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UAHSJwww.uahsj.ualberta.caUniversity of AlbertaHealth Sciences JournalApril 2012 • Volume 7 • Issue 1University of Alberta HealthSciences Journalc/o Medical Students’ Association1-002 Katz Group Center for Pharmacyand Health ResearchUniversity of AlbertaEdmonton, ABT6G 2H7www.uahsj.ualberta.cauahsj@ualberta.caISSN 1712-4735Editors in ChiefAndrew TaylorSebastian VrouweJunior EditorAndrew TangEditor of MusaDr. Tamar RubinInterim Faculty AdvisorDr. Fraser BrenneisFaculty Editor of MusaDr. Pamela Brett-MacLeanEditorial BoardMatthew BeneschAlyssa CruzZachary GuentherNathan HoyDavid LesniakMax LevineJonathan LiuBabak MaghdooriKevin MowbreyAlim NagjiAndrew TangReji ThomasJimmy WangFaculty RepresentativesSerena Westad(Pharmacy Undergraduate)Lisa Dollansky(Nursing Undergraduate)Coral Forrester(Nursing Graduate)Michelle Beveridge(Nutrition and Food Sciences)Liz Bolt (Medical Laboratory Sciences)Danielle Tingley(Dentistry and Dental Hygiene)Lauren Eastman(Medicine)Kayla Atkey(School of Public Health)Julia Esch(Rehabilitation Medicine)Mary-Pat Gibson(Summer Student Research)WebmasterJimmy WangLogo DesignJennifer ChanPublication Layout and DesignMarketing and CommunicationsMarketing ServicesUniversity of AlbertaCover ImageKatie Stringer

ContentsCommentaryOSCE: The subjective experience of an objective examAlim Nagji 2ResearchUncovering the role of topoisomerase II-beta bindingprotein 1 in DNA replication stress responseMark Assmus, Charles Leung, Mark Glover 3PAX3 expression in melanomaZachary Tan and D. Alan Underhill 3Rosiglitazone decreases angiogenesis in the MCL after ACLrupture - A pilot studyChristopher J. DeSutter, Daniel Miller,Catherine Leonard, Robert C. Bray 4reviewClinical application and review of typical and atypicalantipsychotics in the treatment of delusional parasitiosisNathan Y. Hoy, Patricia T. Ting, Stewart Adams 8Stem cells in cardiac repair: A review of the changinglandscape of cardiovascular medicineNicholas A. Avdimiretz 13musaFine art in health sciences: Recognizing students who findtime to make artSarah R. Stonehocker 17On the value of narrative reflective practice: A personalreflectionDebbi Andrews 21It all began with a cup of tea: Introducing narrative reflectivepractice...Marie-Therese Cave, D. Jean Clandinin 23EditorialAs we enter the eighth year of the UAHSJ, we are excited toannounce a number of changes. Two thousand and eleven wasa transition year for the journal, with two major initiatives inthe works. Emphasizing multidisciplinary involvement is anongoing priority, and in the coming years we hope to continuethis momentum by including other health sciences facultiesand schools at the University of Alberta. We have reinstitutedFaculty Representatives to aid in better distributing the journaland, most importantly, solicit even more submissions fromthe talented writers and researchers in our student body. Ona similar note, we also look forward to working with otheruniversities across Canada to widen both our readership andsubmissions base.There have been a number of content changes in the works atthe UAHSJ. Beginning with this issue, we will focus on piecesgeared towards a general health sciences reader: clinical andscientific reviews, summer student abstracts, book reviews,history of medicine pieces, medical education research,personal reflections, and letters. Our hope is that this willcomplement the push for more multidisciplinary involvement.Of course, none of this would be possible without the tirelessefforts of the Journal’s contributors, our Editorial Board, andour new Junior Editor, Andrew Tang. We extend our thanksto the Faculty of Medicine and Dentistry for their generousfinancial support, and Dr. Fraser Brenneis, Vice-Dean ofEducation, who took the time to guide and advise us throughthe publication of this issue. Finally, we would like to warmlywelcome Dr. Tamar Rubin, a PGY-1 resident in Pediatrics, whohas assumed the role of Editor of Musa. Tamar has extensiveexperience in both literary writing and the medical humanities.Many thanks to Dr. Pamela Brett-MacLean, who originallyconceived Musa and will now carry on as its Faculty Editor.Yours,Sebastian Vrouwe and Andrew TaylorEditors in ChiefCONTENTS / EDITORIALRESEARCHEnter stage right: An actor’s adventures in patient centred careNadine L. Cross 27A bite into the media’s image of nursing in an apocalypticworldSherrylynn Kerr 28Albert Ross Tilley: The legacy of a Canadian plastic surgeonKevin S. Mowbrey 30The House of God still worth a read for today’s medicaltraineesAlby Richard 35University of Alberta Health Sciences Journal • April 2012 • Volume 7 • Issue 1 1

COMMENTARYOSCE: The subjective experience of an objective examAlim Nagji, BHScMedical Student (2012), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, CanadaCorrespondence to Alim Nagji, Email: anagji@ualberta.caAbstractThe Objective Structured Clinical Examination (OSCE) is theprimary modality for testing clinical skills throughout medicalschool and in residency training. This article explores the difficultiesof the exam via the subjective perspective of a student in thesystem, commenting on reticent standardized patients, the lackof consensus on what makes an ideal medical student and theabsence of feedback. As the exam celebrates nearly four decades inuse, it is important that we continue to evaluate its usefulness andbrainstorm innovative approaches to advancing the state of clinicalexaminations.The Objective Structure Clinical Examination (OSCE) has rapidlybecome the leading clinical examination in North American MedicalSchools. The unassailable champion of repetitive and reproducibleevaluation, it has become the envy of all other tests. While multiplechoice still holds a prominent position in most medical curricula,that is usually for the convenience of administering the test and thesheer volume of information one can sift through. As a learner, onehas had ample time to exploit the system, mastering the nuances ofthe “all of the following EXCEPT” and “which answer is the BEST”questions. In reality, we have been asked this type of question sincekindergarten and the PBS specials we grew up on sang “one of thesethings is not like the other one.” 1The OSCE is succinctly explained in the abstract of a 1975 BMJ article:“the examination is more objective and a marking strategy can bedecided in advance.” 2 The veracity of the latter half of this requirementis evidenced by the rubric style approach of many modern OSCEs.However, the first part is where the interesting dilemma lies. Is theexamination more objective? From the subjective experience ofstudents, it would hardly seem so.The variability lies in the innate qualities of both the “standardizedpatient” and the examiner. Having worked as a standardized patient,the instructions one often receives is to be as guarded as possibleabout information, refraining from volunteering details unlessspecifically probed. This is in direct contrast to the guidance offeredin basic history taking skills, where students are counselled to allowthe patient to convey the narrative of their illness uninterrupted. Forthose that have participated in OSCEs, it is easy to recall those actorsfrom whom information had to be stolen as if it were precious gems.From many a station I have walked out and, in conversation withmy peers in different tracks, realized that another “standardized”patient had been much more forthcoming with a pivotal piece of thediagnostic puzzle.In Rowntree’s 17 proposals for better assessment, he notes that“there is an assumption rampant in talk of academic standards,that all qualified assessors feel, understand and judge in much thesame way when confronted with the work of a particular student.It is presumed that they would notice and value the same skills andqualities and would broadly agree in their assessments. Abundantevidence attests to the falsity of such assumptions.” 3 In the sameway, examiners vary widely in their preferences of what they believemakes the ideal learner. One need only glance at the complicatedmedical admission system or the behemoth that is the CanadianResident Matching Service (CaRMS) to realize that we cannot agreeon the perfect model student, yet we continue to cling to antiquatedstandards so as to maintain a united front. Despite the broadaccusations suggesting poor inter-rater reliability across a varietyof domains, 4 OSCE examinations remain a mainstay of evaluationdespite their artificial construction and potentially variableenvironment.In the same seminal article, the authors proclaim that the“examination results in improved feed-back to students and staff.” 2This may hold true for the teaching OSCEs, where 2 minutes ofpersonalized commentary follows each station, but for the majorityof exams in medicine, the results are protected and not released. Sowhile occasionally one may receive a grade or score sheet, one isleft waiting for the commentary that can enhance clinical skills orrefine an approach. The majority of instructors emphasize the needto train physicians, not test takers, yet the very nature of receiving apass or a fail undermines the learning process. Research has shownthat overall, detailed, descriptive feedback was found to be mosteffective when given alone, unaccompanied by grades or praise, thedirect opposite of what students usually receive. 5 The OSCE hassignificant advantages over multiple choice questions, providing arich opportunity for students to simulate patient encounters andmaintain some degree of standardization. However, it’s limitationsand shortcomings should be discussed, rather than disputed. Themodern OSCE, nearly 40 years after its rise to prominence, seemsstagnant in the face of the rapid change in the medical community.Perhaps as we enter a new decade of medical education we cancritique our instruments, as well as our students, and developinnovative models to evaluate competence in clinical skills.1. Cooney, J.G. (creator). Seasame Street [Television Series]. New York:PBS 1969.2. Harden, R. McG. Stevenson, M., Downie, W.W. & Wilson, G.M.Assessment of clinical competence using objective structuredexaminations. British Medical Journal 1975;I: 447.3. Rowntree, D. Assessing students: how shall we know them?London: Kogan Page 1977. As cited in: Harden, R., Gleeson, F.A.Assessment of clinical competence using an objective structuredclinical examination (OSCE). Medical Education 1979;13(1):39-54.4. Thistlethwaite, JE. Developing an OSCE station to assess theability of medical students to share information and decisionswith patients: issues relating to interrater reliability and the use ofsimulated patients. Educ Health (Abingdon) 2002;15(2):170-9.5. Lipnevich, A.A., Smith, J.K. Response to assessment feedback: Theeffects of grades, praise and sources of information. Retrieved fromProQuest Digital Dissertations 2008; 3319438.2University of Alberta Health Sciences Journal • April 2012 • Volume 7 • Issue 1

University of Alberta Summer Students’ Research DayIn 2011, over 200 undergraduate students participated in the Faculty of Medicine & Dentistry Summer StudentResearch Program. On October 15, 175 students presented posters at the 44th Annual Summer Students’ ResearchDay. Listed below are the 14 finalists from the poster competition. We congratulate the finalists and all participants.RESEARCHFrom these 14 finalists, two students were selected to represent theUniversity of Alberta at the annual National Students’ ResearchForum in Galveston, Texas. Their abstracts are presented below.Uncovering the role of topoisomerase II-betabinding protein 1 in dna replication stress responseMark Assmus, Charles Leung, Mark GloverDNA replication stress can lead to genomic instability which hasbeen shown to be one of the primary hallmarks of cancer. TopBP1 is acrucial mediator protein found within the replication stress responsein mammalian cells. TopBP1 activates Ataxia telangiectasia mutatedrelated (ATR) kinase which phosphorylates many of the downstreamsubstrates to initiate this response. The replication stress responseinvolves specific interactions between the nine BRCA1 C terminus(BRCT) domains of TopBP1 and various proteins. More specifically,TopBP1 has been shown to provide an essential role in interactingwith both ATR-interacting protein (ATRIP), Rad9-Rad1-Hus1 (9-1-1)complex as well as Mediator of DNA damage checkpoint protein 1(MDC1) which are all essential components of the response pathway.The crystal structure of TopBP1 BRCT 4/5 in complex with MDC1 waspreviously solved in our lab. The structure shows a unique mode ofTopBP1 binding to MDC1 that involves the dimerization of two BRCT4/5 molecules. In an effort to further examine this interaction, I useda fluorescence polarization (FP) binding assay involving an MDC1FITC labelled di-phospho-peptide. I was able to express and purifyGST fusion proteins of TopBP1 BRCT 4/5 and TopBP1 BRCT 5, as wellas TopBP1 BRCT 5 alone, which were used for further FP studies.The results of the FP assays indicated that it is the BRCT 5 bindingpocket which is primarily responsible for the interaction with MDC1and that the dimerization induced by GST allows for tighter binding.Additionally, mutant constructs of the putative BRCT 5 bindingpocket were designed, successfully over-expressed and purified.The FP assays showed decreases in binding affinity associated withmutation of key conserved residues in the binding pocket. FP wasalso used to confirm that the phosphorylation of the MDC1 peptideis essential for TopBP1 BRCT 4/5 recognition. Taken together, theseFP results further support the unique dimerization-based bindingmechanism suggested by the crystal structure.PAX3 expression in melanomaZachary Tan and D. Alan UnderhillThe transcription factor PAX3 is critical for development of neuralcrest lineages including melanocytes. Prior to birth, PAX3 isrequired for the proliferation of melanocyte precursors and it isthought to maintain an ‘undifferentiated plastic state’ in epidermalmelanocytes after birth, as well in melanocyte stem cells. Inaddition, PAX3 is expressed throughout melanoma progression,from nevi to metastatic disease. Nevertheless, little is known abouthow PAX3 carries out these diverse roles. PAX3 is reported to bephosphorylated by Glycogen Synthase Kinase 3ß (GSK3ß). In thepresent study, the potential role of this kinase in modulating PAX3activity in B16F10 melanoma cells was examined using chemicalinhibitors. Fluorescence Activated Cell Sorting (FACS) was usedto assess cell cycle distribution and PAX3 levels were monitoredby immunoblotting. Treatment of cells with the GSK3ß inhibitorslithium chloride (LiCl) or BIO caused decreased cell proliferation(P=0.05) and G2/M accumulation (P=0.05), and was associatedwith increased PAX3 expression (P=0.05). In contrast, knockdownof PAX3 using siRNA resulted in G1 accumulation (P=0.05).Immunofluorescence techniques for exogenous BrdU incorporationand endogenous PS10H3 allowed for direct microscopic visualizationand quantification of cells in S and G2/M phase respectively. UponPAX3 knockdown, there was significantly less BrdU incorporationand PS10H3 staining (P=0.05). Lastly, cell motility assays wereconducted using live-cell Differential Interference Contrast (DIC)microscopy and analyzed using T-Scratch software. Interestingly,inhibition of GSK3ß as well as PAX3 knockdown was associatedwith markedly decreased cellular motility and proliferation. Theseinvestigations identify GSK3ß and as an important modulator ofPAX3 levels in melanoma cells, and also suggest broader roles forPAX3 in regulating the G1 to S-phase transition in melanoma.Student Poster Title SupervisorMark AssmusChristopherBeavingtonAlannaChomynNicholas ChuaAlexandruCojocaruMichelinaKierzekStephanie MahScott MeyerRobyn MillottKian ParseyanAmit PersadRaheemSulemanUncovering the role of topoisomerase II-betabinding protein 1 in DNA replication stressresponseThe structural studies of bacterial lactoferrinbinding protein B from Neisseria meningitidesIsolation of trkA expressing and IB4-bindingsensory neurons through the use of saporinA model system for complex redox enzymematurationUsing inhibition of protein N-myristoylationtowards the design of a synthetically lethaltreatment of B-cell lymphomasElucidating the molecular mechanismsof heart disease-linked mutations ofphospholambanCapase 1 Inhibition in inflammatory boweldisease reduces epithelial cell extrusionInvestigating the quinone binding site ofEscherichia coli fumarate reductaseThe novel interaction betweenN-myristoyltransferase 1 and calnexinProposed improvements for intraspinalmicrostimulation array fabrication andinsertionExpression of ST8Sia family in developingchick retina and their role in AP2deltamediatedaxonal generationDoes long life come from mom? Isolation ofa longevity-conferring mitochondrial DNAmutation in Caenorhabditis elegansDr. Mark GloverDr. Joanne LemieuxDr. Christine WebberDr. Joel H. WeinerDr. Luc G.BerthiaumeDr. Howard S. YoungDr. Julia LiuDr. Joel H. WeinerDr. Marek MichalakDr. Vivian K.MushahwarDr. Roseline GodboutDr. Bernard D.LemireDepartment/DivisionBiochemistryBiochemistryAnatomyBiochemistryCell BiologyBiochemistryMedicine/GastroenterologyBiochemistryBiochemistryCell BiologyOncologyBiochemistryZachary Tan PAX3 expression in melanoma Dr. Alan Underhill OncologyTerri WallerPartial deficiency of adipose trigylceridelipase (atgl) does not protect againstdiabetes-induced cardiac dysfunctionDr. Jason R.B. DyckPediatricsUniversity of Alberta Health Sciences Journal • April 2012 • Volume 7 • Issue 1 3

RESEARCHRosiglitazone decreases angiogenesis in theMCL after ACL rupture - A pilot studyChristopher J. DeSutter, BSc, 1 Daniel Miller, MD PhD, 2 Catherine Leonard, MSc, 2 Robert C. Bray, MD, MSc 21Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada2McCaig Centre for Joint Injury and Arthritis Research, University of Calgary, Calgary, CanadaCorrespondence and reprint requests to Dr. R. Bray, Department of Surgery, University of Calgary, 3330 Hospital Dr. NW,Calgary, Alberta, Canada T2N 4N1, Ph: (403) 220-4244, Fax: (403) 270-0617, Email: rcbray@ucalgary.caABSTRACTIn the anterior cruciate ligament (ACL)transected knee, the medial collateralligament (MCL) incurs numerousphysiological changes that includeinflammation and increased angiogenicactivity resulting in functional deficiency.Peroxisome proliferator activated receptor -γ(PPAR-γ) agonists show promising resultsfor their possible use in osteoarthritistherapies, but there are limited studieslooking at their effects in this area. Thepurpose of this study was to examine theeffect the PPAR-γ agonist rosiglitazonehas on the angiogenic response in theosteoarthritic rabbit model. Six rabbits wereassigned to one of three groups: control(n=2); 4-week right leg ACL transected(ACL-X) (n=2); 4-week right leg ACL-Xtreated with 5 mg/kg per day of rosiglitazone(n=2). The two contralateral MCLs inthe 4-week ACL-X rabbits treated withrosiglitazone were also used as the drugtreated non-ACL transected leg control. Intotal 8 MCLs were analyzed. To measurethe blood vessel volume and angiogenicresponse in the MCLs, the vascularendothelium (CD-31) and vascular smoothmuscle (SMA) volumes of them weredetermined. In the ACL-X rosiglitazonetreated MCL, CD-31 volume decreased3-fold down to control levels, in comparisonto non-treated ACL-X MCLs. Rosiglitazonehad a significant effect on SMA, causingdecreased volume in comparison to non –treated MCLs. In summary, rosiglitazonehas a significant effect on the angiogenicresponse in the ACL ruptured animal model.premature onset of osteoarthritis, themost common type of degenerative jointdisease. 3, 4In the knee, ACL rupture results in anteriortranslation of the tibia in relationshipto the femur resulting in joint laxity(Figure 1). This abnormal biomechanicalenvironment in an ACL ruptured knee isnot only detrimental to cartilage health, butinduces a series of adaptive structural andphysiological changes in secondary jointstabilizing structures. There is angiogenesis,hyperaemia, inflammation and increasedcellularity in the ligaments, meniscus,capsule and synovium of the knee joint. 5-7 Inthe medial collateral ligament (MCL) thereis increased blood flow, increased DNA andRNA synthesis and cellularity 7-10 Due tothe properties of the MCL being degraded,this leads to further cartilage degenerationand altered joint mechanics in the ACLruptured knee. 11There is limited information available onhow this physiological adaptation occurs.The modification of adaptive changes inosteoarthritic tissues has the potential toprovide new information on underlyingmechanisms, leading to new therapies forosteoarthritis. The peroxisome proliferator–activated receptors (PPAR) agonist drugsshow great promise in this area as apotential therapeutic treatment.PPAR agonists are ligand activatedtranscription factors that are part of thenuclear hormone super family. 12 Threedifferent isotypes have been identified:PPAR-α, PPAR-β and PPAR-γ. ThesePPAR endogenous ligands form a diversegroup of fatty acids with their derivativesgenerated by lipid metabolism. 12 Recently,INTRODUCTIONJoint injury and arthritis are major causesof morbidity in the United States. Oneof the most clinically important ligamentinjuries that occur is to the anterior cruciateligament (ACL). Each year in the USA, thereare 80,000 surgical ACL reconstructionsperformed. 1, 2 Patients possessing ACLruptures often complain of recurring lossof joint stability that often leads to theFigure 1. Anterior view of the knee detailing the major ligaments, bones, menisci andtendons. UpToDate (2011). Anterior knee anatomy adult. http://www.uptodate.com/contents/image?imageKey=RHEUM%2F26531 (accessed August 7, 2011).4University of Alberta Health Sciences Journal • April 2012 • Volume 7 • Issue 1

