Sunday, July 22, 2018

3018 Archive B

 Sunday, July 22, 2018

Obstacle to Knowledge: Barry Marshall




“The greatest obstacle to knowledge

is not ignorance;

it is the illusion of knowledge”.

Barry Marshall



I was visiting my good friend in Fremantle in Perth. He was apologetic that Perth is not really near anywhere and all they have is beach and mining.

Sharks too.

He need not have apologised. I was happy to be near where one of the greatest medical breakthrough since Koch’s TB  over a hundred years ago: Helicobacter pylori.

The temperature was in the mid 40s and the plants were unusual!



© Am Ang Zhang 2013


© Am Ang Zhang 2013



© Am Ang Zhang 2013




© Am Ang Zhang 2013


The Nobel Prize in Physiology or Medicine 2005: "for their discovery of the bacterium Helicobacter pylori and its role in gastritis and peptic ulcer disease"

 



Peptic ulcer – an infectious disease!
This year's Nobel Prize in Physiology or Medicine goes to Barry Marshall and Robin Warren, who with tenacity and a prepared mind challenged prevailing dogmas. By using technologies generally available (fibre endoscopy, silver staining of histological sections and culture techniques for microaerophilic bacteria), they made an irrefutable case that the bacterium Helicobacter pylori is causing disease. By culturing the bacteria they made them amenable to scientific study.
In 1982, when this bacterium was discovered by Marshall and Warren, stress and lifestyle were considered the major causes of peptic ulcer disease. It is now firmly established that Helicobacter pylori causes more than 90% of duodenal ulcers and up to 80% of gastric ulcers. The link between Helicobacter pylori infection and subsequent gastritis and peptic ulcer disease has been established through studies of human volunteers, antibiotic treatment studies and epidemiological studies.
Helicobacter pylori causes life-long infection
Helicobacter pylori is a spiral-shaped Gram-negative bacterium that colonizes the stomach in about 50% of all humans. In countries with high socio-economic standards infection is considerably less common than in developing countries where virtually everyone may be infected.
Infection is typically contracted in early childhood, frequently by transmission from mother to child, and the bacteria may remain in the stomach for the rest of the person's life. This chronic infection is initiated in the lower part of the stomach (antrum). As first reported by Robin Warren, the presence of Helicobacter pylori is always associated with an inflammation of the underlying gastric mucosa as evidenced by an infiltration of inflammatory cells.
The infection is usually asymptomatic but can cause peptic ulcer
The severity of this inflammation and its location in the stomach is of crucial importance for the diseases that can result from Helicobacter pylori infection. In most individuals Helicobacter pylori infection is asymptomatic. However, about 10-15% of infected individuals will some time experience peptic ulcer disease. Such ulcers are more common in the duodenum than in the stomach itself. Severe complications include bleeding and perforation.
The current view is that the chronic inflammation in the distal part of the stomach caused byHelicobacter pylori infection results in an increased acid production from the non-infected upper corpus region of the stomach. This will predispose for ulcer development in the more vulnerable duodenum.


How to prove it: He drank the bacteria!

You could say that. I drank the bacteria and at first I was okay. But instead of being perfectly well and having a silent infection, after about five days I started having vomiting attacks. Typically at dawn I would wake up, run to the toilet and vomit. And it was a clear liquid, as if you had drunk a pint of water and regurgitated it straight back. Not only that, there was no acid in it. I remembered from my medical student days that if you have a meal where you drink so much beer that it’s coming back up straight away, it doesn’t have any acid in it. I knew there was something unusual about vomiting and not having acid.

                                                                                        Barry Marshall   

Difficult 10 years:
The medical establishment was difficult to persuade - everyone accepted that ulcers were caused by acid, stress, spicy foods, and should be treated by drugs blocking acid production. The big Pharmas were not happy to see any change as patients will have to take medication for life.


He went to the US to try and persuade the US doctors.

A big battle was still going on. I went to America to fight the battle there, because unfortunately the American medical profession was extremely conservative: ‘If it hasn’t happened in America, it hasn’t happened’. We needed people in the United States to take the treatment which we had developed.

Getting Personal:

The personal stuff was usually said behind my back, and my wife used to catch a bit of it. For example, I was at a conference, presenting our work. By then I had a few converts, who would be saying, ‘Oh, Barry, this is exciting. What are you going to do next?’ So they would talk to me, but 90 per cent of the audience wouldn’t know enough about it. And my wife would be on the bus tour with all the other wives, sitting in behind some of them. One wife would be saying to another one, ‘My husband said he couldn’t believe it. They had that guy from Australia talking about bacteria in the stomach. What a load of rubbish. This drug company’s reputation is mud’ ‑ because that company would be funding the bus tour at the conference. So things like that used to go on behind the scenes.


Finally:

It wasn’t settled until people did a truly double-blind study, using an acid blocker and also amoxicillin and a third antibiotic called tinidazol. All of those antibiotics could be given in a placebo, so one group of patients could take the ‘real’ antibiotics and the others would take antibiotics that were absolutely identical but were ‘fake’, and even the doctors didn’t know which patient was getting which treatment. That trial was done in Austria and was then published in America, in the New England Journal [of Medicine], which would have the most stringent criteria for medical research.
One year later, at a big think-tank in Washington to which I was invited, it was declared proven: ‘The treatment for ulcers is now antibiotics.’ That was vindication, in effect. The implication, once you say that in the United States and the NIH [National Institutes of Health] or somebody like that puts a document out and everyone accepts it, is that you have to follow it. In 1994 there were thousands of professors and scientists in the US making a living off Helicobacter.
“Ideas without precedent are generally looked upon with disfavour 
and men are shocked if 
their conceptions of an orderly world are challenged.” 

Bretz, J Harlen 1928. Dry Falls-Thinking Outside The Box

Also, thinking out of the box can be a good idea. Sometimes it’s better not to know all the dogma, all the things about a very difficult disease. If it’s very difficult, that means people have been working on it for years and they haven’t figured out the cure, which means they haven’t figured out the cause. So having all that knowledge that’s been accumulated in the last 10 or 20 years is really not an advantage, and it’s quite good to go and tackle a problem with a fresh mind when no-one else has had any luck.
                                                                                      Barry Marshall

Sunday, July 15, 2018

Monopoly Game & Mathematics: Save the NHS!


Monopoly Game;  

A friend's husband has always worked for the government and has health insurance (really!!!). That was what she said and she needed a major treatment after being diagnosed with breast cancer privately. 

But:


"If you have treatment with NHS, we will pay you a thousand pounds but you can opt to have the treatment privately, mainly the surgery that will cost us twenty thousand pounds but you are STILL BETTER OFF TO HAVE CHEMOTHERAPY WITH ONE OF THE TOP LONDON HOSPITALS. 

Wow!! Well the consultant also works for the NHS! sO, HIS hOSPITAL!!!

She preferred the Monopoly Game and collected the money! she is fine with the NHS treatment.

Mathematics:



Teenagers 'failing to study maths to a good standard'

Looks like it is not just teenagers:

The NHS is running out of money, so we must give most of it to privateers to save money!!!

                                                           Andrew Lansley/ HSCB



If the private providers are making money and the GP commissioning teams have a limited pot and that Consultants working for the likes of BMI hospitals have a 300% increase in pay compared to old NHS Hospital pay scale, either tax payers are going to be forking out more and more money or someone is not going to get their treatment.

But the sums are somehow wrong! 

Government money is the best money for anyone to make and that is really tax payer’s money. The new NHS will be the private sector’s main source of income, as only 90,000 in the UK are covered by private insurance and often they are offered cash incentives to use the NHS.

It is therefore essential for the private health care companies that the NHS is around, at least in name, so that they can make money by providing a “better value and more competitive” service to the NHS!

Some parts of the NHS will have to remain too, as it is necessary for the private sector to dump the un-profitable patients: the chronic and the long term mentally ill, for example. (Right now, 25% of NHS psychiatric patients are treated by the private sector.  But why? Even in psychiatry, there are cherries to be picked.)

Finally, in order to keep the mortality figures low at competing private hospitals, they need to be able to rush some of their patients off to NHS hospitals at the critical moments!


The following way would save our NHS:

  • Ends discrimination against people with pre-existing conditions.
  • Limits premium spread to normal, high risk and healthy risk to say under 20% either way of normal.
  • Limits premium discrimination based on gender and age.
  • Prevents insurance companies from dropping coverage when people are sick and need it most.
  • Caps out-of-pocket expenses so people don’t go broke when they get sick.
  • Eliminates extra charges for preventive care.
  • Contribute to an ABTA style cover in case Insurers go broke. They will



Our NHS is not without faults and often the faults were to do with government. Impossible targets set up by successive governments have one aim: limit access to health care.




·                           
We could legislate that Insurers will have to pay for any NHS treatment for those covered by them. It will stop Insurers “gaming” NHS hospitals. This will prevent them saving on costly dialysis and Intensive Care. Legislate for full disclosure of Insured status.

Insurers cannot drop coverage or treatment after a set period and even if they do they will still be charged if the patient is transferred to an NHS Hospital.

This will eliminate problems like PIP breast implants.

It will indeed encourage those that could afford it to buy insurance and in any case most firms offer insurance for their employees including the GMC.

To prevent gaming of Insurers by individual patients (I look after their interest too), the medical fee should be paid up front by the patient and then deduction taken from premiums. Corporate clients like those with the GMC should not be gaming Insurers.

Imagine the situation where those with “individual personalised budget” being able to “buy” their own insurance!

In fact, to save money, government can buy insurance for the mental patients and the chronically ill.

This way their will be real choice and insurers will be competing with each other to provide the worst deal.

Why?

What Health Insurer will want the business? 

Perhaps they will go back to the US and we will have our own NHS back.


 




“……The principle of care for all from cradle to grave is worthy and wonderful. But the current reality is a cradle rocked by accountants who are incapable of even counting the number of times that they have rocked it……..” These are the very same people we pay market rate or they will go elsewhere!!!

Monday, June 18, 2018

Gold Standard: Clozapine & Finland.


Autumn Gold and Gold Standard in Finland:


Tiihonen said the pharmaceutical industry is partly to blame for why clozapine has often been overlooked. "Clozapine's patent expired long ago, so there's no big money to be made from marketing it," he said.



© 2012 Am Ang Zhang

There have been many challenges to Clozapine but to the Cockroach Catcher it will remain the Gold Standard for the treatment of Schizophrenia for a long long time.

An extract from The Cockroach Catcher:

……...Martina was already at the adolescent inpatient unit when I arrived. She was supposed to be schizophrenic. The family were refugees from Sudan. They were a small Sect of Catholics that were said to be persecuted.
Martina was not very communicative but her records and observations by her outpatient psychiatrist indicated that the diagnosis was robust enough. However, after over a year in hospital she was not improving and we had tried the newer antipsychotic without making much headway.
There was one thing left to do – to put her on Clozapine.
I was once at one of these big drug firm meetings when all the big boys on the newer antipsychotics were there.
Having filled my plate from the delicious buffet, I sat next to two nicely clad representatives.
“So you ladies are from Novartis?” I did my usual stunt.
“How did you work that one out?”
“Well, you two have the best designer outfits and I guessed you must be from the makers of Clozapine.”
They were there to see what the opposition might come up with but as far as I was concerned no other pharmaceutical would touch them for decades.

After today’s Lancet publication they might not need to worry at all!

The Lancet, Early Online Publication, 13 July 2009
11-year follow-up of mortality in patients with schizophrenia: a population-based cohort study (FIN11 study) Jari Tiihonen et al. 

According to Reuters:
…………An analysis of 10 years' records for 67,000 patients in Finland found that, compared to treatment with the first-generation drug perphenazine, the risk of early death for patients on clozapine was reduced by 26 percent.

By contrast, mortality risk was 41 percent higher for those on Seroquel, known chemically as quetiapine; 34 percent higher with Johnson & Johnson's Risperdal, or resperidone; and 13 percent higher with Eli Lilly's Zyprexa, or olanzapine.
"We know that clozapine has the highest efficacy of all the antipsychotics and it is now clear, after all, that it is not that risky or dangerous a treatment," study leader Jari Tiihonen of the University of Kuopio said in a telephone interview.
"We should consider whether clozapine should be used as a first-line treatment option."Tiihonen estimates clozapine is given to around one fifth of Finnish schizophrenia patients, but less than 5 percent in the United States.Clozapine's side effects include agranulocytosis, a potentially fatal decline in white blood cells, and current rules stipulate the drug can only be used after two unsuccessful trials with other antipsychotics.Tiihonen and colleagues wrote in the Lancet medical journal that these restrictions should be reassessed in the light of their findings, since not using the drug may have caused thousands of premature deaths worldwide.
According to AP:

James MacCabe, a consultant psychiatrist at the National Psychosis Unit at South London and Maudsley Hospital, called the research "striking and shocking." He was not linked to the study.
"There is now a case to be made for revising the guidelines to make clozapine available to a much larger proportion of patients," he said.
Tiihonen and colleagues found that even though the use of anti-psychotic medications has jumped in the last decade, people with schizophrenia in Finland still die about two decades earlier than other people.


Tiihonen said the pharmaceutical industry is partly to blame for why clozapine has often been overlooked. "Clozapine's patent expired long ago, so there's no big money to be made from marketing it," he said.


Clozapine Data: FinlandRCPU.K.NEJM
Abstract:The Lancet.

Related Posts
Abilify/aripiprazole: Akathisia-gate
Alaska Zyprexa: DOJ at last.
Alaska, Good Friday Earthquake and Zyprexa 
Alaska Zyprexa: Follow Up
Bipolar and ADHD: Boys and Breasts
Antipsychotics: Really?
Humber Mental Health Teaching NHS Trust: Learning From The Past.

Monday, June 4, 2018

NYBG: Peony time!

It is that wonderful time of the year to enjoy peonies as they lasted just a very short time!






 All photos ©2018 Am Ang Zhang

Book I recently read: 

Fragile Lives by Stephen Westaby


Hello Summer: BBG4.


Photography: Best lens for portrait & landscape!



A unique picture book consisting of 20 beautiful 9 x7 in. full bleed photos by the author of: corals, turtles, anhinga, blue tang, file fish, butterfly fish, cleaner shrimp, pompano, barracuda, flounder, star fish, and sting ray. A first of the kind tale of aquatic creatures in child-speak. A good introduction of nature to a young child, especially good as a follow-up to a visit to the aquarium; plus two pages of detailed companion




A coffee table quality photobook for a special child, introducing wild life in Africa. Photos of the animals (impala, nyala, kudu, wildebeest, warthog, gruffalo, zebra, rhinoceros, waterbuck, hippopotamus, giraffe, buffalo, elephant, saddlebilled stock) were taken by the author himself during safari trips in Africa.






Multiple Sclerosis: Never say never!

Latest from Dr Weldon:


Note
Over the course of the last ten years I have received a number of emails from persons who, having read these pages, assert that Sarah never had multiple sclerosis. These persons inform me that she had Acute Disseminated Encephalomyelitis (ADEM). Some of these amateur neuroscientists (who have never spoken to, taken a history from, or examined the lady) have been quite strident in their assertions.

Well, Sarah's illness was completely typical of Relapsing-Remitting MS developing into Secondary Progressive disease. Sarah experienced seven relapsing-remitting episodes involving different parts of the CNS over two decades; remissions became partial; then her illness began to slide into the secondary progressive form over two years. This is not seen in ADEM, where the picture is of acute post-infective encephalitis. Although ADEM is seen in adults, it is more often seen in children, peaking between 3 and 10 years. ADEM is rare (7 per 1,000,000); MS is common (1.2 per 1,000). MRI imaging shows different appearances; lesions in ADEM have poorly defined margins; those of MS are more sharply defined. The spatial arrangement and the shape of lesions in the two diseases is different. Sarah's MRI showed lesions typical of MS.

Here is a link to an article on the differences between ADEM and MS: http://adc.bmj.com/content/90/6/636.full
So, it is certain that Sarah had Secondary Progressive MS, a diagnosis made by a consultant neurologist. She (and others) recovered because she was treated rationally using evidence-based medicine. And by evidence-based I mean evidence-based.
Sarah's story has been made public, to assist others, at her request.

Link: http://www.davidwheldon.co.uk/ms-treatment.html

There is suddenly a great interest in one of my earliest posts: 

Multiple Sclerosis, Iguanas and Wrong Foot


In the summer of 2005 I read a rather compelling story in Hospital Doctor. The headline was: “Ignoring the EvidenceDiagnosis of his wife’s progressive multiple sclerosis would not have taken so long had doctors taken a proper history, says Dr David Wheldon.”


It was an extremely well written article. It had to be, as Dr Wheldon’s hobby is poetry writing. He is a microbiologist by profession.
His wife is an accomplished painter and a violin restorer and dealer. As early as 2000, she noticed that she was dragging her right foot on a walking holiday in the Auvergne. She was referred to an orthopaedic surgeon. “Congenital spinal stenosis,” he confidently diagnosed. She got worse. In 2003 she was referred to a neurologist but during the months when she was made to wait for an MRI (why was it not done immediately?) she deteriorated rapidly and was soon unable to walk unaided and had a multitude of other neurological symptoms.
“Progressive multiple sclerosis,” proclaimed the neurologist. "No treatment is available. Just let the disease evolve."
Dr Wheldon at this point commented that a proper history would have allowed for the diagnosis to be made earlier, as his wife had had two transient episodes of weakness of an arm and dimmed vision in one eye.
There was no time to waste and having been given a “no hope” verdict, Dr Wheldon thought that alternatives had to be found. How often have we found patients seeking alternative treatment and sometimes very very alternative treatments once they were told what was thought to be the “truth”? Luckily I learned early on in my medical training that one should “never say never” (as mentioned in the chapter “Miracles” in my book.)
He found the Vanderbilt University work on Chlamydia pneumoniae. The rest, so to speak, was history. His wife was put on two antichlamydial agents and later metronidazole. After some typical reactions his wife started to recover. Eighteen months later, she was able to paint and walk a mile or so.
Some may argue that the recovery had nothing to do with the treatment, but was just one of those rare spontaneous recoveries. I am aware that this is only an isolated case, but there is ongoing research in this area.

Iguana iguana, Costa Rica

So what is the iguana doing in today’s blog? Many iguanas kept as pets are wild, truly wild caught and they carry various bacteria including Chlamydia pneumoniae, which also infect and cause diseases in Koalas, snakes, chameleons, frogs, and green turtles.
According to National Geographic, one of my favourite reads,
“Green, or common, iguanas are also among the most popular reptile pets in the United States, despite being quite difficult to care for properly. In fact, most captive iguanas die within the first year, and many are either turned loose by their owners or given to reptile rescue groups.”
Perhaps we should leave them to stay in the wild.
Dr Zhang should have checked if Tommy, his Wrong Foot patient, kept an iguana. His mother was diagnosed with multiple sclerosis.

Chlamydia pneumoniae site: CPNHELP.ORG


Other Posts on Multiple Sclerosis:

Multiple Sclerosis Treatment – an Update

Links

“Multiple Sclerosis:  A Curable Infectious Disease?”, July 7, 2010, http://perfecthealthdiet.com/?p=157.
“Is Multiple Sclerosis an Autoimmune Disease?”, July 5, 2010, http://perfecthealthdiet.com/?p=151.
“Eleven Steps for Overcoming Alzheimer’s and Other Chronic Infectious Diseases,” July 1, 2010,http://perfecthealthdiet.com/?p=134.
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9 comments:

Sarah Longlands said...
Dear Dr Zhang,

My name is Sarah Longlands, the wife of Dr Wheldon, mentioned above. I found your blog by accident when looking up "David Wheldon" on Google, something I do from time to time to see who is linking to both our web sites.

I thought I would give you a small update:nearly three years on again since the publication of "Ignoring the Evidence" I am still going strong, not having had an adverse MS event since starting treatment in August 2003. When I started I couldn't even hold a paintbrush but now I have worked through watercolours to acrylics and have now moved back to my favourite medium of oil paints and of no mean size. My progressive multiple sclerosis was so aggressive, I really shouldn't be here now, but I am.

