Parents Seeking Perfection Tumble Into Stereotypes
Samantha Critchell, Associated Press- 1/24/2005

NEW YORK - Many parents teach their children that stereotyping is bad. It fuels divisiveness, they'll say. That might be true -- but so might the stereotypes. In "The Perfect Parents Handbook" (St. Martin's Griffin), Jennifer Conklin pokes fun at all the. people she sees at the playground. They all fall into one of nine categories: classic, hip, power, sporty, neotraditional, bohemian, Euro, martyr and paranoid.  "I've met all these types," says Conklin, who did her research over 13 years at the playground as she watched, her three children, now 13, 9 and 7, grow up. She adds: "I didn't have to make one thing up."
     As described in the book, classic parents, who take their kids to Stratton, Vt., every winter and Nantucket, Mass., every summer, worry about getting their children to behave at the country club Christmas party with the grandparents, while hybrid car-driving bohemian parents exert a lot of energy keeping their children away from anyone with an infectious disease since they haven't been vaccinated. Paranoid parents barely let their kids out of the house, let alone their sight, and sporty parents struggle to get along with coaches, referees and fellow team parents as they do laps around the track with their Baby Jogger stroller.
     "Parenthood is a lifestyle. What you push, what kind of stroller you have, is as much a statement about you as what you drive. You can walk into a home and classify what kind of parents they
are by the stuff that surrounds them," Conklin says. The kids are then trained to fall in line from a young age, she explains. It's why some children take fables and legends classes after school while others are at photography lessons.
     There seems to be only one thing that transcends most of the groups: the Gap. Classic Dad wears the khakis and Hip Dad wears the gray T-shirt; Neotrad Mom has the Gap capri pants while her daughter has the backpack. Of course, the Euro family, clad in Dior, W Tod's and Jimmy Choo, wouldn't be caught dead in such gear.
     Conklin says she picks mostly on the upper middle class, which has made a sport out of "perfect parenting." (When it comes to poor or struggling families, Conklin says she sees nothing funny about parents juggling multiple jobs, trying to put food on the table.)
     People tell her she's a "neotrad" parent, probably since she aspires to "do it all" but doesn't always have the means or the ways. Conklin, however, also says she can be a bit martyrish and a bit sporty, which is why she had a hard time understanding why her daughter didn't want to play field hockey.
     Most of these parenting styles were cooked up by baby boomers who need to define and analyze every aspect of their lives, according to Conklin. The previous generation was too busy trying to keep up with the Joneses. "When our parents were raising us, `parenting wasn't a verb," she says. "Parenting is so much about ourselves now, and I'm asking myself, `Are we parenting for each' other rather than our kids?"' She's not faulting modern parents, though. Mothers and fathers, whether they're neotrads sitting on the front porch of their charming-but-run-down home in Evanston, Ill., or power parents breezing in and out of their five bedroom pad in Manhattan's Upper East Side, they're doing everything out of a basic love for their children.
     Even slacker parents, who infiltrate every group, have the best intentions. "They're the ones who put nuts in the cookies," Conklin says with a laugh. "Slackers can be in every group. They don't give time to competition but they do give time to, their kids. ... If you're trying too hard, you're not enjoying parenting or your kids. Maybe slackers have the right idea. I'm happy to know the slacker moms that I do -- and their kids are great!"
     The point of the handbook, Conklin explains, isn't to be cruel or critical; it's supposed to make parents laugh. "However you are raising your children is what you think is the right way to raise your children. It's serious stuff and you can't stop the madness, but you can take one moment to laugh at yourself and the others around you -- who are also taking themselves v-e-r-y seriously," she says.



A Pill's Surprises, for Patient and Doctor Alike
Richard Friedman, M.D., New York Times- 1/25/2005

As a psychopharmacologist, I know that every patient responds slightly differently to medication. But it wasn't until I met Susan that I understood just how differently. She'd come to see me because she was depressed, and I'd successfully treated her with a course of Zoloft, a popular anti-depressant. But as often happens, Susan's desire for sex had vanished along with her depressed mood. "I kind of miss it, but I feel really bad for my husband, who's getting very frustrated," she said.
      The sexual side effects of antidepressants like Zoloft and Prozac -- the class of drugs known as selective serotonin reuptake inhibitors, or S.S.R.I.'s -- are well known. The drugs frequently cause diminished libido, erectile dysfunction in men, and delayed orgasm or an inability to climax at all in women. The same flooding of the brain with serotonin that alleviates depression leads to sexual effects in many patients. Early on, the rates of sexual side effects from S.S.R.I.'s reported in the medical literature were quite low, in the range of 10 percent to 20 percent. But clinicians knew better. Most of their patients reported some sexual effects, and it quickly became clear that the early reports were wrong.
      The reason for this error was simple. Early clinical trials of the drugs did not look for sexual side effects; they just recorded problems that patients spontaneously reported. Because most patients are reluctant to bring up any sexual side effects on their own, the researchers got the false impression that these drugs had little effect on sexuality. When the subjects were specifically asked about sexual side effects, the rates rose to 40 percent to 50 percent.
      Susan fell into that unlucky percentage, and she asked me if anything could be done. There were three possible approaches, I told her. She could stop the drug from time to time, a strategy that might temporarily restore her sex drive but could cause discontinuation symptoms; she could lower the dose of the antidepressant, which might provoke a relapse of depression; or we could try to counteract the side effects with another medication.
      A temporary escape didn't appeal to Susan, so we decided on the third approach, an antidote. The question was, Which one? Serotonin-blocking drugs like Periactin, an antihistamine, treat sexual side effects, but they can also undo the drugs' antidepressant effects. I decided to prescribe Wellbutrin, a different class of antidepressant that has shown some ability to counteract sexual dysfunction caused by S.S.R.I.'s. Little did I know.
      Two weeks later, Susan called from her cellphone to say that the antidote was working. While shopping, she said, she spontaneously had an orgasm that had lasted on and off for nearly two hours . She was more delighted than alarmed, but I was stunned. I have had my share of therapeutic surprises, but this was hard to believe. Was this a medical emergency or unrepeatable fluke that Susan needn't worry about? When I saw her the next day in my office, she was calm and somewhat amused by my concern. After all, since when is an orgasm a cause for alarm? I was worried, though, that the addition of Wellbutrin had set off an episode of mania, an effect that antidepressants can have in up to 5 percent of patients. In that case, her prolonged orgasm might be a symptom of hypersexuality, common in mania. But Susan didn't seem either manic or depressed.
      It seems that for her, the Wellbutrin just had an extreme sexually enhancing effect. Several colleagues told me about patients of theirs who had experienced heightened sexual desire on Wellbutrin, but none of the reports came close to Susan's. That Wellbutrin can enhance sexual pleasure isn't surprising: it increases the activity of dopamine, a key neurotransmitter in the brain's reward pathway. In fact, drugs of abuse, like cocaine, alcohol and opiates, release dopamine in this circuit - and so does sex.
      A year has passed without a recurrence of this surprising side effect. But Susan is enjoying sex now - clearly more than she did before she became depressed. Because this was her first episode of major depression, the chance of a recurrence was only about 50 percent, so I suggested stopping the antidepressant. She liked that idea, but then paused and asked, "Do I have to stop the Wellbutrin, too?" We both laughed.