it has been found that PPAR-γ agonists areinvolved in vascular biology, inflammatoryresponses, tissue repair, cell differentiationand proliferation. 12-15 In arthriticsynoviocytes, PPAR-γ agonists greatlyinhibit inflammatory cytokine expression. 16PPAR-γ agonists have also been expressed inhuman chondrocytes acting as a protective17, 18mechanism for cartilage.PPAR-γ agonists have therapeutic potentialin a variety of clinical conditions. There isliterature showing PPAR-γ agonists role infat metabolism and their anti-inflammatoryactions shown through their effect oninhibiting cytokine expression. 19, 20 Thereare limited published studies looking at theeffect of PPAR-γ agonists in osteoarthritismodels. One study by Kobayashi et al.,using a partial medial menisectomyguinea pig model, found that the PPAR-γagonist pioglitazone reduced cartilagelesion depth and area. 21 By studying theeffect of the PPAR-γ agonist rosiglitazoneon the adaptive physiological responsein ACL ruptured knees (specifically theangiogenic activity), its potential as a newtherapy to treat osteoarthritic patients canbe determined.The purpose of this study is to examine theeffect of the PPAR-γ agonist rosiglitazone onthe physiological and angiogenic responsesin the rabbit model of joint laxity andosteoarthritis. The rabbit model was chosenas we can compare the results obtainedto our established database on adaptivephysiology in rabbit ACL – ruptured joints.It is hypothesized that PPAR-γ agonistswill decrease physiological degenerationof the MCL in the ACL ruptured knee.The blood vessel volume and degree ofangiogenesis occurring in the MCL of theACL ruptured knees will be measured usingimmunohistochemistry for specific markersfor vascular endothelium (CD-31) andvascular smooth muscle (SMA) in the MCL.MATERIALS AND METHODSSubjectsSix young skeletally mature 1-year-old NewZealand white rabbits (4.5 - 6.5kg; RiemansFur Ranch, St. Agatha, Ontario) wereassigned to one of three groups: control(n=2); 4-week right leg ACL transected(ACL-X) (n=2); 4-week right leg ACL-Xtreated with a low dose of 5 mg/kg /day ofrosiglitazone (n=2). The two contralateralMCLs in the 4-week ACL-X rabbits treatedwith rosiglitazone were used as the drugtreated non-ACL ruptured leg controls. Thisresults in a total of 8 MCLs analyzed in thisstudy. Rabbits were kept on a 12 – hourlight/dark cycle and fed standard laboratorychow and tap water ad libitum. All animalswere treated and maintained accordingto the Canadian Council on Animal Careguidelines and this study received approvalby the University of Calgary Faculty ofMedicine Animal Care Committee.ACL transection andRosiglitazone injectionsRabbits were given 0.18 mL of acepromazinemaleate (Atravet ®) intravenously andanesthetized with halothane (2-5%, 1.0 L/min O 2). All ACL transection surgeries werecompleted on the right leg of the rabbits.An anterior tibial draw test was performedon the right leg to ensure no prior ACLinjury existed. The anterior tibial draw testwas done by grasping the tibia with bothhands below the joint line, thumbs placedon either side of the patella, with the tibiapulled anteriorly.An antero-lateral surgical approach wasused. The ligament was exposed by lateralsubluxation of the patella and reflectionof the intra-articular fat pad. The ACL wasisolated using a hooked probe and theligament was transected at the middle witha #12 hooked blade. A second anteriortibial draw was performed to ensure thetransection was complete. Following theunilateral surgery, rabbits were treated withstandard antibiotics and allowed to resumenormal cage activity for four weeks.Rosiglitazone treated animals were injectedsubcutaneously with a low dose of 5 mg/kg of body weight per day for a total of fourweeks. In the ACL-X rabbits, injectionsbegan on the day following the ACLtransection surgery. Since the contralateralMCL was used as the non-operated legrosiglitazone treated control, the 4-weekdrug treatment was simultaneous. At thebeginning and end of the 4-week dosingperiod, anterior tibial draw tests werecompleted on the left leg to ensure no ACLinjury existed.ImmunohistochemistryMCLs were sectioned and labeled for CD-31and SMA according to the following doublelabelprotocol. Rabbits were euthanized thenthe MCLs were harvested from control, ACLruptured and rosiglitazone treated kneesthen cleaned of any extra tissue. Tissues werecryopreserved in serial sucrose solutionsof 10%, 20% and 30% concentrations.Following cryoprotection, ligaments werefrozen in isopentane at -80°C, embeddedin OCT media then stored at -30°C for onemonth until processing. MCLs were cut into100 μm thick longitudinal serial sections andplaced individually in 24 well plastic plates.Sections were washed in phosphate bufferedsaline (PBS) (3 x 10 minutes) then immersedin 10% normal donkey serum (JacksonImmunoresearch, West Grove, PA, USA)/PBS 1% Triton X100 for 1 hour at roomtemperature. MCLs were then incubatedwith mouse anti-human CD-31 antibody(1:50 dilution; Dako, Carpinteria, CA, USA)for 24 hours at 4°C in a humidified chamber.Sections were washed in PBS (3 x 10minutes) and incubated with donkey antimouseCy5 conjugated secondary antibody(1:300 dilution; Jackson Immunoresearch,West Grove, PA, USA) for 2 hours at roomtemperature. Sections were washed inPBS (3 x 10 minutes) then incubated withgoat anti-human smooth muscle actin(SMA) antibody (1:400 dilution, NovusBiologicals, Littleton, CO, USA) for 24 hoursat 4°C, followed by further PBS washesand incubation with donkey anti-goat Cy2conjugated antibody (1:400 dilution; JacksonImmunoresearch, West Grove, PA, USA)for 2 hours at room temperature. Sectionswere then washed for a final time, placedon slides with Fluorsave TM (Calbiochem,Mississauga, Ontario) and coverslipped.Slides were stored in a cardboard slideholder to protect fluorescence loss dueto light.Confocal MicroscopyMCL sections were analyzed using anOlympus Fluoview FV-1000 confocalmicroscope. They were visualized under a10x objective and imaged using 4-micronthick optical z-stack sections. Simultaneousdual channel scanning laser confocalanalysis was performed using preconfiguredCy2 and Cy5 channel settings. Images weresaved in the OIF file format.Statistical AnalysisThe CD-31 and SMA volumes found inthe MCL were determined using ImageJ software. The volumes of CD-31 andSMA in each image were put into an excelspreadsheet and then summed together toget a total volume converted into millilitersfor each ligament. The volumes of CD-31and SMA for each MCL type had theiraverages calculated. Since there are only twosubjects per group, the mean and the rangeof data was the chosen method of statisticalanalysis. If the subjects in each group hadincreased numbers, inferential analysisusing a two – way ANOVA would have beenpreferred for comparative purposes. By usingthis method of analysis, one could theninterpret if rosiglitazone has an effect on theangiogenic response in this pilot study.RESEARCHUniversity of Alberta Health Sciences Journal • April 2012 • Volume 7 • Issue 1 5

trioglitazone greatly inhibited inflammatorycytokine expression, inhibited proteoglycandegradation, MMP-1, MMP-13 and17, 18interleukin-1β production.To look at the role of PPAR-γ agonists onthe angiogenic response following ACLrupture and its effect on secondary jointstabilizing structures, rabbits were given alow dose of 5 mg/kg /day of rosiglitazonefor four weeks then had their MCLs CD-31and SMA volumes measured. This dose waschosen to see if levels less than 30 mg/kgused in another in vivo osteoarthritic guineapig model study would be an effectivetreatment. 21 No rabbit had any ACL injuryprior to surgery or injections. Quantificationof the vascularity in the MCLs showeda significant 3-fold increase in vascularvolume as identified by the volumetric CD-31 antibody label in the ACL transectedknees versus controls. When looking atthe effects of the rosiglitazone treatment,the vascular volumes of the treated ACLtransected MCL was reduced to nearcontrol MCL levels. Overall, rosiglitazonehas the ability to limit excess vascularendothelium development in the MCL afterACL transection.Quantification of the SMA volumes in theMCLs by volumetric SMA antibody labellingwas also performed. Rosiglitazone causeda reduction in SMA volume over untreatedACL ruptured knees. An unexpected findingin this study compared to other studies wasthe similarity between SMA volumes in ACLruptured MCLs and non-operated controlMCLs. Another unexpected finding was thatthe control MCLs had a much greater SMAvolume than the rosiglitazone treated MCLs,while CD-31 volumes in these groups weresimilar. A possible reason for these findingscould be that the rosiglitazone treatmentmay affect the production of MMP-13 andinterleukin-1β differently. In one study, thePPAR-γ agonist pioglitazone was shownto decrease interleukin-1β and MMP-13. 33Interleukin-1β is an angiogenic initiatoreffecting endothelial cell production. MMP-13 is a factor released from endothelialcells, which plays a role in the degradationof fibrous collagens, facilitating vascularsmooth muscle and adventitial cellmigration and proliferation. If rosiglitazoneaffects MMP-13 more than interleukin-1βthis will lead to decreased smooth muscleproduction. Decreased levels of smoothmuscle may contribute to endothelialdysfunction and decreased responsivenessof MCL vasculature, which has been foundin ACL ruptured osteoarthritis models. 34Future studies with increased subjects pergroup, varying dosages of rosiglitazone andmeasurement of markers for interleukin-1βand MMP-13 need to be conducted to gaina better understanding of the mechanismsthat are occurring.This study has two inherent weaknesses,which can confound the results obtained.First, there are only two subjects per group,which is quite low compared to a numberof other rabbit studies conducted. 10, 34 Inthose cases, there were usually minimumsof 6 rabbits per group. The second limitationwas the use of the contralateral MCL in therosiglitazone treated rabbits. Due to thebudgetary constraints of the study, the costincurred to treat separate control rabbitswith rosiglitazone and increased subjects pergroup would not have been feasible.Based on our results, it seems that therosiglitazone treatment has a significantimpact on decreasing angiogenic activityin the MCL of the ACL ruptured rabbitmodel. Due to the reduced angiogenicactivity, the use of this PPAR-γ agonist couldprove beneficial in reducing the negativeeffects angiogenesis has on the structuraland physiological properties of the MCLin response to an ACL ruptured humanknee. Rosiglitazone may prove beneficial inother secondary stabilizing structures andcomponents in the knee. Further studieslooking at the effects of rosiglitazone onthese structures by using RT-PCR, cartilageand meniscal grading, blood flow imaging ofthe MCL and biomechanical testing of theMCL are thus warranted.Overall, quantification of the vasculature ofthe MCL of ACL ruptured and rosiglitazonetreated knees by confocal microscopy hasshown that rosiglitazone significantlydecreased the angiogenic and physiologicaldegeneration of the MCL. Vascularendothelium volumes returned to nearcontrol levels in rosiglitazone treated MCLsin ACL ruptured knees while vascular smoothmuscle volume was lower in rosiglitazonetreated versus non – treated MCLs.ACKNOWLEDGEMENTSThe authors wish to thank the CanadianInstitute for Health Research (CIHR) forproviding the operating funds for thisproject. The authors also thank Tim Leonardfrom the Human Performance Laboratoryat the University of Calgary for histechnical support provided for the confocalmicroscope.REFERENCES1. Baquie P, Brukner P: Injuries presentingto an Australian sports medicine centre: a12‐month study. Clinical Journal of SportsMedicine 1997;7:28‐31.2. Bollen SR, Scott BW: Rupture of theanterior cruciate ligament-a quietepidemic? Injury 1996;27:407‐409.3. Mohtadi GH. Quality of life assessment asan outcome in anterior cruciate ligamentreconstructive surgery: In: Jackson DW,Arnoczky SP, Frank CB, Woo SL-Y, SimonTM, eds. The Anterior Cruciate Ligament,New York, NY: Raven Press, 1993:439-444.4. Nebelung W, Wuschech H. Thirty-fiveyears of follow-up of anterior cruciateligament-deficient knees in high-levelathletes. Arthroscopy. 2005;21:696-702.5. Hefti F, Kress A, Fasel J. Healing of thetransected anterior cruciate ligament in therabbit. J Bone Joint Surg. 1991;73A:373-383.6. Hellio le Graverand MP, Sciore P, EggererJ, Rattner JP, Vignon E, Barclay L, Hart DA,Rattner JB. Formation and phenotype ofcell clusters in osteoarthritis meniscus.Arthritis Rheum. 2001;44(8).7. McDougall JJ, Bray RC. Vascular volumedetermination of articular tissues in normaland anterior cruciate ligament-deficientrabbit knees. Anat Rec. 1998;251:207-213.8. Lo IK, Marchuk L, Majima T, Frank CB,Hart DA. Medial collateral ligamentand partial anterior cruciate ligamenttransection: mRNA changes in uninjuredligaments of the sheep knee. J Orthop Sci.2003;8(5):707-713.9. Matthews J, Chung M, Matyas J. Indirectinjury stimulates scar formation:adaptation or pathology? Connect TissueRes. 2004;45(2):94-100.10. Miller D, Forrester K, Leonard C, Salo P,Bray RC. ACL deficiency and incipientosteoarthritis impairs the vasoconstrictiveefficacy of neuropeptide Y in articulartissues: a laser speckle perfusion imagingstudy. J Appl Physiol. 2005;98(1):329-333.11. Bray RC, Doschak MR, Gross TS,Zernicke RF. Physiologic and mechanicaladaptations of rabbit MCL after ACLtransection.J Orthop Res. 1997;15:830-836.12. Michalik L, Auwerx J, Berger JP, et al.International Union of Pharmacology. LXI.Peroxisome proliferator-activated receptors.Pharmacol Rev. 2006;58(4): 726-741.13. Berger J, Moller DE. The mechanismsof action of PPARs. Ann Rev Med2002;53:409-435.14. Chinetti G, Fruchart JC, Staels B.Peroxisome proliferator-activatedreceptors (PPARs): nuclear receptors at thecrossroads between lipid metabolism andinflammation. Inflamm Res. 2000;49:497-505.15. Escher P, Wahli W. Peroxisome proliferatoractivatedreceptors: insight intomultiple cellular functions. Mutat. Res.2000;448:121-138.RESEARCHUniversity of Alberta Health Sciences Journal • April 2012 • Volume 7 • Issue 1 7

REVIEW16. Ji JD, Cheon H, Jun JB, Choi SJ, Kim YR,Lee YH, Kim TH, Chae IJ, Song GG, YooDH, Kim SY, Sohn J. Effects of peroxisomeproliferator-activated receptor-gamma(PPAR-gamma) on the expression ofinflammatory cytokines and apoptosisinduction in rheumatoid synovialfibroblasts and monocytes. J Autoimmun.2001;17(3):215-221.17. Fahmi H, Di Battista JA, Pelletier JP, MineauF, Ranger P, Martel-Pelletier J. Peroxisomeproliferator-activated receptor gammaactivators inhibit interleukin1-beta inducednitric oxide and matrix metalloproteinase13 production in human chondrocytes.Arthritis Rheum. 2001;44:595-607.18. Francois M, Richette P, Tsagris L, et al.Peroxisome proliferator-activated receptorgamma downregulates chondrocyte matrixmetalloproteinase-1 via a novel compositeelement. Clin Exp Immunol. 2002;129:379-384.19. Jiang C, Ting AT, Seed B: PPAR-gammaagonists inhibit production of monocyteinflammatory cytokines. Nature 1998;391:82-86.20. Ricote M, Li AC, Wilson TM, Kelly CJ, GlassCK: The peroxisome proliferator-activatedreceptor gamma is a negative regulatorof macrophage activation. Nature 1998;391:79-82.21. Kobayashi T. Notoya K. Naito T. Unno S.Nakamura A. Martel-Pelletier J. PelletierJP. Pioglitazone, a peroxisome proliferatoractivatedreceptor gamma agonist,reduces the progression of experimentalosteoarthritis in guinea pigs. Arthritis &Rheumatism 2005;52(2):479-87.22. Brandt KD, Braunstein EM, Visco DM,O’Connor B, Heck D, Albrecht M Anterior(cranial) cruciate ligament transectionin the dog: a bona fide model ofosteoarthritis, not merely of cartilage injuryand repair. J Rheumatol. 1991;18:436-446.23. Frank CB, Shrive NG, Boorman RS, LoIKY, Hart DA: New perspectives onbioengineering of joint tissues: jointadaptation creates a moving target forengineering replacement tissues. AnnBiomed Eng. 2004;32(3):458-465.24. Hashimoto S, Creighton-AchermannL, Takahashi K, Amiel D, Coutts RD,Lotz M. Development and regulation ofosteophyte formation during experimentalosteoarthritis. Osteoarthritis Cartilage.2002;10:180-187.25. Hellio le Graverand MP, Eggerer J, VignonE, Otterness IG, Braclay L, Hart DA.Assessment of specific mRNA levels incartilage regions in a lapine model ofosteoarthiritis. J Orthop Res. 2002;20:535-544.26. Lohmander, LS, Ostenberg A, EnglundM, Roos H. High prevalence of kneeosteoarthritis, pain, and functionallimitations in female soccer players twelveyears after anterior cruciate ligament injury.Arthritis Rheum. 2004;50(10):3145-3152.27. Sah RL, Yang AS, Chen AC, Hant JJ,Halili RB, Yodhioka M, Amiel D, CouttsRD. Physical properties of rabbitarticular cartilage after transection of theanterior cruciate ligament. J Orthop Res.1997;15:197-203.28. Setton LA, Elliott DM, Mow VC. Alteredmechanics of cartilage with osteoarthritis:human osteoarthritis and an experimentalmodel of joint degeneration. OsteoarthritisCartilage. 1999;7:2-14.29. Woo S, Young E, Suh J, Engevretsen, L.Acute injury to ligament and meniscusas inducers of osteoarthritis. In: KuettnerKE, Goldberg VM, eds. OsteoarthriticDisorders: American Academy ofOrthopaedic Surgeons, 1995.30. Walsh DA. Pathophysiological mechanismsof angiogenesis. Adv Clin Chem.2007;44:187-221.31. Bonnet CS, Walsh DA. Osteoarthritis,angiogenesis and inflammation. JRheumatol. 2005;44(1):7-16.32. Chimich D, et al. Water content altersviscoelastic behaviour of the normaladolescent rabbit medial collateralligament. J Biomech. 1992; 25(8):831-837.33. Kobayashi M, Squires GR, Mousa A,Tanzer M, Zukor DJ, Antoniou J, Feige U,Poole AR. Role of interleukin-1 and tumornecrosis factor alpha in matrix degradationof human osteoarthritic cartilage. ArthritisRheum. 2002;52(1):128-13534. Miller D, Forrester K, Leonard C, Hart DA,Salo P, Bray RC. Endothelial dysfunctionand decreased vascular responsiveness inthe anterior cruciate ligament deficientmodel of osteoarthritis. J Appl Physiol.2007;102:1161-1169.Clinical application and review of typical and atypicalantipsychotics in the treatment of delusional parasitiosisNathan Y. Hoy, 1 Patricia T. Ting, MSc, MD, 2 Stewart Adams, MD 31Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada2Deparment of Dermatology and Cutaneous Sciences, Department of Medicine, University of Alberta, Edmonton, Canada3Department of Dermatology, University of Calgary, Calgary, CanadaCorrespondence and reprint requests to: Nathan Hoy, #110 Beddington Co-op Mall, 8220 Centre St. N.E.,Calgary, Alberta, Canada T3K 1J7, Ph: (780) 289-3383, Fax: (403) 275-1143, Email: nhoy@ualberta.caABSTRACTBackground: Delusional parasitosis (DP)is a monosymptomatic hypochondrialpsychosis characterized by a false beliefthat one is infected with parasites.Traditionally, treatment revolved aroundtypical antipsychotics, especially pimozide.Pimozide’s adverse effect profile and theadvent of atypical antipsychotics have madethe latter the treatment of choice. Given thepaucity of randomized control trials andrelatively recent introduction of atypicals,little is known about their efficacy in thetreatment of DP.Objective: The purpose of this study is toreview the evidence for the efficacy and useof both typical and atypical antipsychoticsas treatment modalities for DP, with aspecific emphasis on the newer atypicalpharmacologics. As well, we aim to providesuggestions on how best to implementtreatment in a dermatological setting.Methods: Medline and EMBASE weresearched for available literature for both8University of Alberta Health Sciences Journal • April 2012 • Volume 7 • Issue 1

types of antipsychotics used in the treatmentof DP. A systematic review was notcompleted to allow for discussion of clinicalapplication of treatment.Results: Risperidone and olanzapine arecurrently the most commonly used atypicalantipsychotics in DP treatment and areas efficacious as pimozide (full or partialremission rates of 68% and 90% respectivelyvs. pimozide average of 79%), and havefewer side effects. Other atypicals such asquetiapine, aripiprazole and paliperidoneas well as risperidone long acting injectionshave demonstrated promising remissionrates > 75% in a limited number of patients,but still require further studies to beconsidered first-line therapies.Conclusion: Limited clinical studieswith small study populations implicaterisperidone and olanzapine as first linetreatments, but more randomized controltrials are needed. We also review methodsof how dermatologists may best initiatetreatment with atypical antipsychotics.Keywords: Delusional parasitosis, atypicalantipsychotics, typical antipsychotics,treatmentINTRODUCTIONDelusional parasitosis is amonosymptomatic hypochondrial psychosischaracterized by an unwavering falsebelief that one is infected with parasites. 1Thieberge first described this disorder in1894, and the name delusional parasitosis(DP) was introduced in 1946. 2 Theprevalence of DP is not well established,but is considered rare. Overall, the femaleto-maleratio of affected individuals isapproximately 2:1, with the mean age ofdiagnosis being slightly higher for femalesthan males (mean age, 50 years to 40 years). 3The classification of DP is as either primaryor secondary. Primary DP is characterizedby a somatic delusion lasting for at least1 month, whereby patients do not meetcriterion A for schizophrenia and there canbe no underlying cause of the delusion. 4Secondary DP results from the use of asubstance, organic causes, or other medicalor psychiatric disorders with the mostcommon causes being schizophrenia,diabetes, depression, cardiovascularevents, and neurodegenerative disease. Acomprehensive review of other secondarycauses of DP is discussed by Huber et al.(2007). 5Given that DP is a somatic delusion, patientsoften initially present to dermatologistsinstead of psychiatrists with symptoms ofpruritis, crawling sensations attributed to thepresence of parasites under the skin leadingto secondary excoriations, lichenification,prurigo nodularis and full thicknessulcers. 6, 7 Commonly, patients bring insamples of skin in small boxes as proofthat the parasites exist; this stereotypicalpresentation is referred to as “the matchboxsign.” 8 Furthermore, patients may attemptto rid these “parasites” with anti-scabeticpermethrin cream or even perform harmfulskin cleansing rituals with disinfectantsor pesticides. 9METHODSTreatment of DP requires the differentiationbetween the primary and secondary forms.Treatment of secondary DP relies on treatingthe underlying cause or cessation of theoffending drug. 10 Treatment of primary DPhas mostly revolved around typical and thenewer atypical antipsychotics, which havediffering mechanisms of action comparedto typical antipsychotics. We conducted aliterature search using combinations of thesearch terms: delusion*, parasitosis, typical,atypical, antipsychotics and treatment, inEMBASE and PubMed inclusive of studiespublished prior to May 1, 2010. For studiesinvolving typical antipsychotics, only thosewith n≥20 (including placebo group) werereviewed, since these represent the mostinfluential studies on which the basis oftypical antipsychotic treatment is formed.Due to the relatively recent introductionof atypical antipsychotics in the treatmentof DP, the n values for these studies weresignificantly smaller; thus sample size wasnot used as a definitive exclusion criterion.We included at least one study for eachatypical. The criteria we considered includedthe size of the study, with preference beinggiven to larger sample sizes; whether ornot numerous atypicals were comparedwithin the same study, to control for variabletreatment practices; and how well thestudy represented the general treatmentpopulation with respect to disease severity,co-morbidities and age.RESULTSTypical AntipsychoticsThe most common typical antipsychoticused in the treatment of DP is pimozide. 11Pimozide is an approved treatment forGilles de la Tourette syndrome in the UnitedStates, but it has also been shown to havea therapeutic effect for numerous offlabeldisorders, such as DP. 10-19 Pimozide’sprimary mechanism of action is via centralDopamine-receptor D2 antagonism. 12 Oneadvantage of pimozide over other typicalantipsychotics is its weak noradrenergicreceptor blockade effect which reducesadverse side effects such as orthostatichypotension and dizziness. 14A number of case reports, case series, anddouble-blind crossover trials showingthe effects of pimozide in DP have beenconducted (summarized in Table 1) 15-19 .The first double-blind crossover study wasperformed by Hamann and Avnstorp (1982)which demonstrated that 10 out of 11 DPpatients had a decrease in Brief PsychiatricRating Scale points and improvement ofdelusion and itching following 6 weeksof treatment with pimozide, while onlyone patient from the placebo groupexperienced improvement in the 4 weekevaluation period. 15 In 1986, anotherdouble-blind crossover study showedsignificant improvement in 10 DP patientsadministered 2-8 mg/day of pimozide for3 weeks followed by a relapse following 2weeks of placebo treatment and subsequentimprovement when pimozide was restarted.Improvement was based on the authors’own rating scale using symptoms of DP. 13Although these studies used a placebocontrol, the results are limited by thesmall sample size (i.e. n=11 and n=1013, 15respectively).The rates of partial and full remission arevariable amongst studies with pimozide.Zomer et al. (1998) found a partial to fullremission rate of 61% (11 out of 18 patients)in patients treated with pimozide comparedto 20% (3 out of 15) in the non-treatmentgroup. 16 A survey conducted by Lyell (1983)demonstrated 44 of 66 patients treatedwith pimozide demonstrated full or partialremission (combined remission rate of67%). 17 Partial and full remission of DP inpatients treated with pimozide have beenreported as high as 87% (n = 46)18 to 100%(n=10). 13The long-term efficacy of treatment withpimozide was demonstrated in a follow-upstudy by Lindskov and Baadsgaard (1985). 19Fourteen patients were followed up between19 and 48 months after termination ofpimozide treatment. Seven patients hadimproved, while 4 had deterioration oftheir symptoms and 3 had relapses thatresponded well to intermittent pimozidetreatment.A systematic review conducted by Leppinget al. (2007) found a total of 92 patientstreated with typical antipsychotics forprimary DP. Of those 92, 40 (43%)had partial remission, 45 (49%) hadfull remission and 7 (8%) showed noimprovement or were lost to follow-up. 10 Ofthe 53 patients treated with pimozide, 50had either full or partial remission (94%),REVIEWUniversity of Alberta Health Sciences Journal • April 2012 • Volume 7 • Issue 1 9

