Wednesday, May 27, 2009

Learning From Others: Canada & Chiropractic Manipulation, NICE

The Observer reports:

Backache sufferers will receive spinal manipulation or acupuncture on the
NHS as a result of official guidance being issued this week on how to treat the debilitating condition.
The move will be welcomed by many of the millions of patients with the ailment, which brings widespread misery and costs the country billions of pounds in sick leave, welfare bills and medical treatment.
The new approach will be unveiled on Wednesday by the
National Institute for Health and Clinical Excellence (Nice), which tells the NHS which treatments are worth spending money on. Nice is expected to say that exhaustive research has shown that manipulation of a patient's spine can be effective in relieving the symptoms of low back pain and recommend that GPs refer sufferers for up to nine sessions with an osteopath, chiropractor or physiotherapist who is trained in manipulation, or an acupuncturist.

It may be timely to look at the Canadian view.
Canadian Neurologists Warn against Neck Manipulation
March 13, 2002
Brad Stewart, MD, FRCPC

Sixty-two clinical neurologists from across Canada, all certified members of the Royal College of Physicians and Surgeons, have issued a warning to the Canadian public and provincial governments about the dangers of neck manipulation. The signers include private neurologists as well as chiefs of neurology departments of major teaching hospitals. Calling their concerns significant, they warn that stroke and death due to neck manipulation has been reported in the scientific literature for over 50 years and that manipulation is one of the leading causes of stroke in the under 45-age group. The neurologists express six basic concerns and you can read them

You may argue that with low back pain you should not have your neck manipulated. The problem is that there is a near cult belief in neck manipulation that I feel compelled to warn readers.

See: Paralyzed Alberta woman sues chiropractors, province for $500M
Web: NHS Blog Doctor Quackwatch
Other Posts:
Chiropractic: Strokes and Class Action

Tuesday, May 26, 2009

Harvard: BPA and Nalgene Bottles

Globe and Mail
Harvard is in the news again, this time good news.

Some very brave students at Harvard risked their health for science! Although they were really doing what they have all been doing for sometime: drinking from Nalgene bottles, a sight not uncommon in gyms and sports events; these are unbreakable containers that has been a convenient alternative to metal and glass.

In The Boston Globe on May 22, 2009

Harvard study backs bottle concern
By Beth Daley
A Harvard study released on May 21 supports what many public health specialists have long assumed: Hard plastic drinking bottles containing bisphenol A are leaching notable amounts of the controversial chemical into people's bodies.
Researchers from the Harvard School of Public Health found that people who drank for a week from the clear plastic polycarbonate bottles increased concentrations of bisphenol A - or BPA - in their urine by 69 percent.

The study is the first to definitively show that drinking from BPA bottles increases the levels of the chemical in urine, researchers said. It was published on the website of the journal Environmental Health Perspectives.
BPA is used in hundreds of everyday products. It is used to make reusable, hard plastic bottles more durable and to help prevent corrosion in canned goods such as soup and infant formula.

"If you heat those bottles, as is the case with baby bottles, we would expect the levels to be considerably higher," said Karin B. Michels, senior author of the report and associate professor at the School of Public Health and Harvard Medical School. "This would be of concern since infants may be particularly susceptible to BPA's endocrine-disrupting potential," she said.

Canada banned the use of BPA in baby bottles in 2008, and Massachusetts health officials are now weighing whether to warn pregnant women and young children to avoid food, drinks, and other items containing the chemical.

Numerous animal studies in recent years suggest that low levels of BPA might cause developmental problems in fetuses and young children and other ill effects. The health effects on adults are not well understood although a recent large human study linked BPA concentrations in people's urine to an increased prevalence of diabetes, heart disease, and liver toxicity.

See also:Undergrads volunteer for Nalgene bottle BPA study
Other Posts: To Ban Or Not To Ban: BPA

Harvard related posts:
Harvard: Sleep Apnoea and Faking
Bipolar Disorder in Children
Bipolar and ADHD: Boys and Breasts
Bipolar Disorder: Biederman Einstein God.

Popular Posts:
Teratoma: One Patient One Disease?
Teratoma: An Extract,
A Brief History of Time: CPR (Cardiopulmonary Resuscitation)
House M.D.: Modern Tyranny
House M.D. : 95% vs 5%

Friday, May 22, 2009

The Ring: Child Psychiatry & Human Behaviour

Ring Cycle Mariinsky Theatre /ROH
Some of us may be lucky enough to have grabbed some tickets of the Mariinsky Ring Cycle in London at the Royal Opera House, it is perhaps a good opportunity to look at why such a lengthy opera has remained so popular despite earlier associations with Hitler and Anti-semitism.

I really cannot better the essay written by Alan Wagner in one of the Metropolitan Opera’s Playbill in 2004.

The Ring of the Nibelung and The Ten Commandments
By Alan Wagner 01 Apr 2004
Alan Wagner delves into the moral and spiritual core of Richard Wagner's colossal masterwork.

Little in art created by a single mind compares to the sheer size and scope of Richard Wagner's Der Ring des Nibelungen. Only a genius with a hint of madness could have conceived anything this colossal, let alone willed it into completion over twenty-six years of gestation and creation.

Furthermore, its 18 hours comprising a single music-drama have gripped every generation since its 1876 premiere with incredible power, unleashing a torrent of commentary. In order to so possess both artist and audiences, Wagner's Ring clearly must be more than a simple sword-and-sorcery epic about giants, dwarfs, gods, and heroes.

And it is. Within that immense journey from the dawn of consciousness to the obliteration of an entire cosmic order there is a compelling moral core. However, even though the composer and his audience were unavoidably enmeshed within a Christian European milieu, it is far from your mama's Sunday-school lesson, a long way from the Ten Commandments, those pillars of Western ethics.
Wagner's philosophical convictions underwent similarly significant refashioning. When he began the Ring, he was influenced by Ludwig Feuerbach, whose principal tenet, explicated in The Essence of Christianity, was that man created God, not the other way around. Religion merely reveals truths about mankind's needs, and its most meaningful revelation is that God is love. Therefore, the pathway to salvation, personal and societal, is love.