Sorting Out Ambivalence Over Alcohol and Pregnancy
Jan Hoffman, New York Times- 1/25/2005

When Janet Golden was kicking around in utero 53 years ago, pregnant women of her mother's generation were encouraged to enjoy their 5 o'clock cocktails. A martini calmed nerves; a glass of wine helped a woman to sleep. But don't drink too much, obstetricians cautioned: all those empty calories! By the mid-1960's, many obstetricians even believed that alcohol could halt premature labor. As noted by Dr. Golden, now a medical historian at Rutgers University in Camden, N.J., when women arrived at the hospital in premature labor, they were often handed a vodka and orange juice or given alcohol intravenously. But in 1973, a new diagnosis, fetal alcohol syndrome, had been identified in the children of women who drank heavily during pregnancy. The symptoms included diminished I.Q., small stature, flat face and drooping eyelids.
      In her new book, "Message in a Bottle: The Making of Fetal Alcohol Syndrome" (Harvard University Press), Dr. Golden argues that the political, legal, medical and social response to fetal alcohol syndrome has been inconsistent, often illogical and frequently volatile. If alcoholism has been acknowledged as a disease, she observes, then why have pregnant women who drink been charged with child abuse? Ultimately, she writes, fetal alcohol syndrome is a template on which society continues to rewrite its ambivalent feelings about pregnancy, maternal responsibility, the rights of the fetus and alcoholism.
      In a telephone interview from her home outside Philadelphia, where she lives with her husband and two sons, Dr. Golden said she hoped that her book would be read as an argument for more and better treatment programs. Despite the mandatory labels on every bottle of alcohol now sold in the United States that warn pregnant women not to drink, she said, the syndrome "is still a relatively common birth defect."
Q. What started you thinking about fetal alcohol syndrome?
A. I was fascinated by the labels on the liquor bottles. It puzzled me as to why the first warning was about pregnancy, and not about drunk driving, which kills many more people. As a historian, I asked: surely we must have been thinking about women and pregnancy and drinking for a long time; why are we thinking about it this way now?
Q. Before fetal alcohol syndrome was identified, how did we think about women and pregnancy and drinking?
A. Actually, for most of Western history, societies had been mostly concerned with alcohol abuse by men. It was more prevalent, it was more visible, and it was linked to violence and social disorder. It had enormous social cost: men drank up their wages, beat their wives and children, lost jobs, went to the poorhouse. There was always a concern about whether alcohol affected sperm. People thought it was all there in the egg, and the sperm had to liven it up.
Q. So why were Americans finally able to accept that alcohol could have an impact on a fetus?
A. By 1973, we'd been through thalidomide and the rubella epidemic, which let people understand that the womb was not a protective barrier and that fetuses could be damaged by exposure in utero. Alcohol, too? O.K. That makes sense. And abortion looked like a quick fix to F.A.S. In the early days of Roe v. Wade, physicians openly talked about recommending abortions to pregnant alcoholic women. So: "We've discovered F.A.S., but we have a solution."
Q. How did the beverage industry react to having to label every liquor bottle with warnings?
A. They fought labeling tooth and nail when it was first proposed. They didn't want to have an admission on their packages that there were risks involved in drinking. But after the Cipollone decisions about federal tobacco labeling, they saw that labeling might indemnify them from lawsuits. So they did a political turnaround. Instead, they worked very hard to make sure the warnings didn't appear on the front of bottles and that, most importantly, they didn't appear in beverage advertising, and particularly beer advertising, on TV.
Q. When we as a society concern ourselves with pregnant women who drink, who is the primary patient, the woman or her fetus?
A. By the 1980's and crack babies, we shifted our attention from the problems of women struggling with substance abuse who need health care to taking a criminal justice approach that said, Bad women are doing bad drugs and harming fetuses. Now we had guilty mothers and innocent babies. There was an erosion of sympathy for the women struggling with drinking and a desire to punish them in the name of protecting potential future citizens. You have a legal right to drink as an adult, but women began to be arrested and charged with child endangerment for drinking while pregnant. People who would never walk up to a guy at a bar and say, "Let me call you a cab," felt completely free to walk up to a pregnant woman and say, "You shouldn't be drinking."
Q. How pervasive is fetal alcohol syndrome?
A. The C.D.C. says that 0.2 to 1.5 per 1,000 live births in the U.S. are babies born with F.A.S. It's a real syndrome, and I have no question that it exists.
Q. But wouldn't the number of cases be far greater if we didn't have the warnings?
A. Warnings are very effective for people who want to hear them and heed them. A lot of people said, "So alcohol is bad, I won't touch it when I'm pregnant, and I'll worry about whether I drank the night I conceived." And for those women, giving up alcohol for nine months is not a significant sacrifice. You could feel good that you'd made a decision to promote the health of your fetus, and it's a sign of how responsible you are. But the labeling has not had a major impact on the incidence of F.A.S. Chronic alcoholics and heavy binge drinkers, it appears, don't stop drinking because of a warning label.
Q. If strangers feel it's incumbent upon them to intervene when they see pregnant women drinking at bars or parties, why, as you write, are obstetricians uncomfortable taking a more aggressive role with their patients?
A. If you're diagnosed with diabetes, the doctor can say: "I can send you to a diabetes center with a specialist. You have cancer? I know where to send you. But you have a relapsing chronic alcohol abuse problem? I don't know where to send you. And I am not sure I want to deal with you, because it's relapsing." It's very hard to find treatment beds for pregnant women. And women are reluctant to enter treatment, because they have to put their other children in foster care and they're not sure they will get them back. It's a big commitment on the part of the patient and the obstetrician.
Q. Your book focuses on one diagnosis. What can we extrapolate from it?
A. Diagnoses are developed in a cultural framework and their meanings change. What is important to think about is how we understand a diagnosis, not just from a medical point of view but as a culture that has to respond to people with that diagnosis. And that's true whether you have H.I.V. or diabetes or autism. F.A.S., for example, has gone from, "Oh, look, a scientific discovery!" to being a marker of bad mothering. And that still hasn't led to the creation of new and better services.
Q. Despite the absolutism of the warning labels, do scientists still disagree about what constitutes an unacceptable level of alcohol during pregnancy?
A. My sense is that some researchers see risks at moderate levels of exposure and others say you have to have a significantly high level of exposure. But underlying that is the methodology: you're asking women to recall how much they drank while pregnant. They may not be telling the truth, they may not recall, they may not reveal their illegal drug use as well, and other factors that compromise fetal health. It's not easy research to conduct. It's easy to control the amount of alcohol you give a pregnant rat.
Q. After six years of researching fetal alcohol syndrome, do you now have a gut instinct about whether it's O.K. to drink during pregnancy?
A. I've read so many different arguments from so many different scientists that I don't think I should comment. But in a litigious society, one that is committed to banishing all risk, then you have take a position against all drinking. In theory, anyone could be a terrorist, so everyone has to go through the line at the airport. Whereas in more practical terms, we might be able to develop a profile and only screen certain passengers, but we won't do that. So everyone has to get their luggage X-rayed.