REVIEWTable 1: Efficacy of typical antipsychotics in treatment of DOPStudySampleSize Treatment DoseDuration oftreatment orfollow-upNumber ofpatients withfull or partialremission (%)Number of patientswith no change insymptoms (%)Number of patientswith deteriorationof condition (%)Additional notesHamann and Avnstorp n=11 Pimozide 1-5 mg/day 6 weeks 10 (91 1 (9) 01982 15 n=9 Placebo N/A 4 weeks 1 (9) 0 8 (73) Two lost to follow-up forsenility (n=1) and extensiverelapse (n=1)Ungvari and Vlader n=10 Pimozide 2-8 mg/day 3 weeks 10 (100) 0 01986 13 n=10 Placebo N/A 2 weeks 0 1 (10) 9 (90)Zomer et al. 1998 16 n=18 Pimozide 1-5 mg/day 3-4 weeks 11 (61) 0 7 (39)n=15 None N/A 3 (20) 12 (80) 0Lyell 1983 17 n=66 Pimozide 2-12 mg/day N/A 44 (67) 16 (24) 0 6 lost to follow-upBhatia et al. 2000 18 n=46 Pimozide 4-8 mg/day N/A 40 (87) 0 6 (13)Lindskov andn=14 Pimozide Unknown 19-48 weeksBaadsgaard 1985 19 after terminationof treatment7 (50) 0 4 (29) Three patients with relapsesbut responded to intermittenttreatmentTable 2: Efficacy of atypical antipsychotics in treatment of DOPAtypical AntipsychoticTreatmentSampleSizeDoseNumber of patientswith full or partialremission (%)Number of patientswith no change insymptoms (%)Number of patientswith deterioration ofcondition (%)Number of patients lostto follow up (%)Risperidone 24-28 41 0.25-5 mg/day 28 (68) 1 (2) 0 7 (29) lost to follow up;4 were switched to otherdrugs for varying reasonsincluding requiring a differentantipsychotic for co-morbidpsychiatric disease, andintolerance of risperidone;1 took it once and refused tocontinue medicationOlanzapine 25,26,28 10 2.5-20 mg/day 9 (90) 0 0 1 (10)Quetiapine 27, 28 2 100-150 mg/day 2 (100) 0 0Aripiprazole 30-32 4 10-15 mg/day 3(75) 0 0 1 (25)Paliperidone 33 1 3 mg/day 1 (100) 0 0RLAI 29 1 25-37.5 mg IM 1 (100) 0 0while 3 patients were non-compliant withtreatment. 10 Of note, the sample sizes for theother typical antipsychotic treatments wererelatively small.Atypical AntipsychoticsAtypical antipsychotics differ from typicalantipsychotics in their various mechanismsof action and are generally associated withless extrapyramidal symptoms. Meltzer etal. (1989) 20 proposed that a preference for5-HT2A receptor antagonism rather thanDA D2 receptor antagonism distinguishesthis class of drugs, although a number ofother hypotheses question this. 21, 22 Atypicalantipsychotics used in the treatment ofDP that will be discussed are risperidone,olanzapine, quetiapine, aripiprazole, andpaliperidone (Table 2).A number of case series have utilizedrisperidone as the main treatment modalityfor DP. Gallucci and Beard 23 first establishedrisperidone as a potential treatment of DP.Overall, of the 41 cases of DP treated withrisperidone that we reviewed, 28 had a fullor partial remission, one had no change insymptoms and 12 were lost to follow up orwere switched to another drug during thetreatment course – reasons for switchingmedications include co-morbidities thatcould be simultaneously treated withDP using another drug and unspecifiedintolerance of risperidone (Table 2). 24-28The most recent and largest retrospectivecase study followed 20 patients utilizingatypical antipsychotics for DP. 26 Fifteenpatients were treated with risperidone asthe main atypical antipsychotic and 10 ofthem had full or partial remission, while 5were lost to follow-up. Five patients weretreated with olanzapine as the main atypical10University of Alberta Health Sciences Journal • April 2012 • Volume 7 • Issue 1

antipsychotic. Of these patients, 4 had full orpartial remission, and 1 was lost to follow up.Another case series compared 4 patientstreated with risperidone and onetreated with quetiapine. 27 Three of the 4risperidone-treated patients experiencedtotal resolution of delusions; one of thesethree patients was also on lithium, anotherwas on sertraline and alprazolam as well,and another was also on sertraline anddonepezil. The last risperidone treatedpatient had a decrease in delusions and wason no other medications. The patient treatedwith quetiapine showed partial remissionand was also on venlafaxine, clonazepam,buspirone and bupropion.Shah and Pervez (2009) published onlythe second case report for the use ofrisperidone long-acting injections (RLAI). 29The patient refused to take oral risperidone,but accepted RLAI 25 mg IM every 2 weeks.This dosage was titrated up to 37.5 mg IMon discharge and she then switched to 5mg/day PO risperidone. Her symptomsimproved, although complete remission wasnot achieved.There are also newer atypical antipsychoticswhose efficacy in the treatment of DPhas only been documented in a limitednumber of case studies. One example isaripiprazole. 30-32 Rocha and Hara (2007)documented the first case of aripiprazoletreatment in an 85 year old DP patientand she underwent full remission. 30 Ina subsequent study, 2 patients with DPwere treated with aripiprazole and bothhad complete remission. 31 Paliperidone, anatypical antipsychotic approved by the FDAin 2006, has only been used in one DP case,where an 88 year old man treated with thedrug underwent complete remission. 33DISCUSSIONOur review of typical antipsychoticsindicates that pimozide is an effectivetreatment option for DP. The rates of fullor partial remission were similar to thenumbers reported in a systematic review byLepping et al. (2007). 10 There have been anumber of smaller case reports and studiesutilizing other typical antipsychotics such ashaloperidol, trifluoperazine, flupenthixol andfluphenazine depot, all of which showedexcellent rates of full or partial remission. 10Despite the past successes of pimozide, it isno longer considered first-line treatment ofDP, due to the advent of the safer atypicalantipsychotics. 34Furthermore, the long-term use of pimozideis associated with a number of adverseside effects. Extrapyramidal symptomssuch as tardive dyskinesia, parkinsonismand akathisia occur in less than 10-15%of patients treated with pimozide forschizophrenia, and Gilles de la TouretteSyndrome. 11 It has also been associatedwith clinically significant QT cintervalprolongation, including Torsades de Pointes,possibly due to the calcium channelblocking effects of the drug. 7, 14, 35 These sideeffects, especially its cardiac effects anddrug interactions (drugs metabolized bycytochrome P450 isoenzyme 3A4), makepimozide a non-ideal DP therapy. 34Much less is known about atypicalantipsychotics, because of their relativelyrecent introduction compared to typicalantipsychotics. The largest review to dateof atypical antipsychotic use in DP wasconducted in 2008 by Freudenmann andLepping, 34 which concluded that atypicalantipsychotics should be the first linetherapy for DP.The atypical antipsychotics with the largestsample sizes in our review were risperidoneand olanzapine. Risperidone has beenestablished as the most common atypicalantipsychotic used in the treatment of DP.The particular effectiveness of this drug hasbeen linked to its high affinity for 5-HT 2receptors, a receptor which has been linkedto psychotic processes and perceptualdifferences. 12 Although risperidone’sside effect profile is superior to that oftypical antipsychotics, there are instanceswhere parkinsonism and akathisia havebeen produced by its use and it has beenassociated with a mild increase in metabolicsyndrome. 32 An added benefit of risperidoneis that it is the only atypical antipsychoticavailable as a long-acting depot. Long actinginjections are particularly useful in patientswho are demonstrating harmful behavioursand refusing to comply with oral treatment.The goal of such a treatment would beto help the patient accept their problemis psychological and thus comply withoral therapy.Olanzapine is the second most commonatypical antipsychotic used in DPtreatment. 34 Its side effect profile is alsosuperior to that of pimozide and it rarelycauses extrapyramidal syndrome. However,this medication is closely associated withmetabolic syndrome and sedation. 32 Its useis still limited by a smaller body of evidence,but the fact that three patients treated withrisperidone were switched to olanzapinedue to intolerance suggests it may be a moretolerable drug. 25Quetiapine had an excellent remission rate,but with a small sample size (n=2), morestudies must be done in order to assess itsuse in the treatment of DP. Freudenmannand Lepping (2008) found a full or partialremission rate of 88% after reviewing 8cases. 34 The side effect profile of quetiapineis generally limited to drowsiness, dizzinessand postural hypotension, with minimalrisk of extrapyramidal symptoms or adversecardiac effects. 36 Quetiapine’s excellentside effect profile combined with its highremission rate makes it a potential treatmentfor DP.The results of aripiprazole treatment in DPhave only been published for 4 patients todate with all 4 demonstrating full or partialremission. 23-25 There have not been anyrandomized control trials or placebo crossover studies performed with aripiprazoleand DP, but the case study results arepromising. Adverse effects of aripiprazoleinclude nausea and akathisia, but it is nonsedatingand less often associated withextrapyramidal symptoms and metabolicdisturbances. 37 This excellent side effectprofile may make it beneficial to DP patientswho cannot tolerate the side effects ofother antipsychotics.Paliperidone is the latest atypicalantipsychotic used in the treatment of DP.Paliperidone is the main active metaboliteof risperidone and it blocks 5-HT 2Aand D 2-receptors. It has a long half-life of 24 hours,which decreases the number of daily doses.As well, it decreases the risk of any potentialadverse drug reactions, which is especiallyimportant because many DP patients havenumerous co-morbidities being treatedsimultaneously. 33 The clinical efficacy ofpaliperidone as a treatment for DP needsto be confirmed by further case studies orrandomized control trials.CLINICAL IMPLICATIONSDiagnosis of DP is definitely within thescope of a dermatology practice. However,the psychological basis of the disordermakes initiating therapy in a dermatologistoffice challenging. Patients often feel asif their symptoms are not being seriouslyconsidered when the dermatologist triesto explain that the disease is psychotic innature. Referral to a psychiatrist is oftenmet with anger and frustration, resultingin the patient either seeking the opinionof another dermatologist or resorting toself-treatment, which may be potentiallyharmful. 10 It may be prudent to ask thepatient’s thoughts on you consulting anexpert colleague who deals with similarconditions more frequently. This will openthe door to discussing the managementplan with a psychiatrist, while empoweringthe patient to be actively involved in thetreatment decision.REVIEWUniversity of Alberta Health Sciences Journal • April 2012 • Volume 7 • Issue 1 11

REVIEWIn the event a patient demands a skinbiopsy, it may be worthwhile to do onerather than risk losing rapport with thepatient. Koo and Lee (2001) suggest makinga verbal agreement beforehand, and thatthe patient be more flexible in his or herthinking if the biopsy returns negative; thismay make it easier to convince the patientto take antipsychotic medications afterthe biopsy. 8 When antipsychotic therapyis initiated, it is advisable to offer themedication as an empirical therapy whileemphasizing the potential for reductionin symptoms, like biting and crawlingsensations. 8 Potential side effects of theantipsychotics should be discussed withthe patient beforehand, to enhance patientcompliance. Considering the patient’s comorbiditieswhen selecting the particularantipsychotic to be used can help tailorthe choice; for example, in a patient withdiabetes, olanzapine should be avoideddue to its potential for metabolic syndromeside effects. Depot injections (risperidone)should only be pursued as an optionif the patient is willing to be regularlymonitored by a psychiatric team. Workingin conjunction with the patient’s familyphysician to monitor both the side effects ofthe antipsychotic medication and course ofthe DP will reduce the risks of complicationsfrom the therapy, especially if the patientrefuses the involvement of psychiatry.CONCLUSIONThere has never been a randomizedcontrol trial directly comparing atypicalantipsychotics to typical antipsychotics,which would be useful in establishing aclear treatment of choice for DP. 10 However,based on the efficacy of drugs in bothclasses as shown in Tables 1 and 2, it wouldappear that atypical antipsychotics have alower side effect profile while achieving apartial to full remission rate similar to typicalantipsychotics. The reduction in adverseiatrogenic events would improve patientcompliance to treatment and help constructa therapeutic relationship between thepatient and physician.References:1. Wilson FC, Uslan DZ. Delusionalparasitosis. Mayo Clin Proc. 2004;79:1470.2. Wilson J, Miller H. Delusions of Parasitosis.Archives of Dermatology and Syphilology.1946;54:39-56.3. Boggild AK, Nicks BA, Yen L, VanVoorhis W, McMullen R, Buckner FS,et al. Delusional parasitosis: six-yearexperience with 23 consecutive cases at anacademic medical center. Int J Infect Dis.2010;14:e317-21.4. DSM-IV-TR. Diagnostic and statisticalmanual of mental health disorders (4thed, text revision). In. Washington DC:American Psychiatric Association, 2000.5. Huber M, Kirchler E, Karner M,Pycha R.Delusional parasitosis and the dopaminetransporter. A new insight of etiology? MedHypotheses. 2007;68:1351-8.6. Donabedian H. Delusions of Parasitosis.Clin Infect Dis. 2007;45:e131-4.7. Driscoll MS, Rothe MJ, Grant-KelsJM, Hale MS. Delusional parasitosis:a dermatologic, psychiatric, andpharmacologic approach. J Am AcadDermatol. 1993; 29:1023-33.8. Koo J, Lee CS. Delusions of parasitosis.A dermatologist’s guide to diagnosis andtreatment. Am J Clin Dermatol. 2001;2:285-90.9. Robles DT, Romm S, Combs H, OlsonJ, Kirby P. Delusional disorders indermatology: a brief review. DermatolOnline J. 2008;14:2.10. Lepping P, Russell I, Freudenmann RW.Antipsychotic treatment of primarydelusional parasitosis: systematic review. BrJ Psychiatry. 2007;191:198-205.11. Lorenzo CR, Koo J. Pimozide indermatologic practice: a comprehensivereview. Am J Clin Dermatol. 2004;5:339-49.12. Elmer KB, George RM, Peterson K.Therapeutic update: use of risperidonefor the treatment of monosymptomatichypochondriacal psychosis. J Am AcadDermatol. 2000;43:683-6.13. Ungvari G, Vladar K. Pimozide treatmentfor delusion of infestation. Act Nerv Super(Praha). 1986;28:103-7.14. Opler LA, Feinberg SS. The role ofpimozide in clinical psychiatry: a review. JClin Psychiatry. 1991;52:221-33.15. Hamann K, Avnstorp C. Delusions ofinfestation treated by pimozide: a doubleblindcrossover clinical study. Acta DermVenereol. 1982;62:55-8.16. Zomer SF, De Wit RF, Van Bronswijk JE,Nabarro G,Van Vloten WA. Delusions ofparasitosis. A psychiatric disorder to betreated by dermatologists? An analysis of33 patients. Br J Dermatol. 1998;138:1030-2.17. Lyell A. The Michelson Lecture. Delusionsof parasitosis. Br J Dermatol. 1983;108:485-99.18. Bhatia MS, Jagawat T, Choudhary S.Delusional parasitosis: a clinical profile. IntJ Psychiatry Med. 2000;30:83-91.19. Lindskov R, Baadsgaard O. Delusions ofinfestation treated with pimozide: a followupstudy. Acta Derm Venereol. 1985;65:267-70.20. Meltzer HY. What’s atypical about atypicalantipsychotic drugs? Curr Opin Pharmacol.2004;4:53-7.21. Kapur S, Remington G. DopamineD(2) receptors and their role in atypicalantipsychotic action: still necessary andmay even be sufficient. Biol Psychiatry.2001;50:873-83.22. Westerink BH. Can antipsychotic drugs beclassified by their effects on a particulargroup of dopamine neurons in the brain?Eur J Pharmacol. 2002;455:1-18.23. Gallucci G, Beard G. Risperidone andthe treatment of delusions of parasitosisin an elderly patient. Psychosomatics.1995;36:578-80.24. De Leon OA, Furmaga KM, CanterburyAL, Bailey LG. Risperidone in thetreatment of delusions of infestation. Int JPsychiatry Med. 1997;27:403-9.25. Healy R, Taylor R, Dhoat S, LeschynskaE, Bewley AP. Management of patientswith delusional parasitosis in a jointdermatology/ liaison psychiatry clinic. Br JDermatol. 2009; 161:197-9.26. Kenchaiah BK, Kumar S, Tharyan P.Atypical anti-psychotics in DelusionalParasitosis: a retrospective case series of 20patients. Int J Dermatol. 2010; 45:95-100.27. Wenning MT, Davy LE, Catalano G,Catalano MC. Atypical antipsychotics inthe treatment of delusional parasitosis.Ann Clin Psychiatry. 2003;15:233-9.28. Nicolato R, Correa H, Romano-Silva MA,Teixeira AL, Jr. Delusional parasitosis orEkbom syndrome: a case series. Gen HospPsychiatry. 2006;28:85-7.29. Shah A, Pervez M. Risperidone LongActing Injection (RLAI) in DelusionalParasitosis. German Journal of Psychiatry.2009;12:35-7.30. Rocha FL,Hara C. Aripiprazole indelusional parasitosis: Case report. ProgNeuropsychopharmacol Biol Psychiatry.2007;31:784-6.31. Bennassar A, Guilabert A, Alsina M, PintorL,Mascaro JM, Jr. Treatment of delusionalparasitosis with aripiprazole. ArchDermatol. 2009;145:500-1.32. Sandoz A, LoPiccolo M, Kusnir D, TauskFA. A clinical paradigm of delusionsof parasitosis. J Am Acad Dermatol.2008;59:698-704.33. Freudenmann RW, Kuhnlein P, LeppingP,Schonfeldt-Lecuona C. Secondarydelusional parasitosis treated withpaliperidone. Clin Exp Dermatol.2009;34:375-7.34. Freudenmann RW, Lepping P. Secondgenerationantipsychotics in primary andsecondary delusional parasitosis: outcomeand efficacy. J Clin Psychopharmacol.2008;2:500-8.12University of Alberta Health Sciences Journal • April 2012 • Volume 7 • Issue 1

35. Wykoff RF. Delusions of parasitosis: areview. Rev Infect Dis. 1987;9:433-7.36. Milia A, Mascia MG, Pilia G, ParibelloA, Murgia D, Cocco E, et al. Efficacyand safety of quetiapine treatment fordelusional parasitosis: experience in anelderly patient. Clin Neuropharmacol.2008;31:310-2.37. Narayan V, Ashfaq M, Haddad PM.Aripiprazole in the treatment of primarydelusional parasitosis. Br J Psychiatry.2008;193:258.REVIEWStem cells in cardiac repair: A review of the changinglandscape of cardiovascular medicineNicholas A. Avdimiretz, BScMedical Student (2013), Faculty of Medicine and Dentistry University of Alberta, Edmonton, CanadaCorrespondence to Nicholas Avdimiretz: Email: naa1@ualberta.caAbstractCardiac disease is the leading cause of deathfor both men and women in developedcountries. In Canada, the incidence ofdiabetes and hypertension has recentlyincreased by 90% in middle income groups,resulting in substantially more cardiacdisease. How can medical professionalskeep up with these statistics? Imagine ifphysicians could regenerate the woundedheart post-myocardial infarction, or evenbioengineer an entirely new organ. Thisis the future of cardiovascular medicine.Regenerating myocardium is hardly an easyundertaking; the heart contains about 20million cardiomyocytes per gram of tissue,meaning – in the left ventricle alone – thereare approximately 4 billion cardiomyocytesat risk during a heart attack. Many cells arerequired to replace damaged tissue, makingcomplete regeneration challenging. In lightof the rich therapeutic potential seen inboth adult and embryonic stem cells, it is nosurprise that biomedical research on thesecells has seen an intense amount of activityin the past decade. From fetal-derivedcardiomyocytes and skeletal myoblasts, tobone marrow stromal cells and peripheralblood CD34 + cells, a myriad of cell lineshave been tested to date. The last decadehas seen an explosion of novel approachesusing these cells to restore cardiac functionpost-infarction: from developing cell-basedpacemakers and cardiac grafts, to buildingbioartifical hearts. This review will paint apicture of the rapidly changing landscapeof cardiovascular medicine by elaboratingon these new technologies. Limitationsof these approaches will be discussed, aswell as future developments. In the field ofcell-based cardiac repair, the possibilitiesseem endless.PreambleCardiac disease is the leading causeof death for both men and women indeveloped countries. In fact, cardiovasculardisease – including coronary heart disease,hypertension, stroke, and congestive heartfailure – has ranked as the number onecause of death in the US every year since1900, except during the 1918 influenzaepidemic. 1 In 2007, heart disease accountedfor 26% of all deaths in the US, resultingin an age-adjusted death rate of 211 per100,000 people. 2 Also shocking is the costof medication, health care services, and lostproductivity due to heart disease in the US:a projected $508 billion in 2010. 3 This costis not expected to decrease any time soon.In Canada, the incidence of risk factors forcardiac disease has increased substantiallyover the past decade: both diabetes andhypertension have increased by 90% inmiddle income groups (roughly 50% ofthe population), 4 resulting in substantiallymore cardiovascular disease. What if thereexisted a therapeutic technique to treat thatwhich physicians have for so long deemedincurable? What if one could regenerate thewounded heart after a myocardial infarctionusing stem cells? Imagine if one couldbioengineer a new heart. This could be thefuture of cardiovascular medicine.Over the last decade, the utilization ofstem cells to repair the damaged heart hasseen an explosion of advancements. Noveltherapeutic techniques will be addressed indetail: the methods used and the resultingapplications of these innovations will bedescribed. Limitations of these techniquesand future developments will also bereviewed.Introduction to Cardiac RepairCell therapy has experienced muchgrowth over the last 25-30 years: fromits first applications for reconstitutingthe immune system after a bone marrowtransplant, to treating diabetes withpancreatic islet transplantation. 5 More recenttreatments include those for liver cirrhosis,Huntington’s disease, and Parkinson’sdisease. 6 As for heart disease, the majorityof therapies have been centered on thetreatment of heart damage post-myocardialinfarction (MI). How can myocardial repairoccur in an organ that is thought to beincapable of naturally self-repairing itself?The heart does not experience regenerationas the liver does; following MI, scar tissueforms over the infarcted area. Therefore,much of the research has been gearedtowards using cell-based approaches toregenerate myocardium directly fromdonor stem cells. Regenerating heartmuscle following an MI is hardly an easyundertaking; the myocardium containsabout 20 million cardiomyocytes per gram oftissue, so there are approximately 4 billioncardiomyocytes at risk in the left ventriclealone during a heart attack. Assumingthat any repair therapy restores at least1/2 to 2/3 of the damaged myocardium,true regeneration would require 500 to 800million cells. 7 In light of the therapeuticpotential seen in both adult and embryonicstem cells (coined ES cells by Martin in1981), 8 it is no surprise that biomedicalresearch on these cells has seen an intenseamount of activity in the past decade.Stem Cell SourcesStem cells not only have an unlimitedcapacity to self-renew, but they are alsopluripotent; this means that stem cellscan be induced to differentiate into cellsUniversity of Alberta Health Sciences Journal • April 2012 • Volume 7 • Issue 1 13

