short-term benefit of “immunity boost” through exposure to other children
Health - Activity and Exercise
Specialized activity, exercise programs and equipment; access to the swimming pool and the gym
Health - Access to Health Services
Opportunities for parents to obtain health education and health teaching: referrals to various healthcare professionals
TABLE 1: Summary of early childhood education benefits, as perceived by parents participating in the research study.
However, some participants demonstrated considerable difficulty articulating health benefits. Many described their perception of health as “eating right and exercise,” and struggled with further definitions. Additionally, the described health benefits were viewed as being short-term and immediate, such as nutritional knowledge and improved immunity. As a social determinant of health, early childhood development has both short-term and long-term benefits. The investment into early childhood development yields long-term health advantages by lowering the rates of learning disabilities, mental illness and substance abuse in adulthood, and preventing adolescent pregnancies.1,11 Parents recognized the value of early childhood education on young children, but did not perceive it as being an influential factor for their children’s health later in life. From the perspective of primary health framework, the long-term value of early childhood development and its effect on health in particular need to be better communicated to parents. Healthcare professionals can play a vital role in transmitting these findings and can thus improve participation rates in enriched developmental programs.12
Although the study focused on the benefits of early childhood development on child health, the participants stated that such programs were beneficial for parents as well. Frequently cited advantages included better bonding with the child and understandDuring the interviews, the participating parents mainly stressed ing the child’s needs, as well as an opportunity to socially interact developmental benefits of early childhood education programs, with other parents, thus promoting knowledge exchange. Further and recognized their long-term social and intellectual value. studies are needed to determine improved parental outcomes
RESEARCH IMPLICATIONS: CHILDHOOD DEVELOPMENT IS BENEFICIAL, NOW WHAT?
The Meducator | March 2012
from children’s participation in early childhood programs. However, these findings need to be shared with the parents and health policy stakeholders in order to improve attendance at childhood development centers, and in dealings with the issue of underutilization of childhood development programs.
perfect example of “upstream” thinking: it makes sense to dedicate sought-after healthcare resources towards shaping positive health behaviours and disease prevention, rather than being confronted by the complex necessity of disease treatment.15 As such, understanding parents’ perceptions of early childhood development services has important implications for public health practice. This foundational research can shape the delivery and promotion of early health education—a practice that extends beyond individual health benefits and emphasizes the preventive role of the healthcare system in addressing health and disease-related outcomes.
Although healthcare professionals describe early childhood development as a foundation that impacts individual health behaviours later in life, parents and caregivers may not be fully aware of the full spectrum of developmental and health benefits that it brings.13 OEYCs offer fully government-subsidized childhood development services, yet certain centres remain underutilized in some areas, despite noticeable efforts on the part of operational ACKNOWLEDGEMENTS staff to expand attendance, particularly amongst multicultural, francophone, and aboriginal communities.14 It appears that there I thank Linda O’Mara, RN, PhD for invaluable guidance and is a lack of awareness among the public, in that they perceive par- research mentorship provided throughout the project. I would ticipation in early childhood development programs as simply a like to acknowledge all the parents that participated in the study, form of childcare, and not as a potentially advantageous health and thank Lauren Brydges, R.E.C.E. and Gayle Reese, E.C.E.C. promotion activity. The value of enriched early childhood devel- for facilitating access to Ontario Yearly Years Centers through opment may not seem very apparent at first glance, yet its im- which participants were recruited. This work was supported portance should not be underestimated. From the public health by the Canadian Institutes of Health Research (CIHR) Health perspective, the investment in early childhood education may be a Professional Student Research Award.
Reviewed by Dr. Linda O’Mara, RN, PhD Dr. Linda O’Mara is an Associate Professor at McMaster University School of Nursing. Her primary research interests are currently in public health and primary care collaboration, adolescent health promotion, and nursing education. Currently, she is the site lead of a multi-year study that focuses on public health and primary care collaboration.
Smith-Chant, B. Early childhood education and health. (2009). In Raphael, D. (Ed.), Social determinants of health. (2nd ed.), (pp. 143-156). Toronto: Canadian Scholars’ Press.
Healthy child development. (2003). Retrieved from http:// www.phac-aspc.gc.ca/ph-sp/determinants/determinants-eng. php#healthychild
Canadian Nurses Association. (2005). Social determinants of health and nursing: A summary of the issues. Retrieved from http://www.cnaaiic.ca/CNA/documents/pdf/publications/ BG8_Social_Determinants_e.pdf
Thorne, S., Kirkham, S. R., & MacDonals-Emes, J. (1997). Interpretive description: A non-categorical qualitative alternative for developing nursing knowledge. Research in Nursing & Health, 20(1), 169-177.
What determines health? (2008). Retrieved from http://www. phac-aspc.gc.ca/ph-sp/determinants/index-eng.php
Williams, J., & Holmes, C.(2004). Children of the 21st century: Slipping through the net. Contemporary Nurse, 18(1-2), 5766. Retrieved from http://www.atypon-link.com.libaccess.lib. mcmaster.ca/EMP/doi/abs/10.5555/conu.2004.18.1-2.57
Ontario Children’s Secretariat. (1999). Early Years Study. Toronto: Publication Ontario.
Windsor-Essex County (2007). Ontario Early Years Center Service Plan, 2007-2008. Retrieved from http://www.citywindsor. ca/DisplayAttach.asp?AttachID=8764
Gehlert, S., Sohmer, D., Sacks, T., Mininger, C., McClintock, M., & Olopade, O. (2008). Targeting health disparities: A model linking upstream determinants to downstream interventions. Health Affairs, 27(2), 339-349. Retrived from http://www.ncbi. nlm.nih.gov/pmc/articles/PMC2494954/
Canadian Institute of Child Health. (2004). The health of Canada’s children – A CICH profile: Income inequity. Retrieved from http://www.cich.ca/PDFFiles/ProfileFactSheets/English/ Incomeinequity.pdf
Thomas, H., Camiletti, Y., Cava, M., Feldman, L., Underwood, J., & Wade, K. Effectiveness of parental groups with professional involvement in improving parent and child outcomes (Public Health Practice Project Report). (1999). Retrieved from http:// www.health-evidence.ca/articles/show/16149
Child Development Institute Survey. (2008). Retrieved from http://www.childdevelop.ca/thirdpagefile/healthy_child_development/oeyc/index.html
Ontario Ministry of Children and Youth Services: OEYC Locations. (2009). Retrieved from http://www.children.gov.on.ca/ htdocs/English/topics/earlychildhood/oeyc/ locations/index. asp.
Jack, S. (2006). Utility of qualitative research findings in evidencebased public health practice. Public Health Nursing, 23(3), 277-283.
C RITICAL R EVIEW Ciliary (Dys)function in Human Disease: Mapping the Ciliogenesis Pathway Mustafa Ahmadzai Honours Biology & Pharmacology Program (Co-op), Class of 2012 Laboratory of Dr. William Tsang, Institut de Recherches Cliniques de MontrĂŠal The centrosome coordinates formation of the microtubule network, a key component of the mammalian cytoskeleton. Aside from its supporting role in separating genetic material during cell division, the centrosome facilitates the formation of cilia (ciliogenesis) in non-dividing and differentiated cells. Cilia may be motile or non-motile, participating in a range of physiological activities including mucociliary transport, hearing, vision and kidney filtration processes. Ciliopathies occur when cells fail to undergo ciliogenesis or when cilia are improperly formed, affecting all of these functions to varying degrees. While there is increasing emphasis on the genetic factors contributing to these ciliopathies, many proteins involved in the cilia formation program remain elusive. The use of gene knockdown and functional assays are indispensable tools in determining how various proteins contribute to the onset of ciliopathies, ultimately laying the foundation for the development of future gene- and drug-therapy options.
