The EMR and the Pathologist – A Winning Combo

A pathologist uses the EMR to find out just a little more about the patient whose cerebro-spinal fluid she has under her microscope – and changes her diagnosis.

This patient had a diagnosis of plasma cell myeloma with recent acute mental status changes. So the lone plasma cell or two I was seeing, among the lymphs and monos, could indicate leptomeningeal spread of the patient’s disease process. I reversed the tech diagnosis to atypical and added a lengthy comment – unfortunately there weren’t enough cells to attempt flow cytometry to assess for clonality of the plasma cells to cinch the diagnosis. But with the information in the EMR I was able to get a more holistic picture on a couple of cells and provide better care for the patient. I cringe to wonder if I might have blown them off as lymphs without my crutch.

The much hoped-for improvement in quality due to the adoption of EMRs has been elusive to date, so anecdotal experiences like this will be important evidence to consider in judging the impact of the EMR on health care outcomes.

Kudos to pathologist Gizabeth Shyner, who writes over at Mothers in Medicine and her own blog, Methodical Madness,  for “Thinking Outside the Box”.

Sondheim on Blogging

Actually, I have no idea if the Great One even knows what a blog is. But the preface of his book Finishing the Hat contains what could be the best writing advice this blogger’s ever read.

There are only three principles necessary for a lyric writer (blogger), all of them familiar truisms… In no particular order, and to be written in stone –

Content Dictates Form

Less is More

God is in the Details

all in the service of

Clarity

without which nothing else matters.

Now go forth and write.

(Photo- Jerry Jackson, coutesy Indian U.)

2010 Medblog Awards Winners

Congratulations to the fabulous blogs that have won the coveted Medblog Awards this year! If you don’t read these blogs already, you’re missing out on some great blogging.

  • Best Medical Weblog of 2010 – EMCrit blog. An intense blog from an ER intensivist.
  • 2010’s Best New Medical Weblog – ZDoggMD. Medical rap. Yo.
  • The Best Literary Medical Weblog – StorytellERdoc. This ER doc has a way with words.
  • The Best Clinical Weblog of 2010 – GeriPal. Geriatrics and palliative care, the true angels in healthcare.
  • The Best Health Policies/Ethics Weblog – Covert Rationing Blog. The blog that dares to use the “R” word in healthcare.
  • The Best Medical Technologies/Informatics Weblog – ScienceRoll. Informatics and Genetics.
  • This year’s Best Patient’s Blog – Wheelchair Kamikaze. A go to blog for MS patients and those who love them.

We Must Keep Title X and Planned Parenthood Funding

The House of Representatives will vote this week on continuing resolutions that could end funding for Title X programs and eliminate all Title X Funding going to Planned Parenthood.

Despite the beliefs of their supporters, these resolutions will NOT reduce abortions. In fact, if they pass, abortion rates will surely increase. In addition, vital preventive health services will be cut.

Here are the lies you may have heard about Title X and Planned Parenthood, and the truth you need to know –

Lie #1 : Title X Funding pays for abortion –  FALSE.

It does not, because, by law, it cannot. Here’s what Title X funded for in 2009, straight from the the HHS Website:

  • Contraceptive services for over 5 million family planning users;
  • Over 2 million pap smears, 1% of which had precancerous abnormalities that required treatment;
  • Over 2 million clinical breast exams, 3% of which were abnormal and led to further evaluation or treatment;
  • Over 2 million STD screening tests; and
  • Almost 1 million HIV tests

The majority of Title X funded clinics serve clients with incomes at or below the poverty line, and who have no other funding source for these services. In some states, Planned Parenthood is the only provider of Title X services.

Lie #2 – Planned Parenthood’s Major Business is Abortion – FALSE.

Ninety seven percent of Planned Parenthood’ services are contraception, cancer screening and STD screening and treatment.  Only 3% of the almost 11 million services provided in 2008 were abortions. (Click the pie chart below for detail.)

