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.)
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
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
Every family has their standard spaghetti sauce recipe, and this is ours. It’s hearty meat sauce that is rich in flavors and perfect for a spaghetti dinner. The recipe is based on one from my mother-in-law Irene, lightened a bit by using less olive oil.*
Our Spaghetti Sauce
Put a the teapot filled with fresh water. Open one large 1 lb 13oz can of Italian tomatoes and buzz them on the food processor with a large 1 lb 13 oz can of tomato puree. (Alternatively, just open 2 cans of crushed tomatoes).
Heat 1/4 cup olive oil in a large saucepan on high heat. Add 8-10 minced garlic cloves and 1 tsp fennel seeds and cook, stirring, till they begin to turn color. Immediately add 1 lb lean ground beef, 1/2 to 1 lb ground pork or Italian sausage (removed from casings) and 1/2 to 1 lbs ground veal, and cook, stirring frequently.
While the meat is cooking, put two cubes of beef bouillon into a large pyrex measuring cup and add 2 cups boiling water, stirring to dissolve the cubes.
Just when the meat loses its redness, stir in 3 tbsp flour and the bouillon. Allow to thicken about a minute. Add the tomatoes and stir. (To stretch the sauce further, add a can of tomato paste and a can of water). Add spices – 1 tbsp salt, 1 tbsp sugar, ground black pepper +/- crushed chili pepper to taste, 1 tsp dried oregano (or more to taste), 1 tsp dried basil or 1/4 cup fresh pesto (we almost always use the pesto since we usually have some homemade in the freezer) and 1 cup finely chopped parsley.
Bring the sauce to a boil and simmer for at least an hour.
This recipe makes enough for 2 lbs of spaghetti and tastes best the second day. It freezes well.
For leftovers, dice eggplant and salt it. Toss in oil and garlic and lightly brown. Toss with leftover spaghetti. Spread 1/2 cup mozarella and sprinkle with Parmesan and bake 1/2 hour.
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*The original recipe called for 1/2 cup olive oil. Irene tells me her Italian friend told her you have to use a lot of oil in your spaghetti sauce, and indeed recipes for Neopolitan Tomato Sauce call for 1/2 cup oil. One of these days I’ll make it that way and see if it makes a difference. If any of my Italian readers want to comment, feel free.
Rob Lilwall rode from Siberia to London on a bicycle. That’s about (are you ready?) 30,000 miles, if you include a few little detours to places like Australia, Pap New Guinea, Tibet and Iran. The trip took over three years.
Thanks to our friend Paulie for inviting us to hear him play Klezmer Jazz at Mehanata Bulgarian Bar along with his classmates and teachers from SUNY Purchase. It was a rousing night of music, food and drink. Not to mention meeting a few genuine Bulgarians in the crowd, who told me the music was just like what they listened to at home.
Mehanata Bulgaria is a great place to go to listen and dance to gypsy music, share a hookah and eat Bulgarian food. We all shared a plate of sausages with fried potatoes, grape leaves, cucumber salad and a red pepper puree that was delish. And it cost only $8.99!
Oh, and in case you’re wondering – Paulie is the cool one playing bass.
a doctor is a girl’s best friend, according to a recent article in The NY Times.
The author had what sounds like a case of tellugen effluvium, a temporary loss of hair that occurs when a large number of hair follicles decide to cycle together, usually as a result of stress or sudden hormonal shifts (like giving birth). Fortunately for her, the follicles all cycle back in eventually.
She then goes on to discuss on of the more frustrating causes of hair loss in women – androgenetic alopecia, or male pattern baldness.
I see androgenetic alopecia not infrequently in women who came convinced that they have a treatable hormonal problem. Unfortunately, I’ve yet to find any hormonal abnormalities in these women other than menopause and perimenopause. I have had limited success using hormone replacement for the problem, although I do offer it as a trial. I generally offer Minoxidil, but patients seem to have trouble following through on its use. I tend to avoid Propecia, a drug use in male baldness, since we have limited experience using it in women.
Some of my patients with androgenetic alopecia have had success stemming further hair loss with Spironolactone, a diuretic anti-hypertensive that has the added effect of blocking the testosterone receptor in the skin. It’s not FDA approved for this indication, but we’ve been using spironolactone for years to treat hirutism, as well as for its diuretic effects on pre-menstrual bloating. Spironolactone can cause birth defects in male fetuses, so I never prescribe sprironolactone without concomitant hormonal contraception in women in their reproductive years.
Of course, there are other causes of hair loss – these are just the two most common ones. If you think you losing your hair, see your doctor. Sometimes hair loss can be a symptom of an underlying medical condition such as thyroid disease, although in my experience thyroid problems are more often diagnosed on routine screens before hair loss ever becomes a problem. Rarely, a testosterone-secreting adrenal or ovarian tumor can present with hair loss, though usually this is accompanied by other signs of androgen excess.
