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.”

On the Doctor Shortage

Well said.

To address the shortage of doctors and the incentives that compel young doctors to eschew primary care, Congress needs to think about how to increase doctor pay, institute malpractice reform, and provide subsidies to reduce the amount of debt doctors have to take on. Residency caps should also be raised so teaching hospitals can train more doctors. Without these actions new doctors would be foolish to enter primary care, and thankfully our medical schools do not recruit foolish people. (Herb Pardes, CEO New York Presbyterian Hospital)

The suggested interventions are not mutually exclusive, and movement on any of them will decrease the need for the others. If you reform malpractice and lower debt, doctor’s pay will increase as less income is funneled off to insurance premiums and interest payments.

(HT Howard Luks via Val Jones)

Mammogram Screening Comes under Question

Denise Grady frames the recent debate on mammogram screening in today’s New York Times. The article tag teams and improves upon Gina Kolata’s recent story on the topic.

These articles highlight what we health professionals have known for some time about mammograms – they are not perfect.

About 10% of cancers will be missed by mammography alone. About 65% of so-called “positive mammograms” end up being benign on biopsy. We really don’t know what we are supposed to be doing with DCIS – is it precancerous, and should we be treating it? And finally, some cancers are faster-growing and more likely to kill you than others, and mammography is not so good at figuring out which is which.

Countering this imperfection is the one very important little piece of information that barely gets mentioned in these articles about mammogram screening – the mortality rate from breast cancer is lowered by mammography, by about 20% or so, depending upon which study you quote.

If you’ve never really heard all this before, it’s not surprising. The debate now being played out on the pages of the Times has until now been held pretty exclusively among health care experts, with the results of that debate becoming the recommendations we all know and love – mammograms every 1 to 2 yrs from ages 40 to 50, then annually thereafter, till an as yet not defined upper age, when one weighs the need for mammograms against the overall health and projected longevity of the individual.

If it sounds complicated, well, that’s because it is. And until now, the approach doctors and patients took to complex issues like this was simply – we docs know more than you do. Allow us to weigh and measure the risks and benefits for you, consider costs while we’re are at it, and then we’ll tell you what we think is best and you’ll do it.

The price we are now paying for this simplistic approach to screening is a loss of faith on the part of the public, who have taken our endorsement of mammograms to be a guarantee of infallibility and a promise to lower breast cancer mortality across the board. We’ve struck out on both counts.

So now, like a parent whose child one day sees us as the imperfect humans we are, we docs are having a bit of a mid-life crisis. Do we stick to our guns and keep the same old recommendations, imperfect as they are? Or do we arm our patients with the facts and let them begin to make their own decisions about mammography?

One thing I think we do need to be careful about is allowing the pendulum to swing too far in the other direction – making the decision to advise women to forgo mammography due to a risk of over-diagnosis and over-treatment. This approach, framed in terms of prevention of anxiety and morbidity, but with an underpinning of financial cost savings, uses the same simplistic thinking we’ve used in the past to aim patients in the opposite direction, away from screening.

While there is much talk about how screening may not benefit more indolent cancers, the fact remains that we don’t have reliable non-invasive testing to identify which cancers are slower growing and which are not. Nor do we know how to stratify women into high and low risk groups for these cancers, other than genetic testing and imperfect modeling, which only identify a subset of at-risk women. To substitue another imperfect screening methodology for current guidelines just trades one set of problems for another.

I am more than happy to entertain the mammography debate with my patients, some of whom may want to forgo annual screening when they learn what I know. If I know my patients, I predict that most will continue to accept a chance of a false positives in return for a potentially reduced mortality from breast cancer.

But stay tuned – this discussion is likely to go one for some time.
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Orac takes on the topic. Nice discussion of the issues.

Phils vs Yanks

I’m from Philly, and I love New York. And now, both my teams are playing one another.

This must be how Mr Williams feels when Serena’s playing Venus in the finals. I wonder how he handles it?
Certainly not the way my father used to handle it when we kids set at one another fighting. He’d grab a shock of hair on each of our heads and bang our noggins together. (Not hard, just enough to get our attention…)
Go Phils! Go Yanks! Whoever wins, I’ll be proud. Now get out there and have fun!
Or I’ll knock your heads together.

