Genius or Madness? Tendency Toward Mental Illness May Share Genetic Roots with Creativity

There has long been an association between creative genius and madness. In many respects this apparent relationship is not surprising since both involve a deviation from what is described as a ‘normal’ approach. The ability to think outside the box involves the adoption of perspectives that might not appear obvious to the average person.

Genius or Madness - Schizophrenia and Bipolar Disorder May Share Genetic Roots with Creativity

Van Gogh, Sylvia Plath, Beethoven, Kurt Cobain and Robin Williams are just a few of the many creative geniuses who are believed to have suffered from some form of mental illness. When we examine the intense beauty and power of their creations, and the epic lives many of these individuals led, it can be almost instinctive to want to romanticize aspects of mental illness as it is often seen as the key to their genius. However, anyone who has experienced mental illness, either first-hand or through a loved one, knows that there is nothing romantic about the associated suffering.

Over the years mounting evidence has shown a significantly higher proportion of people who suffer from various forms of mental illness within the creative industries. One study examined 300,000 people who suffered from schizophrenia, bipolar disorder or unipolar depression, and their relatives, and found a distinct over-representation in creative professions for those diagnosed with bipolar disorder as well as undiagnosed siblings of those with schizophrenia or bipolar disorder.

Recently researchers at the Institute of Psychiatry, Psychology & Neuroscience at King’s College London, further explored this relationship. The study, published in Nature Neuroscience in 2015, was designed to establish whether genes linked to creativity could increase the risk of developing schizophrenia and bipolar disorder. Though other studies have found a link between creativity and psychiatric disorders, it had previously never been established whether genetics were responsible for this association, or whether environmental or socio-economic factors were the cause.

Researchers discovered that genetic risk scores for both schizophrenia and bipolar disorder were significantly higher in individuals defined as creative by the parameters of the study. Creative types who exhibited no symptoms of mental illness tended to have genetic risk scores that fell approximately halfway between those with disorders and the general population.

Lead author of the study, Robert Power stated:

“For most psychiatric disorders little is known about the underlying biological pathways that lead to illness. An idea that has gained credibility is that these disorders reflect extremes of the normal spectrum of human behaviour, rather than a distinct psychiatric illness. By knowing which healthy behaviours, such as creativity, share their biology with psychiatric illnesses we gain a better understanding of the thought processes that lead a person to become ill and how the brain might be going wrong. Our findings suggest that creative people may have a genetic predisposition towards thinking differently which, when combined with other harmful biological or environmental factors, could lead to mental illness.”

Though everyone has the ability to express themselves creatively, and anyone can nurture and develop these skills, this study suggests that our genetic predisposition might affect our base creativity levels as well as our tendency toward mental illness.

The Unconscious

Crazy was such a complex concept that encompassed much of what we didn’t understand about the human mind, and the intangible aspects of our reality.” ~ C. Lavers, Jump Into the Blue

One possible explanation for why this relationship between mental illness and creativity exists is because, in both cases, there is an enhanced connection with the unconscious.

The unconscious represents a mystifying, unquantifiable space within each of us. While science is able to document some of what we are capable of at the deeper levels, there is still an enormous amount of mystery around what the unconscious actually is. It is not something that can be dissected and examined with a microscope. We may have mapped so much of our physical world, even explored deep space, but our internal world, where we return every night in sleep, is still predominantly unchartered territory.

What little that we do know about this inner realm is that it has the ability to store masses of data, way beyond any computer in existence today, and also has the ability to make leaps and connections that appear ‘genius’ to our ‘little’ conscious minds. There are countless examples of scientific and cultural breakthroughs that sprang from the unconscious in the form of dreams, visions and imaginative play. Some notable ones include: Einstein’s theory of relativity, M Theory (another theory in physics that unites versions of string theory), the periodic table, modern robotics, the sewing machine, and Mary’s Shelley’s Frankenstein.

Most of us have strong filters in place that limit the flow from the unconscious into conscious awareness. This is important because without any filters we would undoubtedly become overwhelmed in an attempt to process the vast amounts of seemingly wild and illogical content. So a plausible theory regarding the relationship between creativity and mental illness might be explained by a genetic predisposition to having a less stringent filtration system in the brain, which allows for an increased flow between the conscious and the unconscious.

An obvious question that arises from this discussion is whether we can we access the brilliance available to us from the unconscious realm, without the risk of succumbing to the debilitating qualities of mental illness? Fortunately there are many safe practices that are known to both increase our connection to the unconscious, and thus enhance our creativity, and promote our mental health at the same time.

