Wednesday, November 11, 2009

MHRA-Statins

MHRA publishes public assessment report of adverse effects associated with statins

Reference: Drug Safety Update: Volume 3, Issue 4, November 2009
Source: MHRA
Date published: 04/11/2009 16:20
The following is an extract:

“……the review also identified the need for the product information for all
statins to reflect the issues identified from analyses of clinical trial and postmarketing data from case reports of adverse drug reactions. These included sleep disturbance, memory loss, sexual disturbances, depression, and interstitial
pneumopathy. The review also considered published and unpublished data and
relevant clinical guidelines, and concluded that it was important that prescribers
and patients alike are aware of the potential for these adverse reactions.
• Patients should be made aware that treatment with any statin may be
associated with depression, sleep disturbances, memory loss and sexual
dysfunction
• Statins may very rarely be associated with interstitial lung disease. Patients
should seek help from their doctor if they develop presenting features of
interstitial lung disease such as dyspnoea, non-productive cough, and
deterioration in general health (eg, fatigue, weight loss, and fever)

On the basis of the data examined for individual statins and the class as a whole,
the review concluded that there is sufficient evidence to support a possible causal
relationship between statin use and the above adverse reactions. Summaries of
Product Characteristics and Patient Information Leaflets are being amended to
include the potential for these reactions.

Prescribers will wish to be aware of these changes coming through so that they
can discuss them with patients.”

Tuesday, November 10, 2009

Hairy Crabs & Wines

It is a wonderful time of the year to be visiting Hong Kong.



©2009 Am Ang Zhang/Bauhinia Press


The weather is generally cooler and most important of all; it is the season of Hairy Crabs (Eriocher sinensis).








Hairy Crab Eriocher sinensis 
©2009 Am Ang Zhang/Bauhinia Press



By now, the female crabs would be laden with roes and many restaurants advertise their “Crab Dinners”.

Wine drinking in Hong Kong has also taken off in recent years and with the recent zero taxation policy it is fast becoming a major player in the wine auction business and wine drinking has now replaced Cognac drinking in a big way: for health reasons of course.

Traditionally Hairy Crab is served with a Chinese Wine (Shaoxing Yellow Wine 花雕酒 ) and if you can get hold of a good quality one it is a pleasant enough pairing.

Is there an alternative? A question I have been asked a number of times.


Hairy Crabs are harvested as we consumed them are fresh water crustaceans, although the female crabs do spend some time in the sea during the spawning season. The male crab is consumed earlier in the season and has a sweeter and more delicate flavour. The female crab is best about a month later than the male and the good ones have wonderful rich crimson roes with a very distinctive flavourtaste.  Often these are served with a dark rich ginger and vinegar sauce, the vinegar is dark and rich in flavour.


Here is where the problem of wine pairing is: Ginger and vinegar.

The French tended to use one pairing when faced with such a situation: Champagne.
 
If money is no object, my pick would be: Taittinger Comtes de Champagne Rosé Brut of any Vintage you can pick. In 2007, I visited Taittinger and they ran out of the Comtes Rosé. I settled for the Blanc de Blanc and I would suggest that it too will go well with the Hairy Crabs. The French President serves Comtes de Champagne for State banquets. Now you know.

The Rosé indeed have a fairly deep pink colour and would impress your guests as it matches the colour of the roes and the cooked shells.

To enjoy the champagne, I would certainly go easy on the vinegar.

For those looking for value for money, I would go for Gosset Grand Rose NV. Gosset is in the village of Ay and right next door to Bollinger.

Many white wines would go well with Hairy Crabs and my personal preference would be a good Pinot Gris from the Alsace, and at a third the price of basic champagne, it is excellent value for money.

Monday, November 9, 2009

Berlin Wall, Appassionata & The Lives Of Others

It looked as though many more have stopped listening to Beethoven’s  Appassionata.



Maxim Gorky wrote about Lenin listening to Beethoven's Appassionata:
“I know of nothing better than the Appassionata and could listen to it every day. What astonishing, superhuman music! It always makes me proud, perhaps naively so, to think that people can work such miracles!
“Wrinkling up his eyes, Lenin smiled rather sadly, adding: ‘But I can't listen to music very often. It affects my nerves. I want to say sweet, silly things and pat the heads of people who, living in a filthy hell, can create such beauty. One can't pat anyone on the head nowadays, they might bite your hand off. They ought to be beaten on the head, beaten mercilessly, although ideally we are against doing any violence to people. Hm—– what a hellishly difficult job!”
It was said that Lenin was indeed afraid he would otherwise never ‘finished’ the revolution!!!
Henckel von Donnersmarck said he based his film The Lives Of Others on the Appassionata anecdote.

The Lives Of Others/Sony
The Times:
The Lives of Others has caused the most delicious trouble since winning Best Foreign Language film at this year’s Oscars. Few critics expected this modest thriller about the East German Stasi to lift such a glamorous award.
“The plot is as simple as an opera charge sheet. A plump and seedy minister for the arts falls for a famous actress with a drug habit. He orders his lieutenant to bug the flat she shares with her fashionable playwright boyfriend. Wiesler is duly charged to drag up the necessary dirt. Under “Operation Lazlo”, he litters their apartment with secret microphones and moves into the attic to spy on their every twitch.
“Against every trained fibre of his highly tuned mind he starts falling in love with Martina Gedeck’s voluptuous actress, and sympathising with Sebastian Koch’s idealistic writer. The mission to nail this pair of errant artists turns into a desperate soap to save them.”
With the celebration underway for the 20th anniversary of the fall of the Berlin Wall, The Times reported::
“In an extraordinary frank meeting with Mr Gorbachev in Moscow in 1989 — never before fully reported — Mrs Thatcher said the destabilisation of Eastern Europe and the breakdown of the Warsaw Pact were also not in the West’s interests.
“We do not want a united Germany,” she said. “This would lead to a change to postwar borders, and we cannot allow that because such a development would undermine the stability of the whole international situation and could endanger our security.”
Perhaps she stopped listening to The Appassionata!
Anyway, The Berlin Film Festival refused to accept it as an official entry.
They stopped listening too!
In 2007, it was awarded an Oscar for Best Foreign Film.

Sunday, November 8, 2009

NHS: Can we learn from Obama?




As more and more individuals are taking up private health insurance in England, would the government,  have the courage to adopt some of the Obama Plan in reining in the insurance industry. This would prevent the cherry picking by the industry and the dumping of the chronically ill people on the overstretched NHS.

 

The following is a straight quote from the Obama Plan.

 

More Security and Stability

IF YOU HAVE HEALTH INSURANCE, THE OBAMA PLAN:

·                           Ends discrimination against people with pre-existing conditions.
·                           Limits premium discrimination based on gender and age.
·                           Prevents insurance companies from dropping coverage when people are sick and need it most.
·                           Caps out-of-pocket expenses so people don’t go broke when they get sick.
·                           Eliminates extra charges for preventive care like mammograms, flu shots and diabetes tests to improve health and save money.
·                           Protects Medicare for seniors.
·                           Eliminates the “donut-hole” gap in coverage for prescription drugs.



Obama from The White House.

Sunday, November 1, 2009

Drowning and The Marathon


Rehydration stands © 2009 Am Ang Zhang


As the New York Marathon went underway, I am reminded of our much respected professor in medicine, Old Mac.

