Grand Rounds

Welcome to Grand Rounds Vol 5, no 23! We’ve got a wonderful pot luck menu of great posts from around the medical blogosphere, so sit right down and dig in!

Daily Specials

  • In post worthy of the science section of the New York Times, Sandy Szwarc at Junkfood Science shows us just how misguided NYC’s Health commissioner is in proposing a nationwide low-salt initiative.
  • In his fabulous post Measuring Process, Not Belief, Daniel Lende shows us how Shane Battier’s approach to the game of basketball can be a lesson in managing stress, and how, like the NBA’s stats, we may be measuring the wrong thing.
Appetizers

  • Fat Barbie? Maybe that’s not such a good idea, says Dr Deb. I agree.
  • Peanut allergy sufferers are worried now that peanuts are back as airplane snacks. Allergy notes covers the issue from all sides.
Salads

  • Laika gives us some context for interpreting recent studies sowing a lack of effect of nutrients on cancer risk. Or as she puts it “You are what you eat” depends on who you are.
  • From Insureblog – An update on what Big Pharma’s commitment to transparency in their relationships with docs. I’d say too little, too late, but that’s just me…
Main Course

  • David Harlow wonders if mandated nurse-patient ratios will ensue in Massachusetts now that nurses unions are joining forces, and references a recent California study showing no improvement in patient outcomes with higher nurse-patient ratios in that state. That study contradicts previous research I’ve read on the topic, and I think it’s safe to say the jury is still out on this one…Stay tuned. This is a very important issue, with much to be said on both sides of the argument.
  • Sullydog at Receiving, a group blog from docs at a Detroit ER, asks “Are patients customers of the Emergency Department?”, then gives us 10 reasons why they are not. I like reason #10 the best –
  • If you’re heading out for a seafood dinner tonight, you might want to hold off reading this post by Paul S Auerbach, MD on toxins in fish and shellfish. Then again, forewarned is forearmed…
Sides

  • Toni Brayer, MD has a simple yet elegant recipe for braised cabbage, a food rich in vitamins and minerals.
  • Nancy Brown, PhD teaches adolescents about vaginal discharge. And, since she mentions cottage cheese, it’s on topic!
  • Dr AmAng Zhang bestows a little Chinese wisdom about food and medicine.
  • Couples therapy for treatment of anorexia? That’s what the UNC wants to know, as they recruit for a clinical trial. Via Barbara Mivowitz at Sickness and Health.
Beverages

  • Ramona Bates, MD is pouring herself another cuppa’ after new findings from the Nurse’s Health Study showed that coffee drinkers have lower risks of stroke.
Lunch Menu

  • The Samurai Radiologist has a comic about radiology conference, which, as he points out, occurred at lunchtime, so technically he is on topic. Also, one of the sounds made was a “Snicker”, so he gets in on two counts!
  • David Rabiner at Sharp Brains highlights recent research on working memory and brain chemistry.
Desserts

  • Rita Schwab has a wonderful post at Supporting Safe healthcare summarizing what she learned at conflict management skills training. I learned a lot just from reading her post. Thanks, Rita!
  • Diabetes Mine announces the winners of the Diabetes Makover, a three month intensive diet and exercise coaching program. Sounds great, although the cynic in me was a little bit disturbed to see the large self-branded vitamin component of the program. Amy has wisely made that part of the program optional for the prize winners.
Take Out Menu

  • One Big Health Nuts guest posts on How to Cope with Pain about how diet and exercise can alleviate chronic pain.
  • From Jolie Bookspan the Fitness Fixer – If you’re going to kick someone, don’t hyperextend!
Reviews

  • Cases Blog tells us that Wellsphere is using Zagat to allow their members to rate doctors. What’s next? Frank Bruni in my waiting room?
  • Duncan Cross, a patient who blogs about illness from the other side of the exam table, wonders how the widespread use of medical imagery desexualizes our view of the human body. If Dr A is an example of what years of exposure to medical imagery can do, Duncan, I wouldn’t worry.

Thanks for coming, and have a great day!

Next week’s Grand Rounds will be hosted at Health Business Blog. Thanks to Dr Val, who coordinates Grand Rounds and Colin Son for his pre-rounds article about me.

High Protein Carrot Muffins

I’m still searching, baking and tweaking, looking for that perfect Zone diet muffin recipe. Along the way, I’m having fun making and eating some delicious muffins.

While this muffin isn’t quite in the Zone (40% CHO, 30% Protein and 30% Fat), it is very high in protein and made with healthy fat. If you have it with a bit of low fat protein on the side, you’re getting pretty darned close to a perfect Zone breakfast.

These muffins are a variation on a recipe I found at a great little blog called The Food I Cook. I encourage you to read Chris’s original recipe for a great discussion of the ingredients and, if you prefer to use Splenda and can take the higher flax content, you can try his recipe instead.

This recipe makes a nice big batch o’ muffins. They freeze well, and I have been taking one to work every morning for breakfast for the past 2 weeks. With a cup of coffee and a slice of non fat cheese or a half cup of yogurt, they hold me quite nicely till late lunchtime.

