Sunday, January 19, 2020

NHS: Tap Water &The Last Cook.

This was tweeted today:

Prior to my 13-hour on call, I filled up my water bottle from the ward kitchen tap (staff room had no tap/water). I was scolded; That tap water is for patients. Told buy bottled water from M&S or Costa. This article explains why we're so fed up.

This was in my days:

"If we arrived at mid-morning we used to get a nice cup of tea. But that was only since I started bringing in my own tea leaves. We also got served home-made scones and the like.
         All very homely."

 ……I often arrived late at lunch time after the children and nurses had eaten as morning clinics had a habit of running late. With less than ten minutes to spare, the cook would still manage to serve me a bit of some of the things she knew I preferred. Often she felt compelled to sit with me to tell me about her grandchildren or about what the government should really be doing to help the likes of her, a war widow bringing up two sons in this Naval town. I always admired the resilience shining through her stories."

 As the sun sets on our beloved NHS:
                                                           ©Am Ang Zhang 2012

Perhaps it is not that well known that the dismantling of our beloved NHS started long before the present government and the future does not bode well for those of us that likes to keep NHS in the public domain.

Child Psychiatric in-patient units across the country were closed some time after many adult hospitals were closed or down-sized.

To me, the government is too concern with short term results that they impose various changes across the board in Health Care & Education without regard to the long term consequences or costs.

After all, I have made good use of in-patient facilities to un-diagnose ADHD and that would in turn save children from unnecessary medication and the country from unjustified benefit claims.

Such units were also great training grounds for the future generation of psychiatrists and nurses. Instead, most rely on chemicals to deal with a range of childhood psychological problems.

Indeed it was a sad day when the unit closed.

From The Cockroach Catcher:

Chapter 48        The Last Cook

ne of the few things I learned working in some inpatient units was to be appreciative of the ancillary staff. What a cleaner might reveal to us was often more telling than a formal interview. It could well be that often parents were unguarded and more able to reveal things to someone like the cleaner or indeed the cook.
         I was fortunate enough to experience one of the last NHS cooks when I was Senior Registrar at an inpatient unit. The inpatient unit catered for a middle age group spanning the older children to the younger adolescents. It was one of a kind in the U.K. and indeed it was the first to start a national training course for Psychiatric nurses in inpatient care, a good three years before anywhere else.
         The unit was in the middle of town and was considered to be too far from the Hospital for catering purposes.  Instead a cook was employed to cater for the needs of the children and nursing staff.  We doctors were not supposed to eat there. But we did.  Mainly for lunch.
         If we arrived at mid-morning we used to get a nice cup of tea. But that was only since I started bringing in my own tea leaves. We also got served home-made scones and the like.
         All very homely.
         I had since wondered if our great success rate was more to do with having our own cook than all the other therapies and tit bits that we did.
         You never know as people do not really research these things.
         ……I often arrived late at lunch time after the children and nurses had eaten as morning clinics had a habit of running late. With less than ten minutes to spare, the cook would still manage to serve me a bit of some of the things she knew I preferred. Often she felt compelled to sit with me to tell me about her grandchildren or about what the government should really be doing to help the likes of her, a war widow bringing up two sons in this Naval town. I always admired the resilience shining through her stories.
         She also provided me with her down to earth views of what we should do with whichever patient that had come in. I listened. I took note.  You never know.
         Sheena was the mother of two girls we had to admit. They were both ‘soilers’ and they would never touch vegetables at home or anywhere.

         Sheena was petite, worn and a chain smoker.
         But she had two lovely looking girls.
         We knew from the start there were handling issues and most likely diet ones too.
         One of the other reasons for their admission was that by and large there were very few girl ‘soilers’.  
         It was always a good sign when a child flourished in an inpatient setting, and away from home some mothers were more capable of telling you more of what went on.  Some mothers found it easier to talk to one of the non-medical staff, perhaps the cook.
         Mothers got fed too on their visits. More often than not the children preferred their mother to go home than to stay and watch them. That was a different issue. With the money spent on cigarettes and drinks not much was left for food either for the children or the parents. I knew that if we checked for vitamin and other deficiencies we would find them, a problem that had taken Public Health a long time to wake up to. Increasing tax for cigarettes and drinks did not change people’s habit one little bit.
         With a simple routine the girls were clean in no time.   At least during the week as they all went home week-ends, when the unit was closed.
         We were at a loss as to what was going on.
         The girls would get worse over the week-end and soil. This went on for quite a while.
         Then one day the cook talked to me.
         “Sheena never stays Mondays,” she told me.
         I listened.
         “Have you noticed she is always in dark glasses on Mondays?”
         How stupid of me. Now and again I saw her at the door seeing the girls off and yes, she wore huge sunglasses.
         Sheena was not a movie star.
         I arranged to see Sheena.
         She said, “You knew.”
         I nodded.