Lie #3: We can’t afford Title X funding – FALSE.

We can’t afford not to pay for these preventive health services, all of which have been shown to be a cost effective use of federal funds. According to the Guttmacher Institute –

The contraceptive services provided at (Title-X funded) centers helped women and couples avoid 973,000 unintended pregnancies, which would have resulted in 433,000 unplanned births and 406,000 abortions.

By helping women avoid unintended pregnancies, Title X–supported family planning centers saved taxpayers $3.4 billion in 2008—or $3.74 for every $1 spent on contraceptive care.

Lie #4 . Taking Title X funds away from Planned Parenthood will prevent abortion – FALSE.

Loss of funding for contraception means more unplanned pregnancies, which means more abortions.  Without restating the above argument, I’ll state the obvious –

If you want to prevent abortion, you’ll contact your representative and tell him/her to vote against any attempt to eliminate Title X funding.

Take action now.  The threat to funding is real, and the need is urgent.

Linguine with Shrimp and Cilantro Lime Pesto

The weeknight warriors have done it again, this time with a delicious pasta recipe.

My role in the whole operation was limited to finding a recipe after Mr. TBTAM and I agreed over the phone on the ingredients we had in mind – shrimp, lime, pasta. I emailed him the recipe, then went back to work, strolling in the door at 7 to younger daughter having a piano lesson and Mr .TBTAM reading in the den, the table set, salad made, pasta water simmering and the ingredients for the meal prepped and waiting for the final cook after the lesson was over. I quickly made a lemon vinaigrette for the salad and started some applesauce cooking for dessert while Mr. TBTAM cooked and assembled the pasta.

But hey, I did the dishes, so it all comes out even.

Linguine with Shrimp & Cilantro-Lime Pesto
Modified from Bon Appetit, July 2010

This recipe uses Cotijo cheese, or Mexican Parmesan, an artisan cheese made from cow’s milk taken during the rainy season when the grass grows on the mountainside. Coteja is sort of a cross between a mild feta and a parmesan – salty, white, softer than parmesan, but easily crumbled – and does not melt when cooked. We found ours at Fairway, where it was very reasonably priced. You can substitute Feta if you can’t find Cotija.

I was taken aback by the final calorie count on this recipe – for 4 servings, it’s a whopping 830 calories each. Of course, one does not have to have an entire 1/4 pound of pasta per serving, but this stuff is so good it’s like crack. Next time, I’ll portion it to serve 6, cut back the olive oil to 1/4 cup, the tequila to 2 tbsp and up the lime juice to 4 tbsp total to lose some calories – I don’t think it will hurt it at all.  Any other suggestions on lightening this dish without losing its oomph would be most appreciated.

Ingredients

  • 1 1/2 cups fresh cilantro leaves, plus 1/4 cup chopped
  • 1/4 cup coarsely chopped scallions
  • 3 tbsp fresh lime juice
  • 2 garlic cloves, sliced
  • 1 tbsp chopped, seeded serrano pepper
  • 1/2 cup plus 1 tbsp olive oil
  • 1 lb linguine
  • 1 lb medium shrimp, peeled, deveined
  • 3 tbsp tequila
  • 1/4 cup crumbled Cotija cheese

Preparation

Blend 1 1/4 cups cilantro leaves and next 4 ingredients in processor until coarse puree forms. With machine running, gradually add 1/2 cup oil. Season with salt.

Cook linguine in large pot of boiling salted water until al dente. Drain. Meanwhile, heat remaining 1 tablespoon oil in heavy large skillet over medium-high heat. Add shrimp and cook until almost opaque in center, about 3 minutes. Remove skillet from heat; add tequila. Return skillet to heat and stir until sauce is syrupy, about 30 seconds. Add pesto; stir to coat. Remove from heat.

Add pasta to sauce in skillet; toss to coat. Season with salt and pepper. To serve, plate and sprinkle with Cotija cheese and chopped cilantro.
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I’m not the only one making this pasta.