“It took 5 minutes to drown and 20 days to die from dehydration.”


Paula at 49.38 © 2009 Am Ang Zhang

Behind Paula© 2009 Am Ang Zhang
It is amazing that after over 40 years they are just beginning to realise that. Research on Marathon runners showed that many had low sodium, a sure sign of over-hydration.

Related:

 

Ancient Remedy: Modern Outlook




Loquat, Winter Melon & Sapote


49.38 © 2009 Am Ang Zhang

Saturday, October 31, 2009

High End Photography & Wine

It is no secret that I have many hobbies and two of them are photography and wine.



Salzburg in Cibachrome©2008 Am Ang Zhang/ Bauhinia Press


The photo of Salzburg was taken with a Hasselblad CF film camera with a 150mm lens at dusk.


This week in the run up to the New York Marathon I had the opportunity to be at one of the biggest photo show in the world: PDN PHOTO EXPO  and saw at first hand the new Hasselblad Camera: H4D, a mind boggling 60 Mpixel camera. What was perhaps a bit sad was that it was not a square 60 X 60 sensor but a 36 x 48 sensor and anyone with rudimentary mathematics will realise that it is the combination of two 36 x 24 sensor which is now used by Nikon, Canon and Leica in their high end products. Not that long ago we were even told that for digital cameras, there was no need for 36 x 24 sensors as 24 x 18 sensors were perfectly adequate.  When will they produce a Hasselblad sensor of 60 X 60?  I wonder.


Still, the Hasselblad H4D is staggering by any standard, and at very little change for $40,000, it should be.  Purists will feel sad that it may be a Hasselblad in name but it is Fuji with Imacon that developed the camera and the digital scanning technology.


I was also fortunate enough to be at Sherry-Lehmann for the book signing of The Heart of Bordeaux and their wine tasting. The book was more a beautiful coffee table book in time for Christmas, but the tasting was spectacular. It was a grand tasting of the wines of Graves Chateau, the subject matter of the book,  and those of Haut-Brion in particular.


After tasting around the hall starting with the “lesser” wines (for want of a better word as some of the wines were very drinkable), we all drifted to the “top” table. The white Laville-Haut-Brion 2006 was one of the best whites I have tasted in recent times.  It is just amazing what could be done with the right combination of Sauvignon and Semillon grapes.  They told me that this white could stay in the cellar for the next 10, 20 or even 30 years!  Then there were of course both La Mission-Haut-Brion 2006 and Haut-Brion 2006 in its distinctive bottle.


I whispered to myself: why did I like La Mission better?  Haut-Brion is first growth, and La Mission is not even classified.  Someone heard me and said, “ Just look at the price: Haut-Brion, $399.95, La Mission, $735.”


Afterwards I read on their website: 2006 is one of the greatest vintages of La Mission Haut-Brion.   It is difficult to say what Haut-Brion will be like in the years to come, but for now La Mission 2006 is much bigger and richer in every way imaginable.


La Mission Haut-Brion is just across the street from Haut-Brion and yet it is so different. That is why top French wines are so interesting.
 
It was a bonus to meet with Hugh Johnson who wrote the preface of the book.  Amongst other things, I just had to talk to him about Royal Tokaji. The story of this Hungarian wine is a legend in the modern history of wine and of individualism. The famous wines of the region were nearly destroyed during the communist era when mass production of poorer quality wines was the order of the day. George Orwell may well be wrong as the pigs did not recognise what was good. It took some smart footwork and of course a broad knowledge of different wines for Hugh Johnson to rescue this unique desert wine.


Hugh said that they were preparing for a 20th anniversary of the re-establishment of the wines. In his own words: “Tokaji is a wine that would make angels sing out loud in praise”.


Indeed! For now, a drop more of La Mission Haut-Brion.


Wednesday, October 21, 2009

SARS, Freedom & Knowledge



Thirty years ago, I saw mountains as mountains, and waters as waters.

When I arrived at a more intimate knowledge, I came to the point
where I saw that mountains are not mountains, 
and waters are not waters. 
Thirty years on,
I see mountains once again as mountains, and waters once again as waters.

                                 

 Adapted from Ching-yuan (1067-1120)

In 2003 the world was in the grip of a new plague that challenged our knowledge of medicine to its limit.
         For the first time, doctors and nurses who were normally in the forefront of the fight against diseases were fighting for survival from SARS (Severe Acute Respiratory Syndrome), a new and dangerously contagious disease.  The alarm was first raised by its first victim, Carlo Urbani.  He was an Italian physician employed by the World Health Organisation (WHO) and based in Hanoi, Vietnam and he gave the disease its current name. It was as if this newly mutated virus knew what it was on about. Get the doctors as they would be the first who could deal with you. Urbani died. So did some of the medical staff that attended the first few patients.
         Doctors often thought that they would be immune, a God given right I suppose.  Not so this time! The virus obviously knew what it was doing.
         Our knowledge base was in total chaos. What we knew was obviously not good enough. Nor were the most up to date antiviral drugs. Even then in some places they were sold out as rumours spread. There were rumours too of vinegar and certain dietary items giving protection to certain ethnic groups, notably Koreans. The lack of knowledge about this new infective agent led to the great proliferation of myths that were soon spreading like wild fire on the Internet. Anyone with cold symptoms was treated as if he was carrying the plague. It was the plague, the new plague.
         Without any sound knowledge authorities took draconian measures – any measure anyone could dream up.  Some worked well if only to raise public awareness. One actually caused more harm and unfortunately deaths. That was the restriction of movement in one of the tower blocks in Hong Kong – a true quarantine. In the absence of insight into how the infection was spread, more people were infected. Some broke the law and fled the buildings before the quarantine. Unfortunately 321 people were infected and 42 died. Eventually someone was sensible enough to move them to another quarantine site.  Otherwise there would have been more deaths.
         Canada's hasty decision to declare its virus free status when so little was known about the virus proved costly and further eroded the public's trust in governments and people in positions of influence. Clinicians’ view no longer seemed to hold any sway where commercial interest was more important.
         Except in Canada, one advice was almost universally adopted – the wearing of a mask.  During this time, I was in correspondence with many of my medical colleagues and relatives in Hong Kong and Canada. One thing was clear: even the most difficult child complied and wore a mask. To this day one still needs to wear the appropriate mask to visit someone in hospital in Hong Kong, on top of having a dollop of alcohol gel to sterilize one’s hands. Many clinics require patients and staff to do the same.
         Now this must be the clearest lesson to every parent in every land. Where life and death is concerned, there can be no compromise.
         So it started me thinking about my practice, specifically Anorexia Nervosa and other difficult cases that I have encountered.  Take Anorexia, it may have been unnecessarily classified as a mental illness, given that it is the result of the parents giving the individuals concerned too much right and freedom for self determination.  If a child can be made to wear an uncomfortable mask, why can parents not make a child eat?
         The answer may lie with our view of freedom. Many parents of Anorexia Nervosa sufferers are highly educated, and some hold high positions in big corporations and even in Health Authorities. Many are professionals. Many have a great respect for individual freedom and self-determination and unfortunately they get caught in a bind of not being able to be authoritarian as far as their own children are concerned. It is not difficult to see why many parents of Anorexia Nervosa sufferers are not prepared to give up being a modern parent, and until they do, we psychiatrists will have to soldier on with the difficult task of treating what need not necessarily be an illness, let alone a mental one. 
         My second thought is that when something as familiar as chest infection can turn out to be a deadly new plague called SARS, we need to examine again the relationship between our existing knowledge and medical practice. We have to keep an open mind. What we know from the past should be an aid, not a hindrance.

