Archive for the ‘Medicine’ Category

Mosquitos increasing in the UK but global warming not blamed – yet

August 23, 2011

This is a very mildly interesting story from the BBC.

I read every word and realised that I continued reading long after it had ceased to be interesting only because I was waiting for the punch line that it “was all due to global warming”.

It never came.

But it will.

Based on a survey of UK local authorities, reports of mosquito bites over the last 10 years are 2.5 times greater than in the 10 years up to 1996. NHS Direct statistics show 9,061 calls in England complaining of bites and stings from early May this year to now – up nearly 15% from last summer. Not all bite complaints are due to mosquitoes – many can be attributed to bedbugs, midges and fleas.

But conditions in the UK, particularly in southeastern England, are increasingly hospitable to mosquitoes.

“The wet weather through May and June this year, along with a warm summer, has affected the population because mosquitoes like the standing breeding water,” says zoologist Michael Bonsall at Oxford University. …. 

But once upon a time, malaria-carrying mosquitoes could be found in the salt marshes of southeastern England. It is believed that malaria – literally “bad air” – dates back at least to Roman times in the UK, and outbreaks occurred as recently as the years just following World War I.

British doctor Ronald Ross, who discovered the malarial parasite living in the gastrointestinal tract of the Anopheles mosquito in the 19th Century, recruited teams to eliminate the larvae from stagnant pools and marshes. … 

Malaria in England had effectively died out by the 1950s, mostly due to the draining of much of the marshland where mosquitoes bred. But because of the growth of global travel, the number of imported cases of the disease in the UK has risen, with nearly 2,000 a year today.

Go to BBC article 

 

Medtronic pays 5 surgeons $7m kickbacks in just 9 months: The rape of Medicare

August 21, 2011

The Medtronic story is not just about ghost- writing and paying for favourable peer-reviewed scientific papers and supporting researchers to the tune of millions but it is also about all the surgeons in their pocket and how they exploit and “rape” Medicare.

Earl Stevens writes:

Norton Hospital in Louisville, Ky., may not be a household name nationally. But five senior spine surgeons have helped put it on the map in at least one category: From 2004 to 2008, Norton performed the third-most spinal fusions on Medicare patients in the country.

The five surgeons are also among the largest recipients nationwide of payments from medical-device giant Medtronic Inc. In the first nine months of this year alone, the surgeons — Steven Glassman, Mitchell Campbell, John Johnson, John Dimar and Rolando Puno — received more than $7 million from the Fridley, Minn., company. Medtronic and the surgeons say the payments are mostly royalties they earned for helping the company design one of its best-selling spine products.

Corporate whistleblowers and congressional critics contend such arrangements—which are common in orthopedic surgery—amount to kickbacks to stoke sales of medical devices. They argue that the overuse of surgical hardware ranging from heart stents to artificial hips is a big factor behind the soaring costs of Medicare, the government medical-insurance system for the elderly and disabled. ….

Using a Medicare database that tracks hospitals’ billing, The Wall Street Journal was able to ascertain that Norton is among the most aggressive practitioners of spinal fusion in the country.

Spinal fusion has become one of medicine’s most controversial procedures. It involves fusing together two or more vertebrae to alleviate back pain, usually with the help of metal plates, rods and screws implanted in the patient’s back. Tens of thousands of dollars of hardware can go into a single surgery. ….. Conservative spine surgeons argue that a spinal fusion is appropriate only for a small number of conditions, such as spinal instability, spinal fracture or a severe curvature of the spine known as scoliosis, and that financial incentives have caused the procedure to become overused. …

One health insurer, the nonprofit Blue Cross and Blue Shield of North Carolina, announced in September that it would stop paying for spine fusions performed on such patients beginning on Jan. 1. The insurer said that the procedures are “considered not medically necessary.” …

Some recent studies have suggested poor outcomes for spinal fusion.

So much for the Hippocratc Oath which requires “prescribing regimens for the good of my patients according to my ability and my judgment and never doing harm to anyone“.

Related: Medtronics and others – “supporting doctors with multi – million dollar payments”  

Idiot research to show that global warming can be solved by cutting obesity!

