Thursday, July 26, 2018
NHS; The Last Cook & The Last Sunset!
As the sun sets on our beloved NHS:
©Am Ang Zhang 2012
Perhaps it is not that well known that the dismantling of our beloved NHS started long before the present government and the future does not bode well for those of us that likes to keep NHS in the public domain.
Child Psychiatric in-patient units across the country were closed some time after many adult hospitals were closed or down-sized.
To me, the government is too concern with short term results that they impose various changes across the board in Health Care & Education without regard to the long term consequences or costs.
After all, I have made good use of in-patient facilities to un-diagnose ADHD and that would in turn save children from unnecessary medication and the country from unjustified benefit claims.
Such units were also great training grounds for the future generation of psychiatrists and nurses. Instead, most rely on chemicals to deal with a range of childhood psychological problems.
Indeed it was a sad day when the unit closed.
From The Cockroach Catcher:
Chapter 48 The Last Cook
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ne of the few things I learned working in some inpatient units was to be appreciative of the ancillary staff. What a cleaner might reveal to us was often more telling than a formal interview. It could well be that often parents were unguarded and more able to reveal things to someone like the cleaner or indeed the cook.
I was fortunate enough to experience one of the last NHS cooks when I was Senior Registrar at an inpatient unit. The inpatient unit catered for a middle age group spanning the older children to the younger adolescents. It was one of a kind in the U.K. and indeed it was the first to start a national training course for Psychiatric nurses in inpatient care, a good three years before anywhere else.
The unit was in the middle of town and was considered to be too far from the Hospital for catering purposes. Instead a cook was employed to cater for the needs of the children and nursing staff. We doctors were not supposed to eat there. But we did. Mainly for lunch.
If we arrived at mid-morning we used to get a nice cup of tea. But that was only since I started bringing in my own tea leaves. We also got served home-made scones and the like.
All very homely.
I had since wondered if our great success rate was more to do with having our own cook than all the other therapies and tit bits that we did.
You never know as people do not really research these things.
……I often arrived late at lunch time after the children and nurses had eaten as morning clinics had a habit of running late. With less than ten minutes to spare, the cook would still manage to serve me a bit of some of the things she knew I preferred. Often she felt compelled to sit with me to tell me about her grandchildren or about what the government should really be doing to help the likes of her, a war widow bringing up two sons in this Naval town. I always admired the resilience shining through her stories.
She also provided me with her down to earth views of what we should do with whichever patient that had come in. I listened. I took note. You never know.
Sheena was the mother of two girls we had to admit. They were both ‘soilers’ and they would never touch vegetables at home or anywhere.
Sheena was petite, worn and a chain smoker.
But she had two lovely looking girls.
We knew from the start there were handling issues and most likely diet ones too.
One of the other reasons for their admission was that by and large there were very few girl ‘soilers’.
It was always a good sign when a child flourished in an inpatient setting, and away from home some mothers were more capable of telling you more of what went on. Some mothers found it easier to talk to one of the non-medical staff, perhaps the cook.
Mothers got fed too on their visits. More often than not the children preferred their mother to go home than to stay and watch them. That was a different issue. With the money spent on cigarettes and drinks not much was left for food either for the children or the parents. I knew that if we checked for vitamin and other deficiencies we would find them, a problem that had taken Public Health a long time to wake up to. Increasing tax for cigarettes and drinks did not change people’s habit one little bit.
With a simple routine the girls were clean in no time. At least during the week as they all went home week-ends, when the unit was closed.
We were at a loss as to what was going on.
The girls would get worse over the week-end and soil. This went on for quite a while.
Then one day the cook talked to me.
“Sheena never stays Mondays,” she told me.
I listened.
“Have you noticed she is always in dark glasses on Mondays?”
How stupid of me. Now and again I saw her at the door seeing the girls off and yes, she wore huge sunglasses.
Sheena was not a movie star.
I arranged to see Sheena.
She said, “You knew.”
I nodded.
“But I cannot leave him. I have nowhere to go and I shall not get enough benefit money if I am divorced from him. He now goes to the day hospital. Fridays he gets drunk and beats me up. It is like a routine. I try not to get hurt and hide it from the girls. If I walk out, he will find me even if I have somewhere to go. I shall still get beaten up. Now at least I know when it will happen and I can live with that.”
I suggested that I should speak to him but she looked terrified.
She felt he might even kill her if I did and last time he threw a chair at a male nurse who tried to say something.
She was probably right. We often had no idea what people and particularly women put up with. It would be too easy for us to bulldoze in. We had to think twice before intervening unless we had something better to offer. His Schizophrenia diagnosis allowed for a higher level of benefit she would not otherwise get. Who would she meet up with next? Another violent man most likely.
Was it such a cop-out on my part?
Maybe it was, but in a strange way the girls stopped soiling after that one meeting I had with mum. The case left me with some unease - unease not just about what I did or did not do but about keeping patients in the community. Three other lives were affected here and who knows, one day he might go too far. That was before Maria Colwell.
The unit had long since been closed.
The last cook in the NHS retired .
The Cockroach Catcher at: Amazon Kindle US; Amazon Kindle UK ;Lulu.com
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Apr 25, 2014 ... In my book The Cockroach Catcher I described how I was suddenly confronted with a piece of work by Mondrian. I have to confess it was not an ...
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Oct 21, 2012 ... The supervisor, Frances Tustin, wore a head of thick pure white hair. Very short and of rather solid build, she used to wear only trousers, which ...
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Aug 9, 2016 ... I no longer remember Amanda as a severe anorectic but rather a very talented artist who suffered serious abuse. Yet in a society which prides ...
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Sep 3, 2014 ... Chicago: From Magritte to Amanda. Rene Magritte exhibition. Could the Cockroach Catcher have missed this exhibition? Art Institute of ...
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Apr 11, 2016 ... Cape Floristic Region (CFR) of South Africa. ©Am Ang Zhang 2005. South Africa reminds me of my Anorexia Nervosa patient.
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Sep 26, 2016 ... Well, let the truth be told, Am Ang discovered Barbados long before the celebs. He is still very fond of it though he tends to visit when the celebs ...
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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.”
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!
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.
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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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