Healthy Reality Diet

In my work with creativity, I have found that one of the most important ways we can encourage a positive experience of the unconscious is by being aware of what we absorb. In the same way that we need to be aware of what we put into our bodies, because “we are what we eat”, we benefit from being aware of what we put into our minds because our reality responds to what we feed our unconscious. When we place too much focus on the gloomy aspects of life, these qualities become emphasized in our unconscious. There’s nothing like a few hours of depressing media content, a nasty gossip fest, or a dismal, chaotic home environment to negatively taint our perspective. So make sure to include plenty of uplifting, enriching and inspiring content in all that surrounds and touches you.


In terms of creativity, one of the ways meditation can assist our purpose is by promoting the relaxed alpha brainwaves so that they become dominant. When the alpha brainwaves are dominant we find the mental chatter that is common in thebeta state is replaced with a calm, focused clarity that is conducive to finding creative solutions without being overwhelmed.

Meditation is also useful in the creative process because it is particularly good at assisting us to develop the ability to shift perspectives. It’s about stepping back from our thoughts and emotions rather than getting caught up in them, so it helps us cultivate the detachment necessary to ‘allow’ a healthy experience of the creative flow.


A lot of techniques that assist us in creative exploration involve expanding our consciousness or shifting levels of awareness away from the rational, rigid one we normally operate from, to a looser, wilder, more flowing awareness. Because of this, I highly recommend incorporating the practice of grounding into our daily routine as a way to ensure that no matter how far we go, our feet remain firmly planted in the ground. This practice only takes a minute, but helps us to bring our focus to the here and now, soothes our nervous system, and promotes a sense of connection between our physical and non-physical worlds.

Pathophysiology of native coronary, vein graft, and in-stent atherosclerosis.

Plaque rupture, usually of a precursor lesion known as a ‘vulnerable plaque’ or ‘thin-cap fibroatheroma’, is the leading cause of thrombosis. Less-frequent aetiologies of coronary thrombosis are erosion, observed with greatest incidence in women aged <50 years, and eruptive calcified nodules, which are occasionally identified in older individuals. Various treatments for patients with coronary artery disease, such as CABG surgery and interventional therapies, have led to accelerated atherosclerosis. These processes occur within months to years, compared with the decades that it generally takes for native disease to develop. Morphological identifiers of accelerated atherosclerosis include macrophage-derived foam cells, intraplaque haemorrhage, and thin fibrous cap. Foam-cell infiltration can be observed within 1 year of a saphenous vein graft implantation, with subsequent necrotic core formation and rupture ensuing after 7 years in over one-third of patients. Neoatherosclerosis occurs early and with greater prevalence in drug-eluting stents than in bare-metal stents and, although rare, complications of late stent thrombosis from rupture are associated with high mortality. Comparison of lesion progression in native atherosclerotic disease, atherosclerosis in saphenous vein grafts, and in-stent neoatherosclerosis provides insight into the pathogenesis of atheroma formation in natural and iatrogenic settings.

Renal Artery Stenosis

Renal artery stenosis (RAS) is a narrowing of the arteries to one or both of the kidneys that can causehypertension (high blood pressure) and, sometimes, reduced kidney function and size (atrophy). It occurs more commonly in older people with atherosclerosis (hardening of the arteries with plaque buildup, leading to narrowing of the channel where the blood flows). Hypertension caused by RAS is calledsecondary hypertension. This means that, unlike essential or primary hypertension (the most common form of high blood pressure, which does not have a specific known cause), secondary hypertension does have a specific cause. In some cases, diagnosing and treating RAS can result in decreasing or eliminating the need to take medication for hypertension. The narrowing of the kidney arteries in RAS is usually due to atherosclerosis; more rarely it can be caused by abnormal growth of tissue within the wall of the artery. The latter condition, called fibromuscular dysplasia, is potentially curable and is more common in women and younger age groups but can also occur later in life. When atherosclerosis is the cause of RAS, it is especially important to be evaluated and treated for related diseases of the heart and brain, since they are also susceptible to narrowed arteries. Atherosclerosis in those organs can lead to heart attack or stroke.

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The BVM Effect: An Overview of Studies Assessing Airway Management in Out-of-Hospital Cardiac Arrest.

In the majority of papers reviewed, adult patients in OHCA ventilated with a BVM alone were more likely to survive to discharge than those ventilated with an advanced airway.
In the majority of papers reviewed, adult patients in OHCA ventilated with a BVM alone were more likely to survive to discharge than those ventilated with an advanced airway. Photo courtesy Acadian Ambulance

Evolving CPR guidelines follow the growing understanding of the physiology surrounding cardiac arrest. For example, it’s been shown that the maintenance of high-quality chest compressions with minimal interruptions is a cornerstone of providing adequate CPR.1 However, the role of airway and ventilation management during CPR remains less well understood.

