CANADIAN SOCIETY OF CL IN ICAL CHEMISTS

LA SOC IÉTÉ CANADIENNE DES CL IN ICO-CHIMISTES

CANADIAN SOCIETY OF CL IN ICAL CHEMISTS

LA SOC IÉTÉ CANADIENNE DES CL IN ICO-CHIMISTES

P.O. Box 1570 Kingston, Ontario, K7L 5C8 Canada 613.531.8899 office@cscc.ca

Vol. 56 No. 6 November 2014 ISSN 0826-1024

Countdown to Montreal: A Capital of Gastronomy

Montreal is home to thousands of restaurants, many of them world-reknown, many others are less well known, but little gems. Whether your taste runs to haute cuisine, funky cafés, ethnic family-run restaurants from the four corners of the

earth, or friendly pubs, Montreal has it all. You will be in Montreal for the meeting at the height of the café-terrace season when many restaurants spill into the courtyards and onto the sidewalks of Montreal. Before giving an overview of the food scene here and some of my favourites, I would like to speak about the Institut de tourisme et hotelerie du Québec (ITHQ). In many cases it is where Montreal’s current gastronomy began.

The ITHQ was founded in 1968 replacing the École des métiers commerciaux and occupying its premises until 1976 when it moved into its newly built quarters on rue St. Denis in the heart of Montreal’s tourist district. A few of the highlights of the Institute’s evolution follow. In 1991 the ITHQ partnered with the Université de Québec à Montréal to offer a new bachelor’s degree program in tourism and hospitality management, and in 1995 a food research centre was founded. In partnership with Hydro-Québec the institute tests new-generation cooking equipment and in 2000 the Société des Alcools fi nanced the creation of a wine stewardship laboratory. The ITHQ has created partnerships with other schools of its kind with exchange programs, notable in Italy and Switzerland. It has garnered many awards and has given honory degrees to world-reknown chefs including in 2013 to famous French Michelin three-star chef, Pierre Gagnaire. You can eat gourmet food at their restaurant for a fraction of what it would cost in a fi ne restaurant. However reservations have to be made well in advance. I ate dinner there a few years ago and it was excellent. The only reproach is that the restaurant area has the ambiance of a university cafeteria.

I would like to give a brief overview of some of my favourite restaurants. For the ones listed as fi ne dining I would suggest making reservations before coming to Montreal (even a

Café Santrolpol

month before), as the meeting is at the height of the tourist season. Check out the menus, reviews and location on line. Montreal has many up and coming restaurants located all over the city. Some important areas are Old Montreal - where the meeting hotel is located, west of Old Montreal on Notre-Dame Street West, only a seven minute cab ride away, Wellington Street in Verdun, in the South-West of the city, the Plateau-Mile End, on St Laurent Blvd., the Gay Village on Ontario East, and Mont-Royal Ave to name a few. Just look up Montreal Plus or the Urban Spoon.

Fine DiningEven though Montreal does not have any

Michelin three star restaurants, it certainly has may top quality ones. Anyway, this rating would probably price the restaurants out of an affordable range as has happened in other cities.

Old Montreal

Club Chasse et Pêche (423 Rue Saint-Claude)

T h e n a m e t r a n s l a t e s a s " H u n t i n g a n d F i s h i n g C l u b " , which is an ironic reference to the wood-and-leather

decor. The menu changes with the seasons, but original dishes of duck, venison and fresh fi sh feature prominently on the menu. I have eaten here several times and the food is delicious.

CSCC News • November 20142

Bonaparte (443 Saint-François Xavier)

This classic French restaurant located in an old house with decoration inspired by the Napoleonic period is located next to the Centaur Theatre, a Montreal landmark. It offers several table-d’hôtes. The seasonal one is a good deal, a five course meal including coffee for $54.00. I have also eaten here often and though not innovative, the food and service are great.

DowntownEuropea (1227 de la Montagne)

This is not just a restaurant where you go to have a meal. It is a happening. Though upscale it is worth every penny. There are tasting menus but even if you go à-la-carte, there will be little surprise morsels between courses plus a treat to take home at the end – so that you have the feeling that you have just been to grandma’s for dinner if grandma was a gourmet cook and had attentive servants.

I have been several times and it is a treat.

BYOBIn Montreal there are many excellent

BYOB restaurants where food is as good as the top-priced restaurants. You will also save on wine and there is no corking fee in Quebec. Here are two really nice French restaurants that we have tried.

Mile-End, PlateauRestaurant Le French Connection (4675 Boul. St. Laurent.)

This is one of the rare restaurants in Montreal that has the certifi cation “Table aux saveurs du terroire”. This means that all products including meat are local, so this is a great place to get a taste of Quebec. This label is usually reserved for restaurants in the farming regions of Quebec. They have interesting and reasonable tasting menus that change and knowledgeable waiters who very gladly explain what you are about to eat.

Le Margaux (1227 Ave. du Parc)

A t y p i c a l Paris bistro in Montreal, where the specials, of which there are

many, are listed on a blackboard. The Chef is from Bordeaux and this infl uence is seen in many of the dishes. The table d’hôte, reasonable at $45.00, is a four course meal with many choices including for the main course, duck, bison and deer along with

classics like sweetbreads all deliciously prepared and well-presented.

CafésMontreal, like Paris is a city where you

can sit for hours nursing your cappuccino and people watch. As soon as the weather turns pleasant, the tables come out on the sidewalks. Rue St. Denis is a great café street and of course so is Old Montreal, especially around Place Jacques-Cartier. Cafés are not just about coffee but also food, mainly lighter fare.

Old MontrealJardin Nelson (Place Jacques-Cartier)

You have to line up as they don’t take reservations. However, the terrace behind the restaurant with its hanging plants and giant parasols to protect you from the sun and rain is a lovely place for a bite whether it be brunch, lunch, a light dinner or drinks and munchies. Their crêpes both sweet and savory are really good and we had to bring home doggie bags as the portions are generous. Most of the time there is also live jazz. In Montreal we had an unusually warm September and this was one of our last outdoor eating experiences of the summer and thoroughly enjoyable.

