Publication Date 01/06/2012         Volume. 4 No. 5   
Information to Pharmacists

Editorial

From the desk of the editor

Welcome to the June edition for i2P, Information to Pharmacists E-Magazine.
While it is traditional for the pharmacy business cycle to “dampen down” at this time of the year, the lack of optimism in community pharmacy seems more noticeable this year.
While there is much to be concerned about, the old adage about “when the times get tough, the tough get going” has never been truer.
Opportunities abound in this current climate of change. All you have to do is do some forward planning and capture your share of forward movement.
And there is much to excite as is evident in the current articles presented for your use.

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News Flash

Newsflash Updates for June 2012

Newsflash Updates

Regular weekly updates that supplement the regular monthly homepage edition of i2P.
Access and click on the title links that are illustrated.

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Feature Contribution

Inside NZ- Changing Times for Pharmacists

Dr John Dunlop (PGDipPharm, MPharm, DPharm(Auck), FACPP, FNZCP, FPSNZ, MCAPA)

Community pharmacists in New Zealand are waiting with bated breath to see the final iteration of the latest pharmacy services contract.
Most have now attended one or two meetings to become better acquainted with the thrust of the new service specifications which aim to move the funding model away from reliance on a dispensing fee to funding for professional services.
These services may include vaccinations, medication reviews, warfarin testing and looking after patients with long term conditions.
There are two levels of service;
a) those requiring a pharmacist to be registered in the basic scope of practice, and
b) those services – such as vaccinations – that will require the pharmacist to up skill and credentialed for the service provision.

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Share an Innovative Future Direction

Neil Johnston

Some people create scrap-books or family photo albums to preserve memories or important hobby material.
I do similar exercises in a business and a professional sense whenever I find a good idea.
Some of these ideas, commonly found on the Internet, I catalogue for future use by researching all the potential applications that could absorb any new idea, and I write a concept paper about it.
Then, when something new appears that could provide enhancement, I revisit my concept paper and update it with this new information.
As a result, my desktop is littered with a large number of concept papers that are filed for future use, or amalgamated with other concepts as awareness builds for a meaningful project.
They are all projects in development.

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The Pharmacy Guild, because of what it is, will have difficulty promoting the next generation of community pharmacies.

Neil Retallick

Those of you who are regular readers will know that, by and large, I think the Pharmacy Guild of Australia does a pretty good job of promoting the two horns of the interests of its members and the healthcare of the average Australian.
But, as Bob Dylan continues to remind us, “...the times, they are a’changing...” In fact, it is hard to remember a time when community pharmacy was confronted by more dynamic intra-industry and extra-industry forces.

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So you want to be a pharmacist?

Gerald Quigley

I had the pleasure this afternoon of speaking with pharmacy students from RMIT University.
What an inspiring group!
I headed, having read at breakfast, a garbage piece of journalism written in the Herald Sun Melbourne, implying that every pharmacy is ripping you off unless they are selling discounted cold and ‘flu remedies.
In this cynical piece, the journalist naming himself as “Public Defender” quotes “if you do your homework to source a cheaper product, then you are going to end up with money in your pocket”.

Comments: 1

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9 Key Performance Indicators for Building An Effective Profit Plan (Part 1)

Chris Foster

As the 2012 financial year draws to a close, it's a good time to reflect on last year and highlight those things that went well and those that may have impacted negatively in the pursuit of your goals.It's also a great to spend some time re-evaluating your personal and business short, medium and long term goals in the light of events over the last year.The achievement of your goals will in many cases be dependent on setting and aspiring to specific financial targets. It's important that recognise that many of your personal goals will require you to generate sufficient business profits to fund those aspirations

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Smart businesses catch the "Age Wave"

Harvey Mackay

With each passing birthday, some wise guy asks me if I'm finally going to retire.
Oh, how I hate that question.
I love my work, and I love to work.
And as it turns out, I'm part of an emerging demographic: the longevity revolution.
It's also an underrated generation. To confirm my suspicions, I turned to the real expert in this field.

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Where is the care in health care?

Kay Dunkley - BPharm, Grad Dip Hosp Pharm, Grad Dip Health Admin, MPS, MSHPA

I have recently been experiencing health care from a different angle as I have accompanied my elderly mother through a prolonged period of hospitalisation (seven weeks) in five different hospitals, both public and private.  As my mother has short term memory loss and I have her medical power of attorney I believed it was very important to be involved in my mother’s journey through the health care system.  This has provided a very different perspective from either being a care provider in my role as a pharmacist or even from the times I have been a patient.