Thank You, Mr Violinist, Whoever you are…

Mr New York Philharmonic Violinist in the third row stage left, whoever you are, thank you for making last night’s concert a truly joyous experience.

I mean, first there was the Egmont Overture (nice), then Emanual Axe playing Beethoven’s 3rd (such emotion), then the Symphonic Dances from West Side Story (I cried at the third movement), and I thought – why don’t they just stop the program there? What is this Three Cornered Hat business anyway? I was only here because it was Mr TBTAM’s birthday present, and while I like classical music and all, heading to the orchestra is generally not at the top of my Saturday night to-do list, forget it also being Halloween and the third night of the Yanks vs the Phils. Enough is enough.

Then I caught sight of you, barely able to contain yourself in your seat as you played the third part of the Three Cornered Hat, making music not just with your bow, but with your entire body. How much fun was it watching you? You played with pure, unadulterated joy, unembarrassed by the fact that you were the only member of your section moving anything other than the bow. You did not distract from the music, you channeled it, enhanced it. And I will never be able to listen to that piece again without thinking of you.
And smiling.
(Oh, and thanks to the rain delay, we got home by the bottom of the fourth inning, even though we had walked home instead of taking the bus.)

Gastrc Bypass Surgery May Impact Oral Contraceptive Effectiveness

A review article on the effects of bariatric surgery on reproductive function published this month in Fertility and Sterility highlights two studies suggesting that gastric bypass surgeries may make oral contraceptives less effective. (Note – this does not apply to simple gastric banding procedures that limit stomach size but don’t induce malabsorption.)

The studies are very small, but the findings are concerning.

In one study of 40 women, 2 of the 9 women using oral contraceptives became unexpectedly pregnant after jejunal-ilial bypass surgery, despite having used the same method before without failure. None of the women using other methods got pregnant. The second study, conducted in 7 bilio-pancreatic bypass subjects, found that hormone levels 8 hours after taking a progesterone-only birth control pill were lower compared with normal controls. By 24 hours, there was no difference in levels. No unplanned pregnancies were reported.

The paper’s authors hypothesize that malabsorption due to the bypass may be at work here. I also wonder if perhaps the pill’s “effectiveness” in subjects prior to bypass was really the negative impact of their weight on fertility, since we know bypass can improve ovulatory function.

What do we do with this information?

I don’t think that these data are enough to recommend that all women who have had a gastric bypass avoid all oral contraceptives, though it certainly gives one pause. I think it is worth discussing with your surgeon exactly what areas of the stomach and intestine were bypassed and what your risk of malabsorption is. Certainly if one is having diarrhea induced by a bypass procedure, then one must consider that medications are not being properly absorbed.

What I am doing at this point is avoiding the progesterone-only pill in the gastric-bypass population unless I have to use it, since in general, the efficacy of these pills occurs within a narrower range of serum levels. In women who are taking combination pills, I tell them to be extra careful with compliance, and if they miss a pill, to use back up barrier contraception for at least a week, especially if they notice spotting.

Heading to a standard 35 ug rather than a lower dose 20ug pill would be worth considering in this population. The Nuvaring also seems like it may be a good option, since it does not rely on intestinal absorption. Given that the estrogen exposure in the contraceptive patch is about 60% higher than in pills, I would still tend to avoid this method, even in this group, unless I know I have to use it to maintain levels. But that’s just me – talk to your doctor about what’s best for you.

We definitely need larger studies and some consensus guidance on this issue, since more and more women are undergoing bariatric surgery.

“Usual and Customary” is About to Get Redefined

NY States Attorney General Andrew Cuomo yesterday announced the formation of a new not-for-profit research consortium that, within a year, will develop an independent database to determine just what “reasonable and customary” fees are for medical care patients receive from docs outside their insurer’s network. The database will replace the Ingenix database, which was essentially an arm of United Health.