Mentally Ill Kids Incarcerated, Study Finds
Elise Castelli, Los Angeles Times- 1/25/2005

WASHINGTON — Due to a lack of community resources, children as young as 8 are routinely incarcerated in California juvenile detention facilities while awaiting mental health care, according to a House study released Monday. A report commissioned by Rep. Henry A. Waxman (D-Los Angeles) found that of the 43 juvenile detention facilities responding to a survey, 27 held youths waiting for mental health services outside of the justice system. Eighteen of those institutions held such children between the ages of 8 and 12. They included both those who committed crimes and those who didn't but, for example, whose families couldn't handle them and called police. "It's a terrible failure of our healthcare system," Waxman said. "Incarcerating a child who needs mental health care causes worsening symptoms, risks physical injury to the kids and causes unnecessary expenses to the juvenile justice system. They don't know how to handle these kids."
      According to the findings, one in eight juvenile detainees in California is waiting for treatment, or more than 250 each night. The average stay in the detention facility is two months, which is three times longer than the national average. The cost of housing the youths awaiting mental health services is estimated at $10.8 million a year, the report found. "Juvenile detention centers are nearly bankrupt in the resources needed to identify children's mental health problems and provide the level of service needed," said David Steinhart, a California attorney and director of the Commonweal Juvenile Justice Program. "Kids arrested and locked up have multiple problems beyond mental health — including histories of drug abuse and dysfunctional families — and need help." Linda Shelton, who oversees Jane Hahn Juvenile Hall in Willows, said that when youths "go to juvenile hall, if they are receiving mental health services they are stopped. Our institutions are designed to help children involved in criminal activity. They are not psychiatric hospitals."
      Much of the solution to what the report calls "unnecessary incarceration" involves funding for more community-based counseling services, said Susan Burrell, an attorney in San Francisco with the Youth Law Center, a public-interest law firm specializing in issues affecting abused and at-risk children. "The basic problem is that there aren't enough mental health services in the community," she said. "The juvenile justice system becomes a repository for a lot of these kids."
      Burrell said she is hopeful that Proposition 63, which was approved in November and will funnel approximately $800 million a year in taxes on the richest Californians to fund mental health services, will provide some relief. "The good news now is that we have resources under Proposition 63, and the state is looking carefully at the high-needs populations, including children in juvenile justice facilities," Steinhart said. "But mental health needs to work with courts in a more organized way, so children who get dumped in the juvenile justice system get the help they need."
      Stephen W. Mayberg, director of California's Department of Mental Health, emphasized the need for more collaboration between mental health services and the juvenile justice system, which "have different goals and agendas," he said. "We need to view children in context of whole, not just that they committed a crime or that they have mental health issues, but seeing both and realizing that and work together," he said.

Alcohol Produces a Complex Cocktail of Effects
Andy Dworkin, Newhouse News Service- 1/25/2005

"One martini is all right," James Thurber wrote. "Two is too many. Three is not enough." Thurber clearly knew his way around a drink. But just what are those drinks doing around the body to make one feel so very high with one drink and so very low with the next? Definitive answers are scarce. Alcohol may be humankind's oldest and most-used drug. But it remains poorly understood.
     As a drug, alcohol has a singular ability to mess with many of the brain's major messaging systems. That makes it hard to track where all the booze goes in your head and complicated to figure out which switches are flipping, drink by drink, to create those intoxicating feelings.
Add in alcohol's effects on other body parts, including the liver and stomach, and even one drink causes a complex cocktail of effects. "Alcohol is what a pharmacologist would call a very dirty drug," said Dr. Robert Swift, a Brown University psychiatrist and alcohol researcher. "Most drugs work on a specific site in the brain. Alcohol works on many, many sites in the body"
     Alcohol's kick starts in the gut -- the proximal duodenum, to be exact. Most alcohol slips into the blood from that section of the intestines just below the stomach. The blood absorbs surprisingly little alcohol from the stomach itself, Swift said. In fact, enzymes in the stomach -- especially in men-- breakdown alcohol before it intoxicates. That's why eating a big meal makes you less drunk The food slows alcohol's rush to the intestines and traps some in the stomach, where it is destroyed.
But once alcohol hits the blood,; it runs all over the place. The molecules of ethanol -- the chemical name for drinking alcohol -- are so small they slip easily through most organ walls. That includes a natural barrier protecting the brain, said John Crabbe, director of the Portland Alcohol Research. Center at the Veterans Affairs Medical. Center in Portland, Ore.
     The brain's alcohol bath starts the intoxication. And as with most drugs, a good, old fashioned dopamine high seems to explain the high from one good old-fashioned. Although alcohol is a sedative, the average person doesn't notice much sedation from one drink, Crabbe said. What's felt instead is the boost alcohol gives to the dopamine system -- the same system turned on by most addictive drugs, such as methamphetamine and cocaine, said Robert Hitzemann, chairman of behavioral neuroscience at Oregon Health & Science University. Among dopamine's charms is its ability to send pleasure signals after bouts of eating, sex or drinking.
     Smoking magnifies the dopamine effects, Hitzemann added. Some unknown chemical in cigarette smoke interferes with the brain's breakdown of dopamine, leaving more to circulate. That could explain why drinkers and other drug users tend to smoke at the same time, he said. While pleasure flows, the first drink also hits the prefrontal lobe. That brain area, just behind the eyes, hosts functions including behavior, judgment and personality. When alcohol hits the lobe, it causes disinhibition -- the dance-on-the-table, flirt-with-the-boss effects of drinking.
     And though one drink puts few people over the legal blood alcohol limit for driving, it does hurt the brain's ability to perform complex tasks, Hitzemann said. To prove it to yourself, run a little experiment: Time yourself doing a set of 10 long-division problems. Have a drink, then do 10 similar problems. Compare your times. "You can detect impairment in as little as one drink" in the average person, Hitzemann said. "There's no doubt about that" Have another drink, and you probably will start to slow down from the alcohol buzz.
      The dopamine system hasn't quit. Instead, changes to two other neurological systems, subtle af ter one drink, are kicking into high gear. Meet GABA and glutamate --your brain's brake and throttle. Broadly speaking, GABA is an amino acid that limits the activity of neurons in the brain, slowing it down. Alcohol enhances the GABA system. So do Valium and related drugs. For that reason, Crabbe said, doctors treat chronic alcohol withdrawal with Valium-like drugs.
     The glutamate system has the opposite effect Crabbe said: "It's everywhere, and it's `Go fast.'" Drinking dampens glutamate's qualities, further enhancing alcohol's sedative effects. As drinking continues, these sedative effects strengthen. Memory dulls, and confusion sets in. The brain and body have trouble coordinating movement. Eventually, involuntary systems such as breathing start shutting down, which can result in a coma in people who drink very heavily.
     From the first sip, alcohol alters many organs apart from the brain: It dilates blood vessels, making the skin flush and releasing body heat. It irritates the lining of the stomach and increases gastric acid production, which can cause abdominal pain and nausea. Booze works through the liver and other tissues to lower blood sugar levels.
     Alcohol is also a diuretic, meaning that drinking makes you feel an urgent need to urinate.
While the brain turns, and the stomach churns, the liver toils to clear the body of booze. An enzyme called alcohol dehydrogenase changes ethanol into a chemical called acetaldehyde. That is "nasty stuff," Swift said, and fairly toxic. Most people quickly turn acetaldehyde into acetate, which the body makes into sugar and fat. But some -- including at least a third of people of Asian descent -- have a mutant form of the enzyme that turns acetaldehyde into acetate. Those people are stuck with more of the toxic product and its effects, including red-flushed faces, headaches and racing hearts.
     If alcohol is a puzzling story, hangovers are mystery novels. Few people research hangovers, Swift said, perhaps because they work so well to discourage people from excessive drinking. But scientists have several theories about what causes them. A seesaw illustrates one theory; said Kathy Gibson, nurse manager of the inpatient chemical dependency program at Providence Portland Medical Center in Oregon. "Alcohol, no matter how much you consume, takes you out of balance," she said. Consider the boost booze gives to the GABA system and its accompanying limits on glutamate. When alcohol changes these systems, the brain changes, too. That very adaptive organ tries to restore normalcy by growing less sensitive to GABA and more sensitive to glutamate -- basically stepping on the gas to counter alcohol's brake. When alcohol wears off, the brain is still in the foot-on-the-accelerator phase. That leaves the body overly excited and jittery: The heart beats quickly, and blood pressure rises. The newly sober may sweat or bolt awake from early morning sleep. Those effects linger until the brain readjusts to its predrinking GABA and glutamate levels.
     Other scientists think part of a hangover's hell may come less from ethanol than from other ingredients in drinks. Such flavoring and coloring chemicals are called congeners. They are more common in darker beverages, such as red wine, whiskey and some brandy -- precisely the beverages some drinkers blame for their worst hangovers. But others, including Crabbe, question whether anything really causes hangovers other than ethanol and more ethanol. "There's a million pieces of lore out there,' Crabbe said. "I'd be willing to bet that the severity of hangover is dose-o-falcohol related."



