Waiting for the council
November 3, 2011
Better do it yourself
A curious story in the Evening Standard today. Read it here. The mother of Giovanni Peddie, a 14 year old boy who fell to his death from a tower block in April, is blaming the local council for not fitting proper window locks. Nothing too surprising in that.
But Luanda Peddie who, with her husband Tony, a mature student studying social work, has four other children aged between 11 months and nine, is also reported to have said; “Nothing has been done to fix the windows since.”
If true, that is an incredible indictment – of the Peddies. Have Luanda and Tony really not fixed the window themselves? In six months? Are they so lacking in gumption that, even after losing a child to a tragedy like this, they cannot pop down to Homebase and buy a window catch? I do hope poor Mrs Peddie has been misreported, and that her husband has fitted some window locks.
But it set me thinking. People used not to expect the council to keep them safe. And they were wise not to. You can’t rely on the council.
I’m reminded of a lovely research trial done in Nottingham a few years ago by my colleague Denise Kendrick. Denise randomly allocated families living in council houses to receive “a standardised safety consultation and provision of free and fitted stair gates, fire guards, smoke alarms, cupboard locks, and window locks”. An equal number of control households did not get the advice or the guards.
She then counted the number of children seen with injuries in hospital or general practices over the subsequent two years. There was a trend towards more injuries in the home safety advice and guards group! The difference could have occurred by chance. Except for injuries treated in primary care which were statistically significantly increased by the safety advice and equipment! It was published in the BMJ. Read the full report here. It’s a lovely piece of research.
Nor is it an isolated finding. There have been many such trials, and they have been reviewed many times. Overall there is no reduction in childhood injury from the nanny state fitting safety devices in the home. No effect.
The reason is presumably that parents behave differently when the devices are fitted. The are more likely to leave children unattended I guess, and the kids climb over the guards. Something like that.
Of course councils still provide safety devices. Councillors don’t have to pay for them, they want votes, and they want to be seen to be doing something. Similarly health visitors and social workers are all paid a nice salary to give them out. But we should not fool ourselves into thinking the do-gooders are making life safer. They’re not.
If you want to keep your children safe, do it yourself.
Jim Thornton
Not talking
October 30, 2011
Mother Teresa and Philip Larkin on the big questions
Rarely, if ever, have these two appeared in the same headline, but … .
Here’s Larkin’s poem “Talking In Bed”.
Talking in bed ought to be easiest,
Lying together there goes back so far,
An emblem of two people being honest.
Yet more and more time passes silently.
Outside, the wind’s incomplete unrest
Builds and disperses clouds in the sky,
And dark towns heap up on the horizon.
None of this cares for us. Nothing shows why
At this unique distance from isolation
It becomes still more difficult to find
Words at once true and kind,
Or not untrue and not unkind.
Our first reaction is sadness. Sadness at two lovers no longer communicating. No longer finding true and kind things to say, even in bed. But consider things “not untrue and not unkind” – loneliness and the approach, each at a “unique distance”, of the greater isolation of death. Larkin doesn’t spell it out, but the reader can; silence is needed for that.
And Mother Teresa? Towards the end of her life the CBS news anchor Dan Rather asked her what she said when she prayed to God.
“Oh I don’t talk much. I just listen.”
Taken aback, Rather turned the question round. “And what does God say?”
With a twinkle she replied. “He doesn’t talk either. He just listens.”
The saint and the atheist would have understood each other.
Jim Thornton
Burning skyscrapers
October 24, 2011
Save the ground floor first
Last week I attended a Study Group devoted to encouraging and prioritizing research into stillbirth. I didn’t want to go – these things are often talking shops, and I was unsure whether stillbirth really needed money throwing at it. But SANDS, the excellent Stillbirth And Neonatal Death Support group charity were behind the initiative, and the head of the group, my colleague Gordon Smith was persuasive. I was glad I turned up.
