Your Brain on Potato Chips

Or, more accurately, a rat's brain on potato chips.  Last week, PLoS One published a very interesting paper by Dr. Tobias Hoch and colleagues on what happens in a rat's brain when it is exposed to a highly palatable/rewarding food (1).  Rats, like humans, overconsume highly palatable foods even when they're sated on less palatable foods (2), and feeding rats a variety of palatable human junk foods is one of the most effective ways to fatten them (3).  Since the brain directs all behaviors, food consumption is an expression of brain activity patterns.  So what is the brain activity pattern that leads to the overconsumption of a highly palatable and rewarding food?

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US CDC has issued an MMWR describing the growing threat of multidrug-resistant gonorrhea and what public health agencies and partners can do to delay the emergence of cephalosporin-resistant strains, mitigate the public health consequences of expanded resistance, and prevent a return to the era of untreatable gonorrhea. For these strategies and more information, see the MMWR at:

A total of 40 confirmed gonorrhea cases have been reported in Maine through Feb. 16, compared to 54 reported cases in 2012 and 19 reported cases in 2011 during the same period. Some cases are reported more than once and may represent reinfection, recurrent infection, or persistent infection.

The majority of cases have been reported in Androscoggin County, followed by Cumberland County. Maine CDC is issuing biweekly gonorrhea surveillance updates. The most recent report is available at:

Current treatment guidelines and reporting requirements are included in this Health Alert from Dec. 4:

Salt Sugar Fat

I'd just like to put in a quick word for a book that will be released tomorrow, titled Salt Sugar Fat: How the Food Giants Hooked Us, by Pulitzer prize-winning author Michael Moss.  This is along the same lines as Dr. David Kessler's book The End of Overeating, which explains how the food industry uses food reward, palatability, and food cues to maximize sales-- and as an unintended side effect, maximize our waistlines.   Judging by Moss's recent article in New York Times Magazine, which I highly recommend reading, the book will be excellent.  I've pre-ordered it.


Anticoagulant use may be a predictor of overall survival in men with metastatic castration-resistant prostate cancer (mCRPC) receiving docetaxel, retrospective data suggest.
The information, presented in a poster at the 2013 American Society of Clinical Oncology (ASCO) Genitourinary Cancer Symposium in Orlando, Florida, "adds to the growing body of evidence that anticoagulants, including aspirin although not studied here, improve outcome following treatment for prostate cancer," Dr. Mark Buyyounouski, from Fox Chase Cancer Center, Philadelphia, who moderated the poster session, told Reuters Health.
Presenting author Caroline Pratz, a nurse practitioner from the Johns Hopkins Sidney Kimmel Comprehensive Cancer Center in Baltimore, MD, told Reuters Health, "We had an interest in collecting data on these patients who had deep vein thrombosis or pulmonary embolism because we see them frequently in the clinic and we were curious as to how this would affect their overall survival."
Anticoagulants have been postulated to possess antitumor activity, although clinical data supporting this claim are conflicting, she said.
Pratz and her team reviewed the records of 247 consecutive mCRPC patients who received first-line docetaxel chemotherapy from 1998 through 2009, and noted whether anticoagulation was used and if so, the type, indication, and duration.
Twenty-nine men (11.7%) received anticoagulation; 15 for deep vein thrombosis (DVT), nine for pulmonary embolism (PE), and five for both DVT and PE.
Compared to men who received no anticoagulation, those who did had a significant increase in overall survival (hazard ratio for death 0.61; p=0.024). But when types of anticoagulants were analyzed separately, only low molecular weight (LMW) appeared to show a benefit (HR 0.58; p=0.048). The improvement with warfarin was not statistically significant (HR 0.82; p=0.23).
Patients who received any anticoagulant lived a median of 3.8 months longer (median overall survival 20.9 months with any anticoagulant versus 17.1 months with no anticoagulant).
After controlling for a number of other prognostic factors, including alkaline phosphatase, albumin, hemoglobin, prostate specific antigen, number of chemo cycles, and Eastern Cooperative Oncology Group status, anticoagulant use remained a significant predictor of overall survival (HR 0.63; p=0.038).
Pratz said she and her group were surprised by the study results. "It is counter-intuitive to what you think of when you think of blood clots. Typically they can be life threatening, so it was a surprise to us, although it has been reported in some other solid tumor cancers, that this was also the case."
Dr. Buyyounouski added: "These results are particularly compelling given the advanced nature of the disease in the study population."
"We've known for a long time that cancer and blood clots are related, that patients with cancer are more likely to have clotting and that patients with unexplained clotting disorders are more likely to get cancer. So in looking at whether using drugs that inhibit clotting will improve cancer outcomes Pratz and her group found that yes, it looks that way," he said.
Dr. Buyyounouski, a radiation oncologist, cautioned that the study is observational and sheds no light on the possible mechanism by which anticoagulation might benefit cancer outcomes.
"It may interfere with the cancer cells' ability to grow, that is one possibility. Another is that it perhaps interferes with the cancer's ability to stick in blood vessels, and this is one that people think is likely."
The ideal method of anticoagulation, dose, timing, and associated risks all need to be better defined and require further study, he added.
The 2013 Genitourinary Cancers Symposium is co-sponsored by the American Society of Clinical Oncology (ASCO), the American Society for Radiation Oncology (ASTRO), and the Society of Urologic Oncology (SUO).


