Low HRV is a risk factor for pathophysiology and psychopathology

The intimate connection between the brain and the heart was enunciated by Claude Bernard over 150 years ago. In our neurovisceral integration model we have tried to build on this pioneering work. In the present paper we further elaborate our model. Specifically we review recent neuroanatomical studies that implicate inhibitory GABAergic pathways from the prefrontal cortex to the amygdala and additional inhibitory pathways between the amygdala and the sympathetic and parasympathetic medullary output neurons that modulate heart rate and thus heart rate variability. We propose that the default response to uncertainty is the threat response and may be related to the well known negativity bias. We next review the evidence on the role of vagally mediated heart rate variability (HRV) in the regulation of physiological, affective, and cognitive processes. Low HRV is a risk factor for pathophysiology and psychopathology. Finally we review recent work on the genetics of HRV and suggest that low HRV may be an endophenotype for a broad range of dysfunctions.
http://www.ncbi.nlm.nih.gov/pubmed/18771686

"Doctors knock controversial sweating treatment; Surgical procedure leaves many people dripping wet on other parts of the body."

(March 2005) The Canadian news magazine "Macleans" reaches nearly 3 million readers every week. In early March, this publication ran a story about the risks of severe compensatory sweating after endoscopic thoracic sympathectomy (ETS) surgery for the treatment of hyperhidrosis. The story's headline read, "Doctor's knock controversial sweating treatment; Surgical procedure leaves many people dripping wet on other parts of the body." (Editor's note: As of July 2007, this article was no longer available free online. You may, however, purchase the March 2005 edition of Macleans by visiting
this link.)
According to the article, the most common problem following ETS is increased and profuse sweating on other parts of the body, most often the back, legs, groin, and abdomen. This compensatory sweating, reports Macleans, can be mild to severe and occurs in 80 to 90 percent of patients. In one study of people who had surgery for excessive underarm sweating, 90 percent of the patients reported compensatory sweating and half of them were forced to change their clothes during the day because of it.

In related news, major news outlets (including "The New York Times") have reported this week on a massive insurance scam in the US in which thousands of patients from 40 states had been transported to California to undergo unnecessary surgical and diagnostic procedures. Insurers and employers have lost US $350 million in claims paid to date due to the illegal operations.

As part of the scheme, patients traveled to outpatient surgery clinics in California to receive three or more procedures in a single week. Among the procedures unnecessarily performed on these patients, according to The New York Times, was "...a highly unusual procedure to treat 'sweaty palms.'" The paper quoted an expert who said this particular surgery "posed potential risks to the patient because it involved collapsing the patient's lungs and deactiviating a nerve near the spine."

In return for undergoing unnecessary colonoscopies, endoscopies, and surgeries for "sweaty palms", participating patients were paid anywhere from $200 to $2,000 each and may have received discounts on cosmetic surgery.
http://www.sweatsolutions.org/sweatsolutions/Article.asp?ArticleCode=19570137&EditionCode=95129982

Despite the lack of scientific evidence for its effectiveness, the lobotomy became a treatment of choice

Despite the lack of scientific evidence for its effectiveness, the lobotomy became a treatment of choice for severe mental illness in the United States and many other countries.
The history of psychosurgery contains many important lessons about the dangers of using treatment methods that have not been scientifically validated and have only testimonials and uncontrolled case studies for evidence.
http://www.baam.emich.edu...hive/BAAMbnalobotomy.htm

Patients need to be able to value and trust the knowledge and judgement of doctors

http://ama.com.au/node/6569

“Hired guns” still a problem for profession

MEDICAL negligence claims against some doctors are being frustrated and prolonged due to the poor quality of some expert reports, according to medicolegal experts who have renewed calls for changes to the expert witness system.

There was an element of “hired gun” experts in some cases, where legal teams selected a doctor known to hold the views that supported their case, said Cheryl McDonald, who is claims department manager for medical indemnity organisation Medical Insurance Group Australia.

“Sometimes when you see a report and it’s by Dr X you know it’s going to be critical before you’ve even turned the page”, Ms McDonald said.
She said inaccurate or “mischievous” expert witness reporting could drag out claims that had little merit and might never go to court. This increased costs for the insurer which were then passed onto doctors through indemnity premiums.

“Even if the [expert’s] claims are mischievous, they are still lending support to the plaintiff’s claim, which then causes us to continue defending the claim. It’s a problem”, she said.
The calls for changes come after the United Kingdom Supreme Court ruled to remove immunity from prosecution for expert witnesses, which means an expert witness in the UK can now be sued for professional negligence if they provide a negligent opinion. (1)  Issue 14, 18 April 2011
MJA Insight

"We should have the freedom to research all available options."

FORMER Australian of the Year Patrick McGorry has aborted a controversial trial of antipsychotic drugs on children as young as 15 who are "at risk" of psychosis, amid complaints the study was unethical.
The Sunday Age can reveal 13 local and international experts lodged a formal complaint calling for the trial not to go ahead due to concerns children who had not yet been diagnosed with a psychotic illness would be unnecessarily given drugs with potentially dangerous side effects.

Last month, psychiatrists, psychologists and researchers from Australia, Britain and the US lodged a complaint with the ethics committee of Melbourne Health, the umbrella health service that includes Orygen.
They argued there was little evidence onset of psychosis can be prevented and it was potentially dangerous to use antipsychotics on people who merely have risk factors for a psychotic illness. They said there was evidence that up to 80 per cent would never develop a disorder.

Read more: http://www.theage.com.au/national/drug-trial-scrapped-amid-outcry-20110820-1j3vy.html#ixzz1Va6X4ZiU

to protect the public from the aberrant practices of the medical profession

“FIRST do no harm” poignantly captures the raison d’être of our medical boards: to protect the public from the aberrant practices of the medical profession, due to a doctor’s professional or personal shortcomings."
Martin Van Der Weyden: The first principle of medicine
http://www.mjainsight.com.au/

8000 deaths in Australia each year as a result of medical errors, more than the annual road toll of about 1600

In NSW up to 130,000 patients are being harmed or experience near misses each year. There are an estimated 8000 deaths in Australia each year as a result of medical errors, more than the annual road toll of about 1600.
 