REVIEWwith specific functions. 9 Primarily twotypes of mammalian stem cells are used inmyocardial regeneration: embryonic stemcells found in the blastocyst during earlyembryogenesis, and adult stem cells foundin adult tissues acting as progenitor cells.ES cells are pluripotent and can potentiallygive rise to a number of cell types, theyare vital to tissue regeneration therapy,regardless of the field of research. Skeletalmyoblasts, on the other hand, are committedprogenitor cells of skeletal muscle; theyare resistant to ischemia and highlyproliferative. 10 These myoblasts, harvestedfrom neonatal and adult animals, havebeen shown to differentiate into skeletalmyotubes and improve left ventricularfunction following an infarct. 10 Theseresults have been obtained in autologous,syngeneic, allogenic, and xenogenictransplants – largely in mice and rats, butalso in swine and canine subjects. 10Adult bone marrow derived stem cells havealso been studied: there are hematopoieticstem cells, endothelial progenitor cells,and mesenchymal stem cells in adult bonemarrow. Research has shown that treatmentwith mesenchymal stem cells (MSCs –precursors to muscle, bone, tendons, andligaments) improves myocardial functionby limiting ventricular remodeling. 11 Itwas known that intramyocardial injectionof Akt-MSCs (mesenchymal stem cellsoverexpressing the survival gene Akt)restored cardiac function after only 72hours. 11 Gnecchi et al. hypothesized that,because such a rapid recovery could notbe due to differentiation of the donor cells,regeneration was accomplished through theaction of factors provided by the MSCs. 12It was thought that these factors acted ina paracrine fashion to rescue the damagedheart tissue. Gnecchi et al. found that itis possible, in an animal model, to usemesenchymal stem cells to alleviate acuteMI by injecting a cell-free supernatantthat had been recovered from cultures ofmesenchymal stem cells. 12Adult CD34 + cells, easily obtained fromperipheral blood, can trans-differentiateinto cardiomyocytes in vivo at the site ofinjury in mice – yet this is still a work inprogress. 13 Lastly, some sources suggest thatthere are small populations of “residentcardiac stem cells” endogenous to the heartthat may serve a minor role in repair. 14While researchers clearly have many typesof stem cells at their disposal for use incardiovascular therapies, only ES-derivedcardiomyocytes and skeletal myoblastshave been able to achieve a proper levelof cell survival for complete myocardialregeneration. 7Skeletal MyoblastTransplantationStudies on skeletal myoblasts began withwork of Chiu et al., dating back to 1995.His team studied the ability to repairinjured myocardium in the presence ofskeletal muscle cells, called “satellitecells.” 15 Each skeletal muscle fiber containsa few myogenic satellite cells, which arenormally undifferentiated and quiescent.Injury activates these cells, causing them toenter mitosis and restore the functionalityof the fiber. 16 Chiu et al. hypothesized thatsatellite cells, when implanted into injuredmyocardium and influenced by the cardiacenvironment, would undergo “milieudependentdifferentiation.” 15 Chiu et al.conducted two experiments: one in whichthe histological outcome of implantingskeletal satellite cells into acutely damagedmyocardium was observed, and the otherin which the presence of satellite cells atthe site of implantation was confirmed. 15Satellite cells were isolated from samplesobtained from the tibialis anterior muscle ofadult dogs, and then labeled with tritiatedthymidine. Following which, the cellswere grown in vitro for either 10 days or 3weeks and implanted into the cryoinjuredmyocardium of the same animal. A catheterwas used to implant the cells into theinjured left ventricular free wall, which wasacutely damaged by liquid nitrogen. Implantsites were evaluated radiographically toFigure 1. Data comparingthe change in slope of PRSWrelationship at 3 weeks incryoinjured myocardium (white)with that in which myoblasttransplantation failed (grey) andwas successful (black). Courtesy ofNat Med: Taylor, DA.detect the thymidine labels. The resultsshowed successful transdifferentiation ofmyoblast satellite cells into cardiomyocytes:new muscle cells in the implant siteshistologically mimicked cardiac muscle,including the presence of intercalateddiscs, which are unique to cardiac musclefibers. 15 Chiu et al. concluded that thecardiac environment played a role in celldifferentiation, possibly through growthfactors or other signaling pathways.In 1998, Taylor’s group made use of thecryoinfarction and cell implantationtechniques described by Chiu et al. to testwhether skeletal myoblast transplantationactually improves myocardial performance. 17One week following myocardial injury,skeletal myoblasts from the rabbit hindlimbsoleus muscle were transplanted intothe damaged heart of the same rabbit.Following transplantation, 7 of the 12rabbits had an improvement in myocardialperformance: PRSW slope (an indication ofsystolic function and contractility) increased34–400% compared to post-infarct values(Figure 1). 17 Electron microscopy of theimplant sites did not show multinucleatedskeletal fibers, but rather cells thatresembled cardiomyocytes (Figure 2). 17For the first time in animals, myoblasttransplantation into acutely injuredhearts was reported to improve cardiacperformance in vivo.Figure 2. Electron micrographof the transplanted myoblasts.Intercalated discs (i) connectthe myocytes that have beentransplanted. Courtesy of NatMed: Taylor, DA.14University of Alberta Health Sciences Journal • April 2012 • Volume 7 • Issue 1

Embryonic Stem CellTransplantationHuman ES cells served as another jumpingoffpoint for producing differentiatedcardiomyocytes. Could ES cells normalizecardiac performance by being transplantedinto injured myocardium? In 2002, Min’steam set out to answer this question usingrat models. ES cells were transfected withgreen fluorescent protein (GFP) to identifycell survival, and transplanted into malerats after inducing MI by ligating the leftanterior descending coronary artery. 18Hemodynamics and muscle contractionwere evaluated both post-MI and after thetransplantation. Survival of the transplantcells was confirmed by observing GFPexpression. Cardiac α-myosin heavy chainand (α-MHC) and troponin I (cTnI) wereidentified using specific antibodies. Notonly did these cells survive, but they alsoimproved cardiac function. Cardiac musclewall tension was measured to determinemyocyte function at a given ventricularpressure and radius (according to LaPlace’sLaw, wall tension (T) is proportionalto intraventricular pressure (P) andventricular radius (r): T ∝ P ∙ r). Wall tensionincreased ~2-fold in the rats that hadundergone transplants. 18Cell-Based PacemakersThus far, efforts in stem cell transplantationhave been discussed with the goal ofrepairing infarcted cardiac tissue. In 2004,Xue et al. approached cardiac therapyfrom a new angle: would it be possible tocoordinate inactive cardiac muscle cellsto beat synchronously with pacemakerlikedonor cells? Human ES cells weretransfected with GFP and transplantedsubepicardially into guinea pigs in vivo. 19After allowing the stem cells differentiate,a beating outgrowth of cardiomyocytes wasdissected and checked for GFP expression.The cells were then transplanted onto alayer of quiescent rat cardiomyocytes invitro, resulting in synchronous contractionsat ~49 bpm of GFP-expressing cells and ratcardiomyocytes. 19 Without direct contactbetween the two cell lines, there was nosynchronous beating. It is important tonote that, unlike cell-based pacemakers,electronic pacemakers are largely unableto adapt to fluctuating requirements. Inaddition, sensing and pacing leads maybecome dislodged or malpositioned, and thepocket in which the electronic pacemakersits is prone to infection. 20 This researchshows that bio-pacemakers are clinicallyattractive, and may overcome the limitationsof the electronic pacemaker.Figure 3. Photograph of a heart at week 9 posttransplantationof the cellular construct. Note thepresence of neovascularization into the implantedbiograft (B). Courtesy of Circulation: Leor, J.Bioengineered Cardiac GraftsBecause it is generally accepted that themyocardium cannot regenerate after injury,much research has gone into replacingdamaged muscle. 21 For example, Leor et al.tested whether bioengineering cardiac tissuewithin three-dimensional (3D) scaffoldswould enhance cardiac function afterextensive MI. 21 This novel practice involvesthe use of 3D cross-linked biopolymer,which serves as a support structure uponwhich functional cells can grow. Thestructure biodegrades once the cells haveformed their own matrix. Rat cardiac cellswere isolated and cultured, and seeded incylindrical scaffolds made of sodium alginatewith 100 μm pores. 21 Biograft implantationwas performed 7 days post-MI: in eachrat, two scaffolds were attached to the scartissue induced by left main coronary arteryblockage. After 9 weeks, the rats wereeuthanized, and the hearts were examined.Under histology, the scaffolds showed thatthey had successfully merged with theinfarcted area (Figure 3). 21 Control rats weresubjected to heart failure as a result of leftventricular remodeling post-MI – but in thebiografted rats, there was less ventricularremodeling and deterioration.Biotechnology Builds a HeartOver 1,000 Canadians are waiting for adonor heart. 22 Bioartificial hearts couldpotentially circumvent this issue, andprevent significant sequelae associated withallogeneic heart transplantation – includinglong-term immunosuppression, renal failure,and hypertension. 23 Ott et al. describes anattempt to fabricate the construct of anentire heart, complete with vasculatureand inner architecture: it involves“decellularizing” whole adult rat heartsusing detergents, and then repopulatingthem with neonatal cardiac cells (Figure 4). 23This ingenious technique utilizes “nature’splatform” of the heart, rather thanattempting to engineer it from scratch. Notonly does this bioartifical heart mimic thestructure and cellular layout of a true heart –it also functions like one. When stimulatingthe constructs, acceptable measurementsof cardiac function were obtained in 5 outof 8 hearts. 23 It is hypothesized that thebioengineered heart could be used as a fullreplacement organ in end-stage failure.However, this will only be possible withfurther organ maturation, reseeding of theheart’s vasculature with endothelial cells,and scaling up of the technology to workwith human-sized hearts.LimitationsGiven the scarcity of donor hearts availableto meet transplant needs, these approacheshave immense advantages over hearttransplants. However, a number of hurdlesmust be overcome before human ES cellscan be used clinically. For instance, ethicalissues related to accessing embryos limitscientists’ investigations. Also, human EScells must go through rigorous testingbefore the cells can be used as a regenerativetherapy. If transplanted regenerative cells arecontaminated with undifferentiated ES cells,a tumor could form. 24 It has been suggestedthat differentiation of ES cells prior toimplantation may prevent the formationof cancerous teratomas. 25 Also, in most celltransplant studies, many cells are lost beforeblood and nutrient supplies are established. 7Introducing exogenous genes into transplantcells could make them more robust or allowthem to release growth factors. For example,induced pluripotent stem cells have beenstudied by obtaining fibroblasts after geneticreprogramming; however, these have beenshown to form teratomas as well. 26It should also be noted that, in certainanimal models, stem cells end up travellingfrom the heart to other nearby organs onlya few hours post-transplant, and in somecases, the use of skeletal myoblasts hascaused ventricular tachycardia. 27 Cell-basedpacemakers could also lead to arrhythmiasif the graft undergoes changes in ionchannel expression. 19 Innovative methodshave been studied in an attempt to preventarrhythmias. A recent clinical, the CAuSMICstudy, used a novel minimally-invasivecatheter system to deliver autologousmyoblasts to 23 human subjects with NYHAclass II to IV heart failure. 28 This techniqueresulted in significantly improved heartREVIEWUniversity of Alberta Health Sciences Journal • April 2012 • Volume 7 • Issue 1 15

REVIEWradical idea; now it is a popular experimentalconcept with early clinical trials beingconducted around the world. Researchinto this area offers promise to a variety ofmedical fields. However, rigorous testingis still required before moving from benchto bedside.Figure 4. Mounted cadaveric rat hearts. Note that the heart becomes more translucent as cellular material iswashed out of the right ventricle, then the atria, and finally the left ventricle. Courtesy of Nat Med: Ott, HC.failure symptoms, with no difference in theincidence of arrhythmias between treatmentand control. 28 Still, more extensive clinicaltrials are required to overcome the manylimitations of stem cell therapy.Future DevelopmentsTransplant cell engineering, celldifferentiation prior to implantation, andminimally-invasive methods may helpimprove the next generation of techniques.The possibilities seem endless in the fieldof cell-based cardiac repair. Judging by thecurrent explosion of research, it may bepossible to transplant tissue engineeredvalves in the near future. For instance,trileaflet heart valves – fabricated fromscaffolds and seeded with autologousstem cells – have been implanted in sheepusing a minimally-invasive technique,resulting in functional valves. 29 Yet, why stopthere? Complete organogenesis is withinsight. “Organ printing”, the assembly of3D vascularized soft organs, is a feasibletechnology. With the help of computerizedtechnology, sheets of single cells can beplaced one on top of another using a cellprinter, almost like printing paper. 30Stem cells hold the key to rebuildingdamaged tissues. One decade ago, this was aReferences1. American Heart Association. HeartDisease and Stroke Statistics: 2010. Dallas:American Heart Association; 2010.2. Centers for Disease Control andPrevention. Deaths: Leading Causes for2006. National Vital Statistics Reports2010;58(14).3. Lloyd-Jones D, Adams RJ, Brown TM,Carnethon M, Dai S, De Simone G, etal. Heart disease and stroke statistics: 2010Update. Circulation 2010;121:e46–e215.4. Lee DS, Chiu M, Manuel DG, Tu K,Wang X, Austin PC, et al. Trends in riskfactors for cardiovascular disease inCanada: temporal, socio-demographicand geographic factors. Can Med Assoc J2009;181:3-4.5. Pileggi A, Ricordi C, Kenyon NS, Froud T,Baidal DA, Kahn A, et al. Twenty years ofclinical islet transplantation at the DiabetesResearch Institute-University of Miami.Clinical Transplants 2004;177-204.6. Teo AK, Vallier L. Emerging use of stemcells in regenerative medicine. BiochemicalJournal 2010;428:11-23.7. Dinsmore JH, Dib N. Stem Cells andCardiac Repair: A Critical Analysis. J ofCardiovasc Trans Res 2008;1:41-54.8. Martin G. Isolation of a pluripotent cellline from early mouse embryos cultured inmedium conditioned by teratocarcinomastem cells. Proc Natl Acad Sci USA1981;78(12):7634-8.9. Stem Cell Basics: Introduction [Internet].Bethesda (MD): National Institutes ofHealth (US); c2006-2008 [updated 2006Apr 28; cited 2008 Nov 1]. Available fromhttp://stemcells.nih.gov/info/basics/basics1.asp10. Dowell JD, Rubart M, Pasumarthi KB,Soonpaa MH, Field LJ. Myocyte andmyogenic stem cell transplantation in theheart. Cardiovasc Res 2003;58:336-350.11. Mangi AA, Noiseux N, Kong D, HeH, Rezvani M, Ingwall JS, et al.Mesenchymal stem cells modified withAkt prevent remodeling and restoreperformance of infarcted hearts. Nat Med2003;9:1195-1201.12. Gnecchi M, He H, Liang OD, Melo LG,Morello F, Mu H, et al. Paracrine actionaccounts for marked protection of ischemicheart by akt-modified mesenchymal stemcells. Natural Medicines 2005;11(4):367-368.16University of Alberta Health Sciences Journal • April 2012 • Volume 7 • Issue 1

13. Yeh ET, Zhang S, Wu HD, Korbling M,Willerson JT, Estrov Z. Transdifferentiationof human peripheral blood CD34 + -enriched cell population intocardiomyocytes, endothelial cells, andsmooth muscle cells in vivo. Circulation2003;108:2070-2073.14. Boyle AJ, Schulman SP, Hare JM. Is stemcell therapy ready for patients? Stem celltherapy for cardiac repair. Circulation2006;114:339-352.15. Chiu RC-J, Zibaitis A, Kao RL. Cellularcardiomyoplasty: myocardial regenerationwith satellite cell implantation. Ann ThoracSurg 1995;60:12-18.16. Campion DR. The muscle satellite cell: areview. Int Rev Cytol 1984;87: 225-251.17. Taylor DA, Atkins BZ, HungspreugsP, Jones TR, Reedy MC, Hutcheson KA, etal. Regenerating functional myocardium:improved performance after skeletalmyoblast transplantation. Nat Med1998;4:929-933.18. Min JY, Yang Y, Converso KL, Liu L, HuangQ, Morgan JP, et al. Transplantation ofembryonic stem cells improves cardiacfunction in postinfarcted rats. J ApplPhysiol 2002;92:288-296.19. Xue T, Cho HC, Akar FG, Tsang SY, JonesSP, Marbán E, et al. Functional integrationof electrically-active cardiac derivativesfrom genetically-engineered humanembryonic stem cells with quiescentrecipient ventricular cardiomyocytes:Insights into the development of cell-basedpacemakers. Circulation 2005;111(1):11-20.20. De Bakker J, Zaza A. Special issue onbiopacemaking: clinically attractive,scientifically a challenge. Med Biol EngComput 2007;45(2):115-118.21. Leor J, Aboulafia-Etzion S, DarA, Shapiro L, Barbash IM, Battler A,et al. Bioengineered Cardiac Grafts: ANew Approach to Repair the InfarctedMyocardium? Circulation 2000;102(19Suppl 3):III56-61.22. Canadian Institute for Health Information.Canadian Organ Replacement RegisterAnnual Report – Treatment of End-StageOrgan Failure in Canada, 2000 to 2009[Internet]. Ottawa: CIHI; 2011 [cited 2011Jul 10]. Available from: http://secure.cihi.ca/cihiweb/products/2011_CORR_Annual_Report_final_e.pdf.23. Ott HC, Matthiesen TS, Goh SK, BlackLD, Kren SM, Netoff TI, et al. Perfusiondecellularizedmatrix: using nature’splatform to engineer a bioartificial heart.Nat Med 2008;14(2):213-21.24. Rosenstrauch D, Poglajen G, Zidar N,Gregoric ID. Stem cell therapy for ischemicheart failure. Tex Heart Ist J 2005;32:339-347.25. Collins JM, Russell B. Stem Cell Therapyfor Cardiac Repair. J Cardiovasc Nurs2009;24(2):93-97.26. Mosna F, Annunziato F, Pizzolo G,Krampera M. Cell therapy for cardiacregeneration after myocardial infarct:which cell is the best? Cardiovasc HematolAgents Med Chem 2010;8(4):227-243.27. Dib N, McCarthy P, Campbell A, YeagerM, Pagani FD, Wright S, et al. Feasibilityand safety of autologous myoblasttransplantation in patients with ischemiccardiomyopathy. Cell Transplant2005;14:11-19.28. Dib N, Dinsmore J, Lababidi Z, White B,Moravec S, Campbell A, et al. One-yearfollow-up of feasibility and safety of thefirst U.S., randomized, controlled studyusing 3-dimentional guided catheter-baseddelivery of autologous skeletal myoblastsfor ischemic cardiomyopathy (CAuSMICstudy). JACC Cardiovasc Interv 2009;2(1):9-16.29. Schmidt D, Dijkman PE, Driessen-MolA, Stenger R, Mariani C, Puolakka A,etal. Minimally-invasive implantation ofliving tissue engineered heart valves: acomprehensive approach from autologousvascular cells to stem cells. J Am CollCardiol 2010;56(6):510-520.30. Mironov V, Boland T, Trusk T, Forgacs G,Markwald RR. Organ printing: computeraidedjet-based 3D tissue engineering.Trends Biotechnol 2003;21(4):157-61.MUSAFine art in health sciences: Recognizingstudents who find time to make artSarah R. StonehockerMedical Student (2014), Arts and Humanities in Medicine Class Representative,Faculty of Medicine and Dentistry, University of Alberta, Edmonton, CanadaCorrespondence to Sarah Stonehocker: Email: sarah.stonehocker@ualberta.caMaking time for art is not always easy,especially for medical and dental students.Keeping up with lectures, readings,assignments and clinical skills leaves littleroom for photography, painting, sketchingand other artistic projects. 1 The arts can beeasily pushed to the backburner, forgotten,or crowded out by the demands of theseintensive programs. For Katie Stringer,a second year medical student at theUniversity of Alberta, keeping photographya part of her life has become increasinglydifficult: “In some ways it makes me sadto talk about my art these days. While ithas brought me a lot of joy over the years,I now find myself wishing I had more timeto explore my craft.” 2 This sentiment is notunique. As students in health sciences, wecan safely expect an emphasis on scienceand medicine in our studies. However, it’snot only Katie who recognizes the addedvalue of engaging in art. As demonstratedby twenty five undergraduate medicaland dental students, artistic expressionthrough visual arts can play a powerful andmultifaceted role in processing, enjoying andimproving our educational experience.“The sciences and arts were once, notso very long ago, considered to be verysimilar, certainly complementary, andsometimes even overlapping ways ofunderstanding the world. No longer. Todaywe accept such generalizations as thatthe sciences are objective, analytical, andrational whereas the arts are subjective,emotional, and based on intuition.” 3 Thisgenerally accepted division between artand science was challenged by the studentswho showcased their work last April at thelaunch of the University of Alberta Medical& Dental Student Art Show. The idea for theevent was sparked when medical studentContinued on page 20University of Alberta Health Sciences Journal • April 2012 • Volume 7 • Issue 1 17

