The Soup that Never Ends….

It started out as Jessie’s turkey soup on Thanskgiving. A family standard and always delicious. Jessie makes a huge pot, so there was enought left over for all of us to take some home.

It was a bit thick after refrigerating it, so we add a couple of cans of chicken stock, a bit of barley and some chopped fresh mushrooms. My God, that was good. The broth was so rich…. It lasted us two dinners plus Emily’s lunch. But there was still some left over, and of course it had thickened up again.

Today I added some water and a chicken buillon cube and some gorgeous raw Kale with sesame seeds that Nellie left behind in our fridge after her stay at our apartment last weekend. We each had a bowl with dinner tonight and there’s still some left over.

Remember that song you sang as a kid? Time to sing it again….

Ghostwriting – Another Winning Strategy from Big Pharma’s Playbook

Since I’m on the topic of Big Pharma, here’s another eye-opener, this time from the WSJ Blog, about a physician who was offered sole authorship of an abstract for research she never even conducted.

In fact, she had never heard of the drug until receiving the email pitch…“We can draft the abstract, offer our editorial support in developing the content of the abstract and help with the submission process on your behalf,” wrote Liz Burtally, who identifies herself in the email as a medical writer “for the nebivolol team working with Forest Laboratories.”

Sealey asked a lot of questions. Would she be the only author? Yes, she says she was told. When Sealey asked if she would have access to the raw data, the phone went dead. Burtally never called or emailed again.

It’s called Ghost-Writing, and it’s much more common than you think. (Via Hooked: Ethics, Medicine and Pharma. A blog by Howard Brody, MD, author of a book with the same title.)

For those interested in the topic, here’s a little primer on Ghost-Writing from Health Care Renewal Blog,

… ghost-writing practice is common, perhaps accounting for as many as 10% of journal articles. Moreover, stealth marketing campaigns that emphasize ghost-writing may create a bolus of articles that may be enough to dominate the literature on particular topics.

According to a recently published scholarly review on the subject –

In the three years that Healy and Cattell examined, approximately 57% (55 of 96) of all published articles on Zoloft in the peer-reviewed medical literature had originated from Current Medical Directions (A Medical Communications Company engaged by Pfizer – TBTAM) . Not only did the articles from Current Medical Directions outnumber the traditionally authored articles, they appeared in higher-impact journals. Perhaps most significantly, the citation rate for athe articles produced by Current Medical Directions was over five times higher than the citation rate for the traditionally authored articles.

And finally, from Plos, a free article on the topic by Sergio Sismondo –

… during key marketing periods as many as 40% of published articles focusing on specific drugs are ghost managed [24]. Even if the more typical figure is half that, ghost management exerts a huge force on the shape of scientific opinion on new drugs, and does so in the service of marketing.

Makes reading the literature a real challenge these days. I’ve personally taken to looking at the conflict statements before I even read an abstract. But it’s almost impossible to know if an article has been ghostwritten. Peer review does not pick it up. We have to rely on the journal editors to get stricter about forcing disclosure of every single person who contributes to a manuscript.

Maybe it’s time to call in the big guns. Let’s sing together, shall we?

If there’s something fishy
In the research study
Who we gonna’ call?
GHOSTBUSTERS!

If the meta analysis
Don’t look quite right
Who we gonna’ call?
GHOSTBUSTERS!

I ain’t afraid of Big Pharma
I ain’t afraid of Big Pharma…

An Insider’s Look at Big Pharma’s Playbook

A must-read for every doctor and patient is an article in this Sunday’s NY Times Magazine called Dr Drug Rep.

It’s a first person account from a psychiatrist who is recruited by Wyeth Pharmaceuticals to speak on Effexor, an anti-depressant, but whose relationship to the company sours as he begins to respond honestly to questions and criticisms of the drug from prescribers.

Several days later, I was visited by the same district manager who first offered me the speaking job. Pleasant as always, he said: “My reps told me that you weren’t as enthusiastic about our product at your last talk. I told them that even Dr. Carlat can’t hit a home run every time. Have you been sick?”

As disturbing as it was to read about how drug reps influence the message, what was most upsetting was learning how peer-reviewed and published meta-analysis was used by industry-paid researchers to help Effexor stand out among its competitors. Analysies in which new measures of outcome were defined, while standard measures were either ignored or never used.

In his study, he emphasized the remission rates and not the response rates. As I listened to his presentation, I wondered why. Was it because he felt that remission was the only really meaningful outcome by which to compare drugs? Or was it because using remission made Effexor look more impressive than response did?

Originally designed as a method for mining much-needed information from multiple studies to answer important medical questions, it appears that meta-analysis is now just another tool for the pharmaceutical industry to market drugs.