Otherwise we shall never see the mountains and waters for what they really are.                                               


                                                                                                           From The Cockroach Catcher



Recent political decisions on Swine flu would seem to indicate that not much has been learned from the SARS experience in Canada and Hong Kong.

Wednesday, October 14, 2009

Cockroach Wine Catch: Bodega Septima Gran Reserva 2006

It is fun discovering different wines from around the world.

The house of Codorniu is well known to most visitors to Spain as the wine maker of some fine "bubblies" outside of Champagne.

Then they founded Septima in Argentina.


“Septima was founded by Codorníu in 1999 with the purchase of 470 acres in the Luján de Cuyo area of Mendoza at a stunning altitude of 3400 feet, concentrating on Cabernet Sauvignon, Chardonnay, Malbec and the Spanish Tempranillo grape. The winery acquired additional acreage in the Valle de Uco in 2007. Mendoza native Rubén Calvo is winemaker. The ‘high and dry’ climate is the key to the success of the venture. Big swings in day and night temperatures make for excellent color and flavor development; the stony humus soil cooperates to keep the vines in place in what is otherwise a harsh arid climate. Irrigate this soil to the optimum degree, add state-of-the-art modern equipment both in field and winery, and you have a recipe for success.” Elliot Essman, Style Gourmet.


In Panama, because of trade agreements with South America, you can get South American wines for nearly half the price you will need to pay elsewhere in the world.


In New Zealand  you could be paying more than $50 (US$ 38) for a bottle!


Jancis Robinson gave it a gold medal!

Elliot Essman continued:


“The Septima 2006 Gran Reserva is a blend of 58% Malbec, 33% Cabernet Sauvignon and 9% Tannat; these grapes were sourced from three different vineyard blocks, vinified separately and aged twelve months in French and American oak. In color the wine is a profoundly deep ruby. The nose has violet and rose flowers, nutmeg and black pepper spice, brambly red berry fruit, and chocolate. As in the case of its single varietal cousins, this blend is superbly balanced. The medium-body and smooth mouthfeel was the first quality I noticed; the acid is firm, the tannins round. Flavors, none of them too pushy, swirl around each other in turns: red cherry, blackberry, chocolate, sweet cinnamon. The finish is lengthy, showing restrained but lasting acidity and tannin with ripe red fruit and vanilla-laced chocolate at the end. Despite excellent flavor, however, it is the elegant feel of the wine in the mouth that catapults it into a league far beyond its $25 asking price.”

For under $13 in Panama, it is a steal and if you can get it for under $25 anywhere else, it is still a bargain.

Tuesday, October 13, 2009

Panama Canal: Diseases & Failures.


We learn little or nothing from our successes. They mainly confirm our mistakes, while our failures, on the other hand, are priceless experiences in that they not only open up the way to a deeper truth, but force us to change our views and methods. 


C.G. Jung
Jung was referring specifically to psychotherapy with those words. But why should this principle not be applicable to politicians?

 


Panama Canal © 2008 Am Ang Zhang


Most people probably know about the French failure to build the Panama Canal. Many thought that this was due to yellow fever and malaria which were diseases thought to be due to some toxic fume from exposed soil.


In 1879, Ferdinand Marie de Lesseps, with the success he had with the construction of the Suez Canal in Egypt just ten years earlier, proposed a sea level canal through Panama. He was no engineer but a career politician and he rejected outright what the chief engineer for the French Department of Bridges and Highways, Baron Godin de Lépinay proposed, a lock canal.


The engineer was no match for a career politician:


“There was no question that a sea level canal was the correct type of canal to build and no question at all that Panama was the best and only place to build it. Any problems – and, of course, there would be some - would resolve themselves, as they had at Suez.”


“The resolution passed with 74 in favor and 8 opposed. The ‘no’ votes included de Lépinay and Alexandre Gustave Eiffel. Thirty-eight Committee members were absent and 16, including Ammen and Menocal, abstained. The predominantly French ‘yea’ votes did not include any of the five delegates from the French Society of Engineers. Of the 74 voting in favor, only 19 were engineers and of those, only one, Pedro Sosa of Panama, had ever been in Central America.”


The French failed in a spectacular fashion.


Diseases like yellow fever and malaria played their part as a sea level canal involves a good deal more digging.


The discovery of yellow fever being carried by mosquito must be credited to one Cuban physician: Carlos J. Finlay.


For twenty years of his professional life, he stood at the center of a vigorously debated medical controversy: the etiology of yellow fever. Finlay believed that it was waterborne and carried by common mosquitoes: Stegomyia fasciata.


Finlay's advice and experiences proved invaluable to the United States Army Yellow Fever Commission. When the Commission decided to test the mosquito theory, Finlay provided the mosquitoes and Walter Reed of the Commission wrote triumphantly after the success of the experiments of inducing yellow fever by mosquito bites, ‘The case is a beautiful one, and will be seen by the Board of Havana Experts, to-day, all of whom, except Finlay, consider the theory a wild one!’ The US experiments vindicated Finlay's two-decade-long struggle.


Reed acknowledged that ‘it was Finlay's theory, & he deserves much for having suggested it.’


William Crawford Gorgas wrote of Finlay:


"His reasoning for selecting the Stegomyia as the bearer of yellow fever is the best piece of logical reasoning that can be found in medicine anywhere."


The discovery by Major Ronald Ross that malaria was transmitted by mosquitoes (Anopheles)had tremendous impact on the Panama Canal.


Crude oil was used on stagnant water to prevent the mosquito proliferation and nets were used to protect workers. Quinine was extensively used to treat malaria. A lock canal was eventually built by the Americans.


Some say that a large part of the eventual success on the part of the United States in building a canal at Panama came from avoiding the mistakes of the French. Knowing the causes of diseases must have helped.


David McCullough in his book "The Path Between the Seas" wrote: "The fifty miles between the oceans were among the hardest ever won by human effort and ingenuity, and no statistics on tonnage or tolls can begin to convey the grandeur of what was accomplished………It is a work of civilization."


Links

Confucius & A Tale Of Two Cities


1859 Chapman & Hall
“It was the best of times, it was the worst of times, it was the age of wisdom, it was the age of foolishness, it was the epoch of belief, it was the epoch of incredulity.”


Charles Dickens A Tale of Two Cities


Confucius taught that one must look after oneself, then family, then nation before one can rule the world.


So perhaps our leaders and MPs are just following ancient Confucius wisdom.

In The Telegraph:

“Mr Brown used his expenses to pay his brother Andrew Brown £6,577 for cleaning work at his Westminster flat between 2004 and 2006.

Also:

“An inquiry was launched into Miss Smith's expenses claims after it emerged that she had designated her family home in the West Midlands as her second home for expenses purposes, while listing a room at her sister's London house, where she lodged, as her main home.

For once London and Paris may not be all that different:

The Independent:


The possible – or even probable – appointment of a 23-year-old Paris law student to run Europe's largest office development has generated a storm of protest and mockery in France, including an 8,000-name petition on the internet. According to his critics, the student has only one qualification to become the next political boss of the lucrative, prestigious but floundering La Défense business district west of the city centre. The student's name is Jean Sarkozy, the son of the President of the Republic.