  • Michael Beyer does a gorgeous big plating.
  • Mardi suggests a splash of lime juice at serving. Turns out that’s just what my daughter did.
  • Erin made hers with Parmesan and Feta and added some hot pepper flakes.
  • Sally at Bewitching Kitchen notes that it’s unusual to find fish and cheese paired so well.
  • Shea Evans and his cat takes a pretty pic of this pasta.
  • Eye for a Recipe shows you what the pesto looks like before being added to the pasta. Hmmm!!
  • Jennifer makes the pasta while recovering from a belly dancing lesson. That’s one way to work off the calories.
  • Amanda is as excited as I am to have discovered Cotija cheese.

Biologic SuperGlue for Repair of Childbirth Lacerations

Bio-adhesives are a reasonable alternative to sutures for repair of perineal lacerations sustained during childbirth, according to a poster presentation at last week’s annual meeting of the Society for Maternal Fetal Medicine. Researchers at the Hadassah Hebrew University Medical Center in Jerusalem randomized women with first degree perineal tears to either 2-octyl cyanoacrylate (Dermabond) adhesive glue or suture for wound closure. While healing and incisional pain was similar, women who received the adhesive closure were more satisfied than those who were sutured.

In Portugal, bioadhesives have been studied for closure of the top skin layer of an episiotomy repair, and found to shorten the duration of the procedure with similar outcomes to suture in terms of pain, healing and infection.

Biologic adhesives are chemically related to Superglue, which is ethyl-cyanoacrylate. Midwives have been using Superglue for perineal wound repair for some time, according to Anne Frye, who has authored a book on wound closure for midwives, and who gives instructions for its use in repair of perineal lacerations. Apparently Superglue was also used by the military during Vietnam for wound closure.

A Pub Med search on Dermabond finds multiple studies of its use, from plastic surgery to mastectomy, surgical wound closure, retinal surgery, lung and gastric leak closure, and even on esophageal varices. RL Bates mentions Dermabond as an option to repair skin tears in elderly patients. This stuff is turning into the duct tape of the medical profession…

It’s important to remember that adhesives are only for superficial skin closure, as use in deeper layers can cause irritation and burning of tissues. Side effects of their use include irritation and allergic reactions, and of course wound infections and pain can always occur no matter how one closes a wound.

Mrs. Goundo’s Daughter
National broadcast premiere
PBS World’s AfroPop series on February 9, 2011 at 7 pm.
Check local listings for additional dates and times
(The film will be shown multiple times )

Mrs. Goundo’s Daughter follows the tale of a Malian woman protecting her daughter from the harmful tradition of female genital mutilation.

Congrats to my good friend Janet Goldwater and fellow film maker Barbara Attie on this important premiere. I”ll be watching here in NYC on WNET/WLIW.

Abortion does not cause mental illness

Yet another study showing that abortion does NOT lead to future psychiatric problems.

In Denmark, where termination of pregnancy is legal and freely available until the 12th gestational week, we found no significant increase in the incidence rate of psychiatric contact in the 12 months after an induced first-trimester abortion as compared with the 9-month period before the abortion. The incidence rate of psychiatric contact was higher among girls and women who underwent an abortion than among those who underwent delivery, but this relationship was evident before the abortion or childbirth occurred. On the basis of these results, it seems likely that girls and women having induced abortions constitute a population with higher psychiatric morbidity. We interpret this as a selection phenomenon rather than a causal association, since the observed difference in psychiatric morbidity between girls and women having abortions and girls and women delivering antedated the abortion or delivery.

Can we please talk about something else? Like maybe how to help these young women with the issues and unmet contraceptive needs that led to unplanned pregnancy in the first place?

Deepok, Oprah, Jenny, Suzanne – This one’s for you

Comedian Tim Minchin takes on the alternative medicine, pseudo-science, homeopathy crowd as he recounts, in rhyming beat, a dinner party encounter with a beautiful, woo-spouting, tattooed girl called Storm.

