Sunday, July 23, 2017

Music & Knowledge: Mozart & Brain!


© 2005 Am Ang Zhang
As the cock crowed, the grandfather left the house on his half mile walk to the little park by the river for his morning Tai Chi with a group of seniors. He was in fact the leader of the group and it fell upon him, a young looking 83 year old to go through the sequence of Tai Chi moves that had been passed down by his grandfather and others before him. His wife sometimes accompanied him but today she had to baby sit the grand-children as their parents were on an early shift. When they finished they sat around for some social chat and drank green tea from their thermal flasks. He walked home refreshed from the morning’s exercise and social gossips. As he neared home he could hear his grand-daughter practicing the piano. What lovely Mozart! He stepped into the house to find his grandson busy at a Nintendo game.

“Why aren’t you practicing your violin? If you just play computer games, your brain will turn into water.”

His grandson shut down the Nintendo, “Grandma, you should try it some time. It will be good for your brain.”
 “I am too old for it. My brain is all water anyway, according to grandpa!” She just remembered that she had to take her Ginkgo capsules.


The grandson played some scales on the violin and then the Vivaldi A minor. From memory, as that was how he was trained.

At breakfast, the young children listened to Grandpa reciting ancient classical Chinese poems - a long standing family tradition. Soon the grand-children left for school.
Grandma now cracked some walnuts while grandpa got ready to go to the market to see what fresh fish he could buy that day. The walnut was to go with their home reared free range chicken. They grew their own vegetables too.

Later that day they would be having a good game of Mahjong with a retired couple.

Much of what they did would help to maintain their brain fitness.

Ginkgo biloba with its romantic botanical history is no longer the Dementia buster it promised to be. (Those who know of the village in Japan where there are loads of Ginkgo trees could have told you that. The village has the highest Alzheimer rates in Japan.)

I was reminded of Woody Allen’s film, Radio Days, where the young Allen (who else) was brought before the Rabbi by his mother for his advice because Allen was hooked onto the radio. The Rabbi’s skepticism was perhaps not that dissimilar to ours nowadays about iPhones, computer games and brain exercises. Indeed the young Allen should be concentrating on his upcoming Bar Mitzvah and the Torah memorizing.

The Old views on Brain.

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.

If two to four years of “KNOWLEDGE” acquisition can change the size of the brain in a grown adult, what else could we do?

The rest, as they say, is history.



The book covers the changes to the brains of musicians and medical students. It tells us that just three months of memory work can have noticeable effect on the brain of medical students, and music memory work has similar impact on musicians. I was pleased to learn that Bilingualism helps too. From infancy, I and my siblings were brought up with speaking two Chinese dialects at home.

Will medical schools that have abandoned traditional teachings please bring back Anatomy-the old way?

Mozart & 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.

Bridge and Sudoku were mentioned in passing, along with other favourites like crosswords. There is no mention of Mahjong although in the East it is all the rage, nor the memory work required in some religions. Their gods might know a thing or two about the brain.

Mozart's birthday: 27 January 1756


Thursday, July 20, 2017

Proms: Finland & England.

The Proms has just started. And what a start. Sibelius will feature prominently. As the Cockroach Catcher started his listening career on Violin Concertos, it was doubly exciting to hear Lisa Batiashvili’s (1739 Guarneri del Gesu violin) exhilarating Sibelius Violin Concerto.

© 2012 Am Ang Zhang


From Finland:


March 13, 2015
Helsingin yliopisto (University of Helsinki)

Although listening to music is common in all societies, the biological determinants of listening to music are largely unknown. According to a new study, listening to classical music enhanced the activity of genes involved in dopamine secretion and transport, synaptic neurotransmission, learning and memory, and down-regulated the genes mediating neurodegeneration. Several of the up-regulated genes were known to be responsible for song learning and singing in songbirds, suggesting a common evolutionary background of sound perception across species.
Listening to music enhanced the activity of genes involved in dopamine secretion and transport, synaptic function, learning and memory. One of the most up-regulated genes, synuclein-alpha (SNCA) is a known risk gene for Parkinson's disease that is located in the strongest linkage region of musical aptitude. SNCA is also known to contribute to song learning in songbirds.
"The up-regulation of several genes that are known to be responsible for song learning and singing in songbirds suggest a shared evolutionary background of sound perception between vocalizing birds and humans," says Dr. Irma Järvelä, the leader of the study.

