Win Free NYC Taxi Rides for a Year

UPDATE- The Nissan VN200 has won the competition!

At the risk of enlarging the contestant pool and lowering my own odds of winning, I”m telling you all about this great new contest sponsored by the NYC Taxi and Limousine Commission to help pick the winner of the Taxi of Tomorrow.

In 2007, City officials convened a group of stakeholders, including representatives of taxi drivers, owner and passengers, to create a set of goals for the next New York City taxi cab, a project called the Taxi of Tomorrow. In December 2009, the TLC issued a “request for proposals,” inviting auto manufacturers and designers to submit their best ideas for a purpose-built vehicle to serve as a New York City taxicab. Whichever of these designs that the City selects, if any, will be the next New York City taxicab (subject to constant improvements and enhancements) for the next ten years.

Complete a survey rating your top choice among the three finalists, tell the TLC about your taxi riding habits and opinions, and you’ll be entered into a sweepstakes to win free taxi rides (up to $5,000) for an entire year!

I personally liked the Karsan. Be eliminating the passenger front seat and adding a 4th rear facing seat to the back, all passengers can enter and exit the cab with ease, eliminating the “you go first” dance and the old back seat scoot.

From the survey, it also appears that the TLC is considering having an additional taxi light that warns that a passenger is about to be discharged. As a biker, I am ever fearful of car doors opening, so I love that idea.

I also took the opportunity in my survey to recommend that the TLC do a better job of staggering cab start times, with hopes of eliminating the 3:3o -5pm “witching hour” as I call it, when all the cab drivers are heading home to Queens and it’s almost impossible to get a cab.

So head on over and cast your vote, and may the best cab (and the luckiest New Yorker) win.

HRT Worries – This Time, It’s Ovarian Cancer Again….

HRT once again takes the media center stage, this time with new research linking post-menopausal estrogen use to ovarian cancer.

The data comes from a large European study  – the European Prospective Investigation into Cancer and Nutrition – and was presented as a poster (abstract B101 in the linked pdf) at the American Association for Cancer Research Meeting in Philadelphia.

In this study of over 160,000 women with 9 years of follow-up, use of post-menopausal estrogen-only therapy for more than five years was associated with a small but significantly increased of ovarian cancer. The increased risk occurred across all types of estrogens (sorry, Suzanne….) and all routes of administration, and increased with duration of estrogen use.

No increase in ovarian cancer risk was found for women taking estrogen plus progestin therapy.

This is not the first study to suggest that postmenopausal estrogen use may increase the risk of ovarian cancer.

  • The Breast Cancer Detection Demonstration project reported an increased ovarian cancer risk among users of estrogen-only (E) therapy. Similarly, that study found no increase in risk among users of estrogen plus progestin therapy.
  • The Womens’ Health Initiative reported an increase in ovarian cancers among users of combination hormone therapy (E+P) , but that risk was not statistically significant, since the data was based on only 32 cancers. To my knowledge, they have not yet reported ovarian cancer data from the estrogen-only arm of that study.
  • A Swedish study also reported ovarian cancer risks with estrogen only therapy, as well as with sequential estrogen + progestin, but not with combination daily E+P. In that study, a small increase in risk was also seen for low dose vaginal but not oral estrogen, and women who had had a hysterectomy did not have an increased risk of ovarian cancer with any regimen.

Just how big a risk are we talking about?

Unfortunately, I don’t have much to go on here, other than the research abstract (don’t get me started again on the publicity surrounding poster presentations instead of waiting for the peer-reviewed published papers), but let’s see what I can do….

There were 424 cases of ovarian cancer among 162,920 study participants during nine years of follow up, for an overall annual incidence about 3.7 per 10,000.  That number is remarkably similar to the risk for ovarian cancer among WHI participants – 3.4 per 10,000. Both seem a bit high given that the population incidence of ovarian cancer here in the US is 1.3 per 10,000 annually, and may be related to the age of the women in these studies. But lets go on….

Users of estrogen-only therapy had a relative risk for ovarian cancer of 1.65, meaning that their risk was 65% higher than that in women not using hormone therapy. Unfortunately, the abstract does not give us the risk in hormone non-users. But for argument’s sake, let’s suppose it is the same as the US background risk of 1.3 per 10,000.* Then the risk among users of estrogen-only HT would be 2.1 per 10,000, or an additional .02% per year.