August 16, 2011

That researchers need to use “fashionable” catch phrases to ensure funding is not uncommon. That “global warming” is one such catch phrase which has been exploited by a variety of disciplines to justify the most inane work which has then been passed off as cutting-edge research is not new. It has been particularly evident for the last 15 years or so. Linking any research project in any discipline to “global warming” has increased the probability of getting funded.  Linking obesity via human respiration to global warming is one such example of trivialising the already trivial.

Even IF global warming is a problem (which I doubt) and IF carbon dioxide emissions are a cause (which is unlikely) and IF human production of carbon dioxide is significant (which it is not) and IF human respiration produces sufficient carbon dioxide to matter (and it is hardly measurable) and IF general obesity in the human population increases the total of vegetable and animal matter on the planet (which it does not), THEN this so-called research would come up to the level of being just silly.  

As such it is just high quality, idiot-research. 

The latest nonsense is from the Robert Gordon University in Scotland. But the International Journal of Obesity will not gain much in reputation by publishing  such drivel.

International Journal of Obesity , (26 July 2011) | doi:10.1038/ijo.2011.151Global warming: is weight loss a solution?A Gryka, J Broom and C Rolland

But even such nonsense – which is not new – can still capture headlines.

2011: Researchers Suggest Link Between Obesity & Global Warming

2008: Obesity as a cause of global warming? 

2006: Global warming and obesity: the links revealed

The Spine Journal takes on Medtronic and publication of questionable research

August 12, 2011

When medical researchers have financial ties – running into millions of dollars – with pharmaceutical or medical equipment companies, and then publish scientific, peer-reviewed papers which are to the financial benefit of these companies,  questions of scientific misconduct escalate to become questions of scientific fraud.

Medtronic is the world’s largest medical device company and Minnesota’s seventh-largest public company based on revenue, which totaled $15.93 billion for the fiscal year that ended April 29. Medtronic’s Infuse product is a bioengineered bone-growth protein that has been used in spinal fusion procedures for the past nine years and is used in about half of the 80,000 anterior lumbar fusion procedures performed every year in the United States.

According to Twin Cities Business, The Spine Journal recently published two articles about the product, one that claims the product may increase the risk of sterility in men, and another that claims that the product’s adverse effects were not reported in clinical research. Those effects reportedly include inflammation, back pain, infections, and potentially life-threatening complications. The Journal pointed out that researchers for 12 of the product’s 13 industry-sponsored studies had multimillion-dollar “financial associations” with Medtronic.

The Spine Journal seems to be on a crusade:

From the Nature News Blog:

The Spine Journal devoted its entire June issue – two clinical studies, two reviews, two commentaries and a scathing editorial – to picking apart Medtronic’s controversial bone growth treatment, Infuse. The drug, which is a recombinant form of the protein BMP-2, is used in some kinds of spinal fusion surgeries and racked up $900 million in sales last fiscal year, according to the New York Times.

Company-sponsored clinical trials for Infuse found no side effects directly linked to the drug. But a review and reanalysis of these studies published in Spine Journal found that the incidence of adverse events ranged from 10 to 50 percent, depending on the use. What’s more, the same review study, led by Eugene Carragee, of Stanford University School of Medicine in California, reports that the authors of the supporting studies had financial ties to Medtronic ranging from $560,000 to $23,500,000, with a median of $12 million to $16 million. In some cases, the authors of these studies did not disclose the full extent of their financial relationships with Medtronic.

“A consistent number of people involved with these studies got extraordinary sums,” Carragee told the Times.

Side effects of the drug include cancer, fertility problems, infections, dissolving bone, and leg and back pain. According to the Times, Medtronic reported the side effects to the US Food and Drug Administration, as required.

In response to the Spine Journal articles, Medtronic CEO Omar Ishrak issued a  statement  that said: “While the Spine Journal articles raise questions about researchers’ conclusions in their published peer-reviewed literature, the articles do not raise questions about the data Medtronic submitted to the FDA in the approval process or the information available to physicians today through the instructions for use brochure attached to each product sold.”

The US Justice Department is conducting a criminal investigation into whether Medtronic illegally promoted Infuse for “off-label” applications not approved by the FDA, the Times reports.

 

The American Society of Business Publication Editors have acknowledged the efforts of the Spine Journal and awarded them the 2011 “Journalism That Matters” award. From the New York Times Media Decoder blog:

In June, the publication, The Spine Journal, devoted an entire issue to editorials and reports that challenged previous medical studies supporting the safety and effectiveness of Infuse, a bone-growth product sold by Medtronic. The product, a bioengineered material, is used mainly in spinal fusions.