In contrast, listening to music down-regulated genes that are associated with neurodegeneration, referring to a neuroprotective role of music.
"The effect was only detectable in musically experienced participants, suggesting the importance of familiarity and experience in mediating music-induced effects," researchers remark.

The findings give new information about the molecular genetic background of music perception and evolution, and may give further insights about the molecular mechanisms underlying music therapy.
                                                      

But:



The Guardian:Why we are shutting children out of classical music.
April 2, 2009 Tom Service is a 33-year-old classical music critic. For 25 years of concert-going he found himself to be amongst the youngest in the audience.

But there is something else that is strange:

“I've noticed that bus and train stations now pipe canned classical music, day-in, day-out, through their speakers as a way of stopping young people hanging around. So toxic have the associations become, that this experiment actually works: there is evidence that playing Beethoven and Mahler has reduced antisocial behaviour on the transport network.”

He went on:

“An entire generation, aged between 10 and 30, seems radically disenfranchised from classical music. How, and when, did this happen?”
Then in Finland:

“A couple of years ago, I saw a class of seven-year-olds in Helsinki enthusiastically learning Finnish and maths by performing sophisticated little songs with astonishing tuning and rhythm. And this wasn't a music school - just a typical Finnish state primary. Finland only developed its curriculum in the postwar period, but it works: today, the Finns are classical music world-beaters, and their education system has produced more great instrumentalists, conductors and composers per capita than any other country on earth.”

Esa-Pekka Salonen is of course the Principal Conductor of the Los Angeles Philharmonic Orchestra and Finland’s most famous music export in recent times.
I was at a concert recently and a large numbers of players in the orchestra were Koreans. Well apart from steel and TV and cars, the Koreans are now into golf and music in a big way. The LPGA is certainly dominated by Koreans. Could it be that music gave them the edge in golf as well, not just the chopsticks?


Tom again:

“Here is a ready-made answer to the problems of renewing classical music's role in society. Make them statutory requirements for every local authority, and give them the responsibility for rebuilding the network of classical musical possibility that used to resound throughout the country.”
And perhaps throw in golf for good measure.

It was in 1990 that American troops played deafening pop and heavy metal music day and night outside the Vatican Mission to Panama City that Noriega surrendered.


In future, this strategy might have to be changed, Beethoven, Mahler and God forbid even Bach.


Tom Service’s last words:


“We've already lost one generation - we can't afford to lose another.”


Old and New: Multiple Sclerosis & Elgar
The Ring: Child Psychiatry & Human Behaviour
Nobel: Kandel and Lohengrin
Lohengrin: Speech Disability, Design & Hypertension
Easter Passion: Bach, Beethoven and Mahler
'The Knowledge' and the Brain


Monday, July 17, 2017

Portraiture: Rule Breaking!

© 1998 Am Ang Zhang
"You must never shoot up the nostrils!"

Strange I should win the Club's Portrait Competition!

Hasselblad/150mm lens.

Film: Kodax TMax 100

Printed on Record Rapid paper/ Selenium Toned

Selenium Toning is for archiving prints and imparts a lovely tone depending on concentration.


Link: Silverprint
Photography:

Monday, July 10, 2017

Pre-Raphalites & GBM!

The Art Institute of Chicago has quite an interesting collection. What caught my eye the other afternoon was a Pre-Raphaelite, well one of three that Rossetti did and the original I believe was in the Tate, London.