SMH 20.04.07- Condition critical: the poor state of the NSW health system - National

"Safety breaches in Australian healthcare are killing more people than breast cancer or road accidents,"

Associate Professor Bolsin (Source: SMH 11.07.07)

One in Ten Australians are harmed by hospital treatment

The Australian 28.10.08.

Catastrophic medical errors are going unreported

Catastrophic medical errors are going unreported at the Royal Children's Hospital, according to research by doctors, who have called for more measures to prevent them.

In 176 days of research, Reshma Silas and James Tibballs found 405 adverse events in 165 patients at Royal Children's Hospital, with 28 per cent classified as major - an error requiring a significant medical intervention - or catastrophic, defined as an error leading to permanent disability or death. Catastrophic outcomes were found in 12 cases - 3 per cent of the 405 events. It is not known if any children died, although the researchers said one case was the subject of legal action.

In contrast, when the researchers looked at adverse events reported through the hospital's voluntary reporting scheme over the same period, they found 166 events in 100 patients, with the vast majority of reports rated insignificant or minor. Seven per cent were considered moderate, meaning the event led to increased hospitalisation, and 2 per cent were major events, leading to significant medical intervention. No catastrophic events were reported.

There was significant crossover between the patient groups, with three-quarters of these 100 patients involved in the systematic review, leading the researchers to conclude that systematic reporting, through interviews with staff and tracking patient outcomes, was far better at picking up adverse events than voluntary reporting.

Professor Tibballs said a compulsory system of reporting serious adverse events, known as ''sentinel events'', to health departments captured the tip of the iceberg because it only asked for gross and obvious examples of incompetence such as surgery on the wrong body part.

Source: The Age, 07.03.11.

Thousands of people are likely to be dying every year as a result of preventable hospital errors

Doctors and academics yesterday called for more funding of hospital programs to examine adverse events (unintended injuries from medical care) after The Age revealed inadequacies in the voluntary reporting system for such incidents at the Royal Children's Hospital.

Professor of health economics at Monash University, Jeff Richardson, said that if the last major Australian study to estimate the number of deaths due to preventable adverse events was right, 350 patients were dying every two weeks because of the problem.

Professor Richardson said it was astonishing that so little had been done since The Quality in Australian Health Care Study in 1995 estimated about 12,000 Australians were dying each year because of preventable events.

''The issue of adverse events in the Australian health system should dominate all others. However, it would be closer to the truth to describe it as Australia's best kept secret,'' he said.

Source: The Age, 08.03.11.

most surgeons do not have a clear understanding of their short-term outcomes for the majority of procedures

The public would probably be surprised to know that most surgeons do not have a clear understanding of their short-term outcomes for the majority of procedures they perform.

Of even greater concern is the lack of data on long-term outcomes associated with surgical interventions.

Many surgeons argue that they are too busy and do not have the time and resources to conduct this sort of follow-up. This is not entirely without foundation, but it does seem difficult to defend a stance that says “I will continue to work feverishly at the operations I do but not assess how successful my results are”.

Guy Maddern: No excuse for poor surgical outcomes

MJA INSIGHT, 8 August 2011

complete faith in their selected practitioner

Medical practitioners are surprised when their performance is called into question. Many have a feeling of invincibility based on a lifetime of accumulated educational and professional successes.

The public add to this assumption by placing complete faith in their selected practitioner — until some misadventure occurs. Then the blame game starts.

When defending a claim, it is unreasonable to expect defence counsel to be cognisant of international medical literature concerning the condition in dispute. The defendant doctor should make it their job to amass expert opinion so lawyers can filter and present appropriately.
MJA INSIGHT Aug. 1. 2011

12,000 Australians were dying each year because of preventable events

Catastrophic medical errors are going unreported at the Royal Children's Hospital, according to research by doctors, who have called for more measures to prevent them.

Two doctors from the hospital, Reshma Silas and James Tibballs, reported in the journal Quality and Safety in Health Care, that a systematic review of intensive care unit staff and their management of patients picked up hundreds of adverse events, including many that were not detected by the hospital's voluntary reporting system.

Professor Tibballs, a senior intensive care specialist, said the research suggested an ''epidemic of adverse events'' in hospitals that the medical community and broader population knew little about. The 2 doctors found 405 adverse events over 176 days of research. 28% were major errors and 3% were catastrophic. In contrast, when the researchers looked at adverse events reported through the hospital's voluntary reporting scheme over the same period, they found 166 events in 100 patients.

Professor Richardson of Monash University said it was astonishing that so little had been done since The Quality in Australian Health Care Study in 1995 estimated about 12,000 Australians were dying each year because of preventable events.

Source: The Age online, 07.03.11; 08.03.11.

http://www.solicitoradvice.com/

hospital treatment is the second greatest CAUSE of death in Australia

http://www.medicalerroraustralia.com/issues/who_will_take_responsibility.php

Mandatory reporting problematic

Different cultural beliefs may make overseas-trained doctors reticent to report colleagues for impairment or professional misconduct under the new mandatory reporting laws, according to Medical Board of Australia chair, Dr Joanna Flynn.

Mandatory reporting by all registered medical practitioners came into effect on July 1 under new national legislation governing 10 health professions and their national boards, which now fall under the Australian Health Practitioner Regulation Agency (AHPRA).

Under the legislation, registered health practitioners, their employers and education providers must report “notifiable conduct”, such as working while intoxicated, sexual misconduct, or impairment placing the public at risk of substantial harm.

Dr Flynn’s concerns follow a study of almost 1900 US physicians that found 17% knew a colleague who was incompetent to practise but only two-thirds reported them.