PlateauCafé Santropol (3990 St-Urbain)

You cannot come to Montreal and not go to Café Santropol. The café has been around for over 35 years and is frequented not only by students, but also by families and older folk whose student days are long behind them. Behind the café is a garden terrace with colourful wooden furniture and plants and rocks and fountains arranged to give little nooks of privacy. This is an alternative café that has funky decorations and the best restaurant sandwiches that I have ever eaten.

CSCC News • November 2014 3

The molasses whole wheat bread, dark and moist, is made on the premises. It serves as the basis for sandwiches with names like Yelpa Moon (Hungarian cream cheese spread and tomatoes), Northern Lights (Cream cheese, olives, mellow spices and roasted pecans) and Santropol (cream cheese, roast beef and blue cheese). Ham or chicken can be added for a few dollars more. A huge variety of coffees, teas, tisanes and non-alcoholic cold drinks are available.

Première Moisson (various locations all over Montreal)

This a bakery renowned for its breads but also for its Danish (called viennoiseries in Quebec, actually a more accurate name as they originated in Vienna and not Denmark) and French pastries and chocolates. There are tables so this is a great place to have a continental breakfast, pause-café or a light lunch of salads and sandwiches.

Juliette et Chocolat (rue St Denis and other locations)

Another chain worth mentioning. As its name suggests it is very into chocolate. You can even order glasses of different types of molten chocolate-too rich to be simply called hot chocolate. They do have salads that are quite good in order to balance the “sinning”.

In my little epicurean tour I have not touched on the ethnic restaurants as there are far too many in variety and number and are not unique to Montreal. Montreal also has many excellent pubs (e.g. Bière et Compagnie on rue St. Denis), wine bars (e.g. Trois Petits Bouchons on rue St. Denis) and whiskey lounges (e.g. Whiskey Café on Boul. St. Laurent).

So plan your culinary itinerary carefully before you come to Montreal, as you will surely run out of time and appetite and start revving up your exercise regime so that you can enjoy the gastronomy of Montreal.

Dr. Mary-Ann Kallai-SanfaçonChair, CSCC Annual Meeting 2015

Editor-in-Chief’s ColumnIt seems as if I have been on the Editorial Board forever and

yet time has passed so quickly. I have had a great team assisting me, Drs Cheryl Tomalty and Isolde-Seiden-Long and then when she stepped down, Dr Kareena Schnabl and of course Elizabeth Hooper who is responsible for making sure that the issue is well-formatted and goes out on time. Liz is also responsible for all items with a deadline, like the call for award nominations, and that they are included in the appropriate issue.

Computers and the internet have really facilitated the preparation of the newsletter. It is so easy to receive material and most of the editing occurs before the draft is sent to the publisher. This means that very little editing needs to be done before an issue goes out.

Some things have stayed the same. Dr Arlene Crowe has faithfully contributed the Archives Corner to each issue. Café Chat has continued to give news of our members. Lately it has been fi lled with babies, those of our younger members as well as grandchildren of some of the more senior members, myself included.

When I was asked to join the Editorial Board by Dr. David Parry who was the Chair of the Publications Committee - he had two requests - one that we start a series of articles profi ling different clinical biochemistry laboratories and the second was to have more French content.

The goal of the former was to help connect clinical biochemists across our vast country. We have published profi les from practically every province. I hope this tradition will continue as clinical biochemists are now involved with new areas such as immunology and molecular diagnostics. We have also introduced an annual series of articles entitled Meet the New Fellows in which Canada gets to know the newest members of the Academy. This was an initiative of Isolde. As a complement to this, Kareena initiated a series called Meet the Trainees in which trainees would outline who they were, where they were studying and what inspired them to go into clinical biochemistry. In this way we have hoped that CSCC News has helped to keep the CSCC a close family despite its steady growth.

The CSCC has strived to maintain a bilingual face where possible. As part of this mandate, CSCC News has published summaries of the SQBC Annual Meeting in French and English and many articles have also appeared in bilingual format.

We have also initiated a series of articles entitled "Countdown to _____" in order to encourage members to attend the CSCC Annual Meeting. This series usually includes a history of the venue city, activities around and about it and of course articles on the meeting program. It is also hoped that members and their family will stay after the meeting to visit. On several occasions I have written a post-meeting travelogue to encourage members to come back at a future date to see what they have missed.

During my time as Editor-in-Chief we have had articles celebrating UNESCO’s Year of the Chemist and have tried to keep everyone abreast of the new technologies and laboratory practices either already introduced or to be introduced in clinical biochemistry laboratories in the future.

The CSCC News has always been your newsletter and it is only as interesting as the articles that you contribute. I would like to thank the contributors and encourage those of you who have not yet written something to do so in the future. The robustness of the CSCC News can be seen by the number of times we have had requests to reprint articles of interest in the IFCC Newsletter.

So as I fi nish my term, I am confi dent that the new team headed by Dr. Isolde Seiden-Long as Editor-in-Chief will continue in the great tradition of bringing current and interesting information to the members via the CSCC News.

Dr. Mary-Ann Kallai-Sanfaçon, Editor-in-Chief, CSCC News

CSCC News • November 20144

High-Sensitivity Cardiac Troponin: A Canadian Viewpoint from CIHR funded studies

With the support of the CSCC and funding through a Canadian Institutes of Health Research (CIHR) dissemination grant, a

meeting on “High-Sensitivity Cardiac Troponin” was held at the Juravinski Cancer Centre in Hamilton, Ontario on Friday May 30, 2014. For this free one-day event, over 100 individuals attended in person or via the internet the conference with representation across Canada, United States, Europe and Australia.

The day was comprised of a series of presentations, that broke the fi eld into “Current State”, “Current CIHR studies”, and “Future Directions” (see below program). There were lively discussions on cutoffs (as one might expect when discussing cardiac troponin) with the overwhelming consensus from participants that this meeting was an important knowledge translation event (a pleasant surprise to the organizers). For those unable to attend the conference, a document has been published in the November Issue of Clinical Biochemistry:

Canadian Institutes of Health Research dissemination grant on high-sensitivity cardiac troponin

Peter A. Kavsak, Allan S. Jaffe, Peter E. Hickman, Nicholas L. Mills, Karin H. Humphries, Andrew McRae, P.J. Devereaux, Andre Lamy, Richard Whitlock, Sukhbinder K. Dhesy-Thind, Julia M. Potter, and Andrew Worster

The CSCC has generously made this article freely available (i.e., open access) so that the wider clinical and laboratory community can understand where important gaps exist for high-sensitivity cardiac troponin.

