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
This is the home of Barry J. Marshall, J. Robin Warren
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.
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
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 United States
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
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 United States US
“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
Bipolar Disorder: Lithium-The Aspirin of Psychiatry?
Fremantle: Medical Heresy & Nobel
Tasmania & SIDS: The wasted years!
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.
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!
- 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
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 200911-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.
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Alaska, Good Friday Earthquake and Zyprexa
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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
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.
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
Multiple Sclerosis: Never say never!
Latest from Dr Weldon:
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.
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.
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 Evidence: Diagnosis 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
“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.
There are now concerns that Chlamydia pneumoniae might be implicated in other human diseases including atherosclerosis and acute coronary syndromes, and a variety of prostate conditions.
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:
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
Dr Am Ang Zhang
"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."
but wow, they now have something they can make money on! a drug for Fibromyalgia pain (packed with a plethora of side effects)!
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. :-)
The Cockroach Catcher
Whistleblower: Genius & Fraud
It is interesting to come back to somewhere where I can start catching Cockroaches.
See also:
Sunday, June 8, 2014
NHS & Wine: Simon Stevens----Sale or Sail?
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
UnitedHealth has traveled an unlikely path to becoming a
During a media presentation in May in
Asked about the discrepancy, Stevens says the lower figure he is using in
So will Simon sell or sail? Or sell then sail!
for Violations of Federal and State Mental Health Parity Laws - UNH
$3.5 MILLION TO SETTLE FRAUD CHARGES
Thursday, September 3, 2009
Pfizer, Geodon (Ziprasidone ) & The Twist
Is anything sacred anymore?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?
Tuesday, May 22, 2018
NHS Original: Best Health Care!
NHS & Private Medicine: Best Health Care & Porsche
Best Health Care: NHS GP & NHS Specialist
Monday, May 21, 2018
Bipolar Disorder: Lithium-The Cinderella or Aspirin of Psychiatry?
Lithium in Tap Water and Suicide Mortality in Japan.
Bipolar Disorder: Lithium-The Aspirin of Psychiatry?
Fremantle: Medical Heresy & Nobel
Tasmania & SIDS: The wasted years!
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?
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 $
Chile: Salar de Atacama & Bipolar Disorder.
Lithium Bipolar and Nanking
Bipolar Disorder in Children
Bipolar and ADHD: Boys and Breasts
Statins-Harvard-Roosevelt
Bipolar Disorder: Biederman Einstein God.
Antipsychotics: Really?
Bipolar and ADHD: Boys and Breasts
Grand Round: Medicine and War
Bipolar Disorder: Lithium-The Aspirin of Psychiatry?
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.
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.
"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.”
First do no harm.
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.”
“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).
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:
A simple bump on the head can kill you,Natasha Richardson’s Brain Injury
The wussification of the American medical profession.
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
Photography: Hallgrimur Church, Iceland
Saturday, May 19, 2018
Botanical Diversity: From Cloud Forest to Vegetables!
Cloud Forest of Volcan Baru, Panama:
Monday, May 21, 2018
Saturday, May 12, 2018
Photography: Black & White beauty!
Friday, May 11, 2018
Mental Health Awareness: Clozapine & Finland
Gold Standard!
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 200911-year follow-up of mortality in patients with schizophrenia: a population-based cohort study (FIN11 study) Jari Tiihonen et al.
…………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.
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.
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.
Wednesday, May 9, 2018
Mental Health Awareness: Fake? Or What?
South Africa reminded me of my junior doctor and my hiccup boy.
The Cockroach Catcher: Chapter 13 Hiccup Boy
At the time my junior doctor Dr Zola was a girl from
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.
Monday, May 7, 2018
Mental Health Awareness: Bobby Baker & The Peril of Diagnosis
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 was told by the first psychiatrist she saw that she suffered from borderline personality disorder. (Time article link)
“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
A Brief History of Time: Anorexia Nervosa
Tuesday, May 1, 2018
World Class Hospital Medicine: Pride, Hope & Faith!
A quote from a fellow blogger, Dr. No.
The Mayo of the
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.
We used to practice real, good and economical medicine.
Back to the patient:
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.
The Power of Prayers & Teratoma: Brain & NMDA!
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
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:
NHS : Andrew Lansley, his Doctors and MPs.
NHS Reform: Dr House & Integrated Service.
Comments:
Sunday, April 29, 2018
Flat Earth & Miracles: Professor! Professor! 3 month? !
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!
Flat Earth & Miracles: He will never learn to speak!
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.
Flat Earth & Miracles: Duping & Human Kindness!
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.
Finland: Hello Autumn!
Wednesday, April 25, 2018
From Tampopo to Sideways: Merlot at last.
The wine?
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.
Free water:
Thailand:
In Thailand, workers in rice fields, fruit orchards and vegetable patches manage to survive temperatures of over 100°F.
Thursday, April 19, 2018
Osthmanthus & Guava: An older and more sedate time!
FREE eBook: Just drop me a line with your email.
Email: cockroachcatcher (at) gmail (dot) com.
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.
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:
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!
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.
>>>See also Dr No: We Have No Black Boxes
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
Can serve my turn? 'Forgive me my foul murder'?...
And now I'll do't. And so he goes to heaven;
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.
Exchange forgiveness with me, noble Hamlet:
Mine and my father's death come not upon thee,
Nor thine on me.
FREE eBook: Just drop me a line with your email.
Email: cockroachcatcher (at) gmail (dot) com.
The Last Cook in The NHS
Cello & Bach: Anorexia Nervosa
Anorexia Nervosa & Safety Net: The NHS.
Sadness & Abuse: As You Like It.
Abuse Abuse Abuse
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.
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)
Sunday, April 8, 2018
Save the NHS: Control Health Insurers!
Spring is here!
©2014 Am Ang Zhang
Let people opt out of the NHS if it is so bad! But Insurers need to cover every thing.
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.
Summary of a popular post:
Spring is here indeed!
©2014 Am Ang Zhang
Saturday, April 7, 2018
Brain Tumour: Pork and Unusual Treatment.
© Am Ang Zhang 2015
But watch out, even if you do not eat pork:
Neurocysticercosis in an Orthodox Jewish Community in New York City
© Am Ang Zhang 2011