Friday, August 8, 2014

Away on Vacation: Anne of Green Gables Country.

Heading towards Anne of Green Gables country. In the meantime, perhaps you would like to catch up with some of my past postings or even read my book: The Cockroach Catcher

 Young Hawksbill Turtle©2010 Am Ang Zhang


Latest Views on the book:


5.0 out of 5 stars A Must-read for Students of Psychiatry August 10, 2014
Format:Paperback
We all have stories to tell with regard to our experiences as physicians. Zhang is one of our medical school classmates who took it to a different level by writing and publishing a book. The book details how it all started, from the time his family moved to Hong Kong from China, to his years in medical school, to his experience as a child psychiatrist in the UK. The book is full of interesting case studies of actual patients he saw and the challenges he faced dealing with them.
I was captivated by many of the interesting stories in the book. It’s a must-read for all students of psychiatry. It also makes for good reading material for anyone during their leisure moments.

From another doctor friend:

The Cockroach Catcher has evoked many images, memories, emotions from my own family circumstances and clinical experience.

My 80 year old Mum has a long-standing habit of collecting old newspaper and gossip magazines. Stacks of paper garbage filled every room of her apartment, which became a fire hazard. My siblings tricked her into a prolonged holiday, emptied the flat and refurbished the whole place ten years ago. ……My eldest son was very pretty as a child and experienced severe OCD symptoms, necessitating consultations with a psychiatrist at an age of 7 years. The doctor shocked us by advising an abrupt change of school or we would "lose" him, so he opined. He was described as being aloft and detached as a child. He seldom smiled after arrival of a younger brother. He was good at numbers and got a First in Maths from a top college later on. My wife and I always have the diagnosis of autism in the back of our mind. Fortunately, he developed good social skills and did well at his college. He is a good leader and co-ordinator at the workplace. We feel relieved now and the years of sacrifice (including me giving up private practice and my wife giving up a promising administrative career ) paid off.

Your pragmatic approach to problem solving and treatment plans is commendable in the era of micro-managed NHS and education system. I must admit that I learn a great deal about the running of NHS psychiatric services and the school system.

Objectively, a reader outside of the UK would find some chapters in the book intriguing because a lot of space was devoted to explaining the jargons (statementing, section, grammar schools) and the NHS administrative systems. Of course, your need to clarify the peculiar UK background of your clinical practice is understandable.

Your sensitivity and constant reference to the feelings, background and learning curves of your sub-ordinates and other members of the team are rare attributes of psychiatric bosses, whom I usually found lacking in affect! If more medical students have access to your book, I'm sure many more will choose psychiatry as a career. The Cockroach Catcher promotes the human side of clinical psychiatric practice in simple language that an outsider can appreciate. An extremely outstanding piece of work indeed.

From Australia:

I have finished reading The Cockroach Catcher and thoroughly enjoyed it.

Zhang, I particularly liked the juxtaposition and paralleling of your travel stories and observations with your case studies, Of course, I could appreciate it even more, knowing the author and hearing your voice in the text. Because I’m dealing with anorexia, ADD and ADHD students I was very interested in your experiences with patients and parents and your treatment. Amazing how many parents are the underlying causes of their offspring’s angst. It was an eminently readable text for the medically uninitiated like me. Keep writing, Zhang
 Squid ©2010 Am Ang Zhang
From another doctor:

Absolutely riveting! Brings me back to working (in NHS psychiatry) when work was really interesting! The tone is quite conversational; it is like hearing you telling stories. I ordered more copies for my family and friends.

I knew it would be very special and it sure is. To us your trainees it is like going back on the rotation to have the joy of working with you again. The difference is that l can now learn at leisure from this book. Congratulations.
The book is very well written and makes very easy and interesting reading even for the laymen. You learn a lot about the Health System, a lot about child psychiatry and a lot about the growing up and development of the author.

Fascinating account of child psychiatry cases, including some creative yet effective treatments. Anyone who is a parent or around children or really anyone at all actually will find the book surprising, entertaining, thought-provoking, funny and moving.

The book makes me realize the difficult decisions with which a doctor is so often faced, the need for him to have faith in himself and, coupled with that, the need for continued idealism and enthusiasm. These don't, of course, apply only to doctors but are particularly important for them.
Great book. I have bought one to give to my son on his birthday.




