Blogroll Update

I’ve cleaned out the blogroll, removing some links to blogs that sadly, have closed, and added some links to new blogs I have recently discovered. It’s bittersweet to say goodbye at last to those who have already left the blogosphere (but hopefully are still lurking), and always fun to make new friends. Here are some new blogs I’ve discovered.

Just Up the Dose – A fascinating blog from a female doc South Africa, where it’s still bit like the Wild West when it comes to healthcare.

Anatomy on the Beach – I’ve taken to reading med student blogs lately, and am starting a category for them over on the sidebar. I find it’s always good to go back to your roots once in awhile and remember what it was like and why you got into this business in the first place. Not to mention this one’s a singer as well, a man after my own heart…

Dose of Reality – The University of Michigan is sponsoring these medical student blogs. I think that’s great – I wish our place would do the same for employee blogs. I might actually come “out of the closet” from my anonymity.

The Accidental Scientist – A food blog from a scientist “noshing and fumbling her way through the food world.” Substitute “doctor” for “scientist” and that pretty much describes me, too.

If I accidentally deleted you active blog, drop me a line.

There Goes the Neighborhood…

We had brunch last weekend at Barney Greengrass the Sturgon King, the famed Upper West Side restaurant and fish emporium. We were shocked to find that there was no line, and they sat our group of 6 almost immediately. By contrast, the line at Popover’s Cafe, a nice enough but undistinguished place down the street, was out the door.

No line at Barney Greengrass?

Could it be due to the influx of Neaveau Riche to the now toney, high-rent Upper West Side? Types that don’t appreciate a good plate of Nova and eggs or a bit of creamed herring? Do they really prefer an overbaked popover to a cheese blintz, which, by the way, Mr TBTAM’s cousin Maureen declared was the closest she’d ever tasted to Aunt Eleanor’s homemade?

Mr TBTAM says I’m over-reacting, and it was just that we ventured out so late that day. (It was almost 2pm).

I sure hope he’s right…

Tom Yam Goong (Lemongrass Shrimp Soup)

I had the most wonderful lemongrass shrimp soup last week at a little Thai place called Spice on 2nd Ave near 74th st. And only $3 a bowl! Add some crispy spring roll, a bowl of equally delicious coconut chicken soup, some Pad Thai (not the best I’ve ever had, but certainly acceptable), a glass of wine and a beer, and you’ve got dinner for two for around $20. Best cheap meal I’ve had in this city in a long time.

The next night, I found myself craving that shrimp soup, and found a recipe in Thai Home Cooking, a great cookbook that I had picked up in the used book store in Park Slope but had yet to make anything from. The pages for this recipe were wrinkled and stained, a sure sign that this recipe would be a keeper.

And it is. I’m looking forward to making it again after I’ve had time to scout out the right kind of mushrooms and chilies. Because I used canned tomato instead of fresh, my broth was not as clear as I’d like, but it sure was delicious!

Tom Yam Goong (with shrimp)

Lemongrass can be tough to find, even here in New York, unless you live in Chinatown. So be sure you know where to get it before planning this meal. Kaffir are easier to find, and you can store them in the freezer. Once you have the ingredients, this is one of the quickest soups you’ll ever make. Add noodles or serve it over some jasmine rice and you’ve got a really easy dinner. You could also make this soup with chicken if you’d prefer. Cut boneless breast into thin strips and cook in the broth till opaque, about 1-2 minutes.

12 oz jumbo shrimp (king prawns)
3 cups broth or water
2 stalks lemongrass, white part only, cut on a diagonal into 2 inch pieces
6 cloves garlic, crushed
3 tbsp coarsely chopped shallot, preferably pink
1 inch piece galangal or ginger, thinly sliced
2 firm tomatoes, cut into 8 wedges
1 cup straw mushrooms, rinsed and halved (I used button mushrooms)
10 small fresh green chilies, stems removed and halved lengthwise (prik khee nou) (I didn’t have these, so I used chili paste)
2-3 tbsp fish sauce, to taste
5 kaffir lime leaves, coarsely torn
2 tbsp fresh lime juice
1/2 cup coarsely chopped cilantro

Shell and de-vein shrimp, leaving tails intact and reserving shells and heads for broth. Cover and refrigerate till ready to use.