What does this mean for you?

Let’s assume the association is real. Let’s also assume you are miserable with hot flashes or some other menopausal symptom and want to take hormone therapy.

What are your risks?

Well, that depends what regimen you take – estrogen alone or estrogen + progestin. And that, in turn, depends on if you have a uterus. Your risk for ovarian cancer will be further affected by whether or not you actually still have your ovaries.  Combining this data with that from the WHI (statistically, this is not permissible, but I have to practice medicine in real life, so I’m gonna’ do it.), let’s graph it out –

 

Notice that the risk for breast cancer among users of estrogen alone, at least in the WHI, was actually lowered. I put a question mark there because it remains a bit of a puzzle how that data came about, and no one is convinced yet, but there it is. (Update – I think I am beginning to understand how this might be possible. See this post for a possible explanation of these findings)

You can also see that no matter how you look at it, for an individual woman, these are small numbers. What makes them big is when millions of women use HRT – now we are increasing disease rates across a population.

What also becomes obvious is that the best cancer hand, so to speak, is dealt to the woman who has had a hysterectomy with removal of the ovaries. Of course, that woman has also had a major operation, which carries its own risks, so consider that before you go asking for a hysterectomy so you can take your hormones without any increased cancer risks.

Bottom Line

If you choose to take hormone replacement, you should consider both its risks as well as its benefits in making your decision.

Use of estrogen for less than 5 years did not increase ovarian cancer risks in this reported study, and in the WHI, the breast cancer risks did not kick in for the first 3-4 years of use. This suggests that short term use of HRT around menopause carries little risk, and goes along with recommendations that women use the lowest dose for the shortest period of time and reassess the need for continued use on an annual basis.

If you are one of those women who choose to take hormone therapy for prolonged periods of time, your risks, though real, are not large.

Remember too, that there are non-hormonal options for treating many of the symptoms of menopause.
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* I am not a statistician, just a doc trying to figure out how to make this stuff make sense to my patients and inform my own medical practice. If any of my readers having more expertise in this arena wish to jump in to correct me or suggest better numbers, I’m all ears.

Photo credit – Picasso’s Portrait of Dora Maar. From Musee national Picasso, Paris

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12/29/10 UPDATE – I’ve begun rethinking the breast cancer data on estrogen alone, based on something called the Gap Time Theory, which states that it is only because the women in the WHI were 10 years post menopausal that breast cancer risks were lower in the estrogen only arm. If this theory were true, it would remove that potential benefit in women starting estrogen only treatment at menopause. Until we have better studies, all of this is hypothetical, unfortunately.

Herbed White Bean & Sausage Stew

Melissa Clark published a wonderful recipe for white bean stew in last week’s NY Times, marveling that she was able to make it without having to pre-soak her beans. Inspired by her recipe, Mr TBTAM and I decided to shorten the making of this stew even further by using canned beans. The result – a fabulously rich and flavorful autumn dinner in just over an hour.

Herbed White Bean and Sausage Stew

This recipe is a great use for those herbs that remain green in the garden through fall and early winter – rosemary and thyme. In addition to using canned beans, we replaced water with chicken broth, added some diced tomatoes, spiced things up with additional onion and garlic and a few red pepper flakes, and served it with freshly made jumbo croutons. You can lighten this recipe up by using chicken or turkey meatballs instead of sausage.

2 tablespoons extra virgin olive oil, more for serving
1 pound sweet Italian sausage, sliced 3/4-inch thick
2 tablespoon tomato paste
1/2 teaspoon ground cumin
2 medium carrots, finely diced
2 celery stalks, finely diced
1 large or two medium onions, chopped
4 garlic cloves, finely chopped
2 teaspoons kosher salt, or to taste
2 thyme sprigs
1 large rosemary sprig
1 bay leaf
2 14 oz cans chicken broth plus 1 can water
2 – 15.5 oz can Great Northern beans, rinsed and drained
1 – 14.5 oz can diced tomatoes
2 teaspoons balsamic vinegar, more for serving
1/4 tsp red pepper flakes
1/2 teaspoon ground black pepper, more to taste
Jumbo Croutons for garnish (recipe below)

1. Heat the oil in a large stockpot over medium-high heat. Add the sausage and brown until cooked through. Remove sausage from pan and hold.

