A student-run scientifc publication since 1923
University of Toronto Medical Journal Table of Contents
PREFACE ORIGINAL RESEARCH 4 Preface from the Editors 33 To Study the Impact of Acne Vulgaris on the Quality of Life of Patients Amit Batra, Prithpal S Matreja, Amandeep Singh, Ashwani K Gupta, Naveen K Kansal, PML Khanna PERSPECTIVES 5 Riding the Medical Technology Wave to Empower Your Career in Medicine Carolyn McGregor CASE REPORTS 37 Rapidly Progressing De Novo Arachnoid Cyst in 7 Current Limitations and Opportunities for Surgical an Adult Patient Navigation Kenda Alhadid,* Renée Rochelle Cruickshank,* Alireza Ronnie Wong, Jamil Jivraj, Victor X. D. Yang Mansouri, David J. Mikulis, Taufik A. Valiante (*Co-Authors)
OPINION EDITORIALS 10 Police, policy and privacy: A Commentary on Mental Health BOOK REVIEWS Information Disclosures by the Toronto Police Service 42 In Retrospect: Frankenstein and Medical Technology Phillip K. Gregoire Benjamin H. Chin-Yee
12 The State of Pharmaceutical Drug Coverage in Canada Liza Abraham, Patrick E. Steadman
13 Ebola: Context and Current Issues Maia Foster, Thomas M. Dashwood
INTERVIEWS 15 Brain Stimulation and its Role in the Assessment and Management of Movement Disorders Ayan K. Dey
18 Paving the Way in Biomedical Engineering: An Interview with Dr. Molly Shoichet Amirah Momen
20 Healthy Lives for All, Until the Last Breath: An Interview with Dr. Alex Jadad Muskaan Vineet Gurnani, Arnav Agarwal
25 Exploring The Past, Present and Future of Health Technologies with Dr. Joseph Cafazzo Amirah Momen
29 Adding Years to Life: Physiatry, Neurorehabilitation, and Knowledge Translation Ayan K. Dey
All articles are externally peer-reviewed with the exception of poetry, short stories and book reviews. All manuscripts are internally reviewed. Informed consent practices and any conflicts of interest are specified in the articles if applicable.
Cover Artist: Front cover illustration by Diana Grossi, student of the Bionedical Communications Program (1T6), University of Toronto.
UTMJ • Volume 92, Number 1, December 2014 1 ERRATA Our sincere apologies. This page contains the correct staff list for this UTMJ Issue. Volume 92, Number 1, 2014
A student-run scientifc publication since 1923
University of Toronto Medical Journal
Editors-in-Chief Interview Editors Ilyse Darwish Catherine Brown Varuna Prakash Ayan Dey Amirah Momen Aliya Ramjaun Managing Editors Lisa Saldanha Florentina Teoderascu Teja Voruganti Johnny-Wei Bai Section Editors Angela Arisz Sumedha Arya Associate Editors Anand Bery Arnav Aggarwal Benjamin Chin-Yee Sabrina Agnihotri Timothy Chung Monica Blichowski Adrian Cozma Bonnie Cheung Kangping (Kathy) Cui Raymond Chu Sunit Das Mohammed Firdouse Rushi Gandhi Alanna Gilmour Sheliza Halani Inna Gong Dhruvin Hirpara Soroush Larjani Keith Lee Daniel Li Anath Lionel Nicholas Light Cristina Olteanu Rosamond Lougheed Ben Ouyang Ilya Mukovozov Zain Sohail Faisal Naqib Sarah Voll Yuhao Shi Anthony Wan Prachur Shrivastava Margaret Wu Luke Swenson Siqi Xue James Wang Paige Zhang Marie Yan Jeremy Zung Weining Yang
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UTMJ • Volume 92, Number 1, December 2014 Patrons
The University of Toronto Medical Journal is funded in part by its subscribers and the Medical Society. Patronage to the Journal is sub- divided into five categories. UTMJ Friend – $75; UTMJ Patron – $75-99; UTMJ Advocate – $100-149; UTMJ Benefactor – $150-199; and UTMJ Grand Benefactor – >$200. To subscribe, please see the last page of the Journal.
The UTMJ wishes to thank the following patrons for their generous donations:
UTMJ Grand Benefactor Dr. Barry Goldlist
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UTMJ Friend Anne Agur Shabbir Alibhai Edward Cole Helen Demshar David Goldbloom Anna Jarvis Stephen Kraft Chetan Phadke Lannis Lee Tynes
The Editors apologize for any omissions to the above list; this list represents the final version at press time. The list will be updated in future issues.
UTMJ • Volume 92, Number 1, December 2014 3 Preface
Preface from the Editors
Dear Reader,
t is our great pleasure to present to you the first issue Cafazzo shares his perspectives on how technology can enable of UTMJ’s 92nd volume. We are honoured at the oppor- self-management of patients, Dr. Alex Jadad talks about com- Itunity to be stewards of the Journal for the 2014-2015 munication technologies for global public health innovation, academic year. In setting the agenda for the year, we could Dr. Mark Bayley discusses the specialty of physiatry and neuro- not think of a better or timelier topic for our first issue than rehabilitation, and Dr. Molly Shoichet describes advances in Medical Technology. There is perhaps no other sector that regenerative medicine and biomedical engineering. In addi- has undergone as much rapid acceleration and growth over tion to these highlights, we also have a unique examination of the past decade. Be it cutting-edge diagnostics, eHealth solu- medical technology in the classic novel Frankenstein, a case tions, or devices for patients to use at home, there is tremen- report on rapidly progressing arachnoid cysts, and opinion dous potential to improve patient outcomes, lower healthcare editorials from a number of students who are actively en- costs, and increase patient and provider satisfaction. At the gaged in advocacy around hot-button issues currently facing same time, we are continuously challenged to pay due consid- our healthcare system. eration to the iatrogenic effects of technology, and to make As we turn the page on another calendar year, it is cus- judicious, evidence-based use of these innovations. tomary to reflect on the challenges and triumphs of months We intentionally refrained from overly narrowing the past. UTMJ has certainly had its share of both: we spent many scope of this issue, and are thrilled at the resulting diversity of months navigating security breaches and technical setbacks perspectives. Dr. Carolyn McGregor comments on the effects that delayed our production process significantly. This issue, of medical technology on our careers in medicine, while Ron- however, is a clear triumph representing the hard work of nie Wong, Jamil Jivraj, and Dr. Victor Yang explore limitations many dedicated members of the UTMJ team (past and pres- and opportunities for surgical navigation technologies. We ent) who banded together to bring the Journal back on its are also pleased to present interviews from prominent phy- feet. We hope you will enjoy reading this issue as much as we sicians and scientists around Toronto: Dr. Robert Chen dis- have enjoyed producing it. cusses brain stimulation for movement disorders, Dr. Joseph Varuna Prakash and Ilyse Darwish Editors-in-Chief
4 UTMJ • Volume 92, Number 1, December 2014 Perspectives
Riding the Medical Technology Wave to Empower Your Career in Medicine
Carolyn McGregor, AM, PhD, SMIEEE, MACM, Faculty of Business and IT, University of Ontario Institute of Technology
edical technology has changed greatly in the last cal knowledge and patient-related information, intelligently 90 years or so since the inception of this journal. At filtered or presented at appropriate times, to enhance patient Mthat time the term medical technology was largely care’.1 While these have been in existence in rudimentary used to describe equipment used in medical practice and, to form for over a decade, their functionality, purpose, accuracy, a much lesser extent, manually-transcribed medical records. and acceptance is set to accelerate. Additive manufacturing, Just over 50 years ago, intensive care units came into being now commonly referred to as “3D printing” enables the gen- that would ultimately generate the need for new medical eration of solid objects through the addition rather than re- technology that would enable higher frequency monitor- moval of the material used in manufacture through use of ing of many organs and systems within the body. However, data representing the required shape of the structure within around 30 to 40 years ago, medicine and healthcare together a digital file. This form of manufacture is set to disrupt health- with many other industries were beginning to undergo a new care significantly through inexpensive approaches to person- form of medical technology transformation through the use alized bone segment replacements and other applications. of mainframe computers to automate many previously-man- Serious games refers to computer games that are used in ual paper based tasks and to provide an electronic form of an educational context rather than for recreational gaming data persistence. The landscape of the use of computers and and this form of training is gaining use within the domain of related equipment for innovation in healthcare has changed healthcare as it enables inexpensive creation of multiple sce- dramatically since then, and the only thing that is certain in narios and easily supports repetition. The aim of immersive the years to come is that medical professionals must be armed reality games is to immerse any, some or all of the five senses with the tools to understand how to integrate new informa- within the game to improve the realism of the game. While tion technologies and other computing technologies to im- games that attempt to immerse players’ visual and auditory prove healthcare outcomes, improve the working environ- sensing have been around for some time, new approaches for ments for medical professionals, and reduce healthcare costs. tactile, olfactory immersion and even taste are set to bring Innovation can take two forms, namely progressive or dis- new dimensions to the realism of immersive reality experi- ruptive. While progressive innovation has the ability to make ences. improvements to existing processes, disruptive innovation The growing volume of sensor-based data and other completely replaces those processes with new ones. A well- streams of data such as from social media have given rise to a known disruptive innovation was the Amazon.com which new domain known as “Big Data”. Unlike other forms of data, forever more has changed the paradigm of the shopping Big Data arrives in high volume as streams at high velocity or experience for the purchaser, the sale process and customer frequency and can be from a range or variety of sources thus engagement experience for the seller. enabling it to be usually defined by the attributes of the three Clinical decision support systems, 3D printing, Serious foundational V’s of Big Data: volume, velocity, and variety. Games with Immersive Reality and Big Data are four technol- A second by second stream of heart rate data, twitter feeds, ogies that are set to cause the latest disruptive innovations in weather sensors, data streams and mobile phone location the broad domain that is now referred to as health and well- data streams are just a few examples of Big Data. All this data ness. Clinical decision support systems refer to systems that at a personal, community, societal, and/or organizational ‘provide clinicians or patients with computer-generated clini- level has enormous potential to be translated to information, knowledge, and wisdom to improve healthcare outcomes and reduce healthcare costs. Never before has there been such pressure to ensure the progression of research and discovery along with its transla- Corresponding Author: Carolyn McGregor tion to practice together with ongoing, independent quality Faculty of Business and IT, University of Ontario improvement initiatives for improved healthcare outcomes Institute of Technology, Oshawa, Canada and reduced healthcare costs. [email protected]
UTMJ • Volume 92, Number 1, December 2014 5 Perspectives
Riding the Medical Technology Wave to Empower Your Career in Medicine
For newly trained medical professionals set to enter the While many futurists are working to predict the next di- healthcare sector, together with those already practicing, new rections for disruptive innovations and their impact on vari- skills are required to understand how to practice within such ous industries and societies as a whole, we know that medical a constantly changing landscape. In addition, the ability to technology innovation will continue into the future, making critically assess the function, purpose and value proposition impact on healthcare practices and professionals. As always, of any new technology to be introduced in the future will be medical professionals will be required to remain current in a critical skill for any healthcare professional in a leadership the relevant medical technologies of their respective disci- role. One thing that has remained consistent since the estab- plines in the same way they will be required to remain current lishment of the medical profession is that medical technolo- in innovations generated by other areas such as basic science gies themselves are not a magic pill. Their appropriate inte- and genomics. gration within a healthcare practice is what drives healthcare innovation. Acknowledgements In the United States, the American Medical Association This research is funded by the Canada Research Chairs and the American Medical Informatics Association (AMIA) program and Canadian Foundation for Innovation. have worked together to establish a medical subspecialty in References clinical informatics, enabling it to span many disciplines. 1. J. Osheroff, T. J, L. D. A, and Jonathan M., Improving Outcomes with They recognized the fundamental need to have the training Clinical Decision Support: An Implementer’s Guide, 2nd Editio. Chicago: for these required skills for successful research, innovation, Healthcare Information and Management Systems Society (HIMSS), 2005. translation, and implementation of health technologies for- malised within a subspecialty. Many countries are now look- ing to follow suit.
6 UTMJ • Volume 92, Number 1, December 2014 Perspectives
Current Limitations and Opportunities for Surgical Navigation
Ronnie Wong, BEng, MASc, Electrical and Computer Engineering, Ryerson University Jamil Jivraj, BEng, MASc, Electrical and Computer Engineering, Ryerson University Victor X.D. Yang, MD, PhD, PEng, FRCSC, Electrical and Computer Engineering, Ryerson University; Division of Neurosurgery, University of Toronto, Sunnybrook Health Sciences Centre, Brain Sciences Program/Imaging Research, Sunnybrook Research Institute
Introduction out collateral damage.6 In spinal fusion surgery, the accuracy ptical tracking systems (OTS) have been used for with which screws are inserted has a direct surgical impact to medical imaging during surgery long before even the patient. Improperly placed screws to the vertebral body the term biophotonics had been coined. Biophoton- could place potential danger to nearby neural and vascular O 7 ics is the science of using light photons for imaging biological structures, leading to complications which may require revi- materials to acquire surface contours and underlying anatomi- sion surgery,8 with individual patient and also societal health cal features. The term biophotonics was probably coined after care cost implications. the beginning of OTS in neurosurgery. As a subset of image- guided navigation, the idea in using an external device to proj- A Brief Overview of OTS ect onto an anatomical location and guide a tool to that loca- To aid targeting and to minimize intraoperative navigation tion first appeared in literature in 1908.1-3 This external device pitfalls, neurosurgical navigation systems and specifically opti- was the stereotactic frame and it allowed precise guidance cal tracking systems, were developed to help improve surgical coordinates to the anatomical region of interest. Neurosur- accuracy by combining pre-operative imaging modalities such gery was the original clinical application for the stereotactic as magnetic resonance imaging (MRI) and computed tomog- frame3, 4 since brain tissue is highly sensitive to surgical trauma raphy (CT) images with a GPS-like tracking system. Similar to and would therefore require precise guidance to the target how a car’s location is mapped onto the roadways in Google location. Another possibility for early adoption into neuro- Maps in real-time, the OTS maps the tool’s (car) position in surgery is that bony anatomy such as the spine and cranium relation to the body (roadways) via the CT or MRI (Google provided well defined and rigid-body landmarks. Limitations Maps) images. The current standard for surgical navigation to frame-based stereotaxy include patient discomfort, limited inside the operating room (OR) is based on an infrared (IR) view of the surgical field and no awareness to complications sensor array in conjunction with a charge-coupled device such as rupturing a vessel.3 To overcome some of these limi- (CCD) camera that locks onto passive (reflective markers) or 9 tations, frameless stereotaxy was introduced in the 1990s by active light-emitting diode (LED) markers. The typical work- David Roberts3, 5 and gave way to what we see today in surgical flow that one may observe in an OR using an OTS would con- navigation. sist of the following: (1) Place fiducial on patient (2) Acquire preoperative CT or MRI (3) Enable OTS tracking (4) Identify Why OTS? fiducial markers on patient (5) Complete registration process Today, complications encountered in neurosurgical treat- (6) Enable CT or MRI image overlay (7) Verify registration ment of brain tumors, spinal fractures, and deformities con- accuracy for error tolerance (8) Confirm with imaging (9) tinue to have significant impact on the lives of people in Can- Proceed with surgery. ada. Nearly all neurosurgical procedures require some bone Most commercial optical tracking systems will use preop- cutting, typically craniotomy, and bone drilling in order to erative imaging data such as CT or MRI scans but there is now gain access to the target lesion. The danger in this procedure an increasing interest in using intraoperative imaging for navi- is accidental plunging of the drill into the dura and underly- gation. Commercial companies like Philips and Siemens have ing brain, spinal cord, or nerve roots. Therefore, the surgeon introduced cone beam intraoperative imaging systems for the is required to make accurate incisions towards the site with- OR but these units required a dedicated facility.1 On the other hand, Medtronic Inc. originally pioneered mobile intraopera- tive imaging, with the O-Arm system. This consisted of a cone beam CT imaging and associated hardware and software. Such
Corresponding Authors: trend is continuing with additional devices becoming available Ronnie Wong through Health Canada (e.g. BrainLab). Email: [email protected] Jamil Jivraj Email: [email protected] Victor X.D. Yang Email: [email protected]
UTMJ • Volume 92, Number 1, December 2014 7 Perspectives
Current Limitations and Opportunities for Surgical Navigation
What are the Advantages and Disadvantages? due to direct lighting in the surgical light heads. Another opti- Potential advantages in using optical tracking systems in- cal limitation is line-of-sight during tool tracking. Line-of-sight clude cost-effectiveness and training. Manbachi et al.7 demon- is crucial for continuous real-time connection between the strated cost-savings of $70,000 when a group used a navigation tracking tool and OTS. This is not always convenient as other system for pedicle screw insertion for 100 cases and obtained surgical instruments and multiple surgeons may block the ana- a decreased revision rate. For medical training, intraoperative tomical interest. Because of this, operating room set-up prior optical tracking guidance can benefit medical students by hav- to the surgery must take into account the physical footprint of ing a staff surgeon monitor them in real-time and directing these large and obtrusive OTS and intraoperative units or risk corrective measures when required. machine repositioning during the procedure, thereby disturb- Other benefits include increased accuracy during complex ing the workflow and increasing operating times. The worst surgery, minimizing radiation exposure, performing higher case would be canceled usage of the system midway in the pro- volume of surgeries and its use in performing Minimally Inva- cedure due to space constraints and rely back on surgeon ex- sive Surgeries (MIS). Despite these benefits that one can see perience and expertise. All of these errors have left surgeons when using optical tracking systems, Hartl et al.10 conducted with the impression that accuracy decreases during surgery.14 a global survey and found that only 11% of surgeons in North Stieglitz et al. completed a study and found that there is an America and Europe used navigation despite its widespread ongoing loss of neuronavigation accuracy throughout the pro- availability. However, non-users cited disadvantages which in- cedure. The authors used a BrainLab VectorVision2 (Brain- clude high acquisition cost, lack of adequate training, equip- Lab, Feldkirchen, Germany) neuronavigation system and a ment problems and disruption of OR workflow. A typical Medtronic StealthStation (Medtronic) for their studies. The computer-assisted surgical system can cost around $500,000 major factors that contributed to errors were surgical draping, for spinal fusion procedures. Registration times are long7 and attachment of skin retractors and duration of surgery. Early are significant towards overhead operating costs since surgery navigation systems reported tracking errors of 2-3mm15 and cannot proceed until registration is complete.7, 11, 12 Registra- more recent systems using the BrainLab VectorVision2 and tion is essential in spatially aligning the two coordinate systems Medtronic StealthStation reported a mean error of 2.9 mm14 (patient plus CT/MRI imaging data) together.13 Paired-point after the co-registration process. registration is the process that fuses this data together and its accuracy is dependant on matching of the corresponding Next Generation Applications surface points in the preoperative image data. In general, the So where are we now in terms of state-of-the-art? With re- more paired-points the better registration accuracy. The time spect to surgical training, Rosser et al.16 found correlation be- between the pre-operative scans to the time of the procedure tween faster completion and reduced errors in laparoscopic leads to navigation errors due to reference frame shifting, fi- surgeries when surgeons had a background in video games. ducial marker shifting (skin movement), brain-shift, and from Therefore, potential future neurosurgical training may ben- internal changes inside the brain. These pre-operative scans efit in gaming and simulation engines that incorporate the can be as old as a few days to a few months and during this physical and virtual world. Current commercial visualization time, the original positioning of the fiducial markers (via bony in OTS systems consists of three orthogonal 2D images and landmarks) may have shifted.1 Other OTS potential sources a 3D view. As technological leaps unfold in computational of error include imaging errors, surface model generation and gaming power, thereby catapulting 3D rendering and errors (point-to-point selection), tracking device positioning simulation software to push past the old polygon-like world error and registration errors. During the operation, addition- into real-world high definition realism, it is only natural that al navigation errors arise since many of the current systems augmented reality is finally becoming of age. Augmented real- cannot account for breathing compensation, brain-shifting, ity overlays three-dimensional computer generated data onto and unwanted patient shifting due to bedside bumps during the actual world that we see. What is the best way to represent the procedure.14 If this happens, re-registration is required, this visualization data? This is still an understudied topic but further increasing the operating time. In a separate study by future surgeons could potentially become better trained in Kolvukangas et al.,18 they found 200 hazardous situations doc- neurosurgical procedures if optical tracking systems were to umented in the 2012 MAUDE database that used computer become economically feasible and ergonomically easy to use. navigation devices for neurosurgical procedures. It was possi- With respect to surgical robotics, there has been an active ble that a number of these incidents could have been prevent- interest in automating neurosurgical procedures that can ed if the accuracies of those devices were assessed preopera- eliminate surgeon hand tremors, reduce human fatigue, and tively. Another limitation of current optical tracking systems to be used for minimally invasive surgery. Robotic manipula- is OR lighting. The infrared cameras of OTS units require an tor tracking in surgery have been widely explored but a fun- optimal distance away from the surgical field. This minimizes damental problem remains – current commercial OR naviga- obstruction of the reflective IR lighting back to the camera tion systems are a bottleneck in providing accurate real-time
