What else? Yankee Doodle Dandy starring New York boy, James Cagney, with songs by (who else?) George M. Cohan (along with Rodgers and Hart [see below]). The backstage story of the theatrical Cohan family, told in flashback by George M. to FDR, is directed by one of the great, immigrant, studio-contract directors, Michael Curtiz (The Adventures of Robin Hood, Mildred Pierce, Casablanca).
When we finally see Cagney's Cohan play FDR in "Off the Record," the President not only walks, he dances:
When I was courting Eleanor, I told her Uncle Teddy,
I wouldn't run for President, unless the job was steady.
Don't print it. Strictly off the record.
In the current housing market, a seller's serotonin levels may determine just how likely a buyer's low offer will be accepted. Serotonin depletion and the acceptance of unfair offers were recently explored on a smaller scale by researchers at the University of Cambridge and UCLA by using the so-called Ultimatum Game—a game which uncomfortably resembles today's property transactions.
The investigators examined the responses of 20 healthy volunteers, who underwent a double-blind, placebo-controlled depletion of tryptophan,* the amino-acid precursor of serotonin. After the procedure, participants were offered 1 of 3 ways to split a sum of money with another player: fair (45% of stake); unfair (30%); or most unfair (20%).
The investigators found that respondents were significantly more likely to reject "most unfair" offers after tryptophan depletion than after placebo treatment (F = 7.551; P = .013). However, the rejection rates of fair or unfair offers were not significantly affected by tryptophan depletion. On the basis of related assessments, the researchers concluded that the higher rejection of "most unfair" offers with tryptophan depletion could not be attributed to other factors, like changes in mood.
* Acute (5-hour) tryptophan depletion results from the ingestion of a tryptophan-free amino-acid drink (see Young SN et al. Psychopharmacology (Berl). 1985;87:173-177).
Photo: iStockPhoto
Olympic Moments You Missed. If you have some kind of weird, humilating fantasy that you would have to represent your country at Beijing.
The video quality is admittedly terrible, but it's still funny.
In an unprecedented move, Pfizer is immediately cutting off all CME grants given directly to medical education communications companies (MECCs), according to today's press release from the company. However, Pfizer will honor existing grant committments and will continue to provide financial support for physician-directed CME to healthcare facilities and medical societies.
The move unfairly implies that MECCs, unlike other ACCME-accredited organizations, have specifically undermined the credibility of pharma-supported CME; although Pfizer does nothing more than make the implication. Joseph Feczko, Pfizer's Chief Medical Officer, is quoted: "We understand that even the appearance of conflicts in CME is damaging and we are determined to take actions that are in the best interests of patients and physicians." It is presumed that academic centers or medical societies, unlike like MECCs, confer a desirable credibility to CME.
According to the Dow Jones Newswires, Pfizer spent approximately $80 million last year on CME, with less than half given directly to for-profit MECCs. It is unknown if other pharma companies will follow Pfizer's lead; but if MECCs are to survive the current and impending climate of ill will toward pharma-supported CME, they will need to partner up with academic CME offices or medical societies in jointly sponsored CME projects. In this event, MECCs will no longer need independent accreditation from the ACCME, which at last count accredited 155 MECCs.*
HT: WSJ Health Blog
* Not counting initial or reaccreditation ACCME fees, the loss of annual fees from these 155 accredited MECCs would amount to a yearly loss of at least $310,000 for the ACCME.
Update: On a Pfizer-related note, Derek Lowe at In the Pipeline hears rumors of autumn layoffs at Groton.
By now, pretty much everyone has seen the June 19 videotape of Esmin Green, 49, dying on the waiting room floor of Brooklyn's Kings County psychiatric facility, aka G Building, while others―including security guards―saw the prostrate woman and did nothing. Until it was too late.
But reports of inhumane psychiatric care at Kings County Hospital (dubbed "Killer County" by online wags) are nothing new. A search of the NYT archives reveals that repeated and gross deficiencies in treatment existed there at least as far back as the 1960s. On a least 2 occasions, the facility lost its accreditation status, according to the paper. The remarkably dubious history of the public facility, culminating in Green's death, suggests that blame could go as high up as possible, arguably to city hall.