Although the safest and most effective airway management for the patient in cardiac arrest still remains to be ascertained, the initial approach in airway management in out-of-hospital cardiac arrest (OHCA), however, is typically the application of the bag-valve mask (BVM) to assist ventilation. The gold standard for airway management for OHCA has historically been endotracheal intubation (ETI), a procedure requiring considerable training and skills maintenance to be performed successfully.2,3

The development of additional airway adjuncts—including supraglottic airways (SGAs) such as the laryngeal mask airway (LMA) and the King Laryngeal Tube (King LT)—have offered an intermediate approach, providing an advanced airway alternative while generally requiring less training and skill than that required for ETI. Application of these approaches in the prehospital setting has varied widely, depending principally upon the treatment protocols of individual services.

Substantial published research, however, has suggested that advanced airway use in OHCA management is associated with worsened patient outcomes.4–12 This suggests that some survival advantage is associated either with the BVM device specifically, with avoiding the use of advanced airways, or perhaps reasons associated with both.

The objective of the following study was to elucidate a relationship between survival from OHCA and the type of airway technique employed during resuscitative efforts. The spectrum of resuscitative literature was studied to isolate factors associated with survival from OHCA relative to the use of BVM alone vs. advanced airways. Consideration was given to examining each study for any evidence regarding the maintenance of the quality of CPR during resuscitation efforts and its potential relationship to “the BVM effect.”


The authors conducted a literature review in July 2014 to identify papers addressing airway management during OHCA. Electronic databases PubMed and Google Scholar were searched using the keywords out-of-hospital, prehospital, emergency medical services, heart arrest, cardiac arrest, airway and survival. Relevant material was also obtained through reviewing references from articles identified in the study and by contacting subject matter experts. A total of 171 scientific studies were found.

The various airway management techniques analyzed were BVM, SGA (LMA, King LT, Combitube), esophageal obturator airway (EOA) and ETI. Generally the comparisons in the studies focused between BVM and advanced airways or among different advanced airways. Primary outcomes largely focused on survival to discharge, with some studies including neurological function post-discharge as well.

Specific attention was then directed toward criteria addressing cardiac arrest management in the out-of-hospital environment, cardiac arrest victims, comparison of advanced airway with BVM and survival outcomes.

Exclusion criteria included qualitative studies, studies focused on traumatic arrests, studies comparing only advanced airways excluding BVM, and studies solely commenting on the training or feasibility of certain airway use.


Our search found nine observational studies meeting our inclusion criteria and specifically associating survival from OHCA with the type of airway management used during CPR. These papers were published from 1997 to 2014 with patient data ranging from 1990 to 2011. Patient populations varied substantially, with the smallest sample size being 355 and the largest being 649,359.

The datasets covered many different regions across the world, including North America, Europe and Asia. Each paper employed a set of controls for confounding variables, and generally followed the collection of data using recommended Utstein guidelines. Statistical analysis generally involved multivariate regression models with some studies using propensity-score matching.

Study 1 reviewed data from 1991 through 1994 collected in a “Heartstart” program.4 Resuscitation was attempted for 8,651 patients with 3,427 (39.6%) attempts at ETI. The primary results found a survival to discharge rate for patients receiving ETI of 3.7% vs. 9.1% for patients receiving BVM alone (p < 0.001).

Of interest, the proportion of patients intubated increased with the number of defibrillatory attempts and was higher in patients with unwitnessed arrest. The trend in decreased survival with ETI vs. BVM persisted regardless of EMS witnessed, bystander witnessed or unwitnessed arrest, or number of shocks.

The EMS providers in the study followed European Resuscitation Council guidelines, which stated that intubation should only be attempted after three shocks if spontaneous circulation hadn’t been restored. However, a substantial proportion of patients shocked less than three times were intubated, suggesting that these patients regained a pulse but were either not spontaneously breathing or deteriorated into a non-shockable rhythm.4

Study 2 examined almost 11,000 patients with OHCA in which ETI was attempted in 5,118 (47.5%) patients.5This study demonstrated a lower chance of one-month survival correlated with the use of ETI during management of OHCA. Patients who were successfully intubated had a 3.6% one-month survival rate vs. 6.4% who weren’t intubated.5

The authors, in noting the limitations of their study, found that there was no way to control for experience or training in placement of airways by the medics delivering care and that their study wasn’t randomized, making control for possible confounders difficult.5

Study 3 highlighted the unique characteristics of pediatric patients and adults in the OHCA patient population.6 The authors studied 624 patients divided into three age groups: < 1 year (infants; n = 277), 1–11 years (children; n = 154), and 12–19 years (adolescents; n = 193). The study had significant power in their age comparisons and was able to show statistically significant differences among the various age groups studied.