The Spine Journal charged that academic experts paid by Medtronic to conduct earlier research about Infuse had issued biased and misleading results that overstated the product’s benefits and claimed that it did not pose risks.

On Friday, the American Society of Business Publication Editors celebrated the journal’s effort by presenting it with its 2011 “Journalism That Matters” award, an honor given in recognition of coverage that causes change by government or industry.

It is highly unusual for one group of researchers to publicly repudiate the work of professional colleagues. And by throwing down its challenge, the special issue of The Spine Journal, which is the official journal of the North American Spine Society, was something of a turning point in the debate over conflicts of interest in research paid for by makers of medical products.

Medtronic is on the defensive and is conducting a damage limitation exercise:

But there is little doubt that The Spine Journal’s coverage has had an effect. Last week, Medtronic took the unusual step of announcing that it was giving a $2.5 million grant to Yale so that independent researchers could conduct a broad review of all Infuse studies in order to determine the facts. 

Related:

http://www.courier-journal.com/article/20110731/BUSINESS/307310070/Norton-pair-accused-hiding-risks-spine-drug?odyssey=tab|topnews|text|Local%20News

http://beckersorthopedicandspine.com/spine/item/8901-two-more-spine-surgeons-cited-for-underreporting-infuse-complications

http://www.theglobeandmail.com/life/health/new-health/paul-taylor/medtronic-pledges-independent-review-of-bone-graft-product/article2119735/

 

If you can’t kill the virus, kill the cells that contain the virus

August 11, 2011

An ingenious way of getting around the problem of attacking viruses. An MIT press release desribes a development that could transform how viral infections are treated. A team of researchers at MIT’s Lincoln Laboratory has designed a drug that can identify cells that have been infected by any type of virus, then kill those cells to terminate the infection.

Rider TH, Zook CE, Boettcher TL, Wick ST, Pancoast JS, et al. (2011) Broad-Spectrum Antiviral Therapeutics. PLoS ONE 6(7): e22572. doi:10.1371/journal.pone.0022572

Todd Rider invented the PANACEA and DRACO antiviral therapeutics, and previously invented the CANARY (Cellular Analysis and Notification of Antigen Risks and Yields) sensor for rapid pathogen detection and identification: Image MIT

In a paper published July 27 in the journal PLoS One, the researchers tested their drug against 15 viruses, and found it was effective against all of them — including rhinoviruses that cause the common cold, H1N1 influenza, a stomach virus, a polio virus, dengue fever and several other types of hemorrhagic fever.

The drug works by targeting a type of RNA produced only in cells that have been infected by viruses. “In theory, it should work against all viruses,” says Todd Rider, a senior staff scientist in Lincoln Laboratory’s Chemical, Biological, and Nanoscale Technologies Group who invented the new technology.

Because the technology is so broad-spectrum, it could potentially also be used to combat outbreaks of new viruses, such as the 2003 SARS (severe acute respiratory syndrome) outbreak, Rider says.

Other members of the research team are Lincoln Lab staff members Scott Wick, Christina Zook, Tara Boettcher, Jennifer Pancoast and Benjamin Zusman.

McGill University reprimands Professor for medical ghostwriting

August 11, 2011

Something stinks when academics are “helped” to write their papers by professional ghostwriters who are paid for by pharmaceutical companies. It is even worse when the papers are written by the pharmaceutical companies  and academics in the field are flattered or otherwise persuaded by their agents to put their names to the papers. McGill University has “reprimanded” a senior professor, Barbara Sherwin, for the practice but are at pains to point out that she has not been “sanctioned”.

What exactly does a reprimand – which is no sanction – accomplish?

The ghostwriting for what was ostensibly a peer-reviewed scientific article was essentially just promotional literature for Wyeth Pharmaceuticals’ and hormone replacement therapy (HRT). Wyeth paid a New Jersey professional-writing firm, DesignWrite, to help Sherwin produce a paper on treatment options for age associated memory loss that was eventually published in the Journal of the American Geriatrics Society. The paper was published in 2000. Sherwin was listed as the sole author of that paper, even though Karen Mittleman, an employee of DesignWrite, was involved in the process. The paper was published just when critics started raising doubts about hormone-replacement therapy.