In medium saucepan, combine shrimp heads shells and broth or water, and bring to a boil. Using a skimmer, remove the shells and heads and discard. Bring back to a boil Add lemongrass, garlic, shallots and galangal to the broth, then tomatoes, mushrooms, fish sauce and kaffir lime leaves. Simmer gently till mushrooms are soft, then increase to a boil.

Add shrimp to broth and boil for no more than a minute.

Remove soup from heat and stir in lime juice. Transfer to bowls for serving, garnish with fresh cilantro and serve.

(Note – Don’t eat the galangal, lemongrass, kafir or chilies – just push them to the side of your bowl. According to this video I saw, you can leave the chilies out of the broth and put them into individual bowls before serving. Crush to increase spiciness. )

How To Get Pregnant, Part IV – Mom’s Medals

Dinosaur Doc has a very amusing little post about how an aunt’s advice can be the magic a patient needs to conceive. (You’ll need to read the post yourself to learn what to do, but I will tell you that it requires a good strong Southern accent…)

I love the family tales and the old time advice. And like Dinosaur Doc, I, too, sometimes use them in my practice.

When we were growing up, Mom always prayed to Saint Gerard, the patron saint of mothers. In fact, when my parents moved into their first house, Mom buried a St Gerard medal in the yard. Ten years later, pregnant with her 6th of 9 children, she and Dad moved us all to a bigger place. Mom told the woman who bought our house about the medal in the yard, and told her St Gerard would watch over them as he had done us. Five kids later, that woman rang up my mother – “Where’s that damned medal buried? I need to dig it up!”

Now I’m not religious, but I do love my Mom, and I’ve always loved this story. Some years back, I told the story to a patient who was trying to get pregnant, and she asked if my Mom had any more medals (which of course she did). After I asked my Mom a third time for a medal for a patient, she gave me a stash of my own, which I keep in my desk drawer.

I still hand a medal out occasionally, usually to a patient undergoing assisted reproductive technology and looking for a little extra something to help the process along. I have no idea if the medals work, but when you’ve maxing out all the scientific options, what’s wrong with adding in a little hope? (and a little bit of family voodoo…)

The last patient I told this story to was a physician herself who is scheduled to start her third IVF cycle next month. We both figured it couldn’t hurt if she wore the medal on the day of the egg retrieval…

I’ll let you know how it goes for her.
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Read previous posts in this series.

HPV and Breast Cancer? Interesting, but too soon to say

Read a fascinating post in Aetiology regarding the potential role of HPV in the etiology of breast cancer.

Although we are nowhere near proving a direct causation, studies have found HPV DNA in anywhere from 20-85% of tumors studied. (Types 16, 18 and 33 most commonly) However, some studies have found HPV DNA in normal breast tissue as well. So is HPV a cancer-causing agent in the breast or just a bystander? It’s too soon to say. Lots more work is needed on this one, folks.

The data are at odds with known risk factors for breast cancer, such as never having been pregnant. And if there is a link, one should see that breast cancer risk is increased with number of sexual partners, which as far as I know, is not the case.

So be careful before making the leap between hypothesis and recommending HPV vaccination for breast cancer protection. It’s way, way to soon…

The Contestosterone – Amateur Science at its Worst

This week’s This American Life radio program on NPR is devoted to the topic of testosterone. In addition to first person accounts of life at low and high testosterone levels, the show features a contest (Called Contest-tosterone – cute!) in which the program’s staff members have their testosterone levels measured and then try to predict the results according to the personality characteristics of the participants.

The results of the contest surprise everyone. The male with the highest testosterone levels is “a slightly femmy” gay, and the woman with the highest levels is 5 months pregnant.

Ira Glass, the show’s host, then concludes that the test was a dumb idea, because knowing their testosterone levels changed how members of the staff felt about themselves and each other. The men with low levels felt they were less manly, and the woman with the highest level felt “really bossy and aggressive”.

Well, Ira, I agree. The contest was a dumb idea. But not for the reasons you state.

Why the Contest was a dumb idea

Comparative testosterone levels, especially saliva levels, are meaningless in the normal range.

Number one, testosterone levels are not even replicable between labs.