Watson, the IBM supercomputer that grabbed headlines after beating human contestants on Jeopardy!, has commercial applications in healthcare. And its developers have chosen to debut it in oncology.
Watson's first application in cancer is highly focused: recommending the best drug treatment options for patients with stage IV adenocarcinomas, said Mark Kris, MD, from the Memorial Sloan-Kettering Cancer Center in New York City, which is developing the tool with IBM and WellPoint, the managed care company.
"It's the biggest decision in lung cancer treatment," Dr. Kris toldMedscape Medical News. He explained that systemic therapies are the most common form of treatment, and adenocarcinomas are the most common form of lung cancer.
The supercomputer has synthesized an array of data gleaned from thousands of sources, including journal articles, national guidelines, individual-hospital best practices, clinical trials, and even textbooks.
Programming Watson for clinical decision-making in lung cancer "is not an easy task," said Dr. Kris. He pointed out that it took 4 years to program the computer so that it could participate in the game show.
Although Watson is a work in progress, it is currently being used at the Maine Center for Cancer Medicine and Blood Disorders, according to an IBM press statement.
Watson's hardware is physically located in Raleigh, North Carolina, and it uses cloud computing to interface with electronic medical records, Dr. Kris explained.
A clinician enters case notes into an electronic medical record and Watson immediately provides evidence-based and individualized treatment recommendations.
Individual treatment recommendations are updated as case notes become more detailed over time. The "natural language processing," which is the capability of the computer to read and comprehend case notes (in all their variety), is "the heart of Watson," he said.
IBM has produced an 8-minute video, entitled IBM Watson Demo: Oncology Diagnosis and Treatment, that illustrates a clinician interacting with Watson to receive treatment recommendations about a patient with lung cancer.
Watson can help human beings to do the increasingly complex job of being an oncologist, said H. Jack West, MD, from the Swedish Cancer Center in Seattle, Washington, and the author of the Blowing Smoke Medscape blog. He has been following the development of Watson and has commented onlineabout its potential usefulness.
"A computer can incorporate a nearly infinite amount of new data coming out, whereas the human brain can't attend to as much and integrate it," he told Medscape Medical News in an email.
Replacing Doctors?
Dr. West, who is not involved with Watson, sees 2 problems with its use in oncology: first, cancer is "defined by its variability"; and second, clinical decisions are often, in the end, matters of "judgement."
Even the most complex algorithms rely, to some degree, on "classic presentation," he said. Medical practice is less orderly, he noted. "The truth is that just about every cancer case is special and has some unique aspects to it, or at least there are so many extenuating factors that it's hard to be rigidly rule-based," he said.
Ideally, Dr. West would like to see a randomized controlled trial comparing clinical outcomes for patients treated with and without Watson. At the very least, he would like to see Watson's recommendations compared with those from several cancer experts to clarify its value over currently available second opinion.
Dr. West tips his hat to Watson's developers who have admitted that "there is no substitute for the most expert input when it is available." In other words, computers will never replace doctors, both Dr. West and the IBM team assert.
But a high-profile technology pioneer disagrees.
At the 2012 Health Innovation Summit in San Francisco California, Vinod Khosla, a cofounder of Sun Microsystems, reportedly said that computers could replace 80% of doctors. "Healthcare is like witchcraft and just based on tradition," he said. The solution? Data-based, computer-generated decision making.
Watson is "not a replacement" for physicians, according to Dr. Kris. In fact, it will take a "long, long time" to fully develop clinically, he said. However, he added Watson can improve on current oncology resources, such as the National Comprehensive Cancer Network guideline on nonsmall-cell lung cancer.
Dr. Kris, who is one of the authors of this guideline, pointed out that, for stage IV adenocarcinomas, bevacizumab and/or chemotherapy are recommended for patients with a performance status of 0 or 1. The advice is fairly nonspecific for chemotherapy. Two-drug chemotherapy regimens are "preferred," according to the guideline, but it does not specify which of the many of potential chemotherapies are best, nor does it address dosing or length of treatment, Dr. Kris notes.
"Guidelines are a scaffolding...but you've got to finish the building," he explained, referring to the relatively increased "granularity" of detail that Watson will provide and then improve upon as it is further developed.
Dr. Kris, commented on Watson in his Kris on Oncology Medscape blog last year when Memorial-Sloan Kettering entered into its partnership with IBM to develop the technology.
Watson is not the only electronic medical record-mediated computing initiative aimed at facilitating healthcare delivery. Major healthcare players, including McKesson, the American Society of Clinical Oncology, and Aetna, are developing clinical decision-making tools, said Dr. Kris.
In this study, they aimed to test that hypothesis in the much larger IMS-III trial.
IMS-III was a phase 3, randomized, open-label international trial comparing a combined intravenous and intraarterial approach to stroke treatment to standard intravenous tPA alone. The planned target for patient enrollment was 900 patients, randomly assigned in a 2:1 ratio to combined vs standard therapy within 3 hours of stroke onset.
Endovascular therapy included a choice of catheters and devices or intra-arterial tPA based on the lesion characteristics, the experience and training of the investigator, and the specified use of devices.
The trial was halted early for futility after enrollment of 656 patients. Full results were presented here by principal investigator Joseph P. Broderick, MD, from the University of Cincinnati at a session dedicated just to this trial. They were published online simultaneously in the New England Journal of Medicine, and reported by Medscape Medical News.
In the overall analysis, there was no statistically significant difference between the interventions on the primary endpoint, a modified Rankin Scale score of 2 or less at 90 days, indicating functional independence. The absolute difference between groups was 1.5% (95% confidence interval [CI], -6.1% to 9.1%), adjusted for stroke severity by National Institutes of Health Stroke Scale (NIHSS) score. A score of 8 to 19 indicates moderate to severe strokes, and a score of 20 or more indicates the most severe strokes.
In this new time analysis, Dr. Khatri and colleagues used the same methods as in their previous report, excluding patients with very large clots to make a more homogeneous population. Included were patients with M1, M2, or internal carotid artery terminus occlusions who were treated with endovascular therapy and in whom reperfusion was technically successful, defined as a Thrombolysis in Cerebral Infarction (TICI) score of 2 to 3.
Time to successful reperfusion was considered the time from symptom onset to the time the procedure ended, Dr. Khatri noted. Good clinical outcome was defined as a modified Rankin Scale score of 0 to 2, also the primary endpoint of IMS-III.
Of the 656 patients in the overall study, 240 had a qualifying occlusion for this analysis, among whom operators achieved TICI 2/3 reperfusion in 182 (76%). The mean time from symptom onset to reperfusion was 325 minutes (range, 180 to 418 minutes). The longest period was time from symptom onset to start of intravenous tPA, at 121 ± 34 minutes.
After adjustment for baseline variables (such as a baseline Alberta Stroke Program Early CT Score [ASPECTS] of 5 to 10, indicating a favorable computed tomographic scan; lack of disability prior to stroke; and an NIHSS score of 8 to 19 vs 20 or higher, indicating a less severe stroke among these moderately severe strokes), Dr. Khatri said, "we still had a relationship between time to reperfusion and outcome. Every 30-minute delay in reperfusion was associated with a 10% relative reduction in good outcome."
Table. IMS III: Predictors of Favorable Outcome (Modified Rankin Scale Score, 0 to 2)
VariableRisk Ratio (95% Confidence Interval)P Value
Time to reperfusion (every 30-min delay)0.90 (0.82 - 0.99).02
Baseline ASPECTS of 5 to 103.70 (1.25 - 11.00).01
Lack of premorbid disability2.61 (1.05 - 6.50).01
NIHSS score ≤19 vs ≥201.64 (1.07 - 2.51).01

