Saturday, December 10, 2016

Specialism & Neurology: Generalism & Integration!

After my recent visit to Vietnam a book I have been looking forward to became available, and what a read.


Ha Long Bay, Vietnam © 2016 Am Ang Zhang
"......It was only in the late 1970s that the power of this integrative idol manifested. It was a period, historian Paul Forman has observed, that began embracing a culture that worshiped technology, multidisciplinarity, and entrepreneurialism. At precisely this moment of cultural conjuncture, at the moment when neuropharmacology, scanning technologies, and biomolecular science also began to give very real shape to neuroscience and neurobiology and began as well to vest neurology with wholly new understandings of the nerves in sickness and in health, neuroculture began to reframe human self-understanding. ‘The fundamental justification’, as authors of a report for the US National Academy of Sciences for Manpower in Basic Neurologic and Communicative Sciences put it, ‘is that basic insights into neuroscience constitute one of the major scientific achievements of contemporary civilization. Neurology’s long legacy of definitional ambiguity, the propensity of its practitioners for generality, their obvious interests in psychiatry and physiology, and their long history of engaging evolutionary theory had thus served up the feast of arguments, tropes, and rhetorical devices that would feed the appetites of the ‘cerebral subject’ and the Huxlian ‘neurochemical self ’.74
In short, after the Second World War, people figuratively became their brains. They dreamed of and then manufactured extended minds. They used neuroscience to question personhood, behavioural economics, animal-hood, gender, diversity, and even to recast ‘man as machine metaphors’ into new forms. Mind became a digital product of matter; the brain became a computer; the nerves – picking up on an old refrain – became cyber-networks. Snails made manifest the mechanisms of memory. Florescent proteins embedded addiction into the reductive substance of the cell membrane. The brain became a cultural refrain. And many educated people believed it, and many uneducated and young people practised reiterating it. The brain was its own justification. It was civilisation.
Any number of figures in the history of science and medicine could be claimed to have constructed this neurologic metanarrative. Given its claims to historical transcendence, it is easy to imagine as well that any number of figures could be reconstructed in hindsight as the heroes who constructed this new cultural understanding. Yet it was the neurologists who made this world. Indeed, it was the Jacksonian ideal that would ultimately underpin the emergent logic of neuroculture. It was the neurologists, among the physicians, who were most ‘fully engaged in the philosophical status of man’.75 And while that story was not solely a British one, it was nevertheless the British neurologists who resisted the inexorable trends of rational modernity, of progressive administration, and who held on to the promise of generality and catholicity, and defended a world of Newtons and Darwins and a tradition of Jacksons and Sherringtons against a world of normal science and its would-be tradition of scriveners.
What then was the ‘neuro’ in neurology as the British neurologists understood it? If it was a tradition of generalism and integration, and hero worship too, then it was also a powerful and transformative cultural discourse. It was one that borrowed heavily from artistic and literary currents even as it transformed those movements. It was a discourse that saw in the action of disease a new understanding of the living subject, being, and knowing. It drew heavily upon evolutionary theory. And it eventually reforged the essence of humanity into a story of gene regulation, neurotransmitters, membrane physiology, nerve impulses and synaptic transmission. Accordingly sleep, pleasure, pain, memory, language, even fighting and fleeing, became the stuff of central nervous system organisation and limbic systems. It was, in other words, a particular strand of British neurology that provided neuroculture with its essential shape, integrative social structure, and, alas, also laid the foundations for the now-emergent hegemony of the brain and nerves......"                  Stephen T. Casper
© 2016 Am Ang Zhang
Museum of Science, Boston.
"....While Leonardo da Vinci is best known as an artist, his work as a scientist and an inventor make him a true Renaissance man. He serves as a role model applying the scientific method to every aspect of life, including art and music. Although he is best known for his dramatic and expressive artwork, Leonardo also conducted dozens of carefully thought out experiments and created futuristic inventions that were groundbreaking for the time.

His keen eye and quick mind led him to make important scientific discoveries, yet he never published his ideas. He was a vegetarian who loved animals and despised war, yet he worked as a military engineer to invent advanced and deadly weapons. He was one of the greatest painters of the Italian Renaissance, yet he left only a handful of completed paintings...."