icrofilaments comprise linear polymers of actin proteins Microtubules are composed of alpha- and beta-tubulin heterodithat maintain cellular shape. The expansive actin network, mers that polymerize into tubular structures.3 In mammals and which is directly involved in cellular movement, responds to most eukaryotic organisms, microtubule assembly begins at the chemical signals released during development, immune events, centrosome, which serves as the cellâ€™s microtubule organizing and other processes pertinent to cell growth and survival.1 It is centre (MTOC). As a cytoplasmic organelle, the centrosome is well known, for instance, that immune factors stimulate rear- integral to cell division; mitotic microtubules anchor and separate rangement of the actin architecture in neutrophils during inflam- chromosomal DNA, radiating outward from the MTOC across mation, facilitating their amoeboid movement and the elimina- the divisional axis (Figure 1).3,4 The role of the centrosome is far tion of invading pathogens.2 Microtubules comprise the second more robust, however, and extends well beyond the separation of distinct class of cytoskeletal filaments that complements the actin genetic material in mitotic cells. In fact, the centrosome facilitates network. formation of the cilium, a long slender structure that projects out-
FIGURE 1: Microtubule anchoring during mitosis. Several microtubule sub-types facilitate separation of daughter chromatids during mitosis. Aster microtubules
radiate outwards from the MTOC during mitosis and polar microtubules span across opposite poles of the cell. Kinetochore microtubules associate with daughter chromatids, facilitating their separation.6
The Meducator | March 2012
ward from the surface of the cell into the surrounding environment.5
CILIA AND HUMAN DISEASE
mechanism, is anchored to the inner cell surface.6 Here, it polymerizes nine sets of microtubule doublets in a circular arrangement, which forms the ciliumâ€™s skeleton (Figure 2). In addition, most motile cilia and some primary cilia possess a central set of microtubules doublets, which is needed in order for the cilium to bend as a result of interactions with various microtubule-associated motor proteins, such as dynein.6,7
The physiological roles of cilia have been well studied in humans, and most human cells are now thought to possess cilia. These can range from cells of the fallopian tube, which sweep the egg through Loss-of-function gene mutations that compromise cilium formathe reproductive tract, to tracheal epithelial cells, which sweep de- tion can misdirect growth and transcription factors pertinent to bris out of the airways.7 In large part, cilia are classified according organ development. The left-right asymmetry of the human body to their function. Those involved in mucociliary transport in the plan, for instance, is dependent on the whip-like beating of cilia trachea, for instance, are said to be motile since they actively bend in the extra-embryonic tissue during early stages of embryogenand impart force on objects within their vicinity. In contrast, non- esis.12 Without the left-ward sweeping of these growth factors by motile (primary) cilia function as chemo- and mechano-sensors motile cilia, the heart fails to develop on the mid-left side of the by transducing external stimuli into a cellular response. Audi- body and the larger lobe of the liver fails to develop on the right.12 tion, for example, occurs when mechanical sound waves bend hair cells possessing cilia in the inner ear. This electrically excites Until recently, the roles of motile and non-motile cilia in human the hair cells, and stimulates neurons and downstream neuronal diseases were poorly characterized and few ciliogenic proteins had networks, culminating in what is perceived as sound.7 Dysfunc- been studied. Now, advances in experimental techniques permit tion of motile and non-motile cilia has been consistently linked to scrutiny of the genetic mechanisms that contribute to ciliopathies. various developmental and long-term defects, motivating greater Mutations in several genes involved in ciliogenesis have conseresearch into the genetic basis of cilia formation (ciliogenesis).8 quently been linked to ciliopathies through genome-wide and population-based studies concerning Senior-Loken, Meckel-GruCiliogenesis occurs primarily in non-proliferating (quiescent) ber, and Bardedt-Biedl syndromes,8 which involve auditory, visual and differentiated cells, and is facilitated by the mother centri- and renal system complications, as well as severe developmental ole of the centrosome. During interphase, the mother centri- defects, such as anencephaly and mental retardation.9,10 Despite ole migrates to the cell membrane and, through an unknown these findings, little is known regarding the mechanism of cilium formation. Before gene therapy or pharmacological interventions can be developed, researchers must therefore elucidate the key players involved in ciliogenesis.
DECODING THE CILIOGENESIS PROGRAM: RECENT ADVANCES AND BREAKTHROUGHS
FIGURE 2: Microtubule arrangements in cilia. After migrating to the cell membrane, the mother centriole (indicated as the basal body) facilitates formation of the cilium. The cross-sectional view of the basal body indicates a circular pattern of microtubule triplets arranged along the structure circumference. In contrast, the cilium possesses nine doublets of microtubules. Typically, microtubules of the cilium interact with a host of microtubule-associated proteins like dynein, which is a motor protein. The central doublet of microtubules participates in bending of motile and some primary cilia.9
Much like proteins involved in regulating cell division checkpoints, key players that promote or inhibit ciliogenesis have been identified.10,11 In a recent study, Tsang et al. identified the mechanism by which centrosomal proteins interact to modulate ciliogenesis in retinal pigmented epithelial cells.12 Using this cell line, the group demonstrated that interactions between centrosomal protein of 110 kDa (CP110) and centrosomal protein of 290 kDa (Cep290) are necessary in order to suppress cilium formation. Although it was previously known that CP110 participates in centrosome replication, centrosome separation, cytokinesis and ciliogenesis, the exact molecular mechanism(s) by which CP110 modulates these different biological processes were not fully understood. From a clinical standpoint, Cep290 gene mutations have also been extensively linked to various ciliopathies, like nephronophthisis, which is the leading cause of pediatric kidney failure.13 Extensive post-translational modifications of centrosomal microtubules allow them to be detected by indirect immunofluorescence techniques, using antibodies directed against the modified tubulin sub-units coupled with fluorophores. Once
exposed to light, protein-bound antibodies reveal the proteinâ€™s associates with Cep290. Furthermore, unlike wild-type CP110, relative position in the cell by re-emitting light at a visible overexpression of a CP110 mutant incapable of binding Cep290 wavelength. In parallel, loss of function mutations associated can no longer inhibit cilia formation in the affected population. with ciliopathies can be emulated using silencing RNA (siRNA), Collectively, these findings suggested that Cep290 is inherently a class of double-stranded RNA molecules that interferes with ciliogenic and that CP110 is required in order to suppress mRNA and protein expression. Importantly, siRNA provides ciliogenesis.15 a considerable degree of control over gene-expression and is a valuable tool for studying gene function. This experimental approach provided an elegant means of elucidating one component of the cilia formation program. Combining these techniques, Spektor et al. and Tsang et al. Presently, there are few therapeutic options available for found that siRNA-mediated depletion and overexpression of individuals suffering from centrosomal disorders. Undoubtedly, a CP110 augmented and suppressed cilia formation, respectively, deeper understanding of the basic science underlying ciliogenesis suggesting that CP110 is a negative regulator of ciliogenesis.12,15 is critical to the development of drug- and gene-therapy options In striking contrast, Cep290 promotes cilia formation, since later on. To these ends, further research is merited in order to siRNA-mediated knockdown of Cep290 leads to inhibition elucidate missing stages of the cilia formation pathway, including of cilia formation. They also examined protein interaction the identity and properties of the numerous proteins involved in using co-immunoprecipitation and found that CP110 readily the process.
Reviewed by Dr. William Tsang, PhD Dr. Tsang is Assistant Research Professor at the Institut de recherches cliniques de Montreal, Director of the Cell Division and Centrosome Biology research unit, Assistant Research-Professor in the Department of Pathology and Cell Biology at the Universite de Montreal, and adjunct professor in the Department of Medicine at McGill University. His group studies cilia biology and ciliopathies and employs a variety of techniques, such as immunofluorescence microscopy, flow cytometry and mass spectrometry. The valuable mechanistic insights gained from his research will be integral to the development of novel diagnostic and therapeutic interventions for ciliopathies.
Ballestrem C, Wehrle-Haller B, Imhof BA. Actin dynamics in living mammalian cells. J Cell Sci 1998;12, 1649-1658.
Weiner OD, Servant G, Welch MD, Mitchison TJ, Sedat JW, Bourne HR. Spatial control of actin polymerization during neutrophil chemotaxis. Nat Cell Biol 1999;1(2), 75-81.
Nogales E. A structural view of microtubule dynamics. Cell Mol Life Sci 1999;56(1-2), 133-42. Tanaka TU, Desai A. Kinetochore-microtubule interactions: the means to the end. Curr Opin Cell Biol 2008;20(1), 53-63.
Lee K, Battini L, Gusella GL. Cilium, centrosome and cell cycle regulation in polycystic kidney disease. Biochim Biophys Acta 2011;1812(10), 1263-71.
Lodish H, Berk A, Kaiser CA, Krieger M, Scott MP, Bretscher A, Ploegh H, Matsudaira P. Microtubule Structures. In Freeman WH, editors. Molecular Cell Biology. 6th ed. New York: Freeman and Company; 2007.
Satir P, Christensen ST. Overview of structure and function of mammalian cilia. Annu Rev Physiol 2007;69, 377-400.
Christensen ST, Pedersen LB, Schneider L, Satir P. Sensory cilia and integration of signal transduction in human health and disease. Traffic 2007;8(2),97-109.
