Sunday, January 14, 2018

Antidepressants or Lithium! Side Effects but you will live to experience it!

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.


Thank goodness: someone is talking about it.

 Atacama where Lithium is extracted  © Am Ang Zhang 2015

Lithium: The Gift That Keeps on Giving in Psychiatry

Nassir Ghaemi, MD, MPH
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)


Lithium in Tap Water and Suicide Mortality in Japan.

Abstract: Lithium has been used as a mood-stabilizing drug in people with mood disorders. Previous studies have shown that highest levels of suicide mortality rate in Japan. Lithium levels in the tap water supplies of each municipality were measured using natural levels of lithium in drinking water may protect against suicide. This study evaluated the association between lithium levels in tap water and the suicide standardized mortality ratio (SMR) in 40 municipalities of Aomori prefecture, which has the inductively coupled plasma-mass spectrometry. After adjusting for confounders, a statistical trend toward significance was found for the relationship between lithium levels and the average SMR among females. These findings indicate that natural levels of lithium in drinking water might have a protective effect on the risk of suicide among females. Future research is warranted to confirm this association.



"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.

Monday, January 8, 2018

Dark Side: Mother threw own baby in fire!

Dark Side: Mother threw own baby in fire!

Another Baby Murdered: 


“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 major Social Services blunder.

That was at the Metropolitan Opera on Sept. 25th 2015.

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.

The Dark Side:
“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 the mean time unnecessary deaths continued since Dennis O’Neill & Maria Colwell with millions spent on QCs holding public enquiries.            A Chronology of selected inquiries
Darker side:

Doctor suspended for blowing the whistle:

Dr Kim Holt was suspended from Great Ormond Street Hospital.

SOMEONE took a decision at the famous Great Ormond Street Hospital (GOSH), in Bloomsbury, to suspend a senior pediatrician, Dr Kim Holt, from her post.

We know why the good doctor was suspended on full pay.

These are the facts: Dr Holt, a specialist of 25 years  experience, started working in Haringey in a children’s department run by GOSH 
in 2004.

Two years later she started writing to her superiors complaining about the loss of staff, and the risk of a possible “disaster” at the child protection service in Haringey if more doctors were not attached to the department. This was a matter of “public interest” and should be “investigated”, argued Dr Holt. 

As readers will know, such a “disaster” occurred when a locum pediatrician was called in to see Baby P and made a mess of her examination. Two days after the examination Baby P died.

Was Dr Kim Holt patted on the back for her whistle-blowing?
No, someone, or a committee at GOSH, felt offended by Dr Holt’s interference – and suspended her.


Dark Side of The Opera:
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, Verdi’s Il Trovatore  and the dark side. One of Verdi's best!





Most people were looking forward to seeing the Russian superstars take the stage for very different reasons. One hand there was Anna Netrebko, singing her first Leonora at the Met, a character that she has dominated in Europe. And on the other side of the bracket was the return of baritone Dmitri Hvorostovsky to the stage after months of battling a brain tumor. Safe to say that both stars were at very high levels, delivering nuanced and deeply poignant performances.



Monday, January 1, 2018

NHS Hospitals: New Year sale?


 Cassius:
"The fault, dear Brutus, is not in our stars,
But in ourselves."
Julius Caesar (I, ii, 140-141)



© 2013 Am Ang Zhang

Looks as though the following might be surplus to requirements by the new NHS, as it was decreed that clients or service users do not really need hospitals.

The Background:
Historically, London Medical Schools were established in the hospitals in the poorer areas in order that medical students could have enough cases to practice on and in return the poor patients had the advantages of free treatment. There is nothing like volume for medical training.

For a very long time, doctors trained in London were one of the most valued. A Senior Registrar (yes, in those days) can easily get a Consultant job anywhere else in the Commonwealth and often a Professorship (British styled ones). In other words London trained doctors are a highly exportable commodity.

“The shape of the London hospital system has also been affected by developments in medical science and medical education. In many ways it has been the activities of doctors which have determined the pattern of the hospitals. The increasing ability to treat disease and improved standards of care shortened the time patients spent in hospital, raised the demand for services and led to an escalation of cost. The development of specialisation led first to the development of the special hospitals and later to special departments within the general hospitals. Advances in bacteriology, biochemistry, physiology and radiology cre­ated the need for laboratory accommodation and service departments, so that hospitals no longer consisted merely of an operating theatre and a series of wards. Sub-specialisation ultimately meant that services had to be organised on a regional basis and the very reputation of the capital’s doctors affected the number of patients to be seen. The hospitals of central London have long served a population much larger than their local residents.

