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CIRA events focus on the ethics and science of HIV
An impromptu
debate over the case of NuShawn Williams, an upstate New York
man accused of infecting at least nine women with HIV, explored
the legal and public health consequences of criminalizing sexual
behavior linked to deliberate HIV infection. The debate took
place at “Using Law to Regulate Behavior: AIDS and the Criminalization
of Sex,” a symposium sponsored by the Law, Policy and Ethics
Core of the Center for Interdisciplinary Research on AIDS (CIRA).
Some states already have laws on the books that make it a crime
to expose others to HIV infection through sex or blood donations.
Williams, already in prison on drug charges, pleaded guilty to
two counts of reckless endangerment for exposing women to HIV,
and one count of statutory rape for his relationship with a 13-year-old.
Leslie Wolf,
J.D., M.P.H., an assistant professor of medicine at the Center
for AIDS Prevention Studies at the University of California San
Francisco, set forth arguments in favor of and against criminalization
of HIV transmission. She suggested that criminalization of HIV
transmission may be appropriate, but only if statutes are drafted
to target a narrow range of cases and to minimize negative effects
on public health efforts.
In the ensuing
debate, Scott Burris, J.D., professor of law at Temple University,
noted that issues of race and poverty were missing from her discussion.
“Criminalization of HIV exposure is fine in principle,”
Burris said, “but impossible in any social setting.”
The following
day CIRA, in collaboration with the Yale AIDS Program, held AIDS
Science Day ’99 to highlight AIDS research at Yale. Neal
Nathanson, M.D., director of the Office of AIDS Research at the
National Institutes of Health, delivered the conference’s
keynote address, “AIDS Research and the Global Epidemic.”
“Right now in the developing world there are 30 million
people living with HIV/AIDS,” Nathanson said, “and
almost all of them will be dead in 10 years and they will be
replaced by 60 million people.” Although drug therapies
may help stem the spread of AIDS, a vaccine remains elusive,
he said. Once candidate vaccines are identified, he continued,
it could take five years to evaluate their efficacy. “The
future of AIDS research depends on convincing the world that
it is important to sustain research.”
Presentation topics included
needle exchanges, prenatal HIV counseling and testing, and drugs users’ social
networks. Gerald Friedland, M.D., director of the Yale AIDS Program, cautioned
that more study is needed on the pharmacokinetic interactions between anti-HIV
drugs and drugs employed in drug-abuse treatment programs. “Methadone may
alter the pharmacokinetics of antiretroviral drugs and, conversely, antiretroviral
agents may alter the disposition of methadone and other opiate substitution therapies,”
Friedland said, adding that very little data on these interactions is available,
and this is an active area of research at Yale.
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EPH
inaugurates grand rounds series
Connecticut’s
$3.6 billion share of the nationwide tobacco settlement should
be used to fund public health and anti-smoking programs, the
state’s attorney general, Richard Blumenthal, told faculty
and students during a talk April 14 at the Department of Epidemiology
and Public Health. “We have an opportunity to use this money
in a way that literally will save lives,” he said, noting
that some in government would rather use the money for politically
desirable programs such as property tax relief or increased public
school funding. “We continue to face this industry that
will go on marketing to kids and we have to figure out how to
counter it,” Blumenthal added, posing a challenge to his
audience in Winslow Auditorium. “I am inviting you to think
about this problem.”
Blumenthal was the final speaker
in an inaugural series of public health grand rounds that began in December with
a talk on drug policy by Thomas Zeltner, the director general of the Swiss Federal
Office of Public Health. Other speakers were Barry S. Levy, M.D., M.P.H., former
president of the American Public Health Association, and Frank Ruddle, Ph.D.,
Sterling Professor of Biology. “We want to give our students the opportunity
to hear from practitioners of public health in the community, the state and the
nation, as well as experts from fields related to public health,” said Michael
H. Merson, M.D., dean of public health, adding that the roster of speakers will
reach beyond physicians and researchers to include government officials, such
as Blumenthal, whose duties touch on public health issues. Merson said he hopes
to have up to five grand rounds each academic year.
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Non-traditional
medicine is complementary, not alternative, says alumnus who
headed NIH office
Although he
once headed the Office of Alternative Medicine at the National
Institutes of Health, Joseph J. Jacobs, M.D. ’77, HS ’80,
says he never liked the term. “It conjures up this mutually
exclusive range of either/or decisions that patients have to
make,” he told a crowd of about 60 people in the Beaumont
Room at the School of Medicine in April.
