Tuesday, November 20, 2012

Nov 2011-c

Tuesday, November 29, 2011

Technical Details

Take a number of 250mm shots:

 © Am Ang Zhang 2011

Merge them into a single picture:

 © Am Ang Zhang 2011

Convert into Black & White & adjust exposure curve:

 © Am Ang Zhang 2011

Use Duotone in Photoshop to get to the tone you like!!!

Monday, November 28, 2011

Psychiatry: A Cure?

Is there one?

Perhaps, just perhaps!

We are talking about the discipline of psychiatry!!!

Well, perhaps if we abandon the American DSM diagnosis, get back to more traditional European ones and concentrate on core psychiatric conditions as there certainly will not be enough psychiatrists to deal with the ever expanding diagnostic categories, and of course pay a premium for the few that would still do the job. That would mean dealing with severe psychotics that very few of the 'modern' 'TEAM MEMBERS' will want to handle.

And yes, bring back the asylums just like the ones they still have in France  (which is still reckoned to have the best health care in the world). That means abandoning community psychiatry before too many get killed at random or suicides that might be preventable. The only sure thing would be that funding for mental illness (not health) gets diverted to the legal profession.

It is a very sad state of affair.

Nearly a year ago, on the 200th birthday of psychiatry, the British Journal of Psychiatry published a letter signed by 36 psychiatrists, lamenting the downgrading of medical aspects of care in a “wake-up call” to British psychiatry:

“The recent drive within the UK National Health Service to improve psychosocial care for people with mental illness is both understandable and welcome: evidence-based psychological and social interventions are extremely important in managing psychiatric illness. Nevertheless, the accompanying downgrading of medical aspects of care has resulted in services that often are better suited to offering non-specific psychosocial support, rather than thorough, broad-based diagnostic assessment leading to specific treatments to optimise well-being and functioning. In part, these changes have been politically driven, but they could not have occurred without the collusion, or at least the acquiescence, of psychiatrists. This creeping devaluation of medicine disadvantages patients and is very damaging to both the standing and the understanding of psychiatry in the minds of the public, fellow professionals and the medical students who will be responsible for the specialty’s future. On the 200th birthday of psychiatry, it is fitting to reconsider the specialty’s core values and renew efforts to use psychiatric skills for the maximum benefit of patients.”                       ………More

The Times (June 27, 2008) picked up the story in:
Mentally ill are 'jollied along' rather than treated by psychiatrists
“Treatment is often little more than jollying people along,” said Professor Nick Craddock, of the Medical School at Cardiff University, one of 36 signatories of a letter published today in the British Journal of Psychiatry. 

“If a GP suspected a patient had cancer, he wouldn't dream of referring him to anybody other than a cancer specialist. A cancer patient might need jollying along, but what he really needs is the correct diagnosis and treatment. That's what he gets from a specialist. But patients with mental illness are not automatically referred to psychiatrists. If they only see a social worker, there's every chance that mental illness, or underlying physical illness, will be missed. Patients are getting a bum deal.”

The desire not to stigmatise people has also done damage by implying that there is no such thing as mental illness. Patients are now known as “service users” rather than patients — even though, when asked, 67 per cent preferred the word patient and only 9 per cent service user. Treatments are provided at “mental health” centres, not mental illness clinics.

“For those with severe mental illness, to avoid medicalisation is at best confusing and at worst damaging or even life-threatening ... these individuals are being let down by the current state of affairs.”

Against this backdrop, it is not surprising that the UK Psychiatry recruitment crisis has come to a head.

Channel 4 Headline: 
Psychiatry's UK recruitment crisis

“Britain's mental health services are facing a 'catastrophic' shortage of psychiatrists as the NHS increasingly has to rely on overseas doctors to fill posts. 

"Mental health bosses say in some cases doctors are being appointed to posts despite reservations about their suitability, as fewer and fewer UK-trained medics apply for psychiatric posts and overall competition for places falls.