MUSAFine art in health sciences:Recognizing students who find time to make artMice and Men | by Danny Purdy | Media: Pencil Crayon | Size: 8.5x11 inSquare Tree | by Katie StringerMedia: Stitched Photographs | Size: 36x34 in18University of Alberta Health Sciences Journal • April 2012 • Volume 7 • Issue 1

MUSAGive Me Hope | by Vina Nguyen | Media: Acrylic and Crayon | Size: 20x16 inUniversity of Alberta Health Sciences Journal • April 2012 • Volume 7 • Issue 1 19

MUSAContinued from page 17Asha Olmstead noticed the artistic talentof a few of her classmates and suggesteda class art show. As plans progressed,it became clear that there was interestthroughout the faculty, and the show wasexpanded to include students from all fouryears. The event allowed any medical ordentistry student to showcase their artworkfor classmates, colleagues, instructors andfriends, while also supporting a local nonprofitorganization. “I thought the openingnight event was a great opportunity tomodel the different ways of giving to acommunity,” says Roxanne Felix, a researchconsultant and assistant adjunct professorat the University of Alberta School ofPublic Health. 4I was really impressed with theenergy and commitment broughtby the students and faculty tothis event. I think the Universityneeds to foster these kinds ofcross-sector and innovative events.There is obviously a lot of interestand passion for looking at howhealth sciences and the arts interact– now we just need to tap intothat potential! 4Hosting the show within the context of theFaculty of Medicine and Dentistry createda space where the realms of fine art andhealth education could merge. Science andtechnology are already strongly emphasizedin health education, but students whointegrate the arts into their busy schedulesmust be self-motivated. 5 The Art Showwas a way to recognize this effort andcelebrate the results. In total, forty works ofvisual art were displayed, including acrylicpainting, photography, sketches, sculpture,collage, and a short film. Proceeds weredonated to the Multicultural Health BrokersCooperative to establish an “engagementfund” which helps newcomers to Canadaaccess early learning programs and healthrelatedservices for their young children. 6The weeklong exhibit was displayed in theJohn W. Scott Health Sciences Library at theUniversity of Alberta, where the pieces couldbe viewed by students and faculty fromacross campus.The opening night event was agreat example of the “determinantsof health” in two ways. Firstly,the event modelled that “giving”doesn’t have to just be within therealm of our professional skills. Bysharing our talents and our gifts,you can generate many thingsfor the community – includingfundraising as that event did.Secondly, the event generateda sense of social support andcommunity in general among themedical and dentistry students.This kind of social connectednessand gathering for a cause is soimportant for all communities –including students. It providesa type of resiliency that is reallynecessary. 4My hope is that those students who struggleto find space for art will continue to create.In an environment where the function offine art can be questioned, it becomes evenmore important to continue to supportand encourage this effort. “The linkagesbetween arts and the sciences have beenproven in research for years, but how to‘live’ this can be a bit challenging in the waythat our social structures seem to be built,”explains Felix. 4 The structure of medical anddentistry school are especially challengingin this regard. For Katie, the struggle tofind space for art as a medical student hasbeen difficult; “The only consolation I findis knowing that [photography] will alwaysbe there, waiting, for me to tend to theprocess again.” 2As a community it is critical that wecontinue to affirm the insights andperspectives expressed through art. “Withart, it is possible to transcend the limitationsof traditional scientific inquiry and to explorea more human and holistic perspective,”writes Jessie Breton, resident physicianand contributing artist at the event. 7 Thoseworking and studying in health sciencespossess a rich and valuable diversity oftalent and perceptiveness that unfortunatelyoften goes unrecognized and untapped. 8“Arts can contribute a lot to how wepractice and achieve success in the healthsciences – how we strive to create healthyconditions and achieve health with ourclients.” 4 For students themselves, makingart can be a powerful form of self-care; theprocess can be a way of relieving stress,learning concepts, processing emotionsand experiences, and maintaining balance.Taking that next step of sharing our artworkallows us to draw strength and inspirationfrom one another.Art, literature, drama and music,in all their many forms, areexpressions of human creativity;they reflect human joy and sorrow,and human celebration andreflection... They do not merelyhave usefulness in contributingto the development of ends otherthan themselves: they also have anintrinsic value in their own right. 9With the support of the Arts & Humanitiesin Health & Medicine (AHHM) Program atthe University of Alberta, 10 the Medical &Dental Student Art Show will run again inApril, 2012. I invite you to attend this specialevent and be a part of celebrating studentswho find the time to make art.The following excerpts are by students whowere featured at this year’s Art Show:Square TreeKatie Stringer is a medical student in theclass of 2014 at the University of Alberta.Media: Stitched PhotographsSize: 36x34inArtist’s Statement:Our society has traditionally believed inthe photograph’s ability to record the truthin a moment past. If this can still be thecase, then my unadulterated photographsrepresent the history of my personal struggleto gain control in life. For many of us thereare events in our lives that never surface tothe public or even to our closest friends. Wesmile and tidy things up but somewhere inthere is a piece of chaos that goes unspoken.On the whole, we look put-together buton closer inspection we’re people who dealwith stress, difficult relationships, illness,trauma and death. These trees touch uponthe power of human control, or a lackthereof. They are my attempt to wield andinstrument against the natural and unrulyworld. The imperfections in the piece are thetraces of humanity that reveal the truth in allthis: control over life is an illusion.Mice and MenDanny Purdy is a medical student in theclass of 2014 at the University of Alberta.Media: Pencil CrayonSize: 8.5x11inArtist’s Statement:Keeping up with one’s hobbies duringmedical school is sometimes perceived as acompromise, but is a genuinely constructiveactivity that tends to produce a greater levelof satisfaction and enjoyment throughoutone’s career. The importance of ‘balance’is emphasized so heavily during medicaltraining that, at times, it seems clichéd.However, after only one year of medicalschool I recognize the importance of havinga life outside of Medicine. In my case,drawing has been a refreshing reprise fromschoolwork on many occasions. Studying sohard without any physical manifestation ofthe hours you’ve put in can be frustrating,and studying the same subject for daysbecomes tedious. Drawing allows one to be20University of Alberta Health Sciences Journal • April 2012 • Volume 7 • Issue 1

creative, and actually produce somethingtangible. Furthermore, I find that finishinga piece of art into which I’ve put a lot ofthought and effort is an extremely fulfillingactivity.Give Me HopeVina Nguyen is a medical student in theclass of 2012 at the University of Alberta.Media: Acrylic and CrayonSize: 20x16inArtist’s Statement:In medicine, we can become caregiversholding the last source of hope for ourpatients. Unfortunately, sometimes wedo not realize that what we say or do cangreatly impact a patient’s quality of life,their perception of their illness, and theirperseverance to survive and endure difficulttimes in their life. In these situations Ifind that art can help ground and openmy perception of the world. Art also helpsme realize my biases and misconceptionsbefore I act upon them, so that I can becomea more connected healer. As healers weare exposed to a multitude of experiences,from loss and grief, to anxiety and joy. Artcan help us internalize all these emotionalexperiences so that we may learn and growfrom them. In this way, I believe that artnot only nurtures the heart and soul, but itmay also nurture the mind by encouragingcreative, open thinking. Art for me is animportant part of medicine: it satiates myneed for creativity, ensures there is balancein my life, and exercises my mind to stayopen and understanding.References1. Lee, J. & Graham, A. (2001). Studentsperception of medical school stress andtheir evaluation of a wellness elective,Medical Education, 35 (7): 652–659.2. Stringer, K. Personal Interview. 10 August2011.3. Root-Bernstein, RS. (1996). The sciencesand arts share a common creativeaesthetic. The Elusive Synthesis: Aestheticsand Science. Dordrecht: Kluwer AcademicPublishers: 49–82.4. Felix, R. Personal Interview. 12 August2011.5. Brett-MacLean, P. (2007) Use of the Arts inMedical an Health Professional Education.University of Alberta Health SciencesJournal, 4 (1): 26-29.6. Multicultural Health Brokers Co-operative,www.mchb.org7. Breton, J. (2011). Birth marks: An artisticexploration into the medical, personal,societal, and historical dimensions ofpostpartum depression (PPD) througha collection of sketches, collages, andjournalling. University of Alberta HealthSciences Journal, 6 (1): 13-14.8. Brett-MacLean, P., Casavant, M., &Kennedy, D.Y. (2010). Artists AmongUs: Happiness as an element in healthprofessionals’ artist statements. Atrium:The Report of the Northwestern MedicalHumanities and Bioethics Program, 8: 18-20.9. Macnaughton, J. (2000). The humanitiesin medical education: context, outcomesand structures. J Med Ethics: MedicalHumanities, 26: 23–30.10. Art & Humanities in Health & Medicine(AHHM), www.med.ualberta.ca/Home/Education/ ArtsHumanitiesMUSAOn the value of narrative reflective practice: A personal reflectionDebbi Andrews, MDDivisional Director and Associate Professor, Division of Developmental Pediatrics,Faculty of Medicine and Dentistry, University of Alberta, Edmonton, CanadaCorrespondence to Dr. Debbi Andrews: Email: andrewsd@ualberta.caIn December 2010, I attended a workshopon Narrative Reflective Practice (NRP)hosted by the Health Sciences Education andResearch Commons (HSERC) and Centrefor Teaching and Learning (CTL) at theUniversity of Alberta. The workshop facilitator,Dr. Hedy Wald from Brown University,asked participants to prepare and share shortdescriptions of their own experiences usingnarrative writing exercises with students.As I started to work on the customary 3-5Powerpoint slides, I realised that there was verylittle reflection involved in what I was proposingto present, just a bone-dry list of what was done.This didn’t capture the experience of facilitatingan NRP session, and I doubted it would sparkany reflection in the workshop group. I deletedthe slides and took out a pen. The followingis my own narrative reflection that I read tothe group.I am no orator, but I am a writer. I choosetoday to talk about my own experience inteaching and facilitating narrative practice inthe form of a read narrative.For the past two years I have facilitatedsmall group narrative reflective practicesessions for first year medical students aspart of their Patient-Centred Care course. 1These sessions are part of an initiative toinsert exercises in reflection at key pointsduring medical school and residency at theUniversity of Alberta. The themes presentedin the first year include professional identity,professionalism and biomedical ethics. Laterthe students have opportunities to reflect ontheir encounters with patients and staff inclinics and on the hospital wards. I confessthat I was initially drawn to participatingin these sessions for somewhat selfishreasons—I am a writer and wanted a way tointegrate my own writing background withteaching. Now, because of two very differentexperiences in facilitating these groupsfrom last year to this one, I am even morecommitted to the importance of reflectivewriting in medical training. I have a betterunderstanding of what the act of writing canmean for achieving understanding. Let meexplain what I mean.The students’ assignment was to write, thenshare aloud, a one page narrative on thetopic of medical identity—what it meansto become a doctor, both as a generalprocess and how this might apply to themas individuals. For each session the writingprompt was a film that was viewed by theentire first year medical class, followed bya faculty panel who reflected on some ofthe issues from the film and an interactivequestion and answer session. Afterwards,the students wrote their own brief reflectiveresponses to the film, and then, two dayslater they shared those reflections infacilitated small groups.University of Alberta Health Sciences Journal • April 2012 • Volume 7 • Issue 1 21

MUSAAs often happens for busy clinician teachers,my schedule precluded my facilitating at thesame point in the course two years in a row,so the material discussed differed from oneyear to the next. Last year I had facilitateda small group after they watched the movieThe Doctor (1991) starring William Hurtas a callous surgeon who discovers he hascancer and must become a patient. 2 Theexperience changes the way he views hispatients, his family and his life. Although thefilm was fictional, it was based on a real-lifephysician’s memoir. This year I facilitated agroup discussion of The Doctors’ Diaries, acondensed version of the Nova documentaryseries which followed eight Harvard medicalstudents for fifteen years, from the first yearof medical school, through residency, andinto practice. 3Facilitating the two groups was verydifferent. With last year’s group, thenarratives contained significant insightsabout the film The Doctor. Topics presentedin the students’ reflections included personalexperiences of illness, family support, worklifebalance, spirituality, and the conceptof duty assumed upon entering a caringprofession. The students read descriptionsof their own doctors, and also the kinds ofdoctors they wanted to be. Their writingstyles and abilities were varied, but theyhonoured each others’ stories, and thediscussion was very rich.Not so with this year’s group. At first, Ithought it was because of the materialused for this particular session—becauseit was a documentary, not a story, orperhaps because it was about a prestigiousivy-league school, and not “here”. Yetit was clear from the kinds of questionsand comments made during the paneldiscussion that the students had beenemotionally engaged with these real people,and threatened by the very real stresses theHarvard medical students experienced asdepicted in the film. There was somethingelse going on in my group’s session. Ishould have noted it then and put a stopto it because what was done was not whatwas intended, but I didn’t figure it out untilI myself reflected on the process for today’sworkshop.This is what happened. The first studenttook out what I thought was his writtennarrative, and instead of reading italoud, he presented his ideas in a casualconversational style as in any other groupdiscussion. When I glanced at his paper, Isaw it contained some thoughts scrawledacross the page in point format, likespeaker’s notes. Not a narrative. The nextstudent, who had written a full narrative,started to read but when she got to asentence that was similar in its theme tothe first student’s, she followed his lead andapologetically abandoned her text to wingit—“Oh, yeah, I sorta felt the same way,”and “I’ll skip that because it was the same ashe said,” and so on, essentially stripping herresponse of her individual writing style andall the personal narrative details—especiallythe careful selection of WHAT TO SAY.Those two students set the tone of thesession, and the other students followedsuit. No one read more than a fewsentences. Yes, there was a good discussionoverall, but the responses became muddledtogether, and at the end I could notidentify one distinctive story. Why had thishappened? The groups were the same sizeand equally varied in their backgroundsand experiences, we’d started with the sameintroductions process and the studentsseemed comfortable with each other.The session left me unsatisfied. I felt I hadsomehow not done my job as facilitatoralthough I wasn’t able to figure out what Ihad done wrong. I recalled the individualstudent voices from the year before intheir carefully chosen words and phrasingand compared that to the bland “Me,too”-ing of this year’s group. Even oneyoung woman who’d admitted duringthe introductions to having participatedin a poetry—yes, POETRY—group as anundergraduate, became self-conscious ofher written attempts to create a voice andleft off reading her text for the comfortable,conforming anonymity of chat.Perhaps you now can see why I havechosen to read this narrative script insteadof casually discussing my experienceswith reflective writing. Writing and orallanguage are not the same. Oral language,by its speed and spontaneity, is inaccurate.We speak off the cuff and in the moment,trying to communicate with someone whois physically present. This works becausewe have instantaneous feedback from ourcommunicative partners—in their bodylanguage, their attentiveness to the message,the quality of their response. If we’re notmaking sense, we know it—the listener asksquestions to clarify the message, and basedon these questions, we change what we aresaying—repeating, perhaps paraphrasing,altering word choice, even backtrackingor simplifying to arrive at understanding.Speech language pathologists with whomI work call this process “narrative repair.”People who are good communicators don’twait for the questions from the listenerto begin this process. They’re in there atthe first frown or lifted eyebrow, when theinternal “uh-oh” tells then they’d bettergo back and fix things, or they’ll lose theiraudience. They are already starting to pickup the pace before the increasing frequencyof yawns tells them that they are beingboring. This does not happen with writtentext.In writing, the repair is in the edits andmust be done before the “speaker” ever“speaks” his piece, because any clarifyingfeedback will be removed in time and space.This forced clarification creates a powerfulcommunication tool. Spontaneous orallanguage is ephemeral, unless recorded orwritten down. We as listeners are left withan impression of someone else’s truth. Inwriting we aim to achieve our own truth.Writing should stand alone.In John Sandars’ 2009 article in MedicalTeacher he states that reflection is ametacognitive process. 4 I would add thatediting is also a metacognitive process—itrequires us to think about language, todeliberate and become deliberate in ourapproach to a communicative task. Theact of writing slows us down. We carefullyconsider the ways we use words to avoidthe possibilities for ambiguity that canambush the sought-after clarity and ultimatepresentation of our personal truth. Whenwe submit our final written draft, we are nolonger figuring out what we want to say. Weknow. We say, “THIS is what I think. THISis what I feel. THIS is what I believe.” NOT“I’ll say this about that”, but “THIS is what IWANT to say about THAT”.This is the lesson of narrative reflectivepractice, and should be our focus whenwe teach this to others: the deliberateconsideration of what we think and feel andbelieve, and the value of communicatingthese thoughts and feelings and beliefsthrough the deliberate consideration of thewritten word. The narrative reflectiveprocess was not as effective in my smallgroup this year, at least partially becauseI let the discussion stray from the writtenword. Despite the students’ emotionalengagement in The Doctor Diaries, thesuperficial conversations did not capturetheir individual reflections or link theexperience of viewing the film with theirown stories. The discussion never reacheddown to the very deep issues that had arisenfrom the film.Next year I know what to do. If any of thestudents wander away from their requestednarrative reflection, I am going to stopthem and say, “Please read what you wrote,because the words are important.”22University of Alberta Health Sciences Journal • April 2012 • Volume 7 • Issue 1

References1. Brett-MacLean PJ, Cave MT, Yiu V, KelnerD, Ross D. Film as a means to introducenarrative reflective practice in medicineand dentistry: A beginning story presentedin three parts. Reflective Practice.2010;11(4):499-516.2. Haines R. The Doctor [Motion Picture].Burbank (CA): Touchstone Pictures; 1991.3. Barnes M. Doctors’ Diaries [Documentary].Boston (MA): WGBH-TV; 2009.4. Sandars, J. The use of reflection in medicaleducation: AMEE Guide No. 44, MedicalTeacher. 2009;31(8):685-695.MUSAIt all began with a cup of tea: Introducing narrativereflective practice into undergraduate and postgraduatemedical education at the University of AlbertaMarie-Therese Cave, MSc, P.G Dip Couns. Cert. Ed.Assistant Professor, Department of Family Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, CanadaD. Jean Clandinin, PhDProfessor and Director, Centre for Research for Teacher Education and Development, University of Alberta, Edmonton, CanadaCorrespondence to Marie-Therese Cave: Email: marie.cave@ualberta.caAbstractMarie Cave and Jean Clandinin describetheir experience of bringing narrativereflective practice into medical educationat the University of Alberta. In this accountthey discuss their experiences with theprocess of curriculum change, as wellas some of the unique characteristicsof narrative reflective practice inmedical education.Marie-Thérèse Cave:There are certain moments that turn outto have important consequences. Exceptfor flashes of intuitive prescience, rarelyis one able to predict which events willturn out to be the momentous ones.Only in retrospect can one appreciate thesignificance of the beginning points, turningpoints, and contingencies that characterizethe introduction of a curricular innovationin medicine. This is the way it was for theindividuals in the story that follows.I suppose I should be the person to beginthe story. However, for me, it didn’t beginwith the cup of tea. It began weeks before,one morning, when I walked into my officein the Department of Family Medicine tofind a journal on my desk.The journal was the latest edition ofReflective Practice: International andMultidisciplinary Perspectives. The titleitself was enough: This was the firstjournal to address the work in whichI had been involved for more than tenyears. My own education in how to be areflective practitioner, and how to facilitatereflection, began in Liverpool, during myundergraduate work in education. At thetime I was also personally engaged inexploratory learning through the workof John Dewey, and his accounts of howlearning takes place. My self-educationincluded Donald Schon’s writings and alsothat of more local reflective practitioners,like Hawkins and Shohet, in nearby Bath.My education continued later, in Bristol, inmy second career as a counselor and thenas a supervisor of counselors and therapists.My clinical work began with educating andsupervising the practice of counselors andtherapists in Bristol, England. My practicethen expanded to involve physicians, mostlyfamily doctors, who were seeking a wayto reflect upon the challenge of deliveringoptimal care to patients and patients’families, and themselves. As a practitioner,my interest grew from trying to understandhow students learn to understand, to howI, and my peers, made meaning of ourexperiences with clients.When I came to the University of Alberta Iwas able to continue some of this work, asthe College of Family Physicians of Canadahad recently announced their expectationthat residency programs develop curriculain behavioural medicine. This was to be acurriculum that included “opportunitiesfor reflective practice with skilled andsensitive teachers of family medicine.” Asthe Behavioural Medicine coordinator withinthe family medicine residency program,I incorporated a “reflective practice”pedagogy into the curriculum.In the 15 years that followed, I continuedlistening to physician stories, trying to helpresident physicians make meaning of theirexperiences. Some of the medical educators Imet shared my interest in reflective practice,but much of the work in which we wereinvolved together focused on developingcurricula in communication skills and thepractice of patient-centered care.I opened the new journal eagerly. I waskeen to discover if it was a place in whichI could share my interest in reflectivepractice, and read of others in the midst ofsimilar work in medicine. An immediatescan revealed interesting work being donein several of the “helping professions” – innursing, education, and also, surprisingly, inbusiness – but none of the articles focusedon medicine. I then read the list of those onthe international editorial board, and I wassurprised to see the name of a professorat the University of Alberta, in the Facultyof Education. Instinctively I picked up theuniversity directory and made a call. “Dr.Jean Clandinin is in Taiwan,” responded hersecretary, and then she added “you can leavea message if you like.” So I did.D. Jean ClandininThe message from Marie Cave came inthe fall of 2003 while I was in the midstof planning what eventually became theHandbook of Narrative Inquiry: Mappinga Methodology. 1 The handbook was to beinterdisciplinary and inter-professional, andI had a lot to learn. While I knew editinga research methodology handbook fora major international publishing houseUniversity of Alberta Health Sciences Journal • April 2012 • Volume 7 • Issue 1 23

