Preface Preface from the Editors

Preface

Preface from the Editors

t is with both excitement and sadness that we present to etry came onto the stage, dramatically changing the newborn you the final issue of the UTMJ for the 2011-2012 aca- screen to include the identification of more than 50 metabol- Idemic year. Serving as your Editors-in-Chief this year has ic disorders.3 However, with the increasing ability to identify been an immense pleasure, and has allowed us the oppor- disorders comes the complex challenge of treating them, and tunity to carry on the many exciting endeavours and initia- the ensuing debate on the value of identifying a disorder if no tives associated with the UTMJ. For our final issue, we decided viable or definitive treatment currently exists.3 to focus on a topic that is widely popular, multifaceted and The topic of fetal treatment is another issue that often sometimes controversial: obstetrics and gynaecology. comes into the news headlines, with astonishing advances in The landscape of obstetrics and gynaecology is an ever- fetal therapy and fetal surgery. Familiar early fetal therapies changing one. For example, something as seemingly simple include simple procedures, such as the first transplacental as contraception has seen a continuous stream of changes and administration of glucorticoids to mature fetal lungs in situ- advancements over the years, which is evident in our Histori- ations of premature delivery in 1972.4 More advanced fetal cal Perspective article published by Foster in 1969. The prac- surgeries began in the 1980s, often credited to Dr. Mike Har- tice of contraception, centering on the goal of avoiding con- rison at the University of California in San Francisco (UCSF), ception during intercourse, has been document as far back in the setting of congential diaphragmatic hernia.4,5 Docu- as Egyptian times.1 Modern contraception, however, did not mentation of the first successful open fetal surgery also took come into practice until the second half of the 20th century place at UCSF, involving urinary tract decompression.4 Fetal and its associated population explosion.1 The dawn of mod- surgery has since expanded to be able to tackle problems ern contraception is often marked by the introduction of oral such as thoracic space-occupying lesions, lower urinary tract contraception in the 1960s.2 Fondly referred to as “The Pill,” obstructions, cardiac malformations, sacrococcygeal tumors, a popular colloquial name coined by agriculturalist-turned- and myelomeningoceles.4 Still, it is in its arguable infancy reproductive biologist Dr. Gregory Pincus, oral contraception in both technical development and ethical discussion – for harnesses medical knowledge of the sex hormones estrogen example with regard to equality of access, to name one of a and progesterone to suppress ovulation.2 On the heels of oral multitude of concerns. Fetal surgery certainly holds promise contraception has come vaginal rings, transdermal hormone of more exciting developments to come. delivery, intrauterine delivery, intramuscular injections, and Last, but not least, what would a brief discussion on the subcutaneous implants.2 Future developments may see the field of obstetrics and gynaecology be without some reflec- introduction of fertility-regulating vaccines, with targets such tion on the theme of paternalism in medicine, and the inspir- as gonadotropin hormone-releasing hormone (GnRH), mol- ing advancements made away from the ‘doctor knows best’ ecules involved in gamete function, and anti-hCG.2 mentality towards the patient-centered approach of modern On the opposite side of the contraception coin, fetal devel- medical treatment. Nearly all medical and health care train- opment has also witnessed great strides. Reproductive genetic ees today have been indoctrinated with the importance of screening has become a mainstay in fetal development, with respecting patient autonomy. The increasing availability of the ability to identify trisomy 21, neural tube defects, and spe- medical knowledge and dynamic changes in the field of ob- cific autosomal recessive conditions early in gestation.3 Along- stetrics and gynaecology will undoubtedly bring a unique set side such genetic screens come intense debates on the ethics of challenges. On this note, we leave you will an eye-opening of terminating a pregnancy depending on the health status advertisement published in the UTMJ from 1969, clearly an of the child, the likes of which will continued to be explored out-of-date paternalistic approach to be learned from and left in medical curricula and practice for decades to come. At the in the past: slightly less morally charged end of the spectrum, newborn screening has also seen impressive advancements. Newborn screening became an established practice in the 1960s, with the sole goal of identifying newborn phenylketonuria.3 Subse- quent additions to the screen over the next 20 years included congenital hypothyroidism, beta thalassemia, sickle cell disease and cystic fibrosis.3 In the 1990s tandem mass spectrom-