Patient Care vs. Corporate Connections
Reed Abelson & Andrew Pollack, New York Times- 1/25/2005

Like many prominent researchers at the nation's major medical centers, Eric J. Topol, the chief academic officer of the Cleveland Clinic Foundation, has over the years had consulting and financial ties with numerous drug and medical device companies. Dr. Topol, an outspoken cardiologist who frequently opines on the medical issues of the day, has done work for drug companies like Eli Lilly, the Medicines Company and a partnership of Bristol-Myers Squibb and Sanofi-Aventis.
     Recently, however, as he has come under the spotlight for potential conflicts of interest, he said in a letter to one company that he had decided to end most of his relationships to ''maintain my academic credibility.'' The decision follows a report in December by Fortune magazine that Dr. Topol, a leading critic of the painkiller Vioxx, was a paid consultant to a hedge fund that had made money betting that shares of Merck, Vioxx's maker, would fall. Dr. Topol severed his ties with that firm, though he said he had no knowledge of the firm's investment position.
     His voluntary move to end most of his corporate ties comes as drug makers find themselves under greater scrutiny for their relationships to researchers. At the same time, medical centers are trying to deal with doctors who are increasingly entangled with companies whose primary goal is to make money, not necessarily to deliver the most appropriate care.
     The Cleveland Clinic, one of the most entrepreneurial and prestigious medical institutions in the country, for one, is struggling to revamp rules intended to ensure that corporate connections do not lead to bias in patient care or academic research. But it is far from willing to sever all ties. The clinic, a nonprofit health system with nearly $4 billion a year in revenue, has in recent years become the epitome of Medicine Inc., where doctors and researchers are encouraged to develop new drugs, devices and medical treatments.
     It is hardly alone in confronting these ethical questions. But the aggressive and freewheeling capitalist spirit that has taken it to the top of the medical profession has also made conflicts of interest more visible than at many other institutions. Many of Dr. Topol's colleagues on this sprawling 130-acre campus are starting companies and serving as consultants and board members. In some cases, they may use their patients in clinical trials to test new treatments in which they have a financial stake. ''All of these financial arrangements with industry yield various kinds of conflicts,'' said Dr. Jerome P. Kassirer, a former editor in chief for The New England Journal of Medicine, who recently wrote a book, ''On the Take'' (Oxford, 2004), about the undue influence of business on medicine.
     To address those concerns, the Cleveland Clinic says it is overhauling its ethics policies, and will present them to the board for approval, perhaps within weeks. ''We want to protect data from money,'' said Guy M. Chisolm III, a cell biologist who is spearheading the effort. ''Money has no role to play in validating and directing data.'' But getting consensus on solutions is no easy matter, Dr. Chisolm said. ''We've grappled with them, we've debated them.''
     Delos M. Cosgrove, for one, who took over as the clinic's chief executive last October, says he does not believe that across-the-board restrictions are desirable. ''What we want to do is encourage innovation,'' Dr. Cosgrove said. ''There are always going to be conflicts in the world.'' The clinic, even in its new policies, will not prohibit financial relationships that give rise to conflicts. Most medical centers refuse to take this step because they rely on money from private industry, and they argue that any prohibition on outside business ventures would cause the best researchers to flee to institutions that allow them to profit more from their inventions.
     A few academic centers go as far as preventing researchers from studying a drug or a device from a company in which they have any financial interest. Harvard Medical School, for example, does not allow its researchers to receive significant compensation from serving as consultants or holding equity in private companies if they are studying anything related to those companies. But like most institutions, the Cleveland Clinic is trying to avoid outright bans by asking researchers to disclose their ties and trying to minimize the effect of the conflicts. Dr. Mildred K. Cho, a medical ethicist at Stanford University, however, argues that managing conflicts, especially when the institution is itself involved, is ''unlikely to be very effective, given all the pressures that are pushing in one direction.''
     Situated in a dismal area of Cleveland, the clinic, which was founded by four doctors in 1921, essentially operates as a gigantic group medical practice. It takes immense pride in its delivery of cutting-edge medicine, having pioneered angiography and coronary bypass surgery. Under the direction of its former chief executive, Floyd D. Loop, also a cardiac surgeon, the clinic amassed more than a dozen hospitals and focused its attention on one of the most profitable areas of medicine -- cardiac care. Within the last few years, it has started both a medical school and a venture capital fund called the Foundation Medical Partners, which invests in companies founded both on campus and outside. Though it sits in a gritty urban center, the medical center fairly gleams with freshness and wealth. Its paying customers -- patients with insurance -- are able to help finance the clinic's constant expansion and renovation. ''Our facilities are second to none,'' boasted Michael O'Boyle, the system's chief financial officer.