"The Royal College of Psychiatrists (RCP) says cultural awareness is essential to being a good psychiatrist, and warns of an over-reliance on overseas doctors to fill mental health jobs. “
In fact, this recruitment problem was already reported by The Times Higher Education a few days ago (26 May 2009):Concern over shrinking numbers of UK recruits to psychiatry
“’The single most important threat facing psychiatry and the care of people with mental illness in this country is the inability to attract our own medical graduates into psychiatry,’ said Rob Howard, dean of the Royal College of Psychiatrists. 

“Academically it’s a complete disaster because the very best people won’t think of coming into psychiatry, and scholarship won’t move on in this country.

“The proportion of UK nationals among the graduates sitting the college’s membership examinations has fallen from an average of between 15 and 20 % over the past decade to just 6 % last year.

“The changes came about under a scheme, New Ways of Working (NWW), established in 2005. GPs now refer patients with symptoms of mental illness to a team of up to eight people, which will include psychologists, nurses, social workers and a psychiatrist. “

This government (or the next one) must look at NWW again as the statistics speak louder than anything else. Why should junior doctors want to go into a profession where they see “service users” not “patients”, and where the consultant’s role is so much marginalised? It must also be noted that if psychiatrists are allowed to see only the severely disturbed, the emotional burden is extremely high. In time one will lose contact with the range of disturbances that one used to see in a more average psychiatric clinic so essential for the proper understanding of human nature. Also we need to learn how to tell the fakes from the real. No junior would want to be an expert on severe psychosis alone.

“Concern about the fall in applications is so great that the college has called on high-profile figures, including Stephen Fry, the actor and author who has spoken of his history of depression, to urge medical students to specialise in psychiatry.”

A sad day for psychiatry and a sadder one for psychiatric patients.
(Sorry, psychiatric patients do not exist anymore.)

NHS Reform: The Plot Against Consultants!

Unless we act fast, we stand to lose the hospital consultants to the private sector and the hospitals too will go that way. Consultants had been side lined for too long!

In the case of the consultants, a show was made of trying to make them accept much closer supervision by hospital managers, and cut back on their private work. But it soon came to seem that the real aim of doing this was to make them feel more disenchanted with working as salaried NHS employees and readier to go into business – to form doctors chambers, on the model of barristers, or other kinds of business, and sell their services to any employer, public or private, that offered them the best terms. A significant number began to plan to do so and some have begun to. And as the cuts begin to bite there will be unemployment among hospital doctors. As you will have read, consultants are among those scheduled to be laid off by St George’s hospital in Tooting, and elsewhere. Working for private providers will become normal again in a way it hasn’t been since 1948.    The Plot Against the NHS

So do you really think that hospitals are not necessary, or not necessary for the average citizen of England. Soon they will be sold and it will be costly to buy them back.

What about medical training? If these hospitals are sold, who pays?

And watch out, someone, your parent, your spouse, your child and even your MP may need a Hospital Consultant one day. 

It is of course likely that after plotters plotted for nearly 20 years to have the money making part of the NHS privatised, they are unlikely to give up quietly.

Democracy is a peculiar business and there is truth that some of us know who the enemies of the people really were.

Some politician may regret too late for not taking the opportunity and grasp the three hairs on the god of opportunity. The Cockroach Catcher did spell it out not many weeks ago.

That many of the plotters in the Labour camp are now unashamedly working for private health care insurer or provider in one form or another that they did not get the votes from the PEOPLE.

There is much co-operation and collaboration in nature:

 © Am Ang Zhang 2010

One fellow blogger ( Dr No) wrote asking how the NHS could be modeled on Mayo. That got me thinking.

It is of course always easier to criticise and my goodness we bloggers have and for good reasons. We loved the principles of our NHS.

My fellow blogger was right, sooner or later we have to come up with an alternative model.

