The Diaphragm – Now Available at Your Local Pharmacy

7/3/15 UPDATE – THE CAYA DIAPHRAGM IS NOW AVAILABLE IN THE US. HERE’S WHAT YOU NEED TO KNOW TO PRESCRIBE OR OBTAIN IT.

UPDATE  – JANSSEN PHARMACEUTICALS HAS DISCONTINUED PRODUCTION OF THE DIAPHRAGM AS OF FEB 2, 2014. SEE UPDATE HERE.

After a prolonged hiatus, during which diaphragms became as scarce as Elaine’s treasured sponges, the Ortho All Flex diaphragm is back, and it’s now latex-free. The over one-year (at least in my area) shortage happened as the manufacturer transitioned from the old latex to new silicone diaphragms, and suppliers everywhere began back-ordering this important barrier contraceptive.

I called Ortho today, and was informed that the new diaphragms have been available for a few months now. I checked with my local pharmacy, and they advised me they could get a size 75 within 24 hours. At online pharmacies, diaphragms sell for $40-$50. You’ll need to restock spermacidal gel at a price of about $15 a tube – good for 30 or so uses.

Milex also makes non-latex diaphragms (arcing spring and wide seal), but these diaphragms must be ordered by your doctor from Cooper Surgical, as opposed to you filling the prescription at the pharmacy. I’ve been purchasing these diaphragms for my patients for the past year, and will continue to use them for patients whose anatomy calls for the added secure fit of the wide seal or arcing spring.

These days, it seems I rarely prescribe the diaphragm – most women seem to prefer other methods. In my younger years, the diaphragm was a very popular method. It’s a good option if you don’t want to or can’t take hormones. Efficacy ranges from 84-94%, but in motivated couples who use it properly (Mr TBTAM and I were in that group for years), the diaphragm can be extremely effective.  It only works if you use it properly every time you have intercourse, so if that’s not you, then look elsewhere for your birth control.

Don’t use the diaphragm unless you know your partner is HIV negative, since the method requires the use of spermacides, which can increase HIV transmission from an infected partner. Although most women use it without problems, users of the diaphragm have a slight increase in vaginal infections and urinary tract infections.

For more information and to see if the diaphragm is right for you, visit Planned Parenthood’s website.
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More reading on the diaphragm from around the web

Lung Cancer and Women

A new report on lung cancer in women has been published by the Women’s Health Policy and Advocacy Program at Brigham & Women’s Hospital.  Called “Out of the Shadows“, the report seeks to raise awareness about lung cancer, currently the leading cause of cancer deaths in women, and more importantly, to increase funding for research into its prevention, detection and treatment. (HT to Booster Shots, the LA Times’ fabulous health blog, for highlighting the report.)

I encourage you to read the report, which is well written and comprehensive. For a more scientific summary of the issues, I would point you to December’s Seminars in Oncology, a special issue devoted to lung cancer in women.

The report is quite open about the stigma that smoking brings to the issue of lung cancer advocacy, and so seeks to focus our attention instead on those lung cancers that occur in non-smokers, which are on the rise as smokers decline as a percentage of the overall population. Although this rise in lung cancers among non-smokers is not universally accepted, nonetheless one in five lung cancers in women occur in those who have never smoked. That’s a significant number of cancers that deserve our attention and advocacy as much as breast and cervical cancer.

Factors that differentiate lung cancers in women from those in men include a lower mortality in women as well as high rates of cancers among female non smokers.  Differences in hormonal mileau in men and women as well as in the presence of growth regulator genes linked to X chromosome have been suggested as explanations for these sex differences, along with other factors, including the variable susceptibility between men and women to the effects of environmental carcinogens.

Despite the fact that smoking is linked to 80% of lung cancer deaths in women, the report devotes surprisingly little space to strategies aimed at reducing cigarette smoking in women and its policy implications include no strategies towards this goal. I suspect this is because they are trying to drive us away from thinking about lung cancer as just a nicotine related disease, but it is, so let’s face it.

I also find it frustratingly that we have so little information on potential environmental carcinogens other than cigarette smoke that may be causative in lung cancer. The coincident rise in asthma among women makes me believe that the environmental connections are there and must be found if we are to prevent further increases in pulmonary disease and cancer in women.

