Tuesday, April 30, 2019

Medicine: It May Not Be All In The Mind!

Hong Kong ©2012 Am Ang Zhang

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. Given the concern over cost in most health care systems, the need to restrict the use of expensive investigation is understandable. However, with clinical reliance on sophisticated investigations especially in modern medical training, the art of physical examination is perhaps lost to this generation of newly qualified doctors. Moreover, the reliance on the internet for information removes the need to make use of the still most powerful computer of them all – the brain. No more effort is made to attempt to download the information into our brain for future parallel processing.  As a result, vital and glaring clues are often missed and, worse, dismissed because of over-saturation of information.
       The idea that modern medical training requires some time spent in far-flung places where even the stethoscope is a luxury item is a neat attempt to remind future doctors of the importance of clinical judgment  based on physical examination. Unfortunately feedback from medical students that I had the good fortune to teach only confirmed my worst fears. Such attachments are more a chance for them to visit exotic places in the midst of a busy course than to hone the skills of medicine on which their seniors were brought up.

Hong Kong:

When I first started in psychiatry in Hong Kong, I was fortunate enough to work with a consultant who had a very firm grounding in General Medicine. A case I shall never forget was a thirty-five year old man presenting with very sudden phobic symptoms. At the time we had just opened in Kowloon our new District General Hospital Acute Psychiatric Unit with thirty acute beds, shared equally between Males and Female admissions. This allowed for some acute screening before the long trek to the only mental hospital in the colony, which was twenty two miles away in the New Territories. To many visiting relatives, twenty two miles is a long way, especially in the seventies. As we were all part of one big organisation, it was not really a problem to have screening and then transfer only if it became necessary.
            It was important to carry out a thorough physical examination on all patients including a thorough neurological test. This particular patient checked out normal on most things except for a positive Babinski (a reflex that can identify disease of the spinal cord and brain) .  I was totally baffled but instead of dismissing it I asked my consultant to have a look on the morning round. He carried out a full Neurological.
            “Yes, positive Babinski.”
            Now how on earth can positive Babinski be related to phobic symptoms?
            “We shall need an X-ray urgently, but whatever it is it is not psychiatric”, he declared.
            The patient was found to have a special type of very aggressive lung cancer, with extensive metastasis.
            He died within six weeks despite some very aggressive treatment at the time.
            The sad thing about the case was that being right may not in the end change the outcome.  It bore witness to how little we do know and how little we can do even when we do identify the problem.
            This case definitely established a principle for my clinical practice. Psychological diagnosis need not be the first diagnosis. Rule out organics first. 
            Modern medical schools on the other hand pride themselves in concentrating on the role of psychology in bodily dysfunction. It is arguably true that most family doctors do not get to see all the obscure cases we spent so much time studying as a medical student. Yet in time these cases do get to the hospital to be seen by the specialists. Where indeed do they come from?  Are they not referred by the family doctors, or are they simply missed and then picked up by the specialists?
            Do we as psychiatrists think that it is such a brilliant idea to think “psychology” all the time? Do we really think that people want to see their doctor even when there is fundamentally nothing wrong with them?  Is there a grave danger in that assumption?
            Health planners seem to assume that most who turn up at Family Surgeries have nothing seriously wrong, and similarly those who turn up at A & E. The latter group are just there because they could not be bothered to see their Family Doctors earlier.
            Do we need to apply the money test? Charge a small fee for every consultation for any new condition to exclude malingerers, a sort of “deductible”, in insurance terminology?
            Would it not be safer for all concerned that we should remember:  “It may not be all in the mind!”

                          From:  The Cockroach Catcher     Chapter 40  It May Not Be All In The Mind


Daily Telegraph:
Professor dies of lung cancer after doctors dismiss illness as 'purely psychological'Or HERE.

Lisa Smirl, 37, saw three different doctors after she began experiencing a range of symptoms including shortness of breath, wheezing and pain in her arm over the course of a year. But they were all dismissed as anxiety and depression.

By the time the cancer was finally diagnosed it had spread into her brain, bones and liver and was terminal.

In a blog written during her treatment, Cambridge-educated Dr Smirl wrote: "How is it possible that a 36-year-old, health [obsessed] conscious, occasionally social smoking, middle class, fiancée of a doctor can develop metastatic lung cancer unnoticed. How?!?"

"For the last year I'd been battling a range of bizarre and seemingly disparate symptoms that had forced me in September 2011 to go on sick leave from my job as a lecturer (assistant professor).

