Thanks to OBS Housekeeper for pointing me to the amazing pavement drawings by Julian Beever. More here.
Got HPV? Have Some Carrots…
My patients who have HPV invariably ask “Is there anything I can do myself to help clear this infection?”
“Actually”, I tell them, “there is. Most importantly, don’t smoke. And eat your fruits and veggies.”
That’s right. Have a carrot. Or a tomato or some broccoli. Or better yet, a papaya. Because numerous studies suggest that women who eat more fruits and vegetables have lower rates of HPV infection, faster clearance of HPV once they get it, and lower rates of cervical cancer overall.
We don’t know which of the many vitamins and substances found in fruits and vegetables are responsible for this antiviral effect. It could be the combination of substances rather than separate vitamins themselves, since treatments using supplements rather than foods have not been effective. And it’s not at all clear if these foods are helpful once precancerous lesions are established. If veggies do work to prevent cervical cancer, it is most likely early in the natural course of HPV infection.
Large controlled trials are still needed, but, while we are waiting for that evidence, I see no down side to telling my patients with HPV to increase their dietary intake of fruits and vegetables if, like most Americas, they don’t get enough already.
How much fruit and vegetables? According to the American Cancer Society, everyone should have five or more servings of a variety of fruits and vegetables daily to help prevent cancer.
Here’s a great recipe for Carrots.
Glazed Carrots with Lemon (Adapted from the Silver Spoon Cookbook)
The original recipe used sesame seeds instead of pine nuts, and pearl onions instead of shallots. I’ve also made it substituting olive oil for the butter, and it tastes just a delicious.
1 ¾ lb carrots, fairly thickly sliced
3 tbsp butter
2 shallots, chopped
Strained juice and grated rind of ½ lemon
1 Tbsp pine nuts
1 tbsp chopped parsley
Olive oil for drizzling
Put carrots in a bowl. Add water to cover and a pinch of salt. Let soak for 15 minutes then drain. Melt butter in a pan and add shallots. Cook over low heat, stirring occasionally, for 5 minutes. Add lemon juice and rind and cook for a few minutes more. Add carrots, season with salt and pepper and cook for a further 10 minutes.
Meanwhile, lightly toast the pine nuts in a heavy skillet.
Transfer the carrots to a small serving dish, sprinkle with pine nuts and parsley. Drizzle with olive oil and serve.
Serves 4
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Here are a few references…
Int J Cancer 2005, 117 (4):629-637.
What’s Inside?
I, TBTAM the Marvelous, the disciple of the famed Carnac the Magnificent, can see into the future of American Healthcare. In this envelope I hold the answer to all questions. You need only ask and I will reveal…
Ah, Dr Wes, my cardiologist colleague – You say that Medtronics’ direct-to-consumer campaign for the Implantable Cardiac Defibrillator is giving you angst. You ask the Great One to predict whether this will change the way you practice medicine…
Well, take that stethoscope out of your ears and get that guidewire ready, my systolic-minded friend. Because from what I see, Medtronic has done all the right things to assure that your practice will never be the same again.
Medtronics’ Ad Campaign
That’s their Website ad up there. The campaign is called “What’s Inside?” It’s a catchy slogan, both a question and a play on words. What’s inside your body? What’s inside that device? It’s cute. I like it.
And speaking of cute, how about that ICD device itself? It’s sleek, small, and very high tech – I’ve never even had a heart attack, and I want one. In fact, it reminds me of an IPOD or a cell phone. (Do you think it comes in colors? Can I get skinz or ring tones for mine? )
How about the commercial? It’s brilliant, that’s all I have to say. (You can watch it on the web site, just click on the word commercial there). I get all warm and fuzzy when I watch it….
Inside this little device, you may just find…10,0000 more kisses. Snow. 200 more football wins. This is an implantable cardiac defibrillator, a device that’s always there with you, close to your heart, with the power to restart it in case of sudden cardiac arrest, one of the nation’s leading causes of death…
“Close to your heart”. Like your wife, and your grandkids, and your hometown football team. Inside. Close to your heart. It works for me. And for some reason, I’m getting thoughts of Winnie the Pooh. Don’t ask me what in that ad is doing it, but it’s undeniable. When I watch that commercial, I think of Winnie the Pooh.