         “But I cannot leave him. I have nowhere to go and I shall not get enough benefit money if I am divorced from him. He now goes to the day hospital. Fridays he gets drunk and beats me up. It is like a routine. I try not to get hurt and hide it from the girls. If I walk out, he will find me even if I have somewhere to go. I shall still get beaten up. Now at least I know when it will happen and I can live with that.”
         I suggested that I should speak to him but she looked terrified.
         She felt he might even kill her if I did and last time he threw a chair at a male nurse who tried to say something.
         She was probably right. We often had no idea what people and particularly women put up with. It would be too easy for us to bulldoze in.  We had to think twice before intervening unless we had something better to offer. His Schizophrenia diagnosis allowed for a higher level of benefit she would not otherwise get. Who would she meet up with next?  Another violent man most likely.
         Was it such a cop-out on my part?
         Maybe it was, but in a strange way the girls stopped soiling after that one meeting I had with mum. The case left me with some unease - unease not just about what I did or did not do but about keeping patients in the community. Three other lives were affected here and who knows, one day he might go too far.  That was before Maria Colwell. 
         The unit had long since been closed.
         The last cook in the NHS retired .
The Cockroach Catcher on Amazon Kindle UKAmazon Kindle US

Thursday, January 16, 2020

Lithium: Why? Why? Why?

Lithium! It has Side Effects but you will live to experience it!

One of my ex-juniors, now retired, called to ask if I have read about another junior doctor's suicide. How very sad!

Dr. Baldessarini of Harvard:

“Lithium is far from being an ideal medicine, but it’s the best agent we have for reducing the risk of suicide in bipolar disorder,” Dr. Baldessarini says, “and it is our best-established mood-stabilizing treatment.” If patients find they can’t tolerate lithium, the safest option is to reduce the dose as gradually as possible, to give the brain time to adjust. The approach could be lifesaving.

In recent write ups about antidepressants, there is no mention of Lithium. The Cockroach Catcher first worked with one Australian Psychiatrist that worked with Cade and I was, so to speak, very biased towards Lithium. Yes, Lithium has side effects that might be serious. But hang on, you get to live to experience it. Think about it.

"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. After all it is less than one eighth the price of a preferred mood stabilizer that has a serious side effect: liver failure.

Perhaps it is in the British History:

First, why a small group from the Maudsley Hospital in the 1960s could, in an almost malicious manner, have sown scholarly confusion about the true effectiveness of lithium. Aubrey Lewis, professor of psychiatry and head of the Maudsley, considered lithium treatment “dangerous nonsense” (). Lewis’s colleague at the Maudsley, Michael Shepherd, one of the pioneers of British psychopharmacology, agreed that lithium was a dubious choice. In his 1968 monograph, Clinical Psychopharmacology, Shepherd said that lithium was toxic in mania and that claims of efficacy for it in preventing depression rested on “dubious scientific methodology” (). Shepherd also scorned “prophylactic lithium” in an article with Barry Blackwell (). Moreover, Shepherd was publicly contemptuous of Schou. He told interviewer David Healy that Schou had put his own brother on it, and that Schou was such a “believer” in lithium that he seemed to think “really there ought to be a national policy in which everybody could get lithium”

 Atacama where Lithium is extracted  © Am Ang Zhang 2015

Lithium: The Gift That Keeps on Giving in Psychiatry

Nassir Ghaemi, MD, MPH
June 16, 2017

At the recent American Psychiatric Association annual meeting in San Diego, an update symposium was presented on the topic of "Lithium: Key Issues for Practice." In a session chaired by Dr David Osser, associate professor of psychiatry at Harvard Medical School, presenters reviewed various aspects of the utility of lithium in psychiatry.

