Thursday, June 29, 2017

2011: Hip Replacement & Bladder Cancer!

Panama Canal & Medical Science!


As Hip replacement hit the news again, here is my reprint:

  
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
  
  

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.”

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:

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.

Feb 4, 2012

Tribology: Hip Replacement & Cancer


My golfing friend wrote to me asking if I have read the latest in The
Telegraph.

"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. 

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,

Wednesday, June 28, 2017

Norway & Hong Kong: Drunk Or Art Nouveau!


Democracy Or Alcohol?



Ålesund ©2012 Am Ang Zhang

In 1904 fire destroyed most of Ålesund.

It was rebuilt in Art Nouveau style and is arguably the most beautiful city in Norway without the City Hall.

Democracy: Voted against joining EU in 1972 and 1994.


Norway is one of the richest and most contented nations on earth, with a GDP per capita of £40,000 – compared to £23,000 in the UK, and an EU average of £21,150.
Unemployment is at 3.25 per cent, while GDP is growing at 2.75 per cent per year – as it has on average over the last 40 years.

It also regularly tops the UN's survey of quality of life, with a generous welfare system – women receive 46 weeks maternity leave at full salary, compared to Britain's six weeks on 90 per cent – and free education (incl. universities) is provided for all.

The country funds this through its huge reserves of oil, timber and fish which it manages prudently, stashing away large percentages of its oil revenues to fund the future healthcare needs of an ageing population.

Alcohol:


Do we ever learn that prohibition never did anything to alcohol consumption nor would price control? 


With the millions spent on Cocaine in Wall Street and The City, when will we wake up to the fact that these are Tax Free perks?




©2013 Am Ang Zhang

By Wendy Leung - February 27, 2008 05:37 EST
In a place without democracy!

Feb. 27 (Bloomberg) -- Hong Kong's government abolished taxes on wine and beer after posting a record surplus, boosting efforts to turn the city into a wine-trading hub.

The tariffs will be abolished immediately, costing the city government HK$560 million ($72 million) in annual tax revenue.
Tax was 80% before 2007 then 40%


The rest of Hong Kong Tax:
No sales tax
No capital gains tax
No VAT
Maximum salary tax of 20%
Profit tax maximum of 16%
Inheritance tax or estate duty has been abolished since             11February 2006. 

Yet, my doctor friends told me that there is no binge drinking problem like they have in Norway where there is high taxation and much difficulty in buying alcohol.

Strange: A drink too many!

Ålesund Norway©2012 Am Ang Zhang





Solveig Torvik 
December 16, 2010 

Weekend binge drinking is a perplexing feature of Norwegian cultural life to many visitors.

The role of alcohol in Norway often appears to be to consume it until you’re senseless, and alcohol commonly is accepted as an excuse for indulging in antisocial behavior. Binge drinking seemingly isn’t regarded as aberrant behavior in Norway, even by sober citizens who, generally speaking, uncomplainingly tolerate the ensuing brawls and other unpleasant results.

But why do so many people who do live in the “world’s best place” drink until they’re comatose? And why are many of them prone to violence and aggression when drunk? No one knows.

Dr Ole Johan Hoyberg, formerly a hospital-based psychiatrist in Ålesund, told newspaper Sunnmørsposten: “There’s a great deal more drunkenness in the communities that I got an insight about as a hospital doctor. Alcohol abuse is on the point of becoming a national sickness.”

Which seems an odd state of affairs indeed for a nation that’s billed as the world’s best place to live.

Perhaps no tax on alcohol beats democracy!


Monday, June 26, 2017

Mahler: Sadness & Pleasure Principle


©2016 Am Ang Zhang


Farewell                      Wang Wei (701-761)
Dismounting, let me share your farewell wine  
Where, friend are you heading now?
Choking, fate has not been kind to me
Will retire to the southern slopes to seek rest
Enquire no more when I am gone 
Till the end of clouds, endless white clouds!

