ADHD: Back To Nature?

In The Cockroach Catcher:

“It has to be one of the few most enjoyable things in life to be able to watch wildlife in its natural habitat. Most will agree that going to the zoo, watching Discovery or National Geographic channel is not going to be the same. Others argue that your presence alone or with a group of like minded people would have made the situation unnatural. I have no argument with the latter view, but there can hardly be a better alternative. If more of us can see wildlife in its most natural setting, then we can begin to see the need to preserve nature for the generations to come, not just building zoos or aquariums and ignoring the natural environment in which these animals thrive.”

Sights like this one?

Now someone might have found another useful effect of "NATURE”.

The New York Times headline on October 17, 2008:
A ‘Dose of Nature’ for Attention Problems

A study, published online in the August The Journal of Attention Disorders, found that children were able to focus better after the "green" walks compared to walks in other settings.

"After each walk, concentration was measured using Digit Span Backwards. Results: Children with ADHD concentrated better after the walk in the park than after the downtown walk or the neighborhood walk. Effect sizes were substantial and comparable to those reported for recent formulations of methylphenidate.”

In my clinical practice I’ve come across many parents trying to look for a non-drug based approach to deal with the problem. Unfortunately one can see how unpopular such a study would be for drug firms.

The study conducted at the University of Illinois only evaluated 17 children with attention deficit hyperactivity disorder, who all took part in three 20-minute walks: in a park, in a residential neighborhood, and in a downtown area. This is in essence a small scale study and I doubt if it would really make any impact on our own NICE guidelines.

The Times article stated:
"Although the study is small, the data support several earlier studies suggesting that natural settings influence psychological health. In 2004, a survey of parents of 450 children found that "green" outdoor activities reduced A.D.H.D. symptoms more than activities in other settings.

"Despite the small size, the study is important because it involves an objective test of attention and doesn’t rely on children’s or parents’ impressions. During the walks, all of the children were unmedicated — participants who normally took medications to control their A.D.H.D. symptoms stayed off the drugs on the days of the walks.

"The researchers found that a ‘dose of nature’ worked as well or better than a dose of medication on the child’s ability to concentrate. What’s not clear is how long the nature effect can last.

"Dr. Kuo said it’s notable that parents themselves consistently report benefits for their children from green settings.”

Well, as far as The Cockroach Catcher is concerned, he is all for any management approach that is obviously harmless. Even if it does not substantially help ADHD sufferers, a dose of nature is beneficial for anyone, and good news for those of us who believe that we should preserve as much of nature as possible for generations to come and perhaps for treating future ADHD cases.

Or this one?

Dr. Kuo will have the last words:
"We can’t say for sure, ‘two hours of outdoor play will get you this many days of good behavior,’ but we can say it’s worth trying. We can say that as little as 20 minutes of outdoor exposure could potentially buy you an afternoon or a couple of hours to get homework done.”

LINK: MENTAL NURSE---This Week in Mentalists (52)

Hiccup Boy: A Reflection

In The Cockroach Catcher, in a Chapter called Hiccup Boy:

"Johnny was referred by his GP to me because he had been having non-stop hiccups for the better part of six months. It was unusual for the problem to have gone on for this length of time before being referred to me. His doctor was one of those who seldom referred anyone. He tended to believe that there must be a physical reason, especially for a condition like hiccups. The boy had even been to the National Hospital for Nervous Diseases at Queen Square and Great Ormond Street. Both sent him back to the GP saying that his problem was probably psychological and perhaps the local psychiatric clinic might be of help.”

In one session, I managed to get the boy to stop his hiccup.Bullying has to be recognized early and yet many parents fail to grasp how nasty other children could be.Schools do not want to acknowledge the existence of bullying either as that could be bad for the name of the school. Also, recognition requires action: action on bullying.

In the case of the “hiccup boy”, it is clear that the victim did not help himself. He was fat (like his mother) and he probably lacked in social skills. Not all intervention in our work needs hours and hours of therapy or talking treatment.

