LEBRON James took a social media hiatus throughout the NBA playoffs. Now that he’s king again, he unloaded perfectly.

AI projects are underway to help ease the challenges of dementia.

Indian and multinational pharma companies are leading the charge by investing in digital transformation and aligning Indian operations with global standards. Essentially, pharmaceutical water systems are

The National Accreditation Board for Testing and Calibration Laboratories (NABL), under the Quality Council of India (QCI), has announced a collaborative effort with Man─Made Textile Research Association (MANTRA) in Surat to deliver a specialized technical training programme on medical textiles testing.

Robert Musselle, customer engineering manager EMEA at Protolabs shares what you need to consider with 3D printing and plastics prototyping.

WITTMANN BATTENFELD will present the latest solutions for time and cost optimisation in the production of parts with nano structures at Compamed, booth No. F03-1 in hall 8b.

PolyNovo UK – a UK medical devices company specialising in the development of surgical solutions using the patented polymer technology NovoSorb will be exhibiting at MEDICA 2024.

Schultz Medical, a single use instrument company based in Southport, Merseyside have announced they will be exhibiting at MEDICA 2024 in Germany and on the UK Pavilion in Hall 15 hosted by Medilink UK.

Mike Hodgin, director of strategic applications, Meridian Electronics Division discusses enabling and protecting vital medical implants with epoxies.

Bormioli Pharma has announced a partnership with Chiesi, an international, research-focused biopharmaceutical company (Chiesi Group), to supply Carbon Capture PET bottles.

Humans and pigs could both serve as mixing vessels for a bird flu–seasonal flu hybrid, posing a risk of wider spread

A team at Columbia University School of Engineering and Applied Science has developed a technique to enhance chimeric antigen receptor (CAR) T cell therapy in solid tumors. The technique involves engineering E. coli bacteria, that naturally tend to accumulate in the immune privileged core of solid tumors. The bacteria have been engineered to interact with […]

Researchers at North Carolina State University have developed a robotic prosthetic ankle that can provide stability for lower limb amputees. The ankle uses electromyographic sensors placed on the sites of muscles in the residual limb that then convey the intentions of the wearer with regard to movement. So far, the system has been shown to […]

Charco Neurotech, a medtech company based in the United Kingdom, has developed CUE1, a non-invasive wearable that is intended to assist those with Parkinson’s disease to manage their motor symptoms. The device is typically affixed to the sternum, and provides vibratory action in a focused region of the body. The technology is based on the […]

A research team at the University of California San Diego have developed a smartphone attachment that can provide information on changes in pupil size, which can be used to assess neurological phenomena, such as traumatic brain injury and Alzheimer’s disease. Such changes in pupil size have been difficult to characterize in the past in those […]

This week, I’m rerunning some popular posts while we put the finishing touches on DCI’s new 2024-25 Economic Report on Pharmaceutical Wholesalers and Specialty Distributors.

Last week, the Federal Trade Commission (FTC) released the redacted version of administrative complaint against the three largest pharmacy benefit managers (PBMs). The FTC rightly calls out how the gross-to-net bubble can raise patients’ out-of-pocket costs, while also acknowledging how rebates can reduce a plan's (but not the patient’s) costs. Apparently, the FTC believes that PBMs’ customers are pretty dumb, because PBMs are able to prevent plans from “appreciating” such healthcare financing dynamics.

Section V.E. of the complaint (starting on page 23) focuses on the PBMs’ alleged unlawful conduct related to preferring high-list/high-rebate insulin products over versions with lower list prices. I thought it would therefore be fun to take the Wayback Machine to November 2021, when I wrote about this specific topic.

Below, you can review my commentary about the warped incentives behind Viatris’ dual-pricing strategy for its interchangeable biosimilar of Lantus. Much of the FTC’s description of the drug channel aligns with my commentary. But before you fist pump too hard for Ms. Khan’s FTC, you should pause to reflect on the agency’s legal theories in light of plans’ revealed preferences.

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The Food & Drug Administration (FDA) recently approved the first interchangeable biosimilar insulin product: the insulin glargine-yfgn injection from Viatris. Read the FDA’s press release.

Alas, I’m sad to report that the warped incentives baked into the U.S. drug channel will limit the impact of this impressive breakthrough.