Morales CR. Histology of the Respiratory System [homepage on the Internet]. Montreal, Canada: McGill Molson Medical Informatics; [updated 2008; cited 2012 February]. Available from: http://alexandria.healthlibrary.ca.
Davenport JR, Yoder BK. An incredible decade for the primary cilium: a look at a once-forgotten organelle. Am J Physiol Renal Physiol 2005;289(6), F1159-69.
Badano JL, Mitsuma N, Beales PL, Katsanis N. The ciliopathies: an emerging class of human genetic disorders. Annu Rev Genomics Hum Genet 2006;7, 125-48.
McGrath J, Brueckner M. Cilia are at the heart of vertebrate leftright asymmetry. Curr Opin Genet Dev 2003;13(4), 385-92.
Tsang WY, Bossard C, Khanna H, PerĂ¤nen J, Swaroop A, Malhotra V, Dynlacht BD. CP110 suppresses primary cilia formation through its interaction with CEP290, a protein deficient in human ciliary disease. Dev Cell 2008;15(2), 187-97.
Coppieters F, Lefever S, Leroy BP, De Baere E. CEP290, a gene with many faces: mutation overview and presentation of CEP290base. Hum MutaT 2010;31(10), 1097-108.
Spektor A, Tsang WY, Khoo D, Dynlacht BD. Cep97 and CP110 suppress a cilia assembly program. Cell 2007;130(4), 678-90.
The Meducator | March 2012
C RITICAL R EVIEW University Campus Peer Support Centres: Benefits for Student Emotional and Mental Well-Being Ikdip Kaur Brar1*, Jae Eun Ryu2*, Kamran Shaikh3*, Ashlie Altman4, Jeremy Ng5 Motivation for McMaster Life Sciences, Class of 2012; 2Arts and Science, Class of 2014; 3Life Sciences, Class of 2013; Biology and Pharmacology Co-Op, Class of 2012; 5Biology, Class of 2013 *Authors with equal contributions 1 4
Within undergraduate student populations, there has been a rise in the incidence of mental health issues such as depression and anxiety. These problems have been shown to negatively impact emotional wellbeing and academic success.1 Many elements of the undergraduate experience, including stressful transitions from high school to first year, contribute to mental health problems amongst this student body. Peer support is a relatively recent resource for universities to address growing mental health concerns on campus. Peer support, which involves trained students who voluntarily provide emotional support to peers, offers a unique function to student mental health. It can be useful throughout a student’s undergraduate career and is also beneficial to those who provide the support. While it may not replace professional mental health services, it may be a significant addition to the existing student wellness support systems on university campuses today.
UNDERGRADUATE STUDENTS’ MENTAL HEALTH PROBLEMS AND POTENTIAL SOLUTIONS
year prevalence rate of mental illness at 39% in 2011.1 With up to 25% of students in university or college reporting symptoms of depression, and approximately 10% of students having suicidal thoughts, interventions should be considered to improve emotional wellbeing on campuses.1
tudents in university and college, especially those in first year, face many hardships throughout their studies. They may have difficulty dealing with numerous issues, including relationships A survey asking questions relating to perceived stress, internal rewith friends, family, and significant others, as well as academic sources, and social support provided to 2000 university students stress that develops as their term progresses (Figure 1). These is- found a strong positive correlation between perceived feelings of sues make them vulnerable to mental health issues and range from stress and low mental health.8 A lack of proper services to help mild, with students feeling anxious or lonely, to severe, in the alleviate such stress and emphasis on developing protective facform of clinical depression.1,2 These feelings often have a nega- tors such as mastery and self-esteem among the student populative impact on academic performance, retention, and graduation tion can have a negative impact on the overall mental health of rates.3 Additionally, depression and anxiety have been linked to students on campus.8 Services that can help to reduce the stress higher rates of suicide, substance abuse, troubled relationships, that students experience, and to increase mental and emotional and difficulties with sexual identity.1 The Centers for Disease wellbeing, include professional counsellors, psychiatrists, and Control and Prevention reported the suicide rate for young adults peer support centres. Professional counsellors and psychologists to be on the rise, specifically for the 15–19 year age group and are powerful resources students can use to improve and maintain the 20–24 year age group.4 This implies that risk for suicide is a their mental health. Researchers used a questionnaire to survey significant problem during high school and persists among young undergraduate students at the University of Birmingham.9 They adults in university and college.5 Among adults, those aged 18-24 allowed students considered as high-risk for dropping out to unhave the highest reported suicidal tendencies.6 Researchers with dergo professional counselling and found that 15 out of 16 high the World Health Organization’s world mental health survey ini- risk students who underwent counselling successfully completed tiative have shown that identifying and treating depression early their first year.9 Their results suggest that students who reported may reduce the serious consequences of depression and prevent feeling overwhelmed and stressed were less likely to drop out of the consideration of suicide.7 Most alarming of all, an epidemi- university or college after having received professional support.9 ological study by Mackenzie et al. through the College Health Thus, professional counselling can be an effective tool in increasIntervention Projects involving 1,622 Canadian post-secondary ing student retention rates (Figure 1). students found that the 15-21 age category had the highest past-
Overview of the Student Support Process Common Adversities Faced by Incoming Post-Secondary Students:
Amplification of Prior Mental Health Issue
Lost of Social Support
Peer Support Session(s)
Lack of Knowledge and/or Preparation for the University Experience
Unforeseen Academic Hardship
Cost-Effective to Student
Lessened WaitTime to Gain Support
Positive Intervention Provided Before the Need for Professional Counselling
Positive Intervention that Encourages Professional Counselling
Comfortable and Safe Environment Self-Realization and Identification of Disconcerting Thoughts and/or Behaviours
Provision of Support from Diverse Perspectives
Improvement in Ability to Address Adversity
Professional Expertise in Mental Health Illness
A Referral Point when Peer Supporters are Faced with Addressing an Issue Beyond their Scope of Training
FIGURE 1: An Overview of the Student Support Process. The transition into post-secondary education is often filled with various adversities, and yet, any one or combination of factors may require students to seek external support.1,2 In the post-secondary setting, students generally have two institution-established options: peer support session(s) and professional counseling. Student-to-student peer support is unique in that it has the ability to both provide intervention to the supported student so that they may never require professional counselling, as well as encourage those that require professional counseling to identify the need and take that initiative.17, 23 Should these resources be made successfully available to students in need, both options are able to provide the support-seeking student with various benefits to assist them with their successful transition to the university experience.12
emotional wellbeing, but peer support may be more feasible when professional services cannot be utilized (Figure 1).12
DEFINING AND UNDERSTANDING THE PROCESS OF PEER SUPPORT Peer support can be divided into several categories based on three criteria: the medium in which it is conducted; the individuals running the service; and the administration in control of the service.13 One of the major benefits of peer support is that it offers a comfortable environment for the student seeking support. This is due to the fact that the students providing support may have encountered similar life experiences and can relate to them.14 Students providing peer support on university and college campuses have endured many of the stressors that accompany being an undergraduate student. As a result, peer supporters can offer authentic empathy and validation to fellow peers, which can make students feel more comfortable and receptive to the advice and suggestions presented.15 Furthermore, peer support establishes a foundation for an open conversation or discussion aimed at facilitating a desirable change.13 The council of Higher Education Quality concluded that the effectiveness of peer support lies in the fact that students are ultimately in the best position to recognize the problems of their peers.16 This kind of support received by the students can bring a positive change to the emotions that are currently experienced, since it can reduce the sense of loneliness, frustration and other negative feelings. If necessary, the desirable change may involve seeking professional help.13 This is shown in a report that suggests peer support is most successful when diverse perspectives and competencies of supporting students, as well as those of academic and guidance staff, are brought together to take on the complex, multi-dimensional issues encountered by students (Figure 1).17
THE DIFFICULTY OF TRANSITIONING FROM HIGH SCHOOL TO UNIVERSITY