In early drafts of the Ring, the liaison between Siegfried and Brünnhilde brought about a triumphant ending for Wotan's sovereignty. However, by 1854, when Wagner first read the masterpiece that impacted his thinking ever after,
Arthur Schopenhauer's The World as Will and Representation, he was already disillusioned about the perfectibility of either mankind or civilization. The Buddhist-like pessimism of Schopenhauer set the seal for Wagner, and he slid the metaphysical center of the Ring from Siegfried's death to where, as he wrote to his friend August Röckel, "Wotan rises to the tragic height of willing his own destruction."

I will try and look at it from the Child Psychiatrist’s perspective.

The dark side of the gods: (it is sometimes easier if one take GODS in the Ring to mean those in POWER. For the characters read here.) In fact, the gods need not work at all, the Nibelungs work almost all the time.

Disrespectful Wotan is hardly revered unanimously, and even he acknowledges higher authorities. Erda knows things he doesn't; his almost bureaucratic dominance derives solely from treaties engraved in runes on his spear, treaties to which he is subservient.
Born liars
Characters lie as it suits them. Events are initiated by Wotan's spurious promise to the Giants to pay them by giving them Freia in exchange for building Valhalla, a promise he knows he cannot keep, as she is the indispensable symbol of love whose golden apples keep the gods alive. His shady ally, Loge, is defined as a double-dealing trickster. Brünnhilde breaks her promise to her father to allow Siegmund to be killed in combat. Mime makes dissembling a veritable life's work, ably carried forward by his nephew, Hagen, in Götterdämmerung. 

Brünnhilde disobeys Wotan, and his grandson Siegfried destroys his power. Mime, who raises Siegfried from infancy and even makes him toys, is treated with disturbingly cruel contempt by the bumptious hero. Hagen, whom Alberich sired via gold-empowered lust as a tool to retrieve the Ring for him, mutters that if he succeeds he will keep it, not hand it over to his Nibelung father.

Thieving & Misappropriation 
……. misappropriation, of persons or of things, provides much of the plot machinery. First, 
Alberich plunders the Rhinegold, and afterward, theft of others' possessions, including the Ring, motivates action upon action. 
Incest and other illicit sex
The teasing of Alberich by the Rhinemaidens which leads to his abjuring love--love, not lust. The definitive heroine, Brünnhilde, and her Valkyrie sisters are the offspring of an adulterous liaison between Wotan and Erda; Wotan also illegitimately fathers the Wälsung twins by a mortal. Sieglinde's infidelity is excoriated by marriage-goddess Fricka, as is her violation with Siegmund of an even more basic taboo, incest. But Wotan defends the twins ("…those two are in love") and, like most audience members moved by the ardent love music, views both transgressions kindly. 
Fafner kills his brother Fasolt, the first victim of Alberich's curse, and we are off to the homicide races. Hunding slays Siegmund, only to be destroyed by Wotan's contempt. Siegfried kills Fafner, the Giant-turned-dragon, and then, after realizing that Mime is trying to poison him, kills him as well. By the time the gods' destiny climaxes, Hagen has murdered both Siegfried and Gunther and is himself drowned by the Rhinemaidens. Eventually Brünnhilde sets Valhalla ablaze as part of her self-immolation upon Siegfried's funeral pyre ("Thus do I hurl the torch into Valhalla's proud-standing stronghold") and all the gods die.
Greed, greed, greed!
Finally, "coveting that which is your neighbor's" is pretty much the whole raison d'être for the Ring story, starting with Alberich's desire for the Rhinemaidens, then for the gold they guard. Thereafter everybody seems to want what doesn't belong to him or her: the Ring, a sword, a treasure, someone else's wife, sheer power. 
Yet in spite of Wagner's wholesale abandonment of the Decalogue, the bastion of Western morality, Der Ring des Nibelungen generates explosive ethical and metaphysical impact. He started with the absorption, fusion and reinvention of myriad legendary sources, and layered Schopenhauer's philosophy upon Feuerbach's. In Art and Climate Wagner wrote, "there is no true freedom except that which is common to all mankind... The redeemer is therefore love… starting with sexual love, [it] strides forward through love of children, brothers and friends, to universal love of humanity." The emphasis is his. Yet, some years later he wrote to Mathilde Wesendonck, "I can conceive of only one salvation. It is Rest! ...The stilling of every desire!" 

Wagner once wrote to Röckel, "I have come now to realize how much there is, owing to the whole weight of my poetic aim, that only becomes clear through the music." He later described the discontinuity between his "rationally formed ideas" and "the exquisite unconsciousness of artistic creation… guided by wholly different, infinitely more profound intuition."

Music alone would now convey the message. The last moments of Der Ring des Nibelungen are given entirely to the orchestra: there is too much weight for words. Something greater than the story, richer than all the sources, probably better than Wagner himself knew, is brought to a healing close with a tender statement of a motif heard only once before in the Ring, when Sieglinde learns she is bearing her child of love, Siegfried. It is the motif of Redemption Through Love. 

How wonderful it is to wait this long for the protein to be activated.
In the end, Wagner fashioned a masterwork of such extraordinary strength that it transcends analyses, personalities, philosophers, his own prejudices, and even his total disregard for Judeo-Christian society's standards of ethical behaviour.
Out of the highest art came a truth beyond even his explanation. 