8 UTMJ • Volume 92, Number 1, December 2014 Perspectives
Current Limitations and Opportunities for Surgical Navigation
feedback information to the robot. They have measurement References update rates much slower than the robot control cycle.12, 17 1. Cleary, K, Wilson, E, Ordas, S, Banovac, F. Navigation. Intraop Imaging and Image-Guided Therapy. 2014: 93-105. Furthermore, the navigation system errors that were men- 2. Horsley, V, Clarke, RH. The structure and functions of the cerebellum ex- tioned earlier have to be taken into consideration in neuro- amined by a new method. Brain 1908: 31(1): 45-124. 3. Mezger, U, Jendrewski, C, Bartels, M. Navigation in surgery. Langenbecks surgical robotics since these units will operate in anatomically Arch Surg. 2013 Feb: 398: 501-514. tight confined spaces. Real-time tool position tracking would 4. Cleary, K, Wilson, E, Ordas, S, Banovac, F. Navigation. Intraop Imaging and Image-Guided Therapy. 2014: 93-105. therefore be critical for robotic surgery. There is therefore 5. Enchev, Y. Neuronavigation: geneology, reality, and prospects. Neurosurg opportunity for novel technology development to make the Focus 2009:27(3): E11. 6. Haidegger, T, Xia, T, Kazanzides, P. Accuracy improvement of a neurosurgi- procedure safer, faster image acquisition speeds, lowering the cal robot system. Biomed Robotics and Biomech 2008: 836-841. surgical time and in improving surgical outcomes. 7. Manbachi, A, Cobbold, RSC, Ginsberg, HJ. Guided pedicle screw insertion: techniques and training. The Spine Jour. 2014 Mar: 14(1): 165-179. 8. Rahmathulla, G, Nottmeier, EW, Pirris, SM, Deen, HG, Pichelmann, MA. Evolution of OTS: Optical Surface Imaging Intraoperative image-guided spinal navigation: technical pitfalls and their avoidance. Neurosurg Focus. 2014 Mar: 36(3): 1-14. To address the limitations of current state-of-the art optical 9. Piatti, D, Remondino, F, Stoppa, D. State-of-the-art of TOF range-imaging tracking systems, the optical surface imaging (OSI) design was sensors. TOF Range-Imaging Cameras 2013: 1-9. 10. Hartl, R, Lam, KS, Wang, J, Korge, A, Kandziora, F, Audige, L. Worldwide developed in our research lab in hopes of minimizing surgi- Survey on the Use of Navigation in Spine Surgery. World Neuro. 2012 cal work flow interruption and making it more economically Mar:79(1): 162-172. 11. Paleologos, TS, Wadley, JP, Kitchen, ND, Thomas, DG. Clinical utility and accessible. It is currently completing clinical trials for spinal cost-effectiveness of interactive image-guided craniotomy: clinical compari- fusion procedures and can provide guidance to surgeons in- son between conventional and image-guided meningioma surgery. Neuro 2000: 47(1): 40-48. serting pedicle screws, with rapid set up time and fast registra- 12. Claasen, GC, Martin, P, Picard, F. Tracking and control for handheld sur- tion, which is a step above other commercially available surgi- gery tools. Biomed Circuits and Sys Conf 2011: 428-431. 13. Amr, AN, Giese, A, Kantelhardt, SR. Navigation and robot-aided surgery in cal navigation devices. the spine: historical review and state of the art. Robotic Surg Research and To address the issue of intraoperative procedures, current Reviews. 2014: 1: 19-26. 14. Stieglitz, LH, Fichtner, J, Andres, R, Schucht, P, Krahenbuhl, AK, Raabe, A, commercial systems are large and obtrusive in the operating Beck, J. The Silent Loss of Neuronavigation Accuracy: A Systematic Retro- room or are permanently fixed in its own dedicated room. spective Analysis of Factors Influencing the Mismatch of Frameless Stereo- tactic Systems in Cranial Neurosurgery. Neuro. 2013 May: 72(5): 796-807. Our navigation system using OSI is integrated with the operat- 15. Khadem, R, Yeh, CC, Sadeghi-Tehrani, M, Bax, MR, Johnson, JA, Welch, ing room light, intuitive and non-obtrusive. To address the la- JN, Wilkinson, EP, Shahidi, R. Comparative Tracking Error Analysis of Five Different Optical Tracking Systems. Comp Aided Surg 2000 5:98-107. bor intensive and time consuming paired-point point registra- 16. Rosser, JC Jr, Lynch, PJ, Cuddihy, L, Gentile DA, Klonsky, J, Merrell, R. The tion issue, the OSI technique instead uses biophotonics (the impact of video games on training surgeons in the 21st century. Arch Surg 2007: 142: 181-186. science of using light photons for imaging biological materi- 17. Haidegger, T, Kazanzides, P, Benyo, B, Kovacs, L, Benyo, Z. Surgical case als) to automatically detect the surface contours in the entire identification for an image-guided interventional system. Intel Rob and Sys (IROS) 2010: 1831-1836. field of view. The anatomical roadmap is then projected onto 18. Koivukangas, T, Katisko, JPA, Koivukangas, JP. Technical accuracy of optical computer screens in the operating room so that surgeons can and the electromagnetic tracking systems. SpringerPlus 2013: 2(90): 1-7. view the images in real-time as they operate. The navigation system is mounted above the table as the operating room light, for which the positioning and repositioning of the device are similar to how surgeons would move current surgical lights. Workflow is not disturbed and requires minimal operational movements. The device is user friendly and requires minimal setup time. This translates to faster and cheaper operating costs. Current operating room costs are between $100 to $200 per minute in Canada and typical neurosurgical procedures average about six to eight hours, which could translate into significant cost savings or improving throughput. While the spinal surgery trial is ongoing with this device, additional trials in cranial surgeries is underway.
Conclusion Studies have shown that surgical navigation systems have the potential to help reduce surgical time, reduce length of hospital stay, reduce hospital cost and complication rates. New advancement in biophotonics technology and machine vision may further improve the economics and ergonomics of surgi- cal navigation systems and widen clinical adoption.
UTMJ • Volume 92, Number 1, December 2014 9 Opinion Editorials
Police, Policy and Privacy: a Commentary on Mental Health Information Disclosures by the Toronto Police Service
Phillip K. Gregoire, BSc, MSc, Faculty of Medicine, University of Toronto
he relationship between the public good and an indi- sure, and pressure from mental health advocates, the TPS has vidual’s civil liberties has been the subject of much phil- indicated that they will not be changing their disclosure policy.7 Tosophical and political discourse over the past century. The implication of this policy for accessibility to the health Proponents and opponents of dying with dignity, firearm reg- system is profound for persons with mental illness. There is an istration, abortion, and recreational drug policy, among many absence of literature on the effects of this policy, but embarrass- others, have continually debated the extent to which civil liber- ment, perception of stigma, and concern about what others will ties can be trumped by protection of public interest. As society think are well-documented barriers to accessing mental health navigates through the information age, a burgeoning focus has services.8–10 As an example, it may not be possible for an indi- appeared around the concept of privacy as a civil liberty and the vidual to prove that he or she was illegally refused employment proposed rights of individuals to retain control over the body due to the mental health report on their police record check, of information that is known, publicly and institutionally, about and the perception that this discrimination is a possibility could them.1 It is at the intersection of privacy and public health that prevent an individual from accessing emergency care for fear of medical students at the University of Toronto investigated and the consequences. Inability to enter the U.S.A. can also impact subsequently advocated around a practice of mental health in- an individual’s ability to work in many fields that require cross- formation disclosure by the Toronto Police Service (TPS). border travel. The sociological impacts of these barriers could Since 2011, news outlets have reported on stories of Cana- result in delay of access for mental health services or emergency dians who have been refused entry into the United States for services during a crisis, a problem that may compound the al- reasons related to mental health.2,3 Student interest was initially ready low proportion of Canadians with mental illnesses who piqued in November 2013 by a news story of a woman who had access mental health services.11 been denied entry to the United States with the stated reason In order to appreciate why the TPS is resistant to changing being a 2012 hospitalization following a suicide attempt.3 An this policy, it is important to first understand that law enforce- investigative report on the incident, and others like it, by the ment officers (LEOs) are often the first responders to mental Information and Privacy Commissioner (IPC) of Ontario, es- health crises.12–14 Due to the frequency of encounters between tablished that it was the TPS who had collected the data dur- LEOs and persons undergoing a mental health crisis, there is ing emergency responses and entered it into a federally oper- a significant incentive to educate and train officers and imple- ated database called the Canadian Police Information Centre ment effective mental health response protocols.13,15 These (CPIC).4 This database is shared with and among United States changes may also benefit patients by providing more favorable federal agencies, which have the discretion to refuse entry into outcomes when the responding officer is trained in mental the country based on an individual’s history of mental illness.4,5 health.15,16 Information from this database, including mental health re- The public statements from the TPS for maintaining their ports, may also appear in background searches conducted by current policy can be summarized in two main points: the pol- TPS for an individual’s application for employment, education, icy is needed “to protect the person they’re called to deal with, volunteer positions, or other purposes.4 The IPC concluded to protect anyone else and to protect police officers,” and that that the current disclosure policy of this personal information “the issue is not the recording of this information in CPIC, but violates section 32 of the Municipal Freedom of Information the disclosure of this information to U.S. authorities, an issue and Protection of Privacy Act (MFIPPA) and filed an ongoing for the federal government.”4,6,7,17 The first point stems from a application for judicial review of the policy.6 Yet despite this pres- need for LEOs to have an broad understanding of a situation, including mental health issues, when responding to crises in order to effectively manage them.18 The TPS argue that in order to have this context, LEOs need access to a database with previous encounters with persons in Corresponding Author: Phillip K. Gregoire crisis that includes mental health history.4,18 The second point Email: [email protected] defers the responsibility to change the policy. TPS does not control CPIC; rather, it is operated through the RCMP by the National Police Services (NPS) program.19 The TPS has argued
10 UTMJ • Volume 92, Number 1, December 2014 Opinion Editorials
Police, Policy and Privacy: a Commentary on Mental Health Information Disclosures by the Toronto Police Service
that it is beyond their responsibility to modify what enters the 5. United States Immigration and Nationality Act, Section 212 [Internet]. 8 U.S.C. 1182 U.S.A.; Available from: http://www.uscis.gov/iframe/ilink/ database, because concerns about its usage should be addressed docView/SLB/HTML/SLB/act.html. by the NPS program.6 However, the TPS has publicly stated 6. Challis W, McCammon S. Notice of Application for Judicial Review re: Crossing the Line Special Report [Internet]. Toronto, ON; 2014 [cited (and the IPC has confirmed) that entry of mental health data 2014 Nov 23]. p. 1–28. Available from: http://www.ipc.on.ca/images/Re- into CPIC is done on a discretionary, not mandated, basis.4,20 sources/Notice-of-Application-for-Judicial-Review_reCrossingtheLinespe- cialreport.pdf. In order to address the public safety concern of the TPS, the 7. Cribb R. Privacy commissioner attacks police regarding disclosure of IPC created a set of recommendations that recognizes the need mental health records. Toronto Star [Internet]. Toronto, ON; 2014 Jun 06 [cited 2014 Nov 24]; Available from: http://www.thestar.com/news/ for LEOs to have a situational understanding when responding world/2014/06/06/privacy_commissioner_attacks_police_regarding_dis- to suicide attempts, while safeguarding the public from deleteri- closure_of_mental_health_records.html. 4 8. Sareen J, Jagdeo A, Cox B, Clara I, ten Have M, Belik S, et al. Perceived ous uses of this information. These recommendations include: Barriers to Mental Health Service Utilization in the United States, Ontario, limiting suicide attempt data entered into CPIC to attempts that and the Netherlands. Psychiatr Serv [Internet]. American Psychiatric As- sociation; 2014 Oct 9 [cited 2014 Nov 23];58(3):357–64. Available from: could be broadly characterized as endangering the public, cre- http://ps.psychiatryonline.org/doi/full/10.1176/ps.2007.58.3.357. ating a clear and transparent system to review the mental health 9. Wang J. Perceived barriers to mental health service use among individu- als with mental disorders in the Canadian general population. Med Care files, and developing a process by which an individual with in- [Internet]. 2006 [cited 2014 Nov 23];44(2):192–5. Available from: http:// formation in the database may have it removed.4 In response journals.lww.com/lww-medicalcare/Abstract/2006/02000/Perceived_Bar- riers_To_Mental_Health_Service_Use.14.aspx. to the IPC report, 215 medical students at the University of To- 10. Hoge C, Castro C, Messer SC, McGurk D, Cotting D, Koffman RL. Combat ronto signed a petition endorsing these recommendations for duty in Iraq and Afghanistan, mental health problems, and barriers to care. N Engl J Med [Internet]. 2004 [cited 2014 Nov 23];351(1):13–22. Available amending the TPS policy. These students’ voices joined those of from: http://www.nejm.org/doi/full/10.1056/NEJMoa040603. the Ontario Medical Association, the Mental Health Commis- 11. Fleury M-J, Grenier G, Bamvita J-M, Perreault M, Caron J. Determinants Associated with the Utilization of Primary and Specialized Mental Health sioner of Canada, and Centre for Mental Health and Addiction Services. Psychiatr Q [Internet]. 2012 [cited 2014 Nov 24];83(1):41–51. in supporting the recommendations.4,21,22 Available from: http://resolver.scholarsportal.info/resolve/00332720/ v83i0001/41_dawtuopasmhs.xml. The responsibility for changing the way CPIC is used resides 12. Teplin LA, Pruett NS. Police as streetcorner psychiatrist: Managing the with the NPS, but in lieu of a federal level policy change, the mentally ill. Int J Law Psychiatry [Internet]. 1992 Jan [cited 2014 Nov 21];15(2):139–56. Available from: http://www.sciencedirect.com/science/ petitioning student body believes that the TPS has an obliga- article/pii/016025279290010X. tion to ensure that this sensitive information is protected. Given 13. Watson AC, Ottati VC, Draine J, Morabito M. CIT in context: the impact of mental health resource availability and district saturation on call disposi- that entry of data into CPIC is discretionary, this group does tions. Int J Law Psychiatry [Internet]. [cited 2011 Nov 21];34(4):287–94. not believe that it is acceptable for the TPS to defer their duty Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?arti d=3171588&tool=pmcentrez&rendertype=abstract. to uphold the MFIPPA and the privacy rights it guarantees to 14. Steadman HJ, Deane MW, Borum R, Morrissey JP. Comparing outcomes of the NPS.4,20 The IPC recommendations create a compromise major models of police responses to mental health emergencies. Psychiatr Serv. 2000;51(5):645–9. between the needs of the TPS to effectively respond to mental 15. Teller JLS, Munetz MR, Gil KM, Ritter C. Crisis intervention team training health crises and the civil rights of the public to have mental for police officers responding to mental disturbance calls. Psychiatr Serv. 2006;57(2):232–7. health information kept private. 16. Brink R van den, Broer J, Tholen A, Winthorst W, Visser E, Wiersma. D. Future work must be done to better understand the impacts Role of the police in linking individuals experiencing mental health crises with mental health services. BMC Psychiatry [Internet]. 2012 [cited 2014 of the current policy on emergency service use and mental Nov 23];12(171):1–7. Available from: http://www.biomedcentral.com/ health crisis response across Canada. Students at the University content/pdf/1471-244X-12-171.pdf. 17. Artuso A. Ontario suicide attempts being shared with U.S. border officials. of Toronto continue to pursue change to the disclosure policy Toronto Sun [Internet]. Toronto, ON; 2014 Apr 14 [cited 2014 Nov 24]; by advocating at all levels of government and consulting with Available from: http://www.torontosun.com/2014/04/14/ontario-suicide- attempts-being-shared-with-us-border-officials. the TPS and experts in mental health and public policy. 18. Hoffman R, Putnam L. Not Just Another Call... Police Response to People with Mental Illnesses in Ontario [Internet]. Toronto, ON; 2004. Available References from: http://www.pmhl.ca/webpages/reports/Not_Just_Another_Call.pdf. 19. National Police Services (NPS) [Internet]. Government of Canada Royal 1. Nissenbaum H. Protecting privacy in an information age: The prob- Canadian Mounted Police Specialized Policing Services. 2012 [cited 2014 lem of privacy in public. Law Philos [Internet]. 1998 [cited 2014 Nov Nov 23]. Available from: http://www.rcmp-grc.gc.ca/sps/nps-snp-eng.htm. 24];17(5):559–96. Available from: http://www.springerlink.com/index/ 20. Benzie R. Ontario privacy watchdog blasts police for disclosing sui- K625W27565861919.pdf. cide attempts. Toronto Star [Internet]. Toronto, ON; 2014 Apr 14 2. Bridge S. Canadians with mental illnesses denied U.S. entry. Canadian [cited 2014 Nov 24]; Available from: http://www.thestar.com/news/ Broadcasting Corporation [Internet]. 2011 Sep 09 [cited 2014 Nov 21]; queenspark/2014/04/14/privacy_watchdog_blasts_police_for_suicideat- Available from: http://www.cbc.ca/news/canada/canadians-with-mental- tempt_disclosures.html. illnesses-denied-u-s-entry-1.1034903. 21. Tanden V. Ontario’s doctors support action taken by Ontario Privacy Com- 3. Canadian woman refused U.S. entry because of depression. Canadian missioner [Internet]. Ontario Medical Association Press Release. 2014 Broadcasting Corporation [Internet]. Toronto, ON; 2013 Nov 29 [cited [cited 2014 Nov 23]. Available from: https://www.oma.org/Mediaroom/ 2014 Nov 9]; Available from: http://www.cbc.ca/news/canada/toronto/ PressReleases/Pages/actiontakenbyOntarioPrivacyCommissioner.aspx. canadian-woman-refused-u-s-entry-because-of-depression-1.2444960. 22. Canadians’ mental-health info routinely shared with FBI, U.S. customs. 4. Cavoukian A. Crossing the Line: The Indiscriminate Disclosure of At- Canadian Broadcasting Corporation [Internet]. Windsor, ON; 2014 Apr tempted Suicide Information to U.S. Border Officials via CPIC [Inter- 14 [cited 2014 Nov 24]; Available from: http://www.cbc.ca/news/canada/ net]. Toronto, ON; 2014 p. 1–48. Available from: http://www.ipc.on.ca/ windsor/canadians-mental-health-info-routinely-shared-with-fbi-u-s-cus- english/Resources/Reports-and-Submissions/Reports-and-Submissions- toms-1.2609159. Summary/?id=1391.