Viatris is being forced to launch both a high-priced and a low-priced version of the biosimilar. However, only the high-list/high-rebate, branded version will be available on Express Scripts’ largest commercial formulary. Express Scripts will block both the branded reference product and the lower-priced, unbranded—but also interchangeable—version. Meanwhile, Prime Therapeutics will place both versions on its formularies, leaving the choice up to its plan sponsor clients.

Consequently, many commercial payers will adopt the more expensive product instead of the identical—but cheaper—version. As usual, patients will be the ultimate victims of our current drug pricing system.

Below, I explain the weird economics behind this decision, highlight the negative impact on patients, and speculate on what this all could mean for biosimilars’ future. Until plan sponsors break their addiction to rebates, today’s U.S. drug channel problems will remain.
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A new survey of plan sponsors sheds light on their satisfaction with transparency at large and small pharmacy benefit managers (PBMs).

As you will see, clients remain slightly more satisfied with the perceived transparency of smaller PBMs compared with the Big Three PBMs—CVS Caremark, Express Scripts, and Optum Rx.

However, plan sponsors are dissatisfied with transparency about how both large and small PBMs make money. Smaller PBMs have an edge, but it’s narrower than you might think.

Perhaps PBMs’ clients are unable or unwilling to negotiate better deals, write more effective contracts, and switch to more satisfying relationships. Or maybe they don’t mind the current system, despite the challenges for patients. Some argue that transparency could swoop down to solve this problem. Riddle me this: Should we watch what plan sponsors say, or what they do?

Read on to see what you think of my arguments below. Then, click here to share your thoughts with the Drug Channels community.
Read more »

Starting COVID-19 patients on prophylactic anticoagulation within 24 hours of being admitted to hospital has been linked to a reduced risk of mortality.

Consultations on the reclassification of two progestogen-only contraceptive pills from prescription-only to pharmacy medicines have been launched.

A new type of drug that targets chemotherapy directly to cancer cells reduces the risk of death from the most common type of bladder cancer by 30%, a phase III trial in the New England Journal of Medicine has suggested.

Pharmacy negotiators have discussed proposals to take “a patient registration-based approach” to the community pharmacy contractual framework.

By Jonathan Montagu, CEO of HotSpot Therapeutics, as part of the From The Trenches feature of LifeSciVC HotSpot’s trip to Barcelona for the recent European Society of Medical Oncology (ESMO) Annual Meeting was no ‘European Vacation,’ but it was certainly

The post ESMO Reflections: Glimmers of Hope with the Next Wave of I-O Therapies? appeared first on LifeSciVC.

The decade following passage of FDAAA has been one of easing standards for drug approvals in the US, most notably with the advent of “breakthrough” designation created by FDASIA in 2012 and the 21st Century Cures Act in 2016.

Although, as of this writing, there is no nominee for FDA Commissioner, it appears to be safe to say that the current administration intends to accelerate the pace of deregulation, mostly through further lowering of approval requirements. In fact, some of the leading contenders for the position are on record as supporting a return to pre-Kefauver-Harris days, when drug efficacy was not even considered for approval.

Build a better mouse model, and pharma will beat a path to your door - no laws needed.

In this context, it is at least refreshing to read a proposal to increase efficacy standards. This comes from two bioethicists at McGill University, who make the somewhat-startling case for a higher degree of efficacy evaluation before a drug begins any testing in humans.

We contend that a lack of emphasis on evidence for the efficacy of drug candidates is all too common in decisions about whether an experimental medicine can be tested in humans. We call for infrastructure, resources and better methods to rigorously evaluate the clinical promise of new interventions before testing them on humans for the first time.

The author propose some sort of centralized clearinghouse to evaluate efficacy more rigorously. It is unclear what they envision this new multispecialty review body’s standards for green-lighting a drug to enter human testing. Instead they propose three questions:

• What is the likelihood that the drug will prove clinically useful?
• Assume the drug works in humans. What is the likelihood of observing the preclinical results?
• Assume the drug does not work in humans. What is the likelihood of observing the preclinical results?

These seem like reasonable questions, I suppose – and are likely questions that are already being asked of preclinical data. They certainly do not rise to the level of providing a clear standard for regulatory approval, though perhaps it’s a reasonable place to start.

