From its Late Devonian and Early Mississippian resting place of some […]]]> By Bryce Gray

RELATED STORIES

• Three months after derailment, Bakken crude still fuels concerns in town
• VIDEO: Concerns over safety of fuel-carrying trains in wake of Galena
• Oil by rail: a changing landscape

From its Late Devonian and Early Mississippian resting place of some 300 million years, the light, sweet crude of “Bakken gold” is extracted through hydraulic fracturing, or “fracking,” and horizontal drilling techniques. As soon as the oil bubbles to the wellhead at the surface, the process of converting it into a market-ready commodity begins in earnest.

At the wellhead, the crude is stored in stock tanks, and eventually undergoes preliminary heating to remove water.

Natural gas also exits the wells through the drilling process. Satellite imagery shows widespread flaring that sets the region aglow at night, as approximately 30 percent of the area’s natural gas is burned off. When possible, the gas is captured and stored separately from tanks of crude, to be processed into fuels such as propane or butane.

Satellite imagery shows widespread natural gas flaring that sets the region aglow at night, as approximately 30 percent of the area’s natural gas is burned off (Source: NASA)

Ryan Couture, an energy consultant at engineering firm Turner, Mason & Company, said that flaring is not intentionally wasteful, but rather an unfortunate casualty of economics.

“The short answer is there’s not the infrastructure in place to collect it,” he said. “Because as the expansion was going on so quickly in the Bakken for drilling, it’s easier to throw a couple tanks there for liquids, but for the gas, you really need to pipe it.”

After separating out the water and gas, the crude enters the shipment phase of its lifespan. At this stage, it is most commonly loaded into cylindrical model DOT-111 rail cars, which are under growing scrutiny in terms of safety and design.

Those calls have led railroads to voluntarily phase in the use of CPC-1232 rail cars. Billed as being a safer alternative to the maligned DOT-111 models, the design of the 1232 incorporates thicker tanks and head shields positioned at either end of the car, to serve as a buffer in the event of a collision. Despite their goal of enhanced safety, these cars, too, have been involved in explosive derailments, including the accident near Galena, Illinois, in March.

↑ Click on chart of interactive version). While the amount of crude oil traversing the nation by rail has climbed steadily, the destination has shifted dramatically. (Data: U.S. Energy Information Administration)

Once the crude arrives at the refinery, it is finally processed into usable petroleum products, such as gasoline, jet fuel and diesel fuel. This is most commonly done through a distillation process that heats and separates the fuel into products of different weights, determined partially by the demands of the market (lighter fuels, such as gasoline, are typically of greater value than heavier products, like residential fuel oil.)

BAKKEN OIL MORE VOLATILE THAN OTHERS?

The number of high-profile oil train explosions associated with the Bakken oil boom have caused many to question whether the fuel source is more volatile and prone to combustion than other crude oils.

As a light crude, technically Bakken oil is more volatile than heavier hydrocarbons.

“All light crude oils are volatile compared to heavy oils like tar sands,” said Couture. “But it’s consistent with other light crudes.”

Nicole Leonard, an analyst with Bentek Energy, an industry analytics firm, echoed that the properties of Bakken crude are largely consistent with other crudes, but noted that analysis she’s seen places it “on the high end of vapor pressure” compared to similar oil types.

Based on samples tested through May 2014, the federal Pipeline and Hazardous Materials Safety Administration determined that Bakken oil is classified correctly under their safety guidelines, but does exhibit attributes such as a higher gas content, higher vapor pressure and lower flash point.

“We conclude that while this product does not demonstrate the characteristics for a flammable gas, corrosive liquid or toxic material, it is more volatile than most other types of crude – which correlates to increased ignitability and flammability,” the PHMSA report stated.

One assertion circulating in the wake of oil train derailments is that the Bakken crude “separates out” during early-stage processing and shipment, concentrating its more volatile components in one place.

Industry insiders, however, insist that separation – either at the wellhead or naturally during transit – does not occur until the material reaches the refinery.

“When processing to get the water out at the wellhead, there’s not a ton of separation,” said Leonard. “Once you get to the refineries you have to heat it up to a certain temperature to get the different refined products.”

Couture also refuted the notion that Bakken crude undergoes separation prior to the refining process.

“You’re not going to get crude oil stratifying,” he said, noting that tank cars are equipped with specially designed roofs to minimize vapor space.

He believes that Bakken’s newly gained notoriety in the wake of recent derailments is a function of increased risk, with so much oil moving on the nation’s rail system.

“You’re increasing your odds that you’re going to have more instances,” Couture said, noting that the rail trip of oil in Texas is only 400 miles compared to the 2,000-mile trek from North Dakota to the East Coast. “So you have five times the distance and 10 times the crude, [meaning] you have 50 times the odds that you’re going to have a problem.”

As for the explosive recent accidents, Couture chalked that up as an occupational hazard of getting a fuel source to distant markets and refineries.

“These cars are not exploding sitting on the tracks,” he said. “They’re catching on fire after they derail while in motion and the rail cars have actually breached.”

With rail lines traversing densely populated towns and cities around the country, ensuring public safety requires that somebody – whether public or private – invests in more stringent safeguards.

“BNSF has advocated for a safer tank car in the movement of crude oil and finally setting a new federal standard will get the next generation tank car into service and substantially reduce the risk of a release in the event of an incident,” said Roxanne Butler, media relations director for BNSF.

But Couture said engineering against the inherent risks of oil shipment is not feasible for rail companies.

“You’re gonna need to make it indestructible in order to not have a problem,” he said. “You’re talking tens of tons colliding into each other at 50 mph.”

TIME FOR MORE PIPELINES?

The highly publicized rash of oil train derailments has renewed some discussion of whether pipelines – themselves a controversial delivery method– represent a safer alternative for distribution.

“Basically a pipeline is the preferred choice in almost any circumstance,” said Sandy Fielden, a Texas-based analyst at RBN Energy who writes a blog about the Bakken region. “It’s cheaper, it’s more efficient and it’s safer.”

Fielden said that although rail is a less attractive option than pipelines, it won’t go away as a primary shipment option for a number of reasons, including distance. Most notably, pipeline access to refineries along the densely populated East Coast is “unlikely” to happen.

As for shipment to the West Coast, “the Rockies kind of get in the way,” Fielden noted bluntly.

The investment of time and money required to construct pipelines also helped shift the burden to railroads.

“One of the reasons rail was popular is that it takes a lot of time to construct a pipeline,” said Fielden.

Those constraints mean that railroads will continue to bear a disproportionate share of Bakken oil for the foreseeable future, leaving residents near rail lines to hope that new standards for rail cars will keep them out of harm’s way.

Some area residents maintain that those regulations are not enough.

“The new rules out of the D.O.T. are too little too late,” said Lora Chamberlain, an organizer and spokesperson for Chicagoland Oil By Rail, a coalition of concerned citizens. Chamberlain said that the new guidelines are full of loopholes, and can be avoided if certain numbers of oil cars aren’t linked together consecutively.

“It’s just Swiss cheese. There are so many ways for the railroads to get around it. Plus, we don’t think it’s the cars,” she said. “We think it’s the cargo.”

One in an ongoing series of stories examining the impact of millions of gallons of volatile crude oil as it passes in rail tanker cars through densely populated Chicagoland each day.

Tony Gambee, the CEO of a software company in Boulder, Colorado, used to be able to eat an entire slab of ribs in one sitting at his favorite barbecue joint.

Now, it’s two ribs and he’s full. His secret is gastric bypass, a type […]]]> By Jamie Friedlander

Tony Gambee, the CEO of a software company in Boulder, Colorado, used to be able to eat an entire slab of ribs in one sitting at his favorite barbecue joint.

Now, it’s two ribs and he’s full. His secret is gastric bypass, a type of weight loss surgery that promises dramatic results, but often involves a lot of maintenance afterward and some difficult side effects at first, such as vomiting.

Known as bariatric surgery,  procedures to induce weight reduction include gastric bypass, which creates a small stomach pouch; sleeve gastrectomy, which reduces the stomach to 25 percent of its size; lap band surgery, in which a device is placed around the stomach to slow down eating; and duodenal switch surgery, in which 70 percent of the stomach is removed and a large portion of the small intestine is rerouted.

Tony Gambee, before having gastric bypass surgery, at 360 pounds. (Tony Gambee/Courtesy)

All of these surgeries have the same goal: to help severely obese patients lose weight quickly and effectively by restricting how much they can eat as well as how many calories they absorb. Bariatric surgery also helps obese patients control their related conditions, such as diabetes, high blood pressure and sleep apnea.

Recent research from the University of Cincinnati and a research institute in Seattle shows bariatric surgery improves life expectancy in most obese patients in comparison to obese patients who do not have surgery. However, one study suggests a small subset of very obese, diabetic patients may not see increased life expectancy after surgery.

Tony Gambee, after having gastric bypass surgery, at 228 pounds. (Tony Gambee/Courtesy)

Gambee falls into the group with increased life expectancy because of surgery. After contemplating the procedure for a few years, he finally decided to have gastric bypass in July 2014.

He weighed 331 pounds.

Now, in March 2015, he weighs 228 pounds. Gambee partially decided to have surgery for personal reasons.

“I’m 39, I have two teenagers, and I just want to be active and have fun with them and my weight was slowing me down,” he said. “I was like, if I just keep failing at doing this on my own, I’m going to be 50 and look back and say, ‘Geez, I wish I had done something more drastic ten years ago when I could’ve enjoyed this time more.’”

Gambee wrote a list of goals prior to surgery unrelated to the number of pounds he lost. He wanted to walk 18 holes of golf with his son, be able to mountain bike with his other son and have his wife be able to hug him and touch her hands behind his back.

New Research Shows Improved Life Expectancy

One study published recently in the Journal of the American Medical Association (JAMA) followed 2,500 patients for 14 years after they had bariatric surgery in Veterans Affairs hospitals from 2000 to 2011. The study,  by Dr. David E. Arterburn of  the Group Health Research Institute in Seattle, compared them to 7,462 obese control patients who did not have bariatric surgery. The majority of the surgical patients (74 percent) had gastric bypass. In addition, 74 percent of the surgical patients were men.

The study found at the end of the 14-year period, the mortality rate for control patients was 10.4 percent at 5 years and 23.9 percent at 10 years, while the mortality rate for surgical patients was 6.4 percent at five years and 13.8 percent at 10 years. Control patients had an average age of 53 with a BMI of 46 and surgical patients had an average age of 52 with a BMI of 47.

In addition, the study showed the safety of bariatric surgery has improved over the years.

“I think one of the important take home points of the study was that they looked at the mortality risk for patients who had surgery in the early part of the study versus the second half of the study and found that the overall safety of the operation has actually significantly improved over time,” said Dr. Vivek Prachand, a bariatric surgeon and the Director of Minimally Invasive Surgery and Surgery Quality Chief at the University of Chicago Medicine.

However, another recent study has shown that in a very small group of people – diabetics with a body mass index over 62 – bariatric surgery may not actually increase life expectancy. Body mass index, or BMI, is a measure of the correlation between height and weight.