Gordon reminded us that death before, during or immediately after birth is far more common than later deaths in childhood, and potentially easier to prevent than childhood or prematurity related deaths. He compared the billions we spend saving babies from the consequences of extreme prematurity, sometimes even after delivering them early, with the little or nothing we devote to those term babies who die unexpectedly before birth.
We might spend hundreds of thousands of pounds saving the life of a 24 week premature baby, often to leave them with long term handicap. In contrast a simple labour induction costing a few pounds might convert a term stillbirth to a full life in perfect health.
Of course it’s not that simple. We can’t reliably predict who will die, so we would have to induce many mothers to prevent one stillbirth, and we might end up causing extra Caesarean deliveries. But perhaps it would be worth it. Induction doesn’t increase Caesareans by all that much. Maybe we could develop better induction methods. Or we could develop better ways to predict who will die. Whatever else we could be a bit less defeatist.
Gordon drew a vivid analogy. It would be crazy for firemen called to a burning high rise to set up ladders to free people trapped on the top floor before unlocking the ground floor to free the people trapped there. Do the easy stuff first.
I agree. It’s time to look for a way to unlock the term uterus and free those big healthy babies who are dying undelivered. It can’t be that difficult.
Jim Thornton
A viral cause for chronic fatigue
October 16, 2011
Less likely by the day
In 2009 a paper in Science suggested that infection with a mouse leukaemia virus (XMRV) might be linked to chronic fatigue syndrome (CFS). The virus was found in 67% of sufferers but only 3.7% of controls.
It was a newsworthy claim. A viral cause would open the way to antiviral treatment, and even if it didn’t, patients are desperate for a physical cause to be found – no-one likes being labelled as suffering from a psychosmatic illness.
But it didn’t sound likely. CFS, which goes under a range of alternative names, myalgic encephalitis (ME), yuppie flu, and Royal Free Disease, does not behave like an infectious disease, and is not associated with any objective physical signs. The only effective treatment is cognitive behaviour therapy. Most experts believe that it is largely a psychological condition. I certainly do.
Other scientists had doubts about the viral theory from the start. Some were unable to replicate the findings, and others suggested that the CFS samples had been contaminated, accidentally, or deliberately with mouse DNA.
It turns out the doubters were right. On 22 Sept Science published a careful study by nine different laboratories which failed to reliably find the virus in patients who had previously been reported as positive. In the same issue the editors partially retracted the original paper.
The latest news is an allegation here that it wasn’t just accidental contamination, but fraud. The images in the original paper appear to be identical to images presented at a conference on CFS in Ottawa in September to prove something completely different. The source, a cheeky graduate student’s blog, is well worth reading.
And the fraudster?
Judy Mikovits, the lead author of the 2009 paper is in the headlights. She had worked at the National Cancer Institute (NCI) in Maryland from the 1980’s and was awarded her PhD in 1992. Since then according to Google scholar she’s authored or co-authored about 30 papers, many highly cited and in high impact journals. However she was rarely first or last author and in the five years after she left the NCI and moved to California in 2001, she published only five papers, all as a middle author, and all bar one referring to past work done at NCI.
It would not be a big stretch to wonder if her scientific career had peaked when in 2006 she was appointed research director of the Whittemore Peterson Institute (WPI), a private research foundation set up by the parents of a girl affected by CFS.
Her behaviour since 2009 certainly looks flaky. She has claimed, without any evidence whatsoever, that XMRV might be implicated in Autism, Alzheimers disease and multiple sclerosis. Long after her paper had been shown to be at best wrong she was travelling the country speaking at fringe CFS events supported by vitamin and nutritional supplement purveyors and touting her viral assay as a test. Hardly the behaviour of a disinterested searcher after the truth.
Last week the WPI sacked her, albeit for some other misbehaviour, rather than for scientific fraud.
Jim Thornton
A French trial of tranexamic acid (TXA) for post-partum bleeding
October 13, 2011
Hopeless. Not the drug – the research
The clue is in the journal. Critical Care, one where authors pay to get their articles in print. No, there’s no mistake – the author, who does the work, formats the article and hands over copyright, pays $1,825 to the publisher, who makes money from it. It’s not even printed on paper. Just published on the web. We used to call that sort of thing “Vanity Publishing”. The modern label is “author pays”, or for enthusiasts “open access”. I’ll be writing more about this.
