Wednesday, March 25, 2020

Covid-19 or SARS-CoV-2: Airborne so 2 metres distance meaningless!

As Covid-19 virus is now found to be airborne, 2 metres distance will not help. A jogger in front of you may be a symptom free carrier and pass it to the jogger behind.  


Surgeons wear masks mainly to protect the patient being operated on. Perhaps places where people wear masks do not have such a high number of Coronavirus cases: Hong Kong and Taiwan.



Hong Kong Street.


While wearing a mask has become the norm in many places in Asia, the mask frenzy has hit nowhere as hard as Hong Kong. At the height of COVID-19 panic, residents lined up overnight outside drugstores to buy face masks. South Korea, Singapore and Japan have distributed face masks to residents. Taiwan and Thailand have banned the export of masks to meet soaring local demand.


In Hong Kong and Singapore, they don’t shut the place down or put everyone under home quarantine. They do their best to trace every contact and then quarantine only those who had close contact with the infected person. In Hong Kong, “close contact” means fifteen minutes at a distance of less than six feet and without the use of a surgical mask; in Singapore, thirty minutes. If the exposure is shorter than the prescribed limit but within six feet for more than two minutes, workers can stay on the job if they wear a surgical mask and have twice-daily temperature checks. People who have had brief, incidental contact are just asked to monitor themselves for symptoms.  New Yorker:

com/life/sars-how-the-quest-for-a-quick-victory-led-to-costly-error/article22394326/
May23, 2003

“Faced with the World Health Organization's costly declaration on April 23, that Toronto was too dangerous to visit, politicians, health officials and even the news media quickly banded together against a common enemy — and it was not the virus but WHO, the United Nations agency, that had effectively put Canada's largest city under quarantine. ‘That week, that advisory definitely changed our psychology and the way we looked at this outbreak, ’Dr. Low said. ‘I remember . . . we were putting such a positive spin on things, including myself — everybody wanted to be clean of this.’”

"Now Toronto is holding its collective breath through a crucial weekend once again, as health officials cling to hopes of containment even as the numbers of cases and people in quarantine climb. The WHO lifted its travel advisory on April 30. Two weeks later, after the agency removed Toronto from its list of SARS-affected areas, Ontario lifted the provincial emergency status. Behind the scenes, the province disbanded members of its epidemiology team and scaled back its emergency-operations centre to a routine monitoring function. With no known new cases after 20 days, the city had laid down its gloves. On May 16, health staff in area hospitals were instructed that they no longer needed to wear full protective gear. May 16 is emblazoned with regret in Dr. Low's mind: "As soon as the masks and the gloves came off, you can see this dramatic spike in the cases.”



“……There was a new cluster, they told him, centering on patients who had spent time at St. John's Rehabilitation Centre in the city's north end before being transferred to four other Toronto area hospitals. Contact tracing had turned up no epidemiological link to the first outbreak. But a lab test confirmed that one of the four known patients carried the SARS coronavirus deep in his bronchial tract. It was back.”


You really cannot spin the public’s health, or can you? However there was some other form of spinning.

“Dr. Low's head spun with disbelief. ‘You're hearing it all and you're trying to minimize it. You're thinking, No this can't be right, this can't be.'

I know that Influenza A(H1N1) is not SARS, but why should we not learn from it.

The evidence of masks is hereCDC on SARS.


Bus in Hong Kong AFP
In the meantime we are donning masks whatever anyone else may say.

WHO H1N1 UPDATES
SARS ACCOUNTS: Dr Yannie Soo, Tom Buckley.
Other Posts:

SARS, Freedom & Knowledge


Learning from History: Swine Flu & Antibiotics

Learning From History: 1918 Flu Pandemic, Hong Kong SARS, Swine Flu & Influenza A(H1N1)
EBM: Masks, Cathay Pacific Airline, SARS and Influenza A(H1N1)
Swine Flu: WHO Level 5 & The 1976 Vaccine Disaster.
Hong Kong: SARS and Swine Flu
SARS and Quorum Sensing
Hospital Infection: Quorum Sensing

Monday, March 23, 2020

Tristan und Isolde



Tristan und Isolde tonight via Metopera Free Streaming at the time of Coronavirus!