But wait, I’ve left the best for last. Because at the end of the commercial, after the usual disclamiers and warnings, here’s what Medtronics promises…
An ICD could give you many more bedtime stories, tons of hugs and one more thing (Are you ready, Dr Wes?It’s three little words that will change the way you practice medicine forever..) …PEACE OF MIND.
That’s right. I almost didn’t believe it myself, but there it was at the end of the commercial, and on the banner at the Metronic website. In a marketing move swiped straight from the Digene’s HPV Playbook, Medtronic is selling peace of mind as an indication for their implantable defbrillator.
And so, Dr Wes, TBTAM the Magnificent now knows exactly what you are in for. (Plus, I have confirmed it on my Ouija Board. ) I would love it if I were wrong, and only time will tell, but here are my predictions…
Sometime in the Next Few Years…
1. Patients will start calling and coming in to their cardiologists asking if an ICD is right for them. Wives will come with their husbands because the men won’t really want to ask themselves. You will feel torn. You hate sudden cardiac death as much as your patients worry about it. You may even worry about it a bit for yourself. But you also know that ICD’s are not benign devices, and have risks. You do your best to help your patients weight those risks and benefits. This will not be easy, especially if Medtronics acts like Digene, and starts to coach patients on how to convince you they need that ICD for their Peace of Mind. You will stay strong and try to do the right thing.
2. Medtronic will partner with patient arrythmia advocacy groups (or create them if they don’t already exist). These groups will need a catchy name like “The Campaign the End SCA -Sudden Cardiac Arrest”, a celebrity or survivor spokesperson and a mission. Soon, everyone in America knows exactly what Sudden Cardiac Arrest is, and what an ICD can do for them. Some good will actually come of this, because ICD’s can be lifesaving, we all know that. But many patients will be confused by this information, and many many more will start to worry…
3. When cardiologists raise concerns about the potential for overuse of ICD’s, Medtronics will agree with them and promote the use of T-Wave alternans to better predict who needs the defibrillator. Fortunately, Medtronic either makes their own T-wave alternans or partners with a company who sells this device.
4. Legislation will need to be passed mandating coverage of ICD’s and T-wave Alternans on demand, regardless of indication. No problem. Medtronics will “partner” with some government lobbying group with a benign sounding name like “Women in Government” and get that legislation passed asap.
5. A few business-saavy cardiologists will make a fortune running a chain of drive-through ICD Centers implanting on demand. Most cardiologists, however, will continue practicing evidence-based cardiology, and will offer ICD’s to patients based on real indications, and not just peace of mind.
6. Tom Cruise will leave the Church of Scientology, get an ICD implanted for his Peace of Mind and become Medtronic’s spokesperson. Demand will soar.
7. The first doctor will get sued for declining to refer for an ICD. The story will run on 20/20, be picked up by Reuters and hit all the papers. The use of ICD will increase exponentially as cardiologists everywhere try to avoid a lawsuit. Medtronic stock will hit an all-time high.
8. Cardiologists everywhere will get sued for complications related to implanting the device or misfiring of the device. These stories will not get much newsplay. Malpractice rates for cardiologists will rise higher than those of obstetricians.
Welcome to my world, Dr Wes.
The Best of the Science Blogs
Thanks to the Herculean efforts of Bora Zivcovic, the very first anthology of science blogging has been published.
Bora asked for submissions just 3 short weeks ago, and along with a panel of judges waded through 218 blog posts (including one or two from yours truly) to cull out the 50 best blog posts of the year. My posts didn’t make the cut, but don’t let that stop you from reading this marvelous collection from writers who in their real life play physicists, doctors, astronomers, ecologists and more.
I’m just starting my reading, and already I’ve learned that the Big Bang is not really what I thought, that birds can fart, that you can’t divide by zero because it is meaningless (not because it is infinity) and that making love is really making music.