High Protein Carrot Muffins

I’ve listed specific brands in this recipe, not because I am endorsing them, but because my calorie count and nutritional analysis are specific for these brands. Protein powder brands vary a lot in protein and fat content, so read the label before you buy. The one I used has no fat.

As I’ve posted before, the key to great muffins is not over-mixing, so get your wet and dry ingredients all ready before incorporating them in as few strokes as possible before adding the carrots and such.

If you are going for an even lower fat content, use skim milk instead of low fat buttermilk and cut out half the oil and the nuts. If you use skim milk, change the leavening to 4 tsp baking powder and 2 tsp baking soda.

Dry Ingredients
1 cup Stone Ground Whole Wheat Flour
1 cup Spelt flour
1/2 cup Arrowhead Mill Soy Flour
1/2 cup Bob’s Mills Flax Seed Meal
1/2 cup Quaker Old fashioned rolled oats, dry
1/4 cup Brown Sugar
2 tsp vanilla extract
1/2 tsp ground cloves
1 tsp nutmeg
2 tbsp finely chopped crystallized ginger
2 tsp cinnamon
1 tsp salt
5 tsp baking soda

The Good Stuff
2 large granny smith apples
2 cups (just under 1 pound) Shredded Carrots
1/4 cup raisins

1/3 cup ground almonds

Wet Ingredients
2 cups low fat buttermilk
1 cup Jay Robb Whey Protein
4 large Egg Whites (1/2 cup)
2 tbsp olive oil
¼ cup orange juice

Preheat oven to 350 degrees Fahrenheit. Very lightly grease non-stick muffin tins using a very little olive oil.

Whisk dry ingredients together is a large bowl. Set aside.

Peel and core apples and shred using food processor. Set aside in a medium size bowl. Peel carrots and shred using food processor. Add to apples in bowl along with the raisins and ground almonds. Combine them well so they are all distributed evenly in the mix.

Pour buttermilk into a medium size bowl. Whisk in protein powder until well dissolved. Add egg whites, olive oil and orange juice and whisk till foamy.

Add wet ingredients to dry, stirring just enough to incorporate the dry ingredients. DO NOT OVER MIX. Fold in the apple/carrot/raisin/nut mix in as few folds as possible.

Fill muffin tins almost to the top. Bake for 20-25 minutes till done. Let cool a bit in the muffin tin, loosen edges gently and turn out onto a plate to finish cooling.

Flash freeze muffins as soon as they are cool. Pop into the microwave for about 30 seconds to thaw before eating.

Nutrition analysis provided by CalorieCountAbout.com

The nutritional analysis above is for the entire recipe – divide it by the number of muffins you make for the per muffin data. You’ll get between 18-24 muffins with this recipe, depending on how full you make the muffin cups. That’s 130 -170 calories per muffin, with 7.5-10 grams of protein in each. (For you folks on weight watchers, it’s about 3 points for a muffin.)

Think You Hate Brussels Sprouts? Try this Recipe.

As a former brussels sprouts hater, I continue to be surprised at just how delicious this vegetable can be when prepared correctly. This recipe is hands down the best preparation I’ve eaten yet of this much-maligned vegetable.

If you think you hate brussels sprouts, it’s most likely because the ones you’ve eaten have been overcooked. Overcooking brussels sprouts releases Sinigren, a sulfur tasting glucosinate. Sinigren is also found in brocolli, another veggie that tastes best when cooked less.

The best way to prepare Brussels Sprouts is to roast or saute them. Prolonged boiling is a no-no, although a quick blanch will bring out their lovely green color without drawing forth nasty humors.

So now you know. You don’t hate brussels sprouts – just badly cooked brussels sprouts.

Brussels Sprout and Shallot Saute with Golden Raisins and Pine Nuts

This recipe is based on one from Jill Silverman Hough that can be found on Epicurious. I’ve modified it by cutting it in half (sort of), adding golden raisins and cutting back on the butter. It’s still too much fat, but it sure tastes wonderful. I think I could cut the fat and nuts even further and it would still taste great. (Let us know how it turns out if you decide to try that.)

1 pound brussels sprouts, rinsed, outer leaves removed and bases trimmed.
1 tablespoons olive oil
1 tbsp butter
6 medium shallots, thinly sliced (About 1 cup)
3 garlic cloves, thinly sliced
2 tbsp golden raisins
2 tablespoons pine nuts, toasted
1 tablespoon fresh lemon juice

Slice brussels sprouts using thin slicing disc of the food processor.

Heat olive oil in large skillet over medium high heat. Add shallots; sauté until almost translucent, about 3 minutes. Add garlic; stir 1 minute. Add brussels sprouts and sauté until tender, about 8 minutes, adding raisins during the last 2-3 minutes. Stir in 1 tablespoon pine nuts and lemon juice. Season with salt and pepper. Transfer to bowl. Sprinkle with remaining 1 tablespoon pine nuts and serve.
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I’m not the only one cooking Brussels Sprouts!