Insurers often promise to cover as much as 80 percent of those rates for claims from providers outside their network. However, Cuomo’s investigation found that Ingenix had a vested interest in helping set rates low, thus allowing companies to underpay patients for out-of-network services by as much as 28 percent.

Cuomo said the Ingenix database intentionally skewed “usual and customary” rates downward through faulty data collection, poor pooling procedures and the lack of audits.

The new database, to be operated independently by FAIR Health, will remove the conflict of interest and determine fair out-of-network reimbursement rates for consumers throughout the United States, Cuomo said. It also will be an aid to researchers and engine for health care reform, he said.

Cuomo said officials hoped to have the database and consumer Web site operating within a year. (via AP)

It’s amazing what can be accomplished with a little legal muscle, isn’t it? Single-handedly, Cuomo has done more to move health reform forward than the entire Congress has so far.

Just take a look at this timeline to get a sense of the momentum this guy has –

Beginning in January, Attorney General Cuomo secured agreements with every national and regional health insurer operating in New York State to end their use of the Ingenix database and financially commit to the new, independent database:
  • January 13, 2009: UnitedHealth Group Inc. agrees to shut down the Ingenix database and contribute $50 million towards the new, independent database.
  • January 15, 2009: Aetna agrees to end its relationship with Ingenix and contribute $20 million towards the new, independent database.
  • February 2, 2009: Aetna also agrees to reimburse over 73,000 students at over 200 colleges nationwide for underpaying out-of-network claims.
  • February 4, 2009: MVP Health Care agrees to end its relationship with Ingenix and contribute $535,000 towards the new, independent database.
  • February 4, 2009: Cuomo announces intent to sue Capital District Physicians’ Health Plan for defrauding consumers across New York by manipulating rates.
  • February 10, 2009: Independent Health and Health Now, New York Inc. agree to end their relationships with Ingenix and contribute $475,000 and $212,500, respectively, to fund the new database.
  • February 17, 2009: CIGNA agrees to end its relationship with Ingenix and contribute $10 million towards the new, independent database.
  • February 17, 2009: Cuomo announces intent to sue Excellus Health Plan for defrauding consumers across New York by manipulating rates.
  • February 18, 2009: WellPoint, Inc. agrees to end its relationship with Ingenix and contribute $10 million towards the new database.
  • March 3, 2009: Guardian Life Insurance Company of America agrees to end its relationship with Ingenix and contribute $500,000 towards the new database.
  • March 5, 2009: Excellus Health Plan and Capital District Physician’s Plan agree to end their relationships with Ingenix and contribute $775,000 and $300,000, respectively, toward the new database. The companies also agree to re-process claims over the past six years and reimburse members who were underpaid.
  • March 10, 2009: GHI and HIP agree to end their relationships with Ingenix and contribute $1.5 million towards the new database
  • June 18, 2009: Health Net agrees to end its relationship with Ingenix and contribute $1.6 million towards the new database.

God only knows what he was threatening them all with…

Go, Andy!

More IKEA Lamp Love

It’s like having your second child. You can’t imagine there’s room in your heart to love another lamp as much as you love those two matching 365+ Lunta lamps in your den.

Then you fall in love with this gorgeous Alang floor lamp you got to replace the broken lamp in your office. The shade is a gorgeous basket weave, the height is adjustable, and it takes a regular incandescent bulb. (I hate halogens and the new energy saving fluorescents make me depressed…)

We’ll see how long it lasts, but at only $39.99, if it makes it through a year I’ll be happy. It feels pretty solid though, so I’m betting on it for the long haul.

I like the shade so much, I may just do what this Ikea hacker did, and buy another to make me some pendant lamps for over the dining room table.

The Selling of the Blogosphere

Dr Val warns medbloggers what solicitations they receive really mean –

Dr. Val: So let me get this straight, you’d like me to ask my bloggers to embed links to product sites without directly disclosing that they’re paid to do that, leverage their trust and credibility to get people to click on the links – and once they get to the product site you’ll be collecting personal information about them so you can target them more effectively with offers for drugs and other products? …And how much would you pay the blogger?
SalesGuy: About $7 per completed survey.
Dr. Val: So that’s how much it costs to sell a soul these days? We’re not interested. [Click]

Good for you, Dr Val!