     The institution is now pouring some $500 million -- $300 million of which is expected to come from charitable donations -- into a new heart center, intended to showcase the latest in cardiac care and to treat the tens of thousands of heart patients who visit the clinic each year. The expansion comes on the heels of the construction of a new stem-cell research center. All of this display of financial resources has drawn criticism among some in the community that the Cleveland Clinic has provided very little charity care to patients without insurance. It is among a group of hospitals being sued by plaintiffs' lawyers across the country contending that the hospitals violated their obligation as charities by overcharging people without insurance. Some community leaders have mounted legal challenges to the clinic's moves to exempt certain operations from local taxes. The clinic argues that it does its fair share and that any profit goes into areas like research and education. ''We have no shareholders, we have no market capitalization,'' said Mr. O'Boyle. ''What we make we re-invest.'' The clinic also says the lawsuit is without merit.
      Yet the clinic is unabashed in its push to capitalize on the medical expertise of its 1,400 doctors to increase its revenue to finance research. In 2003, the clinic says it filed for more patents per research dollar than the Mayo Clinic, Johns Hopkins Medical Center or Massachusetts General Hospital, the Harvard-affiliated Boston hospital. ''I think they're a lot more entrepreneurial than many of the others,'' said Martin D. Arrick, an analyst with Standard & Poor's, who follows the debt of tax-exempt hospitals. He praises the Cleveland Clinic for investing in those areas where it excels. ''They've followed a strategy of making their core asset shine, and you can see that.''
     Dr. Cosgrove is particularly familiar with the interplay between industry and medicine. He personally holds nearly 20 patents and developed a new catheter that reduced the number of strokes in patients undergoing heart surgery. He also sits on the board of medical device companies like AtriCure and Novare Surgical Systems and serves as a general partner in the venture fund started by the Cleveland Clinic. The venture fund is independent of the clinic, though the clinic has provided about a third of its financing to date. The fund makes its own investment decisions, but the clinic is a special limited partner that receives a share of the profits in return for access to the doctors' expertise. Dr. Cosgrove says he does not plan to sever his outside relationships anytime soon unless the clinic's board determines that these relationships are inappropriate. ''I spent 30 years developing relationships with industry,'' he said. ''I was an inventor and an entrepreneur and asked to be a venture capitalist by the institution.''
     Similar ties abound at the clinic. For example, the venture capital fund has invested in CardioMEMS, a device company in Atlanta started by a clinic doctor. The clinic recently started patient studies of an implantable sensor made by CardioMEMS used in surgery to repair an aortic aneurysm. Dr. Topol also served as a consultant to CardioMEMS. AtriCure, a small Cincinnati company making an atrial fibrillation device, has also received financing from the venture fund. At the same time, the clinic is conducting a clinical trial of a new AtriCure treatment and the clinic's atrial fibrillation center often uses AtriCure products. The clinic has also invested in Novare Surgical Systems. The first use in the United States of Novare's device, an alternative to traditional methods of surgical clamping in beating-heart bypass surgery, was at the clinic.
     Dr. Cosgrove said these kinds of relationships have all been scrutinized by the board, and that he plays no role in any decisions involving the use of devices from these companies. ''There's a difference between being conflicted and the appearance of conflicts,'' Dr. Cosgrove said. But managing the appearance of conflicts, as Dr. Topol learned after Fortune magazine revealed his involvement with the hedge fund, can be difficult.
     ''I think there's a real problem in academics today,'' Dr. Topol said. ''There's a very close-knit relationship with industry, and it's too close when any individual can derive a profit from that relationship.'' Indeed, Dr. Kassirer said it was often quite difficult to discern the subtle factors that affected decisions about patient care. Research has suggested that doctors who invent a medical device tend to use that device even where there are better alternatives available. ''It has an influence on what you do,'' he said.
     The Cleveland Clinic says it is currently reviewing some of the potential conflicts related to its own investments. Under the clinic's current rules, situations that create the potential for conflict of interest for an individual doctor must be approved by a special committee. The proposed policies -- which would also apply to the clinic's own financial relationships -- would lower the amount of the financial benefit that would set off a review to $10,000 from $25,000, with increased involvement by the clinic's Institutional Review Board, which oversees research involving patients. When there are institutional conflicts, including conflicts involving clinic executives, the clinic plans to propose a separate review process that would include members of the clinic's board.
     In recent months, the clinic has had its statisticians or outside specialists review data independently when a study involves a researcher with a potential conflict of interest. Dr. Chisolm acknowledges that these strategies are works in progress. The question raised by ethicists like Dr. Kassirer and Dr. Cho is whether it can be done effectively, if at all. ''The ideal of handling these conflicts of interest,'' Dr. Kassirer said, ''is not to have them at all.''  Click here for a corresponding NYT 12/17/2005 article

