Grand Round: Medicine and War

Grand Round (5) 2 is up.
Host: Monash Medical Student Blog
Thank you Jeffrey for including my post Lithium Bipolar and Nanking with the following comments:

“Or perhaps… will they become suicidal? Could the war environment increase risk of developing bipolar disorders? If so, should they be treated with lithium? Retired psychiatrist and author Dr Am Ang Zhang gives his take at his blog 'The Cockroach Catcher', whilst remembering the Rape of Nanking.”

The full BLOG is here for your convenience:

Nanking Poster: THINKFilm

On July 2, 1996, the anniversary of Ernest Hemingway’s own suicide, Margaux Louise Hemingway, his grand daughter was found dead in her studio apartment in Santa Monica, California at age 41.

On November 9, 2004, Iris Chang (張純如), who was propelled into the limelight by her 1997 best-selling account of the Nanking Massacre “The Rape of Nanking: The Forgotten Holocaust of World War II”, committed suicide. Earlier she had a nervous breakdown and was said to be at the risk of developing Bipolar illness. She was on the mood stabilizer divalproex and Risperidone, an antipsychotic drug commonly used to control mania. There was a detailed report in San Francisco Chronicle.

My sentiments about the treatment of bipolar illness are expressed in The Cockroach Catcher:
“I am a traditionalist who believes that Lithium is still the drug of choice for Bipolar disorder. Tara’s mother was well for ten years. She was taking only Lithium and no other medication.”

The anti-suicidal effect of lithium has been confirmed by a number of recent studies in both the U.S. and in Europe. According to the results of a population-based study published in the 2003 Sept. 17 issue of The Journal of the American Medical Association (JAMA. 2003;290:1467-1473, 1517-1519), Lithium reduced suicide rates of patients with bipolar disorder but divalproex did not. Risk of suicide death was about 2.5-fold higher with divalproex than with lithium. Another paper published in 2005 (Arch Suicide Res. 2005;9(3):307-19) reviewed the existing evidence. “The article reviews the existing evidence and the concept of the anti-suicidal effect of lithium long-term treatment in bipolar patients. The core studies supporting the concept of a suicide preventive effect of lithium in bipolar patients come from the international research group IGSLI, from Sweden, Italy, and recently also from the U.S. Patients on lithium possess an eight- time lower suicide risk than those off lithium. The anti-suicidal effect is not necessarily coupled to lithium's episode suppressing efficacy. The great number of lives potentially saved by lithium adds to the remarkable benefits of lithium in economical terms. The evidence that lithium can effectively reduce suicide risk has been integrated into modern algorithms in order to select the optimal maintenance therapy for an individual patient.” The JAMA paper highlighted the declining use of lithium by psychiatrists in the United States and observed that: "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. My questions are: Will the new generation of psychiatrists come round to Lithium again? How many talented individuals could have been saved by lithium?

Now back to the Japanese atrocities in the Nanking Massacre in 1937, one of history’s worst but relegated to obscurity. The impact of Iris’ book and her tragic death was such on Ted Leonsis, Vice Chairman of AOL, that he went on to produce a film on the subject. The film, Nanking, premiered in Sundance Festival last year, was shortlisted in the documentary feature category of the Academy Awards, and won the Humanitarian award for documentary in the Hong Kong International Film Festival. Mariel Hemingway, younger sister of Margaux, read the words of Minnie Vautrin in the film. Minnie Vautrin was an American missionary renowned for saving the lives of many women at the Ginling Girls College in Nanking, China during the Nanjing Massacre. In 1941, Minnie Vautrin committed suicide.

In July, 2007 the film premiered in Beijing. The BBC said: “It is doubtful, though, it will ever be shown in Japan, where historians claim the massacre has been exaggerated.” Experts estimate the Japanese killed 150,000 to 200,000 people and raped more than 20,000 women and children, but a group of MPs from Japan's governing party recently said no more than 20,000 were killed.

Grand Rounds
OTHERS►►►

Silk Route: Grand Rounds (4) 52

I was in fact away on the Silk Road in North Western China and missed the recent

Medical Grand Rounds. My entry before I set off (not really on a camel) was picked.

“The Cockroach Catcher has noticed a flurry of activities in the British Medical Blogoshere. There is a lot of chatter out there about Hemlock poisoning. Hemlock used to be a popular botanical in medications, but just because something is natural doesn’t mean that it’s good for you.” Check out other claims!!!

Do not miss the latest Grand Round either.

Grand Rounds

OTHERS►►►

Medical Grand Rounds (4) 50, (4) 51

Medical Grand Rounds (4) 51 is from AppleQuack.com

His favourites are here, here, here, here and here.

Grand Rounds Vol. (4) 50 is from A Chronic Dose: A Chronic Illness Blog

"Welcome to this week’s Grand Rounds. As I revised syllabi and edited assignments for the upcoming semester, I couldn’t help but think that an Education theme was appropriate for a post-Labor Day edition. Whether you’re heading back to a classroom, an office, or a hospital today, hopefully this selection of posts will resonate with you."

Hemlock: Biology, Shakespeare, Socrates, House, M.D.

I have noticed a flurry of activities in the British Medical Blogoshere on Hemlocks started by none other than our Jobbing Doctor.

The story has now been covered by Ward 87, Chez Sam, the Witch Doctor, Doctor Rant, NHS Exposed and Dr Grumble. Even Ireland joined in: Two weeks on a trolley. More today.