Beata Beatrix, 1871/72
Art Institute Web Site


A founder of the Pre-Raphaelite Brotherhood, Dante Gabriel Rossetti was both a poet and a painter. In this picture, he portrayed the dying Beatrice from Dante Alighieri’s Vita nuova, a medieval tale of idealized love and loss that had personal meaning for Rossetti, who had lost his wife, the artist Elizabeth Siddal, in 1862. He began the first version of the work, now in the Tate Gallery, London, in 1864, after finding an unfinished oil sketch that he had made of Siddal. The Art Institute’s painting is one of two replicas of the Tate composition, but it is the only one with a predella, the small panel at bottom showing the final meeting of Dante and Beatrice in paradise.

Pre-Raphalites reminded me of our librarian.

She and her husband retired to Dorset and one year we decided to visit their new place and have a taste of the old England they have always raved about. They were from Sheffield but spent a lot of their live there before moving to Sussex. So it was a bit like returning home.
They proudly showed us the guest room because it was decorated with some of the last scrolls of William Morris wall paper that they happened by.

How charming.

After dinner the conversation somehow turned to the Pre-Raphaelites and our librarian promptly produced a book with an amazing painting on its cover.

In a chance encounter with Andrew Lloyd Webber, Josceline Dimbleby asked him bluntly if she could go and see the portrait he had of her great-aunt, Amy Gaskell.

“Ah, that wonderful dark picture,” Andrew said. “Yes, please come……Well, I think she looks rather like you......”

“Did you know that she died young?” Josceline asked Andrew.

“Of a broken heart.”

She told Andrew that she would try to find out more. This led her to start researching into the life of Amy, her mother May and the famous Pre-Raphaelite painter Edward Burne-Jones and the result was the book A Profound Secret[1].

I looked at the book cover and thought the portrait reminded me of the Picasso I used for my Anorexia Blog.

It is said that as a young man Picasso admired the pre-Raphaelites and Edward Burne-Jones so much that in 1900 he would have gone to London rather than Paris had he had the fare.

“There was a hint in the book that she might well have died of Anorexia!” My hostess said.

It was a fascinating book, like good family biographies are, as long as you accept that it is not going to be as organised as fiction. A good writer helps and Josceline Dimbleby is a well established food and travel writer.

For a psychiatrist, it is especially interesting as he is allowed glimpses into the various personalities, their psychiatric problems and the resulting family dynamics, without the interference of the usual psychiatric labelling or coding. Unfortunately self medicating with alcohol, opium and other fancy substances was rife in that era (and perhaps now too) and the result could often be tragic.

Indeed Josceline thought at one point in the book that Amy might have suffered from Anorexia although it was not a known condition at the time. She left it till the end of the book to let us into the final secret. You will have to find out for yourself.


Without the effect of drugs that would double the bodyweight, we have in the end one of the most beautiful portraits of the Pre-Raphaelites. Burne-Jones’ life is of course another psychiatric book: his mother died when he was six days old and many felt that all his life he was searching for the perfect mother he so missed. It is indeed ironical that the art world has been much enriched by what was essentially untreated bereavement.
Psychiatry may need to look again at what we have been doing, as we do not seem to have found another Burne-Jones.


[1] http://www.amazon.com/Profound-Secret-Gaskell-Daughter-Burne-Jones/dp/0385603231


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 our librarian, 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.

Nothing.

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.               


Glioblastoma Multiformis (GBM)

In 2013, I came across an article in the Washington Post[1] about none other than a doctor that was diagnosed with the condition. But his story took a bit of a twist that my further research was to reveal.

When we met our librarian, she told me that the hospital neurosurgeon had also been diagnosed with GBM. He has now retired and is being treated at Queens Square where he trained.

Then another London doctor friend, a paediatric cardiologist has also been diagnosed with the condition. He decided to move back to Hong Kong to be treated, yes by his old Medical School.

Since it has been quite a few decades since I was at Queens Square, I was desperately searching for any information I could find.