Stop Press: Lohengrin Review: FT
"Sunday’s audience, which had grumbled and tittered its way through the performance, was stunned into silence. Suddenly, Lohengrin had become a more troubling, more ambivalent work than we all imagined it to be. In place of utopias, it spoke of false dreams, taboos, uncertainty. The rats’ herd-like belief in a better life had been smashed, just as Lohengrin’s quest for unconditional love had failed. No wonder Wagner called Lohengrin his saddest opera."             
Wagner website.
Independent: Mariinsky Ring
Other Opera Posts:
Other arts posts:

Wednesday, May 20, 2009

House M.D. : Australia

Dr Crippen alerted us to the wonderful story in The Telegraph

A man and his Black & Decker

Natasha Richardson and Medical Technology we looked at the tragic and premature death of Natasha Richardson on a ski-slope in North America. No one was brave enough to treat her on site. To put it in simple terms, no one was brave enough to drill. The delay turned out to be fatal.

"I believe the delay was due to medical technology. CT scanners, MRI scanners and helicopters. That sounds counter intuitive, but think about it. These days, and particularly in the medico-legal climate prevalent in North America, it would be a brave doctor indeed who did not wait for the CT scan before drilling the burr holes. It would be a career making or career breaking decision. Few American doctors are brave. Defensive medicine is the order of the day. You cannot have a migraine in the USA without someone ordering an MRI scan."

Compare Natasha Richardson's story with this:

Nicholas Rossi ABC

"Nicholas Rossi, 13, fell off his bike in the small rural town of Maryborough in Victoria and hit his head. He was not wearing a helmet, and the impact knocked him momentarily unconscious. He recovered enough to go home, but complained to his mother Karen, a trained nurse, of a bad headache. Mrs Rossi took her son to district hospital where Dr Rob Carson, a local GP, was on duty, his family told The Australian newspaper. The boy was kept under observation, but one hour later, he started drifting in and out of consciousness. Dr Carson recognised the problem as internal bleeding in the skull and noticed that one of Nicholas's pupils was larger than the other, another sign of bleeding that was placing pressure on the brain. The injury was the same that recently led to the death of actress Natasha Richardson after a skiing accident. Dr Carson believed Nicholas had torn an artery just above his ear between his skull and his brain, creating a large and life-threatening blood clot. In scenes reminiscent of a television medical drama.

"Dr Carson realised he had minutes to save the boy's life and there was no time to transfer his patient to a hospital with a dedicated brain surgery unit. Instead, he telephoned Dr David Wallace, a neurosurgeon 105 miles away in Melbourne, to help talk him through the operation - which he had never attempted before.But there was one problem. The hospital was not equipped with a surgical drill. Instead, Dr Carson had to use the next best thing - a household drill found in the hospital's maintenance cupboard. He disinfected the drill and, under Dr Wallace's guidance, used it to bore into Nicholas's skull to release the blood clot."

The story has been picked up now by the main stream media across the world: BBC ABC.

Let us remind ourselves:

There are three medical procedures that can be dramatically live-saving.
1. Relieving a tension pneumothorax
2. Performing a tracheotomy
3. Drilling burr holes into a skull.

Looks like House M. D. is back. This time in Australia! Is that why so many doctors are migrating to there? It is a good day for doctors anywhere.

A man and his Black & Decker
A simple bump on the head can kill you
Natasha Richardson’s Brain Injury
The wussification of the American medical profession
House M.D. : 95% vs 5%
House M.D.: Modern Tyranny

Tuesday, May 19, 2009

Bipolar Disorder: Divalproex ER vs Placebo

Just before I retired, it has become fashionable to use anticonvulsants as a mood stabiliser. Being a traditionalist, I felt then that the evidence was not clear and I tended to stick with the trusted lithium.

Well my doubts were confirmed:

Journal of the American Academy of Child & Adolescent Psychiatry:
May 2009 - Volume 48 - Issue 5 - pp 519-532
doi: 10.1097/CHI.0b013e31819c55ec
New Research

A Double-Blind, Randomized, Placebo-Controlled Trial of Divalproex Extended-Release in the Treatment of Bipolar Disorder in Children and Adolescents

Objective: To compare the efficacy and safety of divalproex extended-release (ER) to placebo in a 28-day double-blind study of bipolar disorder in children and adolescents and evaluate the safety of divalproex ER in a 6-month open-label extension study.
Method: In the double-blind study, 150 patients (manic or mixed episode, aged 10-17 years) with baseline Young Mania Rating Scale (YMRS) score of 20 or higher were randomized to once-daily placebo or divalproex ER, which was titrated to clinical response or serum valproate concentration of 80 to 125 μg/mL. Sixty-six patients enrolled in the extension study.
Results: In the double-blind study, a treatment effect was not observed with divalproex ER based on change in mean YMRS score (divalproex ER -8.8 [n = 74]; placebo -7.9 [n = 70]) or secondary measures. Divalproex was similar to placebo based on incidence of adverse events. Four subjects treated with divalproex ER and three treated with placebo discontinued because of adverse events. Mean ammonia levels increased in the divalproex ER group, but only one patient was symptomatic. In the long-term study, YMRS scores decreased modestly (2.2 points from baseline). The most common adverse events were headache and vomiting.
Conclusions: The results of the study do not provide support for the use of divalproex ER in the treatment of youths with bipolar I disorder, mixed or manic state. Further controlled trials are required to confirm or refute the findings from this study. J. Am. Acad. Child Adolesc. Psychiatry, 2009;48(5):519-532.

An earlier Harvard study showed that Lithium reduced suicide risks by as much as 9 fold.

Related Posts:

Bipolar Disorder: Lithium-The Aspirin of Psychiatry?
Lithium Bipolar and Nanking
Bipolar Disorder in Children
Bipolar and ADHD: Boys and Breasts
Bipolar Disorder: Biederman Einstein God.
Antipsychotics: Really?