Scientifi c Program

• Introduction to High-Sensitivity Cardiac Troponin – Current State

• International Guidelines and High-Sensitivity Cardiac Troponin (A. Jaffe)

• High-Sensitivity Cardiac Troponin: Analytical Characteristics and CIHR Completed Studies (P. Kavsak)

• Important Considerations for Establishing a Reference Interval and Using High-Sensitivity Cardiac Troponin Assays (P. Hickman)

• High-Sensitivity Troponin in the Evaluation of Patients With Acute Coronary Syndrome: A Randomized Controlled Trial (N. Mills)

Current CIHR Studies

• Cardiac Troponin and Sex Differences in Outcomes (K. Humphries)

• Clinical and Operational Experience with hs-TnT in Four Large

Urban Emergency Departments, and Plans for Optimization of Assay Utilization (A. McRae)

• Determining the Optimum Treatment Cutoffs For High-Sensitivity Troponin Assays in Patients Presenting to the Emergency Department with Suspected Cardiac Ischemia (A. Worster)

• Vascular events In noncardiac Surgery patIents cOhort evaluatioN(VISION) Study (P. Devereaux)

Future Areas for High-Sensitivity Cardiac Troponin Testing

• Cardiac Surgery (A. Lamy & R. Whitlock)

• Cardio-Oncology (S. Dhesy-Thind)

• Concluding Remarks & Adjournment

Dr. Peter A. Kavsak, Conference speaker

Notes on Psychiatry and the Role of the Clinical Laboratory

This article introduces o u r p r o f e s s i o n a l involvement in a fi eld

perhaps less generally well known to Clinical Biochemists from both medical and clinical perspectives, and yet so fascinating in my opinion. This is the fi eld of Psychiatry, which literally means the ‘treatment of the soul’. The actual term was coined in the beginning of the 1800s by a German physician who found his inspiration in the Greek word for soul, psyche. In modern times Psychiatry is the medical specialty for the study, diagnosis and treatment of mental disorders. Psychiatry is in fact a complex medical specialty as it represents a middle ground between psychology and neurology, requiring a sound knowledge of both social and biological sciences, in particular neurosciences.

But what is good mental health after all? What constitutes a mental disorder and what role can the clinical laboratory possibly play in this fi eld? In answer, please let me elaborate and share my professional viewpoint with you.

The term Psychiatry is closely related to terms such as mind and mood. These two entities infl uence the way a person thinks, reasons, feels, perceives and remembers. It is the brain that carries out all these functions. In layman speak, good mental health is nothing else but the ability to keep in touch with reality, e.g. the ability to handle day-to-day demands, including unexpected problems. In youth it

CSCC News • November 2014 5

is also the ability to integrate with peers and have positive feelings about appearance; in adulthood it is also the ability to retain life satisfaction through maintaining value systems, roles, activities and relationships. In mental illness these functions are affected and can lead to tragic outcomes. At the molecular level the symptoms of mental illness are the results of an altered state of neurotransmission and can be classifi ed into two main classes, positive and negative, leading to an elevated or to a depressed mood, respectively. In medical terms positive symptoms, which are associated with the dopamine receptors, translate into psychosis (literally meaning ‘diseased soul or mind’) and can manifest as hallucinations, delusions or illusions. It is important to understand what these different psychotic symptoms refer to. For instance, hallucinations are sensory perceptions for which there is no external stimulus – they can be auditory (e.g. one hears voices in his head), or visual, or even involve taste or touch. Mania is another example of positive symptoms that translate into mood elevation above the normal. At the other end of the spectrum are the negative symptoms, that are associated with the muscarinic receptors and in which depression is the dominant clinical picture, a feeling characterized by sadness, apathy, pessimism and a sense of loneliness.

If Vincent van Gogh (1853-1890) happens to be one of your favorite painters, then you’d know what a legend his life has become: early failed careers, frequent unstable moods and violent rages, combined with periods of high energy and creativity as an artist, before committing desperate gestures such as cutting his ear off and ultimately committing suicide at 37 years of age. Unfortunately he did not live to enjoy his success, yet his paintings have been among the most expensive ever sold. He is also known for the many letters he wrote to his brother, that have been of tremendous value to physicians including psychiatrists. He showed an incredible awareness of what was happening to him, and described in detail his feelings and his symptoms that included hallucinations, nightmares, stupor, absent mindedness, impotence, insomnia, and anxiety. He also smoked heavily, and frequently drank alcohol to excess, particularly absinthe (a very strong alcoholic beverage, derived from botanicals including Artemisia absinthium and claimed as being hallucinogenic). In retrospect, many competing hypotheses have been put forward about possible medical conditions he could have had, including: acute intermittent porphyria possibly exacerbated by malnutrition and absinthe abuse; lead poisoning presumably caused by excessive use of lead pigments in his work; bipolar disorder based on documented periods of intense activity interspersed with periods of exhaustion and depression; borderline personality disorder in keeping with impulsivity, variable moods, self-destructive behaviour, fear of abandonment, an unbalanced self-image, authority confl icts and other complicated relationships; temporal lobe epilepsy. There is speculation that the foxglove plant (Digitalis purpurea) used for treatment led to digoxin toxicity and may have been responsible for his painting of yellow halos around landscape objects.

For the movie fans, the life of the American mathematician John Nash and his struggles with paranoid delusions (schizophrenia symptoms) is excellently illustrated in the 2001 Hollywood movie ‘A Beautiful Mind’. Delusions are false beliefs, fi rmly held despite

of proof and logical arguments to the contrary. Allegedly, John described seeing himself as a messenger or having a special function in some way, and interestingly enough he even stated: "I wouldn't have had good scientifi c ideas if I had thought more normally." Hmm… not sure how to interpret this statement! Like Vincent, John was aware of his symptoms and the importance in overcoming and/or confi ning them one way or another.