I had my own little email solicitation last week, asking me if I would be interested in being paid to review products on my blog. I headed to the website (Seoblogreviews.com), where I was informed that I would be paid per review, with this little hint –

Are you willing NOT TO MENTION the fact that those reviews are Paid/Sponsored Reviews? (You’ll receive MUCH MORE Paid Reviews Offers if you choose YES).

So basically, advertisers are looking for bloggers to write favorable reviews without revealing that these are ads. If you’re honest, forget about making money. You’ll be outbid by those willing to hide their conflicts of interest.

The FTC is not a day late in their proposed ruling that requires bloggers to reveal income related to their postings.

Suzanne Somers, Larry King and Cancer – Enough is Enough


Suzanne Somers appeared on Larry King Friday night touting her book and pushing docs who use untested cancer therapies, including drugs called Anti-neoplastins and dietary regimens that include large amounts of enzymes coupled with coffee enemas.

In typical fashion, King set the stage in support of Somers by seating her at a table with three of her alternative medicine cronies, leaving Dr Otis Brawley, CMO of the American Cancer Society and the single voice of sanity, to appear via satellite. Despite this, Brawley clearly took the upper hand in the discussion, balancing Somer’s babbling with calm, reasoned facts that in the end, made her appear as exactly who she is – an uninformed layperson who has no idea what she is talking about.

Here’s how it went down –

In 2008, from what I can piece together from a rambling story that took us over a commercial break, Somers had either an allergic reaction or a pulmonary embolism after having dinner with friends, a meal which included a glass of Merlot. While in the hospital, further tests showed multiple masses throughout her lungs and livers, which Somers states, were initially mis-diagnosed as “full body cancer”. However, “for some reason” (like maybe to make a diagnosis?) the docs did a biopsy that showed a fungal infection (coccidiomycosis). This infection, while common, is rarely disseminated except in immune-compromised persons.

How is it that Suzie, the picture of perfect immunity, got such a severe infection?

Here, I’ll let Suzie and Larry tell you what she thinks happened ( if only to give you a sense of what I had to listen to for an hour)…

KING: And what was the final result?
SOMERS: I had none of those diseases. I was either poisoned or I was a substance.
KING: The merlot?
SOMERS:Salir, the merlot, yes….
KING: Do they think that was the cause?
SOMERS:Nobody — nobody knows, because at the…
KING: Could it have been sour?
SOMERS: At the time — at the time, I kept saying, couldn’t this be a poisoning? Couldn’t this be a severe allergic attack? No, it doesn’t look like that on the C.T. scan. What happened? Something blew out my immune system. My immune system, that had been at 43, like that, in five minutes, my immune system was wiped out. And they think what happened was a dormant fungus that all of us in Southern California could have was dislodged. And the day before I was in perfect health and I had had my immune system tested, because I do that because of the books I wrote. And the doctor had said, “Wow, you’re at 43”. And I said…
KING: ” I don’t have a frame of reference.”
SOMERS: He said, “Well,usually, people’s immune systems at your age is two or three. Really good is 10. You’re at 43.
KING: Oh and it was 43.
SOMERS: Forty-three. So I thought…
KING: And you were 63.
SOMERS: No, no, no, no. My immune system.
KING: Oh, I see.
SOMERS: I’m 63 years old.
KING: OK. I’ve got it.
SOMERS: My immune system is 43.
KING: All right

So what Suzie is saying is that a glass of merlot that others had drunk without any adverse effects blew out her entire immune system in less than 5 minutes so that in less than 24 hours, her entire body was riddled with fungal tumors. I won’t even begin to address this – I believe the idiocy speaks for itself.

Oh, and for the record? There is no valid immune test such as she describes.

11/10/09 ADDENDUM – Turns out Suzie was taking adrenal hormone supplements aka “steroids” (think prednisone…) These most likely suppressed her immune system.  I have no words to describe the stupidity.