UTMJ • Volume 92, Number 1, December 2014 11 Opinion Editorials
The State of Pharmaceutical Drug Coverage in Canada
Liza Abraham Patrick E. Steadman
anada’s universal health care system has been viewed ed being unable to afford their prescription drugs.6 This results internationally as a model of success; however, phar- in a non-adherence to treatment plans, and detrimental effects Cmaceutical drug coverage has remained disjointed on health outcomes. A universal, single-payer pharmacare plan and inefficient. The provincial and territorial responsibilities would allow for more equitable access to medically necessary of allocating health resources and funding have resulted in a medications, improve drug safety and appropriate prescribing, fragmented system for coverage of outpatient medications. In and control costs to ensure sustainability for public health fi- addition to these regional differences, access to medications nances. This is evidenced by lower rates of non-adherence in within provinces has been further divided between public and countries with universal drug coverage.7 private insurance coverage. The result of this fractured system There exists strong evidence to support a universal, single is wasted private and public spending. In 2009, Canadian house- payer system for prescription medications coverage.4 Increased holds spent an average of $320 on out-of-pocket expenses for purchasing power and nationalized negotiating power for drug prescription medications and $452 for private health insur- prices will drive costs down. We would also anticipate further ance premiums.1 These costs have continued to rise, with per reductions in costs from elimination of unnecessary adminis- capita spending on prescription drugs increasing by 4% yearly, trative costs associated with private insurers. The belief that a as compared to 2.9% in New Zealand and 1.2% in the United single-payer, first dollar pharmacare program would result in Kingdom.2 Furthermore, costs are expected to rise as chronic significant increased expenditures for the public health sector, disease prevalence and the use of oral chemotherapy drugs in- and would necessitate increased taxes, is inaccurate. Canadians creases. could save between 10-42% of total drug expenditures depend- Our current multi-payer system for prescription medications ing on the pharmacare reform strategies that are considered incurs greater costs in comparison to single-payer systems for and implemented.4 Additionally, a single, evidence-based na- a multitude of reasons. First there are the high costs of admin- tional drug formulary would optimize drug safety and efficacy istration associated with private plans due to insurance com- in treatment, while providing more expansive and equitable panies’ incentive to profit and the high costs associated with coverage for Canadians. client risk assessments.3 Secondly, a multi-payer system reduces We urge you to consider the issue of pharmacare and the the bulk purchasing power of each individual buyer. A single- efforts being put forth by numerous Canadian organizations to payer system would benefit from open market competition bring Canada’s healthcare system into the 22nd century. between multiple manufacturers, yielding lower drug prices. Thirdly, lower generic substitution rates have been observed in References 1. Law MR, Daw JR, Cheng L, Morgan SG. Growth in private payments for multi-payer systems as compared to single-payer drug coverage health care by Canadian households. Health Policy. 2013;110(2-3):141-6. systems.4 2. Gagnon M. A Roadmap to a Rational Pharmacare Policy in Canada. Ot- tawa: CFNU, 2014. Canadian prices for medications are higher compared to all 3. Law MR, Kratzer J, Dhalla IA. The increasing inefficiency of private health other OECD countries with universal coverage of health ser- insurance in Canada. CMAJ 2014;186(12):E470-4. 4. Gagnon M, Hebert G. The economic case for universal pharmacare. 2010 vices. In 2011, total prescription drug expenditures per capita [cited April 2, 2012]; Available from: http://pharmacarenow.ca/wp-con- were only less than USA compared to other OECD countries.2 tent/uploads/2010/09/Universal-Pharmacare-Report-e.pdf 5. PMPRB. Annual report 2008. Ottawa: PMPRB, 2009. While some might argue that drug costs have remained high to 6. Law MR, Cheng L, Dhalla LA. The effect of cost on adherence to prescrip- support pharmaceutical industry investment in Canada, these tion medications in Canada. CMAJ. 2012;184(3):297-302. 7. Morgan SG, Daw JR, Law MR. Rethinking pharmacare in Canada. 2013 policies have not resulted in the expected benefit; Canada’s ra- C.D. Howe Institute: Available from: http://www.cdhowe.org/pdf/Com- tio of pharmaceutical R&D to sales is merely 7.5%.5 As such, our mentary_384.pdf. government must reconsider such policies that do not provide appropriate benefit for Canadians. While the cost burden for Canadians is significant, the clini- cal impact of rising prices for pharmaceutical medications and inequity in access to medications has become an increasingly relevant issue for Canadians. Worryingly, 27% of Canadians re- main without drug coverage and 1 in 10 Canadians have report-
12 UTMJ • Volume 92, Number 1, December 2014 Opinion Editorials
Ebola: Context and Current Issues
Maia Foster Thomas M. Dashwood
ver five thousand people have died of Ebola virus Humanitarian interventions have been criticized for being disease in this year’s unprecedented outbreak in slow and inefficient. For many months, MSF was the primary OWest Africa. Although initial cases were reported in organization treating Ebola. Now, many Western countries March, misconceptions continue to circulate and an effective have contributed billions of dollars of funding, personnel, response has not been implemented. Ebola is a well-studied equipment and other expertise. Vaccines and new treatment disease; its route of transmission and management are es- trials are underway thanks to multinational efforts, yet these tablished, despite there being no cure. Transmission occurs potential solutions could come too late. There may also be through direct contact with bodily fluids, meaning it does barriers to using these treatments and vaccines, such as re- not spread easily.1 Nonetheless, Ebola is dangerous and pre- stricted funds, production of the product at scale, or issues cautions are necessary. The case fatality rate of this epidemic with large-scale distribution. Treatments and vaccines could is around 70%.2 However, by providing supportive care (hy- play a positive role in addressing Ebola, but controlling it dration, nutrition, fever control, treating concomitant infec- now still requires a strong focus on expanding strategies that tions), this rate can be decreased substantially.3 The problem are known to be effective. The EU Health Commissioner, with Ebola is not figuring out how to treat it, or how it spreads, MSF and scientists who have predicted the spread of Ebola which was the case with diseases such as SARS. Rather, a major based on current levels of aid have called for more support complication for responders is the context in which it exists. for established strategies including trained health personnel, This epidemic has many non-medical implications and it will improved public health measures (such as contact tracing), continue to disrupt West Africa if these factors are not quickly faster diagnostics, and more public education.8-10 addressed. Despite these calls, many nations, including Canada, Aus- The spread of Ebola was facilitated by a lack of health tralia and the USA, are imposing increasingly strict forms of infrastructure in Liberia, Sierra Leone and Guinea. These travel restrictions and quarantines, despite evidence suggest- countries are all within the lowest 13 countries on the United ing these strategies are ineffective and may limit the ability Nation’s Adult Health and Health Expenditures Index.4 Be- for nations to monitor Ebola.11 These policies may also deter fore Ebola arrived in West Africa, the number of doctors per health care workers from traveling to West Africa, whilst simul- thousand people in Guinea was 0.1 (in 2005), in Sierra Leone taneously augmenting global fear and misconceptions. it was 0.022 (in 2010), and in Liberia it was 0.014 (in 2008).5 In West Africa, Ebola has escalated local fears and taken a Ambulance services were almost non-existent in the region.3 toll on social support for survivors. According to UNICEF’s In addition, laboratory infrastructure has been insufficient to estimates, 6515 children have lost either one or both of their contribute to timely Ebola control, spurring the World Health parents.12 Under other conditions, extended families would Organization (WHO) to call for cheaper, faster and more be willing to take orphans in. However, there is powerful stig- readily available diagnostic testing.6 ma towards the victims of Ebola and their relatives. Fears of Ebola is taking a further toll on regional health infrastruc- infection have left survivors isolated from their families and ture. Many health care workers have given their lives to Ebola, communities. The stigma has even led people to lie about sick while hospitals and clinics have reduced services or closed due family members for fear of losing their jobs.13 Many Ebola sur- to lack of personnel and resources.3 As a result, other diseases vivors are fighting the stigma by acting as symbols of hope. are being neglected as efforts are shifted to combat Ebola and They are also working in treatment centres and adopting or- resources dwindle. Lack of malaria prevention and treatment phans.14 However, more local awareness programs to promote is a major concern, which has forced Médecins Sans Frontières prevention and dispel myths could help to curb further social (MSF) to focus additional efforts on anti-malaria campaigns.7 consequences. Economic side effects are also being felt through the re- gion. The Food and Agriculture Organization of the United Corresponding Authors: Nations has stated that production of food has been reduced Thomas M. Dashwood because of fear of contagion and mobility restrictions. Fewer Email: [email protected] farmers are working the fields and harvests may not make it to market.15 According to the World Bank, nearly one in two
UTMJ • Volume 92, Number 1, December 2014 13 Opinion Editorials
Ebola: Context and Current Issues
Liberian workers who was employed when the Ebola outbreak 4. Human Development Index (HDI) [Internet]. [Geneva]: United Nations began is now unemployed. Additionally, increased food scar- Development Programme. 2013 [cited 2014 November 23]. Available from: http://hdr.undp.org/en/content/human-development-index-hdi. city has driven up prices beyond what an average person can 5. Global Health Observatory Data Repository: Density per 1000 data by coun- afford. The World Bank also surveyed regions of Liberia that try [internet]. Geneva: World Health Organization (WHO). [1990] – [cited 23 November 2014]. Available from: http://apps.who.int/gho/data/node. have not been affected by Ebola and discovered that food se- main.A1444. curity is deteriorating due to falling incomes, increasing pric- 6. World Health Organization [Internet]. Geneva: World Health Organiza- es, and transportation restrictions. tion (WHO). Urgently needed: rapid, sensitive, safe and simple Ebola diag- nostic tests: Ebola situation assessment – 18 November 2014; 2014 Novem- Recent reports have indicated some improvements in the ber 18 [cited 2014 November 23]. Available from: http://www.who.int/ fight against Ebola. The outbreak in Guinea is now stable, ac- mediacentre/news/ebola/18-november-2014-diagnostics/en/. 7. Médecins Sans Frontières USA [Internet]. New York: : Médecins Sans Fron- cording to the WHO. The Centre for Disease Control has re- tières USA. MSF begins Malaria program in Ebola-ravaged Monrovia, Libe- ported that the spread of Ebola has decreased in Liberia. The ria; 2014 October 30 [cited 2013 November 23]. Available from: http:// World Bank’s fear of a $32bn economic loss has been revised www.doctorswithoutborders.org/article/msf-begins-malaria-program-ebo- la-ravaged-monrovia-liberia. to one tenth of the original estimate. Governments, the Inter- 8. Europa.eu [Internet]. Brussels: Communication Department of the Euro- national Monetary Fund and the World Bank have pledged pean Commission. EU boosts anti-Ebola aid after Commissioners’ mission to worst-hit countries; 2014 November 17 [cited 2014 November 23]. Avail- millions of dollars in loans, debt relief, and grants. However, able from: http://euun.europa.eu/articles/en/article_15748_en.htm. varying percentages of the funds have been disbursed and 9. Lewnard JA, Ndeffo Mbah ML, Alfaro-Murillo JA, Altice FL, Bawo L, Ny- deadlines for delivery remain unclear.16 enswah TG, Galvani AP. Dynamics and control of Ebola virus transmission in Montserrado, Liberia: a mathematical modelling analysis. Lancet. 2014 The sensationalizing of Ebola has done little to educate the Oct;14(12):1189-1195. public, and is detracting from critical discussions of the real 10. International website of Médecins Sans Frontières [Internet]. Geneva: Mé- decins Sans Frontières (MSF). Ebola crisis update – 21 November 2014; issues. Understanding the context of Ebola is just as important 2014 November 21 [cited 2014 November 23]. Available from: http://www. as understanding its biology. It is not enough to test vaccines msf.org/article/ebola-crisis-update-21st-november-2014. and treat the ill. Attention must be given to the social, eco- 11. International website of Médecins Sans Frontières [Internet]. Geneva: Mé- decins Sans Frontières (MSF). Ebola: quarantine can undermine efforts nomic and political issues that exist in the region, and have to curb epidemic; 2014 October 27 [cited 2014 November 23]. Available been exacerbated by this epidemic. In order to ensure this from: http://www.doctorswithoutborders.org/article/ebola-quarantine- can-undermine-efforts-curb-epidemic. type of crisis can be managed in the future, a balanced ap- 12. UNICEF Canada Website [Internet]. Toronto: UNICEF. Ebola Outbreak: proach between resolving the immediate crisis and addressing 8.5 million children at risk; 2014 November 17 [cited 2014 November long-term obstacles is essential. 22]. Available from: http://www.unicef.ca/en/ebola-outbreak-85-million- children-at-risk. 13. Mark M. Surviving Ebola: ‘People still don’t really understand this illness’. The References Guardian [Internet]. 2014 Nov 14 [cited 2014 Nov 22);World News:[about 1. International website of Médecins Sans Frontières [Internet]. Geneva: Mé- 5 p.]. Available from: http://www.theguardian.com/world/2014/nov/14/ decins Sans Frontières (MSF). FAQ - Ebola, about the disease; 2014 August surviving-ebola-people-dont-understand-illness-stigma. 19 [cited 2014 November 18]. Available from: http://www.msf.org/article/ 14. Nichols M, Harding Giahyue J. Defying stigma, survivors join the Ebola fight faq-ebola-about-disease. in West Africa. Reuters U.S. Edition [Internet]. 2014 Oct 27 [cited 2014 2. WHO Ebola Response Team. Ebola Virus Disease in West Africa — The Nov 22];Health:[about 2 p.]. Available from: http://www.reuters.com/ First 9 Months of the Epidemic and Forward Projections. N Engl J Med. article/2014/10/27/us-health-ebola-survivors-idUSKBN0IG23820141027. 2014 Oct; 371:1481-1495. 15. Website of Food and Agriculture Organization of the United Nations [In- 3. Médecins Sans Frontières Canada [Internet]. Toronto: Médecins Sans ternet]. Rome: Food and Agriculture Organization. Ebola outbreak in West Frontières (MSF). [Webcast], Webcast - Stopping Ebola: MSF’s experience Africa; 2014 [cited 2014 November 22]. Available from: http://www.fao. on the front lines of a historic epidemic; 2014 October 30 [cited 2014 No- org/emergencies/crisis/ebola/intro/en/. vember 23]; [10 sec]. Available from: http://www.msf.ca/en/webcast-stop- 16. One US Website [Internet]. Washington: One. Ebola Response Tracker; ping-Ebola-msf%E2%80%99s-experience-front-lines-historic-epidemic. 2014 November 19 [cited 2014 November 22]. Available from: http://www. one.org/us/ebola-tracker/.
14 UTMJ • Volume 92, Number 1, December 2014 Interviews
Brain Stimulation and its Role in the Assessment and Management of Movement Disorders
Ayan K. Dey, MD, PhD Candidate, Institute of Medical Science, Faculty of Medicine, University of Toronto
his article shares the transcript ment disorders continued to grow. After residency, of a recent interview with Dr. I did a fellowship at the NIH where I continued to TRobert Chen, senior scientist research movement disorders using combination of and staff neurologist at the Toronto neurophysiology and imaging. After completing my Western Research Institute. Dr. Chen fellowship I was recruited to a faculty position in To- specializes in movement disorders and ronto where I have been practicing ever since 1998. his research focuses on investigating the pathophysiology of movement dis- UTMJ: Brain stimulation is currently an area of great interest orders and the action mechanism of in the field of neuroscience, could you describe what brain stimulation techniques for the brain stimulation refers to? treatment of movement disorders such Dr. Robert Chen as Parkinson’s disease. RC: Broadly speaking, there are two types of brain stimu- lation; invasive and non-invasive. My research pro- UTMJ: Could you briefly describe your career path and what gram focuses on both types of stimulation. In non-in- brought you to studying movement disorders? vasive brain stimulation, no surgery is required. The most popular form of non-invasive brain stimulation RC: I went to medical school in England after high school is transcranial magnetic stimulation or TMS for short. as that’s how the British system is set up. I complet- TMS involves applying a magnetic coil to the surface ed my first three years at Cambridge and that is ac- of the head which generates a magnetic field which tually when I first became involved in research. My passes through the scalp and induces a current at the first research project was in the field of reproductive target site, thus stimulating the brain. Depending on immunology. Then I started my clinical training in the frequency used, TMS can be used to stimulate London, which is when I started becoming interested or inhibit a given area. That said, TMS can be used in neurology, clinically. I liked the detailed neurologi- to simulate the effects of a focal lesion in a human cal exam, and using my knowledge of anatomy and subject. Another type of non-invasive stimulation is physiology to deduce a localization and diagnosis. called transcranial direct current stimulation. This After finishing my internship in London, England, I does not actually produce neuronal activation but came to Canada. In Canada, I completed a Master’s biases the neuronal membrane. As for invasive brain degree under the supervision of Dr. Peter Ashby who stimulation, the most well-known form is deep brain was a neurologist and neurophysiologist based in To- stimulation or DBS. DBS involves implantation of an ronto. It was during this time that I was introduced electrode into the brain. In the context of movement to neurophysiology research and also to movement disorders, this electrode is generally put into the bas- disorders. I found movement disorders very interest- al ganglia. These electrodes are typically connected ing and again I was mainly drawn to the clinical as- to an implanted pulse generator which consists of a pect. I was fascinated by seeing all the different types battery pack. These generators provide continuous of movement disorders in patients and trying to fig- stimulation but can also be programmed to give in- ure out the right diagnosis. After my research year, I termittent pulses. began my residency in internal medicine at Queens University, followed by specialty training in neurology UTMJ: How did you become interested in brain stimulation at Western University wherein my interest in move- for the study of movement disorders?
RC: I got introduced to magnetic brain stimulation dur- Corresponding Author: ing my masters but at that time, our understanding Ayan K. Dey of brain stimulation was very rudimentary. Then dur- Email: [email protected] ing residency after attending a few neurology confer- ences, I started becoming interested in using brain stimulation to study the motor cortex. Nevertheless, it was mainly during my fellowship at the NIH that I
UTMJ • Volume 92, Number 1, December 2014 15 Interviews
Brain Stimulation and its Role in the Assessment and Management of Movement Disorders
further developed my knowledge of brain stimulation UTMJ: Have there been any clinical trials aimed at assessing using transcranial magnetic stimulation (TMS) and the efficacy of TMS? If so, what is the additional ben- how to use it to study brain plasticity in the context efit of TMS beyond what can be provided by conven- of movement disorders. It was at this time that I truly tional pharmacological treatment? started to appreciate the value of brain stimulation for exploring the pathophysiology of movement dis- RC: Most trials involving TMS introduce it as an add-on orders and the potential to use it therapeutically. therapy for patients who are already on medication. Most of these trials focus on the motor symptoms of UTMJ: At present, what role does non-invasive forms of brain Parkinson’s Disease such as tremors and thus use the stimulation play in the assessment and management Unified Parkinson’s Disease rating scale as a primary of movement disorders such as Parkinson’s disease? outcome measure. In this regard, preliminary studies Do you see it as more of a research tool, assessment have demonstrated some additional benefit of combi- tool or treatment option? nation therapy using TMS and medication relative to medication alone. However there is recently interest RC: Well, I think all of these apply. As a research tool it has in assessing whether TMS can help manage some of been very useful. It has been used to understand brain the non-motor symptoms of Parkinson’s Disease such excitability and plasticity, to further understand the as constipation, fatigue, numbness and depression pathophysiology of Parkinson’s disease and how treat- which are not as effectively managed by drug therapy. ment options such as deep brain stimulation work. It Indeed, a small number of trials have reported reduc- also has a limited role as a diagnostic tool, for example, tions in depression symptoms in those with Parkin- distinguishing some types of parkinsonism from typical son’s disease following repetitive TMS. Nevertheless, Parkinson’s disease. TMS has also been examined as a to date very few studies have investigated the effect of treatment option. Currently repetitive TMS (rTMS) is TMS on other non-motor symptoms and thus further an approved treatment option for medication resistant study is needed to see if TMS would be of benefit. depression in both Canada and the US. There have Overall it is premature to definitively claim whether also been a number of studies that have looked at using TMS is of additional benefit, but preliminary results TMS as a treatment for Parkinson’s disease with a re- are promising. cent meta-analysis showing that it is benefit when given in addition to conventional drug treatment. That said, UTMJ: Is TMS affordable? Is the added benefit clinically sig- while TMS seems like a promising treatment option, nificant enough to warrant the additional cost? more work needs to be done in the form of definitive, large randomized control studies to establish efficacy. RC: A TMS machine itself is not very expensive relative to other medical equipment. The main expense when UTMJ: Building on the idea of TMS as a treatment option, using TMS is that someone has to be there to admin- how does TMS differ from DBS for the management ister TMS….so there is a personnel cost, with ses- of Parkinson’s Disease? From my understanding DBS sions running between 20-30 minutes or more. Also has been largely successful for treating those with drug because it requires patients to travel to a treatment resistant Parkinson’s Disease. Do you think TMS could site, often repeatedly, there is also a significant time ever replace DBS? investment and cost of travel on the part of the pa- tient. These costs add up as a typical treatment course RC: I think they have very different roles. Deep brain stim- would be 10 sessions over 2 weeks or 20 sessions over ulation as you mentioned is very effective for those 4 weeks. That said, at present most medications are found to be suitable for it. However not everyone is cheaper than TMS but what we are trying to still suitable for the surgery. For some individuals the risk determine is if TMS can bring clinically significant of mortality or morbidity is too high. Moreover as it is benefit beyond what can be achieved by medication. invasive, the procedure is inherently more risky with On that note, there are lower cost non-invasive tools risk of hemorrhage or infection. So DBS is really for such as transcranial direct current stimulation which more advanced patients in whom medial therapy is can be bought at a significantly lower price and may insufficient. On the other hand, TMS, if proved ef- potentially be safe and feasible for home use by the ficacious by further research, can be applied much patient with proper training. There are ongoing stud- more widely. The number of people who could po- ies looking into this. tentially benefit from TMS would be far greater be- cause it is a non-invasive treatment. However because UTMJ: Are there any long term side effects of repeated TMS it is a non-invasive procedure, the effects of TMS are or brain stimulation? not permanent and thus patients often require mul- tiple sessions to produce a lasting effect. Thus, I do RC: TMS has been around since the mid-1980s and so far not think it will ever replace DBS but it could be used there are no known long-term side effects. Neverthe- as an adjunctive treatment for additional effect. less, there are some possible risks that we do explain
16 UTMJ • Volume 92, Number 1, December 2014 Interviews
Brain Stimulation and its Role in the Assessment and Management of Movement Disorders
to patients before treatment. The most concerning UTMJ: Finally, it has been proposed that as technology be- risk is the induction of seizures. Previous studies have comes more rooted in the management and assess- reported that seizures can be induced by rTMS. This ment of disease we are losing touch with behavioural is mainly related to the parameters used; namely the and functional outcome measures – do you agree intensity and frequency of the pulses. For this reason with this? If so, what are some of the consequences? there are currently guidelines to limit the stimulation parameters to make it safe. Thus the risk of seizure RC: I would say no. Having said that, I would say we do induction is very low in practice. There are also con- need to be careful in our overall approach. We need cerns regarding the sound of the machine so we pro- to remember to treat the patient not the “scan”. vide earplugs to participants. Sometimes imaging markers, while informative, may not directly relate to the clinical status of the patient. UTMJ: What do you feel has been the overall impact of brain For example, an MRI or positron emission tomogra- stimulation technology and what do you see in the phy (PET) scan may improve without corresponding future? improvements symptoms reported by the patient. Also there is an increased danger of over-interpreting RC: Deep brain stimulation (DBS) certainly has changed abnormal physiological/imaging parameters. Treat- the management of patients with movement disor- ing a patient with abnormal readings may or may not ders as it has been used to effectively treat individu- actually improve clinical outcomes. This is because als who have significant complications with medica- abnormal readings could represent many things. It tion. DBS is also being investigated in a number of could be a compensatory response or a consequence other conditions such as depression and Alzheimer’s of a disease rather than the cause. So I think one disease. Looking into the future, I believe there will needs to be careful in interpreting the meaning of be significant innovations in DBS. Currently, what abnormal test results. It is important to always relate we use is an open loop system. In an open loop sys- test results to the clinical status of the patient. Never- tem, we set parameters which we test clinically and theless, I think technology if we use it properly can then program into the device. In the future what I help us identify surrogate and subclinical markers of think will happen will be the development of close disease before more overt clinical markers appear. loop systems where the intensity and timing of stimu- If such markers can be developed and proven to be lation will vary based on real-time patient data gath- reliable, treatment can begin earlier which may in ered through biosensors. In this way the device will turn improve clinical outcome. Ultimately, one has set its own parameters that are optimized for a given to keep in mind, what really matters is the clinical patient and will be capable of automatically adjusting outcome. parameters as needed. Another technology that I see in the horizon is the use of brain computer interface UTMJ: That concludes the interview questions. Thank you wherein patients will be able to control assistive de- Dr. Chen. vices using brain signals. RC: My pleasure. UTMJ: What about advanced brain imaging techniques such as functional MRI and diffusion imaging? How do you feel they have contributed to the management of brain disorders?