Nobel Laureate: Eric Kandel’s recent book The Age of Insight.



"....In many respects, The Age of Insight imitates those famous Viennese salons, in which artists, scientists and doctors exchanged ideas and gave birth to a new way of thinking about the mind."  Wired


The current Dean of my Medical School is a Conductor as well:

"....As an educator, his pedagogical philosophy of a renaissance education for all young people, with music as a medium to develop intellectual, social and emotional qualities have won praises from students and parents alike."


I have no doubt in my mind that doctors and scientists should embrace art to become better doctors and scientists.

Thursday, December 8, 2016

Autumn Sale: NHS Hospitals!!!

Autumn is here and time may be running out for our NHS Hospitals!


© 2011 Am Ang Zhang



Looks as though the following might be surplus to requirements by the new NHS, as it was decreed that clients or service users do not really need hospitals.

The Background:
Historically, London Medical Schools were established in the hospitals in the poorer areas in order that medical students could have enough cases to practice on and in return the poor patients had the advantages of free treatment. There is nothing like volume for medical training.

For a very long time, doctors trained in London were one of the most valued. A Senior Registrar (yes, in those days) can easily get a Consultant job anywhere else in the Commonwealth and often a Professorship (British styled ones). In other words London trained doctors are a highly exportable commodity.

“The shape of the London hospital system has also been affected by developments in medical science and medical education. In many ways it has been the activities of doctors which have determined the pattern of the hospitals. The increasing ability to treat disease and improved standards of care shortened the time patients spent in hospital, raised the demand for services and led to an escalation of cost. The development of specialisation led first to the development of the special hospitals and later to special departments within the general hospitals. Advances in bacteriology, biochemistry, physiology and radiology cre­ated the need for laboratory accommodation and service departments, so that hospitals no longer consisted merely of an operating theatre and a series of wards. Sub-specialisation ultimately meant that services had to be organised on a regional basis and the very reputation of the capital’s doctors affected the number of patients to be seen. The hospitals of central London have long served a population much larger than their local residents.

It is against this complex background of population movement, poor social conditions, disease, wealth and poverty, professional expertise, critical comment and publicity that the London hospitals developed. A complex institutional pattern emerged. Voluntary hospitals grew up beside the ancient royal and endowed hospitals. A local government service providing institutional care for sick paupers developed alongside the hospitals. A network of fever hospitals, scientifically planned from the outset, was established. Physically near to each other, staffed by doctors who had trained in the same hospitals, and often serving the same people, the different objectives and status of the institutions led them to work in virtual isolation from each other. Each hospital had its own traditions and nobody standing in the middle of a ward could have doubted for a moment the type of hospital he was in. Countless details gave each an atmosphere of its own, and the different methods of administration and levels of staffing set them apart.”                  Geoffrey Rivett





Most of my Medical School Orthopaedic Surgeons were trained here.

The hospital treats almost 10,000 patients a year.

Although most patients would not consider travelling too far for a routine hip replacement, which can probably be done as well in their local district general hospital, the specialist clinics at the Royal National Orthopaedic may provide a reason to make the journey.

Specialist clinics deal with bone tumours, scoliosis (curvature of the spine), rheumatology, spinal injuries, specialist hand and shoulder conditions and sports injuries.

One word of warning – the RNOH's trust did not do well in the Healthcare Commission annual health check.

Strange that. So it may be the next to go.


The Cockroach Catcher was there.

So was the MP, as a patient.

If you have a head injury, stroke or condition affecting the brain, such as Alzheimer's, epilepsy or multiple sclerosis, this is the place to go. Along with the nearby Institute of Neurology, it is major international centre for treatment, research and training. The National Hospital for Neurology and Neurosurgery has 200 beds at its central London site near Euston station, and treated more than 4,500 in-patients and 54,000 outpatients last year.

Healthcare Commission quality of services rating: Good

Perhaps not for sale so soon. Or saving it for the needy MPs?

Neurologists wear bow ties in my days.


