Tuesday, January 31, 2017

Best Medicine & Listening: It's Not Viral!

..….listen to the patient
the patient will give you the diagnosis……
William Osler 1849 – 1919

I suppose in life, it is lucky to have school friends that might one day save your life.
I suppose without sounding racist, it helps if you are Jewish, went to a Jewish school as you are likely to have Jewish school friends who are good doctors.
As they say, God works in mysteriously ways!
I was in the middle of some Scandinavian Fjord on a cruise when I came across a book called Open Heart. Yes, old habits die hard and I still find myself drawn to books about medicine or other people’s medical stories.
The Cruise ©2012 Am Ang Zhang

It is peculiar that the commonest diagnosis the average punter, sorry patient is going to hear from their doctor is:
Yes: It’s viral.
Well, remembering my biology, these creatures are smaller than bacteria and is not really easy to cultivate.
Or is it just a way of saying to the punter/patient, go home and do not ask for the antibiotic.
Now, it may well be OK if it were a simple cough. But what if you were told it is a viral cardiomyopathy?  
Now, this is getting serious.
Yet this is what happened and it happened to Jay Neugeboren
after some investigations by two doctors, one a cardiologist.
About Jay Neugeboren:
Did he smoke?  No!
Was he overweight?  No! 5’7 150lb.
Did he exercise?  Yes, swims a mile every day and plays tennis  full court basketball regularly.
He must have a high cholesterol or BP or family history, it just is not right: No, he had no family history of heart disease, and had normal blood pressure, and better-than-normal levels of cholesterol (both 'good' and 'bad').
His symptoms:
“I had, however, for two months prior to the surgery, been concerned about some shortness of breath I experienced, if intermittently, while swimming, and by an unfamiliar, sporadic pain -- more like a burning sensation -- in my back, between my shoulder blades. When my family doctor suggested I have a check-up with a cardiologist, the cardiologist performed an echo-cardiogram and diagnosed 'a viral cardiomyopathy.' But he saw no urgency in my situation.”
Call his friend 3000 miles away:
At the same time, I had been talking regularly with a childhood friend, Richard Helfant, who was a cardiologist in Los Angeles, and had been Chief of Cardiology at Cedars-Sinai Hospital in Los Angeles. When I told him of the viral cardiomyopathy diagnosis, he shouted into the phone, "It's not viral, goddamnit -- I want you in the hospital as soon as possible."

So, to cut the long story short, a health New York Times author of some 20 books with no family history of heart disease, a better than normal cholesterol level non smoking 1 mile swimmer that would have been classed as healthy by NICE standards had at the age of 60 --had two of his three major coronary arteries turned out to be 100% shut down, and the third major artery, the LAD (Left Anterior Descending Artery, the so-called 'widow-maker') was more than 95% shut down.

His life was saved by emergency quintuple bypass surgery.
What went wrong or what went right?

His childhood friend had made an accurate diagnosis from 3000 miles away because he knew his friend and thus could place his specific symptoms in the context of his full story. What the cardiologist who had misdiagnosed him had done was to pay more attention to tests and numbers and, thus, to forget about the pain between his shoulder blades, which symptom -- referred pain from the heart -- was inconsistent with a diagnosis of viral cardiomyopathy.

His operation took six and half hours at Yale, New Haven Hospital: Medicine at its best and that was over 13 years ago.

It is also not comforting that a study in 1997 of 453 residents in internal medicine and family practice revealed that they failed to identify the distinctive sounds of common heart abnormalities with a stethoscope 80 percent of the time. True, using a stethoscope, listening to the patient and taking a careful history may not be the only ways to accurately diagnose heart disease. But in the words of Dr. Bernard Lown, inventor of the defibrillator, listening to the patient and taking a careful history remains ''the most effective, quickest and least costly way to get to the bottom of most medical problems.''

My old friend the cardiologist has similar concerns. ''The diagnostic acumen of the physician at the bedside, on the phone or in the office, has been severely compromised,'' he told me. ''Because the mind-set has become, 'Well, the tests will tell me anyway, so I don't have to spend a lot of time listening.' ''

…….I worry that our continued focus on medical testing and prescription drugs as the primary ways of preventing heart disease will distract us from a more important element in treating illness: the well-trained doctor who knows his patient.

Sunday, January 29, 2017

Religion & Mountains: Pork & GBM!

Laoshan China

 © Am Ang Zhang 2011    

Thirty years ago, I saw mountains as mountains, and waters as waters.

When I arrived at a more intimate knowledge, I came to the point
where I saw that mountains are not mountains, 
and waters are not waters. 