The study, done by a group of researchers at the University of Cincinnati and published in The Annals of Surgery, analyzed data for approximately 200,000 patients to look at life expectancy. Of  159,000  severely obese diabetic patients, 4,185  had bariatric surgery. The researchers looked at data from the Nationwide Inpatient Sample and the National Health Interview Survey, as well as data from three HMO Research Network sites.

The study found that while life expectancy improved in most diabetic obese patients who underwent bariatric surgery, it might actually reduce life expectancy in “super super” obese patients, which is a category of obesity that applies to people with a BMI over 60, for example a person who is 5 feet 8 inches tall and weighs about 400 pounds. The researchers got these results by using a model that compared severely obese diabetic patients who had bariatric surgery to those who didn’t.

More specifically, the study found that a diabetic, 45-year-old woman with a BMI of 45 gained around 6.7 years of life expectancy upon having bariatric surgery, but once the same woman’s BMI hit 62, life expectancy went down. The researchers reported that they saw similar results for men and women in all age groups.

[soundcloud url=”https://api.soundcloud.com/tracks/195249704″ params=”auto_play=false&hide_related=false&show_comments=true&show_user=true&show_reposts=false&visual=true” width=”100%” height=”300″ iframe=”true” /]

“We were not surprised that most obese diabetic patients benefitted from surgery,” said Dr. Daniel Schauer, an author of the study. “We were surprised though that the most severely obese didn’t.”

“Less than 3 percent of [the people in the study] actually had an initial BMI greater than 60,” said Prachand, who believes it was somewhat misleading to lead the reporting of this study with the finding that applies to 3 percent of patients instead of the finding that applies to 97 percent of patients. “So the confidence upon which you can make those sorts of generalizations is a little bit limited given that it represents a relatively small percentage of the overall sample.”

Dr. Daniel Schauer, a researcher with the University of Cincinnati (University of Cincinnati)

In addition, both Schauer and Prachand noted the study didn’t account for patients’ quality of life.

“I think it’s fair to say that the benefit [of surgery] as far as life expectancy decreases as the BMI goes up,” said Schauer. “But there are other reasons to have bariatric surgery. It improves quality of life and it improves other obesity-associated conditions, like arthritis, diabetes and hypertension.”

Schauer said he and his colleagues are still unsure as to why they got these results. They hypothesize that it could be because patients in the super super obese category had diabetes longer or because they had much more weight to lose in the end, so they were still obese even after weight loss. With the added risks, they may not have achieved all the true benefits of bariatric surgery.

Schauer believes the take-home message from this study should be that the vast number of obese patients actually do benefit from bariatric surgery.

Deciding to Have Surgery

For most people, it isn’t the number on the scale that drives them to surgery.

“I think the public has the perception that most people who seek obesity surgery do so because they don’t like the way they look,” said Prachand. “But when we ask patients ‘Why are you seeking surgery?’ appearance and self esteem tend to be maybe fifth, sixth or eighth on the list. The most common thing is a loss of functional ability and the second most common thing is a newly diagnosed medical problem.”

Before surgery, Gambee was on medication for diabetes and used a  machine at night because of his sleep apnea, a condition in which one’s breathing stops in short spurts while sleeping. Now, Gambee no longer needs the diabetes medication or the machine to correct his breathing.

Blanca Ramirez, a secretary at Loyola University, ultimately decided to have weight loss surgery for health concerns. Her brother had a heart attack at 35, her father had diabetes, high blood pressure and congestive heart failure and her mother has a pacemaker.

Blanca Ramirez, who had a sleeve gastrectomy in August 2012. (Blanca Ramirez)

“That always stayed in the back of my mind, [whether] I would possibly be the next one with some heart condition or some heart issue,” she said.

Ramirez had a sleeve gastrectomy at age 41 in August 2012. At the time of surgery, Ramirez, who is 5 feet 3 inches tall, weighed 215 pounds and had weighed as much as 235 pounds. Now, she maintains an average weight between 150-159 pounds.

Some people have trouble adjusting after bariatric surgery. People can experience side effects that include difficulty swallowing from eating too quickly, dehydration, gallstones, indigestion, nausea and vomiting. Many people also experience dumping syndrome, which is when patients who have had surgery experience nausea, vomiting, cramping, diarrhea, dizziness and lightheadedness shortly after eating.

“You can’t wake up and get off the operating table and say okay, voila! You have to work at it. Nothing in life is that easy.”

-Blanca Ramirez

While neither Gambee nor Ramirez said they had any serious side effects after surgery, they both pointed out that it’s not as simple as having surgery and being done. Even after weight loss surgery, people need to eat healthfully and be active to prevent gaining weight and getting sick.

“You can’t wake up and get off the operating table and say okay, voila!” said Ramirez. “You have to work at it. Nothing in life is that easy.”

Palisades, New York — They rest side by side on a dark bench table, two coarse linen bags labeled with big, round numbers and letters. Mike Kaplan carefully unties the bag labeled “JRI-14-33” and reaches inside.

“That’s a really nice granite,” the 46-year-old geologist […]]]> By Jia You

Palisades, New York — They rest side by side on a dark bench table, two coarse linen bags labeled with big, round numbers and letters. Mike Kaplan carefully unties the bag labeled “JRI-14-33” and reaches inside.

“That’s a really nice granite,” the 46-year-old geologist exclaims as soon as he sees the light gray rock, large as his palm and twice as thick. He takes off his glasses to examine it up close. Outside, cherry trees are blossoming under a clear April sky at Columbia University’s Lamont-Doherty Earth Observatory in the Palisades. But inside the dim underground lab, Kaplan is absorbed with the granite and the clues it holds to climate change.

Yes, it’s the same rock used for flooring tiles and posh kitchen countertops. Except it took Kaplan a month of hiking through Antarctica to find this piece of granite — a time capsule from the ancient past, when our planet emerged from the last Ice Age and the massive ice sheets covering much of North America and Eurasia thawed. Human hunters and gatherers soon started growing their own food. Just like how people bury metal boxes of photos, newsreels and other artifacts for future generations to discover, a melting glacier deposited rock on an island off Antarctica’s northeastern tip some 8,000 years ago — a rock that contained secret messages depicting how the climate changed at the time. Kaplan discovered those messages.

Now, it’s up to him and his colleagues at the observatory, geologists Joerg Schaefer and Gisela Winckler, to figure out what exactly happened all those centuries back. But first, Kaplan needs to pry open the time capsule he holds in his hands. And that takes some chemistry, lots of crushed rocks and, finally, thin residual powders carrying the messages from the past, to be decoded at a national laboratory on the opposite side of the country.

Ancient climate, current crisis
In dark-rimmed glasses, a bright orange sports jacket and brown hiking shoes, Kaplan’s soft-spoken demeanor can mask the endurance it takes to hike in Antarctic conditions. The Bronx native studied geology in college, and discovered a passion for tracking glaciers and climate during a summer research trip to Greenland.

Two decades later, through a collaboration with Argentine scientists funded by the U.S. National Science Foundation, Kaplan and his colleagues turned their attention to the Antarctic Peninsula, the icy continent’s northernmost tip, just about 600 miles across the sea from Cape Horn, the southern tip of South America.

As global temperature rises in recent years, the Antarctic Peninsula has made headlines as one of the fastest warming places on earth, with its ice shelves melting and glaciers accelerating into the ocean. The collapses not only contribute incrementally to rising sea levels, but also give early warnings of alarming climate changes in the region, Kaplan says.

One change that scientists fear is a potential collapse of the massive ice sheet covering west Antarctica, which threatens to push the sea level more than 10 feet higher, says Schaefer, who works with Kaplan on the project. That would devastate millions of lives in coastal areas including New York City, Miami, and New Orleans.

“It’s probably the most vulnerable ice sheet that we have on earth,” he says.

To predict whether and when such a doomsday scenario might occur, climate scientists need to draw a baseline of how climate in the region naturally varies, unaffected by human activities — by looking at how the climate has changed in the past. Kaplan is especially interested in changes during and since the end of the last Ice Age, some 12,000 years ago, when the much larger ice sheets than those we have today collapsed as the Antarctic Peninsula warmed up.

Scientists once thought that such drastic changes occurred on the scale of thousands of years, but they learned that the collapses at the end of the Ice Age actually unfolded in a matter of decades, says Meredith Kelly, a glacial geologist at Dartmouth College who is not involved with Kaplan’s research.

“Those kinds of climate changes, I think, really alarmed scientists,” she says. “Climate changes like that in a decade would really affect people and societies today, so understanding those rapid changes has really been a focus of climate scientists.”

That rings true especially as the earth is warming more now, driven by human dependence on fossil fuels, and the past offers the clearest map for where we might be heading.

But how can scientists reconstruct climate from thousands of years ago? It turns out that glaciers are a good recorder of climate because they are sensitive to even minuscule changes in temperature. And when they start to melt, they leave a record in the rocks they drop as they retreat — time capsules such as Kaplan’s granite.

Like the rising and falling tides, a glacier advances and retreats as its surroundings freeze and warm in cyclical intervals of thousands of years. As a glacier expands, it picks up rocks and sediments along the way and carries them forward. As the temperature rises and the glacier melts, it leaves behind trails of boulders and sediments on the landscape, known as glacial deposits, which can be thousands of miles away from their places of origin. These rocks are easy to spot: The light gray granite in Kaplan’s lab, for example, looks distinct from the dark, coal-like volcanic rocks that make up the island where Kaplan found it.

As these abandoned rocks lie exposed to the air, their transformation into time capsules begins through an interstellar storm of cosmic rays. Cosmic rays are high-energy subatomic particles, accelerated to near light speed when stars explode. Imagine these cosmic rays as pool balls that hurl through space and constantly bombard Earth from all directions. As they enter the earth’s atmosphere, they strike molecules in the upper atmosphere and release other pool balls — subatomic particles called neutrons. The neutrons collide into the surfaces of the rocks on the ground and change their atomic structures, creating a new substance known as Beryllium-10.

The Beryllium-10 carries the secret messages contained in the granite time capsules, the messages that Kaplan and his colleagues decode to figure out how climate changed in the ancient past. That’s because the longer the rocks have been exposed in the air, the more Beryllium-10 they accumulate. So by measuring the amount of Beryllium-10 in a rock sample, Kaplan’s team can deduce when a glacier melted and dropped the rock, and how far the glacier had advanced at that point. Rock by rock, Kaplan and his team can start to piece together a map of changes in glaciers and temperatures in the Antarctic Peninsula during the closing epoch of the Ice Age.

“He’s one of the people … really at the forefront of trying to understand glacial advances and retreats in the past,” says John Chiang, a climate scientist at the University of California, Berkeley.

Finding rocks and moss in Antarctica
Finding a time capsule like Kaplan’s granite is no easy task. The flights themselves required a feat in coordination. To bring the rock back to the lab, Kaplan flew about 5,000 miles from New York to Buenos Aires last January to meet his three Argentine collaborators: geologist Jorge Strelin of the Argentine Antarctic Institute, who planned and led the expedition, and two of his Ph.D. students. It was Kaplan’s second expedition to the island, following a previous trip in 2013.

