Sunday, July 30, 2017

Medicine & Orthodoxy: Heresy & Knowledge!


It is often inconceivable that a small bird of the warbler family can play host to the Cuckoo, which obviously outsizes it by at least three to four times.


Collared Redstart©2008 Am Ang Zhang
This picture was taken in Panama, famed for the abundance of different bird species and as far as I know there are 14 species of Cuckoos in the country.

“It is as foolish to chuck out the old as it is to fully embrace the new.” 

My early guru was referring to the changes happening in the field of psychiatry as the new benzodiazepines were being introduced. How right he was and the same view could well apply to other branches of medicine as well as psychiatry today.

“There is much we can learn from the past. One may even save a life.” 
A Brief History of Time: CPR (Cardiopulmonary Resuscitation)
We have come full circle to some ancient Chinese CPR practice going as far back as 403 B.C.




I mentioned in passing in my book “The Cockroach Catcher” Jenner’s observation and the stir it caused. When I visited his home in Glouscestershire, the curator of the small museum, who was extremely knowledgeable, took pride in telling us how Jenner’s great work on Cowpox vaccination upset the medical establishment on the one hand, and how his observation on the murderous ways of the Cuckoo newborns upset the gentlemanly world of the Ornithologists on the other. It was the Royal Society that awarded him a Fellowship for his keen observation.


©2015 Am Ang Zhang
His work on Cowpox vaccination in the prevention of Smallpox was met with hostile responses. The medical world that was dominated by London at the time could not accept that a country doctor had made such an important discovery. Jenner was publicly humiliated when he brought his findings to London. However, what he discovered could not be denied and eventually his discovery was accepted – a discovery that was to change the world.


It is worth having another look at Brian Martin’s view on:
Dissent and heresy in medicine.
 

Social Science and Medicine, vol. 58, 2004, pp. 713-725.

Brian Martin is Professor of Social Sciences in the School of Social Sciences, Media and Communication at the University of Wollongong, Australia.

Brian uses models on politics and religion to illustrate the model of orthodoxy versus dissent/heresy. You can read his views here.

He noted that challenges from the inside - heresy and dissent - are far more threatening to an establishment than outside challenges. This is true of all establishments, not least medicine.

But why should it be? In a more co-operative environment, these differences become opportunities for learning. Medicine in particular will not progress if all dissenting views are suppressed and smallpox may have indeed killed for another 20 or 30 years or more.

After the discussion on politics and religion he turned his focus medicine.
He then analysed some methods of domination in medical research:


• State power
• Training
• Restriction on entry
• Career opportunities
• Research resources
• Editorial control
• Incentives
• Belief system
• Peer pressure


“Training to become a doctor is a process of enculturation and indoctrination. The heavy work-load of memorisation and intensive practical work discourages independent thinking.”

“Examinations provide a screening process that encourages orthodoxy. For those who pursue a research path through the PhD, the process of writing a thesis or dissertation further weeds out those who might challenge orthodoxy. Some dissidents and even fewer heretics may slip through the training and credentialing system, but then there are few desirable career paths.”

“In order to have a chance, dissidents and heretics need to understand that science and medicine are systems of knowledge intertwined with power, and that if their alternative relies entirely on knowledge, without a power base, it is destined for oblivion.”

FremantleMedical Heresy & Nobel

Peptic ulcer – an infectious disease!
In 2005, Nobel Prize in Physiology or Medicine went to Barry Marshall and Robin Warren, who with tenacity and a prepared mind challenged prevailing dogmas. By using technologies generally available (fibre endoscopy, silver staining of histological sections and culture techniques for microaerophilic bacteria), they made an irrefutable case that the bacterium Helicobacter pylori is causing disease. By culturing the bacteria they made them amenable to scientific study.
In 1982, when this bacterium was discovered by Marshall and Warren, stress and lifestyle were considered the major causes of peptic ulcer disease. It is now firmly established that Helicobacter pylori causes more than 90% of duodenal ulcers and up to 80% of gastric ulcers. The link between Helicobacter pylori infection and subsequent gastritis and peptic ulcer disease has been established through studies of human volunteers, antibiotic treatment studies and epidemiological studies.
Difficult 10 years:
The medical establishment was difficult to persuade - everyone accepted that ulcers were caused by acid, stress, spicy foods, and should be treated by drugs blocking acid production. The big Pharmas were not happy to see any change as patients will have to take medication for life.