The most obvious counterargument here is one that the authors curiously don’t pick up on at all: if we had the ability to accurately (or even semiaccurately) predict efficacy preclinically, pharma sponsors would already be doing it. The comment notes: “More-thorough assessments of clinical potential before trials begin could lower failure rates and drug-development costs.” And it’s hard not to agree: every pharmaceutical company would love to have even an incrementally-better sense of whether their early pipeline drugs will be shown to work as hoped.

The authors note

Commercial interests cannot be trusted to ensure that human trials are launched only when the case for clinical potential is robust. We believe that many FIH studies are launched on the basis of flimsy, underscrutinized evidence.

However, they do not produce any evidence that industry is in any way deliberately underperforming their preclinical work, merely that preclinical efficacy is often difficult to reproduce and is poorly correlated with drug performance in humans.

Pharmaceutical companies have many times more candidate compounds than they can possibly afford to put into clinical trials. Figuring out how to lower failure rates – or at least the total cost of failure - is a prominent industry obsession, and efficacy remains the largest source of late-stage trial failure. This quest to “fail faster” has resulted in larger and more expensive phase 2 trials, and even to increased efficacy testing in some phase 1 trials. And we do this not because of regulatory pressure, but because of hopes that these efforts will save overall costs. So it seems beyond probable that companies would immediately invest more in preclinical efficacy testing, if such testing could be shown to have any real predictive power. But generally speaking, it does not.

As a general rule, we don’t need regulations that are firmly aligned with market incentives, we need regulations if and when we think those incentives might run counter to the general good. In this case, there are already incredibly strong market incentives to improve preclinical assessments. Where companies have attempted to do something with limited success, it would seem quixotic to think that regulatory fiat will accomplish more.

(One further point. The authors try to link the need for preclinical efficacy testing to the 2016 Bial tragedy. This seems incredibly tenuous: the authors speculate that perhaps trial participants would not have been harmed and killed if Bial had been required to produce more evidence of BIA102474’s clinical efficacy before embarking on their phase 1 trials. But that would have been entirely coincidental in this case: if the drug had in fact more evidence of therapeutic promise, the tragedy still would have happened, because it had nothing at all to do with the drug’s efficacy.

This is to some extent a minor nitpick, since the argument in favor of earlier efficacy testing does not depend on a link to Bial. However, I bring it up because a) the authors dedicate the first four paragraphs of their comment to the link, and b) there appears to be a minor trend of using the death and injuries of that trial to justify an array of otherwise-unrelated initiatives. This seems like a trend we should discourage.)

[Update 2/23: I posted this last night, not realizing that only a few hours earlier, John LaMattina had published on this same article. His take is similar to mine, in that he is suspicious of the idea that pharmaceutical companies would knowingly push ineffective drugs up their pipeline.]

Kimmelman, J., & Federico, C. (2017). Consider drug efficacy before first-in-human trials Nature, 542 (7639), 25-27 DOI: 10.1038/542025a

The National Institutes of Health, the crown jewel of biomedical research in the U.S., could face big changes under the new Trump administration, some fueled by pandemic-era criticisms of the agency.

Neurosurgeon Vitor Mendes Pereira has grown accustomed to treating brain aneurysms with only blurry images for guidance.

Equipped with a rough picture of the labyrinthine network of arteries in the brain, he does his best to insert mesh stents or coils of platinum wire—interventions intended to promote clotting and to seal off a bulging blood vessel.

The results are not always perfect. Without a precise window into the arterial architecture at the aneurysm site, Pereira says that he and other neurovascular specialists occasionally misplace these implants, leaving patients at a heightened risk of stroke, clotting, inflammation, and life-threatening ruptures. But a new fiber-optic imaging probe offers hope for improved outcomes.

Pereira et al./Science Translational Medicine

According to Pereira’s early clinical experience, the technology—a tiny snake-like device that winds its way through the intricate maze of brain arteries and, using spirals of light, captures high-resolution images from the inside-out—provides an unprecedented level of structural detail that enhances the ability of clinicians to troubleshoot implant placement and better manage disease complications.

“We can see a lot more information that was not accessible before,” says Pereira, director of endovascular research and innovation at St. Michael’s Hospital in Toronto. “This is, for us, an incredible step forward.”

And not just for brain aneurysms. In a report published today in Science Translational Medicine, Pereira and his colleagues describe their first-in-human experience using the platform to guide treatment for 32 people with strokes, artery hardening, and various other conditions arising from aberrant blood vessels in the brain.

