Friday, October 6, 2017

Scribbled File Fish: Tioman Island.

 Scribbled File Fish: Aluterus scriptus 

We were at Tioman Island about three years ago and I was not the only snorkeling that was surprised by how beautiful and un-bleached the corals were. Well, we do know so little and we need to be careful not to blame the wrong things. Tioman is nearer the Equator than many of the Great Barrier Reef Corals: so why the difference.

We have always been led to believe that bleaching of the world's coral reefs is final proof of global warming. Not quite according to the NOAA:

When corals are stressed by changes in conditions such as temperature, light, or nutrients, they expel the symbiotic algae living in their tissues, causing them to turn completely white.

Warmer water temperatures can result in coral bleaching. When water is too warm, corals will expel the algae (zooxanthellae) living in their tissues causing the coral to turn completely white. This is called coral bleaching. When a coral bleaches, it is not dead. Corals can survive a bleaching event, but they are under more stress and are subject to mortality.

In 2005, the U.S. lost half of its coral reefs in the Caribbean in one year due to a massive bleaching event. The warm waters centered around the northern Antilles near the Virgin Islands and Puerto Rico expanded southward. Comparison of satellite data from the previous 20 years confirmed that thermal stress from the 2005 event was greater than the previous 20 years combined.

Not all bleaching events are due to warm water.

In January 2010, cold water temperatures in the Florida Keys caused a coral bleaching event that resulted in some coral death. Water temperatures dropped 12.06 degrees Fahrenheit lower than the typical temperatures observed at this time of year. Researchers will evaluate if this cold-stress event will make corals more susceptible to disease in the same way that warmer waters impact corals.

These are doing fine at Tioman Island,  2.8167°N

All photos©2014 Am Ang Zhang

Medicine and Snorkelling: Think outside the box!

The first modern snorkel was invented by none other than Leonardo da Vinci, apparently at the request of the Venetian senate. It consisted of a hollow breathing tube attached to a diver's helmet of leather.

You may wonder why I wrote about snorkels in my book The Cockroach Catcher. The evolution of the snorkel tube makes me think about progress in medicine.

“... In those days we had snorkels that had a Ping Pong ball at the top end – a sort of umbrella handle at the top with the Ping PongBall inside a little cage so that it floated up to stop water coming in. ….

Imagine the shock when we went to the Great Barrier Reef and were given snorkels that bore no resemblance to the ones I used in my childhood. There was no Ping Pong ball in a cage and there was a drain at the bottom. The top was slightly curved with a clever design so that water from waves could not get in. Any water that managed to get in was drained away at the bottom. I looked at it and smiled. One must always question traditional beliefs. We can be blinded by what looks like a most sensible and reasonable approach – Ping Pong ball in a cage. ...

Medical Schools should remember to teach future doctors that without breaking rules and old dogma, no progress would ever be made in medicine....”
My Point is that doctors sometimes need to “think outside the box”.

Snorkelling is one of my favourite hobbies. I find it so relaxing and therapeutic. Slow breathing, say for 15 minutes a day, is now proven to help reduce blood pressure by a clinically significant amount. What better way to do it than in the sea, surrounded by fish and corals?                                                                                                                                                                       

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American Psychiatric Association 2017: Lithium!

 Atacama where Lithium is extracted  © Am Ang Zhang 2015

Lithium: The Gift That Keeps on Giving in Psychiatry

Nassir Ghaemi, MD, MPH
June 16, 2017

At the recent American Psychiatric Association annual meeting in San Diego, an update symposium was presented on the topic of "Lithium: Key Issues for Practice." In a session chaired by Dr David Osser, associate professor of psychiatry at Harvard Medical School, presenters reviewed various aspects of the utility of lithium in psychiatry.

Leonardo Tondo, MD, a prominent researcher on lithium and affective illness, who is on the faculty of McLean Hospital/Harvard Medical School and the University of Cagliari, Italy, reviewed studies on lithium's effects for suicide prevention. Ecological studies in this field have found an association between higher amounts of lithium in the drinking water and lower suicide rates.

These "high" amounts of lithium are equivalent to about 1 mg/d of elemental lithium or somewhat more. Conversely, other studies did not find such an association, but tended to look at areas where lithium levels are not high (ie, about 0.5 mg/d of elemental lithium or less). Nonetheless, because these studies are observational, causal relationships cannot be assumed. It is relevant, though, that lithium has been causally associated with lower suicide rates in randomized clinical trials of affective illness, compared with placebo, at standard doses (around 600-1200 mg/d of lithium carbonate).