No-one should be surprised that the quality of articles published this way is poor. Why would anyone pay to get their good stuff published, if a decent journal like the BMJ or Lancet would take it for free. But it got published. Read the full paper here.
It is a randomised trial. Two groups of patients who had just delivered their baby and were bleeding heavily, were randomly allocated, half to tranexamic acid (TXA) a drug which slows down clot breakdown, and half not. But there were problems.
The trial was open; the doctors knew who got the TXA, and the primary endpoint was blood loss, which is notoriously difficult to measure. However carefully you collect it in bags and weigh the swabs, you still have to estimate how much is blood and how much amniotic fluid. The authors claim that the staff measuring the blood loss were unaware whether the patient had received TXA, but this is implausible. The doctors who recruited and randomised the patients and administered the drug to half of them were in the same room. How could they not know what was going on? The authors admit that the blood loss measurements are susceptible to bias.
The time period over which blood loss was measured is also a source of potential bias? The authors state that it was between what they call T1 (time point 1) and two hours later. T1 is reported as time of delivery in figure 1, but as time of inclusion in the text. Does time of inclusion mean time of randomisation, or of drug administration? Presumably the former, but the authors have just told us that the people measuring the blood loss were unaware of the treatment allocation. How could they know that randomisation had happened and it’s timing, but not then be able to see the drug being administered. They need to know it in real time (see below).
I know what it is like when a patient bleeds heavily immediately after delivery – controlled chaos as the baby is passed to anxious relatives, extra staff are called, intravenous lines are sited, drugs to contract the uterus administered, the placenta checked to ensure it’s all out, and the vagina inspected for obvious bleeding vessels. It is inconceivable that T1 is recorded, and the staff stop to measure the blood loss up to that point, and subsequently separately. They must usually just make a guess when its all over. If they occasionally timed their guess at T1 at the drug administration the error would be understandable, but it would have the effect of recording blood loss over a shorter time period in the treatment group because the drug was only administered in that group.
One obvious solution would be to report the total blood loss after the birth. All the swabs could be carefully weighed, and all the blood measured, with no subjective judgement needed as to which came before, and which after T1/enrolment. And since bleeding prior to T1 was greater in the TXA group the effect would be to reduce the apparent effect of TXA. I wonder why it wasn’t reported.
Even if T1 was defined unambiguously, why did the authors not choose the blood lost between it and 30 minutes, or six hours later. Or between any other two time points. Or the drop in haemoglobin, or the number of units transfused. If you measure something 20 different ways and then perform a statistical test to see if the difference you observe could have occurred by chance only one in 20 times, you’ll get an apparently statistically significant result nearly every time. Even with a drug that does nothing at all.
The way to get round this is to publish your primary endpoint, sample size, and statistical tests before you start, or at the very latest before you take a peep at the data. It’s called trial registration. Reputable journals insist on it. Even “author pays” ones usually do. This trial’s registration number ISRCTN09968140 appears at the start of the paper, so sad sacks like me can check the details here. The primary endpoint is indeed blood loss between T1 and two hours. But look closely. Trial registration occurred in Feb 2011, three months after the trial paper was submitted to Critical Care, and three YEARS after the trial was completed! That’s not trial registration in any meaningful sense. We cannot now be sure that the primary endpoint, statistical methods and sample size were really pre-specified.
The way the researchers got consent from women to participate is also interesting. They claim that women gave written consent in accordance with the Declaration of Helsinki, but this can’t be true. There would have been no time to fully inform most women. They would have been bleeding, frightened and exhausted. So they must have used some sort of “consent ritual”. Presumably waved a form in front of her and said “sign here”. Out of 154 eligible women apparently only 2 refused consent! Hmmmm!
It would have been more honest to use waived or deferred consent. In my small experience of doing this for the WOMAN trial about 1/4 of women, or relatives, say no and we respect their wishes. Click here.