Leonardo Tondo, MD, a prominent researcher on lithium and affective illness, who is on the faculty of McLean Hospital/Harvard Medical School and the University of Cagliari, Italy, reviewed studies on lithium's effects for suicide prevention. Ecological studies in this field have found an association between higher amounts of lithium in the drinking water and lower suicide rates.

These "high" amounts of lithium are equivalent to about 1 mg/d of elemental lithium or somewhat more. Conversely, other studies did not find such an association, but tended to look at areas where lithium levels are not high (ie, about 0.5 mg/d of elemental lithium or less). Nonetheless, because these studies are observational, causal relationships cannot be assumed. It is relevant, though, that lithium has been causally associated with lower suicide rates in randomized clinical trials of affective illness, compared with placebo, at standard doses (around 600-1200 mg/d of lithium carbonate).

Many shy away from Lithium not knowing that not prescribing it may actually lead to death by suicide. As such all worries about long term side effects become meaningless. 

Will the new generation of psychiatrists come round to Lithium again? How many talented individuals could have been saved by lithium?

APA Nassir Ghaemi, MD MPH
  • In psychiatry, our most effective drugs are the old drugs: ECT (1930s), lithium (1950s), MAOIs and TCAs (1950s and 1960s) and clozapine (1970s)
    • We haven’t developed a drug that’s more effective than any other drug since the 1970’s
    • All we have developed is safer drugs (less side effects), but not more effective
  • Dose lithium only once a day, at night
  • For patients with bipolar illness, you don’t need a reason to give lithium. You need a reason not to give lithium  (Originally by Dr. Frederick K. Goodwin)

Cade, John Frederick Joseph (1912 - 1980)
Taking lithium himself with no ill effect, John Cade then used it to treat ten patients with chronic or recurrent mania, on whom he found it to have a pronounced calming effect. Cade's remarkably successful results were detailed in his paper, 'Lithium salts in the treatment of psychotic excitement', published in the Medical Journal of Australia (1949). He subsequently found that lithium was also of some value in assisting depressives. His discovery of the efficacy of a cheap, naturally occurring and widely available element in dealing with manic-depressive disorders provided an alternative to the existing therapies of shock treatment or prolonged hospitalization.

In 1985 the American National Institute of Mental Health estimated that Cade's discovery of the efficacy of lithium in the treatment of manic depression had saved the world at least $US 17.5 billion in medical costs.

And many lives too!

I have just received a query from a reader of this blog about Lithium, and I thought it worth me reiterating my views here.      It is no secret that I am a traditionalist who believes that lithium is the drug of choice for Bipolar disorders.
Could Lithium be the Aspirin of Psychiatry? Only time will tell!

Friday, January 10, 2020

Sepsis & Quorum Sensing!

For the past three hundred years……we’ve been completely wrong……we don’t know anything about bacteria until about a decade ago….”

Bonnie Bassler

Bassler group finds an alternative mode of bacterial quorum sensing

Whether they are growing in a puddle of dirty water or inside the human body, large groups of bacteria have to interact with each other and coordinate their behavior in order to perform essential tasks that they would not be able to carry out on their own. Bacteria achieve this coordination through a process called quorum sensing, in which the microorganisms produce and secrete small molecules, called autoinducers, that can be detected by neighboring bacterial cells. Only when a large number of bacteria are present can the levels of secreted autoinducer build up to the point where the community can detect it and, in response, alter their behavior as a coordinated group.
In a paper published last month in PLoS Pathogens(link is external), a team of researchers led by Sampriti Mukherjee and Bonnie Bassler from the Department of Molecular Biology revealed the existence of a new quorum sensing molecule that increases the virulence of the pathogenic bacterium Pseudomonas aeruginosa. The finding could help researchers develop new antimicrobial drugs to treat the serious infections caused by this bacterium.
P. aeruginosa is an incredibly adaptable organism that can grow in diverse environments, from soil and freshwater to the tissues of plants and animals. It thrives on the surfaces of medical equipment and is therefore a major cause of hospital-acquired infections, causing life-threatening conditions, such as pneumonia and sepsis, in vulnerable patients. The bacterium has become resistant to most commonly used antibiotics, making the development of new antimicrobial treatments a priority for both the Centers for Disease Control and Prevention and the World Health Organization.