Accuser Testifies at Trial of Ex-Priest in Abuse Case
Pam Belluck, New York Times- 1/27/2005

CAMBRIDGE, Mass. -- A 27-year-old who has accused a defrocked Boston priest of molesting him 20 years ago took the witness stand on Wednesday and testified that the defendant, Paul R. Shanley, sexually abused him in the church bathroom, the pews, a confession room and the rectory. In the bathroom, the accuser testified, Mr. Shanley "unzipped my pants," and, "if I had to go to the bathroom, he'd watch me go to bathroom." Then, he said, Mr. Shanley would touch him, and "sometimes he would kneel down and try to teach me how to perform oral sex."
      The testimony from the sometimes-teary accuser, a barrel-chested firefighter in a Boston suburb, came on the second day of the trial of Mr. Shanley, who became a lightning rod when the sexual abuse scandal erupted three years ago in the Roman Catholic Archdiocese of Boston.
      In cross-examination, Mr. Shanley's lawyer, Frank Mondano, tried to discredit the accuser by pointing out inconsistencies in his statements and memory and by suggesting that his history of other troubles, including problems with his parents and his behavior in high school, raised questions about his credibility. "The point is, there were times when you had memories of things and other times when you have no memories of those same things," Mr. Mondano said. The accuser, who several times became testy and argumentative with Mr. Mondano, answered that his memory "comes and goes."
      About 24 people have accused Mr. Shanley, 74, of molesting them since the 1960's, most of them coming forward after the scandal broke. This is the sole time Mr. Shanley has faced a criminal trial. The accuser was originally one of four men who made accusations in the case. Prosecutors recently dropped the charges of the other three. Mr. Mondano suggested that the accuser created his account after having talked with the others.
      The prosecution case has not included witnesses who seem able to verify the accusations that Mr. Shanley pulled the accuser out of Sunday morning classes to molest him when he was 6 to 9 years old and groped him in the halls for three years after that. A prosecution witness on Wednesday, a woman who taught the accuser in a second-grade doctrine class at the church, St. Jean the Evangelist Parish in Newton, seemed to lend support to the defendant's case. The teacher, Ann Mari Rousseau, testified in cross-examination that on Sunday mornings the church, which closed a few years ago, bustled with people. People attended Masses at 8, 10 and 11:30 a.m., she said. Priests prepared for the Masses and chatted with parishioners. Lay leaders and choir members milled around, and parents dropped off children for the 8:50 doctrine classes and picked them up at 9:50. "Sunday mornings were very hectic," Ms. Rousseau, now a minister in the United Church of Christ, said in testimony that seemed to raise doubts about whether a priest had time and opportunity to abuse a child. "Would you say that there was a big pile of leisure time?" Mr. Mondano asked. "No," Ms. Rousseau replied, "I would not say that there was any leisure time." Ms. Rousseau also testified that Mr. Shanley never called children out of her class, that she never requested his help in dealing with children who needed discipline and that she never saw him alone with a child.
      Mr. Shanley is charged with three counts of child rape and two counts of indecent assault and battery, accused of orally and digitally assaulting the boy. He faces a maximum sentence of life in prison. His lawyer has said the accuser was motivated by a civil suit he filed against the archdiocese, for which he received a $500,000 settlement last year. The accuser has spoken publicly about his accusations several times in the last three years, but has asked news organizations not to identify him by name during the trial. The accuser has said he recalled his years of abuse in 2002, after his girlfriend called him in Colorado, where he was an Air Force police officer, to tell him about a newspaper article on the abuse and Mr. Shanley. The accusations were first made by a childhood friend of the accuser who became one of the three people later dropped from the case. The accuser said on Wednesday that he was so traumatized by his memories that "I felt like my world was coming to an end" and was unable to function in the Air Force. In relatively short testimony about the accusations, he sniffled, teared up and covered his eyes with a hand.
      Consistently referring to the priest as "Shanley," not "Father Paul," the name most parishioners seemed to use, the accuser said the abuse took several forms. Sometimes, he said, Mr. Shanley asked him to put pamphlets in the church pews and took him to a pew in the front and "put his right arm around me and start touching my penis." Other times, he said, he was summoned to a confession room, where Mr. Shanley "used to undress me and he himself would get undressed and stand in front of the mirror and put his arm around me." Still other times, he said, Mr. Shanley took him to rectory to play a card game called war. '"Every time I lost a hand he'd tell me take off a piece of my clothes," the accuser said, adding, "I always lost." Asked by the prosecutor, Lynn Rooney, what happened when his clothes were off, he said, "I'd somehow get on a winning streak, and he would take his clothes off."
      Mr. Shanley, once a popular priest known in part for looking like a hippie in the 70's, when he ministered to street youths and spoke out against church restrictions on homosexuality, looked calmly at the accuser as he testified. On a lunch break, Mr. Shanley, wearing work boots with his suit and tie as a defense against a snow storm, walked around part of the courtroom, chatting on a cellphone.
      Ms. Rooney's questions elicited troubled aspects of the accuser's background, including that he rarely saw his mother after his parents separated when he was 3 and that as a teenager he was kicked out of the house by his father because of steroid use. He testified that he slept in a park, a parking lot and a friend's basement. Mr. Mondano brought out that the accuser had been repeatedly suspended from high school and that he had told a therapist that his mother had hit him with a wood spoon and that his father had slapped him or kicked him, discipline that he described as "physical abuse." Ms. Rooney's questions also revealed what were apparently memory lapses. When she asked whether he remembered any other type of touching between him and Mr. Shanley, the accuser said he did not. Ms. Rooney showed him a page of a journal he kept, and asked, "Does that help you to remember whether there was any other type of touching?" The man replied, "I see that I wrote it down, but I don't remember it right now."

The Brain: False Assumptions and Cruel Operations
William Grimes, New York Times- 1/27/2005

In the summer of 1849, Walt Whitman walked into an office on Nassau Street in Manhattan to have his head read. Lorenzo Niles Fowler, a phrenologist, palpated 35 areas on both sides of the skull corresponding to emotional or intellectual capacities in the brain. Fowler rated each one on a scale of 1 to 7, with 6 representing the ideal (7 meant dangerous excess). Whitman received a perfect score in nearly every one of Fowler's categories, which bore such fanciful names as "amativeness," "adhesiveness" and "combativeness." Thrilled with his report card, he became an instant convert to phrenology, defined by Ambrose Bierce as "the science of picking a man's pocket through the scalp." Later he donated his magnificent brain to the American Anthropometric Society, which collected it on his death in 1892 and added it to its collection of elite brains.
      There are quite a few such collections, scattered around the globe, and Brian Burrell visits all of them in his offbeat scientific tour in "Postcards From the Brain Museum." His wanderings take him from the Musée de l'Homme in Paris and the Wistar Institute of Anatomy and Biology in Philadelphia to the impressively stocked Institute of the Brain in Moscow, where the brains of Lenin, Stalin, Eisenstein and Pavlov lie in state, or states, having been sliced into thousands of paper-thin slices and stained for scientific study.
      But the study of what, exactly? Nothing at all, it turns out. The brains, many of them dried to the consistency of coal, or fraying badly in their formaldehyde baths, simply take up space in glass jars. In many cases they are inaccessible to the general public, relics of a bygone age when scientists believed that the brains of geniuses and criminals would certainly, when examined, display distinctive physical characteristics. They were wrong. But for most of the 19th century it seemed as if they might be right. Their doomed efforts provide Mr. Burrell with the material for his entertaining, tragicomic tale of scientific failure.
      Blame Byron. After his death in 1824, Greek doctors removed his heart, a common practice, but his brain as well. It was prodigious, weighing in at 6 pounds, at least 25 percent larger than the average, a striking confirmation of the theory linking brain size and genius. Three years later, Beethoven died. His brain too was examined, revealing convolutions twice as numerous and fissures twice as deep as the ordinary brain. These eminent and distinctive brains set scientists off and running to map the brain and the skull and thereby explain the workings of the mind. During what the author calls "the golden age of brain collecting," from 1880 to 1910, hundreds of eminent men and women joined autopsy societies and donated their brains, hoping to receive the kind of validation that Whitman received in 1849.
      Unfortunately, the brains did not cooperate. Some geniuses turned out to have unusually small brains. Criminals and social degenerates often showed the same folds as scientists and artists. Faced with conflicting evidence, leading theorists of the brain fudged, temporized or dug in their heels. Eventually, the entire jerry-built theoretical apparatus simply collapsed, although as a myth or symbol, the brain still retained considerable power. As the Germans closed in on Moscow, the high command drew up plans to seize Lenin's brain and take it back to Berlin. When Einstein died, an overeager pathologist in the hospital removed his brain and took it home, intent on discovering the secrets concealed within. Alas, there were none to be found.

