My New Butter Keeper

We are loving the Butter Keeper my daughter got me for Christmas. This little ceramic jar holds a full stick of butter inside the lid, which is then turned over and placed onto the bottom, which has been filled partway with cold water. The water, changed every 3 days, provides an airtight seal as well as maintaining the temperature cooler than room air. The butter stays at a wonderfully spreadable consistency and small amounts are easy to remove.

Is is wise to store butter outside of the fridge?

Because butter has oils, it can turn rancid (ie, develop an off flavor and smell) if left in contact with air for too long. This is less of a problem with salted versus unsalted butter and can be prevented by wrapping or covering butter when softening it. I have to admit I am particularly sensitive to even small changes in flavor, and always use salted butter because of this issue.
As far as health concerns go, the official party line is to refrigerate your butter, avoiding even the lower temperature butter storage compartment on your fridge door to store butter for more than a few days. Most experts recommend caution when storing butter in a french type butter keeper. Other say butter is safe stored this way for up to two days outside the fridge. When challenged, some appear to hedge, saying that while it is best to keep butter in the fridge, you needn’t worry too much if you don’t.
Mold growth on water filled butter crocks has been reported by some on comment boards around the web, while others state that salting the water and washing your crock in the dishwasher between uses prevents this problem.
How do I store my butter?

Because I love to bake, we buy our butter in bulk packs from Costco and store these in the freezer, keeping one pound at a time in its wrapping and box in the main compartment of the fridge, an an unwrapped stick in the butter keeper on the fridge door.
I plan to use my Butter Keeper to store better at room temp during times when we are using butter quickly enough to prevent spoilage (ie., weekends and during times we are entertaining a lot.) If we are in a cooking/entertaining lull or going to be away for more than a day, I will leave the keeper empty and just enjoy looking at it on my shelf.
I’d be interested in hearing how others handle the butter storage issue, and experiences you may have had using a butter crock.
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More on Butter Storage from Around the Web

Apartment Therapy tackles the question nicely
The Food Network has a video on how the ceramic butter keepers work
FAQ’s about using a french butter keeper
Chowhound readers discuss butter storage

Jack Black Gets a Mammogram

A very funny, if utterly simplistic message from the Men for Women Now Facebook campaign, which uses male celebs to urge women to get mammograms and pap smears.

Despite the controversy over the new mammogram guidelines, it is acknowledged that the test remains under-utilized among women who should have the screening, particularly minorities and women in medically under-served areas. In addition, most cervical cancers occur in women who fail to get Pap smears. So the goal of getting these women to screening is a noble and important one.

Unfortunately, the nuances of cancer screening decisions get lost with these kind of mass marketing campaign. Not to mention the blurred demographic targeted when these guys are used to deliver the message.
Still, I gotta’ say I love Jack Black, who in my opinion is one of the most talented human beings on the planet.

The New Mammogram Guidelines – What You Need to Know

Unless you’ve been living on another planet, you know that in mid-November, the US Preventive Services Task Force released new recommendations on screening mammography, in which they recommended against routine mammogram screening in women under age 50, and recommended that mammograms now be every two years in women ages 50-74.

What you may not have heard is that the Task Force has acknowledged that the mammogram guidelines were poorly worded, and have revised their original statement to clarify their intentions, mostly by removing those two little words “recommends against”.

Here’s how the guidelines now read (changes in red)
  • The USPSTF recommends biennial screening mammography for women aged 50 to 74 years.
  • The decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take patient context into account, including the patient’s values regarding specific benefits and harms.
  • The USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of screening mammography in women 75 years or older.
  • The USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of either digital mammography or magnetic resonance imaging (MRI) instead of film mammography as screening modalities for breast cancer.

They’ve also included this statement right in with the guidelines –

“So, what does this mean if you are a woman in your 40s? You should talk to your doctor and make an informed decision about whether mammography is right for you based on your family history, general health, and personal values.”

What the USPSTF meant to say

What the Task Force is saying is simply this – On a population basis, the net gain from adding 10 years of mammography in all women is small in relation to the risks of over-diagnosis, over treatment, unnecessary biopsies and anxiety. But you, as a patient, in consult with your physician and assessing your own personal risks of breast cancer, may decide you want to get a mammogram anyway.

What they meant to do was to take mammography out of the realm of the knee-jerk, automatic and into the realm of informed decision making. They meant to inform women that mammography’s 15% or so reduction in mortality comes at a price – a price that is physical, emotional and financial, in the form of false positive results, unnecessary biopsies and the anxiety and dollar cost that accompanies them. They also meant to dispel popular overblown notions about what mammograms actually do by clarifying both their benefits and their risks, so that women are making the most informed decision they can about whether or not to have this potentially lifesaving test.