They found that “the incidence of OHCA in infants approaches that observed in adults” and is “lower among children and adolescents.” They also found that “survival to discharge was more common among children and adolescents than infants or adults.” Finally, these authors concluded that there was no significant difference in survival among the types of airways used in pediatric OHCA victims.6

Study 4 evaluated 1,294 nontraumatic OHCA patients from 1994–2008 in southwestern Los Angeles County.7This study found that 1,027 (79.4%) patients received ETI, 131 (10.1%) received either Combitube or EOA, and 131 (10.1%) received only BVM. The overall survival to discharge rate was 4.3%. Odds ratio for survival to discharge of patients receiving BVM compared to ETI was 4.5 (95% CI: 2.3–8.9) after adjusting for bystander CPR, witnessed arrest, age, sex and location of arrest.

Interestingly, the authors found that the group receiving Combitube or EOA had no survivors. In this paper there was a reported rate of bystander CPR of 45%, and no significant association was found between the rate of bystander CPR and survival to discharge.7

Research has shown a substantial survival benefit from OHCA with the use of BVM ventilation rather than advanced airways

Research has shown a substantial survival benefit from OHCA with the use of BVM ventilation rather than advanced airways such as ETI or SGA. Photo Courtney McCain

Study 5 analyzed 355 OHCA patients in Tokyo whose time from emergency call to hospital arrival was > 30 minutes.8 This study focused on comparing outcomes between advanced airway use and BVM use in prolonged cardiac arrest. The authors discovered a significant increase in overall return of spontaneous circulation (ROSC) and ICU admission in patients who received an advanced airway vs. BVM alone. However, no difference in prehospital ROSC or survival to discharge was apparent between the two groups.

Of note, the analysis found a similar time from the emergency call to arrival on scene in both groups, but the patients receiving advanced airways had longer on-scene management times by approximately two minutes. Thus, in OHCA where on-scene care was prolonged, performing an advanced airway may lead to a higher overall rate of ROSC without improving the overall rate of survival.8

Study 6 looked at a South Korean OHCA database including patients from 2006–2008.9 Of 5,278 patients reviewed, 250 (4.7%) received ETI, 391 (7.4%) received LMA and 4,637 (87.9%) received BVM. Overall survival to discharge was found to be 6.9%. Odds ratio for survival to discharge for ETI vs. BVM alone was 1.44 (95% CI: 0.66–3.15) and wasn’t statistically significant. The odds ratio for survival to discharge for the use of LMA vs. BVM alone was 0.45 (CI: 0.25–0.82).

It’s of interest that the study involved EMT-intermediates who were trained in airway placement through the use of manikins as opposed to training on patients in the operating room.

This training using simulation, combined with a median of two LMA uses per provider over two years, might suggest less skill proficiency, though there was no mention in the study of the annual number of ETIs by the providers.9

Study 7 examined the relationship between two advanced airways (SGA and ETI) using data from the Resuscitation Outcomes Consortium (ROC) PRIMED Trial.10 The authors studied the data from 10,455 adult OHCAs between June 2007 and October 2009. In this study, 8,487 patients (81.2%) received ETI and 1,968 (18.8%) received SGA.

The authors found that the overall survival to hospital discharge with satisfactory functional status was 4.7% with ETI and 3.9% with SGA (adjusted odds ratio: 1.40; 95% CI: 1.04–1.89). However, careful analysis of all data points (as revealed in supplemental data fields within the study) in this report reveals that patients receiving no advanced airways (BVM only or BVM after failed advanced airway attempts) had a significantly higher rate of survival to discharge. Indeed, when the final airway management used was BVM, the odds ratio of survival over the successful use of an ETI was 1.79 (CI: 1.33-2.40; p < 0.001).10

Study 8 presented an observational study of patients from the All-Japan Utstein Registry, a vast nationwide database of OHCA patients.11 This study found favorable outcomes with BVM airway management over ETI that had strong statistical significance due to the power produced by this large patient population, revealing a strong inverse relationship between the use of advanced airways and favorable neurological outcomes.

The overall unadjusted favorable neurological survival in this study was 2.2%, ranging between 1.1% for OHCA patients managed with advanced airways and 2.9% for patients managed with BVM (odds ratio: 0.38; 95% CI: 0.36–0.39). This data must be interpreted carefully with respect to the low overall survival in this observational study as compared to various urban centers across the world.11

Study 9, the most recent study found by the authors on this subject, analyzed 10,691 OHCA patients from the Cardiac Arrest Registry to Enhance Survival (CARES) in 2011.12 Of these patients, 5,991 (56%) were treated with ETI, 3,110 (29%) received SGA and 1,929 (18%) had no advanced airway placement. The data demonstrated 5.4% survival to discharge with good neurological outcomes in patients receiving ETI, 5.2% in patients receiving SGA, and 18.6% in patients receiving BVM only.