I have not seen my neurologist since being given the diagnosis. David has, since they work in the same hospital, but although at one point the man showed some interest, this soon passed and the man has never looked at my subsequent improved scans. In fact, he once ran out of the radiologists room exclaiming "I can't look at this!" He is obviously very good at saying "Never."

There are always going to be people willing to put my recovery down to "spontaneous recovery" but I think it very odd that this should have happened within a few hours of downing my first ever doxycycline, after having my first multiple sclerosis relapse twenty years previously, age 24. Then and for many years it was untroubling, with few, easily resolved relapses. Over the years I had been able to forget about it, so I readily accepted the diagnosis of the orthopaedic surgeon. I have since discovered that David married me thinking I might well have MS, because of my clumsiness although by that time I has already decided that it couldn't possibly be the case.

Since starting to recover, David has seen many patients abandoned by the neurological establishment and has written two papers with Charles Stratton of Vanderbilt University about chlamydia pneumoniae and multiple sclerosis. I started writing on http://www.thisisms.com, where a psychologist named Jim Kepner, a sufferer of another disease caused by chlamydia pneumoniae, saw me and started to treat himself. Two and a half years ago this led to him starting a wonderful site: http://www.cpnhelp.org where people from all over the world suffering from any of the many diseases in which CPn is implicated can come together for freely given help and reassurance.

Very best wishes,

Sarah Longlands. 12th April, 2008
Am Ang Zhang said...
Many thanks Sarah for taking the time to make the comment. All the best.

Dr Am Ang Zhang
Anonymous said...
Copied from CPNhelp because I thought you might not see it there:

"Hello again Dr Zhang! I hope you enjoyed your hols, but it was only a tiny flurry really, like the small snowfall we had the other Sunday morning which was gone before most people knew it had been there.

I totally agree with you about the state controls, first set in place in our country when the fat man in hush puppies was health minister, I had only recently both got my MA and acquired MSi and chlamydia pneumoniae was not even realised to be a serious pathogen. I'm glad we have original thinkers over at Vanderbilt and I am so glad I am married to one here, who discovered what they were doing and thought that it was better to get on with treating me rather than waiting for endless double blind trials that would never happen, antibioticsi not being profitable things.......Sarah




An Itinerary in Light and Shadow by a real "Painter of Light"...........Completed Stratton/Wheldon regime for aggressive secondary progressive MS in June 2007, after four years, three of which intermittent. Still slowly improving and no exacerbation since starting. EDSS was 7, now 2, less on a good day."
Anonymous said...
that is the case too, the antibiotics on the protocol used to treat are long off patent & sport the least amount of side effects from the abx themselves. The pharma companies have no interest.

but wow, they now have something they can make money on! a drug for Fibromyalgia pain (packed with a plethora of side effects)!
Gill said...
Hi, I have been recently diagnosed with MS and was also told there was nothing that could be done. My options appeared to be nil or joining the MS Society for group hugs and "learning how to live with my disease". Not a chance I was putting up with that so I started to scour the web and talk to friends recently diagnosed.

I thank my lucky stars that one friend pointed me straight to David Wheldon's site and having met with him, I'm about to start on the protocol. With the help of the pioneering stalwarts on the CPn Help forum mentioned above, David Wheldon, and the inspirational Sarah, I fully intend to see this through. If it's possible to cure it then I'll have a darn good try.

My GP and Neurologist have refused to have anything to do with the Protocol which I find exceedingly strange. I always thought the medical profession were tasked with making patients well by whatever means, it seems however that unless the drug companies are waving some new miracle drug at them, they're not open to looking at old medication used in a new way.

Having read your blog though, I'm going to spend the afternoon scouring the house in case I have a recalcitrant Iguana hiding in a dark corner. Or maybe I'll round up the frogs in the pond and force them to take a Chlamydia Pneumoniae test. :-)
Am Ang Zhang said...
Hello all, back from Hols and the blog engine has restarted.
Am Ang Zhang said...
Sarah's letter is now posted here.

The Cockroach Catcher


Whistleblower: Genius & Fraud

It is interesting to come back to somewhere where I can start catching Cockroaches.


Before then, I realised what a genius our Ex Health Secretary really is:

The Guardian: Lansley's claims about hospital PFI debt 'misleading'!
He has managed to turn so many to now love PFI. Wow!
But wait: he has also set out the justification to sell off the 22 hospitals to the likes of Circle or Netcare. Win! Win!

But is the genius ready to deal with Medical Fraud?

Baltimore Sun:
September 17, 2011

Something didn't look right. Maxim Healthcare nurses were showing up at Richard West's house according to one schedule. But Maxim was billing the government according to another.

West complained to the state: The company was charging for hundreds of hours of work it never did. Officials blew him off, he said. He alerted Medicaid, the state and federal program that paid for his care. Nothing happened.
 
He told a social worker. She expressed concern, but did nothing. But West, a Vietnam vet with muscular dystrophy, kept pushing and pushing, building a giant, accusatory snowball that landed last week — eight years later — on Maxim's Columbia headquarters.

Maxim has signed a criminal and civil settlement related to allegations that it schemed to rip off $61 million from state and federal governments, law enforcement authorities said last week. The company is paying $150 million in penalties and recompense. Eight former Maxim employees so far have pleaded guilty to felony charges in several states.

If Washington is as serious about fighting medical fraud as it pretends to be, it will recruit an army of Richard Wests to burn off leeches like Maxim. Nobody is in a better position to see fraud than patients, who can check the care they receive against what's on the invoice.

Now that West has shown that patients can get rich in the bargain, there's plenty of incentive. Not that his motivation was his $14.8 million share of the settlement. Anger was. He didn't even know about such whistleblower rewards at first.

"Somebody decided to make a profit on my disability," West said in a telephone interview. "This is your country. You see fraud, you should turn them in. That is part of being an American."

Whistleblower rewards under the federal False Claims Act have been around since the Civil War. The recent caseload has been dominated by allegations of Medicare and Medicaid fraud, which costs taxpayers billions of dollars a year.

In almost every instance, the person who alerts law enforcement is a corporate insider, not a patient. West's information in the Maxim case was so compelling, however, that the government credited him as the "original source," with independent and direct knowledge of the fraud.

He kept spreadsheets on the gaping discrepancy between the hours Maxim nurses spent in his home north of Atlantic City, N.J., and the hours Maxim billed Medicaid. Eventually he documented more than 700 hours of bogus charges, according to the New Jersey attorney general.

After a couple months of detective work, West got in touch with Baltimore lawyer Robin Page West (no relation), who specializes in whistleblower lawsuits. Together they built a case, filed it under court seal in 2004 and turned it over to law enforcement. And waited.

West, 63, speaks precisely but with difficulty, in a high-toned voice. He says he commanded an Army track vehicle with 40 mm guns in Vietnam in 1968 and 1969 — the deadliest years of the war there. Yet biding his time while investigators built their file, he said, "was the hardest thing I've ever done."


See also:



Sunday, June 8, 2014

NHS & Wine: Simon Stevens----Sale or Sail?

The Cockroach Catcher was privileged to be having dinner with his good friend.

He covered the bottle when he served his favourite red wine.

"See what you think."

"Fully of blackberry and long with good tannin that has softened."

"1996 and the tannin will keep it going for another 5 years."

"Of all the recent great wines that you have served and that included the second wines of Lafite and Margaux, this is the most impressive. Just like our NHS!"

"But now you have one of the most impressive guys running it."

"Selling it, you mean!"

"I did not want to upset you."

"So you know about Simon Stevens. Not just wines then."

"You need to know that Britain is responsible for producing all the great doctors in the old commonwealth. My cardiologist was trained there. Look at Singapore, Australia & New Zealand, generations of doctors were all trained in the UK and in turn the next generations.
Why do you think that UnitedHealth paid so much to get one of the top UK guys to add a new perspective?

UnitedHealth is based in Minnesota, home of the famous Mayo Clinic and Simon Stevens is married to an American and they have school age children. As you well know, it is not easy for Americans to adjust to British life."

"So you think he is not going to last that long?"

"He has a very natural excuse!"

"Family!"

"Lets see what Bloomberg say:"
BRITISH EXPERIENCE

UnitedHealth followed up on June 30 with another report for lawmakers pinpointing $332 billion in savings through better use of technology and administrative simplification. If enacted, those changes would potentially benefit UnitedHealth's Ingenix data-crunching unit. Ingenix, with annual revenue of $1.6 billion, is poised to establish a national digital clearinghouse to ensure the accuracy of medical payments and provide a centralized service for checking the credentials of physicians.

Stevens, an Oxford-educated executive vice-president at UnitedHealth, once served as an adviser to former British Prime Minister Tony Blair. In that capacity, Stevens tried to fine-tune the U.K.'s nationally run health system. Today he tells lawmakers that the U.S. need not follow Britain's example. Concessions already offered by the U.S. insurance industry—such as accepting all applicants, regardless of age or medical history—make a government-run competitor unnecessary, he argues. "We don't think reform should come crashing down because of [resistance to] a public plan," Stevens says. Many congressional Democrats have come to the same conclusion.

UnitedHealth has traveled an unlikely path to becoming a Washington powerhouse. Its last chairman and chief executive, William W. McGuire, cultivated a corporate profile as an industry insurgent little concerned with goings-on in the capital. From its Minnetonka(Minn.) headquarters, the company grew swiftly by acquisition. McGuire absorbed both rival carriers and companies that analyze data and write software. Diversification turned UnitedHealth into the largest U.S. health insurer in terms of revenue. In 2008 it reported operating profit of $5.3 billion on revenue of $81.2 billion. It employs more than 75,000 people. 


Stevens argues that while UnitedHealth will likely benefit financially from health reform, the company will also aid the cause of reducing costs. He cites what he says is its record of "bending the cost curve" for major employers. 

During a media presentation in May in Washington, Stevens said medical costs incurred by UnitedHealth's corporate clients were rising only 4% annually, less than the industry average of 6% to 8%. But that claim seemed to conflict with statements company executives made just a month earlier during a conference call with investors. On that quarterly earnings call, UnitedHealth CEO Hemsley conceded that medical costs on commercial plans would increase 8% this year. 

Asked about the discrepancy, Stevens says the lower figure he is using in Washington represents the experience of a subset of employer clients who fully deployed UnitedHealth's cost-saving techniques, including oversight of the chronically ill. "These employers stuck at it for several years," he says. "We are putting forward positive ideas based on our experience of what works."

"Wow!"

"So there is not reason for him to leave UnitedHealth! They love him. The best of British & of Oxford!"

"Perhaps he has not left UnitedHealth!"

"So perhaps a sort of UnitedNHS then!"

"Well despite what people say about Obamacare, even Stevens concede that:
.....the U.S. insurance industry—accepting all applicants, regardless of age or medical history—make a government-run competitor unnecessary, he argues.

"NHS as such was the most serious competitor to the Health Insurance Industry. It is serious because there is not even any co-pay!"

"And quality is the same as the actual specialist doctor on either side are the same."

"Only the coffee is better!"

"Whatever Stevens plan to do is not something most of us can begin to guess but my suspicion is that it would not be to anyone's liking..."

"Except the Health Insurance Industry."

"So, he will not follow the US example of insurance industry accepting all applicants, regardless of age or medical history."

"No way!"

"You see, UnitedHealth has decided to leave California because of that."

"Not profitable!"

"If Insurers need to cover everything in England, they would think twice and most likely do a California thing."

"And Stevens can go back to America then!"

"So what is the wine?"

"Big Sail Boat!"                                                              

"Big Sail Boat?"

That the logo might have helped to sell a wine is unthinkable if the wine is no good. Ch. Beychevelle was fortunate enough to have a boat on its label and the Chinese just embrace it now that Lynch Bages hit the roof and there are too many fake 1982 Lafites around.

When my friend stock up on his Beychevelle, it was he told me, just a third of the price right now.

"It will be the next Lynch Bages."

"That is why 50% has been sold to the Japanese!"


"Wow!"             


So will Simon sell or sail? Or sell then sail!



I recently learned that this month a class-action lawsuit has been filed against California United Behavioral Health (UBH), along with United Healthcare Insurance Company and US Behavioral Plan, alleging these companies improperly denied coverage for mental health care.
According to the class action lawsuit, United Behavioral Health violated California’s Mental Health Parity Act, which requires insurers to provide treatment for mental-health diagnosis according to “the same terms and conditions” applied to medical conditions. Specifically, the insurer is accused of denying and improperly limiting mental health coverage by conducting concurrent and prospective reviews of routine outpatient mental health treatments when no such reviews are conducted for routine outpatient treatments for other medical conditions. 
New York:


Pomerantz Law Firm has filed a Class Action Against UnitedHealth Group, Inc. 
for Violations of Federal and State Mental Health Parity Laws - UNH
NEW YORK, March 12, 2013 (GLOBENEWSWIRE) Pomerantz Grossman Hufford Dahlstrom & Gross LLP has filed a class action lawsuit against UnitedHealth Group Inc. (“UnitedHealth” or the “Company”)(NYSE: UNH) and various subsidiaries, including United Behavioral Health.  The class action was filed in the U.S. District Court, Southern District of New York, and docketed under 13 CV 1599, alleging violations of federal and state mental health parity laws and other related statutes. The action has been brought on behalf of three beneficiaries who are insured by health care plans issued or administered by United and whose coverage for mental health claims has been denied or curtailed. These plaintiffs seek to represent a nationwide class of similarly situated subscribers. In addition, the action was filed on behalf of the New York State Psychiatric Association, Inc. (“NYSPA”), a division of the American Psychiatric Association, seeking injunctive relief in a representational capacity on behalf of its members and their patients.

The health insurer violated state law nearly 1 million times from 2006 to 2008 after it was bought by UnitedHealth Group, the Department of Insurance says. The fine, if there is one, is likely to be much less than the maximum allowed.'

UNITED HEALTHCARE INSURANCE AGREES TO PAY U.S.
$3.5 MILLION TO SETTLE FRAUD CHARGES


WASHINGTON, D.C. - United Healthcare Insurance Company has agreed to pay the United States $3.5 million to settle allegations that the company defrauded the Medicare program, the Justice Department announced today.
The government alleges that beginning in or about 1996 and continuing through 2000, United Healthcare's telephone response unit knowingly mishandled certain phone inquiries received from Medicare beneficiaries and providers and then falsely reported its performance information to the Centers for Medicare and Medicaid Services (CMS) concerning the company's handling of those calls. CMS is the federal agency charged with administering the Medicare program.
From October 2, 1995 to October 1, 2000, United Healthcare acted under contract with CMS as a Durable Medical Equipment Regional Carrier. Under that contract, United Healthcare processed Medicare Part B claims for durable medical equipment submitted to it by Medicare beneficiaries, physicians, and other health care providers and suppliers located in the northeastern United States.
"This settlement demonstrates our continuing commitment to pursue vigorously allegations of fraud and abuse in Medicare," said Peter Keisler, Assistant Attorney General for the Department's Civil Division. "Medicare contractors, along with other health care providers, can and will be held accountable for their billing practices. This settlement demonstrates our unwavering pursuit of fraud and abuse."
The allegations of improper conduct were brought to the attention of the government by a former United Healthcare employee, who filed suit under seal in November 2001 under the qui tam or whistleblower provisions of the federal False Claims Act. The United States recently intervened in the whistleblower suit.
As a result of today’s settlement, the whistleblower will receive $647,500 of the settlement amount. United Healthcare did not admit any of the allegations in the complaint in connection with the settlement. Under the False Claims Act, private citizens can bring suit on behalf of the government and share in any awards that are obtained through that legal action.
###


An Entrepreneur!         
UnitedHealth & Big Profits                                                                                                      - 

Thursday, September 3, 2009

Pfizer, Geodon (Ziprasidone ) & The Twist


“The pharmaceutical giant Pfizer agreed to pay $2.3 billion to settle civil and criminal allegations that it had illegally marketed its painkiller Bextra, which has been withdrawn.”

“The government charged that executives and sales representatives throughout Pfizer’s ranks planned and executed schemes to illegally market not only Bextra but also Geodon, an antipsychotic; Zyvox, an antibiotic; and Lyrica, which treats nerve pain. While the government said the fine was a record sum, the $2.3 billion fine amounts to less than three weeks of Pfizer’s sales.”

My main interest is in the antipsychotic Geodon (Ziprasidone )
From Reuters:
“Geodon is FDA-approved only to treat patients ages 18-65 diagnosed with schizophrenia or acute manic or mixed episodes associated with bipolar disorder. However, according to the whistleblower suit unsealed today, Pfizer illegally promoted the sale and use of Geodon for a variety of off-label conditions,
including depression, bipolar maintenance, mood disorder, anxiety, aggression, dementia, attention deficit hyperactivity disorder, obsessive compulsive disorder, autism, posttraumatic stress disorder, and for pediatric, adolescent and geriatric patients.”
That sounds like every known condition!!!
"Pfizer targeted pediatrics and adolescents to expand off-label use and maintained on its payroll an army of more than 250 child psychiatrists nationwide." Kenney stated that, "Pfizer regularly paid generous speaking fees to these child psychiatrists to give what were basically promotional lectures about the benefits of Geodon to their peers, who were naturally also child psychiatrists, despite the fact the drug is not FDA-approved or medically indicated to treat children at all."
"……the purpose and intent of paying so many child psychiatrists is clear-- to gain a foothold within the fastest growing market for antipsychotics --children. The practice of expansive off-label use is dangerous, particularly in children because the drug has not been evaluated for its safety for the unique physiological make up of children."
"……less than 5% of the United States population is diagnosed with schizophrenia or bipolar disorder, yet in 2008 Geodon surpassed the blockbuster benchmark of $1 billion in sales."
"……after drug makers obtain initial FDA approval for a specific use, they often don't bother with expensive testing that would allow them to request a label extension for other uses. They just market the drug off-label."
Danger:
"……among Geodon's most dangerous side effects is its potential to affect the heart's rhythm, a condition known as QT prolongation, which increases the risk of sudden cardiac death." 
Antibiotic as well?
As part of the overall settlement, Pfizer agreed to pay $100 million to resolve allegations that it engaged in the marketing of Zyvox for a variety of off-label conditions beyond the methicillin-resistent Staphylococcus aureus ("MRSA") infections for which Zyvox was FDA-approved.
Is anything sacred anymore?
 
The twist: this is better than a John Grisham Novel
“Authorities called Pfizer a repeat offender, noting it is the company's fourth such settlement of government charges in the last decade. The allegations surround the marketing of 13 different drugs, including big sellers such as Viagra, Zoloft, and Lipitor.”
I was wondering why they could be so blatant:
“In an unusual twist, the head of the Justice Department, Attorney General Eric Holder, did not participate in the record settlement, because he had represented Pfizer on these issues while in private practice.”
What other corporations did he represent?
“Eric Holder, has a net worth of $5.7 million and lobbied on behalf of three companies in the past five years, according to a questionnaire filed by Holder with the Senate Judiciary Committee.
“In the year before Obama appointed him Attorney General, he made more than $2.1 million as a partner at Covington & Burling, a prominent Washington law firm. The money is unsurprising given his high-profile client list, which includes companies like UBS Financial Services, Merck & Co., and Hewlett-Packard. He was also paid to sit on the boards of MCI and Eastman Kodak Company.”


Tuesday, May 22, 2018

NHS Original: Best Health Care!


Friends moved to France after their retirement and lived in one of the wine growing districts.
 ©2008 Am Ang Zhang
They were extremely pleased with the Health Care they received from their doctor locally. After all, not long ago, French Health Care topped the WHO ranking.

Then our lady friend had some gynaecological condition. She consulted the local doctor who referred her to the regional hospital: a beautiful new hospital with the best in modern equipment. In no time, arrangement was made for her to be admitted and a key-hole procedure performed. The French government paid for 70% and the rest was covered by insurance they took out.

They were thrilled.

We did not see them for a while and then they came to visit us in one of our holiday places in a warm country.

They have moved back to England.

What happened?

Four months after the operation they were back visiting family in England. She was constipated and then developed severe abdominal pain. She was in London so went to A & E (ER) at one of the major teaching hospitals.

“I was seen by a young doctor, a lady doctor who took a detail history and examined me. I thought I was going to be given some laxative, pain killer and sent home.”

