Terrace Herb Garden 2011 – Beginnings

It amazes me every spring to look out at what I assume is a dead herb garden and find the chives overwintered and blossoming. I planted that one pot of chives over 10 years ago, and it just won’t quit! At some point I think I’m supposed to move it to a larger pot, but I’m so afraid to disturb what I assume is a perfect container ecosystem.

The sage and oregano also made it though the season, though the sage is mostly wood with a few tiny leaves. We picked up new basil, parsley, thyme, lavendar and mint plants at the Union Square Farmer’s Market yesterday, along with a single hot pepper plant and some red lettuce and mesclun mix that I think I may have packed too tightly into one pot and will probably re-do tomorrow.

The pansies that I picked up for a song one weekend last month in Massachusetts are overflowing the window boxes, and I’ve added a few to the herb garden for color in this early part of the season.

The chocolate vine we planted at the end of last season has taken off, and will need a bit of taming to the trellis.

Unfortunately the ornamental grasses did not survive, so we will be heading to the nursery to get more for this season. I am toying with the idea of turning the grass box into a regular vegetable garden, but really need the height of the grasses to soften the brick corner and give me something to look out at from the kitchen window.

I also plan on getting more basil and really going big on the pesto-making this summer. We had to resort to store bought pesto this past winter, and that’s just wrong.Our freezer may not be big enough to hold what I plan to make, so I think I’ll do some in jars this season.

Am debating about using the rest of the Miracle Gro I have or trying something else to feed the garden this year. Any suggestions in this regard are most welcome..

Unfortunately, one of our favorite nurseries, Liberty Sunset in Brooklyn, has closed. I plan to check out the new Urban Garden Center, run by the same family that ran Dimitri’s, to see what we can find there. What’s your fave place for plants in NYC?

Next project – the roof.

Bialy – My New Bagel

My coffee guy now has bialys and I’m loving them!

A bialy is like a bagel, but smaller, is baked rather than boiled and instead of a hole, has a depression filled with a little mixture of fresh soft onions. Bialys have less calories than bagels – 240 vs 300 calories according to the H&H website, though some websites say the calorie count is even lower. Bialys don’t need cream cheese, so there’s another calorie saving. (Unless of course, you add a very tiny pat of butter, which is what my coffee guy does for me…)

I mostly love that Bialys are from Bialystok, Poland.* This reminds me of Max Bialystock in the Producers, which reminds me of his whacky secretary Ulla who answers the phone “Bialystock and Bloom, got dag pa dig!”, so everytime I get a bialy that’s what I say to myself.

These are the little joys of my morning….

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I’m not the only one who loves bialys …

* The Bialy Eaters: the Story of a Bread and a Lost World is Mimi Sheraton’s history of the bialy and the lost community of Jews from Bialystock. It’s on my to-read list.

Sidewalk Chalk Wisdom

NYC street artist James De la Vega seems to have left a few thoughts behind on the sidewalk outside the hospital.  Glad I caught them this morning on the way to work before the rain started.

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I’m not the only one catching De La Vega’s work –

Doctors, Social Media and Patient Privacy

A Rhode Island emergency room doc has been fired for posting about a trauma patient on her facebook page. While the post did not reveal patient name or personal identifiers, it had enough clinical info that a third party was able to  recognize the patient.

I say if you’re going to write online about a patient, you had better disguise them so well they don’t even recognize themselves, and never post anywhere near the time of the event’s occurrence. Some bloggers I know change age, sex and other details, and post events long after they’ve happened, so no one one could ever know for sure who they’re talking about. Some doc bloggers go so far as to disguise themselves – preferring to remain anonymous both to protect themselves and their patients.

Some medical blogsites are rich with teaching cases, including x-rays and clinical information that, if disguised, would alter the diagnostic possibilities. As online venues begin to replace the time honored medical journal or local grand rounds, how do we keep our ability to teach one another with clinical cases and still respect patient privacy?  In the past, the limited circulation of medical journals kept these cases amongst the medical community, but now with the internet (and the lay public’s interest in medicine), the audience for such case histories is limitless.

It may be time to develop some sort of standard guidelines and release before writing about a patient on a social media site. Email and electronic signatures could streamline that process so that we don’t lose what makes the internet different than the medical journals – immediacy and accessibility. As an example, here is JAMA’s privacy policy and a link to their patient consent.

Identification of Patients in Descriptions, Photographs, Video, and Pedigrees. A signed statement of informed consent to publish (in print and online) patient descriptions, photographs, video, and pedigrees should be obtained from all persons (parents or legal guardians for minors) who can be identified (including by the patients themselves) in such written descriptions, photographs, or pedigrees and should be submitted with the manuscript and indicated in the Acknowledgment section of the manuscript. Such persons should be shown the manuscript before its submission. Omitting data or making data less specific to deidentify patients is acceptable, but changing any such data is not acceptable.

It’s a brave new world out there, folks, so be careful. For the record , I won’t post about a patient without her explicit permission, and even then I disguise her so that no one would recognize her. Which is why this blog is a bit light on patient tales. Food is a much safer topic if you ask me….

