Vaginal Estrogen – Less May Be More

If there’s one thing I’ve learned over the years when it comes to medications, it’s this – more is not necessarily better. You can have too much of a good thing, and less can sometimes be more.

Certainly that’s been the mantra when it comes to hormone replacement in menopause. Since the WHI findings were released in 2002, we’ve all been going lower and lower with estrogen dosing, and finding that, for many women, it’s more than enough to treat the symptoms.

Now, a new low dose formulation of vaginal estrogen, Vagifem 10 ug, approved in Dec 2009, has hit the market. I have to say that I am thrilled to have this option for my patients.(I know, some of you are in shock that I would actually be talking favorably about a new drug, but hey, when they get it right, they get it right.)

Research has shown that vaginal 10 ug estradiol tablets are effective in treating symptoms of postmenopausal vaginal atrophy and dryness. While the previously marketed 25 ug vaginal estradiol preparation was superior in some measures when the two were compared, the lower dose may be all that some women need.

Why go lower dose? After all, the 25 ug vaginal estradiol dose is pretty darned low, and does not typically lead to elevation of estrogen levels above the normal postmenopausal background after the first two weeks of use. But I have had occasional patients complain of breast tenderness in those first two weeks of more intense Vagifem use (you use it once a night in the beginning, then twice a week after that) and even one or two for whom the use of vaginal estrogen triggered a headache. I’ve been anxiously waiting for the lower vaginal dosing ever since the research was published on its relative efficacy. Glad to see it’s finally here.

Medicare recently moved this Vagifem off its preferred formulary, which has been a real problem for a lot of my older patients who no longer can afford it, even though they prefer it over the vaginal creams. As do I, since absorption is probably lower with the vaginal tablets than the creams. (The vaginal ring had the lowest systemic absorption until now, but unfortunately it is too large for some women to use.)  Fortunately, we can customize the cream to a lower dose by just using less of it.

Of course, some women, particularly those at increased risk for breast cancer, are uncomfortable with estrogen in any form. For these women, there are over the counter vaginal moisturizers. And a good  lubricant is helpful for sexual activity, even for some women using vaginal estrogen.

The big question is, will this new low dose vaginal estrogen be low enough for women using aromatase inhibitors? These women suffer terribly from vaginal dryness, but even vaginal estrogen may be too much for them, since we aim for serum estrogen levels of zero in this group. It’s an important question that will need to be studied before any of us are comfortable using even this lower dose preparation in this important subgroup of postmenopausal women.

Brussel Sprouts Gratin with Pine Nuts and Breadcrumb Topping

As I was preparing this dish for dinner, my sister and brother-in-law flatly informed me – “We’re not going to like it. We hate brussel sprouts.” I proceeded to lecture them that the brussel spout flavor they and so many others loved to hate is actually the result of over-cooking, and that I was sure they would love this dish. They did not believe me, and we almost got into a shouting match when I tried to push the point.

You know, of course, how this story ends. Yes! Two more converts to Brussel Sprouts!

Brussel Sprouts Gratin with Pine Nuts and Breadcrumb Topping

This recipe beats my previous fave preparation of sprouts. It’s a modification of a recipe from Bon Appetit that also includes cauliflower. I left the cauliflower out, seeing no need to have to confront the cauliflower haters as well. I use homemade bread crumbs in this recipe. If you use store bought, toast them up in a pan with some olive oil before combining with the pine nuts.

This dish can be assembled beforehand, covered with foil and refrigerated for up to 24 hours before baking. Increase bake time to 45 minutes if going straight from the fridge to the oven.

3 pounds brussels sprouts, trimmed, quartered lengthwise
2 3/4 cups heavy cream or half and half
1/2 cup chopped shallots
1 tablespoon finely chopped fresh sage
1/2 cup homemade breadcrumbs
1/2 cup pine nuts, lightly toasted
2 tablespoons chopped fresh Italian parsley
3 cups grated Parmesan cheese, divided

Cook brussels sprouts in large pot of salted boiling water for 5 minutes. Drain. Transfer sprouts to bowl of ice water to cool. Drain well.

