Friday, December 28, 2012

Photography & Best Camera!: Leica M3!

 I have often been asked: Which is the best camera?

Well, without any hesitation: Leica M3

© 2012 Am Ang Zhang

A 60 year old camera or there about and it still works perfectly without worrying about leaky batteries and dusty shutters like some of the modern DSLRs?

The whole camera feels so solid no wonder journalists prefer it to any other made.

And the lens: nothing came close. It was German precision at its best.

On eBay expect to pay around $1000 for a reasonable one. 

Pictures at an Exhibition © 1998 Am Ang Zhang

Camera: Leica M3
Film: Ilford HP5
Developer: Rodinal for the grainy effect.

Sunday, December 16, 2012

Hospital Medicine & Good Hunch: Perhaps it is not important!

I have written recently that the brain is still the best computer there is and the attempts to impose too much guidelines and protocols will in the end take away what we have known for a long time in medicine as the most important tool: a good hunch.

Statistically, even politicians may fall ill sometimes and it may be too late for some of them to find that the doctor with a good hunch may no longer be around. 

A sad day for medicine.

A Reprint:

Does having a good hunch make you a good doctor or are we all so tick-box trained that we have lost that art. Why is it then that House MD is so popular when the story line is around the “hunch” of Doctor House?

Fortunately for my friend, her GP (family physician) has managed to keep that ability.

My friend was blessed with good health all her life. She seldom sees her GP so just before last Christmas she turned up because she has been having this funny headache that the usual OTC pain killers would not shift.

She would not have gone to the doctor except the extended family was going on a skiing holiday.

She managed to get to the surgery before they close. The receptionist told her that the doctor was about to leave. She was about to get an appointment for after Christmas when her doctor came out and was surprised to see my friend.

I have always told my juniors to be on the look out for situations like this. Life is strange. Such last minute situations always seem to bring in surprises. One should always be on the look out for what patient reveal to you as a “perhaps it is not important”.

Also any patient that you have not seen for a long time deserves a thorough examination.

She was seen immediately.

So no quick prescription of a stronger pain killer and no “have a nice holiday” then.

She took a careful history and did a quick examination including a thorough neurological examination.


Then something strange happened. Looking back now, I did wonder if she had spent sometime at a Neuroligical Unit.

She asked my friend to count backwards from 100.

My friend could not manage at 67.

She was admitted to a regional neurological unit. A scan showed that she had a left parietal glioma. She still remembered being seen by the neurosurgeon after her scan at 11 at night:

“We are taking it out in the morning!”

The skiing was cancelled but what a story.

This first appeared as: 

Thursday, December 13, 2012

NHS: Dawn?

Is it beginning to dawn on some people?

Are the government's health reforms a step forward - or a step 

towards the eventual dismantling of the NHS?

                                                   ©Am Ang Zhang 2011

Gerry Robinson:
Businessman Sir Gerry Robinson fears 'end of the NHS'

Some PCTs have already begun to close.

As the coalition government plans the biggest shake up in the 63-year history of the NHS, businessman and corporate troubleshooter Sir Gerry Robinson offers his viewpoint after spending six months taking the NHS's pulse.

Are the government's health reforms a step forward - or a step towards the eventual dismantling of the NHS?

Two sides of a story:
The changes are better for patients and better for NHS finances according to Dr Kosta Manis, a GP in Bexley. And key to that is the central reform - giving GPs substantial control over budgets instead of the current PCTs.

And that means control over how much they pay for services from the NHS and how much they buy in from the private sector.

In the past, Dr Manis referred patients with heart complaints to a local hospital where consultants usually ordered an often painful and expensive angiogram, using a catheter to probe inside the coronary arteries.

Dr Manis has found a more effective and cheaper alternative, which makes invasive angiograms unnecessary.

Patients at Dr Manis's surgery are examined on the spot to decide whether tests are needed by a top cardiologist, Dr David Brennand-Roper, brought in from a London teaching hospital.

If Dr Manis's patients require further tests, they are sent to a private Harley Street clinic equipped with a high-tech CT scan. They showed a healthy looking lady having the procedure.