2. Add the tomato paste and cumin to the pot. Cook, stirring, about 2 minutes. Add the carrots, celery, onion and garlic. Cook, stirring, until the vegetables have softened, about 5 minutes, adding in the rest of the spices about halfway through. Stir in the beans, chicken broth and tomatoes. Turn the heat up to high and bring to a boil, then reduce heat to low and simmer gently about 1 hour, till the broth thickens. Add the sausage back in during the last 10 minutes.

3. Stir in the vinegar and pepper. Taste and adjust seasoning. Ladle into bowls and serve drizzled with additional vinegar and olive oil. Pass around the croutons.

Yield: 6 to 8 servings.

Jumbo Croutons

Half a Baguette (we had half of one in the freezer)
2-3 tbsp Olive oil
Salt and papper to taste

Thaw the bread if need be, then using a bread knife, cut into 2 inch cubes.Toss with the olive oil, then sprinkle with salt and pepper. spread onto baking sheet and bake at 400 degrees fahrenheit fo about 5-10 minutes, turning a few times during cooking and watching closely so they don’t burn. Serve.

The Journal In-Box

Occasionally, I find the time to sift through medical journals piling up  on my windowsill, or scan the table of contents of the journals that I get delivered via email. Here are a few tidbits I found interesting during my latest foray into the pile –

Diet, Exercise, Pregnancy and PCOS. A 6 week structured diet and exercise regimen significantly enhanced clomid-induced ovulation in infertile women with PCOS previously resistant to ovulation induction. Given that weight reduction will also decrease the risk for diabetes, hypertension and heart disease, that’s one very effective intervention!

DHA in Pregnancy – Is it doing a anything? DHA, despite being recommended as a supplement during pregnancy, did not improve offspring intellectual function or decrease maternal depressive symptoms. So why exactly are we recommending it?

Depo Provera and Fractures – Use of this injectable contraceptive in the UK was associated with a slightly higher rate of fractures in users of all ages, with risk highest after 2-3 years of use. This is not surprising given what we know about DMPA’s effects on bone mass. The risk is not high, and for women who cannot use other methods effectively, Depo remains an important contraceptive option. But for long term DMPA users, the risk for fracture is s a consideration that should be added into the benefit risk equation for use of this contraceptive. (This study was published in August  and I just got around to reading it now…)

Perinatal Mortality in midwife vs Obstetrician-assisted births in the Netherlands. Midwife assisted low risk pregnancies have higher perinatal mortality than high risk, physician assisted pregnancies. This unexpected finding puts the entire Dutch triage system of obstetric care into question. However, as most Ob’s will tell you, much of what can go wrong at delivery is unexpected. Being ready for anything is the safest way to go as far as I’m concerned.

Genital Warts Incidence Trends Downwards after HPV Vaccine Program Initiated in Australia. A 59% decline was seen in women in the age group eligible for the vaccine. Declines were also seen in heterosexual men (who are not vaccinated) suggesting that “herd immunity” may be accumulating. A more important public health outcome will be what happens to cervical cancer rates over time. But this data are encouraging.

NYC Woodpecker

This noisy little guy was going to town on the apple tree on our roof a few weeks back. Haven’t seen him since.

Ginger Stout Cake

Autumn brings thoughts of ginger – ginger snaps, ginger bread, and our new family favorite – Ginger Cake. I’m not sure what makes ginger a cold weather spice in our society. Maybe it’s because in cooler climates like ours, the rhizomes are harvested in autumn. No matter – I love ginger all year round, and keep crystallized ginger in the freezer to use in recipes or munch on whenever I want a tangy bite.

This particular recipe uses both ground and fresh ginger root  – an entire 4 oz of fresh ginger, to be exact. This looks like a lot while you are chopping it,  but don’t worry. It tastes just fine and the small pieces are undetectable in the final product except as flavor. The cake itself is moist, flavorful and really very special.

Making this cake is almost as fun as eating it. Remember that erupting volcano you made for your 4th grade science fair? You get to relive that experience when you add the baking soda to the boiling beer/molasses mixture. Bring the kids in to watch – it really erupts! (Science buffs can tell us why in the comments.)  Make sure you use a large pot, or you’ll have a real mess on your hands.