Sunday, May 17, 2009

Learning From History: SARS, Canada, Masks and Inluenza A (H1N1)

In The Globe and Mail, Canada Link:  ttps://
May23, 2003

“Faced with the World Health Organization's costly declaration on April 23, that Toronto was too dangerous to visit, politicians, health officials and even the news media quickly banded together against a common enemy — and it was not the virus but WHO, the United Nations agency, that had effectively put Canada's largest city under quarantine. ‘That week, that advisory definitely changed our psychology and the way we looked at this outbreak, ’Dr. Low said. ‘I remember . . . we were putting such a positive spin on things, including myself — everybody wanted to be clean of this.’”

"Now Toronto is holding its collective breath through a crucial weekend once again, as health officials cling to hopes of containment even as the numbers of cases and people in quarantine climb. The WHO lifted its travel advisory on April 30. Two weeks later, after the agency removed Toronto from its list of SARS-affected areas, Ontario lifted the provincial emergency status. Behind the scenes, the province disbanded members of its epidemiology team and scaled back its emergency-operations centre to a routine monitoring function. With no known new cases after 20 days, the city had laid down its gloves. On May 16, health staff in area hospitals were instructed that they no longer needed to wear full protective gear. May 16 is emblazoned with regret in Dr. Low's mind: "As soon as the masks and the gloves came off, you can see this dramatic spike in the cases.”

“……There was a new cluster, they told him, centering on patients who had spent time at St. John's Rehabilitation Centre in the city's north end before being transferred to four other Toronto area hospitals. Contact tracing had turned up no epidemiological link to the first outbreak. But a lab test confirmed that one of the four known patients carried the SARS coronavirus deep in his bronchial tract. It was back.”

You really cannot spin the public’s health, or can you? However there was some other form of spinning.
“Dr. Low's head spun with disbelief. ‘You're hearing it all and you're trying to minimize it. You're thinking, No this can't be right, this can't be.'

I know that Influenza A(H1N1) is not SARS, but why should we not learn from it.

The evidence of masks is here. CDC on SARS.

Bus in Hong Kong AFP
In the meantime we are donning masks whatever anyone else may say.


SARS ACCOUNTS: Dr Yannie Soo, Tom Buckley.
Other Posts:

SARS, Freedom & Knowledge

Learning from History: Swine Flu & Antibiotics

Learning From History: 1918 Flu Pandemic, Hong Kong SARS, Swine Flu & Influenza A(H1N1)
EBM: Masks, Cathay Pacific Airline, SARS and Influenza A(H1N1)
Swine Flu: WHO Level 5 & The 1976 Vaccine Disaster.

Hong Kong: SARS and Swine Flu

SARS and Quorum Sensing

Hospital Infection: Quorum Sensing

Friday, May 15, 2009

Nobel: Kandel and Lohengrin

Eric Kandel, M.D.:
"We are what we are through what we have experienced and what we have remembered."

In 2001 I was fortunate enough to be in New Orleans for the American Psychiatric Association Annual Conference. One of the lectures attracted a long queue and it turned out that the Nobel Laureate Eric Kandel was giving his lecture. I was fortunate enough to be able to secure a seat.

"What learning does is to change the strength of the synaptic connections in the brain," Kandel explained, "and this has held true for every form of learning so far analyzed. So, what genetic and developmental processes do is specify the cells that connect to each other, but what they do not specify is the exact strength of those connections. Environmental contingencies, such as learning, play a significant part in the strength of those connections."

"Different forms of learning result in memories by changing that strength in different ways. Short-term memory results from transient changes that last minutes and does not require any new synthesis of proteins, Kandel said. However, long-term memories are based in more lasting changes of days to weeks that do require new brain protein to be synthesized. And this synthesis requires the input of the neuron’s genes."

Lohengrin Royal Opera House
Readers would have noted that a week ago I was at the Royal Opera House Lohengrin.

I have always maintained that there is something fundamentally enjoyable about a piece of music that you are familiar with. It is of course the case with many pop songs. But they were only a few minutes long. Lohengrin runs to nearly four hours.

Yet to me it is one of Wagner’s most wonderful piece of music. On the 8th of May the musical performance was amazing. You can feel the brain re-activating the proteins.

The set was of course from 1977 and bits of it smack of a school play. The costume was extraordinary even after 32 years. Adherence to the classical Grail story is deceptive especially with the unexpected kissing of Elsa and her brother on the lips. I know incest is covered in the Ring cycle but sex seems to be the new black now in opera. Or was Wagner dropping hints on Nietzsche’s relationship with his sister? I did not think it helped the opera Lohengrin.

There is no question though: Lohengrin has one of the best music of all the Wagners including Götterdämmerung.

Autobiography: Eric Kandel
Wagner website.
Other Opera Posts:Lohengrin: Speech Disability, Design & Hypertension
The Dark Side: Il TrovatoreDoctor Atomic
Illness and Morality
Lunar Eclipse
Other arts posts:
Can They Draw: From Picasso to Matisse

Picasso, Medicine and Lloyds
Picasso and Tradition

Thursday, May 14, 2009

Paraguay: Technology Meets Ecology

Loofah drying ----Rolex Award

Elsa Zaldívar takes leftover pieces of a vegetable sponge loofah and mixes them with other vegetable matter and recycled plastic to form strong, lightweight panels that can easily be assembled into simple structures, including houses.
Her technological, eco-friendly solution to her nation’s housing shortage will help save what remains of Paraguay’s rapidly diminishing forests.

Loofah growing--- Rolex Award
She won the Rolex Award for 2008

"In the poverty-stricken countryside of Paraguay, a landlocked country in the heart of South America, an innovative social activist has found a new use for an old vegetable. Elsa Zaldívar, whose longstanding commitment to helping the poor while protecting the environment has won her deep respect in her native land, has found a way to mix loofah – a cucumber-like vegetable that is dried to yield a scratchy sponge for use as abrasive skin scrubber – with other vegetable matter like husks from corn and caranday palm trees, along with recycled plastic, to form strong, lightweight panels. These can be used to create furniture and construct houses, insulating them from temperature and noise. About 300,000 Paraguayan families do not have adequate housing.