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Other posts I’ve written on this topic

Yaz and Blood Clots – Two More Studies Point to Higher Risks

Update – the FDA addresses clot risks and Yaz

Two studies published in this weeks’ British Medical Journal, one from the US and the other from the UK, report that users of drosperinone containing oral contraceptives (Yaz, Yasmin and their generics) have increased relative risks for non-fatal blood clots compared with users of pills containing levonorgestrel.

While neither study is perfect, and indeed have some very major limitations, they add to a growing body of evidence that pills containing drosperinone may impart higher risks for blood clots than older pills. Yaz is not alone in this regard – other studies have suggested that pills containing the newer progestins gestodene and desogestrel also impart slightly high clot risks than the so-called first and second generation pills containing the older progestins norethindrone and levonorgestrel.

I won’t go into the studies’ limitations here, but will say that trying to get our hands around comparative data on clot risks between various pills is an extraordinarily difficult process given that the diagnosis of blood clots is not always straightforward (or correct), pill choices are not randomized and fraught with prescribing bias, and confounding risk factors for clotting are numerous and difficult to control for. I wish folks would stop trying to answer these questions on the quick and cheap using claims and pharmacy databases without requiring chart review and strict diagnostic criteria. But that’s the way these studies are being done, and that’s the data I am being forced to contend with in my practice, so let’s talk about it.  Continue Reading

Strawberry Rhubarb Pie

Although I did not actually make this masterpiece*, if it were being published in a journal I would be last author, Mr TBTAM second, and my daughter first author. I initiated the project and sent Mr TBTAM shopping for the ingredients, but when I invited my daughter to join me in making the pie, she stated “I want to make it myself”.

And so she did.

Nice job, honey.

* The recipe is from Bon Appetit via Epicurious, although we substituted a double recipe of pate brisee from the Pleasures of Cooking for the shortening crust. I guess they get authorship too, huh? I’m think a dusting of confectioners sugar and a dollop of vanilla ice cream would be an excellent way to serve it at Easter Dinner later today.

The OBG Why Me Blues

If I ever get enough time and guts to put together a cabaret act, this is totally gonna’ be my opening number…

The WHI – Yet Another Follow up

This is the study that doesn’t end…
The longterm follow up extends…
Some people started studying hormones in menopause,
And they’ll continue publishing more data just because…
(repeat)

In yet another paper in a major journal, we hear once more from the investigators of the Women’s Health Initiative. This time it’s the long term outcomes of women who took estrogen alone, now seven years out from stopping their hormones. What new information can we learn from this extensive analysis of new data?

Nothing.

Really.

The WHI’s been telling us the same thing about ERT (Estrogen replacement therapy) and HRT (Combination estrogen/progestin therapy)  since 2002, and all each subsequent study does is reinforce and expand on that initial data. The data on breast cancer risk and estrogen alone was first published in 2004, but the media ignored it the. It is only now making it news.

Allow me to summarize what we know  –  Continue Reading

FDA Does the Right Thing re Makena

The FDA has announced that it will allow compounding of hydroxyprogesterone caproate, in the wake of Makena manufacturer K-V Pharmaceutical’s plan to bring the previously inexpensive generic product to market at a price 100 times its cost.

FDA understands that the manufacturer of Makena, KV Pharmaceuticals, has sent letters to pharmacists indicating that FDA will no longer exercise enforcement discretion with regard to compounded versions of Makena. This is not correct.

In order to support access to this important drug, at this time and under this unique situation, FDA does not intend to take enforcement action against pharmacies that compound hydroxyprogesterone caproate based on a valid prescription for an individually identified patient unless the compounded products are unsafe, of substandard quality, or are not being compounded in accordance with appropriate standards for compounding sterile products. As always, FDA may at any time revisit a decision to exercise enforcement discretion.

There will be those who will argue that this will discourage pharmaceutical companies from producing so-called orphan drugs, and somehow try to make this case into something bigger than what it is, which is simply the story of how the new management of one drug manufacturer tried to turn a bad company around by turning a small profit maker into a blockbuster drug.

I happen to agree (for once) with my Pharma-friend Schrugglin’s comment on my prior Makena post that the FDA holds a significant portion of the blame here for not steering this product towards a more reputable manufacturer. I encourage you to read his thoughtful comments if you want Pharma’s side on this issue.

Hopefully the FDA and KV will come to a compromise that will allow Makena to turn a profit for KV without them resorting to price gouging. Stockholders may need to adjust their expectations a bit more in line with reality.

The sad thing is that we have created an industry whose only definition of success is blockbuster.  While that may work for the movie industry, it’s not appropriate for healthcare.  We need to readjust the business model.

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More on Makena –

  • St Louis Dispatch – March of Dines, Am Acad of Peds and ACOG met with KV to persuade KV to lower price
  • Via Pharmalot – KV Stock plummets, and there are parallels to the colchicine story
  • Corante In the Pipeline – Interesting discussion in the comments section on the issue
  • Health Reforms Watch – After Makena – Is there a better business model?
  • Gekkowire outlines KV’s finances and reveals how much it had counted on Makena profits

Loving Doc Martin

No, not the shoes. The British TV series.