The report does a nice job summarizing new technologies for lung cancer screening and treatment without hype, although it is not necessarily without bias. For example, while presenting screening lung CT as controversial, and acknowledging the potential for leadtime bias in early screening interventions, the conclusion tends to focus on the more positive aspects of this screening. It also discusses new non-invasive screening tests by name that are not yet FDA approved, which is sure to get more than a few folks in to their doctor’s office asking for these tests.

Overall, however, I found the report to be both informative, well-referenced and appropriate reading for both lay and professional audiences, and applaud the Women’s Health Policy Advocacy Group for taking on this important health issue for women.

The Gynecologist and Lung Cancer 

As a gynecologist, these are the things I tend to thinks about when it comes to lung cancer in women –

1. HRT and lung cancer – Although hormone replacement has been linked to an increase in lung cancer mortality in women, HRT users do not have higher rates of lung cancer than non users. This correlates with what we know about lung tumors, which is that they can have receptors for estrogens, which in turn can act as growth promotors.  This would suggest caution in using HRT in smokers or others at increased risk for lung cancer as well as a potential role for hormonal treatment in lung cancers similar to hormonal treatments used in breast cancer. (Oral contraceptive use is not linked to lung cancer incidence or mortality.)

2. HPV and Lung Cancer – Is there a link? – I was surprised to see no mention in the report of the possibility of a link between HPV infection in the respiratory tract and lung cancer. It is an intriguing theory that has biologic plausibility. With the coincident shifts in values regarding oral-genital sexual activity and the HPV epidemic among young people, there is an urgent imperative to either repudiate or validate this theory, particularly since we now have an effective vaccine against two of the cancer causing strains of HPV.

3. Smoking and Women – We gynecologists have two reasons to hate cigarettes – lung cancer and cervical cancer.  Both these cancers are strongly linked to smoking, and any effort to tackle lung cancer is a waste if we don’t tackle cigarette smoking.  To continue to allow Big Tobacco to recruit new smokers through aggressive advertising while we struggle to fund lung cancer research is just plain stupid. 
It’s time we regulated tobacco like the drug that it is – a drug with immense risks and no benefit to anyone but the tobacco industry. We need an aggressive, national plan to stop tobacco advertising both here and abroad, to limit tobacco use to prescription access for current smokers while we move them into smoking cessation treatment and to transition tobacco farmers to sustainable and healthful food crops. 
Enough is enough. 

An Ohio Country Bike Ride

A weekend visit to see our daughter at college provided a chance for an early spring bike ride in central Ohio. (It’s what we parents do while the kids sleep till noon on Sunday morning…)

Mr TBTAM and I rented our bikes from Granville Bike Rentals, who delivered them right to the B&B where we were staying in Granville, Ohio, just a few blocks from an entrance to the TJ Evans Recreational Trail. We followed the trail west to its terminus at the granary in Johnstown and back, a total of about 22 miles.

The trail, which originates in Newark, Ohio, follows the old Toledo & Ohio Central railbed and passes through farmland

and forest,

crossing a few streambeds,

 and cutting right through a corn field!

We rode past hills covered with goldenrod,

and stopped to visit with some cows, who were so close we could hear them munching on the grass.

We had some nice conversations with locals on the trail, including one man who was running the exact route we were biking (in training for a marathon.) We also enjoyed this little sign along the trail, obviously posted by a local who must have gotten a few too many visits from the fire marshal responding to calls from passing bikers.

Yep, we’re in America’s heartland all right…

Biking is a great way to settle in to a new locale when visiting, and old rail trails give a unique back-side view of the landscape that I find much more interesting sometimes than the face we see from the streets. Not to mention that the ride is usually fairly level…

By the way, during our visit, we stayed at the Porch House B&B in Granville, which has charming Victorian rooms with lovely private bathrooms and one of the best breakfasts I’ve ever had. (They use eggs from their own chickens!)  I highly recommend it.
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The TJ Evans trail official site
Ohio Bikeways has a video of the TJ Evans trail and travel tips for riding it
Heather took some pretty fall photos along the trail

The Estrogen Dilemma – Hope, Hype or Just One Woman’s Story?