This is an example where NHS money is being spent on a private provider - simply because they have got better kit.

I agree with saving the money where possible, but I really do wonder why we cannot have similar facilities to that Harley Street clinic within the NHS - especially if it presents cost savings.

Surprise! Surprise!

But wait: from the Mayo website
If blockages are found with a traditional coronary angiogram, the doctor can perform a procedure called angioplasty to open the blockages straight away.

However, because no catheter is used with the CT angiogram, if a blockage in one’s heart's arteries is found, a separate procedure (a traditional coronary angiogram) is needed.

So it may not be as straight forward as it first appeared.

Oh and the young healthy looking Angela has a normal CT angiogram! But the decision was made by a top cardiologist. The PCT had to pay for that “normal” CT angiogram. Panorama did not raise any question there.

Dr Manis was also concerned that angiograms were often routinely ordered at the local hospital because they were a source of income for the NHS hospital, not because they were absolutely necessary. Wow!

Remember Mayo again?
Virtually all Mayo employees are salaried with no incentive payments, separating the number of patients seen or procedures performed from personal gain. One surgeon refers to this tradition as a ‘‘disincentive system that works.’’ Adds another surgeon: “By not having our economics tied to our cases, we are free to do what comes naturally, and that is to help one another out. .  .. Our system removes a set of perverse incentives and permits us to make all clinical decisions on the basis of what is best for the patient.”

That was how it used to be in our NHS!!!

It may be simpler to do away with Internal Market and incentive system.

I quoted Prof Waxman in an earlier post:

The internal market’s billing system is not only costly and bureaucratic, the theory that underpins it is absurd. Why should a bill for the treatment of a patient go out to Oldham or Oxford, when it is not Oldham or Oxford that pays the bill — there is only one person that picks up the tab: the taxpayer, you and me.

……..Moving patients from one place to another does not save the nation’s money, though it might save a local hospital some dosh. So the internal market has failed because it does not consider the health of the nation as a whole, merely the finances of a single hospital department, a local hospital or GP practice.
Panorama again:

Andrew Lansley Knew:
The former health secretary agreed that the current system can encourage waste.

"It happens because of the way the payment system in the NHS works at the moment - because it pays for activity. So of course if you incentivise somebody just to do more work, they will do more work," Mr Lansley said.

This naturally provides great potential for waste if hospitals are not vigorous in weeding out unnecessary procedures.

I also have concerns that GP reforms would affect other elements of the NHS, possibly even leading to hospital closures if hospital incomes are significantly reduced as money is spent instead on private health care.

Gerry Robinson again:

Still, I am left with serious doubts about key elements of the plans as they stand.

I think the stakes here are huge. Who is going to be managing that big picture?

Unless somebody really does grab this thing at the centre and has the courage to make unpopular but right decisions then I fear this could spell the end of the NHS.

You can catch Margaret McCartney on the show!

Jobbing Doctor: This is important

Tuesday, December 11, 2012

Money! Money! Money!: HSBC, KPMG & Others!

Autumn is looking good for some:
©2012 Am Ang Zhang

New York Times:
DECEMBER 11, 2012
Federal and state authorities announced on Tuesday that they had secured a record $1.92 billion payment from HSBC to settle charges that the British banking giant transferred billions of dollars for sanctioned nations, facilitated Mexican drug cartels to launder tainted money and worked with Saudi Arabian banks with ties to terrorist organizations.

The case, a major victory for the government, represents the conclusion of a multi-agency investigation. It convened the Justice Department, the Manhattan district attorney’s office, bank regulators and the Treasury Department.

In a filing in Federal District Court in Brooklyn, federal prosecutors said the bank had agreed to enter into a deferred prosecution agreement and to forfeit $1.26 billion. The four-count criminal information filed in the court charged HSBC with failure to maintain an effective anti-money laundering program, failure to conduct due diligence on its foreign correspondent affiliates and violating sanctions and the Trading With the Enemy Act.