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Preface from the Editors

which is the 5th millennium developmental goal of the Unit- ed Nations. Specifically, medical students from several Inter- national Federation of Medical Students’ Associations (IF- MSA) member countries have come together with the goal of developing a questionnaire to determine the content of maternal and child health in the curricula of medical schools worldwide. It is the goal of this group to identify any gaps in medical education, as well as develop peer education pro- grams to address them with the aim of improving the knowledge of the next generation of physicians. In the News and Views section, Locke and Cavacuiti discuss the increasing growth of opioid dependence in Ontario. The authors comment on the increasing mortality due to opioid use, as well as the changing profiles of opioid users in the province and the implications on patient management. This article includes the new Canadian guidelines on safe and effective opioid prescribing for non-cancer pain that was re- leased in November 2011, which is expected to aid in changing the current climate of opioid dependence in Ontario. Our Interviews section begins with an interview between MacDonald and Dr. Todd Mainprize on the subject of the exciting new frontier of MRI-guided focused ultrasound, a technique that allows neurosurgeons to perform brain surgery without invasive surgical procedures. Next, the UTMJ presents an interview with obstetrician and gynaecologist Dr. John Kingdom about his career path, as well as how he stumbled upon the exciting world of placental disease. In our third interview in this issue, Afshar interviews Nobel laureate Dr. Ferid Murad. Dr. Murad received the 1998 Nobel Prize for Medicine for his work with nitric oxide; in this interview, he discusses his views on education and the future of medicine and biomedical research. Under Case Reports, Ho, Ho, Karim, Fu, Chan and Yoshida describe a 40-year-old woman with decompensated cirrhosis Returning to the current issue, our guest editorial by Dr. who presented with a large liver mass suspicious for hepato- Karen Glass deals with the emerging field of oncofertility, or cellular carcinoma (HCC). They discuss the atypical features the preservation of fertility during cancer treatment. This is of this case as well as some options for the treatment of HCC, an important topic as many children and young people de- including surgical resection, liver transplantation, loco-re- velop cancer, either before or during their childbearing years. gional therapies such as ethanol injection, ablation and tran- Fortunately, while many do survive their cancers, their fertility sarterial chemoembolization, and systemic pharmacological may be affected by the treatments they have received. Thus, it treatment options. Following this, Antony, Latchman and Wal- is important to understand how the impact on fertility can be ton present an unusual case of an abdominal mass in a 3-year- minimized, so no opportunities are wasted. old boy, who was also diagnosed with iron-deficiency anemia In Letters to the Editor, Leonardi discusses the decreasing associated with fine motor and language delays. Intriguingly, popularity of the field of obstetrics and gynaecology amongst post-surgery, this mass was found to be a gastric bezoar com- male medicals students and argues for the importance of posed of human hair and carpet fabric. This case highlights equal representation of the sexes in this medical specialty. the phenomenon described as pica, or the ingestion of sub- In addition, probing deeper, Leonardi proposes that improv- stances of no nutritional value, a condition associated with ing medical student experiences during clerkship and having iron-deficiency anemia. good role models may help minimize this disparity. In our In the Quick Diagnosis section, Tran and Chan discuss next letter, Obsorne and Bernard discuss an ongoing initia- melasma, one of the most common hyperpigmentation syn- tive by medical students towards improving maternal health, dromes associated with pregnancy. The authors also present