Thirty years on,
I see mountains once again as mountains, and waters once again as waters.
 Adapted from Ching-yuan (1067-1120)

 © Am Ang Zhang 2015   

A short while back I blogged about GBM and how an innovative treatment may have helped. Being a doctor Dr Anderson noted this:
My wife, Carmen Alicia, called a local friend, also a cardiologist, who sent us to a nearby hospital; there, an MRI exam revealed a small spot on my brain. The neurologist felt it needed to be biopsied to obtain a tissue diagnosis. I immediately returned to Virginia and went to several specialists, who suggested further testing before I decided to have an invasive brain biopsy. I also had a blood test for cysticercosis, an infection that results from eating undercooked pork contaminated with Taenia solium. This common parasite produces cysts all over the body, including the brain. It is the most common reason for seizures in many countries, particularly in India, where children with seizures are first treated for this disease even before other studies are done. My blood test was strongly positive. I started a course of oral medicine to treat it. The test reassured me.
My later research showed that there may indeed be some association of Taenia and GBM. 

Neurocysticercosis (NC) is the most frequent and widespread human parasitic infection of the central nervous system (CNS). Glioblastoma multiforme (GBM) is a neoplasm of CNS in elderly population and may have a similar clinical and radiologic presentation as of NC. The coexistence of NC and neoplastic intracranial lesion in an individual is a very rare entity. The incidence of NC among intracranial space occupying lesions is reported to be 1.2-2.5%.[1–4] Though cerebral cysticercosis may be associated with glioma,[5] but this rare coexistence of NC and brain tumors puts into question a causal relationship between the 2 diseases. Here we report a case in which glioma and cysticercosis appeared concomitantly, with continuing progression of low grade Glioma to high grade Glioma (GBM, WHO grade IV).

So some religious dogma might actually be good for ones health. 

But watch out, even if you do not eat pork:

Neurocysticercosis in an Orthodox Jewish Community in New York City

All the patients and their families adhered to Orthodox Jewish dietary laws, which forbid the eating of pork. Moreover, T. solium taeniasis due to the ingestion of contaminated pork is extremely unlikely in the United States. Cysticerci were detected in only 3 of more than 83 million hogs examined after slaughter under federal inspection in 1990.
The most likely sources of infection in the patients described in this report were women living and working in the patients' homes who had recently emigrated from Latin American countries where T. solium infection is endemic.

Further details:

He is a cardiologist for thirty five years, (so not a neurosurgeon then) but with the diagnosis his research unravelled one of the possible reasons for "catching" GBM.

Why did this tumor happen to me? I never smoked and had had no brain injuries, and there is no history of such tumors in my family. As a cardiologist, I had implanted close to 400 pacemakers in my life and during the procedure was exposed to ionizing radiation (X-rays). In the early days we used portable X-ray machines and gave ourselves some protection by using thin lead gowns. Nowadays, heavy lead gowns are worn, and doctors and technicians protect their thyroid and eyes with shields and glasses. We also use heavy sheets of radiation-protective glass that hang from the ceiling.

At some point in my research, I was surprised by an article by a Johns Hopkins-trained cardiologist who now practices in Israel. He had collected data on 23 invasive radiologists and cardiologists who had developed tumors, of which 17 were GBMs on the left side of the brain. I wrote to the author, who told me that he had learned of several more such cases since his article was published, and he added mine to his file."


" I had a glioblastoma multiforme (commonly called a GBM) grade IV. This is the most malignant brain tumor; no grade II or III exist. A glioblastoma is what killed Sen. Edward M. Kennedy (D-Mass.) in 2009. While rare, it is the most common of the brain tumors. The prognosis is dismal; on average, patients survive only 14 months after diagnosis even with chemotherapy and radiation. After five years, only 5 percent of patients are still alive."

So depressing.

But wait: The Zapping!

" The Preston Robert Tisch Brain Cancer Center at Duke University has the largest experience on the East Coast with my sort of tumor, so I went there for further consultation and treatment.

As doctors there examined me, it was obvious that my tumor had already grown again; in fact, it had quadrupled in size since my initial chemo and radiation. I was offered several treatments and experimental protocols, one of which involved implanting a modified polio virus into my brain. (This had been very successful in treating GBMs in mice.) Duke researchers had been working on this for 10 years and had just received permission from the FDA to treat 10 patients, but for only one a month."

The procedure:

"I was given the Salk polio vaccine to prevent a systemic polio infection.

At Duke, my skull was opened under local anesthesia and I had the viral infusion dripped through a small catheter directly into the tumor in my brain for six hours."

The result:

"I returned to Duke a month after the infusion, and though an MRI showed some expected swelling, the more significant fact was that the tumor had stopped growing. I have gone back to Duke every two months since then, and the tumor, initially the size of a grape, is now a scar, the size of a small pea. It’s been two years since the initial biopsy and radiation, and one year since the experimental polio viral treatment, and I have no evidence of recurrence nor tumor regrowth.