Yaz Makers to Women – “We Screwed Up”

The Misleading Yaz Ad

In a rare move, the FDA has mandated Bayer Pharmaceuticals to run ads correcting misperceptions they’ve created with their ad campaign for Yaz Birth control pills. (via NY Times)

Yaz is FDA-approved as contraception and for treatment of PMDD, a very severe form of PMS that occurs in only about 3% of women. Yaz is also FDA-approved to treat acne. But the Yaz ad targets the common premenstrual symptoms such as irritability, breast pain and bloating – symptoms most women have at one time or another – and implies that Yaz will maintain clear skin. Basically, Bayer is targeting healthy women with typical premenstrual symptoms and no acne.

Think of it as if the makers of Prozac started to target their adertisements to folks having a bad day.

Bayer has taken the same approach in pushing their pill to doctors, assuming we’ll prescribe off label for PMS instead of reserving their pill just for women with PMDD. And in this, they are right. We docs love to find a reason to pick one pill, any pill really, over another. It makes us feel like we’re using our brains and not just blindly throwing a dart at a formulary list. Of course, we have no clinical trial data to support our choice, just a bit of logic that if you want birth cntorol pills and this pill is good for PMDD (and believe me, it does work, though not for everyone), why not try this one? For these patients, the primary indication for treament is contraception, not PMS. The problem with the Yaz ad is that it promotes the non-contraceptive effects of Yaz over the contraceptive effects, and targets them to healthy women.

Unfortunately, we will never know if Yaz treats the milder forms of PMS, because the FDA will not allow clinical trials for PMS – just PMDD. So it’s a bit of a catch-22 for Bayer. I don’t feel sorry for them, though. It’s not like they don’t already have 3 indications for their pill – contracetpion, acne and PMD. They just got greedy for market share. The FDA has very clear guidelines, and Bayer has been flaunting these for a long time now. They deserve this unusual mandate.

What will be interesting is seeing how the new ads affect sales of Yaz. Or how many phone calls I get from worried patients already taking Yaz. Because I’m sure the ad will end with the usual “talk to your doctor” disclaimer.

It will also be interesting to see what the lawyers do with this one. This ad is basically a “Come and get us!” from Bayer to the plaintiffs attorneys. Look for lawyers ads soon.

Wyeth and University of Wisconsin sitting in a tree…

…..selling us their CME!

Wyeth is coming under increasing scrutiny for its incestuous relationship to academic medicine. First, it was discovered that the company contracted for ghost written articles that appeared in mainstream medical journals under big name academic authors.

Now the Milwaukee-Wisconsin Journal Sentinal reports that in the year following the Women’s Health Initiative, Wyeth invested 12 million dollars in a CME program targeting docs who prescribe HRT – a program that the Journal Sentinal reporters claim downplayed the risks and highlighted the benefits of the treatment. Administered through the University of Wisconsin and written almost entirely by Wyeth’s ghost writers at Design Write, the course netted over a million dollars to the university, not including money paid to consultants involved with the course.

The Council on Hormone Education – A Wyeth front group

Wyeth delivered it’s message under the guise of a group they created called The Council on Hormone Education – a consortium whose members were Wyeth, Design Write, the University of Wisconsin, Wyeth’s paid consultants and a smattering of unpaid academics whose point of view on HRT coincided with the group’s agenda. Together the group produced and distributed over 16 newsletters and maintained a website that only recently came down the day after the Sentinal published it’s investigative report. A quick google search finds position statements on HRT from the group sprinkled throughout the web.

As a member of Wyeth’s target audience, I’ve received pretty much all of the material from this program either via mail or online at various venues since 2002. I recall checking into the Council early on and figuring their were a Wyeth front group, and learned to take anything from them with a grain of healthy skepticism.

Is Wyeth the Bad Guy?

The information Wyeth disseminated was technically correct. It just tended to highlight the benefits of HRT, which are real, as opposed to the risks, which are also real. They made sure everyone heard the latest theories that HRT started early on was safer than HRT started later, giving a legitimacy to a theory that, while plausible, has yet to be supported by any randomized clinical trials. They publicized the results of the estrogen-only arm of the WHI, data the media pretty much ignored compared to their reporting on the Prempro combination data.

Wyeth will argue that their message was scientifically-based and necessary to balance out the anti-HRT hysteria perpetrated by the release of the WHI results. That someone needed to point out the flaws of that trial, which failed to enroll women with menopausal symptoms and whose population was a good decade older than the typical new start HRT patient. They will say that their message is much more scientifically based than the mythology perpetrated by the anti-aging crowd, who seem to be getting away with saying anything they want to the American Public without any scrutiny from Congress. That they are being singled out among the field of Big Pharma, whose members all play from the same playbook.

Some of these arguments, if they make them, may even seem defensible. But none of that justifies the use of a front group to take Wyeth’s message to physicians for them. None of it justifies the kind of stealth marketing disguised as CME that has taken over graduate medical education. Or the gostwriting.And none of it justifies playing down the risks of a therapy they are selling.