He prefers to
look at acupuncture, herbs, macrobiotics, massage, biofeedback,
t’ai chi and other regimens as complements, rather than
alternatives, to conventional medicine. Many patients see in
alternative medicine a holistic approach they feel is lacking
in traditional medicine, he said. “What is not so important
is whether this group of alternative medicines have any efficacy,”
he said, noting that they may offer hope to patients. “Patients
trust us with their bodies and should not be afraid to trust
us with their beliefs. We must let our patients know we are not
only listening to them, but hearing them as well.”
During his talk on alternative
medicine in April, part of the Humanities in Medicine lecture series, he described
his own initiation into the world of alternate beliefs. Jacobs, a member of the
St. Regis Mohawk tribe who grew up in Brooklyn, spent his early years as a physician
on a Navajo reservation in New Mexico. Those formative personal and professional
experiences have made him particularly sensitive to his patients’ belief
systems, which he says can be as important to healing as the latest medical technology.
A physician colleague on an Apache reservation once described to him how a tubercular
patient looked at his X-ray, then chanted and danced before allowing conventional
treatment to begin. “When immigrants come into your clinic, what is their
belief structure?” asked Jacobs, now medical director for the Medicaid and
corrections systems in the state of Vermont. “How is it going to influence
the way we deliver health care?”
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Cancer
Center chosen for breast cancer study
The Yale Cancer
Center will participate in a national trial to determine the
effectiveness of two drugs in preventing breast cancer. The STAR
Trial, also known as the Study of Tamoxifen and Raloxifene, began
this spring and will involve 22,000 post-menopausal women at
increased risk for developing breast cancer. The National Surgical
Adjuvant Breast and Bowel Project (NSABBP) is conducting the
study.
Tamoxifen, which has been in
use for 20 years to treat cancer, also has been found effective in preventing
breast cancer. In a previous trial the NSABBP found a 49 percent decrease in invasive
breast cancer among women who received tamoxifen therapy. The new study will seek
to determine whether raloxifene is also effective in preventing breast cancer
and whether it results in fewer side effects than tamoxifen. Raloxifene was recently
approved by the FDA to prevent osteoporosis in postmenopausal women.
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Grant
will support musculoskeletal research
A biologist who isolates a gene
linked to the musculoskeletal system, regardless of where on campus he or she
works, will have increased access to resources for research, thanks to a $1.98
million, five-year grant from the National Institute of Arthritis, Musculoskeletal
and Skin Diseases. The grant to the School of Medicine will fund the new Yale
Core Center for Musculoskeletal Diseases. The center will encourage research into
musculoskeletal disorders such as osteoporosis and provide financial and technical
support, as well as the expertise of its members. The center currently has 25
affiliated researchers, most of them at the medical school.
“There is an appreciation
that musculoskeletal disorders, in particular osteoporosis, are emerging as a
major health concern,” said Karl L. Insogna, M.D., associate professor of
medicine, director of the new center. “There is a need for a more comprehensive
approach to understanding the pathogenesis of these diseases and other musculoskeletal
disorders.”
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What’s
in a yam? Clues to fertility, a student discovers
White yams,
a staple of the diet of the Yoruba people of southwestern Nigeria,
may play a role in the society’s high incidence of fraternal
twinning, according to a student’s research. “You see
families consuming yams three or four times a day,” said
Obinwanne Ugwonali, M.D. ’99, whose thesis on the link between
yams and fertility was one of five to garner awards this year
on Student Research Day. “I think this project will lead
us to understanding more about the mechanisms of the human reproductive
system, specifically the reason why we are typically monotocous
rather than polytocous like other animals,” he said.
Ugwonali’s
adviser, Frederick Naftolin, M.D., professor and chair of obstetrics
and gynecology, said the research is the cornerstone of a group
of related studies of yam intake and genetic predisposition to
multiple births now under way at Yale and Harvard and in Nigeria.
In addition to the biological and anthropological aspects, the
study has medical applications, Naftolin said. “We don’t
know why normally monotocous women become polytocous, but multiple
pregnancy is the most common cause of prematurity, which is the
major cause of perinatal morbidity and mortality,” he said.
Ugwonali’s
interest in yams and fertility started when he worked in Naftolin’s
lab the summer before he entered medical school. Naftolin asked
him to investigate why humans are monotocous, and a Medline search
led Ugwonali to information about the high rate of twinning in
Nigeria. Although some Nigerian tribes have rates of fraternal
twinning ranging from 20 to 30 pairs per thousand births, it
peaks among the Yoruba at 41.6 per thousand. “I’m from
Nigeria and I didn’t know this before,” said Ugwonali,
who is a member of the Ibo tribe. For African-Americans the rate
is 15 per thousand, and for Caucasians in the United States and
the United Kingdom it is between 10 and 11 per thousand. Among
the Yoruba, twins symbolize a duality of blessings and burdens
that is celebrated in hardwood carvings.
