From the depths of the ocean to deep space, the same type of medical treatment given to divers for the bends may prove useful to astronauts during the construction of the international space station, says Richard E. Moon, an anesthesiologist from Duke University Medical Center, Durham, N.C. The bends, also known as gas bubble disease or decompression sickness, occurs when divers, aviators, or astronauts move too quickly from higher to lower atmospheric pressures.

Working outside the international space station in spacesuits elevates astronauts’ risk of decompression sickness, Moon indicates, since the transition from the stations to a space suit rapidly lowers the pressure to which the astronaut is exposed by two-thirds. Nitrogen exhaled under pressure dissolves in the body, but when pressure decreases too rapidly, nitrogen collects in tissues faster than the body can process it. The gas accumulates in joints and blood vessels, forming bubbles that impair oxygen flow to tissues. This causes severe pain, numbness, weakness, and, in some cases, paralysis.

“Although we know of no cases of decompression sickness in space, the number of extravehicular activities (EVAs), even with the Russian program, has been fairly small,” Moon points out. “Cases of decompression sickness in space could occur as the number of EVAs soar into the hundreds during construction of the space station.”

Severe cases of decompression sickness can be fatal, but the illness is usually highly treatable early on. Treatment primarily consists of having the patient breathe 100% oxygen at higher than normal atmospheric pressure inside an enclosed space called a hyperbaric oxygen chamber. The oxygen washes the nitrogen out of the body. There are two types of hyperbaric oxygen chambers: multiplace (holding more than one person) and monoplace (holding a single patient). The multiplace chamber is a large sphere or cylinder about 20 feet in diameter. A doctor or nurse accompanies the patient into the chamber, where the patient inhales oxygen through a head tent or a tightly fitting mask.

Treatment can consist of one to as many as 20 sessions, depending on the severity of the illness. Hyperbaric oxygen therapy also is used to treat patients with carbon monoxide poisoning, smoke inhalation, wounds in areas that have received radiation treatment or have impaired blood supply, and severe infections that destroy tissue.

“We could eliminate the risk of gas bubble disease by having the astronauts breathe pure oxygen for 24 hours, but they don’t have the time,” Moon explains. “Exercising while prebreathing offers a timesaving way to increase blood flow to the tissues and flush out nitrogen. We now know that the gas bubbles not only block the body’s absorption of oxygen, but that they also damage the lining of the blood vessels.” Damage to the endothelium–or blood vessels–then causes the white blood cells to stick to the linings, which, in turn, further reduces blood flow to the tissues for the next two to three hours. “We believe hyperbaric oxygen prevents white blood cells from sticking to the endothelium.”

Scientists know the effects of cocaine on the adult brain and cardiovascular systems, but what about the effects of prenatal exposure on infants? A study by Case Western Reserve University School of Medicine, MetroHealth Medical Center, and University Hospitals of Cleveland (Ohio) followed 415 cocaine-exposed infants to determine how prenatal cocaine exposure affects child development outcomes. They were compared to nonexposed infants on cognitive and motor development until age two. Cocaine exposure does affect a child’s cognitive development, but not motor development, they found.

Mothers and infants were recruited over a two-year period from a high-risk population screened for drug use. Urine samples were obtained immediately before and after labor and delivery, and analyzed for the presence of cocaine metabolites, cannabinoids, opiates, PCP, and amphetamines. Urine tests for drugs were performed on all women who received no prenatal care, appeared to be intoxicated or taking drugs, had a history with the Cleveland Department of Human Services in previous pregnancies, or self-admitted or appeared to be high risk for drug use according to interviews by hospital staff. Meconium was collected from infants’ diapers and screened for drugs.

Researchers found that, for all trimesters, cocaine-using women availed themselves of alcohol, marijuana, and tobacco more frequently and in higher amounts than nonusers. Those who used cocaine were found to be older, had more children, and were less likely to have had prenatal care. They also were less likely to be married; had lower vocabulary, block design, and picture completion scores; and registered higher psychological distress scores. The study found that cocaine-exposed infants had lower gestational age, birthweight, head circumference, and length than nonexposed babies. There were more preterm, low-birthweight, and small-for-gestational-age infants in the exposed group. The rate of mental retardation in cocaine-exposed children at age two was 4.89 times higher than expected in the general population, while the percentage of youngsters with mild delays requiring intervention was almost double the rate of the high-risk noncocaine group.

Lynn Singer of the Case Western Reserve Department of Pediatrics cautions that the team is concerned that the study data will be misinterpreted and used to punish women or to remove children from their families. “Prosecution of women will not address the problems of alcohol and drug abuse. In fact, our study indicates that tobacco exposure also has significant negative effects on infant development. Our findings also indicate that the quality of stimulation and environmental intervention can have a large effect on children’s mental development independent of cocaine or other drug exposure.”