But truth be told, it’s not Wyeth that I’m upset with. I’ve come to expect this kind of behavior from Big Pharma. After all, they have a product to sell. I should expect a sales pitch from them.

In fact, Wyeth isn’t the only pharmaceutical company using the University of Wisconsin to get CME. Pfizer, Bayer and others have joined forces to create and market CME related to their products as well.

Or are we physicians to blame?

No, it’s academic medicine that so disappoints me. The bed we are sharing with Big Pharma is king sized, and big enough for all of us. The University of Wisconsin may be the biggest player, but we’ve all played our part in creating this monster called Pharma-sponsored CME.

We’ve taken their money for paid consultancies. We’ve given and listened to their canned slide show CME lectures because it’s easier than creating them ourselves in the shrinkingly small blocks of protected time academic medicine allows these days. We eat their lunches and go to their sponsored dinners and attend their lectures at medical meetings. We visit the Hall of Wonders at our meetings and stash our cloth satchels with free pens, power bars, flashlights and other trinkets to take home to our kids. We read the throwaways instead of the scientific journals because they’re glossy and faster to read. We have their TV’s and their magazines in our waiting rooms. We visit the internet sites for pharma sponsored CME to fulfill our increasingly CME-laden licensing requirements (and I’m starting to wonder how CME got all mixed up with licensing, now there’s something to investigate…)

Now what do we do?

It’s really time to start to sever the ties. How?

If you’re giving a talk, skip the prepackaged slide sets and make your own. (I have to admit I’ve taken more than a few slides over the years from the free teaching sets offered by some of my medical organizations that were clearly Pharma sponsored CME.)

Look for CME sources in the peer reviewed journals, like the NEJM or see what’s being offered for Pharma Free CME at Pharmed Out. If you see a “sponsored by an unrestricted grant” at the bottom of CME, go find something else to read. If you’re at a medical meeting, skip the box lunch seminars and the Hall of Wonders – go instead for a work out or tour the town you’re visiting. Or read a textbook.

Some of our smaller medical groups are starting to experiment with Pharma free CME. What I can’t understand is why our medical organizations aren’t setting the example by setting up Pharma-free meetings. I don’t expect anything anytime soon from the AMA , but c’mon NAMS or ACOG, how ’bout it?
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Pharma-Free CME at Pharmed Out

Our own Dr Rob on Pharma-sponsored CME
The British Medical Journal on severing the ties (via Schwitzer Health Blog)

Seven Things To Know About Hormones – My Take

The Wall Street Journal gives a nice response to Oprah’s recent HRT hype with an article entitled “Seven Things You Should Know about Hormones. This, of course, is not to be confused with George Carlin’s Seven Words You Can’t Say on TV, which is really funny but won’t help you decide whether or not to take estrogen…

Here’s my take on the seven things –

1. ‘Bio-identical’ hormones are available in FDA-approved forms
I agree. The stuff Suzanne Somers and Oprah are getting compounded is exactly the same chemical ( probably purchased from the same supplier) as Big Pharma uses to make their estradiol patches and creams and progesterone pills.

2. Hormones from compounding pharmacies aren’t safer than conventional HRT.
I completely agree. Any compounding pharmacist or doctor who sells HRT without warning patients about the risks should be put out of business. We don’t stand for this behavior from Big Pharma, and we shouldn’t accept it from these folks. They are couching their sales pitch around women’s wellness and selling women a purported fountain of youth, while trashing Wyeth for doing the same thing with Prempro. FDA – Get on it. And if you don’t have the authority, Congress needs to give it to you. Women’s Rights Groups should be all over this one, but they are unfortunately being duped by these shysters into thinking they are all on the same side.

3. Don’t trust saliva tests.
Ditto. Most of the folks doing saliva testing make money on the testing. Be wary of any doc who has a financial interest in what test he/she orders. Or what vitamins you take.

4. There’s a critical window of time for starting HRT.
Not so fast. It’s a hopeful hypothesis, but it’s just not proven yet. A lot of the docs pushing the hypothesis are also consultants and speakers for pharmaceutical companies who sell HRT. In my heart of hearts I think and hope that they are right, but I’m not willing to tell a patient to count on it. We need studies to prove it.

5. The increased risk of breast cancer appears related to progesterone rather than estrogen.
The key words here are “appears to be”. It’s not written in stone yet, so don’t count on it. And don’t go taking estrogen without progesterone if you still have your uterus – that’s a recipe for uterine cancer. I’m not about to trade one risk for another with my patients.

6. Estrogen applied to the skin, in patch, cream or gel form, may have a lower risk of blood clots and strokes than in pill form.
Agree. This is the one piece of new data that makes the most sense to me and that I am willing to put out there. I prescribe transdermal estrogen preferentially over oral whenever I can. We know clot risk is related to dose and there are well-done studies showing the lesser impact of transdermals on serum clotting factors. There’s no reason to think this won’t translate this to lower incidence of blood clots. Stroke incidence is a little more tricky, since strokes are multifactoral, but if clotting times are closer to normal, that’s one less factor to worry about.

