Sunday, December 22, 2019
Saturday, December 21, 2019
Friends moved to France after their retirement and lived in one of the wine growing districts.
©2008 Am Ang Zhang
They were extremely pleased with the Health Care they received from their doctor locally. After all, not long ago, French Health Care topped the WHO ranking.
Then our lady friend had some gynaecological condition. She consulted the local doctor who referred her to the regional hospital: a beautiful new hospital with the best in modern equipment. In no time, arrangement was made for her to be admitted and a key-hole procedure performed. The French government paid for 70% and the rest was covered by insurance they took out.
They were thrilled.
We did not see them for a while and then they came to visit us in one of our holiday places in a warm country.
They have moved back to England.
Four months after the operation they were back visiting family in England. She was constipated and then developed severe abdominal pain. She was in London so went to A & E (ER) at one of the major teaching hospitals.
“I was seen by a young doctor, a lady doctor who took a detail history and examined me. I thought I was going to be given some laxative, pain killer and sent home.”
“No, she called her consultant and I was admitted straight away.”
To cut the long story short, she had acute abdomen due to gangrenous colon from the previous procedure.
She was saved but she has lost a section of her intestine.
They sold their place in the beautiful wine region and moved back to England.
The best health care in the world.
Now we know.
Let us keep it that way.
NHS & Private Medicine: Best Health Care & Porsche
Do we judge how good a doctor is by the car he drives? I remember medical school friends preferred to seek advice from Ferrari driving surgeons than from Rover driving psychiatrists.
My friend was amazed that I gave up Private Health Care when my wife retired.
“I know you worked for the NHS but there is no guarantee, is there?”
Well, in life you do have to believe in something. The truth is simpler in that after five years from her retirement, the co-payment is 90%.
He worked for one of the major utility companies and had the top-notch coverage.
“The laser treatment for my cataract was amazing and the surgeon drives a Porsche 911.”
Porsche official Website
He was very happy with the results.
“He has to be good, he drives a Porsche.”
Then he started feeling dizzy and having some strange noise problems in one of his ears.
“I saw a wonderful ENT specialist within a week at the same private hospital whereas I would have to wait much longer in the NHS.”
What could one say! We are losing the funny game.
What does he drive?
We are OK then.
Or are we.
He was not any better. And after eight months of fortnightly appointments, the Carrera doctor suggested a mastoidectomy.
Perhaps you should get a second opinion from an NHS consultant. Perhaps see a neurologist.
“I could not believe you said that, his two children are doctors. And he has private health care!” I was told off by my wife.
He took my advice though and he got an appointment within two weeks at one of the famous neurological units at a teaching hospital.
To cut the long story short, he has DAVF.
I asked my ENT colleague if it was difficult to diagnose DAVF.
“Not these days!”
He had a range of treatments and is now much better.
All in the NHS hospital.
“I don’t know what car he drives, but he is good. One of the procedures took 6 hours.”
Best health care.
I always knew: Porsche or otherwise.
Best Health Care: NHS GP & NHS Specialist
Does having a good hunch make you a good doctor or are we all so tick-box trained that we have lost that art. Why is it then that House MD is so popular when the story line is around the “hunch” of Doctor House?
Fortunately for my friend, her GP (family physician) has managed to keep that ability.
My friend was blessed with good health all her life. She seldom sees her GP so just before last Christmas she turned up because she has been having this funny headache that the usual OTC pain killers would not shift.
She would not have gone to the doctor except the extended family was going on a skiing holiday.
She managed to get to the surgery before they close. The receptionist told her that the doctor was about to leave. She was about to get an appointment for after Christmas when her doctor came out and was surprised to see my friend.
I have always told my juniors to be on the look out for situations like this. Life is strange. Such last minute situations always seem to bring in surprises. One should always be on the look out for what patient reveal to you as a “perhaps it is not important”.
Also any patient that you have not seen for a long time deserves a thorough examination.
She was seen immediately.
So no quick prescription of a stronger pain killer and no “have a nice holiday” then.
She took a careful history and did a quick examination including a thorough neurological examination.
Then something strange happened. Looking back now, I did wonder if she had spent sometime at a Neurological Unit.
She asked my friend to count backwards from 100.
My friend could not manage at 67.
She was admitted to a regional neurological unit. A scan showed that she had a left parietal glioma. She still remembered being seen by the neurosurgeon after her scan at 11 at night:
“We are taking it out in the morning!”
The skiing was cancelled but what a story.