Last year, the Mental Hygiene Legal Service (MHLS) and the NY Civil Liberties Union, on behalf of patients, filed suit against the NYC Health and Hospital Corporation (HHC) and others, alleging that the Kings County facility is a "chamber of filth, decay, indifference, and danger where individuals...are subjected to overcrowded and squalid conditions often accompanied by physical abuse and punitive injections of mind-altering drugs." The plaintiffs cite lack of basic sanitation and laundry services, inadequate food, no wheelchair accessibility, vermin infestation, and neglect alternating with verbal or physical abuse from healthcare staff and security personnel.
The HHC, the largest city hospital and healthcare system in the United States, comprises more than a dozen hospitals, including Kings County, in the city's 5 boroughs. The HHC Chairperson, Charlynn Goins, along with HHC President and CEO, Alan D. Aviles, are named defendants in the lawsuit. Goins and Aviles, both lawyers, were appointed to their positions by Mayor Bloomberg in 2004 and 2005, respectively. Yesterday, Aviles provided a written statement to new sources on the death of Green: "We are shocked and distressed by this situation. It is clear that some of our employees failed to act based on our compassionate standards of care."
The suit also names the following defendants, at least 2 of whom are longstanding employees of Kings County:
- Jean G. Leon, RN, Executive Director, Kings County Hospital: Leon, a native of Trinidad, has evidently held her position for at least 13 years (see 2005's "10 years of inspired leadership"). A PR-type video on YouTube featuring Leon was posted April 2008.
- Kathie T. Rones, MD, MPH, Medical Director, Kings County Hospital: Rones, a 1980 graduate of the Brown University School of Medicine and a board-certified internist, has held her position since 1996. She received a tribute for her services from the NY House of Representatives on April 3, 2006.
- David K. Dailey, MD, Chief of Psychiatry, Kings County Hospital: According to the NY State Department of Health, Dailey is a 1981 graduate of the Loyola University Chicago, Stritch School of Medicine and has been licensed in the state since 1998.
- Joseph A. Charlot, MD, Comprehensive Psychiatric Emergency Program, Kings County Hospital: Charlot received his medical degree in 1968 from the State University of Haiti and has had a NY medical license since 1979.
- Ellen B. Tabor, MD, Medical Director, Adult Psychiatric Inpatient Services, Kings County Hospital: Tabor is a 1983 graduate of the Rush University School of Medicine in Chicago. She has held a NY medical license since 1990.
- Jacqueline Purser, Captain, Hospital Police
- Oswald David (or David Oswald), Assistant Director of Nursing/Product Line Manager, Comprehensive Psychiatric Emergency Program, Kings County Hospital
- Elsa P. Bush, Associate Executive Director of Nursing, Kings County Hospital
According to today's NYT, the hospital fired the director of psychiatry, the doctor on duty, and the director of security at Kings County on June 20, the day after Green died. It is not clear if the "director of psychiatry" refers to Dailey, Charlot, Tabor, or someone else. According to Esmin Green's medical records, provided by the NYCLU, a "Dr. Estes" was on duty at the time of her death. Two nurses and one security guard were also "suspended pending union-mandated hearings."
The NY Daily News provides earlier coverage and more background on Esmin Green and Kings County:
June 27 "Shocking death on Kings County Hospital psych ward stirs reform call"
June 22 "Video shows staff ignored patient later found dead"
June 21 "Patient dies waiting for bed at Kings County Hospital"
June 21 "Video shows Brooklyn hospital staff ignore patient later found dead"
May 17 "US Attorney probes claims of patient abuse at Brooklyn psych ward"
In addition to a Federal investigation of civil rights violations at Kings County, the latest reports indicate that criminal charges are being considered in the case of Green's death.