The largest specialist heart and lung centre in the UK, the Royal Brompton and Harefield acquired its reputation through the work of Sir Magdi Yacoub, the internationally renowned surgeon who pioneered heart transplants in theUK the 1980s.

The trust attracts staff and patients from across the country and around the globe, and is a centre for research with between 500 and 600 papers published in scientific journals each year. Its 10 research programmes each received the highest rating in 2006.

Each year, surgeons perform 2,400 coronary angioplasties (where a balloon is threaded through an incision in the groin to the heart and expanded to widen a blocked artery), 1,200 coronary bypasses and 2,000 treatments for respiratory failure – so they do not lack for experience.

Other specialist heart units with strong reputations are Papworth Hospital, Huntingdon, where Britain's first successful heart transplant was carried out in 1979; and the Cardiothoracic Centre, Liverpool, formed in 1991.

Healthcare Commission quality of services rating: Good

It could not be anything else.


The first dedicated cancer hospital in the world, founded in 1851, is still the best. With the Institute of Cancer Research, the Royal Marsden is the largest comprehensive cancer centre in Europe, seeing more than 40,000 patients from the UK and abroad each year.

It has the highest income from private patients of any hospital in Britain, testifying to its international reputation.

Very ready for Medical Tourism!!!

Healthcare Commission quality of services rating: Excellent





The country's largest ear, nose and throat hospital is also Europe's centre for audiological research, with an international reputation for its expertise and range of specialties, all on one site on London's Gray's Inn Road.

Its services range from minor procedures such as inserting grommets (tiny valves placed in the eardrum of a child to drain fluid from the middle ear) to major head and neck surgery. A quarter of its 60,000 patients were referred from other parts of the UK and abroad last year. The hospital has a cochlear implant programme, a snoring and sleep disorder clinic, and a voice clinic, the oldest and largest in the UK. One in 25 people develops voice problems such as hoarseness, but it rises to one in five among, for example, teachers, actors and barristers.

A measure of the Royal National's success is the fact that one third of patients referred from other clinics or hospitals with voice problems has their diagnosis changed on investigation there. Although there are many other centres where throat, nose and ear problems can be treated, none are pre-eminent enough to be included in this guide.

Wow!

Healthcare Commission quality of services rating: Good

Britain's leading national and international referral centre for diseases of the bowel is the only hospital in the UK and one of only 14 worldwide to be recognised as a centre of excellence by the World Organisation of Digestive Endoscopy.

It is a chosen site for the NHS bowel-cancer screening programme being rolled out across the country, which seeks to detect and treat changes in the bowel before cancer develops. Bowel cancer is the second most common cause of cancer in the UK but often goes undetected because sufferers can fail to report important symptoms, such as blood in the faeces, often out of embarrassment.

Bowel cancer can be treated via colonoscopy, to find and remove polyps – growths on the wall of the bowel. The hospital's education programme attracts clinicians from across the UK and overseas with the aim of spreading good practice elsewhere.
The hospital is part of the North West London Hospitals Trust.


The liver unit at King's is the largest in the world. It is one of 31 specialist liver units in the UK, but none can match it for expertise, facilities or state of the art equipment. It offers investigation and treatment for all types of acute and chronic liver disease, which is increasing in the UK.

The unit performs 200 liver transplants a year, and more than 200 patients with liver failure are admitted to its intensive care unit each year.

King's carried out the first successful transplantation of islet cells – part of the pancreas involved in producing insulin – in a Type 1 diabetic, greatly reducing his need for injected insulin. Last month, the Department of Health announced plans to establish six new islet transplantation centres round the country, based on the research at King's.

Healthcare Commission quality of services rating: Excellent


No bargain price, I am afraid.

The Maudsley Hospital

The Cockroach Catcher was there too.

One of Britain's oldest hospitals, the Maudsley's contribution to mental-health care stretches back at least 760 years.

Today it is a centre of excellence for the delivery mental-health care. Its addictions centre offers new treatments for drug abuse, alcoholism, eating disorders and smoking, it provides innovative care for disturbed children and adolescents and is the largest mental-health training institute in the country.