It is against this complex background of population movement, poor social conditions, disease, wealth and poverty, professional expertise, critical comment and publicity that the London hospitals developed. A complex institutional pattern emerged. Voluntary hospitals grew up beside the ancient royal and endowed hospitals. A local government service providing institutional care for sick paupers developed alongside the hospitals. A network of fever hospitals, scientifically planned from the outset, was established. Physically near to each other, staffed by doctors who had trained in the same hospitals, and often serving the same people, the different objectives and status of the institutions led them to work in virtual isolation from each other. Each hospital had its own traditions and nobody standing in the middle of a ward could have doubted for a moment the type of hospital he was in. Countless details gave each an atmosphere of its own, and the different methods of administration and levels of staffing set them apart.”                  Geoffrey Rivett





Most of my Medical School Orthopaedic Surgeons were trained here.

The hospital treats almost 10,000 patients a year.

Although most patients would not consider travelling too far for a routine hip replacement, which can probably be done as well in their local district general hospital, the specialist clinics at the Royal National Orthopaedic may provide a reason to make the journey.

Specialist clinics deal with bone tumours, scoliosis (curvature of the spine), rheumatology, spinal injuries, specialist hand and shoulder conditions and sports injuries.

One word of warning – the RNOH's trust did not do well in the Healthcare Commission annual health check.

Strange that. So it may be the next to go.


The Cockroach Catcher was there.

So was the MP, as a patient.

If you have a head injury, stroke or condition affecting the brain, such as Alzheimer's, epilepsy or multiple sclerosis, this is the place to go. Along with the nearby Institute of Neurology, it is major international centre for treatment, research and training. The National Hospital for Neurology and Neurosurgery has 200 beds at its central London site near Euston station, and treated more than 4,500 in-patients and 54,000 outpatients last year.

Healthcare Commission quality of services rating: Good

Perhaps not for sale so soon. Or saving it for the needy MPs?

Neurologists wear bow ties in my days.


The largest specialist heart and lung centre in the UK, the Royal Brompton and Harefield acquired its reputation through the work of Sir Magdi Yacoub, the internationally renowned surgeon who pioneered heart transplants in the UK the 1980s.

The trust attracts staff and patients from across the country and around the globe, and is a centre for research with between 500 and 600 papers published in scientific journals each year. Its 10 research programmes each received the highest rating in 2006.

Each year, surgeons perform 2,400 coronary angioplasties (where a balloon is threaded through an incision in the groin to the heart and expanded to widen a blocked artery), 1,200 coronary bypasses and 2,000 treatments for respiratory failure – so they do not lack for experience.

Other specialist heart units with strong reputations are Papworth Hospital, Huntingdon, where Britain's first successful heart transplant was carried out in 1979; and the Cardiothoracic Centre, Liverpool, formed in 1991.

Healthcare Commission quality of services rating: Good

It could not be anything else.


The first dedicated cancer hospital in the world, founded in 1851, is still the best. With the Institute of Cancer Research, the Royal Marsden is the largest comprehensive cancer centre in Europe, seeing more than 40,000 patients from the UK and abroad each year.

It has the highest income from private patients of any hospital in Britain, testifying to its international reputation.

Very ready for Medical Tourism!!!

Healthcare Commission quality of services rating: Excellent



The country's largest ear, nose and throat hospital is also Europe's centre for audiological research, with an international reputation for its expertise and range of specialties, all on one site on London's Gray's Inn Road.

Its services range from minor procedures such as inserting grommets (tiny valves placed in the eardrum of a child to drain fluid from the middle ear) to major head and neck surgery. A quarter of its 60,000 patients were referred from other parts of the UK and abroad last year. The hospital has a cochlear implant programme, a snoring and sleep disorder clinic, and a voice clinic, the oldest and largest in the UK. One in 25 people develops voice problems such as hoarseness, but it rises to one in five among, for example, teachers, actors and barristers.

A measure of the Royal National's success is the fact that one third of patients referred from other clinics or hospitals with voice problems has their diagnosis changed on investigation there. Although there are many other centres where throat, nose and ear problems can be treated, none are pre-eminent enough to be included in this guide.

Wow!