Unfortunately, they blew their 15 minutes. Which leaves it to the rest of us to clean up the mess. So, let’s see if I can add my two sense to the party.

What you need to know about the USPSTF

First off, let’s dispel the conspiracy theories. The US Preventive Services Task Force is an independent panel charged with making health care recommendations based on current scientific evidence. They do not make health care policy or decide insurance coverage.

The task force members should have anticipated that the timing of their recommendations coincident with health care reform would lead to misunderstanding about their role. Their cluelessness in this regard alone should be proof that they have no ties with the stakeholders in health care reform, who clearly would have managed the spin upfront.

Which is not to say that the task force’s recommendations won’t be used to guide policy decisions, which is why everyone is taking this all so seriously.

What you need to know about mammograms

The lay public has an almost magical thinking about what mammograms actually do. This is not surprising given the intensity with which we have been advising them to have mammograms over the years. So it is not unexpected that women have been taken aback by the hard reality about mammograms that they are now being asked to accept. That said, here’s what you need to know –

1. Mammograms don’t prevent cancer. They diagnose it. It’s a simple but important distinction that gets clouded by the magical thinking surrounding this screening test. The value of mammography lies in its potential to diagnose cancers at an earlier stage, allowing life-saving treatment to begin earlier.

2.Because they use radiation, mammograms can actually cause cancers. Though a single mammogram has a low risk in this regard, the radiation exposure from annual mammograms over many years adds up. The task force estimated that on a population basis, annual mammograms from age 40-50 would induce 8 breast cancers for every 100,000 women.

3. Mammograms are not a perfect test. In general, they miss about 10% of cancers, more if you have dense breasts, which are more common in women under age 50. In addition, mammograms have a high false positive rate, meaning that if you have an abnormal mammogram, the odds are high that your biopsy will be benign, and technically unnecessary.

The task force estimated that the cumulative risk for a false-positive mammogram with 10 years of annual screening was about 50%. The younger you are, the higher the chance your abnormal mammogram will be a false alarm. The higher your risk of breast cancer going into screening, the lower your risk of a false positive result.

4. Mammograms may be better at diagnosing slower-growing cancers than more aggressive tumors. Think about it. If a tumor is growing slowly, testing once a year will find it sooner rather than later. If it’s a fast growing, aggressive tumor that spreads out of the breast at a smaller size, a test that is done only once a year may not pick it up before it has spread beyond the breast. So we may be finding and over-treating tumors that may never cause much problem, while missing the bad players. (I myself have a harder time accepting this as an argument for cutting back on screening in women under age 50 than for women over age 70.)

In this regard, one of the most problematic diagnoses made by mammography is that of DCIS, or ductal carcinoma in situ, a non-invasive neoplastic growth that looks like breast cancer by has not invaded beyond the duct wall, and may never become invasive. Mammograms are really good at finding DCIS, since its hallmark is calcifications, which tend to show up pretty well even in dense breasts. So we end up treating and even performing a lot of mastectomies because of DCIS, without knowing if we are impacting mortality.

Finally, if mammograms were as good as everyone thinks they are, then we should expect over the years to find less and less advanced breast cancers, since we should be picking them up earlier and treating them. Unfortunately, this has not yet been proven.<

5. Mammograms are a better screening tool in older versus younger women. In women ages 40-49, 1900 mammograms must be performed to prevent a single death in this age group, compared with 1339 women age 50-60, and 377 women age 60-69. This is because breast cancer risk increases with age (meaning a positive result is more likely to be a true positive) and because older women have less dense breasts, so that there are less false negative mammograms.

Measuring mammogram success by years of life saved instead of mortality alone, mammograms starting at age 40 look better as a screening tool, but still perform better in women over age 50.

6. The benefit of annual vs. biennial mammograms is negligible. Meaning you can go every other year without sacrificing much in the way of benefit (about 1-2% absolute risk reduction benefit), and save additional radiation exposure.

7. Despite their imperfections, Mammograms save lives. To the tune of about a 15-20% reduction in women ages 40-49, the group most affected by the new recommendations. This is an important fact that, in my opinion, keeps getting lost in the discussion about the guidelines.

Which brings me to the elephant in the room.