That which has come to be, that is what will come to be;
and that which has been done, that is what will be done; and so there is
nothing new under the sun.
Ecclesiastes 1:9



Reischauer Lecture on Confucius: Family, Nation, and the World

Oh dear: Blue Peter


Saturday, October 10, 2009

Noctors, Piano, Golf & ADHD

My friend just returned from a month at Spring City Golf & Lake Resort in Kunming, Yunnan. He showed me the score cards.





One golf course was designed by Jack Nicklaus and the other by Robert Trent Jones Jr.




“You have to go. The weather is perfect, and so are the courses. You can play 18 holes and not sweat. The ball goes further at this altitude and the caddies are just wonderful.”


Kunming happens to be my birth place. It is north of Vietnam and is well known for its biodiversity and superb year round weather.


China, which just celebrated 60 years of Communist rule, is now embracing golf in a big way. Most golf courses are designed by big name western golf designers or golf champions turn designers. It must indeed seem ironical, as golf is seen by many as a game for the elite. Venezuela has just banned golf for that reason.


Changes in China since the early 80s have been phenomenal. First it abandoned the “Barefoot Doctors” that was started by Mao when doctors and intellectuals were seen as the elite and sent to remote villages to farm. “Barefoot Doctors” with minimal training cannot really deal with more complicated medical cases. It is a shame that we in England do not seem to have learned from the bad experience of China and the politicians have been pushing ahead with reforms in the NHS with the result that “Barefoot Doctors” known as Noctors (Dr. Crippen) are taking over.


At the height of the “Cultural Revolution”, the piano was seen as the definitive sign of bourgeois decadence.


Petroc Trelawny wrote in The Spectator that Fou Ts’ong (one of my favourite Chopin pianists) was forced to seek exile in London, where he later heard his parents had fatally poisoned themselves. Liu Shih Kun, who came second in the Tchaikovsky Competition when Van Cliburn won, was imprisoned by Madame Mao. He survived and has now established a number of piano kindergartens across China, in response to the craze created by Lang Lang’s performance at the 2008 Beijing Olympics. Many Chinese parents now want their children to learn the piano. The BBC reported that an estimated 30 million children in China are now learning the piano.

BBC
Is the piano China’s answer to the problem that is facing many parents in the west, i.e. ADHD? Could it be a novel substitute for Ritalin and other stimulants? With the advent of unproven modern approaches to education at all levels, very few subjects require memory work. Yet in the last decade or so, memory work has been shown to be beneficial to “brain power”, leading to a whole new approach to neuroplasticity. Learning a musical instrument is one way to give the brain the right amount of training.


For now, just as the west is abandoning classical music training as part of the school curriculum, parents in China are paying for their children to have piano lessons. By some reckoning, North America probably consumes 90% of Ritalin and similar stimulants, whereas China is probably consuming 90% of the pianos produced. One factory in the south of China is currently producing 100,000 pianos a day.


Some will argue that such pressure on children is not good. Yet we have to look at Michael Phelps, whose parents abandoned drug treatment for his ADHD in favour of swimming. The modern Chinese parent may indeed have stumbled upon something similar to Michael Phelps’ swimming in dealing with problems of concentration. Many parents actually believe that the discipline of learning the piano is helpful in building a more rounded person, although some may have aspirations that their offspring might be the next Lang Lang.
As China now moves into a new era, the piano practising child may have something else to practise: golf.


The Independent reported that it is the new game that is the game of choice for China’s new elite.


My friend told me that when he was at the Spring City Golf & Lake Resort, a nine year old just won a junior tournament. The boy was only 9 and he scored 71 on his final round playing from the red Tee
He may well be the next Tiger, a piano playing Tiger.



A Book Review: Knowledge, Ginkgo, Software & Brain Fitness





Monday, October 5, 2009

Curiosity & Nobel

The Nobel Prize in Physiology or Medicine 2009
5 October 2009
The Nobel Assembly at Karolinska Institutet has today decided to award The Nobel Prize in Physiology or Medicine 2009 jointly to Elizabeth H. Blackburn, Carol W. Greider and Jack W. Szostak for the discovery of "how chromosomes are protected by telomeres and the enzyme telomerase"



Associated Press, European Pressphoto Agency, Associated Press
From left, Jack Szostak, Carol Greider and Elizabeth Blackburn.


"This year's Nobel Prize in Physiology or Medicine is awarded to three scientists who have solved a major problem in biology: how the chromosomes can be copied in a complete way during cell divisions and how they are protected against degradation. The Nobel Laureates have shown that the solution is to be found in the ends of the chromosomes – the telomeres – and in an enzyme that forms them – telomerase.

Telomeres/NIH File Material

"The long, thread-like DNA molecules that carry our genes are packed into chromosomes, the telomeres being the caps on their ends. Elizabeth Blackburn and Jack Szostak discovered that a unique DNA sequence in the telomeres protects the chromosomes from degradation. Carol Greider and Elizabeth Blackburn identified telomerase, the enzyme that makes telomere DNA. These discoveries explained how the ends of the chromosomes are protected by the telomeres and that they are built by telomerase.

"If the telomeres are shortened, cells age. Conversely, if telomerase activity is high, telomere length is maintained, and cellular senescence is delayed. This is the case in cancer cells, which can be considered to have eternal life. Certain inherited diseases, in contrast, are characterized by a defective telomerase, resulting in damaged cells. The award of the Nobel Prize recognizes the discovery of a fundamental mechanism in the cell, a discovery that has stimulated the development of new therapeutic strategies." Nobel Press Release

Carol Greider told Associated Press that the research was aimed at understanding how cells work, not with the idea for certain implications for medicine.

“Funding for that kind of curiosity-driven science is really important,” she said, adding that disease-oriented research isn’t the only way to reach the answer, but “both together are synergistic.”

It was comforting that Nobel chose to reward this kind of research as any breakthrough in Medicine and indeed Science could only come from fundamental research. It would not be a discovery if you knew what you were looking for.


The New York Times noted that:“Though Americans have once again made a clean sweep of the Nobel medicine prize, two of the three winners are immigrants. Dr. Blackburn was born in Tasmania, Australia, and has dual citizenship; Dr. Szostak was born in London. Dr. Blackburn came to the United States in the 1970s because it was ‘notably attractive’ as a place to do science.”

PDF, Telomeres

Nobel Posts:
Kandel & Doidge: Neuroplasticity & Memory.
Nobel: Kandel and Lohengrin
Chinese Shared Nobel Prize in Chemistry
Papaya and Nobel Prize

Tuesday, September 22, 2009

C. G. Jung: Memories, Dreams & The Soul

C. G. Jung /Henri Cartier-Bresson

“The purpose of analysis is not treatment,”

“That’s the purpose of psychotherapy. The purpose of analysis, is to give life back to someone who’s lost it.”

STEPHEN MARTIN, Jungian.

I have picked out the various bits in Sara Corbett’s account of the publication of The Red Book that may be of interest. The Red Book may turn out to be the most important publication on the human psyche. We all struggle to understand our own lives and it is reassuring to see that one of the greatest thinkers of our time struggled too.