It’s only Wednesday, and so far three patients have come to their visit carrying Cynthia Gorney’s article from Sunday’s NY Times called the “The Estrogen Dilemma“. The article explores the stories of three women who found relief from perimenopausal symptoms by using hormone replacement, framing the discussion in the larger context of what is being called the “window hypothesis” – the idea that starting estrogen replacement in the perimenopause and continuing it into later life may be neuroprotective and even cardio protective, in contrast to beginning its use 10 or more years after menopause, where it can trigger heart disease, strokes and dementia.

The window hypothesis is one way of explaining away the findings of the Women’s Health Initiative, and goes something like this – “The WHI enrolled women who were too late into menopause to benefit from estrogen. If we had instead studied women starting estrogen at the right time, namely the perimenopause, we would have found that it protects against heart disease and Alzheimers.” Or as I explain it to my patients  – “Think of it like exercise. If you work out vigorously and regularly from a young age, you can prevent heart disease. But take an overweight, out of shape 65 year old and have him/her run full out and you could trigger an MI”.

The Times article does a good job framing both the hope and the hype around the window hypothesis, and the dilemma it appears to pose for women entering menopause today, which is this –  If you wait for data that proves the window hypothesis is right, by the time the results are in, you’re outside the window and it’s too late to start HRT. If you start HRT now and the hypothesis is proven wrong, then you’ve been taking medication with potential risks for years without any benefit.  Or, as author Cynthia Gorney so succinctly put it-

If I make the wrong decision about this, I am so screwed.

The pharmaceutical industry, particularly Wyeth, the maker of Premarin, is, not surprisingly, working hard to get the word out about the window hypothesis. Indeed, several of the researchers working on the hypothesis who are quoted in Gorneys article have ties to Wyeth. At the risk of further hyping a hypothesis that may prove to be unfounded, I encourage you to read the Times article, and then take the time to peruse the intelligent discussion in the comments section. If anything it is testimony to just how well-informed the American public has become about HRT.

I myself have been hearing about the hypothesis for years now, but have yet to see definitive data to prove it.  Fortunately, there are studies in progress that may settle the question within the next few years.  But even if the window hypothesis proves to be correct, it will not mitigate the risks of breast cancer that accompany long term estrogen use in the menopause. That risk remains, in my opinion, the biggest concern for my patients when it comes to HRT, and it is surprisingly downplayed in the Times article.

The biggest problem I have with the article is that Gorney’s experience with both menopause and HRT is anything but typical. Most women get through the transition without major mood issues, although crankiness and irritability are common, especially in women who are not sleeping because of night sweats. When true depression hits, as it did for Gorney, antidepressants are needed, with or without hrt (Gorney takes both). I have seen the occasional woman who declares “I am back!” after starting HRT, and one particularly memorable patient whose depression was cured, but this is the exception, not the rule. Most perimenopausal women who take HRT are just relieved to be able to sleep through the night or get through a meeting without hot flashes.

But most importantly, what does Gorney’s individual experience with HRT and mood have to do with the window hypothesis? She is not taking HRT to prevent Alzheimer’s or heart disease – she is using it to augment the effects of her antidepressants. The whole window discussion thing is distracting from the real question at hand for her, which is sinply this – how long should she take HRT? That depends, not on whether the window hypothesis is true, but on how she feels when she tries to stop taking HRT.

If I were Gorney’s doctor, I’d be focusing her off the window hypothesis and onto why she is taking HRT in the first place – for emotional well being. Now that it’s been a few years on the stuff, I’d say, let’s lower your dose and see how you do. If you do well, then stay on that dose for 6 months to a year, then go off and see if you still need it. Based on Gorney’s experience with occasional missed patches, I’ll predict she’ll still need HRT, but will be able to get away with a lower dose. But if she feels just as well off HRT, then I would advise her to stay off. Do everything else she can do to prevent heart disease – diet, exercise, low salt, get enough sleep, you know the drill.

As for using estrogen to prevent Alzheimers, well, that’s a big leap of faith that I for one am not yet ready to take.  Which does not mean that I don’t have an occasional patient (usually a scientist) taking HRT because she hopes it will prevent Alzheimers. Such women, in my experience, are much less worried about breast cancer than about cognitive decline, in an attitude similar to that of Julia Berry, one of the women profiled in the Times article, who had this to say  –

I could have my breasts removed. I like them. But they’re not my life.