For those with historical interests King George III of England is remembered as the ‘mad king who lost America’, however I will not venture into this political controversy. The King experienced recurrent episodes of illness (‘madness’), thought by many historians and scientists to have been due to porphyria, causing him to withdraw from daily business in order to recuperate out of the public eye. A more current school of thought is that the King’s symptoms match the contemporary description of the manic phases of bipolar disorder. For instance, during those times the King would write long sentences of hundreds of words and only a handful of verbs or have incessant verbosity, all an expression of an elevated mood. Of note, his illness did not stop him from reigning for 60 years and according to some historical records he is considered a successful king.

There have been many stories like Vincent’s, John’s or King George’s, famous people or ‘common folk’, old or young, real people or novel characters inspired by the life of those affected by mental illness. But what is most important is that the fi eld of Psychiatry and the reality of mental illnesses have come a long way, at least in western countries, and hopefully this progress will follow in all countries of the world. I was fortunate to join my current workplace, the Centre for Addiction and Mental Health (CAMH) in Toronto, and work at a time of profound transformation, when language has changed and the stigma is being removed. The psychiatric patient is not a ‘lunatic’ or ‘insane’ individual any longer, but a human being in need of medical attention and appropriate treatment, just as deserving as any other patient.

So, what is it that can lead to an ‘altered mind’? We know now that like many other diseases or disorders, impaired mental health has both primary and secondary causes. This is where the terms ‘Psychiatry’ and ‘Medical Psychiatry’ come into place, the former dealing with the primary causes, and the latter dealing with ruling out the secondary causes, but also with monitoring and managing the side effects of psychiatric medication.

The diagnosis of primary mental disorders is actually a complex process. What currently differentiates Psychiatry from other medical fi elds is that diagnosis of primary psychiatric disorders is still completely symptom-based – symptoms regarding thoughts, feelings and perception, behavior, and cognition. Diagnostic criteria are listed in established diagnostic manuals such as the Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the American Psychiatric Association, and the International Classifi cation of Diseases (ICD) published by the World Health Organization. There have been several DSM editions, the most recent one published last year (DSM-5). Its development was expected to be of signifi cant interest to many medical fi elds. It was subjected to much criticism, which is most likely an expression of the gaps we currently have in our understanding of mental illness

CSCC News • November 20146

(actually, a very interesting debate to read and reflect upon). Diagnosing psychiatric symptoms may be needed in a variety of clinical and/or laboratory settings including community (medical office, community hospital), emergency departments, general hospitals (e.g. evaluating precipitating factors of side effects), specialized clinics (addiction clinics) or centers (such as CAMH in Toronto).

Today it is well recognized that psychiatric disorders cover a large array of illnesses, including but not limited to mood-, anxiety-, psychotic-, cognitive-, developmental -, and personality disorders; each of these diseases can present with variable degrees of severity. The role of the Clinical Laboratory in the diagnosis of primary mental disorders is currently limited, but very important for excluding secondary causes, as there are no validated markers for mental disorders. Eliminating possible medical causes for patients presenting with psychiatric symptoms is the fi rst and most crucial step in the evaluation process of psychiatric symptoms. A wide range of medical conditions and treatments may result in abnormal behavior, and many medical disorders may produce or exacerbate psychiatric symptoms in patients with pre-existing mental illness. Medical practitioners from various specialties and clinical laboratory specialists may need to work together, as failure to detect and diagnose underlying medical disorders may result in signifi cant and unnecessary morbidity and mortality. General medical conditions, neurodevelopmental conditions, and substance-related conditions, including drugs of abuse, prescriptions drugs or drug-drug interactions should all be considered a part of a differential diagnosis for psychiatry symptoms. Depression can be caused or exacerbated by medical conditions such as celiac or polycystic ovary disease. A long list of diseases can cause or exacerbate psychosis: collagen vascular diseases, endocrinology disorders, hematological conditions (such as anemia), infectious diseases, and neurological as well as toxicological conditions. Hyperthyroidism or Cushing Disease may present with manic symptoms, and needs to be ruled out or managed accordingly. Some medical disorders are much more common in psychiatric than in the general population, such as porphyrias. Attention is also needed to the side effects of some prescription drugs. Topiramate, a well-known anticonvulsant, can cause delusional parasitosis (e.g. a fi rm belief that the skin is infected by parasites). The NSAID indomethacine can cause psychosis in the elderly or postpartum. PCP, cocaine and amphetamines are all known to induce drug-related psychiatric disorders and need to be considered in a differential diagnosis.

I fi nd some effects of emotional or mental stress on the body quite impressive; such stress can also lead to physical diseases known as ‘psychogenic diseases’. One such disease is pseudocyesis or else false or phantom pregnancy in which there are clinical signs or symptoms of pregnancy (amenorrhea, morning sickness, weight gain, sensation of fetal movement), but there is no pregnancy in reality. A man (partner) can also experience false pregnancy symptoms; the condition is known as sympathetic pregnancy or Couvade syndrome. Historically, Mary Tudor, Queen of England and Ireland (1516–1558) was suspected to have had two phantom pregnancies, though later disputed. It is possible however given the pressure she was under to produce an heir (she never did, thus

opening the door for her half-sister, future Queen Elizabeth I). A number of routine and/or specialized tests are relevant to

the psychiatry fi eld. For instance urea elevation in renal failure is associated with a range of psychiatric signs and symptoms, from fatigue, lassitude and somnolence, to an acute confusional state and delirium (an acute change in mental status); seizures can also occur. Laboratory investigations on various psychiatric signs and symptoms can also include serum calcium; abnormal calcium level is associated with irritability, anxiety, depression, fatigue, lethargy, weakness, apathy, loss of appetite, delirium, polyuria, polydipsia, bone pain, and cardiac toxicity (QTc prolongation and dysrhythmia). In patients with eating disorders, low calcium levels can result from chronic use of laxative abuse. Various psychotropic drugs (lithium, phenobarbital; carbamazepine, phenytoin) can affect calcium level. Several psychiatric and psychotropic- related conditions result in blood gas abnormalities. Patients with CO2 retention because of the COPD can develop severe somnolence or confusional states, particularly after a sedative such as benzodiazepine is given. In anxiety states, hyperventilation is both a cause of respiratory alkalosis and a symptom of the condition. In these patients, hyperventilation can be accompanied by paresthesia, muscle twitching and spasm, dizziness, palpitation and seizures. The patient may become panicked, with further escalation of symptoms. Opioid and barbiturates overdose causes under-breathing and respiratory acidosis. ACTH, which drives corticol production, is increased in persons under stress or using amphetamines, steroids, alcohol or lithium; excess or defi cient cortisol causes symptoms that could be mistaken for primary psychiatric disorders. BNP or NT-proBNP testing is indicated in the older patient reporting excessive fatigue and inability to perform usual activities, symptoms that could be related to congestive heart failure but sometimes mistaken for depression.