Of note, patients receiving ETI tended to be slightly older, more likely to be male, and less likely to receive defibrillation by use of an automated external defibrillator located in a public place. The authors also found that patients receiving BVM alone tended to have suffered OHCA in a public place, that the arrest tended to have been witnessed by EMS, and that the patient was more often in a shockable cardiac rhythm.12

The authors stated their beliefs that the association of improved survival with BVM alone “reflect[ed] the presence of unmeasured and immeasurable confounders.” These confounders could include short distance to the hospital, provider procedural skill, perceived health status of the patient and airway anatomic factors.12

They called for a future study that would integrate information including airway management steps such as duration of attempts, ventilation rates and procedures attempted in the ED.12


The management of OHCA patients remains one of the most difficult clinical challenges in the practice of medicine. These patients may have an arrhythmic cause of arrest that may be rapidly treated through defibrillator efforts, or they may have a cause of arrest that’s the result of a devastating event such as airway obstruction, massive pulmonary embolism, or major trauma that may often be inherently lethal.

The approach to these patients must be systematic, with the rescuer initiating CPR, performing rhythm analysis, managing the airway and providing IV therapy as indicated. The chance of survival for these patients is multifactorial, including the length of time in cardiac arrest, the cause of the arrest and the skill level of the rescuer.

Evidence has become available demonstrating that providing high-quality CPR—as measured by maintaining a high compression fraction,1 satisfactory compression depth,13 appropriate compression rate,14 and limiting peri-shock pauses15—is essential to optimizing survival with good neurological outcome. Nonetheless, growing evidence suggests an additional association with optimizing survival, namely the choice of airway used during resuscitation.

This article has brought together a number of studies that have found an association between the type of airway utilized during cardiac arrest management and survival. The question arises as to whether the choice of the type of airway utilized during resuscitation—i.e., BVM vs. advanced airway—is an independent predictor of survival or whether the airway choice is associated with other factors that may affect the chance for survival.

For example, in study 9, OHCA patients receiving BVM alone were significantly more likely to have suffered cardiac arrest in the presence of an EMS provider, arrested in a public place or been in a cardiac rhythm amenable to defibrillation.12

The underlying cause of this phenomenon remains to be determined. On the other hand, the above associations addressing the benefit of BVM alone over advanced airway, while statistically significant, weren’t orders of greater magnitude. So, the apparent benefit of BVM alone indeed may yet be found to be related to measurable or unmeasurable confounders, as suggested by study 9’s authors.

The underlying cause of this phenomenon remains to be determined.

We propose the BVM effect of enhanced survival with BVM over advanced airway use is also likely unrelated to the maintenance of the overall quality of CPR. Study 8’s authors also found this BVM effect in their enormous observational study, in spite of their overall reported rate of survival from OHCA of a bit less than 3% (only 1.0% with ETI).11

This low overall survival rate, as compared to centers in which OHCA cardiac arrest quality is carefully managed, raises the possibility of potential confounders that might affect survival, such as the quality of CPR performed. Importantly, traumatic arrests were included in this study,11 likely decreasing overall survival compared to a cardiac arrest patient population not including traumatic arrest patients.10

The BVM effect was also present in observational study 7, examining data from the ROC PRIMED trial.10 This observational analysis of the data from a prospective, randomized trial of OHCA patients included only non-trauma patients and excluded various populations (e.g., pediatrics). The study required that the participating agencies meet benchmarks for quality of CPR.

These studies reveal the existence of a BVM effect from multiple regions of the world that are quite heterogeneous. This suggests that this effect persists across regional variations in training, available equipment, attention to CPR quality and skill levels. This effect was also observed independent of the years studied (1990–2011).

Although it’s possible common underlying phenomena produce this effect, it remains to be demonstrated conclusively why OHCA patients managed with BVM alone seem to have improved survival. It has been well described that the patient in cardiac arrest suffers from over-ventilation during resuscitation.16 We propose that it’s more difficult to over-ventilate patients receiving BVM only, as compared to an advanced airway. Thus, part of the cause of the BVM effect may be due to less over-ventilation of patients.

Other possibilities for the BVM effect include less interruption of chest compressions with BVM compared with ETI and other advanced airways, and the avoidance of the risk of esophageal intubation that may occur with ETI, but further study is needed to elucidate the causes of or associations with the BVM effect.

To better understand the cause of the BVM effect, such studies should include factors such as response time, the time to first compression, the quality of CPR, initial cardiac rhythm, interruptions in chest compressions for airway placement, the rate of assisted ventilation, type of airway selected initially, final type of airway placed, time to airway attempt, number of airway attempts, on-scene time and final determined cause of the cardiac arrest. Only through the careful inclusion of these and possibly other parameters in future studies can the cause of the BVM effect be understood.


Numerous studies addressing airway management in OHCA have shown a strong association between improved survival with treatment using BVM alone rather than with advanced airways. This BVM effect appears to persist despite variations in geographical region, patient population, and CPR quality.