“No, she called her consultant and I was admitted straight away.”

To cut the long story short, she had acute abdomen due to gangrenous colon from the previous procedure.

She was saved but she has lost a section of her intestine.

They sold their place in the beautiful wine region and moved back to England.

The best health care in the world. 

Now we know.

Let us keep it that way.


NHS & Private Medicine: Best Health Care & Porsche

Do we judge how good a doctor is by the car he drives? I remember medical school friends preferred to seek advice from Ferrari driving surgeons than from Rover driving psychiatrists.

My friend was amazed that I gave up Private Health Care when my wife retired.

“I know you worked for the NHS but there is no guarantee, is there?”

Well, in life you do have to believe in something. The truth is simpler in that after five years from her retirement, the co-payment is 90%.

He worked for one of the major utility companies and had the top-notch coverage.

“The laser treatment for my cataract was amazing and the surgeon drives a Porsche 911.”

Porsche official Website

He was very happy with the results.

“He has to be good, he drives a Porsche.”

Then he started feeling dizzy and having some strange noise problems in one of his ears.

“I saw a wonderful ENT specialist within a week at the same private hospital whereas I would have to wait much longer in the NHS.”

What could one say! We are losing the funny game.

What does he drive?

A Carrera.

Another Porsche.

We are OK then.

Or are we.

He was not any better. And after eight months of fortnightly appointments, the Carrera doctor suggested a mastoidectomy.

Perhaps you should get a second opinion from an NHS consultant. Perhaps see a neurologist.

“I could not believe you said that, his two children are doctors. And he has private health care!” I was told off by my wife.

He took my advice though and he got an appointment within two weeks at one of the famous neurological units at a teaching hospital.

To cut the long story short, he has DAVF.

I asked my ENT colleague if it was difficult to diagnose DAVF.

“Not these days!”

He had a range of treatments and is now much better.

All in the NHS hospital.

“I don’t know what car he drives, but he is good. One of the procedures took 6 hours.”

Best health care.

I always knew: Porsche or otherwise.


Best Health Care: NHS GP & NHS Specialist


Does having a good hunch make you a good doctor or are we all so tick-box trained that we have lost that art. Why is it then that House MD is so popular when the story line is around the “hunch” of Doctor House?

Fortunately for my friend, her GP (family physician) has managed to keep that ability.

My friend was blessed with good health all her life.  She seldom sees her GP so just before last Christmas she turned up because she has been having this funny headache that the usual OTC pain killers would not shift.

She would not have gone to the doctor except the extended family was going on a skiing holiday.

She managed to get to the surgery before they close. The receptionist told her that the doctor was about to leave. She was about to get an appointment for after Christmas when her doctor came out and was surprised to see my friend.

I have always told my juniors to be on the look out for situations like this. Life is strange. Such last minute situations always seem to bring in surprises. One should always be on the look out for what patient reveal to you as a “perhaps it is not important”.

Also any patient that you have not seen for a long time deserves a thorough examination.

She was seen immediately.

So no quick prescription of a stronger pain killer and no “have a nice holiday” then.

She took a careful history and did a quick examination including a thorough neurological examination.

Nothing.

Then something strange happened. Looking back now, I did wonder if she had spent sometime at a Neurological Unit.

She asked my friend to count backwards from 100.

My friend could not manage at 67.

She was admitted to a regional neurological unit. A scan showed that she had a left parietal glioma. She still remembered being seen by the neurosurgeon after her scan at 11 at night:

“We are taking it out in the morning!”

The skiing was cancelled but what a story.

Best GP

Best Specialist

NHS

Monday, May 21, 2018

Bipolar Disorder: Lithium-The Cinderella or Aspirin of Psychiatry?

Lithium in Tap Water and Suicide Mortality in Japan.

Abstract: Lithium has been used as a mood-stabilizing drug in people with mood disorders. Previous studies have shown that highest levels of suicide mortality rate in Japan. Lithium levels in the tap water supplies of each municipality were measured using natural levels of lithium in drinking water may protect against suicide. This study evaluated the association between lithium levels in tap water and the suicide standardized mortality ratio (SMR) in 40 municipalities of Aomori prefecture, which has the inductively coupled plasma-mass spectrometry. After adjusting for confounders, a statistical trend toward significance was found for the relationship between lithium levels and the average SMR among females. These findings indicate that natural levels of lithium in drinking water might have a protective effect on the risk of suicide among females. Future research is warranted to confirm this association.
Australian Trilogy:

Bipolar Disorder: Lithium-The Aspirin of Psychiatry?

 

Fremantle: Medical Heresy & Nobel

 


Tasmania & SIDS: The wasted years!


"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?


Stephen Fry has disclosed that he attempted suicide last year and only survived the “close run thing” when a colleague found him unconscious after he had taken “huge” quantities of pills and vodka.

Fry suffered a nervous breakdown in 1995 while he was appearing in the West End play Cell Mates and disappeared for several days, coming close to suicide.

In 2006 he made a two-part television documentary called Stephen Fry: The Secret Life of the Manic Depressive, in which he spoke to other celebrities including Carrie Fisher and Tony Slattery about their own problems with the illness. In the programme he also disclosed that he had first attempted suicide aged 17 by taking an overdose.

In 2011 he said of his illness: “The fact that I am lucky enough not to have it so seriously doesn’t mean that I won’t one day kill myself, I may well.”

I hope he is on lithium!  
Unless he is doing a Carrle Fisher!

©Am Ang Zhang 2013

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!

I have just received a query from a reader of this blog about Lithium, and I thought it worth me reiterating my views here.      It is no secret that I am a traditionalist who believes that lithium is the drug of choice for Bipolar disorders.

The following is an extract from The Cockroach Catcher:
“Get him to the hospital. Whatever it is he is not ours, not this time. But wait. Has he overdosed on the Lithium?”

“No. my wife is very careful and she puts it out every morning, and the rest is in her bag.”

Phew, at least I warned them of the danger. It gave me perpetual nightmare to put so many of my Bipolars on Lithium but from my experience it was otherwise the best.

“Get him admitted and I shall talk to the doctor there.”

He was in fact delirious by the time they got him into hospital and he was admitted to the local Neurological hospital. He was unconscious for at least ten days but no, his lithium level was within therapeutic range.

He had one of the worst encephalitis     they had seen in recent times and they were surprised he survived.

Then I asked the Neurologist who was new, as my good friend had retired by then, if the lithium had in fact protected him. He said he was glad I asked as he was just reading some article on the neuroprotectiveness of lithium.

Well, you never know. One does get lucky sometimes. What lithium might do to Masud in the years to come would be another matter.

I found that people from the Indian subcontinent were very loyal once they realised they had a good doctor – loyalty taking the form of doing exactly what you told them, like keeping medicine safe; and also insisting that they saw only you, not one of your juniors even if they were from their own country. It must have been hard when I retired.

Some parents question the wisdom of using a toxic drug for a condition where suicide risk is high. My answer can only be that lithium seems inherently able to reduce that desire to kill oneself, more than the other mood stabilizers, as the latest Harvard research shows.
Lithium has its problems – toxic at a high level and useless at a low one, although the last point is debatable as younger people seem to do well at below the lower limit of therapeutic range.
Many doctors no longer have the experience of its use and may lose heart as the patient slowly builds up the level of lithium at the cellular level. The blood level is a safeguard against toxicity and anyone starting on lithium will have to wait at least three to four weeks for its effect to kick in. In fact the effect does not kick in, but just fades in if you get the drift.
Long term problems are mainly those of the thyroid and thyroid functions must be monitored closely more so if there is a family history of thyroid problems. Kidney dysfunction seldom occurs with the Child Psychiatrist’s age group but is a well known long term risk.
Also if there is any condition that causes electrolyte upset, such as diarrhea, vomiting and severe dehydration, the doctor must be alerted to the fact that the patient is on Lithium.
Could Lithium be the Aspirin of Psychiatry? Only time will tell!
Related Posts:


Chile: Salar de Atacama & Bipolar Disorder.


NHS Plot : 5% & Disintegration!


Inspector: Okay. The rules exist because 95% of the time, for 95% of the people, they’re the right thing  to do.


Question: And the other 5%?
Inspector: Have to live by the same rules. Because everybody thinks they’re in that 5%.



©2012 Am Ang Zhang

Most of us who specialise in different specialist medical disciplines do so for the purpose of dealing with 5% of patients.


Yet it is these 5% that central government try their best to not treat. Despite clever attempts, the NHS soup stayed the same: CCGs, FT Hosp., AQPs, OOH, NHS 111. 


Now:

Referral Scrutiny GPs had been put under pressure to refer through their local scheme. One GP partner in England said a local project that started as a 'very useful and helpful referral assessment service' was starting to become a 'referral blocking service'. The scheme amounted to 'arbitrary decisions made by unqualified administrators', said the GP. Others complained the schemes were 'designed to massage waiting list figures'.


Try calling patients clients too! 


Nowhere in the world is health care more disintegrated than in England and there is even pretend integration speak: integration could mean signing away your right to hospital care when you most need it. NHS reorganisation is an attempt to reduce the 5%. Unfortunately some of the 95% tried to gatecrash the 5% hospital party. No, no NHS111 or OOH or even GPs. 


A&Es are still trusted. Why? Because in England the only difference between public and private health is the Cappuccino; the docs are the same. Except perhaps PIP implants.



In one of the episodes of House M.D.

Inspector: Okay. The rules exist because 95% of the time, for 95% of the people, they’re the right thing  to do.
Question: And the other 5%?
Inspector: Have to live by the same rules. Because everybody thinks they’re in that 5%.


In recent days medical tragedies hit the news with regular frequency. What has happened to medical training?

Being brought up in the older medical tradition I have found it engaging to watch the ever so popular House M.D.

It was a relief to hear from my classmates that they too like watching it.

It would not surprise anyone to find that House M.D. has made it to Medical Humanities, a BMJ Journal:
Medical paternalism in House M.D.
M R Wicclair Medical Humanities 2008Deborah Kirklin in the editorial of the same issue commented:

"Fear and pity are not emotions that Dr Gregory House, star of the popular television series 'House M.D.', acknowledges or accommodates in either his professional or private life. He is arrogant, rude and considers all patients lying idiots. He will do anything, illegal or otherwise, to ensure that his patients—passive objects of his expert attentions—get the investigations and treatments he knows they need. As Wicclair argues, House disregards his patients’ autonomy whenever he deems it necessary So why, given the apparently widely-shared patient expectation that their wishes be respected, do audiences around the world seem so enamoured of House? Wicclair’s answer raises interesting questions about the extent to which patients trust the motivations of their doctors. Perhaps, he suggests, for the many viewers drawn to this arch paternalist, there is something refreshing about a doctor willing to risk all—job, reputation and legal suits—in order to fulfil his duty of care to his patients: the duty to take care that his actions or inactions do not harm his patients. Because, for good or for bad (your call), once you’re House’s patient there is nothing he won’t do, no inaction he will tolerate, if he believes that by failing to act he will harm you.”

Wicclair stated:“Paternalism is clearly against the norms of mainstream medical ethics. Informed consent—the principle that, except in emergency situations, medical interventions require the voluntary and informed consent of patients or their surrogates—is a core ethical principle in healthcare. A corollary of informed consent is that patients who are able to decide for themselves have a right to refuse treatment recommendations. Another core principle is that when patients lack decision-making capacity, surrogates should make decisions in line with the wishes and values of the patient. Both of these principles reflect a strong opposition to paternalism in contemporary medical ethics.”
Contemporary medical ethics! Except perhaps in Anorexia Nervosa where the Mental Health Act could be used to force feed in a number of countries. The fact that such force feeding did not seem to reduce mortality is a different matter as some deaths are not by direct starvation.
Wicclair asked:
“Yet House repeatedly acts paternalistically without giving it a second (or even first) thought. Is he right, and is the antipaternalism of mainstream medical ethics wrong; or is House mistaken and is a strong moral presumption against medical paternalism justified?"
To prevent House M.D. from becoming God they have to make him out to be rude and full of personal problems and he even rides a motorbike.
Wicclair offered a way out:
“In the world of House M.D., choices typically are life-or-death choices: if a patient doesn’t receive a certain medical intervention, the patient will die.
“However, in the real world, choices are not always so stark. ……If, after careful consideration, a competent patient decides against having the procedure, it would be unwarranted for a physician to insist that the patient needs it.”

You can read it
 here (may require subscription).
Yet my personal view is this, you may be rich, famous or even well educated, but you may not know all that you needed to know to make that judgment.
As Dr Crippen pointed out there are just three medical procedures that can be dramatically live-saving. You might also want to read Dr Grumble’s personal account here.

At the Hudson Plane Crash earlier this year a quick thinking ferry captain 
Brittany Catanzaro came quickly to the rescue of passengers in near freezing water. She was not a doctor.

In Hong Kong a man died outside a medical centre because a nurse receptionist was following guidelines, 
Guideline V to be precise.Kevin M.D. was charitable about Canadian Health Care when he looked at the tragic death ofNatasha Richardson. A number of papers only picked up the fact she turned away the earlier ambulance, but then this happened:
"After picking her up from the hotel, there was a 40-minute drive to the community hospital, the Centre Hospitalier Laurentien. She did have a CT scan there, and the decision was made within 2 hours to transport her to a tertiary care center, another hour away in Montreal." 
And still no burr holes after the CT scan?
Dr. Crippen said that the brave physician would have drilled the burr holes without the benefit of a CT scan:"It would be a career making or career breaking decision. Few American doctors are brave. Defensive medicine is the order of the day. You cannot have a migraine in the USA without someone ordering an MRI scan."
Has modern medical training managed the unthinkable of producing a new generation of doctors and other medical staff forgetting that they should use their brain? Or have they all been “guidelined” out? Has the 5% finally become the 95% too? 
3212009


Where were you when we needed you, Dr House M.D.? 
House M.D. must have the last words:
Question: "Isn’t treating patients why we became doctors?"

House: "No, treating illnesses is why we became doctors."

Granddad: Remember Iceland? Why did you not learn?

Hallgrimur Church, Iceland

 ©2012 Am Ang Zhang

The report comes after The Independent revealed that 51 councils who lost £470m when Iceland's banking system collapsed employed Butlers – an ICAP subsidiary – as their treasury management advisors. ICAP in turn received commission from Icelandic banks for brokering 16 per cent of those investments.


The business empire of the Conservative Party treasurer and chief fundraiser Michael Spencer should be investigated over the propriety of its dealings with local councils and other public bodies, MPs say today.

The Communities Select Committee say in a scathing report that the Financial Services Agency (FSA) should investigate whether it is appropriate for one part of Mr Spencer's ICAP empire to assist council finance officers with council investments while another part receives fees for brokering the deals. This could give rise to "actual or perceived conflicts of interest", it said. The FSA said it would consider the request.

Of the 116 local authorities who lost money, 51 received advice from Butlers. 


Granddad: Why? 

I went to school and they told us all about doing good and preserving our oceans and our planet. Your minister insisted that instead of abandoning nuclear power as it was the most expensive failure he would embrace it. Did not sound like learning anything at all:

The climate change secretary, Chris Huhne, has described the UK's nuclear policy as the "most expensive failure of postwar British policy-making" in a "crowded and highly-contested field".

…..Speaking at the Royal Society on Thursday, Huhne said: "If we are to retain public support for nuclear as a key part of our future energy mix then we have to show that we have learned the lessons from our past mistakes."

…..Huhne noted the UK has enough high-level nuclear waste to fill "three Olympic-sized swimming pools, and enough intermediate waste to fill a supertanker". Because of the errors of the past, his department was spending £2bn a year "cleaning up" the "mess" of nuclear waste which he said would rise two thirds next year.

"Nuclear energy has risks, but we face the greater risk of accelerating climate change if we do not embark on another generation of nuclear power. Time is running out. Nuclear can be a vital and affordable means of providing low carbon electricity," he said.

I thought you might have learnt after Andy CoulsonRiotsMurdoch and Liam Fox, you might choose to listen to some decent advice.

Granddad: Why? 

The nuclear power failure may turn out to be the 2nd most expensive failure: The NHS failure is turning out to be many times more.

You should have listened to Baroness Kennedy of The Shaws  who neatly summarise what many bloggers and doctors were saying for months:

Care, not money:
My Lords, I make a declaration that I am a fellow of three royal colleges, too, like the noble Baroness, Lady Cumberlege. I should also say that I am married to a surgeon who has spent his life in the National Health Service. He is from a dynasty of doctors. His grandfather was a doctor, his mother a doctor, his aunt a doctor and now our daughter is entering medical school. They all entered medicine not because they are interested in making money but because they want to care for people. It is the idea of being at the service of others that draws most health carers into medicine. They do not want to run businesses; they do not see their patients as consumers or themselves as providers. They do not see their relationship as commercial and they do not want to be part of anything other than a publicly funded and provided National Health Service.

Private Providers and Secrecy:
Health professionals also feel proud, as all of my husband's colleagues do, that Britain is the only country in the industrialised world where wealth does not in some measure determine access to healthcare. They are saddened that the National Health Service is now facing the prospect of becoming a competitive market of private providers funded by the taxpayer. When we hear talk of accountability, they point out that nothing in the Bill requires the boards of NHS-funded bodies to meet in public, so there will be a lack of transparency. That will be complicated by the fact that private providers are not subject to the Freedom of Information Act, so they can cite commercial sensitivity to cover their activities.

Insurance-based model by stealth:
Others have spoken of the removal of the duty on the Secretary of State to provide healthcare services and pointed out that that duty is now to be with unelected commissioning consortia accountable to a quango, the national Commissioning Board. The Bill does not state that comprehensive services must be provided, so there may well be large gaps in service provision in parts of the country, with no Secretary of State answerable. Providers will be able to close local services without reference of the decision to the Secretary of State. Although the Government say that the treatment will be free at the point of delivery-we hear the calm reassurances-the power to charge is to be given to consortia. That paves the way for top-up charging and could lead eventually to an insurance-based model.

Monitor & family silver:
Monitor, the regulator, is to have the duty to sniff out and eliminate anti-competitive behaviour-and, of course, to promote competition. According to the Explanatory Notes to the original Bill, Monitor is modelled on
"precedents from the utilities, rail and telecoms industries".
How is that for reassurance to the general public? If anything should be a warning that this spells catastrophe, it should be that this is another step in the disastrous selling-off of the family silver to the private sector, with the public eventually being held to ransom and quality becoming second to profitability.

Monitor: Competition or integration.
The regulator, Monitor, will have the power to fine hospital trusts 10 per cent of their income for anti-competitive behaviour. Any decent doctor will tell you that for seamless, efficient care for patients, integration is key to improving quality of life and patient experience. The question is whether competition and integration can co-exist. Evidence from the Netherlands is that they cannot. There, market-style health reforms designed to promote competitive behaviour have meant that healthcare providers have been prevented from entering into agreements that restrict competition, so networks involving GPs, geriatricians, nursing homes and social care providers have been ruled anti-competitive. There is a fear that care pathways, integrated services and equitable access to care in this country will be lost when placed second to market interests.

Delusion of patient choice: Cherry Picking
Under the delusion of greater patient choice, people are to be given a personal health budget. I am interested to hear what happens if it runs out halfway through the year. Private hospitals will enter the fray as treatment providers and, as in other arenas, they will undoubtedly, as others have said, cherry-pick and offer treatment for cases where they can treat a high number of low-risk patients and make a profit-for example, hip and knee replacement, cataracts, ENT and gynae procedures.

NHS Hospitals: Undermined!
It is essential in an acute teaching hospital to retain the case mix, though, so it will be the teaching hospitals that will also provide the loss-making services such as accident and emergency and intensive care and deal with chronic illness and the diseases of the poor, such as obesity-we can name them all. These are essential services but they are also very costly. An ordinary hospital cannot provide them if it does not have the quick throughput cases as well to maintain a financial balance. If relatively easy procedures go to private providers, the loss of revenue to the trusts will eventually lead to them being unable to provide the costly essential services. It will mean that doctors trained in these places are not exposed to all aspects of patient care. Private companies cherry-picking services undermines and destabilises the ability of the NHS to deliver essential services like, as I have mentioned, intensive care units, accident and emergency, teaching, training and research.