Number two, testosterone levels fluctuate within the same individual, especially in women during the menstrual cycle.

Number three, saliva testosterone levels say nothing about testosterone levels in the brain, which is the place you seemed most interested in noting its effects.

And finally, circulating testosterone is just a piece of the picture. There are enzymes that activate testosterone, enzymes that convert testosterone to estrogen and hormone receptors whose activity is regulated by testosterone. All of these things affect a hormone’s activity in the body as much as overall levels do. So trying to describe a person by their testosterone levels is like trying to describe the Mona Lisa by measuring how much paint Da Vinci used.

But most importantly, the reason the contest wasn’t such a great idea was that the number of individuals was far too small to make any statistically meaningful conclusions regarding tesosterone leves. The contest’s results were destined to be meaningless from the start.

Bottom Line

Ultimately, at the extremes, testosterone levels can carry meaning. A woman with a sky-high level virilizes. A man without any testosterone is impotent. And in an individual, variations in one’s own levels can have an impact, as the first person stories in the program showed.

When large groups of individuals are compared, some meaning can be found in comparative tesosterone levels (perhaps). But trying to find meaning comparing tesosterone levels in a small group of people is a pointless exercise. Not to mention confusing for the public who listen to This American Life.

By the way, pregnancy raises testosterone levels. Check Julie’s levels again in 6 months while she’s breastfeeding and her levels will be much lower. But I’ll bet she’s still bossy…

An Inflammatory Video on Inflammatory Breast Cancer

An email with an absolutely frightening You Tube Video attachment is screaming its way across cyberspace to your inbox with the subject line “For all women – watch this video. It is no joke!” The video is a news story called “Inflammatory Breast Cancer – the Silent Killer”.

The news story first aired in 2004, as a response to a Seattle woman’s personal campaign to make sure every woman in America knows about this cancer that afflicted her daughter. Since then, according to the station that originally aired the story, the video has made its way to over 10 million women via the internet. The response has been an upswing in information about IBC both on the web and in conventional media, the creation of a foundation that is raising money for IBC research and treatment, and the opening of the first Center for IBS treatment and Research.

And that’s a good thing.

What’s not a good thing

What’s not such a good thing is the tone of the news story. It has all the makings of a viral scare campaign, not the least of which is the “Silent Killer that strikes without warning” phrase. If you didn’t know about IBC before, you sure as heck know about it now, and probably, like me, were up till 3 am scouring the web to learn more because you were convinced that you had it. And that’s what’s wrong with this latest “tell someone” campaign. It’s knowledge predicated on fear.

You need to know that the medical facts in the video are correct. But the context is not. Statements like “Hope for millions of women” give the sense that this is a very common cancer, when it is just not.

IBC is rare. So rare that docs typically never see a case in their entire career, or like me, see one or two cases in twenty years. But instead of having that knowledge reassure you, the news story uses it to scare you. Because if your doctor never sees a case, they are sure to misdiagnose it, so you’d better be sure that you know how to diagnose it yourself.

Would that it were so simple. The problem with IBS is that it’s early symptoms are so common – breast itch, rash, redness, pain. I’m sure all of us have had these symptoms at some point in our lives. And when it presents, IBC looks a heck of a lot like mastitis, a condition that many, many of us (including me) have had at some point.

Thus, another very important fact this that the video doesn’t tell you is this – If you have the symptoms they describe, the odds are overwhelming that it is not IBC.

Some Context

If you read this blog, you know that I applaud anything that empowers women, and I do believe knowledge is power. But knowledge packaged with hype and fear is the wrong kind of knowledge.

So, let me try and do what the video did not. Let me try to give you some context.

The incidence of breast cancer in the US is 100 per 100,000 women per year. Compare that to the incidence of IBC, which is 2 per 100,000 women per year. That’s about 3000 cases of IBC occurring annually in the whole country.

Now, note that 4.3 million Americans are injured and 40,000 more die in auto accidents every year.

I’ll bet you’re really scared now, aren’t you?

That’s okay. There’s always the subway.
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If you want to learn about IBC in a way that will not frighten you, skip the video and visit MayoClinic.com or the National Cancer Institute Website.