The Elephant in the Room

Breast cancer causes about 4,500 deaths annually in women ages 40-49, and is one of the leading causes of death in women in this age group. (This data does not include cancer deaths occurring after age 49 in women diagnosed in these years.) In the 10 year interval between 40 and 49, then, about 45,000 lives are lost to breast cancer. That’s no small number, and it’s why breast cancer advocates are up in arms at the recommendations.

Which brings me to the real crux of the question – how many of these breast cancer deaths is mammogram preventing in women ages 40-49? Put another way, if you forgo mammograms in that age group, what are your odds of dying as a result of that choice?<

A age 40, what are your odds of dying in the next 10 years from breast cancer?]

This was not an easy number to find. SEER data on cancer mortality groups ages from 35-44, 45-55 and so on, so it’s taken me a long time to find the data. But I finally found it.

At age 40, your chance of developing breast cancer in the next 10 years is 1.44% or about 1 in 69. Your chance of dying from breast cancer in that interval is about 1 in 480. (This compares to a risk of about 1 in 280 for a woman at age 50, 1 in 146 for a woman at age 60, and 1 in 108 at age 70, and so on.) Here’s how that risk looks visually, in the thousand dot graph below, with the red dots representing breast cancer deaths among 1,000 women.

So if mammograms prevent 15% of breast cancer deaths, then if you are 40, and have mammograms for the next 10 years, your chance of dying from breast cancer is reduced from 1 in 480 t0 about 1 in 564.

USA today estimates that annual mammograms reduce the 10 year mortality risk for women ages 40-49 from 1 in 300 to 1 in 357, as compared to women age 50-59 whose risk is reduced from 1 in 112 to 1 in 144.

That’s not a big individual reduction as far as cancer screening goes, especially when one compares it to, say, colon cancer screening, which reduces deaths from colon cancer by as much as 60%.

Looking at the numbers from a population rather than individual standpoint, assuming a US population of about 21 million women age 40-49, routine mammograms in this age group prevents about 680 deaths per year. Is that really worth having 21 million women get an annual test that over 10 years will result in 50% of them having an unnecessary breast biopsy? It certainly does not stand up to the standards we’ve set for screening tests in the past.

But breast cancer advocates will argue that every one of those 680 lives represents someone’s friend, spouse, parent or relative. How can we say those lives aren’t worth saving? But with that kind of argument, we’d be mammogramming 20 year olds. If mammograms were free and perfect, that would be a good argument. But they are neither.

I think when a screening test has such a high potential for false positives and invasive biopsies over time, it makes sense to allow individuals to make their own decisions about that screening. I also believe that breast cancer, because it is a leading cause of death in women age 40-50, deserves to be addressed as a risk, even if it is to decide in an individual to forgo screening.

What if You are High Risk?

The data the task force used to make their recommendations encompassed all women having screening, including both low and high risk women. But what if you are at increased risk?

You can calculate your individual risk for breast cancer by using one of several risk assessment tools – the most commonly used one being the Gail Model. The Gail model can give you your individual risk of being diagnosed with breast cancer in the next 5 years. You can then us this number to discuss with your doctor whether or not you want to start mammograms before age 50. I don’t know that the model can be used to predict mortality reduction from mammography in high risk women, but would say that if your risk for breast cancer approaches that of a 50 year old woman, you should start routine screening mammograms.

An important high risk group not addressed by the guidelines are African American women, who in general are diagnosed at more advanced stages of breast cancer and have higher breast cancer mortality rates than Caucasian women. Given that much of the data being used to support the USPSTF guidelines come from Scandinavian countries, one must question their application to non-white populations, including Hispanic and Asian women. Fortunately, the Gail model does include ethnicity in its risk calculation.

Bottom Line

Mammograms in women under age 50 are less efficient than in women over age 50, and come at a higher cost in terms of over-diagnosis and potential over-treatment. The USPSTF made a decision that the cost differential was enough to recommend against knee-jerk, routine mammograms in all women under age 50, and instead recommend that women discuss the decision with their doctor before deciding to start screening.

The American Cancer Society, the American College of Obstetricians and Gynecologists and the American College of Radiology continue to recommend routine mammogram screening every 1-2 years starting at age 40.

What do I recommend?

I’ve addressed this issue before, and have not changed my practice, which at this point is to offer mammograms starting at age 40 in all my patients. However, I am now framing it as an option rather than an undebatable recommendation for my low risk patients, which means we spending more time discussing the issue before I place the order.