Is it an infectious condition? Why all the people I know are linked to hospitals. Could we have a Dr House style brain storming. Is there any modern treatment as I vaguely remember it as one of the most vicious brain tumours.

OK,  Senator Kennedy has no hospital link, except for treatment there.

But lets see what our doctor/patient found:

Why me[2]?
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.

Well, I think that is as far as we can go on the hospital link. What about others.

Sharp eyed readers reading Anderson’s article would have noticed that it opened with some detail that he did not quite link to his condition but further research revealed some interesting findings.

I have always maintained that in ancient times, there are very observant people that noticed links that few people would have noticed. In order to drive fear into people for their own protection, these observations were somehow incorporated into religious believes.

Yes: Pork[3].
I also had a blood test for cysticercosis, an infection that results from eating undercooked pork contaminated with Tenia 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.

He obviously did not relate Tenia solium to GBM, but my further research showed something rather extraordinary.

There has indeed been case reports of neurocysticercosis[4] associated with GBM. This would now explain what Dr. Anderson reported as a by-line. There is even a case of both husband and wife “catching” GBM[5] and to me Tenia solium infection would be the natural explanation.

Then I discovered something quite shocking: Tenia infection can occur in Orthodox Jews[6]. No, I do not think they secretly eat pork, but apparently they can catch it from nannies from endemic countries.

But the main exciting part of Dr. Anderson’s article was his treatment when the traditional one failed.

It was the use of a modified Poliovirus Vaccine at Duke[7] that attracted his attention.

DURHAM, N.C. – An attack on glioblastoma brain tumor cells that uses a modified poliovirus is showing encouraging results in an early study to establish the proper dose level, researchers at Duke Cancer Institute report.

The treatment, developed at Duke and tested in an ongoing phase 1 study, capitalizes on the discovery that cancer cells have an abundance of receptors that work like magnets drawing the poliovirus, which then infects and kills the cells.

He decided to have the treatment and two years later he appeared on a CBS 60 minutes about the new treatment[8].

Part of the transcript:

Dr. Fritz Andersen showed us the results in another patient -- himself. He's a retired cardiologist and at age 70, he became the second person in the polio trial.

Dr. Fritz Andersen: This is a fairly sizeable temporal tumor, which means...

Scott Pelley: That we see right here.

On the left is his tumor before treatment, on the right a hairline scar where it used to be. Like Stephanie, that was nearly three years ago.

Dr. Fritz Andersen: So when they said that this thing is just a small scar, and we think it's possibly cured. I nearly fell off my chair. I said, "that's, that's, that's impossible." They said, "well, we don't know, but so far it looks fantastic."

Scott Pelley: Do you consider yourself cured? Or do you call it remission?

Dr. Fritz Andersen: I feel it is a cure, and I live my life that way.

Well, he has done well, both our Librarian and the Paediatrician that returned to Hong Kong did not make it.

 




[1] https://www.washingtonpost.com/national/health-science/surgery-radiation-and-chemo-didnt-stop-the-tumor-but-an-experimental-treatment-did/2013/09/23/1b8e8f92-0f4f-11e3-85b6-d27422650fd5_story.html?hpid=z9
[2] https://www.washingtonpost.com/national/health-science/surgery-radiation-and-chemo-didnt-stop-the-tumor-but-an-experimental-treatment-did/2013/09/23/1b8e8f92-0f4f-11e3-85b6-d27422650fd5_story.html?hpid=z9
[3] And the pig, because it has a cloven hoof that is completely split, but will not regurgitate its cud; it is unclean for you. You shall not eat of their flesh, and you shall not touch their carcasses; they are unclean for you.

[4] http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3579054/
[5] http://www.ncbi.nlm.nih.gov/pubmed/24348390
[6] http://www.nejm.org/doi/full/10.1056/NEJM199209033271004
[7] http://bit.ly/20fFFVy
[8] http://cbsn.ws/1BUFFvc