I will quote from my letter back to him:

My view after studying Mayo and also Kaiser Permanente is that these two organisations avoided some of the major pitfalls that have gradually eroded a once great health care provider in the world: The NHS.

Those amongst readers that were trained in this country may not realise that we from Hong Kong would come over to theUK for specialist training. It was for a long time the only way to become a consultant or senior lecturer/professor in Hong Kong. This was despite the weather, yes the weather!!! We indeed were very well trained. Even when we started to have our local specialist training in our teaching hospitals many would still prefer to come over here. Training here gives them an edge so to speak. The US is the other obvious destination but often the ones that went over there stayed there. I stayed in England for the rich culture this country have: opera, concerts, theatres and museum. Major hospitals here are world famous and they were truly the crown jewels. Foundation Trust approach is seen by many as selling off such treasures. 

There were principles of the Mayo Model that was the NHS model of old.

An Egalitarian Culture.
Similar to Mayo, in the NHS, consultant pay peaked after a few years and then there was only the Distinction Awards (or equivalent) to look forward to. If we ignore private income for now, all disciplines are paid the same and it allows for a fairly nice and attractive prospect for new doctors to enter whichever specialty. Currently some specialty such as psychiatry is struggling and chances are private providers will be the norm. I hate to think that it will be the repeat of OOH service with poorly qualified doctors providing inferior care. There may be regulators but what good are they after the event.

In health care, death is irreversible.

No doubt the pay at Mayo is much better but not to the level of others in California or New York. Interestingly in Mainemany doctors want to be salaried paid (more women doctors: children, holiday, insurance etc).
Internal Market:
The internal market has its advantages but the pitfalls are more than its worth. If reform is about better patient care then it is definitely the wrong way as it encourages distortion of good and efficient healthcare.

Mayo did well without it and we could as well. In fact we used to. Such a perverse system has caused a rift between primary and secondary care and is not helpful.

Many argued that it was there to pave the way for partial privatisation. I cannot honestly provide any counter argument. Why waste so much effort for so little return.

The only other possibility is that it is a covert form of rationing and soon not so covert but it would be done by your trusted family doctors, the GPs. It is the shifting of blame.

It has also been argued by those that promote privately controlled consortia that GPs stand to make lots of money. This could be directly from the total health budget or through some financial wizardry on the Stock Market. Remember Four Seasons, Qatar and RBS (our money) buy back?

The Royal Bank of Scotland, the biggest debt provider in a lending syndicate of more than 100, has agreed along with other senior lenders to cut the debts of the embattled Four Seasons by more than 50pc to £780m.

That is why many GPs in the consortia have links with private providers.

So primary care tried to save money and secondary care, for survival tried to extract as much as they could. Patients lose out in the process. It also encourages gross distortion of service at the hospital end and if allowed to continue leads to unholy “gaming” strategies.

On the other hand it is also very easy for some hospitals to fail and be gobbled up by privateers whose interest would be that of the money making specialties and not those that cannot be nicely packaged.

Patients come first:
A friend’s wife consulted me for a second opinion about her cardiac condition as her doctor husband has passed away a few years back. I am no cardiologist so I wrote to my cardiologist classmates (two in Hong Kong and one in the US) and within hours I had three very useful answers: all free. In our new NHS such consultations would have to be paid for. Sad really.

Mayo cross consult bottom to top and top to bottom as well. Who knows the bright young things might really be bright young things (quoted in one of my blogs).

Virtually all Mayo employees are salaried with no incentive payments, separating the number of patients seen or procedures performed from personal gain. That was how it was in our NHS hospitals. Payment for performance encourages gaming.

This sound perverse and is very much against the bonus culture. But remember such culture saw the collapse of the USfinancial system and ours and a few other EU countries including France.

The NHS of old was plagued by a covert two tier system that led to unjustified waiting lists and I do not have a quick answer except to say that paying a better salary is one and the other is a complete separation of private and public health. A limit of 10% if well monitored may work as well as close scrutiny of common waiting time.