STOUT GINGER CAKE

This recipe comes from the Gramercy Tavern, was originally published in Gourmet and is now available on Epicurious. The original recipe calls for Guinness Stout, but here I used a double chocolate Stout that gave it an exceptionally fine flavor. I’ve also added a garnish of sliced candied ginger and serve it with a dollop of  whipped cream. I like my whipped cream with a tad of sugar, but you can make yours unsweetened if you prefer. Thanks to Irene for introducing us to this wonderful cake and talking me through the baking of it.

1 cup stout beer (Guinness or other – I used Young’s Double Chocolate Stout, available at Food Emporium here in NYC)
1 cup molasses (not blackstrap)
½ tbsp. baking soda
4 oz. piece of fresh ginger, peeled and finely chopped by hand (make it as fine as you can)
3 large eggs
1 tsp. vanilla extract
½ cup granulated sugar
½ cup firmly packed brown sugar
¾ cup canola oil (you can use vegetable or peanut oil if that’s what you have on hand)
2 cups all-purpose flour
1 ½ tsps. ground ginger
1 ½ tsps. baking powder
1 tsp. ground cinnamon
½ tsp. ground cloves
¼ tsp. freshly grated nutmeg
1/8 tsp. ground cardamom
½ tsp. freshly ground black pepper
Sweetened whipped cream and and thinly sliced crystallized ginger for topping and garnish

1. Preheat oven to 350 degrees. Butter and flour an 8 or 9 inch tube pan.
2. In a very large saucepan over high heat, combine the stout and molasses and bring to a boil. Turn off the heat and add the baking soda. Allow to sit until the foam dissipates. Stir in the chopped fresh ginger and let it steep while the mixture cools to room temp.
3. Meanwhile, in a bowl, whisk together the eggs and both sugars. Whisk in the vanilla and oil.
4. In a separate bowl, whisk together the flour, ground ginger, baking powder, cinnamon, cloves, nutmeg, cardamom and black pepper.
5. Combine the stout mixture with the egg mixture, then whisk this liquid into the flour mixture, half at a time.
6. Pour the batter into the pan and bake for 1 hour, or until the top springs when gently pressed.  (Mine took exactly an hour, Irene advised you to check yours at 50 minutes) Do not open the oven until the cake is almost done, or the cake may fall slightly. Transfer to a wire rack to cool. Make sure to cool completely and loosen the edges well before inverting onto plate – it should come away intact.

Serve with crystallized ginger slices and whipped cream.

Sweetened Whipped Cream

1 cup cold whipping cream
3 tbsp confectioner sugar
a drop of vanilla

Combine ingredients in a large bowl and whip at high speed using an electric mixer till it forms soft peaks. Refrigerate till use.

HRT and Breast Cancer Deaths – Just in Case You Weren’t Listening the First Time…

A new analysis of long term data from the Women’s Health Initiative confirms what we already knew the first time around – Use of combination hormone replacement (HRT*) is associated with a small, but real, risk of breast cancer. This new 11- year follow up data carries that knowledge out to its not unexpected conclusion – namely, that some (although not most) breast cancers can be fatal, and therefore the the use of HRT can increase breast cancer mortality.

While it may seem a bit of a “Duh”, this study was, in fact, necessary to quell the WHI critics who continued to argue that the breast cancers caused by HRT were somehow less aggressive than those occurring off HRT. (They are not.) It was also a wake up call for many women who were continuing to use HRT and thinking that somehow its risks did not apply to them. A fair number of these women appear to be coming off of HRT, at least in my practice. Others are staying the course and accepting the risks as they have been defined. Either of which is fine with me.

The spin going on around this study – both for and against HRT use – is tremendous and ultimately confusing to women.  The pro-HRT crowd (some of whom have relationships to Pharma) is using language like “The increased risk from using HRT for 5 years is the same as if your menopause occurred 5 years later”, which is technically true but so what?  The bioidentical hormone crowd (usually also selling the same) are using the study to further hype how their regimens are safer than the evil Big Pharma products – based on no data. Which leaves the rest of us to try to find ways to help our patients understand the risks, place them into perspective for themselves and make a decision about how and if to treat their menopausal symptoms.