Underrepresented minorities, graduates of non-US medical schools and doctors practising alone or with one partner were the least likely to report.

http://www.mjainsight.com.au/view?post=mandatory-reporting-requirements-problematic-for-overseas-trained-doctors&post_id=490&cat=news-and-research

When the cure is worse than the illness

http://www.smh.com.au/national/when-the-cure-is-worse-than-the-illness-20110722-1hsp3.html

Where does the belief that medicine is based on science come from?

Writing in the “Opposing views” section of theMJA, Professor John Dwyer, emeritus professor of medicine at the University of NSW, said many alternative therapies are not based on science and it is unethical for doctors to prescribe them in most situations. (1)
Consumers were increasingly exposed to “a plethora of nonsense (non-science) claims that waste their money, distance them from effective care strategies and, not infrequently, cause harm”, he wrote.

Professor Dwyer criticised doctors who practised “integrative medicine”, an approach which combines conventional medicine with complementary and alternative therapies.

“To do so … is to abandon scientific medicine … for an approach that does not believe in testing, is happy to exploit the placebo effect and rejects a psychological influence on health”, he wrote.

Professor Dwyer’s comments sparked a strong response from the Australasian Integrative Medicine Association (AIMA), the peak body for doctors practising integrative medicine.

MJA INSIGHT, July 2011

fraudulent or unethical medical research represents an unacceptable breach of trust for clinicians, health policymakers and the general public

http://www.mja.com.au/public/issues/194_12_200611/myb10505_fm.html

Research fraud — where to from here?

Given the nexus between published research, medical practice and public health policy, the veracity of published medical research is vital. Melbourne newspaper The Age recently reported on an “explosion of medical research fraud” (12 May 2011), and Myburgh’s editorial in this issue of the Journal (→ Fraud in fluid resuscitation research) examines a specific incident of fraud.

Trust in the ethical behaviour of researchers is the cornerstone of medical science and publication. The Guideline for Good Clinical Practice, to which Australia adheres, provides some regulation but not enough to protect against fraud.

http://www.mja.com.au/public/issues/194_12_200611/choice_200611.html

the requirement to practise according to widely accepted professional standards implies the need to be abreast of contemporary clinical practice

http://www.mja.com.au/public/issues/194_05_070311/choice_070311_fm.html

An investigation into the unexpectedly high number of febrile convulsions in children aged less than 5 years after they had received the influenza vaccine in 2010

The World Health Organization defines four categories of serious AEFI: hospital admission or prolongation of an existing hospital admission; permanent disability; any event that is life threatening; or death.6 Using these criteria, 8% (193/2396) of the AEFI reported by passive surveillance in Australia in 2009 were judged to be serious.7 However, unlike many countries where compensation schemes exist for adverse events attributed to a vaccine, Australia has no routine approach to making the assessment of attribution.


Despite detailed epidemiological evidence that was consistent in this case with the causal criteria for an AEFI promulgated by the Institute of Medicine of the National Academies in the United States,8 and despite laboratory evidence showing that the polio virus recovered from this child was similarly pathogenic to a polio virus that has been accepted as causing vaccine-associated paralytic polio,9 the polio expert committee concluded that the evidence was insufficient to support a causal relationship between the oral polio vaccine and transverse myelitis. As causality has not been accepted, this child has received no compensation.
http://www.mja.com.au/public/issues/195_01_040711/kel10252_fm.html

MORE than half the doctors in hospitals do not wash their hands between patients

and only legal action by infected victims is likely to get doctors to clean up their act, an infectious diseases expert, Frank Bowden, says.

Even after a two-year national campaign to urge staff to wash their hands between patients, about half still fail to do so. A national audit of doctors by the healthcare safety and quality commission last year showed 51 per cent failed to comply with hygiene standards.

The result is that hundreds of patients end up with ''hospital-acquired infections'', which can kill them.

Advertisement: Story continues below

Professor Bowden, of the Australian National University, says it would take only one patient to sue a hospital successfully to transform doctors' behaviour.

''Once it becomes plain to the patient population that there is a clear link between the behaviour of their medical attendants and the risk of them contracting an infection while in hospital, it is only going to take one high-profile case of a patient successfully suing a hospital for the climate on hygiene to change.''

In his book Gone Viral - The Germs that Share our Lives, published yesterday, Professor Bowden says that once a legal precedent has been set, the cost of hospital-acquired infection will be ''directly measurable … not hidden as it currently is''.

Read more: http://www.smh.com.au/national/unwashed-hands-put-doctors-in-legal-peril-20110701-1gv6t.html#ixzz1QvDsiR1P

Is he suggesting that the widely accepted espousal of evidence-based medicine is a modern myth?

The pair, along with researchers at John Curtin and the University of Miami, have published new findings suggesting an interplay between obesity and
anti-depressant medicines. The team found in tests with laboratory rats that short-term anti-depressant treatment may be an enduring cause of obesity,
even a long time after treatment is discontinued.
Wong says the perspective she and Licinio have on the anti-depressant-obesity link is ''a bit unusual and a lot of people will not agree with it''.
The scale of the challenge is illustrated by the widespread use of anti-depressants - they are now among the most prescribed drug in the US, she says,
and many would say over-prescribed. But there is meagre information on what proportion of patients taking them become obese.
Anxiety and depression together represent the second most common cause of ill-health in Australia, while obesity plays a frequent role in lethal
conditions like coronary heart disease and diabetes.
''There is a lot of difficulty in understanding depression. It is a complex disease. Studies of depression are not easy to replicate.''
On the other hand, obesity is not seen as a psychiatric disorder, she says.
Licinio and Wong have held professorships in related fields at UCLA and Miami University. Yet for somebody of his research background, it is notable
that Licinio holds deep scepticism about the efficacy of medical treatments for diseases including diabetes, cancer, psychiatry and rheumatoid arthritis.
''Today we look back 150 years ago when people were treated with leeches and think it is crazy. I think in 150 years' time people will look back [at
today's treatments] and think the same thing.''
For some psychiatric disorders, he says, ''We really don't completely understand why the drug acts and what we are doing. Some people respond to the
drug you give and some people don't. Some people have terrible side-effects and other people don't. Some people just are not touched by the drug.''
The range of responses depend on an individual's genetic ''markers'' or make-up. In many cases drug treatment ''is all guess work'', he says.
Is he suggesting that the widely accepted espousal of evidence-based medicine is a modern myth?
''It is not going to make me very popular but I think it is.''
There are several factors behind this apart from the numerous biological differences between humans, including research biased towards selected
patient groups and the complexity of reactions between drugs. According to an American survey, the average geriatric patient is on 14 different
medicines.
But amid the profusion of drugs available, Licinio points to the singular lack of real advance in psychiatric medication.
Serious depression represents a substantial problem in Australia, with 1.4 million sufferers each year. ''Yet nothing we use to treat psychiatric patients
suffering depression and other psychiatric illness today is based on anything discovered in the past 40 years - even though there has been an explosion
in neuroscience.''
http://www.smh.com.au/lifestyle/wellbeing/a-bitter-pill-from-depression-to-obesity-20110513-1em6r.html