Together, the team flew to southern Patagonia, Argentina, and waited two days for the weather to clear. Then, a special Argentine military plane used for flying to Earth’s polar regions carried them to a base camp on the Antarctic Peninsula, where the team boarded military helicopters to their field sites on James Ross Island, near the northeastern tip of the peninsula.

For Kaplan, who has explored the interior central Antarctica before, hiking 12 hours a day during the peninsula’s balmy 30-degree Fahrenheit summer can almost seem like a paradise. Survival wasn’t an issue, he says, and food was abundant: Fresh fruit lasted only about two weeks in the cold, but the snowy ground served as a natural fridge for raw meat. At the end of a day, the team would roast chickens and bake pizza in a pantry camp for dinner.

Even so, there were dreary days when wind storms hit camp at 50 miles per hour or more, forcing the team to cancel all plans for the day and secure their tents with all the rocks they could find. During the strongest gusts, they even held the tent up from the inside.

“During a strong storm, all the snow is blowing, sometimes you cannot see your hand right in front of you,” says Fernando Calabozo, a Ph.D. student in geology at the National University of Cordoba, Argentina, who worked with Kaplan. “It can be really frustrating because you got there with a few work plans, so you try to follow a schedule, and the weather is so bad you can’t go outside.”

Besides chiseling out samples from rocks that stood out from their surroundings, the team also looked for fossils on James Ross Island. Whereas the rocks indicate when glaciers expanded the farthest and just started to melt, fossils of shells and whale bones indicate warmer times when glaciers retreated from parts of the island, and seawater covered sections of the landscape. By dating these fossils, Kaplan could glimpse into windows of warm periods on the island as far back as 40,000 years ago.

For the last stop of the expedition, the team flew to the northern tip of the island specifically to find a fossil moss. About two decades ago, a team of European scientists discovered fossils of moss there and dated them as 11,000 years old. The dead plant has important implications for Kaplan’s research because moss only grows in ice-free lakes. So like any good scientist, Kaplan wanted to verify the age of the fossil moss.

“We flew all the way to the northern tip of the island for that moss, and we weren’t sure if we were going to find it,” he says.

Luck was with them. Just 15 minutes after they settled in camp and started looking around, Kaplan, Calabozo and their other team member Juan Presta, spotted a thick brown chunk of hardened dead moss. Cautiously optimistic, Kaplan and his colleagues spent the rest of the day digging around where they found the plant, until they found it pressed between two sediment layers that were thousands of years old, concrete evidence that the moss was a fossil.

“That was a really nice finding,” Kaplan says.

At the end of the expedition, the rocks and fossils were shipped from Antarctica to Argentina and then to the Lamont-Doherty Earth Observatory, in five Fed Ex boxes weighing 200 pounds. A month later, Kaplan would open one of those boxes and take out a coarse linen bag marked “JRI-14-33.” As he reaches inside for a piece of granite, the quest to open the time capsule begins.

Cracking open a time capsule
Bringing the granite and other rocks back from Antarctica is just the first step in recreating the Antarctica’s past climate. To actually date how long ago glaciers started melting and leaving the rocks exposed to air, Kaplan and his team still needs to know how much Beryllium-10 is contained in the rocks.

To find the Beryllium-10, the secret messages contained in the time capsules, the researchers first need to isolate quartz, the hard, transparent minerals in granite that sparkle under light. That’s where the Berylllium-10 hides.

The process begins with what Kaplan calls the “dirty work” – sawing, crushing, grinding and sieving the rocks into fine particles, which are shaken in acids to obtain pure quartz. Then, lab technicians and students dissolve the pure quartz, and uses chemicals to remove other elements and isolate Beryllium-10. If the process sounds complicated, it’s because it is — it can take a skilled technician up to two months to process a batch of eight to ten samples.

At the end of the process, the researchers fill solid Beryllium-10 powders into a thumb-sized, bullet-shaped stainless steel capsule and send it across the country to the Lawrence Livermore National Laboratory in California, one of a handful labs around the world capable of measuring the exact amount of Beryllium-10 contained.

Once the lab sends the results back to Kaplan, he will conduct the detective work of deducing how long the rocks have been exposed in the air, and thus when the glaciers on James Ross Island melted and deposited the rocks, and thus what the temperature in the Antarctic Peninsula must have been at that time. One data point followed by another, he will plot out a timeline of how climate in the region changed as it emerged from the last Ice Age.

For now, Kaplan’s hands are full. It would take a few years for him to work through the five Fed Ex boxes from his last expedition, in addition to several boxes from the 2013 expedition.

Yet he’s already planning to go back. Just a few weeks ago, with other Lamont scientists, Kaplan applied for funding for yet another trip to the Antarctic Peninsula, this time to stretch his time machine even further back. On his last trip, he and his Argentine colleagues found much older glacial deposits, sandwiched between layers of volcanic rocks, and ancient residues from the sea bottom. Geologists have well-established methods for dating volcanic rocks, which would allow Kaplan to date the old glacial deposits more accurately. Already, the volcanic layers and fossil shells they found indicate that those rocks could be millions of years old.

“It’s much older than anything we’ve worked on in this present project,” he says.

There’s an old Chinese saying that history is a mirror to the future. And Kaplan sees himself as a historian. “I’m interested very much in human history, and I figured it’s probably not a coincidence that I look at time periods in the geologic past,” he says.

He opens a notebook and sketched the granite’s outline on the page. Then he draws nine dots inside the outline in a three by three matrix, and patiently measures the thickness of the rock at each spot. Nine measurements to obtain the rock’s average thickness, which is just one number used to calculate its exposure to air. Back at his office, Kaplan has a shelf of close to 40 yellow- and red-covered notebooks, his field notes over the past two decades.

In the next few months, the granite will be ground and reduced to quartz, then to white powders in a stainless steel capsule, then to an age, then to a number on a graph or in a model. And then, with hundreds of rocks like the granite, the ancient Antarctic Peninsula would come alive: glaciers expanding and retreating over centuries, reacting to dynamic changes in the environment as they are now and far into the future.

Kaplan writes down the last thickness number and closes the notebook. Another day’s work done in writing the climate history of the Antarctica.

Story by Matt Schehl, photos and audio by Alix Hines

DAHOUK, Iraq — At the break of dawn on a […]]]>

Iraq is one of the most bombed-out places in the world, where an estimated 50 million landmines and other munitions that could detonate at any time.

Hassan’s home country of Iraq is one of the most dangerous places on Earth, and not just because of the constant infighting between Sunnis, Shiites and Kurds and the decades of war, insurgencies and terrorism. Many decades of conflict have made Iraq one of the most bombed-out places on earth, where an estimated 50 million landmines, cluster munitions and other pieces of unexploded ordnance could detonate at any time with lethal consequences.

First there was the Iran-Iraq war and Saddam Hussein’s bombing campaign against Hassan’s people, the Kurds. The United States laid millions of mines in the first Gulf War starting in 1991 and dropped tons of ordnance enforcing the subsequent no fly-zone. Then came the Iraq War, and years of bombing and other sustained combat operations to fight insurgents, especially in the south and central areas.

Three years ago, the U.S. withdrew its troops from Iraq, and the American public for the most part has moved on from this conflict. But its legacy endures here.

Some Iraqi government estimates place the cost of cleanup in the billions of dollars, on top of the $258.9 million already spent over the past decade by the United States and smaller amounts by some other foreign donors. Even with a massive influx of money and manpower, Iraq’s mine clearance effort could take decades, if not longer.

In 2009, two United Nations agencies released a highly critical report of clearance efforts in Iraq to date. Their report said unexploded munitions were not only a deadly risk to Iraqis everywhere, but a major roadblock to the economic redevelopment of the country still reeling from the U.S. invasion and occupation, and the brutal civil war and insurgency that followed.

“Iraq is on the brink of a social and environmental crisis if the situation stays as it is now,” Zahim Mutar, head of Baghdad-based NGO Iraqi Mine and UXO Clearance Organization, or IMCO, told the U.N. Office for the Coordination of Humanitarian Affairs at the time.

Since then, things have only gotten worse.

Omer Hassan, site manager for Sterling Global, points out where his team is clearing Valmara 69 anti-personnel mines from the side of a mountain in Dahouk. (Alix Hines/MEDILL)

Omer Hassan, site manager for Sterling Global, points out where his team
is clearing Valmara 69 anti-personnel mines from the side of a mountain in Dahouk. (Alix Hines/MEDILL)

That is especially the case throughout southern and central Iraq, where violence, political uncertainty and corruption have plagued cleanup efforts and precluded some international organizations from operating there.

But it is also the case here in Kurdistan, long considered the one bright spot in Iraq’s long struggle to rid itself of the explosive remnants of war. The explosives litter the landscape, and have killed and maimed farmers as they till their fields, mothers as they walk to the market and, especially, young boys and girls as they try to lead some semblance of a normal childhood.

The International Campaign to Ban Landmines reported in August 2013 that more than 29,000 people have been victims of landmine accidents in Iraq since the late 1980s. Nearly 15,000 of them, including 6,000 deaths, were in Kurdistan.

For years, the U.S.-assisted mine-clearing investment has yielded a healthy return in Kurdistan, whose mine clearing programs – like the regional government itself — are largely autonomous from the central government in Baghdad. Its relative stability and autonomy, and its oil wealth, have allowed more than a dozen non-profit humanitarian groups and private commercial companies like the Tennessee-based Sterling Global to flourish.

But more recently, the terrorist group Islamic State overran parts of Kurdistan, and huge numbers of refugees have been pouring across the border from Syria, swamping both the government and NGO community and setting off hundreds of mines in the process.

And infighting with the Baghdad government has halted much of the money needed for mine clearance efforts here.

I am here, and my leg is there

Hassan’s investment in mine clearance is as much personal as it is professional.

Hassan, 43, grew up in the town of Qaladiza near the Kurdistan border with Iran. From 1980 to 1988, he watched as Iran and Iraq went to war, each side laying mines to destroy the other. Then came the Gulf War, and in its aftermath, the U.S. effort to back Kurdistan’s fearsome Peshmerga fighters as they rose up against Saddam Hussein.

The Iraqi Army struck back hard, laying thousands more mines. Innocent Kurds were being killed and injured at an alarming rate. Then 21, Hassan volunteered to help clear them from his hometown of Qaladiza, near the border with Iran.

After a short training course, Hassan set to work. The morning of August 24, 1991, his team was clearing a farmer’s field and came across an artillery shell protruding from the dirt. Slowly making his way towards the shell, Hassan couldn’t have known that the shell was a decoy; whoever put it there knew anyone but an experienced clearance team would overlook the mines covertly buried around it.

“I didn’t even feel anything, but … everything changed suddenly,” Hassan recalls of the blast. “I saw my leg on the ground: I am here, and it is there.”

Daily visits by his girlfriend, whom he affectionately terms his “lovely”, helped get Hassan through the early days. But the depression overwhelmed him and he was nearly broke from medical expenses. He worried constantly about being a burden on his family, and took the only job he could get – selling cigarettes at the local market.