While the breast cancer risks associated with HRT use appear to be quite real, for a individual woman, they are not that large. Here’s how I explain the risks to my patients –

There will be 7 extra cases of breast cancer and 1.3 additional breast cancer deaths for every 10,000 women per year who use HRT. Said another way, if you use HRT for 20 years, your risk of getting breast cancer will be increased by 1.4 % and your chance of dying from breast cancer will be increased by about a quarter of a percent. If you use HRT for less than 20 years, we can cut those numbers down accordingly.**

If you don’t already know it, I do have my own set of rules for prescribing HRT. This new data has not changed them.

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* HRT means estrogen and progesterone taken together, as opposed to ERT, or estrogen alone. In the WHI, ERT use was actually associated with a lower rate of breast cancer, a finding unique to this study that begs for replication before we can bless ERT as breast-safe.

** The formula I used for cumulative risk is CR = 1 – e-IR*t ,where CR = cumulative risk, IR is the annual incidence and t is the number of years (in this case 20). If any statistician types reading this can confirm my methodology or numbers I’d appreciate it.

Graph above from JAMA. 2010;304(15):1684-1692.

Roast Pork Tenderloin with Braised Cabbage and Port Wine Sauce

The coincidental timing of my husband’s birthday near Columbus Day and peak foliage has turned this once minor family celebration into one of my favorite annual events – a weekend getaway to our cottage in the Endless Mountains with Mr TBTAM’s parents. Add in bro Joe with Rachel and clan in a rented RV, bring eldest daughter in from college, make the weather glorious and warm, go for Sunday brunch at Berry Fields Farm and put the Phillies in the playoffs (with a no-hitter reminiscent of the one that occurred on the day Mr TBTAM was born, which is why his middle name is Donald), and this year’s birthday weekend was very special indeed.

My only disappointment was that Joe’s family had already hiked Ricketts Glen before we arrived, and the meager apple harvest this year meant no apple stand or applesauce makers at the Forksville Fall Festival.

Joe, Rachel and my mother-in-law Irene are all fabulous cooks, so the weekend was one long Iron Chef event that started earlier in the week as we planned and coordinated via phone what we’d make and who would bring what. Since we had brought two separate pairs of tenderloin, we even had a brine-off. Irene had started her tenderloin brining Friday night, but Mr TBTAM and I could not start ours till we arrived to the cottage Saturday late morning, in brine that Joe (who had arrive the night before) had made and set cooling at around 7. It was clear by their rich color that Irene’s tenderloin were the superior brine, but by the time the dish was done no one knew or cared which was which.

We all crammed into the kitchen to cook the birthday dinner together, with Irene and Joe sharing Chef de Cuisine while Rachel and I played Sous Chef. Everyone got along famously, and the dinner was incredible. We served the tenderloin with a side of green beans, homemade applesauce and roasted herb potatoes. The birthday cake was a dense ginger cake with whipped cream (recipe coming soon…).

I don’t have space or time to detail the rest of the food we made that weekend, except to say that the pork leftovers went great with Frugal Fig Flatbread and salad for Sunday dinner, and leftover salad and fig flatbread were delicious additions to omelets and sausage for Monday morning brunch.

But better than the food that weekend were the moments with one another.  Joe and Em jamming on guitar, Joe and Marvin kibbutzing on the porch, me hanging with Rachel under the stars while the kids and the boys watched the game at The Barn, Luke drawing, Mr TBTAM blowing out his candles, laughing with Grace and Nats in the middle of the night, Irene and Rachel cooking breakfast, going on the world’s longest wild goose chase for those elusive fall apples, worrying we’d get tossed out on our ear by the Lake association for parking an RV in the driveway, hiking the lake and just sitting around the fire together talking.

Thanks Irene and Marvin, for joining us again, and thanks Joe, Rachel, Luke and Grace for making the long trip up north. And thank you, Mr TBTAM, for being born on the best weekend of the year.

Roast Pork Tenderloin with Braised Cabbage and Port Wine Sauce

This recipe is based on one from Chef Mark Peel (which can be found in the Gourmet Cookbook) with Irene’s modifications. It’s a lot of work and worth every second. The recipe below will serve 6. We doubled the meat (but not the cabbage) to serve 10 with leftovers.