Artificial vision for the blind was once the stuff of science fiction. Now, however, a limited form of artificial vision is nearing reality. The Dobelle Institute, Commack, N.Y., is working on creating a new cornea–which will allow light into the eye’s interior–through technology. It is using a digital camera mounted on glasses to capture an image and send it to a small computer on a patient’s belt. The images are processed and sent to electrodes implanted in the patient’s visual cortex. The electrodes stimulate the brain, producing a pattern of bright spots that form an image. The technology “may not work for people blinded as children or as infants, because the visual cortex did not develop normally,” explains Bill Dobelle. “But, I would say [it will work] for the vast majority of the blind–98 to 99%.”

The black-and-white image is not solid, but resembles a dot matrix pattern. It’s like looking at a sport scoreboard with different light patterns illuminated to show different scores. Miniaturization of equipment and more-powerful computers has made this artificial vision possible, but it is expensive. The operation, equipment, and necessary training cost $70,000 per patient. Eight experimental surgeries have been performed in Portugal, but the U.S. Food and Drug Administration has not yet approved the procedure.

Other researchers are focusing on new technology to replace damaged retinas, the part of the eye that converts light into electrical impulses that are sent to the brain to be turned into images. Optobionics Corp., Wheaton, Ill., says six blind or nearly blind people can now see light and some can see shapes after having its artificial retina implanted. NASA hopes to begin human testing this year on ceramic detectors that could be implanted in the retina to take over the job of damaged retinal cells. Meanwhile, the Office of Naval Research goes one step further, indicating it is on the way to developing a chip that would replicate the entire nerve center of the retina.

This practical resource from the American Humane Association answers frequently asked questions about the medical aspects of child abuse and neglect. Designed for the nonmedical professional unfamiliar with medical terminology, the third edition translates injuries into clear language for child protective services workers working with medical providers. Thoroughly updated to reflect the latest research on child abuse and neglect, this edition covers burns, fractures, poisoning, sexual abuse, neglect, substance abuse, and family violence. Chapters also highlight the working relationship between CPS workers and medical providers, the importance of understanding differential diagnoses, and techniques to ensure culturally responsive practice. A wealth of charts, illustrations, checklists, and resources make this an accessible reference for any nonmedical professional working with children and families, and it can be used as a training tool and resource. The companion website contains additional materials for supervisors and staff, including photographs, protocols, relevant articles, memoranda of understanding, and useful links.

This study is currently recruiting patients. Sponsored by National Cancer Institute (NCI). This protocol is concerned with the acquisition of blood, skin, and mucosal samples from normal volunteers to support the basic science research activities of the Dermatology Branch.

The research assessment exercise has resulted in substantial reductions in funding to some medical schools and has led to a loss of status for teaching compared with research

The exercise has undervalued clinical and health services research and disadvantaged highly specialised and multidisciplinary research

It also promotes a short term approach to research and is expensive to operate

Proposed changes for the exercise in 2001 should help address these problems, but the fundamental review of research policy and funding by the funding councils provides an opportunity for innovative change

In 1999-2000 the Higher Education Funding Council for England will distribute over 855m [pounds sterling] for research, virtually all of it according to the quality and amount of research done. Quality is assessed through a periodic research assessment exercise. Research is funded selectively so that universities and colleges with high quality research departments get a larger share of the money. The first research assessment exercise to cover the entire higher education sector was undertaken in 1992, the last one was in 1996, and the next will take place in 2001. The research community now has an opportunity to influence the way in which quality of research is assessed after the exercise in 2001 because, from now until autumn 2000, the funding councils for England, Scotland, Wales, and Northern Ireland are undertaking a fundamental review of research policy and funding.

Each higher education institution is allocated a block grant that includes quality related research funding. This quality related funding provides money for the infrastructure of research–helping to cover the costs of the salaries of permanent academic staff, premises, and central computing–while research charities and funding councils provide for direct project costs and contribute to indirect project costs. The quality related research funding is thus the core funding for the university research base and is allocated by the funding councils according to the quality rating of each unit of assessment.

The research assessment exercise

For each clinical unit of assessment, the parent university makes a submission which is given a quality rating after being judged against standards of national and international research excellence. The quality of research submitted for each unit is assessed by a panel of practising researchers in the subject and is based on the quality of publications, numbers of research assistants and research studentships, and income from research grants, particularly peer reviewed funding (such as that from the Medical Research Council and the Association of Medical Research Charities). The panel also seeks evidence of the vitality of the department and its prospects for continuing development. Quality is rated on a seven point scale, from 1 at the bottom through 2, 3a, 3b, 4, and 5 to 5* at the top. A rating of 1 is defined as research quality that equates to attainable levels of national excellence in none or virtually none of the sub-areas of activity, whereas 5* is defined as research quality that equates to attainable levels of international excellence in most sub-areas of activity and attainable levels of national excellence in all others.