Healthcare Commission quality of services rating: Good

Britain's leading national and international referral centre for diseases of the bowel is the only hospital in the UK and one of only 14 worldwide to be recognised as a centre of excellence by the World Organisation of Digestive Endoscopy.

It is a chosen site for the NHS bowel-cancer screening programme being rolled out across the country, which seeks to detect and treat changes in the bowel before cancer develops. Bowel cancer is the second most common cause of cancer in the UK but often goes undetected because sufferers can fail to report important symptoms, such as blood in the faeces, often out of embarrassment.

Bowel cancer can be treated via colonoscopy, to find and remove polyps – growths on the wall of the bowel. The hospital's education programme attracts clinicians from across the UK and overseas with the aim of spreading good practice elsewhere.
The hospital is part of the North West London Hospitals Trust.


The liver unit at King's is the largest in the world. It is one of 31 specialist liver units in the UK, but none can match it for expertise, facilities or state of the art equipment. It offers investigation and treatment for all types of acute and chronic liver disease, which is increasing in the UK.

The unit performs 200 liver transplants a year, and more than 200 patients with liver failure are admitted to its intensive care unit each year.

King's carried out the first successful transplantation of islet cells – part of the pancreas involved in producing insulin – in a Type 1 diabetic, greatly reducing his need for injected insulin. Last month, the Department of Health announced plans to establish six new islet transplantation centres round the country, based on the research at King's.

Healthcare Commission quality of services rating: Excellent


No bargain price, I am afraid.

The Maudsley Hospital

The Cockroach Catcher was there too.

One of Britain's oldest hospitals, the Maudsley's contribution to mental-health care stretches back at least 760 years.

Today it is a centre of excellence for the delivery mental-health care. Its addictions centre offers new treatments for drug abuse, alcoholism, eating disorders and smoking, it provides innovative care for disturbed children and adolescents and is the largest mental-health training institute in the country.

It has pioneered new approaches to the treatment of heroin addiction and its specialists have raised concerns over the link between cannabis and schizophrenia which have led the Government to review changes to the law.

Healthcare Commission quality of services rating: Good




If you have a child with a rare or complicated disorder, this is the place to come.

And they do and many are from the Middle East.

So the bad press would not matter, good for the Medical Tourist trade.

It is the largest centre for research into childhood illness outside the US, the largest centre for children's cancer in Europe and delivers the widest range of specialist care of any children's hospital in the UK.

Great Ormond Street won't treat just any patient, though: it only accepts specialist referrals from other hospitals and community services – in order to ensure it receives the rare and complex cases and not the routine.

I have done that: see Teratoma: An Extract


Paediatrics is one of the most rewarding areas of medicine for doctors because it has seen some of the most spectacular advances over the past 30 years, especially in cancer, where survival has improved dramatically.

Many of those cared for at GOSH still have life-threatening conditions but they are promised the best care both because of the expertise of its medical staff and because of the trust's extraordinary success in attracting charitable donations, which have made it among the best-funded medical institutions in the country.

Healthcare Commission quality of services rating: Excellent.

Baby P or no Baby P.


My eyes still well up when Moorfields is mentioned. Honest.

The largest specialist eye hospital in the country and one of the largest in the world, Moorfields was founded in 1805. It treats more patients than any other eye hospital or clinic in the UK and more than half the ophthalmologists practising in the UK have received specialist training at Moorfields.

However, in recent years the hospital has relied too heavily on its reputation and grown complacent. Though standards of academic excellence are still high, it has neglected the services it offers to patients, which were rated weak on quality by the Healthcare Commission in its annual health check last year.

The hospital carried out 23,000 ophthalmic operations last year, providing surgeons with extensive experience on which to hone their skills. The reputation of the trust is such that it has started to run clinics in distant hospitals, capitalising on its brand. The hospital employs 1,300 staff who work on 13 sites.

Perhaps it is not so good to be following on commercial branding. Stick to medicine!!!

Despite its recent problems, Moorfields remains Britain's most highly-regarded eye treatment centre. No alternative hospitals have a comparable reputation.
Healthcare Commission quality of services rating: Weak

For bargain hunters then.


Material drawn from The Independent.


So do you really think that hospitals are not necessary, or not necessary for the average citizen of England. Soon they will be sold and it will be costly to buy them back.

What about medical training? If these hospitals are sold, who pays?