Walter Freeman worked on more brains than all the 19th-century phrenologists and "cranioscopists" put together. From the mid-1930's to the late 60's, he performed some 3,500 lobotomies on psychologically disturbed patients, a procedure that, thanks to his tireless crusading, became a standard method of treatment in mental hospitals across the United States before the advent of drugs like Thorazine and Prozac.
      In "The Lobotomist," Jack El-Hai's lively biography, Freeman comes across as a classic American type, a do-gooder and a go-getter with a bit of the huckster thrown in. Trained as a neurologist, he found a position at St. Elizabeths, a large mental hospital in Washington, D.C., which, like most institutions then simply warehoused the mentally ill. Freeman was appalled at this waste of human potential. Convinced that mental illness stemmed from organic causes, he searched for a neurological solution and found it in a new procedure, developed by a Portuguese doctor and eventual Nobel laureate, Egas Moniz, who simply cut through neural pathways in the frontal lobes that, he believed, produced harmful or obsessive behavior. Freeman, who dismissed psychoanalysis as a sheer waste of time, jumped at Moniz's new procedure. "Here was something tangible, something that an organicist like myself could understand and appreciate," he later wrote. "A vision of the future unfolded." He formed a partnership with a skilled neurosurgeon, James Watts, and very quickly developed his own procedure, prefrontal lobotomy, which entailed drilling two holes in the skull, above the left and right frontal lobes, and then removing a dozen cores of white neural fibers.
      From the beginning, results varied wildly. One early patient simply rose from his hospital bed on Christmas Eve, put on his hat over the bandages and headed straight for a local saloon to celebrate. Another patient, a 60-year-old woman suffering from agitated depression, became paralyzed on her left side a few hours after the operation, lost the ability to speak, and fell into a coma. She died six days later. More typical were patients who experienced temporary relief from anxiety, obsessions, or hallucinations but later slipped back into severe metal illness, or who became strangely apathetic and lacking in spontaneity. One of his less successful patients was Rosemary Kennedy, a sister of John F. Kennedy, who underwent a lobotomy for agitated depression in 1941 but remained institutionalized for the rest of her life.
      Freeman had a high tolerance for failure. He was taking difficult cases and, as often as not, making it possible for them to go home and put together some semblance of a normal life. In time, he developed a new technique, transorbital lobotomy, that eliminated many of the side effects of prefrontal lobotomy by entering the brain through the eye socket rather than the cranium. The new procedure was quick. In 1952, Freeman once performed 25 transorbital lobotomies in a single day. This was the sort of stunt that caused Freeman's professional colleagues to eye him suspiciously. "I thought I was seeing a circus act," a student nurse said, recalling a performance in which Freeman used both hands at once to cut nerve fibers on both sides of a patient's brain simultaneously. Psychoanalysts regarded Freeman with contempt, and many doctors recoiled at destroying healthy brain tissue. Freeman, a flamboyant figure who affected a cane, a broad-brimmed hat and a long goatee, invited controversy by his slapdash approach to research and his love of the spotlight.
      His enemies triumphed. By the mid-1950's, psychoanalysis and the appearance of new drugs like Thorazine spelled the end of the lobotomy in the United States. Freeman, once hailed as a visionary, now seems little more than a curiosity, another specimen in the brain museum.

Meth Becoming a Threat in Some Cities
Associated Press, 1/27/2005

CHICAGO -- Already known as a rural scourge, methamphetamine is becoming a problem in a number of U.S. cities. Meetings of the 12-step group Crystal Meth Anonymous have increased in Chicago from one night a week a few years ago to five a week. In the Atlanta area, methamphetamine users account for the fastest-growing segment of addicts seeking treatment. Rehabilitation centers there are seeing an uptick in the number of women meth addicts, while officials in Minneapolis-St. Paul say they're treating an alarming number of meth users younger than 18. ``Most people just think it happens in the farmlands and the prairies or out back behind the barn,'' says Carol Falkowski, director of research communications at the Hazelden Foundation in Minnesota. But that's not the case anymore.
      Falkowski found that meth addicts now represent about 10 percent of patients admitted to drug treatment programs in the Twin Cities, compared with 7.5 percent a year ago and about 3 percent in 1998. About a fifth of those meth users who sought help in the last year were minors. She and other experts who track urban drug trends for National Institute on Drug Abuse are meeting this week in Long Beach, Calif., to present their findings. Some have noted a big jump in the use of meth -- particularly in its potent crystal form -- in the past six months to a year. ``It's the new major drug threat,'' says Jim Hall, director of the Center for the Study and Prevention of Substance Abuse at Nova Southeastern University in Florida. He monitors drug use for NIDA in Fort Lauderdale and Miami, where crystal meth is often more sought after than Ecstasy and cocaine. ``Here, it's almost like the early days of cocaine, when cocaine was the chic, expensive champagne of street drugs,'' says Hall, noting that many users come to Miami's trendy South Beach strip in search of the purest, most expensive meth available.
      Methamphetamine -- long a problem on the West Coast -- made its way across the country in the last decade, often taking hold in rural areas, where it's usually made because the process creates a noticeable stench. Increasingly, drug enforcement officials say that mass quantities are also being shipped cross country from ``super labs'' in the Southwest and Mexico. Experts say the drug started to catch on in urban areas in the club and rave scenes and sometimes among particular populations, such as gay men. That's been the case in such cities as Washington, D.C., and Chicago, says Thomas Lyons, a research associate with the Great Cities Institute at the University of Illinois at Chicago. Often, he says, meth use has been associated with increases in sexually transmitted diseases, including HIV.
      One recovering addict who helps organize Chicago's Crystal Meth Anonymous meetings confirms that the gatherings are frequented by gay men -- but he says that, increasingly, he's seeing people from other backgrounds. ``It's become more common that I cross paths with people who say, 'This is my drug of choice,''' says Mike, a 34-year-old former meth user whose organization does not reveal last names to protect group members' privacy.
      Experts elsewhere say their populations of meth users are diversifying, too. Claire Sterk, an Emory University professor who tracks Atlanta's numbers for NIDA, says that while meth users there have traditionally been white, there are early signs that meth is making its way into the city's black and Hispanic communities. Experts in other cities also have noted that some young women are using methamphetamine as a way to lose weight.
      ``It's definitely everywhere,'' says Adam, a 26-year-old former meth addict from suburban St. Louis who also asked that his last name not be used out of fear of embarrassing his family. ``Though I'm not using anymore, I'm sure it would only take me three phone calls to find it'' says Adam, who works in the retirement benefits industry and is getting a business management degree at Saint Louis University.
      He also speaks on behalf of the Partnership for a Drug-Free America, which launched education campaigns in St. Louis and Phoenix last year to try to combat growing meth problems there. The nonprofit plans similar campaigns in at least four other states in the next year, says spokesman Steve Dnistrian. ``Our fear has been that meth will catch on with a new generation of kids who haven't heard about it,'' he says.
      But in some cases, that's already happening, says Dr. Rob Garofalo at Children's Memorial Hospital in Chicago. ``It's the drug that makes me cringe the most,'' says Garofalo, who's come across a growing number of meth users among the patients he treats at the hospital's clinic for older youth. At first, he says, these young meth users see the drug as a ``brightener'' -- one that helps them concentrate, stay up for hours and feel in control. In time, however, users become increasingly paranoid and aggressive. It's also highly addictive -- ``such a slippery slope,'' Garofalo says. ``You can't just dabble in crystal meth.''
      On the Net:
Crystal Meth Anonymous: www.crystalmeth.org/home/index.php
Partnership for a Drug-Free America: www.drugfreeamerica.org