Hospital Infection: Quorum Sensing

This is the story of a much respected retired professor. As he celebrated his 82nd birthday, we have to be thankful that he must have some strong genes to have survived the last eight months. An unfortunate slip at home fractured one of his ankles, and as a pin was needed a surgical procedure was performed in a local hospital by the Orthopaedic surgeon. For the following eight months an otherwise independent and healthy eighty one year old had to suffer the indignity of many more hospital procedures because of a lingering infection.
“I don’t know” was his answer when we visited him and asked if it was the dreaded MRSA.
He was never tested!
Nearly 15 years since the discovery of Quorum Sensing by Nottingham University the topic seemed to be shrouded in some mystery. The Cockroach Catcher read about it by chance in an airline magazine and his own survey of some recent medical school graduates from Cambridge and Southampton indicated that this was not in their curriculum and they had never heard of it.
There is of course a Nottingham Quorum Sensing website and certainly Cambridge produced some research papers.
Bonnie Bassler said that all we knew about bacteriology in the last 300 years is all wrong. Strong words indeed. So are we still teaching medical students all the wrong stuff?
Is professional jealousy at work here? Surely not. But Quorum Sensing will itself lead to other exciting findings about the world of the microbe that has so far got the upper hand on the ever so clever Homo sapiens.
Think MRSA and C.difficile and I am sure you will agree.
I know that it is a new field and much of it theoretical and conjectural but I was a medical student once and the greatest buzz for me then was Heart Transplant, and VAMP treatment for some kind of leukaemia. So could we not let the future doctors have some excitement other than the 3G iPhone?
Surely we need to inspire some great brains to go where no men have gone before.
It is now well established that in France and Holland where hospitals do not run to capacity, they do not have the level of MRSA and C. difficile problem that we have here.
I do not think that is the result of them using some of the methods we have been known to use here, i.e. not testing the patients. Their standard of care is probably different and their wards are not as crowded.
We do seem to have lots of “good” lateral thinkers working in the NHS. In the meantime, our well loved professor has decided to move to sheltered housing. Months of struggling with his immobility and inability to go walking, swimming, shopping and getting on with his daily chores robbed him of his desire to be independent. But at least he survived.
What about his hospital manager? Did he or she get the bonus? 

SARS and Quorum Sensing

There is a chapter in The Cockroach Catcher called “SARS, Freedom and Knowledge”. I wrote about the SARS virus:
“For the first time, doctors and nurses who were normally in the forefront of the fight against diseases were fighting for survival from SARS (Severe Acute Respiratory Syndrome), a new and dangerously contagious disease. ……
Our knowledge base was in total chaos. What we knew was obviously not good enough. Nor were the most up to date antiviral drugs……”
I am not a bacteriologist nor virologist but that did not stop me writing about these little creatures.
When I picked up the in-flight magazine on a recent flight, an article titled “Genius at Work” caught my eye. Bonnie Bassler is the bacteriologist at Princeton who discovered and pioneered the work on what she now called quorum sensing in microbes. To be more precise her initial work was with Vibrio harveyi. Vibrio is in the family of bacteria that causes Cholera. Vibrio vulnificus is carried by oysters and was most likely responsible for the serious illness of Michael Winner, film producer and now food writer of the London Sunday Times.
On following this up back home, I found an article on the website of Howard Hughes Medical Institute – she is one of the HHMI Investigators. From this article, I learned that:
“Virulent bacteria do not want to begin secreting toxins too soon, or the host's immune system will quickly eliminate the nascent infection. Instead, Bassler explained, using quorum sensing, the bacteria count themselves and when they reach a sufficiently high number, they all launch their attack simultaneously. This way, the bacteria are more likely to overpower the immune system….
For the past three hundred years……we’ve been completely wrong……we don’t know anything about bacteria until about a decade ago….”
Wow! Just as we thought we knew everything there is to know about microbes.
Bonnie Bassler will one day get the Nobel prize for medicine. You read it here first.
Fascinated, I wanted to find out more about this genius. I would like to share with you her answers to some of questions that children were invited to ask about her life and work:
“You all asked me essentially the same question: how and when did I get interested in science. As a kid, I loved doing puzzles, solving riddles, and reading mystery books. I also loved animals and always had pets. Around high school, those interests (puzzle solving and animals) convinced me that I should be a veterinarian so I could work on mysterious illnesses in animals and cure them. In college, I realized I did not like big-bloody stuff. It became clear to me that I probably wouldn't enjoy being a vet, but I did not know what I'd do instead. 
Fortunately, the vet curriculum required me to take biochemistry, genetics, and lab courses. Once I got into those classes, I fell in love with doing puzzles about little things (DNA and RNA and proteins and how they all fit together in cells). I also adored doing lab experiments and puzzling over my results. I realized that lab research was the perfect path for me. It allowed me to spend every day figuring out mysteries/puzzles that have to do with what make us alive. What could be a bigger mystery or puzzle? I changed my major in my junior year, and I have not left the lab since. (I still love animals and have a pet—Spark my cat—and I often go hiking hoping to see animals in the wild.)
I think being open-minded about what Nature is trying to tell you is the key to being creative and successful.”