7. Stay tuned.
This, of course, is the hardest part about HRT. It’s not like your menopause is going to wait for the next big randomized, placebo controlled trial. You have to make a decision with imperfect information and uncertainty. And that’s difficult for some women to understand and accept.

Easier to do what Oprah and Suzanne have done and latch onto the compounding pharmacy crowd, who sell certainty and security along with their drugs. But it’s a false security and very dangerous. I find it so sad that these two intelligent women are letting themselves be taken in this way. And even sadder that they are bringing other women along with them into their fantasy of hormonal certainty.

If you’re interested
Here are TBTAM’s Ten Rules for Prescribing HRT.

Now if you’ll excuse me, I have to get back to You Tube…

Happy Groundhog Day

Not the Day. The movie.

Groundhog Day, released in 1993 and starring Bill Murray and Andie Macdowell, is one of the best movies of all time. It appears to be a comedy, but it’s much, much more than that. It’s really a mythical tale of transcendance, a lesson in how to live a life making every day count. Even if that day looks supiciously like the day before. And the day before that. And the day before that…

What do you do to given meaning to your days? That string of little events that repeat themselves day after day? What keeps you going when you’ve gotten there and nothing looks new to you anymore? (If you’re reading this BS, you know what I’m talking about.) How do you live a day and “get it right”?

Watch this movie and learn.

I require myself to watch it at least once a year, and should make myself do it even more often.

Think I’ll watch it tonight.

A Visit to Salzburg – Part 2. A Revisit Tour

This was my third trip to Salzburg, a wonderful place to visit any time of year, though early January would not have been my first choice.  I had some work and sleep to catch up on, and they kept us busy with concerts and dinners, so this won’t be the grand tour. We won’t be taking the Sound of Music Bus Tour, visiting the museums or Fortress, or taking any day trips to visit the salt mines or Hitler’s Eagles Nest, as I did on prior trips.We’re just going to take a few hours to visit my fave spots in this wonderful little city.

Mozartplatz and Mozart Geburtshaus

Mozart was born in Salzburg, and was court musician to the Archbishop here in his early career. The city celebrates him with festivals twice a year, one in late January and a bigger one in the summer. A visit to his birth house is a must.

If you miss the festivals, catch his music at the Mozart Dinner theater- it sounds hoaky, but it really is a nice experience – they serve a menu from Mozart’s era and serenade you with his music. ( Definitely beats the Sound of Music Dinner Theater, which is to be avoided at all costs.)

Chess at Kapitel Platz

St Peter’s Cemetery


Where Maria and the Von Trapp family hid from the Nazis in The Sound of Music.

Michaelskirche


The oldest church in Salzburg. I was treated to an organ solo last time I visited. It was quiet this time, and I was sorry to miss yet again the wonderful concert series held here.

Salzburg Markets

The weekday Green Market is located near Collegiate Church. It was small in this weather, but there were still beautiful breads and meats.  Even better is the Thursday Schrannen Market at Mirabellplatz, and the Christmas markets in December. Maybe next time.

Shopping in Salzburg

Shopping in Salzburg is a cultural experience, as you wander through the old streets and narrow alleyways. There are literally hundreds of shops, and prices are not always so cheap. I mostly window shoppe, but always stop at Furst Condiserie for chocolate and visit the tiny Kaslochl Kaserei near the river just down from the Mozart Geburtzhaus.

I recall my first visit to this tiny family-owned cheese shop 9 years ago. The owner’s two -year old daughter was sitting beside her on the counter. Of course, she’s a big girl now and was in school the morning of my visit, but I had a nice talk with Mom about the cheese business, and bought some local goat cheese for lunch.

My favorite place to shop in Salzburg is Interio. It’s sort of like a slightly upscale IKEA. I got some gorgeous placemats.

Near Interio is Ma Lai a wonderful woman’s clothing shop that mixes new and used clothing.

The Supermarket

One of my favorite things to do in a foreign country is to go food shopping. It makes me feel like a local, and I love exploring the local foods. Here in Austria, it’s the meats that are unusual – many varieties of smokes bacon and pork, with Speck being the local favorite. (My colleague Amos tells me that Speck is amazing, so I buy some to bring home – I’ll tell you how it is once I use it.)

I pick up some teeny sausages for my lunch and head down the aisles. I note that every kind of sugar imaginable is available, including beet sugar.

Entire aisles of chocolate, and I notice mostly locals buying it.

I pick up some tiny noodles for soup and mayonnaise. Why the mayo? It was in a tube!

Biking in Salzburg

On my last trip, I enjoyed biking the path along the river, which runs for miles from Salzburg into neighboring towns. Although I decided to forgo the pedals this trip, winter’s cold and snow doesn’t stop the natives.

My Lunch

Having spent a good 5 hours wandering the city, I headed back to my rooms at the Schloss to enjoy a late afternoon lunch with the provisions I had purchased. I fell in love with the tiny sausages – so delicious!