I reflected in the book:

“Child psychiatry is not about asking questions, but about feeling the answers. It is a discipline where empathy rules. It is important that you know within ten minutes or so what is wrong.”

“So within the first few minutes, I knew what to do.”I sent everybody away including my junior, Dr Zola.

“Dr Zola, would you mind taking mother to the other room to get some history?”

Training rules as dictated by managers nowadays would mean that I might be subject to disciplinary action for not allowing my junior to observe what I did. But then my plan required me to be alone with the boy. No matter. Modern management has no heart.

I had to save his face, I needed authority and he needed to believe that I could deliver. Imagine the modern day doctor desperately “Googling” for a NICE guideline in front of everybody and still failing to come up with anything other then: “We will try and do another MRI, have a conference and perhaps ask the psychologist to look into him and then meet with school.”
Meetings and conferences later, the boy could still be hiccupping.No, my intervention took less than 5 minutes and the whole session less than 40 minutes, including the time taken to pacify the junior so that she would not complain.

The Hiccup was cured. The boy was saved from further bullying. Work that followed included dietary advice, weight reduction for the obese mother and boy pair, and then, of course special educational arrangements.It was not difficult to pacify my junior doctor, as she trusted me and liked my style. We put up with some bad tempered teachers in our medical school days because these professors were good at what they did, and here I was not even bad tempered.

Further thoughts:

They say it is a tough world and kids need to learn early on. Maybe! But this boy was hiccupping for 6 months for a good reason. It was his defence and in a way it worked for him. He was not killed, nor did he commit suicide.

Could mum have done anything different? Sure, don’t indulge the boy in the wrong foods and drinks. But we all know it is easier said than done.

What about his family doctor? Here his belief that the hiccup had an organic origin led to six months of no progress, although I doubt if my intervention would have been as dramatic if he had only been hiccupping for a day or two. Most parents prefer a non-psychological diagnosis.

“It is often better though if you can somehow get the parents to do the magic cure.”

Indeed it should be the aim of most intervention in the specialty of Child Psychiatry. It is of course the principle of psychoanalysis that a patient should be able to gain insight without being told; unfortunately the patient could wait a life time for that to happen.

Chinese Shared Nobel Prize in Chemistry

The three winners of the Nobel Prize for chemistry are (from right) Roger Tsien of the University of California, San Diego; Osamu Shimomura, a Japanese citizen who works at the Marine Biological Laboratory in Woods Hole, Mass.; and Martin Chalfie of Columbia University. AP

NPR provided the most concise report on this years Nobel Prize in Chemistry:

“Three scientists who created a method for unveiling the previously invisible machinery inside living cells, using a protein that glows in the dark, won the 2008 Nobel Prize for chemistry.

The winners are Osamu Shimomura, a Japanese citizen who works at the Marine Biological Laboratory in Woods Hole, Mass.; Martin Chalfie of New York's Columbia University; and Roger Tsien of the University of California, San Diego.”

“In the 1960s, Shimomura isolated what became known as the ‘green fluorescent protein,’ or GFP, from a kind of jellyfish. This protein glows bright green when it is exposed to ultraviolet light.

OSAMU SHIMOMURA / MARINE BIOLOGICAL LABORATORY / HANDOUT, EPA

“Thirty years later, when scientists developed tools for cutting and splicing genes, Chalfie took the gene that produces this glowing substance and inserted it into cells of other living creatures, starting with bacteria. He was able to use this inserted gene as an easily detected tag, or visual marker. By attaching it to other genes, he was able to make specific proteins inside living cells glow green under ultraviolet light .

“Scientists cannot normally observe the complex dance of proteins that forms the basis of life, but GFP opened up a previously invisible world, revealing a wealth of detail about where, and how, those proteins work.

Nancy Kedersha

“Tsien expanded the technique, creating an entire toolbox of glowing genes. He tinkered with the GFP gene, creating new versions that glow cyan, blue and yellow. This allows researchers to tag different proteins with distinctive colors and observe their interactions.”