Other causes of hair loss are alopecia areata, (thought to be an autoimmune disorder), medications (chemotherapy of course being the worst offender), fungal infections, hair processing chemicals and treatments, and other rarer causes.
Finally, don’t forget that hair loss can be one of the side effects of the much touted testosterone therapy in women.
Mabel: I hate half-hearted friends. Loyalty comes before everything.
Margaret:Ye-es; but loyalties cut up against each other sometimes, you know.
That’s the essence of Loyalties, a play currently running in an unlikely venue – the back room of a restaurant in Hunter’s Point, Long Island City. Think Andy Rooney and Judy Garland saying “Let’s put on a show!” – then give them an incredible script, a talented director and a wonderful group of seasoned equity and young non-equity actors and you’ve got a hidden gem of a production just two subway stops off Broadway.
Bayer Pharmaceuticals, the maker of the Mirena IUD, has teamed up with the Mommy marketing site “Mom Central” to sponsor house parties to sell women the Mirena IUD.
According to a warning letter sent to Bayer by the FDA about the worded content of the events –
The Mirena program is a live presentation designed for a consumer audience of “busy moms.” The program is presented in a consumer’s home or other private setting (e.g. private restaurant party) by a representative from Mom Central (a social networking internet site) and a nurse practitioner (Ms. Barb Dehn). The Mirena program submitted to FDA also references a presentation given by a fashion stylist (Ms. Angela Hastings) that immediately follows Ms. Dehn’s presentation regarding the use of Mirena. The script of Ms. Hastings’ presentation regarding fashion tips was not submitted to FDA.
The events start with an intro by a Mom Central rep –
This party was brought to you by Mom Central in partnership with Bayer HealthCare Pharmaceuticals’ Mirena which may help couples keep life simple!”…Barb Dehn is a practicing Women’s Health Nurse Practitioner, award-winning author and nationally recognized health expert from San Francisco. Barb is going to kick things off with a discussion about romance and how to find simple ways to reconnect with our partners.”
Nurse Barb gets the group talking about intimacy by asking icebreaking questions that include the following –
“If you didn’t have to worry about contraception, do you think you would be more likely to be intimate with your partner?”
“Do you think if you didn’t have to worry about taking your birth control everyday, it would help you be more intimate?”
Then, this scripted segway –
“So you mentioned that convenience and reliability are among the most important benefits of your birth control method. One strategy that I recommend for busy couples is choosing a birth control method that allows for spontaneous intimacy and which you don’t have to think about every day, such as the intrauterine contraceptive Mirena®.”
The FDA letter goes on to cite the scripted Mirena info for failing to disclose all the relevant risks of Mirena.
Mom Central had found me through this blog and asked me if I would be interested in hosting an event sponsored by Mirena. As I welcome any opportunity to sit down with some girlfriends with some free food and drink, I was happy to accept….We had an amazing evening, talking about sex, fashion, and living a simpler life. I realized that we don’t actually spend a lot of time talking about sex and relationships. We laughed a lot but also went home with some great tips
Using moms to sell pharmaceutucals? Bayer has gone too far.
This is yet another wonderful dish from May Bsiu’s cookbook The Arab Table: Recipes and Culinary Traditions.
I’ve adapted Bsisu’s recipe by substituting canned for fresh tomatoes and olive for vegetable oil. We served ours with a side of chickpea salad (from the same cookbook), but Bsisu recommends a simple green salad and flatbread.
Kafta
2 pounds ground beef or lamb (we used beef)
1 cup finely chopped parsely
1 pound onions, minced
1 tbsp salt
1/2 tsp black pepper
1/2 tsp ground coriander
1/4 tsp ground cardamom
1/4 tsp ground cinnamon
Combine all ingredients in a large bowl, using you hands, until thoroughly mixed and smooth. Shape into flattened balls and refigerate while preparing the rest of the dish.
Kafta with Potatoes
2 – 14.5 oz cans diced tomatoes with juice
1/4 cup tomato paste
1/2 cup water
3 tbsp olive oil
4 lbs Yukon Gold potatoes, sliced 1/2 inch thick
1/2 pound onions, thinly sliced
5 cloves garlic, thinly sliced
salt and pepper to taste
Kafta (recipe above)
Preheat oven to 350 degrees fahrenheit.
Drain the tomatoes, saving the juice. If necessary, add water to equal 1/2 cup total juice.
Heat 2 tbsp olive oil in a large saute pan on high heat. Add potatoes and saute, turning halfway, till lightly browned.
Transfer to paper towel to drain.