“Jung soon found himself in opposition not just to Freud but also to most of his field, the psychiatrists who constituted the dominant culture at the time, speaking the clinical language of symptom and diagnosis behind the deadbolts of asylum wards. Separation was not easy. As his convictions began to crystallize, Jung, who was at that point an outwardly successful and ambitious man with a young family, a thriving private practice and a big, elegant house on the shores of Lake Zurich, felt his own psyche starting to teeter and slide, until finally he was dumped into what would become a life-altering crisis.


"What happened next to Carl Jung has become, among Jungians and other scholars, the topic of enduring legend and controversy.


“It has been characterized variously as a creative illness, a descent into the underworld, a bout with insanity, a narcissistic self-deification, a transcendence, a midlife breakdown and an inner disturbance mirroring the upheaval of World War I.


“Whatever the case, in 1913, Jung, who was then 38, got lost in the soup of his own psyche. He was haunted by troubling visions and heard inner voices. Grappling with the horror of some of what he saw, he worried in moments that he was, in his own words, “menaced by a psychosis” or “doing a schizophrenia.”


“Had he been a psychiatric patient, Jung might well have been told he had a nervous disorder and encouraged to ignore the circus going on in his head. But as a psychiatrist, and one with a decidedly maverick streak, he tried instead to tear down the wall between his rational self and his psyche.


“For about six years, Jung worked to prevent his conscious mind from blocking out what his unconscious mind wanted to show him. Between appointments with patients, after dinner with his wife and children, whenever there was a spare hour or two, Jung sat in a book-lined office on the second floor of his home and actually induced hallucinations — what he called ‘active imaginations.’ ‘In order to grasp the fantasies which were stirring in me underground, ‘ Jung wrote later in his book ‘Memories, Dreams, Reflections,’ ‘I knew that I had to let myself plummet down into them.’ He found himself in a liminal place, as full of creative abundance as it was of potential ruin, believing it to be the same borderlands traveled by both lunatics and great artists.


“Jung recorded it all. First taking notes in a series of small, black journals, he then expounded upon and analyzed his fantasies, writing in a regal, prophetic tone in the big red-leather book. The book detailed an unabashedly psychedelic voyage through his own mind, a vaguely Homeric progression of encounters with strange people taking place in a curious, shifting dreamscape. Writing in German, he filled 205 oversize pages with elaborate calligraphy and with richly hued, staggeringly detailed paintings.


“What he wrote did not belong to his previous canon of dispassionate, academic essays on psychiatry. Nor was it a straightforward diary. It did not mention his wife, or his children, or his colleagues, nor for that matter did it use any psychiatric language at all. Instead, the book was a kind of phantasmagoric morality play, driven by Jung’s own wish not just to chart a course out of the mangrove swamp of his inner world but also to take some of its riches with him. It was this last part — the idea that a person might move beneficially between the poles of the rational and irrational, the light and the dark, the conscious and the unconscious — that provided the germ for his later work and for what analytical psychology would become.


“The book tells the story of Jung trying to face down his own demons as they emerged from the shadows. The results are humiliating, sometimes unsavory. In it, Jung travels the land of the dead, falls in love with a woman he later realizes is his sister, gets squeezed by a giant serpent and, in one terrifying moment, eats the liver of a little child. ‘I swallow with desperate efforts — it is impossible — once again and once again — I almost faint — it is done.’ At one point, even the devil criticizes Jung as hateful.


“He worked on his red book — and he called it just that, the Red Book — on and off for about 16 years, long after his personal crisis had passed, but he never managed to finish it. He actively fretted over it, wondering whether to have it published and face ridicule from his scientifically oriented peers or to put it in a drawer and forget it. Regarding the significance of what the book contained, however, Jung was unequivocal. “All my works, all my creative activity,” he would recall later, “has come from those initial fantasies and dreams.”


“And yet, Carl Jung’s secret Red Book — scanned, translated and footnoted — will be in stores early next month, published by W. W. Norton and billed as the “most influential unpublished work in the history of psychology.” Surely it is a victory for someone, but it is too early yet to say for whom.


“To talk to Jung’s heirs is to understand that nearly four decades after his death, they continue to reel inside the psychic tornado Jung created during his lifetime, caught between the opposing forces of his admirers and critics and between their own filial loyalties and history’s pressing tendency to judge and rejudge its own playmakers.


“The Red Book is not an easy journey — it wasn’t for Jung, it wasn’t for his family, nor for Shamdasani, and neither will it be for readers. The book is bombastic, baroque and like so much else about Carl Jung, a willful oddity, synched with an antediluvian and mystical reality. The text is dense, often poetic, always strange. The art is arresting and also strange. Even today, its publication feels risky, like an exposure. But then again, it is possible Jung intended it as such. In 1959, after having left the book more or less untouched for 30 or so years, he penned a brief epilogue, acknowledging the central dilemma in considering the book’s fate. ‘To the superficial observer,’ he wrote, ‘it will appear like madness.’ Yet the very fact he wrote an epilogue seems to indicate that he trusted his words would someday find the right audience.


“In the Red Book, after Jung’s soul urges him to embrace the madness, Jung is still doubtful. Then suddenly, as happens in dreams, his soul turns into ‘a fat, little professor,’ who expresses a kind of paternal concern for Jung.


“Jung says: ‘I too believe that I’ve completely lost myself. Am I really crazy? It’s all terribly confusing.’”


“The professor responds: ‘Have patience, everything will work out. Anyway, sleep well.’”


Jung told one of his patients:

“I should advise you to put it all down as beautifully as you can — in some beautifully bound book,” Jung instructed. “It will seem as if you were making the visions banal — but then you need to do that — then you are freed from the power of them. . . . Then when these things are in some precious book you can go to the book & turn over the pages & for you it will be your church — your cathedral — the silent places of your spirit where you will find renewal. If anyone tells you that it is morbid or neurotic and you listen to them — then you will lose your soul — for in that book is your soul.”

He obviously took his own advice and we may all in the end be thankful he did.


Related: C. G. Jung: The Red Book

Sunday, September 20, 2009

C. G. Jung: The Red Book

The New York Times Magazine:



Thomas Hannich for The New York Times
By SARA CORBETT
Published: September 16, 2009
"This is a story about a nearly 100-year-old book, bound in red leather, which has spent the last quarter century secreted away in a bank vault in Switzerland. The book is big and heavy and its spine is etched with gold letters that say “Liber Novus,” which is Latin for “New Book.” Its pages are made from thick cream-colored parchment and filled with paintings of otherworldly creatures and
handwritten dialogues with gods and devils. If you didn’t know the book’s vintage, you might confuse it for a lost medieval tome."
"And yet between the book’s heavy covers, a very modern story unfolds. It goes as follows: Man skids into midlife and loses his soul. Man goes looking for soul. After a lot of instructive hardship and adventure — taking place entirely in his head — he finds it again."
"Some people feel that nobody should read the book, and some feel that everybody should read it. The truth is, nobody really knows. Most of what has been said about the book — what it is, what it means — is the product of guesswork, because from the time it was begun in 1914 in a smallish town in Switzerland, it seems that only about two dozen people have managed to read or even have much of a look at it."
"Of those who did see it, at least one person, an educated Englishwoman who was allowed to read some of the book in the 1920s, thought it held infinite wisdom — “There are people in my country who would read it from cover to cover without stopping to breathe scarcely,” she wrote — while another, a well-known literary type who glimpsed it shortly after, deemed it both fascinating and worrisome, concluding that it was the work of a psychotic."
Perhaps we should be thankful that DSM did not exist then!
Sara Corbett continued:
"THIS COULD SOUND, I realize, like the start of a spy novel or a Hollywood bank caper, but it is rather a story about genius and madness, as well as possession and obsession, with one object — this old, unusual book — skating among those things. Also, there are a lot of Jungians involved, a species of thinkers who subscribe to the theories of Carl Jung, the Swiss psychiatrist and author of the big red leather book. And Jungians, almost by definition, tend to get enthused anytime something previously hidden reveals itself, when whatever’s been underground finally makes it to the surface."