RC: Functional and diffusion imaging tools are excellent research tools that have helped improve our under- standing of a lot of neurological disorders. With func- tional MRI informing us about changes in functional connectivity in the brain and diffusion imaging help- ing us visualize changes in white matter tracks. These tools are now starting to play a bigger role in clinical decision making. For example, neurosurgeons may now use fMRI and diffusion imaging when planning their operations so as to minimize side effects arising from disruption of important tracts or brain regions. Overall, while MRI has been around for a long time, I can see these newer techniques gradually becoming more integrated into clinical practice with time, in addition to being very useful in research.
UTMJ • Volume 92, Number 1, December 2014 17 Interviews
Paving the Way in Biomedical Engineering: An Interview with Dr. Molly Shoichet
Amirah Momen
r. Molly Shoichet holds the (UofT), largely due to my professional interactions Tier 1 Canada Research Chair with Michael Sefton (Chemical Engineering, UofT). I Din Tissue Engineering and is a joined UofT in 1995 with an NSERC University Faculty professor of Chemical Engineering & Award and have been thrilled to build my career here. Applied Chemistry, Chemistry, and Bio- materials & Biomedical Engineering at UTMJ: Can you tell us a bit about what your lab does? What is the University of Toronto. Dr. Shoichet it about regenerative medicine and biomaterials that first received her Bachelor of Science in most interests you? Chemistry from the Massachusetts Insti- tute of Technology (MIT) before going MS: Our inventions are all in biomaterials. We invent new on to complete a Ph.D. in Polymer Sci- materials to overcome problems. These materials are Dr. Molly Shoichet ence and Engineering at the University able to achieve success where others have failed. We of Massachusetts Amherst in 1992. As a world-renowned ex- use a significant amount of biomaterials chemistry to pert in the study of polymers for tissue engineering, drug de- achieve success. Our strategies are enabling. We look livery, and regenerative medicine, Dr. Shoichet’s lab leads the to biomaterials to achieve targeted delivery, grow way in the development of innovative biomedical technologies. cells in 3D, stimulate endogenous stem cells, and de- Through the application of engineering, chemistry, and biol- liver stem cells. ogy, Dr. Shoichet’s work endeavors to solve medical problems, such as how to improve recovery from spinal cord and stroke UTMJ: What role, if any, do particular disease models play injury. A few of Dr. Shoichet’s ongoing research projects in- in your research? Do you endeavor to design bioma- clude the development of novel biodegradable polymers that terials/technologies that are specific to given disease allow for targeted delivery of chemotherapeutic agents and models or is your goal to discover more broadly ap- minimally invasive hydrogels for cell delivery to the brain, reti- plicable solutions to basic physiological problems? na, and spinal cord. Dr. Shoichet’s significant contributions to scientific research have been recognized by many prestigious MS: We use disease models in all aspects of our research. distinctions including the Queen Elizabeth II Diamond Jubilee We look at a biological or medical problem and then Award (2013), the Order of Ontario (2011), and her role as a work backwards to create a series of design criteria that Fellow of the Royal Society of Canada (2008-Present). we think are required to be successful. Inevitably, we are designing solutions to ill-defined problems. Our UTMJ: Can you describe how you came to be interested in results enable us to better define the problem and thus regenerative medicine and your journey from stu- propose a better solution. It is an iterative process. dent to scientist? UTMJ: What are some of the major considerations when de- MS: This is a long answer, but briefly….when I was an un- signing biomaterials and therapeutic technologies that dergraduate student at MIT, I became fascinated with will ultimately move from bench to bedside? Are there polymers. I decided to pursue a PhD in Polymer Sci- any common barriers to successfully achieving clini- ence and Engineering at the University of Massachu- cally useful, safe, and effective biotechnologies? setts Amherst instead of going to medical school (first I deferred med school and then I finally decided not to MS: Simplicity is key. There are many stars that need to align go). During my PhD, I was always interested in medical for a technology to make it into the market. The tech- applications of polymers and thus, when I had the op- nology has to work, it has to be scalable, [and] it has to portunity to join CytoTherapeutics (an encapsulated result in a real clinical benefit – that is, there must be a cell therapy company), I did. Et voila – I had joined market need. A big market is better than a small market, the field of regenerative medicine before it was called if you’re going after venture capital. Safety is key but regenerative medicine. I spent three years in the bio- insufficient. It has to be safe and efficacious. Ultimately, tech industry in the USA (United States of America) you need a strong business team and strategy to transi- and when I started to look for opportunities in Canada, tion from the invention (a patent or family of patents is I was most excited by those at the University of Toronto usually required) to the innovation and the market.
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Paving the Way in Biomedical Engineering: An Interview with Dr. Molly Shoichet
UTMJ: If you had to predict the next big thing in the world UTMJ: What are the three most important characteristics of of regenerative medicine, intelligent drug delivery, a successful/ideal regenerative medicine technology and/or biomaterials, what would it be? (or any biomaterial technology)?
MS: There are so many opportunities. It’s hard to pick MS: To be successful it has to work. For cell transplanta- one. But cell delivery to the retina to overcome blind- tion, the biomaterial has to support cell survival and ness has tremendous potential. Our biomaterials cell integration with the host tissue. strategy is a key component of success. Having bio- materials that are easily injectable while promoting UTMJ: Do you have any mentors or idols in the world of bio- cell survival is key. Another hot area is 3D cell culture medical engineering [BME], healthcare technology, using biomimetic biomaterials to achieve tissue-like or science as a whole that you look to for inspiration? conditions in vitro. MS: In BME, Robert Langer (MIT) is a superstar. He is one UTMJ: What is the importance of interdisciplinary teams in of the founding fathers of tissue engineering and drug the research you do? What is the role of clinicians, if delivery. He’s innovative, creative, generous, and sup- any (i.e. dialogue, research, providing basic scientists portive. Closer to home, Michael Sefton (UofT) is in- with access to data from patient populations, tissue credibly insightful and smart, creative, and supportive. samples…)? He is one of [the] founding fathers of encapsulated cell therapy and blood-contacting materials. MS: Everything we do depends on the strength of our col- laborators and interdisciplinary research teams. We UTMJ: What is the most important thing you have learned work collaboratively with basic biologists, neurosci- over the course of your career in biomedical research? entists, stem cell biologists, surgeons, and clinicians. Our medical colleagues provide us with key insights MS: Take risks. Don’t be reckless, but also don’t fear fail- into the problems that require solutions, design of ure. Stay in the game. Be tenacious. experiments, interpretation of results, and access to human-derived tissue on occasion. UTMJ: Dr. Shoichet, thank you for your time and for sharing your perspective with us. We cannot wait to see what you do next!
UTMJ • Volume 92, Number 1, December 2014 19 Interviews
Healthy Lives for All, Until the Last Breath: An Interview with Dr. Alex Jadad
Muskaan Vineet Gurnani Arnav Agarwal
r. Alejandro R. Jadad Bechara UTMJ: Tell me about yourself and the scope of your work. (Alex Jadad, in short) is a phy- Dsician, educator, researcher, AJ: : I am a physician by training and a healer by voca- and public advocate. He is a Profes- tion. My work focuses on figuring out ways in which sor in the Faculty of Medicine and the we humans could have the longest, healthiest, hap- Dalla Lana School of Public Health, piest possible lives, full of love, and with no regrets, and holds the Canada Research Chair until our last breath – as part of a planet that doesn’t in eHealth Innovation at the University pay the price along the way. Health Network and University of To- So, I try to blend the high-touch with the high-tech. ronto. His mission is to enable people I try to foster what is really meaningful to us as hu- to build full lives through innovative mans – health, happiness, love – with the support of a Dr. Alex Jadad global collaborative efforts enabled by global network of collaborators who use information information and communication tech- and communication technologies to transcend tradi- nologies (ICTs). Alex has been called a “human Internet”, as tional barriers. This also involves obsessive efforts to his research and innovation work seeks to identify and con- eliminate unnecessary suffering. There is a lot of that, nect the best minds, the best knowledge and the best tools most as a result of inequity throughout the world. In- across traditional boundaries to eliminate unnecessary suffer- equities are inequalities that could be corrected, and ing and promote maximum levels of joy. that should be corrected. Dr. Jadad is one of the first physicians in the world with a doctorate in health knowledge synthesis, and has developed UTMJ: What led you to founding the Centre for Global unique methods to collate and distill high-quality health eHealth Innovation, and what does the organization information for decision-making. His development of the represent? widely used Jadad scale has drastically impacted clinical trial appraisal globally, and his work was instrumental to the de- AJ: I began my real career – that of a curious creature, velopment of the Cochrane Collaboration. Furthermore, he learning to unlearn – when I was 17. I was already a spearheaded the creation of the Centre for Global eHealth third year medical student in Colombia, South Amer- Innovation – a simulator of the future and a hub for ICT opti- ica, when I realized, thanks to a couple of school kids mization in health care and society – in 2000. He is also spear- in a very poor area of Bogotá, how disconnected med- heading the founding of the Global People-Centred eHealth icine has become from society at large. They asked Innovation Network to promote research, development, edu- me questions about ‘basuco’, which was a derivate of cation, policy, funding, recognition, and commercialization the coca plant, about which I didn’t have a clue. Even surrounding ICT use for health and wellness, and the People, though I was a medical student at the top faculty of Health Equity and Innovation Group to address the needs of medicine in the country that was leading the world the disadvantaged members of society through youth leader- in the cocaine trade, I did not have a clue about co- ship, global multiculturalism promotion, and supportive care caine or this new thing, which soon became known to patients and their caregivers. Dr. Jadad’s work has been as ‘crack’. Before I was 20 years of age, my research recognized on numerous levels, and his groundbreaking dis- on basuco, from a medical perspective was used by coveries in e-health innovation, global health and research governments and United Nations, as there was very methodology – among other areas – are world renowned. little else available. I do not feel that this was a matter The purpose of this interview is to learn about his jour- of genius; it’s just that there was a gap so wide that ney from the time in which he was a medical student, and it was not easily visible. So, from a very early age, I to explore his views about medical education, medicine, realized that there is a big gap between what people health, the health system, and the future of the species as a need, want, and expect from medicine and what we whole, in the age of global social networks. More information call the health system, and what we are offering. My about his life is available at http://en.wikipedia.org/wiki/ entire career has been devoted to filling that gap. Alejandro_R._Jadad_Bechara. It was cocaine first. The work on cocaine, which is a local anesthetic, helped me become aware that we
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Healthy Lives for All, Until the Last Breath: An Interview with Dr. Alex Jadad
know very little about the management of pain. In AJ: But this one (he pointed) has 5; the one on which you fact, in Canada, medical students get 3-5 times less are sitting. training on pain management than vet students! Something similar has been shown in the UK and UTMJ: That is true. Australia through analyses of medical school curri- cula. We seem obsessed with diagnosing and fixing AJ: Then what’s a chair? people, which are important when we face curable conditions. But when it comes down to chronic illness UTMJ: Something that is used to sit on. or symptoms like pain, which is probably the symp- tom that we humans fear most, we don’t have a clue! AJ: For the record, I am sitting on the floor. Is this a Then, work on pain relief took me to death and chair? dying, which continue to be very neglected. We don’t talk about death, we don’t talk about dying; we know UTMJ: No. who dies when and where, but not how. We avoid talk- ing about death in medical schools, and in the health- AJ: Then what’s a chair? We cannot define pretty much care system in general. So I started to look at death anything. So don’t try to define things. Defining and dying issues, joining forces with others to create things requires precise language, to describe an enti- criteria for a ‘good’ death anywhere in the world. ty in a way that everyone would accept and that would And then, the Web exploded! I could sense it com- include all instances of the entity. So, I asked this ing, when I started playing with what was known as question to myself in the year 2008 when I thought I Mosaic and Gopher, before the Web was publicly had colon cancer. I realized that even if I had colon available – it was only accessible to academics and cancer, I wanted to be healthy. But to be healthy, I government agencies at the time. A few years before, needed to know what health means. I was shocked to in 1990-1991, a patient asked me at the pain unit at think that 20 years of university education made me Oxford whether I would be keen to get an email mes- unable to answer the question ‘what is health?’ What sage from him about his pain, and I said “sure!” Thus, do I mean by health, and how do I know when I am this patient and I started to peek into another gap, healthy? now in the virtual world. I was very good at diagnosing diseases, and I was These big gaps between what people need, what rewarded for diagnosing disease, and trying to treat people want and what people expect from the sys- it. But in horror, I realized that I did not know what tem and our inability to pay attention to them, led health means. I checked the definition (and they to the creation of the Centre for Global eHealth In- called it a definition), that was used for the creation novation, which is in essence, a place that is designed of the World Health Organization in 1948, and it still with change in mind, because the only thing that we reads, ‘health is a state of complete physical, mental can anticipate is change. It is a place where we can and social well-being, and not just the absence of dis- imagine the future – a future where we would all like ease or infirmity’. But who can claim to have com- to live, and that we might be able to create, collab- plete physical, mental, and social wellbeing? You are oratively. So we have a facility where we can simulate tired, you did not sleep well last night, and so you are almost any set of circumstances where we could im- not healthy. You probably have cavities – the preva- prove our health and actually build them, collaborat- lence of tooth cavities is huge (it is the most preva- ing with people from different disciplines, and put- lent chronic disease in the world, a fact that is often ting the person, and the community at the centre ignored). Most people in society have visual prob- (and lead) of the change process. This organization lems. Even if your shoulder aches a little bit, you do creates an opportunity to close the gap, that gap that not have complete physical wellbeing. If you have to has fed my career, sadly, between what we as members wear glasses, you don’t have complete physical wellbe- of society want and need to achieve optimal levels of ing. So in essence, that definition makes us all ‘not health, and what we get, in the age of the Internet healthy’, and makes health impossible to reach. So and social networks. we medicalized our lives, to our advantage of course. In the year 2008, when we were celebrating the 60th UTMJ: How do you define health and illness, and what is the birthday of the World Health Organization, I had the role of technology in addressing the two? privilege to invite the world to participate in a global conversation about the meaning of health, and we AJ: Nothing important can be defined. Try to define a used technology for that. chair – as Wittgenstein, the philosopher, invited us to The British Medical Journal supported this conver- do. What is a chair? sation, and 3 years later, we proposed what is, rath- er than a definition, a conceptualization of health. UTMJ: A surface with 4 legs that someone sits on? When you conceptualize something, you try to de-
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Healthy Lives for All, Until the Last Breath: An Interview with Dr. Alex Jadad
scribe it approximately with what it intends to achieve health is good, very good, or excellent, then you are or with what it makes you feel or with some features healthy! If you have the label of a disease or more that would allow you to recognize it – it is a very dy- than one disease, it is our responsibility as health pro- namic thing. The concept of health we are proposing fessionals to acknowledge this, to honour this, and to is the ability to adapt and to self-manage when we are enable you to remain healthy. If you have a disease facing physical, mental, and social challenges, as indi- that could be treated, we should treat it, of course. As viduals or communities. That implies preventing the this is not the case in most instances, we must look be- preventable, treating the treatable, and transcending yond the biological and medical aspects of an illness the inevitable. If you have a chronic disease, by de- as the main drivers of the decisions we make. fault, it is incurable. We have discovered that having an illness or disease and being healthy are not incom- UTMJ: What role can information and communication tech- patible things. 90% of people with diabetes consider nology play in transforming medical education and themselves to be healthy, for example. Two-thirds healthcare? of people with incurable cancer have been shown to consider themselves healthy – that their health is AJ: Well, it depends on us. What do we want to be? What good, very good, or excellent. is our essence? What is really the role of a physician We really don’t know what disease or illness mean. in the 21st century? What are those things that only We haven’t devoted enough attention to this – who is we as physicians can do that no other group can just to decide what is an illness or a disease? Traditionally, as well or better? When we think in those terms, it it has been the medical profession, which has decid- gets very uncomfortable for us. What justifies our ed what is abnormal. existence in society? If we are the people that make Havi Carel, a philosopher in the UK, who was di- diagnoses and fix people, do we need so many years agnosed with a very serious disease at an early age, of training? Do you really need to go through medi- proposes at least 3 approaches to the conceptualiza- cal school for 20 years to do a bypass on a heart? Do tion of illness. She proposes to take into account the you as a member of society prefer to have a group biological or medical aspects – the naturalist perspec- of people who for three years devote themselves to tive – criteria proposed by people who are experts in learning about how to put a piece of vein on a heart? medicine about what is abnormal – we need to be very What is the role of hospitals? We haven’t thought careful about that. Psychiatry is a clear example – how about this very much either. ‘Hospitals’ come from we decide when something is a mental disease is one the Latin word ‘hospes’, which refers to a ‘guest of the most contentious things. So we need to be very, house’. It is a place where you should feel as com- very careful – even with cancer. Cancer does not seem fortable as you feel at home when you cannot be at to be just a disease; it seems to be at least 250 differ- home because you are not well. What is the role of ent conditions. The more we dig into the biology of hospitals? Probably only 5 things – intensive care, the tumours, the more we realize that using the word major emergencies, major surgeries, exacerbation ‘cancer’ is very similar to using the word ‘infection’. of complex chronic conditions, and experimental “Oh I have an infection!” What does it mean? You can stuff. Everything else should, and could, be happen- have a cold, pimples, or Ebola – all are infections! ing elsewhere. Hospitals are the most dangerous Saying, “I have cancer” – what does it mean? When places in society. Perhaps, most of what is happening we stop to think about what illness is, we realize that in a hospital right now should be happening outside we haven’t stopped to think about what we mean, or those buildings. Information and communication should mean, by it today. So Havi Carel says, yes there technologies should be enabling us to achieve opti- is a biological aspect to illness. mal levels of health by avoiding going to those places, But then there is a societal aspect to illness – how or by connecting us with people who could enable us we as a community consider things to be normal or to adapt and self-manage when we could not do it on abnormal. There are situations like back pain – back our own, or with support from our peers and other pain in other cultures is not an illness or attention members of our communities, or with support from deficit disorder or hyperactivity – that do not exist, community-based professionals. or are not accepted as an illness in other parts of the What kind of medical education do we want? Do we world. That does not mean that they are not diseases want to train people to be technicians, or to be the – but that they are socially determined. Havi Carel storefront for industry to sell their products, or do we insists that at the end of the day we have ignored the want people who are truly enabling the population to phenomenological aspects of our health – how it achieve maximum levels of health in the sense of the feels to the person, the lived experience. That is why ability to adapt and self-manage when faced with phys- we are emphasizing a lot on the self-reports of health ical, mental, and social challenges? If that is the case, status. We are asking people, “In general, how would we need to change medical education dramatically. If you rate or judge your health?” If you feel that your not, we just need to acknowledge that we are techni-
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Healthy Lives for All, Until the Last Breath: An Interview with Dr. Alex Jadad