The treatment of primary psychiatric disorders has come a long way in terms of developments and outcomes. Understanding the very root cause of a disease is of course essential for effective treatment, but is very much still a ‘work in progress’ for many disorders. Meanwhile treatments are based on existing means, observations and/or accidental discoveries. Prior to the 1930s, there were few treatments to offer. Severely disturbed psychiatric patients were of course of most concern, and for which no more than custodial care, sedation and some social support was available. Psychiatric symptoms are by no means specifi c to modern times, as they have been known since earlier times, but it wasn’t till the early decades of the 20th century that a major revolution in the understanding and treatment of mental diseases occurred. Two theories dominated the psychiatry fi eld at the beginning of the 20th century: the psychological or talk theory as espoused by Freud, an Austrian physician, and the biological theory as espoused by Kraepelin, a German physician. The "psychological school" of Freud interpreted mental disease as being due to deviations in the personality, problems in childhood, or other disturbed internal drives caused by external factors. The "biological school", instead, took a more scientifi c approach to mental diseases, particularly the psychoses; they were hypothesized as being caused by pathological alterations of the brain, chemical or structural, and were classifi ed into manic depressive and schizophrenia.

CSCC News • November 2014 7

Current evidence supports the ‘biological school’ and today it is known that psychiatric disorders are highly heritable and are complex genetic disorders. Genes affecting neural circuitry exhibit epistasis (gene-gene interactions) and epigenetic mechanisms (histone modification, DNA methylation) mediate risk for schizophrenia, depression and neuropsychological functions. For example methylation in the glucocorticoid receptor can explain the link between childhood trauma and adult depression.

In search for adequate treatment for mental illnesses, the observation that high fever, convulsions and head trauma improved mental disturbances played an important role. Hippocrates was the fi rst to note that malaria-induced convulsion benefi ted the ‘insane’ patients. A similar phenomenon was also observed by Middle Ages physicians in patients in (then-called) ‘insane asylums’ after a severe bout of fever due to cholera. Along the centuries many physicians have noted that there are very few epileptics who are also schizophrenic, and a biological theory on the incompatibility of convulsions and mental disease slowly evolved. The observation that insulin overdose can cause convulsions was the foundation for the insulin shock technique around the 1930's (today abandoned) to treat psychosis, particularly in schizophrenia patients. The use of electricity to induce convulsions has been of interest to physicians for centuries and led to better outcomes than chemical means. This concept is illustrated by the technique now known as electroconvulsive (formerly electroshock) therapy (ECT), which had its ups and downs since its introduction in 1938, but it is still in use today for treatment of depression (including at CAMH, Toronto) when other treatments have failed. Its safety, in terms of risks for memory loss, has been dramatically improved being currently performed under muscle relaxation to prevent musculoskeletal injury, short-term general anesthesia and overall highly controlled setting. Succinylcholine is the drug of choice for neuromuscular blockade, and patients in whom its use is contraindicated (plasma cholinesterase genetic variants) receive rocuronium or other nondepolarizing agents. Pre-ECT laboratory investigations include CBC, serum electrolytes and renal function tests; PT and PTT for those on anticoagulants; sickle cell screening in black patients.

Two writer personalities subjected to ECT for depression were Ernest Hemingway (1899-1961) and Sylvia Plath (1932-1963). Sadly both committed suicide.

The pre-frontal lobotomy (psychosurgery) has long been abandoned but deserves appreciation for its concept as well as its contribution to the patient care for which it received the Nobel Prize in 1949. This neurosurgical procedure was based on medical case studies showing behavioral changes following damage to frontal lobes. The purpose of the operation was to reduce the symptoms of mental disorder, but this was accomplished at the expense of a person's personality and intellect loss. Rosemary, the sister of the US President JF Kennedy, apparently underwent a lobotomy in 1941 at age 23, which left her permanently incapacitated. American playwright Tennessee Williams’s older sister Rose also received a lobotomy which left her incapacitated for life; the episode seems to have inspired the character Laura in his famous play The Glass Menagarie, also adapted in two well-directed Hollywood movies. Following the introduction of chlorpromazine in the mid-1950s

lobotomy underwent a gradual but defi nite decline.Chlorpromazine is the drug that revolutionized the psychiatric

field. It was accidentally but luckily identified as powerful antipsychotic during the search for new anti-histaminic drugs launched by a French pharmaceutical company, thus opening a new era in the treatment of mental illness. The impact that it had on emptying the psychiatric hospitals has been compared with the impact of penicillin on infectious diseases. Not only had chlorpromazine a good sedation effect (then referred to as ‘sedation without narcosis’), but also dramatically improved the thinking and the emotional behavior of the patients. As chlorpromazine was an effective but not perfect drug, leading to a number of extra-pyramidal side effects, a number of other antipsychotics (as well as antidepressants) continued to be discovered, but chlorpromazine has remained a benchmark in the treatment of schizophrenia.