The anti-woo rant starts around 2:15. But find nine minutes and listen to the whole frickin’ thing. Especially the end  (starting at about 7:30).

Brilliant.

The Levonorgestrel IUD (Mirena) as an Alternative to Hysterectomy for Treatment of Adenomyosis

Diffuse adenomyosis as seen on transvaginal ultrasound

Adenomyosis is a benign condition in which the glands that normally line the inner cavity of the uterus grow within its muscular walls, causing uterine enlargement, heavy, painful menses and anemia. Adenomyosis can be likened to endometriosis within the uterus and, in fact, often co-exists with pelvic endometriosis.

Not all women with adenomyosis have symptoms, and those with mild symptoms can find relief with oral contraceptives or Depo Provera. But for women with more extensive disease whose quality of life and health are threatened by heavy bleeding and pain, and for whom these hormonal interventions fail, the best treatment until now has been hysterectomy.

Now a new study shows that the levonorgestrel IUD (Mirena) may be just as effective as hysterectomy in treating adenomyosis.

The data

Researchers in Turkey randomly assigned women with strictly-diagnosed adenomyosis to treatment with either hysterectomy or insertion of a levonorgestrel IUD (Mirena). At baseline, all the women had heavy menses for at least 6 months, in addition to other symptoms such as dysmenorrhea and painful intercourse. The mean hemoglobin in the groups was 10 gm/dL, indicating significant anemia.

At one year post treatment, both hysterectomy and IUD groups had normal hemoglobin levels and improved quality of life as measured by the World Health Organizations Quality of Life Questionnaire. The study authors state that the IUD group had a greater improvement in psychological and social measures, but I suspect this was because the IUD group has lower scores in these domains at baseline.

Complications of hysterectomy were limited to post op wound infection in one patient. IUD users experienced headache (11%) , acne (5%) , breast tenderness (7%) and transient mood issues (1 subject), but no woman requested removal of her IUD due to side effects. One woman expelled her IUD and went on to hysterectomy.

The Study Has Important Limitations

The authors do not tell us what treatments women had tried before entering this study, so I am a bit wary that they may not have adequately sampled the group of women with adenomyosis who are most likely to warrant hysterectomy – those women who have tried and failed hormonal treatments such as birth control pills. One would never proceed to hysterectomy without at least trying these interventions. If the group studied here included all comers with adenomyosis, and if Mirena was their first attempt at treating the condition, than of course the IUD would prove to be effective (and hysterectomy potentially unnecessary). In the same way, oral contraceptives could be said to be an effective hysterectomy alternative for adenomyosis.

Bottom Line

Not all adenomyosis needs to be treated. But if adenomyosis is causing significant symptoms, the Mirena IUD can be added to the list of treatment options, and may prevent the need for hysterectomy in women with the more severe forms of the condition. Although this particular study is only one year, previous research on Mirena use in adenomyosis has found that it remains effective for at least 3 years, although side effects reduce satisfaction a bit over time.

For any given women, if Mirena’s benefits don’t persist, or if its side effects become intolerable, hysterectomy is still there as an effective and definitive solution to the problem.

Of note, Mirena has also proven to be effective in treating endometriosis.

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Image from Geneva Foundation for Medical Education and Research (I believe these images are royalty free…)

Bisphenol-A (BPA) Associated with Poor Sperm Quality

Yet another study documenting the endocrine-disrupting effects of Bisphenol-A, this time in Chinese males with and without occupational BPA exposure –

Urine bisphenol-A (BPA) level in relation to semen quality.
Li DK, Zhou Z, Miao M, He Y, Wang J, Ferber J, Herrinton LJ, Gao E, Yuan W.