Whereas before, with technologies such as CT scans, MRIs, ultrasounds, and x-rays, clinicians had a satellite-like view of the brain’s vascular network, now they have a Google Street View-like perspective, complete with in-depth views of artery walls, plaques, immune cell aggregates, implanted device positions, and more.

“The amount of detail you could get you would never ever see with any other imaging modality,” says Adnan Siddiqui, a neurosurgeon at the University at Buffalo, who was not involved in the research. “This technology holds promise to be able to really transform the way we evaluate success or failure of our procedures, as well as to diagnose complications before they occur.”

A Decade of Innovation

The new fiber-optic probe is flexible enough to snake through the body’s arteries and provide previously unavailable information to surgeons.Pereira et al./Science Translational Medicine

The new imaging platform is the brainchild of Giovanni Ughi, a biomedical engineer at the University of Massachusetts’ Chan Medical School in Worcester. About a decade ago, he set out to adapt a technique called optical coherence tomography (OCT) for imaging inside the brain’s arteries.

OCT relies on the backscattering of near-infrared light to create cross-sectional images with micrometer-scale spatial resolution. Although OCT had long been used in clinical settings to generate pictures from the back of the eye and from inside the arteries that supply blood to the heart, the technology had proven difficult to adapt for brain applications owing to several technical challenges.

One major challenge is that the fiber-optic probes used in the technology are typically quite stiff, making them too rigid to twist and bend through the convoluted passageways of the brain’s vasculature. Additionally, the torque cables—traditionally used to rotate the OCT lens to image surrounding vessels and devices in three dimensions as the probe retracts—were too large to fit inside the catheters that are telescopically advanced into the brain’s arteries to address blockages or other vascular issues.

“We had to invent a new technology,” Ughi explains. “Our probe had to be very, very flexible, but also very, very small to be compatible with the clinical workflow.”

To achieve these design criteria, Ughi and his colleagues altered the properties of the glass at the heart of their fiber-optic cables, devised a new system of rotational control that does away with torque cables, miniaturized the imaging lens, and made a number of other engineering innovations.

The end result: a slender probe, about the size of a fine wire, that spins 250 times per second, snapping images as it glides back through the blood vessel. Researchers flush out blood cells with a tablespoon of liquid, then manually or automatically retract the probe, revealing a section of the artery about the length of a lip balm tube.

St. Michael’s Foundation

Clinical Confirmation

After initial testing in rabbits, dogs, pigs, and human cadavers, Ughi’s team sent the device to two clinical groups: Pereira’s in Toronto and Pedro Lylyk’s at the Sagrada Familia Clinic in Buenos Aires, Argentina. Across the two groups, neurosurgeons treated the 32 participants in the latest study, snaking the imaging probe through the patients’ groins or wrists and into their brains.

The procedure was safe and well-tolerated across different anatomies, underlying disease conditions, and the complexity of prior interventions. Moreover, the information provided frequently led to actionable insights—in one case, prompting clinicians to prescribe anti-platelet drugs when hidden clots were discovered; in another, aiding in the proper placement of stents that were not flush against the arterial wall.

“We were successful in every single case,” Ughi says. “So, this was a huge confirmation that the technology is ready to move forward.”

“We can see a lot more information that was not accessible before.” —Vitor Mendes Pereira, St. Michael’s Hospital

A startup called Spryte Medical aims to do just that. According to founder and CEO David Kolstad, the company is in discussions with regulatory authorities in Europe, Japan, and the United States to determine the steps necessary to bring the imaging probe to market.

At the same time, Spryte—with Ughi as senior director of advanced development and software engineering—is working on machine learning software to automate the image analysis process, thus simplifying diagnostics and treatment planning for clinicians.

Bolstered by the latest data, cerebrovascular specialists like Siddiqui now say they are chomping at the bit to get their hands on the imaging probe once it clears regulatory approval.

“I’m really impressed,” Siddiqui says. “This is a tool that many of us who do these procedures wish they had.”

Mental health experts are hopeful about the de-stigmatization of behavioral health, the promise of AI and other areas, they shared at a recent conference.

The post 4 Areas Within Mental Health Care that Give Executives Hope appeared first on MedCity News.