Combine cream, shallots, and sage in large saucepan. Bring to boil. Reduce heat; simmer until mixture is reduced to 2 1/2 cups, about 10 minutes. Season with salt. Remove from heat. Cool slightly.

Combine breadcrumbs, pine nuts and parsley. Season with salt and pepper. (Seasoning not needed if you use seasoned homemade crumbs as I do.)

Butter 13x9x2-inch glass baking dish; arrange half of vegetables in dish. Sprinkle with salt and pepper, then 1 1/2 cups Parmesan. Arrange remaining vegetables evenly over, then sprinkle with remaining 1 1/2 cups Parmesan. Pour cream mixture evenly over. (Can be made ahead up to this point.)

Cover gratin with foil. Bake covered 40 minutes at 375 degrees fahrenheit. Uncover; sprinkle breadcrumb topping over and bake uncovered 15 minutes longer.

Paroxetine (Paxil) Impairs Tamoxifen Benefits in Breast Cancer

An important Canadian study has shown that the use of paroxetine (Paxil) in breast cancer patients taking tamoxifen is associated with an increased risk of death from breast cancer. These findings, which were published this week in the British Medical Journal, add to a growing body of evidence that certain (but not all) SSRI antidepressants neutralize tamoxifen’s beneficial effects in treating breast cancer by interfering with it’s metabolism.

First, a few things about the study –

  • The study was done using a combination of pharmacy records, cancer registry records, hospital databases and death certificates in seniors, the age group for whom this data were readily available.
  • The study included women taking both tamoxifen and an SSRI between 1993 and 2005.
  • The median age was 74 years old (range 70-79 years)
  • We know nothing about the stage of breast cancer in these patients
  • By the end of the 2.8 year follow up, 44% of the participants had died from any cause (not surprising given the age of the study cohort), including 15% in whom breast cancer was listed as one of the causes of death.
  • No comparisons were done among women taking tamoxifen only. The researchers compared women taking different SSRI’s to one another, and within each SSRI group, compared different duration of uses as a way to measure the effect of the potential interaction.

What the researchers found

Use of Paxil was associated with an increase in deaths from both breast cancer and other causes during the follow-up period. (See PowerPoint graph ). The increase in risk was higher with longer overlapping use of Paxil with tamoxifen, and ranged from 25% to 91% increase as time on the two drugs together increased, meaning that the risk was almost double with longest use in the study. All of these results were statistically significant. (For those who know statistics, that’s a relative risk of 1.24 to 1.91 and the 95% confidence intervals did not include 1).

In more meaningful layman’s terms, there will be 1 additional breast cancer death for every 20 women taking Paxil and Tamoxifen together 41% of the time (the average in the study). If Paxil is taken the entire time tamoxifen is used, there will be 1 additional death for every 7 women treated with both drugs.

What is additionally interesting about these numbers, according to the study’s researcher Dr. David Juurlink (who graciously agreed to speak to me today), is that 7 is the number of women need to treat with Tamoxifen to prevent one breast cancer death. So, Paxil essentially is neutralizing the tamoxifen effect.

The Results are Biologically Plausible

In order to be effective, tamoxifen must be converted in the body to its active metabolites, the most potent of which is 4-hydroxy-N-desmethyltamoxifen or endoxifen. The conversion of tamoxifen to endoxifen is catalyzed by an enzyme called CYP2D6. SSRI antidepressants interfere with CPY2D6 to varying degrees, with Paxil being the most potent of the SSRI’s in this regard . (So potent that they actually call it “suicide inhibition”.) Thus, use of Paxil makes tamoxifen less effective, attenuating the survival advantage imparted by tamoxifen use.