Click here to buy the book (also available as a pdf download) from Lulu publishers. (Great cover, huh?) Next year, they should publish it in time for the holiday shopping, it would make a great gift for the science lover you love…
Central Park Reservoir
The fog was so thick yesterday, it obscured the skyline and I forgot for a while that I was in the middle of the city. (Click here for more typical Reservoir views.)
Hands down, my favorite place to walk in Central Park. Especially when accompanied by good friends.
Fattening Up my Blogroll
Last week was annual De-Lurking Week. For those of you new to the blogosphere, lurking is when you continually visit someone’s blog without ever commenting. During De-lurking Week, lurkers are urged to come out from the shadows and join into the discussion.
In honor of delurking week, instead of commenting, I am going to put a link in my blogroll over there. Because a comment is a one time thing, but a link is forever… Here are just a few of the many wonderful blogs I’ve been lurking around for a long time, but never got around to linking to them until now:
- Flea: One Pediatrician’s Persepective. Check out his great series on vaccinations.
- Musings of a Distractable Mind. Great title, great images and one of the best Grand Rounds Ever.
- Doctor Anonymous: The Unoffocial site of Blogaholics Anonymous. (Sign me up!)
- DB’s Medical Rants: If you are a med student, check out his lecture on renal physiology.
- Over My Med Body: The pictures alone are worth the visit, and not-too-shabby writing, either.
More to come…
Lighten Up!
Thanks to Grunt Doc for pointing folks to my post series on “How to Get Pregnant“. Despite his telling readers that the series is a poke at our medicalization of normal life, it appears that some readers still don’t get me. Because once again, I’ve gotten a chiding comment from an offended reader accusing me of being insensitive to the needs of women. Here’s what Christian wrote today:
If I asked my physician for advice on how to conceive a healthy child, then I’d expect something a little more helpful than “have sex.” …After years of trying to avoid pregnancy is it so surprising that a woman might have a question or two? Conception isn’t a trivial choice for many women. It’s not unreasonable to expect that your doctor might be able to provides some good advice.
It’s hard to be funny when you are a doctor, particularly when you are writing about subjects as sensitive as reproduction. Therefore, I have designed that humor warning sign up there, and attached it to the post so readers will know right up front not to take me too seriously. We’ll see if it works…
Feel free to use it on your own blogs to warn readers to lighten up.
Category: Second Opinions
HRT Deja Vu
It’s deja vu all over again
-Yogi Bera
If my practice is at all representative of the whole, then expect to read sometime soon that prescriptions for hormone replacement have dropped further in the wake of the recent news that breast cancers rates have declined since the publication of the Women’s Health Initiative in 2002.
In the past 2 weeks, I have had at least 5 patients come in for annuals either telling me that they stopped their HRT or wondering if they should stop as a result of the recent news. All of these women had been using HRT since the WHI results were published in 2002. All had been counseled extensively counseled about the risks of HRT as defined by that landmark study, had received written material outlining the risks, and had been offered non-hormonal alternatives for their symptoms. And all had wanted to continue to use HRT.
Until this new news came out.
The fact that these women are responding this way to these new findings may mean that they really did not believe the WHI findings in the first place, despite my counseling them in a way that I thought was factual and unbiased.
Or perhaps they believed the data, but also believed that it somehow did not apply to them.
Or perhaps it is simply because, as one patient told me – “You get scared when you see the risk you are taking splashed on the front page of the New York Times.”
So we sit and talk, review the numbers and the risks again, and they come again to a decision to use or not use HRT. One patient today decided to stay with HRT, figuring that since she had a major project due at work, this was not the time to upset the apple cart. Two decided to stay off and see how they do. One went onto an SSRI to help her wean off. Yet another finally went to the lower dose that I had been urging her to try.
I’ve asked them all if there was anything I could have said to them before now that would have dissuaded them from their decision to use HRT. Nothing. Did I portray the risks accurately for them? Yes. Should I have been more directive? No. Pushed them harder to avoid HRT? No.
All felt comfortable with the decision they had made previously, and all feel comfortable with the one they are making now. At least until the next news comes out.