"The diagnosis at the time was anxiety and/or depression. And while I was both anxious and depressed, this was due to the increasingly disabling symptoms that my doctor kept insisting were purely psychological.

"So I was actually grateful for a medical diagnosis that confirmed there were objective, physical reasons behind my illness.

"While in some ways this was a terrible surprise, in another it was a huge relief."
Dr Smirl, who is originally from Canada, first experienced shortness of breath and wheezing in late 2010, which was wrongly diagnosed as asthma.

By September 2011, after developing shoulder and arm pain and experiencing 'visual migraines' – in which she lost her vision for half an hour – Dr Smirl was forced to leave her job. She was diagnosed with depression and anxiety and put on antidepressants.

But despite a dramatic weight loss, Dr Smirl claimed three different family doctors refused to consider her symptoms in connection with each other.

In November 2011, a year after she first started having symptoms, she was finally diagnosed with cancer after a doctor agreed to send her for an X-ray.

Dr Smirl, who went on to complete the Great North Run to raise funds for a cancer charity in November 2012, wrote on her blog: "I can't prove it, and this is just my opinion, but I have no doubt in my own mind that my misdiagnosis was in large part due to the fact that I was a middle aged female and that my male doctors were preconceived towards a psychological rather than a physiological diagnosis.

"It is so easy to say that someone's symptoms are 'anxiety' related if they are a little bit complicated, unclear or unusual. Don't repeat my mistakes.

"You know when something is wrong. Find another doctor that you connect with and who takes your concerns seriously. Get referrals. Get tested. Refuse to be dismissed."


My good friend told me about a case that was first thought to be a psychiatric one. It was a severe case of Trichotillomania (hair pulling disorder) that had to be admitted to a mental institution compulsorily.

This is the same friend who alerted us to the radiation dose of some routine health checks.

Trichotillomania is not a condition that requires compulsory admission, so why in this case?

"The patient was sure someone was trying to harm her."

Oh! Acute paranoid psychosis. That makes sense. Anything else? I suppose she had to be on the most up-to-date anti-psychotic and anti-obsessional drugs.

No, before they could pump these drugs into her, her friend bailed her out, against medical advice, and got my friend to see her.

Great friend!

But what could have caused the hair loss?


No way, she was not a spy!

Yes, it was poisoning, not by Polonium, but by Thallium. That was what my friend’s investigation showed.

Thallium has been a noted poison favoured by Secret Services and one famous Graham Young in England. He poisoned his stepmother at the age of 14 and then other members of his family. He was caught and sent to Broadmoor, a maximum security mental hospital in England.

Miraculously he was declared “cured” and released. Nice justice as my friend’s patient was detained by being a victim and they let the perpetrator go despite his diary claiming he planned to kill one person for every year he spent in Broadmoor!

Young then proceeded to find employment as a shopkeeper at Bovingdon, Hertfordshire, where his co-workers were one by one struck by a mysterious illness nicknamed “the Bovingdon Bug”. One died but Young’s arrogance brought his downfall. He challenged the doctor dealing with the “Bug” in a public meeting as to why Thallium poisoning was not considered!

At one time, Thallium was used as a rat poison as even the rats could not detect it by taste. Now it has been banned in most countries but still poses a health risk.

As recently as 2007, two women, a mother and a daughter, who were both born in Russia but became American citizens, had Thallium poisoning on visiting Russia. They survived. The mother is a medical doctor.

It turned out that my friend’s patient was being poisoned by her partner. Prussian Blue was prescribed as the remedy and she survived, sort of, with residual neurological damage due to delay in diagnosis and appropriate treatment.

Paranoid psychosis indeed!

Just remember: it may not be all in the mind.

Tuesday, April 23, 2019

Brexit & Coffee: Fakes and Failures!

With clear evidence that politicians ignore professional advice and that looming Brexit is going to harm patients when there is uncertainty about the availability of certain life-maintaining medications from Insulin down. I am reprinting what I have written about how ignoring professionals cost the French dearly over the construction of the Panama Canal.

Panama has been associated with some fabricated plots. There were the John Le Carre book The Tailor of Panama that was turned into a film, the location shoot of the Quantum of Solace (in Panama, doubling as a country in South America), and the Canoeist faking death, just to mention a few.

Then there was the coffee scandal.
In 1996 in California, a certain  Michel Norton, owner of Kona Kai Coffee was sentenced to 30 months in prison. Apparently for an extended period of time (some reckoned a decade may not be an over estimate), cheaper and “lower grade” Panamanian and Costa Rican coffee were used to pass off as “Pure Kona Coffee”.

