Saturday, April 19, 2014

Australia & Medicine: Hot topics!

Saturday, February 16, 2013

Australia & Cade: Lithium & Toxicity.

© Am Ang Zhang 2013 
       © Am Ang Zhang 2013                                           

The Cockroach Catcher was privileged to be working with an Australian trained psychiatrist when he started in psychiatry in 1969. It was the first time that I have encountered Lithium and Manic-Depressive psychosis (still my preferred name than Bipolar Disorder as Bipolar seemed easier for parents to accept, hence my objection).

I feel it was appropriate to honour Cade for his work on Lithium during my recent visit to Australia.

Cade, John Frederick Joseph (1912 - 1980)
Taking lithium himself with no ill effect, John Cade then used it to treat ten patients with chronic or recurrent mania, on whom he found it to have a pronounced calming effect. Cade's remarkably successful results were detailed in his paper, 'Lithium salts in the treatment of psychotic excitement', published in the Medical Journal of Australia (1949). He subsequently found that lithium was also of some value in assisting depressives. His discovery of the efficacy of a cheap, naturally occurring and widely available element in dealing with manic-depressive disorders provided an alternative to the existing therapies of shock treatment or prolonged hospitalization.

In 1985 the American National Institute of Mental Health estimated that Cade's

discovery of the efficacy of lithium in the treatment of manic depression had saved 

the world at least $US 17.5 billion in medical costs.

But the sad truth is that it was really 15 years before the world embrace lithium and that means more lives could have been saved.

Toxicity: This is one of the main reasons that many new psychiatrists shy away from it.
Yet many lives could have been saved and in medicine one is always trying to balance the benefit and adverse effect of any treatment.

I cannot do better than to quote one of the best articles about Lithium & its toxicity.

Neuropsychopharmacology (1998) 19, 200–205. doi:10.1016/S0893-133X(98)00019-0

Gordon Johnson MB, BS, FRANZCP, FRCPsych, DPM

The report of the effectiveness of lithium in the treatment of mania by John Cade was followed by a number of studies confirming his observations and developing guidelines for safe and effective use. Premature rejection of lithium on safety grounds denied many patients the benefit of treatment and may have cost more lives than it saved. A similar safety alarm was triggered by reports of kidney damage in the late 1970s. Subsequent reports have questioned the significance of anatomical findings, and functional impairment and relationship to lithium treatment. Recent findings support the conclusion that progressive impairment of glomerular and tubular function in patients during lithium maintenance is the exception rather than the rule and is related more to lithium intoxication, maintenance plasma lithium levels, concurrent medications, somatic illness, and age than on time on lithium. Guidelines for lithium use and monitoring of renal function are outlined here>>>>.

Bipolar disorder: divalproex er vs placebo
May 19, 2009

Just before I retired, it has become fashionable to use anticonvulsants as a mood stabiliser. Being a traditionalist, I felt then that the evidence was not clear and I tended to stick with the trusted lithium.

Well my doubts were confirmed:Journal of the American Academy of Child & Adolescent Psychiatry:

A Double-Blind, Randomized, Placebo-Controlled Trial of Divalproex Extended-Release in the Treatment of Bipolar Disorder in Children and Adolescents.

Conclusions: The results of the study do not provide support for the use of divalproex ER in the treatment of youths with bipolar I disorder, mixed or manic state. Further controlled trials are required to confirm or refute the findings from this study. J. Am. Acad. Child Adolesc. Psychiatry, 2009;48(5):519-532.

An earlier Harvard study showed that Lithium reduced suicide risks by as much as 9 fold.

Tuesday, January 29, 2013

Fremantle: Medical Heresy & Nobel

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

Sharks too.

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

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

© Am Ang Zhang 2013

© Am Ang Zhang 2013

© Am Ang Zhang 2013

© Am Ang Zhang 2013

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


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

How to prove it: He drank the bacteria!

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

                                                                                        Barry Marshall   

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

“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

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

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

Getting Personal:

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


It wasn’t settled until people did a truly double-blind study, using an acid blocker and also amoxicillin and a third antibiotic called tinidazol. All of those antibiotics could be given in a placebo, so one group of patients could take the ‘real’ antibiotics and the others would take antibiotics that were absolutely identical but were ‘fake’, and even the doctors didn’t know which patient was getting which treatment. That trial was done in Austria and was then published in America, in the New England Journal [of Medicine], which would have the most stringent criteria for medical research.
One year later, at a big think-tank in Washington to which I was invited, it was declared proven: ‘The treatment for ulcers is now antibiotics.’ That was vindication, in effect. The implication, once you say that in the United States and the NIH [National Institutes of Health] or somebody like that puts a document out and everyone accepts it, is that you have to follow it. In 1994 there were thousands of professors and scientists in the US making a living off Helicobacter.