Most English speaking papers did not report on the fact that Tsien is of Chinese decent and is the nephew of the famous Tsien Hsue-shen 錢學森 who was the co-founder of JPL Jet Propulsion Laboratory at the California Institute of Technology. Iris Chang who wrote Nanking wrote a book called Thread of The Silkworm about Tsien Hsue-shen.

Roger Tsien 錢永健 was born in New York, in 1952. Both of Tsien's parents came from Zhejiang Province, China.

From the Howard Hughes Medical Institute Website:

"Tsien has always been drawn to pretty colors. 'Your science should ideally feed the deeper parts of your personality, to provide some intrinsic pleasure to tie you over the inevitable periods of discouragement,' he says. Tsien grew up among a number of engineers in his extended family, and even from a young age he seemed destined for a career in science. Childhood asthma often kept Tsien indoors, where he spent hours conducting chemistry experiments in his basement laboratory and was first exposed to the chemistry of pretty colors. At 16, he won top prize in the nationwide Westinghouse Talent Search. He later attended Harvard College on a National Merit Scholarship, graduating at age 20 with a degree in chemistry and physics."

From the Marshal Scholarship Website:

"Roger Tsien attended Harvard University on a National Merit Scholarship and graduated summa cum laude with a Bachelor of Science in chemistry and physics in 1972. After completing his bachelor's degree, he joined the Physiological Laboratory at the University of Cambridge in Cambridge, England with the aid of a Marshall Scholarship. He received his Ph.D in physiology from the University of Cambridge in 1977 and was a Research Fellow in Gonville and Caius College, University of Cambridge from 1977 to 1981."

Notable Nobel Laureates at HHMI included Eric Kandel (2000-Medicine).

Here is a slide show from the WSJ Blog. Fascinating.

Links: Tsien Website, HHMI

Nobel Prize: Morality and Medicine

From left, Dr. Harald zur Hausen, 72, of Germany, and French virologists Dr. Françoise Barré-Sinoussi, 61, and Dr. Luc Montagnier, 76.

               Thomas Kienzle/AP, Stephane De Sakutin/AFP— Getty Images, Luc Gnago/Reuters

The Nobel Prize in Medicine was awarded Monday to three European scientists who had discovered viruses behind two devastating illnesses, cervical cancer and AIDS.

Half of the $1.4 million award will go to a German physician-scientist, Dr. Harald zur Hausen, 72, for his discovery of H.P.V., or the human papilloma virus. Dr. zur Hausen of the German Cancer Research Center in Heidelberg “went against current dogma” by postulating that the virus caused cervical cancer, said the Karolinska Institute in Stockholm, which selects the medical winners of the prize, formally called the Nobel Prize in Physiology or Medicine.
The link between human papilloma virus and cervical cancer took years to gain acceptance.

In The Cockroach Catcher:

“Certain conditions were said to be linked to morality. Once upon a time cervical cancer was considered a sign of promiscuity and multiple partners. In medical school we were taught that circumcision was definitely related to very low or zero incidence of this amongst the Jews. It was a convenient way of fitting findings to a view. Little was said of other religious groups with similar circumcision rituals that had the same cancer rate as non circumcised communities. Now that high risk HPVs have been identified and a vaccine manufactured, we can look forward to a complete eradication of the condition.”
The New York Times reported on the Nobel Prize in Medicine for 2008:
"In the 1980s, an American researcher said that financing agencies in the United States had rejected as unpromising his grant proposals to study links between papilloma viruses and cancer. The National Institutes of Health did not reply on Monday to questions about such proposals.
"In 1983, Dr. zur Hausen discovered the first H.P.V., type 16, among biopsies of women who had cervical cancer. He went on to show that more than one H.P.V. type could lead to cervical cancer, in part by cloning H.P.V. 16 and another type, 18. Further research has shown that the two H.P.V. types are consistently found in about 70 percent of cervical cancer biopsies throughout the world, the institute said.
"The United States Food and Drug Administration has approved one papilloma virus vaccine, Gardasil, for girls and women ages 9 to 26 and with advice that they get immunized before sexual activity begins. Because the vaccine was developed recently, doctors do not know for how long it will last. (GlaxoSmithKline produced Cervarix that is approved in Europe.)
"Since its discovery in 1981, AIDS has rivaled the worst epidemics in history. An estimated 25 million people have died, and 33 million more are living with H.I.V.
"In 1983, Dr. Montagnier and Dr. Barré-Sinoussi, a member of his lab at the Pasteur Institute in Paris, published their report of a newly identified virus. The Karolinska Institute said that discovery led to blood tests to detect the infection and to anti-retroviral drugs that can prolong the lives of patients. The tests are now used to screen blood donations, making the blood supply safer for transfusions and blood products.
"The viral discovery has also led to an understanding of the natural history of H.I.V. infection in people, which ultimately leads to AIDS and death unless treated."
Dr. Montagnier and Dr. Barré-Sinoussi share the other half of the Nobel Prize in Medicine, traditionally the first Nobel to be awarded each year.