Asset Stripping: as Southern Cross
Clause 294 allows for the transferring of NHS assets, including land, to third parties, and the selling off of assets. Clause 160 allows for the raising of loans by trusts, so hospitals taken over by the private sector could be asset-stripped and then sold on, as happened with Southern Cross homes.

Practice Boundaries:
The removal of practice boundaries and primary care trust boundaries will mean that commissioning groups will not be coterminous with social services in local authorities, so vulnerable people are more likely to fall through the gaps between GP practices. GPs will also be able to cherry-pick by excluding patients who cost more money and can lead to overspend.

Lawyer-multimillion-pound executive salaries, dividends and fraud:
Then there is the issue of the cost of market-based healthcare. Advertising, billing, legal disputes-I say this as a lawyer-multimillion-pound executive salaries, dividends and fraud could end up consuming a huge amount of the pot that can be spent on front-line services. We will end up, as in America, with that extra stuff taking up 20 per cent of the health budget. The downward spiral of ethics, the increase in dishonesty and the conflicts of interest become huge, and you see the destruction of the public service ethos.

Overdiagnoses, overtreats and overtests.
I want to scream to the public, "Don't let them do it"-and in fact the public are responding by saying in turn, "Don't let them do it". Market competition in healthcare does not improve outcomes. The US has the highest spending in the world and the outcomes are mediocre. The US overdiagnoses, overtreats and overtests. Why? Because that increases revenue. You change the nature of the relationship between doctors and their patients. You get more lawsuits and doctors therefore practise defensive medicine. You ruin your system.
I say this particularly to colleagues on the Liberal Democrat Benches. They may be being encouraged to think that voting against the Bill may bring down the coalition, but all I can say is that the electorate is watching. If people feel failed by the party on this, I am afraid that it will pay a terrible price.

McKinsey et al: 25 year plot:
This has been a 25-year project, done by stealth. It started with the internal market and is now moving to the external market. It was not thought up by mere politicians but by the money men, the private healthcare companies and the consultancies like McKinsey-the people, in fact, who in many ways brought us the banking crisis. They have funded pro-market think tanks and achieved deep penetration into the Department of Health, into many of our health organisations and right into some of the senior levels of my party as well as those on the other Benches.

The NHS is totemic. It is about a pool of altruism and it speaks to who we are as a nation. It is the mortar that binds us in the way that the American constitution does the American people. For us, it is about this system. It really is the place where we are "all in it together"-one of the few places, it would seem at the moment. Doctors get 88 per cent trust ratings with the public, while politicians get 14 per cent. The vast majority of doctors are saying to us, "Withdraw this Bill". We should be listening.

Granddad, I have read most of these behind your back via Twitter and many Blogs. You should have listened. Now we are paying dearly.


Hansard source (Citation: HL Deb, 11 October 2011, c1551



Monday, May 21, 2018

Saturday, May 12, 2018

Photography: Black & White beauty!

Friday, May 11, 2018

Mental Health Awareness: Clozapine & Finland

Gold Standard!


Autumn Gold and Gold Standard in Finland:


© 2012 Am Ang Zhang

There have been many challenges to Clozapine but to the Cockroach Catcher it will remain the Gold Standard for the treatment of Schizophrenia for a long long time.

An extract from The Cockroach Catcher:

……...Martina was already at the adolescent inpatient unit when I arrived. She was supposed to be schizophrenic. The family were refugees from Sudan. They were a small Sect of Catholics that were said to be persecuted.
Martina was not very communicative but her records and observations by her outpatient psychiatrist indicated that the diagnosis was robust enough. However, after over a year in hospital she was not improving and we had tried the newer antipsychotic without making much headway.
There was one thing left to do – to put her on Clozapine.
I was once at one of these big drug firm meetings when all the big boys on the newer antipsychotics were there.
Having filled my plate from the delicious buffet, I sat next to two nicely clad representatives.
“So you ladies are from Novartis?” I did my usual stunt.
“How did you work that one out?”
“Well, you two have the best designer outfits and I guessed you must be from the makers of Clozapine.”
They were there to see what the opposition might come up with but as far as I was concerned no other pharmaceutical would touch them for decades.

After today’s Lancet publication they might not need to worry at all!

The Lancet, Early Online Publication, 13 July 2009
11-year follow-up of mortality in patients with schizophrenia: a population-based cohort study (FIN11 study) Jari Tiihonen et al. 

According to Reuters:
…………An analysis of 10 years' records for 67,000 patients in Finland found that, compared to treatment with the first-generation drug perphenazine, the risk of early death for patients on clozapine was reduced by 26 percent.

By contrast, mortality risk was 41 percent higher for those on Seroquel, known chemically as quetiapine; 34 percent higher with Johnson & Johnson's Risperdal, or resperidone; and 13 percent higher with Eli Lilly's Zyprexa, or olanzapine.
"We know that clozapine has the highest efficacy of all the antipsychotics and it is now clear, after all, that it is not that risky or dangerous a treatment," study leader Jari Tiihonen of the University of Kuopio said in a telephone interview.
"We should consider whether clozapine should be used as a first-line treatment option."Tiihonen estimates clozapine is given to around one fifth of Finnish schizophrenia patients, but less than 5 percent in the United States.Clozapine's side effects include agranulocytosis, a potentially fatal decline in white blood cells, and current rules stipulate the drug can only be used after two unsuccessful trials with other antipsychotics.Tiihonen and colleagues wrote in the Lancet medical journal that these restrictions should be reassessed in the light of their findings, since not using the drug may have caused thousands of premature deaths worldwide.
According to AP:

James MacCabe, a consultant psychiatrist at the National Psychosis Unit at South London and Maudsley Hospital, called the research "striking and shocking." He was not linked to the study.
"There is now a case to be made for revising the guidelines to make clozapine available to a much larger proportion of patients," he said.
Tiihonen and colleagues found that even though the use of anti-psychotic medications has jumped in the last decade, people with schizophrenia in Finland still die about two decades earlier than other people.

Tiihonen said the pharmaceutical industry is partly to blame for why clozapine has often been overlooked. "Clozapine's patent expired long ago, so there's no big money to be made from marketing it," he said.


Clozapine Data: FinlandRCPU.K.NEJM
Abstract:The Lancet.

Related Posts
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Alaska Zyprexa: DOJ at last.
Alaska, Good Friday Earthquake and Zyprexa 
Alaska Zyprexa: Follow Up
Bipolar and ADHD: Boys and Breasts
Antipsychotics: Really?
Humber Mental Health Teaching NHS Trust: Learning From The Past.

Wednesday, May 9, 2018

Mental Health Awareness: Fake? Or What?


Child psychiatry is not about asking questions, 
but about feeling the answers. 
It is a discipline where empathy rules. 

Protea, Cape Floristic Region (CFR) of South Africa
 ©Am Ang Zhang 2005

South Africa reminded me of my junior doctor and my hiccup boy.

The Cockroach Catcher: Chapter 13  Hiccup Boy

  
         J
ohnny was referred by his GP to me because he had been having non-stop hiccups for the better part of six months. It was unusual for the problem to have gone on for this length of time before being referred to me. His doctor was one of those who seldom referred anyone. He tended to believe that there must be a physical reason, especially for a condition like hiccups. The boy had even been to the National Hospital for Nervous Diseases at Queen Square and Great Ormond Street.  Both sent him back to the GP saying that his problem was probably psychological and perhaps the local psychiatric clinic might be of help. 

          At the time my junior doctor Dr Zola was a girl from South Africa who decided that, given the new situation in her country, she wanted to emigrate to Israel where her doctor father, mother and three brothers were. She was an eager learner and would follow me to every single case I saw and even to meetings. She truly shadowed me. I had no complaints at all and she still writes to the clinic every year to tell us how she is doing.  After training with us she was able to get into the professorial child psychiatric department in Jerusalem.



         For what I did to her on this hiccup case she would never forgive me and to this day she will still remind me of it.

         Johnny was an unattractive obese boy of twelve with a similarly unattractive obese mother. Together they looked a picture, an ugly one.
         This led me to draw my first impression: he was a “bullyee”, i.e. someone who would be a target of bullying – in school, in the streets, in football matches and in fact everywhere.
         He was holding a big bottle of Coke - the two litre bottle, and so was mum. It was August and England was having its unusual heat wave.
         This led me to draw my second impression: (no, not about obesity – that is too obvious) he did not hiccup when he was drinking from the bottle.
         So within the first few minutes, I knew what to do.
         “Dr Zola, would you mind taking mother to the other room to get some history?”
         I knew from her look she was reluctant. She had heard of my many magic cures and she knew she was about to miss one. But she had also come to like my style and my work.  She really had no choice but to take mum to another room. Meanwhile Johnny was happily hiccupping away between sips of Coke.
         I have often said to many of my juniors that child psychiatry is not about asking questions, but about feeling the answers. It is a discipline where empathy rules. It is important that you know within ten minutes or so what is wrong.
         Dr Zola, I think, felt it too. She knew I was going to perform one of those cures.

         By the time I asked both of them to come back the hiccups had stopped and I had a mother who looked both surprised and embarrassed, and Dr Zola looked as if she would not talk to me till after the next Sabbath.

         After sending the patient and mother off with instructions and another appointment date, I had to deal with a very unhappy junior.
         “What did you do?” she demanded to know.
         “You really want to know?”
         “Yes, I need to learn.”
         “Something unorthodox.”
         “Did you hypnotise him?”
         “No. Maybe I shall tell you another day as I am not sure if he will sustain his recovery.”
         I did like to tease some of them. Dr Zola was having none of that. It was Friday and I knew she had to leave early for Sabbath, but sunset was later in August.
         I asked if she noticed that he could take long sips of Coke without hiccups and this often did not happen with true hiccups.
         Dr Zola said, “I thought the Coke was one of the factors for his and his mum’s obesity.”
         That was obvious but I decided not to say it as it would be too patronising.
         What happened was I said to Johnny, “It is school, isn’t it?” He nodded. “Now if I sign you off school as of now, do you think these hiccups might go away?” He nodded.
         Dr Zola said, “That’s it?”
         “That’s it. But I really do not think he would have stopped had anyone else been there. I gave him a sense of security. His secret was safe with me.”
         I think in the end Dr Zola understood, but to make a boy who sustained the hiccups for so long stop without resorting to heavy medication like Chlorpromazine or Haloperidol is indeed one of life’s sweet events.
         I do not think my secretary ever got over it when she typed my notes and letter.
         It is often better though if you can somehow get the parents to do the magic cure.
           

           
The Cockroach Catcher has a full review on Amazon.

Here is an excerpt:
BOOK REVIEW, by Peter Chang. 

Reading this book was truly a trip down memory lane for me. Although Zhang settled in the United Kingdom, and I in Canada, I can identify with much of his experience as a psychiatrist. This book helps to demystify mental illness and humanize the doctor-patient relationship. I am very impressed by Zhang's down to earth approach to problem solving. The secret to his success in therapy is the respect that he gives to his patients, their families and his colleagues. Just by listening to his patients and believing in their stories, Zhang is able to perform miracles, such as the "Seven Minute Cure" (Chapter 1), Ping Pong (Chapter 24), and "Bullying" (Chapter 23).

Zhang has a special talent for engaging difficult patient in therapy, as exemplified in "Wrong Foot" (Chapter 12), "Hiccup Boy" (Chapter 13), "Failure" (Chapter 34), and "Yellow Card" (Chapter 46). As Zhang finds coercive treatment distasteful, such as force feeding an anorexic patient, he is good at negotiating with patients so that they would voluntarily eat again to achieve their own individual goals. For instance, the patient in Chapter 34 started to eat again because she did not want to be "sectioned" (meaning certified under mental health laws) which would prevent her from going to the United States to pursue higher education. 

While most doctors are content with taking a medical history, Zhang would listen to his secretary and cleaning staff to learn about the milieu, thus gleaning useful information that can help his patients. It reminds me of Confucian humility. Confucius says: "When three men walk together, I have a teacher among them". 

As Western trained psychiatrists with Chinese heritage, Zhang and I are not confined to particular schools of thought. Neither of us has felt the compunction to subscribe to a particular theory, such as being Freudian, Jungian or a behaviorist. We aim to be "eclectic", that is, to use whatever that works. In 1970's, psychoanalysis dominated training institutions for psychiatrists in U.K. as well as in Canada. I can see in the book that while Zhang is educated in psychoanalysis, he is not bound by it in his practice. His creative and innovative approaches to clinical problems remind me of the now popular "C.B.T." (cognitive behavior therapy). 



Full review on Amazon.




The Cockroach Catcher on Amazon Kindle UKAmazon Kindle US

Monday, May 7, 2018

Mental Health Awareness: Bobby Baker & The Peril of Diagnosis


In The Cockroach Catcher is a Chapter called “The Peril of Diagnosis”, in which I highlighted three cases where a definitive psychiatric diagnosis was in the end more a hindrance than an aid, as that focused all attention on the cure of the symptoms and little else on the resolution of the underlying psychiatric problems.........In one of the letters from my contacts at the clinic, I was told that Jane had to be admitted to a hospital in London. Her weight was so low that she was on tube feeding.
News of a famous heiress just flashed through this morning’s news and the psychodynamics of Jane’s Anorexia Nervosa suddenly became clearer. The heiress witnessed her uncle’s murder and was anorectic ever since. Jane was home when her father died in mother’s arms with a massive haemoptysis (coughing up of blood, a rare but not unknown effect of lung cancer, generally a massive bleed). It must have been very traumatic.
How dim of me. That was bereavement, a slow suicide by someone who felt less worthy to survive........
I recently visited the Wellcome Collection for their Madness and Modernity exhibition: about mental illness and the visual arts in Vienna 1900.
It was an interesting experience looking back at “treatment modalities” of mental disturbance in one of the most cultured city in Europe at the start of the 20th Century. There was an ancient Chinese saying: 50 steps laughing at 100 steps – a reference to a deserter who ran 50 steps from a battle field laughing at someone who ran 100 steps. Are any of our present day methods any better than what the Viennese dreamed up over a century ago? At least the mental patients (yes, still patients) then had somewhere specially designed and safe to practise their art and be contained. Will the next generation of psychiatrists laugh at what we are currently practising?

It was no coincidence that right next to the Madness and Modernity exhibition is the show of 
Bobby Baker’s Diary Drawings: Mental illness and me, 1997-2008.

Bobby Baker Wellcome Trust

Bobby Baker is a successful performance artist who had suffered acute psychiatric problems including self harming, which she captured over a period of 10 years in hundreds of 'diary drawings'. These paintings (158 drawings, selected from a total of 711) and commentaries demonstrated her anger with the mental health service and any viewer thinking of entering psychiatry might be put off forever.

Bobby was told by the first psychiatrist she saw that she suffered from 
borderline personality disorder. (Time article link)
As her story unfolded in her drawings, one gets an uncomfortable feeling about the state of our psychiatric service and wonders if we are even at the 50th step. She has triumphed over some of life’s most frightening experiences despite all.

Bobby Baker Wellcome Collection

“As my ability to function improved, hell became more firmly encased in my skull. I’ve formed the opinion…..that psychosis is a metaphor for extreme suffering. My delusions led to paranoia that a network of professionals was constantly searching for evidence that I was wicked. …….Medication didn’t help – it just made me fatter and fatter.” Bobby Baker Wellcome Collection Exhibition pamphlet.
As a psychiatrist, I could not help being curious about the lack of an early history, having just come from a room showing a replica of Freud’s couch. According to Freud most mental disturbances have roots in one’s early childhood. 
The puzzle was solved when I read in the Observer of an interview with her:

“I don't know how but I must ask about her father next - the classic therapist's question is, in her case, inescapable. Again, a picture speaks first. In Telling Keith, she is weeping, her tears bizarrely swirling upwards. Her mouth is open and a sea floods out - in the middle is a tiny, drowning figure. ‘That's my father,’ Baker says. ‘I know,’ I say. I know because, in her autobiographical show Box Story she told audiences about a summer holiday in Brancaster, Norfolk when she was 15 and had just received her surprisingly good O-level results. Telling her father her news was 'the best moment in my life' and he gave her the happiest of hugs. She asked whether he was coming to lunch? Not straight away, he replied. He would have a dip first. A bit later, they heard a woman's voice shouting, ‘Help! Help! Help! A man's been washed out to sea.’ Her mother leapt to her feet shouting, ‘My husband! My husband!’” 
Kate KellawayObserver, Sunday 28 June, 2009.

Like my own patient, Bobby Baker suffered from bereavement.

You won’t be able to see the Madness and Modernity as it has finished, but the Bobby Baker drawings are on show at the Wellcome until the 2nd of August. Those running our psychiatric services should perhaps have a good look as they may well be featuring in a future Wellcome Exhibition. 



Slide Show: Guardian.
Related:

Can They Draw: From Picasso to Matisse 
Picasso, Medicine and Lloyds 
Picasso and Tradition
“Wake-up Call” to British Psychiatry 


Bipolar and ADHD: Boys and Breasts
Antipsychotics: Really?
New Link:
Jobbing Doctor: What a way to run a service.

Thursday, May 3, 2018

Anorexia Nervosa & Mountains: Misguided Belief in Psychiatric Diagnosis!





 ©2016 Am Ang Zhang 

Thirty years ago, I saw mountains as mountains, and waters as waters.

When I arrived at a more intimate knowledge, I came to the point
where I saw that mountains are not mountains,
and waters are not waters.
Thirty years on,
I see mountains once again as mountains, and waters once again as waters.

                                                                                                   Adapted from Ching-yuan (1067-1120)

There is a misguided belief that Psychiatry is like other branches of medicine, that we make diagnosis as if we know the definitive cause, course of treatment and prognosis.

I accept that even in other branches of medicine, what we used to know sometimes can be turned upside down overnight. We only need to look at the evolution of the understanding and treatment of Leprosy and Tuberculosis over time, and in the modern era, that of HIV/AIDS.
I was brought up to understand that “scientific truth is nothing more than what the top scientists believe in at the time.” In this modern era of “biotech” approach to medicine, new understanding is yet to be found for many conditions. In these cases, are we content to continue with empirical and symptomatic approaches?

Anorexia Nervosa comes to mind and this is one of the conditions that have for want of a better word captured the imagination of sufferers and public alike. I have already posted an earlier blog on its brief history.

Sometimes a diagnosis as powerful as Anorexia Nervosa can be a hindrance to the improvement of “sufferers”. Over my years of practice, I found that those who did well were cases where we indeed moved away from the medical/conventional psychiatric model to a somewhat paradoxical approach.

When I took over the adolescent unit as its consultant in charge there were six Anorexia Nervosa patients in varying stages of emaciation or weight gain depending on from which side you want to look at it.  It is not always wise to have so many anorectic patients together as they do share tricks with each other and it is often more difficult to customise treatment.



         What needed my urgent attention was of course Sammy. Sammy had a very feminine name but preferred the nickname Sammy. Sammy’s Section was due to expire in less than 14 days and I had to compile a report for the Tribunal which would be sitting to decide on her fate.

         It was perhaps a sign of our failure as psychiatrists to effectively treat Anorexia Nervosa that eventually case law was established to regard food in Anorexia Nervosa as medicine. Therefore food may be used forcibly to treat Anorexia Nervosa when the condition becomes life threatening. 

         The usual test of mental capacity no longer applies. Instead the law is used forcibly to feed a generally bright and intelligent person “over-doing” what most consider to be “good”.  They try to eat less and eat healthily by avoiding fat and the like and wham we have the law on them.

         I have to admit that I have not liked this aspect of Sectioning. Unfortunately it is used often, judging by the high numbers of tube fed patients.

         On the other hand not everybody is able to treat Anorexia Nervosa patients or, in reality, do battle with them. It requires experience, energy, time, wit, charisma and often impeccable timing. However, sometimes I do wonder if we are indeed doing a disservice when we take things out of parents’ hands by agreeing to take over.

 ©2016 Am Ang Zhang 
         With hindsight and upon reflecting on a number of cases I have dealt with, I often wonder: if hospitalisation had not been an option at all, would improvement rate and, more importantly, mortality rate have been any different.