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All Evidence Must Pass a Test for Integrity

Peter Sayers

No single source of evidence can be regarded as reliable even if derived from controlled clinical trials and published in a reputable journal.
The reason for this is that there has been no system for validating clinical trials and allowing open comment.  Intellectual fraud is commonplace.
All clinical trials need to be replicated by an independent external body and no published evidence should be regarded as complete without this tick of approval.
A statement regarding replication should appear prominently at the beginning of each published paper to clearly illustrate its status.

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Rolfing, Kinesiology, Crystals and other Preternatural Practices! - Why am I'm paying for them?

Loretta Marron OAM BSc

When the budget came out last month, private health insurance (PHI) was suddenly in the spotlight when funding was allocated for the investigation into so-called 'natural' services they include in their'extras'. Having left Medibank two years ago, when they announced they were including a rebate forhomeopathy, this is music to my ears.

Comments: 9

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Call for urgent paradigm shift to bring nutrition into medicine

Neil Johnston

I was recently sent an email from ACNEM as a follow on from the Second Nutrition in Medicine conference at the Grand Hyatt in Melbourne.
It seems that awareness is growing once again, about the usefulness of nutritional science and its application to the prevention and treatment of illness.
That this subject is not front and centre for any healthcare program has always been a bit bewildering to me.
Of course, you can't patent most nutritional products can you?
It's not that long ago pharmacists had their own college of clinical nutrition...and let it go.

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Taking a Snooze

Mark Neuenschwander

I’ve been thinking about taking a snooze.
The hungry Bermuda Triangle is out my window to the west. I’m on a nine-hour flight between Washington DC and Sao Paul to address I Simpósio Internacional de Farmácia Hospitalar e Clínica. My title is “Traceability and Patient Safety in the Drug Dispensing and Administration Processes Using Barcodes”—a real snoozer. Napping passengers surround me.
Six or seven flights ago, a young woman holding a Costco-sized jar of earplugs stood up as I approached my row.

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Perceptive, Prescient Dr Peter

Barry Urquhart

“The Peter Principle” lives.
 In 1969 Dr Laurence Peter released a management book, with co-author Raymond Hill, which was an irreverent study of what became known as hierachiology.
 The underlying contention of “The Peter Principle” was that everyone in a bureaucracy is promoted to their level of incompetence.
 An extension of the principle, verified by ubiquitous anecdotal observations, is that everything that works will be used in progressively more challenging applications until it fails.

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Pharmacy Clinical Spaces

Neil Johnston

Clinical spaces are those spaces dedicated for fee-paying clinical services..
To date, one of the difficulties of carving a suitable clinical space from a pharmacy environment is the ability to find a quiet spot as well as one that allows for speech privacy.
I have concluded that a range of different spaces are required to deliver pharmacy clinical services so that they are able to be differentiated by type of service and privacy level.
Thus a layout and design for the clinical spaces will become as important as the total layout for the entire pharmacy. Integrating the clinical environment into a retail space will be a significant challenge to overcome, but it is a challenge where creative pharmacists will be able to generate a range of unique pharmacy solutions.

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Vitamin Bashing or Bad Science?

Staff Researcher

Orthomolecular Medicine News Service, June 11, 2012

by Steve Hickey, PhD, Andrew W. Saul, PhD, and Robert G. Smith, PhD
(OMNS June 11, 2012) There is a global tendency to popularize pharmaceutical industry pseudoscience that harms patients and prevents health. Far from being critical, the media are easily taken in by corporate medicine. Two recent examples give food for thought. Like so many others in the media, Alex Hutchinson was misinformed about the underlying science when he wrote "Three Reasons to Reconsider Vitamin Pills." [1] Sometimes the lack of scholarship in medical research is astounding. A recent paper by María Martínez and colleagues illustrates this well. It is bizarrely titled "Dietary Supplements and Cancer Prevention: Balancing Potential Benefits Against Proven Harms." [2]

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Pharma & Wholesaler - Invading Community Pharmacy

