Friday, August 24, 2018
Brain Tumour & Unusual Treatment.: GBM & Pork.
© 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 Hanoi , Vietnam
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
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
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.
Friday, August 17, 2018
Food Labeling: They just print what you want to hear!
Looks like it is not only my patients that fake!
18 September 2015
German carmaker Volkswagen has been ordered by US regulators to recall half a million cars because of a device that disguises pollution levels.
The "defeat device" allows cars to pass lab testing even though they actually emit 40 times the emissions standard.
The illegal system allowed cars to detect when they were undergoing smog emission test and lowered the rate of pollution. Those emission controls were then turned off during ordinary use.
Now how many would take up the recall as it has nothing to do with safety and if you remove the devise you are going to use more diesel.
Forbes thought the same too: read it here!
It was a device to mislead regulators and not consumers. It benefits consumers.
Not quite, just like faked Kona Coffee, it is still caviar but a cheaper species.
Looks like the big boys are moving in as the pickings are better with the rich and famous who can’t tell their burgundies, coffees or now caviar.
I think I like to get my hand on those cheap stuff that could be passed off as fakes.
The Guardian:
Is fine dining having its Apollo 13 moment? I know it's not on the same scale as "Houston
King is the founder and co-owner of the eponymous King's Fine Foods, the UK 's largest supplier of caviar with a client list that includes Buckingham Palace
Random DNA tests taken back in October at King's premises in Richmond
The Cockroach Catcher has always been amazed that in a short time under pressure from consumer groups and the government, food manufacturers and supermarkets managed to produce detail analysis of the product they sell so that consumers can be clear what they are “consuming”!
What he was amazed was how healthy most foods were: sugar free, trans-fat free, cholesterol free. Even when the product has cheese.
Wow! Modern food processing technology! Or was it modern labelling technology!
Then he remembered Ribena. You can read about it here>>>>>
Vancouver ©2012 Am Ang Zhang
I happened to be in one of the world’s most livable city and imagine my surprise when I read this in:
By Sarah Schmidt, Postmedia News
Some of the world's biggest food brands and leading organic labels have understated the amount of bad nutrients — such as fat, sugar and sodium — in their products, or overstated the good ones, internal government tests show.
Kraft, Frito Lay, Unilever and Heinz are among the big names with a product that flunked Canadian Food Inspection Agency (CFIA) testing, conducted to see if nutrition claims on labels live up to their billing.
Loblaw's popular President's Choice brand had multiple "unsatisfactory" tests on products ranging from cereal to spaghetti.
Premium brands like Amy's Kitchen, Eden Organic, Natur-a, Kashi and Yves Veggie Cuisine also fell short on composition claims, as did Canadian food-makers like B.C.-based Sun-Rype Products Ltd. and Quebec-based Aliments Fontaine Sante.
No Sugar:
Among the breads and baked goods tested, Fenwicks "no sugar added" cookies (too much sugar)
Iron:
In the snacks category, Krispy Kernels Inc.'s Island mixed nuts claimed to contain 90 per cent of the recommended daily intake of iron per serving. Samples tested by CFIA found contained a fraction of that: 10.5 per cent.
A sampling of other findings shows the huge discrepancies that can exist between labels and ingredients.
Cholesterol:
Some snacks boasting a "No cholesterol" message on their label showed levels ranging from 4.3 milligrams (Lays Smart Selections chips) to 10.5 mg (Barbara's Cheesepuff Bakes) per portion, according to CFIA tests.
(PepsiCo says its own tests on Lays chips, conducted after CFIA informed the company of the agency's eight unsatisfactory tests involving samples of three Smart Selections chip products, showed the claim was accurate.)
Kraft made the same no-cholesterol claim for its Ritz "Real Cheddar Cheese" crackers, but CFIA testing showed the crackers contained 3.2 mg per portion. Dare's cinnamon snap biscuits contained 4.9 mg, CFIA testing showed.
These discrepancies pale in comparison to the findings of two canned snail products picked up from Dollarama stores in Regina Indonesia
Vitamins:
Canned foods from Unico (pizza sauce), Primo (vegetable soup), Stokely (pumpkin) and Amy's (refried beans, butternut soup) all fell short of their vitamin claims. So did Eden Organic's vegetable spirals, President's Choice organic pasta sauce, Fontaine Sante spinach dip and Island Farms yogurt.
Of the 40 products found to be overstating the amount of vitamins in their products, Yves Veggie Cuisine Ground Round (Mexican flavour) and a prepared pasta dinner by Olivieri Creations stood out for being wildly inaccurate.
The label on Yves Veggie Cuisine Ground Round, a product of the Hain Celestial Group, said each serving contained 80 per cent of the daily value of vitamin A, but CFIA testing showed 3 per cent. And a pre-packaged tortelloni and chicken dinner by Olivieri Creations claimed to contain 110 per cent of the daily value of vitamin C per serving, but CFIA found a serving contained only 1.1 per cent.
