Goethe & Bipolar: Werther or Lithium!

©2014 Am Ang Zhang

The Cockroach Catcher could not miss the great opportunity to see a new production of Werther at the Met.

The 5 hour wait for the day ticket was worth it as one gets to chat to other opera lovers. One originates fromPoland and he managed to get to Bayreuth after a good seven years. Another one tries to be there twice a week during the season.

The Metropolitan Opera in New York offers 150 day tickets and some at the front have been there since 9.30 in the morning.

Even Goethe admitted that killing Werther probably saved him. He completed The Sorrows of Young Werther in just 6 weeks perhaps in a fairly manic phase and established himself as Germany's foremost writer.

Sophie Koch, left, as Charlotte and Jonas Kaufmann in the title role in "Werther" at the Metropolitan Opera.CreditSara Krulwich/The New York Times

The Massenet Opera had one of top tenors Jonas Kaufmann singing Werther and Sophie Koch, Charlotte. The days of fat ladies are probably over as the new breed of female singers are slim and beautiful with very high quality singing to match. One cannot say as much for tenors and so it was such an experience to hear Kaufmann who suited the role perfectly.

Kaufmann in an interview agreed that Goethe probably would have been medicated nowadays.

Lithium perhaps.

 

Just as well it never happened.

 

Jonas Kaufmann in the title role of 'Werther' at the Metropolitan Opera (Brigitte Lacombe/The Metropolitan Opera)

"The greatest tenor of today": Jonas Kaufmann in the Met's new production of "Werther"

„... currently the most in-demand, versatile and exciting tenor in opera. …. To be a great Werther, a tenor must somehow be charismatic yet detached, vocally impassioned yet ethereal. Mr. Kaufmann is ideal in the role. He sings with dark colorings, melting warmth, virile intensity and powerful top notes. There is a trademark dusky covering to his sound that lends a veiled quality to Mr. Kaufmann’s Werther and suits the psychology of the character.”

Anthony Tommasini, New York Times

 

Jonas Kaufmann

Interviews :    1, 2

The Book: The Cockroach Catcher

Lithium Bipolar and Nanking
Bipolar Disorder: Lithium-The Aspirin of Psychiatry?

Other Opera Posts:

NHS: Learning From Boris

The Dark Side: Il Trovatore
Illness and Morality

Doctor Atomic

Lunar Eclipse
Lohengrin: Speech Disability, Design & Hypertension 

Bayreuth: The Ruling Class & Photography

Bright Young Thing: Medicine or Opera!

Peter Grimes: the individual against the ...

ROH: Lulu & Booing

Kandel & Lohengrin: Music & Brain

Capriccio: Poetry or Music

Doctor Atomic

The Ring: Child Psychiatry & Human ...

NHS Must Strike Back: BUPA & Health Insurers!

How the NHS must strike back!!!

1: Legislate that Insurers must pay for NHS treatment.

2: Offer Cappuccino/Green Tea if patients provide BUPA or other insurance details.

3: Patients will still be allowed to be paid by BUPA. Ha!

"In fact, to save money, government can buy insurance 

for 

the mental patients and the chronically ill."

 ©2016 Am Ang Zhang

BUPA is right now paying insured to use NHS!!!

The official letter from Bupa detailing the scheme is headlined: “Giving our members improved choice.”

The patient, speaking on condition of anonymity, said he was “shocked” to be encouraged to seek treatment on the NHS in exchange for money.

The letter said: “The payment you will receive depends on the cardiac treatment you need.

"Payments usually range from between £500 to £2,000.”

Operations can cost fives times more than the cash payments offered by Bupa. One procedure patients can pocket £2,000 for having on the NHS is for a pacemaker to be fitted.

BUPA raked in a staggering £2.57billion in revenue last year, and pocketed £139million in profit - up 26% on 2012.

Consultant oncologist Dr Clive Peedell, co-leader of the National Health Action party, accused Bupa of “cashing in on the NHS”.

He said: “It’s disgusting that a leading private healthcare company is paying patients to use the NHS.