Two executives at behavioral health care companies discussed why it’s important for provider organizations to partner with the 988 Suicide & Crisis Lifeline during a panel at the Behavioral Health Tech conference.

The post There’s an Opportunity for More Providers to Partner with the 988 Lifeline, Execs Say appeared first on MedCity News.

Access to care isn’t enough. Healthcare organizations need to build trust in order to reach underserved communities, experts said on a recent panel.

The post How Can Healthcare Organizations Earn Trust with Marginalized Communities? appeared first on MedCity News.

Here’s how four different health systems are partnering with Microsoft to save time for clinicians.

The post How 4 Health Systems Are Partnering with Microsoft appeared first on MedCity News.

Between 1999 and 2014, opioid use disorder (OUD) among pregnant women more than quadrupled, risking the health of the women—before and after giving birth—and their infants. As states grapple with COVID-19’s exacerbation of the opioid crisis, several are taking innovative steps to address the needs of high-risk groups, including low-income, postpartum patients with OUD.

This paper provides recommendations for circumventing memory problems and reducing execution times for your mixed-modeling analyses, as well as showing the new HPMIXED procedure can be beneficial for certain situations, as with large sparse mixed models.

Singapore's food culture is legendary, with staples such as chicken rice, bak chor mee, laksa, and roti prata feeding generations of locals and visitors alike. But there's one thing they all have in common — carbs! In carb-crazy Singapore, sticking to a keto diet might seem like a gone case and borderline sacrilegious, but trust me, it's doable. I've been through it, and I'm here to share my tips on how you can enjoy our local food scene while staying keto. What is keto? In case you blur about what a ketogenic (keto) diet is, it's all about cutting carbs and eating more fat. Yup, you read that right — more fat. Sounds shiok, right? The goal is to push your body into ketosis, where instead of burning carbs for energy, it burns fat. Hello, weight loss! Beyond that, keto helps you avoid those pesky post-meal sugar crashes — you know, the ones that make want to toh after a heavy meal. My keto experience I first tried keto as a teen, thinking it was just about cutting out rice, bread, and noodles. Wrong! Keto is stricter than that. To stay in ketosis, you've got to limit your carbs to just 20-50g a day.

Megan Fox is pregnant. The 38-year-old actress — who has Noah, 12, Bodhi, ten, and Journey, eight, with her ex-husband Brian Austin Green — has confirmed via social media that she's expecting her first child with Machine Gun Kelly.

TORONTO — A teenager is in critical condition in a British Columbia children's hospital, sick with Canada's first presumptive human case of avian influenza. "This was a healthy teenager prior to this, so no underlying conditions," said provincial health officer Bonnie Henry in a news conference on Tuesday (Nov 12). "It just reminds us that in young people this is a virus that can progress and cause quite severe illness and the deterioration that I mentioned was quite rapid." British Columbia health officials said on Saturday the province had detected Canada's first human case of H5 bird flu in a teenager.

LONDON - Kate, UK's Princess of Wales, will make her most prominent return to royal engagements since having treatment for cancer next month when she hosts an annual Christmas carol service at London's Westminster Abbey. Kate, the wife of heir to the throne Prince William, has only made a handful of public appearances after having major abdominal surgery in January, and then undergoing a course of preventative chemotherapy when subsequent tests revealed the presence of cancer. Last weekend, she attended two high-profile Remembrance events to commemorate those who lost their lives in conflict as part of her gradual return to official duties, but the carol service — ​​​​​the fourth she has organised, will be the first major royal event she has hosted herself. "This year's service provides a moment to reflect upon the importance of love and empathy, and how much we need each other, especially in the most difficult times of our lives," her office, Kensington Palace, said in a statement.

SEOUL - South Korea's military said it will hold a three-day joint exercise with the United States and Japan starting on Wednesday (Nov 13), featuring fighter jets and marine patrol aircraft as well as the US nuclear-powered aircraft carrier USS George Washington. The Freedom Edge exercise is a response to what the South Korean military said were threats from North Korea, which recently conducted an intercontinental ballistic missile test, drawing condemnation from Seoul, Tokyo and Washington. It also comes as the US State Department said North Korean troops have started engaging in combat operations in Russia's war with Ukraine. The exercise will include South Korean and Japanese fighter jets and maritime patrol aircraft, as well as the USS George Washington, Seoul's Joint Chiefs of Staff (JCS) said in a statement. The trilateral exercise follows a first round held earlier this year after the leaders of the three countries agreed at a summit in 2023 to hold annual training drills. Pyongyang has long condemned joint drills between South Korea and the United States, calling them a rehearsal for invasion.