The underlying cause of this phenomenon remains to be determined. Of note, the survival benefit with BVM alone vs. advanced airways doesn’t appear in the pediatric population in the papers reviewed by the authors. The authors recommend that a prospective randomized study be conducted in order to explore this finding and to attempt to determine its causation.

Nikola Tesla and the Discovery of X-rays

Every radiologist is aware of Nikola Tesla’s research in the field of electromagnetism. The International System (SI) unit of magnetic flux density, the Teslacon magnetic resonance imager (Technicare, Solon, Ohio), and Teslascan manganese contrast agent (GE Healthcare, Waukesha, Wis) were all named after him. Without his other inventions like the alternating current supply, Tesla-Knott generator, and fluorescent lights in view boxes, it is impossible to even imagine a workday in a contemporary radiology department (1). But if the discovery of x-rays is mentioned, only a few radiologists associate it with Tesla’s name.

Nikola Tesla (Fig 1) was born in 1856 in the small village of Smiljan, Croatia. After finishing high school in Croatia, he continued his education in engineering in Graz, Austria, until 1878. Four years later he moved to Paris, France, and started working for the Continental Edison Company. In 1884 he emigrated to the United States, where he first began to work with Thomas Edison but soon afterward formed his own Tesla Corporation as competition to Edison’s company. He patented about 300 inventions worldwide, many of which are still famous today. However, Tesla’s experiments with “shadowgraphs” and his observations of the biologic effects of x-rays are not well known, even among radiologists.


Figure 1.  Nikola Tesla (1856–1943) at the age of 36 years. (Courtesy of the Tesla Museum, Belgrade, Serbia; document no. MNT, VI/V, 10.)

Tesla reported that, driven by his observation of mysterious damage to photographic plates in his laboratory, he began his investigation of x-rays (at that time still unknown and unnamed) in 1894 (2). Apart from experiments using the Crookes tube, he invented his own vacuum tube (Fig 2), which was a special unipolar x-ray bulb. It consisted of a single electrode that emitted electrons. There was no target electrode; therefore, electrons were accelerated by peaks of the electrical field produced by the high-voltage Tesla coil. Even then, Tesla realized that the source of x-rays was the site of the first impact of the “cathodic stream” within the bulb (4), which was either the anode in a bipolar tube or the glass wall in the unipolar tube he invented. Nowadays, this form of radiation is known as Bremsstrahlung or braking radiation. In the same article, he stated that the cathodic stream was composed of very small particles (ie, electrons). His idea that the produced rays were minute particles (5) wasn’t wrong at all; many years later, physicists described particle properties of electromagnetic radiation quanta called photons. To avoid heating and melting of the glass wall of his x-ray bulb, Tesla designed a cooling system based on a cold blast of air along the tube, as well as on today’s widely accepted oil bath surrounding the tube (6).


Figure 2.  Drawing illustrates Tesla’s unipolar vacuum tube, consisting of a glass bulb (b), a single electrode (e), and a lead-in conductor (c). The tube can be adapted for use with two electrodes by placing the second electrode at the levels indicated by the dotted lines. Published in Electrical Review, New , April 1, 1896. (Reprinted from reference 3.)

It also seems that he produced the first x-ray image in the United States when he attempted to obtain an image of Mark Twain with the vacuum tube. Surprisingly, instead of showing Twain, the resulting image showed the screw for adjusting the camera lens (7). Later, Tesla managed to obtain images of the human body, which he called shadowgraphs (Fig 3). Tesla sent his images to Wilhelm Conrad Roentgen shortly after Roentgen published his discovery on November 8, 1895. Although Tesla gave Roentgen full credit for the finding, Roentgen congratulated Tesla on his sophisticated images, wondering how he had achieved such impressive results (Fig 4) (7). Moreover, Tesla described some clinical benefits of x-rays—for example, determination of foreign body position and detection of lung diseases (8)—noting that denser bodies were more opaque to the rays (9).


Figure 3.  Shadowgraph of a human foot in a shoe. Tesla obtained the image in 1896 with x-rays generated by his own vacuum tube, similar to Lenard’s tube, at a distance of 8 feet. (Courtesy of the Tesla Museum, Belgrade, Serbia; document no. MNT, VI/II, 122.)


Figure 4.  Roentgen’s letter to Tesla dated July 20th, 1901. The letter reads, “Dear Sir! You have surprised me tremendously with the beautiful photographs of wonderful discharges and I tell you thank you very much for that. If only I knew how you make such things! With the expression of special respect I remain yours devoted, W. C. Roentgen.” (Courtesy of the Tesla Museum, Belgrade, Serbia; document no. MNT, CXLIV, 152.)