Thanks to Linda for tipping me off about this video.

TBTAM on the Dr Anonymous Show

Good News – The writer’s strike is over.

Bad News – You’ll have to wait till April 1st for the next new episode of The Office.

But that means you’ll be free this Thursday evening 2/21 @ 9pm to listen live to the Dr Anonymous Program on Blog Talk Radio featuring his special guest – Me!

So skip yet another Office rerun and come visit with me and Dr A. We’ll be making Sandra Lee’s Kwanza Cake an eleven course dinner for eight while slamming Big Pharma, dissecting the medical literature, giving out free medical advice and discussing the insanity known as gyno-food blogging. Who knows, I may even resurrect the Vagina Blogging song for the occasion!

If you haven’t listened before, Dr A’s program is a great chance to hear the voices of the medical blogosphere in the flesh. I listened to Sid Schwab’s appearance two weeks ago, and it was great fun hearing all the medical bloggers calling in to talk and hanging out with them in the chat room.

To listen, go to Blog Talk Radio
To call in – (646) 716-9514
To chat, you’ll need to register (a relatively painless process…)
If you can’t listen live, don’t dismay – the shows are archived.

Hope to talk with you on Thursday!

Insurers Have it Backwards

New York State is challenging the practice of reimbursement by insurers based on “usual and customary” fees. (Via WSJ) The probe, led by attorney general Andrew Cuomo, targets United Healthcare.

The move takes aim at a common practice among health insurers that can result in higher medical-bill payments for many consumers. While insurers typically pay in-network hospitals and physicians a negotiated fee for medical claims, out-of-network providers are reimbursed “usual and customary” or “reasonable” charges. These charges are set according to what insurers have determined is the going rate for a given procedure or service in a specific area.

In their defense, here’s what United said –

“It’s unfortunate that today’s media event ignored these facts and failed to address the appropriateness of charging out-of-network patients $200 for ‘simple doctor visits’ lasting ’15 minutes’ — which equates to a billing rate of at least $800 an hour,” said Karen Ignagni, president of America’s Health Insurance Plans, the main health-insurance industry lobby.

Well, Karen, you’ve got it backwards. The reason the visit only lasts 15 minutes (and by the way, it’s usually 10) is because all you pay is $50! Do you really think docs like giving healthcare in 10-15 minute increments? If you were really to pay $200 a visit, we could all slow down and give the kind of healthcare patients want and we love to give.

And by the way, for every 15 minutes with a patient in the office, there’s another 10 minutes or more of unreimbursed work such as reviewing labs, calling the patients, playing phone tag, talking to referring physcians, renewing prescriptions, getting authorizations, etc, etc.

But you know that already, don’t you? It’s just that your job depends on you paying as little as possible for it.

Grand Rounds, Vol 4 No 21

A big juicy kiss to David Harlow for including me in his Valentine’s Day edition of Grand Rounds.

For those of you who aren’t familiar with it, Grand Rounds is a weekly compliation of the best of the medical blogs. This week’s edition is extremely well done, the theme being the history of St Valentine’s Day. Did you know that some think the date was chosen because that was when the birds started to mate?

Do head over and have a read.

Look at me, I’m Sandra Lee

You know Sandra Lee – She’s the queen of “Semi-Homemade” on the Food Network.

As my sister Ronnie says, Sandra doesn’t cook – she combines. She shamelessly mixes processed, pre-made ingredients with fresh ones to make it look like she’s cooking. It’s everything that’s wrong with American cooking.

Take for example Sandra Lee’s trio of recipes for macaroni and cheese – all using a box of Kraft Mac and Cheese as the main ingredient. To make it Mexican, add some spices and …more cheese. To make it Italian, just sprinkle some Italian breadcrumbs on top! And add broccoli to make it, well, disgusting.

Now, Kraft Mac and Cheese is the perfect “I’m too lazy to go to the market and get something healthy”cooking. I’ll be the first to admit I’ve had the stuff for dinner on occasion – but it’s a cave in to laziness, a sign of defeat, and I’m not proud of it. I certainly wouldn’t take a photo of it and put it on my website! (Oh, wait – I just did…)

Of course, I’m not the only one out here having problems with Sandra. Almost every food blogger has an anti-Sandra Lee post.