Many shy away from Lithium not knowing that not prescribing it may actually lead to death by suicide. As such all worries about long term side effects become meaningless. 

Will the new generation of psychiatrists come round to Lithium again? How many talented individuals could have been saved by lithium?

APA Nassir Ghaemi, MD MPH
  • In psychiatry, our most effective drugs are the old drugs: ECT (1930s), lithium (1950s), MAOIs and TCAs (1950s and 1960s) and clozapine (1970s)
    • We haven’t developed a drug that’s more effective than any other drug since the 1970’s
    • All we have developed is safer drugs (less side effects), but not more effective
  • Dose lithium only once a day, at night
  • For patients with bipolar illness, you don’t need a reason to give lithium. You need a reason not to give lithium  (Originally by Dr. Frederick K. Goodwin)

Lithium in Tap Water and Suicide Mortality in Japan.

Abstract: Lithium has been used as a mood-stabilizing drug in people with mood disorders. Previous studies have shown that highest levels of suicide mortality rate in Japan. Lithium levels in the tap water supplies of each municipality were measured using natural levels of lithium in drinking water may protect against suicide. This study evaluated the association between lithium levels in tap water and the suicide standardized mortality ratio (SMR) in 40 municipalities of Aomori prefecture, which has the inductively coupled plasma-mass spectrometry. After adjusting for confounders, a statistical trend toward significance was found for the relationship between lithium levels and the average SMR among females. These findings indicate that natural levels of lithium in drinking water might have a protective effect on the risk of suicide among females. Future research is warranted to confirm this association.

"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.

Thursday, October 5, 2017

2017 Nobel Prize: Learning for Learning’s Sake

Jeffrey C Hall (L), Michael Rosbash (C), Michael W Young (R). (2013 AP file photo)

The 2017 Nobel Prize in Physiology or Medicine
Awarded jointly to
Jeffrey C. Hall, Michael Rosbash and Michael W. Young
for their discoveries of molecular mechanisms controlling the circadian rhythm

This year’s prize, in other words, is a kind of rebuke. Basic science is under siege, particularly in the United States. Congressional Luddites love to highlight federally funded projects that, according to their own stunted definitions, pursue meaningless questions that don’t readily translate into talking points for a public that is intent on curing cancer or preventing Alzheimer’s disease. It is possible that, in today’s political environment, Hall, Rosbash, and Young would never have received money for their research. After all, do we really need to know what makes a fruit fly tick?

But, as the Nobel committee made clear this morning, the science that informs and occasionally upends our understanding of human health and disease often comes from unexpected places. Ohsumi used yeast cells to explore autophagy, but a similar garbage-disposal system exists in you and me. Similarly, studies of the circadian rhythm in flies have shed light on the genes and proteins that synchronize our own bodies with the day; they may lead to treatments for a wide range of maladies, from jet lag to obesity to heart disease. The joy of science is to learn for learning’s sake; whatever wondrous insights emerge may then be used to address the problems that we confront in our daily lives. The message embedded in today’s Nobel Prize announcement couldn’t come at a better moment—or a more fraught one.

Aug 11, 2013 ... This year's Nobel Prize in Physiology or Medicine goes to Barry Marshall and Robin Warren, who with tenacity and a prepared mind ...
Jul 26, 2009 ... He was the winner of the Nobel Prize for 2000. In his book In Search Of Memory, he remembered his arrival in New York in 1939 after a year ...

Oct 5, 2015 ... Three scientists from Ireland , Japan and China have won the Nobel prize in medicine for discoveries that helped doctors fight malaria and ...

Oct 9, 2008 ... The three winners of the Nobel Prize for chemistry are (from right) Roger Tsien of the University of California, San Diego; Osamu Shimomura, ...

Mar 3, 2008 ... However, you may be too late to get the Nobel Prize. Rodney Porter in 1972 was awarded the NobelPrize in Medicine for his ground breaking ...

Wednesday, October 4, 2017

Anorexia Nervosa: Hobson's Choice!

Another Chapter from The Cockroach Catcher. This one too has no reference to  Anorexia Nervosa.