So far, when presented with the data, every one of my low-risk patients age 40-50 has decided to have their mammograms. However, more than a few made that decision only after confirming that their insurer would continue to pay for the test. I’ve queried a few as to how much they would pay to have that mammogram if their insurer declined to pay – about $200 seems to be the break point above which those few low risk patients would decline the test based on cost alone. Most women are either willing to pay or fight for payment whatever the cost. (This is by no means a scientific sample, but I think captures the gestalt in my practice, which happens to include a fair number of high risk women.) In the absence of any other screening, most women seemed willing to accept the high rate of biopsy in return for a mortality reduction, however small.

I also frequently order screening sonograms in high risk women with dense breasts, and MRI in women with a first degree relative with premenopausal breast cancer or other risk factors for whom this testing has been recommended.

I am comfortable spacing mammogram screening to every other year, especially since that’s about the frequency many of my patients end up getting them anyway. The task force recommendations have certainly made me more comfortable reassuring the patient who calls a few weeks before her annual mammo is due and can’t be fit into the radiologist schedule for several months.

I have to admit I have some concerns about my risks if and when a patient declines routine mammograms. Will I get sued if I don’t urge her to get a routine mammogram and she ends up with an advanced stage breast cancer at some point in the future? Should I have her sign something to protect myself? What is the minimum I need to document to cover my tail? I’m also wondering how long it will be before the first lawsuit against a doc who follows the taskforce guidelines is filed. Will they try to sue the taskforce members themselves? (I wouldn’t put it past some of the lawyers.)

A Call for a Decision Tool

The Australian Screening Mammogram Decision Trial has a wonderful web-based tool to assist women age 40 in making a decision about mammography. I’d like to see the USPSTF develop a similar tool for American women incorporating the latest data they used. It’s the least they can do to help American women and their physicians begin to incorporate their recommendations into practice.

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Recommended reading
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Photo credit Wikipedia
Note – I clarified morality statistics from a previous version of this post, and apologize if they appeared misleading. They were technically correct, but I think this is clearer. Looking at deaths in this age group overall, cancers as a group account for about 30% of deaths, and breast cancer a third of these, or 10% of deaths overall. Heart disease as a group accounts for about 20% of deaths, with heart attacks about 5% of deaths overall.

Pink Glove Dance

I’ve been too busy to blog yet about the new mammo and cervical cancer recommendations, but promise that I will very soon. In the meantime, enjoy this video made by employees of the Providence St Vincent Health System in Portland, Oregon to raise breast cancer awareness.(Thanks to Carrie for forwarding it to me)

Swedish Meatballs

Swedish Meatballs are one of Mr TBTAM’s specialties, made from a recipe given to him by my mother-in-law Irene, who modified it from The Casserole Cookbook. We usually serve the meatballs with buttered noodles, but they are also traditionally paired with boiled potatoes.

Perfect for those cold winter nights, which I hear they have a lot of in Sweden.

Meatballs Stockholm (Swedish Meatballs)

3 slices toasted rye bread
½ cup milk
1 lb. ground beef
1 egg, slightly beaten
½ small onion, grated
½ small onion, sliced
½ tsp. salt (or more, to taste)
¼ tsp. pepper
¼ tsp. grated nutmeg, ½ tsp. paprika, 1 tsp. dry mustard
4 tbsps shortening
2 cups beef bouillon
2 tbsps. flour
2 tbsps chopped parsley

Trim crusts from toast, break into small pieces and soak in milk for 10 minutes. Mash with a fork until smooth. Mix with meat, grated onion, egg and seasonings. Form into small balls about 2 inches in diameter. Heat shortening in saute pan. Add meatballs and sliced onion to pan and saute until meatballs are nicely browned on all sides. Pour off excess fat from pan and add bouillon. Cover and simmer for 15 minutes. Remove balls from gravy and keep warm. Mix flour with a little water and carefully add to gravy. Add parsley. Replace balls in gravy and heat just to boiling. Serves 4.

Veal and pork may be used in place of some of the beef. The meatballs are especially good if made early in the day and then reheated just before serving.
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Swedish Meatballs from around the web

There are lots of ways to make Swedish meatballs. Variations include using white instead of rye bread, substituting potatoes for bread, adding pork, and even using soy sauce in the gravy. Here are just a few recipes I found –

– Cooks Illustrated’s recipe at What’s on My Plate

– Ikea’s recipe, from their cookbook. Like their furniture, not quite as well-made as one would have hoped. Assembly required.

– Kevin Week’s recipe uses dill and mixes ground pork with the beef. I may try this one next time…

– Jamie tweaks Alton’s recipe by using a tablespoon instead of a scale to portion out the meatball, making the recipe accessible to non-obsessive compulsive cooks.