Dozens Annually Commit Suicide by Train
Associated Press, 1/27/2005

WASHINGTON -- Scores of times each year, people intentionally stand, jump and drive in front of trains, figuring it's a sure way to end their lives. Authorities say Juan Manuel Alvarez wanted to kill himself Wednesday when he drove his SUV onto a railroad track in Glendale, Calif., near Los Angeles. But he changed his mind and left the vehicle on the tracks, causing a chain-reaction derailment that killed 11 people and injured nearly 200. He walked away from the scene virtually unscathed by the crash, although he had apparently slit his wrists and stabbed himself in the chest. It was not immediately clear when he did that. He was held without bail in a hospital jail ward.
      Many others succeed in killing themselves. A 13-year-old girl from suburban Chicago committed suicide in March by walking on commuter rail tracks with her back to the train. A 53-year-old woman killed herself in July by lying down on railroad tracks in Boca Raton, Fla. That month in Kansas the 19-year-old Argonia High School valedictorian was struck and killed by a train after tying himself to the tracks with baling wire. ``They're suffering and they see this as a way of ending the suffering,'' said Dr. Brian Mishara, director of a center that studies suicide at the University of Quebec in Montreal. ``It's not true that it's a sure way of dying.'' In Germany, where there are 18 suicides by train every week, one in 10 survives the attempt -- often with severe injuries, Mishara said.
      The Centers for Disease Control and Prevention report that 112 people nationwide killed themselves using buses, trains and subways in 2002, a tiny percentage of the approximately 30,000 suicides each year. People in the railroad industry say suicide by train happens far more often than people hear about. John Tolman, spokesman for the Brotherhood of Locomotive Engineers and Trainmen, said the average train engineer will see three suicides during his 25 years on the job. A commuter rail engineer will see as many as 20 in his career. ``Where you're frequently interacting with passengers -- with platforms, grade crossings -- that's where the suicides and the close calls are,'' Tolman said.
      Engineers are traumatized when they hit a person, something they can't prevent because trains can't stop on a dime, Tolman said. Engineers and trainmen experience post-traumatic stress disorder afterward, much like Vietnam veterans, he said. Many railroads offer counseling and time off for engineers after they hit a suicide victim, but Tolman said some programs are much better than others.
      Though suicide by train is relatively rare, it's extremely difficult to prevent. And it may be on the rise, especially since news of the Glendale tragedy may inspire copycat attempts. ``The more you publicize it, the more likely this will become a more popular method,'' Mishara said.
      Early Thursday, another apparently suicidal man was arrested in Orange County after he parked his SUV on railroad tracks, according to authorities. He drove off after he was spotted by police, and a dispatcher talked him out of suicide during a cell phone call, authorities said.
      Tom White, American Association of Railroads spokesman, said anecdotal evidence suggests suicides by train are increasing. ``With 140,000 miles of rail line and 150,000 grade crossings, I'm not sure there is any method that's effective in preventing it,'' White said. ``The key is suicide prevention.''
      Karen Marshall, founder of a suicide prevention foundation in Michigan, said people need to recognize suicidal tendencies and seek help. ``The time to have prevented the suicide attempt that the man made yesterday was long before he got behind the wheel of the SUV and headed toward the railroad track,'' she said.
On the Net:
American Association of Railroads: www.aar.org
Suicide statistics: www.suicidology.org/associations/1045/files/Suicide2002.pdf

Accuser's Past Is Focus of Defense for Ex-Priest
Pam Belluck, New York Times- 1/28/2005

CAMBRIDGE, Mass., -- The man who says he was molested as a boy by Paul R. Shanley, a now-defrocked priest, acknowledged a series of problems under cross-examination on Thursday. The accuser, a 27-year-old firefighter in suburban Boston, admitted that for years he had a serious alcohol habit, used large doses of steroids, gambled through a bookkeeper and had a volatile temper that caused problems in his personal and professional life.
      Mr. Shanley's lawyer, Frank Mondano, asked about the accuser's problems, including his statements that his mother severed most ties with him at age 3 and that his father disciplined him violently, in an effort to show that the accuser was not credible. Mr. Mondano was also trying to refute the accuser's contentions that Mr. Shanley caused the difficulties he had had in life.
      The accuser, who says he was pulled out of Christian doctrine classes by Mr. Shanley and molested from age 6 to 12, has said he remembered the abuse only in 2002, after the sexual abuse scandal in the Roman Catholic Church in Boston became public and he was told about similar accusations made against Mr. Shanley by a childhood friend.
      Mr. Mondano says the accuser concocted the accusations, collaborating with three other men who attended the same church in Newton, Mass., to win a civil suit they filed against the Archdiocese of Boston. The archdiocese settled that lawsuit last year with large payments to the men, including $500,000 to the accuser. Since then, prosecutors have dropped the other three men's accusations from the criminal case against Mr. Shanley, who is now charged with orally and digitally assaulting the lone remaining accuser.
      "Did you drink to intoxication on a semiregular basis?" Mr. Mondano asked. "Every day," the accuser said. The man confirmed that he took steroids for eight years. "In one instance you actually smuggled some of the steroids in from Mexico, correct?" Mr. Mondano asked. "Correct," the accuser said. "This was exclusively and totally related to Paul Shanley?" Mr. Mondano asked. "Yes, poor self-image," the accuser said.
      Mr. Mondano questioned the accuser's motives, suggesting that in addition to a monetary settlement, he was seeking a way to be discharged from the Air Force. The lawyer quoted medical records in which the accuser told a psychiatrist that he was going to try to leave the military. He was discharged two months later. Citing the accuser's testimony that the stress of the recovered memories gave him a rash, Mr. Mondano pointed to medical records indicating a diagnosis of ringworm. And Mr. Mondano said another motive might have been homophobia, citing a journal the accuser kept for his civil lawyers in 2002, in which he referred to Mr. Shanley using a pejorative term for "gay."
      Mr. Mondano also suggested that the accuser was seeking publicity in 2002, when he gave several interviews to news organizations, allowing his name and photograph to be used. Mr. Mondano read a journal entry in which the accuser wrote that he was disappointed with an article in The New York Times because it referred to him only briefly. Shortly before the criminal trial, the accuser asked news organizations to stop identifying him.
      Mr. Mondano also questioned details of the accuser's accusations. He pointed out that on Sunday mornings when the accuser says he was pulled out of classes and molested in the bathroom, pews, confessional or rectory, there were many other people in the church, attending or preparing for one of three morning Masses. The accuser said he recalled there being only one men's room in the church, yet he said he did not recall anyone else ever coming in to the bathroom while he was being molested. He said that Mr. Shanley would stand menacingly in the open bathroom door before molesting him, but he also acknowledged under questioning that the door was on a landing of the only staircase to the basement. "So anybody that would be going down the stairs to get into the basement for any purpose would be walking right by the door where Shanley was standing, right?" Mr. Mondano said.
      The accuser also acknowledged that the less invasive touching he says Mr. Shanley initiated from the time he was 9 until he was 12 - patting him through the front or back of his pants - would have happened in front of other people. So far, prosecution witnesses have said they did not see Mr. Shanley make such contact with any child, or take any child out of class.
      During more than five hours of cross-examination Thursday, the accuser became combative at times, snapping at Mr. Mondano. Late in the afternoon, when Mr. Mondano asked about specific accusations of abuse, the accuser sobbed and buried his face in the crook of his arm. The judge called a recess. Later, when the judge told the accuser that he would probably be needed for more testimony on Friday, the man said: "Please don't make me. I can't do this again."