And watch out, someone, your parent, your spouse, your child and even your MP may need a Hospital Consultant one day. 

Say something now.


Cassius:
"The fault, dear Brutus, is not in our stars,
But in ourselves."
Julius Caesar (I, ii, 140-141)


If you think you have read this before: you have indeed. As NHS reform is just re-cycling of earlier political dogma, the Cockroach Catcher can re-cycle his blog posts!!!

Sunday, December 24, 2017

Amanda: My Christmas Story!

Finland ©2012 Am Ang Zhang

Christmas Eve reminds me of one Christmas when I had to see a patient at the hospital. I had to be with our friends in London so the children and my wife had to wait in the car for me. Just as well the children never asked me why my patient could not go home.

 .........At the time, her weight was dangerously low. She was the only patient that I had to keep in the hospital over Christmas. It was rather strange that she seemed quite happy to do so. There were no protests from the parents either.  It meant that I had to see her on Christmas day and I even bought her a nice soft toy for a present, something I had never done before or after.


Amanda
         My old secretary Karen went to work for a plastic surgeon in the local hospital specializing in burns. Out of the blue she gave me a call. 

         “It is about Amanda. You should see her. She has all these scars on her.”

         It had been over two years since I last saw Amanda. It was rather sad as she had a real talent in art and I managed to secure the last ever support from the Education Authorities for accommodation for her at the Art College. But she dropped out after a year.  Nevertheless she still managed to make appointments to see me a couple of times before disappearing.  

         “Why don’t you ask her to arrange to see me next time she has a follow up at the clinic.”

         “That should not be a problem.”
         “But only if she wants to.”
         “I think you may still be of some help.”

         Well, Karen actually drove Amanda to my clinic late that afternoon and I stayed on to see her. Luckily Karen was still in the room with me when Amanda simply decided to lift her T-shirt. She was not wearing anything else underneath and what she revealed was a body covered in a number of three to four inches long keloidal scars. Some were actually over her breasts.

         Karen stayed as chaperone and Amanda did not seem to mind. In our work there are certain risks when you see young people on their own and more so when you see someone like Amanda. I sometimes felt rather unsafe with some of the mothers too.

         Amanda was first presented to me as a severe anorectic who more or less required immediate hospital admission. I put her in the paediatric ward rather than referred her to the hospital as at that time we were having some trouble with the quality of care there.

         At the time, her weight was dangerously low. She was the only patient that I had to keep in the hospital over Christmas. It was rather strange that she seemed quite happy to do so. There were no protests from the parents either.  It meant that I had to see her on Christmas day and I even bought her a nice soft toy for a present, something I had never done before or after.

         Her body weight gradually picked up and it was time for some trial home leave. She pleaded with me not to let her go home even for half a day.

         I did not want her to become dependent on us and there was every sign that she had now settled in on the ward.

         She came back from home leave and decided not to follow our agreed contract. It was popular in those days to have a weight gain contract and we had one too. Of course now I realise how rigidity with a contract can have drawbacks. In fact in child psychiatry too rigid an approach often causes problems one way or another and it is one of the few medical disciplines with which strict guidelines are not a good idea.

         At the time, another patient was on the ward after a serious suicide attempt. She had been abused by her step-father and step-brother over the years. She had had enough and decided to end it all.  I was trying to sort out where she could go as there were all the child protection issues.  She became very friendly with Amanda.

         One day when I arrived on the ward, the Sister-in-charge handed me an envelope and said that Amanda would like me to read it first.

         I have since used the same two pages she wrote as teaching material. Most female junior doctors could not go through with reading it aloud. It is nice to think that years of medical training do not really harden someone. Or was it something too horrible to be faced with?  It was particularly upsetting when the abuser was Amanda’s father.

         Amanda was by then fourteen but her father had been abusing her since she was about eleven. Her mother worked night shifts and father would come to her bed room to tuck her in. This had been going on for as long as she could remember. She started to have budding breasts and her father would at first accidentally brush them and Amanda would be quite annoyed with that. Then one night he started fondling with her breasts and also outside her pants. She was so scared she froze and did not say anything. He went further and further until he penetrated her. She was bleeding quite badly and told her mother, who told her that was what happened to girls when they grew up. She knew what menstrual period was but she said this was different; but mum did not want to know and gave her a box of sanitary pads. Then her period started and she started to worry about becoming pregnant. Her father said it was not a problem and asked her to suck him instead. She recorded that she was sick every time. Then one day her father decided to try her “back-side”. It caused so much bleeding it stained her school skirt and when she told her mother she was bleeding from her “back side” she just said, “Don’t be silly.  It is only a heavy period.”