– Twinkle at Yum Sugar does a streamlined version without gravy, served with lingonberry jam. She gets points for actually being in Sweden while making them…

– Cheap Talk spends way too much time wondering why Swedish meatballs are smaller than their American counterparts. (Very funny…)

Swedish Meat Balls on Foodista

Supplemental Folic Acid in Late Pregnancy Associated with Childhood Asthma

In yet another study assessing the impact of folic acid supplementation in pregnancy, Australian researchers have found an association between use of folic acid supplements in late pregnancy and the risk for asthma in childhood. The risk was not found with use of folate when it was confined to the prenatal period and the first trimester of pregnancy, a time when its use decreases the incidence of neural tube defects such as spina bifida. Intake of folate from dietary sources was also not associated with childhood asthma.

The study is quite muddied with confounding variables, imperfect data sources and no data on supplement use in childhood. Still it raises important concerns, and if its findings are replicated in other studies, it would suggest that folic acid supplementation should be limited to the prenatal and first trimesters. It’s also important not to exceed current dosing recommendations for this important vitamin.

It also underscores what I’ve been telling my patients for years – it’s always preferable to get your vitamins from dietary sources rather than supplements.

Photoshop Healthcare Reform

Congress clearly hasn’t gotten the picture on what America really needs for healthcare reform. Which means you’ll have to create it for them.

To that end, Dr Wes and his wife are holding the first and only US Healthcare Reform Photoshop Contest.

Bring us your snark, your wit, your creativity about the health care reform efforts encapsulated in a single photograph. Photographs in support or against the current efforts will be equally considered, and you, dear internet devotees, will be the final judge. The winner receives an iPod Touch.

See Dr Wes’ blog for rules, get out your cameras and your laptops and make it happen!

Dr Oz Gets it Right

As much as I rant against Dr Oz and as much as the Huffington Post is beginning to annoy me with it’s celebrity gossip and daily almost nude photos, they both just redeemed themselves this week with Oz’s wonderful column entitled. “Real Health Reform – What’s Next?”

We need to create a culture of health and wellness that fosters a nationwide understanding that personal behaviors are a major factor in health and well-being. And at the same time, we need to make the necessary societal changes so that all individuals are supported in making the correct choices. We need to make it easier to do the right thing.

Oz recommends changes as sweeping as reforming the food supply, changing how we feed our children in school, improving air and water quality and finding ways to reduce stress and incorporate physical activity into our daily lives. Its an agenda much larger than anything facing the Senate right now, but includes many things that most American people can start to do today that don’t require an act of Congress.

Ambitious, yes. Impossible, no.

Do the right thing.

I like it.

How to Delete a Calendar from Your iPhone

****Geek alert****
Ignore this post unless you came searching for this solution. 

After switching from Blackberry to Iphone, I forgot to remove Pocket Mac from my Macbook. As a result, when I synced my calendar to my iPhone using Mobile Me, a second calendar was created on my I Phone. Even when I removed Pocket Mac from my Macbook, he calendar remained. I searched everywhere for instructions on deleting it, without success. Then I figured it out. So simple.

Open up iCal on your macbook. You will see a list of your calendars on the top left. Cntrl click the one you want to delete, then scroll down to the “delete” option and Viola – Gone! Now re-sync your iPhone with iTunes. The offending calendar is gone.

This should work with any extraneous calender you’ve accidentally created on your I Phone. Mine just happened to be my Pocket Mac calendar.

Drugs for Cancer Prevention – NY Times Misses the Point

In yet another article addressing the war on cancer, The New York Times today tackles cancer prevention, focusing on alternative and mainstream Pharma products marketed to reduce the risk for cancer.

While author Gina Kolata seems to have done her homework when it comes to the failure of alternative medicine to prevent cancer, she has missed the story completely when it comes to telling why the medical profession and patients may have failed to embrace Big Pharma’s push to use their drugs to prevent breast and prostate cancer. Of course, that’s not surprising since almost exclusively, the experts she interviewed were those who conducted the clinical trials of these drugs.

Since I’m not a urologist, I’m not going to comment on the use of finasteride to prevent prostate cancer, except to point out that the one expert quoted in favor of its use has served as a consultant to Merck and AstraZeneca, both of whom make the drug, while the other works for Astra Zeneca.

So let’s talk about tamoxifen and raloxifene, two drugs that are approved for the prevention of breast cancer.

