Archive for October, 2007

The BMJ has published a report criticising the way drugs are regulated in Europe

Silvio Garattini and Vittorio Bertele of the Mario Negri Institute for Pharmacological Research in Milan are critical of the dominance of pharmaceutical industry priorities in bringing drugs to market. They appeal for a more patient and doctor led priorities.

There are two common issues which doctors and patients have about prescription drugs – firstly, the drugs which are available often don’t work for individual patients, so there is always a desire for drugs which work better than the ones currently available; and secondly, drug company priorities are more market driven – they are more likely to fund research into drugs for developed countries problems than developing countries problems, even though many more people die from common diseases in those latter countries. The reason why the first problem is not addressed by the current system is summed up in the article –

New drugs have only to show they are of good quality, effective, and safe, independently of any reference or comparison to drugs already on the market. This results in overuse of trials against placebo. Even when new drugs are compared with existing treatments, the trials often seek to show equivalence or non-inferiority rather than superiority to those already available. Such trials could allow drugs into the market that are less active or safe than those in current clinical use. This is because the non-inferiority limit includes a higher incidence of adverse events. The wider the limits the smaller the sample needed and consequently the higher the chance of missing a difference and concluding for non-inferiority. Sometimes limits are so wide that what is considered non-inferior statistically may be worse clinically

They conclude

It is unethical to experiment on patients with the sole aim of obtaining a marketing authorisation. New drugs should be required to have some added value (greater efficacy or less toxicity) to current treatments or be cheaper

So true. This is a European perspective but exactly the same problems are present in the US. And what about the majority of people in the world? How could the system be improved to meet the most pressing health needs in the world, rather than just in developed countries?

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knot on wood, originally uploaded by bobsee.

This was a log I walked past on Skye.
It caught my attention.
What did? Well, the hole did actually! It looked like a keyhole, or a secret, very small doorway, or maybe a wormhole in the universe? (Hey, you’d be amazed how the imagination can be stimulated by a walk in the country!)
Anyway, after the hole caught my eye then the swirling lines of the wood entranced me.
Take a look. You can look at this for a LONG time I think. The patterns, the colours, the sense of energies straining and twisting and bending the fibres of the wood and how they all swirl around a space…..and into that space, we can dive, deeper and deeper and deeper.
What do you think you might find, if you let your mind slip down this hole, like Alice, falling down the rabbit hole?

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Here’s an interesting study published in the Journal of Statistical Mechanics: Theory and Experiment …..woah!! Hold on there! Bear with me! I know that sounds a desperately uninteresting journal, but what this author, Gleiser, a physicist, has done is to study the characters in Marvel comics – you know, the superheros, the villains, and the others – 6486 characters in 12942 comics! Now I know you’re probably thinking what on earth are physicists studying Marvel comics for? Well, this is where it gets really interesting. There’s an increasing amount of interest in complex networks – we find them in all walks of life – physical systems, neuropsychological, biological and social systems. Gleiser used a collaborative networks model to analyse the Marvel characters. Basically, each character is a node and then the nodes are connected with lines to represent the relationships between the characters. It’s presented graphically which makes it instantly easy to understand – you’ll need to look at the original article to see that.

Here’s what he found –

All the superhero have loads of connections to other characters. In network theory they are “hubs” – in fact they are super-connected to many other characters. On the hand, the villains are very poorly connected. You can actually pick out the superheroes and the villains really easily from the network map. The reason for the poor connected-ness of the villains is apparently the rules by which the Marvel comic stories were constrained. They weren’t allowed to make villains attractive or to make evil appealing!

I think this is such an interesting piece of work for two reasons –

Firstly, it’s a great demonstration of the applicability of network science.

Secondly, it’s shows you one of the key characteristics of superheroes – get connected!

If you’d like to read more about network science I recommend your read Linked, by Barbarsi.

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Dry stane dyke, originally uploaded by bobsee.

This is what we call a “dry stane dyke” in Scotland. It’s an ancient art and it’s the making of walls with the stones as they are. They aren’t shaped or machined to fit and the art lies in fitting them together without using any cement or mortar to bind them together.
I love their organic uniqueness. They are glorious!
And I love how with time the lichens and the moss soften many of the hard edges and bring the greens and golds and the silvers to the shades of grey.
I love how they weather and how they fit so perfectly well into the fields.

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JAMA (The Journal of the American Medical Association) has published a survey of the links between Medical Schools and the pharmaceutical industry in the US.

They found that 60% of departmental heads had a financial relationship with a drug company as a consultant, member of a scientific advisory board, a paid speaker, an officer, a founder, or a member of the board of directors.

Two thirds of departments at medical schools and large teaching hospitals had relationships with industry that involved research equipment, unrestricted funds, support for research seminars, residency and fellowship training, continuing medical education programmes, discretionary funds to buy food and drink, support for professional meetings, subscriptions to professional journals, and intellectual property licensing.

Overall, they say, 80% of clinical departments and 43% of non-clinical departments had at least one tie with industry.

Now, I don’t know about you, but that concerns me. That’s an awful lot of influence. What do you think the teachers think about it?