C. G. Jung: The Red Book
W.W. Norton & Company

C. G. Jung: Memories, Dreams, Reflections
The Exhibition: Rubin Museum of Art

Saturday, September 19, 2009

McKinsey: NHS & Vogue

Great Barracuda, BVI/ ©2009 Am Ang Zhang

Snorkelling can be very inspirational. I have often wondered why so many fishes stay around the Great Barracuda, running the risk of being gobbled up before the end of the day. Perhaps these fishes have not been warned. The NHS certainly has.


I read that McKinsey, one of the leading Management Consultancy firms is expected to recommend 25% cost cuts at Vogue. They have already advised a 10% staffing cut in The NHS to achieve a saving of £20 billion by 2014.


In actual fact the NHS could have saved even more money by doing away with the likes of McKinsey. A new book was published by one insider Matthew Stewart on management consultants. The Independent had the details:


Masters of illusion: The great management consultancy swindle

Thursday, 17 September 2009

I will just pick out a few points that may be of interest.


The truth:

“Wherever I was in the world, at the beginning of every consulting project, one thing was certain: I would know less about the business at hand than the people I was supposed to be advising.”


How to impress:

“Firstly, they constructed a database of the client's customers, detailing each customer's product and transaction activity over the preceding year. Next they established a clean profit and loss statement for the whole business, including all overheads but excluding extraordinary items. Then, to allocate the revenues and costs of the business to each customer, they devised algorithms based on detailed models of each kind of product and transaction. The complexity of these algorithms, naturally, was such that they were far beyond the powers of most clients to comprehend. The result was an analysis of the exact revenue, expense, and profit to the client attributable to each of its customers. Finally, the team lined up the customers according to their profitability, thus allowing the client to see how much of its profits could be attributed to its most profitable customers, and how much to the least profitable."


The Whale Chart: "The Whale" is a graph. Its official title is "Cumulative Customer Profitability" and it also goes by the generic name "skew chart".

“I eventually came to understand that it is possible to construct a Whale chart for just about any business anywhere. It makes no difference whether the business is inherently good or bad, well-managed or in the hands of chimpanzees. It doesn't even have to be a business – it can be a football game or a population chart.”


It gets better:

“In fact, you don't even have to do the analysis. You can save 80 per cent of the effort by just borrowing data from a previous analysis. There's always going to be a skew. It isn't science; it's a party trick.”


The Clients---including The NHS and Vogue:

"The management consulting industry depends on a small number of gargantuan clients; we thought we were doing pretty well out of one of our clients who spent $12m annually on our services – until we learned that this behemoth's total spending on "strategy" consultants was about $100m per year. In order to grasp why some large organisations (but not others) spend so much money on something as ethereal as "strategy," one must dispose of the naïve idea that consulting involves the transfer of knowledge."


Communication:

"The most important of the all-too-human functions of shaman-consultants is to sanctify and communicate opinion. Like ministers of information, consultants condense the message, smooth out the dissonances, unify the rhetoric, and then repeat and amplify it ad nauseam through the client's rank and file."


Writing your own report card:

“The pretence of knowledge where none is to be had, after all, is also a licence to represent private interest as a public good. Managers of client organisations easily abuse this licence, using shareholder money to pay for consultants in order to confer legitimacy on actions that deserve proper scrutiny from truly independent sources. For consultants, the arrangement has all the beauty of writing your own report card.”

According to the Management Consultants' Association, the NHS spent £300m on external consultancy last year.

The ultimate message:

“……you will be expected to work much harder than you ever have before and your chances of losing your job are infinitely greater than you ever imagined.”

Birthday Grand Rounds: Residency Notes

Related: The New York Observer, The Guardian, The Curse of Nye Bevan

NHS: Budget 2010-£110 Billion, McKinsey

Thursday, September 17, 2009

Medicins sans Frontier: Ethiopia & Polyclinics

I woke up to read about the abolition of frontiers in England in Jobbing Doctors.

Since I now drive 120 miles to see my favourite dentist should I do the same so that I can see my old GP.

“He has retired.” Bother!

This is not Ethiopia but do you think our politicians have your interest at heart or are they paving the way for Polyclincs as surely they cannot have frontiers if they are going to make money. Or are they just trying to catch a few votes?

NHS Blog Doctor: GP boundaries, The Guardian

Related: The Independent, The Guardian, MPs,

Monday, September 14, 2009

First Emperor, Animal Farm & Allyson Pollock


“For centuries, the brutal and tyrannical reign of Qin Shihuangdi, First Emperor of China, was summed up by a four-character phrase, fenshukengru 焚書坑儒, ‘He burned the books and buried the Confucian scholars alive.’”Anthony Barbieri-Low: 21st Sammy Yukuan Lee Lecture. See also: The Independent.

Forty years ago, Colin Douglas, geriatrician and novelist, when on a gap year in a remote secondary school in post-colonial Ghana, was summoned by the headmaster and informed that "we had in our library a book the government didn't think we should read." The book was of course Animal Farm.

Here in The BMJ, he reviewed Allyson Pollock’s Book, NHS plc.

NHS plc/Allyson Pollock

"Allyson Pollock describes her experience in November 2001 at the hands of the House of Commons Health Select Committee, then just refreshed by an influx of New Labour ultras, including one Julia Drown MP, a former health service manager. Against the advice of the committee's chairman and clerks, Ms Drown tabled a rant aimed at undermining Professor Pollock and her Health Policy and Health Services Research Unit at University College London. In the chairman's view such an attack on an individual witness was unprecedented and wrong, yet it nevertheless (by virtue of a nasty but neat little bit of committee footwork) appeared in the final report of an inquiry into the implications of the private finance initiative (PFI) for the NHS.”


Allyson Pollock must count herself lucky for not living in China during the reign of The First Emperor although she did leave the England part of The Kingdom.


“……if you are old enough, or even just curious enough, to wonder whatever happened to the British NHS as first conceived, you might find NHS plc a useful little book. An excellent early reputation—for cost effectiveness and equity based on integrated services, minimal management costs, and a vast and intensely practical pooling of risk—dwindled slowly. This was firstly because of chronic and insidious underfunding, later because a notional internal market began to take it apart, and finally (though the word may still be slightly premature) because of the current assault: a burgeoning, divisive, sometimes mendacious for-profit marketisation of a healthcare system that was once an admired public provision and a right of citizenship in the United Kingdom.”