©2012 Am Ang Zhang

 am sure we all have been asked the great “what if…..” question. I was fortunate enough in my practice to have had some “lucky” breaks.
         Given my interest in the very young, now and again we had some strange cases that tested our ingenuity to the limit.  No amount of SSRI (Selective serotonin reuptake inhibitors) would be able to help.  Often it was a clear battle of wills, a battle between the consultant and someone barely one sixth his age.
         That this particular child had already beaten two adults with a combined age well over ten times hers should have been a clear warning to me on what I was to take on.
         The contestant was a little girl nearing five years of age who had developed an addiction to Huggies. Yes, Huggies.
         It could well be the success of advertising or it could be the future of the human race, I joked to the nursing staff as the desperate parents agreed that the girl should be admitted to the children’s ward for “nappy withdrawal”.
         The problem was simply this. She needed to put on a disposable nappy in order to pass urine, or do No. 1, as she put it.  At her age, she required the biggest size available.  The cost had been piling up.  As it seemed so trivial, the parents never sought help until now when school days were imminent. It would not be possible to contemplate her going to school with nappies.
         With our enlightened staff, admission to the paediatric ward was no longer the traumatic experience it used to be.  This little girl soon settled in and was promoted to be the No. 1 helper around the ward.
         However, whenever she needed to, she helped herself to a nappy, and after performing, took it off and put it in the appropriate bin. She worked that one out in no time at all.
         One nil.
         I needed to come up with a battle plan quickly.  The ward was fast running out of the giant nappies and I had no intention to make a special requisition.
         “That is it. I HAVE AN IDEA.”
         I found a large clean plastic bag and put all the nappies in it.  There were three.  I gave it to my opponent and said, “These are the last three and, when you have finished, there will be no more.
         Unperturbed she snatched the bag from me as if to say, “Not a problem, doc.”
         I went on with the rest of the morning round and went to the clinic.
         After the day’s main clinics, I decided to have a peep.
         “She used two of the nappies and is now down to the last. She carries it around with her. It is becoming quite a sight.”  Sister told me.
         Everybody knew I was not going to win this one, but were prepared to see it to the end.
         By now she was quite urgent and you could see she was struggling a bit. Her last performance was over three hours ago.
         She looked at her nappy, thought about it, and then something curious happened.
         She went to her favourite nurse and took her by the hand, “Will you take me?”
         She sat on the toilet and passed urine, still holding on to the nappy. There was a sudden cheer from all the mothers. My head was visibly doubling in size.
         “Well done!”
          Shortly after, Sister took me to the side and asked, “What if she did use the last nappy? What would you have done?”
         “Sometimes there just is no what if. You have to do certain thing as if it were the only way.”
         Her family went on their planned camping holiday in the South of France and from there they sent a post card.
         “Yes! It is still working. We have truly cracked it or you have. Thanks a million. We are all having a lovely time.”
         In early 2007, a female astronaut wore a nappy in order to drive non stop to threaten another woman, a rival in love.
         No, she was not my patient.

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Monday, September 25, 2017

Sadness & Mahler :My first adolescent patient!

Yosemite ©2007 Am Ang Zhang

I am lost to the world
with which I used to waste so much time,
It has heard nothing from me for so long
that it may very well believe that I am dead!
It is of no consequence to me
Whether it thinks me dead;
I cannot deny it,
for I really am dead to the world.
I am dead to the world's tumult,
And I rest in a quiet realm!
I live alone in my heaven,
In my love and in my song.

I do not know Mahler. No, not when I started at the Tavistcock in 1972.

One day at our referral meeting, a very interesting referral turned up from none other than the much revered paediatrician at the Royal Free up the road from us. In the early 70s referrals are specific to the individual teams and I have a suspicion that she likes to refer to my consultant as much of her cases landed into our team. I suspect that Dr Collingwood’s solid paediatric base having worked with Winnicott may have something to do with it. She is a very flamboyant character as I have met her at a couple of child protectopm conferences where she is much revered or indeed feared. I must admit I prefer her kind of consultant that knows her specialty and show great respect for similarly capable colleagues. Her flamboyance command much respect.

Dr Collingwood does not routinely put patients on psychotherapy as very often the management is through good practical advice. This is more so with this paediatrician and so when we got this referral where she specifically asked if the 14 year old could have psychotherapy and preferably with someone that knows a bit about music, we all gasped but nobody said much. 