Clozapine is another drug that made history in psychiatry. Binding to both serotonin and dopamine receptors, this is the fi rst atypical antipsychotic introduced in Europe in early 1970s but withdrawn four years later due to the dangerous side effect of agranulocytosis. Amazingly, clozapine has remained the only drug that proved effective in treatment-resistant schizophrenia, and was reintroduced on the market some 25 years later, and approved by the FDA in 2002. Due to its side-effects in some patients, particularly agranulocytosis, the drug is used today only in patients who have not responded to other anti-psychotic treatments. The clinical laboratory plays an important role in monitoring hematological parameters, including WBC, to prevent clozapine-induced agranulocytosis. A more recently identifi ed side-effect that can also be fatal is myocarditis, which usually develops in the fi rst month of treatment and manifests as fever possibly accompanied by infections of the upper respiratory, GI or urinary tract. Current monitoring guidelines advise checking CRP (C-Reactive protein) and troponin at baseline and weekly thereafter during the fi rst month while observing the patient for signs and symptoms of illness. Weight gain and diabetes are also notable side effects of clozapine, and routine metabolic monitoring of patients on clozapine with a lipid panel and HbA1c is essential.

Other classes of psychiatric medication include: antidepressants, mood stabilizers, antipsychotics, anxiolytics, and stimulants.

Monitoring patients on antipsychotics also includes measuring the serum concentrations of the drugs. Such tests are currently not commercially available and in-house method development by the clinical lab is required, using specialized techniques such as HPLC or LC-MS/MS with or without solid phase extraction. Our laboratory continues to develop new tests as new drugs are added and/or researched in treatment protocols; the latest developments have been methods for aripiprazole, paliperidone, citalopram enantiomers and buspirone.

Of note, psychotherapy (talk therapy) has remained an important component of mental illness treatment (particularly depression), in keeping with Freud’s theory. In other words, it’s not all about electric shocks and/or drugs, highlighting once again the complexity of the brain. Talk therapy is an effective psychological treatment, and takes various forms depending on its aim, e.g. helping to change the way one thinks and/or behave and focusing on dispelling negative thoughts (cognitive behavioral therapy); analyzing social

CSCC News • November 20148

relationships (interpersonal therapy); looking at the origin of diffi culties (psychodynamic therapy) or providing counselling (counselling therapy). Talk therapy combines art and science, and in this respect I recommend you watch the Don Juan DeMarco movie and enjoy the psychiatric approach to the character’s delusions as well as the memorable play by Marlon Brando (psychiatrist) and Johnny Depp (a would-be 21 year old suicidal patient).

The psychiatric fi eld continues to expand, as does the supporting role of the Clinical Laboratory. Modern diagnosis and treatment options for mental illness, in its various forms, preceded a full understanding of underlying pathophysiologies, explaining why for many decades there has been a paucity of major developments in treatment. However, signifi cant efforts have been made by both independent and consortium research groups toward this goal of trying to identify specifi c brain regions and/or specifi c genes involved in the pathobiology of various mental illnesses. In 2007, a multi-institutional collaboration was established known as the Schizophrenia Working Group of the Psychiatric Genomics Consortium (PGC). A genomic study recently released by the consortium, in which CAMH researchers also participated, identifi ed over 100 locations in the human genome associated with the risk of developing schizophrenia. Not surprisingly, a more clear understanding of the genetic basis of mental illness may lead to disease reclassifi cations and/or new treatment approaches. Schizophrenia, bipolar disorder, major depression, autism, and ADHD are currently thought to be distinct but a recent NIH study has shown that they may share genetic risk factors – in particular two genes involved in regulating calcium flow into neurons, CACNA1C and CACNB2. While genetic factors are defi nitely important in identifying causes of mental disorders, environmental, behavioral and social factors that contribute to mental illness should not be overlooked. No less important, pharmacogenetics studies hold promise for personalized administration of psychiatric pharmacotherapy, thus contributing to better treatment response and reduced side effects. Analyses of CYP2D6 and CYP2C19 mutations, two genes commonly involved in antidepressant and antipsychotic metabolism hold promise to help physicians in choosing the most effective medication to treat mental illness. Therapeutic drug monitoring of antipsychotics is also evolving, and guidelines are being developed as a greater understanding is gained about therapeutic windows, dose-concentration relationships and critical values of various drugs.

Finally, it is also important to know that humans, in general, actually exhibit a remarkable degree of ‘coping’, summed up by the word ‘resilience’. This means that in the face of extreme stress (remember the Life of Pi?) most resist the development of psychiatric disorders.

I do hope that I was able to pique your interest and show the role of the clinical biochemistry in Psychiatry. If you visit the CAMH website you’ll be able to fi nd impressive patient recovery stories all pointing in one direction: our efforts as professionals are worthwhile and, most importantly, from a patient’s viewpoint make their life worth living!

Dr. Cristiana StefanCentre for Addiction and Mental Health, Toronto

Guidelines for writing your abstract

The organization of the CLMC 2015 Meeting in Montreal is well underway. This means that the Abstract submission season is open!

Having been on various abstract reviewing committees over the years, I have seen many proposals that were of great interest but looked as if they had been written in fi ve minutes just before the deadline! Many of these abstracts would probably have been rejected if the reviewers had applied some very basic rejection rules. These rules are indicated in the Abstract Submission Process: Please take a couple of minutes to read them. If you have questions, do not hesitate to contact Head Offi ce by phone or email to obtain the necessary information.

One of the most frequent problems is the length of the abstract. The abstract paragraph (i.e. excluding the title and author(s) affi liation should not be more than 250 words and should be shortened if one or a maximum of two fi gures or tables are included. In a world where all word processing software come with word counting capacity, it is very surprising to receive up to 500 word long abstracts! In many instances, authors did not reduce the length of the abstracts to accommodate an inserted table or fi gure. In such cases, the abstract length must be reduced by 50 words for each fi gure or table. The fi gure must fi t and be legible within a 3.5 inch column! It is so simple to check this by looking at a print of your proposal using the imposed font of Times New Roman or Arial, size 10pt.

The Structured Format is generally well followed although there is sometimes confusion between the Results and Conclusions. In many cases, the results section does not contain a single numerical value making it very diffi cult for the reviewer to have a clear idea of the quality of the work. Remember that awards including travel awards are selected largely based on the abstract!

Poster sessions are a highlight of our annual meeting and constitute a great way to make contact with people sharing similar interests. Unless you accept to write a full length paper, the abstract per se will remain the only trace of your work appearing in a peer reviewed journal. Please make sure that the abstract is at least as good as the rest of your work!