(Note – Not all women are inherently able to optimally metabolize tamoxifen to its active metabolites, and research suggests that so called slow metabolizers of tamoxifen may have worse breast cancer outcomes. Genotyping for CYP2D6 variation may prove to be a useful genetic marker for tailoring of cancer treatment in this group.)
Another expected finding of the study was that women taking Venlafaxine (Effexor) had a reduced risk of breast cancer deaths. Venlafaxine is used to treat the hot flashes associated with tamoxifen use, and women who have hot flashes while using tamoxifen may have better survival, probably because the hot flashes are a good sign that the Tamoxifen is being activated to Endoxifen. So this group would be selected to have better survival from the start, and the use of a weak CYP2D6 inhibitor doesn’t appear to impede this survival advantage within the study group.

What was unexpected in the study results was that fluoxetine (Prozac), another known potent inhibitor of CYP2D6, was not associated with an increase death risk compared to the other less potent CYP2D6 inhibitors. The researchers warn, however, that this may be due to the relatively small numbers of women on this drug in their population. “We want to be careful that this study is not used to bless the use of fluoxetine in tamoxifen users”, says Dr Juurlink.

A few more notes on study design

Given the robustness of the data sets they had, which appear to include both cancer registry and hospital records, it’s a shame that the researchers did not have information on breast cancer stage, an important potential confounding factor. It’s a limitation of the study that they acknowledge in the paper.

I also found it odd that the researchers chose only to compare the SSRI’s to one another, without having a control group of tamoxifen users not taking an SSRI. Juurelink explained that this was a deliberate choice, to avoid potential unknown variables that would affect mortality and be associated with the need to use antidepressants.

Importance of Drug-Drug Interactions

We were first clued in to the potential interactions between SSRI’s and tamoxifen in 2005, when a landmark paper was published in JNCI on the pharmacologic interactions of these two classes of drugs. Since them, several other pharmacologic studies have confirmed the interactions and clarified which SSRI’s are problematic and which are not, and concomitant use of the more potent PYP2D6 inhibitors has decreased. In 2009, a paper presented at the American Society of Clinical Oncology reported that women who used a potent or moderate CYP2D6- inhibiting SSRI (paroxetine, fluoxetine or serttraline) in conjunction with tamoxifen had a two-fold increase in breast cancer recurrence compared to use of weakly-inhibiting SSRI’s (citalopran, escitalopram and fluvoxamine). This BMJ study is the first to report an increase in breast cancer mortality resulting from these interactions.

Enormous credit goes to those who first suspected this interaction between SSRI’s and Tamoxifen, did the excellent research to confirm it, and then went the extra mile to help identify which SSRI’s are safe to use with tamoxifen and which are best to avoid. Treatment of depression in cancer patients can be critical to both their physical as well as emotional recovery, and it’s important that we continue to have options that are effective for depression without interfering with cancer treatment.
What should you do if you are on an SSRI and Tamoxifen?

First of all, DO NOT suddenly stop your SSRI, since severe withdrawal symptoms can occur. DO talk to your doctor about which SSRI medication you are taking. If it is paroxetine or fluoxetine, it is recommended that you try to change to an SSRI that is a less potent or non-inhibitor of tamoxifen metabolism.
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Kelly, C., Juurlink, D., Gomes, T., Duong-Hua, M., Pritchard, K., Austin, P., & Paszat, L. (2010). Selective serotonin reuptake inhibitors and breast cancer mortality in women receiving tamoxifen: a population based cohort study BMJ, 340 (feb08 1) DOI: 10.1136/bmj.c693

Photo licensed from Istockphoto.com

Claims Based Quality Measurement – Wasting My Time

I got a letter from an insurer the other day, warning me that my patient, who had just refilled a prescription for a bisphosphonate I had prescribed almost a year ago for severe osteoporosis (yes, I do still prescribe dugs, despite how I feel about Big Pharma marketing), also had a claims diagnosis in their system for a bleeding peptic ulcer, and was I really sure she should be taking this medication, which could worsen her ulcer?