The title of the article was “High-dose tranexamic acid reduces blood loss in postpartum haemorrhage”. I don’t think so. I’m not saying it doesn’t work. It might or might not. But this trial tells us almost nothing.
At least the authors end by saying there is a need for a large study like the WOMAN trial. Indeed there is.
Jim Thornton
Amis and Larkin on death
October 12, 2011
Two poems
Here’s a good poem by Kingsley Amis. The topic is sex, illicit sex, and the details autobiographical – his friend Robert Conquest really did lend him his London flat for affairs and on one occasion wired up the light switch to a tape machine which spoke the words “lucky sod” when he turned it off! Amis the adulterer tells it like it is, although the details reflect badly on him – the cover story, “till six … quite long enough”, and the crude anticipation of the woman’s physical attributes. But of course the poem is actually about his fears. At first left unclear – no more than a sort of sense of being on the wrong track, or missing the goal somehow, and not even knowing quite why, until the “the different style of caller at my back … but just as set on me”, removes all doubt – this is death calling.
Nothing to Fear
All fixed: early arrival at the flat
Lent by a friend, whose note says Lucky sod;
Drinks on the tray, the cover-story pat
And quite uncheckable; her husband off
Somewhere with all the kids till six o’clock
(Which ought to be quite long enough);
And all worth while: face really beautiful,
Good legs and hips, and as for breasts – my God.
What about guilt, compunction and such stuff?
I’ve had my fill of all that cock;
It’ll wear off, as usual.
Yes, all fixed. Then why this slight trembling;
Dry mouth, quick pulse-rate, sweaty hands,
As though she were the first? No, not impatience,
Nor fear of failure, thank you, Jack.
Beauty, they tell me, is a dangerous thing,
Whose touch will burn, but I’m asbestos, see?
All worth while – its a dead coincidence
That sitting here, a bag of glands
Tuned up to concert pitch, I seem to sense
A different style of caller at my back,
As cold as ice, but just as set on me.
Compare it with a Larkin poem on the same topic. There are plenty to choose from of course, but let’s take a relatively minor poem, Days.
Days
What are days for?
Days are where we live.
They come, they wake us
Time and time over.
They are to be happy in:
Where can we live but days?
Ah, solving that question
Brings the priest and the doctor
In their long coats
Running over the fields.
A masterpiece. No labouring to describe emotion, no “cold as ice” cliches. It shows up Amis’s best line “just as set on me” for what it is, a clever pun.
Larkin leaves all life’s happiness, sadness, friendship, and loneliness for the reader to fill in. And when the days of our life run out, he has no answers. All he offers are the priest and the doctor, running over vast fields, in the cold roaring wind, with only their long coats to protect them. They seem so small. They don’t understand either, which is frightening. Death is frightening. But it’s all unsaid. The reader can fear and despair, or trust and wonder. Larkin hasn’t said the question can’t be answered, just that we don’t seem to have solved it yet.
I love Amis the novelist, but he was only a good poet. His reputation will fade. Larkin will speak to us for ever.
Jim Thornton
To H
October 8, 2011
A poem by Kingsley Amis
Towards the end of his life Kingsley Amis wrote a rather unfunny, slapdash and bad-tempered autobiography, which even his fans wished he’d thought better of. The best thing about it was this poem.
H is Hilary “Hilly” Bardwell, his first wife, and the mother of his two sons Philip and Martin. The first pregnancy had been unplanned and Kingsley made various unsuccessful attempts to help Hilly procure an abortion, illegal in those days, until eventually agreeing to marry her. Their shared sex lives got ever more complicated from then on.
Kingsley was repeatedly unfaithful. His many lovers included his pupil the broadcaster Mavis Nicholson, and the rugby widow visited when Swansea played at home and her husband was safely at the match. The latter “behaved so badly in a bath” in Philip Larkin’s poem Letter to a Friend about Girls. Hilly soon joined in that game and according to Zachary Leader, Amis’s biographer, besides her own conventional affairs, got involved in at least one threesome. Her third child Sally, brought up by Kingsley as his own, was believed by both his sons and, if a close reading of the novel The Folks That Live on the Hill is correct, by Kingsley himself, to have been fathered by someone else.