Martin is surgeon, whose glittering career comes crashing down around him when he develops a phobia which prevents him conducting operations. He makes a life changing decision to retrain as a GP, and applies for a vacant post in the sleepy Cornish hamlet of Portwenn, where he spent childhood holidays.

Doc Martin is as grumpy, short-tempered and brilliant as House, and while he has no cadre of residents to torture, he does have a town full of varied and wonderful characters to annoy him. And of course, there’s a love interest.

We’ve barely started watching, and already there have been these memorable lines –

Patient – Am I your first official patient?
Doc Martin – You are indeed. Collect a thousand loyalty points and you get a free coffin.

Elderly patient with a cough – Could it be something serious?
Doc Martin (writing a script for medicine) –  Yes. Lung cancer.

Patient: And you reckon these will work, do you?
Doc. Martin: No – I just prescribe them for fun.

Doc Martin – Well, there’s the mystery of medicine. Everyone comes to you for an opinion but when you actually give them that opinion nobody really wants it, do they?

I took a bit of umbrage when the only treatment the good doc offered for osteoporosis was an increase in estrogen dosing, but he has the right attitude when it comes to vaccines.

Thanks to Mr TBTAM for discovering this wonderful series in the DVD section of our local library. You can also watch the grumpy Doc on Hulu.

And though they are spelled differently, I actually do love the shoes too. 

Homemade Croutons

We like to buy nice bread, and always store leftovers in the freezer. When the leftovers begin to infringe on Mr TBTAM’s ice cream space, I make breadcrumbs. But what does Mr TBTAM do when I’ve made breadcrumbs and he still has no room for his ice cream?

He makes croutons! (Did I mention he actually cooks more than I do?…) Then he uses them in our fave everyday salad -Bibb lettuce and mesclun greens with goat cheese, dried cranberries and balsamic or lemon vinaigrette.

We’re storing the croutons in an airtight glass jar in the cabinet. I do keep breadcrumbs in the freezer, but I have a feeling these delicious babies will be gone long before they get stale or rancid in the jar. What do you think?

Homemade Croutons

Use whatever dried spices you like, but be generous with the salt and pepper. If you use fresh garlic, better to fry it up in the oil first, then discard the garlic and use the garlic=flavored oil so you don’t get burnt garlic pieces on your croutons.

  • 4 cups cubed leftover French Baguette (If frozen, thaw it just enough to be able to slice it)
  • 1/4 cup olive oil
  • Salt
  • Pepper
  • Dried spices to your liking (we used some garlic powder and paprika, you could use dried herbs)

Directions: Preheat oven to 350 degrees fahrenheit. Toss the bread with olive oil and the spices in a large bowl being sure to coat well. Spread our in a single layer on baking sheet and bake till golden, about 20 minutes, tossing a few times to be sure they brown evenly.
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Crouton Round-up – If you have a favorite crouton recipe, send me a link and I’ll put it here.

  • Celtic Mommy makes her Croutons w/ sourdough bread and parmesan
  • OurGirlBites uses sourdough, garlic and herbs.
  • Cooks Hideout uses Herbs de Provence and just a tbsp of oil for 4 cups of bread, and they look delish!
  • Dogtipper makes bone-shaped croutons for dogs! I have to admit, I’ve been tossing a few to our pup and she loves them…
  • Underground Caterer uses fresh herbs and has instructional pics

An Emotional Grand Rounds

Dr Val at Get Better Health has organized this week’s Grand Rounds submissions according to the emotions they evoke. (No surprise my post on Mikena pricing is assigned to the “Outrage” group…..)

Head on over for some great reading.

The Doctor’s Wife Has Breast Cancer

If you’ve come here looking for Peter Bach’s recent New Yorker essay on his wife’s death, it’s here. And here are my thoughts on his essay.

A Well Blog post series in the NY Times, written by Peter Bach, MD, an attending physician at Memorial Sloan-Kettering Cancer Center in NYC, chronicle’s his experiences with his wife’s diagnosis and treatment for breast cancer.

As painful as it was to read of Bach’s wife’s breast cancer diagnosis and treatment, I found reading the comments section on the first few posts to be equally difficult. The comments ranged from supportive to downright vitriolic, as patients took the opportunity to vent at doctors and a medical system that they perceive gave Bach’s wife better access to treatment than theirs. The bitterness that comes through these comments is astonishing, but should not be.

Fortunately, as the series has progressed, the bitter comments have subsided. (And Bach has a much better photo…) His most recent post on how his wife’s doc refused to spout recurrence numbers for them was quite thought (and comment) provoking.

So, Doc, why not just tell us our odds?

Ruth’s oncologist elaborated on his refusal, promising he would tell us the number just as soon as we told him what probability of recurrence would cause us to make different choices for our lives.

Neither of us had an answer.

I encourage you to spend some time reading this excellent series and discussion it has prompted. I wish Dr Bach’s wife all the best for a speedy recovery and both of them many years ahead together.