They found the time relationship was maintained across ASPECTS groups, NIHSS strata, TICI score achieved, and type of occlusion.
One limitation is that by using the time to the end of the procedure as a surrogate for time to reperfusion, they may have overestimated the actual time to reperfusion, she noted.
Going forward, Dr. Khatri said, they plan to carry out more statistical analyses to help define any "point of no clinical return," where no benefit will be seen even if reperfusion is achieved, probably around the 7-hour mark after symptom onset.
Finally, she showed another analysis plotting the IMS-III results on their previous graph showing probability of good outcome against time to reperfusion, "just raising the possibility that if we had opened up clots faster, transitioned patients faster to IA [intraarterial] therapy, perhaps we would have had a positive trial."
IMS-III was funded by the National Institute of Neurological Disorders and Stroke (NINDS). Dr. Khatri reports significant support from NINDS as part of the IMS-III trial executive committee, significant support from Penumbra as neurology principal investigator for the THERAPY trial and from Genentech as the overall principal investigator for the PRISMS trial in planning stages, and modest support from Travek for Genentech as an unpaid consultant.

Food Reward Friday

This week, Food Reward Friday is going to be a little bit different.  I've received a few e-mails from people who would like to see me write about some of the less obvious examples of food reward-- foods that are less extreme, but much more common, and that nevertheless promote overeating.  Let's face it, even though they're funny and they (sometimes) illustrate the principle, most people reading this blog don't eat banana splits very often, much less pizzas made out of hot dogs.