Out of this chaotic household came the early novels, Lucky Jim, That Uncertain Feeling, I Like it Here, Take a Girl Like You and One Fat Englishmen. And then Kingsley fell in love with the novelist Elizabeth Jane Howard.
Kingsley and Jane married in 1965, and two years later Hilly married a Cambridge classics don, Shackleton Bailey. While married to Bailey, Hilly had a fourth child James (Jaime) fathered by the Liberal peer Alistair (Ali) Boyd the 7th Baron Kilmarnock. Although Ali later became her third husband, being born out of wedlock prevented Jaime from ever inheriting the peerage.
Later still, after Amis had lost his sex drive, and written Jake’s Thing about it, Jane walked out, leaving him to sell their house and split the proceeds. Instead Amis, who by then had plenty of money, but wasn’t much good at looking after himself, installed Hilly and the impoverished Ali in the house. Their role seems to have been mainly as a pair of upmarket housekeepers. Kingsley patronised Ali while Hilly made the meals and tried to keep the two of them apart. But the arrangement seemed to suit. It lasted till Amis’s death in 1995, although as far as we know Kingsley and Hilly never resumed sexual relations.
Hilly died last year. She sounds to have been a wonderful woman. But you don’t need me to tell you that. Read the poem.
To H.
I.
In 1932 when I was ten
In my grandmother’s garden in Camberwell
I saw a Camberwell Beauty butterfly
Sitting on a clump of Michaelmas daisies.
I recognised it because I’d seen a picture
Showing its brownish wings with creamy edges
In a boy’s paper or on a cigarette-card
Earlier that week. And I remember thinking,
What else would you expect? Everyone knows
Camberwell Beauties come from Camberwell;
That’s why they’re called that. Yes, I was ten.
II.
In 1940 when I was eighteen
In Marlborough, going out one winter’s morning
To walk to school, I saw that every twig,
Every leaf in the vicar’s privet hedge
And every stalk and stem was covered in
A thin layer of ice as clear as glass
Because the rain had frozen as it landed.
The sun shone and the trees and shrubs shone back
Like pale flames with orange and green sparkles.
Freak weather conditions, people said,
And one was always hearing about them.
III.
In ’46 when I was twenty-four
I met someone harmless, someone defenceless,
But till then whole, unadapted within;
Awkward, gentle, healthy, straight-backed,
Who spoke to say something, laughed when amused;
If things went wrong, feared she might be at fault,
Whose eye I could have met for ever then,
Oh yes, and who was also beautiful.
Well, that was much as women were meant to be,
I thought, and set about looking further.
How can we tell, with nothing to compare?
Kingsley Amis
The Couple by Tomas Transtromer
October 6, 2011
Two translations
The day he wins the Nobel Prize in Literature is a good one to post a poem. Here are two translations of the same poem. The first by the American poet Robert Bly.
The Couple
They turn the light off, and its white globe glows
an instant and then dissolves, like a tablet
in a glass of darkness. Then a rising.
The hotel walls shoot up into heaven’s darkness.
Their movements have grown softer, and they sleep,
but their most secret thoughts begin to meet
like two colors that meet and run together
on the wet paper in a schoolboy’s painting.
It is dark and silent. The city however has come nearer
tonight. With its windows turned off. Houses have come.
They stand packed and waiting very near,
a mob of people with blank faces.
The second translation is by Robin Fulton
The Couple
They switch off the light and its white shade
glimmers for a moment before dissolving
like a tablet in a glass of darkness. Then up.
The hotel walls rise into the black sky.
The movements of love have settled, and they sleep
but their most secret thoughts meet as when
two colours meet and flow into each other
on the wet paper of a schoolboy’s painting.
It is dark and silent. But the town has pulled closer
tonight. With quenched windows. The houses have approached.