Through a chance encounter, he met an employee of the Mines Advisory Group (MAG), a U.K.-based nonprofit humanitarian agency that had recently arrived in Kurdistan to assist with demining efforts.

MAG, one of the pre-eminent mine action groups in the world, trained Hassan how to use professional international standards for demining: how to methodically plot out a grid over a mined area; how to move forward on one’s belly with nothing more than a stick or trowel and, inch by inch, probe the ground; how to cordon off UXO when found and provide warning markers; how to safely defuse and remove the UXO.

When Hassan and his team find a mine, they rope off the perimeter of the area with red tape to signal danger. (Alix Hines/MEDILL)

When Hassan and his team find a mine, they rope off the
perimeter of the area with red tape to signal danger. (Alix Hines/MEDILL)

It also taught Hassan another skill he’d long coveted: how to speak English.

For the next 20 years, Hassan worked with MAG in clearing unexploded ordnance throughout Kurdistan. Along the way, he married his “lovely” and fathered four children. He found the work immensely satisfying, especially in educating the public on how to recognize, avoid and even clear mines.

“I show myself as an example,” he says. “I tell them, ‘if you do a mistake, you gonna lose a leg, or your life, or your hands, your eyes’.”

Kurdistan’s mine clearance efforts have existed in various forms since 1991, when the Iraqi military and government withdrew from the region under the American no-fly zone Operation Safe Haven, leaving Kurds to manage their own affairs. The Iraqi Kurdistan Mine Action Agency, or IKMAA, was established in 2003, and merged with another key Kurdistan de-mining group in 2012.

IKMAA is responsible for coordinating and prioritizing all unexploded ordnance work in the region. It also does training, mine risk education and victims’ assistance and advocacy. Since that year, it has overseen an average clearance of 1 million square meters annually.

In 2011, Hassan joined one of the commercial mine clearance firms operating in Kurdistan, Sterling Global, as the site manager for its field operations in the region, overseeing its clearance work at the ground level.

It was a good time to make the switch. Sterling Global was expanding rapidly in Kurdistan thanks to all of the oil companies that were doing a booming business, and spending big to protect their expensive infrastructure.

But as Kurdistan was busier than ever clearing its mines and other unexploded ordinance, similar efforts in the rest of Iraq – never very robust or successful to begin with – were coming to a halt.

A social and environmental crisis

For the first few years of the U.S. occupation of Iraq, mine clearance in the south and central regions was a high priority and overseen by the United Nations and then the U.S. government, while the Kurdistan government was allowed to continue the work it was already doing.

Then control – and funding – for the areas outside of Kurdistan shifted to the fledgling Iraqi government in Baghdad and there have been problems ever since.

IMCO, the Baghdad-based NGO, was established in September 2003 and grew to a staff of at least 225 people. It cleared more than 174,000 landmines and pieces of unexploded ordinance and trained other NGOs and Iraqi security forces.

But that was a drop in the bucket, especially given how much ordnance the U.S. has dropped in the country.

During the first three weeks of the 2003 invasion alone, U.S. and British forces deployed approximately 2 million cluster bomb submunitions, much of them in residential areas in places such as Basrah, Najaf, Karbala and Baghdad. Up to 30 percent of these failed to detonate on impact, and more than 10 years later, their deadly debris remains a threat to local populations. So far, there have been at least 8,000 casualties since 2003, including those killed and injured.

The war in Iraq, and the post-9/11 invasion of Afghanistan, were the last times the U.S. military dropped cluster bombs in large numbers. And many of them remain, and are exacting a horrific human toll. From 2001 through 2002, the U.S. dropped 1,228 cluster bombs containing 248,056 sub-munitions in Afghanistan, according to the Congressional Research Service, the independent research arm of Congress.

U.S. and British forces used almost 13,000 cluster munitions containing an estimated 1.8 million to 2 million submunitions during just the first three weeks of combat in Iraq in 2003, the CRS reported in 2008.

The U.S. stopped using the cluster bombs in Iraq in 2003. But the CRS investigators raised questions about why one particular – and popular – cluster munition had been used there after causing so many problems during the post-9/11 war in Afghanistan.

Scripted by Alix Hines, animated by Next Media Animation

“It is widely believed that confusion over U.S. cluster submunitions (BLU-97/B) that were the same color and size as air-dropped humanitarian food packets played a major role in the U.S. decision to suspend cluster munitions use in Afghanistan,” CRS noted, adding, “but not before using them in Iraq.”

The Baghdad government created a National Mine Action Authority but it was so ineffective – and inactive – that it was shut in 2007. The next year, the Ministry of Environment created a Directorate of Mine Action whose mission was to create a national plan of action. It was supported by a Regional Mine Action Center in Basra, which was supposed to coordinate mine action in the south.

In 2008, Iraq signed the Ottawa Convention, the international treaty banning anti-personnel mines. Under the terms of the convention, the Baghdad government committed to rid the country of mines within 10 years and to never use, manufacture, acquire or export them.

But mismanagement and other problems intensified. By 2009, the Baghdad government had banned all civilian land-mine clearance, citing fears that the weapons would end up in the hands of militants. U.S., U.N. and even Iraqi officials were sharply critical of the lack of progress, and finger-pointing ensued.

“They are in the same league as Afghanistan in terms of saturation,” Kent Paulusson, the United Nations Development Fund’s senior mine action adviser for Iraq, said at the time. “The government needs to recognize the size of the problem and deal with it.”

“Some areas are so contaminated,” Paulusson added, “that people can’t live there.”

Rusted munitions in Iraqi Kurdistan. (Alix Hines/MEDILL)

Rusted munitions in Iraqi Kurdistan. (Alix Hines/MEDILL)

A partial survey released that year by the UNDP and UNICEF concluded that contamination plagued the entire country, included 4,000 contaminated hazard areas totaling 670 square miles, or 1,738 square kilometers.

Reporting mechanisms were so inadequate that no one could say for sure where the contamination posed the greatest risks, or how many people had been killed or injured by explosions. But the human toll was mounting, and garnering headlines. Six children were killed and five others severely injured in the southern province of Missan when a bomb exploded as they were playing football.

In response to the UN report, Iraqi Environment Minister Narmin Othman pleaded for international assistance, saying “billions of dollars” would be needed for cleanup. Othman said three companies were helping Iraq and that 17 more were trying to get licenses. But even with such an accelerated effort, Iraq had no chance of meeting the 2018 treaty deadline.

The survey said national and international demining organizations had cleared about 12.5 square miles, or about 20 square kilometers, of Iraq. That left nearly 1,055 square miles, or 1,700 square kilometers, to go. Another official study put it in more human terms: Despite all the cleanup efforts, 1.6 million Iraqis in 1,600 communities were affected, or one in every 20 Iraqis.

The military was still doing mine clearance. But given the mine clearance resource in Iraq at the time, “It would take … about 600 years,” to clear Iraq of mines and other ordnance, Paulusson said.

In 2011, Iraq convened a Higher Committee for Mine Action that brought all government agencies together, to make more headway. The next year, the UN’s top envoy to Iraq, Martin Kobler, said, “Much more needs to be done to rid the country from these lethal threats.”

Meanwhile, the Iraqi mine clearance effort was being increasingly undermined by politics, corruption and the declining security situation. Recent years have shown some minimal improvements, but Iraq remains one of the most contaminated countries on earth.

Things were much different in Kurdistan, where the semiautonomous government had been running its own de-mining program since 1993. When Hassan joined the commercial demining firm Sterling Global in 2011, it had more business than it knew what to do with.

RIGHT PLACE, RIGHT TIME

When Hassan joined Sterling Global, the firm had already been doing business in Iraq for eight years. Known at the time as EOD Technology, the commercial ordinance disposal company was first hired by the U.S. government on the heels of the U.S. invasion as part of Operation Restore Iraqi Oil, or RIO.

Its mission: to follow close behind Coalition Forces to counter any repeat performance of the 1991 Gulf War, when retreating Iraqi forces set ablaze and heavily mined its vast oil fields. After the fall of Baghdad, there was plenty of clearance work, especially around Basrah and the south of Iraq.

“The country is, or was, one big ammunition dump. There were huge stores of ordinance all over the place,” recalls Steve Priestley, a U.K. military sapper at the time who is now Sterling Global’s principal for mine action programs worldwide.

From there, the firm’s operations expanded exponentially, not just in Iraq but in Afghanistan and elsewhere, especially in conflict zones. The company was tasked with triaging an endless stream of ordinance for either repurposing or destruction.

The conclusion of Operation Iraqi Freedom in late 2011 and the impending drawdown of U.S. forces meant less and less work for the firm in the southern parts of Iraq. EODT and Sterling Global merged in 2012, creating one of the world’s largest firms engaged in the clearance of mines and other unexploded ordnance. And they soon found a booming business in oil-rich Kurdistan.

Protective gear for clearance work makes movement difficult and progress slow. (Alix Hines/MEDILL)

Protective gear for clearance work makes movement difficult and progress slow. (Alix Hines/MEDILL)

In recent years, Sterling Global had 13 contracts for humanitarian demining work in Kurdistan, and other ones with international oil and gas companies to make sure that prospective oil exploration areas were cleared of unexploded ordnance. It won more than $10 million in 2013 alone.

Last year, Sterling Global underwent a huge expansion in Kurdistan, creating a 200,000 square-foot regional logistics hub near the capital of Erbil. Its opening was attended by State Department officials, local and regional government officials and commercial oil and gas industry leaders.

But Hassan says a lot of the mine clearance work is now on hold because of political and other problems. He is eager to get keep working.

“I would like to continue my life with these things,” he says. “Our job is very important.”

By Katherine Dempsey

The way you walk or run can help health care professionals learn more about how to improve different kinds of mobility treatment and gauge how well treatment works. Doctors, therapists and researchers use three-dimensional […]]]>
Scripted by Katherine Dempsey, animated by Next Media Animation

By Katherine Dempsey

The way you walk or run can help health care professionals learn more about how to improve different kinds of mobility treatment and gauge how well treatment works. Doctors, therapists and researchers use three-dimensional gait analysis to see how to best help people with arthritis, cerebral palsy and other conditions in addition to gathering data that can help prevent and treat injury.

Rush University Medical Center’s Human Motion Analysis Laboratory uses gait analysis to capture motion and pick up on forces exerted by the way a person walks. Orthopedic surgeon Shane Nho of Midwest Orthopedics at Rush is using the method as part of a study to demonstrate the effectiveness of a surgical procedure called hip arthroscopy in correcting femoral acetabular impingement, or FAI, by proving that people move better after the surgery. The condition typically results from deformities (bumps) on the femur and hip socket, Nho said. It can cause pain and inhibits normal hip movement, and doctors believe it can lead to hip arthritis. Hip arthroscopy smooths out the bone, eliminating the deformities, he noted.