Neil Johnston

Over the past four years, i2P has been promoting the concept of “Pharmacy-in-the-home”, the definition of “home” being where a patient actually lives (private home, nursing home, hostel etc.).
More succinctly, the concept of the development of a mobile pharmacy health service has been a project in progress.
Understandably, the concept of a mobile service has also caught the attention of mobile phone manufacturers and their “app” developers, with the latter starting as an interesting innovation, but now turning into an innovation flood.
There is no doubt that pharmacy must change its model of health delivery and become proactive on behalf of patients - to be mobile and have diversity in health programs and individual services

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The Third Industrial Revolution – Digital Manufacturing Coming to a Pharmacy Near You

Neil Johnston

Sometimes you simply have to stand in awe at some new technology breakthroughs because they expand and transform human endeavours to such a remarkable degree.
In manufacturing, the first phase was the Industrial Revolution in the 19th Century and later, the production line in the early 20th Centrury-the second Industrial Revolution.
Right now we are on the cusp of the Third Industrial Revolution.
Digital manufacturing is upon us and it will transform the way we work and will be disruptive to all major economies.
I2P has always reported on trends that will affect future pharmacy, and we now note that a lot of remarkable technologies are converging in the form of clever software, novel materials, more human-like robotics, a multitude of web-based services plus new processes.
At the heart of these new processes is the 3D printer.
While pharmacists may regard these technologies as “distant” and are used to planning forward strategies on a five-year timeline, we advise that strategies will need to be planned on a continuous 12 month cycle to keep abreast of developments.
Accordingly, pharmacists must plan investment in their own research to harness this new technology.

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Anti-inflammatory drugs may improve survival from severe malaria

Neil Johnston

A novel anti-inflammatory drug could help to improve survival in the most severe cases of malaria by preventing the immune system from causing irrevocable brain and tissue damage.
Walter and Eliza Hall Institute researchers have shown that a new class of anti-inflammatory agents, called IDR (innate defense regulator) peptides, could help to increase survival from severe clinical malaria when used in combination with antimalarial drugs.

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Drug allergy breakthrough

Staff Researcher

Australian researchers have discovered why people develop life-threatening allergies after receiving treatment for conditions such as epilepsy and AIDS.
The research, by the University of Melbourne and Monash University, could lead to the development of a diagnostic test to determine drug hypersensitivity.

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Rutgers Study: Vitamin E in Diet Protects Against Many Cancers

Staff Researcher

Researchers find form commonly used in supplements has no such benefit

Vitamin E in vegetable oils and nuts prevents cancer, according to research done at Rutgers University and the Cancer Institute of New Jersey.
Next time you need to choose between vegetable oil and margarine in that favorite recipe, think about your health and reach for the oil.

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Unlocking the secrets of Indonesia’s natural remedies

Staff Researcher

Supercritical fluid technologies developed by chemical engineers at the University of New South Wales will play a vital role in extracting medicinal compounds from a range of native Indonesian herbs and enable new methods of drug delivery.
A memorandum of understanding was signed today between UNSW and PT SOHO Global Health of Indonesia, a leading pharmaceutical company based in Jakarta, which plans to use these technologies to uncover the evidence-based potential of long-used herbal remedies. 

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SHPA announces new CEO

Staff Writer

SHPA is pleased to announce the appointment of Helen Dowling as the new Chief Executive Officer of SHPA, commencing July 2012.
Helen has been the District Director of Pharmacy for the Hunter New England Local Health District since 2008, and previously was the Director of Pharmacy at the John Hunter Hospital in Newcastle, NSW.

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Substituting Vitamins and Supplements for Pharmaceuticals in Type 2 Diabetes

Staff Researcher

Orthomolecular Medicine News Service, May 28, 2012
Commentary by Stuart Lindsey, PharmD

(OMNS May 28, 2012) Just when you thought it was safe to go back into the drugstore, we are going to question authority yet again. Readers may remember Dr. Stuart Lindsey as the Frustrated Pharmacist (http://orthomolecular.org/resources/omns/v08n05.shtml). He's back and at it once more, this time presenting an important supplement-based approach to type 2 diabetes. This essay presents ideas that are very possibly a large part of the solution. As with all OMNS releases, it is not meant to substitute for medical advice. Persons should consult their own doctor before making any health decision. - Andrew W. Saul, Editor

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A dark chocolate a day keeps the doctor away

Staff Researcher

In good news for all chocolate lovers, a daily dose of dark chocolate could lower the risk of stroke and heart attack, according to new research.
In a study published today in the British Medical Journal, Monash University researchers showed that dark chocolate's blood pressure- and cholesterol-lowering qualities made it a cheap (and tasty) intervention strategy for the 30 per cent of the Australian population at high risk of cardiovascular disease.