He went to the US to try and persuade the US doctors.

A big battle was still going on. I went to America to fight the battle there, because unfortunately the American medical profession was extremely conservative: ‘If it hasn’t happened in America, it hasn’t happened’. We needed people in the United States to take the treatment which we had developed.



“Ideas without precedent are generally looked upon with disfavour 
and men are shocked if 
their conceptions of an orderly world are challenged.” 

Bretz, J Harlen 1928. Dry Falls-Thinking Outside The Box


Also, thinking out of the box can be a good idea. Sometimes it’s better not to know all the dogma, all the things about a very difficult disease. If it’s very difficult, that means people have been working on it for years and they haven’t figured out the cure, which means they haven’t figured out the cause. So having all that knowledge that’s been accumulated in the last 10 or 20 years is really not an advantage, and it’s quite good to go and tackle a problem with a fresh mind when no-one else has had any luck.
                                                                                      Barry Marshall




From a doctor friend:

The Cockroach Catcher has evoked many images, memories, emotions from my own family circumstances and clinical experience.

Your pragmatic approach to problem solving and treatment plans is commendable in the era of micro-managed NHS and education system. I must admit that I learn a great deal about the running of NHS psychiatric services and the school system.

Objectively, a reader outside of the UK would find some chapters in the book intriguing because a lot of space was devoted to explaining the jargons (statementing, section, grammar schools) and the NHS administrative systems. Of course, your need to clarify the peculiar UK background of your clinical practice is understandable.

Your sensitivity and constant reference to the feelings, background and learning curves of your sub-ordinates and other members of the team are rare attributes of psychiatric bosses, whom I usually found lacking in affect! If more medical students have access to your book, I'm sure many more will choose psychiatry as a career. The Cockroach Catcher promotes the human side of clinical psychiatric practice in simple language that an outsider can appreciate. An extremely outstanding piece of work indeed.           More>>>>

The Cockroach Catcher on Amazon Kindle UKAmazon Kindle US

Thursday, July 27, 2017

The Hong Kong Paradox: Poor Air Quality & Longevity.


We all know about the French Paradox by now and basically, by right the French for what they eat should have the highest heart disease rates despite their fondness of cheeses and dare we mention Foie Gras. At least we now have some idea that it was the trans fat that is the culprit. Then there was a hint that it could be the red wine and when a programme was shown in the US, within a year, red wine sale went up 44%. The rest as they say is history.

What about the Hong Kong Paradox?

No, I am not talking about SIDS, yes, it was a bit of a paradox. Nor am I talking about the low infant mortality rate of 1.3 per thousand. That would be seen as a paradox from the point of view of countries like US or UK. Well the paradox is that the doctors used to be trained in specialism in the UK.

But unlike red wine, I doubt if anyone is going to take up this paradox.

On a good day in Autumn© 2013 Am Ang Zhang

As China is now the main manufacturing country for the rest of the world, it is only obvious that its factories pump out all sorts. Hong Kong in the autumn and winter months suffer from serious air pollution. Every medical research would confirm your suspicion, it is bad for health. But wait:


Hong Kong’s women and men enjoy the longest life expectancy in the world, according to data released by Japan’s health and welfare ministry on Wednesday.

The average lifespan for women in Hong Kong is 87.32 years, and local men on average can expect to live to 81.24. Japanese women took second place at 87.05, while Icelandic and Swiss men shared the second position in the men’s category at 81 years.

The overall life expectancy gap between women and men fell by 0.07 year last year, compared with the previous year’s figures.

Polluted air anyone? Good for longevity.



The famous new bridge in Autumn © 2013 Am Ang Zhang
By the way, there is no tax on wine in Hong Kong. Perhaps that is why!!!

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