07/03/08 update: The NY Daily News reports that Pierre R. Arty, MD, the head of psychiatry at Kings County, was 1 of 6 people fired after Esmin Green's death. The others included Kenneth Jones, the hospital's director of security, and the 2 security guards (not 1, as previously reported) seen in the waiting-room videotape.
In its recently released Policy Announcements, the ACCME proposed that the commercial support of CME should only be allowed to continue in the setting of several changes. These proposed changes stipulated that educational needs and CME content should be specified by a "bona fide" organization that does not receive commercial support. Some (eg, Daniel Carlat) have suggested that these organizations may include those that draft core competencies (eg, the American Board of Psychiatry and Neurology) or, perhaps, practice guidelines. However, a responding question to that definition is Must the authors of these guidelines have no ties to industry? Which begs the follow-up, What is the extent of commercial ties among authors of practice guidelines?
This question is examined in the latest issue of Neurology, which reports potential conflicts of interest (COIs) among guideline authors for the American Academy of Neurology (AAN), the flagship organization of practicing neurologists.* The authors reported that, among 50 clinical-practice AAN guidelines examined, more than 90% had at least 1 author with a potential COI, and almost half of all authors had 3 or more COIs. The breakdown of the types of potential COIs is provided:
- Any, 77% (n = 272/351)
- Research, 45%
- Clinical practice, 42% (ie, practice of clinical procedure within last year)
- Personal income, 33% (eg, fees for consulting, speakers' bureaus, ad boards)
- Equity/stock options, 7%
- Expert testimony, 6%
- Fiduciary role, 3% (ie, officer, director, partner, or manager in company)
- Advocacy role, 2% (ie, payment for advocacy in nonprofit organization or government)
- Patent rights/royalties, 2%
The AAN's most recent Policy on Conflicts of Interest (June 2008) stipulates that COIs may be resolved or lessened by avoidance, withdrawal (either from the commercial relationship or the AAN responsibility), or disclosure. However, given the high rate of disclosed COIs among drafters of the AAN guidelines, it appears impractical and unrealistic to expect avoidance or withdrawal. To that point, the AAN currently indicates that "[d]isclosure is the appropriate remedy for mitigating most instances of [COI]."
Of note, two authors of the Neurology article (Holloway and Miyasaki) disclosed their own potential COIs with commercial entities.
* The AAN does not allow industry employees to participate in the guideline process or direct corporate sponsorship of the process; however, the AAN does accept corporate funding generally.
The World Health Organization (WHO) now recommends a line-probe assay (LiPA) for the rapid, 2-day detection of multidrug-resistant tuberculosis* (MDR-TB), according to yesterday's press release. LiPA (eg, GenoType MTBDRplus; Hain LifeScience) extracts and amplifies sputum-derived Mycobacterium tuberculosis DNA, which is then hybridized with oligonucleotide probes to detect genes conferring rifampin or isoniazid resistance (eg, rpoB, katG, inhA).
In a 2006 study, the sensitivity and specificity of a rifampin-resistance LiPA (INNO-LiPA.Rif; Innogenetics) or traditional 2-3-month culture were examined in 420 new or retreatment sputum specimens from Asia, Africa, Europe, or Latin America (Studies suggest that rifampin resistance is a reasonable indicator of MDR-TB, where the prevalence of disease is high.) The concordance between LiPA and culture for rifampin resistance was 99.6%.
|
Result |
LiPA |
Culture |
|
Positive for M. tuberculosis DNA, % |
92.6 |
74.3 |
|
Positive for rifampin-resistance DNA, % |
30.6 |
30.8 |
|
Missed positive specimens |
22 |
100 |
WHO estimates that only 2% of the world's MDR-TB cases are recognized and treated appropriately, and that the multimillion-dollar initiative to systematically implement LiPA testing in 16 countries will increase that percentage to 15% or higher by 2012. Designated countries will receive the tests and appropriate training through the Stop TB Partnership's Global Drug Facility. According to WHO, Lesotho is ready to implement the use of LiPA for rapid MDR-TB detection, and Ethiopia will be ready by the end of this calendar year.