         We do not section people for smoking, drinking, or doing drugs, which all endanger life. Nor do we stop people running the Marathon or eating raw oysters when these activities regularly lead to mortalities.

         Society is coming round to do something about over-eating in children but it will take some time before they apply the Mental Health Acts. 

         To me, the moment a psychiatrist turns to the law he is admitting that he has failed. 

         At least that is my view and if I perpetuated the Compulsory Order with Sammy, I too would be part of that failure.

         There had been no weight gain in Sammy despite the tube feeding and the debate was: shall we increase the feed or shall we wait? Everybody just assumed that she would stay on as a compulsory patient.

         Despite bed rests and even more embarrassingly the use of bedpans, many Anorexia Nervosa patients managed not to gain weight whatever we pumped into them. The balanced feeds were in fact quite expensive. There was no secret that they were aware of the exercises they could perform even on bed rest and the determination not to put on weight had to be seen to be believed. If such determination was applied elsewhere I was sure these young girls could be very successful.

         I had to find an answer, an answer for Sammy and an answer for myself.

         Being forced to eat by the State remained the treatment of choice for everybody except for one stubborn consultant.

         “At least we did all we could,” my staff constantly reminded me.
         “And she is the most determined of all the Anorectics we have right now.”
         More reason to show the others that this new psychiatrist had some other means than brute force, I thought to myself. 

         Yes, I could be as determined as they were.

         The hours of family therapy only brought about accusations and counter accusations with hardly any resolution. Middle class families have certain ways of dealing with things where some branches of family therapy are not particularly good at all.

         The modern trend is certainly moving away from blaming families.  Or that is the rhetoric of most who write publicly about it.

         Whatever the official line, families cannot help feeling blamed.

         “If we are not to blame, why do we need family therapy?”

         “There are so many other families like ours.  Why do they not have the same problem?”

         We may reassure them that there are and that is the truth, but the truth is that there are also Anorexia-free families.

         Yes, it might help if they do find a gene like they did with obesity.  Yet that cannot explain why there are more extremely obese people in say the U.S. which collects gene pools from across the globe.

         So Sammy’s family had the full benefit of eight sessions of family therapy by two very experienced therapists. In the end, there was just a lot of recrimination between all parties including the therapists and all agreed it would not be the way forward. That was when tube-feeding started.

         Minuchin[3] dealt with over-involvement, over-protectiveness and conflict avoidance in these families with no special apology on whether he blamed the family or not. He used to start with a meal session with the family. His success, like many such methods, probably had more to do with his charisma than his method and is thus difficult to replicate.

         For Sammy and her family the message was simple and clear enough, no matter how hard we lied.

         The family had failed and the hospital had to take over.

         That was the blunt truth. 

         But the hospital had failed too and we had to resort to the Mental Health Act on one of society’s most sensible and decent and safest citizens. 

         I decided enough was enough. I could no longer perpetuate the no-blame approach. I could no longer continue to hide behind the power conferred onto me by the law. 

         In short, I had to reverse just about everything that had gone on before, and more.

         Just two weeks before the tribunal sat we had the big review meeting. To most at the unit, the review was fairly routine as there was hardly any choice – a full Section for Hospital Treatment primarily intended for difficult to treat Schizophrenics and difficult to control Bipolars in the acute manic phase. Sammy would be “detained at Her Majesty’s pleasure”, and classed with the likes of the few psychotics who had committed the most heinous murders. To save Sammy’s life, it would be natural to continue with the Mental Health Act.

         Yes there would be weeks of tube feeding and bed rest, but the State had to take over the complete care of this bright young thing for her own sake.

         I could not see any other way either.

         Unless …….I could reverse everything that had gone on before.  

         If our work is to be therapeutic then a sort of therapeutic alliance is important, even if tentative.  Some people do not realise that you can fight with your patient and still have a sort of therapeutic alliance.

         I had a plan.

         These meetings were attended by just about everybody who had anything to do with the patient.  They were held at school times so that most of the teaching staff could be present as well. These meetings also had a tendency to drag on as everybody seemed to have a lot to say about very little, a trait not just limited to psychiatrists but also seen in social workers, therapists, nurses, junior grade doctors, teachers and visiting professionals. People always seemed to have a lot to say on cases where there was the least progress. 

 ©2016 Am Ang Zhang 
         My personal view is that this was a sure sign of anarchy which had unfortunately drifted into our Health Service, encouraged in part by the numerous re-organisations that had gradually eroded the authority of the doctor. 

         Saul Wurman[4], an architect by training but also an author of business and tour books, famously wrote that meetings really do not always need to be an hour long. Why can it not be ten or twenty minutes?

         Could I achieve that?

         After briefly explaining to all the purpose of the meeting, I turned to Sammy, who still had the nasal feeding tube “Micropore’d[5]” securely and said, “What do you think?”

         “It is so unfair.  Now I shall not be able to go to Harvard.”

         It is generally perceived as a given that a U.K. citizen who has been Sectioned will not be able to use the Visa Waiver to visit the U.S. If that person then has to apply for a Visa, having been detained under the Mental Health Act must be a major hindrance, although I have never seen this applied in practice. One of my patients did have to cancel a horse trial trip to Kentucky because she was sectioned at the height of a manic episode.

         I did not know she had aspirations to get to Harvard but I was not surprised given what I already knew about mother.

         “Before I say anything else, can I ask you a few things?”
         “What? Sure!”
         “Do you smoke, drink, take Ecstasy or go out clubbing?”
         “No.  Why?”
         “Do you have piercings and tattoos on you?”
         “Tattoos—yuk!  Yes, I having my ears pierced. That is all.”
         “Do you like Pop music?”
         “No way. I play the violin and I like Bach and Bartok!”
         Everybody was attentive now.
         “Do you shoot heroin or smoke Cannabis?”
         “No way!”
         She was getting annoyed.
         “What about boys and sex?” I felt bad even to ask especially in front of her mother, who I thought would faint if we knew something she did not.
         “How can you even ask and in front of my parents? You know I don’t do things like that!”

         I can remember my own adolescence. I did not do any of those things either and I did not even have pierced ears.

         I then turned to the parents.  Mother was a history teacher at a famous private school in one of England’s most middle class town. She also spent a year at Harvard, hence Sammy’s ambition to follow her. Father was a prominent city lawyer.

         “You have always provided well for her, a good education, European and U.S. holidays, a comfortable home and expensive music lessons.”

         “We are fortunate enough to be able to do that. She is our only child.” Mother replied in a tone implying, “what’s wrong with that?”

         “And she has always been a bright child, strong willed and single minded. She passed her Grade 8 violin with distinction at 14 and could have become a musician. But she wanted to do International Studies.” Mother added.

         “So she always had her way.”
         “She has always got on with everything, studying and practising the violin. And she keeps a tidy bedroom!”
         A tidy bedroom! My goodness, everything was falling into place.
         “Sammy……”
         “Yes……”

         “You know what? You are the first adolescent I know that keeps a tidy bedroom, do not do drugs, do not drink, do not smoke and you do not do a load of other things I asked you about. You are by modern standards a FAILED adolescent!”
         Then I turned to the parents.
         “And you, FAILED parents!”
         “And we FAILED you. We failed you because we had to hide behind the law and force fed you.”
         Sammy said, “I can’t do all those things even if you make me.”
         Ah, the turning point.
         “No, don’t get me wrong. I don’t want you to either.”
         I then told her that I would like to take the tube off her despite lack of progress, or because of it.
         It simply had not worked.
         I wanted her to take over, do what she needed to do and I would decide in about ten days if I had to extend the Treatment Order.
         Forty five minutes. The meeting took forty five minutes as people had to present summaries of different reports, the details of which were irrelevant here.
         The battle was over. Sammy looked relaxed. Nobody was fighting her now. She was back in control.
         I took her off the Section as she started to put on weight and before long she was discharged. 

         We forget how easy it is to entrench. To entrench is a sure way to perpetuate a problem.


Tuesday, May 1, 2018

World Class Hospital Medicine: Pride, Hope & Faith!


Pride:
Those doctors that grew up here may not know but those of us from overseas looked forward to coming for our specialist training in this country. A number of us went to the US and they did well too. There was little doubt that for many the years of training in the top hospitals here will guarantee them nice top jobs in Hong Kong or the rest of the commonwealth.

Why?

We provided World Class Medicine without trying. We did!

                                                                                 A quote from a fellow blogger, Dr. No.

What many politicians may not know is that pride in what we do is often more important than money or anything else. Our pride is one sure way to ensure quality of practice.

Do we really want to take that away now? Years of heartless re-organisation has left many of us dedicated doctors disillusioned. Many young ones have left. Poorly trained doctors that have no right to be practising medicine now even have jobs in some of these well known hospitals. Others are now unable to diagnose the most basic of emergencies such as appendicitis and what hope is there that they will diagnose meningitis?

Can we continue to practise World Class Medicine even if we wanted to?

Here is a reprint:

Tuesday, May 24, 2011

It is well known that we as doctors do not have all the answers and we can only base our diagnosis and treatment on current knowledge.

Patients or their relatives are used to trust the judgment of doctors and always hope for a better or even miraculous outcome. Their faith in their doctor is often supplemented by their own religious faith.

David Cameron is no different and he has stated so on record.

I am not here to analyse his faith.

I am here to re-tell one of the stories of hope and faith I have experienced as a very junior consultant in 1978:

The Mayo of the United Kingdom
The year was 1978 and I was employed by one of the fourteen Regional Health Authorities. The perceived wisdom was to allow consultants freedom from Area and District control that may not be of benefit to the NHS as a whole so the local Area or District Health did not hold our contracts. Even for matters like Annual Leave and Study Leave we dealt directly with RHA.

Referrals were accepted from GPs and we could refer to other specialists within the Region or to the any of the major London Centres of excellence. Many of us were trained by some of these centres and we respected them. They were the Mayos and Clevelands and Hopkins of the United Kingdom.  

Money or funding never came into it and we truly had a most integrated service.
We used to practice real, good and economical medicine.


The unusual cases:
Child Psychiatry like many other disciplines in medicine does not follow rules and do not function like supermarkets. Supermarkets have very advanced systems to track customer demands and they can maximise profit and keep cost down. In medicine we do sometimes get unusual cases that would have been a nightmare for the supermarket trained managers.


As it is so difficult to plan for the unusual it will become even more difficult if the present government had its way (and there is every sign that they will), not only will the reformed NHS find it difficult to cope with the unusual, it will find it extremely difficult to cope with emergencies.



Supermarket:

Why? These cases cost money and in the new world of Supermarket Styled NHS, they have to be dealt with! For that reason, not all NHS hospitals will be failed by Monitor. Some will need to be kept in order that someone could then deal with unprofitable cases. They will be the new fall guys.



But supermarkets can get things wrong too. In Spain after the Christmas of 2009 there were 4 million unsold hams.



©Am Ang Zhang 2010





Back to the patient:

Would my patient be dealt with in the same way in 2011?


     GP to Paediatrician: 13 year old with one stiff arm. Seen the same day.
     Paediatrician to me: ? Psychosis or even Catatonia. 
           Seen same day and admitted to Paediatric Ward, DGH.
     Child Psychiatrist to Gynaecologist: ? Pregnancy or tumour. Still the same day.
     Gynaecologist to Radiologist: Unlikely to be pregnant, ? Ovarian cyst.
     Radiologist (Hospital & no India based): Tell tale tooth: Teratoma.
     Gynaecologist: Operation on emergency basis with Paediatric Anaethetics Consultant. Still Day 1.
     Patient unconscious and transferred to GOS on same day. Seen by various Professors.
     Patient later transferred to Queen’s Square (National Hospital for Nervous Diseases), 
             Seen by more Professors.
     Regained consciousness after 23 days.
     Eventually transferred back to local Hospital.


None of the Doctor to Doctor decisions need to be referred to managers.


We did not have Admission Avoidance then. 

How is the new Consortia going to work out the funding and how are the three Foundation Trust Hospitals going to work out the costs.

The danger is that the patient may not even get to see the first Specialist: Paediatrician not to say the second one: me.

Not to mention the operation etc. and the transfer to the Centres of excellence.


“........Ten years later mother came to see my secretary and left a photo. It was a photo of her daughter and her new baby. She had been working at the local bank since she left school, met a very nice man and now she had a baby. Mother thought I might remember them and perhaps I would be pleased with the outcome. 

"I was very pleased for them too but I would hate for anyone to put faith or god to such a test too often."

The final answer to her PRAYERS:

But perhaps God works through his people in his own way. Discoveries in Medicine should therefore enhance our faith rather than the other way round.

It took nearly 30 years for the real answer to her prayers to really emerge.

 ©2012 Am Ang Zhang


The Bright Young Doctor now:

I was staying at our resort in Boquete and was having dinner with three friends all of them with medical connections. One was in hospital administration and one a nurse. The husband of the nurse was a pharmacist. Somehow the conversation drifted into medical topics and knowing that I am a Child Psychiatrist the pharmacist started talking about his nephew who was nearly sent to a mental institution as he suffers from catatonia and doctors eventually diagnosed schizophrenia and put him on antipsychotics. Luckily the catatonic symptom probably saved him as some bright young thing just read the book Brain On Fire and gave him the Clock Test. That led to the NMDAR antibody testing that proved positive. He responded well to the treatment regime that has been developed and is off all antipsychotic medication.

My Teratoma patient was lucky as she belong to that group that improved without further treatment once the Teratoma was removed. She eventually had a baby.


The Power of Prayers & Teratoma: Brain & NMDA!


Anti-NMDA Receptor Encephalitis

NEW ORLEANS — A mysterious, difficult-to-diagnose, and potentially deadly disease that was only recently discovered can be controlled most effectively if treatment is started within the first month that symptoms occur, according to a new report by researchers from the Perelman School of Medicine at the University of Pennsylvania. The researchers analyzed 565 cases of this recently discovered paraneoplastic condition, called Anti-NMDA Receptor Encephalitis, and determined that if initial treatments fail, second-line therapy significantly improves outcomes compared with repeating treatments or no additional treatments (76 percent versus 55 percent). The research is being presented at the American Academy of Neurology's 64th Annual Meeting in New Orleans.

565 cases! Not so rare!

The condition occurs most frequently in women (81 percent of cases), and predominately in younger people (36 percent of cases occurring in people under 18 years of age, the average age is 19). Symptoms range from psychiatric symptoms, memory issues, speech disorders, seizures, involuntary movements, to decreased levels of consciousness and breathing. Within the first month, movement disorders were more frequent in children, while memory problems and decreased breathing predominated in adults.

My patient was under 18 and presented with catatonia symptoms. She later lose consciousness and was ventilated.

"Our study establishes the first treatment guidelines for NMDA-receptor encephalitis, based on data from a large group of patients, experience using different types of treatment, and extensive long-term follow-up," said lead author Maarten TitulaerMD, PhD, clinical research fellow in Neuro-oncology and Immunology in the Perelman School of Medicine at the University of Pennsylvania. "In addition, the study provides an important update on the spectrum of symptoms, frequency of tumor association, and the need of prolonged rehabilitation in which multidisciplinary teams including neurologists, pediatricians, psychiatrists, behavioral rehabilitation, and others, should be involved."

The disease was first characterized by Penn's Josep Dalmau, MD, PhD, adjunct professor of Neurology, and David R. Lynch, MD, PhD, associate professor of Neurology and Pediatrics, in Annals of Neurology in 2007. One year later, the same investigators in collaboration with Rita Balice-Gordon, PhD, professor of Neuroscience, characterized the main syndrome and provided preliminary evidence that the antibodies have a pathogenic effect on the NR1 subunit of the NMDA receptor in the Lancet Neurology in December 2008. The disease can be diagnosed using a test developed at the University of Pennsylvania and currently available worldwide. With appropriate treatment, almost 80 percent of patients improve well and, with a recovery process that may take many months and years, can fully recover.

Teratoma: finally!

In earlier reports, 59 percent of patients had tumors, most commonly ovarian teratoma, but in the latest update, 54 percent of women over 12 years had tumors, and only six percent of girls under 12 years old had ovarian teratomas. In addition, relapses were noted in 13 percent of patients, 78 percent of the relapses occurred in patients without teratomas.
As Anti-NMDA Receptor Encephalitis, the most common and best characterized antibody-mediated encephalitis, becomes better understood, quicker diagnosis and early treatment can improve outcomes for this severe disease.
The study was presented in a plenary session on Wednesday, April 25, 2012 ET at 9:35 AM at the American Academy of Neurology's annual meeting.
[PL01.001] Clinical Features, Treatment, and Outcome of 500 Patients with Anti-NMDA Receptor Encephalitis

Anti-NMDA-receptor encephalitis: case series and analysis of the effects of antibodies

Of 100 patients with anti-NMDA-receptor encephalitis, a disorder that associates with antibodies against the NR1 subunit of the receptor, many were initially seen by psychiatrists or admitted to psychiatric centres but subsequently developed seizures, decline of consciousness, and complex symptoms requiring multidisciplinary care. While poorly responsive or in a catatonic-like state, 93 patients developed hypoventilation, autonomic imbalance, or abnormal movements, all overlapping in 52 patients. 59% of patients had a tumour, most commonly ovarian teratoma. Despite the severity of the disorder, 75 patients recovered and 25 had severe deficits or died.

Related paper:


                                   >>>>>>The full Chapter: Chapter 29 The Power of Prayers

David Cameronif it was your plan not to have an integrated service, then there is not much we ordinary people could do except pray. If it was not your intention, then could you let us have an integrated service! That way you would not need many accountants and you will save money in doing so.

Just like Mayo Clinic:

“…….Mayo offers proof that when a like-minded group of doctors practice medicine to the very best of their ability—without worrying about the revenues they are bringing in for the hospital, the fees they are accumulating for themselves, or even whether the patient can pay—patients satisfaction is higher, physicians are happier, and the medical bills are lower.”

But it is probably too late:

Pulse: GP consortium chairs are overwhelmingly opposed to any requirement to include hospital consultants on their boards, viewing it as a serious conflict of interest that would undermine the commissioning process, finds a Pulse survey.

King’s Fund: Million £ GP.

See also:



Comments:


Dr No said...
Excellent post - and yes, that is exactly how it used to be. World class medicine without even trying - we just did it, because that is what we did, just as the dolphin swims, and the eagle soars. A key, even vital feature was that the doctors looking after their patients did not need to worry about money or managers. They just got on with it. There was no market to get in the way of truly integrated care. Some may point out that 13 year olds with teratomas are rare, and that is true, but what this case shows us, precisely because of its complexity, is just how capable the system was. And most of the time (of course not always), it dealt just as capably with more routine cases. "How is (sic) the new Consortia going to work out the funding and how are the three Foundation Trust Hospitals going to work out the costs." Exactly. And then: who is going to pay for the staff and their time to work out out all those costs and conduct the transactions?

Sunday, April 29, 2018

Flat Earth & Miracles: Professor! Professor! 3 month? !



   It is not my intention, either as an individual or as a scientist, to express an opinion on religious visions and miracles. Science has generally failed to understand these phenomena and many religions on the whole have tended to ignore scientific explanations.
        For the religious amongst us, a close study of the history of religion would have seen deliberate attempts a couple of millennia ago to trick people into believing certain things supernatural. In a recent visit to Ephesus, we heard tales of how early “Christians” were duped and “cured”.
        When the Western World was in the tight grip of the Catholic Church, the Jesuits were generally regarded as the greatest scholars. They brought Western culture and religion to the East. They must have had a glimpse of the Chinese understanding of the universe and the world. Yet for so long the religious view of Flat Earth held true. Did the Jesuit scholars know the truth or did they pretend not to in order to avoid persecution and possible death? We shall never know.
        Many “visions” have proved to be the work of errant brain waves due either to epilepsy or brain tumours. Yet the Church continued to celebrate these phenomena.