Now in England, only a couple of Medical Schools require biology. In my book, I puzzled over this fact:
“The ability to dissect out a full set of cockroach salivary glands was a prerequisite requirement for medical school entrance in Hong Kong in our days. It is almost a 180 degree turn around nowadays when many young doctors have no idea about the biological world we live in. Nearly all Medical Schools in England no longer specify biology as a prerequisite subject for anybody who wishes to embark on the study of the human body. As we are so intertwined with the rest of the living biological world I find this policy quite extraordinary.”

Aug 23, 2008
Nearly 15 years since the discovery of Quorum Sensing by Nottingham University the topic seemed to be shrouded in some mystery. The Cockroach Catcher read about it by chance in an airline magazine and his own survey of some recent ...

Oct 24, 2010
Vibrio cholerae, like many other bacteria, uses quorum sensing to synchronize gene expression on a population-wide level. Upon infection of its human host, V. cholerae immediately initiates expression of virulence genes ...

May 27, 2011
Instead, Bassler explained, using quorum sensing, the bacteria count themselves and when they reach a sufficiently high number, they all launch their attack simultaneously. This way, the bacteria are more likely to overpower ...

Jun 22, 2011
Guys & Dr House: Quorum Sensing & MRSA. Looks like Dr House is on leave. Surgeon David Nunn reprimanding the TV crew and officials who accompanied. David Cameron and Nick Clegg on their visit to Guy's on 14 June. ...

Cockroaches & Superbugs

Book I am reading:

As the Nazi regime slaughtered millions across Europe during WWII, it sorted people according to race, religion, behavior, and physical condition for either treatment or elimination. Nazi psychiatrists targeted children with different kinds of minds―especially those thought to lack social skills―claiming the Reich had no place for them. Asperger and his colleagues endeavored to mold certain “autistic” children into productive citizens, while transferring others they deemed untreatable to Spiegelgrund, one of the Reich’s deadliest child-killing centers.

SARS ACCOUNTS: Dr Yannie Soo, Tom Buckley.
Useful link: Hong Kong Chinese University Recommendations. CDC CNN
Other Posts:

Wednesday, January 8, 2020

Flat Earth & Miracles: He will never learn to speak!

I have come to the realisation that we still know very little how our brain recovers especially after what appears to be serious damage.  When it manages to, many would see it as a miracle. 

When I was training in London in the 70s, I spent some time at Queen Square. Those in the know will recognize it as the place for neurology this side of the Atlantic. It was drilled into us then that sadly we were given a number of brain cells when we were born and it was all downhill from then on or something to that effect. It was well known that neurologists were great diagnosticians but for most neurological conditions, not much could be done. How depressing indeed. Even as recently as four weeks ago, I heard a young doctor told his father that there was nothing he could do with his brain cells. One is given so many at birth and no more can be expected. Lord Brain (1895-1966) would have been so proud.


Yet it was also London that shook the world with new discoveries about the brain, and the study was on the most unlikely group of people: Taxi drivers. Their “KNOWLEDGE” was the basis of our knowledge on brain plasticity today. The “KNOWLEDGE” is a term officially used to describe the test the Taxi Drivers had to take to get the licence to drive Taxis in London. Streets in London have evolved over time and are not on any grid system at all. Early postmortem examinations led some pathologists to note the small size of the Taxi drivers’ frontal lobes. Yet actual weight measurement showed that size was all relative. It was the enlarged hippocampal region that created that impression. Later work using modern scanning techniques confirmed the early impressions. 

There is no doubt in my mind that it is reasonable to assume that the younger the brain is the better the chance of recovery which many see as a miracle.  