MUSAwas going to be a lot of work, I also knewthe handbook mattered to me. I havespent all my academic life on developinga conceptualization of professionalknowledge; what we termed “personalpractical knowledge.” We conceptualizedthis way of thinking about professionalknowledge as embodied narrativeknowledge: knowledge shaped by personal,institutional, cultural, familial, social andlinguistic narratives. I knew that professionalknowledge was shaped by, enacted,and lived out in multiple personal andprofessional contexts.My scholarly work is undertaken from aDeweyan conceptualization of experience. 2Because of our shared interest in Dewey’swork, I came to meet Donald Schon and hadthe opportunity to share ideas on reflectivepractice and on educating reflectivepractitioners. While Donald Schon did notwork from a narrative conceptualization ofreflective practice or from narrative notionsof practitioner knowledge, we shared a deepcommitment to the work of Dewey and tohow Dewey’s works might help us moveforward in professional education.My long interest in working withpractitioners in reflective ways led to theinvitation to join the editorial board ofReflective Practice. When I returned fromTaiwan, I received the message that MarieCave wanted to talk about reflective practice.I agreed to meet her for tea. I had no idea,beyond her interest in my work on the boardof Reflective Practice, what the meeting wouldbe about. I was intrigued, however, withlearning more about medical education. Mydaughter-in-law is a physician and my sonhad accepted a position in a well-knownfaculty of medicine.This phone call from Marie Cave hadserendipitously coincided with my beingreminded of Rita Charon during my editorialwork for the Handbook. I first met RitaCharon when I was a beginning facultymember at the University of Calgary. Ritawas a member of an NIH taskforce who hadcome to the university to learn more aboutthe possibilities of engaging in qualitativeresearch into the experiences of geriatriccaregivers. Their 1987 visit occurred just asmy colleague, Michael Connelly, and I werecompleting our book Teachers as CurriculumPlanners: Narratives of experience. 3 I was notexpecting Rita’s interest in stories but, as wetalked over those three days, Rita spoke ofphysicians’ stories. She was intrigued by howMichael and I were suggesting a split pagemethod of keeping research field notes: onone side of the page, field notes were writtenwhich documented events and dialogueand so on; on the other side of the page, wewrote our researcher reflections on what washappening to and for us. We had not beenin contact for many years but I rememberedher well because of our shared interests inthe stories professionals told.And so it all began with a cup of tea.Conversation over TeaMarie-Thérèse Cave andD. Jean ClandininWe agreed to meet over tea in the teahousein the university hospital at the end of along and busy day for each of us. Raised ontwo different continents, we learned we hadmuch in common. Born in the same monthin the same year, we had both begun ourprofessional careers in elementary educationand we had both become counselors. Weboth married soon after graduating andwe both had sons the same age who werenow married.We shared stories of our lives, as ourlife compositions had taken us ondifferent paths: Jean’s into academia andMarie’s into delivering training coursesand supervising therapists and healthprofessionals. We connected around thework of Donald Schon and his ideas onreflective practice. 4 As we talked over tea,we were telling and listening to stories and,because there seemed promise here for aworking relationship, we were interestedin possible ways of working together. Herein the hospital’s teahouse we were findingresonance between our stories and we werealso beginning to imagine how we mightcompose a new story, together. We wereboth interested in the processes of becominga physician and both wondered about thelearning experiences that shaped physiciansalong the way.As we composed a story of what we mightdo together, we decided to explore thepossibility of doing some narrative worktogether. Jean had recently read Susan FlorioRuane’s work about an autobiographicalbook study with beginning teachers. 5We wondered what would happen if wegathered a group of beginning physicians toread autobiographies and memoirs writtenby physicians. We imagined this study couldbe a starting point for further collaborativeinquiries into the world of clinical practice.The time was right, not only in medicalschool, but in the larger field of researchand professional education, where the ideasof narrative inquiry and narrative reflectivepractice were taking hold. There was anarrative turn occurring across disciplines.As we tentatively planned the smallstudy that would bring us together asco-researchers, we arranged to meetthe Associate Dean for UndergraduateEducation. We proposed a small qualitativestudy in which the participants wouldread a series of physician-authoredautobiographical books that would serveas triggers for narrative reflections on theirown practices. The study would involveundergraduate students beginning theirclerkships, residents, and beginning familyphysicians. While this was not a narrativeinquiry, we wanted to think narrativelyabout the interwoven ideas of knowledge,context, and identity in professional practice.We both saw this as a way to learn abouteach other as researchers, as well as to learnabout narrative reflective practice as a wayto think about medical education. We werecurious to learn about what happens tophysician learners as they progress throughthe medical curriculum into practice.There was also room to explore differentpedagogical approaches to learning aroundprofessionalism and ethics. The AssociateDean for Undergraduate Education, alongwith postgraduate program directors, wasparticularly interested in these areas ofthe curriculum and the possible impact ofreflection on narratives of practice.The First Study: Beginningthe Journey to NarrativeReflective Practice.In our study, participants read one booka month and then shared their responsesto the stories of the physician authors. Weplanned five sessions over a six-monthperiod. The books were selected to serve astriggers for the participants’ own stories.As the research progressed, Jean continuedto edit the Handbook of Narrative Inquiry. Aspart of her reading, she read Rita Charon’sedited book (with Martha Montello) onnarrative in medical ethics. 6 Marie located aweb-based video demonstration of a parallelchart group, facilitated by Rita Charon. Inthis demonstration, medical student clerkscompleting their internal medicine clerkshiprotation at Columbia Medical School areseen coming together to read aloud theirwritten reflections on a patient encounter.As we worked together on the analysisand interpretation of data from our firststudy, we decided to design another study,this time with family medicine residents.This study would draw on Jean’s previouswork on narrative inquiry, as well as onRita Charon’s work with parallel charts. Wedecided to invite Dr. Charon to come to theuniversity as a visiting scholar to furtherexplore the use of clinician narratives as anaid to reflection on practice.24University of Alberta Health Sciences Journal • April 2012 • Volume 7 • Issue 1

The Arts and Humanities inMedicine ProgramSynchronistically, the Faculty of Medicine& Dentistry was launching a new Arts &Humanities in Health & Medicine (AHHM)program. Both of us were serving on theplanning committee for the launch of theprogram. When Verna Yiu heard that wehad invited Dr. Rita Charon to visit with usto discuss our shared interest in narrativereflective practice, she suggested wecombine our purposes. A renewed invitationwas extended to Dr. Charon as a visitingprofessor and also as a keynote speaker forthe AHHM program launch.We were very excited to learn what Dr.Charon might bring to the faculty and toour research. At around this time, AlanThomson, a well-known gastroenterologist,spoke with Jean and asked for assistancewith some curriculum design work. On theday of the launch, Jean agreed to meet withAlan to share some resources she thoughtmight be helpful to him. Jean was carrying acopy of Narrative Medicine, Charon’s book. 7As Alan and Jean discussed what Jeanbrought for him, he noticed Charon’s bookand asked about it and about the work innarrative Jean and Marie were doing inFamily Medicine. Before Jean left Alan’soffice, she had promised to send him somearticles and chapters on narrative inquiryand some of her work with Marie as well asa chapter from Charon’s book.The launch was well received, and the daysfollowing Charon’s visit led to an expansionof interest in narrative medicine andnarrative reflective practice and a promiseto consider the possibility of visiting Dr.Charon in New York and attending herworkshop at Columbia.The Forward LookingStory UnfoldsWhile Alan Thomson had not been involvedin Dr. Charon’s visit, he had been readingthe literature Jean had sent him. He askedif he could host a dinner one evening todiscuss narrative research possibilitiesfor medical education. Those present atthis dinner were Alan Thomson, AndrewCave (the two physicians in the group),Marie and Jean. Naming our conceptualframework ‘Narrative Reflective Practice’, webegan to imagine how narrative reflectivepractice could become part of the medicalcurriculum. We also began to imagineresearch possibilities that would accompanythe curriculum change. The main purpose ofthe research was to establish the difference,if any, narrative reflective practice played inthe professional development of physiciansand in medical education for physiciansin-training.This represented a continuationof Jean’s work using narrative inquirymethodology to explore the process of theprofessional formation of teachers andadministrators. That evening over dinner webegan work on a research agenda focusedon narrative inquiry and narrative reflectivepractice in medical education. We werecontinuing a narrative turn in the Faculty ofMedicine & Dentistry.Marie was stunned by the alacrity withwhich the small group began planning.All present were keen to discuss narrativeresearch possibilities for a narrative reflectivepractice curriculum in the medical schooland for the faculty. It was decided that inresidency education we would begin byapproaching three disciplines: internalmedicine, family medicine and pediatrics.Our small research group already hadphysician involvement in family medicineand internal medicine. We decided to inviteVerna Yiu as the pediatrician member of ourresearch team, because of her leadership atthe time in the Arts & Humanities in Health& Medicine program and her involvementin supporting Dr. Rita Charon’s visit to theUniversity of Alberta.The following day we sent an email to thethen Dean, Tom Marrie, and were surprisedto receive an immediate response. Herequested that we lead the delivery of acurriculum in narrative reflective practicein all four years of the undergraduatemedical curriculum. Jean and Marie met,again over tea, and further sketched outa developmental curriculum in narrativereflective practice. A subsequent meetingof our small group with the dean allowedus to more fully inform him of our plans.We communicated the need for facultydevelopment and gained funding for someof us to visit Columbia Medical School inNew York and attend Dr. Charon’s two-daynarrative medicine workshop. Fundingalso came from the Department of FamilyMedicine which had already supportedsome of our early research projectsOther academic physicians were learningabout, and expressing interest in, narrativereflective practice. We invited several ofthem to become champions of narrativereflective practice and to become involvedwith the recently formulated curriculumplan. In these early days, those involvedwere developing individual understandingsof narrative medicine and narrativereflection on practice. Some had an interestin promoting an aesthetic and humanisticappreciation of the reading, writing,and listening to stories of patients’ andphysicians’ lives. Others were primarilyinterested in researching the possibilitiesof narrative reflective practice as a tool,or pedagogical approach in physicianformation. Still others saw the value ofnarrative inquiry as a research methodologyin the acquisition of a deeper knowledge ofpatients’ and physicians’ experiences, andby so doing, increasing the evidence basisfor clinical decision making. None of theseunderstandings were mutually exclusive,but it was becoming increasingly evidentthat we needed a common language, sothat we could better articulate our purposes,especially if we were to achieve our goalof engaging students and physicians in acohesive developmental narrative reflectivepractice curriculum within the medicalschool. Faculty development was a priority.Faculty DevelopmentWe began faculty development with aresidential course over three weekendsspread out over several months. The settingwas a retreat located outside of the city.Each weekend started with a review ofpre-assigned key theoretical resources.These included work by John Dewey,Mark Johnson, Alasdair MacIntyre, RobertColes, Mary Catherine Bateson, and DavidCarr. The rest of each weekend was spentin experiential learning about narrativereflective practice. Given that narrativereflective practice is about stories livedand told, 8 we invited participants to accesstheir tacit knowledge of practice throughthe telling and re-telling of their storiesof experience.Working within the three dimensionalnarrative inquiry space, they learned toattend to the past, present and futuredirections of their stories (temporality); toattend to their inner emotions and moraljudgments as well as to unfolding events(sociality); and to the place or places whereevents were occurring. 8 They learned theimportance of “wondering questions,” as anaid to the facilitation of the inquiry. Furtherfaculty development courses were plannedand delivered and, after consultation withvarious curriculum committees, NarrativeReflective Practice pedagogies wereeventually launched, by the champions, inthe first three years of the undergraduatemedical curriculum.In their first year, students have littleclinical experience. To assist in meeting theobjectives related to communication in thePatient Centred Care course, we introducedfilms (visual narratives) as a means offacilitating the narrative reflection of eachMUSAUniversity of Alberta Health Sciences Journal • April 2012 • Volume 7 • Issue 1 25

MUSAphysician learner. Following full-lengthfilm screenings, a panel of faculty membersmodeled narrative reflection by sharingtheir reflections on the visual narrative withthe students. Two days later, the studentsshared their written narrative reflectionson the film in facilitated small groups. Aseries of wondering questions, arising fromthe visual narrative and based around thethree dimensions of narrative inquiry (place,temporality, sociality) assisted in the processof narrative reflective practice. Studentfeedback helped to inform the ongoingevolution of the Narrative Reflective Practice(NRP) module in our first year PatientCentred Care course. 9In second year, Gilbert Scholars, physicianswho work with second year students, weretrained by Jean, Marie, and Alan Thomsonto facilitate narrative reflective practicearound listening to and inquiring into theirexperiences of “the patient’s story.” In theGilbert Scholars’ course, students learn howto take a medical history, and learn how toperform a physical exam. A comparativeresearch study was undertaken that involvedhaving some small groups within the classmeet for a second time with a patient and,in conversation, explore the patients’ storiesof their illness experience. Each studentthen wrote, and shared with peers in theirsmall group, a narrative reflection on thepatients’ stories of their illness. The storiesthe second year students wrote showed howmuch they learned from attending closelyto the stories that patients told of whatwas happening to them. We are hopingto repeat this study in the near future inorder to establish conclusively if there is adifference in history-taking competenciesbetween those students who participate inthe narrative reflective practice interventionand those who do not. In the meantime, werecently introduced additional sessions ofour film-based NRP module into the secondyear Patient Centred Care course.In third year, when students begin theirclinical practice, we found that narrativereflective practice begins to impact thelearner physicians’ professional identityformation. 10 Students in family medicineand surgery clerkship rotations nowparticipate in narrative reflective practiceactivities. In surgery, clerks write anarrative reflection on a surgery clerkshipexperience. 11 In family medicine, studentclerks write parallel charts of a clinicalencounter in practice. 10 As described by RitaCharon, the parallel chart is the place wherethe physician learner writes those thingsthat don’t belong in the chart “but needto be written somewhere”. 7 This exerciseaffords the learner opportunities for bothreflection and reflexive thinking aroundtheir responses to the clinical encounter.In their family medicine rotation, studentsshare their written reflections in facilitatedsmall groups, using the three dimensionalnarrative inquiry dimensions to inquireinto their stories of experiences as writtenin their parallel charts. In addition, someresidents have been involved in facilitatingthe small groups we introduced in ourfirst and second year Patient Centred Carecourse.Pilot studies have been completed in familymedicine and internal medicine residencyprograms. 12,13,14,15,16 At this point, NRP hasnow been introduced in family medicine andsurgery residency programs, and recently aNarrative Reflective Practice journal club hasbegun as a means of supporting continuingprofessional learning for academic andclinical faculty. In addition to the NarrativeReflective Practice initiatives describedabove, we are aware that preceptors whoteach and guide learners in undergraduateand postgraduate programs are exploringvarious approaches to reflection, some ofit narrative reflective practice. This newinitiative marks the achievement of the goalof our original developmental curriculumplan—to become involved in all stages ofmedical education.To date there have been nine publicationsin peer reviewed journals, as well as invitedcontributions to a chapter On LongitudinalIntegrated Clerkships, editors Poncelet A& Hirsch D in the forthcoming editionof “Alliance for Clinical Education’s (ACE)Guidebook for Clerkship Directors.” Ed. BruceMorgenstern. There have been workshopsand peer-reviewed presentations at medicaleducation conferences, and also invitedworkshops and presentations. Our groupof researchers and educators are now partof a global network of pioneers in narrativereflective practice within medical education– and the research is ongoing.Narrative reflective practice and narrativeinquiry are relational. True to form, ourjourney into Narrative Reflective Practicemedical education research began through arelationship – with a cup of tea. We believethis experiential and relational approach tolearning is providing medical learners, at allstages of their journeys as physicians, witha sense of being engaged in a community oflearning, as we each learn from one another,and also experience the unique opportunityto learn from the self, by making tacitknowledge explicit.In a packed curriculum and with busyclinical agendas, Bolton reminds us ofthe importance of noticing moments forstructured reflection. 17 She references theobserver and poet William Wordsworth whowrote, “there are in our existence spots oftime…whence...our minds are nourishedand invisibly repaired. Such momentsare scattered everywhere.” 18 This reflectswell the impulse and motivation that hascompelled us forward, as we continueto explore the potential of NRP in ourcurriculum and collaborate together incontributing to new ideas and visions thatmight inform future directions for medicaleducation.AcknowledgementsOur thanks to the Faculty of Medicine andDentistry and the Department of FamilyMedicine’s Scott McLeod Fund for fundingthe visit of Dr. Charon to the University ofAlberta.We would also like to thank Dr. RichardSpooner, Chair of the Department of FamilyMedicine, for his support of our narrativemedicine initiatives, and again acknowledgethe Scott McLeod fund for grants towardsour research into narrative reflective practice.We acknowledge former Associate Chairs ofUndergraduate Medical Education Dr. ChrisCheesman and Dr. David Raynor, withoutwhom a narrative medicine curriculum inundergraduate medical education couldnever have begun.Our final thanks goes to our colleagues inthe Faculty of Medicine and Dentistry, Dr.Alan Thomson, Dr. Verna Yui, Dr. AndrewCave, Dr. Pam Brett-Maclean and Dr.Michelle Levy who contributed to earlierdrafts of this paper. Thanks to Drs. JonathanWhite, David Ross, Amy Tan, StephenAaron, David Kelner, Jasneet Parmar and JillKonkin who joined with us in pioneeringthese narrative reflective practice pedagogieswithin the undergraduate medicine anddentistry curriculum.References1. Clandinin, D.J. (Ed.). (2007). Handbook ofnarrative inquiry: Mapping a methodology.Thousand Oaks, CA: Sage.2. Dewey, J. (1938). Experience andEducation. Collier Books, New York: 1963.3. Clandinin, D.J., & Connelly, F.M. (1988).Teachers as Curriculum Planners:Narratives of experience. Teachers CollegePress: New York.4. Schön, D. (1983) The ReflectivePractitioner: How Professionals Think inAction. Harper Collins Publishers:5. Ruane, S.F. (1994). The Future Teachers’Autobiography Club: Preparing Educationto Support Literacy Learning in Culturally26University of Alberta Health Sciences Journal • April 2012 • Volume 7 • Issue 1

Diverse Classrooms. English Education.National Council of Teachers of English.6. Charon, R., & Montello, M. (Eds.). (2002).Stories matter: The role of narrative in medicalethics. New York: Routledge.7. Charon, R. (2006). Narrative medicine:Honoring the stories of illness. New York:Oxford University Press.8. Clandinin, D.J., & Connelly, F.M. (2000).Narrative inquiry: Experience and story inqualitative research. San Francisco, CA:Jossey Bass.9. Brett-MacLean, P.J., Cave, M-T., Yiu, V.,Kelner, D., & Ross, D. (2010). Film as ameans to introduce narrative reflectivepractice: A beginning story presented inthree parts. Reflective Practice, 11, 499-516.10. Tan, A. Levy, M., Cave M.T., Ross, S.(2010). Family Medicine Clerkship:Implementation & Outcomes of a NewAcademic and Narrative Reflective PracticeCurriculum. Family Medicine Forum posterpresentation.11. White, J. (2008). The use of reflectivewriting in exploring student experiencesin surgery. Journal of Surgical Education, 65,518-20.12. Cave, M-T., & Clandinin, D.J. (2007).Learning to live with being a physician.Reflective Practice, 8, 75-91.13. Cave, M-T., & Clandinin, D.J. (2007).Revisiting the journal club. Medical Teacher,29, 365-370.14. Clandinin, D.J., & Cave, M-T. (2008).Creating pedagogical spaces for developingdoctor professional identity. MedicalEducation, 42, 765-770.15. Clandinin, D.J., Cave, M-T., Cave, A.,Thomson, A., & Bach, H. (2010). Learningnarratively: Resident physician’ experiencesof a parallel chart process. The InternetJournal of Medical Education, 1 (1), May.16. Clandinin D.J., Cave, M-T., & Cave,A. (2010). Narrative reflective practicein medical education for residents:Composing shifting identities. Advances inMedical Education and Practice, 1, 1-7.17. Bolton, G. (2006). Narrative writing:Reflective enquiry into professionalpractice. Educational Action Research, 14,203-218.18. Wordsworth, W. (1888) in Bolton, G.(1999). The therapeutic potential of creativewriting: Writing myself. Jessica KingsleyPub.: London, p. 67.MUSAEnter stage right: An actor’s adventures in patient centred careNadine L. Cross, RN, BScN, MHScResearch Associate, University Health Network Nursing Academy, York University, Toronto, CanadaCorrespondence to Nadine Cross: Email: nadine.cross@uhn.caAbstractThrough the use of drama and the artof storytelling, Robert Hawke has beensharing his journey of cancer diagnosis andtreatment in a live, one-man comedic playentitled NormVsCancer. In the first personaccount below, Hawke describes how hisplay, when brought to patients, families andhealth professionals, was able to provideinsight into his experience as a patient,and enrich patient centred care (PCC). Thisaccount also address how Rob’s play andhis presence within the healthcare contexthas invigorated and drawn attention to thepractice of PCC at the University HealthNetwork, in Toronto, Canada.What if your nightmare was not anightmare? What if your dreams wereilluminating the possibilities of your life andthe only thing to fear is how to live withinthose possibilities? This is my story such asit is.Five years ago I had thyroid cancer. It tookme completely by surprise and I must sayI was utterly unprepared for it. Diagnosis,surgery and recovery were tough, but whatwas most surprising to me was that thisdisease was so challenging in virtually everyarea of my life as it is with so many of uswho deal with having cancer.I have worked as an actor and writer incomedy for years and shortly after surgery,I began writing and improvising the showthat would become NormVsCancer. It wasn’tas clean cut as that of course - I didn’t wakeup in the morning and say “and now I willwrite a significant piece about my experiencethat will hopefully resonate with others”. Itwas a lot more ragged than that. Alone inmy apartment, I would become upset or sadand would just start acting out conversationsbetween myself, and imaginary characters.Medical professionals might call this aninteresting way of coping with a troubledpsyche; my neighbours might have calledit “batshit crazy”; I called it “theater”. Iactually began to write this stuff down andform a structure around my ramblings thatmade some kind of sense. I managed to getthe show partly written and knew I neededsome help at that point to get any kind offinished piece.With the help of my friend Michael Cohen,we were able to co-create the first versionof NormVsCancer and take it to the PragueFringe Festival three and half months after Ihad surgery. I don’t recommend this. I pridemyself on being prepared and professional;however, under the circumstances, we wereunder a very tight deadline and I just didn’tpossess my usual levels of stamina, creativityand skill. Michael, as a consummateprofessional and director of the play, wantedto make the piece as good as it could bein the time we had. This made for a tenserehearsal period with me breaking downin tears on occasion and even throwing achair across the room at one point. Now,please understand, I don’t believe that this isacceptable behavior at all. In fact, I think thatany actor (or plumber or accountant) whoengages in this kind of conduct deserves tobe fired. My psyche was running amok atthat point and I had all the coping skills of arhino on acid.“Why did you do this?” you might ask.“Why not wait a couple of years for the dustto settle?” Well, it comes down to what Ibelieve is a very basic human need, andthat is the need to tell our stories. I HAD totalk about what had happened to me. Evendealing with my disease in a fictionalizedway helped me to make some sense of itand process it. This was not obvious to meat the time. I thought I was just co-writing afunny show with some dramatic bits.Although this process was difficult and attimes heart-wrenching, it was also a thrillto make something and share it with otherpeople. It has been remarkably gratifying toUniversity of Alberta Health Sciences Journal • April 2012 • Volume 7 • Issue 1 27