Someone with femoral acetabular impingement (FAI) walking, as depicted by motion-capture technology used in Rush University Medical Center’s Human Motion Analysis Laboratory. Courtesy of Robert Trombley, Human Motion Analysis Laboratory

People in Nho’s study can opt to participate in a motion analysis that involves walking and squatting in the Rush lab while wearing reflective markers (small balls) placed on the body. They’re tested before and after surgery, and their movements are compared to the movements of unaffected people to see how significant the difference is, he said. Plus, the study stacks up the way a patient moves before surgery against the way he or she moves after the surgery. The study also collects other data, like range of motion and strength. Data collection is on-going, but Nho says he thinks the gait analysis would supply extra information to confirm that when hip arthroscopy is used to correct FAI, the surgery helps the hip do its job better.

“I think it would prove what we already think we know,” Nho said.

Dr. Najia Shakoor, a rheumatologist at Rush University Medical Center, has used gait analysis to study people with knee osteoarthritis for the last several years. She examines the knee adduction moment, or the amount of force that people apply to the knee’s inner side when they walk. Calculating the knee adduction moment is a way to measure how much load (force) the person is exerting on the knee and it measures whether the person is putting too much force on the inner knee.

Other gait analysis research has demonstrated that osteoarthritis severity, likelihood of pain, and faster progression is linked to more extreme knee adduction moment, she said. Based on findings that barefoot walking and walking in minimalistic shoes were both associated with a decreased knee adduction moment, Shakoor and co-investigators have tested out a “mobility shoe” – a minimalistic, flexible, lightweight shoe – that imitates what it’s like to walk in bare feet. They’ve found that these shoes decrease loading at the inner side of the knee.

Shakoor’s current study investigates how the mobility shoes might be causing changes in foot motion that in turn might be lessening knee load at the inner side of the knee. Along with motion captured via a typical gait analysis with reflective markers on the body, the gait analysis also examines the amount of foot pronation by using additional markers on the feet. Plus, it assesses the foot pressure distribution via a pressure mat. The foot pressure and foot pronation will be compared to the amount of force on the inside of the knee to look for a relationship between pronation and pressure and loading over time, she said. Study participants – who wear the mobility shoes – are tested three times over a period of six months.

If her team can determine whether there’s a link between changes in foot motion and decreased loading over time, Shakoor said, that knowledge can help doctors better treat people dealing with knee osteoarthritis so those people can decrease loading.

Researchers can use gait analysis to look for connections between gait and injury. Karrie Hamstra-Wright, a clinical associate professor of kinesiology and nutrition at the University of Illinois at Chicago, uses three-dimensional gait analysis system in an ongoing study with members of UIC’s cross-country team. She’s looking to help those runners get more information about gait patterns that might be leading to overuse injury. and how injury might affect their gait. Participants get a pre-season gait analysis, and later Hamstra-Wright takes the group of team members who were injured and compares it against the non-injured runner group, searching for contrasts in gait between the groups.

She pointed out that she hasn’t yet noticed any specific gait pattern being a risk factor for overuse injury among these runners, with the caveat that the sample size is still not quite big enough.

“We definitely have quite a bit of time to go before I would expect to see any significant changes,” said Hamstra-Wright, who is also a 2:52 marathoner.

The system Hamstra-Wright and Jones use – called 3D GAIT, another gait analysis system – involves walking or running on a treadmill while cameras capture motion by emitting near-infrared light to reflective markers located on the pelvis, thighs, calves and feet, said Reed Ferber, director of the Running Injury Clinic in Calgary, Canada. Ferber came up with the idea for the system, and the Running Injury Clinic put it into practice in 2008. Out of 39 physical therapy and chiropractic clinics and 14 research sites across the globe using 3D GAIT, UIC is the only place in Illinois using it.

Photo by Katherine Dempsey. Runners move along the Chicago lakefront. Iliotibial band syndrome is the second most common reason for side knee pain among runners. Michael Jones, a clinical assistant professor at the University of Illinois at Chicago, is using 3D gait analysis to help him study it. Iliotibial band syndrome is the second most common reason for side knee pain among runners. Research at the University of Illinois at Chicago, uses 3D gait analysis to help study the problem. Katherine Dempsey/MEDILL

Iliotibial band syndrome is the second most common reason for side knee pain among runners. Research at the University of Illinois at Chicago, uses 3D gait analysis to help study the problem. Katherine Dempsey/MEDILL

Michael Jones, a clinical assistant professor at UIC, is using 3D GAIT to help in understanding more about why iliotibial band syndrome occurs among runners. ITBS, an overuse injury, results from repetitive stress between the side of the femur and the IT band, which extends down the outside of the thigh and affixes itself on the knee. It’s the second most common reason for side knee pain among runners. Jones’s study combines running data from the gait analysis with measurements of sensation and hip and back strength to try to figure out how those three variables link to ITBS. He wants to gain insight into the influences at play to eventually help improve treatment for people with the injury.

“As a physical therapist, I treat people with IT band syndrome,” Jones said. “I’d like to know more about why it happens.”

3D GAIT isn’t just for runners, Ferber noted; it’s also been used to evaluate walkers, people with knee osteoarthritis and athletes who compete recreationally.

3D GAIT and Rush’s motion analysis lab both use reflective markers (little balls) that are placed on the body. Multiple cameras emit near-infrared light, which bounces off of the markers and back into the lenses of the cameras, letting them determine very precisely where in space the markers are located. Both systems can capture movement with millimeter accuracy. The three-dimensional nature allows for gathering images from multiple planes of motion, unlike a one-camera setup. Rush has five force plates that measure the ground reaction force while the person is walking, and a computer calculates rotational forces (torque) acting on body parts. That, in turn, makes it possible for researchers to see atypical forces that are acting on joints of the body. 3D GAIT can get information from 40 to 50 footfalls within about 30 seconds and can break down the data in about 10 seconds, pointed out Ferber, who is also an associate professor of kinesiology at the University of Calgary.

An undergraduate at the University of Illinois at Chicago helps clinical associate professor Karrie Hamstra-Wright with a study using gait analysis to examine the interplay between gait and injury among UIC cross-country runners. Here, he demonstrates pronation, one of 17 biomechanical variables observed with a gait analysis system.

Data from the system goes into a database containing information from more than 3,000 physically active people who have undergone running or walking analyses. It measures 17 biomechanical gait variables such as “peak pronation,” “peak knee rotation” and “peak pelvic drop.” When a person gets a gait analysis using 3D GAIT, a normal range is determined for each of the 17 variables relative to people in the database of the same gender. The person being analyzed can see if they fall outside of that range. That lets doctors and others use scientific data to note how someone’s gait patterns are different than average, Ferber said. Plus, when they make calls about treatment, they can ground those calls in hard facts, he said.

The aim, as Ferber notes, is to “predict injury” for runners and ultimately people who do general physical activity. When people like doctors and physical therapists use 3D GAIT, they can help identify gait problems that might end up in injury and pinpoint the kind of injury that a person might get, he said. Plus, the system can quite accurately figure out appropriate therapy for an injury.

Gait analysis can help kids, too. At the Motion Analysis Laboratory at Shriners Hospitals for Children – Chicago, gait analysis is applied to a variety of clinical purposes. Orthopedic surgeon Peter Smith frequently uses it to help figure out suitable treatment for children with cerebral palsy who have complicated manners of walking.

Jaryn Smith, 19 – one of Smith’s patients but no relation to him – has cerebral palsy that affects both of her legs. She’s been coming to Shriners since 2000 and has undergone many gait analyses, including before and after her surgeries there. She said she thinks gait analysis has helped people at the hospital to know what requires improvement.

“They’re helping me walk better,” she said, referring to hospital staff.

At the Motion Analysis Laboratory, children wearing reflective markers (small Styrofoam balls covered in tape) walk back and forth on a walkway. The cameras emit near-infrared light, which bounces off of the markers and back into the lenses of the camera, recording the person’s motion. Force plates measure how much force the person’s body exerts on the ground as he or she walks, and that lets computer software calculate rotational forces exerted on the joints.  Children also wear wireless electrodes on their skin on distinct muscles, which picks up on when those particular muscles fire.

Software can figure out attributes of the child’s movement, such as joint angles and positions, how quickly the joints move, length of the space between his or her steps, and forces that act on the joints while he or she moves, Graf noted. Doctors and physical therapists and others at Chicago Shriners Hospital can compile all the data gathered to prescribe treatment and also see how a patient changes throughout time. They look at whether the person is using certain muscles improperly (via the electrode data), whether abnormal forces are acting on the joints (via the force plate data) and pressure distribution on the bottom of the foot (via pressure mat data).

Data collection for research also takes place at the motion analysis lab at Chicago Shriners Hospital. Joseph Krzak, senior motion analysis laboratory physical therapist, conducted research for his Ph.D. in kinesiology, nutrition, and rehabilitation at UIC, studying children with hemiplegic cerebral palsy (which directly impacts just one side of the body) with equinovarus foot and ankle deformity. He and co-investigators conducted the study throughout the last five years, and it’s currently in press. They collected their data at Chicago Shriners Hospital.

Equinovarus foot and ankle deformity results from cerebral palsy. When children are affected by the deformity, they point one of their feet inward and walk on the toes of that foot. This can result in pain and greater risk of trips and falls, Krzak said. Children must also use extra energy to get from place to place; what’s more, it can cause skin issues and it might be hard for kids to locate shoes that fit them.

Depending on the child, equinovarus deformity can affect different foot segments in different ways. Krzak wanted to describe how various groupings of foot bones are affected in order to distinguish distinct foot types that children with this particular deformity have. That insight could help doctors, physical therapists and orthotists (who make braces and splints) better decide what kinds of treatments would best help individual patients. Analogous treatment would help people who display the deformity in analogous ways, he said.

The Milwaukee Foot Model for motion analysis, involves placing reflective markers on specific spots on the feet and ankles. Joseph Krzak of Shriners Hospitals for Children – Chicago used the Milwaukee Foot Model to study children with foot and ankle deformities due to cerebral palsy. Courtesy of Joseph Krzak

The Milwaukee Foot Model for motion analysis, involves placing reflective markers on specific spots on the feet and ankles. Joseph Krzak of Shriners Hospitals for Children – Chicago used the Milwaukee Foot Model to study children with foot and ankle deformities due to cerebral palsy. Courtesy of Joseph Krzak

Krzak and the other researchers used a biomechanical model – the Milwaukee Foot Model – to investigate how different parts of a kid’s feet moved, how much those foot parts were moving abnormally when compared with “typically-developing” children, and the directions of abnormal foot movements. The Milwaukee Foot Model allows for more detailed motion-tracking of small bones in the foot. It’s a “specialized” kind of gait analysis, said Gerald Harris, the motion analysis lab technical director, in an email.

“We can identify which particular parts of the foot are moving differently than a group of typically-developing children that don’t have cerebral palsy,” Krzak said.

Krzak’s team found four kinds of equinovarus, grounded in which foot segments were moving irregularly and the

The Milwaukee Foot Model measures the motion of four segments of the foot. Courtesy of Joseph Krzak

The Milwaukee Foot Model measures the motion of four segments of the foot. Courtesy of Joseph Krzak

direction of those movements. More knowledge about how separate foot parts are moving unlike the foot parts of typically-developing kids can lead to more insight about distinct kinds of equinovarus, Krzak said. In turn, doctors, physical therapists, and orthotists can use that knowledge to better determine proper treatment for a child with equinovarus deformity and allow for better post-treatment results.