It’s an ongoing process…
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Graph adapted from J Clin Oncology, 2006, 24 (30): 49E-50.
Category: Second Opinions
How Boys Lose Weight
Warning – Gross generalizations about the differences between the sexes follows. If they don’t apply to you, don’t get mad at me. That’s why they are called gross generalizations… 
When I was 13, I went on the Dr Stillman’s Water Diet and lost 25 pounds. That same summer, my brother Al decided he needed to shape up, so he did what boys do when they want to lose a few pounds. He gave up Cheetos and started running and lifting weights.
Guess who still has the weight problem?
When girls want to lose weight, we starve ourselves. When boys want to lose weight, they cut back on the junk and head to the gym. And they always lose weight faster than we do. And, in my family’s case at least, they keep it off.
Diets don’t work. I am living proof of that. But until recently, I couldn’t wrap my brain around that in a way that was meaningful enough to move me to anything other than frustration.
Lately, though I have been doing a lot of reading, inspired by my friend Sam’s 30 pound weight loss following the program called “Burn the fat, Feed the muscle“. I started reading the program book (it’s over 300 pages, so it’s taking some time), and what I’ve read so far is this – When you diet alone, you lose fat, but also a fair amount of water and muscle. At a certain point, if your calorie intake is too low, you go into starvation mode and your metabolism slows down. So the weight loss slows, and when you go off the diet, you gain wieght back faster than you can say “Cheetos”. Okay, I’m starting to get it…
Then, a few weeks ago, a study is published showing that dieters who don’t exercise don’t just lose muscle – they lose bone! Researchers compared those who went on a diet for a year with those who ramped up their exercise for a year. The former lost an average of 18 lbs, the latter 15 lbs. But most shocking was that the dieters also lost 2% of their bone mass!
So, you go on a diet. You drop 20 pounds. If you do it the way I usually do, which is rapidly, the first 5 pounds of that is probably water, part of it is muscle, a fair amount is fat, and some of it is bone! Then you regain, and you’ve replaced that muscle and bone with fat.
I can hear Henry Higgens now… “I think she’s got it!”
You know what? I just remembered. I was thin for a number of years. I lost 25 pounds during my first 3 months living in New York City. I did absolutely nothing consciously to lose the weight, and in fact, that first year in New York was one filled with culinary awakenings. All I had done was live like a New Yorker, which basically meant that I walked everywhere I went. I exercised. I didn’t diet. I started running shortly thereafter, and even did a few10K’s. And I kept the weight off for almost 10 years.
Then I got pregnant.
Since then it has been nothing but gain, gain and gain. I’ve lost up to 30lbs at a stint using either Weight Watchers or Atkins or South Beach. But it comes right back on, because who can keep that up forever?
Call me an idiot, but I swear that I just realized that at no point since having my kids have I ever gotten back to a regular exercise program. I don’t think I’ve gone to the gym or done my treadmill for more than a week or two at a time. And, since my office is now a scant one block from my apartment, I don’t even walk anymore. No wonder I can’t keep the weight off!
As my friend Sam, who is also a doc, says – “All those years of medical training, and I never really learned about nutrition till I read this book.'”
Well, this year, I’m giving myself a break from dieting. Or, more truthfully, a break from trying to start a diet. This week, I’ve been to the gym 3 times, did cardio and even picked up a few weights. And I’m going to try to do that for most days of this upcoming year of my life. And I’m not going on a diet.
Oh, alright, I’ll give up the Cheetos…
Category: Second opinions, considerations
For Your Consideration…
Voting has opened up for the Medical Weblog Awards over at Medgadget Blog. There are over 100 nominees in 7 different categories. If you aren’t a reader of medical blogs, and want to start with the best, these blogs are the ones to read.
It’s going to be hard to choose the best, but I’ll be casting my votes. I urge you to head on over and do the same.
Congratulations to all the nominees!
Category: Second Opinions
TBTAM Subscriber Update
Bloglet’s Subsciption Service is no longer working or supported, so I’ve changed to Feedblitz.
