Sunday, June 27, 2010

One Patient One disease

This is worth a re-print:

Left, Science Source/Photo Researchers; right, Dr. P: Marazzi/Photo Researchers
White blood cells (left) in the patient's spinal fluid suggested an infection; an X-ray of a teratoma with a tooth (right).

In the New York Times on the 7th of November 2008:

Brain Drain By LISA SANDERS, M.D.

This happened a year ago:

“Dr. Rachel Clark could see the patient through the glass walls of the Massachusetts General Hospital intensive-care unit. A young woman lay on the bed, unconscious. The girl’s mother sat next to her, stroking her head. Just minutes earlier Clark’s pager called her to this ward filled with the sickest patients. The text read: “Unresponsive patient in the I.C.U. Possible Gyn etiology. Please respond asap.” As she made her way through the hospital, Clark, a first-year resident in obstetrics and gynecology, tried to imagine what kind of problem would lead critical-care specialists to call on her to help with a patient in a coma.

“The 26-year-old woman fell ill two months earlier, her mother told Clark. It started with a headache — the worst of her daughter’s life. Her mother took her to the emergency room near their hometown in rural Maine. The doctors there thought it was a migraine and gave her something for the pain. It didn’t help.

“Over the next 10 days her daughter saw six different doctors, had many blood tests and scans and tried a dozen medicines. No one had a diagnosis or a cure.

‘There’s something wrong in my head,’ the young woman kept repeating. ‘It’s just not right.’

“On their last trip to the emergency room, her daughter went crazy. She was talking to people who weren’t there. She was afraid, paranoid. Then suddenly she became violent, lashing out at everyone around her. ‘They told me she was having a psychotic break, that she probably had schizophrenia,’ her mother reported, the horror of that night still audible in her voice. The patient was taken to a psychiatric hospital. A few days later she developed a fever and was sent to yet another hospital. There she had a seizure. After that, she never woke up. She was finally transferred to Massachusetts General in Boston. But even here the doctors had found no answers.”

“The young woman had a history of migraines but was otherwise healthy. She took no medications. She worked in an office and lived with her parents. On exam she no longer had a fever. Her eyes were sometimes open, but she was completely unresponsive, even to pain.”
All investigations drew a blank and out of desperation, the team ordered a CT scan of her body. A tiny cyst was found on her left ovary: A TERATOMA.

One resident was creative to suggest that this tiny cyst, known as a teratoma, could be the cause of her coma.

“Clark searched the medical literature, eventually finding an article, published just months earlier, that described 12 women with what the paper’s author called ovarian teratoma encephalitis. The women had headaches and psychiatric symptoms and became comatose. Each was ultimately found to have a teratoma. Remarkably, most of these women recovered fully once the cyst was removed. Clark was amazed.

Ovarian teratoma encephalitis is so rare that it is still not well understood, but the author of the paper theorized that these particular tumors — which have the potential to grow any type of cell in the body — develop primitive brain cells. Somehow the immune system mistakenly identifies these cells as “foreign” and makes antibodies to destroy them. These antibodies go on to attack the same kind of cells in the brain.

Clark said she felt certain this was what the patient had.

“But the other doctors caring for the patient were skeptical. Every year thousands of patients develop some kind of encephalitis. It’s quite likely that some small percentage of these patients will have one of these common cysts, and yet, for most, the two conditions will be completely unrelated. There have been only a handful of cases that have linked a teratoma and encephalitis over the past 11 years. The odds of this patient falling into that category were infinitesimally small.”

“But Clark persisted. A sample of the patient’s blood was sent to the author of the paper to have him look for the antibody he found in his patients. If that test was positive, then they would take out the tumor.”

“For the next two weeks, Clark checked for the results daily. She eventually discovered that the blood was never tested. Clark almost cried with frustration. While they had been waiting for these results, the patient became even sicker.”

“Another OB-GYN, Dr. Rebecca Kolp, was now in charge of Clark’s team. Clark sought out the doctor and described the patient and what she’d found in her research. She told her about the lost test. Should they wait another two weeks, or should they operate now?”

“Kolp thought about it for only a moment. The intern made a strong case, and although it seemed an unlikely diagnosis, Kolp thought it was worth the risk. Would the girl’s mother be willing to let them operate on her daughter? The mother agreed to the operation immediately. The girl had been sick for so long and seemed only to be getting worse. That afternoon, Kolp removed the tumor.”