So this week's "winner" is something many of you have in your houses right now, and which was also the subject of an interesting recent study... potato chips!

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Make your own non-toxic all-purpose cleaner!

Making your own non-toxic cleaning products is easy and inexpensive.

All you need for an all-purpose cleaner is:
  • 1 and 2/3 cup baking soda
  • 1/2 cup liquid castile soap (found with other soaps in most supermarkets)
  • 2 tablespoons vinegar
  • 16 oz. bottle with a flip-top cap
Mix baking soda and liquid soap with a fork in a bowl.
Add water.
Add vinegar last.
Pour into squeeze bottle. If it is too thick, add more water.
Shake well.

Be sure to label the bottle!

To use: squirt onto surface (tub, sink, toilet, counter) and then scrub and rinse.

Safer, easy, inexpensive and effective!
For more Green Cleaning Recipes visit:

New video game helps kids get ready for disasters

Are you a disaster hero? You can become one with a new game from the American College of Emergency Physicians.

Disaster Hero is an online game created to teach young people — and gamers of all ages! — about preparing for disasters. The game takes players through a series of challenges that will help them learn about preparing an emergency kit and making a disaster plan, as well as staying safe before, during and after four common natural disasters — hurricanes, tornadoes, earthquakes and floods.

Screenshot from Disaster Hero
The game is free and is designed for students in first grade and older. Anyone with a computer and Internet connection can play — no sign-up is required. Players who create a free account can save their scores and design their own character.

Have you played the Disaster Hero game? Let us know your thoughts in the comments!

Country Style Bedrooms 2013 Decorating Ideas

Country Bedroom Style: A Cozy and Welcoming Trend Country bedroom style has a timeless appeal that can be adapted to almost any home.

Here a few points about country bedroom style are given: 

Country style bedroom has become one of the popular styles of the today market due to its casual and modest appeal.
The country bedroom furniture style offers a blend of rustic and romantic flavor with graceful curves.
The furniture used for country style gives you an everlasting pleasure including detailing, molding, and the artful use of woods in each frame, nightstand, armoire and dresser.
For a breathtaking look, you can use plain sheer curtains or print or checked drapes.
If you really want to compliment your country style, then try pieces with pine stain or a painted finish.
Plain overhead lighting with bedside table lamps looks interesting in country style bedroom.
You can try paint with wallpaper borders on the walls for a unique country style.

 If you are a fan of country cottages, you are going to love this. Drool at these carefully crafted country inspired bedrooms with rustic flowing details and old cottage charm.

Body Fatness and Cardiovascular Risk Factors

I recently revisited a really cool paper published in the Lancet in 2009 on body fatness, biomarkers, health, and mortality (1). It's a meta-analysis that compiled body mass index (BMI) data from nearly 900,000 individual people, and related it to circulating lipids and various health outcomes.  This is one of the most authoritative papers on the subject.

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Country Style Kitchens 2013 Decorating Ideas

A country style kitchen is warm, cozy and inviting. It's evocative of a country setting.
The furnishings and decor remind you of the countryside, the outdoors and the gathering of people. Because of its welcoming ambiance, it's currently a popular kitchen style. Always comfortable, it's usually large (although smaller country kitchens work as well).
Decorating a country kitchen involves the selection of furnishings, walls, flooring, windows and accessories.

These English country style kitchen sets from County Kitchen predominantly reflect a traditional style but not without a modern twist on tradition.
I hope you like this collection .....  enjoy it ...!