Dr. Ramond LepageChair, CSCC Abstracts CommitteeCLMC Meeting 2015, Montreal

CSCC News • November 2014 9

The Archives Corner

Marking the 20th anniversary of the CSCC’s Archives Committee

Following several years of suggestions, coaxing and perhaps even some (diplomatic?) nagging, CSCC Council in January 1994 created an Archives Committee. The names of the members appointed to the original committee need little introduction to readers of this column – the Committee was composed mainly of founding members: Drs. Abram Neufeld, located fi rst at Queen Mary Veterans’ Hospital in Montreal, Quebec, but later

at Victoria Hospital in London, Ontario; Reuben Schucher, who was for the bulk of his career at the Jewish General Hospital in Montreal; David B. Tonks, of the Laboratory Centre for Disease Control in Ottawa when CSCC fi rst began in 1956 and then at Montreal General Hospital; and Allan G. Gornall, of the Dept. of Clinical Biochemistry at the University of Toronto. The only non-founding member and serving as the Committee’s Chair was Arlene Crowe, who had been at Hotel Dieu Hospital in Kingston, Ontario until 1992-93, since which time she has enjoyed an active retirement in Calgary, Alberta.

The Committee fi rst met at the annual national conference in Quebec City in 1994, and laid out an agenda to attempt to ensure that CSCC’s important archival documents were all in good order. The most important records, such as Membership Lists, consecutive versions of the Constitution and By-Laws, Minutes of Annual General Meetings and Council Meetings, had been maintained from CSCC’s earliest days, particularly by Dr. Tonks who had served on Council for the Society’s fi rst ten years. Greater concern was expressed for how complete were lesser proceedings, such as CSCC committee meeetings, during the period from 1956 to 1969 when CSCC had no professional business management and paper fi les were merely slightly pruned by the offi cer on Council completing his/her term of offi ce before being passed along to the new person stepping into that position. From 1969 onward, CSCC experienced enormous benefi t from business management fi rst by the Chemical Institute of Canada in Ottawa, secondly by Nason and Associates in Toronto (1981-1987) and thirdly by Elizabeth Hooper and her staff at Events & Management Plus in Kingston, the highly valued

and stable relationship CSCC enjoys to this day.It was on the occasion of CSCC’s 40th anniversary, when

the Annual National Conference was held jointly with AACC in Chicago, that the Archives Committee first made a major contribution to marking a special anniversary year. Each issue of CSCC News that year featured an article of reminiscences by one of the Committee’s founding members, and also “News and Notes” from emeritus members across the country. From time to time since then, the Archives Committee has had a display in CSCC’s booth in the Exhibits area – on one occasion the display was of the covers of the Program from the several meetings held jointly with AACC, and also included a few photographs with viewers being invited to identify members of either AACC or CSCC who unfortunately had escaped being named. In 2007 the CACB’s framed Crest was shown for the fi rst time at both the CSCC and CACB AGM’s and in the Exhibits area during the conference.

Unquestionably, the Committee’s major contribution to CSCC’s archival records was the interviews with “elders” (to quote the term coined by Trefor Higgins), who were mainly but not exclusively founding members, videotaped between 1998 and 2004, from which excerpts were used for the 50th anniversary video shown at CSCC’s annual national conference held in Victoria, BC in 2006. The video was the magnifi cent work of David R. Tonks, son of our own David B. Tonks. Current Chair of the Archives Committee, Dr. Christine Collier, hopes to continue videotaped interviews of long-time CSCC members. In the lead-up to CSCC’s 60th anniversary, the Archives Corner column will treat readers to more detail from the videotapings that didn’t make it into the excerpts used in the 50th anniversary video.

Dr. Arlene Crowe, Archives Committee

The XIIIth International Congress of Pediatric Laboratory Medicine (ICPLM)

The XIIIth International Congress of Pediatric Laboratory Medicine (ICPLM) took place in Istanbul, Turkey, June 20-22, 2014, and drew more than 200 registered participants from over 40 different countries. The Congress, a satellite meeting that preceded the IFCC WorldLab, took place at the same venue. Four Plenary Lectures and twelve Symposia offered more than 30 speakers, and presentations were well acclaimed. The symposia on nutrition, cancer, reference intervals, and panel discussion included speakers from McMaster University and Hospital for Sick Children. Our own CSCC members in attendance as delegates, speakers and/or organizers included: Andrew Don-Wauchope, Joseph Macri, Li Wang, Khosrow Adeli, Vijaylaxmi Grey (chair of the congress). Additionally, more than 50 scientifi c posters were exhibited across the spectrum of pediatric laboratory medicine. Li Wang (BC Children’s hospital) was one of 2 poster award winners. Jakob Zierk of Germany was the second winner.

Under the dynamic leadership of the IFCC Task Force of Pediatric Laboratory Medicine, Chair Vijay Grey (Canada),

CSCC News • November 201410

Past Chair Klaus Kohse (Germany), Vice-Chair Michael Metz (Australia), and members Tim Lang (UK), Patti Jones (USA), Sharon Geaghan (USA), the ICPLM raised enough monies from both sponsorship and registration fees, to make this a fi nancially successful Congress. The CSCC was generous not only in its sponsorship support but also the publication of the proceedings of the congress in Clinical Biochemistry. We thank Pete Kavsak and the editorial staff of Clinical Biochemistry for their efforts. Other national societies also contributed monies towards speakers.

If you weren’t fortunate enough to attend, the short papers proffered are to be found in a special edition of Clinical Biochemistry (Volume 47, Issue 9, Pages 691-864 (June 2014) http://www.sciencedirect.com/science/journal/00099120) devoted to the XIIIth International Congress of Paediatric Laboratory Medicine, thanks to the work of Guest Editors, Vijaylaxmi Grey and Klaus P. Kohse, Tim Lang and Michael Metz.

The XIVth ICPLM will be held in Durban, South Africa, October 2017. Do plan to be there, the preparation has already begun. Pediatric Laboratory medicine is more than about little adults!

Thanks to Elizabeth Hooper and the CSCC offi ce for all the postings about the XIIIth ICPLM 2014 meeting.