Recent data suggests that Berry may not need to make this Sophie’s choice between her brain and her breasts. The mental confusion so many women experience in perimenopause may in fact resolve itself once we come out the other side, irrespective of hormone use. This suggests that it is the widely swinging hormones of perimenopause that pose the most trouble for women, but that once things settle down, so do we.

Now that’s a window hypothesis you won’t hear Big Pharma talking about…
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Picasso’s Portrait of Dora Maar. From Musee national Picasso, Paris

Related posts

More from around the web on the Estrogen Dilemma

  • Patricia Allen, MD reminds us that this article is a personal essay, and that HRT is not the holy grail
  • Dr Mintz advises to read the article with caution

Mirena Price Increase

You may be wondering how, in the wake of healthcare reform, Bayer has seen fit to raise the price of a Mirena IUD to over $700.

Some providers are outraged, and concerned that they will no longer be able to afford to provide this contraceptive method for their patients.

But check out this thread on the Café Pharma boards, where drug reps in the know think the price increase came because Bayer got an indication for use of Mirena to treat heavy menstrual bleeding  –

Mirena prices are already high. I assume the increase is do to the MBL indication. I have never seen a forcast but guessing it could add 100 million to the US market.

That seems about right to me. Mirena has moved from a contraceptive market, where it must enter the field in the same price range as its competitors, to the abnormal bleeding market, where its new price compares quite favorably to interventions such as surgery and endometrial ablation.

And sure enough, it looks as if the plans are already buying into the new price –

Due to a recent price increase by the manufacturer, UMP has increased the allowed amount for the Mirena IUD from $515.85 to $742.42, effective March 15, 2010. Claims for dates of service from March 15, 2010 and later will be paid based on the higher allowed amount depending on the network status of the provider (network 85%; non-network 60%).

Wonder when the birth control pill manufacturers will get wise and try the same thing? After all, we’ve been prescibing oral contraceptives to treat heavy periods for years.

And the game goes on. The losers, in the end, will be the uninsured. Oh wait – there will be no more uninsured now that healtcare reform has passed. I think I finally get it…
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Updates

  • It appears Medicaid has also adjusted its reimbursement to match the new price. So relax, everyone.
  • Docs who don’t want the upfront expense of stocking Mirena can have patients obtain it directly from Caremark through their insurers (though I’d always keep a backup or two around the office in case the one the patient brings drops or is defective…)
  • Bayer has a program to assist uninsured women with the cost of Mirena




Cherry Blossom Time in Washington DC

This year, Spring Break coincided with peak Cherry Blossom Season, so off we went to Washington, DC. A rather last minute home exchange landed us in a beautiful townhouse in Adams Morgan, a perfect home base for our 4 day stay. Here are some highlights of the trip this year –

1. The Smithsonian National Museum of American History – It’s open late during spring break, which meant we could arrive at 4:30 pm and see everything we wanted before closing time at 7:30 pm with no lines. We hung out at Julia Child’s Kitchen for over an hour, watching old videos of Julia’s TV shows and listening to her interviews. It really is such a special exhibit.

2. The National Gallery of Art – Truly a national treasure. The kids loved it!

3. Hillwood Estate and Gardens – in Cleveland Park. If you like Russian Art, French pottery and beautiful gardens, it’s worth a visit. The Japanese Garden, though small, is really quite special.

and the orchid greenhouse is magical.

Probably a better time to visit is in May or June when more is blooming that a few Cherry Blossom trees. If gardens aren’t your thing, then head instead to the nearby Zoo. Combine it with an al fresco lunch at Yanni’s Greek Taverna (best gyro meat I’ve ever had).

4. Potomac Monument and Cherry Blossom Bike Tour – We rented bikes for the kids at the Washington Marina (warning – bring your own helmet or be forced to buy one for $20 and get a trail map ahead of time) and rode along the Washington Memorial Highway portion of the Mt Vernon Trail into the city.

The well-paved and mostly flat trail took us past the small and attractive Reagan Airport, where planes were landing practically over our heads as we rode. We left the trail to cross the Arlington Bridge to visit the Lincoln, Roosevelt and Jefferson Monuments, then rode back across the Mason memorial Bridge to return to the Marina. Total distance  – about 12.5 miles. If you do this ride, do pack a picnic lunch, as food is scarce among the monuments – just some tourist food kiosks with long lines at the Lincoln and Jefferson Monuments. (We ended up parking the bikes and sneaking into the Holocaust Museum Cafe for lunch.)