“Hired guns” still a problem for profession

MEDICAL negligence claims against some doctors are being frustrated and prolonged due to the poor quality of some expert reports, according to medicolegal experts who have renewed calls for changes to the expert witness system.

There was an element of “hired gun” experts in some cases, where legal teams selected a doctor known to hold the views that supported their case, said Cheryl McDonald, who is claims department manager for medical indemnity organisation Medical Insurance Group Australia.

“Sometimes when you see a report and it’s by Dr X you know it’s going to be critical before you’ve even turned the page”, Ms McDonald said.

Beth Wilson, Victoria’s Health Services Commissioner and a qualified lawyer, said the hired gun phenomenon remained a “major problem” with the legal system. She suggested expert witnesses be paid for by the state rather than by legal teams.

“I’d prefer a system where the expert witness was amicus curiae or ‘friend of the court’. Judges should be able to rely on the expert, knowing that their information is not biased towards one side or the other”, she said.

MJA InSight

Legal immunity for experts questioned

THE quality of medical information provided by expert witnesses in legal proceedings is often poor, and may be improved if immunity against prosecution for experts is removed, according to AMA president Dr Andrew Pesce.

Dr Pesce’s comments come in response to a recent United Kingdom Supreme Court judgment that abolished immunity against prosecution for expert witnesses. (1)

Although Australia still provides immunity for expert witnesses, the British case could be used as a precedent if a similar case was brought here.

Dr Pesce said removing immunity might encourage experts to do a better job and therefore protect themselves from litigation. “I don’t think it would be a bad thing. It would make doctors focus on providing reports that were of good quality and that made arguments based on good evidence,” he said.

Although Australian expert witnesses currently have legal immunity, there have been instances where medical boards have taken disciplinary action against doctors who have provided erroneous advice.

Dr Pesce said he had substantial experience reviewing expert witness reports, and had written medical advice for about 12 legal cases.

“Too often in my reviews of some experts’ reports I see things that are not backed up by evidence. Often the information is wrong, and not only is it wrong, but there’s no evidence to support it at all.

“It might be opinion but they’re presenting it as fact,” he said.

- Sophie McNamara

MJA InSight

A pill to enhance moral behaviour? Orwellian concepts not just fiction...

http://www.smh.com.au/technology/sci-tech/racist-angry-the-answer-may-be-in-a-pill-20110407-1d5c9.html

Researchers have become interested in developing biomedical technologies capable of intervening in the biological processes that affect moral behaviour and moral thinking, says a Wellcome Trust research fellow at Oxford University's Uehiro Centre, Dr Tom Douglas. He is a co-author of Enhancing Human Capacities, published this week. 

"Drugs that affect our moral thinking and behaviour already exist but we tend not to think of them in that way," he says. "[Prozac] lowers aggression and bitterness against environment and so could be said to make people more agreeable. Or oxytocin, the so-called love hormone ... 

increases feelings of social bonding and empathy while reducing anxiety. Scientists will develop more of these drugs and create new ways of taking drugs we already know about." 

Kahane does not advocate putting morality drugs in the water supply but does suggest that if administered widely, they might help humanity tackle global issues. 

"Relating to the plight of people on the other side of the world or of future generations is not in our nature," he says. "This new body of drugs could make possible feelings of global affiliation and of abstract empathy for future generations." 

pharmaceutical industry officials acknowledged they were using prisoners for testing because they were cheaper than chimpanzees

By the early 1970s, even experiments involving prisoners were considered scandalous. In widely covered congressional hearings in 1973, pharmaceutical industry officials acknowledged they were using prisoners for testing because they were cheaper than chimpanzees.

As the supply of prisoners and mental patients dried up, researchers looked to other countries.

It made sense. Clinical trials could be done more cheaply and with fewer rules. And it was easy to find patients who were taking no medication, a factor that can complicate tests of other drugs.

Still, in the last 15 years, two international studies sparked outrage.

One was likened to Tuskegee. U.S.-funded doctors failed to give the AIDS drug AZT to all the HIV-infected pregnant women in a study in Uganda even though it would have protected their newborns. U.S. health officials argued the study would answer questions about AZT's use in the developing world.

The other study, by Pfizer Inc., gave an antibiotic named Trovan to children with meningitis in Nigeria, although there were doubts about its effectiveness for that disease. Critics blamed the experiment for the deaths of 11 children and the disabling of scores of others. Pfizer settled a lawsuit with Nigerian officials for $75 million but admitted no wrongdoing.

Last year, the U.S. Department of Health and Human Services' inspector general reported that between 40 and 65 percent of clinical studies of federally regulated medical products were done in other countries in 2008, and that proportion probably has grown. The report also noted that U.S. regulators inspected fewer than 1 percent of foreign clinical trial sites.