According to a presentation about the research that the Duke doctors gave last May, the results so far are promising: “The first patient enrolled in our study (treated in May 2012) had her symptoms improve rapidly upon virus infusion (she is now symptom-free), had a response in MRI scans, is in excellent health, and continues in school 9 months after the return of her brain tumor was diagnosed. Four patients enrolled in our trial remain alive, and we have observed similarly encouraging responses in other patients. One patient died six months following ... infusion, due to tumor regrowth.” They added: “Remarkably, there have been no toxic side effects ... whatsoever, even at the highest possible dose.”

That has been true for me. I feel as fit as I was three years ago, before the first symptoms of the glioblastoma made their appearance. I remain only on an anti-seizure medication."

Sadness medicated to extinction: Schubertiade 2017

"Chicago is the best Village with grand tall buildings": Cockroach Catcher.

©2016 Am Ang Zhang

This is because of all the “villagey” happenings here.

This year is the 13th Schubertiade. This was the continuation of a tradition “re-started” by Thomas Zoells, Founder/Executive Director of the Chicago PianoForte Foundation some 13 years ago to mark the birthday of Franz Schubert every year.

Seven years ago I heard one of the singers said. Her theory is that nowadays people are so uncomfortable with sadness that German romantic poets and the characters they wrote about would have been medicated out.

Live streaming now:  http://www.pianofortestudios.tv/

Yes, there is so much sadness and melancholy and suffering in the Goethe poems which Schubert set to song. It is of course a form of sublimation and in psychiatry most would agree it is also the best psychological defense mechanism.

Friday, January 27, 2017

Torah & Music: Kandel & Brain Formatting!

It was as far back as 1960 when the Cockroach Catcher and a few school friends would sit in the back yard of his friend’s village hut and grind away a black disc. We knew the music well as we do not really have other records. On one side was Bruch’s and the other Mendelssohn’s Violin Concerto. My eyes welled up when Chloe Hanslip came on stage at the Royal Festival Hall to perform the Mendelssohn. Of course she played extremely well (she played a Guarneri del Gesu 1737). As it was, we were all refugees in Hong Kong following Mao’s taking over of China. It was strange that my friend who lives in a hut should own an old gramophone player and one single disc. No matter, it started me on to classical music and I never looked back.

© 2012 Am Ang Zhang

The brain is obviously a very advanced computer: a parallel processing computer! No computer the size of the human brain has yet been made to match its performance. But the brain in computer terminology still need to be formatted like the computer hard disc.

Kandel describe his formatting by his Grandfather 

My grandfather and I liked each other a great deal, and he readily convinced me that he should tutor me in Hebrew during the summer of 1939 so that I might be eligible for a scholarship at the Yeshiva of Flatbush, an excellent Hebrew parochial school that offered both secular and religious studies at a very high level. With his tutelage I entered the Yeshiva in the fall of 1939. By the time I graduated in 1944 I spoke Hebrew almost as well as English, had read through the five books of Moses, the books of Kings, the Prophets and the Judges in Hebrew, and also learned a smattering of the Talmud.”

He went on:
“It gave me both pleasure and pride to learn later that Baruch S. Blumberg, who won the Nobel Prize in Physiology or Medicine in 1976, had also benefited from the extraordinary educational experience provided by the Yeshivah of Flatbush.”

In Hebrew and English!!! That did not seem to have done him and Blumberg much harm. Right now some governments seem hell bent in doing away with rote learning and that includes some medical schools.

In 2001 I was fortunate enough to be in New Orleans for the American Psychiatric Association Annual Conference. One of the lectures attracted a long queue and it turned out that the Nobel Laureate Eric Kandel  was giving his lecture. I was fortunate enough to be able to secure a seat.

"What learning does is to change the strength of the synaptic connections in the brain," Kandel explained, "and this has held true for every form of learning so far analyzed. So, what genetic and developmental processes do is specify the cells that connect to each other, but what they do not specify is the exact strength of those connections. Environmental contingencies, such as learning, play a significant part in the strength of those connections.""Different forms of learning result in memories by changing that strength in different ways. Short-term memory results from transient changes that last minutes and does not require any new synthesis of proteins, Kandel said. However, long-term memories are based in more lasting changes of days to weeks that do require new brain protein to be synthesized. And this synthesis requires the input of the neuron’s genes."

The alternative to Torah and Talmud: Music!

Is the piano China’s answer to the problem that is facing many parents in the west, i.e. ADHD? Could it be a novel substitute for Ritalin and other stimulants? With the advent of unproven modern approaches to education at all levels, very few subjects require memory work. Yet in the last decade or so, memory work has been shown to be beneficial to “brain power”, leading to a whole new approach to neuroplasticity. Learning a musical instrument is one way to give the brain the right amount of training. 

Did the 300,000 or so that took up piano this year in China know a thing or two about brain plasticity? Currently 30 million children are reported to be learning the piano in China.