5. The newly gentrified area around 14th and P. We did our food shopping at Whole Foods and ate at ThaiTanic with the chic young working crowd who are living and flocking to this area in droves. If I were of that age, this might be where I’d live.

6. Shopping in Adams Morgan – We loved Idle Times Books, the Tibet Shop (Tibetan Imports) and Bazaar Atlas (Moroccan and Senegales imports). Having kids along, we did not hit the bars, but would have loved to have had a beer and listened to some West African music.

7. Visiting friend and blogger Linda and her family in nearby Frederick, Maryland. Wish we had more time to visit this lovely little town. Hope to return one day for a meal at Volt.

This was our second spring break in a row in DC, and I want to do it again next year. I loved having a house to stay in, food shopping with the locals, cooking dinner and hanging in the kitchen over coffee in the morning overlooking the garden.  Not to mention having bikes to ride! Thanks to our hosts for opening up their warm and lovely home to us – we’re so glad you had a good time at our place. Let’s do it again next spring!
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Thanks to Nats for lending me her photos from the Gallery visit.

Rustic Shrimp Bisque – A Soup Worth Waiting For

I’ve been waiting for this soup for weeks. Eleven weeks, to be exact. That’s how long I was enrolled in a research diet study, and unable to eat anything other than the food they provided me, which was nowhere near as delicious as this soup.

The study is designed to compare the effects of three different diets – the American Diet, the AHA low fat diet and a maintenance Atkins-type Diet – on weight loss and cardiovascular disease risk. I randomized to the American Diet, meaning that Thursday’s lunch was a slice of pizza with potato chips and an afternoon snack of oreos and chocolate pudding, Saturday’s lunch was hamburger and fries, and the most veggies I ever saw at one sitting was a measly stalk of broccoli. Despite this, I lost 30 lbs over the 11 weeks of the study, primarily because my caloric intake was only 1200 cals per day, carefully calculated based on my basal metabolic rate.

The best part about my diet was that they supplied me all the food, free of charge. Since the research kitchen is located on the floor above my office, that meant stopping in on the way to work for my breakfast, then having lunch delivered to my desk at 1 pm, and dinner dropped off late afternoon for me to take home. Easiest diet I’ve ever undertaken. Not to mention knowing they’d kick me out if I was caught cheating….

I don’t know yet how my cholesterol fared during the diet, but if the pilot data are right, it will be lower simply because I lost so much weight. The big question, of course, is how well I fared compared to my cohorts on the other diets. That, my dears, will have to await publication of the final results.

Before you go congratulating me on my weight loss, let me tell you that much of the weight I lost was poundage I had already shed last year on a Zone Delivery Diet and subsequently regained. This makes me quite typical, a fact that I now understand and have stopped feeling guilty about since reading David Kessler’s book “The End of Overeating“, which I highly recommend for anyone struggling, as I have, to lose or maintain their weight.   Now that I am finished the research diet, however, I intend to be anything but typical. I plan not only to maintain my weight loss, but to keep it going until I reach my wedding weight. What’s different this time?

I’ll be sharing this over the weeks as I continue this new phase of my life, but will give you one major difference. I no longer think of foods as “good’ or “bad” when it comes to losing weight. After all, I lost a lot of weight eating potato chips, pizza, bacon, pancakes, sausage, cookies and french fries.  While I am not advocating a diet composed primarily of these kinds of food, I now inherently understand that I can enjoy previously “forbidden” foods and still lose weight, provided I am conscious of portion control and calories.

I have lost 3 more pounds in the week on my own since finishing the research diet, and have no sense at all that I am dieting. I am just eating the way I ate for the past 11 weeks, which is consciously, slowly and at around 1200 calories per day. Breakfast most days is steel cut oats with chopped dates and a side of turkey bacon or sausage. Lunch today was one of my all time fave sandwiches – part skim mozarella on a sourdough baguette with pesto and tomatoes – and an apple. And dinner? Well, that brings me to this marvelous Rustic Shrimp Bisque.

Mr TBTAM had the nerve to make this soup my first week on the research diet, and all I ever got was the tiniest taste. Talk about torture! Naturally, the minute I was let loose again in the kitchen, the first thing I decided to make was this soup. I calculated it to have about 270 calories a cup – an amount which is plenty filling, especially when the soup is served with a side salad and a small piece of bread. Total cost for the meal – around 540 calories.