Monitoring research is complicated, and rules that are too rigid could slow new drug development. But it's often hard to get information on international trials, sometimes because of missing records and a paucity of audits, said Dr. Kevin Schulman, a Duke University professor of medicine who has written on the ethics of international studies.

These issues were still being debated when, last October, the Guatemala study came to light.

http://news.yahoo.com/s/ap/20110227/ap_on_he_me/us_med_experiments_on_humans

ongoing campaigns to have the treatment banned were supported by the lack of scientific evidence that it was neither safe nor effective

A comprehensive review of electroshock therapy (ECT) has concluded that the risk of damage caused by the procedure cannot justify its continued use in medicine.

The review of more than 100 previous studies and reports into ECT was carried out by two psychologists, Dr John Read of the University of Auckland and Professor Richard Bentall of the University of Bangor in Wales. Both are noted critics of electro shock treatment and the medical model used in psychiatry.

The findings, published in the December issue of the international scientific journal Epidemiologia e Psichiatria Sociale, state there is minimal support for the effectiveness of ECT in the treatment of depression or schizophrenia. In addition, it states there is no evidence of any benefits beyond the treatment period.

It concludes: “Given the strong evidence of persistent and, for some, permanent brain dysfunction ... and the evidence of a slight but significant increased risk of death, the cost-benefit analysis for ECT is so poor that its use cannot be scientifically justified.”

In a statement, Dr Read said the findings suggest that ongoing campaigns by ECT recipients to have the treatment banned were supported by the lack of scientific evidence that it was either safe or effective.

“If we took an evidence-based approach to the heated controversy about ECT it would be banished to the historical rubbish bin of previous treatments thought to be effective in the past, such as rotating chairs, surprise baths and lobotomies,” he said.

Prof Bentall added that the short-term benefits gained by a small minority could not justify the risks to which patients were exposed.

“The continued use of ECT therefore represents a failure to introduce the ideals of evidence-based medicine into psychiatry. This failure has occurred not only in the design and execution of research, but also in the translation of research findings into clinical practice. It seems there is resistance to the research data in the ECT community, and perhaps in psychiatry in general,” he said.

http://wellbeingfoundation.com/news.html

MEDICINE-related deaths are killing more people than heart attacks or cancer

About half a million Australians experience an adverse effect from their prescription medication every year, says pharmacist Ken Lee, whose study “How Safe is Your Prescription?” was launched at the Australian Pharmacy Professional Conference. His research shows about 190 000 hospital admissions a year are associated with medicines and their harmful side effects.


http://www.theaustralian.com.au/news/nation/medications-kill-more-than-cancer-or-heart-attacks/story-e6frg6nf-1226022801971

26000 a year die of murder, 100000 of medical malpractice

" On the national front, the American Medical Association made headlines at its 1992 convention when it declared war against mur­der and pledged to launch a national campaign against violence. "Murders will continue to increase until we start treating it like a public health problem," one attendee was quoted as saying. "If this were due to a virus, the American people and its leaders would be shouting for a cure," said former Surgeon General C Everett Koop. They're right. No one can argue with their message.

The cause of this great crusade, this mobilization of resources, is that more than 26,000 people were murdered in this country last year. Twenty-six thousand deaths is certainly a cause for con­cern. But wouldn't the AMA be better served—and better serve the public—if it expressed outrage on behalf of the 100,000 Americans who die each year from medical abuse and neglect? Shouldn't a medical association feel some obligation to police its own ranks before it tries to police the streets? If the AMA views 26,000 murders as an epidemic, what does it call 100,000 victims of medical malpractice?"

" The Burt case shows that the best way—perhaps the only way under present circumstances—of forcing incompetent doctors out into the open is through the courts. The only way of subject­ing these practitioners to public scrutiny, and deterring malprac­tice is through the public attention attendant to lawsuits and trials. The courts have become the sole policing body for the med­ical profession, and malpractice lawyers have taken on the role of public prosecutors. Major lawsuits, with the major judgments that go with them, may not completely keep negligent physicians from practicing, but they are the one way that currently exists to deter these individuals from practicing their inept brand of medicine. "

Over the years, we have

given a lot of thought to why the medical profession adheres to this code of silence. What is it about this profession that causes it to protect its own at the expense of the public?"

Harvey F. Wachsman: Lethal Medicine

Publisher: Henry Holt & Co

We disagree that surgery and botulinum toxin are treatments of choice in severe cases of hyperhidrosis

The truth is exactly the opposite. Surgery is only rarely necessary, and the editorial quite properly warns of numerous surgical pitfalls, which include recurrence of hyperhidrosis, almost certain impotence, compensatory sweating, permanent neurological damage from anoxia, and death (their words). Botulinum toxin, which they recommend for axillary or plantar hyperhidrosis, requires 12 injections per axilla and 24-36 injections per foot. Even this horrendous procedure gives only 11 months' relief, and antibody formation may reduce long term efficiency.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1118569/

Iontophoresis should be tried before other treatments

Iontophoresis is easy to perform, effective in about 90% of patients in two studies with 54 and 30 participants, free of hazardous side effects, and well accepted by almost all patients.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1118569/

the Kuntz nerve played no part in the success or failure of ETS surgery

If you research the topic of ETS, you will come across various claims and counter-claims
about the importance or otherwise of the Kuntz nerve. The Kuntz nerve is a small nerve
fibre sometimes seen on the second rib not far from the main sympathetic chain. Its
function is not known in humans. Some web-sites on ETS claim success rates of up to
100% for facial blushing because they search for and destroy the Kuntz nerve(s). These
same people also claim to be able to correct failed ETS operations by reoperating and
destroying the Kuntz nerve.
At the meeting of the International Society for Sympathetic Surgery in Germany, May
2003, attended by a majority of the world’s experts in ETS surgery (including us), all but
one of the surgeons present were of the opinion that the Kuntz nerve played no part in the
success or failure of ETS surgery for facial blushing. We share this majority opinion.
www.lapsurgeryaustralia.com.au

"Sympathectomy is a technique about which we have limited knowledge, applied to disorders about which we have little understanding."