From the LUL
U.com website, where you can preview the chapter Seven Minute Cure and if you so wish, order a copy of the book (after creating your own account):

Fascinat
ing! What a great read. Just reading the one chapter made me want to read the whole book. Thank you!
A beautiful opening! A piece written with of all that wit, intelligence and sarcasm! The author has managed to illustrate a boring NHS subject in the most interesting of ways. He has convinced me to read on. The NHS should urgently seek help and advice from this doctor!
Thank goodness for doctors like these!! If the rest of the book is as good as the preview chapter then it will be a fantastic resource for practitioners and the public. 
Fascinating preview chapter. I can't wait to read more.
Horrah for the doctor. Chapter 1: The Seven Minute Cure. The doctor overcame the obstacles faced from the establishment and freed a young child from her prison. Great read.
Other reviews and feedback:
Absolutely riveting! Brings me back to working (in NHS psychiatry) when work was really interesting! The tone is quite conversational; it is like hearing you telling stories. I ordered more copies for my family and friends.
I knew it would be very special and it sure is. To us your trainees it is like going back on the rotation to have the joy of working with you again. The difference is that l can now learn at leisure from this book. Congratulations.
The book is very well written and makes very easy and interesting reading even for thelaymen. You learn a lot about the Health System, a lot about child psychiatry and a lot about the growing up and development of the author.
Fascinating account of child psychiatry cases, including some creative yet effectivetreatments. Anyone who is a parent or around children or really anyone at all actually will find the book surprising, entertaining, thought-provoking, funny and moving.
The book makes me realize the difficult decisions with which a doctor is so often faced, theneed for him to have faith in himself and, coupled with that, the need for continued idealism and enthusiasm. These don't, of course, apply only to doctors but are particularly important for them.
Great book. I have bought one to give to my son on his birthday.
(Note: both father and son are doctors.)




I was in Special Education for many years. I just love the way you dealt with the girl who was bullied, and the boy with Behaviour Disorder. I am buying two more copies, one for my friend who is a psychologist and one for a colleague in Special Education.

I wish I had read your book when I was headmistress. I would have had so much more insight into why some of the pupils behaved the way they did.
I have been a school counsellor for 15 years and we have had regular recommendations on books to read. None of them taught us as much as your book, which would have been very useful for our weekly screening meeting discussions.
Reading the book and his blog, you cannot help admiring the author's width and depth of knowledge, the light-heartedness, the humility, the humane and the human side of people.
You learn a lot about the Health System, a lot about child psychiatry and a lot about the growing up and development of the author. 
What a book! I cried a little. I laughed a little. I know I should not. 
Your stories are amazing. I really enjoy reading it. 
My wife cannot put your book down and I shall not be able to get my hands on it until she has finished.
I was horrified by some of the gruesome cases and agonised at the suffering of some of your patients. But there are moments of laughter and smile at Dr Zhang's wit in handling the cases and patients.
Am Ang, thank you for a wonderful book. You know I could not put it down. My husband is now reading it and he said it is such an easy read as he thought it was all going to be heavy and clinical.
You have such a way with the little ones. What about the 12 year old pretending to be three and a half! My goodness.
Just the village life can fill a book. (Seriously an in-depth version will be much welcome!) Book two can be Life at HKU. And so on... Fascinating!
Having grown up in farming country, I love the Chapter on The Village. I know it is different but so much about village life just clicked with me. Makes me wants to go home to have a look. I would like you to write more about yourself. Just all the little details you are so good with.
I wish I had your book when I was bringing up my kids. I am giving each of my two children a copy. I decided to put down Pillars of The Earth for a while and start your book on a flight. I could not put it down to go to sleep. Wow: it makes so much sense.
I did expect the cover photo to be one of yours – after all, the creative mind needs full exposure, artistic and otherwise. I was just recommending it to some friends.
I never imagine I can have so much fun and gain so much knowledge by reading a book of this sort by, of course, an author with a sense of humour and a deep understanding of human nature. I really enjoyed reading it. Life could be so much easier if we had the chance to do what we like, to let our thoughts be shared by someone we trust, to make sugar pills of nasty encounters and so on and so forth for bearing more positive thinking. Just by a mere short conversation, which hit exactly at the 'dead pit' of the hiccup boy, the hiccup was over. Human nature is just like that. After reading the author's accounts of his cases, I wish I could also be endowed with such wit and wisdom, not so much for curing others, but to let my own body and soul remain healthy and sound always.
Love it. I read it in three days flat. Not only should parents read it; I think all those in the medical profession should read it. There is so much common sense. I am recommending it to my book club. Will you come and talk to them about it?



Can it be that it was all so simple then
Or has time rewritten every line
If we had the chance to do it all again
Tell me - Would we? Could we?
                                                                      The Way We Were


     

Thursday, August 7, 2014

Norway & Hong Kong: Tax & Alcohol.

Do we ever learn that prohibition never did anything to alcohol consumption nor would price control? 