         It is disturbing even for me to give you the details now. But this is what is happening to many children and is happening all around the world. If anything, I probably have toned down the content of that letter. What has gone wrong with mankind?  I cannot say I know any better since my early cockroach catching days. 

         Then on the day I “forced” her to go home he picked her up and made her go down on him in the car on the way home when he parked on a lay-by.

         In the end it was the other girl in the ward who encouraged her to write to me. She told her that she suffered the same for a long time and was stupid enough to try and hurt herself before she could tell anyone.

         There was no time to waste to report this to Social Services. However, Amanda’s father, who worked at the local mental hospital, had a “breakdown” and was admitted under the Mental Health Act the night before all of this came out. Amanda was not aware of this.  When I showed mother what Amanda wrote, she just said to me, “He is in a mental hospital,” and walked out.

         It has taken me years to grasp that maternal failure plays a major role in family sexual abuse. This mother’s action says it all. Can’t you see he is mad?

         It was a most peculiar case. His psychiatrist refused to even let me know of his problem, citing patient doctor confidentiality. He obviously had not worked with child abuse. Mother denied all knowledge of the bleeding incidents and claimed that it was all in Amanda’s imagination and it became very hard trying to place Amanda because her mother would not acknowledge that there was a problem. At this time West[2] was arrested and it helped me at least to understand the unfathomable.

Magritte:
         One of the nurses who got on well with Amanda told me that I should look at her examination portfolio for art. Every picture was morbid.  One struck me with the RenĂ© Magritte[3] style of surrealism. A body of a girl with a penis floating over what looked like a classical stone grave. The head was covered in cloth and separated from the body. There were many daggers on the upper body of this half-man half-woman. There was a sort of school in the distance with small figures of school children. The sky was normal blue with white clouds which contrasted dramatically with the central theme. There was no question that the sky was a Magritte sky, and so was the cloth covered head. The rest was original Amanda.

         I knew then from what I remembered of Erickson that the picture was not just about the past with which one naturally associated but also about the future. Yet it took me a few years to realise that it was about the cutting.

         She said she was now working as a waitress. Her teacher at college did not want her to do all the morbid paintings, so she quit. She had been sleeping with virtually any man she came across and every time she would cut herself afterwards. She wanted to feel something, she told me. What was worst was that whenever she was with a man she saw her father.

         What an outcome. I had spent so much time with this girl and this was in the end what happened. She said one day she would be in a mental hospital like her father, but she hoped to kill herself before then.

         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 itself in social care, she did not become a famous artist with a high income, telling all about her history of abuse in front of a famous chat show host. Nor did she become a movie star telling all after drug and alcohol rehab.

         Instead she was on benefits and I am struggling hard to find something uplifting to end this story.

It has taught me one thing: Anorexia Nervosa may be just a manifestation.


Art Institute of Chicago’s new special exhibition, “Magritte: The Mystery of the Ordinary, 1926-1938.”

 “Magritte was an amazing artist who has much to offer us today,” said Stephanie D’Alessandro, the Gary C. and Frances Comer Curator of Modern Art at the Art Institute, who was instrumental in assembling this exhibition of nearly 80 paintings, plus collages, objects, photographs, periodicals and examples of the artist’s work in advertising.
“I think that living in an age of mobile phones, in which we are so used to acquiring all sorts of information with great speed — and assuming it is ‘correct’ — has resulted in a loss of the ability to let a picture really take us into its own world, with all its unique habits and customs. So working with installation designer, Robert Carson, I’ve tried to create a series of small, initially quite dark spaces that should help make the experience of each art work more intense and intimate, and will let your imagination tell you where you want to go.”
The Magritte show, awash in images at once grotesque and erotic, mundane and mysterious, unspools in more or less chronological order. It begins with the crucial body of work, both paintings and paper collages, that he created in 1926 and exhibited the following year in his first one-man show at the elegant Galerie Le Centaure in Brussels — a show greeted by mostly negative reviews. It moves on to his subsequent time in Paris, where he lived for three years, becoming part of the Surrealist circle led by the French poet and theorist, Andre Breton, and such artists as Salvador Dali and Joan Miro.






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