cians and that we use gadgets to help us do more of beyond what could not be fixed with gadgets, within the same, which may not be meeting the needs of so- a context that is not really a system, but an inefficient ciety. Don’t get me wrong – I’m not talking about not franchise of repair shops which at the end of the day treating the treatable – if there is something treatable might be the biggest threat to our health. it should be treated, and for free! That is what people like Archie Cochrane said – every effective treatment UTMJ: What has guided your work in global health and must be free. Most of what we are doing is trying to eHealth innovation? treat untreatable things and throwing therapeutic op- tions at things that are not going to go away, neglect- AJ: The feeling that we are part of a species that is accel- ing in our medical education the relief of symptoms, erating its own extinction, that global health refers or the social aspects of illness. Loneliness may cause to our ability to adapt and self-manage as members more death amongst old people today than obesity of a species facing challenges as a group – as a super- or high blood pressure. Fatigue is the most disabling organism in trouble – one that should be considered symptom amongst people with cancer. We know little very much part of the planet, not a separate entity try- about how to deal with those important things! ing to control it. We are experiencing an existential Even more importantly, it seems possible to create crisis, from the individual to the planetary levels. The and spread health. As ideas, emotions, and behav- air we breathe, the atmosphere, as Buddhists tell us iours are contagious, health is likely to be transmis- repeatedly, is really our external organ. The water we sible. We have a unique historical opportunity to drink too. We must cherish them, because they are trigger a pandemic of health. Information and com- us. We are truly one. munication technologies could and should play a ma- jor role in speeding it up, particularly through the There are many sources of unnecessary suffering that are activation of our social networks. present everywhere in the world, and that should also be regarded as key drivers of global health activi- UTMJ: And is there a role here for information and commu- ties. Gender inequity is a big one, for sure. Being a nication technology to play? woman, for instance, might be the greatest risk fac- tor for violence in the world. Income disparity is a AJ: Of course! Because most of the issues require bond- big issue of global health, and it is growing. Early in ing, supporting each other, being with people when 2014, it was reported that 85 people had accumulated they feel most vulnerable, and contributing to im- more money than 3.5 billion people. We have been prove their capacity and ability to adapt and to self- putting more emphasis and value on the symbol of manage the challenges that life presents. In many wealth than on the actual wealth that money repre- cases, technology can also boost our efforts to cure sents. One billion people are hungry today, despite the curable, or to prevent the preventable. our capacity to produce enough food for every hu- man. This is global health too. That one billion peo- UTMJ: What are the consequences of our overreliance on ple don’t have shelter, even though we have space, technology? raw materials, knowledge, and energy to secure a roof for everyone in the world. By the way, at a hyperlo- AJ: We become more and more like robots, and less and cal level, tens of thousands of children in Toronto less human. The early industrial titans, perhaps, re- go every day to school without breakfast. Why? In a alized that building robots was too expensive or too country that wastes food worth much more than what complex, so they decided to turn us into robots. I feel would be required to eliminate hunger in the entire that it has been much cheaper, much more effective, world every year – there is no reason. So hunger is to turn humans into robots to perform tasks along not just a problem of India, where 250 million people production lines, than to build robots that could re- don’t have enough to eat. We have problems of hun- place us completely. This has now extended to the ger in a country like Canada. Gender inequity – there service sector, where the “healthcare industry” be- is no country in the world that has same conditions longs. Most of us are becoming, or behaving, like ro- for men and women. Not a single one – Iceland has bots. The educational system seems to be designed to the top index of gender equity and women make less standardize and to make sure that we conform, and money than men for the same type of work. All of are compliant, and that we go into production line- these issues have a lot to do with global health. like activities with division of labour, so we become So yes, we have challenges with traditionally prevent- more and more specialized doing few things, often able infectious diseases in most marginalized parts of just one thing, and one thing only without deviating. the world, but in financially rich areas we are facing The consequences of our overreliance on technology dangerous infections too, mostly caused by antibiotic- is the reduction in our humanity and reinforcement resistant bacteria. Antibiotic resistance and the fact of our transformation into robots and the inability to that there have been no new families of available anti- communicate, to bond, to relieve suffering that goes biotics since the late 80s (mostly because they are not
UTMJ • Volume 92, Number 1, December 2014 23 Interviews
Healthy Lives for All, Until the Last Breath: An Interview with Dr. Alex Jadad
commercially attractive to pharmaceutical compa- bodies, but less and less able to deal with health in the nies), while existing ones are abused may send us to broader sense – the ability to adapt and self-manage, a time (which ended in the early 20th century) when as essential to a full life. We need to stop, think and infections were the main cause of death for humans. question our most cherished assumptions and beliefs, That is global health. So global health for me, is an and join forces with other members of society. Many effort for us humans to act as members of a species faculty members, like me, are willing to work with you at risk of extinction, and to figure out a way in which to find better ways to deal with these types of issues. we could join forces so we can increase our collective The rate of burnout among residents is up to 75%, capacity to adapt and self-manage in the face of all and amongst medical students is about 50%. Most these challenges as part of a sustainable planet that medical students feel powerless to change anything needs to be healthy too! We must also look as deep as – so you have to conform, because you want to get possible. We need to think and deliberate about the your clerkship in a good place and then you conform underlying causes for these sources of suffering. Why because you want to get a certain residency. So you do we invest so little effort in prevention? Why do we keep conforming all your lives, and when you come have malaria now in Africa, Asia, and Latin America, out at the end you don’t remember why you went and no longer in the United States or Europe? In- into medicine in the first place. Most of us said it was evitably, we must start thinking about economics and because we want to help people. Our ability to help politics. people, in my case, to adapt and self-manage and to deal with the challenges of life, sometimes to cure UTMJ: What is one piece of advice you would like to share when problems can be cured, preventing what could with medical professionals and students? be prevented, and transcending, consoling, support- ing, providing as much relief to suffering whenever AJ: I don’t give advice or recommendations ever. I pro- possible is probably more important than anything – vide suggestions. One I would like to share is to be and we are neglecting all those things. Other major urgently patient, to think deliberately before acting, issues that we do not discuss as often or as seriously and to ask questions - Why? What if? So What? - As as we must, and that might be as important as they often as possible. Because we are facing huge chal- are ridiculed and undervalued in medical education lenges, while risking to become willfully blind, most and medicine in general, are love and happiness. You of the time, to the big issues. We are concentrating might want to discuss them in detail on a future occa- on what is easy – let’s diagnose and fix things. We are sion. paying a huge price – we are becoming less and less relevant in society, people are considering us increas- UTMJ: Are there opportunities to get involved with global ingly as technicians who don’t care. health and e-health innovation for medical students We are suffering – our emotional lives are shattered. and professionals? The level of burnout among physicians is very high, even from the early years of medical school. The rates AJ: Many! So please let me know if you are interested of suicide amongst female physicians are multiples of in any of the issues we have discussed today, and I the rates of suicide amongst non-physician members would be more than happy to have a good conversa- of society. Suicide is a leading cause of death amongst tion about efforts to tackle them, together with many medical students, if not the first one now. We are not interesting people in Toronto, Canada and beyond, a happy bunch. We are becoming sad, burnt out, who believe that it is possible for us all to live a full life disconnected from society, and trained to do things as sentient parts of a flourishing planet. that have less and less value in terms of health, and more and more value in terms of the sophistication UTMJ: Thank you very much! of our understanding of the smaller aspects of our
24 UTMJ • Volume 92, Number 1, December 2014 Interviews
Exploring The Past, Present and Future of Health Technologies with Dr. Joseph Cafazzo
Amirah Momen
t was during his time as an under- also around the same time that he was doing a major graduate engineering student at Canadian Foundation for Innovation (CFI) grant to Ithe University of Toronto that Jo- build this place [The Centre for Global eHealth In- seph Cafazzo first became interested in novation]. I was still a staff engineer here but I was biomedical engineering. He later went starting grad school and we built this centre to sort of on to complete a Master’s of Health realize his vision of a very multidisciplinary environ- Science in Clinical Engineering and ment that allows people to solve problems with the a PhD in Health Informatics, also at use of information and communication technology. the University of Toronto. Today, Dr. Although I’m extremely proud of the accomplish- Cafazzo serves as Executive Director ments of biomedical engineering over the past 50 of Healthcare Human Factors (HHF) years, we’ve also created technologies that haven’t Dr. Joseph Cafazzo at the University Health Network, the served us well, haven’t served the people using the largest Human Factors team devoted to research, design, technology, and haven’t served patients very well. evaluation, and consulting related to interactions between Around 2004, at the time that this centre was finally humans and technology in healthcare. He is also the Lead for built through proceeds from the CFI funding, we the Centre for Global eHealth Innovation, a research institute founded this group called Healthcare Human Fac- focused on the development of new technologies designed tors which, again, was meant to have a very critical to improve global health systems. Dr. Cafazzo is Associate look at the use of technology in healthcare. We were Professor in the Department of Health Policy, Management set up to evaluate technologies and inherent in that is and Evaluation as well as the Institute of Biomaterials and a very critical approach [that is] not about function- Biomedical Engineering. In 2010, Dr. Cafazzo received the ality – not whether or not devices fail in a traditional Career Scientist Award on behalf of the Ontario Ministry of sense – but more of a qualitative view from a behav- Health and Long Term Care. Now in his 20th year working ioral-cognitive perspective. How do people interact with the University Health Network, Dr. Cafazzo continues his with technologies that supposedly were designed for efforts towards improving healthcare globally through world- their interactions? And what we find in most cases, es- class research, innovation, and the development of informa- pecially in health technologies, is that there’s a huge tion and communication technologies. gap between the expectations in the abilities of the people who use these technologies and the actual de- UTMJ: Could you describe how you ended up here at the sign. And so, in more recent years, digging deeper Centre for Global eHealth Innovation and what it is into that, it’s been more a question of not just finding that you do here? the problems but solving them.
JC: I think it was in my first year of Engineering […when] * Ed. Note: An interview with Dr. Jadad is also featured in I got introduced to something called “biomedical en- this issue’s ‘Interviews’ section. gineering”, which was bizarre to me – it was this in- tersection of medicine and engineering. I especially UTMJ: You’ve mentioned that you have an appreciation for liked the idea of a program called “Clinical Engineer- how technology can “do as much harm as good.” Can ing”, which is a very applied form of biomedical engi- you tell us what the three most important factors are neering, [and] which [trains] an engineer [who will] in distinguishing the good from the bad with respect be in the clinical setting. I did that master’s program to healthcare technology? and then my career started as a biomedical engineer. I did that for nine years and then I got the itch to do JC: Really good technology is when you don’t even notice further graduate school, a PhD, and I of course gravi- it anymore; it becomes transparent. It kind of just dis- tated towards another degree in biomedical engi- appears. We’re inherently critical beings as it is and neering. But then I met Alex [Alejandro] Jadad* who we only really start noticing technology when it’s not was the founder of the program in eHealth at that working for us. But when something works absolutely time and he kind of convinced me that I should do as it should, you don’t even make note of it. So, I love something different and not necessarily in engineer- the technology that simply gets out of the way. There ing but in eHealth. That was in 2000/2001. This was are times when people remark that “that’s a really
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Exploring The Past, Present and Future of Health Technologies with Dr. Joseph Cafazzo
reliable device; I love that device” and so on. But I UTMJ: You’ve said before that a primary goal of yours is to think one of the examples […] was that the home extend care from the hospital to the home. Is the im- telephone was such a simple device that actually nev- petuous behind that an attempt to move people out er ever broke down and had a very simple interface. of hospital? Why or why not? People don’t think about their home phone […] very much anymore. A lot of people don’t have them any- JC: Yeah…well I think some of it is purely pragmatic more, but it was the device in the home where there because from a hospital perspective – and a lot of was absolutely nothing that would go wrong with it. It people have been asking this for a very long time – was always there. why do we continue pouring money into acute care when our problem is chronic disease? My response UTMJ: And you think that is because it stayed out of the way to that is a couple of things. [Firstly], don’t underes- or because it was reliable? timate hospitals in terms of their ability to deal with chronic diseases. They are changing. Princess Mar- JC: It was highly reliable and had a very simple interface. garet is now the Princess Margaret Cancer Centre. Anybody could use it. It’s no longer Princess Margaret Hospital. So, we’re in some sense dumping the baggage associated with UTMJ: So simple is good, is what you’re saying? the word ‘hospital’. which gives people the impres- sion that it’s really only treating acute exacerbations JC: Well, I think the adage we have is ‘simple, but not of chronic illness. Hospitals have to change, there too simple’. So, it still has to have the functionality needs to be greater continuity of care, and we can’t that we need, but it’s amazing how we make things just discharge a patient and hope for the best. So, unnecessarily complex. One of the examples I love I’m being pragmatic about the fact that, yes it’s true to use is hemodialysis machines. When we were con- chronic illness is what we need to focus on, but it’s templating the use of hemodialysis machines in the not going to be in the traditional way of pushing the home, operated by patients, people thought we were provider out into the community. We have patients crazy…and they were right because the devices were who are capable of doing a lot more than we allow unnecessarily complex. What we’re seeing now after them to. We don’t give them access to information, 10 years of home hemodialysis is that some smart we don’t give them access to tools, [and] we don’t companies are out there redesigning the technology give their family members the ability to help manage. for patients and it’s a lot simpler. It should be no sur- Yet they do this. There are 1.7 million Canadians who prise that it’s not only simpler for them [patients], define themselves as an informal caregiver and they but simpler for the nurses who have been struggling do that without information and are just sort of flying with the technologies for decades. by the seat of their pants, basically. We don’t make use of those people and, quite frankly, we don’t respect UTMJ: OK, so the three things defining great healthcare them the way we should. For me, the only means I technology might be boiled down to technology that have in order to change the system as an engineer is gets out of the way, is simple but not too simple, and through the use of information and communication that is reliable? technology and design.
JC: Yes, that’s right. UTMJ: Do you think more doctors should take an interest in designing medical technology tools? Why might this UTMJ: What do you see as the major themes in healthcare serve in creating better tools? technology today? JC: Of course physicians have to have a hand in the de- JC: Well, from my perspective, and I have this huge bias, sign, but it may not be what you think it is in terms of but I’m particularly interested in the consumer side. sitting down across from a physician and asking them So, the necessary shift towards the patient being questions like “what do you think of this feature?” more involved in their own care. As a consequence and “ what do you think of that feature?” That’s a very of that, patients are having access to the same infor- linear, direct way of the involvement of the physician mation that the providers have fundamentally – as a in the design of technology. What we tend to do is right,[and] as something that they are entitled to as not listen as much as watch clinicians work because owners of their own data. As a consequence of this, the problem with physicians is that they’re experts in [a major theme is] tools for patients to be able to what they do and it’s somewhat paradoxical, but they manage their own care more directly. And so, again, can’t actually articulate how they work. They miss out the migration of technology into the hands of the pa- on immense amount of detail that’s important in the tient, services that were traditionally only available to design of technology that’s intended to support them. them within the four walls of the clinic, are now avail- So there are lots of examples of this: the world fa- able at home. mous thoracic surgeon who is brilliant but can’t teach
26 UTMJ • Volume 92, Number 1, December 2014 Interviews
Exploring The Past, Present and Future of Health Technologies with Dr. Joseph Cafazzo
because they have trouble articulating to their resi- JC: Again, I think it’s a missed opportunity because that dents how it is they do what they do. A concert pianist record is shared and should be shared. So, what’s that is a brilliant pianist but can’t teach piano because the harm in turning the monitor, or the screen or they cannot articulate how it is they do what they do. the iPad, towards the patient and having a discussion And so, their role is to open up their clinic and allow about what’s happening in the record that they’re a designer of technology, an engineer or otherwise, documenting? And [mentioning], “by the way, when to come in and observe how they work, have a conver- you get home you can see it for yourself.” It is their sation about the details, [and] be involved in all the [the patient’s] record, so to me the idea that a physi- iterations. This is not something that happens over- cian being concerned that technology will stand in night [i.e.] that you list a number of specifications the way of the patient… that record is just as much and then on the other end spew out a product and theirs as it is yours in the management of their condi- think that it’s going to work instantaneously. The de- tion. So don’t use it as a barrier, use it as an opportu- sign of technology is very iterative, and to get it right, nity to have a dialogue. that’s the level of involvement we have to have. So, by being open to having people observe how they work, UTMJ: You’ve mentioned the importance of moving tech- [physicians] can contribute more in that way than in nology into the hands of the patient. Do you think any other way. that will be more difficult for those within the ageing population that maybe aren’t as tech-savvy? UTMJ: What do you think are the greatest barriers that pre- vent physicians from adopting the use of new tech- JC: No. It all comes back to the design. We hear this a nology? lot that older patients can’t do this stuff, that they’re not good with technology. Everything we’ve learned JC: Well, I think physicians are very pragmatic. Unless in the last 10 years shows that if the design is right, it’s self-evident that it’s going to help their practice, they can do it. In many of the trials of the technology they’re very wary of technology…probably because we’ve developed we have had octogenarians use the they’ve been burned by it before. Especially, the technology. They have no problem, again, if it’s well promises of electronic health records. We go as far as designed. In two instances of consumer applications, having to pay people to use electronic health records, both in the area of heart-risk assessment and diabetes which is absurd. I see even young physicians opting management, we’ve learned that it’s the older adults for file-folders and paper-based records because the that tend to use the technology more intensively and electronic systems don’t meet their needs, and that’s for longer periods of time than the younger patients. kind of shocking when the new generation of phy- So, it’s a myth that older adults can’t use this technol- sicians still can’t see the virtues of electronic health ogy nor will they. In fact, they use it more frequently records. On the surface and in principle, electronic and they’re more engaged for longer periods of time health records are supposed to make a lot of sense than their younger counterparts. I think that maybe but, pragmatically, if you look at a lot of the prod- it also has to do with [the fact] that when you’re sick ucts that are produced, they take more time and not you tend to be more engaged. There’s a big differ- less. It’s really hard to beat pen and paper so you have ence between someone who has been recently diag- to be very thoughtful in terms of the design of these nosed with diabetes and someone who has had their technologies in order for the adoption to be there. foot amputated as a result of diabetes. There’s a big I think in recent years with the popularity of a lot of difference between someone who smokes and is over- consumer electronics, things like iPads and so on, a weight and someone who is entering heart failure. lot of physicians and nurses alike have an experience Big diagnoses and big traumas in your life can change with this at home that is quite whimsical and they love your behaviors for sure. Maybe that has something to the use of this technology… then they come to work do with it as well. and they feel like they’re stepping back in time 10 or 20 years. I think there’s a great deal of frustration UTMJ: Is there a role for education in this process as well? and they just want basically the same experiences they Motivated patients still need to learn to use new tech- have in the consumer realm. nology.