© 2012 Am Ang Zhang
  

From my book The Cockroach Catcher Chapter 15: Miracles:

First Miracle
         When Professor MacFadzean first arrived in Hong Kong many years ago, he was consulted on a middle-aged Chinese man, a fisherman who had a huge lymph node under his left arm pit. Investigations showed that it was a secondary from a primary in the lung.
         The man asked him, “How long?”
         “Three months. Maximum six.”
         Two year later as the Professor was crossing the harbour on Star Ferry, a man came up to him.  It was not difficult to spot him anywhere in Hong Kong as he was at least a head taller than most, with a bright red face that Scots seem to acquire in Hong Kong.
         “Professor. Professor. Remember me?”
         The man pointed to his armpit.
         No mass.
         “Three months.  Remember?”
         It turned out the man sought the advice of his fortune teller in Shatin on the third day of Chinese New Year, and he had a good “fortune” telling him about an illness disappearing.
         “Now it has disappeared!”
         What a miracle! Fortune telling has been a major growth industry in Hong Kong.  Recently, the richest Chinese business woman left all to her fortune teller.
         “Never be definite about prognosis, especially if it is a bad one. Spontaneous cures have been recorded regularly, especially with lung cancer.”
         To the patient, it was old ways triumphing over modern medicine. It was his “miracle”.


To remember our eminent yet formidable Professor of Medicine, Professor MacFadzean: One Patient One Disease.
I would like to pay tribute to our eminent yet formidable Professor of Medicine, Professor MacFadzean, 'Old Mac' as he was 'affectionately' known by us. He taught us two important things right from the start:

First - One patient, one disease. It is useful to assume that a patient is suffering from a single disease, and that the different manifestations all spring from the same basic disease.

Second - Never say never. One must never be too definitive in matters of prognosis. What if one is wrong?


Flat Earth & Miracles: Duping & Human Kindness!





Saturday, April 28, 2018

Flat Earth & Miracles: He will never learn to speak!

It is reassuring that there are still people that were kind enough to risk everything in order to help others in desperate need. It became more upsetting when you realised that the kind-hearted person has been duped. But then even government has been duped into paying millions of our money to so called charitable organizations we can hardly blame any individual except of course the individual is not losing other people’s money but their own.


Photoshop Miracle:

Black Currant Miracles © 2012 Am Ang Zhang


        It is not my intention, either as an individual or as a scientist, to express an opinion on religious visions and miracles. Science has generally failed to understand these phenomena and many religions on the whole have tended to ignore scientific explanations.
        For the religious amongst us, a close study of the history of religion would have seen deliberate attempts a couple of millennia ago to trick people into believing certain things supernatural. In a recent visit to Ephesus, we heard tales of how early “Christians” were duped and “cured”.
        When the Western World was in the tight grip of the Catholic Church, the Jesuits were generally regarded as the greatest scholars. They brought Western culture and religion to the East. They must have had a glimpse of the Chinese understanding of the universe and the world. Yet for so long the religious view of Flat Earth held true. Did the Jesuit scholars know the truth or did they pretend not to in order to avoid persecution and possible death? We shall never know.
        Many “visions” have proved to be the work of errant brain waves due either to epilepsy or brain tumours. Yet the Church continued to celebrate these phenomena.
The first picture is the original: the rest miracles!


From my book The Cockroach Catcher Chapter 15: Miracles:

Second Miracle
         The second “miracle” I am going to recount was again not experienced by myself but occurred none other than where most miracles happened.
         Jerusalem.
         And in the 20th Century.
         I heard about it at a World Congress on Infant Psychiatry held in Chicago.
         Generally the big plenary sessions at nine in the morning were reserved for the big presentations. Given that it was an Infant Psychiatry Congress, one was surprised to be having a presentation of a case of an older child.
         Yet this was a presentation by one of the most respected professorial units in Jerusalem. The hall was packed and word must have got out that this was going to be good.
         The professor was himself on stage. He was already rather old, but when he spoke he did so with authority and a certain air of natural arrogance. It was the kind of arrogance that came as a matter of course to one who had made a discovery of some kind that none of us in the hall, except his team, had heard of. Perhaps pride is a better word to describe it, but no matter.  Something big.
         His presentation involved the showing of some film clips, one of which was from the BBC archives.
         This boy suffered from severe epilepsy from a very early age and was on four different medications. He never acquired speech, ever.
         He had a younger brother, bright and very advanced, who was reading well before the age of three, not unusual for Jewish boys you might say, but unusual given his brother could not speak.
         His mother sought help for him over the years, and by the time he was twelve, most specialists she consulted told her there was a critical period after which a child would never acquire speech.
         She had said her fair share of prayers at the Synagogue.
         One day, unbeknownst to her, her genius toddler took an overdose of his brother’s medications. He was found in time and his life was not threatened. For four full days after he came out of intensive care, he stopped talking altogether.
         It suddenly occurred to her that it could be the medication that was holding her son back.
         She immediately secured a consultation at a top hospital and the consultant said that it was possible to use other methods to control the epilepsy.
         But it would be drastic, as it involved removing nearly half of his brain.
         “Without medication would he learn to speak?”
         Now this was where the BBC film cut to a big picture of the lady consultant who said, “Never. He is beyond the critical age. He will never learn to speak. Never ever.”
         The Professor in a very solemn voice said from the podium, “She is not one of ours.”
         The boy had the operation. He was now free from epilepsy and free from any medication.
         Mother decided to emigrate to Israel and seek help in the Promised Land.
         “What a wise move.” The Professor interjected again.
         The boy now came under the Professor’s care, and a big team of different therapists started working on him.
         And mother’s prayers were at last answered.
         The boy now spoke fluent Hebrew and reasonable English. Not one but two languages.
         I remembered what one Rabbi said to me at our friend’s son’s Bar Mitzvah, “You know our God will give, but we must work hard.”
         And Old Mac:  Never say never.


Flat Earth & Miracles: Duping & Human Kindness!


To remember our eminent yet formidable Professor of Medicine, Professor MacFadzean: One Patient One Disease.
I would like to pay tribute to our eminent yet formidable Professor of Medicine, Professor MacFadzean, 'Old Mac' as he was 'affectionately' known by us. He taught us two important things right from the start:

First - One patient, one disease. It is useful to assume that a patient is suffering from a single disease, and that the different manifestations all spring from the same basic disease.

Second - Never say never. One must never be too definitive in matters of prognosis. What if one is wrong?



Friday, April 27, 2018

Photoshop Fun: Charcoal Rendition!


Close up, Eucalyptus © Am Ang Zhang 2013



The Original: Original photograph taken with Nikon D70 and ED180/2.8 lens: still amazing after all these years.














High End Photography & Wine








Photography: Tasmania & Bokeh!



Wednesday, April 25, 2018

From Tampopo to Sideways: Merlot at last.

After this post first came out in 2008 when I started blogging, The Cockroach Catcher has at last had a chance to taste a most amazing Merlot. 

It is amazing how easy it is to influence modern day consumers with nothing other than a well made film. As far as wine is concerned the film Sideways has more or less changed the wine landscape of California if not elsewhere. This is because of two simple lines from the film. The wine snob character Miles tells friend Jack before a double-date dinner:

“If anyone orders Merlot, I'm leaving. I am not drinking any……Merlot.”

All of a sudden, it is no longer cool to order Merlot, and Pinot Noir becomes the new Merlot.
The fact that the same snob Miles’ most treasured wine Cheval Blanc
is 45% Merlot is lost to the vast majority. In fact if Petrus had not refused permission, Miles would have drunk Petrus in the film, and that, one of the most expensive wines in the world, is 95% Merlot. Towards the end of the film, he was being comforted by a bottle of Cheval Blanc, 1961 no less and arguably best of the post war ones.

Ours is more recent, 2000 but what a wine. 

Many blogger thought it was a Hollywood goof. To me it is one of the smartest irony: for the Merlot hater to be raving about a Merlot (with Cabernet Franc) is deliberate as it was originally going to be the Petrus. Merlot sale unfortunately suffered, but only the Californian variety.
In the animated hit Ratatouille, feared critic Anton Ego visits Gusteau's, the restaurant in which the movie is set, and orders a bottle of 1947 Château Cheval Blanc to go with his meal. The '47 Cheval Blanc is probably the most celebrated wine of the 20th century. However, there has been no rush to buy cases of this as you are unlikely to find them except in top merchants and private cellars.
I have my own suspicion about some lesser known films that may have influenced wine drinking habits in the Far East.
In 1985 the film Tampopo came out of Japan. This comedy features a truck driver who helps a young widow named Tampopo improve her noodle restaurant, and draws attention to the power of food.
There is a beautiful wine tasting scene, by a group of hobos following the lead of a professor. The professor realises that life as a hobo is much freer, with no one above him telling him what he should do, no targets to meet, and no paperwork.

The wine tasting is not at a winery or a restaurant. It is in a park by the back door of a restaurant. The wine is that little bit left at the bottom of a bottle. There is not enough to go round; so the hobos allow the professor to do the tasting and are content to just listen to his analysis. (In the Cockroach Catcher, I wrote that a blind case presentation at Queen Square was a bit like wine tasting.)

It is one of the most enjoyable scenes for wine lovers and if you are not a wine lover you will become one.

The wine?

Chateau Pichon Longueville Comtesse de Lalande,” announced the professor in perfect French.
This wine has since become a favourite of the Far East.
Chateau Pichon Lalande is not as expensive as the First Growths but is fast catching up. Fortnum and Mason of London used to have a house Pauillac made by Chateau Pichon Lalande. I was tipped off to get the last few bottles some years ago. Now the supplier of their house Pauillac is Chateau Haut Bages Averous, a vineyard next to the new rising star of Bordeaux: Chateaux Lynch-Bages.
The best year in recent vintages has to be 1989, a great year for most of Bordeaux and rumour has it that it will become drinkable in 2009. Hurrah. The 2000 is superb too but recent vintages have all been great and if you can store them buy them now.
The biggest wine influence worldwide came from a documentary. In 1991, after the airing of 60 Minutes on CBS, wine sales went up 44% in the next four weeks in the U.S. It was about the French Paradox: the incidence of coronary heart disease in France being 40% percent lower than in the U.S.
Health sells.
Once upon a time in Hong Kong, when people made money they drank the most expensive Cognac and Scotch, with Hennesy XO and Dimple being the “Gold Standards”, partly because of their highly recognisable bottles. To have such a bottle on your dining table was a sure sign that you had arrived. Now, the status symbol is the most expensive red wine, and it is often taken with just about any dish that is served.
But then the French perhaps always knew; including its own most famous psychoanalyst Jean Laplanche (born 1924). His book The Language of Psychoanalysis was first published in 1967 and translated into English in 1973. All of us training at the Tavistock had a copy and it is to this day one of the best reference books on the subject. He has co-authored a number of other books in psychoanalysis.
What is not so widely known is that Laplanche was for many years the owner of Chateau de Pommard, a Burgundy vineyard, and actively involved with the wine-making processes. He sold the vineyard in 2003 but continues to live on the estate with his wife and to act in the capacity of a consultant to the new owners on wine making matters.

Wine Posts:

Saturday, April 21, 2018

London Marathon: Hyponatraemia & Rehydration


There is little doubt that overhydration is now the biggest threat to the runners. Most fatality is due to hyponatraemia and as far as my searches go, no one has died from dehydration during the various Marathons. 

Despite what you may have read: DEHYDRATION is not the problem. Low SODIUM is!

Elite Marathon runners in the past rarely drank much during races. Mike Gratton, when he won the London Marathon in 1983, apparently drank nothing.

It has been said that even doctors may overlook the role of low sodium in rescues especially as there are sports drinks in abundance. 


Marathon runners who drink too much water are at risk of a deadly condition
Every couple of miles, the 30,000 or so runners competing in the 36th Marine Corps Marathon on Sunday will pass stations stocked with water and sports drinks. Most, hopefully, won’t stop unless thirsty. Some, however, following outdated advice, will drink according to a preset schedule — even downing all they can hold — increasing their risk, doctors say, of a potentially fatal medical condition.
The condition, called exercise-associated hyponatremia, killed Hilary Bellamy of Bethesda two days after she competed in the 2002 Marine Corps Marathon.



© 2016Am Ang Zhang
As runners from around the world prepared themselves for the London Marathon. I will publish my take from an earlier post.


It is amazing to hear of advice on drinking plenty of water in any heat wave both here and in the US.

Marathons:
Marathons are often sponsored by bottled water companies and their main aim is to let the public get he image of runners with bottles of their water.


Of 766 runners enrolled, 488 runners (64 percent) provided a usable blood sample at the finish line. Thirteen percent had hyponatremia (a serum sodium concentration of 135 mmol per liter or less); 0.6 percent had critical hyponatremia (120 mmol per liter or less). On univariate analyses,hyponatremia was associated with substantial weight gain, consumption of more than 3 liters of fluids during the race, consumption of fluids every mile, a racing time of >4:00 hours, female sex, and low body-mass index. 

Modern marathon advice is to up the intake of salty food in the pre-race preparation. When dehydrated taking salt and water alone will not work: see below. 

Watermelon:


When I was growing up in the tropics, one of the fruits we were given after a long walk was watermelon with salt sprinkled on it. This was long before the current understanding of Oral Rehydration. My parents were careful to warn us then that just drinking water is no good. Why? They did not know!

Now I do but watermelon is still my favourite and in the tropics you can buy fresh water melon juice in the summer.

Chinese farm workers:
It has to be said that the diet of many Chinese farm workers was generally higher in sodium, from dried salted fish and vegetables. It is likely that the serum sodium of many such workers would have been at the high end of the normal range. Modern advice on cutting down sodium often does not take account of sweating in hot countries. A friend of mine with hypertension had an epileptic seizure when he went to work in Singapore. Luckily the medical services there were alert to the problem and he survived. He was on a low sodium diet and on diuretics amongst other medications.

Free water:
I also remember one very hot August day when we hiked down Grand Canyon to Angel Point. There were warnings everywhere of the risks and even fatalities on such walks. The National Park did have clean drinking water taps along the way and one particular girl overdid the drinking. She had a narrow escape, as the Ranger fortunately knew a thing or two about rehydration. He put some salt in a can of Sprite and reverted a potentially serious situation.

Thailand:
The first time we went to Thailand the most amazing dip was simply a bowl of sugar that has been mixed with salt and some chopped chilies for good measure. This dip was used for serving unripe mangoes, papayas, guavas and other local fruits, and gave me a taste sensation that was unforgettable. Same principle as ORT.

In Thailand, workers in rice fields, fruit orchards and vegetable patches manage to survive temperatures of over 100°F.

Golf:
The Cockroach Catcher plays golf in his holiday home in the tropics and he uses his own mix of diluted Pomegranate juice and a pinch of salt for Oral rehydration. I would never drink plain water alone.  This is one time where a bit of sugar helped the body to absorb salt and fruit juice is higher in potassium.

When the first public golf course was opened on the beautiful island of Kau Sai Chau in Hong Kong, drinking water was provided along the course. One player drank so much that he nearly died of water intoxication (result of drinking excessive amounts of plain water which causes a low concentration of sodium in the blood leading to amongst other problems: ‘brain’ swelling---cerebral oedema).


Cocktails:
It seems wrong to recommend alcohol but has anyone worked out why cocktails from hot countries would be served with the rim of the glass covered in salt!!!

Drowning:
I remember one of my professors telling us: the body survives dehydration much better than drowning. How right he was, as water intoxication is in a sense a kind of drowning.

Cholera:
I well remember Hong Kong’s cholera epidemic in 1961 and the major cause of death was the rapid loss of fluid due to a specific secretive action of the cholera germ. Patients could die in a matter of hours. The medical profession has long been of the strong belief that Intravenous Fluid (IV Fluid) is the only answer. In that situation, the patient is in shock and to find a vein means a cut-down: literally cutting through the skin to find one. It is a messy business as the patient is violently pumping out fluid in the most horrendous fashion.

Johns Hopkins established a centre in Calcutta in the 1960s to study precisely a better way to replenish the fluid. IV fluids were expensive to manufacture and required medical personnel to administer. Their Clinicians sought help from basic physiology and carried out the first carefully controlled study which showed that intestinal perfusion of cholera patients with saline solutions containing glucose strikingly reduced fluid loss. Put simply, the patients could just drink a glucose and salt solution and the glucose would allow the salt to be piggy backed and absorbed, thus sparing the need to use IV fluids.

“……These compelling findings, however, did not convince the medical establishment, who remained sceptical that such a simple therapy could substitute for traditional intravenous fluid replacement in severely stricken patients under epidemic conditions in the field.”
The World had to wait for a war, this time in Pakistan, when Bangladesh fought for its independence in 1971 and 9 million refugees poured into India and with them cholera. When IV saline treatment was exhausted, Dr Mahalanabis, who had worked at the Johns Hopkins Centre in Calcutta, took the gamble and decided to prescribe a simple solution of glucose and salt in the right proportion for the friends and relatives of the cholera patients, thus saving at least 3.5 million people.  Since that time it was estimated that such a simple and cheap remedy saved at least 40 million more lives.
No wonder The Lancet hailed the development of oral rehydration therapy (ORT) as "the most important medical discovery of the 20th century".
The scientists at Johns Hopkins and Dr Mahalanabis received the Pollin Prize of $100,000 in 2002.


“Ideas without precedent are generally looked upon with disfavor and men are shocked if their conceptions of an orderly world are challenged.” 

Bretz, J Harlen 1928. 

Thursday, April 19, 2018

Osthmanthus & Guava: An older and more sedate time!



Guava fruit and the beautiful trunk.


                                        Osthmanthus fragrans©Am Ang Zhang 2011

In The Cockroach Catcher:


The examinations were finally over and I was back home in the village that I had more or less abandoned for the most of the last five years.  I could not remember skies as bright and temperature as high, but it was a nice interlude from the mad preparations and the nerve-wracking examinations.
         We had an unusually dry May. The worst of the 1966 rains seemed like a distant memory and the crisp blue skies somehow made the heat tolerable. Even back then we seemed to be complaining of the ever rising temperatures in Hong Kong. The way we had been complaining about the rise every year, the temperature should really have reached 110 or more by now. The air-conditioning of offices, followed by that of private homes, necessarily led to the feeling of higher ambient temperatures in the streets.
         The garden was filled with the fragrance of the white tropical jasmines.  That fragrance is only second to that of the Osmanthus (Gui Hua)[1], the flowers of which are tiny and appear more towards winter. We used to collect the Osmanthus flowers, dry them and use them to flavour our best teas.  Jasmine is more a late spring and summer flower and we had a big bush. By nightfall the cooling hill breeze brought with it occasional whiffs that made you want summer to last forever.
         It was a peculiar time for those of us who had lived in or around the university for the past five years.  We left home as school children and now we were back, and with any luck the majority of us would in a few weeks become fully fledged doctors ready to apply our skills.
         We had changed and the rest of the family probably not as much; and yet it was a time to savour – the last of the old before embarking on the new and brave.
         It was good to be reminded of the fine cooking back home, of an older and more sedate time when shopping was done twice a day for fresh ingredients.  This practice of course still continues in some parts of the world.

.........The guavas were not quite ready but our own giant papaya tree seemed capable of fruiting through the year. These were yellow fleshed and delicious though without the special fragrance associated with the red variety. Bananas too grew wild and bunches were cut when ready and suspended from a tripod for indoor ripening. It was too risky to let them ripe on the tree as various animals and birds would have had first claim.


[1] Osmanthus (Gui Hua) - Osmanthus fragrans is a flower native to China that is valued for its delicate fruity-floral apricot aroma. It is especially valued as an additive for tea and other beverages in the Far East.



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Tuesday, April 10, 2018

Tioman Island vs The Great Barrier Reef!

The Great Barrier Reef at 18.2871° S is hitting the news with much bleaching. 



Tioman Island: 2.8167°N Not Bleached.

Ideas without precedent are generally looked upon with disfavour
and men are shocked if their conceptions of an orderly world are challenged.
Bretz, J Harlen 1928.


We have always been led to believe that bleaching of the world's coral reefs is final proof of global warming. Not quite according to the NOAA:

When corals are stressed by changes in conditions such as temperature, light, or nutrients, they expel the symbiotic algae living in their tissues, causing them to turn completely white.