 Agents that target the mTOR axis, which have become particularly important in treating advanced renal cell carcinoma (RCC), have significant adverse cardiovascular effects, a Stanford University team reports.
"The main finding of our study is that cardiovascular side effects of targeted cancer therapies -- particularly the ever-growing class of tyrosine kinase inhibitors -- are extremely common, and far more common than most practitioners appreciate," Dr. Ronald Witteles commented in an email to Reuters Health.
In a paper this month in JACC: Heart Failure, Dr. Witteles and colleagues note that in the last six years, the U.S. Food and Drug Administration has approved the tyrosine kinase inhibitors (TKI) sunitinib, axitinib, sorafenib, and pazopanib; the anti-VEGF (vascular endothelial growth factor) agent bevacizumab; and the mTOR (mammalian target of rapamycin) inhibitors everolimus and temsirolimus for various malignancies.
Among these agents available for the treatment of RCC, sunitinib has been linked most often to cardiovascular toxicity - but not in the phase III trials that led to FDA approval. Instead, the researchers say, "subsequent retrospective and prospective studies have since illuminated the significantly elevated risk of heart failure."
To look into this issue, the team assessed the incidence and severity of adverse cardiovascular effects in 159 patients with advanced metastatic RCC who received targeted therapies at the Stanford Cancer Institute in Stanford, California between 2004 and 2011. Since 2007, most of these patients underwent regular, prospective cardiac monitoring.
TKIs were used in 92% of patients, and sunitinib was the most commonly used agent (64% of patients). Some form of cardiovascular toxicity occurred in 116 (73%) of the patients, most often related to hypertension requiring antihypertensive therapy.
Excluding hypertension, 52 patients (33%) experienced some other cardiotoxicity, ranging from asymptomatic increases in levels of NT-proBNP (N-terminal prohormone of brain natriuretic peptide) to severe heart failure, the investigators report.
Among the 41 patients who received mTOR inhibitors, 17% of those treated with everolimus developed grade 1 heart failure, and 24% of temsirolimus recipients developed grade 3 hypertension, the report indicates.
So how does Dr. Witteles view the benefit-risk balance with use of the targeted therapies? "I certainly don't believe that these agents shouldn't be used, as they often have tremendous efficacy as cancer therapy," he responded, "but patients and physicians need to be aware of the likelihood of cardiovascular side effects so that early treatment can be initiated."
In fact, the team found a very high rate of asymptomatic cardiotoxicity. "In our study," the authors said, "asymptomatic cardiotoxicity, as defined by an elevated NT-proBNP level and/or a decrease in systolic function as estimated by left ventricular ejection fraction, was identified in 43 patients (27%). Given their asymptomatic status, these patients would likely not have been identified without screening."
Screening often allowed for asymptomatic cases to be referred to a heart failure specialist and to begin medical therapy with beta blockers and renin-angiotensin inhibitors. "Accordingly," Dr. Witteles and colleagues conclude, "we propose guidelines for monitoring therapy in this population to potentially improve detection and guide treatment."


The crude birth rate in 2011 was "the lowest rate ever reported for the United States," according to the authors of the Annual Summary of Vital Statistics, published online February 11 inPediatrics.
Expressed as live births per 1000 women, the 2011 crude birth rate was 12.7, down from 13.0 in 2010, 14.4 in 2000, and 24.1 in 1950. Overall, there were 1% fewer children born in the United States in 2011 than in 2010, and 4% fewer than in 2009, lead author Brady E. Hamilton, PhD, from the Division of Vital Statistics, National Center for Health Statistics, Centers for Disease Control and Prevention, Hyattsville, Maryland, and colleagues report. The data come from birth and death certificates for residents of the 50 states and the District of Columbia.
The decline in birth rate among mothers aged between 15 and 19 years was especially dramatic, with an 8% relative decrease between 2010 and 2011 to reach a historic low of 31.3 births per 1000 women in 2011. This represents a 25% relative decrease in birth rate since 2007 and a 49% relative decrease since 1991, the authors say. "If the 1991 rates had continued to prevail from 1992 through 2011, an estimated 3.6 million additional births to women aged 15 to 19 years would have occurred in the United States (with >1 million of those additional births occurring between 2008 and 2011)."
Birth rates among women in the 20- to 24-year age category also decreased, from 90.0 per 1000 women in 2010 to 85.3 per 1000 in 2011, another record low in the United States. In contrast, women aged 40 to 44 years saw a 1% increase in birth rates, going from 10.2 per 1000 in 2010 to 10.3 per 1000 in 2011. There was no change in rate among women aged 45 to 49 years during that period.
The 2011 crude death rate, at 8.1 per 1000 population, was up slightly from 8.0 in 2010 and 7.9 in 2009, although it remains lower than the 8.5 and 9.6 deaths per 1000 population reported in 2000 and 1950, respectively.
However, age-adjusted death rates, which control for variations in age distribution and are considered a better indicator of mortality risk over time than crude death rates, decreased from 7.5 deaths per 1000 US standard population in 2010 to 7.4 in 2011, a relative change of 1.3% and another record low. Deaths among children aged 1 to 19 years accounted for 20,192 of the 2,513,171 total deaths recorded in the United States in 2011. Accidents, homicide, and suicide were the 3 leading causes of death in this age group.
Life expectancy for children born in 2011 was 78.7 years, the same as in 2010. It was highest for Hispanic females, at 83.7 years, and lowest for non-Hispanic black males, at 71.6 years.

How Did the Alleged Abductor Snatch Madeleine McCann?

This is a re-up for this 2010 article by Barbara Nottage, and probably the best place, rather than being directed to the case files, for any newbie to get an understanding of the physics of the thing.

Because let's face it, you don't actually need the case files, it's all here, for it covers the the most fundamental premiss of the case, the "jemmied shutters." Because no jemmied shutters means no abduction; period.

And as well we know, jemmied shutters were there not. Something Leicester Police and Scotland Yard seem unable to grasp.

Or choose to ignore.

Originally posted under the title: Madeleine McCann Was Not Abducted: The Shutters Revisited at Good Quality Wristbands. A place where making use of the search bar, particularly using the same keywords, jemmied shutters, will bring a host of results.

