Jade Goody – Are There Lessons to be Learned?

Dr Crippen, aka The NHS Blog Doctor, has written a very thoughtful response to my recent post on Jade Goody’s cervical cancer. Dr Crippen practices in the UK, and corrects my misperceptions of how low-income folks get care in his country.
No Margaret. You are confusing the UK with the USA. God knows, the NHS is creaking, and we have problems enough, but we do not have “public clinics” for the impoverished poor. In the USA, the impoverished poor, aka the unemployed working class, predominantly black and Latino, may need “public clinics”. In the UK everyone is entitled to a “primary physician” as of right, independent of status and means. Yes, yes, before someone, or no one, or “angry from Tonbridge” writes in, a few people slip through the net, and a few people have incompetent GPs, and there is a difficulty with the homeless who are of no fixed abode, and so on and so forth but by and large most people have a GP. God knows, I do not hold back on criticising the failings of the NHS, but I become amazingly protective when people try to suggest that we have problems akin to those experienced by the medically uninsured in the USA.

I encourage you to head on over and read his post, which includes a description of the cervical cancer screening program in the UK.

Dr Crippen also thinks I went too far in hoping that someone

personally called, warned, cajoled and hollered at [Jade] countless times, until finally, as a last ditch effort, they sent her a certified letter.

You know what? He’s right. I doubt I would have called “countless times”. I was being a bit hyperbolic, probably because I was feeling particularly saddened and frustrated by the fact that a preventable death was about to occur in a young mother of two children.

But I like to think that I would have called Jade at least once if she failed to respond to her letter. Probably twice if I know myself well. And I suspect from reading Dr Crippen’s post that he would have done the same.

So don’t worry, Dr Crippen – you and I are in full agreement that the medical profession does not need anyone breathing down our backs to force patients to accept medical care that they have been duly informed that they need. I was in no way trying to insinuate that the medical profession bore any legal responsibility in Jade’s tragedy. They sent her a letter, she ignored it. Her bad.

That said, the question that remains is simply this – Did anyone call Jade when she failed to follow up on that last abnormal pap smear?

Which is not to imply that they were required to do so, or that the government should mandate it. I’m just speaking as one human being to another. It seems like it would have been the right thing to do.

And I hope someone did it.

That was really all I meant to say.

Pregnancy – Week by Week or Pound by Pound?

Natasha Courtney Smith is photographed weekly during her pregnancy, and writes about her experience at the Daily Mail Online.

I loved the photos
Smith is beautiful. Seeing her body change week by week, with that baby growing inside her, filled me with such joy and awe at this miracle of life.

The essay made me so sad.

It is the typical story of the modern woman’s experience of her body during pregnancy. A journey that begins with joy but quickly turns to self-loathing and sadness –

Almost from the moment I found out I was pregnant, I felt hugely fat…. When I finally had to accept, at the end of month four, that I was now a whole dress size bigger, I actually cried – and went out to buy a pair of size 12 jeans.

This is a woman carrying her first child, and instead of joy, she feels – fat. It’s just wrong. (And yet who among us has not felt the same way?…)

Fortunately, by her fifth month, Smith begins to enjoy her pregnant body.

Bizarrely, though, I suddenly felt hugely confident….I even started to get a thrill from seeing the needle on the scales inching its way towards the 131/2 stone where it would end up… Friends would say reassuringly that most of that extra weight was the baby, and I actually felt rather gleeful as I replied that, no, the baby inside me weighed just a few pounds – and any extra weight was in fact me.

Well, Ms Smith, I think I need to correct you there. Technically, yes, much of the added weight was you. But much more than a few pounds was related to the baby.

Don’t believe me? Here’s how it breaks down in a normal singleton pregnancy –

Weight Gain in Pregnancy

  • Baby – 7.5 lbs (more or less)
  • Placenta – 1.4 lbs
  • Amniotic fluid – 2 lbs
  • Increase in uterine weight – 2 lbs
  • Increase in breasts – 2 lb (more for some)
  • Increase in blood volume – 3 lbs
  • Increase in extracellular fluid (no edema ) 4 lbs

That’s over 20 lbs right there without a single ounce of extra fat gained. Most women will gain about 7 pounds of adipose during pregnancy, for a total normal weight gain of about 30 pounds. But I’d give Natasha another 5 lbs or so for those swollen ankles in her last few weeks.

Now, Smith did gain a bit more than 30 pounds.

She went from about 130 lbs to 188 lbs, for a total gain of 58 pounds. And yet, by 5 months post partum, she’s dropped all but 14 pounds of her pregnancy weight!

I’d say she’s doing just fine. Once she starts to sleep a bit more through the night, it’ll all be gone.