Friday, December 13, 2019
82 years ago, the people of
Nanking, China's ancient capital city, were in the midst of one of the worst atrocities in history, the infamous Rape of Nanking. The truth of what actually happened is at the center of a bitter dispute between China and that continues to play out in present-day relations. Many Chinese see Japan 's election last month of ultraconservative nationalist Shinzo Abe as prime minister as just the latest in a string of insults. And it was recently reported that Japan is considering rolling back its 1993 apology regarding "comfort women," the thousands of women the Japanese army sexually enslaved during World War II.
In 1937, the Japanese Imperial Army, captured
Nanking on Dec. 13. No one knows the exact toll the Japanese soldiers exacted on its citizens, but a postwar Allied investigation put the numbers at more than 200,000 killed and at least 20,000 women and girls raped in the six weeks after the city fell.
It was the mass rapes in Nanking and the brutalization of an entire populace that eventually convinced Japanese military leaders that they needed to contain the chaos. Japanese soldiers began rounding up women and forcing them to serve as sex slaves in so-called comfort stations.
This is what most historians believe. But not in
, where a large faction of conservatives, led by Abe, denies that the Japanese military forced women into sexual slavery. They maintain that any suggestion to the contrary is simply anti-Japanese propaganda and probably spread by Japan . At the furthest end of the spectrum, the minimizing turns to flat-out denial; one professor we interviewed at a top Japanese university adamantly insisted there were no killings or rapes in China Nanking.
Not surprisingly, all this minimizing and denial enrages the Chinese and others in
Asia. But this is a familiar pattern.
Nanking Poster: THINKFilm
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.
Wednesday, December 11, 2019
In Medicine, it is amazing what the Bright Young Doctors can offer. In my day and now!
Thirty years ago, a patient of mine was unconscious for 23 days and it was mother's belief that it was through prayer that her daughter was saved. I did not know anything about NMDA or Autoimmune Encephalitis then nor did Queen Square.
The Bright Young Doctor in my days:
" A good doctor is one who is not afraid to ask for help but he must also know where to ask.
Great Ormond Street.”
“I already did.”
She is going to be a good doctor.
“Well, the Regional unit said that they had no beds so I thought I should ring up my classmate at GOS and she talked to her SR who said “send her in”.”
Who needs consultants when juniors have that kind of network? This girl will do well.
“Everything has been set up. The ambulance will be here in about half an hour and if it is all right I would like to go with her.”
But perhaps God works through his people in his own way. Discoveries in Medicine should therefore enhance our faith rather than the other way round.
It took nearly 30 years for the real answer to her prayers to really emerge.
©2012 Am Ang Zhang
The Bright Young Doctor now:
I was staying at our resort in Boquete and was having dinner with three friends all of them with medical connections. One was in hospital administration and one a nurse. The husband of the nurse was a pharmacist. Somehow the conversation drifted into medical topics and knowing that I am a Child Psychiatrist the pharmacist started talking about his nephew who was nearly sent to a mental institution as he suffers from catatonia and doctors eventually diagnosed schizophrenia and put him on antipsychotics. Luckily the catatonic symptom probably saved him as some bright young thing just read the book Brain On Fire and gave him the Clock Test. That led to the NMDAR antibody testing that proved positive. He responded well to the treatment regime that has been developed and is off all antipsychotic medication.
My Teratoma patient was lucky as she belong to that group that improved without further treatment once the Teratoma was removed. She eventually had a baby.
Anti-NMDA Receptor Encephalitis
NEW ORLEANS — A mysterious, difficult-to-diagnose, and potentially deadly disease that was only recently discovered can be controlled most effectively if treatment is started within the first month that symptoms occur, according to a new report by researchers from the Perelman School of Medicine at the University of Pennsylvania. The researchers analyzed 565 cases of this recently discovered paraneoplastic condition, called Anti-NMDA Receptor Encephalitis, and determined that if initial treatments fail, second-line therapy significantly improves outcomes compared with repeating treatments or no additional treatments (76 percent versus 55 percent). The research is being presented at the American Academy of Neurology's 64th Annual Meeting in
. New Orleans
565 cases! Not so rare!
The condition occurs most frequently in women (81 percent of cases), and predominately in younger people (36 percent of cases occurring in people under 18 years of age, the average age is 19). Symptoms range from psychiatric symptoms, memory issues, speech disorders, seizures, involuntary movements, to decreased levels of consciousness and breathing. Within the first month, movement disorders were more frequent in children, while memory problems and decreased breathing predominated in adults.