Wyeth – through DesignWrite – had commissioned at least 40 scientific papers endorsing the therapy. During 2001, Wyeth sold hormones for HRT worth $2.1 billion.

Apparently Dr. Sherwin is no longer a member of the Quebec Order of Psychologists, which means she can no longer practice under the title of psychologist.

The Montreal Gazette has the full story.

Even more worrying is the Macleans story that Karen Mittleman of DesignWrite – on behalf of Wyeth – actually solicited this paper. There is also a hint of a rather cozy relationship between the Journal of the American Geriatrics Society and DesignWrite.

The stink is more of a stench!

Her alleged transgression came to light in a class-action suit involving 8,400 women against the drug company Wyeth (now part of Pfizer). Lawyers representing the women, who claim they were harmed by their hormone replacement therapy (HRT) drugs, discovered that scientific research papers extolling the virtues of the treatment while downplaying potential harm appeared to have been written, not by the academics who signed their name to the papers, but by writers hired by the pharmaceutical company.
According to court documents filed by the plaintiffs, Wyeth paid the Princeton, New Jersey-based medical communications company DesignWrite to produce articles on HRT for publication in academic journals between 1997 and 2003. DesignWrite would write the papers, then approach leading academics to claim authorship for them.

Sherwin’s relationship with the pharmaceutical company started innocently enough. In the early 1990s, she was invited to give a presentation about her work on androgens and psychological functioning in women. There, she met a woman named Karen Mittleman during the lunch break. Mittleman introduced herself as a PhD and a former academic who worked in medical communications. The pair hit it off, and kept in touch. “I liked her, and considered her a casual friend,” Sherwin told Maclean’s over the phone from her office at McGill.
Several years later, in 1998, Mittleman called Sherwin to ask if she wanted to write a paper for the Journal of the American Geriatrics Society at the invitation of the journal’s editor. The subject was pharmacological treatment options for age-associated memory loss. Sherwin, an expert on hormones and how they influence memory and mood in people, had just completed a grant proposal on the subject, and said she’d be happy to write the article. 
“[Mittleman] told me she would provide support by typing the manuscript and formatting it in the style of that particular journal,” explains Sherwin. The work itself would be based on Sherwin’s notes. In return, Mittleman, a senior writer at DesignWrite, promised to send Sherwin typed drafts for editing, and hard copies of references the professor requested. “I was completely under the impression that [Mittleman] was working for the journal, that it was the journal who hired her.” 

What Mittleman never revealed was that her employer, DesignWrite, had a business relationship with Wyeth and other pharmaceutical companies.

Karen Mittleman, as Antidote has noted, has the perfect Dickensian name for her job as the go-between finding researchers willing to sign their names to papers written by drug companies.

The reprimand by McGill seems little more than a very mild slap on the wrist.

Related: McGill sets bad example on integrity

Medical ghostwriters and scientists guilty of misconduct should be liable

August 3, 2011

I have long thought that scientific publications (and scientific endeavour in general) cannot be exempt from liability for scientific misconduct – at least a civil liability even if  any criminal liability would depend upon the extent of any fraud involved in a publication or in the performance of scientific activity. The liability would obviously start with the scientists/authors but the entire publishing chain including reviewers, editors and publishers and those who commission the science or the ghost writing must carry their share of responsibility and cannot be exempt.

In a scientific context I think ghostwriting – of itself – is tantamount to fraud.

Why cannot a concept of tort or “product liability”apply to scientists?  

It seems to me that the concept of tort or “product liability” should be applicable to the work of scientists and researchers where their work is the result of faking data, fraud or other misconduct since it would be work that “had not been done in good faith”. Tort would apply because the ramifications of their misconduct would extend far beyond their employment contracts with their employers.