UTMJ: Do you think perhaps another aspect to slow adop- JC: Yes, but I think the education is not didactic as you tion of healthcare technologies is not just ease of use, might think it is. The education is, to me, through but also fear of losing the human side of healthcare? self-awareness. That’s where the tools come in, in For example, many physicians have argued that there helping people interpret their lab results, because is something disconnecting about have a computer there are a lot of people walking around with chronic between themselves and a patient during an inter- illness who don’t have a full appreciation of why a view. hemoglobin A1C is important and why your potas- sium level is important if you have CKD and there is
UTMJ • Volume 92, Number 1, December 2014 27 Interviews
Exploring The Past, Present and Future of Health Technologies with Dr. Joseph Cafazzo
no understanding of what can effect those lab param- wearables, and the work that we’ve done in smart eters. So, the education [involves] building up the phone technology is being expanded. What enabled self-awareness around the seriousness of the chronic the smart phone to be such an innovative device is illness and, in fact, the bright spot of this is that it’s now being used in wearable devices that allow us to potentially very manageable. But I don’t think the capture vital signs on a continuous basis as people live traditional means of education are necessarily that their normal lives. Beyond that, we also see the home useful in an electronic form. You’re either going to being full of sensors that are able to monitor patients educate people face-to-face or through some other unobtrusively. So, those are things that will progress means, but the electronic education…I’m not neces- over the next 10 or 20 years but, fundamentally, be- sarily a big fan of. yond the technology, it’s about the role of the patient in self-care and for us to let go in a certain extent. We UTMJ: What major healthcare innovations do you see on the always try to reinsert ourselves…even when there is a horizon over the next 10 to 20 years? new technology that enables patients to do self-care. We kind of reinsert ourselves into that mix and to a JC: Well, we’re not finished on this design Human Fac- certain extent we have to let go of that. We can set tors [work]. You know, a lot of it is advocacy for the directions and so on but we need to allow patients patient. We’re a ways away from the patient being to be able to manage because we can’t afford it any empowered to do more self-care. On the surface, other way. As well, just keeping people aware that the when we show tangible examples of people being future of technology design in healthcare is not cre- very successful at this [using self-care technology], ating a medical device for the home but more about a lot of the decision-makers, the policy people, are taking what we’ve learned from the consumer realm very receptive to it and then the conversation ends. and informing health technologies for the future. We’re so focused on ourselves in the healthcare sys- There’s really no distinction between that doctor or tem and the challenges of treating people coming in that nurse when they’re at home sitting in front of our door that we aren’t thinking far ahead enough to a consumer device and when they walk through the anticipate how we prevent that patient from coming four walls of the clinic. They’re the same person but through our door. I guess it’s the whole health pro- we tend to treat them differently and we tend to treat motion question all over again. So, to me, the advoca- the design of the technology differently. So that de- cy still needs to be there. The technologies will evolve sign philosophy needs to be more pervasive through and we’re [working on] different technologies, like a lot of the health technology manufacturers.
28 UTMJ • Volume 92, Number 1, December 2014 Interviews
“Adding Years to Life”: Physiatry, Neurorehabilitation, and Knowledge Translation
Ayan K. Dey, MD, PhD Candidate, Institute of Medical Science, Faculty of Medicine, University of Toronto
his article shares the transcript of the specialty involves conducting detailed physical of a recent interview with Dr. examinations to determine exactly what the problem TMark Bayley, Medical Director is. The role of the physiatrist in a neurorehabilitation of the Brain and Spinal Cord Rehabili- team is to play a coordinating role in the inter-pro- tation Program at Toronto Rehab and fessional team of providers such as physiotherapists, a specialist in rehabilitation. Dr. Bay- occupational therapists, speech pathologists, [and] ley is also an assistant professor in the pharmacists. That role is to help provide an input as faculty of medicine at the University to the understanding of the underlying pathology of of Toronto and holds the Saunderson the diagnosis and other complications, as is neces- Family Chair in Acquired Brain Injury sary. There is also an emerging science around use Research. As Medical Director, Dr. Bay- of medications and recovery, so we are often consid- Dr. Mark Bayley ley treats people with strokes and other ering which medications to use. In managing com- brain injuries and does research in the field of brain recovery. plications of stroke [for example], a patient may have Specifically, he focuses on identifying, measuring and stan- shoulder pain, spasticity and a component of neuro- dardizing the most effective approaches to neurological re- pathic pain – all of which require treatment in order habilitation. to help the person to maximally recover with the in- put of the other therapists. So we play an important UTMJ: Physical Medicine and Rehabilitation (PM&R) is a role not only in coordinating and understanding the specialty that medical students and most individuals prognosis, but also in facilitating diagnosis and treat- have very little exposure to – that said, could you tell ment of complications of strokes and brain injuries. me about what is unique about PM&R and the role of physiatrists as part of the neurorehabilitation team? UTMJ: Many people have often not heard of physiatry and they confuse it with psychiatry or physiotherapy. MB: Physical medicine and rehabilitation is a relatively new specialty that arose around the time of the World MB: The term physiatry comes from the ancient words for Wars where people were returning from war with “physical doctor” and refers to the physical aspects of many types of injuries. – there were physical, mus- recovery and rehabilitation. So a lot of people con- culoskeletal, neurological, spinal cord injuries, and fuse it with psychiatry because that is the only other amputations. So the specialty arose because there specialty with “-iatry” at the end. So we are trying to was recognition that taking care of people who were raise awareness of that. The other thing is that people recovering and who were returning to usual life re- ask me “do you do physiotherapy?” But my answer is quired a specific set of technologies and understand- that I don’t do the actual therapy, but I work with ing of rehabilitation. The second part of PM&R is the therapists collaboratively to create a program of care. physical medicine part of it, which involves a recogni- We examine the patient and work with the team, tion that not all individuals come in with problems provide treatment and interventions for things such that are exactly musculoskeletal or exactly neuro- as pain management, medications for recovery, and logical, so a lot of what a physiatrist does is that they management of complications that should help the look at problems in a holistic way. Thinking, is this a therapists do their job better. musculoskeletal problem or a neurological problem or is it a little bit of both? The physical medicine side UTMJ: What drew you to physiatry and specifically neurore- habilitation?
Corresponding Author: MB: I was really drawn to physiatry first because I like Ayan K. Dey the fact that physiatry was related to recovery and it Email: [email protected] had a very positive impact on people. I found that you were taking over care of people often at their worst, and helping them to get better. That aspect was combined with my interest in training and exer-
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“Adding Years to Life”: Physiatry, Neurorehabilitation, and Knowledge Translation
cise physiology, as I have been a long distance runner implement it is really interesting to me. One of my and participated in sports all my life. I enjoy the fact particular interests is in the field of implementation you could set goals and you could train within the science that looks at how we change clinician practice context of normal physiological states, but I was also and take the best evidence and get it into practice. I interested in that aspect of training in pathological have been in interested in ensuring that all people in states. I was interested in helping people who had an Ontario and Canada get access to the best possible injury recover using training, exercise and technolo- care. I have been engaged in studying strategies to gy. That said, when I first went into physiatry I actually implement through best practice guidelines, decision thought I would be more of a sports-oriented phys- algorithms, quality based funding procedures that re- iatrist. But what happened was that I found that the ward best practice and other knowledge translation neuro-physiatry was much more fascinating. While tools. Overall, it has been very rewarding to develop far less is known about the brain and the mechanisms these strategies and observe the impact of implemen- of recovery, I found it far more interesting than mus- tation using stroke report cards and other health sys- culoskeletal rehabilitation. That is what led me to tem evaluation reports. neurorehabilitation. UTMJ: What are your least favourite aspects of your job? UTMJ: How would you describe the lifestyle of a physiatrist? MB: I think it would be fair to say, that the least favourite MB: In general, we are very fortunate in PM&R because the aspects of the career is the administrative part of the patients we often see are in a sub-acute phase of recov- day-to-day work which is just collecting data, manag- ery and thus from a lifestyle point of view we tend to ing data, trying to do the paperwork and do the re- have a quite predictable schedule and relatively pre- ports that are necessary. It has also been challenging dictable on-call issues because patients are generally to help raise awareness about this specialty. That is, improving. If a patient does become truly unstable and making sure that people are aware that we are avail- they need the service of acute care, they are typically able to help. I think that has been a big issue for us, so handled by specialists in acute care. Thus the lifestyle it is frustrating when I see a patient that would have tends to be very good in terms of hours of work and ex- benefited from consultation with a physiatrist or any pectation of call. Financially, it is very similar to a lot of rehabilitation professional and they have not been of- the other specialties in medicine, perhaps even a slight fered the opportunity. advantage because of access to daily fees for patients while they are in recovery, as well as opportunities for UTMJ: So what have you been trying to do to promote the third party funding through insurance companies for profession? patients involved in motor vehicle accidents. MB: First of all we are doing a lot of work to highlight the UTMJ: Do physiatrists perform any procedures? importance of rehab in the best practice guidelines. I have been involved in guidelines for concussion, trau- MB: A lot of physiatrists are engaged in nerve conduction matic brain injury (TBI), and stroke. This ensures and EMG. Emerging techniques for physiatrists in- that rehabilitation has a prominent location in each volved in Neurorehabilitation include a lot of inter- of those guidelines, when rehabilitation is appropri- ventions along the lines of botulinum injections or ate and evidence based. We also have raised the im- other focal treatments for spasticity. We also do joint portance of rehabilitation with stakeholder groups, injections, nerve blocks and other focal treatments such as the Heart and Stroke Foundation, Ontario such as trigger point injections and strive to better Neurotrauma Foundation, and other patient/con- understand their role in pain management. sumer groups.
UTMJ: What are your favourite aspects of your job and a ca- UTMJ: How often and how quickly are these guidelines actu- reer in PM&R in general? ally adopted?
MB: From a clinical point of view, I really enjoy working MB: Now that is what is scary. Research suggests that the with patients and helping them recover. During this time from a publication to uptake of the article rang- process, I help explain to them what is going on, help es anywhere from 17-30 years in many cases. So clini- manage their complications and see that a treatment cal practice guidelines are one way to synthesize all plan is put in place so that they are able to return, as that knowledge that is coming out so it is easier for much as possible, to a functional life. But that would clinicians to use. Even with facilitation it can take sev- be a very narrow view of PM&R because I also really eral years to get practice to be widespread. like the research work I do in terms of understanding how recovery works. Understanding more about what UTMJ: What is being done to speed up the process of knowl- is the optimal treatment for people and how we can edge translation?
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“Adding Years to Life”: Physiatry, Neurorehabilitation, and Knowledge Translation
MB: We are using a number of strategies. One of these sistently show that rehabilitation results in improve- things is doing an audit of current practice and feed- ments in function. We are currently doing research ing it back to people. We have generated report cards in patients’ trajectories of care and studying whether on stroke care that have been published for each of access to physiatry improves outcomes – however, I the Local Health Integration Networks (LHINs) to don’t really have the results for that yet. In general promote awareness of where the problems are and to it is hard to separate a physiatrist’s impact from that promote implementation initiatives. We have also im- of the interprofessional rehabilitation team because plemented the guidelines in projects we have done. physiatry is very much team-oriented. Nevertheless, I For example we did a project called SCORE which do believe there is a clear benefit to having access to stands for Stroke Canada Optimization of Rehabilita- a rehabilitation consultation. tion by Evidence where we had 20 sites in Canada implement the guidelines. 10 of them were facilitat- UTMJ: For those interested in neurorehabilitation, what is ed with a facilitator and 10 of them had a passive dis- the difference between taking the PM&R route versus semination. The results showed that the group that the neurology route and then doing a fellowship in had the more active dissemination had better uptake. rehabilitation? We are also developing new technologies such as smartphone apps to help communicate best practice MB: The PM&R is unique in many ways. Similar to taking a guidelines. The idea is that when you are a clinician route through neurology we have a core basis in inter- at the front line you can input some basic data about nal medicine of one and a half years, and we do have the person’s stroke, and then what type of recovery some training in neurology, rheumatology, and ortho- they have had so far, and it will generate a list of sug- pedics. The difference in PM&R is that you then get gested treatments and allow you to pick from them. to see people as they progress through neurorehabili- We believe that this will make it easier for clinicians tation in the program. So during training, we do core to tailor the evidence to the person in front of them. rotations in brain injury, spinal cord injury, stroke rehabilitation, and neuromuscular rehabilitation, UTMJ: All that being said, how often do your patients with and I think that prepares you better for the complex moderate to severe brain injuries recover to the point problems that patients will come to you with. So the that they can function independently and/or return difference is that in neurology you may take a look at to work? What is typically done to help them out? only the neurological elements, whereas in physiatry when we take care of a traumatic brain injury patient, MB: The good news is that if you had a severe brain in- a significant proportion (30-50%) will also have mus- jury. Even those with severe TBIs, 60-80% of them culoskeletal injuries and other physical complications will be able to become functionally independent with that we are very well trained to manage. Similarly, respect to their self-care and be able to return home. some individuals may require treatment for bracing [In] some other forms of brain injury, such as sub- and orthotics, which is part of the training in PM&R. arachnoid hemorrhage and anorexic brain injury, Other people have peripheral nerve injuries that are the prognosis is not as good. However, in general, concomitant with their musculoskeletal injuries; that we are very able to get people to a state of indepen- is also part of the physiatrists’ training. Thus, PM&R dence and self-care. Where we struggle in our work provides you with a comprehensive understanding of is to help people to be able to return to work, [be- the complications patients may experience. The next cause] only about 20% of people with severe injuries major learning component focuses on the physiology will return to work. Similarly, only about half of in- of exercise, which helps provide an understanding of jured patients will become completely independent how training and rehabilitation works. This is some- in the community in terms of banking and budget- thing that you normally would not get exposure to in ing. While I think we are challenged to return them a traditional neurology or rheumatology program. In to their highest function, we have very positive results contrast, neurologists are frequently looking at diag- in returning people to the community. nostics around headache, movement disorders, and other types of neurological disorders. So their focus is UTMJ: With this in mind, has there been research showing on diagnostics and medical treatments, whereas our the specific benefits of seeing a physiatrist? focus is to look at not just the medical treatments. The physiatry toolkit also includes other things such MB: Most of the research in the field looks at whether a pa- as physical techniques, assistive technology, bracing, tient gains access to a comprehensive rehabilitation prosthetics, educational/self-management approach- team and not necessarily a physiatrist. That said, re- es, and cognitive compensatory strategies. search involving randomized control trials in stroke, including observational studies in brain injury, con-
UTMJ • Volume 92, Number 1, December 2014 31 Interviews
“Adding Years to Life”: Physiatry, Neurorehabilitation, and Knowledge Translation
UTMJ: How do you foresee the future of physiatry and the UTMJ: Building on that last question, in an era where many role of technology in facilitating rehabilitation? newly minted specialists are having trouble finding a job, is there a demand for physiatrists in urban cen- MB: I think the future of physiatry is bright in that there ters? Is it different for those interested in sports medi- are so many emerging technologies that will help cine versus neurorehabilitation? rehabilitation. Some people say that genomics and pharmacological agents will put rehabilitation out of MB: In general, there are still many positions available in business. But I don’t believe that because even if we urban centers. We expect the demand for physiatrists do discover growth factors, genetic treatments, or [if] to grow as the population ages and people realize cancer becomes a chronic disease, these people will that there is a benefit to having a physician who un- end up living with chronic disease and require reha- derstands rehabilitation from a holistic point of view. bilitation to maximize their function. For example, if At present many centers within a very short drive of you administer nerve growth factors post-stroke and Toronto do not have a physiatrist. So realistically, now they get a new set of nerve cells, one still needs there will be work for physiatrists for many years to to train those nerve cells how to function. That said, come. I believe the future of rehabilitation is very bright. There are numerous technologies that are coming UTMJ: Finally, what is the state of brain rehabilitation in out that are very exciting. Genetics and genomics Canada and how do we compare to the United States will be very helpful in determining predictive factors and to European countries with respect to helping in- for outcomes. For example, early research has shown dividuals recover? What are things we do particularly that certain people who have the Val-Met variant of well and what are things that need to be improved? Brain-derived Neurotrophic Factor (BDNF) recover differently from others. MB: [One] of the challenges across the country is vari- I think the other new technology that is emerging ability in access. People in Ontario and Toronto have in rehabilitation in addition to the neurological and access to fairly high-quality rehabilitation programs pharmacological treatments is robotic technology. in stroke and brain injury. However in other cen- Such technology can be good assistive devices for tres such as in rural communities, access is far more people in various stages of recovery. Why have a phys- limited. Nevertheless, the access to rehabilitation in iotherapist to guide a repetitive exercise for a patient Canada is better than in many other countries in the when you can get a robot to provide that same care world, including developed countries. We have very without fatigue and very consistently? These robots good access to stroke and brain injury care. Where we can also help deal with the ‘intensity of training’ are lacking however is that our system is not as orga- problem, as these machines do not need to take cof- nized around intensity of treatment as the literature fee breaks or even sleep at night. Robots therefore recommends. The problem stems from constrained have a role in both compensatory and therapeutic budgets that cause people to cut back on physio- uses. therapy and occupational therapy time, when those We are also seeing the emergence of stimulation therapies are the very things patients need to recover. technology. Some examples include: Transcranial So we have variability in the intensity of treatment, Magnetic Stimulation (TMS) for the brain, Func- and that is something that we are actively working on tional Electrical Stimulation (FES) for the limbs, or addressing. even brain-computer interfaces – all of which can be used to improve patient recovery/compensatory out- UTMJ: That concludes the interview questions. Thank you comes. Instead of not being able to walk, you could Dr. Bayley. potentially use cognitively induced evoked potentials to control a mechanical set of legs. Overall, I feel MB: My pleasure. there are a number of different things coming out, driven by a better understanding of recovery due to the advent of non-invasive functional neuroimaging.