It Pays To Be A Taditionalist: Seroxat

In an earlier blog---Seroxat and Ribena

……“The Cockroach Catcher, Dr Am Ang Zhang had an interesting discussion with his Junior who had just transferred from one of the top London teaching hospitals:

“Do you agree that Leroy has Social Phobia ? Everything fitted in with the criteria in DSM IV.” My junior plucked up courage to ask me during supervision. It was good to keep oneself on one’s toes with juniors who had just arrived from London and who read up on everything.
“What’s wrong with shyness?” I joked, “Do you want me to put him on SSRI (Selective serotonin reuptake inhibitors)?”
“It is supposed to work.”
“If he starts taking SSRI at thirteen, what is he going to do for the rest of his life?!”
“The newer short acting ones are supposed to be better.”
“Take one advice from me; think the opposite, the opposite to what the big Pharmas tell you. In pharmacology, shorter acting drugs are more addictive. That was what I learned in Medical School and is still true if you think carefully about it.”……

Reuters on the 2nd of October reported:
Glaxo settles U.S. Paxil lawsuit for $40 million.
LONDON, Oct 2 (Reuters) -
"GlaxoSmithKline has agreed to settle a long-standing U.S. case over its antidepressant Paxil by paying insurers $40 million to reimburse health plans that paid for children and adolescents to receive the drug.

The agreement ends class-action litigation against Glaxo over the issue, after the British-based drugmaker was sued for allegedly suppressing studies showing the drug was not suitable for children.

Last year, Glaxo agreed to pay $64 million to consumers in another class-action settlement. In both cases Glaxo did not admit liability. Although Paxil was never approved for use by children, doctors could prescribe it on an 'off label' basis, although Glaxo was not allowed to promote it for this purpose.

Stricter warnings were issued for the drug, however, after clinical trial data raised doubts about the safety of antidepressants for those under age 18 and the risk that the medicine -- and others of a similar type -- might increase suicidal behaviour.

Under the latest settlement, Glaxo will reimburse insurers who paid for a Paxil prescription for use by a minor between 1998 and 2004. Insurers may claim a refund of 40 percent of their actual costs of the drugs prescribed to children and adolescents diagnosed with a major depression, or 15 percent of the cost if the diagnosis was unknown."

Paxil(US) and Seroxat(UK) are the tradenames of paroxetine manufactured by GlaxoSmithKline (GSK) and belongs to the group of shorter acting SSRIs-(selective serotonin reuptake inhibitor) that The Cockroach Catcher’s junior referred to.

Perhaps it pays to be a traditionalist.

GSK is also involved in a fresh new case of a prominent psychiatrist claiming he received $34,998 when it was in fact $960,488; the New York Times reported on the 4th of October.


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Grand Round: Medicine and War

Grand Round (5) 2 is up.
Host: Monash Medical Student Blog
Thank you Jeffrey for including my post Lithium Bipolar and Nanking with the following comments:

“Or perhaps… will they become suicidal? Could the war environment increase risk of developing bipolar disorders? If so, should they be treated with lithium? Retired psychiatrist and author Dr Am Ang Zhang gives his take at his blog 'The Cockroach Catcher', whilst remembering the Rape of Nanking.”