Cheaper, certainly, as you would not otherwise be doing it. But, INFERIOR? I think many would certainly dispute that. I do not think you can really use an inferior product to pass off as something superior and fool people for long.

So the Ambassador of Panama in Washington D.C. wrote to the 
New York Times:

To the Editor:
I read with amusement about the indictment of a coffee supplier on selling fraudulently marked beans to retailers (news article, Nov. 13).
Without making light of the charges, I am pleased that the coffee buyer for Peet's Coffee and Tea is uncertain that he can tell the difference between the ''cheaper'' Panamanian beans allegedly substituted for the more expensive Kona.
Panama's coffee is among the world's best. In fact, members of my staff have seen Panamanian beans for sale at high-end coffeehouses for little less than Kona. Perhaps we can arrange a taste test of Kona and Panamanian coffee for the sellers mentioned in the article. I am sure that no one will be more pleased with the results than my native coffee growers. 

Panama Coffee is now world famous.

Poor Theresa May, she is not so lucky with Brexit but perhaps she is rich enough not to worry too much about her insulin!

Politician & The Panama Canal

It is a common practice for politicians to ignore professional advice. As The Cockroach Catcher, his wife and friends cruise across this greatest of all human endeavour, he likes to re-post one of the Panama Posts.Sometimes they might get away with it; sometimes it led to failure, gross failure as in the case of the French attempt at building the Panama Canal.Can we really learn anything from such a colossal failure?

We learn little or nothing from our successes. 
They mainly confirm our mistakes, while our failures,
 on the other hand, 
are priceless experiences in that 
they not only open up the way to a deeper truth, 
but force us to change our views and methods. 

Panama Canal © 2008 Am Ang Zhang

Most people probably know about the French failure to build the Panama Canal. Many thought that this was due to yellow fever and malaria which were diseases thought to be due to some toxic fume from exposed soil.

Extracted from the Official Website: Panama Canal Authority /French Construction

In 1879, Ferdinand Marie de Lesseps, with the success he had with the construction of the Suez Canal in Egypt just ten years earlier, proposed a sea level canal through Panama. He was no engineer but a career politician and he rejected outright what the chief engineer for the French Department of Bridges and Highways, Baron Godin de Lépinay proposed, a lock canal.

The engineer was no match for a career politician:

“There was no question that a sea level canal was the correct type of canal to build and no question at all that Panama was the best and only place to build it. Any problems – and, of course, there would be some - would resolve themselves, as they had at Suez.”

“The resolution passed with 74 in favour and 8 opposed. The ‘no’ votes included de Lépinay and Alexandre Gustave Eiffel. Thirty-eight Committee members were absent and 16, including Ammen and Menocal, abstained. The predominantly French ‘yea’ votes did not include any of the five delegates from the French Society of Engineers. Of the 74 voting in favor, only 19 were engineers and of those, only one, Pedro Sosa of Panama, had ever been in Central America.”

The French failed in a spectacular fashion.

Cost to the French: $287 Million (1893 dollars) or $6.8 Billion (2007 dollars)

Many reasons can be stated for the French failure, but it seems clear that the principal reason was de Lesseps’ stubbornness in insisting on and sticking to the sea level plan.  But others were at fault also for not opposing him, arguing with him and encouraging him to change his mind.  His own charisma turned out to be his enemy.  People believed in him beyond reason.

Could any of us learn anything from this experience?

Hermione: "You pay a great deal too dear for what's given freely". -

(Act I, Scene I). The Winter’s Tale.

President Jimmy Carter: Time


Panama Canal: Diseases & Failures.

Thursday, April 18, 2019

First Emperor, Animal Farm & Allyson Pollock

“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 alsoThe Independent.

Forty years ago, Colin Douglas, geriatrician and novelist, when on a gap year in a remote secondary school in post-colonial Ghana, was summoned by the headmaster and informed that "we had in our library a book the government didn't think we should read." The book was of course Animal Farm.
Here in The BMJ, he reviewed Allyson Pollock’s Book, NHS plc.
NHS plc/Allyson Pollock
"Allyson Pollock describes her experience in November 2001 at the hands of the House of Commons Health Select Committee, then just refreshed by an influx of New Labour ultras, including one Julia Drown MP, a former health service manager. Against the advice of the committee's chairman and clerks, Ms Drown tabled a rant aimed at undermining Professor Pollock and her Health Policy and Health Services Research Unit at University College London. In the chairman's view such an attack on an individual witness was unprecedented and wrong, yet it nevertheless (by virtue of a nasty but neat little bit of committee footwork) appeared in the final report of an inquiry into the implications of the private finance initiative (PFI) for the NHS.”