Why had I not realized this till now? Have I really been that naive?

I feel like I need to go back to Go, pay my $200 and start all over again. This game is one I really haven’t fully understood until now.

They really liked my recipe…

I won the Ugliest Food Contest hosted by Not Eating Out in New York, for my rendition of Claudia Rodin’s recipe for Augergines in Spicy Honey Sauce. The prize was having Cathy, the contest host, cook the dish for her Thanksgiving dinner. Okay, so it’s not exactly the same as having a gold statue to display on my bookcase, but it’s my little prize and I’m excited.

I am honored to accept this award on behalf of all my fellow home cooks who struggle to recreate the beautiful masterpieces of cuisine we see on the Food Network and read about in glossy print cooking magazines, only to discover that not everything that is beautiful tastes great, and some things that are ugly are delicious.

Except maybe Mrs W’s Kitty Box Cake – I think that was probably as bad tasting as it looked, but I want desperately to make it anyway…

My New Office

They recently moved my practice back to the Hospital from the off-site office where I have been for almost five years.

I gave up a window and an incredible view and got back convenience, better access to my colleagues and staff and a bit more exercise, since I am now 5 blocks from work instead of one. And of course, me and coffee guy are back on again.

But the big question I know you are asking is – how is the Feng Shui in my new office?

The Old Office

Now I have a few patients who know Feng Shui, and they told me the Feng Shui in my old office was almost perfect. They wanted me to move my little fountain and hang a mirror to bounce the Qi, but other than that, it was just right.

Of course, I never believed in that stuff. But patients constantly remarked how peaceful my old office was and how relaxed they felt in it. And administrators would always bring new physicians and donors around to see my office because they said it was the nicest one in the practice.

So, naturally, I would be worried that the practice move would mess up my Qi. Trust me, there is nothing worse for a medical practice than bad Qi.

The New Office

Turns out that my worries were needless. On Monday, one of my Feng Shui expert patients was in for her annual and informed me that I had gotten it right again. The new place has great Feng Shui.

My desk is facing the door so no one can see my computer screen with patient data on it. Lucky for me this is also the Command Position. Not to mention my back it toward the wall, giving me support.

I have the patient chair next to me so I can type while I talk, but that is also good for the patient so they don’t feel too powerless. Although my desk is facing the shelves, which is not so good, the computer screen in between blocks all the negative Qi energy.

I have plants, so that’s good. And my baskets and pillows, which I brought along from the old office. And this little sand thingy that everyone loves…

But most importantly, I finally have my little fountain in the right place – the Northwest or Money corner. Apparently, flowing water leads to flowing money. Which may be one reason why the Chinese are taking over the world…

I finally got around to putting water in the fountain on Tuesday morning and started it up. It sounds really nice, but so far, nothing’s happened. I went to the cash machine today and my balance is even lower than it was last week, probably beause Mr TBTAM paid some bills.

So my question to all you Feng Shui experts out there is this -How long before the Money Corner thing works?

Because I’m looking at college tuition in 1-2 years, and I don’t think they’ll let me pay with Qi.

A Tale of Two Thanksgivings

My family
Mr TBTAM’s family

Two wonderful meals (Don’t worry- we’ve learned over the years how to pace ourselves) and two wonderful families for which to be thankful.

Hope you all had a great day.

Cabbage Borscht

How do you take your borscht? I take mine with cabbage but no beets, thank you. But this recipe goes either ways. Beets or no beets, it can’t be beat..

Now that I see this photo, it’s clear I need to skim the fat on this batch a bit more, or else refigerate it and skim it tomorrow.

CABBAGE BORSCHT

This recipe from Irene, who got it from her mother and has made some modifications over the years.

1 lb. top rib
2 cans (10.5 oz) beef consomme + 2 cans water
½ cabbage, thinly sliced
2 medium onions, thinly sliced
1 lg. Can diced tomatoes + ½ can water
1 bunch fresh beets, peeled, cut in ½ inch chunks (optional)
1 bay leaf
fresh thyme sprigs or dill
salt and pepper
¼ cup sugar
2 marrow bones
juice of one lemon
1 tbsp. balsamic vinegar

Simmer all ingredients in large soup pot, except marrow bones, lemon juice and vinegar. Remove meat when tender (about 2 hours). Keep warm.

Add marrow bones and simmer 45 minutes longer. Remove marrow bones and save marrow to spread on toast or chop fine and return to soup.

Add lemon juice and vinegar. Taste to adjust seasoning for salt, pepper, sugar, lemon juice or vinegar.

Best made a day ahead so that you can refrigerate and remove fat.