So do what any conscientious physician would do – I call her. (Of course, no one is ever home when I call these days, so it’s another few days of phone tag before I get her.) No, she has not been diagnosed with anything of the kind. Feels great, in fact.

I press the point – did she see her primary for an upset stomach? Have a recent endoscopy? Pain? GI Bleeding? Is she taking any new meds, maybe something for her stomach like an H2 blocker (I name them all).

Nope. Nothing’s new.

Okay, I tell her. Take you meds and I’ll see you in the spring for your check up.

Waste of my time….

Chocolate Zucchini Cake – What a Batter!

I have a confession to make – I am a batter taster.

I love those moments just after the cake pan is put into the oven, when the empty bowl beckons. The kids have absconded with the mixer paddle, which they have licked clean and left somewhere around the apartment, where I will have to fetch it in a few minutes. But for the moment, I am left standing at the counter next to the sink scavenging the Kitchen Aid stainless steel mixing bowl.

My technique is to use the thumb side of the pointer finger, trying to get as much as possible with one swipe as I run it across the bottom and around the rim of the bowl. I lick the batter from my fingers with abandon and without shame, going for every last bit of loveliness I can find. Towards the end, I often have to resort to using the red rubber spatula, but somehow this does not bring the same satisfaction as the finger swipe.

When it becomes clear that I have gotten all I can get without resorting to licking the bowl itself (that would be going too far), I reluctantly let go of the bowl, dropping it into the soapy water in the sink as I imagine that I am Rose, prying Jacks’ frozen fingers from mine and releasing him into the icy blackness alongside the sunken Titanic.

Rules for Batter Eating

As you might expect, there are certain rules for batter eating. This lends to the act a sacredness shared by other religious dietary laws. First, one must wait until the entire batter is made. Baking is chemisty, and early tasting risks upsetting the delicate balance of ingredients in the final product. Just try telling this to your daughter as she reaches into the bowl for a clump of brown sugar and butter you have just creamed while making chocolate chip cookies…

Secondly, one must limit oneself to small amounts of batter, since removing too much for tasting risks not having enough final product to fill the pan. As you might expect, this sets up great personal conflict, and I often feel the inner struggle as I use the rubber spatula to get the last bits of batter into the cake pan, knowing that in doing so, I am leaving less for myself to taste later. (Ah, sweet turmoil!)

Finally, batter is not something to be eaten in anything other than small amounts – some would say not at all – and most certainly not if you are pregnant or immuno-suppressed, since, after all, eating raw eggs risks salmonella. I must say, however, that in almost half a century of licks I have yet to become ill.

You can judge a cake by its batter

I truly believe that one can judge a cake by its batter. In fact, I can say with confidence that if I don’t love a cake uncooked, I won’t like it when it’s finished – so I might as well not waste the energy baking it up. Which reminds me of a tongue twister my mother taught me as a child –
Betty Batter bought some butter.
“But”, she said, “this butter’s bitter!”
“When I put it in my batter,
It makes all my batter bitter.”
So, she bought some better butter
and put it in the bitter batter,
to make the bitter batter better.

If you are a batter taster, you’re going to love making this Chocolate Zucchini cake, which comes from a recipe I found at Alpineberry, who got it from the King Arthur Flour Website. I don’t even care that I didn’t win her King Arthur Cookbook giveaway. This batter is prize enough.

Oh, right. The baked cake was lovely.

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Everyone loves this cake! (But did they taste the batter?)

Screening for Ovarian Cancer Based on Symptoms – Not Good Enough

Thanks to Toni Brayer for pointing out this new study on ovarian cancer symptoms published in the Journal of the National Cancer Institute.

This study confirms previous studies which found that ovarian cancer, long thought to be a silent disease in its early stages, does indeed have symptoms. The problem is that those symptoms – bloating, urinary frequency, pelvic pain, early satiety – are common, non-specific and, according to this new study, 99% of the time not due to an underlying ovarian cancer.