Regarding PFI he continued:

"Since it was Pollock's views on the PFI that so upset its proponents, it is worth summarising them briefly. Costs are now intrinsically higher, because of capital borrowing at higher rates than those available to government, because of cash hungry consultancies and the vast transactional and monitoring costs of countless contracts, and because—for the first time on a large scale in the NHS—commercial profits must be made. To accommodate all these new costs clinical services have been scaled down, while matching assumptions about increased efficiency are only variably delivered. All this, along with the rigidity of a trust based strategy for building hospitals and the locking in effect of contracts fixed for decades, seems to Pollock and many others at best a bad bargain, at worst a naive betrayal that opens the NHS to piecemeal destruction and the eventual abandonment of its founding principles. And all over the country PFIs—greedy, noisy, alien cuckoos in the NHS nest—gobble up its finances and will do so for the next 30 years.”

Next 30 years!


Other concerns:

"Foundation trusts (‘public benefit corporations’—what?) will further disrupt any attempts to build effective local health services, drive the balance of care in the wrong direction, and almost certainly get choosy about the patients they treat. All this will least benefit elderly patients, whose care as our population ages ought to be explicitly identified as the core commitment of our NHS. Will elderly people be surprised? I doubt it. Their long term care was totally abandoned by the NHS in England long ago, and given the direction of current reforms any priority for their acute care would be astonishing. And meanwhile, under the Orwellian rubric of choice and diversity, all manner of dubious, expansionist corporate players, many from the United States, where these things are managed so much worse, are circling, scenting opportunities for private profit in a once great public service.”

I have to thank Dr. Grumble for pointing me to this site that has a write up too.


Rupert Read wrote in OurKingdom:

When I was at Oxford taking PPE 20 years ago, my best friend was Simon Stevens, who went on to become Tony Blair's key health policy adviser. Back then, he was a socialist. Now, he is Chair of United Health Europe, one of the US's giant corporations profiteering from the break-up of the NHS, and angling to take over doctor's surgeries across the UK. That little timeline symbolises quite a lot about what has happened to the NHS.

Why do we still have the great books of Confucious and other scholars? They have all been memorised by scholars and The First Emperor could not kill all of them. When he failed to achieve eternal life and died, the scholars just re-wrote these books again.

The last words go to Colin Douglas:

“Professor Pollock, with the help of many colleagues acknowledged in a list that reads like a roll of honour for services to the real and now threatened NHS, has written a brave, necessary book. And because you know the government thinks you shouldn't read it, you probably should.”

Sunday, September 13, 2009

Old & Young: E. Coli O157

Looks like E. Coli O157:H7 is causing mayhem again, affecting mainly children that visited a farm.

September 13, 2009

Godstone Farm/Gareth Fuller

"Thousands of children across the South of England may be at risk from the E. colibug in what looks to be the largest UK outbreak linked to transmission from farm animals.

"Godstone Farm in Surrey, a popular family attraction where children are encouraged to stroke and touch animals, is closed while the Health Protection Agency (HPA) conducts tests to find out the cause of the outbreak which has left 12 children in hospital, four of them in a serious condition.

"Thirty-six cases, including some adults, have been reported by GPs.

"About 1,000 children, mainly from South London, Surrey, Kent and Sussex, visit the farm every day during the school holidays and at weekends. It is feared that 30,000 children could be at risk of infection."

Remember Scotland 1996?

One of the first major E. Coli O157:H7 outbreak that affected mainly old people in the United Kingdom.

From the BMJ 1996;313:1424 (7 December)

E Coli O157 kills five people in Scotland

"An inquiry had been set up to examine the circumstances behind Britain's worst outbreak of food poisoning from Escherichia coli 0157, which has resulted in five deaths and left 280 people ill.

"The outbreak, in central Scotland, has been linked to cold and cooked meat products sold by a butcher, John Barr and Son, in the Lanarkshire town of Wishawand supplied to dozens of outlets in the surrounding area.

"The deaths have all occurred among elderly people, two of whom were among a group of pensioners who shared a meal at a church in Wishaw on 17 November. They had eaten a steak pie supplied by John Barr, and tests have since confirmed the presence of E coli bacteria in the gravy. It soon became clear, however, that the problem was not confined to Wishaw when people from a wider area began reporting symptoms."

E.Coli O157:H7 can be very virulent and it is believed that as little as 5 individual germs can cause serious damage especially by causing kidney failure. We have little understanding still of how bacteria act but it is now known that E. Coli O157: H7 uses Quorum Sensing. The condition at the farm must have been ideal for them.


We also need to understand about the proliferation of bacteria such as E. Coli and MRSA and C. difficile in our farm animals.

According to The Union of Concerned Scientists:

New Pathways for Transmission: Farm Workers

Microbial Drug Resistance 13(1):69-76.Akwar et al. 2007.

Risk factors for antimicrobial resistance among fecal Escherichia coli from residents on forty-three swine farms.

"Akwar et al. found that people living and working on swine farms where antibiotics were used in feed had increased chances of carrying resistant E. coli. In some cases, the risk of resistance for the farm workers was higher than if they had taken antibiotics themselves. Once farm workers are colonized by resistant bacteria they can transfer them to family members and others in their community."

The use of antibiotics in farm animals is widespread and is not restricted to the treatment of infections but for the enhancment of weight gain. In business terms it is the conversion ratio of feed to weight that matters. The Obama government may well be taking steps to control it due to the rising incidents of Hospital Infections. (See MRSA & Antibiotics: Obama & Farmers.) Chicken and other animals can grow up to twice as fast as 30 years ago when antibiotics were not in the feeds. Scary!

It may therefore require more than "washing hands" if we do not want more outbreaks like this and other ones.

Latest: Twins

Other recent outbreaks: Mother in coma as E coli outbreak strikes

Related Post: MRSA & Antibiotics: Obama & Farmers

Quorum Sensing: E. Coli O157:H7, Hospital Infection: Quorum Sensing, SARS and Quorum Sensing

1996 Report: Pennington Report

E. Coli O157:H7

Thursday, September 10, 2009

NHS & McKinsey: The Professor & 10%

Professor Allyson Pollock is at it again and this time in The Guardian:

Professor Allyson Pollock


The NHS is about care, not markets

The Guardian Thursday 3 September 2009

Downsizing the workforce is a business response to loss of profit – but it doesn't account for the NHS goal of universal healthcare.

I will attempt to look at Professor Pollock’s article in detail especially as we come up to the anniversary of the failure of Lehman Brothers.


Healthcare in the market place:

The core goal of universal healthcare and services planned on the basis of need and not ability to pay is being jettisoned by the turnaround teams and management teams brought in to manage anticipated reductions in NHS budgets. Downsizing the workforce is a traditional response of business to loss of profit where businesses have to pay the costs of operating in a market and earn surpluses for shareholders. Unlike Scotland and Wales, the NHS in England is continuing to pursue market-oriented healthcare in its reform of the NHS. So it should be no surprise that management consultants firm McKinsey have come up with market-oriented solutions to anticipated budgetary shorfalls. They have advised ministers to cut 10% of the NHS workforce in England by 2014, a reduction that will affect services provided primarily to the old and the poor who have among the highest healthcare needs. But strategies to reduce the NHS budget need to pay attention to the role of market structures and how they reduce the ability of the NHS to pool the risks and costs of care across its population.


Administration costs:

The diversion of health spending from patient care to paying for a market are not apparently McKinsey's concern. Take for example the costs of the new market bureaucracy; for more than 40 years administration costs were in the order of 6% of the total budget a year, they doubled overnight to 12% in 1991 with the introduction of the internal market. We have no data today for England, but what we know from the US is that the introduction of for-profit providers increases administrative costs to the order of 30% or more.