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


Tuesday, April 15, 2014

Gustav Mahler: Resurrection!

And behold, it is no judgment;
there are no sinners, no just….
There is no punishment and no reward.
An overwhelming love illuminates our being.
We know and we are.

 ©2014 Am Ang Zhang

"Rise again, yes, rise again thou wilt! Then the glory of God comes into sight. A wondrous light strikes us to the heart. All is quiet and blissful. Lo and behold: there is no judgment, no sinners, no just men, no great and no small; there is no punishment and no reward. A feeling of overwhelming love fills us with blissful knowledge and illuminates our existence.

From silence, the chorus enters, at first almost inaudibly, singing Klopstock’s resurrection poetry. The solo soprano detaches imperceptibly from the chorus and floats above it. Mahler used only two of Klopstock’s three stanzas, and omitted the concluding ‘Hallelujah!’ to each. The remainder of the Symphony’s text was Mahler’s own, started with ‘O glaube’ (‘Oh believe!’), introduced by the mezzo soloist. The end is a soaring E-flat major hymn, from which ‘an overwhelming love lightens our being. We know and we are.’


Musicologists explained the early rejection of the Second Symphony as a result of Mahler's new harmonies. Never before had these been found in music. He overstepped the boundaries of what was considered "beautiful." Music critics and concertgoers found his music too long, too complicated, too bombastic, too neurotic, overly melancholy, and so on. Leonard Bernstein, who led the Mahler revival of the 1960s, claimed that "There was something much deeper in the rejection of Mahler's music." He suggested that "Mahler's music simply hit too close to home, touched too deeply on people's concerns and their fears about life and death. It simply was too true--telling something too dreadful to hear."

Fortunately, the above elements, which were so strongly rejected by the musical establishment of Mahler's day, are now passionately embraced by new generations of listeners. His genius lies in his unique ability to draw together such wildly contrasting elements as intense post-Wagner/Strauss/Bruckner harmonies, Austrian peasant music, Jewish childhood motifs, children's innocence, and a distressing fascination with death. He moulds all of them into a convincing and compelling musical structure.

Youtube: Simon Rattle

Sunday, April 13, 2014

Medicare & NHS : Changing sides!


US taxpayer funded health care for over 65s.
This includes Salomon Melgen, an ophthalmologist from Florida and the latest whipping boy for high-profile medical fraud. In 2012 Melgen received nearly $21 million from Medicare—64 times the average in his field. Put another way, that's more than Lebron James' NBA salary, right?

Not really. Even if we ignore the $9 million in fraud that he is currently being investigated for (and will likely lose), and if we ignore the $700,000 in super PAC money he donated to support New Jersey Senator Robert Menendez (who is also now facing a federal probe for potentially interfering to protect Melgen), and if we ignore the likely fortune he must have paid to get the former head of the Justice Department's Medicare fraud task force, Kirk Ogrosky, to be his attorney—Melgen was never getting close to that $21 million.


As I sort through thousands of photos of my recent stay in Finland: I marvelled at how a country recovered so quickly from Russia & Nazi & provided its citizens with good free health care & child care. The State is still responsible for alcohol sale apart from beer. so the government kept the tax and profits. Not Supermarkets nor Wine Merchants. 

© 2012 Am Ang Zhang

It would seem to me that it was some genius or else some very smart plotters that worked out the scheme (or was it scam) to destroy our NHS of old. The NHS was not without its faults but just recently some Qatari took his private plane to check into a Private Hospital in London. But very quickly he was transferred to an NHS Hospital! No, not a Circle run one. People still have faith in our NHS Hospitals despite Mid Staffordshire or Baby P.

No!No!No! When you are really ill, you want real hospitals. Because by then you do not care about decor, cappuccino or Michelin Star meals. They know that the fabric might be old, but the medicine served is good.

So how can these Management Consultants succeed in the sell off of something as lovely as the Finnish Scenery. 

Simple: History! History! History!

Trojan Horse.

When Iceland banks failed, it was with the collusion of its regulators.

In the film, the Inside Job:

Not too long ago in Iceland, those working for the banking regulator may find themselves employed by the bank that they were “regulating” during one of their visits. We all know what happened to Iceland.

Some very smart people there indeed. Governments never seem to learn as our banks failed too, so did those in the US & Ireland and other countries.