Allyson Pollock must count herself lucky for not living in China during the reign of The First Emperor although she did leave the England part of The Kingdom.

“……if you are old enough, or even just curious enough, to wonder whatever happened to the British NHS as first conceived, you might find NHS plc a useful little book. An excellent early reputation—for cost effectiveness and equity based on integrated services, minimal management costs, and a vast and intensely practical pooling of risk—dwindled slowly. This was firstly because of chronic and insidious underfunding, later because a notional internal market began to take it apart, and finally (though the word may still be slightly premature) because of the current assault: a burgeoning, divisive, sometimes mendacious for-profit marketisation of a healthcare system that was once an admired public provision and a right of citizenship in the United Kingdom.”

Regarding PFI he continued:
"Since it was Pollock's views on the PFI that so upset its proponents, it is worth summarising them briefly. Costs are now intrinsically higher, because of capital borrowing at higher rates than those available to government, because of cash hungry consultancies and the vast transactional and monitoring costs of countless contracts, and because—for the first time on a large scale in the NHS—commercial profits must be made. To accommodate all these new costs clinical services have been scaled down, while matching assumptions about increased efficiency are only variably delivered. All this, along with the rigidity of a trust based strategy for building hospitals and the locking in effect of contracts fixed for decades, seems to Pollock and many others at best a bad bargain, at worst a naive betrayal that opens the NHS to piecemeal destruction and the eventual abandonment of its founding principles. And all over the country PFIs—greedy, noisy, alien cuckoos in the NHS nest—gobble up its finances and will do so for the next 30 years.”

Next 30 years!

Other concerns:
"Foundation trusts (‘public benefit corporations’—what?) will further disrupt any attempts to build effective local health services, drive the balance of care in the wrong direction, and almost certainly get choosy about the patients they treat. All this will least benefit elderly patients, whose care as our population ages ought to be explicitly identified as the core commitment of our NHS. Will elderly people be surprised? I doubt it. Their long term care was totally abandoned by the NHS in England long ago, and given the direction of current reforms any priority for their acute care would be astonishing. And meanwhile, under the Orwellian rubric of choice and diversity, all manner of dubious, expansionist corporate players, many from theUnited States, where these things are managed so much worse, are circling, scenting opportunities for private profit in a once great public service.”

I have to thank Dr. Grumble for pointing me to this site that has a write up too.

Rupert Read wrote in OurKingdom:
When I was at Oxford taking PPE 20 years ago, my best friend was Simon Stevens, who went on to become Tony Blair's key health policy adviser. Back then, he was a socialist. Now, he is Chair of United Health Europe, one of the US's giant corporations profiteering from the break-up of the NHS, and angling to take over doctor's surgeries across the UK. That little timeline symbolises quite a lot about what has happened to the NHS.
Why do we still have the great books of Confucious and other scholars? They have all been memorised by scholars and The First Emperor could not kill all of them. When he failed to achieve eternal life and died, the scholars just re-wrote these books again.
The last words go to Colin Douglas:
“Professor Pollock, with the help of many colleagues acknowledged in a list that reads like a roll of honour for services to the real and now threatened NHS, has written a brave, necessary book. And because you know the government thinks you shouldn't read it, you probably should.”

Sunday, April 14, 2019

Norway and The Answer to Prayer: Teratoma.

We provided World Class Medicine without trying. A quote from a fellow blogger, Dr. No.

Dr No said...
Excellent post - and yes, that is exactly how it used to be. World class medicine without even trying - we just did it, because that is what we did, just as the dolphin swims, and the eagle soars. A key, even vital feature was that the doctors looking after their patients did not need to worry about money or managers. They just got on with it. There was no market to get in the way of truly integrated care. Some may point out that 13 year olds with teratomas are rare, and that is true, but what this case shows us, precisely because of its complexity, is just how capable the system was. And most of the time (of course not always), it dealt just as capably with more routine cases. "How is (sic) the new Consortia going to work out the funding and how are the three Foundation Trust Hospitals going to work out the costs." Exactly. And then: who is going to pay for the staff and their time to work out out all those costs and conduct the transactions?
What many politicians may not know is that pride in what we do is often more important than money or anything else. Our pride is one sure way to ensure quality of practice.

Do we really want to take that away now? Years of heartless re-organisation has left many of us dedicated doctors disillusioned. Many young ones have left. Poorly trained doctors that have no right to be practising medicine now even have jobs in some of these well known hospitals. 

Can we continue to practise World Class Medicine even if we wanted to?