 “HSBC is being held accountable for stunning failures of oversight – and worse – that led the bank to permit narcotics traffickers and others to launder hundreds of millions of dollars through HSBC subsidiaries, and to facilitate hundreds of millions more in transactions with sanctioned countries, ” Lanny A. Breuer, the head of the Justice Department’s criminal division, said in a statement

At the upper echelons of the organization, the Senate report found, some bank executives had ignored warning signs and permitted the illegal behavior to continue unabated from 2001 to 2010.

Something strange here:
Lord Green, was HSBC's chairman from 2006 to 2010, after serving as its chief executive between 2003 and 2006. He is the current UK trade minister.

The original problems began when agents with Immigration and Customs Enforcement spotted questionable trails of money between HSBC’s Mexican and United States operations.

Despite a chorus of warnings from federal banking regulators about the vulnerability of HSBC’s operations throughout the world, the bank didn’t fortify its controls, the Senate report found.

One of HSBC’s branches in the Cayman Islands, the Senate report said, had virtually no oversight despite holding roughly 50,000 client accounts.

Other banks:
Standard Chartered: fined $340m (£203m) to settle federal charges that it laundered money on behalf of four countries, including Iran, that were subject to US economic sanctions.
That deal covered currency transactions made at the bank's New York branch for Iranian, Sudanese, Libyan and Burmese entities from 2001 to 2007.

ING Bank NV, agreed to pay $619m (£384.8m) to settle allegations that it violated sanctions against countries including Cuba and Iran.

Not just banks:

KPMG to Pay $456 Million for Criminal Violations

IR-2005-83, Updated: 14-Aug-2012

WASHINGTON — KPMG LLP (KPMG) has admitted to criminal wrongdoing and agreed to pay $456 million in fines, restitution and penalties as part of an agreement to defer prosecution of the firm, the Justice Department and the Internal Revenue Service announced today.

In the largest criminal tax case ever filed, KPMG has admitted that it engaged in a fraud that generated at least $11 billion dollars in phony tax losses which, according to court papers, cost the United States at least $2.5 billion dollars in evaded taxes. In addition to KPMG’s former deputy chairman, the individuals indicted today include two former heads of KPMG’s tax practice and a former tax partner in the New York, NY office of a prominent national law firm.

By David Glovin - April 2, 2009 00:01 EDT

April 2 (Bloomberg) -- Former KPMG LLP senior manager John Larson was sentenced to 10 years in prison and former partner Robert Pfaff got eight years for selling illegal shelters that helped wealthy clients evade more than $100 million in taxes.

Larson was also fined $6 million yesterday in Manhattan federal court, Pfaff was fined $3 million and both were immediately jailed. Lawyer Raymond Ruble, a former partner at Brown & Wood LLP, was given a 6 1/2-year sentence. The three were convicted on Dec. 17 of tax fraud and other charges.

“All three defendants were central” to the tax shelter scheme, U.S. District Judge Lewis Kaplansaid in court. “They were instrumental in moving it through the KPMG bureaucracy.”


Lord Green urged to explain how much he knew about shamed bank's money laundering.

Profile: The banker who balances God and Mammon
Lord Green is not your everyday banker. He couldn't be further from the profession's image of immoral, bonus-fuelled money-grubbers.

Unfailingly courteous, cerebral and deeply religious, the tall and bone-thin peer sometimes seemed like one of the better sorts of civil servant when he was running the world's local bank. Which is what he was for a number of years (at the Ministry of Overseas Development) having first spent a year working in a hostel for alcoholics where he met his wife, Joy. From there, he joined McKinsey, the management consultancy, where he spent five years and earned a passport into the fast track of finance. He joined HSBC in 1982 and was on the board within 16 years with responsibility for investment banking. He became chief executive in 2003, and, three years later, executive chairman.

Yet the contradictions presented by his faith – he is an ordained minister – and his career never left him. He found the time to pen two books – Serving God, Serving Mammon, reconciling his career with this faith, and Good Value: Choosing a Better Life in Business. Perhaps some of his colleagues should have read them, then the bank's issues may not have arisen.