http://www.pfizer.no/templates/Page____886.aspx

Sympathectomy and fraud - HUGE BILL FRAUD CITED AT CLINICS

March 12, 2005 - By ROBERT PEAR - National Desk - 933 Words

Twelve Blue Cross and Blue Shield plans, working with the F.B.I., said Friday that they had broken up an elaborate insurance scheme in which thousands of patients from 47 states were sent to California to undergo unnecessary surgical and diagnostic procedures, for which doctors filed more than $1 billion of fraudulent insurance claims. Insurance executives and law enforcement officials said that surgery clinics in Southern California typically paid recruiters $2,000 to $4,000 for each patient who received a medical procedure. The patients, they said, received rewards in the form of cash or discounts on cosmetic surgery.

to induce a patient's participation by appeal to their nonrational preferences, this is also a violation of their autonomy

In this paper we argue that the standard focus on problems of informed consent in debates about the ethics of human experimentation is inadequate because it fails to capture a more fundamental way in which such experiments may be wrong. Taking clinical trials as our case in point, we suggest that it is the moral offence of using people as mere means which better characterizes what is wrong with violations of personal autonomy in certain kinds of clinical trials. This account also helps bring out another important way in which the autonomy of the participants in clinical trials my be violated, even in cases where they have given informed consent to their involvement. Where relevant information about the trial is framed in such a way as to induce a patient's participation by appeal to their nonrational preferences, this is also a violation of their autonomy, and one which is distinct from a failure of informed consent. The underlying wrongness of both kinds of violations, we argue, is plausibly captured by the moral offence of using people as mere means.

MEDICAL EXPERIMENTATION, INFORMED CONSENT AND USING PEOPLE
DEAN COCKING 1 JUSTIN OAKLEY 1
1 Centre for Human Bioethics Monash University

vigorous entrepreneurial spirit that was undeterred by the ineffectiveness of their treatment methods

"The new-found experts developed therapeutic empires with a vigorous entrepreneurial spirit that was undeterred by the ineffectiveness of their treatment methods." (Bell DS, 1989)
Med J Aust 151 : 280-284

"It is a lie that sympatholysis may specifically cure patients

with unqualified "reflex sympathetic dystrophy". This was already stated by the father of sympathectomy, Rene Leriche, more than half a century ago.
...it is not an error, but a lie. While conceptual errors are not only forgivable, but natural to inexact medical science, lies, particularly when entrepreneurially inspired are condemnable and call for a peer intervention.

J. Neurology (1999) 246: 875-879

"we know that antibiotics are misused and overused"

Professor Cars was emphatic that although there are knowledge gaps in Australia, we must act now. “We can’t wait for the data; we know that antibiotics are misused and overused. We know that infection control could be improved without new information.”

He attributed the causes of antimicrobial resistance to three things:
• indiscriminate use of antibiotics
• indiscriminate effects of antibiotics, ie, broad activity
• global spread of resistance facilitated by the rapid dynamics of gene transfer between bacteria as a result of travel, trade and poor sanitation and hygiene.

http://www.mjainsight.com.au

Even a surgeon who was convinced that he was not obtaining good results seldom gave up lobotomy

Medical profession is the noblest of all ! . Doctors are akin to God in many ways ! They have the potential to remove the sufferings of mankind . These are the often made quotes about doctors for many centuries. Today’s medical professionals are , a strained lot to fulfil their role expected of them .They have to maintain the social identity and earn enough to sustain their image in society. The onslaught of commercial and pseudo-scientific concepts have ruined the profession considerably.

Those were the days when the family physician concept was flourishing , where in a doctor was taking care of entire family. This concept has taken a different avatar now .

Now a doctor feels , once the patient is seen by him becomes his/her patient rather a property! This perception has grown in a malignant manner , many doctors do not refer to a specialist even in deserving cases fearing patient poaching .

This possessiveness of doctors about their patients leads to many of the unethical behavior .

My case . . .my patient . . . my fees , . . .this sort of approach though appeared good in the past , is rapidly becoming a liability for the patients .Lack of organised health care by private and Government sector also amplifies the issue .It is pathetic to note , at least Govt hospitals have some accountability , majority of private health systems do not have mortality or morbidity auditing .

http://drsvenkatesan.wordpress.com/2010/12/11/why-many-doctors-consider-patients-as-their-property/

Advertised drugs were supported by evidence that was neither "of reasonable quality, nor independent"

Prof Brown is from the Department of Emergency Medicine at Royal Brisbane and Women's Hospital, and the School of Medicine at the University of Queensland.

They said the ban followed discussions with fellow emergency medicine specialists, who had aired concerns such as:

- Advertised drugs were supported by evidence that was neither "of reasonable quality, nor independent".

- There were cases of "dubious and unethical" research practices by the industry, including "ghost authorship" where scientific papers do not disclose all of their authors.

- Academics could also face industry pressure to withhold negative research, and together this could "inflate views of the efficacy" of heavily promoted drugs.

The professors also said drug ads were counter to a medical journal's mission to provide objective data that enabled doctors to make judgments based on the best available evidence.

"Meanwhile doctors - and indeed journal editors - generally deny they are influenced (by the ads), yet clearly they are," they said.

http://news.smh.com.au/breaking-news-national/medical-journal-bans-drug-company-ads-20110203-1aev8.html

How doctors think...

Review RD09 (2010)

WELFARE OF ANAESTHETISTS

SPECIAL INTEREST GROUP

Australian and New Zealand College of Anaesthetists

Australian Society of Anaesthetists

New Zealand Society of Anaesthetists

WHY DON’T YOU HAVE YOUR OWN GP?

HOW MANY EXCUSES CAN YOU FIND?