Ghostwriting and guest authoring in industry-controlled research raise “serious ethical and legal concerns, bearing on integrity of medical research and scientific evidence used in legal disputes,”  say two University of Toronto law professors:

Legal Remedies for Medical Ghostwriting: Imposing Fraud Liability on Guest Authors of Ghostwritten Articles

by Simon Stern, Trudo Lemmens PLoS Med 8(8): e1001070. doi:10.1371/journal.pmed.1001070

Summary Points

  • Ghostwriting of medical journal articles raises serious ethical and legal concerns, bearing on the integrity of medical research and scientific evidence used in legal disputes.
  • Medical journals, academic institutions, and professional disciplinary bodies have thus far failed to enforce effective sanctions.
  • The practice of ghostwriting could be deterred more effectively through the imposition of legal liability on the “guest authors” who lend their names to ghostwritten articles.
  • We argue that a guest author’s claim for credit of an article written by someone else constitutes legal fraud, and may give rise to claims that could be pursued in a class action based on the Racketeer Influenced and Corrupt Organizations Act (RICO).
  • The same fraud could support claims of “fraud on the court” against a pharmaceutical company that has used ghostwritten articles in litigation. This claim also appropriately reflects the negative impact of ghostwriting on the legal system.

CTV News says:

Academics who lend their names to medical and scientific articles that they didn’t actually write are doing little more than prostituting themselves, according to two law professors at the University of Toronto. …. 

Academic ghostwriting is a little-known practice that finally came to the public’s attention after some popular drugs like the now-discontinued painkiller Vioxx started showing serious problems.

Lawsuits revealed that studies that suggested the drugs were safe and effective were often not written by the scientists listed as the authors. Instead, they were ghostwritten by writers working for the drug companies that make the medications. The scientists listed as authors were offered payment in return for attaching their names.

The problem of course is that doctors rely on information in the medical literature to make treatment decisions. That’s when “ghostwritten” articles can have devastating effects: by swaying doctors to give patients improper and even harmful treatment. ….

Penn Psychiatrist Accuses Five Colleagues of Plagiarism

August 2, 2011

Update! 3rd March 2012

University of Pennsylvania whitewashes its own psychiatrists

==================================

Researchers names were apparently appended to a draft prepared by a “communications company” working for and biased in favour of a particular drug company!!!

Ghost-writing for German PhD theses is not uncommon and the suspicion has always been around that medical papers about clinical trials of drugs are not entirely free from the influence of the drug companies involved. But ghost-writing of scientific papers by public relations agents of the drug companies and passing them off as unbiased, objective studies is more than just “scientific misconduct”, it approaches fraud. It reduces scientists to the role of used-car salesmen. In fact the ethics of the used-car salesmen are to be preferred. The Universities who employ such “scientists” are not averse to subordinating their ethics for the sake of funding from the drug companies.

Such scientific misconduct is revealed only when an “insider” feels aggrieved enough to break ranks. The point of aggravation usually involves some dissatisfaction with the financial benefits which often flow from the drug companies – directly or indirectly – to the compliant “researchers”. And when Universities  investigate such wrong-doing themselves they usually whitewash themselves. In this case the “whistle-blower” seems to have been aggrieved at having been “left-out”.

One of those accused – Charles Nemeroff – has already been in hot water for not declaring more than $1.2 million of income from drug companies.

From Science Magazine:

Penn Psychiatrist Accuses Five Colleagues of Plagiarism

A University of Pennsylvania researcher has accused five colleagues of scientific misconduct for allegedly allowing a drug company to put their names on a paper that they did not write. But although federal officials have said “ghostwriting” may be a form of plagiarism, which is prohibited, it’s not clear that the Office of Research Integrity (ORI) would act on this particular case.

The spat involves a June 2001 paper in The American Journal of Psychiatry on a small clinical trial of the antidepressant Paxil that was funded by GlaxoSmithKline (GSK) and the National Institute of Mental Health. In a 8 July letter sent by his attorney to ORI, Penn psychiatrist Jay Amsterdam, a co-investigator on the study but not a co-author of the paper, accuses five colleagues of “allowing their names to be appended to a manuscript that was drafted by” Scientific Therapeutics Information (STI), a medical communications company, that had been “hired by” GSK (then SmithKline Beecham). The complaint also says that the widely cited paper “was biased” in favor of the drug’s efficacy and safety and that Amsterdam felt that Penn colleague Laszlo Gyulai “misappropriated” his data.

ORI should investigate, the complaint says, because National Institutes of Health Director Francis Collins recently wrote that articles ghostwritten by NIH researchers “may be appropriate for consideration as a case of plagiarism.” (ORI only investigates misconduct that took place within 6 years of an accusation, but it makes an exception if the accused scientists are still citing the paper; Gyulai cited it in 2007.)