But Joe Desalazar has taken the anti-Sandra sentiment to a whole new degree, leading the charge with an “I loathe Sandra Lee” recipe meme on his blog FoodieNYC. This month, Joe is challenging us all to make Sandra’s latest recipe for overcooked chicken breast in cream of mushroom soup, and to post a picture of the entire mess on our blog.

Well, Joe, since I don’t have crockpot, I couldn’t make the dish. So instead, figuring it was time somebody did the obvious, I wrote Sandra Lee her anthem. And wouldn’t you know it? Since I stole the music from the musical Grease, the song is only semi-homemade!

I’m Sandra Lee (with apologies to Stockard Channing…)

Double click to play and sing along!
Look at me, I’m Sandra Lee,
I got no creativity.
Won’t make a meal using anything real –
I can’t, I’m Sandra Lee!

Watch me! I‘m not Julia Child.
I don’t use anything grown wild.
I’m corporate paid making semi-homemade.
I’m rich, I’m Sandra Lee!

(spoken)
I don’t cook, I combine.
If it’s canned, it’s just fine.
I don’t care if it’s healthy or green.
Get off your high horse, this is no cooking course –
Would you pull that crap with Paula Dean?

Don’t you wonder how I stay
so skinny when I cook this way?
It’s really no trick, my own food makes me sick –
I’m not stupid, I’m Sandra Lee!

(Spoken)
Now just add a can of cream of mushroom soup, some baby marshmallows, canned mandarin oranges and a box of Duncan Hines cakemix.
Cook it in your crockpot for four hours and serve!

And remember –
Why make it healthy? Why make it delicious?
When you can make it –
Semi-Homemade!
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Thanks to Rachel for pointing me to Joe’s blog. And to PinkPii for the instrumental music.

Thoughts on the Contraceptive Patch and Blood Clot Risks

The FDA has updated the labelingfor the Ortho Evra Patch to warn users that the patch may have a higher risk of blood clots than other lower dose hormonal contraceptives.This is the second major labeling change since the patch was approved in 2001. The first change came in 2005, when it was found that the patch exposed women to increased levels of estrogen compared to low dose pills. This latest labeling change includes data from two recent studies that found a two-fold increase in thrombo-embolic events associated with the patch (as well as a third study that found no increased risk).

Although a bit late, I believe that the FDA is doing the right thing. Women who use the patch need to be informed that they are taking a higher dose estrogen product, and that higher doses may cause more clots.

It’s called informed choice.

A Little Background

In retrospect, I was not surprised to find out in 2005 that the patch has higher estrogen exposure than most pills. Breast tenderness was reported in the clinical trials in around a fifth of patch users, compared with less than 10% of pill users. And I had seen the same complaints from my patients who were using the patch.

In fact, shortly after the patch came on the market, I had begun to wonder about the estrogen levels and how they compared to the pill. Unfortunately, neither the package insert nor the contraceptive literature was helpful – no one source had comparative data. I remember asking the Ortho rep if he could tell me how the estrogen dose in the patch compared with a 35 microgram pill. The answer was something like “It’s like comparing apples and oranges. The trans-dermal dose has a different metabolism, so you can’t compare the dose itself.” Which is technically true.

But what you can compare is total estrogen exposure, something pharmacokinetics experts call “the area under the curve” or AUC. This kind of comparison was published in 2005 in a study comparing the patch to the vaginal contraceptive ring and a 30 ug (standard dose) pill.

Lo and behold, the AUC for patch users was 3.4 times that of ring users and 60% higher than in pill users! Now all that breast tenderness made sense. (This was the kind of data that prompted the Ortho Evra label change in 2005.)

Here was my thinking, simplistic though it may be. If EE levels are 60% higher on the patch than the 30 ug pill, doesn’t that mean the patch is equivalent to a 48 ug pill? And didn’t we long ago stop prescribing 50 ug pills because the clot risk was too high? So if I wasn’t routinely offering my patients the 50 ug pill as a first line method, why would I routinely prescribe the patch as a first line method?

Just because the patch isn’t first line, does not mean it has no place in our birth control armamentarium. 