"I fear the opera will be banned – unless the whole thing is parodied in a bad performance –: only mediocre performances can save me! Perfectly good ones will be bound to drive people mad, – I cannot imagine it otherwise."
Richard Wagner to Mathilde Wesendonck

My great love is Tristan und Isolde, and for that Wagner will have his place in the history of European culture because there he drops all his ideological bullshit, and all his dangerous sides. And finally he is really concentrating on his music and his poetry. And here he develops all his greatness. There is the Wagner that I am looking for.
Gottfried Wagner, TV documentary

"Tristan is not about 'being', it’s about 'becoming'. And it’s not an opera about love, but about death. The fear of death. This is the motor of the opera. There’s nothing more democratic than death."
Daniel Barenboim before his Met debut with Tristan und Isolde

1918 Pandemic: Bacterial Pneumonia as a Cause of Death


We must not shy away from using antibiotics as with Daniel Dae Kim whose physician prescribed him a 'drug cocktail' to treat coronavirus:


This consisted of the antiviral medicine TamiFlu, the antibiotic Azithromycin, a Glycopyrrolate inhaler, and the antimalarial drug Hydroxychloroquine!


Governor of New York: The state has acquired 70,000 doses of Hydroxychloroquine, 10,000 doses of Azithromycin and 750,000 doses of Chloroquine. Trials will start on Tuesday.



Predominant Role of Bacterial Pneumonia as a Cause of Death in Pandemic Influenza: Implications for Pandemic Influenza PreparednessThe Journal of Infectious Diseases DOI: 10.1086/591708 (2008).
David M. Morens, Jeffery K. Taubenberger, and Anthony S. Fauci
National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland Oct 1,2008
Background. Despite the availability of published data on 4 pandemics that have occurred over the past 120 years, there is little modern information on the causes of death associated with influenza pandemics.
Conclusions. The majority of deaths in the 1918–1919 influenza pandemic likely resulted directly from secondary bacterial pneumonia caused by common upper respiratory–tract bacteria. Less substantial data from the subsequent 1957 and 1968 pandemics are consistent with these findings. If severe pandemic influenza is largely a problem of viral-bacterial copathogenesis, pandemic planning needs to go beyond addressing the viral cause alone (e.g., influenza vaccines and antiviral drugs). Prevention, diagnosis, prophylaxis, and treatment of secondary bacterial pneumonia, as well as stockpiling of antibiotics and bacterial vaccines, should also be high priorities for pandemic planning.



Swine Flu: WHO Level 5 & The 1976 Vaccine Disaster.



Friday, March 20, 2020

La Traviata & La Bohème: TB & Morality


As I listen to the performance of La Traviata at The Met of December 15 2018 which is the same one with the same cast we went to on December 22, 2018, I will reprint an earlier blog.

A reprint from Dec. 17 2013

La Traviata & La Bohème: Illness & Morality

In The Cockroach Catcher:


“It would not be a great surprise to anyone who has any inkling of the history of medicine that sooner or later any medical condition with an alleged aetiology of pure psychological origin will prove to have a non psychological cause. This is particularly true of those conditions classified by non-psychiatrists.

In the past, ignorance has led to belief that certain conditions are either punishment by god, visions of great religious significance or simply madness. Accordingly you might be burnt, become a saint or simply be given one of the psychiatric medications.”


Tuberculosis is one such condition that came to mind, more so as last Sunday we saw a production of La Traviata by one of opera’s grandest composers, Giuseppe Verdi.


In 1897, a young nun Thérèse Martin in a convent of Lisieux was dying of tuberculosis. She was essentially writing the equivalent of the modern day blog in the form of a diary. She was 24 then and had led an uneventful and sheltered life, taking the veil at only 15 and in contrast to most saints, she experienced and accomplished little. With her tuberculosis, her health deteriorated rapidly and she spent her last five years in the convent’s infirmary
, continuing to diarise her innermost thoughts and emotions up until her death. The convent published her writings as an autobiography: Story of a Soul. After her death, many miracles were attributed to her intervention. In 1925, she became Saint Thérèse of the Child Jesus and of the Holy Face, and during World War II, Pope Pius XII proclaimed her co-patron saint of France, along with Joan of Arc.

Yet not long before the Industrial Revolution, in folklore, tuberculosis had been regarded as vampirism. As people with TB often had red, swollen eyes, pale skin and coughing blood, stories abounded that the afflicted could only replenish this loss of blood by sucking blood.

All of this changed in the nineteenth century – Mimi in La Bohème, Violetta in La Traviata (from Murger’s Scènes de la vie de Bohème, and Alexander Dumas’ novel La dame aux Camélias) and of course Hugo’s Fantine in Les Misérables. Tuberculosis became the preferred cause of death for a certain type of female character.