"The area’s economy had declined with the collapse of cotton and increasing cultivation of soya, an environmentally disastrous crop that had left soils contaminated and forced families off the land, leaving them without employment. Zaldívar took an interest in loofah, a plant that grows easily in the region, but which had fallen out of favour. She persuaded local women in Caaguazú to consider it as a means of generating income.

"The Rolex Award will finance a promotion centre near Asunción and the construction of three model houses where the panels’ versatility will be displayed for both urban and rural audiences, as well as funding the production of a video that will be used to describe the project to people interested in using similar techniques in other countries.

"Zaldívar’s initial focus for providing low-cost housing remains Paraguay’s deforested countryside. 'We want to find sustainable housing alternatives for the poor, while also discovering new markets for their agricultural products, particularly the loofah. This is a perfect combination,' she says."

You can listen to her here.

Nature Posts:

ECOLOGY: First Bees, Now Bats.
Honey Money Money
Hong Kong: Humpback Whale
Tasmania: Whales & Dolphins-Mother & Baby
It’s a Bird, a Reptile, a Mammal: It’s Platypus

Wednesday, May 13, 2009

EBM: Masks, Cathay Pacific Airline, SARS and Influenza A(H1N1)

Cathay Pacific at Hong Kong International Airport Wikimedia Commons

Hong Kong's main airline, Cathay Pacific, on Saturday backed down on its refusal to allow its flight attendants to wear face masks to protect themselves against swine flu. The change of policy came after the confirmation of East Asia's first swine-flu case in Hong Kong on Friday night and an appeal from the city's health secretary, York Chow. AFP/Standard

It is claimed that there is no evidence that the wearing of face mask is useful. So I tried to search for the evidence.

New Scientist
Face masks are best protection against SARS
02 May 2003 by
Shaoni Bhattacharya

"Face masks offer the best protection in the fight against SARS, reveals a new hospital-based study from Hong Kong.

SARS HK 2003 Medical Staff in Hospital Virgin Media

"Wearing a mask can give a person dealing with SARS patients in hospital up to 13 times more protection compared with not wearing one, says Wing Hong Seto, study lead and chief microbiologist at the Queen Mary Hospital in Hong Kong.

"However only surgical masks and N95 masks - designed to block airborne particles - will work. These masks protect the face from droplets coughed out by infected people, which the team believes is the primary mode of spread. Seto says droplets are probably the main mode of transmission of SARS outside hospitals as well. He says the findings confirmed SARS is not spread through the air - if so only the N95 masks would have been protective.

"Face masks have become a morbid symbol of the impact of SARS in the worst-hit parts of the world. The virus has now killed 416 people across the globe, with over 6000 infections in 29 countries.

"Wearing masks in public places has become commonplace in the Hong Kong and the Chinese mainland, where the disease first emerged. But their effectiveness has been controversial and some commentators say their use has helped stoke an atmosphere of panic.

"But Seto told New Scientist: "Masks seem essential for protection. This finding fits well with droplet transmission, because droplets are generated at the face level."

Statistically significant

"Seto and colleagues from five Hong Kong hospitals and the University of Hong Kong, surveyed over 250 hospital staff exposed to 11 SARS patients between 15 March and 24 March.

"Most of the 13 staff who became infected did wash their hands, and a handful also wore gloves or a paper mask, but none had used a surgical or N95 mask. Analysis of the data showed that the use of surgical or N95 masks was the only measure to give statistically significant protection.

"Paper masks offered little protection, says Seto. 'Such masks, being easily wet with saliva, are never recommended as a precaution against droplets.'

"However, not one of the 69 staff who had used all four recommended protection measures - wearing a mask, gloves, gowns and washing their hands - contracted the virus."

"Seto believes the risk of contracting SARS in public places is 'very low' and so does not wear a mask himself. 'However, I have it ready if I am in a crowded place,' he says. 'I see someone consistently coughing, then I put it on. If I see he is febrile, I strongly advise him to go home and see a doctor. Then I wash my hands and take a good shower on coming home.'

Journal reference:
The Lancet (vol 361, p 1520)

It has to be accepted that there is virtually no rubbish collecting facility in public places in the UK due to worries about bombs and there are no hand washing facilities on buses and other public transports. See NHS Direct Advert.

In any case, Hong Kong has now a second case of of Influenza A (H1N1); a passenger on Cathay Pacific flying in from the US. There has been no local spread so far.

Other Posts:

Monday, May 11, 2009

Corruption: Three Doctors and a Professor.

I woke up to three doctors all writing about a Professor. No, she is not corrupt.
She un-covered what has been going on in the NHS that is corrupt.

Corruption, dishonesty, fraud and cover-up.

Dr Crippen

“IN the BMJ this week, Professor Pollock, discusses the information she has been able to gather by using the Freedom of Information legislation. It was like getting blood out of a stone. It reveals
a tale of duplicity, incompetence, fraud and secrecy as, once again, the government tries to cover up the way in which billions of pounds of taxpayers’ money has been squandered.”


Dr Grumble

“But what has really goaded Grumble into this tirade on secrecy? It wasn't the MPs' expenses. It wasn't even the drug licensing issue. It was frustration that we do not know how much the parts of the NHS that have been privatised are costing. Except that is for one ISTC. You can read about that in an
article written by Allyson Pollock.It's long article. Here's a key bullet point:
The Scottish Regional Treatment Centre treated only 32% of annual contract referrals in the first 13 months of operation at 18% of the annual contract value. If the same patterns apply in England, up to £927m of the £1.5bn may have been paid to ISTCs for patients who did not receive treatment under the wave one ISTC contracts.
Allyson tells it as it is. She can't be much loved in some quarters. She will never be Dame Allyson. Probably she doesn't want to be a dame.She must have difficulty getting funded - except, that is, for
one-way trips to Outer Mongolia.”Say goodbye to your money.