TBTAM PSA : Is Double Click Slowing you Down?

My internet has been increasingly slow lately. As I was waiting for pages to load, I kept seeing “Waiting for http://www.doubleclick.net.”.

Double Click belongs to Google. It’s major product is the DART cookie – a device that lets advertisers track how many users saw their ad, how many clicked through, and which ads users went to. The cookie stays with your browser and gets updated every time you visit a webpage that uses the cookies (like Google).

Can Ad-Double Click be disabled?

The answer is yes!

Simply go to the Adclick website and download a privacy cookie. That’s it!

Really? It’s that easy?

Yep. But there are a few things to know to keep things in place once you’ve opted out of double click –

1. Opting out is a cookie, not a program. So if you remove or diable cookies, doubleclick will come right back as soon as you visit Google and you’ll need to go and opt out again.

2. If you have both IE and Firefox, you’ll need to upload the privacy opt-out cookie to both browsers.

3. It’s not as if you won’t keep getting ads. They’ll just be generic and not targeted to you. (Sorry.)

4. Doubleclick will still be able to track you by your IP address (just like I know the IP addresses of everyone who visits this blog), unless you use an IP blocker or route your visits through another site like AOL.

So, does it really work?

I am ZOOMING!!! (Mouse, don’t fail me now…)

Stem Cell Research – A Beautiful Thing

Mouse Embryonic Stem Cell
Photo credit: Bruce Conklin at the J. David Gladstone Institutes

The California Institute for Regenerative Medicine, that state’s funding agency for stem cell research, held a stem cell photo contest in 2008 among its funded scientists.

From hundreds of entries depicting stem cell research, these 12 were chosen as the most beautiful. The diverse images represent the wide range of stem cell research taking place in California.

To learn more about stem cell research, check out CIRMTV on YouTube.

Thanks to Don Gibbons at CIRM for sharing these beautiful images.

Oprah’s Talking Hormones

I should have expected it. Today, while counseling a patient about hormone replacement, I heard those three little words that I predict will haunt me from this day forward – “But Oprah says..”

Yes folks, Oprah’s in menopause.

“You feel flat and you feel tired, you haven’t had a good night’s sleep in two years [and you’re] just going through the motions, trying to get through the day,” Oprah says. “You feel like your life force is being sucked out of you.”

Now Oprah’s taking hormone replacement, which of course means that America’s women are heading back on the HRT roller-coaster, wondering if they should be forgetting everything they heard in 2002 and doing the same thing as Oprah.To get the conversation going, Oprah’s doing a two-part series on her TV show and running special issue on the topic in her magazine next month. (Thanks, Linda, for the heads up.) I figured I’d better head over to Oprah’s web site and see what ‘s going on.

So what exactly is Oprah saying?

To her credit, Oprah seems to be trying to frame the HRT issue as a debate – “Should you replace your hormones?” she asks. A reasonable question, I’d say.

Her magazine features a well-written article that frames the issues nicely and is medically up to date and fairly well-balanced. Everything you need to know is in there, albeit with a little too much paragraph space given to the theories that support HRT use and not enough to the facts that recommend against it. Still, it’s a good start.

But Oprah’s blowing it with her show.

She gets points for working with Christiane Northrup, the author of the book The Wisdom of Menopause, and the leading medical guru to the public on HRT. While Northrup’s book is a bit too long and a bit woo-woo for most of my patients, it is medically correct, and I really liked her Public TV Special last year.

Oprah also featured a short segment with Dr Wolf Utian from the North American Menopause Society, who faced off against Suzanne Somers on Larry King last year. Utian warned about the risks of HRT – and both he and Northrup recommended that women work in close partnership with their doctor in managing their menopause.
Unfortunately, Northrup’s measured wisdom and Utian’s warnings were no match in grabbing the audience’s attention compared to the anectodal testimonies of Robin McGraw and others about bioidentical hormones.It’s the “HRT changed my life and you should take it too” school of menopause management by girlfriend.
HRT is touted as the cure for everything from weight gain to depression, and as long as its bioidentical, there are no risks. These folks have free rein to spout whatever theories and beliefs they have, unchallenged by Oprah, Northrup or Oprah’s own medical guru, Dr Oz.

Dr Oz dropped the ball

To my disappointment, Dr Oz failed to question the unsubstantiated statements made by Dr Prudence Hall, a practitioner he interviews who prescribes ridiculously high doses of estrogen and progesterone to her patient without once mentioning their potential risks.

This is not informed choice – it’s pure salesmanship, and both the patient and Oz fall for it hook, line and sinker. Oz even puts Hall’s crazy regimen up on the screen as if it were gospel – 2 mg of estradiol and 150 mg of progesterone twice a day – 8 times the starting doses I use in my practice, and much more than most women need even at the start of treatment.

DR OZ – Who should take hormone replacement?
DR HALL – Anyone who has a low hormone should have that hormone replaced.

Huh????? I though we got away from this craziness with the WHI.

