Ortho Diaphragm Discontinued

diaphragmUPDATE 7/3/15: THE CAYA DIAPHRAGM IS NOW AVAILABLE IN THE UNITED STATES. HERE”S WHAT YOU NEED TO KNOW to prescribe to obtain it.

It appears as if Janssen Pharmaceuticals has discontinued production of the Ortho All Flex Diaphragm.  That’s not great news for women wanting the full range of contraceptive options.

The good news is that diaphragms are still available in the United States through Cooper Surgical. It’s a wide seal diaphragm, which may not be suitable for all women, but will probably fit most. Your doctor will have to get a fitting set for this particular diaphragm, and once your size is determined, order it for you rather than you taking a prescription to the pharmacy.

If you happen to be in Europe, you can get a Caya Diaphragm without a prescription.

I suspect the market for diaphragms was just too small for Jaansen to keep it going. I’ve only fitted one woman for a diaphragm in the past 6 months.

That’s a real shame, because the diaphragm is an important contraceptive option for motivated women who can’t or don’t want to use hormones or IUD’s.  When used properly by motivated couples, efficacy can be quite high.  I know – I was a long time diaphragm user, and despite being quite fertile, never had an unplanned pregnancy.

Here’s hoping that the Caya manufacturer will step into the US breach and get the diaphragm back into the hands of women who want to use it.

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More about the diaphragm from

Pollen!

Yew Pollen
Yew Pollen

So I was sitting on my bed on Sunday afternoon (oh all right, I was taking a nap…) and happened to glance out the open door into the garden, where I saw that our Japanese Yew bushes seemed to be smoking.

Really. Several times a minute, at random intervals and from different locations, little puffs of smoke were emanating from between the branches.

I was sure there was a fire, but a closer inspection revealed that this was no smoke. This was pollen, fine as smoke, bursting out of the small flower buds that had cropped up all over the bush this season.

Yew Pollen
Yew Pollen

As the seed pods open, they let out a fine spray of dust-like particles that now coated the tree and, like dust from an old carpet, fell in abundance when the wind blew or when one shook a branch.


It really was an amazing spectacle, watching these yews propagating themselves right in front of our eyes. 

And unfortunately for hay fever sufferers, our noses.

A Graphic Medical Tale

tumblr_n3ktusIZU21rr3k1co1_1280

An otherwise healthy young man develops hugely swollen lymph nodes in his neck and is admitted to Cleveland Clinic for evaluation and treatment. Being also a talented graphic artist and writer, he pens a graphic tale of his experiences in being a patient and a bit of a medical oddity.

On hospitalization, the fortune of living near world-class medical care, and raging against the risky unknowns. Drawn shortly after I left the hospital in January of 2014.

Add my friend Davey Connor to the emerging chorus of patients who aren’t afraid to let us know what it’s like to be on the other side of our stethoscopes.

A great read for docs and patients alike.

Broiled Salmon with Mushrooms and Farro – Inspired by Lyfe Chef Art Smith

Broiled salmon with mushrooms and Farro TBTAM

One of the highlights of my visit to the Medicine X Conference in Palo Alto in September, in addition to my poster presentation and meeting all the amazing e-patients, docs and tech gurus there, was dinner at Lyfe Kitchen.

Founded by former McDonalds CEO Mike Roberts, Lyfe (which stands for Love Your Food Everyday) is the first of a growing chain of healthy, pretty fast food franchises that “put sustainability, our planet and our employees first”.

As soon as I entered Lyfe, I was hooked.

There was a gorgeous live herb garden forming the centerpiece of the place and lending a deliciously fresh scent to the room.

Lyfe herb garden

The food itself was healthy and varied, with plenty of veggie, vegan, low fat and gluten free options on the menu created by Chef Art Smith, who you may know as Oprahs personal chef.  Smith, who himself lost over 100 pounds after being diagnosed with diabetes, has kept dishes under 600 cals, low in saturated fat and sodium, and high in fiber and protein.

Service was faster than a traditional sit down restaurant – diners line up at the counter and place their orders, then sit down with a pager that alerts the servers where they are and when their food is ready. Prices were moderate,  but not cheap, which is to be expected if local food sources are being used and employees treated like human beings.

On to the food – The edamame hummus was delicious. (I have the recipe and will post it soon)

Lyfe edamame dip

as were the flatbread

Lfye pizza

the grilled fish

Lyfe salmon

the veggie burger and the sweet potato fries.

Lyfe burger

Smith’s cookbook Healthy Comfort was on sale at Lyfe, so I picked up a copy for inspiration and dinner ideas.

I’m excited to see healthy food making it closer to the masses and look forward to the day when Lyfe makes it to NYC. If they do, they’ll find some real competition here in the Belgian chain Le Pain Quotidian, an even faster growing chain that serves delicious, organic and healthy food.