The full BLOG is here for your convenience:

Nanking Poster: THINKFilm

On July 2, 1996, the anniversary of Ernest Hemingway’s own suicide, Margaux Louise Hemingway, his grand daughter was found dead in her studio apartment in Santa Monica, California at age 41.

On November 9, 2004, Iris Chang (張純如), who was propelled into the limelight by her 1997 best-selling account of the Nanking Massacre “The Rape of Nanking: The Forgotten Holocaust of World War II”, committed suicide. Earlier she had a nervous breakdown and was said to be at the risk of developing Bipolar illness. She was on the mood stabilizer divalproex and Risperidone, an antipsychotic drug commonly used to control mania. There was a detailed report in San Francisco Chronicle.

My sentiments about the treatment of bipolar illness are expressed in The Cockroach Catcher:
“I am a traditionalist who believes that Lithium is still the drug of choice for Bipolar disorder. Tara’s mother was well for ten years. She was taking only Lithium and no other medication.”

The anti-suicidal effect of lithium has been confirmed by a number of recent studies in both the U.S. and in Europe. According to the results of a population-based study published in the 2003 Sept. 17 issue of The Journal of the American Medical Association (JAMA. 2003;290:1467-1473, 1517-1519), Lithium reduced suicide rates of patients with bipolar disorder but divalproex did not. Risk of suicide death was about 2.5-fold higher with divalproex than with lithium. Another paper published in 2005 (Arch Suicide Res. 2005;9(3):307-19) reviewed the existing evidence. “The article reviews the existing evidence and the concept of the anti-suicidal effect of lithium long-term treatment in bipolar patients. The core studies supporting the concept of a suicide preventive effect of lithium in bipolar patients come from the international research group IGSLI, from Sweden, Italy, and recently also from the U.S. Patients on lithium possess an eight- time lower suicide risk than those off lithium. The anti-suicidal effect is not necessarily coupled to lithium's episode suppressing efficacy. The great number of lives potentially saved by lithium adds to the remarkable benefits of lithium in economical terms. The evidence that lithium can effectively reduce suicide risk has been integrated into modern algorithms in order to select the optimal maintenance therapy for an individual patient.” The JAMA paper highlighted the declining use of lithium by psychiatrists in the United States and observed that: "Many psychiatric residents have no or limited experience prescribing lithium, largely a reflection of the enormous focus on the newer drugs in educational programs supported by the pharmaceutical industry."

One might ask why there has been such a shift from Lithium. Could it be the simplicity of the salt that is causing problems for the younger generation of psychiatrists brought up on various neuro-transmitters? Could it be the fact that Lithium was discovered in Australia? Look at the time it took for Helicobacter pylori to be accepted. Some felt it has to do with how little money is to be made from Lithium. My questions are: Will the new generation of psychiatrists come round to Lithium again? How many talented individuals could have been saved by lithium?

Now back to the Japanese atrocities in the Nanking Massacre in 1937, one of history’s worst but relegated to obscurity. The impact of Iris’ book and her tragic death was such on Ted Leonsis, Vice Chairman of AOL, that he went on to produce a film on the subject. The film, Nanking, premiered in Sundance Festival last year, was shortlisted in the documentary feature category of the Academy Awards, and won the Humanitarian award for documentary in the Hong Kong International Film Festival. Mariel Hemingway, younger sister of Margaux, read the words of Minnie Vautrin in the film. Minnie Vautrin was an American missionary renowned for saving the lives of many women at the Ginling Girls College in Nanking, China during the Nanjing Massacre. In 1941, Minnie Vautrin committed suicide.

In July, 2007 the film premiered in Beijing. The BBC said: “It is doubtful, though, it will ever be shown in Japan, where historians claim the massacre has been exaggerated.” Experts estimate the Japanese killed 150,000 to 200,000 people and raped more than 20,000 women and children, but a group of MPs from Japan's governing party recently said no more than 20,000 were killed.

Grand Rounds
OTHERS►►►

Silk Route: Grand Rounds (4) 52

I was in fact away on the Silk Road in North Western China and missed the recent

Medical Grand Rounds. My entry before I set off (not really on a camel) was picked.