MUSAfind that folks in a similar situation couldfind resonance with their own experience,and by sharing the specifics of this one storywe could find common ground and buildcommunity.I was quite nervous showing this pieceto people who had been through cancer,thinking that I would be judged. After all,who was I to talk about this? These fearswere put to rest after a performance for asmall audience when a man in his fifties justcame up to me without a word, hugged meand walked away.Throughout this theatrical process it hasbeen my pleasure to talk with many cancersurvivors and their families and time andtime again I am struck by how folks whohave been through something of this naturewant to share their experience in order toprocess it in some way. More and more, wesee patients coping with their traumaticexperiences by expressing it in artistic ways.People paint, draw, act, sing, talk or chooseany number of ways to communicate theirexperience. There is clearly value in this forpatients. I don’t know how to measure it,quantify it or put it in a bottle, but it hasbeen my experience that many of us find itvery useful.My wife works in healthcare, and throughher, I was fortunate to meet some innovativeand creative people at the UniversityHealth Network (UHN), Canada’s largestteaching, research and academic hospital.They identified a need for my show to beexperienced by other patients and healthcareprofessionals alike.At UHN, Patient-Centred Care (PCC)is not just a set of words that hang on aplaque by the elevator on a ward; PCC ispart of their guiding philosophy to practice.The philosophy encompasses the valuesof Respect, Human Dignity and Personas-Leader.The staff, which I have come toknow and work with in light of our play,saw NormVsCancer as a wonderful vehicleto make clear the values of PCC. From myunderstanding, the staff at UHN has beenengaged in iterations of PCC educationover the past eight years. They have reacheda crossroads, where the staff is not justhearing second-hand individual patientstories; they are yearning to hear from thepatients themselves.Through NormVsCancer, I have been able tounderstand how to connect with my ownhealthcare team in way I never imagined.We have been able to stimulate lively andprofound discussions with regard to PCCand how it is lived in practice. After eachperformance, patients and professionalsare encouraged to tell their own storiesand talk about what it was like for them intheir own experience. You can practicallyhear the professional silos crumble andpersonal barriers fall, as folks share on a veryhuman level what was for them a significantexperience. It is an honour to be part ofthis process, to share with other patientsof similar yet different experience and tobe working with such dedicated healthprofessionals who wish to advance PCCfrom the patient’s perspective.As a patient, these experiences have givenme a tremendous amount of hope that wehave the ability to make our healthcaresystem more effective, more caring andmore human. How was I to know thatmy cancer diagnosis nightmare wouldawaken me to possibilities – to a life nowilluminated?A bite into the media’s image of nursing in an apocalyptic worldSherrylynn Kerr, BANursing Student (2012), Faculty of Nursing, University of Alberta, Edmonton, CanadaCorrespondence to Sherrylynn Kerr Email: skerr@ualberta.caAbstractIn this article, the portrayal of the nurse inpopular media is compared and contrastedwith that found in professional nursingpublications. The current stereotypicalimage and role of the nurse in contemporaryfilm is described based on the film Dawnof the Dead (2004). 1 Critical thinkingskills; professional ethics and values; theautonomous role of nursing; and theimage of nursing within specific contextsare all investigated and compared. Theoften inaccurate portrayal of nurses withinpopular media still continues to posechallenges to the nursing profession.However, concurrently, there is a trendtowards increasing positive images of thenurse, and evidence of this is certainly seenin Dawn of the Dead.The image and role of the professionalnurse are commonly portrayed in popularmedia. These representations impact publicperception of the nursing profession. 2Unfortunately, there are significantdifferences between these fictitiousportrayals of the nurse, and the realisticexpectations of the profession outlined innursing publications. According to Stanley,the current media trend is to representthe nurse in a more positive manner. 3 Inanalyzing the representation of nursing inthe contemporary film, Dawn of the Dead,I have found evidence of such a trend.Through comparing the nurse in the filmwith professional nurses, I was able toidentify some challenges affecting thecreation of a positive nursing image.The movie Dawn of the Dead depicts aNorth American geographical area thathas been overrun by zombies, who do notpossess higher order thinking. The zombiesin the film are preoccupied with attackingindividuals who have not yet becomezombies. The lead character in the film isa nurse named Ana Clark. Ana and a fewother survivors flee to the nearby CrossRoads Mall. Increasing numbers of zombiesbegin to conglomerate outside the mall,attempting to enter the building and feed onthe survivors.Critical Thinking SkillsThroughout the film, there are casualtiesamong the survivors in the mall. Some ofthese survivors incur bites from the zombies.Ana resourcefully sets up a triage centerand begins to assess, treat, and comfort thenewcomers. As would be expected from aprofessional nurse, she treats the patientswith respect, compassion, and competence. 1Ana uses critical thinking skills to determinethe mechanism of transmission of thezombie infection. Critical thinking can28University of Alberta Health Sciences Journal • April 2012 • Volume 7 • Issue 1

e defined as making judgments about asituation using reflection, and integratinganalysis, evaluation, and inference withknowledge. According to Profetto-McGrath,critical thinking is a necessary componentfor the professional nurse to exerciseevidence-based practice. 1 Due to the threatof zombies and the characters’ isolation inthe mall, it is not possible for Ana to employevidence-based practice by consulting withexperts. Furthermore, there is insufficienttime for properly researched evidence to begenerated and examined. 5 In the literaturereviewing critical thinking skills andevidence based-practice, the professionalnurse would ideally have opportunity toaccess such resources. Nevertheless, in thefilm, Ana uses the best evidence she hasavailable to her in the given situation toguide her practice.In her triage center, Ana finds that one ofher patient’s conditions is deterioratingquickly. She observes and astutelycomments that the patient is cold, and thatshe has never seen such a bad infectionwithout an accompanying fever. Within acouple of minutes, the patient dies. Anaassesses the patient for a pulse, checksthe patient’s breathing, and determinesthat the patient is dead. Ana’s knowledge,assessment skills, and observations in thisscene compare to those of a professionalnurse. A few moments later, the deceasedpatient rises and begins to attack Ana. AfterAna defends herself and kills her formerpatient (now a zombie), Ana evaluates theinformation available, uses inference andprevious knowledge of her interactions withthe zombies, and determines the mechanismof the zombie infection. She determinesthat the zombie infection is spread throughbites. The critical thinking skills employed bythe main character are comparable to thoseexpected of a professional nurse, and areoutlined in peer-reviewed nursing literature.Thus, this film portrays the role of the nursepositively, as comparable to roles outlined inprofessional literature.Professional Nursing Values andEthicsThe film takes place during acommunicable-disease outbreak spreadby zombie bites. The Canadian NursingAssociation (CNA) states that: “During anatural or human-made disaster, includinga communicable disease outbreak,nurses have a duty to provide care usingappropriate safety precautions.” 4 Throughoutthe film, Ana abides by these regulations,using the resources she has available to her.Her actions in this respect are comparableto those expected of a professional nurseaccording to the CNA. 4After discovering the mechanism oftransmission of the zombie infection in hertriage center, Ana tells the group that Frank,one of her fellow survivors, has been bittenand should be quarantined immediately.Another character tells the group he thinksit is too dangerous to keep Frank alive.Our heroine immediately identifies andchallenges the ethics of this situation: “Whatare we talking about here? Are we talkingabout killing him?” 1 Though this situationis not taking place within a formal nursingenvironment or practice, it addresses anumber of nursing values and ethicalresponsibilities.Upon review of the Code of Ethics forRegistered Nurses, I believe that Anais encountering an ethical dilemma.Throughout the career of a professionalnurse, ethical dilemmas and questionsare encountered where the nurse has adifficult choice to make between two equallycompelling courses of action. Ana is facedwith this situation in the film. If Frank iskilled, it will be demoralizing and traumatic,especially for his daughter, who is withhim. However, if Frank is not killed, he willmost likely become a zombie and attack theremaining survivors.Ana’s character is humanizing for theaudience because she reminds us of thisethical dilemma. A professional nursehas specific nursing values and ethicalresponsibilities to uphold. Of the eightvalues outlined in the Code of Ethicsfor Registered Nurses, Ana maintainsfour values that pertain specifically tothis situation: 1) Safe, Compassionate,Competent Ethical Care, 2) InformedDecision Making, 3) Preserving Dignity and4) Promoting Justice. 4 She provides safe,compassionate, competent and ethical carefor all of the survivors—to the best of herability—within her limited environment.She discusses the ethical dilemma regardingFrank’s zombie bite with Frank and thegroup, thereby recognizing, respecting andpromoting Frank’s right to be informedand to make a decision. She recognizesand respects Frank’s intrinsic worth byreminding the group that he has a daughterwho cares for him. And lastly, Ana upholdsprinciples of justice by safeguarding humanrights as much as possible within the givensituation, and promotes the public good forthe group of survivors.Autonomous Role of the NurseAt the very beginning of the film, theaudience is able to see what life is like forAna before the chaotic zombie infectionspreads. Ana interacts with a physician,another health care professional, in theemergency department. The physiciandismisses Ana’s statement that it is the endof her shift and asks her to find a patientwho has been admitted to the hospital.Here, the audience briefly witnesses theheroine in a subservient role in relation tothe physician.This situation relates to the autonomy of thenursing profession. In this particular scenein the film, Ana does not embody the roleof an autonomous professional. However,in clinical settings, nurses do not report tophysicians, as the film portrays. 1 Nursesreport to their supervisor who is usually anurse, not a doctor. This misperception isan ongoing challenge within popular mediasources. As previously discussed, nurseshave their own code of ethics as outlined bythe CNA. 4 Nursing is a distinct autonomousprofession that is regulated and governedby experienced nurses, many of whom holdgraduate level degrees. 6In order to address the discrepancy betweenthe media perception of the autonomy ofnursing and the truly autonomous natureof the profession, nurses must advocate fortheir profession and effectively communicatewith members of the media to demonstrateaccurate representations, and for pride inthe profession of nursing. 2 The image androle of the nurse will continue to evolvein a positive direction when practicingprofessional nurses are actively involvedin a relationship with the media. McNallysuggests that these efforts should begin atan undergraduate level. 6As the film progresses, the audience beginsto see that Ana is capable of practicingautonomously, and that she is most certainlynot subservient to other characters. Rather,Ana carries a leadership role in manyinstances throughout the film, such asindependently setting up a triage centerfor those who are injured and encouraginggroup cohesion to battle attacking zombies.Ana’s autonomous role begins in the filmonce the zombie catastrophe begins.Context of the FilmOverall, the film Dawn of the Dead presentsa positive image of the nurse. I do, however,question the context in which this positiveimage is portrayed. This popular mediaportrayal of the nurse differs from what isfound in the professional nursing literature,as the nurse in this film is acting withina fictional world overrun by zombies. Isthe opportunity for the public to viewMUSAUniversity of Alberta Health Sciences Journal • April 2012 • Volume 7 • Issue 1 29

MUSAthe profession of nursing limited to theconstraints of an apocalyptic setting?This catastrophic zombie world iscomparable to the media representationof nurses during wartime, which presentsnurses as “pure, brave, maternal, and freeof the corruptive taint of war.” 2 Stanleyexamines how nurses are portrayed infeature films and identifies many themesin his data. In analyzing presentationsof nursing throughout history, Stanleyidentifies themes such as: romance; heroism;self-sacrifice; intelligence; nurses as sexobjects; nurses as strong women; nursesas victims; and the dark nurse. 3 Certainqualities, such as self-sacrifice, heroism,and the intelligent nurse, are predominantduring difficult times in history, such as warand depression.In an earlier study, Kalisch and Kalischexamined English-language films releasedbetween 1930 and 1979. 7 Positive imagesand stereotypes of the nurse role areidentified during World War I, the GreatDepression, and World War II. In Dawn ofthe Dead, the nurse is also a strong, positivecharacter who demonstrates professionalnursing during a similar global chaoticevent. Interestingly, Kalisch and Kalisch notethat once war is over, the representationof the nurse in the media reverts to that ofa woman in her “rightful” place. That is,according to Kalisch and Kalisch, the nursereturns to “tending to children in theirhappy homes in the suburbs.” 7Despite the positive depiction of the nursingrole in Dawn of the Dead, it is possible thatnursing roles are only presented positivelyin the media when the nurse is workingin the context of widespread disaster. Thefilm Dawn of the Dead takes place in achaotic environment, creating a challengefor the audience to view the value of therole of the professional nurse within aconventional world.References1. Snyder Z. Dawn of the Dead [MotionPicture]. Universal City (CA): UniversalPictures; 2004.2. Ku E. Nursing image: Reality versus mediaportrayal. Hong Kong Nursing Journal.2005; 41(3):7-12.3. Stanley DJ. Celluloid angels: A researchstudy of nurses in feature films 1900-2007.Journal of Advanced Nursing. 2008;64(1):84-95.4. Code of ethics for registered nurses[Internet]. Ontario: Canadian NursesAssociation [updated 2010 Jun 8; cited2011 Oct 27]. Available from: http://www.cna-aiic.ca/CNA/practice/ethics/code/default_e.aspx.5. Profetto-McGrath, J. Critical thinkingand evidence-based practice. Journal ofProfessional Nursing. 2005;21(6):364-371.6. McNally G. Combatting negative imagesof nursing. Kai Tiaki Nursing New Zealand.2009;15(10):19-21.7. Kalisch PA, Kalisch BJ. The image of thenurse in motion pictures. American Journalof Nursing. 1982;82(4):605-611.Albert Ross Tilley: The legacy of a Canadian plastic surgeonKevin S. MowbreyMedical Student (2014), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, CanadaCorrespondence to Kevin Mowbrey: Email: kmowbrey@ualberta.caABSTRACTThis article chronicles the career of oneof the most important Canadian plasticsurgeons of the twentieth century, AlbertRoss Tilley. Tilley is best known for hisinnovations in burn management duringWorld War II (WWII), and his treatment of agroup of burn patients known affectionatelyas the Guinea Pig Club. In addition to thesuperb surgical skills he applied to thephysical wounds of his patients, Tilley wasalso a pioneer of caring for the emotionaland psychological afflictions sufferedby many airmen of WWII. As one of thefounding fathers of the Canadian Societyof Plastic Surgeons, Tilley’s work wasinstrumental in establishing the specialty,and ensured its prominence for years tocome. Serving in the capacity of leader,educator, and innovator, Tilley remains oneof Canada’s most decorated physicians,and his contributions to the medical fieldcontinue to benefit patient care to this day.Key Words: Plastic Surgery, BurnManagement, Ross Tilley, WWII, The GuineaPig Club, East GrinsteadINTRODUCTIONAs one of the first plastic surgeons inCanada, Dr. Albert Ross Tilley helped shapethe discipline’s foundation (Figure 1). Tilleyinfluenced the trajectory of a burgeoningspecialty, as well as a generation of youngpractitioners who aspired to become partof the profession. Tilley was an innovator ofburn management in the wake of a war thatthreatened to incinerate all those engagedin battle, and the healer of an affliction thatsociety was ill-equipped to handle. Themedicine Tilley dispensed indelibly alteredthe landscape of patient care forever.Tilley’s BackgroundAlbert Ross Tilley was born in Bowmanville,Ontario, on November 24, 1904. 1 Tilley’sinterest in medicine was piqued at an earlyage, as he had the privilege of accompanyinghis father, a general practitioner, while herounded on patients. Tilley graduated fromthe University of Toronto medical school in1929 as a silver medalist. 2 Following medicalschool, he traveled extensively for five years,studying surgery at the Toronto WesternHospital in Ontario, the Roosevelt andBellevue Hospitals in New York, The RoyalInfirmary of Edinburgh in Scotland, andwith the renowned pathologist Sternberg inVienna. 2 By 1935, Tilley was ready to open aprivate practice working at the Wellesley andToronto Western Hospitals.In the same year, Tilley joined the No. 400City of Toronto Squadron of the RoyalCanadian Air Force (RCAF) as a medicalofficer, and began what would turn out to bethe most important training of his career. 2Dr. E. Fulton Risdon, a protégée of SirHarold Gillies, and widely regarded as thefather of modern plastic surgery in Canada,would guide Tilley’s focused training inplastic surgery. At the time, Dr. Risdon was30University of Alberta Health Sciences Journal • April 2012 • Volume 7 • Issue 1

pilots were left to rely on their tactical skillrather than novel engineering to avoid thepotential inferno sloshing around belowthem. To the dismay of hundreds of airmen,this performance requirement, thoughhighly refined, would not prove enough,and many sustained burns renderingthem unrecognizable.MUSAFigure 1. Dr. Albert Ross Tilley.one of only three other plastic surgeonsin Canada, and Tilley became the fourthupon the completion of his training justprior to the outbreak of World War II. 3 Tilleywas called up to active service in 1939, andby 1940 he found himself a commandingofficer and C Surgeon at Trenton MemorialHospital. 3 A year later, he was appointedprincipal medical officer at the RCAFheadquarters in London, England.Shortly after arriving in London, Tilleyreceived a life-altering invitation, theacceptance of which would set into motiona chain of events that literally changedthe faces of hundreds of airmen burned inWWII. Equipped with his newly honed skillsin plastic surgery, Dr. Tilley traveled to theQueen Victoria Hospital in East Grinstead,Sussex in January of 1942. 1 There he wascharged with the task of treating the mostdifficult burn injuries wrought from the pyreof war.Fates Worse Than Death: BurnCasualties Of WWIIHistory has frequently demonstrated thatfactors of circumstance set the stage forgreatness, and one particular confluence ofevents allowed Tilley to produce outstandinginnovations in the field of plastic surgery.One such event that would push Tilley’sskills to their very limit was the nature of theburn casualties of WWII. It is reasonable toassume that being caught in the crosshairsof a Nazi pilot was the worst nightmare ofevery Allied airman, but this was not thecase. The entity that struck unadulteratedfear into the hearts of the RCAF airmenwas fire. Referred to by nicknames like“orange death”, the threat of burning alivewas an unrelenting terror, and many pilotsopenly admitted that gravity or a bullet wasa welcome alternative. 4 On Allied aircraft,whether Spitfire or Hurricane, the vectorcarrying the combustible arch nemesis ofairmen was the fuel tank. 5During the interwar period, the Royal AirForce (RAF) conceived of new and ambitiousstrategies for air warfare of the future.Unfortunately, the demands of this strategypitted fuel tank safety against parametersof performance. In order to produce planesthat could out-fly and out-shoot thecompetition, drastic changes in aeronauticaldesign were necessary, including upgradingthe 87-octane fuel used in the Great War,to the more combustible 100-octane fuel. 7Furthermore, to achieve the highly soughtafterrapid rate of ascent, fuel tanks nowhad to be positioned directly below and infront of the cockpit. In essence, the pilotwould find himself sitting on about 85gallons of fuel in the Spitfire, and 30 gallonsof fuel in the Hurricane. 5 The problemwith implementing previously used tankprotection systems of rubber and metalencasements was that the materials addednearly 50 kg to the plane’s weight. Thisburden cut the maximum range of fighterplanes by nearly 20%, and was a sacrificein performance that top officials of theRAF were unwilling to accept. 4 Ultimately,strategy took priority over safety, andIt is estimated that between 1940-1945,22,000 soldiers burned to death, and 4,500burn victims were recovered from crashes,with 60-80% of those rescued sustainingburns to their hands and face. 8 This scaleof burn casualties had never before beenwitnessed, and was not predicted byAllied strategists. A certain pattern of burninjury presented so frequently to hospitalsthat it was given its own designation.“Airman’s Burn” was described in numerouswartime medical texts as ‘a burn of almostunwavering characteristics due to thesudden exposure of unprotected parts of thebody to intense dry heat or flame, as thoughthe patient were thrust into a furnace for afew seconds and withdrawn.’ The product ofthis process was ‘deep, searing burns, usuallyof third degree to areas of tremendousfunctional importance -- the hands andeyelids in particular.’ 9 The position of thefuel tank often resulted in its contentsexploding in the face of the pilot, whichaccounts for the characteristic facial burnssustained. In addition to the hands and face,airmen commonly suffered burns to theirwrists, neck, thighs, and scalp. 10The motivation of the RAF and RCAF tocommit whatever resources necessary toensure the best treatment possible for itsburned airmen was two-fold. Firstly, theseyoung men had volunteered to fight in theservice of protecting their country, and theindebted nation demanded they receive careof the highest quality. Secondly, pilots werean invaluable resource in the war campaign,especially during the Battle of Britain.During the autumn of 1940, experiencedpilots proved a commodity more critical tovictory than steel or oil. 6 Burn injuries servedto remove airmen from combat for weeksto months at a time, and therefore, the RAFneeded to rehabilitate its most valuableresource as quickly as possible under thethreat of an air campaign failure. Luckily forthe multitude of victims, there were menlike Tilley who were willing and able toset themselves to the task of rehabilitatingthese heroes.Tough As Leather: BurnManagement Before WWIIShortly after arriving at East Grinstead, itbecame apparent to Tilley that the increasingUniversity of Alberta Health Sciences Journal • April 2012 • Volume 7 • Issue 1 31