Despite these ties “more than two thirds of all chairs with a personal relationship with industry reported that their personal relationships had no effect on the various types of departmental functions. A similar percentage claimed that there was no effect on their personal financial status,” the authors say.

No problem. Nothing to see. Move along there………..

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I read a couple of great posts about how people use paper. Across on 43folders. wood.tang’s post about the backs of envelopes  was inspired by Merlin’s post entitled Making friends with paper. (really great little video embedded in that post by the way). Both these guys are making the point that they still use paper preferentially for certain tasks despite being keen on technological solutions. They make the point that there’s something different about interaction with paper. Read the comments from people to both these posts – they are also very interesting and inspiring.

This fits with a point being made in a book I’m reading at the moment – it’s Andy Clark’s Being There. He describes a concept of the extended mind. What he shows is how our physical interaction with the environment allows us to develop and use cognitive functions that our brains either just couldn’t do alone, or certainly couldn’t do so well. One simple example he gives is doing a jigsaw. We pick up the pieces, twirl them round in our fingers, hover them over different spaces and our brains, which are good at pattern-spotting, work with these movements and actions and our hands and brains then work seamlessly to solve the puzzle.

I know that since I started doing the morning pages about a year ago my own creativity and productivity has gone through the roof. This blog here is a good example of that.  Interestingly, I find I almost never ever go back to read anything I’ve written in those daily notebooks. That’s not how they work. It’s the act of writing longhand in a nice notebook which works with the brain to produce the end result – ideas, solutions, decisions etc etc.

How about you? What’s your relationship with paper these days?

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When I was recently on holiday on the Isle of Skye I popped in to An Tuireann for a look around, a bite of lunch (had fabulous home-made, thick chunky oatcakes and crab pate), and to log on to the net via their free wifi connection. While uploading photos to flickr, and writing a post or two for this blog, I got chatting to Mark Goodwin, the Literature Development Officer. A delightful and gentle man. He gave me a few postcards from the Poetry Box and I read the poems on them. They were so good! Here are some extracts I noted –

from At The Shrink, by Angela McSeveny –

I can hear the whisper of his pencil

Against the paper

As he jots down notes.

The point jerks like a seismograph

Measuring the impact of my answers.

I blurt out some startling truth

And watch, baffled,

When his right hand doesn’t move.

Well, I can tell you, that little segment got me re-thinking how I take notes! Amazingly, it had never occurred to me, until I read this, that the movement of my pen on the paper of the patient’s case record might be having an impact on the patient. But more than that, these lines also highlight for me how we all discriminate, categorise and judge what we see, hear, experience. A patient tells their story. I listen, hearing some parts more clearly than others, interrupting, or leading this way or that, according to my interest, and in the process create my version of their story…….which turns out, hopefully, to be similar, but, for sure, will be new, unique and different, co-authored by the pair of us.

from…Night Sister, by Elizabeth Jennings

How is it possible not to grow hard,

to build a shell around yourself when you

have to watch so much pain, and hear it too?


You have a memory for everyone

None is anonymous and so you cure

what few with such compassion could endure

I never met a calling quite so pure.

Reading this again just now, made me think again about that study which measured doctors’ responses to others’ pain. But the last line is the one which really struck me – ‘I never met a calling quite so pure’. You don’t hear much about ‘calling’ any more. Sadly, the current ethos is one of reducing every health carer’s job to a list of tasks and competencies, then assuming that any person who can tick all the correct boxes will be able to carry out exactly the same job. It’s not like that. People matter. The personality, the values and the motivation of a health care worker will shine through, for good or for bad! The new way of selecting young doctors for training posts in the UK uses a computer-based questionnaire system and does not accept the submission of a cv for example, and the candidates for GP training are referred to only by their numbers (to prevent prejudice on the part of the selectors from the candidates’ surnames). How many have a ‘calling’, and would any selector rate such a claim?

And finally, from Elma Mitchell’s, ‘This Poem” –

……even the simplest poem

may destroy your immunity to human emotions

All poems must carry a government warning

Words can seriously affect your heart.

Oh, so true! How a word can sting, burn, wound, comfort, move, excite, quicken or slow the heart! One of my favourite writers is Raymond Carver. He can write both poetry and prose in a way that you can be moved to tears by a tiny handful of his words.

So, what do you think about the relationship between poetry and health? Have you any experiences you’d like to share?

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The Independent on Sunday today carried a special report on adverse drug reactions to prescribed medication in England.

Between 1996 and 2006 in England the number of prescriptions issued by doctors has risen 51%, from 498 million to 752 million. Over the same period the number of reported deaths from adverse reactions to these drugs has shot up 155%, from 382 to 973 (actually they estimate the number of deaths reported is only 10% of the real number – this would give 10,000 deaths a year!) Also over this period the number of serious reactions to drugs has increased 214%, from 5,022 to 15,760, resulting in the occupation of 5,600 beds by patients with these serious problems. This has an estimated cost to the NHS in England of £466 million a year. This is an astonishing sum of money. I can’t help but think about the arguments used against Tunbridge Wells Homeopathic Hospital claiming the cancellation of a contract with them would save about a quarter of a million pounds a year. They could save a lot more than that if drugs were prescribed less frequently and more carefully.