A longitudinal study examining university expectations in freshmen followed 226 Canadian undergraduates before and half-way However, professional counselling services are also accompanied through their first-year.18 The researchers found that the most efby high service costs and wait times. Institutional budget cuts and fective peer programs aim to prepare students for the challenges administrative adjustments have put professional counselling ser- that they may face throughout university or college.18 At the same vices under financial scrutiny.10 Additionally, it has been shown time, they provide students with effective strategies that can be that students will refrain from seeking professional assistance employed to overcome these challenges.18 Considering these facts, when wait times and appointments are involved.11 While provid- it is vital to establish a peer support system that could provide ing professionally trained counsellors for all students who require guidance to help students overcome problems.19,20 such services would be ideal, the reality is that this cannot always be met from a logistical point of view. As a result, peer support Major life transitions, such as changing schools, can be stressful centres have recently been explored as a potentially flexible and since they physically sever existing sources of social support, ininexpensive adjunct to professional counselling. A report that in- cluding family and friends.2 These changes may lead to homesickvestigates this sought to explore a particular model of peer support, ness, which is one of the most frequently reported concerns of recent academic research on its effectiveness, and how these ini- first year college and university students (Figure 1). Homesickness tiatives can be expanded or improved upon to better address the can be problematic if experienced for prolonged periods of time.21 needs of mental health in university settings.12 The report suggests Students who are homesick find it difficult to adapt and perform that both peer support and professional services are beneficial to in new situations because they are far from familiar environments
The Meducator | March 2012
such as their family setting or community.22 Depression and re- Interestingly, peer support has shown to be beneficial for both current thoughts about death or suicide have most often been as- those providing and those receiving support.24 One study trained sociated with students suffering from homesickness.21 Researchers lay people to be peer supporters and used statistical analysis based have found that most first year university students who display on questionnaires to determine benefits of peer support on the signs of insecurity and poor social skills before starting their un- supporters.25 Their research showed that after one- and two-year dergraduate education have a greater tendency to exhibit signs periods of providing support, the volunteer peer supporters reof homesickness during the first few weeks of their first term.22 ported increased psychosocial performance and well-being.25 Counselling or peer support may be an effective way to help stu- Furthermore, individuals who became peer supporters reported dents adjust to the university environment since it is capable of feeling more self-aware.25 Another study used a questionnaire relieving some of the anxiety, depression and stress experienced survey to peer supporters in UK schools.19 The students noted by first year students. Peer support can provide students with the that peer supporters had acquired useful skills and were pleased to skills necessary to manage stress independently. This is done so by show that they cared presumably about their peers.19 Researchers discussing strategies that are specific to the problem the student is also noted that peer supporters experienced a “gratifying sense of encountering (Figure 1).23 responsibility” associated with their roles.24 They also identified qualitative research conducted by another researcher indicating peer supporters show increased self-esteem and confidence.13
THE EFFECT OF PEER SUPPORT SERVICES ON CAMPUS THROUGHOUT STUDENTS’ UNDERGRADUATE CAREERS
THE POTENTIAL OF PEER SUPPORT
Not only is peer support an effective way to combat the stress In recent years, there has been a rise in the number of univerand depression that can accompany the transition from high sity students reporting mental illnesses, indicating a greater need school to university, it can also be useful throughout a student’s for institutions to expand their mental health support services.11 undergraduate career.2 Researchers conducted a web-based survey Peer support centres can be beneficial in improving the emotional at a large university in 2005 and 2007 and screened the results well-being of the student population. However, the issue is that for symptoms of mental disorders.23 Their results indicated that many students with mental health issues do not seek professional 60% of students suffering from at least one mental health issue counselling or peer support services even if they are available on remain afflicted by the same issue two years later.23 This suggests campus.11 The lack of interest in using such professional services that mental health problems can be long-lasting and may persist may be explained by a lack of student knowledge about their exthroughout one’s academic career. Additionally, the study revealed istence or about the services provided.11 A peer support service that less than half of those with a mental health problem received offering both drop-in, immediate support, and the ability to book effective treatment within the two-year time span.23 Only 32.9% appointments would ensure that students can access peer supof those surveyed in 2005 and 42.9% in 2007 had a perceived port services when they need them, without conflicting with their need to receive professional treatment.23 However, those who visit schedules. Through careful steps taken to design, develop, and peer support may benefit because peer supporters can help identi- establish a student-based peer support program, peer support has fy disconcerting thoughts and behaviours and urge those without the potential to be a valuable addition to mental health support a perceived need to receive professional help.20,24 In this case, peer services on university campuses.12 support can be a beneficial addition to student campuses alongside professional services. Reviewed by Dr. Debbie Nifakis, Ed.D., C.Psych Dr. Debbie Nifakis is a Psychologist and the Clinical Director of the Student Wellness Centre. She has practiced psychotherapy at university counselling centres for over thirty years. At McMaster, she co-developed and ran the first Peer Helper Program for over twenty years and has presented at conferences as an invited speaker on the benefits of Peer Helping in post-secondary institutions. About Motivation for McMaster Motivation for McMaster (MFM) was founded in January 2011 to provide motivational lectures free of charge to all McMaster undergraduate students. Believing that more could be offered to students, MFM designed and developed a student-to-student peer support program that was implemented in September 2011. After recruiting and training student peer supporters, MFM officially began providing peer support in October 2011. MFM’s volunteer team provides monthly motivational lectures and up to 25 hours of student peer support every school-week, and has logged more than 2000 hours since January 2011. Authors Ikdip Brar, Jae Eun Ryn, Kamran Shaikh, and Ashlie Altman are peer supporters at MFM. Jeremy Ng is MFM’s co-founder and director of the MFM peer support program. MFM may be contacted at email@example.com. Other Resources Other peer-based student support groups on campus include the following: The Student Success Centre, the Chaplaincy Centre, the Student Health Education Centre (SHEC), and the Queer Students Community Centre (QSCC). Professional counselling on campus is provided at the Student Wellness Centre (SWC).
Mackenzie, S, Wiegel, JR, Mundt, M, Brown D, Saewyc, E, Heiligenstein, E, et al. Depression and suicide ideation among students accessing campus health care. American Journal of Orthopsychiatry. 2011; 81(1):101-7.
Compas, BE, Wagner, BM, Slavin, LA, Vannatta, K. A prospective study of life events, social support, and psychological symptomatology during transition from high school to college. American Journal of Community Psychology. 1986; 14(3):241-57.
Kitzrow, M. The mental health needs of today’s college students: Challenges and recommendations. NASPA Journal. 2003; 41(1):165-79. Centers for Disease Control and Prevention. CDC surveillance summaries. Morbidity and Mortality Weekly Report. 2001; 50:1-34.
Kisch, J, Leino, EV, Silverman, MM. Aspects of suicidal behaviour, depression, and treatment in college students: Results from the spring 2000 National College Health Assessment survey. Suicide and Life Threatening Behavior. 2005; 35(1):3-13. Crosby, AE, Cheltenham, MP, Sacks, JJ. Incidence of suicidal ideation and behavior in the United States, 1994. Suicide and LifeThreatening Behavior. 1999; 29:131-39. Wang, PS, Angermeyer, M, Borges, G, Bruffaerts, R, Chiu, WT, De Girolamo, G, et al. Delay and failure in treatment seeking after first onset of mental disorders in the World Health Organization’s world mental health survey initiative. World Psychiatry. 2007; 6(3):177-85.
Bovier, PA, Chamot, E, Perneger, TV. Perceived stress, internal resources, and social support as determinants of mental health among young adults. Quality of Life Research. 2004; 3(1):16170.
Rickinson, B, Rutherford, D. Increasing undergraduate student retention rates. British Journal of Guidance and Counselling. 1995; 23(2):161-72.
Destefano, TJ, Mellott, RN, Petersen, JD. A preliminary assessment of the impact of counselling on student adjustment to college. Journal of College Counseling. 2001; 4:113-21.
Furr, SR, Westefeld, JS, McConnell, GN, Jenkins, JM. Suicide and depression among college students: A decade later. Professional Psychology: Research and Practice. 2001; 32(1):97-100.
Chatterton, S, Harris, J, Hill, S, Kingsland, L. Helping ourselves: Organizing a peer support centre. Ottawa: Health and Welfare Canada; 1988.
Solomon, P. Peer support/peer provided services underlying processes, benefits, and critical ingredients. Psychiatric rehabilitation journal. 2004; 27(4):392-401.
Mead, S, MacNeil, C. Peer support: What makes it unique? International Journal of Psychosocial Rehabilitation. 2006; 10(2):2937.
Hoffman, M, Richmond, J, Morrow, K, Salomon, K. Investigating ‘sense of belonging’ in first-year college students. Journal of College Students Retention: Research, Theory and Practice. 2002; 4(3):227-56.
Higher Education Quality Council. Guidance and counselling in higher education. London: Higher Education Quality Council; 1994.
Carter, K. & Mcneill, J. Coping with the darkness of transition: Students as the leading lights of guidance at induction to higher education. British Journal of Guidance and Counselling. (1998); 26(3):399-415.