My fellow blogger pointed out that we may need to keep that as a safety valve and I would agree.

Fully Integrated:
How else could we have a fully integrated system unless we do away with competition and the internal market and indeed private providers? The difficulty is that some of the private providers are already “in”. There is little doubt that in the long term we would be paying over the odds for what they provide and if not they will abandon what they do. Business is business.

Too Big: we cannot run the whole NHS as one Mayo Clinic.

I do not dispute that.

The solution is to regionalise the NHS. We did not have many Child & Adolescent Inpatient Units in the country and the two I used to run (one for children and one for adolescent) accepted referrals from three counties in the south of England.
Regionalisation is therefore the way forward and there is no doubt that given our small country it is better to have major centres of excellence run on the Mayo, Cleveland and even the Kaiser model.

Like Mayo Clinic, our NHS could have a seamless health care with no artificial obstacle on referral to hospital consultants or admission or to specialised treatment.

“The best interest of the patient is the only interest to be considered.” 
Mayo brothers.

The NHS had all the ingredients in place for a world class Health Care System.

Sunday, November 27, 2011

Chile to Nanking: Bipolar Disorder & Lithium

Santiago, Chile was the starting point of our recent cruise round Cape Horn. We had a wonderful guide who took us from Santiago city to the Valparaiso port, where we boarded our cruise liner. She was infectiously enthusiastic. She told us that apart from copper, agricultural products and wine, Chile produced something that was very important for her brother.  He suffers from Trastorno Afectivo Bipolar (Bipolar Disorder) and Chile is the world’s largest producer of lithium.

Wikimedia Commons SalarDeatacamaFromChaxa.jpg

May 09, 2008

Nanking Poster: THINKFilm
On July 2, 1996, the anniversary of Ernest Hemingway’s own suicide, Margaux Louise Hemingway, his grand daughter was found dead in her studio apartment in Santa Monica, California at age 41.

On November 9, 2004, Iris Chang (張純如), who was propelled into the limelight by her 1997 best-selling account of the Nanking Massacre “The Rape of Nanking: The Forgotten Holocaust of World War II”, committed suicide. Earlier she had a nervous breakdown and was said to be at the risk of developing Bipolar illness. She was on the mood stabilizer divalproex and Risperidone, an antipsychotic drug commonly used to control mania. There was a detailed report in San Francisco Chronicle.

My sentiments about the treatment of bipolar illness are expressed in The Cockroach Catcher:

“I am a traditionalist who believes that Lithium is still the drug of choice for Bipolar disorder. Tara’s mother was well for ten years. She was taking only Lithium and no other medication.”

The anti-suicidal effect of lithium has been confirmed by a number of recent studies in both the U.S. and in Europe.

According to the results of a population-based study published in the 2003 Sept. 17 issue of The Journal of the American Medical Association (JAMA. 2003;290:1467-1473, 1517-1519), Lithium reduced suicide rates of patients with bipolar disorder but divalproex did not. Risk of suicide death was about 2.5-fold higher with divalproex than with lithium.

Another paper published in 2005 (Arch Suicide Res. 2005;9(3):307-19) reviewed the existing evidence.

“The article reviews the existing evidence and the concept of the anti-suicidal effect of lithium long-term treatment in bipolar patients. The core studies supporting the concept of a suicide preventive effect of lithium in bipolar patients come from the international research group IGSLI, from Sweden, Italy, and recently also from the U.S. Patients on lithium possess an eight- time lower suicide risk than those off lithium. The anti-suicidal effect is not necessarily coupled to lithium's episode suppressing efficacy. The great number of lives potentially saved by lithium adds to the remarkable benefits of lithium in economical terms. The evidence that lithium can effectively reduce suicide risk has been integrated into modern algorithms in order to select the optimal maintenance therapy for an individual patient.”