With the millions spent on Cocaine in Wall Street and The City, when will we wake up to the fact that these are Tax Free perks?




©2013 Am Ang Zhang

By Wendy Leung - February 27, 2008 05:37 EST


Feb. 27 (Bloomberg) -- Hong Kong's government abolished taxes on wine and beer after posting a record surplus, boosting efforts to turn the city into a wine-trading hub.

The tariffs will be abolished immediately, costing the city government HK$560 million ($72 million) in annual tax revenue.
Tax was 80% before 2007 then 40%


The rest of Hong Kong Tax:
No sales tax
No capital gains tax
No VAT
Maximum salary tax of 20%
Profit tax maximum of 16%
Inheritance tax or estate duty has been abolished since             11February 2006. 

Yet, my doctor friends told me that there is no binge drinking problem like they have in Norway where there is high taxation and much difficulty in buying alcohol.

Strange.

Ålesund Norway©2012 Am Ang Zhang





Solveig Torvik 
December 16, 2010 

Weekend binge drinking is a perplexing feature of Norwegian cultural life to many visitors.

The role of alcohol in Norway often appears to be to consume it until you’re senseless, and alcohol commonly is accepted as an excuse for indulging in antisocial behavior. Binge drinking seemingly isn’t regarded as aberrant behavior in Norway, even by sober citizens who, generally speaking, uncomplainingly tolerate the ensuing brawls and other unpleasant results.

But why do so many people who do live in the “world’s best place” drink until they’re comatose? And why are many of them prone to violence and aggression when drunk? No one knows.

Dr Ole Johan Hoyberg, formerly a hospital-based psychiatrist in Ålesund, told newspaper Sunnmørsposten: “There’s a great deal more drunkenness in the communities that I got an insight about as a hospital doctor. Alcohol abuse is on the point of becoming a national sickness.”

Which seems an odd state of affairs indeed for a nation that’s billed as the world’s best place to live.

Monday, August 4, 2014

NHS & Junior Doctors: 1st day & Faith!

Changeover time is here. Like it or not, God has a sense of humour!

.........Perhaps we should catheterise her. She had not been seen to use the toilet for hours although she was not drinking much. She was still going round in her room – we gave her the side room and a nurse – and we put on an input output chart so we knew. The new junior doctor’s car broke down so she was late in examining her.
         Bother, I forgot it was changeover time, when new doctors came in for their new six-month rotation.  This is one of the days of the year not to be ill.
         “Good work Sister. What do we do without you?”
         Sister did the catheterisation but only got about 150ml. The mass was still there.
         I phoned Ob-Gyn. The consultant had left for home, but I got her Senior Registrar.
         He came over. Yes, it was possible that she was pregnant but unlikely as there were no breast changes. He would hate to do an X-ray but that seemed justified in the case of an undiagnosed abdominal mass.
         My mind was racing now. Sometimes you do have to believe what you see. Sometimes you have to believe the parents. She was not one of those girls. She could not be pregnant. So now we had to go through the differential diagnosis for abdominal mass in a young girl of thirteen.
         Ovarian cyst was the obvious one.
         This big?
         Possible.
         No. It cannot be.
         The x-ray came back. The tell tale tooth was there and yes – a Teratoma, the distinctive type of tumour that can include teeth, hair, sometimes, even a jaw and tongue.  I guessed just a split second before the results came back. How annoying.
         Working diagnosis: Teratoma with possible toxic psychosis.
         Emergency operation was arranged. Yes, she would be fine a little while after the operation, I reassured the parents.

         The paediatric junior arrived and took some history and did a quick physical before she was prepared for the theatre. This petite doctor with a very babyish face told me that on her first day in her last job she had to do an emergency tracheotomy. This time she had been on call for the last three nights and the battery in her old Mini could not cope with the heavy frost so she had to wait for AA before coming. She was most apologetic for not having got in earlier.

She asked if I had seen many toxic psychosis cases and I asked if she had come across any in her psychiatric placement. As with all good psychiatrists answering a question with another is in our blood and here it worked well.
         Neither of us knew what was to hit us next.