They stand close up in a throng, waiting,
a crowd whose faces have no expressions.
I like comparing the two. Do the differences reflect multiple meanings in Swedish? I like to think so.
So much older then, I’m younger than that now
October 5, 2011
The Royal Mail‘s missed opportunities
United Parcel Services (UPS)‘s lovely video commercial That’s Logistics, set to the tune of Dean Martin’s That’s Amore, celebrates their association with the 2012 London Olympics. But it made me wonder what The Royal Mail might have been.
In 1984 British Telecom was privatised, the government trousered £5 billion and BT is now one of the world’s largest telecom companies, paying about £0.5 billion per year in corporation tax into the UK treasury. Could the same have happened with the postal service?
It did twice, elsewhere. Deutsch Post, privatized in 1995, is now the world’s largest logistics company DHL. The Dutch postal service, privatised in 1989, ended up as TNT, number four in the world behind UPS itself, and Fed Ex the other privately owned US giant. DHL and TNT each employ hundreds of thousands in highly paid jobs, and every year pour billions of profit into their shareholders pockets and billions of tax into their home country’s treasuries.
But in 1984 Mrs Thatcher had too much else on her plate, and ten years later, the next time the subject came up, Michael Heseltine and John Major dithered, and The Royal Mail remained nationalised. It limps along with a heavily unionised and disgruntled workforce, sometime making a bit of money, more often running at a loss. Its logistics division Parcel Force is tiny in comparison to the giants above.
With its wonderful brand name the world’s first postal service would have easily outshone the Dutch and German offerings. We’ve surely learned from our mistakes. Labour tried again to privatise The Royal Mail in 2008, albeit eventually scared off by union resistance. By all accounts Vince Cable and the Conservative/Lib Dem coalition will have another go soon.
It’s not too late. One day perhaps someone will adapt Dylan’s great lesson-learning song My Back Pages into a different refreshing commercial – this time for a British global logistics giant.
Is Aeroflot a safe airline?
October 4, 2011
Health reforms and patient safety
Four hundred public health doctors have just written an open letter opposing the NHS reforms. They say increased commercialisation and marketisation (sic) will fragment care, risk patient safety, erode trust, widen inequalities, and waste money. They provide no evidence for their claims, which are all highly contested. Other experts, many patients and doctors, and MPs of all parties, are convinced that the NHS is inefficient and wasteful, and would benefit from more competition.
Let’s take just one of the doctors’ claims – patient safety. I work in a large NHS hospital where for many years the routine checks before surgery had been largely honoured in the breach. Surgeons frequently failed to engage with the process, which had degenerated into a tick box exercise performed by ancillary staff. As a result there had been a number of wrong operations or operations on the wrong side. It sounds terrible, but was not untypical of the NHS.
Then, as a result of the earlier Blair reforms, an independent Treatment Centre opened up next door and some of us were deputed to work in it. We suddenly met a completely different culture. The Treatment Centre insisted that surgeons turn up on time, stopped delegating to deputies, and did the pre-op checks themselves. We grumbled, but it was much safer, and the effect spread back to the main NHS hospital. Gradually the checks are getting done properly there as well.
We should not be surprised. The private sector is good at safety, safe food, safe airlines, safe toys for kids. They have a lot to lose if they fail, so they take it seriously. The public sector frequently cuts corners, and covers up lapses. Workers rarely lose their jobs if they break the rules, and slapdash practices persist.
And Aeroflot? Between 1953 and it’s partial privatisation in 1994, state-owned Aeroflot had 126 accidents causing 6,875 deaths, an average of three accidents and 167 deaths per year. In the 17 years since 1994, when it was registered as a joint stock company and the government sold off 49% of its stake, the airline has had only one fatal accident, Flight 821 which crashed at Perm in the Urals in Sept 2008, killing 88 passengers and crew. Click here for more.
The doctors may be experts in public health, but when it comes to patient safety they are just plain wrong.
Jim Thornton
Ripe-tomato.org 