That’s good news, of course, for women with these symptoms. But bad news for those hoping for a means of early detection for ovarian cancer, since early symptom recognition is neither sensitive nor specific enough to be useful as a screening test on a population basis.

This is extremely important for women to understand. Each new screening test gets over-hyped and sets women up with unrealistic expectations about just what it is we docs can do to diagnose this disease. (The latest hope comes from a study that found elevated serum markers in women with ovarian cancer up to three years before their cancer was diagnosed. Unfortunately, the test were not useful in discriminating normals from abnormals until shortly before diagnosis.)
I don’t know if the results of this new symptom screening study will lead to changes in the current recommendations for ovarian cancer screening, so for now I will just reiterate them here –
If you have any of the following symptoms almost daily for more than a few week and these symptoms represent a change from normal for you, see your doctor, preferably a gynecologist.

  • Bloating
  • Pelvic or abdominal pain
  • Urinary urgency or frequency
  • Difficulty eating or feeling full quickly

Prompt medical evaluation may lead to detection at the earliest possible stage of the disease. Remember, though, that these symptoms are almost always caused by something other than ovarian cancer.


Wouldn’t it be great if we had a pill to prevent ovarian cancer?
Wait a minute – we already do! It’s call the Birth Control Pill. According to the National Cancer Institute, use of the pill for even as little as a year lowers ovarian cancer risk by 10-12%, and there is a 50% risk reduction after 5 years of use. Other studies show even higher risk reduction with longer term use.
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Those ovarian cancer awareness wristbands up there are sold to raise funds for the Lynne Cohen Ovarian Cancer Research Foundation. The Susan Komen Foundation sells them too. The Ovarian Cancer Research Fund has a whole store!

More info on ovarian cancer screening from The National Cancer Institute.

Healing Through Multiple Sclerosis

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Artist Cathy Aten talks about how dealing with progressive MS has led her to a remakable place.

My whole process of being an artist has been a 30 year process of editing – What all can you take away and still have the essence of a thing? So, slowly my life is being edited down in the same way that my my art has become edited down – into exactly what is necessary and nothing more.
And you know…What I need is a lot different than what I ever thought I needed. I like this person I’m becoming.

Inspirational.
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Thanks to Wheelchair Kamikaze for highlighting this video, and to Linda and Marie for pointing me to WK.

Is Healthcare ready for the IPad?

First off, I need to address those who think they’re being brilliantly funny comparing Apple’s new product name to a feminine hygiene product – making comments like “Does it come with wings?” and “It’s light and easy to use, but can you swim with it?” (these are the cleaner comments I’ve seen), or calling for the next generation ITampon.

Since when did the word “Pad” become unusable in public discourse? And where were these folks when IBM came out with their Think Pad? It’s stupid, 12-year old funny and just plain dumb. Grow up, ladies and gents.

Now, on to more serious matters.

Is the IPad, as some are suggesting, the next big thing in Medicine? Dana Blakenhorn at ZDNet thinks so, calling medicine the IPad’s “Sweet Spot”-

It’s what your doctor has been dreaming of ever ince the PC revolution began. Imagine this in a flip-up case, in every examination room at your clinic. The nurse sets up the chart, the doctor walks in with a stylus and examines you, and when he’s done the chart goes into the file and the prescription is waiting at the desk for you, printed clearly, along with your Coordination of Care Record. Hand the nurse your credit card and you’re off.

First of all, Dana, that script ain’t waiting at the front desk – it’s already in the pharmacist’s inbox. And my nurse isn’t the one swiping the credit card – my secretary is. But, more importantly, is Dana right?

Is the IPad what I’ve been dreaming of?

Let’s see – I already run my EMR on my PC at work and my Macbook at home, where I can multitask to my heart’s content, and don’t have to re-login to my EMR every time I move back and forth from that app to, say, my calendar, the web or my e-mail. Do I really want a device that does not multitask? Probably not.