HERE ARE 21 !

after Dr Peter Arnold

Australian Medicine November 1997

1. Taking a health problem to another doctor lays me open to professional ridicule for not recognising, myself, that the problem is a) trivial or b) serious.
2. I don’t believe that my symptoms really amount to much; they’re probably just something simple. If I wait awhile they will go away.
3. If I take my symptoms to another doctor, my own diagnosis might be proved wrong!
4. It would place me in a position where I would have to take the “submissive” role of patient and “counselee”, rather than my usually assertive role as doctor and counsellor.
5. I wouldn’t know how to be a patient, being accustomed to being the doctor.
6. Going to another doctor would make me dependent on someone else, when I am used to people being dependent on me.
7. I would have to accept the other doctor’s opinion, whereas I would know more than he/she does on the subject. In particular I would know this patient better than he/she ever could.
8. I can manage my own minor problems - if I’m seriously ill I refer myself to a specialist; why do I need a GP?
9. I’m embarrassed at possibly having to discuss my anxieties about my health - I could be labelled a hypochondriac.
10. I wouldn’t like my life insurance company to know about any illnesses I might have - they might load my policy. If I don’t consult another doctor, they’ll never know.
11. I’m fearful of possibly being forced to disclose aspects of my personality or sexuality which I would rather remained secret
12. Revealing my inner self to a colleague would place him or her at an unfair advantage in our competitive commercial world
13. I know how I would manage a patient presenting with my problems. How can I accept a different way of going about it?
14. Can I place my trust in another doctor, whose training and experience may not be as good as my own? I can accept that a specialist would know more about his/her field of practice than I would (unless he/she is in the same speciality) but how can I accept that a GP might know more than I do?
15. How much do I discuss management, suggest investigations or referral to a specialist? After all, this is the age of patient-doctor partnership. Shouldn’t I have a say in my own management?
16. Any GP would be intimidated by having to attend to me (especially if I am a specialist); he/she would not be able to treat me objectively.
17. How well will the GP respect my confidentiality? Will he or she mention me to a spouse? Indeed the spouse might well be the receptionist! How would that affect our relationship, especially in our close-knit neighbourhood?
18. It isn’t convenient to find the time to see a GP; I’ve got too much work to do looking after my own patients.
19. How do I make an appointment without being embarrassed about having to front up to the receptionist? Do I sit in the waiting room with the other patients, some of whom may have been MY patients too ?
20. How confidential will my records be? Will the receptionist read them?
21. How do I pay the bill? Do I ask to be bulk-billed, or do I pay, and if so at what rate? Do I give a present in appreciation? If so, do I keep giving presents?

http://www.anzca.edu.au/fellows/sig/welfare/review-rd09-why-don2019t-you-have-your-own-gp.html

Medical schools act on pharma influence

Professor James Angus, president of the Medical Deans Australia and New Zealand (the peak body representing medical education in the two countries), said he would address the issue at the next executive meeting of deans later this month.

He was commenting on the results of a survey of 20 Australian medical schools, which assessed their policies regarding disclosure and management of conflict of interest with the pharmaceutical industry, published in the latest MJA.(1)

Coauthor of the study Professor Martin Tattersall, professor of medicine at the University of Sydney, said he suspected there would be some reform and further attention to policies as a result of publication of the study.

However, the current generation of doctors employed in universities, hospitals, public health departments and elsewhere also needed to be much more transparent to their employers and patients about their conflicts of interest, Professor Tattersall said.

“I think the current environment is probably doing medicine and the medical profession a fair amount of harm,” he said.

1. MJA 2011; 194: 121-125.

High doses of common painkillers increase stroke risk

British Medical Journal study links ibuprofen to highest risk of stroke over long term.

The fears relate to non-steroidal anti-inflammatory drugs as well as newer anti-inflammatory drugs known as Cox-2 inhibitors.

Doctors regularly prescribe such drugs to treat painful conditions, including osteoarthritis.

They are given at much higher doses than those found in over-the-counter remedies, which are used for occasional headaches, aches and pains.

The study, in the British Medical Journal, found that compared with a dummy drug lumiracoxib increased the risk of heart attacks, while ibuprofen was linked to the highest risk of stroke (more than treble the risk).

Diclofenac almost tripled the risk, while etoricoxib and diclofenac were associated with around a fourfold increased risk of suffering death from cardiovascular causes.

The authors, from the University of Bern in Switzerland, said: "Although uncertainty remains, little evidence exists to suggest that any of the investigated drugs are safe in cardiovascular terms."

http://www.guardian.co.uk/science/2011/jan/12/high-doses-painkillers-stroke-risk

Fraud Case Rocks Anesthesiology Community

In what experts are calling one of the largest known cases of academic misconduct, a leading anesthesiology researcher has been accused of falsifying data and other fraud in potentially dozens of published studies.

Scott S. Reuben, MD, of Baystate Medical Center in Springfield, Mass., a pioneer in the area of multimodal analgesia, is said to have fabricated his results in at least 21, and perhaps many more, articles dating back to 1996.


A recent PubMed search for Dr. Reuben’s name turned up 72 citations, the most recent an article in the December issue of the Journal of Cardiothoracic and Vascular Anesthesia on preventing the development of chronic pain after thoracic surgery.

What’s particularly surprising given the dimensions of the case, Ms. Johnston said, is that Dr. Reuben’s research managed to raise no alarms among peer reviewers. However, she added, “the peer review system can only do so much. Trust is a major component of the academic world. It’s backed up by the implication that your reputation will be destroyed if you violate that trust.”
http://www.anesthesiology...;a_id=12634&ses=ogs


Reuben prompted a furor in the medical community in March, when he was accused of making up research results in at least 21 published studies and inventing patients in certain instances.
http://www.masslive.com/n...uben_former_chief_o.html

the scope of the Reuben fraud “massive.”

The retractions came after an internal investigation by Baystate turned up evidence of widespread fraud in Dr. Reuben’s research. Jane Albert, a spokeswoman for Baystate, said the inquiry was undertaken after an internal reviewer at the medical center had raised questions last year. Ms. Albert said the hospital’s investigation raised “no allegations concerning any patient care. This was focused on academic integrity.”