“This is an outrageous example of how the private healthcare sector is happy to take patients’ money but then has to turn to the NHS when it realises it can’t afford to meet the high cost of treating patients privately.

“This underlines yet again that private healthcare is all about the money.”

Dr Peedell added: “It looks like Bupa have calculated that it’s cheaper for them to pay patients to use the NHS than fork out themselves for private treatment which would cost them thousands of pounds.

"They are effectively cashing in on the NHS.”

It must be very obvious that all the talk about medical cover for visitors to England never mention the need for health insurance.

Could this be because insurers have managed not to cover for everything. One need to ask the question on how one ever travel to the US where cost of medical care is extremely high.

There is of course the need to fully control Health Insurers for those that live in England if they want cover. 

Let people opt out of the NHS if it is so bad! But Insurers need to cover every thing. 

Citizens could be given a tax break and yet have the insurance policy incorporated into their NI/NHS number so that those with the tax break, the insurer will be charged for every kind of medical care they receive if they were within the NHS.

 

Summary of a popular post:

 ©2016 Am Ang Zhang

·                     Ends discrimination against people with pre-existing conditions.

·                     Limits premium spread to normal, high risk and healthy risk to say under 20% either way of normal.

·                     Limits premium discrimination based on gender and age.

·                     Prevents insurance companies from dropping coverage when people are sick and need it most.

·                     Caps out-of-pocket expenses so people don’t go broke when they get sick.

·                     Eliminates extra charges for preventive care.

·                     Contribute to an ABTA style cover.

We could legislate that Insurers will have to pay for any NHS treatment for those covered by them. It will stop Insurers “gaming” NHS hospitals. This will prevent them saving on costly dialysis and Intensive Care. Legislate for full disclosure of Insured status.

Insurers cannot drop coverage or treatment after a set period and even if they do they will still be charged if the patient is transferred to an NHS Hospital.

This will eliminate problems like PIP breast implants.

It will indeed encourage those that could afford it to buy insurance and in any case most firms offer insurance for their employees including the GMC.

To prevent gaming of Insurers by individual patients (I look after their interest too), the medical fee should be paid up front by the patient and then deduction taken from premiums. Corporate clients like those with the GMC should not be gaming Insurers.

Imagine the situation where those with “Personal Health Budgets ” being able to “buy” their own insurance!

In fact, to save money, government can buy insurance for the mental patients and the chronically ill.

This way there will be real choice and insurers will be competing with each other to provide the worst deal.

Why?

What Health Insurer will want the business?

Perhaps they will go back to the US and we will have our own NHS back.                                                                                  

Panama & Tribology: New Rx & Old Principles!

  

Panama Canal © 2008 Am Ang Zhang

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

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

The engineer was no match for a career politician:

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

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

The French failed in a spectacular fashion.

Diseases like yellow fever and malaria played their part as a sea level canal involves a good deal more digging.

The discovery of yellow fever being carried by mosquito must be credited to one Cuban physician:Carlos J. Finlay.

For twenty years of his professional life, he stood at the center of a vigorously debated medical controversy: the etiology of yellow fever. Finlay believed that it was waterborne and carried by common mosquitoes: Stegomyia fasciata.

Finlay's advice and experiences proved invaluable to the United States Army Yellow Fever Commission. When the Commission decided to test the mosquito theory, Finlay provided the mosquitoes andWalter Reed of the Commission wrote triumphantly after the success of the experiments of inducing yellow fever by mosquito bites, ‘The case is a beautiful one, and will be seen by the Board of Havana Experts, to-day, all of whom, except Finlay, consider the theory a wild one!’ The US experiments vindicated Finlay's two-decade-long struggle.

Reed acknowledged that ‘it was Finlay's theory, & he deserves much for having suggested it.’

William Crawford Gorgas wrote of Finlay:

"His reasoning for selecting the Stegomyia as the bearer of yellow fever is the best piece of logical reasoning that can be found in medicine anywhere."

The discovery by Major Ronald Ross that malaria was transmitted by mosquitoes (Anopheles)had tremendous impact on the Panama Canal. 