Jobbing Doctor

“So my reading is we paid 5 times as much as we needed to for these operations. Much of the data is kept secret because of 'commercial confidentiality'. I'm sorry but this doesn't wash with the Jobbing Doctor. Professor Pollock has started to unpick the
monumental squandering of millions of pounds on work that is either substandard or often not done!”
Links: BMJ Article.

Jobbing Doctor:
Say goodbye to your money.

Dr Grumble:

NHS Blog Doctors:
Corruption, dishonesty, fraud and cover-up.

BMJ Analysis: Allyson M Pollock

Independent sector treatment centres: learning from a Scottish case study
Allyson M Pollock, professor and director, Graham Kirkwood, research fellow
Published 30 April 2009, doi:10.1136/bmj.b1421Cite this as: BMJ 2009;338:b1421

1 Centre for International Public Health Policy, University of Edinburgh, Edinburgh EH8 9AG
Correspondence to: A M Pollock

The value for money of work contracted out to independent sector treatment centres has been hard to assess. Allyson Pollock and Graham Kirkwood look at data from the only such centre in Scotland.
The ISTC programme: time for an overhaulSince 2000, the Department of Health has had an explicit policy of using NHS funds to contract out some elective surgery and associated clinical services to the private for profit sector. This policy of commercialisation is known in England as the Independent Sector Treatment Centre (ISTC) programme, under which the government intends that the private health care industry will provide elective surgery and other clinical services at a projected total cost to the NHS of over £5bn ($7.3bn, 5.6bn).
1 To date the government has contracted for £2.7bn worth of services.2 The core objectives of the programme are to assist the NHS in reducing waiting times, support the shift from primary to secondary care, expand the options for patient choice in the provision of services, promote innovation, and build relationships between the NHS and the private sector.3
The policy has been extraordinarily difficult to evaluate because few data are publicly available.
4 Parliamentary and academic assessments of the value for money and effectiveness of the policy have been hindered by the refusal of the Department of Health to make the contracts public on the grounds of commercial confidentiality.1 Because crucial data have not been submitted by the private sector to Hospital Episode Statistics, quality and performance also remain unevaluated.5 6 In July 2006 the House of Commons Health Committee concluded that lack of data made an assessment of the programme impossible, and in July 2007 the Healthcare Commission could not report on quality of care because ISTCs failed to return and comply with Hospital Episode Statistics data requirements, a situation that continues.1 5 6 The programme remains highly controversial amid concerns that the centres are destabilising NHS trusts, forcing service closures, and undermining quality of care.1

After an appeal under the Freedom of Information Act in Scotland, NHS Tayside has placed the only Scottish ISTC contract in the public domain. Information that remains shrouded in secrecy in England is now publicly available in Scotland, providing the first opportunity to assess performance against the claims made for the policy.

The Scottish ISTC—background
In November 2006, NHS Tayside Health Board contracted Amicus Healthcare (Scotland), a subsidiary of Netcare (UK), which is a subsidiary of the South African healthcare company Netcare, to provide elective procedures over three years for up to 8000 NHS patients at a cost of £18.7m.
7 8 The annual contract comprises £5.67m for referrals for operations; £427 000 for referrals for outpatient appointments; and £144 000 for unspecified additional activity.8 A further supplement of £80 000 was provided by the Scottish government for patients’ travel and accommodation.9
Netcare operates from an NHS hospital; the shared operating theatre is used by the NHS during weekdays and by Netcare at evenings and weekends.
8 The Scottish Regional Treatment Centre has been accepting referrals since December 2006 and patients have been undergoing treatment since February 2007.10 Netcare is also involved in the first two phases, described by the Department of Health as wave one and phase two, of the ISTC programme in England (list of wave one and phase two ISTC contracts for England supplied by Information Centre for Health and Social Care, Oct 2008; available on request).
In August 2005 the management consultants PricewaterhouseCoopers were contracted by the Scottish government to provide "...Financial, Commercial & Contractual Advice to the Scottish Treatment Centre Pilot Project" at a cost of over half a million pounds. In June 2008 they published a 10 month evaluation concluding that the Scottish Regional Treatment Centre represented 11% better value for money than NHS hospitals, findings described by the finance director for NHS Tayside as appearing to show "...the private sector can provide just as good, if not better, care than the NHS but at a significantly lower cost."
9 11 We explored the basis of this claim.

How did the Scottish ISTC perform against the contract?The first problem we encountered was that neither the contract nor PricewaterhouseCoopers’ evaluation conformed to official standards for reporting data to the Information Services Division of NHS National Services Scotland, the agency responsible for producing national health statistics in Scotland.
The contract bases payment for activity on referral data and not actual treatments undertaken. The PricewaterhouseCoopers evaluation was undertaken on the same basis. To establish how many referrals resulted in treatment we asked the Information Services Division in August 2008 to extract data on all treatments reported to them by the Scottish Regional Treatment Centre from 1 December 2006 to 31 December 2007 by health board of residence, type of procedure, and month of treatment (known as Scottish Morbidity Record SMR01 data) for inpatient and day case episodes. We used the Healthcare Resource Group tariffs published in the contract to derive the actual cost of treatments reported to the Information Services Division. We then compared the referral and cost data in the contract and the PricewaterhouseCoopers evaluation with the Information Services Division’s treatment data for the 10 months from 1 December 2006 to 30 September 2007 and 13 months from 1 December 2006 to 31 December 2007, to allow for the 12 week maximum referral-to-treatment time outlined in the contract.
8 9