How did the alleged abductor snatch Madeleine in a time slot of no more than 3-4 minutes?
by Barbara Nottage

One of the curious aspects of the alleged abduction of Madeleine McCann is the extraordinarily tight timetable in which the abduction is supposed to have taken place. Dr Gerald McCann says he went to check on the children at about 9.05pm on 3 May 2007. He also said elsewhere that he had been an unusually long time in the apartment toilet, and that he had been inside all four rooms of the apartment. In addition, he told the world that he had had time during his visit to gaze down on Madeleine, whom he was to describe as ‘lying in the recovery position’, and think how lucky he was to have such a beautiful daughter. By this reckoning, He could not have left the apartment until around 9.10pm or several minutes later.

Meanwhile Jane Tanner, a close friend of the McCanns, has given statements saying that she saw what she thought was a male abductor carrying Madeleine away in his arms from the apartment at around 9.15pm - although we might note here that in August 2009 at a press conference, the McCanns’ chief private investigator, former Detective Inspector Dave Edgar, said that Jane Tanner might have seen a woman, not a man.

The abduction scenario

So let’s examine this situation more closely.

The scenario put forward by the McCanns and their friends runs as follows:

· The abductor must have been watching the apartment for several days before snatching Madeleine on 3 May.

· The McCanns went down to the ‘Tapas bar’ at the Ocean Club at around 8.30pm that evening, with other members of the group arriving during the next half-an-hour or so.

· Dr Matthew Oldfield ‘checked the apartment from the outside’ at around 9.00pm to 9.03pm.

· Dr Gerry McCann returned to his apartment (5A) from the Tapas bar to check on his children at around 9.05pm. The walk to the apartment would have taken one to two minutes. So on his own timing, he would have arrived there around 9.07pm.

· Dr Gerry McCann was briefly in all four rooms of their holiday apartment, during which time he checked his children. He also says he spent an unusually long time in the toilet - maybe up to 5 minutes, though we have never been told why. He tells us that he paused briefly over Madeleine’s bed and thought to himself how very lucky he was to have such a beautiful child.

· Dr Gerry McCann says he noticed that the door to the children’s room was ‘wider open than before’. He says that at 8.30pm it had been open at an angle of about 45 degrees (half open). He remembers (he says) that when he went to check the children at 9.05pm, the door was now open at an angle of 60 degrees (two thirds open).

· The fact that the door - according to Dr Gerald McCann - was now (at 9.05pm) more open more than it was before (at 8.30pm), has been used by him to suggest the possibility that the abductor may have been already in the apartment when he checked on the children, although he says he only realised this possibility some months after the events of the day. Dr Gerry McCann has said that the abductor might have been hiding behind a door or in a wardrobe while he spent several minutes doing his ‘check’ on the children.

· Dr Gerry McCann must have left the room, on his own account, at between 9.10pm and 9.15pm. He then says he encountered a TV cameraman, Jeremy (‘Jes’) Wilkins, on the road back to the Tapas bar at the Ocean Club, and was talking to him for several minutes between 9.10pm and 9.25pm (Jeremy Wilkins confirms the meeting, but says it only lasted three minutes).

· Ms Jane Tanner (partner of Dr Russell O’Brien) says she left the Tapas bar at around 9.15pm and saw a man walking ‘purposefully’, with a child in his arms, along the top of the road running alongside the McCanns’ apartment. She has maintained throughout that she saw this man at almost exactly 9.15pm.

· The McCanns maintain that they left their apartment unlocked. This contrasts however with what they said during the might of 3 May/4 May. In telephone calls to relatives, Dr Gerald McCann told them that an abductor had forced entry into the apartment by jemmying open the shutters. They appear to have changed this story after both the Manager of Mark Warners, Mr john Hill, and the police, found no evidence whatsoever of the shutters having been forced open.

· The McCanns now say, therefore, that the abductor must have entered their apartment through the unlocked patio door. But they maintain that the windows and shutters that they say they found open on Dr Kate McCann checking the children at 10.00pm were because the abductor must have made his escape via that route. They say the abductor must have opened the window and the shutters (which the McCanns say they had had left closed) from the inside, climbed through the window, and taken Madeleine through that window.

· Dr Kate McCann says she returned to the apartment to check on the children at 10.00pm. She says she ‘knew instantly’ that Madeleine had been abducted - and then so did Dr Gerald McCann, minutes later, when he says he arrived at the apartment. Dr Kate McCann later told a TV interviewer that because of the requirement for secrecy about the police investigation, she could not explain why she ‘knew instantly’ that Madeleine had been abducted. She has never explained this, even 2½ years later.

The photographs of the apartment taken by the Portuguese police on the day after Madeleine was reported missing do not show anything which would clearly point to an abduction, certainly not damaged shutters. No forensic evidence whatsoever of the alleged abductor has been found. There were no forensic traces in the room, and no fingerprints on the window, window frame or shutters except for one of Dr Kate McCann’s fingerprints. The lichen on the windowsill was undisturbed.