Pancer, S. M., Hunsberger, B., Pratt, M. W. & Alisat, S. Cognitive complexity of expectations and adjustment to university in the first year. Journal of Adolescent Research. (2000); 15(1):38-57.
Naylor, P, Cowie, H. The effectiveness of peer support systems in challenging school bullying: the perspectives and experiences of teachers and pupils. Journal of Adolescence. 1999; 22(4):46779.
Varenhorst, BB. Why peer helping? The Peer Facilitator Quarterly. 1992; 10(2):13-7.
Shahmohammadi, N. Effectiveness of cognitive-behavioral management of stress on students’ homesickness. Mediterranean Journal of Social Sciences. 2011; 2(6):107-11.
Fisher, S, Hood, B. Vulnerability factors in the transition to university: Self-reported mobility history and sex differences as factors in psychological disturbance. British Journal of Psychology. 1988; 79:309-20.
Zivin, K, Eisenberg, D, Gollust, SE, Golberstein, E. Persistence of mental health problems and needs in a college student population. Journal of Affective Disorders. 2009; 117(3):180-5.
Cowie, H, Hutson, N. Peer support: A strategy to help bystanders challenge school bullying. Pastoral Care in Education. 2005; 23(2):40-4.
Schwartz, CE, Sendor, M. Helping others helps oneself: Response shift effects in peer support. Social Science & Medicine. 1999; 48:1563-75.
The Meducator | March 2012
C RITICAL R EVIEW The Vitamin D Gamble Andrew Webster Bachelor of Health Sciences (Honours), Class of 2015 Studies have shown that most Canadians are deficient in Vitamin D3. In addition to its role in systemic calcium regulation, Vitamin D3 is also proposed to be integral to the suppression of cancer, as well as to the regulation of certain immune and endocrine components. Many experts are seriously concerned that Health Canada’s current Vitamin D3 dosage recommendations are inadequate to facilitate these mechanisms. A bitter debate on dosage has ensued—largely between researchers and regulatory bodies such as Health Canada and the US Institute of Medicine—leaving health practitioners caught in the middle with contradictory directives and information.
itamin D is the colloquial term for Vitamin D3, a secosteroid vided evidence that dietary supplementation is an effective way to prohormone that is naturally produced in certain layers of the compensate for inadequate endogenous Vitamin D3 production. skin.1 It is endogenously synthesized from a naturally occurring As such, there is a unanimous agreement in the Canadian health precursor called 7-dehydrocholesterol (7-DHC), which under- science community that the nationwide deficiency can only be goes further conversion upon continued exposure of the skin to effectively overcome by ensuring Canadians include adequate Vimoderately intense light in the UV-B range.2 tamin D3 supplements in their diet.7
In addition to its well-known role in maintaining the mineral- At this point, however, the unanimity ends. Largely outside public ization of bone, research over the past few decades has unveiled view, a fierce debate has emerged over the definition of an “admultiple potential non-classic actions of Vitamin D3.3 Apart from equate” supplemental dose. On November 30, 2010, Health Cancausing severe bone disorders, deficiencies in Vitamin D3 are also ada and the US Institute of Medicine (IOM) co-released the conthought to contribute to the development of many life-threaten- troversial publication, Dietary Reference Intakes (DRIs) for Vitamin ing cancers, the emergence of a wide variety of autoimmune dis- D and Calcium.7 In this report, Health Canada and IOM took a orders, increased bacterial susceptibility, and the appearance of a conservative stance, recommending 600 IU of Vitamin D3 per day number of diseases resulting from hormone dysregulation (such as for all persons of 9-70 years of age, 400 IU for young children and diabetes and osteomalacia).3 infants, and 800 IU for adults over 70 years. It also set the Tolerable Upper Intake Level at 4,000 IU for those older than 9 years.7 Unfortunately, most Canadians live with insufficient levels of Vi- These dosage recommendations differ only slightly from those of tamin D3 in their bodies.4 Even in the southernmost extremities the Canadian Cancer Institute, which states that 1,000 IU per day of Canada, the latitude and quality of sun exposure during early is adequate for the majority of the adolescent and adult populafall to mid-spring does not provide sufficiently intense exposure tion.8 By contrast, a significant number of researchers in the field of the human skin to UV-B radiation.1 This results in minimal recommend substantially higher daily dosages of between 2,000endogenous Vitamin D3 production during these months. The 4,000 IU for those above 9 years. Many of them also believe that use of sunscreens, while important in reducing the risk of mela- the upper cap could be safely set to 10,000 IU before any toxic noma, inhibits the production of Vitamin D3 during the summer overdose effects are seen.9-11 Health practitioners—those who are months and further compounds this deficiency.2 tasked with providing advice to their patients—are caught in the middle, working with contradictory directives and information. In March 2010, Statistics Canada estimated that 1.1 million Canadians (approx. 4% of the Canadian population) had a Vitamin D3 deficiency so extreme that they were at risk of acquiring osteoNON-CLASSIC ACTIONS OF VITAMIN D3 porosis or osteomalacia if they were adults, and rickets if they were children.5 The study also found that 10% of Canadians had levels Why have so many researchers taken a seemingly radical stance that are inadequate for maintaining bone health, and that 77% of on Vitamin D3 dosage recommendations? Predominantly, many the population did not have appropriate serum levels by Health are worried that a number of the non-classic actions of the vitaCanada’s standards.6 min—including its purported role in suppressing carcinogenesis, maintaining the immune system, and regulating critical hormone Over the past few decades, hundreds of clinical studies have pro- levels—are not sufficiently facilitated when taken at low-dosages.
Vitamin D3 is thought to be involved in the suppression of vari- A major study recently conducted by the University of Maryland ous cancers, including those of endothelial tissue and bone, and postulated that the DNA-binding affinity of the RUNX2 tranpossibly breast, colorectal, and pancreatic cancers.3 The influ- scription factor is increased by non-hydroxylated Vitamin D3 in ence of Vitamin D3 on the latter three cancers is still debated and endothelial, bone, and breast cells.16 In osteoblast cells in the bone, merits further research, however, there are conflicting data from increased RUNX2 DNA-binding affinity amplifies the expression published epidemiological, geographical, laboratory, and clinical of cancer–suppressing proteins that stimulate immature osteoblasstudies.12 Regardless, it is generally agreed upon that adequate tic differentiation and inhibit rapid osteoblastic proliferation.13,16 levels of Vitamin D3 can assist in the successful differentiation of Within cancerous breast cells, it also ensures that such cells do not endothelial and bone cells and can suppress uncontrolled, rapid stimulate the metastatic cancerous development of osteoblasts— cell proliferation.13 thus helping to prevent the spread of cancer from breast to bone.16 Once produced or ingested, Vitamin D3 is initially inactive. It is Meta-analyses of clinical and community studies in the breast canrapidly hydroxylated in the liver to form the hormone 25(OH) cer field have found that Vitamin D3 supplement doses must be D3, and subsequently enters the circulation. In the kidneys, it is in the range of 2,000 IU and 3,000 IU per day to begin to see any hydroxylated on-demand once more, forming the active hormone reduced risks of cancer.17 In other areas, doses exceeding 1,000 IU 1,25(OH)2D3.1 The latter hormone binds with Vitamin D3 recep- are found to be necessary.9 tors (VDRs) that are located in a range of tissues.3 Vitamin D3 also plays a crucial role in regulating both the innate Many of the early cancer studies in the 1990s focused on the pro- and adaptive components of the internal immune system. Withtein-modulating nuclear activity of activated VDRs and the Reti- out appropriate levels of the compound, animals are found to noid X Receptor (RXR) heterodimer, as well as Vitamin D3-DNA have an increased susceptibility to bacterial infection, as well as intercalation.13 Given recent advancements in gene regulation to autoimmune disorders such as multiple sclerosis, rheumatoid research and analytical technologies, however, studies have also arthritis, Type I diabetes mellitus, inflammatory bowel disease, discovered VDR-independent activity of Vitamin D3.14 They have certain forms of lupus, and pre-natal islet cell autoimmunity.18 pinpointed a variety of pro-oncogenic and anti-oncogenic transcription factors that are actively regulated by non-hydroxylated The innate immune system is comprised of non-selective defense Vitamin D3.14 Many of these transcription factors are expressed mechanisms that destroy pathogens. Some of these mechanisms only in specific cell types, and hence the mechanisms of cancer- involve the use of proteins that damage the structural integrity suppression are thought to vary widely between different tissues.3 of bacterial cells.18 Vitamin D3 acts as an intermediate signaling molecule in the production of certain bactericidal peptides, such as cathelocidin.3 These peptides coalesce within phagosomes and severely damage the cell membranes of ingested bacterial cells.18 When toll-like receptors (TLRs) on macrophages are activated, 1-α-hydroxylase (the enzyme catalyzing the hydroxylation of Vitamin D3) and VDRs are immediately produced by the macrophage.3,18 Circulating 25(OH)D3 in the blood is converted to 1,25(OH)2D3.3,18 This subsequently binds with VDR, causing the formation of a VDR-RXR heterodimer complex—allowing for transcription of cathelocidin.18 Deficiency in Vitamin D3 is thus believed to handicap our ability to fight off bacterial infections, as it prevents the sufficient production of bactericidal proteins.18