The accused include Gyulai; Dwight Evans, chair of the Penn psychiatry department; and three researchers at other institutions. They include Charles Nemeroff, who in 2008 was found by Emory University to have failed to report drug company income; he is now chair of psychiatry at the University of Miami.

The complaint has been posted online by the Project on Government Oversight (POGO), a Washington, D.C., watchdog group. Its staff includes Paul Thacker, a former staffer for Senator Charles Grassley (R-IA) who led an investigation alleging that Nemeroff and other psychiatrists hid millions of dollars in drug income from their institutions. POGO wrote President Barack Obama Monday to complain that because Penn concluded that a separate ghostwriting accusation made by POGO against Evans last fall was unfounded, Penn President Amy Gutmann should step down as chair of the Presidential Commission for the Study of Bioethical Issues. “We do not understand how Dr. Gutmann can be a credible Chair of the Commission when she seems to ignore bioethical problems on her own campus,” the letter says.

Skin cells made to behave like nerve cells without the use of stem cells

June 7, 2011

A new paper by researchers at Lund University in the Proceedings of the National Academy of Sciences of the United States of America describes how they have managed to develop nerve cells from human skin cells without using stem cells – a development described as an ethical and medical breakthrough.

Direct conversion of human fibroblasts to dopaminergic neurons

by Ulrich Pfisterer, Agnete Kirkeby, Olof Torper, James Wood, Jenny Nelander, Audrey Dufour, Anders Björklund, Olle Lindvall,Johan Jakobsson, and Malin Parmar

doi:10.1073/pnas.1105135108 PNAS June 6, 2011

Abstract: Recent reports demonstrate that somatic mouse cells can be directly converted to other mature cell types by using combined expression of defined factors. Here we show that the same strategy can be applied to human embryonic and postnatal fibroblasts. By overexpression of the transcription factors Ascl1, Brn2, and Myt1l, human fibroblasts were efficiently converted to functional neurons. We also demonstrate that the converted neurons can be directed toward distinct functional neurotransmitter phenotypes when the appropriate transcriptional cues are provided together with the three conversion factors. By combining expression of the three conversion factors with expression of two genes involved in dopamine neuron generation, Lmx1a and FoxA2, we could direct the phenotype of the converted cells toward dopaminergic neurons. Such subtype-specific induced neurons derived from human somatic cells could be valuable for disease modeling and cell replacement therapy.

The Local reports:

 

 

Swedish team turns skin into nerve cells

Swedish team turns skin into nerve cells

A team of researchers at Lund University in southern Sweden have managed to develop nerve cells from human skin cells without using stem cells – a development described as an ethical and medical breakthrough.

“This fundamentally changes how we look at mature cells and their capacity. Previously a skin cell was thought to always remain a skin cell, but we have shown that it can be any cell,” said Malin Parmar, the Lund University researcher leading the study, to The Local on Tuesday.

The new technique works by reprogramming connective tissue cells, so-called human fibroblasts, directly into nerve cells, opening up a new field with the potential to “take research around cell transplantation to the next level”.

Parmar explained that members of the research team were surprised at how receptive the fibroblasts were for new instructions.

“From the beginning this was mostly an experiment that was fun to try out. But fairly quickly it was shown that the cells were unexpectedly receptive to instructions,” she said.

 

Blueberries and chocolates keep blood pressure in check !

January 15, 2011
Blueberry

Image via Wikipedia

This is good news!

New studies have found that specific properties of blueberries may help reduce the risks of developing high blood pressure. Blueberries contain high concentrations of anthocyanins and are very antioxidant rich. Anthocyanins are very dark in color, usually blue, purple or dark red. Other foods with similar antioxidant qualities are red wine, chocolate, tea, vegetables, and some grains.

For the study, scientists fromHarvard University analyzed information of about 135,000 women and nearly 50,000 men. Individuals were followed for 14 years and were asked to complete health surveys every two years. Each person also had their diet analyzed every four years. None of the individuals experienced hypertension at the start of the research period.

During the study, about 35,000 individuals became hypertensive. Researchers found that individuals consuming a large amount of food containing anthocyanins noticed an 8 percent lower risk of developing hypertension than those who consumed very little. Additionally, people under the age of 60 noticed the most benefit from these antioxidants.

For this study, blueberries appeared to be more effective than strawberries for preventing hypertension.

Red wine followed by dark chocolate and a good helping of blueberries – is something I can live with.