Suzie’s life-changing experience with medical mis-diagnosis leads her on a nationwide chase to interview every quack who exists out there. Larry and Suzie focus on Stanislaw Burzynski, MD, a doc with a big clinic in Houston who claims to have treated over 8000 cancer patients with drugs he calls “anti-neoplastins”. Suzie is incredibly impressed with anectodal stories of miracle cures in Dr Burzyinski’s patients, and even more impressed that Dr B has drugs are in phase 2 clinical trials. Brawley then proceeds to calmly cut down Burzynski, although he is careful not to completely dismiss alternative medicine.

A look at the FDA website finds that indeed, Dr B has over 60 clinical trials of anti-neoplastins initiated since 1998. And of these, not a single one has had published final results. Several studies have been closed due to prolonged inactivity or failure to recruit. A pub med search finds that Dr B has published only preliminary (I presume cherry-picked) results of his phase 2 trials, all in all less than 100 patients.

Thus, while Dr B appears to have started the FDA approval process, he has clearly stalled. (Perhaps because his treatments don’t work?) In the meantime, his attempts to promote these treatments before they are finished being tested is unethical and should be illegal. And his use of Somers, a well-meaning but ill-informed and gullible patient, to promote him is truly astounding.

Yesterday, I blamed the media for kow-towing to Suzie, and allowing her to spread her misinformation to the public. Today, I’m adding her publisher to the blame list. I cannot believe such a book was allowed to be published, let alone publicized the way this book is being sold to the American public.
Since the program, King seems to be at long last backing off in his support of Suzie. His website no longer highlights her appearance, and a video of the segment on CNN’s website mostly features Brawley.

Hopefully Oprah will get the message, and will decline to feature Suzie on her show.

Because enough is enough.

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Suzie’s At it Again

This time it’s a new book about cancer. How do I know? My previous posts about Suzanne Somers on Larry King are getting hundreds of hits a day from her believers searching for her latest appearance on Larry King.

I was all set to get off a round at Suzie’s latest bit of quackery, but looks like Orac has fired the first salvo –

Let’s get one thing straight here. It is not amazing that Somers is still alive after having “rejected chemotherapy.” As I explained at the dawn of this blog, Somers had a stage I tumor with a favorable prognosis. If Somers is going to play the gambit of “I rejected chemotherapy and I’m still alive,” perhaps now is the time to go into more detail than I’ve ever gone into before about her case…

Then he proceeds to blow Somers out of the water as only Orac can. He’s even taken on her case of Valley Fever (coccidiomycosis), which she states was intially mis-diagnosed as “full body cancer” (whatever that is…) –

Most people who contract coccidioidomycosis are either asymptomatic or have mild disease…So why did Somers get such a serious case? It’s a legitimate question, given how she represents her woo regimen as the path to rejuvenation and health.

Let’s see. Somers is 63, but apparently in good health. She also takes all sorts of supplements which, or so she claims, “strengthen the immune system.” But her immune system was obviously not strong enough to prevent her from getting disseminated coccidioidomycosis. Didn’t all those supplements ward off the fungus?

Suzanne Somers is a monster created and sustained by the mainstream media, who do nothing but kow-tow to her. Harry Smith should have his journalist licence revoked (if there is such a thing), for his recent interview with Suzie. Why not just turn the show over to her and stop pretending that this is reporting? Smith claims there are attacks on Somer’s book, but has anyone seen comparable media space given to the voices of reason that counter her quackery? I haven’t. Search for “Suzanne Somers” on CBS news website, and almost everything you get is a pitch from Suzie. Only a single opinion piece, part of a well-written AP series on alternative medicine, takes her on.

To their credit, CNN’s website has a commentary piece by Dr Otis Brawley. But they then flip the finger at Brawley by displaying a prominent ad for Suzie’s appearance on Larry King within the text of his commentary. I don’t see a link to Brawley’s commentary on Larry King’s page about Suzie’s appearance. Shameful.

Look, Suzanne Somers is entitled to her opinion. She’s entitled to take or not take her doctor’s advice. But she’s not entitled to mislead and misinform the American public.

And that is exactly what she is doing.