Verdi at 38 began an affair with a singer who was later to become his wife. Many viewed La Traviata as Verdi’s own way of testing public opinion. His new wife was luckier than Violetta.


Verdi of course was an opera revolutionary and in a letter to his friend Cesarino de Sanctis early in 1853, he wrote, “For Venice I am writing La Dame aux Camélias, a contemporary subject. Another composer might not want to do it perhaps because of the costumes, the period, and a thousand other awkward scruples … But I am doing it with total pleasure. E
verybody screamed in horror when I suggested putting a hunchback on the stage. Well, I was happy to compose Rigoletto.”

He was not so lucky with Venice as they insisted on 1700 costume when Verdi wanted contemporary ones. In that production, Violetta was nowhere near consumptive although it might well be a reflection of sopranos of the time: big and fat.


Luckily for us, his threat to withdraw the opera completely was rescued by a second performance that fitted in with Verdi’s ideal and the opera world was blessed with one of the three most performed operas; La Boheme and Rigoletto being the other two. All three operas remain my favourites.

Carlos Kleiber’s Traviata starring Ileana Cotrubas and Placido Domingo has to be the all time best in my eyes (or more correctly to my ears), closely followed by Angela Gheorghiu’s amazing performance under Sir Georg Solti.

In 1993 we went to Boheme at the Met. A very beautiful and slim Mimi appeared and you could hear the silence in the audience as she started to sing. It was one of the best Boheme’s: Angela Gheorghiu’s debut at the Met.

Tuberculosis sells.
Opera in the end is still one of the best medium as Dumas is hardly known nor performed nowadays.



Thursday, March 19, 2020

The Dark Side: Il Trovatore Another Baby Murdered: Mother threw own baby in fire


Today the Met is streaming this opera for free: here is an earlier blog.


Metopera Website
“A mother stole a baby from a wealthy family. She proceeded to throw her own baby into a fire and bring up the baby from the wealthy family as her own.”

That was not another Social Services blunder.

That was at the Royal Opera House on the 
13th of April 2009.
Verdi’s Il Trovatore is probably well known to most for its Anvil Chorus. For me it is about The Dark Side, the dark side of human nature.

“My hunch is that despite media coverage many of us still fail to grasp the dark side – the dark side of human nature. Until we do, we shall continue to read about child abuse, abductions and murders of the worst kind.” From The Cockroach Catcher.

Much has been written about training others to do the doctor’s work in an attempt to save health cost. What is not covered is the fact that there is training and there is a broader aspect of education. The ability to transmit culture external to genetic coding is what distinguishes Homo sapiens from other animal species on Planet Earth. Many bloggers are well educated in this cultural respect either by design, by choice or by accident. There is now an uncomfortable feeling of de-education in the Brave New World. Will the next generation of doctors, nurses and bloggers be as cultured? I do wonder!

In Il Trovatore, Azucena is the mother who killed her own baby and Manrico was brought up by her. Manrico is the brother of Count Di Luna that burnt Azucena’s mother for being a witch. Azucena had to avenge her mother’s death. How much hate can you hold. She had to throw her own child in the fire, bring up Manrico so that he would one day be killed by his own brother! Unbelievable! The full synopsis here.

Well, that roughly is it, Il Trovatore and the dark side. One of Verdi's best!





London debut: US soprano Sondra Radvanovsky in Il Trovatore
TelegraphThe Royal Opera House. Il Trovatore: unitl May 7, 2009.


Wednesday, February 26, 2020

M + M: Morbidity and Mortality Conference

© Am Ang Zhang 2018



I had a most enjoyable time on a Viking Ocean Cruise to return to the sad case of a Doctor being struck off. Reminds me of the book I read by Gawande: 




In one of the most moving passages in the book, Gawande’s father, in hospice, rises from his wheelchair to hear his son lecture at their hometown university. “I was almost overcome just witnessing it,” Gawande writes.

........Gawande offers no manifesto, no checklist, for a better end of life. Rather, he profiles professionals who have challenged the status quo, including Bill Thomas and other geriatricians, palliative-care specialists, and hospice workers. Particularly inspiring are the stories of patients who made hard decisions about balancing their desire to live longer with their desire to live better. These include Gawande’s daughter’s piano teacher, who gave lessons until the last month of her life, and Gawande’s father, also a surgeon, who continued work on a school he founded in India while dying of a spinal tumor.
He’s awed not only by his father’s strength, but by the hospice care that helped the dying man articulate what mattered most to him, and to do it. Gawande thinks, as he watches his proud father climb the bleachers, “Here is what a different kind of care — a different kind of medicine — makes possible.”