“The next morning it was still dark when Clark arrived at the I.C.U. As she entered the patient’s room she called out the young woman’s name in a hushed voice. No response. The doctor checked the surgical site — it looked fine — and then tried once more to rouse the young woman. No change. Her heart sank. In the paper she’d read, recovery was rapid — often within hours of the operation.

“At rounds, Clark told Kolp that the patient was no better. The attending physician was disappointed but not surprised. They had done all they could. But later that morning Kolp phoned Clark. ‘Rachel, you’re not going believe this,’ she reported excitedly.

‘Your patient is awake.’

“Rachel Clark was elated. Just a few months into her residency, she diagnosed a rare disease, one that she figured she would never see again.”

“A year later another patient arrived with the same story of headache, psychosis and coma. A CT scan revealed a teratoma, and she was operated on the next day. This patient also recovered. It’s worrisome, Kolp said. ‘It makes you wonder how many other woman are languishing out there who might be saved.’”

It is incredible how closely my teratoma case (as described in 
The Cockroach Catcher) mirrored Dr Rachel Clark’s cases. Now, after thirty years, the mystery of why my patient was in coma after surgery is solved!

My patient was indeed in her coma for 23 days. Still she recovered.

My comment about the case was:

I have often wondered if it would be such a disservice to mankind if doctors were not so understanding of the psychological side of things.The possibility of a serious illness being missed is of course a major concern when a patient seeks help for one reason or another. To put psychological conditions at the top of the list of possible diagnosis is dangerous.”

I can well understand what a difficult position Dr Rachel Clark found herself in, to be the lone voice against traditional thinking in the diagnosis of a tricky case. We need such courage amongst our young doctors, but for their own good, perhaps not during their finals viva!

To remember our eminent yet formidable Professor of Medicine, Professor MacFadzean: One Patient One Disease.

The science:

Ovarian teratoma encephalitis is so rare that it is still not well understood, but the author of the paper theorized that these particular tumors — which have the potential to grow any type of cell in the body — develop primitive brain cells. Somehow the immune system mistakenly identifies these cells as “foreign” and makes antibodies to destroy them. These antibodies go on to attack the same kind of cells in the brain.

Friday, June 25, 2010

Away on Vacation:

Aruba ©2010 Am Ang Zhang

Quick dispatches from my vacation.  I hope you enjoy the vacation photos. In the meantime, perhaps you would like to catch up with some of my past postings or even read my book: The Cockroach Catcher.
 Young Hawksbill Turtle©2010 Am Ang Zhang

Latest Views on the book:

From a doctor friend:

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

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

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

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

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

From Australia:

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

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

Absolutely riveting! Brings me back to working (in NHS psychiatry) when work was really interesting! The tone is quite conversational; it is like hearing you telling stories. I ordered more copies for my family and friends.
I knew it would be very special and it sure is. To us your trainees it is like going back on the rotation to have the joy of working with you again. The difference is that l can now learn at leisure from this book. Congratulations.
The book is very well written and makes very easy and interesting reading even for the laymen. You learn a lot about the Health System, a lot about child psychiatry and a lot about the growing up and development of the author.
Fascinating account of child psychiatry cases, including some creative yet effective treatments. Anyone who is a parent or around children or really anyone at all actually will find the book surprising, entertaining, thought-provoking, funny and moving.
The book makes me realize the difficult decisions with which a doctor is so often faced, the need for him to have faith in himself and, coupled with that, the need for continued idealism and enthusiasm. These don't, of course, apply only to doctors but are particularly important for them.
Great book. I have bought one to give to my son on his birthday.
Dr Am Ang Zhang is the author of The Cockroach Catcher.

The Cockroach Catcher: Amazon, Readers' views.

Friday, June 18, 2010

First Emperor, Two Bloggers & Freedom of Speech

That the Lotus can grow out of the dirtiest of water and manages to be  clean is a miracle of mother earth. Some of us managed to do just that.

©2010 Am Ang Zhang

“For centuries, the brutal and tyrannical reign of Qin Shihuangdi, First Emperor of China, was summed up by a four-character phrase, fenshukengru 焚書坑儒, ‘He burned the books and buried the Confucian scholars alive.’”Anthony Barbieri-Low: 21st Sammy Yukuan Lee Lecture. See also: The Independent.