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Preface from the Editors a brief overview of the clinical features, pathology and treat- chronicles the history of house calls, which have played a key ment of melasma. role in the heritage of medicine. Furthermore, the author dis- Anaphylactoid syndrome of pregnancy or amniotic fluid cusses current practices, as well as the future of the house call embolism is a rare, yet life-threatening complication of preg- within the modern healthcare system. nancy, which leads to disseminated intravascular coagulation Last but not least, in the Poetry and Short Story section, (DIC) in about 50% of the cases. In the Case Series section, Badenduck draws on his experience working with the Preven- Frye, Sager, Daly, Barbot, Luce, Rinzler and Forde discuss the po- tion of Mother-To-Child Transmission of HIV project in Zam- tential use of recombinant factor VIIa to treat DIC associated bia. His depiction of the power of a parent’s love as a motivat- with anaphylactoid syndrome of pregnancy in two patients. ing force calls us to support the efforts to improve maternal Next, Kudlow and Chavlovski review the literature that sug- and child health in the developing world. gests that major depressive disorder is a strong independent We believe this issue highlights the many aspects of obstet- risk factor for the development of coronary artery disease. rics and gynaecology and its implications on medicine and They propose that this increase in risk is largely due to a nox- society, and we hope that you enjoy reading it. We would also ious biopsychosocial synergy resulting from the discrimina- like to take this time to thank the 2011-2012 staff of the UTMJ: tion that these patients face in the healthcare setting, which the managing editors, associate editors, copy editors, graphics emphasizes the importance of educating health care provid- editors, and section editors who have helped us continue the ers on this topic. long and rich tradition of the UTMJ, and without whom, this In our Research section, Shafran and Isaac carry out a ret- journal would not be possible. We would also like to sincerely rospective chart review of all patients managed at 3 hospital- thank our faculty advisory board, especially Dr. John Bohnen based heart failure clinics in Calgary. They report that the for his dedication to the UTMJ. Further, we thank the many rate of heart failure decompensation is significantly lower in faculty reviewers, whose support we are deeply indebted to. patients with normal thyroid functions tests than in those with Our gratitude also goes out to our advertisers, subscribers and unmeasured or abnormal tests. Following this, Wells, Srinath, patrons for their continued support. Last but not least, we Free, Forde and Forde analyze the cost-effectiveness of a mobile thank you the readers, for helping make the UTMJ the success phone SMS text-based smoking cessation intervention of that it is. We end with the words of advice Dr. Murad received young adult smokers in the United Kingdom. Results from from Nobel Laureate Dr. Earl Sutherland Jr. at the start of his their study suggest that SMS text-based smoking intervention training: “Train as long as is necessary to master your profes- is more advantageous from health care payer and societal sion and enjoy your work.” We encourage you all to persevere viewpoints. in your training, pursue what brings you joy and passion, and In the first article on Medical Education, Shaikh provides wish you all a most successful and rewarding career. medical trainees with a short, practical tutorial on creating an effective spreadsheet for housing medical research data using Sincerely, the readily available commercial software, Microsoft Excel. The information herein is expected to help readers to build Bailey Dyck and Sheron Perera an efficient, organized and easy to use database. Following Editors-in-Chief this, Blankstein and Blankstein present a complete pre-operative admission guide, which describes 10 steps that are impor- References tant to correctly, safely and efficiently admit a pre-operative 1. Benagiano G, Bastianelli C, and Farris M. Contraception Today. Ann N Y Acad Sci. 2006; 1092: 1-32. patient to the hospital. 2. Dhont M. History of oral contraception. Eur J Contracept Reprod Health In the History of Medicine section, Kassam discusses the Care. 2010; 15 Suppl 2: S12-18. history of the phacoemulsification technique and the aca- 3. Burke W, Tarini B, Press NA, and Evans JP. Genetic screening. Epidemiol Rev. 2011; 33:148-64. demic debate between two prominent English surgeons, 4. Deprest JA et al. The making of fetal surgery. Prenat Diagn. 2010; 30:653- Samuel Sharp and Sir Percival Pott, which was important in 67. ultimately advancing the field of ocular surgery. Next, Herritt 5. Harrison MR. The University of California at San Francisco Fetal Treatment Center: a personal perspective. Fetal Diagn Ther. 2004; 19:513–524.

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