Tesla also experimented with reflected x-rays, using different materials as reflecting surfaces and describing features of transmitted and reflected rays (3,5,10). He thought that the practical purpose of the reflected x-rays was to improve the quality of the shadowgraph by increasing the object-film distance and decreasing exposure time. He was disappointed upon observing that lenses caused no refraction of x-rays (3). Later, it came to be understood that x-rays cannot be refracted by optical lenses due to their high frequency. However, Max von Laue managed to deviate x-rays using crystal lenses in 1912 (11). Tesla explained changes in x-ray characteristics as being caused by variations in x-ray tubes and electrical generators (12). He correctly realized that strong shadows can be produced only at great object-film distances and with short exposure times (5). Moreover, he perceived that bulbs with thick walls produced rays with greater penetrating power (8), which was later explained by the longer deceleration of electrons on the thicker barrier.

Tesla was also among the first to comment on the biologic hazards of working with unipolar x-ray tubes, attributing the harmful effects on the skin to the ozone and the nitrous acid generated by the rays, rather than to the ionizing effects of the radiation (8,13). He described acute skin changes like redness, pain, and swelling, as well as late consequences such as hair loss and new nail growth. He compared sudden pain and irritation of the eyes while working with x-rays to the experience of stepping from a dark room into bright sunlight (5,8). This pain and irritation was considered to be the consequence of eyestrain due to long-lasting observation of the fluorescent screen in darkness. Tesla understood the three main elements of radiation protection: distance, time, and shielding. He discovered that adequate distance from the x-ray source was a useful safety factor. Instead of explaining the sudden diminution of the harmful effects of radiation on the basis of the inverse square law, however, he attributed it to lower ozone concentrations (14). Tesla advised people working at very short distances from the tube (eg, surgeons) to shorten the exposure time to a maximum of 2–3 minutes (15). He also tried to construct a protective shield made of aluminum wires connected to the ground.

The main reason why Tesla’s contribution to the discovery of x-rays hasn’t become better known is that much of his work was lost when his laboratory in New York burnt down on March 13, 1895 (16). Nevertheless, there are many testimonies confirming his legacy of the invention of x-rays. Starting on March 11, 1896 (12), Tesla published a series of articles on the topic of x-rays and their biologic hazards in Electrical Review, New York. Few secrets were unveiled when he gave a lecture before the New York Academy of Sciences in 1897 (2), in which he validated to some degree his primacy in x-ray research. He confirmed publicly that he had been conducting independent research on this topic since 1894, which had unfortunately been interrupted by the fire in his laboratory. He also expressed regret at realizing too late that, despite being prompted by his “guiding spirit,” he had failed to comprehend its mysterious signs…

Nikola Tesla died in 1943 in New York. We will never know who would have gotten the Nobel prize for the discovery of x-rays had Tesla’s work not been lost together with his New York laboratory. The least we can do is appreciate Tesla’s pioneer work in the invention and application of x-rays.

1. HurwitzR. Scenes from the past: Nikola Tesla’s legacy to modern imaging. RadioGraphics2000; 20(4):1020–1022. Abstract,Medline
2. TeslaN. Lecture before the New York Academy of Sciences. New York, NY: Twenty-First Century Books, 1994.
3. TeslaN. An interesting feature of X-ray radiations. Electrical Review New York1896;29(2):13–14.
4. TeslaN. Latest results. Electrical Review New York1896;28(12):147.
5. TeslaN. Latest Roentgen ray investigations. Electrical Review New York1896;28(17):206–207,211.
6. CheneyM. An error of judgment. In: Cheney M. Tesla: man out of time. New York, NY: Touchstone Books, 2001;130–141.
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Bipolar Disorder: Multiple Mood Episodes, but where is the Solution? – Dr.Alok Vinod Kulkarni

Comparative study of Episure™ AutoDetect™ syringe versus glass syringe for identification of epidural space in lower thoracic epidural Joseph EJ, Pachaimuthu E, Arokyamuthu V, Muthukrishnan M, Kannan DK, Dhanalakshmi B – Indian J Anaesth

A Randomized, Controlled Trial of 3.0 mg of Liraglutide in Weight Management — NEJM


Obesity is a chronic disease with serious health consequences, but weight loss is difficult to maintain through lifestyle intervention alone. Liraglutide, a glucagon-like peptide-1 analogue, has been shown to have potential benefit for weight management at a once-daily dose of 3.0 mg, injected subcutaneously.


We conducted a 56-week, double-blind trial involving 3731 patients who did not have type 2 diabetes and who had a body-mass index (BMI; the weight in kilograms divided by the square of the height in meters) of at least 30 or a BMI of at least 27 if they had treated or untreated dyslipidemia or hypertension. We randomly assigned patients in a 2:1 ratio to receive once-daily subcutaneous injections of liraglutide at a dose of 3.0 mg (2487 patients) or placebo (1244 patients); both groups received counseling on lifestyle modification. The coprimary end points were the change in body weight and the proportions of patients losing at least 5% and more than 10% of their initial body weight.