Why do I say that? Well, studies have shown that mom’s weight at one year postparum is inversely related to how many hours her baby is sleeping through the night at 6 months of age. Given that Smith still has a few extra pounds on her, I’d wager little Finn is still up for nightime feeds.

Bottom Line

Our obsession with weight is ruining our experience of our own pregnancies, whittling away little pieces of joy during one of the most special times of our lives.

Instead of worrying about our weight while we are pregnant, we should be finding ways to help new moms get the sleep they need.
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Photo by Caroline Marks at The Daily Mail online

Multimedia Grand Rounds at Doc Gurley

An amazing grand rounds is up this week at Doc Guley’s site. There a webcast, including conversations with many of your favorite medical bloggers, viewer polls and great jokes such as this-
Nurse: Doctor, there’s an invisible man in the waiting room.
Doctor : I’m too busy – tell him I can’t see him

Doc Guley – You may have topped your famous Lost Tampon Video.

Head on over for a listen and a look at this week’s best of the medical blogosphere.

The Invention of the Sims Speculum – Surgical Improvisation

This post was inspired by Doc Gurley’s call for submissions to this week’s Grand Rounds, the theme of which is Improvisation.

J. Marion Sims, often called the “father of modern gynecology”, invented the duck-billed speculum that bears his name and which is still used today during vaginal surgery. The story of its invention is a tale of surgical improvisation that has become legendary in the field of gynecology.

Sims was a family doctor practicing in Montgomery, Alabama in the mid 1800’s. Although he had no expertise in or desire to treat “women’s disorders”, he was referred, in quick succession, three young African slaves suffering from vesicovaginal fistula – a hole between the vagina and the bladder that develops as a result of prolonged obstructed labor. No one had yet developed an operation that could cure the condition, and Sims had declared the women inoperable.

But just before he was about to send the third young women back to her owner’s plantation to live forever with her debilitating condition, something happened that changed both Sim’s mind and the field of medicine forever.

Sims was called upon to care emergently for a white woman who fell from her horse and who was in great pelvic pain. Assuming that her pain was from acute malposition of the uterus, and remembering a trick taught to him by one of his former professors, Sims asked the woman to get on her knees and elbows. He then inserted two fingers into the vagina, vigorously pumping up and down to reposition the uterus. As he did this, the woman’s uterus fell back into position, relieving her pain. At that moment, a large amount of air burst from the vagina. Although this embarrassed the woman, it gave Sims an idea of how he might help the African slave languishing untreated in his backyard hospital.

If depressing the vaginal walls allowed air to get into the vaginal cavity, could he somehow create an instrument to do the same thing and allow access to the area of the fistula?

Forgetting everything for the moment except the value of this important revelation he jumped into his buggy and drove hurriedly to a hardware store in Montgomery where he bought a set of pewter spoons of different sizes. Bending the bowl and part of the handle of one of these at a right angle he placed one of his patients suffering from vesico vaginal fistula in the genupectoral position, inserted the improvised speculum and atmospheric pressure accomplished the rest. The fistulous opening was clearly seen.

“Introducing the bent handle of the spoon I saw everything as no man had ever seen before. The fistula was as plain as the nose on a man’s face. The edges were clear and well defined and the opening could be measured as accurately as if it had been cut out of a piece of plain paper. The walls of the vagina could be seen closing in every direction. The neck of the uterus was distinct and well defined and even the secretions from the neck could be seen as a tear glistening in the eye clear even and distinct and as plain as could be. I said at once “Why can not these things be cured?”

Sims operated using his speculum, but the operation failed. The fistula persisted, albeit smaller than before. It would be years, and many more operations on these same women and others, before he perfected a surgical technique using silver wire suture that resolved the fistulae completely.

Over time, Sims would come under increasing scrutiny and criticism for what some said was unethical experimentation on his patients, who were all female slaves, and whose operations were performed without anesthesia. Sims did give post operative pain relief, in the form of large amounts of opium  – another practice that put him under suspicion.

Reportedly, Sim’s patients themselves remained faithful to him in their desperate hope to resolve their plight – faithful to the point of serving as his surgical assistants when his medical colleagues abandoned him to his experiments.

Some say Sims used the African slaves to experiment on surgical techniques he would someday use with white women under anesthesia, and condemn Sims as a racist monster. Others say he was just a man of his time who gave away service for free to slaves suffering from what had been heretofore an incurable condition.

Whatever you think of Sims, it is important that we remember and honor the three slave women who served as his patients, and known only by their first names – Anarcha, Lucy and Betsey.