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Inject Drugs Without Needles

Staff Researcher

The prospect of less painful medicine shots without needles came a step closer this month, as US researchers revealed how they have developed a device that delivers a controlled, tiny, high-pressure jet into the skin without using a hypodermic needle.
While there are already several jet-devices on the market, they tend to be of an "all or nothing" design that delivers the same amount of drug to the same depth each time.
However the new jet-injection device that researchers at MIT have engineered can be programmed to deliver medicine into the skin in a range of doses to variable depths in a controlled manner.

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Under the influence of magnetic drugs

Staff Researcher

For more than three decades scientists have been investigating magnetic nanoparticles as a method of drug delivery. Now by combining three metals - iron, gold and platinum - pharmacists at the University of Sydney believe they have discovered a method for magnetically directing drugs through the body.

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Injection offers hope for treating auto-immune disease

Staff Researcher

Australian researchers have uncovered a potential new way to regulate the body’s natural immune response, offering hope of a simple and effective treatment for auto-immune diseases.
Auto-immune diseases result from an overactive immune response that causes the body to attack itself.
The new approach involves increasing good regulating cells in the body, unlike most current research which focuses on stopping “bad” or “effector” cells, says lead researcher Dr Suzanne Hodgkinson, from UNSW’s Faculty of Medicine and Liverpool Hospital.

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New survival factor for immune cells identified

Staff Researcher

Ms Eleonora Ottina and Dr Marco Herold have identified a survival factor for immune cells
An international team of researchers has discovered that many of the body’s infection-fighting immune cells require a cell survival protein, called A1, to develop and function. Their finding could lead to a better understanding of conditions including leukaemia, allergy and autoimmunity.
The team discovered that without A1, immune cells called lymphocytes and granulocytes could not develop, or could not respond appropriately to infectious stimuli.

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Home-cooked meals add to life expectancy

Staff Writer

Tucking into a home-cooked meal up to five times a week could add years to your life, according to new research.
The study, recently published in Public Health Nutrition by researchers from Monash University, the National Defense Medical Centre, Taiwan and the National Health Research Institutes, Taiwan, found that people who cooked at home at least five times a week were 47 per cent more likely to still be alive after 10 years.

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Major NIH grant to strike down superbugs

Staff Writer

Professor Roger Nation, Dr Kade Roberts, Dr Tony Velkov and Associate Professor Jian Li. Associate Professor Phil Thompson is also part of the MIPS research team.
Doctors treating infectious disease who are down to the last line of defence against antibiotic-resistant superbugs will be buoyed by an A$4.48 million investment in designing new treatments and therapies.
Awarded by the National Institutes of Health (NIH) in the US, the grant will support researchers from the Monash Institute of Pharmaceutical Sciences (MIPS) and Rempex Pharmaceuticals in California to design and develop new antibiotics that are effective against bacterial ‘superbugs’ that cause life-threatening infections and are resistant to all current antibiotics.

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Tax time – a donation to PSS is a gift to your profession and a deduction for you

Kay Dunkley - BPharm, Grad Dip Hosp Pharm, Grad Dip Health Admin, MPS, MSHPA

Don’t miss out on making your tax deductible donation to PSS before 30 June 2012.  As the end of the financial year approaches the Pharmacists’ Support Service (PSS) invites all Australian pharmacists to consider making a tax deductible donation to support the work of PSS.  According to John Coppock, President of PSS, “PSS provides a listening ear and support to any pharmacist, pharmacy student or intern wishing to call on the toll-free number. All members of the pharmacy profession should support this service.  We have volunteers based in Melbourne who generously give their time to answer calls.  Other pharmacists can support the service through a tax deductible donation.”

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Pharmedia: Patients won't swap GPs for pharmacist consults

Neil Johnston

Editor's Note: There have been two articles recently in Australian medical media regarding clinical services for a fee through non-medical practitioners. The first being was by a standalone nurse practitioner clinic that closed after only a few months of operation.
The second was simply about a survey asking for comment on pharmacist clinical services. This involved one researcher from Flinders University in Adelaide and a small sample of the general public. The survey was conducted in Glasgow, published in the BMJ and reported in Australia through the e-pages of 6Minutes.
It was thought that this item was worthy of comment by Mark Coleman.
The media item follows and Mark's comments appear after the media item.