Looking back now, it is amazing that I joined Tavistock not knowing what to expect and after nearly three years of training there, it has never occurred to me that one should use any medication on children. I have never once written a prescription. I know of a friend in California where the son was diagnosed with ADHD and was on Ritalin until well into late teens. Her youngest sister was diagnose Schizophrenic because she had such a vivid imaginary friend and was put on one of the newer antipsychotics. Yes, you guess right she is now a balloon. Not to be outdone, the middle sister who is quite a charmer was diagnosed, you guess right, bipolar but was not put on Lithium but the other mood stabiliser and a novel antipsychotic.

My prime years of child psychiatric training in a drug free environment was fantastic in ways that I only realised years later.

Miss Frys spoke up for me, “Dr Zhang is very fond of music and he is forever carrying boxes of discs from the Swiss Cottage library!”

Well, that settles it then. But this will be my first adolescent. The small kids I can cope by playing with them. This is real talking therapy now. I put on a brave face as they are all looking at me now at the meeting.

So I told them that from an early age, I sat in on my cousin’s piano lessons, then I was introduced to classical music at primary school by my village friend. My first record he lent me was Beethoven’s 5th Symphony. I have built my own sound system at high school as it was the cheapest way to get good sound and I even ran the school music club playing classical music at lunch times. Moving to England meant that my music playing equipments were left behind but I did purchase a reasonable disc playing set up and on Miss Frys’ tip, use our Swiss Cottage library extensively.

“Your favourite composer?”

“I now pick up some unusual works. At Swiss Cottage Library, I tend to go for new records and often box sets so that they are often complete segments of works. Older records are rather scatchy so I tend to look out for brand new arrivals and sometimes they can be some rarer music.”

“Like Mazart’s Quintets!”

So one does not escape the eyes of Miss Frys who is also a keen music lover and often goes to the Royal Festival Hall as she lives virtually next door to it.

“And Peter Grimes, which of course is Dr Collingwood’s territory!”

I love the way the referral meeting turned into a cultural one. Looking back now, it has as much significance to the likes of Nobel Laureate Kandel as it did in my humble early child psychotherapy training.

Dr Collingwood has a nice bungalow in Aldeburgh which is of course the home of Benjamin Britten and Peter Pears. The opera, I have never heard of until one day the librarian was placing new discs onto the shelves and hinted to me that it was a great one to listen to. Dr Collingwood is one of the volunteer ushers at The Maltings and some years later when our family spent a week at Aldeburgh and we pay pilgrimage to The Maltings for a Peter Pears recital. We met Imogen Holst, daughter of the composer at the sea front.

It took over 30 years for us to see a performance of Peter Grimes at the Royal Opera House[1].

I have by now seen quite a few children in therapy and I have on the whole been quite relaxed about using the toys and drawings throwing in Winnicott’s squiggle game[2] now and again for the children who are a bit too old for the set toys we have. It is interesting that most other junior doctors are more at ease with the older adolescents where they often come round to our case presentations to hear about the younger kids. It was only when I became a consultant that I realise it was unusual to have a preference for the very young children whereas many of my colleagues somehow avoided them.


Now what do I do with this adolescent that our paediatrician thought needs some fairly deep therapy as he seem to be struggling with everything and most serious of all with his mother.

Unlike working as a consultant, I did not get to see the parents at all. Most of the time it would have been Miss Frys or her Social Worker trainee. The Psychologist only access a child if referred by the Consultant.
Some other time, Dr Collingwood would see the parents.

As it turn out, Jonas’ father is a Surgeon at the Hospital where the paediatrician works and his mother teaches piano at his school, one of the best known state school in the area. It is so good that many of the professional class living in Hampstead send their children there. Do we still wonder why good areas have good schools! Of course it is only natural that good areas with intelligent pupils attract good teachers. It goes on.

I have at least learned from Winnicott’s squiggle game the importance of the therapist’s quick response and spontaneity and why should talking to the older child be any different.

Traditional psychotherapist will probably throw up in horroe but at least those I am learning from do not have or suffer from that kind of rigidity.
Much later as a consultant I have adapted this approach well as it helps to establish rapport very quickly especially with parents.

But my supervisor wants to throw me into the deep end and I have no idea what to do.

Jonas first noticed the Mondrian on the wall.