Gait analysis systems add up to the search for better treatment, diagnosis and prevention for problems that impact the legs and feet of millions of people.

Could a much-maligned club drug provide quick relief for tens of thousands of people suffering with treatment-resistant depression? Increasingly, a chorus of voices in the medical and scientific communities are answering “yes.”

The newest salve in […]]]>

Could a much-maligned club drug provide quick relief for tens of thousands of people suffering with treatment-resistant depression? Increasingly, a chorus of voices in the medical and scientific communities are answering “yes.”

The newest salve in the ongoing struggle against the world’s costliest and most widespread mental illness may be ketamine, a drug primarily used as a veterinary anesthetic but approved for limited human use and popular as an illegal street drug. Its novel properties put ketamine outside of the normal classes of accepted antidepressants that raise serotonin levels in many cases.

“Our studies with ketamine include patients for whom nothing has really worked,” said Dr. Ronald Duman, a professor of psychiatry and director of the Abraham Ribicoff Research Facilities at Yale University. “With very low doses of ketamine, two to three hours after [administration], patients show relief.”

Still, he said, “Clinicians are very cautious. There’s a lot of concern because ketamine is a drug of abuse.”

To fully understand the ketamine revolution and why it has intrigued doctors and researchers is to address some of the concerns and shortcomings of traditional antidepressants. Almost all of those medications act as antagonists for the chemicals they work on — that is, they block the binding and reabsorption of those compounds, which allows levels in the brain to build.

Ketamine, sold as Ketalar, is primarily used as a veterinary anesthetic. Source: NPR

 

Instead of the traditional transmission sites, ketamine works on receptors that release glutamate, a neurotransmitter that affects learning and neural activation. Many patients who have already run the pharmacological gamut in search of an effective treatment respond incredibly well to ketamine, raising hopes that the drug may succeed where brand-name SSRIs (Celexa, Prozac, and Paxil) and SNRIs (Efexor and Cymbalta) have failed.

Ketamine research received a timely shot in the arm about one year ago, when the results of a high-profile study were published in the American Journal of Psychiatry. The double-blind study, which enrolled a total of 73 patients at Baylor College of Medicine in Texas and the Icahn School of Medicine at Mount Sinai in New York, sought to establish whether ketamine was a more effective antidepressant treatment than a low doze of midazolam, a traditional hypnotic and anticonvulsant.

A single dose of ketamine improved depressive symptoms within 24 hours in 64 percent of the test subjects, most of whom remained clear of symptoms for seven to 10 days. The scientific community greeted these results with qualified enthusiasm. Drs. James Murrough and Dan Iosifescu, the study’s chief authors, concluded that the experimental results served to “further support NMDA receptor modulation as a novel mechanism for accelerated improvement in severe and chronic forms of depression.” The NMDA receptors are the principle regulators of neural glutamate.

Recent scientific interest notwithstanding, ketamine has traveled a long and perilous road to arrive at the doors of mainstream medical acceptance. First synthesized in 1962 by Dr. Calvin Stevens of Parke-Davis, ketamine was intended to serve as a human anesthetic. After FDA approval, it was given to American troops in the later years of the Vietnam War. Expanded psychiatric use stateside allowed for the drug to be diverted onto the streets, where it found a home in the hippie counterculture with other “downers” like barbiturates and Quaaludes. But ketamine truly came into its own as a recreational drug in the 1990s, when it surfaced as a “club drug” alongside GHB, alkyl nitrates, 2C-B, and MDMA. On dance floors from New York City to Hong Kong, it was know as “Special K” and the “New Ecstasy,” gradually becoming an integral part of the then-booming rave subculture. A string of overdose-related deaths and negative publicity from the educational D.A.R.E. campaign rapidly reduced ketamine’s popularity in the last decade, as drug users began to turn towards opiate painkillers like Oxycodone and MS Contin, which are not only incredibly potent but legal as well.

Starting in the mid-2000s, however, universities and research institutions began to investigate the antidepressant properties of the drug as more failed to respond to traditional antidepressants. Today, multiple studies in the United States, Canada, and Europe are in the process of studying the drug’s psychiatric uses, looking beyond depression to illnesses like anxiety and bipolar disorder. In several states, ketamine is already being distributed legally for medical purposes.

“Private clinics are opening up that are offering ketamine off-label, mostly for neuropathic pain,” said Duman.

Quick relief and apparent resistance to other antidepressants are driving the interest. Traditional antidepressants increase the levels of serotonin and several other neurotransmitters. Tricyclics act primarily on serotonin and norepinephrine, MAOIs on melatonin, epinephrine, and phenethylamine, SSRIs on serotonin, SNRIs on serotonin and norepinephrine, and atypicals that mostly regulate dopamine.

Ketamine is even starting to pique the curiosity of the commercial sector. Naurex, a biopharmaceutical company based in Evanston has been developing and testing a ketamine-like compound known as GLYX-13 for several years. The company recently raised nearly $80 million from private investors like the Cowen Group to finance further research and expanded clinical trials. In a press release published Wednesday, Naurex’s president and CEO Dr. Norbert Riedel expressed optimism that GLYX-13 could open a new front in the fight against depression.

“Currently marketed antidepressants all work via similar pathways in the brain and do not adequately treat 45 percent of individuals with major depression,” Riedel said. “Repeated treatments with GLYX-13 produce a sustained response in patients who inadequately respond to marketed antidepressants.”

Riedel and others at Naurex have gone to pains to clarify that while GLYX-13 works like ketamine, it is chemically distinct and produces fewer of the unsettling dissociative effects ketamine is known for.

“The key takeaways are that Naurex has succeeded where others have struggled by creating a modulator of NMDA that gives a rapid, robust, and durable response without creating a psychomimetic effect,” said Ian Stone, a representative for Naurex.

Naurex’s decision to pursue GLYX-13 instead of ketamine points to the lingering concerns that many still feel about the drug’s use. Though depression patients would receive too little of the drug to bring on its occasionally distressing dissociative effects and hallucinations, reactions can vary considerably from person to person. And while ketamine is not physically addictive in the same way that illicit drugs like cocaine and heroin are, it is possible for users to develop a pronounced psychological dependence.

Still, ketamine seems poised to break into the public consciousness very soon. Government database ClinicalTrials.gov lists over thirty studies recruiting potential patients in the United States and Canada to investigate ketamine’s impact on everything from suicidal ideation to post-operative pain. And, according to Duman, American multinational Johnson & Johnson is currently developing a ketamine nasal spray that may revolutionize access to the drug. With such rapid momentum building, it is difficult to imagine that ketamine will be held back by the reputation of its checkered past for much longer.

 

By Melissa Schenkman

The long-time drug user, the patient taking prescription opioid pain medication, the high school student experimenting with drugs, and the child who confuses pills with candy, all have one thing in common.  They all […]]]>
Scripted by Melissa Schenkman, animated by Next Media Animation

By Melissa Schenkman

The long-time drug user, the patient taking prescription opioid pain medication, the high school student experimenting with drugs, and the child who confuses pills with candy, all have one thing in common.  They all represent people at-risk of an opioid drug overdose, the people NYPD officers have been trained to save.

Police officers armed with naloxone nasal spray, the intranasal opioid drug overdose antidote, have saved 18 lives since a Staten Island program began earlier this year.

The success is spurring the department to make strides in expanding its training, with the goal of equipping the entire police force of approximately 35,000 NYPD officers with naloxone kits. That would extend the program across all five boroughs of New York City.

The next program launch will be in The Bronx, where the rate of unintentional drug overdose deaths rose above the rate in Staten Island in 2013, according to data from New York City’s health department and the Office of the Chief Medical Examiner.

“This type of program goes with our mandate to be good Samaritans for the community,” said Sergeant Steven Sarao, Special Projects Unit, Deputy Commissioner Management, Analysis and Planning. He trains officers enrolled in the program.

In west suburban DuPage County, officers are making headway in the fight against opioid drug overdoses with naloxone as well while the Chicago Police Department continues to grapple with whether to implement an anti-overdose treatment program.

DuPage County’s program kicked off with 364 trained officers at about the same time the Staten Island program began. To date, DuPage has trained 1,699 officers to spot opioid drug overdoses and use naloxone kits. As of Sept. 30, officers have saved 23 lives, according to the DuPage Narcan Annual Report. The program has been implemented at 33 different communities and government units such as the Illinois State Police District 2 within the county.

Prior to the program, DuPage County had a total of 39 opioid overdose related deaths in 2012 and 48 in 2013. Implementing the Naloxone Program has cut these numbers by half, with only 26 deaths in 2014.

“Police officers are usually the first ones there. The program provides them with better equipment for officers to be prepared to help the public,” Sarao said.

Where it all began

The number of opioid drug overdose cases in New York City rose from 8.2 per 100,000 in 2010 to 11.6 per 100,000 in 2013. That’s a 41 percent increase in a three-year span, according to the data from the city’s Department of Health and Mental Hygiene Bureau of Vital Statistics and the Office of the Chief Medical Examiner. And in 2013, 77 percent of deaths from a drug overdose involved a drug from the opioid class.

But Staten Island had the highest rates of opioid drug overdose deaths among all five boroughs, with 20.6 per 100,000 in 2011 and 20.1 per 100,000 in 2012, double the citywide average. In 2013, Staten Island residents also had the highest rate of opioid drug overdose deaths related to using prescription opioid pain relievers in NYC, at 7.3 per 100,000.

After seeing these numbers, Anne Siegler and her department of health colleagues thought about how to combat the problem. Finding a solution led them to ask “Who are the people likely to be there saving lives?” The answer: police officers.

Staten Island, the smallest of the boroughs, with a population of 472, 621, was clearly the place to start.

A $50,000 federal grant made the program possible.

“It’s a small borough with such a big problem, “ said Staten Island Police Officer Christopher Fisher, who has been with the force for over nine years.

Drug overdoses do not discriminate

The stories of overdose victims reach far beyond the stereotypes. People have perceptions of drug overdoses, Sarao said. People think of habitual drug users, but anyone has the potential to have a drug overdose.

Officers have seen everything from the “accidental to overdose to suicide,” Sarao said. “It further illustrates the depth of the problem. It runs across all socioeconomic spectrums.”

It can happen to the elderly lady with cancer or the young child who mistakes colorful opioid pain medication for candy, both unintentionally ingest too much of the medication and then stop breathing.

Several prescription pain medications are in the same opioid class of drugs as heroin. These include morphine, methadone, oxycodone, oxycontin, hydrocodone and fentanyl.

“They are great pain relievers, but they all have a problem that can cause an addiction,” said Dr. Charles Martinez, Deputy Chief Surgeon for the NYPD and medical director of the Emergency Service Unit Tactical Medical Team.

Training

Sarao, Martinez and NYPD Inspector Edward Carrasco direct officer naloxone training.  They teach officers how to identify overdose victims, the questions to ask witnesses, how to administer intranasal naloxone to the overdose victims, and the laws at hand.