It’s still only my first week on my own, and as the growing season arrives, I expect that I will be increasing the fruit and veggie components of my diet. But for now, I am very happy with what I am accomplishing. And loving this soup…

RUSTIC SHRIMP BISQUE

You can go to the NY Times website for the recipe, but let me tell you a few things first –

1. The recipe calls for one fennel bulb, and does not specify a size. I used one half of a large bulb with three stems, and ended up with 6 cups of soup total.  I think if you want to use a whole large bulb, the fennel flavor would not overpower.
2. I pureed my soup much more finely than the original recipe. I found the shrimp, if cooked properly and not too long, get a funny shred if you go for a coarser puree.
3. I would love to try this soup using olive oil instead of butter – if anyone tries it before me, do post a comment and let us know how it tastes.
4. The shrimp stock alone is to die for.
5. This is not a quick soup, but don’t try to shortcut it. In every step, you’ll see marvelous flavors building – just thinking about those shrimp shells browning in the butter, or the tomato paste carmelizing in the bottom of the pot gives me goose bumps.  Take your time, have a glass of wine while you cook if you need it to slow yourself down, and enjoy the experience.
6. The lemon juice and cayenne at the end are critical. You could also pass a little hot sauce at the table if you’ve kept the cayenne to just a pinch.

Enjoy!

More Questions About Questions About Mammography

A well-done analysis in the BMJ this week calls into question previous research that has been used to tout mammography as an effective tool for lowering breast cancer mortality in Denmark.  That previous study compared breast cancer death rates in Copenhagen, where women were offered screening mammography in 1991, to areas in Denmark where mammograms were not offered until 17 years later, and concluded that the introduction of mammogram screening resulted in a 25 % reduction in breast cancer mortality in screened areas.

The new study adds an additional county where screening was offered (with a little implication that perhaps the previous researchers should have included this other area, but I’ll stay out of the academic finger pointing) and then reanalyzes the data.

The researchers found that breast cancer deaths declined nationwide during the time period studied, in all areas, regardless if that area was one offering the screening program. Much of this decline occurred in women ages 40-49, who were too young to have been offered screening. This suggests that it is breast cancer treatment rather than screening that should take the credit for most of the mortality declines in Denmark over the time period studied.

The researchers then go on to make this statement-

We believe it is time to question whether screening has delivered the promised effect on breast cancer mortality.

-practically guaranteeing that I’d have to read their paper and comment on it. So I am.

My take

I’m not convinced that this paper makes the point that mammograms are ineffective. The authors themselves argue that the effect size of mammography, estimated at about 15-16% in randomized trials, is too small to be measured in epidimiologic studies. I  agree. It is just impossible to control all the confounding factors inherent in an entire population of individuals to tease out the effect of a single intervention over time, particularly when breast cancer treatment was evolving so rapidly over the time period being studied.

I have to admit that I have a hard time believing that, for 17 years, women living outside of Copenhagen never entered that fair city to have a mammogram on their own dollar once they found out that their city-dwelling friends were being offered the test and they weren’t. (The paper used to support the claim doesn’t make the case in my opinion.) I know that Europeans have not bought the whole mammogram thing hook, line and sinker the way we here in the States have, but I don’t think it is as black and white as the Danes would like us to believe. (If you are a Danish woman reading this, feel free to enlighten us…) But that’s just an aside.

Bottom Line

This is an important paper in that it effectively refutes previous conclusions about the Danish mammogram screening program. Unfortunately, I don’t think this study stands on any stronger ground in arguing that mammograms are ineffective. Nothing in this paper rescinds the results of the randomized trials, which the authors themselves state find a mortality reduction of about 15-16% for mammography. In my opinion, their results primarily show us that population based data is nearly impossible to use to make any valid conclusions about mammogram screening – either for or against it.
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Hat tip to Gary Schwitzer for pointing me to this study

Already missing him

NHS Blogdoctor has retired from active practice in the NHS and closed his blog.

Healthcare and the NHS is a big topic but I have said what I have to say and increasingly I am just going round and round the houses. I remain committed to the ideal of a decent standard of healthcare being available to all, independent of means and status. Sadly, we are further away from that ideal than we were five years ago when I started NHS BLOG DOCTOR. I am not optimistic about the future.