What would lawyers say about M + M:

- ‘There is one place, however, where doctors can talk candidly about their mistakes, if not with patients, then at least with one another. It is called the Morbidity and Mortality Conference – or, more simply, M+M – and it takes place, usually once a week, at nearly every academic hospital in the country. This institution survives because laws protecting its proceedings from legal discovery have stayed on the books in most states, despite frequent challenges.’ 


I read Gawande when in Peggy's Cove and posted about his book Complications! Honestly, I did not know Gawande was giving the Reith Lectures. 


Peggy's Cove: Charm & Complications!

What a charming place: Peggy's Cove of Halifax.

The Cockroach Catcher was finishing reading the book Complications and such charming old landscape reminds him of the old traditional medical training he received and how some doctors still do. Like the author of this book.

The book reads more like a collection of blog posts and in fact it was. Yet it was real and touching. Sometimes it was brunt and brutal. and after all doctors are as human as anyone. Complications includes those doctors themselves may suffer: mental illness and alcoholism as well as the serious cardiac condition of the author's young son.

We, doctors make mistakes and please we must be allowed to sort them out without affecting career or worst, future medical behaviour.

A great book for doctors in particular and when on holiday in a charming place.

 (Metropolitan Books, 288 pages, $24), a collection of 14 pieces, some of which were originally published in The New Yorker and Slate magazines, Gawande uses real-life scenarios – a burned-out doctor who refuses to quit; a terminal patient who opts for risky surgery, with fatal results – to explore the larger ethical issues that underlie medicine. He asks: How much input should a patient have? How can young doctors gain hands-on experience without endangering lives? And how responsible are these doctors for their mistakes?
While “Complications” is full of tragic errors and near misses, the book is not intended to be an expose. Rather, Gawande asserts, it is meant to deepen our understanding of the intricacies of medicine. “In most medical writing, the doctor is either a hero or a villain,” he says, with an edge in his voice. “What I am trying to do is push beyond that and show how ordinary doctors are – and at the same time show that what they can do is extraordinary.”
John Freeman, Copyright (c) 2002 The Denver Post.

Quotes


- ‘There have now been many studies of elite performers – international violinists, chess grand masters, professional ice-skaters, mathematicians, and so forth – and the biggest difference… is the cumulative amount of deliberate practice they’ve had.’


- ‘We have long faced a conflict between the imperative to give patients the best possible care and the need to provide novices with experience. Residencies attempt to mitigate potential harm through supervision and graduated responsibility. And there is reason to think patients actually benefit from teaching. Studies generally find teaching hospitals have better outcomes than non-teaching hospitals. Residents may be amateurs, but having them around checking on patients, asking questions, and keeping faculty on their toes seem to help. But there is still getting around those first few unsteady times a young physician tries to put in a central line, remove a breast cancer, or sew together two segments of a colon… the ward services and clinics where residents have the most responsibility are populated by the poor, the uninsured, the drunk, and the demented… By traditional ethics and public insistence (not to mention court rulings), a patient’s right to the best care possible must trump the objective of training novices. We want perfection without practice. Yet everyone is harmed if no one is trained for the future. So learning is hidden behind drapes and anesthesia and the elisions of language.’ 


- ‘There is one place, however, where doctors can talk candidly about their mistakes, if not with patients, then at least with one another. It is called the Morbidity and Mortality Conference – or, more simply, M+M – and it takes place, usually once a week, at nearly every academic hospital in the country. This institution survives because laws protecting its proceedings from legal discovery have stayed on the books in most states, despite frequent challenges.’ 

Saturday, February 15, 2020

Celebrity & Other Suicides: Maudsley & Lithium!

One of my ex-juniors, now retired, called to ask if I have read about another celebrity suicide. How very sad! If we look back there has been many such suicides and it is sadder that many are very talented people.                  