It is also important to remember that even today, over two million women in sub-Saharan Africa and Asia suffer from vaginal fistula, as a result of unattended childbirth and violent rape. International efforts are being directed at treatment for these women, but prevention demands that all women have access to skilled birth attendance and access to emergency obstetrical care.
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Sources –

Sims, JM. The Story of My Life. New York, D Appleton & Co, 1894. via Google Books.
Harris, Seale, MD. Women’s Surgeon – The Life Story of Marion Sims. New York, The MacMillan Company, 1950.
Sartin, JS. J Marion Sims, the Father of Gynecology – Hero or Villain?
Ojunaga, D. The Medical Ethics of the Father of Gynecology“. Journal of Medical Ethics 1993; 19: 28-31.

Sims Speculum image from Wikipedia. Surgery Image from National Library of Medicine.

Brain Twister

Ann Bancroft performs “Yma Dream”

The good news is that I get to perform this hilarious monologue based on Thomas Meehan’s “Yma Dream” in my musical theater class production of “The No Frills Revue“.

The bad news is that I have to memorize it.

Grand Rounds at Health Business Blog

David Williams hosts this week’s edition of the best of the medical blogosphere. It’s a great edition. Topics covered include –

While you’re visiting Dr Val, check out her post about about Senator Tom Harkin’s recent comments on the Office of Complimentary Medicine. Looks like his political contributors aren’t getting the research results they bargained for…

The Other Mediterranean Diet- Chickpea Salad

With all this talk about the Mediterranean Diet, I think we sometimes forget to look beyond Greece, Spain and Italy for delicious and healthy foods. I’m speaking of course, of the wonderfully healthy and fascinating cuisines of the Middle East.

Olive oil, of course, is a mainstay of Middle Eastern as well as northern Mediterranean cuisine, and yogurt is common to both as well. But on the Mediterranean’s southern coast, couscous is the carb of choice, dried fruits abound, and lemon juice replaces vinegar (a blessing for migraine sufferers like myself.) Best of all are the spices – cumin, coriander, cinnamon, allspice, turmeric, nutmeg – that continually surprise and delight the palate.

This weekend I discovered a most wonderful Middle Eastern cookbook – The Arab Table by May S. Bsisu. The book is a culinary tour of the Arabian countries of the Middle East – Palestine, Jordan, Yemen, Syria, Morocco, Syria, Egypt and the Arabian Gulf – along with family reminiscences and explanations of customs and holidays that give cultural context to every recipe.

If this, our first foray into May Bsisu’s recipes is any prediction, I’d say the Arab Table is going to become a source of meal ideas at our table for a long time to come.

Dressed Chickpeas

The strong saltiness, cumin and cayenne flavors in this dish may be an acquired taste for some, so I recommend using a third to half the amounts listed below to start and adjusting upwards if you like the flavors. (I happen to love them.) I love parsley, so I actually used almost a 1/4 cup in mine. Bsisu tells us to add feta to turn this side dish into a satisfying lunch. If you do that, I’d serve it on a plate atop a bed of lettuce leaves.

2 cans chickpeas
1 jalapeno pepper, seeded and minced
1/2 pound white onions, finely chopped
2 cloves garlic, mashed
1 1/2 tsp kosher salt
1 1/2 tsp ground cumin
1/4 cup fresh lemon juice
1/3 cup extra virgin olive oil
1 medium tomato, chopped, for garnish
1 tbsp coarsely chopped fresh parsley, for garnish
1/2 tsp cayenne pepper, for garnish

Drain chickpeas and rinse three times under running water. Place in saucepan with water to cover 1 inch, bring to a boil and cook for 1-2 minutes. Drain and cool a few minutes in the colander, then place into a large bowl of cold water. Gently rub the chickpeas between your palms to remove the skins until most of the skins are removed, replenishing the water once or twice as it becomes covered with the skins.

Place the drained chickpeas in a large bowl and add the onion and jalapeno.

Whisk the garlic, salt, cumin, lemon juice and olive oil together in a small bowl. Pour the dressing over the chickpea mixture and toss gently. Serve on a bed of lettuce leaves garnished with tomatoes and parsley.
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Map from Wikipedia

The Tragedy of Jade Goody

Jade Goody, the controversial star of British reality TV, is dying of cervical cancer at age 27. This young woman, who has lived her life in front of the camera for the last 7 years, will die for the camera as well, having sold the rights to film her last days in an ongoing reality show.

Whatever you think of Jade, the publicity generated by her illness has led to a 20% upswing in the number of women getting Pap smears in Britain.

And this is a good thing. Because if Jade’s story causes even one young woman to get the smear that saves her life, it will mean Jade’s death will not have been in vain.

The Irony

Unlike Eva Peron, whose death from cervical cancer occurred in the years before we had access to screening, Jade did get pap smears.

Jade had more than one pap smear, starting in her teens. At one point, she was even treated for precancerous changes of the cervix. And went on to have more follow up smears after that.