(Recipe after the jump) Continue Reading

Almond Cake

Almondcake4

One of life’s better days.

Started with having both girls home for dinner. Add in daylight savings time and the first bike ride of the season in Central Park and life is pretty damned good.  Then give me a sunny afternoon in the kitchen baking and I’m over the top.

This cake will put you over the top, too. From my fave old magazine “Pleasures of Cooking”, it’s dense and sweet but not too sweet due to a touch of lemon tartness and has a wonderfully chewy outer crust.

I made the cake substituting olive for vegetable oil, resulting in a slightly richer and denser cake than the original recipe. Here’s the original cake made with veggie oil by my mother in law Irene-

VEGGIE OIL ALMOND CAKE

and mine made with olive oil. Mine is a little lower because I took some batter off to make cupcakes, which I”ll show you in another post, so concentrate on the crumb texture. See how it’s denser? It actually fell a tad when I took it out of the oven, but was well cooked from what I could tell. It could be my cake pans or the olive oil that made the difference there, I’m not sure.

OLIvE OIL ALMOND CAKE

Both were delicious. When we taste-tested frozen and thawed versions of both cakes with my husband’s family today, they were evenly split on which they preferred. So I’ll leave it to you to decide which you’ll make. I”m sticking with the olive oil because it seems healthier and more authentic and I loved how it tasted.

almondcake2

(See recipe after the jump) Continue Reading

Meditation

From the Massenet opera Thais, performed by Yo Yo Ma.

If love came with background music, this would be it.

100 Migraines

100 nigraines
Lorie Novak –  photographer, artist and fellow migraine sufferer – has created a painfully real portrait of what if looks and feels like to have a migraine. Her site, called 100 Migraines, is a collection of vivid self portraits taken while in the throes of  a migraine.

I have chronic migraine syndrome, and currently have an average of ten to fifteen episodes a month. They began when I was eight years old. I grew up at a time when migraines were not considered a medical condition, as they are now, but an emotional one. As a child and adolescent, I was told I worked too hard, did too much, and was too stressed out. In other words, it was my fault. In my thirties, I read the essay “In Bed” by Joan Didion in which she gives voice to her migraine suffering through words. It was a life-changing moment. In 2009, approximately twenty-five years after reading “In Bed,” I began to photograph myself every time I have a migraine, and have amassed over 700 self-portraits. When I have a migraine, all I want to do is leave my body so I won’t feel the pain. If I am in a semifunctional state, my laptop is my escape—it allows me to ignore my body and, by photographing myself, see my body. I can express what I can’t articulate and make the pain visible.

If you’re wondering what it looks like to have a migraine, just compare these two pics of Lorie with

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and without a headache.

people_novak (2)

I feel your pain, Lorie…

I encourage you to visit the site, which also includes a resource list and information for migraine sufferers.

Saved by the EMR

EMR LIFESAVER.Given all the complaining I and my colleagues do about electronic medical records ,  I thought I’d take the opportunity to tell you about something good that came from having my practice online.

A patient came to see me last week for a check up and requested a prescription for birth control pills.  She’d used them in the past without problems. I wrote the script and sent her on her way.

As I was finishing writing her visit note later that afternoon, I did what I usually like to do but had not had time for while she was in my office – look through her last few visits in the system with other docs. I noticed that she had had a recent CT scan for abdominal pain, something she had forgotten to tell me when I asked about interval medical history. A small presumed angiomyolipoma had been found on her kidney, and was being watched.

I seemed to remember that there was something about angiomyolipomas that could be problematic with hormones. A quick foray into Up to Date and Pub Med reminded me that these tumors, though benign, have receptors for estrogen and progesterone, and have been reported to grow, sometimes rapidly, in pregnancy and on birth control pills.

I immediately called my patient to discuss the issue, and advised her not to fill the prescription I had given her for birth control pills. She would continue to use condoms while considering a copper IUD for birth control. I updated her problem list and medical history to include the CT finding, so that the next doc to see her would find the issue up front instead of fortuitously stumbling onto it while poking around her chart after the visit was over.

This is actually not the first time I’ve happened upon clinically critical information in the EMR that my patients have forgotten to tell me. It’s the one area where the EMR can really make a difference in outcomes.  Of course, this only works when patients have a small enough record, as my patient did, for me to poke around in a few seconds, and best when providers write concise, relevant notes (something the EMR does not facilitate) and update the history and problem lists accordingly.

I’m sure one day someone will figure out a way for that kidney tumor diagnosis to automatically prompt a warning when I go to prescribe birth control pills, but for now I’m happy just to have access to all my patient’s information in one place.