Tamoxifen and Raloxifene

The maker of Evista (raloxifene) is targeting both docs and women, urging them to calculate their lifetime risk for breast cancer and consider taking the drug if that risk for breast cancer is increased. Since raloxifene is also approved for treatment of osteoporosis, the drug makers are selling it as a two for one.

Both tamoxifen and raloxifene cut the risk for breast cancer in half among high risk women who use the drug for 5 years. Tamoxifen also prevents DCIS and LCIS in addition to invasive cancer, while raloxifene does not reduce these risks.

But, Tamoxifen can cause uterine cancers. The risk is low, about 1 in 500, but includes uterine sarcomas, a particularly aggressive tumor, and may persist even after the drug is discontinued. There is no screening for uterine cancer in tamoxifen users – ultrasound is useless, since the endometrium very frequently appears abnormal even if there is no cancer. We docs are left telling women just to tell us if they blee

Now, for women who are taking tamoxifen for treatment of breast cancer, the risk for uterine cancer is almost always outweighed by the benefits in terms of cancer treatment. But for woman who have never had (and may never get) a breast cancer, the uterine cancer risk is a deal breaker, especially when she asks what I can do to screen her and I tell her “nothing”. I can quantify it for her – look, your risk for breast cancer will be reduced from 20% to 10%, I might say – and your risk for uterine cancer increased by less than one percent.

Okay, I’m interested, she might say. So tell me – Are there any other risks?

Yes, I’ll say.

Both raloxifene and tamoxifen carry an increased risk of thromboembolism. According to the package insert for Evista (raloxifene), DVT occurred in 1 out of every 100 women using the drug for an average of 2.6 yrs, over twice the rate for placebo users. Fatal stroke risk was about 1.5 times higher in Evista compared to placebo users, though that risk was concentrated in postmenopausal women at increased risk. Unfortunately, nowhere in the marketing materials for Evista is there a risk calculator that helps me or my patients assess their personal risk for these complications from the drug.

So, I’ll fudge it. Now my risk calculation for this patient looks something like this – Breast cancer, lowered from 20% to 10%. Uterine cancer, increased by 0.2%, but no screening. Blood clot risk = 1%. Fatal stroke risk = 0.3% over 5 yrs if you have risk factors, miniscule if you don’t.

Okay, she’ll ask me. How is it going to make me feel?

Probably fine, I say, but there are some side effects that might bother you, the most common of which is hot flashes in about 10% of users. Some women experience joint pains and leg cramps as well. These symptoms can occasionally be severe, although only about 1% of users stopped the drug because of hot flashes in the clinical trials. And most women will notice an increase in vaginal mucus that, as a gynecologist, I don’t have concerns about. Not uncommonly, my patient will have had a friend who has experienced a bothersome side effects from taking Tamoxifen. That’s usually the kiss of death for any drug – a girlfriend with a side effect…

And oh yeah, there’s also the increased risk for cataracts with Tamoxifen, but not raloxifene.

Now, if a woman has osteoporosis, I can add that to the plus side of the balance scale for raloxifene use. Now I’ve got to do her risk for fracture based on her bone density and talk to her about the other options she may have to treat her osteoporosis as well.

Is anyone really wondering why we docs and our patients haven’t jumped onto Big Pharma’s cancer prevention bandwagon? We’re asking patients to balance competing statistical risks for conditions she may never get, in return for a benefit she may never need.

I do prescribe raloxifene it for treatment of osteoporosis, and if there is a strong family history of breast cancer, I may even try to steer my osteoporotic patients who are not at increased risk for clots towards using it. However, it is the rare patient who chooses this drug over a bisphosphonate such as Fosamax and Actonel when I inform her of the risks and benefits of both these classes of drugs. Even patients with strong family histories of breast cancer just don’t want the potential side effects of a drug in return for a reduced risks for a cancer they may never get.

Hello – Birth Control Pills?

Kolata completely misses out on the fact that millions of women are already taking a pill that reduces their risk for cancer – the birth control pill. It cuts ovarian cancer by up to 80% and endometrial cancer by almost half.

Like Tamoxifen and Raloxifene, the pill carries an increased risk of blood clots, a trade off many women are willing to make in return for prevention of pregnancy, which itself carries an even higher risk of clotting. Not to mention the benefits the pill can confer for women with menstrual disorders such as dysmenorrhea, menorrhagia, endometriosis and its efficacy in treating acne and even PMS. For most healthy young women, the balance of benefits and risks of pill use is favorable, even before considering the cancer prevention aspects of the p

For the record, I inform each and very patient who starts estrogen containing birth control that there is an increased risks of clots. I quantify it for them, tell them that it is a real risk and give them strategies they can use to minimize these risks. Surprisingly, that discussion has rarely deterred a patient from starting on hormonal birth control. It may be that pill patients are younger and feel more invincible than the older women being targeted by the makers of Evista. But I think most of them are actually weighing their risks of pregnancy against the risks of blood clots, comparing this to their perceived downsides of barrier methods and/or the IUD, and coming out on the side of using the pill.