When the First Emperor died, the students that survived just recited the books and they were back in circulation!!!

In CAMPAIGNING FOR HEALTH Julie Mcanulty wrote:

Are Medi Bloggers Being Picked Off?

Two months ago, Dr Crippen, the daddy of medi bloggers retired. It wasn't entirely unexpected - he had had a couple of breaks from blogging before and was showing signs of fatigue. But now Jobbing Doctor has 'taken a break' from blogging, just a few hours after doing a routine post about shoulder injections. He has taken down all his posts and has even removed Sam and Frodo, his two cats from the page. 

One medi blogger could be an accident. Two looks like carelessness. Three? Who's going to be next and what is going on?

Dr Crippen and JD weren't any old bloggers. They were the best and there's a feeling that something a bit more sinister is going on here. Are they getting picked off? And if they are, what can we do to support them?

Some years ago, I visited a country with a repressive regime. The food and clothes were very cheap. But the books were the same price as they are here, which made them six times more expensive for the people of that country than they are for us. The thing that a government prizes and fears above all is the flow of information. They do not take kindly to areas that they have no control over and that is the blogosphere. It is a compliment that we are now attracting this kind of unwelcome attention, but we now have to move and ensure that that conduit of the unvarnished truth does not get blocked.

I was in one of those countries too:
©2010 Am Ang Zhang
And beautiful:

Royal Palace, Phnom Penh©2010 Am Ang Zhang

Very few in Cambodia are over 65. Most doctors disappeared. Nobody wears glasses. At the end of the ‘era’ the ratio of male to female was 1: 5 according to our tour guide.

Of course in France they used to guillotine them: Pol Pot was educated there.

Mallorca©2010 Am Ang Zhang

The Cockroach Catcher is off to Aruba to snorkel; for a few weeks in case some of you thought I gave up too!



Wednesday, June 16, 2010

Oh! No! Not Jobbing Doctor!

Wednesday, 16 June 2010
Every good thing must come to an end.
I am going to take a break from blogging.
When I feel up to it, I might return.
Time for somebody else to take up the cudgels.

Bye bye for now.


 Grey angelfish / Pomacanthus arcuatus ©2008 Am Ang Zhang

Perhaps you now have time to try snorkeling. You cannot blog when you snorkel.


Crippen would have loved it


Blogging Addiction Disorder (BAD)

Tuesday, June 15, 2010

BP: Warnings ignored? Perhaps not!

A heavily oiled pelican flounders on the beach at East Grand Terre Island in Barataria Bay, La. 
(Carolyn Cole / Los Angeles Times / June 4, 2010)

Perhaps not!!!

The chief executive of BP sold £1.4 million of his shares in the fuel giant weeks before the Gulf of Mexico oil spill caused its value to collapse.

By Jon Swaine and Robert Winnett
Published: 05 Jun 2010

Tony Hayward cashed in about a third of his holding in the company one month before a well on the Deepwater Horizon rig burst, causing an environmental disaster.
Mr Hayward, whose pay package is £4million a year, then paid off the mortgage on his family’s mansion in Kent, which is estimated to be valued at more than £1.2million.

There is no suggestion that he acted improperly or had prior knowledge that the company was to face the biggest setback in its history.

His decision, however, means he avoided losing more than £423,000 when BP’s share price plunged after the oil spill began six weeks ago.

More pictures: LA Times
Latest on BP:  Washington Post,The Guardian
Nature Posts

Thursday, June 10, 2010

King’s Fund: Two Doctors & Shakespeare

There is so much we can learn from Shakespeare and the advice is free:

Winter’s Tale, Tristram Kenton Guardian
Hermione: "You pay a great deal too dear for what's given freely". -

(Act I, Scene I). The Winter’s Tale.

Sometimes from blog posts too!

The Shrink in his little corner by Lake Cocytus was in his thinking mode:

“……why am I uneasy about the Kings Fund?

Policy with implemented effective practice, independently generated by experts, what's not to like? I met with and spoke with folk from the Kings Fund, their passion and motivation was self evident. Their message and the change they're effecting was crystal clear. Inspired independent change being joyfully and enthusiastically progressed, what's not to like?