32 UTMJ • Volume 92, Number 1, December 2014 Original Research
To Study the Impact of Acne Vulgaris on the Quality of Life of Patients
Amit Batra, MBBS Student, 3rd Year, Gian Sagar Medical College and Hospital* Prithpal S. Matreja, Associate Professor, Department of Pharmacology, Gian Sagar Medical College and Hospital* Amandeep Singh, Associate Professor, Department of Pharmacology, Gian Sagar Medical College and Hospital* Ashwani K. Gupta, Associate Professor, Department of Pharmacology, Gian Sagar Medical College and Hospital* Naveen K. Kansal, Senior Resident, Department of Dermatology, Gian Sagar Medical College and Hospital* PML Khanna, Professor and Head, Department of Pharmacology, Gian Sagar Medical College and Hospital*
*Village Ram Nagar, District Patiala, Punjab, India 140601
Introduction Abstract cne is a common dermatological disorder affecting Introduction: Acne is a common dermatological more than 85 percent of people between the ages of disorder affecting people between the ages of 12-24 A12-24 years.1, 2 It is a chronic inflammatory disorder years and has been implicated in psychiatric and psy- of pilosebaceous unit with acne lesions distributed in areas chological processes more than many other derma- with well developed sebaceous glands including the face, tological conditions. Evidence have illustrated that back, chest, and upper arms.3 Acne has been considered as effects of this condition are far more than skin deep, a cosmetic trivial problem but it has significant and enduring and may range from dissatisfaction with appearance, emotional and psychological effects.2 Acne has been impli- embarrassment, self-consciousness, and lack of self- cated in psychiatric and psychological processes more than confidence. Many studies have been done in other any other dermatological conditions.4 Many aspects of this countries showing considerable impact on quality of disease contribute to its non dermatological effects: predomi- life of patients with acne vulgaris. The data in the nant adolescent prevalence, anatomical distribution, misper- Indian subcontinent is insufficient. Hence, we de- ceptions regarding aetiology, and social pressures.3 Emphasis signed to conduct this study to assess the impact of on psychosocial impact has shown dissatisfaction with appear- acne vulgaris on the quality of life of patients. ance, embarrassment, self-consciousness, and lack of self con- Methods: 60 consecutive patients suffering from fidence in patients with acnes. There are also reports of social acne vulgaris visiting the out-patient department dysfunction including concern about social interaction with over two months from June 2012 to July 2012 were the opposite gender, appearance in public, interaction with recruited in this cross-sectional study. Patients of ei- strangers, and reduced employment opportunities.5 ther sex in age group of 18-35 years, willing to give Acne vulgaris has been associated with psychiatric disor- written informed consent, were included in the ders varying from clinical depression, social phobia, and cer- study. Acne was assessed using the global acne grad- tain anxiety disorders. The patients suffering from acne have ing system (GAGS). Patients were divided into two reported greater levels of anxiety and depression than other groups: males and females and were assessed for medical populations.3, 5 A study reported higher incidence of quality of life parameters using Cardiff Acne Disabil- clinical depression and suicidal ideation in group with acne ity Index (CADI) and Dermatology Life Quality In- as compared to group suffering from alopecia aerate, atopic dex (DLQI) as outcome measure. dermatitis, and mild to moderate psoriasis.3, 6 Another study Results: All the patients (29 males, 31 females) of acne patients aged 16 years and over attending a United completed the study. The average CADI score was King¬dom dermatology outpatient clinic found a comparable 7.12±0.41 and DLQI score was 8.98±0.57 with slight- levels of social and emotional problems with those in people ly higher scores in females. Comparison between with severe, chronic, and disa¬bling diseases such as arthritis groups using various statistical tests revealed statisti- and epilepsy.1, 7 cally non-significant (p>0.05) results. Conclusion: Both sexes showed moderate disability Corresponding Author: of life with females having slightly more effect. Dr. Prithpal S. Matreja Both sexes showed moderate disability of life with fe- Associate Professor, Department of Pharmacology, males having slightly more effect. Gian Sagar Medical College and Hospital, Village Ram Nagar, Tehsil Rajpura, District Patiala, Punjab 140601 India Phone No.: +91-1762-507118, Mobile No.: +91-9855001847 Fax No.: +91-1762-520024 Email: [email protected]
UTMJ • Volume 92, Number 1, December 2014 33 Original Research
To Study the Impact of Acne Vulgaris on the Quality of Life of Patients
One study done in Malaysia, to study the impact of acne Outcome Measure on quality of life, reported a considerable impact on the qual- ity of life of adolescent school girls,1 and acne vulgaris was Cardiff Acne Disability Index (CADI) one of the most significant factor for patients low perception A well-validated, self-reported, five item questionnaire of general health.4 A study done in Ohio to determine the consist¬ing of questions which relate to feeling of aggres- quality of life of adult patients with acne vulgaris visiting the sion, frustration, interference with social life, avoidance of dermatology clinic showed a significantly impaired quality of public changing facilities, and appearance of the skin -- all life8 with a drastic improvement in quality of life was reported over the last month -- and an indication of how bad the acne in patients applying makeup.9 was now. The CADI score are calculated by summing score Acne is a source of distress and embarrassment and there of each question resulting in a possible maximum of 15 and is a need to study the impact of psychosocial impact and qual- minimum of 0. CADI scores are graded as low (0–4), medium ity of life of young people with acne. A lot of studies have (5–9) and high (10–15). A low cumulative CADI score was been done in other countries which have shown that acne indicative of a low level of disability experienced by patient vulgaris is associated with a considerable impact on the qual- while a higher score indicated a higher level of disability. The ity of life of patients. The data in the Indian subcontinent is patients’ responses to the questionnaire are significantly cor- insufficient hence we designed this study to assess the impact related with clinicians’ assessment of acne severity.11, 12 It is of acne vulgaris on quality of life of patients. usually completed in one minute.
Methodology Dermatology Life Quality Index (DLQI) This prospective, cross sectional study was done on patients The DLQI questionnaire is designed for use in adults, i.e. suffering from acne vulgaris in the Out Patient Department patients over the age of 16. It is self explanatory and can be of Gian Sagar Medical College & Hospital, Patiala, India from simply handed to the patient who is asked to fill it in without June 2012 to July 2012. An assessment of acne was done us- need for detailed explanation. It is usually completed in one ing the global acne grading system (GAGS). GAGS considers to two minutes. Each question has a score range from zero to six locations on the face and chest/upper back, with a factor three. The DLQI is calculated by summing the score of each for each location based roughly on surface area, distribution, question resulting in a maximum of 30 and a minimum of and density of pilosebaceous units. The borders on the face 0. A higher score indicates greater impairment of quality of are delineated by the hairline, jaw line, and ears. No magnify- life. The DLQI can also be expressed as a percentage of the ing glass or skin stretching was allowed, and good lighting is maximum possible score of 30. The Scoring pattern is: 0-1 suggested. Each location is graded separately on zero to four (no effect at all on patient’s life), 2-5 (small effect on patient’s scale, with the most severe lesion within that loca¬tion deter- life), 6-10 (moderate effect on patient’s life), 11-20 (very large mining the local score. Acne is then graded according to the effect on patient’s life), 21-30 (extremely large effect on pa- global score which is the summation of all local scores. The tient’s life).13-15 severity is graded as mild if the score is 1–18, moderate with scores from 19 to 30, severe with scores from 31 to 38, and as Statistics very severe if the score is more than 38. The same researcher The data was presented as mean ± standard error (mean assesses all the patients with acne vulgaris/ multiple research- ± SE). The scores obtained from scales were compared using ers who had been trained equally assess the patients so as to unpaired Student t test and correlation analysis. A p <0.05 was get a uniform score.10 considered statistically significant. Patients of either sex between 18-35 years of age willing to give written informed consent were included in the study. Pa- Results tients suffering with co morbid skin conditions like Psoriasis, 60 patients were enrolled and all of them completed the Lichen planus, chronic medical, surgical conditions, organic study. The average age of patients in study was 21.43±0.41 with brain syndrome, and chronic mental illness were excluded an average GAGS Score of 30.32±1.52. The average CADI and from the study. All pregnant or lactating females were also DLQI score were 7.12 ± 0.41 and 8.98 ± 0.57 respectively. A to- excluded from the study. tal of 29 males and 31 females completed the study and were divided into two groups based on gender. Procedure Prior to the enrolment of the patients, approval was ob- tained from the Institutional Ethics Committee. All the con- Table 1. Characteristic of patients in both groups secutive patients visiting the OPD and suffering from Acne Parameters Males (n=29) Females (n=31) p value vulgaris underwent thorough medical examination and sever- (Mean ± SE) ity of acne was determined based on the GAGS by the der- Age (years) 20.93 ± 0.53 21.93 ± 0.60 0.23 matologist. Patients were divided into two groups based on GAGS 30.52±2.6 30.13±1.78 0.90 the gender, one group was of male patients suffering from acne vulgaris and other group of females; both groups were CADI 6.69± 0.64 7.52± 0.52 0.32 assessed for quality of life parameters. DLQI 8.83 ± 0.87 9.13 ± 0.77 0.80 Both the groups were comparable, using unpaired Student t test
34 UTMJ • Volume 92, Number 1, December 2014 Original Research
To Study the Impact of Acne Vulgaris on the Quality of Life of Patients
Female participants had a slightly higher age as compared Correlation to males though it was not statistically (p>0.05) significant. Fe- GAGS score was significantly (p<0.05) correlated with both males had lower GAGS score, higher mean CADI, and DLQI CADI and DLQI scores in males and females(Table 2). scores as compared to males though it was not statistically sig- nificant (Table 1). Discussion Acne vulgaris has a significant non-dermatological effects due to the specific population being affected, distribution of lesions, misperceptions regarding the cause condition, and strong emphasis being placed on physical appearance. Acne also negatively affects psychological health and psychosocial functioning of the patient affected, with significant impair- ment in self esteem and self image.3 Acne has shown to cause a significant deficit in the health related quality of life using both generic and disease-specific instruments,3, 16 and the deficits in quality of life are as great as those reported by patients with chronic, disabling conditions, such as: asthma, epilepsy, diabetes, or arthritis.3, 7 In the present study the impact of acne vulgaris on quality of life was observed using CADI and DLQI scores. The re- sults showed that GAGS score was significantly correlated with both CADI and DLQI scores in males and females. The CADI Figure 1. CADI scores in both groups score and DLQI score were in range of mild to moderate dis- ability associated with acne vulgaris and females had higher scores as compared to males. CADI Scores Females had comparatively higher scores in all the ques- Table 2. Correlation with GAGS score tions as compared to males, though none of them was statisti- Variable Males Females cally significant (Figure 1). Females were more aggressive/ r p r p frustrated or embarrassed as compared to males. Females had greater feeling of acne interfering with their social life and CADI 0.656 <0.05* 0.582 <0.05* Scores were more prone to avoiding public changing facilities, as compared to males. Females were more concerned with their DLQI 0.676 <0.05* 0.562 <0.05* Scores skin and considered acne as more problematic. *p<0.05 and statistically significant DLQI Scores Females had slightly higher DLQI scores but the pattern for One of the studies done to assess acne patients’ view of each individual question was variable (Figure 2). Females had their general health and quality of life, emphasized that acne higher scores for painful/stinging skin, social/leisure activity had great impact on patient’s general health and affects indi- affected, problem with work/study, and problem created with vidual’s physical and psychological health. The observations friends/relatives as compared to males. Females were more of our study also depicted that acne vulgaris had an impact on influenced by their skin when determining what clothes to quality of life of patients.4 wear. Males scored higher on the following parameters: em- The results of our study are in accordance with an earlier barrassed/ self-conscious, difficulty to do any sport, consumed study where it was found the acne impacted the quality of life time, and caused sexual difficulties. Males considered acne in- of patients. However, this study recruited patients between terfering with their shopping/ looking after their home. the ages of 13-18 years, whereas in our study we enrolled pa- tients within the age group of 18-35 years.1 Another cross sectional and longitudinal survey to de- termine the effects of acne vulgaris on the quality of life of adult dermatology patients concluded that acne vulgaris sig- nificantly affects patients quality of life. The results of this study are in accordance with our study where we observed moderate affect on quality of life of patients though it was not statistically significant.8 Another observation of this study was that regardless of the severity of acne, older adults were more affected by their acne, whereas in our study we only included those patients who were between the age group of 18-35 years.8 Figure 2. DLQI scores in both groups
UTMJ • Volume 92, Number 1, December 2014 35 Original Research
To Study the Impact of Acne Vulgaris on the Quality of Life of Patients
A study done in the psychiatry outpatient department of a Source of Funding teaching medical institution in New Delhi found significantly This projects is a part of ICMR-STS (Indian Council of higher psychiatric morbidity in patients with acne vulgaris Medical Research – Short term Studentship Program) 2012. and there was positive correlation between the mean GHQ The project has been supported by ICMR-STS 2012 program. scores and perceived severity. Similarly in our study, a signifi- cant correlation of GAGS score in both males and females References with DLQI and CADI scores was observed.17 1. Hanisah, A., Omar, K., Shah, S.A. Prevalence of acne and its impact on the quality of life in school-aged adolescents in Malaysia. J. Primary. Health. Another study done to assess the effect of acne on acne re- Care. 1: 20-25 (2009). lated quality of life and its correlation to acne clinical severity 2. Dunn, L.K., O’Neil, J.L., Feldman, S.R. Acne in adolescents: Quality of conducted in university female students attending the univer- life, self-esteem, mood, and psychological disorders. Dermatology. On- line. Journal. 17:1 url. http://dermatology-s10.cdlib.org/1701/1_re- sity medical clinics with acne complaints in Saudi Arabia ob- view/1_10-00256/feldman.html (2011). served no correlation between acne severity (GAGS scoring 3. Hanna, S., Sharma, J., Klotz, J. Acne vulgaris: More than skin deep. Der- system) and quality of life impairment, as assessed by CADI matology. Online. Journal .9 :3 url.http://dermatology-s10.cdlib.org/93/ commentary/acne/hanna.html (2003). score. The observations of this study are quite different from 4. Robaee, A.A.A. Assessment of general health and quality of life in patients our study, as in our study we found a significant correlation of with acne using a validated generic questionnaire. Acta. Dermatoven. APA. 15; 157-164 (2009). GAGS score with both CADI and DLQI scores in both males 5. Kokandi, A. Evaluation of acne quality of life and clinical severity in acne fe- and females. The results showed that acne did have an impact male adults. Dermatology. Research. Practice. ; doi:10.1155/2010/410809 on quality of life.5 (2010). 6. Gupta, M.A., Gupta, A.K. Depression and suicidal ideation in dermatology There are certain limitations in our study. Firstly, the sam- patients with acne, alopecia areata, atopic dermatitis and psoriasis. Br. J. ple size could have been larger, but the duration of study was Dermatol. 139: 846-850 (1998). only two months hence we tried to include patients who ful- 7. Mallon, E.M., et.al. The quality of life in acne: a comparison with general medical conditions using generic questionnaires. Br. J. Dermatol. 140: 672- filled the eligibility criteria. Secondly, a comparison with the 676 (1999). intervention arm could be done, but any intervention could 8. Lasek, R.J. and Chren, M.M. Acne vulgaris and the quality of life of adult dermatology patients. Arch. Dermatol. 134: 454-458 (1998). have prolonged the duration of study and we would not have 9. Hayashi, N., et.al. Make-up improves the quality of life of acne eruptions been able to complete the study in the allotted two months. during treatments. Eur. J. Dermatol. 15: 284-287 (2005). Another limitation of the study is that it doesn’t take into ac- 10. Doshi, A., Zaheer, A., Stiller, M.J. A comparison of current acne grading systems and proposal of novel system. Int. J. Dermatol. 36: 416–418 (1997). count duration of disease and trials/failure of previous treat- 11. Motley, R.J. and Finlay, A.Y. Practical use of a disability index in the routine ment. management of acne. Clin. Exp. Dermatol. 17: 1-3 (1992). 12. Motley, R.J. and Finlay, A.Y. How much disability is caused by acne? Clin. Exp. Dermatol. 14: 194-198 (1989). Conclusion 13. Finlay, A.Y. and Khan, G.K. Dermatology life quality index (DLQI): A sim- The results of our study demonstrated that acne vulgaris ple practical measure for routine clinical use. Clin. Experimental. Derma- tol. 19: 210-216 (1994). had a moderate impact on quality of life of patients and the 14. Lewis, V.L. and Finlay, A.Y. Ten years experience of the dermatology life effect was more on females, as compared to males. This was quality index (DLQI). J. Investig. Dermatol. Symp. Proc. 9: 169-180 (2004). evidenced by the higher scores among female participants, 15. Hongbo, Y., Thomas, C.L., Harrison, M.A., Slak, M.S., Finlay, A.Y. Translat- ing the science of quality of life into practice: What do dermatology life though it was not statistically significant. The severity of acne quality index scores mean? J. Invest. Dermatol. 125: 659-664 (2005). vulgaris had significant correlation with both DLQI and CADI 16. Klassen, A.F., Newton, J.N., Mallon, E. Measuring quality of life in people scores in both males and females. The results of our study referred for specialist care of acne: Comparing generinc and disease-specif- ic measures. J. Am. Acad. Dermatol. 43: 229-233 (2000). show that there is a need to educate the patients, as well as 17. Srivastava, S., Bhatia, M.S., Das, P., Bhattacharya, S.N. A cross-sectional peer groups, about the reasons for acne so as to encourage study of quality of life and psychiatric morbidity in patients with acne vul- early treatment. The study also highlights that we need to be garis. JPPS. 5: 86-89 (2008). compassionate when dealing with patients with acne vulgaris.
36 UTMJ • Volume 92, Number 1, December 2014 Case Reports
Rapidly Progressing De Novo Arachnoid Cyst in an Adult Patient
Kenda Alhadid,* MD, Institute of Medical Sciences, University of Toronto Renée Rochelle Cruickshank,* MB, BS, Division of Neurosurgery, General Hospital, Port of Spain, Trinidad and Tobago Alireza Mansouri, MD, Division of Neurosurgery, University of Toronto David J. Mikulis, MD, FRCR, Institute of Medical Sciences, University of Toronto; Joint Department of Medical Imaging, University Health Network; Toronto Western Hospital, University Health Network Taufik A. Valiante, MD, PhD, FRCSC, Institute of Medical Sciences, University of Toronto; Division of Neurosurgery, University of Toronto; Toronto Western Hospital, University Health Network; Division of Fundamental Neurobiology, Toronto Western Re- search Institute, Toronto Western Hospital; Krembil Neuroscience Centre (*Co-Authors)
Introduction Abstract ntracranial arachnoid cysts are fluid-filled lesions com- posed of cerebrospinal fluid (CSF) representing approxi- Intracranial arachnoid cysts are thought to be 1 primarily congenital lesions that are commonly Imately 1% of all intracranial lesions. Primary arachnoid cysts are considered to be congenital malformations due to found incidentally on brain imaging. Other pos- abnormal splitting of the two lipid layers of the arachnoid tulated pathophysiological mechanisms include membrane. Secondary cysts can develop after trauma, men- meningeal infections, trauma, or iatrogenic ingitis, neurological surgery, or subarachnoid haemorrhage.2 causes (e.g. post neurosurgical procedures). Regardless of their etiology, arachnoid cysts predominantly The spontaneous appearance of these cysts is maintain a benign course of progression; they remain stable very rare. In this report we present the first case in size and are usually asymptomatic.3 Rapid growth of arach- of an arachnoid cyst occurring spontaneously in noid cysts found incidentally has been reported to be a rare a 54 year-old man presenting with progressively occurrence.4 A recent study assessing the prevalence and natu- worsening headaches with subsequent imaging ral history of arachnoid cysts on magnetic resonance imaging showing a new arachnoid cyst at the left cerebel- (MRI) images of 48,417 adult patients reported the incidental lopontine angle (CPA). Serial MRI tests revealed finding of arachnoid cysts in 661 of these patients. To examine the course of progression, they followed 203 patients with a the cyst to be expanding rapidly, coinciding with total of 213 intracranial arachnoid cysts for 3.8 ± 2.8 years and worsening of the patient’s headaches, tinnitus, found that five cysts enlarged over time, while only two patients and an ataxia. Thus, the decision was made to of- experienced the development of new neurological symptoms.4 fer surgical intervention. While arachnoid cysts Regarding spontaneous arachnoid cysts: only four cases have in adults are primarily thought to follow a stable been illustrated in the literature thus far, all occurring in young course in most cases, the rapid progression in this children.5-8 Herein we present the case of a 54-year-old patient case suggests that close monitoring with serial im- with a CPA arachnoid cyst arising spontaneously and expanding aging may be warranted. rapidly over a short period of time with neurological sequelae. To the best of our knowledge, this is the first such report in an adult patient.
Case Report
History and Examination A 54-year-old, right-handed man presented to our clinic with a one-year history of severe daily headaches, left-sided facial paresthesias, and tinnitus. His headaches were acute Corresponding Author: in onset, sharp in nature, bitemporal with no radiation, and Kenda Alhadid were not associated with any other symptoms. They had no Toronto Western Hospital 4W-436, 399 Bathurst Street identifiable trigger, would last for several minutes, and were Toronto, Ontario, Canada M5T 2S8 increasing in frequency and severity as time passed. While ini- Phone: (416) 603-5460 Fax: (416) 603-5298 tial imaging had been negative (Figure 1A), subsequent im- Email: [email protected] aging demonstrated the appearance of an intracranial extra- axial cyst at the left CPA (Figure 1B, 1C).
UTMJ • Volume 92, Number 1, December 2014 37 Case Reports
Rapidly Progressing De Novo Arachnoid Cyst in an Adult Patient
Figure 1. T2–weighted (A) MRI study performed on May 2009, demonstrates absence of any intracranial lesion. T2-weighted (B) and fluid attenuated inversion recovery (FLAIR) (C) MRI studies performed on Nov. 2010 show a small, non-enhancing cystic structure at the Figure 2. T2-weighted (A) and FLAIR (B) images taken in June 2011 left cerebellopontine angle (CPA) that is well-defined and isointense shows increase in cyst size: 13 x 12.6 x 17 mm in the craniocaudal, to cerebrospinal fluid measuring 9 x 13 mm in the transverse and transverse, and anteroposterior dimensions respectively. anteroposterior dimensions respectively.