If you are currently subscribed to my blog, then you should get a message from Feedblitz inviting you to re-subscribe through them. If you did not get that message, and wish to continue getting my blog posts via email, please complete the Feedblitz form over there on the right sidebar.
I apologize for the inconvenience, and thanks for reading!
The Perfect Scone
It’s moist and crumbly, it’s delicious, it’s delighful! It’s a recipe so special that it inspired a new musical sensation, and it’s my New Year’s gift to you, Dear Readers…
And so, without further ado, ladies and gentlemen, allow me to present – The Perfect Scone!
This recipe is the culmination of a year long search for that elusive pastry, and was well worth the journey. I want to thank those who commented on my previous scone posts, especially Waynetta, Chairwoman, Katy, and Laura, all of whom shared their recipes and suggestions. I consider this recipe to be a group effort. In the end, the recipe I created was closest to that of my sister, the OBS Housekeeper, without whose nagging I would never have finally finished this culinary journey. OBS, we tried your recipe and even taste-tested it with Irene, who gave it the thumbs up. In the end, though, I went for an ever so-slightly different recipe containing butter instead of Crisco.
Here is what I learned about scones along the way:
1.The British scone is more akin to an American biscuit, and the American scone is more like the Irish scone. I have been looking for the perfect British scone.
2. Most scone recipes do not have enough liquid, and are too dry for my taste. Perhaps this is where the clotted cream comes in…
3. Technique is paramount. Work quickly once the liquid is added. A soft shaggy mass is what you are aiming for. Just fold it once or twice, pat it down and cut out your scones. Don’t mess too much.
4. Use only double-acting, aluminum-free baking powder. Here in the US, that is Rumford Baking Powder. (Thanks OBS for this tip.) Or, do as Cooks Illustrated does, and make your own baking powder (1/4 baking soda, 1/4 tsp salt and 1/2 tsp cream of tarter make 1 tsp baking powder.)
5. I really love scones!
The Perfect Scone
2 C flour
1 tsp. salt
1/4 cup sugar
2 1/2 tsp. baking powder (Aluminum-free)
6 tbsp butter, cold, cut into pieces
1 C heavy cream, half & half or a combination
½ C chocolate chips, raisins or other small dried fruit bits
A bit of milk in a small bowl
Sugar
Preheat oven to 400 degrees Fahrneheit.
Mix together flour, salt, sugar and baking powder. Cut in butter using pastry cutter till it is the consistency of coarse corn meal. Add chocolate chips and mix until they are coated.
Make a well in the center, and pour in cream. Mix with a wooden spoon just enough to get all the dry ingredients incorporated. Dump the dough onto a table. (It should be a shaggy soft mass.) Fold the dough once or twice, then pat the dough into a circle ½ inch high. Cut with a biscuit cutter. (Size of cutter depends on if you like little or bigger scones. Standard size is 2 inches)
Place scones on an ungreased baking sheet. Brush the tops with a bit of milk and sprinkle with sugar. Bake for 12 to 15 minutes.
Makes 8-10 scones.
Category: Food
Fosamax – Can You Stop After 5 Years?
Stopping aledronate (Fosamax) after 5 years of use may be a reasonable option for many women using this osteoporosis-fighting drug, according to a research study published this week in the Journal of the American Medical Association.
In this multicenter study, which was funded by Fosamax manufacturer, Merck, and designed jointly by both Merck and non-Merck investigators, women who had been using Fosamax for 5 years were randomly assigned to continue aledronate for another 5 years, to continue for 5 years at a lower dose, or to take a placebo for 5 years.
Not surprisingly, stopping aledronate after 5 years led to a decline in bone mineral density at both the hip and the spine, and bone turnover increased. The loss of bone, though significant, was small, so that bone densities five years later were still higher than they were when aledronate was first started.
Women who stopped aledronate after 5 years did not have an increase in the rate of new non-vertebral fractures.
However, there was a significantly higher risk of vertebral fractures in women who stopped aledronate.
The protection provided by continuing aledronate beyond 5 years was evident among women whose T scores (measured at the hip) were below -2.0 at baseline and in women who had a prior risk of fracture. For women whose baseline bone density was above -2.0, the risk for fracture was the same whether or not they stopped or continued aledronate.