As the table
shows, the annual contract is for 2624 referrals at a total value of £5 667 464. The PricewaterhouseCoopers evaluation for 1 December 2006 to 30 September 2007 shows that the Scottish Regional Treatment Centre received about 2200 referrals at a cost of £2 642 000. However, the evaluation does not show which procedures patients were being referred for or how the total cost was derived. The Information Services Division data show that over the same period the centre undertook 498 procedures: 19% of the volume of referrals it was contracted to handle annually. By the end of September 2007, the actual value of work done by the centre was £533 213. Thirteen months into the contract the Information Services Division data show that only 831 procedures—32% of the annual contract referral volume and 38% of the PricewaterhouseCoopers referral estimate—had been undertaken, at a cost that we estimated at just over £1m, 18% of the annual contract value. This leaves £1.6m of the PricewaterhouseCoopers estimate of payments made unaccounted for. We did not analyse outpatient activity and neither did PricewaterhouseCoopers.
View this table:[in this window][in a new window]
Table 1 Comparison of annual contract referral and cost specification for Scottish Regional Treatment Centre with data from PricewaterhouseCoopers’ 10 month review and data reported to Information Services Division*
One caveat to our analysis is that NHS Tayside’s record for returning SMR01 data was among the worst in Scotland, with a lower than average accuracy of reporting diagnoses.
12 13 SMR01 returns from NHS Tayside to the Information Services Division on 11 August 2008 were estimated to be 93% complete for the last quarter of 2007, but this level of incompleteness does not account for the low treatment numbers we found. Additionally, the Scottish Regional Treatment Centre may have under-reported procedures to the Information Services Division; the Healthcare Commission found that completeness of data from ISTCs in England was poor for the first three years of the programme.6

Value for money and risk

The UK government’s claims of value for money hinge on the transfer of risks and costs from the public to the private sector through the contract. The absence of evidence to justify the government’s claims has been highlighted elsewhere.
4 This contract shows that the complex payment mechanism, far from transferring risk to the private sector, increases the risks and costs to the health boards. First, the contract and payment mechanisms require the health board to meet the requisite monthly referral volume—regardless of patients’ needs—or to meet the costs associated with any shortfall, a system known as "take or pay". In this contract Netcare is paid up to 90% of the monthly referral value regardless of the volume of referrals made. Second, the health board pays regardless of whether patients who are referred receive actual treatment unless it can prove that the Scottish Regional Treatment Centre failed to carry out a treatment. Netcare may have been paid up to £3m for patients who did not receive treatment.
Contracts based on payment for referrals rather than actual treatments provide scope for gaming, undertreatment, and cost inflation, not least when the health board is penalised for under-referring by volume and where lack of data makes external monitoring impossible.

Implications for the English ISTC programme

Data availability and data qualityIn England the government’s refusal to publish contracts is compounded by the ISTCs’ failure to provide complete, NHS-standard data on performance and actual work completed. From 32 ISTCs operating in January 2008 that returned Hospital Episodes Statistics data in the second quarter of financial year 2007-8, the primary diagnosis was missing or invalid for 42.6% of patients, compared with 0.1% for NHS operated treatment centres; 13.3% had a missing or invalid primary procedure code, compared with 5.8% in NHS centres; and 64.1% had a missing or invalid ethnicity classification, compared with 16.8% in NHS centres.

Basis of payment in the English contractsIn Scotland Netcare is paid monthly on the basis of all referrals made by the health boards: a marked departure from usual standards of commissioning, reporting, and paying for activity in the NHS, which under the internal market were typically on a cost per case or block contract for treatments or services. England, like Scotland, bases its payment mechanism for wave one ISTC contracts on referrals from primary care trusts rather than on work actually done. The total value of the wave one English ISTC contracts is £1.5bn and these contracts are 100% "take or pay" based on contracted referral value.
2 3 Phase two contracts have been adjusted to reflect payment for actual treatment but there is still an unspecified guaranteed minimum fee payable to the ISTCs from the primary care trusts, which according to the Department of Health varies between contracts. The Department of Health has published data on wave one and phase two ISTCs where contract completion is said to be 85%, but the documentation does not state whether this figure was based on referrals or actual treatments.2 If the Scottish findings hold true for wave one in England then up to £927m of the £1.5bn may have been paid to ISTCs for patients who did not receive treatment. It is important to clarify how the data published by the Department of Health are collected, recorded, and defined, and whether they have been independently validated against Hospital Episode Statistics returns.

The Department of Health and NHS Information Centre documentation are not in accord with each other, but it would appear that Netcare has also been awarded contracts in wave one of the ISTC programme in England for general elective surgery in Manchester (nominal contract value £86.1m), a mobile ophthalmology service (£41.7m), and possibly as many as five walk in centres (value undisclosed). In partnership with the private company InHealth, Netcare appears to been awarded phase two NHS contracts for diagnostics across 47 sites in England worth £155.2 m.
2 14

ISTC subsidies and trainingIn addition to the tariff, the independent sector treatment centres receive a subsidy known as a premium for the first five years to cover costs such as bidding costs, but the amount received is unclear.
The NHS is contractually obliged to buy back £187m of independent centre facilities at the end of the contracts if the providers do not wish to continue operating. Some of the contracts expire at the beginning of 2010. Hugh Risebrow, chief executive of the private company Interhealth Canada, which runs two of the wave one centres, said that the independent providers faced potential problems refinancing loans to fund their facilities; the Department of Health may have to step in to support the private sector.