What kind of women might want to use the patch? Well, some women take other meds that interfere with the effectiveness of birth control pills. Topamax is the most common such drug. For these women, the higher estrogen levels in the patch may be enough to give them the protection they need against pregnancy.

Another candidate for the patch is the woman who can’t remember to take a pill and is unable to use a barrier or IUD. Such a woman will often be willing to accept the higher estrogen dose in return for protection against pregnancy. This is not an unreasonable trade-off if you have had an unplanned pregnancy due to missed pills. However, is you want ease of use and compliance, you could also use the Nuva Ring, which comes at a much lower dose (but the clotting risks have not been compared). So that’s your choice.

The CME Response

I am getting a bit perturbed with all the posturing and spinning about the patch out there in CME land. All the thought leaders with conflict disclosure lists longer than my CV, who are weighing in on the clot data. Arguing that the studies are not conclusive, that one study used medical chart data and the other insurance claims data, etc., etc. Some are insinuating that the media is over-hyping the risks of the Patch, despite what seems to me to be quite responsible reporting on this issue.

C’mon guys. Most of you have spent the last 4 decades convincing us all that pills are safer than they were years ago, largely because the estrogen dose is lower. Don’t ask us to ignore those risks now.

More questions

I keep asking myself – Could Ortho and the FDA not have known this data? Didn’t anyone ask how the patch and the pill compare? If they were seeing breast tenderness and nausea at a higher than expected rate in patch vs. pill users in the clinical trial, didn’t they wonder what estrogen levels were?

So I went back and read the initial FDA review of the patch to see what sort of data was presented in this regard. Turns out the reviewers did note that weekly estrogen exposure was higher in patch than pill users, and directly related this data to the two pulmonary emboli reported in clinical trials.

There were two Pulmonary Emboli reported during the trial in patch users, one of which Ortho tried to discount since there was a protocol violation. The FDA’s reviewer disagreed and insisted that both cases be counted. The reviewer also recommended that the package insert reflect a concern that the patch has an increased risk for venous thromboembolism. In the end, the package insert merely stated that “it is unknown if the risk of venous thromboembolism with Ortho Evra is different than that for oral contraceptive users.”

Now what the FDA and Ortho could have done was to approve the patch as a niche method with known higher estrogen levels which, on balance, could be seen as an acceptable price to pay for the ease of use and compliance. Instead it was approved and marketed it as a first line method for any woman, with no discussion as to how estrogen levels might compare to other products already available out there. And I think that was just wrong.

Compare this to how Ortho advertizes their pill Ortho Tricyclen lo – “Do you want a high level of effectiveness and a low level of hormones?” it asks us on their web site. As if any of these methods have low hormones – they all work because their hormone levels are supra-physiological. But Ortho’s marketing folks know that women believe lower hormone levels are better. Why? Because that’s what we’ve been telling them for years!

The right way to label the patch

So, to make a very long story short, it took us 7 years to get here, but the FDA prodcut labeling for Ortho Evra is finally appropriate.

And Ortho’s website now states, “The patch is a not for everyone”. And that’s right. The patch is a niche method. It absolutely should remain on the market for those women who for whatever reason, can’t or don’t want other methods and are willing to accept a slightly higher clot risk in return for the benefit of effective contraception. But it’s not for everyone.

So, what is the risk?

Actually, despite everything I’ve just said, the risk for getting a blood clot on either the pill or the patch is quite low. How low? Well, that depends on what you think the background risk for DVT is in the general female population. For argument’s sake, let’s say that risk is 5 per 100,000 women per year. (A commonly quoted number, represented by that little red dot at the bottom right of the grid of 10,000 women).

The risk with oral contraceptives would be about 20 per 100,000 and the risk with the patch about 40 per 100,000 women per year.

Now, compare that to the risk of a DVT in pregnancy – about 16 per 10,000.
These are very low risks, aren’t they?

But multiply them by the millions of women using a method for decades of their life, and you can see that the differences in risk can lead to significant increases in population rates of DVT. And, if you had a choice between two birth control methods that were equally effective for you, you might want to choose the one with a lower risk. On the other hand, if the method with the higher risk was more effective for you, you might be willing to accept the increased risk in return for that efficacy.

As I said, it’s all about informed choice.
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