Warmer water temperatures can result in coral bleaching. When water is too warm, corals will expel the algae (zooxanthellae) living in their tissues causing the coral to turn completely white. This is called coral bleaching. When a coral bleaches, it is not dead. Corals can survive a bleaching event, but they are under more stress and are subject to mortality.

In 2005, the U.S. lost half of its coral reefs in the Caribbean in one year due to a massive bleaching event. The warm waters centered around the northern Antilles near the Virgin Islands and Puerto Rico expanded southward. Comparison of satellite data from the previous 20 years confirmed that thermal stress from the 2005 event was greater than the previous 20 years combined.

Not all bleaching events are due to warm water.

In January 2010, cold water temperatures in the Florida Keys caused a coral bleaching event that resulted in some coral death. Water temperatures dropped 12.06 degrees Fahrenheit lower than the typical temperatures observed at this time of year. Researchers will evaluate if this cold-stress event will make corals more susceptible to disease in the same way that warmer waters impact corals.

The Great Barrier Reef at 18.2871° S is hitting the news with much bleaching. 

These are doing fine at Tioman Island,  2.8167°N












All photos©2014 Am Ang Zhang

Medicine and Snorkelling: Think outside the box!

The first modern snorkel was invented by none other than Leonardo da Vinci, apparently at the request of the Venetian senate. It consisted of a hollow breathing tube attached to a diver's helmet of leather.

You may wonder why I wrote about snorkels in my book The Cockroach Catcher. The evolution of the snorkel tube makes me think about progress in medicine.

“... In those days we had snorkels that had a Ping Pong ball at the top end – a sort of umbrella handle at the top with the Ping PongBall inside a little cage so that it floated up to stop water coming in. ….

Imagine the shock when we went to the Great Barrier Reef and were given snorkels that bore no resemblance to the ones I used in my childhood. There was no Ping Pong ball in a cage and there was a drain at the bottom. The top was slightly curved with a clever design so that water from waves could not get in. Any water that managed to get in was drained away at the bottom. I looked at it and smiled. One must always question traditional beliefs. We can be blinded by what looks like a most sensible and reasonable approach – Ping Pong ball in a cage. ...

Medical Schools should remember to teach future doctors that without breaking rules and old dogma, no progress would ever be made in medicine....”
                                                                         
My Point is that doctors sometimes need to “think outside the box”.


Snorkelling is one of my favourite hobbies. I find it so relaxing and therapeutic. Slow breathing, say for 15 minutes a day, is now proven to help reduce blood pressure by a clinically significant amount. What better way to do it than in the sea, surrounded by fish and corals?                                                                                                                                                                       





The Cockroach Catcher on Amazon Kindle UKAmazon Kindle US       

NHS & Gawande: Morbidity and Mortality Conference M+M

The GMC warned that the safety of hospital patients is being put at risk because inexperienced young doctors are too often being left in charge of A&E and other units. We need to look at the way medical liability is covered in Hospitals where indeed all juniors must be covered by a consultant in one way or another. The responsibility would indeed be that of the hospital management and not on the poor Junior Doctor.  The difficulty is the choice between NO doctor or a less experienced one. Should the patient be told or should the A&E just be closed? Will management do that or just continue to abuse the poor juniors and blame them when things go wrong. No wonder my friends' children prefer to become lawyers. 


I read Gawande when I was touring Peggy's Cove and posted about his book Complications! Honestly, I did not know Gawande was giving the Reith Lectures. 

Latest Gawande Book:


In one of the most moving passages in the book, Gawande’s father, in hospice, rises from his wheelchair to hear his son lecture at their hometown university. “I was almost overcome just witnessing it,” Gawande writes.

........Gawande offers no manifesto, no checklist, for a better end of life. Rather, he profiles professionals who have challenged the status quo, including Bill Thomas and other geriatricians, palliative-care specialists, and hospice workers. Particularly inspiring are the stories of patients who made hard decisions about balancing their desire to live longer with their desire to live better. These include Gawande’s daughter’s piano teacher, who gave lessons until the last month of her life, and Gawande’s father, also a surgeon, who continued work on a school he founded in India while dying of a spinal tumor.
He’s awed not only by his father’s strength, but by the hospice care that helped the dying man articulate what mattered most to him, and to do it. Gawande thinks, as he watches his proud father climb the bleachers, “Here is what a different kind of care — a different kind of medicine — makes possible.”

What would lawyers say about M + M:

- ‘There is one place, however, where doctors can talk candidly about their mistakes, if not with patients, then at least with one another. It is called the Morbidity and Mortality Conference – or, more simply, M+M – and it takes place, usually once a week, at nearly every academic hospital in the country. This institution survives because laws protecting its proceedings from legal discovery have stayed on the books in most states, despite frequent challenges.’ 

            >>>See also Dr No: We Have No Black Boxes
                                               Abetternhs's Blog  What are we afraid of?

August 27 2014:

What a charming place: Peggy's Cove of Halifax.

The Cockroach Catcher was finishing reading the book Complications and such charming old landscape reminds him of the old traditional medical training he received and how some doctors still do. Like the author of this book.

The book reads more like a collection of blog posts and in fact it was. Yet it was real and touching. Sometimes it was brunt and brutal. and after all doctors are as human as anyone. Complications includes those doctors themselves may suffer: mental illness and alcoholism as well as the serious cardiac condition of the author's young son.

We, doctors make mistakes and please we must be allowed to sort them out without affecting career or worst, future medical behaviour.

A great book for doctors in particular and when on holiday in a charming place.










All photos©2014 Am Ang Zhang  

 (Metropolitan Books, 288 pages, $24), a collection of 14 pieces, some of which were originally published in The New Yorker and Slate magazines, Gawande uses real-life scenarios – a burned-out doctor who refuses to quit; a terminal patient who opts for risky surgery, with fatal results – to explore the larger ethical issues that underlie medicine. He asks: How much input should a patient have? How can young doctors gain hands-on experience without endangering lives? And how responsible are these doctors for their mistakes?
While “Complications” is full of tragic errors and near misses, the book is not intended to be an expose. Rather, Gawande asserts, it is meant to deepen our understanding of the intricacies of medicine. “In most medical writing, the doctor is either a hero or a villain,” he says, with an edge in his voice. “What I am trying to do is push beyond that and show how ordinary doctors are – and at the same time show that what they can do is extraordinary.”
John Freeman, Copyright (c) 2002 The Denver Post.

Quotes

- ‘There have now been many studies of elite performers – international violinists, chess grand masters, professional ice-skaters, mathematicians, and so forth – and the biggest difference… is the cumulative amount of deliberate practice they’ve had.’

- ‘We have long faced a conflict between the imperative to give patients the best possible care and the need to provide novices with experience. Residencies attempt to mitigate potential harm through supervision and graduated responsibility. And there is reason to think patients actually benefit from teaching. Studies generally find teaching hospitals have better outcomes than non-teaching hospitals. Residents may be amateurs, but having them around checking on patients, asking questions, and keeping faculty on their toes seem to help. But there is still getting around those first few unsteady times a young physician tries to put in a central line, remove a breast cancer, or sew together two segments of a colon… the ward services and clinics where residents have the most responsibility are populated by the poor, the uninsured, the drunk, and the demented… By traditional ethics and public insistence (not to mention court rulings), a patient’s right to the best care possible must trump the objective of training novices. We want perfection without practice. Yet everyone is harmed if no one is trained for the future. So learning is hidden behind drapes and anesthesia and the elisions of language.’ 

- ‘There is one place, however, where doctors can talk candidly about their mistakes, if not with patients, then at least with one another. It is called the Morbidity and Mortality Conference – or, more simply, M+M – and it takes place, usually once a week, at nearly every academic hospital in the country. This institution survives because laws protecting its proceedings from legal discovery have stayed on the books in most states, despite frequent challenges.’ 

Monday, April 9, 2018

Hamlet: Forgiveness



The Cockroach Catcher
Chapter 26  Forgiveness

KING CLAUDIUS
….My fault is past. But, O, what form of prayer
Can serve my turn? 'Forgive me my foul murder'?...

Now might I do it pat, now he is praying;
And now I'll do't. And so he goes to heaven;

Hamlet Act 3, Scene 3.
William Shakespeare


S
ometimes we are reminded of our patients in the most unusual way.  One summer we had the opportunity to go on a Baltic Cruise which started and finished in Copenhagen. It is unavoidable on such tours to come across tragic stories in history.  The different Baltic countries had their fair share of wars, sieges, slaughters and some of the most macabre murders in the history of mankind.

© Am Ang Zhang 2006

         Our last stop was outside Elsinore and those of us who were interested were tendered to visit Kronborg Castle, the setting for Shakespeare’s Hamlet.
            Hamlet reminded me of Anita.    

She refused to attend school because of Hamlet.  In my work I have come across many unusual patients but it has never occurred to me that someone would refuse school because of Hamlet.
         I can still remember being called to see her on a Domiciliary Visit as she had refused to come to the clinic.  The parents were not very forthcoming and felt that at seventeen, she should be able to talk to me herself.
         She reluctantly agreed. We then had a most interesting discussion about Hamlet. She was upset because her English teacher did not like what she wrote about Hamlet. The essay was about Hamlet and forgiveness. She felt that Hamlet indeed should have been more “forgiving” and killed his uncle when he was praying.
         “So what if the uncle goes to Heaven?  Big deal!”
         “Instead,” she added, “he got himself killed as well.”
         Our sweet prince was no hero to her and that upset her teacher. He really wanted the class to write about Hamlet and Laertes exchanging forgiveness.

LAERTES
           Exchange forgiveness with me, noble Hamlet:
           Mine and my father's death come not upon thee,
           Nor thine on me.
        Hamlet, Act 5, Scene 2
         She then refused to return to school. At least that was what appeared to be the problem.
         I eventually got her back to school and persuaded her to see me at the clinic regularly for the next eight months or so. She wrote a good deal and told me that she kept a diary that was kept under lock and key. She said whatever happened she would never let anyone see it, not even her psychiatrist, as she would probably have to kill that person afterwards. I did not ask to see it and told her that I had no intention of asking to see it in future.
         Teenagers have their secrets and I certainly want to respect that, I thought. She did show me some other writings and she had some very interesting and unusual things to say.
         Looking back, I often wondered about the challenges we faced, having to base our diagnosis and treatment on some of the most subjective things related to us by our often very disturbed patients.  We could hardly expect to get any “truth” from them, and yet various psychiatric professional bodies seem to accept psychiatric diagnosis made in this way as infallible.  She probably did give me a clue but unfortunately I missed it.
         One day she was very distressed, saying she thought she might have caught something from a Spanish Waiter that she slept with. I was a bit puzzled as she did not appear to be the promiscuous type and certainly not the type who would sleep with someone she hardly knew.
         We had some discussion and I advised her to go to the Special STD Clinic to have it seen to.
         She never turned up again despite several reminders.
         Then she came to the notice of the adult psychiatric department following a serious overdose. This was on the day of her father’s death. She saw a lady psychiatrist and disclosed to her that her father had been abusing her since she was eleven. She never kept any follow-up appointments though and there had not been any further episodes of self harm.
         Nearly a quarter of a century later we had four boys referred because of serious sleep disturbance.  One of my colleagues at the clinic made an initial home visit and afterwards asked to see me in a distressed state.
         She said it was one of the worst cases she had ever come across and asked me to see the mother, who happened to be my patient twenty some years prior.
         It was Anita.
         She, who should be in her early 40s then, appeared worn and exhausted, and looked much older than her age.
         When her father died it was all too much for her. She said she was very confused by what happened to her. She admitted that there never was a Spanish Waiter but she was hoping that I would inquire further.  She was desperate to understand what was going on then.
         “The overdose woke me up,” she recalled, “I felt I had to forgive what my father did to me.”
         She decided to go into journalism. One of her assignments was to do an article on a notorious murderer.  For that, she had to interview that murderer in prison.
         “That was the start of all my troubles.”
         Fascinated by her first case experience, she became a voluntary prison visitor for those prisoners who did not have any visitor of their own.
         “We live in a very forgiving society.”
         Then she met this man that was to become her husband. He was serving time for murder.
         “He killed his father who abused him for as long as he knew,” Anita recalled, “I could identify with him and I felt so sorry for him.”
         Was it the process of reparation?  I too struggled to understand her.
         She found herself falling in love with him.
         Prisons allowed conjugal visits and before long she had two boys by him. Because of her and the children the parole board soon granted him day release passes.
         A murderer granted day release!  Not long after he was out on license.
         We indeed do have a rather forgiving penal system.
         “But he never even knew his father, let alone killed him!”
         By age nineteen he was doing time in a borstal and soon after his release he killed the landlord who took pity on him and gave him board and lodging. The landlord was unfortunate enough to catch him trying to steal from him.
         “I did not know until the trial.”
         It is amazing how protective we are of convicted criminals. I could never understand why the probation service did not warn her.
         No wonder the public has little faith in our rather liberal judicial and parole system.  People sitting on parole boards seem to continue to fail to see into the darker side of the human psyche. Often those trained to understand the human mind also appear not to understand, or are they so driven by performance targets and results that they just want another successful treatment to add to their credit?
         This man had “anger management” therapy when he was doing time. The truth is a psychopathic personality is capable of adapting to suit his ulterior motive. We do have too many psychiatric casualties from such unfortunate releases from maximum security mental hospitals and I am not even referring to psychotic patients.
         He could not hold his job as a security guard and started to do break-ins. He was open to his wife and she said she did not understand why she never informed his probation officer.
         “Perhaps I was afraid of him but he convinced me that these people would get their money back from insurance and he was never going to hurt anyone as he loved her and the children and did not want to be locked up again.”
         One cannot help wondering how much the wives of “famous” serial killers actually knew and to what extent they were convinced by the arguments put forward by their spouses.
         She had two more boys.
         One day he decided that they could make more money if he set her up as a prostitute. He would stop the house break-ins as it was getting more dangerous with the alarms set up by people.
         Surprisingly she went along.
         “I had to do something to stop his burglary activities.  I did not want to lose him.”
         “I was sick over the first client.  As it reminded me so much of what my father did, I told him I could not do it.”
         The next day he said he was resuming his break-in business.
         “The rest is in the papers.”
         He came home when the children were having tea. He was covered in blood.
         “The idiots tried to stop me!” he told her.
         The children were screaming.  Suddenly she felt a strong repulsion and called the police.
         Even the most forgiving philanthropist had her limits.
         “I was thinking more of my children. I was not going to be like my mother. I was sure she knew all along.”
         I had to agree.
         How could this ever have been allowed to happen? What did her forgiveness do to her? Could I have done anything?
         He was tried for murder and sentenced to life imprisonment without parole. What he did was much worse than what he told her on the day he came home covered in blood, but that was by and by. Hopefully no one will think it unkind to lock him away forever. You never know.
         Anita had to pick up the pieces of her life again, having had her long held belief in good human nature and forgiveness totally demolished.
         It was probably destroyed a long time ago by someone she should have been able to trust.

Read more:

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

 

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

Sadness & Abuse: As You Like It.

Abuse Abuse Abuse

All is not well in this beautiful part of the OLD WORLD that is Austria.
Salzburg, Austria ©2008 Am Ang Zhang


Josef Fritzl, an engineer in his seventies was found to have kept his 42-year-old daughter locked in his cellar since she was 19. The woman, who bore her father seven children during her captivity, was discovered only after one of the children she had with her father fell into a coma in hospital.



Austria does not have the monopoly of family abuse.

I can only quote from Chapter 27 in The Cockroach Catcher:

And your experience makes you sad:
I had rather have a fool to make me merry
than experience to make me sad…..
(from: As You Like It - Act II, Scene 7)


With so many quotable quotes from As You Like It you may wonder why I would chose to pick this one.
      Perhaps it is a warning to young doctors to enjoy the blessings of inexperience. Luckily for me sadness brought about by experience from my clinical work is mercifully little but I would be either dishonest or heartless to say that there has been none.
      As You Like It happens to be one of the few popular plays of Shakespeare that are often performed in schools, maybe apart from Dreams, and for most it is basically a comedy with a happy ending.
      My wife and I went to a recent production at BAM (Brooklyn Academy of Music) by none other than Peter Hall with his daughter playing Rosalind – their New York debut.  Few would imagine Sir Peter picking Brooklyn for his debut but in the end it was a great experience. The New York Times said that it was more reviving than spending a week in the Caribbean. Having been an accidental resident in the Caribbean for two years I would dispute the comparison but totally agreed with the sentiments expressed.
      At the BAM, it was like walking into a renovation site and in many ways I hope they leave it that way as it was rather charming. It was a most fitting setting for Shakespeare. I accept that they have to make sure it is safe.
      It was at the start of my psychiatric training in England when I asked one of my gurus about reading matter.  Apart from Shakespeare, he recommended Ibsen.  I have since read Ibsen's plays but still come back to Shakespeare, who seemed to be able to pick up so many strands of human experience.
      My ideal Shakespeare is indeed one that can be performed on a bed sheet with a few broomsticks for prop and without wanting to sound derogatory, I would say that this was exactly the approach adopted by this production.
      Much was left to the imagination and it worked.