It has pioneered new approaches to the treatment of heroin addiction and its specialists have raised concerns over the link between cannabis and schizophrenia which have led the Government to review changes to the law.

Healthcare Commission quality of services rating: Good




If you have a child with a rare or complicated disorder, this is the place to come.

And they do and many are from the Middle East.

So the bad press would not matter, good for the Medical Tourist trade.

It is the largest centre for research into childhood illness outside the US, the largest centre for children's cancer in Europe and delivers the widest range of specialist care of any children's hospital in the UK.

Great Ormond Street won't treat just any patient, though: it only accepts specialist referrals from other hospitals and community services – in order to ensure it receives the rare and complex cases and not the routine.

I have done that: see Teratoma: An Extract


Paediatrics is one of the most rewarding areas of medicine for doctors because it has seen some of the most spectacular advances over the past 30 years, especially in cancer, where survival has improved dramatically.

Many of those cared for at GOSH still have life-threatening conditions but they are promised the best care both because of the expertise of its medical staff and because of the trust's extraordinary success in attracting charitable donations, which have made it among the best-funded medical institutions in the country.

Healthcare Commission quality of services rating: Excellent.

Baby P or no Baby P.


My eyes still well up when Moorfields is mentioned. Honest.

The largest specialist eye hospital in the country and one of the largest in the world, Moorfields was founded in 1805. It treats more patients than any other eye hospital or clinic in the UK and more than half the ophthalmologists practising in the UK have received specialist training at Moorfields.

However, in recent years the hospital has relied too heavily on its reputation and grown complacent. Though standards of academic excellence are still high, it has neglected the services it offers to patients, which were rated weak on quality by the Healthcare Commission in its annual health check last year.

The hospital carried out 23,000 ophthalmic operations last year, providing surgeons with extensive experience on which to hone their skills. The reputation of the trust is such that it has started to run clinics in distant hospitals, capitalising on its brand. The hospital employs 1,300 staff who work on 13 sites.

Perhaps it is not so good to be following on commercial branding. Stick to medicine!!!

Despite its recent problems, Moorfields remains Britain's most highly-regarded eye treatment centre. No alternative hospitals have a comparable reputation.
Healthcare Commission quality of services rating: Weak

For bargain hunters then.


Material drawn from The Independent.


So do you really think that hospitals are not necessary, or not necessary for the average citizen of England. Soon they will be sold and it will be costly to buy them back.

What about medical training? If these hospitals are sold, who pays?

And watch out, someone, your parent, your spouse, your child and even your MP may need a Hospital Consultant one day. 

Say something now.


Cassius:
"The fault, dear Brutus, is not in our stars,
But in ourselves."
Julius Caesar (I, ii, 140-141)

Patagonia & Nudibranch: Einstein, Music & Memory!



©2015 Am Ang Zhang

No I did not do any diving in Patagonia!


We were having dinner at our Ecocamp in Patagonia with a very interesting couple.
The husband is aiming to climb the Matterhorn and somehow in the conversation we talked about their other adventures that included Diving. I show them some of my underwater pictures. Somehow Nudibranch was mentioned and as it turned out we exchange email addresses and became good friends.

Nudibranch reminded me of Aplysia and Kandel:







Nudibranch © 2009 Irene Man


Nudibranch is so named because of its naked gills.
Here is a description in The National Geographic:

Nudibranchs crawl through life as slick and naked as a newborn. Snail kin whose ancestors shrugged off the shell millions of years ago, they are just skin, muscle, and organs sliding on trails of slime across ocean floors and coral heads the world over.

Found from sandy shallows and reefs to the murky seabed nearly a mile down, nudibranchs thrive in waters both warm and cold and even around billowing deep-sea vents. 