The program is a peer-based training program, where officers are trained and then go on to train fellow officers who often work in the same department. This enables trainers to have good insight into situations their fellow officers may find themselves in, Siegler said.

When it comes to using naloxone in both New York City and in DuPage County, the 911 Good Samaritan Law is at play. The law encourages anyone witnessing an overdose “to do the right thing and call for help.” It also affords some protection from criminal charges and prosecution to the overdose victims.

“We want this to be something positive,” Carrasco said. As part of the Good Samaritan Law officers collect non-identifying information from overdose victims.

“We don’t collect intel. Our purpose is to administer it and get them to the hospital to get them the help that they need,” Sarao said.

NYPD are afforded an additional level of protection by the Overdose Law in New York State. The overdose law “protects the non-medical person who administers naloxone in the setting of overdose from liability.” Liability is always a concern, though, when it comes to a medical intervention.

“It helps us to want to use it because we know there are no repercussions if we want to use it and it doesn’t work,” Fisher said.

Back at home

Dr. Steven Aks, an emergency room physician and director of the Toxikon Consortium at Chicago’s Cook County Hospital operates a naloxone program with patients who have an opioid addiction problem and their families.

He hopes to get more physicians actively engaged in prescribing naloxone and training families to administer it.

As a member of the American College of Medical Toxicology’s Board of Directors, Aks recently co-authored a position statement entitled, Expanding access to naloxone in the United States, published in Clinical Toxicology.

The statement concludes that access to naloxone beyond a healthcare setting is an important part of addiction treatment and a safety issue, stating:

“It is an effective medication whose timely administration will frequently prevent opioid-induced overdose death.  Current political and and medico-legal barriers excessively restrict access to naloxone for those in need.”

Over the years Aks has had many interactions with patients in an overdose scenario here in Chicago,  including those overdosing on prescription painkillers.

“The prescription opioid problem is on the radar. Managing chronic pain is controversial,” Aks said.

People who can’t get prescription painkillers, often seek out heroin, which is less costly, he said.

As for the Chicago Police Department, “Unfortunately our department has no current plans to implement a naloxone program, now or in the near future,” stated a representative of the Office of News Affairs, who responded in an email.

When an overdose occurs, the window of time to reverse course is only “precious minute,” Martinez said. Police officers are the first of the first-responders on the scene and the naloxone program makes those minutes count.

“The program is changing the role of the police officer from law enforcer to life saver,” Martinez said.

Scripted by Michaela Meaney, animated by Next Media Animation

By Michaela Meaney

At 53 years old, arthritis controlled Timothy Byrne’s life. The pain in his hip affected just about everything he did. He could not sleep. He had trouble getting in and out of the car. Even bending over […]]]>

Scripted by Michaela Meaney, animated by Next Media Animation

By Michaela Meaney

At 53 years old, arthritis controlled Timothy Byrne’s life. The pain in his hip affected just about everything he did. He could not sleep. He had trouble getting in and out of the car. Even bending over to start the lawn mower felt like a challenge.

“I really couldn’t pull the pull cord on the lawn mower anymore because of the pain factor,” said Byrne, of Wickliffe, Ohio, now 57 years old. “And, you know, if it takes three of four pulls to get the lawn mower started, I could hardly pull it once without being in excruciating pain, much less walking to mow it once it started.”

Byrne’s job as a butcher also required him to be on his feet nearly 45 hours a week, walking, standing and constantly moving around. So in 2010 Byrne decided the pain was too much to bear. He scheduled what is called a Birmingham hip resurfacing, an alternative procedure to a traditional total hip replacement.

Byrne has since returned to his active lifestyle and said he does not experience any problems with his hip. But the procedure does have its drawbacks and not every patient has a success story like Byrne’s. For older, less active patients and smaller patients, they face an increased risk of a type of fracture that would not occur in a total hip replacement.

WHAT IS A BHR?

A hip resurfacing differs from a total hip replacement in one major way: much of the bone is spared.

The femoral head, or the rounded part of the femur covered in cartilage, is connected to the pelvis by the acetabulum, or the hip socket. In a total hip replacement (THR), the femoral head and neck are removed and a metal implant replacing that part of the bone is inserted into the bone marrow cavity. A metal cup is also placed inside the hip socket, and since the implant’s head is smaller in size than the body’s original femoral head, a liner is also placed inside the cup. In most cases the liner is plastic and the implant’s head is metal, but heads and liners can also be made of ceramic.

In a hip resurfacing, the femoral head and neck are not removed but rather reshaped. The head is essentially smoothed down as areas where it lacked cartilage are cut off and a new surface is created. A mushroom-shaped implant is then cemented over what remains of the patient’s femoral head. In this procedure a cup is also placed into the hip socket, but no liner is inserted since the femoral head remains closer in size to that of the body’s original bone.

“It’s literally like putting on a hat instead of cutting off your head,” said Dr. Peter Brooks, orthopedic surgeon at the Cleveland Clinic.

Dr. Peter Brooks (r, back) and his team perform a Birmingham hip resurfacing, an alternative to a total hip replacement, at the Cleveland Clinic’s Euclid Hospital.

In addition to hip resurfacing, Brooks also specializes in total hip and knee replacements. Since the FDA approved the procedure in 2006, Brooks has performed over 2,200 Birmingham hip resurfacing procedures (BHR) – more than 300 per year – with a failure rate of less than 0.5 percent.

“Most surgeons don’t do resurfacing,” Brooks said, who is also a consultant for Smith & Nephew, the company that manufactures the BHR device. “Perhaps 1 percent of orthopedic surgeons will even do resurfacing devices, so just statistically you’re very unlikely to meet a surgeon that does resurfacing.” For surgeons to perform the procedure, the FDA requires they go through a special training.

The Birmingham hip resurfacing was developed in Birmingham, England, in the late 1990s by British orthopedic surgeon, Derek McMinn, the surgeon who trained Brooks.

When it comes to hip resurfacing, “Birmingham” is more like a brand name for the device’s design and technique, as there are other resurfacing devices available and ones in the past that were taken off the market. In fact just this year two devices available in the U.S. were taken off the market, Brooks said. According to the 2013 annual report released by the Australian Orthopaedic Association National Joint Replacement Registry, BHR was the most used device with the one of the lowest failure rates in procedures reported to the registry.

A PROCEDURE FOR YOUNGER PATIENTS

Byrne was only 53 when he received his BHR, as is the case with most patients who have the procedure.

“I understood there were greater limitations placed on you after a complete hip replacement as compared with a Birmingham,” said Byrne. “And that’s why I went with the Birmingham, because it was considered, they said, ‘a young person’s hip replacement,’ because after the Birmingham you could get back to doing whatever you wanted to with fewer limitations than a hip replacement.”

But the BHR is not for everyone. Brooks screens patients and normally only selects younger, active patients with large, strong bones. If it is done in an older patient, “you’ve lost two of the most common advantages of hip resurfacing – the increased activity levels and the ability to avoid a revision total hip replacement,” he said.

ACTIVITY LEVELS

One of the reasons why a patient would be able to get back to an active lifestyle with a BHR is because of the device’s design. The average size of a femoral head in a hip resurfacing patient is 52 millimeters, according to Brooks. But in a THR the femoral head and neck are cut off and replaced by an implant. If a patient receives an implant with a head that is 32 millimeters, a liner must compensate the rest of that space, and this opens up the opportunity for the device to pop out of the socket.

With a younger patient the likelihood of an implant popping out of the socket may be greater than with an older patient, since younger patients are usually more active than older patients. And according to Brooks, the most common reason for repeated hip surgery in the U.S. is the device popping out. In more than 2,200 BHR procedures performed by Brooks, not a single device has popped out of a patient’s hip socket.

As younger patients also tend to be more active, they may still continue to do things that would affect their hip implant, such as playing high impact sports. For Dr. Riyaz Jinnah, orthopedic surgeon at Southeastern Health, this is something he would discourage his THR patients from doing.

“What you’re worried about more is the loosening of the component from the bone,” said Jinnah, who has been doing hip resurfacing since the 1980s and Birmingham hip resurfacing since being trained by McMinn in 2006. Since the 80s Jinnah has done over 1,500 hip resurfacing procedures.

Brooks agreed that impact sports are not recommended for THR patients. With resurfacing patients, it’s a different story.

A Birmingham hip resurfacing device, made from a composite of cobalt and chrome, is a small implant used in the alternative procedure to total hip replacement. Michaela Meaney/MEDILL

“There’s actually a tiny gap in between the ball and the socket, and it’s designed to pull fluid in with movement,” Brooks said. “So your resurfacing device actually does better and lasts longer if you’re active.”

Texas Rangers pitcher Colby Lewis had a hip resurfacing in 2013 and has since returned to playing major league baseball. The only professional athlete who returned to the field with a THR was Bo Jackson, after being injured during a football game in 1991. However he returned to the MLB and not the NFL.

“The big advantage of that type of hip replacement is the recovery of your range of motion, for people like ballerinas, dancers, or people that don’t want their hip to come out of the socket,” said Dr. William Long, orthopedic surgeon at Good Samaritan Hospital in Los Angeles. “If they’re going to put themselves at risk of that, that hip does better than other hips in that area.” Long is also the medical director of Good Samaritan’s Orthopaedic Computer Surgery Institute.

AVOIDING A REVISION SURGERY

The plastic liner in the THR also presents an issue. It wears.

“Many times I go into surgery just to change a plastic, like you would change your breaks,” Brooks said. “Maybe pads this time, another time you might need something more, eventually you just get a new car.”

Brooks also said a ceramic liner may crack.

A Birmingham hip resurfacing device compared to two total hip replacement devices (l to r). Michaela Meaney/MEDILL

The THR changes the way weight is distributed throughout the femur, which can have adverse effects on the upper part of the bone. According to Brooks, when the top of the femur is cut off and the implant is placed down the bone marrow cavity, a patient’s body weight is transferred to the end of the implant.

“As a result the remaining bone of the upper femur is not loaded. So it gets weak,” Brooks said. “So you lose bone on the day of surgery, you lose bone through weakening over the next four of five years as the body adapts, and in fact, you gain thicker bone farther down in your leg where the stresses are now being transferred.”

Because the bone has become weak, there is potential for a fracture.

So why would a BHR not be viable for older patients?  A THR works better for them because they generally have a shorter life expectancy.

“The main advantage of resurfacing in younger people is that it gives them another step before they need a revision of a total hip replacement,” Brooks said.

Jinnah explained that in a 60-year-old patient a THR would last on average 15 to 20 years.

“But if you’re 40 and you’re doing a total hip, then you’re going to have to have a revision and then another revision, so really resurfacing started as looking for something less radical as a total hip so that we could, they way that I put it is, add one more bite at the cherry,” Jinnah said.

NOT FOR EVERYONE

Often times the BHR is marketed as a less invasive procedure, since more of the bone is saved when compared to a THR. However Brooks explained otherwise:

“It’s actually more invasive because these parts are bigger, chunkier parts, you need a somewhat longer incision to get them in, and the dissection – the separation of your muscles and ligaments – is more extensive with a resurfacing. So it is actually a bigger operation than hip replacement,” he said.