TBTAM Family Scrabble Record

Our family record for most points in a single Scrabble turn was set tonight by Mr TBTAM with the word EQUATE. With a triple letter on the Q and a double word, that’s 70 points!

It was an exciting family moment, and Mr TBTAM even called his Mom to tell her. (I know – we need to get a life…)

Of course, this is nothing compared to the world record set by Michael Cresta in 2006 with the word QUIXOTRY – 365 points. Cresta covered two triple word squares, giving him 9 times the value of the word, and captured the 50 point bonus for using all his letters. He also set the record for the most points in a game – 830.

I wonder what his mom said?

HPV and Oral Cancer – What Are the Risks?

Increasing evidence suggests that HPV infection of the mouth and throat, presumably acquired through oral-genital contact with an infected partner, can lead to squamous cell cancers of the tongue and tonsils.You know what HPV is, right? Human Papilloma Virus. The same virus that can cause cervical cancer in women and anal cancers in both men and women.

Scientists have been suspecting for years that this virus might be responsible for squamous cell cancers of the oral cavity. Turns out that it is, though it may be a more recent phenomenon related to the increasingly widespread nature of HPV infection.

What is the Evidence?

1. The incidence of certain oral cancers is rising

Doctors and dentists are seeing increasing numbers of tonsillar and tongue cancers in young men and women, even as rates of other oral cancers and the use of tobacco, a factor typically associated with increased risk of oral cancer, have declined, and rates of oral sex have increased.

Confounding factors may be an increase in binge drinking, another risk factor for oral cancer, and the fact that tonsillectomies are no longer regularly performed. But upwards of one quarter of individuals with oral cancer these days do not have a history of drinking or smoking, suggesting that another risk factor is emerging. That factor appears to be HPV.

2. HPV DNA is found in oral cancer cells

Somewhere between 40 and 75% of tongue and tonsillar cancers contain HPV16 DNA. HPV 16 is the HPV genotype most frequently found in cervical and anal cancers, and is known to be sexually transmitted.

Scientists testing tumor samples from Sweden’s tumor registry in 2007 found that the rate of HPV DNA presence in tonsillar cancers increased from 23% in 1975 to 68% in 2002.

3. The risk for oral cancer increases with number of oral sex partners

Having more than 6 lifetime oral sex partners is associated with a greater than threefold increase in oral cancer risk. (NEJM) This risk appears independent of the risk imparted by smoking and alcohol, which is associated with HPV-negative cancers. Again, this suggests that there are separate pathways to oral cancer, one mediated by HPV and the other via some other factor modified that is by alcohol and nicotine.

What is Your Risk for Getting Oral Cancer?

It’s really, really low. According to the SEER database, the the annual incidence of oral cancer is about 10 per 100,000 annually (6 per 100,000 for women and 16 per 100,000 for men.)
So extrapolating from the research, having had oral sex with more than 6 partners would raise the annual risk of oral cancer in a male to 48 per 100,000.
Of course, that’s just the annual risk. The lifetime risk of getting oral cancer is considerably higher, about 1%, give or take, depending upon how old you live to be.
So, if these numbers hold for HPV related cancers as well, and you have more than 6 oral sex partners, your lifetime risk for oral cancer by age 70 will be about 3 %. Which looks like this –
But, the risk of dying from oral cancer is much, much lower, about 2.5 per 100,000 annually, and ranges from 1.3 per 100,000 in individuals under age 65 to about 12 per 100,000 in those age 65 and older. Since HPV cancers are less aggressive than other oral cancers, I don’t think we can extrapolate historic mortality data, so I won’t. But I would suspect that the risk of dying from an HPV-related oral cancer is even lower than the numbers I just quoted.

(This is rough math, and probably not statistically proper, but it’s the best I can do with the data I have. Others who are better at statistics, please feel free to comment and correct this estimate and I will revise if need be.)

By comparison, the annual incidence of cervical cancer in women is about 7 per 100,000 and the mortality about 2.5 per 100,000. The lifetime risk is about half that of oral cancer in males, due, I suspect, to Pap smear screening in women.

Are There Other Risk Factors?

HPV is only one risk factor for oral cancer, though given the advent of the HPV vaccine, it is sure to be the one that gets the most press.

Smoking, excessive alcohol intake and poor dental care are also very important risk factors, as is a diet low in fruits and vegetables. In one study in Poland, 56% of oral cancers could be attributed to smoking, 31% to excessive drinking, 47% to poor dental hygiene and dental care, and low fruit intake to 12%.