It should be reassuring to Fosamax users to know that no excess in adverse events occurred in the 10 year Fosamax use group, and no cases of osteonecrosis of the jaw were reported in the over 1000 Fosamax users in this study. There were also few differences in outcomes when the 5mg and 10 mg Fosamax doses were compared.
Understanding the results
Bone is a living tissue, undergoing constant reformation via a delicate balance between the breakdown of old bone by osteoclasts and the formation of new bone by osteoblasts. If bone breakdown exceeds bone formation, bone loss results.
Fosamax is one of a class of drugs called bisphosphonates. These drugs bind to the bone to cause the aptosis (cell death) of osteoclasts. This shifts the balance of bone turnover in favor of new bone formation.
Bisphosphonates bind very tightly to bone and can remain there for up to ten years. During this time, they continue to increase bone density and prevent fractures. Although no adverse effect of prolonged use has been reported, concerns remain, particularly in light of recent reports about osteopnecrosis of the jaw in bisphosphonate users. Interest has been growing to find ways to limit bisphosphonate use to shorter periods of time. This study was done in order to determine if Fosamax use could be limited to 5 years and still be effective.
Bottom Line
If you have been taking aledronate for 5 years, and your hip T score is above -2.0, it appears that you can stop your aledronate for 5 years without increasing your fracture risk. Women with certain medical conditions or at increased risk for fracture may do best to stay with with their medciation, so talk to your doctor to see if this applies to you.
If your hip T score is less than -2.0, then stopping aledronate will not increase you chance of a hip fracture over the next 5 years, but your risk of spinal fracture will increase. This increased risk is small and should be weighed against the risks of continuing the drug. Talk to your doctor about your options. If you are at high risk for fracture, it is probably advisable to continue taking you medication. A a one to two year drug holiday might be a good compromise between stopping your medication altogether and staying on it continuously. You could also consider lowering the dose.
If you do stay on bisphonsphonates for 10 years or more, be reassured that to date, long term use has not been found to increase the risk for adverse events.
Do these results with aledronate apply to other bisphosphonates, in particular, risedronate or Actonel? We have no data, but Actonel has a similar mechanism of action and duration of action to Fosamax, so it may not be unreasonable to expect similar results. Again, talk to your doctor.
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Patient information about osteoporosis from the National Osteoporosis Foundation and from The Hospital for Special Surgery.
Physician’s Guide to the Prevention and Treatment of Osteoporosis. This great resource from the NOF is downloadable and free with registration.
Category: Second Opinions
Got PMS? Have a Kookie!
Here’s a great gift idea for that special someone who suffers from PMS – a little box of sweets from the PMS Kookie Company. I got these decadently rich chocolate cupcakes last night for a Secret Santa gift. The chocolate chip cookies were also delicious.
Of course, these are best eaten with either a tall glass of milk or cup of warm tea while relaxing in your PMS Bath.
Category: Food and Second Opinions
I Lost It on the Streets
I left my wallet in a cab on Wednesday. I was a few minutes late for a lunch date with my daughter, and it must have slid from my lap to the floor as I rushed out the door of the cab. I realized it as soon as I closed the door, but by the time I turned around, the cab was zooming off.
Luckily, I had a few bucks in my pocket, so I was able to pay for lunch, a meal during which I debated calling the credit card companies right away, or waiting to see if someone had found my wallet. We decided that I would wait a few hours.
Sure enough, my secretary called me about 3 hours later. The next fare, a sweetheart of a guy named Alex, had found the wallet, and tracked me down through my hospital ID. He would be at Grand Central for the next hour. Did I want to come there, or should he come to my office tomorrow? This guy was saving my life, and now he was offering to schlep to my office!
Problem was I had no money and no metro card, so Mr TBTAM headed over to Grand Central for me and retrieved the wallet. Unfortunately, he did not get Alex’s address, so I can’t send him the wine I had planned to get him.
So, Alex, wherever you are, thanks. It’s people like you who make me love this city. Have a wonderful holiday.
Category: Considerations