FIGURE 1: Diagram of VDR, RUNX2, RXR interactions on the transcriptional level.15
The adaptive immune system, on the other hand, employs antigenspecific targeting that allows for “learned” elimination of pathogens by specialized cells.3 Vitamin D3 is thought to be involved in specific mechanisms that suppress the autoimmune functions of this system.18 Under certain circumstances, such as an abnormally low level of immature dendritic cells (DCs) and high levels of inflammatory cytokine production by monocytes, the body begins to produce antibodies against its self-antigens.18 One of the roles of immature DCs is to present self-antigens to T-cells in a way that facilitates the buildup and maintenance of immune system tolerance to host cells. Too low a level of immature DCs can result in a low tolerance to the body’s own cells, leading to excessive autoimmune responses.18 By various complex mechanisms involving the differentiation of T- and B-cells, Vitamin D3 inhibits DC differentiation and maturation, and thus preserves adequate levels
The Meducator | March 2012
of the immature DC phenotype needed in order to suppress the Insulin, unlike PTH and FGF23, has a less-obvious connection development of autoimmune disorders.18 Vitamin D3 also inhib- with Vitamin D3. Although the mechanism is not fully underits the production of inflammatory cytokines by monocytes and stood, it is thought that 1,25(OH)D3 stimulates insulin secretion, increases the production of anti-inflammatory cytokines, so that largely through the interaction of VDRs with calbindin-D28K.3 when autoimmune responses do occur, widespread inflammatory The latter, when fully activated, can also help to prevent the cydamage does not ensue.3,13,18 tokine-mediated destruction of β-cells. Hence, Vitamin D3 deficiency can lead to insulin dysregulation as well as an increased risk for Type I diabetes mellitus.3
THE DOSAGE DEBATE
Macrophage or Keratinocyte
The putative non-classic actions of Vitamin D3 are considerable and diverse. Dosage plays a significant role in determining the effectiveness of Vitamin D3 supplementation in driving these mechanisms.
FIGURE 2: Diagrams depicting the action of 25(OH)D3 and 1,25(OH)2D3 on the innate and adaptive immune system.3
Health Canada’s previously mentioned report was published following a joint Canadian and US evaluation of existing research Similar to the results of many clinical trials, Vitamin D3 supple- surrounding the disputed non-classic actions and their requimentation dosages used in studies testing MS- or other autoim- site dosages of Vitamin D3.7 Surprisingly, the report concluded mune-afflicted patients, only seem to produce positive results that the potential anti-cancer and auto-immune benefits of inwhen exceeding levels of 4,000 IU per day.19 This is far above creased Vitamin D3 intake have not yet been proven, nor the poHealth Canada’s recommended dosage. tential overdose risks, including kidney and other internal organ calcification,not yet accounted for.7 It even went so far as to deFinally, Vitamin D3 also plays a critical role in hormonal regula- clare that “there is no additional health benefit associated with tion. Three major classes of hormones are regulated by Vitamin D3 Vitamin D intakes above the level of the new Recommended Diincluding Parathyroid hormone (PTH), Fibroblast Growth Factor etary Allowance”.7 23 (FGF23), and insulin.3 The regulatory action of Vitamin D3 on the first two hormones forms a negative feedback loop that modu- Since the release of the report, many in the field have criticized lates blood serum levels of 1,25(OH)2D3.3 This is accomplished its method of meta-analysis, describing it as overly-cautious and by hormonal control over the transcription of 1-α-hydroxylase in hyper-stringent.20,21 Many health practitioners had hoped for betthe kidney. PTH upregulates this transcription and stimulates the ter guidance and expected a recommendation of at least 1,000 hydroxylation of 25(OH)D3 in the kidney to 1,25(OH)2D3. In IU per day for any age category, the level thought to constitute contrast, FGF23 downregulates transcription of 1-alpha-hydrox- the absolute minimum dose needed for any significant overall ylase, and inhibits further 1,25(OH)D3 production. By interact- benefit.4,11,21 Perhaps Health Canada’s stance is a consequence of ing with VDRs, 1,25(OH)2D3 inhibits the further secretion of the overblown Vitamin E-cardiovascular research throughout the PTH and stimulates the production of FGF23.3 Together, the 1990s, after which few claims were found to be entirely valid.22 concentrations of 1,25(OH)2D3, PTH and FGF23 maintain serum 1,25(OH)2D3 levels at a constant and adequate level.3 When A recently-released American meta-analysis study seems to agree imbalances in these hormones occur, as caused by inadequate in- with Health Canada’s position. The United States Preventive Sertake levels of Vitamin D3, other conditions can develop, such as vices Task Force report states that a number of the clinical cancerosteomalacia (in the case of FGF23).3,12 prevention studies lacked properly-controlled external variables such as family health history, while the statistical methods of others were not appropriate.23,24 They concluded that many of the proposed cancer-suppressing effects of Vitamin D3 were not yet sufficiently evidenced. However, the report also judged that further research and re-evaluation are required to establish proper Vitamin D3 dosage recommendations.23,24
FIGURE 3: Diagrams depicting the interactions of Vitamin D3, FGF23, and PTH.3
As the hype surrounding Vitamin D eventually diminishes and studies are performed that examine the validity of previous experiments and conclusions, we may see that the accepted scope of the vitamin’s non-classic actions will recede. However, even if only a handful of these non-classic actions are proven, the potential therapeutic effects of vitamin D will still bolster general public health.
Reviewed by Dr. Jonathan (Rick) Adachi, MD, FRCPC Dr. Rick Adachi is a Professor in the Department of Medicine at McMaster University, and is the Alliance for Better Bone Health Chair in Rheumatology. Currently, he is involved in the Canadian Multicentre Osteoporosis Study, and has been looking into the structural analysis of bone and cartilage as measured by pQCT and pMRI.
Nees F. Kirk/Othmer Encyclopedia of Chemical Technology. Vol. 1: A to Alkaloids. Vol. 2: Alkanolamines to Antibiotics (Glycopeptides). 4. Auflage. (Reihenherausgeber: J. I. Kroschwitz). Herausgegeben von M. Howe-Grant. Wiley, Chichester. Vol. 1: 1991. XXII, 1087 S., geb. 135.00 £ – ISBN 0-471-52669-X; Vol. 2: 1992. XXVIII, 1018 S., geb. 135.00 £ – ISBN 0-471-52670-3. Angewandte Chemie 1993;105(2):318319. Tian XQ, Chen TC, Matsuoka LY, Wortsman J, Holick MF. Kinetic and thermodynamic studies of the conversion of previtamin D3 to vitamin D3 in human skin. Journal of Biological Chemistry 1993 July 15;268(20):14888-14892.
Vitamin D and prevention of breast cancer: Pooled analysis. The Journal of Steroid Biochemistry and Molecular Biology (3– 5):708.
Aranow CM. Vitamin D and the Immune System. Journal of Investigative Medicine 2011 August;59(6):881-886.
Kimball S, Vieth R, Dosch H, Bar-Or A, Cheung R, Gagne D, et al. Cholecalciferol Plus Calcium Suppresses Abnormal PBMC Reactivity in Patients with Multiple Sclerosis. Journal of Clinical Endocrinology & Metabolism 2011 September 01;96(9):28262834.
Heaney RP, Holick MF. Why the IOM recommendations for vitamin D are deficient. Journal of Bone and Mineral Research 2011;26(3):455-457.
Bikle D. Nonclassic Actions of Vitamin D. Journal of Clinical Endocrinology & Metabolism 2009 January 01;94(1):26-34.
Schwalfenberg G. Not enough vitamin D. Canadian Family Physician 2007 May 01;53(5):841-854.
Holick MF. Resurrection of vitamin D deficiency and rickets. J Clin Invest 2006 08/01;116(8):2062-2072.