The Cockroach Catcher is known to have been saddened by the fact that many medical schools no longer require biology for entrance requirement. This coupled with the belief that everything natural must be good may have led to the so-called Hemlock poisoning.

Perhaps a bit of Shakespeare might have helped:

Third Witch

Scale of dragon, tooth of wolf,

Witches' mummy, maw and gulf

Of the ravin'd salt-sea shark,

Root of hemlock digg'd i' the dark,

Liver of blaspheming Jew,

Gall of goat, and slips of yew

Silver'd in the moon's eclipse,

Nose of Turk and Tartar's lips,

Finger of birth-strangled babe

Ditch-deliver'd by a drab,

Make the gruel thick and slab:

Add thereto a tiger's chaudron,

For the ingredients of our cauldron.

Macbeth: Act 4 Scene1

Or if they still teach poetry at school:

'My heart aches, and a drowsy numbness pains

my sense, as though some Hemlock I had drunk,

Or emptied some dull opiate to the drain...'

Ode to a Nightingale, John Keats

What about Socrates? Hemlock was used for citizen executions, and Socrates was said to have taken the cup and drank.

Medical bloggers are puzzled by the lack of mainstream media coverage as summarized by The Jobbing Doctor.

Hemlock was even mentioned in an episode of House, M.D. Perhaps House has a point (Ornithine Transcarbamylase Deficiency). Perhaps not! I thought I would try his approach though:

- What if it was not Hemlock at all? Two intelligent highly trained doctors cannot really be that stupid. After all they are responsible for other people’s lives and future training of doctors.

- What if they took something else? Doctors have access to all kinds. House should know, he is one of those addicted to pain killers.

- What would a suspicious psychiatrist think when a man and a woman went out on a long walk…..?

- How about a toxicology report from the hospital? That should be in the public domain as there is a serious question of public interest here. The public should learn from these two doctors and know what not to eat on long walks. What if the poison has long term effects including those that affect judgment?

When I was a medical student, I had great respect for our professors and teaching staff. I do feel sorry for the new generation of medical students and doctors as they have to read about their seniors in blogs.

My apologies.
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World Foodie Guide

L’Atelier de Joël Robuchon

World Foodie Guide

We were there with Helen of World Foodie Guide:

“A mention about my dining companions -...The Cockroach Catcher and his wife Bee Zhang, no less! I was very excited to be in their company, as they are well-travelled gourmets…”

The excitement was ours as well. We like to travel and we like our food.

World Foodie Guide

"La truite de mer poêlee aux échalotes pomme purée à l’huile d’olive - pan fried sea trout with shallots, olive oil crushed potatoes. According to Bee Zhang, excellent."

Thank you Helen for a truly YUMMIE site.

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Chiropractic: Strokes and Class Action

In my Child Psychiatric practice, I was often asked by parents if they should see a chiropractor about their neck problem. I did wonder if dealing with a difficult child really did cause a “pain in the neck”. These questions are difficult as I am not in the habit of endorsing something that may indeed be potentially harmful.

The New York Times recently ran this headline:

The Claim: Manipulating Your Neck Could Lead to a Stroke

“Manipulating your neck is supposed to relieve pain, not cause it. But years ago neurologists noticed a strange pattern of people suffering strokes shortly after seeing chiropractors, specifically for neck adjustments.

Their hypothesis was that a chiropractic technique called cervical spinal manipulation, involving a forceful twisting of the neck, could damage two major arteries that lead through the neck to the back of the brain. Strokes in people under age 45 are relatively rare, but these cervical arterial dissections are a leading cause of them.

Studies that followed suggested a link. One at Stanford that surveyed 177 neurologists found 55 patients who suffered strokes after seeing chiropractors. Another, published in the journal Neurologist, said young stroke patients were five times more likely to have had neck adjustments within a week of their strokes than a control group. It estimated an incidence of 1.3 cases for every 100,000 people under 45 receiving neck adjustments.”

In June of this year the CBC (Canadian Broadcasting Corporation) reported:

Paralyzed Alberta woman sues chiropractors, province for $500M

"A perfectly healthy young woman's (Sandra Nette) life has been irreparably and devastatingly damaged as a result of her exposure to a chiropractor's manipulation of the vertebrae in her upper neck to correct alleged subluxations," the statement of claim says.

"The procedure is an ineffective and dangerous one which chiropractors employ routinely. Ideological practitioners of chiropractic masquerading in the white smock of science perpetuate its unregulated, indiscriminate use with the condonation and protection of their supposed regulator against all reason. It has got to be stopped."

The report went on to describe what happened:

“In her statement of claim, Nette says she went for a treatment session at the chiropractor's, during which he manipulated her neck.

After the session, she says, she felt dizzy as she was driving home and pulled over, calling her husband for help. As he was carrying her into the hospital emergency bay, she collapsed and went into convulsions, suffering permanent neurological damage.”

“After life-saving surgery at the University of Alberta Hospital, Sandy, a senior land administrator in the oil and gas industry, was left almost completely paralysed, a quadriplegic totally dependent on machines, hospital staff and her husband for her life support and care.” According to Rabble Canada.

In an age when famous people and celebrities endorse non mainstream medical treatment, it is important that we are reminded of the pitfalls of untested If parents were to ask me the same question nowadays, perhaps I would have a more definitive answer for them.