He will be missed.

What I find interesting is that Dr Crippin not only stopped blogging, he took  his blog down. Completely. Just try googling him – Nothing there.

I wonder what led him to pull the whole thing off the servers.   I guess he just didn’t want to be bothered with dealing with any repercussions of previous writings.  Close the books. Turn the page. Move on.  I get it.

Still, it would have been nice if he had left it up there for posterity.

Enjoy whatever comes next, Dr Crippin.

There’s No Place Like Home

It’s funny, but I barely remember the first time I visited New York. I was nine years old, and went with my Dad and brother to see the World’s Fair in Queens. I remember the It’s a Small World Exhibit, but mostly I remember the car ride home on the Jersey Turnpike, gazing out at the brightly lit New York skyline and realizing for the first time that if it’s dark outside, you can actually look sideways out the window and not get car sick.

The next time I visited New York, I was on an eight grade class trip. I think we went to the United Nations, but I don’t recall that. Here are the two things I do remember – (1) singing “99 Bottles of Beer on the Wall”while stuck in traffic coming out of the Lincoln Tunnel onto 42nd Street, which in those days was lined with Peep Shows and Porn Shops and (2) being a smart-ass with my friends and leaving a one-cent tip at the restaurant in Tudor City where we were packed in and served overcooked Salisbury Steak, which was basically inedible. (Even then, I was a food critic..)

The third time I visited New York, I fell in love.

It was a day trip I took during college with my best friends. I think we must have seen a play, but for the life of me, I don’t remember what it was. This time it was lunch at Mama Leone’s, which even I, the rube from Philly, recognized as cattle call for tourists – the place was loud and packed and I felt like a number.  And the portions?  HUGE. Like “I think I’m gonna’ be sick”, huge.  So we decided to walk it off with a stroll in Central Park. And it was there, sitting under the Wisteria Arbor on the West Drive, that I fell. Hard.

Maybe it was  the intoxicating floral perfume. Combined with post-prandial carbohydrate overload and a bit of a buzz from the wine we had with lunch. And a warm spring day and best friends. And that skyline. (Clearly, it was not the food…) All I knew was – I was in love. With a city. And I knew – I had to move here.

So after college, I did. I spent two years living in the Village and going to grad school at NYU, a time during which I moved four times with a succession of three different room mates, ran out of money after 6 months and started working full time and going to school at night, lost my innocence and my baby fat, suffered a few bouts of great loneliness, fell in love,  had my heart broken and broke one myself, and tried and failed to get into medical school, until I tried again and was accepted to a school back in Philly. I was so happy to just get in that I didn’t think twice about leaving New York. I had more important things to do than be in love with a city.

So, I moved back home. Where I got my MD, did a residency, joined a med school faculty, moved a few more times. Alone the way, I met Mr TBTAM and the rest is history on that front. We had a kid, bought a house – you know the deal. I think I came back up to New York to visit once or twice, but my heart was in Philly. Or so I thought. Until one day, during a time when I was feeling a bit frustrated in my job, someone offered me another one here. It took me about a minute to consider it before I knew the answer had to be yes. It took Mr TBAM a little longer than that to warm to the idea, but he pretty quickly did (not that I gave him much choice). So we sold the house and the car, took the kid and moved to the Big Apple.

That was almost 16 years ago. Since then, we’ve only moved once, within the same building, to a bigger apartment. We lucked into the world’s best nanny, had another kid and sent both our girls to NYC public schools, which have their problems but have overall served us well. And I learned that while New York City can sometimes be a lonely place for a single person, it’s heaven for a family.

Needless to say, New York City and I are still going strong. Which is not to say that I am happy 24-7, or that life has been perfect. Because it is not. For a time there around 9-11, New York and I were in a rough patch. Not that I ever thought of leaving, because I didn’t.  But it wasn’t fun in those days – how could it be?  And yet, we came through it, New York and I, stronger than ever. We made it through the worst and are still together.