The JAMA paper highlighted the declining use of lithium by psychiatrists in the United States and observed that:

"Many psychiatric residents have no or limited experience prescribing lithium, largely a reflection of the enormous focus on the newer drugs in educational programs supported by the pharmaceutical industry."

One might ask why there has been such a shift from Lithium.

Could it be the simplicity of the salt that is causing problems for the younger generation of psychiatrists brought up on various neuro-transmitters?

Could it be the fact that Lithium was discovered in Australia? Look at the time it took for Helicobacter pylori to be accepted.

Some felt it has to do with how little money is to be made from Lithium.

My questions are: Will the new generation of psychiatrists come round to Lithium again? How many talented individuals could have been saved by lithium?

Bipolar disorder: divalproex er vs placebo

May 19, 2009

Just before I retired, it has become fashionable to use anticonvulsants as a mood stabiliser. Being a traditionalist, I felt then that the evidence was not clear and I tended to stick with the trustedlithium.

Well my doubts were confirmed:Journal of the American Academy of Child & Adolescent Psychiatry:
May 2009 - Volume 48 - Issue 5 - pp 519-532
doi: 10.1097/CHI.0b013e31819c55ec
New Research

A Double-Blind, Randomized, Placebo-Controlled Trial of Divalproex Extended-Release in the Treatment of Bipolar Disorder in Children and Adolescents

Conclusions: The results of the study do not provide support for the use of divalproex ER in the treatment of youths with bipolar I disorder, mixed or manic state. Further controlled trials are required to confirm or refute the findings from this study. J. Am. Acad. Child Adolesc. Psychiatry, 2009;48(5):519-532.

An earlier Harvard study showed that Lithium reduced suicide risks by as much as 9 fold.

Lithium for Manic-Depressive Disorder (Bipolar Disorder):

Cade, John Frederick Joseph (1912 - 1980)
Taking lithium himself with no ill effect, John Cade then used it to treat ten patients with chronic or recurrent mania, on whom he found it to have a pronounced calming effect. Cade's remarkably successful results were detailed in his paper, 'Lithium salts in the treatment of psychotic excitement', published in the Medical Journal of Australia (1949). He subsequently found that lithium was also of some value in assisting depressives. His discovery of the efficacy of a cheap, naturally occurring and widely available element in dealing with manic-depressive disorders provided an alternative to the existing therapies of shock treatment or prolonged hospitalization.

In 1985 the American National Institute of Mental Health estimated that Cade's discovery of the efficacy of lithium in the treatment of manic depression had saved the world at least $US 17.5 billion in medical costs.

And many lives too!

Mahogony: Swietenia macrophylla

Mahogony (Caoba)

Swietenia macrophylla©Am Ang Zhang 2011

Seeds & Fruits of Swietenia macrophylla©Am Ang Zhang 2011

Mahogany is one of the world's premiere furniture hardwoods. Old growth trees can reach 40m in height and 1.5m in diameter. Its crown is rounded with extending branches. The wood is of excellent quality and used in fine furniture construction, woodworking, instruments, and architectural carpentry. The tree does not fare well in singles species plantations, due to attack by the shoot-borer (Hypsipyla grandella), which leaves the tree forked. Extensive pruning of young trees and planting in low concentrations are necessary.

The seeds may indeed offer some chemical molecule that may be useful for  treating diabetes.

Nature Posts:

Cashew: Hard Nut!

NHS: The Way We Were! Free!
FREE eBook: Just drop me a line with your email.

Email: cockroachcatcher (at) gmail (dot) com.

Saturday, November 26, 2011

Mystery Objects?

©Am Ang Zhang 2011

Clue: they are from a tree!!!
Answers via Email to Cockroachcatcher (at) gmail (dot) com.

Nature Posts:

Cashew: Hard Nut!

NHS: The Way We Were! Free!
FREE eBook: Just drop me a line with your email.

Email: cockroachcatcher (at) gmail (dot) com.

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