So why, in habitats swirling with voracious eaters, aren't nudibranchs picked off like shrimp at a barbecue? The 3,000-plus known nudibranch species, it turns out, are well equipped to defend themselves. Not only can they be tough-skinned, bumpy, and abrasive, but they've also traded the family shell for less burdensome weaponry: toxic secretions and stinging cells. A few make their own poisons, but most pilfer from the foods they eat. Species that dine on toxic sponges, for example, alter and store the irritating compounds in their bodies and secrete them from skin cells or glands when disturbed. Other nudibranchs hoard capsules of tightly coiled stingers, called nematocysts, ingested from fire corals, anemones, and hydroids. Immune to the sting, the slugs deploy the stolen artillery along their own extremities.


Memory & Knowledge: Talmud & Taxi

In 2001 I was fortunate enough to be in New Orleans for the American Psychiatric Association Annual Conference. One of the lectures attracted a long queue and it turned out that the Nobel Laureate Eric Kandel was giving his lecture. I was fortunate enough to be able to secure a seat.

"Different forms of learning result in memories by changing that strength in different ways. Short-term memory results from transient changes that last minutes and does not require any new synthesis of proteins, Kandel said. However, long-term memories are based in more lasting changes of days to weeks that do require new brain protein to be synthesized. And this synthesis requires the input of the neuron’s genes." Eric Kandel.

In his book In Search Of Memory, he remembered his arrival in New York in 1939 after a year under the Nazi in Vienna:

“My grandfather and I liked each other a great deal, and he readily convinced me that he should tutor me in Hebrew during the summer of 1939 so that I might be eligible for a scholarship at the Yeshiva of Flatbush, an excellent Hebrew parochial school that offered both secular and religious studies at a very high level. With his tutelage I entered the Yeshiva in the fall of 1939. By the time I graduated in 1944 I spoke Hebrew almost as well as English, had read through the five books of Moses, the books of Kings, the Prophets and the Judges in Hebrew, and also learned a smattering of the Talmud.”

Eric Kandel/Amazon


“It gave me both pleasure and pride to learn later that Baruch S. Blumberg, who won the Nobel Prize in Physiology or Medicine in 1976, had also benefited from the extraordinary educational experience provided by the Yeshivah of Flatbush.”

In Hebrew and English!!! That did not seem to have done him and Blumberg much harm. Right now some governments seem hell bent in doing away with rote learning and that includes some medical schools.

Lord 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.


Knowledge:

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 license 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.

Music, poetry & anatomy:

Playing musical instruments requires both manual dexterity and memory work, and musicians are often good mathematicians, possibly because of the proximity of the areas in the brain for these functions, although it may not be that clear cut. Making children recite poems is not a bad idea either, nor indeed the study of Latin, or anatomy work for medical students, as these activities all help to exercise their brain.
Einstein loved his violin!

He played the violin with passion and often performed at musical evenings. He enchanted audiences, particularly women, one of whom gushed that "he had the kind of male beauty that could cause havoc."

He also empathized with Mozart's ability to continue to compose magnificent music even in very difficult and impoverished conditions. In 1905, the year he discovered relativity, Einstein was living in a cramped apartment and dealing with a difficult marriage and money troubles.

That spring he wrote four papers that were destined to change the course of science and nations. His ideas on space and time grew in part from aesthetic discontent. It seemed to him that asymmetries in physics concealed essential beauties of nature; existing theories lacked the "architecture" and "inner unity" he found in the music of Bach and Mozart.

In his struggles with extremely complicated mathematics that led to the general theory of relativity of 1915, Einstein often turned for inspiration to the simple beauty of Mozart's music.

"Whenever he felt that he had come to the end of the road or into a difficult situation in his work, he would take refuge in music," recalled his older son, Hans Albert. "That would usually resolve all his difficulties."


Now lessons in music instruments are no longer offered in most state schools in the U.K., nor is Latin. Medical schools are moving away from rote learning. Good intentions may indeed have major drawbacks that could affect generations to come.

By the way, if you have been trained to have a good memory, that ability will transfer easily to the remembering of the taste of wine! Think about it, the brain is very economical in its application, and is still the best computer around.

Mmmm….perhaps that is why two of my friends started learning the piano when they retired. And they joined wine clubs too. They too might know a thing or two.

If we want our children to have a future, bring back music, rote learning and poetry, and let medical students toil through anatomy.

For us, learn a new instrument & drink wine!