For now, just as the west is abandoning classical music training as part of the school curriculum, parents in China are paying for their children to have piano lessons. By some reckoning, North America probably consumes 90% of Ritalin and similar stimulants, whereas China is probably consuming 90% of the pianos produced. One factory in the south of China is currently producing 100,000 pianos a day.

As a child psychiatrist, I find the ones on ADHD showed great promise but I doubt if we are ever going to see the end of the stimulants’ hold on the condition in the West. It is interesting to note that Stimulants never took off in China, a country with a fifth of the world’s population. Computer games, on the other hand, have really taken off there.

Friday, January 20, 2017

Singapore Health Care: Good but Not Free!!!

Singapore ©2013 Am Ang Zhang

The Cockroach Catcher recently visited Singapore and is most impressed with how a city state emerged from British Colonial rule to become a shining example to the rest of the world both in terms of Employment, Education, Rule of Law and most importantly Health Care.

Until now, most health care in England has been “free” at the point of delivery. This indeed may be where the trouble really is.

When I was growing up in Hong Kong, education was not free nor was it compulsory. Yet most of us valued it. Every single bit of book, pencil and paper were paid for by hard working parents. There was no abuse of any of those items. Primary education became compulsory (and free) from 1979, yes, late.

Well, one thing I have to admit about British Colonialist is that they generally leave a good government behind. How that is achieved is a mystery to many but in general a stable government with a single policy for 150 years or so may well be one of them. In recent years, the Civil Service in Hong Kong and Singapore had been very efficient and whatever corruption there may have been had been contained or controlled.

Old Singapore Today©2013 Am Ang Zhang
Citizens of England might be surprised to hear that for most of us, health care is not free.

No, not for those of us who pay national insurance and taxes and if we include VAT, that is just about everybody.

Singapore: NO! NOT FREE!

Singapore’s health delivery is not free at any point. This has the singular advantage of preventing the over-utilisation of any of its healthcare services. As England struggled to stem the flow of new EU citizens from coming to use (or abuse) our NHS, Singapore’s system simply see to it that it would not happen. Yet there is a safeguard in public health for what is known as a catastrophic situation which happened during the SARS outbreak.

Singaporeans are considerably healthier than Americans, yet pay, per person, about one-fifth of what Americans pay for their healthcare.

So how does Singapore achieve such impressive results?
The key to Singapore’s efficient health care system is the emphasis on the individual to assume responsibility towards their own health and, importantly, their own health expenditure.

The state recovers 20-100 percent of its public healthcare outlay through user fees. A patient in a government hospital who chooses the open ward is subsidized by the government at 80 percent. Better-off patients choose more comfortable wards with lower or no government subsidy, in a self-administered means test.
I've heard a lot of smart people warn that co-payments are penny-wise but pound-foolish, because people cut back on high-benefit preventive care. Unless someone is willing to dispute Singapore's budgetary and health data, it looks like we've got strong counter-evidence to this view: Either Singaporeans don't skimp on preventive care when you raise the price, or preventive care isn't all it's cracked up to be.
More details on how Singapore's system works:
  • There are mandatory health savings accounts: "Individuals pre-save for medical expenses through mandatory deductions from their paychecks and employer contributions... Only approved categories of medical treatment can be paid for by deducting one's Medisave account, for oneself, grandparents, parents, spouse or children: consultations with private practitioners for minor ailments must be paid from out-of-pocket cash..."
  • "The private healthcare system competes with the public healthcare, which helps contain prices in both directions. Private medical insurance is also available."
  • Private healthcare providers are required to publish price lists to encourage comparison shopping.
  • The government pays for "basic healthcare services... subject to tight expenditure control." Bottom line: The government pays 80% of "basic public healthcare services."
  • Government plays a big role with contagious disease, and adds some paternalism on top: "Preventing diseases such as HIV/AIDS, malaria, and tobacco-related illnesses by ensuring good health conditions takes a high priority."
  • The government provides optional low-cost catastrophic health insurance, plus a safety net "subject to stringent means-testing."
                                                             The Undercover Economist

So in Singapore private clinics are responsible for 80% of primary care but public hospitals cover 80% of hospital care!


Singapore has some of the best public hospitals in the Far East if not the world so much so that even those with private insurance often chose to have their operations in a public hospital but staying in a more private room if their insurance covers it. Public hospitals of this level of excellence become the natural competitor for the private market and helps to keep overall cost down without the need of draconian legislation. Such good public hospitals also provide some of the best training grounds for future generations of top class doctors.


Singapore together with Iceland has one of the lowest Infant Mortality rates in the world, a third the figure of the USA.

 Singapore: Now ©2013 Am Ang Zhang


Read also:


The Singapore health system – achieving positive health outcomes with low expenditure                                               by   John Tucci