Statistics Canada. Vitamin D Status of Canadians 2007 to 2009. 2010 April 14.
Langois K, Greene-Finestone L, Little J, Hidiroglou N, Whiting S. Vitamin D status of Canadians as measured in the 2007 to 2009 Canadian Health Measures Survey. Statistics Canada CatalogueHealth Reports March 2010;82-003-X.
Blumberg JB, Frei B. Why clinical trials of vitamin E and cardiovascular diseases may be fatally flawed. Commentary on “The Relationship Between Dose of Vitamin E and Suppression of Oxidative Stress in Humans”. Free Radical Biology and Medicine 2011;43(1):1374-1376
Chung M, Lee J, Terasawa T, Lau J, Trikalinos TA. Vitamin D With or Without Calcium Supplementation for Prevention of Cancer and Fractures: An Updated Meta-analysis for the U.S. Preventive Services Task Force. Annals of Internal Medicine 2011 December 20;155(12):827-838.
Ross AC, Manson JE, Abrams SA, Aloia JF, Brannon PM, Clinton SK, et al. The 2011 Report on Dietary Reference Intakes for Calcium and Vitamin D from the Institute of Medicine: What Clinicians Need to Know. Journal of Clinical Endocrinology & Metabolism 2011 January 01;96(1):53-58.
National Research Council. Dietary Reference Intakes for Calcium and Vitamin D. Washington, D.C.: The National Academies Press; 2010.
Canadian Cancer Society. Sensitivity to Vitamin D. 2010; Accessed December, 2011.
Garland CF, French CB, Baggerly LL, Heaney RP. Vitamin D Supplement Doses and Serum 25-Hydroxyvitamin D in the Range Associated with Cancer Prevention. Anticancer Research February 2011 February 2011;31(2):607-611.
Dawson-Hughes B, Heaney RP, Holick MF, Lips P, Meunier PJ, Vieth R. Estimates of optimal vitamin D status. Osteoporosis International 2005;16(7):713-716.
Vieth R. Vitamin D supplementation, 25-hydroxyvitamin D concentrations, and safety. The American Journal of Clinical Nutrition 1999 May 01;69(5):842-856.
National Institutes of Health-Office of Dietary Supplements. Dietary Supplement Fact Sheet: Vitamin D. 2011 June 24.
Mechanisms of the Anti-Cancer and Anti-Inflammatory Actions of Vitamin D. Annu Rev Pharmacol Toxicol (1):311.
Fleet JC, Desmet M, Johnson R, Li Y. Vitamin D and cancer: a review of molecular mechanisms. - Biochemical Journal 2012 Jan 1;441(1):61-76.
Gutierrez S, Liu J, Javed A, Montecino M, Stein GS, Lian JB, et al. The Vitamin D Response Element in the Distal Osteocalcin Promoter Contributes to Chromatin Organization of the Proximal Regulatory Domain. Journal of Biological Chemistry 2004 October 15;279(42):43581-43588.
Underwood KF, D’Souza DR, Mochin MT, Pierce AD, Kommineni S, Choe M, et al. Regulation of RUNX2 transcription factorDNA interactions and cell proliferation by vitamin D3 (cholecalciferol) prohormone activity. Journal of Bone and Mineral Research 2011:n/a-n/a.
The Meducator | March 2012
I N T E RV I E W S P O T L I G H T The Role of Drama in the Health Sciences Interview with Hartley Jafine BA, MA Conducted by Ilia Ostrovski1, Brian Chin2 and Shelly Chopra1 Bachelor of Health Sciences (Honours), 1Class of 2014; 2Class of 2012
Hartley Jafine is an instructor of theatre and arts-based courses in the Bachelor of Health Sciences program. He has studied and used applied drama—a form of theatre that is now being used as a tool for social and interpersonal skill development—as an educational medium for many years. The Meducator recently had the opportunity to interview Jafine on the effectiveness of applied drama in helping students regain their passion and health professionals understand their patients.
Your work focuses primarily on the use of drama as because of the structure that they find themselves in. The presan educational technique. Could you please elabo- sures and the demands of clerkship do not necessarily allow them rate on what applied drama entails and how you got in- to develop skills like compassion and empathy. volved in this area?
Once third-year medical students enter their clerkship year, they Typically when I tell people that I facilitate drama and arts-based begin to discover that their idealistic views are not necessarily courses in a health science program, I get the same response compatible with the realities. What typically happens is that med“Hmmm…how does that work?” Well, the link is very simple and ical students become complacent instead of trying to find alternait all started when I was completing my Masters of Arts in ap- tive ways of being. This is where applied theatre directors such as plied drama. Applied drama is a field that uses theatre as a tool for Bertolt Brecht and Constantin Stanislavski come in. Stanislavski personal or social development and growth. As an MA student I created theatre in the form of psychological realism: an audience started to investigate how theatre could be applied in a hospital member would go to his play and leave the play thinking “yes, that setting. The intent was to take a space that is typically very fright- is the way it is, I felt that too and that must be the way it always is”. ening and a place that no one wants to be in and turn it into a This creates a type of environment that continually perpetuates a space that is a bit more positive. From this idea, I started to think problem. Brecht, however, created theatre where audience memabout how theatre could be used in professional healthcare train- bers leave thinking “wait a minute, life should not be like that, ing settings and how theatre could be applied to health science there should be a way out for that person and something needs to education, and that led me to where I am currently. As a PhD change.” Third-year medical students tend to follow Stanislavski’s student, I am investigating the role theatre could play in health route where they continue to feed into the systemic problem inscience education and training to develop transferable skills like stead of trying to find new ways to rally against it. The problem is that as medical students begin to lose their compassion and lose communication, empathy, and collaboration skills. their empathy this impacts other spaces such as their collaboration with other healthcare professionals and their communication with What are the common expectations of students in future patients.
What purpose does theatre serve in medical educaStudents typically enter medical school when they have the most tion? idealistic attitude and the most compassion because they have chosen a career as a healer. They are going into a profession where they are going to ‘do good’ so to speak. The problem arises once Theatre skills are life skills and the skills that an actor learns in they enter third year or clerkship. The idealism and the compas- becoming a pro-theatre artist are equally applicable to healthcare sion and the empathy starts to decline a little bit, and that is partly professionals. Engaging in these theatre-based mediums allows
participants to develop transferable skills, like communication, skills and presence, as well as identified psychological resilience as collaboration, the idea of presence and active listening, being an outcome of taking the theatre course. in the moment, and empathizing with another human being. Through theatre, participants are able to embody other characters, In addition to curriculum-based applied drama, theatre has been perhaps characters that are suffering from illness or disease. By liv- used in extracurricular settings as well and for quite some time. ing a patient’s experiences, healthcare professionals might be able The University of Toronto’s medical school has been doing their to learn something new and then use that newfound knowledge annual production “Daffodil” for 101 years as of 2012 and the when engaging with a future patient in a clinical setting. University of Western Ontario, has been doing their medical school show “Tachycardia” since the 1950s. What this says to me Not only can theatre develop important transferable skills that can is that theatre has a presence and continues to have this presence then be applied to clinical settings, but engaging with theatre and in medical schools, which are not two things which you typically the arts can have another really important effect; allowing one to think would go together. The reason for this success is that these regain play. Play can substantially improve the mental and psycho- shows typically address fears and anxieties that the medical stulogical health of professionals. As we get older, we tend to play less dents are facing at the time. This links directly to the central goals and less and that’s because play is seen as frivolous, unproductive, of applied drama; to explore the anxieties and fears that we are and something only children do. But what we do not realize is currently facing and to explore alternative ways of existence. Crethat through engagement with the act and art of play, we can gain ating plays around the fears and anxieties of clerkship, or applyhuge benefits. Play encourages individuals to seek out optimism. ing and matching residency programs really resonate with mediPlay gives the immune system a bounce. Play allows for the de- cal school audiences. It is this engagement with theatre that gives velopment of a sense of community. These roles can all contribute them the opportunity to laugh and make fun of the system they to the mental health of the healthcare professional and studies find themselves battling and working within. repeatedly show that through engagement with play, healthcare professionals mark a higher level of psychological resilience. From your personal experience, how is this form of
education typically received by students? How can applied drama maintain the mental wellbeing of healthcare professionals working in high- I have facilitated theatre and arts-based programs in the Bachelor stress environments? of Health Sciences program for the past five years. From my lived
experience and from my research, I have noticed the importance So, in our society, and particularly in the world of health sciences, that students have identified of engaging with theatre. From their there is this notion of performing perfection. There are extreme personal reflections, from conversations, from research, I have dispressures in the healthcare field to be perfect, to not admit mis- covered that students who engage with theatre, especially students takes, or to never share any weaknesses or anxieties. Now, this is who are in health science programs—which are very outcomeunderstandable because healthcare professionals are dealing with oriented in their curriculums—identified that through the process important stakes, other peoples lives, but the problem arises when of participating in theatre courses and through arts-based medinot admitting anxieties or mistakes has a detrimental effect on the ums, they have developed important transferable skills, skills like health and the psychological wellbeing of healthcare professionals. communication, empathy and collaboration, as well as being able And so, theatre can allow the space for healthcare professionals to to develop a strong sense of identity and having the ability to play discuss these anxieties, to discuss these fears, to explore alternative and have fun, which, as I have said, has huge psychological benways of being. In a theatre space, it’s ok if people make mistakes, efits. Additionally, I have facilitated workshops at the Canadian it’s ok if people fail, it’s about celebrating these, and saying “ok, Conference on Medical Education. The physicians who attended, that happened, now what can we do to fix it, what other world discussed with me how embodying a character who was suffering exists where this doesn’t happen.” It is through engaging with the- from depression, from anxiety, from other illnesses, gave them a atre, hopefully, that they can reduce their anxiety and leave with better understanding of what those patients and individuals go the mental health necessary to their practice. through. They can then take this in to their practice when engaging with their patients in the future.