Peel’s original recipe uses pork loin and brines for 2-3 days. We used tenderloin and brined for 6-8 hours. We also substituted chicken for veal stock in the port wine sauce. We saw no need to blanch the cabbage before sauteing, as Peel does in his original recipe. Finally, doubling the cabbage and using red onions and more garlic adapted it further to our tastes.

Brine
2 quarts water
1/3 cup Kosher salt
3 tablespoons granulated sugar
4 cloves garlic
2 tablespoons cracked black peppercorns
A few red pepper flakes
1 tablespoons dried thyme
4 whole cloves
4 whole allspice, cracked
1 bay leaf

Pork
2 pork tenderloins, 3/4 to 1 lb each
1 head (2 pound) red cabbage, cored, split and cut into thin slices (The thinnest you can get without using a food processor or mandoline)
Freshly cracked black pepper
2 large red onions, peeled and cut into 1/2-inch-thick round slices
1 tablespoon olive oil
2 large garlic cloves, peeled and chopped (2 teaspoon)
1/4 cup balsamic vinegar
8 fresh sage leaves, chopped fine  (optional – we left them out)
1 tablespoon drained capers

Port Wine Sauce
1 tablespoon (1/2 ounce) unsalted butter
2 large shallots, trimmed, peeled, and chopped (2 tablespoons)
1/4 cup balsamic vinegar
1 cup ruby port or sweet marsala wine
1 cup canned beef or chicken broth
1 tbsp butter (to add at the end)

  • Brine the pork. Combine 2 quarts of water, 1/3 cup kosher salt, sugar, garlic cloves, peppercorns, red pepper flakes, thyme, cloves, allspice, and bay leaf in a large stockpot and bring to a boil. Reduce the heat to low and simmer for 15 minutes. Remove the stockpot from the heat, transfer the brine to a large mixing bowl, allow to cool to room temperature, then refrigerate until cold, at least 2 hours. When the brine is thoroughly chilled, add the tenderloin, ensuring that it is completely immersed, and refrigerate, covered, for 6-8 hours. When ready to roast, remove the meat from the brine, and dry with kitchen towels.
  • Cook the pork and onions. Preheat the oven to 400 degrees. Season the pork lightly with black pepper. (It should not need salt.) In a large cast-iron skillet, over medium-high heat, brown the pork loin on all sides, then remove the pork to a platter and reserve. Distribute the onion slices on the bottom of the cast-iron skillet and place the browned pork loin on top. Transfer to the oven and roast until the internal temperature of the pork is 150 degrees, about 15- 20 mins. (15 mins if you like it pink, 20 mins if you like it more well done.)
  • Prepare the Port Wine Sauce. While the pork is roasting, prepare the Port Wine Sauce. In a small saucepan, over medium-high heat, melt the butter. Sauté the shallots until wilted, about 5 minutes. Pour in 1/4 cup balsamic vinegar and cook until completely absorbed, about 2 to 3 minutes. Add the port wine and cook until 1/2 cup remains, about 5 to 10 minutes. Add the stock and cook until the sauce begins to thicken, about 5 to 10 minutes. Strain the sauce through a fine-mesh, stainless-steel strainer into a small pot and keep warm. Add the butter just before serving.
  • Caramelize the onions. Remove the cast-iron skillet from the oven, transfer the pork loin from the skillet to a platter and let it rest in a warm spot. Using a stainless-steel spatula, scrape the bottom of the skillet to loosen any browned particles. Remove an of the onions that are burned. Sauté the remaining onions over medium heat until caramelized, about 10 minutes, remove from the pan and reserve.
  • Saute the cabbage. Add a little olive oil if needed to the pan and heat. Add the garlic and cabbage. Sauté until the cabbage is thoroughly heated through, and crisp-tender, about 4 to 5 minutes. Add the 1/4 cup balsamic vinegar and the caramelized onions, stir briefly, add the sage and capers, and season with kosher salt and black pepper to taste. Remove from the heat and keep warm till the sauce is reduced and ready.
  • Serve. To serve, cut the pork loin into 1/2-inch-to-2-inch-thick slices. Place the cooked cabbage on a large warm platter. Arrange the slices of pork on the cabbage, ladle the sauce over, and serve immediately.

Doc Gurley in Haiti

She’s tweeting her medical mission in Haiti.  So tragic are the unmet medical needs of these people.

docgurley Doc Gurley

Saw an alone 9-month-pregnant 19 yr old. No birth kit, no string for the cord, no plan for who would be with her.