Within the funding system as a whole weightings are given to each broad area of research so that, for example, laboratory and clinical subjects receive more funding than the humanities. The total funding for a given subject is calculated by multiplying the funding associated with the quality rating by the volume of research in that subject. Volume of research in each unit of assessment is measured according to five separate components–numbers of academic staff active in research, research assistants, research fellows, and postgraduate students and research income from charities. The number of academic staff active in research is the most important measure of volume and accounts for up to two thirds of the total. Quality ratings 1 and 2 attract no funding, whereas a rating of 5* attracts about four times as much funding as a rating of 3b for the same volume of research activity. Thus the funding of research is highly selective. In 1998-9, 75% of research funds from the Higher Education Funding Council for England went to just 26 of the more than 100 higher education institutions.

Effect of the research assessment exercise on medical research

The three clinical units of assessment (clinical laboratory sciences, community based clinical subjects, and hospital based clinical subjects) are the most important units for medical schools, but the quality of research in other units from the 69 subject areas (including clinical dentistry, nursing, subjects allied to medicine, preclinical subjects, biological sciences, and biochemistry) will also affect the allocation of quality related research funding to universities that have associated medical schools.

In a report of an independent task force on clinical academic careers,[2] only six medical schools (out of more than 20) had at least one unit of assessment with a score of 5 or 5*. The report divided medical schools and postgraduate institutions into four bands and commented that the ratings of the 19 medical schools in the lower two bands were very disappointing, yet it also pointed out that Sir Robert May, the government’s chief scientific advisor, had written to the task force emphasising that he regarded clinical medicine as one of Britain’s research strengths, both absolutely and relatively. However, it is impossible to be certain about the comparative performance of Britain in medical research because the measures used by May were not the same as those used in the research assessment exercise.

Step right up, little lady, and get your serotonin selective reuptake inhibitors (SSRIs) to treat anything and everything that ails the mind and body–social phobias, eating disorders, insomnia, headaches and depression, to name but a few. This “medication,” guar-an-teed safe and efficacious by the phantasmagoria of federal science, is prescribed to reduce the symptoms of whatever ails you and to assure healthy and happier lives.

Ah, but caveat emptor, my friend! A recent study conducted by Arif Khan, medical director of the Northwest Clinical Research Center in Bellevue, Wash., and adjunct professor of psychiatry at Duke University School of Medicine, has revealed startling numbers of suicides committed and suicides attempted in the clinical trials for the new SSRI antidepressants–numbers that for years had been hidden from both prescribing physicians and the public.

Kahn has examined the official clinical drug-trial data for all SSRIs approved by the Food and Drug Administration (FDA) between 1985 and 2000, in which 71,604 participants in the clinical trials were treated with antipsychotics, all SSRIs and anticonvulsants. The rate of suicides in the general public is 11 in 100,000, which means an incidence rate for those participating in the SSRI clinical trials of nearly 68 percent–that’s 718 suicides for every 100,000. Kahn’s research further revealed that nearly 4 percent of SSRI drug-trial participants attempted suicide within the following year.

Because people with a history of suicide are excluded from drug trials, the dramatically elevated drug-trial numbers revealed by Kahn raise important questions. Given the large number of attempted and completed suicides among drug-trial participants, why were these drugs approved by the FDA? Furthermore, since the new SSRIs are approved to reduce risk among depressed patients, does this data require a re-evaluation of the efficacy and safety of SSRIs?

Asked what the FDA considers an acceptable number of deaths in clinical trials, Thomas Laughren, team leader for the neuropharmachological drug-products division of the FDA, tells INSIGHT, “Your question is not particularly pertinent because these trials are not designed to influence suicide. If you look at any one individual trial it is very unlikely you will find a suicide in the trial, and generally we don’t.”

You see, says Laughren, “It’s only if you accumulate data across a large number of trials that you even have enough data to look at. What you do see in individual trials is that patients who get drugs improve more than patients who get placebo. That’s what we see. When you do a meta-analysis across a large number of trials and you look at the other outcomes of suicide and attempted suicide, you don’t see any particular benefit from being assigned the drug compared to placebo.”

Which, of course, is the point. And Laughren further announced that “the drug is not approved for the treatment of suicide. They are approved for the treatment of depression. Dr. Khan’s findings and our findings suggest that these drugs that we’re studying and approving for depression don’t appear to have a benefit on the outcome of suicide. That is not to say that they don’t have a benefit in treating depression.”

The drugs don’t have a “benefit” on the outcome of suicide, which they in fact increase dramatically, but they do have a “benefit” for depression. How is this possible when in fact the clinical trials for SSRIs show the suicide rate increased by 68 percent?