Different to Scotland and Wales:

So why hasn't McKinsey advocated making savings along the lines of Scotland and Wales by reintegrating trusts into area-based planning structures and thereby abolishing billing, invoicing, the enormous finance departments, marketing budgets and management consultants, lawyers, commercial contracts? In this way one could project savings of anything from £6-24bn a year for England.


PFI:

A second set of savings would be the high costs of PFI where the taxpayer, having bailed out the banks, is now paying almost twice as much as it should for some PFI hospitals through high rates of interest and returns to shareholders. The total money raised from private finance so far is £12.27bn but the NHS will pay out £41.4bn for the availability of buildings and a total of £70bn over the life of the contracts. The irony is that the patient and the public are rebuilding the banks' balance sheets using scarce NHS funds intended for patient care and staff, especially in community-based services.


ISTC:

A third saving could be made by cancelling the contracts for the £5bn ISTCs programme – research in Scotland extrapolated to England has shown as much as £1bn has been wasted by giving money to for-profit ISTCs for work that was not carried out in the first wave.

Then there are all the other contracted out services including the pharmaceutical bill of £14bn. Are these contracted out elements part of the McKinsey scrutiny? It is doubtful since the company travels the world advocating market solutions.


Failures:

And here we run up against the fundamental problem of retaining marketeers to advise on healthcare. Markets mean reducing the capacity of the NHS to pool the costs of care across the whole service, substituting instead hospitals, clinics and practices that have to pay their way like businesses and, like businesses, can fail. Needs-based planning, once the hallmark of the NHS in England, is being replaced by strategies to deal with artificially created market failure.

Solutions are sought from outside consultants and turnaround teams using unsubstantiated assertions that the NHS is inefficient and can increase productivity. What the selective use of data and evidence mask is the failure to view the system as a whole and to remember that its core goal is universal healthcare, not concocted operating surpluses.


Winners and losers should not be what universal healthcare is about:

In contrast to Wales and Scotland, England has established hospitals and services as competing trusts or firms operating in a market; competition has replaced the mechanisms which enabled health authorities to monitor and respond and direct resources to the needs of the populations that are being served. But markets create winners and losers – and the unpublished McKinsey report is an attempt at refereeing.


The moral is that if the Department of Health in England commissions private management consultants that derive their profits from markets you will get market solutions. It is the commissioning, not McKinsey's report itself, that should give offence.

From the Book by Allyson Pollock: NHS plc

The NHS is being dismantled and privatised. Very soon every part of it will have been ‘unbundled' and commodified...a new business dynamic is taking charge of the ways in which services are provided and patients are responded to. The dramatic costs involved - in terms of loss of equal access and universal standards, as well as of money - are concealed by claims of ‘commercial confidentiality' and by tearing up the once-exemplary systems of NHS accounting

I just hope the Professor will not be one of the 10%.

Grand Rounds: Vol. 5 No. 52 Suture for a Living

What is wrong with the market approach:

Cars: Rover-MG, GM Europe, US Cars

Banks: Northern Rock, HBOS, RBS, Bonus at RBS

Related: Corruption: Three Doctors and a Professor.

Others:

NHS & the Repeal Of The Glass-Steagall Act

To Intervene Or Not: A Colossal Failure Of Common Sense.

Article: The Guardian

Thursday, September 3, 2009

Pfizer, Geodon (Ziprasidone ) & The Twist


In the New York Times:

“The pharmaceutical giant Pfizer agreed to pay $2.3 billion to settle civil and criminal allegations that it had illegally marketed its painkiller Bextra, which has been withdrawn.”


“The government charged that executives and sales representatives throughout Pfizer’s ranks planned and executed schemes to illegally market not only Bextra but also Geodon, an antipsychotic; Zyvox, an antibiotic; and Lyrica, which treats nerve pain. While the government said the fine was a record sum, the $2.3 billion fine amounts to less than three weeks of Pfizer’s sales.”


My main interest is in the antipsychotic Geodon (Ziprasidone )

  

From Reuters:

“Geodon is FDA-approved only to treat patients ages 18-65 diagnosed with schizophrenia or acute manic or mixed episodes associated with bipolar disorder. However, according to the whistleblower suit unsealed today, Pfizer illegally promoted the sale and use of Geodon for a variety of off-label conditions,

including depression, bipolar maintenance, mood disorder, anxiety, aggression, dementia, attention deficit hyperactivity disorder, obsessive compulsive disorder, autism, posttraumatic stress disorder, and for pediatric, adolescent and geriatric patients.”

That sounds like every known condition!!!

"Pfizer targeted pediatrics and adolescents to expand off-label use and maintained on its payroll an army of more than 250 child psychiatrists nationwide." Kenney stated that, "Pfizer regularly paid generous speaking fees to these child psychiatrists to give what were basically promotional lectures about the benefits of Geodon to their peers, who were naturally also child psychiatrists, despite the fact the drug is not FDA-approved or medically indicated to treat children at all."


"……the purpose and intent of paying so many child psychiatrists is clear-- to gain a foothold within the fastest growing market for antipsychotics --children. The practice of expansive off-label use is dangerous, particularly in children because the drug has not been evaluated for its safety for the unique physiological make up of children."


"……less than 5% of the United States population is diagnosed with schizophrenia or bipolar disorder, yet in 2008 Geodon surpassed the blockbuster benchmark of $1 billion in sales."


"……after drug makers obtain initial FDA approval for a specific use, they often don't bother with expensive testing that would allow them to request a label extension for other uses. They just market the drug off-label."


Danger:

"……among Geodon's most dangerous side effects is its potential to affect the heart's rhythm, a condition known as QT prolongation, which increases the risk of sudden cardiac death."


Antibiotic as well?

As part of the overall settlement, Pfizer agreed to pay $100 million to resolve allegations that it engaged in the marketing of Zyvox for a variety of off-label conditions beyond the methicillin-resistent Staphylococcus aureus ("MRSA") infections for which Zyvox was FDA-approved.


Is anything sacred anymore?
 

The twist: this is better than a John Grisham Novel

Associated Press:

“Authorities called Pfizer a repeat offender, noting it is the company's fourth such settlement of government charges in the last decade. The allegations surround the marketing of 13 different drugs, including big sellers such as Viagra, Zoloft, and Lipitor.”

I was wondering why they could be so blatant:

“In an unusual twist, the head of the Justice Department, Attorney General Eric Holder, did not participate in the record settlement, because he had represented Pfizer on these issues while in private practice.”

What other corporations did he represent?

“Eric Holder, has a net worth of $5.7 million and lobbied on behalf of three companies in the past five years, according to a questionnaire filed by Holder with the Senate Judiciary Committee.

“In the year before Obama appointed him Attorney General, he made more than $2.1 million as a partner at Covington & Burling, a prominent Washington law firm. The money is unsurprising given his high-profile client list, which includes companies like UBS Financial Services, Merck & Co., and Hewlett-Packard. He was also paid to sit on the boards of MCI and Eastman Kodak Company.”


Grande Rounds: Voume5, No 51 at Medic999

Links: Eric Holder,Pfizer Whistleblower, Associated Press, Reuters.

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