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All Evidence Must Pass a Test for Integrity

Peter Sayers

articles by this author...

Peter Sayers is vitally concerned about pharmacy professional practice - its innovation, its research and development, and its delivery to create an ongoing revenue stream. Delivery of healthcare is increasingly involved with Information Technology systems. All perspectives in IT must be considered for the impact on pharmacy practice and its viability.

No single source of evidence can be regarded as reliable even if derived from controlled clinical trials and published in a reputable journal.
The reason for this is that there has been no system for validating clinical trials and allowing open comment.  Intellectual fraud is commonplace.
All clinical trials need to be replicated by an independent external body and no published evidence should be regarded as complete without this tick of approval.
A statement regarding replication should appear prominently at the beginning of each published paper to clearly illustrate its status.

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Currently, when a published paper is found to be faulty, it may (or may not) be retracted in a low key fashion (compared to the original high key publishing) and noted in a quiet corner of the retracting journal. Nothing is done to retract other papers that have derived clinical conclusions from the information published in the original journal and is dispersed in other journals creating endless problems in tracking and adjusting faulty information.

Journals should take the initiative and set up a perpetual dedicated page to report on retractions from all sources.

The medical community is slowly waking up to this horrific problem and is beginning to take a fresh look at how evidence is prepared and published.
Some academics have even been jailed for fraud, but the shadowy Pharma companies that create the climate for fraud have still to be made accountable.

Risk management techniques also play a part here.
When I was involved in developing a website that would hold confidential information, I was dismayed to find that certifying authority for a site, did little more than take out an insurance policy to cover the risk of being sued for a large sum of money, should the website be hacked.
Certainly there were basic security checks and an attempt to hack the site by a security certificate provider, but it was only an elementary level of skill involved.
In other words, the insurance policy was the primary method of protection-the ability to sustain one or more major claims.

This same concept has pervaded the development of a drug.

With a pipeline of genuine drugs slowly drying up, drug companies began developing drugs they knew to have risk associated with them. Many companies actually suppressed known adverse problems.
Insurance became the main method of “quality control”.
In other words, an estimate was made of the potential risk (in dollar terms) of being sued for manufacturing and distributing a drug which had limited (or no) efficacy for the condition it was supposed to treat.
Hormone replacement therapy (HRT) is one such treatment that has been discredited (oestrogen is a cancer “promoter”), yet papers are still being published refuting the adverse findings in HRT.
HRT once represented one of the biggest global revenue sources for drug manufacturers and the lure of big dollars once again was shown to be the reason for trying to prop up that market at all costs.
Where is the morality in manufacturing a drug and marketing it in a manner that puts the ability to pay damages claims ahead of efficacy and patient safety.
This is why organisations such as the Friends of Science in Medicine have to be suspect because their membership is substantially medical academics – the same group that actually develop drug evidence that is targeted by Pharma companies to ensure “evidence” is positive for their particular drugs.
A recent survey identified that at least 15% of medical academics have been involved with academic fraud at some level.
For the FSM to claim that complementary medicines are not evidence-based and that controlled trials are the only valid form of acceptable evidence ignores the problem that this “mainstream evidence” is harmful and is involved with numerous and increasing, death rates.
Using safety as a measure of a drug’s effectiveness, complementary medicines outstrip mainstream medicines with ease.
Ignoring the long history of safety and effectiveness coupled with anecdotal evidence through use by many health practitioners, is not a reasonable reason for the FSM to trample over a particular form of evidence base and supplant their own version.
It defies logic that anyone would want to argue that the corrupt mainstream medical base is one that should be imposed on all others – it is not an acceptable alternative and is so discredited it should simply be ignored until it is satisfactorily cleaned up.