“What this [increased suicide rate] would tell us,” says Laughren, “is that this is a serious condition, not a trivial condition. Depression is a serious condition. If you look at individual trials there are so few suicides that you wouldn’t be able to make sense of it all. It’s only after you look across multiple development programs over a very long period of time that you have enough events that you can get this kind of analysis.”

So, does this mean that FDA should wait longer periods of time before approving such drugs? “No,” says Laughren, “because the data are very clearly showing that these drugs benefit patients. What this tells us is that it is very difficult to exclude patients that are suicidal. As hard as you try you really are not able to predict who is suicidal and who is not. It [the trial data] does not tell us that being in clinical trials puts you at risk of suicide. It is not surprising to see a few suicides when you look at a fairly large number of patients, many of whom are followed for months or years.”

But the data show the suicide rate is elevated 68 percent when comparing SSRI participants to those given placebo and to the general population. So the question isn’t whether being in a clinical trial puts a person at risk, but whether a particular drug puts a participant in a clinical trial at risk. Besides, what good does it do to be declared officially less depressed if it means you are 68 percent more likely to kill yourself?.

And Robert Whitaker, author of Mad in America: Bad Science, Bad Medicine and the Enduring Mistreatment of the Mentally Ill, tells INSIGHT that, “Clinical trials are skewed against the placebo.” Basically, explains Whitaker, “What happens in these drug trials is that people who respond well are put into an extension of the trial. The point is that the longer people are kept on whatever arm they’re in–either placebo or drug–you expect suicide rates to drop over time. It’s only the good responders through the six-week trials that are put into the extension trials, and so it’s biased against the placebo because after six weeks no one is kept on to do extensions on placebo.”

WINNIPEG — Will expanded medical schools increase the supply of care by family practioners?

A study at the Manitoba Health Centre suggests that it will not. According to a study reported in the Journal of the Canadian Medical Association in August:

* Family practicioners between 30 and 49 years of age (64% of the workforce) provided 20% fewer visits per year than their same-age peers did 10 years previously.

* Conversely, FPS 60 to 69 years of age (11% of the workforce) provided 33% more visits per year than the corresponding group a decade earlier.

On a per capita basis, the number of FPS declined by 5%, from 97 per 100,000 population in 1991/92 to 92 per 100 000 population in 2000/01, which paralleled changes in national estimates of FP supply.

Per capita visit rates among Winnipeg citizens (3.5 per year in 2000/01) and average work-loads among FPS (4,193 visits per year in 2000/01) were stable over the decade.

“Given these data, the perpetual focus of policy-makers and care providers on increasing numbers of FPS will not help in diagnosing or treating issues of supply, workloads and access to care,” the article states.

Medical Apartheid: The Dark History of Medical Experimentation on Black Americans From Colonial Times to the Present by Harriet A. Washington Doubleday, December 2006 $27.95, ISBN 0-385-50993-0

For years, accessing the medical establishment has made blacks feel, well, ill at ease.

Now comes a well-researched text by a former award-winning health reporter, who reveals why: The roots of established medicine has fueled the black American health deficit and for decades has sparked blacks’ paranoia toward the health-care system.

As she weaves history, science and culture, Washington takes complex information and makes it reader-friendly. Her text traces the abuse, examines the pseudoscience used to exploit prisoners and black women and outlays how race and technology prey on black Americans today.

Her writing so pinpoint, she brings literary drama to describing how diseases vex the human body. Her narratives so crisp, she brings to wrenching life the abuse of blacks by the establishment.

For example, there’s J. Marion Sims, the first man credited with founding a hospital for women in New York. The backstory: his breakthrough in fistula treatment came out of his brutal research on enslaved black women.

Washington also reveals that blacks were used in teaching hospitals for amputations and other procedures and were seen as nothing more than bodies for clinical demonstrations.

Her best chapter comes as she revisits the syphilis experiment the United States Public Health Service performed in Tuskegee. With it, she exposes one of the most damaging encounters between blacks in the 20th century and the modern medical establishment. No, the health service did not give blacks syphilis, but the psychological fallout of the misguided experiment continues to taint African American views of medicine.

At times, she lapses into preachiness. Her judgments on Eunice Rivers, the black nurse who was paid to shepherd the black men to hospitals during the Tuskegee experiment, seem unnecessarily harsh. At times, some of the medical references seemed written for an audience of health-care professionals, but these are small flaws.

Problems between blacks and the medical establishment continue: there is the erosion of medical consent and the exportation of medical experimentation on Africa’s poor. Washington acknowledges the problems but gives few clues on how the average citizen can guard against them.

Caption: John I. Kukral (center, holding plaque), President & CEO of Blackstone Real Estate Advisors, was the honoree at the record-setting “Winter’s Eve Gala” benefiting National Jewish Medical and Research Center. Pictured above (l-r) are: Michael E. Pralle, Thomas M. Flexner, Karin and John Kukral, Owen D. Thomas and Dr. Lynn Taussig, the president of the hospital.