You’re thinking it’s the apps, right? Lots of separate cool apps, all of which do really neat things like let me read EKGs or keep lists of patients or look up drug interactions. None of which talk or import data to one another and all of which I need to move back and forth between. Those apps?

Well, let’s see…My EMR looks up pharmacies and drug interactions, lets me access Up-to-Date from within my patient’s record, pulls in lab results from 3 different laboratory vendors and radiology reports from any of our offices and allows my patient to access these herself online. If she’s admitted to the hospital, I can access that chart through a different app, and the discharge summary and op notes make it into my office EMR. That’s one hell of an app, I’d say. Can’t think of too much more I need.

As for games and videos, I guess there’s always lunchtime, but I generally use that time to return phone calls, so…nope.

But wait – What if the IPad were to let me take a photo of say, a skin lesion, and plop it right into my patient’s chart – how cool would that be? Or I could Skype a patient and provide real time care over the internet – now we’re on the 21st Century! Oops, I forgot. No camera on the Ipad…

Maybe it’s the AT&T 3G network you’re thinking about. The one that drops my IPhone calls at least half the time? That 3G network? Not to mention I can’t access it anyway from my office, where the hospital’s concrete walls render even the best of cellphones powerless.

Ok, forget 3G. Maybe the IT guys at work will put in a router for me. That would be nice. Then, instead of being tied to my desk, I could go from room to room with my Ipad. But of course, I’ll need a way to keep the device clean. After all, Staph Aureus is ubiquitous, and has been found on hospital keyboards. Unfortunately, I don’t think I can use any of the current cleaners I have on the Ipad. That’s a problem.

The Real Question

It seems to me that the real question is not “Is Healthcare ready for the Ipad” but “Is the Ipad ready for Healthcare?” And the answer, sadly, is not just yet.

I’ll just have to keep on dreaming…
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More on the Ipad and Healthcare from around the Web
  • Dr Anonymous gives his thoughts on the Ipad – It’s the software, stupid.
  • John Halemka weighs in with some thoughtful questions about the Ipad’s suitability for patient care, but concludes it is “definitely worth a pilot”.
  • MobiHealth News takes the pulse of the Healthcare industry on the Ipad – Bottom line – not just yet.
  • IMedicalApps shows one place in healthcare where the Ipad shines – Anatomy Imaging
  • Brandon Glenn at Medcity does a great job summarizing the Ipad’s limitations
  • Chris Paton at the Health Informatics Forum likes the Ipad for docs – the comments from software developers are well worth a read if you want to see what the future for the Ipad may hold
  • Joseph Kim at Kevin, MD has 10 ways to use the IPad in your practice (none of which includes an EMR) 
  • Steve Woodruff , writing at Kevin Md, thinks the IPad will be a game changer in Healthcare. The operative word, in my opinion, is “will”.
  • Mike Kirkwood thinks a few EMR vendors, most notable EPIC (the one I use) are poised to enter the Iphone/IPad world. Now that would be very nice….

Working Class Foodie’s Apple Cake

I’ve been enjoying watching Working Class Foodie, a Web Show on Hungry Nation that features Rebecca and Max, two siblings with “a love of cooking and eating” who create simple meals using seasonal, local ingredients for under $8 a serving.

Their traditional apple cake recipe is a perfect example of simply delicious food. It’s your basic Jewish Apple Cake made from a recipe Rebecca and Max got from their aunt Tracy, who prefaced her recipe with these words to her niece and nephew – “Don’t mess it up!”