A British Medical Association spokesperson said –

The British Medical Association said last night that the figures amounted to a “wake-up call” and is calling for better training in the medical profession. Dr Peter Maguire, deputy chairman of the BMA Board of Science, said: “This big rise in fatal and serious adverse drug reactions should be a wake-up call to all doctors. We have a large number of new medications, but there are also fake drugs coming into the market, and more and more people are using herbal and over-the-counter drugs, as well as all the existing prescription drugs. On top of that, people are living longer and we have the situation of polypharmacy, where we treat people with several medications.

These figures are quite shocking aren’t they? The contemporary paradigm of medicine is to focus on the disease and try to treat either the pathology or the symptoms with drugs in the first instance. Despite the rise of Evidence Based Medicine, drug trials do not typically identify the adverse reactions to drugs. We have to wait until people in the real world start to experience them before we see the problems. We should be cautious about prescribing, and we need to put more effort into understanding and developing non-drug solutions to health problems (after all, four out of ten of the top reported drugs are prescribed for mental health problems). However, drugs can make a huge difference to peoples’ lives. They are often necessary. So we have to train doctors to be better prescribers. One of the main problems identified in this report is that patients often complained that a drug was causing them problems but the doctors didn’t pay heed to what the patient said. This is fundamental. Doctors should listen to their patients. Carefully. And should trust what they tell them.

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leaf, originally uploaded by bobsee.

Today in the UK, it’s Leaf Sunday. Apparently this is THE day when the leaves of autumn are supposed to look their most colourful. If you’d like a map of where in the UK to go ‘leaf peeping‘ then here’s one here.

This time of year always reminds me of a thing John Peel once told about on his radio show years and years ago. He suggested a nice thing to do at this time of year might be to go out and pick up a leaf that had fallen from the trees and write on the leaf the word “Hello” with black marker pen. Then someone walking along might see the leaf, pick it up and see the “Hello” and their day might be a better day. I know, sounds kinda ridiculous, doesn’t it? But go on, try it! And if you pick up any leaves with “Hello” on them, tell me about it, will you?

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This headline caught my eye in today’s Guardian – ‘I was trapped into being alive’. It’s an interview with Robert Wyatt. Ah, Robert Wyatt…….now that takes me back to the late 60s, early 70s, when my friends and I were great Soft Machine fans. So I immediately start to think about that band and head off to youtube to see what I can find. Oh, delight, delight! In two vids there is a live recording of the Softs performing Out-bloody-rageous from the glorious Third album – now this might, or might not, be your cup of tea, but here’s the second part – with Robert Wyatt on drums, Elton Dean on sax, Hugh Hopper on bass and Mike Ratledge on the keyboards. I have this on vinyl (must get round to digitizing my three or four hundred albums!) but haven’t heard it for years!

I’ll leave you to explore more of you like, but this music was revolutionary in its time. It was fresh, exciting and innovative. It was real musicianship. Well, Robert Wyatt fell out of a window and broke his back paralysing him from the waist down for the rest of his life. In his solo career though, he has produced some of his greatest work. He has a most unusual singing voice. Here he is singing Elvis Costello’s Shipbuilding –

In the interview, he says that during his deepest depression in the 90s he was

quite unable to sleep. Couldn’t lie still, revolving in the bed all night, and Alfie had to go upstairs to sleep. Wheeling up and down the corridor at 20 miles an hour, I couldn’t stop. I couldn’t write. I lost my sight, I suddenly needed glasses. It felt like dying, but that would have been a release. Physically, as it turns out, I’m very resilient. I was trapped in having to be alive.

Wow! I think that’s an amazing statement. In fact, I meet quite a lot of people who have this kind of experience. Even in the midst of the most awful suffering they discover that they have some kind of life force, some determination to be alive, some resilience, which keeps them toe to toe with the struggle of living and denies them the escape of non-existence.

The final part of the interview really grabbed me too –

Wyatt says his work is instinctive. “A French journalist asked if my music was spiritual, and I said, ‘Only in the original sense of spirit meaning breath.’ I am a breathing animal. If anything, I get lower, not higher, in art to work things out, relying on animal instincts to guide me through what sounds right. Beyond that, it’s unknowable, verbally inaccessible.” He adds, with characteristic self-effacement: “That’s why I work with musicians.”

What a wonderful exploration of the concepts of spiritual versus animal instincts, weaving them together, blurring their distinctions, to focus on what he calls the “unknowable, verbally inaccessible”. Now, I love stories, and I love to write. I am a great fan of words and it delights me to hear my patients’ stories every day but one of the other bigger loves of my life is music. And I think dear, old Robert Wyatt has just hit the nail on the head and explained some of that to me. I know I’ve mentioned here a few times, Deleuze’s three ways of thinking, but this makes me realise that two of my most favourite ways of experiencing the world are through stories and through music.

So, from this little headline in the Guardian, I take a wander down memory lane, accessing almost forgotten parts of my being, find myself singing along to Shipbuilding, and musing about the totally bloody amazing thing it is to be a human being.

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