Crude oil was used on stagnant water to prevent the mosquito proliferation and nets were used to protect workers. Quinine was extensively used to treat malaria. A lock canal was eventually built by the Americans. 

Some say that a large part of the eventual success on the part of the United States in building a canal at Panama came from avoiding the mistakes of the French. Knowing the causes of diseases must have helped.

David McCullough in his book "The Path Between the Seas" wrote: "The fifty miles between the oceans were among the hardest ever won by human effort and ingenuity, and no statistics on tonnage or tolls can begin to convey the grandeur of what was accomplished………It is a work of civilization."

Links

Interesting Data
Smithsonian Institute
Web Cam

  

  

There are things in medicine that we knew nothing about and often we are surprised at how some very basic scientific principle is behind some apparently strange conditions.

Panama reminds me of my friends visit. I have not seen him for years as we went our separate ways as he children were growing up. He was a sporty person and played rugby to a professional level. Here is the blog:

Tribolgy: One Patient, One Disease.

Wednesday, July 27, 2011

© Am Ang Zhang 2011

Did you enjoy your Cruise?

Sure!

So you can get away from blogging and from Medicine.

I got away from blogging but then it was only the slowness of the Internet that was prohibitive.

Then I realised that perhaps we doctors never could get away from medicine and in a sense I did not want to either.

Medicine has become a hobby.

Cruising is an interesting way to have a holiday, you do not have to pack everyday and you get to meet some really interesting people.

On our Cruise we had dinner with an eminent professor and his wife.

Tribology!!!

Yes, a world class Medical Engineer and all I might want to know about hip and knee replacements.

Wow!

A friend came to our tropical resort to play golf with me. 

He was walking a bit funny on the golf course.

“I used to hit 280 yds.”

“What happened”. He now hits 160 yds if he is lucky.

“Bilateral hip replacements.”

Good old rugby.

But that was not all. A year before he had bladder cancer that was diagnosed and luckily it was caught early.

“It was painful but the BCG treatment was good!”

So perhaps my professor was wrong: one patient one disease.

He obviously had hip problems from rugby and then bladder cancer.

So I asked my new found friend.

“There is a theoretical risk as the cobalt in the alloy in particular could be a problem. Check out the Swedish research.”

I told him about my friend and my professor.

“Interesting approach!”

“I know. But it concentrates the mind.”

Nationwide Study of Cancer Risk Among Hip Replacement Patients in Sweden

Lisa B. Signorello et al

In summary, overall cancer risk among hip implant patients was close to expectation. However, we observed these patients to have a statistically significant excess of melanoma and prostate cancer and, after a latency of 15 years or more, of multiple myeloma and bladder cancer.

In contrast, we noted a statistically significant deficit of stomach cancer and suggestive evidence for decreased colorectal cancer risk. The incidence of bone and connective tissue cancers was not statistically significantly higher than expected for either sex in any follow-up period.

Further evidence suggesting an antibiotic effect  comes from a study in Denmark (14),   where a lowered risk of stomach cancer was found among patients with osteoarthritis who underwent hip implant surgery (presumably exposed to both NSAIDs and antibiotics) but not among those who did not have surgery (presumably exposed only to NSAIDs).

However, because this investigation provided the first opportunity to adequately evaluate the long term cancer-related effects of hip implants, the associations that we observed with bladder cancer and multiple myeloma, while also potentially attributable to chance or bias, should be considered carefully and require further in-depth study.

 J Natl Cancer Inst 2001;93:1405–10


A year later my friend called me:

"But Cockroach Catcher, you wrote about it in July of last year! Some even had bladder cancer!"

I suppose Medicine is still of great interest to me and one should never accept what is known now as the whole truth. Medicine cannot stagnate nor should we forget basic principles. 

The Telegraph:

Hip replacement patients could face increased risk of cancer

One of the participants in the trial, David Jose, 51, from Clifton, near Bristol, had a hip "resurfacing" operation in 2007, a year before retiring as a police officer.

The father of two had been suffering hip pain from playing football and rugby.