Butternut Squash Polenta With Sausage and Onions

polenta sausage

Quick!  Before  winter ends, you’ve got to make this stick to your ribs, warm the cockles of your heart, comfort food supremo dish of butternut squash polenta with sausage. Thanks to Melissa Clark of the NY Times for this recipe, which I encourage you to read and watch her cook on the NY Times website.  

This really is a perfect recipe for the end of winter,  when you think you’ve had all the butternut squash you think you can stand, but there’s really not much else at the Farmer’s Market.  It sort of sneaks the squash in by melting it into the polenta, adding a bit of “what is that?” flavor while still allowing the corn flavor to shine through. It also rounds out this one dish meal so you don’t need to serve a separate vegetable. (We did, however, put out small side bowls of home made applesauce, which were a perfect accompaniment.)

Melissa’s is a very basic recipe that lends itself to creative tweaking, so we doubled the squash and the fennel seeds and adding grated Parmesan and some chopped parsley to the polenta. We also added a tablespoon of sherry to the polenta near the end of its cooking, just because it seemed like the right thing to do.  Next time, I may try making the polenta with a mix of chicken broth and milk (see video here), and skip the cheese.

In addition to watching Melissa’s video, I encourage you to read this post on polenta making so you know how to tell when the polenta is done – much later in the cooking process than you think.

(See recipe after the jump) Continue Reading

Penne w/ Broccoli Rabe, Sausage & Sun-Dried Tomatoes

Penne w: broccoli rabe, sausage and sundried tomatoes

If you’ve spent the afternoon at the Signature Theater seeing Open House by Will Eno (“People have been trying nobly for years and years to have plays solve in two hours what hasn’t been solved in many lifetimes. This has to stop.” I laughed so hard I cried…) and want to have dinner over in time to watch the Oscars,  this is the dish to make. I hate to even use the word “quick” to describe this meal, because it cheapens it. This is no fast food you’ve ever eaten before. It is rich, complex, and absolutely delicious.

Thank you, Lidia Bastianich for this recipe. If there were an Oscar for great Italian cooking, it’s be yours.

(See Recipe after the jump)  Continue Reading

Celery Root Soup with Caramelized Pears

CERELRY ROOTSOUP WITH PEARS

A huge shout out to Adam Roberts, whose blog The Amateur Gourmet has been a constant source of great recipes, fun stories and sometimes silly songs, for pointing me to this wonderful soup recipe from chef Alfred Portale’s cookbook Simple Pleasures.

This was indeed a delicious soup,  and may very well be one of the best we’ve ever made.  If you want to make it too, here is the recipe.  The only thing I’d do differently is to add a little more stock to thin the soup a bit.

This is what I love about food blogs – they point us to great cookbooks that may have passed beneath our radar when they were first published, in this case Portale’s Simple Pleasures (C 2004). A quick perusal of the web finds several recipes from the book, which I’ve linked to below.  I hope to try a few more of them (The Filet with Madiera and the Spinach Custards for staters), and have added Portale’s book to my must get list and his restaurant Gotham Bar and Grille to my must go list.

I know, I know. You’re wondering how I’ve never heard of Portale or Gotham Grill before, especially since I claim to have lived here in New York for so many years. But you see, as much as I love food, I’m more a home cook in the Big City that a Big City restaurant scene player.

This soup may very well change that.

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More recipes from Simple Pleasures 

No, It’s Not Within Your Parental Rights to Perform Your Daughter’s Abortion

scales abortion vs safety

I’m as pro-choice as a person can be, but this story about a mother purchasing medical abortion meds online and administering them to her daughter gives me the chills.

There are those who will use this story to claim that abortion restrictions are leading to illegal abortions.

With clinics closing across the country, illegal medication abortions are and will continue to be a growing reality. This latest case is a red flag that anyone can be arrested as aiding a patient, regardless of age or relationship.

We all fear that at some point this could happen, but this was not the case here.  Abortion is legal in Pennsylvania, and an adolescent can obtain an abortion with one parent’s consent.

I think we need to be very, very careful that in supporting a woman’s right to choose, we also support the protections necessary to ensure that women’s lives are not endangered.

Pro-choice does not mean that we need to have an abortion provider on every corner.   It does mean that we need to have abortion that is safe, accessible and affordable.  For now, at least in Pennsylvania, we have this, and this mother and her daughter certainly had it.

All this mother needed to do was to drive her daughter to Planned Parenthood in Wilkes Barre or any of the other legal and safe family planning providers in central Pennsylvania, most less than an hour away.  I know this area of rural Pennsylvania very well, and pretty much everything, including the mall, is almost an hour away. This is not an unthinkable reality or an unreasonable barrier to care.

Though I do not agree with Pennsylvania’s parental consent provision, it did not pose a barrier to this woman’s daughter obtaining an abortion.  What worries me more is whether this mother’s unwillingness to use the medical system was so she could control the outcome and be sure the abortion happened.  