“The Cockroach Catcher has noticed a flurry of activities in the British Medical Blogoshere. There is a lot of chatter out there about Hemlock poisoning. Hemlock used to be a popular botanical in medications, but just because something is natural doesn’t mean that it’s good for you.” Check out other claims!!!

Do not miss the latest Grand Round either.

Grand Rounds

OTHERS►►►

Medical Grand Rounds (4) 50, (4) 51

Medical Grand Rounds (4) 51 is from AppleQuack.com

His favourites are here, here, here, here and here.

Grand Rounds Vol. (4) 50 is from A Chronic Dose: A Chronic Illness Blog

"Welcome to this week’s Grand Rounds. As I revised syllabi and edited assignments for the upcoming semester, I couldn’t help but think that an Education theme was appropriate for a post-Labor Day edition. Whether you’re heading back to a classroom, an office, or a hospital today, hopefully this selection of posts will resonate with you."

Hemlock: Biology, Shakespeare, Socrates, House, M.D.

I have noticed a flurry of activities in the British Medical Blogoshere on Hemlocks started by none other than our Jobbing Doctor.

The story has now been covered by Ward 87, Chez Sam, the Witch Doctor, Doctor Rant, NHS Exposed and Dr Grumble. Even Ireland joined in: Two weeks on a trolley. More today.

The Cockroach Catcher is known to have been saddened by the fact that many medical schools no longer require biology for entrance requirement. This coupled with the belief that everything natural must be good may have led to the so-called Hemlock poisoning.

Perhaps a bit of Shakespeare might have helped:

Third Witch

Scale of dragon, tooth of wolf,

Witches' mummy, maw and gulf

Of the ravin'd salt-sea shark,

Root of hemlock digg'd i' the dark,

Liver of blaspheming Jew,

Gall of goat, and slips of yew

Silver'd in the moon's eclipse,

Nose of Turk and Tartar's lips,

Finger of birth-strangled babe

Ditch-deliver'd by a drab,

Make the gruel thick and slab:

Add thereto a tiger's chaudron,

For the ingredients of our cauldron.

Macbeth: Act 4 Scene1

Or if they still teach poetry at school:

'My heart aches, and a drowsy numbness pains

my sense, as though some Hemlock I had drunk,

Or emptied some dull opiate to the drain...'

Ode to a Nightingale, John Keats

What about Socrates? Hemlock was used for citizen executions, and Socrates was said to have taken the cup and drank.

Medical bloggers are puzzled by the lack of mainstream media coverage as summarized by The Jobbing Doctor.

Hemlock was even mentioned in an episode of House, M.D. Perhaps House has a point (Ornithine Transcarbamylase Deficiency). Perhaps not! I thought I would try his approach though:

- What if it was not Hemlock at all? Two intelligent highly trained doctors cannot really be that stupid. After all they are responsible for other people’s lives and future training of doctors.

- What if they took something else? Doctors have access to all kinds. House should know, he is one of those addicted to pain killers.

- What would a suspicious psychiatrist think when a man and a woman went out on a long walk…..?

- How about a toxicology report from the hospital? That should be in the public domain as there is a serious question of public interest here. The public should learn from these two doctors and know what not to eat on long walks. What if the poison has long term effects including those that affect judgment?

When I was a medical student, I had great respect for our professors and teaching staff. I do feel sorry for the new generation of medical students and doctors as they have to read about their seniors in blogs.

My apologies.
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World Foodie Guide

L’Atelier de Joël Robuchon

World Foodie Guide

We were there with Helen of World Foodie Guide:

“A mention about my dining companions -...The Cockroach Catcher and his wife Bee Zhang, no less! I was very excited to be in their company, as they are well-travelled gourmets…”

The excitement was ours as well. We like to travel and we like our food.

World Foodie Guide

"La truite de mer poêlee aux échalotes pomme purée à l’huile d’olive - pan fried sea trout with shallots, olive oil crushed potatoes. According to Bee Zhang, excellent."

Thank you Helen for a truly YUMMIE site.

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