There is much talk of the role of the regulator Monitor in safeguarding our health care. It was the genius thinking this is a way to fool us into thinking : ALL IS WELL.

Perhaps we should look at our most famous regulator: FSA. (Financial Services Authority).

The FSA was dragged into the news recently as its first head Sir Howard Davies, resigned as director of London School of Economics for eight years over "a mistake". The "mistake" was to advise the LSE's council to accept £1.5m research funding from a foundation controlled by Colonel Muammar Gaddafi's son, Saif.                                 More>>>>>>>>>

So, were there any other "mistakes" when he was head of FSA?


17 July 2008
The Financial Services Authority will be dealt yet another hefty blow to its credibility today, as the Parliamentary Ombudsman, Ann Abraham, reverses her decision of five years ago and accuses it of maladministration for its role in the collapse of Equitable Life eight years ago.

"The case of Equitable Life, which echoes earlier cases such as Vehicle & General in the 1970s and shares some similarities with the current example of Northern Rock, illustrates the need for absolute clarity as to what can and cannot be expected from financial regulation and the development of shared understandings as to the limits to the protection that such regulation offers to investors both before and after problems arise, as they inevitably will," said Ms Abraham.

"Key, however, is that those responsible for undertaking financial regulation should act in a way that is compatible with the duties and powers which Parliament has conferred on them. Those responsible for the prudential regulation of Equitable Life failed to do so throughout the period covered in my report."
Sir Howard Davies was previously employed by McKinsey and Company and was Special Advisor to the Chancellor of the Exchequer.

I was reading a book by Philip Delves Broughton on Harvard Business School (HBS): Ahead of the Curve.

He may not be the first to observe that HBS loves Marines, Mormons and McKinseyKim Clark  must indeed be the most famous sons of The Church of Latter Day Saints and PDB’s article in The Sunday Times: “Harvard’s masters of the apocalypse” may indeed be aptly titled.

He opened with:

If his fellow Harvard MBAs are all so clever, how come so many are now in disgrace?

From Royal Bank of Scotland to Merrill Lynch, from HBOS to Lehman Brothers, the Masters of Disaster have their fingerprints on every recent financial fiasco.

We MBAs are haunted by the thought that the tag really stands for:
Mediocre But Arrogant, Mighty Big Attitude, Me Before Anyone and Management By Accident.

For today’s purposes, perhaps it should be Masters of the Business Apocalypse.
On RBS (Royal Bank of Scotland)
When I was a student at Harvard Business School, between 2004 and 2006, I recall a distinguished professor of organisational behaviour, Joel Podolny, telling us proudly of his work with Fred Goodwin at RBS. At the time, RBS looked like a corporate supermodel and Podolny was keen to trumpet his role in its transformation. A Harvard Business School case study of the firm entitled The Royal Bank of Scotland: Masters of Integration, written in 2003, began with a quote from the man we now know as Fred the Shred or the World’s Worst Banker: “Hard work, focus, discipline and concentrating on what our customers need. It’s quite a simple formula really, but we’ve just been very, very consistent with it.”
Harvard Business School alumni include Stan O’Neal and John Thain, the last two heads of Merrill Lynch, plus Andy Hornby, former chief executive of HBOS, who graduated top of his class. And then of course, there’s George W Bush, Hank Paulson, the former US Treasury secretary, and Christopher Cox, the former chairman of the Securities and Exchange Commission (SEC), a remarkable trinity who more than fulfilled the mission of their alma mater: “To educate leaders who make a difference in the world.”

Trojan Horse: The Guardian

A global consultancy firm seeking to profit out of the fallout from the shake-up to the NHS is being paid £250,000 a year by the government for advice on the transition towards health secretary Andrew Lansley's vision of the service.

The American firm, McKinsey Inc, with estimated revenues of £4.1bn a year, has been advising the Department of Health on how best to manage the radical changes since March. McKinsey is also one of a group of private consultants that have united to provide paid-for advice to GPs as they prepare for life after the reforms.
Family doctors need help from private companies because of the government's decision to abolish primary care trusts as part of their controversial changes to the health service, a move criticised as a step towards privatisation.

The head of Monitor (a sort of health FSA!) is Dr Bennett. 

Monitor: Recent exchanges in Parliament

Q 195 Jeremy Lefroy (Stafford) (Con):  I have a couple of questions about the role of Monitor. The first is about the Mid Staffordshire trust into which the Francis inquiry is looking at the moment. It seems to me as the local Member of Parliament that Monitor approved the foundation trust status without going into sufficient detail as to the status of that trust, particularly the quality of care at the time. What assurances can you give us that Monitor’s approval of foundation trusts will be more rigorous in the future than it was in the case of Mid Staffordshire? 