But when those follow up smears showed a recurrence of abnormal cells, Jade ignored letters that were sent to her advising her to come in for follow up and treatment.

Why? Because she was scared..

“They had sent a letter to me ages ago, telling that I needed to go in for an operation, but I had been too scared to do anything about it,” Goody confessed.

So Jade put the whole thing out of her mind and pretended it never happened. Until repeated episodes of pain and hemorrhage became symptoms she could no longer ignore. But by then, the tumor had spread beyond the cervix to her uterus. And while a radical hysterectomy and chemotherapy staved the cancer off for awhile, it returned this past month with a vengeance.

And now Jane Goody is going to die.

Let me stop beating around the bush

What has been on my mind all week since I first read about Jade’s story, and what I want to ask is simply this –

Did any health professional ever actually call Jade and try to get her in for treatment in all that time after her Paps came back abnormal? A nurse? A doctor? Anyone?

Please don’t tell me the only contact ever made with this frightened young woman was a series of letters, each one scarier than the next. Please tell me someone called her personally and tried to get her in.

Look, I know Jade was stupid.

No one, even Jade, I suspect, would say otherwise. Ignoring multiple abnormal Pap smear letters was not the first or the last stupid thing Jade Goody ever did. This is a kid who, in front of millions, stripped nude during a game of poker, made an ass of herself shouting racial slurs to an Indian housemate and then gave a blow job under the covers to another housemate. We’re not talking rocket scientist here.

But I’ve seen Jade in interviews that I’ve watched over the past few days, trying to wrap my head around this tragedy. This kid doesn’t hold anything back. She is completely genuine, self-effacing and ready to admit her shortcomings. She’s an idiot, but she knows it. And she is anything but unreachable emotionally. I just can’t believe that someone couldn’t have convinced her to come in sooner if they’d just talked to her.

Please tell me someone tried to reach her.

Jade seems to have had multiple interactions with the health care system during those years between the abnormal smears and her ultimate diagnosis. Times when she visited doctors for pain or gastrointestinal symptoms that were probably related to her growing cancer.

Did these doctors know about her abnormal smears? Did Jade think to tell them? (Probably not…) Were the letters being sent from the NHS cervical cancer screening program separate from Jade’s actual ongoing medical care?

Heck, did Jade even have a source of ongoing care, or, god forbid, a primary physician? I doubt it. This is, after all, a lower class girl from a very rough upbringing – someone, I suspect, whose only contact with the health care system was in public clinics and ERs. She probably bounced around ER’s and hospitals during those years, failing follow up appointments, checking out AMA so she could appear in one or another publicity venue, denying that there was really anything wrong. (Update – Dr Crippen corrects my misperceptions of the British system…)

She even tried to delay her surgery after her diagnosis so she could stay on TV, till they told her she’d be dead in 3 weeks unless she went into the hospital right away.

So maybe I’m completely off base.

Maybe, just maybe, there were docs and nurses who tried to help Jade. Folks who personally called, warned, cajoled and hollered at her countless times, until finally, as a last ditch effort, they sent her a certified letter. Health professional who really cared about Jade and wanted to help her, although ultimately she refused their help.

Maybe Jade was just really that stupid.

I hope so. Because otherwise, the tragedy is not just Jade’s, but all of ours.
______________________________________________________

Update –
Dr Crippen reponds to my post with a very thoughtful post of his own regarding Jade.
I respond to Dr Crippen.

For more information about cervical cancer, see these sites –

Jade Goody Photo from Wikimedia

Healthcare Hedging

I saw a patient this morning for an emergency appointment.

The emergency? Her husband is suddenly losing his job due to downsizing at his firm, which is losing contracts in the bad economy. She wanted to get her annual appointment in before March 1, when his insurance coverage ends. (She is a self-employed minister and they have no other insurance.)

Her exam was fine. We got her squeezed in for a mammogram and a bone density tomorrow. (She has had osteopenia and has been on a bisphosphonate for a number of years.)

But here was my dilemma – If her bone density is not improved, I would want to check a vitamin D level and urine NTX. If it is improving, I probably would not do these tests this year.

But by the time I get the results of her bone density, her insurance will have run out and she won’t be able to afford the tests.

So I did the tests today, even though I don’t know yet if I will need the results to manage her condition. She is also refilling her bisphosphonate for another 90 day supply, even though there is a chance I will discontinue it if her bone density is improved significantly.

Of course, their COBRA could end up coming through, in which case we could have waited and potentially saved the system the cost of those test and her meds. But she won’t hear about that coverage till next week.

She also asked if, while I was at it, I could send off “a panel of tests” that she might need in the upcoming year, but that I refused to do. She just saw her rheumatologist 6 months ago, after all.

And I can only potentially waste so much of the American healthcare dollar.

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)