When will we learn to "allow" miracles to happen.

Photoshop Miracle:
Black Currant Miracles © 2012 Am Ang Zhang

        It is not my intention, either as an individual or as a scientist, to express an opinion on religious visions and miracles. Science has generally failed to understand these phenomena and many religions on the whole have tended to ignore scientific explanations.
        For the religious amongst us, a close study of the history of religion would have seen deliberate attempts a couple of millennia ago to trick people into believing certain things supernatural. In a recent visit to Ephesus, we heard tales of how early “Christians” were duped and “cured”.
        When the Western World was in the tight grip of the Catholic Church, the Jesuits were generally regarded as the greatest scholars. They brought Western culture and religion to the East. They must have had a glimpse of the Chinese understanding of the universe and the world. Yet for so long the religious view of Flat Earth held true. Did the Jesuit scholars know the truth or did they pretend not to in order to avoid persecution and possible death? We shall never know.
        Many “visions” have proved to be the work of errant brain waves due either to epilepsy or brain tumours. Yet the Church continued to celebrate these phenomena.
The first picture is the original: the rest miracles!

From my book The Cockroach Catcher Chapter 15: Miracles:

Second Miracle
         The second “miracle” I am going to recount was again not experienced by myself but occurred none other than where most miracles happened.
         And in the 20th Century.
         I heard about it at a World Congress on Infant Psychiatry held in Chicago.
         Generally the big plenary sessions at nine in the morning were reserved for the big presentations. Given that it was an Infant Psychiatry Congress, one was surprised to be having a presentation of a case of an older child.
         Yet this was a presentation by one of the most respected professorial units in Jerusalem. The hall was packed and word must have got out that this was going to be good.
         The professor was himself on stage. He was already rather old, but when he spoke he did so with authority and a certain air of natural arrogance. It was the kind of arrogance that came as a matter of course to one who had made a discovery of some kind that none of us in the hall, except his team, had heard of. Perhaps pride is a better word to describe it, but no matter.  Something big.
         His presentation involved the showing of some film clips, one of which was from the BBC archives.
         This boy suffered from severe epilepsy from a very early age and was on four different medications. He never acquired speech, ever.
         He had a younger brother, bright and very advanced, who was reading well before the age of three, not unusual for Jewish boys you might say, but unusual given his brother could not speak.
         His mother sought help for him over the years, and by the time he was twelve, most specialists she consulted told her there was a critical period after which a child would never acquire speech.
         She had said her fair share of prayers at the Synagogue.
         One day, unbeknownst to her, her genius toddler took an overdose of his brother’s medications. He was found in time and his life was not threatened. For four full days after he came out of intensive care, he stopped talking altogether.
         It suddenly occurred to her that it could be the medication that was holding her son back.
         She immediately secured a consultation at a top hospital and the consultant said that it was possible to use other methods to control the epilepsy. 
         But it would be drastic, as it involved removing nearly half of his brain.
         “Without medication would he learn to speak?”
         Now this was where the BBC film cut to a big picture of the lady consultant who said, “Never. He is beyond the critical age. He will never learn to speak. Never ever.”
         The Professor in a very solemn voice said from the podium, “She is not one of ours.”
         The boy had the operation. He was now free from epilepsy and free from any medication.
         Mother decided to emigrate to Israel and seek help in the Promised Land.
         “What a wise move.” The Professor interjected again.
         The boy now came under the Professor’s care, and a big team of different therapists started working on him.
         And mother’s prayers were at last answered.
         The boy now spoke fluent Hebrew and reasonable English. Not one but two languages.
         I remembered what one Rabbi said to me at our friend’s son’s Bar Mitzvah, “You know our God will give, but we must work hard.”
         And Old Mac:  Never say never.

Flat Earth & Miracles: Duping & Human Kindness!

To remember our eminent yet formidable Professor of Medicine, Professor MacFadzean: One Patient One Disease.
I would like to pay tribute to our eminent yet formidable Professor of Medicine, Professor MacFadzean, 'Old Mac' as he was 'affectionately' known by us. He taught us two important things right from the start:

First - One patient, one disease. It is useful to assume that a patient is suffering from a single disease, and that the different manifestations all spring from the same basic disease.

Second - Never say never. One must never be too definitive in matters of prognosis. What if one is wrong?