RESULT(S): After adjustment for potential confounders using linear regression, increasing urine BPA level was statistically significantly associated with [1] decreased sperm concentration, [2] decreased total sperm count, [3] decreased sperm vitality, and [4] decreased sperm motility. Compared with men who did not have detectable urine BPA levels, those with detectable urine BPA had more than three times the risk of lowered sperm concentration and lower sperm vitality, more than four times the risk of lower sperm count, and more than twice the risk of lower sperm motility. The urine BPA level was not associated with semen volume or abnormal sperm morphology. Similar dose-response associations were observed among men with environmental BPA exposure at levels comparable with those in the U.S population. Despite a markedly reduced sample size, the inverse correlation between increased urine BPA levels and decreased sperm concentration and total sperm count remained statistically significant.

CONCLUSION(S): These results provide the first epidemiologic evidence of an adverse effect of BPA on semen quality.

That bolded sentence there in the results section is the kicker.

Bisphenol-A exposure is not just an issue in men with occupational exposure – its impact can be seen in men with urinary BPA levels similar to those found in the US population. (something that the American Chemical Council seems to have conveniently ignored in its press release response to the study…)

The more research I read on Bisphenol-A, much of it in the reproductive health literature, the more I become convinced that the potential harms from use of this synthetic plastic additive are real.

Here’s advice from the NIH on reducing your BPA exposure

  • Don’t microwave polycarbonate plastic food containers. Polycarbonate is strong and durable, but over time it may break down from over use at high temperatures.
  • Polycarbonate containers that contain BPA usually have a #7 on the bottom
  • Reduce your use of canned foods.
  • When possible, opt for glass, porcelain or stainless steel containers, particularly for hot food or liquids.
  • Use baby bottles that are BPA free

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This research was published in this month’s Fertility and Sterility. On line version of the data was released in October and covered somewhat in the media at that time.

Building a Hospital in Haiti

Partners in Health is building a state of the art teaching medical facility in Mirebalais in Haiti’s underserved Central Plateau.

My niece Annie helped design the waste and water treatment parts of the project as part of her engineering internship with Northeastern University, and and will be joining the Partners group upon graduation. It’s so inspiring to see this wonderful project coming to fruition and to know that she will be a part of it!

You can be part of it too, by donating, volunteering or, like Annie, working for Partners in Health.

Partners in Health was founded by Paul Farmer and colleagues in 1987 to serve the poor in Haiti. Farmer’s story is the subject of Tracy Kidder’s book Mountains Beyond Mountains: The Quest of Dr. Paul Farmer, a Man Who Would Cure the World.

Philadelphia Abortion Doc Charged with Murder

Kudos to the Philadelphia Grand Jury for seeing past the politics of abortion that could have divided their opinion, and recognizing this case for what it is – the prosecution of a bad doctor delivering dangerous and horribly bad medical care to poor minority women while the negligent Department of Health did nothing to shut him down –

Let us say right up front that we realize this case will be used by those on both sides of the abortion debate.  We ourselves cover a spectrum of personal beliefs about the morality of abortion.  For us as a criminal grand jury, however, the case is not about that controversy; it is about disregard of the law and disdain for the lives and health of mothers and infants.  We find common ground in exposing what happened here, and in recommending measures to prevent anything like this from ever happening again.

That a medical practice such as this could still exist in a city where there are so many well-run, safe facilities offering the full range of reproductive health services is almost beyond belief.

That the Pennsylvania Department of Health would ignore the numerous complaints against this clinic – including one filed by one of Philadelphia’s most reputable adolescent medicine specialists  – is criminal.

And if someone at the Department of Health thought they were protecting women’s rights by neglecting to inspect abortion clinics, they got it wrong.

A second reason proffered by DOH attorneys for not licensing abortion clinics –that abortion is “controversial” – is just insulting. Abortion is a legal medical procedure. Any controversy surrounding the issue should not affect how the law is enforced or whether the Department of Health protects the safety of women seeking health care.

We made abortion legal so that it could be safe. Not so that butchers like Gosnell could be allowed to practice.

I hope they put him away for a very, very, very long time.