Add remaining oil to skillet and heat. Add onions and saute till soft and translucent, about 5 minutes. Add garlic and saute another 1-2 minutes, being careful not to burn the garlic.
Dissolve the tomato paste in the saved tomato juice and pour it over the cooked onions. Season with salt and pepper and cook for 15 minutes until the onions have melted slightly into the sauce.
Meanwhile, spread the Kafta in a 9×12 inch baking dish. Arrange the potatoes atop, overlapping if necessary. Layer the tomatoes atop the potatoes, then spread the onion mixture evenly over the tomatoes. Bake until the tomato sauce is thickened, the meat is deep brown and potatoes are tender, about 1 hour.
Let sit 10 minutes before serving. To serve, cut into squares, spooning some of the sauce directly over each square.
Although I may be stressed, I’m not climbing the walls just yet.
But I needed something to keep my measuring cups hanging together without handcuffing them to each other. I hate those sets that force you to hold all four cups at once when all you want is the 1/4 cup measurer. I also hate using precious drawer space to store something that I’d prefer at easy reach.
When I saw these carabiner-like quick release keychains at the counter in my local hardware store, I knew I’d hit on the solution.
These little darlings are cheap and come in various sizes and colors, making them both attractive and useful for hanging almost anything together. The quick release spring connector takes a split second to press down, allowing me to remove just the measuring cup or tool I need. Sometimes when I’m doing a lot of cooking, I just take all 4 cups out and use them, then wash them and hang them back together with the carabiner when I am done.
Of course, these carabiners are not meant for climbing – I’d say quick release is not exactly a good idea when you’re hanging from a large rock in the sky.
Where to buy them
I have no idea who makes the carabiners I bought, so I looked on the web to see where else one might buy them. It seems they are the penultimate “Made in China” item, mostly given away as promotional items or sold in bulk. I did find a one pack of 6 on Amazon for $9.95 and another
It’s a Kitchen Carabiner Giveaway!
I bought a few extra carabiners at the hardware store and will give them away to one lucky winner via a random drawing. To enter, just post a comment to this post before the drawing on February 1st. Tweet, link to or Facebook this giveaway and you get an extra entry (just post a second comment telling me you did so with the link.) Make sure you leave either a link to your blog or some other way for me to contact you if you win.
There may be misuse of consultation codes going on, but this study does not necessarily prove that. The methodology does not include medical record review, the standard by which coding choices are verified or refuted, and relies entirely on the referring physician’s determination of what the specialist should be billing.
How does CPT define a consultation? It says simply this –
“A consultation is a type of service provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or appropriate source.”
Pretty vague, right? It is this vagueness that has allowed for the widespread use of consultation codes. Notice I said “widespread” and not “overuse”. One could argue that CPT’s is deliberately vague so as to allow specialist physicans to code consultations in a variety of clinical scenarios, which is in fact what they do. This is not necessarily “erroneous billing”. The term “overuse” implies fraud, and places blame at the foot of the specialist for our healthcare costs.
Medicare clearly does not want to pay for consultations anymore. We get that. But to imply that this is because doctors are overusing consultation codes or billing erroneously is to place blame on docs, rather than just admit that Medicare is looking for ways to shift payments towards primary care.
There is a genuine argument that the differential in specialist fees, based on the widespread use of consultation codes, is one of the forces driving docs into specialty care instead of primary care and that changing to payment schedule to give more dollars to primary care may begin to remedy the situation. The study’s author states this argument nicely –
Higher payment for consultation codes, while not adding a significant percentage to the overall Medicare budget, sends a signal that primary care cognitive services are not valued equally with such services provided by other specialties. At a time when we want to encourage new physicians to consider primary care and support current practitioners, this differential sends adissonant message. Furthermore, as patients are increasingly responsible for out-of-pocket payments, it is difficult to explain to them why consultant physicians are paid so much more than their primary care physicians for the same or less time spent with them.
There is however, also a counter-argument that specialists incur additional years and costs of training that should be compensated in some way. It’s a complex issue without a simple answer, and both sides have valid points of view.
Nominations are now being accepted at Medgaget Blog for the 2009 Medical Blog Awards.
Best part about the awards? Discovering new blogs. I’ve already found four blogs I hadn’t heard of before in the nomination comments.
Of course, I’m still waiting for a Medical/Food Blog category. Maybe next year…
We love serving Pastitsio, also known as Greek Lasagna, to our friends and family. Made with pasta, meat sauce and bechamel, and flavored with nutmeg and cinnamon, pastitsio somehow seems more special than Italian Lasagna, and never fails to get raves from dinner guests.