David Bennett: Yes. I was not around at the time, but looking at the evidence, the trust was approved at a time when it was not delivering appropriate care to its patients, and that was wrong. Monitor has done three core things in the light of that, all based on an external review of what happened and why, and therefore what lessons can be learned. First, it has set a clear quality bar. That did not exist before—there was no clear definition of what was an adequate level of safe care for any trust to be providing to be authorised. In conjunction with the CQC and the Department of Health, there is now a clear definition of what the quality bar should be. 
Q 196 Jeremy Lefroy:  Sorry, are we saying that there was not a clear quality bar for approval of foundation trusts up till now? 
David Bennett: There has been for a while, but not at the time of Mid Staffordshire. 

Dr Bennett was a Director at McKinsey & Co. In his 18 years with McKinsey he served a wide range of companies in most industry sectors, but with a particular focus on regulated, technology-intensive industries.
Average citizen might think, he is a doctor regulating Health Care, it must be OK then. Well, he is not a Medical Doctor. Do you think the genius would put a doctor in the Trojan horse? 
There were more:

© 2012 Am Ang Zhang


Q 203 Mr Barron:  I was on the Health Committee during the previous Parliament, when it looked into the independent sector treatment centre programme. I had conversations with more than one company running the programme that said they felt threatened by the pensions implications, with the work force working in the independent sector while keeping the NHS rewards such as pensions. I call them distortions, but most of us have one. By implication, what does that mean? 
David Bennett: I think again of Sonia’s point. There are lots of considerations. Yes, pensions are an issue, but as someone said there is an issue around the complexity of the cases that we have dealt with. 
Q 204 Mr Barron:  I accept that. ISTCs were contracted for cases that were not likely to go wrong in surgery, because there was no back-up in the hospitals or institutions if someone needed to go into ITU, and so on. I understand that exactly. 

Sue Slipman: The only thing I would add is that it is clearly the public sector that is carrying the responsibility for the education and training of people across the system as a whole. There are balances here in those imbalances, and we would certainly be pressurising Monitor very hard to take them into account. 
The Chair:  I think that they accept that. 

Emily Thornberry:  I am tempted to press you further, David, given the profound implications of what you said in relation to work force pensions. We are about to pass this legislation and you are saying, “Take it on trust, as it will all be sorted out.” But we are talking about millions of people’s pensions here, and it is difficult not to push you at this stage. 

Worse than that, you said in an incomplete answer earlier that there were other obvious distortions and advantages that the NHS had over the private sector. I wonder whether you could list anything else, on top of pensions, that you might think might of? 
David Bennett: I said that obvious distortions are creating advantage within the NHS. I was also saying that there are other distortions in the market, and Sue has just pointed out two of them. At the moment, it is the public sector that has to pay for R and D, and it is the public sector that pays for training. That places the public sector at a disadvantage. That needs to be taken into account. 
Q 208 Emily Thornberry:  Do you have any others? 
David Bennett: I do not have a comprehensive list.        More>>>>>>>>>>


“You can’t get fired for hiring McKinsey & Company.”

It often goes unmentioned, but McKinsey has indeed offered some of the worst advice in the annals of business. Enron? Check. Time Warner’s merger with AOL? Check. General Motors’s poor strategy against the Japanese automakers? Check. It told AT&T in 1980 that it expected the market for cellphones in the United States in 2000 would amount to only 900,000 subscribers. It turned out to be 109 million. The list goes on.

A thought-provoking new book called “The Firm: The Story of McKinsey and Its Secret Influence on American Business,” which comes out next Tuesday, offers a fascinating look behind the company’s success.

The book, by Duff McDonald, chronicles McKinsey’s rise but also raises an important question about it that is applicable to the entire netherworld of consultants, advisers and other corporate hangers-on: “Are they worth it or not?”

The answer amounts to hundreds of billions of dollars annually. Indeed, the army of advisers whispering into the ear of Verizon and Vodafone (its C.E.O. is a former McKinsey partner) over the weekend for their work on the $130 billion deal stand to make over $200 million alone. And, perhaps most important, they don’t have to give the money back if the deal turns sour.

Mr. McDonald’s book explores the remarkable and intriguing disconnect between the advice McKinsey offers and the ultimate results.


NHS & Market Forces: Uncomfortable Readings!!!