And as with any other surgical procedure, the risks of infection and blood clots are also present.

However with the BHR there are two main risks unique to the procedure. The first is too much metal debris in the body.

The BHR device is a composite of cobalt and chrome. Chromium naturally occurs in all humans but it occurs at very low levels. The amount raises with a BHR, but not by that much.

“Right now, un-operated, we have less than a half a part per billion of chromium circulating in our bodies,” Brooks said. “After a properly done Birmingham, you can expect that level to roughly triple to about one and a half parts per billion.”

Brooks explained that too much metal debris could cause pain, swelling, tissue destruction and damage parts of the body like the heart. Metal debris could get into the body through one of three possibilities:

• The device implanted was not a Birmingham. Brooks noted that some devices spread excess metal debris more than others.

• The procedure was not done correctly. If the device’s cup is inserted into the socket at an incorrect angle, the head will rest on the rim, or the edge of the socket. Then the entire day the head’s rounded surface will scrape against the flat edge and metal shavings will make their way into the body, said Brooks.

• The patient is too small. This means patients with smaller bones, usually women, have less of a success rate than those with larger bones. A 2012 study published in The Lancet on behalf of the National Joint Registry for England and Wales looked at hip resurfacings in 31,932 patients. In women, those with smaller resurfaced heads had higher failure rates. With the BHR, Smith & Nephew’s smallest sizes begin at 38 millimeters, but Brooks will not resurface any women that fall under the first three sizes. Brooks also explained that hip dysplasia, which affects more women and causes the femoral head to twist out of the socket, can adversely affect a hip resurfacing as well.

The other risk unique to a hip resurfacing is a femoral neck fracture. Because the femoral head and neck are not removed in a resurfacing when they would be in a THR, the neck is weaker while in recovery from being grinded down during the procedure.

“That femoral neck piece, that piece of bone it could break,” said Long. “And a total hip will never break at the neck, almost never.”

To limit the possibility of that happening, Brooks advises his patients not to do any activity that could put too much pressure on the weak bone for the first year. Jinnah also recommends his patients to do the same, but only during six months of recovery.

“And I tell people it’s like ice cream falling out of your ice cream cone,” Brooks said. “Everybody cries and you have to get another one. Unfortunately the other one with a resurfacing will be a total hip replacement, and that will disappoint you.”

Long, who specializes in revision joint replacement surgery, said he believes it is too much of a risk to leave the femoral neck attached.

“Well if they put a stem in there the patient could be active immediately, and they wouldn’t have to have any year period to hope the bone gets stronger to prevent it from breaking,” Long said. “Why have a fat neck that breaks when you can have a metal neck that will never break?”

Long also explained that even if the neck does not break from being too weak, it does have the possibility of breaking if the resurfacing is not done correctly.

“If you don’t have everything perfect, the neck can hit the cup, and the neck breaks because of that,” he said. Long does not perform hip resurfacing, but he did spend a week in Vietnam learning informally from McMinn.

WHAT IT COMES DOWN TO

Like any surgical procedure, there are benefits and risks to doing a resurfacing. For Brooks it is about picking the right patient, the right device and the right surgeon.

Both Brooks and Jinnah stressed the importance of picking a surgeon who has done a large volume, as it takes more time to learn the complicated procedure.

“I’m doing more than 300 a year, and at that I’m still learning and I’ve been doing it for eight years,” Brooks said.

But Jinnah said that doctors should not deny the patient of the procedure if the patient is a viable candidate.

“If you don’t do them don’t do them, but send them to people who do,” Jinnah said. “Don’t deprive the patient of that thing.”

However most surgeons are more likely to recommend a procedure they do and think is best.

Long, who does over 100 revision joint replacements each year, does believe that the BHR is a good procedure.

“I’m not saying one is bad and one is good, or one is great and one is mediocre, I’m saying that I believe that what I do is better,” he said.

Brooks said, “Really the only way if you’re a patient to know if you’re a candidate for a resurfacing is to speak with someone who does it.”

A record number of measles cases is hitting the U.S. this year compared to any time since 2000 when measles was virtually eliminated. The cause: a drop in inoculations, according to the Centers for Disease Control and […]]]>

A record number of measles cases is hitting the U.S. this year compared to any time since 2000 when measles was virtually eliminated. The cause: a drop in inoculations, according to the Centers for Disease Control and Prevention.

Measles cases have reached a record number in 2014 compared with previous years. Photo courtesy: http://www.cdc.gov/media/releases/2014/images/p0529-measles.pdf

 

There have been 603 reported cases of the measles virus from January 1 through October, according to the CDC. This is the highest number of reported cases since measles elimination was declared in the U.S. in 2000.

Vaccinations are a staple weaved into the fabric of global public health. They have been credited with ridding the world of smallpox, eradicating polio nationwide, and temporarily eliminating the measles virus in the United States.

Arguably, “vaccines are one of the greatest public health achievements of all time,” said Tina Tan, infectious diseases attending physician at Lurie Children’s Hospital in Chicago.

But even though they’ve been credited with these advances, vaccines have come under fire in the last 20 years. Rumors linking childhood immunizations to food allergies, diabetes, asthma and autism have frightened increasing numbers of parents into refusing to vaccinate their children, despite CDC recommendations.

Public health professionals credit the Measles-Mumps-Rubella vaccine with the elimination of the measles virus in the U.S. in 2000. That meant that there had been no continuous measles virus transmission in the U.S. for 12 months. However, in 1998, the MMR vaccine came under intense criticism when a now discredited study published in the British journal, “The Lancet,” linked an ingredient found in the MMR vaccine to autism.

Even though the study was widely discredited by peer-reviewers even before it was retracted by the journal in 2010, many parents still refuse to have the vaccine administered to their children.

“There has definitely been an increase in parents who refuse any or all CDC and AAP [the American Academy of Pediatrics] recommended childhood vaccines,” Tan said. “There is still a lot of misconceptions and mistrust surrounding vaccines and a lot of inaccurate or wrong information that is freely available on the internet.”

Photo courtesy: http://www.cdc.gov/measles/cases-outbreaks.html

 

With fewer people across the country immunizing their children with the MMR vaccine, 20 different outbreaks accounted for 89 percent of the 603 measles cases this year and the cases have room to grow.

“Routine use of the childhood vaccines has decreased most diseases by greater than 95 percent compared to the pre-vaccine era,” Tan said. “The use of vaccines was what resulted in the global eradication of smallpox and in the goal for the eradication of polio.”

So should everyone get vaccinated? The short answer is no. According to the CDC’s website, some people shouldn’t be immunized — particularly those who are allergic to an ingredient found in any of the vaccinations. Eula Biss, mother and author of the book “On Immunity,” agrees.  A vaccinated child in a community full of unvaccinated children is at a greater risk of catching a vaccine-preventable illness than an unvaccinated child in a community full of vaccinated children is, asserts Biss, a Chicago author.

Community or “herd” immunity implies an inoculation of the majority in order to prevent an outbreak of disease. Photo courtesy: http://www.cdc.gov/vaccines/vac-gen/whatifstop.htm

 

In a sense, we inoculate the majority who can safely receive vaccinations to help protect the immunity of those around us, including the small minority that cannot be vaccinated. That immunity also protects those who refuse to be vaccinated. But protection spreads thinner when the numbers who refuse increase. “It shouldn’t be seen as asking too much for people to accept the risk of vaccination in exchange for the value that it offers in terms of protecting other people,” Biss said.

Still, there is risk associated with vaccinations. For example, rotavirus disease is a gastrointestinal illness that is most common in infants and young children. RotaShield, the vaccination created to prevent the disease, was recalled after one to two infants for every 10,000 doses experienced a severe allergic reaction. Biss shared an event that illustrates her perspective on that risk. She said she had what doctors termed a low-risk pregnancy leading up to the birth of her son. Even so, she experienced a severe, life-threatening incident immediately after her son was born in which her uterus inverted, causing her to lose a considerable amount of blood in just a matter of minutes. This only happens to one in 3,000 women, doctors told her.

“That one in 3,000 number got translated to me as very, very rare,” Biss said. “And then when I began researching vaccines, I learned that if a vaccine that we were giving children had a [serious] side effect rate of 1 in 3,000, it would not be allowed on the market. In terms of childbirth, we consider that rate very rare. With vaccines, it would be an unacceptably high rate.”

This ethical internal conflict is one that plagues mothers around the nation. Amira Kando, a Glendale Heights mother of six, hasn’t followed the government vaccine recommendations for her last three children. Her youngest remains completely unvaccinated. As she researched and learned more about vaccines, she said she concluded that the risk involved might be too great.

She said: “My responsibility to my child as a parent is to keep them as healthy as possible and not put on any additional risk by putting any chemicals in their bodies that are known to cause harm.”

That moral dilemma was something Biss also faced when deciding whether or not to immunize her son.

“With the awareness that it carried risk, I thought ‘How would I feel about this if he is the one who has an adverse reaction?’” she questioned. “And when I reflected on it deeply, I thought, ‘It would be horrible, and tragic, but I don’t think I’ll regret having done something that I think is essential to the good health of our society as a whole.’”

A brief history of vaccinations
Immunizations have saved millions of lives in the 200 years since the modern concept of vaccinations was introduced. Before vaccines, the smallpox virus devastated communities across the world. As early as 400 B.C., physicians knew that the people who survived smallpox were able to resist the virus for the rest of their lives, notes Dr. Stephen Riedel, professor of pathology at Baylor University in Waco, Texas, in an article on the history of the disease.

Riedel’s recounts how, in 1796, British surgeon Edward Jenner applied that knowledge to introduce a simple form of a smallpox vaccination using the pus from cows infected with cowpox. According to the Jenner Institute’s website, Jenner would take matter from oozing pocks on infected cows and rub it against the open skin of a non-immune individual. In many cases, the people he inoculated were able to live their lives without ever contracting smallpox, regardless of exposure to the virus. This process of inoculation, while not as sanitary as the way it’s practiced now, set the stage for the immunizations we know today. Smallpox was declared eradicated around the world in 1980 by the World Health Organization, and experts believe vaccinations played a large role in eliminating the disease.

Jenner’s smallpox vaccine was the first inoculation that worked. Vaccines to prevent tetanus, diphtheria, polio, yellow fever, hepatitis A and B and other diseases were developed in Jenner’s wake.

In the early 20th century, polio was the most feared disease in the U.S. It crippled an average of more than 35,000 people nationwide each year, according to the CDC. A researcher named Dr. Jonas Salk developed the polio vaccine in 1952, the year the nation endured its greatest polio outbreak with 58,000 confirmed cases. Salk tested the vaccine on more than 600,000 children in 1954. By 1994, after additional edits were made to make the vaccine more efficient, the disease was declared eradicated from the U.S. However, polio it is still prevalent in other countries. An on-going effort by the World Health Organization to eradicate polio worldwide was announced in 1988, and that effort continues today.