Dr. Vijaylaxmi Grey.

Dr. Chris McCudden, a clinical biochemist from Ottawa Hospital, is listed in Clinical Chemistry as the author of one of the Top Most downloaded “Pearls of Laboratory Medicine”, for his short article on vitamin D.

Pearls of Laboratory Medicine are short 5-10 minute peer-reviewed presentations, each about a particular analyte available to members of the Clinical Chemistry Trainee Council. Pearls are available in English, Chinese, Spanish and Portuguese. Register for the Trainee Council at www.traineecouncil.org.

News fromCSCC Head Office

Accreditation for a MeetingApplications to have your conference/meeting accredited by CACB will now take place online.

To apply for accreditation, notify the CSCC Head Offi ce that you wish to apply. You will be sent instructions on how to access the program.

All applications will now be electronic.

‘Boot Camp’ for Oral ExamsA CACB exam preparation course will be held in Toronto the weekend of April 11-12, 2015. The course will be offered to trainees who will take the oral exam next June in Montreal. Dr. Steve Hill is heading up the faculty and planning is underway.

Entering your 2014 PD Credits – 2014 ChangesWhy not get your PD credits in order now, rather than waiting until the deadline of February 28, 2015? All Fellows need to record a minimum of 25 credits a year to be in good standing, plus 150 PD credits with credits in at least 3 categories over the period 2012-14.

Please note that employment is no longer considered eligible for credits. Category 5 is now solely for Service-associated Learning, for example committee work/journal reviewer. As back-up proof you will need to provide a letter or email of invitation to do the service or meeting minutes indicating your presence.

Categories 6,1 and 6.2 are consolidated into a single category 6 with an expanded scope for “Teaching in Laboratory Medicine” with 2 credits for every hour claimed. Go to the chart at Academy/Professional Development to see a full chart of credit categories, examples, and documentation necessary if you are audited.

25 Fellows will again be audited for the credits they claimed in 2014, as chosen by a random draw. To avoid having to scramble to fi nd the documentation, why not collect it as you go along?

Those credits that are entered through the CE Code Entry system on the website do not need back-up. Your proof of attendance is provided by supplying the attendance code from the session.

Check out the Website’s New LookThe website has been changed! If you have ideas for useful additions to the website, send us an email at offi ce@eventsmgt.com

CSCC News • November 2014 11

J O B # 2 7 3

CSCC News • November 201412

The CSCC News is published bimonthly by the Canadian Society of Clinical Chemists and distributed to the members by the Society. Letters to the Editor must be signed and should not exceed 200 words in length. Chairs of Committees and Local Sections are requested to submit announcements and reports of activities.

Deadline for Submissions:

December 31 January issueFebruary 28 March issueApril 30 May issueJune 30 July issueAugust 30 September issueOctober 30 November issue

Notices from members seeking employment may be inserted without charge, and box-number replies may be arranged. Notices from institutions will be invoiced at $150 and include a notice on the website on the Job Opportunities page.

Views and reports appearing in CSCC News do not necessarily have the endorsement of the Society. Address general communications to the Editor care of the CSCC Head Offi ce.

Editor in Chief: Dr. Mary-Ann Kallai-Sanfaçon

Associate Editors: Dr. Cheryl Tomalty, Dr. Kareena Schnabl

Publication Offi ce:

CSCC News

C/o CSCC Head Offi ce4 Cataraqui St., Suite 310, Kingston ON K7K 1Z7Tel: 613-531-8899 • Fax: 613-531-0626offi ce@cscc.ca

CALENDAR OF EVENTS

2014-2015 Executive & Council of the CSCC

President David Kinniburgh 2013-2015President-Elect Andrew Lyon 2013-2015Secretary Stephen Hill 2012-2015Treasurer Ivan Blasutig 2014-2017Councillors Isolde Seiden Long 2014-2016 Vathany Kulasingam 2013-2015 AbdulRazaq A.H. Sokoro 2013-2015

Division Heads:

Education & Scientifi c Affairs Allison Venner 2013-2016Professional Affairs Julie Shaw 2013-2016Publications Curtis Oleschuk 2012-2015Executive Director Elizabeth Hooper

2014-2015 Board of Directors of the CACB

Chair Sheila Boss 2014-2017Secretary Lianna Kyriakopoulou 2012-2015Chair, Accreditation Annu Khajuria 2012-2015Chair, Certifi cation Mary-Ann Kallai-Sanfaçon 2013-2016Chair, Credentials Cheryl Tomalty 2014-2017Chair, Maintenance of Competence Paul Yip 2013-2016Liaison, Nominations & Awards Ihssan Bouhtiauy 2013-2016Committees

If you would like to announce your meeting, please send at least 3 months in advance to offi ce@cscc.ca

January 29-30, 201513th Cytokines & Infl ammation ConferenceParadise Point Resort & Spa, San Diegohttps://www.gtcbio.com/conferences/cytokines-infl ammation-agenda#day2

March 20-12, 20153rd EFLM-BD European Conference on Pre-analytical PhasePorto Palácio Hotel, Porto, Portugal - http://www.preanalytical-phase.org

June 20-24, 20152015 CSCC-CAP Joint Annual Conference (Canadian Laboratory Medicine Congress (CLMC)Clinical Biochemistry on the MoveWestin Montréal Hotel, Montréal Quebec - http://www.clmc.ca/2015/

June 21-25, 2015Euromedlab Paris 201521st IFCC-EFLM Congress of Clinical Chemistry and Laboratory MedicinePalais des congrès, Paris - http://www.paris2015.org/

June 29-July 1, 2015International Society for Enzymology Annual Conference 2015Corfu Greece - ediamandis@mtsinai.on.ca

July 26-30, 20152015 Annual Meeting & Clinical ExpoAACC, Atlanta Georgia

October 11-15, 201514th International Congress of Therapeutic Drug Monitoring & Clinical Toxicology 2015Rotterdam, the Netherlands - http://iatdmct2015.org/

T H A N K S T O O U R C S C C N E W S S P O N S O R S !

Season’s Gre� ings� om the

CSCC Editorial Board