Prevention is the holy grail for Big Pharma

Let’s face it – an indication for prevention of a disease grows the potential market of a drug by millions. But if you’re going to market a drug to healthy individuals, it better be free of risk or have some other benefit that patients can see right away.

Otherwise, it just ain’t gonna’ sell.

Which probably explains why Kolata tells the story of the cancer prevention challenge as though it were a failed pharmaceutical marketing campaign. Missing from her article, unfortunately, is the question that asks whether pharmaceuticals are really the right strategy to prevent cancer. Or that asks if we really mean to ask 100% of men over 50 to take a drug to prevent prostate cancer, when, in the same breath, we are telling them we should stop screening for it? Or whether 100% of women over 60 take a drug that increases their risk for thromboembolism and uterine cancer so that 20% of them won’t get breast cancers that some are suggesting may regress or be so indolent that they will die of something else before it kills them?

Of course, we could just sell them another drug to lower their clotting risks..

Macaroons for the Chemo Tummy

The good thing about being both a doctor and a cook is that when you don’t have any more medicine to offer, there’s always the food.

Case in point – my sister’s chemo-induced nausea. Despite maximum doses of Zofran, she still finds herself quite queasy, usually between meals. We decided to try some mint lemonade and bingo! – the stuff really works for her. She’ll nurse a tall glass all afternoon to help keep her tummy in control.

Then, her good friend Lorraine, an onco nurse, told us she heard anectodal reports from her colleagues that macaroons were also helpful for chemo and radiation induced GI distress, both upper and lower. Well, that was all I needed to head to the kitchen to whip up a batch of cousin Jessie’s macaroons. Indeed, Sis found them useful when she has that empty stomach queaziness. (They didn’t work if she had already eaten something that makes her nauseus.)

Unfortunately, Sis is now on a low residue diet and macaroons are off the list. Coconut is a nut, after all, so don’t overdo it, and avoid them completely if you are at risk for obstruction. And remember, both these foods are high in sugar, so take them in small doses. Fortunately, that’s the way they seem to work best – a sip here, a nibble there…

Minted Lemonade

Make lemonade either homemade or from canned concentrate. (I would not use powdered) in a 2 qt pitcher withy a lid. Tear up a whole lotta’ mint leaves (we use about a 1/4 cup torn leaves) and mix them in with the lemonade. Store in the fridge – it will keep for several days. Serve over lots of ice. Alternatively, freeze the mint with water in ice cube trays and use the mint ice cubes in your lemonade.

Jessie’s Macaroons

I’m sure any macaroon recipe would work, but these macaroons are the best I’ve ever had. Cousin Jessie makes for Passover every year, so of course, they are flourless. Be sure to use unsweetened coconut – the sweetened stuff has additives like propylene glycol and sulfites.

2/3 cup egg white
¾ cup sugar
1/8 tsp salts2 ½ cup natural coconut
1 tbsp cornstarch
1 tsp vanilla
½ tsp almond extract
1 tbsp white corn syrup
Almonds

Combine all ingredients, stirring well, in a moderate size saucepan. Heat over mod heat till warm. Off heat let stand 10 mins. Line baking sheet with parchment paper. Drop by tsp or small scoop onto baking sheet and place half an almond on top. Bake in 325 oven 18-20 mins till golden. Let cool on the paper. Store in a tightly covered container.
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Sorry for Poor Quality photo – it was taken with my old phone.

Impaired Physicians – in the Bathroom?

So I’m sitting here taking my required annual hospital online training, and I read that one of the signs of an impaired physician is “frequent bathroom use”.

Guess that puts all us perimenopausal and pregnant female docs who drink water and coffee and also happen to have bladders under suspicion.

Treating Vitamin D Deficiency

If, like me, you are doc who is increasingly screening for and finding vitamin D deficiency, you’re probably wondering the best way to replenish body stores of this essential vitamin.

I have found that simply telling my vitamin D deficient patients to increase their daily intake of Vitamin D3 to 800-1200 IU does not result in adequate levels. I have had success using 50,000 IU Ergocalciferol (Vit D2) weekly for 12 weeks, transitioning to 1000-1200 IU Vit D3 daily after that for long term replacement.