Going by the above scenario, which the McCanns and their ‘Tapas 9’ friends have maintained, the abductor (if there was one) must have either entered the apartment before Dr Matthew Oldfield’s check at around 9.03pm and Dr Gerry McCann’s check which began at 9.05pm/9.07pm – a version put forward by the McCanns months after Madeleine was reported missing - McCanns now want us to believe - or after Dr Gerry McCann left at 9.10pm to 9.15pm and before he was (allegedly) seen by Jane Tanner at 9.15pm.

The problems with this abduction scenario

There are many problems associated with this specific abduction scenario above that the McCanns and their ‘Tapas 9’ friends have generated.

As we have seen just now, there is no forensic evidence that the alleged abductor was even in the McCanns’ apartment, still less that an abductor climbed in or out of the window.

Further, the window is high enough in the children’s room to make it physically very difficult for an abductor to climb through it. It was reported to be 91cm. above the floor - exactly three feet. The window itself is only around 60cm x 60cm (2ft x 2ft). The abductor would therefore have had to climb some three feet, with Madeleine with him, in his arms or over his shoulder. In addition, he would have to have managed this feat without leaving any forensic traces on the window-sill.

Madeleine must have weighed at least two stone (12kg). A task such as this would have meant balancing against the window frame itself, in which case traces of clothing fibres would surely have been found. Even then, it would have been almost impossible to climb through this window even if Madeleine had been asleep. It is surely even more unlikely that the abductor could have laid Madeleine down on the floor or a bed in the children’s bedroom, then climbed out of the window, and then reached back inside the bedroom to pick Madeleine out of the room - all of this without Madeleine or either of the twins waking up.

This whole abduction operation would clearly have been still more difficult either if Madeleine had woken up whilst being abducted, or one or both twins had done so. To maintain the abduction scenario, therefore, it is necessary to believe that Madeleine slept through the entire abduction operation. The description given by Jane Tanner of an alleged abductor carrying a child also describes the child as quiet and presumably asleep.

Moreover, to escape via the window, as the McCanns claim, the abductor would have had to open the shutters. Mark Warners, however, explained that it was only possible to open the shutters from the inside. They are operated by pulling a cord, or strap, on the inside. It is a highly relevant fact (again confirmed by Mark Warners) that when these heavy metal shutters were opened, the whole process is extremely noisy.

But no-one heard the shutters being opened. Moreover, the children’s room was directly overlooked by a tall block of apartments on the other side of the street. Had the abductor really climbed out of that window, he would have been in the view of dozens of windows overlooking Apartment 5A. We now know that the shutters to Apartment 5A were actually closed when the police and Mark Warners’ staff arrived to check them. The McCanns’ initial explanation for this fact were that the shutters ‘must have been closed by the abductor as well as opened by him’. We have seen that the shutters could not be opened from the outside. This claim by the McCanns that the abductor ‘must have tried to close the shutters behind him’ prompts two related and very obvious questions:

1) having gained entry through an open patio door, what would possess an abductor to leave via a three-foot high, two-foot square closed window, with the shutters also closed? The McCanns’ abduction scenario would require him to have opened the windows and shutters, then tried to close the shutters behind him, when he could have simply walked through the already-open patio doors.

2) why and how, having allegedly scooped up Madeleine in his arms and opened the window and the shutters, would he have had the time and the physical ability to then close the shutters, all without making any sound or leaving any trace, without being seen by anyone, and without waking either Madeleine or the twins?

Moreover, all this would have had to have been accomplished in the dark - unless the alleged abductor switched the lights on when he entered the apartment and then remembered to switch them off again as he was making his exit. No-one saw any lights on in the apartment. The McCanns have admitted that they left the children in the darkness, with the shutters and curtains closed, when they went out for their evening’s entertainment.

Therefore, to sum up - according to the McCanns’ scenario, the abductor would have to have:

* First - either picked an opportunity to enter the apartment after the McCanns had left for the Tapas bar at between 8.30pm and 9.00pm - or entered the apartment immediately after he had seen first Dr Matthew Oldfield and then Gerry McCann enter and leave the apartment at around 9.05pm to 9.15pm;

[NOTE: if the former of these two alternatives, then the abductor must have been in the apartment with Dr Gerry McCann during the five to ten minutes or so he was checking on the children - as Dr McCann indeed claimed last year]

* Second - walked through the open patio door without being seen;

* Third - found Madeleine in the dark;

* Fourth - picked her up, without waking her or the twins, and without leaving any forensic trace on the bed;

* Fifth - opened the window - without leaving any fingerprints;

* Sixth - opened the shutters from the inside (with nobody hearing him doing so, and once again without leaving any fingerprints);

* Seventh - climbed through the window, somehow carrying Madeleine with him - again without being seen by anyone, and again without leaving any fingerprints;

* Eighth - he would then have had to close the very noisy shutters, using controls operated from the inside - while still having Madeleine in his arms, or having laid her down on the patio, and

* Ninth - he made his escape without being seen by anyone except for afew fleeting seconds by Jane Tanner at around 9.15pm.