This recipe differs from others apple cake recipes I’ve seen in several ways – First the ratio of sugar to flour is almost 1:1. Other recipes I’ve seen have about a 2:3 proportion, making this cake considerably on the sweeter side. Perhaps to balance out the sugar, there’s a heck of a lot of cinnamon – 2 tbsp to be exact, compared to 2 tsp in most other traditional apple cake recipes. (Not to worry, it doesn’t overpower.) In many ways, the batter reminded me of the Commissary Carrot Cake (one of my fave cakes of all time – I’ll make and post it for you someday), and indeed when I checked that recipe, the proportions of eggs, flour, sugar and oil were almost identical.
The recipe gives the option of of using either white or brown sugar – I decided to go half and half with each. It also offers the choice of apple chunks or layered slices – I went with the chunks, since that’s how Rebecca does it in her video. I also followed more of a standard approach to combining the ingredients, mixing the dry ingredients in one bowl and the wet in another, then combining them, as opposed to Rebecca’s dump it all in at once approach. It’s just the way I learned to make oil-based cakes.Mr TBTAM absolutely loved this cake, as did my daughter and her friends. It was moist and flavorful, with a delightfully crispy crust. The cake did fall just a tad away from the crust as it cooled, but the dusting of confectioners sugar hid the unevenness of the top that resulted. The apple chunks were like little pieces of love embedded in sweetness. I have to admit, the cake was a bit sweet for my taste and I enjoyed the more natural sweetness of the apples in contrast to the sugariness of the cake.

I’d like to try this cake with some whole wheat flour substituting for some of the white flour and with a bit less sugar. I’ll bet the whole wheat would play off the apples really well. I think I’ll try it using one of those 2:3 ratio recipes, leave the skins on the apples, slice them paper thin and layer them. There’s a nice Polish Apple Cake recipe in Marlena Spieler’s book Jewish Cooking that I’ve been wanting to try that fits that bill pretty well.
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Rebecca and Max make their Aunt Tracy’s Apple Cake.

Medblog Award Finalists Announced

Wow. I never thought I’d make it to the finals of the Medblog Awards. And yet, there I am, nominated for best medical blog. I’m honored. Thanks to those who nominated me and to the judges for selecting me for the finals.

Voting starts today over at Medgadget. I encourage you to peruse the blogs nominated in all 7 categories – there are some wonderful sites worth adding to your blogroll. Then, cast your vote for your faves, sit back and watch the returns. It may not be as exciting as Massachusetts, but it’ll be fun!

I Can Has Grand Rounds

This week’s Grand Rounds is the The LOL edition at Emergiblog!

My particular faves

Inspiring – a post by Dr Rob (who is hosting next week). A must-read for doctors and patients alike

Neglect – A nurse tries to fill in the hole left when family and friends are far away from a hospitalized patient . (Great writing, this.)

Radiation Injury- Another Argument for Checklists

This week’s NY Times tells the heartwrenching tale of two patients who suffered radiation injuries during treatment for cancer. In one case, a 43 year old man being treated for tongue cancer recieved seven times the prescribed radiation – a lethal dose – to the head and neck. A woman recieved three times the recommended radiation dose to her breast, leading to a chronic festering wound that took over a year to heal – she ultimately died of her cancer. In both cases, there were multiple missed opportunities to identify the computer error and prevent the injury.

I encourage you to read this excellent article which explores both the hope and the risks of radiation therapy.

Stories like these cry out for a technological solution – a failsafe mechanism on the expensive and complicated equipment used to target and deliver radiation to treat cancerous tumors.

And yet, I found myself wondering if a simple checklist might have worked just as well.

We already use checklists when giving chemotherapy, with each dose being checked by two individuals prior to its administration.

We need a similar nationwide standard for radiation therapy.
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Orac does a thoughtful analysis of the article, including a call for checklists. THe discussion in the comments section is well worth reading

Sondheim, b.i.d.*

Take your morning dose with your musical theater class doing a read/sing through of Side by Side by Sondheim. (Everyone sounded great!)

Take your afternoon dose with your best college buds seeing A Little Night Music. (Angela Lansbury is perfect, Catherine Zeta Jones born to the role and Alexander Hanson the sexiest Fredrik ever. The supporting cast is equally excellent. Go see it!)

Food interactions (such as lunch at La Masseria) can occur, and may increase the level of joy.
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b.i.d. – Doctor speak for twice a day