Now a study has been published showing that a regimen of 50,000 IU ergocalciferol weekly for 8 weeks, followed by 50,000 IU ergocalciferol every other week is effective for up to 6 yrs at restoring and maintaining adequate vitamin D levels in most vitamin D deficient patients. For those with normal levels to start, the every other week regimen alone is sufficient to maintain them. This regimen is fairly cheap, about $6 a month here in NYC.

This study reinforces the results of another recent study showing that, for most patients, Vitamin D2 is as effective as D3 in restroing and maintaining normal levels of vitamin D.

That’s good to know.

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11/30/10 UPDATE – New IOM guidelines tell us that levels of Vitamin D at or above 20ng/dL are normal, levels above 30 ng/dL have no proven benefit, and levels above 50ng/dL may be harmful. Most of my patients have levels in the mid 20’s, even with treatment, so I find this very reassuring.

My First I Phone Dinner

Driving home from Brooklyn Sunday afternoon, trying to figure out what to have for dinner, Mr TBTAM recalls a recipe for Butternut Squash Ginger Soup that he heard that morning on Weekend Edition. Using the google app on my new I Phone, I find the recipe and consult it at the supermarket, where I buy the ingredients we need. Then, still using my I Phone, I consult the same recipe in the kitchen and cook up the soup. Never once heading to the computer or printing anything out.

Now if someone could just write an app that does the dishes…

Butternut Squash Ginger Soup

Modified from the recipe on the NPR website. I made my own 5 spice, and found it quite strong, so I reduced the amount by half in this recipe. I also did not do the whole fried ginger and orange peel topping in the original, but it looks like a fun idea. I also decided to cube the squash before roasting it, both to speed up the process and to get additional carmelization. Finally, depending on the size of squash you use, you may find you need to add addtional broth to thin the soup a bit.

Soup

1 medium-size butternut squash
1 tbsp olive oil
salt and pepper
2 -3 cups of vegetable broth
2 tablespoons finely minced ginger
1/2 teaspoon Chinese 5 spice
1 cup white wine
Salt and pepper to taste

Topping

1 cup creme fraiche
1 tablespoon fresh squeezed orange juice

Preheat oven to 350 degrees. Peel and cut butternut squash in half lengthwise, remove seeds and then cut into 2 inch cubes. Toss with olive oil, salt and pepper and roast on baking sheet for about 30 minutes, tossing halfway through so it evenly browns. Put in food processor and process with ginger and spices till smooth. Add one cup of the broth into the feed tube, process a few seconds then transfer to a medium sized stock pot and whisk in remaining 1 cup broth and wine, adding more broth if soup seems to thick. Heat through until simmering. Salt to taste.

Mix creme fraiche and orange juice together.

Serve soup in bowl with creme fraiche swizzle on top.

Bye-Bye Consultation Codes

Consultation CPT codes are being eliminated by Medicare starting January 1. 2010. (The link is to the federal register – the relevent section starts p 162.)

In the CY 2010 PFS proposed rule (74 FR 33551), we proposed, beginning January 1, 2010, to budget neutrally eliminate the use of all consultation codes (inpatient and office/outpatient codes for various places of service except for telehealth consultation G-codes) by increasing the work RVUs for new and established office visits, increasing the work RVUs for initial hospital and initial nursing facility visits, and incorporating the increased use of these visits into our PE and malpractice RVU calculations.

Medicare claims the rulting will be budget neutral, and has balanced it with a 6% increase in RVU’s for office-based and 0.3% for in-hospital E&M services. There will be new modifiers used to identify the admitting physican and the consultants.

There’s still another 30 days to comment, though it appears pretty final to me. I’d expect managed care to follow suit.

I have mixed feelings on this one. It’s always nice to be consulted by a colleague on a challenging case, and to have this recognized by an increased reimbursement. But I know there are specialists out there who bill each and every new patient as a consult and require a referral physician name before even seeing any patient. I resent their consultant letters thanking me for referring my patient for a routine preventive service, when I never even made the referral.

One could argue that there needs to be compensation for the additional years of training and expense that specialists incur. At the same time, the imbalance in reimbursement between subspecialists and primary care has led to a shortage of primary care docs.

This ruling may be one small step towards a resolution of the primary care shortage.
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Addendum – According to this analysis, the elimination of consultation codes will save Medicare $534.5 million anually. The authors point out that the ruling “sends a signal that primary care cognitive services are not valued equally with such services provided by other specialties.”