ISTCs are explicitly allowed to cherry pick, selecting the low risk patients. Browne and colleagues have shown how case mix in ISTCs differs from that in the NHS, making any comparisons of costs and quality difficult.
16 Our analysis also shows that ISTCs are performing the easier procedures within the contract. For example, data from the Information Services Division show that only 6% of referrals contracted for joint replacement and 11% for general surgery resulted in actual treatments, compared with referrals for minor procedures, which have much higher rates of treatment completion of over 80%. In either case the effect may be serious and destabilising for the NHS in terms of both finances and training. An NHS study by Clamp and colleagues showed a 19% reduction in the number of total hip and knee procedures done by junior doctors in an NHS hospital in Derby after the opening of a local ISTC.17

Implications for accountability and future policy decisions

The proper and productive use of public money is an indispensable element of any modern, well managed, and fully accountable democratic state.
18 The evaluation and monitoring of a contract between the public and the private sector should be relatively straightforward—payment given for services rendered—but our analysis raises four main issues, which are supported by other commentators.1 5 6 19 First, lack of access to data due to commercial confidence clauses means that the contracts, performance, and value for money cannot be scrutinised. Second, these problems are compounded by incompleteness of data collected and provided by ISTCs, and by the failure on the part of the commercial directorate and Department of Health to enforce adequate data collection and reporting requirements. Third, in this instance the contract and the evaluation by PricewaterhouseCoopers departed radically from normal reporting and costing of work; it is based on referrals made rather than actual treatments delivered. This approach raises questions about the value for money of the contract and about the role and value for money of the independent auditors. Fourth, the government’s failure to release the value for money methodology in England, combined with lack of data, means that the claim that ISTCs are good value for money has no basis in evidence. The release and analysis of the contract in Scotland provides no evidence to support the claim that the Scottish centre is efficient or good value for money; rather, data from the Information Services Division suggest that the centre may have been paid up to £3m for patients who did not receive treatment.

The Healthcare Commission announced a review of services at the private for profit ISTC in Eccleshill after a coroner’s verdict of death by misadventure aggravated by neglect for one patient.
20 But its scope now needs to be widened: the release and publication of all ISTC contracts should be mandatory, together with their accounts, including expenditure on staffing, administration, and profits. The centres should also be obliged to collect data on patients, staff, beds, and quality of care in full compliance with the NHS. Only then can this study be replicated in England. Without the data, inequalities in distribution of resources and access to high quality care can not be monitored and parliament cannot account for the use of public money. The time has come to call a moratorium on ISTC contracts until all the existing contracts have been published, and the centres properly assessed and investigated.

Main points
In England and Scotland the first wave of contracts for independent sector treatment centres (ISTCs) have been drawn up on the basis of referrals made by primary care trusts, not actual treatments given.

Our analysis of the only Scottish ISTC contract and a private sector report on value for money shows that the requirements for collecting and reporting data, for contracts, and for evaluation do not conform to NHS standards.

The Scottish Regional Treatment Centre treated only 32% of annual contract referrals in the first 13 months of operation at 18% of the annual contract value. If the same patterns apply in England, up to £927m of the £1.5bn may have been paid to ISTCs for patients who did not receive treatment under the wave one ISTC contracts.

Contracts should not be renewed and new contracts should not be signed until a proper independent evaluation has been published assessing referrals, actual treatments carried out, and payments made for work done along with value for money analysis. Full contract details and costs must be placed in the public domain for this assessment to take place.

Cite this as: BMJ 2009;338:b1421Contributors and sources: Both authors had full access to all of the data (including statistical reports and tables) in the study. GK takes responsibility for the accuracy of the data analysis. AP has studied and published widely on the financing of health care, the funding and structures of primary care, intermediate care, and long term care, and health and globalisation and public private partnerships. GK has worked on projects in England and Scotland involving routine hospital episode statistics data. The paper was produced collaboratively; AP is the guarantor for the article.
Competing interests: None declared.
Ethical approval: The data extract was authorised by the ISD Privacy Advisory Committee.
Provenance and peer review: Not commissioned, externally peer reviewed.
Independent Sector Treatment Centres. Fourth report of session 2005-06. Volume 1. London: House of Commons Health Committee, 2006.
Department of Health. Independent Sector Treatment Centres contract information. 2008.
Department of Health. ISTC manual (February 2006). 2006.
Pollock AM, Godden S. Independent sector treatment centres: evidence so far. BMJ 2008;336:421-4.[Free Full Text]
Healthcare Commission. Independent sector treatment centres: the evidence so far. 2008.
Healthcare Commission. Independent sector treatment centres. A review of the quality of care. 2007.
Tayside NHS Board. Chief executive’s report 25/2007. 2007. (Your NHS Tayside; About NHS Tayside; The board and its committees; Tayside NHS Board; Agendas, minutes and papers 29th March 2007; Item 8).
Brodies LLP. Scottish Regional Treatment Centre—Stracathro. Contract documents. 2006.
PriceWaterhouse Coopers. Stracathro Regional Treatment Centre 10 month contract review. 2008.
NHS Tayside Delivery Unit Committee. Report No 16/2008. Scottish regional treatment centre (SRTC). 2008.
Dowie M. Stracathro centre gets healthy report. Press and Journal 2008 Jun 27., =.
Information Services Division NHS Scotland. Managing data quality. SMR completeness estimates. 2008.
Information Services Division NHS Scotland. Data quality assurance. 2008.
Department of Health. Maps of treatment centre locations. Download map of phase 2 diagnostic schemes—April 2008. 2008.
Gainsbury S. Independent sector treatment centres could keep subsidies. Health Service Journal 2008 Dec 18.
Browne J, Jamieson L, Lewsey J, van der MJ, Copley L, Black N. Case-mix and patients’ reports of outcome in independent sector treatment centres: comparison with NHS providers. BMC Health Serv Res 2008;8:78.[CrossRef][Medline]
Clamp JA, Baiju D, Sr, Copas DP, Hutchinson JW, Rowles JM. Do independent sector treatment centres (ISTC) impact on specialist registrar training in primary hip and knee arthroplasty? Ann R Coll Surg Engl 2008;90:492-6.[CrossRef][ISI][Medline]
Lord Sharman. Holding to account. London: HM Treasury, 2001
Appleby J. First wave ISTCs: what do we know? Health Serv Journal 2007 Dec 6.
West D. Patient death sparks review of independent treatment centre. Health Serv J 2009 Jan 12.
(Accepted 16 March 2009)