Oprah, I’m disappointed.

You had such good intentions, but you’re giving way to the hype, and taking your viewers along with you. Like poor Michelle, who you promise to take to Dr Hall for her “Oprah Hormone Makover”-

OPRAH:…It’s ultimately up to you to make the choice for what’s right for your body. We just want women to start to feel better and to be in charge of your own health. Because you don’t have to feel this bad. Look at Michelle. Michelle, there is hope for you.

MICHELLE: I’m going to get myself some of these hormones.

OPRAH: Yeah. Yeah.

MICHELLE: Sign me up!

This is not letting Michelle make her own decisions, Oprah. This is pulling her into your club. HRT is not a makover that you offer your viewers for free. It’s a medical treatment, with risks and benefits about which every woman deserves to be properly informed. Your show, unfortunately, is not informing. It’s hyping.

Things are no doubt going to get even worse when Oprah gives the stage over to Suzanne Sommers later this week for part 2 of her HRT series. (Northrup will be airing a Webcast Thursday evening that will be worth listening to, but I don’t think is going to be on the show again.).

Disclaimer

I take HRT, and I prescribe it to my patients who want to use it for treatment of menopausal symptoms. Every one of my patients who takes HRT is informed of the potential risks, and their decision to use it or not is made in light of their own risk factors, symptoms and concerns.

In the end, most of my menopausal patients don’t need HRT or don’t want the risks, and we either find them non-hormonal alternatives or they find other ways to handle their symptoms. It’s called informed choice.

I prescribe FDA-approved regimens, mostly bioidentical but not always, and sometimes custom-made formulations for women who can’t find the right regimen among the approved products. I recommend the lowest dose for the shortest time, and prefer transdermal estrogen over oral forms if possible.

I also offer alternatives to HRT, including SSRI’s and neurontin for hot flashes, low dose vaginal estrogen for dryness (along with over the counter non-hormonal remedies for the same), and encourage all my patients to eat well, exercise, avoid dietary and stress triggers for hot flashes and take care of themselves.

If you want to learn about HRT

Check out the readings listed at the bottom of this post. Or my series on HRT. Or talk to your doctor.

And remember, just because Oprah’s doing it, does not mean it’s right for you. Use her show to start the conversation, but take the responsibility to inform yourself and do what’s best for your menopause.
Not Oprah’s.
_______________________________________________
Menopause Reading list
-The Menopause Guidebook by North American Menopause Society – The Cliff Notes of menopause management. Everything you need to know without the hype.
–Is It Hot in Here, or Is It Me? by Barbara Kantrowitz and Pat Wigert Kelly – The What to Expect while you’re in Menopause book. Q&A format, easy to read in short segments.
–The Wisdom of Menopause by Christiane Northrup. The Torah of Menopause – Everything’s there, along with the book of Job. Read it and believe.
–Our Bodies, Ourselves for the New Century. If you liked the original, you’ll love this version.
–Medicine Net answers FAQ’s about bio-identical HRT and Oprah.
–TBTAM on HRT – my four part series. Everything I needed to say.

The Maldistribution of Healthcare in America

Two posts from my Google Reader today illustrate the problem we have in distribution of healthcare here in America –

Paul Levy writes how partners Healthcare is building an ambulatory center within 8 miles of the much smaller Norwood Hospital, duplicating services almost exactly and presenting unnecessary competition for patient business.

…the new center is 75,000 square feet and will offer the following specialties: Primary Care, General Surgery, Plastic Surgery, Orthopaedic Surgery, Cardiology, Cardiac Diagnostics, Dermatology, Diagnostic Imaging, Women’s Health, Rheumatology, Rehabilitation Services including Cardiac Rehab, Physiatry and Pain Management.

I now understood why my colleagues at little Norwood Hospital were nervous. Their website says they offer the following services, among others: Surgery, Obstetrics, Cardiology, Dermatology, Radiology, Neurology, Orthopaedics, Gastroenterology, Cancer Care, and Pediatrics. Not a complete overlap, but quite a bit.

Edwin Leap, MD writes about the limitations of practicing emergency medicine in the rural south without the services and expertise he had when he worked in a big city hospital –

…we were seeing some 25,000 patients per year in a 10 bed ED, in a 120 bed hospital. We had one cardiologist, but no cath lab. We had no neurologist, pulmonologist, neurosurgeon, toxicologist, trauma team or pediatric subspecialties….We don’t have residents to help with the volume and we don’t have a trauma team. There is, now, a helicopter service taking our patients to the regional trauma referral center, but when they can’t come, it’s 40 minutes away by ground.

Looks like the Big City has more hospitals than they need. And rural America doesn’t have enough.

Ironically, we have similar maldistribution of retail services in America.

I have dozens of stores within a few miles of my home here in NYC, where Bloomies, Nordstrums, Target, Gap, Old Navy, Sears, Saks and Macy’s all compete for my busness. But I have to drive 40 minutes to the mall from my country house in the Endless Mountains of Pennsylvania, where my choices are limited to Walmart and Sears.