It is recommended that pharmacists do not blindly accept “evidence” for any drug unless it has been fully tested for integrity-an element that currently invalidates all published evidence from whatever source.
To assist in this regard the site Retraction Watch should be monitored for flawed evidence. Go to:
http://retractionwatch.wordpress.com/2012/05/22/leading-cancer-vaccines-researcher-retracts-paper-for-figure-discrepancies-flagged-by-watchdog-blog/  

The following is an extract from the Retraction Watch blog:
Leading cancer vaccines researcher retracts paper for figure “discrepancies” flagged by watchdog blog

with 23 comments

Gerold Schuler, a German immunology researcher who shared the 2006 Deutscher Krebspreis — aka the German Cancer Prize — for his work that contributed to cancer vaccines has retracted a paper in International Immunology following concerns raised by a German science watchdog blog.

Here’s the notice:

After publication of our article “Optimizing the exogenous antigen loading of monocyte-derived dendritic cells”, several discrepancies have been brought to our attention. In Figure 1 and Figure 2A, in contrast to what is stated in the figure legends, identical control staining is shown within the various parts of the figures. In Figure 3, the dot-plots with values shown as 10.2 and 10.8 were obtained using the same data file, as were those with 12.9 and 14.1. In Figure 7, the dot-plots with values of 9.8 and 16.2 turned out to be derived from the same data set. The appropriate experiments are being repeated, but in the meantime the authors would like to retract the original manuscript and apologize for these errors.

The paper has been cited 14 times, according to Thomson Scientific’s Web of Knowledge, most recently by a PLoS ONE paper, “A Double-Blind Randomized Phase I Clinical Trial Targeting ALVAC-HIV Vaccine to Human Dendritic Cells.”

The paper’s use of the same controls in a number of images — which has tripped up a number of other authors about whom we’ve written — was noted last year here, here, and here by the Abnormal Science blog. The posts also raise questions about other papers by Schuler’s team.”

The rate of retractions is increasing daily.

I also submit a report prepared to refute evidence cited by Professor Edvard Ernst and cited by the FSM as being the best authority for reference for complementary medicines.
This is done purely to provide balance in what has been previously reported.
Click here to view comment

And if more evidence is required for the volume of retractions being generated, please view this extract passed on to me as I began writing this article:

Retracted Publications in the Drug Literature.

Samp JCSchumock GTPickard AS.

Source

Center for Pharmacoeconomic Research, Department of Pharmacy Practice, College of Pharmacy, University of Illinois at Chicago, Chicago, Illinois.

Abstract

Recent studies have suggested an increase in the number of retracted scientific publications. It is unclear how broadly the issue of misleading and fraudulent publications pertains to retractions of drug therapy studies. Therefore, we sought to determine the trends and factors associated with retracted publications in drug therapy literature. A PubMed search was conducted to identify retracted drug therapy articles published from 2000-2011. Articles were grouped according to reason for retraction, which was classified as scientific misconduct or error. Scientific misconduct was further divided into data fabrication, data falsification, questions of data veracity, unethical author conduct, and plagiarism. Error was defined as duplicate publication, scientific mistake, journal error, or unstated reasons. Additional data were extracted from the retracted articles, including type of article, funding source, author information, therapeutic area, and retraction issue. A total of 742 retractions were identified from 2000-2011 in the general biomedical literature, and 102 drug studies met our inclusion criteria. Of these, 73 articles (72%) were retracted for a reason classified as scientific misconduct, whereas 29 articles (28%) were retracted for error. Among the 73 articles classified as scientific misconduct, those classified as unethical author conduct (32 articles [44%]) and data fabrication (24 articles [33%]) constituted the majority. The median time from publication of the original article to retraction was 31 months (range 1-130). Fifty percent of retracted articles did not state a funding source, whereas pharmaceutical manufacturer funding accounted for only 13 articles (13%) analyzed. Many retractions were due to repeat offenses by a small number of authors, with nearly 40% of the retracted studies associated with two individuals. We found that a greater proportion of drug therapy articles were retracted for reasons of misconduct and fraud compared with other biomedical studies. It is important for health care practitioners to monitor the literature for retractions so that recommendations for drug therapy and patient management may be modified accordingly.

© 2012 Pharmacotherapy Publications, Inc.


It is past time where the TGA started to get its house in order and begin to tackle corrupt evidence at its source - and that does not start with complementary medicine.
Creating a database to monitor retractions globally sounds like a good start
Let us see some action occurring with the "big boys" in the drug industry and let the FSM start to rationalise its actions into more productive and realistic activities.
When commonsense prevails and health practitioners have information they can believe in then a measurement of what our health system should promote becomes feasible.

 

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