“Did some kid do that? Very neat!”

Perhaps he is right. Picasso wanted to draw like a kid too.

Then he noticed the records I was about to return to the library: Mozart Quintets.

“Mozart’s best as he wrote for himself!”

That was how we started. Some might think I plotted it by putting the records on my desk. I wish I could have claimed to have planned it. I think sometimes spontaneity may be best.

But this boy knows his music and yet I am not quite prepared for what he gave me as the sessions progress.

Many thought the therapist is suppose to be a mirror and be there to let the patient see more clearly about their own psyche. Others are more assertive and felt compelled to make interpretations not realising that often one is limited by ones own psyche or understanding of it. Hence the need for some personal analysis to deal with that aspect.

There is of course a world of difference between reflection and interpretation. My personal feeling is that there needs to be a balance between the two.

Psychotherapy is thus quite far removed from medical history taking. In a severe medical episode, there is a need to get a clear view of the events leading to the episode in order that appropriate investigation is carried out to be followed by the right course of treatment.

Psychotherapy afforded us with the luxury of a deeper understanding of the patient without having to ask probing questions. It goes without saying that with the more frequent sessions of therapy the therapist gains a very deep understanding of the patient without the need to go through an intensive and compact history taking. We also tend to remember these patients literally for ever.

Jonas hardly sees his father as he is busy his patients. His mother would have been a concert pianist but she had to make a choice between bringing up Jonas and looking after a rather nice house on the Heath. But she has high hopes for Jonas, her only child.

Yes, to be something she could only dream of, a concert pianist. Jonas has been a good piano player but once he turned nine told mother he would like to learn the violin.

He picked that up in no time and is now on to Grade 8 exam for violin. He left his Piano at Grade 5.

As I progressed with Jonas, it became clear the very strange role I am playing. I am his mother that he can talk to and argue with. And perhaps practice with. In truth it was easier as I am not his mother and on the other hand I am. But I am the one who could provide some answer his mother would not give him.

One day I have a complete set of Brahms Symphonies on my desk, from the library of course, and he casually asked if Brahms was my favourite composer or not.

Brahms 1st Symphony was a present given to me by one of my uncles when I made my amplifier. He worked for Abbotts in Hong Kong and when I got to medical school, he gave me my Littmann Stethoscope.

“I love the 1st especially the solo violin part in the last movement.”

“Well, you should listen to Mahler as he used various bits of singing unlike Beethoven’s Choral Symphony. And my best Mahler is his Third Symphony, though everybody else I know prefer the 2nd.”

The truth is I have two commuting friends that are fond of music and Mahler has not been one they talk about.
Yosemite ©2007 Am Ang Zhang
I tried that day to secure any Mahler and could only find one: Das Lied von der Erde.

It was a shock to my commuting friends especially when they read the details: Chinese poems translated by a German?

During the next session, I have not seen Jonas more enthused and energetic. He could not wait to tell me more about Mahler[3]. The 3rd Symphony[4]s all about nature and is so positive and energising.
I have to say now that I have probable gained more from this one patient than I have from any other. To be introduced to Mahler at the time when London was just waking up to it and wake up it did.

We were able to talk about the struggle of Mahler and of the sadness of the death of his daughter and eventually him dying of Rheumatic Heart Disease[5].

One day he was able to declare that his struggles were nothing compare to Mahler’s.

It is interesting that he never really talked about his own sadness as Mahler’s overshadow his and yet in true traditional psychotherapy style he has gain his own insight.

His time with me, or was it my time with him was coming to an end. Dr Collingwood is highly intuitive and on the recommendation of my psychotherapy supervisor helped me to terminate the therapy. It was perhaps a credit for a state funded system like the NHS that one does not need to hang on to therapy for ensuring adequate income. The main danger for privately funded psychotherapy is the unnecessarily prolonged therapy periods with the result that the patient is addicted to the therapist or the other way round.

On his last session, he told me he has got his distinction in Grade 8 Violin but he did not want to be a violinist.

He wants to be a conductor.

As I wrote this, I Googled and found that he is now a conductor for a German Opera Company.

No, Jonas is not his real name.

In 2009, Das Lied von der Erde was performed in Hong Kong and The Mahler 3rd in December of 2016[6], a sort of home coming. Thank you Jonas for introducing me to Mahler.

Nature & Mahler: Royal Festival Hall!