According to old Chinese advice, it is wise never to discuss politics or religion even amongst best friends.  

Religious belief can often blur judgment in the wisest of people.

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 argue with her then.

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.

My recent visit to this beautiful church in Norway reminded me of my patient. and i cannot believe that it took another 30 years for the true answer to arrive. 

Beautiful Church in Tromso, Norway.

© 2019 Am Ang Zhang

The following is extracted from The Cockroach Catcher: Chapter 29 The Power of Prayers.

  Some time in early February of 1978 I was called to do a Home Visit on a thirteen year old girl by Dr Pinkerton, a paediatric consultant. Dr Pinkerton had been the local Paed for years and was generally well regarded. She had, in my short time as consultant, referred a couple of cases, most notably that of a Tourette syndrome and a boy with non-stoppable hiccups. Both cases put me in her A-list and I gathered that not many were on that list. Needless to say I realised too that her cases were never straightforward or simple.  Those she would have dealt with herself. The girl had upper arm stiffness on the left side and Dr Pinkerton could not find much else wrong with her, and so it crossed her mind that perhaps there was something psychiatrically wrong.  The girl was also carrying out some strange rituals around the house and Dr Pinkerton did wonder about psychosis or even catatonia.

 The x-ray came back. The tell tale tooth was there and yes – a Teratoma[5], the distinctive type of tumour that can include teeth, hair, sometimes, even a jaw and tongue.  I guessed just a split second before the results came back. How annoying.
         Working diagnosis: Teratoma with possible toxic psychosis.
         Emergency operation was arranged. Yes, she would be fine a little while after the operation, I reassured the parents.
         The paediatric junior arrived and took some history and did a quick physical before she was prepared for the theatre. This petite doctor with a very babyish face told me that on her first day in her last job she had to do an emergency tracheotomy. This time she had been on call for the last three nights and the battery in her old Mini could not cope with the heavy frost so she had to wait for AA before coming. She was most apologetic for not having got in earlier.
         She asked if I had seen many toxic psychosis cases and I asked if she had come across any in her psychiatric placement. As with all good psychiatrists answering a question with another is in our blood and here it worked well.
         Neither of us knew what was to hit us next.
         At 2 A.M. I had a call from her.
         “Your patient – I mean our patient could not be aroused after the operation. Yes they removed the teratoma, complete and intact. It is bigger than any specimen I have seen but she could not be aroused.  Any ideas?”
         “Call the paediatrician on call in the regional paediatric unit and I will be in.”
         What happened?  I asked myself as I drove to the hospital.
         What had we done? This was fast becoming a nightmare situation.
         What was I going to say to the parents?

         Something else was going on here, and I was not happy because I did not know what it was. I was supposed to know and I generally did. After all I was the consultant now.........

Read the whole chapter: Chapter 29  The Power of Prayers

In medicine, truly new discoveries are uncommon and with the emergence of guidelines and protocols it has become even more difficult to make new discoveries. It has taken over 30 years before I could understand what happened to my Teratoma patient. Luckily for her, the treatment she received would have been in line with what we know now of the condition.

Hospital Medicine indeed has its important place and most important of all in the discovery of new conditions and establishing diagnostic and treatment programmes.

It is perhaps timely to remind the next generation of Bright Young Things that become doctors to remember that psychiatric symptoms presented by a patient may indeed be the presentation of a neurological condition.

This is more so for bizarre combinations of psychiatric and other symptoms. It was in the last five years or so that much progress has been made on what is now called Anti-NMDA Receptor Encephalitis.

Who knows, one day medical scientists might be able to decipher the most difficult of psychiatric conditions: Schizophrenia. Bright Young Psychiatrist might have noticed that Clozapine, one of the most effective drugs for schizophrenia has a marked effect on the immune system.

In the mean time Pennsylvania might have something they could be proud of: the discovery of this new neurological condition.

For now, my patient’s parents’ prayer has been answered. 

Chapter 29  The Power of Prayers

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 TitulaerMD, PhD, clinical research fellow in Neuro-oncology and Immunology in the Perelman School of Medicine at the University of Pennsylvania. "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."

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 University of Pennsylvania 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.

Teratoma: finally!

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

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.

Related paper:

Post Script:
“Ten years later mother came to see my secretary and left a photo. It was a photo of her daughter and her new baby. She had been working at the local bank since she left school, met a very nice man and now she had a baby. Mother thought I might remember them and perhaps I would be pleased with the outcome.

I was very pleased for them too but I would hate for anyone to put faith or god to such a test too often.”