Thus, he was referred for a surgical assessment. His neu- Post-Operative Course rological exam on his initial visit to the neurosurgery clinic At one-month follow-up, the patient had experienced sig- was within normal limits. He had no relevant past medical or nificant relief from his headaches with persistence of mild surgical history and there was no history of trauma or cen- left-sided, peri-orbital paresthesias. A follow-up MRI scan ac- tral nervous system (CNS) infections. Initially, conservative quired four months post-operatively was not suggestive of cyst management was selected. Follow-up imaging in 6 months, recurrence (Figure 3). however, showed a modest increase in cyst size (Figure 2A, 2B). Nonetheless, given the absence of further neurological Discussion deficits, conservative management continued. Upon the next The most frequently occurring primary lesions in the CPA follow-up six months later, the patient reported worsening are acoustic neuromas, meningiomas, epidermoid cysts, and, left-sided facial paresthesias and an increasingly unsteady gait less commonly, arachnoid cysts. Due to the increased utilization with three falls. The repeat brain MRI image demonstrated of neuroimaging over the past three decades, there has been a further enlargement of his left CPA cyst. At this point, based significant increase in the detection of intracranial arachnoid on the progression of symptoms and the radiological appear- cysts among both adult and pediatric populations.2,4,9 These ance of the lesion, surgical intervention was recommended. cysts most commonly appear in the middle fossa. Posterior He underwent a suboccipital craniotomy for gross-total resec- fossa cysts are much less common and CPA cysts represent 5% tion of the arachnoid cyst (Figure 3A, 3B). of all intracranial arachnoid cysts.10 Establishing a radiologi- cal diagnosis is of paramount importance to guiding the man-
A B
Figure 3. A) intraoperative image of arachnoid cyst visible in left CPA, B) intraoperative image post cyst marsupialization.
38 UTMJ • Volume 92, Number 1, December 2014 Case Reports
Rapidly Progressing De Novo Arachnoid Cyst in an Adult Patient
Table 1. Summary of case reports that document intracranial arachnoid cysts that expanded over time and produced neurological deficits
Authors and Time to Surgical Age Gender Presentation Cyst location Outcome year expansion management Uncomplicated Kumangai et General Right middle 8 months Male 8 months Open fenestration procedure al., 1986 Convulsions fossa Symptoms resolved Okumura et al., Developmental Bilateral middle Cystoperitoneal Uncomplicated 7 years Male 7 years 1995 delay fossa shunt procedure McDonald P., Uncomplicated Left middle Cystoperitoneal Rutka J. 6 months Male Asymptomatic 6 months procedure fossa shunt 1997 Symptoms resolved Sensorineural Uncomplicated Ottaviani et al., Left cerebellar Cystoperitoneal 21 years Male hearing loss and 1 year procedure 2002 convexity shunt tinnitus Symptoms resolved Uncomplicated Eslick et al., Diplopia and Right cerebello- Suboccipital 54 years Male 1 year procedure 2002 headaches pontine angle craniotomy Symptoms resolved Uncomplicated Developmental Left middle Rao et al., 2005 7 months Male 6 months Open fenestration procedure delay fossa Symptoms resolved Delayed lan- Uncomplicated guage Right anterior procedure Rao et al., 2005 4 years Female 4 years Open fenestration development, fossa Symptoms of mass strabismus effect resolved Uncomplicated Struck et al., Obstructive 1 year, 8 Endoscopic 2 years Male Suprasellar procedure 2006 hydrocephalus months fenestration Symptoms resolved Uncomplicated Gazioglu et al., Progressive gait Endoscopic 40 years Male Posterior fossa 6 months procedure 2010 imbalance fenestration Symptoms resolved Sensorineural Kessler et al., Left cerebello- 72 years Male hearing loss and Not mentioned in report 2010 pontine angle tinnitus Occipital Uncomplicated Kurabe et al., Suboccipital 25 years Female headache and Posterior fossa 7 years procedure 2011 craniotomy nausea Symptoms resolved Sensorineural Uncomplicated Olaya et al., hearing loss Right cerebello- Endoscopic 7 years Male 6 months procedure 2011 and facial nerve pontine angle fenestration Symptoms resolved palsy Uncomplicated Glosso-pharyn- Right cerebello- Suboccipital Cho et al., 2011 54 years Female 2 years procedure geal Neuralgia pontine angle craniotomy Symptoms resolved Intraparenchymal Intra-axial Zheng et al., Left sided hemorrhage post-op. 54 years Female Right parietal 3 years Parietal craniotomy 2013 hemiparesis Managed conserva- lobe tively Case series Al-Holou et al., Examined natural history for intracranial arachnoid cysts in children: at mean follow-up of 3.5 ± 2.7 years, 11 out of 111 cysts 2010 had increased in size. Al-Holou et al., Examined natural history for intracranial arachnoid cysts in adults: at mean follow-up of 3.8 ± 2.8 years, 5 out of 213 cysts 2013 had increased in size.
UTMJ • Volume 92, Number 1, December 2014 39 Case Reports
Rapidly Progressing De Novo Arachnoid Cyst in an Adult Patient
trigger. This could lead to the expansion of this duplication in the arachnoid lining, forming a discrete cyst by one of the mechanisms mentioned above. Given the complexity of the CPA, progressive enlargement of any lesion within this space will ultimately result in neuro- logical sequelae through direct compression of the surround- ing structures, including the cerebellum and cranial nerves. Expected range of consequent symptoms would include but not be limited to: facial nerve palsy, non-specific headaches, facial paresthesias, hypo/hyperacusis, tinnitus, neuralgias, gait disturbances, and vertigo. Our patient’s symptoms of headaches, left sided tinnitus, left-sided facial paresthesias, and imbalance were typical of a space-occupying lesion locat- ed in the left CPA and compressing the left cerebellar hemi- sphere, along with the fifth and eighth cranial nerves. Regarding management of these lesions, it is widely agreed upon that small cysts that remain stable in size with limited neurological symptoms should be left untreated and patients are followed with serial imaging. Surgical intervention is con- sidered in the presence of expanding lesions with evidence of symptoms that are of a progressive nature coinciding with cyst progression, or if complications develop, such as intracys- tic hemorrhage or hydrocephalus. Surgical options include Figure 4. Post-operative T2-weighted MRI study performed four gross total resection, shunting of cyst content, or minimally months post cyst resection. invasive procedures such as endoscopic fenestration or ste- reotactic cyst aspiration.14,28,29 agement of CPA lesions.11 Arachnoid cysts appear on MRI In summary, while most arachnoid cysts follow a benign imaging as homogeneous, non-enhancing lesions that have course, our case of a spontaneously appearing primary intra- a well-defined circumference with no discernible wall, no in- cranial arachnoid cyst that expanded over a short period of ternal complexity, and are filled with fluid that displays the time suggests that rapid progression of cyst volume does oc- same signal characteristics as that of CSF. On fluid-attenuated cur and perhaps close follow-up is necessary. Investigation of inversion recovery (FLAIR) and diffusion weighted imaging further spontaneous arachnoid cysts in adults may help bet- (DWI) sequences, arachnoid cysts maintain low signal inten- ter our understanding of the pathophysiology responsible for sity, which helps differentiate them from epidermoid cysts. such lesions. Several case series and surveillance studies have concluded that the vast majority of arachnoid cysts detected incidentally References remain stable in size and do not produce neurological symp- 1. Boutarbouch, M., El Ouahabi, A., Rifi, L., Arkha, Y., Derraz, S., El Kham- lichi, A Management of intracranial arachnoid cysts: institutional experi- 4,12-15 toms. However, there are an increasing number of case ence with initial 32 cases and review of the literature. Clin Neurol Neuro- reports that ascribe pathogenic behavior to arachnoid cysts: surg. 110(1):1-7, 2008. 2. Osborn, A.G., Preece, M.T. Intracranial cysts: radiologic-pathologic correla- cysts that enlarge over time and produce neurologic deficits tion and imaging approach. Radiology 239(3):650-64, 2006. (Table 1)4-7,12,16-25 3. Westermair T., Schweitzer T., Ernestus R.I. Arachnoid Cysts, Neurodegen- Given the absence of a history of trauma, infection, or erative Diseases. Landes Bioscience and Springer Science and Business Me- dia, 2012, pp 37-50. surgical procedure, our case represents the first known in- 4. Al-Holou, W.N., Terman, S., Kilburg, C., Garton, H.J., Muraszko, K.M., cidence of an arachnoid cyst arising spontaneously in an Maher, C.O. Prevalence and natural history of arachnoid cysts in adults. J adult. Several theories have been discussed in an attempt to Neurosurg 118(2):222-31, 2013. 5. Rao, G., Anderson, R.C., Feldstein, N.A., Brockmeyer, D.L. Expansion of explain why some congenital arachnoid cysts expand and be- arachnoid cysts in children: report of two cases and review of the literature. come symptomatic. The first theory suggests that an osmotic J Neurosurg 102(3):314-7, 2005. 6. Struck, A.F., Murphy, M.J., Iskandar, B.J.. Spontaneous development of a gradient created between the intracystic fluid and extracystic de novo suprasellar arachnoid cyst. Case report. J Neurosurg 104(6):426-8, medium leads to fluid accumulation within the cyst.26 Other 2006. propositions include hypersecretion of CSF from the cells lin- 7. Okumura, Y., Sakaki, T., Hirabayashi, H. Middle cranial fossa arachnoid cyst developing in infancy. Case report. J Neurosurg 82(6): 1075-7, 1995. ing the cyst wall, or a ball-valve mechanism where an anatom- 8. Martínez-Lage, J.F., Ruiz-Maciá, D., Valentí, J.A., Poza, M.. Development of ic communication between the cyst and subarachnoid space a middle fossa arachnoid cyst. A theory on its pathogenesis. Childs Nervous produces a functional one-way valve drawing fluid towards the System 15:94–97, 1999. 9. Zada, G., Krieger, M.D., McNatt, S.A., Bowen, I., McComb, J.G.. Patho- 27 cyst’s lumen. Currently, there are no mechanistic theories genesis and treatment of intracranial arachnoid cysts in pediatric patients explaining the generation of a spontaneous arachnoid cyst. younger than 2 years of age. Neurosurg Focus 22(2):E1, 2007. 10. Johnson, R.D., Chapman, S., Bojanic, S. Endoscopic fenestration of middle One hypothetical mechanism that could explain this spon- cranial fossa arachnoid cysts: does size matter?. J Clin Neurosci 18(5): 607- taneous development could be the congenital duplication 12, 2011. of the arachnoid membrane at the left CPA with an obscure
40 UTMJ • Volume 92, Number 1, December 2014 Case Reports
Rapidly Progressing De Novo Arachnoid Cyst in an Adult Patient
11. Cincu, R., Agrawal, A., Eiras, J. Intracranial arachnoid cysts: current con- 21. Kessler, P., Bodmer, D. Arachnoid cyst of the cerebellopontine angle caus- cepts and treatment alternatives. Clin Neurol Neurosurg. 109: 837–43, ing tinnitus and hearing loss. Otol Neurotol 32(1): E1-2, 2011. 2007. 22. Kurabe, S., Sasaki, O., Mitsuhashi, D., Koike, T. Growing posterior fossa 12. Al-Holou, W.N., Yew, A.Y., Boomsaad, Z.E., Garton, H.J., Muraszko, K.M., arachnoid cyst causing tonsillar herniation and hydrocephalus. Arch Neu- Maher, C.O. Prevalence and natural history of arachnoid cysts in children. rol 12:1606-7, 2011. J Neurosurg Pediatr 5(6):578-85, 2010. 23. Olaya, J.E., Ghostine, M., Rowe, M., Zouros, A. Endoscopic fenestration 13. Vernooij, M.W., Ikram, M.A., Tanghe, H.L., Vincent, A.J., Hofman, A., Kres- of a cerebellopontine angle arachnoid cyst resulting in complete recovery tin, G.P., Niessen, W.J., et al. Incidental findings on brain MRI in the gen- from sensorineural hearing loss and facial nerve palsy. J Neurosurg Pediatr eral population. N Engl J Med 1;357(18):1821-8, 2007. 7(2):157-60, 2011. 14. Pradilla, G., Jallo, G. Arachnoid cysts: case series and review of the litera- 24. Cho, T.G., Nam, T.K., Park, S.W., Hwang, S.M. Glossopharyngeal Neuralgia ture. Neurosurg Focus 22 (2): E7, 2007. Caused by Arachnoid Cyst in the Cerebellopontine Angle. J Korean Neuro- 15. Weber, F., Knopf, H. Incidental findings in magnetic resonance imaging of surg Soc 49 : 284-286, 2011 the brains of healthy young men. J Neurol Sci 15;240(1-2):81-4, 2006. 25. Zheng, J., Wang, J., Wang, S., Cao, Y., Zhao, J. Serial observation of an en- 16. Kumagai, M., Sakai, N., Yamada, H., Shinoda, J., Nakashima, T., Iwama, T., larging intracerebral arachnoid cyst. Clin Neurol Neurosurg 115(2):227- Ando, T. Postnatal development and enlargement of primary middle cra- 31, 2013 nial fossa arachnoid cyst recognized on repeat CT scans. Childs Nerv Syst 26. Basaldella, L., Orvieto, E., Dei Tos, A.P., Della Barbera. M., Valente, M., 2(4):211-5, 1986 Longatti, P. Causes of arachnoid cyst development and expansion. Neuro- 17. McDonald, P.J., Rutka, J.T. Middle cranial fossa arachnoid cysts that come surg Focus 15;22(2):E4, 2007. and go. Report of two cases and review of the literature. Pediatr Neurosurg 27. Gosalakkal, J.A. Intracranial arachnoid cysts in children: a review of patho- 1:48-52, 1997. genesis, clinical features, and management. Pediatr Neurol 26(2):93-8, 18. Ottaviani, F., Neglia, C.B., Scotti, A., Capaccio, P. Arachnoid cyst of the cra- 2002. nial posterior fossa causing sensorineural hearing loss and tinnitus: a case 28. Khan, I.S., Sonig, A., Thakur, J.D., Nanda, A. Surgical management of intra- report. Eur Arch Otorhinolaryngol 259(6): 306-8, 2002. cranial arachnoid cysts: clinical and radiological outcome. Turk Neurosurg 19. Eslick, G.D., Chalasani, V., Seex, K. Diplopia and headaches associated with 23(2):138-43, 2013. cerebellopontine angle arachnoid cyst. ANZ J Surg 72(12): 915-7, 2002 29. Wester, K. Arachnoid cysts in adults: experience with internal shunts to the 20. Gazioglu, N., Kafadar, A.M., Tanriover, N., Abuzayed, B., Bıceroglu, H., Ci- subdural compartment. Surg Neurol 45(1):15-24, 1996. plak, N. Endoscopic management of posterior fossa arachnoid cyst in an adult: case report and technical note. Turk Neurosurg 4:512-8, 2010.
UTMJ • Volume 92, Number 1, December 2014 41 Book Reviews
In Retrospect: Frankenstein and Medical Technology
Benjamin H Chin-Yee, BSc, MD/MA Candidate, Faculty of Medicine, and Institute for the History and Philosophy of Science and Technology, University of Toronto
early two centuries since its publication, Mary Shel- Frankenstein tells the now-familiar tale of the scientist Victor ley’s Frankenstein; or, The Modern Prometheus (1818) Frankenstein, who, driven by a desire to discover the myster- Nhas become popular mythology in our techno-scien- ies of life, endeavours to create a human being but produces tific culture, capturing the ongoing tension between utopian a monster who brings eventual misery and ruin to his creator. visions of science and their potentially dystopian consequenc- Frankenstein’s motives are not alien to modern medical sci- es.1 Read as a Romantic critique of Enlightenment rational- ence; he hopes his experiments will “banish disease from the ism, Frankenstein is often cited today as a warning against the human frame” and “renew life where death had apparently dangers posed by unbridled pursuit of scientific knowledge devoted the body to corruption.” The protagonist’s downfall and dominion over nature.2 A more nuanced reading of Shel- results from his overzealous pursuit of knowledge and failure ley’s novel, however, suggests less of a categorical opposition to recognize the social and moral responsibilities entailed by to science, but rather reveals a prescient reflection on sci- his research. Frankenstein’s fateful experiment -- the anima- ence’s social dimension, with important lessons for medical tion of his cadaveric construction -- is necessary to create his technology. being; however, it is the scientist’s subsequent rejection of his creation combined with the prejudices of society that make the monster who wreaks havoc on humankind. Shelley’s narrative dispels what has been called the “myth of purity,” the view that distinguishes between ‘pure’ science and applied science or technology, with the former operating in isolation from social values, and the latter being the sole fo- cus of ethical deliberation.3 Frankenstein’s technology, which enables him to imbue dead matter with life, lands him in ethi- cal quandary. Yet from the beginning his investigations are guided by a utilitarian moral of social improvement through control over nature. His research is not ‘pure,’ but rather is informed by Enlightenment values -- that life can be created, death overcome, nature conquered. As Frankenstein pro- claims, “Life and death appeared to me ideal bounds, which I should first break through, and pour a torrent of light into our dark world.” Shelley criticizes these values: “frightful must it be; for supremely frightful would be the effect of any hu- man endeavour to mock the stupendous mechanism of the Creator of the world.” Frankenstein shows how technology is never the straight- forward application of value-free science, but rather the ex- pression of a continuum of moral and social factors that shape all stages of scientific research. This lesson is important in an age in which we enjoy the benefits of many technologies, but must also reflect on the values they embody. For example, as- sisted reproductive technologies have undoubtedly brought joy to many parents unable to conceive; however, we must also recognize how socio-cultural notions of motherhood influence this research, which may frame child-bearing as a fulfillment of biological destiny, placing “pronatalist” pres- 4 Figure 1. Frontispiece to 1831 edition of Frankenstein by Theodor Von sures on women. On the other end of the spectrum, medical Holst (Tate Britain, London). technologies offer the possibility of prolonging human life; nonetheless, this pursuit of longevity raises concerns over the medicalization of aging and the goals of end-of-life care. Fran- Corresponding Author: kenstein gives us pause to reflect on the types of knowledge we Benjamin H Chin-Yee wish to pursue to create medical technologies that improve E-mail: [email protected] -- rather than harm -- human life.
42 UTMJ • Volume 92, Number 1, December 2014 Book Reviews
In Retrospect: Frankenstein and Medical Technology
today the concept of the ‘natural’ no longer serves as a guide to normative ethics, Shelley’s narrative suggests that a return to an idealized ‘state of nature’ is not only impossible, but also undesirable. The creature’s existence before entering human society is far from ideal: “I was a poor, helpless, miser- able wretch; I knew, and could distinguish, nothing; but feel- ing pain invade me on all sides I sat down and wept.” From this primitive state, technology can improve human life. The creature discovers fire and is “overcome with delight at the warmth,” relishing in the Promethean gift. However, he soon learns that fire not only brings pleasure, but also pain and de- struction -- “How strange, [he] thought, that the same cause should produce such opposite effects!” -- burning his hand in the flames, and later setting ablaze the cottage of the De Lacey family after they reject him. Like fire, Frankenstein’s life-giving technology offers utilitarian hope, but is accompa- nied by damaging consequences. Shelley captures these con- trasting aspects of scientific knowledge, which is capable of bettering humanity, but also threatens to render it miserable. Although some pundits may allude to Frankensteinian dystopias to support exaggerated claims of the dangers of techno-science, Shelley’s novel should be read as a more bal- anced case study of scientific research gone awry that argues for social responsibility in science and ethical application of technology. Almost two hundred years later, Shelley’s tragic tale continues to evoke both hope in and fear of science, im- parting important lessons for scientific research and medical technology.
Figure 2. 1840 portrait of Mary Wollstonecraft Shelley by Richard References Rothwell (National Portrait Gallery, London). 1. Shelley M. Frankenstein; or, The Modern Prometheus. London: Penguin Books; 1985. 2. Davies H. Can Mary Shelley’s Frankenstein be read as an early research eth- Frankenstein captures this dualism of benefit and harm pro- ics text? Med Humanities. 2004;30:32-5. duced by technology. Contrary to some Romantics, Shelley 3. Kitcher P. Science, Truth, and Democracy. Oxford: Oxford University Press; 2001. does not advocate the abandonment of science and technol- 4. Purdy LM. Assisted Reproduction, Prenatal Testing, and Sex Selection. ogy and return to a Rousseauian ‘state of nature.’ Just as how In: Kuhse H, Singer P, editors. A Companion to Bioethics. Malden: Wiley- Blackwell; 2009. p. 178-92.
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48 UTMJ • Volume 92, Number 1, December 2014