Sun-Rype, Oasis and Bolthouse Farms were among the juice brands that overstated — by about double — the amount of a vitamin.
Two juices from Dewlands fared worse; each boasted 35 per cent of the daily value of vitamin A, butnone was detected in either.
Omega acids:
Big-brand products that failed to live up to their omega-3 or omega-6 fatty acid claims included President's Choice Angus burgers, Kraft House Italian dressing and Country Harvest tortillas. Hellmann's mayonnaise under-delivered on the amount of polyunsaturated fatty acids, as did Kashi's honey almond flax cereal.
Specialty products that overstated one these so-called "good fats" include Natur-a soy beverages, So Good fortified soy beverage, Ruth's cereal, and Mom's Healthy Secrets cereal.
GoldSeal canned salmon, Ocean's canned salmon, Our Compliments salmon burgers and High Liner salmon were among the fish products that overstated the amount of omega-3 or omega-6 fatty acids.
Salt:
Some products pitched as reduced in sodium didn't live up to their billing, including Heinz "25 per cent less sodium" Dora the Explorer vegetable and pasta soup, Eden Organic "low salt" canned green lentils, rice and beans, R.W. Knudsen Family "low sodium" vegetable cocktail, "50 per cent less sodium" President Choice crackers, and "low sodium" President's Choice tomato and roasted red pepper soup.
There were also "unsatisfactory" discrepancies in three different Bread Works Bakery "low in sodium" cracker products, with one containing 277.8 mg of sodium, not 70 mg, according to CFIA tests.
Two different cans of Unico artichokes, picked up four months apart, were found to be saltier than claimed on the Nutrition Facts Table.
Calories:
"Light tasting" Nutriwhip testing showed 68 calories per portion, not 20 as claimed on the label. A green tea beverage from Tempest Tea claimed to contain just 5 calories, but testing showed 106 calories per portion.
If it could happen in Canada
Twitter:
Canadian Food Inspection Agency cuts cause Vancouver food inspectors unit to disband straight.com/food/630636/ca… via @georgiastraight
First Posted as
Food Labels: Real or Really? April 21, 2012.
Thursday, August 16, 2018
Anorexia Nervosa : Enmeshment & Failure!
©2013Am Ang Zhang
Alert readers would have noted a number of Anorexia Nervosa cases on this blog and in my book, The Cockroach Catcher and that Minuchin’s name has indeed been mentioned.
Regardless of what present day psychiatrists (and that includes those dealing with Anorexia Nervosa, Minuchin have in one way or another inspired us in our dealings with Anorexia Nervosa and of course families in general.
He has inspired me the most in my work with families and with Anorexia Nervosa in particular.
He was born in Argentina and soon served in the Israeli army before continuing his training including that of psychoanalysis in New York US
Minuchin above all helped me in my understanding of family dynamics and in turn in my personal dealings with problem families and Anorexia Nervosa.
Minuchin has recognized a group of family system characteristics that reflect the family dynamics of patients with anorexia nervosa:
Enmeshment:
This is a transactional style where family members are highly involved with one another. There is excessive togetherness, intrusion on other's thoughts, feelings and actions, lack of privacy, and weak family boundaries. Members often speak for one another, and perception of the self and other family members is poorly differentiated. A child growing up in this type of family learns that family loyalty is of primary importance. This pattern of interaction hinders separation and individuation later in life.
Overprotectiveness:
This refers to the excessive nurturing and protective responses commonly observed. How can the psychiatrist begin to argue against such a good trait! Pacifying behaviors and somatization are prevalent.
Rigidity:These families are heavily committed to maintaining the status quo. The need for change is denied, thereby preserving accustomed patterns of interaction and behavioral mechanisms. Rigidity is commonly observed in the family cycle during periods of natural change where accommodation is necessary for proper growth and development. You must have seen families where for every single day of the week they eat the same meal year in year out.
Avoidance of conflict/ conflict resolution:
Family members have a low tolerance for overt conflict, and discussions involving differences of opinion are avoided at all costs. Problems are often left unresolved and are prolonged by avoidance maneuvers. Everyone would come up with a highly believable excuse. After all everyone is very clever!
Apart from classical Autism, parents of many sufferers of Anorexia Nervosa are amongst the most successful in their own profession. Many are CEOs of major corporations including Hospital Trusts and PCTs. Minuchin’s powerful understanding of the family dynamics has allowed me to navigate the very difficult terrain. More so than trying to learn Tango!
Minuchin
It is not easy to admit to failures and harder still for doctors to do so especially if they did everything right and according to protocol.
Doing the “right” thing is not an indication of success.
Hardly.
Yes. I am coming back to Anorexia Nervosa again and I do not apologise for it. I am apologising for our failures though
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.
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.
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 feed 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.