He is the current UK trade minister.

The Government has appointed KPMG UK chairman John Griffith-Jones as the first chair designate of the Financial Conduct Authority.

Griffith-Jones will join the FSA board on September 1, 2012 as a non-executive director and deputy chair.

Sunday, December 9, 2012

MRSA & Antibiotics: Farmers or Doctors!

Do we continue to blame the doctors when animals are given antibiotic to help them grow?

©2010 Am Ang Zhang

It's no secret that factory farms use unconscionable amounts of antibiotics when fattening up animals for market. In Germany, however, veterinarians play a crucial role in the abuse. Many are getting rich in the process, but the risks to both human and animals are many.

They had sold huge quantities of drugs, some of which were not approved, and dispensed dozers of liters of medications to animals to which they should never have been administered. Investigators with the public prosecutor's office in the western city of Wiesbaden called the operation a "pharmacy on wheels." Antibiotics were allegedly stored on pallets. A former employee told investigators at the time that the veterinary clinic was essentially a mail-order operation for drugs, and that the pharmaceutical industry had expressed its gratitude by giving the clinic huge discounts.

"Some veterinarians' profit margins are bigger than those of cocaine dealers," says Nicki Schirm, who has been a veterinarian in the state of Hesse for more than 25 years. When a veterinarian finds a sick chick among 20,000 other chicks, he treats the discovery as justification to preventively treat the entire flock with antibiotics, says Rupert Ebner, a veterinarian from the Bavarian city of Ingolstadt. "Nowadays, flock or herd health monitoring is the code name for the generous administration of drugs," says Ebner. In many cases, he adds, fake diagnoses are used to provide a justification for the use of antibiotics.

In large veterinary practices, profits from the sale of drugs can account for up to 80 percent of revenues. This is mainly due to the volume discounts offered by the pharmaceutical industry and the sweet privilege known as the right to dispense -- a special provision for the pharmaceutical monopoly. For more than 150 years, veterinarians have been allowed to both prescribe and sell medications -- with almost no supervision whatsoever.


But this could change. Veterinarians have come into the political firing line after testing of animal populations in the western states of Lower Saxony and North Rhine-Westphalia revealed the large-scale presence of antibiotics. In North Rhine-Westphalia, Green Party Environment Minister Johannes Remmel ordered the testing of 182 flocks on commercial chicken farms. More than 90 percent of the animals had been treated with antibiotics, many multiple times, so that they were essentially being fed a constant diet of drugs. Others were given the medications for only one or two days, which isn't long enough and is in violation of the conditions for licensing the drugs. Such results raise suspicions that the drugs were being used to guarantee the success of the poultry fattening operation rather than to fight disease.

Both farmers and veterinarians are now under suspicion, prompting Agriculture Minister Ilse Aigner to push for a tightening of Germany's Pharmaceutical Products Act and a "careful review" of veterinarians' right to dispense drugs.

Some 900 tons of antibiotics were fed to animals in Germany in 2010. This is 116 tons more than in 2005, and more than three times as much as the entire German population takes annually. Pharmaceutical producers were required to report their 2011 sales of veterinary drugs by the end of March. A number of companies did not comply, prompting the Federal Office of Consumer Protection and Food Safety to request the information in writing.

Even though there are fewer than 5 million pigs in the UK, and over 33 million sheep, it is worth noting that according official figures pig farming accounts for approximately 60% of all UK farm antibiotic use, and sheep farming for less than 0.3% This means that use per animal is about 1,500  times higher in pig farming than it is in sheep farming. Although sheep and pigs are not directly comparable these statistics help to illustrate the fact that even though the use of some antibiotics on farms has now been banned many producers have simply switched to others and overall antibiotic use remains very high.

Although the use of antibiotics for growth promotion has now been banned in all EU countries, many of the antibiotics still used as growth promoters in pigs in the US (such as tetracycline, penicillin and tylosin) remain available as feed additives for prophylactic use in the UK at growth promoting rates, as long as a veterinary prescription is obtained.

Related: New York Times