What this woman did for her daughter was not safe. She claims to be a nurse, (turns out she is a nurse’s aide, not a nurse) which makes what she did even more egregious. She bought drugs over the internet without a prescription, practiced medicine without a license, and endangered her daughter’s health.

What she did was stupid, and what she did was illegal.

Even More on Nuvaring and Clot Risks

NuvaRing_compressed

Merck, the makers of Nuvaring, have announced that they will settle the lawsuits pending against them from women who claim harm from using the ring.  It may be a wise business decision, but surprising given the two recent studies that, unlike the large Danish study published in 2012, find no increased blood clot risk among new users of the Nuvaring compared to women who use older birth control pills.

I’ve updated my prior post on the Ring to address the newer more reassuring data, and point you to this wonderfully written article in the NPR Shots blog for the best summary of the evidence and opinion to date.

Bottom Line

All estrogen containing contraceptives can increase the risk of blood clots. Nuvaring’s risk may or may not be higher than that of older pills containing the protesting levonorgestrel, and more in line with that from desogesterel or drosperinone (YAZ, Yasmin) containing pills.  However, the preponderance of data at this point suggest that the ring’s risks are not higher than that of older pills. Time (and perhaps more studies) will tell if this will change.

For women unable or unwilling to accept the small but real risk for clots from using estrogen containing contraceptives, there are plenty of great, and sometimes even more effective, methods out there – IUDs, progesterone only pills, shots and implants.

Poached Pears

POACHED PEARS

Wonderfully simple, delicious, and almost decadent when paired with chocolate in any form, like a chocolate torte perhaps?… Even better when paired with good friends, lively conversation and a few well-chosen readings at a wonderful dinner party thrown by Paula and Tony.  Thanks, guys, we had a great time!

POACHED PEARS

I was inspired by David Lebowitz’s post on how to poach pears, which is really not a recipe but a suggestion. I made up my own combo and proportions of spices, and you should do the same. But I  found the sauce begging for a touch of salt, so I added it. Perfection!

  • 4 Bosc pears
  • 1 quart water
  • 1 1/3 cup sugar
  • 2 small or 1 large stick cinnamon
  • 2 large slices crystallized ginger
  • Juice of one clementine + 1/2 its rind.
  • Juice of one lemon +  1/2 its rind
  • A few peppercorns
  • 1/4 tsp salt
  • Parchment paper

Dissolve sugar in water in a large saucepan over low heat. Peel, quarter and core the pears, and add to water-sugar mixture along with the spices. Cut the parchment paper into a circle with a smaller circle cut out in the middle and lay atop (See Lebowitz’s post for pics and detailed instructions – it keeps the pears from browning).

Simmer on low heat for 30 minutes, till pears are soft. Remove pears and spices with a slotted spoon and boil down the juice to about 1/2 cup. Store in fridge till ready to serve, then briefly reheat the pears in the sauce and serve warm. Each pear serves two.

The Book of Mormon

Book of Mormon

Loyal readers know that this morning, when I awoke to a major snowstorm, my first thought was “Book of Mormon tickets!”

The Book of Mormon has been selling out months in advance since before it opened, but a major snow storm? That means cancellations and empty seats and maybe, just maybe, a shot at a ticket in my lifetime.

So Mr TBTAM, who teaches at a private school and had a snow day, headed on over to the box office this afternoon to see if he could score us two seats.

And as it turns out, there were cancellations. At $170 and $250 a seat. But you don’t know my husband. Full price for a theater ticket? What, are you nuts?…

But wait!  There were SRO tickets for $25 apiece!  (Who knew?…)  But you don’t know me. Stand for a whole play? What, are you nuts?…

That left the daily lottery. Which was what we were banking on.

I mean it was a literal blizzard out there. How many people stand outside the box office in the snow two hours before showtime hoping to get their name pulled out of a hat for a couple of lousy $32 single seats?

About 350 people, if you really want to know.

Really.

And that’s about 50 more than the average on a Thursday night. Guess I’m not the only one who woke up today with a bright idea.

The good news was that because of the storm, there were a few more seats than usual available for the lottery. Thirty seats in total, to be exact.

But the best news?

WE WON THE LOTTERY AND SCORED TWO SEATS!

I mean, what are the odds?…

So at 5:30 I ran out of the office, then home to feed and walk the dog, then over to take the R train to 49th and 7th, arriving to meet Mr TBTAM at the theater with 30 minutes to spare. That meant time for a bathroom stop before the play, while the ladies’ rooms was empty. (I mean, what are the odds of that?…)

And as for the Book of Mormon musical itself, all I can say is SEE IT. It is absolutely brilliant.


There are moments when I pinch myself, wondering if I really am living the New York City dream.

But tonight? I know I am.