In 1996 Ugwonali
went to Nigeria on a Downs fellowship to begin his research.
After analyzing age, socioeconomic factors and other variables,
Ugwonali focused on diet. Demographic and scientific studies
conducted in the early 1970s pointed to white yams as the culprit
in the mystery of multiple births in southwestern Nigeria. Ugwonali
interviewed people about their eating habits and made his own
observations. “We suspected environmental factors,”
he said. “The only factor that ended up being different
from the ones we controlled was yams.” In laboratories at
Yale and in Nigeria, he fed rats a diet of yams and saw the average
size of their litters double from about four to about nine.
“Our hypothesis
is that yams act as anti-estrogens,” he said, noting that
he hasn’t investigated the precise chemical link between
yams and fertility and has yet to isolate an anti-estrogen from
yams. Anti-estrogens fool the brain into thinking there is insufficient
estrogen, causing it to release more of a hormone called gonadotrophin
and increase the ovulation rate, he said.
Ugwonali, who began his residency
in orthopaedics at Columbia-Presbyterian Medical Center in New York, plans to
continue his research in Brazil, where many Yoruba were brought as slaves in colonial
times. He wants to determine if the high incidence of multiple births persists
there among the Yoruba, who have maintained elements of their language, religion,
cultural identity and diet, including consumption of white yams.
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Yale
researchers find ways to ward off delirium in hospitalized patients and eliminate
home hazards for the elderly
In separate
studies, Yale geriatricians have found two ways to help the elderly
maintain their physical and cognitive function. One study surveyed
the homes of elderly people for physical hazards that can be
easily eliminated. The other demonstrated the efficacy of a program
to prevent delirium in elderly hospitalized patients.
Thomas M. Gill,
M.D., associate professor of medicine, conducted the study on
home hazards such as poor lighting, exposed electrical cords,
throw rugs and insufficient bathroom grab rails or stairway banisters.
Gill believes the potential for disabling accidents can be decreased
by assessing potential hazards in the home and correcting them.
The delirium
study examined the effects of the Elder Life Program, designed
to ward off delirium among elderly hospitalized patients through
a mix that includes conversation, exercise and memory aids. The
program has been found to reduce symptoms by 40 percent, according
to a study published in the March 4 issue of the New England
Journal of Medicine.
The study, according
to leader Sharon Inouye, M.D., M.P.H. ’89, associate professor
of medicine, compared an intervention group with a control group,
which had a higher rate of delirium. The Elder Life Program is
the first major clinical program designed to prevent rather than
treat delirium. It focuses on six risk factors for delirium —vision
loss, hearing impairment, dehydration, sleep deprivation, cognitive
im-pairment and immobility from prolonged bed rest.
Trained volunteers took patients
for walks three times a day, talked about current events and offered warm milk
rather than sedatives to induce sleep at night. A bedside bulletin board lists
names of doctors and nurses, as well as a schedule of daily tests and activities.
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Estrogen
treatment increases brain activity in mature adults
In a study of 46 postmenopausal
women, Yale researchers found that estrogen therapy stimulated activity in areas
of the brain that deal with the type of short-term memory used in common, everyday
tasks. “It is significant that there was a change,” said Sally E. Shaywitz,
M.D., leader of the study and professor of pediatrics and in the Child Study Center.
“It shows that there is flexibility in the neural circuitry in mature adults.”The
study, she said, suggests that estrogen affects brain organization for memory
in postmenopausal women. The findings were published in the Journal of the
American Medical Association in April.
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Magnetic
stimulation offers relief
to schizophrenia patients
Pulsing a magnetic
field into the brain can temporarily reduce or stop the imaginary
voices heard by schizophrenic patients, Yale researchers reported
at the May meeting of the American Psychiatric Association in
Washington. The investigational treatment, transcranial magnetic
stimulation (TMS), involves placing an electromagnetic coil on
the scalp, then turning current on and off to create a pulsing
magnetic field which is directed at the temporo-parietal cortex.
This brain region plays a critical role in processing speech.
Half of the study’s 12 participants reported clinically
significant reductions in their hallucinations following TMS.
These improvements were sustained for periods ranging from several
days to six weeks. The study is continuing with an additional
20 patients, said Ralph Hoffman, M.D., deputy medical director
of the Yale Psychiatric Institute, who led the study. “Patients
will get a more extended course of TMS. Starting this summer
we are going to be doing our own neuroimaging studies to better
understand what TMS is doing in the brain,” Hoffman said. |