Gave supplies+discussed how to ask helper to wash hands. Nothing sharp&clean for cord so gave scalpel. Acted out birth, w/handwashing #hai

Also saw woman with overwhelming postpartum uterus infection. Someone used hands at delivery to pull out pieces of placenta (see next tweet)

Saw 14yrold girl w/months of excruciating pain, mass in her lower belly, wasting. Ruptured appy? Tumor? Left her w/ narcotics, antibiotics.

Also, women do not have menstrual protection supplies

I’ve been asked, if there are no pads, what do women use? In the cases I saw, one used a page of a magazine & another a dinner-napkin.#haiti

God bless you, Doc Gurley, and the members of your team for all you are doing. What can we do to help?

Baby Born from 20-Year old Embryo

It appears to be the new record for a cryopreserved embryo-birth.

In 1990 a couple underwent In Vitro Fertilization. They eventually had a healthy baby. They also, as is common, had a number of microscopic embryos that hadn’t been implanted, but were viable. They decided to anonymously donate them. Now, one of those embryos has produced a little boy, 20 years after being created. (via NPR)

In related embryo-news, Colorado has another personhood rights bill on the ballot for November.

As used in sections 3, 6, and 25 of Article II of the state constitution, the term “person” shall apply to every human being from the beginning of the biological development of that human being.

So here’s my question – under the proposed Colorado amendment, would this kid be legal to drink on his first birthday? I’m just sayin’…

Seriously, Colorado, just say no to proposition 62. Its proponents plan to use it to try and outlaw birth control pills and IUD’s.

O’Hare Airport Flu Shot Booth

A smart idea for busy travelers with a little down time before the flight. At $35 a shot, thirty to fifty travelers a day are taking advantage of the convenience.

I would have gotten one myself, but I’ll be getting mine free at work.

Someone Finally Did the Math…


Breaking news from what is being called the most comprehensive survey of American’s sexual behavior in two decades –

85 percent of the men said their latest sexual partner had an orgasm, while only 64 percent of the women reported having an orgasm in their most recent sexual event.

Or, as Sally said to Harry –

It’s just that all men are sure it never happened to them and most women at one time or another have done it – so you do the math.

Join the World’s Largest Virtual Choir

Composer Eric Whitacre, who rocked You Tube earlier this year by conducting an online choir of 185 singers from over 20 countries, is now recruiting singers for his next virtual choir.

Between now and December 31, singers can videotape themselves singing Whitacre’s composition “Sleep”, using sheet music uploaded from the composer’s website and conducted by him in an online video. Uploading your video to YouTube will then allow Whitacre to grab it and compile the choir for a performance sometime next year.

Whitacre hopes to break the current virtual choir record of 900 singers held by The Amplichoir, a marketing campaign in which singers uploaded themselves singing “Lollipop” in hopes of winning free tickets to the 2009 MTV Music Awards.

There are no freebies being offered for Whitacre’s virtual choir members, other than the chance to be a part of something incredibly special. I’ve signed on and am currently learning “Sleep” , with plans to upload it sometime in October. (You can listen here to some of the videos already submitted to You Tube.)

You needn’t be a professional singer or have the world’s most perfect voice to join this virtual choir. In fact, Whitacre says that he has yet to turn a singer away  –

Just the act of learning the music, singing a take that’s 5 minutes long and uploading it on You Tube to an entire world community, generally weeds out most of the people that would’t make it anyway.  But…one of the great things about choral music, and one of the things that I like – not being a great singer – is that the mass of voices tends to blend out those that aren’t so beautiful.

So if  you love to sing, as I do, I hope you’ll join in the music. It’s going to me amazing!

Topical Hormones Used by Adults May Expose Children and Pets

The FDA is warning that estrogen exposure may occur when children and pets come into contact with the skin where women have used a topical estrogen spray. The warning comes on the heels of adverse event reports of premature puberty, nipple swelling and breast enlargement in children exposed to Evanmist, a spray-on estrogen preparation used to treat menopausal symptoms. Pets exposed to Evamist may exhibit signs such as mammary/nipple enlargement and vulvar swelling.