Well, it's just that more than a small part of me feels intense disquiet that it's not really that independent. In fact, isn't it all well represented either directly by Department of Health workforce (directly or indirectly through Select Committee or quango appointment), or private health company presidents, or Monitor, or other interest groups. So not independent at all. Indeed, they're placed to advance either government policy or the interests of private healthcare companies, yet overtly state they're independent. Grrrr.

He admitted he was not the first to spot it.

Dr Clive Peedell 
2 December 2009 in Hospital Dr.:

1. Simon Stevens - president of Global Health at UnitedHealth Group. He was previously the Prime Minister’s health advisor.
2. Dr Penny Dash - adviser to a wide range of organisations including the NHS, independent health care providers, pharmaceutical companies and private equity groups. She’s a former DoH head of strategy and planning, who worked closely with Alan Milburn, in the development of the NHS Plan. She is a partner at management consultants McKinsey.
3. Strone Macpherson - chairman of Tribal consulting. The Tribal group has been appointed to the DoH’s framework for procuring external support for commissioners, i.e. PCTs pay Tribal to help with their commissioning functions. Tribal also provides ‘technical experts’ in all aspects of funding, from PFI, LIFT and public procurement to social enterprises and boast the largest health architectural practice in Europe.  
4. Jude Goffe - a founding non-executive director at Monitor, the regulator of NHS foundation trusts.
5. Professor Julian Le Grand - former health advisor to Tony Blair and the leading academic proponent of the choice agenda.
6. David Wootton - lawyer and partner at Allen & Overy in London, an international law firm specialising in mergers and acquisitions, corporate transactions and corporate governance.
7. Dame Jacqueline Docherty - a former member of the management executive at the Department of Health, the Scottish Office, she’s now the chief exec at West Middlesex Hospital.
8. Cyril Chantler is chairman of the King’s Fund. He is an adviser to the Associate Parliamentary Health Group. This group enables parliamentarians, policy makers, healthcare professionals and the health industry to promote and discuss the national health agenda.

In view of the above membership of this board, it must be hard for the think-tank to be as objectively independent on government health policy as it claims to be. This is only reinforced by the appointment of Professor Chris Ham, another former DoH advisor as its new CEO. 

Dr Clive Peedell concludes:

It’s time to recognise that the King’s Fund has a significant proportion of former DoH advisors, and people with commercial interests that could benefit from pro-market NHS reforms, helping to guide its work.

Tuesday, June 8, 2010

NHS: Consultants, Children & Games

A few days ago I quoted one of Doctor Zorro’s recent posts:

 “The medical Consultants must have known full well what was happening at the sharp end. Unless they were blind and deaf they can not have been unaware of the avoidable suffering and death being inflicted upon their patients. Patients to whom they owed their ultimate loyalty. They as much as anyone let their patients down.

“It could be argued of course that they were, like other staff, intimidated into silence, knowing full well what would happen to any individual who spoke out.”

His final verdict:

“Cowardice. Craven, inexcusable cowardice for which they should be thoroughly ashamed.”

Looks like someone listen to what he wrote:

The world-famous Great Ormond Street Hospital has been left in crisis after around half of its top medical staff signed a formal letter of no confidence in its management.
Between 40 and 50 of the hospital's senior consultants have demanded that the chief executive, Jane Collins, resign amid what one described as "growing concerns over patient care".

The letter has been organised by a group of around 20 consultants convened by their professional body, the British Medical Association, at a meeting in its London headquarters on the evening of May 5.

      Photo: ALAMY                        In the weeks since, the letter was circulated around senior staff at the hospital for signature.

It has now been submitted to the chairman of Great Ormond Street, the Labour peer Baroness Blackstone.

Here is a little twist:

A spokesman for Great Ormond Street refused to deny the existence of a letter of no confidence, but insisted that the chairman had not yet “received” one.

"The Chair of the Trust met four consultants last week and discussed a variety of concerns they had regarding the running of the hospital," the spokesman said.
"At that meeting a letter [of no confidence] was mentioned but neither she nor the Chief Executive have received it. The Chair will respond to the letter when she has it."

GOS is a Hospital for Children and children like to play games, perhaps others too.

NHS: Two Consultants & Freedom of Speech