Mrs Coleman
      Now and again in our work we get an indescribably sad case.  Sometimes what started out as a rather straightforward case might begin to roll downhill so fast that we would be forever taking deep breaths thinking: can it get any worse?  We would question if what we were doing was making any difference at all to what seemed like a predetermined course where no intervention would be able to make any impact on the final outcome.
      One thing is for sure, real life is not like a play – you have only one chance to perform it and often not everything is clear.
      Mrs Coleman came to see me about her daughter within months of my appointment as a consultant.  With my new job came advantages and disadvantages. I used to be able to ask my seniors about cases, especially the difficult ones. Suddenly I was supposed to know it all. I used to have a big team working on a case, to the point that when the patient came to me there was hardly anything left for me to discover. Single-handed consultants are “on their own”. They are lucky to have a social worker and perhaps a psychologist. I had both but the psychologist was not really part of our team – she happened to be sharing the same building. She belonged to the old school, which meant she knew her field and she did not try to be a social worker.  For a while it became fashionable to blame everything on background and upbringing. Any disturbed child not performing well at school had nothing to do with teaching methods or intelligence but everything to do with social background. What were the implications for the social background of bright high achieving children?
      There was some excitement in the clinic when it was known that a shepherd’s family had been referred.
      Shepherds?  "As You Like It" sprang into my mind.
      We have lambs so we must have shepherds – so I thought.  It is true that we seldom had referrals from the farming community. I can only remember one other case and that was when I was a trainee. Shepherds also conjure up scenes of nativity and there is a sort of biblical romantic feel to it.
      What we did have was something quite different. As it was unfortunately the lambing season, the shepherd Mr Coleman, though making a valiant appearance, was as good as asleep during most of the session. Mrs Coleman talked through the session with her rather charming old Sussex accent.
      Mrs Coleman at the time had two children but it was the older daughter Laura of nine with whom she was having trouble.   Tom, some eighteen months younger, was a happy-go-lucky sort of boy. Laura had a whole range of behavioural problems. She had recently taken to soiling in her pants.
      It was often our practice for the social worker to do a preliminary home visit, and my social worker told me that she was most impressed with their home when she visited. They lived in a tied cottage on the farm. The children’s grandfather was a shepherd and he had two sons, the older one working on the dairy side. There was also a daughter, the children’s aunt, and her husband was the local milkman. The aunt had children similar in age to Laura and Tom. She worked part time in the local greengrocer’s and between her and Laura’s mother they split the fetching from school and childcare. The aunt unfortunately was recently diagnosed with breast cancer and was having different kinds of treatment at the local hospital. Luckily her husband was a milkman and could take over the afternoon part of the childcare arrangement whenever necessary. Mrs Coleman took the children to school on the days when the aunt had to go to hospital.
      The aunt was a strong lady, Mrs Coleman told me, and she was sure she would outlive her.
      It was an old cottage they lived in and my social worker told me that Mrs Coleman kept the place clean and tidy. It was therefore most upsetting to her when her nine year old daughter started soiling herself.
      It was mostly in the afternoon but not everyday.
      As my social worker had just started her training at the Tavistock Clinic on child therapy it was a good chance for her to take the girl on for some individual therapy sessions. Like my old consultant did when I was in training, it was now my turn to see mother.
      This seemed to be a simple enough family and I did wonder at the beginning if there was much to unfold.
      I was proved wrong.
      Within two to three weeks of Laura starting therapy, Tom the younger brother refused to go to school. It was natural for everybody to think that there was some jealousy involved. So I arranged for mother to bring him to see me. It was rather obvious from the start that he was not very bright and that his not going to school had little or nothing to do with Laura but more to do with the fact that he could not keep up with the work and was being teased at school very badly. He tried to hit back at one particular boy and was told off by one of the teachers on duty at play-time. He did not want to go back. I arranged for the psychologist to assess him.
      Yes, he was functioning at a much younger age and yes, he needed to go to a special school. In those days it was called an ESN school – school for the Educationally Subnormal.  The SSN school was for the Severely Subnormal.  In the 90s, it was deemed more polite to call the subnormal children “special”.
      Both schools were local and extremely well run. Tom was transferred and seemed to have settled down well there.
      Not bad. I congratulated myself.
      Laura was getting on well with her new therapist. She was attending without any problem and was doing nice drawings, according to my social worker.
      Mrs Coleman was grateful that I sorted out her son.  Tom, who had always been a Daddy’s boy, had upset father very much with his escapade but as he had now settled in his new school father was rather pleased. He in fact went to the same school so he made it a point to turn up to thank me once everything settled.
      Mmmm, perhaps we are not escaping the genetics theory.
      As a precaution, we also tested Laura but she turned out to be rather bright.
      Genetics, you are wrong.
      Not so, Mrs Colman must have thought. She was rather perturbed when I told her. She started crying and pleaded with me to keep the secret she was about to tell me.
      Her husband was not Laura’s father.
      Mrs Coleman had worked at the local butcher’s since she left school and he was always all over her. Before long he was having intercourse with her at the back of the shop. He always gave her extra for that part of the service and she was happy with the extra bit of money. The butcher’s wife had a stroke a few years back and had been bed ridden.
      “It was not the money,” Mrs Coleman assured me. She did not want me to think of her as a slut.
      None of the mothers I saw wanted me to think badly of them and it often took a while before they would reveal their secrets.
      Mrs Coleman had also been seeing the shepherd but never gave him much thought as she felt he was rather stupid. The butcher was much brighter.
      Then one day some accident happened and she found herself pregnant. But the butcher was not going to divorce his wife. She was the one with the money.
      She decided that the next best thing was to let the shepherd sleep with her as long as he married her. He was so pleased with himself and they had a big white wedding in the local church. 
      So Laura was the butcher’s daughter and not her husband’s. Now that I had proved Laura was clever, she was afraid I might ask awkward questions although she doubted if her husband would ever really work it out for himself.
      Once a parent realised that you had ways to get to the truth, they often started revealing things that you wished they never did.
      The butcher had some idea that Laura was his and had been slipping even more extra money for mother to buy her things. He never had any other children.
      I never broke my promise and to this day I do not think that her husband ever knew.
      What was to unfold was what caused most sadness.
      I attended some special seminar on sexual abuse and at the time some rather ugly looking anatomical dolls were produced for the sole purpose of diagnosing Sexual Abuse. They were anatomical in that a whole family set including parents and grandparents, children and adolescent all had what was described as anatomically correct parts - females with breasts, nipples, vagina and anus; and males with penis and anus; and all the orifices were so to speak fully functional. These dolls all had proper clothes on and yet all the clothes could come off.
      The idea was that normal children played with them as normal dolls but abused children would perform with the anatomical parts.
      I had a full set ordered, having spent sometime persuading the managers that others had labs and X-rays and so on, but these were the only tools we required for the specific job.
      Laura was the first to discover them and before my social worker’s eyes one of the male figure’s penis was in the girl’s mouth. She told my social worker that was what Uncle Tom liked.
      What followed were special “disclosure” interviews conducted under camera. Uncle Tom was the milkman. It happened to both girls. When the boys were in the kitchen playing computer games on the TV, slowly the girls were made to suck him. That was when Laura started soiling.
      Mrs Coleman went berserk. Arrangements had to be made for alternative child care which really meant she had to cut short her hours at the butcher’s. Uncle Tom moved to his mother’s as a temporary measure pending Social Service investigation and Police enquiry.
      Mrs Coleman could not sleep at night and called her GP. He asked her to pray with him as she had to be forgiving. She was so angry and when she was cleaning around the house she managed to get some caustic liquid all over herself and had to be admitted to hospital. She was also referred to the adult psychiatric department.
      She started attending an anger management group at the hospital.  It was thought to be the best way to help her deal with recent events.
      One day when I went in to work, my social worker was already there and in tears. Mrs Coleman had just taken a massive overdose of Paracetamol and her liver was thought to be too far gone to survive.  She died a rather painful death and we were all deeply saddened.
      Could we have done any better?  Was the truth too much for Mrs Coleman to bear?  Would she still be alive if we had not discovered the sex abuse?  We would never know. We might have rescued Laura from sex abuse but now she had lost her mother. Mrs Coleman was right about one thing though, her sister-in-law did outlive her.
      As Shakespeare said, “…….And your experience makes you sad…..”
      I wanted to hide the dolls.



Sunday, April 8, 2018

Save the NHS: Control Health Insurers!

Spring is here!


 ©2014 Am Ang Zhang


It must be very obvious that all the talk about medical cover for visitors to England never mention the need for health insurance.

Could this be because insurers have managed not to cover for everything. One need to ask the question on how one ever travel to the US where cost of medical care is extremely high.

It may well be prudent for government to insist that non EU visitors to this country must have mandatory Health Insurance as part of the admission requirement. This should apply to students and tourists alike. After all nobody in their right mind would dream of going to the US without proper insurance.

We have managed to get people to insure their cars, why not their bodies.

There is of course the need to fully control Health Insurers for those that live in England if they want cover. 

Let people opt out of the NHS if it is so bad! But Insurers need to cover every thing. 

Citizens could be given a tax break and yet have the insurance policy incorporated into their NI/NHS number so that those with the tax break, the insurer will be charged for every kind of medical care they receive if they were within the NHS.

 ©2014 Am Ang Zhang

If we are not careful Private Insurance will creep into England without a single bit of control as it is singularly important to stop Insurers to reject those with pre-existing conditions or dump them once they have a chronic illness such as Type 1 Diabetes. 

Patients could have to start to pay charges to use basic NHS services such as GPs because the health service’s finances have become so dire, the leader of Britain’s doctors has warned. 
Dr Mark Porter, the head of the British Medical Association (BMA), said that whoever takes office after the general election will inevitably be tempted to bring in charges and may not be deterred by the unpopularity of such a seismic change to the health service.
....“You say it’s politically toxic. It’s not, really, is it? Look at dentistry and look at social care. They carry with them exactly the same offer to the public by which the NHS was set up; that we will remove from you – this society, us acting collectively – the terrible fear of bankrupting yourself by having an illness, by needing healthcare.
“And yet we allow people to be bankrupted by social care and we allow people to be deterred from seeking dental care because of charges,” Porter said.
Can we think of ways round this?
There is little doubt that a system based on insurance will need smart legislation to control the insurers. If the NHS is going to make use of wealthier individuals to use Health Insurance, then the same smart laws will need to be enacted for the regulation of Insurers. We should have learnt through the banking failures that in business, there is no such thing as self regulation.


Here are some things the law will do:
·         It will prohibit insurance companies from refusing to sell coverage to people simply because they have one or more pre-existing conditions.
·         It will also prohibit them from cancelling our coverage when we get sick just to avoid paying for our care.
·         It will prohibit insurers from charging women more than men for comparable coverage and will not allow them to charge older folks more than three times as much as younger folks.
·         It will require them to spend at least 80 percent of what we pay in premiums actually paying claims and improving care.
·         It will allow young adults—who comprise the largest segment of the uninsured—to stay on their parents’ policies until age 26.

 

Summary of a popular post:

·                     Ends discrimination against people with pre-existing conditions.
·                     Limits premium spread to normal, high risk and healthy risk to say under 20% either way of normal.
·                     Limits premium discrimination based on gender and age.
·                     Prevents insurance companies from dropping coverage when people are sick and need it most.
·                     Caps out-of-pocket expenses so people don’t go broke when they get sick.
·                     Eliminates extra charges for preventive care.
·                     Contribute to an ABTA style cover in case Insurance Companies go bust and many might.

We could legislate that Insurers will have to pay for any NHS treatment for those covered by them. It will stop Insurers “gaming” NHS hospitals. This will prevent them saving on costly dialysis and Intensive Care. Legislate for full disclosure of Insured status.

Insurers cannot drop coverage or treatment after a set period and even if they do they will still be charged if the patient is transferred to an NHS Hospital.

This will eliminate problems like PIP breast implants.

It will indeed encourage those that could afford it to buy insurance and in any case most firms offer insurance for their employees including the GMC.

To prevent gaming of Insurers by individual patients (I look after their interest too), the medical fee should be paid up front by the patient and then deduction taken from premiums. Corporate clients like those with the GMC should not be gaming Insurers.

Imagine the situation where those with “individual personalised budget” being able to “buy” their own insurance!

In fact, to save money, government can buy insurance for the mental patients and the chronically ill.

This way there will be real choice and insurers will be competing with each other to provide the worst deal.

Why?

What Health Insurer will want the business? 

Spring is here indeed!

©2014 Am Ang Zhang


Perhaps they will go back to the US and we will have our own NHS back.                                                                                   

Saturday, April 7, 2018

Brain Tumour: Pork and Unusual Treatment.

 © Am Ang Zhang 2015   

                                                                                                      
A short while back I blogged about GBM and how an innovative treatment may have helped. Being a doctor Dr Anderson noted this:
My wife, Carmen Alicia, called a local friend, also a cardiologist, who sent us to a nearby hospital; there, an MRI exam revealed a small spot on my brain. The neurologist felt it needed to be biopsied to obtain a tissue diagnosis. I immediately returned to Virginia and went to several specialists, who suggested further testing before I decided to have an invasive brain biopsy. I also had a blood test for cysticercosis, an infection that results from eating undercooked pork contaminated with Tenia solium. This common parasite produces cysts all over the body, including the brain. It is the most common reason for seizures in many countries, particularly in India, where children with seizures are first treated for this disease even before other studies are done. My blood test was strongly positive. I started a course of oral medicine to treat it. The test reassured me.
My later research showed that there may indeed be some association of Tenia and GBM. 



Neurocysticercosis (NC) is the most frequent and widespread human parasitic infection of the central nervous system (CNS). Glioblastoma multiforme (GBM) is a neoplasm of CNS in elderly population and may have a similar clinical and radiologic presentation as of NC. The coexistence of NC and neoplastic intracranial lesion in an individual is a very rare entity. The incidence of NC among intracranial space occupying lesions is reported to be 1.2-2.5%.[1–4] Though cerebral cysticercosis may be associated with glioma,[5] but this rare coexistence of NC and brain tumors puts into question a causal relationship between the 2 diseases. Here we report a case in which glioma and cysticercosis appeared concomitantly, with continuing progression of low grade Glioma to high grade Glioma (GBM, WHO grade IV).


So some religious dogma might actually be good for ones health. 


But watch out, even if you do not eat pork:


Neurocysticercosis in an Orthodox Jewish Community in New York City



All the patients and their families adhered to Orthodox Jewish dietary laws, which forbid the eating of pork. Moreover, T. solium taeniasis due to the ingestion of contaminated pork is extremely unlikely in the United States. Cysticerci were detected in only 3 of more than 83 million hogs examined after slaughter under federal inspection in 1990.
The most likely sources of infection in the patients described in this report were women living and working in the patients' homes who had recently emigrated from Latin American countries where T. solium infection is endemic.

In 2003 the world was in the grip of a new plague that challenged our knowledge of medicine to its limit.

         For the first time, doctors and nurses who were normally in the forefront of the fight against diseases were fighting for survival from SARS (Severe Acute Respiratory Syndrome), a new and dangerously contagious disease.  The alarm was first raised by its first victim, Carlo Urbani.  He was an Italian physician employed by the World Health Organisation (WHO) and based in HanoiVietnam and he gave the disease its current name. It was as if this newly mutated virus knew what it was on about. Get the doctors as they would be the first who could deal with you. Urbani died. So did some of the medical staff that attended the first few patients.

         Doctors often thought that they would be immune, a God given right I suppose.  Not so this time! The virus obviously knew what it was doing.



A doctor friend had just been diagnosed with GBM (glioblastoma multiforme) grade IV. My hospital librarian had the same tumour and told me that the hospital neurosurgeon got it too. Another close friend who is an ENT surgeon has just been diagnosed with NPC (Nasopharyngeal Carcinoma).

Looks like doctors are no longer as immune as we like to believe and that goes for those that worked closely with doctors like our beloved librarian.                                                                .

More about the DOCTOR I mentioned earlier:

He is a cardiologist for thirty five years, (so not a neurosurgeon then) but with the diagnosis his research unravelled one of the possible reasons for "catching" GBM.
Why?

Why did this tumor happen to me? I never smoked and had had no brain injuries, and there is no history of such tumors in my family. As a cardiologist, I had implanted close to 400 pacemakers in my life and during the procedure was exposed to ionizing radiation (X-rays). In the early days we used portable X-ray machines and gave ourselves some protection by using thin lead gowns. Nowadays, heavy lead gowns are worn, and doctors and technicians protect their thyroid and eyes with shields and glasses. We also use heavy sheets of radiation-protective glass that hang from the ceiling.

At some point in my research, I was surprised by an article by a Johns Hopkins-trained cardiologist who now practices in Israel. He had collected data on 23 invasive radiologists and cardiologists who had developed tumors, of which 17 were GBMs on the left side of the brain. I wrote to the author, who told me that he had learned of several more such cases since his article was published, and he added mine to his file."

GBM

" I had a glioblastoma multiforme (commonly called a GBM) grade IV. This is the most malignant brain tumor; no grade II or III exist. A glioblastoma is what killed Sen. Edward M. Kennedy (D-Mass.) in 2009. While rare, it is the most common of the brain tumors. The prognosis is dismal; on average, patients survive only 14 months after diagnosis even with chemotherapy and radiation. After five years, only 5 percent of patients are still alive."

So depressing.

But wait: The Zapping!

" The Preston Robert Tisch Brain Cancer Center at Duke University has the largest experience on the East Coast with my sort of tumor, so I went there for further consultation and treatment.

As doctors there examined me, it was obvious that my tumor had already grown again; in fact, it had quadrupled in size since my initial chemo and radiation. I was offered several treatments and experimental protocols, one of which involved implanting a modified polio virus into my brain. (This had been very successful in treating GBMs in mice.) Duke researchers had been working on this for 10 years and had just received permission from the FDA to treat 10 patients, but for only one a month."

The procedure:

"I was given the Salk polio vaccine to prevent a systemic polio infection.


At Duke, my skull was opened under local anesthesia and I had the viral infusion dripped through a small catheter directly into the tumor in my brain for six hours."

The result:

"I returned to Duke a month after the infusion, and though an MRI showed some expected swelling, the more significant fact was that the tumor had stopped growing. I have gone back to Duke every two months since then, and the tumor, initially the size of a grape, is now a scar, the size of a small pea. It’s been two years since the initial biopsy and radiation, and one year since the experimental polio viral treatment, and I have no evidence of recurrence nor tumor regrowth.

According to a presentation about the research that the Duke doctors gave last May, the results so far are promising: “The first patient enrolled in our study (treated in May 2012) had her symptoms improve rapidly upon virus infusion (she is now symptom-free), had a response in MRI scans, is in excellent health, and continues in school 9 months after the return of her brain tumor was diagnosed. Four patients enrolled in our trial remain alive, and we have observed similarly encouraging responses in other patients. One patient died six months following ... infusion, due to tumor regrowth.” They added: “Remarkably, there have been no toxic side effects ... whatsoever, even at the highest possible dose.”

That has been true for me. I feel as fit as I was three years ago, before the first symptoms of the glioblastoma made their appearance. I remain only on an anti-seizure medication."


Laoshan China

 © Am Ang Zhang 2011    


Thirty years ago, I saw mountains as mountains, and waters as waters.

When I arrived at a more intimate knowledge, I came to the point
where I saw that mountains are not mountains, 
and waters are not waters. 

Thirty years on,
I see mountains once again as mountains, and waters once again as waters.
                                
 Adapted from Ching-yuan (1067-1120)

Tuesday, July 3, 2018

Lohengrin review


 – Klaus Florian Vogt compelling in sharp Mitteleurope update

4/5stars4 out of 5 stars.
Royal Opera House, London
Director David Alden pushes the power politics in the war-ravaged setting for the ROH’s first new Lohengrin for 41 years
Jennifer Davis as Elsa von Brabant and Klaus Florian Vogt as Lohengrin
 Wagner by way of Barry Manilow … Jennifer Davis as Elsa von Brabant and Klaus Florian Vogt as Lohengrin. Photograph: Tristram Kenton for the Guardian
It’s 41 years since the Royal Opera introduced a new Lohengrin. That production, directed by Elijah Moshinsky and last seen in 2009, was a largely traditional affair, crammed with dark-ages Christian and pagan symbolism reflecting the strange mixture in Wagner’s libretto. Its replacement, directed by David Alden (his second new Covent Garden show of the season, after last autumn’s Semiramide), takes a very different line. Paul Steinberg’s designs and Gideon Davey’s costumes suggest a relocation to the first half of the 20th century, somewhere in central Europe. The skewed brick facades of the modular set, with their gaping windows and steel gangways and girders, imply a country ravaged by war and a society teetering on the brink of totalitarianism, a threat that becomes vividly real before the end of the opera.
For Alden, it’s all about power politics – the story of an enfeebled king, so desperate to assert his authority that he wears his crown throughout, who sees the arrival of Lohengrin as the answer to his expansionist prayers and the means of turning around the fortunes of his beaten army. To King Heinrich, Elsa’s fate and, to some extent, the machinations of Ortrud and Telramund are subsidiary. Perhaps Ortrud’s invocation of the dark arts sits rather uneasily in this modern militaristic world, and there’s little symbolism here, except for the eruption of flags in the final scene, all emblazoned with a swan, which has become a fascist emblem. The only references to Christianity are the unavoidable ones in the text, while the famous wedding march at the beginning of the third act is wryly sent up on stage.
As one would expect from this director, everything about the production is vividly detailed and thoughtfully cogent, typically lit from low angles to produce looming expressionist shadows and stark contrasts. Every one of the protagonists is sharply defined. There’s no boat and no swan for Lohengrin’s arrival or departure, just a lighting effect to suggest its beating wings, as the set splits to reveal Klaus Florian Vogt sitting on the ground, in a white suit and open-necked shirt, for all the world like a 1970s pop singer: a Bee Gee perhaps or Barry Manilow.
Lohengrin
Pinterest
 Expressionist shadows … Lohengrin. Photograph: Tristram Kenton for the Guardian
Vogt begins and ends his role in a rather disembodied mezza voce, and if his tone never becomes exactly fulsome, he is always compelling, especially when singing quietly. Every word counts, and Lohengrin’s revelation of who he is in the final scene is spellbinding. He’s well matched also to the Else of Jennifer Davis, who conveys innocence and vulnerability in a thoroughly musical way. A product of the Jette Parker young artists’ scheme, Davis is a lyric soprano with a bit of extra steel, and a more than plausible actor. Their antagonists are nicely complementary, too – if Thomas J Mayer’s ranting Telramund sometimes strays into pantomime-villain territory, he contrasts perfectly with this Ortrud, as Christine Goerke moves from icy control to avenging vamp at the flick of a switch, even if the vocal ride is bumpy at times.
Together with Georg Zeppenfeld’s vacillating king and Kostas Smoriginas’s threatening, crippled Herald, they all fit perfectly into Alden’s dramatic scheme, and integrate just as smoothly into Andris Nelsons’ musical one. Nelsons’ gloriously comprehensive conducting, full of moments of quiet, rapt intensity and surging, tremulous excitement, superbly realised by the ROH Orchestra, is one of this new production’s biggest plusses of all.
  • This article was amended on 10 June 2018. The previous version stated the king’s name as Friedrich.

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