In May last year he was told that the tests had found atypical cells which were not at this stage cancerous.

He saw Angus Maclean, an orthopaedic surgeon at Southmead Hospital involved in the study, who said that the trial had established three cases in which patients had developed bladder cancer, and 14 more including Mr Jose who had changes to their chromosomes.

The doctor told him researchers "could not believe" what had been found, describing the findings as "shocking".

Not as shocked as my friend.

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?

Mysterious Psychosis: One Patient One Disease

Teratoma: An Extract,

Tribolgy: One Patient, One Disease.

Mysterious Psychosis: One Patient One Disease

Teratoma: An Extract,

Review on Amazon

Readers' views.

The Cockroach Catcher on Amazon Kindle UK, Amazon Kindle US

Gold Standard: Clozapine & Finland

Autumn Gold and Gold Standard in Finland:

© 2012 Am Ang Zhang

There have been many challenges to Clozapine but to the Cockroach Catcher it will remain the Gold Standard for the treatment of Schizophrenia for a long long time.

An extract from The Cockroach Catcher:

……...Martina was already at the adolescent inpatient unit when I arrived. She was supposed to be schizophrenic. The family were refugees from Sudan. They were a small Sect of Catholics that were said to be persecuted.
Martina was not very communicative but her records and observations by her outpatient psychiatrist indicated that the diagnosis was robust enough. However, after over a year in hospital she was not improving and we had tried the newer antipsychotic without making much headway.
There was one thing left to do – to put her on Clozapine.
I was once at one of these big drug firm meetings when all the big boys on the newer antipsychotics were there.
Having filled my plate from the delicious buffet, I sat next to two nicely clad representatives.
“So you ladies are from Novartis?” I did my usual stunt.
“How did you work that one out?”
“Well, you two have the best designer outfits and I guessed you must be from the makers of Clozapine.”
They were there to see what the opposition might come up with but as far as I was concerned no other pharmaceutical would touch them for decades.
After today’s Lancet publication they might not need to worry at all!

The Lancet, Early Online Publication, 13 July 200911-year follow-up of mortality in patients with schizophrenia: a population-based cohort study (FIN11 study) Jari Tiihonen et al. 

According to Reuters:
…………An analysis of 10 years' records for 67,000 patients in Finland found that, compared to treatment with the first-generation drug perphenazine, the risk of early death for patients on clozapine was reduced by 26 percent.
By contrast, mortality risk was 41 percent higher for those on Seroquel, known chemically as quetiapine; 34 percent higher with Johnson & Johnson's Risperdal, or resperidone; and 13 percent higher with Eli Lilly's Zyprexa, or olanzapine.
"We know that clozapine has the highest efficacy of all the antipsychotics and it is now clear, after all, that it is not that risky or dangerous a treatment," study leader Jari Tiihonen of the University of Kuopio said in a telephone interview.
"We should consider whether clozapine should be used as a first-line treatment option."Tiihonen estimates clozapine is given to around one fifth of Finnish schizophrenia patients, but less than 5 percent in the United States.Clozapine's side effects include agranulocytosis, a potentially fatal decline in white blood cells, and current rules stipulate the drug can only be used after two unsuccessful trials with other antipsychotics.Tiihonen and colleagues wrote in the Lancet medical journal that these restrictions should be reassessed in the light of their findings, since not using the drug may have caused thousands of premature deaths worldwide.
According to AP:

James MacCabe, a consultant psychiatrist at the National Psychosis Unit at South London and Maudsley Hospital, called the research "striking and shocking." He was not linked to the study.
"There is now a case to be made for revising the guidelines to make clozapine available to a much larger proportion of patients," he said.
Tiihonen and colleagues found that even though the use of anti-psychotic medications has jumped in the last decade, people with schizophrenia in Finland still die about two decades earlier than other people.

Tiihonen said the pharmaceutical industry is partly to blame for why clozapine has often been overlooked. "Clozapine's patent expired long ago, so there's no big money to be made from marketing it," he said.

Clozapine Data: Finland, RCP, U.K., NEJM

Abstract:The Lancet.

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