Our Pastitsio is based on an old artery-clogging recipe from Jeff Smith’s cookbook The Frugal Gourmet Cooks Three Ancient Cuisines, which in turn comes from a Greek Orthodox Church cookbook called Greek Cooking in an American Kitchen. The original recipe calls for 9 eggs, 16 tbsp of butter and not a drop of olive oil! I’ve enlightened it quite a bit, although it is still quite a rich dish.
Something tells me this is not the original Greek version of Pastitsio – after all, the Mediterranean Diet is supposed to be healthy, right? I figure this Americanized version evolved when Greek immigrant housewives, unable to find (or afford) olive oil at the local A&P, turned to butter – and the rest is history.
But then, I asked the Greeks who run our local Pizza joint how they make their pastitsio at home. (These guys are the real thing, complete with accents.) “Butter” was their unequivocal answer. “We use butter for baking, and olive oil in our salads. Olive oil in Pastitsio would not taste right.” Our nurse manager, Maria, who is also Greek, concurs. “They do make it in Greece with olive oil, but it’s an entirely different dish. My kids don’t like it.” The pastitsio her kids love is made with two sticks of butter, making me wonder if her mother knew the ladies who wrote that church cookbook up there…
I did find a healthier Pastitsio recipe in John Kaldes’ cookbook Made in Greece. (Faithful readers may recall John from our little foray to the fish market in Newark…) John’s recipe uses no butter, not even in the bechamel, and calls for two different Greek cheeses. A bechamel made with olive oil – that’s got to be the authentic recipe.
I think I am going to make John’s Pastitsio next time and see how it stands up to the American version. I’ll let you know how it turns out. Better yet, John, how about a little Pastitsio Throw Down? (Update – The Throwdown is a go! Probably sometime early spring. Stay tuned…)
ARTERY CLOGGING, CROWD PLEASING, BIG, FAT AMERICAN PASTISTIO
Even I’m not going to use two sticks of butter in one recipe, so I’ve cut back considerably on that as well as the eggs. I also make a larger quantity of sauce than the original recipe, and serve it atop, since the Pastitsio can be a bit dry otherwise. I do what Jeff Smith suggests, and line my ziti up in rows so it looks pretty when sliced. Serve with a big side of green salad.
Meat Mixture
2 tbsp olive oil
1 large peeled and finely chopped onion
2 cloves garlic, chopped
2 pounds lean ground beef
2 large can peeled tomatoes, pulsed on processor (or used chopped tomatoes)
Salt and pepper to taste
1/2 tsp ground cinnamon
1/8 tsp clovesMacaroni
4 qt water
salt
1 lb ziti
2 eggs, lightly beaten
2 tbsp butter, melted
1/2 cup grated Parmesan cheeseBechamel
4 tbsp butter
4 tbsp flour
2 cups warm milk
2 eggs, beaten lightly
2 tbsp dry sherry
1/2 tsp freshly ground nutmeg
1/2 cup Parmesan cheese
Salt and pepper to tasteHeat olive oil in a large skillet. Saute onion and garlic till golden. Add beef and cook till it just loses its red color, then add the remaining meat mixture ingredients and simmer, uncovered, for 30-45 minutes. It should be thick. Set aside.
Meanwhile, bring the water to a boil in a large stockpot. Add salt and ziti and cook, uncovered about 7-8 minutes. Drain and place in a large bowl. Add melted butter and beaten eggs and grated cheeses. Put half this mixture into the bottom of a greased 9x9x2 inch baking pan and top with about 2/3 of the meat mixture. (You’ll reserve the rest of the meat mixture, keeping it warm to serve atop the final dish). Cover the meat with the remaining half of the pasta.
Prepare the white sauce by melting butter in a large saucepan. Stir in flour and cook for a minute. Gradually add the heated milk, stirring constantly, and cook till thickened and smooth. Beat the eggs in a separate bowl, then stir in 1/2 cup of the bechamel. Blend and stir the egg/sauce mixture back into the bechamel in the saucepan and continue to stir over low heat til thickened. Add remaining ingredients to the sauce.
Pour the sauce over the ziti and bake at 350 degrees Fahrenheit for 25-30 minutes, or until the top is delicately browned. Let sit for at least 10 minutes. Serve with a bit of sauce atop each serving.
Like Christopher Columbus or Magellan, I travel across the uncharted waters of the web in search of one thing or another, and discover new worlds I never knew existed. Here are a few medical blogs I discovered in my travels –
Academic OB/Gyn – A kindred spirit in Hawaii. With a podcast!
Medical Lessons – Heme/Onc, Journalist, breast cancer survivor. Not to mention, fellow New Yorker, fellow Cornell faculty member and our kids were in pre-school together. Oh yeah, and she’s written for Huffington. Not that I’m jealous or anything….
See you around the blogosphere!