The difference, of course, is that retail emergencies are rare, and never life-threatening. Wish I could say the same for healthcare emergencies.

Kudos to Dr Leap for all he does, and good luck there at Norwood Hospital.

A Visit to Salzburg – Part 1

I know, I know. You’re wondering, what would be worth a second trip across the Atlantic just one week after returning from London? I’ll tell you. The Salzburg Seminars, that’s what.

This was my third time serving as a volunteer faculty member at the Open Medical Institute’s Salzburg Seminars – a week long intensive training for physicians from Central and Eastern Europe, Central Asia, the former Soviet Union, and this year for the first time, Qatar. Funded by the American Austrian Foundation and held at the beautiful Schloss Arenberg (photo above), the Seminars are a great chance to update the old slide set and meet some amazing individuals who practice medicine without the resources we take for granted here in the United States.

This year, I gave lectures on Family Planning, Vaginal and Vulvar Diseases and Menopause. My colleagues from Weill Cornell Medical College and the University of Vienna tackled Uterine Fibroids, Gynecologic Cancers, Obstetrical Ultrasound, Ob and Gyn Hemorrhage and Emergencies, Ethics, Patient Safety and the Internet in Medicine. The international fellows gave some amazing case presentations for discussion.

We had lots of conversations about healthcare in our respective countries. And all I can say is, despite all the issues we have in the United States, I wouldn’t want to be practicing medicine anywhere else but here. Not when I hear tale of docs whose only way of surviving financially is to take tips from patients who pay to squeeze into the surgical schedule ahead of the cue. Or of abdominal emergencies handled in hospitals that don’t have a CT scanner. And not a single fellow has a microscope in their office, forcing them to rely on gram stain only for management of vaginitis. (A poor substitute for an in office wet prep in my opinion.)

Most of these docs would give their eye teeth to spend some time learning medicine in the United Sates, be it something as simple as an observership or as complex as a second residency. Unfortunately, visa regulations in their countries and ours make this extremely difficult. But all of them will be offered observerships in Vienna and in Germany at the Institute’s expense.

I’ve been part of the Salzburg Seminars for nine years now, and each time I return anticipating that there can’t be much for me to teach these doctors now that the Internet has reached Eastern Europe. But up to date information, while freely flowing, is not free. I forget that my own unlimited access via Cornell’s Online Medical Library is a luxury most physicians do not have. Just having the latest English-language textbook in their field is considered a major coup for these hard working docs, who grilled me on which textbooks I recommended. I admitted that I left textbooks long ago for online access, and advised them that a better use of their limited funds might be an annual subscription to Up To Date. (At least the exchange rate will be in their favor…).

One thing we can all afford to do is to stay in touch, and I look forward to keeping in contact with all the wonderful doctors I met last week. (Already I’ve gotten two new friend requests from them on Facebook). I gave them the address of my blog, and told them all about the medical blogosphere and Grand Rounds. Who knows? There could be an aspiring medical blogger among them…

Next up – A Little Tour of Salzburg, and of course some food photos.

Ovarian Cancer and Obesity – Weighing the Risks

A recent research study reports an increased risk of ovarian cancer among obese women.

Since every woman I know thinks she is fat, this report is sure to raise anxiety levels across the board. So let’s see if I can calm things down a bit by placing the data in perspective.

First off, you need to know your BMI. Go here and calculate it , then come back. For those of you who are too lazy to click the link, you can think of it this way – your BMI is 30 if you are 5’2″ and 150 lbs, 5’5″ and 180 lbs or 5’8″ and 200 lbs.

Got your BMI? Okay. Here’s the data –

Women with a BMI of 30 or more had a relative risk of 1.6 for ovarian cancer compared to women whose BMI is < 25. That means for every 1 case of ovarian cancer in the thin women, there were 1.6 cases among the obese women. Almost double the rate. Sounds pretty bad, right?

Well, that depends on how risky ovarian cancer is to start with. Turns out ovarian cancer is not that common, whether you are thin or fat. The risk in this study was less than 1% over the 7 years of the study.

Here’s how it looks visually – There are 1000 dots in each group, representing 1000 women. The red dots represent the women who got ovarian cancer in the 7 years of the study.

What about the risk among HRT users? Well, in that group, obese women’s risk for ovarian cancer was no higher than thinner women’s risk, because thinner women on HRT have a higher risk of ovarian cancer than their thin counterparts who don’t use HRT. How high?  For every 1000 women on HRT there were 3-4 cases of ovarian cancer. Same as with obese women.

Bottom Line

Obesity increases your risk for ovarian cancer. Fortunately, that risk is still quite low – certainly not high enough to warrant anything other than routine screening.

But add it to the increased risks of diabetes, hypertension, hyperlipidemia, heart disease and breast cancer associated with obesity, and maybe it’s enough to get you thinking more seriously about losing  weight. Not to mention the improvement in your quality of like when you can sleep without snoring or apnea, exercise comfortably, wear the clothes you love and just plain feel better.