These other risk factors appear to be independent of HPV infection in causing oral cancers, and scientists hypothesize two separate paths to oral cancer, one driven by HPV and the other by these other risk factors. Supporting this idea is the fact that HPV-related oral cancers tend to be less aggressive and have better prognosis than those without HPV. In addition, tobacco and alcohol appear to be synergistic in promoting cancers that are negative for HPV, but not in cancers that test positive for the vurus, again suggesting separate mechanisms for malignant transformation.

What Can You Do Now to Prevent Oral Cancer?

1. Don’t smoke
2. Drink to moderation
3. Brush your teeth and see your dentist regularly.
4. Add fruits and vegetables to your diet.
5. Limit your number of oral sexual partners

Will HPV vaccination be added to that list? I expect it will be. The vaccine prevents HPV 16, the subtype most often found in oral cancers.

Merck, the manufacturer of the vaccine, is conducting clinical trials of their HPV vaccine in young men. I would anticipate a “Tell someone” campaign about oral cancers directed at this population sometime in the near future. Time will tell, and only Merck’s marketing department knows for sure.

In the meantime, be careful out there, okay? Oral sex is a very intimate activity. Why not reserve it for those you love? That would limit your partners quite nicely.

Cheese-Stuffed Eggplant

He’s actually a pretty darned good cook, the man that I married.

Last Saturday Mr TBTAM whipped up a little din-din using recipes from Nick Stellino’s cookbook Mediterranean Flavors. This little gem of a cookbook features flavors and recipes based on the cuisines of Italy, Greece, Turkey, Spain, North Africa and the Middle East. Stellino’s recipes are beautifully written, with clear, easy-to-follow instructions that leave nothing in doubt, making them suitable for even the most novice of cooks. (The recipe that follows is my abbreviated version of Stellino’s instructions.)

Dinner also included Tunisian Chickpea Soup (recipe another day) and green salad with a lemon vinaigrette. Friend Annette supplied dessert, a gorgeous fruit tart from the Food Emporium under the Queensboro Bridge.

Let’s just say that by the time we were all done, the eggplants weren’t the only thing stuffed….

Cheese-Stuffed Eggplant
These actually taste very light, and are wonderful as an appetizer, side dish, or if you are vegetarian, a main dish. The only change in this recipe is to use Kosher instead of regular salt, so I increased the quantity a bit.

4 Japanese Eggplant
1 tsp Kosher salt
2 tbsp olive oil
6 tbsp grated Parmigiano Reggiano
4 tbsp goat or ricotta cheese
1/4 tsp black pepper
1 egg, separated
1/4 cup Italian breadcrumbs
2 tbsp oil-packed sun-dried tomatoes
1 head roasted garlic
2/3 cup chicken stock

Cut the eggplant in half lengthwise, leaving skins attached. Score flesh with a sharp knife, but don’t cut through the skin. Rub cut surfaces with 1/2 tsp salt. Place eggplant halves cut-side down on paper towels and drain for 15 mins.

Preheat oven to 400 degrees Fahrenheit. Brush cut surfaces of eggplant with olive oil and place cut side down on 18×13 inch non stick baking pan. Bake for 15 mins. Cool for 15 mins.

Gently scoop the pulp from the eggplant, leaving skins intact for later. Put pulp in food processor, and add 2tbsp Parmesan, goat or ricotta cheese, remaining salt, pepper, egg yolk, bread crumbs, sundried tomatoes and roasted garlic. Pulse till just mixed, about 30 secs.

Whip egg whites till stiff. Fold into the eggplant mixture with a rubber spatula. Fill the reserved eggplant skins with the eggplant mixture, mounding slightly. Place in a 9×13 inch baking dish and pour chicken stock around them. Sprinkle eggplant halves with the remaining Parmesan cheese and bake at 450 degrees Fahrenheit for 30 mins., until golden brown. Cool for 5-10 mins. and serve.

Stellino serves them on a small bed of tomato sauce. We just had them as they were – delicious.

Dove Does it Again

This time it’s a video called Onslaught, which shows the images of the female body that young girls are bombarded with by the media.

It’s part of Dove’s Campaign for Real Beauty. I like the message.

Can’t say I use the soap, though, being a gal who goes for the more squeaky clean feel. And in the end, it’s really all about selling soap, isn’t it?

If you didn’t see their first video called “Evolution” here it is. I thought it was even more powerful than this new one.

Thanks for California Now for pointing me to these videos.

Dove Does it Again

This time it’s a video called Onslaught, which shows the images of the female body that young girls are bombarded with by the media.

It’s part of Dove’s Campaign for Real Beauty. I like the message.

Can’t say I use the soap, though, being a gal who goes for the more squeaky clean feel. And in the end, it’s really all about selling soap, isn’t it?