Dr. Baldessarini of Harvard:


“Lithium is far from being an ideal medicine, but it’s the best agent we have for reducing the risk of suicide in bipolar disorder,” Dr. Baldessarini says, “and it is our best-established mood-stabilizing treatment.” If patients find they can’t tolerate lithium, the safest option is to reduce the dose as gradually as possible, to give the brain time to adjust. The approach could be lifesaving.
In recent write ups about antidepressants, there is no mention of Lithium. The Cockroach Catcher first worked with one Australian Psychiatrist that worked with Cade and I was, so to speak, very biased towards Lithium. Yes, Lithium has side effects that might be serious. But hang on, you get to live to experience it. Think about it.
"Many psychiatric residents have no or limited experience prescribing lithium, largely a reflection of the enormous focus on the newer drugs in educational programs supported by the pharmaceutical industry."

One might ask why there has been such a shift from Lithium.
Could it be the simplicity of the salt that is causing problems for the younger generation of psychiatrists brought up on various neuro-transmitters?
Could it be the fact that 
Lithium was discovered in Australia? Look at the time it took for Helicobacter pylori to be accepted.

Some felt it has to do with how little money is to be made from Lithium. After all it is less than one eighth the price of a preferred mood stabilizer that has a serious side effect: liver failure.
Some felt it has to do with how little money is to be made from Lithium. After all it is less than one eighth the price of a preferred mood stabilizer that has a serious side effect: liver failure. 


Maudsley and Lithium

First, why a small group from the Maudsley Hospital in the 1960s could, in an almost malicious manner, have sown scholarly confusion about the true effectiveness of lithium. Aubrey Lewis, professor of psychiatry and head of the Maudsley, considered lithium treatment “dangerous nonsense” (). Lewis’s colleague at the Maudsley, Michael Shepherd, one of the pioneers of British psychopharmacology, agreed that lithium was a dubious choice. In his 1968 monograph, Clinical Psychopharmacology, Shepherd said that lithium was toxic in mania and that claims of efficacy for it in preventing depression rested on “dubious scientific methodology” (). Shepherd also scorned “prophylactic lithium” in an article with Barry Blackwell (). Moreover, Shepherd was publicly contemptuous of Schou. He told interviewer David Healy that Schou had put his own brother on it, and that Schou was such a “believer” in lithium that he seemed to think “really there ought to be a national policy in which everybody could get lithium”



 Atacama where Lithium is extracted  © Am Ang Zhang 2015

Lithium: The Gift That Keeps on Giving in Psychiatry

Nassir Ghaemi,  June 16, 2017
At the recent American Psychiatric Association annual meeting in San Diego, an update symposium was presented on the topic of "Lithium: Key Issues for Practice." In a session chaired by Dr David Osser, associate professor of psychiatry at Harvard Medical School, presenters reviewed various aspects of the utility of lithium in psychiatry.
Leonardo Tondo, MD, a prominent researcher on lithium and affective illness, who is on the faculty of McLean Hospital/Harvard Medical School and the University of Cagliari, Italy, reviewed studies on lithium's effects for suicide prevention. Ecological studies in this field have found an association between higher amounts of lithium in the drinking water and lower suicide rates.

These "high" amounts of lithium are equivalent to about 1 mg/d of elemental lithium or somewhat more. Conversely, other studies did not find such an association, but tended to look at areas where lithium levels are not high (ie, about 0.5 mg/d of elemental lithium or less). Nonetheless, because these studies are observational, causal relationships cannot be assumed. It is relevant, though, that lithium has been causally associated with lower suicide rates in randomized clinical trials of affective illness, compared with placebo, at standard doses (around 600-1200 mg/d of lithium carbonate).
Many shy away from Lithium not knowing that not prescribing it may actually lead to death by suicide. As such all worries about long term side effects become meaningless. 
Will the new generation of psychiatrists come round to Lithium again? How many talented individuals could have been saved by lithium?APA Nassir Ghaemi, MD MPH
  • In psychiatry, our most effective drugs are the old drugs: ECT (1930s), lithium (1950s), MAOIs and TCAs (1950s and 1960s) and clozapine (1970s)
  • We haven’t developed a drug that’s more effective than any other drug since the 1970’s
  • All we have developed is safer drugs (less side effects), but not more effective
  • Dose lithium only once a day, at night
  • For patients with bipolar illness, you don’t need a reason to give lithium. You need a reason not to give lithium  (Originally by Dr. Frederick K. Goodwin)


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.
And many lives too!
I have just received a query from a reader of this blog about Lithium, and I thought it worth me reiterating my views here.      It is no secret that I am a traditionalist who believes that lithium is the drug of choice for Bipolar disorders.Could Lithium be the Aspirin of Psychiatry? Only time will tell!
Latest: British Journal of Psychiatry