My patient was under 18 and presented with catatonia symptoms. She later lose consciousness and was ventilated.
"Our study establishes the first treatment guidelines for NMDA-receptor encephalitis, based on data from a large group of patients, experience using different types of treatment, and extensive long-term follow-up," said lead author
Maarten Titulaer, MD, PhD, clinical research fellow in Neuro-oncology and Immunology in the Perelman School of Medicine at the . "In addition, the study provides an important update on the spectrum of symptoms, frequency of tumor association, and the need of prolonged rehabilitation in which multidisciplinary teams including neurologists, pediatricians, psychiatrists, behavioral rehabilitation, and others, should be involved." University of Pennsylvania
The disease was first characterized by Penn's Josep Dalmau, MD, PhD, adjunct professor of Neurology, and David R. Lynch, MD, PhD, associate professor of Neurology and Pediatrics, in Annals of Neurology in 2007. One year later, the same investigators in collaboration with Rita Balice-Gordon, PhD, professor of Neuroscience, characterized the main syndrome and provided preliminary evidence that the antibodies have a pathogenic effect on the NR1 subunit of the NMDA receptor in the Lancet Neurology in December 2008. The disease can be diagnosed using a test developed at the
and currently available worldwide. With appropriate treatment, almost 80 percent of patients improve well and, with a recovery process that may take many months and years, can fully recover. University of Pennsylvania
In earlier reports, 59 percent of patients had tumors, most commonly ovarian teratoma, but in the latest update, 54 percent of women over 12 years had tumors, and only six percent of girls under 12 years old had ovarian teratomas. In addition, relapses were noted in 13 percent of patients, 78 percent of the relapses occurred in patients without teratomas.
As Anti-NMDA Receptor Encephalitis, the most common and best characterized antibody-mediated encephalitis, becomes better understood, quicker diagnosis and early treatment can improve outcomes for this severe disease.
The study was presented in a plenary session on Wednesday, April 25, 2012 ET at 9:35 AM at the American Academy of Neurology's annual meeting.
[PL01.001] Clinical Features, Treatment, and Outcome of 500 Patients with Anti-NMDA Receptor Encephalitis
Anti-NMDA-receptor encephalitis: case series and analysis of the effects of antibodies
Of 100 patients with anti-NMDA-receptor encephalitis, a disorder that associates with antibodies against the NR1 subunit of the receptor, many were initially seen by psychiatrists or admitted to psychiatric centres but subsequently developed seizures, decline of consciousness, and complex symptoms requiring multidisciplinary care. While poorly responsive or in a catatonic-like state, 93 patients developed hypoventilation, autonomic imbalance, or abnormal movements, all overlapping in 52 patients. 59% of patients had a tumour, most commonly ovarian teratoma. Despite the severity of the disorder, 75 patients recovered and 25 had severe deficits or died.
Anti-NMDA Receptor Encephalitis: Diagnosis, Psychiatric Presentation, and Treatment
The following is extracted from The Cockroach Catcher: Chapter 29 The Power of Prayers.
The following is extracted from The Cockroach Catcher: Chapter 29 The Power of Prayers.
According to old Chinese advice, it is wise never to discuss politics or religion even amongst best friends. Religious belief can often blur judgement in the wisest of people. In psychiatry it is sometimes not easy. This is particularly true in cases of florid psychosis, which often presents with symptoms of hallucination, delusion and even vision. I remember my early days of psychiatry in a mental hospital in
Hong Kong. Yes, it was the days of 2000-bed hospitals. Yes, it was the days of Medical Superintendents who had supreme power and all doctors of whatever rank and experience were Mental Health Officers with special authority to sign papers for compulsory admissions. The forensic unit was contained within the same complex. Those were the days when we encountered psychosis in the raw so to speak. All the colony’s really mad people were admitted to this one place set in the furthest corner of the colony. In our year seven of us decided without much discussion that we all wanted to go into psychiatry. That was over 10% and all had quite idealistic reasons. It was perhaps a bit of a disappointment to our parents that we did not pursue a more conventional specialty that might provide us with more status and financial reward. Then there was the fear of contamination that somehow one might become mad too. Recent day medical students are said to shy away from psychiatry for these same reasons. Education seems to have little effect on superstition. ......................................….read the full Chapter: HERE
Cahalan's new memoir is called Brain On Fire-My Month of Madness.