A recent PubMed search for Dr. Reuben’s name turned up 72 citations, the most recent an article in the December issue of the Journal of Cardiothoracic and Vascular Anesthesia on preventing the development of chronic pain after thoracic surgery.

Josephine Johnston, an attorney specializing in research integrity at the Hastings Center, in Garrison, N.Y., called the scope of the Reuben fraud “massive.”
http://www.anesthesiologynews.com/ViewArticle.aspx?d_id=3&a_id=12634&ses=ogst

6% admitted failing to present data if it contradicted their previous research

Firstly, if you're planning a career in scientific fraud, then medicine is an excellent place to start.

Findings in complex biological systems - like "people" - are often contradictory and difficult to replicate, so you could easily advance your career and never get caught.

And fraud is not so unusual, depending on where you draw the line. In 2005 the journal Nature published an anonymous survey of 3,247 scientists: 0.3% admitted they had falsified research data at some point in their careers, in acts of outright fraud; but more interestingly, 6% admitted failing to present data if it contradicted their previous research.

Reuben (Scott S Reuben) was at the other end of the scale. He simply never conducted various clinical trials he wrote about for 10 years.

In some cases he didn't even pretend to get approval to conduct studies on patients, but just charged ahead and invented the results all the same.

The details haven't come out yet - investigators have asked various academic journals to formally withdraw at least 21 studies - but fabrication is often easier to spot than selective editing, and some people have argued for various fraud detection tools to be used more commonly by academic journals.

...

And in medicine, data isn't an arbitrary or abstract thing: Reuben's work examined the best way to manage pain after operations, and he provided evidence that non-opiate medications are equally effective.

Now that field is in turmoil. And pain really matters.

http://www.guardian.co.uk/commentisfree/2009/mar/14/bad-science-medicine-fraud

fraud and bias in medical research - BMJ 12 Feb 2009

Because of the massive quantity of material published each month in medical journals, readers of those journals are likely to focus on reading the prestigious ones. Readers are likely to assume that these prestigious journals would be less likely to have an industry bias in their selection of articles for publication. That assumption is questionable, at least in the UK, according to a new study published in the British Medical Journal (12 Feb 2009).

Dr. Ben Goldacre writes:

The British Medical Journal this week publishes a complex study that is quietly one of the most subversive pieces of research ever printed. It analyses every study ever done on the influenza vaccine - although it's reasonable to assume that its results might hold for other subject areas - looking at whether funding source affected the quality of a study, the accuracy of its summary, and the eminence of the journal in which it was published....

We already know that industry-funded studies are more likely to give a positive result for the sponsors' drug, and in this case too, government-funded studies were less likely to have conclusions favouring the vaccines. We already know that poorer quality studies are more likely to produce positive results - for drugs, for homeopathy, for anything - and 70% of the studies they reviewed were of poor quality. And it has also been shown that industry-funded studies are more likely to overstate their results in their conclusions.

But Tom Jefferson and colleagues looked, for the first time, at where studies are published. Academics measure the eminence of a journal by its "impact factor": an indicator of how commonly, on average, research papers in that journal go on to be referred to by other research papers. The average journal impact factor for the 92 government-funded studies was 3.74; for the 52 studies wholly or partly funded by industry, the average impact factor was 8.78. Studies funded by the pharmaceutical industry are massively more likely to get into the bigger, more respected journals.

http://www.guardian.co.uk/commentisfree/2009/feb/14/bad-science-medical-research

reporting bias is a widespread phenomenon in the medical literature

Reporting bias represents a major problem in the assessment of health care interventions. Several prominent cases have been described in the literature, for example, in the reporting of trials of antidepressants, Class I anti-arrhythmic drugs, and selective COX-2 inhibitors.

Regarding pharmacological interventions, cases of reporting bias were, for example, identified in the treatment of the following conditions: depression, bipolar disorder, schizophrenia, anxiety disorder, attention-deficit hyperactivity disorder, Alzheimer's disease, pain, migraine, cardiovascular disease, gastric ulcers, irritable bowel syndrome, urinary incontinence, atopic dermatitis, diabetes mellitus type 2, hypercholesterolaemia, thyroid disorders, menopausal symptoms, various types of cancer (e.g. ovarian cancer and melanoma), various types of infections (e.g. HIV, influenza and Hepatitis B), and acute trauma. Many cases involved the withholding of study data by manufacturers and regulatory agencies or the active attempt by manufacturers to suppress publication. The ascertained effects of reporting bias included the overestimation of efficacy and the underestimation of safety risks of interventions.In conclusion, reporting bias is a widespread phenomenon in the medical literature. Mandatory prospective registration of trials and public access to study data via results databases need to be introduced on a worldwide scale. This will allow for an independent review of research data, help fulfil ethical obligations towards patients, and ensure a basis for fully-informed decision making in the health care system.

http://www.ncbi.nlm.nih.gov/pubmed/20388211

Superior results in the leucotomized groups - Medical bias and conflicts of interest

Abstract

During the past two decades intracranial surgery for intractable mental disease has evolved in the direction of greater precision in and the making of smaller lesions. The most experience has been with bilateral stereotactically produced lesions of a few milliliters' volume in the white matter related to the limbic system. These have been placed just above the anterior half of the corpus callosum in the fibers deep to the gyrus cinguli or in the fibers below the anterior horns of the lateral ventricles or in both areas. Such operations have nearly eliminated the sequelae of the earlier much more extensive lobotomies. Critical and thorough evaluations in Great Britain of relatively small numbers of patients operated on compared with retrospectively matched controls not operated on have revealed superior results in the leucotomized groups. The mental disorders most clearly responding to this surgery appear to be those characterized by stereotypy of an excessive and futile emotional response — i.e., phobias, anxieties, obsessions, depressions and the affective component (when present) of schizophrenia. (N Engl J Med 289:1117–1125, 1973)

William H. Sweet, M.D., D.Sc.

N Engl J Med 1973; 289:1117-1125November 22, 1973