How is theatre currently being integrated into academic settings? The use of theatre in health science education and training has
Today, theatre is being used in health science education in medical schools across Canada, the USA, England, and other parts of the world. A former student of mine, who took my Theatre for Development (HTH SCI 3CC3) course, was accepted into University of Alberta’s medical school. Using the knowledge he gained through this course, he developed his own theatre course within the medical school. A recently conducted study identified that through the engagement in theatre-based games and exercises, these medical students developed empathy skills, communication
been increasing year by year—which is fantastic—but the problem, the obstacle, is that it tends to only exist on the fringes, as elective courses, as extracurricular intervention. What needs to happen now is that healthcare professionals need to find ways to fully integrate theatre into their curriculum because engaging in theatre offers important benefits that all participants in health science education can grow from.
The Meducator | March 2012
Research Highlights AT MCMASTER
Compiled by Khizer Amin and Bhavik Mistry
Image adapted from: sxc.hu
Image adapted from: sxc.hu
Image adapted from: http://jnnp.bmj.com
Recently, Dr. Mark Larché, the Canada Research Chair in Allergy & Immune Tolerance and a professor in the McMaster Department of Medicine, developed a vaccine that can be used to assist people with cat allergies. The researchers targeted a particular amino acid sequence from the protein released on the cat’s fur that stimulates an allergic response. Larché produced a vaccine by coding the key components of the amino acid sequence that would provide relief for a large portion of the population. In this immunotherapy, the vaccine targets the allergen-specific T cells with the synthetic peptides. This study has prompted the possibility for other possible vaccines related to common allergies.
Doctors have repeatedly warned of the dangers of a high sodium diet, and it is generally accepted that too much salt is not good for you. However, researchers at McMaster, including Dr. Martin O’Donnell and Dr. Salim Yusuf, have found that both low and high levels can have negative effects on the heart. The analysis included almost 30,000 people who were at an increased risk of heart disease. It was found that urinary sodium excretions greater or less than 4 to 5.99 grams per day were associated with an increased risk of cardiovascular death and hospitalization due to coronary heart failure.
Huntington’s disease (HD) is an age-related neurodegenerative disorder resulting in gradual motor loss and cognitive decline. Currently, there exists no cure for HD and no known method to halt disease progress. In collaboration with researchers at the University of Alberta, Dr. Ray Traunt’s cell biology lab has discovered a successful intervention in rodent studies. Infusion of GM1, a lipid, into the brains of rodents with HD inhibited a toxic protein known as huntingtin. Moreover, GM1 addition was able to restore normal brain function through unknown repair mechanisms. Hence, the logical next step is to look for drugs that can potentially mimic the effects of GM1.
Larché, H. Lee, J. Kleine-Tebbe, R.P. et al. Development and Preliminary Clinical Evaluation of a Peptide Immunotherapy Vaccine for Cat Allergy. Journal of Allergy and Clinical Immunology, 2011; 127 (2).
Donnell MJO, Yusuf S, Gao P, Mann JF, Mcqueen M, Sleight P, et al. Urinary Sodium and Potassium Excretion and Risk of Cardiovascular Events. Journal of the American Medical Association, 2011;306(20):2229–38.
Di Pardo A., Maglione V., Alpaugh M., Horkey M., Atwal R.S., Sassone J., et al. Ganglioside GM1 induces phosphorylation of mutant huntingtin and restores normal motor behavior in Huntington disease mice. Proceedings of the National Academy of Sciences, 2012.
Image adapted from: sxc.hu
Image adapted from: sxc.hu
Image adapteed from: success.org
A recent study suggests that routine populationbased screening programs for autism may not be necessary. Autism is a neurodevelopmental disorder that can have several implications, including difficulty in areas such as communication, fine and gross motor skills, and intellectual skills. Dr. Jan Willem Gorter, a researcher in McMaster’s CanChild Centre for Childhood Disability Research and associate professor of paediatrics, and his team conducted a literature review assessing the effectiveness of autism screening programs. They discovered that none of the tests contained all facets of a useful screening program, including accuracy, sensitivity, specificity and predictive value. Gorter argues for the need of a randomized control trial analyzing the usefulness and implications of the autism screening program.
Researchers at McMaster’s Department of Biology led by Dr. David Rollo have found that a key to promoting longevity may involve consuming just the right mix of dietary supplements. Mice were supplemented with a complex mix of ingredients – such as vitamins, garlic, ginseng, and green tea extract – that previous research had shown to be useful in counteracting various aging mechanisms. Supplemented mice showed no loss of total daily locomotion and cognitive decline was offset. Consumption of the supplement resulted in modest increases in life span but the delay in the onset of functional decline suggests the possibility that “growing up” may not always equal “growing old”.
An investigation conducted by Dr. Matthew Kwan, a post doctoral fellow of the Department of Family Medicine has found that an adolescent’s physical activity drops 24% by early adulthood. The longitudinal cohort study, published in the American Journal of Preventive Medicine, followed 683 Canadians chosen from Statistics Canada’s National Population Health Survey. Participants were followed up twice a year for a span of 12 years starting at the age of 12 -15. The results show that there was a greater decrease in physical activity amongst men than women. However, the gender differences in physical activity may be due to the impact of major life transitions such as getting married or having a child. Understanding the gender differences highlights the need for genderspecific interventions to prevent the decline of physical activity in men and to increase the physical activity in women.
Al-Qabandi, M., Gorter, J.W., Rosenbaum, P. Early Autism Detection: Are We Ready for Routine Screening? Pediatrics, 2011; 128 (1).
Aksenov V., Long J., Liu J., Szechtman H., Khanna P., Matravadia S., et al. A complex dietary supplement augments spatial learning, brain mass, and mitochondrial electron transport chain activity in aging mice. Age, 2011; DOI 10.1007/s11357-011-9325-2.
Ejim L, Farha MA, Falconer SB, Wildenhain J, Coombes BK, Tyers M, et al. Combinations of antibiotics and nonantibiotic drugs enhance antimicrobial efficacy. Nat Chem Biol. 2011 Jun;7(6):348-350.
WRITE FOR US
The Meducator is currently accepting Research Insight and Critical Review articles for our next issue. For more information about how to write for us, send us an email at: firstname.lastname@example.org
Visit our website at www.meducator.org to view our new web archives. The website gives access to an online version of this issue.
ACKNOWLEDGEMENTS The Meducator would like to thank the Bachelor of Health Sciences (Honours) Program, the McMaster Students Union, the McMaster Alumni Association and the McMaster Student Services Committee for their generous support.
Follow The Meducator on Facebook: www.facebook. com/meducator & on Twitter (@TheMeducator). Our Facebook and Twitter pages post regular MedWires, which update you on current advances in the health sciences. YouTube Channel The Meducator has launched a new YouTube channel! Watch our recent videos at: www.youtube.com/MeducatorTV Feedback This issue contains many new changes for The Meducator. We would like to hear your feedback on these changes. Post on our Facebook page or send us an emailâ€”we value your input.
The Meducator | March 2012
Follow us on Facebook and online!