The operation of climbing through the window would have been physically very difficult, if not impossible, to do without (a) even brushing away even a tiny piece of the years-old lichen growing on the window-sill or (b) leaving any clothing fibres or other forensic evidence.

He must in addition have accomplished this whole operation in near total darkness and without being seen or heard by anyone except Jane Tanner. At the very moment that Jane Tanner says she saw the alleged abductor, Dr Gerald McCann was chatting away to holiday friend Jeremy (‘Jez’) Wilkins. Neither man saw or heard the alleged abductor despite being so close.

If the abductor had Madeleine in his arms as he climbed out of the window, and bearing in mind he was in near darkness, he would have been unable to see anything below her or much to either side as he fumbled through the window and shutters and tried to escape from the apartment precincts. Why he would do this when there was an open patio door to walk back through is incomprehensible. The McCanns only came up with the scenario of the abductor entering the unlocked patio door and then escaping via the window after learning that there was no evidence that the shutters had been tampered with, as they had told their relatives the night Madeleine disappeared.

Finally let us look for a moment at another aspect of the McCanns’ scenario. They have claimed on many occasions that an abductor must have been ‘casing the joint’ for several days beforehand - and then pounced and abducted Madeleine when he had the chance. The McCanns claim that he would have been closely watching them, including observing what the McCanns claim as their routine of half-hourly checking.

The McCanns have gone further and have suggested - in a lengthy TV interview for the BBC’s Panorama programme - that the abductor must have been making notes on their movements, allegedly carefully observing the times of their departures from the apartment. But this does not seem plausible given that neither the McCanns, nor their ‘Tapas 9’ friends, have given any details of how often (if at all) they were checking on their children whilst out wining and dining – apart from on the night Madeleine was reported missing.

Another problem about the McCanns’ abduction scenario is that there is nowhere that the abductor could have been observing the McCanns’ apartment without being seen - unless, that is, he was living or operating from one of the flats opposite the McCanns’ apartment, some of which overlooked it. It is understood that the occupants of these flats have all been investigated and their statements corroborated. None of them had anyone in their flat who was watching the McCanns’ apartment, nor was anyone seen acting suspiciously or hanging around in that area during the week the McCanns and their friends were there, except for one man who has been identified and eliminated from police enquiries.

The other obvious problem about the claim of an abductor ‘casing the joint’ is this:- Suppose an abductor had been watching the McCanns’ apartment day in and day out. On the McCanns’ own timeline, he would have seen the McCanns leave for the Tapas bar at 8.30pm. If, therefore, as claimed, an abductor had been watching the premises, he would presumably have chosen a moment as soon as possible after 8.30pm to abduct Madeleine - i.e., immediately after Drs Gerry and Kate McCann had left for the Tapas bar (on their own account) at around 8.30pm.

Yet, if he had entered the flat just after the McCanns left at 8.30pm, how come he was not long gone 35-40 minutes later when Dr Gerald McCann did his check? After all, Dr McCann now believes that the abductor may have even been present for the entire five to ten minutes or so that he was doing his check i.e. between 9.05pm and 9.10pm/9.15pm.

Yet a further difficulty for this improbable scenario is that Dr Matthew Oldfield claims that he did two checks - one at around 9.00pm, (various times have been given for this alleged check) and the other around 9.30pm. Dr Oldfield claims that during his 9.00pm visit he ‘checked’ from the outside but saw and heard nothing. He also said that the shutters were ‘tight shut’. If indeed the abductor really had entered before both Dr Matthew Oldfield’s alleged check (around 9.00pm) and Dr McCann’s check (around 9.05pm), then he was exceptionally lucky, to put it mildly, not to have been detected by either man.

There are equal if not even greater problems with the suggestion that the abductor entered the apartment and removed Madeleine only after Drs Oldfield and McCann had done their checks. Would any abductor really have dashed into the apartment after first seeing Dr Oldfield checking the outside of the apartment at around 9.00pm - and then seen Gerry spending five to ten minutes checking between 9.05pm and 9.15pm? It would surely have been far too risky.

And if he entered the apartment after Dr Gerry McCann left at say 9.10pm at the earliest, he would scarcely have had time to enter the flat, remove Madeleine, open the window and shutters, close them behind him etc. and then be seen by Jane Tanner at 9.15pm.

Sadly, no British newspaper or magazine has offered an analysis, like the one above, of the unlikelihood of the abduction having occurred in the way the McCanns and their ‘Tapas 9’ friends claim it ‘must have’ happened.

I conclude by saying that I am not saying the abduction of Madeleine never happened. But I confess I do find it very difficult to understand, given all that has been said about it, how it could have happened."