Pleasure Principle:


Sigmund Freud’s Pleasure Principle is well known, but his other small “contribution” to mankind, i.e. his unofficial discovery of Cocaine, is probably less so. He in fact became quite an enthusiastic user of cocaine, in addition to smoking a large quantity of cigars, up to 20 a day. He developed jaw cancer and had to endure 33 operations and eventually died of it. 
I am not here to encourage the use of cocaine or cigars (as if people who used them needed encouragement). 
Instead I am going to talk about some of my pleasure pursuits. I have from an early age been interested in music though I have never played any instrument except the “gramophone” if you can call it an instrument. It can also be said that I play these instruments by “proxy” through my children. I have always had a multitude of hobbies: photography, electronics (I built my own radios and valve amplifiers), and snorkeling to name a few. Arriving in London in the early 70s allowed for easy access to France and French wine and food remains one of my most pleasurable pursuits, though my interest in wines has now been extended to Port and other non-French wines. 


Sadness

In life one goes through difficult times and we Chinese are fairly philosophical about it – unhappiness is often viewed as something secondary to external circumstances such as loss and bereavement, political injustice (which has afflicted most of our families) and other life events that are beyond our control. Our classical poets wrote about such sadness and generally accepted what life befell them. 

When life events do not go our way, some turn to religion, although more and more people nowadays turn to the “happy pill” (drugs). One can also seek comfort in Music, Poetry, Photography, Writing (and blogging), Painting, Fishing, Knitting, Travel and of course Food and Wine. 

In an age when people sought happiness in all ways possible we need to remind ourselves that sadness has been the driving force behind many writers and composers.

Mahler wrote Kindertotenlieder to five poems written by Rückert. Rückert wrote 428 poems following the death of his two children from Scarlet Fever. 

Mahler lived in an age when bacteriology was very much in its infancy. There was still little understanding of the role Streptococcus played in a range of illnesses from Scarlet Fever to Rheumatic Heart Disease and Radium was often used to treat Streptococcal related conditions.  

Mahler’s own daughter tragically died from Scarlet Fever four years after writing Kindertotenlieder and Mahler himself contracted Rheumatic heart disease. When there was still little understanding of the etiology of diseases, superstition came into play so much so that Mahler did not want to write a ninth symphony. It was the start of the Curse of the Ninth Symphony.

Das Lied von der Erde was indeed the result as it was composed after his Eighth Symphony and he did not want to name it his Ninth. 

Mahler conceived the work in 1908 when he was already unwell with his heart condition. A volume of ancient Chinese poetry under the title of The Chinese Flute (Chinesische Flöte) repoetized by Hans Bethge was published in German and Mahler was very much taken by the vision of earthly beauty expressed in these verses. Fate he felt has been unkind to him but he felt able to accept it in his own fashion.

                                                          

Mahler died on May 18th 1911 in Vienna.

"I think it is probably the most personal composition I have created thus far."    Gustav Mahler

The first performance of Das Lied von der Erde was conducted by Bruno Walter after Mahler's death. 

Bruno Walter described it as: "the most personal utterance among Mahler's creations, and perhaps in all music."

My first encounter was in the early 70s with the recording by Janet Baker and Waldemar Kmentt (with Kubelik conducting the Bavarian Radio Symphony Orchestra). I still think it is one of the very best performances of Das Lied von der Erde.

Monday, June 19, 2017

Germany: Health Care & Smoking!





Germans contributes 7% of salary before tax and employers match that amount.

In return, patients get access to care which is so rapid that national waiting data is not collected.

Germany's spending on health care is relatively high, just over 11% of its wealth, compared to 9.8% in the UK and it has more doctors and hospital beds per patient than the UK.

The Caesarean rate is higher, so is the use of MRI for diagnosis and the length of hospital stay.

Many doctors in Germany set up in practice on their own, as GPs or out-of-hospital specialists, but as cities are more popular that leaves rural areas with a shortage.

Most patients feel they can see a doctor easily, so for example the number of visits to the equivalent of A&E is very low compared to the UK.

While out of hours care has been reorganised, GPs and other out of hospital doctors are often still involved in helping provide cover on a rotation.

All Photos: 

©2017 Am Ang Zhang 


Apart from Greece, they have the highest % of smokers in the First World and they are between 20 to 24. Patriotic??