At baseline, the mean (±SD) age of the patients was 45.1±12.0 years, the mean weight was 106.2±21.4 kg, and the mean BMI was 38.3±6.4; a total of 78.5% of the patients were women and 61.2% had prediabetes. At week 56, patients in the liraglutide group had lost a mean of 8.4±7.3 kg of body weight, and those in the placebo group had lost a mean of 2.8±6.5 kg (a difference of −5.6 kg; 95% confidence interval, −6.0 to −5.1; P<0.001, with last-observation-carried-forward imputation). A total of 63.2% of the patients in the liraglutide group as compared with 27.1% in the placebo group lost at least 5% of their body weight (P<0.001), and 33.1% and 10.6%, respectively, lost more than 10% of their body weight (P<0.001). The most frequently reported adverse events with liraglutide were mild or moderate nausea and diarrhea. Serious events occurred in 6.2% of the patients in the liraglutide group and in 5.0% of the patients in the placebo group.


In this study, 3.0 mg of liraglutide, as an adjunct to diet and exercise, was associated with reduced body weight and improved metabolic control.

High-Sensitivity Cardiac Troponin I and B-Type Natriuretic Peptide as Predictors of Vascular Events in Primary Prevention Impact of Statin Therapy


Background—Cardiac troponin and B-type natriuretic peptide (BNP) concentrations are associated with adverse cardiovascular outcome in primary prevention populations. Whether statin therapy modifies this association is poorly understood.

Methods and Results—We measured high-sensitivity cardiac troponin I (hsTnI) in 12 956 and BNP in 11 076 participants without cardiovascular disease in the Justification for the Use of Statins in Prevention: An Intervention Trial Evaluating Rosuvastatin (JUPITER) trial before randomization to rosuvastatin 20 mg/d or placebo. Nearly 92% of participants had detectable circulating hsTnI, and 2.9% of men and 4.1% of women had levels above proposed sex-specific reference limits of 36 and 15 ng/L, respectively. hsTnI concentrations in the highest tertile were associated with a first major cardiovascular event (adjusted hazard ratio [aHR], 2.19; 95% confidence interval, 1.56–3.06; P for trend <0.001). BNP levels in the highest tertile were also associated a first cardiovascular event (aHR, 1.94; 95% confidence interval, 1.41–2.68; P for trend <0.001). The risk of all-cause mortality was elevated for the highest versus the lowest tertiles of hsTnI (aHR, 2.61; 95% confidence interval, 1.81–3.78; P for trend <0.001) and BNP (aHR, 1.45; 95% confidence interval, 1.03–2.04; P for trend 0.02). Rosuvastatin was equally effective in preventing a first cardiovascular event across categories of hsTnI (aHR range, 0.50–0.60) and BNP (aHR range, 0.42–0.67) with no statistically significant evidence of interaction (P for interaction=0.53 and 0.20, respectively).

Conclusions—In a contemporary primary prevention population, baseline cardiac troponin I and BNP were associated with the risk of vascular events and all-cause mortality. The benefits of rosuvastatin were substantial and consistent regardless of baseline hsTnI or BNP concentrations.

Rationale for the Evaluation of Fluoxetine in the Treatment of Enterovirus D68-Associated Acute Flaccid Myelitis

his Viewpoint discusses the potential antiviral efficacy of fluoxetine in patients with enterovirus-D68–associated acute flaccid myelitis.

Enterovirus D68 (EV-D68) has emerged worldwide as an important cause of respiratory disease. Between mid-August 2014 and January 15, 2015, the Centers for Disease Control and Prevention confirmed 1153 cases of EV-D68–associated respiratory illness originating from 49 states. With this outbreak, there have been at least 107 cases of children presenting with acute flaccid myelitis associated with lesions identified on magnetic resonance imaging that were largely restricted to the spinal gray matter.1– 4 Children with this syndrome typically present with an acute febrile respiratory syndrome followed within 2 weeks by the development of acute flaccid myelitis, characterized by motor weakness, decreased tone and reflexes, and relatively preserved sensation. Weakness is of acute onset, preferentially affects upper limbs, and is often asymmetric. Cranial nerve involvement, including facial weakness, dysarthria, or dysphagia, may occur. Findings from the electrodiagnostic and magnetic resonance imaging studies are consistent with involvement of spinal cord motor neurons. Most patients have an associated cerebrospinal fluid pleocytosis. Paralysis has typically been prolonged and recovery incomplete. The exact role of EV-D68 in this syndrome has not been conclusively established, but approximately 50% of affected children have polymerase chain reaction–amplifiable EV-D68 RNA in nasopharyngeal or other upper respiratory tract secretions but not, to date, in cerebrospinal fluid.1,2,4