Now, I don’t think a day goes by that I don’t get that little jump of joy to realize that I call this place home. Like when I walk home from a play on Broadway. Or head to the bus after a parent teacher conference and find myself on the steps of Lincoln Center. Or stop in at St Patrick’s to light a candle for my Mom. Or strike up a conversation at the hair dressers with another client and find out she’s getting ready to sing in the Opera that night at the Met. Or ride my bike in Central Park, shop for dinner at the Union Square Market, go to a Friday night movie at the Film Forum, get off the subway at Bryant Park to meet a friend for lunch, stop in at the Metropolitan Museum after a doctor’s appointment or gaze out the window of the bus home from Laguardia Airport and realize I’ve just passed 5 Equadorian restaurants in two blocks and wonder how soon I can come back to try one of them.

You know that feeling you get when you walk in the door of your house after a crazy day, or a long trip away? You drop your bags and your heart rate slows down, your spine softens, your feet sink into the entryway carpet and you feel every muscle in your body relax. Everything’s right again. You’re home.

Well, that’s exactly how I feel now when I come out of the Lincoln Tunnel onto 42nd street. It’s absolutely  true. I just sink down in my seat, look out the window, take a long, deep, contented breath, and smile as I head into that bright as day all night long, neon-plastered, subway faster, tourist gawking, vendor hawking, corporate whoring, pigeon soaring, traffic stalling, theater crawling, Big Ball falling, pedestrian malling, tour bus loading, restaurant rowing, taxi honking, honkey-tonking place called Times Square.

I’m home.

Moving Pains and More MedBlog Finds

Sorry if things have been a bit quiet around here lately. I’m in the midst of a blog makeover as I migrate from Blogger to WordPress.  Being both an idiot and a cheapskate, I’m trying to do all the work myself, which is beginning to suck away both my time and my energy. But I love how the new site is looking, and hopefully so will you. You can expect to find all the recipes compiled and categorized, travelogue links and lots of medical info that will hopefully be more accessible than it is now via the blog archives.

At the moment, however, I’m crashed over at WordPress. This nice Headway theme I found that seemed so easy to use isn’t as easy as it looks. Waiting on customer support to help me fix what seems to be a really big bug before I can do anything further.  Not to mention all the tweaking I need to do to the old post images to get them transferred over. I’ll let you know when it’s all done…

In the meantime, new Medical blogs are cropping up all over. It’s fun finding them. Here are a few more recent finds –

Gyno Gab – Billed as “All things gynecology, STDs, obstetrics, women’s health. Your questions, my thoughts, the buzz on what’s new and in the news by a Board Certified Obstetrician and Gynecologist.”

OB Cookie – All Hail the gyno-food blog!

Dr Griever’s EMR – A Canadian physician documents her experience with EMR implementation and usage in a family practice. Most interesting is reading how she begins to tap the EMR to track and improve the quality of care in her practice.
Mommy Doctor – Self described anesthesiologist by day, suburban Ninja mom by night, scientist, iPhone addict, internet geek, occasional blogger, grateful Christian, cookbook reader but not user, tiny Asian bombshell happily married to big white guy. Hmm….I’d add excellent blogger to that list. Just read this post and you’ll know what I mean.
Forbes Science Business Blog – Another excellent mainstream blog, joining the ranks of the WSJ healthblog and Tara Parker Pope’s blog in the NY Times.

See you all soon, hopefully at my new place!

Research Results Reporting by Press Release

Roche has decided they can’t wait for either a scientific meeting or a journal publication – they’re releasing their clinical trial results now by press release.

Here’s their latest press release on the ‘results’ of their clinical trial of Avastin in ovarian cancer –

Roche (SIX: RO, ROG; OTCQX: RHHBY) announced today that a phase III study showed the combination of Avastin (bevacizumab) and chemotherapy followed by maintenance use of Avastin increased the time women with advanced ovarian cancer lived without their disease worsening (progression-free survival or PFS) compared to chemotherapy alone. A preliminary assessment of safety noted adverse events previously observed in pivotal trials with Avastin. Data from the study will be submitted for presentation at the 2010 American Society of Clinical Oncology (ASCO) annual meeting, June 4 to 8, 2010.

Note, if you will, the complete absence of any data.

Which means one of two things – either  (1) “lived longer” means something like a few weeks, and Roche figures they’d better hurry up and get their little stock bump now before the real results come out in June; or (2) the results are so fantastic that they just couldn’t wait to tell us all. Anyone wanna’ venture a guess as to which it is?

Doesn’t the FDA regulate this sort of stuff?