If you didn’t see their first video called “Evolution” here it is. I thought it was even more powerful than this new one.

Thanks for California Now for pointing me to these videos.

Will a Hysterectomy Make You Fat?

No, according to a British study published in this week’s Maturitas. Removal of the uterus, with or without removal of the ovaries, is unlikely to lead to weight gain.

The investigators used data from two British prospective health studies that enrolled over 6,000 women born in 1948 and 1956 and followed them longitudinally throughout their lives.

Although women who had a hysterectomy had higher BMI and waist circumference in middle age than women who had not had this surgery, this was because they were already heavier to start with, not because they had had a hysterectomy. After surgery, these women merely continued on their previous trajectory of weight gain, as did their same-sized cohorts who had not had the surgery.

In unadjusted analyses there was a difference of 1.18 kg/m2 (95% CI: 0.64, 1.74) in mean BMI and of 2.72 cm (1.45, 3.99) in waist circumference at age 44–45 years between women who had undergone hysterectomy and those who had not in the 1958 cohort, and differences of 0.76 kg/m2 (−0.05, 1.57) and 0.34 cm (−1.58, 2.26) at age 43 years and 0.81 kg/m2 (0.14, 1.49) and 1.45 cm (−0.15, 3.05) at age 53 years in the 1946 cohort. These differences attenuated and were no longer significant after adjustment for pre-hysterectomy BMI and confounders. There was no strong evidence of variation in associations by oophorectomy status, timing, route of or reason for procedure. (italics mine)

Such is the value of longitudinal objectively measured data. Although previous cross sectional and cohort studies have shown weight gain after hysterectomy, none of these controlled as well for pre-hysterectomy weight, and none had the kind of objective measure of pre-hysterectomy weight used in this study, where subjects had nurse visits for measurement of weight and other vital signs throughout their life.

It is known that menopausal women begin to shift their weight to the middle, and that hormone replacement prevents this change. In this study, however, hormone replacement only accentuated the difference in BMI between women who had hysterectomies and those who did not. We do know that obese women have more hot flashes than thinner women, and perhaps they ended up using more HRT. That’s just a thought on my part.

Some other thoughts

So, women who were heavier to start with end up with more hysterectomies.

Although this study did not address the question, one has to ask – why? What is it about higher weight that leads to hysterectomy?

One factor could be that obesity raises the risk for endometrial cancer. Other risk factors for endometrial cancer are diabetes, hypertension and lifelong irregular menses such as those experienced by women with polycystic ovarian syndrome, all conditions linked to obesity. Obesity is also associated with higher rates of uterine fibroids and prolapse of the uterus, two common causes for hysterectomy. In the study reported here, women having hysterectomies for reasons of fibroids and prolapse had higher BMI’s, while those with cancer had lower BMI’s.

It was interesting to me that women born later in this study had less hysterectomies by their mid 40’s than their older counterparts, suggesting that they and their physicians were finding ways to avoid surgery to treat their conditions. Indeed, we now have a number of good non-surgical interventions for fibroids, so that less women should have to have surgery for this indication as time goes on.

Unfortunately, this study also showed that women of lower socioeconomic status had higher rates of hysterectomies, making me wonder if they had access to the kinds of treatments throughout their reproductive life that could have prevented their surgery.

Bottom Line

If you are deciding whether or not to have a hysterectomy, concern about weight gain related to the surgery does not appear to be important factor in your decision-making. That leaves you more time to really talk to your doctor about what your options are and what’s best for you, surgery or not.
_________________________________________________

Venus at the Mirror and Three Graces. Paul Rubens (1577-1640)

My Latest Addiction – Gertie’s Artichoke Tapenade

No, it’s not drugs or alcohol. It’s Gertie’s Artichoke Tapanade, and I got mine at Costco.

This stuff is incredible – a simple mix of artichokes, olive and safflower oil, green olives, key lime, vinegar, salt and spices. 29 calories for 2 tbsp, 2.5 grams fat (no trans fats) and 0.3 gm fiber per serving.(That’s 1 point for you WW fans)

Makes a great party appetizer served with baked pita triangles or crackers, but I’m trying to figure out how else to use it – maybe on pasta?

Here’s a recipe that sounds similar…

Grand Rounds: Volume 4, No 8

From the Saguaro Desert in Arizona comes this weeks grand rounds, hosted by none other than Dr Anonymous, who is becoming less and less so given his photo over there. So stop on over for this week’s best of the medical blogosphere.

While you’re there, be sure to check out the post from Dr Bongi’s blog Other Things Amanzi. Dr Bongi is a general surgeon from South Africa, and his blog is always a great read.