Photomicrograph of M. tuberculosis in sputum smear stained with Ziehl-Neelson acid-fast stain. Courtesy of CDC/Ronald W. Smithwick.
* Defined as resistance to both rifampin and isoniazid.
There are no optimistic forward-looking statements here.
Today, Myriad Genetics announced that its experimental agent tarenflurbil (Flurizan) failed to affect cognition or activities of daily living in early Alzheimer's disease, the primary endpoints of a large (N = 1600), 18-month, phase 3 trial. Tarenflurbil is an NSAID enantiomer of flurbiprofen. The company's CEO reported that, consequently, the development of the compound would be discontinued.
This news follows on the heels of the missed primary endpoints in a phase 2 trial of bapineuzumab in mild-to-moderate Alzheimer's disease, which were nevertheless spun as favorably as possible by developers Elan and Wyeth.
With the exceptions of "St. Elsewhere" and "Scrubs," both of which reasonably captured the high-flying absurdities of medical training, I've rarely watched medical dramas. The aversion had been based partly on time constraints but mostly on eye-rolling inaccuracies, like when the impossibly trained Mandy Patinkin went directly from performing a heart transplant to separating conjoined twins on "Chicago Hope."
I've also had an aversion to most documentary-type medical programs—probably for the same reason that a short-order cook wouldn't watch a reality-based show called "Diner" in his downtime. Nevertheless, when a TV series calls itself the venerably hip "Hopkins," it's hard to ignore. According to the show's website, this documentary-type medical program advertises "an intimate look at the men and women who call The Johns Hopkins* Hospital their home." (At this point, I assume—rightly, it turns out—that the referenced men and women are the hospital's physicians and not its long-term inpatients.) The first of 6 episodes aired on ABC last Thursday but is also available for online viewing.
Depicting a world where health care costs and insurance matters don't exist,† the premier installment of "Hopkins" showcases the work of 3 physicians: the hospital's first female urology resident (ahem, both Duke and U Penn had their first female urology residents more than 20 years ago), a remarkable migrant farm worker turned neurosurgeon, and a cardiothoracic surgeon whose marriage is falling apart. And while the show clearly attempts to emphasize the real poignancy of their real work—which is actually made less real by the cloying use of singer-songwriter tracks‡—it inadvertently shows how boneheaded the best of us can be when attempting to connect with patients. For instance, the neurosurgeon delivers the not-so-reassuring, "There's a fine line between life and death," to a clearly anxious man who is about to undergo resection of an undefined brain tumor. And the CT surgeon attempts to apologize to a woman in the ER who just endured the pain of a chest tube with, "Are we still friends?" Her reaction, or lack of it, pretty much says the accurate, "We were never friends."
Then there's the filming of the CT surgeon's home life, or what's left of it, to add personal drama that's evidently characteristic of "ER" or Grey's Anatomy." The problem—and we've become desensitized to this fact with the proliferation of reality-based shows—is that the pain of his young children, like that of the Hopkins patients, is indeed real. Which begs the question: It's one thing to embrace the filming of your medical practice, but why on God's green would you subject your children's divorce-induced anguish to the TV camera?
* Of course, we can't forget the capitalized "The" in front of "Johns Hopkins," anymore than we can forget it in front of "New England Journal of Medicine."
† To its credit, "Hopkins" did show how a patient with a documented brain tumor had to wait several weeks for an appointment with a neurosurgeon.
‡ I'm reminded here of John Belushi smashing the guitar of the folk singer on the stairs of the Delta House.
Ripe for a decent remake, 1973's The Day of the Jackal is still excellent entertainment. Based on Frederick Forsyth's popular novel, the cinematic hunt for the would-be assassin of Charles de Gaulle is directed by one of the great, versatile directors of old (or older) Hollywood, Fred Zinnemann (Oklahoma!, High Noon). The English actor Edward Fox, probably best known for his role as the Jackal, shows the right amount of slickness, sinew, and detachment as the one-minded hitman.
P.S. See if you can spot a young Derek Jacobi (hey, he doesn't stutter!) in a supporting role.