MUSAFigure 2. Queen Victoria Hospital at East Grinstead (Left above). Schematicof Queen Victoria Hospital (Left below). Image from article of unknown sourceabout the opening of the new Canadian wing at Queen Victoria Hospital (Right).number of Canadian burn casualtiesflooding the hospital would need their ownward. Under Tilley’s planning and leadershipas the newly appointed chief surgeonand commanding officer, Royal CanadianEngineers prepared to erect a 50-bed wingthat would cost $80,000 and take a year tobuild. 2-4 Upon its completion in 1944, theCanadian wing had a staff of over 50 peopleincluding orderlies, specialist nurses, andclerks (Figure 2).For decades before WWII, patients withsevere burns were deemed terminal and thestandard of care consisted of administeringminute amounts of saline, a gargantuandose of morphine, and orders for thepatient to return home so they could besurrounded by their loved ones as deathswiftly followed. 11 Burn patients werescarcely encountered in teaching hospitalsbecause their case was viewed as hopelessand admission rarely occurred. The reasonthat major burns rapidly killed nearlyeveryone sustaining them was shock, andthe inability of the medical profession toadminister effective treatment to halt itsprogression. 8 Severe burns would initiatea chain reaction of events beginning withmassive fluid loss from the wound, followedby shock and the successive failure ofmultiple organ systems until the patient wasno longer able to cling to life. If by somedivine intervention the patient perseveredthrough the shock, the next hurdle to theirrecovery was infection. With odds stacked sohighly against recovery from severe burns,the treatments that developed were largelychemical interventions geared towardsminor burns, with surgical involvement arare occurrence. 10 Breakthroughs in treatingshock changed everything.The 1920s saw physicians tinkering with theidea of fluid resuscitation, but out of fear ofunknown adverse effects, they never daredto give fluid in the amounts necessary tostem the tide of shock. 8 It was not until the1930s that saline and plasma transfusionswere gradually being administered inever-increasing volumes. Eventually, thetreatment of shock had evolved to suchan extent that the majority of severe burnshistorically viewed as death sentences nolonger produced corpses for coffins, butextremely complicated patients requiringspecialized, multifaceted care. 4 The advancesin shock therapy inadvertently created a newpatient population that needed treatmentdesperately. The physicians of the day did allthey could using the tools available to them.The results, however, proved unacceptableto physicians like Tilley.When the first wave of severely burnedairmen presented to hospital, the majortreatment method centered aroundcoagulation. A coagulating agent wouldbe applied to the burn, which caused atough hide of scab-like tissue to encasethe wound. 10 This functioned as a physicaldressing of sorts, and was thoughtadvantageous by many physicians in itsability to protect the wound, prevent lifethreateningfluid loss, and guard againstsepsis. 8 The coagulant that was administerednearly universally was tannic acid, 12 thevery same substance used in the leatherindustry to stiffen hides. Metal tubes oftannic acid were so widely distributed, thatat the outset of the war, they could be foundin almost every ER, medic bag, and first-aidkit in Allied territory. In theory, coagulationtherapy served both as immediate firstaid,as well as a long-term treatmentthat remained in place until new tissuehad grown underneath, after which thecoagulum could be removed. 13The reality of treating airmen’s burns withtannic acid turned out to be so disastrousthat it prompted one of Tilley’s mentors atthe Queen Victoria Hospital, the great SirArchibald McIndoe, to undertake a crusadeagainst its continued use. The problems withtreating airmen’s burn with coagulation32University of Alberta Health Sciences Journal • April 2012 • Volume 7 • Issue 1

therapy were numerous. Tannic acid appliedto burns of the hands resulted in stiffnessto the point of complete immobility. 14In addition to stiffness, the thick hide ofcoagulated tissue exacerbated edema, andconstricted an already diminished circulation.This compression of blood flow in the handsfrequently resulted in ischemia, necrosis,and the loss of fingers. 14 The black escharproduced also made it very difficult for themedical staff to detect infections, which oftenwent unrecognized until the indicative aromawafted into the nostrils of patient and staff.With the goal of avoiding septicemia, thecoagulum was then ripped from the woundso antiseptic agents could be administered,but this commonly proved ineffective andagonizingly painful for the patient. 10Results of coagulants applied to burns of theface were equally distressing. Gentian violetwas used for facial burns due to the beliefthat it was more ‘delicate’ than tannic acid. 15Despite its purported virtue, gentian violetleft facial tissue rigid, and eyelids so taut thatthe patient often suffered corneal scratchesor ulceration from being unable to blink. 15 Iflucky enough to avoid irrevocable blindnessduring the gentian treatments, the patientthen had to worry about the subsequentscarring that often everted the eyelids.Setting aside their immediate harm, thelong-term hindrance posed by coagulationtherapy was that it completely obliteratedviable grafting surfaces. Once the coagulumwas removed, its place was taken by thickspindles of keloid scarring, the likes ofwhich vaporized hope for any degree ofreconstruction. 15Fortunately for the hundreds of patientswho suffered burns of the hands andface, McIndoe was able to persuade themajority of his colleagues, and the scientificcommunity at large, that the heinous resultsof tannic acid justified the banishment of itsuse across Europe. 16Pulled From The Furnace: Tilley’sApproach To Burn ManagementWith coagulation therapy for third-degreeburns of the hands and face effectivelybanned by the late 1940s, thanks to theadvocacy of McIndoe and Tilley, thechallenge of implementing an efficacioustreatment regimen for severe burns loomedover the wards of East Grinstead. Theapproach cultivated by McIndoe and Tilleyat the Queen Victoria Hospital, which servedas the prototype for burn management andwas duplicated at centers across Europe,consisted of three vital components. 4 Inorder to preserve surfaces viable for grafting,atraumatic dressings were essential. Theform of dressing most commonly usedconsisted of a single layer of Tulle Gras, anon-adhesive bandage composed of fabricwith variable proportions of paraffin and oilimpregnating the material, placed directlyon the surface of the wound, followed bya sterile saline compress over top. 14 Thebenefits of this method became apparentanytime staff needed to remove thedressings to clean the wound, or examineit for signs of infection; the Tulle Gras couldbe changed easily without inciting anyadditional trauma at the burn site.The second pillar of burn managementTilley utilized was the saline bath (Figure 3).Ablution was viewed as a critical method inmaintaining clean, healthy wounds as wellas being instrumental in the granulationprocess. 14 In addition to fostering a viablegrafting surface, saline baths also allowedpatients to keep their wounds flexible. Thiswas especially important for burned hands,which were much more mobile under waterand proved quite favorable for circulationand the salvaging of the greatest proportionof digits possible. 16 Patients under Tilley’scare would soak for an hour in tubs ofsaline, two to three times daily, during whichFigure 4. Surgery at the QueenVictoria Hospital.time, dressings would seamlessly float offthe burn site and save the patient from thepotential agony of removing them underdry conditions. 10To achieve a truly successful treatmentregimen, Tilley’s management of burns alsohad to neutralize infections. “Sulphanamidedusting” was one strategy employed, inwhich a powder form of sulphanamide, anantibiotic, was gently sprinkled over thesurfaces of burns. 14 For burns of the hand,plastic bags filled with powder encasing theinjured limb were used. 14 Tilley also noticedthat the wool blankets used in hospitalsharbored and transmitted infections toscores of patients across Europe, therefore,he had them exchanged with layered linens.One of the more ‘radical innovations’employed at Queen Victoria Hospital wasto ensure physical separation of the burnunit from other wards of the hospital, whichbroke with the convention of burn patientsinterspersed throughout various wards. 4 Thisserved to cut the rampant infection ratesproduced by cross-contamination betweenpatient groups that had plagued hospitals inthe past. Patients at highest risk were thosewith burn wounds and jaw injuries, and theywere housed in special isolation units.With the sulphanamide-tulle gras-salinesequence producing patients whoseburns remained conducive to subsequentreconstructive therapy, Tilley now set himselfto the task of restoring the hands and faceshis patients had lost (Figure 4). One ofTilley’s first objectives was to reconstructthe ears of his patients: “without them” heasked, “how could a man hold his glasseson?” 3 Most men would need betweenbetween ten and fifty operations, requiringthem to be in and out of the hospital for atleast three years. It was customary to planeight surgeries per year, alternating threeMUSAFigure 3. Saline bath at Queen Victoria Hospital.University of Alberta Health Sciences Journal • April 2012 • Volume 7 • Issue 1 33

MUSAto four weeks in hospital, with two to threeweek breaks outside. 10Generally, acromiothoracic flaps wereutilized for deep unilateral burns, but incases where adequate free grafts could beproduced, patients were treated in thisway entirely. 8 During his tenure at QueenVictoria hospital, Tilley would replacecountless noses, reform a multitude of earsand eyelids, and re-establish facial featuresfor hundreds of men; all of this with theobjective of giving his patients the chanceto return to a normal state of existence. ButTilley’s operative virtuosity was not all heoffered his patients….A Scalpel, A Guinea Pig, And ATender Hand: Tilley’s ApproachTo The Patient RelationshipBy 1944, the Canadian wing at QueenVictoria Hospital opened, and Tilley waspromoted to the rank of Group Captain.In June of the same year, Tilley foundhimself standing in front of King GeorgeVI at Buckingham Palace with the Order ofthe British Empire being bestowed uponhim. 1 This prestigious award was fittingrecognition of Tilley’s success in Britain;along with the work of McIndoe and thehospital staff, they had become “the mostformidable and effective response to burninjuries, anywhere in the world.” 4The work at Queen Victoria hospital was sogroundbreaking that it brought one patientto remark in jest, “we’re nothing but abunch of damn guinea pigs!” Subsequently,the Guinea Pig Club was formed in 1941,by a group of airmen who had sufferedburn injuries in the war and were treatedat the Queen Victoria Hospital. Consistingof nearly 650 members of a dozen differentnationalities, the club was one of the firstsupport groups in medical history. 17 TheFigure 5. Tilley poses for a photo symbolizing thecare he gave to his real patients, the Guinea Pigs.camaraderie and sense of belonging fosteredby the club has been acknowledged bymany historians as instrumental in thetherapeutic success ultimately achievedat East Grinstead. 4 The Guinea Pig Clubhelped shield patients from suffering theirdisfigurement in isolation, and gave itsmembers the strength to venture out intothe world, and walk the streets wearing theirwounds as testaments of their sacrifice. Tilleyserved as president of the Canadian branchof the Guinea Pig Club, and continued tooperate on over two hundred of its membersfor the next forty years (Figure 5). 3Tilley dedicated a tremendous amount ofpersonal attention to the emotional andpsychological condition of his patients. Afteroperating all day and into the evening, Tilleywould rest briefly in his living quarters onlyto make his way back to the hospital at 23:00h to check how his patients were faringafter their surgeries. 4 In a medical landscapedominated by rampant paternalism,Tilley was a trailblazing pioneer of patientempowerment who went to great lengthsto educate his patients about every aspectof their care, every nuance of their surgeries,and the intricate details of what they couldexpect during recovery. 18 Where manysurgeons of the day saw their involvementin patient care beginning and ending in theoperating room, Tilley was a fierce proponentof the importance of a patient’s psychologicalwellbeing in their overall rehabilitation. In hiscare of the Guinea Pigs, Tilley transcendedthe customary duties of a physician and roseto become a shining light that illuminated acomprehensive path to recovery. 18For decades after the war, Guinea Pigsfrom across the world would come togetherfor an annual celebration where one oftheir toasts was always to the care theyreceived from Tilley. Out of gratitude forTilley’s commitment to them, the GuineaPig Club funded a bronze bust of theirbeloved physician, which was installed inthe Canadian wing of the Queen VictoriaHospital. The sculpture commemorates theman whose tender hand pulled them fromthe furnace, and allowed them to transcendwhat had once been thought of as a fateworse than death. 2No Sign Of Slowing Down:Tilley’s Life After The WarUpon his return from Britain in 1945, Tilleybecame a consulting physician at ChristieStreet Hospital and Toronto WellesleyHospital. For several years between 1949-1965, Tilley also spent three days everymonth in Kingston where he worked as astaff physician at the Hotel Dieu, KingstonGeneral, and Kingston Military Hospitals. 2As one of only ten other plastic surgeonspracticing in Canada after the war ended,Tilley was extremely busy laying theframework for the future of his specialty.His colleagues viewed Tilley as a physiciancapable of breaking new ground. In July of1942, he led the first all-Canadian plasticsurgery operation, and a few years later asan assistant professor at Queens University,he became the first to offer formal accreditedcourses in the specialty. 2 Tilley also inventedseveral surgical instruments, such as aningenious hand splint, and was the first to19, 20design the tube pedicle flap.Tilley was one of the twelve foundingfathers of the Canadian Society of PlasticSurgeons in 1947. At its second annualmeeting on June 2, 1948, the society’smembers empowered Tilley to draft a feeschedule for the operations performed mostcommonly by plastic surgeons. 20 Appointedvice-president in 1953, and then presidentin 1954, Tilley’s leadership of The CanadianSociety of Plastic Surgeons helped establishthe profession in Canada and paved the wayfor the exponential growth and prosperity itwould experience in subsequent years. 20As his specialty flourished across thecountry, Tilley continued to infuse hisdiscipline with respect and integrity ashe campaigned for years to develop burntreatment facilities in Ontario. In 1984, hisvision came to fruition and the Ross TilleyBurn Centre opened at Wellesley Hospital. 21Only three years after becoming the firstplastic surgeon to be appointed a memberof the Order of Canada, Tilley also assumedthe role of Founder and Director of the first19, 21adult burn centre in Canada.Even after retiring from practice at Wellesleyand Sunnybrook hospitals in 1981,Tilley continue to be recognized for hisoutstanding career. An elementary school inhis hometown of Bowmanville was namedin his honour, and he was inducted intoCanada’s Aviation Hall of Fame in 2006. 1,3After dedicating much of his 84 years of lifeto his patients, Albert Ross Tilley passedaway on April 19, 1988. 21CONCLUSIONThe distinguished and illustrious careerof Albert Ross Tilley exemplifies many ofthe qualities sought after by physicianstoday. As a surgeon, he is rememberedfor his meticulous technical skill, soundjudgment, and tireless work ethic. He wasa leader, innovator, and educator whoseefforts sculpted an immature specialty intoa refined profession. As a man, Tilley’s virtueand character stood beyond reproach, and34University of Alberta Health Sciences Journal • April 2012 • Volume 7 • Issue 1

he was acknowledged with Canada andBritain’s highest honours.The most valuable lesson that Tilley’s legacyoffers this generation of medical studentsand physicians, can be gleaned from hisfirst encounters at East Grinstead. Standingat the bedside of his patient and assessingthe medicines he had at his disposal, Tilleyshook his head and resolved to do better;he refused to surrender to the limitationsdictated by existing medical practice.Tilley tossed aside the contemporaneoustreatment of coagulation therapy, the meritsof which were being espoused by expertsin the field. With a steadfast convictionthat his patients deserved a higher levelof treatment, Tilley worked tirelessly withMcIndoe and hospital staff to producea revolutionary regimen that ultimatelysaved the hands, faces, and livelihoods ofhundreds of men. Tilley’s actions at QueenVictoria Hospital serve as a reminderto modern day practitioners of theirresponsibility to address deficient aspectsof patient care, and to innovate, whennecessary, in order to provide patients withthe best possible medicine.Acknowledgments: I would like to thankDr. Gordon Wilkes of the University ofAlberta, and Dr. Steven Morris of DalhousieUniversity for their generous guidance in theproduction of this article.References:1. Albert Ross Tilley. Alberta: Canada’sAviation Hall of Fame; c2011 [cited 2011Jun 10]. Available from http://www.cahf.ca/members/T_members.php#A.%20Ross%20Tilley2. Gray C. Profile of A. Ross Tilley. Can MedAssoc J. 1983;129:154.3. Wilton P. WW II “guinea pigs” playedcrucial role in refining plastic surgery inCanada. CMAJ. 1998;159(9):1158-9.4. Mayhew ER. The Reconstruction ofWarriors: Archibald McIndoe, the RoyalAir Force, and the Guinea Pig Club. 1st ed.London: Greenhill Books; 2004.5. Downing T, Johnston A. The SpitfireLegend. History Today. 2000; 50(9):19-25.6. Keegan J. The Second World War. 1st ed.New York: Penguin Books; 1989.7. Bailey G. The Narrow Margin of Criticality:The Question of the Supply of 100-OctaneFuel in the Battle of Britain. EnglishHistorical Review. 2008;123(501):395-411.8. Jackson DM. Burns: McIndoe’scontribution and subsequent advances.Annals of the Royal College of Surgeons ofEngland. 1979;61:335-40.9. McIndoe AH. Total reconstruction of theburned face. Br J Plast Surg. 1983;36:410-20.10. Geomelas M, Ghods M, Ring A, OttomannC. “The Maestro”: A Pioneering PlasticSurgeon—Sir Archibald McIndoe and HisInnovating Work on Patients With BurnInjury During World War II. J Burn CareRes. 2011;32(3):363-68.11. Alger EM. On Cutaneous Burns. MedicalRecord. 1898;53(22):766-68.12. Mitchiner PH. Treatment of burns andscalds with special reference to the use oftannic acid. The Lancet. 1933;233-39.13. Gordon RM. Treatment of burns by tannicacid. The Lancet. 1928;336-37.14. Hunter JB, Gillies H, McIndoe AH, HudsonRV, Colebrook L, Kilner TP. Treatment ofBurns. The Lancet. 1940;621-622.15. McIndoe AH. The Misuse of Tannic Acid.The Lancet. 1940;627-28.16. McIndoe AH. Burns of the Hands andFace. The Lancet. 1940;655.17. Andrew DR. The Guinea Pig Club. AviatSpace Environ Med. 1994;65(5):428-33.18. Feasby WR. The Official History ofthe Canadian Medical Services, 1939-1945. Department of National Defense,Directorate of History and Heritage.1956;363-366.19. Cheng H. Firsts in Canadian Plasticand Reconstructive Surgery. Universityof Toronto, Division of Plastic andReconstructive Surgery website. 2010[cited 2011 Jun 1]. Available from http://www.uoftplasticsurgery.ca/main.php?p=1154&s=120. Douglas LG. History of the CanadianSociety of Plastic Surgeons. 1st ed. Quebec:Canadian Society of Plastic Surgeons; 1983.21. Taylor JR. Canadian Society of PlasticSurgeons: Tribute to our founders. Can JPlast Surg. 1997;5(1):22-32.MUSAThe House of God still worth a read for today’s medical traineesAlby Richard, BScMedical Student (2013), Faculty of Medicine, University of Calgary, Calgary, Canada,PhD Candidate (Neuroscience), Montreal Neurological Institute, McGill University, Montreal, CanadaCorrespondence to Alby Richard: Email: alby.richard@mcgill.caTHE HOUSE OF GODBy Samuel ShemNew York, NY, Dell, 2003 (first published:New York, NY, Richard Marek, 1978).ISBN 978-0385337380Medical training has changed a great dealover the past thirty years, along with theway medicine is practiced in general. Thisis interesting to consider in the contextof the American medical system, whichhas the dubious honor of boasting themost sophisticated yet unevenly accessiblemedical system. In light of this, it is perhapsnot surprising that at some point alongthe way voices of dissent would emerge,even from within the ranks of the medicalestablishment itself.Samuel Shem’s (the pen name of Dr.Stephen Bergman) House of God wasfirst published in 1978, as a semiautobiographicalaccount of Dr. Roy Basch’sinternship year in the eponymous hospital.With the ripples of the civil rights movementstill being felt, and the Watergate scandalshowcasing the moral ambiguity of thenation’s highest offices, Shem’s honestand at times disturbing portrayal of oneof America’s most prestigious teachinghospitals was a timely contribution to thechanging social and political landscape.Now, over three decades later, even asophomore medical student on the brinkof entering clerkship may be struck by Dr.Bergman’s candid observations concerningthe challenges of medical education. Thisbook offers a compelling caricature of someUniversity of Alberta Health Sciences Journal • April 2012 • Volume 7 • Issue 1 35

MUSAgeneral themes that many facing a career ina medical discipline are likely to encounter:from management of chronically ill patients,to acrimonious relationships (both personaland professional) with fellow colleagues.If you have not yet read the House of God,your first thought may be whether thisfictionalized account from the 1970s hasany relevance to the plight of today’smedical trainee. The short answer, whichbecomes obvious even after the first fewchapters describing Roy’s arrival to theHouse, is a resounding yes. There are ofcourse elements of the book that will bedifficult to reconcile with the reality ofresident life thirty years later: The text islittered with outdated medical references,and is punctuated throughout with atone of arcane paternalism that would beunacceptable by today’s standards. Theseanachronisms, however, beyond remindingus that the book is situated in another eraaltogether, are also important for anotherreason. They allow today’s reader toappreciate those egregious aspects of theAmerican healthcare system of the 1970’sfor their comic relief, and serve to reinforcemany of the book’s themes. Furthermore,the fact that many of its themes still applytoday only reinforces Bergman’s talent andperspicacity.By introducing us to the morbid humourand unsavory behaviour which Roy andhis colleagues would often invoke to makesense of the difficult situations in whichthey found themselves, Bergman reveals theimportance of having a stress outlet. We seethis evinced through different charactersin the book. The narcissistic Pinkuscomes to mind, with his utter emotionaldetachment from his ICU patients, coupledwith his nearly monastic devotion to hisown running routine and sculpted calves.The lack of an appropriate outlet is alsomirrored in Roy’s steadily mounting innerturmoil as his internship year progresses.Our protagonist’s ongoing awareness of themacabre, often futile nature of his variouscoping strategies gives the narrative furtherdepth and tension, and keeps the readerwondering just how much more Roy cantake.Bergman’s development of secondarycharacters to further explore thecomplexities of internship is nicelyaccomplished. Notable among these is Barry,his clinical psychologist girlfriend, whoseunwavering presence serves as a moralcounterweight to his frenetic mood swingsand constant disequilibrium. Indeed, Barry’sviews often come across as a reminder ofthe humanity and basic conscientiousnessthat Roy begins the year with, but graduallyloses, as he sinks further into the soulsuckingdrudgery of ward-based medicine atthe House.Roy’s in-house sanity is provided by theenigmatic and brilliant senior resident,known only as the ‘fat man’, whosesacrosanct “Laws” of the House come toform the basis of most of Roy’s clinicaldecisions, often in flagrant disregard toeverything his previous medical educationhas taught him. While some may seemtrite at first (e.g. law #4 “THE PATIENT ISTHE ONE WITH THE DISEASE”), others,such as law #13, come to signify one of thebook’s pervasive themes: “THE DELIVERYOF GOOD MEDICAL CARE IS TO DO ASMUCH NOTHING AS POSSIBLE”. Thisstatement may seem fairly counterintuitiveat first, but gains considerable tractionwhen considered in the context of Roy’smisadventures at the House.The House is also a rich resource onterminology for any new initiate to themedical sphere, and worth the read fromthat perspective alone. Here we find theorigins of terms that many of us may befamiliar with already, such as GOMER (‘getout of my emergency room’); BUFF (thecareful art of making a chart look good,which often treads the fine line betweenperjury and embellishment); and TURF(using any excuse possible to hand offcare of your patient to another service ordepartment). While such catchwords maynot be used very frequently today, the spiritof these terms almost certainly persists, asmany with first-hand clinical experience willrecognize.Dr. Bergman also addresses the notion ofhierarchy throughout the book, and howembedded it is at all levels of training andadministration. While his criticisms areoften oblique and bordering on subversive(often at the expense of one of Roy’s seniorcolleagues or House staff), they are alsopoignant and hilarious. A particularlymemorable image is that of the Leggo, Roy’suptight and oblivious superior staff member,with his stethoscope in its default positionwinding down into his trousers (which Roy/Bergman playfully mocks throughout thebook). Interestingly, Bergman’s depictionallows the reader some first-hand insightinto both the folly and utility of thisentrenched system, the relics of which arestill present today.At the end of the day, The House of Godis a pleasant and engrossing read, andthere is much to be gained in reflecting onRoy’s tumultuous foray into the world ofhospital-based medicine. The prescience ofthis book and the ‘Laws of the House’ areworth noting today as we find ourselvesin the midst of health care system that isunderfunded, short-staffed, and overused.In critiquing the medical system in whichwe train and work (albeit through the lensof a 1970s intern), The House of God forcesthe reader to consider just how sustainableour current practices are. This message isespecially pertinent in the context of ourageing population, since many of our currentpractices in medicine were founded in Roy’sera of relative resource abundance.36University of Alberta Health Sciences Journal • April 2012 • Volume 7 • Issue 1

Thank youThe UAHSJ wishes to thank theFaculty of Medicine and Dentistry fortheir generous support of this project.

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