While the FDA warning applies only to Evanmist, other topical estrogen preparations, including lotions, creams and gels, have been implicated by veterinarians after animals presented with sometimes dramatic signs of exposure to topical estrogen used by their owners.

The North American Menopause Society is compiling a nationwide registry of possible topical estrogen exposure to children and pets –

NAMS asks your help in compiling cases of secondary estrogen exposure in pets or in persons. We’ve established a dedicated email address at NAMS (nams@menopause.org) for you to submit case reports. We also encourage you to report cases directly to the FDA (FDA MedWatch Adverse Event Reporting Form FDA 3500 for persons;6 Form FDA 1932a for pets available online.7 )

In the meantime, if you use topical estrogens, wash your hands after applying and before handling food or touching animals or small children. Make sure lotions, sprays, gels and creams are allowed to dry thoroughly , and cover involved skin before coming into contact with small children or pets. Do not let your pet lick estrogen exposed skin.

The same advice applies to men using topical testosterone gels, which have been known to cause virlization in women and children exposed inadvertently to these hormones from contact with the skin of males using these preparations.

Preventing Breast Cancer Deaths – How Much Credit Does Mammography Get?

Much less, it appears, than we’ve been giving it.

So say researchers who measured breast cancer mortality before and after the introduction of routine mammography screening in Norway. They compared breast cancer death rates between two groups of women in their 50’s – those who were offered routine mammograms and those who were not – between 1996 and 2005.

Their thinking goes something like this – If mammography prevents breast cancer mortality, then women who were offered mammograms should have fewer breast cancer deaths now compared with historical rates before mammogram screening was offered. And they did – about 7 less deaths per 100,000 person-years (the so-called screening effect in that chart up  there).

But here’s the rub – women who did not have screening mammography also had less deaths than their historical counterparts – about 5 less per 100,000 person-years. (The so-called time effect)

This means that the mortality reduction credited to mammograms is about 2 per 100,000 person years, or about a 10% reduction in breast cancer deaths. The lion’s share of mortality reduction appears to be due to advances in breast cancer treatment and possibly medical care in general, something researchers have long suspected but have been unable to prove.

What do the Critics Say?

Experts at the American Cancer Society have criticized some aspects of this study. They point out that while mammography had little impact on mortality in early stage breast cancer, the impact on stage 2 disease mortality was significant. They also criticize the very short follow up period of the study – an average of 2.2 years. Finally, they cite the lack of control of subject behavior (or “contamination” as women may have accessed mammograms outside the national program), and the fact that Norway’s mammogram screening program coincided with a national program of multidisciplinary breast cancer treatment that is not in place in the United States, making mammography potentially more important here.  The ACS continues to recommend annual mammgraphy in average risk women starting at age 40.

The accompanying editorial in the New England Journal of Medicine takes a a different tack, and suggests that the decision to preform screening mammography is, in fact, “a close call”, but stops short of actually making the call.  (I encourage you to read the editorial – it summarizes well the results, strengths and limitations of the Norwegian study.)

My Take

I’m not sure that we should use the results of this population-based data to refute the results of randomized trials, which have shown mammography to reduce mortality by about 25% in women ages 50-59.  In evidence-based medicine, the randomized trials tend to win out.

Still, the data presented make a compelling argument that on a national scale, mammograms may have had limited impact compared with advances in and coordination of breast cancer treatment.

I’ve raised the question before as to whether mortality should be the only bar against which we measure mammography. I wonder if women who get diagnosed with breast cancer on screening mammography have more very early stage disease, more options for localized therapy instead of mastectomy, or less use of chemotherapy than women who do not have mammgorams routinely? I’ve yet to see much discussion on this issue among the decision makers on mammography, but suspect it’s an important consideration for women.

What I’m Doing in My Practice

I’m continuing to recommend screening mammography in women ages 50 and above, and in high risk women at an appropriate age depending on family history. This study is raising important questions for that group, and is sure to generate a few phone calls and fuel some discussions during office hours, but I’m not changing my recommendations just yet in this age group.

For average risk women under age 50, I’ve recently begun to have individualized discussions about the screening mammography, and learning that it’s not an easy discussion to have. To that end, I initiated a project with my colleagues here at Cornell and at Memorial Sloan Kettering Cancer Center to begin to develop tools to assist women and their clinicians in having informed discussions about mammography. We just got a small pilot grant – wish us luck!
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