At 2 A.M. I had a call from her.
        “Your patient – I mean our patient could not be aroused after the operation. Yes they removed the teratoma, complete and intact. It is bigger than any specimen I have seen but she could not be aroused.  Any ideas?”
        “Call the paediatrician on call in the regional paediatric unit and I will be in.”
        What happened?  I asked myself as I drove to the hospital.
        What had we done? This was fast becoming a nightmare situation.
        What was I going to say to the parents?
        Something else was going on here, and I was not happy because I did not know what it was. I was supposed to know and I generally did. After all I was the consultant now.
        Thank goodness she could breathe without assistance. That was the first thing I noticed. I saw mother in the corner obviously in tears. She asked if her daughter would be all right. I cannot remember what I said but knowing myself I could not have said anything too discouraging. But then I knew I was in tricky territory and it was unlikely to be the territory of a child psychiatrist.
        A good doctor is one who is not afraid to ask for help but he must also know where to ask.
        “Get me Great Ormond Street.”
        “I already did.”
        She is going to be a good doctor.
        “Well, the Regional unit said that they had no beds so I thought I should ring up my classmate at GOS and she talked to her SR who said “send her in”.”
        Who needs consultants when juniors have that kind of network?  This girl will do well.
        “Everything has been set up. The ambulance will be here in about half an hour and if it is all right I would like to go with her.”
        “Yes, you do and thanks a lot.”

        I told mother that we were transferring her daughter to the best children’s hospital in England if not in the world and the doctor would stay with her in the ambulance. She would be fine.


.........She was impressed with mother’s faith and trust in God.
        She said mother was near to tears. It was bad enough to have such a large Teratoma and then to have the patient unconscious with no one knowing what was going on was very frightening.
        “I have seen some deaths as a medical student but never since I was registered. I do not want this to be my first.”
        I knew the feeling well but what could I say? A doctor has to face it some time.
        “Do you believe there is God?” She asked
        “Do you really think I can answer that one?”
        “Well, you have more experience.”
        “To me it is like reading a good book. You would not know until the end.”
        “So you mean I am not going to know until then.”
        “Interpret whichever way you like. I remember Jung in his Memoir gave quite an account on the Holy Trinity.  There were seventeen bishops in Jung’s family including his own father. Jung had always been puzzled by deity and the bible and most of all by the concept of the Holy Trinity. I know many religious philosophers struggle with that too. By some accident he had access to his father’s inner library. He saw this folder clearly marked Holy Trinity. The relief was phenomenal. He could now have the answer. He hesitated before opening the folder.”
        “What did the folder contain?”
        “See, you want the last chapter. I wanted to know as well. The folder contained pieces of blank paper.”
        “That was it?”

        “That was it.”

  A  reprint:

NHS & Ham: World Class Medicine without trying!

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

Why?

We provided World Class Medicine without trying. A quote from a fellow blogger, Dr. No.


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

Do we really want to take that away now? Years of heartless re-organisation has left many of us dedicated doctors disillusioned. Many young ones have left. Poorly trained doctors that have no right to be practising medicine now even have jobs in some of these well known hospitals. 

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


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

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

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

I am not here to analyse his faith.

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

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


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


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


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

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

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

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


©Am Ang Zhang 2010


Back to the patient:

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


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


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


We did not have Admission Avoidance then. 

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


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


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


Here is an extract from my book The Cockroach Catcher:  

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:


          …………Something else was going on here, and I was not happy because I did not know what it was. I was supposed to know and I generally did. After all I was the consultant now.

          Thank goodness she could breathe without assistance. That was the first thing I noticed. I saw mother in the corner obviously in tears. She asked if her daughter would be all right. I cannot remember what I said but knowing myself I could not have said anything too discouraging. But then I knew I was in tricky territory and it was unlikely to be the territory of a child psychiatrist.

          A good doctor is one who is not afraid to ask for help but he must also know where to ask.

          “Get me Great Ormond Street.”

          “I already did.”

          She is going to be a good doctor.

          “Well, the Regional unit said that they had no beds so I thought I should ring up my classmate at GOS and she talked to her SR who said “send her in”.”

          Who needs consultants when juniors have that kind of network?  This girl will do well.

          “Everything has been set up. The ambulance will be here in about half an hour and if it is all right I would like to go with her.”

          “Yes, you do and thanks a lot.”

          I told mother that we were transferring her daughter to the best children’s hospital in England if not in the world and the doctor would stay with her in the ambulance. She would be fine.


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

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



Pride & World Class in Pennsylvania!                                             



Anti-NMDA Receptor Encephalitis

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

565 cases! Not so rare!

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

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

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

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

Teratoma: finally!

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

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

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

Related paper:

Anti-NMDA Receptor Encephalitis: Diagnosis, Psychiatric Presentation, and Treatment

Chapter 29  The Power of Prayers

                                                        
                   

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

King’s Fund: Million £ GP.

See also:

NHS Reform: Dr House & Integrated Service.



Can it be that it was all so simple then
Or has time rewritten every line
If we had the chance to do it all again
Tell me - Would we? Could we?
                                                                      The Way We Were

The Cockroach Catcher on Amazon Kindle UKAmazon Kindle US                                                                                                                                                                                                                     =