A grand prize of $10 million is up for grabs at the upcoming Toto draw on Thursday (Nov 14) at 9.30pm. The Group 1 prize money has snowballed over the past three draws after no Group 1 winners were picked. According to Singapore Pools' website, the prize started at $1.2 million on Nov 4 before snowballing to $2.9 million on Nov 7 and $6 million on Nov 11. The last draw on Monday yielded three Group 2 winners who won $215,010 each. Tomorrow's draw will be a cascade draw, meaning that the prize money will be split between the Group 2 winners in the event that no Group 1 winner is chosen. If there are no Group 2 winners, the prize will be split among the Group 3 winners, and so on. The last time a Group 1 prize snowballed above $10 million was during the October 21 draw where two lucky winners bagged over $6.6 million each.

JAKARTA — Indonesia said on Monday (Nov 11) it does not recognise China's claims over the South China Sea despite signing a joint maritime development deal with Beijing, as some analysts warned the agreement risked compromising the country's sovereign rights. Beijing has long clashed with its Southeast Asian neighbours over territory in the South China Sea, which it claims sovereignty over in almost its entirety via a "nine-dash line" on its maps that cuts into the exclusive economic zones (EEZ) of several countries. Joint agreements with China in the strategic waterway have for years been sensitive, with some claimant states wary of entering into deals they fear could be interpreted as legitimising Beijing's vast claims. An arbitral tribunal in 2016 said the Chinese claim, based on its old maps, has no basis under international law, a decision China refuses to recognise. A joint statement issued at the weekend during Indonesian President Prabowo Subianto's visit to Beijing mentioned the two countries had "reached important common understanding on joint development in areas of overlapping claims".

ISLAMABAD — The International Monetary Fund's Pakistan mission chief Nathan Porter on Tuesday (Nov 12) opened unusual talks with Pakistan over a US$7 billion (S$9.4 billion) bailout approved by its board in September, the finance ministry and sources said. The unscheduled visit of the IMF mission and talks beginning with meeting the country's finance team are too early for first review of the IMF's Extended Fund Facility (EFF), which is due in the first quarter of 2025. The chiefs of Pakistan's central bank and federal board of revenue also attended the meeting besides other officials from both the sides, the statement said. The ministry and the IMF have not officially released details of the visit. Sources in the finance ministry said the Nov 11-15 visit will discuss recent developments and programme performance to date, adding the mission was not part of the first review. The sources declined to be identified as they were not authorised to speak with the media. Pakistan has been struggling with boom-and-bust economic cycles for decades, leading to 23 IMF bailouts since 1958.

Aug 1, 2023

Using the private journals of commission secretaries Henry Marie Brackenridge and Dr. William Baldwin, as well as Captain Sinclair, this chapter will explore the establishment of American naval identity through its diplomatic experiences in South America. It will also exhibit the role of the U.S. Navy in a proto framework of the Monroe Doctrine.

Pakistan's National Security Adviser to the Prime Minister, Mahmud Ali Durrani, on the 2008 bombing of the Indian Embassy in Kabul

During a March 28 meeting with Assistant Secretary or South and Central Asian Affairs Boucher, Foreign Minister-designate Shah Mehmood Qureshi confirmed that the new government wanted to work with the U.S. to combat extremism, increase trade and extend cooperation with India and Afghanistan.

In a wide-ranging meeting with CODEL McCaskill February 17, National Security Advisor Shivshankar Menon touched on several regional security and trade-related issues.

Zardari made repeated pleas for drones to be "put in Pakistan's hands" so that Pakistan would own the issue and drone attacks (including collateral damage) would not provoke anti-americanism.

President Musharraf also asked the U.S. to put more pressure on India to negotiate over Kashmir, concluding that the time is ripe for resolution of the issue.

Menon emphasized that India had been tough on Pakistan with regard to accountability, but restrained in its rhetoric and actions.

Benazir Bhutto claimed that the Sindh Government had informed her that if she goes to Larkhana (her ancestral home), she would be attacked.

Even with support from the government, serious threats against Bhutto will persist.